Benchmarking clinical practice in surgery: looking beyond traditional mortality rates.

This paper proposes two new measures to assess performance of surgical practice based on observed mortality: reliability, measured as the area under the ROC curve and a living score, the sum of individual risk among surviving patients, divided by the total number of patients. A Monte Carlo simulation of surgeons' practice was used for conceptual validation and an analysis of a real-world hospital department was used for managerial validation. We modelled surgical practice as a bivariate distribution function of risk and final state. We sampled 250 distributions, varying the maximum risk each surgeon faced, the distribution of risk among dead patients, the mortality rate and the number of surgeries performed yearly. We applied the measures developed to a Portuguese cardiothoracic department. We found that the joint use of the reliability and living score measures overcomes the limitations of risk adjusted mortality rates, as it enables a different valuation of deaths, according to their risk levels. Reliability favours surgeons with casualties, predominantly, in high values of risk and penalizes surgeons with deaths in relatively low levels of risk. The living score is positively influenced by the maximum risk for which a surgeon yields surviving patients. These measures enable a deeper understanding of surgical practice and, as risk adjusted mortality rates, they rely only on mortality and risk scores data. The case study revealed that the performance of the department analysed could be improved with enhanced policies of risk management, involving the assignment of surgeries based on surgeon's reliability and living score.

Measuring recession severity and its impact on healthcare expenditure.

The financial crisis that manifested itself in late 2007 resulted in a Europe-wide economic crisis by 2009. As the economic climate worsened, Governments and households were put under increased strain and more focus was placed on prioritising expenditures. Across European countries and their heterogeneous health care systems, this paper examines the initial responsiveness of health expenditures to the crisis and whether recession severity can be considered a predictor of health expenditure growth. In measuring severity we move away from solely gross domestic product (GDP) as a metric and construct a recession severity index predicated on a number of key macroeconomic indicators. We then regress this index on measures of total, public and private health expenditure to identify potential relationships. Analysis suggests that for 2009, the Baltic States, along with Ireland, Italy and Greece, experienced comparatively severe recessions. We find, overall, an initial counter-cyclical response in health spending (both public and private) across countries. However, our analysis finds evidence of a negative relationship between recession severity and changes in certain health expenditures. As a predictor of health expenditure growth in 2009, the derived index is an improvement over GDP change alone.

Reference pricing system and competition: case study from Portugal.

AIM: To characterize the patterns of competition for a sample of drugs in the Portuguese pharmaceutical market before (January 2002-March 2003) and after (April 2003-June 2003) the introduction of the reference pricing system (RPS). METHODS: We performed a descriptive, retrospective, longitudinal analysis, with monthly observations from January 2002 until June 2003 of 15 homogeneous groups. The groups represented the upper limit of public pharmaceutical expenditure in the RPS segment in 2003 (n=270). Measures of competition were: 1) number of presentations; 2) prescriptions' concentration in the generic and originator (brand) segments, using Herfindahl-Hirschman Index (HHI); and 3) dominant positions of market leader in the homogeneous group. A correlation analysis between the number of presentations, the HHI, and the dominant position of the market leader was performed using Pearson coefficient of correlation. RESULTS: The structure of the market changed with the introduction of RPS. We found an increasing number of generic presentations (from 4+/-3 to 7+/-4; mean+/-standard deviation) and a decrease in the HHI for the generics market segment (from 0.7+/-0.2 to 0.6+/-0.3). There was a negative correlation between those variables that increased after the introduction of RPS (from -0.6 to -0.8). The HHI for brands and the dominant positions remained unchanged. CONCLUSION: After the implementation of RPS, the increased competition was mainly driven by economic and social agents in the generics market segment but not in the brands market segment.