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Objective: To assess trends in hospital price disclosures after the Centers for Medicare & Medicaid Services (CMS) Final Rule went into effect. Data Sources and Study Setting: The Turquoise Health Price Transparency Dataset was used to identify all US hospitals that publicly displayed pricing from 2021 to 2023. Study Design: Price‐disclosing versus nondisclosing hospitals were compared using Pearson's Chi‐squared and Wilcoxon rank sum tests. Bayesian structural time‐series modeling was used to determine if enforcement of increased penalties for nondisclosure was associated with a change in the trend of hospital disclosures. Data Collection/Extraction Methods: Not applicable. Principal Findings: As of January 2023, 5162 of 6692 (77.1%) US hospitals disclosed pricing of their services, with the majority (2794 of 5162 [54.1%]) reporting their pricing within the first 6 months of the final rule going into effect in January 2021. An increase in hospital disclosures was observed after penalties for nondisclosure were enforced in January 2022 (relative effect size 20%, p = 0.002). Compared with nondisclosing hospitals, disclosing hospitals had higher annual revenue, bed number, and were more likely to be have nonprofit ownership, academic affiliation, provide emergency services, and be in highly concentrated markets (p < 0.001). Conclusions: Hospital pricing disclosures are continuously in flux and influenced by regulatory and market factors. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study. DATA SOURCES AND STUDY SETTING: Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration. STUDY DESIGN: Qualitative study of discharge planning using CTA. DATA COLLECTION/EXTRACTION METHODS: Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis. PRINCIPAL FINDINGS: We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task. CONCLUSIONS: A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research.

ObjectiveTo reweight the Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator [PSI] 90) from weights based solely on the frequency of component PSIs to those that incorporate excess harm reflecting patients' preferences for outcome-related health states.Data sourcesNational administrative and claims data involving hospitalizations in nonfederal, nonrehabilitation, acute care hospitals.Study designWe estimated the average excess aggregate harm associated with the occurrence of each component PSI using a cohort sample for each indicator based on denominator-eligible records. We used propensity scores to account for potential confounding in the risk models for each PSI and weighted observations to estimate the "average treatment effect in the treated" for those with the PSI event. We fit separate regression models for each harm outcome. Final PSI weights reflected both the disutilities and the frequencies of the harms.Data collection/extraction methodsWe estimated PSI frequencies from the 2012 Healthcare Cost and Utilization Project State Inpatient Databases with present on admission data and excess harms using 2012-2013 Centers for Medicare & Medicaid Services Medicare Fee-for-Service data.Principal findingsIncluding harms in the weighting scheme changed individual component weights from the original frequency-based weighting. In the reweighted composite, PSIs 11 ("Postoperative Respiratory Failure"), 13 ("Postoperative Sepsis"), and 12 ("Perioperative Pulmonary Embolism or Deep Vein Thrombosis") contributed the greatest harm, with weights of 29.7%, 21.1%, and 20.4%, respectively. Regarding reliability, the overall average hospital signal-to-noise ratio for the reweighted PSI 90 was 0.7015. Regarding discrimination, among hospitals with greater than median volume, 34% had significantly better PSI 90 performance, and 41% had significantly worse performance than benchmark rates (based on percentiles).ConclusionsReformulation of PSI 90 with harm-based weights is feasible and results in satisfactory reliability and discrimination, with a more clinically meaningful distribution of component weights.

