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Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study.

ABSTRACT: BACKGROUND:The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction. METHODS:Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010-2017. Outcomes included return to hospital or death within 30 days, acute length of stay (LOS), volume of admissions, and patient characteristics. RESULTS:At 2 years post-QBPs, the percentage of hip fracture patients who returned to hospital or died was 3.13% higher in absolute terms (95% CI: 0.37% to 5.89%) than if QBPs had not been introduced. There were no other statistically significant changes for return to hospital or death. For LOS, the only statistically significant change was an increase for prostate cancer surgery of 0.33 days (95% CI: 0.07 to 0.59). Volume increased for congestive heart failure admissions by 80 patients (95% CI: 2 to 159) and decreased for hip fracture surgery by 138 patients (95% CI: -183 to -93) but did not change for pneumonia or prostate cancer surgery. The percentage of patients who lived in the lowest neighborhood income quintile increased slightly for those diagnosed with congestive heart failure (1.89%; 95% CI: 0.51% to 3.27%) and decreased for those who underwent prostate cancer surgery (-2.08%; 95% CI: -3.74% to -0.43%). INTERPRETATION:This policy initiative involving a change to hospital funding for certain conditions was not associated with substantial, jurisdictional-level changes in access or quality.

SUBMITTER: Li AH

PROVIDER: S-EPMC7437861 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study.

Li Alvin Ho-Ting AH Palmer Karen S KS Taljaard Monica M Paterson J Michael JM Brown Adalsteinn A Huang Anjie A Marani Husayn H Lapointe-Shaw Lauren L Pincus Daniel D Wettstein Marian S MS Kulkarni Girish S GS Wasserstein David D Ivers Noah N

PloS one 20200819 8

<h4>Background</h4>The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction.<h4>Methods</h4>Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010-2017. ...[more]

PMID: 32813687

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Project description:BackgroundHealth care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery.MethodsThis was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends.ResultsThe difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was - 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours - 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy.ConclusionsWe found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

Project description:BackgroundSince 2011, the Government of Ontario, Canada, has phased in hospital funding reforms hoping to encourage standardised, evidence-based clinical care processes to both improve patient outcomes and reduce system costs. One aspect of the reform - quality-based procedures (QBPs) - replaced some of each hospital's global budget with a pre-set price per episode of care for patients with specific diagnoses or procedures. The QBP initiative included publication and dissemination of a handbook for each of these diagnoses or procedures, developed by an expert technical group. Each handbook was intended to guide hospitals in reducing inappropriate variation in patient care and cost by specifying an evidence-based episode of care pathway. We explored whether, how and why hospitals implemented these episode of care pathways in response to this initiative.MethodsWe interviewed key informants at three levels in the healthcare system, namely individuals who conceived and designed the QBP policy, individuals and organisations supporting QBP adoption, and leaders in five case-study hospitals responsible for QBP implementation. Analysis involved an inductive approach, incorporating framework analysis to generate descriptive and explanatory themes from data.ResultsThe 46 key informants described variable implementation of best practice episode of care pathways across QBPs and across hospitals. Handbooks outlining evidence-based clinical pathways did not address specific barriers to change for different QBPs nor differences in hospitals' capacity to manage change. Hospitals sometimes found it easier to focus on containing and standardising costs of care than on implementing standardised care processes that adhered to best clinical practices.ConclusionImplementation of QBPs in Ontario's hospitals depended on the interplay between three factors, namely complexity of changes required, internal capacity for organisational change, and availability and appropriateness of targeted external facilitators and supports to manage change. Variation in these factors across QBPs and hospitals suggests the need for more tailored and flexible implementation supports designed to fit all elements of the policy, rather than one-size-fits-all handbooks alone. Without such supports, hospitals may enact quick fixes aimed mainly at preserving budgets, rather than pursue evidence- and value-based changes in care management. Overestimating hospitals' change management capacity increases the risk of implementation failure.

