Overlapping DNA methylation profile between placentas with trisomy 16 and early-onset preeclampsia.

INTRODUCTION: Maternal preeclampsia is associated with altered placental development in the first trimester of pregnancy. Confined placental trisomy 16 mosaicism (CPM16) is a genetic abnormality of the placenta that is highly predisposing to preeclampsia. We previously demonstrated widespread alterations in DNA methylation in 3rd trimester placentae associated with chromosomally normal early-onset preeclampsia (EOPET) and questioned whether similar changes would be associated with CPM16, making this condition a potential model for studying EOPET-associated changes early in pregnancy. METHODS: Using the Illumina Infinium HumanMethylation450 BeadChip, 3rd trimester CPM16 placental samples (N = 10) were compared to gestational age matched controls, and to 1st trimester trisomy 16 placentae (N = 5). RESULTS: DNA methylation differences associated with CPM16 were identified at 2254 CpGs using stringent criteria (FDR < 0.01, Δß > 0.15). A subset of these differences (11%; p < 0.0001) overlapped those observed in chromosomally normal EOPET using similarly stringent criteria (FDR < 0.01; Δß > 0.125). Importantly, the majority of EOPET-associated CpGs were significantly altered (p < 0.05) in CPM16 with a similar Δß distribution. This was true for CPM16 with (N = 5) and without (N = 5) EOPET, although EOPET cases showed a tendency towards larger changes. Of the shared CPM16/EOPET associated changes, three CpGs near two genes (ARGHEF37 and JUNB) were also altered in 1st trimester trisomy 16 placentae. DISCUSSION: Despite the limited sample size, widespread DNA methylation changes are observed in Trisomy 16 that overlap those seen previously in chromosomally normal EOPET. Hence, Trisomy 16 may provide a model to study the progression of placental changes that occurs in EOPET across different gestational ages.

An integrated doctoral educational model for developing researchers in health care strategic management.

Doctoral education varies according to how students that graduate from a particular program are prepared for various type of careers. PhD programs principally work to develop researchers; researchers produce and disseminate new knowledge in a given area of expertise. This manuscript looks specifically at a PhD program designed to produce researchers in healthcare strategic management. This program is based in a business school and builds on general business principles to produce strategists that do research in the healthcare context. The business school program (type B) will be analyzed according to the areas (or potential areas) of research done by its graduates. The different areas are shown in a table where one axis is research content (i.e., specifically what the functional area of research is) and the other axis is publication outlet (i.e., what journal the research is disseminated in). Advantages of the type B program are compared to advantages of a PhD program based in a healthcare administration or healthcare management school (type H program) in terms of publications in these different areas.

The paradox prescription: leading the medical group of the future.

Leaders of health care organizations must constantly deal with paradox in and around their organizations. The paradox profile is a modeling technique for examining how organizations prioritize their dealings with the eight competing issues from which the four paradoxes are derived. This article demonstrates the leadership challenges that exist when a paradox is present and how these tensions differ when the integrative status of the medical group--as either part of an integrated system or not--is considered.

Competitive forces in the medical group industry: a stakeholder perspective.

Applying Porter's model of competitive forces to health care, stakeholder concepts are integrated to analyze the future of medical groups. Using both quantitative survey and qualitative observational data, competitors, physician suppliers, integrated systems new entrants, patient and managed care buyers, and hospitals substitutes are examined.

Strategic choices for medical group practices.

This is the sixth in a series of articles (1) describing how to identify, assess, diagnose and strategically manage key medical group practice (MGP) stakeholders and (2) interpreting the results from the Facing the Uncertain Future (FUF) study. This article continues (from the previous article in this series) the discussion of the vital strategic stakeholder management process of choosing the most effective strategies for key stake holders based on two strategic priorities: reducing stakeholders potential for threat and enhancing their potential for cooperation. From this critical strategic priority-setting process. strategies are classified as either involving, collaborating, defending, or monitoring. Using data from the FUF project, four medical group practice (MCP) stakeholders are analyzed. These are the integrated delivery system/network (lDS/N) itself as well as its components: physicians, hospitals and managed care organizations (MCOs). The FUF project's MGP executive respondents believe these four stakeholders will be some of the most important MGP stakeholders in the year 2000. The FUF study was conducted jointly between the Center for Research in Ambulatory Health Care Administration (CRAHCA), the research and development arm of the Medical Group Management Association (MGMA), Englewood. Colo., and The Institute for Management and Leadership Research (IMLR). College of Business Administration at Texas Tech University, Lubbock, Texas. MGMA s American College of Medical Practice Executives (ACMPE), faculty of Texas Tech University's Ph.D. and M.BA programs in Health Organization Management (HOM), and faculty from the University of Alabama at Birmingham collaborated on the project. Abbott Laboratories. Abbott Park. Ill., provided funding for the FUF project The administration of Round One was completed in the fall of 1994. The administration of Round Two was completed in the summer of 1995. Selected Round One (i.e.. health care experts) and Round Two (i.e., MGP executives) results have previously been presented in educational programs and publications.

