Utilización de datos masivos para la evaluación del desempeño del Sistema Nacional de Salud

[spa] El derecho universal a la atención sanitaria básica requiere un sistema sanitario sustentado sobre los mandatos explícitos de la maximización de la salud, respondiendo a las expectativas de la población de cobertura y la articulación de un sistema de financiación que garantice la sostenibilidad de la provisión de los servicios. Sin embargo, la diversidad de las necesidades en salud y la heterogeneidad de los tipos de atención sanitaria hacen necesaria la medición del desempeño atendiendo a dominios específicos. Esto implica la adaptación de los principios generales de la medición del desempeño a áreas de enfermedades concretas o niveles de atención sanitaria específicos, como pueda ser la atención hospitalaria en los centros de agudos, los cuales representan más del 60% del presupuesto público destinado a salud. La presente tesis doctoral, haciendo uso de la base de microdatos clínicos-administrativos hospitalarios más extensa existente en España, evalúa el desempeño del Sistema Nacional de Salud (SNS), entre 2003 y 2015, monitorizando a los proveedores de los servicios hospitalarios de agudos. Para ello se recoge en 5 artículos, con enfoques metodológicos complementarios, los análisis de dominios específicos de las dimensiones del desempeño, como son el gasto hospitalario, la eficiencia técnica y la calidad de los servicios, atendiendo, por último, a la evaluación del desempeño de la prestación de los servicios sanitarios a través de la fórmula de partenariado público-privado (PPP) de los mismos. Los principales hallazgos muestran que, en el SNS, donde no existe un mercado “real” dada la naturaleza puramente "pública" del sistema de salud español, el gasto público hospitalario se encuentra, de manera sostenida en el tiempo, determinado por la utilización de los servicios, en detrimento de los factores asociados a los costes de los factores productivos empleados, una vez que ajustados los factores de necesidad de la población en términos de envejecimiento y carga de enfermedad. El gasto hospitalario dibujó, en la evolución de su tasa de crecimiento interanual, un escenario de profunda inercia con el ciclo macroeconómico. Así mismo, en el contexto descentralizado del SNS, destaca el elevado impacto de las Comunidades Autónomas como “clúster” en la explicación del gasto hospitalario, lo que sugiere que factores no observados a nivel de éstas, aunque determinantes en la toma de decisiones, están afectando al gasto de las áreas sanitarias de manera diferente. En términos técnicos, los hospitales de agudos que sirven al SNS experimentaron de forma generalizada una mejora de su eficiencia y su calidad, enfatizado por el progreso tecnológico, aunque estas mejorasse comportaron de manera desigual cuando nos adentramos al detalle en cada uno de los proveedores. Es decir, no todos los hospitales que experimentaron mejoras en su eficiencia mejoraron igualmente su calidad, ni viceversa. Por último, contrastando el PPP de Alzira con sus pares homogéneos de titularidad pública, ésta alcanza resultados estadísticamente peores que los proveedores de referencia en la mayoría de las hospitalizaciones potencialmente evitables (HPE); en mortalidad por infarto, CABG e ictus isquémico; en la mayoría de los procedimientos de bajo valor y en eficiencia técnica. En algunos indicadores, el desempeño del 2015 empeoró respecto al 2003 (en la HPE por deshidratación, en histerectomía en condiciones benignas, en cirugía de espalda o reemplazo de rodilla, y en mortalidad por CABG o ictus isquémico). No obstante, entre un 25% y un 50% de sus homogéneos comparables de titularidad pública obtuvieron un desempeño peor que Alzira. Así mismo, Alzira se comportó como referente en indicadores como la mortalidad tras la intervención coronaria percutánea (ICP) y en términos del gasto hospitalario per cápita, deflactado y ajustado por gravedad.[cat] El dret universal a l'atenció sanitària bàsica requereix d’un sistema sanitari basat sobre els mandats explícits de la maximització de la salut, que responguin a les expectatives de la població de cobertura i l'articulació d'un sistema de finançament que garanteixi la sostenibilitat de la provisió dels serveis. No obstant això, la diversitat de les necessitats en salut i l'heterogeneïtat dels tipus d'atenció sanitària fan necessari el mesurament de l'acompliment atenent dominis específics. Això implica l'adaptació dels principis generals del mesurament de l'acompliment a àrees de malalties concretes o nivells d'atenció sanitària específics, com pugui ser l'atenció hospitalària en els centres d'aguts, els quals representen més del 60% del pressupost públic destinat a salut. En aquesta tesi doctoral, fent ús de la base de microdades clínico-administratives hospitalàries més extensa existent a Espanya, s’avalua l'acompliment del Sistema Nacional de Salut (SNS), entre 2003 i 2015, monitoritzant als proveïdors dels serveis hospitalaris d'aguts. Per a això, es recull en 5 articles, amb enfocaments metodològics complementaris, les anàlisis de dominis específics de les dimensions de l'acompliment, com són la despesa hospitalària, l'eficiència tècnica i la qualitat dels serveis, atenent, finalment, a l'avaluació de l'acompliment de la prestació dels serveis sanitaris a través de la fórmula de partenariat públic-privat (PPP) d'aquests. Les principals troballes mostren que, en el SNS, on no existeix un mercat “real” donada la naturalesa purament "pública" del