Management, Organization & Financing
studying and perhaps changing certain aspects of service
delivery to improve the productive efficiency of their clinics.
Primary Funding Source: AHRQ
Call for Papers
Inside the Black Box: How Management Characteristics
Influence the Delivery of Patient Care
Chair: Gary Young, Department of Veterans Affairs and
Boston Univeristy School of Public Health
Sunday, June 26 • 10:30 am – 12:00 pm
●Clinic Characteristics Related to the Efficient Production
of Health for Adults with Diabetes
Todd Gilmer, Ph.D., Patrick O'Connor, M.D., MPH, William
Rush, Ph.D.
Presented By: Todd Gilmer, Ph.D., Assistant Professor,
Family and Preventive Medicine, UCSD, 9500 Gilman Drive,
La Jolla, CA 92093-0622; Tel: (858)34-7596; Fax: (858) 5344642; Email: tgilmer@ucsd.edu
Research Objective: Of long standing interest to health
services researchers as well as medical group administrators
and managers are factors related to the productive efficiency
of medical firms such as hospitals, physician groups, and
clinics. Recent research has illustrated the need for health
econometric studies that analyze the production of final goods
such as improved health or health related quality of life rather
than intermediate goods such as procedures or visits. This
research builds on both objectives, examining characteristics
of medical groups and clinics related to efficiency in the
production of health. The objective of this study was to
analyze the productive efficiency of medical groups and clinics
in improving the health of adults with diabetes by reducing the
estimated risk of morbidity and mortality related to diabetes.
Study Design: Prospective cohort study with data from
surveys of patients, clinic medical directors and managers,
and medical group medical directors and administrators, plus
medical record reviews merged with 3 years of medical claims.
Risk of morbidity and mortality related to diabetes is
estimated using the revised UKPDS risk engine (revised to
include cardiovascular risk factors). Health care costs are
estimated using detailed data on resource use and common
Medicare payment methodologies.
Population Studied: 1,628 adults with diabetes receiving care
in a large Midwestern health care organization receiving care
in 84 clinics within 18 medical groups.
Principal Findings: Preliminary results indicate that some
clinic characteristics are related to productive efficiency
including staffing and several elements of the CCM. Ongoing
research will determine the robustness of these findings to
alternative definitions of output and modeling strategies.
Conclusions: Most clinic characteristics were not significant
predictors of productive efficiency for adults with diabetes.
The robustness of these findings and the mechanisms by
which some specific factors affect efficiency deserve further
evaluation.
Implications for Policy, Delivery, or Practice: Clinic
managers and/or medical group adminitrators may consider
●How do Physicians in Managed Care Networks Respond
to an Increase in Clinical Autonomy?
Tricia Johnson, Ph.D.
Presented By: Tricia Johnson, Ph.D., Assistant Professor,
Health Systems Management, Rush University, 1700 West
Van Buren Street, TOB Suite 126B, Chicago, IL 60612; Tel:
(312) 942-7107; Fax: (312) 942-4957; Email:
tricia_j_johnson@rush.edu
Research Objective: Managed care organizations are
introducing less restrictive products to the market and
modifying existing plans to improve provider and consumer
satisfaction with the delivery and financing of health care. This
paper addresses how an increase in clinical autonomy,
through a shift to less restrictive managed care products,
affects health care utilization. A two-dimensional analytic
process is used to examine changes in the methods of care
and intensity of utilization for the treatment of back pain. We
identify three general characteristics of health care services
most likely to change following an increase in clinical
autonomy, including a service’s profit margin, historical
patterns of over-utilization, and the effect of an increase in
clinical autonomy on the likelihood a payer detects
unnecessary utilization. This study tests these predictions
following a relaxation of utilization management constraints
and compares changes in utilization among managed care
network and non-network providers.
Study Design: This is a quasi-experimental study design.
Population Studied: The state of California implemented
changes to the workers’ compensation system in 1993 that
effectively relaxed utilization management oversight on health
care providers. A subsequent appeals board decision in 1996
further broadened providers’ clinical autonomy. Data include
120,000 back injury claims occurring between 1993 and 2000.
Claims are classified as receiving network care if they receive
75% or more care from a managed care network provider. A
multinomial logit model is used to estimate the probability
that an injured worker is treated with a particular pattern of
care over time. Changes in the intensity of utilization are
studied using a non-linear generalized method of moments
approach.
Principal Findings: The likelihood of an occupational back
injury receiving chiropractic care increased by 40% overall. In
addition, the service intensity results demonstrated an
absolute and relative shift toward more profitable services
(e.g., diagnostic testing, diagnostic services and surgery), and
a further increase in services that had been historically overutilized in the treatment of back pain (e.g., physical medicine,
surgery and diagnostic testing). Claims treated by network
providers consistently used fewer services than otherwise
similar claims treated by non-network providers. Network
cases received 10.5 fewer physical medicine procedures, 2.9
fewer chiropractic procedures, and 0.5 fewer diagnostic
radiology and ultrasound exams.
Conclusions: If the end product of the managed care
backlash is an increase in clinical autonomy, results suggest
that utilization and expenditures are likely to increase, due to
both more costly methods of treatment and a higher service
intensity.
Implications for Policy, Delivery, or Practice: Managed carebased utilization management may not completely eliminate
changes in utilization following policy-based changes in
clinical autonomy.
Primary Funding Source: No Funding
●Civility Among Healthcare Employees: The Impact on
Patients
Mark Meterko, Ph.D., David Mohr, Ph.D., Martin Charns,
DBA, Nicholas Warren, Sc.D., Michael Hodgson, M.D.
Presented By: Mark Meterko, Ph.D., Manager, Methodology
& Survey Unit, Center for Organization, Leadership &
Management Research, VHA HSR&D, VA Medical Center
(152M), 150 South Huntington Avenue, Boston, MA 02130;
Tel: (617)278-4433; Fax: (617)232-9500; Email:
mark.meterko@med.va.gov
Research Objective: Workplace civility can be defined as the
degree to which coworkers treat each other with respect,
individual differences are valued, and managers are able to
work well with individuals from different backgrounds. Little
systematic research has examined the degree of civility among
professional employees and/or its relationship to
organizational performance. The goals of the present study
were to report on the development of a measure of workplace
civility, to examine its distributional properties among a large
group of healthcare staff, and to explore its relationship to
patient satisfaction.
Study Design: This study involved the secondary analysis of
data from three independently administered Veterans Health
Administration (VHA) surveys: an employee survey, and
inpatient and outpatient satisfaction surveys. The relevant
section of the employee survey consisted of 26 agree/disagree
items representing specific aspects of work life, plus one
overall job satisfaction item. The inpatient survey consisted of
76 items representing 10 specific domains of care including
access, staff courtesy, continuity of care, and physical comfort.
The outpatient survey consisted of 66 items representing
similar domains.
Population Studied: The employee survey was distributed
anonymously to all VHA employees during spring 2004;
110,490 (52%) responded. Both patient surveys were
conducted by mail and involved monthly random samples of
service users for the period corresponding to the employee
survey. Overall response rates were 56% (n=39,657) among
inpatients and 70% (n=74,667) among outpatients.
Aggregate patient satisfaction scale scores were computed for
125 acute care hospitals and 130 outpatient sites.
Principal Findings: Exploratory factor analysis of the
employee data suggested that four underlying dimensions
could account for 64% of the variance in the 26 relevant
items. We identified these dimensions as representing
management for achievement (10 items), civility and coworker relations (10 items), physical conditions (5 items), and
pace of work (1 item). Internal consistency reliabilities ranged
from .81 to .93. Overall, facility-level correlations between
employee job satisfaction and patient satisfaction with quality
and service ranged from -.06 to .49 and were generally
stronger with regard to inpatient as compared to outpatient
care. Of the four employee job evaluation scales, civility was
the most strongly related to patients’ evaluations of their care,
both outpatient (median r = .29 across 12 dimensions) and
inpatient (median r = .44 across 10 dimensions). Correlations
indicated that organization culture, also measured by the
employee survey, and civility were very strongly related. The
relationship between culture and patient satisfaction, however,
was moderate at best, and was much weaker than the
relationship between civility and patient satisfaction.
Conclusions: The degree of general civility and cooperation
among employees was positively related to independent
measures of both inpatient and outpatient satisfaction. The
overall pattern of correlations between organization culture,
employee evaluations of their work life and patient satisfaction
suggest that organization culture may promote certain kinds
of employee interactions, which in turn affect patient
experience.
Implications for Policy, Delivery, or Practice: Results
suggest that general civility and cooperation among
employees may have a strong, positive “spill-over effect” on
patients in a health-care setting. The content of the civility
measure suggests several specific aspects of work life under
management control that could be changed to enhance the
civility of staff interactions.
Primary Funding Source: VA
●The Effect of Physician Group Culture and Structure on
Patients' Utilization and Qualtiy of Care Outcomes
Amy Smalarz, MS, FAHM, BS
Presented By: Amy Smalarz, MS, FAHM, BS, AHRQ Fellow,
Schneider Institute, Brandeis University, 13 Edith Road,
Framingham, MA 01701; Tel: (508) 405-1012; Email:
smalarz@brandeis.edu
Research Objective: Medical group practices and other
healthcare organizations today are facing increasing pressures
to reduce physician practice variations by lowering their costs
and improving their quality of care. In an attempt to achieve
this task, the focus is shifting from a narrow concept of
looking at the individual physician to a more sophiscated
understanding of the organization as a system, in which many
factors, such as culture and structure, directly or indirectly
affect patient outcomes and the groups’ performance. This
study will examine two items: the culture and structure of
physician groups as well as the effects of culture and structure
on physician groups’ utilization of resources and their
patients’ quality of care outcomes. Questions being
addressed include: What are the variations of cost and quality
of care measures/outcomes among the physician groups
measured? How do physician groups’ cultures and structures
differ? What are the levels of agreement for the individual
components on the group level characteristics from the
surveys? Controlling for case and illness severity, particular
physician characteristics and specific environmental factors,
what effect do physician group’s culture and structures have
on the designated outcomes?
Study Design: Methods for analyzing the data include
Regression Analysis, Hierarchical Lineal Modeling (HLM) and
Data Envelopment Analysis (DEA) analysis. First, I analyze
the physician groups’ performance based on specified
utilization of resources and quality of care outcomes.
Regression and HLM analyses was used for the claims data. I
then surveyed the physician groups along with their office
managers with validated survey instruments regarding their
culture and structure. The final step is to link the physician
groups’ performance results to their culture and structure
surveys. Here DEA analysis was performed to estimate the
best practices of physician groups by comparing the groups
simultaneously.Nadler et al’s Congruence Model will be the
basis for my conceptual model, which embodies a view of the
organization as a system allowing me to study culture and
structure of physician groups as independent variables
affecting patients' outcome measures.
Population Studied: I have surveyed approximately 1300
physician groups in the state of Massachusetts for this study,
as well as 60 office managers/administrators. Therefore, the
data for this study consists of 1) respondents to the culture
survey, 2) respondents to the structure survey, 3) a local
Insurer’s claims database and 4) current HEDIS data.
Principal Findings: Findings are preliminary, but final results
are will be ready in late March/early April. I am in the midst of
compiling the final results. However, initial findings do show
variation among physician groups does exist. There is also
variation among the cultures of the physician groups.
However, the extent of the effect of culture and structure will
be better determined once final calculations are made.
Conclusions: Even though this project is not yet complete, it
will be completed before the Conference and I would
appreciate the opportunity to present this work. It has great
implications on how physician practices are structured and
incentivised.
Implications for Policy, Delivery, or Practice: Ultimately,
this study will contribute to our understanding of the affect of
a physician groups’ culture and structure on their patients’
outcomes. Moreover, this study will provide information on
better ways to align the incentives provided to physicians with
the desired outcomes for consumers, employers and insurers.
Purchasers and third party payors have turned to pay-forperformance for hospitals and medical groups, in an attempt
to monitor and manage their providers. Insurers have
primarily offered incentives to their providers to encourage
them to provide high quality, lower cost care. In addition,
insurers have imposed financial incentives on consumers to
make them more price conscious of the services they are
receiving. One result of such a payment system could be a
reduction of the variations in healthcare outcomes. However,
even with these incentives being provided to all parties,
variation in healthcare outcomes continues to exist.
Employers nationally are now pushing insurers to rank
providers and give consumers financial incentives to choose
the highest-quality, least-expensive doctors and hospitals. The
state of Massachusetts (the purchaser) has encouraged Tufts
Health Plan to implement such a program. Tufts Health Plan
has implemented their tiered hospital program, Navigator in
the year 2004. Massachusetts state employees enrolled in
Tufts Health Plan will pay higher co-payments for overnight
stays in hospitals that the Plan considers either more
expensive, lower in quality or both and lower co-payments for
those hospitals deemed less expensive and higher in quality or
both. Insurers, such as Tufts and Harvard Pilgrim Health Plan
are considering expanding the tiered program to physicians
and their medical groups. However, questions still remain as
to what factors contribute to the variation in healthcare
outcomes. Before applying a tiered program on physicians
and their respective groups, which places financial incentives
and burdens on the consumers, we should have a better
understanding of the factors that explain the existing
variations. Also, if the incentive system changes patterns of
where care is sought, then non-preferred providers will want to
change but will not know what is needed. A large and growing
number of physicians in the United States now work in
medical group practice settings. And although there is ample
evidence that organizational setting substantially influences
health care quality, relatively little is known about the influence
of organizational factors associated with medical group
performance. This research gap is particularly large when it
comes to understanding the ways in which physician group
culture and structure affect patient outcomes. Solomon
provided strong evidence that differences in the organization
of group practice affects patients’ experiences of care. The
purpose of my study is to take that one step further and
examine whether the historical cost and quality of care
performance of physician groups influence the groups’
cultures and structures. This study will expand Dr. Kralewski’s
survey of culture and validate the assumption that culture is
measurable. Payors and insurers provide incentives to their
physician groups to induce better quality and higher efficient
services. But are these groups providing the right incentives?
Understanding physician group cultures and how the
physician groups are organized and influenced can help to
improve the incentives provided- they can key in on what the
group will pay attention to and work with them. I have the
potential to create a typology of physician group cultures that
result in successful outcomes, i.e. lower costs, higher quality.
This is important because each physician group has its own
balance and this understanding of differences is important to
recognize and appreciate. Knowing successful models for
organizational cultures and structures that lead to better cost
and quality of care outcomes for patients can benefits all
parties involved: patients, physicians and third parties.
Primary Funding Source: AHRQ
●The Role of Management Support in Implementing
Innovative Clinical Practices
Carol VanDeusen Lukas, EdD, Mark Meterko, Ph.D., David
Mohr, Ph.D., Marjorie Nealon Seibert, MBA
Presented By: Carol VanDeusen Lukas, EdD, Senior
Investigator, Center for Organization, Leadership and
Management Research, Department of Veterans Affairs, VA
Boston HCS, 150 South Huntington Avenue, Boston, MA
02130; Tel: (617)232-9500 x5685; Fax: (617)232-6140; Email:
carol.vandeusenlukas@med.va.gov
Research Objective: Management support is widely seen as
an important factor in the implementation of innovative
clinical practices. Without management support, it is argued,
an innovation may be adopted on a trial basis or small scale,
but will not be spread or sustained. The objective of this study
was to add to our understanding of the role of management
support for innovation by examining its relationship with the
implementation of a clinical innovation, Advanced Clinic
Access (ACA), across the Department of Veterans Affairs (VA).
We hypothesized that two dimensions of management
support are important: 1) personal commitment by senior
leaders (e.g., expressing support) and 2) organizational
commitment by senior management (e.g., allocating
resources; using review, feedback and accountability systems
to support and guide implementation).
Study Design: Analyses were based on data collected for a
comprehensive evaluation of the implementation and
effectiveness of ACA in VA. ACA is a set of principles for
managing clinics so that patients have access to medical care
when they want it. The evaluation was an observational study
of natural variation in clinic wait times and in the extent of
implementation of ACA in 78 VA medical centers (VAMCs).
For the current study, data were drawn from two sources: 1)
semi-structured telephone interviews with the points of
contact for ACA in each VAMC and 2) mailed surveys of staff
in six clinic areas targeted to implement ACA. We conducted
regression analyses to test the strength of personal
commitment and organizational commitment in predicting
variation in the extent of ACA implementation in primary care.
We examined 1) the direct effects of both dimensions of
management support and 2) the effects of management
support mediated through other variables such as use of
performance feedback and staff training and communication.
Population Studied: The analyses are based on data from 78
VAMCs with a focus on primary care for clinic-specific
measures.
Principal Findings: Organizational commitment was a
stronger predictor of ACA implementation than was personal
commitment. Mediating variables, including performance
data feedback and use, and communication and training were
also important, though not always positively. Staff problem
recognition did not contribute signficantly to the prediction
equations.
Conclusions: Finding that organizational commitment
measures are stronger predictors than personal commitment
measures suggests that the presence of an organizational
infrastructure to support an innovation is as important or
more important than leaders’ personal advocacy for change.
Implications for Policy, Delivery, or Practice:
Understanding the key dimensions of management support
can improve an organization's ability to put those elements
into place, and thus improve the likelihood that a clinical
innovation will be successfully implemented.
Primary Funding Source: VA
Call for Papers
Providers Under Pressure: Effects of Competition,
Payment & Ownership
Chair: Gary Young, Cooper Health System
Monday, June 27 • 9:00 am – 10:30 am
●Hospital Ownership and Performance: An Integrative
Research Review
Karen Eggleston, Ph.D., Yu-Chu Shen, Ph.D., Joseph Lau,
M.D., Ph.D., Christopher Schmid, Ph.D.
Presented By: Karen Eggleston, Ph.D., Assistant Professor,
Economics, Tufts University, Braker Hall, Medford, MA 02155;
Tel: (617)627-5948; Fax: (617)627-3917; Email:
karen.eggleston@tufts.edu
Research Objective: Although for-profit, not-for-profit, and
government hospitals have co-existed for a long time, to what
extent performance systematically differs according to
ownership form remains controversial. This study aims to
explain why studies to date have often found conflicting
results, and to present a range of meta-analysis estimates
summarizing to what extent ownership impacts performance
under different assumptions.
Study Design: We apply formal statistical methods of metaanalysis and meta-regression to analyze results from studies
of hospital ownership between 1990 and 2004. Metaregression allows us to understand to what extent the
estimated effects of hospital ownership on performance vary
because studies differ in sample size, state or region studied,
years of data, sophistication of method used to disentangle
ownership from other factors such as patient case-mix, etc.
Population Studied: We review all empirical studies
completed between January 1990 and July 2004 (published or
unpublished) that analyze US acute general short stay
hospitals (or patients that were treated in such hospitals) and
that compare performance of more than one hospital
ownership form. We identify about 200 articles that fit our
search and selection criteria, and group them into the
following categories of hospital performance: financial state,
staffing, mortality and other patient outcomes,
uncompensated care and other community benefits.
Principal Findings: We find that specific study features -such as time period covered or sophistication of controls for
patient differences, selection bias and market spillovers -- can
account for a substantial fraction of the variance in research
findings on how hospital ownership impacts performance.
Conclusions: Ownership does impact performance, but to
what extent depends on the performance measure and on
other factors such as degree of market competition. Prudent
users of ownership research should be aware that certain
study features are associated with specific research results.
Implications for Policy, Delivery, or Practice: Conflicting
empirical results have left regulators with no clear guidance
when facing policy decisions that can potentially affect forprofit, not-for-profit, or government hospitals differently.
Understanding the source of these variations can help
policymakers to craft policies that appropriately acknowledge
the similarities and differences in performance between
hospitals of different ownership form.
Primary Funding Source: RWJF
●Does Physicial Quality Affect Bargaining Power Over
Price in Third Party Contracts?
Donald Klepser, Ph.D., MBA, William R. Doucette, Ph.D., John
M. Brooks, Ph.D.
Presented By: Donald Klepser, Ph.D., MBA, Assistant
Professor, College of Pharmacy, University of Nebraska
Medical Center, 986045 Nebraska Medical Center, Omaha,
NE 68198-6045; Tel: (402) 965-3828; Fax: (402) 559-5673;
Email: donald-klepser@uiowa.edu
Research Objective: A recent focus on the use of value-based
purchasing by employers and public purchasers of health care
has drawn attention to the potential for reimbursement
mechanisms to reward and improve health care quality.
However, there is little empiric evidence to suggest that
current payment systems are able to incorporate quality. That
is, does a physician’s past practice quality influence the prices
received in a selective contracting system? Economic theory
suggests that higher quality physician services should be
associated with higher prices, but no previous research has
examined if provider level quality is rewarded and/or
encouraged in selective contract bargaining. This research
used a bargaining power model developed by Brooks and
colleagues to 1. assess whether cardiologist groups have
bargaining power over price and 2. evaluate whether this
bargaining power varies with physician quality as measured by
previous physician treatment decisions relative to accepted
measures of treatment quality.
