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Hospital-Physician Collaboration: Landscape of Economic Integration and Impact on Clinical Integration

2008 Milbank Quarterly  
Context: Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P). Methods: This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost,
more » ... of HPRs on cost, quality, and clinical integration. Findings: The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians. Conclusions: Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.
doi:10.1111/j.1468-0009.2008.00527.x pmid:18798884 pmcid:PMC2690342 fatcat:p2n7hibyy5fh3m6hdjyghazftm

Horizontal and Vertical Integration of Physicians: A Tale of Two Tails [chapter]

Lawton Robert Burns, Jeff C. Goldsmith, Aditi Sen
2013 Advances in health care management  
ROBERT BURNS ET AL.  ...  Marshfield (WI) 1916 Mayo Clinic Rochester (MN) 1880 Palo Alto Medical Clinic Palo Alto (CA) 1930 Permanente Medical Group Northern California 1945 Scott & White Clinic Temple (TX) 1897 LAWTON  ... 
doi:10.1108/s1474-8231(2013)0000015009 pmid:24749213 fatcat:dxuzn6qfjvbffbxgwua7rel4gu

Physician preference items: what factors matter to surgeons? Does the vendor matter?

Lawton R Burns, Michael Housman, Robert Booth, Aaron Koenig
2018 Medical Devices : Evidence and Research  
The USA devotes roughly $200 billion (6%) of annual national health expenditures to medical devices. A substantial proportion of this spending occurs during orthopedic (eg, hip and knee) arthroplasties -two high-volume hospital procedures. The implants used in these procedures are commonly known as physician preference items (PPIs), reflecting the physician's choice of implant and vendor used. The foundations for this preference are not entirely clear. This study examines what implant and
more » ... t implant and vendor characteristics, as evaluated by orthopedic surgeons, are associated with their preference. It also examines other factors (eg, financial relationships and vendor tenure) that may contribute to implant preference. Methods: We surveyed all practicing orthopedic surgeons performing 12 or more implant procedures annually in the Commonwealth of Pennsylvania. The survey identified each surgeon's preferred hip/knee vendor as well as the factors that surgeons state they use in selecting that primary vendor. We compared the surgeons' evaluation of multiple characteristics of implants and vendors using analysis of variance techniques, controlling for surgeon characteristics, hospital characteristics, and surgeon-vendor ties that might influence these evaluations. Results: Physician's preference is heavily influenced by technology/implant factors and sales/ service factors. Other considerations such as vendor reputation, financial relationships with the vendor, and implant cost seem less important. These findings hold regardless of implant type (hip vs knee) and specific vendor. Conclusion: Our results suggest that there is a great deal of consistency in the factors that surgeons state they use to evaluate PPIs such as hip and knee implants. The findings offer an empirically derived definition of PPIs that is consistent with the product and nonproduct strategies pursued by medical device companies. PPIs are products that surgeons rate favorably on the twin dimensions of technology and sales/service.
doi:10.2147/mder.s151647 pmid:29391836 pmcid:PMC5768327 fatcat:g3e4sdviqrfadafw27ht5uaumi

Revisiting the Relationship between Managed Care and Hospital Consolidation

Robert J. Town, Douglas Wholey, Roger Feldman, Lawton R. Burns
2007 Health Services Research  
ACKNOWLEDGMENTS This work was supported by the Robert Wood Johnson Foundation through a grant from the Changes in Health Care Financing and Organization initiative (Grant #50491).  ... 
doi:10.1111/j.1475-6773.2006.00601.x pmid:17355590 pmcid:PMC1955242 fatcat:3hs7pu2arfbnlgxohdhpgztcpu

Implant vendors and hospitals

Lawton R. Burns, Michael G. Housman, Robert E. Booth, Aaron Koenig
2009 Health Care Management Review  
doi:10.1097/ pmid:19104260 fatcat:e52i43uugnczbhu4al6w2kkwpu

Is the System Really the Solution? Operating Costs in Hospital Systems

Lawton Robert Burns, Jeffrey S. McCullough, Douglas R. Wholey, Gregory Kruse, Peter Kralovec, Ralph Muller
2015 Medical Care Research and Review  
Hospital system formation has recently accelerated. Executives emphasize scale economies that lower operating costs, a claim unsupported in academic research. Do systems achieve lower costs than freestanding facilities, and, if so, which system types? We test hypotheses about the relationship of cost with membership in systems, larger systems, and centralized and local hub-and-spoke systems. We also test whether these relationships have changed over time. Examining 4,000 U.S. hospitals during
more » ... hospitals during 1998 to 2010, we find no evidence that system members exhibit lower costs. However, members of smaller systems are lower cost than larger systems, and hospitals in centralized systems are lower cost than everyone else. There is no evidence that the system's spatial configuration is associated with cost, although national system hospitals exhibit higher costs. Finally, these results hold over time. We conclude that while systems in general may not be the solution to lower costs, some types of systems are.
doi:10.1177/1077558715583789 pmid:25904540 fatcat:m75wyw6uwbez7ecfoyzvfw4k6i

