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Background: Best practice guidelines from the ACS recommend that patients with open fractures receive antibiotics within 1-hour of presentation. Checklists are effective mechanisms for improving safety and compliance in surgical settings. The current study investigates implementation of a trauma bay checklist, referred to as MARTY, to improve administration of antibiotics in open extremity fractures at a level I trauma center., Methods: Retrospective pre-post design. Population consisted of trauma alerts from January to December 2021 (pre-MARTY) and 2022 (post-MARTY) with open fractures. Outcome measures included antibiotics administered within 1-hour of presentation and in the trauma bay. Bivariate and multivariate analyses were performed to estimate differences in both measures., Results: Our sample included 339 encounters, 174 pre-MARTY and 165 post-MARTY implementation. In the pre-MARTY period, 57.5% of encounters received antibiotics within 1-hour of presentation with 46.0% occurring in the trauma bay, in comparison to 65.5% and 54.5% in the post-MARTY period. In adjusted models, there were greater odds of antibiotic administration within 1-hour (OR = 1.654, P = .038) and prior to leaving the trauma bay (OR = 1.660, P = .041) than pre-MARTY. Encounters with higher-grade fractures were more likely to receive timely antibiotics ( P <=.001)., Discussion: Our study estimates improved compliance of antibiotic administration after implementation of MARTY after adjusting for encounter characteristics. Findings from this study demonstrate improved compliance, but this compliance is often still lacking in those with higher injury severity scores. Findings from this study may be used to inform approaches to further improve trauma care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Heart failure remains a major health problem. But its early diagnosis remains a significant challenge especially among the Paediatric population. A standardized highly sensitive and specific clinical basis of diagnosis requiring no sophisticated equipment readily elicitable at the patients beside at presentation is required., Objective: The study set out to determine the accuracy of a clinical scoring scheme for the diagnosis of heart failure in infants in Ibadan, Nigeria, using B-type natriuretic peptide (BNP) as gold standard., Methodology: Forty-five consecutive infants admitted into the Paediatric wards of the University College Hospital and the Adeoyo Maternity Teaching Hospital in Ibadan, Nigeria were evaluated with the Ibadan Childhood Heart Failure Index (ICHFI) and those with clinical score of > 3 were recruited. Their plasma BNP levels and those of 45 age-matched controls were also measured., Results: There was a strong positive correlation (0.920) between the ICHFI scores and plasma BNP values (rs = 0.920, P = 0.000). At a cut-off score of 2, the ICHFI has a sensitivity of 97.6%, specificity of 89.8%, a positive predictive value of 88.9% and a negative predictive value of 97.8%. The receiver operating characteristic curve plotted had an AUC of 0.978 at the 95% CI, 0.951-1.000; P < 0.001., Conclusion: The ICHFI was found to be an accurate tool for the diagnosis of heart failure in infants and it is therefore recommended for use in primary care and resource challenged settings for the rapid diagnosis, grading of the severity of heart failure and monitoring of treatment.

Background: Approximately 80% of multihospital system member hospitals in U.S. urban areas are clustered with other same-system member hospitals located in the same market area. A key argument for clustering is the potential for reducing service duplication across cluster members., Purpose: The aim of this study is to examine the effects of characteristics of hospital clusters on service duplication within 339 hospital clusters in U.S. metropolitan statistical areas and adjacent counties in 2002., Methodology/approach: Ordinary least squares regression is used to estimate the relationship between cluster characteristics in 1998 and duplicated services per cluster member in 2002., Findings: Duplication is higher in hospitals clusters with higher case mix index and higher bed size range. Duplication is lower in hospital clusters with more members, for-profit ownership, and more geographic dispersion., Practice Implications: Increases in the size of hospital clusters allow more opportunities for service rationalization. For-profit clusters may be innovators in rationalization activity, and they should be studied in this regard. Clusters with a higher case mix, lower geographic dispersion, and hub-and-spoke design (with high bed-size range) may find service reallocation less feasible.

Since the 1990s, rapid consolidation in the hospital sector has resulted in the vast majority of hospitals joining systems that already had a considerable presence within their markets. We refer to these important local and regional systems as "clusters." To determine whether hospital clusters have taken measurable steps aimed at improving the quality of care-specifically, by concentrating low-volume, high-complexity services within selected "lead" facilities-this study examined within-cluster concentrations of high-risk cases for seven surgical procedures. We found that lead hospitals on average performed fairly high percentages of the procedures per cluster, ranging from 59 percent for esophagectomy to 87 percent for aortic valve replacement. The numbers indicate that hospitals might need to work with rival facilities outside their cluster to concentrate cases for the lowest-volume procedures, such as esophagectomies, whereas coordination among cluster members might be sufficient for higher-volume procedures. The results imply that policy makers should focus on clusters' potential for restructuring care and further coordinating services across hospitals in local areas.