Objective: To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence‐based solutions to persistent racial and ethnic inequities in health outcomes. Data Sources and Study Setting: This project was conducted as a component of the Agency for Healthcare Research and Quality's (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government. Study Design: Expert group consensus, informed by stakeholder engagement and targeted evidence review. Data Collection/Extraction Methods: Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQ's 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors' consensus. Principal Findings: Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data‐driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity‐informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross‐cutting themes regarding research workforce and research timelines. Conclusions: As the nation's primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care. [ABSTRACT FROM AUTHOR]

Objective: To provide a research agenda and recommendations to address inequities in access to health care. Data Sources and Study Setting: The Agency for Healthcare Research and Quality (AHRQ) organized a Health Equity Summit in July 2022 to evaluate what equity in access to health care means in the context of AHRQ's mission and health care delivery implementation portfolio. The findings are a result of this Summit, and subsequent convenings of experts on access and equity from academia, industry, and the government. Study Design: Multi‐stakeholder input from AHRQ's Health Equity Summit, author consensus on a framework and key knowledge gaps, and summary of evidence from the supporting literature in the context of the framework ensure comprehensive recommendations. Data Collection/Extraction Methods: Through a stakeholder‐engaged process, themes were developed to conceptualize access with a lens toward health equity. A working group researched the most appropriate framework for access to care to classify limitations identified during the Summit and develop recommendations supported by research in the context of the framework. This strategy was intentional, as the literature on inequities in access to care may itself be biased. Principal Findings: The Levesque et al. framework, which incorporates multiple dimensions of access (approachability, acceptability, availability, accommodation, affordability, and appropriateness), is the backdrop for framing research priorities for AHRQ. However, addressing inequities in access cannot be done without considering the roles of racism and intersectionality. Recommendations include funding research that not only measures racism within health care but also tests burgeoning anti‐racist practices (e.g., co‐production, provider training, holistic review, discrimination reporting, etc.), acting as a convener and thought leader in synthesizing best practices to mitigate racism, and forging the path forward for research on equity and access. Conclusions: AHRQ is well‐positioned to develop an action plan, strategically fund it, and convene stakeholders across the health care spectrum to employ these recommendations. [ABSTRACT FROM AUTHOR]

ObjectiveTo assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes.Data sourcesMultiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data.Study designCross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse.Data collection/extraction methods1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions).Principal findingsFinancial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]).ConclusionsHigher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

ObjectiveTo operationalize constructs from each of the Consolidated Framework for Implementation Research domains and to present psychometric properties within the context of evidence-based approaches for promoting colorectal cancer screening in federally qualified health centers (FQHCs).MethodsData were collected from FQHC clinics across seven states. A web-based Staff Survey and a Clinic Characteristics Survey were completed by staff and leaders (n = 277) from 59 FQHCs.ResultsInternal reliability of scales was adequate ranging from 0.62 for compatibility to 0.88 for other personal attributes (openness). Intraclass correlations for the scales indicated that 2.4 percent to 20.9 percent of the variance in scale scores occurs within clinics. Discriminant validity was adequate at the clinic level, with all correlations less than 0.75. Convergent validity was more difficult to assess given lack of hypothesized associations between factors expected to predict implementation.ConclusionsOur results move the field forward by describing initial psychometric properties of constructs across CFIR domains.

ObjectiveTo identify positive deviant (PD) physician organizations of Accountable Care Organizations (ACOs) with robust performance management systems (PMSYS).Data sourceThird National Survey of Physician Organizations (NSPO3, n = 1,398).Study designOrganizational and external factors from NSPO3 were analyzed.Data collection/extraction methodsLinear regression estimated the association of internal and contextual factors on PMSYS. Two cutpoints (75th/90th percentiles) identified PDs with the largest residuals and highest PMSYS scores.Principal findingsA total of 65 and 41 PDs were identified using 75th and 90th percentiles cutpoints, respectively. The 90th percentile more strongly differentiated PDs from non-PDs. Having a high proportion of vulnerable patients appears to constrain PMSYS development.ConclusionsOur PD identification method increases the likelihood that PD organizations selected for in-depth inquiry are high-performing organizations that exceed expectations.

