Dying trajectory in the last year of life: does cancer trajectory fit other diseases?

PURPOSE: To examine differences in the pattern of functional decline among persons dying of cancer and other leading noncancer causes of death. DESIGN: Mortality followback survey of next of kin listed on death certificate. SETTING: Probability sample of all deaths in the United States. PARTICIPANTS: Next of kin for 3,614 decedents that represented 914,335 deaths. MEASUREMENTS: Days of difficulty with activities of daily living and mobility in the last year of life. RESULTS: Relative to other decedents, patients with cancer experienced an increased rate of functional impairment beginning as late as 5 months prior to death. For example, only 13.9% of patients with cancer had difficulty getting out of bed or a chair 1-year prior to death. This increased from 22.2% to 63.0% in the last five months of life. In contrast, decedents from other diseases had higher rates of functional impairment 1 year prior to death (approximately 35% had difficulty getting out of bed or chair) and they manifested a more gradual increase in the level of functional decline (approximately 50% had difficulty getting out of bed). Precipitous functional decline was associated with hospice involvement and dying at home. CONCLUSION: Persons dying of cancer experienced sharp functional decline in the last months of life whereas other decedents' have a more gradual decline. The more precipitous functional decline was associated with hospice involvement and dying at home.

Facility effects on racial differences in nursing home quality of care.

This paper reviews the literature on racial/ethnic differences in nursing home quality, segregated access to nursing home care, and organizational and community factors that may influence access and quality of care. We present illustrative data on county demographics and the racial mix of African American residents in nursing homes in these counties for a sample of four states. We also briefly describe plans for multilevel modeling to test variation in racial/ethnic disparities in care as a function of nursing home structures and processes and community context.

Key challenges in studying organizational issues in the delivery of healthcare to older Americans.

OBJECTIVE: Drawing from the articles presented in this special issue, to provide an overview of three key challenges facing researchers in the area of organizational issues in primary care delivery to older adults. CONCLUSIONS: To improve the quality of research done in this area we would recommend that researchers attend to the complexity of (1) defining an appropriate unit of analysis; (2) reframing our traditional models of service delivery to reflect ongoing changes in healthcare system actors and boundaries; and (3) reconceptualizing the outcomes of care to reflect adequately the reality of care for the aging patient.

Linkage strategies of rural hospitals--independent hospital, local health system, and/or externally linked facility.

Strategies associated with ownership or management of a range of health service facilities, service sharing, and other coordination activities are important to the viability of many rural hospitals. This article articulates a set of linkage strategies employed by rural hospitals. Such strategies and their environmental and organizational correlates are assessed in a sample of 46 rural Pennsylvania hospitals.

The effects of hospital characteristics and radical organizational change on the relative standing of health care professions.

This paper examines the effects of hospital characteristics and radical organizational change on the relative representation of health care professions in hospitals over the period of the 1980s. Health care organizations, and hospitals in particular, represent organizations where multiple professional groups make competing claims of expertise that often conflict. The question our research seeks to answer is whether different constellations of organizational characteristics and organizational changes affect the outcome of these professional conflicts. Using the annual census of hospitals compiled by the American Hospital Association, we examine the effects of several characteristics of community hospitals on the relative representation of specific professional groups. We find that hospital mergers favor physicians at the expense of administrators, and multihospital system affiliation favors technical core occupations at the expense of administrators. Measures of organizational growth and decline increase the relative representation of physicians and administrators compared to nurses, and increase the probability that hospitals will employ physicians' assistants and nurse practitioners. Our results are evaluated in light of recent developments in the sociology of medicine and research on the relative standing of occupations in other industries.

Through the lenses of organizational sociology: the role of organizational theory and research in conceptualizing and examining our health care system.

This paper reviews various theoretical perspectives on organizational change which have been and could be applied to medical organizations. These perspectives are discussed as both filters influencing our observations (research) and mirrors of the shifting dynamics of delivery system reform (policy). We conclude with an examination of how such theories can provide useful insights into our rapidly changing health care system.

Leadership instability in hospitals: the influence of Board-CEO relations and organizational growth and decline.

This study tested whether leadership instability--a systemic pattern of frequent succession in the top management position of an organization--was associated with sociopolitical structures that define the relationship between the board and chief executive officer (CEO), controlling for temporal patterns of the organizational life-cycle stage. In organizations that are not profit maximizing and subject to considerable uncertainty, such governance properties were hypothesized to affect leadership instability independent of organizational growth or decline. Results of regression analyses demonstrate strong main effects of board-CEO relations, net of the impact of organizational life cycle, on leadership instability.

