A randomized controlled trial of a shared decision making intervention for diabetes prevention for women with a history of gestational diabetes mellitus: The Gestational diabetes Risk Attenuation for New Diabetes (GRAND study).

BACKGROUND: Gestational diabetes mellitus (GDM) is a risk factor for the development of type 2 diabetes. Metformin and lifestyle change through a Diabetes Prevention Program (DPP) are equally effective in preventing diabetes in patients with a GDM history, so women can choose a strategy based on their preferences. This study aims to test whether shared decision making (SDM) can help women with a history of GDM increase adoption of evidence-based strategies and lose weight to lower their risk of incident diabetes in real-world settings. METHODS: This pragmatic randomized controlled trial (RCT) will test the effectiveness of SDM for diabetes prevention among 310 overweight/obese women with a history of GDM and prediabetes from two large health care systems (n = 155 from UCLA Health and n = 155 from Intermountain Healthcare). The primary outcome is the proportion of participants who lose ≥5% body weight at 12 months. Secondary outcomes include uptake of DPP and/or metformin and other patient-reported outcomes such as patient activation and health-related quality of life. Rates of GDM in a subsequent pregnancy will be an exploratory outcome. A descriptive analysis of costs related to SDM implementation will also be conducted. CONCLUSION: This is the first RCT to examine the effectiveness of SDM on weight loss, lifestyle change and/or metformin use, and other patient-reported outcomes in participants with a GDM history at risk of developing diabetes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03766256. Registered on 6 December 2018.

The cost-saving effect of continuity of care (COC): an analysis of institutional COC on diabetic treatment costs using panel 2SLS regressions.

BACKGROUND: The high costs of chronic conditions call for new treatment approaches that reduce costs while ensuring desirable health outcomes. There has been a growing transformation of care delivery models from conventional referral systems to integrated care models. This study seeks to evaluate the cost-saving impact of integrated care delivery model under pay-for-performance (P4P) scheme with continuity of care at institution level (ICOC). METHODS: We analyzed the Taiwan National Health Insurance claim data of 21,725 diabetic patients who visited clinics and/or hospitals at least four times a year for 8 years. Using average local provider P4P participation rate (for each accreditation level) as an instrumental variable in two-stage least squares (2SLS) regressions, we have estimated consistent estimates of the ICOC elasticities for all-cause inpatient and outpatient costs. RESULTS: Our results show that ICOC significantly reduced inpatient costs but increased outpatient costs with the elasticity for treatment costs of -11.6 and 1.03, respectively. The decrease in inpatient costs offset the increase in outpatient costs and the resulting total cost saving showed significant association with ICOC. The saving effect of ICOC is especially robust among patients who used clinics as their principal source of care. CONCLUSIONS: Institutional continuity of care has a substantial impact on the treatment costs of diabetes patients. In the context where inpatient care costs are significantly higher than that of the outpatient care, ICOC would lead to a meaningful cost-saving effect. For new diabetes patients, care by clinics demonstrated the strongest saving effect.

Shared decision-making among non-physician healthcare professionals: Enhancing patient involvement in women's reproductive health in community healthcare settings.

OBJECTIVE: Shared decision-making (SDM) is an important approach to patient-centered care in women's reproductive healthcare. This study explored SDM experiences and perceptions among non-physician healthcare professionals. METHODS: We completed 20 key-informant interviews with non-physician healthcare professionals (i.e., NP, RN, CNM, doula, pharmacist, chiropractor) living in Indiana (September 2019-May 2020) who provided community-based women's reproductive healthcare. Interviews were audio-recorded, transcribed, and analyzed using an expanded grounded theory framework. Constant comparative analysis identified emergent themes. RESULTS: Professionals noted community-based healthcare required contextualized decision-making approaches. Results identified listening, decisional ownership, and engagement strategies that enhanced SDM involvement. Findings suggested outcome-oriented SDM concepts, including decisional ownership and investigative listening to enhance SDM. Providers redefined 'challenging' patients as engaged in their healthcare and discussed ways SDM improved healthcare experience beyond one visit. CONCLUSION: Findings offered insight into actionable and practical strategies for enhancing SDM in community-based women's reproductive healthcare. The findings offer strategies to improve SDM by addressing barriers and facilitators among professionals. This extends SDM beyond the patient-physician dyad and supports broader application of SDM. PRACTICE IMPLICATIONS: Incorporating professionals' experiences into SDM concepts can enhance SDM in community-based women's healthcare practice, offering opportunities to support a culture of SDM across settings.

