Publications by authors named "Shoou-Yih D Lee"

57 Publications

Can Collaboration Between Nonprofit Hospitals and Local Health Departments Influence Population Health Investments by Nonprofit Hospitals?

Med Care 2021 Apr 23. Epub 2021 Apr 23.

Wharton School, Leonard Davis Institute of Health Economics, University of Pennsylvania, 413 Colonial Penn Center, Philadelphia, PA Department of Health Systems, Management and Policy, Colorado School of Public Health, Aurora, CO Department of Health Administration, College of Health Professions, Virginia Commonwealth University, Richmond, VA Department of Economics, University of Colorado Denver, Denver, CO.

Background: The patient protection and Affordable Care Act (ACA) sought to improve population health by requiring nonprofit hospitals (NFPs) to conduct triennial community health needs assessments and address the identified needs. In this context, some states have encouraged collaboration between hospitals and local health department (LHD) to increase the focus of community benefit spending onto population health.

Objectives: The aim was to examine whether a 2012 state law that required NFPs to collaborate with LHDs in local health planning influenced hospital population health improvement spending.

Research Design: We merged Internal Revenue Service data on NFP community benefit spending with data on hospital, county and state-level characteristics and estimated a difference-in-differences specification of hospital population health spending in 2009-2016 that compared the difference between hospitals that were required to collaborate with LHDs to those that were not, before and after the requirement.

Measures: The primary outcome was population health spending divided by operating expenses.

Results: We found that the requirement for hospital-LHD collaboration was associated with increased mean population health spending of ∼$393,000-$786,000 (P=0.03). This association was significant in 2015-2016, perhaps reflecting the lag between assessments and implementation. Urban hospitals were responsible for most of the increased spending.

Conclusions: Policymakers have sought to encourage hospitals to increase their investment in population health; however, overall community benefit spending on population health has remained flat. We found that requiring hospital-LHD collaboration was associated with increased hospital investment in population health. It may be that hospitals increase population health spending because collaboration improves expected effectiveness or increases hospital accountability.
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http://dx.doi.org/10.1097/MLR.0000000000001561DOI Listing
April 2021

A Retrospective Comparison of Guidelines to Assess Hospital-diagnosed Urinary Tract Infection in Nursing Home Residents.

Am J Infect Control 2021 Apr 16. Epub 2021 Apr 16.

Senior Associate Dean for Research and Strategic Initiatives, Interim Chair, Department of Physical Therapy, Martha V. and Wickliffe S. Lyne Professor of Health Administration, College of Health Professions, Virginia Commonwealth University, 900 E. Leigh Street, Box 980233, Richmond, VA 23298. Electronic address:

Background: Inappropriate antibiotic treatments for urinary tract infection (UTI) in nursing home (NH) residents are common and contribute to antibiotic resistance. Published guidelines aim to improve accurate assessment, diagnosis, and treatment of UTIs. This study assessed whether records from hospitalized NH residents diagnosed with UTI, while comparing the Cooper Tool and Stone criteria, supported appropriate treatment.

Methods: A retrospective chart review was conducted using electronic medical record (EMR) data from residents of 3 NHs who were diagnosed with UTI when hospitalized over a 3-year period. The Cooper Tool and Stone criteria were used to assess treatment appropriateness.

Results: Of 79 hospitalized residents treated for UTI, 11 (13.9%) were appropriately treated according to the Cooper Tool and 9 (11.4%) according to Stone. The two criteria agreed in 9 of the cases including 100% of those with catheters. Urinalysis was documented in 72% of residents and 24% had documentation of culture and sensitivity.

Conclusions: Appropriate UTI treatment rates using both tools were low but much higher in those with catheters. Future research is necessary to validate the use of these tools in the hospital setting which have the potential to improve treatment accuracy and reduce unnecessary antibiotics use.
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http://dx.doi.org/10.1016/j.ajic.2021.04.001DOI Listing
April 2021

Dispersion in the hospital network of shared patients is associated with less efficient care.

Health Care Manage Rev 2020 Dec 8. Epub 2020 Dec 8.

Jordan Everson, PhD, MPP, is Assistant Professor, Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee. E-mail: Julia R. Adler-Milstein, PhD, is Associate Professor, School of Medicine, University of California, San Francisco. John M. Hollingsworth, MD, MS, is Associate Professor, Department of Urology, University of Michigan, Ann Arbor. E-mail: Shoou-Yih D. Lee, PhD, is Professor, Department of Health Management and Policy, University of Michigan, Ann Arbor.

Background: There is growing recognition that health care providers are embedded in networks formed by the movement of patients between providers. However, the structure of such networks and its impact on health care are poorly understood.

Purpose: We examined the level of dispersion of patient-sharing networks across U.S. hospitals and its association with three measures of care delivered by hospitals that were likely to relate to coordination.

Methodology/approach: We used data derived from 2016 Medicare Fee-for-Service claims to measure the volume of patients that hospitals treated in common. We then calculated a measure of dispersion for each hospital based on how those patients were concentrated in outside hospitals. Using this measure, we created multivariate regression models to estimate the relationship between network dispersion, Medicare spending per beneficiary, readmission rates, and emergency department (ED) throughput rates.

Results: In multivariate analysis, we found that hospitals with more dispersed networks (those with many low-volume patient-sharing relationships) had higher spending but not greater readmission rates or slower ED throughput. Among hospitals with fewer resources, greater dispersion related to greater readmission rates and slower ED throughput. Holding an individual hospital's dispersion constant, the level of dispersion of other hospitals in the hospital's network was also related to these outcomes.

Conclusion: Dispersed interhospital networks pose a challenge to coordination for patients who are treated at multiple hospitals. These findings indicate that the patient-sharing network structure may be an overlooked factor that shapes how health care organizations deliver care.

Practice Implications: Hospital leaders and hospital-based clinicians should consider how the structure of relationships with other hospitals influences the coordination of patient care. Effective management of this broad network may lead to important strategic partnerships.
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http://dx.doi.org/10.1097/HMR.0000000000000295DOI Listing
December 2020

Comparing Mortality of Peritoneal and Hemodialysis Patients in an Era of Medicare Payment Reform.

Med Care 2021 02;59(2):155-162

Departments of Population Health Sciences.

