Physicians and organizations: strange bedfellows or a marriage made in heaven?

Underscoring the importance of physician-organization alignment as a necessary condition for building and sustaining integrated healthcare systems, this article provides information regarding the nature of such alignment, the key influential factors, and the processes employed to make alignment a reality. Structural and strategic factors address the influence of environmental, market, and organizational characteristics on alignment. The strategic intent of organizations and physicians, and physician perspectives on the effects of integration, are explored. Key processes examined include building trust, placing physicians in management and governance, and developing physician leadership. Continuing issues and challenges are considered, and a set of principles to help guide the journey of physicians and organizations toward successful alignment is suggested.

Organizational correlates of access to primary care and mental health services in drug abuse treatment units

Primary care and mental health services improve drug abuse treatment clients' health and treatment outcomes. To examine the association between clients' access to these services and the characteristics of drug treatment organizations, we analyze data from a national survey of the unit directors and clinical supervisors of 618 outpatient drug abuse treatment programs in 1995 (88% response rate). In multivariate models controlling for client characteristics and urban location, public units, units with more human resources, and methadone programs delivered more primary care services. Public units, Joint Commission on Accreditation of Health Care Organizations-accredited units, nonmethadone units, and units with more staff psychiatrists or psychologists delivered more mental health services. We conclude that organizational factors may influence drug abuse treatment clients' access to primary care and mental health services. Changes in the treatment system that weaken or eliminate public programs, over-burden staff, de-emphasize quality standards or lessen methadone availability may erode recovering clients' tenuous access to these services.

Managed care and processes to integrate physicians/hospitals

This article describes the extent to which hospitals use different integrative processes to assimilate physicians and assesses the extent to which their use is associated with managed care penetration and hospital characteristics. Results from a national survey of 1,495 community hospitals indicate that these integrative processes are quite prevalent. The use of integrative processes tends to be more prevalent in hospitals that are large, urban, involved in teaching, and members of hospitals systems. Use of particular integrative processes also appears to be associated with different thresholds of managed care penetration.

Managed care and technical efficiency in outpatient substance abuse treatment units

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs.

A causal model of voluntary turnover among nursing personnel in long-term psychiatric settings

Causal modeling was used to explore the processes by which individual characteristics, job satisfaction, and intention to quit explain turnover among nursing personnel in 29 Department of Veterans Affairs (VA) long-term psychiatric settings. The sample consisted of 1,106 registered nurses (RNs), licensed practical nurses (LPNs), and nurses' aides. We conceptualized turnover as a multistage process linking social and experiential orientations, attitudes toward the job, the decision to quit, and the behavior of actually quitting. Intention to quit was the strongest direct predictor of turnover. Professional growth opportunities and workload were important indirect predictors of turnover. Dissatisfaction with work hazards and relationships with coworkers were both indirect and direct predictors of turnover. Attitudes towards the job varied by nursing group. LPNs and aides were less satisfied than RNs with autonomy and work hazards. RNs were more dissatisfied with workload. We conclude that strategies to promote retention need to address aspects of jobs tailored to specific nursing groups.

Trust between managers and physicians in community hospitals: the effects of power over hospital decisions

Trust is a key element of effective work relationships between managers and physicians. Despite its importance, little is known about the factors that promote trust between these two professional groups. We examine whether manager and physician power over hospital decisions fosters manager-physician trust. We expect that with more power, managers and physicians will have greater control to enforce decisions that benefit the interests of both groups. Subsequently, they may gain confidence that their interests are supported and have more trust for each other. We test proposed hypotheses with data collected in a national study of chief executive officers and physician leaders in community hospitals in 1993. Findings indicate that power of managers and physicians over hospital decisions is related to manager-physician trust. Consistent with our expectations, physicians perceive greater trust between the two groups when they hold more power in four separate decision-making areas. Our hypotheses, however, are only partially supported in the manager sample. The relationship between power and trust holds in only one decision area: cost/quality management. Our findings have important implications for physician integration in hospitals. A direct implication is that physicians should be given the opportunity to influence hospital decisions. New initiatives, such as task force committees with open membership or open forums on hospital management, allow physicians a more substantial involvement in decisions. Such initiatives will give physicians more "voice" in hospital decision making, thus creating opportunities for physicians to express their interests and play a more active role in the pursuit of the hospital's mission and objectives.

