Management, Organization & Financing
Call for Papers
Organizational & Market Structure, Patient Care
Outcomes, & Financial Performance in HCO’s
Chair: Jacqueline Zinn, Temple University
Sunday, June 25 • 10:30 am – 12:00 pm
●Variation in Resources Use on End-of-Life Patients
between Teaching and Community Hospitals
John Cai, Ph.D., Maria Schiff, MS
Presented By: John Cai, Ph.D., Senior Health Policy Analyst,
Massachusetts Division of Health Care Finance and Policy, 2
Boylston Street, Boston, MA 02116; Tel: 6179883137;
Email: john.cai@state.ma.us
Research Objective: Although information on quality and
cost of health care is gaining more importance through the
movement toward consumer-driven health care, information
on quality and cost of end-of-life (EOL) care is still very
limited. Especially for EOL patients, more resource use is
often not associated with better quality of care. This study
focused on the final hospital stay of EOL patients to see
whether there are systematic differences in resource use
between teaching and community hospitals. Age, case-mix,
and ICU bed availability were explored to explain these
differences.
Study Design: With 2004 Massachusetts hospital inpatient
discharge data, the study population included hospitalizations
of EOL patients in general acute hospitals, i.e. patients who
either died or were discharged into hospice: 8,360 in teaching
hospitals and 11,219 in community hospitals. ICU use,
number of significant procedures, LOS, and total charges were
compared between these two hospital groups and further by
three age groups: under-65, 65-79, and over-79. Although
focusing on the final hospital stay helps to control for case-mix
differences, we calculated case-mix index (CMI) for EOL
patients in both teaching and community hospitals based on
APR15DRG cost weights, and further decomposed teaching
hospital charges into CMI effect and teaching effect. The ICU
bed to total bed ratio was used to predict hospitals’ ICU
admission rate.
Principal Findings: EOL patients in teaching hospitals used
significantly more resources by all measures than those in
community hospitals: percentage of patients admitted into
ICU (46.4% vs. 36.8%), percentage of patients with over 3
significant procedures (41.9% vs. 22.0%), average LOS (10.5
vs. 7.3 days), and total hospital charges ($70,727 vs. $20,752).
The age profile of EOL patients in teaching hospitals (spread
equally in three age groups) was younger than community
hospitals (16% in under-65 group and 52% in over-79 group).
Although resource uses and their differences between
teaching and community hospitals tended to decline with
rising patient age, these differences remained significant even
for the over-79 patient group. The higher CMI of teaching
hospitals (2.97 vs. 1.81) accounted for only 27% of the
difference in total hospital charges, even after controlling for
age. Higher ICU admission rate of EOL patients among
teaching hospitals was positively associated with their higher
ICU/total bed ratios while the same relationship did not
appear to exist among community hospitals.
Conclusions: Teaching hospitals in Massachusetts tend to
manage end-of-life patients with substantially more resources
than community hospitals even after controlling for the
impact of patients’ age and disease severity.
Implications for Policy, Delivery, or Practice: Although
statewide, more patients have been choosing to die outside of
hospitals over the last ten years (primarily shifting to nursing
homes), both the number and proportion of hospital deaths
have been shifting from community hospitals to teaching
hospitals at the same time, even among old-age patients.
Considering the quality and cost implications of end-of-life
care, the reversal trend would be beneficial to patients as well
as to society.
Primary Funding Source: Massachusetts Division of Health
Care Finance and Policy
●Quality of Care in Specialty Orthopedic and Competing
General Hospitals
Peter Cram, M.D., M.B.A., Mary Vaughan-Sarrazin, Ph.D.,
Brian Wolf, M.D., Jeffrey N. Katz, M.D., MS, Gary E. Rosenthal,
M.D.
Presented By: Peter Cram, M.D., M.B.A., Assistant Professor,
Internal Medicine, University of Iowa College of Medicine, 200
Hawkins Drive, 6GH SE Rm 611, Iowa City, IA 52242; Tel:
(319)353-6894; Fax: (319)356-3086;
Email: peter-cram@uiowa.edu
Research Objective: The objective of this study was to
compare the characteristics and outcomes of patients
undergoing total hip replacement (THR) and total knee
replacement (TKR) surgery in specialty orthopedic and
competing general hospitals
Study Design: A retrospective cohort study.
Population Studied: Medicare Provider and Analysis Review
(MedPAR) Part A public use data files were used to identify all
patients who underwent major joint replacement (either THR
or TKR) surgery during 1999-2003. Next, we identified the 100
most specialized orthopedic hospitals in the United States,
defined as those hospitals with the highest proportion of their
total 2003 Medicare admissions categorized as Major
Diagnostic Category (MDC) 8 (Diseases of the
Musculoskeletal System). We eliminated from this list all
hospitals providing general obstetrical or pediatric care (N=55)
and all teaching hospitals (N=7) as there is widespread
consensus that such hospitals do not qualify as specialty
orthopedic hospitals, resulting in the identification of 38
specialty orthopedic hospitals. A comparison group of
general hospitals was defined as all hospitals performing
major joint replacement in the same geographic region as one
or more specialty hospitals (N=517). We compared
demographic characteristics, comorbidities, socio-economic
status (as measured by U.S. Census data at the zip-code
level), and hospital procedural volume for THR and TKR, of
patients treated in specialty orthopedic and general hospitals.
Finally, logistic regression models were used to assess the risk
of suffering an adverse outcome (defined as a composite
endpoint of death, readmission, or selected surgical
complications) for patients who underwent major joint
replacement (THR or TKR) in specialty orthopedic hospitals
relative to general hospitals after adjusting for patients’
characteristics and hospital procedural volume.
Principal Findings: For THR, the 38 specialty hospitals and
competing general hospitals performed 4,683 and 47,105
procedures respectively. For TKR, the specialty and general
hospitals performed 10,234 and 89,531 procedures.
Demographic characteristics were similar in specialty and
general hospitals, but patients in specialty hospitals had lower
rates of most important comorbid conditions including
diabetes, heart failure, and renal failure (P<.05 for all) and
resided in zip-codes with higher per-capita incomes and
higher housing values than patients in general hospitals.
Specialty hospitals had significantly greater procedural
volumes for both THR (33 vs. 20: P=.05) and TKR (75 vs. 40;
P=.006) In unadjusted analyses, adverse outcomes were
significantly less common in specialty hospitals compared to
general hospitals for THR (3.0% vs. 6.9%; P <.001) and TKR
(2.1% vs. 3.5%; P <.001). In regression models, after adjusting
for patients’ characteristics, hospital procedural volume, and
type of procedure (THR or TKR) the odds of adverse
outcomes were significantly reduced for patients who
underwent major joint replacement in specialty hospitals
relative to general hospitals (OR 0.62, 95% CI 0.54-0.72;
P<.001).
Conclusions: Specialty orthopedic hospitals care for patients
who are wealthier and have less comorbid illness and perform
higher volumes of joint replacements than general hospitals.
After adjusting for the healthier patients and greater
procedural volumes, specialty hospitals demonstrate
improved outcomes relative to competing general hospitals.
Implications for Policy, Delivery, or Practice: While
proliferation of specialty orthopedic hospitals should result in
improved outcomes for many patients requiring major joint
replacement, it is uncertain how this may affect access for
financially less desirable patient.
Primary Funding Source: The VA and the NCRR
●Improving Hospital Performance: The Effects of
Organizational and Market Factors
H. Joanna Jiang, Ph.D., Bernard Friedman, Ph.D., James W.
Begun, Ph.D.
Presented By: H. Joanna Jiang, Ph.D., Social Scientist, Center
for Delivery, Organization and Markets, Agency for Healthcare
Research and Quality, 540 Gaither Rd, Rockville, MD 20850;
Tel: 301-427-1436; Fax: 301-427-1430;
Email: joanna.jiang@ahrq.gov
Research Objective: This study examines hospitals that
successfully became high quality-low cost providers over time,
in relation to changes in organizational and market
characteristics. The study focuses on the post-Balanced
Budget Act period of 1997 to 2001 during which hospitals
were subject to considerable financial pressures and likely to
implement operational changes to enhance performance.
Study Design: Hospitals were classified into performance
quadrants based on risk-adjusted mortality and cost.
Mortality rate is a weighted composite of 10 risk-adjusted
morality indicators covering common medical conditions and
surgical procedures. Cost per discharge was derived from
hospital charges using cost-to-charge ratios and adjusted for
case mix, severity of illness, and area wage index. The
likelihood of moving to the low mortality-low cost (high-
performing) quadrant over time was examined through
logistic regression, separately for each group of hospitals
stratified by initial performance – low mortality-high cost, high
mortality-low cost, and high mortality-high cost. Financial
performance was compared between hospitals moving to the
high-performing quadrant and hospitals not making the move.
Population Studied: A total of 944 nonfederal, general acute
hospitals in 10 states (AZ, CA, CO, FL, GA, IA, IL, NY, TN, WI)
with data available from the AHA Annual Hospital Survey, the
Healthcare Cost and Utilization Project, and the CMS
Medicare Cost Report. Data on market characteristics were
obtained from Area Resource File and InterStudy HMO
County Surveyor.
Principal Findings: Approximately 11% of the hospitals
moved from other quadrants in 1997 to the high-performing
quadrant in 2001. For hospitals in the low mortality-high cost
quadrant in 1997, reduced nurse staffing level, lower skill mix,
and decrease in high-tech profitable services were significantly
associated with the likelihood of moving to the highperforming quadrant. Hospitals in markets with increased
hospital competition and number of HMOs were more likely
to become high-performing through cost containment. For
hospitals in the high mortality-low cost quadrant initially,
increased nurse staffing level with no change in skill mix as
well as increased share of Medicare patients were significantly
associated with the likelihood of moving into the highperforming group. For hospitals in the high mortality-high
cost quadrant initially, increases in high-tech profitable
services and outpatient surgeries were significantly associated
with the likelihood of moving to the high-performing quadrant.
Lastly, hospitals that moved to the high-performing quadrant
over time achieved significantly higher operating and total
margins in 2001 than those not making the move, even
though both groups of hospitals had no significant differences
in either of the ratios initially.
Conclusions: The findings of this study highlight the
important role of prior performance, internal operations, and
market competition in hospital performance improvement.
Among hospitals not classified as high-performing initially, the
effectiveness of various strategies is contingent on the
hospital’s baseline performance. Achieving high quality-low
cost performance also is linked to better financial
performance.
Implications for Policy, Delivery, or Practice: In the absence
of extra financial incentives, a significant portion of hospitals
are able to achieve performance improvement in response to
competitive pressures and payment constraints. Hospital
adaptive behaviors and the concurrent effects of market forces
should be considered in evaluating pay-for-performance
programs.
Primary Funding Source: AHRQ
●The Effect of Chain Acquisition on Dialysis Facilities’
Cost, Quality, and Practice Patterns
Alyssa Pozniak, M.A.E.
Presented By: Alyssa Pozniak, M.A.E., Health Management
and Policy, University of Michigan, 109 S. Observatory St., Ann
Arbor, MI 48109; Tel: (734) 994-0041; Fax: (734) 998-6620;
Email: apozniak@umich.edu
Research Objective: To measure how health care costs,
practice patterns, and quality outcomes of Medicare dialysis
facilities change post chain acquisition.
Study Design: In 2003, there were approximately 325,000 End
Stage Renal Disease (ESRD) patients in the US, translating to
more than a 30-fold increase in patients since Medicare’s
ESRD program began over 30 years ago. Correspondingly, the
number of dialysis facilities more than doubled between 1988
and 2003 to accommodate the growing patient base.
However, the number of chain-affiliated facilities grew at a
much faster rate than overall facility growth. Over the same 15
year time period, chain-affiliated dialysis centers increased
eleven-fold: just 248 (14%) of dialysis providers were chainaffiliated in 1988 versus 2,822 (61%) in 2003. Building off of
previous research that examined the determinants of chain
acquisition, this study examines what happens postacquisition. A logistic regression was used to predict the
probability of chain acquisition from which propensity scores
were calculated. The propensity scores were then used to
analyze the difference in Medicare allowable costs, the use of
dialysis-related drugs, facility staffing and practice patterns,
and clinical outcomes between dialysis facilities that were and
were not acquired by a chain between 1997 and 2003. The
first through third years post acquisition were considered.
Population Studied: All freestanding dialysis facilities with
Cost Reports (CMS-265-94) from 1997 through 2003.
Hospital-based dialysis units (approximately 18% of ESRD
facilities) are excluded because of dissimilar reporting
methodology.
Principal Findings: Preliminary results suggest that dialysis
facilities acquired by a chain have different quality outcomes
two to three years post-acquisition. Specifically, facilities that
were acquired by a chain had a greater percentage increase in
the number of their patients achieving quality outcomes than
those facilities not acquired by a chain. There were no
significant differences between acquired versus non-acquired
in terms of practice patterns, although additional years after
acquisition may reveal differences. Composite Rate costs
were not significantly different between the two provider types
during the three years post acquisition. However, additional
analyses that includes other costs (e.g., Epogen and other
Separately Billable items) may reveal differences between
independent and chain-affiliated facilities. Interestingly,
facilities with a relatively higher likelihood of acquisition were
more likely to have lower costs, ceteris paribus.
Conclusions: The findings suggest that dialysis facilities
acquired by a chain may improve the quality of their care more
quickly than facilities that remain independent. However,
these and other significant differences do not occur until the
third year after acquisition. Therefore, any potential benefits
associated with chain membership are not realized
immediately. Further refinement of the model will more fully
explore the importance of the propensity scores.
Implications for Policy, Delivery, or Practice: This research
contributes to a better understanding of the effect of dialysis
chains on facility costs, practice patterns, and quality.
Medicare pays for the vast majority of ESRD-related care, so
policymakers may be particularly interested in how this
dominant organization form in the dialysis industry effects
these factors and if the changes are permanent versus
transitory. The findings also have important implications for
pay-for-performance and other quality-focused initiatives.
Primary Funding Source: No Funding
●Systematic Review of Hospital Ownership and Quality of
Care: What Explains the Different Results in the Literature?
Yu-Chu Shen, Ph.D., Karen Eggleston, Ph.D., Joseph Lau,
M.D., Christopher Schmid, Ph.D., Jia Chan, MS
Presented By: Yu-Chu Shen, Ph.D., Assistant professor of
economics, Graduate School of Business and Public Policy,
Naval Postgraduate School, 555 Dyer Road, Monterey, CA
93955; Tel: 831-656-2951; Fax: 831-656-3407;
Email: yshen@nps.edu
Research Objective: Whether quality of care in governmentowned, not-for-profit, and for-profit hospitals systematically
differ is of considerable policy importance in the U.S. and
other countries. A large empirical literature on this topic
provides conflicting evidence. The objective of this systematic
review is to examine what factors explain the diversity of
findings regarding hospital ownership and quality of care, as
well as measures of benefits provided to a hospital’s
surrounding community.
Study Design: We employed random-effects meta-regression
analysis to quantify to what extent various study
characteristics account for heterogeneity of findings. The
dependent variable is the standardized effect size from each
study. Empirical features of each study (such as each study’s
methodology, time period of the data or regions covered, etc)
serve as explanatory variables.
Population Studied: The study population encompasses
articles and unpublished manuscripts of general, acute, shortstay hospitals in the US that used multivariate analysis to
study hospital performance. Through a systematic search and
selection process, we identified 46 studies in two broad
categories: 31 studies of patient outcomes (including all-cause
and heart-specific mortality rates and adverse events rates)
and 15 studies of charity care (including uncompensated care,
unprofitable services, and community benefits).
Principal Findings: For studies of patient outcomes
comparing not-for-profit and for-profit hospitals, study
features that can explain most of the variation in effect sizes
include (1) analytic methods (type of disease or outcome
studied, whether or not the study adjusted for patient comorbidities) and (2) data sources. Differences in unit of
analysis also yield contrasting findings: patient outcomes do
not statistically differ across all three ownership forms when
analyses were done at the patient level, whereas hospital-level
analyses find the highest rates of adverse outcomes at
government hospitals, lower rates at for-profits, and the
lowest rates at not-for-profit hospitals. We find that studies
using in-hospital measures tend to find smaller differences
between not-for-profit and for-profits than those that use alllocation time-specific measures that link patients to death
certificates. For charity care, analytic methodology explains a
large share of study heterogeneity for government-private
comparisons, but not among private hospitals. Additionally,
studies examining nationally representative samples, and of
Florida in particular, tend to find for-profits provide less
charity care, whereas California for-profit hospitals seem to be
providing comparable amounts as their not-for-profit
counterparts.
Conclusions: Although there is much variation in study
results, overall, most studies do not find much difference
between for-profit and not-for-profit hospitals in patient
outcomes, and find either no difference or for-profit providing
less community benefits than not-for-profit hospitals. Most
nationally reprehensive studies comparing not-for-profit and
government hospitals found government ownership to have
higher short-term mortality rates, but find no difference in
other aspects of patient outcomes or community benefits.
Implications for Policy, Delivery, or Practice: Our study
provides practical tools for researchers who want to synthesize
observational studies in health services research. Our results
indicate that there appears to be as much heterogeneity
among hospitals of the same ownership form as across
ownership forms. Policymakers should beware of advocates
who selectively cite studies from this literature to support their
views. Policies should go beyond ownership distinctions to
address substantial variation in performance among providers
of the same ownership form.
Primary Funding Source: RWJF
Call for Papers
Organizational Culture, Climate & Mission
Chair: Rebecca Wells, University of North Carolina, Chapel Hill
Sunday, June 25 • 3:45 pm – 5:15 pm
●Identifying Safety Net Hospitals Among Academic Health
Centers
Samuel Hohmann, Ph.D., MSHSM
Presented By: Samuel Hohmann, Ph.D., MSHSM, Senior
Research Analyst, Information Architecture, University
HealthSystem Consortium, 2001 Spring Road, Suite 700, Oak
Brook, IL 60523; Tel: (630) 942-1740;
Email: hohmann@uhc.edu
Research Objective: To identify academic medical centers
(AMCs) providing a significant proportion of care to Medicaid
and/or indigents and characterize operational and clinical
differences between these and other AMCs.
Study Design: Retrospective cohort study. All hospitals
(HCOs) reporting UB-92 billing abstract data to UHC for
patients discharged in 2004 were assigned a safety net status
based on the percent of discharges who were Medicaid or
indigent (payer codes). Those HCOs with 25 percent or more
were considered safety net HCOs following the
recommendations of the National Association of Public
Hospitals to Congress in 2001. Safety net HCOs were further
subdivided into those with more than 40% Medicaid and/or
indigent discharges, those with 30-40% Medicaid and/or
indigent discharges, and those with 25-30% Medicaid and/or
indigent discharges. Comparisons based on safety net index
were performed by ownership, clinical service mix, severity
(case mix), and outcomes for similar patient types. Other
comparisons were by payer, percent cost and length of stay
(LOS) outliers, age, admission source, and presence of
trauma diagnoses.
Population Studied: All patients discharged in 2004 from
hospitals submitting data to the University HealthSystem
Consortium Clinical Data Base. Discharges were flagged with
a safety net index, one of four levels of percent of Medicaid
and/or indigent discharges noted above. The lowest level,
less than 25%, was assigned to hospitals not considered
safety net hospitals.
Principal Findings: About half of the HCOs in the UHC
database were determined to be safety net HCOs. Twenty
three of these had safety net indexes in the highest level, 18 in
the 30-40% level, and 11 in the lowest leve still considered a
safety net HCO. Almost 80% of the safety net HCOs were
public (state university, statewide authority, county, or local
hospital district), and half of these had 40% or more "safety
net" discharges. By service mix, safety net HCOs had more
pediatric discharges (20% vs. 15%), more obstretics
discharges (13% vs. 9%), more trauma care (10% vs. 5%), but
less cardiothoracic surgery(1.5% vs. 5%) and fewer transplant
cases (1% vs. 3%). Safety net HCOs had fewer Medicare
discharges fewer and other non-Medicaid discharges. Average
age of discharges among safety net HCOs was about 7 years
younger than non-safety net HCOs, 40 vs. 47 years old. Safety
net HCO discharges had fewer comorbid or chronic
conditions than non-safety net HCOs. Safety net HCOs had
fewer cost outliers but more LOS outliers. They also had
fewer surgical cases, but significantly more admissions from
the emergency room. There was also a significant difference
in LOS by DRG. Two thirds of the DRGs with at least 300
discharges among safety net HCOs in the study period had
longer LOS than non-safety net HCOs. Twenty six of the
DRGs had LOS that was one day or more longer than nonsafety net HCOs. Trauma did not appear to be a factor driving
the increased LOS. In fact, the LOS of trauma-flagged cases
in non-trauma DRGs was shorter than non-trauma flagged
cases.
Conclusions: Safety net HCOs provide many of the same
services that other academic medical centers (AMCs) provide,
however, safety net HCOs often differ in proportion of the
types of service, types of patients, and patient outcomes. The
purpose of this analysis was to document quantitative
differences between safety net HCOs and other HCOs.
Although impacts on outcomes have been illustrated, for
example, LOS differences by DRG betweens afety net AMCs
and other AMCs, further analylsis must follow.
Implications for Policy, Delivery, or Practice: Meaningful
groups of safety net HCOs have been defined. Researchers
and other analysts should use this type of classification for
comparative reporting. The groups may be stratified by
ownership, proportion of dishcarges that are safety net
patients, geographic distribution (state or region), or other
criteria.
Primary Funding Source: No Funding
●Productivity and Turnover in Primary Care Practices: The
Role of Participative Decision Making
Dorothy Hung, Ph.D., M.A., M.P.H., Thomas G. Rundall,
Ph.D., Deborah J. Cohen, Ph.D., Alfred F. Tallia, M.D., M.P.H.,
Benjamin F. Crabtree, Ph.D.