Background: Prior studies have shown peritoneal dialysis (PD) patients to have lower or equivalent mortality to patients who receive in-center hemodialysis (HD). Medicare's 2011 bundled dialysis prospective payment system encouraged expansion of home-based PD with unclear impacts on patient outcomes. This paper revisits the comparative risk of mortality between HD and PD among patients with incident end-stage kidney disease initiating dialysis in 2006-2013.

Research Design: We conducted a retrospective cohort study comparing 2-year all-cause mortality among patients with incident end-stage kidney disease initiating dialysis via HD and PD in 2006-2013, using data from the US Renal Data System and Medicare. Analysis was conducted using Cox proportional hazards models fit with inverse probability of treatment weighting that adjusted for measured patient demographic and clinical characteristics and dialysis market characteristics.

Results: Of the 449,652 patients starting dialysis between 2006 and 2013, the rate of PD use in the first 90 days increased from 9.3% of incident patients in 2006 to 14.2% in 2013. Crude 2-year mortality was 27.6% for patients dialyzing via HD and 16.7% for patients on PD. In adjusted models, there was no evidence of mortality differences between PD and HD before and after bundled payment (hazard ratio, 0.96; 95% confidence interval, 0.89-1.04; P=0.33).

Conclusions: Overall mortality for HD and PD use was similar and mortality differences between modalities did not change before versus after the 2011 Medicare dialysis bundled payment, suggesting that increased use of home-based PD did not adversely impact patient outcomes.
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http://dx.doi.org/10.1097/MLR.0000000000001457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855236PMC
February 2021

Measurement Approaches to Partnership Success: Theory and Methods for Measuring Success in Long-Standing Community-Based Participatory Research Partnerships.

Prog Community Health Partnersh 2020 ;14(1):129-140

Background: Numerous conceptual frameworks have been developed to understand how community-based participatory research (CBPR) partnerships function, and multiple measurement approaches have been designed to evaluate them. However, most measures are not validated, and have focused on new partnerships. To define and assess the meaning of success in long-standing CBPR partnerships, we are conducting a CBPR study, Measurement Approaches to Partnership Success (MAPS). In this article we describe the theoretical underpinnings and methodological approaches used.

Objectives: The objectives of this study are to 1) develop a questionnaire to evaluate success in long-standing CBPR partnerships, 2) test the psychometric qualities of the questionnaire, 3) assess the relationships between key variables and refine the questionnaire and theoretical model, and 4) develop mechanisms and a feedback tool to apply partnership evaluation findings.

Methods: Methodological approaches have included: engaged a community-academic national Expert Panel; conducted key informant interviews with Expert Panel; conducted a scoping literature review; conducted a Delphi process with the Expert Panel; and revised the measurement instrument. Additional methods include: conduct cognitive interviews and pilot testing; revise and test final version of the questionnaire with long-standing CBPR partnerships; examine the reliability and validity; analyze the relationship among variables in the framework; revise the framework; and develop a feedback mechanism for sharing partnership evaluation results.

Conclusions: Through the application of a theoretical model and multiple methodological approaches, the MAPS study will result in a validated measurement instrument and will develop procedures for effectively feeding back evaluation findings in order to strengthen authentic partnerships to achieve health equity.
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http://dx.doi.org/10.1353/cpr.2020.0015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7439287PMC
February 2021

Trends in Regional Supply of Peritoneal Dialysis in an Era of Health Reform, 2006 to 2013.

Med Care Res Rev 2020 Mar 6:1077558720910633. Epub 2020 Mar 6.

Duke University, Durham, NC, USA.

Peritoneal dialysis (PD), a home-based treatment for kidney failure, is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis. Yet <10% of patients receive PD. Access to this alternative treatment, vis-à-vis providers' supply of PD services, may be an important factor but has been sparsely studied in the current era of national payment reform for dialysis care. We describe temporal and regional variation in PD supply among Medicare-certified dialysis facilities from 2006 to 2013. The average proportion of facilities offering PD per hospital referral region increased from 40% (2006) to 43% (2013). PD supply was highest in hospital referral regions with higher percentage of facilities in urban areas ( = .004), prevalence of PD use ( < .0001), percentage of White end-stage renal disease patients ( = .02), and per capita income ( = .02). Disparities in PD access persist in rural, non-White, and low-income regions. Policy efforts to further increase regional PD supply should focus on these underserved communities.
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http://dx.doi.org/10.1177/1077558720910633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483785PMC
March 2020

Trends in Peritoneal Dialysis Use in the United States after Medicare Payment Reform.

Clin J Am Soc Nephrol 2019 12 21;14(12):1763-1772. Epub 2019 Nov 21.

Departments of Medicine,

Background And Objectives: Peritoneal dialysis (PD) for ESKD is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis (HD), but has historically been underused. We assessed the effect of the 2011 Medicare prospective payment system (PPS) for dialysis on PD initiation, modality switches, and stable PD use.

Design, Setting, Participants, & Measurements: Using US Renal Data System and Medicare data, we identified all United States patients with ESKD initiating dialysis before (2006-2010) and after (2011-2013) PPS implementation, and observed their modality for up to 2 years after dialysis initiation. Using logistic regression models, we examined the associations between PPS and early PD experience (any PD 1-90 days after initiation), late PD use (any PD 91-730 days after initiation), and modality switches (PD-to-HD or HD-to-PD 91-730 days after initiation). We adjusted for patient, dialysis facility, and regional characteristics.

Results: Overall, 619,126 patients with incident ESKD received dialysis at Medicare-certified facilities, 2006-2013. Observed early PD experience increased from 9.4% before PPS to 12.6% after PPS. Observed late PD use increased from 12.1% to 16.1%. In adjusted analyses, PPS was associated with increased early PD experience (odds ratio [OR], 1.51; 95% confidence interval [95% CI], 1.47 to 1.55; <0.001) and late PD use (OR, 1.47; 95% CI, 1.45 to 1.50; <0.001). In subgroup analyses, late PD use increased in part due to an increase in HD-to-PD switches among those without early PD experience (OR, 1.59; 95% CI, 1.52 to 1.66; <0.001) and a decrease in PD-to-HD switches among those with early PD experience (OR, 0.92; 95% CI, 0.87 to 0.98; =0.004).

