Health Management

Connecting the Dots: Interprofessional Health Education and Delivery System Redesign at the Veterans Health Administration

Connecting the Dots: Interprofessional Health Education and Delivery System Redesign at the Veterans Health Administration
Academic Medicine, Vol. 89, no. 8, pp. 1113-1116. DOI: 10.1097/ACM.0000000000000312

Gilman, S.C., D. Chokshi, J.L. Bowen, K.W. Rugen, and M. Cox
08/01/2014

Health systems around the United States are embracing new models of primary care using interprofessional team-based approaches in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. Less often discussed are the implications of new models of care for health professions education, including education for physicians, nurse practitioners, physician assistants, and other professions engaged in primary care. Described here is the interaction between care transformation and redesign of health professions education at the largest integrated delivery system in the United States: the Veterans Health Administration (VA). Challenges and lessons learned are discussed in the context of a demonstration initiative, the VA Centers of Excellence in Primary Care Education. Five sites, involving VA medical centers and their academic affiliates in Boise, Cleveland, San Francisco, Seattle, and West Haven, introduced interprofessional primary care curricula for resident physicians and nurse practitioner students beginning in 2011. Implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities. To realize new models for interprofessional teaching, faculty, staff, and trainees must understand the histories, traditions, and program requirements across professions and experiment with new approaches to achieving a common goal. Key recommendations for redesign of health professions education revolve around strengthening the union between interprofessional learning, team-based practice, and high-value care.

What Passes and Fails as Health Policy and Management

What Passes and Fails as Health Policy and Management
Journal of Health Politics, Policy and Law, Vol. 39, No. 5, October 2014 DOI 10.1215/03616878-2813719

Rodwin, Victor G. and David Chinitz
07/18/2014

The field of health policy and management (HPAM) faces a gap between theory, policy and practice. Despite decades of efforts at reforming health policy and health care systems, prominent analysts state that the health system is ‘‘stuck’’ and that models for change remain ‘‘aspirational.’’ We discuss four reasons for the failure of current ideas and models for redesigning health care: (1) the dominance of microeconomic thinking; (2) the lack of comparative studies of health care organizations and the limits of health management theory in recognizing the importance of local contexts; (3) the separation of HPAM from the rank and file of health care, particularly physicians; and (4) the failure to expose medical students to issues of HPAM. We conclude with suggestions for rethinking how the field of HPAM might generate more promising policies for health care providers and managers by abandoning the illusion of context-free theories and, instead, seeking to facilitate the processes by which organizations can learn to improve their own performance.

Are hospitals “keeping up with the Joneses”?: Assessing the spatial and temporal diffusion of the surgical robot

Are hospitals “keeping up with the Joneses”?: Assessing the spatial and temporal diffusion of the surgical robot
Healthcare : the Journal of Delivery Science & Innovation, Vol. 2, no. 2, pp. 152-157. DOI: 10.1016/j.hjdsi.2013.10.002

Li, H., M.H. Gail, B.R. Scott, H.T. Gold, D. Walter, D, M. Liu, C.P. Gross, and D.V. Makarov
07/01/2014

Background: The surgical robot has been widely adopted in the United States in spite of its high cost and controversy surrounding its benefit. Some have suggested that a “medical arms race” influences technology adoption. We wanted to determine whether a hospital would acquire a surgical robot if its nearest neighboring hospital already owned one.

Methods: We identified 554 hospitals performing radical prostatectomy from the Healthcare Cost and Utilization Project Statewide Inpatient Databases for seven states. We used publicly available data from the website of the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale, CA) combined with data collected from the hospitals to ascertain the timing of robot acquisition during year 2001 to 2008. One hundred thirty four hospitals (24%) had acquired a surgical robot by the end of 2008. We geocoded the address of each hospital and determined a hospital's likelihood to acquire a surgical robot based on whether its nearest neighbor owned a surgical robot. We developed a Markov chain method to model the acquisition process spatially and temporally and quantified the “neighborhood effect” on the acquisition of the surgical robot while adjusting simultaneously for known confounders.

Results: After adjusting for hospital teaching status, surgical volume, urban status and number of hospital beds, the Markov chain analysis demonstrated that a hospital whose nearest neighbor had acquired a surgical robot had a higher likelihood itself acquiring a surgical robot (OR=1.71, 95% CI: 1.07–2.72, p=0.02).

Conclusion: There is a significant spatial and temporal association for hospitals acquiring surgical robots during the study period. Hospitals were more likely to acquire a surgical robot during the robot's early adoption phase if their nearest neighbor had already done so.

