Comparing health outcomes among hospitals: the experience of the Lombardy Region

The strange case of less C-sections: Hospital ownership, market concentration, and DRG-tariff regulation

We evaluate the relationship between hospital ownership and responses to a policy providing large financial incentives for vaginal deliveries and financial disincentives for C-sections. We compare for-profit, nonprofit, and public hospitals operating in a public health care system organized according to the quasi-market model. We first theoretically show that hospital ownership matters insofar different hospitals are characterized by different ethical preferences. We also show that competition makes ownership less important. We then consider the case study of Lombardy in Italy. We exploit spatial variation in hospital ownership and in market concentration at the local level to evaluate the relationship between ownership and the probability of C-section. According to theory, empirical results strongly suggest that competitive pressures from alternative providers tend to homogenize behaviors. However, in local monopolies, in presence of a strong monetary incentive toward vaginal deliveries, we do observe less C-section from private for-profit hospitals than from public and private nonprofit hospitals, especially when C-sections are medically appropriate.

Is there scope for mixed markets in the provision of hospital care?

Market oriented reforms in hospital care have produced a variety of quasi markets that differ for the type of providers that are allowed to compete. Mixed markets, where public hospitals compete alongside private ones, are increasingly common, but the literature does not agree on their performances and their desirability. We review the contributions in this field by proposing a common framework which allows to account for the different approaches proposed to model public hospitals. In this paper we show under which conditions mixed markets perform better in terms of average quality, and we review the empirical literature to determine whether these conditions are met. In general, pure forms (private or public competition) are superior to mixed markets, unless patients interpret public hospitals as reference suppliers, and quality of care is important. The empirical evidence on these key questions shows that public hospitals behave differently from private organisations, but they are not necessarily less efficient. Research into patients choices seems to suggest that ownership is a value, but the empirical literature is still rather scant. From a policy point of view, our review suggests that there does not seem to be a clear answer to whether this market form should be used. Local conditions are going to play an important role.

Geographic variation in inpatient costs for Acute Myocardial Infarction care: Insights from Italy

Geographic variations in healthcare expenditures have been widely reported within and between countries. Nevertheless, empirical evidence on the role of organizational factors and care systems in explaining these variations is still needed. This paper aims at assessing the regional differences in hospital spending for patients hospitalized for Acute Myocardial Infarction (AMI) in Tuscany and Lombardy regions (Italy), which rank high in terms of care quality and that have been, at least until 2016, characterized by quite different governance systems. Generalized linear models are performed to estimate index, 30-day and one-year hospitalization spending adjusted for baseline covariates. A two-part model is used to estimate 31-365 day expenditure. Adjusted hospital spending for AMI patients were significantly higher in Lombardy compared with Tuscany. In Lombardy, patients experienced higher re-hospitalizations in the 31-365 days and longer length of stays than in Tuscany. On the other hand, no significant regional differences in adjusted mortality rates at both acute and longer phases were found. Comparing two regional healthcare systems which mainly differ in both the reimbursement systems and the level of integration between hospital and community services provides insights into factors potentially contributing to regional variations in spending and, therefore, in areas for efficiency improvement.

A turnaround strategy: improving equity in order to achieve quality of care and financial sustainability in Italy

BACKGROUND

Equity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems. However, systematic performance management strategies for achieving equity are still weaker than those aimed at achieving financial sustainability and quality of care. Using a vertical equity perspective, the overarching aim of this paper is to examine how improving equity in quality of care impacts on financial sustainability. We applied a simulation to indicators of the heart failure clinical pathway in Tuscany (central Italy), in order to quantify the equity gaps and financial resources that could be reallocated in the absence of performance inequities.

METHODS

The analysis included all patients hospitalized for heart failure as a principal diagnosis in 2014. We selected five indicators: hospitalization rate, 30-day readmission, cardiology visits, and the utilization of beta-blockers, and ACE inhibitors and sartans. For each indicator, the simulation followed three steps: 1) stratification by socioeconomic status (SES), using education as a proxy for SES; 2) computation of the vertical equity indicator; and 3) assessment of the financial value of the equity gap.

