Variability in Costs across Hospital Wards. A Study of Chinese Hospitals

Introduction

Analysts estimating the costs or cost-effectiveness of health interventions requiring hospitalization often cut corners because they lack data and the costs of undertaking full step-down costing studies are high. They sometimes use the costs taken from a single hospital, sometimes use simple rules of thumb for allocating total hospital costs between general inpatient care and the outpatient department, and sometimes use the average cost of an inpatient bed-day instead of a ward-specific cost.

Purpose

In this paper we explore for the first time the extent and the causes of variation in ward-specific costs across hospitals, using data from China. We then use the resulting model to show how ward-specific costs for hospitals outside the data set could be estimated using information on the determinants identified in the paper.

Methodology

Ward-specific costs estimated using step-down costing methods from 41 hospitals in 12 provinces of China were used. We used seemingly unrelated regressions to identify the determinants of variability in the ratio of the costs of specific wards to that of the outpatient department, and explain how this can be used to generate ward-specific unit costs.

Findings

Ward-specific unit costs varied considerably across hospitals, ranging from 1 to 24 times the unit cost in the outpatient department — average unit costs are not a good proxy for costs at specialty wards in general. The most important sources of variability were the number of staff and the level of capacity utilization.

Practice Implications

More careful hospital costing studies are clearly needed. In the meantime, we have shown that in China it is possible to estimate ward-specific unit costs taking into account key determinants of variability in costs across wards. This might well be a better alternative than using simple rules of thumb or using estimates from a single study.     

Development of unit cost for the health services offered at King FAHD Central hospital Jazan,Saudi Arabia

BackgroundEfficiency remains one of the most important drivers of decision making in health care system. Fund allocators need to receive structured information about the cost healthcare services from hospitals for better decisions related to resource allocation and budgeting. The objective of the study was to estimate the unit cost for health services offered to inpatients in King Fahd Central hospital (KFCH) Jazan during the financial year 2018.MethodsWe applied a retrospective approach using a top-down costing method to estimate the cost of health care services. Clinical and Administrative departments divided into cost centres, and the unit cost was calculated by dividing the total cost of final care cost centres into the total number of patients discharged in one year. The average cost of inpatient services was calculated based on the average cost of each ward and the number of patients treated.ResultsThe average cost per patient stayed in KFCH was SAR 19,034, with the highest cost of SAR 108,561 for patients in the Orthopedic ward. The average cost of the patient in the Surgery ward, Plastic surgery, Neurosurgery, Medical ward, Pediatric ward and Gynecology ward was SAR 33,033, SAR 29,425, SAR 23,444, SAR 20,450, SAR 9579 and SAR 8636 respectively.ConclusionThis study provides necessary information about the cost of health care services in a tertiary care setting. This information can be used as a primary tool and reference for further studies in other regions of the country. Hence, this data can help to provide a better understanding of tertiary hospital costing in the region to achieve the privatization objective.     

The Costs of Delivering Integrated HIV and Sexual Reproductive Health Services in Limited Resource Settings

Objective

To present evidence on the total costs and unit costs of delivering six integrated sexual reproductive health and HIV services in a high and medium HIV prevalence setting, in order to support policy makers and planners scaling up these essential services.

Design

A retrospective facility based costing study conducted in 40 non-government organization and public health facilities in Kenya and Swaziland.

Methods

Economic and financial costs were collected retrospectively for the year 2010/11, from each study site with an aim to estimate the cost per visit of six integrated HIV and SRH services. A full cost analysis using a combination of bottom-up and step-down costing methods was conducted from the health provider’s perspective. The main unit of analysis is the economic unit cost per visit for each service. Costs are converted to 2013 International dollars.

Results

The mean cost per visit for the HIV/SRH services ranged from $Int 14.23 (PNC visit) to $Int 74.21 (HIV treatment visit). We found considerable variation in the unit costs per visit across settings with family planning services exhibiting the least variation ($Int 6.71-52.24) and STI treatment and HIV treatment visits exhibiting the highest variation in unit cost ranging from ($Int 5.44-281.85) and ($Int 0.83-314.95), respectively. Unit costs of visits were driven by fixed costs while variability in visit costs across facilities was explained mainly by technology used and service maturity.

