Variations in Inpatient Mortality Among Hospitals in Different System Types, 1995 to 2000

Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment?

INTRODUCTION

Vertical integration models involve integrating services from different levels of care (e.g., primary care, acute care, post-acute care). Therefore, one of their main objectives is to increase continuity of care, potentially improving outcomes like efficiency, quality, and access or even enabling cost containment.

OBJECTIVES

This study conducts a literature review and aims at contributing to the contentious discussion regarding the effects of vertical integration reforms in terms of efficiency, costs containment, quality, and access.

METHODS

We performed a systematic search of the literature published until February 2020. The articles respecting the conceptual framework were included in an exhaustive analysis to study the impact of vertical integration on costs, prices of care, efficiency, quality, and access.

RESULTS

A sample of 64 papers resulted from the screening process. The impact of vertical integration on costs and prices of care appears to be negative. Decreases in technical efficiency upon vertical integration are practically out of the question. Nevertheless, there is no substantial inclination to visualise a positive influence. The same happens with the quality of care. Regarding access, the lack of available articles on this outcome limits conjectures.

CONCLUSIONS

In summary, it is not clear yet whether vertically integrated healthcare providers positively impact the overall delivery care system. Nevertheless, the recent growing trend in the number of studies suggests a promising future on the analysis of this topic.

Hospital-based health systems 20 years later: A taxonomy for policy research and analysis

OBJECTIVE

Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments.

DATA SOURCES

The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS).

STUDY DESIGN

Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems.

DATA COLLECTION

Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms.

PRINCIPAL FINDINGS

Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system.

CONCLUSIONS

The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.

Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality

BACKGROUND AND PURPOSE

The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata.

METHODS

Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme.

RESULTS

There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51-0.59], P<0.001; endovascular therapy: 1.63% versus 2.41%, adjusted odds ratio, 0.64 [0.57-0.73], P<0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%, P<0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 [0.94-1.0], P=0.086; large towns, 1.05 [1.01-1.09], P=0.009; small towns, 1.10 [1.06-1.15], P<0.001; micropolitan rural, 1.16 [1.11-1.21], P<0.001; and remote rural 1.21 [1.15-1.27], P<0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 [1.00-1.26], P<0.001) to 2017 (adjusted odds ratio, 1.27 [1.13-1.42], P<0.001).

CONCLUSIONS

Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.

Factors associated with hospital participation in Centers for Medicare and Medicaid Services' Accountable Care Organization programs

BACKGROUND

In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models.

PURPOSE

The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs.

METHODOLOGY

Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs.

RESULTS

Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation.

CONCLUSION

MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts.

PRACTICE IMPLICATIONS

Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

A systematic review of vertical integration and quality of care, efficiency, and patient-centered outcomes

BACKGROUND

Small independent practices are increasingly giving way to more complex affiliations between provider organizations and hospital systems. There are several ways in which vertically integrated health systems could improve quality and lower the costs of care. But there are also concerns that integrated systems may increase the price and costs of care without commensurate improvements in quality and outcomes.

PURPOSE

Despite a growing body of research on vertically integrated health systems, no systematic review that we know of compares vertically integrated health systems (defined as shared ownership or joint management of hospitals and physician practices) to nonintegrated hospitals or physician practices.

METHODS

We conducted a systematic search of the literature published from January 1996 to November 2016. We considered articles for review if they compared the performance of a vertically integrated health system and examined an outcome related to quality of care, efficiency, or patient-centered outcomes.

RESULTS

Database searches generated 7,559 articles, with 29 articles included in this review. Vertical integration was associated with better quality, often measured as optimal care for specific conditions, but showed either no differences or lower efficiency as measured by utilization, spending, and prices. Few studies evaluated a patient-centered outcome; among those, most examined mortality and did not identify any effects. Across domains, most studies were observational and did not address the issue of selection bias.

PRACTICE IMPLICATIONS

Recent evidence suggests the trend toward vertical integration will likely continue as providers respond to changing payment models and market factors. A growing body of research on comparative health system performance suggests that integration of physician practices with hospitals might not be enough to achieve higher-value care. More information is needed to identify the health system attributes that contribute to improved outcomes, as well as which policy levers can minimize anticompetitive effects and maximize the benefits of these affiliations.

