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Objective To evaluate the impact of the national essential medicines scheme and zero-mark-up policy on antibiotic prescribing behaviour. Methods In rural Guangxi, a natural experiment compared one county hospital which implemented the policy with a comparison hospital which did not. All outpatient and inpatient records in 2011 and 2014 were extracted from the two hospitals. Primary outcome indicator was antibiotic prescribing rate (APR) among children aged 2–14 presenting in outpatients with a primary diagnosis of upper respiratory tract infection (URTI). We organised independent physician reviews to determine inappropriate prescribing for inpatients. Difference-in-difference analyses based on multivariate regressions were used to compare APR over time after adjusting potential confounders. We conducted 12 in-depth interviews with paediatricians, hospital directors and health officials. Results A total of 8219 and 4142 outpatient prescriptions of childhood URTIs were included in the intervention and comparison hospitals, respectively. In 2011, APR was 30% in the intervention and 88% in the comparison hospital. In 2014, the intervention hospital significantly reduced outpatient APR by 21% (95% CI:−23%, −18%), intravenous infusion by 58% (95% CI: −64%, −52%) and prescription cost by 31 USD (95% CI: −35, −28), compared with the controls. We collected 251 inpatient records, but did not find reductions in inappropriate antibiotic use. Interviews revealed that the intervention hospital implemented a thorough antibiotics stewardship programme containing training, peer review of prescriptions and restrictions for overprescribing. Conclusion The national essential medicines scheme and zero-mark-up policy, when implemented with an antimicrobial stewardship programme, may be associated with reductions in outpatient antibiotic prescribing and intravenous infusions.

Chronic heart failure (HF) is a complex and costly disease. Daily weight and symptom monitoring is the cornerstone of HF management. Little information exists about feasibility of a mobile monitoring intervention among minority patients with HF.We developed and tested usability of a mobile-monitoring system in minority patients with HF in a 2:1 randomized controlled trial. We tracked usage and obtained feedback on usability and the system overall at 1, 2, and 3 months.Forty-two participants aged 53.0 ± 9.4 years (mean ± standard deviation) were randomized to the mobile-monitoring intervention group. They included the following: 67% males, 76% White Hispanics, 21% African Americans, and 52% with high school education or less. Over the 3-month intervention period, 26 (62%) participants used the system over 50% of the time. Overall, on a 1.0-7.0 scale for both, program satisfaction scores were excellent (mean 6.84 ± 0.46), and the usability ratings were all above 6.0. Comparing 1- to 3-month responses, there was a substantial increase in the percentage of participants who felt the system was easy to use after they had gotten used to it (84% vs. 94%) and that navigating the system was not complicated (78% vs. 84%). Almost all participants said that the program made them feel more secure about their health and that they would stay enrolled in a program like this. None of them had used a similar system before.A mobile phone-based disease management program is feasible in a minority county hospital population and offers a modality to help reduce ethnic disparity.

Chronic heart failure (HF) causes significant morbidity, mortality, and cost. Managing HF requires considerable self-management skills and self-efficacy. Little information exists about feasibility and potential impact of a mobile monitoring intervention to improve self-efficacy and quality of life (QoL) among minority patients with HF.We developed a mobile phone-assisted case management program and tested its impact on outcomes in minority patients with HF in a 2:1 randomized controlled trial. We evaluated self-care efficacy, knowledge, behavior, and QoL at baseline and 3 months.We enrolled 61 participants: intervention 42, usual care 19; mean age ± SD: 55 ± 10 years; 64% male; 75% white Hispanic, 25% African American; and 56% high school education or less. Comparison of the two groups with respect to changes from baseline to 3 months showed significant differences for Self-Efficacy for Managing Chronic Disease (2.09 ± 2.32, p-value = 0.005); health distress scale (-1.1 ± 1.5, p-value = 0.017); and QoL (Role Physical, 23.6 ± 44.5, p-value = 0.042, and General Health, 11.1 ± 14.2, p-value = 0.012).A mobile phone-based disease management program may help improve self-care efficacy and QoL in a minority population and offers a modality to help reduce ethnic disparity.

Background There is a high unmet need for limiting and spacing child births during the postpartum period. Given the consequences of closely spaced births, and the benefits of longer pregnancy intervals, targeted activities are needed to reach this population of postpartum women. Our objective was to establish the determinants of contraceptive uptake among postpartum women in a county referral hospital in rural Kenya. Methods Sample was taken based on a mixed method approach that included both quantitative and qualitative methods of data collection. Postpartum women who had brought their children for the second dose of measles vaccine between 18 and 24 months were sampled Participants were interviewed using structured questionnaires, data was collected about their socio-demographic characteristics, fertility, knowledge, use, and access to contraceptives. Chi square tests were used to determine the relationship between uptake of postpartum family planning and: socio demographic characteristics, contraceptive knowledge, use access and fertility. Qualitative data collection included focus group discussions (FDGs) with mothers and in-depth interviews with service providers Information was obtained from mothers’ regarding their perceptions on family planning methods, use, availability, access and barriers to uptake and key informants’ views on family planning counseling practices and barriers to uptake of family planning Results More than three quarters (86.3%) of women used contraceptives within 1 year of delivery, with government facilities being the most common source. There was a significant association (p ≤ 0.05) between uptake of postpartum family planning and lower age, being married, higher education level, being employed and getting contraceptives at a health facility. One third of women expressing no intention of having additional children were not on contraceptives. In focus group discussions women perceived that the quality of services offered at the public facilities was relatively good because they felt that they were adequately counseled, as opposed to local chemist shops where they perceived the staff was not experienced. Conclusion Contraceptive uptake was high among postpartum women, who desired to procure contraceptives at health facilities. However, there was unmet need for contraceptives among women who desired no more children. Government health facility stock outs represent a missed opportunity to get family planning methods, especially long acting reversible contraceptives, to postpartum women. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4510-6) contains supplementary material, which is available to authorized users.