Determinants of the Availability of Hepatitis C Testing Services in Opioid Treatment Programs: Results From a National Study

Determinants of the Availability of Hepatitis C Testing Services in Opioid Treatment Programs: Results From a National Study
American Journal of Public Health, 2014 (June), 104(6): 75-82. doi: 10.2105/AJPH.2013.301827

Frimpong, J.A., D’Aunno, T. & Jiang, L.
06/17/2014

OBJECTIVES: We examined trends and organizational-level correlates of the availability of HCV testing in opioid treatment programs.

METHODS: We used generalized ordered logit models to examine associations between organizational characteristics of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey and HCV testing availability.

RESULTS: Between 2005 and 2011, the proportion of opioid treatment programs offering HCV testing increased but largely because of increases in off-site referrals rather than on-site testing. HCV testing availability was higher in opioid treatment programs affiliated with a hospital and those receiving federal funds. Opioid treatment programs providing both methadone and buprenorphine were more likely to offer any HCV testing, whereas opioid treatment programs providing only buprenorphine treatment were less likely to offer on-site testing. HCV testing availability was associated with more favorable staff-to-client ratios.

CONCLUSIONS: The increasing use of off-site referrals for HCV testing in opioid treatment programs likely limits opportunities for case finding, prevention, and treatment. Declines in federal funding for opioid treatment programs may be a key determinant of the availability of HCV testing in opioid treatment programs.

Evidence-based treatment for opioid disorders: A 23-year national study of methadone dose levels

Evidence-based treatment for opioid disorders: A 23-year national study of methadone dose levels
Journal of Substance Abuse Treatment, in press. DOI: 10.1016/j.jsat.2014.06.001

D’Aunno, T., Pollack, H.A., Frimpong, J.A. & Wuchiett, D.
06/10/2014

Effective treatment for patients with opioid use problems is as critical as ever given the upsurge in heroin and prescription opioid abuse. Yet, results from prior studies show that the majority of methadone maintenance treatment (MMT) programs in the US have not provided dose levels that meet evidence-based standards. Thus, this paper examines the extent to which US MMT programs have made changes in the past 23 years to provide adequate methadone doses; we also identify factors associated with variation in program performance. Program directors and clinical supervisors of nationally-representative methadone treatment programs were surveyed in 1988 (n = 172), 1990 (n = 140), 1995 (n = 116), 2000 (n = 150), 2005 (n = 146), and 2011 (n = 140). Results show that the proportion of patients who received doses below 60 mg/day—the minimum recommended—declined from 79.5 to 22.8% in a 23-year span. Results from random effects models show that programs that serve a higher proportion of African-American or Hispanic patients were more likely to report low-dose care. Programs with Joint Commission accreditation were more likely to provide higher doses, as were a program that serves a higher proportion of unemployed and older patients. Efforts to improve methadone treatment practices have made substantial progress, but 23% of patients across the nation are still receiving doses that are too low to be effective.

The global cancer divide: relationships between national healthcare resources and cancer outcomes in high-income vs. middle- and low-income countries

The global cancer divide: relationships between national healthcare resources and cancer outcomes in high-income vs. middle- and low-income countries
Journal of Epidemiology & Global Health, Vol 4, no. 2, pp. 115-124. DOI: 10.1016/j.jegh.2013.10.004

Batouli, A., P. Jahanshahi, C.P. Gross, D.V. Makarov, and J.B.Yu
06/01/2014

Background: Cancer continues to rise as a contributor to premature death in the developing world. Despite this, little is known about whether cancer outcomes are related to a country’s income level, and what aspects of national healthcare systems are associated with improved cancer outcomes.

Methods: The most recent estimates of cancer incidence and mortality were used to calculate mortality-to-incidence ratio (MIR) for the 85 countries with reliable data. Countries were categorized according to high-income (Gross Domestic Product (GDP) > $15,000) or middle/low-income (GDP < $15,000), and a multivariate linear regression model was used to determine the association between healthcare system indicators and cancer MIR. Indicators study included per capita GDP, overall total healthcare expenditure (THE), THE as a proportion of GDP, total external beam radiotherapy devices (TEBD) per capita, physician density, and the year 2000 WHO healthcare system rankings.

Results: Cancer MIR in high-income countries (0.47) was significantly lower than that of middle/low-income countries (0.64), with a p < 0.001. In high-income countries, GDP, health expenditure and TEBD showed significant inverse correlations with overall cancer MIR. A $3040 increase in GDP (p = 0.004), a $379 increase in THE (p < 0.001), or an increase of 0.59 TEBD per 100,000 population (p = 0.027) were all associated with a 0.01 decrease in cancer MIR. In middle/low-income countries, only WHO scores correlated with decreased cancer MIR (p = 0.022); 12 specific cancer types also showed similar significant correlations (p < 0.05) as overall cancer MIR.

