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29. Creating an Operational Definition of Degree of Clinical Integration

AE Sales, VA Puget Sound Health Care System; NR Every, VA Puget Sound Health Care System

Objectives: The primary aim of this paper is to describe methods of operationalizing degree of clinical integration. This is one component of a study in which we test the hypothesis that higher levels of clinical integration in cardiology lead to improved patient outcomes. It has been suggested that more integrated organizations are likely to produce better outcomes than those that are less integrated. A hierarchy of integration has been outlined in which clinical integration (integration among clinical providers) is regarded as the highest form of integration. However, clinical integration is difficult to measure. We describe a set of measures of degree of clinical integration.

Methods: We site-visited ten VA medical centers in five Networks (VISNs 13, 18, 19, 20, 22) included in the study with cardiac catheterization labs. At each tertiary VAMC, we interviewed the Chief of Cardiology, Chief of Staff, and Director using structured interview guides. These probed for detailed information describing the arrangements for referral and consultation between the tertiary centers and its referring facilities. Interviews were conducted by senior investigators in the study. We also mailed survey instruments to all primary care providers and cardiologists in the 26 facilities, both tertiary and non-tertiary, in the study. Areas covered in the mailed instruments included satisfaction with communication and referral, and main method of communicating. Integration variables were created using three separate sources: Chief of Cardiology’s (COC) description of communication structure at both tertiary and non-tertiary facility; Primary Care Providers’ (PCP) assessment of communication between cardiology and primary care; and cardiologists’ assessment of communication.

Results: Each tertiary VAMC has between four and seven non-tertiary facilities referring patients for cardiology services, ranging from non-tertiary hospitals to stand-alone outpatient clinics. The methods and arrangements for consultation and patient referral varied widely across the sites, ranging from tertiary staff cardiologists visiting remote sites to contracting extensively with community cardiology services, to telephone and written contact only with patient referral for complex problems. The COC and Cardiologists’ reports of communication and integration correlate highly while those of PCPs’ do not.

Conclusions: VAMCs vary widely in how cardiology consultation and referral services are arranged. Underlying the different arrangements are differing degrees of clinical integration among the facilities. It is possible to construct one or more variables to describe degree of clinical integration among these facilities. PCPs’ perceptions of communication for cardiology consultation differ from those of cardiologists and Chiefs of Cardiology. It is probable that individual PCPs do not have as much in-depth knowledge of cardiology consultation processes and structures than do specialists in cardiology.

Impact: These results are likely to be of interest to clinicians, managers, and researchers studying organizational integration. Successful measurement of degree of clinical integration, coupled with patient outcome measurement, will assist in making decisions about how best to organize services provision. In addition, understanding differing perception among types of providers may lead to improvements in communication.