Do Nonprofit Hospitals Evaluate Their Community Benefit Activities?

CONTEXT: Nonprofit hospitals in the United States are required to conduct a community health needs assessment (CHNA) every 3 years to identify the most pressing health issues in their community and then develop an implementation strategy for addressing these health issues. CHNA reports must include "evaluation of the impact of any actions that were taken to address the significant health needs identified in the immediately preceding CHNA." OBJECTIVE: To determine whether and how nonprofit hospitals are responding to the requirement to evaluate their implementation strategies addressing their community's priority health needs. DESIGN: Using content analysis, we reviewed CHNA reports of all Minnesota nonprofit hospitals (n = 96) since regulations were finalized in December 2014. SETTING: Nonprofit hospitals in Minnesota. MAIN OUTCOME MEASURES: Reports were coded to determine whether hospitals are responding to the evaluation requirement and the types of evaluation measures (process vs outcome indicators) used to assess hospitals' activities. RESULTS: Most of the reports (116 of 136 reports, or 85.3%) include narrative evaluating community benefit programs, showing widespread conformity with the IRS (Internal Revenue Service) mandate. All of the evaluations use process indicators, such as the number of individuals reached. More than half of the evaluations (64 of 116 reports, or 55.2%) also use outcome indicators, with many reporting short- and medium-term changes in health-related knowledge and behaviors. Use of outcome indicators increased substantially in CHNAs in the 2017-2020 period compared with 2015-2016. CONCLUSIONS: In general, Minnesota hospitals are using program evaluation to assess their community benefit implementation strategies, although the extent to which they evaluate their strategies varies considerably between hospitals. While the use of outcome indicators of impact has increased over time, levels of use suggest the importance of incorporating public health expertise in CHNA work.

Complexity Science, Nursing, and COVID-19.

Understanding a bewildering crisis like a pandemic as 'normal' may be empowering.

A taxonomy of hospitals based on partnerships for population health management.

BACKGROUND: Hospitals face growing pressures and opportunities to engage with partner organizations in efforts to improve population health at the community level. Variation has been observed in the degree to which hospitals develop such partnerships. PURPOSE: The aim of this study was to generate a taxonomy of hospitals based on their partnerships with external organizations, employing the theoretical notion of organizations' focus on exploration versus exploitation. METHODOLOGY: With 1,238 valid cases from the 2015 American Hospital Association Population Health Survey, our study uses items asking about the level of partnership strength for 36 named partner types. Excluding three variables with low reliability, 33 variables are classified into six partner groups by factor analysis. Then, cluster analysis is conducted to generate a taxonomy of hospitals based on their partnerships with the six partner groups. FINDINGS: Of 1,238 hospitals, 26.1% are classified as exploratory hospitals that develop more collaborative relationships with partners outside the medical sector. Exploitative hospitals (18.3%) focus on relationships with traditional medical sector partners. Ambidextrous hospitals (27.0%) develop partnerships both in and outside the medical sector. Finally, independent hospitals (28.6%) do not establish strong partnerships. Larger hospitals, not-for-profit hospitals, and teaching hospitals are more likely to be classified as exploratory. PRACTICE IMPLICATIONS: The four-cluster taxonomy can provide hospital and health system leaders and managers with a better understanding of the wide variation in partnerships that hospitals establish and insights into their different strategic options with regard to partnership development.

Strategic Differentiation of High-Tech Services in Local Hospital Markets.

This study assesses organizational and market factors related to high-tech service differentiation in local hospital markets. The sample includes 1704 nonfederal, general acute hospitals in urban counties in the United States. We relate organizational and market factors in 2011 to service differentiation in 2013, using ordinary least squares regression. Data are compiled from the American Hospital Association Annual Survey of Hospitals, Area Resource File, and Centers for Medicare and Medicaid Services. Results show that hospitals differentiate more services relative to market rivals if they are larger than the rival and if the hospitals are further apart geographically. Hospitals differentiate more services if they are large, teaching, and nonprofit or public and if they face more market competition. Hospitals differentiate fewer services from rivals if they belong to multihospital systems. The findings underscore the pressures that urban hospitals face to offer high-tech services despite the potential of high-tech services to drive hospital costs upward.

Determinants of Community-Related Expenses of US Tax-Exempt Hospitals, 2013.

