The short-term effects of merger on hospital operations

OBJECTIVE

The short-term effects of merger on three areas of hospital operations - scale of activity, personnel/staffing practices, and operating efficiency - is examined.

DATA SOURCES

Secondary data obtained from the AHA Annual Surveys (1980-1990) were applied to analyze 92 hospital mergers over the period 1982-1989.

STUDY DESIGN

The study employed a multiple time-series design involving a six-year longitudinal assessment of change in hospital operating characteristics before and after merger, and a parallel analysis of change in a randomly selected group of nonmerging hospitals.

DATA COLLECTION

Pooled, cross-sectional data files were constructed. Comparisons were evaluated using paired and two-sample t-tests.

PRINCIPAL FINDINGS

General merger effects occurred primarily in areas related to operating efficiency. Merger resulted in slowing rates of preexisting trends, rather than dramatic improvements in operating practices.

CONCLUSIONS

The short-term impact of merger was generally modest but differed by the conditions under which the merger occurred. Specifically, mergers occurring later in the study period and mergers between similarly sized hospitals displayed greater change in operating characteristics than those occurring earlier in the study period and those between hospitals of dissimilar size. Such differences are attributed respectively to increased competitive pressures after PPS and to greater opportunities for consolidation and efficiencies in mergers involving similarly sized hospitals.

Loosening the Gordian Knot of governance in integrated health care delivery systems

A new organizational species is emerging--the integrated health care delivery system. Aligned with both the anticipated provisions of federal and state health care reform initiatives and emerging purchaser demands, integrated delivery systems could dominate many health care markets by the end of this decade. Integration is both the defining feature and key imperative of such systems. Because of the unique position of boards, governance is potentially the ultimate integrator. Yet little attention had been focused on integrated delivery system governance. Accordingly, this article will address the governance of integrated delivery systems through three questions: (1) What are the distinguishing characteristics of integrated health care delivery systems? (2) What are the distinctive issues and challenges associated with governing integrated delivery systems? and (3) What different forms of governance can be employed by these systems and what factors influence the effectiveness of these forms?

Determinants of rural hospital conversion. A model of profound organizational change

One widely discussed response to the severe problems faced by many rural hospitals is to convert them into organizations that provide health services other than general, acute inpatient care. This study identifies conversions that occurred nationally from 1984 to 1991. The study also empirically examines the determinants of conversion, using rural hospitals that did not convert (between 1984 and 1991) as a comparison group. The authors examine a set of factors that makes radical organizational change necessary (eg, poor performance) and reduces resistance to such change (eg, proximity to other hospitals). Results from discrete-time logistic regression show that converters are more likely than nonconverters to: have poor performance and fewer beds; be located very near to or very distant from similar hospitals; operate in larger communities; devote more of their care to areas other than acute inpatient care; and be members of multihospital systems. Converters also are less likely to be government owned. The need for future research on the effects of conversion is discussed.

The changing strategies in operation for transposition of the great vessels

Between July 3, 1985, and February 24, 1994, a total of 55 infants underwent arterial switch procedures for the repair of transposition of the great vessels. Thirty-five infants had an intact ventricular septum and 20 had ventricular septal defects. To date, there have been three late deaths, one in the group with an intact ventricular septum and two in the group with a ventricular septal defect. Early postoperative complications included atrial dysrhythmias, prolonged ventilation, inability to close the sternum, and tension on the coronary arteries. Follow-up echocardiographic data for 44 patients indicate that pulmonary artery gradients are a worrisome postoperative problem, especially in infants who have ventricular septal defects.

Tricuspid atresia and annular hypoplasia: report of a familial occurrence

Occurrence of a similar cardiac malformation in multiple family members has been reported for many lesions. Neither tricuspid atresia nor tricuspid annular hypoplasia and tricuspid atresia has been described in multiple members of the same family. We report two cases of tricuspid atresia and one case of tricuspid annular hypoplasia with an atrial septal defect in siblings. The findings in this family suggest an autosomal recessive pattern of inheritance for abnormal tricuspid valve morphogenesis.

Midazolam sedation for percutaneous liver biopsy

Control of patient respiration is needed to safely perform percutaneous liver biopsy (PLB) and may be adversely affected by sedation. The purpose of this study was to evaluate the safety of PLB with intravenous midazolam and to evaluate patient acceptance of PLB with and without sedation. Two hundred seventeen consecutive patients underwent 301 percutaneous liver biopsies. One hundred fifty-one of the biopsies were done after the patients were sedated with intravenous midazolam immediately before the biopsy. The last 61 patients were questioned after the biopsy to evaluate the discomfort of the procedure, their memory of the procedure, and their willingness to undergo another PLB. The major complication rate was similar in the midazolam-treated (0.7%) and untreated (0.7%) groups. The midazolam-treated patients had a numerically lower mean pain score (1.5 +/- 0.4 vs 4.0 +/- 0.7) (mean +/- SEM) (P = 0.07) and significantly lower mean memory score (4.8 +/- 0.7 vs 9.9 +/- 0.1) (P < 0.01) than the untreated patients. The treated and untreated groups had similar mean willingness for repeat PLB scores (9.3 +/- 0.3 vs 9.1 +/- 0.6). We conclude that: (1) there is no increased risk of PLB with midazolam and (2) patients have less memory of the procedure with midazolam.

