Microstructure alterations in beef intramuscular connective tissue caused by hydrodynamic pressure processing.

Scanning electron microscopy (SEM) was utilized to evaluate microstructural changes in intramuscular connective tissue of beef semimembranosus muscle subjected to hydrodynamic pressure processing (HDP). Samples were HDP treated in a plastic container (HDP-PC) or a steel commercial unit (HDP-CU). Control and HDP samples were obtained immediately post-treatment and after 14days of aging for SEM and Warner-Bratzler shear force (WBSF) analysis. Immediately post-treatment, HDP treated samples exhibited lower (P<0.01) WBSF than did controls. After aging, HDP-PC samples had lower (P<0.01) WBSF than that of aged controls. SEM analysis indicated that HDP-PC treatment disrupted the integrity of the collagen fibril network of the endomysium in both the non-aged and aged samples. Aging effects on the intramuscular connective tissue were observed in the HDP-PC and control samples. Both WBSF and connective tissue changes were greater in the HDP-PC than in the HDP-CU treated samples. Data suggest that shockwave alterations to connective tissue contribute to the meat tenderization of HDP.

Quality improvement of kosher chilled poultry.

Pathogens like Listeria monocytogenes are of great concern in the poultry industry. Poultry, which are subjected to the kosher slaughtering and koshering process, may introduce even higher risks than conventially slaughtered poultry due to the potential for microbial cross-contamination at several critical points in the koshering line, particularly in the chillers. The effect of Microgard (MIC) and Nisin (NIS) on reducing total microbial counts, inhibiting L. monocytogenes, and prolonging shelf life was evaluated. In this work we applied dips of poultry into solutions of NIS, active against Gram-positive bacteria, and MIC, which is a bacteriocin mixture that retards growth of Gram-negative bacteria, and a mixture of organic acids. These treatments inhibited both inoculated and naturally occurring L. monocytogenes on poultry, and increased shelf life, at 6 C, from 2 to 4 d (end of shelf life was considered when total aerobic counts reached 7 log cfu/g).

Physician-system alignment: introductory overview.

The papers in this Special Supplement are based on research funded by the participating members of the joint Center for Health Management Research (CHMR) and Center for Organized Delivery Systems (CODS), and supported by the National Science Foundation under its Industry-University Cooperative Research Center Program. This 3-year research initiative from 1996 through 1999 involved 69 physician organizations (primarily organized medical groups as opposed to IPAs) associated with 14 organized delivery systems. The groups ranged in size from three to 958 with an average size of 76.4 and a median size of 25.0. Comparisons of the study groups with United States physician groups overall are shown in Table 1. The study groups are larger and more likely to be multispecialty than all groups in the United States. The organized delivery systems range in size from one hospital to 80 hospitals with an average of 21 hospitals per system and a median of 11 hospitals per system. They average 4.6 affiliated medical groups with a range from one to 23. The organized delivery systems range in total revenues in 1998 from $340 million to $6.2 billion with an average of $2.1 billion. All the study systems are not-for-profit. Most are located in single market areas, but several are located in multiple markets. For the most part, they represent some of the larger most experienced organized delivery systems in the country. Among the primary objectives of the study was to identify the factors most strongly associated with physician alignment with the health care system and the consequences for the implementation of evidence-based care management practices. The study was also designed to identify the barriers and facilitators to achieving such alignment and its consequences.

The ties that bind: interorganizational linkages and physician-system alignment.

