Health care costs make up nearly a fifth of U.S. gross domestic product, but health care is a peculiar thing to buy and sell. Both a scarce resource and a basic need, it involves physical and ...emotional vulnerability and at the same time it operates as big business. Patients have little choice but to trust those who provide them care, but even those providers confront a great deal of medical uncertainty about the services they offer.Selling Our Soulslooks at the contradictions inherent in one particular health care market-hospital care. Based on extensive interviews and observations across the three hospitals of one California city, the book explores the tensions embedded in the market for hospital care, how different hospitals manage these tensions, the historical trajectories driving disparities in contemporary hospital practice, and the perils and possibilities of various models of care.
As Adam Reich shows, the book's three featured hospitals could not be more different in background or contemporary practice. PubliCare was founded in the late nineteenth century as an almshouse in order to address the needs of the destitute. HolyCare was founded by an order of nuns in the mid-twentieth century, offering spiritual comfort to the paying patient. And GroupCare was founded in the late twentieth century to rationalize and economize care for middle-class patients and their employers. Reich explains how these legacies play out today in terms of the hospitals' different responses to similar market pressures, and the varieties of care that result.
Selling Our Soulsis an in-depth investigation into how hospital organizations and the people who work in them make sense of and respond to the modern health care market.
To cut costs and maximize profits, hospitals in the United States and many other countries are outsourcing such tasks as cleaning and food preparation to private contractors. InCleaning Up, the first ...book to examine this transformation in the healthcare industry, Dan Zuberi looks at the consequences of outsourcing from two perspectives: its impact on patient safety and its role in increasing socioeconomic inequality. Drawing on years of field research in Vancouver, Canada as well as data from hospitals in the U.S. and Europe, he argues that outsourcing has been disastrous for the cleanliness of hospitals-leading to an increased risk of hospital-acquired infections, a leading cause of severe illness and death-as well as for the effective delivery of other hospital services and the workers themselves.
Zuberi's interviews with the low-wage workers who keep hospitals running uncover claims of exposure to near-constant risk of injury and illness. Many report serious concerns about the quality of the work due to understaffing, high turnover, poor training and experience, inadequate cleaning supplies, and on-the-job injuries. Zuberi also presents policy recommendations for improving patient safety by reducing the risk of hospital-acquired infection and ameliorating the work conditions and quality of life of hospital support workers. He makes the case that hospital outsourcing exemplifies the trend towards "low-road" service-sector jobs that threatens to undermine society's social health, as well as the physical health and well-being of patients in health care settings globally.
Background: There is substantial variation in the cost and intensity of care delivered by US hospitals. We assessed how the structure of patient-sharing networks of physicians affiliated with ...hospitals might contribute to this variation. Methods: We constructed hospital-based professional networks based on patient-sharing ties among 61,461 physicians affiliated with 528 hospitals in 51 hospital referral regions in the US using Medicare data on clinical encounters during 2006. We estimated linear regression models to assess the relationship between measures of hospital network structure and hospital measures of spending and care intensity in the last 2 years of life. Results: The typical physician in an average-sized urban hospital was connected to 187 other doctors for every 100 Medicare patients shared with other doctors. For the average-sized urban hospital an increase of 1 standard deviation (SD) in the median number of connections per physician was associated with a 17.8% increase in total spending, in addition to 17.4% more hospital days, and 23.8% more physician visits (all P < 0.001). In addition, higher "centrality" of primary care providers within these hospital networks was associated with 14.7% fewer medical specialist visits (P < 0.001) and lower spending on imaging and tests (-9.2% and -12.9% for 1 SD increase in centrality, P < 0.001). Conclusions: Hospital-based physician network structure has a significant relationship with an institution's care patterns for their patients. Hospitals with doctors who have higher numbers of connections have higher costs and more intensive care, and hospitals with primary care-centered networks have lower costs and care intensity.
Return visits to the emergency department (ED) or hospital after an index ED visit strain the health system, but information about rates and determinants of revisits is limited.
To describe revisit ...rates, variation in revisit rates by diagnosis and state, and associated costs.
Observational study using the Healthcare Cost and Utilization Project databases.
6 U.S. states.
Adults with ED visits between 2006 and 2010.
Revisit rates and costs.
Within 3 days of an index ED visit, 8.2% of patients had a revisit; 32% of those revisits occurred at a different institution. Revisit rates varied by diagnosis, with skin infections having the highest rate (23.1% 95% CI, 22.3% to 23.9%). Revisit rates also varied by state. For skin infections, Florida had higher risk-adjusted revisit rates (24.8% CI, 23.5% to 26.2%) than Nebraska (10.6% CI, 9.2% to 12.1%). In Florida, the only state with complete cost data, total revisit costs for the 19.8% of patients with a revisit within 30 days were 118% of total index ED visit costs for all patients (including those with and without a revisit).
Whether a revisit reflects inadequate access to primary care, a planned revisit, the patient's nonadherence to ED recommendations, or poor-quality care at the initial ED visit remains unknown.
Revisits after an index ED encounter are more frequent than previously reported, in part because many occur outside the index institution. Among ED patients in Florida, more resources are spent on revisits than on index ED visits.
Agency for Healthcare Research and Quality.
Background: Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in ...hospitals would facilitate the design and implementation of interventions. Objectives: To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline. Research Design: We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals. Subjects: We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response). Measures: The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines. Results: Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area. Conclusions: Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.
