Abstract
The literature on hospital competition and quality is young; most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured severity and transfer/discharge practices. Only one research team has evaluated related process and outcome measures, and none has exploited chart-review or patient survey-based data. Prior studies have generated inconsistent findings, suggesting the need for additional research. We describe the strengths and limitations of various approaches to quality measurement, summarize how quality has been operationalized in studies of hospital competition, outline three mechanisms by which competition may affect hospital quality, and propose measures appropriate for testing each mechanism.
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American Medical Association, Council of Medical Service. (1984). “Quality of Care.” JAMA 256, 1032–1034.
Ashton, C. M., et al. (1994). “A Method of Developing and Weighting Explicit Process of Care Criteria for Quality Assessment.” Medical Care 32, 755–770.
Ashton, C. M., et al. (1997). “The Association between the Quality of Inpatient Care and Early Readmission: A Meta-Analysis of the Evidence.” Medical Care 35, 1044–1059.
Ashton, C. M., et al. (1999). “An Empirical Assessment of the Validity of Explicit and Implicit Process-of-Care Criteria for Quality Assessment.” Medical Care 37, 798–808.
Ayanian, J. Z. and J. S. Weissman. (2002). “Teaching Hospitals and Quality of Care: A Review of the Literature.” Millbank Quarterly 80, 569–593.
Baker, D. W., et al. (2002). “Mortality Trends during a Program that Publicly Reported Hospital Performance.” Medical Care 40, 879–890.
Benbassat, J. and M. Taragin. (2000). “Hospital Readmissions as a Measure of Quality of Health Care: Advantages and Limitations.” Archives of Internal Medicine 160, 1074–1081.
Best, W. R., et al. (2002). “Identifying Patient Preoperative Risk Factors and Postoperative Adverse Events in Ad-ministrative Databases: Results from the Department of Veterans Affairs National Surgical Quality Improvement Program.” Journal of the American College of Surgeons 194, 257–266.
Caplan R. A., K. L. Posner and F. W. Cheney. (1991). “Effect of Outcome on Physician Judgments of Appropri-ateness of Care.” JAMA 265, 1957–1960.
Chassin, M. R., et al. (1989). “Differences among Hospitals in Medicare Patient Mortality.” Health Services Research 24, 1–31.
Chassin, M. R., et al. (1998). “The Urgent Need to Improve Health Care Quality. Institute of Medicine National Roundtable on Health Care Quality.” JAMA 280, 1000–1005.
Cutler, D. (1995). “The Incidence of Adverse Medical Outcomes Under Prospective Payment.” Econometrica 63, 29–50.
Devers, K. J., L. R. Brewster and L. P. Casalino. (2003). “Changes in Hospital Competitive Strategy: A New Medical Arms Race?” Health Services Research 38, 447–469.
Donabedian, A. (1980). Explorations in Quality Assessment and Monitoring.The Definition of Quality and Approaches to its Assessment. Ann Arbor: Health Administration Press, Vol. I, pp. 13–15.
Donabedian, A. (2003). An Introduction to Quality Assurance in Health Care, Rashid Bashshur (ed.). New York: Oxford University Press.
Dranove, D., et al. (2003). “Is More Information Better? The Effects of 'Report Cards' on Health Care Providers.” Journal of Political Economy 111, 555–588.
Dudley, R. A., et al. (2000). “Selective Referral to High-Volume Hospitals: Estimating Potentially Avoidable Deaths.” JAMA 283, 1159–1166.
Elixhauser, A., et al. (1998). “Comorbidity Measures for Use with Administrative Data.” Medical Care 36, 8–27.
Fisher, E. S., et al. (1992). “The Accuracy of Medicare's Hospital Claims Data: Progress Has Been Made, but Problems Remain.” American Journal of Public Health 82, 243–248.
Ford, E. S. and R. S. Cooper. (1995). “Racial/Ethnic Differences in Health Care Utilization of Cardiovascular Procedures: A Review of the Evidence.” Health Services Research 30, 237–252.
