Horizontal and Vertical Integration of Health Care Providers: A Framework for Understanding Various Provider Organizational Structures

The value of admission avoidance: cost-consequence analysis of one-year activity in a consolidated service

BACKGROUND

Many advantages of hospital at home (HaH), as a modality of acute care, have been highlighted, but controversies exist regarding the cost-benefit trade-offs. The objective is to assess health outcomes and analytical costs of hospital avoidance (HaH-HA) in a consolidated service with over ten years of delivery of HaH in Barcelona (Spain).

METHODS

A retrospective cost-consequence analysis of all first episodes of HaH-HA, directly admitted from the emergency room (ER) in 2017-2018, was carried out with a health system perspective. HaH-HA was compared with a propensity-score-matched group of contemporary patients admitted to conventional hospitalization (Controls). Mortality, re-admissions, ER visits, and direct healthcare costs were evaluated.

RESULTS

HaH-HA and Controls (n = 441 each) were comparable in terms of age (73 [SD16] vs. 74 [SD16]), gender (male, 57% vs. 59%), multimorbidity, healthcare expenditure during the previous year, case mix index of the acute episode, and main diagnosis at discharge. HaH-HA presented lower mortality during the episode (0 vs. 19 (4.3%); p < 0.001). At 30 days post-discharge, HaH-HA and Controls showed similar re-admission rates; however, ER visits were lower in HaH-HA than in Controls (28 (6.3%) vs. 34 (8.1%); p = 0.044). Average costs per patient during the episode were lower in the HaH-HA group (€ 1,078) than in Controls (€ 2,171). Likewise, healthcare costs within the 30 days post-discharge were also lower in HaH-Ha than in Controls (p < 0.001).

CONCLUSIONS

The study showed higher performance and cost reductions of HaH-HA in a real-world setting. The identification of sources of savings facilitates scaling of hospital avoidance.

REGISTRATION

ClinicalTrials.gov (26/04/2017; NCT03130283).

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes

OBJECTIVE

To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls.

SUMMARY BACKGROUND DATA

It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients.

METHODS

Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality.

RESULTS

We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001].

CONCLUSIONS

Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

Effects of vertical integration on the healthcare system in China: a systematic review and meta-analysis

Vertical integration is one possible way to improve the performance of a healthcare system; however, its effects are inconsistent, and there is a lack of evidence from undeveloped nations. This study aims to systematically review the evidence regarding effects of vertical integration on healthcare systems in China. We searched PubMed, Embase, Cochrane Library, Web of Science, ProQuest Health & Medicine Collection, China Knowledge Resource Integrated Database and Wanfang databases from April 2009 (initiation of new healthcare reform) to May 2021 for randomized controlled trials (RCTs), controlled before and after (CBA) trials, cohort studies and interrupted time series (ITS) trials. Vertical integration in the included studies must involve both primary health institutions and secondary or tertiary hospitals. After screening 3109 records, we ultimately analysed 47 studies, including 27 CBA trials, 18 RCTs and 2 ITS trials. The narrative synthesis shows that all but three studies indicated that vertical integration improved efficiency (utilization and cost of health services), quality of public health services and medical services, health provider-centred outcomes (knowledge and skill) and patient-centred outcomes (patients' clinical outcomes, behaviour and satisfaction). Despite the heterogeneity of vertical integration interventions across different studies, the meta-analysis reveals that it lowered diastolic blood pressure (mean difference (MD) -8.41, 95% confidence interval (CI) -15.18 to -1.65) and systolic blood pressure (MD-5.83, 95% CI -9.25 to -2.40) among hypertension patients, and it lowered HbA1c levels (MD -1.95, 95% CI -2.69 to -1.21), fasting blood glucose levels (MD -1.02, 95% CI -1.53 to -0.50) and 2-hour postprandial blood glucose levels (MD -1.78, 95% CI -2.67 to -0.89). The treatment compliance behaviour was improved for hypertension participants (risk ratio (RR) 1.08, 95% CI 1.04-1.13) and for diabetes patients (RR 1.32, 95% CI 1.08-1.61). Vertical integration in China can improve efficiency, quality of care, health provider-centred outcomes and patient-centred outcomes, but high-quality original studies are highly needed.

Improving health equity through health care systems research

OBJECTIVE

To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes.

DATA SOURCES AND STUDY SETTING

This project was conducted as a component of the Agency for Healthcare Research and Quality's (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government.

STUDY DESIGN

Expert group consensus, informed by stakeholder engagement and targeted evidence review.

DATA COLLECTION/EXTRACTION METHODS

Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQ's 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors' consensus.

PRINCIPAL FINDINGS

Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines.

CONCLUSIONS

As the nation's primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.

Hub and spoke framework for study of surgical centralization within United States health systems

BACKGROUND

Hospital consolidation into health systems has mixed effects on surgical quality, potentially related to degree of surgical centralization at high-volume (hub) sites. We developed a novel measure of centralization and evaluated a hub and spoke framework.

METHODS

Surgical centralization within health systems was measured using hospital surgical volumes (American Hospital Association) and health system data (Agency for Healthcare Research and Quality). Hub and spoke hospitals were compared using mixed effects logistic regression and system characteristics associated with surgical centralization were identified using a linear model.

RESULTS

Within 382 health systems containing 3022 hospitals, system hubs perform 63% of cases (IQR 40-84%). Hubs are larger, in metropolitan and urban areas, and more often academically affiliated. Degree of surgical centralization varies ten-fold. Larger, multistate, and investor-owned systems are less centralized. Adjusting for these factors, there is less centralization among teaching systems (p ​< ​0.001).

