Determinants of nursing home performance: examining the relationship between quality and efficiency By Nailya O. DeLellis, MPH, Ph.D. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2010 Director: Dr. Yasar Ozcan, Professor, Department of Health Administration To assess the relationship between quality of care and efficiency of nursing homes this study used 10% random sample of non-hospital based nursing homes of size 20-360 beds and occupancy rate of 5-100% in OSCAR database 2008 (n=1430). Data Envelopment Analysis was used to calculate efficiency score and Structural Equations Modeling was used to assess the effect of environmental factors on efficiency score and quality measures as well as relationship between efficiency and quality of care. Logistic regression was performed to find the factors that affect high performance, defined as high efficiency and high quality. In the study’s sample, 149 facilities (10.4%) had an efficiency score of 1, which indicates perfect efficiency. The average efficiency score of nursing homes in the sample was 0.854 (0.079 min; 0.145 std). Competition positively affects efficiency, with a path coefficient 0.09 (t-value = 2.65). Although the path coefficients relating competition with process and with outcome quality were positive (0.08 and 0.04, respectively), the results were not statistically significant. Stronger position of payers in the market positively affects process quality of care (path coefficient = 0.15, (t-value = 2.48). Higher efficiency of nursing homes is associated with higher outcome quality (path coefficient of 0.06, t-value = 1.99), but lower process quality (path coefficient of –0.20 , t-value = –2.95). Only 7.4% of nursing homes in the sample could efficiently provide high quality services, which was defined as high performance in the study. Among the factors that demonstrated statistically significant coefficients in the regression were the size of a facility, the availability of registered nurses, excess demand, and for-profit status. The study provides evidence of the trade-off between efficiency and process quality, in which higher efficiency of a nursing home is associated with lower process quality of care. Findings in the study also suggested that higher efficiency is associated with higher outcome quality.

This study examines specific organizational, operational, financial and environmental characteristics to identify factors that are associated with increased likelihood of hospitals' CPOE adoption decision in six rollout regions of the Leapfrog initiatives.Resource dependence theory provides theoretical basis for the study. The study is retrospective observational in design. Individual hospitals are the unit of analysis. The Leapfrog Group's 2002-survey collection serves the primary data source. Univariate statistical methods along with bivariate and ordinal logistic regression models are used to analyze the data. The models provided support for multiple hypotheses for both the adoption and early adoption decisions of study hospitals. The operational characteristics of ownership, in-house physician staff, case mix index and the environmental characteristic of HMO penetration rate had a positive effect on management's adoption decisions. The operational characteristic excess capacity, the organizational characteristic community orientation, the financial characteristic of operating income per admission, and the environmental characteristic of number of HMO contracts had a significant negative effect on CPOE adoption decisions.

Healthcare is an organizational field that has undergone profound change in the last few decades, an era characterized by market reform. Healthcare production has revealed both economic and quality problems in past eras, and reporting on these problems can be seen to have contributed to pressures for social reform. Yet, the move toward more market-oriented governance structures and design solutions also reflects a wider isomorphic institutional tendency for organizing social order.The conceptual frame work of this study takes a pessimistic stance on whether the market reform has achieved the intended goals with respect to advancing organizational quality performance. The framework draws on institutional theory and complementary collective action notions in organization theory concerned with boundedly rational decision-making to reason that healthcare evidences certain contextual characteristics that are not a good fit with the market enterprise model of organizing organizations. Specifically, hazards to the efficient market thesis were considered to include uncertain outcomes, a high degree of technical and coordination complexity, and the need to account for intertemporal process transformations of significant duration.A longitudinal design was used to test efficient market thesis propositions. Inpatient administrative data was used to develop two latent hospital quality performance variables, a Mortality quality indicator and an Errors quality indicator. The two latent variables were derived from three selected AHRQ patient safety indicators and an inpatient mortality rate. The measurement model was validated as evidencing significant systematic between-hospital variation. Audited survey data, along with inpatient discharge data was used to develop hospital economic performance variables and process control variables.A set of predictive supply-and-demand models were used to test: 1) whether there is evidence of any trend in quality performance, and how market competition relates to observations of improvement; 2) whether quality cost more; and, 3) whether preferences for better quality outcomes related to hospital economic performance. A hierarchical linear model growth-curve design was employed to assess the predicted relationships and to account for unmeasured organizational dependent relations determinant of hospital quality performance. The unaccounted for systematic between-hospital variance was taken to estimate an "unspecified" hospital-specific institutional effect, independent of material-resource factors. The measurement model results for each of the quality indicators selected evidenced construct validity for patient-level risk-adjustment. Each quality indicator demonstrated a significant systematic between-group variance component in all of the four years studied. The two latent hospital quality performance variables also demonstrated systematic between-hospital variance in growth trajectories in the linear growth-curve model.The predictive models evidenced no significant growth rate trend for either of the quality indicators, indicating the competitive bar on quality performance was unaffected during this period of market reform. Neither was there any evidence that pricing mechanism were able to price the utility of better outcomes, as higher quality did not cost more. Neither was there evidence that consumer preferences for better quality related to better hospital economic performance, as measured by hospital operating margins.

