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This research tests the effect of hospital ownership and size on value-based purchasing scores. Representative samples were randomly selected of short-term acute-care hospitals from across the nation and grouped into 3 categories of both ownership and size. The ownership categories are as follows: (1) for-profit, (2) nonprofit, and (3) government. The size categories are as follows: (1) small, 99 beds or fewer; (2) medium, 100 to 249 beds; (3) large, 250 beds or more. Value-based purchasing scores for the 12 process-of-care (PC) measures and the 8 patient experience-of-care (Hospital Consumer Assessment of Healthcare Providers and System [HCAHPS]) measures were calculated and combined into their single total performance score (TPS). The results reveal that for-profit controlled hospitals outperform both nonprofit and government-controlled hospitals in PC measures, HCAHPS measures, and value-based purchasing TPSs. The results also reveal that small hospitals (≤99 beds) outperform both medium hospitals (100-249 beds) and large hospitals (≥250 beds) in PC measures, HCAHPS measures, and TPS. Results are discussed. [ABSTRACT FROM AUTHOR]

The article presents a study which examined if hospital size is associated with in-hospital death of critically adults with an admitting diagnosis of Congestive Heart Failure (CHF). Data from British Columbia Health Database were used in the study. Results showed that the odds ratio for in-hospital death associated with an increasing of the number of hospital beds was 1.12. It concluded that there was no significant difference in the adjusted rate of in-hospital deaths based on the number of acute hospital beds.

Background: Despite numerous indications for perioperative benzodiazepine use, associated risks may be exacerbated in elderly and comorbid patients. In the absence of national utilization data, we aimed to describe utilization patterns using national claims data from total hip/knee arthroplasty patients (THA/TKA), an increasingly older and vulnerable surgical population., Methods: We included data on 1,863,996 TKAs and 985,471 THAs (Premier Healthcare claims data, 2006-2019). Benzodiazepine utilization (stratified by long- and short-acting agents) was assessed by patient- and health care characteristics, and analgesic regimens. Given the large sample size, standardized differences instead of P values were utilized to signify meaningful differences between groups (defined by value >0.1)., Results: Among 1,863,996 TKA and 985,471 THA patients, the utilization rate of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short-acting benzodiazepines, while 7.9% received long-acting benzodiazepines, utilization rates 68.4% and 7.7% in THA, respectively. Benzodiazepine use was particularly more frequent among younger patients (median age [interquartile range {IQR}]: 66 [60-73]/64 [57-71] among short/long-acting compared to 69 [61-76] among nonusers), White patients (80.6%/85.4% short/long-acting versus 75.7% among nonusers), commercial insurance (36.5%/34.0% short/long-acting versus 29.1% among nonusers), patients receiving neuraxial anesthesia (56.9%/56.5% short/long-acting versus 51.5% among nonusers), small- and medium-sized (≤500 beds) hospitals (68.5% in nonusers, and 74% and 76.7% in short- and long-acting benzodiazepines), and those in the Midwest (24.6%/25.4% short/long-acting versus 16% among nonusers) in TKA; all standardized differences ≥0.1. Similar patterns were observed in THA except for race and comorbidity burden. Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (measured in oral morphine equivalents [OMEs]) was substantially higher. This was even more pronounced in patients who received long-acting agents (median OME with no benzodiazepines utilization 192 [IQR, 83-345] vs 256 [IQR, 153-431] with short-acting, and 329 [IQR, 195-540] with long-acting benzodiazepine administration). Benzodiazepine use was also more frequent in patients receiving multimodal analgesia (concurrently 2 or more analgesic modes) and regional anesthesia. Trend analysis showed a persistent high utilization rate of benzodiazepines over the last 14 years., Conclusions: Based on a representative sample, 4 of 5 patients undergoing major orthopedic surgery in the United States receive benzodiazepines perioperatively, despite concerns for delirium and delayed postoperative neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, which may project implications for perioperative pain management., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Background and Purpose: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated., Methods: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage., Results: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], P <0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], P <0.001)., Conclusions: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

To examine the association between patient and hospital characteristics and inferior vena cava filter (IVCF) utilization in patients with venous thromboembolism (VTE).The 2013 to 2014 Nationwide Readmissions Database was used to define a cohort of patients with VTE aged ≥18 after a primary VTE diagnosis. Comorbidities of interest were classified via diagnosis codes and IVCF placement was identified via procedure code. Chi square analysis tested differences between patient and hospital-level characteristics and whether or not IVCFs were placed. A hierarchical logistic regression model estimated the relationship between patient-level factors (demographics, socioeconomic status, comorbidities), hospital-level factors (bed size, teaching status, urbanity) and whether or not IVCFs were placed. Additional models were specified to examine goodness of fit across methodological alternatives.There were 212,395 VTE hospitalizations, with 12.18% (n = 25,877) receiving IVCF placement. There were significant differences between those who did and did not receive IVCF placement; notably, those receiving IVCFs were older (P < .001), had Medicare insurance more than private (P < .001), longer lengths of stay (P < .001), and were in privately owned hospitals (P < .001). IVCF placement remained significantly associated with patient and hospital-level characteristics following multivariate adjustment via hierarchical logistic regression; notably, age >80 (adjusted Odds Ratio [aOR]: 2.53, 95% confidence interval [CI]: 2.25-2.85), ≥13 comorbid conditions (aOR: 3.85, 95% CI: 3.25-4.27), and privately owned hospitals (aOR: 1.21, 95% CI: 1.08-1.36). Optimal goodness-of-fit was achieved with a combination of random effects and patient-level fixed effects.These findings provide evidence that combinations of patient and hospital-level factors are related to whether patients with VTE receive IVCFs.

Objectives: Previous examinations of the relationship between patient experience and patient safety initiatives find that higher patient experience evaluations correspond to reduced incidence of adverse events. Little is known, however, about the impact of hospital organizational characteristics on this relationship. The purpose of this study is to examine the degree to which hospital size moderates the relationship between patient experience and patient safety., Methods: A lagged cross-sectional ordinary least squares regression tests a hypothesis of a diminishing effect of hospital size on the relationship between patient evaluations of their interpersonal care experience and hospital's central-line associated bloodstream infection (CLABSI) is tested on a sample of 1740 US hospitals using data compiled from Hospital Compare and the American Hospital Association., Results: The results find that the magnitude of the relationship between patient experience and patient safety initiatives is diminished as hospital size increases and suggest that care providers' ability to deliver care in a manner that is simultaneously responsive to individual patient needs and preferences and reliable in its avoidance of adverse events is influenced by hospital size. An additional fractional logit is presented, which accounts for restrictions in the dependent variable further support study findings.

Background: Centers for Medicare & Medicaid Services reimbursement is now contingent on quality measures such as patient satisfaction as determined by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). In providing patient-centered care that is guided by patient satisfaction measures, it is critical to understand system-level factors that may influence how patients assess their care experiences. One important system-level influence to consider is hospital size., Methods: HCAHPS scores, number of hospital beds, and nursing magnet status were obtained from publically available Hospital Compare, American Hospital Directory, and Magnet Hospitals Web sites, respectively. An aggregate score for patient satisfaction was created across all domains of the HCAHPS. Multilevel regression modeling was performed to examine the associations between hospital size and HCAHPS aggregate and individual dimensions., Results: Hospital size was significantly associated with patient satisfaction such that larger size was associated with lower satisfaction (β = -.312, P < .001). Hospital size was most strongly associated with less patient satisfaction on the following HCAHPS items: "receiving help as soon as needed" (β = -.441, P < .001), "room and bathroom cleanliness" (β = -.286, P < .001), and doctor communication (β = -.213, P < .001), whereas nurse communication (β = .194, P < .001) was the one modifiable dimension that was associated with more favorable ratings in larger hospitals. Magnet nursing designation was significantly associated with larger hospital size (P < .001)., Conclusion: Patient satisfaction scores may be lower in large hospitals because of patients' perceptions of hospital cleanliness, receiving help on time, and doctor communication. Focusing on improving these factors may improve patient satisfaction scores for larger hospitals.

