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Biomedical subjects

J A Alexander

Publications and source records attributed to J A Alexander.

At least 37 records · Page 2Linked to original sources
PubMed2000

Medical and psychosocial services in drug abuse treatment: do stronger linkages promote client utilization?

OBJECTIVE: To examine the extent to which linkage mechanisms (on-site delivery, external arrangements, case management, and transportation assistance) are associated with increased utilization of medical and psychosocial services in outpatient drug abuse treatment units. DATA SOURCES: Survey of administrative directors and clinical supervisors from a nationally representative sample of 597 outpatient drug abuse treatment units in 1995. STUDY DESIGN: We generated separate two-stage multivariate generalized linear models to evaluate the correlation of on-site service delivery, formal external arrangements (joint program/venture or contract), referral agreements, case management, and transportation with the percentage of clients reported to have utilized eight services: physical examinations, routine medical care, tuberculosis screening, HIV treatment, mental health care, employment counseling, housing assistance, and financial counseling services. PRINCIPAL FINDINGS: On-site service delivery and transportation assistance were significantly associated with higher levels of client utilization of ancillary services. Referral agreements and formal external arrangements had no detectable relationship to most service utilization. On-site case management was related to increased clients' use of routine medical care, financial counseling, and housing assistance, but off-site case management was not correlated with utilization of most services. CONCLUSIONS: On-site service delivery appears to be the most reliable mechanism to link drug abuse treatment clients to ancillary services, while referral agreements and formal external mechanisms offer little detectable advantage over ad hoc referral. On-site case management might facilitate utilization of some services, but transportation seems a more important linkage mechanism overall. These findings imply that initiatives and policies to promote linkage of such clients to medical and psychosocial services should emphasize on-site service delivery, transportation and, for some services, on-site case management.

Ambulatory Care Facilities↗
PubMed1999

On-site primary care and mental health services in outpatient drug abuse treatment units.

Providing health services to drug abuse treatment clients improves their outcomes. Using data from a 1995 national survey of 597 outpatient drug abuse treatment units, this article examines the relationship between these units' organizational features and the degree to which they provided onsite primary care and mental health services. In two-stage models, Joint Commission on Accreditation of Healthcare Organizations-certified and methadone programs delivered more on-site primary care services. Units affiliated with mental health centers provided more on-site mental health services but less direct medical care. Units with more dual-diagnosis clients provided more on-site mental health but fewer on-site HIV/AIDS treatment services. Organizational features appear to influence the degree to which health services are incorporated into drug abuse treatment. Fully integrated care might be an unattainable ideal for many such organizations, but quality improvement across the treatment system might increase the reliability of clients' access to health services.

Adolescent↗
PubMed1999

Organizational correlates of access to primary care and mental health services in drug abuse treatment units.

Primary care and mental health services improve drug abuse treatment clients' health and treatment outcomes. To examine the association between clients' access to these services and the characteristics of drug treatment organizations, we analyze data from a national survey of the unit directors and clinical supervisors of 618 outpatient drug abuse treatment programs in 1995 (88% response rate). In multivariate models controlling for client characteristics and urban location, public units, units with more human resources, and methadone programs delivered more primary care services. Public units, Joint Commission on Accreditation of Health Care Organizations-accredited units, nonmethadone units, and units with more staff psychiatrists or psychologists delivered more mental health services. We conclude that organizational factors may influence drug abuse treatment clients' access to primary care and mental health services. Changes in the treatment system that weaken or eliminate public programs, over-burden staff, de-emphasize quality standards or lessen methadone availability may erode recovering clients' tenuous access to these services.

Cross-Sectional Studies↗
PubMed1999

Physician involvement in management and governance: the moderating effects of staff structure and composition.

Many hospitals are actively pursuing strategies that integrate physicians into their management and governance structures. Despite expectations that these strategies improve hospital efficiency, empirical studies have failed to provide consistent evidence that physician involvement in hospital management and governance improves hospital efficiency. This article examines factors that may moderate the relationship between physician participation in hospital management and governance and hospital efficiency.

Cross-Sectional Studies↗
PubMed1999

Do market-level hospital and physician resources affect small area variation in hospital use?

This study evaluates the effect of market-level physician and hospital resources on hospital use. It is anticipated that higher hospital discharges are associated with (1) greater hospital and physician resources, (2) more differentiated hospital and physician resources, and (3) higher levels of teaching intensity in the community. Data on 14 modified diagnostically related groups (DRGs) and 58 hospital market communities in Michigan are analyzed during a 7-year period. Findings indicate that physician resources, hospital resources, differentiation of hospital and physician resources, and teaching intensity contribute only modestly to discharges, holding constant the socioeconomic attributes of the community and adjusting for the variation in hospital use over time. With the inclusion of hospital and physician resource variables, socioeconomic factors remain important determinants of the variation across market communities. Findings are discussed in terms of their implications for health care organizations, managed care programs, and cost control efforts in general.

Adult↗
PubMed1999

Consequences of organizational change in U.S. hospitals.