Study Design: This retrospective observational study used
1997-98 Medstat MarketScan and Centers for Medicare and
Medicaid Services data to model the effect of market factors
and practice level cardiac care performance in the previous
year on cardiologist group bargaining power. The cardiologist
group-insurance plan bargaining power estimate was based
on the negotiated price, and the highest and lowest prices
received in a market for a bundle of five common cardiology
procedures, office visit, Doppler echocardiography,
echocardiography, stress test, and ECG. The performance
measures consisted of two process quality measures, postacute myocardial infarction beta-blocker prescribing rates and
post-AMI cholesterol screening rates, and two outcome
measures, post-AMI 28 day readmission rates and post-AMI
average patient cost. Cardiology group quality measures were
estimated according to HEDIS and CIHI guidelines and were
based on the claims in the Medstat data. Ordinary least
squares analyses were performed to identify significant
predictors of group bargaining power.
Population Studied: The unit of observation for this study
was the cardiology group-insurance plan dyad. Bargaining
power measures were estimated for 452 distinct cardiology
group-insurer dyads. Insufficient data for some quality
measures restricted some analyses to a subset of the 452
observations.
Principal Findings: Bargaining power was modeled at the
cardiology group level with physician quality, market and
insurer factors significantly influencing cardiology group
bargaining power. There was a statistically significant negative
relationship between the 28-day AMI patient readmission rate
and cardiologist bargaining power, suggesting that higher
quality is related to higher bargaining power. Cardiologists
per capita and primary care physicians per capita were both
significantly related to cardiologist bargaining power.
Conclusions: It is possible to estimate and model provider
level bargaining power and it appears as though providers
may be able to influence the prices they receive based on their
performance. However, future research is needed to validate
these findings in a larger sample.
Implications for Policy, Delivery, or Practice: The results of
this study suggest that provider quality is being incorporated
into the bargaining process used to set prices for physician
services.
Primary Funding Source: No Funding
●An Evaluation of Hospital Capital Investment after BBA
Tae Hyun Kim, Michael J. McCue, D.B.A.
Presented By: Tae Hyun Kim, Research Assistant, Health
Administration, Virginia Commonwealth University, 1108 East
Clay Street, Richmond, VA 23298; Tel: (804)828-5329; Fax:
(804)828-1894; Email: kimth@vcu.edu
Research Objective: This study aims to evaluate the
relationship between the amount and the type (fixed vs.
moveable) of capital expenditures of hospitals with their
market, mission, operational, and financial factors after the
Balanced Budget Act (BBA) of 1997. The research objectives
of this study are to investigate the following questions: 1) Did
hospital market conditions, such as competition, number of
physicians and increased utilization by patients affect the
demand for capital expenditures? 2) Did investor-owned and
system-affiliated hospitals demonstrate a difference in capital
investment? 3) How did the hospital capacity and complexity
of services influence capital investment? 4) Did the amount
of liquidity, cash flow and debt capital relate to the amount of
capital expenditures?
Study Design: Empirical analysis for this study employs
pooled cross-sectional and time series design. The empirical
models are estimated by ordinary least squares (OLS)
regressions and then heteroskedasticity and serial correlation
are tested for further estimation. The dependent variable is
defined as capital investment per unit of fixed assets, and is a
function of previous stated market, mission, operational,
financial and control variables. Models will be evaluated by
type of investment (fixed vs. moveable) as well. Hospital
financial statements data, including capital investment, are
obtained from the Centers for Medicare and Medicaid
Services’ (CMS) Medicare cost report data. Other data
sources include the American Hospital Association’s (AHA)
Annual Survey of Hospitals and the Area Resource File (ARF).
Population Studied: To estimate the effects of being in the
post-BBA period on the amount and type of investment, the
study population consists of U.S. hospitals during the fiscal
years 1998-2002.
Principal Findings: Recent anecdotal evidence indicates that
the average annual growth in hospital capital expenditure
between 1997 and 2001 was just one percent (HFMA, 2004).
More specific findings of this study will be based on the test of
the following hypotheses: H1: Hospitals operating in markets
with a greater number of physicians, patient utilization and
competition will have capital investment. H2: For-profit and
system-affiliated hospitals are more likely to possess a greater
amount of capital investment. H3: Hospitals with a larger bed
size, fewer unoccupied beds and wider range of services will
have greater capital investment. H4: Hospitals with higher
liquidity and cash flow and less debt capital will have greater
capital investment.
Conclusions: This study will demonstrate that Medicare
reimbursement cuts from the Balanced Budget Act of 1997
may have impacted the funding of future hospital capital
needs during the late 1990’s and early 2000’s. Results will
also suggest that certain characteristics are critical in the
amount and the type of hospital capital investment.
Implications for Policy, Delivery, or Practice: Identification
of the factors associated with capital investment will enable
hospital managers and investors to monitor the capital need
of hospitals and to improve their capital planning. In addition,
the results will inform policy makers and government
regulators if the difference in capital spending is attributable
to market structure or hospital decisions.
Primary Funding Source: No Funding
●Does Hospital Price Competition Influence Nurse
Staffing and Quality of Care?
Julie Sochalski, Ph.D., Kevin Volpp, M.D., Ph.D., R. Tamara
Konetzka, Ph.D., Jingsan Zhu, MBA, Joanne Spetz, Ph.D.
Presented By: Julie Sochalski, Ph.D., Associate Professor,
School of Nursing, University of Pennsylvania, 420 Guardian
Drive, Philadelphia, PA 19104; Tel: (215)898-3147; Fax:
(215)573-7492; Email: julieas@nursing.upenn.edu
Research Objective: Price competition between hospitals has
been shown to reduce the rate of growth in hospital costs,
though little is known about how price competition has
affected quality of care. This study examines whether price
competition among hospitals induced reductions in nurse
staffing and the consequences for patient outcomes.
Study Design: The study focuses on hospitals in California
where selective contracting legislation, passed in 1982, created
significant price competition among hospitals which resulted
in lower hospital cost growth. Annual hospital financial data
and patient discharge data for 1983 through 2001 from
California’s Office of Statewide Health Planning and
Development were used to determine whether increasing
price competition led to cutbacks in the total hospital
workforce and in particular the hospital nursing workforce
(RN, LVN, and nurse aides), and to examine if and how these
effects differ across hospital market areas. We assess the
impact of these staffing changes on 30-day inpatient mortality.
We include HMO penetration as well as an interaction
between HMO penetration and hospital market concentration
to examine whether managed care effects are mediated by
hospital market area competition. We use hospital fixed
effects to control for time-invariant differences between
hospitals.
Population Studied: 478 short-term acute hospitals and
657,523 patients with a primary diagnosis of AMI linked with
state death certificates.
Principal Findings: RN hours per patient day (RN ratio) rose
with increasing HMO penetration from 1988-1997 and then
declined significantly through 2001. In contrast, the trends in
the most competitive markets showed significantly that
competition was associated with lower nurse staffing from
1993-1997 and higher nurse staffing ratios from 1998-2001.
LVN hours per patient day fell consistently with increasing
HMO penetration and this was also true since 1988 for nurse
aides. AMI mortality declined significantly as the RN ratio
rose, though changes in LVN and nurse aide hours did not
influence differential mortality. While mortality rose to a
significantly greater degree in more competitive markets, this
effect did not appear to be mediated by the changes in the RN
ratio.
Conclusions: Price competition has influenced hospital
decisions about the use of nursing services among RNs,
LVNs, and nurse aides. Decreases in RN staffing led to higher
mortality rates for AMI patients. However, reductions in nurse
staffing did not appear to be the mechanism by which
increasing price competition negatively affects mortality.
Implications for Policy, Delivery, or Practice: The causal
association between mortality and RN staffing could fuel the
debate on the advisability of mandatory hospital nurse staffing
ratios, recently legislated in California and under consideration
nationwide. Increasing staffing levels alone, though, will not
be sufficient to ameliorate the adverse effects of other market
forces on quality of care.
Primary Funding Source: Doris Duke Charitable Foundation
●Differences in For-Profit and Not-For-Profit Hospital
Behavior: an Examination of Failure-to-Rescue in the
Aftermath of the Balanced Budget Act of 1997
David Song, M.D., Kevin G. Volpp, M.D., Ph.D.
Presented By: David Song, M.D., Ph.D. Candidate, Health
Care Systems, The Wharton School of Business, 1815 JFK
Boulevard #829, Philadelphia, PA 19103; Tel: (215) 561-0895;
Email: dasong@wharton.upenn.edu
Research Objective: Previous research demonstrated that
cuts in reimbursements to hospitals due to the Balanced
Budget Act of 1997 (BBA) had an adverse impact on heart
attack mortality in California. That work was inconclusive in
detecting differences in heart attack mortality trends between
for-profit (FP) and not-for-profit (NFP) hospitals. The
objective of our study is to determine whether the BBA had an
adverse impact on death rates following surgical
complications (failure-to-rescue rates), and whether there are
differences in hospital behavior between FP and NFP hospitals
following the law’s implementation.
Study Design: We used Medicare cost reports, California
hospital-level data from OSHPD, and California patient
discharge data from 1996-2000 – in order to: (1) determine
whether FP hospitals adversely adjusted failure-to-rescue rates
to a greater degree than NFP hospitals due to the BBA, and
(2) attribute differences to changes in registered nurse (RN)
staffing levels. Using revenue forecasts from the AHA, we
simulated the impact of the BBA for each hospital to construct
a measure of BBA’s impact on hospital revenue (low,
medium, high impact). We modeled patient-level failure-torescue in CA as a function of hospital and market
characteristics, controlling for patient risk factors,
intertemporal trends, and hospital’s BBA revenue exposure.
We also modeled hospital-level RN staffing as a function of
these same hospital and market characteristics, including BBA
revenue exposure and ownership form.
Population Studied: 130,889 CA patients who developed the
following surgical complications from 1997 to 2000: acute
renal failure, pulmonary embolism, pneumonia, sepsis, shock,
and GI hemorrhage.
Principal Findings: For a given expected change in total
revenue during the immediate post-BBA period, patients in FP
hospitals had a statistically significant increase in mortality
from complications relative to patients in NFP hospitals. In
1999, FP hospitals that were moderately impacted by BBA
experienced an increase of 3.6 deaths per 100 patients more
than NFP hospitals (p=0.09), while this difference is 2.0
deaths per 100 patients (p>0.1) in the highest quartile of BBA
revenue impact. In 2000, patients at FP hospitals experienced
5.5 more deaths per 100 patients than at NFP hospitals
(p=0.06) in mid-impact hospitals, while the difference was 4.0
deaths per 100 patients (p=0.10) in the hospitals most
impacted by BBA quartile. In 1999 and 2000, patients at FP
hospitals in the lowest quartile experienced 1.5 (p>0.1) and 3.1
(p>0.1) fewer deaths per 100 patients, respectively, than at
NFP hospitals in the lowest quartile. For a 1 percent decrease
in revenue from the BBA, FP hospitals cut RN staffing levels
by 0.4 RN hours per adjusted patient day (p<0.05). We did
not find a significant association between BBA revenue
change and RN staffing level change in NFP hospitals; this
differential response by ownership form was statistically
significant (p=0.02). However, changes in failure-to-rescue
rates were not attributable to these staffing cuts (p>0.1).
Conclusions: FP hospitals responded to BBA cuts to a greater
degree than NP hospitals by cutting RN staffing levels and
patients at FP hospitals experienced marginally higher failureto-rescue rates, though the higher failure-to-rescue rates were
not directly mediated by changes in RN staffing levels.
Implications for Policy, Delivery, or Practice: The
government’s attempt to reign in health care costs could
adversely impact health care quality in acute hospitals,
particularly at FP hospitals. The quality impacts and
cost/quality tradeoffs of cost-saving reforms should be
monitored closely.
Primary Funding Source: National Bureau of Economic
Research and Doris Duke Charitable Foundation
Related Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Using Risk Adjustment Models to Compare Illness
Burden and Health Care Utilization in TRICare Prime
Arlene Ash, Ph.D., Amresh Hanchate, Ph.D., Jeanne
Speckman, MSc, Jennifer Fonda, MA, Nancy McCall, Sc.D.,
Thomas V. Williams, Ph.D.
Presented By: Arlene Ash, Ph.D., Research Professor, Health
Care Research Unit, Boston University School of Medicine,
720 Harrison Avenue, Boston, MA 02118; Tel: (617) 638-7518;
Fax: (617) 638-8026; Email: aash@bu.edu
Research Objective: Health care expenditures of populations
are strongly influenced by their overall illness burden (casemix). Thus, understanding non-medical factors that influence
health care utilization and costs requires risk adjustment.
Several mature risk adjustment systems have been developed
for extracting illness burden profiles from computerized
encounter records, and used extensively for understanding
and managing health care delivery systems including
Medicare, Medicaid, the Veteran’s Health Administration, and
many commercial insurers in the US. We applied three risk
adjustment tools to the Military Health System, to evaluate
their overall ability to predict costs and to judge concordance
between illness burden and health care spending across
different subgroups.
Study Design: 2.3 million TRICARE Prime beneficiaries
continuously enrolled throughout FY2001-2002, were
randomly split into an estimation sub-sample of 1.8 million
and a validation sample of 0.5 million. The three risk
adjustment models (ACG, CDPS, DCG) were used separately
with FY 2001 diagnoses (ICD-9-CM codes) to obtain healthbased predicted expenditures for FY 2002 for the validation
sample. Predictive ratios (mean predicted / mean actual) were
calculated to assess concordance between illness burden and
actual expenditures. Subpopulations were obtained based on
individual rank, location and service type.
Population Studied: We obtained administrative data on
enrollment and claims (including diagnoses) for all TRICARE
Prime enrollees in fiscal years 2001 and 2002 under the age of
65 and continuously enrolled during FY2001-2002.
Principal Findings: The average annual health care
expenditure among TRICARE Prime enrollees in FY2002 was
$1,796. Expenditures for most subgroups were rather closely
matched to predictions for those groups based on each of the
three risk adjustment methods (predictive ratios near 1.00),
although the models varied in their ability to predict. For
instance, partitioning by beneficiary status (active duty, retired,
dependent) indicated a wide range of subpopulation mean
actual expenditures – from $1,413 among active duty to $2,897
among retired (a factor of more than 2 to 1), while predictive
ratios ranged from 0.93 to 1.03. We examined actual vs.
predicted costs separately for beneficiaries by whether their
residence was in a catchment area for a Military Treatment
Facility (MTF), with the thought that those closer to such
facilities might be higher utilizers. Mean actual expenditures
for the catchment group was $1,826, $94 more than that for
the non-catchment population. In contrast all three riskadjustment models predicted mean costs for catchment
population to be about $100 lower.
Conclusions: Off-the-shelf risk adjustment models developed
in other populations work well for predicting costs in the
MHS. The ability to predict health-based costs for important
subgroups offers the opportunity to explore non-medical
contributions to cost. The discrepancy between actual and
expected costs for enrollees in the Military Health System is
just one example of discrepancies that deserve further
exploration.
Implications for Policy, Delivery, or Practice: Populationbased risk adjustment tools are likely to be as useful in
understanding variations in health care utilization and costs in
the MHS as in other health care delivery systems.
Primary Funding Source: Department of Defense
●Estimating Hospital Efficiency: Comparing Results From
Stochastic Frontier Analysis and Neural Networks for
Single Output
Shalini Bagga, MA, M. Mahmud Khan, Ph.D., Ila M. Semenick
Alam, Ph.D.
Presented By: Shalini Bagga, MA, Graduate Student,
Economics, Tulane University, 206 Tilton Hall, Tulane
University, New Orleans, LA 70118; Tel: (504) 862-8348; Email:
sbagga@tulane.edu
Research Objective: This paper focuses on different methods
of estimating hospital efficiency, and pinpoints factors that
can affect the efficiency of our hospitals, while controlling for
quality. We estimate the efficiency of 415 hospitals from all
over US.
Study Design: Efficiency has been estimated by explicitly
controlling for quality of the services provided, using the
following controlling factors: teaching status, location, size,
ownership, geographic region, severity, reservation quality,
race of the patients, insurance status, median household
income of patients, share of patients admitted on the
weekends. Quality measures outlined by AHRQ were derived
from the data set, controlling for patients’ age and sex.
Efficiency is estimated using two methodologies: (i) Stochastic
frontier analysis using Cobb-Douglas, translog, and Box-Cox
specifications; and (ii) Artificial Neural Network (ANN). This
is the first paper to estimate hospital efficiency using ANN.
Population Studied: Data is combined from two different
sources: Nationwide Inpatient Sample (NIS) and Medicare
Cost Reports, for the year 2001.
Principal Findings: Both the scaled and unscaled ANN
measures give higher mean efficiencies for both models. We
then estimate efficiency using a known production function to
find out how each model actually performs.
Conclusions: Results indicate that a correct method of
frontier estimation would be to first plot the inputs and
output. If the function is relatively simple and there is no
significant non-linearity, the stochastic frontier analysis can be
undertaken instead of the ANN methodology. This is because
the ANN techniques are costly in terms of software costs and
time. In other words, a cost-benefit analysis should be
performed before choosing a method to calculate efficiency.
Implications for Policy, Delivery, or Practice: Results
indicate that a correct method of frontier estimation would be
to first plot the inputs and output. If the function is relatively
simple and there is no significant non-linearity, the stochastic
frontier analysis can be undertaken instead of the ANN
methodology.
Primary Funding Source: No Funding Source
●Fatal Deviations & Collateral Consequences: Physicians
Barred from Participating in Medicare & Medicaid for
Fraud and Abuse Violations.
Jane Bolin, Ph.D., JD, BSN, Bita A. Kash, MBA, Linda Clark,
MHA
Presented By: Jane Bolin, Ph.D., JD, BSN, Assistant Professor,
Health Policy & Management, Texas A&M HSC School of
Rural Public Health, 3000 Briarcrest Suite 300, Bryan, TX
77802; Tel: (979) 862-4238; Fax: (979) 862-8371; Email:
jbolin@srph.tamhsc.edu
Research Objective: (1) Examine and identify factors
associated with physician exclusion from medical practice for
fraud and abuse; (2) Examine likelihood of specific categories
of exclusion using multivariate analysis.
Study Design: Using multivariate probit analysis we examine
physicians who have been excluded from participating in
Medicare or Medicaid programs for fraud and abuse.
Descriptive statistics are conducted analyzing associations
between type of medical practice, are, race, sex, and type of
sanction. Dependent variables in multivariate probit analysis
are (1) fraud related sanction (2) adverse license action; (3)
adverse peer review and (4) drug conviction.
Population Studied: We analyzed a combined database of
OIG exclusions + AMA demographic and professional
background data resulting in a match of 3,196 sanctioned or
prosecuted physicians, including MDs and Osteopaths.
Principal Findings: Any fraud sanction strongly predicts exit
from the practice of medicine, with 71% of all physicians in the
exclusion database reporting retirement or professional
inactivity. Specialties most often associated with exclusion are
internal medicine (24%) and family/general/pediatric
physicians (22%). Most common violations leading to
exclusion are license revocation or suspension (56%), and
fraud related crime (29%). Probit analysis showed that
family/general/pediatric physicians are significantly more likely
than other physicians in the database to be excluded for
controlled substances (p < .05); while Blacks, Hispanics and
Asians are significantly more likely than Whites to be excluded
for fraud (p <.05). However, Blacks, Hispanics and Asians are
less likely than Whites to be excluded from Medicare or
Medicaid participation for an adverse licensing action (p <
.05).
Conclusions: This research provides evidence that there is an
association between a physician’s specialty and the type of
conduct resulting in exclusion from Medicare or Medicaid
participation. This research suggests that there may be an
association between an MD’s race and type of sanction.
Implications for Policy, Delivery, or Practice: Each year
hundreds of physicians are sanctioned and ultimately
excluded from participating in Medicare and Medicaid patient
care programs. Further examination of key predictors
associated with fraud and abuse may provide federal and state
regulators with more effective deterrents and prevention
measures precluding fraud or patient harm and averting the
fatal professional consequences for physicians.
Primary Funding Source: Texas A&M School of Rural Public
Health
●A Multi-institutional Assessment of Resource Use in
Primary and Revision Total Joint Replacement
Kevin Bozic, M.D., MBA, James M Naessens, MPH, Amy
Wagie, BS, Danial Berry, M.D., Miriam Cisternas, MA, Sridant
Durbhakhala, M.D.
Presented By: Kevin Bozic, M.D., MBA, Assistant Professor in
Residence, Department of Orthopaedic Surgery, University of
California San Francisco, 500 Parnassus, MU 320W, San
Francisco, CA 94143-0728; Tel: (415) 476-3900; Fax: (415) 4761304; Email: BozicK@orthosurg.ucsf.edu
Research Objective: Measure differences in patient and
procedure characteristics and hospital resource utilization
between different types of primary and revision TJR
procedures at three high volume joint replacement centers.
Study Design: A retrospective cost-identification cohort study
design was used to collect and analyze clinical, demographic
and economic data for unilateral primary or revision total hip
replacement (THR) procedures and unilateral primary or
revision total knee replacement (TKR) procedures that were
performed at one of three academic centers. THR was defined
by four CPT codes: 27130 (primary total hip arthroplasty),
27134 (revision acetabular component only), 27137 (revision
femoral component only), and 27138 (two-component
revision). TKR was defined by three CPT codes: 27447
(primary total knee arthroplasty), 27486 (revision total knee
arthroplasty, one component), and 27487 (revision total knee
arthroplasty, both components). Partial hip arthroplasty
(27132) and partial knee replacement (27446) were excluded.