The Anderson and Aday access framework (1974) is utilized to investigate the association of individual and community level, predisposing, socio-demographic, and enabling factors, on potential and realized access to coronary heart disease (CHD) preventive care. The cross-sectional study is based on a sample of adults age 18-85 from the Medical Expenditure Panel Survey (MEPS) who were identified with CHD risk or who had a CHD diagnosis.Variables from the MEPS and the Area Resource File (ARF) are used to test logistic regression models for dependent variables measuring primary and secondary CHD preventive care services. The primary preventive care measures include blood cholesterol testing, blood pressure checks, and, diet, exercise and smoking cessation counseling. The secondary preventive measures include beta-blocker reciept after myocardial infarction (MI) and statin drug use for the treatment of high blood cholesterol.Being uninsured is associated with a reduced likelihood of receiving primary CHD preventive care. Overall study results indicated gender and race are more consistent predictors of the receipt of CHD preventive care services than individual enabling or community characteristics. Women had a greater likelihood of receiving primaryCHD preventive care services than men. Hispanics are less likely than Caucasians to receive primary CHD preventive care services, except for blood cholesterol testing for which they are more likely to receive. Blacks are more likely than Caucasians to have blood cholesterol testing, but are no less likely to receive the other primary CHD preventive care measures. Blacks demonstrate a lower likelihood of receiving secondary CHD preventive care than Caucasians, specifically beta-blocker post myocardial infarction indicating that disparities in secondary CHD preventive care persist for segments of the study population. Persons over 75 years of age are less likely to receive primary CHD preventive care services as well as the secondary preventive measure ofstatin use for high blood cholesterol.Community level factors did not improve the logistic regression model for the receipt of CHD preventive care, yet, when predicting potential access for preventive services, persons from a higher percent Hispanic or black community were less likely to have a usual source of care.

General acute care hospitals play a particularly important role in the delivery of children's mental health given the extant lack of alternatives to long term hospitals for patients requiring a restrictive treatment environment (Glied and Cuellar, 2003). This cross-sectional study identifies environmental and organizational factors associated with general acute care and children's hospitals in the United States that provide hospital-based child/adolescent psychiatric services and the number of services. Two macro-level theories, Resource Dependence Theory and Institutional Theory were used to identify environmental and organizational factors. A nationwide sample of hospitals was drawn from the 2003 AHA annual survey. Data from the 2002 AHA annual survey, Area Resource File and American College of Graduate Medical Education was used for the independent variables. There were three analyses, correlation, descriptive and logistic regression. Results demonstrate that hospitals in markets with a low percentage of non-white children, higher family median income, high hospital community orientation, and high percentage of not for profit hospitals are more likely to offer child psychiatric services. Organizational factors associated with an increased likelihood to providing child psychiatric services include hospitals identified as Catholic, public or children's and those with a child psychiatric residency program. Three factors were associated with hospitals providing a high number of child psychiatric services and include hospitals in metropolitan statistical areas, system affiliation, and general acute care hospitals. This study demonstrated that 1. large hospitals are more likely to offer child psychiatric services and a high number of services, 2. children's hospitals provide child psychiatric services, but not a high number of them, and 3. hospitals with a high number of service offerings are mainly located in MSA's and more likely to offer outpatient substance abuse services. Significant results were obtained in the analysis of hospital characteristics and the provision of child psychiatric services, but weaker results were observed when analyzing the number of services. Further research is needed to identify factors with stronger associations to the level of service offerings.