Organizational change has become commonplace among U.S. hospitals. Empirical investigations of the consequences of organizational change, however, are relatively scarce, and findings of existing studies are inconsistent. In this article, the authors review the rationale and performance implications of hospital organizational change in three areas: (1) the development of new multi-institutional arrangements, (2) change in traditional ownership and management configurations, and (3) diversification in organizational products/services and consolidation of organizational scale. Empirical research on hospital change published between 1980 and 1999 in the health services research, social science, and business literatures is reviewed to highlight the potential pitfalls that hospitals may encounter in their effort to remain viable. The article also summarizes the strengths and weaknesses of current hospital change research and provides specific suggestions for future research in this area.

Health Services Research↗
PubMed1999

Endoscopic evaluation of the esophagus in infants and children immediately following intraoperative use of transesophageal echocardiography.

OBJECTIVE: Intraoperative transesophageal echocardiography (TEE) has evolved as an essential technique for use during pediatric cardiac surgery; however, few studies have evaluated the safety of TEE in children. This series reports endoscopic examination of the esophagus following intraoperative TEE in pediatric patients. METHODS: Fifty children undergoing congenital heart surgery underwent flexible esophagoscopy that was performed after completion of their heart surgery and after the removal of the transesophageal echo probe. The patients' ages ranged from 4 days to 10 years old, and their weight ranged from 3.0 to 39.8 kg, with a mean weight of 12.6 kg. RESULTS: Thirty-two of 50 patients (64%) had abnormal results shown on esophageal examinations; this occurred more frequently in the subset of patients weighing < 9 kg. No long-term feeding or swallowing difficulties were noted in any of the 48 patients who survived. CONCLUSIONS: Intraoperative TEE in infants and children frequently caused mild mucosal injury. Care must be exercised in the insertion and manipulation of the probes.

Cardiac Surgical Procedures↗
PubMed1999

Financial and organizational determinants of hospital diversification into subacute care.

OBJECTIVE: To examine the financial, market, and organizational determinants of hospital diversification into subacute inpatient care by acute care hospitals in order to guide hospital managers in undertaking such diversification efforts. STUDY SETTING: All nongovernment, general, acute care, community hospitals that were operating during the years 1985 through 1991 (3,986 hospitals in total). DATA SOURCES: Cross-sectional, time-series data were drawn from the American Hospital Association's (AHA) Annual Survey of Hospitals, the Health Care Financing Administration's (HCFA) Medicare Cost Reports, a latitude and longitude listing for all community hospital addresses, and the Area Resource File (ARF) published in 1992, which provides county level environmental variables. STUDY DESIGN: The study is longitudinal, enabling the specification of temporal patterns in conversion, causal inferences, and the treatment of right-censoring problems. The unit of analysis is the individual hospital. KEY FINDINGS: Significant differences were found in the average level of subacute care offered by investor-owned versus tax-exempt hospitals. After controlling for selection bias, financial performance, risk, size, occupancy, and other variables, IO hospitals offered 31.3 percent less subacute care than did NFP hospitals. Financial performance and risk are predictors of IO hospitals' diversification into subacute care, but not of NFP hospitals' activities in this market. Resource availability appears to expedite expansion into subacute care for both types of hospitals. CONCLUSIONS: Investment criteria and strategy differ between investor-owned and tax-exempt hospitals.

Cross-Sectional Studies↗
PubMed1999

How other members of the top management team see the nurse executive.

This study compared how top-level organizational groups within Veterans Affairs Medical Center (VAMC) top management teams perceived nurse executives' participation in strategic decision making. Nurse executives' perceptions of their own involvement in strategic decision making generally agreed with the views of both chiefs of staff and directors. However, the associate director's perceptions of the nurse executive's involvement often differed significantly with those of the nurse. Nurse executives will be better prepared to function effectively within the top management team if they are aware of patterns in how they are perceived by other members.

Attitude of Health Personnel↗
PubMed1999

Managing hospitals in turbulent times: do organizational changes improve hospital survival?

OBJECTIVE: To examine (1) the degree to which organizational changes affected hospital survival; (2) whether core and peripheral organizational changes affected hospital survival differently; and (3) how simultaneous organizational changes affected hospital survival. DATA SOURCES: AHA Hospital Surveys, the Area Resource File, and the AHA Hospital Guides, Part B: Multihospital Systems. STUDY DESIGN: The study employed a longitudinal panel design. We followed changes in all community hospitals in the continental United States from 1981 through 1994. The dependent variable, hospital closure, was examined as a function of multiple changes in a hospital's core and peripheral structures as well as the hospital's organizational and environmental characteristics. Cox regression models were used to test the expectations that core changes increased closure risk while peripheral changes decreased such risk, and that simultaneous core and peripheral changes would lead to higher risk of closure. PRINCIPAL FINDINGS: Results indicated more peripheral than core changes in community hospitals. Overall, findings contradicted our expectations. Change in specialty, a core change, was beneficial for hospitals, because it reduced closure risk. The two most frequent peripheral changes, downsizing and leadership change, were positively associated with closure. Simultaneous organizational changes displayed a similar pattern: multiple core changes reduced closure risk, while multiple peripheral changes increased the risk. These patterns held regardless of the level of uncertainty in hospital environments. CONCLUSIONS: Organizational changes are not all beneficial for hospitals, suggesting that hospital leaders should be both cautious and selective in their efforts to turn their hospitals around.