Equal access to novel surgical technologies remains a policy concern as hospitals adopt robotic surgery with increasing prevalence. This study sought to determine whether socioeconomic factors influence access to robotic surgery. All laparoscopic and robotic fundoplications and paraesophageal hernia repairs performed by a surgical group over 6 years at a county and two neighboring private hospitals were identified. Robotic use by hospital setting, age, gender, reported ethnicity, estimated income, insurance payer, and diagnosis were examined. Of 418 patients identified, 180 (43%) presented to the county hospital, where subjects were younger (51.1 versus 56.2 years, p < 0.001) with lower estimated income ($50,289 versus $62,959, p < 0.001). In the county setting, there was no difference in reported ethnicity (p = 0.169), estimated income (p = 0.081), or insurance payer (p = 0.535) between groups treated laparoscopically versus robotically. There was no difference in the treatment groups by estimated income in the private hospital setting (p = 0.308). Overall higher estimated income and insurance payer were associated with a higher chance of undergoing robotic procedures (p < 0.001). Presence of a paraesophageal hernia was associated with increased chance of undergoing robotic therapy in all comparisons (p < 0.001). No disparity in access to robotic surgery offered in the county hospital was observed based on age, gender, reported ethnicity, estimated income, or insurance payer. Patients with higher income and private insurers were more likely to present to the private hospital setting where robotics is utilized more often. The presence of a paraesophageal hernia was a significant factor in determining robotic therapy in both settings.

Background Patients discharged against medical advice (AMA) have higher rates of readmission and mortality than patients who are conventionally discharged. Bioethicists have proposed best practice approaches for AMA discharges, but studies have revealed that some providers have misconceptions about their roles in these discharges. Objective This study assessed patient characteristics and provider practices for AMA discharges at a county hospital and provider perceptions and knowledge about AMA discharges. Design This mixed-methods cross-sectional study involved chart abstraction and survey administration. Participants Charts were reviewed for all AMA discharges (n = 319) at a county hospital in 2014. Surveys were completed by 178 healthcare providers at the hospital. Results Of 12,036 admissions, 319 (2.7%) ended with an AMA discharge. Compared with conventionally discharged patients, patients who left AMA were more likely to be young, male, and homeless and less likely to be Spanish-speaking. Of the AMA patients, 29.6% had capacity documented, 21.4% had medications prescribed, and 25.7% had follow-up arranged. Of patients readmitted within 6 months after AMA, 23.5% left AMA again at the next visit. Attending physicians and trainee physicians were more likely than nurses to say that AMA patients should receive medications and follow-up (94% and 84% vs 64%; P Conclusions Although providers overall felt comfortable determining capacity and discussing AMA discharges, they rarely documented these discussions. Nurses and physicians differed in their thinking regarding whether to arrange follow-up for patients leaving AMA, and in practice arrangements were seldom made. Journal of Hospital Medicine 2017;12:11-17.

Background Neurological disorders are an economic and public health burden which requires efficient and adequate medical resources. Currently, little is known about the status of the quality of neurological care services available in China. As neurological primary care is mostly provided at the county hospital level, investigation of this geographical level is required. The aim of this study is to evaluate currently available neurology care services in Yangtze River Delta Urban Agglomerations in east China. Methods A multi-site, county-level hospital-based observational survey was conducted in east China from January 2017 to December 2017. A questionnaire was made to assess hospital and the departmental patient care capabilities, human resources and technical capacity in neurology departments. Results Of 228 hospitals across the Yangtze River Delta Urban Agglomerations, 217 documents were returned. Of these, 22 were excluded due to invalid hospital information or duplicate submission. Overall, most hospitals have neurology departments (162, 83.1%) while less than half of the hospitals have a stroke center (80, 41.0%) and neurology emergency department (46, 23.6%). Among 162 hospitals with neurology department, 5 were excluded due to inadequate sharing, leaving 157 hospitals for analysis. About 84.1% of these neurology departments can administer intravenous thrombolysis while about one third of them has the ability to perform arterial thrombectomy (36.9%). In addition, 46.2% of hospitals can carry out computed tomography angiography (CTA) in emergency room. Tertiary care hospitals are much more equipped with modern medical resources compared to the secondary hospitals. In four administrative regions, the neurology services are better in more economically advanced regions. Conclusions Neurological care services need to be enhanced at the county-level hospitals to improve health care delivery.

Background The I-PASS framework is increasingly being adopted for patient handoffs after a recent study reported a decrease in medical errors and preventable adverse events. A key component of the I-PASS handoff included assignment of illness severity. Objective We evaluated whether illness severity categories can identify patients at higher risk of overnight clinical deterioration as defined by activation of the rapid response team (RRT). Methods The I-PASS handoff documentation created by internal medicine residents and patient charts with overnight RRT activations from April 2016 through March 2017 were reviewed retrospectively. The RRT activations, illness severity categories, vital signs prior to resident handoff, and patient outcomes were evaluated. Results Of the 28 235 written patient handoffs reviewed, 1.3% were categorized as star (sickest patients at risk for higher level of care), 18.8% as watcher (unsure of illness trajectory), and 79.9% as stable (improving clinical status). Of the 98 RRT activations meeting the inclusion criteria, 5.1% were labeled as star, 35.7% as watcher, and 59.2% as stable. Patients listed as watcher had an odds ratio of 2.6 (95% confidence interval 1.7–3.9), and patients listed as star had an odds ratio of 5.2 (95% confidence interval 2.1–13.1) of an overnight RRT activation compared with patients listed as stable. The overall in-hospital mortality of patients with an overnight RRT was 29.6%. Conclusions The illness severity component of the I-PASS handoff can identify patients at higher risk of overnight clinical deterioration and has the potential to help the overnight residents prioritize patient care.

