Regionalization of services within a multihospital health maintenance organization.

Among the many factors that may explain lower costs for enrollees in Health Maintenance Organizations (HMOs) is the possibility that the HMO provides inpatient services more efficiently. While direct cost comparisons are in appropriate, it is reasonable to examine whether the Kaiser program in the San Francisco Bay Area regionalizes services among its ten hospitals. The presence of each of 43 facilities/services reported is examined in a regression model that includes type of hospital, size, a size-type interaction, and the distance to the nearest competing facility. When the generally smaller size of the Kaiser hospitals was controlled for, Kaiser hospitals had fewer technologically based services and concentrated these services in larger hospitals. Kaiser had more outpatient-oriented services. Among non-Kaiser hospitals, some specialized facilities were competitively distributed.     

Keeping an eye on Kaiser the giant

The Kaiser name is everywhere in California, and because of its size, competing hospitals tend to keep close track of what the company is doing. Through mergers and affiliations, more facilities are building the marketing and financial muscle needed to do battle with the giant. Meanwhile, as Kaiser has expanded outside the West Coast, struggles have accompanied the successes.     

Medical Cost-Offset Following Treatment Referral for Alcohol and Other Drug Use Disorders in a Group Model HMO

The purpose of this study was to determine whether specialty alcohol and other drug (AOD) treatment is associated with reduced subsequent medical care costs. AOD treatment costs and medical costs in a group model health maintenance organization (HMO) were collected for up to 6 years on 1,472 HMO members who were recommended for specialty AOD treatment, and on 738 members without AOD diagnoses or treatment. Addiction Severity Index measures were also obtained from a sample of 293 of those recommended for treatment. Changes in medical costs did not differ between treatment and comparison groups. Nor did individuals with improved treatment outcomes have greater reductions in medical costs. AOD treatment costs were not inversely related to subsequent medical costs, except for a subgroup with recent AOD treatment. In the interviewed sample, better treatment outcomes did not predict lower subsequent medical costs. Multiple treatment episodes may hold promise for producing cost-offsets.Donald K. Freeborn, PhD, is a senior investigator at Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227, USA.Frances L. Lynch, PhD, is an investigator at Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227, USA.John P. Mullooly, PhD, is a senior investigator at Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227, USA.Daniel M. Dickinson, MA, CADC, is a clinical manager at the Department of Addiction Medicine, Kaiser Permanente, One Town Center Office, 10163 S.E. Sunnyside Road, Suite 490, Clackamas, OR 97015, USA.     

Inconsistencies between self-reported ethnicity and ethnicity recorded in a health maintenance organization

PURPOSE: Information on patient ethnicity in hospital admissions databases is often used in epidemiologic and health services research. However, the extent of consistency of these data with self-reported ethnicity is not well studied, particularly for specific Asian subgroups. We examined agreement between ethnicity in records of a sample of members of five Northern California Kaiser Permanente medical centers with self-reported ethnicity. METHODS: Subjects were 3168 cases and 2413 controls aged 45 years and older from a study of fractures. Ethnicity recorded in the Kaiser admissions database (primarily inpatient) was compared with self-reported ethnicity from the study interviews. RESULTS: Among study subjects with available Kaiser ethnicity, sensitivities and positive predictive values of the Kaiser classification were high among blacks (0.95 for both measures) and whites (0.98 and 0.94, respectively), slightly lower among Asians (0.88 and 0.95, respectively), and considerably lower among Hispanics (0.55 and 0.81, respectively) and American Indians (0.47 and 0.50, respectively). Among Asian subgroups, the proportion classified as Asian was high among Chinese (0.94) and Japanese (0.99) but lower among Filipinos (0.79) and other Asians (0.74). Among the 228 (4%) subjects who self-identified with multiple ethnicities, 13 of 18 white + Hispanic subjects were classified as being white, and of the 77 subjects identifying as part American Indian, only one was classified as being American Indian in the Kaiser database. CONCLUSIONS: Given the importance of ethnicity information, medical facilities should be encouraged to adopt policies toward collecting high quality data.     