Conclusions: More patients started, stayed on, and switched to PD after dialysis payment reform. This occurred without a substantial increase in transfers to HD.
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http://dx.doi.org/10.2215/CJN.05910519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6895485PMC
December 2019

Effect of a community-based participatory health literacy program on health behaviors and health empowerment among community-dwelling older adults: A quasi-experimental study.

Geriatr Nurs 2019 Sep - Oct;40(5):494-501. Epub 2019 Mar 29.

School of Nursing, National Yang-Ming University, Taipei, Taiwan. Electronic address:

This study evaluated the effect of a community-based participatory health literacy program aimed at improving the health behaviors and health empowerment for older adults. A two-group pretest and posttest quasi-experimental design with surveys conducted at baseline (T), immediately after the intervention (T), and 6 months after the intervention (T). The intervention group (n = 94) attended a 12-week health literacy program; while the comparison group (n = 78) did not. The results demonstrated that intervention group had significantly better health behavior practices for weight control (OR = 3.71, 95% CI = 1.59-8.64), regular exercise (OR = 15.26, 95% CI = 1.92-121.13), and health information navigation (OR = 2.61, 95% CI = 1.16-5.84). Health empowerment was significantly higher in the intervention group than the comparison group (p < 0.01).This study suggests that integrating community-based participatory design is effective in improving some health behaviors and health empowerment in older adults over a short period.
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http://dx.doi.org/10.1016/j.gerinurse.2019.03.013DOI Listing
April 2020

Medicare's New Prospective Payment System on Facility Provision of Peritoneal Dialysis.

Clin J Am Soc Nephrol 2018 12 19;13(12):1833-1841. Epub 2018 Nov 19.

Departments of Population Health Sciences and.

Background And Objectives: Peritoneal dialysis is a self-administered, home-based treatment for ESKD associated with equivalent mortality, higher quality of life, and lower costs compared with hemodialysis. In 2011, Medicare implemented a comprehensive prospective payment system that makes a single payment for all dialysis, medication, and ancillary services. We examined whether the prospective payment system increased dialysis facility provision of peritoneal dialysis services and whether changes in peritoneal dialysis provision were more common among dialysis facilities that are chain affiliated, located in nonurban areas, and in regions with high dialysis market competition.

Design, Setting, Participants, & Measurements: We conducted a longitudinal retrospective cohort study of =6433 United States nonfederal dialysis facilities before (2006-2010) and after (2011-2013) the prospective payment system using data from the US Renal Data System, Medicare, and Area Health Resource Files. The outcomes of interest were a dichotomous indicator of peritoneal dialysis service availability and a discrete count variable of dialysis facility peritoneal dialysis program size defined as the annual number of patients on peritoneal dialysis in a facility. We used general estimating equation models to examine changes in peritoneal dialysis service offerings and peritoneal dialysis program size by a pre- versus post-prospective payment system effect and whether changes differed by chain affiliation, urban location, facility size, or market competition, adjusting for 1-year lagged facility-, patient with ESKD-, and region-level demographic characteristics.

Results: We found a modest increase in observed facility provision of peritoneal dialysis and peritoneal dialysis program size after the prospective payment system (36% and 5.7 patients in 2006 to 42% and 6.9 patients in 2013, respectively). There was a positive association of the prospective payment system with peritoneal dialysis provision (odds ratio, 1.20; 95% confidence interval, 1.13 to 1.18) and PD program size (incidence rate ratio, 1.27; 95% confidence interval, 1.22 to 1.33). Post-prospective payment system change in peritoneal dialysis provision was greater among nonurban (<0.001), chain-affiliated (=0.002), and larger-sized facilities (<0.001), and there were higher rates of peritoneal dialysis program size growth in nonurban facilities (<0.001).

Conclusions: Medicare's 2011 prospective payment system was associated with more facilities' availability of peritoneal dialysis and modest growth in facility peritoneal dialysis program size.

Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_11_19_CJASNPodcast_18_12_.mp3.
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http://dx.doi.org/10.2215/CJN.05680518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6302340PMC
December 2018

Patient Satisfaction Is Associated With Dialysis Facility Quality and Star Ratings.

Am J Med Qual 2019 May/Jun;34(3):243-250. Epub 2018 Sep 18.

3 University of Michigan, Ann Arbor, MI.

The Dialysis Facility Compare Star Rating and the Quality Incentive Program (QIP) generate separate performance scores from clinical measures, and the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey evaluates patient satisfaction across 6 separate domains related to nephrologists, dialysis facility, and information transmission. This study examined the relationship of the 3 measures for US clinics, modeling the 6 ICH-CAHPS domains as independent variables and QIP and star ratings as dependent variables. Among 3176 dialysis clinics, domains assessing dialysis facility and information transmission had a consistently stronger relationship with QIP and star ratings than the domains assessing nephrologists: QIP, β (95% CI) = 1.62 (1.26-1.97) for dialysis facility staff rating, 0.70 (0.35-1.05) for nephrologists; star rating, odds ratio (95% CI) = 1.38 (1.29-1.49) for dialysis facility staff rating, 1.17 (1.09-1.25) for nephrologists. Patient satisfaction is associated with dialysis care quality, with surprising differences between nephrologists and dialysis facilities.
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http://dx.doi.org/10.1177/1062860618796310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422762PMC
April 2020

Is health literacy associated with greater medical care trust?

Int J Qual Health Care 2018 Aug;30(7):514-519

Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.

Objective: To examine the relationship between health literacy and trust in physicians and in the healthcare system.

Design: A cross-sectional survey of a nationally representative sample of adults.

Setting: Taiwan.

Participants: Non-institutionalized adults (N = 2199).

Main Measures: Trust in physicians was a composite measure assessing respondents' general trust in physicians and their perceptions of their physician's communication, medical skills, beneficence, honesty, confidentiality, respect and fairness. Trust in the healthcare system was a single-item measure. Health literacy was measured by four items.

Results: Respondents with higher health literacy had, overall, higher levels of trust in physicians (P<0.001) and in the healthcare system (P = 0.04). Health literacy remained significantly and positively associated with trust in physicians (P<0.001) and in the healthcare system (P = 0.001) after adjusting for respondents' sociodemographic characteristics.