CONTEXT: Tax-exempt hospitals in the United States are required to report community benefit expenses on their federal tax forms. Two categories of expenses critical to the public health mission of hospitals are the "community health improvement" and "community-building" expense categories. The community health improvement expenses formally qualify as a community benefit, whereas community-building expenses do not. Increasing both types of spending would be consistent with the growing evidence on the effects of social determinants on population health. OBJECTIVE: To identify characteristics associated with the level of community health improvement and community-building expenses reported by tax-exempt hospitals. DESIGN: The general acute care hospital is the unit of analysis. We utilize secondary data for all US general acute care hospitals that filed their own Internal Revenue Service Form 990 Schedule H for 2013 (n = 1508). We apply linear regression analysis to an explanatory model with 8 independent variables. MEASURES: The primary dependent variables are percentage of operating expenses devoted to community health improvement and to community building. The independent variables include 4 hospital-level measures, 3 county-level measures, and a measure of state requirements for community benefit. RESULTS: The level of community health improvement expenses is positively associated with bed size, system membership, profit margin, and urban location. In states where tax-exempt hospitals are required to demonstrate community benefit to the state, there is lower community health improvement spending. Teaching hospitals also demonstrate lower community health improvement spending. Results for community-building expenses mirror those for community health improvement except that teaching hospital status and per capita income lose significance and hospital competition gains significance in the negative direction. CONCLUSIONS: Leaders among tax-exempt hospitals in community-related spending are hospitals that are larger, more profitable, members of systems, and located in urban areas and in states that do not have community benefit requirements.

Trends in lobular carcinoma in situ management: endocrine therapy use in California and New Jersey.

PURPOSE: The diagnosis of lobular carcinoma in situ (LCIS) is a strong risk factor for breast cancer. Endocrine therapy (ET) for LCIS has been shown to decrease breast cancer risk substantially. The purpose of this study was to evaluate the trends of ET use for LCIS in two large geographic locations. PATIENTS AND METHODS: We identified women, ages 18 through 75, with a microscopic diagnosis of LCIS in California (CA) and New Jersey (NJ) from 2004 to 2014. We evaluated trends in unadjusted ET rates during the study period and used logistic regression to evaluate the relationship between patient, tumor, and treatment characteristics, and ET use. RESULTS: We identified 3,129 patients in CA and 2,965 patients in NJ. The overall use of ET during the study period was 14%. For the combined sample, women in NJ were significantly less likely to utilize ET then their counterparts in CA (OR 0.77, CI 0.66-0.90, NJ vs. CA). In addition, patients in the later year period (OR 1.27, CI 1.01-1.59, 2012-2014 vs. 2004-2005) and women who received an excisional biopsy (OR 2.35, CI 1.74-3.17), were more likely to utilize ET. Uninsured women were less likely to receive ET (OR 0.61, CI 0.44-0.84, non-insured vs. insured status). CONCLUSIONS: We observed that an increasing proportion of women are using ET for LCIS management, but geographical differences exist. Health insurance status played an important role in the underutilization of ET. Further research is needed to assess patient outcomes given the variations in management of LCIS.

Embracing uncertainty, managing complexity: applying complexity thinking principles to transformation efforts in healthcare systems.

BACKGROUND: Complexity thinking is increasingly being embraced in healthcare, which is often described as a complex adaptive system (CAS). Applying CAS to healthcare as an explanatory model for understanding the nature of the system, and to stimulate changes and transformations within the system, is valuable. MAIN TEXT: A seminar series on systems and complexity thinking hosted at the University of Toronto in 2016 offered a number of insights on applications of CAS perspectives to healthcare that we explore here. We synthesized topics from this series into a set of six insights on how complexity thinking fosters a deeper understanding of accepted ideas in healthcare, applications of CAS to actors within the system, and paradoxes in applications of complexity thinking that may require further debate: 1) a complexity lens helps us better understand the nebulous term "context"; 2) concepts of CAS may be applied differently when actors are cognizant of the system in which they operate; 3) actor responses to uncertainty within a CAS is a mechanism for emergent and intentional adaptation; 4) acknowledging complexity supports patient-centred intersectional approaches to patient care; 5) complexity perspectives can support ways that leaders manage change (and transformation) in healthcare; and 6) complexity demands different ways of implementing ideas and assessing the system. To enhance our exploration of key insights, we augmented the knowledge gleaned from the series with key articles on complexity in the literature. CONCLUSIONS: Ultimately, complexity thinking acknowledges the "messiness" that we seek to control in healthcare and encourages us to embrace it. This means seeing challenges as opportunities for adaptation, stimulating innovative solutions to ensure positive adaptation, leveraging the social system to enable ideas to emerge and spread across the system, and even more important, acknowledging that these adaptive actions are part of system behaviour just as much as periods of stability are. By embracing uncertainty and adapting innovatively, complexity thinking enables system actors to engage meaningfully and comfortably in healthcare system transformation.

