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At many hospitals, private-practice physicians still admit their own patients and are accustomed to autonomy in clinical practice. This creates challenges for hospital's efforts to improve the efficiency, quality, and value of care. Experienced inpatient-focused physicians – 'Physician Advocates' – could act as liaisons between private practitioners and the fast-paced inpatient microsystem. We conducted a controlled pre-post ('differences-in-differences') analysis at an academic medical center where private-practice physicians care for about 40% of medical inpatients and hospitalist groups care for 60%. In the intervention, 'Physician Advocates' participated in daily multidisciplinary 'Progression of Care Rounds,' offering suggestions to increase care quality for private-practice physicians' patients. Controls were cared for by a large, well-established hospitalist group, which convened separate, unchanged multidisciplinary rounds. Outcomes were length of stay (LOS; primary outcome), 30-day readmissions, and inpatient mortality. In a risk-adjusted analysis of 31,632 medical inpatients, LOS declined by 4 hours more from the baseline period to the post-intervention period in the intervention group relative to the control group (ratio: 0.96, 95% CI: 0.93–0.99, p = 0.004). Readmissions declined 22% more in the intervention group (OR: 0.78, 95% CI: 0.63–0.97, p = 0.023). Mortality was unchanged (OR: 1.23, 95% CI: 0.78–1.93 p-value = 0.378). Among inpatients cared for by private practitioners, adding Physician Advocates to multidisciplinary rounds was associated with improved LOS and reduced readmissions – measures of efficiency and value. The Physician Advocates approach should be tested in diverse health systems because it allows hospitals to leverage the expertise of on-site clinicians while respecting the traditional private-practice care model, in which primary care physicians manage their hospitalized patients. [ABSTRACT FROM AUTHOR]

Introduction: Deep brain stimulation of the internal globus pallidus is an effective treatment for dystonia. However, there is a large variability in clinical outcome with up to 25% non-responders even in highly selected primary dystonia patients. In a large cohort of patients we recently demonstrated that the variable clinical outcomes of pallidal DBS for dystonia may result to a large degree by the exact location and stimulation volume within the pallidal region. Here we test a novel approach of programing based on these insights: we first defined probabilistic maps of anti-dystonic effects by aggregating individual electrode locations and volumes of tissue activated of > 80 patients collected in a multicentre effort. We subsequently modified the algorithms to be able to test all possible stimulation settings of de novo patients in silico based on the expected clinical outcome and thus potentially predict the best possible stimulation parameters for the individual patients. Methods: Within the framework of a BMBF-funded study, this concept of a computer-based prediction of optimal stimulation parameters for patients with dystonia will be tested in a randomized, controlled crossover study. The main parameter for clinical efficacy and primary endpoint is based on the blinded physician rating of dystonia severity reflected by Clinical Dystonia Rating Scales for both interventions (best clinical settings and model predicted settings) after 4 weeks of continuous stimulation. The primary endpoint is defined as "successful treatment with model predicted settings" (yes or no). The value is "yes" if the motor symptoms with model predicted settings are equal or better (tolerance 5% of absolute difference in percentages) to clinical settings. Secondary endpoints will include measures of quality of life, calculated energy consumption of the neurostimulation system and physician time for programming. Perspective: We envision, that computer-guided deep brain stimulation programming in silico might provide optimal stimulation settings for patients with dystonia without the burden of months of programming sessions. The study protocol is designed to evaluate which programming method is more effective in controlling motor symptom severity and improving quality of life in dystonia (best clinical settings and model predicted settings). Trial registration Registered with ClinicalTrials.gov on Oct 27, 2021 (NCT05097001). [ABSTRACT FROM AUTHOR]

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The article highlights the results of the 2021 Bunbury Regional Hospital Clinical Engagement and Morale Survey, conducted by the Australian Medical Association of Western Australia. Topics discussed include the physicians' classification level, communication between physicians and senior executives, and organizational culture.

The article reports on the strained relationship between doctors and Western Australia Country Health Service (WACHS) senior executives, as revealed by the Bunbury Regional Hospital Clinical Engagement and Morale Survey. Other issues identified in the survey include disengaged clinical workforce, levels of intimidation and disregard by the WACHS senior executives, and quality of healthcare provided by the regional hospital.

Training residents to become competent in common bedside procedures can be challenging. Some hospitals have attending physician–led procedure teams with oversight of all procedures to improve procedural training, but these teams require significant resources to establish and maintain. We sought to improve resident procedural training by implementing a resident-run procedure team without routine attending involvement. We created the role of a resident procedure coordinator (RPC). Interested residents on less time-intensive rotations voluntarily served as RPC. Medical providers in the hospital contacted the RPC through a designated pager when a bedside procedure was needed. A structured credentialing process, using direct observation and a procedure-specific checklist, was developed to determine residents' competence for completing procedures independently. Checklists were developed by the residency program and approved by institutional subspecialists. The service was implemented in June 2016 at an 850-bed academic medical center with 70 internal medicine and 32 medicine-pediatrics residents. The procedure service functioned without routine attending involvement. The impact was evaluated through resident procedure logs and surveys of residents and attending physicians. Compared with preimplementation procedure logs, there were substantial increases postimplementation in resident-performed procedures and the number of residents credentialed in paracenteses, thoracenteses, and lumbar punctures. Fifty-nine of 102 (58%) residents responded to the survey, with 42 (71%) reporting the initiative increased their ability to obtain procedural experience. Thirty-one of 36 (86%) attending respondents reported preferentially using the service. The RPC model increased resident procedural training opportunities using a structured sign-off process and an operationalized service. [ABSTRACT FROM AUTHOR]

Family Health Strategy, the primary health care program in Brazil, has been scaled up throughout the country, but its expansion has been heterogeneous across municipalities. We investigate if there are unique municipal characteristics that can explain the timing of uptake and the pattern of expansion of the Family Health Strategy from years 1998 to 2012. We categorized municipalities in six groups based on the relative speed of the Family Health Strategy uptake and the pattern of Family Health Strategy coverage expansion. We assembled data for 11 indicators for years 2000 and 2010, for 5,507 municipalities, and assessed differences in indicators across the six groups, which we mapped to examine spatial heterogeneities. Important factors differentiating early and late adopters of the Family Health Strategy were supply of doctors and population density. Sustained coverage expansion was related mainly to population size, marginal benefits of the program and doctors’ supply. The uptake was widespread nationwide with no distinct patterns among regions, but highly heterogeneous at the state and municipal level. The Brazilian experience of expanding primary health care offers three lessons in relation to factors influencing diffusion of primary health care. First, the funding mechanism is critical for program implementation, and must be accompanied by ways to support the supply of primary care physicians in low density areas. Second, in more developed and bigger areas the main challenge is lack of incentives to pursue universal coverage, especially due to the availability of private insurance. Third, population size is a crucial element to guarantee coverage sustainability over time. [ABSTRACT FROM AUTHOR]

