Essays on the Organisation of Hospital Care

This thesis focuses on the organisational determinants of quality of care in the hospital sector. It consists of three chapters, of which the first two investigate determinants of quality at the hospital (economies of scale) or surgeon level (surgical skills), while the third examines the trade-off between hospital quality and costs. Using patient-level data from hospitals in the English National Health Service, these essays contribute to the understanding of the optimal organisation of hospital care, related to the consolidation of hospital activity (Chapter 1), surgeons’ work schedules (Chapter 2) or the efficient use of hospital resources (Chapter 3). Chapter 1 investigates the existence of hospital economies of scale in quality for planned hip replacement. It makes use of rich condition-specific patient-reported outcome measures which increase the scope for risk-adjustment. It shows that hospital volume, though positively correlated with health outcomes, does not have a causal effect on patient health after accounting for volume endogeneity. Chapter 2 focuses on a key actor of quality of care – surgeons – by exploring how breaks in surgical practice impact health outcomes for patients admitted after a hip fracture. Using a large panel of surgeons in England, it finds that short breaks of four to six days reduce 30-day mortality rates by around six percent relative to surgeons who had no prior breaks. Further, results show that short breaks alter the choice of treatment, holding other patient characteristics fixed. Chapter 3 estimates the effect of reducing inpatient length of stay, a possible cost-containment strategy for hospitals, on 28-day readmission rates for emergency chest pain patients. Patients who are discharged on the same day as admission have lower readmission rates. However, the effect disappears after instrumenting for patients’ length of stay, indicating that there is no causal effect of same-day discharge on health outcomes in this context.