Geraci, J. M., et al. (1997). “International Classification of Diseases, 9th Revision, Clinical Modification Codes in Discharge Abstracts Are Poor Measures of Complication Occurrence in Medical Inpatients.” Medical Care 35, 589–602.
Geweke, J., G. Gowrisankaran and R. Town. (2003). “Bayesian Inference for Hospital Quality in a Selection Model.” Econometrica 71, 1215–1238.
Ghali, W. A., et al. (1996). “Searching for an Improved Clinical Comorbidity Index for Use with ICD-9-CM Administrative Data.” Journal of Clinical Epidemiology 49, 273–278.
Goldman, R. L. (1992). “The Reliability of Peer Assessments of Quality of Care.” JAMA 267, 958–960.
Gormley, W. T., Jr. and D. L. Weimer. (1999). Organizational Report Cards. Cambridge, MA: Harvard University Press, pp. 134–144.
Gowrisankaran, G. and R. Town. (2003). “Competition, Payers, and Hospital Quality.” Health Services Research 38, 1403–1421.
Green, J., et al. (1990). “The Importance of Severity of Illness in Assessing Hospital Mortality.” JAMA 263, 241–246.
Halm, E. A., C. Lee and M. R. Chassin. (2002). “Is Volume Related to Outcome in Health Care? A Sys-tematic Review and Methodologic Critique of the Literature.” Annals of Internal Medicine 137, 511–520.
Hammer, P. J. and W. M. Sage. (2002). “Antitrust, Health Care Quality, and the Courts.” Columbia Law Review 102, 545–649.
Hayward, R. A., L. F. McMahon, Jr. and A. M. Bernard. (1993). “Evaluating the Care of General Medicine Inpatients: How Good Is Implicit Review?” Annals of Internal Medicine 118, 566–568.
Hibbard, J. H. and J. J. Jewett. (1997). “Will Quality Report Cards Help Consumers?” Health Affairs 16(3), 218–228.
Hibbard, J. H., J. Stockard and M. Tusler. (2003). “Does Publicizing Hospital Performance Stimulate Quality Improvement Efforts?” Health Affairs 22(2), 84–94.
Ho, V. and B. H. Hamilton. (2000). “Hospital Mergers and Acquisitions: Does Market Consolidation Harm Patients?” Journal of Health Economics 19, 767–791.
Hofer, T. P. and R. A. Hayward. (1996). “Identifying Poor-Quality Hospitals: Can Hospital Mortality Rates Detect Quality Problems for Medical Diagnoses?” Medical Care 34, 737–753.
Hofer, T. P., et al. (2000). “Discussion between Reviewers Does Not Improve Reliability of Peer Reviewof Hospital Quality.” Medical Care 38, 152–161.
Iezzoni, L. I., et al. (1994). “Using Administrative Data to Screen Hospitals for High Complication Rates.” Inquiry 31, 40–55.
Iezzoni, L. I. (1997). “The Risks of Risk Adjustment.” Journal of the American Medical Association 278, 1600–1607.
Institute of Medicine. (1990). Medicare: A Strategy for Quality Assurance, K. N. Lohr (ed.). Washington, DC: National Academy Press.
Institute of Medicine. (1999). Measuring the Quality of Health Care.A Statement by the National Roundtable on Health Care Quality, M. S. Donaldson (ed.). Washington, DC: National Academy Press.
Ioannidis, J. P. A. and J. Lau. (2001). “Evidence on Interventions to Reduce Medical Errors. An Overview and Recommendations for Future Research.” Journal of General Internal Medicine 16, 325–334.
Jencks, S. F., D. K. Williams and T. L. Kay. (1988). “Assessing Hospital-Associated Deaths from Discharge Data. The Role of Length of Stay and Comorbidities.” JAMA 260, 2240–2246.
