Hospital-based health systems 20 years later: A taxonomy for policy research and analysis.

OBJECTIVE: Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments. DATA SOURCES: The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS). STUDY DESIGN: Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems. DATA COLLECTION: Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms. PRINCIPAL FINDINGS: Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system. CONCLUSIONS: The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.

Hospital, patient, and local health system characteristics associated with the prevalence and duration of observation care.

OBJECTIVE: To examine the association between hospital, patient, and local health system characteristics and the likelihood, prevalence, and duration of observation care among fee-for-service Medicare beneficiaries. DATA SOURCES: The 100 percent Medicare inpatient and outpatient claims and enrollment files for 2009, supplemented with 2007 American Hospital Association Survey and 2009 Area Resource File data. STUDY DESIGN: Using a lagged cross-sectional design, we model the likelihood of a hospital providing any observation care using logistic regression and the conditional prevalence and duration of observation care using linear regression, among 3,692 general hospitals in the United States. PRINCIPLE FINDINGS: Critical access hospitals (CAHs) have 97 percent lower odds of providing observation care compared to other hospitals, and they conditionally provide three fewer observation stays per 1,000 visits. The provision of observation care is negatively associated with the proportion of racial minority patients, but positively associated with average patient age, proportion of outpatient visits occurring in the emergency room, and diagnostic case mix. Duration is between 1.5 and 2.8 hours shorter at government-owned, for-profit hospitals, and CAHs compared to other nonprofit hospitals. CONCLUSIONS: Variation in observation care depends primarily on hospital characteristics, patient characteristics, and geographic measures. By contrast, local health system characteristics are not a factor.

Development of peer-group-classification criteria for the comparison of cost efficiency among general hospitals under the Korean NHI program.

OBJECTIVES: To classify general hospitals into homogeneous systematic-risk groups in order to compare cost efficiency and propose peer-group-classification criteria. DATA SOURCES: Health care institution registration data and inpatient-episode-based claims data submitted by the Korea National Health Insurance system to the Health Insurance Review and Assessment Service from July 2007 to December 2009. STUDY DESIGN: Cluster analysis was performed to classify general hospitals into peer groups based on similarities in hospital characteristics, case mix complexity, and service-distribution characteristics. Classification criteria reflecting clustering were developed. To test whether the new peer groups better adjusted for differences in systematic risks among peer groups, we compared the R(2) statistics of the current and proposed peer groups according to total variations in medical costs per episode and case mix indices influencing the cost efficiency. DATA COLLECTION: A total of 1,236,471 inpatient episodes were constructed for 222 general hospitals in 2008. PRINCIPAL FINDINGS: New criteria were developed to classify general hospitals into three peer groups (large general hospitals, small and medium general hospitals treating severe cases, and small and medium general hospitals) according to size and case mix index. CONCLUSIONS: This study provides information about using peer grouping to enhance fairness in the performance assessment of health care providers.

Hospital centers of excellence defy geographic trends.

A study of "centers of excellence" of hospitals finds that dominant hospitals of excellence-those with citations in many specialties-are in relatively smaller metropolitan areas.

The diffusion of Magnet hospital recognition.

BACKGROUND: Magnet recognition is promoted by many in the practice community as the gold standard of nursing care quality. The Magnet hospital population has exploded in recent years, with about 8% of U.S. general hospitals now recognized. PURPOSE: The purpose of this study was to identify the characteristics that distinguish Magnet-recognized hospitals from other hospitals within the framework of diffusion theory. METHODOLOGY/APPROACH: We conceptualize Magnet recognition as an organizational innovation and Magnet-recognized hospitals as adopters of the innovation. We hypothesize that adoption is associated with selected characteristics of hospitals and their markets. The study population consists of the 3,657 general hospitals in the United States in 2008 located in metropolitan or micropolitan areas. We used logistic regression analysis to estimate the association of Magnet recognition with organizational and market characteristics. FINDINGS: Empirical results support hypotheses that adoption is positively associated with hospital complexity and specialization, as measured by teaching affiliation, and with hospital size, slack resources, and not-for-profit or public ownership (vs. for-profit). Adopters also are more likely to be located in markets that are experiencing population growth and are more likely to have competitor hospitals within the market that also have adopted Magnet status. A positive association of adoption with baccalaureate nursing school supply is contrary to the hypothesized relationship. PRACTICE IMPLICATIONS: Because of its rapid recent growth, consideration of Magnet program recognition should be on the strategic planning agenda of hospitals and hospital systems. Hospital administrators, particularly in smaller, for-profit hospitals, may expect more of their larger not-for-profit competitors, particularly teaching hospitals, to adopt Magnet recognition, increasing competition for baccalaureate-prepared registered nurses in the labor market.

