Papers by Nathalie McIntosh
Medical Care, Jul 9, 2020
Background: Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may... more Background: Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination. Objective: The objective of this study was to determine VA patients' and clinicians' experiences of coordination across VA and non-VA settings. Design: Observational mixed methods using patient surveys and clinician interviews. Sampled patients were diagnosed with type 2 diabetes mellitus and either cardiovascular or mental health comorbidities. Participants and Measures: Patient perspectives on coordination were elicited between April and September 2016 through a national survey supplemented with VA administrative records (N = 5372). Coordination was measured with the 8-dimension Patient Perceptions of Integrated Care survey. Receipt of non-VA care was measured through patient selfreport. Clinician perspectives were elicited through individual interviews (N = 100) between May and October 2017. Results: Veterans who received both VA and non-VA care reported significantly worse care coordination experiences than Veterans who only receive care in VA. Clinicians report limited information exchange capabilities, which, combined with bureaucratic and opaque procedures, adversely impact clinical decision-making. Conclusions: VA is working through a shift in how Veterans receive health care by increasing access to care from non-VA providers. Study findings suggest that VA should prioritize coordination of care in addition to access. This could include requiring monitoring of patient-experienced care coordination, surveys of referring and consulting clinicians, and pilot testing and evaluation of interventions to improve coordination.
American journal of medical genetics, 1991
In 1971, Costello described a new syndrome in 2 patients. The major clinical findings comprise sh... more In 1971, Costello described a new syndrome in 2 patients. The major clinical findings comprise short stature; redundant skin of the neck, palms, soles, and fingers; curly hair; relative macrocephaly; depressed nasal bridge; papillomata around the mouth and nares; distinct facial gestalt; hyperextensible joints; and mental retardation. We present a third patient and review the manifestations of this condition.
The Permanente Journal, Dec 1, 2017
Introduction: Health care sector corruption diverts resources that could otherwise be used to imp... more Introduction: Health care sector corruption diverts resources that could otherwise be used to improve access to health services. Use of private-sector practices such as a public-private partnership (PPP) model for hospital governance and management may reduce corruption. In 2011, a government-run hospital in Lesotho was replaced by a PPP hospital, offering an opportunity to compare hospital systems and practices. Objective: To assess whether a PPP model in a hospital can help curb corruption. Methods: We conducted 36 semistructured interviews with key informants between February 2013 and April 2013. We asked about hospital operations and practices at the government-run and PPP hospitals. We performed content analysis of interview data using a priori codes derived from the Corruption in the Health Sector framework and compared themes related with corruption between the hospitals. Results: Corrupt practices that were described at the government-run hospital (theft, absenteeism, and shirking) were absent in the PPP hospital. In the PPP hospital, anticorruption mechanisms (controls on discretion, transparency, accountability, and detection and enforcement) were described in four management subsystems: human resources, facility and equipment management, drug supply, and security. Conclusion: The PPP hospital appeared to reduce corruption by controlling discretion and increasing accountability, transparency, and detection and enforcement. Changes imposed new norms that supported personal responsibility and minimized opportunities, incentives, and pressures to engage in corrupt practices. By implementing private-sector management practices, a PPP model for hospital governance and management may curb corruption. To assess the feasibility of a PPP, administrators should account for cost savings resulting from reduced corruption.
Prenatal Diagnosis, Nov 1, 1993
Data from 2907 transcervical CVS cases performed on singleton pregnancies were reviewed retrospec... more Data from 2907 transcervical CVS cases performed on singleton pregnancies were reviewed retrospectively and villus sample size was correlated with cytogenetic results, placental location, maternal age at the expected date of confinement (EDC), gestational age at the time of sampling, birth weight, gestational age at the time of delivery, and pregnancy outcome. No correlation was noted between villus sample size and maternal age, gestational age at sampling, gestational age at delivery, birth weight, or pregnancy outcome. An inverse correlation between villus sample size and percentage of abnormal cytogenetic findings was statistically significant (X2 = 8·53, p <0·01). The percentage of small samples was greater when the placenta was anterior, lateral, or fundal than when the placenta was posterior.
