The effects of group size and group economic factors on collaboration: a study of the financial performance of rural hospitals in consortia.
STUDY QUESTIONS: To determine factors that distinguish effective rural hospital consortia from ineffective ones in terms of their ability to improve members' financial performance. Two questions in particular were addressed: (1) Do large consortia have a greater collective impact on their members? (2) Does a consortium's economic environment determine the degree of collective impact on members? DATA SOURCES AND STUDY SETTING: Based on the hospital survey conducted during February 1992 by the Robert Wood Johnson Hospital-Based Rural Health Care project of rural hospital consortia. The survey data were augmented with data from Medicare Cost Reports (1985-1991), AHA Annual Surveys (1985-1991), and other secondary data. STUDY DESIGN: Dependent variables were total operating profit, cost per adjusted admission, and revenue per adjusted admission. Control variables included degree of group formalization, degree of inequality of resources among members (group asymmetry), affiliation with other consortium group(s), individual economic environment, common hospital characteristics (bed size, ownership type, system affiliation, case mix, etc.), year (1985-1991), and census region dummies. PRINCIPAL FINDINGS: All dependent variables have a curvilinear association with group size. The optimum group size is somewhere in the neighborhood of 45. This reveals the benefits of collective action (i.e., scale economies and/or synergy effects) and the issue of complexity as group size increases. Across analyses, no strong evidence exists of group economic environment impacts, and the environmental influences come mainly from the local economy rather than from the group economy. CONCLUSION: There may be some success stories of collaboration among hospitals in consortia, and consortium effects vary across different collaborations. RELEVANCE/IMPACT: When studying consortia, it makes sense to develop a typology of groups based on some performance indicators. The results of this study imply that government, rural communities, and consortium staff and steering committees should forge the consortium concept by expanding membership in order to gain greater financial benefits for individual hospitals. (+info)
The adoption of provider-based rural health clinics by rural hospitals: a study of market and institutional forces.
OBJECTIVE: To examine the response of rural hospitals to various market and organizational signals by determining the factors that influence whether or not they establish a provider-based rural health clinic (RHC) (a joint Medicare/Medicaid program). DATA SOURCES/STUDY SETTING: Several secondary sources for 1989-1995: the AHA Annual Survey, the PPS Minimum Data Set and a list of RHCs from HCFA, the Area Resource File, and professional associations. The analysis includes all general medical/surgical rural hospitals operating in the United States during the study period. STUDY DESIGN: A longitudinal design and pooled cross-sectional data were used, with the rural hospital as the unit of analysis. Key variables were examined as sets and include measures of competitive pressures (e.g., hospital market share), physician resources, nurse practitioner/physician assistant (NP/PA) practice regulation, hospital performance pressures (e.g., operating margin), innovativeness, and institutional pressure (i.e., the cumulative force of adoption). PRINCIPAL FINDINGS: Adoption of provider-based RHCs by rural hospitals appears to be motivated less as an adaptive response to observable economic or internal organizational signals than as a reaction to bandwagon pressures. CONCLUSIONS: Rural hospitals with limited resources may resort to imitating others because of uncertainty or a limited ability to fully evaluate strategic activities. This can result in actions or behaviors that are not consistent with policy objectives and the perceived need for policy changes. Such activity in turn could have a negative effect on some providers and some rural residents. (+info)
Zimbabwe's hospital referral system: does it work?
BACKGROUND: Anecdotal evidence has suggested inefficiency in the pyramidal health care referral system established in Zimbabwe in 1980, as part of its primary health care (PHC) model. AIM: To assess the functioning of the pyramidal referral system in two rural districts surrounding Harare, Zimbabwe, with regard to two common indicator conditions: pneumonia in children and malaria in adults. METHODS: For a three-month period, all complete inpatient records with discharge diagnoses of pneumonia or malaria from three hospitals representing different levels of care were analyzed (n = 227). Data were collected on demographic and patient care variables. The appropriateness of admissions and referrals was determined by an assessment of the severity of illness and 'intensiveness' of care required. Data were analyzed for differences among the three hospitals and between the two indicator conditions. Per night inpatient bed costs for each hospital were also calculated. RESULTS: For pneumonia in children, 56.8% of patients admitted at the secondary level, 53.8% of patients at the tertiary level and 57.8% of patients at the quaternary level were of mild severity. For malaria in adults, 74.0% of patients seen at the secondary level, 81.5% of patients at the tertiary level and 54.3% at the quaternary level were of mild severity. For pneumonia, were no differences in severity between the three hospitals whereas for malaria significant case-mix differences among the hospitals were found. Most patients attending the highest level referral facility were inappropriate admissions who could have been treated at a lower level of care. The majority of patients at all the hospitals studied had used that hospital as their first or second point of contact with the health services. There were large variations in the inpatient per night bed costs between the three hospitals. CONCLUSIONS: Using the indicator diseases of pneumonia in children and malaria in adults, this study concluded that this network did not meet design expectations as the central level referral hospital cared for a similar case-mix of patients as the district level, but at six times the cost. The appropriateness of admissions and referrals could be improved by developing or strengthening intermediate level facilities, by changing mechanisms of access to specialist facilities and by training health professionals in community settings. (+info)
Establishing a laboratory for surveillance of invasive bacterial infections in a tertiary care government hospital in a rural province in the Philippines.