sistema de salut espanyol, la despesa pública hospitalària es troba, de manera sostinguda en el temps, determinada per la utilització dels serveis (hospitalitzacions mèdiques, intervencions quirúrgiques amb ingrés i cirurgia ambulatòria), en detriment dels factors associats als costos dels factors productius emprats, una vegada que s'ajusten els factors de necessitat de la població, en termes d'envelliment i càrrega de malaltia. La despesa hospitalària va dibuixar, en l'evolució de la seva taxa de creixement interanual, un escenari de profunda inèrcia amb el cicle macroeconòmic. Així mateix, en el context descentralitzat del SNS, destaca l'elevat impacte de les Comunitats Autònomes com a “clúster” en l'explicació de la despesa hospitalària, la qual cosa suggereix que factors no observats a nivell d’aquestes, encara que determinants en la presa de decisions, estan afectant la despesa de les àrees sanitàries de manera diferent. Des d’un enfocament tècnic, els hospitals d'aguts que serveixen al SNS van experimentar de forma generalitzada una millora de la seva eficiència i la seva qualitat, emfatitzat pel progrés tecnològic, encara que aquestes millores es comporten de manera desigual quan ens endinsem al detall en cadascun dels proveïdors. És a dir, no tots els hospitals que van experimentar millores en la seva eficiència van millorar igualment la seva qualitat, ni viceversa. Finalment, contrastant el PPP d'Alzira amb els seus parells homogenis de titularitat pública, aquesta aconsegueix resultats estadísticament pitjors que els proveïdors de referència en la majoria de les hospitalitzacions potencialment evitables (HPE); en mortalitat per infart, CABG i ictus isquèmic; en la majoria dels procediments de baix valor i en eficiència tècnica. En alguns indicadors, l'acompliment del 2015 va empitjorar respecte al 2003 (en la HPE per deshidratació, en histerectomia en condicions benignes, en cirurgia d'esquena o reemplaçament de genoll, i en mortalitat per CABG o ictus isquèmic). No obstant això, entre un 25% i un 50% dels seus homogenis comparables de titularitat pública van obtenir un acompliment pitjor que Alzira. Així mateix, Alzira es va comportar com a referent en indicadors com la mortalitat després de la intervenció coronària percutània i en termes de la despesa hospitalària per càpita, deflactada i ajustada per gravetat.[eng] The universal right to get basic healthcare requires a health system based on the explicit mandates of maximizing health, responding to the covered population's expectations and the articulation of a financing system that guarantees the sustainability of the provision of healthcare services. However, the diversity of health needs and the heterogeneity of healthcare types of services make necessary the measurement of performance according to specific domains. This implies adapting the general principles of performance measurement to specific disease areas or specific healthcare levels of attention, such as hospital care in acute care hospitals, which represent more than 60% of the public budget allocated to health. This doctoral thesis, using the biggest clinical-administrative real-world data infrastructure in Spain, assesses the performance of the National Health System (NHS), between 2003 and 2015, by monitoring the providers of the acute care hospital services. For this porpoise, 5 scientific papers are gathered, analysing specific domains of the dimensions of performance. Dimensions such as hospital expenditure, technical efficiency and quality of services were assessed through complementary methodological approaches. Finally, the performance assessment of the provision of healthcare services under the formula of public-private partnership (PPP) is also addressed. The main findings showed how, in the SNHS, where there is no "real" market in place due to the purely "public good" nature of the Spanish health system, public hospital expenditure is consistently determined by the use of services (medical hospitalizations, surgical interventions with admission and day-case surgery), rather than by factors associated to the costs of the factors of production employed, once the factors associated to population needs, in terms of aging and burden of disease, are adjusted. At the same time the evolution of its interannual growth rate showed a scenario of deep inertia towards the macroeconomic cycle. Likewise, in the decentralised context of the SNHS, the huge impact of the autonomous communities as "cluster" on healthcare area hospital expenditure strongly suggest that unobserved factors at regional level, although determinant for the decision-making process, are affecting the expenditure differently. Finally, assessing a PPP performance, Alzira’s achievements were statistically worse than those in benchmark public-tenured providers in most of potentially avoidable hospitalizations (PAH); in mortality due to Myocardial Infarction, CABG and Ischaemic Stroke, in most of low value procedures, and in technical efficiency. Moreover, in some indicators, performance in 2015 worsened since 2003; in particular, in PAH for dehydration, in the rate of hysterectomies in benign conditions, in the rates of back surgery or knee replacement, and in mortality due to CABG or ischemic stroke. However, between a 25% and a 50% of public tenured peers performed worse than Alzira. Likewise, Alzira behaved as a benchmark in a number of indicators, -mortality after PCI, and deflated, severity-adjusted per capita expenditure in specialized care

