Meta-Analysis

. 2014 Oct 27;9(10):e109975.

doi: 10.1371/journal.pone.0109975. eCollection 2014.

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis

Karen S Palmer¹, Thomas Agoritsas², Danielle Martin³, Taryn Scott⁴, Sohail M Mulla⁴, Ashley P Miller⁵, Arnav Agarwal⁴, Andrew Bresnahan⁶, Afeez Abiola Hazzan⁴, Rebecca A Jeffery⁷, Arnaud Merglen⁸, Ahmed Negm⁹, Reed A Siemieniuk¹⁰, Neera Bhatnagar¹¹, Irfan A Dhalla¹², John N Lavis¹³, John J You⁴, Stephen J Duckett¹⁴, Gordon H Guyatt⁴

Affiliations

¹ Faculty of Health Sciences and Faculty of Science Simon Fraser University, Burnaby, British Columbia, Canada.
² Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Divisions of General Internal Medicine and Clinical Epidemiology, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
³ Department of Family and Community Medicine, Department of Health Policy Management and Evaluation, University of Toronto and Medical Affairs and Health Systems Solutions at Women's College Hospital, Toronto, Ontario, Canada.
⁴ Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
⁵ Memorial University of Newfoundland, St. John's, Newfoundland, Canada.
⁶ Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
⁷ Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
⁸ Paediatric Outcome Research Team, The Hospital for Sick Children, Toronto, Ontario, Canada and Division of General Pediatrics, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
⁹ Rehabilitation School, McMaster University, Hamilton, Ontario, Canada.
¹⁰ Department of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
¹¹ Health Sciences Library, McMaster University, Hamilton, Ontario, Canada.
¹² St. Michael's Hospital, Department of Medicine and Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
¹³ Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; McMaster Health Forum, Centre for Health Economics and Policy Analysis, Department of Political Science, McMaster University, Hamilton, Ontario, Canada and Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America.
¹⁴ Grattan Institute, Carlton, Victoria, Australia.

PMID: 25347697
PMCID: PMC4210200
DOI: 10.1371/journal.pone.0109975

Meta-Analysis

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis

Karen S Palmer et al. PLoS One. 2014.

. 2014 Oct 27;9(10):e109975.

doi: 10.1371/journal.pone.0109975. eCollection 2014.

Authors

Affiliations

¹ Faculty of Health Sciences and Faculty of Science Simon Fraser University, Burnaby, British Columbia, Canada.
² Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Divisions of General Internal Medicine and Clinical Epidemiology, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
³ Department of Family and Community Medicine, Department of Health Policy Management and Evaluation, University of Toronto and Medical Affairs and Health Systems Solutions at Women's College Hospital, Toronto, Ontario, Canada.
⁴ Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
⁵ Memorial University of Newfoundland, St. John's, Newfoundland, Canada.
⁶ Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
⁷ Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
⁸ Paediatric Outcome Research Team, The Hospital for Sick Children, Toronto, Ontario, Canada and Division of General Pediatrics, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
⁹ Rehabilitation School, McMaster University, Hamilton, Ontario, Canada.
¹⁰ Department of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
¹¹ Health Sciences Library, McMaster University, Hamilton, Ontario, Canada.
¹² St. Michael's Hospital, Department of Medicine and Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
¹³ Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; McMaster Health Forum, Centre for Health Economics and Policy Analysis, Department of Political Science, McMaster University, Hamilton, Ontario, Canada and Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America.
¹⁴ Grattan Institute, Carlton, Victoria, Australia.

PMID: 25347697
PMCID: PMC4210200
DOI: 10.1371/journal.pone.0109975

Erratum in

Correction: Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis.
PLOS ONE Staff. PLOS ONE Staff. PLoS One. 2015 Mar 24;10(3):e0121163. doi: 10.1371/journal.pone.0121163. eCollection 2015. PLoS One. 2015. PMID: 25803858 Free PMC article. No abstract available.

Abstract

Background: Activity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care.

Methods: We undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication.

Results: Of 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk = 1.24, 95% CI 1.18-1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences.

Conclusions: Transitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

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Conflict of interest statement

Competing Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare as follows: (1) KSP, DM, IAD, GHG have non-salary support from the Canadian Institute for Health Research for the submitted work; (2) JL, JJY report that their institution received reimbursement from Canadian Institute for Health Research for the submitted work; (3) TS reports salary from Canadian Institute for Health Research for the submitted work; (4) TA and AM each report grants from the Swiss National Science Foundation during the period the study was conducted; (5) No financial relationships in the previous 3 years with companies that might have an interest in the submitted work; (6) No non-financial interests that influenced the submitted work.

Figures

**Figure 2. Acute Care Mortality Forest Plot.**

**Figure 4. Discharge Destination Forest Plot.**

See this image and copyright information in PMC

References

1. Canadian Institute for Health Information (2009) Health Care in Canada 2009: A decade in review. Ottawa, Ont. Available: https://secure.cihi.ca/free_products/HCIC_2009_Web_e.pdf Accessed 2013 July 11.
1. O'Reilly J, Busse R, Hakkinen U, Or Z, Street A, et al. (2012) Paying for hospital care: the experience with implementing activity-based funding in five European countries. Health Econ Policy Law 7: 73–101. - PubMed
1. Canadian Institute for Health Information, Activity-Based Funding Unit. (2010) A primer on activity-based funding. Ottawa (ON): The Institute Available: http://www.cihi.ca/CIHI-ext-portal/pdf/internet/primer_activity_based_fu... Accessed 2013 July 22.
1. Busse R, Geissler A, QuentinW, Wiley M, eds. (2011) Diagnosis-Related Groups in Europe: Moving towards Transparency, Efficiency and Quality in Hospitals. Maidenhead, England: World Health Organization on behalf of European Observatory on Health Systems and Policies Series, McGraw Hill, Open University Press. Available: http://www.euro.who.int/__data/assets/pdf_file/0004/162265/e96538.pdf Accessed 2014 March 21.
1. Palmer KS, Martin D, Guyatt GH (2013) Prelude to a systematic review of activity-based funding of hospitals: potential effects on cost, quality, access, efficiency, and equity. Open Medicine 7: e94–e97. - PMC - PubMed

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Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis

Affiliations

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis

Authors

Affiliations

Erratum in

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical