Douglas R. Wholey

The effects of patient, hospital, and physician characteristics on length of stay and mortality.

This article compares the ability of hospital and physician characteristics to explain variations in length of stay and mortality, controlling for factors associated with severity of illness. The analysis is based on 54,571 discharges, covering 11 medical and five surgical conditions, from nonfederal general hospitals in one state during 1988. Results suggest that both hospital and physician characteristics are important predictors of both outcome measures. Contrary to previous research, the volume of patients with the same condition treated by the hospital increases both length of stay and mortality. The volume of patients with the same condition treated by the physician increases length of stay among patients with medical conditions, decreases length of stay among those with surgical conditions, and decreases mortality. One interesting finding is that the medical school attended by the physician influences the patients length of stay. Findings are interpreted in light of research evidence on factors affecting medical outcomes and recent federal efforts to improve quality of care.

Management Practices and the Quality of Care in Cardiac Units

IMPORTANCE To improve the quality of health care, many researchers have suggested that health care institutions adopt management approaches that have been successful in the manufacturing and technology sectors. However, relatively little information exists about how these practices are disseminated in hospitals and whether they are associated with better performance. OBJECTIVES To describe the variation in management practices among a large sample of hospital cardiac care units; assess association of these practices with processes of care, readmissions, and mortality for patients with acute myocardial infarction (AMI); and suggest specific directions for the testing and dissemination of health care management approaches. DESIGN We adapted an approach used to measure management and organizational practices in manufacturing to collect management data on cardiac units. We scored performance in 18 practices using the following 4 dimensions: standardizing care, tracking of key performance indicators, setting targets, and incentivizing employees. We used multivariate analyses to assess the relationship of management practices with process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for acute myocardial infarction (AMI). SETTING Cardiac units in US hospitals. PARTICIPANTS Five hundred ninety-seven cardiac units, representing 51.5% of hospitals with interventional cardiac catheterization laboratories and at least 25 annual AMI discharges. MAIN OUTCOME MEASURES Process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for AMI. RESULTS We found a wide distribution in management practices, with fewer than 20% of hospitals scoring a 4 or a 5 (best practice) on more than 9 measures. In multivariate analyses, management practices were significantly correlated with mortality (P = .01) and 6 of 6 process measures (P < .05). No statistically significant association was found between management and 30-day readmissions. CONCLUSIONS AND RELEVANCE The use of management practices adopted from manufacturing sectors is associated with higher process-of-care measures and lower 30-day AMI mortality. Given the wide differences in management practices across hospitals, dissemination of these practices may be beneficial in achieving high-quality outcomes.

Public health systems: a social networks perspective.

OBJECTIVE To examine the relationship between public health system network density and organizational centrality in public health systems and public health governance, community size, and health status in three public health domains. DATA SOURCES/STUDY SETTING During the fall and the winter of 2007-2008, primary data were collected on the organization and composition of eight rural public health systems. STUDY DESIGN Multivariate analysis and network graphical tools are used in a case comparative design to examine public health system network density and organizational centrality in the domains of adolescent health, senior health, and preparedness. Differences associated with public health governance (centralized, decentralized), urbanization (micropolitan, noncore), health status, public health domain, and collaboration area are described. DATA COLLECTION/EXTRACTION METHODS Site visit interviews with key informants from local organizations and a web-based survey administered to local stakeholders. PRINCIPAL FINDINGS Governance, urbanization, public health domain, and health status are associated with public health system network structures. The centrality of local health departments (LHDs) varies across public health domains and urbanization. Collaboration is greater in assessment, assurance, and advocacy than in seeking funding. CONCLUSIONS If public health system organization is causally related to improved health status, studying individual system components such as LHDs will prove insufficient for studying the impact of public health systems.

The HMO industry: evolution in population demographics and market structures.

