Health Policy

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy
Medical Care, Vol. 53, no. 1, pp. 71-78. DOI: 10.1097/MLR.0000000000000259

Sivarajan, G., G.B. Taksler, D. Walter, C.P. Gross, R.E. Sosa,and D.V. Makarov

Introduction: The rapid diffusion of the surgical robot has been controversial because of the technology’s high costs and its disputed marginal benefit. Some, however, have suggested that adoption of the robot may have improved care for patients with renal malignancy by facilitating partial nephrectomy, an underutilized, technically challenging procedure believed to be less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with increased utilization of partial nephrectomy.

Methods: We used all payer data from 7 states to identify 21,569 nephrectomies. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Annual Survey and publicly available data on timing of robot acquisition. We used a multivariable difference-in-difference model to assess at the hospital-level whether robot acquisition was associated with an increase in the proportion of partial nephrectomy, adjusting for hospital nephrectomy volume, year of surgery, and several additional hospital-level factors.

Results: In the multivariable-adjusted differences-in-differences model, hospitals acquiring a robot between 2001 and 2004 performed a greater proportion of partial nephrectomy in both 2005 (29.9% increase) and 2008 (34.9% increase). Hospitals acquiring a robot between 2005 and 2008 also demonstrated a greater proportion of partial nephrectomy in 2008 (15.5% increase). In addition, hospital nephrectomy volume and urban location were also significantly associated with increased proportion of partial nephrectomy.

Conclusions: Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure. This is one of the few studies to suggest robot acquisition is associated with improvement in quality of patient care.

Shanghai rising: health improvements as measured by avoidable mortality since 2000

Shanghai rising: health improvements as measured by avoidable mortality since 2000
International Journal of Health Policy Management; 4(1), 1–6.

Gusmano, MK., Rodwin, VG. Wang C., Weisz D., Luo L., and Hua F.

Over the past two decades, Shanghai, the largest megacity in China, has been coping with unprecedented growth of its economy and population while overcoming previous underinvestment in the health system by the central and local governments. We study the evolution of Shanghai’s healthcare system by analyzing “Avoidable Mortality” (AM) – deaths amenable to public health and healthcare interventions, as previously defined in the literature. Based on analysis of mortality data, by cause of death, from the Shanghai Municipal Center for Disease Control and Prevention, we analyze trends over the period 2000–10 and compare Shanghai’s experience to other mega-city regions – New York, London and Paris. Population health status attributable to public health and healthcare interventions improved dramatically for Shanghai’s population with permanent residency status. The age-adjusted rate of AM, per 1,000 population, dropped from 0.72 to 0.50. The rate of decrease in age-adjusted AM in Shanghai (30%) was comparable to New York City (30%) and Paris (25%), but lower than London (42%). Shanghai’s establishment of the Municipal Center for Disease Control and Prevention and its upgrading of public health and health services are likely to have contributed to the large decrease in the number and rate of avoidable deaths, which suggests that investments in public health infrastructure and increasing access to health services in megacities – both in China and worldwide – can produce significant mortality declines. Future analysis in Shanghai should investigate inequalities in avoidable deaths and the extent to which these gains have benefitted the significant population of urban migrants who do not have permanent residency status.

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The Top Ten Global Health Supply Chain Issues: Perspectives from the Field

The Top Ten Global Health Supply Chain Issues: Perspectives from the Field
Operations Research for Health Care. 3(4) 226-230.

Privett, N. and D. Gonsalves

In the battle for global health, supply chains are often found wanting. Yet most of what is known about in-country pharmaceutical supply chains resides in the experiences of individual stakeholders, with limited amounts of this knowledge captured in technical reports and papers. This short communication taps into the collective experience and wisdom of global health supply chain professionals through interviews and surveys to identify and prioritize the top 10 global health pharmaceutical supply chain challenges: (1) lack of coordination, (2) inventory management, (3) absent demand information, (4) human resource dependency, (5) order management, (6) shortage avoidance, (7) expiration, (8) warehouse management, (9) temperature control, and (10) shipment visibility. As such, this work contributes to the foundational knowledge of global health pharmaceutical supply chains. These challenges must be addressed by researchers, policy makers, and practitioners alike if global pharmaceutical supply chains are to be developed and improved in emerging regions of the world.

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; 44(3): 547–559. doi:

Gusmano, MK. Rodwin, VG. and Weisz, D.

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; 39 (5): 1113-1126. doi: 10.1215/03616878-2813719

Rodwin, VG. and Chinitz, DP.

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.


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