Implementation of evidence-based interventions (EBIs) in under-resourced schools serving ethnic and racial minority youth is challenged by intervention, individuals', and setting characteristics. Engaging community members in equitable partnership improves implementation outcomes and provides resources (e.g., workforce capacity, funding), but can be time intensive. Rapid and rigorous approaches for improving the implementation of EBIs in under-resourced schools is necessary to address youth mental health needs. In this paper, we describe a 6-week internship program for high school students (n = 8) that used community-based participatory research (CBPR) and user-centered design (UCD) principles to adapt a cognitive behavioral skills curriculum. We assessed the process by categorizing barriers discussed and addressed using the Consolidated Framework for Implementation Research, and qualitatively exploring youth perceptions of the adapted curriculum. Barriers included intervention complexity, intervention design, communication, and resource availability. Adaptations focused on design simplification (e.g., renaming the curriculum TEB: Thoughts, Emotions, Behaviors) and dissemination strategies (e.g., creating social media content). Thematic analysis of intern interviews revealed the adapted curriculum as appropriate for students, helpful, and broadly applicable. Interns also expressed ownership over the curriculum and provided recommendations for future implementation. Overall, our study suggests the following: (1) CBPR and UCD can be integrated to adapt EBIs for racial and ethnic minority youth in school settings; (2) UCD principles can expedite the adaptation process; (3) design participation fosters a sense of ownership; (4) youth involvement in the design process can spur support from other stakeholder groups including policymakers; and (5) engaging youth as co-creators requires financial and human resources.

Much interest exists in physicians' ability and willingness to adapt their practice styles, as research demonstrates that many physicians practice in ways that are not aligned with the best available scientific evidence. We exploit migration patterns of primary care physicians in Massachusetts over a span of 8 years by tracking physician migrations to practice sites comprised of new peers who shared actual physical working space. We examined whether a patient's likelihood of receiving an inappropriate referral for diagnostic imaging, specifically a magnetic resonance imaging (MRI), was associated with a change in the work environment of the referring physician. Study results indicate that migrating physicians changed their practice style for imaging relatively soon after migration in conformance with the average practice style of their new peer group regardless of whether or not the practice style was aligned with evidence-based standards for diagnostic imaging. To place our results in context, a 1 percentage point difference in average inappropriate MRI referral rates between a migrating physician's new and previous work environment was associated with approximately a 14% change in the probability that a patient received an inappropriate MRI referral. The effect diminished with greater variability in inappropriate MRI referral rates within the new peer group. The results show that physician practice style may deviate from evidence-based standards and vary markedly among physicians within a work environment. At the same time, physician practice style is also malleable in either direction-more or less likely to deviate from evidence-based standards in conformance with the average practice style of their new peer group. These results imply that healthcare managers can employ various institutional-level interventions to influence physician behavior in the direction of evidence-based practice by including strategies directed towards developing strong peer influence in physicians' work environments.

Much interest exists in physicians’ ability and willingness to change their practice style as research demonstrates that many physicians practice in ways that are not aligned with the best available scientific evidence. We exploit migration patterns of primary care physicians in Massachusetts over a span of eight years by tracking physician migrations to practice sites comprised of new peers. We examined whether a patient’s likelihood of receiving an inappropriate referral for diagnostic imaging, specifically an MRI, was associated with a change in a physician’s work environment. Study results indicate that migrating physicians did change their practice style for imaging soon after migration in conformance with the prevailing practice style of their new peer group, which directly influenced a patient’s likelihood of receiving an inappropriate MRI. Physician practice style appeared malleable in either direction – more or less likely to deviate from evidence-based standards based on the new prevailing practice style of their new peer group. The effect did diminish with greater variability within the new peer group for inappropriate MRI referral rates. The results suggest that healthcare managers can influence physician behavior in the direction of evidence-based practice by adopting strategies directed towards developing strong peer influence in physicians’ work environments.