A clinical bacteriologic laboratory was established in a tertiary care government hospital in The Philippines, where expert bacteriologic laboratories do not usually exist at this level of health care. The laboratory was jointly established by the Research Institute for Tropical Medicine (RITM) (Manila, The Philippines) and the National Public Health Institute (KTL) (Helsinki, Finland). The laboratory was planned, its personnel were trained, and its functioning was continuously supported by the RITM and KTL. The following aspects were of utmost importance in establishing the laboratory and launching its work: 1) the support of the RITM bacteriologic laboratory, with back-up and consultations from KTL; 2) creation and maintenance of personal contacts between clinicians and laboratory staff with an emphasis on clinical relevance and rapid reporting of laboratory results; 3) the consideration of the quality aspects of the work from the start; and 4) keen follow-up of the bacteriologic results and their clinical significance and use, of practical laboratory work, and of quality assurance aspects. In the first two years of its operation, the laboratory identified Streptococcus pneumoniae and Haemophilus influenzae as the most important causes of severe pneumonia, sepsis or meningitis in children less than two years of age, and Salmonella typhi as the most frequent significant isolate from the blood cultures, being found most often in school age children and young adults. (+info)
The changing landscape of health care financing and delivery: how are rural communities and providers responding?
Rural communities have not kept pace with the recent dramatic changes in health care financing and organization. However, the Medicare provisions in the Balanced Budget Act of 1997 will require rural providers to participate in the new systems. Case studies revealed the degree of readiness for change in six rural communities and charted their progress along a continuum, as reflected in three sets of activities: the development of networking; the creation of new strategies for managing patient care; and the adoption of new methods for contracting with health insurers. Some communities had constructed highly integrated systems, whereas others were just beginning to change their billing practices; a few were signing contracts for capitated care, in contrast to those that were resisting discounts in current fee structures. These six rural areas still have considerable ground to cover before their health care organization and financing reach the levels achieved by urban communities. (+info)
Information quality in a remote rural maternity unit in Ghana.
The collection of accurate maternal outcome data enables causes of morbidity and mortality to be identified, which in turn permits interventions to be targeted appropriately. It also allows estimates to be made about the importance of various indicators in predicting birth outcome. These indicators can then be compared between health services, across time and against programme objectives, thus ensuring a management information system that informs policy and provides for real change. A review was done of data collection at the antenatal clinic and maternity ward in a remote rural hospital in northern Ghana. The data collected came from maternity ward records and participant observation, and they highlight deficiencies in the record management procedures. It is argued that exhorting staff to greater accuracy, although obvious, may not be the only solution, because of the structural impediments that often give an illusion of accuracy. The best data need to be collected within the constraints of the equipment and the people. Furthermore, to make the task more meaningful, regular feedback needs to be provided so that the process of record keeping is relevant to those who do it. Ministries of health need to conduct regular audits, like this microanalysis, so that policies are not based on data that are analyzed under a presumption of accuracy. (+info)
Mortality after acute myocardial infarction is lower in metropolitan regions than in non-metropolitan regions.
STUDY OBJECTIVES: To compare in-hospital mortality for acute myocardial infarction (AMI) between metropolitan and non-metropolitan hospitals after adjustment for patients' severity; to examine the role of the use of effective cardiac medications in the possible mortality difference between these types of hospital. DESIGN: Retrospective cohort study. SETTING: 47 acute public hospitals in metropolitan and non-metropolitan areas of New South Wales, Australia, taking part in the Acute Cardiac Care Project based on medical record review. PATIENTS: 1665 patients with principal discharge diagnosis of AMI from February to June 1996. MAIN RESULTS: There was no difference in crude mortality rate (assessed as seven day mortality) between metropolitan and non-metropolitan hospitals (11.0% compared with 10.7% respectively, p=0.893). After adjustment for severity in a logistic regression model, the odds of death in non-metropolitan hospitals was significantly higher than in metropolitan hospitals (odds ratio = 1. 90; 95% CI 1.21, 3.23). The addition of the use of effective cardiac medications to the model resulted in the difference between hospital type becoming non-significant (odds ratio=1.09; 95% CI 0.57, 2.07). CONCLUSIONS: In-hospital mortality in non-metropolitan hospitals was higher than that in metropolitan hospitals, after adjustment for patients' severity. This might partly be explained by the difference in use of effective cardiac medications between hospital type. (+info)
The evolution of rural outreach from Package Library to Grateful Med: introduction to the symposium.
Outreach is now a prevailing activity in health sciences libraries. As an introduction to a series of papers on current library outreach to rural communities, this paper traces the evolution of such activities by proponents in health sciences libraries from 1924 to 1992. Definitions of rural and outreach are followed by a consideration of the expanding audience groups. The evolution in approaches covers the package library and enhancements in extension service, library development, circuit librarianship, and self-service arrangements made possible by such programs as the Georgia Interactive Network (GaIN) and Grateful Med. (+info)