Skip to main content
NCBI home page
Health Services Research logoLink to Health Services Research
. 1998 Jun;33(2 Pt 2):354–380.

Organizational structure and the delivery of primary care to older Americans.

J S Zinn 1, V Mor 1
PMCID: PMC1070356  PMID: 9618675

Abstract

OBJECTIVE: To explore how internal factors, such as organizational size, mission, ownership, and managerial communication and control structures, affect the delivery of primary care to older Americans across a wide variety of practice settings: ambulatory practices, hospitals, nursing homes, and home healthcare agencies. DESIGN: Use of the structure/process/outcome paradigm and contingency theory to examine the empirical research linking structural factors to outcomes. CONCLUSION: Using these studies as a background, we consider the implications for the provision of primary care to older Americans including the impact of evolving intraorganizational structure in healthcare organization.

Full text

PDF
354

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Aaronson W. E., Zinn J. S., Rosko M. D. Do for-profit and not-for-profit nursing homes behave differently? Gerontologist. 1994 Dec;34(6):775–786. doi: 10.1093/geront/34.6.775. [DOI] [PubMed] [Google Scholar]
  2. Applebaum R., Phillips P. Assuring the quality of in-home care: the "other" challenge for long-term care. Gerontologist. 1990 Aug;30(4):444–450. doi: 10.1093/geront/30.4.444. [DOI] [PubMed] [Google Scholar]
  3. Applegate W., Deyo R., Kramer A., Meehan S. Geriatric evaluation and management: current status and future research directions. J Am Geriatr Soc. 1991 Sep;39(9 Pt 2):2S–7S. doi: 10.1111/j.1532-5415.1991.tb05926.x. [DOI] [PubMed] [Google Scholar]
  4. Bachman S. S., Collard A. F., Greenberg J. N., Fountain E., Huebner T. W., Kimball B., Melendy K. An innovative approach to geriatric acute care delivery: the Choate-Symmes experience. Hosp Health Serv Adm. 1987 Nov;32(4):509–520. [PubMed] [Google Scholar]
  5. Barr D. A. The effects of organizational structure on primary care outcomes under managed care. Ann Intern Med. 1995 Mar 1;122(5):353–359. doi: 10.7326/0003-4819-122-5-199503010-00006. [DOI] [PubMed] [Google Scholar]
  6. Beers M. H., Fingold S. F., Ouslander J. G., Reuben D. B., Morgenstern H., Beck J. C. Characteristics and quality of prescribing by doctors practicing in nursing homes. J Am Geriatr Soc. 1993 Aug;41(8):802–807. doi: 10.1111/j.1532-5415.1993.tb06173.x. [DOI] [PubMed] [Google Scholar]
  7. Boult C., Boult L., Murphy C., Ebbitt B., Luptak M., Kane R. L. A controlled trial of outpatient geriatric evaluation and management. J Am Geriatr Soc. 1994 May;42(5):465–470. doi: 10.1111/j.1532-5415.1994.tb04965.x. [DOI] [PubMed] [Google Scholar]
  8. Branco K., Teno J., Mor V. Advance care planning among nursing home residents prior to the Patient Self-Determination Act. J Health Soc Policy. 1995;7(1):37–52. doi: 10.1300/j045v07n01_03. [DOI] [PubMed] [Google Scholar]
  9. Brook R. H., Kamberg C. J., Lohr K. N., Goldberg G. A., Keeler E. B., Newhouse J. P. Quality of ambulatory care. Epidemiology and comparison by insurance status and income. Med Care. 1990 May;28(5):392–433. [PubMed] [Google Scholar]
  10. Brown R. S., Clement D. G., Hill J. W., Retchin S. M., Bergeron J. W. Do health maintenance organizations work for Medicare? Health Care Financ Rev. 1993 Fall;15(1):7–23. [PMC free article] [PubMed] [Google Scholar]
  11. Burns L. R. Medical organization structures that promote quality and efficiency: past research and future considerations. Qual Manag Health Care. 1995 Summer;3(4):10–18. doi: 10.1097/00019514-199503040-00002. [DOI] [PubMed] [Google Scholar]
  12. Burns L. R., Wholey D. R. The effects of patient, hospital, and physician characteristics on length of stay and mortality. Med Care. 1991 Mar;29(3):251–271. doi: 10.1097/00005650-199103000-00007. [DOI] [PubMed] [Google Scholar]