Drivers and Barriers for Adopting Accreditation at Local Health Departments for Their Performance Improvement Effort.

CONTEXT: A national system of voluntary public health accreditation for state, local, and tribal health departments (local health departments [LHDs]) is part of a movement that aims to improve public health performance with ultimate impact on population health outcomes. Indiana is a good setting for the study of LHD accreditation adoption because several LHDs reported de-adopting accreditation in a recent statewide survey and because 71% of Indiana counties serve populations of 50 000 or less. DESIGN: A systematic method of analyzing qualitative data based on the Performance Improvement Model framework to expand our understanding of de-adoption of public health accreditation. SETTING/PARTICIPANTS: In 2015, we conducted a key informant interview study of the 3 LHDs that decided to delay their engagement in the accreditation based on findings from an Indiana survey on LHD accreditation adoption. The study is an exploration of LHD accreditation de-adoption and of the contributions made to its understanding by the Performance Improvement Model. RESULT: The study found that top management team members are those who champion accreditation adoption, and that organizational structure and culture facilitate the staff's embracing of the change. The Performance Improvement Model was found to enhance the elucidation of the inner domain elements of Consolidated Framework for Implementation Research in the context of de-adoption of public health accreditation. CONCLUSION: Governing entities' policies and priorities appear to mediate whether the LHDs are able to continue accreditation pursuit. Lacking any of these driving forces appears to be associated with decisions to de-adoption of accreditation. Further work is necessary to discern specific elements mediating decisions to pursue accreditation. This study demonstrates the added knowledge of Performance Improvement Model (PIM) to the CFIR framework. A large scale study is called to further clarify and discern supports of specific to the needs of individual LHDs for their performance improvement effort.

Addressing Medicaid Expansion from the Perspective of Patient Experience in Hospitals.

BACKGROUND: More Medicaid holders are entering the healthcare system consequential to Medicaid expansion. Their experience has financial consequences for hospitals and crucial implications for the provision of patient-centered care. This study examined how the hospital characteristics, especially the rates of Medicaid coverage and racial/ethnic minorities, impact the quality of inpatient care. METHODS: Using data for years 2009-2011 for 870 observations of California hospitals, and data collected from patients via the Hospital Consumer Assessment of Healthcare Providers and Systems survey coupled with data from the Healthcare Cost and Utilization Project and American Hospital Association Annual Survey, we used a generalized estimating equation approach to evaluate patients' experience with hospital care. Our multivariate model includes a comprehensive set of characteristics capturing market, structural, process, and patient demographics associated with the patient's hospital stay. RESULTS: The findings indicate that high concentrations of Medicaid patients in the hospital negatively impact the perceived patient experience. In addition, all things being equal, hospitals with higher concentrations of Hispanic, Black, and Asian patients received lower patient satisfaction results on 28 of the 30 regression coefficients capturing patient satisfaction, with 22 of the 30 negative coefficients statistically significant. CONCLUSIONS: Hospitals serving higher concentrations of Medicaid patients and more racial/ethnic diverse patients experienced a less satisfactory patient experience than patients utilizing other payers or patients who were White. Our research magnifies the challenge for addressing the disparities that exist in healthcare. Further research is called for clarifying the underlying reasons for these disparities and the optimal strategies for addressing these problems.

It's Not Just a Yes or No Answer: Expressions of Local Health Department Accreditation.

