Diagnostic Accuracy of a Clinical Scoring Scheme in Childhood Heart Failure.

BACKGROUND: Heart failure remains a major health problem. But its early diagnosis remains a significant challenge especially among the Paediatric population. A standardized highly sensitive and specific clinical basis of diagnosis requiring no sophisticated equipment readily elicitable at the patients beside at presentation is required. OBJECTIVE: The study set out to determine the accuracy of a clinical scoring scheme for the diagnosis of heart failure in infants in Ibadan, Nigeria, using B-type natriuretic peptide (BNP) as gold standard. METHODOLOGY: Forty-five consecutive infants admitted into the Paediatric wards of the University College Hospital and the Adeoyo Maternity Teaching Hospital in Ibadan, Nigeria were evaluated with the Ibadan Childhood Heart Failure Index (ICHFI) and those with clinical score of > 3 were recruited. Their plasma BNP levels and those of 45 age-matched controls were also measured. RESULTS: There was a strong positive correlation (0.920) between the ICHFI scores and plasma BNP values (rs = 0.920, P = 0.000). At a cut-off score of 2, the ICHFI has a sensitivity of 97.6%, specificity of 89.8%, a positive predictive value of 88.9% and a negative predictive value of 97.8%. The receiver operating characteristic curve plotted had an AUC of 0.978 at the 95% CI, 0.951-1.000; P < 0.001. CONCLUSION: The ICHFI was found to be an accurate tool for the diagnosis of heart failure in infants and it is therefore recommended for use in primary care and resource challenged settings for the rapid diagnosis, grading of the severity of heart failure and monitoring of treatment.

Factors underlying organizational change in local health care markets, 1982-1995.

This article examines the association between characteristics of local health care market areas in 1982 and the penetration of new organizational forms in those markets in 1995. The Northeast and South exhibit less organizational form development than the West. Local markets with higher population size and greater density of specialty physicians in 1982 are associated with greater proportions of the markets being covered by a wide variety of organizational forms in 1995.

Strategic hospital alliances: do the type and market structure of strategic hospital alliances matter?

BACKGROUND: Throughout the 1990s, hospitals formed local alliances to defend against increasingly powerful hospital rivals and to improve their market positions relative to aggressive and consolidating managed-care organizations. An important consequence of hospitals combining or aligning horizontally at the local level is a significant consolidation of hospital markets. OBJECTIVE: The aim of this study was to examine the relationship between the type of the local strategic hospital alliances (SHAs), market, environment, and operational factors with financial performance. METHODS: The study is a cross-sectional analysis of the financial performance across SHAs in all metropolitan statistical areas in 1995. RESULTS: SHAs with dominant or dominant for-profit (FP) hospitals are not more financially successful than other SHAs. SHAs in markets with high health maintenance organization (HMO) or SHA penetration have lower revenues per case-mix adjusted discharge. The operational characteristics, proportion of teaching members in the SHA, and SHA bed size, result in higher revenues and expenses, whereas greater SHA technical efficiency results in lower costs. CONCLUSIONS: Health care organizations are centralizing their operations and governance. This study shows that this trend has not added financial value to hospital collectives, at least at this point in their development.

Strategic hospital alliances: impact on financial performance.

Acute care hospitals have increasingly been forming local strategic hospital alliances (SHAs), which consume considerable resources in forming and may affect the competitiveness of provider markets. This research shows that SHAs and market factors, which have been perceived to be threats to hospitals, are related to hospitals' financial performance. Among the findings are that SHA members have higher net revenues but that they are not more effective at cost control. Nor do the higher net revenues result in higher cash flow. However, increasing SHA penetration in a market is related to lower net revenues per case. In addition, the penetration of private health maintenance organizations in markets is associated with lower revenues and expenses.

Local markets and systems: hospital consolidations in metropolitan areas.

OBJECTIVE: This study examines the formation of local hospital systems (LHSs) in urban markets by the end of 1992. We argue that a primary reason why hospitals join LHSs is to achieve improved positions of market power relative to threatening rivals. DATA SOURCES/DATA COLLECTION: The study draws from a unique database of LHSs located in and around metropolitan statistical areas (MSAs). Data were obtained from the 1991 AHA Annual Hospital Survey, updated to the year 1992 using information obtained from multiple sources (telephone contacts of systems, systems lists of hospitals, published changes in ownership, etc.). Other measures were obtained from a variety of sources, principally the 1989 Area Resources File. STUDY DESIGN: The study presents cross-sectional analyses of rival threats and other factors bearing on LHS formation. Three characteristics of LHS formation are examined: LHS penetration of urban areas, LHS size, and number of LHS members located just outside the urban boundaries. LHS penetration is analyzed across urban markets, and LHS size and rural partners are examined across the LHSs. PRINCIPAL FINDINGS: Major hypothesized findings are: (1) with the exception of the number of rural partners, all dependent variables are positively associated with the number of hospitals in the markets; the rural partner measure is negatively associated with the number of hospitals; (2) the number of doctors per capita is positively associated with all but the rural penetration measure; and (3) the percentage of the population in HMOs is positively associated with local cluster penetration and negatively associated with rural system partners. Other findings: (1) average income in the markets is negatively associated with all but the rural penetration measure; (2) LHS size and rural partners are both positively associated with nonprofit system ownership; and (3) they are also both negatively associated with the degree to which their multihospital systems are geographically concentrated in a single state. CONCLUSIONS: The findings generally support the argument that LHS formation is the product of hospital providers attempting to improve positions of power in their local markets.

Foundations of market restructuring: local hospital cluster and HMO infiltration.

Much has been said about the rapid penetration of HMOs. Yet, little attention has been given to another, equally important trend--the consolidation of hospitals into local systems and networks. The number of local hospital clusters has increased significantly in recent years. They are now taking the lead in the majority of markets across the country in forming integrated systems.