Acute postictal cerebral imaging

BACKGROUND AND PURPOSE

Imaging of postictal patients is performed to investigate causes of seizure, such as space-occupying lesions or other "structural" processes; however, abnormalities may be found that reflect physiological or pathologic alterations due to seizure activity. The purpose of this study was to determine the brain imaging findings in patients in the immediate postictal period who presented with altered mental status or weakness.

METHODS

Ten patients who were examined for postictal neurologic derangement were studied (nine by CT and one by MR imaging) within 12 hours of ictus. Four of the CT studies and the one MR study included administration of contrast material. Follow-up examinations were performed 1 day to 11 months later. These studies were reviewed retrospectively.

RESULTS

CT findings included focal gyral swelling (10/10), effacement of adjacent cortical sulci (2/10), decreased gyral attenuation by CT (8/9), and mild to moderate gyral enhancement after injection of contrast material (5/5). MR imaging findings included gyral swelling, increased signal intensity on T2-weighted images, and enhancement after injection of contrast agent. The abnormalities were located in the frontal lobes (9/10, with bilateral involvement in 6/10), the parietal lobes (4/10), the temporal lobes (2/10), and the occipital lobe (1/10). Follow-up studies revealed complete or subtotal reversal of these abnormalities.

CONCLUSION

Although there are numerous causes of gyral swelling and enhancement, such as infarction and neoplasm, if these conditions are reversible and correspond to clinical findings, then the differential diagnosis is narrowed to postictal change, reversible ischemia, complicated migraine, or resolved inflammation/infection.

The challenges of governing public-private community health partnerships

This article identifies key challenges that arise in governing public-private partnerships designed to improve community health status. Using telephone interview and focus group data, we describe how the 25 public-private community health partnerships participating in the Community Care Network (CCN) Demonstration Program grapple with three interrelated clusters of governance issues: turf, community accountability, and growth and development.

Directors' perceptions of the effects of managed care in outpatient substance abuse treatment

This study examines the perceptions of unit directors' regarding the effects of managed care on outpatient treatment and operations. Specifically, we propose that perceptions vary as a function of managed care penetration, managed care complexity, and the stringency of managed care oversight procedures. Data are from a nationally representative sample survey of 236 outpatient substance abuse treatment organizations conducted in 1995. Study findings support the thesis that directors' perceptions vary systematically with specific attributes of managed care. Specifically, directors' perceptions of positive managed care effects are associated with two managed care oversight procedures: (a) managed care limits on the number of sessions provided; and (b) managed care requirements for follow-up after treatment. Directors perceptions of negative effects of managed care are significantly related to (a) managed care penetration, (b) managed care complexity; and (c) four different managed care oversight procedures. These results have implications for treatment given the rapid growth in managed behavioral care.

Public-private collaboration in health and human service delivery: evidence from community partnerships

The collaboration among public–private partnerships that applied to the Community Care Network (CCN) demonstration program of the Hospital Research and Educational Trust is examined. These partnerships link broad-based community coalitions with health and human service providers in efforts to improve community health and local service delivery. Although they willingly collaborated in identifying community health needs, coordinating services, and reporting to the community, partnership participants showed less alacrity in joining forces to reduce redundancy and increase efficiency. Such patterns suggest that organizations might best profit from working together on activities that maintain existing power relations and that have the potential to add prestige and attract new clients. Collaboration in these areas may be essential to building a foundation of trust that leads to future cooperation in more sensitive areas.

Managed care penetration in outpatient substance abuse treatment units

The authors present the first nationally representative data on managed care penetration in the outpatient substance abuse treatment (OSAT) sector. Thirty-eight percent of all OSAT units were involved in some form of managed care in 1995, with 22 percent of their client base covered by managed care. There is also variation in managed care penetration and activity across different types of treatment units. Private for-profit units are involved in managed care to a greater extent than are public and private, not-for-profit organizations. Units affiliated with a hospital have greater participation and penetration than other units. Smaller OSAT facilities have a disproportionately large percentage of their client base in managed care arrangements. Finally, private managed care arrangements are more prevalent, more evenly distributed across organizational types, and represented in larger numbers than are public sources of managed care.

