Control under times of uncertainty: the relationship between hospital competition and physician-patient disputes

Does hospital competition improve the quality of outpatient care? - empirical evidence from a quasi-experiment in a Chinese city

BACKGROUND

Although countries worldwide have launched a series of pro-competition reforms, the literature on the impacts of hospital competition has produced a complex and contradictory picture. This study examined whether hospital competition contributed to an increase in the quality of outpatient care.

METHODS

The dataset comprises encounter data on 406,664 outpatients with influenza between 2015 and 2019 in China. Competition was measured using the Herfindahl-Hirschman index (HHI). Whether patients had 14-day follow-up encounter for influenza at any healthcare facility, outpatient facility, and hospital outpatient department were the three quality outcomes assessed. Binary regression models with crossed random intercepts were constructed to estimate the impacts of the HHI on the quality of outpatient care. The intensity of nighttime lights was employed as an instrumental variable to address the endogenous relationship between the HHI and the quality of outpatient care.

RESULTS

We demonstrated that an increase in the degree of hospital competition was associated with improved quality of outpatient care. For each 1% increase in the degree of hospital competition, an individual's risk of having a 14-day follow-up encounter for influenza at any healthcare facility, outpatient facility, and hospital outpatient department fell by 34.9%, 18.3%, and 20.8%, respectively. The impacts of hospital competition on improving the quality of outpatient care were more substantial among females, individuals who used the Urban and Rural Residents Basic Medical Insurance to pay for their medical costs, individuals who visited accredited hospitals, and adults aged 25 to 64 years when compared with their counterparts.

CONCLUSION

This study demonstrated that hospital competition contributed to better quality of outpatient care under a regime with a regulated ceiling price. Competition is suggested to be promoted in the outpatient care market where hospitals have control over quality and government sets a limit on the prices that hospitals may charge.

Workplace violence against COVID-19 front-line healthcare workers versus non-front-line in Hangzhou, China: a cross-sectional study

OBJECTIVES

Workplace violence (WPV) against healthcare workers (HCWs) is a global issue. Our research aimed to elucidate the status and associated factors of WPV among front-line/non-front-line HCWs during the COVID-19 pandemic.

DESIGN

This cross-sectional study was conducted among HCWs in Hangzhou City through multistage sampling from December 2020 to January 2021.

PARTICIPANTS

This study included 14 909 valid samples (N=3748 front-line HCWs and N=11 161 non-front-line HCWs).

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed the WPV status by Chinese version of WPV questionnaire. Binary logistic regression model was established to examine the associated factors of front-line/non-front-line HCWs experiencing WPV.

RESULTS

The total WPV prevalence equalled 37.25% for front-line HCWs and 27.73% for non-front-line HCWs. Among front-line HCWs, females were less likely to experience WPV (OR 0.837, 95% CI 0.710 to 0.988), while individuals who were undergraduate (OR 1.251, 95% CI 1.061 to 1.541) and had higher professional title (intermediate: OR 1.475, 95% CI 1.227 to 1.772; advanced: OR 1.693, 95% CI 1.294 to 2.216) were more likely to suffer from WPV; for non-front-line HCWs, individuals who aged over 50 years old (OR 0.721, 95% CI 0.563 to 0.969), had worked between 10 and 19 years (OR 0.847, 95% CI 0.749 to 0.958) and worked in the non-graded hospital (OR 0.714, 95% CI 0.614 to 0.832) had less chance to experience WPV, while individuals who had higher educational level (undergraduate: OR 1.323, 95% CI 1.179 to 1.484; ≥graduate: OR 1.519, 95% CI 1.217 to 1.895), were nurse (OR 1.142, 95% CI 1.031 to 1.265), and had higher professional title (intermediate: OR 1.458, 95% CI 1.297 to 638; advanced: OR 1.928, 95% CI 1.607 to 2.313) were more inclined to suffer from WPV (p all<0.05).

CONCLUSIONS

This study indicates that the prevalence of WPV among front-line HCWs is significantly higher than among non-front-line HCWs. Policy-makers should prioritise COVID-19 front-line HCWs, especially those with high educational levels and professional titles.

Medical Malpractice Litigation After Spine Surgery in Beijing Between 2013 and 2018

OBJECTIVE

The aim of this study was to analyze the characteristics of alleged medical malpractice litigation involving spine surgery in Beijing between 2013 and 2018.

METHODS

Two online legal databases, Wusong and Weike, were queried for court verdicts involving spine surgery from January 2013 to December 2018 in Beijing. For all included cases, data pertaining to defendants, plaintiffs, case outcomes, allegations, and verdicts were abstracted, and descriptive analyses were performed.

