Service mix and financial performance in rural hospitals: A contingency theory perspective.

BACKGROUND: Rural hospitals are increasingly at risk of closure. Closure reduces the availability of hospital care in rural areas, resulting in a disparity in health between rural and urban citizens, and it has broader economic impacts on rural communities as rural hospitals are often large employers and are vital to recruiting new businesses to a community. To combat the risk of closure, rural hospitals have sought partnerships to bolster financial performance, which often results in a closure of services valuable to the community, such as obstetrics and certain diagnostic services, which are viewed as unprofitable. This can lead to poor health outcomes as community members are unable to access care in these areas. PURPOSE: In this article, we explore rural hospital service offerings and financial performance, with an aim to illuminate if specific service offerings are associated with positive financial performance in a rural setting. METHODS: Our study used hospital organization data, as well as county-level demographics with periods of analysis from 2015 and 2019. We employed a pooled cross-sectional regression analysis with robust standard errors examining the association between total margin and service lines among rural hospitals in the United States. RESULTS: The findings suggest that some services deemed unprofitable in urban and suburban hospital settings-such as obstetrics and drug/alcohol rehabilitation-are associated with higher margins in rural hospitals. Other unprofitable service lines-such as psychiatry and long-term care-are associated with lower margins in rural hospitals. CONCLUSION: Our results suggest the need of rural hospitals to choose services that align with environmental circumstances to maximize financial performance. PRACTICE IMPLICATION: Hospital administrators in rural settings need to take a nuanced look at their environmental and organizational specifics when deciding upon the service mix. Generalizations regarding profitability should be avoided to maximize financial performance.

Quantification of glistenings in intraocular lenses using a ballistic-photon removing integrating-sphere method.

An alternative method for quantification of glistenings in intraocular lenses (IOLs) using an integrating sphere with an adjustable back aperture to remove ballistic photons is presented. Glistenings in soft IOLs have been known for more than a decade; however, their severity and visual impact are still under investigation. A number of studies have been made to quantitatively describe glistenings in IOLs. Quantization and precise grading of IOLs will provide needed information to evaluate the severity and visual impact of glistenings in patients. We investigated the use of a simple modification of an integrating-sphere method to eliminate ballistic photons to quantitatively measure scattered light from glistenings in IOLs. The method described in this paper provides a simple and effective way to quantitatively characterize glistenings in vitro. It may be especially useful to quantify scattering associated with low-grade glistenings where the density of the scattering centers is low. Finally, the modified integrating-sphere method may also be generally applicable to quantitatively characterize scattering from other optical media.

Evaluation of Potential Optical Radiation Hazards from LED Flashlights.

We performed optical radiation safety evaluations of LED flashlights to determine if they pose potential ocular hazards. Six commercially available flashlight samples were randomly selected from various vendors online. They were evaluated in accordance with specifications provided in the American National Standards Institute/Illuminating Engineering Society of North America (ANSI/IESNA) Standards RP 27.1 and RP 27.3. Four of the flashlights were found to have relatively high blue-light-weighted radiance values with short times (40 to 50 s) to reach the exposure limit specified in RP 27.1. These flashlights are in Risk Group 2 and present a moderate risk for retinal damage. Two of the flashlights are in Risk Group 1 and present a low risk for retinal damage. None of the flashlights present an ultraviolet (UV) radiation hazard or a retinal thermal hazard. Cautionary labeling on the packaging as required by RP 27.3 and on the flashlight handle is recommended for flashlights and on other handheld light sources that are in Risk Group 2 or Risk Group 3.

Increased UVA exposures and decreased cutaneous Vitamin D(3) levels may be responsible for the increasing incidence of melanoma.

Cutaneous malignant melanoma (CMM) has been increasing at a steady exponential rate in fair-skinned, indoor workers since before 1940. A paradox exists between indoor and outdoor workers because indoor workers get three to nine times less solar UV (290-400 nm) exposure than outdoor workers get, yet only indoor workers have an increasing incidence of CMM. Thus, another "factor(s)" is/are involved that increases the CMM risk for indoor workers. We hypothesize that one factor involves indoor exposures to UVA (321-400 nm) passing through windows, which can cause mutations and can break down vitamin D(3) formed after outdoor UVB (290-320 nm) exposure, and the other factor involves low levels of cutaneous vitamin D(3). After vitamin D(3) forms, melanoma cells can convert it to the hormone, 1,25-dihydroxyvitamin D(3), or calcitriol, which causes growth inhibition and apoptotic cell death in vitro and in vivo. We measured the outdoor and indoor solar irradiances and found indoor solar UVA irradiances represent about 25% (or 5-10 W/m(2)) of the outdoor irradiances and are about 60 times greater than fluorescent light irradiances. We calculated the outdoor and indoor UV contributions toward different biological endpoints by weighting the emission spectra by the action spectra: erythema, squamous cell carcinoma, melanoma (fish), and previtamin D(3). Furthermore, we found production of previtamin D(3) only occurs outside where there is enough UVB. We agree that intense, intermittent outdoor UV overexposures and sunburns initiate CMM; we now propose that increased UVA exposures and inadequately maintained cutaneous levels of vitamin D(3) promotes CMM.