Presented By: Dorothy Hung, Ph.D., M.A., M.P.H., Research
Scientist, Sociomedical Sciences, Columbia University,
Mailman School of Public Health, 722 W. 168th Street, Suite
526B, New York, NY 10032; Tel: (212) 342-0154; Fax: (212) 3429097; Email: dh2237@columbia.edu
Research Objective: Many observers of the U.S. medical care
system believe that primary care is at a crossroads, challenged
by a host of issues ranging from inefficient organizational
structures and care approaches to an explosion of clinical
guidelines that increase demand for services. In the face of
these pressures, there are mounting efforts to rethink,
redesign, and rebuild primary care practices (PCPs) to
increase their effectiveness. This study contributes to these
efforts by examining associations between participative
decision making (PDM), productivity, and staff turnover in
PCPs. The study draws upon established organizational
theories of participation that emphasize both cognitive and
affective influences on employee output and behavior.
Study Design: This research used data collected from PCPs
participating in a national initiative sponsored by the Robert
Wood Johnson Foundation. Cross-sectional survey data on
organizational attributes of 49 practices located in all major
regions of the U.S. were analyzed. Ordinary least squares
estimation was used to examine associations between
productivity and PDM as well as formal structures such as
staff meetings. The association between practice staff
turnover and PDM was also examined.
Population Studied: Primary care practices.
Principal Findings: Practice productivity, measured as the
number of patients seen per week standardized by the number
of full-time equivalent healthcare providers, was positively
associated with staff participation in decisions regarding
quality improvement, practice change, and clinical operations
(p<0.05). Formal structures such as staff meetings were not
associated with productivity. High levels of participation in
decision making were associated with reduced turnover
among non-clinicians and administrative personnel (p<0.05).
Conclusions: Including staff members in practice decisions
may play an important role in improving productivity and
reducing turnover in PCPs. Organizational theories such as
the cognitive “human resources” and affective “human
relations” models offer plausible explanations for the
relationships found in this study, suggesting that enhanced
information processing, employee satisfaction and morale
lead to increased productivity and staff retention. Staff
meetings may be an obvious tool for practice managers
considering practical ways to facilitate staff participation.
However, the lack of an association suggests that formal staff
meetings may often be used for routine information sharing,
rather than leveraged for the opportunities that they present to
discuss open-ended practice issues. Additionally, involving
staff in practice decisions promotes mindfulness, which is a
social feature characterized by openness to new ideas and
perspectives. A mindful approach to decision making is
proactive, actively soliciting a diversity of opinions from staff
members with different roles, levels of education, and
backgrounds in order to learn and improve practice
functioning.
Implications for Policy, Delivery, or Practice: Our findings
have implications for the implementation of a participative
model emphasizing greater staff participation and
involvement in practice issues. This may be an important
strategy for improving performance outcomes such as
productivity and stability in PCPs.
Primary Funding Source: RWJF
●Does Safety Climate Moderate the Impact of Staffing
Adequacy and Work Environment on Nurse Injuries?
Barbara Mark, Ph.D., Michael Belyea, Ph.D., David Hofmann,
Ph.D., Linda Hughes, Ph.D., Cheryl Jones, Ph.D., YunKyung
Chang, M.H.A.
Presented By: Barbara Mark, Ph.D., Sarah Frances Russell
Distinguished Professor, School of Nursing, University of
North Carolina at Chapel Hill, Carrington Hall CB#7460,
Chapel Hill, NC 27599-7460; Tel: (919) 843-6209; Fax: (919)843-3168; Email: bmark@email.unc.edu
Research Objective: Concerns about patient safety have
escalated dramatically since the publication of the IOM’s To
Err is Human. Less attention has been given to the
contribution of staffing and the work environment to
prevention of injuries in hospital-based registered nurses
(RNs). The implications of work-related injuries are clear.
Needle sticks, for example, can expose RNs to hepatitis B,
hepatitis C, and HIV, while back injuries can lead to significant
long-term disability. We tested a causal model examining the
impact of external hospital characteristics (geographic region,
HMO penetration, urban/rural status); hospital characteristics
(size, case mix index, teaching status, high technology
services, integrated system membership, and magnet status),
and nursing unit characteristics (availability of support
services, work complexity, patient acuity, and unit size) on the
adequacy of two dimensions of nurse staffing (one dimension
reflected the proportion of RNs and their educational level; the
other, the average tenure of RNs on the unit, their expertise,
and level of commitment to patient care), and work
environment (reflecting RNs’ participation in decision-making,
level of autonomy, and extent of collaboration with other
clinical disciplines). The adequacy of nurse staffing and the
work environment, as well as the moderating effect of safety
climate, were hypothesized to affect the number of needle
sticks and nurse back injuries.
Study Design: The Outcomes Research in Nursing
Administration Project (ORNA) is a multi-site longitudinal
causal modeling study that collected three waves of primary
data from RNs in a national random sample of 144 short-term
non-profit, non-governmental general acute care hospitals
with more than 100 beds.
Population Studied: Data were collected three times over a
six-month time period from 3718 registered nurses on 286
general medical-surgical nursing units.
Principal Findings: We used generalized linear mixed models
to account for the clustered sample. External hospital
characteristics as well as teaching status and work complexity
predicted the first measure of staffing adequacy; the
availability of support services and work complexity predicted
the second measure of staffing adequacy. Magnet status,
availability of support services and work complexity predicted
the quality of the work environment. For needle sticks, the
interactions of safety climate and the first measure of staffing
adequacy, and the interaction of safety climate and work
environment were significant. When safety climate was high,
staffing adequacy reduced the number of needlesticks, while
work environment reduced needle sticks only at low levels of
safety climate. For back injuries, a positive safety climate
reduced the impact of work environment on back injuries.
Conclusions: The model demonstrates the importance of
including moderating effects of safety climate in
understanding needle sticks and back injuries in RNs working
in acute care hospitals.
Implications for Policy, Delivery, or Practice: Knowledge of
the moderating effects of safety climate enables
administrators to design strategies to address nurse injuries
in ways that extend beyond current practices. In particular,
the findings suggest that preventing injuries to nurses will
require managerial approaches that simultaneously enhance
the adequacy of nurse staffing, the quality of the work
environment, and emphasize a climate that supports safe
work practices.
Primary Funding Source: National Institute of Nursing
Research
●Homogeneity of Organization Culture and Performance
in Healthcare
Mark Meterko, Ph.D., Amy Smalarz, Ph.D., Hai Lin, M.D.,
M.P.H.
Presented By: Mark Meterko, Ph.D., Manager, Methodology
& Survey Unit, Center for Organization, Leadership &
Management Research (COLMR), VA HSR&D, VA Medical
Center (152M), 150 S Huntington Avenue, Boston, MA 02130;
Tel: (857) 364-4608; Fax: (857) 364-6104; Email:
mark.meterko@med.va.gov
Research Objective: Some researchers argue that
homogeneity of organization culture enhances performance
by fostering unity among employees regarding mission, vision
and values, thereby allowing top managers to more readily
focus staff efforts on strategic priorities. Others argue that
cultural divergence is beneficial: units with different specific
functions have cultures that are suited to those functions, and
this cultural heterogeneity ultimately enhances overall
organizational performance by allowing each unit to operate in
the most effective manner. Some support for the efficacy of
both models has been reported within healthcare
organizations, but studies have involved inconsistent culture
measures and relatively limited samples. Using a standard
methodology across more than 4000 workgroups at 130
medical centers, the goals of the present study were to: (a)
examine the degree of cultural homogeneity, and (b) explore
the relationship between cultural homogeneity and
independently-measured performance (patient satisfaction).
Study Design: This study involved the secondary analysis of
data from three independent sources within the Veterans
Health Administration (VHA): an employee survey, and two
surveys of patients -- inpatient and outpatient. The relevant
section of the employee survey consisted of 14 agree/disagree
items that were averaged to create scale scores representing
four general organization cultural orientations: teamwork,
entrepreneurial, bureaucratic and rational. Workgroups were
distinguished by unique ID numbers shared by all
respondents from that unit. Cultural homogeneity within a
facility was examined using both the range and standard
deviation of workgroup-level scores within that facility on each
culture dimension. Patient satisfaction was also measured by
survey. The inpatient survey consisted of 76 items used to
compute 10 multi-item scale scores representing specific
domains of care including access, staff courtesy, coordination
of care, and physical comfort. The outpatient survey consisted
of 66 items representing 11 similar domains.
Population Studied: The employee survey was administered
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
services users aggregated over the period corresponding to
the employee survey. Overall response rates were 56% among
inpatients (n=29,657) and 70% among outpatients
(n=74,667). Aggregate organization culture and patient
satisfaction scale scores were computed for 130 medical care
delivery sites.
Principal Findings: A total of 4401 workgroups each with 10
or more respondents were identified, an average of 28.5
workgroups per delivery site. Tremendous variation was
observed across workgroups nationally on all four dimensions
of organizational culture. For example, on the teamwork
culture dimension, workgroup mean scores ranged from 1.46
to 4.48 on a 5-point agree/disagree scale. The variation across
workgroups within facilities was less, but still substantial. On
the teamwork culture dimension, for example, workgroups
within facilities differed by as little as 0.75 points and as much
as 2.55 points on the 5-point scale; the average range across
workgroups within facilities was 1.55 points. The teamwork
standard deviations (SD) across workgroups within facilities
ranged from 0.21 to 0.57 (mean: 0.38). We observed many
correlations of medium effect size (in the .20 to .39 range)
between cultural homogeneity and patient satisfaction. For
example, the range of bureaucratic culture means across
workgroups within facilities was correlated at this level with 9
of 10 inpatient care dimensions and 5 of 11 outpatient care
dimensions. Without exception, these relationships were
negative. That is, greater range in culture across workgroups
was associated with lower patient satisfaction. A similar
pattern was observed using the standard deviation of
workgroup means within facilities as the measure of cultural
homogeneity, but fewer noteworthy relationships were
observed.
Conclusions: Considerable variability was observed in the
culture of workgroups both between and within delivery sites
even when those facilities were part of the same healthcare
organization. Further, this cultural heterogeneity was
negatively associated with patient satisfaction.
Implications for Policy, Delivery, or Practice: Results
suggest that greater homogeneity of culture across
workgroups within facilities may be desirable, at least with
regard to customer satisfaction. Further research should
explore the relationship between cultural homogeneity and
other independently-measured outcomes such as costs and
employee turnover rates.
Primary Funding Source: VA
●An Evaluation of the Influence of Primary Care Practice
Climate on the Health of Medicare Beneficiaries
Douglas Roblin, Ph.D., David H. Howard, Ph.D., Junling Ren,
MEd, Edmund R. Becker, Ph.D.
Presented By: Douglas Roblin, Ph.D., Research Scientist,
Research Department, Kaiser Permanente Georgia, 3495
Piedmont Rd. NE, Bldg. 9, Atlanta, GA 30305; Tel: 404-3644805; Fax: 404-364-7361; Email: douglas.roblin@kp.org
Research Objective: According to the Chronic Care Model,
prepared, pro-active practice teams are an essential element
for improving the health of patients with chronic diseases.
Previously, Alexander et al. (Health Services Research, 2005)
found that patients with serious mental illnesses treated in VA
facilities showed greater improvement if treated by a team
with high levels of staff participation. We evaluated the
influence of primary care practice climate on the health status
of Medicare beneficiaries in a group-model Medicare
managed care plan.
Study Design: The study population consists of enrollees age
65+ who completed both rounds of the Medicare Health
Outcomes Survey, a nationwide survey of randomly-selected
Medicare managed care enrollees, in 2000-2004. Health
status (SF-36) was assessed at baseline and two years later at
follow-up. In this health plan enrollees receive care from one
of 16 semi-autonomous primary care teams, which consist of
3-4 practitioners. Practice climate was assessed by surveying
team members and support staff in 2000. Responses were
aggregated to practice-level scores. Practice climate is a
multidimensional construct of perceived task delegation and
management, role collaboration, and teamwork. Using
ordinary least squares regression with a random effect for
team, we examined the impact of practice climate on four
subscales of the SF-36 measured at follow-up: physical
functioning, mental functioning, role emotional functioning,
and mental health functioning. Control variables included the
baseline SF-36 score for the relevant subscale, age, gender,
race, baseline survey year, educational attainment, cigarette
consumption, marital status, and self-reported disease
(congestive heart failure, diabetes, stroke, cancer, COPD,
angina, heart attack). By controlling for the baseline score, we
effectively measure the impact of practice climate on the
change in the score from baseline to follow-up. For each
dependent variable, we ran two regressions, one for the entire
sample, the other for respondents with 1+ disease.
Population Studied: 1,015 respondents, 292 of whom
reported one or more disease
Principal Findings: Practice climate was significantly related
to the change in physical functioning among patients with a
self-reported disease (p = 0.06), and significantly related to
the change in mental health functioning in the entire sample
(p = 0.07). The magnitude of the effect on the change in
physical functioning was small; less than 4% of the average
change. The magnitude of the effect on the change in mental
health functioning was larger; 25% of the average change.
Practice climate was not significantly related to the change in
physical functioning in the entire sample or to the change in
other subscales of the SF-36.
Conclusions: The results suggest that primary care practices
where task delegation and management, role collaboration,
and teamwork are perceived relatively favorably may yield
better physical function among elderly patients with 1 or more
major morbidities than primary care practices where team
structures and processes are perceived less favorably. The
extent of influence on physical function, however, may not be
clinically meaningful.
Implications for Policy, Delivery, or Practice: Results
suggest that primary care teams with favorably perceived task
delegation and management, role collaboration, and
teamwork provide effective care to patients with serious
diseases.
Primary Funding Source: CDC
Call for Papers
Provider & Organizational Responses to
Payment & Policy Changes
Chair: Stephen Mick, Virginia Commonwealth University
Monday, June 26 • 10:30 am – 12:00 pm
●Within Hospital Payer and Race Differences in the Early
Use of Drug-Eluting Coronary Stents
Andrew Epstein, Ph.D., M.P.P., Jonathan Ketcham, Ph.D., Saif
S. Rathore, M.P.H., Jeptha Curtis, M.D., Harlan Krumholz,
M.D. SM, Sean Nicholson, Ph.D.
Presented By: Andrew Epstein, Ph.D. MPP, Assistant
Professor, Division of Health Policy and Administration, Yale
University School of Public Health, 60 College St, Room 301,
New Haven, CT 06520-8034; Tel: (203)785-6924; Fax:
(203)785-6287; Email: andrew.epstein@yale.edu
Research Objective: To assess differences in use of drugeluting coronary stents by patient payer type and race overall
and within hospital in the first nine months following FDA
approval.
Study Design: Using Health Care Utilization Project National
Inpatient Sample (NIS) data from 2003, we identified patients
receiving either bare metal or drug-eluting stents (DES). We
compared crude rates of DES use by payer type and race with
chi-square analyses. Logistic regression was used to model
DES use by payer type and race, controlling for calendar
quarter, patient age, sex, admission type/source, comorbid
conditions (as identified by Elixhauser) and household
income, as well as hospital location, ownership, teaching
status, total number of mechanical coronary
revascularizations (percutaneous coronary interventions [PCIs]
and coronary artery bypass graft surgeries), and proportion of
revascularizations that were PCIs. To account for possible
confounding by hospital, models were re-estimated using
fixed effects logistic regression. All analyses accounted for the
NIS complex survey design.
Population Studied: Adults aged 30 and older who received
coronary stents at hospitals performing at least 5 PCIs in 2003
(N=114,528 discharges from 265 hospitals).
Principal Findings: Overall DES use in this nationallyrepresentative sample was 43.8%. Compared with privatelyinsured (47.0%) patients, crude DES use was lower among
Medicaid (36.7%) and uninsured (34.3%) patients. Black
patients (37.3%) received DES less frequently than white
patients (44.0%). Adjusted DES use overall was lower by 8.1
percentage points (95% CI: 6.0-10.3) among Medicaid
patients and 9.0 percentage points (95% CI: 6.9-11.2) among
uninsured patients relative to private-pay patients, and was 5.5
percentage points (95% CI: 2.5-8.4) lower among black
patients relative to white patients. Findings were similar in
hospital fixed effects analyses, indicating differential treatment
patterns within hospitals contributed to payer and race
differences in DES use. Adjusted for other factors, Medicaid
patients had a 7.8 percentage point (95% CI: 5.6-10.1) lower
rate of DES use than privately-insured patients treated at the
same hospital; this difference was 8.0 percentage points (95%
CI: 6.3-9.7) for uninsured patients relative to private-pay
patients. Relative to white patients, DES use was 3.5
percentage points (95% CI: 1.9-5.1) lower among black
patients. All comparisons are significant at p=0.001.
Conclusions: Medicaid, uninsured, and black patients were
significantly less likely to receive DES on average than privatepay and white patients treated at the same hospital, even after
accounting for a range of other patient characteristics.
Implications for Policy, Delivery, or Practice: While recent
research has emphasized the role of hospital referral patterns
in explaining differences in access to medical technology, this
study documents sizable within-hospital differences in
treatment by payer and race. Preferentially providing expensive
new technologies to patients on the basis of payer or race, in
the absence of clinical justification, may exacerbate inequities
in health care delivery.
Primary Funding Source: No Funding
●A Linear Programming Approach to Optimizing the
Distribution of Health Care Providers Across a Multi-Site
Staff Model Managed Care System: A Case of EvidenceBased Management
Daniel Harris, Ph.D., Afi Harrington, Ph.D., DeAnn Farr, Ph.D.
Presented By: Daniel Harris, Ph.D., Senior Project Director,
Institute for Public 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: Large, multi-site staff model managed
care systems must assure an adequate supply and mix of
providers to meet current and expected demand for care by
eligible populations. We were asked by the management of
one such system, which offers triple-option insurance
coverage and operates a delivery system that provides most of
the care required by its insureds, to develop a model to help
them optimize the distribution of a finite supply of staff
providers across geographically widely dispersed hospital and
clinic sites to minimize cost to the system while satisfying
demand.
Study Design: We used an operations research approach
(linear programming) to mathematically model the elements
of provider workforce allocation and to solve for an objective
function that minimizes cost subject to a set of clinical and
operational constraints. We tested the model with FY04 data,
supplied by the system, that allowed us to (1) estimate
demand (utilization) and productivity by provider specialty by
site, (2) identify existing positions (authorized staff provider
jobs) and human resources (actual “bodies” to fill them) by
specialty and discipline throughout the system, and (3)
develop cost factors for estimating the value of the objective
function. We also performed a sensitivity analysis comparing
the “base case” results with various revised constraints to
assess the robustness of the model under conditions of
imperfect data as well as to identify the impact of various
constraint conditions on the model’s solution. Available data
allowed us to estimate demand for care provided within as
well as outside of the system’s facilities.
Population Studied: We studied the demand for care of the
system’s 870,000 enrollees; the portion of it that could be met
by the system’s almost 1,800 providers in its 22 owned
hospitals and 130 stand alone and branch ambulatory clinics;
and the portion needing to be purchased from external
inpatient facilities and ambulatory practices with which the
system contracts.
Principal Findings: The model was able to reach a solution
within a tolerance of 1% of optimality in an acceptable amount
of computer run time. The solution differed significantly from
the prevailing distribution, and identified over- and undersupplied specialties by site and across the system. The model
was robust across varying conditions set on demand,
productivity, and cost estimates, and reacted predictably to
varying its constraints. Simulated productivity improvements
as well as increasing system capacity understandably
improved the value of the objective function and allowed us to
project for management the degree of improvement expected
to be associated with varying degrees of productivity and
capacity increases.
Conclusions: Our approach successfully modeled an
optimum solution and is being used by the system’s
management in its workforce planning. The system is
contracting with us to run the model in subsequent years with
updated data. This approach is applicable to similar managed
care systems.
Implications for Policy, Delivery, or Practice: It is possible
to use linear programming techniques to support evidencebased management for optimizing the distribution and mix of
a finite supply of managed care system providers.
Primary Funding Source: Other Government
●Physician-Hospital Gainsharing: Evidence from Early
Adopters’ Experience in Cardiology
Jonathan Ketcham, Ph.D., Michael Furukawa, Ph.D.
Presented By: Jonathan Ketcham, Ph.D., Assistant Professor,
School of Health Management and Policy, Arizona State
University, W.P. Carey School of Business, PO Box 874506,
Tempe, AZ 85287-4506; Tel: (480)965-5507;
Email: ketcham@asu.edu
Research Objective: Medical supplies and devices,
particularly “physician preference items”, represent a large
and growing portion of hospital costs. Historically, antikickback and Stark regulations have limited the financial
arrangements that may exist between hospitals and
physicians, and physicians often have strong financial ties with
device manufacturers. The Office of Inspector General recently
has approved several gainsharing programs, in which
hospitals pay physicians a share of reductions in hospital
costs. The objective of this study is to examine the cost
savings achieved by early adopters of gainsharing programs in
cardiology, and to determine whether the savings derive from
lower utilization, lower prices, substitution of lower-priced
items, or patient selection.
Study Design: We employ difference-in-difference analysis to
compare changes in prices, utilization, and patient
characteristics between hospitals and physicians participating
in gainsharing with those that have not. Data from 2000-2005
were provided by Goodroe Healthcare Solutions, which
designed every OIG-approved gainsharing program to date.
The data provide detailed, patient-level clinical data on
indication, presentation, and patient history, which we use to
measure patient selection and to risk-adjust. The data also
report which devices and supplies were used for each patient,
and the price paid by the hospital for each of them. In addition
to these individual device costs, patient-level costs are
reported separately for labor, contrasts, thrombolytics, and
electrophysiology. Patient-level differences-in-differences
regressions are used to determine the savings due to
gainsharing in each of these areas, and within each area, the
extent of cost differences due to use of fewer items,
substitution of lower-priced items for higher priced items,
lower prices for given items, and patient risk profiles.
Population Studied: 873,968 patients treated by 30,848
physicians in cardiac catheterization labs in 133 hospitals
around the US from 2000-2005. The data include every
patient in these hospitals treated for a range of diagnoses
including congestive heart failure, angina, and myocardial
infarction.
Principal Findings: Preliminary difference-in-difference
analysis indicates that the main cost savings result from lower
average price per item, due to both lower prices of given items
and greater reliance on lower-priced items. Savings appear in
a number of areas but are most evident for electrophysiology.