Letters Health AffairsVol. 40, No. 9: Care For Elders, Prices & More Inappropriate Diagnostic Imaging: The Authors ReplyGary J. Young, Ngoc Thai, E. David Zepeda, and Stephen Flaherty AffiliationsNortheastern University Boston, MassachusettsBoston University Boston, MassachusettsHarvard Pilgrim Healthcare Boston, MassachusettsPUBLISHED:September 2021No Accesshttps://doi.org/10.1377/hlthaff.2021.01206AboutSectionsView articleView Full TextView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions View article"Inappropriate Diagnostic Imaging: The Authors Reply." Health Affairs, 40(9), p. 1515TOPICSMagnetic resonance imagingPhysiciansAccess to care Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 8 September 2021 Information© 2021 Project HOPE—The People-to-People Health Foundation, Inc.PDF downloadRelated articlesInappropriate Diagnostic Imaging08 Sep 2021Health Affairs

The transition among many US physicians from independent practice to hospital employment has raised concerns about whether employed physicians will be more inclined to refer patients for hospital-based services that are unnecessary or inappropriate. Using claims data for 2009-16, we conducted a difference-in-differences analysis to investigate whether this form of hospital-physician integration is associated with inappropriate referrals for magnetic resonance imaging (MRI), a widely used mode of diagnostic imaging, for three common medical conditions: lower back pain, knee pain, and shoulder pain. Study findings indicate that the odds of a patient receiving an inappropriate MRI referral increased by more than 20 percent after a physician transitioned to hospital employment. Most patients who received an MRI referral by an employed physician obtained the procedure at the hospital where the referring physician was employed. These results point to hospital-physician integration as a potential driver of low-value care.

Background In the United States, a long-standing debate has existed over advantages/disadvantages of general versus specialty hospitals. A recent stream of research has investigated whether general hospitals accrue performance benefits from a focus strategy; a strategy of specializing in certain clinical conditions while remaining a multiproduct firm. In contrast, a substantial and long-standing body of research on hospitals has been concerned with the absolute volume of cases in a service area as an indication of experience based largely on the idea that absolute volume confers learning opportunities. Purpose We investigated whether hospital focus and experience in a service area have complementary effects or are largely substitutive for hospital performance. Methodology/Approach Key data sources were patient discharge records and hospital discharge profiles from California's Office of Statewide Health Policy and Development for years 2010-2014. We specified hospital focus as the proportion of total cardiology-related discharges and hospital experience as the cumulative volume of cardiology-related discharges for each hospital. Performance was specified using quality (inpatient mortality and 30-day readmission) and efficiency (length of stay and cost) patient-level performance metrics. We analyzed the data using logistic and log-linear ordinary least squares regression models. Results Study results generally supported our hypotheses that focus and experience are related to better quality and efficiency performance and that the effects are largely substitutive for hospitals. Conclusion Our study extends the literature by finding that hospitals exhibit distinct and stable patterns regarding their positioning on focus and experience and that these patterns have important implications for hospitals' performance in terms of quality and efficiency. Practice Implications Many general hospitals in the United States may be stretched too thin across service areas for which they lack necessary patient volumes for clinical proficiency. A viable alternative is to select a limited set of service areas on which to focus.

The aim of this study was to evaluate the effectiveness of a flexible modular cognitive-behavioral theory (CBT) skills curriculum delivered by paraprofessionals in a community organization targeting high-risk justice-involved youth. Programmatic data were collected from 980 high-risk young men (Mage, 21.12; SD, 2.30), and Cox proportional hazards regression was used. The results showed that compared with young men with no CBT encounters, those with one or more CBT encounters had a 66% (hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.28-0.42; p < 0.001) lower risk of unenrolling from programming, 65% (HR, 1.65; 95% CI, 1.29-2.12; p < 0.001) higher risk of obtaining a job, and no difference in risk of engaging in new criminal activity while enrolled in programming (HR, 0.99; 95% CI, 0.78-1.25; p = 0.918), despite higher risk factors. Training paraprofessionals to deliver CBT skills to high-risk populations is effective and has scalability potential.