  13. Cavalieri T. A., Chopra A., Gray-Miceli D., Shreve S., Waxman H., Forman L. J. Geriatric assessment teams in nursing homes: do they work? J Am Osteopath Assoc. 1993 Dec;93(12):1269–1272. [PubMed] [Google Scholar]
  14. Dansky K. H., Brannon D., Wangsness S. Human resources management practices and patient satisfaction in home health care. Home Health Care Serv Q. 1994;15(1):43–56. doi: 10.1300/J027v15n01_04. [DOI] [PubMed] [Google Scholar]
  15. Davis M. A. On nursing home quality: a review and analysis. Med Care Rev. 1991 Summer;48(2):129–166. doi: 10.1177/002570879104800202. [DOI] [PubMed] [Google Scholar]
  16. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966 Jul;44(3 Suppl):166–206. [PubMed] [Google Scholar]
  17. Epstein A. M., Hall J. A., Fretwell M., Feldstein M., DeCiantis M. L., Tognetti J., Cutler C., Constantine M., Besdine R., Rowe J. Consultative geriatric assessment for ambulatory patients. A randomized trial in a health maintenance organization. JAMA. 1990 Jan 26;263(4):538–544. [PubMed] [Google Scholar]
  18. Eustis N. N., Kane R. A., Fischer L. R. Home care quality and the home care worker: beyond quality assurance as usual. Gerontologist. 1993 Feb;33(1):64–73. doi: 10.1093/geront/33.1.64. [DOI] [PubMed] [Google Scholar]
  19. Farley D. E., Ozminkowski R. J. Volume-outcome relationships and in-hospital mortality: the effect of changes in volume over time. Med Care. 1992 Jan;30(1):77–94. doi: 10.1097/00005650-199201000-00009. [DOI] [PubMed] [Google Scholar]
  20. Fleming G. V. Hospital structure and consumer satisfaction. Health Serv Res. 1981 Spring;16(1):43–63. [PMC free article] [PubMed] [Google Scholar]
  21. Fleming S. T. Primary care, avoidable hospitalization, and outcomes of care: a literature review and methodological approach. Med Care Res Rev. 1995 Mar;52(1):88–108. doi: 10.1177/107755879505200106. [DOI] [PubMed] [Google Scholar]
  22. Flood A. B., Scott W. R., Ewy W. Does practice make perfect? Part I: The relation between hospital volume and outcomes for selected diagnostic categories. Med Care. 1984 Feb;22(2):98–114. [PubMed] [Google Scholar]
  23. Flood A. B., Scott W. R., Ewy W., Forrest W. H., Jr Effectiveness in professional organizations: the impact of surgeons and surgical staff organizations on the quality of care in hospitals. Health Serv Res. 1982 Winter;17(4):341–366. [PMC free article] [PubMed] [Google Scholar]
  24. Flood A. B. The impact of organizational and managerial factors on the quality of care in health care organizations. Med Care Rev. 1994 Winter;51(4):381–428. doi: 10.1177/107755879405100402. [DOI] [PubMed] [Google Scholar]
  25. Gustafson D. H., Hundt A. S. Findings of innovation research applied to quality management principles for health care. Health Care Manage Rev. 1995 Spring;20(2):16–33. [PubMed] [Google Scholar]
  26. Hannan E. L., O'Donnell J. F., Kilburn H., Jr, Bernard H. R., Yazici A. Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals. JAMA. 1989 Jul 28;262(4):503–510. [PubMed] [Google Scholar]
  27. Hughes R. G., Hunt S. S., Luft H. S. Effects of surgeon volume and hospital volume on quality of care in hospitals. Med Care. 1987 Jun;25(6):489–503. doi: 10.1097/00005650-198706000-00004. [DOI] [PubMed] [Google Scholar]
  28. Hulka B. S., Romm F. J., Parkerson G. R., Jr, Russell I. T., Clapp N. E., Johnson F. S. Peer review in ambulatory care: use of explicit criteria and implicit judgments. Med Care. 1979 Mar;17(3 Suppl):i-vi, 1-73. [PubMed] [Google Scholar]
  29. Kane R. A., Kane R. L. Long-term care: variations on a quality assurance theme. Inquiry. 1988 Spring;25(1):132–146. [PubMed] [Google Scholar]
