A longitudinal study of the effects of graduate medical education on hospital operating costs

OBJECTIVE: To examine the effect of graduate medical education sponsorship on hospital operating costs over a seven-year period, to test for a longitudinal association between teaching intensity and cost, and to determine whether the indirect medical education (IME) payment adjustments made under Medicare's Prospective Payment System are appropriate. DATA SOURCES: Medicare cost and payment data from the Hospital Cost Report Information System and other related HCFA files, from FFY 1989 through 1995. The study population consists of all short-stay hospitals (approximately 5,000) participating in Medicare and receiving case payments by diagnosis-related groups. STUDY DESIGN: The original cost functions used to develop indirect medical education payment adjustments under PPS are re-estimated with panel data. Specification changes are included based on findings from critiques of the original hospital cost model. Additional variations on the model are explored to test for differences by hospital status, to control for the effect of additional disproportionate share and outlier payments, and to isolate the effects of improved case-mix measurement on model results. PRINCIPAL FINDINGS: Fixed effects regression produces no evidence of a significant within-hospital association between increased sponsorship of medical residents and increased cost per case. In models designed to capture a cross-sectional association, operating costs are positively related to teaching activity, but the association shows a decline in strength over time. In all years, the strength of the association is significantly greater among hospitals eligible for disproportionate share adjustments and among major teaching hospitals. Controlling for secular trends of increased teaching intensity results in a pattern of declining cross-sectional teaching coefficients that supports a theory that observed teaching effects are the result of unmeasured case severity. CONCLUSIONS: A significant but declining cost differential is observed between teaching and nonteaching hospitals. The association appears to be related to hospital and patient characteristics that cannot be controlled using currently available case-mix and wage indices. Longitudinal models do not provide evidence to support a payment adjustment formula that allows individual hospitals to recompute their IME adjustment rates as their teaching ratios rise or fall from year to year. Cross-sectional findings suggest that re-estimations of the teaching effect may be appropriate when significant improvements occur in Medicare case-mix measurement.     

Nurse Working Conditions, Organizational Climate, and Intent to Leave in ICUs: An Instrumental Variable Approach

Objective. To investigate causes of nurse intention to leave (ITL) while simultaneously considering organizational climate (OC) in intensive care units (ICUs) and identify policy implications.
Data Sources/Study Setting. Data were obtained from multiple sources including nurse surveys, hospital administrative data, public use, and Medicare files. Survey responses were analyzed from 837 nurses employed in 39 adult ICUs from 23 hospitals located in 20 separate metropolitan statistical areas.
Study Design. We used an instrumental variable technique to assess simultaneously the relationship between OC and ITL. We estimated ordinary least squares and reduced form regressions to determine the extent of simultaneity bias as well as the sensitivity of our results to the instrumental variable model specification.
Principal Findings. Fifteen percent of the nurses indicated their ITL in the coming year. Based on the structural model, we found that nurses' ITL contributed little if anything directly to OC, but that OC and the tightness of the labor market had significant roles in determining ITL ( p values <.05). Furthermore, OC was affected by the average regionally adjusted ICU wages, hospital profitability, teaching, and Magnet status ( p values <.05).
Conclusions. OC is an important determinant of ITL among ICU nurses. Because higher wages do not reduce ITL, increased pay alone without attention to OC is likely insufficient to reduce nurse turnover. Implementing interventions aimed at creating a positive OC, as found in Magnet hospitals, may be a more effective strategy.     

Hospital type and patient outcomes: an empirical examination using AMI readmission and mortality records

This paper investigates whether there are differences in patient outcomes across different types of hospitals using patient‐level data on readmission and mortality associated with acute myocardial infarction (AMI). Hospitals are grouped according to their ownership type (private, public teaching, public non‐teaching) and their location (metropolitan, country and remote country). Using data collected from 130 Victorian hospitals on 19 000 patients admitted to a hospital with their first AMI between January 2001 and December 2003, we consider how the likelihood of unplanned re‐admission and mortality varies across hospital type. We find that there are significant differences across hospital types in the observed patient outcomes – private hospitals persistently outperform public hospitals. Copyright © 2009 John Wiley & Sons, Ltd.     

