Association between adopting emergency department crowding interventions and emergency departments' core performance measures.

OBJECTIVES: To estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model. RESULTS: Between 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75-0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76-0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41-0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73-0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79-0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35-0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57-0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64-0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72-0.98, P < .05) are associated with decrease in the odds of a patient LWBS. CONCLUSIONS: Majority of interventions did not significantly associated with ED' core performance measures.

Reliability, validity and measurement invariance of the Simplified Medication Adherence Questionnaire (SMAQ) among HIV-positive women in Ethiopia: a quasi-experimental study.

BACKGROUND: Adherence to antiretroviral therapy is critical to the achievement of the third target of the UNAIDS Fast-Track Initiative goals of 2020-2030. Reliable, valid and accurate measurement of adherence are important for correct assessment of adherence and in predicting the efficacy of ART. The Simplified Medication Adherence Questionnaire is a six-item scale which assesses the perception of persons living with HIV about their adherence to ART. Despite recent widespread use, its measurement properties have yet to be carefully documented beyond the original study in Spain. The objective of this paper was to conduct internal consistency reliability, concurrent validity and measurement invariance tests for the SMAQ. METHODS: HIV-positive women who were receiving ART services from 51 service providers in two sub-cities of Addis Ababa, Ethiopia completed the SMAQ in a HIV treatment referral network study between 2011 and 2012. Two cross-sections of 402 and 524 female patients of reproductive age, respectively, from the two sub-cities were randomly selected and interviewed at baseline and follow-up. We used Cronbach's coefficient alpha (α) to assess internal consistency reliability, Pearson product-moment correlation (r) to assess concurrent validity and multiple-group confirmatory factor analysis to analyze factorial structure and measurement invariance of the SMAQ. RESULTS: All participants were female with a mean age of 33; median: 34 years; range 18-45 years. Cronbach's alphas for the six items of the SMAQ were 0.66, 0.68, 0.75 and 0.75 for T1 control, T1 intervention, T2 control, and T2 intervention groups, respectively. Pearson correlation coefficients were 0.78, 0.49, 0.52, 0.48, 0.76 and 0.80 for items 1 to 6, respectively, between T1 compared to T2. We found invariance for factor loadings, observed item intercepts and factor variances, also known as strong measurement invariance, when we compared latent adherence levels between and across patient-groups. CONCLUSIONS: Our results show that the six-item SMAQ scale has adequate reliability and validity indices for this sample, in addition to being invariant across comparison groups. The findings of this study strengthen the evidence in support of the increasing use of SMAQ by interventionists and researchers to examine, pool and compare adherence scores across groups and time periods.

The role of psychological safety and learning behavior in the development of effective quality improvement teams in Ghana: an observational study.

BACKGROUND: As lower-income countries look to develop a mature healthcare workforce and to improve quality and reduce costs, they are increasingly turning to quality improvement (QI), a widely-used strategy in higher-income countries. Although QI is an effective strategy for promoting evidence-based practices, QI interventions often fail to deliver desired results. This failure may reflect a problem with implementation. As the key implementing unit of QI, teams are critical for the success or failure of QI efforts. Thus, we used the model of work-team learning to identify factors related to the effectiveness of newly-formed hospital-based QI teams in Ghana. METHODS: This was a cross-sectional, observational study. We used structural equation modeling to estimate relationships between coaching-oriented team leadership, perceived support for teamwork, team psychological safety, team learning behavior, and QI implementation. We used an observer-rated measure of QI implementation, our outcome of interest. Team-level factors were measured using aggregated survey data from 490 QI team members, resulting in a sample size of 122 teams. We assessed model fit and tested significance of standardized parameters, including direct and indirect effects. RESULTS: Learning behavior mediated a positive relationship between psychological safety and QI implementation (ß = 0.171, p = 0.001). Psychological safety mediated a positive relationship between team leadership and learning behavior (ß = 0.384, p = 0.068). Perceived support for teamwork did not have a significant effect on psychological safety or learning behavior. CONCLUSIONS: Psychological safety and learning behavior are key for the success of newly formed QI teams working in lower-income countries. Organizational leaders and implementation facilitators should consider these leverage points as they work to establish an environment where QI and other team-based activities are supported and encouraged.

Diabetes Is Associated with Clinical Decompensation Events in Patients with Cirrhosis.

