Cost, Quality, and Utilization After Hospital-Physician and Hospital-Post Acute Care Vertical Integration: A Systematic Review

Vertical integration of health systems-the common ownership of different aspects of the health care system-continues to occur at increasing rates in the United States. This systematic review synthesizes recent evidence examining the association between two types of vertical integration-hospital-physician (n = 43 studies) and hospital-post-acute care (PAC; n = 10 studies)-and cost, quality, and health services utilization. Hospital-physician integration is associated with higher health care costs, but the effect on quality and health services utilization remains unclear. The effect of hospital-PAC integration on these three outcomes is ambiguous, particularly when focusing on hospital-SNF integration. These findings should raise some concern among policymakers about the trajectory of affordable, high-quality health care in the presence of increasing hospital-physician vertical integration but perhaps not hospital-PAC integration.

A more complete measure of vertical integration between physicians and hospitals

OBJECTIVE

To develop an accurate and reproducible measure of vertical integration between physicians and hospitals (defined as hospital or health system employment of physicians), which can be used to assess the impact of integration on healthcare quality and spending.

DATA SOURCES AND STUDY SETTING

We use multiple data sources including from the Internal Revenue Service, the Centers for Medicare and Medicaid Services, and others to determine the Tax Identification Numbers (TINs) that hospitals and physicians use to bill Medicare for services, and link physician billing TINs to hospital-related TINs.

STUDY DESIGN

We developed a new measure of vertical integration, based on the TINs that hospitals and physicians use to bill Medicare, using a broad set of sources for hospital-related TINs. We considered physicians as hospital-employed if they bill Medicare primarily or exclusively using hospital-related TINs. We assessed integration status for all physicians who billed Medicare from 1999 to 2019. We compared this measure with others used in the existing literature. We conducted a simulation study which highlights the importance of accurately identifying integrated physicians when study the effects of integration.

DATA COLLECTION/EXTRACTION METHODS

We extracted physician and hospital-related TINs from multiple sources, emphasizing specificity (a small proportion of nonintegrated physicians identified as integrated).

PRINCIPAL FINDINGS

We identified 12,269 hospital-related TINs, used for billing by 546,775 physicians. We estimate that the percentage of integrated physicians rose from 19% in 1999 to 43% in 2019. Our approach identifies many additional physician practices as integrated; a simpler TIN measure, comparable with prior work, identifies only 30% (3877) of the TINs we identify. A service location measure, used in prior work, has both many false positives and false negatives.

CONCLUSION

We developed a new measure of hospital-physician integration. This measure is reproducible and identifies many additional physician practices as integrated.

Vertically Stackable Ovonic Threshold Switch Oscillator Using Atomic Layer Deposited Ge0.6Se0.4 Film for High-Density Artificial Neural Networks

Nanodevice oscillators (nano-oscillators) have received considerable attention to implement in neuromorphic computing as hardware because they can significantly improve the device integration density and energy efficiency compared to complementary metal oxide semiconductor circuit-based oscillators. This work demonstrates vertically stackable nano-oscillators using an ovonic threshold switch (OTS) for high-density neuromorphic hardware. A vertically stackable Ge0.6Se0.4 OTS-oscillator (VOTS-OSC) is fabricated with a vertical crossbar array structure by growing Ge0.6Se0.4 film conformally on a contact hole structure using atomic layer deposition. The VOTS-OSC can be vertically integrated onto peripheral circuits without causing thermal damage because the fabrication temperature is <400 °C. The fabricated device exhibits oscillation characteristics, which can serve as leaky integrate-and-fire neurons in spiking neural networks (SNNs) and coupled oscillators in oscillatory neural networks (ONNs). For practical applications, pattern recognition and vertex coloring are demonstrated with SNNs and ONNs, respectively, using semiempirical simulations. This structure increases the oscillator integration density significantly, enabling complex tasks with a large number of oscillators. Moreover, it can enhance the computational speed of neural networks due to its rapid switching speed.

Metallic Nanoalloys on Vertical GaAs Nanowires: Growth Mechanisms and Shape Control of Ni-GaAs Compounds

GaAs nanowires are promising candidates for emerging devices in a broad field of applications (e.g., nanoelectronics, photodetection, or photoconversion). These nanostructures benefit greatly from a vertical integration, as it allows for the exhibition of the entire nanowire surface. However, one of the main challenges related to vertical integration is the conception of an efficient method to create low resistive contacts at nanoscale without degrading the device performance. In this article, we propose a complementary metal-oxide-semiconductor (CMOS)-compatible approach to form alloyed contacts at the extremities of vertical GaAs nanowires. Ni-based and Pd-based alloys on different vertical GaAs nanostructures have been characterized by structural and chemical analyses to identify the phase and to study the growth mechanisms involved at the nanoscale. It is shown that the formation of the Ni3GaAs alloy on top of nanowires following the epitaxial relation Ni3GaAs(0001)∥GaAs(111) leads to a pyramidal shape with four faces. Finally, guidelines are presented to tune the shape of this alloy by varying the initial metal thickness and nanowire diameters. It will facilitate the fabrication of a nanoalloy structure with tailored shape characteristics to precisely align with a designated application.

From active affordance to active inference: vertical integration of cognition in the cerebral cortex through dual subcortical control systems

In previous papers, we proposed that the dorsal attention system's top-down control is regulated by the dorsal division of the limbic system, providing a feedforward or impulsive form of control generating expectancies during active inference. In contrast, we proposed that the ventral attention system is regulated by the ventral limbic division, regulating feedback constraints and error-correction for active inference within the neocortical hierarchy. Here, we propose that these forms of cognitive control reflect vertical integration of subcortical arousal control systems that evolved for specific forms of behavior control. The feedforward impetus to action is regulated by phasic arousal, mediated by lemnothalamic projections from the reticular activating system of the lower brainstem, and then elaborated by the hippocampus and dorsal limbic division. In contrast, feedback constraint-based on environmental requirements-is regulated by the tonic activation furnished by collothalamic projections from the midbrain arousal control centers, and then sustained and elaborated by the amygdala, basal ganglia, and ventral limbic division. In an evolutionary-developmental analysis, understanding these differing forms of active affordance-for arousal and motor control within the subcortical vertebrate neuraxis-may help explain the evolution of active inference regulating the cognition of expectancy and error-correction within the mammalian 6-layered neocortex.

Variation in tiered network health plan penetration and local provider market characteristics

OBJECTIVE

To understand variation in enrollment in tiered network health plans (TNPs) and the local provider market characteristics associated with TNP penetration.

DATA SOURCES AND STUDY SETTING

We used 2013-2017 Massachusetts three-digit ZIP code level employer-sponsored health insurance enrollment data, data on physician horizontal and vertical affiliations from the Massachusetts Provider Database, state hospital reports in 2013, 2015, and 2017, and the 2013-2017 Massachusetts All-Payer Claims database.

STUDY DESIGN

Linear regressions were used to estimate associations between TNP and local provider market characteristics.

DATA EXTRACTION

We constructed measures of TNP penetration and local provider market characteristics and linked these data using three-digit ZIP code.

PRINCIPAL FINDINGS

TNP penetration was at least 10% in all employer market sectors and highest among jumbo sized employers. All state employee health plan enrollees were in a tiered network health plan. Among enrollees not in the state employee health plan, TNP penetration varied from 6.0% to 19.6% across three-digit ZIP codes in Massachusetts. TNP penetration was higher in areas with less horizontal and vertical physician market concentration.

