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OBJECTIVE: To assess maternal and neonatal clinical short-term outcomes and women's experiences with singleton low-risk in-hospital deliveries in a routine care setting. METHODS: In 13 community hospitals in the Cantons of Zurich (10), St. Gallen (2) and Schwyz (1), participating in the "Canton of Zurich Outcomes Project", trained hospital staff recorded clinical outcome data. Patients completed a questionnaire at the end of the hospital stay. Over two measurement cycles, 3395 eligible women entered the study and 2079 (61%) returned the questionnaire. RESULTS: Sixty-seven percent of women had spontaneous and 11% had assisted vaginal deliveries, 12% delivered by emergency, and 10% by elective Caesarean section. The episiotomy rate in vaginal deliveries was 46% (95% CI 44-48%). Ten percent of neonates had umbilical cord artery pH < or =7.15 (95% CI 9-11%) and Apgar scores at five minutes were < or = 7 in 3% (95% CI 2.5-3.6%). Reporting negative experiences with hospital care and an insufficient state of knowledge at discharge were strongly associated with mode of delivery. The top three issues new mothers were most likely to report about feeling little or not informed about were postpartum pelvic floor exercises (22%), management of vaginal bleedings (12%), and alternatives of infant feeding (10%). CONCLUSION: In a setting of routine care poor short-term outcomes were rare in women giving birth in hospitals, and neonates and most mothers were discharged with a level of information that at least ensured a smooth transition to follow-up maternal care. Poor clinical results and patient-reported negative experiences concentrate in few individuals. Restrictive approaches that reduce the frequency of instrumental vaginal delivery, and routine episiotomy remain an important objective for quality improvement.

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This study is an investigation into the epidemiologic and socioeconomic impact of osteoporosis-associated hip fractures in Austria. We determined age- and gender-specific incidence rates of osteoporosis-associated hip fractures for all patients treated in hospitals in 1995 and calculated mortality rates, hospitalization days and direct costs of hospitalization. The data were obtained from the hospital discharge statistics for all general hospitals and for all hospitals of the General Austrian Accident Insurance. To calculate the portion of hip fractures attributable to osteoporosis in a given age-group, a basic, non-osteoporotic incidence of hip fractures was determined for ages 20-39, using gender-specific regression models. 11,379 patients with osteoporotic hip fractures underwent treatment in Austrian hospitals in 1995, accounting for 79 percent of all hip fracture patients treated. 82 percent of those were female, with the highest incidence among women aged 95 years and older with a rate of 3,000/100,000. For male patients the highest incidence was observed for the age-group of 90-94 years with 1,743/100,000. International comparisons indicate these incidence rates to be similar to those reported for the Swiss population. In 1995, 778 patients or 6.8 percent of all patients with osteoporotic hip fractures died during hospitalization. Hospital care of patients with osteoporotic hip fractures required an overall 250,268 bed-days with an age-group-specific length of stay between 8.5-27 days for female and 16-23 days for male patients. The total cost of hospital treatment of osteoporotic hip fractures in Austria was ATS 1,043,379,000 (US$ 103,509,800), with average costs per patient of ATS 91,700 (US$ 9,097). Due to the aging of the population in the years to come, an increase of osteoporotic hip fractures among individuals aged 50 years and older must be expected. The economic importance of this development and its impact on the health care system must be considered as significant.

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Variations in physician practice style, within and between countries, account for much of the differences in the utilization of scarce health care resources. Practice style differences are particularly important at the end of life, when a substantial amount of resources are consumed. We use a hypothetical case of a severely ill elderly patient to identify factors associated with aggressive treatment and to test whether physicians in the US practice differently from their counterparts in other countries. Data come from a random sample of practicing physicians in three industrialized countries, the United States, Canada and Germany (N = 1369). Although the case stated that the chance of survival of the patient was low, 73% of all physicians selected the aggressive treatment. Physicians from the United States were the most aggressive (86%), followed by Germany (68%) and Canada (61%). Practicing in the United States was the strongest predictor of aggressiveness in the multiple linear logistic regression; German and Canadian physicians were one fourth as likely to use aggressive treatment. Specialty training, older age and being a resident all increased the likelihood of selecting the more aggressive treatment. The fear of being sued for malpractice and income did not have an effect on treatment decisions.