We find evidence that gainsharing lowered utilization in some
categories.
Conclusions: Cost savings from gainsharing in cardiology
appears largely due to lowering prices and shifting physician
utilization patterns toward lower-priced items. The financial
incentives of gainsharing appear to alter physician practice
patterns and subsequently influence hospitals’ ability to
negotiate price discounts. Implications for other hospitals and
physicians, however, are tentative because early adopters of
gainsharing might respond to its incentives differently than
others.
Implications for Policy, Delivery, or Practice: While early
adopters have reported large savings from gainsharing,
ranging from $1.4-$4million annually, uncertainty about how
that has been achieved has contributed to the slow adoption
of gainsharing programs by other hospitals. Greater
understanding of gainsharing’s impact on physician practice
patterns, prices hospitals receive from manufacturers, and
resulting patient care will inform both hospitals’ decisions to
adopt gainsharing and policymakers’ ongoing debate about
permitting or prohibiting it.
Primary Funding Source: ASU Health Sector Supply Chain
Research Consortium
●Physician Billing Behavior in Two State Programs
Eric Seiber, Ph.D.
Presented By: Eric Seiber, Ph.D., Assistant Professor, Public
Health Sciences, Clemson University, 523 Edwards Hall,
Clemson, SC 29634; Tel: 864-656-6206; Fax: 864-656-6227;
Email: seiber@clemson.edu
Research Objective: Physician billing is treated as exogenous
in the academic literature, and has attracted very little
econometric attention. A similar disinterest exists among
Federal policy makers, with the Government Accountability
Office frequently criticizing the reliance on generally weak state
oversight and the lack of federal resources overseeing the $174
billion federal dollars contributed to the Medicaid program
(2004). This weak oversight regime raises questions about
whether a profit maximizing physician would accept their
billing decisions as exogenously determined. In state
programs, physician prices are typically set by a fixed price
schedule or through negotiations with the payer. Although
price is fixed, physicians still have the power to choose the
complexity level or billing code for the visit. If oversight is
weak and probability of detection low, physicians can be
expected to choose higher reimbursement codes or “upcode”
on the margin. This study tests (1) whether physicians bill
office visits at equal levels of complexity across state programs
and (2) whether the billing behavior changes over time (a.k.a.
code creep).
Study Design: The study uses 2001–2003 health care claims
data (n=680,000) from the South Carolina Medicaid program
and SC State Employee Health Plan to estimate a fixed effects
ordered probit model of physician office visit billing where the
provider assigns one of five complexity levels (billing codes)
for the visit. An array of program dummies and physicianspecific fixed effects and interaction terms control for
physician practice and program wide differences, while an
interaction term between the physician fixed effects and the
Medicaid dummy test for differential billing between the two
programs. Simulations demonstrate the magnitude of the
effects on the two programs.
Population Studied: All 2001-2003 physician office visits in
the South Carolina Medicaid program and SC State Employee
Health Plan.
Principal Findings: Substantial code creep was evident in the
data, with increases of 10% per year for high complexity
codes. Physicians participating in only one program or who
billed under separate tax numbers billed at the highest
complexities. Physicians as a whole billed Medicaid at slightly
lower complexities, but individual physicians demonstrated
substantial differences between the two programs, with the
most aggressive providers being 33% more likely to bill
Medicaid the high complexity codes.
Conclusions: The results suggest that physicians do have
pricing power, but the same results do not support the
hypothesis of differential billing. Physicians in this sample
proved equally aggressive towards both state programs,
increasing their diagnosis codes in every year of the sample.
Implications for Policy, Delivery, or Practice: Code creep in
physician billing is an equally pervasive problem in both state
sponsored plans, and remains a little explored determinant of
healthcare cost inflation.
Primary Funding Source: Strom Thurmond Institute for
Public Policy
●Organizational Factors Related to Hospital Organ
Donation Rates
Pamela Spain, Ph.D., Robert E. Hurley, Ph.D.
Presented By: Pamela Spain, Ph.D., Postdoctoral Fellow, Cecil
G. Shep's Center for Health Services Research, The University
of North Carolina at Chapel Hill, 725 Martin Luther King Jr.
Blvd., Chapel Hill, NC 27599; Tel: (919) 966-7123;
Email: pspain@schsr.unc.edu
Research Objective: The increasing need for organs available
for transplantation has been the target of several legislative
efforts, most recently CMS’ Conditions of Participation in
1998. However, the number of donors has remained virtually
flat in the years following the legislation. Although there is
substantial hospital-level variation in donor recovery rates,
empirical studies of donation trends from the organizational
perspective are lacking. This study examined hospital factors
that are associated with organ donor recovery performance.
Study Design: A longitudinal panel design was applied to
data from 2000 – 2002. Outcome variables included the
number of potential donors, the number of actual donors, and
the proportion of potentials that became actual donors, the
donor conversion rate, or DCR. Analyses included univariate
correlations and multivariate regression, and the hospital was
the unit of analysis.
Population Studied: The population was non-federal, short
term general hospitals from seven states of HCUP’s State
Inpatient Databases (SID) program. Whether a discharge was
a potential donor was determined using ICD-9 diagnosis and
procedure codes consistent with causes and mechanisms of
donor death, and hospitals with at least one potential donor
every year were included in the sample (n=293 hospitals). SID
data were linked with American Hospital Association and the
United Network for Organ Sharing data for hospital
characteristics and actual donor counts. Measures from 2000
were used for all predictor variables.
Principal Findings: In sample hospitals, the mean number of
potential donors was 8.5, the mean number of actual donors
was 3.8, and the mean DCR was 45.9%. The overall DCR for
the sample was unchanged between 2000 and 2002,
indicating that hospitals did not improve their donor recovery
rates. As expected, a hospital’s numbers of potential donors
and actual donors were negatively correlated with its
proportion of Medicare patients (-0.27, p<.01), and positively
correlated with its size (0.43), proportion of trauma deaths
(0.60), proportion of nonwhite patients (0.13), number of
transplant programs (0.35), and non-profit status (0.14) (all
p<.05). The key, somewhat unexpected, finding from
multivariate regression was that although large trauma
hospitals and transplant hospitals had more potential donors
and more actual donors, when compared with smaller nontrauma, non-transplant hospitals, they actually had lower
DCRs. Restated, large trauma hospitals and transplant
hospitals recovered a smaller proportion of their potential
donors.
Conclusions: Less than half of all potential donors are being
actualized in the U.S., and hospitals that have the most
potential donors are recovering a relatively smaller proportion
of them. In these hospitals with the most potential,
improvements in donor recovery rates would ultimately result
in substantial increases in organs available for transplantation.
Implications for Policy, Delivery, or Practice: Policy makers
should consider evaluating hospitals on the proportion of
potential donors recovered, and not just on the number of
actual donors. Policy makers should also consider the relevant
organizational characteristics when developing policies
designed to increase the number of organs.
Primary Funding Source: AHRQ
Related Posters
Management, Organization & Financing
Poster Session A
Sunday, June 25 • 2:00 pm – 3:30 pm
●The Increasing Complexity of Primary Care
Elmer Abbo, M.D., JD, Qi Zhang, Ph.D., Martin Zelder, Ph.D.,
Elbert Huang, M.D., M.P.H.
Presented By: Elmer Abbo, M.D., JD, Assistant Professor of
Medicine, Section of General Internal Medicine, The
University of Chicago, 1601 S. Indiana Ave., Unit #403,
Chicago, IL 60616; Tel: (773) 834-2790; Fax: (773) 834-2238;
Email: eabbo@medicine.bsd.uchicago.edu
Research Objective: There is growing concern of a
developing crisis in primary care as frustration amongst
practitioners is increasing and recruitment into the field is
declining. And yet in the last decade, practitioners are seeing
fewer patients for longer visits with increased reimbursement
per visit. However, past studies of visit time or reimbursement
did not account for changes in the complexity of practice.
Changes in complexity may be affecting satisfaction and
interest in the field and has important implications to
reimbursement. We sought to explore whether complexity in
primary care is increasing, and if so, whether this accounts for
longer visits.
Study Design: We utilized the National Ambulatory Medical
Care Survey, a nationally representative sample of nonhospital based ambulatory clinics, to identify all adult patient
visits to from 1997 to 2003. Demographic and physician
variables were obtained as well direct physician time spent per
patient. A measure of complexity was constructed to capture a
range of acute, chronic, and preventive activities by assigning
a weight of one “clinical point” for each diagnosis code (up to
3), each medication (up to 6), each diagnostic test (blood
pressure, urinalysis, EKG, x-ray, mammography, other
imaging, pregnancy test, pap smear, hematocrit or CBC,
cholesterol, PSA, and other blood), physical therapy, or each
act of counseling (diet, exercise, mental health or stress, and
tobacco cessation) documented for the visit. These
components were weighted equally. A measure of efficiency
was created by dividing physician time by complexity. We log
transformed time, complexity, and efficiency because data
were highly skewed. Year was treated as a continuous variable.
Adjusted analyses were performed using the generalized linear
model. Results are reported in terms of incidence rate ratios
(IRRs), which express the factor that the dependent variable is
multiplied in response to a one unit increase in a covariate.
Population Studied: Adult patient visits to physicians in
general internal medicine, family practice, general practice,
and geriatrics.
Principal Findings: In unadjusted analysis, a trend towards
increased time from 18.0 to 19.8 minutes/visit (p=.08) was
observed. Complexity increased significantly from 5.5 to 6.4
clinical points (p<.001), a 16% increase from 1997 to 2003.
Efficiency remained unchanged around 2.7 minutes per point.
In stratified analysis, complexity increased regardless of age or
payer type. In adjusted analysis, year was statistically
significant (IRR 1.018, p<.001). With each year, complexity
increased 1.8%. Increasing age, Medicare and Medicaid
status, female sex, and solo practice also significantly
predicted greater complexity. In adjusted analysis of visit time,
complexity was a significant predictor (IRR 1.038, p<.001). For
each additional clinical point, visit time increased by 3.8%.
Conclusions: Complexity in non-hospital based primary care
is increasing. Increasing complexity is significantly associated
with longer visit times.
Implications for Policy, Delivery, or Practice: Growing
frustration and decreased recruitment in primary care may be
related to the increasing complexity of care. Since primary
care is critical to the delivery of acute, chronic, and preventive
care, both public and private insurers should consider whether
changes in primary care reimbursement are warranted in
order to improve the resources available in primary care
practice to respond to the increasing complexity of care.
Primary Funding Source: CDC
●Hospitals’ Community Orientation as an Influencing
Variable on Outpatient Medical Service Utilization
Jong-Deuk Baek, Ph.D., Carleen H. Stoskopf, Sc.D., Yunho
Jeon, M.S.
Presented By: Jong-Deuk Baek, Ph.D., Research Associate,
Health Services Policy and Management, Univeristy of South
Carolina, 800 Sumter Street, Columbia, SC 29208; Tel: (803)
777-2772; Fax: (803) 777-1836; Email: baekj@mailbox.sc.edu
Research Objective: To investigate the impact of the degree
of a hospital's community orientation on outpatient medical
service utilization.
Study Design: This study is a secondary data analysis with
multiple regression based on AHA 2000 hospital data. Nine
items are used to measure community orientation and we
made a summated scale based on those items (0-9). For
outpatient service utilization, the number of outpatient
services excluding emergency room visits and the number of
outpatient surgical procedures. Several variables that influence
outpatient service utilization are controlled, such as hospital
type (ownership), size (number of beds), staffing, number of
managed care contracts, and MSA. The control variables for
the percent of Medicare and the percent of uninsured in the
county where the hospital is located come from BRFSS 2000.
Population Studied: The unit of analysis is the hospital and
the analysis includes 638 hospitals across the United States
after refining the data set.
Principal Findings: The community orientation is significantly
associated with outpatient medical service utilization. The
more community oriented a hospital is, the more significant
the association with the increase of outpatient services and
the number of outpatient surgical procedures performed. A
hospital that is categorized as a community hospital has a
higher community orientation score, and is associated with
higher use of outpatient service.
Conclusions: Hospitals with a higher degree of community
orientation show greater outpatient utilization than those with
lower community orientation after controlling for some
variables. Community orientation and being a designated
community hospital increases outpatient service utilization.
Implications for Policy, Delivery, or Practice: Hospitals
need to be more involved in their communities, and by doing
so increase outpatient service utilization. This is concurrent
with hospitals’ effort to enhance outpatient services to control
their operation expenses incurred by inpatient medical
services. Thus, hospitals, community orientation can decrease
costs by enhancing outpatient services in the long term.
Primary Funding Source: No Funding
●Characteristics of Organizations that Achieve Higher
Performance: A Study of 16 Academic Medical Centers
Raj Behal, M.D., M.P.H.
Presented By: Raj Behal, M.D., M.P.H., Senior Medical
Director, Clinical Effectiveness & System Redesign, University
HealthSystem Consortium, 2001 Spring Rd Suite 700, Oak
Brook, IL 60523; Tel: 6309544892; Email: rbehal@uhc.edu
Research Objective: Develop an understanding of leadership
characteristics, organizational structures and systems that
either hinder or enhance performance in teaching hospitals
Study Design: Longitudinal observational study of a
convenience sample of 16 academic medical centers in the
U.S.
Population Studied: US academic medical centers that
engaged in transactional or transformational changes to
improve clinical outcomes or redesign of infrastructure for
performance improvement
Principal Findings: The following characteristics were
associated with the organizations that improved performance:
1) The senior leadership acknowledged that clinical outcomes
needed improvement; 2) the focus was on improving clinical
outcomes, particularly inpatient mortality, and not on the
infrastructure for performance improvement; 3) quantitative
goals and accountability were clearly established; 4) clinical
chairs were personally engaged in the improvement process;
5) performance data were reviewed by senior leadership on a
regular basis; 6) evidence-based practices were utilized to
improve systems, processes and clinical outcomes.
Achievement of better patient outcomes was independent of
presence of sophisticated information technology including
computerized order entry systems.
Conclusions: Organizations that establish clear goals for
improving patient outcomes and are able to engage senior
physician leaders in the improvement process are more likely
to achieve results. While infrastructure to support quality
improvement is an important issue, it should not be the
primary target for interventions.
Implications for Policy, Delivery, or Practice: Senior
leadership of hospitals should emphasize improvement in
patient outcomes such as mortality and leverage
accountability as a management tool to engage physician
leaders in such efforts.
Primary Funding Source: No Funding
●The Effect of Financial Incentives on the Volume of
Diagnostic Imaging Ordered by Physicians
Mythreyi Bhargavan, Ph.D., Cristian Meghea, Ph.D., Jonathan
H. Sunshine, Ph.D.
Presented By: Mythreyi Bhargavan, Ph.D., Director of
Research, Research, American College of Radiology, 1891
Preston White Dr, Reston, VA 20191; Tel: 703-715-4394; Fax:
703-264-2443; Email: mbhargavan@acr.org
Research Objective: Medical imaging is a large component of
health care costs in the United States, with an estimated
annual cost almost $100 billion, and has one of the fastest
growth rates (approximately 10% per year) among all medical
services. Imaging is usually provided through physician
referral, and therefore, may be influenced by financial
incentives faced by the referring physician. The objective of
this study is to measure the effect of physician financial
incentives, as captured by whether the physician billed for any
imaging procedure during the year, on the utilization of
imaging studies, controlling for diagnoses, patient
demographics and co-morbidities, geographic location,
practice setting (physician office, outpatient hospital, or
inpatient hospital), and other physician-related factors.
Study Design: We use claims data from a large national
employer plan for five years (1999-2003). We identify patients
with certain conditions such as headache, knee pain, and
heart disease. If a treating physician is observed to perform or
bill for an imaging procedure during a year, that treating
physician is flagged as potentially having a financial interest in
the imaging, and is termed an imager for that technique, for
example, MR-imager or CT-imager. We restrict our analysis to
physicians who have at least 100 claims in each year to avoid
misclassifying physicians as a result of inadequate information
on them. We construct episodes of care and for each episode,
observe whether an image was ordered, the type of image, and
total imaging costs. Each medical condition is analyzed
independently. Outcomes of interest for each patient are (a)
whether there was a diagnostic image, (b) type of image, and
(c) total costs of imaging. Logistic regression is used to
analyze outcome (a), multinomial and ordered logistic
regression to analyze outcome (b), and log-linear regression
for outcomes (c).
Population Studied: Physicians providing care to employees
enrolled in a large national employer’s health plan during the
years 1999-2003
Principal Findings: Between 1999 and 2003, patients with
headaches, were approximately 4 times (4.5 in 1999, 3.7 in
2003) as likely to have a CT if the treating physician had a
financial interest in a CT unit than if he or she did not, and
nearly 3 times (3.3 in 1999, 2.8in 2003) as likely to have an
MRI is the treating physician was an MR imager than if her or
she was not. However, there was little significant difference in
average imaging dollars per patient for those who did get an
image. Patients with knee pain with MR imagers as treating
physicians were more than 3 times (3.5 in 1999, 3.1 in 2003) as
likely to have a knee MRI as patients of non-MR-imagers. Of
those who did get an image, patients of MRI imagers had
imaging costs 1.6-1.8 times (1.6 in 2003, 1.8 in 2000 and
2001) the imaging costs of patients of non-MR imagers.
Conclusions: There is some evidence that probability of
imaging is higher if a treating physician has a financial interest
in the imaging equipment than if the patient is treated by a
physician with no financial interest in the imaging.
Implications for Policy, Delivery, or Practice: The results of
this study will assist policy makers and payers in designing
effective incentive structures and educational initiatives for
physicians to ensure appropriate imaging utilization.
Primary Funding Source: No Funding
●Governance Types and Hospital Performance in Latin
America
Richard Bogue, BA, MA, Ph.D., Gerard LaForgia, Ph.D., Claude
H. Hall, Jr., M.H.A.
Presented By: Richard Bogue, BA, MA, Ph.D., Senior
Research Fellow & Director, Center for Health Futures, Florida
Hospital, 200 N. Lakemont Av., Winter Park, FL 32792; Tel:
407-646-7119; Fax: 407-646-7146; Email:
richard.bogue@flhosp.org
Research Objective: Latin American (LA) governments are
challenged in meeting the health care needs of their people
within the fiscal constraints they face. Hence, LA health
systems remain a focus of experimentation and reform in
health care and hospital management and governance. The
research objective was to identify types of hospital governance
in LA and to examine whether and how these governance
types are associated with hospital performance.
Study Design: Authors surveyed 397 hospital administrators
in Argentina, Brasil, Colombia and Mexico. Cluster analysis
identified four governance types based on organizational
elements theorized to affect hospital behavior: budgetary unit
of government; autonomous unit of government; corporatized
unit of a private system; or privatized and autonomous unit.
These types were compared in five analyses: (a)
administrators' ratings of own hospital performance; (b)
hospital performance indicators, such as occupancy and costs
per bed; (c) performance tracking vis-a-vis standards; (d)
ratings of criteria for selecting leadership; and (e) hospital
administrators' qualifications. ANOVA with post hoc
comparisons were used for interval- and ratio-level data, Mann
Whitney U for ordinal data, and Cramer's V chi-square for
nominal data.
Population Studied: The administrators of 397 LA hospitals
responded from the 600 targeted (150 from each of the four
nations).
Principal Findings: The Privatized and Corporatized
governance types were generally associated with better
performance. Performance differences were noted for facility
and equipment upkeep, availability of medicines and auxiliary
services, administrative and labor efficiency, and clinical
quality, including the level of nursing training. Meanwhile, the
Budgetary governance type seems to be held accountable for a
broader set of accountabilities. Hospitals governed under
Privatized and Corporatized models tended to have more nonclinical, business-oriented leadership.
Conclusions: Market-oriented reforms--freeing hospitals from
institutional and governmental control--seem to be associated
with better hospital performance. However, some socially
beneficial accountabilities demanded of public hospitals may
be lost if market-based reforms are pursued without taking
them into account. A class of professional hospital
administrators seems to be evolving conjointly with
experimentation in health system reform.
Implications for Policy, Delivery, or Practice: Those with
policy-shaping authority are encouraged to continue pursuing
market-oriented health system reforms. The continued
development of mechanisms for training and certifying
hospital administrators who are prepared for new models of
hospital governance seems well advised. But important
cautions about market-based reforms need to be included in
the analysis of the costs and benefits of reform initiatives. The
governance types emerging from this study may contribute to
organizing frameworks for implementing and evaluating
health system reforms.
Primary Funding Source: The World Bank
●The Impact of Direct-to-Consumer Advertising (DTCA) in
Orthopaedics: Results of an Opinion Survey Sent to
Physicians
Kevin Bozic, M.D., M.B.A., Amanda Smith, M.P.H., Sanjo
Adeoye, M.B.A., Sanaz Hariri, M.D., Harry Rubash, M.D.
Presented By: Kevin Bozic, M.D., MBA, Associate Professor,
Orthopaedic Surgery, UCSF, 500 Parnassus Avenue, MU320W, San Francisco, CA 94143; Tel: 415-476-3900;
Email: bozick@orthosurg.ucsf.edu
Research Objective: Over the past decade, there has been
significant demand from health care consumers for
information related to the diagnosis and treatment of chronic
illness. During this same time period, physicians, health
plans, hospitals, pharmaceutical companies, and medical
device manufacturers have all recognized the benefits of
marketing their products and services directly to the end user.
As a result, there has been tremendous growth of direct-toconsumer advertising (DTCA) in healthcare. Although there
are numerous studies evaluating the impact of DTCA in the
pharmaceutical industry, there are no equivalent studies in
orthopaedic surgery. Our objective was to evaluate and
quantify the impact of DTCA on consumer demand, resource
utilization, and the patient-physician relationship in total joint
replacement.
Study Design: We used an opinion survey sent to members
of two major orthopaedic surgeon membership societies,
asking a series of questions about: (1) Awareness and
exposure of direct-to-consumer advertising in orthopaedics;
(2) Experiences and length of interactions with patients who
have been exposed to direct-to-consumer advertising; (3) Level
of satisfaction with the quality and accuracy of information
provided in direct-to-consumer advertising; and (4) General
opinion of direct-to-consumer advertising.
