The purpose of this prospective study is to examine the effects of differences in utilization controls on HMO enrollees' health, satisfaction with quality of care and access, and disenrollment. Previous studies of alternative care systems have shown that they are able to decrease costs (Luft, 1981; Anderson, Herald, Butler, Kohrman, & Morrison, 1985), but have not examined the organizational structure within the organization that oversees utilization. No prior studies have examined the effects of different types and degrees of utilization controls on the health, satisfaction, and access of enrollees. For this investigation, Williamson's (1975) theory of organizations, transaction costs economics, is used as the analytic framework. It is applicable to a study of utilization controls because it explains the organizational design or "governance structure" adopted to promote economic efficiency. Data for this study comes from the National Medicare Competition Evaluation's (NMCE) initial and follow-up beneficiary surveys and was merged with data about the plans. Data on the utilization controls to which the enrollees were exposed comes from the NMCE case studies prepared about six months after the plans started enrolling Medicare patients. Data on health, satisfaction, and access measures comes from the beneficiary surveys. The surveys were conducted about a year apart; the first one occurring upon enrollment in the HMOs. Separate analyses using ordinary least squares and logit regression techniques were performed for 1,175 continuous enrollees and 376 disenrollees using the merged data. The disenrollees were treated as a distinct group because their leaving the HMO may have been motivated by dissatisfaction with utilization control. The analysis found that exposure to different types and stringency of utilization controls was not associated with changes in enrollees' health. They did affect satisfaction with quality of care and appointment convenience. Disenrollment was significant; 18% of the enrollees left the plans during the study. Utilization controls accounted for 49.2% of the variance in disenrollment from the plans.

har_ass This research focuses on the relationship between hospital acquisition and operational performance, market factors, and organizational factors following the Balanced Budget Act of 1997. Resource dependence and financial theory guided the methodology. According to resource dependence theory, organizations desire to remain autonomous until they are faced with scarce resources. This scarcity of resources is caused by the dynamic interaction with the external environment. Financial theory recognizes the organizations ability to be successful by ensuring access to capital through profitability, strong bond ratings, lines of credit, and equity financing. The Balanced Budget Act of 1997 reduced hospital Medicare reimbursement and will have an influence on hospital acquisition. The following research questions guide this study: • What are the market, operational, and organizational factors that profile the characteristics of hospitals acquired after the Balanced Budget Act? Underlying research questions evaluate whether acquired hospitals are inefficiently managed and operate financially at a loss. They become targets for takeover because they lack the capital to modernize their plant and to expand their size and services. However, acquired hospitals may have a strong market position. • Do acquired hospitals operate at a financial loss? • Do acquired hospitals own aging plant and equipment and lack the financial capital to replace their plant and equipment? • Do acquired hospitals have facilities located in markets with less competition and fewer HMOs? • Do acquired hospitals have smaller facilities and provide fewer services? Given the results of the descriptive statistics and logistic regression, it may be concluded that reductions in Medicare reimbursement have reduced hospital return on assets, and have resulted in fewer hospital acquisitions. On an individual hospital basis, those facilities with lower occupancy rates, fewer services, older facilities and for-profit status are likely targets for hospital acquisition.

