Disparities in Regular Health Care Utilisation in Europe

Despite common recommendations and quasi universal health care coverage in all European countries, there are large differences in the utilisation patterns of different health services. Little comparative information is available on different types of health service utilisation and variations in utilisation patterns over a longer time span. The objective of this study is to compare and investigate individual and cross-country determinants of health care utilisation habits over the life span across European countries. We found that while there is a general shift toward more regular and preventive care utilisation in all countries; there are still significant social inequalities between countries and cohorts. There is also evidence that once the individual effects have been isolated, cross-cohort and country differences in the prevalence of regular care use are partly associated with differences in welfare states interventions.Healthcare, Social inequalities, Welfare state, Multi-level models, Lifespan analysis, International comparisons.

Impact of health care system on socioeconomic inequalities in doctor use

This study examines the impact of health system characteristics on social inequities in health care use in Europe, using data from national surveys in 13 European countries. Multilevel logistic regression models are estimated to separate the individual level determinants of generalist and specialist use from the health system level and country specific factors. The results suggest that beyond the division between public and private funding and cost-sharing arrangements in health system, the role given to the general practitioners and/or the organization of the primary care might be essential for reducing social inequities in health care utilisation.Equity, Health system, Doctor utilisation, Multilevel, International

Estimation du surcoût des événements indésirables associés aux soins à l'hôpital en France

Les événements indésirables associés aux soins (EIS) représentent non seulement un problème de sécurité et de qualité des soins pour les patients, mais également un problème économique puisque leurs conséquences financières peuvent être importantes. Cependant, jusqu’ici en France, il n’y avait aucune étude de coût à l’échelle nationale regardant l’impact économique des événements indésirables associés aux soins. Notre étude exploite les données hospitalières collectées en routine afin d’établir l’importance et les conséquences économiques de neuf EIS à l’hôpital. Nous avons suivi la méthodologie développée aux Etats-Unis pour construire des indicateurs de sécurité des patients (PSI) et dénombrer les EIS à l’hôpital. Les surcoûts et allongements de durées de séjour liés aux EIS sont mesurés selon deux méthodes : la méthode de stratification et l’analyse de régression. Les résultats montrent qu’environ 0,5 % des séjours hospitaliers sont associés à l’un ou l’autre des neuf événements indésirables évalués dans notre étude. Il existe toutefois de fortes disparités de surcoûts, ceux-ci pouvant varier de près de 500 € pour les traumatismes obstétricaux à plus de 15 000 € pour les septicémies. Ces surcoûts sont étroitement corrélés avec la durée des séjours et l’intensité des soins. Quatre événements indésirables (désordres physiologiques et métaboliques postopératoires, septicémies, escarres et embolies pulmonaires) concentrent 90 % du coût total de prise en charge des événements indésirables en 2007. Notre étude contribue à repérer les domaines où intervenir en priorité et cibler les ressources visant à l’amélioration de la sécurité des patients.événements indésirables, indicateurs de sécurité, qualité des soins, coût, PMSI.

Activity based payment in hospitals: Principles and issues drawn from the economic literature and country experiences

In 2005, France joined the ranks of most other developed countries when it introduced an activity based payment system to finance all acute care hospitals. Despite some basic principles in common, the design of these systems can vary significantly across countries. In order to understand better the issues raised by the new system in France, this paper examines the economic rationale for such a system, the key implementation decisions to be made and the challenges involved. The principle of paying hospitals according to their activity in relation to homogeneous groups of patients has some obvious advantages to improve efficiency and the transparency in health care financing. However, the literature and the experience of the other countries presented in this paper show that this mechanism of payment presents a certain number of risks and requires regular and careful adjustments to obtain the benefits expected of such a system. To ensure both the clinical and economic coherence of the classification used to define hospital activity, and to establish the corresponding level of tariffs, constitute two major challenges. The principle of paying a fixed price which is directly indexed on the average costs observed and which remains common to all types of hospitals has been increasingly subject to criticism. Furthermore, activity based payment, by its nature, can induce some perverse effects which requires complementary regulatory mechanisms to guarantee the quality of the care and equitable access. From the point of view of controlling health expenditure, it is equally important to follow closely the evolution of health care activity in different hospital settings, as well as in ambulatory care, since activity based payment may encourage hospitals to increase their activity by inducing greater demand for profitable services while shifting part of their costs towards medium/long-term care settings or to home-based or informal care.Activity based payment, hospital, regulation, international comparison.

