Irene Fraser

Review: how do hospital organizational structure and processes affect quality of care?: a critical review of research methods.

Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedians structure—process—outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure—quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance ones understanding of the relationship between organizational characteristics and quality of care.

Wrestling with Typology: Penetrating the "Black Box" of Managed Care by Focusing on Health Care System Characteristics

The health care system has undergone a fundamental transformation undermining the usefulness of the typology of the health maintenance organization, the independent practice association, the preferred provider organization, and so forth. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain—financial features, structure, care delivery and management policies, and products—and by key roles in the health care system—sponsor, plan, provider intermediary organization, and direct services provider. The matrix is a tool for researchers, administrators, clinicians, data collectors, regulators, and other policy makers. It suggests a new set of players to be studied, emphasizes the relationships among the players, and provides a checklist of independent, control, and interactive variables to be included in analyses.

The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression

Background The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum. Methods We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥2 HIV medical visits separated by ≥90 days in the year. Persons not retained completed ≥1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients’ transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART. Results Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437). Conclusions Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.

Improving Efficiency and Value in Health Care: Introduction

The Agency for Healthcare Research and Quality (AHRQ) is pleased to sponsor the first theme issue for Health Services Research (HSR), a new feature whereby excellent and ground-breaking health services research will be gathered around an important “theme” and published in a dedicated issue of the journal. The first theme chosen to introduce this feature is “Improving Efficiency and Value in Health Care,” a topic that presents puzzles for researchers and policy makers alike. In this issue, HSR aims to present some of the best research in this area in time to contribute to the national debate and the collective interest about health care that attends election years.

Putting Practice into Research

For many years, health services researchers have contended that clinicians and others who deliver, manage, purchase, or influence health care should seek out and use the latest and best evidence when making clinical, managerial, and policy decisions. This campaign has brought both good news and a challenge. The good news is that the message is meeting a receptive audience. This past year, for example, when large employers formed the Leapfrog Group to use their collective purchasing power to improve patient safety, they began with extensive reviews of the research on factors and practices associated with safe outcomes and cited this evidence in their messages (Leapfrog Group 2001). The challenge is that the onus is now on the research community to show it can carry out its half of the job: producing information that is timely, on point, and in a format decision-makers can use. Meeting this challenge requires researchers do the same thing they ask of the health care system itself: talk with their customers, closely examine their systems and processes to see what works and does not work, and do the reengineering and innovation necessary to make sure that research, like health care itself, is more timely, efficient and customer-centered. To ensure responsiveness to user needs, the Agency for Healthcare Research and Quality (AHRQ), as part of a broader set of initiatives, started such conversations years ago. The Agency consulted with a wide range of existing and potential users of our research to determine how it could improve what we do and how we do it. One innovation directly resulting from this consultation and redesign process was the decision to support practice-based research networks, in which people in the field delivering health care or managing health care systems are an integral part of the research enterprise. Over the past two years, AHRQ created an Integrated Delivery System Research Network (IDSRN) and also developed new planning and infrastructure grants for primary care practice-based research networks (PBRNs). This AHRQ Update discusses the impetus and rationale for the new programs, briefly describes the IDSRN and PBRN initiatives, and then discusses the broader implications of these models for the research community.

Healthcare Coverage for HIV Provider Visits Before and After Implementation of the Affordable Care Act

BACKGROUND Before implementation of the Patient Protection and Affordable Care Act (ACA) in 2014, 100 000 persons living with human immunodeficiency virus (HIV) (PLWH) lacked healthcare coverage and relied on a safety net of Ryan White HIV/AIDS Program support, local charities, or uncompensated care (RWHAP/Uncomp) to cover visits to HIV providers. We compared HIV provider coverage before (2011-2013) versus after (first half of 2014) ACA implementation among a total of 28 374 PLWH followed up in 4 sites in Medicaid expansion states (California, Oregon, and Maryland), 4 in a state (New York) that expanded Medicaid in 2001, and 2 in nonexpansion states (Texas and Florida). METHODS Multivariate multinomial logistic models were used to assess changes in RWHAP/Uncomp, Medicaid, and private insurance coverage, using Medicare as a referent. RESULTS In expansion state sites, RWHAP/Uncomp coverage decreased (unadjusted, 28% before and 13% after ACA; adjusted relative risk ratio [ARRR], 0.44; 95% confidence interval [CI], .40-.48). Medicaid coverage increased (23% and 38%; ARRR, 1.82; 95% CI, 1.70-1.94), and private coverage was unchanged (21% and 19%; 0.96; .89-1.03). In New York sites, both RWHAP/Uncomp (20% and 19%) and Medicaid (50% and 50%) coverage were unchanged, while private coverage decreased (13% and 12%; ARRR, 0.86; 95% CI, .80-.92). In nonexpansion state sites, RWHAP/Uncomp (57% and 52%) and Medicaid (18% and 18%) coverage were unchanged, while private coverage increased (4% and 7%; ARRR, 1.79; 95% CI, 1.62-1.99). CONCLUSIONS In expansion state sites, half of PLWH relying on RWHAP/Uncomp coverage shifted to Medicaid, while in New York and nonexpansion state sites, reliance on RWHAP/Uncomp remained constant. In the first half of 2014, the ACA did not eliminate the need for RWHAP safety net provider visit coverage.

Employers: Quality Takers or Quality Makers?

This article provides a synthesis of past research to help understand the extent to which employers are using their considerable market power to drive health care quality. Are employers quality takers or quality makers? The literature provides some clues about aspects of quality employers are attempting to influence, strategies they are pursuing to influence quality, and their impact. Some employers are interested in some indicators of quality and are incorporating them in a variety of different purchasing strategies. The indicators most frequently used by employers, however, probably are not the ones that clinical experts and policy makers would select as most reflective of clinical quality. It appears that employers as a group are becoming more informed quality takers but are not yet quality makers—with the exception of a few well-resourced outliers. Recent events provide mixed signals about whether the future employer role in influencing quality will diminish, stall, or flourish.

Quality improvement: new contributions from the field of health services research.

Recent publication and wide press coverage of an Institute of Medicine (IOM) study documenting the extent and nature of patient safety problems (Kohn, Corrigan, and Donaldson 2000) broadened public understanding of a fundamental and discouraging finding from the field of health services research—the quality of care delivered in the United States varies greatly and cannot be presumed. This builds on earlier findings that quality problems are not isolated and confined to a narrow list of circumstances and settings; rather, they are found in all regions of the country, in small and large communities