OBJECTIVES: Liver cirrhosis is a leading cause of morbidity and mortality in the USA. Diabetes is common and increasing in incidence. Patients with compensated cirrhosis and diabetes may be at greater risk of clinical decompensation. We examined the risk of decompensation among a large sample of working-aged insured patients dually diagnosed with compensated cirrhosis and diabetes. METHODS: This retrospective study used MarketScan® Commercial Claims and Encounters and Medicare Supplemental Databases (2000-2013). Decompensation events included incident ascites, spontaneous bacterial peritonitis, variceal bleeding, hepatic encephalopathy, acute renal failure, and hepatocellular carcinoma. Dually diagnosed patients were defined as patients with cirrhosis and diabetes using previously published ICD-9 coding strategies. Adjusted odds ratios (ORs), hazard ratios (HRs), and confidence intervals (CI) were estimated using logistic regression and Cox proportional hazard models. RESULTS: Of 72,731 patients with compensated cirrhosis, 20,477 patients (28.15 %) were diagnosed with diabetes. After controlling for patient characteristics and medication usage, the odds of developing any decompensation event were 1.14 times higher for patients with cirrhosis and diabetes than for patients with cirrhosis only (95 % CI 1.08-1.21, P value <0.01). In the Cox proportional hazard model, patients who were dually diagnosed with diabetes had a 1.32 times higher HR (95 % CI 1.26-1.39, P value <0.01) after controlling for time-to-event. CONCLUSIONS: Patients dually diagnosed with compensated cirrhosis and diabetes had a higher risk of having decompensation events. Careful management of diabetes in patients with liver disease may reduce the risk of clinical decompensation in this population.

Using intervention mapping to develop an implementation strategy to improve timely uptake of streamlined birth-dose vaccines in the Democratic Republic of the Congo.

Despite the policy recommendation and effectiveness of administering the hepatitis B birth-dose vaccine (HepB-BD) to newborns to prevent mother-to-child hepatitis B transmission, timely uptake remains an issue. Countries adopting the HepB-BD to their national immunization schedule report programmatic challenges to administering the vaccine within the recommended 24-hour window after delivery. Further, while the World Health Organization recommends streamlining three birth-dose vaccines (HepB-BD, BCG, and OPV0), scarce Sub-Saharan(SSA)-based literature reports on a streamlined and timely approach to birth-dose vaccines. As more SSA countries adopt the new birth-dose vaccine to their immunization schedules, a systematically developed implementation strategy-Vaccination of Newborns-Innovative Strategies to Hasten Birth-Dose vaccines' delivery (VANISH-BD)-will facilitate the adoption and implementation of timely birth-dose vaccine uptake. In this paper, we describe the development of the implementation strategy using intervention mapping, an evidence-based and theory-driven approach. We report on the development of our intervention, beginning with the needs assessment based in Kinshasa Province, Democratic Republic of the Congo (DRC), informing step 1 of intervention mapping. The intervention is contextually relevant, locally produced, sustainable, and designed to improve timely birth-dose vaccine uptake in the DRC. We intend to inform future implementers about improving timely and streamlined birth-dose vaccine uptake and for VANISH-BD to be adapted for similar contexts.

Childhood immunization uptake determinants in Kinshasa, Democratic Republic of the Congo: ordered regressions to assess timely infant vaccines administered at birth and 6-weeks.

BACKGROUND: Despite global efforts to reduce preventable childhood illness by distributing infant vaccines, immunization coverage in sub-Saharan African settings remains low. Further, timely administration of vaccines at birth-tuberculosis (Bacille Calmette-Guérin [BCG]) and polio (OPV0)-remains inconsistent. As countries such as Democratic Republic of the Congo (DRC) prepare to add yet another birth-dose vaccine to their immunization schedule, this study aims to improve current and future birth-dose immunization coverage by understanding the determinants of infants receiving vaccinations within the national timeframe. METHODS: The study used two ordered regression models to assess barriers to timely BCG and first round of the hepatitis B (HepB3) immunization series across multiple time points using the Andersen Behavioral Model to conceptualize determinants at various levels. The assessment leveraged survey data collected during a continuous quality improvement study (NCT03048669) conducted in 105 maternity centers throughout Kinshasa Province, DRC. The final sample included 2398 (BCG analysis) and 2268 (HepB3 analysis) women-infant dyads living with HIV. RESULTS: Between 2016 and 2020, 1981 infants (82.6%) received the BCG vaccine, and 1551 (68.4%) received the first dose of HepB3 vaccine. Of those who received the BCG vaccine, 26.3%, 43.5%, and 12.8% received BCG within 24 h, between one and seven days, and between one and 14 weeks, respectively. Of infants who received the HepB3 vaccine, 22.4% received it within six weeks, and 46% between six and 14 weeks of life. Many factors were positively associated with BCG uptake, including higher maternal education, household wealth, higher facility general readiness score, and religious-affiliated facility ownership. The factors influencing HepB3 uptake included older maternal age, higher education level, household wealth, transport by taxi to a facility, higher facility general and immunization readiness scores, and religious-affiliated facility ownership. CONCLUSIONS: This study demonstrated that the study participants' uptake of vaccines was consistent with the country average, but not in a timely manner. Various factors were associated with timely uptake of BCG and HepB3 vaccines. These findings suggest that investment to strengthen the vaccine delivery system might improve timely vaccine uptake and equity in vaccine coverage.

