Improve Hospital Efficiency Research Articles

Waiting it out: consultation delays prolong in-patient length of stay

BackgroundDecreasing delays for hospitalised patients results in improved hospital efficiency, increased quality of care and decreased healthcare expenditures. Delays in subspecialty consultations and procedures can cause increased length of stay...

Improving hospital efficiency: assessment of a Surgical Suite through a Root Cause Analysis

Improving hospital efficiency: assessment of a Surgical Suite through a Root Cause Analysis

Real-time location system-based asset tracking in the healthcare field: lessons learned from a feasibility study

BackgroundNumerous hospitals and organizations have recently endeavored to study the effects of real-time location systems. However, their experiences of system adoption or pilot testing via implementation were not shared with others or evaluated in a real environment. Therefore, we aimed to share our experiences and insight regarding a real-time location system, obtained via the implementation and operation of a real-time asset tracking system based on Bluetooth Low Energy/WiFi in a tertiary care hospital, which can be used to improve hospital efficiency and nursing workflow.MethodsWe developed tags that were attached to relevant assets paired with Bluetooth Low Energy sensor beacons, which served as the basis of the asset tracking system. Problems with the system were identified during implementation and operation, and the feasibility of introducing the system was evaluated via a satisfaction survey completed by end users after 3 months of use.ResultsThe results showed that 117 nurses who had used the asset tracking system for 3 months were moderately satisfied (2.7 to 3.4 out of 5) with the system, rated it as helpful, and were willing to continue using it. In addition, we identified 4 factors (end users, target assets, tracking area, and type of sensor) that should be considered in the development of asset tracking systems, and 4 issues pertaining to usability (the active tag design, technical limitations, solution functions, and operational support).ConclusionsThe successful introduction of asset tracking systems based on real-time location in hospitals requires the selection of clear targets (e.g., users and assets) via analysis of the user environment and implementation of appropriate technical improvements in the system as required (e.g., miniaturization of the tag size and improvement of the sensing accuracy).

PMS15 - Improving Hospital Efficiency Using Time-Driven Activity-Based Costing (Tdabc) In Total Knee Arthroplasty (Tka): A Japanese Experience

PMS15 - Improving Hospital Efficiency Using Time-Driven Activity-Based Costing (Tdabc) In Total Knee Arthroplasty (Tka): A Japanese Experience

Estimating technical efficiency of Turkish hospitals: implications for hospital reform initiatives

BackgroundThe Government of Turkey has initiated a series of major health reforms in 2003 with an objective of increasing access to health care services and improving efficiency of public and private hospitals. This study attempts to understand the technical efficiency of public and private hospitals in Turkey to better guide hospital reform.MethodsWe use data from 1079 public and private hospitals and translog stochastic production frontier was adopted to estimate technical inefficiency of hospitals.ResultsResults indicate that there is no statistically significant difference in the degree of inefficiency of hospitals by geographic location or its level of economic development. Efficiency scores vary significantly across hospital types with Ministry of Health (MoH) General Hospitals being the most efficient followed by MoH teaching hospitals. Better performance of MoH hospitals may be due to successful implementation of 2003 health reforms in Turkey, which intended to improve resource utilization within and across MoH hospitals. Among MoH hospital types, integrated county hospitals were the least efficient. Since the hospital outcome measure did not include the value of medical training, efficiency scores of university hospitals became relatively low. Wide variability of efficiency scores of private general hospitals implies the existence of both highly efficient and inefficient hospitals in the private sector.ConclusionsEfficiency differences of various hospital types can be leveraged to guide future reforms by emphasizing the strengths of general hospitals and improving the referral system from county hospitals to general hospitals. Encouraging resource sharing across hospitals, as being done by the 2011 reforms, should further improve hospital efficiency. Promoting private hospitals may not necessarily be efficiency enhancing due to high variability of private hospitals in terms of efficiency scores. Similarly, implementation of common productivity standards and quality control measures are likely to improve hospital technical efficiency scores further.

Reducing Length of Stay by Enhancing Patients' Discharge: A Practical Approach to Improve Hospital Efficiency.