Johnston, J. A., et al. (2002). “Impact of Different Measures of Comorbid Disease on Predicted Mortality of Intensive Care Unit Patients.” Medical Care 40, 929–940.
Kaboli, P. J., et al. (2001). “Length of Stay as a Source of Bias in Comparing Performance in VA and Private Sector Facilities. Lessons Learned from a Regional Evaluation of Intensive Care Outcomes.” Medical Care 39, 1014–1024.
Kashner, T. M. (1998). “Agreement between Administrative Files and Written Medical Records. A Case of the Department of Veterans Affairs.” Medical Care 36, 1324–1336.
Keeler, E. B., et al. (1992). “Hospital Characteristics and Quality of Care.” JAMA 268, 1709–1714.
Kessler, D. and J. Geppert. (2003). “The Effects of Hospital Competition on Variation in Utilization and Quality of Care.” Presented at Agency for Healthcare Research and Quality/Federal Trade Commission Provider Competition and Quality Conference, May 28, 2003.
Kessler, D. and M. McClellan. (2000). “Is Hospital Competition Socially Wasteful?” The Quarterly Journal of Economics 115, 577–615.
Khuri, S. F., et al. (1999). “Relation of Surgical Volume to Outcome in Eight Common Operations: Results from the VA National Surgical Quality Improvement Program.” Annals of Surgery 230, 414–432.
Klabunde, C. N., et al. (2000). “Development of a Comorbidity Index Using Physician Claims Data.” Journal of Clinical Epidemiology 53, 1258–1267.
Kressin, N. R. and L. A. Petersen. (2001). “Racial Differences in the Use of Invasive Cardiovascular Procedures: Review of the Literature and Prescription for Future Research.” Annals of Internal Medicine 135, 352–366.
Lawthers, A. G., et al. (1995). “Designing and Using Measures of Quality Based on Physician Office Records.” Journal of Ambulatory Care Management 18, 56–72.
Lawthers, A. G., et al. (2000). “Identification of In-Hospital Complications from Claims Data: Is it Valid?” Medical Care 38, 785–795.
Leibenluft, R. F. (2003). “Healthcare Antitrust: What's Next from the Federal Agencies?” Health Lawyers News April 2003, 18–23.
Luck, J., et al. (2000). “How Well Does Chart Abstraction Measure Quality? A Prospective Comparison of Standardized Patients with the Medical Record.” American Journal of Medicine 108, 642–649.
Luft, H. S., S. S. Hunt and S. C. Maerki. (1987). “The Volume-Outcome Relationship: Practice-Makes-Perfect or Selective-Referral Patterns?” Health Services Research 22, 157–182.
Luft, H. S., et al. (1986). “The Role of Specialized Clinical Services in Competition among Hospitals.” Inquiry 23, 83–94.
Luft, H. S. and P. S. Romano. (1997). Report on Heart Attack, 1991–1993, Volume 3: Detailed Statistical Results. Sacramento, CA: California Office of Statewide Health Planning and Development.
Marciniak, T. A., et al. (1998). “Improving the Quality of Care for Medicare Patients with Acute Myocardial Infarction. Results from the Cooperative Cardiovascular Project.” JAMA 279, 1351–1357.
Marshall, M. N., et al. (2003). “Can Health Care Quality Indicators be Transferred between Countries?” Quality and Safety in Health Care 12, 8–12.
McManus, M. A., et al. (2000). “How Far Have State Medicaid Agencies Advanced in Performance Measurement for Children?” Archives of Pediatrics & Adolescent Medicine 154, 665–671.
Melnick, G. A. and J. Zwanziger. (1988). “Hospital Behavior under Competition and Cost-Containment Policies. The California Experience, 1980 to 1985.” JAMA 260, 2269–2275.
Mitchell, P. H. and S. M. Shortell. (1997). “Adverse Outcomes and Variations in Organization of Care Delivery.” Medical Care 35, NS19-NS32.
