Medical Care Research and Review

Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.

The authors use a statewide survey to examine care seeking behavior in the emergency department (ED). Most patients who go to the ED (69.3%) do so mainly for conditions they believe are urgent. Time before seeking ED care is highly variable from immediately (28.7%) to more than 1 week (7.0%) and is only weakly related to the perceived urgency of medical condition. Healthier individuals initiate ED care more rapidly than sicker patients. In retrospect, 80.4% of patients would go to the same ED if they had the same medical episode but this percentage falls substantially with increased ED waiting time. Subject to some limitations uncovered in model specification tests, the study highlights several correlates of ED care seeking behavior that may be useful for designing strategies to divert some patients away from the ED. It also raises larger questions, however, about whether diversion is optimal from patient and health system perspectives.

Given persistent barriers to effective electronic health record (EHR) system implementation and use, the authors investigated implementation training practices in six organizations reputed to have ambulatory care EHR system implementation “best practices.” Using the lenses of social cognitive and adult learning theories, they explored themes related to EHR implementation training using qualitative data collected through 43 key informant interviews and 6 physician focus groups conducted between February 2009 and December 2010. The authors found consistent evidence that training practices across the six organizations known for exemplary implementations were congruent with the tenets of these theoretical frameworks and highlight seven best practices for training. The authors’ analyses suggest that effective training programs must move beyond technical approaches and incorporate social and cultural factors to make a difference in implementation success. Taking these findings into account may increase the likelihood of successful EHR implementation, thereby helping organizations meet “meaningful use” requirements for EHR systems.

The effect of hospital organizational affiliation on perinatal outcomes is unknown. Using the 2004 American Hospital Association Annual Survey and Healthcare Cost and Utilization Project State Inpatient Databases, the authors examined relationships among organizational affiliation, equipment and service availability and provision, and in-hospital mortality for 5,133 infants across five states born with very low and extremely low birth weight and congenital anomalies. In adjusted bivariate probit selection models, the authors found that government hospitals had significantly higher mortality rates than not-for-profit nonreligious hospitals. Mortality differences among other types of affiliation (Catholic, not-for-profit religious, not-for-profit nonreligious, and for-profit) were not statistically significant. This is encouraging as health care reform efforts call for providers at facilities with different institutional values to coordinate care across facilities. Although there are anecdotes of facility religious affiliation being related to health care decisions, the authors did not find evidence of these relationships in their data.

Long-term acute care hospitals (LTACs) are an increasingly common discharge destination for patients recovering from intensive care. In this article the authors use U.S. Medicare claims data to examine regional- and hospital-level variation in LTAC utilization after intensive care to determine factors associated with their use. Using hierarchical regression models to control for patient characteristics, this study found wide variation in LTAC utilization across hospitals, even controlling for LTAC access within a region. Several hospital characteristics were independently associated with increasing LTAC utilization, including increasing hospital size, for-profit ownership, academic teaching status, and colocation of the LTAC within an acute care hospital. These findings highlight the need for research into LTAC admission criteria and the incentives driving variation in LTAC utilization across hospitals.

More than 8% of employed RNs licensed since 2004 in the United States were educated overseas, yet little is known about the conditions of their recruitment or the impact of that experience on health care practice. This study assessed whether the labor rights of foreign-educated nurses were at risk during the latest period of high international recruitment: 2003 to 2007. Using consensus-based standards contained in the Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Health Professionals to the United States, this study found 50% of actively recruited foreign-educated nurses experienced a negative recruitment practice. The study also found that nurses educated in low-income countries and nurses with high contract breach fees, were significantly more likely to report such problems. If, as experts believe may occur, the nursing shortage in the United States returns around 2014, oversight of international recruitment will become critically important to delivering high-quality health care to Americans.