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Guida P, Iacoviello M, Passantino A, Scrutinio D. Measures of hospital competition and their impact on early mortality for congestive heart failure, acute myocardial infarction and cardiac surgery. Int J Qual Health Care 2019; 31:598-605. [PMID: 30380059 DOI: 10.1093/intqhc/mzy220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 05/25/2018] [Accepted: 10/15/2018] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To measure competition amongst providers and to examine whether a correlation exists with hospitals mortality for congestive heart failure (CHF), acute myocardial infarction (AMI), isolated-coronary artery bypass graft (CABG) or valve surgery. DESIGN Cross-sectional study based on publically available data from the National Outcome Evaluation Program (Edition 2016) of the Italian Agency for Regional Health Services. SETTING AND PARTICIPANTS Patients discharged during 2015 for CHF or AMI, and between 2014 and 2015 for cardiac surgery (respectively, from 662, 395 and 91 hospitals). MAIN OUTCOME MEASURES Risk-adjusted mortality rates at 30 days and measures of hospital competition for areas centred on hospital' location (fixed-radius 50-150 km, variable-radius to capture 10-30 hospitals and 6-10% of national volume). Competition was estimated as number of providers and Herfindahl-Hirschman Index (HHI). RESULTS Indicators of competitions varied by condition and were sensitive to method used for the area definition. Hospital mortality after AMI and valve surgery increased with competition in areas identified by the variable-radius method (higher rates for a greater number of hospitals or lower HHIs). In area with fixed radius of 100-150 km, competition reduced mortality after CABG procedures (lower rates for a greater number of hospitals or smaller HHIs). Neither the number of hospitals nor HHI correlated with outcomes in CHF. CONCLUSIONS The measures of hospital competition changed according to definition of local market and results in mortality correlations varied among conditions. Understanding the relationship between hospital competition and outcomes is important to identify strategies to improve quality of care.
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Affiliation(s)
- Pietro Guida
- Division of Cardiology and Cardiac Rehabilitation, Scientific Clinical Institutes Maugeri, IRCCS, Institute of Cassano delle Murge, Cassano delle Murge, Bari, Italy
| | - Massimo Iacoviello
- Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari, Italy
| | - Andrea Passantino
- Division of Cardiology and Cardiac Rehabilitation, Scientific Clinical Institutes Maugeri, IRCCS, Institute of Cassano delle Murge, Cassano delle Murge, Bari, Italy
| | - Domenico Scrutinio
- Division of Cardiology and Cardiac Rehabilitation, Scientific Clinical Institutes Maugeri, IRCCS, Institute of Cassano delle Murge, Cassano delle Murge, Bari, Italy
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Is Bigger Better?: The Effect of Hospital Consolidation on Index Hospitalization Costs and Outcomes Among Privately Insured Recipients of Immediate Breast Reconstruction. Ann Surg 2019; 270:681-691. [PMID: 31356269 DOI: 10.1097/sla.0000000000003481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To examine the relationship between hospital market competition and inpatient costs, procedural markup, inpatient complications, and length of stay among privately insured patients undergoing immediate reconstruction after mastectomy. METHODS A retrospective cross-sectional analysis of privately insured female patients undergoing immediate breast reconstruction in the 2009 to 2011 Nationwide Inpatient Sample was performed. The Herfindahl-Hirschman index was used to describe hospital market competition; associations with outcomes were explored via hierarchical models adjusting for patient, hospital, and market characteristics. RESULTS A weighted total of 42,411 patients were identified; 5920 (14.0%) underwent free flap reconstruction. In uncompetitive markets, 6.8% (n=857) underwent free flap reconstruction, compared with 13.6% (n=2773) in highly competitive markets and 24.6% (n=2290) in moderately competitive markets. For every 5 additional hospitals in a market, adjusted costs were 6.6% higher (95% CI: 2.8%-10.5%), for free flap reconstruction, and 5.1% higher (95% CI: 2.0%-8.4%) for nonfree flap reconstruction. Similarly, higher procedural markup was associated with increased hospital market competition both for nonfree flap reconstruction (5.5% increase, 95% CI: 1.1%-10.1%) and for free flap reconstruction (8.2% increase, 95% CI: 1.8%-15.0%). Notably, there was no association between incidence of inpatient complications or extended length of stay and hospital market competition among either free flap or nonfree flap reconstruction patients. CONCLUSIONS Decreasing market competition was associated with lower inpatient costs and equivocal clinical outcomes. This suggests that some of the economies of scale, access to capital and care delivery efficiencies gained from increased market power following hospital mergers are passed onto payers and consumers as lower costs.
