The biggest question in health care at the moment is how to reduce costs without compromising quality. But we still know very little about the relationship between inputs or costs and outcomes for patients. There is some research – largely qualitative – on characteristics of high-performing hospitals. And it is mainly hospitals, rather than other kinds of provider organisations, which are studied. But even this literature is characterised by a circularity of argument – good facilities attract good staff which treat patients well… And is it true?
I was thinking about this when reading a paper by Veena Raleigh and colleagues looking at patient-reported experience across services http://tinyurl.com/dxqstho. They found that some hospitals consistently performed better than others. Their analysis showed that foundation and teaching status and proportion of white inpatients were positively associated with high patient ratings – deprivation, not so much. In other words, some hospitals in tough places still managed to perform consistently well on patient measures such as dignity, respect, cleanliness.
What else do we know? Jha and colleagues in large quantitative analyses in the US looked at the relationship between efficiency and structural characteristics, such as nursing levels and outcomes http://content.healthaffairs.org/content/28/3/897.abstract. They found that low-cost hospitals perform worse on quality indicators and patients were less satisfied. So much, so predictable perhaps – but worth stating in a climate where payers may look only at the bottom line and seek out low-cost alternatives. A more recent study by Stukel and co in Canada http://jama.jamanetwork.com/article.aspx?articleid=1105068, confirming these findings, provide further insight into why hospital costs may be related to patient outcomes. Their careful work showed for instance that patients in high-spending hospitals received a higher intensity of nursing care and more visits from specialists.
There is also an interesting debate about performance by specialty or whole-institution – Dr Foster and all, take note. This is a large and contested area, but research for instance by Shwartz and colleagues in the US http://mcr.sagepub.com/content/68/3/290.abstract suggest that hospitals who perform well on a composite measure were often not in the top quintile for individual measures. That is, there may be pockets of excellence from clinical teams or specialties in otherwise poor performing trusts.
There does not appear to be a simple blueprint for successful organisations. For instance, we know that larger is not always better – an evidence review by Rod Sheaff some time back found no consistent relationship between the size and performance of an organisation (over and above the relationship between volume and quality for specialist procedures). http://www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1318-055 The review similarly found no consistent or strong relationship between performance and other factors such as leadership style or economic environment.
There does not appear to be a simple blueprint for successful organisations. For instance, we know that larger is not always better – an evidence review by Rod Sheaff some time back found no consistent relationship between the size and performance of an organisation (over and above the relationship between volume and quality for specialist procedures). http://www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1318-055 The review similarly found no consistent or strong relationship between performance and other factors such as leadership style or economic environment.
So where do we go from here? Veena Raleigh’s work suggests system-level determinants of good patient experience – and that some trusts can deliver against the odds. We know something – largely from North America – about the relationship between organisational input and performance. But, given the importance of the question, the paucity of high quality research in this area is striking http://www.ncbi.nlm.nih.gov/pubmed/22871420. It would be good to see ambitious studies in the UK which tackled these big questions. What does good look like – and do we get what we pay for?
