Hospital procedures concentration: how to combine quality and patient choice.

The main focus of this PhD thesis is the use of managerial tools in the healthcare sector. In particular, the principal topic we focus on is the volume-outcome association, a relationship that has been empirically identifed in medical specialties. According to this relationship, there exists a positive association between the number of interventions (the so called volume of activity) performed by a facility and the quality of clinical outcomes, measured in terms of patients’ health conditions. The volume-outcome association has been identifed back in 1979, and it has been particularly documented in the last two decades for a variety of interventions and different outcome measures. All the studies mainly reveal that there is a positive effect of volume on outcomes for each medical procedure, although its extent varies depending on the clinical area itself. The observed trend can be explained by two main factors: (i) on a hospital level, the structure by which care is organised is likely to be poorer in low volume hospitals, which might lack consistent processes for postoperative care or for dealing with ostoperative complications; (ii) on a personnel level, outcomes may also be related to the familiarity of the staff with the treatment. Despite the number of studies focusing on it, the volume–outcome association still raises interest, due to the persistence of low volumes performed in healthcare facilities, in particular in Italian hospitals. Our starting point is the National Outcome Evaluation Program (PNE), a project sponsored by the Italian government that each year, from 2012, reports hospitals clinical performances with the objective to assess healthcare service quality levels. While many researchers have focused on the existence of the volume-outcome association from a clinical perspective, this PhD project deepens the volume-outcome association from a managerial perspective, by including it in a planning problem. The planning problem analysed consists in the decision of how to distribute volumes of activity among wards of hospitals perating in a same geographical area. In particular, among the different specialties, we consider surgery wards, since better results for higher volumes are especially plausible for this case. Our ultimate bjective is to exploit the information contained within the volume–outcome association and, as a consequence of the existing link among volume and outcomes, to reach an optimal planning for hospital wards. In this way, the reorganization of hospitals operating in a territory (planning decision) translates into the improvement of healthcare organization outcomes (clinical result). We take as reference healthcare system the Italian National Healthcare System (Servizio Sanitario Nazionale, SSN), a public health system that provides universal coverage for comprehensive and essential health services. The formulation of our problem varies depending on which actor is considered. In the SSN, there is a central decision maker, the commissioner, in charge of guaranteeing the compliance with the principles of universality, equality and equity. It is represented by an institutional figure at the national level, i.e., the Ministry of Health. However, all the administrative levels (e.g., Regions, municipalities, etc.) have to ollaborate in order to guarantee health quality to all the citizens. Hence, we can think of a commissioner at each layer of the system, which is responsible for the population health. Beyond the commissioner, other actors compose the Italian healthcare system. In particular, three other categories are involved in planning problems: providers, physicians and patients. Commissioners emand to providers to supply healthcare services. Providers (i.e., hospital administrators) answer through the supply of the requested services. Medical staff (surgeons, anesthetists, nurses, etc.) are the experts who deal with patients, who in turn receive the service. It should be noticed that there is no constraint enforcing patients to choose a specifc hospital where to be treated, and no patient is forced to receive healthcare services. Each actor has its own interests and perspectives, and therefore it is relevant to keep into consideration their different behaviors and interactions. Since the allocation of operation volumes to healthcare structures is a strategic decision that deals with territorial healthcare confguration and people health needs, we initially take the perspective of the commissioner, who is the first actor involved in this decision process. All the other actors will face the consequences of such strategic choice: providers will have to adapt the capacity of their structures to the new planned demand; medical staff will have to arrange new shifts and work organisation; patients will face new openings/closures of hospitals and will have to choose where to be treated. Among them, we reckoned as particularly worthy of attention the patients’ perspective, since their behaviour can alter the whole commissioner plan. The thesis is structured as follows. Chapter 2 summarizes the relevant literature. The chapter is organized in two sections dedicated to the two main felds of studies we refer to, namely location and allocation problems (from the health management literature) and choice models (from the health economics literature). Moreover, a section of the chapter reports the state of the art of the researches that have been conducted on the volume–outcome association. Chapter 3 is dedicated to the policy maker’s perspective. We take the point of view of the commissioners, i.e., that of planning the volume to be allocated to each hospital, and we propose an approach (based on mathematical programming) to determine the number of interventions to be strategically allocated to surgery wards, given several constraints related to hospital capacity, demand satisfaction and pidemiological concerns. Concentration vs. scattering of interventions among healthcare structures are explored in terms of quality and equity offered to the whole population. The proposed approach is tested on four case studies taking into account real life factors (such as reallocation of interventions, geographical distribution of hospitals, volume threshold constraints, and dissimilarities among hospital performances), and results are compared with real data from the PNE. Chapter 4 focuses on patients’ perspective. Specifcally, we analysed patients’ choice, in terms of hospital where they have decided to be treated, together with the list of hospitals that were available to them. By using the econometric methodology of the conditional logit, we modeled the trade-off faced by patients between hospitals’ characteristics, i.e., distance and quality. Eventually, we applied the choice model to Hospital Discharge Data for colon cancer patients in Piedmont from 2004 to 2014, showing patients’ revealed preferences. Results shed some light on how patients can react to facility specialization or closure, depending on demographic, social and clinical factors. Chapter 5 gathers the two perspectives and merge them. The objective is to support planning decisions that (i) are effective in terms of better health outcomes and (ii) guarantee patients’ choices to respect the volumes that have been strategically planned. To this aim, we explored two distinct approaches. The frst approach enriches the one proposed in Chapter 3 with the commissioner point of view, by adding constraints involving patients, e.g., the maximum distance they are willing to travel. The second approach, instead, aims to fully integrate patients’ and policy maker’s perspectives, by inserting predictions on patients’ behaviour within the decisional process of the policy maker. Eventually, results from all the approaches are compared, in terms of organizational quality and population health

