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A quantitative comparison of cost efficiency between a public hospital and a private hospital in New Zealand and a qualitative analysis of efficiency from the perspective of dual practitioners

Over the last century there has been a significant improvement in the provision of health care services by both the public and private hospitals. There has been improvements in technology and knowledge in medicine, better allocation of resources and also a better understanding of health economics.

In New Zealand, a dual health care system exists to provide health care services. A public system provides health care to all New Zealanders, free of charge. It is operated and funded by the local District Health Boards (DHBs), whose funds are set via a population-based principle and distributed by the Ministry of Health (MOH). Alongside the public health system is a private system that provides more elective and non-acute services. Private organizations operate on a fee-for-service basis, whereby the patient or private insurer pays.

Though both hospital systems are expected to be level with each other, there exists the assumption amongst the general population that private hospitals are more efficient than public hospitals. This is based on the theory that “in a competitive market, providers are more likely to be efficient because they have an incentive to drive down costs in order to maintain profits.”1,2 In addition recent estimates reported private hospitals in New Zealand performing around 150,000 elective surgical procedures per year, whilst public hospitals performed only around 120,000 elective operations per year3. So the superiority of one system over the other has been a topic of debate for many years.

Recent estimates report the health care cost in New Zealand for the year 2009/10 totaled up to $12.6 billion, and the May 2011 forecast estimated that the cost for the year 2011/12 is likely to reach $13.7 billion. To try and reduce the costs, the health-care system in New Zealand is undergoing a series of cutbacks4. However, it proves a struggle to meet the steadily growing demand for high-quality health care services and keep it free of charge to the population. Though the demand for elective surgeries has increased, the growth in elective services available has not been proportional in the public health sector. This has led to an increase in waiting list times and delays in the provision of health care services. Reports released by the New Zealand government reported that throughout New Zealand, across a broad range of specialties, 2371 patients had waited longer than six months for their first specialist assessments. As well as 2161 patients who were planned for a specific treatment, but had not received their treatment within six months5.

Our study objectives were to determine whether the private health sector was indeed more efficient than the public health sector and if so, identify areas of efficiency in the private health sector that could be applied to the public health sector to improve performance and throughput.  To determine whether the private health sector is more efficient, we will attempt to analyze and compare the costs of specific procedures (i.e. laparoscopic cholecystectomy, total hip replacement and tonsillectomy with adenoidectomy) between the public and private hospital; as well as look at specific variables such as operation time, post-operative recovery time, and length of stay. In addition, to identify areas for improvement in the public health sector we will interview dual practitioners, who have experience in both public and private hospitals who may offer insight into possible areas of improvement.

Authors of Report

Katie Barrett, Umayr Hassan, Ridzuan Ismail, Guy Kibby, Joanna Ly, Pei Yee Onn, Tony Ryu, Sartika Broto Suharjo, Brighton Tsai.

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Patterns Of ED Use Among Young People In Dunedin: Long-Term Trends And Impacts Of Student Drinking Events

The consequences of the student drinking culture in Dunedin are well publicised in the media, particularly when associated with specific ‘drinking events’ such as the Hyde Street Keg Party or the Toga Party during Orientation week. These reports support the view that there are high levels of youth binge drinking in the city.  

It is well known that New Zealand has a pervasive culture of drinking to excess. The Law Commission’s 2010 submission stated that 25% of drinkers (700,000 New Zealanders) typically drink large quantities when they drink. They found that 60% of drinkers had consumed enough to feel drunk in the last 12 months; 12% felt drunk one to three times a month and 10 percent felt drunk at least weekly. Of this last group, 18-24 year old men are disproportionately represented, with 33% reporting drinking enough to feel drunk at least weekly [1].

These figures come despite common knowledge of harms associated with over-consumption and binging (greater than six units per drinking session for males older than 18 and greater than four units for females) of alcohol [2].

Authors of Report

Yun Kern Chai, Lukas Frei, Han Jiang, Gareth Keat, Tim Lequeux, Rachel Lister, Hemanth Subramaniam, Nemi Turakhia.

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The Clinical Utility of Capsule Endoscopy, Magnetic Resonance Enterography and Enteroclysis in Dunedin Public Hospital

Objectives

The objective of our study was to investigate the effectiveness of Capsule Endoscopy (CE), Magnetic Resonance Enterography and Enteroclysis (MR) in small bowel disease. Firstly, diagnostic accuracy was evaluated by using diagnostic yield, sensitivity and consistency of findings. Secondly, the influence on patient management was evaluated by determining changes in management, the association between investigation findings and management, and the association between investigational diagnoses and management.

Methods

The study was a retrospective audit of CE and MR investigations performed in Dunedin Public Hospital between 27/11/2008 and 17/02/2011. A total of 45 CE and 77 MR patients were included. Patient data was collected from medical records with the use of a standardised data extraction form. The data was then statistically analysed.

Results

The diagnostic yield was 73.3% for CE and 82.9% for MR. For a subset of MR patients who underwent surgery, sensitivity of MR was 89.0% and consistency of MR findings to surgical findings was 75.2%. Overall, 24.4% of CE patients and 54.4% of MR patients had a change in management plan. No significant associations between either CE findings or diagnosis and management were found because of small patient numbers and lack of follow-up information. A significant association was found for changes in type of medication for the MR findings of moderate enhancement OR=8.05 (CI=2.04,31.86) and fistulas OR=7.48, (CI=1.77,31.67). A significant association was found for surgical management for the MR findings of strictures OR=6.4 (CI=1.63,25.1) and scarring OR=12.8 (CI=2.20,74.3). Following MR, a significant association was found for a change in medical type for the diagnosis of acute Crohn’s Disease OR=13.5 (CI=2.58,70.7) and fibrotic Crohn’s Disease OR=10.4 (1.80,65). There was also a significant association between surgical management and the diagnosis of fibrotic Crohn’s Disease OR=8.0 (CI=2.16,29.6).