Comparison of the effectiveness of major trauma services provided by tertiary and secondary hospitals in malaysia.

BACKGROUND: The effectiveness of trauma services provided by three hospitals operating at different levels of care, district general (DGH), tertiary care, and central tertiary, were compared in Malaysia. METHODS: Cases were recruited prospectively for 1 month. Outcome measures included death or, among survivors, disability at discharge. RESULTS: Leading causes of injuries were road traffic (72%), falls (9%), industrial (6%), and assaults (5%). Fifty-nine percent of cases were direct admissions and 41% were interhospital transfers. Of the 286 direct admissions, 12% arrived by ambulance and the remainder mostly by private car. For direct admissions, logistic regression identified an increased odds of dying associated with admission to DGH (compared with central tertiary) (odds ratio [OR], 9.8; 95% confidence interval [CI], 1.3-73.7), severe injuries (Injury Severity Score > 15) (OR, 33.1; 95% CI, 7.5-146.7), and older age (> or = 55 years) (OR, 10.8; 95% CI, 2.0-56.8). Disability at discharge was associated with being severely injured (OR, 6.4; 95% CI, 2.4-17.1). CONCLUSION: In this study in Malaysia, admission to DGH, older age, and severe injuries are associated with increased odds of fatality.

Measuring shortages of hospital nurses: how do you know a hospital with a nursing shortage when you see one?

Lack of clarity in definitions of shortages of hospital registered nurses may cause problems for effective policy making, particularly if different measures for identifying a nurse shortage lead to different conclusions about which hospitals and regions are experiencing a shortage. The authors compared different methods of identifying hospitals and regions with a shortage of registered nurses, including both relatively subjective measures (e.g., a hospital administrator's report of a nurse shortage) and more objective measures (e.g., number of registered nurses per inpatient year). Associations were strongest between self-reported shortage status and nursing vacancy rates and weaker for self-reported shortage status and registered nurses per inpatient year and overall regional supply of nurses. Different definitions of nursing shortage are not equally reliable in discriminating between hospitals and regions with and without nursing shortages. When faced with reports sounding an alarm about a hospital nursing shortage, policy makers should carefully consider the definition of shortage being used.

Gestión por procesos en el Hospital de Zumárraga y Modelo Europeo de Excelencia: gestión y evaluación de la mejora continua / Process Management at Zumárraga Hospital and European Excellence Model: evaluation and management of continuous improvement

En el Hospital de Zumárraga se ha abordado la gestión por procesos como un proyecto de mejora continua enmarcado en los principios de la calidad total. Se trata de un sistema de gestión que facilita a las personas el conocimiento de qué hay que mejorar, aportando las herramientas necesarias para dicha mejora; favorece la implicación de los profesionales y la sinergia del hospital para aumentar la eficacia y eficiencia de los servicios que se ofrecen a nuestros clientes. Durante el año 1999 se ha desarrollado el proyecto, se ha realizado la necesaria formación del personal, se ha elaborado el mapa del hospital y los diagramas de todos los procesos del centro. Se han nombrado los gestores de cada proceso y ellos han elaborado las misiones e indicadores de los mismos. Para proceder en los próximos meses a la priorización de las acciones de mejora de cada proceso y a su control por medio del plan de gestión anual. El Modelo de Excelencia del EFQM constituye un instrumento útil y práctico para la evaluación del sistema de gestión del hospital. Así mismo, la gestión por procesos influye de manera positiva y determinante en la evaluación de los diferentes criterios del Modelo (AU)

The impact of health maintenance organization penetration on the use of hospitals that serve minority communities.