Conclusions: Our findings demonstrate that health literacy is positively associated with trust. Actionable plans targeting health literacy at the national and local levels to establish a health literate care environment may contribute to enhancing trust in physicians and the healthcare system.
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http://dx.doi.org/10.1093/intqhc/mzy043DOI Listing
August 2018

Impact of a Problem-Based Learning (PBL) Health Literacy Program on Immigrant Women's Health Literacy, Health Empowerment, Navigation Efficacy, and Health Care Utilization.

J Health Commun 2018 15;23(4):340-349. Epub 2018 Mar 15.

c Family Medicine Division , Taipei City Hospital , Taipei City , Taiwan.

We evaluated the effectiveness of a problem-based learning (PBL) health literacy program aimed to improve health literacy, health empowerment, navigation efficacy, and health care utilization among immigrant women in Taiwan. We employed a quasi-experimental design that included surveys at the baseline, immediately after the intervention, and 6 months after the intervention. The intervention group participated in a 10-session PBL health literacy program and the comparison group did not. Results showed that 6 months after the intervention, the intervention group had significantly fewer ER visits and hospitalizations than the comparison group. The intervention group reported a greater decrease in delaying/avoiding health care due to communication barriers. Although the intervention group showed improvement in health literacy, health empowerment and navigation self-efficacy, the differences were not statistically significant. The PBL health literacy program resulted in fewer ER visits and hospitalizations, and better health care access among immigrant women. Cognitive and psychological outcomes examined in the study appeared more difficult to change. The PBL health literacy program effectively improved health care utilization and reduced barriers to health care access among immigrant women in Taiwan. It would be useful to examine the effectiveness of the program in other populations.
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http://dx.doi.org/10.1080/10810730.2018.1445798DOI Listing
October 2019

Development and validation of a Weight-Specific Health Literacy Instrument (WSHLI).

Obes Res Clin Pract 2018 Mar - Apr;12(2):214-221. Epub 2017 Dec 18.

Department of Health Management and Policy, The University of Michigan School of Public Health, USA.

Objective: Develop/validate a weight-specific health literacy instrument.

Methods: The development of weight-specific health literacy measurement consisted of seven phases: (a) a literature review; (b) consultation with weight management experts; (c) generation of an item pool; (d) selection of items via the Delphi method; (e) pilot testing; (f) a national survey; and (g) examination of the psychometric properties of the results.

Results: A random sample of 362 Taiwanese adults completed the face-toface survey. The results of factor analysis indicated reasonable good fit of a 2-factor model (χ/df=1.1, p=0.18; RMSEA=0.02, CFI=0.99, TLI=0.99). Construct validity testing showed that the both factors were significantly correlated with s-MHLS (γ=0.71, p<0.001; γ=0.22, p<0.001), comprehension (γ=0.32, p<0.001: γ=0.10, p<0.05), and writing (γ=0.44, p<0.001: γ=0.11, p<0.05). Predictive validity testing showed that the first factor had significant correlations with weight management efficacy (γ=0.16, p<0.001), and three weight management behaviors. The second factor was significantly correlated with weight management efficacy (γ=0.11, p<0.05) but not with the 3 weight management behaviors.

Conclusions: On the basis of the psychometric results, we conclude that the final version of Weight-Specific Health Literacy Instrument (WSHLI) includes the 13 items. It is a valid and reliable tool for weight management research and evaluation in Mandarin Chinese speaking populations.
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http://dx.doi.org/10.1016/j.orcp.2017.11.003DOI Listing
April 2019

Health literacy and health outcomes in chronic obstructive pulmonary disease.

Respir Med 2016 06 27;115:78-82. Epub 2016 Apr 27.

Department of Health Policy and Management, School of Global Public Health, University of North Carolina, Chapel Hill, USA.

Background: There is little information worldwide about the impact of health literacy (HL) on clinical outcomes of COPD. Our aim was to quantify inadequate HL in Spain, as measured by the Short Assessment of Health Literacy for Spanish Adults questionnaire, and to examine the associations between HL and both COPD outcomes and health status.

Methods: 296 COPD patients of 68(SD = 9) years and a FEV1%predicted of 53%(SD = 18%) were enrolled and followed-up for one year. 59% showed "inadequate" HL.

Results: Individuals with inadequate HL were older (70[SD = 9] vs 65[SD = 8] years; p < 0.001) and had less knowledge of their disease, as measured by the low HL-COPD questionnaire, (6.9[SD = 2.3] vs 7.5[SD = 1.9]; p < 0.001). While their lung function was no different, they reported significant differences in mMRC (1.6[SD = 1] vs 1.4[SD = 1]; p < 0.001), CAT (19.2[SD = 8.1] vs 18.3[SD = 7.5]; p = 0.049), and EQ-5 (3.1[SD = 2.2] vs 2.3[SD = 1.9]; p < 0.00). Those with inadequate HL had also higher risk of having ≥2 comorbidities (OR = 1.87; 95%CI = 1.14-3.08), need of assistance (OR = 2.5; 95%CI = 1.5-4.2), anxiety/depression (OR = 1.9; 95%CI = 1.2-3.0), admissions or visits to the emergency department (OR = 1.70; 95%CI = 1.1-2.7), and all-cause deaths in the following year (3.8% (SE = 1.1%) vs 0%; p = 0.051).

Conclusions: Inadequate HL is prevalent among COPD patients and it is related to health status and relevant clinical outcomes of the disease. HL needs to be considered when planning the care for COPD patients.
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http://dx.doi.org/10.1016/j.rmed.2016.04.016DOI Listing
June 2016

Elaborating on theory with middle managers' experience implementing healthcare innovations in practice.

Implement Sci 2016 Jan 4;11. Epub 2016 Jan 4.

Office of Nursing Research and Innovation, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA.

Background: The theory of middle managers' role in implementing healthcare innovations hypothesized that middle managers influence implementation effectiveness by fulfilling the following four roles: diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation. The theory also suggested several activities in which middle managers might engage to fulfill the four roles. The extent to which the theory aligns with middle managers' experience in practice is unclear. We surveyed middle managers (n = 63) who attended a nursing innovation summit to (1) assess alignment between the theory and middle managers' experience in practice and (2) elaborate on the theory with examples from middle managers' experience overseeing innovation implementation in practice.

