A robust technique based on VLM and Frangi filter for retinal vessel extraction and denoising.

The exploration of retinal vessel structure is colossally important on account of numerous diseases including stroke, Diabetic Retinopathy (DR) and coronary heart diseases, which can damage the retinal vessel structure. The retinal vascular network is very hard to be extracted due to its spreading and diminishing geometry and contrast variation in an image. The proposed technique consists of unique parallel processes for denoising and extraction of blood vessels in retinal images. In the preprocessing section, an adaptive histogram equalization enhances dissimilarity between the vessels and the background and morphological top-hat filters are employed to eliminate macula and optic disc, etc. To remove local noise, the difference of images is computed from the top-hat filtered image and the high-boost filtered image. Frangi filter is applied at multi scale for the enhancement of vessels possessing diverse widths. Segmentation is performed by using improved Otsu thresholding on the high-boost filtered image and Frangi's enhanced image, separately. In the postprocessing steps, a Vessel Location Map (VLM) is extracted by using raster to vector transformation. Postprocessing steps are employed in a novel way to reject misclassified vessel pixels. The final segmented image is obtained by using pixel-by-pixel AND operation between VLM and Frangi output image. The method has been rigorously analyzed on the STARE, DRIVE and HRF datasets.

Technology versus humanism: how patients perceive the use of electronic health records in physicians' offices--a qualitative study.

Electronic Health Records (EHRs) have the potential to improve the quality of care. In view of the accelerated adoption of EHRs, there is a need to understand conditions necessary for their effective use. Patients are the focus of healthcare and their perceptions and expectations need to be included in developing and implementing EHRs. The purpose of this study was to gather exploratory qualitative information from patients about their experiences and perceptions regarding the effects of EHRs on healthcare quality in physicians' offices. We conducted five focus groups with patients representing a random mix of diverse socio-demographic backgrounds in Oklahoma. Related to EHRs, patients reported improvements on the technical side of care but no change on the human side. They expressed concerns about the potential for breach of confidentiality and security of medical records. They were also concerned about the possibility of governmental agencies or insurance companies having unauthorized access to patient records. Patients differentiated between the human and technical sides of care and reported no change or improvement in the doctor-patient interaction. Patients have an important perspective on the use of EHRs and their perceptions and experiences should be considered in the development, adoption and implementation of EHRs. Otherwise, the use of EHRs may not be fully effective. There is also a need to educate patients about the potential benefits and risks of EHRs and the steps being taken to mitigate such risks.

The Impact of Hospital Characteristics on the Availability of Radiology Services at Critical Access Hospitals.

PURPOSE: Although all critical access hospitals (CAHs) provide basic medical and radiographic imaging services, it remains unclear how CAHs provide additional imaging services given relatively low patient volumes and high resource costs. The aim of this study was to examine whether CAHs with more resources or access to resources through affiliation with larger systems are more likely to offer other imaging services in their communities. METHODS: Linking data from the American Hospital Association's annual hospital surveys and the American Hospital Directory's annual surveys from 2009 to 2011, multivariate logistic regressions were performed to estimate the likelihood of individual CAHs with greater financial resources or network affiliations providing specific imaging services (MRI, CT, ultrasound, mammography, and PET/CT), while adjusting for the number of beds, personnel, inpatient revenue share, case mix, rural status, year, and geographic location. RESULTS: Hospital total expenditures were positively associated with the provision of MRI (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19), mammography (OR, 1.11; 95% CI, 1.01-1.16), and PET/CT (OR, 1.04; 95% CI, 1.01-1.06). Network affiliation was positively associated with the availability of MRI (OR, 1.75; 95% CI, 1.27-2.39), CT (OR, 2.17; 95% CI, 1.15-4.09), ultrasound (OR, 2.03; 95% CI, 1.17-3.52), and mammography (OR, 2.00; 95% CI, 1.47-2.71). Rural location was negatively associated with the availability of PET/CT (OR, 0.65; 95% CI, 0.49-0.88). CONCLUSIONS: Total hospital expenditures and network participation are important determinants of whether CAHs provide certain imaging services. Encouraging CAHs' participation in larger systems or networks may facilitate access to highly specialized services in rural and underserved areas.

The scope and distribution of imaging services at critical access hospitals.