Objective: To assess whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and survival for ovarian cancer., Methods: We used the National Cancer Database to perform a retrospective cohort study of women with ovarian cancer from 2004 to 2013. Hospitals were stratified by annual case volume into quintiles (2 or less, 2.01-5, 5.01-9, 9.01-19.9, 20 cases or greater) and by adherence to ovarian cancer quality metrics into quartiles. Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to the quality metrics., Results: A total of 100,725 patients at 1,268 hospitals were identified. Higher volume hospitals were more likely to adhere to the quality metrics. Both 2- and 5-year survival increased with hospital volume and with adherence to the measured quality metrics. For example, 2-year survival increased from 64.4% (95% CI 62.5-66.4%) at low-volume to 77.4% (95% CI 77.0-77.8%) at high-volume centers and from 66.5% (95% CI 65.5-67.5%) at low-quality to 77.3% (95% CI 76.8-77.7%) at high-quality hospitals (P<.001 for both). For each hospital volume category, survival increased with increasing adherence to the quality metrics. For example, in the lowest volume hospitals (two or less cases annually), adjusted 2-year survival was 61.4% (95% CI 58.4-64.5%) at hospitals with the lowest adherence to quality metrics and rose to 65.8% (95% CI 61.2-70.8%) at the hospitals with highest adherence to the quality metrics (P<.001). However, lower volume hospitals with higher quality scores still had survival that was lower than higher volume hospitals., Conclusion: Although both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer, low-volume hospitals that provide high-quality care still have survival rates that are lower than high-volume centers.

Study Design: Cross-sectional study using data from the Health Care Cost and Utilization Project Kids' Inpatient Database., Objective: Blood loss during spinal fusion surgery may lead to the need for transfusion. Preoperative identification of patient-related, procedure-related, or hospital-related risk factors for blood transfusion would allow for implementation of interventions designed to control excessive bleeding., Summary of Background Data: Several studies have analyzed predictors associated with transfusion in spinal fusion. Identified predictors include age, female sex, anemia, comorbidities, number of fusion levels, osteotomy, and greater hospital volume. There have been few studies examining these predictors in children undergoing spinal fusion., Methods: Using Kids' Inpatient Database data, univariate and multivariate logistic regression was used to calculate unadjusted and adjusted odds ratios (aOR). P values of less than 0.05 were considered statistically significant., Results: We identified 9538 pediatric hospitalizations (patients <21 yr) with spinal fusion in 2009. Overall, 25.1% were associated with blood transfusion. The following factors were associated with transfusions: female sex (aOR 1.14, P = 0.023), black race (aOR 1.35, P = 0.005), length of hospital stay (aOR 1.03, P < 0.001), anterior approach/lumbar segment (aOR 2.11, P = 0.011) and posterior approach/lumbar segment (aOR 2.75, P < 0.001) compared with anterior approach/cervical segment, midlength fusion (aOR 1.71, P < 0.001), and long length fusion (aOR 2.85, P < 0.001) compared with short length. Higher transfusion rates were observed in patients with complications of fever and hematoma but not wound infection., Conclusion: This study showed significant patient-, procedure-, and hospital-related predictors of allogeneic and autologous blood transfusion in spinal fusion in the pediatric age group. Higher health care resource utilization of length of stay and additional procedures are directed toward care of this transfused subgroup. Therapies to reduce blood loss and transfusion requirement are necessary for this pediatric population., Level of Evidence: 4.

Background: Anesthesiologists are frequently involved in efforts to meet perioperative quality metrics. The degree to which hospitals compete on publicly reported quality measures, however, is unclear. We hypothesized that hospitals in more competitive environments would be more likely to compete on quality and thus perform better on such measures. To test our hypothesis, we studied the relationship between competition and quality in hospitals providing procedural cardiac care and participating in a national quality database., Methods: For hospitals performing heart valve surgery (HVS) and delivering acute myocardial infarction (AMI) care in the Hospital Compare database, we assessed the degree of intrahospital competition using both geographical radius and federally defined metropolitan statistical area (MSA) to determine the degree of intrahospital competition. For each hospital, we then correlated the degree of competition with quality measure performance, mortality, patient volume, and per-patient Medicare costs for both HVS and AMI., Results: Six hundred fifty-three hospitals met inclusion criteria for HVS and 1898 hospitals for AMI care. We found that for both definitions of competition, hospitals facing greater competition did not demonstrate better quality measure performance for either HVS or AMI. For both diagnoses, competition by number of hospitals correlated positively with cost: partial correlation coefficients = 0.40 (0.42 for MSA) (P < 0.001) for HVS and 0.52 (0.47 for MSA) (P < 0.001) for AMI., Conclusions: An analysis of the Hospital Compare database found that competition among hospitals correlated overall with increased Medicare costs but did not predict better scores on publicly reported quality metrics. Our results suggest that hospitals do not compete meaningfully on publicly reported quality metrics or costs.

Objective: Patient satisfaction with the health care experience has become a top priority for Centers for Medicare and Medicaid Services. With resources and efforts directed at patient satisfaction, we evaluated whether high patient satisfaction measured by HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys correlates with favorable outcomes., Methods: Medical centers were identified from the University HealthSystem Consortium database from 2011 to 2012. Variables included hospital characteristics, process measure compliance, and surgical outcomes. Chi-squared analysis was used to evaluate for variables associated with high patient satisfaction (defined as hospitals that scored above the 50th percentile of top box scores)., Results: We identified 171 hospitals with complete data. The following variables were significantly associated with high overall patient satisfaction: large hospitals, high surgical volume, and low mortality (P < 0.001). Compliance with process measures and patient safety indicators, as well as length of stay, did not correlate with overall satisfaction. The presence of complications (P = 0.491) or increased rate of readmission (P = 0.056) were not found to affect patient satisfaction. Low mortality index was consistently found to be associated with high satisfaction across 9 of 10 HCAHPS domains., Conclusions: We found that hospital size, surgical volume, and low mortality were associated with high overall patient satisfaction. However, with the exception of low mortality, favorable surgical outcomes were not consistently associated with high HCAHPS scores. With existing satisfaction surveys, we conclude that factors outside of surgical outcomes appear to influence patients' perceptions of their care.