Findings: Middle managers rated all of the theory's hypothesized four roles as "extremely important" but ranked diffusing and synthesizing information as the most important and selling innovation implementation as the least important. They reported engaging in several activities that were consistent with the theory's hypothesized roles and activities such as diffusing information via meetings and training. They also reported engaging in activities not described in the theory such as appraising employee performance.

Conclusions: Middle managers' experience aligned well with the theory and expanded definitions of the roles and activities that it hypothesized. Future studies should assess the relationship between hypothesized roles and the effectiveness with which innovations are implemented in practice. If evidence supports the theory, the theory should be leveraged to promote the fulfillment of hypothesized roles among middle managers, doing so may promote innovation implementation.
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http://dx.doi.org/10.1186/s13012-015-0362-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4700583PMC
January 2016

EHR Adoption and Hospital Performance: Time-Related Effects.

Health Serv Res 2015 Dec 16;50(6):1751-71. Epub 2015 Oct 16.

School of Public Health (Health Management and Policy), University of Michigan, Ann Arbor, MI.

Objective: To assess whether, 5 years into the HITECH programs, national data reflect a consistent relationship between EHR adoption and hospital outcomes across three important dimensions of hospital performance.

Data Sources/study Setting: Secondary data from the American Hospital Association and CMS (Hospital Compare and EHR Incentive Programs) for nonfederal, acute-care hospitals (2009-2012).

Study Design: We examined the relationship between EHR adoption and three hospital outcomes (process adherence, patient satisfaction, efficiency) using ordinary least squares models with hospital fixed effects. Time-related effects were assessed through comparing the impact of EHR adoption pre (2008/2009) versus post (2010/2011) meaningful use and by meaningful use attestation cohort (2011, 2012, 2013, Never). We used a continuous measure of hospital EHR adoption based on the proportion of electronic functions implemented.

Data Collection/extraction Methods: We created a panel dataset with hospital-year observations.

Principal Findings: Higher levels of EHR adoption were associated with better performance on process adherence (0.147; p < .001) and patient satisfaction (0.118; p < .001), but not efficiency (0.01; p = .78). For all three outcomes, there was a stronger, positive relationship between EHR adoption and performance in 2010/2011 compared to 2008/2009. We found mixed results based on meaningful use attestation cohort.

Conclusions: Performance gains associated with EHR adoption are apparent in more recent years. The large national investment in EHRs appears to be delivering more consistent benefits than indicated by earlier national studies.
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http://dx.doi.org/10.1111/1475-6773.12406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4693851PMC
December 2015

A Generalized Assessment of the Impact of Regionalization and Provider Learning on Patient Outcomes.

Med Decis Making 2016 11 13;36(8):990-8. Epub 2015 Jul 13.

University of Michigan, Ann Arbor, MI (AP, JSM, JEM, JTW, BKH)

We present a generalized model to assess the impact of regionalization on patient care outcomes in the presence of heterogeneity in provider learning. The model characterizes best regionalization policies as optimal allocations of patients across providers with heterogeneous learning abilities. We explore issues that arise when solving for best regionalization, which depends on statistically estimated provider learning curves. We explain how to maintain the problem's tractability and reformulate it into a binary integer program problem to improve solvability. Using our model, best regionalization solutions can be computed within reasonable time using current-day computers. We apply the model to minimally invasive radical prostatectomy and estimate that, in comparison to current care delivery, within-state regionalization can shorten length of stay by at least 40.8%.
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http://dx.doi.org/10.1177/0272989X15593282DOI Listing
November 2016

Maternal and Hospital Factors Associated with First-Time Mothers' Breastfeeding Practice: A Prospective Study.

Breastfeed Med 2015 Jul-Aug;10(6):334-40. Epub 2015 Jun 25.

2 Department of Health Management and Policy, University of Michigan School of Public Health , Ann Arbor, Michigan.

Continuity of breastfeeding is infrequent and indeterminate. Evidence is lacking regarding factors associated with breastfeeding at different postpartum time points. This prospective study investigated the change in, and correlates of, breastfeeding practices after delivery at a hospital and at 1, 3, and 6 months postpartum among first-time mothers. We followed a cohort of 300 primiparous mothers of Taiwan who gave birth at two hospitals during 2010-2011. Logistic and Cox regression analyses were performed to determine factors that were correlated with breastfeeding practices. In the study sample, the rate of exclusive breastfeeding during the hospital stay was 66%; it declined to 37.5% at 1 month and 30.2% at 3 months postpartum. Only 17.1% of women reported continuing breastfeeding at 6 months. Early initiation of breastfeeding, rooming-in practice, and self-efficacy were significantly related to exclusive breastfeeding during the hospital stay. After discharge, health literacy, knowledge, intention, and self-efficacy were positively and significantly associated with breastfeeding exclusivity. Later initiation (hazard ratio=1.53; 95% confidence interval, 1.05, 1.97), shorter intention (hazard ratio=1.42; 95% confidence interval, 1.13, 1.68), and self-efficacy (hazard ratio=0.98; 95% confidence interval, 0.96, 0.99) were important predictors of breastfeeding cessation within 6 months of delivery. Continuous breastfeeding practice for 6 months is challenging and difficult for new mothers. Results showed that factors related to breastfeeding varied over time after delivery. Interventions seeking to sustain breastfeeding should consider new mothers' needs and barriers at different times.
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http://dx.doi.org/10.1089/bfm.2015.0005DOI Listing
April 2016

Health literacy as the missing link in the provision of immigrant health care: A qualitative study of Southeast Asian immigrant women in Taiwan.

Int J Nurs Stud 2016 Feb 4;54:65-74. Epub 2015 Apr 4.

Department of Health Management and Policy, The University of Michigan, School of Public Health, 1420 Washington Heights, Ann Arbor, MI 48109-2029, USA. Electronic address:

Objectives: Language and communication barrier are main contributors to poor health outcomes and improper use of health care among immigrants. The purpose of this study was to explore and understand specific language and communication problems experiences by Southeast Asian immigrant women in Taiwan.

