Dolores G. Clement

Impacts of market and organizational characteristics on hospital efficiency and uncompensated care.

Background: Hospitals have confronted a difficult financial environment given many factors, including expansion of managed care, changes in public policy, growing market competition for certain services, and growth in the number of uninsured. Policy makers have expressed concern that hospitals may forgo providing care to the indigent as a means to reduce costs and become more efficient when faced with financial pressures. Purpose: This article examined the effects of environmental pressures on two dimensions of hospital performance: hospital efficiency and uncompensated care provision. Methodology/Approach: Longitudinal data for the Commonwealth of Virginia from 1998 to 2004 were analyzed. Data Envelopment Analysis and bivariate probit were used to examine the factors associated with efficiency and uncompensated care. Findings: The results indicated that a positive relationship between hospital efficiency and uncompensated care provision exists. That is, hospitals that are categorized as efficient are likely to provide more uncompensated care. We also found that hospitals tended to provide more uncompensated care when increased demand for these services occurred in a market. Increases in Medicare or Medicaid patient share reduced the provision of uncompensated care. In relation to hospital efficiency, the results indicated that HMO penetration and Medicaid patient share reduced hospital efficiency. Practice Implications: This study found that efficient hospitals tend to provide more uncompensated care over time. The findings also suggest that hospitals alter their efficiency and provision of uncompensated care in response to a number of environmental pressures, but it may depend on the type of pressures or uncertainties encountered.

Are Women With Self-Reported Cognitive Limitations at Risk for Underutilization of Mammography?

Functional limitations (namely, limitations in activities of daily living and instrumental activities of daily living) have previously been demonstrated to exert a negative influence on mammography utilization. This study examines self-reported cognitive limitation in addition to sociodemographic, functional, and other health-related factors to determine their relationship with self-reported mammography use in the previous year. Data from the 1998 National Health Interview Survey was analyzed for 6,053 women, ages 50 years and older. Just over 44% of women with self-reported cognitive impairment (n = 351) reported a mammogram in the previous year, compared with 55% of unimpaired women (n = 5,702). Logistic regression analysis indicates that the presence of a cognitive limitation significantly reduced the likelihood of a mammography in the previous year (p < 0.05) after controlling for other sociodemographic, functional, and health-related factors. Women with self-reported cognitive limitations were 30% less likely than unimpaired women to utilize mammography after controlling for various forms of disability and other factors. Thus, women with cognitive impairments may be at risk for underutilization of mammography and therefore at risk for later-stage breast cancer diagnoses.

Heart failure symptom relationships: a systematic review.

Background:Heart failure is a prevalent chronic health condition in the United States. Individuals who have heart failure experience as many as 2 to 9 symptoms. The examination of relationships among heart failure symptoms may benefit patients and clinicians who are charged with managing heart failure symptoms. Objective:The purpose of this systematic review was to summarize what is known about relationships among heart failure symptoms, a precursor to the identification of heart failure symptom clusters, as well as to examine studies specifically addressing symptom clusters described in this population. Methods:The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed in the conduct of this systematic review. PubMed, PsychINFO, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Database were searched using the search term heart failure in combination with a pair of symptoms. Results:Of a total of 1316 studies identified from database searches, 34 were included in this systematic review. More than 1 investigator found a moderate level of correlation between depression and fatigue, depression and anxiety, depression and sleep, depression and pain, anxiety and fatigue, and dyspnea and fatigue. Conclusions:The findings of this systematic review provide support for the presence of heart failure symptom clusters. Depression was related to several of the symptoms, providing an indication to clinicians that individuals with heart failure who experience depression may have other concurrent symptoms. Some symptom relationships such as the relationships between fatigue and anxiety or sleep or pain were dependent on the symptom characteristics studied. Symptom prevalence in the sample and restricted sampling may influence the robustness of the symptom relationships. These findings suggest that studies defining the phenotype of individual heart failure symptoms may be a beneficial step in the study of heart failure symptom clusters.

Are consumers reshaping hospitals? Complementary and alternative medicine in U.S. Hospitals, 1999-2003.

Abstract: All types of acute care hospitals across the U.S. are becoming increasingly involved in offering CAM services. Hospitals appear to be responding to consumer demand, CAM specific market forces, and their organizational missions but not to regulatory mandates.

The diffusion of bariatric surgery programs within US community hospitals, 1995 to 2000

This paper assessed the rapid diffusion of bariatric surgery programs, the surgical treatment for morbid obesity, in US hospitals between 1995 and 2000 and the impact of organisational factors and environmental factors associated with adoption or expansion. We found that diffusion of bariatric surgery programs was consistent with findings of diffusion of other medical innovation with two distinct components: expansion in existing programs and initiation of new programs. Our results provided limited support for the association between some organisational and environmental factors and development of bariatric surgery programs in hospitals. Concerning the cost growth associated with the dramatic increase in bariatric procedures, different implications could be derived from this study for hospitals, payers and policy makers.

HMO survival: determination of optimal size.

The concept of prepaid health care as embodied by health maintenance organizations (HMOs) provides variety in the provision and coverage of health care benefits. This is important in the development of a diverse and appropriate health care system for the US. HMOs were developed to provide a cost-effective, alternative form of health care delivery and financing to ensure access and continuity. HMOs can achieve this only by sustaining organizational viability. A survivor analysis modelling technique is employed to analyze the optimal size of HMOs by region model type and profit status over the period from 1977 through 1986. A determination of an optimal size category establishes a survival criterion for HMOs. A minimum enrolment of at least 25,000 members should be achieved as quickly as possible. This minimum standard can be used as a guide for initial success, however a higher enrollment in the 40,000 to 60,000 member range appears necessary for longer-term survival.

Evaluating Health Services, Programs, and Systems

Evaluation will continue to play an important role for health care managers in all coun- tries, particularly in light of population-based planning, for several reasons. First, the organiza- tion of formal and informal alliances in the health care industry and the competition among them will prompt managers to continuously evaluate morbidity, mortality, and disability trends associated with service delivery and treatment of health problems in order to modify or discard services and treatments that are not efficient, effective, and of high quality. Second, the number and size of social programs have grown over time with the broadening scope of government involvement in health and social service issues. The application of epidemiological methods is useful for monitoring the health of the population and identifying changes over time. Epidemiology is based on the premise that health problems that can be identified often can be corrected. Last, programs addressing the needs of aging populations will proliferate and necessitate evaluation to assess changing needs, assure that expectations are met, and promote achievement of the desired health outcomes.Epidemiological methods can be used effectively to target identified needs and to assess the implications of programs or interventions for health care policy.