Background: A volume-outcome relationship has been found for acute myocardial infarction (AMI); however, the mechanisms underlying the relationship remain unclear. In particular, it is not known whether processes of care are mediators of the volume-outcome relationship, that is, whether the mechanisms underlying the relationship are through processes of care., Objective: We used nationwide population-based data to examine the mediating effects of processes of care on the relationships of physician and hospital volume with AMI mortality., Methods: We analyzed all 6838 ST-elevation myocardial infarction (STEMI) patients admitted in 2008, treated by 740 physicians in 142 hospitals through Taiwan's National Health Insurance Research Database. Multilevel meditational models were performed after adjustment for patient, physician, and hospital characteristics to test the relationships among physician and hospital volume, processes of care, and 30-day STEMI mortality., Results: Physicians with higher volume had higher use of percutaneous coronary intervention and aspirin, and lower mortality in the following year, and the processes of care were mediators of the relationship between physician volume and mortality. Low-volume hospitals had higher mortality in the following year than medium-volume hospitals. In stratified analyses the relationships only existed in nonlarge hospitals., Conclusions: Physicians with high volume perform better on certain processes of care than those with medium and low volume, and have better outcomes for patients with AMI. The processes of care could partly explain the relationship between physician volume and AMI mortality. However, the relationships existed in nonlarge hospitals but not in large hospitals.

Objective: Tracheal intubation in PICUs is associated with adverse tracheal intubation-associated events. Patient, provider, and practice factors have been associated with tracheal intubation-associated events; however, site-level variance and the association of site-level characteristics on tracheal intubation-associated event outcomes are unknown. We hypothesize that site-level variance exists in the prevalence of tracheal intubation-associated events and that site characteristics may affect outcomes., Design: Prospective observational cohort study., Setting: Fifteen PICUs in North America., Subjects: Critically ill pediatric patients requiring tracheal intubation., Interventions: None., Measurement and Main Results: Tracheal intubation quality improvement data were collected in 15 PICUs from July 2010 to December 2011 using a National Emergency Airway Registry for Children with robust site-specific compliance. Tracheal intubation-associated events and severe tracheal intubation-associated events were explicitly defined a priori. We analyzed the association of site-level variance with tracheal intubation-associated events using univariate analysis and adjusted for previously identified patient- and provider-level risk factors. Analysis of 1,720 consecutive intubations revealed an overall prevalence of 20% tracheal intubation-associated events and 6.5% severe tracheal intubation-associated events, with considerable site variability ranging from 0% to 44% tracheal intubation-associated events and from 0% to 20% severe tracheal intubation-associated events. Larger PICU size (> 26 beds) was associated with fewer tracheal intubation-associated events (18% vs 23%, p = 0.006), but the presence of a fellowship program was not (20% vs 18%, p = 0.58). After adjusting for patient and provider characteristics, both PICU size and fellowship presence were not associated with tracheal intubation-associated events (p = 0.44 and p = 0.18, respectively). Presence of mixed ICU with cardiac surgery was independently associated with a higher prevalence of tracheal intubation-associated events (25% vs 15%; p < 0.001; adjusted odds ratio, 1.81; 95% CI, 1.29-2.53; p = 0.01). Substantial site-level variance was observed in medication use, which was not explained by patient characteristic differences., Conclusions: Substantial site-level variance exists in tracheal intubation practice, tracheal intubation-associated events, and severe tracheal intubation-associated events. Neither PICU size nor fellowship training program explained site-level variance. Interventions to reduce tracheal intubation-associated event prevalence and severity will likely need to be contextualized to variability in individual ICUs patients, providers, and practice.

Background: Hospital infection control strategies and programs may not consider control of methicillin-resistant Staphylococcus aureus (MRSA) in nursing homes in a county., Methods: Using our Regional Healthcare Ecosystem Analyst, we augmented our existing agent-based model of all hospitals in Orange County (OC), California, by adding all nursing homes and then simulated MRSA outbreaks in various health care facilities., Results: The addition of nursing homes substantially changed MRSA transmission dynamics throughout the county. The presence of nursing homes substantially potentiated the effects of hospital outbreaks on other hospitals, leading to an average 46.2% (range, 3.3%-156.1%) relative increase above and beyond the impact when only hospitals are included for an outbreak in OC's largest hospital. An outbreak in the largest hospital affected all other hospitals (average 2.1% relative prevalence increase) and the majority (~90%) of nursing homes (average 3.2% relative increase) after 6 months. An outbreak in the largest nursing home had effects on multiple OC hospitals, increasing MRSA prevalence in directly connected hospitals by an average 0.3% and in hospitals not directly connected through patient transfers by an average 0.1% after 6 months. A nursing home outbreak also had some effect on MRSA prevalence in other nursing homes., Conclusions: Nursing homes, even those not connected by direct patient transfers, may be a vital component of a hospital's infection control strategy. To achieve effective control, a hospital may want to better understand how regional nursing homes and hospitals are connected through both direct and indirect (with intervening stays at home) patient sharing.

Background: Organizational studies widely acknowledge the importance of the relationship between CEO's career histories and managerial performance. Although the health care management literature largely explores the role of CEOs, whether and how top managers' career histories affect their own performance remains still unknown in this industry., Purpose: The aim of this study was to investigate the career histories of health care CEOs and to explore their impact on managerial performance., Methodology: Primary data were collected from a sample of 124 CEOs leading health care organizations in the Italian National Health Service in 2008. Biographic data were accessed to gather information about relevant CEOs' demographics and their career histories. The relevance of CEOs' prior experience was considered, taking into account the prominence of health care organizations in which they passed through in their career histories. Regression analyses were employed to assess the impact of CEOs' career histories on their managerial performance., Findings: Top managers already appointed as CEOs were more likely to achieve higher levels of performance. Careers with long tenure within the National Health Service appear to increase managerial performance. Those CEOs who accumulated prior experience in a large number of health care structures and who spent time working at the most prominent hospitals were also more likely to achieve higher levels of managerial performance., Implications: In health care, a CEO's career history does impact his or her managerial performance. Specifically, patterns of career that imply higher mobility across health care organizations are important. Although interorganizational mobility is significant for CEO performance, the same does not hold for mobility across industries. These findings contribute to the current debate about the need for management renovation within health care organizations.

Background: Health care organizations face an increasing demand for strategic change and innovation; however, there are also several barriers to innovation that impede successful implementation., Purposes: We aimed to shed light on key issues of innovation management in hospitals and provide empirical evidence for controlling the size and innovativeness of a hospital's new health service and process portfolio. We show how health care managers could align the need for exploration and exploitation by applying both informal (e.g., employee encouragement) and formal (e.g., analytical orientation and reward systems) organizational mechanisms., Methodology: To develop hypotheses, we integrated the innovation management literature into the hospital context. Detailed information about the innovation portfolio of 87 German hospitals was generated and combined with multirespondent survey data using ratings from management, medical, and nursing directors. Multivariate regression analysis was applied., Findings: The empirical results showed that an analytical approach increased the size of innovation portfolios. Employee encouragement amplified the degree of innovativeness of activities in the portfolio. Reward systems did not have direct effects on the composition of innovation portfolios. However, they adjusted bottom-up employee and top-down strategic initiatives to match with the existing organization, thereby decreasing the degree of innovativeness and enforcing exploitation., Practice Implications: Hospitals should intertwine employee encouragement, analytical approaches, and formal reward systems depending on organizational goals.

