背景:独立治疗中心(ITC)的数量大幅增长。然而,鲜为人知的是,该部门是否存在量-质量关系,以及是否有其他可能的组织因素调解这种关系。这项研究的目的是更好地理解这种可能的关系。
方法:数据来源于荷兰健康和青年护理监察局(IGJ)和荷兰患者协会。我们使用了4年(2014-2017年)的纵向数据,包括三种不同的质量衡量标准:1)结构和工艺指标的综合,2)术后感染,3)患者满意度。我们通过侵入性治疗的数量来测量体积。我们调整了三个重要的组织特征:(1)劳动力规模,(2)连锁会员,(3)所有权状态。对于统计推断,采用随机效应分析。我们还对体积-质量关系进行了几次健壮性检查,包括分数logit模型。
结果:数量较高的ITC在结构上得分较高,与低容量ITC相比,过程和结果(即术后感染)指标-尽管对结果影响不大。然而,具有较高容量的ITC没有较高的患者满意度。量的边际效应递减-换句话说,L形曲线。中介结构因素对量-质量关系的影响(即劳动力规模,链成员资格和所有权状态)不太清楚。我们的发现表明,连锁成员资格对患者满意度有负面影响。此外,营利性提供商在净发起人得分上得分更高。
结论:我们的研究肯定地表明,通过结构,过程和结果(即术后感染)指标。然而,体积对术后感染的影响很小,并且在较高的量下,边际收益(就较低的术后感染而言)减少。此外,容量与患者满意度无关。此外,结构性中介因素与质量之间的联系是脆弱的。
BACKGROUND: The number of independent treatment centres (ITCs) has grown substantially. However, little is known as to whether the volume-quality relationship exists within this sector and whether other possible organisational factors mediate this relationship. The aim of this study is to gain a better understanding of such possible relationships.
METHODS: Data originate from the Dutch Health and Youth Care Inspectorate (IGJ) and the Dutch Patients Association. We used longitudinal data from 4 years (2014-2017) including three different quality measures: 1) composite of structural and process indicators, 2) postoperative infections, and 3) patient satisfaction. We measured volume by the number of invasive treatments. We adjusted for three important organisational characteristics: (1) size of workforce, (2) chain membership, and (3) ownership status. For statistical inference, random effects analysis was used. We also ran several robustness checks for the volume-quality relationship, including a fractional logit model.
RESULTS: ITCs with higher volumes scored better on structure, process and outcome (i.e. postoperative infections) indicators compared to the low-volume ITCs - although only marginally on outcome. However, ITCs with higher volumes do not have higher patient satisfaction. There is a decreasing marginal effect of volume - in other words, an L-shaped curve. The effect of the intermediating structural factors on the volume-quality relationship (i.e. workforce size, chain membership and ownership status) is less clear. Our findings suggest that chain membership has a negative influence on patient satisfaction. Furthermore, for-profit providers scored better on the Net Promoter Score.
CONCLUSIONS: Our study shows with some certainty that the quality of care in low-volume ITCs is lower than in high-volume ITCs as measured by structural, process and outcome (i.e. postoperative infection) indicators. However, the size of the effect of volume on postoperative infections is small, and at higher volumes the marginal benefits (in terms of lower postoperative infections) decrease. In addition, volume is not related to patient satisfaction. Furthermore, the association between the structural intermediating factors and quality are tenuous.