American Hospital Association↗
PubMed1998

A causal model of voluntary turnover among nursing personnel in long-term psychiatric settings.

Causal modeling was used to explore the processes by which individual characteristics, job satisfaction, and intention to quit explain turnover among nursing personnel in 29 Department of Veterans Affairs (VA) long-term psychiatric settings. The sample consisted of 1,106 registered nurses (RNs), licensed practical nurses (LPNs), and nurses' aides. We conceptualized turnover as a multistage process linking social and experiential orientations, attitudes toward the job, the decision to quit, and the behavior of actually quitting. Intention to quit was the strongest direct predictor of turnover. Professional growth opportunities and workload were important indirect predictors of turnover. Dissatisfaction with work hazards and relationships with coworkers were both indirect and direct predictors of turnover. Attitudes towards the job varied by nursing group. LPNs and aides were less satisfied than RNs with autonomy and work hazards. RNs were more dissatisfied with workload. We conclude that strategies to promote retention need to address aspects of jobs tailored to specific nursing groups.

Adult↗
PubMed1998

Managed care and technical efficiency in outpatient substance abuse treatment units.

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs.

Ambulatory Care↗
PubMed1998

The challenges of governing public-private community health partnerships.

This article identifies key challenges that arise in governing public-private partnerships designed to improve community health status. Using telephone interview and focus group data, we describe how the 25 public-private community health partnerships participating in the Community Care Network (CCN) Demonstration Program grapple with three interrelated clusters of governance issues: turf, community accountability, and growth and development.

Community Health Planning↗
PubMed1998

Managed care and processes to integrate physicians/hospitals.

This article describes the extent to which hospitals use different integrative processes to assimilate physicians and assesses the extent to which their use is associated with managed care penetration and hospital characteristics. Results from a national survey of 1,495 community hospitals indicate that these integrative processes are quite prevalent. The use of integrative processes tends to be more prevalent in hospitals that are large, urban, involved in teaching, and members of hospitals systems. Use of particular integrative processes also appears to be associated with different thresholds of managed care penetration.

Delivery of Health Care, Integrated↗
PubMed1998

Physician and clinical integration among rural hospitals.

The pressures for closer alignment between physicians and hospitals in both rural and urban areas are increasing. This study empirically specifies independent dimensions of physician and clinical integration and compares the extent to which such activities are practiced between rural and urban hospitals and among rural hospitals in different organizational and market contexts. Results suggest that both rural and urban hospitals practice physician integration, although each emphasizes different types of strategies. Second, urban hospitals engage in clinical integration with greater frequency than their rural counterparts. Finally, physician integration approaches in rural hospitals are more common among larger rural hospitals, those proximate to urban facilities, those with system affiliations, and those not under public control.

Analysis of Variance↗
PubMed1998

Physicians and organizations: strange bedfellows or a marriage made in heaven?

Underscoring the importance of physician-organization alignment as a necessary condition for building and sustaining integrated healthcare systems, this article provides information regarding the nature of such alignment, the key influential factors, and the processes employed to make alignment a reality. Structural and strategic factors address the influence of environmental, market, and organizational characteristics on alignment. The strategic intent of organizations and physicians, and physician perspectives on the effects of integration, are explored. Key processes examined include building trust, placing physicians in management and governance, and developing physician leadership. Continuing issues and challenges are considered, and a set of principles to help guide the journey of physicians and organizations toward successful alignment is suggested.

Delivery of Health Care, Integrated↗
PubMed1998

Acute postictal cerebral imaging.

BACKGROUND AND PURPOSE: Imaging of postictal patients is performed to investigate causes of seizure, such as space-occupying lesions or other "structural" processes; however, abnormalities may be found that reflect physiological or pathologic alterations due to seizure activity. The purpose of this study was to determine the brain imaging findings in patients in the immediate postictal period who presented with altered mental status or weakness. METHODS: Ten patients who were examined for postictal neurologic derangement were studied (nine by CT and one by MR imaging) within 12 hours of ictus. Four of the CT studies and the one MR study included administration of contrast material. Follow-up examinations were performed 1 day to 11 months later. These studies were reviewed retrospectively. RESULTS: CT findings included focal gyral swelling (10/10), effacement of adjacent cortical sulci (2/10), decreased gyral attenuation by CT (8/9), and mild to moderate gyral enhancement after injection of contrast material (5/5). MR imaging findings included gyral swelling, increased signal intensity on T2-weighted images, and enhancement after injection of contrast agent. The abnormalities were located in the frontal lobes (9/10, with bilateral involvement in 6/10), the parietal lobes (4/10), the temporal lobes (2/10), and the occipital lobe (1/10). Follow-up studies revealed complete or subtotal reversal of these abnormalities. CONCLUSION: Although there are numerous causes of gyral swelling and enhancement, such as infarction and neoplasm, if these conditions are reversible and correspond to clinical findings, then the differential diagnosis is narrowed to postictal change, reversible ischemia, complicated migraine, or resolved inflammation/infection.

Adult↗