This study evaluates the productivity changes for the Veterans Integrated Service Networks (VISNs) that the Veterans Health Administration (VHA) created, comparing performance in 1994 with that in 2004. This represents periods before and after the VHA in 1995 reconfigured provider units into 21 regionalized delivery systems and engaged in other important system innovations. Productivity is measured using the Malmquist Index approach (a longitudinal version of the data envelopment analysis [DEA]). Results indicate that the VISN restructuring generally produced improvements in overall productivity (Malmquist scores) and in VISN adaptations to structural/technological change. They also show that the VISNs overall did not produce "changes in efficiency," reflecting challenges they may have faced in making "technical change" through management adaptations. The findings are consistent with what would be expected, given the major changes that did occur within the VHA in recent years as well as the before and after design used in this study.

Background: The literature points to possible efficiencies in local-hospital-system performance, but little is known about the internal dynamics that might contribute to this. Study of the service arrangements that nearby same-system hospitals have with one another should provide clues into how system efficiencies might be attained., Purposes: The purpose of this research was to better understand the financial and operational effects of service sharing and receiving arrangements among nearby hospitals belonging to the same systems., Methodology/approach: Data are compiled for the 1,227 U.S. urban acute care hospitals that belong to multihospital systems. A longitudinal structural equation model is employed-environmental pressures and organizational characteristics in 1997 are associated with service sharing and receiving arrangements in 2000; service sharing and receiving arrangements are then associated with performance in 2003. Service sharing and receiving are measured by counts of services focal hospitals report that are not duplicated by other-system hospitals within the same county. Linear Structural Relations (LISREL) is used to estimate the model., Findings: In general, market competition from managed care and hospitals influences hospitals to exchange services. For individual hospitals, service sharing has no effects on operational efficiency and financial performance. Service receiving, however, is related to greater efficiencies and higher profits., Practice Implications: The findings underscore the asymmetrical relationships that exist among local-system hospitals. Individual hospitals benefit from service receiving arrangements but not from sharing arrangements-it is better to receive than to give. To the extent that individual hospitals independently determine service capacities, systems may not be able to effectively rationalize service offerings.

Background: The rapid increase in the number of hospitals becoming members of multihospital systems in recent decades has led to the formation of local and regional clusters that have the potential to function as regional systems, a model long advocated as a policy strategy for improving health system performance., Purpose: This study addresses both cluster efficiency and the hierarchical configuration with which hospitals are grouped into clusters., Methodology/approach: This study uses 2004 data from the American Hospital Association Annual Survey multihospital system designations updated to 2005. Efficiencies are measured using data envelopment analysis., Principal Findings: The data envelopment analysis results show that 20 clusters or 5.8% of the sample of 343 clusters are highly efficient; the remaining 323 or 94.2% of the clusters received lesser efficiency scores, averaging 0.73 on the data envelopment analysis measure. The study found the number of beds in the primary hospitals and the percentage of hospitals in the clusters that were urban, two of three variables that reflect patterns of regional model service configurations, to be significantly correlated with cluster efficiency., Conclusion: Results suggest that many hospital clusters have evolved service configurations that are consistent with historically conceptualized regional organizational forms and that the particular regional pattern of distributing service capacities across cluster members might contribute to measured performance. The study also confirms the applicability of data envelopment analysis for assessing the performance of complex, multiunit organizations.

Background: Hospital administrators face challenging decisions about whether to maintain, cut, or add services in response to changes in consumer demand or managed-care pressures. The challenge is heightened for services that are also offered by other hospitals in the local community., Purposes: This study provides evidence on the financial effects of providing services that are also provided by other hospitals in the same county. Its purpose is to help guide administrators and policy makers in assessing the wisdom of service duplication at the local level., Methodology/approach: The unit of analysis is the individual hospital. The study reports data from the 2,204 general acute care hospitals located in counties with more than one hospital. A longitudinal path model is constructed for the years 1998, 2000, and 2002, with environmental and organizational factors from 1998 affecting service duplication in 2000, which in turn affects financial performance in 2002. Maximum likelihood estimation in linear structural relations is used to evaluate the path model and its coefficients., Findings: Hospital competition is associated with higher levels of duplication of inpatient, ancillary, and high-tech services. Duplication of inpatient services is associated with higher costs but also with higher operating margin. Duplication of ancillary services is associated with higher return on assets. Duplicated high-tech services are financial losers for hospitals. Higher levels of duplicated high-tech services are associated with higher cost per day, higher cost per discharge, and lower operating margin., Practice Implications: From the standpoint of financial impact on the hospital, administrators should reexamine the costs and benefits of offering high-tech services that are offered by other providers in the local area. The higher costs may not be offset by revenues. Duplicated ancillary and inpatient services, on the other hand, produce some positive financial returns.

