Essays on long-term care and hospital care

This thesis consists of four empirical essays, contributing to the understanding of key policy issues related to the maximisation of the efficiency of health care provision. Two policy areas are considered and the English NHS is used as a case study throughout. Chapters 2-4 contribute to a growing literature around the interface between acute hospital care and long-term care. This is closely related to the debate around integrating care. Chapter 2 evaluates the impact of long-term care supply on the discharge destination and hospital length of stay of hip fracture and stroke patients. The results indicate hospital stays are shorter for hip fracture patients when nearby care-home bed supply is high. No effect of care-home beds is found for the length of stay of stroke patients or the discharge destination of either patient group. Chapter 3 models delayed discharges from hospital across local government areas (Local Authorities). The findings suggest there are fewer delays in Local Authorities with more care-home beds. Further, higher care-home bed supply and lower population in neighbouring Local Authorities also leads to fewer delayed discharges in the local area. Chapter 4 evaluates the impact of hospital characteristics on delayed hospital discharges. The results indicate that hospitals with more autonomy and a proven track record of good performance incur fewer delayed discharges. The second policy area considered is the use of financial incentives to encourage a shift in patient care expected to improve efficiency. Chapter 5 evaluates a policy of paying hospitals a higher rate for same day discharges than overnight stays when treating specific conditions. The results indicate some positive effects from the policy introduced. Same day discharge rates are higher for eight out of 32 conditions. Considerable heterogeneity in response is also observed, some of which might be driven by features of the conditions

Environmental persuasion and Roman Catholic Church interior design after Vatican Council II, 1963-present: A case study of Notre Dame Chapel, Omaha, Nebraska

For an environment to produce a change in attitude, or at least begin that transformation, it is necessary to view it as part of the communication/persuasion process. Environments both reflect communication and modulate it, channel it, control it, facilitate it, or even inhibit it (Rapoport, 1982). Environmental meaning is often expressed through signs, materials, colors, forms, sizes, furnishings, landscaping, maintenance, and even in some instances, by people themselves (Bachelard, 1969; Blomeyer, 1979; Cralik, 1976). Therefore, spatial meanings or messages can be conveyed by walls or other sharp breaks, or by transitions (Reed, 1974). Thus, environment can produce a sense of belonging (Brebner, 1982) which adds to the comfort felt in the milieu. All people seem to share a need for comfort in their environment, but it is significant that people seem to define comfort or belonging according to perceptual filters that are definitely their own (Broadbent, Bunt, and Jencks [Eds.J, 1980)

Coronary artery bypass grafts and diagnosis related groups: patient classification and hospital reimbursement in 10 European countries

The prospective reimbursement of hospitals through the grouping of patients into a finite number of categories (Diagnosis Related Groups, DRGs), is common to many European countries. However, the specific categories used vary greatly across countries, using different characteristics to define group boundaries and thus those characteristics which result in different payments for treatment. In order to assist in the construction and modification of national DRG systems, this study analyses the DRG systems of 10 European countries

Why do patients having coronary artery bypass grafts have different costs or length of stay? : An analysis across ten European countries

We analyse variations in costs or lengths of stay (LoS) for 66,587 patients from ten European countries receiving a coronary artery bypass graft (CABG) procedure. In five of these countries, variations in cost are analysed using log-linear models. In the other five countries, negative binomial regression models are used to explore variations in LoS. We compare how well each country’s Diagnosis Related Group (DRG) system and a set of patient-level characteristics explain these variations. The most important explanatory factors are the total number of diagnoses and procedures, although no clear effects are evident for our CABG-specific diagnostic and procedural variables. Wound infections significantly increase length of stay and costs in all countries. There is no evidence that countries using larger numbers of DRGs to group CABG patients were better at explaining variations in cost or LoS. However, refinements to the construction of DRGs to group CABG patients might recognise first and subsequent CABGs or other specific surgical procedures, such as multiple valve repair

Why are there long waits at English Emergency Departments?

A core performance target for the English National Health Service (NHS) concerns waiting times at Emergency Departments (EDs), with the aim of minimising long waits. We investigate the drivers of long waits. We analyse weekly data for all major EDs in England from April 2011 to March 2016. A Poisson model with ED fixed effects is used to explore the impact on long (> 4 hour) waits of variations in demand (population need and patient case-mix) and supply (emergency physicians, introduction of a Minor Injury Unit (MIU), inpatient bed occupancy, delayed discharges and long-term care). We assess overall ED waits and waits on a trolley (gurney) before admission. We also investigate variation in performance among EDs. The rate of long overall waits is higher in EDs serving older patients (4.2%), where a higher proportion of attendees leave without being treated (15.1%), in EDs with a higher death rate (3.3%) and in those located in hospitals with greater bed occupancy (1.5%). These factors are also significantly associated with higher rates of long trolley waits. The introduction of a co-located MIU is significantly and positively associated with long overall waits, but not with trolley waits.. There is substantial variation in waits among EDs that cannot be explained by observed demand and supply characteristics. The drivers of long waits are only partially understood but addressing them is likely to require a multi-faceted approach. EDs with high rates of unexplained long waits would repay further investigation to ascertain how they might improve