Central service in Siberia

In 1992, eight healthcare professionals from United Hospital in Grand Forks, North Dakota spent six weeks in Ishim, in the Siberian region of Russia, on a medical information exchange to observe the methods of healthcare delivery, assess the needs of medical facilities and share technical advice where applicable. Ishim's CS workers were anxious to learn how to better utilize the resources they had--which were few. Supplies were so limited that CS workers were provided little personal protective equipment; there were not even gloves available for handling contaminated instruments in the washing and decontamination areas. Ishim's facility reprocessed virtually everything, including tongue depressors and surgeons' gloves. The CS department cleaned, assembled and sterilized instruments for Ishim City Hospital's OR and for the city's 28 clinics. When United's representatives returned to the U.S., they formed a supply committee to procure instruments and other needed materials for the Russian hospital and clinics.     

Implementing right-to-know legislation for health care workers in Manitoba: a bipartite sectoral train-the-trainer approach.

In October 1988, right-to-know legislation was introduced in Canada. This presented a technical and administrative challenge to the health care sector. With over 170 health care facilities in Manitoba to be brought into compliance, some large, some small, some rural, some urban, a cooperative approach was needed. A labor-management steering committee with representatives from a cross-section of facilities as well as the various health care unions was formed to design and implement a train-the-trainer program. A small-group, highly participatory modular program was developed with input from all parties, and delivered across the province by trainers selected jointly by labor and management. The program achieved its goal of assisting member facilities to implement the legislation. Follow-up surveys and discussions with health care workers showed improved understanding of labelling requirements, material safety data sheet interpretation, and requirements for hazard control. This first bipartite program empowered the health care workforce to use its newly acquired right-to-know, and has provided the incentive to implement other cooperative safety and health programs.     

Ethics Committees in the Rural Midwest: Exploring the Impact of HIPAA

ABSTRACT:  Context: Confidentiality of personal health information is an ethical principle and a legislated mandate; however, the impact of the Health Insurance Portability and Accountability Act (HIPAA) on ethics committees ethics committees is limited. Purpose: This study investigates the prevalence, activity, and composition of ethics committees located in rural central and southern Illinois. Additionally, the impact of the HIPAA Officer serving on the committee is reported. Methods: Surveys were mailed to the "Administrator or Ethics Committee Chairperson" at rural Illinois hospitals and skilled care facilities. Survey items included committee composition and perception of HIPAA-related involvement. Findings: Over one third (36.7%) of the facilities reported having formal ethics committees. Hospitals were more likely (79.3%) to have ethics committees than skilled nursing facilities (20.7%). Ethics committee members usually include an administrator, nurse, and physician. The smaller the facility (based on number of beds), the more likely it was to have a HIPAA Officer on the committee. Committees with a HIPAA Officer were more likely to be involved in monitoring and/or remediation of HIPAA privacy and security violations. Most respondents, however, did not feel the committee should be involved in these issues. Conclusions: Although the sample size is too small to generalize, HIPAA does seem to have an effect on the issues discussed by ethics committees. Furthermore, ethics committees that include a HIPAA Officer in the membership report increased committee involvement in HIPAA related issues .     

Healthcare-associated infection among residents of long-term care facilities: a cohort and nested case-control study

Knowledge of infection control measures in nursing homes is limited. This study aimed to assess the incidence of, and potential risk factors for, healthcare-associated infection in long-term care facilities in Norway. Incidence of healthcare-associated infection was recorded prospectively in six long-term care facilities located in two major cities in Norway between 1 October 2004 and 31 March 2005. For each resident with an infection we aimed for two controls in a nested case-control study to identify potential risk factors. Incidence of infection was 5.2 per 1000 resident-days. Urinary and lower respiratory tract infections were the most common. Patients confined to their beds [odds ratio (OR=2.7)], who stayed <28 days (OR=1.5), had chronic heart disease (OR=1.3), urinary incontinence (OR=1.5), an indwelling urinary catheter (OR=2.0) or skin ulcers (OR=1.8) were shown to have a greater risk for infection. Age, sex and accommodated in a two- versus single-bed room were not significant factors. Incidence of infection in nursing homes in Norway is within the range reported from other countries. This study identified several important risk factors for healthcare-associated infection. There is a need to prevent infection by implementing infection control programmes including surveillance in long-term care facilities.     