Hospital-physician vertical integration is on the rise. While increased efficiencies may be possible, emerging research raises concerns about anticompetitive behavior, spending increases, and uncertain effects on quality. In this review, we bring together several of the key theories of vertical integration that exist in the neoclassical and institutional economics literatures and apply these theories to the hospital-physician relationship. We also conduct a literature review of the effects of vertical integration on prices, spending, and quality in the growing body of evidence ( n = 15) to evaluate which of these frameworks have the strongest empirical support. We find some support for vertical foreclosure as a framework for explaining the observed results. We suggest a conceptual model and identify directions for future research. Based on our analysis, we conclude that vertical integration poses a threat to the affordability of health services and merits special attention from policymakers and antitrust authorities. [ABSTRACT FROM AUTHOR]

The relationship between physicians and hospitals has dramatically changed over the last decade, with the employer-employee model supplanting the traditional model of private physicians with hospital admitting privileges. We examine the motivation for this form of vertical integration by considering physician-hospital alignment as a tool to increase bargaining power with private insurers. We find a positive and significant relationship between private insurance concentration on physician-hospital alignment, which is driven predominantly by for-profit hospitals. [ABSTRACT FROM AUTHOR]

Introduction: The intoxicated person may cause harm to others, often requiring expert evaluation for the determination of guilt. The primary aim of this study was to determine the mechanisms of mistakes that led 17 doctors accused of working under the influence of alcohol to face malpractice. We also wanted to clarify what were the legal, professional, and financial consequences - depending on specific patient outcomes.Method: We based analysis on the review and meta-analysis of the past forensic evaluation reports of institution-run forensics programs. Furthermore, we apply thematic analysis using combination of grounded theory and Pierre Bourdieu's theoretical framework.Results: During the 2010-2016 timeframe, the regional forensic service opinionated on 17 physicians (3F, 14M) subjected to disciplinary action due to providing treatment under the influence of alcohol. In total, there were 157 patients potentially affected by malpractice - out of those, four were harmed; only one qualified for compensation. In the remaining 153 patients - only 11 persons reported having had awareness about the doctors' intoxication and apparent inability to perform the job, yet they agreed to receive care. Overall, in over 90% of patients, the physician did not harm anyone to a degree threatening patient's life. The supporting staff did not report experiencing distress either. The results of a blood test for the presence of alcohol were available for only four cases. Therefore, it was impossible to analyze the correlation between intoxication level and performance in providing care. All in all, in our analysis - less than 10% of 157 patients' care were compromised by provider's intoxication, either due to a mistake in diagnosis, medical procedure, or lacking communication skills.Conclusion: For physicians, working under the influence of alcohol is an uncommon phenomenon, but when it occurs - patients are at risk for receiving poor treatment. Presented analysis indicates that patients - just as much as supporting staff - frequently agree to receive supervision and care from a drunk doctor, despite possible harm. Therefore, it is evident that patients as much as supporting staff fear retaliation, leading to underreporting of these cases. [ABSTRACT FROM AUTHOR]

Background: There have been few studies of the outcome in elderly patients who have suffered in-hospital cardiac arrest (IHCA) and the association between cardiac arrest characteristics and survival.Aim: The aim of this large observational study was to investigate the survival and neurological outcome in the elderly after IHCA, and to identify which factors were associated with survival.Methods: We investigated elderly IHCA patients (≥70years of age) who were registered in the Swedish Cardiopulmonary Resuscitation Registry 2007-2015. For descriptive purposes, the patients were grouped according to age (70-79, 80-89, and ≥90years). Predictors of 30-day survival were identified using multivariable analysis.Results: Altogether, 11,396 patients were included in the study. Thirty-day survival was 28% for patients aged 70-79 years, 20% for patients aged 80-89 years, and 14% for patients aged ≥90years. Factors associated with higher survival were: patients with an initially shockable rhythm, IHCA at an ECG-monitored location, IHCA was witnessed, IHCA during daytime (8 a.m.-8 p.m.), and an etiology of arrhythmia. A lower survival was associated with a history of heart failure, respiratory insufficiency, renal dysfunction and with an etiology of acute pulmonary oedema. Patients over 90 years of age with VF/VT as initial rhythm had a 41% survival rate. We found a trend indicating a less aggressive care with increasing age during cardiac arrest (fewer intubations, and less use of adrenalin and anti-arrhythmic drugs) but there was no association between age and delay in starting cardiopulmonary resuscitation (CPR). In survivors, there was no significant association between age and a favourable neurological outcome (CPC score: 1-2) (92%, 93%, and 88% in the three age groups, respectively).Conclusions: Increasing age among the elderly is associated with a lower 30-day survival after IHCA. Less aggressive treatment and a worse risk profile might contribute to these findings. Relatively high survival rates among certain subgroups suggest that discussions about advanced directives should be individualized. Most survivors have good neurological outcome, even patients over 90 years of age. [ABSTRACT FROM AUTHOR]

Introduction: Emergency physician (EP) turnover is a significant issue that can have strong economic impact on hospital systems, as well as implications on research efforts to test and improve clinical practice. This work is particularly important to researchers planning randomized trials directed toward EPs because a large degree of turnover within a physician group would attenuate the effectiveness of the desired intervention. We sought to determine the incidence and factors associated with EP workforce changes.Methods: In an attempt to determine EP turnover and workforce change, data from the INSTINCT (INcreasing Stroke Treatment through INterventional behavior Change Tactics) trial were used. The INSTINCT trial is a prospective, cluster-randomized, controlled trial evaluating a targeted behavioral intervention to increase appropriate use of tissue plasminogen activator in acute ischemic stroke. Individual EPs staffing each of the study hospitals were identified at baseline and 18 months. Surveys were sent to EPs at both intervals. Models were constructed to investigate relationships between physician/hospital characteristics and workforce change.Results: A total of 278 EPs were identified at baseline. Surveys were sent to all EPs at baseline and 18 months with a response rate of 72% and 74%, respectively. At 18 months, 37 (15.8%) had left their baseline hospital and 66 (26.3%) new EPs were working. Seven EPs switched hospitals within the sample. The total number of EPs at 18 months was 307, a 10.8% overall increase. Among the 24 hospitals, 6 had no EP departures and 5 had no new arrivals. The median proportion of EP workforce departing by hospital was 16% (interquartile range [IQR] ¼ 4%–25%; range ¼ 0%–73%), and the median proportion added was 21% (IQR ¼ 7%–41%; range ¼ 0%–120%). None of the evaluatedcovariates investigating relationships between physician/hospital characteristics and workforce change were significant.Conclusion: EP workforce changes over an 18-month period were common. This has implications for emergency department directors, researchers, and individual EPs. Those planning research involvinginterventions upon EPs should account for turnover as it may have an impact when designing clinical trials to improve performance on healthcare delivery metrics for time-sensitive medical conditions suchas stroke, acute myocardial infarction, or trauma. [West J Emerg Med. 2013;14(1):16–22.]