Objective: To investigate how the health services research (HSR) workforce supply in the United States has evolved over the last 5 years. Data Sources: Membership data of AcademyHealth participants, professional networking websites, PubMed, grant databases, and the Integrated Postsecondary Education Data System. Study Design: Descriptive study comparing size and characteristics of the HSR workforce and graduates identified across multiple data sources. Lists of authors and principal investigators (PIs) were merged and de‐duplicated to identify unique counts. Pearson's chi‐squared test was used to compare characteristics between members and nonmembers of AcademyHealth. Data Collection: Downloaded files from websites and received survey data extracted by AcademyHealth between 2016 and 2020. Principal Findings: The workforce size ranged from 9610 to 28,136, depending on data source. Common employers included universities, government settings, and health systems. Little overlap in employers existed for individuals with potentially competing skill sets. The HSR workforce appeared more diverse than the US adult population, with two to three times greater representation among Asian individuals yet lower representation among Black/African American (30%) and Hispanic (75%) individuals compared with the US population. Exactly 87,721 master's and 3105 doctoral degree graduates from core HSR fields were added over 5 years from public and not‐for‐profit institutions. Including for‐profit institution graduates increased the count by 15% for master's and 30% for doctoral graduates. Hispanic (any race), Black/African American, and multiracial individuals gained representation among core HSR graduates, with for‐profit institutions substantially contributing to the number of Black/African American graduates. Conclusions: The HSR workforce is growing with increasing diversity among its graduates compared with previous studies. Additional work is needed to understand how employers value the contributions of those trained in HSR. Continued efforts are needed to ensure HSR workforce diversity to frame critical research questions and develop programs and policies that reflect the needs of the community. [ABSTRACT FROM AUTHOR]

Objective: To describe a process model for assisting partners in addressing requirements of legislation and review policy analysis, planning, and evaluation design processes and tools. Throughout its 25-year history, the United States Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) program has been a forerunner in partnering with organizational leaders to improve health care. The Foundations of Evidence-based Policymaking Act of 2018 provided new opportunities for QUERI and other implementation scientists to support federal agency leaders in implementing, evaluating, and reporting on congressionally mandated programs. Although implementation scientists have the skills to support partnered implementation and evaluation, these skills must be adapted for congressionally mandated projects as many scientists have limited experience in policy analysis and the intersection of data informing organizational policy, programs, and practices (i.e., evidence-based policy)., Data Sources and Study Setting: During the conduct of four congressionally mandated projects, our national VA QUERI team developed processes and tools to achieve the goals and aims of our VHA partners and to ensure our collective work and reporting met legislative requirements., Study Design: Our process model, program planning, and analysis tools were informed by an iterative process of refining and adapting the tools over a period of six years, spanning the years 2017 to 2023., Principal Findings: Work to support our partners was conducted across three phases: preparation and planning, conducting implementation and evaluation, and developing the congressionally mandated report. The processes and tools we developed within the context of mutually respectful and honest partnerships have been critical to our QUERI center's success in this area., Conclusions: Lessons we learned may help other scientists partnering in VA or other federal agencies to plan, conduct, and report on congressionally mandated projects., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

ObjectiveTo determine how access to percutaneous coronary intervention (PCI) is distributed across demographics.Data sourcesSecondary data from the 2011 American Hospital Association (AHA) survey data combined with 2010 Census.Study designWe calculated prehospital times from 32,370 ZIP codes to the nearest PCI center. We used a multivariate logit model to determine the odds of untimely access by the ZIP code's concentration of vulnerable populations.Data collectionWe used ZIP code-level data on community characteristics from the 2010 Census and supplemented it with 2011 AHA survey data on service-line availability of PCI for responding hospitals.Principal findingsFor approximately 306 million Americans, the median prehospital time to the nearest PCI center is 33 minutes. While 84 percent of Americans live within one hour of a PCI center, the odds of untimely access are higher in low-income (OR: 3.00; 95 percent CI: 2.39, 3.77), rural (8.10; 95 percent CI: 6.84, 9.59), and highly Hispanic communities (2.55; 95 percent CI: 1.86, 3.49).ConclusionsWhile the majority of Americans live within 60 minutes of a PCI center, rural, low-income, and highly Hispanic communities have worse PCI access. This may translate into worse outcomes for patients with acute myocardial infarction.