Design: This qualitative study used focus groups and in-depth interviews to uncover the experiences of immigrant women regarding their access to and utilization of health care in Taiwan.

Participants: Eight focus groups were conducted with 62 Southeast Asian immigrant women and 23 individual in-depth interviews with a wide range of stakeholders who had diverse background and intimate knowledge of immigrant-relating health care issues were performed.

Results: Directed content analysis was applied and identified four major themes concerning conditions that influenced immigrant women's use of health information and services: (1) gaining access to health information, (2) navigating in health care delivery system, (3) interactions during health care encounters, and (4) capability of using health information and services. Findings from this study suggest that, without basic language and literate skills, the majority of immigrant women had inadequate health literacy to manage health information and navigate the Taiwan health care system. Interpersonal communication gap between immigrant women and health care providers exists because of lack of health literacy in addition al language and cultural barriers.

Conclusion: With limited language and health literacy skills, immigrant women face numerous challenges in navigating the health care system, interacting with health care providers, and gaining access to proper health care. Future efforts are necessary to enhance individual's health literacy and establish health literate environment.
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http://dx.doi.org/10.1016/j.ijnurstu.2015.03.021DOI Listing
February 2016

The health literate health care organization 10 item questionnaire (HLHO-10): development and validation.

BMC Health Serv Res 2015 Feb 1;15:47. Epub 2015 Feb 1.

Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupener Strasse 129, Cologne, 50933, Germany.

Background: While research on individual health literacy is steadily increasing, less attention has been paid to the context of care that may help to increase the patient's ability to navigate health care or to compensate for their limited health literacy. In 2012, Brach et al. introduced the concept of health literate health care organizations (HLHOs) to describe the organizational context of care. This paper presents our effort in developing and validating an HLHO instrument.

Method: Ten items were developed to represent the ten attributes of HLHO (HLHO-10) based on a literature review, an expert workshop, a focus group discussion, and qualitative interviews. The instrument was applied in a key informant survey in 51 German hospitals as part of a larger study on patient information and training needs (PIAT-study). Item properties were analyzed and a confirmatory factor analysis (CFA) was conducted to test the instrument's unidimensionality. To investigate the instrument's predictive validity, a multilevel analysis was performed that used the HLHO-10 score to predict the adequacy of information provided to 1,224 newly-diagnosed breast cancer patients treated at the sample hospitals.

Results: Cronbach's α of the resulting scale was 0.89. CFA verified the one-factor structure after allowing for the correlation for four pairs of error terms. In the multilevel model, HLHO-10 significantly predicted the adequacy of information as perceived by patients.

Conclusion: The instrument has satisfactory reliability and validity. It provides a useful tool to assess the degree to which health care organizations help patients to navigate, understand, and use information and services. Further validation should include participant observation in health care organizations and a sample that is not limited to breast cancer care.
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http://dx.doi.org/10.1186/s12913-015-0707-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4332719PMC
February 2015

Meeting patients' health information needs in breast cancer center hospitals - a multilevel analysis.

BMC Health Serv Res 2014 Nov 25;14:601. Epub 2014 Nov 25.

Background: Breast cancer patients are confronted with a serious diagnosis that requires them to make important decisions throughout the journey of the disease. For these decisions to be made it is critical that the patients be well informed. Previous studies have been consistent in their findings that breast cancer patients have a high need for information on a wide range of topics. This paper investigates (1) how many patients feel they have unmet information needs after initial surgery, (2) whether the proportion of patients with unmet information needs varies between hospitals where they were treated and (3) whether differences between the hospitals account for some of these variation.

Methods: Data from 5,024 newly-diagnosed breast cancer patients treated in 111 breast center hospitals in Germany were analyzed and combined with data on hospital characteristics. Multilevel linear regression models were calculated taking into account hospital characteristics and adjusting for patient case mix.

Results: Younger patients, those receiving mastectomy, having statutory health insurance, not living with a partner and having a foreign native language report higher unmet information needs. The data demonstrate small between-hospital variation in unmet information needs. In hospitals that provide patient-specific information material and that offer health fairs as well as those that are non-teaching or have lower patient-volume, patients are less likely to report unmet information needs.

Conclusion: We found differences in proportions of patients with unmet information needs between hospitals and that hospitals' structure and process-related attributes of the hospitals were associated with these differences to some extent. Hospitals may contribute to reducing the patients' information needs by means that are not necessarily resource-intensive.
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http://dx.doi.org/10.1186/s12913-014-0601-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4247601PMC
November 2014

Sequencing of EHR adoption among US hospitals and the impact of meaningful use.

J Am Med Inform Assoc 2014 Nov-Dec;21(6):984-91. Epub 2014 May 22.

Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.

Objective: To examine whether there is a common sequence of adoption of electronic health record (EHR) functions among US hospitals, identify differences by hospital type, and assess the impact of meaningful use.

Materials And Methods: Using 2008 American Hospital Association (AHA) Information Technology (IT) Supplement data, we calculate adoption rates of individual EHR functions, along with Loevinger homogeneity (H) coefficients, to assess the sequence of EHR adoption across hospitals. We compare adoption rates and Loevinger H coefficients for hospitals of different types to assess variation in sequencing. We qualitatively assess whether stage 1 meaningful use functions are those adopted early in the sequence.

Results: There is a common sequence of EHR adoption across hospitals, with moderate-to-strong homogeneity. Patient demographic and ancillary results functions are consistently adopted first, while physician notes, clinical reminders, and guidelines are adopted last. Small hospitals exhibited greater homogeneity than larger hospitals. Rural hospitals and non-teaching hospitals exhibited greater homogeneity than urban and teaching hospitals. EHR functions emphasized in stage 1 meaningful use are spread throughout the scale.

Discussion: Stronger homogeneity among small, rural, and non-teaching hospitals may be driven by greater reliance on vendors and less variation in the types of care they deliver. Stage 1 meaningful use is likely changing how hospitals sequence EHR adoption--in particular, by moving clinical guidelines and medication computerized provider order entry ahead in sequence.

Conclusions: While there is a common sequence underlying adoption of EHR functions, the degree of adherence to the sequence varies by key hospital characteristics. Stage 1 meaningful use likely alters the sequence.
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http://dx.doi.org/10.1136/amiajnl-2014-002708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215052PMC
May 2015

Facilitators and barriers to effective smoking cessation: counselling services for inpatients from nurse-counsellors' perspectives--a qualitative study.

