Do hospital mergers reduce costs?

Proponents of hospital consolidation claim that mergers lead to significant cost savings, but there is little systematic evidence backing these claims. For a large sample of hospital mergers between 2000 and 2010, I estimate difference-in-differences models that compare cost trends at acquired hospitals to cost trends at hospitals whose ownership did not change. I find evidence of economically and statistically significant cost reductions at acquired hospitals. On average, acquired hospitals realize cost savings between 4 and 7 percent in the years following the acquisition. These results are robust to a variety of different control strategies, and do not appear to be easily explained by post-merger changes in service and/or patient mix. I then explore several extensions of the results to examine (a) whether the acquiring hospital/system realizes cost savings post-merger and (b) if cost savings depend on the size of the acquirer and/or the geographic overlap of the merging hospitals.

[Survey of family members, who's relatives were included in the palliative network Bielefeld e. V. and recently died]. / Befragung von Zugehörigen verstorbener Palliativpatienten in der ambulanten Versorgung des Palliativnetzes Bielefeld e. V.

BACKGROUND: The Palliative Network Bielefeld e. V. is a cooperation between family doctors and palliative care doctors based on the "agreement to implement palliative home care for terminally ill patients". The doctors are supported by coordinators, who regularly communicate with the patients resp. their family members and call in other co-operation partners (nursing services, ambulant hospice services, physiotherapists, psychologists or pastors) as required. METHOD: In order to collect data about the scope of services and the quality of work of the palliative network a questionnaire was sent to the family members 4 weeks after the patient had passed away. RESULTS: A total of 105 family members were asked, 94 completed questionnaires could be retrieved. 65% of the included patients died at home. Every other included patient had been taken care of for longer than a month. Of all professional groups who came into operation every day, nusring service and palliative nursing service were asked most frequently (52% resp. 41%), of those who came into operation several times a week, family doctors were asked most frequently (26%). 87% of the interviewees were "very content" or "content" with the coordinators, 73% resp. 74% with the family and palliative care doctors and 60% resp. with the nursing services and palliative nursing services. More than 90% of the interviewees stated that needs were realised and disorders were quickly acted on "at all times" or "predominantly". CONCLUSIONS: Correlations between the descriptive results could not be evaluated statistically because of sample size and incomplete frequency of answers. Nevertheless some trends can be shown. Overall contentment seems to increase as much as the percentage of patients who die at home and the duration of care in palliative network grow. The palliative network should be enhanced.

From strategy to action: how top managers' support increases middle managers' commitment to innovation implementation in health care organizations.

BACKGROUND: Evidence suggests that top managers' support influences middle managers' commitment to innovation implementation. What remains unclear is how top managers' support influences middle managers' commitment. Results may be used to improve dismal rates of innovation implementation. METHODS: We used a mixed-method sequential design. We surveyed (n = 120) and interviewed (n = 16) middle managers implementing an innovation intended to reduce health disparities in 120 U.S. health centers to assess whether top managers' support directly influences middle managers' commitment; by allocating implementation policies and practices; or by moderating the influence of implementation policies and practices on middle managers' commitment. For quantitative analyses, multivariable regression assessed direct and moderated effects; a mediation model assessed mediating effects. We used template analysis to assess qualitative data. FINDINGS: We found support for each hypothesized relationship: Results suggest that top managers increase middle managers' commitment by directly conveying to middle managers that innovation implementation is an organizational priority (ß = 0.37, p = .09); allocating implementation policies and practices including performance reviews, human resources, training, and funding (bootstrapped estimate for performance reviews = 0.09; 95% confidence interval [0.03, 0.17]); and encouraging middle managers to leverage performance reviews and human resources to achieve innovation implementation. PRACTICE IMPLICATIONS: Top managers can demonstrate their support directly by conveying to middle managers that an initiative is an organizational priority, allocating implementation policies and practices such as human resources and funding to facilitate innovation implementation, and convincing middle managers that innovation implementation is possible using available implementation policies and practices. Middle managers may maximize the influence of top managers' support on their commitment by communicating with top managers about what kind of support would be most effective in increasing their commitment to innovation implementation.

Organizational and environmental correlates of the adoption of a focus strategy in U.S. hospices.