ObjectiveTo characterize the health risk of enrollees in California's state-based insurance marketplace (Covered California) by metal tier, region, month of enrollment, and plan.Data source/study setting2014 Open-enrollment data from Covered California linked with 2012 hospitalization and emergency department (ED) visit records from statewide all-payer administrative databases.Data collection/extraction methodsChronic Illness and Disability Payment System (CDPS) health risk scores derived from an individual's age and sex from the enrollment file and the diagnoses captured in the hospitalization and ED records. CDPS scores were standardized by setting the average to 1.00.Principal findingsAmong the 1,286,089 enrollees, 120,573 (9.4 percent) had at least one ED visit and/or a hospitalization in 2012. Higher risk enrollees chose plans with greater actuarial value. The standardized CDPS health risk score was 11 percent higher in the first month of enrollment (1.08; 99 percent CI: 1.07-1.09) than the last month (0.97; 99 percent CI: 0.97-0.97). Four of the 12 plans enrolled 91 percent of individuals; their average health risk scores were each within 3 percent of the marketplace's statewide average.ConclusionsProviding health plans with a means to assess the health risk of their year 1 enrollees allowed them to anticipate whether they would receive or contribute payments to a risk-adjustment pool. After receiving these findings as a part of their negotiations with Covered California, health plans covering the majority of enrollees decreased their initially proposed 2015 rates, saving consumers tens of millions of dollars in potential premiums.

ObjectivesNarrative review of the impact of pay-for-performance (P4P) and public reporting (PR) on health care outcomes, including spillover effects and impact on disparities.Principal findingsThe impact of P4P and PR is dependent on the underlying payment system (fee-for-service, salary, capitation) into which these schemes are introduced. Both have the potential to improve care, but they can also have substantial unintended consequences. Evidence from the behavioral economics literature suggests that individual physicians will vary in how they respond to incentives. We also discuss issues to be considered when including patient-reported outcome measures (PROMs) or patient-reported experience measures into P4P and PR schemes.ConclusionWe provide guidance to payers and policy makers on the design of P4P and PR programs so as to maximize their benefits and minimize their unintended consequences. These include involving clinicians in the design of the program, taking into account the payment system into which new incentives are introduced, designing the structure of reward programs to maximize the likelihood of intended outcomes and minimize the likelihood of unintended consequences, designing schemes that minimize the risk of increasing disparities, providing stability of incentives over some years, and including outcomes that are relevant to patients' priorities. In addition, because of the limitations of PR and P4P as effective interventions in their own right, it is important that they are combined with other policies and interventions intended to improve quality to maximize their likely impact.

ObjectiveThe concurrent use of multiple health care systems may duplicate or fragment care. We assessed the characteristics of veterans who were dually enrolled in both the Veterans Affairs (VA) health care system and a Medicare Advantage (MA) plan, and compared intermediate quality outcomes among those exclusively receiving care in the VA with those receiving care in both systems.Data sources/study settingVA and MA quality and administrative data from 2008 to 2009.Study designWe used propensity score methods to test the association between dual use and five intermediate outcome quality measures. Outcomes included control of cholesterol, blood pressure, and glycosylated hemoglobin among persons with coronary heart disease (CHD), hypertension, and diabetes.Data collection/extraction methodsVA and MA data were merged to identify VA-only users (n = 1,637) and dual-system users (n = 5,006).Principal findingsWe found no significant differences in intermediate outcomes between VA-only and dual-user populations. Differences ranged from a 3.2 percentage point (95 percent CI: -1.8 to 8.2) greater rate of controlled cholesterol among VA-only users with CHD to a 2.2 percentage point (95 percent CI: -2.4 to 6.6) greater rate of controlled blood pressure among dual users with diabetes.ConclusionsFor the five measures studied, we did not find evidence that veterans with dual use of VA and MA care experienced improved or worsened outcomes as compared with veterans who exclusively used VA care.