OBJECTIVES: To examine the association between the degree of alignment between physicians and health care systems, and interorganizational linkages between physician groups and health care systems. METHODS: The study used a cross sectional, comparative analysis using a sample of 1,279 physicians practicing in loosely affiliated arrangements and 1,781 physicians in 61 groups closely affiliated with 14 vertically integrated health systems. Measures of physician alignment were based on multiitem scales validated in previous studies and derived from surveys sent to individual physicians. Measures of interorganizational linkages were specified at the institutional, administrative, and technical core levels of the physician group and were developed from surveys sent to the administrator of each of the 61 physician groups in the sample. Two stage Heckman models with fixed effects adjustments in the second stage were used to correct for sample selection and clustering respectively. RESULTS: After accounting for sample selection, fixed effects, and group and individual controls, physicians in groups with more valued practice service linkages display consistently higher alignment with systems than physicians in groups that have fewer such linkages. Results also suggest that centralized administrative control lowers physician-system alignment for selected measures of alignment. Governance interlocks exhibited only weak associations with alignment. CONCLUSIONS: Our findings suggest that alignment generally follows resource exchanges that promote value-added contributions to physicians and physician groups while preserving control and authority within the group.

Implementing evidence-based medicine: the role of market pressures, compensation incentives, and culture in physician organizations.

OBJECTIVES: To assess the extent to which market pressures, compensation incentives, and physician medical group culture are associated with the use of evidence-based medicine practices in physician organizations. METHODS: Cross-sectional exploratory study of 56 medical groups affiliated with 15 integrated health systems from across the United States, involving 1,797 physician respondents. Larger medical groups and multispecialty groups were overrepresented compared with the United States as a whole. Data are from two sources: (1) surveys of physicians assessing the culture of the medical groups in which they work, and (2) surveys of medical directors and other managerial key informants pertaining to care management practices, compensation methods, and the management and governance of the medical groups. Physician-level data were aggregated to the group level to attain measures of group culture and then merged with the data regarding care management, incentives, and management and governance. Stepwise multiple regression was used to examine the study hypotheses. RESULTS: As hypothesized, the number of different types of compensation incentives used (cost containment, productivity, quality) was positively associated with the comprehensiveness of care management practices. The degree of salary control (ie, market-based salary grades and ranges versus the use of bookings or fees and individual negotiation) was also positively associated with the deployment of care management practices. As hypothesized, market pressures in the form of percentages of health maintenance and preferred provider organization patients seen were generally positively associated with the use of care management practices. Organizational culture had no association except that a patient-centered culture in combination with a greater number of different types of compensation incentives used was positively associated with greater use of care management practices. CONCLUSIONS: Both compensation incentives and managed care market pressures were significantly associated with the use of evidence-based care management practices. The lack of association for culture may be due to the relatively amorphous nature of most physician organizations at this point.

Factors associated with physician involvement in care management.

BACKGROUND: Enthusiasm for the concept of care management (CM) has led to unprecedented growth in the number of guidelines and protocols, but provider organizations have struggled to enlist the active support and participation of physicians in CM activities. OBJECTIVES: To empirically examine the factors influencing physician participation in and attitudes toward CM activities. METHODS: Data on 1,514 physicians were used to predict physician attitudes toward CM and their perceptions of group CM behaviors. Dependent variables were modeled using two-stage Heckman selection bias models with fixed effects corrections. Independent predictors included physician- and group-level controls as well as six potential CM participation and attitude facilitators. RESULTS: Physician participation in the implementation phase of CM activities was positively related to participation and attitude. However, physician participation in the development phase may be negatively related to later participation in CM activities. Management involvement in development phase has mixed effects (positive or no effect), but their involvement in the implementation phase was somewhat negatively related to CM participation and attitude. Financial incentives for participation in CM activities and presence of a useful management information system also appeared to be positively related to attitude and participation. CONCLUSIONS: Appropriate physician and management involvement, as well as financial incentives and useful management information systems may facilitate physician participation in CM activities. Physician involvement in implementation of CM practices appears to be important, whereas their involvement in the development phase may be negatively related to later attitudes and participation. The findings call for a more in-depth understanding of the timing of physician input in CM activities.

Physician commitment to organized delivery systems.