Background and Purpose: We evaluated the impact that duration as a primary stroke center (PSC) had on tissue-type plasminogen activator (tPA) utilization for acute ischemic stroke., Methods: A retrospective analysis of the Illinois Hospital Association CompData was performed identifying those patients with primary discharge diagnosis of acute ischemic stroke based on International Classification of Diseases version 9 codes. We assessed utilization of tPA by International Classification of Diseases version 9 procedure code (99.10). We categorized patients as cared for at non-PSC, PSC >1 year before, ≤1 year before, ≤1 year after, and >1 year after certification. We used generalized estimating equations to calculate adjusted odds ratios for tPA utilization by PSC category., Results: Among 119,539 acute ischemic stroke patients (mean age, 72 years; 55.2% women), tPA use was 1.9% but increased by PSC category (P<0.001): (1) non-PSC 0.9%; (2) >1 year before PSC certification 1.4%; (3) ≤1 year before certification 3.2%; (4) ≤1 year after certification 4.3%; and (5) >1 year after certification 6.5%. Adjusting for age, insurance status, admission source, year of study, region of Illinois, and hospital bed size, the odds of tPA utilization increased with advancing stage of PSC certification (highest category: adjusted odds ratio, 2.37; 95% confidence interval, 1.52-3.71)., Conclusions: Although increasing over time, stroke thrombolysis is strongly impacted by the PSC certification process. Rather than waning or stagnating, tPA utilization increases at PSC from the earliest phases of preparation through certification and subsequent maintenance.

Objective: To evaluate the volume-outcome relationship after lung cancer resection using 3 alternative measures of the effect of volume., Summary Background Data: Many studies of lung cancer resection indicate that hospital volume predicts mortality. However, controversy exists regarding the strength and validity of this association. Because thresholds of procedure volume are used to recommend the regionalization of care, investigation of the validity of the volume-outcome relationship is necessary., Methods: Lung cancer resection patients were identified in the 2007 Nationwide Inpatient Sample. Hospital volume was measured using 3 different methods: as a continuous linear function, as a nonlinear function using restricted cubic splines, and as the frequently used method of quintile categories. The statistical significance of the relationship between hospital volume and mortality risk was assessed, adjusted for patient age, comorbid disease, and for correlated events within hospitals., Results: Forty thousand four hundred and sixty lung cancer resection patients from 436 hospitals were identified. All 3 models demonstrated excellent performance characteristics (C index = 0.92, Nagelkerke R = 0.37). No significant association was demonstrated between hospital procedure volume and in-hospital mortality when measured as a linear or nonlinear function using splines. However, a statistically significant relationship was found for volume categorized into quintiles, although its relative contribution to the predictive capacity of the model was very small (likelihood ratio = 2.55, P = 0.04)., Conclusions: The apparent impact of hospital lung cancer resection volume on mortality is dependent on how volume is defined and entered into the regression equation. Hospital lung cancer resection volume is not a predictor of mortality and should not be used as a proxy measure for surgical quality.

Objective: In this community-based study, we assessed the advantages of laparoscopic gastrectomy (LG) and the impact of volume-related hospital characteristics on gastrectomy care., Background: The quality of gastrectomy care and the potential effects of volume-related hospital characteristics on gastrectomy care have not been comprehensively evaluated to date., Methods: We used a Japanese administrative database of 17,761 patients across 258 hospitals delivering both open gastrectomy and LG during 6-month periods in 2006, 2007, and 2008. We examined patient demographics, principal diagnosis, comorbidities, and complications, hospital patient volume, proportion of LG procedures accomplished, teaching status and care processes, length of hospital stay, total charge, and operative time. Multivariate analyses were used to compare LG with open gastrectomy in terms of mortality, complications, operative or postoperative blood transfusion, resource use and operative time., Results: LG was performed in 3,914 (22%) patients and was associated with significantly shorter length of hospital stay, lower total charge, and longer operative time. Higher hospital volume was associated with less mortality, lower frequency of transfusion, shorter length of hospital stay, lower total charge, and shorter operative time. Higher procedures accomplished were associated with fewer complications, higher frequency of transfusion, greater resource use, and longer operative time., Conclusions: Laparoscopic gastrectomy offers significant economic advantages over open gastrectomy. However, LG was associated with increased operative time and required greater blood transfusion volume once indicated, which might drive gastrectomy care to use more prudent approaches in hospitals with higher procedures accomplished rates. Stakeholders should recognize the wide variation in hospital practices, skill training and efficient gastrectomy care, in addition to the volume-quality relationship.

Background and Purpose: Quality of care may be influenced by patient and hospital factors. Our goal was to use multilevel modeling to identify patient-level and hospital-level determinants of the quality of acute stroke care in a stroke registry., Methods: During 2001 to 2002, data were collected for 4897 ischemic stroke and TIA admissions at 96 hospitals from 4 prototypes of the Paul Coverdell National Acute Stroke Registry. Duration of data collection varied between prototypes (range, 2-6 months). Compliance with 8 performance measures (recombinant tissue plasminogen activator treatment, antithrombotics < 24 hours, deep venous thrombosis prophylaxis, lipid testing, dysphagia screening, discharge antithrombotics, discharge anticoagulants, smoking cessation) was summarized in a composite opportunity score defined as the proportion of all needed care given. Multilevel linear regression analyses with hospital specified as a random effect were conducted., Results: The average hospital composite score was 0.627. Hospitals accounted for a significant amount of variability (intraclass correlation = 0.18). Bed size was the only significant hospital-level variable; the mean composite score was 11% lower in small hospitals (≤ 145 beds) compared with large hospitals (≥ 500 beds). Significant patient-level variables included age, race, ambulatory status documentation, and neurologist involvement. However, these factors explained < 2.0% of the variability in care at the patient level., Conclusions: Multilevel modeling of registry data can help identify the relative importance of hospital-level and patient-level factors. Hospital-level factors accounted for 18% of total variation in the quality of care. Although the majority of variability in care occurred at the patient level, the model was able to explain only a small proportion.

Background: Previous research has demonstrated that employment-based benefits are important for the recruitment and retention of nursing assistants (NAs)., Purpose: The objectives of this study were to describe the availability of benefits offered to NAs and to explore the association between nursing home organizational characteristics and NA benefits using the political economy of aging framework., Methodology: Cross-sectional data on 944 nationally representative nursing homes were derived from the 2004 National Nursing Home Survey. Benefits were measured as a composite variable of five NA benefits weighted by cost. A linear regression model was used to examine the relationship between nursing home organizational characteristics and NA benefits., Findings: For-profit/nonchain ownership and Medicaid occupancy were negatively associated with NA benefits. Facility size, not-for-profit ownership (chain or nonchain), occupancy level, nurse staffing level, union involvement, and education of the nursing home administrator were positively associated with NA benefits., Practice Implications: Nursing home organizational characteristics may explain some of the variations in the availability of benefits and may be informative for policy and practice to improve benefits as a potential strategy to recruit and retain NAs. In particular, for-profit, freestanding facilities and facilities with high proportions of Medicaid residents should consider cost-effective initiatives to enhance the benefit package offered to NAs.

Objective: To examine factors that influence the morbidity and mortality of peripartum hysterectomy and analyze the effect of hospital volume on maternal mortality., Methods: We examined women who underwent peripartum hysterectomy at the time of cesarean delivery in a quality and resource utilization database. Procedure-associated intraoperative, perioperative, and postoperative medical complications, length of stay, intensive care unit use, and maternal mortality were analyzed. Hospitals were stratified into tertiles based on procedure volume and complications and compared using adjusted generalized estimating equations. Results are reported as odds ratios., Results: Maternal mortality among the 2,209 women who underwent peripartum hysterectomy was 1.2%. After adjusting for other clinical and demographic factors, perioperative mortality was 71% (odds ratio 0.29, 95% confidence interval 0.10-0.88) lower in women who underwent operation at high-volume hospitals compared with those treated at low-volume facilities. Hospital volume had no effect on the rates of intraoperative injuries, medical complications, length of stay, or transfusion. In contrast, compared with women treated at low-volume centers, patients who underwent operation at high-volume hospitals had a lower incidence of perioperative surgical complications (odds ratio 0.66, 95% confidence interval 0.47-0.93) and a lower rate of intensive care unit usage (odds ratio 0.53, 95% confidence interval 0.34-0.83)., Conclusion: Peripartum hysterectomy is associated with substantial morbidity and mortality. Maternal mortality is lower when the procedure is performed in high-volume hospital settings., Level of Evidence: II.

Background: Contraindications to laparoscopic cholecystectomy (LC) have diminished over the last decade but still conversion rate is about 5% to 6% in elective cases and higher in acute cholecystitis., Aim: The aim of this study was to analyze whether the conversion rate is related to low (100 LC/y) versus high-volume hospitals (HVHs; >300 LC/y)., Methods: From 1999 to 2004, operations were performed in a low-volume hospital (LVH) and a HVH, divided into 3 groups: primary open cholecystectomy (OC), LC, and conversion (CC). These groups were analyzed with regard to indications, intraoperative findings, reason for conversion, and postoperative complications, and compared between the 2 hospitals., Results: In LVHs of the 550 patients who underwent cholecystectomy, 19 were OC (3.5%). Of the 531 patients who were started with laparoscopy, 5.3% (28 patients) were CC. In HVHs of the 1634 patients who underwent cholecystectomy, 82 were OC (5%). Of the 1552 patients who were started with laparoscopy, 5.8% (85 patients) were CC; P=0.7496. Dense adhesions (LVH 35.8% and HVH 37.6%, P=0.8544), severe cholecystitis (LVH 39.8% and HVH 34%, P=0.6199), and difficulties with the anatomy in Calot's triangle (LVH 7.2% and HVH 8.2%, P=0.8531) were the main reasons for conversion. There was no difference in the postoperative complication rate and reoperation rate between a LVH and a HVH., Conclusions: There is no difference in conversion rate in LC in LVHs versus HVHs. The quality of LC and even CC is similar in LVH and HVH.

Hospitals engage in medical referral system relations voluntarily, by virtue of their own service capacities. These capacities include medical technology, equipment supply, and patient management, which are assessed individually by medical institutions in efforts to control costs and maintain efficiency in tertiary hospitals. This study assessed referral networks according to the institutional isomorphism theory of new economic sociology. As a result, the referral networks were shown to exhibit emergent structural hierarchy via cumulative clustering by established year and were not affected by attributive variables such as region, bed number, and year of establishment. In particular, the networks evidenced institutional isomorphism with certain central hospitals. As a consequence, personal indices were shown to decrease in accordance with its period, and only the structural index increased. Normative pressures cause organizations to become hierarchically homogenized, in accordance with the principle of organizational learning in specialized fields. Therefore, normative isomorphism on the basis of public domains should be considered an inherent factor in the development of referral networks.

Introduction: Multiple studies have used administrative datasets to examine the epidemiology of sepsis in general, but the entity of postoperative sepsis has been studied less intensively. Therefore, we undertook an analysis of the epidemiology of postoperative sepsis using the Nationwide Inpatient Sample, the largest in-patient dataset available in the United States., Methods: Elective admissions of patients aged 18 yr or older with a length of stay more than 3 days for any 1 of the 20 most common elective operative procedures were extracted from the dataset for the years 1997-2006. Postoperative sepsis was defined using the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes; severe sepsis was defined as sepsis along with organ dysfunction. Logistic regression was used to assess the significance of temporal trends after adjusting for relevant demographic characteristics, operative procedure, and comorbid conditions., Results: We identified 2,039,776 admissions for analysis. The rate of severe sepsis increased from 0.3% in 1997 to 0.9% in 2006. This trend persisted after adjusting for relevant covariables-the adjusted odds ratio of severe sepsis per year increase in the study period was 1.12 (95% CI, 1.11-1.13; P < 0.001). The in-hospital mortality rate for patients with severe postoperative sepsis declined from 44.4% in 1997 to 34.0% in 2006; this trend also persisted after adjustment for relevant covariables-the adjusted odds ratio per year was 0.94 (95% CI, 0.93-0.95; P < 0.001)., Conclusion: During the 10-yr period that we studied, there was a marked increase in the rate of severe postoperative sepsis but a concomitant decrease in the in-hospital mortality rate in severe sepsis.

The increasing diversification of the nation's population poses significant challenges in providing care that meets the needs of culturally diverse patients. Human resource management plays a vital role in developing a more culturally competent workforce. This exploratory study examines current efforts by human resource directors (HRDs) in Alabama's general hospitals to recruit more diverse candidates, train staff, and make language access resources available. A questionnaire was developed based on the Office of Minority Health's Culturally and Linguistically Appropriate Services standards. The HRDs of the 101 Alabama general hospitals served as the study's target population. A sample of 61 responses, or 60.4% of the population, was obtained. The findings indicate that most HRDs are focusing their efforts on recruiting racially/ethnically diverse candidates and training clerical and nursing staff to care for culturally and linguistically diverse patients. Less effort is being focused on recruiting candidates who speak a different language, and only 44.3% have a trained interpreter on the staff. The HRDs who indicated that they work closely with organizations that provide support to diverse groups were more likely to recruit diverse employees and have racially/ethnically and linguistically diverse individuals in leadership positions. It is crucial that health care organizations take the necessary steps to diversify their workforce to broaden access, improve the quality and equity of care, and capture a greater market share.

Background: Few studies have assessed associations of surgeons' practice volume with processes of care that lead to better outcomes., Objective: We surveyed surgeons treating colorectal cancer to determine whether high-volume surgeons were more likely to collaborate with other physicians in decisions about adjuvant therapies., Subjects and Methods: Surgeons caring for patients with colorectal cancer in multiple regions and health-care organizations were surveyed to assess their volume of colorectal cancer resections and participation in decisions about adjuvant chemotherapy and radiation therapy. We used logistic regression to assess physician and practice characteristics associated with surgical volume and the relation of surgical volume and these other characteristics to collaborative decision-making regarding adjuvant therapies., Results: Of 635 responding surgeons, those who identified themselves as surgical oncologists or colorectal surgeons were more likely than others to report high volume of colorectal cancer resections (P < 0.001), as were those who practiced at a comprehensive cancer center (P = 0.06) and attended tumor board meetings weekly (vs. quarterly or less, P = 0.09). Most surgeons reported a collaborative role in decisions about chemotherapy and radiation therapy. However, in adjusted analyses, higher-volume surgeons more often reported a collaborative role with other physicians in decisions about chemotherapy (P < 0.001) and radiation therapy (P < 0.001)., Conclusions: Higher-volume surgeons are more likely to report collaborating with other physicians in decisions about adjuvant therapies for patients following colorectal cancer surgery. This collaborative decision-making of higher-volume surgeons may contribute to outcome differences by surgeon volume.