BACKGROUND: The hospice industry has experienced rapid growth in the last decade and has become a prominent component of the U.S. health care delivery system. In recent decades, the number of hospices serving nursing facility residents has increased. However, there is paucity of research on the organizational and environmental determinants of this strategic behavior. PURPOSE: The aim of this study was to empirically identify the factors associated with the adoption of a nursing facility focus strategy in U.S. hospices. A nursing facility focus strategy was defined in this study as a strategic choice to target the provision of hospice services to skilled nursing facility or nursing home residents. METHODOLOGY/APPROACH: This study employed a longitudinal study design with lagged independent variables in answering its research questions. Data for the study's dependent variables are obtained for the years 2005-2008, whereas data for the independent variables are obtained for the years 2004-2007, representing a 1-year lag. Mixed effects regression models were used in the multivariate regression analyses. FINDINGS: Using a resource dependence framework, the findings from this study indicate that organizational size, community wealth, competition, and ownership type are important predictors of the adoption of a nursing facility focus strategy. PRACTICE IMPLICATIONS: Hospices may be adopting a nursing facility focus strategy in response to increasing competition. The decision to focus the provision of care to nursing facility residents may be driven by the need to secure stability in referrals. Further empirical exploration of the performance implications of adopting a nursing facility focus strategy is warranted.

Enhancing capacity management.

It is essential for organizations to be able to accept patients requiring care. Capacity planning and management are necessary to ensure an organization has an accepting physician/service, an available bed, and staff to care for the patient and family. This organization implemented strategies including communication plans, staffing guidelines, morning rounds, proactive planning, and an escalation process to reverse the trend of not being able to accept all patients.

[Establishing an Ambulatory Health-Care Centre (AHCC) at a University Hospital]. / Gründung eines Medizinischen Versorgungszentrums (MVZ) an einem Universitätsklinikum.

BACKGROUND: Since January 2004 hospitals have the opportunity to establish an ambulatory health-care centre (Medizinisches Versorgungszentrum - MVZ) as a result of the introduction of the Health-care Modernisation Act (Gesetz zur Modernisierung der gesetzlichen Krankenversicherung - GMG). After about a half-year preparatory phase, the UKE, in September 2004, began operation of the "Ambulanzzentrum des UKE GmbH" (a limited liability company) as the first MVZ at a university hospital in Germany. We report here on the establishment of the MVZ and the experience made. MATERIALS AND METHODS: In the initial phase, only the medical fields of radiation therapy and nuclear medicine were represented. Both disciplines, especially radiation therapy, were existentially threatened by the extensive loss of ambulatory patients. The central motive for the establishment of the ambulatory health-care centre was to secure the survival of both disciplines and to preserve existing jobs. After it was put into operation, the referrals from practice-based colleagues to both radiation therapy and nuclear medicine increased quickly. The positive developments caused other departments of the UKE to express their interest in supplementing their outpatient activities with facilities in the MVZ. RESULTS: Over the following years, the ambulance centre grew steadily. Now 24 departments are represented in the MVZ, and the centre has a total of 49 positions for physicians contracted by and registered within the German public health insurance system. The number of salaried doctors has risen to 85, although many of these only work part time in the MVZ. Also more than 83 non-medical staff members were hired over the years. These were mostly physiotherapists, radiographers, and medical assistants. With the growing number of departments in the MVZ, the number of treated cases grew steadily. Currently approximately 20 000 cases are treated in each quarter of a year. CONCLUSIONS: The experience made while establishing an ambulatory health-care centre is very positive. Better cross-sectoral medicine, support of referring practice-based colleagues, content of centre-physicians and a strengthening of research and teaching summarise the experience of the last 7 years accurately. The outpatient centre of UKE GmbH will strive to continue to expand its range of medical services into other medical fields whenever it makes sense.

Economies of scale and scope in the Danish hospital sector prior to radical restructuring plans.

OBJECTIVE: The Danish hospital sector faces a significant rebuilding program driven by recent regional reform and guidelines for acute admission hospitals. Within the next 5-10 years, the number of public hospitals offering acute admission will be reduced from 35 to approximately 20 larger hospitals. As the administrative data may be biased during the middle of a restructuring process our objective was to analyze whether the configuration of Danish public hospitals was subject to economies of scale and scope prior to the restructuring plans. METHODS: We estimated a quadratic cost function using panel data on the total costs for somatic treatment, casemix adjusted DRG-production values, and other cost drivers for the three years before the 2007 reforms. A short-run cost function was used to derive estimates of a long-run cost function by applying the envelope condition. Next, we estimated economies of scale and scope. RESULTS: We identified moderate-to-significant economies of scale and scope. This indicates that the Danish hospital sector was characterized by unexploited gains from consolidation. CONCLUSIONS: Our results suggest that the proposed plans have the potential to result in hospitals that are more efficient. However, post-restructuring studies elsewhere show that the strategy of horizontal integration has failed.

