Patient Perspectives on a Decision Aid for Systemic Lupus Erythematosus: Insights and Future Considerations.

OBJECTIVE: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide spectrum of clinical manifestations. A decision aid (DA) for SLE was developed and implemented in 15 rheumatology clinics throughout the United States. This study explored the experiences of patients who viewed the DA to understand how patients engage with and respond to the SLE DA. METHODS: We conducted a qualitative descriptive study using semistructured interviews with a convenience sample of 24 patients during May to July 2022. RESULTS: Patients recognized the value of the SLE DA in providing general knowledge about SLE and different treatment options. However, patients expressed a desire for more comprehensive lifestyle information to better manage their condition. Another theme was the importance of having multiple formats available to cater to their different needs, as well as tailoring the DA to different stages of SLE. CONCLUSION: This study contributes to a broader understanding of how to provide patient-centered care for patients with SLE by offering practical insights that can inform the development of more effective, patient-centric health information technologies for managing chronic diseases, ultimately improving patient outcomes. Overall, this study underscores the significance of optimizing both the information content and determining the appropriate delivery of the tool for its future sustainability.

Patterns and trends in local health departments' efforts to promote access to care in local communities throughout the United States: The contributions of governance structures.

Public health agencies like local health departments (LHDs) play an important role in addressing healthcare access disparities and service delivery gaps in local communities throughout the United States. Previous research has provided important snapshots into specific access issues confronted by LHDs; however, the literature lacks a more comprehensive view of LHDs' efforts to ensure broad access to care, how these have evolved over time more recently, and whether certain types of LHDs governance structures are more likely to engage in activities to ensure access to care. The purpose of this study was to address these gaps in the literature by exploring the prevalence of different activities to ensure access to care, describing how the prevalence of these activities have evolved over time, and examining whether the prevalence of these activities varied as a function of different governance structures. Using pooled, cross-sectional survey data from four waves of a survey (2009, 2013, 2016, 2019) of LHDs in the United States, the univariate and bivariate analysis revealed that, over time, LHDs have generally increased their efforts to assess gaps in access to healthcare services and across all healthcare categories (i.e., medical, dental, behavioural health) but especially for behavioural health. Poisson regression models showed that LHDs with a more decentralised decision-making structure were associated with more activities to ensure access to care, as compared to more centralised structures. Collectively, our findings indicate that despite growth in the number and percentage of LHDs assessing and addressing gaps in services, opportunities still exist to enhance access to healthcare services in local communities, particularly in the areas of dental and behavioural health. Our findings also suggest that stakeholders interested in improving LHDs' efforts to ensure access to care in local communities may want to pay close attention to governance features of LHDs.

Association between the number of adopted implementation strategies and contextual determinants: a mixed-methods study.

BACKGROUND: The successful implementation of evidence-based innovations to improve healthcare delivery often requires a well-planned strategy to support their use. With a greater recognition of the importance of an implementation process, researchers have turned their attention to implementation strategies and their customization to target specific organizational barriers and facilitators. Further, there is a paucity of empirical evidence demonstrating the link between implementation determinants and the number of selected implementation strategies. The purpose of this mixed methods analysis is to examine how formatively assessed barriers and facilitators to implementation relate to the number and type of implementation strategies adopted to address context-specific factors. METHODS: A mixed methods evaluation that included 15 rheumatology clinics throughout the United States that were planning for implementation of an evidence-based shared decision-making aid for patients with lupus. Quantitative data consisted of a count of the number of implementation strategies used by a clinic. Qualitative data collection was guided by the Consolidated Framework for Implementation Research (CFIR) and relied upon semi-structured interviews with 90 clinic members between November 2018 and August 2019. RESULTS: Using the CFIR, we found that local clinic factors (Inner Setting Domain) resulted in different perceptions about Planning and Executing the DA (Process Domain); these domains were most likely to distinguish between the number and type of implementation strategies adopted by the clinics. In contrast, Intervention characteristics, Individual Characteristics, and the Outer Setting did not differentiate between the groups with different numbers of implementation strategies. The number and type of chosen strategies were not those associated with the context-specific factors. CONCLUSIONS: Findings show that, despite recognition of the value of customizing implementation strategies for the contexts in which they are applied, they are too often chosen in a manner that fail to adequately reflect the diverse settings that may present unique factors associated with implementation. Our findings also highlight the importance of the inner context - both in terms of structural characteristics and existing work processes - as a driving factor for why some organizations select different numbers and types of implementation strategies.

