PubMed Health⌕ Search

Biomedical subjects

Rowena Jacobs

Publications and source records attributed to Rowena Jacobs.

11 recordsLinked to original sources
PubMed2007

The effects of expanding patient choice of provider on waiting times: evidence from a policy experiment.

Long waiting times for inpatient treatment in the UK National Health Service have been a source of popular and political concern, and therefore a target for policy initiatives. In the London Patient Choice Project, patients at risk of breaching inpatient waiting time targets were offered the choice of an alternative hospital with a guaranteed shorter wait. This paper develops a simple theoretical model of the effect of greater patient choice on waiting times. It then uses a difference in difference econometric methodology to estimate the impact of the London choice project on ophthalmology waiting times. In line with the model predictions, the project led to shorter average waiting times in the London region and a convergence in waiting times amongst London hospitals.

Choice Behavior↗
PubMed2006

The market for elective surgery: joint estimation of supply and demand.

This paper develops models of the demand for and supply of elective (non-emergency) surgery using a panel of quarterly data for 200 English hospitals over the period 1995-2002. Unusually, distinct measures of supply (outpatients seen and inpatient admissions) and demand (outpatient referrals and decisions to admit) are available for each observation. These offer the opportunity to estimate separate empirical models of supply and demand using ordinary least squares (OLS) regression methods. However, the strong correlation between the residuals of these models suggests some merit in the deployment of seemingly unrelated regression (SUR) methods. Although both static and dynamic SUR estimations leave the results largely qualitatively unchanged, SUR estimation can have a considerable quantitative effect relative to the OLS results. For example, SUR estimation generates a lower elasticity of inpatient demand with respect to waiting time than that obtained via OLS. The results offer an important justification for more careful econometric modelling of hospital behaviour than has traditionally been employed in the health economics literature.

Elective Surgical Procedures↗
PubMed2006

Exploring the determinants of NHS performance ratings: lessons for performance assessment systems.

OBJECTIVES: A basic tenet of effective performance management is that decision makers should be held responsible only for aspects of performance over which they have control. We examine the degree to which variations in the performance of health care organizations are explained by a range of factors that are subject to differing degrees of managerial control. METHODS: We use multiple regression methods and data on 304 National Health Service (NHS) Primary Care Trusts (PCTs) in England for 2002/03 to analyse the relationship between their performance, as measured by 'star ratings' and nine key performance targets, and a large number of explanatory variables. We classify the explanatory variables into five groups along a spectrum from 'no managerial control' to 'total managerial control'. We also analyse the relationship between PCTs that are service purchasers and their main providers to assess the degree to which their performance is linked. RESULTS: For all of the key performance targets, most of the variation in performance is unexplained, although variables in groups 1, 2 and 3 (less managerial control) explain the largest proportion of variation. We find some evidence that socioeconomic and geographic factors have an impact on performance. We also find a positive relationship between the performances of purchaser and provider organizations. CONCLUSIONS: The star ratings did not allow for the different environmental circumstances within which PCTs operate and which affect their performance. Policy-makers should exercise caution in using such performance indicators to regulate health care organizations.

England↗
PubMed2005

The effect of financial incentives on gatekeeping doctors: evidence from a natural experiment.

In many health care systems generalist physicians act as gatekeepers to secondary care. Under the English fundholding scheme from 1991/1992 to 1998/1999 general practices could elect to be given a budget to meet the costs of certain types of elective surgery (chargeable electives) for their patients and could retain any surplus. They did not pay for non-chargeable electives or for emergency admissions. Non-fundholding practices did not bear the cost of any type of hospital admissions. Fundholding is to be reintroduced from April 2005. We estimate the effect of fundholding using a differences in differences methodology on a large 4-year panel of English general practices before and after the abolition of fundholding. The abolition of fundholding increased ex-fundholders' admission rates for chargeable elective admissions by between 3.5 and 5.1%. The effect on the early wave fundholders was greater (around 8%) than on later wave fundholders. We also use differences in differences for two types of admissions (non-chargeable electives, emergencies) not covered by fundholding as additional controls for unobserved temporal factors. These differences in differences in differences estimates suggest that the abolition of fundholding increased ex-fundholders' chargeable elective admissions by 4.9% (using the non-chargeables DID) and by 3.5% (using the emergencies DID).

Algorithms↗
PubMed2005

How robust are hospital ranks based on composite performance measures?

BACKGROUND: Composite indices of healthcare performance are an aggregation of underlying individual performance measures. They are increasingly being used to rank healthcare organizations. Although composite indicators present the "big picture" in a way that is easy to interpret, misleading conclusions may be drawn if attention is not paid to key methodological issues in their construction. OBJECTIVES: We examine variability in performance measures in the context of the construction and use of composite measures. We illustrate how variability in the underlying data and the resulting composite may undermine the robustness of performance measures in health care. We also illustrate how variation in the methodological rules applied to aggregate the individual indicators can have an important impact on composite scores. METHODS: We use data for 117 English acute hospitals to illustrate the generic methodological issues. The variance in performance measures is partitioned into "controllable" and "uncontrollable" elements. We create a composite index from the underlying performance indicators and use Monte Carlo simulations to examine the robustness of the composite. RESULTS: Random variation beyond the control of organizations gives rise to considerable uncertainty in hospital scores. Composites are also sensitive to changes made to the weighting system and to the aggregation rules. Some hospitals can jump almost half of the league table as a result of subtle changes. CONCLUSIONS: Great care is warranted in interpreting the results of composite performance measures. Suggestions for their future development are made.