Mukamel, D. B., J. Zwanziger and A. Bamezai. (2002). “Hospital Competition, Resource Allocation and Quality of Care.” BMC Health Services Research 2, 10. http://biomedcentral.com/1472-6963/2/10
Mukamel, D. B., J. Zwanziger and K. J. Tomaszewski. (2001). “HMO Penetration, Competition, and Risk-Adjusted Hospital Mortality.” Health Services Research 36, 1019–1035.
Nichols, L. M., et al. (2004). “Are Market Forces Strong Enough to Deliver Efficient Health Care Systems? Confidence is Waning.” Health Affairs 23(2), 8–21.
Pauly, M. V. (2003). “Competition in Medical Services and the Quality of Care: Concepts and History.” Presented at Agency for Healthcare Research and Quality/Federal Trade Commission Provider Competition and Quality Conference, May 28, 2003.
Peabody, J. W., et al. (2000). “Comparison of Vignettes, Standardized Patients, and Chart Abstraction. A Prospective Validation Study of 3 Methds for Measuring Quality.” JAMA 283, 1715–1722.
Pine, M., et al. (1997). “Predictions of Hospital Mortality Rates: A Comparison of Data Sources.” Annals of Internal Medicine 126, 347–354.
Quan, H., G. A. Parsons and W. A. Ghali. (2002). “Validity of Information on Comorbidity Derived from ICD-9-CM Administrative Data.” Medical Care 40, 675–685.
Reason, J. (2000). “Human Error: Models and Management.” BMJ 320, 768–770.
Rhew, D. C., M. B. Goetz and P. G. Shekelle. (2001). “Evaluating Quality Indicators for Patients with Community-Acquired Pneumonia.” Joint Commission Journal on Quality Improvement 27, 575–590.
Robinson, J. C. and H. S. Luft. (1987). “Competition and the Cost of Hospital Care, 1972 to 1982.” JAMA 257, 3241–3245.
Robinson, J. C., D. W. Garnick and S. J. McPhee. (1987). “Market and Regulatory Influences on the Availability of Coronary Angioplasty and Bypass Surgery in U.S. Hospitals.” New England Journal of Medicine 317, 85–90.
Robinson, J. C., et al. (1988). “Hospital Competition and Surgical Length of Stay.” JAMA 259, 696–700.
Romano, P. S., L. L. Roos and J. G. Jollis. (1993). “Further Evidence Concerning the Use of a Clinical Comorbidity Index with ICD-9-CM Administrative Data.” Journal of Clinical Epidemiology 46, 1085–1090.
Romano, P. S. and D. H. Mark. (1994). “Bias in the Coding of Hospital Discharge Data and Its Implications for Quality Assessment.” Medical Care 32, 81–90.
Romano, P. S. and B. K. Chan. (2000). “Risk-adjusting Acute Myocardial Infarction Mortality: Are APR-DRGs the Right Tool?” Health Services Research 34, 1469–1489.
Romano, P. S., et al. (2002). “Can Administrative Data be Used to Compare Postoperative Complication Rates Across Hospitals?” Medical Care 40, 856–867.
Roos, L. L., et al. (1997). “Complications, Comorbidities, and Mortality: Improving Classification and Prediction.” Health Services Research 32, 229–238.
Rosenthal, G. (1997). “Weak Associations Between Hospital Mortality Rates for Individual Diagnoses: Implications for Profiling Hospital Quality.” American Journal of Public Health 87, 429–433.
Rosko, M. (2001). “Cost Efficiency of US Hospitals: A Stochastic Frontier Approach.” Health Economics 10, 539–551.
Rothman, K. J. (1990). “No Adjustments Are Needed for Multiple Comparisons.” Epidemiology 1, 43–46.
Sari, N. (2002). “Do Competition and Managed Care Improve Quality?” Health Economics 11, 571–584.
Savitz, D. A. and A. F. Olshan. (1995). “Multiple Comparisons and Related Issues in the Interpretation of Epidemiologic Data.” American Journal of Epidemiology 142, 904–908.
