Integrated Health Organization Research Articles

Ovarian Cancer Rates After Hysterectomy With and Without Salpingo-Oophorectomy

To estimate ovarian and peritoneal cancer rates after hysterectomy with and without salpingo-oophorectomy for benign conditions. All patients after hysterectomy for benign disease from 1988 to 2006 in Kaiser Permanente Northern California, an integrated health organization. Incidence rates per 100,000 person-years were calculated. Of 56,692 patients, the majority (54%) underwent hysterectomy with bilateral salpingo-oophorectomy; 7% had hysterectomy with unilateral salpingo-oophorectomy, and 39% had hysterectomy alone. There were 40 ovarian and eight peritoneal cancers diagnosed during follow-up. Median age at ovarian and peritoneal cancer diagnosis was 50 and 64 years, respectively. Age-standardized rates (per 100,000 person-years) of ovarian or peritoneal cancer were 26.7 (95% confidence interval [CI] 16-37.5) for those with hysterectomy alone, 22.8 (95% CI 0.0-46.8) for hysterectomy and unilateral salpingo-oophorectomy, and 3.9 (95% CI 1.5-6.4) for hysterectomy and bilateral salpingo-oophorectomy. Rates of ovarian cancer were 26.2 (95% CI 15.5-37) for those with hysterectomy alone, 17.5 (95% CI 0.0-39.1) for hysterectomy and unilateral salpingo-oophorectomy, and 1.7 (95% CI 0.4-3) for those with hysterectomy and bilateral salpingo-oophorectomy. Compared with women undergoing hysterectomy alone, those receiving an unilateral salpingo-oophorectomy had a hazard ratio (HR) for ovarian cancer of 0.58 (95% CI 0.18-1.9) and those undergoing bilateral salpingo-oophorectomy had an HR of 0.12 (95% CI 0.05-0.28). The removal of both ovaries decreases the incidence of ovarian and peritoneal cancers. Removal of one ovary might also decrease the incidence of ovarian cancer but warrants further investigation. II.

Annual review of health care management: revisiting the evolution of health systems organization.

Dramatic changes to the structure of health systems since the 1980s has seen the development of large, integrated health organizations designed to provide scale and scope advantages, improve the quality of care and health outcomes, and provide greater bargaining power relative to payers and large employers. This transition has led to greater interest in understanding hospitals and health systems as complex systems. Two important themes emerged from this effort: 1. Creation and organization of physician-health organizations, and alignment of these organizations with hospital or system structure; and 2. Viewing health care organizations as complex systems, leading to new perspectives on design and management of these organizations. In Volume 15, Reuben McDaniel and L. Robert Burns, authors of two influential articles on these themes from earlier volumes of AHCM, revisit the evolution of health systems organization in light of regulatory and organizational evolution in health care, including the Patient Protection and Accountable Care Act of 2010, and increasing consolidation of health systems. Five additional refereed papers assess the latest evidence on physician integration, complexity, and system redesign.

Piloting integrated care

An integrated health organisation is showing how the government pilots could work.

Mortality and morbidity of non-systolic heart failure treated with angiotensin-converting enzyme inhibitors: A propensity-adjusted case–control study

BackgroundThe effect of treatment with angiotensin-converting enzyme inhibitors (ACEIs) on the prognosis of patients newly diagnosed with heart failure with preserved systolic function (HF-PSF) is unclear. We evaluate the relationship of commencing ACEI therapy (C-ACEI-T) with the morbidity and mortality of patients with HF-PSF. MethodsProspective propensity-adjusted cohort study over 5 years on 1120 adults diagnosed with HF-PSF for the first time, within an integrated health organization in Spain. We analyzed the independent relationship between C-ACEI-T and mortality, and morbidity, stratifying patients according to comorbidity, after a multivariable adjustment for potential confounders. ResultsThe 865 patients (77.2%) who C-ACEI-T were younger, with more cardiovascular comorbidity. During the median follow-up of 908.3 days (interquartile range 558.6–1302.0) 580 patients (51.8%) died, and 727 (64.9%) were hospitalized. Using an intention-to-treat analysis, C-ACEI-T was associated with a lower risk of all-cause (RR [CI 95%] 0.34 [0.23 to 0.46]), and cardiovascular (RR 0.28 [0.20 to 0.36]) mortality, and a lower age- and sex-adjusted rate of hospitalization (per 100 persons-year), 12.3 vs. 19.4, (P<0.001 in all cases), even after adjustment for the propensity to take ACEIs, or other medications, comorbidities, and other potential confounders. ConclusionIn this prospective observational study the establishment of ACEI therapy is associated with a reduced mortality and morbidity of patients with newly diagnosed non-systolic heart failure.