Comparing Hospital Efficiency: An Illustrative Study of Knee and Hip Replacement Surgeries in Spain

WHO’s Health Systems Performance Assessment framework suggests monitoring a set of dimensions. This study aims to jointly assess productivity and quality using a treatment-based approach, specifically analyzing knee and hip replacement, two prevalent surgical procedures performed with consolidated technology and run in most acute-care hospitals. Focusing on the analysis of these procedures sets out a novel approach providing clues for hospital management improvements, covering an existing gap in the literature. The Malmquist index under the metafrontier context was used to estimate the productivity in both procedures and its decomposition in terms of efficiency, technical and quality change. A multilevel logistic regression was specified to obtain the in-hospital mortality as a quality factor. All Spanish public acute-care hospitals were classified according to their average severity attended, dividing them into three groups. Our study revealed a decrease in productivity mainly due to a decrease in the technological change. Quality change remained constant during the period with highest variations observed between one period to the next according to the hospital classification. The improvement in the technological gap between different levels was due to an improvement in quality. These results provide new insights of operational efficiency after incorporating the quality dimension, specifically highlighting a decreasing operational performance, confirming that the technological heterogeneity is a critical question when measuring hospital performance

Quality and technical efficiency do not evolve hand in hand in Spanish hospitals: Observational study with administrative data.

OBJECTIVE:Recent evidence on the Spanish National Health System (SNHS) reveals a considerable margin for hospital efficiency and quality improvement. However, those studies do not consider both dimensions together. This study aims at jointly studying both technical efficiency (TE) and quality, classifying the public SNHS hospitals according to their joint performance. METHODS:Stochastic frontier analysis is used to estimate TE and multilevel logistic regressions to build a low-quality composite measure (LQ), which considers in-hospital mortality and safety events. All hospitalizations discharged in Spain in 2003 and 2013, in 179 acute-care general hospitals, were studied. Four scenarios of resulting performance were built setting yearly medians as thresholds for the overall sample, and according to hospital-complexity strata. RESULTS:Overall, since 2003, median TE improved and LQ reduced -from TE2003:0.89 to TE2013:0.93 and, from LQ2003:42.6 to LQ2013:27.7 per 1,000 treated patients. The time estimated coefficient showed technical progress over the period. TE across hospitals showed scarce variability (CV2003:0.08 vs. CV2013:0.07), not so the rates of LQ (CV2003:0.64 vs. CV2013:0.76). No correlation was found between TE values and LQ rates. When jointly considering technical efficiency and quality, hospitals dealing with the highest clinical complexity showed the highest chance to be placed in optimal scenarios, also showing lesser variability between hospitals. CONCLUSIONS:Efficiency and quality have improved in Spanish public hospitals. Not all hospitals experiencing improvements in efficiency equally improved their quality. The joint analysis of both dimensions allowed identifying those optimal hospitals according to this trade-off