Usefulness of cytopathology and histology in the evaluation of Barrett's esophagus in a community hospital

BACKGROUND

Brush cytology and histology have been found to be complementary in the evaluation of Barrett's esophagus at a referral medical center. This study evaluated the usefulness of brush cytology and histology in a community hospital setting.

METHODS

One hundred consecutive patients with Barrett's esophagus underwent esophagogastroscopy performed by four staff gastroenterologists. Four quadrant biopsy specimens for histopathology at 3-cm intervals throughout the Barrett's segment and one brushing for cytology were obtained. All specimens were interpreted by four board-certified staff pathologists in a blinded fashion.

RESULTS

Histologic diagnosis included three adenocarcinomas, one high-grade dysplasia, six low-grade dysplasias, and one indeterminate dysplasia. Cytology diagnosed the same three adenocarcinomas, no high-grade dysplasia, three low-grade dysplasia, and two indeterminate dysplasias. The case of high-grade dysplasia on histology was diagnosed as normal by cytology. The six patients found to have low-grade dysplasia by histology were found to have low-grade dysplasia (3), indeterminate dysplasia (2), and no abnormality (1) by cytology. In no case was a higher grade of dysplasia diagnosed by cytology than by histology.

CONCLUSION

Adding brush cytology to histology increased the cost but not the diagnostic yield in the evaluation of Barrett's esophagus in a community hospital setting.

Determinants of mental health providers' expectations of patients' improvement

OBJECTIVE

Characteristics of individual mental health providers and of treatment settings were examined to determine their effects on providers' expectations about the improvement of patients with serious mental illness.

METHODS

The sample consisted of 1,567 treatment providers working in 107 inpatient and outpatient units or programs in 29 Veterans Affairs mental health facilities. They completed a questionnaire about their prognostic expectations and a broad range of attitudes toward job satisfaction, professional relations, and team functioning. Unit or program directors of all 107 units completed another questionnaire about the average functional ability of patients, unit workload, and unit size. Hierarchical linear modeling was used to assess the effects of both individual and unit-level attributes on providers' expectations of improvement in clinical symptomatology and social-functional skills of patients in their care.

RESULTS

The providers had generally low expectations about the improvement of patients with serious mental illness. Expectations were higher among staff in units or programs that were smaller and that had an outpatient focus, a greater proportion of staff involved in the treatment team, and higher-functioning patients. Individual characteristics significantly associated with prognostic expectations were occupation, age, and membership on the treatment team.

CONCLUSIONS

Prognostic expectations among providers of care to persons with serious mental illness vary with identifiable individual and unit or program characteristics. The latter may be amenable to manipulation and intervention to improve mental health providers' prognostic expectations.

Effects of inhaled nitric oxide in patients with hypoxemia and pulmonary hypertension after cardiac surgery

BACKGROUND: Cardiopulmonary bypass can increase pulmonary vascular tone and decrease ventilation-perfusion matching by impairing the pulmonary endothelial production of nitric oxide. OBJECTIVES: We tested the hypothesis that inhalation of exogenous nitric oxide decreases the ratio of mean pulmonary arterial pressure to mean system arterial pressure and the intrapulmonary shunt fraction and increases the ratio of arterial blood oxygen tension to fraction of inspired oxygen in patients in whom the ratio of mean pulmonary arterial pressure to mean systemic arterial pressure is more than 0.50, and the ratio of arterial blood oxygen tension to fraction of inspired oxygen is less than 300 mm Hg in the first 24 hours after cardiopulmonary bypass surgery. METHODS: Only those patients who had estimates of the ratio of mean pulmonary arterial pressure to mean systemic arterial pressure and the ratio of arterial blood oxygen tension to fraction of inspired oxygen determined preoperatively were enrolled. Hemodynamic variables were recorded, and blood samples were obtained for oximetric analysis 5 minutes before and 30 minutes after inhalation of nitric oxide began. The concentration of nitric oxide inhaled was maintained at 20 parts per million. The data were analyzed by using Friedman's repeated measures analysis of variance. RESULTS: Thirteen patients were enrolled in the study. The mean preoperative ratio of mean pulmonary arterial pressure to mean systemic arterial pressure was 0.63 +/- 0.08 (standard error of the mean), and the mean preoperative ratio of arterial blood oxygen tension to fraction of inspired oxygen was 131 +/- 15 mm Hg. No differences between preoperative and postoperative values were detected. Inhalation of nitric oxide decreased the ratio of mean pulmonary arterial pressure to mean systemic arterial from 0.53 +/- 0.07 to 0.39 +/- 0.5 and increased the ratio of arterial blood oxygen tension to fraction of inspired oxygen from 167 +/- 35 mm Hg to 235 +/- 45 mm Hg. Inhalation of nitric oxide also decreased the intrapulmonary shunt fraction from 0.29 +/- 0.05 to 0.19 +/- 0.04. CONCLUSIONS: Inhalation of nitric oxide selectively decreases pulmonary vascular tone and increases ventilation-perfusion matching in patients with persistent pulmonary hypertension and hypoxemia after surgery requiring cardiopulmonary bypass. Inhalation of nitric oxide may be a valuable adjunctive therapy for these patients.