With the exception of Kaiser, HMOs in the 1970s were predominantly locally sponsored organizations serving limited geographic markets. National HMO firms proliferated in the 1980s so that today they compete among themselves and with local HMOs in most metropolitan areas of the United States. Along with the growth of national firms, the mid-1980s saw an increase in HMO mergers, acquisitions, consolidations and bankruptcies (Freudenheim 1988). What was once termed the “HMO movement” is now universally, and sometimes cynically, referred to as the “HMO industry” (Gruber, Shadle, and Polich 1988). The dynamics of change within the HMO industry have been chronicled in yearly published reports (or “snapshots”) and sporadic coverage of newsworthy events, such as the dissolution of Maxicare Health Plans (Pincus 1988). However, analyses of HMO industry changes have focused primarily on overall growth in enrollment and in number of HMOs (see, for instance, Gruber, Shadle, and Polich 1988). In this article, we extend these analyses, employing a population ecology framework and a longitudinal data set covering the years 1978–1989. We begin by discussing the changing environment for HMOs over the past decade and critiquing the existing literature on the determinants of HMO growth, entry, and exit. Then we present data related to the evolutions of HMO organizational demographics and market structures during this period. First, we describe the overall development of the industry, with an emphasis on HMO entries, exits, mergers, and acquisitions. We follow this with an analysis of changes over time in the distribution of HMOs, both by type of HMO (e.g., individual practice association) and by national versus local HMO sponsorship. Data are also presented concerning changes in local HMO market structures over time. A concluding discussion focuses on factors that may influence future patterns of changes in the HMO industry.

The Effect of Physician and Corporate Interests on the Formation of Health Maintenance Organizations

Change in professional social organization is in part a consequence of client interests, professional interests, and professional heterogeneity. Professional reorganization, which often manifests itself in organization formation, should be most likely to occur when interests of corporate clients are strong and professional diversity leads some professional groups to expand their jurisdiction by organizing. We examine these arguments with a study of health maintenance organization (HMO) formation. We find that corporate interests, professional interests, and professional demographics affect professional interests, with the larger effects being attributed to corporate interests and professional demographics.

Rural Emergency Department Staffing and Participation in Emergency Certification and Training Programs

CONTEXT The practice of emergency medicine presents many challenges in rural areas. PURPOSE We describe how rural hospitals nationally are staffing their Emergency Departments (EDs) and explore the participation of rural ED physicians and other health care professionals in selected certification and training programs that teach skills needed to provide high-quality emergency care. METHODS A national telephone survey of a random sample of rural hospitals with 100 or fewer beds was conducted in June to August 2006. Respondents included ED nurse managers and Directors of Nursing. A total of 408 hospitals responded (96% response rate). FINDINGS A majority of rural hospitals use more than one type of staffing to cover the ED. The type of staffing varies by time period and ED volume. On weekdays, about onethird of hospitals use physicians on their own medical staff; one third use contracted coverage; 18% use both; and 14% use physician assistants and/or nurse practitioners with a physician on-call. Hospitals are more likely to use a combination of medical staff and contracted coverage on evenings and weekends. Advanced Cardiac Life Support training is common, but Pediatric Advanced Life Support, Advanced Trauma Life Support, and training in working as a team are less common. More registered nurses working in rural EDs have taken the Trauma Nursing Core Course than the Emergency Nursing Pediatric Course. CONCLUSIONS Rural ED staff would benefit from additional continuing education opportunities, particularly in terms of specialized skills to care for pediatric emergency patients and trauma patients and training in working effectively in teams.

Physicians’ Perceptions of Managed Care: A Review of the Literature

In this article, the authors review the health services research literature regarding physician attitudes and opinions relating to managed care and how managed care has affected their clinical practice. This literature suggests that physician perceptions of managed care are largely related to the nature of their ties to managed care plans and to their selection of practice setting. There are substantial limitations in study designs and execution, suggesting that many of the published findings should be viewed with caution; the research basis regarding physicians’ perceptions of managed care is not as strong as the number of articles published on this subject would suggest. The review concludes with suggestions for the conduct of future research on this topic.

The diffusion of information technology among health maintenance organizations.

This article examines the information technology functions, staffing and cost, services provided, and advanced technologies among health maintenance organizations (HMOs) using a national sample of HMOs from mid-1995. HMOs have a well-developed capability to use data from administrative functions, such as claims processing. Nationally affiliated HMOs and HMOs in markets with greater HMO penetration support more IT functions. Relatively little work has been completed integrating clinical with administrative systems.

Care guides: employing nonclinical laypersons to help primary care teams manage chronic disease.

Lay persons (“care guides”) without previous clinical experience were hired by a primary care clinic, trained for 2 weeks, and assigned to help 332 patients and their providers manage their diabetes, hypertension, and congestive heart failure. One year later, failure by these patients to meet nationally recommended guidelines was reduced by 28%, P < .001. Improvement was seen in tobacco usage, blood pressure control, pneumonia vaccination, low-density lipoprotein cholesterol levels, annual eye examinations, aspirin use, and microalbuminuria testing. Care guides served an average of 111 patients at an annual per patient cost of

Enter at Your Own Risk: HMO Participation and Enrollment in the Medicare Risk Market

392. Further testing of this model is warranted.