Int J Environ Res Public Health 2014 May 6;11(5):4782-98. Epub 2014 May 6.

Department of Nursing, School of Nursing, National Yang-Ming University, No. 155, Section 2, Li-Nong St. Beitou, Taipei 11221, Taiwan.

Tobacco use has reached epidemic levels around the World, resulting in a world-wide increase in tobacco-related deaths and disabilities. Hospitalization presents an opportunity for nurses to encourage inpatients to quit smoking. This qualitative descriptive study was aimed to explore nurse-counsellors' perspectives of facilitators and barriers in the implementation of effective smoking cessation counselling services for inpatients. In-depth interviews were conducted with 16 nurses who were qualified smoking cessation counsellors and who were recruited from eleven health promotion hospitals that were smoke-free and located in the Greater Taipei City Area.  Data were collected from May 2012 to October 2012, and then analysed using content analysis based on the grounded theory approach. From nurse-counsellors' perspectives, an effective smoking cessation program should be patient-centred and provide a supportive environment. Another finding is that effective smoking cessation counselling involves encouraging patients to modify their lifestyles. Time constraints and inadequate resources are barriers that inhibit the effectiveness of smoking cessation counselling programs in acute-care hospitals. We suggest that hospitals should set up a smoking counselling follow-up program, including funds, facilities, and trained personnel to deliver counselling services by telephone, and build a network with community smoking cessation resources.
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http://dx.doi.org/10.3390/ijerph110504782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4053899PMC
May 2014

Costs and benefits of transforming primary care practices: a qualitative study of North Carolina's Improving Performance in Practice.

J Healthc Manag 2014 Mar-Apr;59(2):95-108

Primary care organizations must transform care delivery to realize the Institute for Healthcare Improvement's Triple Aim of better healthcare, better health, and lower healthcare costs. However, few studies have considered the financial implications for primary care practices engaged in transformation. In this qualitative, comparative case study, we examine the practice-level personnel and nonpersonnel costs and the benefits involved in transformational change among 12 primary care practices participating in North Carolina's Improving Performance in Practice (IPIP) program. We found average annual opportunity costs of $21,550 ($6,659 per full-time equivalent provider) for maintaining core IPIP activities (e.g., data management, form development and maintenance, meeting attendance). This average represents the cost of a 50% full-time equivalent registered nurse or licensed practical nurse. Practices were able to limit transformation costs by scheduling meetings during relatively slow patient care periods and by leveraging resources such as the assistance of IPIP practice coaches. Still, the costs of practice transformation were not trivial and would have been much higher in the absence of these efforts. Benefits of transformation included opportunities for enhanced revenue through reimbursement incentives and practice growth, improved efficiency and care quality, and maintenance of certification. Given the potentially high costs for some practices, policy makers may need to consider reimbursement and other strategies to help primary care practices manage the costs of practice redesign.
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June 2014

Inertia in health care organizations: A case study of peritoneal dialysis services.

Health Care Manage Rev 2015 Jul-Sep;40(3):203-13

Virginia Wang, PhD, MSPH, is Assistant Professor, Department of Medicine, Division of General Internal Medicine, Duke University, Durham, North Carolina, and Investigator, Center for Health Services Research in Primary Care, Durham VA Medical Center, North Carolina. E-mail: Shoou-Yih D. Lee, PhD, is Associate Professor, Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor. Matthew L. Maciejewski, PhD, is Professor, Department of Medicine, Division of General Internal Medicine, Duke University, Durham, North Carolina, and Research Career Scientist, Center for Health Services Research in Primary Care, Durham VA Medical Center, North Carolina.

Background: Change is difficult for health care organizations where adoption of new practices is notoriously slow. Inertial behavior may reflect organizations' rational, strategic nonresponse to its environment or latent, institutionalizing preservation of dominant organizational routines and norms. Such strategic and selective influences of organizational inertia have different implications on the efficacy of policy to induce intended change.

Purpose: The aim of this study was to examine whether strategic and selective factors were associated with the provision of peritoneal dialysis (PD) services in outpatient dialysis facilities in the United States between 1995 and 2003.

Approach: We conducted a longitudinal retrospective study of all outpatient end-stage renal disease dialysis facilities, using 1995-2003 administrative data from the U.S. Renal Data System.

Findings: Less than half of U.S. dialysis facilities offered PD, and this pattern was stable despite substantial growth of dialysis facilities entering the market. We found little support for strategic influences and some evidence that selective factors were predictive of dialysis facilities' PD provision.

Practice Implications: Although the design of many policy and health care reform efforts widely accepts the strategic perspective of altering incentives and the environment to induce change, the presence of selective inertial influences raises concerns about the efficacy of policy intervention in the face of institutionalized organizational behavior that may be less amenable to policy intervention. Incentives recently introduced by Medicare to increase facility provision of PD may be less effective than might be expected.
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http://dx.doi.org/10.1097/HMR.0000000000000024DOI Listing
March 2016

Reliability and validity of the American Hospital Association's national longitudinal survey of health information technology adoption.

J Am Med Inform Assoc 2014 Oct 12;21(e2):e257-63. Epub 2014 Mar 12.

University of Michigan School of Public Health, Ann Arbor, Michigan, USA University of Michigan School of Information, Ann Arbor, Michigan, USA.

Objective: To evaluate the internal consistency, construct validity, and criterion validity of a battery of items measuring information technology (IT) adoption, included in the American Hospital Association (AHA) IT Supplement Survey.

Methods: We analyzed the 2012 release of the AHA IT Supplement Survey. We performed reliability analysis using Cronbach's α and part-whole correlations, construct validity analysis using principal component analysis (PCA), and criterion validity analysis by assessing the items' sensitivity and specificity of predicting attestation to Medicare Meaningful Use (MU).

Results: Twenty-eight items of the 31-item instrument and five of six functionality subcategories defined by the AHA all produced reliable scales (α's between 0.833 and 0.958). PCA mostly confirmed the AHA's categorization of functionalities; however, some items loaded only weakly onto the factor most associated with their survey category, and one category loaded onto two separate factors. The battery of items was a valid predictor of attestation to MU, producing a sensitivity of 0.82 and a specificity of 0.72.