A national study of the efficiency of hospitals in urban markets.

Using a sample of 3,000 urban hospitals, this article examines the contributions of selected hospital characteristics to variations in hospital technical efficiencies, while it accounts for multiple products and inputs, and controls for local environmental variations. Four hospital characteristics are examined: hospital size, membership in a multihospital system, ownership, and payer mix (managed care contracts, percent Medicare, and percent Medicaid). Ownership and percent Medicare are consistently found to be related significantly to hospital efficiency. Within the ownership variable, government hospitals tend to be more efficient and for-profit hospitals less efficient than other hospitals. Higher percentages of Medicare payment are negatively related to efficiency. While not consistently significant across all five of the MSA size categories in which the analyses are conducted, possession of managed care contracts, membership in a multihospital system, and size all are consistently related positively to hospital technical efficiency. These variables are also all significant when the hospitals are examined in a combined analysis. Percent Medicaid was not significant in any of the analyses. Implications for policy and the need for methodological work are discussed.

Local hospital systems: forerunners of regional systems?

Over the past several decades, the hospital industry has been undergoing a major organizational change that has until now been little examined. Local hospital systems (LHSs) are combinations of two or more hospitals that are in the same company and located in or around the same metropolitan areas in this country. This article presents the first detailed examination of the 402 such systems that have been identified to date. LHSs offer great potential for achieving the cost, quality, and access benefits that are often attributable to regional systems. The degree to which LHSs have attained some basic structural features expected of regional systems are examined. Differences are compared within ownership categories. Issues and challenges facing leaders in the field, should they hope to achieve the potential of regional systems, are discussed.

Ownership and organizational performance. A comparison of technical efficiency across hospital types.

Using a national data base of urban hospitals, the effect of ownership (government, nonprofit, and for-profit) on the technical efficiency of hospitals was examined. Efficiency scores were computed using a method called data envelopment analysis. Controlling for environmental and hospital characteristics, for-profit hospitals were found somewhat less frequently and government hospitals consistently more frequently in the efficient category. When examining highly inefficient hospitals as a percentage of those receiving inefficient scores, for-profit hospitals appeared to be highly inefficient relative to the other ownership forms. Government and nonprofit hospitals were somewhat indistinguishable from one another regarding their percentages of highly inefficient scores. For-profit hospitals also tended to use supply and capital asset (hospital size) inputs less efficiently, and service and labor inputs more efficiently than hospitals in the other ownership categories.

Birth order in small multihospital systems.

The strategic behaviors of small multihospital systems have received little attention in the literature despite the fact that small systems are the predominant scale among multihospital systems. This study examines one important aspect of small-system strategic behaviors: the birth-order or evolutionary patterns of hospital acquisition. The evolutionary patterns of acquisition are compared across three strategic model types studied elsewhere: local market, investment, and historical. Using data obtained from a variety of sources, local market model systems are found, in the sequence of acquisition, to be significantly different from the other two model types in terms of relative distances of acquisitions from the initiating or parent hospital, the sizes of acquisition hospitals, the complexity of those hospitals, and the likelihood that the acquisitions are located in rural areas. Differences between parents and acquisitions are also significant, as hypothesized, for the market model system types, although they are not generally significant for the other two model types. The findings suggest that the market model represents an important strategic form that may have important implications for the restructuring of hospital markets.

Quasi firms: strategic interorganizational forms in the health care industry.

In response to significant political, governmental, and socioeconomic changes affecting the health care industry, health care organizations are forming a wide variety of loosely coupled interorganizational arrangements. In this article, loosely coupled forms are classified according to the extent to which they are designed to achieve strategic purposes. The quasi firm is defined as a loosely coupled arrangement created to achieve long-lasting and important strategic purposes. Mechanisms that are needed to ensure the continuity of quasi firms are explored, and an agenda for further research is given.

Strategic orientations of small multihospital systems.

Strategic behaviors of organizations can be classified along two dimensions--growth orientations, or patterns of evolution over time, and action orientations, or strategic aggressiveness in undertaking a particular growth orientation. We create measures of growth and action orientations for small multihospital systems and test the validity of the growth and action orientation typologies, using data from a sample of small multihospital systems. Growth and action orientations do appear to exist independently of each other, and they are related to the ownership status of the systems. Not-for-profit and church-other systems exhibit similar strategic orientations, unlike those of Catholic and investor-owned systems.

Managing interorganizational dependencies in the new health care marketplace.

To survive, let alone thrive, in an increasingly competitive and threatening environment, health care organizations must skillfully manage their dependencies. Such dependencies traditionally have been managed through marketplace exchanges (buying and selling) and ownership relationships (acquisition, merger, and business development). An alternative strategy for designing and managing interorganizational relationships, the quasi-firm, is introduced. The quasi-firm is a hybrid market/ownership arrangement that allows participating organizations to pursue strategically important purposes while simultaneously preserving a high degree of functional and legal autonomy. We suggest that this distinctive interorganizational form is particularly well suited to the features of the new health care marketplace.

Industry distinctiveness: implications for strategic management in health care organizations.

The health care industry is characterized at its core by the requirement that the organization and financing of services recognize the concept of need for health care. This requirement is reflected in industry characteristics of market failure, professional dominance of physicians, and public concern with equal access to care. While market failure is decreasing as a result of the emergence of insurance companies as the "new consumers" of health services, physician dominance and concerns for access continue to be strong. These characteristics mean that successful health care organizations will be local-market focused, decentralized, and tied to community cultures. With regard to training of health services administrators, education should be strengthened in the area of strategy development, with appropriate recognition given to the distinctiveness of the health care industry.