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Differences in the costs of health care systems among industrialized countries has been the focus of several studies. Labor costs, specifically the amount of resources used for administration, are considered to contribute to differences in overall health care costs. To determine differences in the use of labor resources, especially administrative and managerial, among American, Austrian and German hospitals, we use a convenience sample of one Austrian, one German and two United States (US) tertiary care centers. In our analysis we used payroll data of the four hospitals. First, we categorized job titles and created job categories. Subsequently, we calculated full time equivalents (FTEs) per job category and compared them across countries. Adjustments were made for differences in health systems. The main outcome measures were FTEs per patient day and per discharge in each job category. In the US hospitals > 19% of FTEs were in administrative categories as compared with < 8% in the European hospitals. For administrative managers, US hospitals used > 11 times the labor per patient day of the European institutions. Among administrative areas, the largest absolute FTE difference was in financial operations. US hospitals used > 5 FTEs of personnel per 10,000 patient days versus < 1.0 FTE in the European hospitals. Given the kinds of administrative work done in US hospitals compared to Austria and Germany, differences in the organization and financing of these countries' health care systems may account for an important part of the higher number of US personnel.

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The aim of our study was to evaluate the reliability of pulse oximetry in detecting both hyper- and hypoxaemic states and to create clinically feasible alarm limits. A total of 792 readings of a pulse oximeter and corresponding values of arterial oxygen tension from 146 (79M, 67F) artificially ventilated preterm newborns with indwelling umbilical artery catheters were compared. Predictive value analysis of pulse oximeter readings related to arterial oxygen tension confirmed the ability of the pulse oximeter to identify both hypoxaemia and hyperoxaemia. However, a clinically feasible and safe range of alarm limits for maintenance of arterial oxygen tension of 40-90 mmHg (5.3-12 kPa) could only be established at a sensitivity level less than 0.9. At a level of 0.85, the alarm range on the pulse oximeter was 92.5-95%. Based on these findings, we are concerned about using pulse oximetry as the sole means of oxygen monitoring for preterm infants receiving supplementary oxygen. A combination of the pulse oximetry with other methods of blood-gas monitoring seems mandatory.

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A 1994 opinion survey again shows Americans less satisfied with their health care system than Canadians and (West) Germans are with theirs. Americans also report more problems in paying for care and receiving needed services. However, overall satisfaction in Canada and Germany has fallen. Important cultural differences between the countries were identified. Americans have higher expectations for medicine and a stronger preference for spending more nationally on health care. The most dramatic difference is Americans' antipathy to government. Public confidence in heads of U.S. federal health agencies is the lowest of any institution or agency in the three countries.

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Stairs are among the most hazardous features of the everyday environment, yet stairway falls have received little research attention. A stratified random sample of Austrian residents was surveyed in person in 1989. Of over 55,000 respondents, 147 reported a stairway injury in the previous year that limited activity for at least one day. Thirty-seven percent of these injuries resulted in hospitalization. Extrapolating to the entire country of 8 million people, each year some 20,000 Austrians sustain serious stairway injuries resulting in over 7,500 hospitalizations. The incidence of stairway injury increases monotonically with age, and females are more at risk than males. The stereotypical stairway injury victim is an elderly woman, not highly educated, who is unmarried and living alone.

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BACKGROUND: The United States is considering enacting a national health plan and global health care budget similar to those in other countries. There are few data on the effects of such policies on physicians and patients. METHODS: We conducted a telephone survey of 602 physicians in the United States, 507 physicians in Canada, and 519 physicians in the former West Germany from February through May 1991; the response rates were 44 percent, 49 percent, and 41 percent, respectively. Among other topics, the questionnaire included measures of satisfaction with the health care system and with medical practice. RESULTS: In the United States, 23 percent of the physicians surveyed thought the health care system worked well, as compared with 33 percent in Canada and 48 percent in West Germany. Seventy-three percent of U.S. physicians reported that patients' inability to afford necessary treatment was a serious problem, as compared with 25 percent in Canada and 15 percent in West Germany. Seventy-seven percent of West Germany physicians, 56 percent of Canadian physicians, and 54 percent of U.S. physicians said the shortage of competent nurses was a serious problem. In Canada, 50 percent of the respondents cited the lack of well-equipped medical facilities as a problem, as compared with 14 percent in the United States and 20 percent in West Germany. CONCLUSIONS: Programs of universal coverage and cost containment necessitate important trade-offs. In Canada and West Germany, physicians do not report serious problems of access to care for the poor and uninsured. In the United States, doctors do not face the limited access to sophisticated forms of medical technology that was reported in Canada or the diminished quality of some services reported in West Germany.

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To explore the concerns of practicing physicians as a way to inform the health reform debate, the authors conducted a survey of physicians in the United States, Canada, and Germany. Survey results indicate that U.S. physicians are most likely to view affordability as the greatest barrier to access to care for their patients. However, unavailability of services and long waiting times were cited most often by Canadian physicians. German physicians did not cite access problems as frequently as Canadian physicians did; other measures of satisfaction were closer to U.S. levels, suggesting fewer trade-offs if the United States were to adopt aspects of the German health care system.

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