Abstract
BackgroundHealth care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery.MethodsThis was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends.ResultsThe difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was − 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours − 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy.ConclusionsWe found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.
Highlights
Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences
The aim of this study was to determine whether implementation of the Quality-Based Procedures (QBPs) funding reform, along with dissemination of best practice clinical pathways, in a large population-based cohort from Ontario, Canada (2018 population ≈ 14.5 million) was associated with (1) decreased wait times for hip fracture surgery without the unintended consequences of; (2) increased wait times for other extremity fracture surgeries not funded through the QBP mechanism [16]; and/or (3) increased after-hours provision of hip fracture surgery[17]
Identification of Patients We identified all patients in Ontario, Canada undergoing surgery for hip fractures, ankle fractures, tibial plateau fractures, and appendectomy between April 1, 2012 and February 28, 2017
Summary
Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. Evidence shows that the everyday practice of medicine is “characterised by wide variations that have no basis in clinical science”, leading to variability in patient outcomes [4]. These reforms include “Quality-Based Procedures (QBPs)”, a hospital funding initiative implemented in Ontario, Canada. QBPs, a novel variant of activity-based funding (ABF) [5], are a procedure- and diagnosisspecific approach to funding hospitals They involve a pre-set price per episode of care, coupled with a best practice clinical pathway for each of the pre-specified diagnoses and procedures. The funding for QBPs was carved out of each hospital’s global budget, and reallocated back as a fixed price for a fixed volume of targeted care
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