Population Studied: 4533 THR procedures and 3508 TKR
procedures performed at Mayo Clinic, Rochester, Minnesota;
Massachusetts General Hospital, Boston; or University of
California, San Francisco Medical Center between January 1,
2000 and January 31, 2003 were included.
Principal Findings: Patients with either revision THR or TKR
were older and had higher ASA class than primary patients.
Mean total operative time was significantly longer for both
component revision THR (303.2 minutes) and isolated
femoral component revision THR (293.4 minutes) than for
isolated acetabular component revision THR (237.6 minutes)
or primary THR (198.7 minutes). Mean total operative time
was significantly longer for both component revision TKR
(265.3 minutes) and single component revision TKR (220.5
minutes) than for primary TKR (199.7 minutes) (p<0.0001).
Hospital costs were highest for both component revision THR
(138%), followed by isolated femoral component revision THR
(129%), isolated acetabular component revision THR (101%)
and primary THR (100%) (p<0.0001). Hospital costs were
highest for both component revision TKR (138% of primary
TKR costs), followed by single component revision TKR
(114%) and primary TKR (100%) (p<0.0001).
Conclusions: Significant differences exist between patient
characteristics, procedure characteristics, and hospital
resource utilization among different types of primary and
revision TJR procedures. The lack of differentiation between
types of revision TJR procedure in the current ICD-9-CM
procedure coding system limits the utility of these codes in
evaluating differences in characteristics in large public
datasets such as the MEDPAR database. We found that both
component revision THR procedures were 38% more costly
than primary THR procedures, and both component revision
TKR procedures were 38% more costly than revision TKR
procedures. Despite these differences, hospital
reimbursement is the same for all TJR procedures under
DRG’s 209 and 471, regardless of differences in patient
characteristics or resource utilization.
Implications for Policy, Delivery, or Practice: The significant
discrepancy between resource utilization and reimbursement
for revision TJR procedures has resulted in substantial
financial losses for hospitals that perform high volumes of
revision TJR procedures and has created perverse financial
disincentives that have deterred many hospitals from
providing care for patients with failed TJRs. Having more
detailed, accurate and descriptive ICD-9-CM procedure codes
would enhance public health efforts and could lead to more
equitable reimbursement for appropriate total joint revision
procedures.
Primary Funding Source: Institutional
Study Design: Each study was designed to quantify the wellbeing outcomes and expenditures associated with different
community-based approaches to care provided in the context
of a system of national health insurance. Multiple-perspective
client well-being outcome measures were used. In two
studies, caregiver burden also was analysed. A common
approach to quantification and evaluation of expenditures for
service consumption was used in all 12 studies.
Population Studied: In the 12 studies, sample composition
and size varied. Studies were of vulnerable adults,
adolescents, seniors with a variety of chronic illnesses and
circumstances.
Principal Findings: The nature of community-based health
services (health vs. disease care orientation) was found to
have direct and measureable impact on total expenditures for
health service utilization and client well-being outcomes. In
most cases, a recurring pattern of equal or better client
outcomes, yet lower expenditures for use of community-based
health services, was associated with well-integrated health
oriented services.
Conclusions: Integrated services aimed at factors which
determine health care superior when compared to individual,
fragmented, disease oriented, and focussed approaches to
care. The main lesson from the 12 studies are that it is as or
more effective and as or less expensive to offer complete,
proactive, community health services to persons living with
chronic circumstance than to provide focussed, on-demand,
piecemeal services.
Implications for Policy, Delivery, or Practice: Complete
services would have a psychosocial and mental health focus
included with the physical care approach. Furthermore,
people with coexisting risk factors (age, living arrangements,
mental distress and problem-solving ability), are the ones who
most benefit at lower expense from health oriented, proactive
interventions.
Primary Funding Source: Health Canada and the Ontario
Ministry of Health and Long Term Care
●Economic Evaluations of Community-Based Care:
Lessons From 12 Studies in Ontario
Gina Browne, Ph.D., RN, Jacqueline Roberts, MSc, RN,
Amiram Gafni, Ph.D., Carolyn Byrne, Ph.D., RN, Robin Weir,
Ph.D., RN, Basanti Majumdar, PhD, RN
Presented By: Kathleen Carey, Ph.D., Assistant Professor,
School of Public Health, Boston University, 715 Albany Street,
Boston, MA 02118; Tel: (781) 687-2140; Fax: (781) 687-2376;
Email: kcarey@bu.edu
Research Objective: Contract management, where day-to-day
operation is contracted to an outside organization, is a
growing form of organization in the U.S. hospital industry yet
one that has received surprisingly little attention in health
services research. Limited evidence suggests that contract
management may improve hospital performance, however
there is not much understanding of what contract managers
do and at what social costs they may attain efficiencies. One
area of concern is potential adverse effects on access to care,
as contract-managed (CM) hospitals, which are frequently
located in rural areas, tend to offer fewer services. However,
contract managers may reduce services that are duplicated in
the community, thus contributing to efficiency. This research
explores these consequences of contract management by
comparing CM hospitals with neighboring hospitals to
Presented By: Gina Browne, Ph.D., RN, Founder & Director,
System-Linked Research Unit on Health and Social Service
Utilization; Professor, Nursing & C.E.&B., School of Nursing,
McMaster University, Faculty of Health Sciences at Frid Street,
75 Frid Street, Building T30, Hamilton, Ontario, L8P 4M3; Tel:
(905) 525-9150 x22293; Fax: (905) 528-5099; Email:
browneg@mcmaster.ca
Research Objective: A series of 12 randomized trials
examined clients in community settings in Southern Ontario
suffering from a variety of chronic physical and mental health
conditions. These studies funded by Health Canada and the
Ontario Ministry of Health are appraised using a framework
for evaluating possible outcomes of economic evaluation.
●Contract Management in U.S. Hospitals: Community
Benefits and Neighborhood Effects
Kathleen Carey, Ph.D., Avi Dor, Ph.D.
determine the impact of their service offerings on the
community.
Study Design: The major data source is the American
Hospital Association (AHA) database for 1997 and 2002 from
which we identify 74 unique service offerings for CM and
traditionally managed hospitals. Descriptive analyses show
the percentage of CM hospitals offering a specific service
compared to non-CM hospitals for each service in each year.
We also calculate by service/year the percentage of CM
hospitals offering and not offering the service for which the
service was available at a ‘neighbor’ hospital located within 10
and 20-mile radii. Using a multinomial ordinal logistic model
for each service, we estimate the probability that a CM
hospital adds, exhibits no change in, or drops the service
between 1997 and 2002. Independent variables measuring
neighboring hospital service offerings allow us to test
hypotheses regarding whether CM service provision is related
to that of local competitors. Controls for county level demand
side factors obtained from the Area Resource File include age
and population distributions, MDs per capita, HMO
penetration rate, total Medicare and Medicaid patients, per
capita income, and unemployment. We apply the generalized
estimating equation (GEE) method of estimation in order to
accommodate the statistical dependence between repeated
observations on hospitals. We also group services and
perform alternative estimations for 15 service dimensions.
Population Studied: We include all acute care nonfederal U.S.
hospitals for the years 1997 and 2002.
Principal Findings: Preliminary analyses indicate that while
CM hospitals offer fewer services than traditionally managed
hospitals, both management types experienced a modicum of
growth in service provision. With the exception of geriatric
and long-term care services, CM hospitals without
neighboring hospitals within 10 or 20 mile radii provide fewer
services than do CM hospitals amid neighbors. Services tend
to be offered by ‘neighbor’ hospitals much more often when
the core CM hospital also offers the service than otherwise.
Conclusions: The disadvantages of lower service provisions
in CM hospitals may not be offset by efficiency gains
associated with a reduction in service duplication.
Implications for Policy, Delivery, or Practice: Contract
management is a growing channel for introducing private
incentives into the predominantly not-for-profit U.S. hospital
industry. In the public interest, it is essential that societal cost
and benefits be included in the valuation of efficiencies
following from contract adoption.
Primary Funding Source: No Funding Source
●The Economic Costs of Percutaneous Coronary
Intervention (PCI) and Thrombolytic Therapy in the
Treatment of Acute Myocardial Infarction (AMI)
Thomas Concannon, MA, David M. Kent, M.D., MS, Joni
Beshansky, RN, Sharon-Lise Normand, Ph.D., Harry Selker,
M.D., MSPH, Joseph P. Newhouse, Ph.D.
Presented By: Thomas Concannon, MA, Pre-Doctoral
Scholar, Health Policy, Harvard University, 49 Symphony
Road, Boston, MA 02115; Tel: (617)236-6567; Email:
concann@fas.harvard.edu
Research Objective: Based on clinical evidence that primary
coronary intervention (PCI) confers survival benefit over
thrombolytic therapy (TT) in the treatment of acute myocardial
infarction (AMI), many hospitals have moved to provide PCI
on a 24/7 basis. Expansion of PCI capability has extended to
many small community-based hospitals where lower
procedure volumes may be associated with poorer outcomes
and higher costs, and this expansion continues in the absence
of up-to-date and reliable estimates of the economic costs of
both PCI and TT. This research is intended to establish a
generalizable method for estimating the economic costs of
PCI and TT in hospitals of varying size.
Study Design: The variable costs of initial and follow-up care
after an index AMI are observed directly from the
Eclipsys/Transition Systems, Inc. (TSI) cost system of TuftsNew England Medical Center. Clinical trial literature is used
to project initial and follow-up care for each treatment through
30 days and 6 months. Fixed costs for PCI, including those
associated with building and staffing a new cardiac
catheterization (“cath”) lab, are obtained from interviews with
hospitals recently undergoing such expansion. Fixed costs are
absorbed into the average cost of PCI by assuming that new
cath labs operate for 10 years in a hospital with a moderate
volume of 200 AMIs per year. Sensitivity analyses provide
cost estimates in hospitals with both larger and smaller
volumes.
Population Studied: AMI patients seen during 2002 for initial
and follow-up care at Tufts-New England Medical Center.
Principal Findings: The results are expected to provide 1) a
generalizable model for estimating the fixed and variable costs
of the PCI and TT in hospitals of varying size 2) sound
estimates of the 30 day and 6 month economic costs of PCI
and TT in a hospital with a moderate volume of 200 AMIs per
year.
Implications for Policy, Delivery, or Practice: In the rapidly
changing environment of emergency care for AMI, the results
should be of interest to hospital providers, third party payers
and policy makers.
Primary Funding Source: AHRQ
●Organizational Attributes Important in Leaders' Efforts
to Transform Health Care
Irene E. Cramer, Ph.D., MSSA, Michael Shwartz Ph.D.; Sally K.
Holmes MBA, Joseph Restuccia DrPH, Alan B. Cohen ScD,
Carol VanDeusen Lukas EdD, Jenny Sullivan, MA, Mark
Meterko, PhD, Martin P. Charns, DBA
Presented By: Irene E. Cramer, Ph.D., MSSA, Investigator,
Center for Organization, Leadership and Management
Research, Veterans Administration Boston Healthcare System,
150 South Huntington Avenue (152M), Boston, MA 02130; Tel:
(617) 232-9500 x5758; Fax: (617) 278-4438; Email:
irene.cramer@med.va.gov
Research Objective: To transform healthcare, leaders must
focus on attributes related to quality. In our evaluation of the
Robert Wood Johnson Foundation’s Pursuing Perfection (P2)
Program, we examine how twelve organizations (seven P2
sites and five comparison sites) with strong commitments to
quality improvement (QI) have attempted to transform patient
care. We describe findings from a survey of employees at P2
sites that assessed organization-wide and workgroup-specific
characteristics associated with perceived quality of patient
care.
Study Design: We designed a mail survey targeted to
employees at all levels of an organization. The questions,
reflecting the Institute of Medicine’s Crossing the Quality
Chasm’s Six Aims (IOM), focused on the organization’s
values and behaviors, workgroup-specific values and
behaviors, employee job satisfaction, and demographics.
Population Studied: We used the P2 organizations’ lists of
paid employees and affiliated physicians to identify a stratified
random sample of physicians, nurses, other clinical
employees, non-clinical employees, and P2 staff. The sample
of 2470 reflects a mean response rate of 36%, ranging
between 26%-40%.
Principal Findings: Factor analysis and multitrait analysis
were used to develop and assess 13 scales. These scales and
selected individual survey items were subsequently used in
stepwise regression models to predict two dependent
variables: assessment of the quality of patient care, and
comfort with having a family member treated at the hospital.
Covariates forced into the models included demographics (job
category, age, gender), time worked at the organization and in
the current workgroup, involvement with QI activities, and
familiarity with P2 activities. Prediction models for both
outcomes were examined at two levels: organization and
workgroup. R2s of .461 and .423 were obtained for the two
models. Significant in both models at the organizational level
were employees’ perceptions about organizational
commitment to perfect care, recognition that drastic
measures are needed, plans to achieve quality goals,
employment of people with passion and influence to make
change, and commitment to preventing delays. Significant in
both models at the workgroup level were employees’
perceptions of the coordination of care, whether patients get
appropriate amounts of care, whether delays affect care,
workgroup functioning, and communication with other
workgroups. These ten variables represent 88% of the total
R2s for each model. Other organizational variables significant
in one of the two models include the organization’s
communication about change, use of easily understandable
clinical measures, efficiency, and a focus on patient
centeredness. Workgroup-specific variables significant in one
of the two models include a commitment to quality reflected
in daily activities, difficulties addressing quality problems
across workgroups, integration of innovation into workgroup
efforts, adequate resources/support adequate for
improvement, process to inform patients when harm is done
to them, and current and past employee job satisfaction.
Conclusions: At the organization level, important variables
associated with quality were related to the organization’s focus
on change and strategic planning; at the workgroup level,
variables reflected day-to-day functioning of the unit.
Implications for Policy, Delivery, or Practice: Variables
identified as having a significant relationship to perceived
quality can help organizations prioritize strategic, operational
and attitudinal changes necessary for achieving their goals.
Primary Funding Source: RWJF
●The Nature of Internal Mediator and Moderator
Influences in an Healthcare System in Transition
Stiofan DeBurca, Ph.D., MA
Presented By: Stiofan deBurca, Ph.D., M.A, Chief Officer, ,
Health Service Executive, Mid-Western Area, 31-33 Catherine
Street, Limerick, Ireland, Tel: 00353 61 483249; Fax: 00353
61483516; Email: treidy@mwhb.ie
Research Objective: This study explores the nature of internal
mediator and moderator influences through the perspectives
of two major activity domains in the Mid-Western Health
Board as a healthcare system in transition. The general
context of this case study relates to reform in the public
service and in healthcare systems with particular reference to
the Irish experience. Theorectical perspectives clarify the
nature of management and the professions and the tensions
between them. Models and approaches in the literature on
organisational change and leadership are also examined.
Study Design: An inductive grounded research method, in
this study, avoids a priori assumptions of leadership in a
context of ambiguity and uncertainty. This provides
opportunity to discover alternative explanations of internal
change influence. The analytic framework is based upon
category/paradigm analysis which relies on multiple data
streams generated through two major activity domains
(managerial and professional).
Population Studied: The study population where managerial
and professional employees of the Mid Western Regional
Services this provides a wide range of dispersed health and
personal social health services. They represent managerial and
professional domains both at corporate level and in a variety
of service settings. They provide six data groups in this
qualitative study which was conducted over a period of 3
years.
Principal Findings: The findings are presented as an
emergent model which accounts for the various components,
categories and the inter-linkages arising from the analysis of
the respondents' data. These components are external and
internal contexts, antecedent and actual experience from the
perspectives of two major domains, emerging as three activity
strands: mediator influences, mediating through people and
the operational system. The model's holistic framework is
therefore grounded in the domains' interpretation of their
experience of internal mediators and moderators of change.
Conclusions: The relevant extant literature demonstrates the
relevance of the emergent model as an explanatory and
evelopmental framework. it elucidates aspects of the internal
logic of the organisation's influencing capacity as mediators
and moderators of change rather than imposing external
reductionist logic on participants' experience. Some
recommendations for future research are indicated.
Implications for Policy, Delivery, or Practice: The
emergence of a grounded model based upon the subjects'
naratives provides a departure from traditional n-step
programmatic change models which are conventionally
problematic in healthcare systems. It fits the lived experience
of the subjects and is dynamic - processical and contextual in
nature. Consequently it is compatible with its own internal
and external drivers and levers for change.
Primary Funding Source: Corporate Body
●Measuring Hospital Surge Capacity
Derek DeLia, Ph.D.
Presented By: Derek DeLia, Ph.D., Assistant Professor/Senior
Policy Analyst, Rutgers Center for State Health Policy, 317
George Street, New Brunswick, NJ 08901-2008; Tel: (732)9323105; Fax: (732)932-0069; Email: ddelia@ifh.rutgers.edu
Research Objective: Hospitals require adequate surge
capacity to respond to mass casualty events (e.g., terrorist
attacks, natural disasters). Surge capacity can vary from day to
day and its measurement may be affected by the types of
services that are included when defining “unavailable
capacity”. This paper develops and compares alternative
measures of surge capacity to be used in emergency planning
and management.
Study Design: Surge capacity is measured as the percentage
of hospital beds that are unused – specifically, 100 minus the
inpatient occupancy rate (OR). Alternative measures of this
capacity are developed by varying the period of time covered
(daily vs. quarterly) and services counted in the OR numerator
(e.g., ambulatory surgery). All OR calculations are performed
using licensed (rather than maintained) beds. This produces
conservative (i.e., larger) estimates of surge capacity than
would be obtained using maintained beds. Since it is done
consistently in all calculations, the use of licensed beds for
calculating OR’s does not affect comparisons among
alternative measures.
Population Studied: New Jersey acute care hospitals in the
third quarter of 2002 (n=78). Remaining quarters of 2002 will
be added to the analysis.
Principal Findings: In 2002-Q3, the average hospital in NJ
had an OR of 56%, which suggests 44% of inpatient capacity
would have been available for an unexpected surge in patient
volume. Moreover, 98% of hospitals had OR’s less than 90%
suggesting more than 10% surge capacity for most hospitals
in 2002-Q3. Surge capacity is significantly less, however, for
some hospitals during certain days within the quarter. For
example, 22% of the hospitals experienced at least one day
with at least 95% of its beds occupied leaving little surge
capacity available. Among these hospitals, the average
percentage of days at this high level of occupancy was 42%.
When ambulatory surgery is included in the calculation, the
average daily OR rises to 71% and the percentage of hospitals
experiencing at least one day with at least 95% of its beds
occupied rises to 35%. Among this larger group of hospitals,
however, the average percentage of days at this high level of
occupancy falls to 33%.
Conclusions: Quarterly measures of hospital occupancy can
greatly overstate available surge capacity on certain days of the
year. Failure to account for the use of surgical beds for
ambulatory surgery leads to a further overstatement of surge
capacity.
Implications for Policy, Delivery, or Practice: Hospital
occupancy rates are typically reported for quarters or months
and account for inpatient utilization only. This analysis shows
that emergency resource planning requires routine
measurement of daily variation in surge capacity in addition to
levels of surge capacity within a fixed period of time. To fully
understand surge capacity on a daily basis, the resource
requirements for ambulatory surgery must be considered also.
This measurement can be used to identify recurring periods of
peak demand and hospital service areas that frequently
experience periods of constrained surge capacity. These
refined measures may be used to target investments in
emergency response capabilities and better manage hospital
patient flow.
Primary Funding Source: New Jersey Department of Health
and Senior Services
●Threat of Malpractice Lawsuit, Physician Behavior and
Health Outcomes: Testing the Presence of Defensive
Medicine
Praveen Dhankhar, MA, M. Mahmud Khan, Ph.D., Ila M.
Semenick Alam, Ph.D.
Presented By: Praveen Dhankhar, MA, Graduate Student,
Economics, Tulane University, 206 Tilton Hall, Tulane
University, New Orleans, LA 70118; Tel: (504)862-8348; Email:
pdhankm@tulane.edu
Research Objective: The purpose of this study is to examine
the potential consequences of medical malpractice lawsuits
on obstetric care interventions. The fear of malpractice
lawsuits is considered one of the causes of increased Csection deliveries (defensive medicine). This paper intends to
examine the following questions: Does the threat of
malpractice lawsuits lead to defensive medicine? Does the risk
of lawsuit affect physician behavior and health outcomes?
What is the impact of malpractice lawsuit risk on health
outcomes of the patients?
Study Design: Physician behavior in obstetrics is modeled as
a fixed effects logit with claim frequency and claim severity as
measures of malpractice fear in each state. To measure
malpractice risk, we use the National Practitioner Data Bank
(NPDB), a comprehensive data set of all paid claims for
medical malpractice. For the inpatient data we use the
Nationwide Inpatient Sample (NIS) which provides detailed
information on all inpatient hospital stays. Because medical
malpractice risk is greater for patients with severe medical
complications, the data is divided into two groups: necessary
C-section and unnecessary C-section. Using this classification,
this is the first paper to provide an estimate of excess resource
use in obstetrics.
Population Studied: Women and Neonates.
Principal Findings: Results suggest that a higher degree of
malpractice risk increases the probability of C-section delivery.