Journal of Genetic Counseling, Jul 29, 2006
Games are defined as ongoing series of complementary ulterior transactions that are superficially... more Games are defined as ongoing series of complementary ulterior transactions that are superficially plausible but have a concealed motivation to maximize pay‐offs and minimize penalties for the initiator. While some games are harmless and part of socialization, others are destructive. Destructive game‐playing in clinical supervision, in which game‐playing (initiated by either supervisors or students) interferes with a student's realization of internship goals, has been documented in some allied healthcare professions but has not yet been studied in genetic counseling. Genetic counselors and clinical supervisors of genetic counseling students were anonymously surveyed regarding their experiences with destructive game‐playing. Results show that such games do occur in genetic counseling clinical supervision. Some games are the same or similar to ones previously described in other health‐care professions; others may be unique to genetic counseling. The purpose of this paper is to document these games as a first step to facilitating dialogue, understanding and awareness of them.
Journal of General Internal Medicine, May 1, 2019
Health systems and reform, Feb 17, 2015
CONTENTS Introduction Background of the Lesotho PPP Methods Results Discussion Limitations Conclu... more CONTENTS Introduction Background of the Lesotho PPP Methods Results Discussion Limitations Conclusions and Implications References Abstract-Public-private partnerships (PPPs) seek to expand access to quality health services in ways that best leverage the capacities and resources of both sectors. There are few examples of PPPs in the hospital sector in developing countries, and little is known about how the involvement of the private sector transforms the delivery of health services in this context. In 2006, the government of Lesotho adopted a PPP approach for the health sector, contracting out to design, build, and operate a hospital network in its capital district. This case study examines differences between a government-run hospital and the PPP-run hospital that replaced it, using in-depth interviews with key informants, observation of management systems, and document review. Key informants emphasized changes in infrastructure, communication, human resource management, and organizational culture that improved quality and demand for services. Important drivers of improved performance included better defined policies and procedures, empowerment and training of managers and staff, and increased accountability. Well-functioning support systems kept the hospital clean and equipment functioning, reduced stock-outs, and allowed staff to do the jobs they were trained to do. The Lesotho PPP model provides insight into the mechanisms by which publicprivate partnerships may increase access and quality of care.
Health Affairs, Jun 1, 2015
Health care public-private partnerships (PPPs) between a government and the private sector are ba... more Health care public-private partnerships (PPPs) between a government and the private sector are based on a business model that aims to leverage private-sector expertise to improve clinical performance in hospitals and other health facilities. Although the financial implications of such partnerships have been analyzed, few studies have examined the partnerships' impact on clinical performance outcomes. Using quantitative measures that reflected capacity, utilization, clinical quality, and patient outcomes, we compared a government-managed hospital network in Lesotho, Africa, and the new PPP-managed hospital network that replaced it. In addition, we used key informant interviews to help explain differences in performance. We found that the PPPmanaged network delivered more and higher-quality services and achieved significant gains in clinical outcomes, compared to the government-managed network. We conclude that health care publicprivate partnerships may improve hospital performance in developing countries and that changes in management and leadership practices might account for differences in clinical outcomes.
Journal of General Internal Medicine, Sep 20, 2022
Thesis (Ph.D.)--Boston UniversityHospitals are increasingly providing services for more medically... more Thesis (Ph.D.)--Boston UniversityHospitals are increasingly providing services for more medically complicated patients who require the care of multiple providers. This results in complex interdependent work relationships that require coordination to optimize patient care. Consequently, coordination-- especially between nurses and physicians who constitute the main providers of care-- may play an increasingly important role in the provision of quality care to hospitalized patients. Three studies were done to examine the role of intra- and interprofessional coordination of nurses and physicians in inpatient medical care. All were cross-sectional, descriptive studies using multivariate linear regression methodology, with data aggregated and analyzed at the facility level. Both primary data obtained from surveys of nurse managers, attending physicians and chiefs of medicine, and secondary data obtained from surveys of staff nurses and administrative data sources were used. Study One: The impact of provider