A dramatic change in the hospital industry is the increasing emphasis on linking provider payment to quality performance metrics. This is one of several considerations leading hospitals to employ physicians. Yet, there is little evidence regarding whether physician employment as a form of hospital-physician integration leads to better operational performance. Using data from 201 California hospitals that experienced a total of 405,766 eligible opportunities to conform to external performance metrics (conformance quality) for treating patients in the cardiovascular service area, we empirically evaluated the relationship between physician employment and conformance quality. We also evaluated whether the presence of core capabilities in the hospital's cardiovascular service area complements or substitutes for physician employment. Findings suggest that physician employment is not only positively associated with conformance quality, but also associated with more consistent conformance quality. Moreover, the presence of core capabilities in the service area substitutes for physician employment. Theoretical, managerial, and policy implications are discussed.

OBJECTIVE:To examine patterns and determinants of nonindex readmissions for Medicare as well as non-Medicare patients both before and immediately after the adoption of Medicare's Hospital Readmission Reduction Program (HRRP) in 2012. Nonindex readmissions are readmissions to hospitals that are different from the one from which the patient was discharged. METHODS:Observational analysis of statewide database from California comprising patient-level discharge reports. Mixed-effects logistic regression models examined the association between nonindex readmissions and both hospital- and patient-level characteristics. RESULTS:Nonindex readmissions for the population studied were approximately 25%, but the percentage of such readmissions was significantly higher for non-Medicare patients than those enrolled in Medicare. Nonindex readmissions were associated with several patient- and hospital-level characteristics from which patients were discharged. The adoption of the HRRP did not have any appreciable impact on the general pattern of nonindex readmissions. CONCLUSIONS:A substantial percentage of hospital readmissions are to nonindex hospitals, but the general pattern and determinants of these events have not changed following the adoption of the HRRP. As preventable readmissions continue to gain attention as a key quality indicator for hospital care, further investigations are needed to understand the potential value of nonindex readmissions as a quality indicator for hospital care.

There were some errors in the variables in this paper.

Operational focus has been a long standing topic of interest to the operations management (OM) and strategic management fields. Operational focus is also of much interest in health care where a long standing debate has existed over advantages/disadvantages of general (i.e., multi-product) vs specialty (i.e., single product) hospitals invoking classic issues regarding economies of scope versus pure play. As such, a recent stream of research has looked at whether performance benefits accrue to general hospitals by specializing in certain clinical conditions based on the relative volume of cases a hospital treats with those conditions. In contrast, the field of health services research places much emphasis on a hospital’s absolute volume of cases for a given condition, based largely on the idea that absolute volume confers learning opportunities (operational experience). However, relatively little research considers the intersection of focus and experience. Using 308,764 patient discharge records from 263 California hospitals over a five-year period, we empirically evaluated the intersection between focus and experience in cardiology operating units. Findings suggest that the effects of focus and experience on performance (lower inpatient mortality, shorter length of stay) are largely substitutive without any difference in cost. Theoretical, managerial, and policy implications are discussed

Provisions of the Affordable Care Act (ACA) encouraged tax-exempt hospitals to invest broadly in community health benefits. Four years after the ACA's enactment, hospitals had increased their average spending for all community benefits by 0.5 percentage point, from 7.6 percent of their operating expenses in 2010 to 8.1 percent in 2014.

A dramatic change in the hospital industry is the increasing emphasis on linking provider payment to quality performance metrics. This is one of several considerations leading hospitals to vertically integrate by employing physicians. Yet, there is little evidence regarding whether this form of vertical integration leads to better operational performance. Using data from 217 California hospitals that experienced a total of 417,046 eligible opportunities to conform to external performance metrics (conformance quality) for treating patients in the cardiology operating unit, we empirically evaluated the relationship between physician employment and conformance quality. We also evaluated whether certain operational conditions (health IT adoption, operational focus, and operating experience) complement or substitute for physician employment. Findings suggest that physician employment is not only positively associated with conformance quality but also associated with more consistent conformance quality. Moreover, health IT adoption is a substitute for physician employment. Theoretical, managerial, and policy implications are discussed.