  30. Kane R. L., Gardner J., Wright D. D., Snell G., Sundwall D., Woolley F. R. Relationship between process and outcome in ambulatory care. Med Care. 1977 Nov;15(11):961–965. doi: 10.1097/00005650-197711000-00010. [DOI] [PubMed] [Google Scholar]
  31. Karuza J., Katz P. R. Physician staffing patterns correlates of nursing home care: an initial inquiry and consideration of policy implications. J Am Geriatr Soc. 1994 Jul;42(7):787–793. doi: 10.1111/j.1532-5415.1994.tb06543.x. [DOI] [PubMed] [Google Scholar]
  32. Kayser-Jones J. S., Wiener C. L., Barbaccia J. C. Factors contributing to the hospitalization of nursing home residents. Gerontologist. 1989 Aug;29(4):502–510. doi: 10.1093/geront/29.4.502. [DOI] [PubMed] [Google Scholar]
  33. Kelly J. V., Hellinger F. J. Physician and hospital factors associated with mortality of surgical patients. Med Care. 1986 Sep;24(9):785–800. doi: 10.1097/00005650-198609000-00001. [DOI] [PubMed] [Google Scholar]
  34. Knaus W. A., Draper E. A., Wagner D. P., Zimmerman J. E. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med. 1986 Mar;104(3):410–418. doi: 10.7326/0003-4819-104-3-410. [DOI] [PubMed] [Google Scholar]
  35. Kochersberger G., Hielema F., Westlund R. Rehabilitation in the nursing home: how much, why, and with what results. Public Health Rep. 1994 May-Jun;109(3):372–376. [PMC free article] [PubMed] [Google Scholar]
  36. Kramer A. M., Shaughnessy P. W., Bauman M. K., Crisler K. S. Assessing and assuring the quality of home health care: a conceptual framework. Milbank Q. 1990;68(3):413–443. [PubMed] [Google Scholar]
  37. Kruzich J. M., Clinton J. F., Kelber S. T. Personal and environmental influences on nursing home satisfaction. Gerontologist. 1992 Jun;32(3):342–350. doi: 10.1093/geront/32.3.342. [DOI] [PubMed] [Google Scholar]
  38. Leatt P., Schneck R. Nursing subunit technology: a replication. Adm Sci Q. 1981 Jun;26(2):225–236. [PubMed] [Google Scholar]
  39. Lindsay M. I., Jr, Hermans P. E., Nobrega F. T., Ilstrup D. M. Quality-of-care assessment. I. Outpatient management of acute bacterial cystitis as the model. Mayo Clin Proc. 1976 May;51(5):307–312. [PubMed] [Google Scholar]
  40. Linn M. W., Gurel L., Linn B. S. Patient outcome as a measure of quality of nursing home care. Am J Public Health. 1977 Apr;67(4):337–344. doi: 10.2105/ajph.67.4.337. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Lohr K. N., Donaldson M. S. Assuring quality of care for the elderly. Law Med Health Care. 1990 Fall;18(3):244–253. doi: 10.1111/j.1748-720x.1990.tb00027.x. [DOI] [PubMed] [Google Scholar]
  42. Luft H. S., Bunker J. P., Enthoven A. C. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979 Dec 20;301(25):1364–1369. doi: 10.1056/NEJM197912203012503. [DOI] [PubMed] [Google Scholar]
  43. Luft H. S., Hunt S. S., Maerki S. C. The volume-outcome relationship: practice-makes-perfect or selective-referral patterns? Health Serv Res. 1987 Jun;22(2):157–182. [PMC free article] [PubMed] [Google Scholar]
  44. Lurie N., Christianson J., Finch M., Moscovice I. The effects of capitation on health and functional status of the Medicaid elderly. A randomized trial. Ann Intern Med. 1994 Mar 15;120(6):506–511. doi: 10.7326/0003-4819-120-6-199403150-00010. [DOI] [PubMed] [Google Scholar]
  45. Maerki S. C., Luft H. S., Hunt S. S. Selecting categories of patients for regionalization. Implications of the relationship between volume and outcome. Med Care. 1986 Feb;24(2):148–158. doi: 10.1097/00005650-198602000-00006. [DOI] [PubMed] [Google Scholar]
  46. Meissner P., Andolsek K., Mears P. A., Fletcher B. Maximizing the functional status of geriatric patients in an acute community hospital setting. Gerontologist. 1989 Aug;29(4):524–528. doi: 10.1093/geront/29.4.524. [DOI] [PubMed] [Google Scholar]
  47. Miller R. H., Luft H. S. Managed care plan performance since 1980. A literature analysis. JAMA. 1994 May 18;271(19):1512–1519. [PubMed] [Google Scholar]