Conclusions: The analysis of this study suggested that cancer MIR is greater in middle/low-income countries. Furthermore, the WHO healthcare score was associated with improved cancer outcomes in middle/low-income countries while absolute levels of financial resources and infrastructure played a more important role in high-income countries.

Electronic Health Record Use, Intensity of Hospital Care, and Patient Outcomes

Electronic Health Record Use, Intensity of Hospital Care, and Patient Outcomes
American Journal of Medicine, Vol. 127, no. 3, pp. 123-130. DOI: 10.1016/j.amjmed.2013.11.010

Blecker, S., K. Goldfeld, N. Park, D. Shine, J.S. Austrian, R. Scott Braithwaite, M.J. Radford, and M.N. Gourevitch
03/01/2014

Objective: Previous studies have suggested that weekend hospital care is inferior to weekday care and that this difference may be related to diminished care intensity. The purpose of this study was to determine whether a metric for measuring intensity of hospital care based on use of the electronic health record was associated with patient-level outcomes.

Methods: We performed a cohort study of hospitalizations at an academic medical center. Intensity of care was defined as the hourly number of provider accessions of the electronic health record, termed “electronic health record interactions.” Hospitalizations were categorized on the basis of the mean difference in electronic health record interactions between the first Friday and the first Saturday of hospitalization. We used regression models to determine the association of these categories with patient outcomes after adjusting for covariates.

Results: Electronic health record interactions decreased from Friday to Saturday in 77% of the 9051 hospitalizations included in the study. Compared with hospitalizations with no change in Friday to Saturday electronic health record interactions, the relative lengths of stay for hospitalizations with a small, moderate, and large decrease in electronic health record interactions were 1.05 (95% confidence interval [CI], 1.00-1.10), 1.11 (95% CI, 1.05-1.17), and 1.25 (95% CI, 1.15-1.35), respectively. Although a large decrease in electronic health record interactions was associated with in-hospital mortality, these findings were not significant after risk adjustment (odds ratio 1.74, 95% CI, 0.93-3.25).

Conclusions: Intensity of inpatient care, measured by electronic health record interactions, significantly diminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals should consider monitoring and correcting temporal fluctuations in care intensity.

Adoption of evidence-based clinical innovations: The case of buprenorphine use by opioid treatment programs.

Adoption of evidence-based clinical innovations: The case of buprenorphine use by opioid treatment programs.
Medical Care Research & Review, 2014 (February), 71(1):43-60. doi: 10.1177/1077558713503188. Epub 2013 Sep 18.

Andrews, C., D’Aunno, T, Friedmann, P.D. & Pollack, H.A.
02/18/2014

This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations' technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs' decisions to adopt evidence-based clinical innovations such as buprenorphine use.

HIV testing in the nation’s opioid treatment programs, 2005-2011: The role of state regulations

HIV testing in the nation’s opioid treatment programs, 2005-2011: The role of state regulations
Health Services Research, 2014 (February), 49(1):230-48. DOI: 10.1111/1475-6773.12094

D’Aunno, T., Pollack, H.A., Jiang, L., Metsch, L.R. & Friedmann, P. D.
02/03/2014

Objective: To identify the extent to which clients in a national sample of opioid treatment programs (OTPs) received HIV testing in 2005 and 2011; to examine relationships between state laws for informed consent and pretest counseling and rates of HIV testing among OTP clients.

Data Source: Data were collected from a nationally representative sample of OTPs in 2005 (n = 171) and 2011 (n = 200).

Study Design: Random-effects logit and interval regression analyses were used to examine changes in HIV testing rates and the relationship of state laws to HIV testing among OTPs.

Data Collection: Data on OTP provision of HIV testing were collected in phone surveys from OTP managers; data also were collected on state laws for HIV testing.

Principal Findings: The percentage of OTPs offering HIV testing decreased significantly from 93 percent in 2005 to 64 percent in 2011. Similarly, the percentage of clients tested decreased from an average of 41 percent in 2005 to 17 percent in 2011. OTPs located in states whose laws do not require pretest counseling and that use opt-out consent were more likely to provide HIV testing and to test higher percentages of clients.

Conclusions: The results show the need to increase HIV testing among OTP clients; the results also underscore the beneficial possibilities of dropping pretest counseling as a requirement for HIV testing and of using the opt-out approach to informed consent for testing.

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