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Improving Quality by Aligning Physicians—Exploring Substance Abuse Treatment Centers

NRSA Trainees Research Conference Slide Presentation (Text Version)

By Sayeda Haq

On June 2, 2007, Sayeda Haq made a slide presentation on Improving Quality by Aligning Physicians at the 13th Annual National Research Service Award (NRSA) Trainees Research Conference. This is the text version of the slide presentation. Select to access the slide presentation (Powerpoint® File, 245 KB).

Slide 1

Improving Quality by Aligning Physicians—Exploring Substance Abuse Treatment Centers

Sayeda Haq
Schneider Institute for Health Policy
The Heller School for Social Policy and Management
Brandeis University

Slide 2

Substance Abuse Care & Alignment

Alignment is crucial in SA care as…

Most physicians work for specialized treatment centers, often for multiple organizations
Treatment modalities vary sharply

Diverse treatment philosophy and orientation among all providers
Large number of non-physician providers

Thomas 2007

Slide 3

Quality Chasm in Substance Abuse Care

People with a substance use disorder: 22 million*
People receiving care: 3.5 million*
*2001 (aged 12 or older)
SAMHSA, DHHS Pub #SMA 05-3999, 2005

Effective treatments exist and continually improve.
However, as with general health care, deficiencies in care
delivery prevent many from receiving appropriate
treatments.
IOM Quality Chasm Series, 2006

Slide 4

New Medication - Buprenorphine

Offers several clinical advantages over Methadone

Can be prescribed in physicians' office
Does not have severe withdrawal symptoms
Daily dosing not needed due to long-acting effects
No detectable 'high'

2000: Federal Legislation allows MDs to prescribe in office visits
2002: FDA approves outpatient prescription

However…

Four years after legislation, not incorporated into common
treatment of substance abuse

Slide 5

An Alignment Problem?

In multivariate result, organizational support remained important in MD's adoption decision, after controlling for MD demographics, case mix, practice characteristics etc. Chart depicts the following:

When Organization Recommends:

MD Prescribes: 74%
MD Does Not Prescribe: 26%

When Organization Does Not Recommend:

MD Prescribes: 44%
MD Does Not Prescribe: 56%

Thomas 2007

Slide 6

What Determines Alignment?

Financial incentives - most studied domain
Administrative strategies, e.g. utilization review, referral
requirements

Significant number of studies

Structural characteristics of organization, e.g. location of
practice site, availability of services, supporting staff and
governance style

Some studies

Normative influence, e.g. formal and informal interaction
and feedback from professional colleagues, organizational
culture

Very few studies
Difficult to measure

Landon et al (1998)

Slide 7

Conceptual Framework

	Enabling	Coercive
High Formalization	*Enabling bureaucracy* Encourage motivation based on identification Efficiencies of high formalization as well as positive attitudinal outcomes	*Mechanistic* Negative attitudinal outcomes, low levels of motivation/satisfaction Formalization seen as a necessary evil
Low Formalization	*Organic* Empowers employees in non-routine tasks Encourage motivation based on identification, positive attitudinal outcomes	*Autocratic* Negative attitudinal outcomes, low levels of motivation/satisfaction

Adler and Borys, 1996

Slide 8

Research Question & Hypotheses

What specific structural or normative strategies used by organizations are effective in aligning physicians?

Physicians' alignment (loyalty, commitment) increases when:

Organizations offer value-added services, such as training, supporting staff, etc.
Governance-style is consensus-based and participatory.
Leadership shares information leading to goal-congruence.
Free flow of information, frank discussion of failures, collegial relationship exists among employees.

Slide 9

Analytical Model

Organizations:

Treatment
Organization

Strategies (independent variables):

Structural
- Value-added
- Operational

Normative/informative
- Formal
- Informal

Alignment (dependent variable):

When organization adopts and affiliated MDs prescribe

Bulleted items are in three boxes. Arrows go from the first box (Treatment and Organization) to the second box (Structural and Normative/informative) to the third box (When organization adopts and affiliated MDs prescribe).

Slide 10

Sample – Study Population

Part of a larger study by Schneider Institute

MD Survey – Addiction specialists and facility directors
- N = 271 (69% response rate)
Organization survey – Facility directors
- N = 125 (51% response rate)
Analysis on merged dataset
- N = 72 MDs, representing 46 organizations
- Unit of analysis is respondents (N = 72)
- Aligned = 24 (33%); Not-aligned = 48 (67%)
- 6-point scale independent variables
  - 1 through 4: not much
  - 5,6: very much

Slide 11

Preliminary (Bivariate) findings

Structural	Structural	Structural	% Aligned	% Non-Aligned
Value-added	Orgs encourage training*	Very much	46	54
Value-added	Orgs encourage training*	Not much	26	74
Operational	Whole team involved in clinical decisions**	Very much	46	54
Operational	Whole team involved in clinical decisions**	Not much	13	87

Normative	Normative	Normative	% Aligned	% Non-Aligned
Formal	General agreement on opiate Tx method*	Very much	50	50
Formal	General agreement on opiate Tx method*	Not much	26	74
Informal	Med Dir perceived as sharing medical info***	Very much	51	49
Informal	Med Dir perceived as sharing medical info***	Not much	14	86
Informal	Strong identification w/org. mission**	Very much	41	59
Informal	Strong identification w/org. mission**	Not much	0	100

* p-value < 0.1, ** p-value < 0.05, *** p-value < 0.01

Slide 12

Research Implications

Health services research is consistent with broader organizational theory of governance
Organizations indeed affect physician's practice-behavior
This study explicitly measures, specifies and evaluates strategies that organizations can adopt to align autonomous professionals
Policy Implication
- Findings help bridge the gap between knowledge and practice both in SA treatment and in general health care system

Current as of October 2007

Internet Citation:

Haq, Sayeda. Improving Quality by Aligning Physicians—Exploring Substance Abuse Treatment Centers. Text Version of a Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/fund/training/haqtxt.htm