Conclusion

For all services, variability in unit costs and cost components suggest that potential exists to reduce costs through better use of both human and capital resources, despite the high proportion of expenditure on drugs and medical supplies. Further work is required to explore the key drivers of efficiency and interventions that may facilitate efficiency improvements.     

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey

Background

There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.

Methods and Findings

We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.

Conclusion

African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas. Please see later in the article for the Editors'' Summary     

Containing Health Care Costs: A Critical Test of the Public-Private Joint Venture in Health

As the federal government shifted from its traditional roles in health to the payment for personal health care, the relationship between public and private sectors has deteriorated. Today federal and state revenue funds and trusts are the largest purchasers of services from a predominantly private health system. This financing or “gap-filling” role is essential; so too is the purchaser''s concern for the costs and prices it must meet. The cost per person for personal health care in 1980 is expected to average $950, triple for the aged. Hospital costs vary considerably and inexplicably among states; California residents, for example, spend 50 percent more per year for hospital care than do state of Washington residents. The failure of each sector to understand the other is potentially damaging to the parties and to patients. First, and most important, differences can and must be moderated through definite changes in the attitudes of the protagonists.     

The Financial Impact of the ‘Zero-Markup Policy for Essential Drugs’ on Patients in County Hospitals in Western Rural China

Objective

With a quasi-experimental design, this study aims to assess whether the Zero-markup Policy for Essential Drugs (ZPED) reduces the medical expense for patients at county hospitals, the major healthcare provider in rural China.

Methods

Data from Ningshan county hospital and Zhenping county hospital, China, include 2014 outpatient records and 9239 inpatient records. Quantitative methods are employed to evaluate ZPED. Both hospital-data difference-in-differences and individual-data regressions are applied to analyze the data from inpatient and outpatient departments.

Results

In absolute terms, the total expense per visit reduced by 19.02 CNY (3.12 USD) for outpatient services and 399.6 CNY (65.60 USD) for inpatient services. In relative terms, the expense per visit was reduced by 11% for both outpatient and inpatient services. Due to the reduction of inpatient expense, the estimated reduction of outpatient visits is 2% among the general population and 3.39% among users of outpatient services. The drug expense per visit dropped by 27.20 CNY (4.47 USD) for outpatient services and 278.7 CNY (45.75 USD) for inpatient services. The proportion of drug expense out of total expense per visit dropped by 11.73 percentage points in outpatient visits and by 3.92 percentage points in inpatient visits.

Conclusion

Implementation of ZPED is a benefit for patients in both absolute and relative terms. The absolute monetary reduction of the per-visit inpatient expense is 20 times of that in outpatient care. According to cross-price elasticity, the substitution between inpatient and outpatient due to the change in inpatient price is small. Furthermore, given that the relative reductions are the same for outpatient and inpatient visits, according to relative thinking theory, the incentive to utilize outpatient or inpatient care attributed to ZPED is equivalent, regardless of the 20-times price difference in absolute terms.     

Costs of Dengue Control Activities and Hospitalizations in the Public Health Sector during an Epidemic Year in Urban Sri Lanka

Background

Reported as a public health problem since the 1960s in Sri Lanka, dengue has become a high priority disease for public health authorities. The Ministry of Health is responsible for controlling dengue and other disease outbreaks and associated health care. The involvement of large numbers of public health staff in dengue control activities year-round and the provision of free medical care to dengue patients at secondary care hospitals place a formidable financial burden on the public health sector.

Methods

We estimated the public sector costs of dengue control activities and the direct costs of hospitalizations in Colombo, the most heavily urbanized district in Sri Lanka, during the epidemic year of 2012 from the Ministry of Health’s perspective. The financial costs borne by public health agencies and hospitals are collected using cost extraction tools designed specifically for the study and analysed retrospectively using a combination of activity-based and gross costing approaches.

