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1.  Public hospital quality report awareness: evidence from National and Californian Internet searches and social media mentions, 2012 
BMJ Open  2014;4(3):e004417.
Objectives
Publicly available hospital quality reports seek to inform consumers of important healthcare quality and affordability attributes, and may inform consumer decision-making. To understand how much consumers search for such information online on one Internet search engine, whether they mention such information in social media and how positively they view this information.
Setting and design
A leading Internet search engine (Google) was the main focus of the study. Google Trends and Google Adwords keyword analyses were performed for national and Californian searches between 1 August 2012 and 31 July 2013 for keywords related to ‘top hospital’, best hospital’, and ‘hospital quality’, as well as for six specific hospital quality reports. Separately, a proprietary social media monitoring tool was used to investigate blog, forum, social media and traditional media mentions of, and sentiment towards, major public reports of hospital quality in California in 2012.
Primary outcome measures
(1) Counts of searches for keywords performed on Google; (2) counts of and (3) sentiment of mentions of public reports on social media.
Results
National Google search volume for 75 hospital quality-related terms averaged 610 700 searches per month with strong variation by keyword and by state. A commercial report (Healthgrades) was more commonly searched for nationally on Google than the federal government's Hospital Compare, which otherwise dominated quality-related search terms. Social media references in California to quality reports were generally few, and commercially produced hospital quality reports were more widely mentioned than state (Office of Statewide Healthcare Planning and Development (OSHPD)), or non-profit (CalHospitalCompare) reports.
Conclusions
Consumers are somewhat aware of hospital quality based on Internet search activity and social media disclosures. Public stakeholders may be able to broaden their quality dissemination initiatives by advertising on Google or Twitter and using social media interactively with consumers looking for relevant information.
doi:10.1136/bmjopen-2013-004417
PMCID: PMC3963102  PMID: 24618223
Public Health; Health Services Administration & Management
2.  Provider-Hospital “Fit” and Patient Outcomes: Evidence from Massachusetts Cardiac Surgeons, 2002–2004 
Health Services Research  2011;46(1 Pt 1):1-26.
Objective
To examine whether the “fit” of a surgeon with hospital resources impacts cardiac surgery outcomes, separately from hospital or surgeon effects.
Data Sources
Retrospective secondary data from the Massachusetts Department of Public Health's Data Analysis Center, on all 12,983 adult isolated coronary artery bypass surgical admissions in state-regulated hospitals from 2002 through 2004. Clinically audited chart data was collected using Society of Thoracic Surgeons National Cardiac Surgery Database tools and cross-referenced with administrative discharge data in the Division of Health Care Finance and Policy. Mortality was followed up through 2007 via the state vital statistics registry.
Study Design
Analysis was at the patient level for those receiving isolated coronary artery bypass surgery (CABG). Sixteen outcomes included 30-day mortality, major morbidity, indicators of perioperative, and predischarge processes of care. Hierarchical crossed mixed models were used to estimate fixed covariate and random effects at hospital, surgeon, and hospital × surgeon level.
Principal Findings
Hospital volume was associated with significantly reduced intraoperative durations and significantly increased probability of aspirin, β-blocker, and lipid-lowering discharge medication use. The proportion of outcome variability due to unobserved hospital × surgeon interaction effects was small but meaningful for intraoperative practices, discharge destination, and medication use. For readmissions and mortality within 30 days or 1 year, unobserved patient and hospital factors drove almost all variability in outcomes.
Conclusions
Among Massachusetts patients receiving isolated CABG, consistent evidence was found that the hospital × surgeon combination independently impacted patient outcomes, beyond hospital or surgeon effects. Such distinct local interactions between a surgeon and hospital resources may play an important part in moderating quality improvement efforts, although residual patient-level factors generally contributed the most to outcome variability.
doi:10.1111/j.1475-6773.2010.01169.x
PMCID: PMC3034259  PMID: 20849555
Quality of care; care processes; cardiac surgery; hierarchical modeling; mixed models
3.  Managing Care? Medicare Managed Care and Patient Use of Cardiologists 
Health Services Research  2010;45(2):329-354.
Objective
To examine the impact of Medicare managed care (MMC) versus Medicare fee for service (MFFS) on stent patients' use of physicians with lower resource use and better outcomes.
Data Sources/Study Setting
Retrospective secondary data from 2003 through 2006 for 67,476 patients without acute myocardial infarction, staying 2 or more days in hospital, and treated by 486 physicians in Florida performing 10 or more cases per quarter.
Study Design
Analysis was at the patient level. Multivariate logistic models estimated the probability of an MMC patient using a physician with a particular risk-adjusted profile rank with respect to hospital peers.
Principal Findings
No differences were found in usage of physicians with shorter admissions. Compared with MFFS, MMC patients were significantly less likely to use physicians whose average mortality was the lowest/lowest quartiles/below median among facility peers, and more likely to use a physician ranked below median on live discharges directly home (not needing home health care, skilled nursing care, or a subacute hospital convalescence). Similar results were found with emergency admissions, and where physicians both attended and treated.