Schneeweiss, S., et al. (2001). “Performance of Comorbidity Scores to Control for Confounding in Epidemiologic Studies Using Claims Data.” American Journal of Epidemiology 154, 854–864.
Seagrott, V. and M. Goldacre. (1994). “Measures of Early Postoperative Mortality: Beyond Hospital Fatality Rates.” BMJ 309, 361–366.
Shortell, S. M. and E. F. X. Hughes. (1988). “The Effects of Regulation, Competition, and Ownership on Mortality Rates Among Hospital Inpatients.” The New England Journal of Medicine 318, 1100–1107.
Smith, M. A., et al. (1997). “Peer Reviewof the Quality of Care: Reliability and Sources of Variability for Outcome and Process Assessments.” JAMA 278, 1573–1578.
Sohn, M., et al. (2002a). “Competition, Volume, and Level of Care in Neonatal Intensive Care in California.” University of Chicago Working Paper.
Sohn, M., et al. (2002b). “The Association Between Competition, Volume and Mortality Among Patients Receiving Coronary Angioplasty.” University of Chicago Working Paper.
Stukenborg, G. J., D. P. Wagner and A. F. Connors, Jr. (2001). “Comparison of the Performance of Two Co-morbidity Measures, With and Without Information from Prior Hospitalizations.” Medical Care 39, 727–739.
Thomas, E. J., E. J. Orav and T. A. Brennan. (2000). “Hospital Ownership and Preventable Adverse Events.” Journal of General Internal Medicine 15, 211–219.
Thomas, J. W. and T. P. Hofer. (1998). “Research Evidence on the Validity of Risk-Adjusted Mortality Rate as a Measure of Hospital Quality of Care.” Medical Care Research and Review 55, 371–404.
Thompson, J. R. (1998). “Invited Commentary: Re: Multiple Comparisons and Related Issues in the Interpretation of Epidemiologic Data.” American Journal of Epidemiology 147, 801–806.
van Doorn, C., et al. (2001). “Risk Adjustment for Older Hospitalized Persons: A Comparison of Two Methods of Data Collection for the Charlson Index.” Journal of Clinical Epidemiology 54, 694–701.
Volpp, K. G. M., et al. (2003). “Market Reform in New Jersey and the Effect on Mortality from Acute Myocardial Infarction.” Health Services Research 38, 503–521.
Wei, F., et al. (1995). “Are PRO Discharge Screens Associated with Postdischarge Adverse Outcomes?” Health Services Research 30, 489–506.
Weiner, J. P., et al. (1995). “Variation in Office-Based Quality. A Claims-Based Profile of Care Provided to Medicare Patients with Diabetes.” JAMA 273, 1503–1508.
Weingart, S. N., et al. (2002). “Discrepancies between Explicit and Implicit Review: Physician and Nurse Assess-ments of Complications and Quality.” Health Services Research 37, 483–498.
Wong, H. and R. Mutter. (2003). “The Effects of Hospital Consolidations on Quality of Care.” Presented at Agency for Healthcare Research and Quality/ Federal Trade Commission Provider Competition and Quality Conference, May 28, 2003.
Zhang, J. X., T. J. Iwashyna and N. A. Christakis. (1999). “The Performance of Different Lookback Periods and Sources of Information for Charlson Comorbidity Adjustment in Medicare Claims.” Medical Care 37, 1128–1139.
Zwanziger, J. and G. A. Melnick. (1988). “The Effects of Hospital Competition and the Medicare PPS Program on Hospital Cost Behavior in California.” Journal of Health Economics 7, 301–320.
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Romano, P.S., Mutter, R. The Evolving Science of Quality Measurement for Hospitals: Implications for Studies of Competition and Consolidation. International Journal of Health Care Finance and Economics 4, 131–157 (2004). https://doi.org/10.1023/B:IHFE.0000032420.18496.a4
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DOI: https://doi.org/10.1023/B:IHFE.0000032420.18496.a4