CONCLUSIONS

A hub-spoke framework applies to most health systems but centralization varies significantly. Future studies of health system surgical care should assess the contributions of surgical centralization and teaching status on differential quality.

Utilization, Steering, and Spending in Vertical Relationships Between Physicians and Health Systems

Importance

Vertical relationships (eg, ownership or affiliations, including joint contracting) between physicians and health systems are increasing in the US.

Objective

To analyze how vertical relationships between primary care physicians (PCPs) and large health systems are associated with changes in ambulatory and acute care utilization, referral patterns, readmissions, and total medical spending for commercially insured individuals.

Design, Setting, and Participants

This case-control study with a repeated cross-section, stacked event design analyzed outcomes of patients whose attributed PCP entered a vertical relationship with a large health care system in 2015 or 2017 compared with patients whose attributed PCP was either never or always in a vertical relationship with a large health system from 2013 to 2017 in the state of Massachusetts. The sample consisted of commercially insured patients who met enrollment criteria and who were attributed to PCPs who were included in the Massachusetts Provider Database in 2013, 2015, and 2017 and for whom vertical relationships were measured. Enrollee and claims data were obtained from the 2013 to 2017 Massachusetts All-Payer Claims Database. Statistical analyses were conducted between January 5, 2021, and June 5, 2023.

Exposure

Evaluation-and-management visit with attributed PCP in 2015 to 2017.

Main Outcomes and Measures

Outcomes (which were measured per patient-year [ie, per patient per year from January to December] in this sample) were utilization (count of specialist physician visits, emergency department [ED] visits, and hospitalizations overall and within attributed PCP's health system), spending (total medical expenditures and use of high-price hospitals), and readmissions (readmission rate and use of hospitals with a low readmission rate).

Results

The sample of 4 030 224 observations included 2 147 303 females (53.3%) and 1 881 921 males (46.7%) with a mean (SD) age of 35.07 (19.95) years. Vertical relationships between PCPs and large health systems were associated with an increase of 0.69 (95% CI, 0.34-1.04; P < .001) in specialist visits per patient-year, a 22.64% increase vs the comparison group mean of 3.06 visits, and a $356.67 (95% CI, $77.16-$636.18; P = .01) increase in total medical expenditures per patient-year, a 6.26% increase vs the comparison group mean of $5700.07. Within the health care system of the attributed PCPs, the number of specialist visits changed by 0.80 (95% CI, 0.56-1.05) per patient year (P < .001), a 29.38% increase vs the comparison group mean of 2.73 specialist visits per patient-year. The number of ED visits changed by 0.02 (95% CI, 0.01-0.03) per patient year (P = .001), a 14.19% increase over the comparison group mean of 0.15 ED visits per patient-year. The number of hospitalizations changed by 0.01 (95% CI, 0.00-0.01) per patient-year (P < .001), a 22.36% increase over the comparison group mean of 0.03 hospitalizations per patient-year. There were no differences in readmission outcomes.

Conclusions

Results of this case-control study suggest that vertical relationships between PCPs and large health systems were associated with steering of patients into health systems and increased spending on patient care, but no difference in readmissions was found.

A qualitative analysis of factors influencing the implementation of antiretroviral treatment adherence policy in Ghana: stakeholders perspective

BACKGROUND

The Joint United Nations Programme on HIV/AIDS launched the 90-90-90 initiative. Failure to meet the target reflects the difficulties in successfully implementing HIV treatment policy. There are research gaps in exploring personal and external factors influencing HIV treatment in Ghana. To fill this gap, we explored individual and environmental (interpersonal, community and structural) factors influencing stakeholders' HIV treatment policy implementation in Ghana.

METHODS

Fifteen qualitative semi-structured in-depth interviews were conducted among representatives in different management positions at hospitals, health directorates, the Ghana AIDS Commission, the National AIDS and STI control program, and the National Association of People Living with HIV.

RESULTS

Using thematic analysis, the findings suggest that individual and environmental factors such as attitude towards policy, awareness of HIV treatment policy, training received on policy implementation, difficulties related to patient factors, alternate sources of HIV care, inefficient policy decision-making, monitoring and evaluation of HIV treatment policy, lack of HIV treatment policy implementation training, poor availability of logistics, policy and guidelines, infrastructure, organization of training, and staff availability may hinder successful HIV treatment policy implementation.

CONCLUSION

Several individual and environmental (interpersonal, community and structural) factors seem to influence HIV treatment policy implementation. To ensure successful policy implementation stakeholders need to receive training on new policies, availability of sufficient supplies of material resources, inclusive decision-making, receive supportive monitoring of policy implementation, and oversight.

Towards achieving interorganisational collaboration between health-care providers: a realist evidence synthesis

Background

Interorganisational collaboration is currently being promoted to improve the performance of NHS providers. However, up to now, there has, to the best of our knowledge, been no systematic attempt to assess the effect of different approaches to collaboration or to understand the mechanisms through which interorganisational collaborations can work in particular contexts.

Objectives

Our objectives were to (1) explore the main strands of the literature about interorganisational collaboration and to identify the main theoretical and conceptual frameworks, (2) assess the empirical evidence with regard to how different interorganisational collaborations may (or may not) lead to improved performance and outcomes, (3) understand and learn from NHS evidence users and other stakeholders about how and where interorganisational collaborations can best be used to support turnaround processes, (4) develop a typology of interorganisational collaboration that considers different types and scales of collaboration appropriate to NHS provider contexts and (5) generate evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing interorganisational collaboration arrangements.

Design

A realist synthesis was carried out to develop, test and refine theories about how interorganisational collaborations work, for whom and in what circumstances.