Participation in Value-Based Payment Programs and U.S. Acute Care Hospital Population Health Partnerships.

GOAL: The goal of this study was to describe the prevalence and pattern of population health partnerships by hospitals and examine whether these partnerships were associated with different types of payment model programs. METHODS: We conducted a cross-sectional analysis of 3,012 U.S. hospitals using data from the American Hospital Association's Annual Survey, the Area Health Resources File, and the County Health Rankings & Roadmaps data. We ran a multivariable Poisson regression model to examine the relationship between value-based payment designs and the number of population health partnerships. Binary logistic regression models were used to assess whether participation in value-based payment design programs was associated with specific types of population health partnerships. PRINCIPAL FINDINGS: We found that two thirds or more of hospitals used more informal collaborative partnerships with local or state government, faith-based organizations, and local businesses; formal alliances were most common with health insurance companies and other healthcare providers. Accountable care organizations and bundled payment program participation were associated with greater numbers of population health partnerships, whereas hospital ownership of a health plan was not associated with significantly greater numbers of population health partnerships. APPLICATIONS TO PRACTICE: Hospitals were engaged in an intermediate number of partnerships (mean = 3.5, out of 8.0 possible), with opportunities for more partnerships with specific types of organizations (faith-based organizations, health insurance companies). Our findings also suggest that certain types of payment models, particularly those that are less capital intensive and entail less extensive organizational transformation on the part of hospitals, may support hospital engagement in population health partnerships. Hospital leaders need to monitor these partnerships continually to determine if they can capitalize on opportunities to play a more prominent role in population health management in local communities.

Assessing the Performance Value of the Baldrige Journey: A Comparison of Baldrige Applicants and Nonapplicants.

GOAL: The national Baldrige program has supported performance excellence in healthcare since 1999. Previous studies have compared the performance of Baldrige hospital recipients to nonrecipients. This study, however, sought to address the question of whether the mere pursuit of the Baldrige award provides value. METHODS: This study used propensity score matching with linear and quantile regression techniques to understand the impact of hospitals applying the Baldrige Excellence Framework across a comprehensive set of standardized industry performance measures, regardless of award recognition. PRINCIPAL FINDINGS: The analysis demonstrated that Baldrige applicants outperformed non-Baldrige applicants in select operational measures of efficiency (such as inpatient average length of stay), patient experience, and financial measures (including return on net assets, days in accounts receivable, and expenses as a percentage of patient revenues). However, there was no statistically significant difference in clinical performance between Baldrige applicants and nonapplicants. PRACTICAL APPLICATIONS: The findings from this study suggest that hospital leaders can realize significant gains with select operational and financial measures without compromising clinical outcomes when applying the Baldrige Excellence Framework to their organizations.

Antecedents of geographical expansion: The case of federally qualified health centers.