UNLABELLED: The identification and exploration of moderators of health department accreditation remain limited by current dichotomous conceptualizations of pursuit. METHODS: A 2015 survey measured Indiana local health department (LHD) accreditation pursuit and progress, classifying respondents by progress evidence. Covariates included attitudes about the future impact of accreditation on funding and performance, health department size, geography, health outcome ranking, and quality improvement (QI) programing. RESULTS: Four classifications of accreditation pursuit emerged and were found to have greater association with covariates than standard dichotomous measures. "Active Pursuit" was associated with formal QI programing and a belief that accreditation will impact future funding and performance. "Intent Only" was associated with no QI programing and no completion of accreditation prerequisites. "Discontinued" was associated with the belief that accreditation will not impact future performance. "Not Pursuing" was associated with no interest or plan to complete prerequisites and reported belief that accreditation will not impact future health department funding or performance. CONCLUSION: More granular characterizations of accreditation pursuit may improve understanding of influential factors. This measurement framework should be validated in studies of LHDs in other states.

Using a social entrepreneurial approach to enhance the financial and social value of health care organizations.

In this study, a conceptual framework was developed to show that social entrepreneurial practices can be effectively translated to meet the social needs in health care. We used a theory-in-use case study approach that encompasses postulation of a working taxonomy from literature scanning and a deliberation of the taxonomy through triangulation of multilevel data of a case study conducted in a Taiwan-based hospital system. Specifically, we demonstrated that a nonprofit organization can adopt business principles that emphasize both financial and social value. We tested our model and found comprehensive accountability across departments throughout the case hospital system, and this led to sustainable and continual growth of the organization. Through social entrepreneurial practices, we established that both financial value creation and fulfilling the social mission for the case hospital system can be achieved.

ED services: the impact of caring behaviors on patient loyalty.

INTRODUCTION: This article describes an observational study of caring behaviors in the emergency departments of 4 Ascension Health hospitals and the impact of these behaviors on patient loyalty to the associated hospital. These hospitals were diverse in size and geography, representing 3 large urban community hospitals in metropolitan areas and 1 in a midsized city. METHODS: Research assistants from Purdue University (West Lafayette, IN) conducted observations at the first study site and validated survey instruments. The Purdue research assistants trained contracted observers at the subsequent study sites. The research assistants conducted observational studies of caregivers in the emergency departments at 4 study sites using convenience sampling of patients. Caring behaviors were rated from 0 (did not occur) to 5 (high intensity). The observation included additional information, for example, caregiver roles, timing, and type of visit. Observed and unobserved patients completed exit surveys that recorded patient responses to the likelihood-to-recommend (loyalty) questions, patient perceptions of care, and demographic information. RESULTS: Common themes across all study sites emerged, including (1) the area that patients considered most important to an ED experience (prompt attention to their needs upon arrival to the emergency department); (2) the area that patients rated as least positive in their actual ED experience (prompt attention to their needs upon arrival to the emergency department); (3) caring behaviors that significantly affected patient loyalty (eg, making sure that the patient is aware of care-related details, working with a caring touch, and making the treatment procedure clearly understood by the patient); and (4) the impact of wait time to see a caregiver on patient loyalty. A number of correlations between caring behaviors and patient loyalty were statistically significant (P < .05) at all sites. DISCUSSION: The study results raised considerations for ED caregivers, particularly with regard to those caring behaviors that are most closely linked to patient loyalty but that occurred least frequently. The study showed through factor analysis that some caring behaviors tended to occur together, suggesting an underlying, unifying dimension to that factor.

Visualizing desirable patient healthcare experiences.