CONCLUSIONS

Market competition, rather than the absolute quantity of physicians in an area, is associated with TNP penetration.

CVS Health's Acquisition of Oak Street Health Reconfirms Market Viability of Private Equity Investment in Value-Based Payment Models for Primary Care

For over a decade and for the foreseeable future, federal agencies have made efforts to promote value-based care through various incentive schemes, such as the recent "Regulatory Sprint to Coordinated Care." Federal incentive schemes and other "macro tailwinds" have brought in private equity investors, especially in the context of primary care for Medicare beneficiaries. Oak Street Health and its private equity backers were pioneers in this space, applying buy-and-build strategies to create "next-generation" primary care networks "that focus largely or entirely on Medicare Advantage enrollees." Although Oak Street Health persuasively established a workable "playbook" for private equity investment in value-based care, and forecasts have been favorable, the ultimate market viability of this value-based playbook hinges on whether or not private equity investors can locate corporate buyers. The market viability of such a strategy has now been reconfirmed by the acquisition of Oak Street Health by CVS Health ("CVS"), announced February 8, 2023, and closed May 2, 2023, especially given that the incentives and the efficiencies associated with this deal are likely to be applicable to large-scale vertically integrated "payvider" corporations more generally. This Recent Transaction Comment examines CVS's acquisition of Oak Street Health to consider what factors might lead vertically integrated health care corporations to acquire value-based primary care networks in the future, and what knock on effects such acquisitions might have on future private equity buyouts in health care.

Vertical integration and corporate value under the uncertainty shock: Natural experiment evidence from the COVID-19 pandemic

Using the exogenous shock of the COVID-19 pandemic, we examine whether vertical integration creates value for firms when facing increasing uncertainty. Using cross-sectional data during the outbreak of the COVID-19 pandemic, we find that there is a significant and positive correlation between vertical integration and cumulative abnormal return in the event window of the COVID-19. Furthermore, when external transaction costs are higher or internal organization costs are lower during the COVID-19 pandemic, the above results are more pronounced. Our results indicate that vertical integration could avoid uncertainty, reduce transaction costs, hence improving corporate value, providing empirical evidence for theories about the uncertainty and vertical integration in transaction-cost economics.

The effect of hospital-physician integration on hospital costs

This study evaluates whether hospital costs are lower when hospitals integrate with physician practices. It addresses a common element in policy attempts to contain healthcare costs, which is to encourage greater coordination in healthcare delivery. Despite a clear trend toward greater hospital-physician integration, there is little direct evidence about whether integration lowers hospital costs. The results in this paper show that hospital costs increase by one to three percent after hospital-physician integration. We also do not find consistent evidence that hospital-physician integration is associated with higher quality but potentially more costly hospital care. The modest increase in hospital costs appears to derive from an increase in outpatient visits, rather than from higher costs of inpatient care. These findings do not support the hypothesis that increased coordination between hospitals and physicians has led to lower hospital costs.

Are We Facing the End of Gross Anatomy Teaching as We Have Known It for Centuries?

The status of anatomy education in undergraduate medical education has dramatically changed over the course of the past century. From the most important and time-consuming component of the preclinical program, anatomy education has reduced in size and status, and yielded in curricular space to accommodate other disciplines and topics. Meanwhile, radiology has become more prominent, as a means to visualize anatomy, not only in clinical care but also in education. For this perspective paper, the authors, all with backgrounds in anatomy, radiology and/or medical education, conducted structured conversations with several academic colleagues with similar backgrounds, reviewed pertinent literature and analyzed the causes of the historical decline of a knowledge domain of medical education, that nevertheless is widely considered essential for medical students and graduates. After this analysis, the authors propose four ways forward. These directions include systematic peer teaching and development of anatomy education as a scholarly domain, further vertical integration with postgraduate medical education, full integration with radiology education, and capitalizing on educational technology. Schools in several industrialized countries have made steps in these directions, which can be further strengthened. In less affluent countries, and in countries with curricula strongly determined by tradition, these steps are less easy to make. To respond to changes in global health and health care, combined with the inevitable technological progress, and international mobility, we believe all schools will move in these directions, slower or faster.

Transfer of anatomy during surgical clerkships: an exploratory study of a student-staff partnership

OBJECTIVES

This qualitative study aims to explore how fourth-year medical students on the surgery course perceived a clinical anatomy workshop organised by near-peer student teachers in partnership with faculty.

METHODS

Forty-seven medical students participated in a workshop on clinical anatomy in the dissection laboratory. A voluntary response sampling method was used. The students' perceptions of the workshop were explored through a thematic content analysis of transcribed, semi-structured group interviews and written comments.

RESULTS

A majority of the students had not revisited the dissection laboratory since their second year, and all students described the workshop as a unique opportunity to vertically integrate anatomical knowledge. Four main themes were identified as most valuable for the students' learning experience, namely that the workshop 1) was taught by knowledgeable and friendly near-peer tutors (NPTs), 2) consisted of highly relevant anatomical content, 3) offered a hands-on experience of cadavers in the dissection laboratory, and 4) was taught in a focused session in the middle of the surgery course.

CONCLUSIONS

 This study shows how hands-on workshops in clinical anatomy, developed in student-staff partnerships and taught by NPTs, can enable senior medical students to recall and vertically integrate anatomical knowledge during surgical clerkships. The results have implications for curriculum design, giving voice to senior students' wishes for spaced repetition and vertical integration of pre-clinical anatomy knowledge during their clinical training. Moreover, this study may inspire other students and faculty to develop similar near-peer teaching activities through student-staff partnerships.

Hospital-physician integration and risk-coding intensity

Hospital-physician integration has surged in recent years. Integration may allow hospitals to share resources and management practices with their integrated physicians that increase the reported diagnostic severity of their patients. Greater diagnostic severity will increase practices' payment under risk-based arrangements. We offer the first analysis of whether hospital-physician integration affects providers' coding of patient severity. Using a two-way fixed effects model, an event study, and a stacked difference-in-differences analysis of 5 million patient-year observations from 2010 to 2015, we find that the integration of a patient's primary care doctor is associated with a robust 2%-4% increase in coded severity, the risk-score equivalent of aging a physician's patients by 4-8 months. This effect was not driven by physicians treating different patients nor by physicians seeing patients more often. Our evidence is consistent with the hypothesis that hospitals share organizational resources with acquired physician practices to increase the measured clinical severity of patients. Increases in the intensity of coding will improve vertically-integrated practices' performance in alternative payment models and pay-for-performance programs while raising overall health care spending.

Vertical Integration Versus Physician Owners: Trends in Practice Structure Among Breast Cancer Surgeons

OBJECTIVE

The objective of this study was to document changes in physician practice structure among surgeons who treat women with breast cancer.

DESIGN

We merged cancer registry records from 5 large states with Medicare Part B claims to identify each surgeon who treated women with breast cancer. We added information from SK&A surveys and extensive internet searches. We analyzed changes in breast surgeons' practice structure over time.

MEASURES

We assigned each surgeon-year a practice structure type: (1) small single-specialty practice; (2) single-specialty surgery or multispecialty practice with ownership in an ambulatory surgery center (ASC); (3) physician-owned hospital; (4) multispecialty; (5) employed.

