Do managerial incentives matter? The effect of hip fracture surgery delays and outcomes (with M. Lippi Bruni).

In most OECD countries, pre-surgery waiting time has become a process indicator of the quality of care for hip fracture patients, and international clinical guidelines recommend hip fracture surgery to be provided within two days of hospitalisation. To help achieve this target, in year 2011 the Italy’s Emilia-Romagna region implemented a policy under which hospital performance was monitored and evaluated, allowing the chief executives of Local Health Authorities and hospital Trusts to receive additional rewards if they managed to achieve increases in the proportion of hip fracture patients operated on within two days after hospital admission. In this paper, we empirically test the effect of the policy on shortening waiting times for hip fracture surgery by using a difference-in-differences analysis on patient-level data between 2007 and 2016. We find that the introduction of managerial incentives had the effect to reduce hip fracture surgery delays. The effect is statistically significant from year 2012 onwards, and cumulates over time. Moreover, we find that the policy did not just affect the cases near the incentive threshold of two days, but also induced a shift in the overall distribution of waiting times. Finally, our findings suggest no significant effects in terms of post-operative length of stay. The results may provide useful insights to develop targeted policy interventions in similarly regulated health care settings.

The impact of alternative rehabilitation settings on health outcomes for hip fracture patients: Evidence from a propensity score analysis (with A.C. Leucci).

Osteoporotic fractures represent one of the major health problems in developed countries. In the recent years, an increasing number of studies have addressed the issue of how hip fracture patients should be treated in order to improve health outcomes. The objective of this paper is to study the influence of alternative rehabilitation settings on adverse health outcomes for patients following a hip fracture. Using administrative data on elective patients discharged from publicly financed providers in the Italy’s Emilia-Romagna region between 2014 and 2017, we analyze adverse health outcomes as measured in terms of mortality rates within 30 days of acute care discharge. The treatment groups considered in the analysis consist of patients assigned to the alternative discharge strategies, including in-hospital rehabilitation care, ambulatory care, home care, and care provided by community hospitals or other long-term care facilities. Due to the effect of some patients’ characteristics on their discharge destination, we use propensity score matching methods to reduce the potential bias in estimating the impact of different rehabilitation settings on adverse health outcomes. We find that alternative forms of post- acute rehabilitative care significantly affect patients’ health outcomes. The results provide some evidence that improvements in health outcomes for patients with hip fracture can to some extent be achieved by altering the destination of discharge.

The impact of pro-market reforms on commissioner behavior in the English NHS (with M. Dusheiko, M. Goddard and H. Gravelle).

This paper focuses on the effect of the introduction of prospective payments, intended in part to change purchaser behaviour, on trends in the concentration of commissioners’ elective admissions in the English National Health Service (NHS). We find little or no evidence of significant changes in commissioning patterns in the first and partial stage of policy implementation. However, as the prospective payment was extended to all elective admissions, we find a lower concentration of purchasers’ elective admissions across providers and an increase in switching of referrals amongst providers. Our findings provide important implications for the organization of commissioning not only in the English context, but also in other countries with similar payment systems.

Disentangling the effect of waiting times on hospital choice: Evidence from a panel data analysis. Quaderni – Working Paper DSE, 2018, p. 1-39, Department of Economics, University of Bologna, ISSN: 2282-6483 (with M. Lippi Bruni and C. Ugolini).

This study examines the effect of waiting times on hospital choice by using patient-level data on elective Percutaneous Transluminal Coronary Angioplasty (PTCA) procedures in the Italian NHS over the years 2008-2011. We perform a multinomial logit analysis including conditional logit and mixed logit specifications. Our findings show the importance of jointly controlling for time-invariant and time varying dimensions of hospital quality in order to disentangle the effect of waiting times on hospital choice. We provide evidence that patients are responsive to changes in waiting times and aspects of clinical quality within hospitals over time, and estimate the trade-off that patients make between different hospital attributes. The results convey important policy implications for highly regulated health care markets.