Can governments do it better? Merger mania and hospital outcomes in the English NHS

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Waiting times and socioeconomic status: evidence from England

Waiting times for elective surgery, like hip replacement, are often referred to as an equitable rationing mechanism in publicly-funded healthcare systems because access to care is not based on socioeconomic status. Previous work has established that that this may not be the case and there is evidence of inequality in NHS waiting times favouring patients living in the least deprived neighbourhoods in England. We advance the literature by explaining variations of inequalities in waiting times in England in four different ways. First, we ask whether inequalities are driven by education rather than income. Our analysis shows that education and income deprivation have distinct effects on waiting time. Patients in the first quintile with least deprivation in education wait 9% less than patients in the second quintile and 14% less than patients in the third-to-fifth quintile. Patients in the fourth and fifth most income-deprived quintile wait about 7% longer than patients in the least deprived quintile. Second, we investigate whether inequalities arise "across" hospitals or "within" the hospital. The analysis provides evidence that most inequalities occur within hospitals rather than across hospitals. Moreover, failure to control for hospital fixed effects results in underestimation of the income gradient. Third, we explore whether inequalities arise across the entire waiting time distribution. Inequalities between better educated patients and other patients occur over large part of the waiting time distribution. Moreover we find that the education gradient becomes smaller for very long waiting. Fourth, we investigate whether the gradient may reflect the fact that patients with higher socioeconomic status have a different severity as proxied through a range of types and the number of diagnoses (in addition to age and gender) compared to those with lower socioeconomic status. We find no evidence that differences in severity explain the social gradient in waiting times

Impact of laparoscopic versus open surgery on hospital costs for colon cancer: a population-based retrospective cohort study

OBJECTIVE: Laparoscopy is increasingly being used as an alternative to open surgery in the treatment of patients with colon cancer. The study objective is to estimate the difference in hospital costs between laparoscopic and open colon cancer surgery. DESIGN: Population-based retrospective cohort study. SETTINGS: All acute hospitals of the National Health System in England. POPULATION: A total of 55 358 patients aged 30 and over with a primary diagnosis of colon cancer admitted for planned (elective) open or laparoscopic major resection between April 2006 and March 2013. PRIMARY OUTCOMES: Inpatient hospital costs during index admission and after 30 and 90 days following the index admission. RESULTS: Propensity score matching was used to create comparable exposed and control groups. The hospital cost of an index admission was estimated to be £1933 (95% CI 1834 to 2027; p<0.01) lower among patients who underwent laparoscopic resection. After including the first unplanned readmission following index admission, laparoscopy was £2107 (95% CI 2000 to 2215; p<0.01) less expensive at 30 days and £2202 (95% CI 2092 to 2316; p<0.01) less expensive at 90 days. The difference in cost was explained by shorter hospital stay and lower readmission rates in patients undergoing minimal access surgery. The use of laparoscopic colon cancer surgery increased 4-fold between 2006 and 2012 resulting in a total cost saving in excess of £29.3 million for the National Health Service (NHS). CONCLUSIONS: Laparoscopy is associated with lower hospital costs than open surgery in elective patients with colon cancer suitable for both interventions

Impact of 'high-profile' public reporting on utilization and quality of maternity care in England: a difference-in-difference analysis

Objectives To evaluate the impact of high profile public reporting on utilisation and perceived quality of maternity services in England. Methods Analysis of national hospital administrative data using difference in difference models with propensity score matching and analysis of two maternity surveys from 2007 and 2010. Outcomes were counts of women admitted for delivery of a baby and the percentage of women rating their care positively in 2007 and 2010. Results Hospitals publicised as providing the best maternity care in England had fewer admissions annually and lower occupancy rates (63.0% vs. 77.3%; p=0.09) than the national comparison group. Hospitals publicised as providing the worst maternity care were predominantly in the greater London area, with more women aged 15-34 years in their catchment areas than the national comparison group. There was no statistically significant change in overall maternity admissions in the best hospitals (+ 2.2%, p=0.40 at six months), or the worst hospitals (- 2.8%, p=0.49 at six months) during any period in the thirty-six months after public reporting relative to baseline. Compared to the national comparison group the worst rated hospitals experienced greater improvements in perceived quality after public reporting but these findings were not maintained in the matched analysis. Conclusions High profile public reporting of maternity care in England was not associated with changes in the utilisation of maternity services or improvements in patient reported quality. These findings provide further evidence that public reporting is unlikely to drive major improvements in health system performance through the mechanism of patient choice

Measuring NHS output growth

We report estimates of output growth for the National Health Service in England over the period 2003/4 to 2006/7. Our output index is virtually comprehensive, capturing as far as possible all the activities undertaken for NHS patients by both NHS and non-NHS providers across all care settings. We assess the quality of output by measuring the waiting times and survival status of every single patient treated in hospital, and we allow for improved disease management in primary care. We propose and apply a method that avoids the traditional requirement for consistent definition of output categories over time in construction of output indices. Use of our approach is critical: it would be not otherwise be possible to calculate output growth for the NHS over the years we consider in any meaningful way. After correcting for significant improvements in data collection in the early period, output growth for the NHS between 2003/4 to 2006/7 averages 5.1% per year, of which 1% is due to improvements in the quality of care

What explains variation in the costs of treating patients in English obstetrics specialties?

We assess patients admitted to English obstetrics departments to identify what proportion of variation in their costs is explained by patient characteristics and what proportion is due to departmental characteristics. Hospital Episode Statistics records for every patient admitted to obstetrics departments are matched to Reference Cost data by HRG reported by all English hospitals for the year 2005/6. Our sample consists of 951,277 patients in 136 departments. We estimate fixed effects models analysing patient-level costs, explore departmental characteristics that drive variation in costs at department-level and explore the sensitivity of results to the use of the full sample and sub-samples of obstetrics patients. Patient costs depend on various diagnostic characteristics over and above the HRG classification, particularly whether the patient suffered infection. After controlling for patient characteristics a substantial amount of unexplained variation in costs remains at departmental level. Higher costs are evident in departments that are not supported by a neonatology specialty and where factor prices are higher. There is evidence of lower costs in departments with high volumes of activity. We identify departments where further scrutiny of their high costs is required