BACKGROUND: Federally qualified health centers (FQHCs) are pivotal safety net primary care providers for the medically underserved. FQHCs have complex organizational designs, with many FQHCs providing care at multiple physical locations ("sites"). The number of sites, however, varies considerably between FQHCs, which can have important implications for differential access that may perpetuate disparities in quality of care. PURPOSE: The objective of this study is to explore the organizational and environmental antecedents of the number of sites operated by each FQHC. The findings of this study contribute to a better understanding of FQHCs' expansion that has vital implications for cost and access outcomes. METHODOLOGY/APPROACH: The study is based on data between the years 2012 and 2018. Using multivariate growth curve modeling, we analyzed the final sample, consisting of 5,482 FQHC-years. RESULTS: The level of competition, measured as the number of FQHC sites in the Primary Care Service Area (PCSA) and the number of primary care physicians per 1,000 PCSA residents, was positively associated with the number of FQHC sites. The number of patients, the level of federal grant, and the year were also positively associated with the number of FQHC sites, whereas percentage of Medicaid patients; workforce supply, measured as primary care physician assistants per 1,000 PCSA residents; Medicaid expansion; and state/local funding available for FQHCs were not. CONCLUSION: Findings of this study indicate that competition, especially between peer FQHCs, is significantly associated with FQHC expansion. PRACTICE IMPLICATIONS: This result suggests that FQHC managers and policymakers may closely monitor cost, access, and quality implications of competition and FQHC expansion.

The organizational and environmental characteristics associated with hospitals' use of intensivists.

BACKGROUND: As large numbers of coronavirus disease 2019 (COVID-19) patients were admitted to intensive care units (ICUs) in 2020 and 2021, the United States faced a shortage of critical care providers. Intensivists are physicians specializing in providing care in the ICU. Although studies have explored the clinical and financial benefits associated with the use of intensivists, little is known about the organizational and market factors associated with a hospital administrator's strategic decision to use intensivists. PURPOSE: The aim of this study was to use the resource dependence theory to better understand the organizational and market factors associated with a hospital administrator's decision to use intensivists. METHODOLOGY: The sample consisted of the national acute care hospitals (N = 4,986) for the period 2007-2017. The dependent variable was the number of full-time equivalent intensivists staffed in hospitals. The independent variables were organizational and market-level factors. A negative binomial regression model with state and year fixed effects, clustered at the hospital level, was used to examine the relationship between the use of intensivists and organizational and market factors. RESULTS: The results from the analyses show that administrators of larger, not-for-profit hospitals that operate in competitive urban markets with relatively high levels of munificence are more likely to utilize intensivists. PRACTICE IMPLICATIONS: When significant strains are placed on ICUs like what was experienced during the COVID-19 pandemic, it is imperative that hospital administrators understand how to best staff their ICUs. With a better understanding of the organizational and market factors associated with the use of intensivists, practitioners and policymakers alike can better understand how to strategically utilize intensivists in the ICU, especially in the face of a continuing pandemic.

Environmental and organizational correlates and motivations for provider-sponsored health plan ownership in the post-reform era.

BACKGROUND: The 1980s to 1990s saw many health systems in the United States enter and exit the insurance market in the form of provider-sponsored health plans (PSHPs). Reforms and value-based reimbursement methods have stimulated health care organizations to reconsider PSHP as a logical strategy. PURPOSE: The aim of this study was to examine market and organizational factors associated with PSHP ownership and motivations for engaging in PSHP after health care reforms. The resource dependence theory was used as a theoretical lens. METHODOLOGY/APPROACH: A sequential quantitative to qualitative mixed-methods design was used. The quantitative analysis examined data for 5,849 U.S. hospitals. Results were synthesized with qualitative findings from 10 semistructured interviews representing eight health systems in five states. RESULTS: Organizational and environmental characteristics were significantly associated with PSHP ownership. Hospital and payer concentration, Medicare penetration, income, unemployment rate, government, and for-profit and metro area hospitals were associated with a lower likelihood of PSHP ownership. Salaried physician arrangements, clinically integrated network membership and adoption of other risk-bearing arrangements were associated with higher odds of PSHP ownership. Interviewees described PSHP as the culmination of the journey to value-based care and as a strategy to improve patient care, compete, and diversify revenue streams. CONCLUSIONS: Both market and organizational factors are important considerations for hospitals contemplating PSHP ownership, and motivations for ownership cover a broad range of financial, competitive, strategic, and mission-based goals. PRACTICE IMPLICATIONS: Hospitals considering PSHP ownership must carefully evaluate their competitive landscapes and organizational resources to ensure optimal conditions for this strategy. PSHP ownership has high start-up costs and requires a long-term organizational commitment.