Mental health and chemical dependency services at US transplant centers

The purpose of this study was to assess the availability of mental health (MH) and chemical dependency (CD) services at US transplant centers, because appropriate psychosocial assessment and care is associated with better transplant outcomes. We used the 2017-2018 American Hospital Association survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases to quantify availability of services and examined associations of hospital- and health services area-level characteristics with odds of offering services with generalized linear mixed models. We found that 15% of transplant centers did not offer MH services and 62% did not offer CD services. Hospitals were more likely to offer MH services if they were larger (OR [95% CI]: 1.03 [1.01, 1.06]) and had a lower rate of uninsured patients in the health services area (OR [95% CI]: 0.89 [0.80, 0.99]) and were more likely to offer CD services if they were larger (OR [95% CI]: 1.02 [1.01, 1.03]) or were members of a system (OR [95% CI]: 2.31 [1.26, 4.24]). Additional research is needed to understand whether lack of MH or CD services at transplant centers affects patients' ability to access comprehensive psychosocial care and whether this affects patient outcomes.

Impact of the Medicare hospital readmissions reduction program on vulnerable populations

BACKGROUND

The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different types of vulnerable populations. The aim of this study was to analyze the impact of the HRRP on readmissions for three targeted conditions (acute myocardial infarction, heart failure, and pneumonia) among four types of vulnerable populations, including low-income patients, patients served by hospitals that serve a high percentage of low-income or Medicaid patients, and high-risk patients at the highest quartile of the Elixhauser comorbidity index score.

METHODS

Data on patient and hospital information came from the Nationwide Readmission Database (NRD), which contained all discharges from community hospitals in 27 states during 2010-2014. Using difference-in-difference (DD) models, linear probability regressions were conducted for the entire sample and sub-samples of patients and hospitals in order to isolate the effect of the HRRP on vulnerable populations. Multiple combinations of treatment and control groups and triple difference (DDD) methods were used for testing the robustness of the results. All models controlled for the patient and hospital characteristics.

RESULTS

There have been statistically significant reductions in readmission rates overall as well as for vulnerable populations, especially for acute myocardial infarction patients in hospitals serving the largest percentage of low-income patients and high-risk patients. There is also evidence of spillover effects for non-targeted conditions among Medicare patients compared to privately insured patients.

CONCLUSIONS

The HRRP appears to have created the right incentives for reducing readmissions not only overall but also for vulnerable populations, accruing societal benefits in addition to previously found reductions in costs. As the reduction in the rate of readmissions is not consistent across patient and hospital groups, there could be benefits to adjusting the policy according to the socioeconomic status of a hospital's patients and neighborhood.

Assessing Trends in Hospital System Structures From 2008 to 2015

BACKGROUND

The Affordable Care Act introduced a major systematic change aimed to promote coordination across the care continuum. Yet, it remains unknown the extent to which hospital system structures have changed following the Affordable Care Act. The structure of hospital systems has important implications for the cost, quality, and accessibility of health services.

OBJECTIVES

To assess trends in the structures of hospital systems.

RESEARCH DESIGN

We aggregated data from the American Hospital Association (AHA) Annual Survey to the system level. Using a panel of hospital systems from 2008 to 2015, we assessed trends in the number of hospital systems, their size, ownership characteristics, geospatial arrangements, and integration with outpatient services.

RESULTS

In the period 2008-2015, there was an increasing percentage of hospitals that were system affiliated as well as growth in the number of hospital systems. A greater percentage of hospital systems that were organized as moderately centralized systems transitioned to centralized systems than to decentralized systems (19.8% vs. 4.7%; P<0.001). In terms of geospatial arrangement, a greater percentage of hub-and-spoke systems moved to a regional design than to national systems (20.0% vs. 8.2%; P<0.05). An increasing trend over time toward greater integration with outpatient services was found in a measure of total system level integration with outpatient services.

CONCLUSIONS

Our findings suggest that hospital systems may be moving toward more regional designs. In addition, the trend of increasing integration offered across hospital systems overall, and as portion of total integration, suggests that systems may be increasing their services along the continuum of care.

Correlates of interorganizational relationship strategies among critical access hospitals

BACKGROUND

Interorganizational relationships (IORs) between hospitals and other health care providers have many potential benefits for critical access hospitals (CAHs) that operate in resource-constrained environments. Given the potential benefits of IORs, especially for CAHs, it is important to identify the conditions that support or hinder IOR development. However, most research examining IORs isolates individual types of relationships while ignoring the practical reality that many hospitals participate in a portfolio of relationships simultaneously.

PURPOSE

The aim of the study was to examine the IOR strategies of CAHs as a function of market and organizational characteristics.