Local governance and community financing of primary care: evidence from Nepal

Improved community participation in the financing of primary health care (PHC) is important for sustaining quality and availability of care in developing countries. This study asks whether the social status of members on a local support committee is associated with community contributions to PHC. A survey of PHC financing was conducted at 42 health facilities in two rural districts of Nepal (Jumla and Nawal Parasi). Complete data were available for 37 clinics. At each health facility, a trained interviewer collected information from the clinic administrator about the caste characteristics of the Village Development Committees (VDC) and the financial contributions made by VDCs towards the operation of the health facilities. Bivariate and multivariate logistic regression assessed the likelihood of financial contribution as it related to the caste and gender composition of the VDC as well as other characteristics of the VDC and the facility. VDCs with a majority of committee members in castes other than the highest two had higher odds of contributing to the health centre. We conclude that local development committees with a greater representation of middle and low caste members are more likely to contribute financially to the local health facility. Future research must determine the factors that lead some villages to include low caste villagers in local government.     

Cooperation in the care of the institutionalized elderly in a rural community

OBJECTIVE: To develop a method of addressing and minimizing the institutional, cultural, and regulatory barriers to the care of nursing facility residents in our community. METHODS: Nurses, administrators, and medical directors from all the nursing facilities in our community plus representatives from the community hospital participated in a monthly meeting where difficult issues in the care of nursing facility residents were discussed. The committee developed responses to these issues that were implemented throughout the community. RESULTS: This committee has provided an opportunity for the whole community to address problems in the care of the institutionalized elderly. Systems have been developed which have improved communication between nurses and physicians and between nursing facilities and the hospital. Community standards for the care of common problems in nursing facility residents have also been developed. Other unexpected benefits have included community discussion of regulatory concerns, nurse assistant education, and care at the end of life, as well as coordination of laboratory services in the nursing facilities. Other rural communities may find a similar approach useful.     

Le comité de retour d’expérience (CREX) : une méthode pour l’amélioration de la sécurité des soins

BackgroundAn experience feedback committee (CREX, Comité de Retour d’EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties.MethodsWe performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results.ResultsThe CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a “pilot” responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety.ConclusionSafety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units.     

Characteristics of long-term care facilities associated with standing order programs to deliver influenza and pneumococcal vaccinations to residents in 13 states