Rural doctors are naturally effective teachers

ABSTRACT: As part of a larger project, the authors observed the teaching of nine rural doctors in rural centres in southern Queensland. The observations were designed to provide data about the realities of teaching and learning in rural settings, so that they could be used to refine an existing model which described effective clinical teaching in hospital settings. Once refined, the model is to form the foundation of a video-based rural teaching resource kit for use in rural general practice and hospital settings. While the observation strategy was excellent in serving the wider purpose, the observations also revealed important information about effective teaching per se. Essentially, rural practitioner—teachers in the sample were very effective facilitators of quality learning,¹ despite their lack of formal teacher education. This paper reports the characteristics of their effective teaching, taken from a synthesis of the observation data. The proposition is that a great deal about effective teaching can be learnt from them. A second, broader proposition is that there are implications for those who seek to provide teacher education for medical teachers in all situations.     

Quality of clinical supervision as perceived by attending doctors in university and district teaching hospitals

CONTEXT: Attending doctors (ADs) play important roles in the supervision of specialist registrars. Little is known, however, about how they perceive the quality of their supervision in different teaching settings. We decided to investigate whether there is any difference in how ADs perceive the quality of their supervision in university teaching hospital (UTH) and district teaching hospital (DTH) settings. METHODS: We used a standardised questionnaire to investigate the quality of supervision as perceived by ADs. Fifteen items reflecting good teaching ability were measured on a 5-point Likert scale (1-5: never-always). We investigated for factors that influenced the perceived quality of supervision using Likert scale items (1-5: totally disagree-totally agree) and open-ended questionnaires. RESULTS: A total of 83 ADs (UTH: 51; DTH: 32) were eligible to participate in the survey. Of these, 43 (52%) returned the questionnaire (UTH: 25; DTH: 18). There was no difference in the overall mean of the 15 items between the UTH (3.67, standard deviation [SD] 0.35) and DTH (3.73, SD 0.31) ADs. Attending doctors in the DTH group rated themselves better at 'teaching technical skills' (mean 3.50, SD 0.70), compared with their UTH counterparts (mean 3.0, SD 0.76) (P = 0.03). Analysis of variance of the overall means revealed no significant difference between the different hospital settings. CONCLUSIONS: The results suggest that teaching hospital environments do not influence how ADs perceive the quality of their supervision. Lack of time for teaching was perceived as responsible for poor supervision. Other factors found to influence AD perceptions of good supervision included effective teaching skills, communication skills and provision of feedback.     

Functional form and risk adjustment of hospital costs: Bayesian analysis of a Box-Cox random coefficients model

While risk-adjusted outcomes are often used to compare the performance of hospitals and physicians, the most appropriate functional form for the risk adjustment process is not always obvious for continuous outcomes such as costs. Semi-log models are used most often to correct skewness in cost data, but there has been limited research to determine whether the log transformation is sufficient or whether another transformation is more appropriate. This study explores the most appropriate functional form for risk-adjusting the cost of coronary artery bypass graft (CABG) surgery. Data included patients undergoing CABG surgery at four hospitals in the midwest and were fit to a Box-Cox model with random coefficients (BCRC) using Markov chain Monte Carlo methods. Marginal likelihoods and Bayes factors were computed to perform model comparison of alternative model specifications. Rankings of hospital performance were created from the simulation output and the rankings produced by Bayesian estimates were compared to rankings produced by standard models fit using classical methods. Results suggest that, for these data, the most appropriate functional form is not logarithmic, but corresponds to a Box-Cox transformation of -1. Furthermore, Bayes factors overwhelmingly rejected the natural log transformation. However, the hospital ranking induced by the BCRC model was not different from the ranking produced by maximum likelihood estimates of either the linear or semi-log model.     

