Health Policy

Syndemic Vulnerability, Sexual and Injection Risk Behaviors, and HIV Continuum of Care Outcomes in HIV-Positive Injection Drug Users

Syndemic Vulnerability, Sexual and Injection Risk Behaviors, and HIV Continuum of Care Outcomes in HIV-Positive Injection Drug Users
AIDS & Behavior, Sep 2014. DOI: 10.1007/s10461-014-0890-0

Mizuno, Y., D.W. Purcell, A.R. Knowlton, J.D. Wilkinson, M.N. Gourevitch, and K.R. Knight

Limited investigations have been conducted on syndemics and HIV continuum of care outcomes. Using baseline data from a multi-site, randomized controlled study of HIV-positive injection drug users (n = 1,052), we examined whether psychosocial factors co-occurred, and whether these factors were additively associated with behavioral and HIV continuum of care outcomes. Experiencing one type of psychosocial problem was significantly (p < 0.05) associated with an increased odds of experiencing another type of problem. Persons with 3 or more psychosocial problems were significantly more likely to report sexual and injection risk behaviors and were less likely to be adherent to HIV medications. Persons with 4 or more problems were less likely to be virally suppressed. Reporting any problems was associated with not currently taking HIV medications. Our findings highlight the association of syndemics not only with risk behaviors, but also with outcomes related to the continuum of care for HIV-positive persons.

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

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.

Using Comparative Analysis to Address Health System Caricatures

Using Comparative Analysis to Address Health System Caricatures
International Journal of Health Services, Volume 44, Number 3, Pages 547–559, 2014. Baywood Publishing Co., Inc. doi:

Michael K. Gusmano, Victor G. Rodwin, and Daniel Weisz

To learn from health care systems abroad, we must move beyond simplistic characterizations and compare different systems with respect to salient performance measures. Despite findings from recent cross-national studies suggesting that many health care systems outperform the United States, claims by U.S. public officials often fail to acknowledge the actual accomplishments of health care systems abroad. We document significant variation among the United States and France, Germany, and England, which provide universal coverage, albeit in different ways. As previously documented, the United States has the highest rate of mortality amenable to health care. We extend this work by adding two indicators: (a) access to timely and effective primary care as measured by hospital discharges for avoidable hospital conditions; and (b) use of specialty services as indicated by coronary revascularization (bypass surgery and angioplasty), adjusted for the burden of coronary artery disease. Our findings indicate that: (a) the United States suffers the gravest consequences of financial barriers to primary care; (b) in all four countries, older people (65+) receive fewer revascularizations than their younger counterparts once we account for disease burden; and (c) in France, patients receive the most revascularizations, after adjusting for the burden of disease.

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

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.

Association of weekend continuity of care with hospital length of stay

Association of weekend continuity of care with hospital length of stay
International Journal for Quality in Health Care, Vol. 26, no. 5, pp. 551-563. DOI: 10.1093/intqhc/mzu065

Blecker, S., D. Shine, N. Park, K. Goldfeld, R.Scott Braithwaite, M.J. Radford, and M.N. Gourevitch

Objective: The purpose of this study was to evaluate the association of physician continuity of care with length of stay, likelihood of weekend discharge, in-hospital mortality and 30-day readmission.

Design: A cohort study of hospitalized medical patients. The primary exposure was the weekend usual provider continuity (UPC) over the initial weekend of care. This metric was adapted from an outpatient continuity of care index. Regression models were developed to determine the association between UPC and outcomes.

Setting: An academic medical center.

Main: outcome measure Length of stay which was calculated as the number of days from the first Saturday of the hospitalization to the day of discharge.

Results: Of the 3391 patients included in this study, the prevalence of low, moderate and high UPC for the initial weekend of hospitalization was 58.7, 22.3 and 19.1%, respectively. When compared with low continuity of care, both moderate and high continuity of care were associated with reduced length of stay, with adjusted rate ratios of 0.92 (95% CI 0.86–1.00) and 0.64 (95% CI 0.53–0.76), respectively. High continuity of care was associated with likelihood of weekend discharge (adjusted odds ratio 2.84, 95% CI 2.11–3.83) but was not significantly associated with mortality (adjusted odds ratio 0.72, 95% CI 0.29–1.80) or readmission (adjusted odds ratio 0.88, 95% CI 0.68–1.14) when compared with low continuity of care.

Conclusions: Increased weekend continuity of care is associated with reduced length of stay. Improvement in weekend cross-coverage and patient handoffs may be useful to improve clinical outcomes.

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

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.


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