coordination on provider perceptions of patient care and job satisfaction in inpatient medicine examined the association between intra- and interprofessional coordination and provider perceptions of the quality of patient care, and provider job satisfaction and intent to leave. Study Two: Organizational predictors of provider perceptions of coordination in inpatient medicine examined the association between organizational factors and provider perceptions of inpatient coordination. Study Three: The impact of provider coordination on patient outcomes examined the association between perceptions of intra- and interprofessional coordination and patient satisfaction; in-hospital fall, pressure ulcer, readmission and mortality rates; hospital costs; and lengths of stay. These studies contribute to the literature by assessing the impact of perceived coordination on patient and provider outcomes, and by identifying the organizational factors associated with perceptions of coordination. Results indicated that greater intra- and/ or interprofessional coordination may be associated with: better provider perceptions of patient care, patient satisfaction, and physician job satisfaction; higher hospital costs; and lower provider intent to leave and mortality rates. An organization's explicit commitment to patient care, to resources that enable providers to do their jobs, and to strategies that enhance communication between providers may improve coordination. Some factors, such as appropriate staffing, may be pre-requisites before coordination can have an impact on some patient outcomes
Journal of Genetic Counseling, Feb 1, 2003
Is there a “Down syndrome” personality? Genetics and Mental Retardation Syndrome: A New Look at B... more Is there a “Down syndrome” personality? Genetics and Mental Retardation Syndrome: A New Look at Behavior and Interventions by Elisabeth M. Dykens, Robert M. Hodapp, and Brenda M. Finucane makes a strong argument that there is. The book summarizes what is currently known about the behavioral characteristics of nine genetic syndromes (Down syndrome, Williams syndrome, fragile X syndrome, Prader–Willi syndrome, velocardiofacial syndrome, Rubinstein–Taybi syndrome, Smith–Magenis syndrome, Angelman syndrome, and 5p-syndrome) and suggests that genetic disorders affect many aspects of behavior, from cognition and language to adaptive and maladaptive behaviors. This may not seem new to some (at least intuitively), but the study of etiologybased behavior in genetic conditions is in its infancy and surprisingly few studies have been done to delineate the behaviors and learning profiles of individuals using etiology-based criteria. While behavioral scientists have traditionally done studies grouping individuals by IQ or other non etiology-based criteria, geneticists have traditionally taken an alternative approach by characterizing the medical aspects of each genetic syndrome and, apart from brief references to unusual behavior or cognition, paid little attention to the subtleties of the learning profiles or behaviors of their patients. The authors, a child clinical psychologist, a developmental psychologist, and a genetic counselor, bring an understanding of both the genetic and behavioral psychology literatures, and build a bridge between the two that combines the wealth of information that behavioral psychologists and others have amassed pertaining to individuals with mental retardation, and made sense of it from an genetic etiologybased point of view. The book is organized into three sections. The first is divided into two chapters. One chapter gives an overview of issues related to defining and measuring behavioral phenotypes and the other is an introduction to genetics. These chapters, especially the one on behavioral issues (from a genetic counselor point of view), are necessary to understand the behavioral information presented later.
American journal of medical genetics, Feb 1, 1992
The Ebstein anomaly is a rare congenital heart disease involving the position and structure of th... more The Ebstein anomaly is a rare congenital heart disease involving the position and structure of the tricuspid valve. Although most cases are sporadic, familial occurrence has been documented. We report on 2 sisters, born to consanguineous parents, who were diagnosed prenatally with severe Ebstein anomaly.
Medical Care, 2022
Background-Care coordination is critical for patients with multiple chronic conditions, but fragm... more Background-Care coordination is critical for patients with multiple chronic conditions, but fragmentation of care persists. Providers' perspectives of facilitators and barriers to coordination are needed to improve care. Objectives-We sought to understand providers' perspectives on care coordination for patients having multiple chronic diseases served by multiple providers. Research Design-Based upon our earlier survey of patients with multiple chronic conditions, we selected 8 medical centers having high and low coordination. We interviewed providers to identify facilitators and barriers to coordination and compare them between patient-rated high sites and low sites and between primary care-mental health and primary care-medical/surgical specialty care. Subjects-Physicians, nurses and other clinicians in primary care, cardiology and mental health (N=102) in 8 Veterans Affairs medical centers.