Discussion: The battery of items performed well on most indices of reliability and validity. However, they lack some components of ideal survey design, leaving open the possibility that respondents are not responding independently to each item in the survey. Despite measuring only a portion of the objectives required for attestation to MU, the items are a moderately sensitive and specific predictor of attestation.

Conclusions: The analyzed instrument exhibits satisfactory reliability and validity.
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http://dx.doi.org/10.1136/amiajnl-2013-002449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173179PMC
October 2014

Impact of caring for grandchildren on the health of grandparents in Taiwan.

J Gerontol B Psychol Sci Soc Sci 2013 Nov 21;68(6):1009-21. Epub 2013 Sep 21.

Correspondence should be addressed to Li-Jung Ku, Institute of Public Health, National Cheng Kung University, No. 1, University Road, Tainan City 701, Taiwan. E-mail:

Objectives: To understand how caring for grandchildren affects the physical and mental health of grandparents in Taiwan.

Method: Grandparents aged 50 and older from 4 waves of the Taiwan Longitudinal Study on Aging (1993-2003, n = 3,711) were divided into 7 categories based on living arrangement and caregiving history. Generalized estimation equations controlling for sociodemographic characteristics and disease status were used to estimate the relationship between caregiving and 4 outcomes: self-rated physical health, mobility limitation, life satisfaction, and depressive symptoms.

Results: Compared with noncaregivers, long-term multigenerational caregivers were more likely to report better self-rated health, higher life satisfaction, and fewer depressive symptoms. We found some evidence of reduced mobility limitations for both skipped-generation and nonresidential caregivers relative to noncaregivers. The associations in self-rated health and depressive symptoms were more pronounced in long-term caregivers than among those who recently started caregiving.

Discussion: Improvements in self-rated health and mobility associated with caregiving support our hypothesis that caring for grandchildren can be beneficial for grandparents in Taiwan, especially for long-term multigenerational caregivers. Comparing Taiwanese grandparents across different types of caregiving shows that the associations of grandparent caregiving with health vary by living arrangement and duration. However, these findings may not be causal because caregiving and health outcomes were observed simultaneously in our data.
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http://dx.doi.org/10.1093/geronb/gbt090DOI Listing
November 2013

Hospital ownership and community benefit: looking beyond uncompensated care.

J Healthc Manag 2013 Mar-Apr;58(2):126-41; discussion 141-2

College of Public Health, Ohio State University, Columbus, USA.

Not-for-profit (NFP) hospitals have come under increased public scrutiny for management practices that are inconsistent with their charitable focus. Of particular concern is the amount of community benefit provided by NFP hospitals compared to for-profit (FP) hospitals given the substantial tax benefits afforded to NFP hospitals. This study examines hospital ownership and community benefit provision beyond the traditional uncompensated care comparison by using broader measures of community benefit that capture charitable services, community assessment and partnership, and community-oriented health services. The study sample includes 3,317 nongovernment, general, acute care, community hospitals that were in operation in 2006. Data for this study came from the 2006 American Hospital Association Hospital Survey and the 2006 Area Resource File. We used multivariate regression analyses to examine the relationship between hospital ownership and five indicators of community benefit, controlling for hospital characteristics, market demand, hospital competition, and state regulations for community benefit. We found that NFP hospitals report more community benefit activities than do FP hospitals that extend beyond uncompensated care. Our findings underscore the importance of defining and including activities beyond uncompensated care when evaluating community benefit provided by NFP hospitals.
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July 2013

Oral health literacy levels among a low-income WIC population.

J Public Health Dent 2011 ;71(2):152-60

Department of Pediatric Dentistry, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Objectives: To determine oral health literacy (OHL) levels and explore potential racial differences in a low-income population.

Methods: This was a cross-sectional study of caregiver/child dyads that completed a structured 30-minute in-person interview conducted by two trained interviewers in seven counties in North Carolina. Sociodemographic, OHL, and dental health-related data were collected. OHL was measured with a dental word recognition test [Rapid Estimate of Adult Literacy in Dentistry (REALD-30)]. Descriptive, bivariate, and multivariate methods were used to examine the distribution of OHL and explore racial differences.

Results: Of 1658 eligible subjects, 1405 (85 percent) participated and completed the interviews. The analytic sample (N=1280) had mean age 26.5 (standard deviation = 6.9) years with 60 percent having a high school degree or less. OHL varied between racial groups as follows: Whites--mean score = 17.4 (SE = 0.2); African-American (AA)--mean score = 15.3 [standard error (SE) = 0.2]; American Indian (AI)--mean score = 13.7 (SE = 0.3). Multiple linear regression revealed that after controlling for education, county of residence, age, and Hispanic ethnicity, Whites had 2.0 points (95 percent CI = 1.4, 2.6) higher adjusted REALD-30 score versus AA and AI.

Conclusions: Differences in OHL levels between racial groups persisted after adjusting for education and sociodemographic characteristics.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3145966PMC
http://dx.doi.org/10.1111/j.1752-7325.2011.00244.xDOI Listing
September 2011

Health literacy and women's health-related behaviors in Taiwan.

Health Educ Behav 2012 Apr 8;39(2):210-8. Epub 2011 Jul 8.

University of Michigan, Ann Arbor, MI, USA.

Extant health literacy research is unclear about the contribution of health literacy to health behaviors and is limited regarding women's health issues. The primary purpose of this study is to investigate the association between health literacy and five health behaviors (Pap smear screening, annual physical checkup, smoking, checking food expiration dates, and monitoring physical changes) in women and to test whether the association is mediated by health knowledge. A national sample of 1,754 female adults in Taiwan was included in the study. Result showed that health literacy was positively and independently related to checking food expiration dates and monitoring physical changes, and that health literacy was not related to physical checkup and Pap smear screening. Interestingly, women with high health literacy were more likely to be a current smoker. Study findings suggest that efforts to improve health promotion behaviors in women should consider health literacy as an important factor and that the effect of health literacy on health prevention behaviors may vary by women's access to care.
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http://dx.doi.org/10.1177/1090198111413126DOI Listing
April 2012