Multihospital system affiliation as a survival strategy for rural hospitals under the prospective payment system.

The introduction of Medicare's Prospective Payment System (PPS) has disproportionately increased financial pressures on rural hospitals and posed challenges to the survival of these institutions. Increasingly, rural hospitals are seeking strategies that can enhance their chances for survival in a turbulent and hostile environment. This study examined the survival effects of one such strategy, multihospital system affiliation. Specifically, we assessed: (1) whether and how different types of system affiliation in the post-PPS era affect the likelihood of rural hospital survival; (2) whether particular structural, environmental and hospital performance characteristics moderate the effects of system affiliation on rural hospital survival; and (3) whether systematic selection by rural hospitals into multihospital systems potentially accounts for observed relationships between system affiliation and survival. Proportional hazards analyses indicate that system affiliation with investor-owned systems significantly reduces survival probabilities of rural hospitals. Affiliation with not-for-profit systems or system affiliation under contract management arrangements does not affect survival probabilities of rural hospitals. These general findings are moderated by the effects of hospital ownership and size at the time of affiliation. Finally, study findings indicated that systematic selection by poor performing rural hospitals into investor-owned systems has occurred in the post-PPS era. No evidence of selection into not-for-profit systems was discovered.

Governing boards and profound organizational change in hospitals.

Over the past decade the importance of governing boards as policy-making setting and oversight units within organizations has increased dramatically. Although this is true for both corporate- and private-sector organizations (Bacon and Brown 1977; Gelman 1988), it is particularly relevant to the health sector. Hospital governing boards, long considered inconsequential in hospital management, have recently become subject to closer scrutiny. The role of governing boards in decisions affecting hospital strategy and hospital performance is once again a topic of some interest in boardrooms and hospital trade journals. Impressive evidence of the renewed interest in governance is provided by the funding of an instructional consortium by the S.K. Kellogg Foundation to help strengthen trusteeship and governing board decision making, and to improve education for health services managers in the area of governance. Members of the consortium include the Hospital Research and Educational Trust, the American Hospital Association, the American College of Healthcare Executives, and the Association for University Programs in Health Administration. Among the activities being undertaken by this consortium is the development of a self-assessment tool/methodology for boards, a bibliography and reference guide on effective governance for practicing trustees, research workshops for faculty in health administration programs, and a teaching guide on governance and trustee leadership. Despite this interest, the question with which we began this article persists. Do governing boards make a difference? In the course of our review of previous work on governance we found that, more often than not, that question has been transformed into: how do boards influence hospital performance? And very often that question has been further narrowed into: which board structure leads to better hospital performance? We have argued for a respecification of the initial question. Rather than pursuing a definition of the maximally performing governing board, we should perhaps shift our focus back to a fuller understanding of board structure and function, and its influence on hospital change. The model developed here combines four essential, and very basic, questions: 1. What are the basic dimensions that underlie structural variation in different types of governing boards? 2. How do these board types influence structural change in hospitals? 3. How is the effect of board influence on change itself likely to change over time as a function of the hospital's general pattern of growth, decline, stability, or instability?(ABSTRACT TRUNCATED AT 400 WORDS)

Synergy, influence, and information in the adoption of administrative innovations.

The adoption processes of two related administrative innovations in the private sector dealing with employee health are examined. Results of multiple logistic regressions using survey data on a sample of Illinois firms suggest that these two innovations are synergistically linked, such that the adoption of one increases the likelihood of the subsequent adoption of the other.

The effects of environmental characteristics on the structure of hospital clusters.

The population ecology view that variation in sets or clusters of organizations should be isomorphic with variation in cluster environment was used here to explain structural variation among hospital clusters. The structural characteristics studied were range of services offered within the cluster, average size of hospitals in the cluster, and cluster differentiation. In the causal model that was developed and evaluated, variation in the patient environment and variation in the supplier environment were compared. Four lagged panels of data on a national sample of fifteen hospital clusters demonstrated the relative superiority of supplier variables over patient variables. Supplier group preferences were more powerful than patient needs in determining the range of services offered by the cluster. Furthermore, increasing the range of services in the cluster had a positive, significant effect on average hospital size, whereas size apparently exerted no effect on range of cluster facilities. Cluster differentiation seems to be causally affected by range of services, average hospital size, and by the periodic closing of hospitals over time.