Gastric signet ring cell carcinoma (GSRC) is a rare but increasingly prevalent tumor histotype whose clinical features and natural history are poorly understood, particularly in the USA and minorities.To examine the occurrence, clinico-demographic characteristics, oncologic features, treatment, and outcomes of GSRC in a predominantly minority county hospital setting and benchmark them against data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program.We queried biopsy-proven GSRC cases at a Los Angeles County hospital, from 2004 to 2017. Clinical characteristics, treatment, and survival data were collected and compared to SEER data.We identified 63 patients with GSRC. Compared to SEER, our cohort was significantly younger (52.6 vs. 63.5 years, p 0.01), Hispanic/Latino predominant (81% vs. 20%, p 0.01), had higher overall stage (86% vs. 69% with stage III/IV, p 0.01), and more frequent node involvement (89% vs. 49%, p 0.01). Lower tumor stage, Helicobacter pylori positivity, and surgical intervention were associated with significantly longer median survival (all p 0.05), which was similar in our study compared to SEER (median 12.6 vs. 9.0 months, p = 0.26).Patients with GSRC within the Los Angeles County population have different clinical characteristics compared to what has been reported in SEER. Our cohort was younger, and despite having more advanced disease, did not have shorter survival. Further study is needed to better identify protective and risk factors in this population and improve understanding of the etiopathogenesis and natural history of this malignancy.

随着心血管疾病发患者数增加和分级诊疗的强化，心血管学科已成为县级医院能力建设的重点。县级医院心血管学科的发展方向与大型医疗机构存在明显差异。县域心血管学科的定位必须与本地区的实际情况相结合，其发展路径应遵循以下4个步骤：从提升县域亟须的心血管疾病诊疗技术入手，以建设覆盖院前、院内、院后的心血管学科体系为基础，带动心血管相关学科共同发展，最终形成县乡村一体化的心血管及相关疾病的协同防治体系。.

County-level hospitals, as medical and health centers in the counties, are mainly responsible for providing medical care for common and frequently-occurring diseases as well as rescuing acute critical patients. In 2018, editors of the Chinese Journal of Emergency Medicine evaluated the current situation of the emergency departments of county-level hospitals and found an unbalanced, inadequate, irregular, and unstable status existed among them. In order to provide developmental principles and constructional goals for the emergency departments of county-level hospitals, which located in different regions and with uneven foundations, Emergency Medical Branch of Chinese Medical Association particularly formulated this expert consensus. It not only suits for county-level general hospitals but also offers reference to the traditional Chinese medicine hospitals and specialized hospitals. The consensus includes: duties and scope of the emergency department, flow layout, equipment configuration and technology, job setting and staffing, management of emergency department, information construction and centralized construction. Construction specifications are divided into basic standards and recommended standards. The terms in the text are basic standards, and recommendations are improvements on basic standards. The basic standards are mainly suitable for the 2 Grade general hospitals, and the recommended standards mainly for 3 Grade general hospitals.

The zero-markup drug policy (ZMDP) was heralded as the biggest reform to China’s modern health system. However, there have been a very limited number of investigations of the ZMDP at county hospital level, and those limited county hospital studies have several limitations in terms of sample representativeness and study design. We investigated the overall and dynamic effects of ZMDP at traditional Chinese medicine (TCM) county hospitals. We obtained longitudinal data from all TCM county hospitals in 2004–16 and the implementation year of ZMDP for each hospital. We used differences-in-difference methods to identify the overall and dynamic effects of ZMDP. On average, the ZMDP reform was associated with the reduction in the share of revenue from drug sales (3.1%), revenue from western medicines sales (12.7%), revenue from medical care services (3.6%) and gross hospital revenue (3.4%), as well as increased government subsidies (24.4%). The ZMDP reform was not significantly associated with the number of annual outpatient and inpatient visits. In terms of dynamic effects, the share of revenue from drug sales decreased by 2.5% in the implementation year and by about 5% in the subsequent years. Revenue from western medicine sales fell substantially in the short term and continued to drop in the long term. Government subsidies went up strikingly in the short term and long term, and revenue from medical care services and gross revenue decreased only in the implementation year. The ZMDP achieved its stated goal through reducing the share of revenue from drug sales without disrupting the availability of healthcare services at TCM county hospitals. The success of ZMDP was mainly due to the huge growth in the government’s financial investment in TCM hospitals.

This study aimed to evaluate the effects of the differences between two typical payment methods for the new rural cooperative medical scheme (NRCMS) in China on the utilisation of inpatient services. Interrupted time-series analysis (ITSA) and propensity score matching (PSM) were used to measure the difference between two typical payment methods for the NRCMS with regard to the utilisation of inpatient services. After the reform was formally implemented, the level and slope difference after reform compared with pre-intervention (distribution of inpatients in county hospitals (DIC), distribution of inpatients in township hospitals (DIT) and the actual compensation ratio of inpatients (ARCI)) were not statistically significant. Kernel matching obtained better results in reducing the mean and median of the absolute standardised bias of covariates of appropriateness of admission (AA), appropriateness of disease (AD). The difference in AA and AD of the matched inpatients between two groups was &minus, 0.03 (p-value = 0.042, 95% CI: &minus, 0.08 to 0.02) and 0.21 (p-value &lt, 0.001, 95% CI: &minus, 0.17 to 0.25), respectively. The differences in the utilisation of inpatient services may arise owing to the system designs of different payment methods for NRCMS in China. The causes of these differences can be used to guide inpatients to better use medical services, through the transformation and integration of payment systems.