RESULTS

All indicators showed performance gaps regarding inequities across SES-groups. For the hospitalization rate and 30-day readmission, resources could have been reallocated, if the performance of patients with a low SES had been equal to the performance of patients with a high SES, which amounted to €2,144,422 and €892,790 respectively. In contrast, limited additional resources would have been required for prescriptions and cardiology visits.

CONCLUSIONS

Reducing equity gaps by improving the performance of low-SES patients may be a crucial strategy to achieving financial sustainability in universal coverage healthcare systems. Universal healthcare systems, which aim to pursue financial sustainability and quality of care, are thus urged to develop performance management actions to improve equity. This approach should not only include the measurement and public disclosure of equity indicators but be part of a comprehensive evidence-based strategy for the management of chronic conditions along the clinical pathway.

Insights on the effectiveness of reward schemes from 10-year longitudinal case studies in 2 Italian regions

BACKGROUND

Pay for performance (P4P) programs have been widely analysed in literature, and the results regarding their impact on performance are mixed. Moreover, in the real-life setting, reward schemes are designed combining multiple elements altogether, yet, it is not clear what happens when they are applied using different combinations.

OBJECTIVES

To provide insights on how P4P programs are influenced by 5 key elements: whom, what, how, how many targets, and how much to reward.

METHODS

A qualitative longitudinal analysis of 10 years of P4P reward schemes adopted by the regional administrations of Tuscany and Lombardy (Italy) was conducted. The effects of the P4P features on performance are discussed considering both overall and specific indicators.

RESULTS

Both regions applied financial reward schemes for General Managers by linking the variable pay to performance. While Tuscany maintained a relatively stable financial incentive design and governance tools, Lombardy changed some elements of the design and introduced, in 2012, a P4P program aimed to reward the providers. The main differences between the 2 cases regard the number of targets (how many), the type (what), and the method applied to set targets (how).

CONCLUSION

Considering the overall performance obtained by the 2 regions, it seems that whom, how, and how much to reward are not relevant in the success of P4P programs; instead, the number (how many) and the type (what) of targets set may influence the performance improvement processes driven by financial reward schemes.

Do private hospitals outperform public hospitals regarding efficiency, accessibility, and quality of care in the European Union? A literature review

European countries have enhanced the scope of private provision within their health care systems. Privatizing services have been suggested as a means to improve access, quality, and efficiency in health care. This raises questions about the relative performance of private hospitals compared with public hospitals. Most systematic reviews that scrutinize the performance of the private hospitals originate from the United States. A systematic overview for Europe is nonexisting. We fill this gap with a systematic realist review comparing the performance of public hospitals to private hospitals on efficiency, accessibility, and quality of care in the European Union. This review synthesizes evidence from Italy, Germany, the United Kingdom, France, Greece, Austria, Spain, and Portugal. Most evidence suggests that public hospitals are at least as efficient as or are more efficient than private hospitals. Accessibility to broader populations is often a matter of concern in private provision: Patients with higher social-economic backgrounds hold better access to private hospital provision, especially in private parallel systems such as the United Kingdom and Greece. The existing evidence on quality of care is often too diverse to make a conclusive statement. In conclusion, the growth in private hospital provision seems not related to improvements in performance in Europe. Our evidence further suggests that the private (for-profit) hospital sector seems to react more strongly to (financial) incentives than other provider types. In such cases, policymakers either should very carefully develop adequate incentive structures or be hesitant to accommodate the growth of the private hospital sector.

Evaluating organizational change in health care: the patient-centered hospital model

BACKGROUND

An increasing number of hospitals react to recent demographic, epidemiological and managerial challenges moving from a traditional organizational model to a Patient-Centered (PC) hospital model. Although the theoretical managerial literature on the PC hospital model is vast, quantitative evaluations of the performance of hospitals that moved from the traditional to the PC organizational structure is scarce. However, quantitative analysis of effects of managerial changes is important and can provide additional argument in support of innovation.