Context: Current intensive care unit performance measures include in-hospital mortality after intensive care unit admission. This measure does not account for deaths occurring after transfer to another hospital or soon after discharge and therefore, may be biased., Objective: Determine how transfer rates to other acute care hospitals and early post-discharge mortality rates impact hospital performance assessments using an in-hospital mortality model., Design, Setting, and Participants: Data were retrospectively collected on 10,502 eligible intensive care unit patients across 35 California hospitals between 2001 and 2004., Measures: We calculated the rates of acute care hospital transfers and early post-discharge mortality (30-day overall mortality-30-day in-hospital mortality) for each hospital. We assessed hospital performance with standardized mortality ratios (SMRs) using the Mortality Probability Model III. Using regression models, we explored the relationship between in-hospital SMRs and the rates of hospital transfers or early post-discharge mortality. We explored the same relationship using a 30-day SMR., Results: In multivariable models, for each 1% increase in patients transferred to another acute care hospital, there was an in-hospital SMR reduction of -0.021 (-0.040-0.001). Additionally, a 1% increase in early post-discharge mortality was associated with an in-hospital SMR reduction of -0.049 (-0.142-0.045). Assessing hospital performance based upon 30-day mortality end point resulted in SMRs closer to 1.0 for hospitals at high and low ends of in-hospital mortality performance., Conclusions: Variations in transfer rates and potentially discharge timing appear to bias in-hospital SMR calculations. A 30-day mortality model is a potential alternative that may limit this bias.

Rationale: Moving patients from low-performing hospitals to high-performing hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival., Objective: To characterize the existing critical care network in terms of the pattern of transfers., Methods: In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations., Measurements: We measured the characteristics of the interhospital transfer network and the extent to which intensive care unit patients are referred to each hospital in that network--a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical, and radiologic capabilities., Results: There were 47,820 transfers of critically ill patients among 3308 hospitals. 4.5% of all critical care stays of any length involved an interhospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital positions were associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals' centrality., Conclusions: Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.

Objective: To determine the in-hospital mortality rates for patients undergoing colorectal resection for malignant or benign conditions, and to identify risk factors for in-hospital death, particularly the relationships with surgeon and hospital volume., Background: Although there is strong evidence that complex cancer operations are best performed at specialized high-volume centers and by high-volume surgeons, the relationship between surgeon and hospital volume and perioperative outcomes is less well defined for more common procedures such as colorectal resections, particularly for benign diseases., Methods: We obtained data from the Canadian Institute for Health Information Discharge Abstract Database on all adult patients who underwent colorectal resection between April 1, 2005 and March 31, 2006. We performed a logistic regression to identify variables associated with a higher likelihood of in-hospital death., Results: Twenty-one thousand seventy-four patients underwent colorectal resection, with the majority being elective (59.4%). Malignancy represented the most common indication for resection (56.8%), followed by diverticular disease (16.2%) and inflammatory bowel disease (7.1%). The overall in-hospital mortality rate among patients undergoing colorectal resection was 5.3%. Increased age (adjusted Odds Ratio [OR]: 1.97 per 10 years, P < 0.001), urgent operation (OR: 2.63, P < 0.001), indication for resection (P < 0.001), nature of the surgery (P < 0.001), and several comorbidities were all independently associated with an increased risk of death. Surgeons with higher volumes of colorectal resections achieved significantly lower mortality rates (OR: 0.92 per 20 cases/y, P = 0.003), corresponding to an adjusted mortality rate of 5.6% for surgeons in the bottom decile (1 case per year) compared with 4.5% for surgeons in the top decile (greater than 43 cases per year). Hospital volume was not associated with mortality (OR: 1.00 per 10 cases, P = 0.504)., Conclusions: This large, population-based study suggests that surgeons who perform high volumes of colorectal resections achieve lower in-hospital mortality rates than surgeons with low volumes, whereas the hospital volume does not influence mortality.

Using data from the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, we examined the magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions (ACSCs). An estimated $9.5 billion in charges incurred in rural hospitals nationwide in 2002 was found to be associated with hospitalizations due to ACSCs. Our findings suggest that the smaller a rural hospital, the greater the portion of its financial resources used to treat patients with ACSC. Regional variation in ACSC-related hospital charges is generally consistent with the geographic variation in the population's economic status and primary care physician supply-residents of the South region have the poorest access to primary healthcare. In summary, smaller rural communities spend more of their healthcare resources on avoidable hospital inpatient care than do larger rural communities, leaving smaller rural communities potentially fewer resources to spend on preventive and primary healthcare. Health intervention programs and health policies should be designed to increase access to and utilization of appropriate preventive and primary healthcare in rural areas, especially in small and remote communities.

Background: Long-term nursing home care is primarily funded by out-of-pocket payments and public Medicaid programs. Few studies have explored price growth in nursing home care, particularly trends in the real cost of a year spent in a nursing home., Objectives: To evaluate changes in private and public prices for annual nursing home care from 1977 to 2004, and to compare nursing home price growth to overall price growth and growth in the price of medical care., Research Design: We estimated annual private prices for nursing home care between 1977 and 2004 using data from the National Nursing Home Survey. We compared private nursing home price growth to public prices obtained from surveys of state Medicaid offices, and evaluated the Bureau of Labor Statistics Consumer Price Indexes to compare prices for nursing homes, medical care, and general goods and services over time., Results: Annual private pay nursing homes prices grew by 7.5% annually from $8645 in 1977 to $60,249 in 2004. Medicaid prices grew by 6.7% annually from $9491 in 1979 to $48,056 in 2004. Annual price growth for private pay nursing home care outpaced medical care and other goods and services (7.5% vs. 6.6% and 4.4%, respectively) between 1977 and 2004., Conclusions: The recent rapid growth in nursing home prices is likely to persist, because of an aging population and greater disability among the near-elderly. The result will place increasing financial pressure on Medicaid programs. Better data on nursing prices are critical for policy-makers and researchers.

Background: Current data on the association between surgeon and hospital volumes and patient outcomes after hip fracture surgery is inconclusive. We hypothesized that surgeons and hospitals with higher caseloads of hip fracture care have better outcomes as measured by decreased postoperative complications and mortality, shorter length of stay in the hospital, routine disposition of patients on discharge, and decreased cost of care., Methods: This is a retrospective cohort study using the Nationwide Inpatient Sample database. Data were extracted on 97,894 patients surgically treated for a hip fracture for the years 1988 through 2002. Multiple linear regression models were used to estimate the adjusted association between surgeon and hospital volume and outcomes for femoral neck and pertrochanteric hip fracture care., Results: The in-hospital mortality rate for those patients who had hip fracture fixation by a low-volume surgeon (<7 procedures/yr) was significantly higher than for those whose procedure was performed by a high-volume surgeon (>15 cases/yr) (p = 0.005). The incidence of transfusion, pneumonia, and decubitus ulcer were also higher in those patients managed by a low-volume surgeon (p = <0.05). Conversely, hospital volume was not associated with significant differences in mortality although low-volume hospitals (<57 cases/yr) were associated with higher rates of postoperative infection, pneumonia, transfusion, and nonroutine discharge (p = <0.05). Both low-volume hospitals and surgeons were associated with longer lengths of stay (p = <0.05)., Conclusions: This study provides evidence that surgeon volume, but not hospital volume, is associated with decreased mortality in the treatment of hip fractures. Both surgeon and hospital volume seem to be associated with nonfatal morbidity and length of stay.

Recent reports suggest the need for further study of the impact of organizational characteristics on quality-related activities in health centers. To better understand these issues, a cross-sectional assessment of quality-related activities in Health Resources and Services Administration-funded health centers was conducted using a mailed questionnaire. Associations between the extent and frequency of quality-related activities and organizational characteristics, including location, size, and accreditation status, were examined. In general, the frequency and type of most quality-related activities did not vary greatly by size and location, but differed by accreditation status. The findings can be explained in part by Health Resources and Services Administration/Bureau of Primary Health Care requirements and implementation of their Accreditation Initiative.