The purpose of this study was to determine the factors associated with outsourcing of information systems (IS), and if there is a difference in IS sourcing based on the strategic value of the outsourced functions. The theoretical framework is based upon a synthesis of strategic management theory (SMT) and transaction cost economics (TCE) as they apply to vertical integration in the health care sector; therefore, IS sourcing behavior was conceptualized as a case of vertical integration. The conceptual model proposed that sourcing behavior would be determined by asset specificity, uncertainty, the interaction of asset specificity and uncertainty, bargaining power, corporate strategy needs, and the strategic value of the IS functions outsourced.A cross sectional design was used, consisting of data from the American Hospital Association (AHA), the Area Resource File (ARF), the HIMSS Analytics database, and the Centers for Medicare and Medicaid Services (CMS) hospital cost reports for 2003. The final sample consisted of 1,365 health care delivery systems and 3,452 hospitals. Analysis was conducted using a two-stage negative binomial regression model (using instrumental variables) to correct for suspected endogeneity. Tests of joint restrictions using the group of variables derived from TCE and SMT, respectively, were done with the dependent variable divided between strategic and non-strategic IS functions (the division was done based on a model of Core IS Capabilities developed as a model for a high-performance IS function).The results supported the relationship between bargaining power and IS outsourcing. Results for asset specificity and corporate strategy needs were significant in the opposite direction than hypothesized. No other findings were significant. These results suggest that hospital system managers are likely not considering significant factors when making sourcing decisions, including the relative strategic value of the functions they are outsourcing. This study contributes to the limited body of knowledge surrounding IS sourcing behavior in the health care sector. Future research should examine the effect of cost on IS sourcing decisions, and consider the use of alternative theoretical frameworks, particularly Institutional Theory.

Although prior research has found differences in costs and financial performance across different types of hospital systems, there has been no systematic study of variations in patient quality of care or safety indicators across different systems. Our study examines whether five main types of health systems - centralized (CHS), centralized physician/insurance (CPIHS), moderately centralized (MCHS), decentralized (DHS), and independent (IHS) - as well as other hospital characteristics are associated with differences in quality of patient care. Data were assembled for 6 years (1995 - 2000) from multiple sources. We used 4 AHRQ risk adjusted inpatient quality indicators (IQIs) and 5 risk-adjusted patient safety indicators (PSIs) as dependent variables. Random effects models were used in the analysis.It was found that the IQI and PSI models have different patterns. In the IQI models, CHS hospitals have lower AMI, CHF, Stroke, and Pneumonia mortality rates than hospitals in other system types. The PSI models did not indicate any systems' effects on adverse event rates. It was also found that system hospitals' compliance with the JCAHO performance area indicator for availability of patient specific information was associated with lower rates of CHF, Stroke, Pneumonia, and Infection due to medical care.The findings suggest that centralization of hospital structures may improve internal clinical processes by enhancing coordination of activities, communication between providers, timely adjustments of processes of care delivery and structures to external pressures. A lack of systems' effect on adverse events may be explained by a newness of the patient safety issues for hospitals and possible changes in reporting patterns of medical errors after the Institute of Medicine report of 1999. A system hospitals' compliance with the JCAHO performance area indicator may indicate improvements in information and clinical record systems.Hospital systems hold much potential for hospitals in improving patient quality of care and safety because they provide a laboratory for studying the health care process and sharing lessons across multiple institutions. Based on our findings, we recommend that future studies use a combination of IQIs and PSIs when examining institutional quality of care because both provide different and complementary information.