Overall, we do not find evidence of defensive medicine. In fact,
marginal benefit of additional resource use is much higher
than its marginal cost.
Conclusions: This is the first paper to find that benefits from
medical malpractice are much higher than costs and there is
no defensive medicine.
Implications for Policy, Delivery, or Practice: The policy
implications of this research are that medical malpractice laws
should be reformed with great caution and medical
malpractice system should be made more accessible for
injured patients. Since the marginal benefit from medical
malpractice is much higher than marginal cost, making the
medical malpractice system more accessible for injured
patients will move the system towards the optimal level of
medicine, where marginal benefit of medicine is equal to
marginal cost.
Primary Funding Source: No Funding Source
●The Human Capital Competencies Inventory for Nurse
Managers: Development and Psychometric Testing
Kathleen Donaher, RN, Ph.D., Gail Russell, EdD, Kathleen
Scoble, EdD, Jie Chen, Ph.D., Carol Ellenbecker, Ph.D.
Presented By: Kathleen Donaher, RN, Ph.D., Director,
Research and development, Reciprocal Envisioning, 7 Ocean
View Drive # 308, Boston, MA 02125; Tel: 617 593 9949;
Email: Kathleendonaher@umb.edu
Research Objective: To develop and estimate the
psychometric properties of a 5 competency 58 item inventory
of skills based activites in one managment practice
Study Design: Competency modeling
Population Studied: Nurse managers practicing in first line
and midlevel positions in one state
Principal Findings: Content and construct validity and
reliability in known groups.
Conclusions: Early support for Mastery Path in management
development
Implications for Policy, Delivery, or Practice: Management
development as a mechanism to achieve standards of practice
and performance outcomes
Primary Funding Source: Sigma Theta Tau
●Inpatient Rehabilitation Facilities: Organizational
Variation in Strategic Response to Prospective Payment
Elizabeth Durkin, Ph.D.
Presented By: Elizabeth Durkin, Ph.D, Research Associate,
Mental Health Services and Policy Program, Northwestern
University, 339 East Chicago Avenue, Room 717, Chicago, IL
60630; Tel: (312) 503-2195; Fax: (312) 503-2936;
Email: e-durkin@northwestern.edu
Research Objective: To examine how both organizational
level factors within an inpatient rehabilitation facility (IRF) and
demands from their external environments constrain an IRF’s
ability to respond strategically to the financial incentives found
within the Medicare Prospective Payment System (IRF-PPS).
Study Design: We chose an exploratory study design because
the paucity of organizational research on IRFs precluded the
development of testable hypotheses grounded in the
literature. The study consisted of in-person interviews with
IRF administrators and clinical supervisors, lasting 60-90
minutes. The number of participants per site ranged from 3-5.
We used a focused interview method that began with a list of
specific questions, and then tailored aspects of the questions
(the order, the level of detail, follow-up probes, etc.) to the
individual organization and earlier responses. Transcriptions
of the audiotaped interviews were then analyzed using a
modified grounded theory approach to identify important
themes across the sampled sites.
Population Studied: Ten IRFs in three states. Within states,
we used a maximum variation sampling strategy to capture
variation across key organizational characteristics:
organizational structure (unit within an independent hospital,
unit within a system hospital, freestanding IRF); ownership,
size, medical school affiliation, and urban vs. rural location.
Principal Findings: There is wide variation in the strategies
IRFs used to respond to the IRF-PPS. Across sites, the range
of strategies included measures such as re-educating staff,
developing strict audit controls on paperwork, reducing length
of stay, developing new intra- and inter-organizational
alliances, modifying admission criteria, and restructuring
internal communication processes. The adoption of strategic
responses early on in the transition to the IRF-PPS appeared
driven by the IRF’s projected financial gain or loss under the
PPS, their organizational structure, their size, and the
ideological orientation of the medical director.
Conclusions: Policies aimed at modifying health care practice
and costs often rest on the unexamined assumption that
organizations of the same type will all respond similarly to a
new policy. Evidence suggests that organizational responses
can vary widely due to the constellation of internal and
external pressures unique to each organization. In the years
during which the IRF-PPS was proposed and implemented,
IRFs experienced pressure from a number of sources other
than Medicare. This exploratory study begins to suggest how
major organizational features might be associated with an
IRF’s ability to respond to multiple, competing demands.
Future research is needed to identify the organizational
features that can reliably predict the adoption of particular
strategic responses by IRFs.
Implications for Policy, Delivery, or Practice: The
introduction of any new payment system may have
unanticipated consequences for quality and patient outcomes.
Being able to draw the connection between a policy and its
consequences accurately requires a thorough understanding
of the organizations addressed by the policy. Instead of
“blanket” policies applicable to all IRFs regardless of
organizational structure or environmental pressures, future
modifications of the IRF-PPS should tailor incentives to the
major organizational features that drive strategic options.
Such tailoring should improve the alignment between the
policy and its desired consequence
Primary Funding Source: NIDDR
●Decentralization in Health-Care Organizations: Motives,
Meaning and Impacts
Mark Exworthy, Ph.D., BSc, Martin Powell, Ph.D., Stephen
Peckham, MA, Ian Greener, Ph.D.
Presented By: Mark Exworthy, Ph.D., BSc, Senior Lecturer,
School of Management, Royal Holloway - University of
London, Egham, Surrey, TW20 0EX; Tel: 44-1784-414186; Fax:
44-1784-439854; Email: M.Exworthy
Research Objective: To investigate the link between
decentralization and the performance of health-care
organizations.
Study Design: Literature review of international evidence from
electronic database and manual searches. Keywords included
decentralization, centralization, federal, devolution,
regionalization, Limits: (a) Search period: published since
1974, (b) English language only. The evidence on
organizational performance was categorized according to the
following criteria: efficiency (technical and allocative), equity,
health outcomes, process measures, accountability,
responsiveness, staff satisfaction, and adherence to external
guidelines or targets.
Principal Findings: a. Unclear definitions: Decentralization
comprises many different organisational and political
developments which seek to relocate power away from the
centre. The literature drew on several academic disciplines
which used different cognate terms. Little linkage was found
between disciplines and definitions. b. Conceptual confusion:
There was a lack of conceptual clarity around which aspects of
power and authority are decentralized and the sources and
destination of power shifts. The aspects of institutional power
that might be decentralized include inputs, process and
outcomes. The source and destination of power might also be
defined in organisational and/or geographical terms. Hence,
power might be decentralized from central government to
states, regions or localities. It might shift power from
corporate headquarters to lower tiers within the organizational
hierarchy. However, this diversity makes generalization
problematic across different health-care systems and even
organizations. c. Weak measures: Despite the diversity of
definitions, decentralization programs have often adopted
fiscal measures (given their relative convenience). However,
the shift of executive or political authority necessitates other
(less clear-cut) forms of measurement. These might include
the balance of power involving a compromise between
professional/clinical autonomy versus executive decisionmaking. Hence However, causation and attribution problems
make any evaluation challenging. d. The evidence that
decentralization might improve organizational performance is
weak. Claims of lower costs, greater responsiveness to patient
needs, and greater efficiency (among others) lacked a strong
evidence base.
Conclusions: Decentralization is a global theme within
health-care systems. However, its use as an effective tool for
policy-makers and executives is limited because of weak
definitions, a limited conceptual base, a lack of meas ures of
decentralization and a weak evidence base relating to its
effectiveness. Qualitative and quantitative methods will be
required to capture the multiple ways in which the impacts of
decentralization can be measured.
Implications for Policy, Delivery, or Practice: To ensure that
opinion rather than evidence informs decision-making, there
is need for further research to ascertain the association
between decentralization and organizational performance.
Policy-makers and health executives need to recognize the
limitations and opportunities posed by the various forms of
decentralization. There is a need to understand the
compromises that inevitably need to be made including the
balance between local/clinical autonomy and central control
and between efficiency and equity. These compromises will
depend heavily on local context but will ultimately determine
whether decentralization ultimately realizes the benefits that
are often attributed to it.
Primary Funding Source: UK National Health Service
●The Dearth of Real-Time Science-Based Medicine: A
Review of Medical Registries and Outcomes To Investigate
their Potential Use for Real-Time Improvement in Patient
Safety
Lori Ferranti, MBA, MSN, David Dilts, MBA, Ph.D.
Presented By: Lori Ferranti, MBA, MSN, Ph.D. graduate
student, Management of Technology, Vanderbilt University,
342 Featheringill Hall Box 1518, Nashville, TN 37235; Tel:
(615)662-9780; Fax: (615)322-7996; Email:
lori.ferranti@vanderbilt.edu
Research Objective: Generate a new framework that
demonstrates the current types and utilization of medical
registries, their relationship to patient outcomes, and
highlights future needs for registries in real-time patient safety
and outcomes tracking.
Study Design: PubMed search identified 1612 medical registry
articles, which were reduced to 1092 by excluding those
nonmedical, (43) falling outside our medical definition, and
those N/A (467), which included those without abstracts. This
work extended a previous study of Ferranti and Dilts, by
refining definitions and adding the combined reference of
registries and outcomes.
Population Studied: A systematic search was completed
using PUBMED for the years 1998-2002 to identify medical
registries and outcomes research.
Principal Findings: Medical registry articles were parsed
resulting in 1092 medical related articles, which when cross referenced for Outcomes resulted in 28% (n=313) of the
articles outcomes related. This limited correlation points to an
opportunity to initiate further IT utilization for outcomes
tracking and ultimately patient safety. The medical registries
were then divided into 2 groups. The first group is active
registries, defined as real –time, prospective registry of
ongoing evaluation of patient outcomes while collection
continues. An example of this type of registry is the Children’s
Oncology Group’s ALL registry. Interesting, while this type has
the most potential for influence on patient outcomes, they
comprised a mere 2.4% (n=26) of the articles. Type 2: passive
registries provide a retrospective analysis of data or provide a
statistical data bank. These population, administrative, or
condition research based registries, often used as pure data
sources include the SEER and birth defects registries were
94.3% (n=103) of the registry references. There were 7.1%
(n=77) articles that did not provide sufficient information to
assign a category. Next, we divided the articles according to
primary registry references. 45% (n=490) of the articles used
the registry for data sourcing for a research study population,
18% (n=198) for disease focused population, and the
remaining articles references were for other reasons, such as,
establishment, financials, quality, technical. Of particular note,
14 active registries were reference in 2002, whereas only 3
were referenced in 1998. While registries are increasingly being
established to track conditions, patient populations, there is a
scarcity of research on the association of registries, their
utilization, and their position in tracking outcomes and patient
safety.
Conclusions: Building upon previous research, the
refinement of registry definitions along with previous results,
reveal that active registries are a small percentage of all
registries. And that all registries, particularly active registries,
have not reached their full potential, falling short in providing
timely outcomes or outcomes tracking. Evidence shows that
more research and ongoing analysis needs to be conducted to
explore a registry and outcomes relationship.
Implications for Policy, Delivery, or Practice: While there is
the potential for IT to assist in the redesigning of healthcare
systems to include outcomes as advocated by IOM, and the
Leapfrog group, the current registry utilization does not meet
this objective. Registries and their ability to track outcomes
needs further examination and should include timely analysis.
Primary Funding Source: No Funding Source
●Costs of Disability: Burden of Out-of-Pocket Expenditures
Patricia Findley, DrPH, MSW, Wenhui Wei, Ph.D., Usha
Sambamoorthi, Ph.D.
Presented By: Patricia Findley, DrPH, MSW, Assistant
Reserach Professor, Program for Disability Research, Rutgers
University, 303 George Street, Suite 405, New Brunswick, NJ
08901; Tel: (732)932-3421; Fax: (732)932-1894; Email:
pfindley@rci.rutgers.edu
Research Objective: This study examines patterns of out-ofpocket health care expenditures by individuals with disabilities.
Study Design: Secondary data analyses of longitudinal
household component of the Medical Expenditure Survey
(MEPS) for the calendar year 2001. Disabled individuals were
identified as those who had difficulty in any area of activity of
daily living as a result of their impairment or problems in body
function, including psychological functions during the
calendar year.At the individual level, we measured the burden
of OOP spending in 3 ways: 1) likelihood of having positive
OOP spending for dental and DME among those who had any
dental or DME expenditures; 2) absolute level of spending
among those who had positive OOP spending in total,
prescription medicine, dental and DME categories; and 3) the
proportion of income spent out-of-pocket on health care
services.Group differences were tested with chi-square
statistic. Multiple regressions including ordered probit were
used to examine patterns of out-of-pocket (OOP) expenditures
among disabled individuals.
Population Studied: Study sample was based on individuals
with disability in the working age group (i.e. between 21 and
64 years). We also restricted our analysis to those who were
alive as of end of 2001 and who had positive health care
expenditures. Our final study population comprised of 3,284
individuals with substantial cognitive and/or physical
limitations.
Principal Findings: Although, only 2% of total expenditures
were for durable medical equipment; individuals paid 53% of
these expenditures out-of-pocket. The corresponding figures
were 4% and 48% for dental care. Overall, 9% of income was
spent on health care services. Uninsured individuals had high
OOP burden, and public health insurance coverage had a
protective effect on OOP burden.
Conclusions: Although the greatest proportion of health care
expenditures was borne by third party payers, however, the
substantial burden left to those with disabilities and their
family members as OOP spending places an significant strain
on an already stressed family system. The high burden of OOP
expenditures among the disabled, specifically among the
vulnerable subgroups, can impact independent living.
Implications for Policy, Delivery, or Practice: Disabled
individuals need special attention in terms of prescription
drug coverage and programs that will protect them from high
OOP burden.
Primary Funding Source: Institute of Child Health and
Disability. Medical Rehabilitation
●Health Value Added: Improving Organizational
Performance Through Integtrated Accounability
Nurit Friedman, MS, MPA, Ehud Kokia, M.D., Joshua Shemer
Presented By: Nurit Friedman, MS, MPA, Director of
Research and Evaluation, Research and Evaluation, Maccabi
Healthcare Services, 27 Hemered Street, Tel Aviv, Tel: 972-35143663; Fax: 972-3-5143795; Email: nurit@mac.org.il
Research Objective: The objective of this paper is to describe
an innovative health services management model, Health
Value Added (HVA), for improving organizational
performance through integrated accountability for quality of
care, patient satisfaction, and costs. HVA was developed and
implemented by Maccabi Healthcare Services, Israel's second
largest health maintenance organization.
Study Design: The implementation of HVA was evaluated
using both quantitative and qualitative methods in order to
determine impacts and to understand the organizational
changes that accounted for them.
Population Studied: The paper is based on an evaluation of
HVA's application to the care of 40,000 diabetic members of
the HMO from 2001 to 2004.
Principal Findings: The evaluation study indicated that HVA
helped the organization improve the overall care of the
diabetic population while actually lowering costs. The
qualitative data indicated that these outcomes were the result
of "integrated accountability" for performance.
Conclusions: Integrated accountability means that caregivers
and managers look beyond their specific roles to the impact of
their actions on all three factors. Prior to HVA, costefficiency and quality of care were managed separately. Costs
were monitored in a systematic, on-going way, whereas quality
of care was monitored sporadically through specific research
projects initiated without an overall strategic view. HVA
placed quality of care and member satisfaction at the same
level as costs in terms of their importance for determining
performance. It also linked them to the strategic goals of the
organization. HVA also moved the focus of performance
evaluation from functions to the outcomes created by the
combined impact of all functions on specific areas of health.
As a result, HVA increased cross-functional collaboration
among people who traditionally worked within organizational
"silos".
Implications for Policy, Delivery, or Practice: HVA provides
a tool that enables healthcare organizations to enact a
strategic shift from treatment of disease to health promotion
in an environment characterized by rising competition,
increased consumerism, and diminishing resources. The
model defines indicators of health and translates them into
specific performance measures that integrate quality of care,
member satisfaction, and costs. However, its implementation
requires computerized information systems that can support
on-going, real time evaluation of performance at all levels of
the organization. Finally, HVA also requires the creation of
new management structures and mechanisms for continually
monitoring performance and ensuring that actions are taken
to keep the organization moving towards its strategic goals as
defined by the indicators.
Primary Funding Source: Maccabi Healthcare Services.
●Population-Based Trends in Volumes, Rates, and
Charges for Inpatient and Outpatient Lumbar Spine
Surgery
Darryl Gray, M.D., Sc.D., Richard A. Deyo, M.D., MPH,
William Kreuter, MPA, Sohail K. Mirza, M.D., Patrick J.
Heagerty, Ph.D., Leighton Chan, M.D.
Presented By: Darryl Gray, M.D., Sc.D., Medical Officer,
Center for Quality Improvement and Patient Safety, Agency for
Healthcare Research and Quality, 540 Gaither Road, Rockville,
MD 20850; Tel: (301) 427-1326; Fax: (301) 427-1341; Email:
dgray@ahrq.gov
Research Objective: Lumbar spine surgery represents a
common but controversial set of procedures used to treat
acute and chronic low back pain. While therapeutic
procedures of many types are increasingly performed on an
outpatient basis, the extent to which lumbar spine procedures
are performed in such settings is unknown. Possible
reductions in cost, variable effects on patient satisfaction and
unknown safety implications of shorter postoperative
immobilization and monitoring may be associated with
outpatient lumbar spine surgery. Therefore, we assessed
population-based trends in the frequencies of inpatient and
outpatient lumbar spine surgery.
Study Design: For this retrospective cohort study, we
developed algorithms based on combinations of International
Classification of Diseases Clinical Modification (Ninth
Revision) diagnosis and procedure codes and Current
Procedure Terminology-4 procedure codes for use in
identifying lumbar spine surgery procedures. We excluded
patients with diagnosis codes for fractures, cancer, or
infections of the spine, and those with procedure codes for
cervical spine surgery. We applied these algorithms to
available administrative data on procedures performed in
various intervals from 1994-2000. This included a weighted
~20% nationwide sample of inpatient discharges, the
Nationwide Inpatient Sample (NIS) generated by the Agency
for Healthcare Research and Quality’s Healthcare Cost and
Utilization Project (HCUP. Complete statewide counts of
inpatient and outpatient procedures were generated by
combining data from HCUP’s State Inpatient Databases
(SIDs) and State Ambulatory Surgery Databases (SASDs) for
four states (Colorado, Florida, Maryland and New York)
comprising ~16% of the US population. We also obtained
nationwide sample inpatient and outpatient procedure data
from the National Center for Health Statistics’ National
Hospital Discharge Survey (NHDS) and National Survey of
Ambulatory Surgery (NSAS) respectively. We aggregated
facility charges, which exceed costs but do not include
physician fees. Census data were used to calculate age and
sex-adjusted population-based rates.
Population Studied: US adults 20+ years of age
Principal Findings: NHDS and NSAS data indicate that
outpatient surgery comprised only 3.4% (95% CI=3.3%, 3.5%)
of procedures performed in 1994. Combined SID and SASD
data indicate that outpatient cases comprised 9.1% (95%
CI=8.8%, 9.4%) of procedures performed in 1997, versus
17.2% (95% CI=16.9%, 17.4%) for 2000, for example. NIS
data indicate that nationwide inpatient surgery rates were
156.6 cases/100,000 adults in 1994, versus 155.1/100,000 in
1997, and 161.2/100,000 in 2000. We applied the
abovementioned ratios of outpatient:inpatient procedures to
NIS inpatient data to generate nationwide estimates of
inpatient+outpatient procedure rates. Our data indicate that
combined rates of inpatient+outpatient procedures rose from
162.1 cases/100,000 in 1994 to 176.8/100,000 in 1997, to
195.3/100,000 in 2000. For 2000, we estimated that
~325,000 inpatient procedures were performed nationwide,
with charges approaching $6.1 billion (US). These were
accompanied by ~67,000 outpatient procedures, with charges
exceeding $435 million.
Conclusions: US population-based rates of lumbar spine
surgery continue to rise. Outpatient surgery represents a
growing proportion of these expensive procedures.
Implications for Policy, Delivery, or Practice: Given the
increasing frequency and importance of lumbar spine surgery
performed on an outpatient basis, outpatient procedures
should be explicitly included in current and future evaluations
of volumes, safety, costs and outcomes of lumbar spine
surgery.
Primary Funding Source: National Institute for Arthritis,
Musculoskeletal and Skin Diseases
●Correlates and Consequences of Primary Care
Productivity
Daniel Harris, Ph.D., John LeFavour, Ph.D.
Presented By: Daniel Harris, Ph.D., Senior Project Director,
Center for Healthcare Research, The CNA Corporation, 4825
Mark Center Drive, Alexandria, VA 22311; Tel: (703) 824-2283;
Fax: (703) 824-2511; Email: harrisd@cna.org
Research Objective: Productivity, the ability to produce a unit
of desired output with a given unit of input in a given period
of time, is frequently cited as key to successfully providing
healthcare in a financially constrained and competitive
managed care environment. We analyzed how various factors
impact the labor productivity of primary care clinics and how
that productivity impacts achieving other desired clinical,
administrative, and financial performance goals.