Effects of inhaled nitric oxide in patients with hypoxemia and pulmonary hypertension after cardiac surgery

BACKGROUND

Cardiopulmonary bypass can increase pulmonary vascular tone and decrease ventilation-perfusion matching by impairing the pulmonary endothelial production of nitric oxide.

OBJECTIVES

We tested the hypothesis that inhalation of exogenous nitric oxide decreases the ratio of mean pulmonary arterial pressure to mean system arterial pressure and the intrapulmonary shunt fraction and increases the ratio of arterial blood oxygen tension to fraction of inspired oxygen in patients in whom the ratio of mean pulmonary arterial pressure to mean systemic arterial pressure is more than 0.50, and the ratio of arterial blood oxygen tension to fraction of inspired oxygen is less than 300 mm Hg in the first 24 hours after cardiopulmonary bypass surgery.

METHODS

Only those patients who had estimates of the ratio of mean pulmonary arterial pressure to mean systemic arterial pressure and the ratio of arterial blood oxygen tension to fraction of inspired oxygen determined preoperatively were enrolled. Hemodynamic variables were recorded, and blood samples were obtained for oximetric analysis 5 minutes before and 30 minutes after inhalation of nitric oxide began. The concentration of nitric oxide inhaled was maintained at 20 parts per million. The data were analyzed by using Friedman's repeated measures analysis of variance.

RESULTS

Thirteen patients were enrolled in the study. The mean preoperative ratio of mean pulmonary arterial pressure to mean systemic arterial pressure was 0.63 +/- 0.08 (standard error of the mean), and the mean preoperative ratio of arterial blood oxygen tension to fraction of inspired oxygen was 131 +/- 15 mm Hg. No differences between preoperative and postoperative values were detected. Inhalation of nitric oxide decreased the ratio of mean pulmonary arterial pressure to mean systemic arterial from 0.53 +/- 0.07 to 0.39 +/- 0.5 and increased the ratio of arterial blood oxygen tension to fraction of inspired oxygen from 167 +/- 35 mm Hg to 235 +/- 45 mm Hg. Inhalation of nitric oxide also decreased the intrapulmonary shunt fraction from 0.29 +/- 0.05 to 0.19 +/- 0.04.

CONCLUSIONS

Inhalation of nitric oxide selectively decreases pulmonary vascular tone and increases ventilation-perfusion matching in patients with persistent pulmonary hypertension and hypoxemia after surgery requiring cardiopulmonary bypass. Inhalation of nitric oxide may be a valuable adjunctive therapy for these patients.

Effects of market position and competition on rural hospital closures

OBJECTIVE

To examine the dynamic effects of competition and hospital market position on rural hospital closures.

DATA SOURCE/STUDY SETTING

Analysis of all rural community hospitals operating between 1984 and 1991, with the exception of sole-provider hospitals. Data for the study are obtained from four sources: the AHA Annual Surveys of Hospitals, the HCFA Cost Reports, the Area Resource File, and a hospital address file constructed by Geographic Inc.