Knowledge, Beliefs and Attitudes of Somali Men in Olmsted County, Minnesota, U.S., on the Human Papillomavirus Vaccine and Cervical Cancer Screening: January 17, 2015.

This study explores the general knowledge of Human Papillomavirus vaccine (HPV) and cervical cancer screening (CCS) among Somali men in the U.S., who are major decision-makers in Somali households. HPV infects both men and women, and causes genital warts and cervical cancer (CC). High mortality from CC persists among minorities due to low uptake of preventive tools. Eleven questions assessed general knowledge of HPV and CCS among 30 Somali male respondents. The knowledge of HPV and CCS by education level, age, and years lived in the U.S., was assessed using the health belief model. Most respondents had no knowledge of HPV vaccine and CCS, and low perceived susceptibility to HPV infection. There is need for more research on Somali men's attitude to HPV vaccine and CCS uptake among Somali adolescents and women.

A Measure of the Potential Impact of Hospital Community Health Activities on Population Health and Equity.

CONTEXT: Many hospitals in the United States are exploring greater investment in community health activities that address upstream causes of poor health. OBJECTIVE: Develop and apply a measure to categorize and estimate the potential impact of hospitals' community health activities on population health and equity. DESIGN, SETTING, AND PARTICIPANTS: We propose a scale of potential impact on population health and equity, based on the cliff analogy developed by Jones and colleagues. The scale is applied to the 317 activities reported in the community health needs assessment implementation plan reports of 23 health care organizations in the Minneapolis-St Paul, Minnesota, metropolitan area in 2015. MAIN OUTCOME MEASURE: Using a 5-point ordinal scale, we assigned a score of potential impact on population health and equity to each community health activity. RESULTS: A majority (50.2%) of health care organizations' community health activities are classified as addressing social determinants of health (level 4 on the 5-point scale), though very few (5.4%) address structural causes of health equity (level 5 on the 5-point scale). Activities that score highest on potential impact fall into the topic categories of "community health and connectedness" and "healthy lifestyles and wellness." Lower-scoring activities focus on sick or at-risk individuals, such as the topic category of "chronic disease prevention, management, and screening." Health care organizations in the Minneapolis-St Paul metropolitan area vary substantially in the potential impact of their aggregated community health activities. CONCLUSIONS: Hospitals can be significant contributors to investment in upstream community health programs. This article provides a scale that can be used not only by hospitals but by other health care and public health organizations to better align their community health strategies, investments, and partnerships with programming and policies that address the foundational causes of population health and equity within the communities they serve.

Moving Upstream in U.S. Hospital Care Toward Investments in Population Health.

EXECUTIVE SUMMARY: The root causes for most health outcomes are often collectively referred to as the social determinants of health. Hospitals and health systems now must decide how much to "move upstream," or invest in programs that directly affect the social determinants of health. Moving upstream in healthcare delivery requires an acceptance of responsibility for the health of populations. We examine responses of 950 nonfederal, general hospitals in the United States to the 2015 American Hospital Association Population Health Survey to identify characteristics that distinguish those hospitals that are most aligned with population health and most engaged in addressing social determinants of health. Those "upstream" hospitals are significantly more likely to be large, not-for-profit, metropolitan, teaching-affiliated, and members of systems. Internally, the more upstream hospitals are more likely to organize their population health activities with strong executive-level involvement, full-time-equivalent support, and coordination at the system level.The characteristics differentiating hospitals strongly involved in population health and upstream activity are not unlike those characteristics associated with diffusion of many innovations in hospitals. These hospitals may be the early adopters in a diffusion process that will eventually include most hospitals or, at least, most not-for-profit hospitals. Alternatively, the population health and social determinants movements could be transient or could be limited to a small portion of hospitals such as those identified here, with distinctive patient populations, missions, and resources.