Study Design: We used routinely collected FY04
administrative data from a multi-facility staff model managed
care system to develop two measures of labor productivity:
RVUs generated per primary care provider per day and
managed care panel size per provider. Using multivariate
analysis techniques, we identified correlates of productivity
from among factors hypothesized to impact it, including panel
demographics and utilization patterns, primary care workforce
characteristics, nature of the primary care service, and the
clinical content and context of the service. We also used
regression and path analytic methods to assess the direct and
indirect effects of productivity and its correlates on the
performance goals of population health and preventive care,
patient and provider satisfaction, medical management, cost
of care, and cost effectiveness and profitability. We then
arrayed clinics on a grid formed by crossing the dimensions of
productivity and performance goal achievement, and identified
those that were high on one but low on the other. Finally, we
made selective site visits to several of these high-low clinics to
identify what accounted for their location on this grid.
Population Studied: The primary care clinics in 119 medical
treatment facilities operated worldwide by the US Navy for
active duty service members, their dependent family
members, and retirees/survivors and their dependents.
Principal Findings: Correlates and levels of productivity
varied significantly by type of treatment facility; e.g., larger,
more multi-function and organizationally specialized facilities
achieve higher levels of productivity through intensity of
clinical encounters while smaller, more single function and
organizationally generalized facilities achieve productivity
through volume of encounters. Clinical and administrative
support staff increase productivity as expected. Productivity
was generally positively associated with proportion of new
patient encounters, walk-in visits, and care for non-enrollees
eligible for space available fee-based care in this open-panel
managed care system, and negatively associated with
proportion of established patient encounters, appointmentbased visits, and maternity care. Productivity was also
generally associated with performance on other goals, but this
varied by facility type and a number of outliers ran counter to
this association. Further, some productivity correlates are
associated with performance net the effect of productivity
itself.
Conclusions: Productivity is affected by the resources
available to support the production of medical services, how
those resources are organized, and how patient care is
managed.
Implications for Policy, Delivery, or Practice: Productivity is
a means to achieving performance goals. Our study assesses
the ability of this means to achieve several desired ends,
demonstrates that productivity can exist without achieving
these ends, and identifies several factors that management
can control and manipulate to improve the chances of
achieving them.
Primary Funding Source: Dept of the Navy/Dept of Defense
●Estimating Typical Compensation: Regression/ANOVA
versus Pointing
Richard Harris, Ph.D., Salvatore Martino, EdD, John
Culbertson, MS
Presented By: Richard Harris, Ph.D., Director of Research,
Research, Amer. Soc. of Radiologic Technologists, 15000
Central Avenue SE, Albuquerque, NM 87123; Tel: (505) 8161865; Fax: (505) 298-5063; Email: rharris@asrt.org
Research Objective: A common question asked of
professional societies is "How does my salary (or my staff's
salaries) compare to similar professionals' salaries?". One
answer is the mean wage for those who share the querying
member's professional profile (education, years in profession,
etc.). An alternative is to use an additive model to generate a
predicted salary. We compare these two strategies and a
combination thereof.
Study Design: Populations: Predictor-variable structure
(Warts vs. Uncorrelated Predictors) x Relationship of wages to
independent variables (Warts vs. Additive). Each population:
220,819 profiles of scores on 8 attributes (workplace state,
primary discipline, highest level of education, etc.)with
marginal distributions that match known proportions of
registered radiologic technologists (R.T.s). Warts predictorvariable structure and wages/i.v. relationship match those
displayed by registered R.T.s. Samples: Random samples of
size 6300 from each population. Estimation (queryanswering) approaches: Pointing [“Typical” hourly wage for a
given profile estimated as the mean wage for all R.T.s in the
sample who fit that profile of scores on the attributes];
Regression/ANOVA [Typical hourly wage = grand mean of
sample plus additive effect marginal mean minus grand
mean) of that R.T.’s level on each of the predictors]; and
Combination: [Typical wage = mean wage for all R.T.s in the
sample who fit a subprofile based on as many of the attributes
as possible while being represented by at least 30 cases, plus
the additive effects of the remaining attributes].
Performance measures: Percent of population for whom an
estimate is computable. Root-mean-square difference between
estimate and population mean of R.T.s fitting a given profile,
averaged across all R.T.s in the population who have a score
on each demographic variable in the profile.
Population Studied: Four hypothetical populations as defined
above.
Principal Findings: Very nearly 100% of all queries can be
answered via regression, regardless of how many and which
particular attributes are included in the profile. Regression
and pointing approaches yield identical answers to singleattribute queries, of which almost all can be answered. On
average, samples from the Warts population provide answers
to 8-attribute queries via pointing for only 6% of the 74,877
profiles represented in the population. Corresponding figure
for queries that specify state and discipline is 81.9% of the 518
population profiles, while all 10 type-ofinstitution/credentialing profiles are represented in 86% of the
samples from Warts. Samples from the Warts/Additive
population yield regression-based typical-wage estimates for 8attribute queries whose root-mean-squared (RMS) error
(averaged across all R.T.s who might ask the question) is
$2.62. RMS error for pointing estimates (averaged across the
much lower percent of the population for whom an answer is
possible) is $2.90. Simulation runs continue for combinedapproach estimates and for the other three populations.
Conclusions: Results for the Warts/Additive population
strongly favor the additive-model approach. However, we
anticipate that results from populations in which the wages/i.v
relationship is non-additive will favor pointing. Percent
queries answerable by the combination approach should be
similar to the regression approach; its accuracy, close to the
average of the other two approaches’.
Implications for Policy, Delivery, or Practice: Useful in
meeting the need of professionals and their managers for
accurate compensation benchmarks.
Primary Funding SourceASRT research budget
●Implementing Mandated Innovations in Health Research
Alliances: The Role of the Innovation Champion
Christian Helfrich, Ph.D., MPH, Bryan J. Weiner, Ph.D.,
Martha M. McKinney, Ph.D.
Presented By: Christian Helfrich, Ph.D., MPH, Postdoctoral
Fellow, Health Services Research and Development, VA Puget
Sound Health Care System, 1100 Olive Way, Suite 1400,
Seattle, WA 98101; Tel: (206)277-1655; Fax: (206)764-2935;
Email: helfrich@unc.edu
Research Objective: Research has documented the existence
of innovation champions who throw their weight behind an
innovation, risking personal credibility in order to overcome
organizational inertia and resistance. This research has
primarily focused on implementation of voluntary innovations
within discrete organizations. Little is known about the role of
innovation champions in building support for mandated
innovations in loosely coupled research alliances. This study
explores the role of innovation champions in helping health
research alliances define and implement an externallymandated innovation requiring significant changes in their
scientific agendas. We sought to determine whether or not an
innovation champion is a necessary antecedent to effective
innovation implementation in a research alliance and to
identify contextual conditions that moderate the champion’s
role.
Study Design: We conducted holistic case studies in four
cancer research networks implementing externally-mandated
CP/C research programs. We coded and thematically
analyzed data from transcribed interviews with 65 clinical
investigators and administrative staff. Additional data sources
included a questionnaire completed by each research
network’s chief operations officer and archival documents,
such as grant applications and progress reports.
Population Studied: The study population includes four
clinical cooperative groups funded by the National Cancer
Institute (NCI). Although cancer centers, academic medical
centers, and community cancer care providers joined these
research alliances to conduct cancer treatment clinical trials,
NCI broadened the groups’ mandate in 1987 to include new
and unfamiliar research on methods of preventing and
detecting cancer and managing related symptoms.
Principal Findings: Three of the four cooperative groups
effectively implemented CP/C research programs. They
defined CP/C research to be compatible with their missions,
developed and/or acquired the expertise necessary to design
the research protocols, and devised methods of recruiting
healthy but at-risk individuals to prevention studies. Two of
these cooperative groups had one or more innovation
champions; in both cases champions emerged from among
senior leadership. Although the third cooperative group
lacked an innovation champion, the senior leadership
provided strong support for cancer prevention clinical trials
evolving from the group’s research on adjuvant
chemotherapies. The fourth cooperative group designed
relatively few CP/C protocols and experienced repeated
problems accruing patients (although they were able to accrue
to CP/C trials developed by other cooperative groups). In this
cooperative group, no champion emerged. Senior leadership
provided limited support and the CP/C research agenda,
which centered on behavioral interventions and pain
management, was operationally quite different from the
organization’s prior research. Where champions emerged in
the first two cases, an important role was recruiting and
mentoring researchers with critical new skill sets for CP/C.
This also built an active constituency for CP/C research within
the alliances.
Conclusions: An innovation champion does not appear to be
strictly necessary where there is support from senior
leadership and where the innovation has a good operational fit
with the organization. Innovation champions in alliances may
play a critical role in building constituencies for the
innovation.
Implications for Policy, Delivery, or Practice: Alliances can
effectively implement even complex, mandated innovations
without an innovation champion, provided there is strong
support from senior leadership, encouragement from an
active external change agent, and the innovation’s operational
fit is good.
Primary Funding Source: NCI
●Insurance Ownership Type and the Impact on Medicare,
Medicaid, and Individual Non-government Product
Offerings
Diane Howard, MPH, Ph.D., Kevin Croke, Ph.D., Edward
Mensah, Ph.D., Ross Mullner, Ph.D.
Presented By: Diane Howard, MPH, Ph.D.,
Instructor/Program Director, Allied Health, Health Systems
Management, Rush University, 1700 West Van Buren Street,
Chicago, IL 60612; Tel: (312) 942-5406; Fax: (312) 942-4957;
Email: Diane_M_Howard@rush.edu
Research Objective: To determine if there are distinctions
between for-profit and non-profit insurance plans in providing
Medicare, Medicaid, and Individual non-governmental
products.
Study Design: Longitudinal data analysis of financial,
marketing, and medical management data on insurance
companies considered to be in a strategic group to determine
there are trends in providing Medicare, Medicaid, and
Individual non-governmental products. A survey collection
tool was developed to retrieve data across 29 variables by
insurance plan. The data were input into Excel spreadsheets
and then migrated into STATA™ for statistical analysis.
Individual product trends were analyzed for a five-year period
to determine differences by insurance ownership type.
Population Studied: The study population consisted of 35
Aetna plans in 24 states; 124 BCBS plans in 45 states and the
District of Columbia; 45 Cigna plans in 28 states; and 23
UnitedHealth plans in 22 states.
Principal Findings: Premium dollars associated with group
products exceed premium dollars associated with Medicare,
Medicaid, and Individual non-governmental products across
the four national companies. Medicaid and Individual nongovernmental products were terminated more often than
other products across all ownership types. When Blue Cross
Blue Shield plans were analyzed across for-profit, non-profit,
and mutual ownership types, the companies had distinct
preferences for product offerings.
Conclusions: The study provides evidence that health plans
will limit their exposure to Medicare, Medicaid, and Individual
non-governmental products in preference to
Comprehensive/Group products.
Implications for Policy, Delivery, or Practice: These results
highlight the importance of promoting public-private
partnerships to promote insurance access by individual
subscribers.
Primary Funding Source: No Funding Source
●Paying for Prescription Drugs – Economic Implications
of Benefit Caps
John Hsu, M.D., MBA, MSCE, Mary Price, MA, Richard Brand,
Ph.D., Rita Hui, PharmD, MS, Joseph Newhouse, Ph.D.,
Joseph Selby, Ph.D., MPH
Presented By: John Hsu, M.D., MBA, MSCE, Physician
Scientist, Division of Research, Kaiser Permanente Northern
California, 2000 Broadway, 3rd Floor, Oakland, CA 94612; Tel:
(510) 891-3601; Fax: (510) 891-3606; Email: jth@dor.kaiser.org
Research Objective: There is limited information on the net
impact of cost-sharing for prescription drugs in patients with
Medicare insurance. We examined the impact of prescription
drug benefit caps on total direct medical costs, and four
component costs: emergency department (ED),
hosptialization, outpatient, and pharmacy costs, in a prepaid,
integrated delivery system (IDS).
Study Design: We compared annual direct medical costs for
subjects with and without a prescription drug benefit cap
using a two-part model, while adjusting for age, gender, SES,
race/ethnicity, comorbidity, prior utilization (ED, office,
hospital), copayment levels (ED, office, prescription drug),
and medical center. To determine the optimal covariate
structures, we used the AIC approach. To determine the
optimal transformation approach, we used the Box-Cox test.
In part one of the model, we investigated which subjects had
direct medical costs using logisitic regression. In part two of
the model, we investigated the mean of the log tansformed
direct medical costs using linear regression for those subjects
with any direct medical costs. To retransform the mean log
costs, we estimated the correction factor by modeling the
residual variance as a function of the covariates. We
combined the two parts and the correction factor to find
expected costs for the subjects with and with out a benefit
cap; we expressed the results as a relative cost (RC).
Population Studied: The 183,595 Medicare subjects had a
mean age of 74.5 years (SD=6.8), 58.8% were female and
77.0% were white. In 2003, 79.5% of subjects had a $1,000
annual drug benefit cap, and the remaining subjects had no
benefit limit; all subjects had tiered prescription drug
copayments.
Principal Findings: In 2003, 97.1% and 97.4% of cap and
non-cap subjects respectively had any direct costs during the
year. Subjects with a benefit cap had lower mean total annual
direct medical costs compared to subjects with no cap with a
relative cost (RC) of 96.3% (95% CI: 93.5% – 99.2%). There
were significant reductions in prescription drug costs
(RC=77.1%, 95% CI: 74.5% – 79.8%), but significant increases
in ED costs (RC=109.4%, 95% CI: 104.9% – 114.1%). There
also was a trend towards a significant increase in non-elective
hospitalization costs (RC=109.8% 95% CI: 100.0% – 120.6%).
Conclusions: In patients age 65 and older with Medicare
insurance, prescription drug benefit caps were associated with
some overall cost savings. Most of the savings was in
prescription drugs, but these were at least partially offset by
cost increases in other medical areas such for ED visits and
non-elective hospitalizations. These data are consistent with
previous findings of lower drug adherence and worse
physiologic outcomes as measured by laboratory tests, which
were associated with the cap as compared to the non-cap
subjects.
Implications for Policy, Delivery, or Practice: Drug benefit
caps appear to save some money in the short-term. Much of
the significant reduction in prescription drug costs, however,
may be offset by increases in costs for other medical services.
Further research is needed to assess the clinical effects of
benefit caps, and to assess the net economic effects over
longer periods of time.
Primary Funding Source: AHRQ
●Group Visits in Safety Net Hospitals and Health
Systems: A Model For Increasing Access To Care
Jennifer Huang, MS, Betsy Carrier, MBA
Presented By: Jennifer Huang, MS, Senior Research Analyst,
National Association of Public Hospitals and Health Systems,
1301 Pennsylvania Avenue NW, Suite 950, Washington, DC
20004; Tel: (202) 585-0100; Fax: (202) 585-0101; Email:
jhuang@naph.org
Research Objective: Public hospital systems tend to be large
complex organizations with high inpatient and outpatient
volumes. Several models of group visits have been adopted in
office-based settings, often improving efficiency and patient
access to outpatient care, but little is known about their
prevalence or feasibility in safety net hospital systems. Group
visits, also known as “shared medical appointments,” provide
outpatient care to groups of 10-15 patients in one 60-90
minute appointment slot. This study describes applications of
group visit models in safety net systems and identifies ways
that group visits are integrated into chronic care management,
and primary care and specialty clinics.
Study Design: Researchers at the National Association of
Public Hospitals and Health Systems (NAPH), a membership
organization of 120 metropolitan safety net hospitals,
developed case studies of hospital systems that adapted
group visit models to their clinical practices. Case study sites
were selected from hospitals that responded to a brief survey
on current group visit practices. Case studies include
information about the characteristics of group visits, the types
of patients included in various group visit models, the
frequency of visits, anecdotal impact on patient and provider
satisfaction and keys to successful implementation.
Population Studied: Thirteen safety net hospitals or health
systems in 12 states that collectively provide 13.3 million
outpatient visits annually. Patients receiving care at these
hospital systems are disproportionately uninsured and
members of racial and ethnic minority groups.
Principal Findings: Public hospital systems can successfully
implement group visit practices as an important component
of their strategy to address growing demand for both primary
care and specialty services. Group visits are also viewed as a
mechanism to create medical homes for patients. Practices
varied across the case study hospitals, with most indicating
that they had adapted an “off-the-shelf” model to the
particular needs of their health care organization. All case
study sites reported positive patient and provider satisfaction
with group visits. The availability of space for the visits and
inadequate reimbursement from all payers were the most
commonly cited concerns in the decision to use group visits.
Staff and patient buy-in were key factors in the success of the
intervention.
Conclusions: Group visits help to improve access and quality
goals in safety net hospitals and health systems. The group
visit model can be modified to fit the needs of an institution,
providers and patients. In addition, we found that additional
baseline information is needed to quantify and evaluate the
benefits of group visits on the health system, clinic efficiency,
for patients, and for providers.
Implications for Policy, Delivery, or Practice: Groups visits
are one of many strategies that should be considered when
trying to manage demand for services, but the practice is slow
to spread within and across safety net hospitals. Given that
group visits can enhance quality, efficiency and satisfaction,
public and private insurers should reevaluate payment
decisions that create disincentives for these activities.
Primary Funding Source: National Association of Public
Hospitals and Health Systems
●A Measure of Deference to Expertise in Acute Care
Hospitals
Linda Hughes, Ph.D., RN, Yunkyung Chang, MPH, RN,
Barbara Mark, Ph.D., RN, FAAN
Presented By: Linda Hughes, Ph.D., RN, Research Associate
Professor, School of Nursing, University of North Carolina at
Chapel Hill, Carrington Hall, Room 217, CB # 7460, Chapel
Hill, NC 27599-7460; Tel: (919) 843-3156; Fax: (919) 843- 3168;
Email: lchughes@email.unc.edu
Research Objective: While work characteristics should
determine the organizational approach to point-of-service
decision-making, hospitals, by tradition, rely on chain-ofcommand decision-making with strict adherence to standard
operating procedures. This approach is inconsistent with that
identified in studies of “high reliability” organizations. Such
organizations emphasize deference to expertise, meaning that
decision authority migrates to those in the organization,
including front-line workers, who have the expertise and
access to real-time information needed to respond to
problems. Before “reliability” of acute care hospitals can be
studied, a measure of deference to expertise as an approach
to point of service decision-making is needed. The purpose of
this study was to develop psychometric properties of the
Deference to Expertise Scale (DES).
Study Design: The design was a cross-sectional mailed survey
using lists of currently licensed registered nurses obtained
from boards of nursing in Idaho, Texas, Kentucky, and North
Dakota. These states were chosen because lists can be
restricted to nurses employed at acute care hospitals.
Population Studied: The sample was 330 registered nurses
who provide direct patient care and anonymously completed
and returned a questionnaire.
Principal Findings: The DES is a seven-item, six-point
summated rating scale designed to measure how frequently
nurses encounter situations in which they are constrained
from using their expertise to respond to patient needs. DES
items were generated from a qualitative study in which nurses
described management of clinical situations in which an
unauthorized intervention is warranted in response to
changes in a patient. Seven nurses from the qualitative study
reviewed DES items as clinical experts and four nurse
researchers rated items for content domain relevance (CVI =
.95). Item analysis resulted in Cronbach’s alpha = .89. Interitem correlations ranged from .44 to .68 suggesting minimum
redundancy among items. Factor analysis using maximum
likelihood estimation yielded a single factor solution
accounting for 56% of the total variance. Beginning support
for construct validity was demonstrated with moderately
strong correlations between DES scores and scores on the
Autonomy from Physicians Scale (r = .50, p < .01), Job
Enlargement Scale (r = .20, p < .01), Organizational
Relationships Scale (r = .27, p < .01), and Quality of
Employment Survey Autonomy Subscale (r = .47, p < .01).
Nurses with 7 or more years of unit experience had
significantly higher DES scores than did nurses with 0 to 2 or
3 to 6 years of unit experience (F = 7.38, p < .001).
Conclusions: Findings provide beginning support for the DES
as a valid and reliable measure of deference to expertise in
acute care hospitals.
Implications for Policy, Delivery, or Practice: Studies have
demonstrated that nurse staffing and experience are
associated with lower mortality and failure to rescue in acute
care hospitals. The DES will allow theoretical models to be
tested in which deference to expertise is specified to mediate
relationships between nurse staffing and experience and
patient outcomes.
Primary Funding Source: Sarah Frances Russell
Distinguished Professorship Fund and The University of
North Carolina at Chapel Hill, School of Nursing, Faculty
Research Opportunity Grant.
●Development of an Instrument to Measure Attitudes,
Facilitators, and Barriers Regarding the Use of EvidenceBased Practice by Nurse Managers
Janice Jones, Ph.D., RN, CNS, Kay Sackett, EdD, RN
Presented By: Janice Jones, Ph.D., RN, CNS, Associate
Clinical Professor of Nursing, Nursing, University at Buffalo,
910 Kimball Tower, Buffalo, NY 14052; Tel: (716)829-2304; Fax:
(716)829-2021; Email: jsylakow@buffalo.edu
Research Objective: Over the past thirty years, 85 studies
have appeared in the nursing literature examining research
utilization by direct-care nursing care providers. To date, there
have been no studies addressing the usage of evidence-based
practices by nurse managers in the acute care setting.