METHODOLOGY

The sample consisted of CAHs operating in the United States between the years 2002 and 2012. For each year, hospitals were assigned to one of four mutually exclusive IOR categories: (a) no IOR, (b) vertical IOR only, (c) horizontal IOR only, and (d) both vertical and horizontal IOR. Organizational characteristics were categorized as structural, operational, and financial. Environmental characteristics were categorized as sociodemographic, physical, and health delivery system-related. A multinomial logistic regression model was used to assess the relationship between IOR strategies and organizational and environmental characteristics, with results reported as average marginal effects.

RESULTS

Approximately 41% of the CAHs were pursuing a combined vertical and horizontal IOR strategy, 20% were pursuing a vertical IOR-only strategy, 18% were pursuing a horizontal IOR-only strategy, and 21% were not engaged in an IOR strategy. Among the organizational characteristics, the type of IOR strategy used by a hospital varied as a function of ownership, total margin, days cash on hand, number of community orientation activities, and census. In contrast, among the environmental characteristics, only the number of community health centers in the community was associated with the type of IOR strategy pursued.

CONCLUSION

CAHs' construction of IOR portfolios may be more dependent on organizational attributes than by environmental conditions.

Do All Hospital Systems Have Market Power? Association Between Hospital System Types and Cardiac Surgery Prices

OBJECTIVE

This study explores the price implications of hospital systems by analyzing the association of system characteristics with selected cardiac surgery pricing.

DATA SOURCE

Using a large private insurance claim database, the authors identified 11 282 coronary artery bypass graft (CABG) cases and 49 866 percutaneous coronary intervention (PCI) cases from 2002 to 2007.

STUDY DESIGN

We conducted a retrospective observational study using generalized linear models.

PRINCIPAL FINDINGS

We found that the CABG and PCI prices in centralized health and physician insurance systems were significantly lower than the prices in stand-alone hospitals by 4.4% and 6.4%, respectively. In addition, the CABG and PCI prices in independent health systems were significantly lower than in stand-alone hospitals, by 15.4% and 14.5%, respectively.

CONCLUSION

The current antitrust guidelines tend to focus on the market share of merging parties and pay less attention to the characteristics of merging parties. The results of this study suggest that antitrust analysis could be more effective by considering characteristics of hospital systems.

Optimal Network for Patients with Severe Mental Illness: A Social Network Analysis

It is still unclear what the optimal structure of mental health care networks should be. We examine whether certain types of network structure have been associated with improved continuity of care and greater social integration. A social network survey was carried out, covering 954 patients across 19 mental health networks in Belgium in 2014. We found continuity of care to be associated with large, centralized, and homophilous networks, whereas social integration was associated with smaller, centralized, and heterophilous networks. Two important goals of mental health service provision, continuity of care and social integration, are associated with different types of network. Further research is needed to ascertain the direction of this association.

Preventable Hospital Admissions and 30-Day All-Cause Readmissions: Does Hospital Participation in Accountable Care Organizations Improve Quality of Care?

This study evaluates quality performance of hospitals participating in Medicare Shared Savings and Pioneer Accountable Care Organization (ACO) programs relative to nonparticipating hospitals. Overall, 198 ACO participating and 1210 propensity score matched, nonparticipating hospitals were examined in a difference-in-difference analysis, using data from 17 states in the years 2010-2013. The authors studied preventable hospitalizations for conditions sensitive to high-quality ambulatory care-chronic obstructive pulmonary disease (COPD) and asthma, chronic heart failure (CHF), complications of diabetes-and 30-day all-cause readmissions potentially influenced by hospital care. A decrease was found in preventable hospitalizations for COPD and asthma and for diabetes complications for ACO participating hospitals, but no significant differences for preventable CHF hospitalizations and 30-day readmissions. Mixed results may be attributable to insufficient incentives for ACO participating hospitals to decrease 30-day readmissions, whereas disease-focused initiatives may have a beneficial effect on preventable hospitalizations for COPD and asthma and complications of diabetes.

Hospital Characteristics and the Agency for Healthcare Research and Quality Inpatient Quality Indicators: A Systematic Review

BACKGROUND

The Agency for Healthcare Research and Quality Inpatient Quality Indicators (IQIs) include inpatient mortality for selected procedures and medical conditions. They have assumed an increasingly prominent role in hospital comparisons. Healthcare delivery and policy-related decisions need to be driven by reliable research that shows associations between hospital characteristics and quality of inpatient care delivered.