Objective: We aim to compare patients' perspectives on communication with their hospital physicians (HPs) and primary care physicians (PCPs) on patients' dietary and herbal supplements (DHS) use.Methods: We conducted a cross-sectional prospective study among in-patients using structured questionnaires on DHS use. Multivariate logistic regression models assessed variables influencing doctor-related reasons for patients' nondisclosure of supplement use.Results: Of 452 DHS users identified, 133 (29.4%) used herbs and 319 (70.6%) used non-herbal supplements. DHS users reported that PCPs were more aware of DHS consumption than HPs (70.1% vs. 34.1%, P<0.0001). PCPs initiative to detect supplement use was higher compared with HPs (P<0.0001). Doctor-related reasons for non-disclosure of DHS use were more prominent in a hospital setting. Multivariate logistic regression model suggested association between older patient age and doctor-related non-disclosure (p=0.03). DHS use was recorded in only 33 patients medical files.Conclusions: Doctor-patient communication concerning DHS use is significantly poorer during hospitalization compared with primary-care settings. A significant barrier for in-hospital disclosure is doctor-related.Practice Implications: Continuity of care between community and hospital physicians regarding patients' DHS use should be improved due to the safety implications of such use. Educating physicians on DHS and improving communication could bridge this gap. [ABSTRACT FROM AUTHOR]

Healthcare service in itself is one of the most crucial, most sensitive services in the world. Advancement in healthcare infrastructures, equipment and manpower are rapid day by day. "Healthcare service providers", the definition is changing from commonly perceived "doctors" to "doctors plus managers". The healthcare practice has changed all its way from individual practice to communal, organised hospital systems; resources are pooled in a common place; where patients expect for every kind of treatment once they enter the common roof. However, the hospital only can understand the role the doctor and manager play together for quality healthcare services. The two now cannot be separated despite of several disparities that appear between them. There should always be an effort to bridge the gap between them which appears between them despite serving the common goal. Doctor manager collaboration including collaboration of education system shall bring the real bond between them to understand each other, understand system and pace for their common goal. [ABSTRACT FROM AUTHOR]

Background: Policy dialogues are critical for developing responsive, effective, sustainable, evidence-informed policy. Our multidisciplinary team, including researchers, physicians and senior decision-makers, comprehensively evaluated The Winnipeg Central Intake Service, a single-entry model in Winnipeg, Manitoba, to improve patient access to hip/knee replacement surgery. We used the evaluation findings to develop five evidence-informed policy directions to help improve access to scheduled clinical services across Manitoba. Using guiding principles of public participation processes, we hosted a policy roundtable meeting to engage stakeholders and use their input to refine the policy directions. Here, we report on the use and input of a policy roundtable meeting and its role in contributing to the development of evidence-informed policy. Methods: Our evidence-informed policy directions focused on formal measurement/monitoring of quality, central intake as a preferred model for service delivery, provincial scope, transparent processes/performance indicators, and patient choice of provider. We held a policy roundtable meeting and used outcomes of facilitated discussions to refine these directions. Individuals from our team and six stakeholder groups across Manitoba participated (n = 44), including patients, family physicians, orthopaedic surgeons, surgical office assistants, Winnipeg Central Intake team, and administrators/managers. We developed evaluation forms to assess the meeting process, and collected decision-maker partners' perspectives on the value of the policy roundtable meeting and use of policy directions to improve access to scheduled clinical services after the meeting, and again 15 months later. We analyzed roundtable and evaluation data using thematic analysis to identify key themes. Results: Four key findings emerged. First, participants supported all policy directions, with revisions and key implementation considerations identified. Second, participants felt the policy roundtable meeting achieved its purpose (to engage stakeholders, elicit feedback, refine policy directions). Third, our decision-maker partners' expectations of the policy roundtable meeting were exceeded; they re-affirmed its value and described the refined policy directions as foundational to establishing the vocabulary, vision and framework for improving access to scheduled clinical services in Manitoba. Finally, our adaptation of key design elements was conducive to discussion of issues surrounding access to care. Conclusions: Our policy roundtable process was an effective tool for acquiring broad input from stakeholders, refining policy directions and forming the necessary consensus starting points to move towards evidence-informed policy. [ABSTRACT FROM AUTHOR]

A well-functioning Doctor-Manager relationship plays a crucial role in the success of a healthcare organization. As the healthcare industry gets more competitive and corporatized, it often leads to friction between these two professionals due to their difference in work cultures; creating discontent. This discontent among the doctors and the managers hampers the efficiency of a healthcare organization. This article attempts to shed some light on both doctor as well as manager's perspective on the issue of their dissatisfaction. We also aim to explain how the gap between these two professionals can be bridged and consider some strategies that might help in tackling this problem. [ABSTRACT FROM AUTHOR]

The article focuses on relationship between healthcare organizations and physicians with compliance to the Stark Law, which prohibits physicians to refer Medicare patients to the same entity for health services.