OBJECTIVES: Health maintenance organization (HMO) penetration has made hospital markets more price competitive. Hospitals in minority communities may be at a competitive disadvantage because they serve patients who are, on average, sicker and more likely to be uninsured or underinsured. This study estimated the impact of HMO penetration on the use of hospitals in minority communities during 1987 to 1992. METHODS: Using a sample of 1,413 short-term general hospitals from the 85 largest metropolitan statistical areas, the determinants of hospitals' patient volumes were estimated. Hospitals located in predominately nonwhite neighborhoods were designated minority hospitals, and other hospitals were designated nonminority hospitals. Using regression analysis, the impact of HMO penetration and concentration on hospitals' patient volumes were estimated. By interacting the HMO penetration and concentration variables with a minority hospital indicator variable, HMOs' impact on minority hospitals was calculated. RESULTS: Health maintenance organization penetration was correlated with lower patient volumes in minority hospitals and higher patient volumes in nonminority hospitals. Competition in HMO markets was correlated with lower patient volumes for all hospitals. This effect was stronger for minority hospitals. CONCLUSIONS: These findings suggest that minority hospitals may be at risk of losing patients as HMO penetration increases.

Top 100 hospitals. Reaching for the clouds.

The nation's Top 100 hospitals combine razor's edge management with an ability to take a marketplace punch and maintain their balance sheet. And more often than not, they're found in markets highly influenced by managed care and for-profit healthcare companies.

Treating early-stage breast cancer: hospital characteristics associated with breast-conserving surgery.

Despite growing acceptance of the fact that women with early-stage breast cancer have similar outcomes with lumpectomy plus radiation as with mastectomy, many studies have revealed the uneven adoption of such breast-conserving surgery. Discharge data from the Hospital Cost and Utilization Project, representing multiple payers, locations, and hospital types, demonstrate increasing trends in breast-conserving surgery as a proportion of breast cancer surgeries from 1981 to 1987. Women with axillary node involvement were less likely to have a lumpectomy, even though consensus recommendations do not preclude this form of treatment when local metastases are present. Non-White race, urban hospital location, and hospital teaching were associated with an increased likelihood of having breast-conserving surgery.

Consultoria psiquiatria em Hospital Geral do Exercito: experiencia de um ano / Psychiatric consultation in Army General Hospital: experience of 1 year

Este trabalho visa transmitir a experiencia inedita na literatura mundial de Interconsulta Psiquiatrica em Hospital Militar (Hospital Geral de Campo Grande-HCeGC), no periodo de marco de 1992 a marco de 1993. Pretende, ainda, comparar os dados obtidos quanto ao numero de casos atendidos, idade, sexo, estado civil, categoria e situacao militar atual, Forca Armada a que pertence, escolaridade, unidade solicitante, motivo e autor do pedido, medicacao em uso, exame neurologico, diagnostico e conduta psiquiatrica, com dados da literatura civil, propondo a expansao da Interconsulta a outras Organizacoes Militares de Saude, nao so do Comando Militar do Oeste (CMO), mas tambem de outros Comandos.

Limitation of private attending pediatricians' neonatal intensive care privileges in level III institutions throughout the United States.

