Gordon D. Brown

Effect of physician profiling on utilization - Meta-analysis of randomized clinical trials

OBJECTIVES: An American Medical Association survey reported that more than half of physicians are subjects of either clinical or economic profiling. This multilevel meta-analysis was designed to assess the clinical effect of peer-comparison feedback intervention (profiles) in changing practice patterns.METHODS: Systematic computerized and manual searches were combined to retrieve articles on randomized controlled clinical trials testing profiling reports. Eligible studies were randomized, controlled clinical trials that tested peer-comparison feedback intervention and measured utilization of clinical procedures. To use all available information, data were abstracted and analyzed on three levels: (1) direction of effects, (2)p value from the statistical comparison, and (3) odds ratio (OR).MAIN RESULTS: In the 12 eligible trials, 553 physicians were profiled. The test result wasp<.05 for the vote-counting sign test of 12 studies (level 1) andp<.05 for the z-transformation test of 8 studies (level 2). There were 5 trials included in the OR analysis (level 3). The primary effect variable in two of the 5 trials had a nonsignificant OR. However, the overall OR calculated by the Mantel-Haenszel method was significant (1.091, confidence interval: 1.045 to 1.136).CONCLUSIONS: Profiling has a statistically significant, but minimal effect on the utilization of clinical procedures. The results of this study indicate a need for controlled clinical evaluations before subjecting large numbers of physicians to utilization management interventions.

From a blame culture to a just culture in health care.

Background: A prevailing blame culture in health care has been suggested as a major source of an unacceptably high number of medical errors. A just culture has emerged as an imperative for improving the quality and safety of patient care. However, health care organizations are finding it hard to move from a culture of blame to a just culture. Purpose: We argue that moving from a blame culture to a just culture requires a comprehensive understanding of organizational attributes or antecedents that cause blame or just cultures. Health care organizations need to build organizational capacity in the form of human resource (HR) management capabilities to achieve a just culture. Methodology: This is a conceptual article. Health care management literature was reviewed with twin objectives: (a) to ascertain if a consistent pattern existed in organizational attributes that lead to either blame or just cultures and (2) to find out ways to reform a blame culture. Conclusions: On the basis of the review of related literature, we conclude that (a) a blame culture is more likely to occur in health care organizations that rely predominantly on hierarchical, compliance-based functional management systems; (b) a just or learning culture is more likely to occur in health organizations that elicit greater employee involvement in decision making; and (c) human resource management capabilities play an important role in moving from a blame culture to a just culture. Practice Implications: Organizational culture or human resource management practices play a critical role in the health care delivery process. Health care organizations need to develop a culture that harnesses the ideas and ingenuity of health care professional by employing a commitment-based management philosophy rather than strangling them by overregulating their behaviors using a control-based philosophy. They cannot simply wish away the deeply entrenched culture of blame nor can they outsource their way out of it. Health care organizations need to build internal human resource management capabilities to bring about the necessary changes in their culture and management systems and to become learning organizations.

Methods of Randomized Controlled Clinical Trials in Health Services Research

The randomized controlled clinical trial is an increasingly used method in health services research. Analysis of methodology is needed to accelerate practical implementation of trial results, select trials for meta-analysis, and improve trial quality in health services research. The objectives of this study are to explore the methodology of health services research trials, create and validate a streamlined quality evaluation tool, and identify frequent quality defects and confounding effects on quality. The authors developed a quality questionnaire that contained 20 evaluation criteria for health services research trials. One hundred one trials from the Columbia Registry of Controlled Clinical Trials were evaluated using the new quality tool. The overall agreement between independent reviewers, Cohens kappa, was 0.94 (±0.01). Of a possible score of 100, the trials received an average score of 54.8 (±12.5). Five evaluation criteria indicated significant quality deficiencies (sample size, description of case selection, data on possible adverse effects, analysis of secondary effect variables, and retrospective analysis). The quality of study characteristics was significantly weaker than the quality of reporting characteristics (P <0.001). The total average scores of Medline-indexed journals were better than the non-Medline-indexed journals (P < 0.001). There was a positive correlation between the overall quality and year of publication (R = 0.21, P < 0.05). The authors conclude that the new quality evaluation tool leads to replicable results and there is an urgent need to improve several study characteristics of clinical trials. In comparison to drug trials, site selection, randomization, and blinding often require different approaches in health services research.

HR and IT capabilities and complementarities in knowledge-intensive services

The main premise of this article is that human resources (HR) and information technologies (IT) are central rather than support functions in knowledge-intensive services. By building management capabilities in both HR and IT, knowledge-intensive services can transform their business processes that, in turn, enable them to provide exemplary services to the customers. Our arguments are grounded in the three related theoretical frameworks of the resource-based view, organizational capabilities, and the theory of complementarities. We suggest that the research and practice in HR and IT fields may have to focus on HR and IT capabilities rather than HR practices or IT investments as the sources of sustainable competitive advantage since capabilities better fit the definition of a ‘resource’ than HR practices or IT investments. Further, organizational capabilities in both HR and IT may enable knowledge-intensive services to transcend the inherent tradeoff between cost and responsiveness. We also discuss the role of HR and IT in knowledge management.

A Comparison of Contract-Managed and Traditionally Managed Nonprofit Hospitals

During the past five years, contract management of nonprofit hospitals by for-profit corporations has increased markedly. However, while a number of studies have been conducted on investor-owned hospitals and proprietary hospital systems, contract-managed hospitals have not been evaluated systematically. This paper reports a pilot study which compares a sample of 32 nonprofit hospitals under management contracts with matched hospitals under traditional in-house management. Although few major differences were found between the study hospitals, the findings indicate that contract-managed hospitals tend to offer a somewhat broader range of services, especially in the outpatient area, have younger, more highly educated administrators, and show lower cost per patient stay largely due to somewhat lower employee-to-bed and payroll-to-total expense ratios and shorter lengths of stay.

Decision support system in a Patient-Centered Medical Home

Patient-Centered Medical Home is a care delivery model to transform how primary care is delivered in the United States. The information technology revolution has brought about several advancements and solutions for medicine and care delivery, and medical homes are no exception to this. Traditionally, such information technology solutions tend to be isolated in development and fragmented in implementation. However, it is only through a robust decision support system that these medical homes can in fact provide truly coordinated and patient-centered care. The paper describes preliminary work that has been completed at the University of Missouri Health System and next steps in achieving high quality care delivery through a decision support system implementation.

Organizational Assessment: Concept, Method and Application

The concept of organizational assessment of health institutions is explored in terms of why it is becoming increasingly popular, alternative approaches, and its potential as a tool for quality assurance or program evaluation. There is an outline of an approach to developing standardized performance criteria and a design for carrying out an assessment through a self-assessment method. Illustrations of the application of the model are included.