Background: The increasing pervasiveness of mobile technologies has given potential to transform healthcare by facilitating clinical management using software applications. These technologies may provide valuable tools in sexual health care and potentially overcome existing practical and cultural barriers to routine testing for sexually transmitted infections. In order to inform the design of a mobile health application for STIs that supports self-testing and self-management by linking diagnosis with online care pathways, we aimed to identify the dimensions and range of preferences for user interface design features among young people. Methods: Nine focus group discussions were conducted (n = 49) with two age-stratified samples (16 to 18 and 19 to 24 year olds) of young people from Further Education colleges and Higher Education establishments. Discussions explored young people's views with regard to: the software interface; the presentation of information; and the ordering of interaction steps. Discussions were audio recorded and transcribed verbatim. Interview transcripts were analysed using thematic analysis. Results: Four over-arching themes emerged: privacy and security; credibility; user journey support; and the task-technology-context fit. From these themes, 20 user interface design recommendations for mobile health applications are proposed. For participants, although privacy was a major concern, security was not perceived as a major potential barrier as participants were generally unaware of potential security threats and inherently trusted new technology. Customisation also emerged as a key design preference to increase attractiveness and acceptability. Conclusions: Considerable effort should be focused on designing healthcare applications from the patient's perspective to maximise acceptability. The design recommendations proposed in this paper provide a valuable point of reference for the health design community to inform development of mobile-based health interventions for the diagnosis and treatment of a number of other conditions for this target group, while stimulating conversation across multidisciplinary communities. [ABSTRACT FROM AUTHOR]

Background: Health decision-making requires evidence from high-quality data. As one example, the Discharge Abstract Database (DAD) compiles data from the majority of Canadian hospitals to form one of the most comprehensive and highly regarded administrative health databases available for health research, internationally. However, despite the success of this and other administrative health data resources, little is known about their history or the factors that have led to their success. The purpose of this paper is to provide an historical overview of Canadian administrative health data for health research to contribute to the institutional memory of this field. Methods: We conducted a qualitative content analysis of approximately 20 key sources to construct an historical narrative of administrative health data in Canada. Specifically, we searched for content related to key events, individuals, challenges, and successes in this field over time. Results: In Canada, administrative health data for health research has developed in tangent with provincial research centres. Interestingly, the lessons learned from this history align with the original recommendations of the 1964 Royal Commission on Health Services: (1) standardization, and (2) centralization of data resources, that is (3) facilitated through governmental financial support. Conclusions: The overview history provided here illustrates the need for longstanding partnerships between government and academia, for classification, terminology and standardization are time-consuming and ever-evolving processes. This paper will be of interest to those who work with administrative health data, and also for countries that are looking to build or improve upon their use of administrative health data for decision-making. [ABSTRACT FROM AUTHOR]

Background: With the introduction and implementation of a variety of government programs and policies to encourage adoption of electronic medical records (EMRs), EMRs are being increasingly adopted in North America. We sought to evaluate the completeness of a variety of EMR fields to determine if family physicians were comprehensively using their EMRs and the suitability of use of the data for secondary purposes in Ontario, Canada. Methods: We examined EMR data from a convenience sample of family physicians distributed throughout Ontario within the Electronic Medical Record Administrative data Linked Database (EMRALD) as extracted in the summer of 2012. We identified all physicians with at least one year of EMR use. Measures were developed and rates of physician documentation of clinical encounters, electronic prescriptions, laboratory tests, blood pressure and weight, referrals, consultation letters, and all fields in the cumulative patient profile were calculated as a function of physician and patient time since starting on the EMR. Results: Of the 167 physicians with at least one year of EMR use, we identified 186,237 patients. Overall, the fields with the highest level of completeness were for visit documentations and prescriptions (>70 %). Improvements were observed with increasing trends of completeness overtime for almost all EMR fields according to increasing physician time on EMR. Assessment of the influence of patient time on EMR demonstrated an increasing likelihood of the population of EMR fields overtime, with the largest improvements occurring between the first and second years. Conclusions: All of the data fields examined appear to be reasonably complete within the first year of adoption with the biggest increase occurring the first to second year. Using all of the basic functions of the EMR appears to be occurring in the current environment of EMR adoption in Ontario. Thus the data appears to be suitable for secondary use. [ABSTRACT FROM AUTHOR]

In an effort to meet the challenges of the post-health reform marketplace, hospitals have accelerated the practice of employing physicians. Despite this trend, many hospitals require their employed physicians to also maintain membership and privileges on the medical staff--the self-governing entity comprised of fellow physicians that oversees the practice of medicine within the hospital setting. Recent case law identifies at least two salient issues that will likely arise from physicians' dual roles as hospital employee and medical staff member and be a point of negotiation and litigation: (1) the applicability of "due process" rights, which are typically afforded in medical staff peer review actions, to employment termination actions, and (2) the obligation to report employment termination actions to the federal government's National Practitioner Data Bank, a central database for information about medical staff peer review actions and other incidents that may reflect on physicians' competence and quality of care. This article examines how and why these issues may become points of contention and proposes various practical solutions to avoiding or mitigating such conflicts. [ABSTRACT FROM AUTHOR]

Hospitals and physicians have been working together for years in providing specialized health services. However, hospital-physician relationships are considered lukewarm at the best. We build on psychological contract theory to develop an in-depth understanding of how physicians ( N = 15) and hospital executives ( N = 15) in Belgium experience and interpret obligations in their working relationship. Our analysis yielded a rich understanding of mutual obligations and areas of ambiguity. Two major themes emerged from the analysis. A distinction should be made between administrative obligations (adequate support and responsive decision making) and professional obligations (clinical excellence and physician autonomy). Two areas of ambiguity could be identified reflecting both dimensions. An economic trade-off exists in the day-to-day interaction and therefore views on how the care should be organized differ. In addition, the extent to which medical decisions should take into account the corresponding impact on hospital finance varies. [ABSTRACT FROM AUTHOR]

Background: Hospitals face increasingly competitive market conditions. In this challenging environment, hospitals have been struggling to build high-quality hospital–physician relationships. In the literature, two types of managerial strategies for optimizing relationships have been identified. The first focuses on optimizing the economic relationship; the second focuses on the noneconomic dimension and emphasizes the cooperative structure and collaborative nature of the hospital-physician relationship. We investigate potential spillover effects between the perceptions of physicians of organizational exchange and their customer-oriented behaviors. Methods: A cross-sectional study was conducted on 130 self-employed physicians practicing at six Belgian hospitals. Economic exchange was measured using the concept of distributive justice (DJ); noneconomic exchange was measured by the concept of perceived organizational support (POS). Our outcomes consist of three types of customer-oriented behaviours: internal influence (II), external representation (ER), and service delivery (SD). Results: Our results show a positive relationship between DJ and II (adjusted R2 = 0.038, t = 2.35; p = 0.028) and ER (adjusted R2 = 0.15, t = 4.59; p < 0.001) and a positive relationship between POS and II (adjusted R2 = 0.032, t = 2.26; p = 0.026) and ER (adjusted R2 = 0.22, t = 5.81; p < 0.001). No relationship was present between DJ (p = 0.54) or POS (p = 0.57) and SD. Organizational identification positively moderates the relationship between POS and ER (p = 0.045) and between DJ and ER (p = 0.056). The relationships between POS and II (p = 0.54) and between DJ and II (p = 0.99) were not moderated by OI. Professional identification did not moderate the studied relationships. Conclusion: Our results demonstrate that both perceptions of economic and noneconomic exchange are important to self-employed physicians' customer-oriented behaviours. Fostering organizational identification could enhance this reciprocity dynamic. [ABSTRACT FROM AUTHOR]