Objective: To examine whether quality of dental care varies by age and over time and whether community‐level characteristics explain these patterns. Data Source: Deidentified medical and dental claims from a commercial insurer from January 2015 to December 2019. Study Design: A retrospective cohort study. The primary outcome was a composite quality score, derived from seven dental quality measures (DQMs), with higher values corresponding to better quality. Hierarchical regression models identified person‐ and zip code–level factors associated with the quality. Data Collection/Extraction Methods: Continuously enrolled US dental insurance beneficiaries younger than 21 years of age. Principal Findings: Quality was assessed for 4.88 million person‐years covering 1.31 million persons. Overall quality slightly improved over time, mostly driven by substantial improvements among children aged 0–5 years by 0.153 points/year (95% confidence interval [CI]:0.151, 0.156). Quality was poorest and declined over time among adolescents with only 20.5% of DQMs met as compared to 42.6% among aged 0–5 years in 2019. Dental professional shortage, median household income, percentages of African Americans, unemployed, and less‐educated populations at the zip code level were associated with the composite score. Conclusion: Quality of dental care among adolescents remains low, and place of residence influenced the quality. Increasing the supply of dentists and oral health promotion strategies targeting adolescents and low‐performing localities should be explored. [ABSTRACT FROM AUTHOR]

ObjectiveTo illustrate methodological considerations when assessing the relationship between patient care experiences and mortality.Data sourceMedical Expenditure Panel Survey data (2000-2005) linked to National Health Interview Survey and National Death Index mortality data through December 31, 2006.Study designWe estimated Cox proportional hazards models with mortality as the dependent variable and patient experience measures as independent variables and assessed consistency of experiences over time.Data extraction methodsWe used data from respondents age 18 or older with at least one doctor's office or clinic visit during the year prior to the round 2 interview. We excluded subjects who died in the baseline year.Principal findingsThe association between overall care experiences and mortality was significant for deaths not amenable to medical care and all-cause mortality, but not for amenable deaths. More than half of respondents were in a different care experience quartile over a 1-year period. In the five individual experience questions we analyzed, only time spent with the patient was significantly associated with mortality.ConclusionsDeaths not amenable to medical care and the time-varying and multifaceted nature of patient care experience are important issues to consider when assessing the relationship between care experience and mortality.

ObjectivesEight grant teams used Agency for Healthcare Research and Quality infrastructure development research grants to enhance the clinical content of and improve race/ethnicity identifiers in statewide all-payer hospital administrative databases.Principal findingsGrantees faced common challenges, including recruiting data partners and ensuring their continued effective participation, acquiring and validating the accuracy and utility of new data elements, and linking data from multiple sources to create internally consistent enhanced administrative databases. Successful strategies to overcome these challenges included aggressively engaging with providers of critical sources of data, emphasizing potential benefits to participants, revising requirements to lessen burdens associated with participation, maintaining continuous communication with participants, being flexible when responding to participants' difficulties in meeting program requirements, and paying scrupulous attention to preparing data specifications and creating and implementing protocols for data auditing, validation, cleaning, editing, and linking. In addition to common challenges, grantees also had to contend with unique challenges from local environmental factors that shaped the strategies they adopted.ConclusionsThe creation of enhanced administrative databases to support comparative effectiveness research is difficult, particularly in the face of numerous challenges with recruiting data partners such as competing demands on information technology resources. Excellent communication, flexibility, and attention to detail are essential ingredients in accomplishing this task. Additional research is needed to develop strategies for maintaining these databases when initial funding is exhausted.