Data sources

Data sources were gathered from peer-reviewed and grey literature, realist interviews with 34 stakeholders and a focus group with patient and public representatives.

Review methods

Initial theories and ideas were gathered from scoping reviews that were gleaned and refined through a realist review of the literature. A range of stakeholder interviews and a focus group sought to further refine understandings of what works, for whom and in what circumstances with regard to high-performing interorganisational collaborations.

Results

A realist review and synthesis identified key mechanisms, such as trust, faith, confidence and risk tolerance, within the functioning of effective interorganisational collaborations. A stakeholder analysis refined this understanding and, in addition, developed a new programme theory of collaborative performance, with mechanisms related to cultural efficacy, organisational efficiency and technological effectiveness. A series of translatable tools, including a diagnostic survey and a collaboration maturity index, were also developed.

Limitations

The breadth of interorganisational collaboration arrangements included made it difficult to make specific recommendations for individual interorganisational collaboration types. The stakeholder analysis focused exclusively on England, UK, where the COVID-19 pandemic posed challenges for fieldwork.

Conclusions

Implementing successful interorganisational collaborations is a difficult, complex task that requires significant time, resource and energy to achieve the collaborative functioning that generates performance improvements. A delicate balance of building trust, instilling faith and maintaining confidence is required for high-performing interorganisational collaborations to flourish.

Future work

Future research should further refine our theory by incorporating other workforce and user perspectives. Research into digital platforms for interorganisational collaborations and outcome measurement are advocated, along with place-based and cross-sectoral partnerships, as well as regulatory models for overseeing interorganisational collaborations.

Study registration

The study is registered as PROSPERO CRD42019149009.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 6. See the NIHR Journals Library website for further project information.

Community pharmacy and primary health care - Types of integration and their applicability: A narrative review

BACKGROUND

There is an urgent need for health care systems to be more efficient and efficacious. An approach to integrate public and private provider organizations such as community pharmacies and public primary health care (PHC) merits consideration. The objective of this review was to identify the types of integration in health care settings and discuss their applicability to the potential integration of community pharmacy and PHC.

METHODS

A narrative review using Medline, Scopus and SciELO databases was performed in which terms related to health were combined with terms related to integration. Levels and Types of integration: 14 types of integration were identified (two in breadth, seven as enablers and five in system levels). A model was created which classifies and assigns the types of integration to the different levels of the health system and to the breadth, intensity, and enablers of the integration process. Due to the nature of community pharmacy and PHC system, a horizontal integration at the micro level, supported by meso and macro levels policy, is suggested. The different elements of intensity and enablers can significantly influence the process.

CONCLUSION

The application of principles, concepts and types of integration suggest that it might be feasible and practical to integrate community pharmacies and PHC. However, the conflictive historical context would need to be overcome with appropriate policy and incentives.

Federated blockchain system (FBS) for the healthcare industry

Blockchain is a distributed technology that introduced the well known Bitcoin cryptocurrency into action. Blockchain has been considered for research by many countries and industries. It is being applied in many fields such as the healthcare domain. Many companies started using Blockchain to increase the security and privacy of the Electronic Healthcare Records for their patients. The work in this paper discusses some existing healthcare problems and challenges. In addition, the paper reviews some related work models and provides a comparison that shows their objectives and limitations. Also, a proposed Federated Blockchain System (FBS) is introduced to provide solutions for these healthcare problems and elaborates the technical details of the system architecture. Moreover, the effectiveness of the system has been validated which showed an average of 68-100 ms for performing query operations and average of 0.944-19.041 s for performing writing operations on the system. Finally, a discussion of the system validation and future work are presented.

Impact of merging two university hospitals on surgical outcome after esophagogastric and hepato-pancreato-biliary surgery: Results from a retrospective study

Background

Due to centralization and super-specialization in medicine, hospital mergers are increasingly common. Their effect on postoperative outcomes in highly specialized surgical departments is unclear. As quality metrics often worsen after major organizational changes, preservation of quality of care during an hospital merge is of the utmost importance.

Objective

To evaluate the effect of a merger of two Dutch university hospitals on quality of surgical care, volume, and timeliness of care.

Methods

The upper gastro-intestinal and hepato-biliary-pancreatic sections merged on the 27th of January 2020 and the 31th of May 2021 respectively. Outcomes of all adult surgical patients were compared six months before and six months after the merger. Short-term quality metrics, volume, and timeliness of care were assessed.

Results

Overall, a cohort of 631 patients were included of whom 195 were upper gastro-intestinal (97 prior to the merger, 98 after the merger) and 436 (223 prior to the merger, 213 after) hepato-biliary-pancreatic patients. There were no differences in mortality, readmission, number and severity of complications, volume, and timeliness of care six months post-merger as compared to before merger.

Conclusion

This study shows that a hospital merger of two university hospitals can be performed without jeopardizing patient safety and while benefitting from centralization of highly specialized care and enhancement of medical research.

Key message

This study investigated the impact of a merger of two Dutch university hospitals on quality of care, timeliness of care, and volume. It showed no deterioration in the evaluated short-term quality metrics, volume or timeliness for upper GI and HPB surgery, suggesting that a hospital merger of two university hospitals can be performed safely, while benefitting from centralization of highly specialized care and enhancement of medical research.

Nursing Care Coordination in Primary Healthcare for Patients with Complex Needs: A Comparative Case Study

Introduction

Despite nurses' substantial role in care coordination, few education programs exist to better support them in this role. Identification of a set of core care coordination activities across heterogeneous care coordination programs would facilitate the development of a standard of practice. We sought to examine care coordination activities across two care coordination programs in Family Medicine Groups in Quebec, and their relationship to the program design.

