Different regional organisational models and the quality of health care: the case of coronary artery bypass graft surgery.
OBJECTIVE
The Italian regions of Emilia-Romagna and Lombardy within the Italian National Health Service provide an opportunity to see if two different approaches to the organisation of care--one more hierarchical and planned, the other more competitive and market-like--influence its quality through examining the relationship between the number of coronary artery bypass grafts (CABGs) and the rate of in-hospital mortality using administrative data for the period 1996-1998.


METHODS
Descriptive statistics and logistic regression models were used.


RESULTS
The volume-outcome relation was statistically significant in both regions (odds ratio 0.71, P < 0.0001). Although CABG performance in Emilia-Romagna was slightly poorer than in Lombardy (OR 1.22, P < 0.05), the potential advantage in terms of the reduced risk of death for patients treated at high-volume versus low-volume hospitals was significantly greater. In Emilia-Romagna, the average performance advantage of high-volume units was more substantial in the case of private accredited hospitals than public hospitals (OR = 0.50, P < 0.0001 versus OR = 0.64, P < 0.0001). In Lombardy, the performance advantage of concentrating CABG procedures was greater in private research hospitals (OR = 0.67, P < 0.0001), whereas results were not statistically significant for the other types of hospital, indicating a good level of performance in both public and private hospitals even at low volumes. This also partially explained the lower mortality rate observed in that region.


CONCLUSIONS
The degree of hierarchical regionalisation versus market-like arrangements characterising the two systems produced contrasting effects in terms of the quality of CABG surgery. Lombardy's more competitive environment appeared to achieve better performance in terms of a slightly lower probability of adverse outcomes, in a system with no formal assessment of population need and very high per capita revascularisation rates. To improve performance in the more hierarchical system adopted in Emilia-Romagna would require considerable effort to increase CABG surgery in low-volume cardiac units, and to sharpen performance incentives.
Nobilio
Lucia
L
Department of Economics, University of Bologna, Bologna, Italy.
Ugolini
Cristina
C
D000368:Aged; D002300:Cardiac Care Facilities / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data; D001026:Coronary Artery Bypass / Q000401:mortality* / Q000706:statistics & numerical data*; D005260:Female; D006302:Health Services Research; D017052:Hospital Mortality; D016304:Hospitals, Private / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D006779:Hospitals, Public / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007558:Italy / Q000453:epidemiology; D016015:Logistic Models; D017146:Models, Organizational; D019984:Quality Indicators, Health Care; D014600:Utilization Review / Q000706:statistics & numerical data