RESULTS

In 2003, nearly 74% of breast cancer surgeons belonged to small single-specialty practices. By 2014, this percentage fell to 51%. A shift to being employed (vertical integration) accounted for only a portion of this decline; between 2003 and 2014, the percentage of surgeons who were employed increased from 10% to 20%. The remainder of this decline is due to surgeons opting to acquire ownership in an ASC or a specialty hospital. Between 2003 and 2014, the percentage of surgeons with ownership in an ASC or specialty hospital increased from 4% to 17%.

CONCLUSIONS

Dramatic changes in surgeon practice structure occurred between 2003 and 2014 across the 5 states we examined. The most notable was the sharp decline in the prevalence of the small single-specialty practice and large increases in the proportion of surgeons either employed or with ownership in ACSs or hospitals.

Trends in Orthopedic Surgeon Practice Consolidation From 2008 to 2019

BACKGROUND

In the past decade, physician practices have merged into larger group practices (ie, horizontal consolidation) and have been acquired by hospitals and health systems (ie, vertical consolidation), leaving fewer practices independent. The implications of these changes can be profound, affecting the prices for and spending on physician services, access to care, patients' choice of providers, and quality of care.

METHODS

We used IQVIA data on orthopedic surgeon practice sites that included information on health system or hospital ownership, group medical practice participation, and average patient volume. We calculated the number and size of group medical practices as measures of horizontal consolidation and the percentage of practice sites owned by a health system or hospital as a measure of vertical consolidation. We also calculated the Herfindahl-Hirschman Index to measure market concentration.

RESULTS

We found significant horizontal and vertical consolidation nationally and across all regions of the United States. This consolidation has led to much more concentrated markets, as measured by Herfindahl-Hirschman Index, for orthopedic surgeon services. These trends are consistent with studies looking at consolidation of other types of providers.

CONCLUSION

Orthopedic surgeon practices, like other provider types, have consolidated at a rapid rate over the past decade. A variety of factors may have contributed, including the move away from fee-for-service to alternative payment arrangements, changes in Medicare payment policies, private equity activity, and evolving physician preferences. Due to the potential impacts of this consolidation, more research is needed to examine some of these contributing factors.

A task-based learning strategy in preclinical medical education

Preclinical task-based learning (TskBL) is a simulated learning approach in which the focus for students is a real task done by a medical professional. TskBL includes standardized patient encounters and is helpful to provide early clinical exposure. Our study aimed at planning, implementing, and assessing TskBL among first-year medical students and comparing it to the conventional method of tutorials in the physiology MBBS curriculum. This is a nonequivalent group quasi-experimental study approved by the institutional ethics committee. TskBL was conducted for seven topics among first-year medical students of Kasturba Medical College, Mangalore for three academic years. Participants were divided into a TskBL group and a control group. Both groups attended the theory classes in physiology, practical sessions, and clinical examinations concerning the tasks. After this, the TskBL group underwent TskBL, and the control group underwent tutorials. Pretest and posttest assessments were conducted by using a multiple choice question (MCQ) test and objective structured clinical examinations (OSCEs).The mean TskBL scores for MCQ (exception: hypertension, myasthenia gravis, and chronic obstructive pulmonary disease) and OSCE (exception: anemia and hypertension) were significantly higher than the tutorial group. Pretest and posttest scores revealed significantly higher MCQ and OSCE scores for TskBL (exception: MCQ score for hypertension and chronic obstructive pulmonary disease). The tutorial group did not show a significant improvement in test scores for all the tasks. The TskBL strategy could be used for topics that are likely to be encountered by the students during clinical attachments. Small group teaching can include TskBL in preference to tutorials to provide early clinical exposure in medical schools.

Vertical Integration and Physician Practice Labor Composition

With the growth of vertical integration among physician practices (i.e., hospital-physician integration), there have been many studies of its effects on health care treatments and spending. It is unknown if integration shapes provider configurations, especially against the backdrop of increasing employment of nurse practitioners (NPs) and physician assistants (PAs) across specialties. Using a longitudinal panel of 144,289 practices (2008-2015), we examined the association of vertical integration with NP and PA employment. We find positive associations between vertical integration and newly employing NPs and PAs within physician practices; however, the relationships differ by practice specialty type as well as timing of vertical integration. Supplementary analyses offer supporting evidence for coinciding enhancements to practice productivity, diversification, and provider task allocation. Our results suggest that vertical integration may promote interdisciplinary provider configurations, which has the potential to improve care delivery efficiency.

Hospital-cardiologist integration often occurs without a practice acquisition

OBJECTIVE

To describe how much of the recent increase in hospital-cardiologist integration has come from acquisitions of physician practices compared to individual employment decisions. While the role of physician practice acquisitions has received considerable attention in the news, integration may also be driven by individual physicians accepting employment at hospital-based practices.

DATA SOURCES

American Medical Association Physician Masterfile and Medicare data.

STUDY DESIGN

Analysis of changes in hospital-cardiologist integration from 2011-2018. We measured increases in integration and changes in the number of independent and hospital-owned practices.

DATA COLLECTION/EXTRACTION METHODS

N/A PRINCIPAL FINDINGS: 18 percent of cardiologists were integrated in 2011, rising to 25 percent in 2016. Of this rise, 48 percent occurred with no acquisitions. Physicians who had completed residencies in the past five years (early-career physicians) had higher rates of integration which also increased over time: the percentage of early-career physicians joining hospital systems rose from 25 to 32 percent, indicating rapid growth in the number of physicians who began their careers working in hospital-based sites.

CONCLUSIONS

A large and growing portion of hospital-cardiologist integration came from hospital employment at the individual physician level. Future policies focused on preserving competition and affordability may benefit from better understanding this form of consolidation.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities

OBJECTIVE

To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes.

DATA SOURCES

Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014.

STUDY DESIGN

We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions.

DATA EXTRACTION METHODS

We identified Medicare beneficiaries discharged from a hospital to IRF.

PRINCIPAL FINDINGS

In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals.

CONCLUSIONS

Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.

[The five-year dynamics of main indices of functioning of neurosurgical service of the Russian Federation]