Methods

We performed a comparative case study of two care coordination programs in primary care targeting frequent users of healthcare services and people with Alzheimer's disease and related disorders. Data collection included documents and semi-structured interviews with key informants.

Results

Several activities were common to both programs, such as patient identification; assessment, development of an individualized service plan; and linking patients and caregivers with professionals and services. However, their components were different due to the impact of the integrated care program design, policy environment, and the target patient populations' complex needs.

Discussion

The homogeneity or heterogeneity of patients' complex needs shapes their care trajectory and the intensity of their care coordination needs. As the complexity of these needs grows, so does the necessity to build the care coordinators' capacity for integrated care.

Primary healthcare reform for chronic conditions in countries with high or very high human development index: A systematic review

OBJECTIVE

To address the growing burden of chronic disease globally, many countries have developed a national policy for primary healthcare reform. In some countries with high and very high human development index, evaluations of the implementation of these reforms have been published. To date, there has been no systematic review of these evaluations. The objectives of this review are to identify: (a) the vision for primary healthcare; (b) the features of primary healthcare reforms; and (c) evaluation findings of primary healthcare reforms.

METHODS

A systematic literature review was conducted guided by the PRISMA statement. We searched for academic articles and grey literature from 1 March 2008 to 1 September 2020. Screening and data extraction were conducted by two authors. Descriptive analysis and narrative synthesis were applied.

RESULTS

A vision for integrated primary healthcare shifting chronic disease management from specialist hospital services to primary care was found to require new organization and funding models such as collaborative primary healthcare networks and commissioning along with shared governance across health sectors. The need for general practitioner leadership and engagement to support primary healthcare reform was identified. Although there was evidence of barriers in progressing primary healthcare reform, evaluation results showed some positive outcomes, most notably shifts in services towards increased primary care access and utilization.

DISCUSSION

A challenge in undertaking the review was the heterogeneity of articles with little consistency in how primary healthcare reform was evaluated and reported on across countries. Evaluation of national health reforms involves complex system-wide projects and is an area that needs further exploration and discussion to determine the most appropriate methodologies for collecting and analysing large-scale data with consideration for service and health outcomes.

Price Effects Of Vertical Integration And Joint Contracting Between Physicians And Hospitals In Massachusetts

Vertical integration in health care has recently garnered scrutiny by antitrust authorities and state regulators. We examined trends, geographic variation, and price effects of vertical integration and joint contracting between physicians and hospitals, using physician affiliations and all-payer claims data from Massachusetts from the period 2013-17. Vertical integration and joint contracting with small and medium health systems rose from 19.5 percent in 2013 to 32.8 percent in 2017 for primary care physicians and from 26.1 percent to 37.8 percent for specialists. Vertical integration and joint contracting with large health systems slightly declined, whereas geographic variation in these physician affiliations rose. We found that vertical integration and joint contracting led to price increases from 2013 to 2017, from 2.1 percent to 12.0 percent for primary care physicians and from 0.7 percent to 6.0 percent for specialists, with the greatest increases seen in large health systems. These findings can inform policy makers seeking to limit growth in health care prices.

Shifting paradigms: Developmental milestones for integrated care

Frameworks for understanding integrated care risk underemphasizing the complexities of the development of integrated care in a local context. The objectives of this article are to (1) present a novel strategy for conceptualizing integrated care as developing through a series of milestones at the organizational level, and (2) present a typology of milestones empirically generated through the analysis of four cases of integrated community-based primary health care (ICBPHC) in Canada and New Zealand. Our paper reports on an analysis of 4 specific organizational case studies within a large dataset generated for an international multiple case study project of exemplar models of ICBPHC. Drawing on earlier analyses of 359 qualitative interviews with patients, caregivers, health care providers, managers, and policymakers, in this article we present a detailed analysis of 28 interviews with managers and leaders of local models of integrated care. We generated a detailed timeline of the development of integrated care as expressed by each participant, and synthesized themes across timelines within each case to identify specific milestone events. We then synthesized across cases to generate the broader milestone categories to which each event belongs. We generated 5 milestone categories containing 12 more specific milestone events. The milestone categories include (1) strategic relational, (2) strategic process change, (3) internal structural, (4) inter-organizational structural, and (5) external milestones. We propose a comprehensive framework of developmental milestones for integrated care. Milestones represent a compelling strategy for conceptualizing the development of integrated care. Practically, policymakers and health care leaders can support the implementation of integrated care by examining the history and context of a given model of care and identifying strategies to achieve milestones that will accelerate integrated care. Further research should document additional milestone events and advance the development of dynamic frameworks for integrated care.

Hospital physicians' experiences and reflections on their work and role in relation to older patients' pathways - a qualitative study in two Norwegian hospitals

Background

Older patients are the most frequent users of initial hospital admissions and readmissions. Both hospital admission and discharge require communication and coordination between healthcare professionals within the hospital, and between professionals in hospitals and primary healthcare. We have identified few studies exploring hospital physicians’ perspectives on older patients’ pathways in the interface between hospital and primary healthcare services. The aim of this study was to explore hospital physicians’ experiences and reflections on their work and role in relation to older patients’ pathways between hospital and primary healthcare. Specifically, we focused on the challenges they faced and how they dealt with these in relation to admission and discharge, and their suggestions for service improvements that could facilitate older patients’ pathway.

Methods

We used a qualitative approach, conducting individual in-depth interviews with 18 hospital physicians from two hospitals in eastern Norway. Data were analyzed using systematic text condensation, in line with a four-step prosedure developed by Malterud.

