The Extent Hospital Organizational Factors Influence Inpatient Care Delivery: A Case Study Looking at Knee and Hip Replacement Surgery.

There is a body of Implementation and Dissemination research describing the importance of "context"-the characteristics describing the setting where a process or innovation occurs-when evaluating delivery, outcomes and cost of health services. These contextual factors, which can occur at the system, organization, or provider level, may either facilitate or erect barriers to the utilization of evidence-based practices and the outcomes achieved. This paper examines the influence of organizational structure and operating environment characteristics of where inpatient health care is delivered, controlling for patient and provider characteristics, on health services delivery and outcomes achieved. We used inpatient cost-of-care to represent the bundle of services provided to patients receiving primary knee and hip replacement procedures. Data includes patient level data from discharge records for 62 140 knee replacements and 42 392 hip replacements from the 2015 AHRQ Healthcare Cost and Utilization Project State Inpatient Discharge database and hospital characteristics from the 2015 American Hospital Association survey. Multi-level linear estimation models controlling for patient and payer characteristics were employed to assess the impact of specific organizational and operating environment factors. We found that although patient and payer characteristics significantly impacted the inpatient cost of care, there is significant variation between hospitals and among physicians within a hospital beyond what can be explained by patient, payer and local price effect characteristics. Organizational and physician characteristics that had the most significant impact on cost of care included the volume of services provided, urban location, and for-profit ownership. These factors can inform future policy and program design and evaluation.