Impact of Competition Versus Centralisation of Hospital Care on Process Quality: A Multilevel Analysis of Breast Cancer Surgery in France

Document Type : Original Article

Authors

1 IRDES, Institut de Recherche et documentation en Economie de la Santé, Paris, France

2 Institut Gustave Roussy, Biostatistical and Epidemiological Division, Paris, France

3 Department of Biostatistics and Epidemiology, Institut Gustave Roussy, University Paris-Saclay, Villejuif, France

4 Oncostat (CESP U1018 INSERM), Labeled Ligue Contre le Cancer, University Paris-Saclay, Villejuif, France

Abstract

Background
The implications of competition among hospitals on care quality have been the subject of considerable debate. On one hand, economic theory suggests that when prices are regulated, quality will be increased in competitive markets. On the other hand, hospital mergers have been justified by the need to exploit cost advantages, and by evidence that hospital volume and care quality are related.
 
Methods
Based on patient-level data from two years (2005 and 2012) we track changes in market competition and treatment patterns in breast cancer surgery. We focus on technology adoption as a proxy of process quality and examine the likelihood of offering two innovative surgical procedures: immediate breast reconstruction (IBR), after mastectomy and sentinel lymph node biopsy (SLNB). We use an index of competition based on a multinomial logit model of hospital choice which is not subject to endogeneity bias, and estimate its impact on the propensity to receive IBR and SLNB by means of multilevel models taking into account both observable patient and hospital characteristics.
 
Results
The likelihood of receiving these procedures is significantly higher in hospitals located in more competitive markets. Yet, hospital volume remains a significant indicator of quality, therefore benefits of competition appear to be sensitive to the estimates of the impact of volume on care process. In France, the centralisation policy, with minimum activity thresholds, have contributed to improving breast cancer treatment between 2005 and 2012.
 
Conclusion
Finding the right balance between costs and benefits of market competition versus concentration of hospital care supply is complex. We find that close to monopolistic markets do not encourage innovation and quality in cancer treatment, but highly competitive markets where many hospitals have very low activity volumes are also problematic because hospital quality is positively linked to patient volume.

Keywords


  1. Gravelle H, Santos R, Siciliani L. Does a hospital's quality depend on the quality of other hospitals? a spatial econometrics approach. Reg Sci Urban Econ. 2014;49:203-216. doi:10.1016/j.regsciurbeco.2014.09.005
  2. Gaynor M. What Do We Know About Competition and Quality in Health Care Markets? National Bureau of Economic Research; 2006. http://www.bristol.ac.uk/media-library/sites/cmpo/migrated/documents/wp151.pdf.  Accessed September 8, 2020.
  3. OECD. Competition in the Provision of Hospital Services. OECD Journal of Competition Law and Policy. 2007;8(3):153-247. doi:10.1787/clp-v8-art8-en
  4. Brekke KR, Siciliani L, Straume OR. Hospital competition and quality with regulated prices. Scand J Econ. 2011;113(2):444-469. doi:10.1111/j.1467-9442.2011.01647.x
  5. Kessler DP, McClellan MB. Is hospital competition socially wasteful? Q J Econ. 2000;115(2):577-615. doi:10.1162/003355300554863
  6. Tay A. Assessing competition in hospital care markets: the importance of accounting for quality differentiation. Rand J Econ. 2003;34(4):786-814.
  7. Vogt WB, Town R, Williams CH. How has hospital consolidation affected the price and quality of hospital care? Synth Proj Res Synth Rep. 2006;(9):15231.
  8. Cooper Z, Gibbons S, Jones S, McGuire A. Does Hospital Competition Improve Efficiency? An Analysis of the Recent Market-Based Reforms to the English NHS. London: Centre for Economic Performance; 2010. CEP Discussion Paper No 988. https://ideas.repec.org/p/cep/cepdps/dp0988.html.
  9. Gozvrisankaran G, Town RJ. Competition, payers, and hospital quality. Health Serv Res. 2003;38(6 Pt 1):1403-1421. doi:10.1111/j.1475-6773.2003.00185.x
  10. Mukamel DB, Zwanziger J, Tomaszewski KJ. HMO penetration, competition, and risk-adjusted hospital mortality. Health Serv Res. 2001;36(6 Pt 1):1019-1035.
  11. Propper C, Burgess S, Green K. Does competition between hospitals improve the quality of care?: Hospital death rates and the NHS internal market. J Public Econ. 2004;88(7-8):1247-1272. doi:10.1016/S0047-2727(02)00216-5
  12. Mutter RL, Wong HS, Goldfarb MG. The effects of hospital competition on inpatient quality of care. Inquiry. 2008;45(3):263-279. doi:10.5034/inquiryjrnl_45.03.263
  13. Gaynor M, Moreno-Serra R, Propper C. Death by Market Power: Reform, Competition and Patient Outcomes in the National Health Service. National Bureau of Economic Research; 2010. NBER Working Paper Series. 2010;16164. https://www.nber.org/papers/w16164.pdf.  Accessed September 8, 2020.
  14. Hu J, Jordan J, Rubinfeld I, Schreiber M, Waterman B, Nerenz D. Correlations Among Hospital Quality Measures: What "Hospital Compare" Data Tell Us. Am J Med Qual. 2017;32(6):605-610. doi:10.1177/1062860616684012
  15. Profit J, Zupancic JA, Gould JB, et al. Correlation of neonatal intensive care unit performance across multiple measures of quality of care. JAMA Pediatr. 2013;167(1):47-54. doi:10.1001/jamapediatrics.2013.418
  16. Shleifer A. A theory of yardstick competition. Rand J Econ. 1985;16(3):319-327.
  17. Berta P, Martini G, Moscone F, Vittadini G. The association between asymmetric information, hospital competition and quality of healthcare: evidence from Italy. J R Stat Soc Ser A Stat Soc. 2016;179(4):907-926. doi:10.1111/rssa.12214
  18. Gobillon L, Milcent C. Spatial disparities in hospital performance. J Econ Geogr. 2013;13(6):1013-1040. doi:10.1093/jeg/lbs065
  19. Choné P, Evain F, Wilner L, Yilmaz E. Introducing Activity-Based Payment in the Hospital Industry: Evidence from French Data. CESifo Working Paper. 2013; No. 4304. http://hdl.handle.net/10419/77670.
  20. McFadden D. Conditional Logit Analysis of Qualitative Choice Behaviour. Frontiers in Econometrics. 1973:105-142. https://eml.berkeley.edu/reprints/mcfadden/zarembka.pdf.  Accessed September 8, 2020.
  21. McFadden D. Econometric models of probabilistic choice. In: Manski CF, McFadden D, eds. Structural Analysis of Discrete Data with Econometric Applications. Cambridge: The MIT Press; 1981.
  22. Coldefy M, Com-Ruelle L, Lucas-Gabrielli V. Travel Distances and Travel Times to Nearest Health Care in Metropolitan France. Questions d’économie de la santé n°164. IRDES; 2011. https://www.irdes.fr/EspaceAnglais/Publications/IrdesPublications/QES164.pdf.  Accessed September 8, 2020.23.
  23. Brutel C. Un maillage du territoire français. Insee Première; 2011. No 1333. https://www.insee.fr/fr/statistiques/1280952.  Accessed September 8, 2020.
  24. Karaca-Mandic P, Town RJ, Wilcock A. The effect of physician and hospital market structure on medical technology diffusion. Health Serv Res. 2017;52(2):579-598. doi:10.1111/1475-6773.12506
