Beyond patient care: a qualitative study of rural hospitals' role in improving community health.

OBJECTIVES: Rural population face more health disadvantages than those living in urban and suburban areas. In rural communities, hospitals are frequently the primary organisation with the resources and capabilities to address health issues. This characteristic highlights their potential to be a partner and leader for community health initiatives. This study aims to understand rural hospitals' motivations to engage in community health improvement efforts and examine their strategies to address community health issues. DESIGN: Eleven semistructured interviews were conducted with key leaders from four rural hospitals in a US Midwestern state. On-site and telephone interviews were audio-recorded and transcribed. The combination of inductive and deductive qualitative analysis was applied to identify common themes and categories. SETTINGS: Participating hospitals are located in US rural counties that have demonstrated progress in creating healthier communities. RESULTS: Three types of motivation drive rural hospitals' community health improvement efforts: internal values, economic conditions and social responsibilities. Three categories of strategies to address community health issues were identified: building capacity, building relationships and building programmes. CONCLUSIONS: Despite the challenges, rural hospitals can successfully conduct community-oriented programmes. The finds extend the literature on how rural hospitals may strategise to improve rural health by engaging their communities and conduct activities beyond patient care.

Organizational Attributes Associated With Medicare ACO Quality Performance.

PURPOSE: To evaluate associations between geographic, structural, and service-provision attributes of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and the ACOs' quality performance. METHODOLOGY: We conducted cross-sectional and longitudinal analyses of ACO quality performance using data from the Centers for Medicare and Medicaid Services and additional sources. The sample included 322 and 385 MSSP ACOs that had successfully reported quality measures in 2014 and 2015, respectively. RESULTS: Results show that after adjusting for other organizational factors, rural ACOs' average quality score was comparable to that of ACOs serving other geographic categories. ACOs with hospital-system sponsorship, larger beneficiary panels, and higher posthospitalization follow-up rates achieved better quality performance. CONCLUSION: There is no significant difference in average quality performance between rural ACOs and other ACOs after adjusting for structural and service-provision factors. MSSP ACO quality performance is positively associated with hospital-system sponsorship, beneficiary panel size, and posthospitalization follow-up rate.

Critical Access Hospital Use of TeamSTEPPS to Implement Shift-Change Handoff Communication.

Implementation of handoff as part of TeamSTEPPS initiatives for improving shift-change communication is examined via qualitative analysis of on-site interviews and process observations in 8 critical access hospitals. Comparing implementation attributes and handoff performance across hospitals shows that the purpose of implementation did not differentiate between high and low performance, but facilitators and barriers did. Staff involvement and being part of the "big picture" were important facilitators to change management and buy-in.

Medicare Accountable Care Organizations: Quality Performance by Geographic Categories.

Purpose. This policy brief continues the work of the RUPRI Center analyzing the performance of Medicare Accountable Care Organizations (ACOs) serving rural areas. In this brief, we examine the differences in performance on four domains of quality measures and the overall quality score among Medicare Shared Savings ACOs with different levels of rural presence. Key Findings. (1) ACOs located in rural counties performed better than those in urban counties on Care Coordination/Patient Safety, Preventive Health, and At-Risk Population domain scores and the overall quality score in 2014. (2) Urban ACOs performed better than ACOs in other geographic categories on the Patient/Caregiver Experience score in 2014. (3) ACOs in all geographic categories improved their quality performance between 2014 and 2015.

Medicare Accountable Care Organizations: Beneficiary Assignment Update.

This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services (CMS) Accountable Care Organization (ACO) regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Overall, the regulatory changes are intended to (1) encourage ACOs to participate in two-sided risk contracts, (2) increase the likelihood that beneficiaries are assigned to the physician (and ACO) from whom they receive most of their primary care services, and (3) make it easier for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to participate in ACOs. Understanding ACO beneficiary assignment policies is critical for ACO in managing their panel of ACO providers and beneficiaries.

A Rural Taxonomy of Population and Health-Resource Characteristics.

This policy brief reports the newly developed taxonomy of rural places based on relevant population and health-resource characteristics; and discusses how this classification tool can be utilized by policy makers and rural communities. Key Findings. (1) We classified 10 distinct types of rural places based on characteristics related to both demand (population) and supply (health resources) sides of the health services market. (2) In descending order, the most significant dimensions in our classification were facility resources, provider resources, economic resources, and age distribution. (3) Each type of rural place was distinct from other types of places based on one or two defining dimensions.

Cluster-randomized trial of a physician/pharmacist collaborative model to improve blood pressure control.

