The relationship between technical efficiency and quality of care in hospitals is studied in the context of resource availability in hospital organizations. The resource availability of hospitals is conceptualized by organizational slack. An integrated model is developed encompassing the source of organizational slack, its impact on technical efficiency and on quality of care, and its impact on the relationship between efficiency and quality. Organizational threat as an environmental factor affecting the level of slack is measured by the level of competition and regulation. Organizational slack is measured using financial and operational indicators of the hospitals. Technical efficiency is estimated by efficiency "scores generated using the Data Envelopment Analysis. Mortality rates of Medicare patients are used as the proxy for quality of care in individual hospitals. The sample is composed of 832 urban, not-for-profit hospitals in the United States. The data are compiled from the Health Care Finance Administration data set and the American Hospitals Association annual survey data set. Hypotheses are tested using ordinary least squares regression and logistic regression. The analysis reveals that the level of and change in organizational slack have a negative relationship with efficiency and a positive relationship with quality of care. The results also indicate that environmental threat has a negative effect on level of slack, and efficiency has a negative effect on quality of care. The findings are discussed in terms of the theoretical implications for the concept of organizational slack and the implications for health policy and hospital management.

The study purpose is to link hospital structure, represented by each hospital’s professional contingent, service mix, and inpatient capacity; and its environment, characterized by the penetration of managed care enrollees. The secondary purpose is to test the relationship between hospital structural change and subsequent hospital performance. The study employs a non-experimental panel design, with a sample of 1882 community hospitals (service type: general medical and surgical). Environmental variables are measured for the base year 1989. Hospital structural variables are measured for 1989 and 1994, with change variables computed. Performance variables are measured for 1989 and 1995, with change computed for cost measures. Hospital structural change is viewed as a dependent variable related to the environment, as well as an independent variable related to performance. Descriptive data are extracted from the American Hospital Association Annual Survey of Hospitals. Hospital cost performance data are from the Health Care Financing Administration Prospective Payment System Minimum Data Sets. Hospital mortality data for 1989 are from Medicare Hospital Mortality Information. HMO enrollment data are extracted from the Interstudy Edge and aggregated to metropolitan statistical area (MSA) level. Market competition data are from the 1989 Area Resource File. A Herfindahl-Hirschman index (HHI) is calculated for each hospital’s MSA. Analytical hypotheses are tested using ordinary least squares (OLS) technique. Results from Part 1 suggest that where HMO penetration was relatively high, sample hospitals tended to contain growth in their registered nurse (RN) staff between 1989 and 1994. Higher HMO penetration is also associated with more stabilization in occupancy rates, preventive services, and ambulatory workload. In contrast, market competition is associated with changes to a higher Medicare case-mix index (CMI), and increase in ambulatory visits. Results from Part 2 indicate positive associations between increased RN staff and hospital cost growth between 1989 and 1995. Hospitals which did not experience an increased CMI are similarly linked with cost growth. Alternatively, reduction in hospital bedsize is associated with more controlled growth in hospital cost per patient day. Several control variables display noteworthy associations with the variables of interest. Theoretical and management implications for community hospitals are discussed.

The purpose of this study is to examine the determinants of the new entry of an HMO into a Medicare risk contract using a resource dependence—diversification model. This study is conducted through a non-experimental, panel design With one year time lag. An HMO’s market is defined as the service area. The primary sample for this study is composed of 440 HMOS that do not have a Medicare risk contract as of January 1994. Data for the variables are extracted from the 1994 and 1995 InterStudy and Group Health Association of America (GHAA) directories, the 1996 Area Resource File, the 1994 County and City Data Book, the 1993 County Business Patterns. Additional supplementary data on adjusted average per capita cost (AAPCC) and county-level Medicare beneficiaries are obtained from the Health Care Financing Administration. The dependent variable is discrete indicating an HMO’s market entry. Independent variables are grouped into four categories: market structure, resource munificence, market price, and organizational attributes. Twelve hypotheses are tested using multivariate logistic regression. This analysis reveals that HMO enrollment size is a predominant, positive factor in predicting a new market entry. HMOs are also sensitive to the level of AAPCC rates in making a market entry decision. Results from hypothesis testing suggest that competition encourages a new market entry. The importance of resource munificence is not statistically supported. This study demonstrates the appropriateness of a panel design to verify a cause-effect relationship and the applicability of the service area as an HMO’s market. This study also contributes to the theoretical understanding of an HMO’s market entry.