OBJECTIVES

To systematically review the literature on associations between hospital characteristics and IQIs.

METHODS

We systematically searched PubMed and gray literature (2000-2012) for studies relevant to 14 hospital characteristics and 17 IQIs. We extracted data for study characteristics, IQIs analyzed, and hospital characteristics (e.g., teaching status, bed size, patient volume, rural vs. urban location, and nurse staffing).

RESULTS

We included 16 studies, which showed few significant associations. Four hospital characteristics (higher hospital volume, higher nurse staffing, urban vs. rural status, and higher hospital financial resources) had statistically significant associations with lower mortality and selected IQIs in approximately half of the studies. For example, there were no associations between nurse staffing and four IQIs; however, approximately 50% of studies showed a statistically significant relationship between nurse staffing and lower mortality for six IQIs. For two hospital characteristics-higher bed size and disproportionate share percentage-all statistically significant associations had higher mortality. Five hospital characteristics (teaching status, system affiliation, ownership, minority-serving hospitals, and electronic health record status) had some studies with significantly positive and some with significantly negative associations, and many studies with no association.

CONCLUSIONS

We found few associations between hospital characteristics and mortality IQIs. Differences in study methodology, coding across hospitals, and hospital case-mix adjustment may partly explain these results. Ongoing research will evaluate potential mechanisms for the identified associations.

Impact of network size and demand on cost performance for high- and low-quality healthcare service organizations

Purpose

Healthcare networks are becoming ubiquitous, yet it is unclear how hospitals with varying quality capabilities would fare by being affiliated with large healthcare networks. The purpose of this paper is to first consider the deductive configuration perspective and distinguish high and low quality hospitals by using clinical and experiential quality as two dimensions of quality capability. Next, it examines the impact of healthcare network size on operating costs of hospitals. Additionally, the paper investigates the interaction effect of hospital demand and healthcare network size on operating costs.

Design/methodology/approach

The paper uses a dataset that was created by combining five separate sources. Cluster analysis technique is used to classify hospitals into four groups – holistic quality leaders (high clinical and experiential quality capability), experiential quality focusers (low clinical quality capability and high experiential quality capability), clinical quality focusers (high clinical capability and low experiential quality capability), and quality laggards (low clinical and experiential quality capability). The authors test the research hypotheses by means of regression analyses after controlling for several contextual characteristics.

Findings

The results show that affiliation with large healthcare networks reduces operating costs for quality laggards, but increases these costs for experiential quality focusers and clinical quality focusers. The hypothesized positive relationship between healthcare network size and costs is not supported for holistic quality leaders. The authors find that clinical quality focusers and holistic quality leaders can complement higher utilization levels in their operations due to increased demand and healthcare network size to reduce their operating costs per day.

Originality/value

There has been increasing evidence suggesting that hospitals must carefully manage both clinical and experiential quality. By focusing on both clinical and experiential quality, unlike experiential quality focusers and clinical quality focusers, holistic quality leaders are not adversely affected by the size of their network. The results suggest that experiential quality focusers and clinical quality focusers should either embrace holistic quality management or restrict the size of their networks to maintain their quality level and to reduce coordination costs.

Leveraging Diverse Data Sources to Identify and Describe U.S. Health Care Delivery Systems

Health care delivery systems are a growing presence in the U.S., yet research is hindered by the lack of universally agreed-upon criteria to denote formal systems. A clearer understanding of how to leverage real-world data sources to empirically identify systems is a necessary first step to such policy-relevant research. We draw from our experience in the Agency for Healthcare Research and Quality's Comparative Health System Performance (CHSP) initiative to assess available data sources to identify and describe systems, including system members (for example, hospitals and physicians) and relationships among the members (for example, hospital ownership of physician groups). We highlight five national data sources that either explicitly track system membership or detail system relationships: (1) American Hospital Association annual survey of hospitals; (2) Healthcare Relational Services Databases; (3) SK&A Healthcare Databases; (4) Provider Enrollment, Chain, and Ownership System; and (5) Internal Revenue Service 990 forms. Each data source has strengths and limitations for identifying and describing systems due to their varied content, linkages across data sources, and data collection methods. In addition, although no single national data source provides a complete picture of U.S. systems and their members, the CHSP initiative will create an early model of how such data can be combined to compensate for their individual limitations. Identifying systems in a way that can be repeated over time and linked to a host of other data sources will support analysis of how different types of organizations deliver health care and, ultimately, comparison of their performance.