The neurosurgery is one of the most innovative and hi-tech directions of scientific and clinical activity that significantly contribute into improvement of health and improvement of quality and longevity of human life. This positioning specifies actuality of implementing on regular basis the analysis of trends of its development with purpose to improve corresponding indices of its efficiency, to develop conditions for continuity of medical process, to ensure equal accessibility of specialized neurosurgical medical care to population in the Regions of the Russian Federation. The purpose of the study was to describe and to analyze indices of neurosurgical service functioning to support decision making related to development of professional partnership and ensuring for population of different regions of Russia equal access to profile specialized medical care. The data of 2015-2019 was collected from 85 Subjects of the Russian Federation contained in the forms of state statistical observation "Data on activity of divisions of medical organization providing medical care in hospital conditions" and "Data on medical organization". The analysis of the collected data was implemented using such statistical tools as simple (unweighted) arithmetical mean values, specific weight of indices values, mean-root-square (standard) deviation from average values, coefficient of variation (mean-square distance and average value ratio). The data set considered as homogeneous if coefficient of variation did not exceed 33%. The study revealed that in the Russian Federation, at the mean, provision of beds of neurosurgical profile to population in 2015-2019 decreased from 9.22 to 8.83 beds per 100 000 of population. In 2019, intensity of hospitalization made up to 2.77±1.06 cases per 1000 of population. The average duration of treatment for five years decreased for 1 day and in 2019 made up to 8.47 days (9.96±2.3 days on beds for adults and 7.00±2.1 on beds for children). The mean annual occupancy of one bed of neurosurgical profile for adults decreased from 319.6±31.3 days in 2015 to 311.7±29.8 days in 2019 and for children from 305.4±28.3 days in 2015 to 289.0±29.1 days in 2019. The total hospital lethality of neurosurgical beds in 2019 consisted 1.22±1.19% that is 22.7% less than in 2015 (1.50±1.37%). The number of implemented surgical operations increased from 146.4 in 2015 to 179.1 thousand in 2019, i.e. for 22.4% and made up to 2.7 operations per 1000 of population. The postoperative lethality decreased from 9.63±7.07% in 2016 to 8.19±4.48% in 2019. In 2019, there were 1.91±0.61 neurosurgeons (natural persons) per 100 000 of population. The total number of established posts of neurosurgeons in 2019 made up to 4792.25 units (in 2015 - 4629.75 units) and out of them 4318 units are occupied (in 2015 - 4264 units). The occupied units covered 2923 neurosurgeons as natural persons. On average, per one neurosurgeon (natural person) in the Subjects of the Russian Federation fall 4.7±1.30 beds of neurosurgical profile (from 2.6 to 10.7), 54.7± 24.6 surgical operations on nervous system per year (from 14 to 162), 137.8±41.1 cases of neurosurgical beds hospitalization (from 60 to 300). In five years, the structure of types of surgical operations on nervous system changed insignificantly. The surgeries in case of degenerative diseases of spline prevail and their specific weight increases. In Russia, significant differentiation of the Regions in level of resource support of medical care of neurosurgical profile continue to remain. At that, the Russian neurosurgeons in average implement three times less operation per year than their respective colleagues from Western Europe. In Russia, the main portion of neurosurgical operations is implemented in case of degenerative diseases of spine while in the developed foreign countries in case of cerebral stroke that is one of the main causes of death all around the world. To ensure equal access of population of different Subjects of Russia to profile specialized medical care an integration of clinical and administrative processes (vertical integration) is needed. The important role in solution of this task belongs to National medical research centers organized in Russia on the basis of leading Federal state scientific medical organizations.

Biomedical Courses Should Also Be Designed for Dental Students: The Perceptions of Dental Students

INTRODUCTION

It can be challenging integrating biomedical sciences into dentistry programs. The aim was to examine students' perceptions of how joint biomedical courses with medical students and courses tailored for dental students supported their clinical studies.

MATERIALS AND METHODS

The target group was clinical phase dental students. Cross-sectional survey data were collected using a questionnaire, which consisted of questions covering biomedical and clinical study content and learning methods.

RESULTS

A total of 110 (82%) students completed the survey. Students had difficulty recognising the relevance of joint biomedical courses for clinical work, but when the link was clear, their interest in the content increased. The closer the respondents were to graduation, the less relevance they expressed the biomedical sciences had. Almost all students (95%) wanted more dental content for the early study years.

DISCUSSION

The student perspective provides valuable information for the development of biomedical courses. Students should be offered customised courses that include dental content and perspectives on clinical work, whenever suitable to the didactic content of the basic science course. Our study shows that the dental perspective needs greater integration with the biomedical content. This also supports interprofessional learning and appreciation for the other field's contribution to human health.

The Effects of Accountable Care Organizations Forming Preferred Skilled Nursing Facility Networks on Market Share, Patient Composition, and Outcomes

BACKGROUND

Through participation in payment reforms such as bundled payment and accountable care organizations (ACOs), hospitals are increasingly financially responsible for health care use and adverse health events occurring after hospital discharge. To improve management and coordination of postdischarge care, ACO hospitals are establishing a closer relationship with skilled nursing facilities (SNFs) through the formation of preferred SNF networks.

RESEARCH DESIGN

We evaluated the effects of preferred SNF network formation on care patterns and outcomes. We included 10 ACOs that established preferred SNF networks between 2014 and 2015 in the sample. We first investigated whether hospitals "steer" patients to preferred SNFs by examining the percentage of patients sent to preferred SNFs within each hospital before and after network formation. We then used a difference-in-difference model with SNF fixed effects to evaluate the changes in patient composition and outcomes of preferred SNF patients from ACO hospitals after network formation relative to patients from other hospitals.

RESULTS

We found that preferred network formation was not associated with higher market share or better outcomes for preferred SNF patients from ACO hospitals. However, we found a small increase in the average number of Elixhauser comorbidities for patients from ACO hospitals after network formation, relative to patients from non-ACO hospitals.

CONCLUSIONS

After preferred SNF network formation, there is some evidence that ACO hospitals sent more complex patients to preferred SNFs, but there was no change in the volume of patients received by these SNFs. Furthermore, preferred network formation was not associated with improvement in patient outcomes.

The Association between Hospital-Physician Vertical Integration and Outpatient Physician Prices Paid by Commercial Insurers: New Evidence

This study assessed the relationship between hospital ownership of physician organizations (known as hospital-physician vertical integration) and facility fees billed to commercial insurers and physician service prices. Healthcare claims came from the IBM® MarketScan® Commercial Database (2012-2016, N = 30,716,800 office visit claims [CPT codes 99211-99215]), and hospital-physician vertical integration measures were from SK&A Office Based Physicians Database provided by IQVIA. Multi-variate, fixed-effect models were used to regress prices on market-level hospital-physician vertical integration; models included geographic market and year fixed effects, claim-level variables, and time-varying market-level variables. Analyses did not find that market-level hospital-physician vertical integration was associated with the billing of facility fees for office visits. However, vertical integration was associated with office visit physician prices for some specialties. A 10-percentage-point increase in vertical integration was associated with a 1.0% price increase for primary care, a 0.6% increase for orthopedics, and a 0.5% increase for cardiology; no such association was found for obstetrics/gynecology or oncology. When comparing metropolitan statistical areas (MSAs) in the bottom quartile of changes in vertical integration from 2012 to 2016 to MSAs in the top quartile, we found the following relative price increases based on predicted values for claims in the top quartile: $1.64 (1.9% of mean 2012 predicted price) for primary care to $2.30 (3.1%) for orthopedics to $3.13 (3.4%) for cardiology. Differences in predicted price accounted for an estimated $45.8 million in additional expenditure on primary care office visits in the top quartile of MSAs in 2016. In summary, market-level hospital-physician vertical integration was positively associated with physician prices for select specialties, but was not associated with changes in the use of facility-fee billing. More evidence on the quality effects of hospital-physician vertical integration is needed, as price increases that are not accompanied by measurable quality improvements should be part of any regulatory review.

Do Medicare's Facility Fees Incentivize Hospitals to Vertically Integrate with Oncologists?

Within the past decade, the U.S. health care market has undergone massive vertical integration, prompting economists to study the underlying causes and consequences of hospital-physician integration. This paper examines whether or not hospitals strategically choose to vertically integrate with clinical oncologists in order to capture facility fees, a commonly cited reason for increased consolidation in the health care market. To address this question, I match data on hospitals' ownership of clinical oncologists with Medicare payment data disaggregated to the physician and specific service level. I leverage a 2014 policy change that drastically altered the payment structure of Medicare's facility fees paid to hospitals for evaluation and management services-and yet, it did not alter the direct payments made to physicians. Contrary to popular belief, I find no evidence that the financial incentives of facility fees have an effect on the probability that a hospital and a clinical oncologist vertically integrate.