  48. Mor V., Rice C. Physician use among patients receiving cancer chemotherapy. Cancer. 1993 Jan 1;71(1):219–225. doi: 10.1002/1097-0142(19930101)71:1<219::aid-cncr2820710134>3.0.co;2-o. [DOI] [PubMed] [Google Scholar]
  49. Nyman J. A. Improving the quality of nursing home outcomes. Are adequacy- or incentive-oriented policies more effective? Med Care. 1988 Dec;26(12):1158–1171. doi: 10.1097/00005650-198812000-00006. [DOI] [PubMed] [Google Scholar]
  50. Oxman A. D., Thomson M. A., Davis D. A., Haynes R. B. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995 Nov 15;153(10):1423–1431. [PMC free article] [PubMed] [Google Scholar]
  51. Palmer R. H., Louis T. A., Hsu L. N., Peterson H. F., Rothrock J. K., Strain R., Thompson M. S., Wright E. A. A randomized controlled trial of quality assurance in sixteen ambulatory care practices. Med Care. 1985 Jun;23(6):751–770. doi: 10.1097/00005650-198506000-00001. [DOI] [PubMed] [Google Scholar]
  52. Payne B. C., Lyons T. F., Neuhaus E. Relationships of physician characteristics to performance quality and improvement. Health Serv Res. 1984 Aug;19(3):307–332. [PMC free article] [PubMed] [Google Scholar]
  53. Proenca E. J. Why outcomes management doesn't (always) work: an organizational perspective. Qual Manag Health Care. 1995 Summer;3(4):1–9. doi: 10.1097/00019514-199503040-00001. [DOI] [PubMed] [Google Scholar]
  54. Rhee S. O. Factors determining the quality of physician performance in patient care. Med Care. 1976 Sep;14(9):733–750. doi: 10.1097/00005650-197609000-00002. [DOI] [PubMed] [Google Scholar]
  55. Rhee S. O., Luke R. D., Lyons T. F., Payne B. C. Domain of practice and the quality of physician performance. Med Care. 1981 Jan;19(1):14–23. doi: 10.1097/00005650-198101000-00003. [DOI] [PubMed] [Google Scholar]
  56. Riley G., Lubitz J. Outcomes of surgery among the Medicare aged: surgical volume and mortality. Health Care Financ Rev. 1985 Fall;7(1):37–47. [PMC free article] [PubMed] [Google Scholar]
  57. Rohrer J. E., Momany E. T., Chang W. Organizational predictors of outcomes of long-stay nursing home residents. Soc Sci Med. 1993 Aug;37(4):549–554. doi: 10.1016/0277-9536(93)90290-k. [DOI] [PubMed] [Google Scholar]
  58. Romm F. J., Hulka B. S. Peer review in diabetes and hypertension: the relationship between care process and patient outcome. South Med J. 1980 May;73(5):564–568. doi: 10.1097/00007611-198005000-00006. [DOI] [PubMed] [Google Scholar]
  59. Ross C. E., Duff R. S. Quality of outpatient pediatric care: the influence of physicians' background, socialization, and work/information environment on performance. J Health Soc Behav. 1978 Dec;19(4):348–360. [PubMed] [Google Scholar]
  60. Rubin H. R., Gandek B., Rogers W. H., Kosinski M., McHorney C. A., Ware J. E., Jr Patients' ratings of outpatient visits in different practice settings. Results from the Medical Outcomes Study. JAMA. 1993 Aug 18;270(7):835–840. [PubMed] [Google Scholar]
  61. Safran D. G., Tarlov A. R., Rogers W. H. Primary care performance in fee-for-service and prepaid health care systems. Results from the Medical Outcomes Study. JAMA. 1994 May 25;271(20):1579–1586. [PubMed] [Google Scholar]
  62. Sainfort F., Ramsay J. D., Monato H., Jr Conceptual and methodological sources of variation in the measurement of nursing facility quality: an evaluation of 24 models and an empirical study. Med Care Res Rev. 1995 Mar;52(1):60–87. doi: 10.1177/107755879505200105. [DOI] [PubMed] [Google Scholar]
  63. Shaughnessy P. W., Schlenker R. E., Hittle D. F. Home health care outcomes under capitated and fee-for-service payment. Health Care Financ Rev. 1994 Fall;16(1):187–222. [PMC free article] [PubMed] [Google Scholar]
