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As part of the Measurement Approaches to Partnership Success study, we investigated the relationship between benefits and costs of participation in long-standing community-based participatory research (CBPR) partnerships using social exchange theory as a theoretical framework. Three major findings were identified: (a) the concept of benefits and costs operating as a ratio, where individual benefits must outweigh costs for participation, applies to early stages of CBPR partnership formation; (b) as CBPR partnerships develop, the benefits and costs of participation include each other’s needs and the needs of the group as a whole; and (c) there is a shift in the relationship of benefits and costs over time in long-standing CBPR partnerships, in which partners no longer think in terms of costs but rather investments that contribute to mutual benefits.

Mixed methods research (MMR) is versatile, pragmatic, and adaptable to constraints and opportunities during a research process. Although MMR has gain popularity in health services management research, little is known about how the research approach has been used and the quality of research. We conducted a systematic review of 198 MMR articles published in selected U.S.-based and international health services management journals from 2000 through 2018 to examine the extent of MMR application and scientific rigor. Results showed limited, yet increasing, use of MMR and a high degree of correspondence between MMR designs and study purposes. However, most articles did not clearly justify using MMR designs and the reporting of method details and research integration were inadequate in a significant portion of publications. We propose a checklist to assist the preparation and review of MMR manuscripts. Additional implications and recommendations to improve transparency, rigor, and quality in MMR are discussed.

POLICY POINTS: Dissemination of Choosing Wisely guidelines alone is unlikely to reduce the use of low‐value health services. Interventions by health systems to implement Choosing Wisely guidelines can reduce the use of low‐value services. Multicomponent interventions targeting clinicians are currently the most effective types of interventions. CONTEXT: Choosing Wisely aims to reduce the use of unnecessary, low‐value medical services through development of recommendations related to service utilization. Despite the creation and dissemination of these recommendations, evidence shows low‐value services are still prevalent. This paper synthesizes literature on interventions designed to reduce medical care identified as low value by Choosing Wisely and evaluates which intervention characteristics are most effective. METHODS: We searched peer‐reviewed and gray literature from the inception of Choosing Wisely in 2012 through June 2019 to identify interventions in the United States motivated by or using Choosing Wisely recommendations. We also included studies measuring the impact of Choosing Wisely on its own, without interventions. We developed a coding guide and established coding agreement. We coded all included articles for types of services targeted, components of each intervention, results of the intervention, study type, and, where applicable, study quality. We measured the success rate of interventions, using chi‐squared tests or Wald tests to compare across interventions. FINDINGS: We reviewed 131 articles. Eighty‐eight percent of interventions focused on clinicians only; 48% included multiple components. Compared with dissemination of Choosing Wisely recommendations only, active interventions were more likely to generate intended results (65% vs 13%, p < 0.001) and, among those, interventions with multiple components were more successful than those with one component (77% vs 47%, p = 0.002). The type of services targeted did not matter for success. Clinician‐based interventions were more effective than consumer‐based, though there is a dearth of studies on consumer‐based interventions. Only 17% of studies included a control arm. CONCLUSIONS: Interventions built on the Choosing Wisely recommendations can be effective at changing practice patterns to reduce the use of low‐value care. Interventions are more effective when targeting clinicians and using more than one component. There is a need for high‐quality studies that include active controls.

Individuals with kidney failure receiving dialysis have high morbidity and mortality rates and their condition is associated with poor health-related quality of life.[1][1] To address these unacceptably poor outcomes, the nephrology community has called for innovation in dialysis therapy and

This study aimed to (1) examine what patient-centeredness means for older adults and family caregivers, and (2) assess circumstances underlying their preference for geriatric care. We conducted separate focus groups with older adults and family caregivers of older adults about health care experiences and expectations and conducted a vignette-based experiment to assess preference for geriatric care. Participants expressed a need for greater skill and empathy and integration of caregivers. They preferred geriatric care to usual primary care with increasing social, health, and healthcare complexity. Distinct needs of older adults should be considered in referral practices to geriatric medicine.