RESULTS

A total of 186 legal cases were identified, and 122 cases were excluded because of irrelevance or insufficient information. Of the patients in the 64 cases included in this investigation, 40.6% were male. The mean age of the plaintiffs was 53.2 ± 18.6 years. The most common complaint addressed in this study is inadequate consent (53.1%; n = 34), followed by additional surgery required (40.2%; n = 26), being unsatisfied with the outcome of surgery (17.6%; n = 11), postoperative paralysis (15.6%; n = 10), and postoperative infection (15.6%; n = 10). The most common primary disease among all the cases is lumbar spinal stenosis (28.1%; n = 18), followed by spinal tumor (18.8%; n = 12), cervical spondylosis (17.2%; n = 11), vertebral fracture (14.1%; n = 9), deformity (12.5%; n = 8), and others (9.3%; n = 6). Spine surgeons successfully defended themselves in 13 cases (20.3%), which resulted in no indemnity payment. The remaining 51 cases (79.7%) were closed with an average verdict payout of U.S. $22,597, which was significantly lower than the average compensation claimed by the plaintiff (U.S. $11,3762) (P < 0.05).

CONCLUSIONS

This study comprehensively summarized the medical alleged malpractice litigation after spine surgery in Beijing. Given the rapid growth rate of spine surgery and the burden of related alleged medical malpractice litigation, it is valuable for spine surgeons to understand the potential legal impact of spine surgery. The most common complaint addressed in this study is inadequate consent. The findings in the present study highlight that in China, spine surgeons should pay more attention to communication with patients and perform spine surgery based on abnormal imaging as opposed to what the history and physical examination dictate, which can help reduce the litigation rate and improve the patient experience.

Enhancing doctor-patient relationships in community health care institutions: the Patient Oriented Four Habits Model (POFHM) trial-a stepped wedge cluster randomized trial protocol

BACKGROUND

The poor relationship between doctors and patients is a long-standing, global problem. However, current interventions tend to focus on the training of physicians, while patient-targeted interventions still need to be improved. Considering that patients play a significant role in outpatient consultations, we developed a protocol to assess the effectiveness of the Patient Oriented Four Habits Model (POFHM) in improving doctor-patient relationships.

METHODS

A cross-sectional incomplete stepped-wedge cluster randomized trial design will be conducted in 8 primary healthcare institutions (PHCs). Following phase I of "usual care" as control measures for each PHC, either a patient- or doctor-only intervention will be implemented in phase II. In phase III, both patients and doctors will be involved in the intervention. This study will be conducted simultaneously in Nanling County and West Lake District. The primary outcomes will be evaluated after patients complete their visit: (1) patient literacy, (2) sense of control and (3) quality of doctor-patient communication. Finally, a mixed-effects model and subgroup analysis will be used to evaluate the effectiveness of the interventions.

DISCUSSION

Fostering good consultation habits for the patient is a potentially effective strategy to improve the quality of doctor-patient communication. This study evaluates the implementation process and develops a rigorous quality control manual using a theoretical domain framework under the collective culture of China. The results of this trial will provide substantial evidence of the effectiveness of patient-oriented interventions. The POFHM can benefit the PHCs and provide a reference for countries and regions where medical resources are scarce and collectivist cultures dominate.

TRIAL REGISTRATION

AsPredicted #107,282 on Sep 18, 2022; https://aspredicted.org/QST_MHW.

Director's Perceived Competition and Its Relationship with Hospital's Competitive Behaviors: Evidence from County Hospitals in China

Background

This study was conducted for assessing the degrees of perceived competition reported by county hospital directors in rural China as well as hospitals’ competitive behaviors in response to competition.

Methods

The data were collected from Analysis of Provider Payment Reforms on Advancing China’s Health (APPROACH) project which had been implemented among county hospitals in China’s Guizhou province. Competition was measured by asking hospital directors to rate the levels of competitive pressure as they perceived. Hospitals’ competitive behaviors were obtained by asking hospitals’ directors about specific strategies they had adopted. A multivariable linear regression model was developed to examine the relationship between perceived competition and the positivity of competitive behavior, and multivariable logistic regressions were used to evaluate the influence of perceived competition on the adoption of specific competitive strategies.

Results

Among 218 directors engaged in this study, 210 (96.3%) directors reported the perception of certain degrees of competition, for which the competitive pressure was mainly posed by public hospitals (42.4%). Director-perceived competition level was found to be positively associated with the positivity of competitive behavior, and directors under higher competitive pressure were found to be more likely to adopt multiple competitive strategies including improving the efficiency of hospitals’ internal management, optimizing hospitals’ environment as well as promoting health-care services.

Conclusion

This study suggested that almost all of the county hospital directors in rural China perceived certain degrees of competitive pressure, and higher levels of perceived competition were found to be significantly associated with increased positivity in adopting competitive strategies. Our findings are expected to provide evidence-based implications for the implementation of a series of pro-competition policies throughout health-care reforms.

Measuring Public Reaction to Violence Against Doctors in China: Interrupted Time Series Analysis of Media Reports

Background

Violence against doctors in China is a serious problem that has attracted attention from both domestic and international media.