BACKGROUND: Standing order programs (SOPs) are effective evidence-based interventions in which nurses or pharmacists are authorized to vaccinate according to an approved protocol without a physician order or examination. National rates for influenza and pneumococcal vaccination in long-term care facilities (LTCF) are far below HP2010 goals of 90%. OBJECTIVES: The aim of this study was to describe the prevalence of SOPs and other types of immunization programs in LTCFs and determine characteristics of LTCFs implementing SOPs. DESIGN: Mailed survey. SETTING: All Medicare- or Medicaid-licensed LTCFs in 13 states. PARTICIPANTS: Directors of Nursing (DONs). MEASUREMENTS: Survey collecting information on SOPs and barriers to their use in respondents' LTCF. Data from this survey were linked to the On-line Survey and Certification Administrative Record (OSCAR), a federal administrative database containing structural, staffing and other information on LTCFs. RESULTS: A total of 3,451 of 4,366 (79%) LTCFs completed surveys. Few facilities used SOPs for influenza (9%) or pneumococcal vaccination (7%). The greatest use of influenza SOPs compared with other immunization program types were seen in facilities that were government owned or owned by nonprofit entities compared with for-profit entities (15% and 10% vs. 7%; odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.5 to 3.4 and OR = 1.4, CI = 1.1 to 1.8, respectively); dually-certified (both Medicare- and Medicaid-certified) nursing facilities compared with distinct part skilled nursing facilities in which beds are set aside for residents with a specific payment source (11% vs. 7%; OR = 1.6, CI = 1.3 to 2.1); independent facility compared with one that is part of a multi-facility chain (10% vs. 7%; OR = 1.3, CI = 1.1 to 1.7); and lower acuity index (resident resource needs) compared with higher (10% vs. 7%; OR = 1.4, CI = 1.1 to 1.7). Findings were similar for pneumococcal vaccination SOPs. SOP use varied substantially by state (range = 0% to 23% influenza; range = 3% to 15% pneumococcal). The most frequently reported barriers to SOP use were legal concerns: liability for the facility (53%) and staff lacking legal authority (39%) to vaccinate by standing orders. CONCLUSIONS: Although LTCFs with certain characteristics used SOPs more often, overall few facilities (<10%) used SOPs to improve vaccination rates. SOP use varied by state indicating that state policies or other factors may promote or inhibit SOP use. More studies are needed to examine the causes of state-level variations in vaccination interventions and their relationships to health outcomes of residents in LTCFs. The federal government's resources to promote SOPs should focus on all LTCFs, but with a particular focus on those that are less likely to be using SOPs and that represent a large proportion of homes nationally (i.e., for-profit and chain facilities).     

Infection control in Queensland long-term care facilities

In July 2000 a statewide infection control survey was mailed out to 483 long-term care facilities (LTCFs) in Queensland, Australia. The survey aimed to identify the presence and composition of infection control programmes in LTCFs and to investigate their relationship to the process elements of infection control programmes. A response rate of 43 per cent (n=206) was achieved.The survey found that almost all LTCFs (97 per cent) had an infection control programme in place. A majority (70 per cent) had an infection control committee or another committee with responsibility for infection control. The time allocated to infection control was only 1-2 hours per week in the majority (56 per cent) of facilities, and there was no correlation between this time allocation and bed numbers. Almost all (99 per cent) facilities provided infection control education to their staff. Most facilities conducted surveillance for urinary tract infection, respiratory tract infection or wound and skin infection. Surveillance data was used for staff feedback, education and/or accreditation in 95 per cent of facilities.Further investigation is warranted in order to identify the amount of time required to fulfil infection control responsibilities in LTCFs. This study also suggests that minimum standard definitions for surveillance are required for the LTCF in order to facilitate data collection and analysis, benchmarking ability and possible aggregation of information.     

Physical activity and colorectal cancer

Physical activity has been inconsistently associated with rectal cancer despite the consistent association between physical activity and colon cancer. In this study, the authors evaluated the association between physical activity and rectal cancer using the same questionnaire used to evaluate the previously reported association with colon cancer. A population-based study of 952 incident cases of cancer in the rectum and rectosigmoid junction and 1,205 age- and sex-matched controls was conducted in Utah and northern California at the Kaiser Permanente Medical Care Program between 1997 and 2002. Vigorous physical activity was associated with reduced risk of rectal cancer in both men and women (odds ratio (OR) = 0.60, 95% confidence interval (CI): 0.44, 0.81 for men; OR = 0.59, 95% CI: 0.40, 0.86 for women). Among men, moderate levels of physical activity also were associated with reduced risk of rectal cancer (OR = 0.70, 95% CI: 0.51, 0.97). Participation in vigorous activity over the past 20 years conferred the greatest protection for both men and women (OR = 0.55, 95% CI: 0.39, 0.78 for men; OR = 0.44, 95% CI: 0.30, 0.67 for women). In summary, physical activity was associated with reduced risk of rectal cancer in these data. The reduced risk was similar to that previously observed for colon cancer.     