DATA COLLECTION AND ANALYSIS

Variables are merged to construct pooled, time-series observations for study hospitals. Hospital closure is specified as a function of hospital market position, market level competition, and control variables. Discrete-time logistic regressions are used to test hypotheses.

PRINCIPAL FINDINGS

Rural hospitals operating in markets with higher density had higher risk of closure. Rural hospitals that differentiated from others in the market on the basis of geographic distance, basic services, and high-tech services had lower risks of closure. Effects of market density on closure disappeared when market position was included in the model, indicating that differentiation in markets should be taken into account when evaluating the effects of competition on rural hospital closure.

CONCLUSIONS

Our findings suggest that rural hospitals can reduce competitive pressures through differentiation and that accurate measures of competition in geographically defined market areas are critical for understanding competitive dynamics among rural hospitals.

Nurse staffing patterns and hospital efficiency in the United States

The objective of this exploratory study was to assess the effects of four nurse staffing patterns on the efficiency of patient care delivery in the hospital: registered nurses (RNs) from temporary agencies; part-time career RNs; RN rich skill mix; and organizationally experienced RNs. Using Transaction Cost Analysis, four regression models were specified to consider the effect of these staffing plans on personnel and benefit costs and on non-personnel operating costs. A number of additional variables were also included in the models to control for the effect of other organization and environmental determinants of hospital costs. Use of career part-time RNs and experienced staff reduced both personnel and benefit costs, as well as total non-personnel operating costs, while the use of temporary agencies for RNs increased non-personnel operating costs. An RN rich skill mix was not related to either measure of hospital costs. These findings provide partial support of the theory. Implications of our findings for future research on hospital management are discussed.

Continuous negative extrathoracic pressure in neonatal respiratory failure

OBJECTIVE

In uncontrolled clinical trials, negative extrathoracic pressure has been shown to be an effective respiratory support. We aimed to assess its role in the context of current neonatal intensive care.

DESIGN

A randomized controlled trial, with sequential analysis of matched pairs of infants. Matching was undertaken by stratified randomization from 15 groups divided according to gestational age, oxygen requirement, and whether patients were intubated at 4 hours of age.

SETTING

Two neonatal intensive care units.

PATIENTS

Two hundred forty-four patients (birth weight 1.53 +/- 0.69 kg (mean +/- SD); gestational age 30.4 +/- 3.5 weeks) with respiratory failure.

INTERVENTIONS

Patients were randomized at 4 hours of age to receive either standard neonatal intensive care, or standard care plus continuous negative extrathoracic pressure (CNEP, -4 to -6 cmH2O) applied within a purpose-designed neonatal incubator. OUTCOME SCORES: Clinical scores were calculated for each infant at 56 days of age, or death if earlier. Scores included measures for mortality, respiratory outcome, the presence of cerebral ultrasound abnormalities, patent arterial duct, necrotizing enterocolitis, and retinopathy. The treatment given for the higher score for each pair was recorded and the cumulative net number of pairs favoring CNEP plotted in the sequential analysis to provide an ethical early termination strategy. Individual components of the outcome score and other secondary measurements were analyzed on completion of the trial.

RESULTS

The sequential analysis reached a decision boundary after 122 out of a possible maximum of 124 pairs were completed. The overall outcome score showed an overall significant benefit for CNEP. Secondary analysis showed that the use of CNEP was associated with an increase in mortality, cranial ultrasound abnormalities, and pneumothoraces, which were not statistically significant. However, 5% fewer patients were intubated (95% confidence interval [CI], 0-10), and the total duration of oxygen therapy among surviving infants at 56 days was lower (20.5 days, compared with 38.9 in controls; difference 18.4 days, 95% CI 3.8 to 33.0). Among all infants, the mean total duration of oxygen therapy was 18.3 days among CNEP-treated infants compared with 33.6 days among the controls (difference -15.3 days, 95% CI -0.2 to -30.4). This reduction in mean levels is entirely attributable to substantially fewer patients requiring prolonged oxygen therapy, the median duration of treatment being very similar in the two groups. As a result, commensurately fewer surviving infants showed chronic lung disease of prematurity.