For years, hospitals have responded to inefficiencies by adding more resources, whereas research suggests that it is a flow problem. King Faisal Specialist Hospital and Research Center decided to improve efficiency and enhance patient flow through improving patient discharge and reducing length of stay. Eight interventions were implemented; dedicating slots in diagnostic services for discharges, improving communication, eliminating pending exams, identifying discharges the day before, prioritizing laboratory tests, coordinating discharge medication processing and utilizing case management. 14.1% of discharges after improvement, compared to 21.7% before, experienced delays. Discharge cycle duration was reduced from 17.9 to 9.2 hours. 4.1% of discharges after improvement, compared to 14.8% before, experienced procedures delays. Procedure turnaround time was reduced from 46.9 to 15.3 hours. Average length of stay (ALOS) was reduced from 12 days to less than 10. Improving hospital efficiency is an integrated process and the responsibility of all hospital staff.

Does expanding primary healthcare improve hospital efficiency? Evidence from a panel analysis of avoidable hospitalisations in 5506 municipalities in Brazil, 2000–2014

BackgroundHospitals account for the major share of health expenditure. Primary healthcare may improve efficiency at the hospital level by reducing avoidable admissions. We examined whether rapid expansion of primary healthcare...

IP065. Length of Stay Following Thoracic Endovascular Aortic Repair (TEVAR) Depends on Indication