BACKGROUND: Health care systems have developed many types of contracting vehicles with physicians. The immediate aim of these vehicles has been to foster physician commitment and alignment to the system. The ultimate aim of these vehicles has been to garner managed care contracts, reduce costs, and improve quality. To date, most of these vehicles have failed to improve physician commitment. This may be one reason why the ultimate outcomes have not been observed. Consequently, systems are experimenting with new methods to partner with physicians. One new method is to segment physicians into tightly linked and loosely linked strategic alliances and devote different levels of resources and attention to each. OBJECTIVES: This study evaluates whether the segmentation of physicians into tightly linked versus loosely linked strategic alliances improves the commitment of physicians to the system. The study then investigates which constituent elements of the tightly linked strategic alliances exhibit the greatest association with commitment. DESIGNS AND SUBJECTS: The study uses a cross-sectional design and survey data drawn from 1,965 physicians affiliated with 14 health care systems around the country. Tightly linked physicians typically practiced in hospital-sponsored group practices, whereas loosely linked physicians typically used the system's hospitals as their primary site of inpatient practice. MEASURES: Commitment is measured by seven different scales drawn from the literature on organizational commitment, loyalty, and identification. Some of the scales refer to physician attitudes, whereas others describe physician behaviors. The literature suggests that commitment is associated with both instrumental/utilitarian considerations (eg, older age, tenure with system, admissions to system, receipt of a stipend, etc.) as well as administrative involvement/participation considerations (eg, decision-making roles). A series of physician background and practice characteristics are used here to model these two types of factors. RESULTS: The study finds small but significant differences in commitment between physicians in tightly linked versus loosely linked alliances. Multivariate analyses suggest that instrumental/utilitarian factors (eg, age, receipt of stipend, percent of admissions to the system) may exhibit stronger associations with commitment than the physician's administrative involvement in the organization. CONCLUSIONS: To the degree that physician commitment is possible, systems should appeal to physicians' calculative motivations using extrinsic rewards rather than normative involvement in the organization.

Risk assumption and physician alignment with health care organizations.

OBJECTIVES: To examine the association between risk assumption by individual physicians and physician groups and the degree of alignment between physicians and health care systems. METHODS: A cross sectional comparative analysis using a sample of 1,279 physicians practicing in loosely affiliated arrangements and 1,781 physicians in 61 groups closely affiliated with 14 vertically integrated health systems. Measures of physician alignment were based on multiitem scales validated in previous studies and derived from surveys sent to individual physicians. Measures of risk assumption were developed from surveys sent to the administrator of each of the 61 physician groups in the sample and to physicians affiliated with these groups. Two stage Heckman models with fixed effects adjustments in the second stage were used to correct for sample selection and clustering respectively. RESULTS: After accounting for selection, fixed effects, and group and individual controls, physicians in groups with larger proportional revenue from managed care displayed greater normative commitment and system loyalty than physicians in groups with lower proportional managed care revenue. Individual-level managed care risk was also positively related to both normative commitment and group behavioral commitment to the system. Physicians in groups with larger physician equity positions expressed lower levels of normative commitment to the system. Physician productivity compensation was negatively related to all measures of alignment. Finally, group emphasis on individually-based incentives for staff physicians was negatively related to system identification. CONCLUSIONS: Our findings suggest that organizations must balance individually-based risk schemes with those that emphasize the performance of the group and the system to achieve long-term goals of loyalty, identification, and commitment to the system.

Physician-system relationships: stumbling blocks and promising practices.

OBJECTIVES: To identify the barriers, facilitators, and potential better practices to achieving physician-system alignment. METHODS: Interviews using a semi-structured, open-ended protocol were conducted during a total of 18 site visits, each usually 2 days in length, covering multiple topics of physician group-system alignment. Interviews were conducted with members of the target physician group, key leaders of the health care system, and representatives of physicians not in the target group. The summary of the interviews for each of the site visits was analyzed to determine barriers, facilitators, and better practices for achieving more effective relationships between physician groups and health care systems. RESULTS: A number of barriers to more effective relationships between physician groups and health systems were identified. Barriers related to environment, culture, and information systems were most prevalent. Other major general areas of barriers encountered were physician leadership, group-system relationship, compensation and productivity, care management practices, group strategy, and accountability. Examples of practices that may help to resolve some of these issues were also identified. CONCLUSIONS: Physician-system relationships can and do cause problems for improving health care. The evidence from the conducted site visits suggests that specific strategies may help improve these relationships but more research is needed in order assess the actual impact of these strategies.

