Comparing Hospital Efficiency: An Illustrative Study of Knee and Hip Replacement Surgeries in Spain.

WHO's Health Systems Performance Assessment framework suggests monitoring a set of dimensions. This study aims to jointly assess productivity and quality using a treatment-based approach, specifically analyzing knee and hip replacement, two prevalent surgical procedures performed with consolidated technology and run in most acute-care hospitals. Focusing on the analysis of these procedures sets out a novel approach providing clues for hospital management improvements, covering an existing gap in the literature. The Malmquist index under the metafrontier context was used to estimate the productivity in both procedures and its decomposition in terms of efficiency, technical and quality change. A multilevel logistic regression was specified to obtain the in-hospital mortality as a quality factor. All Spanish public acute-care hospitals were classified according to their average severity attended, dividing them into three groups. Our study revealed a decrease in productivity mainly due to a decrease in the technological change. Quality change remained constant during the period with highest variations observed between one period to the next according to the hospital classification. The improvement in the technological gap between different levels was due to an improvement in quality. These results provide new insights of operational efficiency after incorporating the quality dimension, specifically highlighting a decreasing operational performance, confirming that the technological heterogeneity is a critical question when measuring hospital performance.

Public-private partnerships in the Spanish National Health System: The reversion of the Alzira model.

In the statutory Spanish National Health System (SNHS), the role of public provision is prominent. Nonetheless, since the inception of the SNHS, Regional Health Authorities have also purchased hospital care from private not-for-profit or for-profit providers, usually complementing public provision. Over the years, the autonomous community of Valencia has championed the use of Public Private Partnerships (PPP) in the form of administrative concessions (AC) awarded to private providers. In the La Ribera Health Department, which includes Alzira, the company Ribera Salud held the concession to provide hospital and primary care to the registered population since 1999 - and this became known as the Alzira model. In April 2018, when the administrative concession was expected to be renewed, Valencia's Health Authority decided to terminate the concession and to revert to direct public provision. While most stakeholders - and in particular the left-wing regional government - were in favour of reverting to public provision, advocates of the Alzira model argued that it was superior in terms of productivity, per capita expenditure and quality. The termination of the Alzira model led to further regulatory changes enacted in the Law for Health 8/2018, which clearly states that public provision is the preferred model of service delivery and new (tighter) requirements are defined for any future PPPs aiming to settle in the autonomous community of Valencia. This paper describes the process and provides background information to understand the underlying reasons of this policy development.

A comparative performance analysis of a renowned public private partnership for health care provision in Spain between 2003 and 2015.

BACKGROUND: Recently, the once archetype of the public private partnership (PPP) in the Spanish National Health System (SNHS), namely the Alzira's Model, has come to an end. Advocates defended the superiority of PPPs over public-tenured provision, in terms of quality and technical efficiency. This paper profiles and compares Alzira's life-cycle performance with similar public-tenured providers. METHODS: Observational study on secondary data from virtually all hospital care episodes produced in 51 integrated providers (i.e., administrative healthcare areas) and 67 hospitals, in 2003 and 2015. Alzira's 2015 performance (and its variation since 2003) was compared with all public-tenured peers in the SNHS, using 26 indicators analysing the differences in age-sex standardized rates of events or risk-adjusted mortality, severity-adjusted hospital expenditure and hospital technical efficiency. RESULTS: In comparison with the corresponding public-tenured peers, Alzira's 2015 performance was statistically worse than the benchmark in the majority of indicators (15 out of 26); yet, its performance was one of the best in the SNHS in adjusted-mortality after Percutaneous Coronary Intervention (PCI). Over time, Alzira showed a statistically greater 2003-2015 improvement than its peers' average in eleven of the indicators, and a lower improvement in nine. CONCLUSIONS: In this comprehensive comparative study on Alzira's performance, this PPP has not generally outperformed public-tenured providers, although in some areas of care its developments have been outstanding.

Quality and technical efficiency do not evolve hand in hand in Spanish hospitals: Observational study with administrative data.