Background: Health information technology (HIT) is designed to help reduce medical errors and improve quality of care and efficiency by providing the right information for the right patients in the right place at the right time. Nevertheless, substantial variation currently exists in the adoption of electronic medical records (EMRs) resulting in differences in hospital HIT capacity., Purpose: The purpose of this article is to examine the impact of different types of multihospital system affiliation on EMR adoption in hospitals in the United States., Methodology: A cross-sectional design was used with a sample of 4,017 hospitals in the United States. Secondary data were retrieved from the Health Information and Management Systems Society Analytics Database. Multiple regression analysis was used to examine the impact of multihospital system affiliation on EMR level of adoption., Findings: The mean EMR adoption level varies significantly between independent hospitals and hospitals owned by a system for small hospitals. After adjusting for the number of operating rooms, the number of emergency room visits, and the number of hospital total full-time equivalent staff, small hospitals owned by multihospital systems were associated with 0.25 higher mean EMR adoption level (p < .05) than independent hospitals and no significant relationship was observed for hospitals that were leased/managed by a system. There was no significant effect of multihospital system membership on EMR level of adoption for medium and large hospitals., Practice Implications: Small hospitals owned by multihospital systems had a significantly higher EMR level compared with independent hospitals. These findings have significant implications for small hospitals that are struggling to improve their HIT capacity. Smaller hospitals in ownership arrangements with larger health care systems have an advantage over small independent hospitals in HIT capacity possibly because of the greater availability of capital, access to shared HIT capacity, and other resources including technical expertise.

Context: Although hospital procedure volume is clearly related to operative mortality with many cancer procedures, its effect on late survival is not well characterized., Objective: To examine relationships between hospital volume and late survival after different types of cancer resections., Design: Using the national Surveillance Epidemiology and End Results (SEER)-Medicare linked database (1992-2002), we identified all patients undergoing major resections for lung, esophageal, gastric, pancreatic, colon, and bladder cancer (n = 64,047). Relationships between hospital volume and survival were assessed using Cox proportional hazards models, adjusting for patient characteristics and use of adjuvant radiation and chemotherapy., Study Participants: U.S. Medicare patients residing in SEER regions., Main Outcome Measures: 5-year survival., Results: Although there were statistically significant relationships between hospital volume and 5-year survival with all 6 cancer types, the relative importance of volume varied markedly. Absolute differences in 5-year survival probabilities rates between low-volume hospitals (LVHs) and high-volume hospitals (HVHs) ranged from 17% for esophageal cancer resection (17% vs. 34%, respectively) to only 3% for colon cancer resection (45% vs. 48%). Absolute differences in 5-year survival between LVHs and HVHs fell between these ranges for lung (6%), gastric (6%), pancreatic (5%), and bladder cancer (4%). Volume-related differences in late survival could not be attributed to differences in rates of adjuvant therapy., Conclusions: Along with lower operative mortality, HVHs have better late survival rates with selected cancer resections than their lower-volume counterparts. Mechanisms underlying their better outcomes and thus opportunities for improvement remain to be identified.

Objective: To determine whether hospital site is independently associated with length of intensive care unit (ICU) stay in those patients who die in hospital after experiencing a cardiac arrest., Design: Retrospective cohort study., Setting: Thirty-one Canadian ICUs, all but one being members of the Critical Care Research Network., Patients: All patients admitted to these ICUs after resuscitation from a cardiac arrest., Interventions: None., Measurements and Main Results: Retrospective analysis of prospectively collected clinical data. Using gamma regression with ICU length of stay as the dependent variable, we found the following variables to be independently associated with ICU length of stay: age, gender, Acute Physiology and Chronic Health Evaluation II score, Glasgow Coma Scale score, hospital size, and hospital site., Conclusions: In this cohort of patients admitted to ICU after cardiac arrest, hospital site was strongly associated with ICU length of stay after controlling for patient-specific factors. Variation in processes of care among ICUs may point to opportunities for improvement.

Background: Greater hospital volume has been associated with lower mortality after colorectal cancer surgery. The contribution of surgeon volume to processes and outcomes of care is less well understood. We assessed the relation of surgeon and hospital volume to postoperative and overall mortality, colostomy rates, and use of adjuvant radiation therapy., Methods: From the California Cancer Registry, we studied 28,644 patients who underwent surgical resection of stage I to III colorectal cancer during 1996 to 1999 and were followed up to 6 years after surgery to assess 30-day postoperative mortality, overall long-term mortality, permanent colostomy, and use of adjuvant radiation therapy., Results: Across decreasing quartiles of hospital and surgeon volume, 30-day postoperative mortality ranged from 2.7% to 4.2% (P < 0.001). Adjusting for age, stage, comorbidity, and median income among patients with colorectal cancer who survived at least 30 days, patients in the lowest quartile of surgeon volume had a higher adjusted overall mortality rate than those in the highest quartile (hazard ratio, 1.16; 95% confidence interval, 1.09-1.24), as did patients in the lowest quartile of hospital volume relative to those treated in the highest quartile (hazard ratio, 1.11; 95% confidence interval, 1.05-1.19). For rectal cancer, adjusted colostomy rates were significantly higher for low-volume surgeons, and the use of adjuvant radiation therapy was significantly lower for low-volume hospitals., Conclusions: Greater surgeon and hospital volumes were associated with improved outcomes for patients undergoing surgery for colorectal cancer. Further study of processes that led to these differences may improve the quality of colorectal cancer care.

In a changing world, organizations must change as surely as individuals must change. Recent years have seen an increase in organizational "flattening," the tendency to shrink the organizational structure through the removal of layers in the hierarchy. At present, flattening is especially prevalent in health care, particularly hospitals, as the industry adjusts to various external pressures through mergers, acquisitions, and sometimes closures. Although organizational growth, or "fattening," is usually slow, occurring sometimes imperceptibly over long periods, flattening is usually abrupt and therefore painful. Organizations are trimming down and becoming smaller unto themselves while becoming components of larger entities, health systems. Concurrent with these changes is the proliferation of freestanding provider organizations providing specialized services formerly offered only in the hospital setting. Especially affected are first-line supervisors and middle managers. Those who are fortunate enough to survive reengineering, merger, or organizational flattening will find their roles altered considerably. More work, more employees, more responsibility, more territory to cover overall-these are the lot of the department manager following most of today's organizational adjustments. The manager's primary defense against obsolescence in the new health care environment is to become as multifaceted as possible, recognizing that one's future security lies not in constancy and specialization but rather in flexibility and adaptability.

Objective: To assess whether significant variations in observed cesarean rates in U.S. military hospitals may be attributed to differences in clinical case mix., Methods: Hospital discharge records for births in U.S. military hospitals in 2002 were grouped into mutually exclusive clinical strata to calculate predicted cesarean rates for subgroups defined by maternal race, health plan, hospital location, delivery volume, teaching status, and neonatal intensive care unit (NICU) status. The 95% confidence interval (CI) around each standardized ratio (SR) of the observed-to-predicted cesarean rate was used to assess statistical significance., Results: Observed cesarean rates were significantly higher than predicted rates for small hospitals (23.1% and 20.4%, respectively, SR 1.13, 95% CI 1.08-1.19), teaching hospitals (23.7% and 22.5%, respectively, SR 1.05, 95% CI 1.02-1.08), black women (25.1% and 22.8%, respectively, SR 1.10, 95% CI 1.05-1.14), and other minorities (22.7%, and 21.6%, respectively, SR 1.05, 95% CI 1.01-1.09). No significant differences between observed and predicted cesarean rates were found across hospital locations or NICU status. Significant differences found for non-managed care beneficiaries were attributed to teaching status of the hospitals in which they delivered., Conclusion: Clinical case mix does not adequately account for the relatively high rates of cesarean delivery observed for small hospitals and teaching hospitals and among black women in the study population. Further study is recommended to identify additional clinical and nonclinical factors that should be considered when comparing performance across institutions, health plans, or individual providers.