High healthcare cost has drawn much attention and healthcare service providers (HSPs) are expected to deliver high-quality and consistent care. Therefore, an intimate understanding of the most desirable experience from a patient's and/or family's perspective as well as effective mapping and communication of such findings should facilitate HSPs' efforts in attaining sustainable competitive advantage in an increasingly discerning environment. This study describes (a) the critical quality attributes (CQAs) of the experience desired by patients and (b) the application of two visualization tools that are relatively new to the healthcare sector, namely the "spider-web diagram" and "promotion and detraction matrix." The visualization tools are tested with primary data collected from telephone surveys of 1,800 patients who had received care during calendar year 2005 at 6 of 61 hospitals within St. Louis, Missouri-based, Ascension Health. Five CQAs were found by factor analysis. The spider-web diagram illustrates that communication and empowerment and compassionate and respectful care are the most important CQAs, and accordingly, the promotion and detraction matrix shows those attributes that have the greatest effect for creating promoters, preventing detractors, and improving consumer's likelihood to recommend the healthcare provider.

Using data mining to segment healthcare markets from patients' preference perspectives.

PURPOSE: This paper aims to provide an example of how to use data mining techniques to identify patient segments regarding preferences for healthcare attributes and their demographic characteristics. DESIGN/METHODOLOGY/APPROACH: Data were derived from a number of individuals who received in-patient care at a health network in 2006. Data mining and conventional hierarchical clustering with average linkage and Pearson correlation procedures are employed and compared to show how each procedure best determines segmentation variables. FINDINGS: Data mining tools identified three differentiable segments by means of cluster analysis. These three clusters have significantly different demographic profiles. PRACTICAL IMPLICATIONS: The study reveals, when compared with traditional statistical methods, that data mining provides an efficient and effective tool for market segmentation. When there are numerous cluster variables involved, researchers and practitioners need to incorporate factor analysis for reducing variables to clearly and meaningfully understand clusters. ORIGINALITY/VALUE: Interests and applications in data mining are increasing in many businesses. However, this technology is seldom applied to healthcare customer experience management. The paper shows that efficient and effective application of data mining methods can aid the understanding of patient healthcare preferences.

Satisfaction and value: a meta-analysis in the healthcare context.

Understanding healthcare performance from the patient's perspective has attracted more attention from the scholars and practitioners as consumers are becoming the driving force to the innovation of healthcare delivery in the knowledge economy (Morath 2003; Scott 2003). However, most of the studies have been constrained in the methods by which the clinical professionals assess what they perceived as the patient's value. This research attempts to examine the constructs for the conceptualization of patient value and its relationship with patient satisfaction. The results indicate that the providers' skills and knowledge and their respectful communication with the patients are the most important. These attributes followed by the providers' level of empathy and attention and the physical environment factors.

Building customer capital through knowledge management processes in the health care context.

BACKGROUND: Customer capital is a value generated and an asset developed from customer relationships. Successfully managing these relationships is enhanced by knowledge management (KM) infrastructure that captures and transfers customer-related knowledge. The execution of such a system relies on the vision and determination of the top management team (TMT). The health care industry in today's knowledge economy encounters similar challenges of consumerism as its business sector. Developing customer capital is critical for hospitals to remain competitive in the market. PURPOSES: This study aims to provide taxonomy for cultivating market-based organizational learning that leads to building of customer capital and attaining desirable financial performance in health care. With the advancement of technology, the KM system plays an important moderating role in the entire process. METHODOLOGY/APPROACH: The customer capital issue has not been fully explored either in the business or the health care industry. The exploratory nature of such a pursuit calls for a qualitative approach. This study examines the proposed taxonomy with the case hospital. The lessons learned also are reflected with three US-based health networks. FINDINGS: The TMT incorporated the knowledge process of conceptualization and transformation in their organizational mission. The market-oriented learning approach promoted by TMT helps with the accumulation and sharing of knowledge that prepares the hospital for the dynamics in the marketplace. Their key knowledge advancement relies on both the professional arena and the feedback of customers. The institutionalization of the KM system and organizational culture expands the hospital's customer capital. PRACTICE IMPLICATIONS: The implication is twofold: (1) the TMT is imperative for the success of building customer capital through KM process; and (2) the team effort should be enhanced with a learning culture and sharing spirit, in particular, active nurse participation in decision making and frontline staff's role in providing a delightfully surprising patient experience.