OBJECTIVE: This study examined variation in the implementation of Californias Full Service Partnerships (FSPs), which are supported housing programs that do whatever it takes to improve outcomes among persons with serious mental illness who are homeless or at risk of homelessness. DATA SOURCES/SETTING: Ninety-three FSPs in California. STUDY DESIGN: A mixed methods approach was selected to develop a better understanding of the complexity of the FSP programs. The design structure was a combined explanatory and exploratory sequential design (qual→QUAN→qual) where a qualitative focus group was used to develop a quantitative survey that was followed by qualitative site visits. The survey was used to describe the breadth of variation based on fidelity to the Housing First model, while the site visits were used to provide a depth of information on high- versus low-fidelity programs. PRINCIPAL FINDINGS: We found substantial variation in implementation among FSPs. Fidelity was particularly low along domains related with housing and service philosophy, indicating that many FSPs implemented a rich array of services but applied housing readiness requirements and did not adhere to consumer choice in housing. CONCLUSIONS: There remains room for improvement in the recovery-orientation of FSPs. Fortunately, we have identified several processes by which program managers and counties can increase the fidelity of their programs.

OBJECTIVE: Study a quality improvement approach for implementing evidence-based employment services at specialty mental health clinics. DATA SOURCES/STUDY SETTING: Semistructured interviews with clinicians and administrators before, during, and after implementation. Qualitative field notes, structured baseline and follow-up interviews with patients, semistructured interviews with patients after implementation, and administrative data. STUDY DESIGN: Site-level controlled trial at four implementation and four control sites. Hybrid implementation-effectiveness study with mixed methods intervention evaluation design. DATA COLLECTION/EXTRACTION METHODS: Site visits, in-person and telephone interviews, patient surveys, patient self-assessment. A total of 801 patients completed baseline surveys and 53 clinicians and other clinical key stakeholders completed longitudinal qualitative interviews. PRINCIPAL FINDINGS: At baseline, sites varied in the availability, utilization, and quality of supported employment. Each site needed quality improvement for this service, though for differing reasons, with some needing development of the service itself and others needing increased service capacity. Improvements in knowledge, attitudes, beliefs, and referral behaviors were evident in mid- and postimplementation interviews, though some barriers persisted. Half of patients expressed an interest in working at baseline. Patients at implementation sites were 2.3 times more likely to receive employment services during the study year. Those who had a service visit were more likely to be employed at follow-up than those who did not. CONCLUSIONS: Studies of implementation and effectiveness require mixed methods to both enhance implementation in real time and provide context for interpretation of complex results. In this study, a quality improvement approach resulted in superior patient-level outcomes and improved clinician knowledge, attitudes, and behaviors, in the context of substantial variation among sites.

ObjectiveTo determine whether, following implementation of California's minimum nurse staffing legislation, changes in acuity-adjusted nurse staffing and quality of care in California hospitals outpaced similar changes in hospitals in comparison states without such regulations.Data sources/study settingData from the American Hospital Association Annual Survey of Hospitals, the California Office of Statewide Health Planning and Development, the Hospital Cost Report Information System, and the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project's State Inpatient Databases from 2000 to 2006.Study designWe grouped hospitals into quartiles based on their preregulation staffing levels and used a difference-in-difference approach to compare changes in staffing and in quality of care in California hospitals to changes over the same time period in hospitals in 12 comparison states without minimum staffing legislation.Data collection/extraction methodsWe merged data from the above data sources to obtain measures of nurse staffing and quality of care. We used Agency for Healthcare Research and Quality's Patient Safety Indicators to measure quality.Principal findingsWith few exceptions, California hospitals increased nurse staffing levels over time significantly more than did comparison state hospitals. Failure to rescue decreased significantly more in some California hospitals, and infections due to medical care increased significantly more in some California hospitals than in comparison state hospitals. There were no statistically significant changes in either respiratory failure or postoperative sepsis.ConclusionsFollowing implementation of California's minimum nurse staffing legislation, nurse staffing in California increased significantly more than it did in comparison states' hospitals, but the extent of the increases depended upon preregulation staffing levels; there were mixed effects on quality.