Associations between low literacy and health status measures: cross-sectional analyses of two physical activity trials.

Arthritis researchers have thoroughly documented a powerful relationship between years of education and health outcomes, but they have not documented the role of literacy. The authors examined the associations between literacy and arthritis health status measures. Participants were recruited from southeastern urban and rural areas. Rapid Estimate of Adult Literacy in Medicine, which provides an estimate of reading level in less than 3 minutes, was administered to 447 participants at baseline in 2 community-based randomized controlled trials of lifestyle interventions designed for aging sedentary adults with arthritis. Those who read below ninth grade were considered to have low literacy. Among the 447 study participants, the median sample age was 69 years. A majority of the participants were women (86%), Caucasian (80%), overweight or obese (72%). Of all participants, 20% had low literacy. Significantly more African Americans (54%) than Caucasians (12%) had low literacy levels (p < .001). Individuals with low literacy did not have significantly worse disability or arthritis symptoms than individuals with adequate literacy (all ps > .05). Among our study participants, 1 in 5 had low literacy, but literacy was not associated with health status in this population.

Sustainability of Funding for HIV Treatment Services: A Cross-Sectional Survey of Patients' Willingness to Pay for Treatment Services in Nigeria.

BACKGROUND: About 50% of individuals needing HIV treatment are unable to access required services primarily due to the inability of the Nigerian HIV treatment program to meet patient needs. We explored patient willingness to pay for HIV treatment, which can inform the feasibility of cost recovery through patient fees to contribute to the funding of HIV treatment services in Nigeria. METHODS: We conducted a cross-sectional survey of 400 people living with HIV randomly selected from 15 health care facilities providing free HIV treatment services in 2 medium and high HIV burden states (Lagos, Enugu) and the Federal Capital Territory Abuja. We calculated the elasticity of the price that patients were willing to pay per month relative to the estimated current cost of providing HIV treatment services per patient and determined the patient coverage and potential cost recovery at each price point. RESULTS: We found that 92% of patients were willing to pay for HIV treatment. The mean amount patients were willing to pay was 3,000 naira (US$7.50) per month with about 18% of patients willing to pay the current monthly price of 5000 naira (US$12.50). The availability of financial support from family and friends (odds ratio [OR]=14.209; P=.001; 95% confidence interval [CI]=0.151, 0.285), lack of employment (OR=0.190; P=.02; 95% CI=0.015, 0.202), monthly income (OR=2.476; P<.001; 95% CI=84.698, 737.233), and change in monthly income (OR=2.015; P<.001; 95% CI=0.003, 0.229) were associated with willingness to pay. CONCLUSION: Many Nigerian patients are willing to contribute to funding for HIV treatment and this can enhance domestic funding for HIV treatment and equitable access to treatment through proper segmentation of patients based on willingness and capacity to pay. Measures must be put in place to reduce the cost of accessing HIV treatment and promote financial empowerment of people living with HIV to improve willingness to pay for treatment.

Implementation Approaches for Introducing and Overcoming Barriers to Hepatitis B Birth-Dose Vaccine in sub-Saharan Africa.

In sub-Saharan Africa (SSA), chronic viral hepatitis B (HBV) affects more than 60 million people. Mother-to-child transmission is a major contributor to the ongoing HBV epidemic and yet only 11 of 54 (20.3%) SSA countries have introduced the birth dose of HBV vaccine (HepB-BD) into their regular immunization schedule. As more African countries adopt HepB-BD, implementation approaches must be targeted to ensure effective and timely HepB-BD delivery, especially in rural and under-resourced settings. We conducted a systematic literature review of published literature using PubMed. We included 39 articles published from January 2010 to August 2020, as well as gray literature, case studies, and research performed in SSA. We describe barriers to the uptake of HepB-BD in SSA at the policy, facility, and community levels and propose solutions that are relevant to stakeholders wishing to introduce HepB-BD. We highlight the importance and challenge of reaching infants who are born outside of health care facilities (i.e., home deliveries) with HepB-BD in partnership with community health workers. We also discuss the critical role of maternal education and community engagement in future HepB-BD scale-up efforts in SSA.