Results

The participants emphasized challenges in the communication about patients across the two service levels. Moreover, they described being in a squeeze between prioritizing patients and trying to ensure a proper flow of patients through the hospital wards, but with restricted possibilities to influence on the admissions. They also described a frustration regarding the lack of influence on the healthcare delivery after discharge. The participants had various suggestions for service improvements which might be beneficial to older patients.

Conclusions

The results demonstrate that the hospital physicians perceived being squeezed between professional autonomy and limited capacity at the hospital, and between their medical judgement as a specialist and their power to decide on hospital admissions for old patients and also on the delivery of health care services to patients after discharge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07846-1.

Examination of care processes and treatment optimization for head and neck cancer patients in a community setting “hub and hub” model

Objective

To examine referral pattern, the timing of diagnostic/staging processes, and treatment initiation for new head and neck cancer patients in a community setting.

Methods

Patients with a newly diagnosed previously untreated diagnosis of head neck cancer managed at Asplundh Cancer Pavilion/Abington Memorial Hospital from October 2018 to March 2020. Source of referral and preceding workup were examined as well as intervals between initial head and neck consult and various timepoints of treatment initiation.

Results

One hundred and five patients were included in the study. The primary referral sources were external general otolaryngology (56.3%). Oral surgery and dermatology obtained tissue biopsy approximately 80% of the time before referral. The average time from the ordering of initial staging positron emission tomography/computed tomography to finalized results was 14 days (range: 10–25 days). Patients referred from dermatology and oral surgery were more likely to require single modality care, namely definitive surgical management. Time to treatment initiation average was 37 days (range: 29–41 days). Patients with longer treatment times noted significantly higher times to both radiation and medical oncology consults (48.42 vs. 18.13 days; P < 0.001).

Conclusions

No notable differences in treatment initiation times were identified based on referral source or extent of workup performed before head/neck surgery consult. It appears the largest opportunities for improvement in terms of reducing overall treatment length exist in the optimization of radiation initiation time.

Head/neck cancer, treatment initiation.

Vertical integration in the Australian community care setting: Can it work? A theoretical review of current literature

Vertical integration (VI) is considered a strategic management plan whereby an organisation has ownership of its supply chain. It is utilised as a method for managing the economic needs and approaches of an organisation and ensuring that a product is readily available for use. From a healthcare perspective, this pertains to the coordination of services or levels of care and allows for adaptation to changing circumstances. This study reviews existing literature on VI in a healthcare setting to assess feasibility and effectiveness of this proposed solution. A theoretical literature review was performed utilising conceptual categorisation to understand how VI may benefit community care organisations, using the needs of a local organisation as an example. Seventeen articles were included from a range of databases and grey literature with findings categorised according to two research questions. The findings suggest that for VI to be effective and efficient it is important to consider the following themes: market failure, barriers to entry, productive capabilities and specific healthcare issues. In conclusion, from a management and economic perspective, when markets are not functioning efficiently and are in disequilibrium, VI may provide an appropriate avenue to address these problems, in particular for community care organisations.

Improving Quality Outcomes: The Value of Diabetes Care and Education Specialists

Given the growing prevalence and accelerating cost of diabetes, there is an urgent need to expand strategies in health care that improve access and outcomes and reduce the financial and human burden of the disease. Diabetes care and education specialists (DCESs) are well positioned to assist health care systems with delivery models that enhance diabetes care through evidence-based standards and quality improvement strategies. DCESs have increased opportunities to apply their competencies in primary, specialty, hospital, and acute care settings; accountable care organizations; community settings; research; and academia. Two national certification programs provide an evidence-based foundation for quality in the specialty, with updated competencies guiding practice. This article serves as a call to action for health care systems to integrate specialists in diabetes care and education into diabetes care delivery models and raise awareness of the positive impact these professionals have on the lives of people with diabetes.

States' Merger Review Authority Is Associated With States Challenging Hospital Mergers, But Prices Continue To Increase

States can challenge proposed hospital mergers by using antitrust laws to prevent anticompetitive harms. This observational study examined additional state laws-principally charitable trust, nonprofit corporation, health and safety, and certificate-of-need laws-that can serve as complements and substitutes for antitrust laws by empowering states to be notified of, review, and challenge proposed hospital mergers through administrative processes. During the period 2010-19, 862 hospital mergers were proposed, but only forty-two (4.9 percent) were challenged by states, including thirty-five by states without federal involvement, of which twenty-five (71.4 percent) originated in the eight states with the most robust merger review authority. The twenty-five challenges resulted in two mergers being blocked; three being abandoned; and twenty being approved with conditions, including seven with competitive-impact conditions. Hospital market concentration and prices increased at similar rates in these eight states versus other states, potentially because most challenges allowed mergers to proceed with conditions that did not adequately address competitive concerns. Although these findings do not reveal an optimal state framework, elements of advanced state merger review authority may have the potential to improve poorly functioning hospital markets.

Cancer prevention, risk reduction, and control: opportunities for the next decade of health care delivery research

In this commentary, we discuss opportunities to optimize cancer care delivery in the next decade building from evidence and advancements in the conceptualization and implementation of multi-level translational behavioral interventions. We summarize critical issues and discoveries describing new directions for translational behavioral research in the coming decade based on the promise of the accelerated application of this evidence within learning health systems. To illustrate these advances, we discuss cancer prevention, risk reduction (particularly precision prevention and early detection), and cancer treatment and survivorship (particularly risk- and need-stratified comprehensive care) and propose opportunities to equitably improve outcomes while addressing clinician shortages and cross-system coordination. We also discuss the impacts of COVID-19 and potential advances of scientific knowledge in the context of existing evidence, the need for adaptation, and potential areas of innovation to meet the needs of converging crises (e.g., fragmented care, workforce shortages, ongoing pandemic) in cancer health care delivery. Finally, we discuss new areas for exploration by applying key lessons gleaned from implementation efforts guided by advances in behavioral health.