OBJECTIVE:To quantify the level of adherence to imaging guidelines for three common clinical indications for a commercially insured population.DESIGN:Retrospective analysis of administrative claims data for commercially insured individuals with diagnostic imaging claims (MRI and X-ray) for either uncomplicated low back pain, non-traumatic knee pain or non-traumatic shoulder pain.SETTING:The State of Massachusetts for 2010 and 2013.PARTICIPANTS:Adults with no chronic conditions and without evidence of prior management in the 12 months preceding to the initial office visit for each of the clinical indications.MAIN OUTCOMES MEASURES:Imaging procedures performed within 30 days of the initial office visit were classified as appropriate or inappropriate according to adherence to imaging guidelines from American College of Radiology.RESULTS:More than 60% of lumbar spine MRI's were deemed inappropriate in 2010 and in 2013. Over 30% of MRI's for shoulder pain and knee pain were inappropriate in 2010 and in 2013. Patients age 18-59 with inappropriate imaging claims had significantly lower rates of surgical procedures within 90 days of imaging than those with appropriate imaging. Inappropriate imaging accounted for over 20% of annual imaging costs for the three clinical indications.CONCLUSIONS:Reducing inappropriate imaging procedures can lead to substantial savings through the elimination of unnecessary and low value procedures. Increased awareness of and adherence to best practice guidelines should be a focus of efforts to cut waste in our healthcare system.

Objective: Posttraumatic stress disorder (PTSD) is a debilitating psychiatric illness that frequently remains undiagnosed and untreated. While extensive research has been conducted among veterans, little research has evaluated course of treatment for PTSD in a general hospital setting.Methods: We utilized data from the Partners HealthCare Research Patient Data Registry to evaluate mental health treatment utilization, including psychotherapy and pharmacotherapy, by patients with recently diagnosed primary PTSD following DSM-IV criteria between January 1, 2002, and June 30, 2011. We additionally evaluated predictors of treatment utilization 6 months postdiagnosis.Results: Among 2,475 patients with recently diagnosed primary PTSD, approximately half (55.7%) had any therapy visit and 10% had at least 12 therapy visits in the 6 months following diagnosis. Approximately half (47.0%) received a psychiatric prescription, with 29.3% receiving a selective serotonin reuptake inhibitor (SSRI), 11.8% receiving an atypical antipsychotic, and 24.4% receiving a benzodiazepine. Latinos were 25% (95% CL = 1.09, 1.43) more likely to have an SSRI prescription, 35% (95% CL = 1.05, 1.75) more likely to have an atypical antipsychotic prescription, and 28% (95% CL = 1.19, 1.38) more likely to receive any psychotherapy. Women were 49% (95% CL = 0.42, 0.63) less likely to have an atypical antipsychotic prescription. Patients with Medicare were 23% (95% CL = 0.67, 0.88) less likely to have any psychotherapy, and patients with Medicaid were 35% (95% CL = 0.46, 0.92) less likely to have 12 or more therapy visits.Conclusions: Many patients with a primary diagnosis of PTSD do not receive psychotherapy, and psychiatric prescriptions, including atypical antipsychotics and benzodiazepines, are common. Future research is needed to determine the quality of care received and explore subpopulation-specific barriers limiting access to care.

Background: As hospital employment of physicians becomes increasingly common in the United States, much speculation exists as to whether this type of arrangement will promote hospital operating efficiency in such areas as supply chain management. Little empirical research has been conducted to address this question.Purpose: The aim of this study was to provide an exploratory assessment of whether hospital employment of physicians is associated with better supply chain performance. Drawing from both agency and stewardship theories, we examined whether hospitals with a higher proportion of employed medical staff members have relatively better supply chain performance based on two performance measures, supply chain expenses and inventory costs.Approach: We conducted the study using a pooled, cross-sectional sample of hospitals located in California between 2007 and 2009. Key data sources were hospital annual financial reports from California's Office of Statewide Health Policy and Development and the American Hospital Association annual survey of hospitals. To examine the relationship between physician employment and supply chain performance, we specified physician employment as the proportion of total employed medical staff members as well as the proportion of employed medical staff members within key physician subgroups. We analyzed the data using generalized estimating equations.Findings: Study results generally supported our hypothesis that hospital employment of physicians is associated with better supply chain performance.Practical Implications: Although the results of our study should be viewed as preliminary, the trend in the United States toward hospital employment of physicians may be a positive development for improved hospital operating efficiency. Hospital managers should also be attentive to training and educational resources that medical staff members may need to strengthen their role in supply chain activities.