Travel time, availability of emergency obstetric care, and perceived quality of care associated with maternal healthcare utilisation in Afghanistan: A multilevel analysis.

Limited understanding of factors such as travel time, availability of emergency obstetric care (EmOC), and satisfaction/perceived quality of care on the utilisation of maternal health services exists in fragile and conflict-affect settings. We examined these key factors on three utilisation outcomes: at least one skilled antenatal care (ANC) visit, in-facility delivery, and bypassing the nearest public facility for childbirth in Afghanistan from 2010 to 2015. We used three-level multilevel mixed effects logistic regression models to assess the relationships between women's and their nearest public facilities' characteristics and outcomes. The nearest facility score for satisfaction/perceived quality was associated with having at least one skilled ANC visit (AOR: 2.02, 95% CI: 1.21, 3.36). Women whose nearest facility provided EmOC had a higher odds of in-facility childbirth compared to women whose nearest facility did not (AOR: 1.24, 95% CI: 1.04, 1.48). Nearest hospital travel time (AOR: 0.95, 95% CI: 0.93, 0.98) and nearest facility satisfaction/perceived quality (AOR: 0.34, 95% CI: 0.14, 0.82) were associated with lower odds of women bypassing their nearest facility. Afghanistan has made progress in expanding access to maternal healthcare services during the ongoing conflict. Addressing key barriers is essential to ensure that women have access to life-saving services.

Couple communication and contraception use in urban Senegal.

OBJECTIVES: Couple communication about family planning has been shown to increase uptake of contraception. However, couple communication is often measured based solely on one partner's report of communication. This research investigates the influence of couple-reported communication about family planning on current and future use of contraception using couple-level data. METHODS: We used baseline data from the Measurement, Learning, and Evaluation (MLE) project collected through household surveys in 2011 from a cross-sectional representative sample of women and men in urban Senegal to conduct secondary data analysis. We used multivariable logit models to estimate the average marginal effects of couple communication about family planning on current contraception use and future intention to use contraception. RESULTS: Couple communication about family planning reported by both partners was significantly associated with an increased likelihood of current use of contraception and with future intention to use contraception among non-contracepting couples. Couples where one partner reported discussing family planning had a 25% point greater likelihood of current contraception use than couples where neither partner reported discussing, while couples where both partners reported discussing family planning had a 56% point greater likelihood of current contraception use, representing more than twice the effect size. Among couples not using contraception, couples where one partner reported discussing family planning had a 15% point greater likelihood of future intention to use contraception than couples where neither partner reported discussing, while couples where both partners reported discussing family planning had a 38% point greater likelihood of future intention to use contraception. CONCLUSION: These findings underscore the importance of the inclusion of both partners in family planning programs to increase communication about contraception and highlight the need for future research using couple-level data, measures, and analysis.

Impact of nursing unit turnover on patient outcomes in hospitals.

PURPOSE: The aim of this study was to examine how nursing unit turnover affects key workgroup processes and how these processes mediate the impact of nursing turnover on patient outcomes. METHODS: A secondary data analysis was used to test the hypothesized model. This study used registered nurse and patient data from 268 nursing units at 141 hospitals collected as part of the Outcomes Research in Nursing Administration (ORNA II) project. Nursing units provided monthly nursing unit turnover rates for 6 consecutive months, and registered nurses completed questionnaires measuring workgroup processes (group cohesion, relational coordination, and workgroup learning). Patient outcome measures included unit-level average length of patient stay, patient falls, medication errors, and patient satisfaction scores. RESULTS: Nursing units with moderate levels of turnover were likely to have lower levels of workgroup learning compared to those with no turnover (p<.01). Nursing units with low levels of turnover were likely to have fewer patient falls than nursing units with no turnover (p<.05). Additionally, workgroup cohesion and relational coordination had a positive impact on patient satisfaction (p<.01), and increased workgroup learning led to fewer occurrences of severe medication errors (p<.05). CONCLUSIONS: The findings of this study provide specific information on the operational impact of turnover so as to better design, fund, and implement appropriate intervention strategies to prevent registered nurse exit from nursing units. Further investigation is needed to assess the turnover-outcomes relationship as well as the mediating effect of workgroup processes on this relationship. CLINICAL RELEVANCE: Managing nursing unit turnover within appropriate levels at the nursing unit is critical to delivering high-quality patient care.

