Variations in hospital quality and outcomes under a financial incentive scheme

    Student thesis: Phd


    High and equitable quality of care are core goals of the English National Health Service. Policy makers have experimented with various ways to improve quality, including use of financial incentives. The effects of these incentives on health outcomes and the distribution of care are not known. The aim of this study was to examine variations in hospital quality and outcomes at patient level under a financial incentive scheme in England.In October 2008 a financial incentive scheme under which quality of care was measured by process measures was introduced for 24 hospital Trusts in the North West of England. The process measures of care from this Advancing Quality initiative were linked at spell level to health outcomes and administrative hospital records. The data consisted of 252,284 spells between October 2008 and March 2013.First, I examined whether financially incentivised improvements in quality of care were associated with better patient outcomes. I examined how mortality and readmission were related to process measures using bivariate probit, probit, random effects and fixed effects estimations. I found that several of the incentivised process measures of care are associated with improved patient outcomes. I estimated that Advancing Quality saved 129 lives and avoided 121 readmissions over a four-and-a-half year period.Second I examined whether quality of care from a hospital incentive scheme is distributed equitably at a patient level. Multinomial and sequential logistic regressions were used to show that process measures of care overall were distributed in favour of patients from lower income score areas. Process measures of care delivered during an emergency admission were distributed in favour of patients from higher income score areas but this was driven by patient severity. Process measures based on advice appeared to be driven by capacity to benefit and were distributed in favour of patients from lower income score areas. Process measures of care for elective admissions regarding delivery of drugs were distributed equitably.Third, I examined if the quality of care was lower at the weekend. The in-hospital mortality rate is known to be higher for weekend admissions than for weekday admissions but it is not known whether this was due to lower quality of care. Using logistic regressions, incentivised quality of care was found to be consistent throughout the week. The weekend mortality effect can be explained by patient volume, which suggested that patient case mix may be different between weekdays and weekends.Overall, quality of care under an incentive scheme was found to positively impact on health outcomes, be distributed equitably, and be the same at weekends as weekdays. Further research is needed using quality of care indicators from all Trusts in the English National Health Service. Furthermore further research examining how trusts exclude patients from financial incentive schemes is also needed.
    Date of Award1 Aug 2016
    Original languageEnglish
    Awarding Institution
    • The University of Manchester
    SupervisorMatthew Sutton (Supervisor), Stephen Campbell (Supervisor) & Tim Doran (Supervisor)


    • Weekend effect
    • Quality
    • Equity
    • Financial Incentives
    • Hospital

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