Inernational research in health care management: its need in the 21st century, methodological challenges, ethical issues, pitfalls, and practicalities

PURPOSE

This commentary argues in favor of international research in the 21st century. Advances in technology, science, communication, transport, and infrastructure have transformed the world into a global village. Industries have increasingly adopted globalization strategies. Likewise, the health sector is more internationalized whereby comparisons between diverse health systems, international best practices, international benchmarking, cross-border health care, and cross-cultural issues have become important subjects in the health care literature. The focus has now turned to international, collaborative, cross-national, and cross-cultural research, which is by far more demanding than domestic studies. In this commentary, we explore the methodological challenges, ethical issues, pitfalls, and practicalities within international research and offer possible solutions to address them.

DESIGN/METHODOLOGY/APPROACH

The commentary synthesizes contributions from four scholars in the field of health care management, who came together during the annual meeting of the Academy of Management to discuss with members of the Health Care Management Division the challenges of international research.

FINDINGS

International research is worth pursuing; however, it calls for scholarly attention to key methodological and ethical issues for its success.

ORIGINALITY/VALUE

This commentary addresses salient issues pertaining to international research in one comprehensive account.

Adoption of evidence-based clinical innovations: the case of buprenorphine use by opioid treatment programs

This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations' technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs' decisions to adopt evidence-based clinical innovations such as buprenorphine use.

Insights from a national survey into why substance abuse treatment units add prevention and outreach services

Background

Previous studies have found that even limited prevention-related interventions can affect health behaviors such as substance use and risky sex. Substance abuse treatment providers are ideal candidates to provide these services, but typically have little or no financial incentive to do so. The purpose of this study was therefore to explore why some substance abuse treatment units have added new prevention and outreach services. Based on an ecological framework of organizational strategy, three categories of predictors were tested: (1) environmental, (2) unit-level, and (3) unit leadership.

Results

A lagged cross-sectional logistic model of 450 outpatient substance abuse treatment units revealed that local per capita income, mental health center affiliation, and clinical supervisors' graduate degrees were positively associated with likelihood of adding prevention-related education and outreach services. Managed care contracts and methadone treatment were negatively associated with addition of these services. No hospital-affiliated agencies added prevention and outreach services during the study period.

Conclusion

Findings supported the study's ecological perspective on organizational strategy, with factors at environmental, unit, and unit leadership levels associated with additions of prevention and outreach services. Among the significant predictors, ties to managed care payers and unit leadership graduate education emerge as potential leverage points for public policy. In the current sample, units with managed care contracts were less likely to add prevention and outreach services. This is not surprising, given managed care's emphasis on cost control. However, the association with this payment source suggests that public managed care programs might affects prevention and outreach differently through revised incentives. Specifically, government payers could explicitly compensate substance abuse treatment units in managed care contracts for prevention and outreach. The effects of supervisor graduate education on likelihood of adding new prevention and outreach programs suggests that leaders' education can affect organizational strategy. Foundation and government officials may encourage prevention and outreach by funding curricular enhancements to graduate degree programs demonstrating the importance of public goods.

Overall, these findings suggest that both money and professional education affect substance abuse treatment unit additions of prevention and outreach services, as well as other factors less amenable to policy intervention.

Organizational survival in the outpatient substance abuse treatment sector, 1988-2000

Substance abuse remains one of the most pressing health issues in the United States today, yet treatment supply continues to lag far behind need. Given the hostile environments treatment facilities face, their survival is a matter of pressing policy concern. Results from analyses of National Drug Abuse Treatment System Survey (NDATSS) data from 1988 through 2000 suggest that organizational attributes such as age, size, and client severity and resource dependencies such as reliance on government revenue affect survival, but their effects change over time. By the mid-1990s, director involvement in state and local policy making was positively associated with subsequent survival; later that decade, directors' professional credentials affected survival as well. Results also show that serving clients with multiple substance abuse problems became a survival liability by the late 1990s. Facilities that treat clients with multiple addictions may need additional financial support to serve these particularly vulnerable clients.

Factors associated with interorganizational relationships among outpatient drug treatment organizations 1990-2000

OBJECTIVE

To identify the factors associated with drug abuse treatment center participation in interorganizational relationships (IORs).

DATA SOURCES

Three nationally representative samples of outpatient drug abuse treatment units surveyed in 1990, 1995, and 1999/2000 as part of the National Drug Abuse Treatment System Survey (NDATSS), stratified by public/private status, treatment modality (methadone or nonmethadone), and organizational affiliation.

STUDY DESIGN

Probit analyses on 647 lagged treatment center-year observations from the years 1990 to 1995 with outcomes in 1995 and 2000, respectively. Standard errors were adjusted for clustering of center-year observations within centers.