Use of temporary nurses and nurse and patient safety outcomes in acute care hospital units.

BACKGROUND: To deal with nursing shortages and inadequate hospital nurse staffing, many solutions have been tried, including utilizing temporary nurses. Relatively little attention has been given to use of temporary nurses and its association with both nurse and patients outcomes. PURPOSE: : The purpose of this study is to investigate the association between use of temporary nurses and nurse (needlesticks and back injuries) and patient (patient falls and medication errors) safety outcomes at the nursing unit level. METHODOLOGY/APPROACH: Data came from a large organizational study which investigated the relationship between registered nurse (RN) staffing adequacy, work environments, organizational, and patient outcomes. The sample for this study was 4,954 RNs on 277 nursing units in 142 hospitals. FINDINGS: Nurses working on nursing units with high levels (more than 15%) of external temporary RN hours were more likely to report back injuries than nurses working on nursing units that did not use external temporary RNs. Nurses working on these nursing units also reported greater levels of patient falls compared with those who did not use temporary RNs. This study found that nurses working on nursing units with moderate levels (5-15%) of external temporary RN hours reported fewer medication errors than those without using any external temporary RNs. PRACTICE IMPLICATIONS: Hospitals need to monitor the levels of temporary nurse use and maintain a level of approximately 15% to ensure both nurse and patient safety outcomes. The temporary nurse use to manage nursing shortfall may provide both benefit and harm to nurse and patient safety depending on the level of the use.

National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility.

In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015 at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2 h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2 h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2 h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.

What is full capacity protocol, and how is it implemented successfully?

BACKGROUND: Full capacity protocol (FCP) is an internationally recognized intervention designed to address emergency department (ED) crowding. Despite FCP international recognition and positive effects on hospital performance measures, many hospitals, even the most crowded ones, have not implemented FCP. We conducted this study to identify the core components of FCP, explore the key barriers and facilitators associated with the FCP implementation, and provide practical recommendations on how to overcome those barriers. METHODS: To identify the core components of FCP, we used a non-experimental approach. We conducted semi-structured interviews with key informants (e.g., division chiefs, medical directors) involved in the implementation of FCP. We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. We used a template analysis approach to determine the relevance of the CFIR constructs to implementing the FCP. We analyzed the responses to the interview questions about FCP definition and FCP key principles, compared different hospitals' FCP official documents, and consulted with the original FCP developer. We then used an adaptation framework to categorize the core components of FCP into three main groups. Finally, we summarized practical recommendations for each barrier based on information provided by the interviewees. RESULTS: A total of 32 interviews were conducted. We observed that FCP has evolved from the idea of transferring boarded patients from ED hallways to inpatient hallways to a practical hospital-wide intervention with several components and multiple levels. The key determinant of successful FCP implementation was collaboration with inpatient nursing staff, as they were often reluctant to have patients boarded in inpatient hallways. Other determinants of successful FCP implementation were reaching consensus about the criteria for activation of each FCP level and actions in each FCP level, modifying the electronic health records system, restructuring the inpatient units to have adequate staffing and resources, complying with external regulations and policies such as fire marshal guidelines, and gaining hospital leaders' support. CONCLUSIONS: The key determinant in implementing FCP is creating a supportive and cooperative hospital culture and encouraging key stakeholders, including inpatient nursing staff, to acknowledge that crowding is a hospital-wide problem that requires a hospital-wide response.

Correction: Who Treats Patients with Diabetes and Compensated Cirrhosis.

[This corrects the article DOI: 10.1371/journal.pone.0165574.].

Organizational network strengthening effects on antiretroviral therapy initiation and adherence.

The WHO recommends antiretroviral therapy (ART) initiation immediately after HIV diagnosis. When HIV services are fragmented and poorly coordinated, initiation of ART can be delayed. MEASURE Evaluation conducted an organizational network intervention in Addis Ababa, Ethiopia, which increased referral network density and client satisfaction in the intervention versus control networks. The objective of our study was to extend the parent study by assessing effects of network density on the speed of ART initiation and adherence to ART. Measures of client-time since HIV diagnosis, use of ART, satisfaction with HIV-related services, and adherence were obtained from cross-sectional interviews with female service recipients with HIV/AIDS at baseline (T1, 402) and at 18-month follow-up (T2, 524) and compared between network sites. We used weighted least squares estimation with probit regression techniques in a structural equation modeling framework for analyses. On average at follow-up, clients in the intervention network were more likely to have quicker ART initiation, and were initiated on ART 15 days faster than clients in the control network. Moreover, quicker ART initiation was associated with higher adherence. A unit increase in speed of ART initiation was associated with 0.5 points increase in latent adherence score in the intervention group (p < .05). Satisfaction with care positively predicted adherence to ART. Network density had no direct effect on ART adherence. This quasi-experiment demonstrated that increased referral network density, through improved HIV client referrals, can enhance speed of ART initiation, resulting in improved adherence.

