FOUR ESSAYS ON PERFORMANCE MEASURES BASED ON PATIENT-REPORTED OUTCOMES

Agency relationships, and associated information symmetries, exist in many areas of economic activity including healthcare. Information on healthcare providers’ relative performance can be used to reduce information asymmetries and hold providers to account. This collection of essays focuses on the appropriate derivation and use of performance measures to incentivise healthcare providers in the English National Health Service (NHS). It gives special consideration to the role of patient self-reported health status measures to assess the differential effect of healthcare providers’ care on their patients’ health. The thesis explores three themes: the relationship between variation in resource use and quality, the appropriate assessment and reporting of multidimensional hospital performance, and the use of performance information to motivate hospitals in a public reporting context. Chapter 2 examines cost variation between hospitals for the four surgical procedures covered by the national patient-reported outcome measures (PROM) programme. It explores the empirical relationship between costs and patient health outcomes to assess the claim of hospital providers that their higher costs are justified by better quality of care. Chapter 3 sets out an empirical methodology to conduct provider performance comparisons when there are multiple dimensions of health-related quality of life affected by treatment. It discusses the advantages and disadvantages of analysing disaggregate PROM data for the purpose of informing prospective patients, clinicians and managers. Chapter 4 extends the previous chapter by providing a methodology for assessing and summarising multidimensional provider performance using dominance criteria. This methodology is then applied to study the performance of providers of hip replacement surgery with respect to length of stay, emergency readmissions, waiting time and improvements in PROMs. Chapter 5 estimates the demand elasticity of providers with respect to quality. It makes use of choice models to assess the usefulness of disseminating hospital PROM scores to prospective patients as a market-based incentive for providers to compete on quality

Inequality of opportunity in a land of equal opportunities: The impact of parents' health and wealth on their offspring's quality of life in Norway

Background: The literature on Inequality of opportunity (IOp) in health distinguishes between circumstances that lie outside of own control vs. eforts that – to varying extents – are within one’s control. From the perspective of IOp, this paper aims to explain variations in individuals’ health-related quality of life (HRQoL) by focusing on two separate sets of variables that clearly lie outside of own control: Parents’ health is measured by their experience of somatic diseases, psychological problems and any substance abuse, while parents’ wealth is indicated by childhood fnancial conditions (CFC). We further include own educational attainment which may represent a circumstance, or an efort, and examine associations of IOp for diferent health outcomes. HRQoL are measured by EQ-5D-5L utility scores, as well as the probability of reporting limitations on specifc HRQoL-dimensions (mobility, self-care, usual-activities, pain & discomfort, and anxiety and depression). Method: We use unique survey data (N=20,150) from the egalitarian country of Norway to investigate if diferences in circumstances produce unfair inequalities in health. We estimate cross-sectional regression models which include age and sex as covariates. We estimate two model specifcations. The frst represents a narrow IOp by estimating the contributions of parents’ health and wealth on HRQoL, while the second includes own education and thus represents a broader IOp, alternatively it provides a comparison of the relative contributions of an efort variable and the two sets of circumstance variables. Results: We fnd strong associations between the circumstance variables and HRQoL. A more detailed examination showed particularly strong associations between parental psychological problems and respondents’ anxiety and depression. Our Shapley decomposition analysis suggests that parents’ health and wealth are each as important as own educational attainment for explaining inequalities in adult HRQoL. Conclusion: We provide evidence for the presence of the lasting efect of early life circumstances on adult health that persists even in one of the most egalitarian countries in the world. This suggests that there may be an upper limit to how much a generous welfare state can contribute to equal opportunities

Multidimensional performance assessment using dominance criteria

Public sector organisations pursue multiple objectives and serve a number of stakeholders. But stakeholders are rarely explicit about the valuations they attach to different objectives, nor are these valuations likely to be identical. This complicates the assessment of their performance because no single set of weights can be legitimately chosen by regulators to aggregate outputs into unidimensional composite scores. We propose the use of dominance criteria in a multidimensional performance assessment framework to identify best practice and poor performance under relatively weak assumptions about stakeholders’ preferences. We estimate multivariate multilevel models to study providers of hip replacement surgery in the English NHS with respect to their performance in terms of length of stay, readmission rates, post-operative patient-reported health status and waiting time. We find substantial correlation between objectives and demonstrate that ignoring the correlation can lead to incorrect assessments of performance

Hospital Variation in Patient-Reported Outcomes at the Level of EQ-5D Dimensions : Evidence from England