PURPOSE: The purpose of this study was to better understand the availability and scope of imaging services at critical access hospitals (CAHs) throughout the United States. METHODS: Recent American Hospital Association (AHA) annual survey data (containing 1,063 variables providing comprehensive information on organizational characteristics and availability of various services at 6,317 hospitals nationwide) and US census data were merged. Imaging survey data included mammography, ultrasound, CT, MRI, single photon emission CT, and combined PET/CT. Availability and characteristics of imaging services at the 1,060 CAHs in 45 states for which sufficient data were available were studied. RESULTS: Mammography, ultrasound, and some form of CT were the most widely available of all imaging services, but were available in all CAHs in only 13%, 33%, and 56% of all states, respectively. In no states were ≥64-slice CT, MRI, single photon emission CT, and combined PET/CT available in all CAHs. CONCLUSIONS: An overall scarcity of access to imaging services exists at CAHs throughout the United States. With 19.3% of the US population residing in rural areas and almost entirely dependent on CAHs for health services, the policy implications for imaging access could be profound. Further research is necessary to investigate the effect of imaging access on CAH patient outcomes.

The use of the HIV test: a conflict choice approach.

The study introduces the "Conflict-Choice model" (C-C) as an analytic framework for studying consumer demand for health and healthcare. The proposed approach integrates the Theory of Consumer Behavior (TCB), the Investment Theory of Demand (ITD), and the Health Belief Model (HBM) into a single model that might be applied to a wide spectrum of health behavior and use of health services. Separating the episode of care into the two phases (patient initiated and physician dominated), the C-C model is limited to the individual's decision to seek service. This phase is dominated by two conflicting and undesirable outcomes that the patient seeks to avoid. The first is discomfort or disutility that accompanies the use of care. The second is the discomfort of illness and a reduced ability to perform social and economic roles, an outcome that may result in a potential decline in income. In this conflict-choice situation, the interrelation between two undesirable conditions and related avoidance gradients result in a behavioral equilibrium. The study applied this framework to the use or non-use of HIV tests. The analysis used the responses of 196,081 individuals in the Behavioral Risk Factor Surveillance System (BRFSS) of 2003. The analyses supported the expectations based on the newly developed conflict-choice theoretical framework and support the adoption of policies that reduce the tendency to avoid care while increasing the avoidance of undesirable health outcomes.

The effect of macroeconomic conditions on the care decisions of the employed.

BACKGROUND: Medical care utilization has been found to be affected indirectly by changes in economic conditions through associated changes in employment or insurance status. However, if individuals interpret external macroeconomic conditions as employment risk, they may alter decisions to seek care even if they remain both employed and insured. OBJECTIVE: To examine the relationship between macroeconomic fluctuations and the medical care usage of Americans who are both employed and insured. RESEARCH DESIGN: Restricting the Medical Expenditure Panel Survey from 1995 to 2008 to respondents whose employment status and insurance status did not change, we employed a fixed-effect Poisson model to examine the association between state average annual unemployment rates and the utilization of 12 medical services. RESULTS: The average annual state unemployment rate was found to be a significant factor in hospital outpatient visits (P < 0.01) and emergency room visits (P < 0.01). A one percentage point increase in the unemployment rate was found to produce an additional 0.67 hospital outpatient visits and 0.14 emergency room visits. CONCLUSIONS: State unemployment rates were found statistically significantly associated with several of the medical services studied, suggesting macroeconomic conditions are an important factor in the medical decisions of employed and insured individuals. Thus, policy changes that increase access among the unemployed or uninsured may mitigate this employment risk effect and create incentives that potentially alter the utilization decisions among those currently both employed and insured.

The current state of electronic health record (EHR) use in Oklahoma.

There is ample evidence of the positive impact of electronic health records (EHR) on operational efficiencies and quality of care. Yet, growth in the adoption of EHR and sharing of information among providers has been slow. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provides financial incentives for eligible providers to adopt and implement EHR. Until now, little information was available regarding the use of EHR in Oklahoma. Sponsored by the Oklahoma Health Information Exchange Trust (OHIET), this study reveals that the frequency of use of EHR among Oklahoma providers is near the national average. Although a large number of Oklahoma physicians have received Medicaid incentive payments for planned adoption, implementation, or upgrade of EHR systems, relatively few eligible providers in Oklahoma have been certified to receive Medicare incentive payments through the Centers for Medicare and Medicaid Services (CMS) and even fewer have actually received these incentive payments.

