Assessing the quality of public services: For-profits, chains, and concentration in the hospital market.

We examine variation in US hospital quality across ownership, chain membership, and market concentration. We propose a new measure of quality derived from penalties imposed on hospitals under the flagship Hospital Readmissions Reduction Program, and use regression models to risk-adjust for hospital characteristics and county demographics. While the overall association between for-profit ownership and quality is negative, there is evidence of substantial heterogeneity. The quality of for-profit relative to non-profit hospitals declines with increasing market concentration. Moreover, the quality gap is primarily driven by for-profit chains. While the competition result mirrors earlier findings in the literature, the chain result appears to be new: it suggests that any potential quality gains afforded by chains are mostly realized by not-for-profit hospitals.

Information and vaccine hesitancy: The role of broadband Internet.

We examine the effect of Internet diffusion on the uptake of an important public health intervention: the measles, mumps and rubella (MMR) vaccine. We study England between 2000 and 2011 when Internet diffusion spread rapidly and there was a high profile medical article (falsely) linking the MMR vaccine to autism. OLS estimates suggest Internet diffusion led to an increase in vaccination rates. This result is reversed after allowing for endogeneity of Internet access. The effect of Internet diffusion is sizable. A one standard deviation increase in Internet penetration led to around a 20% decrease in vaccination rates. Localities characterized by higher proportions of high skilled individuals and lower deprivation levels had a larger response to Internet diffusion. These findings are consistent with higher skilled and less-deprived parents responding faster to false information that the vaccine could lead to autism.

Do responses to news matter? Evidence from interventional cardiology.

We examine physician responses to a global information shock and how these impact their patients. We exploit international news over the safety of an innovation in healthcare, the drug-eluting stent. We use data on interventional cardiologists' use of stents to define and measure cardiologists' responsiveness to the initial positive news and link this to their patients' outcomes. We find substantial heterogeneity in responsiveness to news. Patients treated by cardiologists who respond slowly to the initial positive news have fewer adverse outcomes. This is not due to patient-physician sorting. Instead, our results suggest that the differences are partially driven by slow responders being better at deciding when (not) to use the new technology, which in turn affects their patient outcomes.

JUE Insight: Is hospital quality predictive of pandemic deaths? Evidence from US counties.

In the large literature on the spatial-level correlates of COVID-19, the association between quality of hospital care and outcomes has received little attention to date. To examine whether county-level mortality is correlated with measures of hospital performance, we assess daily cumulative deaths and pre-crisis measures of hospital quality, accounting for state fixed-effects and potential confounders. As a measure of quality, we use the pre-pandemic adjusted five-year penalty rates for excess 30-day readmissions following pneumonia admissions for the hospitals accessible to county residents based on ambulance travel patterns. Our adjustment corrects for socio-economic status and down-weighs observations based on small samples. We find that a one-standard-deviation increase in the quality of local hospitals is associated with a 2% lower death rate (relative to the mean of 20 deaths per 10,000 people) one and a half years after the first recorded death.

Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study.

OBJECTIVE: To examine the impact of nursing team size and composition on inpatient hospital mortality. DESIGN: A retrospective longitudinal study using linked nursing staff rostering and patient data. Multilevel conditional logistic regression models with adjustment for patient characteristics, day and time-invariant ward differences estimated the association between inpatient mortality and staffing at the ward-day level. Two staffing measures were constructed: the fraction of target hours worked (fill-rate) and the absolute difference from target hours. SETTING: Three hospitals within a single National Health Service Trust in England. PARTICIPANTS: 19 287 ward-day observations with information on 4498 nurses and 66 923 hospital admissions in 53 inpatient hospital wards for acutely ill adult patients for calendar year 2017. MAIN OUTCOME MEASURE: In-hospital deaths. RESULTS: A statistically significant association between the fill-rate for registered nurses (RNs) and inpatient mortality (OR 0.9883, 95% CI 0.9773 to 0.9996, p=0.0416) was found only for RNs hospital employees. There was no association for healthcare support workers (HCSWs) or agency workers. On average, an extra 12-hour shift by an RN was associated with a reduction in the odds of a patient death of 9.6% (OR 0.9044, 95% CI 0.8219 to 0.9966, p=0.0416). An additional senior RN (in NHS pay band 7 or 8) had 2.2 times the impact of an additional band 5 RN (fill-rate for bands 7 and 8: OR 0.9760, 95% CI 0.9551 to 0.9973, p=0.0275; band 5: OR 0.9893, 95% CI 0.9771 to 1.0017, p=0.0907). CONCLUSIONS: RN staffing and seniority levels were associated with patient mortality. The lack of association for HCSWs and agency nurses indicates they are not effective substitutes for RNs who regularly work on the ward.