The rate of emergent groin hernia repair in developing countries is poorly understood. A retrospective analysis of groin hernia repairs performed at a county hospital in Guatemala [Hospital Nacional de San Benito (HSNB)] was undertaken and compared to a literature review in developed countries. Patients with incarcerated hernias were interviewed to determine factors related to late presentation. Twenty-five percent of patients with groin hernias in this analysis presented at HNSB emergently (vs. 2.5–7.7% in developed countries). Most patients were male in their fifth decade of life. Ten percent of hernias were femoral. There was no delay in scheduling patients for surgery presenting for elective repair. Most patients lived within 20 miles of the hospital, but only 50% of patients returned for their follow-up appointment. Most patients with an incarcerated inguinal hernia (56%) did not seek medical attention because of family obligations, but when they did, this decision was influence by their children (66%). None of the patients presenting with an incarcerated hernia had education past secondary school. In fact, most (56%) did not have any form formal education. Nearly 90% of patients who had an incarcerated hernia repaired thought that the hospital provided good-to-excellent care. A high number of patients present emergently for groin hernia repair at a county hospital in Guatemala compared to developed countries. Our data suggest that emergent hernias are likely the result of patient-related issues rather than health care system limitations.

Objectives Physicians working with palliative patients have a substantial risk of emotional exhaustion because of their daily confrontation with suffering and death. Common concerns include alexithymia, high stress, low perceived social support and a greater burnout risk. This longitudinal study aimed to evaluate the effectiveness of Balint training in preventing the development of these symptoms in these medical professionals. Material and Methods The design of the study was longitudinal. A group of 69 physicians working with palliative patients from 5 county hospitals in Romania (33 men, 36 women) participated in the study. Out of them, 31 joined and systematically attended a local Balint group whereas the others did not participate in such a group, either during the study or previously. They were given, both at the beginning (2015) and at the end of the study (2017), 4 psychometric instruments assessing alexithymia ( Bagby’s Toronto Alexithymia Scale ), perceived stress ( Cohen and Williamson’s Perceived Stress Scale ), social support ( Duke-UNC Functional Social Support Questionnaire ) and burnout ( Maslach Burnout Inventory ). A split-plot ANOVA analysis was used for evaluating the significance of Balint groups participation, with gender and age considered as auxiliary variables. Results In the study group, Balint training significantly improved the scores of global burnout (F(1, 64) = 25.104, p < 0.0001), 2 of its components (emotional exhaustion (F(1, 64) = 18.390, p < 0.0001) and depersonalization (F(1, 64) = 10.957, p < 0.002), alexithymia (F(1, 64) = 3.461, p < 0.0001) and perceived social support (F(1, 64) = 57.883, p < 0.0001), but not the scores of perceived stress and low personal accomplishment. Gender had an additional contribution in decreasing alexithymia (F(1, 64) = 7.436, p < 0.009) and increasing perceived social support (F(1, 64) = 15.426, p < 0.0001), with higher effects in men. Conclusions This study points to the potential usefulness of Balint training in addressing alexithymia and burnout, and in improving perceived social support among physicians working with palliative patients. As the Balint method is easily understood and does not require special investments, it could represent a cost-effective instrument of addressing job-related psychological risks. Int J Occup Med Environ Health. 2019;32(1):53–63

To investigate the current state of sedation, analgesia and blood glucose management in intensive care units (ICUs) of county hospitals in Guizhou Province of China, and to provide the evidences for improving quality control in critical care medicine.In March 2018, 3-4 ICUs of hospitals in every prefecture (one hospital per county) in Guizhou Province were visited to do the field survey. The patients' nursing records within 24 hours after ICU admission were reviewed, and the information such as gender, age, major diagnosis at the ICU admission, the time of admission, were collected. Moreover, the conditions about sedation and analgesia drug use and monitoring, blood pressure, blood glucose as well as and the usage of insulin and ventilator were recorded. Because not all the needed information of every ICU or patient was obtained, only the numbers of the ICUs and patients whose required information had been obtained were analyzed.Twenty-eight county hospitals in nine prefectures of Guizhou Province and 152 ICU patients were surveyed. There was a median of 5 (4, 7) patients stayed in every ICU on the day of survey. A total of 152 patients were enrolled, with 102 male (67.1%) and 50 female (32.9%); the median age was 65.0 (51.5, 74.8) years old; the major diagnosis at ICU admission was mainly cerebral diseases which accounted for 50.0% (76/152), and the second place was digestive system diseases which accounted for 13.8% (21/152); 53.8% (78/145) of patients were admitted to ICUs during 08:00-18:00. The percentages of ICUs which had patients received sedation and analgesia were 92.6% (25/27) and 88.9% (24/27) respectively, while only 44.4% (12/27) and 18.5% (5/27) of them were evaluated the depth of sedation and the level of pain respectively. There was 49.0% (71/145) of patients received sedation, and 33.8% (24/71) of them was evaluated by sedation scores; 49.7% (72/145) of patients received analgesia, and 13.9% (10/72) of them were evaluated by pain scores. The proportions of invasive mechanical ventilation in the patients with sedation or analgesia were both higher than those in the patients without sedation or analgesia [sedation compared with non-sedation: 85.9% (61/71) vs. 21.6% (16/74), analgesia compared with non-analgesia: 87.5% (63/72) vs. 19.2% (14/73), both P0.01]. The incidence of hypotension was similar between the sedated patients and the non-sedated patients [55.9% (38/68) vs. 40.3% (29/72), P0.05], while the incidence of hypotension was higher in the patients with analgesia as compared with that in the patients without analgesia with significant difference [56.9% (41/72) vs. 38.2% (26/68), P0.05]. Within 24 hours after ICU admission, there were 40.7% (59/145) and 5.5% (8/145) of patients had hyperglycemia (random blood glucose level ≥ 11.1 mmol/L) or hypoglycemia (random blood glucose level ≤ 3.9 mmol/L) respectively. No insulin was used to control the blood glucose level in the patients who had hypoglycemia or did not have hyperglycemia. However, only 23.7% (14/59) of patients with hyperglycemia were treated with insulin, the initiation of insulin therapy was triggered when median blood glucose level was 19.8 (16.8, 24.5) mmol/L.The evaluation of analgesia and sedation in the ICUs of county hospitals in Guizhou Province was seriously inadequate and needed to be strengthened urgently. Moreover, the strategy of blood glucose management was also needed to be improved.