Making sense of the French public hospital system: a network-based approach to hospital clustering using unsupervised learning methods

BACKGROUND

Hospitals in the public and private sectors tend to join larger organizations to form hospital groups. This increasingly frequent mode of functioning raises the question of how countries should organize their health system, according to the interactions already present between their hospitals. The objective of this study was to identify distinctive profiles of French hospitals according to their characteristics and their role in the French hospital network.

METHODS

Data were extracted from the national hospital database for year 2016. The database was restricted to public hospitals that practiced medicine, surgery or obstetrics. Hospitals profiles were determined using the k-means method. The variables entered in the clustering algorithm were: the number of stays, the effective diversity of hospital activity, and a network-based mobility indicator (proportion of stays followed by another stay in a different hospital of the same Regional Hospital Group within 90 days).

RESULTS

Three hospital groups were identified by the clustering algorithm. The first group was constituted of 34 large hospitals (median 82,100 annual stays, interquartile range 69,004 - 117,774) with a very diverse activity. The second group contained medium-sized hospitals (with a median of 258 beds, interquartile range 164 - 377). The third group featured less diversity regarding the type of stay (with a mean of 8 effective activity domains, standard deviation 2.73), a smaller size and a higher proportion of patients that subsequently visited other hospitals (11%). The most frequent type of patient mobility occurred from the hospitals in group 2 to the hospitals in group 1 (29%). The reverse direction was less frequent (19%).

CONCLUSIONS

The French hospital network is organized around three categories of public hospitals, with an unbalanced and disassortative patient flow. This type of organization has implications for hospital planning and infectious diseases control.

The Impact of Health Delivery Integration on Cancer Outcomes

Although integrated health care has largely been associated with increases in prices and static or decreased quality across many disease states, it has shown some successes in improving cancer care. However, its impact is largely equivocal, making consensus statements difficult. Critically, integration does not necessarily translate to clinical coordination, which might be the true driver behind the success of integrated health care delivery. Moving forward, it is important to establish payment models that support clinical care coordination. Shifting from a fragmented health system to a coordinated one may improve evidence-based cancer care, outcomes, and value for patients.

The Integrated Performance Management System: A Key to Service Trajectory Integration

INTRODUCTION

This article presents an experience of deploying an integrated performance management system as a catalyst for the integration of a service trajectory for children in vulnerable situations. Called ''Jimmy'', the project identifies how the integrated performance management system makes it possible to improve accessibility, continuity of services and well-being at work among stakeholders.

METHODS

An action research was conducted in a large healthcare organization in Canada, between August 2016 and October 2018. Data was systematically collected throughout the various cycles of research using field notes, more than 350 hours of observations, 15 interviews and 3 focus groups.

RESULTS

This research supports using an integrated performance management system as a model for collaborative management that supports both horizontal and vertical integration in the service trajectory. The use of visual boards and status sheet meetings were determining factors for service integration and the functioning of integrated teams. This also led to improvements in accessibility and continuity of services, as well as in employee well-being.

DISCUSSION AND CONCLUSION

Supported by the various tools of the integrated performance management system, Project ''Jimmy'' reinforces the implementation of linkage and coordination models, which in turn helps create strong connections among teams. The status sheet meetings and visual boards are tools that vertically integrate different hierarchical levels and horizontally integrate various front-line stakeholders through the user-oriented trajectory.

Payer perceptions of the use of real-world evidence in oncology-based decision making

BACKGROUND: Randomized controlled trials (RCTs), the gold standard of safety and efficacy evidence, are conducted in select patients that may not mirror real-world populations. As a result, healthcare decision makers may have limited information when making formulary decisions, especially in oncology, given accelerated regulatory approvals and niche patient populations. Real-world evidence (RWE) studies may help address these knowledge gaps and help inform oncology formulary decision making. OBJECTIVE: To assess US payer perceptions regarding the use and relevance of RWE in informing oncology formulary decisionmaking. METHODS: A national survey containing single-answer, multiple-answer, and free-response questions evaluated 4 key areas: (1) the value of RWE, (2) barriers to RWE, (3) sources of RWE, and (4) use of RWE in outcomes-based contracting. The survey was distributed to 221 US payers through the Academy of Managed Care Pharmacy (AMCP) Market Insights program in February 2020. Ten additional respondents were invited to discuss the survey results. The survey results were presented primarily as frequencies of responses and were evaluated by the respondent's plan size, type, and geography (regional vs national). Differences in responses for categorical data were compared using a Pearson Chi-Square or a Fisher's Exact test. Two-tailed values are reported and a level of ≤ 0.05 was used to indicate statistical significance. RESULTS: The national survey had a 45.9% response rate, with 106 payers responding. Most were from managed care organizations (MCOs; 47.5%) and pharmacy benefit managers (PBMs; 37.4%), with 54.5% from large plans (≥ 1 million lives) and 45.5% from small plans (< 1 million lives). Respondents were largely pharmacists (89.9%), with 55.6% overall indicating their job was a pharmacy administrator. Most (84.9%) used RWE to inform formulary decisions in oncology to support comparative effectiveness in the absence of head-to-head clinical trials (4.1 on a scale of 1 = Not At All Useful to 5 = Extremely Useful) and validation of National Comprehensive Cancer Network (NCCN) recommendations (4.0). Almost half (41.5%) used RWE results to inform off-label usage decisions. Payers valued RWE pre-launch to inform formulary and contracting decisions and desired real-world comparative effectiveness data post-launch to validate coverage decisions. However, the majority of payers (54.7%) did not conduct their own real-world studies. Commonly considered RWE sources included claims data (79.2%), medical records (68.9%), prospective cohort studies (60.4%), patient registries (36.8%), and patient outcome surveys (33.0%). Barriers to conducting internal RWE studies included the lack of resources and personnel, analytic capabilities, appropriate in-house data, and perceived value in conducting analyses. Payers expressed interest in using outcomes-based contracting in oncology; few have direct experience, and operationalizing through value measurement is challenging. CONCLUSIONS: RWE providing comparative treatment data, validation of NCCN treatment recommendations, and information on off-label usage are appreciated pre launch with post launch validation. DISCLOSURES: Pfizer provided funding for this research, and employees of Pfizer led the development of the survey and contributed to the manuscript as authors. Arondekar and Niyazov are employees of Pfizer; Oderda, Biskupiak, and Brixner are managers of Millcreek Outcomes Group and were paid as consultants on this project. Burgoyne was a consultant for Pfizer on this project. Malone was paid by Millcreek Outcomes as a consultant on this project.

Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems

PURPOSE

Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation.

MATERIALS AND METHODS

We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation.

RESULTS

Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer-accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (P > .05).

CONCLUSION

The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.

The bigger, the better? A systematic review on the impact of mergers on primary care organizations

Background

Primary care services are the first point of contact in a healthcare system; in the last years, many mergers and reconfigurations have taken place in this setting. The aim of this study is to summarize the literature evidence on the relationship between the increase in the size of these organizations and their performance.

Methods

A systematic review of the literature was carried out querying EMBASE, MEDLINE and Web of Science databases, from their inception to January 2020. Articles which quantitatively assessed outcomes and process indicators of merger/structural reorganization of primary care organizations and qualitative articles that assessed staff perception and satisfaction were included in the review.

Results

A total of 3626 articles was identified and another study was retrieved through snowball search; 11 studies were included in the systematic review. Studies about lipid profile evaluation and emergency admissions for chronic conditions showed moderate evidence in supporting the merging of primary care organizations; conversely, clinical outcome studies did not reach a sufficient level of evidence to support merging actions. A moderate evidence of a negative effect on patient’s perspective was found.

Conclusion

Actually, there is no strong evidence in favour or against merging of primary care organizations without equivocation. This review supports the possibility to identify indicators for evaluating a merging process of primary care organizations and for adopting eventual remedies during this process. Further efforts should be made to identify additional indicators to assess merge actions among primary care organizations.

Distribution of Genomic Testing Resources by Oncology Practice and Rurality: A Nationally Representative Study

PURPOSE

Oncologists are increasingly using molecular profiling to inform personalized patient treatment decisions. Despite its promising utility, the integration of genomic testing into diverse clinical health care settings across geographic settings has been understudied.

METHODS

We used data from the National Survey of Precision Medicine in Cancer Treatment, a nationally representative sample of practicing US oncologists, to assess the availability of six genomic testing resources, including on-site pathology, contracts with outside laboratories, on-site genetic counselors, internal policies or protocols for using genomic and biomarker testing, electronic medical record alerts, and genomic or molecular tumor boards. We used multivariate logistic regression models to examine differences in the availability of each genomic testing resource by practice type and rurality while adjusting for payer mix and patient volume.

RESULTS

A larger proportion of multispecialty group and academic practices had genomic testing resources available compared with solo and nonacademic practices. Electronic medical record alerts were the least available resource, whereas contracts with outside laboratories were the most available resource. Compared with urban practices, there were significantly fewer practices located in rural areas that had on-site pathology, on-site genetic counselors, protocols for genomic tests, and molecular tumor boards.

CONCLUSION

Genomic testing resources varied by practice type and geography among a nationally representative sample of practicing oncologists. This variation has important implications for the development of interventions and policies to support the more equitable delivery of precision oncology to patients with cancer.

Designing delivery models of traditional and complementary medicine services: a review of international experiences

BACKGROUND

The World Health Organization advocates integration of traditional and complementary medicine (T&CM) into the conventional health services delivery system. Integrating quality services in a patient-centred manner faces substantial challenges when T&CM is delivered within a health system dominated by conventional medicine. This review has synthesized international experiences of integration strategies across different contexts.

SOURCES OF DATA

Publications describing international experiences of delivering T&CM service in conventional healthcare settings were searched. Backward and forward citation chasing was also conducted.

AREAS OF AGREEMENT

Capable leaders are crucial in seeking endorsement from stakeholders within the conventional medicine hierarchy and regulatory bodies. However, patient demands for integrative care can be successful as demonstrated by cases included in this review, as can the promotion of the use of T&CM for filling effectiveness gaps in conventional medicine. Safeguarding quality and safety of the services is a priority.

AREAS OF CONTROVERSY

Different referral mechanisms between conventional and T&CM practitioners suit different contexts, but at a minimum, general guideline on responsibilities across the two professionals is required. Evidence-based condition-specific referral protocols with detailed integrative treatment planning are gaining in popularity.

GROWING POINTS

Interprofessional education is critical to establishing mutual trust and understanding between conventional clinicians and T&CM practitioners. Interprofessional communication is key to a successful collaboration, which can be strengthened by patient chart sharing, instant information exchange, and dedicated time for face-to-face interactions.