The problematic fit of diagnosis and strategy for medical group stakeholders--including IDS/Ns.

This article extends stakeholder management theory using data from 270 medical practice executives to identify key stakeholders and determine the "fit" between stakeholder diagnosis and stakeholder management strategy. Four optimal and 12 suboptimal situations are identified.

Medical practice and physician executives face the uncertain future. Strategic stakeholder management III.

This article, third in a series addressing stakeholder management, presents preliminary findings of Round Two data from the "Facing the Uncertain Future" study. One purpose of this study is to determine how experts define key stakeholders of medical group practices now and how these stakeholders might change by the year 2000. This analysis highlights a comparison of two expert panels: medical practice executives (MPEs) and physician executives (PEs). The purpose was to ascertain whether or not MPE and PE perspectives for the present and predictions for the future differed on a series of key issues. The key issues discussed are: organizational goals, who will be responsible for managing the organization towards these goals, assessment of the external environment and identification of key stakeholders. MPEs and PEs, with the exception of the physician manager and several current organizational goals, view the present similarly and also showed convergence in their predictions for 2000. Despite different training and career experiences, our analysis found that MPEs and PEs view the present and future in surprisingly similar ways. As a result, MPEs and PEs are encouraged to be less preoccupied with perceived differences in perspective and, instead, focus their energies on developing clear strategies and specific tactics to strengthen their organization's position in this turbulent environment.

Integrated delivery systems/networks in the uncertain future. Strategic stakeholder management, Round One continued.

This article presents an analysis of Round One data with a focus on integrated delivery systems/networks (IDS/Ns). These complex, multifaceted organizations are growing in importance in the turbulent health care industry. The emergence of these multi-organizational forms requires that all health care industry organizations--medical groups, hospitals, payer organizations, suppliers--adapt to the ever-increasing demands placed on them as the industry experiences revolutionary changes. The findings presented in this article were compiled from the responses of 580 health care industry experts about the uncertain future facing health care executives. These respondents represented virtually every health care organizational form, including medical groups, physicians, hospitals, payer organizations, academic researchers, pharmaceutical firms and other health care industry suppliers. Each of these health care respondent panels answered hundreds of questions pertaining to both the present (1994) and the future (1999). These analyses seek to describe the different relationships between medical groups, their stakeholders and IDS/Ns, and how they will change over the years of 1994 to 1999. We also present experts' perceptions and predictions about five other key stakeholders of medical groups--managed care organizations, governments, employers, system hospitals and patients.

Strategic stakeholder management. First round results from 'Facing the Uncertain Future'.

Authors summarize preliminary results from the first round of a two-round modified Delphi study called "Facing the Uncertain Future." Health care experts were asked to comment on the status of the health care industry in 1994 when the study began and their predictions for change by 1999. Major findings based on the 580 responses received include: (1) the continued movement of the U.S. health care industry from a primarily private insurance industry to one in which medical groups and hospitals will be members of integrated delivery systems/networks (IDS/N); (2) the increasing dominance of the components of IDS/Ns in 1999 (components are defined as: medical practices, system hospitals, managed care organizations and IDS/Ns); and (3) the potential effects of IDS/Ns on the health care industry, including: increases in cost effectiveness, quality of administrative management and the quality of physician leadership, as well as decreases in availability of advanced medical technology and the duplication of ancillary services, facilities and equipment. The study is being conducted jointly by the Medical Group Management Association and Texas Tech University with funding from Abbott Laboratories.

Urban-rural hospital affiliations: assessing control, fit, and stakeholder issues strategically.

Urban-rural hospital affiliations are an outgrowth of both the external pressures on rural hospitals to survive and the need for urban hospitals to maintain or increase their share of the tertiary referral market. This article discusses the significant role of stakeholders in these affiliations, develops a fourfold typology of urban-rural hospital affiliations based on the notions of organizational control and fit, suggests four generic strategies for forming affiliations, and analyzes four actual cases of affiliation.

Negotiating with interactive scenarios and strategies.

Physician executives need to negotiate effectively with a wide range of parties. In those negotiations, they should consider the relative importance of both substantive and relationship outcomes in selecting initial negotiation strategies. Of course, these strategies may or may not be successful, depending on the strategies used by the other party. Hence, the physician executive must consider the other party's strategy and how it and his or her initial strategy are likely to interact both before and during negotiations.

Negotiating for more than a slice of the pie.