Just how integrated are integrated delivery systems? Results from a national survey.

This article examines three emergent processes in physician-hospital integrated delivery systems (IDSs). We find these processes are underdeveloped based on data gathered from a national sample of hospitals drawn from nine health care systems. These processes are also loosely coupled with the structures used to integrate physicians and hospitals, as well as with the environmental context in which they occur. Such loose coupling entails both advantages and disadvantages for IDSs.

Strategies for effective management participation in community health partnerships.

This article develops guidelines for effective health services management participation in community health partnerships. Drawing on our study of Community Care Network (CCN) Demonstration, the strategic alliance literature, and other research, we describe six challenges that health services managers are likely to face as partnership participants and discuss the strategies that they might use to deal with them.

Principles and performance of an electron spin echo spectrometer using far infrared lasers as excitation sources.

We have built an electron spin echo spectrometer operating at 604 GHz, extending the frequency limit of existing spectrometers by more than a factor of 4. In order to handle this high frequency we have used optical techniques, i.e., molecular gas lasers for the excitation pulses and far infrared techniques for the heterodyne detection system. The different components of the spectrometer are described in detail and first experimental results are given.

Interorganizational factors affecting the delivery of primary care to older Americans.

OBJECTIVE: To discuss different types and forms of interorganizational linkages involved in the provision of primary care to older Americans, along with their distinguishing characteristics. RESEARCH STRATEGY: To take advantage of these linkage characteristics. The strategy requires a partnership with health services organizations and providers actually involved in the provision of services along with a planned sequence of activities involving hypotheses and methods development, intervention trials, and finally, demonstration and implementation. CONCLUSION: Because older Americans are frequent users of health services, their need for continuity and access provides an opportunity to examine changes to the delivery system and to monitor the system's capability for meeting their healthcare needs.

Physicians and organizations: strange bedfellows or a marriage made in heaven?

Underscoring the importance of physician-organization alignment as a necessary condition for building and sustaining integrated healthcare systems, this article provides information regarding the nature of such alignment, the key influential factors, and the processes employed to make alignment a reality. Structural and strategic factors address the influence of environmental, market, and organizational characteristics on alignment. The strategic intent of organizations and physicians, and physician perspectives on the effects of integration, are explored. Key processes examined include building trust, placing physicians in management and governance, and developing physician leadership. Continuing issues and challenges are considered, and a set of principles to help guide the journey of physicians and organizations toward successful alignment is suggested.

An exploratory analysis of market-based, physician-organization arrangements.

The growth of physician-organization arrangements (e.g., PHOs, MSOs) by physician specialty groups and delivery organizations is widely acknowledged. Yet, little is known about these new organizational forms. This paper presents a descriptive analysis of physician-organization arrangements (POAs) using survey data obtained from 79 organizations. The analysis examines the extent to which healthcare delivery organizations are engaged in the development of POAs, the number of physicians involved in POAs, and the decision-making control and strategies associated with POAs. These attributes are examined for the sample as a whole and relative to the institutional and market conditions facing study participants. Results are discussed in terms of their implications for health services managers.

The challenges of governing integrated health care systems.

As health care delivery organizations develop into integrated health care systems, new and significant challenges arise with respect to how such systems should be governed. This article explores several key governance issues that organizations are likely to encounter as they attempt to effect the transition from hospital or multihospital system governance arrangements to those appropriate for integrated systems.

Alliances in health care: what we know, what we think we know, and what we should know.

Alliances are the organizations of the future. This article builds on the lessons from industry identifying important areas requiring definition and basic understanding of alliance structure, process, and outcome in health care services.