UBC Theses and Dissertations

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UBC Theses and Dissertations

An economic investigation of the quality of hospital care in British Columbia Lundman, Susan Brenda


The quality of health and hospital care is usually measured by one of three basic approaches. Structure measures assess the inputs used or available for use in the treatment of patients. Assessments of process look at "how" patients were treated. Outcomes measures are concerned with the end-results of care. Outcomes have considerable intuitive appeal to consumers and it is assumed in this thesis that quality is defined in terms of outcomes; providers (e.g. physicians) however may have preferences for hospital structure for its own sake. Structure and process measures are generally regarded as proxies for outcomes measures. They are used because they are easier to measure than outcomes, but the relations between the proxies and outcomes have not been completely tested. This thesis is concerned with the empirical verification of the relationship between two types of measures, structure and outcomes of hospital care at the aggregate level, and a possible link between provider preferences for structure and observed "excess" structure. The outcomes measures are based on adjusted hospital death rates. The adjustment factors draw on detailed diagnostic and demographic information available in the British Columbia hospital reporting system. Several possible adjustment factors (proxies for severity) are considered. The structure measures include measures of inputs per case, and measures of the facilities and services offered by a hospital. The discussion centres on three hypotheses. The first two concern the empirical relation between structure and outcomes. The first hypothesis that the two types of assessment are equivalent was tested using correlation analysis of alternative outcomes measures and structure measures. The results indicate that structure cannot be substituted for outcomes measures in the evaluation of quality. The second hypothesis is that there is ineffective or "excess" structure. This is demonstrated if the impact of incremental structure on outcomes is not positive. The results generally support the existence of excess structure. Extensive regression analysis and exploration of possible weakness did not result in the modification of the basic conclusion. The third hypothesis is that such "excess" structure arises and persists because providers value structure for its own sake, and are able to impose their preferences on hospitals. The discussion is essentially theoretical and considerable evidence supporting the hypothesis is provided, although no formal proof is offered. Physicians value structure because it enables them to increase their income and/or leisure, and also to satisfy their professional desires with respect to their working environment. Arguments are presented to support the claim that physicians get some of the structure they want because of imperfections in real-world agency relations and the institutional features of the health care system. Given the basic premise of the thesis (that consumers would define quality in terms of outcomes), the results of both the empirical and theoretical investigations have implications for policy. Policy changes suggested in the discussion that concludes the thesis are concerned with resource allocation within the hospital system, quality measurement, monitoring of policy changes, and incentives and programs to modify provider preferences.

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