PRINCIPAL FINDINGS

Centers with greater motivation to form IORs (e.g., as a result of client diversity or government revenue) were more likely to do so, as were centers with greater opportunities to form IORs (e.g., centers whose directors participated in policy making).

CONCLUSIONS

Both motivating and enabling factors promoted the formation of IORs by drug abuse treatment centers. Managed care also played a distinct role, in this case appearing to undermine interorganizational cooperation. Because IORs can improve access to care and quality, policy makers should consider using both incentives and support such as management training to promote IOR formation.

Community referral sources and entry of treatment-naive clients into outpatient addiction treatment

This study assessed the association of sources of client referral with enrollment of treatment-naive clients. Data from the 1995 (n = 618) and 2000 (n = 745) waves of the National Drug Abuse Treatment Survey (DATSS), a panel study of outpatient substance abuse treatment units (OSAT), were analyzed. Enrollment of treatment-naive clients was defined as the percentage of OSAT clients who entered treatment in the past 30 days with no prior treatment for substance abuse. A generalized estimating equation model simultaneously assessed the association of each referral source with the dependent variable, while controlling for potential confounding and accounting for correlation of unit-level responses over time. In the multivariable model, OSAT units with a greater proportion of treatment-naïve clients had received more referrals from employee assistance programs and the criminal justice system, and fewer referrals from mental health agencies. No effect of referral from medical or social service agencies was observed. These results highlight the role of coercive community institutions in treatment outreach efforts to persons in earlier phases of the "addiction career."

Accessibility of addiction treatment: results from a national survey of outpatient substance abuse treatment organizations

OBJECTIVES

This study examined organization-level characteristics associated with the accessibility of outpatient addiction treatment.

METHODS

Program directors and clinical supervisors from a nationally representative panel of outpatient substance abuse treatment units in the United States were surveyed in 1990, 1995, and 2000. Accessibility was measured from clinical supervisors' reports of whether the treatment organization provided "treatment on demand" (an average wait time of 48 hours or less for treatment entry), and of whether the program turned away any patients.

RESULTS

In multivariable logistic models, provision of "treatment on demand" increased two-fold from 1990 to 2000 (OR, 1.95; 95 percent CI, 1.5 to 2.6), while reports of turning patients away decreased nonsignificantly. Private for-profit units were twice as likely to provide "treatment on demand" (OR, 2.2; 95 percent CI, 1.3 to 3.6), but seven times more likely to turn patients away (OR, 7.4; 95 percent CI, 3.2 to 17.5) than public programs. Conversely, units that served more indigent populations were less likely to provide "treatment on demand" or to turn patients away. Methadone maintenance programs were also less likely to offer "treatment on demand" (OR, .65; 95 percent CI, .42 to .99), but more likely to turn patients away (OR, 2.4; 95 percent CI, 1.4 to 4.3).

CONCLUSIONS

Although the provision of timely addiction treatment appears to have increased throughout the 1990s, accessibility problems persist in programs that care for indigent patients and in methadone maintenance programs.

Trends in comprehensive service availability in outpatient drug abuse treatment

Comprehensive medical and psychosocial services are essential to quality addiction treatment, but their availability declined in the 1980s. To determine whether this downward trend in the availability of comprehensive services continued in the 1990s, we analyzed data from a national panel study of outpatient substance abuse treatment units in 1990, 1995, and 2000. Response rates were greater than 85%. Regarding the availability of comprehensive services, including physical examinations, routine medical care, mental health services, financial counseling and employment counseling, administrators reported whether any substance abuse treatment client received the service in the past year. With the exception of physical examinations, whose reported availability increased from 1990 to 1995, and financial counseling, whose reported availability decreased during the same time, the reported availability of comprehensive services changed little during the 1990s. These findings highlight the continuing need to monitor access to comprehensive services and other quality markers in addiction treatment over time.

Selective contracting in managed care: the case of substance abuse treatment

The authors address two critical questions concerning managed care and outpatient substance abuse treatment organizations. Specifically, they consider (1) to what extent selective contracting occurs between managed care firms and treatment providers and (2) what attributes of treatment providers and their operating environments are associated with selective contracting. Using data from a nationally representative sample of outpatient treatment organizations, the authors find evidence of systematic selection. Several indicators of providers' quality and costs, including accreditation status, private ownership, size, and prior experience with managed care, are positively associated with managed care contracting. By contrast, units providing methadone treatment are less likely to be involved in managed care. To a lesser extent, characteristics of treatment providers' operating environment, including extent of competition based on costs and attributes of the Medicaid managed care program, are also positively associated with managed care contracting.

Linkage to medical services in the Drug Abuse Treatment Outcome Study

BACKGROUND

An episode of substance abuse treatment is an opportunity to link substance-abusing patients to medical care at a time when management of medical problems might stabilize recovery and long-term health. However, little is known about the ability of organizational linkage mechanisms to facilitate the delivery of medical care to this population.