Length of stay (LOS) is a quality metric used for pathway development to improve hospital efficiency. We sought to define the predictors of prolonged LOS in patients undergoing thoracic endovascular aortic repair (TEVAR) for dissection or aneurysm by comparing demographic, operative, and postoperative factors in the National Surgical Quality Improvement Program (NSQIP). Patients undergoing TEVAR from 2005 to 2015 in the NSQIP were separated into dissection and aneurysm populations using International Classification of Diseases-Ninth Revision diagnosis codes. Groups were compared with χ2 analysis and t-tests. Prolonged LOS was defined as those patients at or above the 75th percentile for LOS (≥11 days). Univariate and multivariate logistic regression identified factors associated with prolonged LOS. There were 3021 patients undergoing TEVAR identified: 858 (28.4%) for dissection, and 2163 (71.6%) for aneurysm. Aneurysm patients were older (71.2 ± 11.7 vs 63.1 ± 13.6 years; P < .001), more Caucasian (76.8% vs 61.8%; P < .001), and had higher rates of chronic comorbidities (chronic obstructive pulmonary disease, cardiac history, diabetes, peripheral vascular disease, transient ischemia attack; P < .001). In contrast, dissection patients had higher American Society of Anesthesiologists classifications (P < .001), lower preoperative hematocrit (34.9 ± 5.4 vs 36.8 ± 5.8; P < .001), more emergent cases (32.4% vs 15.4%; P < .001), extended ventilator courses (11.7% vs 9.0%; P = .028), and longer hospital LOS (10.2 ± 10.8 vs 8.5 ± 10.3 days; P < .001). Multivariable analysis identified low hematocrit (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.88-0.96; P < .001; OR, 0.90; 95% CI, 0.87-0.93; P < .001), postoperative stroke (OR, 4.02; 95% CI, 1.57-10.26; P = .004; OR, 2.67; 95% CI, 1.27-5.62; P = .01), extended ventilator course (OR, 4.21; 95% CI, 2.05-8.66; P < .001; OR, 4.72, 95% CI, 2.55-8.73; P < .001), postoperative pneumonia (OR, 3.33, 95% CI, 1.13-9.84; P = .029; OR, 6.69; 95% CI, 3.18-14.08; P < .001), and reoperation (OR, 2.28; 95% CI, 1.25-4.13; P = .007; OR, 2.18; 95% CI, 1.36-3.5; P = .001) as significant predictors of prolonged LOS in both dissection and aneurysm patients, respectively (Table). In the aneurysm population, chronic obstructive pulmonary disease (OR, 1.53; 95% CI, 1.04-2.26; P = .033), low preoperative albumin (OR, 0.64; 95% CI, 0.48-0.84; P = .002), dependent functional status (OR, 1.84; 95% CI, 1.15-2.96; P = .011), and postoperative urinary tract infection (OR, 2.18; 95% CI, 1.32-4.92; P = .006) additionally predicted longer LOS. In evaluating trends in LOS over time, emergent patients had greater LOS compared to nonemergent patients, with nonemergent dissection patients staying longer than nonemergent aneurysm patients (P < .001, Fig). These results reflect the differing populations of patients in the application of TEVAR. Aneurysm patients had more medical comorbidities, while dissection patients were more often operated on in an emergent fashion. Not surprisingly, both groups displayed prolonged LOS with postoperative complications as well as emergent status. Indication for TEVAR should be taken into account in devising hospital pathways to reduce LOS.TableMultivariable logistic regression of prolonged length of stay (LOS) in dissection vs aneurysm patientsVariableDissectionThoracic aortic aneurysmOR (95% CI)P valueOR (95% CI)P valuePreoperative ASA class1.38 (0.97-1.96).0741.09 (0.81-1.46).588 Diabetes0.98 (0.4-2.39).9561.11 (0.64-1.93).715 Dialysis0.95 (0.29-3.1).9271.24 (0.47-3.26).657 Emergency surgery0.69 (0.43-1.1).1191.2 (0.77-1.87).413 Dependent functional status1.15 (0.67-1.98).6191.84 (1.15-2.96).011 Cardiac history……1.44 (0.99-2.08).055 COPD……1.53 (1.04-2.26).033 Albumin0.75 (0.53-1.06).0990.64 (0.48-0.84).002 Creatinine1.09 (0.9-1.33).3671.08 (0.9-1.3).421 Hematocrit0.92 (0.88-0.96)<.0010.9 (0.87-0.93)<.001 WBC1.05 (1-1.1).0740.99 (0.95-1.02).495 Sex……0.94 (0.67-1.3).693Postoperative Stroke/TIA4.02 (1.57-10.26).0042.67 (1.27-5.62)0.01 Fail to wean >48 hours4.21 (2.05-8.66)<.0014.72 (2.55-8.73)<.001 Number of MI events……0.91 (0.3-2.75).865 Number of AKI events1.49 (0.44-5).5190.61 (0.23-1.64).326 Number of DVT events2.41 (0.54-10.67).2462.7 (0.74-9.76).131 Number of sepsis events12.3 (2.35-64.5).0031.42 (0.55-3.66).473 Number of UTI events1.83 (0.54-6.22).3332.54 (1.32-4.92).006 Operation time1 (1-1).151 (1-1).006 Bleeding requiring transfusion0.85 (0.5-1.45).5561.18 (0.79-1.75).427 Sepsis1.22 (0.24-6.31).8120.69 (0.25-1.89).465 Pneumonia3.33 (1.13-9.84).0296.69 (3.18-14.08)<.001 Reintubation1.32 (0.6-2.9).4841.76 (0.95-3.27).072 AKI4.31 (0.34-53.91).2581.91 (0.46-8.01).375 Reoperation2.28 (1.25-4.13).0072.18 (1.36-3.5).001AKI, Acute kidney injury; ASA, American Society of Anesthesiologists; CI, confidence interval; COPD, chronic obstructive pulmonary disease; DVT, deep vein thrombosis; MI, myocardial infarction; OR, odds ratio; TIA, transient ischemic attack; UTI, urinary tract infection; WBC, white blood cells. 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Abstract 246: Length of Stay and Its Association With Get With the Guidelines-stroke Award Recognition