Objective: To assess a widely recognized multihospital system taxonomy., Data Sources: The original taxonomy was based on American Hospital Association (AHA) Annual Survey Data for the years 1994 and 1995 and a reexamined version, on 1998 AHA data., Study Design: We assess the appropriateness of using data designed to capture local hospital/system interrelationships to develop a taxonomy of multihospital systems. DATA ABSTRACTION METHODS: The original and reexamined taxonomies used dichotomous measures of service availability, physician practice ownership, and managed care offerings., Principal Findings: The data and measures used to formulate the taxonomy are not appropriate for classifying multihospital systems at the company level., Conclusions: Taxonomic studies of multihospital systems are very much needed; future taxonomic studies should make clear distinctions between systems at local versus company levels.

In past years, many SHAs formed in local urban markets to better compete for managed care contracts. In response to 1990s forces, these SHAs appear to have adapted product, production, and selling orientations to their markets, aimed at large institutional purchasers of health care. However, health care markets have evolved differently than anticipated. SHAs and their hospitals should now adopt the marketing orientation and focus more on patients and enrollees.

This article examines the association between characteristics of local health care market areas in 1982 and the penetration of new organizational forms in those markets in 1995. The Northeast and South exhibit less organizational form development than the West. Local markets with higher population size and greater density of specialty physicians in 1982 are associated with greater proportions of the markets being covered by a wide variety of organizational forms in 1995.

Background: Throughout the 1990s, hospitals formed local alliances to defend against increasingly powerful hospital rivals and to improve their market positions relative to aggressive and consolidating managed-care organizations. An important consequence of hospitals combining or aligning horizontally at the local level is a significant consolidation of hospital markets., Objective: The aim of this study was to examine the relationship between the type of the local strategic hospital alliances (SHAs), market, environment, and operational factors with financial performance., Methods: The study is a cross-sectional analysis of the financial performance across SHAs in all metropolitan statistical areas in 1995., Results: SHAs with dominant or dominant for-profit (FP) hospitals are not more financially successful than other SHAs. SHAs in markets with high health maintenance organization (HMO) or SHA penetration have lower revenues per case-mix adjusted discharge. The operational characteristics, proportion of teaching members in the SHA, and SHA bed size, result in higher revenues and expenses, whereas greater SHA technical efficiency results in lower costs., Conclusions: Health care organizations are centralizing their operations and governance. This study shows that this trend has not added financial value to hospital collectives, at least at this point in their development.

Acute care hospitals have increasingly been forming local strategic hospital alliances (SHAs), which consume considerable resources in forming and may affect the competitiveness of provider markets. This research shows that SHAs and market factors, which have been perceived to be threats to hospitals, are related to hospitals' financial performance. Among the findings are that SHA members have higher net revenues but that they are not more effective at cost control. Nor do the higher net revenues result in higher cash flow. However, increasing SHA penetration in a market is related to lower net revenues per case. In addition, the penetration of private health maintenance organizations in markets is associated with lower revenues and expenses.

Objective: This study examines the formation of local hospital systems (LHSs) in urban markets by the end of 1992. We argue that a primary reason why hospitals join LHSs is to achieve improved positions of market power relative to threatening rivals., Data Sources/data Collection: The study draws from a unique database of LHSs located in and around metropolitan statistical areas (MSAs). Data were obtained from the 1991 AHA Annual Hospital Survey, updated to the year 1992 using information obtained from multiple sources (telephone contacts of systems, systems lists of hospitals, published changes in ownership, etc.). Other measures were obtained from a variety of sources, principally the 1989 Area Resources File., Study Design: The study presents cross-sectional analyses of rival threats and other factors bearing on LHS formation. Three characteristics of LHS formation are examined: LHS penetration of urban areas, LHS size, and number of LHS members located just outside the urban boundaries. LHS penetration is analyzed across urban markets, and LHS size and rural partners are examined across the LHSs., Principal Findings: Major hypothesized findings are: (1) with the exception of the number of rural partners, all dependent variables are positively associated with the number of hospitals in the markets; the rural partner measure is negatively associated with the number of hospitals; (2) the number of doctors per capita is positively associated with all but the rural penetration measure; and (3) the percentage of the population in HMOs is positively associated with local cluster penetration and negatively associated with rural system partners. Other findings: (1) average income in the markets is negatively associated with all but the rural penetration measure; (2) LHS size and rural partners are both positively associated with nonprofit system ownership; and (3) they are also both negatively associated with the degree to which their multihospital systems are geographically concentrated in a single state., Conclusions: The findings generally support the argument that LHS formation is the product of hospital providers attempting to improve positions of power in their local markets.