Negotiation is an important way for physician executives to manage conflict and to accomplish new projects. Because of the rapidly changing nature of the health care environment, as well as conflicts and politics within their organizations, managers need to effectively negotiate with a wide range of other parties. Managers should consider the relative importance of both the substantive and relationship outcomes of any potential negotiation. These two factors may guide the executive's selection of initial negotiation strategies.

Achieving competitive advantage through strategic human resource management.

The framework presented here challenges health care executives to manage human resources strategically as an integral part of the strategic planning process. Health care executives should consciously formulate human resource strategies and practices that are linked to and reinforce the broader strategic posture of the organization. This article provides a framework for (1) determining and focusing on desired strategic outcomes, (2) identifying and implementing essential human resource management actions, and (3) maintaining or enhancing competitive advantage. The strategic approach to human resource management includes assessing the organization's environment and mission; formulating the organization's business strategy; assessing the human resources requirements based on the intended strategy; comparing the current inventory of human resources in terms of numbers, characteristics, and human resource management practices with respect to the strategic requirements of the organization and its services or product lines; formulating the human resource strategy based on the differences between the assessed requirements and the current inventory; and implementing the appropriate human resource practices to reinforce the strategy and attain competitive advantage.

Hospital-physician joint ventures: a strategic approach for both dimensions of success.

Joint ventures between hospitals and the physicians on their medical staffs have produced successes and failures. Each joint venture has two very different dimensions of success--financial and collaborative. The most successful ventures are able to accomplish both of these often conflicting goals. To enhance hospital executives' success in joint ventures with physicians, a strategic approach with a series of six steps and their corresponding models or maps is proposed. The steps in this strategic approach are: (1) identify key stakeholders and linkages among them; (2) surface stakeholder conflict using problem-oriented maps; (3) diagnose the venture on both dimensions of success; (4) classify the venture using both dimensions of success; (5) select a strategy to optimize the venture's current potential for success; and (6) select an approach to transform the venture with limited potential for success.

Assessing key stakeholders: who matters to hospitals and why?

A key stakeholder perspective, informed by illustrative quantitative and qualitative data, is developed for hospital administrators. These data provide answers to the questions, Who matters to hospitals? and Why do they matter? A tool kit for assessing stakeholders also is presented to help hospital executives identify their institutions' key stakeholders, determine the power of these stakeholders and their core values, and define who within their institutions should be responsible for the routine management of different stakeholders. These tools facilitate the management of each key stakeholder, ensuring that each strategic decision is examined in terms of the likely reaction of key stakeholders and is supplemented with plans for gaining stakeholder acceptance. Managers should recognize that the answers to Who matters? and Why? will vary by type of hospital and by the specific issue being addressed.

Stakeholder strategies for the physician executive.

If physician executives are to be effective in confronting the environmental turbulence and uncertainty facing their organizations, they must effectively manage their stakeholders. This article extends the stakeholder approach described in the May-June 1989 issue of Physician Executive as a tool for the physician executive in the development of practical strategies to cope with turbulence and uncertainty. We suggest four generic strategies physician executives can use: involve supportive stakeholders, monitor marginal stakeholders, defend against nonsupportive stakeholders, and collaborate with mixed-blessing stakeholders. As an overarching strategy, a physician executive should try to change the organization's relationships with a stakeholder from a less favorable category to a more favorable one. The stakeholder can then be managed using the generic strategy most appropriate for the category.

Stakeholder issues for the physician executive.

If physician executives are to cope with the environmental turbulence and uncertainty facing their organizations, they must effectively manage their "stakeholders." The stakeholder approach helps integrate managerial concerns that are frequently treated separately, such as strategic management, marketing, human resource management, "organizational politics," and social responsibility. The stakeholder perspective enables medical managers to relate important issues to the development of strategies for handling potentially conflicting demands for effectiveness and efficiency from various stakeholders. Medical managers should minimally satisfy the needs of marginal stakeholders while they maximally satisfy the needs of key stakeholders. To identify key stakeholders, a physician executive should critically assess each stakeholder's potential to threaten the organization and its potential to cooperate. This assessment should account for such factors as the stakeholder's relative power, the specific context and history of the organization's relations with it, the specific issues under consideration, and other key stakeholders influencing the organization.

Stakeholder supportiveness and strategic vulnerability: implications for competitive strategy in the HMO industry.

A conceptual and empirical analysis of the strategic vulnerability of HMOs shows that they are strategically vulnerable on the social dimension of stakeholder supportiveness. One of the major implications of this finding is that HMOs' cost leadership strategy cannot be sustained, given the competition from such substitutes as PPAs.

A strategic approach for negotiating with hospital stakeholders.

Executives should consciously formulate negotiation strategies which are linked to the broader strategic posture of the hospital. This approach provides a diagnostic and action-oriented framework for (1) determining and focusing on desired outcomes and (2) anticipating actions stakeholders are likely to take.