Thesis (MPH) -- University of Limpopo, 2012. / Background: Youth friendly services were introduced in all the ten districts t of Lesotho to meet the adolescents health needs including reproductive health of adolescents. Despite this initiative there is still a high prevalence of teenage pregnancy and human immunodeficiency virus (HIV) infection among young people. Aim: The aim of the study was to investigate the utilization, and factors influencing the utilization of reproductive health services (RHS) among high school adolescents in Thaba-Tseka district of Lesotho. Methodology: This was a quantitative descriptive cross-sectional study. The study population was adolescents aged between 13 -19 years in the two high schools in the district. A total of 800 adolescents were asked to complete a structured, self-administered questionnaire. Descriptive statistics were used to summarise demographics, sexual activity, experience of sexually transmitted infections (STIs), and awareness and use of RHS. The chi-square test was used to identify associations between categorical variables, and binary logistical regression modelling was used to identify significant predictors of utilisation of RHS. Results: The response rate was 97.5% (780/800), but only 723 questionnaires had sufficient data to be analysed. The mean age of respondents was 16.4 years with a standard deviation of 1.7years. Of the respondents, 49.5% (358/723) had been sexually active with the youngest age at sexual debut of 8 years. Of these, 71.5% (256/358) were presently sexually active; 82.4% (295/358) had low overall levels of awareness of RHS; 37.9% (136/358) had ever visited the adolescent health corner (AHC); 34.9% (125/358) reported that there was a place that provided RHS in their local clinic; 57.3% (205/358) had ever used condoms; and 56.7% (203/358) had experienced a STI; Of those presently sexually active, 89.5% (229/256) used some form of contraceptive, with 95.2% (218/229) buying condoms from a retail shop although only 94.0% (205/218) reported using them, while 38.9% (89/229) also obtained them from the AHC. Only 13.3% (27/203) of those who had experienced signs of STI ever visited the AHC for treatment. Of those who knew about RHS, 54.4% (68/125) utilized the services. Statistically significant predictors of RHS utilization were having a friend using RHS (odds ratio [OR] =8.87; P value< 0.001) and access to RHS (OR=7.97; P < 0.001). Participants in higher grades were significantly less likely to use RHS compared to participants in lower grades (OR=0.21; P<0.001). Conclusion: Almost half of the adolescents engage in sexual activity at an early age and RHS are under-utilised, mostly because of lack of access. There is a need to embark on increasing accessibility of RHS among adolescents to promote utilization of RHS.

State and federal aid payments to local governments have grown explosively over the last fifteen years. One reason for this growth is that the donor governments can alter a local government's budget choices through grants. Grants have not remedied social problems, however, because the local governments' responses to grants were not anticipated. Economists have broadened our understanding, but debates remain about the proper modeling of local buur grant impact knowledge. Accordingly, this study examined the effects of thdgeting and, because researchers used aggregated data, gaps exist in oree types of mental health grants on the budget allocations for Oregon counties. The theoretical literature on the expenditure effects of grants was first reviewed. The constrained maximization, median voter, and budget maximization models of local fiscal decision-making were described and then compared as to their predictions about the effects of different grants. It was concluded that too little was known about budgetary processes to use or compare the models' predictions. Empirical studies were then reviewed. Researchers, largely using demand frameworks, found that grants significantly affected local spending and that different grants induced different spending responses. Their estimates of the stimulus differed, though. Moreover, little or no research was undertaken on the employment, wage, and output effects of grants. The theoretical and statistical problems with these studies were examined. These problems were: (1) the misspecification of aid variables; (2) the aggregation of government units and public services; (3) the lack of institutional and political realism. A theoretical model of Oregon counties' expenditure and production decision-making for mental health services was developed based on the insights and criticisms of existing models. The model consists of eleven equations; some describing the "expenditure stage" of the budget process, others describing the "output stage". It was argued that county commissioners make the expenditure decisions, and that mental health administrators make the production decisions. The framework allowed us to examine the effects of mental health grants on expenditures, wages, staff numbers, patient numbers, and output and to study the determinants of grant participation. Using regression analysis, the equations were estimated from the observations for 31 Oregon counties in fiscal year 1975-1976. Ordinary least squares was used in the expenditure and grant participation equations. Two-stage and three-stage least squares were used in the rest. Regressions were run for western and eastern Oregon counties when possible. For all observations, the major findings suggested that a dollar of state matching mental health aid per capita stimulated per capita mental health expenditures by $1.37, increased the professional staff by .556 to .762 persons per 10,000 county residents and increased average professional salaries by $2,173. A dollar of federal matching aid per capita appeared to have an expenditure effect of $1.03, an employment effect of .722, and no salary effect. A dollar of non-matching aid per capita had an estimated expenditure effect of $1.00, an estimated employment effect of .35, and no salary effect. In eastern Oregon, the major findings indicated that the marginal expenditure effect of federal aid was $1.41, the marginal expenditure effect of non-matching aid was $.96, and that state matching aid had no expenditure effect. In western Oregon, a dollar of state matching aid per capita had an estimated expenditure effect of $2.23, a professional employment effect of 1.25, and no significant salary effect. A dollar of non-matching aid per capita had an estimated expenditure effect of $1.67, and no significant employment or salary effects. In all regressions, the mental health grant estimates were not statistically different from one another. Finally, a production function for mental health services was unsuccessfully estimated and discussed. / Graduation date: 1979