Project description:ImportanceHospital funding reforms for prostate cancer surgery may have altered management of localized prostate cancer in the province of Ontario, Canada.ObjectiveTo determine whether changes in hospital funding policy aimed at improving health care quality and value were associated with changes in the management of localized prostate cancer or the characteristics of patients receiving radical prostatectomy (RP) for localized prostate cancer.Design, setting, and participantsThis population-based, interrupted time series study used linked population-based administrative data regarding adults in Ontario with incidental localized prostate cancer and those who underwent RP for localized prostate cancer. Patients who underwent RP were compared with patients who underwent surgical procedures for localized renal cell carcinoma, which was not included in the policy change but was subjected to similar secular trends and potential confounders. Monthly outcomes were analyzed using interventional autoregressive integrated moving average models. Data were collected from January 2011 to November 2017 and analyzed in January 2019.ExposuresFunding policy change in April 2015 from flexible block funding for all hospital-based care to prespecified payment amounts per procedure for treatment of localized prostate cancer, coupled with the dissemination of a diagnosis-specific handbook outlining best practices.Main outcomes and measuresInitial management (RP vs radiation therapy vs active surveillance) and tumor risk profiles per management strategy among incident cases of localized prostate cancer. Additional outcomes were case volume, mean length of stay, proportion of patients returning to hospital or emergency department within 30 days, proportion of patients older than 65 years, mean Charlson Comorbidity Index, and proportion of minimally invasive surgical procedures among patients undergoing RP for localized prostate cancer.ResultsA total of 33?128 patients with incident localized prostate cancer (median [interquartile range (IQR)] age, 67 [61-73] years; median [IQR] cases per monthly observation interval, 466 [420-516]), 17?159 patients who received radical prostatectomy (median [IQR] age, 63 [58-68] years; median [IQR] cases per monthly observation interval, 209 [183-225]), and 5762 individuals who underwent surgery for renal cell carcinoma (median [IQR] age, 62 [53-70] years; median [IQR] cases per monthly observation interval, 71 [61-77]) were identified. By the end of the observation period, radical prostatectomy and radiation therapy were used in comparable proportions (30.3% and 28.9%, respectively) and included only a small fraction of low-risk patients (6.4% and 2.9%, respectively). No statistically significant association of the funding policy change with most outcomes was found.Conclusions and relevanceThe implementation of funding reform for hospitals offering RP was not associated with changes in the management of localized prostate cancer, although it may have encouraged more appropriate selection of patients for RP. Mostly preexisting trends toward guideline-conforming practice were observed. Co-occurring policy changes and/or guideline revisions may have weakened signals from the policy change.

Project description:OBJECTIVE:To evaluate whether hospital re-accreditation improves quality, patient safety and reliability over three accreditation cycles by testing the accreditation life cycle model on quality measures. DESIGN:The validity of the life cycle model was tested by calibrating interrupted time series (ITS) regression equations for 27 quality measures. The change in the variation of quality over the three accreditation cycles was evaluated using the Levene's test. SETTING:A 650-bed tertiary academic hospital in Abu Dhabi, UAE. PARTICIPANTS:Each month (over 96 months), a simple random sample of 10% of patient records was selected and audited resulting in a total of 388?800 observations from 14?500 records. INTERVENTIONS:The impact of hospital accreditation on the 27 quality measures was observed for 96 months, 1-year preaccreditation (2007) and 3?years postaccreditation for each of the three accreditation cycles (2008, 2011 and 2014). MAIN OUTCOME MEASURES:The life cycle model was evaluated by aggregating the data for 27 quality measures to produce a composite score (YC) and to fit an ITS regression equation to the unweighted monthly mean of the series. RESULTS:The results provide some evidence for the validity of the four phases of the life cycle namely, the initiation phase, the presurvey phase, the postaccreditation slump and the stagnation phase. Furthermore, the life cycle model explains 87% of the variation in quality compliance measures (R2=0.87). The best-fit ITS model contains two significant variables (?1 and ?3) (p?0.001). The Levene's test (p?0.05) demonstrated a significant reduction in variation of the quality measures (YC) with subsequent accreditation cycles. CONCLUSION:The study demonstrates that accreditation has the capacity to sustain improvements over the accreditation cycle. The significant reduction in the variation of the quality measures (YC) with subsequent accreditation cycles indicates that accreditation supports the goal of high reliability.

Project description:IntroductionIn low-income countries, Surgical Site Infection (SSI) is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals.MethodsWe conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design.ResultsFrom a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks) and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks) in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these.ConclusionImplementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution.

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Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study.

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Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study.

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