The importance of understanding and measuring health system structural, functional, and clinical integration

OBJECTIVE

We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration.

DATA SOURCES

Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019.

STUDY DESIGN

Exploratory study using thematic comparative analysis to describe factors that may lead to high performance.

DATA COLLECTION

We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs.

PRINCIPAL FINDINGS

Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise."

CONCLUSIONS

Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms.

Hospital admissions after vertical integration of general practices with an acute hospital: a retrospective synthetic matched controlled database study

Background

New healthcare models are being explored to enhance care coordination, efficiency, and outcomes. Evidence is scarce regarding the impact of vertical integration of primary and secondary care on emergency department (ED) attendances, unplanned hospital admissions, and readmissions.

Aim

To examine the impact of vertical integration of an NHS provider hospital and 10 general practices on unplanned hospital care

Design and setting

A retrospective database study using synthetic controls of an NHS hospital in Wolverhampton integrated with 10 general practices, providing primary medical services for 67 402 registered patients.

Method

For each vertical integration GP practice, a synthetic counterpart was constructed. The difference in rate of ED attendances, unplanned hospital admissions, and unplanned hospital readmissions was compared, and pooled across vertical integration practices versus synthetic control practices pre-intervention versus post-intervention.

Results

Across the 10 practices, pooled rates of ED attendances did not change significantly after vertical integration. However, there were statistically significant reductions in the rates of unplanned hospital admissions (−0.11, 95% CI = −0.18 to −0.045, P = 0.0012) and unplanned hospital readmissions (−0.021, 95% CI = −0.037 to −0.0049, P = 0.012), per 100 patients per month. These effect sizes represent 888 avoided unplanned hospital admissions and 168 readmissions for a population of 67 402 patients per annum. Utilising NHS reference costs, the estimated savings from the reductions in unplanned care are ∼£1.7 million.

Conclusion

Vertical integration was associated with a reduction in the rate of unplanned hospital admissions and readmissions in this study. Further work is required to understand the mechanisms involved in this complex intervention, to assess the generalisability of these findings, and to determine the impact on patient satisfaction, health outcomes, and GP workload.

Vertical integration of head, neck, and special senses module in undergraduate medical curriculum

Vertical integration is believed to increase motivation by providing context for the learning. In this quasi-experimental study, cohort I took two horizontally integrated modules: structure and function of head, neck, and special senses in the second year, and pathophysiology and clinical sciences in the third year. Cohort II took a combined, vertically integrated module in the second year. Data from the questionnaire and examination scores were compared. Response rate was 80.1% (125/156) for cohort I and 57.6% (98/170) for cohort II. Response to the statement that vertical integration provides context to basic sciences was mixed with a higher agreement in cohort II (51.5 vs. 37.2%; P = 0.04). Cohort II was least satisfied with the appropriateness of self-study time (52.0 vs. 34.7%; P = 0.01). However, cohort II felt that the basic sciences lectures (90.8 vs. 69.4%; P < 0.01) and the clinical skills sessions (85.7 vs. 62.1%; P < 0.01) were more effective. Cohort II was less satisfied with clinical lectures (80.6 vs. 56.1%; P < 0.01) and was less confident in achieving clinical learning objectives (72.8 vs. 40.8%; P < 0.01). Mean multiple-choice questions and problem-based learning scores were similar. However, the short-answer question score was higher for cohort I [82.48 (SD 14.9) vs. 70.74 (SD 17.9); P < 0.01]. Overall, the idea of early vertical integration had a mixed response. It improved the effectiveness of basic sciences lectures and clinical skills sessions. Achievement of clinical learning outcomes was compromised. A disparity in the module's duration and curricular content, and students' ability to grasp clinical concepts and faculty's expectations are the possible reasons. Increased duration and better communication with clinical faculty may improve early introduction of vertical integration.

Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model?

OBJECTIVE

We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model.

DATA SOURCES

We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas.

STUDY DESIGN

We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR.

PRINCIPAL FINDINGS

Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant.

CONCLUSIONS

When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.

Landscape of Health Systems in the United States

Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.

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

INTRODUCTION

Current U.S. policy and payment initiatives aim to encourage health care provider accountability for population health and higher value care, resulting in efforts to integrate providers along the continuum. Providers work together through diverse organizational structures, yet evidence is limited regarding how to best organize the delivery system to achieve higher value care.

METHODS

In 2016, we conducted a narrative review of 10 years of literature to identify definitional components of key organizational structures in the United States. A clear accounting of common organizational structures is foundational for understanding the system attributes that are associated with higher value care.

RESULTS

We distinguish between structures characterized by the horizontal integration of providers delivering similar services and the vertical integration of providers fulfilling different functions along the care continuum. We characterize these structures in terms of their origins, included providers and services, care management functions, and governance.

CONCLUSIONS AND DISCUSSION

Increasingly, U.S. policymakers seek to promote provider integration and coordination. Emerging evidence suggests that organizational structures, composition, and other characteristics influence cost and quality performance. Given current efforts to reform the U.S. delivery system, future research should seek to systematically examine the role of organizational structure in cost and quality outcomes.

Longitudinal curriculum development: gradual optimization of a biochemistry seminar

Objective: The Master Plan for Medical Studies 2020 places additional emphasis on curricular development processes. In addition, institutes may recognize a need to optimize their courses, for example because of poor evaluations. Frequently, however, the resources required for comprehensive optimizations are not available. In the present study, we aimed to use the example of a biochemistry seminar that takes place in the preclinical part of the medical degree at Ulm University Medical School to show how a course can be successfully optimized in small steps and evaluation results can be used for quality assurance. Methods: Similar to a continuous improvement process (CIP), over the course of five years a biochemistry seminar was gradually optimized in three steps. This process used structural, methodological, and content components, such as vertical integration, the inverted classroom method, and competence orientation. For quality assurance, we analyzed the official, standardized evaluation sheets from a total of n=1248 students. We evaluated the optimization process on the basis of responses to evaluation statements that were arranged into categories such as "organization, structure, implementation" and "quality of teaching," free text information, and the results of a pilot study conducted in parallel. We then determined the usefulness of the students' evaluation results for evaluating the optimization process. Results: Each developmental step resulted in a significantly more positive overall evaluation of the seminar by the students. This result was independent of whether the development was on a structural or methodological/content-related level. In addition, the evaluations of the categories that were optimized were significantly better. For example, the vertical integration and introduction of the inverted classroom method were accompanied by a better evaluation of the "quality of teaching" and a change in the structure led to a higher score in the category "organization, structure, implementation." A comparison with the free text evaluation sheets and the results of the pilot study supports the results. Conclusion: Although optimization of a curriculum or course is a major task, it can also be successfully completed in small steps. With this approach, new learning goals, for example as required in the Master Plan for Medical Studies 2020, can be continuously integrated and student satisfaction with a course can be increased. Student evaluation results can represent a kind of quality assurance in this process and can provide important impulses for optimization.

Near peer teaching in general practice: option or expectation?