Primary care organizations must transform care delivery to realize the Institute for Healthcare Improvement's Triple Aim of better healthcare, better health, and lower healthcare costs. However, few studies have considered the financial implications for primary care practices engaged in transformation. In this qualitative, comparative case study, we examine the practice-level personnel and nonpersonnel costs and the benefits involved in transformational change among 12 primary care practices participating in North Carolina's Improving Performance in Practice (IPIP) program. We found average annual opportunity costs of $21,550 ($6,659 per full-time equivalent provider) for maintaining core IPIP activities (e.g., data management, form development and maintenance, meeting attendance). This average represents the cost of a 50% full-time equivalent registered nurse or licensed practical nurse. Practices were able to limit transformation costs by scheduling meetings during relatively slow patient care periods and by leveraging resources such as the assistance of IPIP practice coaches. Still, the costs of practice transformation were not trivial and would have been much higher in the absence of these efforts. Benefits of transformation included opportunities for enhanced revenue through reimbursement incentives and practice growth, improved efficiency and care quality, and maintenance of certification. Given the potentially high costs for some practices, policy makers may need to consider reimbursement and other strategies to help primary care practices manage the costs of practice redesign.

Improving health care and quality of life for older adults in the U.S. requires increased attention to the informal caregivers supporting aging relatives. Studies estimate that over 40 million unpaid caregivers provide more than $400 billion of unpaid care; however, there is little research examining the scope and variety of support caregivers provide. Less research has examined how caregivers conceptualize their experience beyond “caregiver burden”. A more comprehensive understanding of the types of support caregivers provide and caregiver perceptions of their role and purpose are critical to enhancing policies, e.g., the Family and Medical Leave Act, to be more responsive to caregiver needs. This study seeks to (a) identify the ways informal caregivers provide support and (b) describe what it means to be a caregiver from the perspective of informal caregivers. We conducted four focus groups with informal caregivers (relatives or partners) in Southeastern Michigan (n=18) and conducted qualitative thematic analyses. Support that caregivers provide ranges from financial planning to medical decision-making to social engagement. While caregivers face frustration and isolation consistent with “caregiver burden,” they also recognize positive attributes of being a caregiver such as overcoming adversity and helping elderly relatives maintain dignity. These attributes contribute to their identity of what it means to be a caregiver and perceived capacity to improve their relative’s health. Our findings suggest that we are underestimating the scope of work involved in care-giving and that a wider range of activities should be considered when developing workplace policies and resources to promote caregiver wellness.

The rate of successful health care innovation implementation is dismal. Middle managers have a potentially important yet poorly understood role in health care innovation implementation. This study used self-administered surveys and interviews of middle managers in health centers that implemented an innovation to reduce health disparities to address the questions: Does middle managers’ commitment to health care innovation implementation influence implementation effectiveness? If so, in what ways does their commitment influence implementation effectiveness? Although quantitative survey data analysis results suggest a weak relationship, qualitative interview data analysis results indicate that middle managers’ commitment influences implementation effectiveness when middle managers are proactive. Scholars should account for middle managers’ influence in implementation research, and health care executives may promote implementation effectiveness by hiring proactive middle managers and creating climates in which proactivity is rewarded, supported, and expected.

Despite the appeal of peritoneal dialysis (PD) among patients, payers, and providers, its use in the United States has been limited and declining. Prior research has found that patient factors explain little variation in PD utilization, and little is known about the contribution of dialysis facility factors. The authors examined market factors associated with the provision of PD services in dialysis facilities between 1995 and 2003. Less than half of dialysis facilities offered PD. PD provision was not explained by disease trends or patient characteristics commonly associated with PD use. Facilities were more likely to offer PD in less competitive and less spatially concentrated markets. PD services may not be available to all patients who would benefit from it and there may be insufficient demand, economics of scale, or incentives for facilities to provide PD. These findings warrant further investigation on dialysis facilities’ provision of a preferred, potentially beneficial, and cost-effective therapy.

The study extended the work on governing boards and organization change by examining how governing board configurations influenced major organizational change in U.S. hospitals. Also examined were ...

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.