Conclusions
Florida percutaneous coronary interventions patients insured by MMC used physicians with worse outcome profiles than those of MFFS patients. Results were not consistent with hospital care differences, physician–patient, or payor–physician selection, but they were consistent with selection of unobservably sicker members into MMC and concentration of MMC among physicians.
doi:10.1111/j.1475-6773.2009.01070.x
PMCID: PMC2838149  PMID: 20050932
Managed care; quality; resource use; incentives; selection effects
4.  Learning by Doing, Scale Effects, or Neither? Cardiac Surgeons after Residency 
Health Services Research  2009;44(6):1960-1982.
Objective
To examine impacts of operating surgeon scale and cumulative experience on postoperative outcomes for patients treated with coronary artery bypass grafts (CABG) by “new” surgeons. Pooled linear, fixed effects panel, and instrumented regressions were estimated.
Data Sources
The administrative data included comorbidities, procedures, and outcomes for 19,978 adult CABG patients in Florida in 1998–2006, and public data on 57 cardiac surgeons who completed residencies after 1997.
Study Design
Analysis was at the patient level. Controls for risk, hospital scale and scope, and operating surgeon characteristics were made. Patient choice model instruments were constructed. Experience was estimated allowing for “forgetting” effects.
Principal Findings
Panel regressions with surgeon fixed effects showed neither surgeon scale nor cumulative volumes significantly impacted mortality nor consistently impacted morbidity. Estimation of “forgetting” suggests that almost all prior experience is depreciated from one quarter to the next. Instruments were strong, but exogeneity of volume was not rejected.
Conclusions
In postresidency surgeons, no persuasive evidence is found for learning by doing, scale, or selection effects. More research is needed to support the cautious view that, for these “new” cardiac surgeons, patient volume could be redistributed based on realized outcomes without disruption.
doi:10.1111/j.1475-6773.2009.01018.x
PMCID: PMC2796309  PMID: 19732169
Learning by doing; scale economies; cardiac surgery; panel models; instruments
5.  Why technology matters as much as science in improving healthcare 
Background
More than half a million new items of biomedical research are generated every year and added to Medline. How successful are we at applying this steady accumulation of scientific knowledge and so improving the practice of medicine in the USA?
Discussion
The conventional wisdom is that the US healthcare system is plagued by serious cost, access, safety and quality weaknesses. A comprehensive solution must involve the better translation of an abundance of clinical research into improved clinical practice.
Yet the application of knowledge (i.e. technology) remains far less well funded and less visible than the generation, synthesis and accumulation of knowledge (i.e. science), and the two are only weakly integrated. Worse, technology is often seen merely as an adjunct to practice, e.g. electronic health records.
Several key changes are in order. A helpful first step lies in better understanding the distinction between science and technology, and their complementary strengths and limitations. The absolute level of funding for technology development must be increased as well as being more integrated with traditional science-based clinical research. In such a mission-oriented federal funding strategy, the ties between basic science research and applied research would be better emphasized and strengthened.
Summary
It bears repeating that only by applying the wealth of existing and future scientific knowledge can healthcare delivery and patient care ever show significant improvement.
doi:10.1186/1472-6947-12-103
PMCID: PMC3468390  PMID: 22963227
6.  One and done? Equality of opportunity and repeated access to scarce, indivisible medical resources 
BMC Medical Ethics  2012;13:11.
Background
Existing ethical guidelines recommend that, all else equal, past receipt of a medical resource (e.g. a scarce organ) should not be considered in current allocation decisions (e.g. a repeat transplantation).
Discussion
One stated reason for this ethical consensus is that formal theories of ethics and justice do not persuasively accept or reject repeated access to the same medical resources. Another is that restricting attention to past receipt of a particular medical resource seems arbitrary: why couldn’t one just as well, it is argued, consider receipt of other goods such as income or education? In consequence, simple allocation by lottery or first-come-first-served without consideration of any past receipt is thought to best afford equal opportunity, conditional on equal medical need.
There are three issues with this view that need to be addressed. First, public views and patient preferences are less ambiguous than formal theories of ethics. Empirical work shows strong preferences for fairness in health care that have not been taken into account: repeated access to resources has been perceived as unfair. Second, while difficult to consider receipt of many other prior resources including non-medical resources, this should not be used a motive for ignoring the receipt of any and all goods including the focal resource in question. Third, when all claimants to a scarce resource are equally deserving, then use of random allocation seems warranted. However, the converse is not true: mere use of a randomizer does not by itself make the merits of all claimants equal.
Summary
My conclusion is that not ignoring prior receipt of the same medical resource, and prioritizing those who have not previously had access to the medical resource in question, may be perceived as fairer and more equitable by society.
doi:10.1186/1472-6939-13-11
PMCID: PMC3467161  PMID: 22624597

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