The impact of mental health support for the chronically ill on hospital utilisation: Evidence from the UK.

Individuals with common mental disorders (CMDs) such as depression and anxiety frequently have co-occurring long-term physical health conditions (LTCs) and this co-occurrence is associated with higher hospital utilisation. Psychological treatment for CMDs may reduce healthcare utilisation through better management of the LTC, but there is little previous research. We examined the impact of psychological treatment delivered under the nationwide Improving Access to Psychological Therapies (IAPT) programme in England on hospital utilisation 12-months after the end of IAPT treatment. We examined three types of hospital utilisation: Inpatient treatment, Outpatient treatment and Emergency Room attendance. We examined individuals with Chronic Obstructive Pulmonary Disease (COPD) (n = 816), Diabetes (n = 2813) or Cardiovascular Disease (CVD) (n = 4115) who received psychological treatment between April 2014 and March 2016. IAPT episode data was linked to hospital utilisation data which went up to March 2017. Changes in the probability of hospital utilisation were compared to a matched control sample for each LTC. Individuals in the control sample received IAPT treatment between April 2017 and March 2018. Compared to the control sample, the treated sample had significant reductions in the probability of all three types of hospital utilisation, for all three LTCs 12-months after the end of IAPT treatment. Reductions in utilisation of Emergency Room, Outpatient and non-elective Inpatient treatment were also observed immediately following the end of psychological treatment, and 6-months after, for individuals with diabetes and CVD, compared to the matched sample. These findings suggest that psychological interventions for CMDs delivered to individuals with co-occurring long-term chronic conditions may reduce the probability of utilisation of hospital services. Our results support the roll-out of psychological treatment aimed at individuals who have co-occurring CMDs and long-term chronic conditions.

Socioeconomic deprivation and ethnicity inequalities in disruption to NHS hospital admissions during the COVID-19 pandemic: a national observational study.

INTRODUCTION: Hospital admissions in many countries fell dramatically at the onset of the COVID-19 pandemic. Less is known about how care patterns differed by patient groups. We sought to determine whether areas with higher levels of socioeconomic deprivation or larger ethnic minority populations saw larger falls in emergency and planned admissions in England. METHODS: We conducted a national observational study of hospital care in the English National Health Service (NHS) in 2019-2020. Weekly volumes of elective (planned) and emergency admissions in 2020 compared with 2019 were calculated for each census area. Multiple linear regression analysis was used to estimate the reductions in volumes for areas in different quintiles of socioeconomic deprivation and ethnic minority populations after controlling for national time trends and local area composition. RESULTS: Between March and December 2020, there were 35.5% (3.0 million) fewer elective admissions and 22.0% (1.2 million) fewer emergency admissions with a non-COVID-19 primary diagnosis than in 2019. Areas with the largest share of ethnic minority populations experienced a 36.7% (95% CI 24.1% to 49.3%) larger reduction in non-primary COVID-19 emergency admissions compared with those with the smallest. The most deprived areas experienced a 10.1% (95% CI 2.6% to 17.7%) smaller reduction in non-COVID-19 emergency admissions compared with the least deprived. These patterns are not explained by differential prevalence of COVID-19 cases by area. CONCLUSIONS: Even in a healthcare system founded on the principle of equal access for equal need, the impact of COVID-19 on NHS hospital care for non-COVID patients has not been spread evenly by ethnicity and deprivation in England. While we cannot conclusively determine the mechanisms behind these differences, they risk exacerbating prepandemic health inequalities.

The importance of surgeons and their peers in adoption and diffusion of innovation: An observational study of laparoscopic colectomy adoption and diffusion in England.

Little is known about the role of clinicians in accounting for adoption and diffusion of medical innovations, especially within the English National Health System. This study examines the importance of surgical consultants and their work-based networks on the diffusion of an important innovation, minimally invasive elective laparoscopic colectomy for colorectal cancer. The study used linked patient-level and workforce data on 260,110 elective colectomies and 1288 consultants between 2000 and 2014, to examine adoption of laparoscopic colectomy pre- and post-introduction of clinical guidelines and total share of colectomies performed laparoscopically by adopters. Laparoscopy as a share of elective colectomy increased from 0% in 2000 to 53% in 2014. Surgeons, rather than hospitals, were the principal agents accounting for the increase and explain 46.6% of the variance in laparoscopic colectomy use. Female surgeons, surgeons trained outside the United Kingdom, and recent graduates had higher rates of laparoscopy adoption. More experienced surgeons and surgeons with more peers who perform laparoscopy were more likely to adopt, adopt early and have greater use of laparoscopy. Targeting clinicians, rather than hospitals, is central to increasing adoption and diffusion of new medical technologies.

The Wider Impacts of the Coronavirus Pandemic on the NHS.

The coronavirus pandemic has had huge impacts on the National Health Service (NHS). Patients suffering from the illness have placed unprecedented demands on acute care, particularly on intensive care units (ICUs). This has led to an effort to dramatically increase the resources available to NHS hospitals in treating these patients, involving reorganisation of hospital facilities, redeployment of existing staff and a drive to bring in recently retired and newly graduated staff to fight the pandemic. These increases in demand and changes to supply have had large knock-on effects on the care provided to the wider population. This paper discusses likely implications for healthcare delivery in the short and medium term of the responses to the coronavirus pandemic, focusing primarily on the implications for non-coronavirus patients. Patterns of past care suggest those most likely to be affected by these disruptions will be older individuals and those living in more deprived areas, potentially exacerbating pre-existing health inequalities. Effects are likely to persist into the longer run, with particular challenges around recruitment and ongoing staff shortages.

Recessions and Health: The Long-Term Health Consequences of Responses to the Coronavirus.

The lockdown measures that were implemented in the spring of 2020 to stop the spread of COVID-19 are having a huge impact on economies in the UK and around the world. In addition to the direct impact of COVID-19 on health, the following recession will have an impact on people's health outcomes. This paper reviews economic literature on the longer-run health impacts of business-cycle fluctuations and recessions. Previous studies show that an economic downturn, which affects people through increased unemployment, lower incomes and increased uncertainty, will have significant consequences on people's health outcomes both in the short and longer term. The health effects caused by these adverse macroeconomic conditions will be complex and will differ across generations, regions and socio-economic groups. Groups that are vulnerable to poor health are likely to be hit hardest even if the crisis hit all individuals equally, and we already see that some groups such as young workers and women are worse hit by the recession than others. Government policies during and after the pandemic will play an important role in determining the eventual health consequences.

The causal effect of education on chronic health conditions in the UK.

We study the causal impact of education on chronic health conditions by exploitng two UK education policy reforms. The first reform raised the minimum school leaving age in 1972 and affected the lower end of the educational attainment distribution. The second reform is a combination of several policy changes that affected the broader educational attainment distribution in the early 1990s. Results are consistent across both reforms: an extra year of schooling has no statistically identifiable impact on the prevalence of most chronic health conditions. The exception is that both reforms led to a statistically significant reduction in the probability of having diabetes, and this result is robust across model specifications. However, even with the largest survey samples available in the UK, we are unable to statistically rule out moderate size educational effects for many of the other health conditions, although we generally find considerably smaller effects than OLS associations suggest.

Spatial competition and quality: Evidence from the English family doctor market.

We examine whether family doctor firms in England respond to local competition by increasing their quality. We measure quality in terms of clinical performance and patient-reported satisfaction to capture its multi-dimensional nature. We use a panel covering 8 years for over 8000 English general practices. We measure competition as the number of rival doctors within a small distance and control for a large number of potential confounders. We find that increases in local competition are associated with increases in patient satisfaction and to a lesser extent in clinical quality. However, the magnitude of the effect is small.

The effect of school sports facilities on physical activity, health and socioeconomic status in adulthood.

This paper focuses on the long-term impacts of attending a high school with inadequate sports facilities. We use prospective data from the British National Child Development Study, a continuing panel of a cohort of 17,634 children born in Great Britain during a single week of March 1958. Our empirical approach exploits the educational system they were exposed to: children were sorted by educational ability at age 11, but conditional on educational ability, attended their closest school. This produces quasi-random variation in the quality of the school sports facilities across respondents. We use this variation between cohort members residing within the same local authority area, and focus on outcome measures of physical activity, health, health-related lifestyle activities, and socioeconomic status, collected at ages between 33 and 50 years. We control for any potential links between the inadequacy of sports facilities and inadequacy of other facility types, and test that allocation to school type is random with respect to pre-high school observables. We find that attending a school with inadequate sports facilities led to a statistically significant, modest decrease in the likelihood of physical activity participation during adulthood. In contrast, we find no evidence that inadequate sports facilities worsened adulthood measures of physical and mental health, lifestyle or socioeconomic status.

The impact of publicly subsidised health insurance on access, behavioural risk factors and disease management.