Corporate and philanthropic models of hospital governance: a taxonomic evaluation

OBJECTIVE

We assess the theoretical integrity and practical utility of the corporate-philanthropic governance typology frequently invoked in debates about the appropriate form of governance for nonprofit hospitals operating in increasingly competitive health care environments.

DATA SOURCES

Data were obtained from a 1985 national mailed survey of nonprofit hospitals conducted by the American Hospital Association (AHA) and the Hospital Research and Educational Trust (HRET).

STUDY DESIGN

A sample 1,577 nonprofit community hospitals were selected for study. Representativeness was assessed by comparing the sample with the population of non-profit community hospitals on the dimensions of bed size, ownership type, urban-rural location, multihospital system membership, and census region.

DATA COLLECTION

Measurement of governance types was based on hospital governance attributes conforming to those cited in the literature as distinguishing corporate from philanthropic models and classified into six central dimensions of governance: (1) size, (2) committee structure and activity, (3) board member selection, (4) board composition, (5) CEO power and influence, and (6) bylaws and activities.

PRINCIPAL FINDINGS

Cluster analysis and ANCOVA indicated that hospital board forms adhered only partially to corporate and philanthropic governance models. Further, board forms varied systematically by specific organizational and environmental conditions. Boards exhibiting more corporate governance forms were more likely to be large, privately owned, urban, and operating in competitive markets than were hospitals showing more philanthropic governance forms.

CONCLUSIONS

Findings suggest that the corporate-philanthropic governance distinction must be seen as an ideal rather than an actual depiction of hospital governance forms. Implications for health care governance are discussed.

Identifying Blalock-Taussig shunts using a Silastic band

Placement of an encircling Silastic band around Blalock-Taussig shunts facilitates identification and ligation of the shunt at the time of corrective operation. This technique of "shunt banding" is particularly useful for left-sided shunts, both native and modified. We have noted no complications, specifically shunt constriction. Placement of the band adds minimal operative time during shunt placement and substantially lessens the time and amount of dissection required during subsequent procedures.

Leadership instability in hospitals: the influence of Board-CEO relations and organizational growth and decline

This study tested whether leadership instability--a systemic pattern of frequent succession in the top management position of an organization--was associated with sociopolitical structures that define the relationship between the board and chief executive officer (CEO), controlling for temporal patterns of the organizational life-cycle stage. In organizations that are not profit maximizing and subject to considerable uncertainty, such governance properties were hypothesized to affect leadership instability independent of organizational growth or decline. Results of regression analyses demonstrate strong main effects of board-CEO relations, net of the impact of organizational life cycle, on leadership instability.

Oxygen saturation and breathing patterns in preterm infants with cyanotic episodes

The pathophysiology of cyanotic/apnoeic episodes in preterm infants was investigated using overnight tape recordings of beat-to-beat arterial oxygen saturation (SaO2), plethysmographic waveforms from the oximeter, breathing movements and nasal airflow. Recordings were made in 16 preterm infants with recurrent cyanotic episodes of unknown cause that had received stimulation or resuscitation, and 15 preterm controls, matched for birth weight, post-conceptional and postnatal age. The recordings were analysed for baseline SaO2, the number of hypoxaemic episodes (SaO2 < or = 80% for > or = 4 s) and the breathing patterns associated with each episode. There was a significant difference in the total number of hypoxaemic episodes between patients and controls (520 versus 100; p < 0.01), but no difference was found for mean baseline SaO2 (98.6 versus 99.0%; p > 0.05). The mean duration of each hypoxaemic episode in the patients was 9.5 s compared with 5.8 s in the controls (p < 0.01). Although most hypoxaemic episodes (62 and 76%) were associated with pauses in breathing movements, a proportion (8 and 18%, respectively) occurred despite continuous airflow and breathing movements in both patients (6 of 16) and preterm controls (2 of 15). The rate of decrease in SaO2 was significantly more rapid during these latter hypoxaemic episodes than during episodes associated with isolated apnoeic pauses (8.5 versus 3.2% per second, p = 0.02). Preterm infants with cyanotic episodes have increased numbers of clinically unapparent hypoxaemic episodes, some of which have continued ventilation and rapid desaturation. The pathogenesis of these episodes warrants further investigation.