India's Healthcare Industry: A System Perspective [chapter]

Lawton Robert Burns, Lawton R. Burns
India's Healthcare Industry  
Chapter 7, written by James Calderwood, Carter Clement, Arunavo Roy, Ravi Shah, and Lawton Robert Burns, examines the Aravind Eye Care System.  ...  Chapter 6, coauthored by Lawton Robert Burns, Prashanth Jayaram, and Richa Bansal, provides an overview of the medical tourism industry in India.  ... 
doi:10.1017/cbo9781107360242.002 fatcat:zyden3qutndb3j7p2ehn2v6e4a

Healthcare innovation across sectors: convergences and divergences [chapter]

Lawton Robert Burns
The Business of Healthcare Innovation  
Healthcare innovation across sectors: convergences and divergences Lawton R. Burns and Stephen M.  ... 
doi:10.1017/cbo9780511488672.009 fatcat:mcgesagepzhzfadaipvzsvmoui

Pharmaceutical strategy and the evolving role of merger and acquisition [chapter]

Lawton Robert Burns, Sean Nicholson, Joanna P. Wolkowski, Lawton R. Burns
The Business of Healthcare Innovation  
It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.
doi:10.1017/cbo9781139176620.003 fatcat:cr5oaznnovhvjfozsk2iyfwwai

Foreword [chapter]

William C. Hsiao, Lawton Robert Burns, Gordon G. Liu
China's Healthcare System and Reform  
Sammut and Lawton Robert Burns).  ...  Chapter 2, by Lawton Robert Burns and Yanzhong Huang, expands upon some of the issues dealt with in this chapter.  ... 
doi:10.1017/9781316691113.001 fatcat:stq52ligfvatdoxpxneze42a4e

Cost-effectiveness analyses for mirtazapine and sertraline in dementia: randomised controlled trial

Renee Romeo, Martin Knapp, Jennifer Hellier, Michael Dewey, Clive Ballard, Robert Baldwin, Peter Bentham, Alistair Burns, Chris Fox, Clive Holmes, Cornelius Katona, Claire Lawton (+12 others)
2013 British Journal of Psychiatry  
Depression is a common and costly comorbidity in dementia. There are very few data on the cost-effectiveness of antidepressants for depression in dementia and their effects on carer outcomes. Aims To evaluate the cost-effectiveness of sertraline and mirtazapine compared with placebo for depression in dementia. Method A pragmatic, multicentre, randomised placebo-controlled trial with a parallel cost-effectiveness analysis (trial registration: ISRCTN88882979 and EudraCT 2006-000105-38). The
more » ... 0105-38). The primary cost-effectiveness analysis compared differences in treatment costs for patients receiving sertraline, mirtazapine or placebo with differences in effectiveness measured by the primary outcome, total Cornell Scale for Depression in Dementia (CSDD) score, over two time periods: 0–13 weeks and 0–39 weeks. The secondary evaluation was a cost-utility analysis using quality-adjusted life years (QALYs) computed from the Euro-Qual (EQ-5D) and societal weights over those same periods. Results There were 339 participants randomised and 326 with costs data (111 placebo, 107 sertraline, 108 mirtazapine). For the primary outcome, decrease in depression, mirtazapine and sertraline were not cost-effective compared with placebo. However, examining secondary outcomes, the time spent by unpaid carers caring for participants in the mirtazapine group was almost half that for patients receiving placebo (6.74 v. 12.27 hours per week) or sertraline (6.74 v. 12.32 hours per week). Informal care costs over 39 weeks were £1510 and £1522 less for the mirtazapine group compared with placebo and sertraline respectively. Conclusions In terms of reducing depression, mirtazapine and sertraline were not cost-effective for treating depression in dementia. However, mirtazapine does appear likely to have been cost-effective if costing includes the impact on unpaid carers and with quality of life included in the outcome. Unpaid (family) carer costs were lower with mirtazapine than sertraline or placebo. This may have been mediated via the putative ability of mirtazapine to ameliorate sleep disturbances and anxiety. Given the priority and the potential value of supporting family carers of people with dementia, further research is warranted to investigate the potential of mirtazapine to help with behavioural and psychological symptoms in dementia and in supporting carers.
doi:10.1192/bjp.bp.112.115212 pmid:23258767 fatcat:6rbeoh3gb5df3mx374j7q5i5ia

Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial

Sube Banerjee, Jennifer Hellier, Michael Dewey, Renee Romeo, Clive Ballard, Robert Baldwin, Peter Bentham, Chris Fox, Clive Holmes, Cornelius Katona, Martin Knapp, Claire Lawton (+13 others)
2011 The Lancet  
Depression is common in dementia causing considerable distress, and other negative impacts. Treating it is a clinical priority but the evidence base is sparse and equivocal. Methods The HTA-SADD (study of the use of antidepressants for depression in dementia) trial was a multi-centre parallel group double-blind placebo-controlled pragmatic RCT of the clinical effectiveness of sertraline and mirtazapine (primary outcome 13 weeks; long term 39 weeks). Eligibility: probable or possible Alzheimer's
more » ... ossible Alzheimer's Disease, depression (4+ weeks), and Cornell Scale for Depression in Dementia (CSDD) score of 8+, from 9 English old age psychiatry services. Exclusions: clinically too critical (eg suicide risk); contra-indication to medication; taking antidepressants; in another trial; and having no carer. Interventions: (1) sertraline, (2) mirtazapine, and (3) placebo, all with normal care. Target doses: 150mg sertraline or 45mg mirtazapine daily. The objective was to determine clinical effectiveness of sertraline and mirtazapine in reducing depression 13 weeks post-randomisation compared with placebo. The main outcome was CSDD score. Randomisation: 1:1:1 allocation with stratified computer-generated block randomisation by centre with randomly varying block sizes by a Trials Unit, independent of trial team. Medication and placebo were identical for each antidepressant. Referring clinicians, research workers, participants, pharmacies and statisticians were blinded until analyses were completed. Findings 326 participants were randomised (111 placebo, 107 sertraline, 108 mirtazapine). The main outcome, mean differences (95%CI) in CSDD at 13 weeks from an adjusted linear mixed model were: placebo/sertraline 1.17 (-0.23 to 2.58, p=0.10); placebo/mirtazapine 0.01 (-1.37 to 1.38, p=0.99); and mirtazapine/sertraline 1.16 (-0.25 to 2.57, p=0.11). There were no statistically significant differences in depression score between groups at 13 or 39 weeks. The placebo group had fewer adverse reactions (29/111, 26%) than sertraline (46/107, 43%) or mirtazapine (44/108, 41%; p=0.017) and fewer serious adverse events rated as severe (p=0.003). 39 week mortality was equal with five deaths in each group. Interpretation This is a trial with negative findings but important clinical implications. The data suggest that the antidepressants tested, given with normal care, are not clinically effective (compared with placebo) for clinically significant depression in Alzheimer's disease and there are harms associated with their use. This implies a need to change current practice of antidepressants being the first line treatment of depression in Alzheimer's disease. . Finally we would like to thank the research 16 workers and MHRN and DeNDRoN clinical study officers who together recruited the largest number of people with depression in dementia ever gathered into an RCT:
doi:10.1016/s0140-6736(11)60830-1 pmid:21764118 fatcat:sa27crt6w5gm7psh45qmk5tnoy

* * rn~o FloriUa Delegation. ~TANDING ( OMMITTEK C TIAIS [ ( ~\1

Jim Cobb, Carol Cycmanick, Nancy Dick, Simon Ferro, Diane Glasser, Jorge Perez, Alzo Reddick, Nadine Smith, Myrtle Smith-Carroll, Marvin Rosen, Nicholas Alexiou, Jon Ausman (+237 others)
Second Day Session of the 1996 Democratic National ConventionReception honoring the Florida Delegation hosted by Governor Lawton Chiles, Lt.  ... 

Office of Development A Special Thanks State Bar of Georgia Student Trial Lawyers Association 2002-2003 Donor Recognition Chief Justice's Commission on Professionalism THE LEGACY SOCIETY

Janice Griffith, Noah Langdale, Eldridge Memillan, Clifford Oxford, Ben Johnson, A Correll, W Lee Burge, Carl Patton, Alleen Deutsch, Delita Marsland, Alumni Relations Coordinator, Dom Wyant (+451 others)
2003 unpublished
Davis is a judicial law clerk for the Honorable Robert J.  ...  Roberts of Wake Forest Law School) entitled Land Use Planning and Development Regulation Law as part of its Practitioner Treatise Series.  ... 

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

T.E.F. Abbott, T. Ahmad, M.K. Phull, A.J. Fowler, R. Hewson, B.M. Biccard, M.S. Chew, M. Gillies, R.M. Pearse, Rupert M. Pearse, Scott Beattie, Pierre-Alain Clavien (+2645 others)
2018 British Journal of Anaesthesia  
The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital
more » ... s in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multilevel generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained 1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32-0.77); P<0.01], but no difference in complication rates [OR 1.02 (0.88-1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62-0.92); P<0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61-0.88); P<0.01; I2=89%). Conclusions Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.
doi:10.1016/j.bja.2017.08.002 pmid:29397122 fatcat:ot6rc4jhjbfefcnttjkmap2rke