Intra-hospital correlations among 30-day mortality rates in 18 different clinical and surgical settings

Objective

To examine whether a correlation exists in hospitals among 30-day mortality rates for different types of hospitalizations.

Design

Cross-sectional study of hospital care based on publically available Italian data from the National Outcome Evaluation Program Edition 2015 of the Italian Agency for Regional Health Services.

Setting and Participants

Patients hospitalized with a diagnosis of congestive heart failure, acute myocardial infarction, chronic renal failure, chronic obstructive pulmonary disease exacerbation, femoral neck fracture, ischemic stroke and non-variceal upper gastrointestinal bleeding, or those who underwent isolated cardiac valve procedure, isolated coronary artery bypass graft surgery, non-ruptured abdominal aortic aneurysm repair and interventions for the following tumors: colon, kidney, brain, lung, stomach, rectal, liver or pancreatic cancer.

Main Outcome Measures

Condition-specific 30-day crude and risk-adjusted mortality rates.

Results

A total of 808 280 admissions were reported from 844 institutions (median of 4 conditions evaluated per hospital; interquartile range 2-8). Volumes and outcome varied by clinical and surgical conditions across hospitals. Out of 153 pairs of different conditions, 41 were statistically significant in terms of concordance with crude mortality rates and 44 for their adjusted values. The hospital mean percentile rank for 30-day mortality, a composite measure that summarized the multiple indicators, increased significantly alongside number of conditions per hospital with a significant reduction of mortality when most of the studied conditions were treated in the same hospital.

Conclusions

The variability in 30-day mortality rates at hospital level and the correlation between risk mortality rates suggest that there may be common hospital-wide factors influencing short-term mortality.

Impact of Health System Affiliation on Hospital Resource Use Intensity and Quality of Care

OBJECTIVE

To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality.

DATA SOURCES

Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012.

STUDY DESIGN

We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals.

DATA COLLECTION

Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association.

PRINCIPAL FINDINGS

Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals.

CONCLUSIONS

Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options.

Heart Failure in Rural Communities

Patients with chronic heart failure (CHF) living in rural areas face an increased risk of adverse cardiovascular events. Even in countries with universal access to health care, rural areas are characteristically underserved, with reduced health care providers supply, greater distance to health care centers, decreased physician density with higher reliance on generalists, and high health care staff turnover. On the other hand, patient-related characteristics vary widely among published data. This review describes the epidemiology of CHF in rural or remote settings, organizational and patient-related factors involved in cardiovascular outcomes, and the role of interventions to improve rural health care.

Predictors of Gaps in Patient Safety and Quality in U.S. Hospitals

OBJECTIVE

To explore predictors of gaps between observed and best possible Hospital Compare scores in U.S. hospitals.

DATA SOURCES

American Hospital Association Annual Survey; Area Resource Files; Centers for Medicare and Medicaid Services Medicare Provider and Analysis Review; and Hospital Compare data.

STUDY DESIGN

Using Stochastic Frontier Analysis and secondary cross-sectional data, gaps between the best possible and actual scores of Hospital Compare quality measures were estimated. Poisson regressions were used to ascertain financial, organizational, and market predictors of those gaps.

DATA EXTRACTION

Data were cleaned and matched based on hospital Medicare IDs. All U.S. hospitals that matched on analysis variables in 2007 were in the study (1,823-2,747, depending upon gap variable).

PRINCIPAL FINDINGS

Most hospitals have a greater than 10 percent gap in quality indicators. Payer mix, registered nurse staffing, size, case mix index, accreditation, being a teaching hospital, market competition, urban location, and region were strong predictors of gaps, although the direction of the association with gaps was not uniform across outcomes.

CONCLUSIONS

A significant percentage of hospitals have gaps between their best possible and observed quality scores. It may be better to use gap scores than observed scores in payments systems. More SFA research is needed to know how to lower gaps through changes in hospital and market characteristics.

The influence of institutional pressures on hospital electronic health record presence

Electronic health records (EHR) are a promising form of health information technology that could help US hospitals improve on their quality of care and costs. During the study period explored (2005-2009), high expectations for EHR diffused across institutional stakeholders in the healthcare environment, which may have pressured hospitals to have EHR capabilities even in the presence of weak technical rationale for the technology. Using an extensive set of organizational theory-specific predictors, this study explored whether five factors - cause, constituents, content, context, and control - that reflect the nature of institutional pressures for EHR capabilities motivated hospitals to comply with these pressures. Using information from several national data bases, an ordered probit regression model was estimated. The resulting predicted probabilities of EHR capabilities from the empirical model's estimates were used to test the study's five hypotheses, of which three were supported. When the underlying cause, dependence on constituents, or influence of control were high and potential countervailing forces were low, hospitals were more likely to employ strategic responses that were compliant with the institutional pressures for EHR capabilities. In light of these pressures, hospitals may have acquiesced, by having comprehensive EHR capabilities, or compromised, by having intermediate EHR capabilities, in order to maintain legitimacy in their environment. The study underscores the importance of our assessment for theory and policy development, and provides suggestions for future research.