Patient memory before and after cardiac operations

The memories of 20 patients undergoing elective operations on the heart were assessed by a comprehensive battery of standardized psychometric tests. Testing was conducted 1 to 2 days before, 7 to 10 days after, and 1 month after each operation. Twenty age-matched, healthy control subjects were given the same battery of tests at comparable times. Compared with healthy subjects, the patient group had significantly lower scores on 3 of 19 tests before, 10 of 19 tests 1 week after, and 5 of 19 tests 1 month after surgical intervention. The patient group had similar test performances before and 1 week after the operations and improved on 3 of 19 measures 1 month after the operations. Degrees of illness and cardiopulmonary bypass variables were significantly related to only a small subset of memory measures. Results of this study are consistent with previous reports that underscore the contribution of nonspecific aspects of surgical intervention to neuropsychologic dysfunction in the immediate postoperative period. We conclude that neither the illness nor the surgical variables are directly related to substantial variance in cognitive function after operations on the heart.

Use of transesophageal echocardiography to visualize an anomalous right coronary artery arising from the left main coronary artery (single coronary artery)

This case report demonstrates a role for transesophageal echocardiography in defining the course of anomalous coronary arteries. Origin of the right coronary artery (RCA) from the left main (LM) (single coronary artery) is an exceedingly rare congenital anomaly. It is not always benign and may result in myocardial infarction. This may be due to compression between the aorta and the pulmonary artery. Transesophageal echocardiography offers a low-risk, noninvasive means of imaging the proximal coronary arteries. In the majority of patients, the proximal segments of the three major coronaries can be clearly visualized. With the addition of color flow, it is possible to visualize flow in most patients. Proximal obstructive lesions can be seen in some patients although sensitivity thus far seems low.

The effect of the social organization of work on the voluntary turnover rate of hospital nurses in the United States

In light of current concerns over nursing shortages and productivity, voluntary turnover among hospital nurses in the United States has assumed renewed importance as a managerial issue. This study examines the thesis that the social organization of work in hospitals is an important determinant of the voluntary turnover rate among registered nurses. This perspective differs from previous work in this area in that both turnover and its determinants are conceptualized at the organizational rather than individual level, thus opening the way for administrative intervention to reduce turnover. The conceptual model is tested using multiple regression techniques on a sample of 435 hospitals. Results suggest that organizational characteristics and environmental conditions are important contributors to turnover. Organizational characteristics are stronger predictors of turnover than are economic factors.

Familial cardiac myxoma

The majority of cardiac myxomas occur sporadically as isolated lesions in the left atrium of middle-aged women. However, a "familial" form and a "syndrome" form of this lesion have been identified. The syndrome myxoma can present with pigmented skin lesions and peripheral or endocrine neoplasms. The familial and syndrome forms of cardiac myxomas can usually be distinguished from the sporadic form by the presentation at a younger age, the unusual location and multicentricity of the lesions, and the presence of rare pathological conditions. In addition, a higher rate of recurrent lesions is usually associated with the familial and syndrome forms of this disease. To date, 15 families with cardiac myxomas have been reported in the world's literature. Here we present 2 additional case reports.

The Blalock-Taussig shunt in the newborn infant

Children with pulmonary oligemia often require palliation in the newborn period. The Blalock-Taussig shunt has been shown to offer adequate palliation in the older child, but its use in the newborn period remains controversial. A retrospective review of 51 neonates younger than age 2 weeks undergoing a Blalock-Taussig shunt (or modification) was performed. The operative mortality rate was 5.8%. Six children (15.4%) required reoperation in the first year of life for inadequate shunt function. The modification with interposition grafts necessitated reoperation more often than shunts performed with the subclavian artery.

Acute vascular rejection of the coronary arteries in human heart transplantation: pathology and correlations with immunosuppression and cytomegalovirus infection

Prior studies of vascular rejection in transplanted human hearts have stressed the importance of accelerated coronary arteriosclerosis (chronic vascular rejection). We, however, have had four patients with sudden onset of acute heart failure within 90 days of transplantation who have died without significant myocardial interstitial rejection or the concentric intimal thickening with dense collagen that is typical of chronic vascular rejection. In contrast, the coronary arteries in our patients had a prominent lymphocytic infiltrate, a loosely organized intimal thickening composed of smooth muscle cells, and extensive endothelial injury. We believe that these changes define acute vascular rejection of the coronary artery. In 14 transplanted hearts obtained consecutively, at autopsy or at a second transplant procedure, graft failure was caused by acute coronary vascular rejection in six cases and by chronic coronary vascular rejection in one case. The remaining seven patients showed no evidence of vascular rejection and died primarily of sepsis. Cytomegalovirus (CMV) disease was present in 6 of 7 patients with vascular rejection, of which 43% were CMV-negative recipients of hearts from CMV-positive donors. The adoption of a triple-drug protocol, in which azathioprine was added to cyclosporine and prednisone, reduced the incidence of acute vascular rejection from 27% to 8%. We conclude that acute coronary vascular rejection may be initially seen as global cardiac ischemia in the absence of significant interstitial myocardial rejection. Further, acute vascular rejection should be pathologically distinguished from chronic vascular rejection, although both are probably stages in the natural history of immune-mediated vascular injury.