Population Studied: Orthopaedic surgeons who specialize in
hip and knee replacement procedures. In total, we collected
survey information from 362 orthopaedic surgeons from
private and academic practices across the United States.
Principal Findings: Orthopaedic surgeons claim the
frequency of patient-initiated discussions resulting from
exposure to DTCA has increased dramatically over the last
three years. Length of time a physician spends with a new
patient is increasing as well, with 82.0% of physicians saying
that patient-initiated discussions about a specific type of
implant or surgical approach increase the amount of time they
spend with new patients. Although patient awareness and
access to information has increased in recent years, only 1
physician out of 362 (.03%) said patients are aware of the
costs associated with new technologies, and only 8.8% said
their patients are more aware of the risks and complications
associated with new technologies. The doctor-patient
relationship is impacted as well, with 74.2% of physicians
admitting that patients who have been exposed to DTCA try to
influence their opinion in a way that might be harmful to
them, and 52.7% of physicians have felt pressured to use a
particular surgical approach or specific type of implant based
on a patient request.
Conclusions: Overall, orthopaedic surgeons have seen an
increase in patient exposure to DTCA correlating with the shift
in marketing dollars from physicians to consumer markets.
Physicians in general had a negative opinion of direct-toconsumer advertising, most often because of a lack of clear
information in the advertisements about costs, risks,
complications, and benefits of certain procedures or
technologies. Although previous research has shown the
majority of DTCA in orthopaedics is initiated by physicians
and hospitals, most surgeons in this study believed that the
increase in DTCA was primarily industry-driven.
Implications for Policy, Delivery, or Practice: DTCA often
confuses/misleads the consumer which can lead to
inappropriate demand for a particular surgical technique or
implant technology. If the physician disagrees with the
patient’s request for a particular surgical technique or implant,
this strains the patient-physician relationship and consumes a
very important resource, the physician’s time. Physician
compliance with the demand, if inappropriate, creates an
environment of decreased quality of care, inappropriate use of
technology, increased utilization of valuable resources and a
diminished role of the physician in clinical decision making.
Primary Funding Source: No Funding
●“Evaluation of the Regionalized Trauma Care System in
the State of Texas
Dan Culica, M.D., Ph.D., Lu Ann Aday, Lorne D. Bain, Ph.D.,
James Rohrer, Ph.D.
Presented By: Dan Culica, M.D., Ph.D., Assistant Professor,
Management, Policy and Community Health, UT School
Public Health, 5323 Harry Hines Blvd. V8.112N, Dallas, TX
75390; Tel: 214-648-1070; Fax: 214-648-1081; Email:
dan.culica@utsouthwestern.edu
Research Objective: The main aim pursued in this
investigation was to evaluate the theoretical framework of
regionalized trauma care. The assumptions underlying this
study to verify the theory were threefold: the survival of trauma
cases is greater at Level I and II trauma centers than if treated
at lower level centers after adjusting for severity, and
probability of survival is lower for transferred trauma cases
due to increased severity, but after adjustment for severity
transfer is not related to survival.
Study Design: To document appropriateness of
regionalization the authors examined the survival of all injured
cases hospitalized over 2 years in trauma centers in Texas.
Population Studied: The outcome measure was survival
following an injury for cases that were treated in any trauma
center in the state of Texas.
Principal Findings: Survival was disproportionately lower at
Level II and mostly Level I compared to Level III and IV
trauma centers. When adjusting for severity the difference in
survival was of smaller amplitude. Moreover, survival among
the cases transferred to Level I or II trauma centers did not
differ among them or compared to the centers with less
expertise when adjusting for severity and mortality risk.
Patients older than 45, of Hispanic origin, and with some type
of insurance were less likely to survive at these centers. Lower
survival was associated with shorter length of hospital stay
and increased severity of illness.
Conclusions: The study raises the question whether
regionalization in its current form is the appropriate
framework for the organization of trauma care in Texas. Small
variation in survival at centers with highest expertise, indicate
the need to revisit the entire concept of regionalized trauma
care or particular elements of its structure.
Implications for Policy, Delivery, or Practice: One solution
suggested here is to have trauma centers with similar
expertise at the core of the system acting as “Emergency
Hospitals” which would connect with all the other hospitals in
the region regardless of their expertise in an integrative model.
Primary Funding Source: No Funding
●Domains, Difference and Delivery in a HCO
Stiofan de Burca, Ph.D., MA, CFIPD
Presented By: Stiofan de Burca, Ph.D., MA, CFIPD, Adjunct
Prof., Sociology, University of Limerick, 5, Thornville, Nr. Circ.
Rd., Limerick, Ireland.; Tel: +353-61-453496;
Email: stiofan.deburca@gmail.com
Research Objective: Identify the key consequences of
variation in managers` and professionals`perceptions of
leadership and change roles in the Mid-Western Health Board
,Ireland.
Study Design: An ethnographic,pluralist case study of actors`
insights and experiences of internal change influencers.This
was conducted over three years by a "complete insider" with
multi-method data collection and inductive analysis
generating an analytic text.
Population Studied: Six data groups, comprising 24 data sets
of managers,senior professionals and service groups from a
variety of settings and levels throughout the organisation.
Principal Findings: Inter and intra-disciplinary tensions were
reported initially in and between the Regional Hospital and
other acute services and primary physicians(GPs ).More
positive relationships existed with managerial levels.
Reasonable evidence of a shared purpose leadership, vision,
values,relationships and a sense of ownership indicated
positive change. The level of achievement was moderated by
systemic, professional and intrinsic factors. Managers`
purpose and role definitions were in broad alignment.While
specific in their change leadership role, they were not so in
relation to ownership in the system. Clinician` and Directors`
of Nursing purpose and role alignment was specific to their
own domains` responsibility for quality, management,
leadership and teams. The traditional separation of managers
and professionals in role identities was evident although both
agreed on the need for dispersed leadership. Their matched
expectations and indications of leadership profiled their "ideal
types" and "prototypes".For example, both domains`
expectation of system-wide leadership from management was
consistent with the latters` prototype as "change leader". They
also expected domain styles to be contextually determined.
While professionals were domain-oriented, Managers had
inter-level problems in "letting go" and "taking on"
responsibility for change.That had consequences at times for
local ownership. Real change was reported at all levels in
relation to structures,processes and patient services.Senior
professionals noted positive change in the organisational
climate and relationships.
Conclusions: The domains` different occupational realities
was evident in their orientation, roles and responsibilities,
leader prototypes and their actions. Such factors promoted
separate identities , inhibit professional ownership of the
change process and greater convergence of
purpose(ref.Kouses and Mico,1979).This resonates with
Edmondstone`s(1986)attribution to issues in developing a
common vision in the NHS and Griffin`s (2002) paradoxes
and tensions inherent in complex adaptive systems. Evidence
of "domain shift" was reported in the later part of the study
when professionals engaged formally in management
structures and processes(ref.Forbes and Prime, 2000).
However, Management were still the change activists in
Acute Care.
Implications for Policy, Delivery, or Practice: Dispersed
ownership and collective processes emphasising the quality of
relational links are key to effective leadership in complex
systems. Connectedness is inescapable. The trans-disciplinary
nature of managerial activities in such systems need models
grounded in their substantive settings to modify domain
variation and and accomodate the client voice.
Primary Funding Source: MWHB
●Barriers to the Efficient Delivery of Diabetic Eye Care for
Veterans
Carol E Fletcher, Ph.D., RN, Fatima Makki, M.P.H., M.S.W., S.
Jill Baker, MA, M.S.W., Katherine Bent, Ph.D., RN, Brook
Watts, M.D., Steven J. Bernstein, M.D., M.P.H.
Presented By: Carol E Fletcher, Ph.D., RN, Research Health
Science Specialist, HSR&D (11-H), Veterans Health
Administration, Box 130170, Ann Arbor, MI 48113-0170;
Tel: (734)769-7100, x16212; Fax: (734)761-2617;
Email: carol.fletcher@med.va.gov
Research Objective: To: 1) determine providers’ perspectives
regarding barriers to the efficient delivery of eye care for
patients with diabetes; and 2) assemble suggestions and
observations from practice for improving the delivery of eye
care.
Study Design: Using a mixed-methods design, information
from focus groups at one VA medical center was used in
developing a 35 question mailed survey answered on a 5-point
scale from strongly disagree to strongly agree. The survey’s
purpose was to assess the adequacy of clinic resources for
diabetic eye care, how the eye clinic interacts with other parts
of the system, job satisfaction, job related functions,
accomplishment of overall goals, and problems in the
functioning of the clinic. Results were analyzed with
frequencies and factor analysis. In-person semi-structured
interviews following the same areas of inquiry were then
conducted, recorded, transcribed, reviewed, and coded.
Population Studied: The population included personnel at 6
VA Medical Centers. The sample consisted of all eye clinic
personnel including attending physicians, residents, nurses,
technicians, and clerks plus primary care physicians who
interact with the clinics and eye clinic administrators.
Principal Findings: 166 surveys were returned (64%). 82% of
respondents found the work rewarding and 81% agreed or
strongly agreed that clinic care is “high quality”. But 58%
rated staffing as inadequate, 50% agreed they were too busy to
provide all care needed, 50% found the work highly stressful,
34% found equipment lacking, 85% said patients have to wait
too long to be seen, and 50% would not recommend the clinic
to a friend or veteran. Approximately 80 interviews were
completed. While supporting the themes identified in the
survey additional issues were associated with: implementation
of Advanced Clinic Access nationwide to decrease waiting
times for appointments; impact of the integration vs.
separation of Optometry and Ophthalmology functions in the
same clinic; pros and cons of initial eye screening by
technicians using non-mydriatic cameras; how to optimally
use technicians to support physicians; and adequate follow-up
of patients, e.g., screening stable, non-insulin dependent
diabetics every 2 years rather than yearly. Suggestions for
improvement included: ways to make working in the clinics
more attractive to ophthalmologists, examples of the
successful integration of optometry with ophthalmology,
optimal use of clinic personnel, maximizing the potential of
electronic medical records, and restructuring lines of
authority.
Conclusions: Providers are dedicated to providing good
diabetic eye care to veterans, but multiple factors impede their
efforts. Eye clinics in the VA are currently inundated with
patients. An aging veteran population plus new veterans will
place additional strain on an already overburdened system.
While some clinics are meeting the challenge, others are
struggling.
Implications for Policy, Delivery, or Practice: Improving the
efficiency of eye care delivery is an essential piece in providing
the care needed by and mandated for veterans. Those
working in the clinics are well suited to observe processes that
can be improved. Addressing barriers described and
evaluating suggestions made can lead to more efficient
delivery of eye care. Successful processes need to be shared,
supported, and implemented system-wide.
Primary Funding Source: VA
●Responding to Europe: Adapting the UK health services
to EU health policies
Scott Greer, Ph.D.
Presented By: Scott Greer, Ph.D., Assistant Professor, Health
Management and Policy, University of Michigan School of
Public Health, 109 Observatory St., Ann Arbor, MI 480192029; Tel: 734-936-1217; Email: slgreer@umich.edu
Research Objective: This study explores the challenges that
the development of EU health policy creates for the existing
organization and finance of the National Health Services
(NHS) systems of England, Northern Ireland, Scotland and
Wales. The challenges come largely from the extension of
single European market law into health services, led by the
European Court of Justice's interpretation of treaties, and the
consequent expansion of patient and professional mobility in
previously closed systems. The responses take the form of
policies that adapt to EU law and investment by health
stakeholders in influencing EU health policies as they develop.
Study Design: The data is a combination of 41 elite interviews
in the UK and EU, government documents (principally EU
legislation court cases), and participant observation at
policymaking events. This includes almost every ranking
government official involved in the UK. Qualitative analysis
identifies the major areas of EU health policy development
relevant to the UK, as seen by interviewees, their perceptions
of the likely consequences of developing policy, and their
responses.
Population Studied: Stakeholders (principally governments,
professional organization officers, and top managers) of the
English (UK), Northern Irish, Scottish and Welsh health
services.
Principal Findings: The development of EU health policy
poses three kinds of challenges. The first is patient mobility.
Policymakers do not see patient mobility in itself as a serious
threat (given small numbers) but the administrative costs of
adapting to it could be serious. The second is professional
mobility and regulations. It worries policymakers because it
promises to reduce the monopsonistic power that NHS
systems enjoy, although NHS systems are, relatively, highwage recruiters. The third threat emerges from the
development of a legal framework incorporating health into
the EU internal market. By opening the NHS to competition
from across Europe, and in the name of Europe-wide
competition limiting the scope of practices such as waiting
lists EU law could require substantial reconfiguration of
purchasing and regulation in the NHS systems.
Conclusions: The existing structures of the NHS systems
depend on a distinctive, nonmarket mix of regulation and
finance. Both are increasingly incompatible with developing
EU law. Even if the disciplines of competition prove to be
weak, the challenges of fitting the NHS systems into an EU
regulatory framework are substantial. This creates new policy
challenges and incentives to invest in influencing EU health
policy, although awareness of the threat and investment in
either influence over EU politics, or in capacity to identify and
respond to challenges, varies substantially around the UK.
Implications for Policy, Delivery, or Practice: There are two
further implications. One is that the fast pace of current EU
health policymaking has put considerable strain on UK
policymakers' ability to identify emerging policies and respond
to them while they can still be influenced. This could be
mitigated by improving intergovernmental coordination and
monitoring. Second, it suggests that the existing structure of
the NHS systems will be destabilized by incorporation into an
EU market that delegitimizes both basic financial tools (such
as waiting lists) and regulatory instruments (any that apply
UK-specific standards).
Primary Funding Source: The Nuffield Trust
●Costs of Cardiac Procedures in the Veterans Health
Administration
Peter Groeneveld, M.D., MS, Gregory B. Kruse, MSc., M.P.H.
Presented By: Peter Groeneveld, M.D., MS, Assistant
Professor of Medicine, Center for Health Equity Research and
Promotion, Philadelphia VA Medical Center, 3900 Woodland
Avenue - 9East, Philadelphia, PA 19104-4155; Tel: (215) 8982569; Fax: (215) 573-8778; Email: peter.groeneveld@va.gov
Research Objective: Growth in major medical technology
utilization is an important source of rising healthcare costs.
However, it is uncertain what the costs of technology use are
in the Department of Veterans Affairs (VA), as the VA's health
system operates with global budgets and does not generate
patient bills from which the costs of care can be abstracted.
We hypothesized that cardiovascular procedures within VA are
associated with substantial healthcare costs, and that these
costs may differ depending on hospital characteristics.
Study Design: We examined the use of 4 cardiovascular
procedures (aortic valve replacement[AVR], dual chamber
pacemaker implant[DCP], implantation of a cardioverterdefibrillator[ICD], and percutaneous coronary intervention
[PCI]) that are rapidly growing in volume of use among VA
medical centers. We used the VA’s Decision Support System
for healthcare encounter cost attribution, by which every
hospitalization or outpatient encounter within the VA system
is assigned a cost based on the resources used from six "cost
centers" tied to global budgets. We fitted a logistic regression
model with receipt of the procedure of interest within 30 days
as the dependent variable and with patient demographics,
comorbidities and technology-specific clinical predictors (e.g.,
the diagnosis of acute myocardial infarction for percutaneous
coronary intervention) to all patients admitted to a VA hospital
between 1997-2003 to derive a propensity score model for
procedure receipt. We then matched the propensity scores of
each procedure recipient to four non-recipients with similar
propensity scores at the time of hospitalization. Finally, we
aggregated costs of care for each patient in the matched
cohorts for the 365 days starting with the index hospital
admission date, and we fitted a multivariate regression model
where the logarithm of cost was the dependent variable.
Receipt of the primary procedure, patient-level demographics,
comorbidities, and predictor diagnoses, as well as hospitallevel factors such as whether the hospital was an academic
center or was located in an urban area, were independent
variables. We then applied the model to assess the cost
difference between procedure recipients and non-recipients in
the four hospital categories (i.e., combinations of urban and
academic status). We used 1000 bootstrap replications to
calculate 95% confidence intervals for the cost difference.
Population Studied: Veterans with cardiovascular disease
who were potential procedure candidates, 1997-2003.
Principal Findings: We found that the differences in costs of
care for procedure recipients versus non-recipients
significantly varied depending on hospital characteristics. AVR
was more costly at academic, urban hospitals ($46,900)
compared to non-academic urban ($39,200), academic nonurban ($39,100), and non-academic, non-urban hospitals
($32,900), p=0.01 for the difference. ICD costs were
significantly lower in urban hospitals ($26,100 academic,
$27,700 non-academic) than in non-urban centers ($32,500
academic, $34,500 non-academic), p=0.01. DCP costs did not
differ among hospitals (overall mean = $9,900, 95%
confidence interval $8,600-$11,100), nor did PCI costs (overall
mean=$1,800, 95% confidence interval $1,100-$2,500).
Conclusions: Use of selected cardiovascular procedures such
as aortic valve replacement and implantable defibrillators
results in different cost increases at different types of VA
medical centers. Other cardiac procedures have more
uniform cost increases.
Implications for Policy, Delivery, or Practice: Some types of
VA medical centers may face greater fiscal challenges than
others in providing cardiovascular procedures due to their
higher costs in certain settings. As procedure volumes grow,
these cost differences may have substantial budgetary impact.
Primary Funding Source: VA, Leonard Davis Institute for
Health Economics
●The Hospitalist Model: A Strategy for Success in U. S.
Hospitals
Jeffrey Harrison, Ph.D., M.B.A., M.H.A., Richard J. Ogniewski,
M.H.A.
Presented By: Jeffrey Harrison, Ph.D., MBA, MHA, Assistant
Professor, Health Administration, University of North Florida,
4567 St. Johns Bluff Road, South, Jacksonville, FL 32224-2673;
Tel: (904) 620-1440; Fax: (904) 620-1035;
Email: jharriso@unf.edu
Research Objective: The objective of this study is to evaluate
the efficiency and performance of hospitals in the United
States that use the Hospitalist model for providing inpatient
services. The results provide an opportunity for improved
management of healthcare resources as well as the potential
to identify savings in U.S. healthcare expenditures. The study
has managerial implications for hospital executives to improve
organizational performance and from a policy perspective
highlights the importance of implementing innovative
programs to address inefficiency in the health care industry.
Study Design: The study utilized a multivariate logistic
regression model to identify significant relationships between
hospitals with the hospitalist program and those without. The
data were drawn from the American Hospital Association
Annual Survey of Hospitals (AHA), the Area Resource File
(ARF), and the Centers for Medicare and Medicaid Services
Minimum Data Set (CMS) for the year 2001.
Population Studied: The study examined 264 hospitals
composed of 66 hospitals with hospitalist programs and 198
hospitals without hospitalist programs. The data involved 66
hospitals utilizing the hospitalist model plus a random sample
of non-hospitalist organizations numbering three times the
number of hospitalist organizations.
Principal Findings: The study found that organizations using
the hospitalist model are located in communities with higher
HMO penetration, have more hospital beds, more clinical
services, and more managed care contracts. More
importantly, from an operating performance perspective,
organizations using the hospitalist model have higher
occupancy rates, a higher return on assets and a lower
average length of stay.
Conclusions: The findings of this study are consistent with
recent literature that suggests the hospitalist model is an
effective method to improve the efficiency and profitability of
acute care hospitals. Additionally, the hospitalist model will
increase efficiency, reduce length of stay and improve the
allocation of resources within the acute care hospital industry.
The link between hospital profitability and the use of the
hospitalist model suggests that this is a viable clinical
approach to managing acute care in hospitals as a
mechanism to improve financial performance
Implications for Policy, Delivery, or Practice: These results
have important managerial implications as the hospital
industry faces a more competitive environment. Hospital
managers who wish to improve efficiency and profitability are
challenged to implement programs that can positively affect
the hospital’s financial status. This study clearly demonstrates
that the hospitalist model is an opportunity to improve
efficiency. Additionally, it’s clear that as hospital bed size
increases and clinical complexity grows, the importance of a
hospitalist program is more evident. It suggests that the use
of inpatient clinical practice protocols developed within the
hospitalist model improves efficiency and fosters higher
quality outcomes. Therefore, managers are encouraged to
integrate hospitalist programs in the strategic planning
process to ensure operational efficiency and organizational
profitability. From a policy perspective, the hospitalist model
is an effective mechanism to integrate outpatient, inpatient
and long term care. Successful management of the continuum
of care is critical to conserving national health resources and
may be the key to ensuring individual hospital survival.
Primary Funding Source: No Funding
●Social Capital and the Healthcare Safety Net
Jennel Harvey, M.H.S.A.
Presented By: Jennel Harvey, MHSA, Graduate Teaching
Associate/Ph.D Candidate, Public Administration and Policy,
University of Arizona, 1130 E Helen, McClelland Hall 405,
Tucson, AZ 85721; Tel: 520-626-3290/ 615-9671; Fax: 520-6265549; Email: jharvey@email.arizona.edu
Research Objective: This study provides an empirical
examination of the relationship between community social
capital and the delivery and financing of uncompensated
healthcare services by federally-qualified health centers
(FQHCs)and private physicians in 379 communities.
Study Design: Quantitative analysis methods were used to
analyze data on community social capital, FQHC grant
revenues and hours of charity care provided by private
physicians. OLS regression models were used to estimate the
relationship between community social capital indicators and
health care provider outcomes.
Population Studied: Federally qualified health center sites
(N=1248) and private physicians (N=12,000).
Principal Findings: Preliminary analysis indicated that among
social capital indicators, measures of political participation
were the strongest predictors of FQHC grant revenue while
measures of community voluntarism were the strongest
predictors of private physicans' provision of charity care.
FQHC grant revenue was positively and significantly
correlated to private physician charity care. Both models
indicated that individual and organizational characteristics
such as organizational size, provider gender/ethnicity, and
managed care penetration were stronger predictors (in
comparison to community social capital) of health care
provider outcomes.