General Practice (GP) trainees who teach medical students do so as near peers with established educational benefits for all concerned. Through teaching, GP trainees consolidate their own knowledge and skills whilst students value the experience of learning from teachers closer in age and stage. Importantly, involving GP trainees as teachers increases primary care teaching capacity and promotes GP as a potential career option for undergraduates. However, whilst junior doctors are often to be found teaching on hospital wards and in clinics, GP trainees based in primary care appear to have fewer opportunities to teach. This article encourages the promotion of near peer teaching in primary care on several levels. We make practical suggestions of potential benefit to the individual GP trainee, trainer and practice. We also discuss ways in which key stakeholders, including medical schools and those organising post-graduate primary care training programmes, may promote near peer teaching in GP. We propose that all medical students should have experience of being taught by GP trainees, and that all future general practitioners should have training and experience of teaching undergraduate medical students.

Remote Gating of Schottky Barrier for Transistors and Their Vertical Integration

This paper introduces a strategy to modulate a Schottky barrier formed at a graphene-semiconductor heterojunction. The modulation is performed by controlling the work function of graphene from a gate that is placed laterally away from the graphene-semiconductor junction, which we refer to as the remote gating of a Schottky barrier. The remote gating relies on the sensitive work function of graphene, whose local variation induced by locally applied field effect affects the change in the work function of the entire material. Using Kelvin probe force microscopy analysis, we directly visualize how this local variation in the work function propagates through graphene. These properties of graphene are exploited to assemble remote-gated vertical Schottky barrier transistors (v-SBTs) in an unconventional device architecture. Furthermore, a vertical complementary circuit is fabricated by simply stacking two remote-gated v-SBTs (pentacene layer as the p-channel and indium gallium zinc oxide layer as the n-channel) vertically. We consider that the remote gating of graphene and the associated device architecture presented herein facilitate the extendibility of graphene-based v-SBTs in the vertical assembly of logic circuits.

Specialty Physician Designation in Referrals from a Vertically Integrated PCMH

Introduction:

Primary care referrals to specialty physicians once relied upon the medical skill of the specialist, the quality of past communication, and previous consultative experiences. As health systems vertically integrate, patterns of specialty physician referral designation are not known.

Methods:

This cross-sectional study from a patient-centered medical home (PCMH) evaluated the proportion of referrals with named specialists. All outpatient specialty referrals from the PCMH between July and December of 2014 were eligible for inclusion, and 410 patients were randomly selected for chart review. The outcome of interest was specialty physician designation. Other variables of interest included PCMH provider experience, the reason for referral, and time to specialty visit. Univariate analysis was performed with Fisher exact tests.

Results:

Of 410 specialty referrals, 43.7% were made to medical specialties, 41.7% to surgical specialties, and 14.6% to ancillary specialties. Resident physicians placed 224 referrals (54.6%), faculty physicians ordered 155 (37.8%), and advanced practice providers ordered 31 (7.6%). Only 11.2% of the specialty referral orders designated a specific physician. No differences appeared in the reason for referral, the referral destination, the proportion of visits scheduled and attended, or the time to schedule between those referrals with and without specialty physician designation. Faculty physicians identified a specific specialist in 21.4% of referrals compared to residents doing so in 4.9% (P < .0001).

Conclusion:

Patient-centered medical home referrals named a specific specialty physician infrequently, suggesting a shift from the historical reliance on the individual characteristics of the specialist in the referral process.

Reduction in Hospitals' Readmission Rates: Role of Hospital-Based Skilled Nursing Facilities

Hospital readmission within 30 days of discharge is an important quality measure given that it represents a potentially preventable adverse outcome. Approximately, 20% of Medicare beneficiaries are readmitted within 30 days of discharge. Many strategies such as the hospital readmission reduction program have been proposed and implemented to reduce readmission rates. Prior research has shown that coordination of care could play a significant role in lowering readmissions. Although having a hospital-based skilled nursing facility (HBSNF) in a hospital could help in improving care for patients needing short-term skilled nursing or rehabilitation services, little is known about HBSNFs' association with hospitals' readmission rates. This study seeks to examine the association between HBSNFs and hospitals' readmission rates. Data sources included 2007-2012 American Hospital Association Annual Survey, Area Health Resources Files, the Centers for Medicare and Medicaid Services (CMS) Medicare cost reports, and CMS Hospital Compare. The dependent variables were 30-day risk-adjusted readmission rates for acute myocardial infarction (AMI), congestive heart failure, and pneumonia. The independent variable was the presence of HBSNF in a hospital (1 = yes, 0 = no). Control variables included organizational and market factors that could affect hospitals' readmission rates. Data were analyzed using generalized estimating equation (GEE) models with state and year fixed effects and standard errors corrected for clustering of hospitals over time. Propensity score weights were used to control for potential selection bias of hospitals having a skilled nursing facility (SNF). GEE models showed that the presence of HBSNFs was associated with lower readmission rates for AMI and pneumonia. Moreover, higher SNFs to hospitals ratio in the county were associated with lower readmission rates. These findings can inform policy makers and hospital administrators in evaluating HBSNFs as a potential strategy to lower hospitals' readmission rates.

Technological Platform for Vertical Multi-Wafer Integration of Microscanners and Micro-Optical Components

We describe an original integration technological platform for the miniaturization of micromachined on-chip optical microscopes, such as the laser scanning confocal microscope. The platform employs the multi-wafer vertical integration approach, combined with integrated glass-based micro-optics as well as micro-electro-mechanical systems (MEMS) components, where the assembly uses the heterogeneous bonding and interconnecting technologies. Various heterogeneous components are disposed in vertically stacked building blocks (glass microlens, MEMS actuator, beamsplitter, etc.) in a minimum space. The platform offers the integrity and potential of MEMS microactuators integrated with micro-optics, providing miniaturized and low cost solutions to create micromachined on-chip optical microscopes.

Hospital Vertical Integration Into Subacute Care as a Strategic Response to Value-Based Payment Incentives, Market Factors, and Organizational Factors: A Multiple-Case Study

This study explores the extent to which payment reform and other factors have motivated hospitals to adopt a vertical integration strategy. Using a multiple-case study research design, we completed case studies of 3 US health systems to provide an in-depth perspective into hospital adoption of subacute care vertical integration strategies across multiple types of hospitals and in different health care markets. Three major themes associated with hospital adoption of vertical integration strategies were identified: value-based payment incentives, market factors, and organizational factors. We found evidence that variation in hospital adoption of vertical integration into subacute care strategies occurs in the United States and gained a perspective on the intricacies of how and why hospitals adopt a vertical integration into subacute care strategy.

The impact of provider consolidation on physician prices

When a clinic system is acquired by an integrated delivery system (IDS), the ownership change includes both vertical integration with the hospital(s), and horizontal integration with the IDS's previously owned or "legacy" clinics, causing increased market concentration in physician services. Although there is a robust literature on the impact of hospital market concentration, the literature on physician market concentration is sparse. The objective of this study is to determine the impact on physician prices when two IDSs acquired three multispecialty clinic systems in Minneapolis-St Paul, Minnesota at the end of 2007, using commercial claims data from a large health plan (2006-2011). Using a difference-in-differences model and nonacquired clinics as controls, we found that four years after the acquisitions (2011), average physician price indices in the acquired clinic systems were 32-47% higher than expected in absence of the acquisitions. Average physician prices in the IDS legacy clinics were 14-20% higher in 2011 than expected. Procedure-specific prices for common office visit and inpatient procedures also increased following the acquisitions.