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Shen VCY, Ward WJ, Chen LK. Systematic review and meta-analysis on the effect of hospital competition on quality of care: Implications for senior care. Arch Gerontol Geriatr 2019; 83:263-270. [DOI: 10.1016/j.archger.2019.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/02/2019] [Accepted: 05/02/2019] [Indexed: 12/18/2022]
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Wright JD, Chen L, Accordino M, Taback B, Ananth CV, Neugut AI, Hershman DL. Regional Market Competition and the Use of Immediate Breast Reconstruction After Mastectomy. Ann Surg Oncol 2018; 26:62-70. [PMID: 30327971 DOI: 10.1245/s10434-018-6825-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prior work has shown that the competitiveness of the market in which hospitals operate is associated with use of surgical procedures. This study examined the association between regional market competition and use of breast reconstruction for women with breast cancer and ductal carcinoma in situ undergoing mastectomy. METHODS Women who underwent mastectomy from 2010 to 2011 recorded in the National Inpatient Sample were selected. The competitive market environment for each hospital in which patients were treated was estimated using the Herfindahl-Hirschman Index. Multivariable models were developed to examine the association between regional market competition and breast reconstruction, with adjustment for other clinical, demographic, and structural variables. RESULTS Immediate breast reconstruction was performed for 9902 (45%) of 22,011 women. The rate of immediate breast reconstruction was 34.5% at hospitals in non-competitive markets, 49% at hospitals in moderately competitive markets, and 56.4% at hospitals in highly competitive markets (P < 0.0001). In a multivariable model, women in moderately competitive markets were 24% (risk ratio [RR] 1.24; 95% confidence interval [CI] 1.10-1.41) more likely to undergo immediate breast reconstruction than women in noncompetitive markets, whereas those in competitive markets were 25% (RR 1.25; 95% CI 1.11-1.41) more likely to have reconstruction. Later year of treatment, higher census tract income level, and residence in an urban area were associated with an increased likelihood of reconstruction (P < 0.05 for all). In contrast, older age, non-white race, and non-commercial insurance were associated with a lower likelihood of reconstruction (P < 0.05 for all). CONCLUSION Patients who undergo mastectomy at hospitals in competitive markets are more likely to undergo immediate breast reconstruction.
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Affiliation(s)
- Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA. .,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, USA. .,New York Presbyterian Hospital, New York, USA.