Much has been said about the rapid penetration of HMOs. Yet, little attention has been given to another, equally important trend--the consolidation of hospitals into local systems and networks. The number of local hospital clusters has increased significantly in recent years. They are now taking the lead in the majority of markets across the country in forming integrated systems.

Using a sample of 3,000 urban hospitals, this article examines the contributions of selected hospital characteristics to variations in hospital technical efficiencies, while it accounts for multiple products and inputs, and controls for local environmental variations. Four hospital characteristics are examined: hospital size, membership in a multihospital system, ownership, and payer mix (managed care contracts, percent Medicare, and percent Medicaid). Ownership and percent Medicare are consistently found to be related significantly to hospital efficiency. Within the ownership variable, government hospitals tend to be more efficient and for-profit hospitals less efficient than other hospitals. Higher percentages of Medicare payment are negatively related to efficiency. While not consistently significant across all five of the MSA size categories in which the analyses are conducted, possession of managed care contracts, membership in a multihospital system, and size all are consistently related positively to hospital technical efficiency. These variables are also all significant when the hospitals are examined in a combined analysis. Percent Medicaid was not significant in any of the analyses. Implications for policy and the need for methodological work are discussed.

Over the past several decades, the hospital industry has been undergoing a major organizational change that has until now been little examined. Local hospital systems (LHSs) are combinations of two or more hospitals that are in the same company and located in or around the same metropolitan areas in this country. This article presents the first detailed examination of the 402 such systems that have been identified to date. LHSs offer great potential for achieving the cost, quality, and access benefits that are often attributable to regional systems. The degree to which LHSs have attained some basic structural features expected of regional systems are examined. Differences are compared within ownership categories. Issues and challenges facing leaders in the field, should they hope to achieve the potential of regional systems, are discussed.

Using a national data base of urban hospitals, the effect of ownership (government, nonprofit, and for-profit) on the technical efficiency of hospitals was examined. Efficiency scores were computed using a method called data envelopment analysis. Controlling for environmental and hospital characteristics, for-profit hospitals were found somewhat less frequently and government hospitals consistently more frequently in the efficient category. When examining highly inefficient hospitals as a percentage of those receiving inefficient scores, for-profit hospitals appeared to be highly inefficient relative to the other ownership forms. Government and nonprofit hospitals were somewhat indistinguishable from one another regarding their percentages of highly inefficient scores. For-profit hospitals also tended to use supply and capital asset (hospital size) inputs less efficiently, and service and labor inputs more efficiently than hospitals in the other ownership categories.

The strategic behaviors of small multihospital systems have received little attention in the literature despite the fact that small systems are the predominant scale among multihospital systems. This study examines one important aspect of small-system strategic behaviors: the birth-order or evolutionary patterns of hospital acquisition. The evolutionary patterns of acquisition are compared across three strategic model types studied elsewhere: local market, investment, and historical. Using data obtained from a variety of sources, local market model systems are found, in the sequence of acquisition, to be significantly different from the other two model types in terms of relative distances of acquisitions from the initiating or parent hospital, the sizes of acquisition hospitals, the complexity of those hospitals, and the likelihood that the acquisitions are located in rural areas. Differences between parents and acquisitions are also significant, as hypothesized, for the market model system types, although they are not generally significant for the other two model types. The findings suggest that the market model represents an important strategic form that may have important implications for the restructuring of hospital markets.

To survive, let alone thrive, in an increasingly competitive and threatening environment, health care organizations must skillfully manage their dependencies. Such dependencies traditionally have been managed through marketplace exchanges (buying and selling) and ownership relationships (acquisition, merger, and business development). An alternative strategy for designing and managing interorganizational relationships, the quasi-firm, is introduced. The quasi-firm is a hybrid market/ownership arrangement that allows participating organizations to pursue strategically important purposes while simultaneously preserving a high degree of functional and legal autonomy. We suggest that this distinctive interorganizational form is particularly well suited to the features of the new health care marketplace.

