AJMC: Market competition doesnt drive HF quality improvement
 |
Quality indicators that are made publicly available may influence hospital behavior in a number of ways, suggested Jared Lane K. Maeda, PhD, MPH, of the Healthcare Business Section of Thomson Reuters in Washington, D.C., and Anthony T. LoSasso, PhD, of the Division of Health Policy and Administration at the University of Illinois at Urbana-Champaign. For instance, hospitals may view improvements measured with indicators as a means for gaining market share, for achieving professional standards and for upholding their public image. The authors hypothesized that market competition may serve as a catalyst for hospital performance, driving quality higher the more competitive a hospital market became.
The researchers chose HF to test their theory because it is a condition measured through the Joint Commission’s ORYX hospital performance measurement program. Using that database, they could examine four quality indicators: discharge prescription of ACE and ARB medications; assessment of left ventricular function (LVF); smoking cessation counseling; and instructions at patient discharge.
For their sample, they extracted data for patients who were 18 years old or older and were admitted to one of 3,011 Joint-Commission-accredited acute care hospitals between 2003 to 2006 with LV systolic HF. For a secondary analysis, they aggregated hospitals into hospital referral regions (HRRs).
They linked ORYX data with American Hospital Association Annual Survey’s data on hospital characteristics and Area Resource File data on market-level characteristics to set control variables; accessed Medicare Provider and Analysis Review files to determine market share; and calculated quarterly measures of market competition using the Herfindahl-Hirschman Index.
Maeda and LoSasso found that over the study period smoking cessation counseling and discharge instructions showed the largest performance increases on average, at 45 percent and 38 percent, respectively. The two clinical measures showed progress but it was smaller, with ACE/ARB medications prescribed at discharge improving 12 percent and LVF assessment improving 13 percent.
Adjusted multivariate analyses showed market competition affecting only one indicator, LVF assessment. They found that the least competitive and second least competitive markets performed better than the most competitive market for this indicator, at 2.9 percent and 1.9 percent, respectively.
On the other hand, in an HRR-level multivariate analysis, the least competitive market performed 5.1 percent worse than the most competitive market for smoking cessation counseling.
“A possible reason that market competition did not have a stronger effect on the HF quality indicators overall could be that hospitals might be engaged in greater competition along ‘price’ and other ‘non-price’ dimensions, which may result in decreased processes of care,” they wrote.
Maeda and LoSasso proposed that patients may not use the Joint Commission’s public reports to make healthcare decisions, instead basing their choices on physician affiliation, personal experience and anecdotal evidence. That may explain some of the disconnect between market competition and hospital performance, they wrote.
They pointed out that hospitals across all competitive markets showed improvements in their adherence to quality measures over time. “[O]n average, hospitals were engaged in substantial quality improvement efforts over time either through an actual increase in performance or through better documentation,” they wrote.
Among the study’s limitations, they acknowledged that while about 80 percent of U.S. hospitals are Joint Commission-accredited, the remaining 20 percent were not included in the study. The data were self-reported; guidelines and association quality initiatives may have increased adherence rates; and HF, while common and costly, was the only condition examined.
“Market competition might be a blunt instrument and it may not be the most suitable policy tool to drive hospital quality improvement efforts,” they wrote. Instead, they recommended the use public reporting programs if the goal is to improve hospitals’ processes of care, because their findings showed hospital performance improved over time. “Alternative policy solutions should be considered to facilitate meaningful efforts to drive quality improvement initiatives,” they concluded.