Background and Objectives: The average length of stay (ALOS) provides important information regarding care efficiency and the financing of hospitals. A shorter ALOS helps to reduce hospital costs, increase capacity optimization, and improve hospital efficiency. A longer ALOS can be associated with reduced readmission rates and mortality rates. The objective of this study was to analyze the ALOS for stroke patients based on etiology subtype and Get With The Guidelines (GWTG)-Stroke award recognition. Methods: A retrospective review of the ALOS for hemorrhagic and ischemic stroke patients was conducted for the states of Illinois, Iowa, and Michigan from 99 hospitals using GWTG-Stroke from July 2014 through December 2015. Stroke subsets, GWTG award status, and ALOS were examined. Results: The national ALOS is 5.22 days for ischemic stroke, 12.75 days for subarachnoid hemorrhage (SAH), and 8.5 days for intracerebral hemorrhage (ICH). The ALOS for ischemic stroke was 4.36 days for non-award winning hospitals and 4.52 days for award winning hospitals. The ALOS for SAH was 7.51 days for non-award winning hospitals and 10.77 days for award winning hospitals. The ALOS for ICH was 18.63 days for non-award winning hospitals and 6.80 days for award winning hospitals. Further broken down, hospitals with a higher award (gold vs silver), had longer ALOS for both SAH and ICH (11.11 vs 8.72 and 7.07 vs 5.84 respectively), while there was no significant difference in ALOS for ischemic stroke. Conclusions: This study demonstrated that GWTG-Stroke award winning hospitals have a shorter ALOS for ICH and a higher ALOS for SAH than non-award winning hospitals. Those hospitals that have attained gold award status more closely align with national ALOS. Thus, hospitals that are more adherent to guideline recommended care via a quality improvement program may be more efficient when providing care, which impacts hospitals costs.

Does participation in health information exchange improve hospital efficiency?

The federal government allocated nearly $30 billion to spur the development of information technology infrastructure capable of supporting the exchange of interoperable clinical data, leading to growth in hospital participation in health information exchange (HIE) networks. HIEs have the potential to improve care coordination across healthcare providers, leading ultimately to increased productivity of health services for hospitals. However, the impact of HIE participation on hospital efficiency remains unclear. This dynamic prompts the question asked by this study: does HIE participation improve hospital efficiency. This study estimates the effect of HIE participation on efficiency using a national sample of 1017 hospitals from 2009 to 2012. Using a two-stage analytic design, efficiency indices were determined using the Malmquist algorithm and then regressed on a set of hospital characteristics. Results suggest that any participation in HIE can improve both technical efficiency change and total factor productivity (TFP). A second model examining total years of HIE participation shows a benefit of one and three years of participation on TFP. These results suggest that hospital investment in HIE participation may be a useful strategy to improve hospital operational performance, and that policy should continue to support increased participation and use of HIE. More research is needed to identify the exact mechanisms through which HIE participation can improve hospital efficiency.

Palliative Care: A Partnership Across the Continuum of Care.

Palliative care services are becoming more prevalent in the United States as greater portions of the population are requiring end-of-life services. Furthermore, recent policy changes and service foci have promoted more continuity and encompassing care. This study evaluates characteristics that distinguish hospitals with a palliative care program from hospitals without such a program in order to better define the markets and environments that promote the creation and usage of these programs. This study demonstrates that palliative care programs are more likely in communities with favorable economic factors and higher Medicare populations. Large hospitals with high occupancy rates and a high case mix index use palliative care programs to better meet patient needs and improve hospital efficiency. Managerial, nursing, and policy implications are discussed relating to further usage and implementation of palliative care programs.

Implementation of a Trauma Service Activation and Admission Policy for Very Elderly Trauma Patients: Impact on Hospital Efficiency and Patient Outcomes