METHODS

We take advantage of a quasi-experimental setting and of a unique administrative data set on the population of hospital discharge charts (HDCs) over a period of 9 years of Lombardy, the richest and one of the most populated region of Italy. During this period three important hospitals switched to the PC model in 2010, whereas all the others remained with the functional organizational model. This allowed us to develop a difference-in-difference analysis of some selected measures of efficiency and effectiveness for PC hospitals focusing on the "between-variability" of the 25 major diagnostic categories (MDCs) in each hospital and estimating a difference-in-difference model.

RESULTS

We contribute to the literature that addresses the evaluation of healthcare and hospital change by providing a quantitative estimation of efficiency and effectiveness changes following to the implementation of the PC hospital model. Results show that both efficiency and effectiveness have significantly increased in the average MDC of PC hospitals, thus confirming the need for policy makers to invest in new organizational models close to the principles of PC hospital structures.

CONCLUSIONS

Although an organizational change towards the PC model can be a costly process, implying a rebalancing of responsibilities and power among hospital personnel (e.g. medical and nursing staff), our results suggest that changing towards a PC model can be worthwhile in terms of both efficacy and efficiency. This evidence can be used to inform and sustain hospital managers and policy makers in their hospital design efforts and to communicate the innovation advantages within the hospital organizations, among the personnel and in the public debate.

Patient satisfaction, patients leaving hospital against medical advice and mortality in Italian university hospitals: a cross-sectional analysis

Background

Healthcare systems are increasingly focusing on outcomes that are the endpoints of care: patient health status and patient satisfaction. The availability of patient satisfaction (PS) data has encouraged research on its relationship with other outcomes, such as mortality. In Italy, an inter-regional performance evaluation system (IRPES) provides 13 regional healthcare systems with a multidimensional assessment of appropriateness, efficiency, financial sustainability, effectiveness, and equity. For university hospitals, IRPES includes the percentage of patients leaving hospital against medical advice (PLHAMA) and mortality rates at the ward level. This paper investigates the relationship between PS and PLHAMA across and within regional healthcare systems in Italy. Secondly, PLHAMA is used as a PS proxy to investigate its relationship with mortality at the ward level in the IRPES university hospitals.

Methods

PLHAMA and mortality rates were gathered from administrative data, and PS scores from patient surveys. We explored the association between PS and PLHAMA through a correlation analysis, using data for the 13 IRPES regions. We tested this relationship also at the clinical directorate level in 28 hospitals in Tuscany (5482 interviewed patients in 100 clinical directorates). Secondly, we explored the association between PLHAMA and mortality at the ward level through correlation and regression analyses, using data of 405 wards of eight clinical specialties within 24 IRPES university hospitals.

Results

Lower PLHAMA rates were associated with a higher PS in both regional and clinical directorate levels. A positive association between PLHAMA and mortality was shown at the ward level for IRPES university hospitals, with different results for medical and surgical clinical specialties.

Conclusions

PS is an important performance dimension that provides healthcare managers and professionals with useful insights for improving care quality and effectiveness. Based on the study results, the PLHAMA rate could be regularly measured to highlight patient dissatisfaction. Due to the association between PLHAMA and mortality, this study also provides evidence of the importance of the patient perspective in assessing the quality of healthcare services. This relationship proved to be significant for surgical clinical units, suggesting the need for further analysing outcomes considering their different determinants in medical and surgical care.

Are performance measurement systems useful? Perceptions from health care

BACKGROUND

Prior literature identified the use of Performance Measurement Systems (PMS) as crucial in addressing improved processes of care. Moreover, a strategic use of PMS has been found to enhance quality, compared to non-strategic use, although a clear understanding of this linkage is still to be achieved. This paper deals with the test of direct and indirect models related to the link between the strategic use of PMS and the level of improved processes in health care organizations. Indirect models were mediated by the degree of perceived managerial discretion.