Conclusions: Community social capital alone does not have a
significant impact on health care resources. The economic
status of the community and demographic characteristics of
providers explain a great deal of the variance in FQHC
financial capacity to care for the uninsured and private
physicians' willingness to provide charity care.
Implications for Policy, Delivery, or Practice: Efforts to build
community capacity to care for the low-income and uninsured
may include strategies for the creation and mobilization of
community social capital particularly, political participation.
However, this must be part of a larger strategy that includes
efforts to raise the socio-economic status of community
members and increase health insurance coverage.
Primary Funding Source: No Funding
●The Association of VHA Facilities’ Organizational Culture
to Time-to-EKG for Acute Coronary Syndrome Patients
Christian Helfrich, Ph.D., M.P.H., Haili Sun, Ph.D., Anne E.
Sales, Ph.D., MSN, YuFang Li, Ph.D., RN, Stephen Fihn, M.D.,
M.P.H.
Presented By: Christian Helfrich, Ph.D., M.P.H., PostDoctoral Fellow, Health Services Research and Development,
VA Puget Sound Healthcare, 1100 Olive Way, Suite 1400,
Seattle, WA 98101; Tel: 206-277-1655;
Email: christian.helfrich@med.va.gov
Research Objective: A key performance measure for acute
coronary syndrome (ACS) care in VHA is the time to EKG for
ACS patients presenting to urgent care. Organizational theory
suggests that organizational culture is an important
determinant of how facilities achieve quality improvements.
The objective of this study was to determine if facility-level
organizational culture is associated with time to EKG.
Study Design: Retrospective patient data came from the FY
2004 External Peer Review Program, a detailed monthly VHA
chart review that includes all patients with a discharge
diagnosis of ACS. Organizational culture data came from the
May 2004 All Employee Survey, a survey of VHA employees
(51.8% response rate) including items based on four
previously-validated organizational culture subscales
measuring innovation, stability, performance, and
collaboration in a facility. Responses were aggregated to the
facility level. We used hierarchical regression modeling to
predict patient-level time to EKG as a function of facility-level
organizational culture adjusting for facility technical capacity,
patient age, gender, ethnicity, presentation without chest pain,
and off-hours presentation (between 5PM and 7AM).
Population Studied: Patients discharged from VHA facilities
in fiscal year 2004 with a primary diagnosis of acute
myocardial infarction or unstable angina (ICD 9 codes 410.xx),
excluding patients transferred in from other facilities and
patients whose AMI occurs during inpatient admission for
other conditions.
Principal Findings: A total of 7,704 ACS patients from 134
VHA facilities were identified. Median time to EKG was 9
minutes (25 percentile = 2 minutes and 75 percentile = 33
minutes). Aggregate subscale scores (1 = lowest, 5 = highest)
ranged from 2.5 – 4.1 for innovation; 2.3 – 3.7 for stability; 2.9
– 4.1 for performance; and 2.2 – 3.9 for collaboration.
Innovation, performance and collaboration subscales were
positively correlated (0.91 to 0.94), and were negatively
correlated with the stability subscale (-0.21 to -0.41). No
subscale was associated with differences in the time to EKG.
Patients presenting with atypical symptoms waited 42 minutes
longer, on average, for an EKG than those presenting with
chest pain (p < 0.0001). Neither patient age, gender,
ethnicity, off-hours presentation, nor facilities’ technical
capacity were associated with time to EKG.
Conclusions: We do not find evidence of an effect from
facility-level organizational culture on the time to EKG for ACS
patients.
Implications for Policy, Delivery, or Practice: Putting effort
into culture change to promote quality improvement in this
area may be less useful than effort into helping clinicians
recognize patients with atypical symptoms.
Primary Funding Source: VA
●Out-of-Pocket Costs and Medication Compliance in 12
Countries
Richard Hirth, Ph.D., John Piette, Ph.D., Scott Greer, Ph.D.,
Justin Albert, BS, Eric Young, M.D.
Presented By: Richard Hirth, Ph.D., Associate Professor,
Health Management and Policy, Univ. of Michigan School of
Public Health, 109 S. Observatory, Ann Arbor, MI 48109-2029;
Tel: (734)936-1306; Fax: (734)764-4338;
Email: rhirth@umich.edu
Research Objective: Because pharmaceuticals have
contributed disproportionately to increases in health
spending, drug costs have become a prominent policy issue.
Studies have measured cross-national pharmaceutical price
differences, focusing on the full price regardless of who pays.
However, across countries and across patients within a
country, financial burdens fall to differing extents on
government, private insurers, and patients. While the full
price of drugs has implications for total health expenditures in
a country, out-of-pocket (OOP) costs may be more salient to
therapy compliance and patient outcomes. However, the
ability to study international variations in OOP costs and their
effect on compliance has been hampered by the lack of
comparable data from different countries. We present data
from a unique international survey that overcomes some of
these limitations.
Study Design: We compared rates of patient-reported OOP
medication costs and non-purchase due to cost across
representative samples of hemodialysis patients from the US,
Japan, Australia, New Zealand, Belgium, Canada, France,
Germany, Italy, Spain, Sweden, and UK. Logistic regression
models were estimated to identify characteristics associated
with patients having to pay for medications and not
purchasing medications due to cost.
Population Studied: The Dialysis Outcomes and Practice
Patterns Study (DOPPS) includes 7496 hemodialysis patients
from 12 countries, employing the same sampling strategy and
survey in each country. Focusing on patients with one welldefined illness (end-stage renal disease) and mode of
treatment (in-center hemodialysis) created a clinically
homogeneous study population across countries.
Principal Findings: The proportion of patients paying OOP
for drugs varied from 29% in France to 99% in Australia/New
Zealand. Median monthly OOP among patients reporting
positive OOP varied from $10 in the UK to $80 in the US.
The proportion of patients reporting non-purchase of
medications due to costs varied from 3.1% in Japan to 28.6%
in the US. Countries with higher OOP burdens generally had
higher rates of cost-related non-purchase. Odds of paying
positive OOP costs were higher for patients with higher
incomes, college educations, private insurance, or members
of their country's ethnic majority. Relative to Europe, odds of
facing OOP costs were higher in the US and Canada, and
lower in Japan. Odds of cost-related non-purchase were
higher for those who faced OOP costs, whose OOP costs
exceeded their country's average, had lower incomes, and
were younger, unemployed, and ethnic minorities. Relative to
Europe, non-purchase was less likely in Japan and more likely
in the US.
Conclusions: This study documents substantial variation in
OOP costs and cost-related non-purchase of prescriptions
across countries, and provides evidence on factors related to
non-purchase.
Implications for Policy, Delivery, or Practice: Few
randomized trials compare cost-sharing arrangements.
Therefore, policy-makers must evaluate drug policy options
based on what is known about the impact of cost-sharing
implemented by private and public sector payers. The current
study represents a significant advance, by taking advantage of
the variation in cost-sharing across 12 counties. Patients in
some countries were more or less likely to skip medications
than would be expected on the basis of OOP costs, indicating
that cultural factors or other aspects of health care delivery
and financing systems may influence cost-related noncompliance.
Primary Funding Source: Grant from Amgen to University
Renal Research Associates
●Evidence-Based Approaches to Primary Care Staffing
Mix: Functional Job Analysis
Sylvia Hysong, Ph.D., Richard G. Best, Ph.D., Frank I. Moore,
Ph.D.
Presented By: Sylvia Hysong, Ph.D., health services
researcher, Houston Center for Quality of Care & Utilization
Studies, Michael E. DeBakey VA Medical Center, 2002
Holcombe Blvd. (152), Houston, TX 77030; Tel: 713-794-8616;
Fax: 713-794-7359; Email: sylvia.hysong@med.va.gov
Research Objective: Due to its wide breadth of possible
services, developing effective primary care staffing mixes is
often subjective, and unsystematic. Functional Job Analysis
(FJA), used for many years by numerous other industries, may
provide the evidence base needed to make informed primary
care staffing mix decisions. This research thus has three
objectives: (1) Describe the content of tasks performed in a
range of VHA primary care settings; (2) Identify the extent of
overlap in tasks performed by various primary care job titles
(indicative of opportunities for work reallocation); (3) Perform
work allocation trade off modeling using data from the
previous objectives.
Study Design: This project involved two phases. In Phase I
we used standard FJA protocol to generate task statements
representative of the work performed by seven primary care
job titles : Task statements generated via FJA focus groups
were edited by certified FJA analysts, reviewed by the focus
group participants for accuracy, and rated by the analysts
along ten work content dimensions. All primary care
personnel in seven VA facilities received the finalized list,
where they verified whether they performed each task, and
estimated frequency and duration for each task they
performed. These data, along with salary grade from the PAID
employee database and cost information from the Office of
Personnel Management, were used in Phase II to create
“what-if” scenarios illustrating simulated cost and time
savings resulting from reallocating tasks from one job title to
another.
Population Studied: Focus groups: 17 focus groups among
81 health care personnel (Physician, NP/PA, RN, LVN, Health
Technician, Clerk, and Pharmacist) across six VA facilities;
Survey: 224 primary care personnel in seven VA facilities.
Principal Findings: The work of primary care can be classified
along four major functions: service delivery, administrative
duties, logistic support, and workforce management. Most
task statements fall within service delivery, comprising
activities such as patient assessment, treatment, education,
and care coordination. Most service delivery task statements
consist of care coordination. Of the 243 tasks, MDs reported
performing 58%, NP/PAs 55%, RNs 71%, LVN 55%, clerks 18%
and health-techs 20%. Although most primary care tasks fell
in the mid-scale range or below on the FJA work content
complexity dimensions, those with higher ratings were
primarily performed by physicians and advanced practitioners.
Nevertheless, large overlap occurred between MDs, NP/PA,
and RNs. For example, of the tasks performed by MDs, 86%
are also performed by NP/PAs, and 77% by RNs. Similarly,
LVNs report performing 75% of RN tasks, and RNs report
performing 93% of clerk tasks.
Conclusions: Significant opportunities exist for reallocating
primary care work more effectively.
Implications for Policy, Delivery, or Practice: FJA, in concert
with responsibility allocation trade off modeling, could be
used at the facility level to aid staffing decisions in primary
care. FJA could also be used at the regional and national levels
to inform primary care staffing policy. FJA as an evidencebased personnel management tool could significantly
influence work efficiency, employee satisfaction, and quality of
care.
Primary Funding Source: VA
●The Impact of the DPC Payment System on Hospital
Productivity Change in Japan
Hiroo Ide, MA
Presented By: Hiroo Ide, MA, Research Associate,
Department of Planning, Information, and Management,
University of Tokyo Hospital, Hongo 7-3-1, Bunkyo-ku, Tokyo,
113-8655; Tel: +81-3-5800-8716; Fax: +81-3-5800-8765;
Email: idea-tky@umin.ac.jp
Research Objective: There are over 9,000 acute and general
hospitals in Japan, and a new “per-day payment” system by
Diagnosis Procedure Combinations (DPC) was introduced
into 88 hospitals, mainly university hospitals. The difference
between the DPC payment system and DRG/PPS is that the
former reimburses lump-sum charges on a per-day basis
without operation, treatment, and other expensive charges.
The purposes of the system are to standardize the quality of
health services and to restrain increasing national healthcare
expenditure.
Study Design: Because my objective was to examine the
impact of the DPC payment system, I analyzed panel data of
25 public University Hospital (UH) and 81 large acute Public
Hospitals (PH) by using Data Envelopment Analysis (DEA) to
measure malmquist indices of productivity change. The
analytical periods were: before the introduction of the DPC
payment system, fiscal year 2001 and 2002; and after its
execution, fiscal year 2003.
The analytical advantage of DEA is that it conducts multi-input
and multi-output, and I applied seven inputs: the number of
beds (BED), the area of facilities in square meters (AREA),
operational cost in dollars (OC), the number of physicians
(DR), the number of the nurses (NS), the number of the para
medicals (PM) and the number of administrators and clerks
(OTHER), and four outputs: operational revenue in dollars
(OR), the reciprocal numbers of average length of stay
(ALOS), the number of inpatients (IP) per day and the number
of outpatients per day (OP).
Population Studied: Descriptive statistics showed that BED
of UH was 733.9 and its of PH was 621.9, AREAs were
78,622.4 and 43,149.1, OCs were 122,931,718 and 107,880,817,
DRs were 235.9 and 83.4, NRs are 463.8 and 425.8, PMs were
122.3 and 90.9, OTHERs were 127.8 and 74.5, ORs were
125,329,357 and 110,692,205, ALOSs were 0.4208 and 0.5902,
IPs are 621.9 and 542.7, and OPs were 1,360.2 and 1387.3 in
average.
Principal Findings: Total Productivity Change (PC) from
FY2001 to FY2002 (the first period) was 0.995 and from FY
2002 to FY2003 (the second period) was 0.990. We broke
down total productivity change into Efficiency Change (EC)
and Technical Change (TC) by UH and PH. UH’s average PC
was 0.985, EC was 1.050, and TC was 0.947 in the first period,
and 0.967, 0.959 and 1.004 in the second period. PH’s
average PC was 0.999, EC was 1.028, and TC was 0.995 in the
first period, and 0.999, 0.973 and 1.006 in the second period.
I examined average PC, EC and TC by t-test. TC in the first
period and PC and EC in the second period were statistically
significant, being below the 5% level.
Conclusions: PC of both UH and PH had decreased through
the analytical periods and UH’s negative productivity change
in the second period was more clearly observed. But I
analyzed limited data, only three years data and small
samples.
Implications for Policy, Delivery, or Practice: Some
countries use DRG/PPS, but former studies show that the
productivity has not improved. I report there is the possibility
that DPC payment system might have a slightly negative
impact on productivity change in Japan.
Primary Funding Source: No Funding
●Monetary and Non-monetary Drivers of Physician Job
Satisfaction: Insights from a Cross-National Comparative
Survey
Katharina Janus, Ph.D., Volker E. Amelung, Ph.D., Laurence C.
Baker, Ph.D., Michael Gaitanides, Ph.D., Friedrich W.
Schwartz, Ph.D., M.D., Thomas G. Rundall, Ph.D.
Presented By: Katharina Janus, Ph.D., Visiting Scholar, School
of Public Health, University of California, Berkeley, 140 Warren
Hall, MC 7360, Berkeley, CA 94720;
Email: Kjanus2121@aol.com
Research Objective: To assess the effects of monetary and
non-monetary factors on physician job satisfaction among two
similar samples of physicians, one each from Germany and
the United States.
Study Design: This study is a cross-national comparative
survey. Based on existing satisfaction studies we designed a
self-administered questionnaire that contained 28 items,
including items measuring several dimensions of physician
job satisfaction; the monetary and non-monetary incentives
the physicians experienced in the recent past; other job-related
potential confounding factors; and socio-demographic
questions. Respondents were asked to rate each job
satisfaction item on five-point Likert scales regarding both
satisfaction with and importance of the item. In Germany,
data collection took place from December 2004 until February
2005; in the US, the time frame of collection was from
October until December 2005.
Population Studied: We surveyed physicians who spent more
than 50% of their time in patient care (and less than 50% in
research) at the teaching hospital of the Hannover Medical
School and at San Francisco General Hospital, a teaching
hospital of the University of California, San Francisco. The
combined sample size was 1,089 and included only physicians
whose department chiefs agreed to participate in the study.
Principal Findings: The study populations had very similar
socio-demographic characteristics and work experience.
Interestingly, non-monetary incentives were the strongest
drivers of physician satisfaction in both countries. In
Germany, autonomy in medical decision-making, perceived
effectiveness of organizational decision-making, career
opportunities, and professional relations were most strongly
associated with physician job satisfaction, while in the U.S.
autonomy in medical decision-making, leadership issues,
cooperation and communication among health care
professionals, and monetary incentives had the highest
impact on physician job satisfaction.
Conclusions: This study sheds light on the underlying factors
that contribute to physician job satisfaction in the US and
Germany, and it provides insights into the reasons for
physicians abandoning medical practice. Our data suggest
that non-monetary factors are important determinants of
physician job satisfaction, perhaps more important than
monetary incentives that may augment or reduce physicians’
base incomes, and that this relationship transcends national
boundaries. Further studies in different settings in both
countries will be necessary to set-up a scoring model that
assigns values to monetary and non-monetary incentives and
combines them to form a comprehensive incentive system
applicable within each country’s medical, political, and
economic systems.
Implications for Policy, Delivery, or Practice: In order for a
health system to recruit and retain physicians, it may be
necessary for a system’s physician strategy to shift from
focusing primarily on hard, monetary and compensationrelated factors to a broader focus that incorporates the soft,
non-monetary factors that affect physicians’ job satisfaction.
This is of particular importance as human resources consume
about 70% of the total health care budget and are the crucial
production factor in health care delivery. If the drivers of
physician satisfaction and decision-making are not
understood, quality and cost-effectiveness objectives will be
difficult to achieve in any health care system.
Primary Funding Source: Fritz-Thyssen-Foundation and
university funds
●Patient Benefits from Participating in an Integrated
Delivery System? Impact on Coordination of Care,
Satisfaction, Willingness to Recommend and Clinical
Outcomes
Cori Kautz, M.A., Ph.D., ABD, Jody Hoffer Gittell, Ph.D., R.
William Lusenhop, M.S.W., Ph.D. ABD, Dana Beth Weinberg,
Ph.D., John Wright, M.D.
Presented By: Cori Kautz, M.A., Ph.D., ABD, Research
Associate, Heller School for Social Policy and Management,
704 West Hollis Street, Nashua, NH 03062; Tel: 603 598
2826; Email: ckautz@brandeis.edu
Research Objective: One goal of integrated delivery systems
has been to improve the coordination of care and associated
quality outcomes for patients. This study assesses whether
receiving care from providers who belong to the same
integrated delivery system improves patient-perceived
coordination, patient satisfaction, willingness to recommend
the care team, and/or patient’s clinical outcomes.
Study Design: To minimize differences arising from surgery
itself and to isolate the effects of provider membership in the
integrated delivery system, we enrolled patients who received
surgery from the same surgical department in the same acute
care hospital. Depending on the network membership of their
post-acute care providers (rehabilitation, home care, and
primary care providers), these patients had differing levels of
participation in the integrated delivery system after discharge.
We used hospital records to determine membership of a
patient’s post-acute care providers in the integrated delivery
system. We used baseline, six-week, and twelve-week surveys
of patients to assess the impact of participation in the
integrated delivery system on patient-perceived coordination,
patient satisfaction, willingness to recommend, and clinical
outcomes. Patients who were enrolled in the study received
surgery from one of four participating surgeons. We used
random effects linear regression methods to control for
correlated errors arising from patients who received surgery
from the same surgeon.
Population Studied: A study was conducted of 222 patients
who received primary unilateral total knee arthroplasty
between November 2003 and March 2004 at an acute care
hospital in a large integrated delivery system.
Principal Findings: We found that network membership of a
patient’s post-acute care providers has few observable effects
on coordination, patient satisfaction, willingness to
recommend, or clinical outcomes.
Conclusions: Our results are inconsistent with expectations
that integrated delivery systems will improve coordination and
associated quality outcomes for patients. We discuss potential
reasons for this lack of observed effects and argue for the
usefulness of the approach developed here for assessing
patient benefits from participating in an integrated delivery
system.
Implications for Policy, Delivery, or Practice: Our study has
important implications for healthcare researchers, providers,
and policymakers. While much of the research on integrated
delivery systems focuses on more macro outcomes such as
financial performance, our study focuses on patient benefits.
Furthermore, we offer a novel approach for assessing the
impact of an integrated delivery system on patient outcomes.
The approach developed here takes advantage of the fact that
patients receiving similar treatments typically have varying
levels of participation in a given network. By assessing the
impact of patient participation in that network on patient
outcomes, researchers can achieve a baseline measure of
network effectiveness.
Primary Funding Source: CWF
●Assessing the Degree of the Culture-Gap Between
Medical Doctors and Managers in Dutch Hospitals
Andrea H.J. Klopper-Kes, Msc, Celeste P.M. Wilderom, Prof.
Dr., Wim H. van Harten, Prof. Dr.
Presented By: Andrea H.J. Klopper-Kes, Msc, Ph.D. student,
School of Business, Public Administration and Technology,
University of Twente / Ziekenhuisgroep Twente, P.O. Box
7600, Almelo, 7600 SZ; Tel: ++ 546-693406;
Fax: ++546-693520; Email: h.klopper@zgt.nl
Research Objective: Effective co-operation between medical
doctors and managers in hospitals is assumed to have a
positive influence on the quality of care, although firm
evidence is scarce. In order to find relevant cultural aspects, a
literature plus pilot empirical study was done. In literature we
found corroborating aspects of the need of effective hospital
co-operation. We decided to use the intergroup theory as we
assume the presence of a latent conflict, including a culturegap between hospital doctors and managers.
Study Design: We selected Krawleski's (1996) questionnaire
on culture in medical group practices, as it covers relevant
professional key aspects, and we adapted it to the Dutch
situation. Additionally we drafted 5 overall questions on
perception of: contentment with the co-operation, perceived
overall quality of care and perceived magnitude of influence
between medical doctors and managers. We piloted the
questionnaire by visiting medical doctors and managers from
three different Dutch hospitals. Apart from having them fill
out the questionnaire, in our presence, we interviewed them
about the questionnaire and the relationship between medical
doctors and managers within the hospital organisation. We
explicitly included an evaluation of the questionnaire.
Population Studied: Hospital managers and medical doctors
in three Dutch hospitals (n = 12).
Principal Findings: Despite the small n, we already found
remarkable significant differences between the two groups.
The medical doctors are more positive about the degree of
collegiality, quality emphasis, cohesiveness and co-operation
between managers and doctors than the managers. Managers
estimate the degree of professional autonomy by doctors
higher than doctors do themselves. In the added overall
questions, we found significant differences in the contentment
with the co-operation between managers and medical doctors.