Background The incidence of inappropriate admissions in China has become the shackle of its’ service supply system. This research aims to assess the level of children’s inappropriate admissions to county hospitals in rural China and identify the characteristics and determinants of children’s inappropriate admissions. Methods A retrospective review was conducted on data of children aged 0–14 years. A total of 771 children medical records in four county hospitals was collected by stratified random sampling in Midwestern China and was evaluated through the Rural Appropriateness Evaluation Protocol. A questionnaire survey was conducted among doctors whose names were shown in medical records. Chi-square test was used to analyse the characteristics of inappropriate admissions, and a binary logistic regression model was used to examine the determinants of inappropriate admissions. Results Inappropriate admissions indicate that patients who could have been treated as outpatients received services as inpatients. The average rate for inappropriate admissions of children in county hospitals was 61.35%. The highest rate of inappropriate admissions was found among children aged 1–5 years (68.42%). Inappropriate admissions mostly occurred in children with respiratory diseases (72.45%), circulatory diseases (72.22%) and certain infectious diseases and parasitic diseases (70.37%). Binary logistic regression analysis showed that county, normal health status, treating department, disease, the length of hospital stay and the doctor’s self-evaluation on the understanding about the degree of the patient’s feelings were determinants for children’s inappropriate admissions. Conclusions County hospitals have a high rate of inappropriate admissions of children. The relationship of children’s inappropriate admissions to age distribution and the insurance compensation is affected by disease and hospitalisation expenses, respectively. The determinants of children’s inappropriate admissions are directly related to the weak level of primary care services in the health service system, the initial requirements requested by children’s admission decision makers and the interests among medical institutions and doctors. Electronic supplementary material The online version of this article (10.1186/s12913-019-3944-1) contains supplementary material, which is available to authorized users.

Study Objective To determine follow-up rates for adolescent patients who underwent medical abortion compared with adult patients, identify patient factors associated with follow-up, and evaluate contraceptive choices at the time of follow-up. Design, Setting, and Participants A retrospective cohort study of adolescent patients (ages 15-19 years) who underwent first-trimester medical abortions at John H. Stroger, Jr. Hospital of Cook County from 2014 through 2017. Interventions None. Main Outcome Measures Rate of follow-up after medical abortion, demographic factors associated with higher follow-up rates, and contraceptive choices by adolescents at follow-up encounters. Results During the study period, 8111 medication abortions were performed in our clinic. Adolescents accounted for 446 of these patients (446/8111; 5.5%). Among adolescents, the follow-up rate was 231/446 (51.8%). We determined the follow-up rates among a random sample of patients ages 20-24 years (n = 494) and 25-39 years (n = 397) to be 213/494 (43.1%), and 161/397 (40.5%), respectively. African American adolescents were significantly less likely to follow-up compared with their Hispanic and white counterparts (relative risk, 0.76; 95% confidence interval, 0.66-0.89). Those enrolled in college were significantly more likely to follow-up compared with those who reported lower levels of education (relative risk, 1.4; 95% confidence interval, 1.0-1.9). Only 2.5% of adolescents reported ever using a tier 1 contraception option before presenting for an abortion and among those who did follow-up, only 18% chose a tier 1 option for ongoing pregnancy prevention. Conclusion Approximately half of our adolescent study population is at risk for undetected failed medical abortion and subsequent unplanned pregnancy.

To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting.Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval.All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria.The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment.The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.

Objective The universal genetic testing initiative (UGTI) is a quality improvement effort to increase rates of guideline-based genetic counseling (GC) and genetic testing (GT) of patients with potentially hereditary cancers. The UGTI was disseminated to a county hospital gynecologic oncology clinic that serves a diverse, indigent patient population. Methods Using the Model for Improvement quality improvement framework, interventions including integrated GC, clinic tracking, assisted GC referrals, and provider education were tested over 26 months. A retrospective data review included patients with high-grade, non-mucinous epithelial ovarian, fallopian tube, and primary peritoneal cancers (HGOC) and endometrial cancers (EC) diagnosed between 9/1/12–8/31/16. Statistical analyses were performed to describe the population and to evaluate rates of recommendation and use of immunohistochemistry tumor testing (IHC), GC, and GT. Results A cohort of 241 patients (57 HGOC, 184 EC) were included. At the conclusion of the study 84.2% of HGOC patients were referred for GC, 89.6% (43/48) completed GC, and 90.7% (39/43) completed GT. Of EC patients, 81.0% were recommended to have IHC and 62.4% (93/149) completed IHC. Patients with HGOC diagnosed during dissemination of UGTI were significantly more likely to receive a recommendation for GC (p = 0.02) and to complete GT (p = 0.03) than those diagnosed before UGTI. Patients with EC were significantly more likely to complete IHC if diagnosed after UGTI than those diagnosed prior to dissemination (p Conclusions The UGTI can be adapted to increase use of guideline-based cancer genetics services in a diverse, indigent, gynecologic cancer patient population.

