Fanny Goude1,2, Sverre A C Kittelsen3, Henrik Malchau4,5,6,7, Maziar Mohaddes5,6,7, Clas Rehnberg8. 1. Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, 17177, Stockholm, Sweden. fanny.goude@ki.se. 2. Centre for Health Economics, Informatics and Health Services Research, Stockholm Health Care Services, Region Stockholm, Tomtebodavägen 18A, 17177, Stockholm, Sweden. fanny.goude@ki.se. 3. Frisch Centre, Gaustadalléen 21, 0349, Oslo, Norway. 4. Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA. 5. Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg university, Medicinaregatan 3, 41390, Göteborg, Sweden. 6. Swedish Hip Arthroplasty Register, Centre of Registers Västra Götaland, Medicinaregatan 18 G, 41345, Göteborg, Sweden. 7. Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Mölndal, Sweden. 8. Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, 17177, Stockholm, Sweden.
Abstract
BACKGROUND: Competition-promoting reforms and economic incentives are increasingly being introduced worldwide to improve the performance of healthcare delivery. This study considers such a reform which was initiated in 2009 for elective hip replacement surgery in Stockholm, Sweden. The reform involved patient choice of provider, free establishment of new providers and a bundled payment model. The study aimed to examine its effects on hip replacement surgery quality as captured by patient reported outcome measures (PROMs) of health gain (as indicated by the EQ-5D index and a visual analogue scale (VAS)), pain reduction (VAS) and patient satisfaction (VAS) one and six years after the surgery. METHODS: Using patient-level data collected from multiple national registers, we applied a quasi-experimental research design. Data were collected for elective primary total hip replacements that were carried out between 2008 and 2012, and contain information on patient demography, the surgery and PROMs at baseline and at one- and six-years follow-up. In total, 36,627 observations were included in the analysis. First, entropy balancing was applied in order to reduce differences in observable characteristics between treatment groups. Second, difference-in-difference analyses were conducted to eliminate unobserved time-invariant differences between treatment groups and to estimate the causal treatment effects. RESULTS: The entropy balancing was successful in creating balance in all covariates between treatment groups. No significant effects of the reform were found on any of the included PROMs at one- and six-years follow-up. The sensitivity analyses showed that the results were robust. CONCLUSIONS: Competition and bundled payment had no effects on the quality of hip replacement surgery as captured by post-surgery PROMs of health gain, pain reduction and patient satisfaction. The study provides important insights to the limited knowledge on the effects of competition and economic incentives on PROMs.
BACKGROUND: Competition-promoting reforms and economic incentives are increasingly being introduced worldwide to improve the performance of healthcare delivery. This study considers such a reform which was initiated in 2009 for elective hip replacement surgery in Stockholm, Sweden. The reform involved patient choice of provider, free establishment of new providers and a bundled payment model. The study aimed to examine its effects on hip replacement surgery quality as captured by patient reported outcome measures (PROMs) of health gain (as indicated by the EQ-5D index and a visual analogue scale (VAS)), pain reduction (VAS) and patient satisfaction (VAS) one and six years after the surgery. METHODS: Using patient-level data collected from multiple national registers, we applied a quasi-experimental research design. Data were collected for elective primary total hip replacements that were carried out between 2008 and 2012, and contain information on patient demography, the surgery and PROMs at baseline and at one- and six-years follow-up. In total, 36,627 observations were included in the analysis. First, entropy balancing was applied in order to reduce differences in observable characteristics between treatment groups. Second, difference-in-difference analyses were conducted to eliminate unobserved time-invariant differences between treatment groups and to estimate the causal treatment effects. RESULTS: The entropy balancing was successful in creating balance in all covariates between treatment groups. No significant effects of the reform were found on any of the included PROMs at one- and six-years follow-up. The sensitivity analyses showed that the results were robust. CONCLUSIONS: Competition and bundled payment had no effects on the quality of hip replacement surgery as captured by post-surgery PROMs of health gain, pain reduction and patient satisfaction. The study provides important insights to the limited knowledge on the effects of competition and economic incentives on PROMs.