1. Variations in Quality Outcomes Among Hospitals in Different Types of Health Systems, 1995 - 2000 Askar Chukmaitov, M.D., M.P.A. Askar Chukmaitov, M.D., M.P.A. Virginia Commonwealth University Gloria J. Bazzoli, Ph.D. Virginia Commonwealth University Agency For Healthcare Research and Quality, Grant #R01 HS13094

2. Forces to reduce costs and improve quality of care motivated hospitals to join health systems in the 1990s Forces to reduce costs and improve quality of care motivated hospitals to join health systems in the 1990s Bazzoli et al. (2000) have found differences in costs and financial performance across hospital system types Bazzoli et al. (2000) have found differences in costs and financial performance across hospital system types Did not examine hospitals quality performance across different types of hospital systems Did not examine hospitals quality performance across different types of hospital systems Important issue given concerns regarding safety and quality Important issue given concerns regarding safety and quality 44,000 to 98,000 hospital deaths in the US each year caused by medical errors (IOM, 1999) 44,000 to 98,000 hospital deaths in the US each year caused by medical errors (IOM, 1999) Rationale for the Study

3. Design Design Longitudinal analysis of 1995-2000 data Longitudinal analysis of 1995-2000 data Data: Data: AHA, HCUP (SID) 1995-2000 AHA, HCUP (SID) 1995-2000 Sampling Sampling All nonfederal, short-term, general medical- surgical hospitals from 11 states (AZ, CA, CO, FL, IA, MD, MA, NJ, NY, WA, and WI) All nonfederal, short-term, general medical- surgical hospitals from 11 states (AZ, CA, CO, FL, IA, MD, MA, NJ, NY, WA, and WI) Analytic Approach Analytic Approach Adjusted Least Square Means (ALSM) calculated for each IQI and PSI: Adjusted Least Square Means (ALSM) calculated for each IQI and PSI: Patient age, gender, acuity, and case-mix Patient age, gender, acuity, and case-mix Methods

4. Key Variables Hospitals in Different Types of Health Systems: Hospitals in Different Types of Health Systems: Centralized Health System (CHS), Centralized Physician/Insurance Health System, Moderately Centralized Health System (MCHS), Decentralized Health System (DHS), Independent Hospital System (IndHS) (Bazzoli et al. 1999) Centralized Health System (CHS), Centralized Physician/Insurance Health System, Moderately Centralized Health System (MCHS), Decentralized Health System (DHS), Independent Hospital System (IndHS) (Bazzoli et al. 1999) Patient Outcomes: Patient Outcomes: IQIs are measures of mortality rates for specific diagnosis; IQIs are measures of mortality rates for specific diagnosis; IQIs selected for study: AMI, CHF, Stroke, GI hemorrhage, and Pneumonia IQIs selected for study: AMI, CHF, Stroke, GI hemorrhage, and Pneumonia PSIs are adverse events or complications that occur during care; PSIs are adverse events or complications that occur during care; Selected PSIs: complications of anesthesia, death in low mortality DRGs, decubitus ulcer, infections due to medical care, post-op hemorrhage, post-op PE and DVT, sepsis, and accidental puncture and laceration Selected PSIs: complications of anesthesia, death in low mortality DRGs, decubitus ulcer, infections due to medical care, post-op hemorrhage, post-op PE and DVT, sepsis, and accidental puncture and laceration

5. Centralized Health System (CHS) Centralized Physician/ Insurance Health System (CPIHS) Moderately Centralized Health System (MCHS) Decentralized Health System (DHS) Independent Hospital System (IndHS) high degree of centralization in hospital services, physician arrangements, and insurance products high levels of centralization for physician arrangements and insurance products at the health system level; hospital services not highly centralized moderate levels of centralization for all service/product dimensions high levels of decentralization in hospital services, physician arrangements, and insurance products at the hospital level little differentiation of: hospital services, physician arrangements, and insurance products (Bazzoli et al. 1999) Description of Various Types of Health Systems

6. Trends in Health Systems in 1995 – 2000

7. Results for Different System Types IQI mortality rates for AMI, CHF, Stroke, GI hemorrhage, and Pneumonia: The best performers – hospitals in DHS, CHS, and CPIHS in the 1995 – 2000 period The best performers – hospitals in DHS, CHS, and CPIHS in the 1995 – 2000 period Significantly better than hospitals in other system types Significantly better than hospitals in other system types PSI adverse event rates: Less clear and less significant trends for the best or the worse performers Less clear and less significant trends for the best or the worse performers However, hospitals in more centralized health systems tend to perform worse than hospitals in other system types for a number of PSIs However, hospitals in more centralized health systems tend to perform worse than hospitals in other system types for a number of PSIs

8. Results Results for Different System Types

10. Results for IQI and PSI Indicators Over Time Increase in IQI mortality rates outcomes after 1998, except AMI Increase in IQI mortality rates outcomes after 1998, except AMI Leveling or increase in PSI adverse events after 1998 Leveling or increase in PSI adverse events after 1998

11. Results for IQI and PSI Indicators Over Time

13. Hospitals in more centralized health systems and in Decentralized Health Systems have better IQIs than hospitals in other systems. This relationship holds over time. Hospitals in more centralized health systems and in Decentralized Health Systems have better IQIs than hospitals in other systems. This relationship holds over time. Hospitals in more centralized health systems tend to perform worse in terms of PSI, even though differences are not always significant. Hospitals in more centralized health systems tend to perform worse in terms of PSI, even though differences are not always significant. Future research needs to examine the organizational characteristics and internal processes adopted by different systems that lead to higher quality of care as measured by IQI and PSI performance. Future research needs to examine the organizational characteristics and internal processes adopted by different systems that lead to higher quality of care as measured by IQI and PSI performance. Performance on many indicators declined after 1998 – suggestive of BBA effect. Performance on many indicators declined after 1998 – suggestive of BBA effect. Future research needs to look for potential adverse quality effects from BBA or potentially other market/policy factors. Future research needs to look for potential adverse quality effects from BBA or potentially other market/policy factors. Significance to Policy