Objective

This study investigates readers’ responses to media reports on violence against doctors to identify attitudes toward perpetrators and physicians and examine if such trends are influenced by national policies.

Methods

We searched 17 Chinese violence against doctors reports in international media sources from 2011 to 2020. We then tracked back the original reports and web crawled the 19,220 comments in China. To ascertain the possible turning point of public opinion, we searched violence against doctors–related policies from Tsinghua University ipolicy database from 2011 to 2020, and found 19 policies enacted by the Chinese central government aimed at alleviating the intense patient–physician relationship. We then conducted a series of interrupted time series analyses to examine the influence of these policies on public sentiment toward violence against doctors over time.

Results

The interrupted time series analysis (ITSA) showed that the change in public sentiment toward violence against doctors reports was temporally associated with government interventions. The declarations of 10 of the public policies were followed by increases in the proportion of online public opinion in support of doctors (average slope changes of 0.010, P<.05). A decline in the proportion of online public opinion that blamed doctors (average level change of –0.784, P<.05) followed the declaration of 3 policies.

Conclusions

The government’s administrative interventions effectively shaped public opinion but only temporarily. Continued public policy interventions are needed to sustain the reduction of hostility toward medical doctors.

The Association of Market Mix of Hospital Ownership With Medical Disputes: Evidence From China

The prevalence and severity of medical disputes in China have attracted the attention of society and academia, and how to alleviate medical disputes has become a major concern. Following the implementation of a series of policies, the private sector in China’s hospital market has expanded rapidly over the past decade. It remains unknown whether the market mix of hospital ownership could alleviate medical disputes, this study aims to bridge the gap. Data are collected from all hospitals (2171) in Sichuan province, China, from 2012 to 2015. Using a negative binomial hurdle model, the results show that for hospitals with disputes, the private hospital market share has an inverted U-shaped relationship with the number of disputes. However, no significant relationship is found between the private hospital market share and the probability of dispute occurrence. For hospitals with disputes, competition plays a protective role in the effect of the private hospital market share on the number of disputes, hindering the increase in the number of disputes and facilitating a more rapid drop. However, medical quality is found to play an insignificant role in that effect. The findings also support encouraging new private hospitals in China rather than privatizing existing public hospitals.

Does County-Level Medical Centre Policy Influence the Health Outcomes of Patients with Trauma Transported by the Emergency Medical Service System? An Integrated Emergency Model in Rural China

This study aimed to assess the effect of the county-level medical centre policy on the health outcomes of trauma patients transported by emergency medical service (EMS) system in rural China. The methodology involved the use of electronic health records (EHRs, after 2016) of patients with trauma conditions such as head injury (n = 1931), chest (back) injury (n = 466), abdominal (waist) injury (n = 536), and limb injury (n = 857) who were transported by EMS to the county-level trauma centres of Huining County and Huan County in Gansu, China. Each patient was matched with a counterpart to a county-level trauma centre hospital by propensity score matching. Cox proportional hazard models were used to estimate the hazard ratios (HRs) of such patients in different hospitals. The HRs of all patients with the abovementioned traumatic conditions transported by EMS to county-level trauma centre hospitals were consistently higher than those transported by EMS to traditional hospitals after adjusting for numerous potential confounders. Higher HRs were associated with all patients with trauma (HR = 1.249, p < 0.001), head injury (HR = 1.416, p < 0.001), chest (back) injury (HR = 1.112, p = 0.560), abdominal (waist) injury (HR = 1.273, p = 0.016), and limb injury (HR = 1.078, p = 0.561) transported by EMS to the county-level trauma centre hospitals. Our study suggests that the construction of county-level medical centre provides an effective strategy to improve the health outcomes of EMS-transported trauma patients in Gansu, China. Policy makers can learn from the experience and improve the health outcomes of such patients through a personalised trauma treatment system and by categorizing the regional trauma centre.

Does Hospital Competition Harm Inpatient Quality? Empirical Evidence from Shanxi, China

This study aimed to determine whether hospital competition is associated with improved in-hospital mortality in Shanxi, China. We included a total of 46,959 hospitalizations for acute myocardial infarction (AMI) and 44,063 hospitalizations for pneumonia from 2015 to 2017. Hospital competition was measured as Herfindahl⁻Hirschman Index based on the patient predicted flow approach. Two-level random-intercept logistic models were applied to explore the effects of hospital competition on quality for both AMI and pneumonia diagnoses. Hospital competition exerts negative or negligible effects on inpatient quality of care, and the pattern of competition effects on quality varies by specific diseases. While hospital competition is insignificantly correlated with lower AMI in-hospital mortality (odds ratio (OR): 0.94, 95% confidence interval (CI): 0.77⁻1.11), high hospital competition was, in fact, associated with higher in-hospital mortality for pneumonia patients (OR: 1.99, 95% CI: 1.51⁻2.64). Our study suggests that simply encouraging hospital competition may not provide effective channels to improve inpatient quality of health care in China's current health care system.