We apply data envelopment analysis to discharge data from the 115 hospitals in the rural state of a study hospital to answer three questions. We use a case study to investigate the usefulness and limitations of data envelopment analysis for assessing three common questions regarding hospital market capture for elective inpatient surgery. (i) The hospital studied in this paper performs 40% of the neurosurgery and 25% of the inpatient urology surgery in its state. Workloads are twice that of the hospitals with the next largest workloads. In contrast, the hospital performs 9% of its state's cardiac surgery and has a workload half that of the largest volume hospital. The cardiac surgeons want more operating room time, faster turnovers, and capital investment for minimally invasive equipment. Controlling for the distance patients would need to travel for care, would increasing capacity likely increase cardiac surgery workload? (ii) The study hospital has fewer hospitalizations for thoracic surgery than for any other specialty. Is thoracic surgery inpatient workload of 121 lung resections large or small compared with those of orthopedics' 213 hip replacements, urology's 132 nephrectomies, and cardiac surgery's 304 coronary artery bypass grafts? (iii) The hospital's busiest specialty by discharges is orthopedics. How sensitive is the hospital's orthopedic workload to changes in decision making at nearby competing hospitals?

Small hospitals form a vital part of the health care safety net, serving communities that would often otherwise lack acute care. It is, therefore, important to understand how strategies unfold in these organizations. We used semistructured interviews to ask chief executive officers (CEOs) of seven small hospitals in Pennsylvania how they viewed their competitive environments and how their strategies evolved. Systematic semi-inductive analyses of these data reveal two major themes. First, CEOs of small hospitals perceive highly dynamic and hostile environments but do not stress complexity. Second, continual negotiations with key stakeholders facilitate the translation of CEOs' insights into organizational strategies.

Unlabelled: We studied when allocated, but unfilled, operating room (OR) time of surgical services should be released to maximize OR efficiency. OR time was allocated for two surgical suites based on OR efficiency. Then, we analyzed real OR schedules. We added new hypothetical cases lasting 1, 2, or 3 h into OR time of the service that had the largest difference between allocated and scheduled cases (i.e., the most unfilled OR time) 5 days before the day of surgery. The process was repeated using the updated OR schedule available the day before surgery. The pair-wise difference in resulting overutilized OR time was calculated for n = 754 days of data from each of the two surgical suites. We found that postponing the decision of which service gets the new case until early the day before surgery reduces overutilized OR time by <15 min per OR per day as compared to releasing the allocated OR time 5 days before surgery. These results show that when OR time is released has a negligible effect on OR efficiency. This is especially true for ambulatory surgery centers with brief cases or large surgical suites with specialty-specific OR teams. What matters much more is having the correct OR allocations and, if OR time needs to be released, making that decision based on the scheduled workload., Implications: Provided operating room (OR) time is allocated and cases are scheduled based on maximizing OR efficiency, then whether OR time is released five days or one day before the day of surgery has a negligible effect on OR efficiency.

Unlabelled: Productivity measurements based on "per operating room (OR) site" and "per case" are not influenced by staffing ratios and have permitted meaningful comparisons among small samples of both academic and private-practice anesthesiology groups. These comparisons have suggested that a larger sample would allow for clinical groups to be compared using a number of different variables (including type of hospital, number of OR sites, type of surgical staff, or other organizational characteristics), which may permit more focused benchmarking. In this study, we used such grouping variables to compare clinical productivity in a broad survey of academic anesthesiology programs. Descriptive, billing, and staffing data were collected for 1 fiscal or calendar year from 37 academic anesthesiology departments representing 58 hospitals. Descriptive data included types of surgical staff (e.g., academic versus private practice) and hospital centers (e.g., academic medical centers and ambulatory surgical centers [ASCs]). Billing and staffing data included total number of cases performed, total American Society of Anesthesiologists units (tASA) billed, total time units billed (15-min units), and daily number of anesthetizing sites staffed (OR sites). Measurements of total productivity (tASA/OR site), billed hours per OR site per day (h/OR/d), surgical duration (h/case), hourly billing productivity (tASA/h), and base units/case were compared. These comparisons were made according to type of hospital, number of OR sites, and type of surgical staff. The ASCs had significantly less tASA/OR site, fewer h/OR/d, and less h/case than non-ASC hospitals. Community hospitals had significantly less h/OR/d and h/case than academic medical centers and indigent hospitals and a larger percentage of private-practice or mixed surgical staff. Academic staffs had significantly less tASA/h and significantly more h/case. tASA/h correlated highly with h/case (r = -0.68). This study showed that the hospitals at which academic anesthesiology groups provide care are not all the same from a clinical productivity perspective. By grouping based on type of hospital, number of OR sites, and type of surgical staff, academic anesthesiology departments (and hospitals) can be better compared by using clinical productivity measurements based on "per OR site" and "per case" measurements (tASA/OR, billed h/OR/d, h/case, tASA/h, and base/case)., Implications: Organizational factors, including type of hospital, number of operating rooms, and type of surgical staff, influence the clinical productivity of academic anesthesiology departments. Reporting quartile data by focused grouping variables allows anesthesiology groups to compare their clinical productivity with groups practicing in similar clinical settings.

Objectives: This article examines the organizational characteristics of nursing homes associated with increasing and decreasing use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA) in 1991., Methods: Nationally representative data from the 1992 and 1997 On-Line Survey Certification of Automated Records are used first to provide descriptive analyses and second for multinomial logistic regression analyses of organizational factors associated with an increase or decrease in physical restraint use., Results: The results show that 2,331 nursing homes increased their use of restraints by >4% and 2,100 decreased their use of restraints by >3%. Ownership, Alzheimer's special care units, and average occupancy rates have bidirectional influence and are associated with both decreases and increases in restraint use, depending on their values. Chain membership and staffing levels of rehabilitation services are associated with increases in restraint use, whereas Medicaid census and private-pay census are associated with decreases in restraint use. Change factors were also important. An increase in Medicaid census and a change to chain membership since 1991 have an unsettling effect on care practices, increasing restraint use., Conclusions: Although the period used in this analysis represents a time frame in which the restraint reduction mandates of the NHRA were in effect, these results show that some nursing homes have increased their use of physical restraints. The organizational characteristics of these nursing homes differ from those that decreased their use of physical restraints.

The objective was to examine the relative contributions of market, hospital, and nursing unit characteristics to the prediction of nursing unit skill mix. The strongest predictors of nursing skill mix were found to be the technological sophistication of the hospital, the volume of services offered, and the percentage of patients covered by managed care payors. The results suggest that skill mix on nursing units is buffered from market forces but is highly sensitive to hospital characteristics. These factors need to be taken into account when decisions are made about the allocation of personnel resources. In this article, the terms "nursing skill mix" and "nurse staffing" are used interchangeably.