Background: Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity. Methods and Findings: We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare's "Value-Based Purchasing" program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p < 0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p < 0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement. Conclusions: Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare's hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.

BACKGROUND: Minority populations bear a disproportionate burden of chronic disease, due to higher disease prevalence and greater morbidity and mortality. Recent research has shown that several factors, including confidence to self-manage care, are associated with better health behaviors and outcomes among those with chronic disease. OBJECTIVE: To examine the association between minority status and confidence to self-manage cardiovascular disease (CVD). STUDY SAMPLE: Survey respondents admitted to 10 hospitals participating in the "Expecting Success" program, with a diagnosis of CVD, during January-September 2006 (n = 1107). RESULTS: Minority race/ethnicity was substantially associated with lower confidence to self-manage CVD, with 36.5% of Hispanic patients, 30.7% of Black patients, and 16.0% of white patients reporting low confidence (P < 0.001). However, in multivariate analysis controlling for socioeconomic status and clinical severity, minority status was not predictive of low confidence. CONCLUSIONS: Although there is an association between race/ethnicity and confidence to self-manage care, that relationship is explained by the association of race/ethnicity with socioeconomic status and clinical severity.

This research examines how teams organize knowledge sourcing (obtaining access to others' knowledge or expertise) and investigates the performance trade-offs involved in two approaches to knowledge sourcing in teams. One approach a team can take is to specialize, such that a small number of members source knowledge on behalf of the team. This specialized knowledge-sourcing approach lowers search costs. The other approach has most or all team members engaging in knowledge sourcing. This broad approach means that more team members interact directly with the knowledge source, and thus may understand the knowledge better. These options present a sourcing paradox: teams cannot reap the advantages of specialized sourcing and the advantages of broad sourcing. They face performance tradeoffs. Further under some conditions performance tradeoffs will be more pronounced. Specifically, specialized knowledge sourcing depends on within team knowledge sharing, and so conditions that hinder knowledge sharing in a team are likely to reduce the effectiveness of the specialized approach. Using archival data from several hundred software development projects in an Indian software services firm, we find support for most of our hypotheses. Our findings offer insight for theory and practice into how team organization, organizational knowledge resources, and within-team knowledge sharing can aid team performance.