Cancer is the second leading cause of death in the U.S and is more common among the elderly. Since frailty and other age related conditions put the elderly at risk for nursing home care, nursing homes may be the site of care and death for many elderly cancer patients. However, there is a large gap in knowledge concerning cancer treatment of elderly nursing home residents. Since residents rely heavily on their nursing facilities, nursing homes might influence them in their treatment decisions. After controlling for resident and nursing home market characteristics, this study applies Andersen’s Behavioral Model to examine whether nursing home organizational characteristics (nurse staffing level, nursing skill mix, and quality deficiencies) are related to the use of cancer-related medical services for treatment (oncologist visits, cancer-directed surgery, chemotherapy or radiation therapy), and palliative care (pain medication and hospice services) among 1,183 Medicaid and Medicare insured residents of nursing homes in Michigan from 1996-2000. Using data from the Medicare claim file, Medicaid claim file, Michigan tumor registry, Area Resource File, Michigan Medicaid Nursing Home Cost Report, and Online Survey, Certification and Reporting (OSCAR), the study used logistic regression to predict the utilization of cancer-related medical services. The results generally did not support the hypotheses. Nursing staffing level and nursing skill mix did not predict any cancer-related medical service utilization. Cancer care may be more associated with patient characteristics, such as age, which are usually taken into consideration when physicians suggest treatments, than nursing home organizational characteristics. However, relative to residents of nursing homes with the highest quartile of quality deficiencies, residents of nursing homes in the lowest quartile of quality deficiencies had a decreased likelihood of utilizing hospice care (OR=.509; 95%CI=.325 to .796; p=.003). Residents in high quality nursing homes may want to stay in the same place and not transfer to another facility for hospice care while residents in poor quality nursing homes may be motivated to use hospice care. Even though this study did not successfully find that higher nurse staffing level, nursing skill mix, quality of care are associated with greater opportunity of utilizing cancer-related medical services, this study was successful in laying out an empirically sound base framework to analyze this association. Future research can incorporate other states or nationwide data to re-examine this relationship using this study as a base model.

New medical technologies have been viewed as the primary cause of rising health are expenditures by health policy researchers in the United States. Since the mid 1990s, with the prevalence of obesity among Americans, the utilization of bariatric surgery, a medical innovation, has increased rapidly among U.S. hospitals. Generally, current literature only states that the volume of bariatric procedures is increasing dramatically.Very limited studies have been conducted to investigate the growth of bariatric procedures.The objective of this study is (1) to provide a detailed description about the adoption and utilization of bariatric procedure in hospitals in 11 states, and (2) to identify the factors significantly enhancing hospitals to adopt or expand the service of surgical treatment for obesity.A panel design from 1995 to 2000 was employed in this study. Several databases are merged together for the final analysis. The descriptive analyses show that the increase in bariatric procedures is coming from two contributors: the entry of hospitals into the market of bariatric surgery, and the continuous expansion of capacity of offering the surgery by antecedent adopters. The panel analyses provided mixed support to the factors influencing hospitals' decision on adoption or expansion of bariatric surgery. The fixed-effects logit model suggests that hospital size, competition and cumulative adoption rate in a local market are strong predictors of hospitals' adoption of the surgery. The fixed effects model shows that ownership status, payment mix improvement, and cumulative adoption rate in a local market are strongly impact the expansion rate of bariatric procedures in hospitals.These findings suggest determinants enhancing hospitals to adopt or expand the bariatric service program. As the provision of bariatric procedures continues to increase among U.S. hospitals, health plans and policy makers will face greater challenges to balance the demand of patients with morbid obesity and the rapid increasing healthcare expenditures related to the surgery.

Objective: The primary objective of this study was to examine the relationship between hospital structural characteristics and penalization status (penalized or not penalized) in any given hospital acquired condition (HAC) Reduction Program year, FY 2015 through 2018. Structural characteristics included hospital type, case mix index, average daily census, bed size, ownership, disproportionate share percentage, location, and American Nurses Credentialing Center Magnet status. The secondary objective of the study was to determine whether a hospital's penalization status across one or more HAC Reduction Program years is related to quality performance (Total HAC Score) in subsequent years. These objectives were achieved through retrospective, longitudinal, multivariate regression analysis using 4 publicly available data sources. Background: The intention of pay-for-performance programs, including the Centers for Medicare and Medicaid HAC Reduction Program, is to improve the quality of care delivered; however, the theoretical and conceptual basis of pay-for-performance programs and their efficacy in improving care are widely debated. This study was designed to address the gap in knowledge related to the efficacy of value-based reimbursement as a means of motivating providers and organizations to improve healthcare quality. Results: Higher average daily census, disproportionate share percentage, and case mix index were associated with increased likelihood of receiving a penalty in the HAC Reduction Program. Approximately half (49%) of who did not experience a penalty at all improved their Total HAC Score. 51% of hospitals with 1 year of penalty improved their Total HAC Score; 54% of hospitals with 2 years of penalty improved their Total HAC Score; 73% of hospitals with 3 years of penalty improved their Total HAC Score. Conclusions: Despite the inability of some hospitals to meet the benchmark to avoid penalty, the vast majority of hospitals improved their performance over time. This finding holds promise for value-based reimbursement as a means for improving HAC incidence.