Combined Linkage and Association Analysis in Pedigrees

We applied a combined linkage and association model for quantitative traits in pedigrees to identify possible functional polymorphisms and to test for association resulting from population stratification and admixture. Functional polymorphisms are identified as variants that are significantly associated with a trait (high x² value) and showing no residual evidence of linkage (low lod score). Applying our model to the simulated data in the population isolate (replicate 1) we correctly identified the polymorphism in gene 6 (MG1) that affects Q1. Without modeling association the lod score for Q1 was 5.4. At the site of the functional variant (5782 bp) the association x² was 88.1 on 1 df (p < 0.001) and the lod score was 0.003. We estimated a 3.7‐unit increase in the average Q1 for each extra copy of the polymorphism (95% CI = 2.95–4.41) and there was no evidence of population stratification or admixture (x²= 0.08 on 2 df). For Q5 and gene 2, modeling the sequence variants at 11 loci simultaneously identified multiple functional variants. Including the main effect of 11 marker genotypes reduced the lod score at gene 2 from 8.7 to 0.9. Again, no evidence of population stratification or admixture was found (all x²< 4.9 on 2 df; p > 0.05). © 2001 Wiley‐Liss, Inc.     

多媒体教学法和传统教学法在消化内科教学中的应用对比分析

目的比较多媒体教学法和传统教学法在消化内科教学中的应用。方法选择某院2010年2月～2010年6月消化内科学生160人,在教学中大部分内容采用多媒体教学法,本组学习为多媒体组,同时选择2010年2月～2010年6月160名采用传统教学方法的学生为传统组;学习结束后,分别采用问卷调查表的形式对两组学生的学习兴趣、学习态度进行调查,比较教学结束时两组学生的考试成绩。结果 94.23%的学生认为多媒体教学方法优于传统模式,90.77%的学生认为学习内容掌握情况提高;95%的学生认为该教学模式易于理解和接受。多媒体组期中考试成绩为(82.3±14.2)分;期末考试成绩为(84.6±13.2)分,期末比期中成绩略有提高,但差异无统计学意义(P﹥0.05);多媒体组期中与期末考试成绩略高于传统组,但两组比较差异无统计学意义(P﹥0.05)。结论多媒体教学能明显提高消化内科学教学的质量,但并不是万能的。传统教育具有一定的片面性,两者有机的结合可以达到最佳的教学效果。     

Multilevel moderated mediation model with ordinal outcome

Although increasingly complex models have been proposed in mediation literature, there is no model nor software that incorporates the multiple possible generalizations of the simple mediation model jointly. We propose a flexible moderated mediation model allowing for (1) a hierarchical structure of clustered data, (2) more and possibly correlated mediators, and (3) an ordinal outcome. The motivating data set is obtained from a European study in nursing research. Patients' willingness to recommend their treating hospital was recorded in an ordinal way. The research question is whether such recommendation directly depends on system‐level features in the organization of nursing care, or whether these associations are mediated by 2 measurements of nursing care left undone and possibly moderated by nurse education. We have developed a Bayesian approach and accompanying program that takes all the above generalizations into account.     

Impact of a smoke-free hospital campus policy on employee and consumer behavior

OBJECTIVE: Although smoke-free hospital campuses can provide a strong health message and protect patients, they are few in number due to employee retention and public relations concerns. We evaluated the effects of implementing a clean air policy on employee attitudes, recruitment, and retention; hospital utilization; and consumer satisfaction in 2003 through 2005. METHODS: We conducted research at a university hospital campus with supplemental data from an affiliated hospital campus. Our evaluation included (1) measurement of employee attitudes during the year before and year after policy implementation using a cross-sectional, anonymous survey; (2) focus group discussions held with supervisors and security personnel; and (3) key informant interviews conducted with administrators. Secondary analysis included review of employment records and exit interviews, and monitoring of hospital utilization and patient satisfaction data. RESULTS: Employee attitudes toward the policy were supportive (83.3%) at both institutions and increased significantly (89.8%) at post-test at the university hospital campus. Qualitatively, administrator and supervisor attitudes were similarly favorable. There was no evidence on either campus of an increase in employee separations or a decrease in new hiring after the policy was implemented. On neither campus was there a change in bed occupancy or mean daily census. Standard measures of consumer satisfaction were also unchanged at both sites. CONCLUSION: A campus-wide smoke-free policy had no detrimental effect on measures of employee or consumer attitudes or behaviors.