Predictors of hospital CEO affiliation with a professional association.

Based on a 2008 cross-sectional survey of 582 hospital CEOs in the United States, this study reports the findings of two logistic regression models designed to identify CEO and hospital characteristics associated with Member and Fellow status in the American College of Healthcare Executives (ACHE). The purpose of the study was to understand the personal and organizational characteristics of those CEOs who choose to be Members and Fellows of a professional association such as ACHE. The results showed that most (74 percent) of the respondents considered ACHE to be their primary professional association. The results also revealed that a master's degree in health administration [beta = .88, t(427) = 5.35, p < .0001], male gender [beta = .59, t(427) = 3.01, p = .002], and financial incentives provided by the parent hospital [beta = .25, t(427) = 2.73, p = .006] were statistically positively linked with Member status in ACHE. A master's degree in health administration [beta = .81, t(424) = 5.79, p < .0001], male gender [beta = .39, t(424) = 2.25, p = .02], and age [beta = .02, t(424) 2.32, p = .02] were also statistically positively associated with Fellow status in ACHE. Notably, organizational factors such as size, geographic location, for-profit status, and financial strength of the hospital do not seem to play an important role in the CEOs' decision to become a Member or Fellow of ACHE. The implication of these findings is that membership and fellowship at a professional association are influenced by characteristics of the individual, and incentives provided by employers can encourage employees to get involved with their professional associations.

The Saudi health care system: a view from the minaret.

This review article provides information about the origins, history, evolution and current status of the Saudi healthcare system, which is currently being transformed from a publicly financed and managed welfare system to a market-oriented, employment-based, insurance-driven system. Since its inception in the 1920s, the system has provided free healthcare to all Saudi nationals at publicly owned facilities run by government-employed administrators and healthcare providers. For millions of foreign workers in the country, healthcare at privately owned for-profit facilities has been paid for either by the employer or by the individual. At the completion of the three-stage transition, everyone in the country, whether employed in the public or private sector, is expected to have insurance coverage provided by the employer. All Ministry of Health-owned hospitals will be divested to the private sector, whereas primary health centres are likely to be retained by the government. Many of the operational details of the transition are unclear at this stage and will be worked out in the coming years. This paper provides a context for these changes and highlights some of the existing issues and weaknesses. The article also points to some of the future challenges and cautions against pitfalls involved in the complete transformation of the system.

Factors affecting the value of professional association affiliation.

BACKGROUND: The resource-based view of the firm suggests that organizations must obtain valuable resources from external sources to obtain lasting benefits. Professional associations today exist in every industry and offer resources to assist their affiliates' organizations and individual members. Today, there are more than 23,000 national and 64,000 state, local, and regional professional associations that claim to significantly benefit their affiliates. The value of these benefits and what organizational and individual factors that may affect their value have not been explored. PURPOSE: This article explores the influence of organizational and individual factors on the value of resources offered by a prominent health care professional association. METHODOLOGY/APPROACH: Data from a national survey of hospital CEOs were combined with American Hospital Association data for descriptive statistics and regression analyses to examine the organizational and individual characteristics influencing the value of professional association affiliation. FINDINGS: Our research suggests that most hospital CEOs perceived value in the resources provided by their primary professional organization. In addition, both organizational and individual factors contributed to the perceived value of professional association affiliation. Significant organizational influences included hospital ownership and system membership, which were related to less importance and value from affiliation. Positive and significant individual characteristics included certification as an association fellow and CEOs who have a high value for coaching. Interestingly, men perceived less organizational value from affiliation and older CEOs saw less individual value. PRACTICAL IMPLICATIONS: Executives considering affiliating with a professional association can better understand how existing affiliates perceive and value the associations' benefits. In addition, executives and professional associations can be more informed how professional association affiliation is significantly influenced by organizational and individual characteristics. Individuals, organizations, and professional associations should be aware of the perceptions and differences among those who do and could avail themselves of professional association resources.

Factors affecting the continuing education of hospital CEOs and their senior managers.