BACKGROUND: The purpose of this study was to evaluate if a physician/pharmacist collaborative model would be implemented as determined by improved blood pressure (BP) control in primary care medical offices with diverse geographic and patient characteristics and whether long-term BP control could be sustained. METHODS AND RESULTS: Prospective, cluster-randomized trial of 32 primary care offices stratified and randomized to control, 9-month intervention (brief), and 24-month intervention (sustained). We enrolled 625 subjects with uncontrolled hypertension; 54% from racial/ethnic minority groups and 50% with diabetes mellitus or chronic kidney disease. The primary outcome of BP control at 9 months was 43% in intervention offices (n=401) compared with 34% in the control group (n=224; adjusted odds ratio, 1.57 [95% confidence interval, 0.99-2.50]; P=0.059). The adjusted difference in mean systolic/diastolic BP between the intervention and control groups for all subjects at 9 months was -6.1/-2.9 mm Hg (P=0.002 and P=0.005, respectively), and it was -6.4/-2.9 mm Hg (P=0.009 and P=0.044, respectively) in subjects from racial or ethnic minorities. BP control and mean BP were significantly improved in subjects from racial minorities in intervention offices at 18 and 24 months (P=0.048 to P<0.001) compared with the control group. CONCLUSIONS: Although the results of the primary outcome (BP control) were negative, the key secondary end point (mean BP) was significantly improved in the intervention group. Thus, the findings for secondary end points suggest that team-based care using clinical pharmacists was implemented in diverse primary care offices and BP was reduced in subjects from racial minority groups. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00935077.

Medicare Accountable Care Organizations: program eligibility, beneficiary assignment, and quality measures.

Accountable Care Organizations (ACOs) are groups of providers (generally physicians and/or hospitals) that may receive financial rewards by maintaining or improving care quality for a group of patients while reducing the cost of care for those patients. The Patient Protection and Affordable Care Act of 2010 (ACA) established a Medicare Shared Savings Program (MSSP) and accompanying Medicare ACOs to "facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce unnecessary costs." The MSSP now includes 343 ACOs; an additional 23 ACOs participate in the Medicare Pioneer ACO demonstration program, and there are approximately 240 private ACOs. Based on our analysis, among the Medicare ACOs 119 operate in both rural and urban counties and seven operate exclusively in rural counties. A little over 24 percent of non-metropolitan counties are included in Medicare ACOs. To assist rural providers considering ACO formation, this policy brief describes MSSP eligibility and participation requirements, beneficiary assignment processes, and quality measures.

Trends in hospital network participation and system affiliation, 2007-2012.

Key Findings. (1) Hospital network participation from 2007 to 2012 increased in larger hospitals (more than 150 beds), non-government not-for-profit hospitals, and metropolitan hospitals. Network participation changed inconsistently in other types of hospitals. (2) Hospital system affiliation has generally increased in hospitals of all sizes, non-government not-for-profit hospitals, hospitals in all census regions, CAHs, and both metropolitan and nonmetropolitan hospitals. There are notably higher percentages of system affiliation among midsized and large hospitals, investor-owned hospitals, and metropolitan hospitals compared to their counterparts.

Governing board, C-suite, and clinical management perceptions of quality and safety structures, processes, and priorities in U.S. hospitals.

To achieve quality improvement in hospitals requires greater attention to systems thinking than is typical at this time, including a shared understanding across different levels of the hospital of the current state of quality improvement efforts. A self-administered survey assessed the perceptions of board members, C-suite executives, and clinical managers regarding quality activities and structures. This instrument, the Hospital Leadership and Quality Assessment Tool (HLQAT), includes 13 domains in six conceptual areas that we believe are major organizational drivers of quality and safety: (1) commitment of senior leaders, (2) a vision of exemplary quality, (3) a supportive culture, (4) accountable leadership, (5) appropriate organizational structures, and (6) adaptive capability. HLQAT survey results from a convenience sample of more than 300 hospitals were linked to performance on the Centers for Medicare & Medicaid Services (CMS) Core Measures. The results show significantly different perceptions between the groups. Higher HLQAT scores for each respondent group were associated with better hospital performance on the CMS Core Measures. There is no magic bullet--no one domain dominates. Leaders in higher-performing hospitals appear to be more effective at conveying their vision of quality care and creating a culture that supports an expectation that staff and leadership will work across traditional boundaries to improve quality.

Similar blood pressure values across racial and economic groups: baseline data from a group randomized clinical trial.