Surgical Outcomes in Human Immunodeficiency Virus–Infected Patients in the Era of Highly Active Antiretroviral Therapy

Matched patients who test positive or negative for human immunodeficiency virus (HIV) who are undergoing comparable operations have similar complication rates and outcomes. A retrospective study of surgical outcomes in HIV-infected and matched HIV-noninfected patients. Baseline information including HIV-related laboratory results, complications, and mortality was collected from printed and electronic records through 12 postoperative months. Kaiser Permanente Medical Care Program-Northern California, an integrated health organization with more than 3 million members, including more than 5000 HIV-infected members. From July 1,1997, through June 30, 2002, HIV-infected members undergoing surgical procedures were matched 1:1 with HIV-noninfected patients undergoing surgical procedures by type, location, and year of surgery as well as by sex and age. Surgical procedures studied included appendectomy, arthrotomy or arthroscopy, bowel resection, cholecystectomy, cardiothoracic procedures, hernia repair, hysterectomy, hip or knee replacement, laparoscopy or laparotomy, and mammoplasty. Complications and mortality through 12 postoperative months, comparisons between HIV-infected and HIV-noninfected patients using matched-pair analyses, and HIV-infected cohort data were analyzed using the Fisher exact test and logistic regression. Of 332 HIV-infected-HIV-noninfected pairs (mean age, 46.7 years; male sex, 91%), more than 95.0% were followed up through 12 postoperative months or until their deaths. Pairs had similar comorbidities, length of hospital stay, and number of postoperative surgical visits (P>.05, all variables). Among HIV-infected patients, the median years with HIV infection was 8.4 years; median CD4 T-cell count was 379/microL; 61.5% of these patients had an HIV RNA level less than 500 copies per milliliter; and 68% were receiving highly active antiretroviral therapy. Various complications were no more frequent among HIV-infected than in HIV-noninfected patients (11.1% vs 10.2%; P = .79), except for pneumonia (P = .04). There were more deaths within the 12 postoperative months in HIV-infected patients (10/332 vs 2/332; P = .02); 2 patients died 30 days or less after being operated on. Among HIV-infected patients, viral load of 30 000 copies per milliliter or more was associated with increased complications (adjusted odds ratio, 2.95; P = .007), but a CD4 cell count less than 200/muL was not associated with poorer outcomes. The HIV-infected patients had more incidences of postoperative pneumonia and higher 12-month mortality, although other operative outcomes were comparable for HIV-infected and HIV-noninfected patients. Viral suppression to fewer than 30 000 copies per milliliter reduced surgical complications.

The Financial Performance of Integrated Health Organizations

This study examines the impact of integration strategies on the financial performance of hospitals, physicians, and health plans over time. Results from a study of 36 large integrated health organizations (IHOs) suggest that financial performance is adversely affected by the scale of investment in integration but not necessarily by the timing or sequencing of the investments made. The results also suggest that some integration strategies have more detrimental effects on financial performance than do others. Finally, the results show that centralized integrative structures appear more financially successful than are less centralized structures.

PRACTITIONER APPLICATION: The Financial Performance of Integrated Health Organizations

PRACTITIONER APPLICATION: The Financial Performance of Integrated Health Organizations

Assessing the Extent of Integration Achieved Through Physician-Hospital Arrangements

In this article we examine management service organizations (MSOs), physician-hospital organizations (PHOs), hospital-affiliated independent practice associations (IPAs), and hospital-sponsored "group practices without walls" (GPWWs) that allow physicians to retain their practices and link hospitals and health systems to physicians through contractual arrangements. Also examined were medical foundations (MFs), integrated salary models (ISMs), and integrated health organizations (IHOs) that own the physical assets of physician practices and contract with payors for physician and hospital services. The research provides several new insights for understanding the structure and process of physician-hospital integration. It was found that the extent of processual integration in physician-hospital organizational arrangements can be measured along six dimensions: administrative and practice management services; physician financial risk-sharing; joint ventures to create new services; computer linkages; physician involvement in strategic planning; and salaried physician arrangements. These dimensions are consistent with the conceptual and empirical dimensions developed by others. These findings refute the notion raised by some industry observers that the new physician-hospital organizational models simply formalize integrative activities already in place. Earlier studies from the 1980s reported that hospitals integrated physicians through involvement in governance, capital planning, and the provision of practice management services. In contrast, we found that current integration.