METHODS

A PLS analysis on a survey of 97 Italian managers working for health care organizations in the Lombardy region was conducted. The response rate was 77.6%.

RESULTS

The strategic use of PMS in health care organizations directly and significantly (p < 0.001) enhances performance in terms of improved processes. Perceived managerial discretion is positively and significantly (p < 0.001) affected by the strategic use of PMS, whereas the mediation effect is non-significant.

CONCLUSIONS

This study contributes to the literature investigating the design and implementation of a non-financial measurement tool, such as the non-financial information included into a balanced scorecard (BSC), in health care organizations. Managers in health care organizations can benefit from the strategic use of PMS to effectively allocate their time to strategic opportunities and threats, which might arise and affect organizational, output-related performance, such as improving processes.

Dynamic clustering of hazard functions: an application to disease progression in chronic heart failure

We analyse data collected from the administrative datawarehouse of an Italian regional district (Lombardia) concerning patients affected by Chronic Heart Failure. The longitudinal data gathering for each patient hospital readmissions in time, as well as patient-specific covariates, is studied as a realization of non homogeneous Poisson process. Since the aim behind this study is to identify groups of patients behaving similarly in terms of disease progression and then healthcare consumption, we conjectured the time segments between two consecutive hospitalizations to be Weibull distributed in each hidden cluster. Adding a frailty term to take into account the within subjects unknown variability, the corresponding patient-specific hazard functions are reconstructed. Therefore, the comprehensive distribution for each time to event variable is modelled as a Weibull Mixture. We are then able to easily interpret the related hidden groups as healthy, sick, and terminally ill subjects.

Propensity score matching with clustered data. An application to the estimation of the impact of caesarean section on the Apgar score

This article focuses on the implementation of propensity score matching for clustered data. Different approaches to reduce bias due to cluster-level confounders are considered and compared using Monte Carlo simulations. We investigated methods that exploit the clustered structure of the data in two ways: in the estimation of the propensity score model (through the inclusion of fixed or random effects) or in the implementation of the matching algorithm. In addition to a pure within-cluster matching, we also assessed the performance of a new approach, 'preferential' within-cluster matching. This approach first searches for control units to be matched to treated units within the same cluster. If matching is not possible within-cluster, then the algorithm searches in other clusters. All considered approaches successfully reduced the bias due to the omission of a cluster-level confounder. The preferential within-cluster matching approach, combining the advantages of within-cluster and between-cluster matching, showed a relatively good performance both in the presence of big and small clusters, and it was often the best method. An important advantage of this approach is that it reduces the number of unmatched units as compared with a pure within-cluster matching. We applied these methods to the estimation of the effect of caesarean section on the Apgar score using birth register data. Copyright © 2016 John Wiley & Sons, Ltd.

Benchmarking facilities providing care: An international overview of initiatives

We performed a literature review of existing benchmarking projects of health facilities to explore (1) the rationales for those projects, (2) the motivation for health facilities to participate, (3) the indicators used and (4) the success and threat factors linked to those projects. We studied both peer-reviewed and grey literature. We examined 23 benchmarking projects of different medical specialities. The majority of projects used a mix of structure, process and outcome indicators. For some projects, participants had a direct or indirect financial incentive to participate (such as reimbursement by Medicaid/Medicare or litigation costs related to quality of care). A positive impact was reported for most projects, mainly in terms of improvement of practice and adoption of guidelines and, to a lesser extent, improvement in communication. Only 1 project reported positive impact in terms of clinical outcomes. Success factors and threats are linked to both the benchmarking process (such as organisation of meetings, link with existing projects) and indicators used (such as adjustment for diagnostic-related groups). The results of this review will help coordinators of a benchmarking project to set it up successfully.

Antipsychotic drug exposure and risk of pulmonary embolism: a population-based, nested case-control study

BACKGROUND

Only three observational studies investigated whether exposure to antipsychotics is associated with an increased risk of pulmonary embolism, with conflicting results. This study was therefore carried out to establish the risk of pulmonary embolism associated with antipsychotic drugs, and to ascertain the risk associated with first- and second-generation antipsychotic drugs, and with exposure to individual drugs.