Familial recurring cardiac myxoma

A 34-year-old woman presented with her fourth occurrence of an atrial myxoma and a right lower lung field mass. Her surgical history was extensive. In addition to resection of three previous atrial myxomas, she had undergone resection of her adrenal glands as a teenager because of Cushing's syndrome, and a hysterectomy at age 26 revealed a myxoid leiomyoma. Family history was remarkable as a maternal uncle and daughter died from embolic complications of left atrial myxomas and her sister previously had a left atrial myxoma resected. The patient underwent uncomplicated removal of the myxoma, and resection of the lung mass revealed a granuloma. A review of typical and atypical aspects of cardiac myxomas is provided including a rare and recently described syndrome of familial cardiac myxoma associated with Cushing's syndrome, spotty skin pigmentation and other myxoid tumors.

Magnetic resonance findings in a patient with internuclear ophthalmoplegia. Neuroradiological-clinical correlation

A 49-year-old female presented with symptoms compatible with internuclear ophthalmoplegia. Magnetic resonance using T2-weighted images showed an eccentric area of high signal intensity in the mid pons corresponding to the right medial longitudinal fasciculus. Magnetic resonance is the method of choice when internuclear ophthalmoplegia is suspected. The findings should be differentiated from the normal central hyperintensity called the "pseudo MLF hyperintensity."

Adaptive change in corporate control practices

Multidivisional organizations are not concerned with what structure to adopt but with how they should exercise control within the divisional form to achieve economic efficiencies. Using an information-processing framework, I examined control arrangements between the headquarters and operating divisions of such organizations and how managers adapted control practices to accommodate increasing environmental uncertainty. Also considered were the moderating effects of contextual attributes on such adaptive behavior. Analyses of panel data from 97 multihospital systems suggested that organizations generally practice selective decentralization under conditions of increasing uncertainty but that organizational age, dispersion, and initial control arrangements significantly moderate the direction and magnitude of such changes.

Radiation-associated valvular disease

The prevalence of radiation-associated cardiac disease is increasing due to prolonged survival following mediastinal irradiation. Side effects of radiation include pericarditis, accelerated coronary artery disease, myocardial fibrosis and valvular injury. We evaluated the cases of three young patients with evidence of significant valvular disease following mediastinal irradiation. One patient underwent the first reported successful aortic and mitral valve replacement for radiation-associated valvular disease (RAVD) as well as concurrent coronary artery revascularization. A review of the literature revealed 35 reported cases of RAVD, with only one successful case of valve replacement that was limited to the aortic valve. Asymptomatic RAVD is diagnosed 11.5 years after mediastinal irradiation compared with 16.5 years for symptomatic patients, emphasizing that long-term follow-up is important for patients receiving mediastinal irradiation. This study defines a continuum of valvular disease following radiation that begins with mild asymptomatic valvular thickening and progresses to severe valvular fibrosis with hemodynamic compromise requiring surgical intervention.

Acute porphyria presenting with hyperamylasemia

An elevation of serum amylase and lipase has not been reported previously to occur with porphyria. In this report, we describe a patient who presented with the clinical and laboratory picture of pancreatitis: elevated amylase, lipase, amylase-creatinine clearance ratio, and with abdominal pain. Only after extensive evaluation, was the patient found to have porphyria. On two separate occasions, with hematin therapy, her serum amylase decreased, as did her clinical symptoms of porphyria and her urinary quantitative porphyrins. This suggests an association between elevation of the serum amylase and lipase with acute porphyria. Moreover, this association can lead to delay in establishing the diagnosis of acute porphyria.

Identification of 7-(2-hydroxyethyl)guanine as a product of alkylation of calf thymus DNA with clomesone

Evidence at the molecular level is presented in support of alkylation of O6-guanine moieties of DNA as the mechanism of cytotoxicity of Clomesone to HT-29 cells and consists in the isolation and identification of a product resulting from alkylation of calf thymus DNA with Clomesone, followed by depurination to yield 7-(2-hydroxyethyl)guanine, whose formation is reasonably explained by O6-guanine chloroethylation followed by intramolecular alkylation at N7 of guanine and subsequent hydrolysis to the hydroxyethylguanine.