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首页 Equity, waiting times, and NHS reforms- retrospe…

Equity, waiting times, and NHS reforms- retrospective study.pdf

Equity, waiting times, and NHS …

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2012-02-23 0人阅读 举报 0 0 暂无简介

简介:本文档为《Equity, waiting times, and NHS reforms- retrospective studypdf》,可适用于经济金融领域

RESEARCHEquity,waitingtimes,andNHSreforms:retrospectivestudyZacharyNCooper,PhDcandidateinpublicpolicy,AlistairMcGuire,professorofhealtheconomics,SJones,chiefstatistician,JLeGrand,RichardTitmussprofessorofsocialpolicyABSTRACTObjectiveTodeterminewhetherobservablechangesinwaitingtimesoccurredforcertainkeyelectiveproceduresbetweenandintheEnglishNationalHealthServiceandtoanalysethedistributionofthosechangesbetweensocioeconomicgroupsasanindicatorofequityDesignRetrospectivestudyofpopulationwide,patientleveldatausingordinaryleastsquaresregressiontoinvestigatethestatisticalrelationbetweenwaitingtimesandpatients’socioeconomicstatusSettingEnglishNHSfromtoParticipantspatientswhohadelectivekneereplacement,whohadelectivehipreplacement,andwhohadelectivecataractrepairMainoutcomemeasuresDayswaitedfromreferralforsurgerytosurgeryitselfsocioeconomicstatusbasedonCarstairsindexofdeprivationResultsMeanandmedianwaitingtimesroseinitiallyandthenfellsteadilyovertimeByvariationinwaitingtimesacrossthepopulationtendedtobelowerInwaitingtimesanddeprivationtendedtobepositivelyrelatedBytherelationbetweendeprivationandwaitingtimewaslesspronounced,and,insomecases,patientsfromthemostdeprivedfifthwerewaitinglesstimethanpatientsfromthemostadvantagedfifthConclusionsBetweenandwaitingtimesforpatientshavingelectivehipreplacement,kneereplacement,andcataractrepairinEnglandwentdownandthevariationinwaitingtimesforthoseproceduresacrosssocioeconomicgroupswasreducedManypeoplefearedthatthegovernment’sNHSreformswouldleadtoinequity,butinequitywithrespecttowaitingtimesdidnotincreaseifanything,itdecreasedAlthoughprovingthatthelaterstagesofthosereforms,whichincludedpatientchoice,providercompetition,andexpandedcapacity,wasacatalystforimprovementsinequityisimpossible,thedatashowthatthesereforms,ataminimum,didnotharmequityINTRODUCTIONUntilrecently,hospitalwaitingtimeswereviewedasanimportantproblemfortheNationalHealthServiceHowever,overthepastyears,asthegovernmentinEnglandincreasedthesupplyofdoctors,increasedfundingforthehealthservice,setrigidwaitingtimetargets,and(morerecently)introducedmarketbasedreforms,waitingtimeshavedroppedconsiderablyYet,whereasNHSwaitingtimesarewidelyacceptedtohavefallenbetweenand,littleisknownaboutwhetherthedropinwaitingtimeshasbeenequitablydistributedwithrespecttosocioeconomicstatusOneofthemainfearsassociatedwiththelaterstagesofthesereformswhichincludedincreasedchoiceforpatients,theuseoftreatmentprovidersfromtheindependentsector,andcompetitionbetweenproviderswaswhetheranyimprovementsinqualityordropsinwaitingtimeswouldcomeattheexpenseofequityWeusedpopulationwide,patientleveldatatoexaminetheextentofanyobservablechangesinwaitingtimesforcertainkeyelectiveproceduresbetweenandandtoanalysethedistributionofthosechangesbetweensocioeconomicgroupsWerelatethesechangestothreedistinctperiodsingovernmentpolicyduringthattime:aperiodfromtowhenthegovernmentfocusedonwaitinglists,notwaitingtimes,andmoderatelyincreasedfundingaperiodfromtowhenfundingincreaseddramaticallyandthegovernmentfocusedontargetsandperformancemanagementandaperiodfromtowhenthegovernmentexpandedsupplyandintroducedpatientchoiceandprovidercompetitionMETHODSWeexaminedpatientlevel,nationalhospitalactivitydatafordaycasesandinpatientcasesinEnglandfromJanuarytoDecemberTheDrFosterUnitatImperialCollegeLondonprocessedandcleanedthedatabeforepassingthemtoDrFosterIntelligenceinananonymisedformWeexaminedthreecommon,highvolumeelectivesurgicalproceduresthatallhadchronicallylongwaitingtimes:kneereplacement(OPCScodesW,W,andW),hipreplacement(OPCScodesW,W,andW),andcataractrepair(OPCScodeC)WelookedatnonrevisioncasesforallthreeproceduresObservationswerelimitedtopatientsseekingelectivecarefromtheirusualplaceofresidenceObservationswereexcludediftheyhadanymissingdatafieldsforexample,ifthemonthoryearthepatientwastreated,thepatient’sdeprivationstatus,orthepatient’sagewasmissingNocorrelationexistedbetweenmissingdataandarea,deprivation,year,orpatient’sageanymissingdataseemedtobetheresultofcodingCowdrayHouse,LondonSchoolofEconomics,LondonWCAAEDrFosterIntelligence,LondonECALADepartmentofSocialPolicy,LondonSchoolofEconomicsCorrespondenceto:ZCooperzcooperlseacukCitethisas:BMJ:bdoi:bmjbBMJ|ONLINEFIRST|bmjcompageoferrors,whichwererandomWealsoexcludedobservationsforwhichapatient’swaitingtimewasgreaterthanthreeyearsWeassumedthatanycasewithawaitingtimegreaterthanthreeyearswasatypicalandshouldnotbereflectedinamacroanalysisofwaitingtimesThedataretainindividualpatients’postcodes(whichareremovedbeforedeliverytoDrFosterIntelligence)Thisallowsobservationstobelinkedtopatients’localareacharacteristicsWecalculateddeprivationbyusingtheCarstairsindexofdeprivationattheoutputarealevelandbrokethelevelofdeprivationintopopulationfifthsTheCarstairsindexofdeprivationisacompositedeprivationindexbasedoncarownership,unemployment,overcrowding,andsocialclasswithinoutputareas,calculatedbytheOfficeofNationalStatisticsTheCarstairsindexservesasourproxyforpatients’socioeconomicstatusInourstudy,deprivationwastheleastdeprivedfifthanddeprivationwasthemostdeprivedfifthWaitingtimesweremeasuredasthetimefromwhenthepatientwasreferredbyaspecialistforsurgerytothetimethepatientactuallyhadsurgeryWethusmeasuredtimefromthedecisiontoadmituntiltheactualsurgery,irrespectiveofwhathappenedinbetweenThismethodisquitedifferentfromthereportedwaitingtimemethodusedbytheEnglishDepartmentofHealthForinstance,DepartmentofHealthfigureswillresetthewaitingtimetozeroifapatientdoesnotattendordeclinesareasonableofferofadmissionEqually,ifapatientisunwellorunfitforsurgery,thistimeissubtractedfromtheirwaitingtimeWecalculatedmeanandmedianwaitingtimesforeachyearandeachprocedureWeusedttestsandWilcoxonsignedrankteststodeterminewhetherastatisticallysignificantdifferenceinmeanandmedianwaitingtimesexistedfortheperiodsof,,andThosethreeperiodsroughlycorrespondtowhathavebeenlabelledasthethreestagesofgovernmentpolicytotacklewaitingtimes,asnotedaboveWeusedanalysisofvarianceandnonparametricrankteststodeterminewhetherastatisticallysignificantintrayearvariationinwaitingtimesexistedbetweenfifthsofdeprivationFinally,weusedordinaryleastsquaresregressionwithrobuststandarderrorstodeterminewhetherpatients’deprivationlevelwasassociatedwithwaitingtimes,controllingforthepatients’age,sex,areatype(city,townandfringe,hamletandisolateddwelling,andvillage),andtheyearofprocedureWeranregressionsondatafromthreeperiodsthatcorrespondedtochanginggovernmentpolicy(,,and)independentlyNoindividualpatientswereidentifiableinthisstudyAlldatawerepresentedinaggregateformTheStataSEsoftwarepackagewasusedforstatisticalanalysisRESULTSThetotalnumberofobservationscomprisedkneereplacements,hipreplacements,andcataractrepairsIntotal,()ofkneereplacementobservations,()ofhipreplacementobservations,and()ofcataractprocedureobservationswereexcludedformissingdataWeexcludedkneereplacementprocedures,hipreplacementprocedures,andcataractproceduresbecausetheyhadwaitingtimesgreaterthanthreeyearsAftertheseamendments,theobservationswerelimitedtokneereplacements,hipreplacements,andcataractrepairsdoneinEnglishNHSpatientsbetweenandForallthreeprocedures,meanandmedianwaitingtimesroseinitiallyandthensteadilyfell(fig)However,whatisofparticularinterestforourpurposesiswhathappenedtowaitingtimesbrokendownbysocioeconomicstatus,asmeasuredbytheCarstairsindexofdeprivationFigureshowsmeanwaitingtimesforallthreeprocedures,brokendownbydeprivationIndeprivationandwaitingtimetendedtobepositivelyrelatedthegreaterthedegreeofdeprivation,thelongerthewaitingtimeBywaitingtimesweremuchmoreuniformlydistributedacrosstheYearKneereplacementHipreplacementCataractrepairWaitingtime(days)Waitingtime(days)Waitingtime(days)MeanMedianFig|Meanandmedianwaitingtimesforkneereplacement,hipreplacement,andcataractrepairRESEARCHpageofBMJ|ONLINEFIRST|bmjcomspectrumofdeprivationforcataractrepairandkneereplacement,thedistributionhadactuallyreversedtoshowanegativerelationbetweenwaitingtimeanddeprivationWefoundastatisticallysignificantdifferenceinwaitingtimesforeachprocedurebetweeneachofourthreeperiods(P<)determinedbyttestsandWilcoxonsignranktestsStatisticalsignificanceatthislevelwasmaintainedwithaBonferronicorrectiontoaccountforthepossibilityofrandomeventsoccurringoverthestudytimeperiodWefoundastatisticallysignificantintrayearvariationinwaitingtimesbetweendeprivationgroupsforallthreeproceduresforallyears,excepthipreplacementsinand,measuredwithanalysisofvarianceandKruskalWallisranktests(P<)WeusedordinaryleastsquaresregressiontoestablishtherelationbetweenwaitingtimesandfifthsofdeprivationoverthethreetimeperiodsTables,,andsummarisetheresultsforthethreeproceduresAscanbeseenfromtheβcoefficientsonthesocioeconomicstatusvariablesforeachtimeperiod,therelationbetweenwaitingtimesandthedeprivationfifthsalsochangedovertimeEachunitincreaseintheβcoefficientrepresentsaonedayincreaseinwaitsForallthreeprocedures,eachsuccessivetimeperiodwasassociatedwithastatisticallysignificantreductioninwaitingtimesMoreinterestingly,lessvariationinwaitingtimesexistedacrosssocioeconomicgroupsovertimeForexample,forhipreplacementsurgeryineachsuccessiveincreaseindeprivationfifthwasassociatedwithastatisticallysignificantincreaseinwaitingtimeofbetweenoneandtwoweekscomparedwiththeleastdeprivedfifth(P<)InvariationsinwaitingtimesbetweendeprivationfifthstendedtobelargeandsignificantEachprocedureshowedamodifiedUshapeddistribution,withthemiddlefifthswaitingthelongestforcareInverylittledifferenceexistedindayswaiteddependingonpatients’deprivationfifthInfact,patientsfromthemostdeprivedfifthhavingeitherakneereplacementoracataractrepairwaitedlesstimethanpatientsfromtheleastdeprivedfifth(P<)DISCUSSIONBetweenand,waitingtimesforelectivekneereplacements,hipreplacements,andcataractrepairsdroppedsignificantlyandequity,measuredasthevariationinwaitingtimesaccordingtosocioeconomicstatus,improvedWaitingtimesandwaitinglistshavelongbeenaconcernintheNHS,particularlyforhighvolume,electivesurgicalproceduressuchaskneereplacements,hipreplacements,andcataractrepairsHowever,aswaitingtimeshavedroppedTable|Regressioncoefficientsforkneereplacementsβcoefficient(CI)Tstatisticβcoefficient(CI)Tstatisticβcoefficient(CI)TstatisticDeprivationfifth:(to)***(−to)(−to)(to)***(to)***(to)*(to)***(to)***(−to)(to)**−(−to−)***−−(−to−)***−Femalesex(to)**(to)**(to)***Age:s(to)***(to)***(to)***s(to)***(to)***(to)***s(to)***(to)***(to)***s(to)***(to)***(to)***Year:(to)***NANANANA(to)***NANANANA(to)***NANANANANANA−(−to−)***−NANANANA−(−to−)***−NANANANA−(−to−)***−NANANANANANA−(−to−)***−NANANANA−(−to−)***−ObservationsNANANARNANANANA=notapplicableModelrunwithrobuststandarderrorsdeprivationfifthservesasreferencecategoryfordeprivation,maleisreferencecategoryforsex,andunderyearsisreferencecategoryforagemodelalsocontrolsforareatype(city,town,hamletandisolateddwelling,village)andprovidertype(private,foundationtrust,teachinghospital,specialisthospital,traditionalNHS)dependentvariable=waitingtimeforkneereplacement,measuredindays*P<**P<RESEARCHBMJ|ONLINEFIRST|bmjcompageofoverthepastdecade,examiningwhetherthereductionsinwaitingtimeshaveproducedequitableresultsatanationallevelisworthwhilePreviousresearchhasshownthatgreaterdeprivationisassociatedwithlongerwaitsinScotland,andasmallscalestudyofpatientsinEnglandfromApriltofoundsomeinequityinthedistributionofwaitingtimesThegovernment’spoliciestotargetwaitingtimesinEnglandcanlargelybebrokendownintothreeperiods:onebetweenand,asecondfromto,andathirdfromtoDuringtheperiod,thegovernmentfocusedonreducingthenumberofpatientsonwaitinglists(asopposedtowaitingtimes),amodestincreaseinfundingoccurred,operationalandtechnicalsupportforreducingwaitinglistsincreased,andtherhetoricofgovernmentpolicyshiftedfromanemphasisoncompetitiontooneoncooperationandcollaborationHowever,aftertwoyearsofattemptingtoshortenwaits,waitingtimeshadrisen,notfallen,apolicyfailureforwhichthethensecretaryofstateforhealth,FrankDobson,tookpersonalresponsibilityandissuedanationalapologyThesecondwaitingtimepolicyperiod,fromto,sawdramaticincreasesinfundingandtheimplementationofwaitingtimetargetscoupledwithperformancemanagementaspartofacommandandcontrolpolicylabelledbyBevanandHoodas“targetsandterror”italsosawtheplantingoftheseedsofchoiceandcompetitionandexpandedsupplyasoutlinedintheNHSplanThisperiodoftargetsandcentralisationwasassociatedwithreductionsinwaitingtimesincomparisonwithScotland,whichabandonedtargetsduringthisperiodThefinalperiodofgovernmentpolicyfromtocentredonexpandingthecapacityinthesystem,increasingtheuseofprovidersfromtheprivatesector,andintroducinggreaterchoiceforpatientsandcompetitionbetweenprovidersThroughoutthesecondhalfofpatientswaitingmorethansixmonthsforcareweregivenachoiceofattendinganalternativeproviderthathadashorterwaitingtimeinpatientshavingcataractrepairgenerallyhadachoiceoffourormoreproviders,andbeginninginearlytheaimwasforalmostallpatientstohaveachoiceoffourormoreprovidersattheirpointofreferralThisperiodwasalsoassociatedwithacontinuingfallinwaitingtimes,despiteadramaticriseinoverallactivityGiventheplethoraofreformsaimedatreducingwaitingtimesintroducedbetweenandinEngland,ascribingthedropinwaitingtimesthatoccurredaftertoonepolicyreformratherthananotherisdifficultTheriseinfunding,therigidgovernmenttargets,andincreasedchoiceandcompetitionarealllikelytohaveplayedaroletogetherinshorteningpatients’waitsThefocusofthisstudy,however,islessontheoverallreductionofwaitingtimesandmoreonhowtherelationbetweendeprivationandwaitingtimeshaschangedoverthepastdecadeInadditiontoreducingwaitsandimprovingquality,thegovernment,alongwithseveralpolicymakersandadvisersclosetogovernment,arguedthatthereforms,especiallythoseassociatedwithchoiceforpatients,wouldbeavehicletoimproveequityTheyarguedthatinhealthserviceswithoutformalisedchoice,someformofprivilegealwaysexistsformiddleclassandupperclassusers,whousetheir“voice”tonegotiateforbetterserviceswithinthepubliclyfundedserviceorcanaffordtoaccesscareintheprivatesectorCreatingformalchoiceinthehealthservice,thegovernmentargued,wouldgiveallpatientsgreaterpowertoaffecttheiruseofresources,irrespectiveoftheirsocioeconomicstatus,aswellasprovidingamoreefficientsystemformatchingsupplytodemandLikewise,theargumentwasthatthemarketbasedreformswouldimproveallocativeefficiencyanddrivedownthelongwaitsthatwerefeltbypoorpeopleinparticularIncontrast,severalanalystsarguedthattheexpansionofchoiceforpatientsandcompetitionbetweenproviderswouldnotonlynotimproveequitybutwouldharmitAmongotherlinesoftheirargument,YearKneereplacementHipreplacementCataractrepairWaitingtime(days)Waitingtime(days)Waitingtime(days)Fifth(leastdeprived)FifthFifthFifthFifth(mostdeprived)Fig|Meanwaitingtimesforkneereplacement,hipreplacement,andcataractrepair,bydeprivationfifthRESEARCHpageofBMJ|ONLINEFIRST|bmjcomcriticsofchoiceandcompetitionhavearguedthatbetteroffpeoplewerebetterequippedtochooseandthatthereformswouldproduceincentivestofocusonwealthypeopletothedetrimentofthepoorHence,abeliefexistedthatproponentsofthegovernment’sreformshadoverlookedthepossiblyseriousnegativeimpactthatchoiceandcompetitioncouldhaveonequityAlthoughinitialresultsfromthepilotofchoiceinLondonsuggestedthatlittleornodifferenceexistedinth

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Equity, waiting times, and NHS reforms- retrospective study

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