The health care industry is characterized at its core by the requirement that the organization and financing of services recognize the concept of need for health care. This requirement is reflected in industry characteristics of market failure, professional dominance of physicians, and public concern with equal access to care. While market failure is decreasing as a result of the emergence of insurance companies as the "new consumers" of health services, physician dominance and concerns for access continue to be strong. These characteristics mean that successful health care organizations will be local-market focused, decentralized, and tied to community cultures. With regard to training of health services administrators, education should be strengthened in the area of strategy development, with appropriate recognition given to the distinctiveness of the health care industry.

This study examined the effect of group affiliation on the use of technical (length of stay, lab tests, etc.) and clinical (rendering and requesting consultations) resources by physicians practicing within a large acute care hospital. Comparisons in use were made between physicians in 1) a prepaid group practice (Colorado Permanente Medical Group [Kaiser]); 2) a fee-for-service group practice; and 3) "unaffiliated" physicians. Patient data were adjusted whenever possible for patient diagnosis and severity. In comparison to other physicians in the hospital, the prepaid group physicians utilized somewhat fewer technical resources, though the results were not statistically significant. Differences in the use of clinical resources were statistically significant, with the fee-for-service group physicians using consulting services the most and prepaid group physicians using them the least. The results indicate that 1) fee-for-service group structures may reinforce the incentives to share in consultation revenues; 2) prepaid group physicians may experience difficulty becoming integrated into the informal structures of physician practice patterns; and 3) the control of groups over the use of technical hospital resources may be substantially weakened when groups do not own or control the hospitals to which they admit their patients.

This study has attempted to determine the relationship between physician domain of practice and their quality of medical care. The study examined whether there was a quality difference in practice either 1) between general practitioners and specialists, or 2) between specialists practicing within and outside their specialty domains. The sample consisted of 454 physicians of Hawaii, involving 18 specialty categories: general practitioners (133) and specialists (321). The study finds that when the general practitioners in this study practices without limitation, their quality of care was not as good as that of the specialists. The study also found that when the specialists practiced outside their specialty areas, the relative quality of their performance declined. The latter finding was sustained even when other important practice and background variables were held constant. The study also discusses its generalizability and policy implications.

Group practice administrators are understandably concerned about the drawbacks and the benefits of formal affiliation of their groups with hospitals or other healthcare institutions. An administrator may wonder: "Should we align ourselves with this particular institution at this time?" or "What kinds of formal arrangements should we enter into?" A good administrator is also a good negotiator, and as such, will try to consider and include the opinions of the other participants in actions involving his group. When considering affiliation with an organization, the administrator will try to understand the drawbacks and the benefits as seen from the other side of the fence.

In response to significant political, governmental, and socioeconomic changes affecting the health care industry, health care organizations are forming a wide variety of loosely coupled interorganizational arrangements. In this article, loosely coupled forms are classified according to the extent to which they are designed to achieve strategic purposes. The quasi firm is defined as a loosely coupled arrangement created to achieve long-lasting and important strategic purposes. Mechanisms that are needed to ensure the continuity of quasi firms are explored, and an agenda for further research is given.

Strategic behaviors of organizations can be classified along two dimensions--growth orientations, or patterns of evolution over time, and action orientations, or strategic aggressiveness in undertaking a particular growth orientation. We create measures of growth and action orientations for small multihospital systems and test the validity of the growth and action orientation typologies, using data from a sample of small multihospital systems. Growth and action orientations do appear to exist independently of each other, and they are related to the ownership status of the systems. Not-for-profit and church-other systems exhibit similar strategic orientations, unlike those of Catholic and investor-owned systems.

The study has attempted to determine how client/colleague dependence influences medical care received by patients. We have tested physician compliance with standards of care according to the degree to which the practice is visible to, and dependent upon, colleagues. Physician performance is measured in terms of compliance with established professional standards in five areas of practice: 1) the quality of medical care; 2) appropriateness of hospital admissions; 3) appropriateness of length of hospital stay; 2) overstays and 5) understays. The sample consisted of 3316 hospital episodes from 22 general hospitals in the state of Hawaii, and the analysis was conducted via multiple-classification analysis (MCA). Specifically, it was found that from the more colleague-dependent physicians, patients received care with: 1) higher scores on an index of quality of care; 2) more justified admissions; 3) more appropriate lengths of stay; 4) fewer overstays; but 5) more understays. These results remained even after adjusting for a number of physician, client and type-of-practice variables. The findings of this study suggest the significant role that the informal structure of physician practice plays in influencing physician performance. Various sociological implications for control of professional practice are discussed in terms of 1) provision of incentives to encourage an increase in the formalization of otherwise informal physician relationships, and 2) tying formal control mechanisms to informal processes of control.