| | - Ling Chen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA
| | - Melissa Accordino
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, USA.,New York Presbyterian Hospital, New York, USA
| | - Bret Taback
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA
| | - Cande V Ananth
- Mailman School of Public Health, Columbia University, New York, USA
| | - Alfred I Neugut
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, USA.,New York Presbyterian Hospital, New York, USA.,Mailman School of Public Health, Columbia University, New York, USA
| | - Dawn L Hershman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, USA.,New York Presbyterian Hospital, New York, USA.,Mailman School of Public Health, Columbia University, New York, USA
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The relationship of hospital market concentration, costs, and quality for major surgical procedures. Am J Surg 2018; 216:1037-1045. [PMID: 30060911 DOI: 10.1016/j.amjsurg.2018.07.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/22/2018] [Accepted: 07/24/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our objective was to determine the association between indicators of surgical quality - incidence of major complications and failure-to-rescue - and hospital market concentration in light of differences in costs of care. METHODS Patients undergoing coronary artery bypass graft (CABG), colon resection, pancreatic resection, or liver resection in the 2008-2011 Nationwide Inpatient Sample were identified. The effect of hospital market concentration on major complications, failure-to-rescue, and inpatient costs was estimated at the lowest and highest mortality hospitals using multivariable regression techniques. RESULTS A weighted total of 527,459 patients were identified. Higher market concentration was associated with between 4% and 6% increased odds of failure-to-rescue across all four procedures. Across procedures, more concentrated markets had decreased inpatient costs (average marginal effect ranging from -$3064 (95% CI: -$5812 - -$316) for CABG to -$4876 (-$7773 - -$1980) for liver resection. CONCLUSION In less competitive (more concentrated) hospital markets, higher overall risk of failure-to-rescue after complications was accompanied by lower inpatient costs, on average. These data suggest that market controls may be leveraged to influence surgical quality and costs.
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Min A, Scott LD, Park C, Vincent C, Ryan CJ, Lee T. Impact of Medicare Advantage penetration and hospital competition on technical efficiency of nursing care in US intensive care units. Int J Health Plann Manage 2018; 33:733-745. [PMID: 29635856 DOI: 10.1002/hpm.2528] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/11/2018] [Accepted: 03/13/2018] [Indexed: 11/08/2022] Open
Abstract
This study aimed to evaluate technical efficiency of US intensive care units and determine the effects of environmental factors on technical efficiency in providing quality of nursing care. Data were obtained from the 2014 National Database of Nursing Quality Indicators and the Centers for Medicare and Medicaid Services. Data envelopment analysis was used to estimate technical efficiency for each intensive care unit. Multilevel modeling was used to determine the effects of environmental factors on technical efficiency. Overall, Medicare Advantage penetration and hospital competition in a market did not create pressure for intensive care units to become more efficient by reducing their inputs. However, these 2 environmental factors showed positive influences on technical efficiency in intensive care units with certain levels of technical efficiency. The implications of the study results for management strategies and health policy may vary according to the levels of technical efficiency in intensive care units. Further studies are needed to examine why and how intensive care units with particular levels of technical efficiency are differently affected by certain environmental factors.
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Affiliation(s)
- Ari Min
- College of Nursing, Yonsei University, Seoul, South Korea
| | - Linda D Scott
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Chang Park
- College of Nursing, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Catherine Vincent
- College of Nursing, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Catherine J Ryan
- College of Nursing, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Taewha Lee
- College of Nursing, Yonsei University, Seoul, South Korea
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Cerullo M, Chen SY, Dillhoff M, Schmidt CR, Canner JK, Pawlik TM. Variation in markup of general surgical procedures by hospital market concentration. Am J Surg 2018; 215:549-556. [DOI: 10.1016/j.amjsurg.2017.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/13/2017] [Indexed: 12/17/2022]