A criticism of behavioral health care delivery is that it has largely missed the social determinants of behavioral health disorders and their diagnosis. Toward addressing this criticism, this study evaluates the delivery of behavioral health care as a part of primary care operations. Focusing on the treatment of depression, the study results show that: (i) primary care clinics operating in communities with superior social environment characteristics are associated with improved depression outcomes in the short term, and (ii) psychosocial resources (social and emotional support) and the built environment (man‐made resources and infrastructure to support human activity) of primary care clinics are associated with sustaining the improvement in depression outcome in the long term. Centering our attention on IT‐enabled, evidence‐based, and affordable primary care as mechanisms that can enable the integration of behavioral and medical care delivery, the results suggest that IT‐enabled and evidence‐based primary care are associated with improvements in depression outcomes. We also find that the effect of improving the affordability of behavioral health care delivery depends on the community's socioeconomic status. Primary care clinics in socioeconomically disadvantaged communities practicing cost‐containment are associated with improvements in depression outcomes, and, therefore, can contribute toward reducing disparities in behavioral health care delivery. Counter to our original expectations, we find that the effect of evidence‐based care on improvements on depression outcomes increases as the availability of medically trained behavioral health care specialists practicing in a community increases lending support to concerns that primary care clinics in resource‐rich communities obtain greater benefit from quality improvement interventions.

In this study we examine the effects of horizontal inter‐organizational arrangements on inventory costs for hospitals facing two key environmental conditions, namely the logistics services infrastructure where the hospital is located and the demand uncertainty for clinical requirements that a hospital experiences. Utilizing detailed data from hospitals in the State of California, we investigated the potential mitigating effects of affiliation with multi‐hospital systems while controlling for service performance. We argue that these arrangements potentially influence managers' confidence in their supply chains, which in turn impacts inventory accumulation. Results suggest that while affiliation with local, regional, and national systems has mitigating effects under weak logistics services infrastructure, the mitigating effect is greatest for affiliation in local systems. The results also point to potential for improved operating efficiency with system affiliation, a factor that is often not considered in policy discussions regarding hospital system formation. Theoretical and managerial implications are discussed.

BackgroundAmong Latinos, living in a locality with greater Latino ethnic density may be protective for mental health, although findings vary by Latino subgroup, gender and birthplace. Although little studied, Latino residential segregation may capture different pathways linking risk and protective environmental factors to mental health than local ethnic density.MethodsThis study evaluated the association between residential segregation and mental distress as measured by the Kessler-10 (K10) among Latino participants in the National Latino and Asian American Study (NLAAS). Census data from 2000 was used to calculate metropolitan statistical area (MSA) residential segregation using the dissimilarity and isolation indices, as well as census tract ethnicity density and poverty. Latino subgroup (Puerto Rican, Mexican American, Cuban American and other Latino subgroup), gender and generation status were evaluated as moderators.ResultsAmong 2554 Latino participants in NLAAS, residential segregation as measured by the isolation index was associated with less mental distress (β −0.14, 95% CI −0.26 to −0.03 log(K10)) among Latinos overall after adjustment for ethnic density, poverty and individual covariates. Residential segregation as measured by the dissimilarity index was significantly associated with less mental distress among men (β −0.56, 95% CI −1.04 to −0.08) but not among women (β −0.20, 95% CI −0.45 to 0.04, p-interaction=0.019). No modification was observed by Latino subgroup or generation.ConclusionsAmong Latinos, increasing residential segregation was associated with less mental distress, and this association was moderated by gender. Findings suggest that MSA-level segregation measures may capture protective effects associated with living in Latino communities for mental health.