This matches the answers given on the pilotted dimension in
the adapted questionnaire, managers indicated to be less
satisfied with the co-operation with doctors than the medical
doctors with their managers. Another remarkable finding is
that managers perceive the degree of influence of medical
doctors as higher than their own influence, whilst medical
doctors perceive their influence as being lower than the
influence of managers.
Conclusions: The results are pointing towards some
understandable differences between medical doctors and
managers. The dimensions collegiality and quality emphasis
are more applicable to medical doctors. This reflects the
literature on outcomes of differences between two groups in
terms of the identification with the peer group, the aim for
professional status and also the technical supremacy of
medical doctors. More study needs to be done on the findings
on contentment with the doctors/managers co-operation by
the doctors. Furthermore, the medical doctors - even though
they feel they have less control than the managers - are still
perceived to be quite powerful by hospital managers.
Implications for Policy, Delivery, or Practice: Although we
only piloted the questionnaire on a small amount of
respondents, these findings give us confidence that both the
questionnaire, and the overall questions are suitable for our
study-objective. The next steps are the quantitative validation
of the translated questionnaire, assessing the differences in a
large population and studying the correlation between the
relative culture-gap and hospital performance.
Primary Funding Source: No Funding
●Making Sense of Organizational Outcomes Using
Complexity Science
Luci Leykum, M.D., M.B.A., Jacqueline Pugh, M.D., Michael
Parchman, M.D., M.P.H., Valerie Lawrence, M.D., Polly
Hitchcock-Noel, Ph.D., Reuben McDaniel, EdD
Presented By: Luci Leykum, M.D., MBA, Assistant Professor
of Medicine, Medicine, University of Texas Health Science
Center at San Antonio, Veterans Affairs Health Care System,
7400 Merton Minter Blvd, Amb Care 11C6, San Antonio, TX
78229; Tel: 210 949 3819; Fax: 210 567 4423;
Email: lleykum@verdict.uthscsa.edu
Research Objective: The evidence regarding the impact of
organizational interventions on clinical outcomes is mixed,
especially for patients with chronic disease. Complexity
science, or the science of complex adaptive systems (CAS),
suggests that interventions leveraging the ability of
participants to learn, interact, self-organize, and co-evolve will
lead to improved patient outcomes. We examined the
relationship between the presence of these four characteristics
of complex adaptive systems in organizational interventions
and outcomes of patients with Type II diabetes.
Study Design: We conducted a systematic review of the effect
of organizational interventions on outcomes of patients with
Type II diabetes. Eligible studies were randomized or
controlled clinical trials identified by a search of Medline from
1989 to 2004 after testing a broad array of potential search
terms for organizational strategies. Eligible publications were
independently reviewed and then jointly abstracted by teams
of reviewers with clinical and methodological expertise. Two
raters then independently evaluated each study to assess the
extent to which the intervention incorporated one or more of
these characteristics of a CAS: individuals’ capacity/ability to
learn; the interconnections between individuals; the ability of
participants to self-organize; and the tendency of participants
to co-evolve. The kappa for these scores between reviewers
was 0.8. The strength of the outcomes of each study was
then assessed by two independent raters on a scale of 0 (no
effect), 0.5 (mixed results), and 1 (intervention effective) based
on the type (process versus outcome), number, and statistical
significance. The kappa for these scores was 0.8. We used
Fisher’s exact test to test the significance of the relationship
between each individual CAS characteristic, as well as total
number of characteristics, and strength of outcomes.
Population Studied: Adults with Type II diabetes.
Principal Findings: 6251 potential studies were identified by
the literature search, 169 were reviewed in detail and 31 met
eligibility criteria. At least one characteristic of a complex
adaptive system was utilized in 28 of the 31 studies. Twenty
interventions utilized 2 to 3 characteristics, most commonly
increasing the ability of participants to learn and to
interconnect with other individuals. 3 studies reported no
improvement in any endpoints, 17 reported significant
improvement, and the remainder reported mixed results.
There was a significant relationship between the number of
characteristics and the strength of outcomes (Chi-square
32.3, p=0.001). Positive outcomes were significantly related to
interventions affecting the interconnections between
individuals and allowing participants to co-evolve (p<0.001,
p=0.01, respectively. Interventions focusing on individuals’
ability to learn were not significantly related to positive
intervention effects.
Conclusions: Improved outcomes in Type II diabetes were
significantly associated with organizational interventions that
had characteristics of complex adaptive systems in their
design. We observed a greater effect for interventions that
promoted interconnections between, and co-evolution of,
individuals. Those interventions incorporating a greater
number of characteristics demonstrated the greatest
improvement in diabetes-related outcomes.
Implications for Policy, Delivery, or Practice: This study
suggests that interventions which consider the health care
delivery system, as a complex adaptive system can
significantly improve patient outcomes. Specifically, these
results suggest that attention should be focused on
individuals’ ability to interact, self-organize, and co-evolve.
The data also suggest that interventions with strategies
targeting multiple CAS characteristics may be most effective in
improving health outcomes. Further research should address
how best to translate the theoretical constructs of complex
adaptive systems into interventions that improve the
outcomes of chronically ill patients.
Primary Funding Source: VA
●Hospital Competition under Global Budgets: Evidence
from Diabetes Outpatient Treatments in Taiwan
Ya-Ming Liu, Ph.D., Chi-Ta Chen, MA
Presented By: Ya-Ming Liu, Ph.D., Assistant Professor,
Economics, National Cheng Kung University, No. 1 University
Road, Tainan, 701; Tel: 886-6-2757575 x50258;
Fax: 886-6-2766491; Email: ymliu@mail.ncku.edu.tw
Research Objective: The global budget payment system was
implemented in July 2002, to curb the growth of health care
expenses after launching the National Health Insurance
program since 1995 in Taiwan. Compared with fee-forservices, it is believed that the introduction of global budgets
may bring an adverse effect on the welfare of patients. The
main purpose of this study is to examine whether the negative
effect from the implementation of global budgets could be
offset by hospital competition from the aspect of outpatient
services for diabetes patients.
Study Design: We divide hospital markets into two groups:
the control group with increasing HHI value and the
treatment group with decreasing HHI after the
implementation of global budgets. Using the difference-indifference method we examine the effect of hospital
competition on diabetes outpatient treatment under different
payment scheme: fee-for-service in 2001 and global budgets in
2003. Dependent variable is the frequency of six
recommended procedures: ophthalmology examination,
hemoglobin A1C, total cholesterol, urinalysis, triglycerides, and
blood glucose test, which have been done for a patient within
one year to measure the performance of hospitals. The
frequency of procedures is weighted by the frequency of that
procedure should be done within one year in order to reflect
the relative importance of each procedure. Patients’ severity is
measured by the types of combination pharmacological
therapy.
Population Studied: This study employs cohort data from the
National Health Research Database 2001 and 2003, using the
simple sampling method to randomly sample four groups
with 50,000 patients within each group from the entire
database. We use ICD-9-CM to select diabetes patients and
identify the primary-care-source provider as the one a patient
visit most often within a year. After the profiling process, there
are 5,384 and 5,267 patients, accounting for 0.56% and 0.55%
of total diabetes patients for 2001 and 2003 respectively from
all hospitals in Taiwan.
Principal Findings: After implementing the global budgets,
the treatment group where the hospital market becomes more
competitive one shows the higher weighted frequency of
procedures by 0.24, accounting for 8% of that for the control
group before implementing the global budgets. Furthermore,
after using multiple regression method to control other
relevant variables, the coefficient was positive but became
non-significant.
Conclusions: Under market mechanism, hospitals tend to
attract patients by conducting more procedures during each
visit under fee-for-services. However, global budgets give
hospitals incentive to control expenditures by decreasing the
intensity of services. Results indicate that hospital competition
appeared to offset the adverse effect from the implementation
of global budgets.
Implications for Policy, Delivery, or Practice: This study
attempts to show how cost containment policy could be
harmonized with market mechanism. The policy to facilitate
market mechanism, in conjunction with appropriate cost
containment strategies, may provide an avenue to improve
health care quality and decrease medical expenditures
simultaneously. However, future research is needed to
validate the findings from various aspects of health services
under different context of institutions in a longer study period.
Primary Funding Source: National Science Council, Taiwan
●Environmental and Organizational Determinants of
Hospital Subacute Care Service Diversification
Huabin Luo, Ph.D., Richard Shewchuk, Ph.D., Jeffrey
Burkhardt, Ph.D.
Presented By: Huabin Luo, Ph.D., Assistant Professor,
Management & Human Resources, Mount Olive College, 634
Henderson Street, Mount Olive, NC 28365;
Tel: (205) 261-8580; Email: hluo@moc.edu
Research Objective: Government mandated cost
containment measures, managed care reimbursement
capitation, and other factors provided a strong financial
incentive for hospitals to find alternatives to inpatient care.
However, the effects of managed care on hospital
diversification were largely unknown. We examined hospital
diversification into subactue care services in relation to unique
market and organizational determinant factors.
Study Design: A longitudinal study design was applied to
examine the trend of hospital subacute care service
diversification. The data for this study were obtained from
three sources: (1) AHA (hospital data); (2) Area Resource File
(ARF) (market data); and (3) InterStudy (HMO enrollments
data). To address the complexities involved in the
measurement of the outcome variable—the likelihood of
diversification, the amount of diversification, and the changes
over time, an integrated two-part model was specified. This
approach represents a methodological advance from
traditional Heckman model and two-part model in that it
combined the traditional two separate models into one
concurrently estimated model, and accommodated the three
well-known problems of the outcome variable: excessive zeros,
skewness, and correlated observations.
Population Studied: The study sample consisted of 2,506
general, acute care U.S. hospitals over a five-year period.
Principal Findings: The main findings indicated that
competitive institutional pressures (mimetic effects),
demographics (percentage of population age 65 years and
older in the market), and organizational characteristics (notfor-profit) had effects on the likelihood as well as on the
amount of subacute care service diversification. However, the
effects of HMO penetration on hospital diversification were
not observed.
Conclusions: Hospital subacute care service diversification is
influenced by competition and Medicare population in the
Health Service Area (HSA).
Implications for Policy, Delivery, or Practice: Traditional
models used to examine semi-continuous and other complex
outcome variables are really two separate models and do not
fully address the relationship that exists in the data. As a
consequence these models could introduce considerable
untoward consequences for strategic and policy decisions. The
integrated model developed in this study more realistically
accommodated the association between the likelihood as well
as the amount of subacute care service diversification, by
examining them simultaneously in the context of time-varying
and time-invariant covariates. The application of appropriate
analytical strategies that comprehensively address data
complexities often inherent in health service data should be
addressed.
Primary Funding Source: No Funding
●Leadership and Succession Planning in U.S. Hospitals
Ann Scheck McAlearney, Sc.D., M.S.
Presented By: Ann Scheck McAlearney, Sc.D., M.S., Assistant
Professor, Health Services Management and Policy, The Ohio
State University, 1841 Millikin Road, Cunz Hall, 4th Floor,
Columbus, OH 43210-1229; Tel: 614-292-0662; Fax: 614-4386859; Email: mcalearney.1@osu.edu
Research Objective: Despite considerable evidence
supporting the importance of succession planning and
leadership development to ensure that strong leaders are
prepared to guide healthcare organizations into the future,
little is known about whether and how healthcare
organizations and leaders focus on these planning and
development needs. Two nationwide research studies were
designed to improve our understanding of succession
planning and leadership development in health care, and
identify actionable opportunities for health care organizations
to pursue.
Study Design: Despite considerable evidence supporting the
importance of succession planning and leadership
development to ensure that strong leaders are prepared to
guide healthcare organizations into the future, little is known
about whether and how healthcare organizations and leaders
focus on these planning and development needs. Two
nationwide research studies were designed to improve our
understanding of succession planning and leadership
development in health care, and identify actionable
opportunities for health care organizations to pursue.
Population Studied: In the qualitative study, 200 key
informants were interviewed. Experts interviewed (n=40)
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=17.4 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: While a majority of study respondents
reported no current plans to leave their organizations (64%),
one out of ten respondents did note they were planning to
leave the organization within the next year, and another
quarter of the respondents indicated plans to leave within the
next 2-4 years. Considerable variability across organizations
showed limited use of formal succession planning programs,
and multiple opportunities for investment in leadership
development, depending on expectations with respect to
strategic organizational priorities. When asked to speculate
about future competencies that might be required of
healthcare executives, interview respondents focused on three
main areas: 1) focus on ethics and values, 2) comfort with
information technology language and capabilities, and 3)
cultural competence. Considering these predictions in the
context of transformational leadership theory, both the first
and third competency areas have linkages to visionary or
transformational leadership.
Conclusions: : In looking to the future, healthcare
organizations must take into consideration the high likelihood
of leadership changes, thus indicating a continual need for
succession planning and development. And with glaring
needs in the areas of inclusion and diversity, organizations
would do well to foster opportunities for persons of color and
women to reach the chief executive level. When they do, it will
be interesting to re-evaluate the relationships between
leadership styles and impact from these different perspectives.
Implications for Policy, Delivery, or Practice: Findings from
this study can help organizations as they attempt to assess,
build, and enhance their own succession planning and
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
●The On-Call Crisis: A Statewide Assessment of the Costs
of Providing On-Call Specialist Coverage
K. John McConnell, Ph.D., Nadia Arab, BA, Christopher F.
Richards, M.D., Craig D. Newgard, M.D., M.P.H., Tina D.
Edlund, M.P.H.
Presented By: K. John McConnell, Ph.D., Assistant Professor,
Emergency Medicine, Oregon Health & Science University,
3181 SW Sam Jackson Park Rd., Mail Code CR-114, Portland,
OR 97239; Tel: (503) 494-1989; Fax: (503) 494-4640;
Email: mcconnjo@ohsu.edu
Research Objective: A major and recent change in the
delivery of emergency care has been an increasing reluctance
of specialists to take emergency call. Despite anecdotal
evidence, there is a lack of data about how hospitals are
responding to these changes. The objective of this study was
to conduct a comprehensive statewide survey of hospitals to
provide evidence about the prevalence and magnitude of
stipends for taking emergency call, and to assess the ways in
which hospitals are limiting services.
Study Design: This was a cross-sectional, standardized survey
of CEOs from all hospitals with emergency departments in
Oregon (N = 56). This email-based survey asked about
payments made to specialists (including orthopedists, general
surgeons, trauma surgeons, neurosurgeons, hand surgeons,
obstetricians, and neurologists). The survey examined the
impact of on-call shortages on changes in hospitals’ trauma
designation and their ability to provide 24-7 coverage for
certain specialties.
Population Studied: Hospitals in Oregon with emergency
departments (N = 56).
Principal Findings: We received responses from 54 out of 56
hospitals, representing a 96% response rate (100% of trauma
centers). The two hospitals that did not respond were small
(<20 beds), rural hospitals. 23 of 54 (43%) Oregon hospitals
pay a stipend to at least one specialty, and 17 (31%) hospitals
guarantee pay for uninsured patients seen on call. Trauma
surgeons, neurosurgeons, and orthopedists were the
specialists most likely to receive stipends. Stipends ranged
from $300 per month to over $3000 per night, with a median
stipend of $1000 per night to take call. Trauma surgeons, for
example, are paid stipends at 7 of 54 (13%) hospitals, with a
mean payment of $1,106 per night (range: $100/night to
$2640/night). 7 of 54 (13%) hospitals have had their trauma
designation affected by on-call issues. 26 hospitals (48%)
have lost the ability to provide 24-7 coverage for at least one
specialty. Furthermore, smaller hospitals noted that they did
not use stipends but had resorted to overemploying some
specialists, using locum tenens contracts to maintain on-call
coverage, or simply dropping coverage for certain specialties.
Conclusions: On-call shortages are prevalent in Oregon and
affect hospital financing and delivery of services. In total, we
estimate that hospitals in Oregon provide approximately $13M
annually in stipends to specialists to maintain on-call
coverage. This figure does not include the guaranteed pay that
some hospitals offer for services provided to uninsured
patients, nor does it include other costs associated with
maintaining call coverage, such as locum tenens
arrangements or overemploying some specialists. As a result
of the challenge of maintaining call, many hospitals noted a
lack of 24/7 coverage for certain specialties and some
hospitals’ trauma designation has been affected.
Implications for Policy, Delivery, or Practice: The specialist
on-call shortage may degrade the effectiveness of the trauma
system and may adversely affect the quality of emergency care.
As a solution to this problem, hospitals in Oregon and
elsewhere in the country may soon make efforts to regionalize
on-call care for some specialties.
Primary Funding Source: No Funding
●Orchestrating Physician Choice of Costly Clinical Items
Kathleen Montgomery, Ph.D., Eugene Schneller, Ph.D.
Presented By: Kathleen Montgomery, Ph.D., Professor,
Management, University of California, Riverside, 238 Anderson
Hall, Riverside, CA 92521; Tel: (951) 827-7319; Fax: (951) 8273970; Email: kmont@ucr.edu
Research Objective: The supply environment represents a
promising, but understudied, arena for improving resource
utilization. This paper analyzes the strategies undertaken by
hospitals to shape physician behavior and counter supplier
power in purchasing costly physician preference items (e.g.,
cardiac and orthopedic implants). Traditionally, physicians
have determined which item to use for a particular patient
based on non-cost-related factors reflecting personal
preferences for particular products, as well as physician
relationships with manufacturers’ representatives. The wide
variation in physician preferences inhibits hospitals from
obtaining favorable pricing (e.g., manufacturers may charge
different hospitals between $3,000 to $10,000 for identical
items). We seek to understand how approaches to
standardization and related incentives, such as peer influence,
value analysis teams and gainsharing, contribute to aligning
physician choices with hospital cost reduction goals, while
preserving quality of care and patient safety.
Study Design: A qualitative case-study design was used to
generate interview data from clinical and managerial
representatives with first-hand information about the efforts in
their facility to achieve and/or improve standardization of
clinical preference items. Over two-dozen semi-structured
interviews were conducted in hospitals and corporate offices
within five different hospital systems. Interviews were also
conducted with several representatives of leading
manufacturers of clinical preference items, and interview data
were augmented with written documents, such as relevant
policies and guidelines developed by facilities. Qualitative
analytical procedures were employed to code and analyze the
interview and archival data.
Population Studied: The hospital systems were members of
a research consortium, the Center for Health Management
Research, which provides financial and logistical support for
research addressing organizational and managerial issues of
interest to consortium members.
Principal Findings: Findings indicate two broad models of
standardization: (1) standardization via price caps for
particular item categories (the “capitated” model), and (2)
standardization via limitations on range of manufacturers or
products (the “formulary” model). The capitated model, which
preserves more choice for physicians and restricts
manufacturers’ pricing flexibility, is gaining in favor and
receives greater support from physicians. The formulary
model requires more extensive product equivalency
assessments, a task that interviewees find burdensome,
complicated by inadequate product comparison data.
Hospitals instituting the position of clinical resource specialist
report greater physician participation in standardization.
Physician also value hospitals’ incentives of commitments to
improve clinical facilities, scheduling, and training. Managers
expressed interest in the potential of direct financial
gainsharing, but some report reluctance to embrace
gainsharing in the current unsettled legal environment.
Conclusions: Hospitals’ standardization efforts target the
balance of power between hospital leadership, physicians, and
manufacturers. Although hospitals have limited ability to
overrule physician decision autonomy, this study
demonstrates that hospitals can effectively reduce the power
held by manufacturers through price capitation, without
interfering to an unacceptable degree with physician choice.
Implications for Policy, Delivery, or Practice: The
relationship between manufacturers and clinicians has long
frustrated hospitals’ efforts to control supply costs. This study
reveals mechanisms hospitals can undertake to alter the
manufacturer-clinician relationship without compromising the
goals of quality of care and patient safety. It also provides a
framework for future research into the potential of gainsharing
incentives.
Primary Funding Source: Center for Health Management
Research
●Measuring the Impact of Environmental and
Organizational Changes on Nursing in Rural Hospitals:
Survey Development
Robin Newhouse, Ph.D.
Presented By: Robin Newhouse, Ph.D., Nurse Researcher/
Assistant Professor, Nursing Administration/ School of
Nursing, The Johns Hopkins Hospital/ University, 1863
Crownsville Rd, Annapolis, MD 21401; Tel: (410) 266-5417;
Fax: (410) 614-1115; Email: rnewhou1@jhmi.edu
Research Objective: The objective of this research was to: 1)
develop an instrument to identify how environmental and
organizational changes have affected nursing in rural hospitals
since 1995; and 2) explore the issues surrounding
implementation of evidence-based practice in rural hospitals.
Study Design: The designs used were qualitative with survey
development and pilot testing to obtain adequate
psychometric estimates. Taped interviews were conducted by
phone using open-ended questions. Survey items were
constructed based on content analysis of qualitative data.
Content validity was estimated by four expert judges. The
survey was then pilot tested with twenty rural nurse executives
who completed two phone interviews two weeks apart to
estimate test-retest reliability and internal consistency.
Population Studied: Ten rural hospital nurse executives
completed a taped phone interview. Twenty nurse executives
completed two phone interviews using the constructed survey.
Principal Findings: Content analysis of qualitative data
produced three domains: environment, organization and
nursing. Content validity of the draft instrument was judged
to be 1.0 by 4 experts after minor revisions. Items with
significant test-retest correlations at or above p=.10 and
acceptable item-total correlations were included in the final
survey. Cronbach’s alpha for each domain is as follows;
environment [legislative (a=.76) and isolation (a=.91)];
organizational [hospital environment (a=89), quality (a=.76),
and quality influences (a=.77)]; and nursing [nursing
influences (a=.87) and evidence-based practice (a=.83)]. The
resulting instrument consists of 102 questions.
Conclusions: The resulting survey has adequate estimates of
reliability and validity and items represent issues unique to
rural hospital experience.
Implications for Policy, Delivery, or Practice: Changes in
legislation have resulted in decreasing financial margins in
rural hospitals. The affect of these changes on the delivery of
nursing care is unknown. Nursing care is positively related to
favorable patient outcomes. The survey constructed in this
study will be used in subsequent research to measure the
impact of legislative and organizational changes on nursing
and patient outcomes in rural hospitals.