To explore the causes of failure to activate the rapid response system (RRS). The organisation has a recognised incidence of staff failing to act when confronted with a deteriorating patient and ...leading to adverse outcomes.
A multi-method study using the following: a point prevalence survey to determine the incidence of abnormal simple bedside observations and activation of the rapid response team by clinical staff; a prospective audit of all patients experiencing a cardiac arrest, unplanned intensive care unit admission or death over an 8-week period; structured interviews of staff to explore cognitive and sociocultural barriers to activating the RRS.
Southern Health is a comprehensive healthcare network with 570 adult in-patient beds across four metropolitan teaching hospitals in the south-eastern sector of Melbourne.
Frequency of physiological instability and outcomes within the in-patient hospital population. Qualitative data from staff interviews were thematically coded.
The incidence of physiological instability in the acute adult population was 4.04%. Nearly half of these patients (42%) did not receive an appropriate clinical response from the staff, despite most (69.2%) recognising their patient met physiological criteria for activating the RRS, and being 'quite', or 'very' concerned about their patient (75.8%). Structured interviews with 91 staff members identified predominantly sociocultural reasons for failure to activate the RRS.
Despite an organisational commitment to the RRS, clinical staff act on local cultural rules within the clinical environment that are usually not explicit. Better understanding of these informal rules may lead to more appropriate activation of the RRS.
Few studies have analyzed contemporary data on outcomes at US teaching hospitals vs nonteaching hospitals.
To examine risk-adjusted outcomes for patients admitted to teaching vs nonteaching hospitals ...across a broad range of medical and surgical conditions.
Use of national Medicare data to compare mortality rates in US teaching and nonteaching hospitals for all hospitalizations and for common medical and surgical conditions among Medicare beneficiaries 65 years and older.
Hospital teaching status: major teaching hospitals (members of the Council of Teaching Hospitals), minor teaching hospitals (other hospitals with medical school affiliation), and nonteaching hospitals (remaining hospitals).
Primary outcome was 30-day mortality rate for all hospitalizations and for 15 common medical and 6 surgical conditions. Secondary outcomes included 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions.
The sample consisted of 21 451 824 total hospitalizations at 4483 hospitals, of which 250 (5.6%) were major teaching, 894 (19.9%) were minor teaching, and 3339 (74.3%) were nonteaching hospitals. Unadjusted 30-day mortality was 8.1% at major teaching hospitals, 9.2% at minor teaching hospitals, and 9.6% at nonteaching hospitals, with a 1.5% (95% CI, 1.3%-1.7%; P < .001) mortality difference between major teaching hospitals and nonteaching hospitals. After adjusting for patient and hospital characteristics, the same pattern persisted (8.3% mortality at major teaching vs 9.2% at minor teaching and 9.5% at nonteaching), but the difference in mortality between major and nonteaching hospitals was smaller (1.2% 95% CI, 1.0%-1.4%; P < .001). After stratifying by hospital size, 187 large (≥400 beds) major teaching hospitals had lower adjusted overall 30-day mortality relative to 76 large nonteaching hospitals (8.1% vs 9.4%; 1.2% difference 95% CI, 0.9%-1.5%; P < .001). This same pattern of lower overall 30-day mortality at teaching hospitals was observed for medium-sized (100-399 beds) hospitals (8.6% vs 9.3% and 9.4%; 0.8% difference between 61 major and 1207 nonteaching hospitals 95% CI, 0.4%-1.3%; P = .003). Among small (≤99 beds) hospitals, 187 minor teaching hospitals had lower overall 30-day mortality relative to 2056 nonteaching hospitals (9.5% vs 9.9%; 0.4% difference 95% CI, 0.1%-0.7%; P = .01).
Among hospitalizations for US Medicare beneficiaries, major teaching hospital status was associated with lower mortality rates for common conditions compared with nonteaching hospitals. Further study is needed to understand the reasons for these differences.
This report explores the evolving role that hospital emergency departments play in the U.S. health care system. EDs evaluate and manage complex and high-acuity patients, are the major point of entry ...to inpatient care, and serve as “the safety net of the safety net” for patients who cannot get care elsewhere. The report examines the role that EDs may come to play in either contributing to or reducing the rising costs of health care.
Context: Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and ...under what conditions each type of investment works better to improve outcomes. Objective: To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes. Design, Setting, and Participants: Outcomes of 665 hospitals in 4 large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data. Main Outcome Measures: A 30-day inpatient mortality and failure-to-rescue. Results: The effect of decreasing workloads by 1 patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9% and 10%, respectively. The effect of 10% more Bachelors of Science in Nursing Degree nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%. Conclusions: Although the positive effect of increasing percentages of Bachelors of Science in Nursing Degree nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.
Reproducing Race, an ethnography of pregnancy and birth at a large New York City public hospital, explores the role of race in the medical setting. Khiara M. Bridges investigates how race--commonly ...seen as biological in the medical world--is socially constructed among women dependent on the public healthcare system for prenatal care and childbirth. Bridges argues that race carries powerful material consequences for these women even when it is not explicitly named, showing how they are marginalized by the practices and assumptions of the clinic staff. Deftly weaving ethnographic evidence into broader discussions of Medicaid and racial disparities in infant and maternal mortality, Bridges shines new light on the politics of healthcare for the poor, demonstrating how the "medicalization" of social problems reproduces racial stereotypes and governs the bodies of poor women of color.
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