This entry provides an overview of the health care delivery system in Taiwan, followed by a discussion of the country's national health insurance program – the major source of financing for the health care delivery system – its design and operational features. Next we examine the challenges that the health care delivery system faces and the response of the government. We also discuss the role and future of traditional Chinese medicine (TCM) in the Taiwanese health care delivery system. Keywords: health care system; health insurance; medicine; social policy

This study examines the comparative distributions of postresident international medical graduates (IMGs) and US medical graduates (USMGs) in high and low poverty areas of US cities. Existing research has established that IMGs are more likely than USMGs to practice in urban areas, yet there is the question whether IMGs locate more frequently than USMGs in urban poverty areas.Data from the 1997 AMA Physician Masterfile and 1990 US Census were merged to classify physicians' practices into low- and high-poverty areas in selected cities.In 14 cities with populations of 2.5 million or more, IMGs were located in a statistically significant disproportion in poverty areas of 7 cities. Of 36 cities with populations of 1,000,000 to 2,499,999, there were 5 cities that had significant IMG disproportions in poverty areas. Of a random sample of 27 cities with populations of 250,000 to 999,999, there were 2 cities that had significant IMG disproportions. Many cities in all three size categories had a large proportionate IMG complement of the total physician workforce located within high-poverty areas.IMGs were found in disproportionate numbers in poverty areas in a number of US cities, especially the very largest ones. These findings are discussed in light of the current debate about a physician surplus and initiatives to reduce the number of IMGs in residency training.

The objectives of this study are to compare the rural location of international medical graduates (IMGs) and U.S. medical graduates (USMGs) by specialty (primary care vs. specialty care) according to geographical measures of need. This study utilized a cross-sectional survey using the 1997 American Medical Association Physician Masterfile for all active post-resident allopathic physicians and the Area Resource File (ARF) (Bureau of Health Professions, 1996) for all active post-resident osteopathic physicians in 1995 in the rural U.S. physician work force (N = 69,065). Allopathic physician ZIP code location was matched to county data using the ARF. The key measure was the difference in proportions between USMGs and IMGs in each state's rural counties characterized by need: high infant mortality, low socioeconomic status, high proportion of nonwhite population, high proportion of population 65 years and older, and low physician-to-population ratio. Primary care and specialty care rural physicians were studied separately. A disproportion of IMGs were located in needy rural counties of more states than were USMGs. Further, IMG disproportions were generally larger than USMG disproportions when they existed. Disproportions of IMGs tended to be located more often in the central and south census regions. Disproportions of specialty care IMGs were more frequent and of greater magnitude than those of primary care IMGs. Variations in the relative and absolute numbers of IMGs and USMGs among the states was wide. Services delivered by active post-resident primary care and specialty care IMGs appeared to be disproportionate to their overall number compared with USMGs in numerous needy rural counties. The extent of the IMG "safety net" presence differed, however, by the criteria used. Still, proposed limits on IMG entry into U.S. residency training may create long-term problems of access to rural physician services absent policies to induce USMGs or midlevel practitioners to locate in such areas. State-by-state assessments of the potential impact of IMG restrictions are called for because of the wide state-level variation that existed in comparative IMG-USMG distributions.

Organizational change has become commonplace among U.S. hospitals. Empirical investigations of the consequences of organizational change, however, are relatively scarce, and findings of existing studies are inconsistent. In this article, the authors review the rationale and performance implications of hospital organizational change in three areas: (1) the development of new multi-institutional arrangements, (2) change in traditional ownership and management configurations, and (3) diversification in organizational products/services and consolidation of organizational scale. Empirical research on hospital change published between 1980 and 1999 in the health services research, social science, and business literatures is reviewed to highlight the potential pitfalls that hospitals may encounter in their effort to remain viable. The article also summarizes the strengths and weaknesses of current hospital change research and provides specific suggestions for future research in this area.

Trust is a key element of effective work relationships between managers and physicians. Despite its importance, little is known about the factors that promote trust between these two professional groups. We examine whether manager and physician power over hospital decisions fosters manager-physician trust. We expect that with more power, managers and physicians will have greater control to enforce decisions that benefit the interests of both groups. Subsequently, they may gain confidence that their interests are supported and have more trust for each other. We test proposed hypotheses with data collected in a national study of chief executive officers and physician leaders in community hospitals in 1993. Findings indicate that power of managers and physicians over hospital decisions is related to manager-physician trust. Consistent with our expectations, physicians perceive greater trust between the two groups when they hold more power in four separate decision-making areas. Our hypotheses, however, are only partially supported in the manager sample. The relationship between power and trust holds in only one decision area: cost/quality management. Our findings have important implications for physician integration in hospitals. A direct implication is that physicians should be given the opportunity to influence hospital decisions. New initiatives, such as task force committees with open membership or open forums on hospital management, allow physicians a more substantial involvement in decisions. Such initiatives will give physicians more "voice" in hospital decision making, thus creating opportunities for physicians to express their interests and play a more active role in the pursuit of the hospital's mission and objectives.