Background Single disease payment program based on clinical pathway (CP-based SDP) plays an increasingly important role in reducing health expenditure in china and there is a clear need to explore the scheme from different perspectives. This study aimed at evaluating the effect of the scheme in rural county public hospitals within Anhui, a typical province of China,using uterine leiomyoma as an example. Methods The study data were extracted from the data platform of the New Rural Cooperative Medical Office of Anhui Province using stratified-random sampling. Means, constituent ratios and coefficients of variations were calculated and/or compared between control versus experiment groups and between different years. Results The total hospitalization expenditure (per-time) dropped from 919.08 ± 274.92 USD to 834.91 ± 225.29 USD and length of hospital stay reduced from 9.96 ± 2.39 days to 8.83 ± 1.95 days(P

Visual impairment is common among rural Chinese children, but fewer than a quarter of children who need glasses actually own and use them. To study the effect of rural county hospital vision centers (VC) on self-reported glasses ownership and wearing behavior (primary outcome) among rural children in China, we conducted a cluster-randomized controlled trial at a VC in the government hospital of Qinan County, a nationally-designated poor county. All rural primary schools (n = 164) in the county were invited to participate. Schools were randomly assigned to either the treatment group to receive free vision care and eyeglasses, if needed, or control group, who received glasses only at the end of the study. Among 2806 eligible children with visiual impairment (visual acuity &le, 6/12 in either eye), 93 (3.31%) were lost to follow-up, leaving 2713 students (45.0% boys). Among these, glasses ownership at the end of the school year was 68.6% among 1252 treatment group students (82 schools), and 26.4% (p &lt, 0.01) among 1461 controls (82 schools). The rate of wearing glasses was 55.2% in the treatment group and 23.4% (p &lt, 0.01) among the control group. In logistic regression models, treatment group membership was significantly associated with spectacle ownership (Odds Ratio [OR] = 11.9, p &lt, 0.001) and wearing behavior (OR = 7.2, p &lt, 0.001). County hospital-based vision centers appear effective in delivering childrens&rsquo, glasses in rural China.

In this article, we review the challenges and opportunities afforded by working in a government setting by providing the perspective of the Veterans Affairs experience as well as the county/public hospital experience from Los Angeles County Department of Health Services. This article highlights processes and services that are unique to practicing rheumatology in a government setting, specifically, resource allocation with clinic space and staffing; protocols for access to conventional and biologic disease modifying antirheumatic drugs; and research opportunities for rheumatologists working in a government setting. Our aim is to expand the reader's understanding of this practice setting.

To investigate the risk factors of ventilator-associated pneumonia (VAP) and the distribution and drug resistance of pathogens in intensive care unit (ICU) of county hospital.234 patients on mechanical ventilation for more than 48 hours admitted to ICU of Shexian People's Hospital of Huangshan City from January 2016 to June 2018 were enrolled. The clinical data of all patients including gender, age, past medical history, exposure to antibiotics, medication, the duration of mechanical ventilation, the length of ICU stay, serum albumin, tracheotomy, re-intubation, prognosis, and pathogenic bacteria and drug sensitivity test of VAP patients were collected. The patients were divided into VAP group and non-VAP group according to the occurrence of VAP. The differences of each index between the two groups were compared. The risk factors of VAP were analyzed by multivariate Logistic regression. The distribution and drug resistance of pathogenic bacteria in sputum culture of lower respiratory tract of VAP patients were analyzed.Among the 234 patients on mechanical ventilation, 95 patients had VAP, and the incidence of VAP was 40.60%. (1) Risk factors of VAP: it was shown by univariate analysis that there were significant differences between VAP patients and non-VAP patients in past history, the duration of mechanical ventilation, the length of ICU stay, albumin28 g/L, antibiotic exposure and tracheotomy, but there were no significant differences in gender, age, glucocorticoid, sedative, gastric motility and coma between the two groups. It was shown by multivariate Logistic regression analysis that brain injury and cerebrovascular accident, the duration of mechanical ventilation7 days, albumin28 g/L and tracheotomy were independent risk factors for VAP occurrence [brain injury: odds ratio (OR) = 41.40, 95% confidence interval (95%CI) = 2.14-799.60, P = 0.014; cerebrovascular accident: OR = 36.07, 95%CI = 1.86-699.64, P = 0.018; the duration of mechanical ventilation7 days: OR = 1.23, 95%CI = 1.11-1.36, P0.001; albumin28 g/L: OR = 2.27, 95%CI = 1.03-5.01, P = 0.042; tracheotomy: OR = 3.33, 95%CI = 1.30-8.56, P = 0.012]. (2) Distribution and drug resistance of VAP pathogens: a total of 108 strains of pathogens were isolated from sputum samples of 95 patients with VAP. Gram-negative (GVAP was associated with brain injury and cerebrovascular accident, duration of mechanical ventilation7 days, albumin28 g/L and tracheotomy. VAP patients were infected mainly with G

Objective: The aim of this work was to investigate the prevalence of premature thelarche (PT) in 18-month-old girls, and the incidence of clinically evaluated PT for girls aged 18–36 months. Methods: In the prevalence substudy, a prospective population-based cohort of 3,140 girls born at Northern Älvsborg county hospital (NÄL) in Trollhättan, Sweden, was followed for 2 years. Girls with breast development at the 18-month health check were referred to one pediatric center in NÄL for evaluation. All girls with PT were included and followed for clinical outcome and 17β-estradiol. The prospective incidence substudy covered 8 years in a 10-year period and included all girls aged 18–36 months born at NÄL who were clinically evaluated for PT. Results: The prevalence of PT at 18 months in our cohort was 1.6/1,000. The 5 girls with PT no longer showed symptoms at the follow-up 3–6 months later. The incidence was 1.1/1,000 for girls aged 18–36 months and 1.0/1,000 for girls aged 18–30 months who were clinically evaluated for their PT. Conclusion: This is the first prospective population-based study of PT and it shows a prevalence of PT at age 18 months of 1.6/1,000. The incidence of clinically evaluated PT was 1.1/1,000. Our result is in line with other studies reporting the incidence of PT from medical records (0.4–40/1,000). The outcome of PT in our study, as in the other studies, is that the great majority of girls show only benign symptoms.