Results

The total cost of dengue control and reported hospitalizations was estimated at US$3.45 million (US$1.50 per capita) in Colombo district in 2012. Personnel costs accounted for the largest shares of the total costs of dengue control activities (79%) and hospitalizations (46%). The results indicated a per capita cost of US$0.42 for dengue control activities. The average costs per hospitalization ranged between US$216–609 for pediatric cases and between US$196–866 for adult cases according to disease severity and treatment setting.

Conclusions

This analysis is a first attempt to assess the economic burden of dengue response in the public health sector in Sri Lanka. Country-specific evidence is needed for setting public health priorities and deciding about the deployment of existing or new technologies. Our results suggest that dengue poses a major economic burden on the public health sector in Sri Lanka.     

The cost of universal health care in India: a model based estimate

Introduction

As high out-of-pocket healthcare expenses pose heavy financial burden on the families, Government of India is considering a variety of financing and delivery options to universalize health care services. Hence, an estimate of the cost of delivering universal health care services is needed.

Methods

We developed a model to estimate recurrent and annual costs for providing health services through a mix of public and private providers in Chandigarh located in northern India. Necessary health services required to deliver good quality care were defined by the Indian Public Health Standards. National Sample Survey data was utilized to estimate disease burden. In addition, morbidity and treatment data was collected from two secondary and two tertiary care hospitals. The unit cost of treatment was estimated from the published literature. For diseases where data on treatment cost was not available, we collected data on standard treatment protocols and cost of care from local health providers.

Results

We estimate that the cost of universal health care delivery through the existing mix of public and private health institutions would be INR 1713 (USD 38, 95%CI USD 18–73) per person per annum in India. This cost would be 24% higher, if branded drugs are used. Extrapolation of these costs to entire country indicates that Indian government needs to spend 3.8% (2.1%–6.8%) of the GDP for universalizing health care services.

Conclusion

The cost of universal health care delivered through a combination of public and private providers is estimated to be INR 1713 per capita per year in India. Important issues such as delivery strategy for ensuring quality, reducing inequities in access, and managing the growth of health care demand need be explored.     

Control Costs,Enhance Quality,and Increase Revenue in Three Top General Public Hospitals in Beijing,China

Background

With market-oriented economic and health-care reform, public hospitals in China have received unprecedented pressures from governmental regulations, public opinions, and financial demands. To adapt the changing environment and keep pace of modernizing healthcare delivery system, public hospitals in China are expanding clinical services and improving delivery efficiency, while controlling costs. Recent experiences are valuable lessons for guiding future healthcare reform. Here we carefully study three teaching hospitals, to exemplify their experiences during this period.

Methods

We performed a systematic analysis on hospitalization costs, health-care quality and delivery efficiencies from 2006 to 2010 in three teaching hospitals in Beijing, China. The analysis measured temporal changes of inpatient cost per stay (CPS), cost per day (CPD), inpatient mortality rate (IMR), and length of stay (LOS), using a generalized additive model.

Findings

There were 651,559 hospitalizations during the period analyzed. Averaged CPS was stable over time, while averaged CPD steadily increased by 41.7% (P<0.001), from CNY 1,531 in 2006 to CNY 2,169 in 2010. The increasing CPD seemed synchronous with the steady rising of the national annual income per capita. Surgical cost was the main contributor to the temporal change of CPD, while medicine and examination costs tended to be stable over time. From 2006 and 2010, IMR decreased by 36%, while LOS reduced by 25%. Increasing hospitalizations with higher costs, along with an overall stable CPS, reduced IMR, and shorter LOS, appear to be the major characteristics of these three hospitals at present.

Interpretations

These three teaching hospitals have gained some success in controlling costs, improving cares, adopting modern medical technologies, and increasing hospital revenues. Effective hospital governance and physicians'' professional capacity plus government regulations and supervisions may have played a role. However, purely market-oriented health-care reform could also misguide future healthcare reform.     

A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis

Background

To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale.

Methods and Findings

Our cost-effectiveness analysis from the provider''s perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26–67.06) in intervention hospitals compared to US$31.1 (95% CI 30.67–47.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19–2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A “what-if” analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3.