  64. Sheridan J. E., White J., Fairchild T. J. Ineffective staff, ineffective supervision, or ineffective administration? Why some nursing homes fail to provide adequate care. Gerontologist. 1992 Jun;32(3):334–341. doi: 10.1093/geront/32.3.334. [DOI] [PubMed] [Google Scholar]
  65. Shortell S. M., LoGerfo J. P. Hospital medical staff organization and quality of care: results for myocardial infarction and appendectomy. Med Care. 1981 Oct;19(10):1041–1055. doi: 10.1097/00005650-198110000-00006. [DOI] [PubMed] [Google Scholar]
  66. Shortell S. M., Zimmerman J. E., Rousseau D. M., Gillies R. R., Wagner D. P., Draper E. A., Knaus W. A., Duffy J. The performance of intensive care units: does good management make a difference? Med Care. 1994 May;32(5):508–525. doi: 10.1097/00005650-199405000-00009. [DOI] [PubMed] [Google Scholar]
  67. Showstack J. A., Rosenfeld K. E., Garnick D. W., Luft H. S., Schaffarzick R. W., Fowles J. Association of volume with outcome of coronary artery bypass graft surgery. Scheduled vs nonscheduled operations. JAMA. 1987 Feb 13;257(6):785–789. [PubMed] [Google Scholar]
  68. Silverman M., Musa D., Martin D. C., Lave J. R., Adams J., Ricci E. M. Evaluation of outpatient geriatric assessment: a randomized multi-site trial. J Am Geriatr Soc. 1995 Jul;43(7):733–740. doi: 10.1111/j.1532-5415.1995.tb07041.x. [DOI] [PubMed] [Google Scholar]
  69. Sloan F. A., Perrin J. M., Valvona J. In-hospital mortality of surgical patients: is there an empiric basis for standard setting? Surgery. 1986 Apr;99(4):446–454. [PubMed] [Google Scholar]
  70. Spector W. D., Takada H. A. Characteristics of nursing homes that affect resident outcomes. J Aging Health. 1991 Nov;3(4):427–454. doi: 10.1177/089826439100300401. [DOI] [PubMed] [Google Scholar]
  71. Stuck A. E., Siu A. L., Wieland G. D., Adams J., Rubenstein L. Z. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet. 1993 Oct 23;342(8878):1032–1036. doi: 10.1016/0140-6736(93)92884-v. [DOI] [PubMed] [Google Scholar]
  72. Teresi J., Holmes D., Benenson E., Monaco C., Barrett V., Ramirez M., Koren M. J. A primary care nursing model in long-term care facilities: evaluation of impact on affect, behavior, and socialization. Gerontologist. 1993 Oct;33(5):667–674. doi: 10.1093/geront/33.5.667. [DOI] [PubMed] [Google Scholar]
  73. Weiner J. P., Parente S. T., Garnick D. W., Fowles J., Lawthers A. G., Palmer R. H. Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes. JAMA. 1995 May 17;273(19):1503–1508. doi: 10.1001/jama.273.19.1503. [DOI] [PubMed] [Google Scholar]
  74. Weissert W. C., Scanlon W. J. Determinants of nursing home discharge status. Med Care. 1985 Apr;23(4):333–343. doi: 10.1097/00005650-198504000-00005. [DOI] [PubMed] [Google Scholar]
  75. Wells K. B., Manning W. G., Jr, Valdez R. B. The effects of a prepaid group practice on mental health outcomes. Health Serv Res. 1990 Oct;25(4):615–625. [PMC free article] [PubMed] [Google Scholar]
  76. Yordi C. L., Waldman J. A consolidated model of long-term care: service utilization and cost impacts. Gerontologist. 1985 Aug;25(4):389–397. doi: 10.1093/geront/25.4.389. [DOI] [PubMed] [Google Scholar]
  77. Zimmer J. G., Groth-Juncker A., McCusker J. A randomized controlled study of a home health care team. Am J Public Health. 1985 Feb;75(2):134–141. doi: 10.2105/ajph.75.2.134. [DOI] [PMC free article] [PubMed] [Google Scholar]
  78. Zinn J. S., Aaronson W. E., Rosko M. D. Variations in the outcomes of care provided in Pennsylvania nursing homes. Facility and environmental correlates. Med Care. 1993 Jun;31(6):475–487. doi: 10.1097/00005650-199306000-00001. [DOI] [PubMed] [Google Scholar]
  79. Zinn J. S., Brannon D., Mor V. Organizing for nursing home quality. Qual Manag Health Care. 1995 Summer;3(4):37–46. doi: 10.1097/00019514-199503040-00005. [DOI] [PubMed] [Google Scholar]

Articles from Health Services Research are provided here courtesy of Health Research & Educational Trust

RESOURCES