BACKGROUND: Discharge against medical advice (DAMA) has been associated with increased morbidity and re-admission of the patients who have been DAMA. The present study aims to evaluate the prevalence of DAMA and to determine the associated factors for DAMA. METHODS: A cross-sectional study was conducted from April 2012 to September 2012 in 17 hospitals in Tabriz, Iran. Data collection was performed using a two-part checklist including demographic factors, information about hospital and DAMA reasons. The profile of all DAMA patients was studied. RESULTS: The overall DAMA rate among hospitals was 5.7%. The highest DAMA rates were from private and educational hospitals, 10.8% and 9.6% respectively. The lowest rates were from social security hospitals with 2.5%. In this study, sex, age, month and health insurance were significant predictors of DAMA. CONCLUSION: In comparison to other studies, relatively higher rates of DAMA in this study show the need for conducting additional studies to define the causes of DAMA and to devise appropriate interventions to decrease DAMA rate. Determining DAMA rate and its determinants can play an important role in early detection of these at-risk patients and in instituting appropriate intervention. [ABSTRACT FROM AUTHOR]

Ethics consultation is a commonly applied mechanism to address clinical ethical dilemmas. However, there is little information on the viewpoints of health care providers towards the relevance of ethics committees and appropriate application of ethics consultation in clinical practice. We sought to use qualitative methodology to evaluate free-text responses to a case-based survey to identify thematically the views of health care professionals towards the role of ethics committees in resolving clinical ethical dilemmas. Using an iterative and reflexive model we identified themes that health care providers support a role for ethics committees and hospitals in resolving clinical ethical dilemmas, that the role should be one of mediation, rather than prescription, but that ultimately legal exposure was dispositive compared to ethical theory. The identified theme of legal fears suggests that the mediation role of ethics committees is viewed by health care professionals primarily as a practical means to avoid more worrisome medico-legal conflict. [ABSTRACT FROM AUTHOR]

Background: There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with. Methods: This was an explorative, descriptive study using qualitative methods (individual and focus group interviews). We conducted 19 individual interviews and 4 focus group interviews with nurses and physicians working in the ICU or the general ward of 10 Dutch hospitals. Results: The ethical problems in the context of ICU admission and discharge can be divided into problems concerning full bed occupancy and problems related to treatment decisions. The gap between the high level of care the ICU can provide and the lower care level in the general ward sometimes leads to mutual misunderstandings. Our results indicate that when professionals of different wards feel there is a collective responsibility and effort to solve a problem, this helps to prevent or alleviate moral distress. ICU patients' wishes are often unknown, causing healthcare professionals to err on the side of more treatment. Additionally, the highly technological nature of intensive care appears to encourage over-treatment. Conclusions: It is important for ICUs and general wards to communicate and cooperate well, since there is a mutual dependency for optimal patient flow between the different departments. Interventions that improve the understanding and cooperation between these wards may help mitigate ethical problems. The nature of the ICU environment makes it important for healthcare professionals to be aware of the risk of over-treatment, reflect on why they do what they do, and be mindful of a possible negative impact of over-treatment on their patients. Early discussion of a patient's wishes with regard to treatment options is important in preventing over-treatment. [ABSTRACT FROM AUTHOR]

Se realizó un estudio para conocer las actividades docentes en las que participan los médicos de familia del Área de Salud "Plaza de la Revolución" en su relación con el policlínico y los hospitales. Además se evaluó el estado actual del sistema de referencia y contrarreferencia, por considerarlo un importante recurso formativo para el médico de la atención primaria. Fue un estudio descriptivo de índole retrospectiva por conducto del cual se exploraron mediante encuestas los criterios de los médicos de familia y la población que recibe los servicios de salud en esta área. Mediante la técnica del grupo nominal se conocieron los criterios de los médicos de los hospitales base, en relación con el tema. Se identificó que la organización de actividades docentes a los médicos de familia en el policlínico dista de ser óptima, pero es superior a la de los hospitales, en los que no se programan actividades conjuntas con la Atención Primaria. El sistema de referencia y contrarreferencia presenta dificultades apreciables, que revelan una comunicación deficiente entre los profesionales de ambos niveles en relación con la atención continuada y la conducción de pacientes comunes.A descriptive and retrospective study was conducted to know about the participation of the family physicians from the "Plaza de la Revolución" health area in the teaching activities carried out at the polyclinic and at the hospitals. The present status of the reference and counterreference system was evaluated due to its importance as an informative resource for the psysicians ot the primary care level. The family physicians and the population receiving medical attention at this health area were surveyed to know their criteria. The opinions of the doctors working at the base hospitals on this topic were obtained by using the technique of nominal group. It was proved that the organization of teaching activities for family physicians at the polyclinic is far from being the best, but is better that of the hospitals, where no activities are programmed for the physicians from the primary care level. The system of reference and counter reference has considerable difficulties that show a deficient communication between professionals of both levels as regards continuing education and the management of common patients.

Objective To examine the benefits of compassion practices on two indicators of patient perceptions of care quality-the Hospital Consumer Assessment of Healthcare Providers and systems ( HCAHPS) overall hospital rating and likelihood of recommending. Study Setting Two hundred sixty-nine nonfederal acute care U. S. hospitals. Study Design Cross-sectional study. Data Collection Surveys collected from top-level hospital executives. Publicly reported HCAHPS data from October 2012 release. Principal Findings Compassion practices, a measure of the extent to which a hospital rewards compassionate acts and compassionately supports its employees (e.g., compassionate employee awards, pastoral care for employees), is significantly and positively associated with hospital ratings and likelihood of recommending. Conclusions Our findings illustrate the benefits for patients of specific and actionable organizational practices that provide and reinforce compassion. [ABSTRACT FROM AUTHOR]

Purpose – The perpose of this paper is to analyse recent changes in the management of French public hospitals, following a reform enacted in 2009 and aimed at bolstering the managerial roles of doctors. Design/methodology/approach – The paper is exploratory and is based on both the analysis of French literature dealing with the results of the 2009 reform, and ten semi-directed interviews with clinical managers and top leaders in the public hospital sector. Findings – The author reports on the major hospital management reforms of 2009 and analyse the implications for the medical profession and management. The author shows that the involvement of the classical clinical leaders has become less regulated as the units no longer have a clear legal basis. The governance of the newly introduced “medical poles” appears to be shaped by various factors: there is high correlation between centrality, prestige and “clan involvement”, which suggests that professionals holding new responsibilities obtain power and legitimacy by consolidating pre-existing networks. While it is often argued that high-quality clinical leadership is a key factor of organisational success, the findings suggest that the performance of clinical managers relies on this network and legitimacy acquired from it. Originality/value – Drawing on the “sociology of translation” and actor-network theory (Callon and Latour, 1991), this paper provides a new conceptual framework for the analysis of the transformation of the role of clinical leaders, arguing that this transformation depends highly on their abilities to build and use networks. The findings challenge the French tradition of public management that presupposes a clear division of power between doctors and administrative staff. [ABSTRACT FROM AUTHOR]

Background Belgian hospitals face a growing shortage of physicians and increasingly competitive market conditions. In this challenging environment hospitals are struggling to build effective hospital-physician relationships which are considered to be a critical determinant of organizational success. Methods Employed physicians of a University hospital were surveyed. Organizational attributes were identified through the literature and two focus groups. Variables were measured using validated questionnaires. Descriptive analyses and linear regression were used to test the model and relative importance analyses were performed. Results The selected attributes predict hospital attractiveness significantly (79.3%). The relative importance analysis revealed that hospital attractiveness is most strongly predicted by professional attributes (35.3%) and relational attributes (29.7%). In particular, professional development opportunities (18.8%), hospital prestige (16.5%), organizational support (17.2%) and leader support (9.3%) were found to be most important. Besides these noneconomic aspects, the employed physicians indicated pay and financial benefits (7.4%) as a significant predictor of hospital attractiveness. Work-life balance and job security were not significantly related to hospital attractiveness. Conclusions This study shows that initiatives aimed at strengthening physicians' positive perceptions of professional and relational aspects of practicing medicine in hospitals, while assuring satisfactory financial conditions, may offer useful avenues for increasing the level of perceived hospital attractiveness. Overall, hospitals are advised to use a differentiated approach to increase their attractiveness to physicians. [ABSTRACT FROM AUTHOR]

The current Romanian medical system is going throw a complex process of reform based mainly in winning the citizens, professionalization the management and increasing the funding levels. The present study is an analysis of the satisfaction level felt by medical staff in emergency reception units in Bucharest hospitals and brings a novelty in the field of medical research, based on the problems approached and the emphasis placed in observation the quality and the performance of medical services. This study shows how satisfied is a medical personnel in the working environment and identify what are the main drawbacks that generate disaffection and inefficiency in public medical emergency services in Bucharest. The research methodology used is based on a target group consisting of medical personnel's in emergency reception units analyzed. The tools used for data collection were questionnaires and non-participatory observations were processed by computer program called SPSS. The results obtained from the medical staff examined shows dissatisfaction towards salary level, the level of endowment with modern equipment and informative materials available which capture the need to create a remuneration system based on performance criteria and competitiveness associated with a penalty system in parallel. The beneficiaries of this study are researchers in the medical field, hospitals surveyed, managers and representatives of research and development departments of analyzed hospitals taking into account their low activity in recent years. [ABSTRACT FROM AUTHOR]

Background: Orthopaedic surgery practices can provide substantial value to healthcare systems. Increasingly, healthcare administrators are speaking of the need for alignment between physicians and healthcare systems. However, physicians often do not understand what healthcare administrators value and therefore have difficulty articulating the value they create in discussions with their hospital or healthcare organization. Many health systems and hospitals use service lines as an organizational structure to track the relevant data and manage the resources associated with a particular type of care, such as musculoskeletal care. Understanding service lines and their management can be useful for orthopaedic surgeons interested in interacting with their hospital systems. Questions/purposes: We provide an overview of two basic types of value orthopaedic surgeons create for healthcare systems: financial or volume-driven benefits and nonfinancial quality or value-driven patient care benefits. Methods: We performed a search of PubMed from 1965 to 2012 using the term 'service line.' Of the 351 citations identified, 18 citations specifically involved the use of service lines to improve patient care in both nursing and medical journals. Results: A service line is a structure used in healthcare organizations to enable management of a subset of activities or resources in a focused area of patient care delivery. There is not a consistent definition of what resources are managed within a service line from hospital to hospital. Physicians can positively impact patient care through engaging in service line management. Conclusions: There is increasing pressure for healthcare systems and hospitals to partner with orthopaedic surgeons. The peer-reviewed literature demonstrates there are limited resources for physicians to understand the value they create when attempting to negotiate with their hospital or healthcare organization. To effectively negotiate for resources to provide the best care for patients, orthopaedic surgeons need to claim and demonstrate the value they create in healthcare organizations. [ABSTRACT FROM AUTHOR]

Background: There is broad recognition that the healthcare crisis in the United States is going to require a response and change in clinical practice. The management structure of Geisinger Health System is unique, and this has the potential to change the dynamics of surgeon-administration alignment. Questions/purposes: Our goal is to summarize and clarify the relationship between orthopaedic surgeons and the healthcare system at Geisinger, evaluate the positive and negative aspects, and consider which components may be reproducible. Methods: This overview arises from a review of management publications, discussions with orthopaedic attendings and administrators, and personal observations and comparison with my previous 15-year university-based practice. Results: The Geisinger Health System has always been physician-run. The overall efficiency and pragmatic approach found at Geisinger relies heavily on changing surgeon behavior to match what is optimal for the system rather than the individual. This approach appears to bring greater stability and more consistent outcomes, but only by removing what some see as the art of medicine and at the loss of perceived provider autonomy. Despite the rigid demands placed on the surgeon, the system remains adaptable to change and appears to retain faculty at a high rate. Conclusions: The Geisinger System is unique in its ability to control an insurance plan, multiple hospitals, and a large physician group. Through clear protocols and behavioral pressure, it demands surgeon alignment with the system as a whole and in return provides a stable work environment. It is not ideal for all surgeons and it is unclear whether it can be reproduced in a less structured setting. [ABSTRACT FROM AUTHOR]