Objective: We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration.Data Sources: Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019.Study Design: Exploratory study using thematic comparative analysis to describe factors that may lead to high performance.Data Collection: We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs.Principal Findings: Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise."Conclusions: Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms. [ABSTRACT FROM AUTHOR]

ObjectiveTo examine the relationship between practices' reported use of patient-centered medical home (PCMH) processes and patients' perceptions of their care experience.Data sourcePrimary survey data from 393 physician practices and 1,304 patients receiving care in those practices.Study designThis is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients' care experience and the use of PCMH processes in the practices where they receive care.Data collectionWe linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.Principal findingsWe found that practices' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.ConclusionsIn our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.

Objective: To present revised core competencies for doctoral programs in health services research (HSR), modalities to deliver these competencies, and suggested methods for assessing mastery of these competencies.Data Sources and Data Collection: Core competencies were originally developed in 2005, updated (but unpublished) in 2008, modestly updated for a 2016 HSR workforce conference, and revised based on feedback from attendees. Additional feedback was obtained from doctoral program directors, employer/workforce experts and attendees of presentation on these competencies at the AcademyHealth's June 2017 Annual Research Meeting.Principal Findings: The current version (V2.1) competencies include the ethical conduct of research, conceptual models, development of research questions, study designs, data measurement and collection methods, statistical methods for analyzing data, professional collaboration, and knowledge dissemination. These competencies represent a core that defines what HSR researchers should master in order to address the complexities of microsystem to macro-system research that HSR entails. There are opportunities to conduct formal evaluation of newer delivery modalities (e.g., flipped classrooms) and to integrate new Learning Health System Researcher Core Competencies, developed by AHRQ, into the HSR core competencies.Conclusions: Core competencies in HSR are a continually evolving work in progress because new research questions arise, new methods are developed, and the trans-disciplinary nature of the field leads to new multidisciplinary and team building needs. [ABSTRACT FROM AUTHOR]

Objective: This study examines the stock and supply including educational pipeline of health services researchers (HSRers) in the United States.Data Sources: National Institutes of Health Research Portfolio Online Reporting Tools, Agency for Healthcare Research and Quality Grants On-Line Database, Health Services Research Projects in Progress, PubMed, Integrated Postsecondary Education Data System, AcademyHealth membership database, and social networks.Study Design: Exploratory descriptive analysis of individuals involved in health services research (HSR) in the United States as of 2015/16.Principal Findings: The HSRer stock grew by 25 percent to 45 percent between 2007 and 2015/16, which was slower than the previous measurement period. The growth in the number of doctoral and master's degrees conferred in core HSR fields has been slowing in recent years. Minorities are underrepresented among HSRers, but this trend may improve over time given the diversity of the educational pipeline. Hispanics, however, were generally underrepresented in the educational pipeline.Conclusions: The average annual growth rate of HSRers appears to be within range of national recommendations. Additional work is needed to assess whether supply of HSRers is meeting demand and to ensure a competent and diverse educational pipeline that meets the needs of an evolving health system. [ABSTRACT FROM AUTHOR]

Objective: To develop an enriched set of core competencies for health services and policy research (HSPR) doctoral training that will help graduates maximize their impact across a range of academic and nonacademic work environments and roles.Data Sources/study Setting: Data were obtained from multiple sources, including literature reviews, key informant interviews, stakeholder consultations, and Expert Working Group (EWG) meetings between January 2015 and March 2016. The study setting is Canada.Study Design: The study used qualitative methods and an iterative development process with significant stakeholder engagement throughout.Data Collection/extraction Methods: The literature reviews, key informant interviews, existing data on graduate career trajectories, and EWG deliberations informed the identification of career profiles for HSPR graduates and the competencies required to succeed in these roles. Stakeholder consultations were held to vet, refine, and validate the competencies.Principal Findings: The EWG reached consensus on six sectors and eight primary roles in which HSPR doctoral graduates can bring value to employers and the health system. Additionally, 10 core competencies were identified that should be included or further emphasized in the training of HSPR doctoral students to increase their preparedness and potential for impact in a variety of roles within and outside of traditional academic workplaces.Conclusion: The results offer an expanded view of potential career paths for HSPR doctoral graduates and provide recommendations for an expanded set of core competencies that will better equip graduates to maximize their impact on the health system. [ABSTRACT FROM AUTHOR]

