Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial.

BACKGROUND: Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS. DESIGN: A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome. DISCUSSION: The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction. TRIAL REGISTRATION: Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014).

Coordination of care for early-stage breast cancer patients.

OBJECTIVE: Little is known about how care is coordinated for patients with diseases requiring multidisciplinary treatments. How complex care is coordinated may affect a patient's chance of receiving the full complement of care provided by multiple physicians. We sought to describe approaches used to coordinate care for women with early-stage breast cancer, a disease often treated by multiple different disciplines in the outpatient setting. DESIGN: Case studies of 6 hospitals with in-depth semi-structured interviews with providers of breast cancer care and their support staff. SETTING: Five hospitals in downstate New York and 1 hospital in upstate New York. PARTICIPANTS: Sixty-seven interviews were conducted including 35 physicians, 9 nurses, 4 senior clinical or quality directors, 10 administrative assistants, and 9 patient educators and navigators. MEASUREMENTS AND MAIN RESULTS: Content analysis of interviews revealed 7 different coordination mechanisms including tracking of referrals, patient support, regularly-scheduled multidisciplinary meetings, feedback of performance data, use of protocols, computerized systems, and a single physical location. No site had any systematic mechanism to track results of referrals or receipt of care provided by other physicians. All physicians used follow-up appointments to check on patients' receipt of care, but only half of the physicians had an approach to follow up missed appointments. Real-time multidisciplinary meetings with a patient management focus and systematic use of patient support programs, such as patient educators and navigators, were perceived to be valuable. CONCLUSIONS: Numerous coordination mechanisms exist. No site has the ability to systematically track care provided by multiple different specialists. The most valued mechanisms are under the hospital's aegis. Hospitals should consider implementing coordination mechanisms to improve delivery of multidisciplinary care.

Clinical service lines in integrated delivery systems: an initial framework and exploration.

The increasing pressures on integrated healthcare delivery systems (IDSs) to provide coordinated and cost-effective care focuses attention on the question of how to best integrate across multiple sites of care. One increasingly common approach to this issue is the development of clinical service lines that integrate specific bundles of services across the operating units of a system. This article presents a conceptual model of service lines and reports results from a descriptive investigation of service line development among members of the Industry Advisory Board--a research consortium comprising IDSs. The experiences of these IDSs (1) provide valuable insights into the range of organizational arrangements and implementation issues that are associated with service line management in healthcare systems and (2) suggest aspects of service line management worthy of further inquiry.

An analysis of physician antitrust exemption legislation: adjusting the balance of power.

Current antitrust law restricts physicians from joining together to collectively negotiate. However, such activities may be approved by state laws under the so-called state action immunity doctrine and by federal legislation under an explicit antitrust exemption. In 1999, Texas became the first state to pass physician antitrust exemption legislation allowing physicians, under certain defined circumstances, to collectively negotiate fees with health plans. Last year, similar legislation was introduced in the US Congress, in 18 state legislatures, and in the District of Columbia. This legislation was passed only in the District of Columbia where its implementation was blocked by the city's financial control board. Nonetheless, legislation permitting physicians to collectively negotiate fees with managed care plans has been introduced in 10 state legislatures this year, and there is continued interest in introducing similar legislation in the US Congress. This analysis examines the basic features of this legislation and its potential impact on the balance of power between physicians and managed care plans.

Provider integration and local market conditions: a contingency theory perspective.

In recent years we have witnessed an expanding array of organizational arrangements for providing health care services in the U.S. These arrangements integrate previously independent providers at one or more points on the continuum of care. The presence of so many of these arrangements raises the question of whether certain types are more effective than are others to help providers adapt to their environment. This article discusses contingency theory as a conceptual lens for guiding empirical studies of the effectiveness of different types of arrangements.

Health care reorganization and quality of care: unintended effects on pressure ulcer prevention.

BACKGROUND: Health care reorganizations, with a change in focus from inpatient to outpatient care, are becoming increasingly frequent. Little is known regarding how reorganizations may affect risk-adjusted outcomes for those programs, usually inpatient, that lose resources as a result of the change in organizational focus. OBJECTIVES: To determine changes in risk-adjusted rates of pressure ulcer development over an 8-year period, the final 3 of which were characterized by a significant reorganization of the health care system. DESIGN: This was an observational study that used an existing database. SUBJECTS: Subjects were residents of Department of Veterans Affairs long-term care units between 1990 and 1997 who were without a pressure ulcer at an index assessment. MEASURES: The study examined risk-adjusted rates of pressure ulcer development, and proportions of new ulcers that were severe (stages 3 or 4) were calculated for successive 6-month periods. RESULTS: Between 1990 and 1994, risk-adjusted rates of pressure ulcer development declined significantly, by 27%. However, beginning in 1995, rates began to increase, and in 1997 they were similar to those in 1990. The proportion of new ulcers that were severe increased significantly over time (P = 0.01). CONCLUSIONS: The reorganization of the VA that began in 1995, with its emphasis on outpatient care, was associated with an increase in rates of pressure ulcer development. This highlights the need to carefully monitor the quality of care in programs that may be losing resources as a result of the reorganization.

