Effects of competition and bundled payment on the performance of hip replacement surgery in Stockholm, Sweden: results from a quasi-experimental study.

OBJECTIVE: To evaluate the effects of competition and a bundled payment model on the performance of hip replacement surgery. DESIGN: A quasi-experimental study where a difference-in-differences analytical framework is applied to analyse routinely collected patient-level data from multiple registers. SETTING: Hospitals providing hip replacement surgery in Sweden. PARTICIPANTS: The study included patients who underwent elective primary total hip replacement due to osteoarthritis from 2005 to 2012. The final study sample consisted of 85 275 hip replacement surgeries, where the exposure group consisted of 14 570 surgeries (n=6380 prereform and n=8190 postreform) and the control group consisted of 70 705 surgeries (n=32 799 prereform and n=37 906 postreform). INTERVENTION: A reform involving patient choice, free entry of new providers and a bundled payment model for hip replacement surgery, which came into force in 2009 in Region Stockholm, Sweden. OUTCOME MEASURES: Performance is measured as length of stay of the surgical admission, adverse event rate within 90 days following surgery and patient satisfaction 1 year postsurgery. RESULTS: The reform successfully improved the adverse event rate (1.6 percentage reduction, p<0.05). Length of stay decreased less in the more competitive market than in the control group (0.7 days lower, p<0.01). These effects were mainly driven by university and central hospitals. No effects of the reform on patient satisfaction were found (no significance). CONCLUSIONS: The study concludes that the incentives of the reform focusing on avoidance of adverse events have a predictable impact. Since the payment for providers is fixed per case, the impact on resource use is limited. Our findings contribute to the general knowledge about the effects of financial incentives and market-oriented reforms.

The effects of competition and bundled payment on patient reported outcome measures after hip replacement surgery.

BACKGROUND: Competition-promoting reforms and economic incentives are increasingly being introduced worldwide to improve the performance of healthcare delivery. This study considers such a reform which was initiated in 2009 for elective hip replacement surgery in Stockholm, Sweden. The reform involved patient choice of provider, free establishment of new providers and a bundled payment model. The study aimed to examine its effects on hip replacement surgery quality as captured by patient reported outcome measures (PROMs) of health gain (as indicated by the EQ-5D index and a visual analogue scale (VAS)), pain reduction (VAS) and patient satisfaction (VAS) one and six years after the surgery. METHODS: Using patient-level data collected from multiple national registers, we applied a quasi-experimental research design. Data were collected for elective primary total hip replacements that were carried out between 2008 and 2012, and contain information on patient demography, the surgery and PROMs at baseline and at one- and six-years follow-up. In total, 36,627 observations were included in the analysis. First, entropy balancing was applied in order to reduce differences in observable characteristics between treatment groups. Second, difference-in-difference analyses were conducted to eliminate unobserved time-invariant differences between treatment groups and to estimate the causal treatment effects. RESULTS: The entropy balancing was successful in creating balance in all covariates between treatment groups. No significant effects of the reform were found on any of the included PROMs at one- and six-years follow-up. The sensitivity analyses showed that the results were robust. CONCLUSIONS: Competition and bundled payment had no effects on the quality of hip replacement surgery as captured by post-surgery PROMs of health gain, pain reduction and patient satisfaction. The study provides important insights to the limited knowledge on the effects of competition and economic incentives on PROMs.

A performance comparison of patient pathways in Nordic capital areas - a pilot study for ischaemic stroke patients.

Aims: This article describes and discusses the extension of performance measurement using an episode-based approach so that the measurement includes primary care, and social and long-term-care services. By using data on incident stroke patients from the capital areas of four Nordic countries, this pilot study: (a) extended the disease-based performance analysis to include new indicators that better describe patient care pathways at different levels of care; (b) described and compared the performance of care given in the four areas; (c) evaluated how additional information changed the rankings of performance between the areas; and (d) described the trends in performance in the capital areas. Methods: The construction of data was based on a common protocol that used routinely collected national registers and statistics linked with local municipal registers. We created new variables describing the timing of discharge to home and institutionalisation, as well as describing the use and cost of primary and social hospital services. Risk adjustment was performed with four different sets of confounders. Results: Differences existed in various performance indicators between the four metropolitan areas. The ranking was sensitive to the risk-adjustment method. The study showed that for stroke patients a performance comparison with data that are only from secondary and tertiary care, and without a valid severity measure, is not sufficient for international comparisons. Conclusions: Extending and deepening international performance analysis in order to cover patient pathways, including primary care and social services, is very useful for benchmarking activities when focusing on diseases affecting older people.

The productivity development of total hip arthroplasty in Sweden: a multiple registry-based longitudinal study using the Malmquist Productivity Index.

