HCAD 9000 Week 8 Discussion Chapter Example

Chapter 5 Discussion: What Acquisition Changed in Referral Information, What Record Conversion Explains and Two Conclusions the Findings Do Not Support

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Walden University

HCAD 9000: Healthcare Administration Dissertation

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Month Day, Year

Chapter 5 Discussion: What Acquisition Changed in Referral Information, What Record Conversion Explains and Two Conclusions the Findings Do Not Support

Answers to the Research Questions

Research Question 1 concerned how complete referral information from acquired practices was, judged against practices the system never bought. Completeness improved: averaged over every period after acquisition, acquired practices gained roughly one of the eight index items more than comparison practices did, at Cedar Basin Health, the composite system studied.

Research Question 2 concerned timeliness, judged the same way. Timeliness improved: the share of referrals with their information available to the specialist ahead of the first appointment climbed 19 percentage points more than in comparison practices.

Research Question 3, added after data collection began and reported as exploratory, asked whether those changes depended on conversion to the system's electronic record. They did: completeness and timeliness were unchanged in the months between acquisition and conversion and rose after conversion, to a level about two items above comparison practices.

Interpretation

The finding on Research Question 3 shapes the reading of the other two. Because nothing changed between acquisition and conversion, the averages reported for Research Questions 1 and 2 combine a period with no change and a period with a large one. The study's results therefore indicate that ownership on its own did not change referral information; the change appeared once acquired practices and specialists used the same record. A reader who took only the first two answers would conclude that acquisition improved referral information. The third answer suggests that the improvement followed a specific operational change that acquisition made possible but did not bring about immediately.

The item-level results point in the same direction. The largest increases were in the current medication list, allergies and recent laboratory results. These are items that a shared electronic record makes visible to the specialist without anyone attaching them; a specialist opening the patient's chart sees the medication list whether or not the referring physician sent it. The items that depend on what the referring physician writes, such as the reason for referral and stated urgency, changed little. The reading that follows is that conversion improved access to information already recorded elsewhere, rather than changing what referring physicians communicated.

The specific clinical question offers the clearest test of that reading. It was present in about 30% of referrals in every group and period, before and after conversion. A shared record does not supply this item, because only the referring physician knows what they want the specialist to answer. The finding that it did not change is consistent with the interpretation that conversion improved access to stored information and did not change referral practice itself.

The timeliness finding follows the same pattern. Before conversion, referral documents from acquired practices still traveled by fax or through the patient, as they did from independent practices. After conversion, documents in the shared record were available to the specialist as soon as they were entered. The rise in timeliness is what this mechanism would produce, and its timing, after conversion rather than after acquisition, matches it.

The Study Among Other Studies

Earlier research established that acquisition changes where referrals go. Carlin et al. (2016) found that acquired practices shifted referrals toward the acquiring hospital. The present results add a second effect: after the shared record arrives, what travels with those referrals changes as well. The two findings fit together: the referrals that integration directs to its own specialists are the ones that, after conversion, arrive with more complete information.

Research on the quality effects of integration has been mixed. Machta et al. (2019) found inconsistent evidence across studies, and Scott et al. (2017) reported that standard hospital quality measures did not improve once hospitals affiliated with physicians. The present study's results suggest one possible reason for these null and mixed findings: if improvements in coordination depend on record conversion, and conversion follows acquisition by more than a year, studies measuring outcomes soon after acquisition may be looking before any operational change has occurred. This is a suggestion about timing, not a claim that integration improves quality, which this study did not measure.

On referral communication itself, O'Malley and Reschovsky (2011) documented that primary care physicians and specialists disagree about how often information is sent and received, and Gandhi et al. (2000) documented frequent gaps in the information specialists receive. This study measured what the specialist actually had before the visit, rather than what physicians reported, and found that before conversion about half of referrals arrived on time with incomplete information. That finding agrees with the earlier work. The persistent absence of a specific clinical question also agrees with it, since earlier studies identified unclear referral purpose as a common complaint among specialists.

Post et al. (2018) found the economic evidence pointing toward higher prices after integration and judged the quality evidence thin. This study does not address prices. Its contribution is to a part of the question that the price literature does not reach: whether integration changes how information moves between clinicians.

Two Readings the Findings Do Not Support

The first reading this study does not support is that acquisition improves care. The study measured the information available to specialists, not diagnoses, treatments or outcomes. More complete referral information is plausibly connected to better specialty visits, but this study did not test that connection, and the improvement in information says nothing on its own about whether patients were better served.

The second reading this study does not support is that record conversion alone produced the change. Conversion coincided with other changes at each acquired practice, including training on the system's referral order and, in some practices, new referral coordinators. The study could not separate these. The finding is that the change followed conversion and not acquisition; what about conversion produced it remains open.

Limitations

Four limitations constrain these conclusions. First, the comparison practices were those that continued to refer to the system's specialists and were not acquired. They may differ from acquired practices in ways that affect referral behavior, such as interest in being acquired; pre-period trends were similar, but similar trends do not rule out every difference. Second, the third research question was added after data collection began, so its results are exploratory and should be confirmed in a study designed to test them. Third, practices that converted late contribute fewer periods after conversion, so the post-conversion estimate rests more heavily on early converters, which may have been better prepared. Fourth, the study covers one system and four specialties; systems with different record platforms or conversion schedules may show different results.

Implications for Further Research

Three lines of research follow. A study linking referral completeness to visit outcomes, such as repeat testing or the need for a second visit, would address the gap between information and care that this study leaves open. A study separating record conversion from the training and staffing changes that accompany it would identify which part of conversion matters. Finally, studies of acquisition's effects on quality would benefit from recording when operational changes such as record conversion occurred, so that their analyses do not average across periods before and after the change.

References

Carlin, C. S., Feldman, R., & Dowd, B. (2016). The impact of hospital acquisition of physician practices on referral patterns. Health Economics, 25(4), 439-454. https://doi.org/10.1002/hec.3160

Gandhi, T. K., Sittig, D. F., Franklin, M., Sussman, A. J., Fairchild, D. G., & Bates, D. W. (2000). Communication breakdown in the outpatient referral process. Journal of General Internal Medicine, 15(9), 626-631. https://doi.org/10.1046/j.1525-1497.2000.91119.x

Machta, R. M., Maurer, K. A., Jones, D. J., Furukawa, M. F., & Rich, E. C. (2019). A systematic review of vertical integration and quality of care, efficiency, and patient-centered outcomes. Health Care Management Review, 44(2), 159-173. https://doi.org/10.1097/HMR.0000000000000197

O'Malley, A. S., & Reschovsky, J. D. (2011). Referral and consultation communication between primary care and specialist physicians: Finding common ground. Archives of Internal Medicine, 171(1), 56-65. https://doi.org/10.1001/archinternmed.2010.480

Post, B., Buchmueller, T., & Ryan, A. M. (2018). Vertical integration of hospitals and physicians: Economic theory and empirical evidence on spending and quality. Medical Care Research and Review, 75(4), 399-433. https://doi.org/10.1177/1077558717727834

Scott, K. W., Orav, E. J., Cutler, D. M., & Jha, A. K. (2017). Changes in hospital-physician affiliations in U.S. hospitals and their effect on quality of care. Annals of Internal Medicine, 166(1), 1-8. https://doi.org/10.7326/M16-0125