Reappraisal of PRRS Immune Control Strategies: The Way Forward

The control of porcine reproductive and respiratory syndrome (PRRS) is still a major issue worldwide in the pig farming sector. Despite extensive research efforts and the practical experience gained so far, the syndrome still severely affects farmed pigs worldwide and challenges established beliefs in veterinary virology and immunology. The clinical and economic repercussions of PRRS are based on concomitant, additive features of the virus pathogenicity, host susceptibility, and the influence of environmental, microbial, and non-microbial stressors. This makes a case for integrated, multi-disciplinary research efforts, in which the three types of contributing factors are critically evaluated toward the development of successful disease control strategies. These efforts could be significantly eased by the definition of reliable markers of disease risk and virus pathogenicity. As for the host’s susceptibility to PRRSV infection and disease onset, the roles of both the innate and adaptive immune responses are still ill-defined. In particular, the overt discrepancy between passive and active immunity and the uncertain role of adaptive immunity vis-à-vis established PRRSV infection should prompt the scientific community to develop novel research schemes, in which apparently divergent and contradictory findings could be reconciled and eventually brought into a satisfactory conceptual framework

Improving surgical outcomes through optimal volumes allocation

In this paper, we propose an innovative managerial use of the volume-outcome association, a relation that associates higher volume of activity to better results. We analyze how this relation can be used to help decision makers in allocating surgery interventions among health care structures, a relevant long term planning problem. We analytically study different objective functions in order to drive the allocation process towards better health conditions for patients. We provide a decision support tool for health policy makers, which helps achieving better population health, in terms of quality and fairness. Our approach has been tested on three case studies taking into account real life factors such as geographical distribution of hospitals, specialization thresholds and hospital performance. Results have been compared to the real data from the Italian National Outcome Evaluation Program

Hospital volume allocation: integrating decision maker and patient perspectives

Planning problems in healthcare systems have received greater attention in the last decade, especially because of the concerns recently raised about the scattering of surgical interventions among a wide number of different facilities that can undermine the quality of the outcome due to the volume-outcome association. In this paper, an approach to plan the amount of surgical interventions that a facility has to perform to assure a low adjusted mortality rate is proposed. The approach explicitly takes into account the existing interaction among patients' choices and decision makers' planning decisions. The first objective of the proposed approach is to find a solution able to reach quality in health outcomes and patients' adherence. The second objective is to investigate the difference among solutions that are identified as optimal by either only one of the actors' perspective, i.e., decision makers and patients, or by considering both the perspectives simultaneously. Following these objectives, the proposed approach is applied to a case study on Italian colon cancer interventions performed in 2014. Results confirm a variation in the hospital planned volumes when considering patients' behaviour together with the policy maker plan, especially due to personal preferences and lack of information about hospital quality

Improving surgical outcomes through optimal volumes allocation

reserved3noCodice ISI non ancora disponibilieIn this paper, we propose an innovative managerial use of the volume-outcome association, a relation that associates higher volume of activity to better results. We analyze how this relation can be used to help decision makers in allocating surgery interventions among health care structures, a relevant long term planning problem. We analytically study different objective functions in order to drive the allocation process towards better health conditions for patients. We provide a decision support tool for health policy makers, which helps achieving better population health, in terms of quality and fairness. Our approach has been tested on three case studies taking into account real life factors such as geographical distribution of hospitals, specialization thresholds and hospital performance. Results have been compared to the real data from the Italian National Outcome Evaluation Program.mixedAlfieri, Arianna; Listorti, Elisabetta; Matta, AndreaAlfieri, Arianna; Listorti, Elisabetta; Matta, Andre