Generation and Use of Evidence by Local Health Departments: The Role of Leader Attributes.

OBJECTIVE: The purpose of this study was to examine whether certain types of leaders were associated with the degree to which local health departments (LHDs) generate and use evidence to inform their service offering. DESIGN: Pooled, cross-sectional analysis using 4 waves (2010, 2013, 2016, and 2019) of the National Profiles of Local Health Departments sponsored by the National Association of County and City Health Officials (NACCHO). Univariate analysis was used to assess the extent to which LHDs were generating and using evidence to improve the health of their local communities and whether this changed over time. Multinomial logistic regression models were used to examine the relationships between LHD leader attributes and the extent to which LHDs were generating and using evidence. PARTICIPANTS: Between 1496 and 2087 (varied by survey round) LHDs from throughout the United States. MAIN OUTCOME MEASURES: Two outcome variables pertaining to the generation of evidence: (1) how recently an LHD completed a community health assessment and (2) how recently an LHD completed a community health improvement plan. A third outcome variable reflected how extensively an LHD used the Community Guide, a compendium of evidence-based findings. RESULTS: In 2010, 25.1% and 41.4% of all LHDs had not completed a community health assessment or a community health improvement plan, respectively; by 2019, those figures declined significantly to 14.6% and 24.7%. Similarly, in 2010, 61.7% of all LHDs were not using the Community Guide; by 2019, that percentage declined significantly to 42.5%. Multivariable analysis revealed that leader experience was a more robust correlate of evidence generation and use by LHDs than leader education. CONCLUSIONS: While LHDs' generation and use of evidence have grown over the past decade, there is room for improvement. Local health department leader attributes-education and experience-highlight targeted opportunities to fill gaps in the use of evidence-based public health practices.

Better Together? An Examination of the Relationship Between Acute Care Hospital Mergers and Patient Experience.

EXECUTIVE SUMMARY: The United States is experiencing another wave of hospital mergers. Whether patients benefit from these mergers, however, remains an open issue for many interested stakeholders. One measure of the potential benefit of hospital mergers is how they affect patient experience. This study used a quasi-experimental design to examine the relationship between hospital mergers and four different Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings (i.e., overall, physician communication, nurse communication, and staff responsiveness). The study findings showed an association between hospitals that experienced a merger and slower growth in HCAHPS scores for two of the four HCAHPS domains (overall and nurse communication) when compared to matching hospitals that did not merge. Findings from this study can guide and inform hospital administrators, health system boards, state and federal government regulators and policymakers, and others across the spectrum of healthcare stakeholders.

Sustaining participation in multisector health care alliances: The role of personal and stakeholder group influence.

BACKGROUND: Cross-sectoral collaborative organizations (e.g., alliances, coalitions) bring together members from different industry sectors to ameliorate multifaceted problems in local communities. The ability to leverage the diverse knowledge and skills of these members is predicated on their sustained participation, which research has shown to be a significant challenge. PURPOSE: The purpose of this study was to investigate how alliance member perceptions of decision-making influence relate to sustained participation in the alliance and its activities. METHODOLOGY: An Internet-based survey of 638 members of 15 multistakeholder health care alliances participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality program was conducted. Ordinal logistic regression path analysis was used to estimate the relationship between two types of influence (personal influence and general stakeholder influence), perceived value of alliance participation, and intentions regarding future participation. FINDINGS: Alliance members saw less participation value when their personal influence was believed to be lower than the influence of other alliance members (b = -0.09, p < .05). This type of influence was not significantly associated with the anticipated level of future participation. In contrast, imbalances in general stakeholder group influence was not significantly associated with perceived value, but greater imbalances were associated with a decreased likelihood of future participation (OR = 0.52, 95% CI [0.32, 0.83]). PRACTICE IMPLICATIONS: Our findings highlight the important yet complicated task of balancing perceptions of influence; leaders must keep the desired outcomes in mind when considering what type of influence to attend to.