When big isn't beautiful: lessons from England and Scotland on primary health care organisations.

United Kingdom primary care trusts resembled the primary health care organisations (PHCOs) that have been proposed for Australia--for example, Medicare Locals. They resulted in a loss of innovation, creativity, motivation and morale among general practitioners and other front-line staff. English primary care trusts are being abolished and £80 billion will be handed over to GP commissioners. Management theory and practical experience shows repeatedly the dangers of reorganising into larger units. Lessons for Australia are to defer deciding on the size of PHCOs until their purposes are clear, to enshrine the principle of subsidiarity, and to opt for networking of the current Divisions of General Practice over mergers. So far, debate on the functions and structures of PHCOs has been muted. It is now time for vigorous debate.

Improving outcome for patients with pancreatic cancer through centralization.

BACKGROUND: High-volume institutions are associated with improved clinical outcomes for pancreatic cancer. This study investigated the impact of centralizing pancreatic cancer surgery in the south of the Netherlands. METHODS: All patients diagnosed in the Eindhoven Cancer Registry area in 1995-2000 (precentralization) and 2005-2008 (implementation of centralization agreements) with primary cancer of the pancreatic head, extrahepatic bile ducts, ampulla of Vater or duodenum were included. Resection rates, in-hospital mortality, 2-year survival and changes in treatment patterns were analysed. Multivariable regression analyses were used to identify independent risk factors for death. RESULTS: Some 2129 patients were identified. Resection rates increased from 19·0 to 30·0 per cent (P < 0·001). The number of hospitals performing resections decreased from eight to three, and the annual number of resections per hospital increased from two to 16. The in-hospital mortality rate dropped from 24·4 to 3·6 per cent (P < 0·001) and was zero in 2008. The 2-year survival rate after surgery increased from 38·1 to 49·4 per cent (P = 0·001), and the rate irrespective of treatment increased from 10·3 to 16·0 per cent (P < 0·001). There was no improvement in 2-year survival in non-operated patients. After adjustment for relevant patient and tumour factors, those undergoing surgery more recently had a lower risk of death (hazard ratio 0·70, 95 per cent confidence interval 0·51 to 0·97). Changes in surgical patterns seemed largely to explain the improvements. CONCLUSION: High-quality care can be achieved in regional hospitals through collaboration. Centralization should no longer be regarded as a threat by general hospitals but as a chance to improve outcomes in pancreatic cancer.

Patient safety features are more present in larger primary care practices.

OBJECTIVES: This study aimed to explore whether specific characteristics of a general practice organization were associated with aspects of patient safety management. METHODS: Secondary analysis of data from 271 primary care practices, collected in 10 European countries. These data were collected by a practice visitor and physician questionnaires. For this study we constructed 10 measures of patient safety, covering 45 items as outcomes, and 6 measures of practice characteristics as possible predictors for patient safety. RESULTS: Eight of the 10 patient safety measures yielded higher scores in larger practices (practices with more than 2 general practitioners). Medication safety (B 0.64), practice building safety (B 0.49) and incident reporting items (B 0.47) showed the strongest associations with practice size. Also measures on hygiene (B 0.37), medical record keeping (B 0.30), quality improvement (B 0.28), professional competence (B 0.24) and organized patient feedback items (B 0.24) had higher scores in larger practices. CONCLUSION: Larger general practice practices may have better safety management, although through our measurements no causal relationship could be established in this study.

Making sense of delays in outpatient specialty care: a system perspective.