Managing healthcare services in the global marketplace.

The world is getting "flatter"; people, information, technology, and ideas are increasingly crossing national borders. U.S. healthcare is not immune from the forces of globalization. Competition from medical tourism and the rapid growth in the number of undocumented aliens requiring care represent just two challenges healthcare organizations face. An international workforce requires leaders to confront the legal, financial, and ethical implications of using foreign-trained personnel. Cross-border institutional arrangements are emerging, drawing players motivated by social responsibility, globalization of competitors, growth opportunities, or an awareness of vulnerability to the forces of globalization. Forward-thinking healthcare leaders will begin to identify global strategies that address global pressures, explore the opportunities, and take practical steps to prepare for a flatter world.

Who Treats Patients with Diabetes and Compensated Cirrhosis.

BACKGROUND: Increasingly, patients with multiple chronic conditions are being managed in patient-centered medical homes (PCMH) that coordinate primary and specialty care. However, little is known about the types of providers treating complex patients with diabetes and compensated cirrhosis. OBJECTIVE: We examined the mix of physician specialties who see patients dually-diagnosed with diabetes and compensated cirrhosis. DESIGN: Retrospective cross-sectional study using 2000-2013 MarketScan® Commercial Claims and Encounters and Medicare Supplemental Databases. PATIENTS: We identified 22,516 adults (≥ 18 years) dually-diagnosed with diabetes and compensated cirrhosis. Patients with decompensated cirrhosis, HIV/AIDS, or liver transplantation prior to dual diagnosis were excluded. MAIN MEASURES: Physician mix categories: patients were assigned to one of four physician mix categories: primary care physicians (PCP) with no gastroenterologists (GI) or endocrinologists (ENDO); GI/ENDO with no PCP; PCP and GI/ENDO; and neither PCP nor GI/ENDO. Health care utilization: annual physician visits and health care expenditures were assessed by four physician mix categories. KEY RESULTS: Throughout the 14 years of study, 92% of patients visited PCPs (54% with GI/ENDO and 39% with no GI/ENDO). The percentage who visited PCPs without GI/ENDO decreased 22% (from 63% to 49%), while patients who also visited GI/ENDO increased 71% (from 25% to 42%). CONCLUSIONS: This is the first large nationally representative study to document the types of physicians seen by patients dually-diagnosed with diabetes and cirrhosis. A large proportion of these complex patients only visited PCPs, but there was a trend toward greater specialty care. The trend toward co-management by both PCPs and GI/ENDOs suggests that PCMH initiatives will be important for these complex patients. Documenting patterns of primary and specialty care is the first step toward improved care coordination.

Use of mental health services after hurricane Floyd in North Carolina.

OBJECTIVE: The aim of this study was to examine the impact of a natural disaster, Hurricane Floyd, on the use of mental health services in a Medicaid population in North Carolina. METHODS: Difference-in-differences techniques were used to determine month-by-month and 12-month postevent average effects of the hurricane on the use of mental health services at the county level. The exposure group was drawn from 14 severely affected counties, and the control group was drawn from 56 unaffected counties. Data were analyzed from July 1998 (14 months before the hurricane) to September 2000 (12 months after the hurricane). RESULTS: The number of per-enrollee per-month outpatient visits to psychologists or licensed clinical social workers and the number of outpatient visits to non-mental health specialists showed a statistically significant increase over the 12-month postevent period, whereas the number of inpatient admissions for behavioral health reasons decreased. Dollars spent on antianxiety medication per enrollee per month showed a statistically significant decrease. CONCLUSIONS: The aftermath of Hurricane Floyd was associated with significantly greater use of mental health services in the Medicaid community in North Carolina for a few services. However, it is unclear whether changes in utilization patterns were due to the greater demand for services or to the availability of other services that may have served as substitutes. The results of this study underscore the importance of planning for service implementation and delivery after similar events in other states.