Benchmarking↗
PubMed2004

The effect of practice budgets on patient waiting times: allowing for selection bias.

Under the UK fundholding scheme, general practices could elect to hold a budget to meet the costs of some types of elective surgery (chargeable admissions) for their patients. It was alleged that patients of fundholding practices had shorter waits for elective surgery than the patients of non-fundholders. Comparison of waiting times between fundholding and non-fundholding practices are potentially confounded by selection bias as fundholding was voluntary. We estimate the effect of a practice's fundholding status on the waiting times of its patients using both cross-sectional methods (OLS, propensity score, instrumental variables, Heckman selection correction and Heckman heterogenous effects estimators) and difference in differences methodologies to correct for selection bias. The estimated effect of fundholding status was to significantly reduce the waiting times for chargeable admissions of the patients of fundholders by 4.1-6.6% (or 4-7 days) with the instrumental variables and Heckman selection correction estimators yielding the highest estimates. We also find that patients of fundholding practices had shorter waits (by 3.7% or 2 days) for non-chargeable elective admissions, suggesting that fundholders were able to obtain shorter waits for all types of elective admissions.

Budgets↗
PubMed2004

Is patient choice an effective mechanism to reduce waiting times?

In many countries, patient choice is a routine part of the normal healthcare system. However, many choice initiatives in secondary care are part of policies aimed at reducing waiting times. This article provides evidence on the effectiveness of patient choice as a mechanism to reduce waiting times within a metropolitan area. The London Patient Choice Project was a large-scale pilot offering patients on hospital waiting lists a choice of alternative hospitals with shorter waiting times. A total of 22 500 patients were offered choice and 15 000 accepted. The acceptance rate of 66% was very high by international standards. In this article we address two questions. First, did the introduction of choice significantly reduce waiting times in London relative to the rest of the country where there was no choice? Second, how were the waiting times of London patients not offered choice affected by the choice regime? We examine the evidence on these issues for one specialty, orthopaedics. A difference-in-difference analysis is used to compare waiting times for hospitals within London before and after the introduction of choice. Although there was a small but significant reduction in waiting times in London relative to other areas where there was no patient choice, the main effect of the choice regime was to produce convergence of mean waiting times within London. Convergence was achieved by bringing down waiting times at the hospitals with high waiting times to the levels that prevailed in hospitals with low waiting times. This represented a clear improvement in equity of access, an important objective of the English National Health Service.

Choice Behavior↗
PubMed2003

Hospital efficiency targets.

Cost-efficiency targets, used to encourage downward pressure on hospital unit costs, have been employed within the UK NHS for many years. There has been considerable speculation that these targets create incentives to reduce beds and increase occupancy rates at the expense of holding spare capacity to accommodate fluctuations in emergency admissions. This research used panel data for the period 1994/1995-1999/2000, supplemented by a series of semi-structured interviews, to explore the strategies Trusts employ to reduce unit costs. No relationship could be found between published targets and changes in unit costs, nor that targets were successful in reducing the dispersion of unit costs over time. Interviews revealed that efficiency gains required of Trusts, usually dictated by the local health economy, often bore no correspondence to the national or regional published targets. Results further indicated that contrary to prior speculation, Trusts divide into two distinct groups, those with high occupancy rates and those with a high proportion of free beds to accommodate emergencies, with Trust characteristics displaying stability over time. A pressing need for future work is the development of measures to encourage efficiency that take account of quality improvement.

Cost Control↗
PubMed2003

Variation in unit costs of hospitals in the English National Health Service.

OBJECTIVES: In England, the Department of Health places high priority on reducing the variation in unit costs of National Health Service (NHS) hospitals. Efficiency targets are set for hospitals to create incentives for relatively high cost hospitals to reduce their costs and shift performance closer to that of their lower cost counterparts. We examine empirically the dispersion in unit costs to assess the extent of variation in the productivity of hospitals and trends over time. METHODS: We use econometric panel data techniques on data from 235 NHS acute hospital trusts over a six-year period, 1994/95 to 1999/00, supplemented with information from semi-structured interviews with key individuals in hospitals and purchasing bodies. RESULTS: There appears to have been no reduction in variation during this period. Relative unit costs for individual trusts also appear stable, with little movement from relatively high cost to low cost. Judging from limited quantitative evidence outside health care, the variation in costs between NHS hospitals may be comparatively low. CONCLUSIONS: Given all the other aspects of hospital performance that government is seeking to change, reduction in the dispersion of unit costs per se should not be a major policy objective. It is far more important to examine variation in quality-adjusted unit costs.

Cost Allocation↗
PubMed2003

Comparing the efficiency of national health systems: a sensitivity analysis of the WHO approach.

The World Health Organization (WHO) has used econometric methods to measure the efficiency of health care systems. We assess the robustness of WHO results to definitions of efficiency and statistical procedures. Originally analysed by the WHO, the data are for 1997 (50 countries) and 1993-1997 (141 countries). The efficiency of each country in promoting population health is estimated after taking into account health care expenditure, all other expenditure and education levels. Efficiency scores are compared under different definitions of efficiency and different estimation methods. The results show that the country rankings and efficiency scores are sensitive to the definition of efficiency and choice of model specification. We conclude that econometric methods can yield insights into complex socioeconomic phenomena. However, the lack of robust results to reasonable alternative specifications suggests that it is premature to use the methods adopted by the WHO to construct league tables of health systems.

Data Collection↗