Objective: To examine factors associated with 0- to 7-day admission after outpatient surgery in high-volume specialties: general surgery, orthopedics, urology, ear/nose/throat, and podiatry.Study Design: We calculated rates and assessed diagnosis codes for 0- to 7-day admission after outpatient surgery for Centers for Medicare and Medicaid Services (CMS) and Veterans Health Administration (VA) dually enrolled patients age 65 and older. We also estimated separate multilevel logistic regression models to compare patient, procedure, and facility characteristics associated with postoperative admission.Data Collection: 2011-2013 surgical encounter data from the VA Corporate Data Warehouse; geographic data from the Area Health Resources File; CMS enrollment and hospital admission data.Principal Findings: Among 63,585 outpatient surgeries in 124 facilities, 0- to 7-day admission rates ranged from 5 percent (podiatry) to 28 percent (urology); nearly 66 percent of the admissions occurred on the day of surgery. Only 97 admissions were detected in the CMS data (1 percent). Surgical complications were diagnosed in 4 percent of admissions. Procedure complexity, measured by relative value units or anesthesia risk score, was associated with admission across all specialties.Conclusion: As many as 20 percent of VA outpatient surgeries result in an admission. Complex procedures are more likely to be followed by admission, but more evidence is required to determine how many of these reflect potential safety or quality problems. [ABSTRACT FROM AUTHOR]

Objective: To develop core competencies for learning health system (LHS) researchers to guide the development of training programs.Data Sources/study Setting: Data were obtained from literature review, expert interviews, a modified Delphi process, and consensus development meetings.Study Design: The competencies were developed from August to December 2016 using qualitative methods.Data Collection/extraction Methods: The literature review formed the basis for the initial draft of a competency domain framework. Key informant semi-structured interviews, a modified Delphi survey, and three expert panel (n = 19 members) consensus development meetings produced the final set of competencies.Principal Findings: The iterative development process yielded seven competency domains: (1) systems science; (2) research questions and standards of scientific evidence; (3) research methods; (4) informatics; (5) ethics of research and implementation in health systems; (6) improvement and implementation science; and (7) engagement, leadership, and research management. A total of 33 core competencies were prioritized across these seven domains. The real-world milieu of LHS research, the embeddedness of the researcher within the health system, and engagement of stakeholders are distinguishing characteristics of this emerging field.Conclusions: The LHS researcher core competencies can be used to guide the development of learning objectives, evaluation methods, and curricula for training programs. [ABSTRACT FROM AUTHOR]

Objective: To document erosion in the New York University Emergency Department (ED) visit algorithm's capability to classify ED visits and to provide a "patch" to the algorithm.Data Sources: The Nationwide Emergency Department Sample.Study Design: We used bivariate models to assess whether the percentage of visits unclassifiable by the algorithm increased due to annual changes to ICD-9 diagnosis codes. We updated the algorithm with ICD-9 and ICD-10 codes added since 2001.Principal Findings: The percentage of unclassifiable visits increased from 11.2 percent in 2006 to 15.5 percent in 2012 (p < .01), because of new diagnosis codes. Our update improves the classification rate by 43 percent in 2012 (p < .01).Conclusions: Our patch significantly improves the precision and usefulness of the most commonly used ED visit classification system in health services research. [ABSTRACT FROM AUTHOR]