Evolution of public hospitals expenditure by healthcare area in the Spanish National Health System: the determinants to pay attention to

Abstract Background In Spain, hospital expenditure represents the biggest share of overall public healthcare expenditure, the most important welfare system directly run by the Autonomous Communities (ACs). Since 2001, public healthcare expenditure has increased well above the GDP growth, and public hospital expenditure increased at an even faster rate. This paper aims at assessing the evolution of need-adjusted public hospital expenditure at healthcare area level (HCA) and its association with utilisation and ‘price’ factors, identifying the relative contribution of ACs, as the main locus of health policy decisions. Methods Ecological study on public hospital expenditure incurred in 198 (HCAs) in 16 Spanish ACs, between 2003 and 2015. Aggregated and annual log-log multilevel models, considering ACs as a cluster, were modelled using administrative data. HCA expenditure was analysed according to differences in population need, utilization and price factors. Standardised coefficients were also estimated, as well as the variance partition coefficients. Results Between 2003 and 2015, over 59 million hospital episodes were produced in Spain for an overall expenditure of €384,200 million. Need-adjusted public hospital expenditure, at HCA level, was mainly associated to medical and surgical hospitalizations (standardized coefficients 0.32 and 0.28, respectively). The ACs explained 42% of the variance not explained by HCA utilization and ‘price’ factors. Conclusions Utilization, rather than ‘price’ factors, may be explaining the difference in need-adjusted public hospital expenditure at HCA level in Spain. ACs, third-payers in the fully devolved Spanish National Health System, are responsible for a great deal of the variation in hospital expenditure

Evolution of monthly deflated need-adjusted public hospital expenditure by group of hospitals.

Hospitals are clustered according to the average complexity of the episodes they attended to. Group 1 includes hospitals that treat the least complex cases on average, up to Group 4, which includes hospitals that treat the most complex episodes of care. The overlapping line “MA12centred” stands for the 12th-order centred moving average of hospital expenditure.</p

Descriptive statistics and figures.

IntroductionThe sustainability of public hospital financing in Spain is a recurring issue, given its representativeness in annual public healthcare budgets which must adapt to the macroeconomic challenges that influence the evolution of spending. Knowing whether the responsiveness of hospital expenditure to its determinants (need, utilisation, and quasi-prices) varies according to the type of hospital could help better design strategies aimed at optimising performance.MethodsUsing SARIMAX models, we dynamically assess unique nationwide monthly activity data over a 14-year period from 274 acute-care hospitals in the Spanish National Health Service network, clustering these providers according to the average severity of the episodes treated.ResultsAll groups showed seasonal patterns and increasing trends in the evolution of expenditure. The fourth quartile of hospitals, treating the most severe episodes and accounting for more than 50% of expenditure, is the most sensitive to quasi-price factors, particularly the number of beds per hospital. Meanwhile, the first quartile of hospitals, which treat the least severe episodes and account for 10% of expenditure, is most sensitive to quantity factors, for which expenditure showed an elasticity above one, while factors of production were not affected.ConclusionsBelonging to one or another cluster of hospitals means that the determinants of expenditure have a different impact and intensity. The system should focus on these differences in order to optimally modulate expenditure not only according to the needs of the population, but also according to the macroeconomic situation, while leaving hospitals room for manoeuvre in case of unforeseen events. The findings suggest strengthening a network of smaller hospitals (Group 1)–closer to their reference population, focused on managing and responding to chronicity and stabilising acute events–prior to transfer to tertiary hospitals (Group 4)–larger but appropriately sized, specialising in solving acute and complex health problems–when needed.</div

Definition of the classification quadrants.

<p>Definition of the classification quadrants.</p

Impact on public hospital expenditure, by subgroup of hospitals, according to 1% variation in one of the specified determinants.

Impact on public hospital expenditure, by subgroup of hospitals, according to 1% variation in one of the specified determinants.</p

Observed to predicted need-adjusted public expenditure interannual growth in hospital care.

Goodness of fit of models: Cgr1- corrected R2 = 0.9886, model Cgr2- corrected R2 = 0.9928, model Cgr3—corrected R2 = 0.9930, model Cgr4—corrected R2 = 0.9925).</p

Inputs, outputs and quality indicators. Descriptive statistics.

<p>Inputs, outputs and quality indicators. Descriptive statistics.</p