Clinical practice guidelines in the nursing home.

Clinical practice guidelines are an important tool for improving quality of care. This study determined whether and how guidelines are being used in nursing homes. We surveyed staff at 36 Department of Veterans Affairs (VA) nursing homes. Employees were asked whether they were familiar with guidelines as well as whether 5 specific guidelines had been read, were available, and had been adopted. Among 1065 respondents (60% of those surveyed), 79% reported familiarity with guidelines. The proportion of staff at a facility reporting adoption was generally less than 50%. Those nursing homes in which a high percentage of the staff reported adoption of one guideline were more likely to have adopted other guidelines. However, staff were not more likely to report adoption of a specific guideline when the nurse manager stated that it was adopted. We conclude that staff at VA nursing homes are familiar with guidelines. Guideline adoption at individual nursing homes, however, is not a systematic process involving the entire staff.

Patient satisfaction with hospital care: effects of demographic and institutional characteristics.

BACKGROUND: There are a growing number of efforts to compare the service quality of health care organizations on the basis of patient satisfaction data. Such efforts inevitably raise questions about the fairness of the comparisons. Fair comparisons presumably should not penalize (or reward) health care organizations for factors that influence satisfaction scores but are not within the control of managers or clinicians. On the basis of previous research, these factors might include the demographic characteristics of patients (eg, age) and the institutional characteristics (eg, size) of the health care organizations where care was received. OBJECTIVES: The goal of this study was to examine the extent to which a patient's satisfaction scores are related to both his/her demographic characteristics and the institutional characteristics of the health care organization where care was received. METHODS: We conducted an analysis of secondary data from the Veterans Health Administration (VHA), US Department of Veterans Affairs. The database contained patient responses to self-administered satisfaction questionnaires and information about demographic characteristics. Additional data from VHA were obtained regarding the institutional characteristics of the hospitals where patients received their care. RESULTS: Among demographic characteristics, age, health status, and race consistently had a statistically significant effect on satisfaction scores. Among the institutional characteristics, hospital size consistently had a significant effect on patient satisfaction scores. CONCLUSIONS: Study results can be interpreted as justifying the need to adjust patient satisfaction scores for differences in patient population among health care organizations. However, from a policy perspective, such adjustments may ultimately create a disincentive for health care organizations to customize their care.

Community control and pricing patterns of nonprofit hospitals: An antitrust analysis.

Traditional control of nonprofit hospitals by the communities they serve has been offered as justification for restraining antitrust enforcement of mergers that involve nonprofit hospitals. The community is arguably a constraint on a nonprofit's inclination to exercise market power in the form of higher prices; however, community control is likely to be attenuated for hospitals that through merger or acquisition become members of hospital systems--particularly those that operate on a regional or multiregional basis. We report findings from a study in which we examined empirically the relationship between market concentration and pricing patterns for three types of nonprofit hospitals that are distinguishable based on degree of community control: an independent hospital, a member of a local hospital system, and a member of a nonlocal hospital system. Study results indicated that when conditions existed to create a more concentrated market, (1) all three types of nonprofit hospitals exercised market power in the form of higher prices, and (2) hospitals that were members of nonlocal systems were more aggressive in exercising market power than were either independent or local system hospitals. The results have important implications for antitrust enforcement policy.

Implementing quality improvement in hospitals: the role of leadership and culture.

Many advocates of quality improvement (QI) suggest that there is a link between an organization's leadership commitment and culture and its ability to implement a QI initiative. This paper reports empirical evidence from a study of QI implementation in Veterans Health Administration (VHA) hospitals that supports this hypothesized linkage. The findings suggest that the extent to which top management becomes directly involved in QI activities determines the degree of QI implementation. Additionally, study findings suggest that a culture emphasizing innovation and teamwork provides an important foundation for implementing a QI initiative. We discuss the implications of these findings for organizational leaders interested in implementing QI.

Patterns of coordination and clinical outcomes: a study of surgical services.