OBJECTIVES

The goal of this study was to examine whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs.

RESEARCH DESIGN

This was a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. Hierarchical linear models evaluated the effect of on-site delivery, formal and informal referral, case management emphasis, and transportation on the log-transformed number of medical visits at the 1-month in-treatment patient interview.

MEASURES

Program directors' surveys provided organizational information, including the linkage mechanism used to deliver medical care. Patients reported the number of medical visits during the first month of drug abuse treatment.

RESULTS

Exclusive on-site delivery increased medical utilization during the first month of drug abuse treatment (beta estimate, 0.22; standard error [SE], 0.06; P <0.001). Transportation services also increased 1-month medical utilization (beta estimate, 0.13; SE, 0.03; P <0.001).

CONCLUSIONS

Exclusive on-site delivery of medical services increased drug abuse treatment patients' utilization of medical services in the first month of treatment. Transportation assistance warrants strong policy consideration as a facilitator of medical service delivery. Future research should clarify whether program-level linkage to medical services improves the patient-level outcomes of drug abuse treatment.

Increasing access and providing social services to improve drug abuse treatment for women with children

AIMS

To assess the impact of a substance abuse treatment program for women with children designed to increase access to treatment through transportation, outreach and child-care services. Also, to assess the impact of using access services on the use of other services and on treatment effectiveness.

DESIGN

A quasi-experimental non-equivalent control group design was used with path analysis to examine the impact of participation in an enhanced services program that provided transportation, outreach and child-care services on the use of other social services and on the use of alcohol and illicit drugs.

SETTING

Treatment clients were interviewed in-person at enhanced treatment programs and regular substance abuse programs.

PARTICIPANTS

Study participants included a randomly selected sample of women with children who were clients of the Illinois Department of Children and Family Services. Participants were enrolled in enhanced or regular substance abuse treatment programs.

MEASUREMENTS

Study participants completed in-person interviews about their characteristics, services use and past and current substance use.

FINDINGS

Participation in the enhanced program was negatively related to substance use. Further, use of access services was related to use of social services which in turn, was negatively related to substance use.

CONCLUSION

The study indicates that services that enhance access to treatment and respond to the range of social service needs of women are important for effective substance abuse treatment for women with children.

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.

The effects of treatment team diversity and size on assessments of team functioning

Team-based health care assumes that groups representing multiple disciplines can work together to implement care plans that are comprehensive and integrated. It also assumes that professionals can function effectively in an interdependent relationship with members of other occupational groups. However, we know little about what makes effective team functioning. This article examines the factors related to health care team functioning, with specific emphasis on team demographic composition and size. Hierarchical linear modeling is used to analyze 106 Veterans Affairs (VA) hospitals. Results indicate that individuals who operate on more heterogenous and larger teams have lower perceptions of team functioning.

The strategies and autonomy of university hospitals in competitive environments

University-owned hospitals face increasingly threatening and unstable environments. This article examines the strategies that university-owned hospitals are using, and can use, to respond to their changing environments. Further, it examines factors that can hinder or promote the effective development of university-owned hospital strategies.

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.

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.

Determinants of mental health providers' expectations of patients' improvement

OBJECTIVE

Characteristics of individual mental health providers and of treatment settings were examined to determine their effects on providers' expectations about the improvement of patients with serious mental illness.

METHODS

The sample consisted of 1,567 treatment providers working in 107 inpatient and outpatient units or programs in 29 Veterans Affairs mental health facilities. They completed a questionnaire about their prognostic expectations and a broad range of attitudes toward job satisfaction, professional relations, and team functioning. Unit or program directors of all 107 units completed another questionnaire about the average functional ability of patients, unit workload, and unit size. Hierarchical linear modeling was used to assess the effects of both individual and unit-level attributes on providers' expectations of improvement in clinical symptomatology and social-functional skills of patients in their care.

RESULTS

The providers had generally low expectations about the improvement of patients with serious mental illness. Expectations were higher among staff in units or programs that were smaller and that had an outpatient focus, a greater proportion of staff involved in the treatment team, and higher-functioning patients. Individual characteristics significantly associated with prognostic expectations were occupation, age, and membership on the treatment team.

CONCLUSIONS

Prognostic expectations among providers of care to persons with serious mental illness vary with identifiable individual and unit or program characteristics. The latter may be amenable to manipulation and intervention to improve mental health providers' prognostic expectations.