Hospital ownership of postacute care providers and the cost of care.

BACKGROUND: Hospitals are facing incentives to manage the total cost of care for episodes of illness, including the costs of inpatient care as well as the cost of care provided by physicians and postacute care (PAC) providers. PAC is an especially important component of the overall cost of care. One strategy hospitals employ in managing this cost is to own PAC providers. Prior work on the relationship between PAC ownership and cost has reached mixed conclusions. PURPOSE: The aim of this study was to examine the associations between the episodic costs of care and hospital ownership of PAC providers, including skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRF). METHODOLOGY: We examine panel data on hospital ownership of PAC providers from the American Hospital Association for 2013-2015 and cost of care data from Centers for Medicare & Medicaid Services' Value-Based Purchasing Program. Using ordinary least squares, we quantify the association between a hospital's PAC ownership choice (both ownership of any PAC provider and ownership of particular types of providers) and the episodic cost of care. RESULTS: In 2015, 80% of hospitals owned some type of PAC provider. We find that ownership of SNFs and HHAs is associated with a lower episodic cost of care, whereas ownership of inpatient rehabilitation facilities is associated with higher episodic costs of care. The effects of ownership do not differ for hospitals that participate in a voluntary shared saving program (Bundled Payment for Care Improvement). CONCLUSION: The effects of PAC ownership vary by the type of PAC provider owned. Our results suggest that ownership of SNFs and HHAs may be a viable strategy for success in reimbursement programs that reward hospitals for managing the total costs for episodes of care.

CEO Turnover Among U.S. Acute Care Hospitals, 2006-2015: Variations by Type of Geographic Area.

EXECUTIVE SUMMARY: Recent reports have documented rising rates of CEO turnover. This phenomenon can have negative implications for hospitals and their surrounding communities, particularly in under-resourced rural communities. Ostensibly, components of the Affordable Care Act have addressed some of these resource challenges and may have helped to slow the CEO turnover trend in rural areas. We examined this possibility with a longitudinal analysis of U.S. acute care hospitals over an extended period (2006-2015) to examine whether patterns of CEO change differed for hospitals in different types of geographic areas (e.g., rural vs. urban). The rates revealed by our analysis seem to be problematic, with nearly one-quarter of all U.S. hospitals experiencing a change in CEO every 3 to 4 years, on average. Moreover, while the likelihood of a CEO change increased significantly over time for hospitals in nearly all types of geographic areas, it was nearly twice as large for frontier hospitals in areas with fewer than 2,500 residents compared to urban and rural hospitals. Our study suggests that the stability of hospital CEO leadership has declined over the past decade, particularly for vulnerable frontier hospitals, and highlights the need for recruitment and retention strategies to address this challenge.

Market and organizational factors associated with hospital vertical integration into sub-acute care.

BACKGROUND: Changes in payment models incentivize hospitals to vertically integrate into sub-acute care (SAC) services. Through vertical integration into SAC, hospitals have the potential to reduce the transaction costs associated with moving patients throughout the care continuum and reduce the likelihood that patients will be readmitted. PURPOSE: The purpose of this study is to examine the correlates of hospital vertical integration into SAC. METHODOLOGY/APPROACH: Using panel data of U.S. acute care hospitals (2008-2012), we conducted logit regression models to examine environmental and organizational factors associated with hospital vertical integration. Results are reported as average marginal effects. FINDINGS: Among 3,775 unique hospitals (16,269 hospital-year observations), 25.7% vertically integrated into skilled nursing facilities during at least 1 year of the study period. One measure of complexity, the availability of skilled nursing facilities in a county (ME = -1.780, p < .001), was negatively associated with hospital vertical integration into SAC. Measures of munificence, percentage of the county population eligible for Medicare (ME = 0.018, p < .001) and rural geographic location (ME = 0.069, p < .001), were positively associated with hospital vertical integration into SAC. Dynamism, when measured as the change county population between 2008 and 2011 (ME = 1.19e-06, p < .001), was positively associated with hospital vertical integration into SAC. Organizational resources, when measured as swing beds (ME = 0.069, p < .001), were positively associated with hospital vertical integration into SAC. Organizational resources, when measured as investor owned (ME = -0.052, p < .1) and system affiliation (ME = -0.041, p < .1), were negatively associated with hospital vertical integration into SAC. PRACTICE IMPLICATIONS: Hospital adaption to the changing health care landscape through vertical integration varies across market and organizational conditions. Current Centers for Medicare and Medicaid reimbursement programs do not take these factors into consideration. Vertical integration strategy into SAC may be more appropriate under certain market conditions. Hospital leaders may consider how to best align their organization's SAC strategy with their operating environment.