Background Changes in the national drug policy always have impact on the drug utilization. In the context of China health care reform, what changes had happened in the trend of drug utilization in public hospitals? Has this change met the expectations of policy design? This study was conducted to explore the trend of medicine consumption in county public hospitals before and after health care reform, and to provide real-world evidence to help assess the effectiveness of national drug policy. Methods A cross-sectional study was performed to investigate the drug utilization trends of 6 county public hospitals in Anhui Province, which is the first pilot area of China health care reform. Data were collected before and after the implementation of the China National Essential Medicine Policy (NEMP) to analyse the drug utilization indicators, such as the drug utilization constituent ratio, the rate of essential medicine usage and the rate of antibiotic consumption. Results Chemicals are used most frequently and account for 60%~ 70%, followed by oral agents of proprietary Chinese medicine. The results also show increased consumption of Chinese medicine injections (χ 2 = 28.428, P

Background and objectives: Many pediatric patients have been treated with antibiotics during their hospitalization. There is a need to improve antibiotic prescribing for pediatric patients because many of these prescriptions are inappropriate. Antibiotic consumption analysis was conducted at the Children&rsquo, s Clinical University Hospital to identify targets for quality improvement. Materials and Methods: A one day cross-sectional point prevalence survey (PPS) was conducted in May and November 2011&ndash, 2013 using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antibiotic treatment on the day of survey. Total consumption of systemic antibiotics belonging to the ATC J01 class (except amphenicols (J01B) and a combination of antibacterials (J01R)) was also analyzed by using a defined daily dose (DDD) approach and antibiotic drug utilization (90%DU) for the period 2006&ndash, 2015. Results were compared with results in 2017 using the DDD and 90%DU methodology. Results: The most commonly used antibiotic group in all PPS, except in May and November 2011, was other &beta, lactam antibiotics (J01D): 42 (40%) prescriptions in May 2013 and 66 (42%) and November 2011. In 2006&ndash, 2015 and also in 2017, the most commonly used antibiotic groups were penicillins (J01C) and other &beta, lactam antibiotics (J01D)&mdash, 76% (90%DU) of the total antibiotic consumption registered in 2006, 73% in 2015 and 70% in 2017. Starting in 2008, amoxicillin was the most commonly used antibiotic at the hospital. The usage of ceftriaxone increased from 3% in 2006 to 13% in 2015, but decreased in 2017 (7%). Conclusions: Study results from 2006&ndash, 2015 showed that there was a need to establish a stronger antibiotic prescribing policy in the hospital reducing the use of broad-spectrum antibiotics (especially 3rd generation cephalosporins) and increasing the use of narrower spectrum antibiotics. It was partly achieved in 2017 with some reduction in ceftriaxone use.

ObjectiveThe lack of coordinated and appropriate healthcare across sectors has produced more patients for county hospitals in China. This study examined differences in patient choice between township and county hospitals for readmission after a first township hospitalisation, and the determinants that influenced this choice.DesignA retrospective study of readmissions across hospitals after a first admission in township hospital. A township–township (TT) inpatient group and a township–county (TC) inpatient group were compared. A two-level logistic regression model was used to examine the determinants of choice for hospital readmission.SettingData were drawn from a population-based health utilisation database for Qianjiang District, China, from 1 January 2008 to 31 December 2013.ParticipantsThis study focused on readmitted patients whose first admission was in a township hospital. Readmission cases were identified as the same diagnosis (International Classification of Diseases, Tenth Revision) in a subsequent hospitalisation within 30 days. In total, 6764 readmissions had first admissions in township hospitals.Primary outcome measuresPatient choice for hospital readmission after a first township hospitalisation.ResultsThe TT group accounted for 62.5% (4225) and the TC group for 37.5% (2539) of readmissions in 6 years, and the proportion of TC readmissions in total inpatients increased from 1.66% to 1.89%. Readmission rates varied among towns (pConclusionsPatients whose first admission was in a township hospital were more likely to be readmitted to a county hospital. A combination of first LOS and interval between admissions may be an effective identification index for TC readmission.Trial registration numberChiCTR-OOR-14005563.

Workplace violence (WPV) against health workers is a public concern worldwide. Yet little is known about WPV in Chinese county level hospitals and its risk factors. The current study aimed to examine the prevalence of and the risk factors of WPV in county hospitals. A total of 1,388 health workers were interviewed in eight county hospitals in four counties of Zhejiang Province. Results indicated that 7.8% of participants suffered physical attacks and 21.2% suffered physical threats, 51.6% experienced or witnessed Yi Nao (medical disturbance created by gangs using extreme means to obtain compensation from a hospital) at least once in the past year. Physical attacks were seen significantly more in physicians (10.9%) than in nurses (5.9%). Physicians were threatened at 27.1%, followed by nurses at 20.2%. Compared with general medicine, health workers working in emergency were significantly more likely to suffer physical attacks (odds ratio [OR] = 2.7, 95% confidence interval [CI] = [1.4, 5.2], p < .01) and WPV (physical attacks or threats; OR =2.5, 95% CI = [1.6, 4.1], p < .001). Being encouraged to tolerate WPV was correlated with physical attacks (OR = 6.1, 95% CI = [3.5, 10.4], p < .001) and WPV (OR = 6.7, 95% CI = [4.6, 9.8], p < .001). Health workers in county hospitals were vulnerable to encounter WPV. This highlights the need for a focused systematic prevention concerning health workers’ safety and governmental regulations and the need for hospitals to encourage their employees to report the WPV.