Evidence-based practice encompasses experimental and nonexperimental research studies, random-controlled studies,
meta analyses, qualitative data, organizational or best practice
guidelines, and expert opinion to a lesser degree. The
initiation of evidence-based practices by nurses has been of
great concern and nurse researchers continue to pursue use
of evidence-based and/or best practice clinical guidelines. The
nursing literature has documented numerous barriers for staff
nurses in implementing best practice changes such as
knowledge level and time management problems. Research
instruments have focused on the barriers and facilitators of
nursing research in general but there are no instruments to
suggest who might be the best person(s) to actually initiate
evidence-based practices. The authors suggest that nurse
managers have both the expertise and time to initiate and
evaluate the use of evidence-based practices in the acute care
hospital setting.
Study Design: The researchers combined four instruments as
the basis for their questionnaire design: the Evidence-Based
Practice Belief Scale (EBPB) and the Evidence-Based Practice
Implementation Scale (EBPI) developed by Fineout-Overholt;
the Barriers Scale by Funk, Champagne, Wiese and Tornquist
and the Barrier to Nursing Research Utilization tool by Upton.
All four questionnaires have established reliability and validity.
Face validity, understandability, and feasibility for the newly
created Barriers, Facilitators and Implementation of EvidenceBased Practices Scale was accomplished by nursing faculty
considered clinical experts in their fields. Test-retest reliability
by nurse managers is currently being conducted. Cronbach’s
alpha will be determined using a national sample in a larger
study planned this year.
Population Studied: Ten nurse managers in the Western
New York region completed a test-retest of the newly created
questionnaire during a two week period of time. The
questionnaire will eventually be utilized in a larger study
planned with nurse managers from various states and
institutions across the United States.
Principal Findings: An overview of instrument development
and correlation coefficients will be discussed. Suggestions for
refinement of the instrument would be a welcomed
discussion.
Conclusions: The appropriateness of this tool to determine
the best person(s) to initiate evidence-based practices will be
reported. This tool will serve as a basis for a larger study in
assessing nurse managers’ attitudes, facilitators, barriers, and
use of evidence-based practices nationwide.
Implications for Policy, Delivery, or Practice: Healthcare
providers have espoused the concept of evidence based
practice; however a systematic process by which clinical
problems are identified and evidence-based practices are
developed and implemented has not been defined in the acute
care setting.
A paradigm shift to embrace evidence-based practices to
increase the speed of knowledge dissemination must occur in
the health care arena. The goal is to provide quality patient
care that is clinically effective, cost-effective care, efficient and
demonstrates favorable outcomes.
Primary Funding Source: No Funding Source
●Trends in Drug Development Time and Price
Salomeh Keyhani, MS, M.D., MPH, Marie Diener-West, Ph.D.,
Neil Powe, M.D., MPH, MBA
Presented By: Salomeh Keyhani, MS, M.D., MPH, Assistant
Professor of Health Policy, Health Policy, Mount Sinai School
of Medicine, One Gustave L. Levy Place, Box 1077, NY, NY
10029; Tel: (212) 659-9563; Fax: (212) 423-2998; Email:
salomeh.keyhani@mountsinai.org
Research Objective: Previous reports on drug development
times have been based on proprietary data reported by the
pharmaceutical industry and increasingly longer clinical trial
times have been alleged as one reason leading to higher drug
prices. We examined trends in post-investigational new drug
application (IND) development time and drug price.
Study Design: We assembled data on post-IND development
time, drug characteristics, Food and Drug Administration
(FDA) regulatory designations and drug prices. We obtained
data on length of post-IND drug development time, the IND
filing date and the New Drug Application approval date. We
also obtained information on FDA regulatory designations
(Fast Track Status/Accelerated Review) for drug approval, and
the order in which drugs were approved in each class from the
FDA. We calculated the separate time periods for clinical trial,
regulatory review and total post-IND development for drugs
classified into different clinical groups. We examined trends in
length of post-IND-development, clinical trial and regulatory
review periods over time and compared how changes in
development over time varied by drug group, regulatory
designation, annual sales and by whether a drug was 1st in its
chemical class or not.
Population Studied: We conducted a retrospective study of
168 drugs with development data available in the Federal
Register Government Printing Office database approved by
the FDA between 1994-2002.
Principal Findings: Median total post-IND drug development
and clinical trial times for drugs approved between 1994-2002
was 6.3 years and 5.1 years respectively. The median clinical
trial time was shortest for infectious disease agents (4.5 years)
and longest for psychiatric drugs (7.2 years) (p-value <0.05).
Post-IND development time decreased on average by 244
days each year (p-value <0.001). Average retail prescription
drug prices increased every year from $27.0 in 1990 to $65.0
in 2000. Post-IND development time also decreased within
each clinical drug group. The decreases in development time
were a result of decreases in both clinical trial and regulatory
review periods. The median clinical trial period of drugs with
fast track status was 4.4 years, while the median clinical trial
period of drugs without this designation was 6.7 years (pvalue <0.05). The decreases in post-IND development time
observed were also apparent in drugs that did not receive fast
track status or accelerated review. The median post-IND
development time of drugs with annual sales greater than
$100 million was 1.5 years less than drugs with lower annual
sales (p-value <0.05). Median post-IND development time of
drugs first in their chemical class was longer than their
counterparts; however this difference was not statistically
significant.
Conclusions: Post-IND drug development times have
decreased significantly in the past decade and development
time varies greatly among drug groups. FDA regulatory
designations have led to rapid drug approval; however,
development time has also decreased independent of FDA
regulatory designations.
Implications for Policy, Delivery, or Practice: Despite
shorter post-IND development times, drug prices continue to
rise making development time an unlikely cause of higher
drug prices. To our knowledge, this is the first analysis of
development time based on publicly available data
Primary Funding Source: Robert Wood Johnson Clinical
Scholar
●Building HR Capability in Health Care Organizations
Naresh Khatri, Ph.D., Lanis L. Hicks, Ph.D.
Presented By: Naresh Khatri, Ph.D., Assistant Professor,
Health Management and Informatics, University of Missouri Columbia, 302 Clark Hall, Columbia, MO 65211; Tel: (573)8842510; Fax: (573)882-6158; Email: KhatriN@health.missouri.edu
Research Objective: This paper performs an extensive review
of literature, examines mechanisms through which HR
provides competitive advantage to health care organizations,
and develops a comprehensive concept of HR capability.
Study Design: The first step was to conduct an extensive
literature review on the resource-based view. This review
included articles from general management literature as well
as health care management literature. It revealed several
mechanisms through which HR can provide sustainable
competitive advantage to knowledge-based and serviceoriented organizations. Based on the review of literature, a
comprehensive conception of HR capability was then
developed.
Population Studied: Review of articles on HR in general
management and health care management journals and
databases to date.
Principal Findings: The importance of human resource
management to the success or failure of health care
organizations has been generally overlooked. Despite the
growing evidence on the impact of HR on organizational
performance in other industries, there have been relatively few
attempts to assess the implications of this evidence for health
care organizations. There is currently very little information
about HR or what makes for an effective HR function in health
care organizations.
The extant literature on the resource-based view is quite
enthusiastic about HR as a source of sustainable competitive
advantage to organizations. Several interconnected and
important themes point toward HR’s strategic role in
managing service organizations. However, health care
organizations need to develop HR capabilities to manage their
human resources strategically. HR capability consists of five
dimensions: (1) competent HR Director and enlightened top
management, (2) elevated status of HR in the organization,
(3) professionally qualified HR staff, (4) HR function as a
repository of HR technical knowledge, (5) integrated human
resource information system.
Conclusions: Given that the largest proportion of expenditure
in health care organizations is invariably staff costs (about 65
to 80 percent of the total cost), the low level of interest in HR
is quite surprising. Getting HR “right” has to be at the core of
any sustainable solution to health system performance. There
is clearly a long way to go in developing HR capability in
health care organizations.
Implications for Policy, Delivery, or Practice: The resourcebased view suggests that competitive advantage does not
arise from replicable or imitable resources/practices, no
matter how impressive or economically valuable they may be,
but from complex, causally ambiguous, and intangible
resources. This view sharply contradicts the commonly
accepted notion of ‘best practices’ in health care
organizations. Thus, the uncritical adoption or imitation of the
‘best practices’ approach in health care organizations needs to
be investigated. The role of the HR Director in developing HR
capability of an organization is important. Thus, health care
organizations need to make sure that they fill this critical
position with a professionally competent individual. Moreover,
the HR Director needs to have the same status as other top
management team members. Health care organizations are
knowledge-based and service-oriented. HR is suggested to be
fundamental to such organizations. Thus, outsourcing of HR,
other than unimportant, peripheral activities, is likely to be
counterproductive because outsourcing of critical HR tasks
depletes an organization’s capacity to manage its core
business.
Primary Funding Source: No Funding Source
●Do Emotionally Intelligent Health Services Leaders
Attract Better Employees?
Susan Kruml, Ph.D., Gill Siteraneos, Ph.D., Sandra Pierce,
MHA
Presented By: Susan Kruml, Ph.D., Assistant Professor,
Management, University of South Dakota, 414 East Clark
Street, Vermillion, SD 57069; Tel: (605)677-5554; Fax:
(605)677-5427; Email: skruml@cableone.net
Research Objective: Nearly 30 years of research by the Gallup
organization reveals what it takes for organizations to attract,
focus, and keep the most talented employees. Gallup found
that workplace strength, measured by employee engagement,
is the best predictor of turnover, productivity, safety, and
profitability. Engaged employees are psychologically
committed to their role, rise to the challenge of their work
every day, are in roles that use their talents, know the scope of
their job, and are always looking for new and different ways of
achieving outcomes (Buckingham & Coffman, 1999). Due to
the complex and rapidly changing challenges facing health
services organizations, maintaining an engaged workforce is
and will continue to be essential to long-term sustainability.
The Gallup research indicates that great leaders are the critical
players in a workplace in which employees are engaged. While
Gallup describes how these great leaders behave, or should
behave, it does not empirically link leader characteristics to
employee engagement. However, a rapidly emerging
literature on emotional intelligence may illuminate the link.
Emotional intelligence (EI) is the “ability to read the political
and social environments, and landscape them; to intuitively
grasp what others want and need, what their strengths and
weaknesses are; to remain unruffled by stress; and to be
engaging” (Stein & Book, 2000). Research supports the
hypothesis that the most effective leaders possess a high
degree of emotional intelligence (e.g., Bar-On, 2002;
Goleman, 2004; Stein & Book, 2000). This study answers
three questions: 1) Do leaders with higher emotional
intelligence have more engaged employees?; 2) What is the EI
profile of leaders whose employees are highly engaged?; and,
3) What is the EI profile of leaders whose employees are not
engaged?
Study Design: This field study used two valid and reliable selfreport survey instruments. The independent variable, EI, was
measured using the Bar-On Emotional Quotient Inventory
(EQ-i). An overall score and 15 subscale scores were
generated for each leader. The dependent variable, employee
engagement, was captured using the Gallup Q-12 measure of
employee engagement. The Q12 was administered to each
leader’s direct reports. Direct reports’ grand mean scores
were assigned to the respective leaders.
Population Studied: Respondents included leaders (anyone
with a direct report) at all levels in an acute care hospital in
the Midwest. Eighty-nine of the 120 leaders participated.
Principal Findings: The data collection is complete and the
analysis is in progress, scheduled to be done by the end of
January. Primary methods include regression analysis and
discriminant analysis.
Conclusions: TBA
Implications for Policy, Delivery, or Practice: There are
several practical implications for this research. For example,
the emotional intelligence profile of leaders whose employees
are engaged can be used by health services organizations to
more effectively and efficiently target their recruiting and
development efforts. The paper also will discuss the findings
with respect to leaders’ competencies regarding team
building, conflict management, ability to buffer stress, impulse
control, and interpersonal relations.
Primary Funding Source: N/A,
●Production Efficiency of Medical Groups in the United
States
Rui Li, M.D.
Presented By: Rui Li, M.D, Ph.D Candidate, Health Services
and Policy Analysis, University of California at Berkeley, 2225
Acton Street, Berkeley, CA 94702; Tel: (510)643-0551; Email:
rli@berkeley.edu
Research Objective: After managed care plays a key part in
the US health care system, changes in the US health care
system created great changes in physician group practice.
Physician organizations are becoming larger. More and more
physician groups are owned by HMOs or hospital systems
instead of physicians. The physician compensation structures
also change dramatically. More and more physicians are paid
on base salary basis instead of productivity. All of those
changes affect the production efficiency of physician
organizations. But few empirical results addressed the
production efficiency of group practice in the managed care
setting. This study, using national surveys of physician
organizations in the United States, examines how different
organizational characteristics affect production efficiency in
medical groups.
Study Design: The study uses a Cobb-Douglas behavior
production function to model the production of medical
groups and individual physicians. Productivity is measured as
patient visits per year per physician. Independent variables
include capital and labor inputs, clinical information
technology and organizational characteristics such as
ownership, specialty type, and physician compensation
methods.
Population Studied: This study uses two data sets. National
Survey of Physician Organizations and the Management of
Chronic Illness (NSPO) collected between September 2000
and September 2001 and Medical Groups Management
Association Production and Compensation Survey
(MGMAPCS) collected in 1999, 2000 and 2001. NSPO is a
survey of physician organizations at the group level. NSPO
surveyed physician organizations with 20 or more physicians
in the United States. MGMAPCS is a national survey of
medical groups of any size and individual physicians.
Principal Findings: Physicians respond to financial
incentives. Comparing to a straight base salary payment
method, Physician paid 100% on productivity increased
patient visits by 66%; physician paid 50-99% on productivity
increased patient visits by 59%; physician paid 1-49% on
productivity increased patient visits by 23%. Similar effects are
found both at the group level and individual level in the two
data sets. The study also found large effect of ownership on
productivity of physicians. HMO or hospital systems, or
managed companies owned medical groups have more than
20% productivity than physician owned medical groups.
Conclusions: Physicians respond to financial incentives.
Payment scheme on productivity boost productivity compare
to pure base salary payment. The results highlight the role of
using financial incentives to achieve organizational goals
without sacrificing physician productivity. In addition,
ownership matters in the production efficiency of medical
groups.
Implications for Policy, Delivery, or Practice: These results
highlight the importance of financial incentives in determining
physician behavior. It also provides the medical group
administrators evidence to improve the organizational
structure of the groups and use proper financial incentives to
increase physician productivity and achieve the most efficient
intra-organizational structure.
Primary Funding Source: RWJF
●Preventing Perinatal HIV Transmission: Barriers to
Universal Hospital Testing
Frances Margolin, MA, Heidi Whitmore, MPP, Kali Stanger,
BA, Jeremy Pickreign, MS, Ray Kang, BA
Presented By: Frances Margolin, MA, Senior Director,
Operations and Applied Research, Health Research and
Educational Trust, One North Franklin, 30th floor, Chicago, IL
60606; Tel: (312)422-2607; Fax: (312)422-4568; Email:
fmargolin@aha.org
Research Objective: Hospitals are uniquely positioned to
prevent the hundreds of perinatal HIV infections in infants
born in the US. With the recent approval of reliable rapid HIV
tests, hospitals can quickly identify HIV-positive pregnant
women and immediately provide access to antiretroviral
drugs. While prenatal treatment is ideal, antenatal prophylaxis
and immediate treatment of the neonate are both effective in
reducing the risk of transmission. CDC recommends that all
hospitals adopt a policy of routine rapid HIV testing for
women presenting to labor and delivery with undocumented
HIV status. However, little is known about barriers to
universal HIV testing of pregnant women in US hospitals and
how readily hospitals will be able to adopt the
recommendation to use the rapid test. This study identifies
those barriers.
Study Design: In 2004 we surveyed US hospitals to assess
hospital practices and policies relating to perinatal HIV
transmission. The survey examined prenatal care, labor and
delivery, and neonatal nursery settings. In addition, data from
the American Hospital Association annual survey on hospital
and market characteristics and CDC data on HIV prevalence
were used.
Population Studied: All US hospitals performing 300 or more
births per year (N= 2,512 hospitals), identified in the 2002
AHA hospital survey. In total, 1,250 hospitals responded
(50%).
Principal Findings: The major factors identified as barriers to
universal HIV testing were the same in both prenatal care and
labor and delivery: privacy, regulation, and state and local
laws. More than 70% of respondents to these questions
labeled them as important barriers. Concerns about false
positive tests (49%) and about medical liability (52%) were
labeled as important barriers to universal testing in labor and
delivery by about half of respondents. In contrast, concerns
about links to and cost of follow-up care were each labeled
“not important” by 60% or more of respondents.
Conclusions: From hospitals’ perspective, state and local
laws and regulations are significant barriers to universal HIV
testing of pregnant women and women in labor and delivery
with undocumented HIV status. Related issues include the
consequences of acting on false positive tests and resulting
medical liability. Costs and availability of care are not
frequently cited as barriers.
Implications for Policy, Delivery, or Practice: State laws and
regulations, combined with concerns about patient privacy
and HIPAA, are perceived as barriers to eliminating perinatal
HIV transmission. To increase the rate of HIV testing in
prenatal care and labor and delivery, states should adopt
legislation reflecting the reliability of rapid tests and allowing
disclosure of results and treatment before receipt of
confirmatory tests. Hospital staff need clarification and better
understanding of current state/local requirements. Education
in current standards of care, along with tools and training in
ways to counsel women about HIV testing and their HIV
status while respecting their need for privacy and
confidentiality, should help alleviate hospital staff concerns.
Primary Funding Source: CDC
●Leadership Development in Health Care: Evidence from
Two Nationwide Studies
Ann Scheck McAlearney, Sc.D., MS
Presented By: Ann Scheck McAlearney, Sc.D., MS, Assistant
Professor, Health Services Management and Policy, The Ohio
State University, 1583 Perry Street, Atwell 246, Columbus, OH
43210; Tel: (614)292-0662; Fax: (614)438-6859; Email:
mcalearney.1@osu.edu
Research Objective: Despite considerable evidence
supporting strong leadership development practices across
industries, it is unclear whether and how health care
organizations and leaders focus on this development. Two
nationwide research studies were designed to improve our
understanding of leadership development in health care, and
identify actionable opportunities for health care organizations
to pursue.
Study Design: First, an extensive qualitative study conducted
between September 2003 and December 2004 used key
informant interviews, case studies, and market research to
explore the issues of appropriate content and process for
health care leadership development. Hour-long in-person and
telephone interviews were taped, transcribed, and analyzed
used deductive and inductive methods, including a grounded
theory approach to explore emergent themes. Second, a 72item mailed and electronic survey of chief executives in all U.S.
hospitals asked questions about the leadership development
opportunities offered by these organizations and pursued by
the respondents. Survey data analyses included descriptive
statistics, chi-squared analyses, linear regression, and logistic
regression. Transformational leadership theory and
management learning principles provided a conceptual
framework for both studies.
Population Studied: In the qualitative study, 160 key
informants were interviewed. Experts interviewed (n=35)
included consultants, recruiters, association leaders, and
academic researchers. Sixty total case studies included 48
with health care systems and hospitals which had reportedly
designed and implemented internal healthcare leadership
development programs, and 12 with non-provider
organizations which offered external healthcare leadership
development opportunities. In the nationwide survey, 844
hospital and health system chief executives responded
(response rate=17.2 percent). Respondents were
predominantly white (96 percent), male (84 percent), and
middle-aged (83 percent ages 45-64), consistent with other
descriptions of this population.
Principal Findings: A wide range of leadership development
practices currently exist in U.S. health care organizations, with
job assignments (78 percent), skills-based training (62
percent), and personal coaching (62 percent) reportedly most
common. Least common were formal mentoring programs
(32 percent), but interest in such programs was frequently
expressed by case study participants. Formal leadership
development programs reportedly exist in only one-third of the
organizations represented by our respondents. Across case
studies, most formal programs were reportedly fairly new, and
no interviewed experts reported participating in an
organizational leadership development program, although
some had helped create them. Considerable variability across
organizations showed multiple options for leadership
development program investments and definitions of
program scope, depending on expectations for the leadership
development function with respect to strategic organizational
priorities. Consensus across interviewed experts and
organizational representatives suggested that the bulk of
responsibility for leadership development in health care
remains personal, but expectations are increasing for
organizations to help.
Conclusions: Despite being responsible for a $1.3 trillion
dollar industry, health care leaders’ options and decisions to
develop their leadership skills and capabilities are
inconsistent, at best. Formal programs exist in only one-third
of organizations, and are rarely available in smaller U.S.
hospitals. Low-cost options are available, but any investment
requires solid and sustained commitment from senior
leadership.
Implications for Policy, Delivery, or Practice: Findings from
this study can help organizations as they attempt to assess,
build, and enhance their own leadership development
practices to ensure that the leaders of the future are properly
identified, recruited, trained, and retained.
Primary Funding Source: Center for Health Management
Research
●Interhospital Trauma Transfer Practices
K. John McConnell, Ph.D., Craig D. Newgard, M.D., MPH,
Jerris R. Hedges, M.D., MS
Presented By: K. John McConnell, Ph.D., Assistant Professor,
Center for Policy and Research in Emergency Medicine,
Oregon Health & Science University, 3181 SW Sam Jakcson
Park Road, Mail Code CR-114, Portland, OR 97239; Tel: (503)
494-1989; Fax: (503)494 4640; Email: mcconnjo@ohsu.edu
Research Objective: Factors associated with interhospital
transfer among injured patients remained undefined. There
has been speculation that hospitals may use trauma transfers
as a method of ‘dumping’ patients who are uninsured or
whose insurance is expected to reimburse at a low rate. We
sought to assess non-clinical factors associated with
emergency department (ED) transfer to a higher level of care,
based on an analysis of trauma patients initially presenting to
non-trauma centers.