Organizational and environmental factors influencing hospital community orientation.

BACKGROUND: Community orientation refers to hospitals' efforts to assess and meet the health needs of the local population. Variations in the number of community orientation-related activities offered by hospitals may be attributed to differences in organizational and environmental characteristics. Therefore, hospitals have to strategically respond to these internal and external constraints to improve community health. Understanding the facilitators and barriers of hospital community orientation is important to health care managers facing pressure from the external environment to meet the expectations of the community as well as Affordable Care Act guidelines. PURPOSE: The purpose of this study was to examine the organizational and environmental factors that promote or impede hospital community orientation. METHODOLOGY: A multivariate regression with random effects was conducted using data from the American Hospital Association Annual Survey from 2007 to 2010 and county level data from the Area Health Resource Files. FINDINGS: Not-for-profit, system-affiliated, network-affiliated, and larger hospitals have a higher degree of community orientation. In addition, the percentage of the county residents under the age of 65 years with health insurance and hospitals in states with certificate-of-need laws were also positively related to the degree of community orientation. During the study period, it appears that organizational factors mattered more in determining the degree of community orientation. PRACTICE IMPLICATIONS: Overall, a better understanding of the factors that influence community orientation can assist hospital administrators and policymakers in stimulating the hospital's role in improving population health and its responsiveness to community health needs. These efforts may occur by building interorganizational relationships or by incentivizing those hospitals that are least likely to be community oriented.

The perceived importance of intersectoral collaboration by health care alliances.

There is growing interest in the use of intersectoral collaboration (e.g., alliances, coalitions, partnerships) to address complex, health-related issues in local communities. Relatively little empirical research, however, has examined how to foster and sustain collaboration across sectors during later stages of development, despite a recognition that the needs and goals for collaboration may change over time. The purpose of this study was to address this gap by examining the perceptions of alliance participants regarding the importance of collaborating with different industry sectors as alliances transitioned from stable, prescriptive foundation support to a more uncertain future. Our findings suggest that, in addition to the contextual characteristics highlighted in previous research, the perceived importance of intersectoral collaboration varies for different types of alliances and participants. Moreover, the salience of these characteristics varied for different types of collaboration, in our case, collaboration with nonmedical health care sectors and nonhealth care sectors. Collectively, our findings point to the importance of thinking more comprehensively, across multiple levels of influence, when considering ways to foster or sustain intersectoral collaboration.

Hospital Vertical Integration Into Subacute Care as a Strategic Response to Value-Based Payment Incentives, Market Factors, and Organizational Factors: A Multiple-Case Study.

This study explores the extent to which payment reform and other factors have motivated hospitals to adopt a vertical integration strategy. Using a multiple-case study research design, we completed case studies of 3 US health systems to provide an in-depth perspective into hospital adoption of subacute care vertical integration strategies across multiple types of hospitals and in different health care markets. Three major themes associated with hospital adoption of vertical integration strategies were identified: value-based payment incentives, market factors, and organizational factors. We found evidence that variation in hospital adoption of vertical integration into subacute care strategies occurs in the United States and gained a perspective on the intricacies of how and why hospitals adopt a vertical integration into subacute care strategy.