Finding more efficient ways to organize and deliver medical care is a major policy and management concern in the United States. High levels of expenditures for administrative and coordinating functions are attributed to the fact that health care systems are not "seamless" and that excessive transaction or friction costs are incurred in the exchanges between providers and purchasers and among providers. Renewed interest in vertical integration as a means to addressed these problems is being explored in the empirical literature, but rigorous theory-based investigations are rare. This study is a theory-based exploration of how hospitals address the "make-or-buy" decision of acquiring nursing home services for patients requiring post-acute stay placement. The purpose of the study is to investigate under what circumstances hospitals chose to undertake formal arrangements to acquire nursing home services for patients to be discharged, rather than simply arranging for each discharge in the "spot market." In some instances this may be long-term contracting or leasing of beds, while in other instances it may mean the hospital acquires or develops its own skill nursing facility--a form of vertical integration. The study adopts Oliver Williamson's transaction cost economics theory as the theoretical basis for the study. This framework argues that the most efficient mode of transacting is determined by analyzing three dimensions of the transaction: uncertainty, frequency, and asset specificity (supplier identity). At higher levels of each of these dimensions, organizations are more likely to observe that "markets fail" and that formal arrangements between buyers and sellers are preferable, with vertical integration representing the "make" versus "buy" option. The study uses data from the American Hospital Association Survey and other sources to identify if and how hospitals have made formal arrangements for nursing home services. It tests ten hypotheses derived from the theory that focus on the three dimensions of transactions and interactions among them. The methodology uses several analytical approaches to establish the validity of the measures of the dimensions, and then tests the hypotheses using multivariate logistic regression to contrast various modes of transaction. The importance of transaction uncertainty and specificity are strongly supported in the findings, while transaction frequency is weakly correlated to higher degrees of integration. The results are consistent with both the theoretical arguments advanced by transaction cost economics and with prior research, which is only available from non-health care applications. The study makes an important, and perhaps unique, contribution to empirically operationalizing and testing a transaction cost economics-based interpretation of the decision to vertically integrate in health care. It also provides useful insight into the need for vertical integration to be selectively adopted as it may not be the most efficient mode of organization in all "make or buy" decision opportunities.

With the increasing focus on patient safety and human error, understanding how practitioners make decisions during critical incidents is important. Despite the move towards evidence-based practice, research shows that much decision making is based on intuition and heuristics (“rules of thumb”). The purpose of this study was to examine and evaluate the methodologic feasibility of a strategy for comparing traditional cognition versus the use of algorithms programmed on a personal digital assistant (FDA) in the management of unanticipated critical events by certified registered nurse anesthetists (CRNAs). A combined qualitative-quantitative methodology was utilized. The quantitative element consists of a pilot study using a cross-over trial design. Two case scenarios were carried out in a full-scale, high fidelity, simulated anesthesia care delivery environment. Four subjects participated in both scenarios, one without and one with a PDA containing a catalog of approximately 30 events with diagnostic and treatment related information in second scenario. Audio—videotaping of the scenarios allowed for definitive descriptive analysis of items of interest, including time to correct diagnosis and definitive intervention. The qualitative approach consisted of a phenomenological investigation of problem solving and perceptions of FDA use and the simulation experience by the participants using “think aloud” and retrospective verbal reports, semi-structured group interviews, and written evaluations. Qualitative results revealed that participants found the PDA algorithms useful despite some minor technical difficulties and the simulated environment and case scenarios realistic, but also described feelings of expectation, anxiety, and pressure. Problem solving occurred in a hypothetico-deductive manner. More hypotheses were considered when using the PDA. Time to correct diagnosis and treatment varied by scenario, taking less time with the PDA for one but taking longer with the PDA for the other, likely due to differences in pace and intensity of the two scenarios. The methodologic investigation revealed several areas for improvement including more precise control of case scenarios. All participants agreed with the value of using high fidelity simulation, particularly for problem solving of critical events, and provided useful information for more effective utilization of this tool for education and research.

Smoke (plume) is produced when tissue is cut or coagulated with lasers or electrosurgery devices during surgery. Research has documented that surgical smoke creates a serious workplace hazard for over 500,000 healthcare workers. Toxic gases create an offensive odor, small particulate matter causes respiratory complications, and pathogens may be transmitted within the surgical smoke to the surgical team. Previous research notes that smoke evacuation recommendations are not being consistently followed by perioperative nurses. The purpose of this study is to determine key indicators that are associated with compliance with smoke evacuation recommendations by perioperative nurses. The Diffusion of Innovation theory by Rogers serves as the model since it describes key indicators for the adoption of an innovation, including individual innovativeness, perceptions of the innovation attributes, and organizational innovativeness. A descriptive explanatory/exploratory study was conducted using a validated and piloted survey that consisted of both expert-generated questions and adaptations of previously proven measures. A population of AORN (Association of periOperative Registered Nurses) staff nurse members who have e-mail addresses (N=20,272) was targeted as the universe. A random sampling consisting of 4000 nurses were invited to respond to a web-based survey during a two-month period. There were 777 completed responses representing a 19.4 percent response rate. The SPSS statistical computer package was employed to analyze the data using frequency/descriptive statistical techniques and bivariate analyses to examine the relationship between the key indicators and compliance with smoke evacuation recommendations. Major findings reveal that specific key indicators influencing compliance include increased knowledge and training, positive perceptions about the complexity of the recommendations, and larger facilities with increased specialization, interconnectedness, and leadership support. The study outcomes are planned to be disseminated via lectures and articles. Promoting a safe surgical environment is a top priority for perioperative nurses. By identifying key predictors that influence compliance with smoke evacuation practices, a better understanding of the many factors that influence perioperative nurse practices is fostered. Nurse training programs can be developed that directly target and address these key predictors so that a safe and healthy surgical environment free from surgical smoke can be promoted.