OBJECTIVE: To determine the privileges of Private Attending Pediatricians (PAP) in caring for newborns requiring intensive (ITC), intermediate (IMC), or continuing (CC) care in Level III neonatal intensive care units (NICUs) throughout the United States. DESIGN: A two-page mail questionnaire was sent to 429 Level III NICUs to obtain the statement best describing the PAPs' privileges, the number of PAP, and some of the PAPs' functions. Level III NICUs were classified by geographic region as Eastern, Central, or Western United States. RESULTS: Responses were received from 301 NICUs (70%) representing 48 states, the District of Columbia, and > 9000 PAP. Twenty-two institutions had no PAP. In the remaining 279 institutions, 96% (267/279) had restricted the PAPs' privileges partially or completely. In 32% (88/279), the PAP were not allowed to render any type of NICU care. In 18% (51/279) of the institutions, the PAP were allowed to render CC only. In 27% (76/279) of the institutions, the PAP were allowed to render IMC and CC only. Limitation of PAPs' privileges were reported in all geographic areas in the U.S., were more pronounced in the Eastern than the Central or Western sections of the country, and were noted in institutions with small (< or = 10) as well as large (> or = 60) numbers of PAP. Limitation of PAPs' privileges was determined by the PAP him/herself in many institutions. Proficiency in resuscitation was considered to be a needed skill. Communication with parents of an infant under the care of a neonatologist was encouraged. CONCLUSIONS: The PAPs' privileges were limited partially or completely in most Level III NICUs. Knowledge of this restricted role impacts significantly on curriculum design for pediatric house officers, number and type of health care providers required for Level III NICUs and future house officer's career choices.

Follow-up survey of inpatients with AIDS and HIV infection: economic impact on hospitals in North Carolina.

This study is a 2-year follow-up to a 1987-1988 survey of North Carolina hospitals regarding hospital utilization by patients with acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV) infection. Almost 99% of the state's hospitals participated in the re-survey for the fiscal year 1989-1990. The number of general hospitals treating these patients grew by 57%; HIV/AIDS inpatients increased by 189% from 540 to 1,561. Total general hospital charges for HIV/AIDS inpatients increased from $7,685,000 to $26,957,000, an increase of 251%. Of these charges the amount that was uncompensated by insurance increased by 293% to $7,733,000. Fifteen large tertiary general hospitals treated 80% of the HIV/AIDS inpatients and accounted for $6,093,000 (79%) of the uncompensated charges related to these patients.

Inpatients with AIDS and AIDS-related complex: economic inpact on hospitals in North Carolina.

To determine the economic impact of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) cases on North Carolina hospitals, we collected inpatient data from all North Carolina hospitals on charges and number of patients discharged with these diagnoses. More than 97% of the state's hospitals responded to the survey for the study year (1987-1988). There were 540 AIDS/ARC discharges from 58 North Carolina general hospitals and 125 AIDS/ARC discharges from 13 other types of hospitals, for a statewide total of 665 patients. The total general hospital charges for AIDS/ARC inpatients in North Carolina were approximately $7.7 million per year, and almost $2 million of these charges were uncompensated by any insurance. The greatest burden of cost for this care was borne disproportionately by 15 of the 58 general hospitals, accounting for 82% of the discharges.

An analysis of case mix complexity using information theory and diagnostic related grouping.

Case mix complexity measurements are essential to determine health care efficiency and effectiveness. Measures of patient care processes and outcomes must be adjusted for case mix before valid comparisons can be made. Hospital reimbursement, particularly prospective reimbursement, must take into account differences in case mix. In addition, a key variable for hospital classification is case mix. There are, however, no widely accepted easily computed case mix measures. Information theory measures of case mix have been developed but their acceptance has been limited by a lack of verification of their basic assumption that concentration of disease is related to clinical complexity. We discuss the rationale underlying the mathematical computaton of information theory measures and demonstrate a statistically significant relationship between clinical measures of case mix complexity and information theory measures of case mix complexity.

Emergency medical services in crisis: an Italian case study.

This paper deals with the system of emergency medical services in Italy. More specifically, it is a case study of the organization and operation of this system in the region of Tuscany. Recent decentralization decrees have established regional governments with major responsibilities for health care, including emergency medical services. The effects of a long history of social and political cleavages on provision of these services at the regional level are presented and discussed. The paper concludes that prospects for rational reform of emergency care service are dim.