Primary Funding Source: Sigma Theta Tau International
●Impact of Hospital Structure and Leadership upon
Resource Use to Improve Nursing Vitality
Patricia Parkerton, Ph.D. M.P.H., Marjorie Pearson, Ph.D.
MSHS, Lynn Soban, Ph.D. M.P.H., Valda V. Upenieks, Ph.D.
RN, Jack Needleman, Ph.D.
Presented By: Patricia Parkerton, Ph.D. M.P.H., Assistant
Professor, Health Services, UCLA School of Public Health,
650 Charles Young Drive South, Los Angeles, CA 90095; Tel:
(310) 825-2926; Fax: (310) 825-3317; Email: parkert@ucla.edu
Research Objective: Concerns about the quality and safety of
hospital care have emphasized the need to reduce nursing
turnover and improve workplace environment. We assess the
readiness and processes undertaken to improve staff vitality
by hospitals participating in the pilot phase of the
Transforming Care at the Bedside initiative. TCAB is a
collaborative-based effort to support change, team processes,
and effective practices on medical/surgical units.
Study Design: An observational study of selected key
hospitals participating in the TCAB quality improvement
collaborative led by the Institute for Healthcare Improvement
(IHI) and funded by The Robert Wood Johnson Foundation.
This collaborative was a two year, complex intervention during
which support and training were provided by IHI and
hospitals committed significant resources. Both qualitative
and quantitative data on the hospital’s structure, change
processes, and improvement in nursing vitality were gathered
from a baseline survey, semi-structured on-site interviews with
150 hospital staff, monthly progress reports posted to the
collaborative extranet, and collaborative meeting observation.
Dichotomous measures of the hospitals’ structures and
change readiness were created for factors with hypothesized
impact. The interview data were used to create a
dichotomous variable for staff-reported improvement in
workplace vitality.
Population Studied: Thirteen geographically and
organizationally diverse hospitals, selected as innovators and
early adopters (based on criteria such as Magnet hospital
status and participation in other IHI collaboratives) chose to
join in this pilot phase, 2004-2006, of the TCAB initiative.
Principal Findings: Preliminary results for the first year of
collaborative participation show that staff reported an increase
in workplace vitality at 7 of the 13 hospitals. Of the 12 with
sufficient time and data completion, 6 reported improved
vitality. The striking variations among these hospitals did not
suggest influence of size, academic status, or membership in
a hospital system. Because there was a parallel leadership
collaborative, all hospitals had at least one senior leader with
prior IHI experience. It was the active participation by the
Chief Nursing officer (r = .845) that was most highly
associated with increased vitality. These same hospitals were
more likely to hold magnet status (r = .598). There are also
early indications of the contribution of an MD champion (r =
.354) and QI staff involvement (r = .354). March completion of
the collaborative will make quantitative relationships
clearer..The expressions of nurses, staff, and leaders lend a
richness to the interpretation of those associations.
Conclusions: Improved workplace vitality for nurses on
medical-surgical units is associated with active leadership
from the Chief Nursing Officer and prior efforts to achieve
Magnet status. Other structural variation was not significantly
associated with improved vitality during the first year.
Implications for Policy, Delivery, or Practice: Policy makers,
healthcare administrators, and quality improvement managers
interested in improving the effectiveness and stability of
hospital services should focus on processes and resources
that enhance the capacity of nurses and their teams to provide
evidence-based services.
Primary Funding Source: RWJF
●Quantifying IT Risk Management in Healthcare!
Ebrahim Randeree, M.B.A.
Presented By: Ebrahim Randeree, MBA, Ph.D. Candidate,
Management Science & Systems, University at Buffalo, 248
Jacobs Management Center, Buffalo, NY 14260; Tel: (716) 2077251; Fax: (716) 645-6117; Email: er4@buffalo.edu
Research Objective: Provides an introduction to information
assurance and knowledge concerns within the healthcare field.
The paper reviews barriers to the assessment of IT risk. A
model for risk assessment will be suggested with data and
measures. Finally, the focus will turn to critical issues for
research in the area of risk assessment for secure knowledge
management and information assurance within the healthcare
IT context.
Study Design: Theory Driven w/models of risk assessment
presented.
Population Studied: Hospitals
Principal Findings: Provides risk model for IT security lapses
Conclusions: Quantified information systems risk can be
achieved and incorporated into security and information
assurance models. The focus of healthcare organizations on
fiscal responsibility and financial stability has led to a path of
lowering debt and improving ROI. The tangible benefits of
risk mitigation can be measured in terms of attacks prevented
or redundant security measures that were needed if an
adverse event occurred. The complete assurance program
cannot be measured from a financial perspective. The
application of standard financial risk measures does not apply
to security.
Implications for Policy, Delivery, or Practice: Justifying IT
spending on new technology to secure the organization can be
easily captured in expenditure equations but the cost to
benefit ratio does not capture the potential savings from any
incurred expenses if an event is stopped. Measuring the
economic impact of intangible benefits is difficult at best and
impossible at worst.
Primary Funding Source: No Funding
●Creating a Culture of Security under HIPAA
Ebrahim Randeree, M.B.A.
Presented By: Ebrahim Randeree, MBA, Ph.D. Candidate,
Management Science & Systems, University at Buffalo, 248
Jacobs Management Center, Buffalo, NY 14260; Tel: (716) 2077251; Fax: (716) 645-6117; Email: er4@buffalo.edu
Research Objective: Security initiatives that are driven by
HIPAA and EMR implementation have altered the medical
landscape. With increased external and internal scrutiny,
compliance to organizational policies requires a
comprehensive approach to promote successful outcomes.
Beyond technological and policy initiatives, organizations
need to establish a "culture of security" built on trust. This
paper explores the influence of trust based mechanisms in
creating cultural shifts within organizations.
Study Design: Literature review with analysis of levels of trust
Population Studied: Hospital Employees
Principal Findings: Challenge lies with the individual success can be achieved through effective culture shifts
Conclusions: The culture of security must be reinforced by
management initiatives. Each level of trust must be explored
to create a shared responsibility for the organization.
Implications for Policy, Delivery, or Practice: Develops new
insights into the culture chnage through a focus on trust
relationships to improve compliance.
Primary Funding Source: No Funding
●An Analysis of the Characteristics of Health Centers
facing Financial Deficits
Dylan Roby, Ph.D.
Presented By: Dylan Roby, Ph.D., Senior Research Associate,
Center for Health Policy Research, UCLA, 10911 Weyburn Ave,
Suite 300, Los Angeles, CA 90024; Tel: 310-794-3953; Fax: 310794-2686; Email: droby@ucla.edu
Research Objective: Health Centers are invariably at risk of
financial failure, and must patch together funding from a
variety of sources in order to care for their largely uninsured
and underserved patient population. This study examines the
determinants of financial deficits in health centers, and how
they could affect operations and provision of patient care.
Study Design: Several multivariate strategies were used to
study the relationship of deficits with health center
characteristics and state/local environmental factors. The
Uniform Data System (UDS) was used to conduct logistic and
linear regressions using a pooled five-year (1998-2002)
dataset, along with a cross-sectional time series linear
regression model on the non-pooled panel dataset for the
same years.
Population Studied: Federally Funded Community and
Migrant Health Centers in operation from 1998 to 2002.
Principal Findings: The analyses indicate that factors
associated with financial deficits are patient income, higher
proportions of privately insured and Medicare users, lack of
migrant users, location in the eastern U.S., provision of dental
services, and low county unemployment.
Conclusions: These factors should be carefully monitored by
health center boards, executives, program officers in the
Bureau of Primary Health Care, federal, state, and local
policymakers, and advocates in the National Association of
Community Health Centers and state Primary Care
Associations.
Implications for Policy, Delivery, or Practice: Improved
monitoring efforts are likely to help health centers avoid
financial problems and deal with them successfully through
technical assistance, loans, and supplemental grants from
state, local, and federal agencies. These monitoring efforts will
be helpful in managing health center expansions, and dealing
with future policy issues around Medicaid payment and
benefits and the Medicare FQHC upper payment limit (UPL).
Primary Funding Source: No Funding
●International and U.S. Experiences of Health Technology
Assessment of Pharmaceuticals: Implications for the U.S.
Health Care Sector
Rosa Rodriguez-Monguio, Ph.D., Enrique Seoane-Vazquez,
Ph.D.
Presented By: Rosa Rodriguez-Monguio, Ph.D., Clinical
Assistant Professor, School of Public Health and Center for
HOPES, Ohio State University, A333 Starling-Loving Hall. 320
West 10th Avenue, Columbus, OH 43210; Tel: (614) 247-4245;
Fax: (614) 293-5412; Email: rmonguio@sph.osu.edu
Research Objective: To compare the experiences of the
Australia, Canada, Denmark, Sweden, and the UK related to
health technology assessment (HTA) of pharmaceuticals for
formulary and reimbursement decision making with the US
experiences of the Department of Defense (DoD), managed
care organizations in the framework of the Academy of
Managed Care Pharmacy (AMCP) format, the PBM Medco,
and the Massachusetts Medicaid/University of Massachusetts
system.
Study Design: The information was collected from Medline
and web pages of the organizations using a structured
questionnaire developed by the authors that included the
following issues: structure and role of the organization, HTA
process, participation of pharmaceutical companies and the
society in the process, use of guidelines, and utilization of the
assessment in formulary and reimbursement decision making.
Population Studied: U.S. and 5 OECD countries.
Principal Findings: Organizations outside of the U.S. have
certain degree of independence in the development of their
functions, and report to the Ministry of Health (Australia,
Denmark, Sweden) or to central and regional governments
(Canada, UK). U.S. organizations combine HTA and
management of the pharmacy benefits functions.
International organizations assess public reimbursement of
drugs and promote rational use of drugs. Organizations in
Australia, Denmark and Sweden also assess drug pricing. U.S.
organizations decide about inclusion of drugs in formularies
and reimbursement of drugs. Guidelines for economic
evaluation are published by international organizations and by
the AMCP. Outside of the U.S., sponsor companies may
initiate the HTA, with the exception of UK where the decision
is responsibility of the ministries of health. In the U.S. the
HTA is initiated by the organization. Societal participation
(e.g. patients, health professionals) is required in all
experiences outside of the U.S. Outside of the U.S. internal or
external consultants collect relevant clinical and economic
information. In the U.S. the collection of information is an
internal activity. A scientific committee (outside of the U.S.)
or a pharmacy and therapeutics committee (in the U.S.) is
appointed to evaluate the available evidence and elaborate a
report with an appraisal and recommendations. Outside of
the U.S. the organization executive body (board, director)
reviews the report elaborated by the scientific committee,
consults the interested parties and proposes a final
reimbursement and/or pricing recommendation to the
government(agency, ministry, cabinet). In the U.S. the
organism that conducts the HTA also has the responsability
for the final decision, with the exception of the PBM business
where payers have a limited participation in that final decision.
Conclusions: The analysis shows a variety of organizations,
objectives, roles, procedures and decision making processes
related with formulary decision making and reimbursement of
pharmaceuticals. While the 5 countries included in the study
established a national HTA organization, the U.S. has a variety
of organizations and experiences.
Implications for Policy, Delivery, or Practice: The U.S.
should consider the implementation of a national HTA
organization for pharmaceuticals and other health care
technologies. This national organization would generate a
transparent system for HTA and would also promote rational
use of drugs and health technologies in the public and private
financed health care sectors.
Primary Funding Source: Other Goverment
●Estimating Hospital Efficiency for Performing Bariatric
Surgery
Nilay Shah, Ph.D., Ritesh Banerjee, Ph.D.
Presented By: Nilay Shah, Ph.D., Associate Consultant,
Health Sciences Research, Mayo Clinic, 200 First St. SW,
Rochester, MN 55905; Tel: (507) 266-5130; Fax: (507) 284-1731;
Email: shah.nilay@mayo.edu
Research Objective: There has been a significant increase in
the number of individuals receiving surgical treatment, also
known as bariatric surgery, for the treatment of obesity.
Bariatric surgeries grew by more than 400 percent and
bariatric surgery centers increased by over 140 percent
between 1998 and 2002. Further, total hospitalization costs
for bariatric surgery increased by six-fold between 1998 and
2002. The objective of this paper is to estimate the efficiency
of hospitals for performing bariatric surgery in the United
States.
Study Design: We use a stochastic frontier cost function to
derive hospital-specific measures of inefficiency. The cost
function accounts for patient demographic characteristics,
severity, and outcomes. Patient severity is measured using All
Patient Refined- Diagnosis Related Groups (APR-DRGs). We
also estimate the level of hospital inefficiency by hospital
characteristics such as teaching status, ownership, and
location using separate cost frontiers. Models are estimated
using data from the 2003 National Inpatient Sample (NIS).
Population Studied: All patients with an ICD-9 procedure
code (44.31 or 44.93) for bariatric surgery are included in the
analysis.
Principal Findings: There were 202 hospitals that performed
at least 1 bariatric surgery totaling more than 17,000 surgeries.
Approximately 25 percent of the hospitals performed less than
10 procedures and 55 percent of the hospitals performed less
than 50 procedures. We find that inefficiency accounts for
20.4 percent of total hospital costs. This estimate was robust
to alternative model specifications. We also find that teaching
hospitals are more inefficient compared to non-teaching
hospitals and for profit hospitals are more efficient compared
to not-for-profit hospitals. We do not find much difference in
efficiency between the high volume (> 50 procedures) and low
volume (<=50 procedures).
Conclusions: We find that there are large inefficiencies in
performing bariatric surgeries. We also find that non-teaching
hospital and for-profit hospitals are more efficient in
performing bariatric surgeries. Surprisingly, the volume of
surgeries performed at an institution does not seem to affect
the efficiency.
Implications for Policy, Delivery, or Practice: Hospital
administrators may want to study the factors that may
increase the efficiency of performing bariatric surgery, while
payers may want to evaluate other institutional factors besides
procedure volume when contracting for bariatric surgery.
Primary Funding Source: No Funding
●Estimating the Unit Cost Function and Unit Costs of
Medicare Hospital Outpatient Services
Daniel Shostak, M.P.H., M.P.P.
Presented By: Daniel Shostak, M.P.H., M.P.P., Consultant,
2445 Lyttonsville Road, #1505, Silver Spring, MD 20910; Tel:
(301) 758-2106; Email: danielshos@aol.com
Research Objective: The study specified and explored the
unit cost function and unit costs of Medicare hospital
outpatient services. Building upon data used by The Centers
for Medicare and Medicaid Services (CMS), the study
examined what facility characteristics affect outpatient unit
costs and the nature of the observed changes (e.g., economies
of scale, economies of scope, etc.). Section 411 of the
Medicare Modernization Act instructed the Secretary of
Health and Human Services to conduct a study to determine
if rural hospital outpatient costs exceed urban hospital
outpatient costs. The Act authorized the Secretary to provide
an appropriate adjustment to rural hospitals beginning 1
January 2006 if the research determined that rural facilities
had greater costs. The Centers for Medicare and Medicaid
Services (CMS) conducted and published for comment the
authorized research in the Hospital Outpatient Prospective
Payment System (OPPS) Notice of Proposed Rule Making (70
Federal Register 42698-42701, 25 July 2005). After reviewing
comments, CMS finalized a 7.1 percent payment adjustment
for rural Sole Community Hospitals (70 Federal Register
68557-68561, 10 November 2005).
Study Design: This study examined linear regression results
of a specified unit cost function for Medicare hospital
outpatient service. In keeping with the CMS approach, the
regression equation model was specified in double logarithm
form. Unit outpatient costs were regressed against
independent variables including: Beds, hospital specialty
status, local wage index, outpatient volume, rural/urban
status, service-mix index, and Sole Community Hospital
status. The independent variables were obtained from CMS
and reflect the Agency's designations.
Population Studied: General and specialty hospitals receiving
Medicare payments in 2004.
Principal Findings: 1. The CMS studies are replicable with
publicly available data; 2. The CMS data can be used to
examine a unit cost function and unit costs for Medicare
outpatient services; 3. The specified model provides an
acceptable level of explanatory power with an adjusted RSquare of approximately 0.50. 4. Statistically significant (pvalue <.10) regression coefficients were estimated for local
wage index, service-mix index, outpatient volume, beds,
rural/urban status, hospital specialty status, and Sole
Community Hospital status. 5. A statistically significant
negative coefficient for outpatient volume implies that
economies of scale may be present within outpatient services
of hospitals.
Conclusions: CMS researchers have performed a valuable
service in preparing data and analyses about the unit costs of
Medicare outpatient services. Though limited to a narrow
legislatively mandated research question, their work makes an
important contribution to the ongoing discussion about
specifying and understanding both outpatient cost functions
and unit costs. Building upon their work, this research reveals
an statistically acceptable cost-function and that several
hospital characteristics have statistically observable influence
over Medicare outpatient unit costs.
Implications for Policy, Delivery, or Practice: The Medicare
Hospital Outpatient Prospective Payment System (OPPS)
seeks to provide payment equity by adjusting service
payments to several unique characteristics of facilities. This
goal requires ongoing examination of two policy relevant
questions. First, what characteristics affect outpatient unit
costs? Second, how should these results be translated into
payment policy. This study reports that a number of facility
characteristics affect unit costs. Furthermore, several of these
characteristics currently are not incorporated directly in
payment policy including beds, outpatient volume, and service
mix. This study proposes that incorporating additional facility
characteristics may improve payment equity in the OPPS.
Primary Funding Source: No Funding
●Administrative Delay And Secondary Disability Following
Patricia Sinnott, PT, Ph.D., M.P.H.
Presented By: Patricia Sinnott, PT, Ph.D., M.P.H., Health
Economist, Health Economics Resource Center (HERC), VA
Palo Alto Health Care System, 795 Willow Road 152 MPD,
Menlo Park, CA 94116; Tel: 650-493-5000 x23955;
Fax: 650-617-2639; Email: patricia.sinnott@va.gov
Research Objective: Occupational low back injury is a
pervasive disorder and extensive research has failed to explain
a wide variation in outcomes. The objective of this study was
to identify whether a component of the administrative system
not studied before, the practice of delaying claim acceptance,
had a significant influence on injured worker disability.
Study Design: Logistic regression predicted the influence of
administrative delays to claim acceptance on whether a case
would become chronic (took more than 91 days of temporary
disability) controlling for individual, economic, diagnostic
severity and physician experience variables.
Population Studied: The data are 1993 – 2000 claim files
provided by the California Workers’ Compensation Institute,
and estimated to include approximately 50% of all claims for
low back injury filed in California during that period. Cases
with at least one day of temporary disability paid were selected
for the analysis (N=32,584).
Principal Findings: Those cases with delays greater than 14
days experienced increasing risk of becoming chronic with
each two week interval that passed, the largest increase
occurring between two and four weeks. At 14 days after the
injury, compared to the least severe cases, the moderately
severe cases had more than double the probability of
becoming chronic and the most severe cases had almost
triple the probability of becoming chronic.
Conclusions: Delays in claim acceptance for injured workers
are associated with increased probabilities of an individual
developing a chronic problem, that is, taking more than 91
days of temporary disability off work. Longer delays are
associated with increasing probabilities of becoming chronic.
The influence of administrative delays on claim acceptance
has not been previously studied in either the workers'
compensation or health care fields.
Implications for Policy, Delivery, or Practice: These results
suggest that administrative organization and efficiency (or the
lack thereof)can have an important influence on the outcome
of care for individuals who suffer from musculoskeletal
illnesses or injuries. These findings also suggest that
efficiency in employer and insurer claim management practice
can contribute to better outcomes for their employees and
insureds.
Primary Funding Source: VA
●It Was the Best of Times, It Was the Worst of Times: A
Tale of Two Years in Not-for-Profit Hospital Investments
Paula Song, M.H.S.A., MAE, Dean G. Smith, Ph.D, John R.C.
Wheeler, Ph.D.
Presented By: Paula Song, MHSA, MAE, Doctoral Student,
Department of Health Management and Policy, University of
Michigan, 555 S. Forest Street, Ann Arbor, MI 48105; Tel:
7346479604; Fax: 7349986341; Email: phsong@umich.edu
Research Objective: As reimbursement rates and profit
margins from patient services decline, investment income is
becoming an increasingly important source of funds for notfor-profit (NFP) hospitals. Surprisingly, little is known about
how much investment reserves represent and how they are
handled among NFP hospitals. The purpose of this research
is to evaluate investment strategies in financial assets among
NFP hospitals. Specifically, this paper seeks to explore how
NFP hospitals allocate and manage financial assets, how
much risk hospitals employ in their investment strategies, and
evaluate the risk and return tradeoff under contrasting market
conditions.
Study Design: Senior financial officers from health care
institutions were surveyed via telephone as part of the
Commonfund Benchmark of Health Care Institutions annual
survey. Using two years of survey data for fiscal years 2002 &
2003, we analyze NFP hospitals’ investment strategies by
comparing asset size, investment management
characteristics, board characteristics, asset allocation, levels of
risk (measured by percent allocated equities), and annual
returns. Univariate regression analysis is utilized to evaluate
the relationship between risk and return.
Population Studied: Not-for-profit hospitals and health
systems with minimum long-term investment funds of $50
million.
Principal Findings: NFP hospitals have sizeable long-term
financial assets averaging over $558 million in 2002 and $634
million in 2003. Two-thirds of these funds are invested in
long-term operating funds, followed by defined benefit
pension funds and insurance reserves; management of these
funds is primarily outsourced. NFP hospitals allocate, on
average, 50 percent of their operating assets to equities.
Under favorable market conditions, an increased exposure to
risk results in an upward sloping relationship with returns,
consistent with investment theory predictions. Under weaker
market conditions, this relationship breaks down and we
observe a negative, significant relationship between increased
risk and returns. NFP hospitals that have high risk exposure
report significantly higher annual returns than hospitals with
low risk investment strategies, but experience far less stability
around these returns.