AREAS TIMELY FOR DEVELOPING RESEARCH

Research is needed on the optimal methods for financing integrated care to ensure equitable access, as well as in remuneration of T&CM practitioners working in integrative healthcare.

Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries

OBJECTIVE

To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes.

DATA SOURCES

Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data.

STUDY DESIGN

Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse.

DATA COLLECTION/EXTRACTION METHODS

1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions).

PRINCIPAL FINDINGS

Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]).

CONCLUSIONS

Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

Evaluating Telehealth Adoption and Related Barriers Among Hospitals Located in Rural and Urban Areas

Purpose

To assess telehealth adoption among hospitals located in rural and urban areas, and identify barriers related to enhanced telehealth capabilities in the areas of patient engagement and health information exchange (HIE) capacity with external providers and community partners.

Methods

We used the 2018 American Hospital Association (AHA) Annual Survey and IT Supplement Survey. We applied state fixed effects multivariate analyses and Oaxaca decomposition to estimate the variation of outcomes of interest by hospital geographies.

Findings

Our research showed substantial differences in telehealth adoption among hospitals located in rural, micropolitan, and metropolitan areas, where adoption rates increase with urbanicity. Rural hospitals were least likely to have telehealth systems with patient engagement capabilities such as the ability to view their health information online and electronically transmit medical information to a third party. They were also the least likely to report that clinical information was available electronically from outside providers. Our model explained 65% of the rural/urban difference in telehealth adoption, 55% of the number of telehealth services adopted, and 43%‐49% of the rural/urban difference in telehealth barriers.

Conclusion

Findings demonstrated significant barriers to telehealth use among hospitals located in rural and urban areas. For rural hospitals, barriers include lack of HIE capacity among health care providers in the community, and lack of patient engagement capability.

(Dis)Integrated Care? Lessons from East London

INTRODUCTION

This paper examines one of the NHS England Pioneers programmes of Integrated Care, which was implemented in three localities in East London, covering the area served by one of the largest hospital groups in the UK and bringing together commissioners, providers and local authorities. The partners agreed to build a model of integrated care that focused on the whole person. This qualitative and participatory evaluation looked at how an ambitious vision translated into the delivery of integrated care on the ground. The study explored the micro-mechanisms of integrated care relationships based on the experience of health and social care professionals working in acute and community care settings.

METHODS

We employed a participatory approach, the Researcher in Residence model, whereby the researcher was embedded in the organisations she evaluated and worked alongside managers and clinicians to build collaboration across the full range of stakeholders, develop shared learning, and find common ground through competing interests, while trying to address power imbalances. A number of complementary qualitative methods of data generation were used, including documentary analysis, participant observations, semi-structured interviews, and coproduction workshops with frontline health and social care professionals to interpret the data and develop recommendations.

RESULTS

Our fieldwork exposed persistent organisational fragmentation, despite the dominant rhetoric of integration and efforts to build a shared vision at senior governance levels. The evaluation identified several important themes, including: a growing barrier between acute and community services; a persisting difficulty experienced by health and social care staff in working together because of professional and cultural differences, as well as conflicting organisational priorities and guidelines; and a lack of capacity and support to deliver a genuine multidisciplinary approach in practice, despite the ethos of multiagency being embraced widely.

DISCUSSION

By focusing on professionals' working routines, we detailed how and why action taken by organisational leaders failed to have tangible impact. The inability to align organisational priorities and guidelines on the ground, as well as a failure to acknowledge the impact of structural incentives for organisations to compete at the expense of cooperation, in a context of limited financial and human resources, acted as barriers to more coordinated working. Within an environment of continuous reconfigurations, staff were often confused about the functions of new services and did not feel they had influence on change processes. Investing in a genuine bottom-up approach could ensure that the range of activities needed to generate system-wide cultural transformation reflect the capacity of the organisations and systems and address genuine local needs.

LIMITATIONS

The authors acknowledge several limitations of this study, including the focus on one geographical area, East London, and the timing of the evaluation, with several new interventions and programmes introduced more or less simultaneously. Some of the intermediate care services under evaluation were still at pilot stage and some teams were undergoing new reconfigurations, reflecting the fast-pace of change of the past decade. This created confusion at times, for instance when discussing specific roles and activities with participants. We tried to address some of these challenges by organising several workshops with different teams to co-interpret and discuss the findings.

Rethinking palliative care in a public health context: addressing the needs of persons with non-communicable chronic diseases

Non-communicable chronic diseases (NCCDs) are the main cause of morbidity and mortality globally. Demographic aging has resulted in older populations with more complex healthcare needs. This necessitates a multilevel rethinking of healthcare policies, health education and community support systems with digitalization of technologies playing a central role. The European Innovation Partnership on Active and Healthy Aging (A3) working group focuses on well-being for older adults, with an emphasis on quality of life and healthy aging. A subgroup of A3, including multidisciplinary stakeholders in health care across Europe, focuses on the palliative care (PC) model as a paradigm to be modified to meet the needs of older persons with NCCDs. This development paper delineates the key parameters we identified as critical in creating a public health model of PC directed to the needs of persons with NCCDs. This paradigm shift should affect horizontal components of public health models. Furthermore, our model includes vertical components often neglected, such as nutrition, resilience, well-being and leisure activities. The main enablers identified are information and communication technologies, education and training programs, communities of compassion, twinning activities, promoting research and increasing awareness amongst policymakers. We also identified key 'bottlenecks': inequity of access, insufficient research, inadequate development of advance care planning and a lack of co-creation of relevant technologies and shared decision-making. Rethinking PC within a public health context must focus on developing policies, training and technologies to enhance person-centered quality life for those with NCCD, while ensuring that they and those important to them experience death with dignity.