Performance on proficiency test (PT) surveys provides an objective and consistent evaluation of laboratory quality. The goal of the study, a retrospective review of existing PT results (2003) from six clinical laboratories in northeastern Ohio and western Pennsylvania was to determine the relationship of PT performance to the personnel credentials of the laboratory testing personnel. Predictor variables included the practitioner's major area of study, degree, certification and years of laboratory experience. The study group consisted of 174 testing personnel and 11,689 proficiency-testing results, of which 11,233 were valid and included in the study. Of the 11,233 results, there were 11,120 results graded acceptable (99.0%) and 113 results were unacceptable (1.0%). The most common type of error was a technical problem (35, 31.0%) Logistic regression analysis of the full model (n=11,233, χ2 = 20.416, p=0.002) with all predictors included, showed statistical significance for the predictor, clinical laboratory major (p=0.018). Those individuals without a clinical laboratory major (EXP β = 1.820) were almost twice as likely to produce an unacceptable result when compared to those individuals with a clinical laboratory major. The study supports the hiring of laboratory personnel who have completed a formal clinical laboratory education program. As the laboratory workforce shortage intensifies, the performance of laboratory personnel with limited years of clinical experience or those lacking a clinical laboratory major or educational degree may be important. An opportunity exists for health care facilities to investigate the benefits of clinical laboratory education programs to replenish qualified and experienced laboratory personnel.

New consumer driven health insurance products are designed to contain health care costs by making consumers more accountable for the care they receive through being responsible for more cost sharing, making decisions regarding health care providers they will use, and increasing exposure to and use of health information for services and providers. Potential benefits of consumer driven products include increased information regarding personal health and a more knowledgeable patient base. Potential drawbacks of consumer driven products include negative impacts on consumers with chronic and complex health conditions. The purpose of this study was to ascertain differences in health services utilization and health status for health plan members with diagnoses that are consistent with heart failure, coronary artery disease and/or diabetes mellitus who make the transition from a health plan Health Maintenance Organization (HMO) to a Consumer Driven Health Plan (CDHP). Health plan members who changed plans were compared to those who remained in the HMO during a one year time period (2006). Utilization measures included primary care physician visits, specialist physician visits, inpatient admissions, outpatient procedures and emergency room visits. Health status was measured by member acuity risk scores. Selection bias was partially controlled by including only members who did not have a choice between an HMO or CDHP in the study. Logistic analysis and MANOVA were used to obtain study results. No statistically significant differences in utilization for members in the CDHP were seen for primary care visits, specialist physician visits, inpatient admissions and emergency room visits when compared to members in the HMO. Controlling for age, gender, income level, physician coinsurance levels and acuity, the utilization of outpatient procedures was significantly lower in the CDHP. The independent variable showing significance for all utilization analyses was the 2006 risk score that was used as a proxy for member acuity. Study results for comparison of changes in health status could not be obtained due irregularity in predicted 2007 risk scores for members in the CDHP. In this initial study of the first year of CDHP experience, benefit design seemed to have limited influence on the behavior of individuals. Future studies may include longitudinal analyses and refinement of risk measurement techniques.