Effect of hospital referral networks on patient readmissions

Previous studies have shown that referral networks encompass important mechanisms of coordination and integration among hospitals, which enhance numerous organizational-level benefits, such as productivity, efficiency, and quality of care. The present study advances previous research by demonstrating how hospital referral networks influence patient readmissions. Data include 360,697 hospitalization events within a regional community of hospitals in the Italian National Health Service. Multilevel hierarchical regression analysis tests the impacts of referral networks' structural characteristics on patient hospital readmissions. The results demonstrate that organizational centrality in the overall referral network and ego-network density have opposing effects on the likelihood of readmission events within hospitals; greater centrality is negatively associated with readmissions, whereas greater ego-network density increases the likelihood of readmission events. Our findings support the (re)organization of healthcare systems and provide important indications for policymakers and practitioners.

Did budget cuts in Medicaid disproportionate share hospital payment affect hospital quality of care?

BACKGROUND

Medicaid Disproportionate Share Hospital (DSH) payments are one of the major sources of financial support for hospitals providing care to low-income patients. However, Medicaid DSH payments will be redirected from hospitals to subsidize individual health insurance purchase through US national health reform.

OBJECTIVES

The purpose of this study is to examine the association between Medicaid DSH payment reductions and nursing-sensitive and birth-related quality of care among Medicaid/uninsured and privately insured patients.

METHODS

Economic theory of hospital behavior was used as a conceptual framework, and longitudinal data for California hospitals from 1996 to 2003 were examined. Hospital-fixed effects regression models were estimated. The unit of analysis is at the hospital level, examining 2 aggregated measures based on the payer category of discharged patients (ie, Medicaid/uninsured and privately insured).

PRINCIPAL FINDINGS

The overall study findings provide at best weak evidence of an association between net Medicaid DSH payments and hospital quality of care for either Medicaid/uninsured or the privately insured patients. The magnitudes of the effects are small and only a few have significant DSH effects.

CONCLUSIONS

Although this study does not find evidence suggesting that reducing Medicaid DSH payments had a strong negative impact on hospital quality of care for Medicaid/uninsured or privately insured patients, the results are not necessarily predictive of the impact national health care reform will have. Research is necessary to monitor hospital quality of care as this reform is implemented.

Correlations among risk-standardized mortality rates and among risk-standardized readmission rates within hospitals

BACKGROUND

Hospital-level, 30-day risk-standardized mortality and readmission rates are publicly reported for Medicare patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia, but the correlations among mortality rates and among readmission rates within US hospitals for these conditions are unknown. Correlation among measures within the same hospital would suggest that there are common hospital-wide quality factors.

METHODS

We designed a cross-sectional study of US hospital 30-day risk-standardized mortality and readmission rates for Medicare fee-for-service beneficiaries from July 2007 to June 2009. We assessed the correlation between pairs of risk-standardized mortality rates and pairs of risk-standardized readmission rates for AMI, HF, and pneumonia.

RESULTS

The mortality cohort included 4559 hospitals, and the readmission cohort included 4468 hospitals. Every mortality measure was significantly correlated with every other mortality measure (range of correlation coefficients, 0.27-0.41, P < 0.0001 for all correlations). Every readmission measure was significantly correlated with every other readmission measure (range of correlation coefficients, 0.32-0.47, P < 0.0001 for all correlations). For each condition pair and outcome, one-third or more of hospitals were in the same quartile of performance. Correlations were highest within large, nonprofit, urban, and/or Council of Teaching Hospitals members. For any given condition pair, the correlation between readmission rates was significantly higher than the correlation between mortality rates (P < 0.01 for all pairs).

CONCLUSION

Risk-standardized readmission rates are moderately correlated with each other within hospitals, as are risk-standardized mortality rates. This suggests that there may be common hospital-wide factors affecting hospital outcomes.