Thesis (Ph. D.)--Open University. BLDSC no. DX219994.

Thesis (Ph. D.)--University of Texas at Austin, 2003. / Vita. Includes bibliographical references. Available also from UMI Company.

This commentary is a reflective account of research published over the last eleven years. It highlights the themes underlying the publications and tracks the development of the author's research skills while simultaneously showing the impact of the publications on knowledge in the areas covered. Three themes from the research are highlighted. The first relates to the research participants in the publications who include detained and voluntary psychiatric patients, minority ethnic groups and carers. Members of these groups can all be described as marginalised or disadvantaged and are known to sometimes have poorer experiences of health and health services. Their experiences are the second theme. The commentary then highlights some issues in the research as the third theme, in particular the often unrecognised impact of the methods used and concepts employed on the research findings. Although some limitations of these are described, the commentary demonstrates the complexity of the concepts and issues and suggests that these should be acknowledged more widely. A possible way forward is by greater involvement of service users and altering the research perspectives. The next section discusses the impact of being a contract researcher during a period of greater recognition of the importance of listening to patients and their carers. This has had a bearing on both the research and the author's development as a researcher. The commentary then provides reflections on the individual publications submitted detailing the roles played by the author and recent research in the area. Some overarching ethical issues are also discussed. The ultimate aim of all the research presented here has been to improve the experiences of health service users and it is concluded that in each case it has contributed, even if only in a small way, to this aim whether to the academic literature or more directly to service improvement.

published_or_final_version / Public Health / Master / Master of Public Health

Aims To investigate the impact of organisational change on the delivery of health services in remote and rural Scotland using, as an example, changes in the organisation of out of hours primary care, and to identify the attributes of successful innovation in remote and rural health provision. Methods The thesis comprised a thematic literature review; in depth interviews with key stakeholders, and case studies based in remote communities. Results The literature review identified recurring attributes of successful innovation. Interviews with remote and rural GPs showed that working out of hours had been, or still was, an integral part of life as a GP. Most agreed there had been an impact on family life. Advantages and challenges of remote and rural working were identified; many GPs could not envisage a better way of delivering services. This was contested by managers. There were divergent views of the 2004 GMS contract. The GPs who opted out of 24 hour responsibility experienced a transformational change in working life. All in all, there was a lack of understanding, and trust, between organisations. NHS 24 and Scottish Ambulance Service were criticised. There had been little change in out of hours service delivery since 2005, and the present configuration was seen as expensive and unsustainable. Despite these acknowledged difficulties, the view was that difficult decisions had been avoided, and a long-term solution that fits the area was required. The case studies added detail and contextual understanding of delivery of services. This could vary even within a practice area. Service delivery on islands was different, with a stronger tie between community and practice, governed by transport logistics, and difficult to understand from an outside perspective. Conclusions. The delivery of out of hours services in remote and rural Scotland has been a difficult and contested issue. Context can have different impacts, even within a very small area. Failure to innovate was associated with lack of collaboration, lack of strategy, lack of understanding of local context, and avoidance of difficult decisions. The organisational change literature demonstrated that receptive contexts for change were not present.