The proliferation of elective services in U.S. urban hospitals.

BACKGROUND: Although adding convenience for both patients and providers, the proliferation of elective services and equipment in U.S. general hospitals contributes to higher costs and raises concerns about quality and overuse. PURPOSES: We assess the relationship of two forces-health system membership and market competition-with the diffusion of elective services and equipment. METHODOLOGY/APPROACH: The sample consists of all urban U.S. nonfederal general acute hospitals in 2010 (n = 2,467). Elective equipment and services are defined by 25 services offered by less than 33% of urban general hospitals. We relate the number of elective services to environmental and organizational conditions, adopting a contingency theory perspective. Ordinary least squares regression is used to estimate the associations among the key variables. FINDINGS: Market competition is positively associated with numbers of elective services. The effect of health system membership varies by system type, with the most developed integrated systems showing a positive relationship with the quantity of elective services, relative to freestanding hospitals. Members of less-developed integrated systems, however, have fewer elective services than freestanding hospitals. PRACTICE IMPLICATIONS: The evidence on market competition is consistent with a medical arms race scenario in which hospitals pursue elective services and equipment to compete with each other. Membership in highly integrated systems does not act as a constraint on the pursuit of elective services and equipment but instead may independently promote it. It may be unrealistic to expect hospitals to resist offering elective services in the face of competitive and organizational considerations that encourage proliferation.

Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback.

OBJECTIVE: To improve safety practices and reduce adverse events in perinatal units of acute care hospitals. DATA SOURCES: Primary data collected from perinatal units of 14 hospitals participating in the intervention between 2008 and 2012. Baseline secondary data collected from the same hospitals between 2006 and 2007. STUDY DESIGN: A prospective study involving 342,754 deliveries was conducted using a quality improvement collaborative that supported three primary interventions. Primary measures include adoption of three standardized care processes and four measures of outcomes. DATA COLLECTION METHODS: Chart audits were conducted to measure the implementation of standardized care processes. Outcome measures were collected and validated by the National Perinatal Information Center. PRINCIPAL FINDINGS: The hospital perinatal units increased use of all three care processes, raising consolidated overall use from 38 to 81 percent between 2008 and 2012. The harms measured by the Adverse Outcome Index decreased 14 percent, and a run chart analysis revealed two special causes associated with the interventions. CONCLUSIONS: This study demonstrates the ability of hospital perinatal staff to implement efforts to reduce perinatal harm using a quality improvement collaborative. Findings help inform the relationship between the use of standardized care processes, teamwork training, and improved perinatal outcomes, and suggest that a multiplicity of integrated strategies, rather than a single intervention, may be essential to achieve high reliability.

Decreasing Malpractice Claims by Reducing Preventable Perinatal Harm.

OBJECTIVE: To evaluate the association of improved patient safety practices with medical malpractice claims and costs in the perinatal units of acute care hospitals. DATA SOURCES: Malpractice and harm data from participating hospitals; litigation records and medical malpractice claims data from American Excess Insurance Exchange, RRG, whose data are managed by Premier Insurance Management Services, Inc. (owned by Premier Inc., a health care improvement company). STUDY DESIGN: A quasi-experimental prospective design to compare baseline and postintervention data. Statistical significance tests for differences were performed using chi-square, Wilcoxon signed-rank test, and t-test. DATA COLLECTION: Claims data were collected and evaluated by experienced senior claims managers through on-site claim audits to evaluate claim frequency, severity, and financial information. Data were provided to the analyzing institution through confidentiality contracts. PRINCIPAL FINDINGS: There is a significant reduction in the number of perinatal malpractice claims paid, losses paid, and indemnity payments (43.9 percent, 77.6 percent, and 84.6 percent, respectively) following interventions to improve perinatal patient safety and reduce perinatal harm. This compares with no significant reductions in the nonperinatal claims in the same hospitals during the same time period. CONCLUSIONS: The number of perinatal malpractice claims and dollar amount of claims payments decreased significantly in the participating hospitals, while there was no significant decrease in nonperinatal malpractice claims activity in the same hospitals.

High-risk centers and the benefits for lower-risk transplants.