Study Objective To evaluate the prevalence of anemia among female adolescents and young adults seeking abortion care at a county hospital, and to determine its associated factors. Design A cross-sectional retrospective study. Setting John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois. Participants Young women (N = 2916; ages 11-24 years) who underwent first trimester medical or surgical termination in 2016. Interventions and Main Outcome Measures Hemoglobin concentration at time of presentation, age, gestational age, body mass index, race/ethnicity, education, sexually transmitted infection status, and insurance status. Results On average, women were 21 (SD, 2.2) years old, 87% (2545 of 2916) African-American, and 64% (1863 of 2916) were Medicaid recipients. Gestational age at time of presentation ranged from 4 weeks 6 days to 13 weeks 6 days, and 58% (1695 of 2916) had surgical termination. Overall, 16% (451 of 2916) had hemoglobin concentrations of less than 11 g/dL. Categorization of severity showed that 4% (126 of 2916) of women had moderate and 11% (325 of 2916) had mild anemia. Only 2.6% of women (75 of 2916) had any history of anemia, and 91% (412 of 451) of anemic women did not have a preexisting anemia diagnosis. Fifteen percent of anemic women (51 of 451) had positive sexually transmitted infection screening, but positive status was not associated with anemia in crude or multivariable models (P = .4-.6). In a multivariable model, later gestational age, decreasing body mass index, and multiparity were significantly associated with anemia prevalence after adjustment. Conclusion Our study showed an elevated prevalence of undiagnosed anemia. Ultimately, the abortion care setting can be an intersection for continued ambulatory care and provides an important opportunity to diagnose and educate young women on anemia management.

This study examined the representativeness of the County Health Rankings and Roadmaps (CHR) measure of potentially preventable hospitalizations, which is derived from Medicare inpatient claims data, as an indicator of potentially preventable hospitalizations for adults aged ≥18 years. Potentially preventable hospitalizations were evaluated using rates of ambulatory care sensitive conditions (ACSCs). CHR rates of hospitalization for ACSCs based on Medicare data for 2010, Agency for Healthcare Research and Quality Prevention Quality Indicator #90 Overall Composite (PQI #90 Composite) rates of ACSCs based on hospital inpatient data for adults aged ≥18 years for 2011, and 2011 total mortality rates for adults aged ≥18 years for 212 counties in 3 US states were evaluated. Pearson correlation analyses were used to assess the linear association between the PQI #90 Composite and CHR rates of hospitalization for ACSCs as well as associations of these measures with total mortality. Steiger's Z-test was conducted to examine whether the PQI #90 Composite and CHR measures of health care quality were similarly correlated with total mortality. The age- and sex-adjusted PQI #90 Composite for adults ≥18 years was moderately correlated with the CHR rate of hospitalization for ACSCs. The PQI #90 Composite and CHR measures of hospitalization for ACSCs were similarly correlated with mortality. These findings suggest that in the absence of easily accessible, high-quality data for adults aged ≥18 years, the CHR measure of potentially preventable hospitalizations provides a modest but acceptable approximation of county-level disparities in potentially preventable hospitalizations for the US adult population.

BACKGROUND: Physicians widely prescribe benzodiazepines (BZD) despite well-recognized harms. OBJECTIVE: To determine county and provider characteristics that predict high-intensity BZD prescribing by primary care physicians (PCPs) to Medicare beneficiaries. DESIGN: Cross-sectional analysis of the 2015 Medicare Part D Public Use Files (PUF). SUBJECTS: n = 122,054 PCPs who prescribed 37.3 billion medication days. MAIN MEASURES: Primary outcome was intensity of BZD prescribing (days prescribed/total medication days) at the county- and physician levels. PCP and county characteristics were derived from the Part D PUF, Area Health Resources Files, and County Health Rankings. Logistic regression determined the characteristics associated with high-intensity (top quartile) BZD prescribing. KEY RESULTS: Beneficiaries were prescribed over 1.2 billion days of BZD in 2015, accounting for 2.3% of all medication days prescribed in Part D. Top quartile counties had 3.1 times higher BZD prescribing than the lowest (3.4% vs. 1.1%; F = 3293.8, df = 3, p

Despite international efforts to increase performance of laparoscopic cholecystectomy (LC) in rural Guatemala, the vast majority of cholecystectomies are still performed via the open cholecystectomy (OC) approach. Our goal was to explore barriers to the adoption of LC in Guatemala as well as possible mechanisms to overcome them. We reviewed 9402 cholecystectomies performed over 14 years by surgeons at the Hospital Nacional de San Benito (HNSB) in El Peten, Guatemala, with either an open or a laparoscopic approach. We conducted personal interviews with all the surgeons who perform cholecystectomies at HNSB to determine current practice and barriers to adopting LC. Overall, seven general surgeons were interviewed who regularly perform cholecystectomy. Of the total number of cholecystectomies reviewed, 8440 (90%) were open and 962 (10%) were laparoscopic. The mean number of cholecystectomies performed per surgeon was 1341.1 ± 1244.9, with OC at 1205.7 ± 1194.9, and LC at 137.4 ± 188.0. Lack of formal training in laparoscopy was identified in 57% of surgeons. Lack of government funds to implement a laparoscopic program was noted by 71% of surgeons (29% felt there was insufficient ancillary staff, 29% poor allocation of hospital funding to purchase laparoscopic equipment/training). Lack of sufficient laparoscopic equipment was identified by 71% of surgeons. Ninety percent of cholecystectomies performed by surgeons at HNSB continue to be OC. The major limitation is the lack of funding to provide sufficient equipment or ancillary staff. The majority of surgeons preferred to perform LC if these problems could be addressed.