This article examines the influences on executives' continuing education in hospitals. It uses data from a national survey on professional development conducted in 2009 by the American College of Healthcare Executives (ACHE) to explore how organizational and individual characteristics are related to the amount of continuing education (CE) taken by chief executive officers (CEOs) and the commitment to CE by their senior managers. Our findings suggest that the organizational characteristics of ownership, size, and region and the individual characteristics of gender, professional affiliation, and the focus of CE may influence how much CE CEOs take. CEOs from for-profit, larger hospitals and ACHE members tend to take less CE. Likewise, senior managers' commitment to CE is influenced by region, gender, the CEO's personal CE hours, and the focus of the CE. Surprisingly, ACHE membership is associated with lower amounts of personal CEO CE. Also, female CEOs appear to engender greater commitment to CE in their senior managers. Finally, CE focused on change increases the senior managers' commitment, while a focus on new technology lessens it. For those organizations seeking to meet current and future challenges by creating a learning organization, CE is essential. Understanding factors that influence the amount of and commitment to CE is important. We hope our research adds to this understanding and that leaders will seek to improve the dedication and value of CE in their organizations.

Hospital chief executive officer perspective on professional development activities.

A study was undertaken to develop understanding of hospital chief executive officers' (CEOs') perspectives concerning importance and impact of professional development activities in US hospitals. It was also intended to reveal CEO preferences for various modalities of professional development including membership in professional societies, attainment of credentials, and coaching by mentors. A mail survey of 582 hospital CEOs made use of a pilot-tested questionnaire with 30 close ended multipart questions. Results showed that most CEOs assigned a high level of importance to professional development and favored conferences, seminars, and networking opportunities, but low priority assigned to online activities such as webinars. They reported lending support to senior managers for participation in these activities by providing financial resources and by allowing time off to engage in these activities. The respondents indicated that the importance of various modalities of professional development has either increased or remained high over the recent 5 years. Conclusions suggest that verifiable quantitative data are needed for understanding of the frequency of participation and resource commitment of health care organizations toward the professional development of CEOs and senior managers. The results of this perceptual study reveal a high level of importance accorded to various forms of professional development activities by the participating CEOs.

Global nurse migration: its impact on developing countries and prospects for the future.

The worldwide shortage of nurses, which results from a global undersupply and high attrition rates, affects developed countries in the West the same way as it affects developing countries in Asia, Africa and Latin America. The difference lies in the fact that developing countries serve as a readily available source of trained nurses for developed countries in Europe, North America and parts of Oceania. Strong "pull" and "push" factors favour wealthier nations in the West in their efforts to deal with domestic shortages through overseas recruitment. Thus, the ongoing nursing shortage in developing countries is worsened by a loss of thousands of trained nurses every year to emigration. This paper brings into focus the magnitude of the problem in terms of the number of nurses migrating to and from various countries and its impact on developing countries. The paper also examines some of the ongoing efforts in developing countries to mitigate the problem, and sheds light on the prospects for improvement in the foreseeable future.

Global nurse migration: its impact on developing countries and prospects for the future.

The worldwide shortage of nurses which results from a global undersupply and high attrition rates affects developed countries in the West the same way as it affects developing countries in Asia, Africa and Latin America. The difference lies in the fact that developing countries serve as a readily available source of trained nurses for developed countries in Europe, North America and parts of Oceania. Strong "pull" and "push" factors favour wealthier nations in the West in their efforts to deal with domestic shortages through overseas recruitment. Thus, the ongoing nursing shortage in developing countries is worsened by a loss of thousands of trained nurses every year to emigration. This paper brings into focus the magnitude of the problem in terms of the number of nurses migrating to and from various countries and its impact on developing countries. The paper also examines some of the ongoing efforts in developing countries to mitigate the problem and sheds light on the prospects for improvement in the foreseeable future.

Is chief executive officer turnover good for the hospital?

This study examined the general characteristics of chief executive officers (CEOs) and their hospitals and the perceived impact of CEO turnover on various organizational activities. A mail-based survey included 156 hospital CEOs in 6 states in the West South Central, West North Central, and Mountain regions. Neither hospital and CEO characteristics nor the impact on various organizational activities and performance indicators was significantly different among the 6 states compared. Overall, CEOs reported relatively short tenures, frequent promotion from within the organization to CEO level, and common involuntary departure of their predecessors. Respondents overwhelmingly reported a positive impact of leadership change on financial performance, employee morale, and organizational culture.

Which hospitals give discounts? The role of institutional and environmental factors.