METHODS

We identified 84,253 adult individuals who began antipsychotic treatment in a large Italian health care system. Cases were all cohort members who were hospitalized for non-fatal or fatal pulmonary embolism during follow-up. Up to 20 controls for each case were extracted from the study cohort using incidence density sampling and matched by age at cohort entry and gender. Each individual was classified as current, recent or past antipsychotic user. The occurrence non-fatal or fatal pulmonary embolism was the outcome of interest.

RESULTS

Compared to past use, current antipsychotic use more than double the risk of pulmonary embolism (odds ratio 2.31, 95% confidence interval 1.16 to 4.59), while recent use did not increase the risk. Both conventional and atypical antipsychotic exposure was associated with an increase in risk, and the concomitant use of both classes increased the risk of four times (odds ratio 4.21, 95% confidence interval 1.53 to 11.59).

CONCLUSIONS

Adding the results of this case-control study to a recent meta-analysis of three observational studies substantially changed the overall estimate, which now indicates that antipsychotic exposure significantly increases the risk of pulmonary embolism.

Making governance work in the health care sector: evidence from a 'natural experiment' in Italy

The Italian Health care System provides universal coverage for comprehensive health services and is mainly financed through general taxation. Since the early 1990s, a strong decentralization policy has been adopted in Italy and the state has gradually ceded its jurisdiction to regional governments, of which there are twenty. These regions now have political, administrative, fiscal and organizational responsibility for the provision of health care. This paper examines the different governance models that the regions have adopted and investigates the performance evaluation systems (PESs) associated with them, focusing on the experience of a network of ten regional governments that share the same PES. The article draws on the wide range of governance models and PESs in order to design a natural experiment. Through an analysis of 14 indicators measured in 2007 and in 2012 for all the regions, the study examines how different performance evaluation models are associated with different health care performances and whether the network-shared PES has made any difference to the results achieved by the regions involved. The initial results support the idea that systematic benchmarking and public disclosure of data are powerful tools to guarantee the balanced and sustained improvement of the health care systems, but only if they are integrated with the regional governance mechanisms.

Defining hospital's internal boundaries. An organisational complexity criterion

The aim of this paper is to provide empirical evidences supporting the definition of hospital wards' boundaries in organisational designing processes, by suggesting services aggregation criteria that are focused on organisational complexity. In order to test the research hypotheses, a panel data analysis was conducted on Lombardy hospitals in Italy. Information was gathered both from administrative records - aggregated at in-patient ward level - and general registry offices. The results highlight that the wards offering integrated services perform better than those that are more specialised. However, for growing levels of within-complexity, the positive effects of formal integration between wards tend to reduce. Some guidelines for practitioners engaged in defining hospitals' organisational structures can be drawn from the empirical analysis.

Ensemble of trees approaches to risk adjustment for evaluating a hospital's performance

A commonly used method for evaluating a hospital's performance on an outcome is to compare the hospital's observed outcome rate to the hospital's expected outcome rate given its patient (case) mix and service. The process of calculating the hospital's expected outcome rate given its patient mix and service is called risk adjustment (Iezzoni 1997). Risk adjustment is critical for accurately evaluating and comparing hospitals' performances since we would not want to unfairly penalize a hospital just because it treats sicker patients. The key to risk adjustment is accurately estimating the probability of an Outcome given patient characteristics. For cases with binary outcomes, the method that is commonly used in risk adjustment is logistic regression. In this paper, we consider ensemble of trees methods as alternatives for risk adjustment, including random forests and Bayesian additive regression trees (BART). Both random forests and BART are modern machine learning methods that have been shown recently to have excellent performance for prediction of outcomes in many settings. We apply these methods to carry out risk adjustment for the performance of neonatal intensive care units (NICU). We show that these ensemble of trees methods outperform logistic regression in predicting mortality among babies treated in NICU, and provide a superior method of risk adjustment compared to logistic regression.