OBJECTIVES: To assess whether delays to outpatient specialty care can be solved by improving the way supply and demand are matched, without adding capacity. METHODS: A systematic review of the interventions applied by 18 clinics using the model of 'advanced access' and a statistical analysis of the effects of the interventions on their delays. RESULTS: The clinics applied different combinations of interventions aimed at improving the way they match supply and demand, improving the efficiency of the way supply is organised and at reducing unnecessary demand. Fourteen clinics show statistically significant improvements. Two probably significantly improved and two clinics did not. Their access reduced on average 55%, from 47 to 21 days. CONCLUSIONS: It seems that delays in outpatient specialty care can be solved to a large extend by improving the way supply and demand are matched. Policy makers should analyse whether delays are caused by capacity problems or matching problems. For the latter, it appears more effective to invest in the ability to react then the ability to plan. Policy makers should create incentives for clinics to keep access short and remove incentives that stimulate delays.

Predicting research use in nursing organizations: a multilevel analysis.

BACKGROUND: No empirical literature was found that explained how organizational context (operationalized as a composite of leadership, culture, and evaluation) influences research utilization. Similarly, no work was found on the interaction of individuals and contextual factors, or the relative importance or contribution of forces at different organizational levels to either such proposed interactions or, ultimately, to research utilization. OBJECTIVE: To determine independent factors that predict research utilization among nurses, taking into account influences at individual nurse, specialty, and hospital levels. DESIGN: Cross-sectional survey data for 4,421 registered nurses in Alberta, Canada were used in a series of multilevel (three levels) modeling analyses to predict research utilization. METHODS: A multilevel model was developed in MLwiN version 2.0 and used to: (a) estimate simultaneous effects of several predictors and (b) quantify the amount of explained variance in research utilization that could be apportioned to individual, specialty, and hospital levels. FINDINGS: There was significant variation in research utilization (p <.05). Factors (remaining in the final model at statistically significant levels) found to predict more research utilization at the three levels of analysis were as follows. At the individual nurse level (Level 1): time spent on the Internet and lower levels of emotional exhaustion. At the specialty level (Level 2): facilitation, nurse-to-nurse collaboration, a higher context (i.e., of nursing culture, leadership, and evaluation), and perceived ability to control policy. At the hospital level (Level 3): only hospital size was significant in the final model. The total variance in research utilization was 1.04, and the intraclass correlations (the percent contribution by contextual factors) were 4% (variance = 0.04, p <.01) at the hospital level and 8% (variance = 0.09, p <.05) at the specialty level. The contribution attributable to individual factors alone was 87% (variance = 0.91, p <.01). CONCLUSIONS: Variation in research utilization was explained mainly by differences in individual characteristics, with specialty- and organizational-level factors contributing relatively little by comparison. Among hospital-level factors, hospital size was the only significant determinant of research utilization. Although organizational determinants explained less variance in the model, they were still statistically significant when analyzed alone. These findings suggest that investigations into mechanisms that influence research utilization must address influences at multiple levels of the organization. Such investigations will require careful attention to both methodological and interpretative challenges present when dealing with multiple units of analysis.

The impact of hospice programs on U.S. hospitals.

This study demonstrates that hospice programs are more likely in communities with favorable economic factors and higher Medicare populations. Large hospitals with high occupancy rates and more clinical services use the hospice as an alternative to inpatient care thereby improving hospital efficiency and profitability.

Characteristics of mixed diagnostic radiology-radiation oncology practices.

OBJECTIVE: Our objectives were to describe the characteristics of "mixed practices"-that is, practices performing both diagnostic radiology and radiation oncology services-and to compare mixed practices with multiradiologist diagnostic radiology-only practices. MATERIALS AND METHODS: In 1999, the American College of Radiology surveyed 970 practices by mail, using a 65-item questionnaire. A response rate of 66% was achieved. Responses were weighted such that they were representative of all the radiology practices in the United States. The estimates cited in this article were primarily drawn from this 1999 survey. RESULTS: Mixed practices were nearly evenly divided between large (area population, > or = 1 million) and small metropolitan areas (area population, from 50,000 to 1 million). We found that 63% of mixed practices were nonacademic private practices; 27% were academic. Approximately 50% contained 15 or more members. Mixed practices were predominantly owned by members of the practice and predominantly served both hospitals and nonhospital settings. At least 90% of mixed practices performed mammography, imaging-guided breast biopsy, sonography, and nuclear medicine. We found that compared with multiradiologist diagnostic radiology-only practices, mixed practices were larger and were more likely to be academic, to serve both hospital and nonhospital settings, and to perform interventional and nuclear medicine procedures. CONCLUSION: The characteristics of a mixed practice differ from those of a multiradiologist diagnostic radiology-only practice.