La qualité des soins en France : comment la mesurer pour l'améliorer ?

Définir et évaluer la qualité des soins est une démarche fondamentale si l'on veut améliorer le système de santé. Malgré sa réputation « de meilleur système de santé dans le monde », selon l’OMS, la France est en retard sur l'étude de la qualité des soins. Il n’existe pas à l’heure actuelle de système d’information permanent sur la qualité et la sécurité des soins et les données demeurent partielles, contradictoires et difficilement accessibles. Afin d'obtenir une image globale des problèmes de qualité de soins et développer des stratégies pour l’améliorer, il est important de recueillir des données de manière systématique et sur une base nationale cohérente. Cet article fournit une vue d'ensemble des données disponibles sur la qualité de soins en France en suivant le cadre d’analyse et les recommandations internationales pour mesurer la qualité. En comparant la situation de la France à celles d’autres pays développés, elle vise également à identifier les lacunes et les points forts du système actuel pour améliorer la gestion de la qualité des soins.Qualité, comparaison internationale, système, France

How well do DRGs for appendectomy explain variations in resource use? : An analysis of patient-level data from 10 European countries

Appendectomy is a common and relatively simple procedure to remove an inflamed appendix, but the rate of appendectomy varies widely across Europe. This paper investigates factors that explain differences in resource use for appendectomy. We analysed 106,929 appendectomy patients treated in 939 hospitals in ten European countries. In stage one, we tested the performance of three models in explaining variation in the (log of) cost of the inpatient stay (seven countries) or length-of-stay (three countries). The first model used only the Diagnosis Related Groups (DRGs) to which patients were coded; the second used a core set of general patient-level and appendectomy-specific variables; and the third model combined both sets of variables. In stage two, we investigated hospital-level variation. In classifying appendectomy patients, most DRG systems take account of complex diagnoses and comorbidities, but use different numbers of DRGs (range: 2 to 8). The capacity of DRGs and patient-level variables to explain patient-level cost variation ranges from 34% in Spain to over 60% in England and France. All DRG systems can make better use of administrative data such as the patient’s age, diagnoses and procedures, and all countries have outlying hospitals that could improve their management of resources for appendectomy

Changing roles of health insurers in France, Germany, and the Netherlands:any lessons to learn from Bismarckian systems?

Bismarckian health systems are mainly governed by social health insurers, but their role, status, and power vary across countries and over time. We compare the role of health insurers in three distinct social health insurance systems in improving health systems' efficiency. In France, insurers work together as a single payer within a highly regulated context. Although this gives insurers substantial bargaining power, collective negotiations with providers are highly political and do not provide appropriate incentives for efficiency. Both Germany and the Netherlands have introduced competition among insurers to foster efficiency. However, the rationale of insurer competition in Germany is unclear because contracts are mostly concluded at a collective level and individual insurers have little power to influence health system efficiency. In the Netherlands, insurer competition is substantially more effective, but primarily focused on price and cost containment. In all three countries, the role of insurers has been transforming slowly to respond to common challenges of assuring care quality and continuity for an ageing population. To assure sustainability, they need to ensure that care providers cooperate with the same quality and efficiency objectives, but their capacity to do so has been limited by insufficient support to enforce public information on provider quality.</p

Impact du volume d’activité sur les résultats de soins à l’hôpital en France

Cette étude contribue à la littérature sur le lien entre le volume d’activité et les résultats de soins en exploitant pour la première fois les données hospitalières françaises à l’échelle nationale. Elle teste l’existence et l’ampleur de la corrélation volume-résultats afin de répondre à une question majeure pour l’organisation des soins hospitaliers : est-ce que les résultats de soins sont meilleurs dans les établissements lorsque l’activité consacrée à ces soins est plus élevée ? Les résultats montrent que le volume d’activité constituerait un bon critère de régulation pour améliorer les résultats dans certains domaines mais qu’il y aurait peu de bénéfice à concentrer l’activité hospitalière au-delà d’un certain point.This study contributes to the literature on the link between hospital volume and outcomes of care by exploiting for the first time the French hospital data at a national level. The analysis tests the existence and the strength of the correlation for eight conditions in order to answer the following question: are the results of care systematically better in hospitals when the activity devoted to this care is higher? The results suggest that activity volumes may be a good measure of regulating quality in certain domains, but there would be little additional benefit to centralize hospital activity beyond a certain point