In 2006, the Massachusetts healthcare reform was introduced to mandate health insurance, extend eligibility of publicly subsidised health insurance, improve quality and access to care and develop preventive health services. The objective of this study was to determine the impact of expanding publicly subsidised health insurance through the Massachusetts reform on access to primary care, disease management and behavioural risk factors. Using cross-sectional data from the Behavioural Risk Factor Surveillance System (BRFSS) from 2001 to 2010 and exploiting the selective introduction of the healthcare reform, we assessed its impact on primary care access, behavioural risk factors, such as obesity, and receipt of diabetes management tests. We did so using a differences-in-differences methodology by comparing Massachusetts with other New England States for 131,002 adults under 300% of the federal poverty level and by race/ethnicity within this group. Triple difference estimates were also conducted to control for potential within state time varying confounding factors. The results suggest that increasing publicly subsidised health insurance had a positive impact on primary care access for lower income adults, particularly those that are white. However, with the exception of improvements in alcohol consumption for one specific group (lower income whites) the reform had no effect on behaviour risk factors or diabetes disease management. The aims of the reform were to improve access to care and through this, behavioural risk factors and diabetes management. This study suggests that while access to care was increased, reducing risk factors attributed to health risky behaviour and diabetes cannot be sufficiently done simply by extending health insurance coverage and the provision of preventive services. This suggests that more targeted interventions are required.

Competition in health care: lessons from the English experience.

The use of competition and the associated increase in choice in health care is a popular reform model, adopted by many governments across the world. Yet it is also a hotly contested model, with opponents seeing it, at best, as a diversion of energy or a luxury and, at worst, as leading to health care inequality and waste. This paper subjects the use of competition in health care to scrutiny. It begins by examining the theoretical case and then argues that only by looking at evidence can we understand what works and when. The body of the paper examines the evidence for England. For 25 years the United Kingdom has been subject to a series of policy changes which exogenously introduced and then downplayed the use of competition in health care. This makes England a very useful test bed. The paper presents the UK reforms and then discusses the evidence of their impact, examining changes in outcomes, including quality, productivity and the effect on the distribution of health care resources across socio-economic groups. The final section reflects on what can be learnt from these findings.

Wolves in sheep's clothing: Is non-profit status used to signal quality?

Why do many firms in the healthcare sector adopt non-profit status? One argument is that non-profit status serves as a signal of quality when consumers are not well informed. A testable implication is that an increase in consumer information may lead to a reduction in the number of non-profits in a market. We test this idea empirically by exploiting an exogenous increase in consumer information in the US nursing home industry. We find that the information shock led to a reduction in the share of non-profit homes, driven by a combination of home closure and sector switching. The lowest quality non-profits were the most likely to exit. Our results have important implications for the effects of reforms to increase consumer provision in a number of public services.

Does Quality Affect Patients' Choice of Doctor? Evidence from England.

Reforms giving users of public services choice of provider aim to improve quality. But such reforms will work only if quality affects choice of provider. We test this crucial prerequisite in the English health care market by examining the choice of 3.4 million individuals of family doctor. Family doctor practices provide primary care and control access to non-emergency hospital care, the quality of their clinical care is measured and published and care is free. In this setting, clinical quality should affect choice. We find that a 1 standard deviation increase in clinical quality would increase practice size by around 17%.

Assaults, murders and walkers: The impact of violent crime on physical activity.

We investigate an underexplored externality of crime: the impact of violent crime on individuals' participation in walking. For many adults walking is the only regular physical activity. We use a sample of nearly 1 million people in 323 small areas in England between 2005 and 2011 matched to quarterly crime data at the small area level. Within area variation identifies the causal effect of local violent crime on walking and a difference-in-difference analysis of two high-profile crimes corroborates our results. We find a significant deterrent effect of violent crime on walking that translates into a drop in overall physical activity.

Genetic markers as instrumental variables.

The use of genetic markers as instrumental variables (IV) is receiving increasing attention from economists, statisticians, epidemiologists and social scientists. Although IV is commonly used in economics, the appropriate conditions for the use of genetic variants as instruments have not been well defined. The increasing availability of biomedical data, however, makes understanding of these conditions crucial to the successful use of genotypes as instruments. We combine the econometric IV literature with that from genetic epidemiology, and discuss the biological conditions and IV assumptions within the statistical potential outcomes framework. We review this in the context of two illustrative applications.

Free to Choose? Reform, Choice, and Consideration Sets in the English National Health Service.

Choice in public services is controversial. We exploit a reform in the English National Health Service to assess the effect of removing constraints on patient choice. We estimate a demand model that explicitly captures the removal of the choice constraints imposed on patients. We find that, post-removal, patients became more responsive to clinical quality. This led to a modest reduction in mortality and a substantial increase in patient welfare. The elasticity of demand faced by hospitals increased substantially post- reform and we find evidence that hospitals responded to the enhanced incentives by improving quality. This suggests greater choice can raise quality.