OBJECTIVES: Allogeneic hematopoietic cell transplantation (HCT) is the transplantation of stem cells from a donor and an effective treatment for many hematologic malignancies. We sought to compare allogeneic HCT survival outcomes and hazard of death among US centers that treat higher-risk patients versus those in centers that do not perform lower-risk HCT procedures. STUDY DESIGN: We utilized 2008 to 2010 Center for International Blood and Marrow Transplant Research data. We categorized patients into 4 risk categories that align with factors shown in the literature to be associated with HCT survival. We stratified centers into those that do and do not conduct high-risk pre-transplant HCT. METHODS: To further evaluate the association between pre-transplant mortality risk and HCT survival by transplant center, we examined the association between risk category score and hazard of death using Cox proportional hazard modeling. RESULTS: There were 12,436 HCT recipients at 147 transplant centers. Of the 147 centers, 74 performed HCT for patients ranging from the lowest risk category to the highest category, and 73 centers performed only lower-risk HCT. Adjusting for all other factors, lower-risk patients that underwent transplants in lower- or higher-risk centers had a similar relative hazard of death (P ≤ .05). CONCLUSIONS: Low-risk patients had similar survival outcomes irrespective of whether they underwent transplant at higher- or lower-risk centers. Patient and payer policy implications could include initiatives that reduce travel for low-risk patients. Similarly, HCT center administrators and providers that manage higher-risk patients need not expect commensurate benefits in survival for lower-risk patients.

Exploratory analysis of high CT scan utilization in claims data.

PURPOSE: This study explores characteristics that distinguish higher and lower CT use by patients and referring physicians in a population of members of a large health insurance plan. METHODS: We analyzed 310,467 CT scan claims from 2009-10 in a health plan serving approximately 1.5 million members. Patients who used CT scans and their referring physicians were classified into utilization categories. Characteristics distinguishing higher from lower utilization categories were identified. RESULTS: Among patients receiving CT scans, patient characteristics that distinguished higher from lower utilization of scans were: male, older, seeing more total providers, using more prescription and total resources, classified as frail, having higher treatment group severity, and having government insurance. Among physicians ordering scans, physician characteristics that distinguished higher from lower referrals for CT scans were: male, board-certified, in group practice, and in particular specialties. Ownership interest was associated with higher claim volumes in a curvilinear manner but was not associated with claims per physician. Higher total referral counts were related to single-specialty practice type and larger group size. External reviewers (4 physicians) observed that the empirical relationships had plausible explanations based on reasonable medical decision-making. CONCLUSIONS: Aggregate-level review of claims for CT scans in a health plan revealed no striking anomalies in associations of patient and referring physician characteristics with higher utilization. Claims research that examines particular conditions and patients with high utilization rates and physicians with high referral rates would advance the evidence base for quality improvement.

Service duplication within urban hospital clusters.

BACKGROUND: Approximately 80% of multihospital system member hospitals in U.S. urban areas are clustered with other same-system member hospitals located in the same market area. A key argument for clustering is the potential for reducing service duplication across cluster members. PURPOSE: The aim of this study is to examine the effects of characteristics of hospital clusters on service duplication within 339 hospital clusters in U.S. metropolitan statistical areas and adjacent counties in 2002. METHODOLOGY/APPROACH: Ordinary least squares regression is used to estimate the relationship between cluster characteristics in 1998 and duplicated services per cluster member in 2002. FINDINGS: Duplication is higher in hospitals clusters with higher case mix index and higher bed size range. Duplication is lower in hospital clusters with more members, for-profit ownership, and more geographic dispersion. PRACTICE IMPLICATIONS: Increases in the size of hospital clusters allow more opportunities for service rationalization. For-profit clusters may be innovators in rationalization activity, and they should be studied in this regard. Clusters with a higher case mix, lower geographic dispersion, and hub-and-spoke design (with high bed-size range) may find service reallocation less feasible.

Lymph node evaluation for colon cancer in an era of quality guidelines: who improves?