Determinants of profound organizational change: choice of conversion or closure among rural hospitals

Because of severe operating and resource constraints, many rural community hospitals are confronted with pressures to abandon core strategies related to acute inpatient care. Little is known, however, about why hospitals would choose to convert to organizations that provide non-acute care health services as an alternative to closure. We argue that rural hospitals are more likely to convert when conditions are in place that enable them to make major shifts from their current domains to ones that are more hospitable. To the extent that resources are available in alternative domains and rural hospitals possess the strategies necessary to exploit these resources, rural hospitals are more likely to convert rather than close. To examine our proposed hypotheses, we analyze national data from all rural hospitals from 1984 through 1991. Results indicate that conversion is more likely to occur than closure when resources in the market are abundant, competition for hospital resources is high, and hospitals have established strategies to provide alternative forms of health care. Findings from this study indicate that environmental and organizational factors can increase a rural hospital's risk of conversion as an alternative to closure.

Determinants of rural hospital conversion. A model of profound organizational change

One widely discussed response to the severe problems faced by many rural hospitals is to convert them into organizations that provide health services other than general, acute inpatient care. This study identifies conversions that occurred nationally from 1984 to 1991. The study also empirically examines the determinants of conversion, using rural hospitals that did not convert (between 1984 and 1991) as a comparison group. The authors examine a set of factors that makes radical organizational change necessary (eg, poor performance) and reduces resistance to such change (eg, proximity to other hospitals). Results from discrete-time logistic regression show that converters are more likely than nonconverters to: have poor performance and fewer beds; be located very near to or very distant from similar hospitals; operate in larger communities; devote more of their care to areas other than acute inpatient care; and be members of multihospital systems. Converters also are less likely to be government owned. The need for future research on the effects of conversion is discussed.

Hospital corporate restructuring and financial performance

In the last decade, an important innovation in the organizational structure of acute care hospitals occurred. Many hospitals restructured by creating subsidiaries that segment assets or services into separate corporations. We know relatively little about the effects of such restructuring. This paper examines the association of restructuring with financial performance of not-for-profit hospital firms. The study uses data from all not-for-profit acute care hospital firms in Virginia, the only state for which the unique study data are available. We find that the consolidated financial performance of hospital firms is influenced by factors that affect the hospital's financial performance (i.e., payer-mix, staffing and service mix) but not the number or size of non-hospital subsidiaries. Future research should examine the effect of restructuring on other types of performance.

Ownership and performance of outpatient substance abuse treatment centers

BACKGROUND

Little is known about the organization and performance of outpatient substance abuse treatment (OSAT) centers. We examine several performance measures of OSAT units, including clients treated, services provided, revenue sources, financial performance, and access to care, in relation to ownership of the center.

METHODS

Data were drawn from a national random sample of 575 OSAT centers (85.8% response rate) participating in a telephone survey conducted in 1988. Analysis of variance by ownership was conducted on each performance measure, with differences subjected to tests of statistical significance.

RESULTS

Descriptive results show that major funding sources differ by ownership. Private for-profit centers generate higher profits, charge higher prices, and achieve higher levels of financial performance than public and not-for-profit centers. Public centers provide better access to care for persons who are unable to pay.

CONCLUSIONS

There appear to be substantial and interrelated differences by ownership type in the financing and operation of OSAT units.

Structural change in academic health centers

In response to opportunities and threats in their environments, academic health centers (AHCs) are making important changes in their structure. Several AHCs have legally separated their university hospital from the university. In contrast, other AHCs are linking the university hospital more closely to the medical school by concentrating authority for key decisions in the office of an AHC executive. This article draws from a national study of AHCs and examines the advantages and disadvantages of such changes in AHC structure. An important reason for these changes is maximizing revenues from patient care; an important consequence is the increased salience of patient care among the multiple purposes of AHCs.

Hospital alliances: cooperative strategy in a competitive environment

The resource dependence perspective is used to describe the formation of hospital alliances. Characteristics of alliances and their various strategies and structures are discussed. A life cycle model provides a framework for viewing the development and growth of alliances. Several dimensions for assessing alliance performance are proposed.

Hospital-physician relations under hospital prepayment

Fundamental changes now occurring in the field of health services may make it increasingly difficult to develop or maintain satisfactory hospital-physician relations. This paper examines the nature of hospital-physician relations following the introduction of an experimental hospital prepayment program that capped budgets in nine hospitals for a 5-year period. Results from longitudinal analyses based on data from key physicians, hospital administrators, and board members indicate generally positive "effects" on hospital-physician relations, except for increased strain in the system. In most respects, there were no adverse effects on the work relations of physicians, in the perceived quality of medical care, or in the institutional performance of physicians at the nine participating hospitals after the introduction of prepayment. Moreover, to some extent, the prepayment program appears to have been effective in controlling hospital costs and is perceived by the principal participants to have been successful.

A life-cycle model of organizational federations: the case of hospitals

Hospital federations are a form of multiorganizational collaboration in which a management group coordinates and directs the activities of three or more organizations. This paper introduces a life-cycle model of federations that focuses on factors that influence the transition from one stage to another.