Study Design: Retrospective cohort analysis using a
population-based state trauma registry of patients initially
presenting to one of 42 non-trauma centers from 1998-2003
and requiring either admission or transfer. We used
probabilistic matching to link ambulance records with hospital
ED records and state trauma registry data. Then, we modeled
the likelihood of transfer by adjusting for multiple measures of
injury severity (including, e.g., Injury Severity Scale [ISS] score,
hypotension, placement of chest tube, intubation). We
included data on the distance to the nearest higher level
trauma center, hospital and patient characteristics, including
age, race, gender, and insurance type. Our analysis used
approaches that controlled for heterogeneity among hospitals
and between years.
Population Studied: 10,990 persons presenting at one of 42
non-trauma centers in Oregon, from 1998-2003, and requiring
either admission or transfer. 3,807 (35%) of these patients
were transferred for higher level of care.
Principal Findings: Measures of injury severity were strongly
associated with the probability of transfer, and younger
patients (<=14 years) were also more likely to be transferred to
a higher level of care. More isolated hospitals (measured by
distance to nearest higher level trauma center) were also less
likely to transfer patients after adjusting for other important
factors. Among a subsample of less severely injured patients
(ISS < 9), we found some evidence that uninsured patients
were more likely to be transferred than privately insured
patients (although this finding was sensitive to model
specification).
Conclusions: After adjusting for important clinical factors,
there was substantial variability among hospital transfer
practices in sending trauma patients to a higher level of care
and some evidence for patient ‘dumping’ based on insurance
status.
Implications for Policy, Delivery, or Practice: There is a
need for easily applied, objective, data-driven guidelines for
interhospital transfer of injured patients. Further, there is
apparently some potential for reduced rates of
reimbursements and higher rates of uninsured to increase the
financial pressure on higher level trauma centers.
Primary Funding Source: CDC
●JCAHO Accreditation Surveys as a Measure of Process
Quality for VA Heart Failure Patients
Maurice Moffett, Ph.D., Carol M. Ashton, M.D., MPH, Robert
O. Morgan, Ph.D.
Presented By: Maurice Moffett, Ph.D., Assistant Professor /
Health Economist, Houston Center for Quality of Care &
Utilization Studies, Michael E. DeBakey VAMC (152), Baylor
College of Medicine, 2002 Holcombe Boulevard, Houston, TX
77030; Tel: (713)794-857; Fax: (713)748-7359; Email:
mauricem@bcm.tmc.edu
Research Objective: All Veteran Affairs (VA) Medical Centers
offering inpatient services use the JCAHO accreditation
process. Compliance with Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) standards and
preparation for the triennial survey is time consuming and
costly, however, the effects on quality of care have never been
investigated. The goal of this study is to assess the role of
JCAHO surveys as a measure of process quality.
Study Design: VA administrative inpatient databases were
used to extract hospital characteristics, patient characteristics
and treatment outcomes for all admissions for Heart Failure
(DRG 127) from the first quarter 1996 to the fourth quarter
2003. Patient outcomes were death during stay, death within
30 days of discharge, 90-day readmission, and patient
misadventures. These data were combined with JCAHO
survey data and include the full survey score, 45 performance
area scores, and date of inspection. Performance area scores
were grouped into Patient Focused Functions (PFF- e.g.
assessment and treatment procedures and medication use),
Organizational Functions (OF – e.g. leadership, and human
resource management), and Structures with Functions (SF –
e.g. credentialing and governance). Adjusting for time trends,
hospital size, specialty in heart failure, age, gender, income,
admission, and co-morbidities, we examined how variation in
PFF, OF and SF explained variation in patient outcomes.
Population Studied: Individuals admitted for heart failure
into VA hospitals between 1996 and 2003.
Principal Findings: Variation in Full Survey scores showed no
significant associations with outcomes of care. Better PFF
scores were associated with reduced patient mortality within
30 days of discharge (p=0.01), reduced 90-day readmission
rates (p=0.05), and fewer patient misadventures (p=0.004).
In contrast, better OF scores were associated with worse
patient outcomes; including higher 30-day mortality
(p=0.001), more 90-day readmissions (p<0.001) and more
patient misadventures (p=0.04). Better SF scores were
associated with worse 30-day mortality (p=0.09) but fewer
patient misadventures (p=0.05).
Conclusions: Patient-focused performance area scores are
indicators of process quality. However, the inverse
relationships between OF scores and patient outcomes are
disturbing. If these performance areas measure aspects of
organizational efficiency, our findings may demonstrate a
tradeoff between efficiency and care quality.
Implications for Policy, Delivery, or Practice: Full Survey
scores from JCAHO hospital inspections do not predict quality
of care. Improvements in overall scores depend on
improvements in both PFF and OF scores which appear to
have opposing associations with patient outcomes.
Primary Funding Source: VA
●Evidenced-Based Health Services Management: Do We
Have the Tools to Do the Job?
Esther B. Neuwirth, Ph.D., Thomas Rundall, Ph.D., Julie
Schmittdiel, PhD, John Hsu, M.D., MBA, MSCE
Presented By: Esther B. Neuwirth, Ph.D., AHRQ Posdoctoral
Fellow, School of Public Health, University of California,
Berkeley, 140 Warren Hall, MC 7360, Berkeley, CA 94720; Tel:
(510)883-9530; Email: ebneuwirth@berkeley.edu
Research Objective: We investigated the availability of webbased resources for evidenced-based organizational decisionmaking.
Study Design: We conducted a qualitative review of webbased tools and resources targeting organizational decisionmakers. We then categorized the resources into three areas:
(1) generic tools and resources for making important
operational and strategic decisions intended to improve
patient safety and quality of care; (2) tools and resources
available for making decisions regarding the implementation
of computer-based health information technology (HIT); and
(3) tools and resources available for making decisions about
the application of patient cost sharing/benefit design. We then
assessed the comprehensiveness of each tool, including
deficiencies in scope or process. Finally, we identified gaps in
available tools targeting health services managers seeking to
gather and use evidence. This review supports a larger study
on identifying methods to support evidence use in
organizational decision-making.
Principal Findings: There are web-based tools currently
available to make decisions about patient safety and quality,
HIT, and benefit design. There, however, were few case
studies or evaluations of these tools. Moreover, no web-based
compendium currently exists of evidence-based tools and
resources for organizational decision-making. There also were
few sites summarizing available evidence, e.g. structured
reviews of studies on the impact of organizational structures
and processes on patient safety and quality of care, the effects
of computer-based health information technology, or the
effects of cost-sharing. Finally, much of the existing evidence
from structured reviews and other evidence-based resources
has not been translated into management guidelines for
health services managers.
Conclusions: These preliminary findings suggest that there is
a dearth of web-based tools and resources. There are few
examples or evaluations of the use of the tools, nor are there
sources of evidence or guidelines aimed at health services
managers.
Implications for Policy, Delivery, or Practice: Despite the
promise of using evidence in making organizational decisions,
few web-based tools and resources exist. Further work is
needed to identify what types of resources may be most useful
for health services managers, and how best to disseminate
these resources.
Primary Funding Source: AHRQ
●Legislative, Strategic, and Organizational Influences On
Rural Hospital Nursing
Robin Newhouse, Ph.D.
Presented By: Robin Newhouse, Ph.D., Nurse Researcher,
Assistant Professor, Nursing Administration, The Johns
Hopkins Hospital, University School of Nursing, 1863
Crownsville Road, Annapolis, MD 21401; Tel: (410)614-2805;
Fax: (410)614-1115; Email: rnewhou1@1863crow
Research Objective: To explore the impact of legislative,
strategic, and organizational changes on nursing in rural
hospitals since 1995.
Study Design: Focus group
Population Studied: Eleven Rural Hospital Nurse Executives
who attended American Organization of Nurse Executives in
April 2004.
Principal Findings: Content analysis yielded three major
themes: external environmental (physical isolation, patient
population, services needed, legislation), internal
organizational (patient acuity, volume, services, technology,
financial margin and strategy, staffing, leadership, culture, and
resources), and nursing infrastructure (staffing, salary,
Registered Nurse (RN)- Physician (MD) conflict, continuity of
care, competency, culture, politics and leadership).
Conclusions: Rural hospital nurse executives face distinctive
issues and challenges as a result of legislative, strategic, and
organizational changes.
Implications for Policy, Delivery, or Practice: Further study
of the impact of policy and strategy decisions on rural nursing
is needed, so that the impact of legislation on the rural
nursing can inform policy decisions. Specific strategies for
supporting quality improvement in rural hospitals must
consider the unique nature of the rural setting.
Primary Funding Source: No Funding Source
●Franchising in Healthcare: Its Absence and Potential
Alyssa Pozniak, MAE, Ph.D. candidate
Presented By: Alyssa Pozniak, MAE, Ph.D. candidate, School
of Public Health - Health Management & Policy, University of
Michigan, 109 Observatory Street, Ann Arbor, MI 48109; Tel:
734-994-0041; Email: apozniak@umich.edu
Research Objective: There are varying organizational forms
among healthcare providers, ranging from arm’s length
contracting to full integration. However, between these two
affiliation extremes is franchising – a well-established and
successful business model in other industries – that is nearly
nonexistent in healthcare. This paper investigates the dearth
of franchising in healthcare and explores its potential as a cost
containing, quality maintaining business strategy.
Study Design: I present a conceptual framework of
franchising and how it applies to the healthcare industry
through a critical review of the healthcare, economic, and
business literature. Theory and current healthcare trends also
are used to better understand why franchising is not more
prevalent in healthcare.
Population Studied: Not Applicable.
Principal Findings: Franchising is common in a wide variety
of industries, including restaurants and hotels. It also has
been employed with varying levels of success in several
healthcare sectors, including primary care, cardiac labs, home
healthcare staffing, dentistry, and optometry.
Franchising offers several advantages over a fully-integrated
system to providers. Both offer lower costs via economies of
scale and business acumen, but franchising grants more
autonomy to the provider than a fully-integrated system does,
something especially well suited to the entrepreneurial nature
of many healthcare providers. Additionally, less monitoring to
ensure quality compliance with the trade name is needed with
franchises than in employee organizations since the provider
has a financial interest in the business’ success.
With the franchised brand name, a motivated local owner, and
lower costs, theory predicts increased demand, potentially
alleviating previously unmet healthcare demand. Although it
also could translate to provision of “unnecessary” care, this
concern of supplier-induced demand is not unique to
franchising and might be less of a threat than in fullyintegrated systems, given the firm’s and providers’ incentives.
The presence of health insurance distorts some of the
consumer benefits attributable to franchising. But for the unand under-insured, franchising offers increased availability of
services and a means to search and sort on quality through
the franchise’s brand name. The reduced search costs
associated with franchising are likely to become even more
valuable as medical savings accounts and other consumerdriven healthcare gain popularity. However, some consumers’
concerns that franchising’s brand-quality link may not hold for
healthcare services warrants further study.
Conclusions: Although some healthcare sectors have
experimented with franchising, it has largely been overlooked
as a viable business model. Franchising’s potential benefits to
the consumer include reduced search effort by relying on
brand names, lower costs via economies of scale, and, unlike
company-owned outlets, increased efficiency from the
entrepreneurial provider. Further research is needed to better
understand consumer perception of healthcare “branding”
and if franchising is a sustainable organizational strategy for
sectors within the US healthcare system.
Implications for Policy, Delivery, or Practice: With
burgeoning healthcare costs, increasing rates of un-/underinsured, and persistent concerns about quality, policymakers
may find franchising an attractive intermediary between arm’s
length contracting and full integration. Its comparative
benefits include accessing entrepreneurial trait of healthcare
providers, expertise in local markets, and better alignment of
incentives. As consumers face increased responsibility of their
healthcare costs and quality, they also could benefit from
franchising.
Primary Funding Source: No Funding Source
●The Role of Leadership in Supporting Healthcare
Excellence
Janice Pringle, Ph.D., Nicholas Emptage, MA
Presented By: Janice Pringle, Ph.D., Research Assistant
Professor, Department of Phamacy and Therapeutics,
University of Pittsburgh, 449 Falk Clinic, Pittsburgh, PA 15261;
Tel: (412)648-8560; Fax: (412)648-9253; Email:
pringlej@ireta.org
Research Objective: There is much literature supporting the
association between many leadership qualities in varied
industries with positive organizational change leading to
targeted areas of excellence. The role of leadership in
achieving healthcare excellence is less developed, but studies
of this association indicate similar leadership qualities to other
industries are important. This paper will define leadership
within an organizational structure, and present the various
forms of leadership associated with organizational excellence
both within and outside of healthcare.
Study Design: A conceptual model will be proposed for how
specific leadership qualities can facilitate an organization’s
ability to develop attributes known to be associated with
excellent performance. In addition, the paper will compare and
contrast the similarities between evidence supporting specific
qualities of leadership with specific types of positive
organizational change, leading to demonstrated excellent
outcomes for industries within and outside of healthcare. The
paper will also provide information on two developed case
studies conducted by the authors of hospital leadership
attempting to achieve excellence in patient safety and in an
addiction treatment system leadership in achieving excellent
clinical outcomes.
Principal Findings: The results of these case studies will be
compared with the proposed conceptual model, and tentative
conclusions offered as to why the organizations studied did or
did not achieve their intended goals.
Implications for Policy, Delivery, or Practice: Finally, the
paper will suggest areas in need of further investigation to
further elucidate the conceptual model, and develop
applications for supporting healthcare leadership attempting
to achieve clinical excellence.
Primary Funding Source: AHRQ
●Liquidity Constraints and Fixed Capital Investment in
Not-for-Profit Hospitals
Kristin Reiter, Ph.D., John Wheeler, Ph.D., Dean Smith, Ph.D.
Presented By: Kristin Reiter, Ph.D., Senior Research
Associate, Health Management and Policy, University of
Michigan, 1718 Dunmore Road, Ann Arbor, MI 48103; Tel:
(734) 996-0640; Email: kreiter@umich.edu
Research Objective: Hospitals are facing reduced access to
debt financing – the primary source of funds used to support
their investments in plant and equipment. At the same time,
many hospitals are demonstrating lagging investment.
Ideally, hospital investment decisions should be based solely
on the availability of projects that generate value to the
hospital and its community. However, previous research has
shown that in the presence of capital market imperfections,
investment decisions may be dependent on financing sources.
Previous research has also shown that organizational net
worth may play a role in mitigating the effects of capital
market imperfections. Unlike investor-owned hospitals, notfor-profit hospitals have little access to outside equity
financing as a substitute for debt. In addition, not-for-profit
hospitals have unique relationships with capital markets since
there is no shareholder ownership. This study assesses
whether investment in property and equipment is constrained
by the availability of internally-generated cash flows (liquidity)
for not-for-profit hospitals with relatively low net worth.
Study Design: This study employs a split-sample approach
where the number of days cash on hand (a measure of net
worth) is used to classify hospitals into “liquidity-constrained”
and “not-liquidity-constrained” groups. Fixed capital
investment is modeled as a function of debt and equity
financing variables as well as a series of variables to control
for investment demand. Fixed-effects, two-stage least squares
analysis is used to assess the relationship between fixed
capital investment and debt and equity financing in “liquidityconstrained” and “not-liquidity-constrained” hospitals.
Population Studied: Hospitals studied comprise a multi-state
sample of 300 private not-for-profit, short-term, general
medical and surgical hospitals reporting complete audited
financial data over the period 1996-1999 in the Merritt
Research Services Investor Tools database. All of the
hospitals studied are municipal borrowers.
Principal Findings: Hospitals classified as liquidityconstrained demonstrate a significant dependence of
investment on the previous year’s cash flow from operations.
In addition, liquidity-constrained hospitals appear to trade-off
investments in fixed capital with investments in short-term
financial securities. In contrast, hospitals classified as notliquidity-constrained exhibit no significant relationships
between fixed capital investment and sources of debt or equity
financing.
Conclusions: For not-for-profit hospitals with relatively low
net worth, as measured by the number of days cash on hand,
fixed capital investment decisions depend on the availability of
internally-generated sources of financing. The investmentfinancing relationship may reflect a real premium on outside
funds as a result of capital market imperfections.
Alternatively, the investment-financing relationship may reflect
the actions of risk-averse not-for-profit hospital managers.
Implications for Policy, Delivery, or Practice: Capital market
imperfections affect hospital investment decisions and thereby
access to and quality of care. Overcoming the effects of
capital market imperfections may require changes in
reimbursement policy, expansion of Federal loan programs
that reduce risk to lenders, or education regarding the
existence of such programs. Further research should address
the appropriateness of trade-offs between fixed and financial
investments, and the effect of these trade-offs on hospital
output.
Primary Funding Source: Rackham Pre-Doctoral Fellowship,
University of Michigan
●The Adoption and Diffusion of Innovations in Provider
Organizations: A Critical Review of the Literature
Colleen Rye, BA, John R. Kimberly, Ph.D.
Presented By: Colleen Rye, BA, Doctoral Candidate, Health
Care Systems, The Wharton School, University of
Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104; Tel:
(610) 529-2817; Email: cbeecken@wharton.upenn.edu
Research Objective: In the last thirty years, a wide array of
innovative medical technologies has flooded health care
systems worldwide, offering potentially beneficial advances in
diagnosis and treatment in a growing number of clinical
domains. These technologies account for some of the most
spectacular improvements in population health outcomes in
the developed world, as well as for a nontrivial proportion of
growth in expenditures. Health care provider organizations
are the primary consumers of these medical innovations, and
understanding the factors that inhibit or facilitate diffusion of
innovations to these organizations is important in addressing
cost, quality, and access issues. Given the importance of the
issues, the purpose of this paper is to (i) compile a
comprehensive, interdisciplinary database of studies
examining the adoption and rejection of innovations in health
care provider organizations; (ii) organize these studies using a
conceptual model; (iii) assess the strengths and weaknesses
of this literature; and (iv) provide suggestions on directions
for future research. This literature review was carried out in
the context of a larger, interdisciplinary project at the
University of Pennsylvania designed to examine the adoption
and diffusion of medical innovations among physicians and
organizations.
Study Design: To initiate data collection, we conducted
computerized searches through the National Library of
Medicine’s PubMed service. We relied on PubMed’s medical
subject headings (“MeSH”) and searched all abstracts with
the major topic headings “Diffusion of Innovation”,
“Organizational Innovation”, and “Information
Dissemination”, totaling 6,197 abstracts. We then collected all
appropriate citations in seven literature reviews on
organizational innovation. Finally, we searched the reference
sections of all articles identified through the first two steps.
For this review, we focused on research articles published in
English-language peer-reviewed journals from 1960 through
the present. In addition, a study had to meet the following
criteria for inclusion: (i) at least one level of analysis was at the
organizational level; (ii) the authors utilized qualitative or
quantitative empirical research methods; (iii) the innovation
was developed outside of the organization; (iv) the dependent
variable was adoption of innovation; and (v) the organization
studied was a health care provider organization. Interestingly,
a total of 70 studies met all of these criteria. Each study
identified was reviewed independently by the authors and
coded for methods and content based on an extensive data
extraction form.
Population Studied: This review includes articles examining
adoption of innovations in provider organizations, including
but not limited to hospitals, physician group practices,
substance abuse treatment centers, nursing homes, and other
physician organizations.
Principal Findings: The rate of growth in medical innovations
has been paralleled by the rate of growth in adoption and
diffusion studies. We found that many studies have explored
determinants of innovation adoption in isolation, particularly
those having to do with environmental forces, interorganizational connections, organizational attributes, and
innovation characteristics. However, an increasing number of
studies explore the relationships among these categories.
Conclusions: Based on our review, it is clear that future
research should be based on longitudinal designs, utilize
multi-dimensional constructs, and incorporate qualitative as
well as quantitative methods.
Primary Funding Source: Mack Center for Technological
Innovation
●Financial Preconditions for Successful Community
Initiatives for the Uninsured
Paula Song, MHSA, MAE, Dean G Smith, Ph.D.
Presented By: Paula Song, MHSA, MAE, Doctoral Student,
Department of Health Management and Policy, University of
Michigan, 555 South Forest Street, Ann Arbor, MI 48104; Tel:
(734)647-9604; Fax: (734)998-6341; Email:
phsong@umich.edu
Research Objective: The purpose of this research is to
identify financial preconditions or common characteristics
among medical care organizations that are conducive to
successful community initiatives for the uninsured.
Study Design: This study is a component of an overall
evaluation the Robert Wood Johnson Foundation (RWJF)
sponsored Community in Charge (CIC) program of 15 sites
across the US. We collected financial data from multiple
sources including hospital cost reports and annual statements
for fiscal year 2000/01. We also conducted interviews with key
leaders from hospitals and other providers at four sites. The
interviews added insight on the financial burdens of
uncompensated care and how providers have responded to
these burdens.
