English treatment centres are treating less complex patients than hospitals

BMJ 2009; 339 doi: (Published 02 November 2009) Cite this as: BMJ 2009;339:b4540
  1. Roger Dobson
  1. 1Abergavenny

    Dedicated treatment centres in England seem to be treating less complex cases in particular treatment categories than hospitals but are getting the same funding per treatment.

    Patients treated in standalone centres dedicated to a small number of high volume elective procedures are less likely to come from deprived areas, have fewer diagnoses, and undergo fewer procedures than hospital patients, concludes a study that was based on data from more than 3.3 million patients (Health Policy doi:10.1016/j.healthpol.2009.09.013).

    “Our analysis finds evidence that hospitals are treating patients of greater complexity than treatment centres,” say the authors, from the Centre for Health Economics, University of York, and other centres. “If these observed differences between hospitals and treatment centres drive costs, then payments should be refined to ensure fair reimbursement.”

    The study looked at whether the complexity of cases in hospitals and treatment centres differed within 29 payment categories, defined by “healthcare resource groups” (HRGs) that indicate the expected level of resources needed to treat a patient with a given diagnosis. Around 100 treatment centres in England—half of which, the authors say, are operated by private sector companies—specialise in one or two high volume elective procedures, such as hip and knee replacements.

    The authors say, “If treatment centres routinely treat patients with less complex needs within a healthcare resource group, they may profit at the expense of NHS hospitals. If so, this would suggest that the prospective payment system is unfair.”

    They say that providers are paid the same fixed price per patient categorised to the same HRG, a pricing arrangement that assumes that the same types of patient are being seen in treatment centres as in hospitals. But they add that several reasons explain why the case mix may differ between public providers. If, for example, the treatment centres are private, they may, say the authors, wish to treat a less complex case mix to boost profits.

    Data concerning 3 334 535 patients were included in the analysis, of whom 77 358 (2.3%) were treated in treatment centres. Those treated in treatment centres were 3.3 years older, but this is thought to be because most such centres restrict treatment to the over-18s.

    For most HRGs there was little difference in length of stay between patients treated in hospitals and treatment centres—possibly because most patients were treated as day cases—but for some procedures, particularly knee and hip replacements, patients treated in hospital had longer lengths of stay.

    Orthopaedic patients in hospitals were younger than those in treatment centres and more likely to have come from deprived areas. They also had longer waiting times, longer lengths of stay, more diagnoses, and more procedures.

    The overall results showed that patients treated in hospital were more likely to come from deprived areas than those at treatment centres. Patients treated in hospital also tended to have more diagnoses.

    In another analysis the authors found that patients treated in NHS centres tended to have more diagnostic and procedure codes than those treated at private centres.

    “Differences may stem from the exclusion criteria some centres employ,” said the study’s lead author, Andrew Street. “If these centres treat cheaper patients, they should be paid less than the standard HRG price.”


    Cite this as: BMJ 2009;339:b4540

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