Conclusion

Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions. Please see later in the article for the Editors'' Summary     

Direct cost associated with acquired brain injury in Ontario

ABSTRACT: BACKGROUND: Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada. METHODS: A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer's perspective. RESULTS: Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65 % of the total treatment cost in the first year overwhelming all other cost components. CONCLUSIONS: The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.     

Determinants of per diem Hospital Costs in Mental Health

Introduction

An understanding of differences in hospital costs between patient groups is relevant for the efficient organisation of inpatient care. The main aim of this study was to confirm the hypothesis that eight a priori identified cost drivers influence per diem hospital costs. A second aim was to explore further variables that might influence hospital costs.

Methods

The study included 667 inpatient episodes consecutively discharged in 2014 at the psychiatric hospital of the Medical Centre- University of Freiburg. Fifty-one patient characteristics were analysed. Per diem costs were calculated from the hospital perspective based on a detailed documentation of resource use. Mixed-effects maximum likelihood regression and an ensemble of conditional inference trees were used to analyse data.

Results

The study confirmed the a priori hypothesis that not being of middle age (33–64 years), danger to self, involuntary admission, problems in the activities of daily living, the presence of delusional symptoms, the presence of affective symptoms, short length of stay and the discharging ward affect per diem hospital costs. A patient classification system for prospective per diem payment was suggested with the highest per diem hospital costs in episodes having both delusional symptoms and involuntary admissions and the lowest hospital costs in episodes having neither delusional symptoms nor somatic comorbidities.

Conclusion

Although reliable cost drivers were identified, idiosyncrasies of mental health care complicated the identification of clear and consistent differences in hospital costs between patient groups. Further research could greatly inform current discussions about inpatient mental health reimbursement, in particular with multicentre studies that might find algorithms to split patients in more resource-homogeneous groups.     

Distribution of NHS funds between fundholding and non-fundholding practices.

OBJECTIVES--To estimate the amount spent on specific hospital care by health agencies in 1993-4 and compare it with the resources allocated to patients registered with fundholding practices for the same type of care. To investigate whether fundholding practices and health agencies pay different amounts for inpatient care. DESIGN--Examination of hospital episode statistics, 1991 census data, and family health services authority and health agency records. SETTING--Health agencies and fundholding practices in the former North West Thames Regional Health Authority. MAIN OUTCOME MEASURES--Amount per capita allocated to inpatient and outpatient care for patients registered with fundholding and non-fundholding practices. Average specialty cost per finished consultant episode for health agencies and fundholding practices. RESULTS--The ratio of per capita funding for patients in non-fundholding practices to those in fundholding practices ranged from 59% to 87% for inpatient and day case care and from 36% to 106% for outpatient care. Average specialty costs per episode were similar for fundholding practices and health agencies. CONCLUSIONS--Fundholding practices seem to have been funded more generously than non-fundholding practices in North West Thames.     

Part-time hospitalization programs: the neglected field of community psychiatry.

Part-time hospitalization for persons with psychiatric disorders is underdeveloped, underutilized and often poorly understood, but should be encouraged in view of the unsatisfactory living conditions of patients discharged from hospital who still require care, the reductions in psychiatric impatient populations and numbers of beds, the increasing costs of health services and the current fiscal restraints. Day and night hospitals can provide an alternative to inpatient or outpatient treatment, rehabilitation for the long-term patient or treatment for the patient in transition from inpatient to outpatient status. The day hospital can also provide a diagnostic setting. Such programs help preserve the patient''s position in the family and the community, minimize the ill effects of hospitalization, and lower capital and operating costs of the psychiatric services. Awareness by medical and paramedical services of the value of these programs would increase their utilization. Shifting the emphasis of administrative and fiscal policies from inpatient to part-time hospitalization programs is also required.     

Variations and Determinants of Hospital Costs for Acute Stroke in China

Background

The burden of stroke is high and increasing in China. We modelled variations in, and predictors of, the costs of hospital care for patients with acute stroke in China.

