Specialization in health care delivery: assessing quality and factors affecting location
Johnson, Andrew Brian
MetadataShow full item record
Several new organizational health care delivery forms have developed in recent decades. For hospital services, the number of single specialty hospitals (SSHs) providing cardiac and orthopedic/surgical services has grown significantly. Physician-owners claim that these SSHs use limited-scope and economies of scale to provide higher quality of care and reduce costs. While SSH costs have been studied, a comprehensive assessment of SSH quality of care and an evaluation of factors affecting SSH location is useful. For primary care services, significant growth in the number of retail health clinics (RHCs) has employed nurse practitioners (NPs) to provide care for a limited set of low-acuity conditions. Whether state regulations limiting the ability of NPs to practice independently affect RHC location is not known. To assess whether SSHs provide higher quality of care than competing general hospitals, we compared process of care and outcome measures for SSHs and general hospitals in the same health care market for 2008 through 2011. Cardiac SSHs had better scores for some outcomes. All SSHs had some better and some worse process of care scores, although scores for all hospitals increased over time and differences between SSHs and general hospitals diminished. Any improvements in quality of care were not robust to other factors. To evaluate the economic factors affecting hospital service specialization, we used ordered logistic regression to model presence of an SSH or ambulatory surgery center (ASC) on supply, demand, and regulatory factors. A higher degree of hospital specialization is associated with higher population levels and growth, more specialists and operating rooms per capita, and the absence of certificate of need laws. To assess economic factors affecting RHC location and test whether regulations limiting NP practice autonomy affect RHC location, we used logistic regression to model presence of an RHC on relevant economic factors and state regulations limiting NP practice autonomy. RHC location is associated with higher private insurance levels and certain factors affecting primary care supply, but is unhindered by regulations limiting NP practice autonomy. Each new form of in health care delivery examined appears uniquely affected by geographic differences in supply, demand, and regulatory factors.
Thesis (Ph.D.)--Boston University