CONCLUSIONS

The use of continuous negative pressure improves the respiratory outcome for neonates with respiratory failure.

Leadership for quality improvement in health care; empirical evidence on hospital boards, managers, and physicians

This article explores factors promoting leadership from the top for hospital quality improvement (CQI/FQM). From literature on governance, quality improvement, and organization theory, working hypotheses were developed about the effects of physician and management involvement in governance on CQIITQM adoption, board leadership for quality, and top management leadership for quality. Hypotheses were tested using a sample of 2,030 hospitals obtained by merging two national mailed surveys. Probit and logistic regression showed physician involvement in governance played a significant role in CQI/FQM adoption and board activity in quality improvement. Formal management involvement in governance demonstrated little effect on CQI/FQM adoption, board leadership for quality, or top management leadership for quality. Informal management involvement in governance, as reflected in opportunities to influence board composition, had negative effects on board and top management leadership for quality. Top management leadership for quality increased board leadership for quality. Implications are discussed.

Adult cerebrovascular disease: role of modified rapid fluid-attenuated inversion-recovery sequences

PURPOSE

To compare a rapid fluid-attenuated inversion-recovery (FLAIR) sequence with T1-weighted, fast spin-echo proton density-weighted, and T2-weighted images in the evaluation of cerebrovascular disease.

METHODS

All patients underwent standard T1-, proton density-, and T2-weighted fast spin-echo and fast FLAIR MR imaging at 1.5 T. Images were compared for lesion size, location, and conspicuity.

RESULTS

Forty-five infarctions were identified on T2-weighted and fast FLAIR sequences. Lesion size was comparable on the proton density-weighted, fast T2-weighted, and fast FLAIR sequences, although lesion conspicuity was superior on the fast FLAIR images in 43 (96%) of the lesions. Associated periventricular and pontine hyperintensities were more extensive on the fast FLAIR images.

CONCLUSION

Our modified fast FLAIR technique provided improved conspicuity of infarctions and white matter disease as compared with T1-, proton density-, and T2-weighted spin-echo images, and a reduced scan time compared with conventional FLAIR sequences in patients with cerebrovascular disease.

Hepatitis C and inclusion body myositis

Hepatitis C is known to be associated with a myriad of autoimmune diseases. Inclusion body myositis is an inflammatory myopathy of unknown etiology. We report the first case of chronic hepatitis C with inclusion body myositis.

Determinants of profound organizational change: choice of conversion or closure among rural hospitals

Because of severe operating and resource constraints, many rural community hospitals are confronted with pressures to abandon core strategies related to acute inpatient care. Little is known, however, about why hospitals would choose to convert to organizations that provide non-acute care health services as an alternative to closure. We argue that rural hospitals are more likely to convert when conditions are in place that enable them to make major shifts from their current domains to ones that are more hospitable. To the extent that resources are available in alternative domains and rural hospitals possess the strategies necessary to exploit these resources, rural hospitals are more likely to convert rather than close. To examine our proposed hypotheses, we analyze national data from all rural hospitals from 1984 through 1991. Results indicate that conversion is more likely to occur than closure when resources in the market are abundant, competition for hospital resources is high, and hospitals have established strategies to provide alternative forms of health care. Findings from this study indicate that environmental and organizational factors can increase a rural hospital's risk of conversion as an alternative to closure.

Organizational approaches to integrated health care delivery: a taxonomic analysis of physician-organization arrangements

Integrated health care organizations depend fundamentally on bringing organizations and physicians into closer alignment. Little empirical research has been conducted on the organizational mechanisms by which such alignment is attempted. This study employed primary data from 79 hospitals and health care systems to identify current approaches to aligning the strategic and economic interests of organizations and physicians. An empirical classification of both unbundled and structured physician-organization arrangements (POAs) resulted in 5 distinct strategic configurations. These configurations were differentiated by key contextual factors that shape patterns of development and operation of POAs. Particularly salient among these were managed care penetration, organization size, locus of control, and organization strategy. Results of the taxonomic analysis underscore the facts that most delivery organizations employ multifaceted rather than single approaches to physician integration and that these approaches are endemic to particular environmental and organizations conditions.