Background: Physician-hospital alignments are becoming more common in today's healthcare environment. In the community setting, these relationships can impact quality of care as well as physician and hospital bottom lines. Alignment strategies take many different forms and can be advantageous to both the community orthopaedist and the community hospital, but certain key factors must be present to prevent a failed effort. Both the physician and hospital must be clear about their goals and expectations to overcome barriers and ensure success. Questions/purposes: We outline alignment strategies, goals, expectations, and implementation of a community-based, hospital alignment program and key factors that must be present to prevent a failed effort. Search Strategy: We queried PubMed and the AAOS web site for the terms 'physician hospital alignment', 'hospital physician alignment', and 'clinical integration'. We initially identified 65 articles and identified 19 that described the formation, evaluation, and examples of community hospital alliances. Results: In 2012, multiple business arrangements have been developed to deal with this vision for our healthcare future. One of these strategies known as alignment is generally considered to be a relationship among patients, orthopaedic surgeons, and stakeholders to fulfill these quality benchmarks and deliver improved quality care. Community practices have unique developmental barriers that must be negotiated for this process to be successful. Conclusions: The majority of hospital-based, orthopaedic care is practiced in the community settings far away from large, urban medical centers. Despite the relatively rural nature of these orthopaedic practices, patients, physicians, and all other orthopaedic stakeholders share a common goal of providing safe, quality health care at an affordable price. [ABSTRACT FROM AUTHOR]

Background: The increasing cost of providing health care is a national concern. Healthcare spending related to providing hospital care is one of the primary drivers of healthcare spending in the United States. Adoption of advanced medical technologies accounts for the largest percentage of growth in healthcare spending in the United States when compared with other developed countries. Within the specialty of orthopaedic surgery, a variety of implants can result in similar outcomes for patients in several areas of clinical care. However, surgeons often do not know the cost of implants used in a specific procedure or how the use of an implant or technology affects the overall cost of the episode of care. Questions/purposes: The purposes of this study were (1) to describe physician-led processes for introduction of new surgical products and technologies; and (2) to inform physicians of potential cost savings of physician-led product contract negotiations and approval of new technology. Methods: We performed a detailed review of the steps taken by two centers that have implemented surgeon-led programs to demonstrate responsibility in technology acquisition and product procurement decision-making. Results: Each program has developed a physician peer review process in technology and new product acquisition that has resulted in a substantial reduction in spending for the respective hospitals in regard to surgical implants. Implant costs have decreased between 3% and 38% using different negotiating strategies. At the same time, new product requests by physicians have been approved in greater than 90% of instances. Conclusions: Hospitals need physicians to be engaged and informed in discussions concerning current and new technology and products. Surgeons can provide leadership for these efforts to reduce the cost of high-quality care. [ABSTRACT FROM AUTHOR]

Background: The relationships between physicians and hospitals are viewed as central to the proposition of delivering high-quality health care at a sustainable cost. Over the last two decades, major changes in the scope, breadth, and complexities of these relationships have emerged. Despite understanding the need for physician-hospital alignment, identification and understanding the incentives and drivers of alignment prove challenging. Questions/purposes: Our review identifies the primary drivers of physician alignment with hospitals from both the physician and hospital perspectives. Further, we assess the drivers more specific to motivating orthopaedic surgeons to align with hospitals. Methods: We performed a comprehensive literature review from 1992 to March 2012 to evaluate published studies and opinions on the issues surrounding physician-hospital alignment. Literature searches were performed in both MEDLINE and Health Business™ Elite. Results: Available literature identifies economic and regulatory shifts in health care and cultural factors as primary drivers of physician-hospital alignment. Specific to orthopaedics, factors driving alignment include the profitability of orthopaedic service lines, the expense of implants, and issues surrounding ambulatory surgery centers and other ancillary services. Conclusions: Evolving healthcare delivery and payment reforms promote increased collaboration between physicians and hospitals. While economic incentives and increasing regulatory demands provide the strongest drivers, cultural changes including physician leadership and changing expectations of work-life balance must be considered when pursuing successful alignment models. Physicians and hospitals view each other as critical to achieving lower-cost, higher-quality health care. [ABSTRACT FROM AUTHOR]

Background: Recently, quality, financial, and regulatory demands have driven physicians to seek alignment opportunities with hospitals. The motivation for alignment on the part of physicians and hospitals is now accelerating because the new paradigm under healthcare reform requires an increased focus on improving quality, cost, and efficiency. Questions/purposes: We (1) identify the key drivers for physician-hospital alignment models; (2) summarize comanagement as a physician-hospital alignment model; and (3) explore a detailed case study of comanagement as an option to better align physicians with hospital goals on quality, safety, and outcomes. Methods: A Medline abstract review was performed that identified 45 references that discuss options for physician-hospital alignment. None of the articles identified provide a detailed example of successful alignment structures. A detailed case study of a successful comanagement alignment program is reviewed. Results: The key drivers for alignment are inpatient growth rates, declining reimbursements, and the opportunity to improve quality, decrease costs, and increase efficiency. Two general strategies of alignment involve noneconomic and/or economic integration. In our example, comanagement with economic integration was chosen as the preferred structure for physician-hospital alignment. Conclusions: The choice of structure will vary depending on the existing relationships and governance of the hospital and the physicians in the targeted area of focus. The measure of success in building physician-hospital alignment is measured in improvements in care for the patient, reduced cost of care delivery, and improved relations between physicians and hospital leadership. [ABSTRACT FROM AUTHOR]

Context: It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together? Methods: Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews. Findings: In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members' cherished value of autonomy by emphasizing coordination, not 'integration'; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change. Conclusions: The ACO appears to be a model flexible enough to work in synchrony with whatever social strategies are most context appropriate, with the potential to promote alignment and functional integration without demanding common identification with a superordinate group. 'Soft integration' may be a promising alternative to the vertically integrated model that, though widely assumed to be ideal, has remained unattainable for most organizations. [ABSTRACT FROM AUTHOR]

Abstract: During the past decade, entrepreneurship in the healthcare sector has become increasingly important. The aging society, the continuous stream of innovative technologies and the growth of chronic illnesses are jeopardizing the sustainability of healthcare systems. In response, many European governments started to reform healthcare during the 1990s, replacing the traditional logic of medical professionalism with business-like logics. This trend is expected to continue as many governments will have to reduce their healthcare spending in response to the current growing budget deficits. In the process, entrepreneurship is being stimulated, yet little is known about intra-hospital dynamics leading to entrepreneurial behavior. The purpose of this article is to review existing literature concerning the influence of intra-organizational dynamics on entrepreneurship among physicians and managers in hospitals of Western countries. Therefore, we conducted a theory-led, systematic review of how intra-organizational dynamics among hospital managers and physicians can influence entrepreneurship. We designed our review using the neo-institutional framework of . We analyze these dynamics in terms of power dependencies, interest dissatisfaction and value commitments. Our search revealed that physicians'' dependence on hospital management has increased along with healthcare reforms and the resulting emphasis on business logics. This has induced various types of responses by physicians. Physicians can be pushed to adopt an entrepreneurial attitude as part of a defensive value commitment toward the business-like healthcare logic, to defend their traditionally dominant position and professional autonomy. In contrast, physicians holding a transformative attitude toward traditional medical professionalism seem more prone to adopt the entrepreneurial elements of business-like healthcare, encouraged by the prospect of increased autonomy and income. Interest dissatisfaction and competing value commitments can also stimulate physicians'' entrepreneurship and, depending on their relative importance, determine whether it is necessity-based or opportunity-driven. [Copyright &y& Elsevier]

The article presents a study on the professional performance's peer assessment through hospitalist physicians. The study examined the responses of 22 hospitalist physicians in assessing the clinical skills of their peers. The study shows that the correlativity among scale details and the variable that states the chosen doctor of a person for his or her loved one renders validity evidence to the assessment scale. Thus, the study could be used in identifying the top performers in the hospital.