This paper examines baseline characteristics from a prospective, cluster-randomized trial in 32 primary care offices. Offices were first stratified by percentage of minorities and level of clinical pharmacy services and then randomized into 1 of 3 study groups. The only differences between randomized arms were for marital status (P=.03) and type of insurance coverage (P<.001). Blood pressures (BPs) were similar in Caucasians and minority patients, primarily blacks, who were hypertensive at baseline. On multivariate analyses, patients who were 65 years and older had higher systolic BP (152.4 ± 14.3 mm Hg), but lower diastolic BP (77.3 ± 11.8 mm Hg) compared with those younger than 65 years (147.4 ± 15.0/88.6 ± 10.6 mm Hg, P<.001 for both systolic and diastolic BP). Other factors significantly associated with higher systolic BP were a longer duration of hypertension (P=.04) and lower basal metabolic index (P=.011). Patients with diabetes or chronic kidney disease had a lower systolic BP than those without these conditions (P<.0001). BP was similar across racial and socioeconomic groups for patients with uncontrolled hypertension in primary care, suggesting that patients with uncontrolled hypertension and an established primary care relationship likely have different reasons for poor BP control than other patient populations.

Baccalaureate education in nursing and patient outcomes.

OBJECTIVES: The aim of this study was to examine the effects of registered nurse (RN) education by determining whether nurse-sensitive patient outcomes were better in hospitals with a higher proportion of RNs with baccalaureate degrees. BACKGROUND: The Future of Nursing report recommends increasing the percentage of RNs with baccalaureate degrees from 50% to 80% by 2020. Research has linked RN education levels to hospital mortality rates but not with other nurse-sensitive outcomes. METHODS: This was a cross-sectional study that, with the use of data from 21 University HealthSystem Consortium hospitals, analyzed the association between RN education and patient outcomes (risk-adjusted patient safety and quality of care indicators), controlling for nurse staffing and hospital characteristics. RESULTS: Hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis or pulmonary embolism and shorter length of stay. CONCLUSION: The recommendation of the Future of Nursing report to increase RN education levels is supported by these findings.

Accountable care organizations in rural America.

Key Findings. (1) Medicare Accountable Care Organizations (ACOs) operate in non-metropolitan counties in every U.S. Census Region. (2) 79 Medicare ACOs operate in both metropolitan and non-metropolitan counties. (3) Medicare ACOs operate in 16.7% of non-metropolitan counties. (4) 9 ACOs operate exclusively in non-metropolitan counties, including at least 1 in every U.S. Census Region.

Estate and business planning for the retiring physician.

Retiring physicians have much to think about for estate planning purposes. The authors stand ready to help physicians sell or close their medical practice, navigate the 2010 Tax Act, take advantage of current planning opportunities, and prepare appropriate estate planning documents. Every estate is unique, so it is important to contact an estate planning advisor before taking any action.

Vaginal (Crinone 8%) gel vs. intramuscular progesterone in oil for luteal phase support in in vitro fertilization: a large prospective trial.

OBJECTIVE: To compare the efficacy of intravaginal and IMP for luteal phase support in IVF cycles. DESIGN: Prospective trial. SETTING: Tertiary care private practice. PATIENT(S): Women 25-44 years old with infertility necessitating treatment with IVF. From April 1, 2008-April 1, 2009, 511 consecutive patients were enrolled; 474 completed participation, and 37 were excluded for no autologous ET (freeze all, donor recipients, failed fertilization/cleavage). There were no demographic differences between the two treatment groups. INTERVENTION(S): Luteal phase support using either Crinone or P in oil starting 2 days following oocyte retrieval. MAIN OUTCOME MEASURE(S): Pregnancy and delivery rates stratified by patient age. RESULT(S): Overall, patients who received vaginal P had higher pregnancy (70.9% vs. 64.2%) and delivery (51.7% vs. 45.4%) rates than did patients who received IMP. Patients <35 who received vaginal P had significantly higher delivery rates (65.7% vs. 51.1%) than did patients who received IMP. There were no differences, regardless of age, in the rates of biochemical pregnancy, miscarriage, or ectopics. CONCLUSION(S): In younger patients undergoing IVF, support of the luteal phase with Crinone produces significantly higher pregnancy rates than does IMP. Crinone and IMP appear to be equally efficacious in the older patient.

Comparison of patient outcomes in Magnet® and non-Magnet hospitals.

OBJECTIVE: : This study compared patient outcomes and staffing in Magnet® and non-Magnet hospitals. BACKGROUND: : The pursuit of Magnet designation is a highly regarded program for improving staff and patient outcomes. Research has confirmed that Magnet hospitals provide positive work environments for nurses. Research related to patient outcomes in Magnet hospitals is scarce, and results vary. METHODS: : The University Health Systems Consortium provided the clinical and operational databases for the study. Using bivariate and multivariate analyses, a comparison of patient outcomes and nurse staffing in general units and ICUs of Magnet and non-Magnet hospitals was studied. OUTCOMES: : Non-Magnet hospitals had better patient outcomes than Magnet hospitals. Magnet hospitals had slightly better outcomes for pressure ulcers, but infections, postoperative sepsis, and postoperative metabolic derangement outcomes were worse in Magnet hospitals. Magnet hospitals also had lower staffing numbers. CONCLUSIONS: : Magnet hospitals in this study had less total staff and a lower RN skill mix compared with non-Magnet hospitals, which contributed to the outcomes.

Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals.

BACKGROUND: Nurse staffing has been linked to hospital patient outcomes; however, previous results were inconsistent because of variations in measures of staffing and were only rarely specific to types of patient care units. OBJECTIVE: To determine the relationship between nurse staffing in general and intensive care units and patient outcomes and determine whether safety net status affects this relationship. RESEARCH DESIGN: A cross-sectional design used data from hospitals belonging to the University HealthSystem Consortium. SUBJECTS: Data were available for approximately 1.1 million adult patient discharges and staffing for 872 patient care units from 54 hospitals. MEASURES: Total hours of nursing care [Registered Nurses (RNs), Licensed Practical Nurses, and assistants] determined per inpatient day (TotHPD) and RN skill mix were the measures of staffing; Agency for Healthcare Research and Quality risk-adjusted safety and quality indicators were the outcome measures. RESULTS: TotHPD in general units was associated with lower rates of congestive heart failure mortality (P<0.05), failure to rescue (P<0.10), infections (P<0.01), and prolonged length of stay (P<0.01). RN skill mix in general units was associated with reduced failure to rescue (P<0.01) and infections (P<0.05). TotHPD in intensive care units was associated with fewer infections (P<0.05) and decubitus ulcers (P<0.10). RN skill mix was associated with fewer cases of sepsis (P<0.01) and failure to rescue (P<0.05). Safety-net status was associated with higher rates of congestive heart failure mortality, decubitus ulcers, and failure to rescue. CONCLUSIONS: Higher nurse staffing protected patients from poor outcomes; however, hospital safety-net status introduced complexities in this relationship.

Implementation of evidence-based practices: Applying a goal commitment framework.

BACKGROUND: The implementation of evidence-based practices translates research findings into practice to reduce inappropriate care. However, this process is slow and unpredictable. The lack of a coherent theoretical basis for understanding individual and organizational behavior limits our ability to formulate effective implementation strategies. PURPOSE: The study objectives are (a) to test the goal commitment framework that explains mechanisms impacting outcomes of major depressive disorder (MDD) screening guideline implementation and (b) to understand the effects of implementation outcomes on provider practice related to MDD screening. METHODS: Using data from the Determinants of Clinical Practice Guideline Implementation Effectiveness Study, the national sample included 2,438 clinicians from 139 Veteran Affairs acute care hospitals with primary care clinics. We used hierarchical generalized linear modeling to assess the following implementation outcomes: agreement with, adherence to, improvement in knowledge of guidelines, and delivery of best practices as a function of clinician input into implementation, teamwork, involvement in quality improvement activities, participative culture, interdepartmental coordination, frequency, and utility of performance feedback. We then estimated self-reported MDD screening practices as a function of these four implementation outcomes. FINDINGS: Results showed that having input into implementation, involvement in quality of care improvement, teamwork, and perceived value of performance feedback were positively associated with implementation outcomes. Provider self-assessed guideline adherence was positively associated with the likelihood of appropriate MDD screening. IMPLICATIONS: Factors related to increased goal commitment positively predicted key implementation outcomes, which in turn enhanced care delivery. This study demonstrates that the goal commitment framework is useful in assisting managers to assess factors that facilitate implementation. In particular, participation, feedback, and team work equip organizational participants with better information about implementation targets, thereby increasing adherence. Instituting or improving systems or programs to facilitate timely, appropriate performance feedback and provider participation may help enhancing organizational change and learning.

A cluster-randomized effectiveness trial of a physician-pharmacist collaborative model to improve blood pressure control.

UNLABELLED: Numerous studies have demonstrated the value of team-based care to improve blood pressure (BP) control, but there is limited information on whether these models would be adopted in diverse populations. The purpose of this study was to evaluate whether a collaborative model between physicians and pharmacists can improve BP control in multiple primary care medical offices with diverse geographic and patient characteristics and whether long-term BP control can be sustained. This study is a randomized prospective trial in 27 primary care offices first stratified by the percentage of underrepresented minorities and the level of clinical pharmacy services within the office. Each office is then randomized to either a 9- or 24-month intervention or a control group. Patients will be enrolled in this study until 2012. The results of this study should provide information on whether this model can be implemented in large numbers of diverse offices, if it is effective in diverse populations, and whether BP control can be sustained long term. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00935077.