Factors associated with hospital bankruptcies: a political and economic framework.

Between 2000 and 2006, 42 U.S. acute care hospitals filed for bankruptcy protection under federal law. This article explores hospital bankruptcies over a six-year period. Bankrupt hospitals are compared with their competitors, and hospitals surviving bankruptcy are compared with those organizations that eventually close. Finally, this article identifies nonfinancial factors associated with the filings and categorizes these factors into a political and economic framework. A literature review of hospital trade publications is used to identify organizations filing for bankruptcy during this period. Data gathered from these resources are used in concert with American Hospital Association data to identify hospital characteristics and publicly available information on factors surrounding hospital bankruptcy filings. Data on the status of hospitals after filing are also collected to determine whether bankruptcy reorganization is successful or results in hospital closure. Results indicate that 67 percent of hospitals filing for bankruptcy during this time eventually ceased operating. Bankrupt hospitals are smaller than their competitors. They are also less likely to belong to a system and more likely to be investor owned. Factors associated with filing organizations are placed into a political and economic framework derived from Park's work on municipal bankruptcy filings. Common nonfinancial factors associated with hospital bankruptcies include mismanagement, increased competition, and reimbursement changes.

Evaluation of the Potential Optical Radiation Hazards with Led Lamps Intended for Home Use.

The authors evaluated the potential for ocular damage from optical radiation emitted by Light Emitting Diode (LED) based lamps used for general illumination. Ten LED lamps were randomly selected off the shelf from a local home improvement store. The LEDs were behind diffusers in half of these lamps, while in the other half, the LEDs were clearly visible. In addition, a battery powered LED lantern having a LED source behind a diffuser was measured. The optical radiation emissions from two common incandescent lamps were also measured to compare the relative hazards of LED and incandescent lamps. All lamp samples were evaluated in accordance with procedures specified in the American National Standards Institute/Illuminating Engineering Society of North America (ANSI/IESNA) Standard RP-27.3. For comparison purposes, the lantern and 100 W incandescent lamps were also evaluated according to ANSI RP-27.1. These measurements indicate that no lamp evaluated poses any photobiological hazard, and therefore, all lamps fall in the RP-27.3 category of Exempt Group. However, when evaluated in accordance with RP-27.1, the 100 W incandescent lamp would be classified in Risk Group 1 (low risk), while the LED lantern would be classified in Risk Group 2 (moderate risk).

Retinal phototoxicity: a review of standard methodology for evaluating retinal optical radiation hazards.

Optical radiation (light) safety standards can be difficult to use for the evaluation of light hazards to the retina, even for persons experienced in radiometry and photometry. This paper reviews terminology and methodology for evaluating optical radiation hazards to the retina in accordance with international standard ISO 15004-2 Ophthalmic instruments-Fundamental requirements and test methods, Part 2: Light hazard protection (2007). All optical radiation safety standards use similar methods. Specifically, this paper illustrates how to evaluate the retinal hazards from various ophthalmic instruments including the following: diffuse illumination of the cornea; incident light diverging at the cornea (direct ophthalmoscope, operation microscope, fixation lamp); and incident light converging at the cornea (indirect ophthalmoscope, fundus camera, slit lamp biomicroscope). A brief review of radiometry and the use of certified optical components by manufacturers as specified by the ISO standard is also provided. Finally, the authors provide examples of the use of photometric measurements in hazard evaluation.

Study of filtered light on potential retinal photic hazards with operation microscopes used for ocular surgery.

There have been numerous reports of retinal photic injury from operation microscopes used during cataract surgery. The risk of injury has been associated with the intensity of the light directed into the eye, short-wavelength emission, user technique, exposure time, and direct axial lighting. We evaluated use of light transmission filters to modify a tungsten-halogen light source spectrum to reduce the risk of retinal photic injury. A two-light source filter combination was found with a color profile acceptable for intraocular surgery that reduces the risk of retinal photic injury by a factor of approximately 2.5.

Endoilluminators: evaluation of potential retinal hazards.

The potential for retinal photic injury from exposure to endoilluminators was evaluated. The spectral irradiance for each endoilluminator configuration was weighted with the American Conference of Government Industrial Hygienists (ACGIH) aphakic action spectrum. The result was compared with the threshold limit value (TLV) published by the ACGIH and a time to TLV (timeTLV) was calculated for each configuration. The calculated timeTLV ranged from 0.27 to 3.5 min, times that are significantly shorter than typical operating times. The effects of incorporating short-wavelength cutoff filters were evaluated and found to significantly increase the timeTLV. Exposure reduction techniques for use during surgery are discussed.