Long-term care provision, hospital bed blocking, and discharge destination for hip fracture and stroke patients

We examine the relationship between long-term care supply (care-home beds and prices) and (i) the probability of being discharged to a care home and (ii) length of stay in hospital for patients admitted to hospital for hip fracture or stroke. Using patient level data from all English hospitals and allowing for a rich set of demographic and clinical factors, we find no association between discharge destination and long term care beds supply or prices. We do, however, find evidence of bed blocking: hospital length of stay for hip fracture patients discharged to a care home is shorter in areas with more long-term care beds and lower prices. Length of stay is over 30% shorter in areas in the highest quintile of care home beds supply compared to those in the lowest quintile

Productivity of the English National Health Service : 2017/18 update

This report updates the Centre for Health Economics’ time-series of National Health Service (NHS) productivity growth for the period 2016/17 to 2017/18. NHS productivity growth is measured by comparing the growth in outputs produced by the NHS to the growth in inputs used to produce them. NHS outputs include all the activities undertaken for NHS patients wherever they are treated in England. It also accounts for changes in the quality of care provided to those patients. NHS inputs include the number of doctors, nurses and support staff providing care, the equipment and clinical supplies used, and the facilities of hospitals and other premises where care is provided

Transcriptomic comparison of invasive bigheaded carps (\u3ci\u3eHypophthalmichthys nobilis\u3c/i\u3e and \u3ci\u3eHypophthalmichthys molitrix\u3c/i\u3e) and their hybrids

Bighead carp (Hypophthalmichthys nobilis) and silver carp (Hypophthalmichthys molitrix), collectively called bigheaded carps, are invasive species in the Mississippi River Basin (MRB). Interspecific hybridization between bigheaded carps has been considered rare within their native rivers in China; however, it is prevalent in the MRB. We conducted de novo transcriptome analysis of pure and hybrid bigheaded carps and obtained 40,759 to 51,706 transcripts for pure, F1 hybrid, and backcross bigheaded carps. The search against protein databases resulted in 20,336–28,133 annotated transcripts (over 50% of the transcriptome) with over 13,000 transcripts mapped to 23 Gene Ontology biological processes and 127 KEGG metabolic pathways. More transcripts were detected in silver carp than in bighead carp; however, comparable numbers of transcripts were annotated. Transcriptomic variation detected between two F1 hybrids may indicate a potential loss of fitness in hybrids. The neighbor-joining distance tree constructed using over 2,500 one-to-one orthologous sequences suggests transcriptomes could be used to infer the history of introgression and hybridization. Moreover, we detected 24,792 candidate SNPs that can be used to identify different species. The transcriptomes, orthologous sequences, and candidate SNPs obtained in this study should provide further knowledge of interspecific hybridization and introgression

Survival in Patients Receiving Prolonged Ventilation: Factors that Influence Outcome

Background Prolonged mechanical ventilation is increasingly common. It is expensive and associated with significant morbidity and mortality. Our objective is to comprehensively characterize patients admitted to a Ventilator Rehabilitation Unit (VRU) for weaning and identify characteristics associated with survival. Methods 182 consecutive patients over 3.5 years admitted to Temple University Hospital (TUH) VRU were characterized. Data were derived from comprehensive chart review and a prospectively collected computerized database. Survival was determined by hospital records and social security death index and mailed questionnaires. Results Upon admission to the VRU, patients were hypoalbuminemic (albumin 2.3 ± 0.6 g/dL), anemic (hemoglobin 9.6 ± 1.4 g/dL), with moderate severity of illness (APACHE II score 10.7 + 4.1), and multiple comorbidities (Charlson index 4.3 + 2.3). In-hospital mortality (19%) was related to a higher Charlson Index score ( P = 0.006; OR 1.08-1.6), and APACHE II score ( P = 0.016; OR 1.03-1.29). In-hospital mortality was inversely related to admission albumin levels ( P = 0.023; OR 0.17-0.9). The presence of COPD as a comorbid illness or primary determinant of respiratory failure and higher VRU admission APACHE II score predicted higher long-term mortality. Conversely, higher VRU admission hemoglobin was associated with better long term survival (OR 0.57-0.90; P = 0.0006). Conclusion Patients receiving prolonged ventilation are hypoalbuminemic, anemic, have moderate severity of illness, and multiple comorbidities. Survival relates to these factors and the underlying illness precipitating respiratory failure, especially COPD

Testing the bed-blocking hypothesis : does higher supply of nursing and care homes reduce delayed hospital discharges?

Hospital bed blocking occurs when hospital patients are ready to be discharged to a nursing home but no place is available, so that hospital care acts as a more costly substitute for long-term care. We investigate the extent to which higher supply of nursing home beds or lower prices can reduce hospital bed blocking. We use new Local Authority level administrative data from England on hospital delayed discharges in 2010-13. The results suggest that delayed discharges do respond to the availability of care-home beds but the effect is modest: an increase in care-homes bed by 10% (250 additional beds per Local Authority) would reduce delayed discharges by about 4%-7%. We also find strong evidence of spillover effects across Local Authorities: higher availability of care homes or fewer patients aged over 65 in nearby Local Authorities are associated with fewer delayed discharges