The article looks at the works of professor Paul-André Crépeau which focus on laws and relations among patients, physicians, and health institutions in Québec. It retraces the origins of the debate concerning the qualification of relationships between a patient and a health establishment by commenting on the founding of each proposed responsibility regime. It demonstrates that this controversy is based on an hospital's irresponsibility for a physician's fault.

Background With the passing of time, knowledge like other resources can become obsolete. Thus, people in a healthcare system need to update their knowledge in order to keep pace with the ongoing changes in their operational environment. Information technology continually provides a great amount of new knowledge which can lead to healthcare professionals becoming overloaded with knowledge. This overloading can be alleviated by a process of unlearning which enables the professional to retain just the relevant and critical knowledge required to improve the quality of service provided by them. Objective This paper shows some of the tools and methods that Hospital-in-the-Home Units (HHUs) have used to update the physician–patient knowledge and the technology knowledge of the HHUs' personnel. Design A survey study was carried out in the HHU in Spanish health system in 2010. Setting Fifty-five doctors and 62 nurses belonging to 44 HHUs. Interventions None. Results Three hypotheses are presented and supported, which suggest that technology and physician–patient knowledge is related to the unlearning context and the unlearning context impacts positively on the quality of health services provided. Conclusion The key benefits of the unlearning context for the quality of service provided in HHUs are clear: it enables them to identify and replace poor practices and also avoids the reinvention of the wheel (e.g.: by minimizing unnecessary work caused by the use of poor methods) and it reduces costs through better productivity and efficiency (improving services to patients). [ABSTRACT FROM PUBLISHER]

The article discusses the approaches that would provide opportunities to improve collaboration efforts between hospitals and physicians in healthcare industry in the U.S. It mentions the alignment of hospital and physician incentives that should be considered by health care systems to establish a coordinated and integrated care model necessary to deliver high quality and efficient services. It cites the need of hospitals to develop measures in order to work effectively with their physicians.

Abstract: Objective: The authors’ goal was to assess physicians’ perception of antibiotic prescribing practice and of bacterial resistance. Design: We questioned 503 interns and senior physicians in the Nice University Hospital. Results: Three hundred and twenty-two out of five hundred and three (64 %) physicians answered the questionnaire. Antibiotic resistance was perceived as a national problem by 98 % of physicians, but only 74 % rated the problem as important in their own daily practice. Fifty-nine percent of interns and 34 % of senior physicians respectively had received some training on antibiotic prescribing in the past 12 months. Only 33 % of physicians knew the exact prevalence of MRSA in their hospital. Senior physicians were more confident than interns when prescribing an antibiotic. The three issues they were the less confident with were: indications of antibiotic combinations, reassessment, and duration of antibiotic treatment. They were aware that antibiotic overuse, prescription of broad-spectrum molecules, or subtherapeutic doses of antibiotics were the three major causes of antibiotic resistance. They believed that the most useful measures to improve antibiotic prescription were: availability of guidelines, specific courses, readily accessible advice from an infectious diseases specialist, and audit plus feedback. Conclusions: The collected data provides useful information for the implementation of strategies to optimize adherence to good antimicrobial stewardship. [ABSTRACT FROM AUTHOR]

Abstract: Background: Payment schemes exist for health care in the United States that are perverse and, in many cases, antithetical to the goals of all concerned. A fundamental reorganization will be required if care is to be broadened and sensible economies achieved. Methods: For some time, we have experimented intellectually with reorganization of the specialist/hospital axis in contemporary medical care, seeking a more functional relationship among the parties (ie, doctors, nurses, hospitals, and their patients). Results: A virtual partnership between surgical specialists and the hospital provides many of the favored factors for productive and mutually respected care for patients with a feasible method for limiting costs. Conclusions: A virtual partnership, as exemplified for 3 major surgeries, could create a relationship that benefits the patient, the surgical specialist, the hospital, and the ethical payer. [Copyright &y& Elsevier]

Healthcare costs continue to increase dramatically, while quality remains a significant problem. Reform measures adopted by Congress will fuel expansion of these costs, further stressing taxpayers and employers and forcing hospitals to adopt transformational changes as they adjust to increased demands for services and shrinking reimbursement. Cost control and quality improvement can be achieved through increased competition or greater government intervention. Competition will require unpalatable changes to the healthcare system to decrease costs without further restricting access or decreasing quality. Increased government intervention will result in changes to reimbursement and hospital-physician relations and increased demands for improved care. To improve cost and quality while preserving increased access, we advocate for a universal standard coverage of Americans; accountable healthcare system leadership; leverage of information resources to make utilization decisions and evaluate performance; alignment of physician, hospital, and payer incentives to focus on care outcomes rather than profit maximization; and the use of quasicompetition to allow for consumer choice within this system. [ABSTRACT FROM AUTHOR]

Abstract: We study the relationship between physician–hospital integration and its relation to monitoring IT utilization. We develop a theoretical model in which monitoring IT may complement or substitute for integration and test these relationships using a novel data source. Physician labor market heterogeneity identifies the empirical model. We find that monitoring IT utilization is increasing in integration, implying that expanded firm boundaries complement monitoring IT adoption. We argue that the relationship between monitoring IT and firm boundaries depends upon the contractibility of the monitored information. [Copyright &y& Elsevier]

The economic environment and the current health care debate have prompted a critical reevaluation of previous and current physician-hospital integration models. Even though the independent, self-employed, private practice, medical staff remains the most common model, surgical specialists such as vascular surgeons are increasingly being employed and integrated into health care delivery systems. The degree of integration varies from minimal to full integration or full employment. This review defines the forces driving these changes and analyzes the strengths and weaknesses of each employment model from the physicians'' point of view. Strategies for the successful implementation of a 21st century integrative employment model are discussed. [Copyright &y& Elsevier]

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