Methods and Findings

Baseline characteristics and hospital costs for 5,255 patients were collected using the prospective register-based ChinaQUEST study, conducted in 48 Level 3 and 14 Level 2 hospitals in China during 2006–2007. Ordinary least squares estimation was used to determine factors associated with hospital costs. Overall mean cost of hospitalisation was 11,216 Chinese Yuan Renminbi (CNY) (≈US$1,602) per patient, which equates to more than half the average annual wage in China. Variations in cost were largely attributable to stroke severity and length of hospital stay (LOS). Model forecasts showed that reducing LOS from the mean of 20 days for Level 3 and 18 days for Level 2 hospitals to a duration of 1 week, which is common among Western countries, afforded cost reductions of 49% and 19%, respectively. Other lesser determinants varied by hospital level: in Level 3 hospitals, health insurance and the occurrence of in-hospital complications were each associated with 10% and 18% increases in cost, respectively, whilst treatment in a teaching hospital was associated with approximately 39% decrease in cost on average. For Level 2 hospitals, stroke due to intracerebral haemorrhage was associated with a 19% greater cost than for ischaemic stroke.

Conclusions

Changes to hospital policies to standardise resource use and reduce the variation in LOS could attenuate costs and improve efficiencies for acute stroke management in China. The success of these strategies will be enhanced by broader policy initiatives currently underway to reform hospital reimbursement systems.     

Counting the Cost of Diabetes in the Solomon Islands and Nauru

Aim

To determine the costs associated with diabetes to governments, people with diabetes and their carers, and its impact on quality of life in two Pacific Island countries—the Solomon Islands and Nauru.

Materials and Methods

This cross-sectional cost of illness study was conducted on 330 people with type 2 diabetes (197 from the Solomon Islands and 133 from Nauru) using a structured cost of illness survey questionnaire adapted from the Australian DiabCo$t study. Quality of life was measured by the EQ-5D Visual Analogue Scale.

Results

There were 330 respondents (50% female; mean duration of diabetes 10.9 years; mean age 52.6 years). The estimated annual national cost of diabetes incurred by the Solomon Islands government was AUD12.8 million (AUD281 per person/year) and by Nauru government was AUD1.2 million (AUD747 per person/year). The major contribution to the government costs was inpatient services cost (71% in the Solomon Islands and 83% in Nauru). Annual expenditure for diabetes was approximately 20% of the governments’ annual health care expenditure. Considerable absenteeism and retirement from work due to diabetes was found.

Conclusions

This study found substantial public and personal costs associated with diabetes. The findings provide objective data on which health policy, funding and planning decisions about the prevention and control of diabetes in the Solomon Islands and Nauru can be reliably based and subsequently evaluated.     

LAT Software Induced Savings on Medical Costs of Alcohol Addicts' Care - Results from a Matched-Pairs Case-Control Study

Lesch Alcoholism Typology (LAT) is one of the most widely used clinical typologies of alcohol addiction. Study tested whether introduction of LAT software in clinical practice leaded to improved outcomes and reduced costs. Retrospective matched-pairs case-control cost comparison study was conducted at the Regional Addiction Center of the University Clinic in Serbia involving 250 patients during the four-year period. Mean relapse frequency followed by outpatient detoxification was 0.42±0.90 vs. 0.70±1.66 (LAT/non-LAT; p = 0.267). Adding relapses after inpatient treatment total mean-number of relapses per patient was 0.70±1.74 vs. 0.97±1.89 (LAT/non-LAT; p = 0.201). However, these relapse frequency differentials were not statistically significant. Total hospital costs of Psychiatry clinic based non-LAT addicts'' care (€54,660) were significantly reduced to €36,569 after initiation of LAT. Mean total cost per patient was reduced almost by half after initiation of LAT based treatment: €331±381 vs. €626±795 (LAT/non-LAT; p = 0.001). Mean cost of single psychiatry clinic admission among non-LAT treatment group was €320±330 (CI 95% 262–378) and among LAT €197±165 (CI 95% 168–226) (p = 0.019). Mean LAT software induced net savings on psychiatric care costs were €144 per patient. Total net savings on hospital care including F10 associated somatic co-morbidities amounted to €295 per patient. More sensitive diagnostic assessment and sub-type specific pharmacotherapy and psychotherapy following implementation of LAT software lead to significant savings on costs of hospital care.