OBJECTIVE: Recent evidence on the Spanish National Health System (SNHS) reveals a considerable margin for hospital efficiency and quality improvement. However, those studies do not consider both dimensions together. This study aims at jointly studying both technical efficiency (TE) and quality, classifying the public SNHS hospitals according to their joint performance. METHODS: Stochastic frontier analysis is used to estimate TE and multilevel logistic regressions to build a low-quality composite measure (LQ), which considers in-hospital mortality and safety events. All hospitalizations discharged in Spain in 2003 and 2013, in 179 acute-care general hospitals, were studied. Four scenarios of resulting performance were built setting yearly medians as thresholds for the overall sample, and according to hospital-complexity strata. RESULTS: Overall, since 2003, median TE improved and LQ reduced -from TE2003:0.89 to TE2013:0.93 and, from LQ2003:42.6 to LQ2013:27.7 per 1,000 treated patients. The time estimated coefficient showed technical progress over the period. TE across hospitals showed scarce variability (CV2003:0.08 vs. CV2013:0.07), not so the rates of LQ (CV2003:0.64 vs. CV2013:0.76). No correlation was found between TE values and LQ rates. When jointly considering technical efficiency and quality, hospitals dealing with the highest clinical complexity showed the highest chance to be placed in optimal scenarios, also showing lesser variability between hospitals. CONCLUSIONS: Efficiency and quality have improved in Spanish public hospitals. Not all hospitals experiencing improvements in efficiency equally improved their quality. The joint analysis of both dimensions allowed identifying those optimal hospitals according to this trade-off.

Female preventive practices: breast and smear tests.

Breast cancer and cervical cancer are the most common female cancers in Spain and in many developed countries. The main goal of this paper is to identify the determinants of individual decisions on breast screening and smear testing, that is to say, the decision to take a test for the first time and the decision to test with suitable regularity. To that end, we have combined analyses of micro and macro data (the Spanish National Health Survey and Spanish Regional Social Indicators) and employed multilevel estimation models. Among the main results, we highlight the fact that regional public screening programmes improve individual decisions on screening (more women testing for the first time and more women testing regularly) and, furthermore, they generate positive synergies; for example, regional public programmes for smear testing improve individual decisions on both cervical and breast cancer screening. In addition, we conclude that it is not only important to know if the numbers of women undergoing breast screening and smear testing are increasing, it is also important to know if they are testing regularly.

Absentismo de pacientes citados en las consultas de Atención Especializada en el Consorcio Aragonés Sanitario de Alta Resolución: repercusiones económicas y demoras / No disponible

Fundamento. El absentismo en las consultas es uno de los principales problemas en los centros deAtención Especializada; su existencia genera ineficiencias económicas y productivas. Encontrar solucionespara mitigarlo supondrá un avance en el camino de prestar un servicio sanitario excelente.Objetivo. Definir el perfil del tipo de paciente citado que no acude a las consultas de AtenciónEspecializada, estimar la repercusión económica que este hecho supone, su influencia en las demorasasistenciales y aplicar soluciones para intentar mitigar el problema.Método. Se analizaron 35.500 citas en el periodo comprendido entre mayo y septiembre de2008 del Consorcio Aragonés Sanitario de Alta Resolución (CASAR) mediante un análisis estadísticodescriptivo-bivariado para definir una regresión logística del absentismo, y así determinar el perfil delpaciente que no acude a la citación. Se han analizado las características de edad, sexo, nacionalidad,tipo de consultas y especialidad demandada.Resultados. Se encontraron diferencias estadísticamente significativas en el tiempo de demora, elcentro de especialidades, la especialidad médica y la nacionalidad de las personas que practicabanel absentismo.Conclusiones. Fijado el perfil del paciente que no acude a su cita se han de iniciar las actuacionesen las especialidades donde existe mayor probabilidad de producirse fallos en las citas. Por otrolado, se aconseja la creación de grupos de trabajo para desarrollar los protocolos de actuación de losDepartamentos de Gestión de Pacientes (guías de consultas externas) y de Documentación(AU)

Basis. The non-attendance in outpatient appointments is one of the major problems in hospitalsbecause it generates economic and productive inefficiencies. Recommendations for improving outpatientattendance must help to reach a better health service quality. Objective. To determine the main features of the non-attenders in outpatient appointments,estimate economic costs, influence in appointment delays and offer some solutions to reduce thisproblem.Method.We analyzed 35.500 appointments at CASAR over a five months period (from May toSeptember 2008) with a statistic analysis defining a logistic regression of non-attendance and establishthe profile of non-attenders. The main social features studied are age, sex, nacionality, and firstand successive consultations.Results. The difference between the social features of attenders and non-attenders were smallbut we found a positive significance between delay, place of the appointment, speciality and nationalityand non-compliance with scheduled appointments.Conclusions.We determined the profile of non-attender in the CASAR and proposed some solutionsin those specialities where outpatients present higher likely of non-compliance. Furthermore, weadviced the creation of some groups to develop measures to improve the communication in the scheduleof appointments(AU)