  25. Aggarwal A, Lewis D, Mason M, Purushotham A, Sullivan R, van der Meulen J. Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study. Lancet Oncol. 2017;18(11):1445-1453. doi:10.1016/s1470-2045(17)30572-7
  26. Rococo E, Mazouni C, Or Z, Mobillion V, Koon Sun Pat M, Bonastre J. Variation in rates of breast cancer surgery: a national analysis based on French Hospital Episode Statistics. Eur J Surg Oncol. 2016;42(1):51-58. doi:10.1016/j.ejso.2015.09.020
  27. Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2014;32(13):1365-1383. doi:10.1200/jco.2013.54.1177
  28. Surgical guidelines for the management of breast cancer. Eur J Surg Oncol. 2009;35 Suppl 1:1-22. doi:10.1016/j.ejso.2009.01.008
  29. Reuben BC, Manwaring J, Neumayer LA. Recent trends and predictors in immediate breast reconstruction after mastectomy in the United States. Am J Surg. 2009;198(2):237-243. doi:10.1016/j.amjsurg.2008.11.034
  30. National Institute for Health and Care Excellence (NICE). Improving Outcomes in Breast Cancer: Manual Update. London: NICE; 2002.
  31. Harnett A, Smallwood J, Titshall V, Champion A. Diagnosis and treatment of early breast cancer, including locally advanced disease--summary of NICE guidance. BMJ. 2009;338:b438. doi:10.1136/bmj.b438
  32. Jeevan R, Cromwell DA, Browne JP, et al. Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England. Eur J Surg Oncol. 2010;36(8):750-755. doi:10.1016/j.ejso.2010.06.008
  33. van Steenbergen LN, van de Poll-Franse LV, Wouters MW, et al. Variation in management of early breast cancer in the Netherlands, 2003-2006. Eur J Surg Oncol. 2010;36 Suppl 1:S36-43. doi:10.1016/j.ejso.2010.06.021
  34. Zhong T, Fernandes KA, Saskin R, et al. Barriers to immediate breast reconstruction in the Canadian universal health care system. J Clin Oncol. 2014;32(20):2133-2141. doi:10.1200/jco.2013.53.0774
  35. Rice N, Leyland A. Multilevel models: applications to health data. J Health Serv Res Policy. 1996;1(3):154-164. doi:10.1177/135581969600100307
  36. Carey K. A multilevel modelling approach to analysis of patient costs under managed care. Health Econ. 2000;9(5):435-446. doi:10.1002/1099-1050(200007)9:53.0.co;2-z
  37. Quan H, Li B, Couris CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173(6):676-682. doi:10.1093/aje/kwq433
  38. McVea KL, Minier WC, Johnson Palensky JE. Low-income women with early-stage breast cancer: physician and patient decision-making styles. Psychooncology. 2001;10(2):137-146. doi:10.1002/pon.503
  39. Brekke KR, Gravelle H, Siciliani L, Straume OR. Hospital Quality Competition: A Review of the Theoretical Litterature. In: Dormont B, Milcent C, eds. Competition Between Hospitals: Does it Affect Quality of Care? Paris: Editions Rue d'Ulm; 2018:25-67.
  40. Bevan G, Skellern M. Does competition between hospitals improve clinical quality? a review of evidence from two eras of competition in the English NHS. BMJ. 2011;343:d6470. doi:10.1136/bmj.d6470
  41. Varkevisser M, van der Geest SA, Schut FT. Do patients choose hospitals with high quality ratings? Empirical evidence from the market for angioplasty in the Netherlands. J Health Econ. 2012;31(2):371-378. doi:10.1016/j.jhealeco.2012.02.001
  42. Brekke KR, Holmås TH, Monstad K, Straume OR. Socio-economic status and physicians' treatment decisions. Health Econ. 2018;27(3):e77-e89. doi:10.1002/hec.3621
  43. Maliski SL, Kwan L, Krupski T, Fink A, Orecklin JR, Litwin MS. Confidence in the ability to communicate with physicians among low-income patients with prostate cancer. Urology. 2004;64(2):329-334. doi:10.1016/j.urology.2004.03.042
  44. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128-1137. doi:10.1056/NEJMsa012337
  45. Chappel AR, Zuckerman RS, Finlayson SR. Small rural hospitals and high-risk operations: how would regionalization affect surgical volume and hospital revenue? J Am Coll Surg. 2006;203(5):599-604. doi:10.1016/j.jamcollsurg.2006.07.009
  46. Or Z, Renaud T. Volume d'activité et résultats des soins en France : une analyse multiniveaux des données hospitalières. Rapport de l'IRDES. 2009. https://www.irdes.fr/Publications/Rapports2009/rap1777.pdf.  Accessed September 8, 2020.
  47. Pons-Tostivint E, Daubisse-Marliac L, Grosclaude P, et al. Multidisciplinary team meeting and EUSOMA quality indicators in breast cancer care: a French regional multicenter study. Breast. 2019;46:170-177. doi:10.1016/j.breast.2019.06.001
Volume 11, Issue 4
April 2022
Pages 459-469
  • Receive Date: 20 December 2019
  • Revise Date: 09 September 2020
  • Accept Date: 13 September 2020
  • First Publish Date: 30 September 2020