Family medicine practices are currently threatened by factors such as poor reimbursement, physician stress, shortage of providers, and difficulties in providing prompt access and reliable continuity of care. The external environment faced by family medicine practices is extremely complex and characterized by high pressure from regulatory sources, decreasing reimbursement levels, an increasing rate of change in technologies and care delivery processes, and increasing patient and community expectations. Over the last several years there have been many efforts in family medicine to respond to the challenges presented by the external environment. The majority of these efforts focus on redesigning the delivery of health care services and improving business functionality at the practice level. These innovations include incorporating a patient-centered team approach to providing care, increasing use of advanced technologies, improving functional office space, emphasizing quality and outcomes, and enhancing practice finances. This study explored innovations in family medicine practices to redesign the delivery of health care services and improve business functionality. This research also examined whether environmental factors and organizational characteristics influence strategies to redesign the practice of family medicine. The study employed an integrated set of theoretical frameworks from organizational sociology in evaluating the environmental influences on innovative efforts. Institutional theory was used to provide a conceptual framework to explain the connection between innovations in family medicine practices and three institutional forces within the environment: coercive forces, mimetic forces, and normative forces. Resource dependency theory was used to explain physician practice motivators for change based on a dependence on scarce financial, human, and information resources. The study utilized multiple secondary data sets to define the external environment and an organizational survey of family medicine practices to understand the utilization of innovations and environmental influences. Descriptive statistics and multivariate analysis were used to reveal innovations and to determine the impact of environmental factors on the implementation of redesign strategies. The study results provide essential information on innovations undertaken by family medicine practices in Virginia and how environmental factors and organizational characteristics influence efforts to redesign.

This study examined the relationships among the variables health literacy, social support, and patient activation. The subjects were 90 elderly, community residing adults meeting the inclusion criteria and who volunteered to participate in the study and completed three survey instruments: the Short Form of Functional Health Literacy (Parker, Baker, Williams & Nurss, 1995); the Medical Outcomes Survey (MOS) Social Support Survey Instrument (Sherboume & Stewart, 1991); the Patient Activation Measure (PAM) Short-Form (Hibbard, Mahoney, Stockard, & Tusler, 2005); and a demographic form. A correlational design was used to test the hypotheses that social support and health literacy are positively related to patient activation. Health literacy was significantly and positively related to patient activation. Multiple regression analysis was used to determine whether health literacy explained a significant proportion of the variance in patient activation. Neither health literacy or social support explained a significant proportion of the variance. Demographic variables of age, level of education, gender, marital status, and self-rated health accounted for a small, but statistically significant proportion of the variance. Implications of these findings include that social support did not have significant effects on patient activation. Health professionals should continue to explore additional directions to ameliorate the negative effects of low health literacy and activate patients, including reactions to health problems.

The goal of this dissertation is to better understand the complex relationship between the stresses encountered by US. service personnel during the Gulf War and eventual physical and psychological health outcomes among its veterans. By developing and validating a stress model using structural equation modeling techniques, it is hoped that knowledge regarding wartime stress and its potential impact on the health of veterans will be gained. This knowledge can be used to guide future policy decisions on how to minimize the deleterious health consequences associated with deployment and combat, as well as furnishing a basis for future studies that examine the link between stress and health outcomes. A structural equation model is developed to test a number of hypotheses concerning the relationship between stress and eventual psychological health and physical health outcomes among Gulf War veterans. A core model is first created to test whether or not physical health is a function of psychological health without stress in the equation. This model then expands to test whether or not physical health is a function of psychological health in light of differences in stressful exposures/experiences encountered by Gulf War veterans. The model finally further expands to test whether or not physical health is a function of psychological health and stressful wartime experiences/exposures adjusting for differences in veterans’ age, gender, race, and marital status. The models theoretical foundation centers on the “Stimulus-based Model of Stress,” developed by Drs. Thomas Holmes and Richard Rahe in the late 1960’s. Holmes and Rahe viewed stressful life events as additive in nature and that the more stress an individual experienced in a period of time, the more likely they were to suffer from a variety of physical and psychological illnesses. They developed a stress scale to measure the stressful life experience so as to predict health outcomes. This study likewise quantified stressful wartime exposures/experiences by creating a stress scale that could measure the stress level of individual veterans. This stress scale was then used to create stress scores of veterans based upon their wartime experiences/exposures. These stress scores were then incorporated into the above structural equation model to determine the effect of wartime stress on veterans’ physical and psychological health outcomes. The dissertation has drawn upon prior research regarding stress and health outcomes in the creation of its stress model. Goodness-of-Fit tests were performed to determine whether the pattern of variances and covariances in the data is consistent with the structural (path) model specified. The model was respecified to obtain a better fit by adding correlated error terms based upon the modification indices and theoretical considerations.