Examination of hospital characteristics and patient quality outcomes using four inpatient quality indicators and 30-day all-cause mortality

The study objective was to examine hospital mortality outcomes and structure using 2008 patient-level discharges from general community hospitals. Discharges from Florida administrative files were merged to the state mortality registry. A cross-sectional analysis of inpatient mortality was conducted using Inpatient Quality Indicators (IQIs) for acute myocardial infarction (AMI), congestive heart failure (CHF), stroke, pneumonia, and all-payer 30-day postdischarge mortality. Structural characteristics included bed size, volume, ownership, teaching status, and system affiliation. Outcomes were risk adjusted using 3M APR-DRG. Volume was inversely correlated with AMI, CHF, stroke, and 30-day mortality. Similarities and differences in the direction and magnitude of the relationship of structural characteristics to 30-day postdischarge and IQI mortality measures were observed. Hospital volume was inversely correlated with inpatient mortality outcomes. Other hospital characteristics were associated with some mortality outcomes. Further study is needed to understand the relationship between 30-day postdischarge mortality and hospital quality.

A taxonomy of state public health preparedness units: an empirical examination of organizational structure

OBJECTIVE

State public health preparedness units (SPHPUs) were developed in response to federal funding to improve response to disasters: a responsibility that had not traditionally been within the purview of public health. The SPHPUs were created within the existing public health organizational structure, and their placement may have implications for how the unit functions, how communication takes place, and ultimately how well the key responsibilities are performed. This study empirically identifies a taxonomy of similarly structured SPHPUs and examines whether this structure is associated with state geographic, demographic, and threat-vulnerability characteristics.

DESIGN

Data representing each SPHPU were extracted from publically available sources, including organizational charts and emergency preparedness plans for 2009. A cross-sectional segmentation analysis was conducted of variables representing structural attributes.

SETTING AND PARTICIPANTS

Fifty state public health departments.

MAIN OUTCOME MEASURES

Variables representing "span of control" and "hierarchal levels" were extracted from organizational charts. Structural "complexity" and "centralization" were extracted from state emergency preparedness documents and other secondary sources.

RESULTS

On average, 6.6 people report to the same manager as the SPHPU director; 2.1 levels separate the SPHPU director from the state health officer; and a mean of 13.5 agencies collaborate with SPHPU during a disaster. Despite considerable variability in how SPHPUs had been structured, results of the cluster and principal component analysis identified 7 similarly structured groups. Neither the taxonomic groups nor the individual variables representing structure were found to be associated with state characteristics, including threat vulnerabilities.

CONCLUSIONS

Our finding supports the hypothesis that SPHPUs are seemingly inadvertently (eg, not strategically) organized. This taxonomy provides the basis for which future research can examine how SPHPU structure relates to performance measures and preparedness strategies.

Dynamic analysis of interhospital collaboration and competition: empirical evidence from an Italian regional health system

BACKGROUND

Policymakers stimulate competition in universalistic health-care systems while encouraging the formation of service provision networks among hospital organizations. This article addresses a gap in the extant literature by empirically analyzing simultaneous collaboration and competition between hospitals within the Italian National Health Service, where important procompetition reforms have been implemented.

PURPOSE

To explore how rising competition between hospitals relates to their propensity to collaborate with other local providers.

METHODS

Longitudinal data on interhospital collaboration and competition collected in an Italian region from 2003 to 2007 are analyzed. Social network analysis techniques are applied to study the structure and dynamics of interhospital collaboration. Negative binomial regressions are employed to explore how interhospital competition relates to the collaborative network over time.

RESULTS

Competition among providers does not hinder interhospital collaboration. Collaboration is primarily local, with resource complementarity and differentials in the volume of activity and hospital performance explaining the propensity to collaborate.

CONCLUSIONS

Formation of collaborative networks among hospitals is not hampered by reforms aimed at fostering market forces. Because procompetition reforms elicit peculiar forms of managed competition in universalistic health systems, studies are needed to clarify whether the positive association between interhospital competition and collaboration can be generalized to other health-care settings.

Understanding hospital performance: the role of network ties and patterns of competition

BACKGROUND

To improve efficiency and quality, a number of policies have recently been implemented to increase competition and cooperation within the health systems of many countries. We theorize how hospital performance, measured as productivity, is contingent upon network embeddedness, the extent to which a hospital is involved in a network of interconnected interorganizational relationships.

PURPOSE

The aim of this study was to explore the effects on hospital productivity resulting from both collaborative network ties and competitive relationships between providers.