Very elderly trauma patients (VETs) were routinely admitted to nonsurgical services at our institution; therefore, a trauma service activation and admission policy was implemented. Our goal was to determine policy success and impact on efficiency and outcomes. VETs, defined as trauma patients aged >89 years, admitted before and after policy implementation were reviewed. Demographics included age, gender, Injury Severity Score, Glasgow Coma Score, admission diagnosis, mechanism of injury, admission service, and comorbidities. Efficiency included intensive care unit length of stay (ICU-LOS) and hospital length of stay (H-LOS). Outcomes included complications, discharge disposition, and mortality. Statistical analysis included Chi square, Fisher's exact test, and regression analyses, significance denoted by P < 0.05. 375 VETs were investigated. Demographic analysis revealed differences in Injury Severity Score (9.4 + 5.4 vs 7.2 + 4.0, P < 0.001), coronary artery disease (2.1% vs 38.2%, P < 0.001), neurologic disease (7.4% vs 28.24%, P < 0.001), and intracranial hemorrhage (15.6% vs 6.1%, P = 0.01). The most common mechanism of injury and admission diagnosis was fall and femur fracture. VETs admitted to the trauma service increased from 28.3 per cent to 40.5 per cent, P = 0.02. Efficiency analysis revealed differences in ICU-LOS (4.0 + 4.2 days vs 0.7 + 1.3 days, P < 0.001) and H-LOS (7.3 + 4.9 days vs 6.3 + 5.5 days, P = 0.005). Outcomes analysis revealed differences in pneumonia (0.8% vs 5.3%, P = 0.01), acute respiratory distress syndrome (0% vs 2.3%, P = 0.04), discharge to skilled nursing facility (75.8% vs 57.3%, P < 0.001), but no difference in mortality. Regression analyses revealed that trauma service admission was associated with decreased ICU-LOS and H-LOS. The trauma service activation and admission policy for VETs led to improved hospital efficiency.

Clinical characteristics and preventable acute care spending among a high cost inpatient population.

BackgroundA small proportion of patients account for the majority of health care spending. The objectives of this study were to explore the clinical characteristics, patterns of health care use, and the proportion of acute care spending deemed potentially preventable among high cost inpatients within a Canadian acute-care hospital.MethodsWe identified all individuals within the Ottawa Hospital with one or more inpatient hospitalization between April 1, 2010 and March 31, 2011. Clinical characteristics and frequency of hospital encounters were captured in the information systems of the Ottawa Hospital Data Warehouse. Direct inpatient costs for each encounter were summed using case costing information and those in the upper first and fifth percentiles of the cumulative direct cost distribution were defined as extremely high cost and high cost respectively. We quantified preventable acute care spending as hospitalizations for ambulatory care sensitive conditions (ACSC) and spending attributable to difficulty discharging patients as measured by alternate level of care (ALC) status.ResultsDuring the study period, 36,892 patients had 44,066 hospitalizations. High cost patients (n = 1,844) accounted for 38 % of total inpatient spending ($122 million) and were older, more likely to be male, and had higher levels of co-morbidity compared to non-high cost patients. In over half of the high cost cohort (54 %), costs were accumulated from a single hospitalization. The majority of costs were related to nursing care and intensive care unit spending. High cost patients were more likely to have an encounter deemed to be ambulatory care sensitive compared to non-high cost inpatients (6.0 versus 2.8 %, p < 0.001). A greater proportion of inpatient spending was attributable to ALC days for high cost versus non-high cost patients (9.1 versus 4.9 %, p < 0.001).ConclusionsWithin a population of high cost inpatients, the majority of costs are attributed to a single, non-preventable, acute care episode. However, there are likely opportunities to improve hospital efficiency by focusing on different approaches to community based care directed towards specific populations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1418-2) contains supplementary material, which is available to authorized users.

Data envelopment analysis on evaluating the efficiency of public hospitals in Tianjin, China

Public hospitals are the most important components of health systems and account for a large proportion of health resources in China. However, few researches on the efficiency assessment of public hospitals have been conducted in Tianjin, China. On the basis of the data of annual health service report in 2013 from the Ministry of Health, we measured the relative efficiency of the tertiary general public hospitals in Tianjin and estimated the magnitudes of output increase and/or input reduction by using data envelopment analysis to improve hospital efficiency. The main findings of this study indicate that more than half of the sample hospitals operate at a technical and scale efficiency, and the prevalent scale inefficiency is increasing returns to scale. Moreover, it is a prominent issue that health resource constraint and resource waste coexist. Health policy-makers and hospital administrators would need to address these problems by taking comprehensive measures such as optimizing the allocation of health resources, implementing hierarchical diagnosis and treatment, as well as innovating medical-service operating mechanism of public hospital to improve the people’s wellbeing.