Revisiting Financial Conflicts of Interest in FDA Advisory Committees

Context

The Food and Drug Administration (FDA) Safety and Innovation Act has recently relaxed conflict-of-interest rules for FDA advisory committee members, but concerns remain about the influence of members’ financial relationships on the FDA''s drug approval process. Using a large newly available data set, this study carefully examined the relationship between the financial interests of FDA Center for Drug Evaluation and Research (CDER) advisory committee members and whether members voted in a way favorable to these interests.

Methods

The study used a data set of voting behavior and reported financial interests of 1,379 FDA advisory committee members who voted in CDER committee meetings that were convened during the 15-year period of 1997–2011. Data on 1,168 questions and 15,739 question-votes from 379 meetings were used in the analyses. Multivariable logit models were used to estimate the relationship between committee members’ financial interests and their voting behavior.

Findings

Individuals with financial interests solely in the sponsoring firm were more likely to vote in favor of the sponsor than members with no financial ties (OR = 1.49, p = 0.03). Members with interests in both the sponsoring firm and its competitors were no more likely to vote in favor of the sponsor than those with no financial ties to any potentially affected firm (OR = 1.16, p = 0.48). Members who served on advisory boards solely for the sponsor were significantly more likely to vote in favor of the sponsor (OR = 4.97, p = 0.005).

Conclusions

There appears to be a pro-sponsor voting bias among advisory committee members who have exclusive financial relationships with the sponsoring firm but not among members who have nonexclusive financial relationships (ie, those with ties to both the sponsor and its competitors). These findings point to important heterogeneities in financial ties and suggest that policymakers will need to be nuanced in their management of financial relationships of FDA advisory committee members.     

"Stockless" cost reduction in the operating room

St. Paul-Ramsey Medical Center in St. Paul, MN became one of the first hospitals in the United States to initiate a "stockless" par level inventory system. Successes with stockless led the hospital to look at implementing it in the OR to achieve a reduction of expense to revenue. Materiel Management and Surgical Services discussed a number of issues relevant to implementing a stockless program, including product flow, accuracy and cost of case carts and preference cards, item pricing, committed usage of items brought into the system and establishment of a steering committee. Specific OR issues and practices required evaluation and adjustment, such as the routine use of emergency direct ordering. Information systems support was brought in and a products committee established to do education and oversee the program. Savings for 1993-94 were $185,146.     

Structured review of neonatal deaths in a managed care organisation

We sought to quantify neonatal mortality (< 28 days) in a 10-hospital system, determine what proportion was associated with suboptimal neonatal care and make recommendations on how neonatal mortality rates (NMRs) could be used in quality improvement efforts. Deaths were identified using electronic linkage to the State of California Death Certificate Tapes. Individual fatalities were reviewed by a minimum of two physicians who did not care for the infant. Deaths were classified as either being associated with suboptimal care or not. For deaths where suboptimal care was an issue, emphasis was on delineating the process involved in the death. Subjects were all neonatal deaths among 64 469 babies born in 1990–91 in the 10 birth facilities of the Kaiser Permanente Medical Care Program, Northern California Region. A total of 241 neonatal deaths were identified. Adjusting for prematurity by increasing the follow-up period in preterm babies (included as neonatal deaths if they died up to 40 weeks corrected gestational age + 27.9 days) increased overall mortality rates by 5%. Birthweight-specific NMRs in Kaiser Permanente are similar to those of other published reports. Among the 198 deaths in babies weighing  500 g at birth, only 14 (7%) were possibly associated with suboptimal care. In populations with access to health insurance, reporting only aggregate NMRs is of limited use. The number of deaths that could be ascribed to suboptimal neonatal care is very small and measuring variations in rates of such deaths is difficult. Future measurements of quality of care will require more sophisticated measures, database systems, review strategies and dissemination methods.     

Adapting to change: the advantage of modular clinic design

Architects have applied modular design concepts for years. Projects benefiting most are those where a few room types are repeated often. Ambulatory care facilities are excellent candidates because this project type typically consists of a large number of rooms that can be standardized. The new Kaiser Permanente Santa Clara Medical Office Building illustrates the benefits and flexibility of modular design.