OBJECTIVE: The increasing demand for total hip arthroplasty (THA) combined with limited resources in healthcare puts pressure on decision-makers in orthopaedics to provide the procedure at minimum costs and with good outcomes while maintaining or increasing access. The objective of this study was to analyse the development in productivity between 2005 and 2012 in the provision of THA. DESIGN: The study was a multiple registry-based longitudinal study. SETTING AND PARTICIPANTS: The study was conducted among 65 orthopaedic departments providing THA in Sweden from 2005 to 2012. OUTCOME MEASURES: The development in productivity was measured by Malmquist Productivity Index by relating department level total costs of THA to the number of non-cemented, hybrid and cemented THAs. We also break down the productivity change into changes in efficiency and technology. RESULTS: Productivity increased significantly in three periods (between 1.6% and 27.0%) and declined significantly in four periods (between 0.8% and 12.1%). Technology improved significantly in three periods (between 3.2% and 16.9%) and deteriorated significantly in two periods (between 10.2% and 12.6%). Significant progress in efficiency was achieved in two periods (ranging from 2.6% to 8.7%), whereas a significant regress was attained in one period (3.9%). For the time span as a whole, an average increase in productivity of 1.4% per year was found, where changes in efficiency contributed more to the improvement (1.1%) than did technical change (0.2%). CONCLUSIONS: We found a slight improvement of productivity over time in the provision of THA, which was mainly driven by changes in efficiency. Further research is, however, needed where differences in quality of care and patient case mix between departments are taken into account.

European Regional Differences in All-Cause Mortality and Length of Stay for Patients with Hip Fracture.

The objective of this study was to compare healthcare performance for the surgical treatment of hip fractures across and within Finland, Hungary, Italy, the Netherlands, Norway, Scotland, and Sweden. Differences in age-adjusted and sex-adjusted 30-day and one-year all-cause mortality rates following hip fracture, as well as the length of stay of the first hospital episode in acute care and during a follow up of 365 days, were investigated, and associations between selected country-level and regional-level factors with mortality and length of stay were assessed. Hungary showed the highest one-year mortality rate (mean 39.7%) and the lowest length of stay in one year (12.7 days), whereas Italy had the lowest one-year mortality rate (mean 19.1 %) and the highest length of stay (23.3 days). The observed variations were largely explained by country-specific effects rather than by regional-level factors. The results show that there should still be room for efficiency gains in the acute treatment of hip fracture, and clinicians, healthcare managers, and politicians should learn from best practices. This study demonstrates that an international comparison of acute hospital care is possible using pooled individual-level administrative data.

Individual and Regional-level Factors Contributing to Variation in Length of Stay After Cerebral Infarction in Six European Countries.

Using patient-level data for cerebral infarction cases in 2007, gathered from Finland, Hungary, Italy, the Netherlands, Scotland and Sweden, we studied the variation in risk-adjusted length of stay (LoS) of acute hospital care and 1-year mortality, both within and between countries. In addition, we analysed the variance of LoS and associations of selected regional-level factors with LoS and 1-year mortality after cerebral infarction. The data show that LoS distributions are surprisingly different across countries and that there is significant deviation in the risk-adjusted regional-level LoS in all of the countries studied. We used negative binomial regression to model the individual-level LoS, and random intercept models and ordinary least squares regression for the regional-level analysis of risk-adjusted LoS, variance of LoS, 1-year risk-adjusted mortality and crude mortality for a period of 31-365 days. The observed variations between regions and countries in both LoS and mortality were not fully explained by either patient-level or regional-level factors. The results indicate that there may exist potential for efficiency gains in acute hospital care of cerebral infarction and that healthcare managers could learn from best practices.

Acute Myocardial Infarction, Use of Percutaneous Coronary Intervention, and Mortality: A Comparative Effectiveness Analysis Covering Seven European Countries.

Percutaneous coronary interventions (PCI) on acute myocardial infarction (AMI) patients have increased substantially in the last 12-15 years because of its clinical effectiveness. The expansion of PCI treatment for AMI patients raises two questions: How did PCI utilization rates vary across European regions, and which healthcare system and regional characteristic variables correlated with the utilization rate? Were the differences in use of PCI associated with differences in outcome, operationalized as 30-day mortality? We obtained our results from a dataset based on the administrative information systems of the populations of seven European countries. PCI rates were highest in the Netherlands, followed by Sweden and Hungary. The probability of receiving PCI was highest in regions with their own PCI facilities and in healthcare systems with activity-based reimbursement systems. Thirty-day mortality rates differed considerably between the countries with the highest rates in Hungary, Scotland, and Finland. Mortality was lowest in Sweden and Norway. The associations between PCI and mortality were remarkable in all age groups and across most countries. Despite extensive risk adjustment, we interpret the associations both as effects of selection and treatments. We observed a lower effect of PCI in the higher age groups in Hungary.

Costs and Quality at the Hospital Level in the Nordic Countries.

This article develops and analyzes patient register-based measures of quality for the major Nordic countries. Previous studies show that Finnish hospitals have significantly higher average productivity than hospitals in Sweden, Denmark, and Norway and also a substantial variation within each country. This paper examines whether quality differences can form part of the explanation and attempts to uncover quality-cost trade-offs. Data on costs and discharges in each diagnosis-related group for 160 acute hospitals in 2008-2009 were collected. Patient register-based measures of quality such as readmissions, mortality (in hospital or outside), and patient safety indices were developed and case-mix adjusted. Productivity is estimated using bootstrapped data envelopment analysis. Results indicate that case-mix adjustment is important, and there are significant differences in the case-mix adjusted performance measures as well as in productivity both at the national and hospital levels. For most quality indicators, the performance measures reveal room for improvement. There is a weak but statistical significant trade-off between productivity and inpatient readmissions within 30 days but a tendency that hospitals with high 30-day mortality also have higher costs. Hence, no clear cost-quality trade-off pattern was discovered. Patient registers can be used and developed to improve future quality and cost comparisons.