Conclusions

CE was effective in terms of diagnostic accuracy but inconclusive in the influence on patient management because of missing data on outcomes. MR was effective in terms of both diagnostic accuracy and influence on patient management.

Authors of Report

Yu Kai Lim, William Lu, Anita Tong, Han Joon Choi, Joshua Tang, Lisa Kaan, Varun Desai, James Slater, Sharafuddin Shah.

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The Drunk Elephant in the room Alcohol and the Emergency Department: Testing a data collection system

Introduction

Alcohol causes harm. This fact is now well known throughout the word, yet alcoholic beverages are still a common part of today's society. We seem to continue to ignore the harm that it is doing to us, and only look at the social benefits that we might gain from it.

Aim

To develop a pilot study for collection of alcohol related data in the emergency department, and implement it in the Emergency department of Kew Hospital, Invercargill.

Method

After a review of the literature two questions were developed – “Is this presentation related to alcohol?” and “Have you consumed alcohol in the last twenty four hours?” These two questions were asked by clinical staff in the Emergency Department of Kew Hospital over a one week period. The collected data was then analyzed.

Results

There were 644 presentations to the Emergency department of which 612 had both questions completed. 48 different staff members inputted data of which only 5 entered incomplete data. There were 3.27% (20) presentations related to alcohol and 6.37% of people had consumed alcohol in the previous 24 hours.

Conclusion

This study has developed a workable system for collecting alcohol data in the Emergency department setting. With a few adjustments, this system can be implemented long term.

Authors of Report

Nadine Stringer, Katie Woodhouse, Simon Rankin, Tori Blank.

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The synchronisation of patient journeys between the Emergency Department and receiving departments in Dunedin hospital

Objectives

The aims of this study were 1) to determine the perceptions of key personnel on the causes of, and potential solutions to, delays in transferring patients from the Emergency Department (ED) to inpatient wards, and 2) to identify demographic, ED and hospital factors associated with a greater transfer time.

Methods

This was a cross-sectional study with two arms; the first involving structured interviews completed by clinical charge nurses in 15 inpatient wards at Dunedin Public Hospital, as well as the head orderlie, and the second involving extracting routinely-recorded, retrospectively-collected data on factors that could contribute to delays in transferring patients from ED to inpatient wards, and, using a uni-variate analysis, comparing these with the admission cycle time (the time from decision to admit each patient until their arrival on the ward) to establish any significant associations.

Results

Inadequate staffing both in ED and on the receiving wards, insufficient number of inpatient beds and delayed discharge of inpatients were the most commonly identified causes of delays in patient transfer according to staff surveys. Potential solutions identified included increasing the number of nursing staff accompanying patients in transit and creating transitional areas for stable patients who are awaiting admission or discharge adjacent both ED and the receiving wards, respectively. From the data accessed on 1060 patients admitted via ED during March 2011, admission cycle time (ACT) was statistically and clinically significantly associated with source of referral, day of arrival, arrival period, number of ambulances arriving during the patient’s ED stay, daily hospital occupancy and percentage of ED patients admitted to hospital (p<0.05), while receiving ward occupancy was not significantly associated with ACT.

Conclusions

Several patient-, staff- and hospital-related factors were identified through staff surveys and data analysis as associated with, and potentially causative of, delays in patient transfer from ED to the inpatient wards. These are potential targets in attempting to better understand and improve patient flow from ED to the hospital, and thus reduce ED overcrowding.

Authors of Report

Julius Glasson, Kirollos Kamel, Geoffrey Manins, Steven Murugayah, Heidi Perkins, Yi Shen, Annika Sjoeholm, Sharon Tay, Vicky Yin.

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Timeliness of delivering adjuvant chemotherapy in resected stage III colorectal cancer

Context

New Zealand has one of the world’s highest rates of colorectal cancer. It has long been known that adjuvant chemotherapy improves survival in patients with colorectal cancer, and is generally given around 8 weeks post-surgery. Recent evidence suggests that receiving adjuvant chemotherapy at 4 weeks post-surgery improves outcomes.

Objective

To identify the steps in the current pathway from surgery to chemotherapy for patients with resected stage III colorectal cancer in Dunedin and Invercargill Public Hospitals, and to identify the median time from surgery to initiation of adjuvant chemotherapy, and other key time intervals. We then aim to identify factors implicated in possible delays and provide recommendations that will act to improve the current system, shortening the time from surgery to initiation of adjuvant chemotherapy.

Methods

Interviews were carried out with key people in the services involved in the pathway from surgery to chemotherapy. The NHI numbers of patients with stage III colorectal cancer who had received chemotherapy between 1/1/09 and 31/3/11 were obtained from Dunedin and Invercargill Public Hospitals. Dates were collected for key steps along the pathway from surgery to chemotherapy.

Results

63 patients were included in this study. Median time from surgery to chemotherapy was 56 days in Dunedin and 60 days in Invercargill. 2% of patients received chemotherapy by 4 weeks post-surgery. Patients without surgical complications received chemotherapy only one day earlier than those with complications.

Conclusions

Delays are largely due to health system factors rather than patient factors such as surgical complications. Key areas of delay were identified in referrals, pathology reporting, CT imaging and the oncology specialist appointment. Recommendations addressing these issues are discussed.

Authors of Report

Lewis Agius, Jeremy Bates, Adam Chen, YanYi Chuah, Andrew Gemmell, Jun Kwon, Sean Lance, Saleh Mohammed, Sophie Parker, Jared Williams, Logan Wingate, Briary Zachernuk.

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