A novel phased-concept course for the delivery of anatomy and orthopedics training in medical education

Integration of anatomy and clinical teaching is a theoretical ideal, yet there is a worldwide paucity of such amalgamation. These teaching models provide support for medical trainees, an important element in Germany where orthopedic intern numbers have declined and anecdotal evidence suggests disinterest in orthopedics. The aim of the study was to develop an integrated anatomy-surgical course for undergraduate medical training, assess the model developed, and explore how medical students perceive orthopedics as a career. The course was to deliver medical anatomy and clinical orthopedic training, focusing on interdisciplinary teaching and learning, vertical integration of clinical knowledge and skills, and professional interaction. Survey evaluation of the course and students' perceptions of orthopedic careers was performed, including Likert-type responses rating variables of interest. A phased-concept program of five courses, each optional and under one-week in duration, was developed parallel to the undergraduate medical program. Delivered by anatomists and surgeons, courses included biomechanics, advanced dissection, surgical approaches, casts and implants, and sports medicine. Course data indicate positive support for course format, stimulation of interest, and high clinical relevance. Students are generally interested in surgery, and identify hierarchy, lawsuits, bureaucracy and physical stress as barriers to orthopedic careers. This novel phased-concept successfully delivers combined anatomy and surgery training in a vertically-integrated format while addressing students' clinical and professional skills. The format facilitates an appreciation of potential career options in orthopedics, while fostering professional skills during medical training. Barriers to careers in orthopedics can now be addressed in future courses. Anat Sci Educ 10: 372-382. © 2016 American Association of Anatomists.

Longitudinal retention of anatomical knowledge in second-year medical students

The Radboud University Medical Center has a problem-based, learner-oriented, horizontally, and vertically integrated medical curriculum. Anatomists and clinicians have noticed students' decreasing anatomical knowledge and the disability to apply knowledge in diagnostic reasoning and problem solving. In a longitudinal cohort, the retention of anatomical knowledge gained during the first year of medical school among second-year medical students was assessed. In May 2011, 346 medical students applied for the second-year gastro-intestinal (GI) tract course. The students were asked to participate in a reexamination of a selection of anatomical questions of an examination from October 2009. The examination consisted of a clinical anatomy case scenario and two computed tomography (CT) images of thorax and abdomen in an extended matching format. A total of 165 students were included for analysis. In 2011, students scored significantly lower for the anatomy examination compared to 2009 with a decline in overall examination score of 14.7% (±11.7%). Decrease in knowledge was higher in the radiological questions, compared to the clinical anatomy cases 17.5% (±13.6%) vs. 7.9% (±10.0%), respectively, d = 5.17. In both years, male students scored slightly better compared to female students, and decline of knowledge seems somewhat lower in male students (13.1% (±11.1%) vs. 15.5% (±12.0%), respectively), d = -0.21. Anatomical knowledge in the problem-oriented horizontal and vertical integrated medical curriculum, declined by approximately 15% 1.5 year after the initial anatomy course. The loss of knowledge in the present study is relative small compared to previous studies. Anat Sci Educ 10: 242-248. © 2016 American Association of Anatomists.

Vertical integration of basic science in final year of medical education

Background:

Development of health professionals with ability to integrate, synthesize, and apply knowledge gained through medical college is greatly hampered by the system of delivery that is compartmentalized and piecemeal. There is a need to integrate basic sciences with clinical teaching to enable application in clinical care.

Aim:

To study the benefit and acceptance of vertical integration of basic science in final year MBBS undergraduate curriculum.

Materials and Methods:

After Institutional Ethics Clearance, neuroanatomy refresher classes with clinical application to neurological diseases were held as part of the final year posting in two medical units. Feedback was collected. Pre- and post-tests which tested application and synthesis were conducted. Summative assessment was compared with the control group of students who had standard teaching in other two medical units. In-depth interview was conducted on 2 willing participants and 2 teachers who did neurology bedside teaching.

Results:

Majority (>80%) found the classes useful and interesting. There was statistically significant improvement in the post-test scores. There was a statistically significant difference between the intervention and control groups' scores during summative assessment (76.2 vs. 61.8 P < 0.01). Students felt that it reinforced, motivated self-directed learning, enabled correlations, improved understanding, put things in perspective, gave confidence, aided application, and enabled them to follow discussions during clinical teaching.

Conclusion:

Vertical integration of basic science in final year was beneficial and resulted in knowledge gain and improved summative scores. The classes were found to be useful, interesting and thought to help in clinical care and application by majority of students.

Restrictions to Pharmacy Ownership and Vertical Integration in Estonia-Perception of Different Stakeholders

Objectives: From 2020, the ownership of community pharmacies in Estonia will be limited to the pharmacy profession, and the vertical integration of wholesale companies and community pharmacies will not be allowed. The aim of this study was to evaluate the perception of different stakeholders in primary healthcare toward the new regulations of the community pharmacy sector in Estonia. Methods: A qualitative electronic survey was distributed to the main stakeholders in primary healthcare and higher education institutions providing pharmacy education (n = 40) in May 2015. For data analysis, the systematic text condensation method was used. Results: The study participants described two opposing positions regarding the development of community pharmacies in the future. Reform supporters emphasized increased professional independence and more healthcare-oriented operation of community pharmacies. Reform opponents argued against these ideas as community pharmacists do not have sufficient practical experience and finances to ensure sustainable development of the community pharmacy sector in Estonia. Conclusion: Based on the current perception of all respondents, the future operation of the community pharmacy sector in Estonia is unclear and there is urgent need for implementation criteria for the new regulations.

The Impact of Hospital Acquisition of Physician Practices on Referral Patterns

Multiple parties influence the choice of facility for hospital-based inpatient and outpatient services. The patient is the central figure, but their choice of facility is guided by their physician and influenced by hospital characteristics. This study estimated changes in referral patterns for inpatient admissions and outpatient diagnostic imaging associated with changes in ownership of three multispecialty clinic systems headquartered in Minneapolis-St. Paul, MN. These clinic systems were acquired by two hospital-owned integrated delivery systems (IDSs) in 2007, increasing the probability that hospital preferences influenced physician guidance on facility choice. We used a longitudinal dataset that allowed us to predict changes in referral patterns, controlling for health plan enrollee, coverage, and clinic system characteristics. The results are an important empirical contribution to the literature examining the impact of hospital ownership on location of service. When this change in ownership forged new relationships, there was a significant reduction in the use of facilities historically selected for inpatient admissions and outpatient imaging and an increase in the use of the acquiring IDS's facilities. These changes were weaker in the IDS acquiring two clinic systems, suggesting that management of multiple acquisitions simultaneously may impact the ability of the IDS to build strong referral relationships.