Conclusions: NFP hospitals hold substantial levels of
financial assets. NFP hospitals are increasing allocations to
equity and taking on more risk. NFP hospitals that do take on
more risk have magnified returns, both positively and
negatively, but more is needed to better understand what
drives NFP hospitals’ acceptance for risk. NFP hospitals with
heavy reliance on investment income to provide a financial
cushion or boost total profit margins will be sensitive to
fluctuations in investment performance.
Implications for Policy, Delivery, or Practice: Fluctuations in
investment performance may influence the provision of
certain services, e.g. charity care, or capital investment
decisions. Additionally, investment performance can distort
the perceived financial health of hospitals, potentially
impacting reimbursement rates or pricing strategies. NFP
hospitals’ tax-exempt status and access to low-cost debt
facilitates the accumulation of investment reserves; therefore,
policy may play an increasing role in ensuring that hospitals
are good stewards of investment funds. As investment activity
continues to increase among NFP hospitals, understanding
how hospitals invest, the risk and rewards associated with
different investment strategies is important in ensuring that
NFP hospitals make sound investment choices.
Primary Funding Source: No Funding
●Organizational Characteristics and Preventive Services
Delivery: A Qualitative Investigation
Joseph Sudano, Ph.D., Marisa Abbe, MA, Catherine Demko,
Ph.D., Kristin Victoroff, DDS, James Lalumandier, DDS,
Steven Wotman, DDS
Presented By: Joseph Sudano, Ph.D., Assistant Professor,
Medicine, Case Western Reserve University, Rammelkamp
236a, 2500 MetroHealth Drive, Cleveland, OH 44109; Tel:
(216) 778-1399; Fax: (216) 778-3945;
Email: jsudano@metrohealth.org
Research Objective: To investigate whether various
organizational characteristics and other potentially mutable
factors are associated with different levels of preventive
services delivery (PSD) in dental offices using qualitative
methods and data.
Study Design: As part of the Direct Observation Study,
trained research-hygienists visited dental practices for a period
of 4 days. Over the course of the site visit, researchers directly
observed 20-50 patient encounters with the dentist, hygienist,
or both. Survey and qualitative data (field jottings, debriefing
session notes) were collected regarding practice environment,
staff relations, and provider-patient interactions.
PSD included a set of a priori determined practitioner
behaviors, including hygiene instruction/education, oral
cancer screening, and smoking and nutrition counseling.
Using grounded-theory, we identified practices at the extremes
of high and low PSD, based on cumulative positive or negative
statements in the qualitative data. We also validated our
categorizations based on quantitative data collected while
observing 24 behavior-specific codes during the dental
encounter. We then employed purposive sampling to include
practices that varied on dentist sex, practice location (urban,
suburban/small city and rural), and those that were both high
and low on PSD. Our theoretical orientation stems from a
synthesis of several organizational behavior theories, including
contingency, complexity, and ecological theory. Using these
theories, we generated a list of characteristics hypothesized to
influence PSD levels. These included: dentist sex, practice
location, use of technology, social capital (staff relationships),
specialization (division of labor), formalization (production
goals, policies and procedures), management orientation
(lateral, hierarchical, authoritarian), number of staff, and
patient population (SES and insurance status). We generated
a comparative matrix of factors and PSD categories and
analyzed data from 40 practices, 20 categorized as high PSD
and 20 low PSD, and then identified groups of factors
associated with high PSD. Finally, we searched for
“counterfactual” examples of practices where any of the
identified salutary patterns of factors or individual factors were
not present.
Population Studied: 120 dental practices, part of a practicebased dental network in Northern Ohio.
Principal Findings: Several factors were associated with those
practices categorized as high on PSD. High PSD practices
were more likely to exhibit high social capital (good staff
relationships) and to have lateral or hierarchical management
orientations. Most frequently however, among the factors we
investigated, one clear pattern emerged that distinguish
between high and low practices. High PSD practices had the
presence of one or more clinical staff members functioning in
the role of PSD "champion." The champion not only believed
in the benefits of prevention but promoted it among patients
and staff alike. This role is further detailed in several case
studies and exemplar statements from the qualitative data.
Conclusions: Having staff members that are leaders in PSD is
a ubiquitous component in our findings.
Implications for Policy, Delivery, or Practice: These findings
have practical implications for dental education and practice
patterns. Future research regarding interventions to increase
PSD may benefit specifically from a human capital orientation
in primary and continuing educational programs, focusing on
personality characteristics, management philosophy and
provider beliefs about PSD.
Primary Funding Source: NIH/NIDCR
●Dynamics and Causes of Medical Imaging’s
Extraordinarily Rapid Growth
Jonathan Sunshine, Ph.D., Cristian Meghea, Ph.D., Mythreyi
Bhargavan, Ph.D.
Presented By: Jonathan Sunshine, Ph.D., Senior Director for
Research, Research, American College of Radiology, 1891
Preston White Drive, Reston, VA 20191; Tel: 703-648-8924;
Email: jsunshine@acr.org
Research Objective: Health costs are again growing rapidly,
and MedPAC has identified medical imaging as one of the
most rapidly growing components within the total. We
present a detailed portrait of medical imaging’s growth,
analyzing the growth in ways that help identify its causes and
possible remedies.
Study Design: We analyze 1986 to 2004 data from Medicare’s
Physician-Supplier Procedure Summary (PSPS, formerly
BMAD) file, measuring imaging in physician work relative
value units (PWRVUs), a metric not distorted by shifts in
settings or changes in payment rates. Medicare constitutes
about 1/3 of U.S. imaging services, has a consistent data set
and a stable population, and presumably is broadly
representative of all U.S. imaging.
Population Studied: All fee-for-service Medicare beneficiaries.
Principal Findings: Imaging per beneficiary increased by
more than 200%, from 0.9 PWRVUs in 1986 to 3.0 in 2004,
compared to an approximately 10% increase that would be
expected from the aging of the Medicare population. The
pace of increase was fairly steady throughout the 18-year
period. Per beneficiary imaging by cardiologist increased by
1650%, increasing from 5% of total imaging in 1986 to 26% in
2004. Per beneficiary imaging by radiologists increased by
150%, falling from 78% to 60% of total imaging. Per
beneficiary imaging by all others increased by 170%, falling
from 17% to 14% of total imaging. Cardiac imaging increased
from 8% of total imaging to 28%. Despite Medicare’s 1998
addition of coverage for screening mammography,
mammography increased only from 4% to 5% of total
imaging. Other X-ray imaging decreased from 41% to 15% of
total imaging. Higher-tech, non-cardiac imaging remained
fairly constant at 47-51%. Within cardiac imaging, all three
major forms (coronary angiography, echocardiography, and
cardiac nuclear medicine) increased by at least 500% per
beneficiary. All three are now performed dominantly by
cardiologists. Cardiac nuclear medicine was initially
performed 67% by radiologists and 13% by cardiologists, but
cardiologists increased their per-beneficiary volume by over
5000% and now provide 66% of this imaging.
Conclusions: Cardiac imaging in particular, not high-tech
imaging in general, had the highest growth rate, with all three
of its major components showing extraordinary growth.
Growth in the imaging performed by cardiologists closely
paralleled the growth in imaging of the heart. Imaging—
including that performed by radiologists—is almost always
ordered by the treating physician. Thus, our aggregate timeseries findings on percentage shares of imaging and on
growth rates support the cross-sectional, individual-physicianlevel literature that finds non-radiologists who do their own
imaging (“self-referrers”)—and hence obtain the revenues
from imaging—order 2-4 times as much imaging as
colleagues in the same specialty seeing patients with the same
problems, but who send their patients to radiologists for
imaging.
Implications for Policy, Delivery, or Practice: Payers need to
find ways—possibly through utilization review or changes in
financial incentives—to counter the financial incentives of selfreferral. Appropriateness criteria for diagnostic tests (unlike
the general situation for treatment) need to address not
merely the appropriateness of individual imaging procedures,
but also, when multiple procedures are each, individually,
appropriate, how many and what combination of procedures
constitutes good care.
Primary Funding Source: No Funding
●A Comparison of Magnet and Non-Magnet Hospitals on
Better Quality Measures:Heart Attack, Heart Failure, and
Pneumonia Adult Patients
Teresa Tai, Ph.D.
Presented By: Teresa Tai, Ph.D., Associate Professor,
Management, Quinnipiac University, 275 Mount Carmel
Avenue, Hamden, CT 06518; Tel: (203)582-8279; Fax:
(203)582-8664; Email: teresa.tai@quinnipiac.edu
Research Objective: The purpose of this study was to
examine whether “magnet hospitals” known to be good places
to practice nursing continue to provide better quality care to
patients with heart attack, heart failure, and pneumonia than
non-magnet hospitals. This study presents a unique
opportunity to investigate the effects of excellence nursing
services on quality of care in a large case-control analysis.
Study Design: Case-control study
Population Studied: To compare the quality of care provided
to patients with heart attack, heart failure, and pneumonia by
magnet status, a case-control study was conducted in the fall
of 2005. Magnet hospitals were identified from the American
Nursing Credentialing Center web site. All hospitals in United
States that received magnet designation as of September 8,
2005 are eligible for inclusion in this study (n=154). Children’s,
cancer, surgical, and rehabilitation hospitals were excluded
from this study because they did not provide heart attack,
heart failure, and pneumonia care to adult patients. The final
study group consisted of 133 magnet hospitals across the
country. The control group consists of 266 general medical
and surgical hospitals that did not received a magnet
designation as of September 8, 2005. Using the US News
Directory of America’s Hospital website, two control nonmagnet hospitals were matched by the nearest driving
distance from each magnet hospital. Matching magnet
hospitals with non-magnet hospitals with comparable
geographic, economic and demographics characteristics helps
control confounding bias in case-control study. Next, 18
hospital quality performance measures – 8 heart attack, 4
heart failure, and 6 pneumonia care quality indicators – were
obtained for each magnet and non-magnet hospital from the
CMS’s Hospital Compare website.
Principal Findings: Heart Attack: Magnet hospitals
outperformed non-magnet hospitals in five of the eight heart
attack quality measures. Magnet hospitals were significantly
more likely to give heart attack patients aspirin at arrival,
aspirin at discharge, Beta Blocker at arrival, Beta Blocker at
discharge, and adult smoking cessation advice/counseling
than non-magnet hospitals. Heart Failure: Two of the four
heart failure quality measures were statistically significant.
Magnet hospitals were significantly more likely to give heart
failure patients assessment of left ventricular function and
adult smoking cessation/counseling than non-magnet
hospitals. Pneumonia: Only one of the six pneumonia quality
measures was statistically significant. Magnet hospitals were
significantly more likely to give pneumonia patients
oxygenation assessment than non-magnet hospitals.
Conclusions: Consistent with prior research, magnet
hospitals continue to provide better care to patients when
compared with non-magnet hospitals.
Implications for Policy, Delivery, or Practice: Magnet
hospital as an employer of choice model was long known to
be a long term solution to the recruitment and retention of
high qualified nurses. Magnet program is still attractive after
all these years because it uses team- and culture-building, high
degree of nurse autonomy, participative management, good
communications with physicians, strong and visible nursing
leadership, and strong board commitment for measurably
improved patient care, rather than rely on quick fixes such as
wages, sign on bonus, and agency workers to solve nursing
shortages. In an environment common with controversy
about patient safety in hospitals, medical error rates, and
nursing shortages, consumers need to know how good the
care is at their local hospitals. It can also regain public trust in
quality patient care. Considerable research has examined the
benefits of magnet program. Yet no research has examined
the variations of quality performance by magnet designation
or not. This study explained the variations and reaffirmed the
long-term competitive advantage of a magnet status.
Primary Funding Source: No Funding
●An Organizational Model of Transformational Change in
Health Care Systems
Carol VanDeusen Lukas, Ed.D., Sally K. Holmes, M.B.A., Alan
B. Cohen, Sc.D., Martin P. Charns, DBA, Irene E. Cramer,
Ph.D., Michael Shwartz, Ph.D., Joseph Restuccia, Dr.P.H.,
Ph.D.
Presented By: Carol VanDeusen Lukas, Ed.D., Investigator,
Center for Organization, Leadership and Management
Research, VA Boston Healthcare System, 150 S Huntington
Avenue (152M), Boston, MA 02130; Tel: 857-364-5685; Fax: 857364-4438; Email: Carol.VanDeusenLukas@med.va.gov
Research Objective: In 2001, the Robert Wood Johnson
Foundation (RWJF) responded to IOM reports of
unacceptable deficiencies in health system performance by
creating a major new initiative, the Pursuing Perfection (P2)
Program. Through P2, RWJF provided grant funding to seven
healthcare systems to pursue perfect care. P2 goals included
achieving dramatic improvement in patient care quality
through system redesign and organizational transformation.
The research reported here is based on the RWJF-funded
national evaluation of the P2 program. One of the major
goals of the evaluation was to identify the key elements that
move healthcare organizations toward their goal of
transforming patient care quality.
Study Design: A multi-disciplinary study team conducted
comparative case studies in seven P2 healthcare systems and
five comparison healthcare systems over 3.5 years. Using a
mixed-methods evaluation design, the primary data sources
were: 1) extensive qualitative interviews with leadership,
employees and affiliated medical staff of participating
organizations (n>1000 interviews, visiting each organization
up to 7 times); 2) a survey of employee attitudes and
perceptions in eight of the participating organization (n =
2470, response rate = 36%); and 3) document review of
planning materials and organization performance measures.
Population Studied: The evaluation includes 12 healthcare
systems: the seven systems that received RWJF P2 grant
funding; and five systems that serve as comparison sites to
provide a basis for distinguishing the effects of P2
participation from trends in the healthcare environment. The
comparison systems included two sites that received P2 initial
planning grants but were not selected for implementation
funding; and three systems recognized through public ratings
and professional networks as high-performing organizations
with reputations for a focus on providing quality care. The 12
systems include single hospitals, multi-hospital systems,
integrated delivery systems and health plans in all regions of
the United States. In each system, interviews were conducted
with the organization's leadership, staff involved in
transformation activities, and frontline clinical staff. The
survey was administered to a sample of staff at all
organizational levels (clinical and non-clinical) as well as
affiliated physicians.
Principal Findings: From interviews, survey findings and
document review, we identified five elements critical to
organizations’ achieving sustained improvements in providing
mission-driven, high quality, patient-centered care. The five
critical elements include: 1) an impetus to transform that
creates a sense of urgency; 2) leadership commitment to
quality and change; 3) improvement projects that involve
multi-disciplinary front-line teams in meaningful problem
solving; 4) structures and processes to facilitate alignment of
improvement with organizational priorities and strategy
throughout the organization; and 5) structures and processes
to facilitate interconnectedness across organizational
boundaries. Underlying and bringing these elements together
are two premises. First, creating organizational infrastructure
to support perfect care requires substantial organizational
change. Second, substantial systemic change or
transformation requires an interaction of the key elements to
reflect an organization with clear strategic direction and
support from organization leaders, front-line staff activity and
involvement in change and management support to link the
two in the organizational fabric. These features, identified
initially through analysis of qualitative interview data, were
congruent with subsequent survey results.
Conclusions: Healthcare organizations have utilized quality
improvement tools and techniques for many years, but often
these efforts are limited in scope and impact. For example, an
organizational focus on a particular disease or process may
yield limited but not sustained results. Organizational
transformation requires that improvements are sustained,
spread throughout the organization and made integral to
everyday work. Based on research findings from highperforming organizations, the critical elements identified in
the P2 evaluation suggest multiple organizational dimensions
required to undertake and support transformational change.
The critical elements are illustrated with examples of best
practices as well as barriers and challenges encountered
among study organizations.
Implications for Policy, Delivery, or Practice: The model
suggested by the critical elements informs healthcare
managers about supports and structures to be considered in
launching transformational improvement efforts. For
example, a version of the proposed model is currently being
tested by medical centers in the Department of Veterans
Affairs to create organizations that facilitate the use of
evidence-based clinical guidelines and thus reduce the gap
between research and clinical practice.
Primary Funding Source: Robert Wood Johnson Foundation
●The Determinants of Out-sourcing Strategy: Evidence
from Hemodialysis Centers in Taiwan
Shu-Chuan Jennifer Yeh, Ph.D., Chiu-Yueh Tsai, M.B.A., FangTse Chen, M.B.A., Hsiao-Tang Hsu, BA
Presented By: Shu-Chuan Jennifer Yeh, Ph.D., Associate
Professor, Institute of Health Care Management, National Sun
Yat-sen University, 70 Lian Hai Road, Kaohsiung, 80424; Tel:
886-7-5252000 x4874; Fax: 886-7-5251511;
Email: syeh@cm.nsysu.edu.tw
Research Objective: Healthcare organizations are facing
tremendous pressure from economic constraints. With the
pressures, healthcare organizations are searching for ways to
reduce costs and improve financial feasibility. A common
strategy is to seek support from the open market and
outsource. The purposes of this study were to examine the
most frequent out-souring items among hemodialysis centers
as well as to investigate the determinants of making the outsourcing decision.
Study Design: This is a cross-sectional and survey research
with individual hemodialysis center as the unit of analysis. The
structured survey questionnaire included the organizational
characteristics, items of outsourcing and the factors of making
decision to outsource. Both descriptive analysis and logistic
regression were used to analyze the data.
Population Studied: 103 chief executive officers of
hemodialysis centers that have or not have outsourcing their
business functions.
Principal Findings: Sixty-two hemodialysis centers (60.2%)
are currently involved the activities of outsourcing. The mean
dialysis beds are 25.22 beds with standard deviation 11.54.
Around 53% are freestanding, while 47% are hospital based.
The results indicate that the top five of frequent out-sourcing
items are maintenance for medical equipment, medical waste
disposal, tax filing and accounting, legal consulting, and
cleaning & laundry, respectively. The statistically significant
determinants of out-sourcing strategy include reducing costs
of medical supplies (ß=.995, p-value=.09; Odds Ratio (OR) =
2.71, 95% confidence interval (95% CI) =1.28-5.71); assisting
on supporting business (handling medical waste disposal &
cleaning & laundry) (ß=.757, p-value=.02; OR = 2.13, 95% CI
=1.12-4.04); health insurance claim issue (ß=.904, p-value=.01;
OR = 2.47, 95% CI =1.24-4.93); assisting on maintenance
(including electronic, water, air conditioning, computer
software) (ß=1.162, p-value=.01; OR = 3.19, 95% CI =1.32-7.74).
Conclusions: The management problems were impetus in
outsourcing. The process led to reduce costs, downsizing, and
changes to work practices. Similarly, the use of outsourcing
solves industrial relations issues and takes up higher rates of
reimbursement which produce financial benefit for
hemodialysis centers. Both the political and economic nature
influences the decision making of outsourcing.
Implications for Policy, Delivery, or Practice: Managerial
decision making can be enhanced with the exploration of the
full complement of reasons for the outsourcing decision.
Primary Funding Source: National Science of Council Taiwan
●Strategic Orientation and Response to Public Disclosure
of Quality Performance in Nursing Homes
Jacqueline Zinn, Ph.D., M.B.A., Dana B. Mukamel, Ph.D.,
William D. Spector, Ph.D., David L. Weimer, Ph.D., Kimberly
Edgecomb, MS
Presented By: Jacqueline Zinn, Ph.D., M.B.A., Professpr, Risk,
Insurance and Healthcare Management, Temple University,
413 Ritter Annex, Philadelphia, PA 19122; Tel: (215) 204-1684;
Fax: (215) 204-4712; Email: jacqueline.zinn@temple.edu
Research Objective: In November 2002, CMS began
publishing quality measures on its Nursing Home Compare
website with the intent to provide consumers with objective
information regarding how well nursing homes manage
resident care. Publication represents a major change in the
operating environment that could influence the nursing
home's ability to attract and retain residents. Nursing homes
appear to be selectively choosing whether and how to respond
to public disclosure of their performance. This study assesses
whether differences in strategic orientation as identified by the
Miles and Snow typology are associated with differences in
nursing home response to the publication of quality
measures.
Study Design: We designed a survey to determine when and
if specific actions were taken in response to measure
publication. Respondents were also asked to identify the
strategic type (prospector, analyzer, defender or reactor)that
best characterized their facility by selecting the appropriate
unlabeled description. These were the primary dependent
variables. Because of their strong market orientation,
prospectors were hypothesized to be more likely to respond
(and to respond sooner) by taking specific actions than other
strategic types. For-profit status, chain affiliation, baseline
quality scores and perceived competition were included in the
model to control for other factors that could influence nursing
home response. The models (one for each specific response)
were estimated by logistic regression.
Population Studied: We surveyed nursing home
administrators in a national 10% random sample (1,502
facilities). 724 responded,a response rate of 48.2%.
Principal Findings: In general, results indicate differences in
response to quality measure publication by strategic
orientation. Compared to defenders, prospectors were
significantly more likely, and reactors less likely to take action
after the initial reporting period. Furthermore, compared to
prospectors, defenders were 62% more likely to take no action
whatsoever in response to publication. Relative to defenders,
both prospectors and analyzers were more likely to investigate
reasons for poor scores and to change priorities of existing
quality programs. Prospectors are almost twice as likely to
revise job descriptions in response to publication. Initial
published quality score and perceived competition were also
associated with response. However, there was no association
between the likelihood of communicating about scores with
relatives or families and strategic orientation.
Conclusions: Consistent with expectations, nursing homes
oriented towards strategic adaptation in response to
environmental change (prospectors, and to a lesser extent
analyzers)are more likely to take corrective action in response
to quality measure publication. Defenders (43% of our
sample) are less likely to respond.
Implications for Policy, Delivery, or Practice: In light of
continuing quality problems in nursing home care, the
effectiveness of sole reliance on regulatory approaches has
come under closer scrutiny. Publication of quality measures is
a market-based solution with the underlying rationale that
quality will increase in response to market demand created by
an informed public. However, our study found that the
response may not be uniform across nursing home providers.
From a policy perspective, this suggests that a combination of
market and regulatory approaches may be needed to motivate
quality improvement. From a practice perspective, our study
highlights the importance of proactive management in
improving quality of care.
Primary Funding Source: NIA