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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.

PURPOSE To explore internal medicine residents' and geriatrics fellows' perceptions of how personal, social, and institutional characteristics contribute to their professional identity and subspecialty decisions related to geriatric medicine. METHOD The authors conducted 23 in-depth, semistructured interviews with internal medicine residents, with and without an interest in geriatrics, and geriatrics fellows across 3 academic medical centers in the United States from October 2018 through June 2019. They then used a qualitative narrative approach to analyze the interview data. RESULTS Trainees related personal experiences, such as exposure to physicians and experiences with grandparents, to their interest in medicine. Trainees with an interest in geriatrics at 2 institutions did not feel supported, or understood, by peers and mentors in their respective institutions but maintained their interest in the field. The following variations between institutions that are supportive and those that are not were noted: the number of geriatricians, the proximity of the institution to geriatrics clinics, and the ways in which institutional leaders portrayed the prestige of geriatric medicine. Institutional characteristics influenced trainees' understanding of what it meant to be a doctor, what meaning they garnered from work as a physician, and their comfort with different types of complexity, such as those presented when providing care to older adults. CONCLUSIONS Institutional characteristics may be particularly important in shaping trainee interest in geriatric medicine. Institutions should encourage leadership training and opportunities for geriatricians so they can serve as role models and as hands-on mentors for trainees beginning in medical school. Increasing the number of geriatricians requires institutions to increase the value they place on geriatrics to generate a positive interest in this field among trainees. Institutions facilitating formation of professional identity and sense of purpose in work may consider engaging geriatricians in leadership and mentoring roles as well as curriculum development.

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.

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.

OBJETIVO: Desarrollar y validar un instrumento breve para evaluacion de alfabetismo en salud en el idioma portugues. METODOS: El instrumento desarrollado consiste de 50 itens que evaluan la capacidad del individuo de pronunciar y comprender terminos medicos comunes. Las propiedades psicometricas se evaluaron en una muestra de 226 ancianos brasilenos. La validez del constructo se establecio por la correlacion con el numero de anos de escolaridad, relato de alfabetismo funcional y desempeno cognitivo global. La validez discriminatoria fue establecida por la exactitud del instrumento en la deteccion de alfabetismo en salud inadecuado, definido como la incapacidad de comprender correctamente prescripciones medicas estandarizadas. RESULTADOS: Las correlaciones con los criterios de constructo presentaron magnitud moderada a alta (coeficientes de Spearman = 0,63 a 0,76). El instrumento presento tambien consistencia interna satisfactoria (Cronbach = 0,93) y buena confiabilidad examen-reexamen (coeficiente de correlacion intra-clase = 0,95). El area bajo la curva caracteristica de operacion del receptor para deteccion de alfabetismo inadecuado fue 0,82. Una version con 18 itens fue derivada y presento propiedades psicometricas similares. CONCLUSIONES: El instrumento desarrollado presento buena validez y consistencia en una muestra de ancianos brasilenos y puede ser utilizado en ambientes clinicos o de investigacion con la finalidad de detectar alfabetismo en salud inadecuado.

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.

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 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.

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.

The intent of the study was to develop and validate a comparable health literacy test for Spanish-speaking and English-speaking populations.The design of the instrument, named the Short Assessment of Health Literacy-Spanish and English (SAHL-SE), combined a word recognition test, as appearing in the Rapid Estimate of Adult Literacy in Medicine (REALM), and a comprehension test using multiple-choice questions designed by an expert panel. We used the item response theory (IRT) in developing and validating the instrument.Validation of SAHL-SE involved testing and comparing the instrument with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at the University of North Carolina Healthcare System.Based on IRT analysis, 18 items were retained in the comparable test. The Spanish version of the test, SAHL-S, was highly correlated with other Spanish health literacy instruments, Short Assessment of Health Literacy for Spanish-Speaking Adults (r=0.88, p.05) and the Spanish Test of Functional Health Literacy in Adults (TOFHLA) (r=0.62, p.05). The English version, SAHL-E, had high correlations with REALM (r=0.94, p.05) and the English TOFHLA (r=0.68, p.05). Significant correlations were found between SAHL-SE and years of schooling in both Spanish- and English-speaking samples (r=0.15 and 0.39, respectively). SAHL-SE displayed satisfactory reliability of 0.80 and 0.89 in the Spanish- and English-speaking samples, respectively. IRT analysis indicated that the SAHL-SE score was highly reliable for individuals with a low level of health literacy.The new instrument, SAHL-SE, has good reliability and validity. It is particularly useful for identifying individuals with low health literacy and could be used to screen for low health literacy among Spanish and English speakers.

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.

To examine organizational features of Veterans Affairs (VA) primary care programs hypothesized to be associated with better diabetes control, as indicated by hemoglobin A1C (HbA1C) levels.Cross-sectional cohort.We established a cohort of 224 221 diabetic patients using the VA Diabetes Registry and Dataset and VA corporate databases. The 1999 VHA (Veterans Health Administration) Survey of Primary Care Practices results were combined with individual patient data. A 2-level hierarchical model was used to determine the relationship between organizational characteristics and HbA1C levels in 177 clinics with 82 428 cohort members.The following attributes were associated with lower (better) HbA1C and were statistically significant at P.05: greater authority to establish or implement clinical policies (lower by 0.21%), greater staffing authority (0.28%), computerized diabetes reminders (0.17%), notifying all patients of their assigned provider (0.21%), hiring needed new staff during fiscal year 1999 (0.18%), having nurses that report only to the program (0.16%), and being a large academic practice (0.27%). Associated with higher (worse) HbA1C were programs reporting that patients almost always see their assigned provider (greater by 0.18%), having a quality improvement program involving all nurses without all physicians (0.38%), having general internal medicine physicians report only to the program (0.20%), and being located at an acute care hospital (0.20%).Programs that are associated with better diabetes control simultaneously have teams that actively involve physicians in quality improvement, use electronic health information systems, have authority to respond to staffing and programmatic issues, and engage patients in care.

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.