INTRODUCTION: In the 1990s, several organizations began recommending evaluation of > 12 lymph nodes during colon resection because of its association with improved survival. We examined practice implications of multispecialty quality guidelines over the past 20 years recommending evaluation of ≥ 12 lymph nodes during colon resection for adequate staging. MATERIALS AND METHODS: We used the 1988 to 2009 Surveillance, Epidemiology, and End Results program to conduct a retrospective observational cohort study of 90,203 surgically treated patients with colon cancer. We used Cochran-Armitage tests to examine trends in lymph node examination over time and multivariate logistic regression to identify patient characteristics associated with guideline-recommended lymph node evaluation. RESULTS: The introduction of practice guidelines was associated with gradual increases in guideline-recommended lymph node evaluation. From 1988 to 1990, 34% of patients had > 12 lymph nodes evaluated, increasing to 38% in 1994 to 1996 and to > 75% from 2006 to 2009. Younger, white patients and those with more-extensive bowel penetration (T3/4 nonmetastatic) and high tumor grade saw more-rapid increases in lymph node evaluation (P < .001). Multivariate analyses demonstrated a significant interaction between year of diagnosis and both T stage and grade, indicating that those with higher T stage and higher grade were more likely to receive guideline-recommended care earlier. CONCLUSION: The implementation of lymph node evaluation guidelines was accepted gradually into practice but adopted more quickly among higher risk patients. By identifying patients who are least likely to receive guideline-recommended care, these findings present a starting point for promoting targeted improvements in cancer care and further understanding underlying contributors to these disparities.

Public health as a distinct profession: has it arrived?

This article reviews the elements consistent with the definition of a "profession" in the contemporary United States and argues that public health should be considered a distinct profession, recognizing that it has a unique knowledge base and career paths independent of any other occupation or profession. The Welch-Rose Report of 1915 prescribed education for public health professionals and assumed that, although at first the majority of students would be drawn from other professions, such as medicine, nursing, and sanitary engineering, public health was on its way to becoming "a new profession." Nearly a century later, the field of public health has evolved dramatically in the direction predicted. It clearly meets the criteria for being a "profession" in that it has (1) a distinct body of knowledge, (2) an educational credential offered by schools and programs accredited by a specialized accrediting body, (3) career paths that include autonomous practice, and (4) a separate credential, Certified in Public Health (CPH), indicative of self-regulation based on the newly launched examination of the National Board of Public Health Examiners. Barriers remain that challenge independent professional status, including the breadth of the field, more than one accrediting body, wide variation in graduate school curricula, and the newness of the CPH. Nonetheless, the benefits of recognizing public health as a distinct profession are considerable, particularly to the practice and policy communities. These include independence in practice, the ability to recruit the next generation, increased influence on health policy, and infrastructure based on a workforce of strong capacity and leadership capabilities.

Hospital characteristics associated with maintenance or improvement of guideline-recommended lymph node evaluation for colon cancer.

BACKGROUND: Over the past 20 years, surgical practice organizations have recommended the identification of ≥12 lymph nodes from surgically treated colon cancer patients as an indicator of quality performance for adequate staging; however, studies suggest that significant variation exists among hospitals in their level of adherence to this recommendation. We examined hospital-level factors that were associated with institutional improvement or maintenance of adequate lymph node evaluation after the introduction of surgical quality guidelines. RESEARCH DESIGN: Using the 1996-2007 SEER-Medicare data, we evaluated hospital characteristics associated with short-term (1999-2001), medium-term (2002-2004), and long-term (2005-2007) guideline-recommended (≥12) lymph node evaluation compared with initial evaluation levels (1996-1998) using χ tests and multivariate logistic regression analysis, adjusting for patient case-mix. RESULTS: We identified 228 hospitals that performed ≥6 colon cancer surgeries during each study period from 1996-2007. In the initial study period (1996-1998), 26.3% (n=60) of hospitals were performing guideline-recommended evaluation, which increased to 28.1% in 1999-2001, 44.7% in 2002-2004, and 70.6% in 2005-2007. In multivariate analyses, a hospital's prior guideline performance [odds ratio (OR) (95% confidence interval (CI)): 4.02 (1.92, 8.42)], teaching status [OR (95% CI): 2.33 (1.03, 5.28)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 3.39 (1.39, 8.31)] were significantly associated with short-term guideline-recommended lymph node evaluation. Prior hospital performance [OR (95% CI): 2.41 (1.17, 4.94)], urban location [OR (95% CI): 2.66 (1.12, 6.31)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 6.05 (2.32, 15.77)] were associated with medium-term performance; however, these factors were not associated with long-term performance. CONCLUSIONS: Over the 12-year period, there were marked improvements in hospital performance for guideline-recommended lymph node evaluation. Understanding patterns in improvement over time contributes to debates over optimal designs of quality-improvement programs.