Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Strategic Decentralization in Channels

The purpose of this paper is to understand the effect of strategic interaction on a manufacturer's channel-structure decision. In the model I analyze, if there were no strategic interaction, then the manufacturer would prefer vertical integration to decentralization. With strategic interaction, however, decentralization can be a Nash equilibrium strategy (as McGuire and Staein [McGuire, Timothy, Richard Staelin, 1983a. An industry equilibrium analysis of downstream vertical integration. (Spring) 161–192.] showed). So the question arises, What is it about strategic interaction that makes decentralization a Nash equilibrium strategy? The answer I give is that strategic interaction makes it possible for a manufacturer's retail demand curve to rise when he decentralizes. I show that this raising of the demand curve on decentralization can happen only if one of the following (mutually exclusive) conditions is satisfied: (1) the manufacturers' products are demand substitutes at the retail level and strategic complements at the manufacturer or retailer levels, (2) the manufacturer's products are demand complements at the retail level and strategic substitutes at the manufacturer or retailer levels. Strategic complementarity at the retailer (manufacturer) level means that if one retailer (manufacturer) raises his price, then the other retailer (manufacturer) would raise his price as well; strategic substitutability is just the opposite. These results show that what is important for decentralization to occur is not how (demand) substitutable the two manufacturers' products are (as one might have thought from earlier works in the literature), but rather the nature of coupling between demand dependence and strategic dependence.channels of distribution, decentralization, vertical integration, strategic dependence

Market Segmentation, Self-Selection, and Product Line Design

The purpose of this paper is to develop a theory of market segmentation based on consumer self-selection. The extant theory is based on the third-degree price discrimination model of Pigou, central assumptions of which are that the firm can directly address individual segments and isolate them. By using consumer self-selection, I am relaxing these assumptions. In the context of a monopolist designing a product line, I show that this relaxation has significant implications for how the products and prices are chosen and what they look like. In particular, segments may be aggregated even though there are no economies of scale. Furthermore, consumer self-selection enables us to model “cannibalization” and competition among firms.market segmentation, self-selection, aggregation of segments, product line design

Comment—Managing Channel Profits: Comment

In a recent paper in this journal, Jeuland and Shugan (Jeuland, A., S. Shugan. 1983. Managing channel profits. (Summer) 239–272.) proposed a quantity discount schedule as a way of coordinating a channel. As they put it on p. 253 of their paper, “a quantity discount schedule which would fix the retailer's and hence the manufacturer's profits to some fixed linear function of total channel profits would lead the channel to maximize profits.” The purpose of this note is to show that a quantity discount schedule is for channel coordination.

Product and Price Competition in a Duopoly

This paper provides a theoretical rationale for the dictum: It pays to find a niche in the market. Two (identical) firms compete on product (quality) and price, choosing products before prices. I identify conditions for the existence of a pure (perfect) Nash equilibrium. Different firms choose different products (and charge different prices) in equilibrium, but the equilibrium is inefficient: There is an alternative placement of two products that would increase total surplus