OBJECTIVE: To test the hypothesis that surgical services combining relatively high levels of feedback and programming approaches to the coordination of surgical staff would have better quality of care than surgical services using low levels of both coordination approaches as well as those surgical service using low levels of either coordination approach. STUDY SETTING: A study sample of 44 academically affiliated surgical services that are part of the Department of Veterans Affairs. STUDY DESIGN: In a cross-sectional analysis, surgical services were assigned to one of three groups based on their scores on feedback and programming coordination measures: high on both measures; high on one measure, low on the other; and low on both. Univariate and multivariate analyses were used to assess differences among these groups with respect to three quality indicators: risk-adjusted mortality, risk-adjusted morbidity, and staff perceptions of quality. DATA COLLECTION/EXTRACTION METHODS: Risk-adjusted mortality and morbidity came from an outcomes reporting program within the Department of Veterans Affairs that entails the prospective collection of clinical data from patient charts. Data on coordination practices and perceived quality came from a survey of surgical staff at each of the 44 participating surgical services. PRINCIPAL FINDINGS: The group of surgical services using high feedback and high programming had the best perceived quality. This group also had the lowest morbidity, but the difference was statistically significant with respect to only one of the two other groups: the group with low feedback and low programming. No significant group differences were found for mortality. CONCLUSIONS: Study results provide partial support for the hypothesis that high levels of feedback and programming should be combined for optimal quality of care. Study results also suggest that staff coordination is more important for improving morbidity than mortality in surgical services.

Best practices for managing surgical services: the role of coordination.

Growing evidence exists that patient outcomes are related to how effectively health care organizations coordinate work responsibilities among their staffs. However, information is lacking on actual practices that can be used to achieve effective coordination. This article reports on a National Veterans Affairs Surgical Risk Study, in which the authors studied the coordination practices of 20 surgical services that, based on risk-adjusted mortality and morbidity rates, occupied different ends of the patient outcomes continuum.

Validating risk-adjusted surgical outcomes: site visit assessment of process and structure. National VA Surgical Risk Study.

BACKGROUND: Risk-adjusted mortality and morbidity rates are often used as measures of the quality of surgical care. This study was conducted to determine the validity of risk-adjusted surgical morbidity and mortality rates as measures of quality of care by assessing the process and structure of care in surgical services with higher-than-expected and lower-than-expected risk-adjusted 30-day mortality and morbidity rates. STUDY DESIGN: A structural survey of 44 Veterans Affairs Medical Center surgical services and site visits to 20 surgical services with higher-than-expected and lower-than-expected risk-adjusted outcomes were conducted. Main outcome measures included assessment of technology and equipment, technical competence of staff, leadership, relationship with other services, monitoring of quality of care, coordination of work, relationship with affiliated institutions, and overall quality of care. RESULTS: Surgical services with lower-than-expected risk-adjusted surgical morbidity and mortality rates had significantly more equipment available in surgical intensive care units than did services with higher-than-expected outcomes (4.3 versus 2.9, p < 0.05). Site-visitor ratings of overall quality of care were significantly higher for surgical services with lower-than-expected morbidity and mortality rates (6.1 versus 4.5 for high outliers, p < 0.05); technology and equipment were rated significantly better among low-outlier services (7.1 versus 4.8 for high outliers, p < 0.001). Masked site-visit teams correctly predicted the outlier status (high versus low) of 17 of the 20 surgical services visited (p < 0.001). CONCLUSIONS: Significant differences in several dimensions of process and structure of the delivery of surgical care are associated with differences in risk-adjusted surgical morbidity and mortality rates among 44 Veterans Affairs Medical Centers.

Fast, flexible, and fluid: the continuing success of the Charlotte-Mecklenburg Hospital Authority in an era of public hospital crisis.

The changing face of health care delivery continues to challenge public hospitals, and many of these hospitals are in danger of closing. Increasing numbers of uninsured patients, coupled with state and federal cuts in Medicaid spending, threaten to worsen the situation. These facilities' survival may well depend upon their ability to create integrated delivery systems (IDSs). However, public hospitals are likely to face significant barriers in forming and participating in IDSs. This article present some of the barriers facing public hospitals as they attempt to form an IDS. Additionally, the authors present a brief case study of a public hospital whose successful efforts to form an IDS began before the IDS concept became popular. In forming an IDS this public hospital has strengthened its commitment to research, education, and the delivery of quality public health care.

Quality improvement in the US Veterans Health Administration.

The Veterans Health Administration, the largest government-operated health-care system in the United States, has been actively engaged in quality improvement activities since 1990. These activities have been implemented on both a system-wide and facility-specific basis. Some quality improvement efforts have been targeted to specific clinical services; others relate to the overall process of providing patient care. This paper provides an overview of three quality improvement activities in the Veterans Health Administration and considers the research and managerial issues they raise.

Bridging public and private sector quality assurance.

Just as the private sector has emerged as the predominant force the greater efficiency in the delivery of health care services, so too is the private sector gaining importance as a source of quality oversight strategies. Public reliance on private sector quality assurance efforts is being fueled by such developments as the growth in the number and diversity of private health care accrediting agencies, and the increase in consumer and purchaser-driven demands for comparative information about the quality of health care providers.