METHODOLOGY

We used panel data collected between 2003 and 2007 from 35 hospitals in Abruzzo, one of the most populated regions of central Italy. We used secondary data of hospital activities regarding both clinical and administrative aspects. For each year, we examined the intensity of interhospital competition and the unique position each provider has within a larger network of relationships with other hospitals. Other idiosyncratic organizational characteristics were examined as well.

FINDINGS

Our results show that hospital productivity is negatively related to the degree of competition that a hospital faces and positively related to the degree with which hospitals establish collaborative relationships. We also found that the negative impact on hospital productivity due to competition was lessened when hospitals were more likely to create cooperative network ties.

PRACTICE IMPLICATIONS

Because interhospital collaboration and competition are related to hospital productivity, they should constitute a core element in the strategic planning of a hospital's operation. Health administrators should implement policies that favor collaborative network ties at the regional level and mitigate interorganizational rivalries when establishing collaborative relationships with local competitors.

Quality of care and patient outcomes in critical access rural hospitals

CONTEXT

Critical access hospitals (CAHs) play a crucial role in the US rural safety net. Current policy efforts have focused primarily on helping these small, isolated hospitals remain financially viable to ensure access for individuals living in rural areas in the United States; however, little is known about the quality of care they provide or the outcomes their patients achieve.

OBJECTIVES

To examine the quality of care and patient outcomes at CAHs and to understand why patterns of care might differ for CAHs vs non-CAHs.

DESIGN, SETTING, AND PATIENTS

A retrospective analysis in 4738 US hospitals of Medicare fee-for-service beneficiaries with acute myocardial infarction (AMI) (10,703 for CAHs vs 469,695 for non-CAHs), congestive heart failure (CHF) (52,927 for CAHs vs 958,790 for non-CAHs), and pneumonia (86,359 for CAHs vs 773,227 for non-CAHs) who were discharged in 2008-2009.

MAIN OUTCOME MEASURES

Clinical capabilities, performance on processes of care, and 30-day mortality rates, adjusted for age, sex, race, and medical comorbidities.

RESULTS

Compared with other hospitals (n = 3470), 1268 CAHs (26.8%) were less likely to have intensive care units (380 [30.0%] vs 2581 [74.4%], P < .001), cardiac catheterization capabilities (6 [0.5%] vs 1654 [47.7%], P < .001), and at least basic electronic health records (80 [6.5%] vs 445 [13.9%], P < .001). The CAHs had lower performance on processes of care than non-CAHs for all 3 conditions examined (concordance with Hospital Quality Alliance process measures for AMI, 91.0% [95% CI, 89.7%-92.3%] vs 97.8% [95% CI, 97.7%-97.9%]; for CHF, 80.6% [95% CI, 79.2%-82.0%] vs 93.5% [95% CI, 93.3%-93.7%]; and for pneumonia, 89.3% [95% CI, 88.6%-90.0%] vs 93.7% [95% CI, 93.6%-93.9%]; P < .001 for each). Patients admitted to CAHs had higher 30-day mortality rates for each condition than those admitted to non-CAHs (for AMI: 23.5% vs 16.2%; adjusted odds ratio [OR], 1.70; 95% confidence interval [CI], 1.61-1.80; P < .001; for CHF: 13.4% vs 10.9%; adjusted OR, 1.28; 95% CI, 1.23-1.32; P < .001; and for pneumonia: 14.1% vs 12.1%; adjusted OR, 1.20; 95% CI, 1.16-1.24; P < .001).

CONCLUSION

Compared with non-CAHs, CAHs had fewer clinical capabilities, worse measured processes of care, and higher mortality rates for patients with AMI, CHF, or pneumonia.

Strategy, Structure, and Patient Quality Outcomes in Ambulatory Surgery Centers (1997-2004)

The purpose of this study was to examine potential associations among ambulatory surgery centers’ (ASCs) organizational strategy, structure, and quality performance. The authors obtained several large-scale, all-payer claims data sets for the 1997 to 2004 period. The authors operationalized quality performance as unplanned hospitalizations at 30 days after outpatient arthroscopy and colonoscopy procedures . The authors draw on related organizational theory, behavior, and health services research literatures to develop their conceptual framework and hypotheses and fitted fixed and random effects Poisson regression models with the count of unplanned hospitalizations. Consistent with the key hypotheses formulated, the findings suggest that higher levels of specialization and the volume of procedures may be associated with a decrease in unplanned hospitalizations at ASCs.