Offering discounts on list prices in exchange for a large volume of business is a common practice in the healthcare industry. However, little is known about the characteristics of hospitals that engage in this practice or about the circumstances that promote this strategy. On the basis of data from the American Hospital Association and the Centers for Medicare and Medicaid Services, the authors reveal that hospital size, Medicare patient volume, net income, medical school affiliation, location in a metropolitan statistical area, and hospital system membership are factors positively linked with the amount of discounts provided by hospitals to third-party payers.

Comparison of resource utilization and clinical outcomes between teaching and nonteaching medical services.

PURPOSE: To compare the resource utilization and clinical outcomes of medical care delivered on general internal medicine inpatient services at teaching and nonteaching services at an academic hospital. METHODS: From February to October 2002, 2189 patients admitted to a 450-bed university-affiliated community hospital were assigned either to a resident-staffed teaching service (n = 1637) or to a hospitalist- or clinic-based internist nonteaching service (n = 552). We compared total hospital costs per patient, length of hospital stay (LOS), hospital readmission within 30 days, in-hospital mortality, and costs for pharmacy, laboratory, radiology, and others between teaching and nonteaching services. RESULTS: Care on a teaching service was not associated with increased overall patient care costs ($5572 vs. $5576; P = .99), LOS (4.92 days vs. 5.10 days; P = .43), readmission rate (12.3% vs. 10.3%; P = .21), or in-hospital mortality (3.7% vs. 4.5%; P = .40). Mean laboratory and radiology costs were higher on the teaching service, but costs for the pharmacy and for speech therapy, occupational therapy, physical therapy, respiratory therapy, pulmonary function testing, and GI endoscopy procedures were not statistically different between the 2 services, and residents did not order more tests or procedures. Case mix and illness severity, as reflected by the distribution of the most frequent DRGs and mean number of secondary diagnoses per patient and DRG-specific LOS, were similar on the 2 services. CONCLUSIONS: At our academic hospital, admission to a general internal medicine teaching service resulted in patient care costs and clinical outcomes comparable to those admitted to a nonteaching service.

Incoming and outgoing hospital CEOs: what kind of help do they want?

CEO turnover, although common, is expensive and disruptive for everyone involved. Both incoming and outgoing CEOs would welcome help in making the transition a painless experience. Through a 2005 nationwide survey of 805 current hospital CEOs, the authors obtained comments and suggestions in response to three open-ended questions about specific activities or processes that would help incoming and outgoing CEOs. Mostly, CEOs felt the need for a structured orientation process, succession planning, concrete peer and organizational support, training on recruitment and retention for the board, and an adequate separation package including continued healthcare coverage.

Perceptions of hospital CEOs about the effects of CEO turnover.

Empirical evidence is scarce on chief executive officer (CEO) turnover in U.S. hospitals, with potentially serious implications for many of these organizations. This study, based on a nationwide survey of CEOs at non-federal general surgical and medical community hospitals conducted in the spring of 2004, reports the perceptions of hospital CEOs regarding the circumstances and impact of CEO turnover on U.S. hospitals. In the opinion of the respondents, the impact includes competitors taking advantage of turnover by luring employees and physicians away from the target hospital, significantly increasing the likelihood of other senior executives leaving the hospital, and many of the important strategic activities being delayed or cancelled altogether. Interestingly, the perceptions of CEOs regarding the effects of turnover do not seem to differ regardless of voluntary or involuntary circumstances of turnover. However, there is a notable bias in emphasizing the perceived negative implications of respondents' own departures and allegedly positive effects of their predecessors' departures.

Co-morbidity in an elderly inpatient population: are the risks of co-existing conditions differentially distributed?

This study examines the distribution of co-morbidity among 167,738 inpatients, aged 65 or more, who experienced an episode of hospitalization during 1999 in short-term institutions that are located in Oklahoma. The analysis was conducted in two phases. In the first, logistic regression analysis was used to examine covariates that separate inpatients who presented at least one secondary diagnosis from those who were not co-morbid. Limited to those whose condition was complicated by at least one secondary diagnosis, Probit analysis was used to assess the covariates of the number of co-existing conditions. The covariates examined were the individual's racial status, demographic attributes, primary diagnosis, source of admission and discharge destination. Results indicate that the oldest of the elderly, African Americans and, to a lesser extent, Native Americans presented more complex cases than other members of the study population. The paper concludes with the policy implications that are associated with the differential distribution of co-morbidity.