The study proposes that organizations engaged in related acquisition may encourage CEO succession as a mechanism for integrating acquired organizations. Further, we suggest that the risk of CEO succession at the time of acquisition will vary based on the need for integrative action and the power of acquired organizations. Results show that CEO succession is more likely when the participating organizations have incompatible types of ownership and when acquired CEOs have longer tenure than their counterparts. Conversely, the probability of CEO succession is lower among larger acquired organizations. Performance of the acquired organization does not affect the relationship between related acquisition and CEO succession.

One in five physicians practising in the US received their initial medical qualifications in another country. Contrary to expectations, a large cadre come from developed nations such as New Zealand and Australia. In particular, these two countries provide a unique prism with which to view the international flow of medical talent. While they differ from developing nations that primarily export physicians without attracting others in return, they are distinguished from importing nations such as the US which rarely export. Our analysis is based on a unique dataset collected from three cross-sectional sources. We found that, compared to post-resident physicians remaining at home, New Zealand medical graduates (NZMGs) and Australian medical graduates (AMGs) in the US are typically older, more likely to be male, more likely to have received their initial medical qualifications from certain schools, less likely to be employed in a public hospital setting, more likely to work in a medical school and more likely to practice in a specialty than primary care. Additional findings show that NZMGs and AMGs in the US are more likely than other US physicians to have established themselves in areas with 50 000 or more people and are therefore more likely to serve a population with sociodemographic characteristics typical of the nation's urban centers. It appears then, that NZMGs and AMGs may be emigrating to the US for educational and professional opportunities that may be unavailable at home. In short, the emigration of NZMGs and AMGs may be an instance of what has come to be called the `international equity problem' or `brain drain'. However, losses resulting from the disproportionate migration of New Zealand and Australian physicians to the US may be compensated for by the importation of foreign trained physicians from other nations. Future analysis must be extended to take this facet of the international flow phenomena into account.

PURPOSE This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. METHODS We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. RESULTS Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the fi rst year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of perform- ing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no signifi cant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. CONCLUSIONS In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.

Health care organization leaders and policy makers seeking ways to reform the delivery of health care have become increasingly interested in transformational change. To foster understanding of how organizational transformation occurs and to stimulate further research, we report findings from a systematic review of empirical research on transformational change in the health care and non–health care literature, with a focus on the antecedents, processes (or paths), and outcomes of transformational change. Fifty-six studies, of which 13 were in health care, met our selection criteria. With one exception, all were published since 1990, indicating the recent upsurge of interest in this area. Limited differences were found between health care and non–health care studies. Available research documents the multiplicity of factors affecting change and the complexity of their interactions, but less information is available about the processes of transformational change than about its antecedents and consequences. Research and practice implications are discussed.

Background Middle managers have received little attention in extant health services research, yet they may have a key role in healthcare innovation implementation. The gap between evidence of effective care and practice may be attributed in part to poor healthcare innovation implementation. Investigating middle managers' role in healthcare innovation implementation may reveal an opportunity for improvement. In this paper, we present a theory of middle managers' role in healthcare innovation implementation to fill the gap in the literature and to stimulate research that empirically examines middle managers' influence on innovation implementation in healthcare organizations. Discussion Extant healthcare innovation implementation research has primarily focused on the roles of physicians and top managers. Largely overlooked is the role of middle managers. We suggest that middle managers influence healthcare innovation implementation by diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation. Summary Teamwork designs have become popular in healthcare organizations. Because middle managers oversee these team initiatives, their potential to influence innovation implementation has grown. Future research should investigate middle managers' role in healthcare innovation implementation. Findings may aid top managers in leveraging middle managers' influence to improve the effectiveness of healthcare innovation implementation.