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Cerullo M, Chen SY, Dillhoff M, Schmidt C, Canner JK, Pawlik TM. Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery. JAMA Surg 2017; 152:e172158. [PMID: 28746714 PMCID: PMC5831444 DOI: 10.1001/jamasurg.2017.2158] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 04/09/2017] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Trade-offs involved with market competition, overall costs to payers and consumers, and quality of care have not been well defined. Less competition within any given market may enable provider-driven increases in charges. OBJECTIVE To examine the association between regional hospital market concentration and hospital charges for hepatopancreaticobiliary surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This study included all patients undergoing hepatic or pancreatic resection in the Nationwide Inpatient Sample from January 1, 2003, through December 31, 2011. Hospital market concentration was assessed using a variable-radius Herfindahl-Hirschman Index (HHI) in the 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from November 19, 2016, through March 2, 2017. INTERVENTIONS Hepatic or pancreatic resection. MAIN OUTCOMES AND MEASURES Multivariable mixed-effects log-linear models were constructed to determine the association between HHI and total costs and charges for hepatic or pancreatic resection. RESULTS Weighted totals of 38 711 patients undergoing pancreatic resection (50.8% men and 49.2% women; median age, 65 years [interquartile range, 55-73 years]) and 52 284 patients undergoing hepatic resection (46.8% men and 53.2% women; median age, 59 years [interquartile range, 49-69 years]) were identified. Higher institutional volume was associated with lower cost of pancreatic resection (-5.4%; 95% CI, -10.0% to -0.5%; P = .03) and higher cost of hepatic resection (13.4%; 95% CI, 8.2% to 18.8%; P < .001). For pancreatic resections, costs were 5.5% higher (95% CI, 0.1% to 11.1%; P = .047) in unconcentrated hospital markets relative to moderately concentrated markets, although overall charges were 8.3% lower (95% CI, -14.0% to -2.3%; P = .008) in highly concentrated markets. For hepatic resections, hospitals in highly concentrated markets had 8.4% lower costs (95% CI, -13.0% to -3.6%; P = .001) compared with those in unconcentrated markets and charges that were 13.4% lower (95% CI, -19.3% to -7.1%; P < .001) compared with moderately concentrated markets and 10.5% lower (95% CI, -16.2% to -4.4%; P = .001) compared with unconcentrated markets. CONCLUSIONS AND RELEVANCE Higher market concentration was associated with lower overall charges and lower costs of pancreatic and hepatic surgery. For complex, highly specialized procedures, hospital market consolidation may represent the best value proposition: better quality of care with lower costs.
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Affiliation(s)
- Marcelo Cerullo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sophia Y. Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Dillhoff
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
| | - Carl Schmidt
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
| | - Joseph K. Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M. Pawlik
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
- Deputy Editor, JAMA Surgery
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The Influence of Hospital Market Competition on Patient Mortality and Total Performance Score. Health Care Manag (Frederick) 2017; 35:266-76. [PMID: 27455368 DOI: 10.1097/hcm.0000000000000117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Affordable Care Act of 2010 launch of Medicare Value-Based Purchasing has become the platform for payment reform. It is a mechanism by which buyers of health care services hold providers accountable for high-quality and cost-effective care. The objective of the study was to examine the relationship between quality of hospital care and hospital competition using the quality-quantity behavioral model of hospital behavior. The quality-quantity behavioral model of hospital behavior was used as the conceptual framework for this study. Data from the American Hospital Association database, the Hospital Compare database, and the Area Health Resources Files database were used. Multivariate regression analysis was used to examine the effect of hospital competition on patient mortality. Hospital market competition was significantly and negatively related to the 3 mortality rates. Consistent with the literature, hospitals located in more competitive markets had lower mortality rates for patients with acute myocardial infarction, heart failure, and pneumonia. The results suggest that hospitals may be more readily to compete on quality of care and patient outcomes. The findings are important because policies that seek to control and negatively influence a competitive hospital environment, such as Certificate of Need legislation, may negatively affect patient mortality rates. Therefore, policymakers should encourage the development of policies that facilitate a more competitive and transparent health care marketplace to potentially and significantly improve patient mortality.
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Rice SD, Rice MJ, Wedig G. Is Our US Health Care System Actually a Market-Based Economy? Anesth Analg 2015; 121:1114-1115. [PMID: 26378713 DOI: 10.1213/ane.0000000000000829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Scott D Rice
- Department of Economics, Vanderbilt University, Nashville, Tennessee Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, Simon Business School, University of Rochester, Rochester, New York
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O'Neill L. If more competition is the answer, why hasn't it worked? Anesth Analg 2015; 120:3-4. [PMID: 25625247 DOI: 10.1213/ane.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Liam O'Neill
- From the Department of Health Management and Policy, University of North Texas, Fort Worth, Texas
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