A Vertically Integrated Junctionless Nanowire Transistor

A vertically integrated junctionless field-effect transistor (VJ-FET), which is composed of vertically stacked multiple silicon nanowires (SiNWs) with a gate-all-around (GAA) structure, is demonstrated on a bulk silicon wafer for the first time. The proposed VJ-FET mitigates the issues of variability and fabrication complexity that are encountered in the vertically integrated multi-NW FET (VM-FET) based on an identical structure in which the VM-FET, as recently reported, harnesses a source and drain (S/D) junction for its operation and is thus based on the inversion mode. Variability is alleviated by bulk conduction in a junctionless FET (JL-FET), where current flows through the core of the SiNW, whereas it is not mitigated by surface conduction in an inversion mode FET (IM-FET), where current flows via the surface of the SiNW. The fabrication complexity is reduced by the inherent JL structure of the JL-FET because S/D formation is not required. In contrast, it is very difficult to dope the S/D when it is positioned at each floor of a tall SiNW with greater uniformity and with less damage to the crystalline structure of the SiNW in a VM-FET. Moreover, when the proposed VJ-FET is used as nonvolatile flash memory, the endurance and retention characteristics are improved due to the above-mentioned bulk conduction.

Vertically Integrated Multiple Nanowire Field Effect Transistor

A vertically integrated multiple channel-based field-effect transistor (FET) with the highest number of nanowires reported ever is demonstrated on a bulk silicon substrate without use of wet etching. The driving current is increased by 5-fold due to the inherent vertically stacked five-level nanowires, thus showing good feasibility of three-dimensional integration-based high performance transistor. The developed fabrication process, which is simple and reproducible, is used to create multiple stiction-free and uniformly sized nanowires with the aid of the one-route all-dry etching process (ORADEP). Furthermore, the proposed FET is revamped to create nonvolatile memory with the adoption of a charge trapping layer for enhanced practicality. Thus, this research suggests an ultimate design for the end-of-the-roadmap devices to overcome the limits of scaling.

Vertically stacked color tunable light-emitting diodes fabricated using wafer bonding and transfer printing

We report on the vertically stacked color tunable light-emitting diodes (LEDs) fabricated using wafer bonding with an indium tin oxide (ITO) layer and transfer printing by the laser lift-off process. Employing optically transparent and electrically conductive ITO as an adhesion layer enables to bond the GaN-based blue and AlGaInP-based yellow LEDs. We find out that the interdiffusion of In, O, and Ga at the interface between ITO and GaP allows the strong bonding of the heterogeneous optoelectronic materials and the integration of two different color LEDs on a single substrate. The efficacy of this method is demonstrated by showing the successful control of color coordinate from the vertically stacked LEDs by modulating the individual intensity of blue and yellow emissions.

Benefits and challenges of multi-level learner rural general practices--an interview study with learners, staff and patients

BACKGROUND

General practices vary in the provision of training and education. Some practices have training as a major focus with the presence of multi-level learners and others host single learner groups or none at all. This study investigates the educational benefits and challenges associated with 'multi-level learner' practices.

METHODS

This paper comprised three case studies of rural general practices with multiple levels of learners. Qualitative data were collected from 29 interviews with learners (n = 12), staff (n = 12) and patients (n = 5). Interviews were initially analyzed using open and axial coding and thematic analysis.

RESULTS

Thematic analysis showed 'multi-level learning' in general practices has benefits and challenges to learners and the practice. Learner benefits included knowledge exchange, the opportunity for vertical peer learning, a positive learning environment and the development of a supportive network. The presence of multi-level learners promoted sharing of knowledge with all staff, a sense of community, an increase in patient services and enthused supervisors. Challenges for learners included perception of decreased access to supervisors, anxiety with peer observation, reduced access to patient presentations and patient reluctance to be seen by a learner. Practice challenges were administration requirements, high learner turnover, infrastructure requirements and the requirement for supervisors to cater to a range of learner level needs.

CONCLUSIONS

The presence of medical students, interns and registrars in general practice has educational benefits to the learners extending to the other stakeholders (staff and patients). Multi-level learners present challenges to the learners and the practice by increasing pressures on resources, staff (administrative and supervisors) and infrastructure.

Anatomy integration blueprint: A fourth-year musculoskeletal anatomy elective model

Current undergraduate medical school curricular trends focus on both vertical integration of clinical knowledge into the traditionally basic science-dedicated curricula and increasing basic science education in the clinical years. This latter type of integration is more difficult and less reported on than the former. Here, we present an outline of a course wherein the primary learning and teaching objective is to integrate basic science anatomy knowledge with clinical education. The course was developed through collaboration by a multi-specialist course development team (composed of both basic scientists and physicians) and was founded in current adult learning theories. The course was designed to be widely applicable to multiple future specialties, using current published reports regarding the topics and clinical care areas relying heavily on anatomical knowledge regardless of specialist focus. To this end, the course focuses on the role of anatomy in the diagnosis and treatment of frequently encountered musculoskeletal conditions. Our iterative implementation and action research approach to this course development has yielded a curricular template for anatomy integration into clinical years. Key components for successful implementation of these types of courses, including content topic sequence, the faculty development team, learning approaches, and hidden curricula, were developed. We also report preliminary feedback from course stakeholders and lessons learned through the process. The purpose of this report is to enhance the current literature regarding basic science integration in the clinical years of medical school.

Physician opinions about an anatomy core curriculum: a case for medical imaging and vertical integration

Pre-clinical anatomy curricula must provide medical students with the knowledge needed in a variety of medical and surgical specialties. But do physicians within specialties agree about what anatomical knowledge is most important in their practices? And, what is the common core of anatomical knowledge deemed essential by physicians in different specialties? Answers to these questions would be useful in designing pre-clinical anatomy courses. The primary aim of this study was to assess the importance of a human gross anatomy course by soliciting the opinions of physicians from a range of specialties. We surveyed 93 physicians to determine the importance of specific anatomical topics in their own practices. Their responses were analyzed to assess variation in intra- and inter-departmental attitudes toward the importance of anatomy. Nearly all of the topics taught in the course were deemed important by the clinicians as a group, but respondents showed little agreement on the rank order of importance of anatomical topics. Overall, only medical imaging received high importance by nearly all respondents, and lower importance was attached to embryology and lymphatic anatomy. Our survey data, however, also suggested distinct hierarchies in the importance assigned to anatomical topics within specialties. Given that physicians view the importance of anatomy differently, we suggest that students revisit anatomy through a vertically integrated curriculum tailored to provide specialty-specific anatomical training to advanced students based on their areas of clinical interest. Integration of medical imaging into pre-clinical anatomy courses, already underway in many medical schools, is of high clinical relevance.

Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study

INTRODUCTION

Frail older people experience frequent care transitions and an integrated healthcare system could reduce barriers to transitions between different settings. The study aimed to investigate care transitions of frail older people from acute hospital wards to community healthcare or community hospital wards, within a system that had vertically integrated acute hospital and community healthcare services.

THEORY AND METHODS

The research design was a multimethod, qualitative case study of one healthcare system in England; four acute hospital wards and two community hospital wards were studied in depth. The data were collected through: interviews with key staff (n = 17); focus groups (n = 9) with ward staff (n = 36); interviews with frail older people (n = 4). The data were analysed using the framework approach.

FINDINGS

THREE THEMES ARE PRESENTED: Care transitions within a vertically integrated healthcare system, Interprofessional communication and relationships; Patient and family involvement in care transitions.

DISCUSSION AND CONCLUSIONS

A vertically integrated healthcare system supported care transitions from acute hospital wards through removal of organisational boundaries. However, boundaries between staff in different settings remained a barrier to transitions, as did capacity issues in community healthcare and social care. Staff in acute and community settings need opportunities to gain better understanding of each other's roles and build relationships and trust.