During the past few decades, the nursing workforce has been in crisis in the United States and around the world. Many health care organizations in developed countries recruit nurses from other countries to maintain acceptable staffing levels. The Philippines is the centre of a large, mostly private nursing education sector and an important supplier of nurses worldwide, despite its weak domestic health system and uneven distribution of health workers. This situation suggests a dilemma faced by developing countries that train health professionals for overseas markets: how do government officials balance competing interests in overseas health professionals' remittances and the need for well-qualified health professional workforces in domestic health systems? This study uses case studies of two recent controversies in nursing education and migration to examine how Philippine government officials represent nurses when nurse migration is the subject of debate. The study finds that Philippine government officials cast nurses as global rather than domestic providers of health care, implicating them in development more as sources of remittance income than for their potential contributions to the country's health care system. This orientation is motivated not simply by the desire for remittance revenues, but also as a way to cope with overproduction and lack of domestic opportunities for nurses in the Philippines.

Background The use of tocolytic hospitalization in antenatal care is controversial and worthy of more research. We investigated individual, institutional, and area factors that affect the use of tocolytic hospitalizations in Taiwan where fertility has rapidly declined. Methods Longitudinal data from the 1996 to 2004 National Health Insurance Research Database in Taiwan were used to identify tocolytic hospitalizations. The probit model was used to estimate factors associated with tocolytic hospitalizations. Results The decline in fertility was significantly associated with the probability of tocolytic hospitalizations. Several physician and institutional factors-including physician's age, hospital ownership, accreditation status, bed size, and teaching status-were also significantly correlated to the dependent variables. Conclusions The provision of inpatient tocolysis is influenced not only by clinical considerations but also by physician, institutional, and area factors unrelated to clinical need. Fertility declines in Taiwan may have led obstetricians/gynecologists to provide more tocolysis to make up for their lost income. If the explanation is further validated, reimbursement policies may need to be reviewed to correct for overuse of inpatient tocolysis. The correlation could also be explained by the increasing use of artificial reproductive technologies and higher social value of newborns. In addition, the physician and institutional variations observed in the study indicate potential misuse of inpatient tocolysis that warrant further investigation.

Over the past two decades, end-of-life organizations have served an increasing number of children and young adults and expanded services important to terminally ill youth, and yet we know little about these organizations. The purpose of this study was to describe the characteristics of end-of-life care organizations that admitted children and young adults to hospice care. Using data from the 2007 National Hospice and Palliative Care Organization (NHPCO) Survey, we conducted a descriptive analysis of operational, mission, market, and financial characteristics, and explored a sub-analysis by age group. Our analysis revealed that these organizations had similar profit status, ownership, and payer mix when compared to the hospice industry. However, they differed in agency type, referrals, organizational size, geographic location, team member caseload, and revenues. We also found important differences in organizations that provided hospice care by age groups (infants, toddler, school-age children, and adolescents/young adults) in geographic location, region, agency type, accreditation, and team member caseload. These findings have managerial and policy implications.

In the United States, a debate has existed for decades about whether foreign-trained physicians (known in the US as 'international medical graduates' or 'IMGs') and US medical graduates (USMGs) have been differentially distributed such that IMGs were more likely to be found in locales characterized as high in need or medical underservice. This 'safety net' hypothesis has been countered by the IMG 'surplus exacerbation' argument that IMGs have simply swelled an already abundant supply of physicians without any disproportionate service to areas in need. Through an analysis of the American Medical Association Physician Masterfile and the Area Resource File, we classified post-resident IMGs and USMGs into low and high need counties in each of the US states, compared the percentage distributions, and determined whether IMGs were found disproportionately in high need or underserved counties. Using four measures (infant mortality rate, socio-economic status, proportion non-white population, and rural county designation), we show that there were consistently more states having IMG disproportions than USMG disproportions. The magnitude of the differences was greater for IMGs than for USMGs, and there was a correlation between IMG disproportions and low doctor/100,000 population ratios. These findings are shown to exist simultaneously with two empirical facts: first, not all IMGs were located in high new or underserved counties; second, IMGs were more likely than USMGs to be located in states with a large number of physicians. The juxtaposition of an IMG presence in 'safety net' locales and of IMGs' contribution to a physician abundance is discussed within the context of the current debate about a US physician 'surplus' and initiatives to reduce the number of IMGs in residency training.

Objective: Not-for-profit (NFP) hospitals have come under increased public scrutiny for management practices that are inconsistent with their charitable focus. Of particular concern is the amount o...