Exploring efficiency differences between medical home and non-medical home hospitals

Although research on the delivery and effectiveness of medical home care in the outpatient setting is rapidly emerging, little is known about the performance of hospitals claiming to have adopted a medical home model. Exploring the linkages between medical home programs and measures of hospital efficiency is a step towards understanding if this model of care can help stem rising healthcare costs and increase hospital productivity. To explore this relationship this study employed a retrospective, cross-sectional, two-stage approach involving (1) bias-corrected data envelopment analysis (DEA) and (2) Tobit regression. Findings from the DEA suggest that a total of 119 of 2212 U.S. hospitals were technically efficient in 2012. Also, hospitals claiming to have a medical home program were more efficient (0.73) than those reporting not having a medical home program (0.69). The regression model predicts an association between hospitals reporting to have a medical home program and hospital efficiency while controlling for hospital and market characteristics. More research is necessary to determine what proponents of medical home programs are advantageous for improving hospital efficiency, and how programs can be tailored to reduce unnecessary spending while improving the quality of care provided in a hospital setting.

Implementation of an Acute Care Surgery Service in a Community Hospital: Impact on Hospital Efficiency and Patient Outcomes

A service led by acute care surgeons managing trauma, critically ill surgical, and emergency general surgery patients via an acute care surgery model of patient care improves hospital efficiency and patient outcomes at university-affiliated hospitals and American College of Surgeons-verified trauma centers. Our goal was to determine whether an acute care surgeon led service, entitled the Surgical Trauma and Acute Resuscitative Service (STARS) that implemented an acute care surgery model of patient care, could improve hospital efficiency and patient outcomes at a community hospital. A total of 492 patient charts were reviewed, which included 230 before the implementation of the STARS [pre-STARS (control)] and 262 after the implementation of the STARS [post-STARS (study)]. Demographics included age, gender, Acute Physiology and Chronic Health Evaluation 2 score, and medical comorbidities. Efficiency data included length of stay in emergency department (ED-LOS), length of stay in surgical intensive care unit (SICU-LOS), and length of stay in hospital (H-LOS), and total in hospital charges. Average age was 64.1 + 16.4 years, 255 males (51.83%) and 237 females (48.17%). Average Acute Physiology and Chronic Health Evaluation 2 score was 11.9 + 5.8. No significant differences in demographics were observed. Average decreases in ED-LOS (9.7 + 9.6 hours, pre-STARS versus 6.6 + 4.5 hours, post-STARS), SICU-LOS (5.3 + 9.6 days, pre-STARS versus 3.5 + 4.8 days, post-STARS), H-LOS (12.4 + 12.7 days, pre-STARS versus 11.4 + 11.3 days, post-STARS), and total in hospital charges ($419,602.6 + $519,523.0 pre-STARS to $374,816.7 + $411,935.8 post-STARS) post-STARS. Regression analysis revealed decreased ED-LOS-2.9 hours [P = 0.17; 95% confidence interval (CI): -7.0, 1.2], SICU-LOS-6.3 days (P < 0.001; 95% CI: -9.3, -3.2), H-LOS-7.6 days (P = 0.001; 95% CI: -12.1, -3.1), and 3.4 times greater odds of survival (P = 0.04; 95% CI: 1.1, 10.7) post-STARS. In conclusion, implementation of the STARS improved hospital efficiency and patient outcomes at a community hospital.

Weekend Discharges and Length of Stay Among Veterans Admitted for Chronic Obstructive Pulmonary Disease.

Discharge rates are substantially lower on weekends, though the impact on hospital length of stay (LOS) is not fully understood. The primary objective was to examine the association of weekend discharges with hospital LOS. We also examined the association of weekend discharges with readmission, mortality, and postdischarge follow-up. A cohort study of 25,301 patients who were admitted to Veterans Affairs hospitals for chronic obstructive pulmonary disease during October 01, 2008-September 30, 2010, including 3845 patients discharged on the weekend (Saturday or Sunday) and 21,456 discharged on weekdays (Monday through Friday). There were significantly fewer discharges on the weekend (1922 per weekend day vs. 4279 per weekday, P<0.01). Inpatient status during the weekend at any point in hospitalization was associated with an increased LOS of 0.59 day [95% confidence interval (CI), 0.54-0.63 d]. Discharge on the weekend was not associated with increased odds of 30-day hospital readmission [odds ratio (OR)=1.00; 95% CI, 0.90-1.10] or lack of primary care follow-up visit within 14 days of discharge (OR=0.94; 95% CI, 0.85-1.03). However, weekend discharges were significantly associated with lower odds of mortality within 30 days after discharge (OR=0.80; 95% CI, 0.65-0.99). The presence of fewer weekend discharges was associated with significantly longer hospital lengths of stay. Weekend discharges were not associated with higher readmission rates and had lower rates of mortality compared with weekdays discharges. Identifying methods to increase weekend discharges may create an opportunity to improve hospital efficiency.