Population Studied: Hospitals, community health centers,
insurers, physicians, and community leaders in Alameda,
Austin, Birmingham, Spokane and Wichita.
Principal Findings: There are four financial preconditions
associated with successful CIC program initiation.
The first precondition is the perception of substantial costs
due to uncompensated care. This precondition garners the
attention of community leaders and providers and motivates
participation in the program. The second precondition is
relative financial stability among providers, enabling them to
dedicate resources to the program. We find that levels of
profitability vary by site and among providers within a site.
However, if the overall provider market is financially stable,
providers can afford to participate in the program. The third
precondition involves the financial position of third party
payers, particularly for programs that follow the health
insurance expansion model. Similarly, the stability of state
funding for Medicaid and other government programs for the
uninsured affects program success. The final precondition is
the ability to create new sources of funding -- critical for the
sustainability and long-term viability of the programs. Shortrun grant support can help organize a community, but longerrun sources of funding are necessary to sustain a program.
For example, data on select hospitals in Wichita’s donated
care model indicate uncompensated care approaching 9% of
overall operating expenses, yet positive net incomes of
approximately 4% in a stable health insurance market.
Providers were willing to donate their services, and Wichita
also obtained new sources of funding for prescription drug
coverage enabling them to be a successful program.
Conclusions: We find that “successful” CIC sites that satisfy
these financial preconditions are able to initiate a program
with promising levels of activity. Good starts are observed
where providers are somewhat financially strained by
uncompensated care, but are not so strained that they cannot
afford to participate. Minimum levels of financial stability are
necessary for organizations to actively participate in the
program. Even with good starts, the long-run viability of these
programs depends upon sustained sources of funding.
Implications for Policy, Delivery, or Practice: Communities
interested in starting initiatives like Communities in Charge
should evaluate their own financial environment to determine
if it meets any of the above preconditions. Communities that
share similar financial characteristics may position themselves
for greater participation from providers, payers, and
community leaders and increase the likelihood of a successful
program.
Primary Funding Source: RWJF
●Closures of Hospital Services: How Often, and What
Impact?
Joanne Spetz, Ph.D., Paul Kirby, MA, Lisa Simonson Maiuro,
Ph.D., Paul Kirby, MA, Richard Scheffler, Ph.D.
Presented By: Joanne Spetz, Ph.D., Associate Professor,
Community Health Systems, University of California, San
Francisco, 3333 California Street, Suite 410, San Francisco, CA
94118; Tel: (415)502-4443; Fax: (415)-502-4992; Email:
jojo@alum.mit.edu
Research Objective: Financial pressures may induce
hospitals to drop services that are perceived as unprofitable.
As a result, some communities may lose access to needed
services. There is little research that examines changes in
service availability among hospitals that have remained in
operation during a time of economic turbulence for the
hospital industry.
Study Design: We examined changes in availability in hospital
products using a service classification system that reflects the
bases on which hospital competition is likely to occur. We
then examined patient choice of hospital and distances
traveled for services that closed frequently in California, using
linear multivariate regression analyses. Finally, case studies
provided insight into how communities were affected by
service changes.
Population Studied: All California hospitals that reported
patient discharge data to the Office of Statewide Health
Planning and Development (OSHPD) in 1995 and 2002.
Principal Findings: The services offered by hospitals were
generally stable over this time period. A few hospitals closed
many of their services, and some services were more likely to
close than others. The services offered by hospitals were
generally stable over this time period. A few hospitals closed
many of their services, and some services were more likely to
close than others. Obstetric services were closed most often.
Hospitals eliminating this service represented less than 10%
of the sample. Rural hospitals were disproportionately
affected. The multivariate analysis focused on distances
traveled by obstetrics patients, as well as the probability of an
obstetrics patient bypassing the nearest hospital. Maternal
age has the strongest effect on travel decisions, with older
women more likely to travel for care. The age effect was larger
for cesarean deliveries. Distances to nearby hospitals and the
volumes of deliveries at those hospitals also affected travel
distance and the probability of bypassing the nearest hospital.
Controlling for these characteristics, there was not a general
trend toward increased travel distances in general, although
patients who lived closest to the hospitals that closed services
may have experienced to increase in travel. These changes
had no effect on rates of cesarean delivery or complicated
delivery. The case studies revealed that hospitals that closed
obstetrics services did so because they faced large financial
losses in that department. All hospitals reported that they
offered highly personalized labor and delivery care. They also
did not offer neonatal care for complicated cases. All
hospitals have continued to face financial losses since the
closures of their obstetrics departments.
Conclusions: Financial pressures may induce hospitals to
drop certain categories of services that are perceived as
unprofitable. However, closures of services were not
widespread in California between 1995 and 2002. Most
hospitals that have remained in operation have maintained
their service mix. Closures in obstetrics services have been
attributed to issues related to low volume or low
reimbursement, as well as to increasing competition from
hospitals that offer specialized neonatal care, which is
attractive to older mothers.
Implications for Policy, Delivery, or Practice: The impact of
service closures on communities appears small. Key
informants interviewed as part of the case studies concurred
with this assessment. In fact, the willingness of patients to
travel for hospital care is one of the causes of closures of
services.
Primary Funding Source: California HealthCare Foundation
●Structural Characteristics of Breast Cancer Care in Los
Angeles County
Diana M. Tisnado, Ph.D., Jennifer Malin, MD, Ph.D., May-Lin
Tao, M.D., Fang Ashlee Hu, Ph.D., Patricia A. Ganz, M.D.,
Katherine L. Kahn, M.D.
Presented By: Diana M. Tisnado, Ph.D., Assistant Professor,
Department of Medicine - Division of GIM & HSR, UCLA, 911
Broxton Avenue, Los Angeles, CA 90095-1736; Tel: (310) 7940711; Fax: (310)794-0732; Email: dtisnado@mednet.ucla.edu
Research Objective: Understanding how structure impacts
process and outcomes is vital to quality improvement efforts,
yet little is known about the structure of breast cancer care.
We conducted a physician survey to characterize the clinical
epidemiology of the structure of breast cancer care, and
ultimately to evaluate the impact of structure on the quality of
care patients receive.
Study Design: Cross-sectional study of the structure and
organization of care associated with the physicians for a
population-based sample of 1245 women with incident breast
cancer associated with the Los Angeles Womens’ Health
Study (LAWHS). The 2004 survey represented a number of
conceptual domains: Facilities and Resources, Physician
Support, Patient Support, Coordination, and Financial
Incentives.
Population Studied: Data are from 112 medical oncologists
(response rate 67%) practicing in Los Angeles County.
Principal Findings: Self-report data indicated the medical
oncologists were predominantly male (69%) and white (62%),
with mean age = 53 (SD=9). Breast cancer represented 40% of
their incident cancer cases. Respondents worked in 1.6 unique
offices on average, and were asked to report about the one in
which they see most of their patients. The following were
present within their main practice settings: surgeons (47%),
care coordinator or navigators (47%), radiation oncologists
(42%), nutritionists (42%), mental health providers (42%)
primary care physicians (40%), and physical therapists (37%).
Although respondents overwhelmingly reported working
without much input from others to decide about use of
chemotherapy (94%) and opiates (89%), many described
collaborating with colleagues in the delivery of several
specified services: deciding about the possible use of radiation
(67%) and type of breast surgery (63%), evaluation and
treatment of depressive symptoms (51%), management of
comorbidities (42%), and arm-related symptoms such as
lymphedema (40%). Provider network restrictions imposed by
health plans or medical organizations were reported to
sometimes, often, or always pose barriers to referrals to high
quality mental health providers (41%), plastic surgeons (34%),
and medical oncologists for second opinions (31%). Medicaid
not being accepted was reported to sometimes, often, or
always pose a barrier to referral to high quality plastic
surgeons (65%), mental health providers (57%), and medical
oncologists for second opinions (47%). The majority of
respondents reported that their personal financial incentives
favored neither reducing nor expanding individual services to
patients, but were reported by some to favor expanding the
use of: office-based parenteral chemotherapy (31%) and
growth factor injections (31%), and enrollment in clinical trials
(22%).
Conclusions: Substantial variation exists in the structure of
care regarding facilities and resources, collaborative care,
barriers to referrals, and financial incentives. Structural
aspects of care which may influence how care is delivered
include restrictions on practice, such as restricted provider
networks, and financial incentives.
Implications for Policy, Delivery, or Practice: Although
barriers to referrals have been widely reported, this is among
the first systematic studies to report this finding among
patients with incident breast cancer. We believe these analyses
will provide a basis for improving the quality of care breast
cancer patients receive by identifying mutable factors to target
for quality improvement interventions.
Primary Funding Source: California Breast Cancer Research
Program
●Contributions of Know-What and Know-How to
Performance Improvement in Complex Service
Organizations
Anita Tucker, DBA, Amy Edmondson, Ph.D., Ingrid
Nembhard, MS
Presented By: Anita Tucker, DBA, Assistant Professor,
Operations and Information Management, University of
Pennsylvania, 3730 Walnut Street, Philadelphia, PA 191046340; Tel: (215) 573-8742; Fax: (215) 898-3664; Email:
tuckera@wharton.upenn.edu
Research Objective: We aim to contribute to a growing body
of work on organizational learning by identifying the activities
used purposefully by members of healthcare organizations to
import better work practices, so as to improve patient
outcomes. This type of operational learning typically requires
hands-on experience with the new practice (Carrillo et al.,
2000). For clarity in this paper, we use the term “know-what”
to refer to technical or scientific knowledge about the practice
targeted for improvement (i.e., information generally found in
medical literature) and the term “know-how” for operational
knowledge about implementation of the targeted practice
change. These terms highlight that knowing what practice to
change is a separate challenge from knowing how to
effectively implement that practice change.
Study Design: We collected data in two phases. In the first
phase, we gathered observational data and conducted
interviews with neonatologists, nurse practitioners, nurses
and respiratory therapists at four NICUs to better understand
the research context. In phase two, we administered a survey
to collect quantitative data on improvement projects
undertaken in NICUs. We administered this survey to 3059
healthcare professionals from 23 NICUs and 4 maternity
wards, receiving a total of 1813 responses for overall response
rates of 59% for individual respondents and 52% for NICUs.
The individuals surveyed represented a wide range of
professions including nurses, neonatologists, respiratory
therapists, social workers, unit secretaries, pharmacists,
medical directors, and nursing unit managers. In addition,
281 individuals completed an additional section of the survey
about a specific improvement project conducted on their unit
in which they had participated. As hospital units undertook
multiple improvement projects, we received information about
multiple projects for each unit. After removing data from
projects for which had only one survey response, or for which
we could not identify a project, we had survey data on 57
improvement projects from 20 hospital units, for an average
of 2.85 projects per unit.
Population Studied: We studied a group of neonatal
intensive care units in a multi-hospital collaborative designed
to facilitate process and outcome improvement. During the
two-year collaboration, multidisciplinary teams from 44
NICUs in the United States and Canada came together five
times to learn about existing best practices and to develop
new, better practices in seven focus areas: the delivery of
family-centered care, discharge planning, infection control,
maternal and newborn departmental collaboration, pain and
sedation, respiratory care management, and staffing.
Principal Findings: We found that engaging in more “knowhow” activities—such as pilot tests, dry runs, and enabling
staff to provide feedback—contributed to higher
implementation success. However, we did not find evidence
linking “know-what” activities—such as literature reviews—
with implementation success (F = 7.46, p = .002; know-how
beta=.660, p=.01; know why beta= .17, p=.428). Our results
also show that psychological safety-- which fosters open
sharing of suggestions within work groups—is a prerequisite
for engaging in such exploratory learning activities. However,
psychological safety has no bearing on the use of learning
activities to generate know-what.
Conclusions: In summary, the current study shows that, in
contrast to prior theory on organization learning know-what
and know-how do not equally contribute to groups’ ability to
successfully implement new work practices. Although
effective adoption first requires knowledge of what practice to
implement, success seems to depend most heavily upon
activities that create organizational understanding of how to
translate a concept into practice—even when the level of
process knowledge is high (i.e. the practice is welldocumented and supported). Thus, our findings support
Kilo’s (1999) assertion that knowing that one should do
something is not equivalent to knowing how to do it.
Implications for Policy, Delivery, or Practice: Our results
show that engaging in activities that generate knowledge
about how to translate concept into practice greatly benefits
frontline teams striving to implement improved processes.
These activities – namely, pilot tests, dry runs and
opportunities for staff to offer feedback about practices and
their implementation – consistently allowed teams to reach
their implementation goals. Conversely, know-what activities –
specifically, literature reviews, dissemination of articles
supporting the use of the practice to staff and use of resource
guides listing recommended practices – had no effect on
implementation success. These findings mirror Mukherjee et
al.’s (1998) finding that operational not conceptual learning
activities predict goal achievement, and suggest that knowwhat is necessary but not sufficient for implementation
success (Kilo, 1999). Without know-how activities to
familiarize work teams with the practice in practice and to
allow the adaptation the practice to their context,
implementation efforts falter. Numerous reputable
organizations have repeatedly issued evidence-based
guidelines for patient care, yet physician compliance remains
poor (McGlynn et al., 2003). A review of the literature on
physician non-compliance showed that lack of awareness
about a practice was an issue in many instances (i.e. knowwhat), but that lack of belief in the efficacy of the practice and
limited understanding of how to implement the practice were
greater barriers when physicians knew of practices (Cabana et
al., 1999). Know-how activities provide opportunities to
overcome these barriers. Work groups buy into the project
and commit to full implementation because they have shaped
the practice and have seen the results of their trials.
Primary Funding Source: Division of Research, Harvard
Business School; and Fishman-Davidson Center University of
Pennsylvania
●Constructive Technology Assessment as a tool to
enhance controlled introduction of microarray prognostics
in breast cancer treatment
Willem H. van Harten, M.D., Ph.D., MPH, Kim Karsenberg,
MSc, Kirsten Douma, MSc, Marjan J. Hummel, Ph.D., JM,
Bueno de Mesquita, M.D.
Presented By: Willem H. van Harten, M.D., Ph.D., MPH,
Member Executive Board of Directors, Executive Board of
Directors, Netherlands Cancer Institute-Antoni van
Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam, 1066
CX; Tel: (0031) 205122860; Fax: (0031) 206691449; Email:
w.v.harten@nki.nl
Research Objective: In 2004 the Dutch Board of Health Care
Insurance (CVZ) started a program of controlled introduction
of promising innovations. To explore the potential of
constructive technology assessment (CTA) to improve the
adequacy of microarray prognostics in breast cancer treatment
in the early adoption phase, a systematic CTA-analysis was
performed.
Study Design: The adequacy of the technology was studied
using the aspects of quality as defined by the Institute of
Medicine in a pre- and post introduction measurement. This
included process analysis before and after introduction, using
documentation and patientfile analysis, semi-structured
interviews of team-members and structured patient
interviews; the latter and consultation-recordings were used to
measure the impact on doctor-patient relationship.
Theoretical cases were presented to the prescribing
physicians, and the actual prescriptions of physicians,
compared to guideline based advice, were recorded to analyse
the impact of microarray tests in clinical practice.
Population Studied: In the early adoption phase 7 hospitals
participated. Out of 250 patients 75 were eligible for testing.
(In June 2005 the results of 15 hospitals and around 175 tested
patients can be presented)
Principal Findings: There were considerable differences in
the process of breast cancer diagnosis and treatment per
hospital. The introduction of microarrays changed the role of
the pathologist due to the necessity of rapid tissue handling.
In some cases the multidisciplinary team decision proces was
either delayed or even changed. Large differences in
implementation time occurred.
A discrepancy of about 30% comparing the results the
national guideline concerning adjuvant chemotherapy and the
advice based on the microarray test. The physicians tended to
follow the test based advice in case of negative guideline (low
risk) versus positive test (=high risk for metastasis). Because
of limited numbers it is not yet clear whether a defensive
course is followed in case of a reverse discrepancy. Discrepant
results leading to chemotherapy can confuse patients. No
information was obtained that indicated reduced operational
efficiency or safety problems. The issue of patient-rights
concerning banked-tissues, with the perspective of new
microarray on proteomic tests infuture, is not settled.
Conclusions: The results indicate a potential gain in
efficiency, the numbers being insufficient for a cost-benefit
analysis in this phase.
The patient orientation can be improved, especially by training
physicians and preparing patients for the possibility of
discrepant results. Timeliness needs to be improved through
logistic adaptations. Equity and safety have not proven to be
an issue, although jurisdiction concerning the stored tissue
needs to be cleared.
Implications for Policy, Delivery, or Practice: Based on
these results, adaptations in logistics and patient information
procedure were decided upon. The National Council will fund
introduction in a second round of 25 (early majority) hospitals.
CTA seems to be an approach that contributes in improving
the adequacy of a technology in the early phases of its
introduction when a formal HTA including cost effectiveness
analysis is not possible. In the early majority phase an
additional Cost Effectiveness Analysis is foreseen.
Primary Funding Source: The Dutch Council of Health Care
Insurances.
●Rogers’ Replication Framework Revisited: Navigating the
Complexity of Health Networks
Lei Zhang, MPA, Karen Minyard, Ph.D., Lei Zhang, MPA
Presented By: Lei Zhang, MPA, Ph.D Candidate; Graduate
Research Assistant, Georgia Health Policy Center, Andrew
Young School of Policy Studies, 14 Marietta Street, Suite 221,
Atlanta, GA 30303; Tel: (404)651-3104; Fax: (404)651-3147;
Email: alhlzx@langate.gsu.edu
Research Objective: Successful replication of model
programs is the concern of many researchers and
practitioners in health care. Previous replication studies
examined the diffusion of innovations among individuals or
organizations. However, with the growing popularity of new
organizational forms such as collaborative networks, these
frameworks might require modifications. The objective of this
paper is to examine the application of Rogers’ diffusion
framework to community health networks.
Study Design: Five case studies were conducted over an 18
month period. As part of the case studies, site visits were
conducted. Ten to twenty-five interviews were conducted with
informants from each site. Interview questions were
developed to assess the applicability of Rogers’ diffusion
framework to health networks. Atlas-ti was used to code the
notes and compare findings horizontally (within sites) and
vertically (across sites).
Population Studied: Five case study sites (Wichita, Kansas;
Paris, Arkansas; Milwaukee, Wisconsin; Olympia, Washington;
and Forsyth, Georgia) were selected because of their
geographic and operational diversity. Each site was either a
beta site for a replicable model or was attempting to replicate
a combination of models. The intent of each site's initiative is
to provide coverage and/or access to care to individuals who
have difficulty finding or navigating conventional insurance
arrangements and public programs. This analysis is based on
84 interviews with key informants across the five case study
sites. Interviewees included program directors and
implementers, providers, state/local government officials,
community advocates, funders, and other health care
professionals.
Principal Findings: All five beta sites share the following
characteristics with regard to successful replication of the
model program(s) from their alpha sites. They all adopted the
program as a response to the needs of their communities;
have either formal or semi-formal community network
partnerships; maintained good communications (mainly
interpersonal) both with the alpha sites and with members in
the collaborations; featured strong leadership support; relied
heavily on pooled resources such as funding, facilities, as well
as personnel, and benefited immensely from commitment of
boards, staff and network members to achieve outstanding
performances.
Conclusions: Difficulty of replication can be attributed to the
complexity of the innovations, the complexity of the network
organization, and the differences in context between alpha
and beta sites. Innovations are most easily transferred when
they are simple and quick, and when their benefits are easily
observable. However, initiatives to improve access and health
status are necessarily complex, and their results generally are
not quickly or clearly observable. As a result, every factor that
influences innovation diffusion must be pursued more
intensively.
Implications for Policy, Delivery, or Practice: To
successfully transfer complex programs across complicated
network settings, we need to (1) thoughtfully adapt models to
local circumstances; (2) enhance leadership capacity that
includes the ability to develop a wide variety of highly
interconnected network partners with high levels of knowledge
and to manage and facilitate the collaboration and
communication among partners; (3) expand opportunities for
interpersonal communications; and (4) capitalize strategically
on the context of community programs.
Primary Funding Source: CWF, Healthcare Georgia
Foundation, Washington Health Foundation
●Leadership & Succession in the Enterprising Family
Andrew Zmuda, MFT
Presented By: Andrew Zmuda, MFT, Drexel University, 1924
Sussex Ave, Cherry Hill, NJ 08003; Tel: (856) 616-0144; Email:
andyzmuda@comcast.net
Research Objective: The purpose of this proposal is to
instigate a phenomenological inquiry and to discover family
member and key employee perceptions of leadership
characteristics as they influence succession decision-making
in a multigenerational family-owned business. This proposal
presents the primary research question: What characteristics
of leadership are important to the successful intergenerational
transition of power in family businesses?
Study Design: This study is based upon a qualitative, case
study research methodology that will assist in understanding a
particular social situation, event, or interaction and people’s
experiences, meanings, and understanding of that event or
interaction.
Population Studied: Multigenerational family owned
businesses in the United States.
Principal Findings: This paper is currently in the proposal
stage; as such, no findings are available at this time.
Conclusions: This paper is currently in the proposal stage; as
such, no conclusions are available at this time.
Implications for Policy, Delivery, or Practice: This paper is
currently in the proposal stage; as such, no implications are
available at this time.
Primary Funding Source: No Funding Source