Journal of General Internal Medicine, Sep 21, 2010
BACKGROUND AND OBJECTIVE: Patient-provider language barriers may play a role in health-care dispa... more BACKGROUND AND OBJECTIVE: Patient-provider language barriers may play a role in health-care disparities, including obtaining colorectal cancer (CRC) screening. Professional interpreters and language-concordant providers may mitigate these disparities. DESIGN, SUBJECTS, AND MAIN MEASURES: We performed a retrospective cohort study of individuals age 50 years and older who were categorized as English-Concordant (spoke English at home, n=21,594); Other Language-Concordant (did not speak English at home but someone at their provider's office spoke their language, n=1,463); or Other Language-Discordant (did not speak English at home and no one at their provider's spoke their language, n=240). Multivariate logistic regression assessed the association of language concordance with colorectal cancer screening. KEY RESULTS: Compared to English speakers, non-English speakers had lower use of colorectal cancer screening (30.7% vs 50.8%; OR, 0.63; 95% CI, 0.51-0.76). Compared to the English-Concordant group, the Language-Discordant group had similar screening (adjusted OR, 0.84; 95% CI, 0.58-1.21), while the Language-Concordant group had lower screening (adjusted OR, 0.57; 95% CI, 0.46-0.71). CONCLUSIONS: Rates of CRC screening are lower in individuals who do not speak English at home compared to those who do. However, the Language-Discordant cohort had similar rates to those with English concordance, while the Language-Concordant cohort had lower rates of CRC screening. This may be due to unmeasured differences among the cohorts in patient, provider, and health care system characteristics. These results suggest that providers should especially promote the importance of CRC screening to non-English speaking patients, but that language barriers do not fully account for CRC screening rate disparities in these populations.
Thesis (Ph.D.)--Boston UniversityHospitals are increasingly providing services for more medically... more Thesis (Ph.D.)--Boston UniversityHospitals are increasingly providing services for more medically complicated patients who require the care of multiple providers. This results in complex interdependent work relationships that require coordination to optimize patient care. Consequently, coordination-- especially between nurses and physicians who constitute the main providers of care-- may play an increasingly important role in the provision of quality care to hospitalized patients. Three studies were done to examine the role of intra- and interprofessional coordination of nurses and physicians in inpatient medical care. All were cross-sectional, descriptive studies using multivariate linear regression methodology, with data aggregated and analyzed at the facility level. Both primary data obtained from surveys of nurse managers, attending physicians and chiefs of medicine, and secondary data obtained from surveys of staff nurses and administrative data sources were used. Study One: The impact of provider coordination on provider perceptions of patient care and job satisfaction in inpatient medicine examined the association between intra- and interprofessional coordination and provider perceptions of the quality of patient care, and provider job satisfaction and intent to leave. Study Two: Organizational predictors of provider perceptions of coordination in inpatient medicine examined the association between organizational factors and provider perceptions of inpatient coordination. Study Three: The impact of provider coordination on patient outcomes examined the association between perceptions of intra- and interprofessional coordination and patient satisfaction; in-hospital fall, pressure ulcer, readmission and mortality rates; hospital costs; and lengths of stay. These studies contribute to the literature by assessing the impact of perceived coordination on patient and provider outcomes, and by identifying the organizational factors associated with perceptions of coordination. Results indicated that greater intra- and/ or interprofessional coordination may be associated with: better provider perceptions of patient care, patient satisfaction, and physician job satisfaction; higher hospital costs; and lower provider intent to leave and mortality rates. An organization's explicit commitment to patient care, to resources that enable providers to do their jobs, and to strategies that enhance communication between providers may improve coordination. Some factors, such as appropriate staffing, may be pre-requisites before coordination can have an impact on some patient outcomes
JNCI Monographs, 2012
Background Multilevel intervention research holds the promise of more accurately representing rea... more Background Multilevel intervention research holds the promise of more accurately representing real-life situations and, thus, with proper research design and measurement approaches, facilitating effective and efficient resolution of health-care system challenges. However, taking a multilevel approach to cancer care interventions creates both measurement challenges and opportunities. Methods One-thousand seventy two cancer care articles from 2005 to 2010 were reviewed to examine the state of measurement in the multilevel intervention cancer care literature. Ultimately, 234 multilevel articles, 40 involving cancer care interventions, were identified. Additionally, literature from health services, social psychology, and organizational behavior was reviewed to identify measures that might be useful in multilevel intervention research. Results The vast majority of measures used in multilevel cancer intervention studies were individual level measures. Group-, organization-, and community-level measures were rarely used. Discussion of the independence, validity, and reliability of measures was scant. Discussion Measurement issues may be especially complex when conducting multilevel intervention research. Measurement considerations that are associated with multilevel intervention research include those related to independence, reliability, validity, sample size, and power. Furthermore, multilevel intervention research requires identification of key constructs and measures by level and consideration of interactions within and across levels. Thus, multilevel intervention research benefits from thoughtful theory-driven planning and design, an interdisciplinary approach, and mixed methods measurement and analysis.
The American Journal of Human Genetics, 1998
Journal of General Internal Medicine
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Papers by Nathalie McIntosh