•Background. The English Department of Health has introduced routine collection of patient-reported outcome data for selected surgical procedures to facilitate patient choice and increase hospital accountability. However, using aggregate health outcome scores, such as EQ-5D utilities, for performance assessment purposes causes information loss and raises statistical and normative concerns. Objectives. For hip replacement surgery, we explore a) the change in patient-reported outcomes between baseline and follow-up on 5 health dimensions (EQ-5D), b) the extent to which treatment impact varies across hospitals, and c) the extent to which hospital performance on EQ-5D dimensions is correlated with performance on the EQ-5D utility index. Methods. We combine information on pre- and postoperative EQ-5D outcomes with routine inpatient data for the financial year 2009–2010. The sample consists of 21,000 patients in 153 hospitals. We employ hierarchical ordered probit risk-adjustment models that recognize the multilevel nature of the data and the response distributions. The treatment impact is modeled as a random coefficient that varies at the hospital level. We obtain hospital-specific empirical Bayes (EB) estimates of this coefficient. We estimate separate models for each EQ-5D dimension and the EQ-5D utility index and analyze correlations of EB estimates across these. Results. Hospital treatment is associated with improvements in all EQ-5D dimensions. Variability in treatment impact is most pronounced on the mobility and usual activities dimensions. Conversely, only pain/discomfort and anxiety/depression correlate well with performance measures based on utilities. This leads to different assessments of hospital performance across metrics. Conclusions. Our results indicate which hospitals are better than others in improving health across particular EQ-5D dimensions. We demonstrate the importance of evaluating dimensions of the EQ-5D separately for the purposes of hospital performance assessment

Waiting time prioritisation : Evidence from England

A number of OECD countries have introduced waiting time prioritisation policies which give explicit priority to severely ill patients with high marginal disutility of waiting. There is however little empirical evidence on how patients are actually prioritised. We exploit a unique opportunity to investigate this issue using a large national dataset with accurate measures of severity on nearly 400,000 patients. We link data from a national patient-reported outcome measures survey to administrative data on all patients waiting for a publicly funded hip and knee replacement in England during the years 2009-14. We find that patients suffering the most severe pain and immobility have shorter waits than those suffering the least, by about 24% for hip replacement and 11% for knee replacement, and that the association is approximately linear. These differentials are more closely associated with pain than immobility, and are larger in hospitals with longer average waiting times. These result suggests that doctors prioritise patients according to severity even when no formal prioritisation policy is in place and average waiting times are short

In the modern era of percutaneous coronary intervention: Is cardiac rehabilitation engagement purely a patient or a service level decision?

Aims: Despite the proven benefits of cardiac rehabilitation (CR), utilization rates remain below recommendation in the percutaneous coronary intervention cohort in most European countries. Although extensive research has been carried out on CR uptake, no previous study has investigated the factors that lead patients to attend the initial CR baseline assessment (CR engagement). This paper attempts to provide new insights into CR engagement in the growing percutaneous coronary intervention population. Methods and results: In total, we analysed data on 59,807 patients who underwent percutaneous coronary intervention during 2013 to 2016 (mean age 65 years; 25% female). Twenty factors were hypothesized to have a direct impact on CR engagement and they were grouped into four main categories; namely socio-demographic factors, cardiac risk factors, medical status and service-level factors. A binary logistic regression model was constructed to examine the association between CR engagement and tested factors. All but one of the proposed factors had a statistically significant impact on CR engagement. Results showed that CR engagement decreases by 1.2% per year of age (odds ratio 0.98) and is approximately 7% lower (odds ratio 0.93) in female patients, while patients are 4.4 times more likely to engage if they receive a confirmed joining date (odds ratio 4.4). The final model achieved 86.6% sensitivity and 49.0% specificity with an area under the receiver operating characteristic curve of 0.755. Conclusion: The present results highlight the important factors of the likelihood of CR engagement. This implies that future strategies should focus on factors that are associated with CR engagement

Who keeps on working? The importance of resilience for labour market participation

Background It is widely recognized that individuals’ health and educational attainments, commonly referred to as their human capital, are important determinants for their labour market participation (LMP). What is less recognised is the influence of individuals’ latent resilience traits on their ability to sustain LMP after experiencing an adversity such as a health shock. Aim We investigate the extent to which resilience is independently associated with LMP and moderates the effect of health shocks on LMP. Method We analysed data from two consecutive waves of a Norwegian prospective cohort study. We followed 3,840 adults who, at baseline, were healthy and worked full time. Binary logistic regression models were applied to explain their employment status eight years later, controlling for age, sex, educational attainment, health status at baseline, as well as the occurrences of three types of health shocks (cardiovascular diseases, cancer, psychological problems). Individuals’ resilience, measured by the Resilience Scale for Adults (RSA), entered as an independent variable and as an interaction with the indicators of health shocks. In separate models, we explore the role of two further indicators of resilience; locus of control, and health optimism. Results As expected, health shocks reduce the probability to keep on working full-time. While both the RSA and the two related indicators all suggest that resilience increases the probability to keep on working, we did not find evidence that resilience moderates the association between health shocks and LMP