DRG data for better decision-making in Croatia: planning for a greater use of same-day surgical admissions

Background In 2006, Croatia implemented AR-DRGs with the aim of increasing hospital output transparency, incentivizing efficient resource use, and measuring hospital performance and quality. Despite the intentions of this initiative, up until very recently, the hospital payment system continued to be based on historical budgets, although hospitals have been reporting inpatient activity using the DRG classifications. Only now is transition to a DRGbased payment system being planned. In 2013-2014, a Hospital Master Planning Project was undertaken to rationalize the hospital service delivery network and to improve efficiency. The Project also sought to create incentives to encourage the greater use of same-day inpatient services and improve the organization of the delivery of rehabilitation and palliative care services. The Project reported that the Croatian Health Insurance Fund (HZZO) does not have a strategy to encourage the utilization of same-day admissions. These services are primarily counted as part of the total DRG output for all admitted cases. Croatia uses AR-DRG version 5.2, which provides for 20 designated same-day DRGs. In the case of same-day surgical cases, the HZZO pays hospitals through two parallel systems. The first is through DRGs, where there are only 2 are same-day surgical groups (C15B and C16B); the second is through the outpatient system, which has 17 same-day surgical case categories that, in terms of clinical activity, are replicated in the DRG system. The use of both systems and their uncoordinated pricing creates a situation in which hospitals do not have financial incentives to increase the use of same-day surgical procedures. Recognizing that the increased use of same-day admissions would improve hospital efficiency, the Master Planning Project recommended that these admissions should be increased by 20% to 40% over a 3-year period. It appears, however, that these recommendations were made in the absence of a detailed analysis of the types of same-day procedures currently provided by hospitals. The Project did not recommend how hospital could increase their volume of same-day inpatient services, describe individual hospitals’ capacity to do so, or analyze hospital waiting lists.

Impaired postural stability after laparoscopic surgery.

Early postoperative mobilisation may reduce patient morbidity and improve hospital efficiency by accelerated discharge. The aim of this study was to measure postural stability early after laparoscopic surgery in order to assess how early it is safe to mobilise and discharge patients. We included 25 women undergoing outpatient gynaecological laparoscopic surgery in the study. Patients received standardised anaesthesia with propofol, remifentanil and rocuronium. Postural stability was assessed preoperatively, at 30 min after tracheal extubation, and at discharge from the post-anaesthesia care unit using a force platform where sway area, mean sway and sway velocity were determined. The assessments were done with eyes closed and with eyes open. The primary outcome was the change in sway area with eyes closed 30 min after extubation. Data are reported as median (25-75% range). Three patients could not perform all the test's 30 min after extubation. Thirty minutes after extubation, sway area with eyes closed had increased significantly with 84 mm(2) (9-172, P = 0.011) and 108 mm(2) with eyes open (25-295, P = 0.0017). Median mean sway had also increased significantly 30 min postoperatively. No significant changes were found for sway velocity. We found no significant changes in mean sway, sway area or sway velocity at discharge from the post-anaesthesia care unit approximately 2 h after surgery. Postural stability was significantly impaired 30 min after outpatient gynaecological laparoscopic surgery. However, the postural stability was normalised at discharge from the post-anaesthesia care unit 2 h after surgery.

Does Participation in Health Information Exchange Improve Hospital Efficiency?

Policy makers and practitioners argue that exchange of clinical data across the healthcare system through health information exchanges (HIEs) is a key step to improving health service delivery in t...