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Improving catchment area definitions when measuring quality of care

Oftentimes, we want to measure the quality of care of a give hospital or health care system. The easiest way of doing this is to measure the quality of care received by patients who go to that hospital. These patients, however, may attend multiple hospitals during they year. Further, if quality of care includes avoiding hospitalizations, we need to identify not only patients who had a hospital admission but patients who were at risk of going to that hospital if a preventable admission occurred.

One way to model quality of care is to use catchment areas. Catchment areas are typically aggregations of geographic units. For instance, hospital service areas (HSAs) are aggregations of ZIP codes. However, previous research has shown that HSA-based catchment areas only capturing 50% to 80% of hospital admissions for their given population. One could use larger geographic regions—such as hospital referral regions (HRRs)—but then one is susceptible to assigning patients to hospitals over which they are unlikely to have responsibility for their care.

My previous research on the hospital wage index (see here and here) proposed assigning a weighting of the geographic units While that approach aimed to measure geographic variation in wages where data was available by geography rather than by person, an interesting paper by Falster, Jorn and Leyland (2017) proposes a different approach using individual patient data and a methodology known as multiple-membership multi-level model multi-level.

To explain this model, consider first a standard approach whereby where I people are clustered within J hospitals or HSAs. Yij is the outcome, xpi are the regression parameters for P person-level variables, and xqj are the
regression parameters for Q hospital-level variables. This multilevel model captures the effects of clustering by allowing both regression parameters and error terms to exist at different hierarchical levels.

A multiple-membership multilevel model extends this approach by allowing a weighted structure for each of the hospital-level components as follows:

Faster and co-authors apply this model to date on preventable hospitalizations in NSW Australia using weighted hospital service area networks (weighted-HSANs). The authors contend that:

Between-hospital variation in rates of preventable hospitalization
was more than two times greater when modeled using weighted-HSANs rather
than HSAs. Use of weighted-HSANs permitted identification of small hospitals with
particularly high rates of admission and influenced performance ranking of hospitals,
particularly those with a broadly distributed patient base

While this approach is a significant improvement for an academic setting, it is problematic to operationalize in terms of quality improvement. In order to improve quality, hospitals need clear rules regarding the patients to which it is attributed. While the authors compellingly argue that multiple-membership multilevel models do a better job mof measuring quality retrospectively than would be the case using HSAs alone, operationalizing the use of weighted HSANs in practice would be more difficult due to the model complexity. Nevertheless, this approach clearly highlights the challenges of using HAS-based catchment areas to measure quality of care.


  • Falster, Michael O., Louisa R. Jorm, and Alastair H. Leyland. “Using Weighted Hospital Service Area Networks to Explore Variation in Preventable Hospitalization.” Health Services Research (2017).

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Does calorie labeling work?

I am generally skeptical of broad, top-down approaches to improve health. For instance, soda taxes are one example.  While soda is clearly not got for you, should unhealthy drinks like Red Bull be taxed?  Why single out soda?  What about cheesecake?  Thus, these efforts–while well intentioned–can seem arbitrary and paternalistic. On the other hand, posting […]

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Understanding The Value Of Innovations In Medicine

Today, there was an excellent briefing put on by Health Affairs at the National Press Club. The topic was “Understanding the Value of Innovations in Medicine” and the briefing contained two panel discussions (see agenda).  The first panel , “Many Stakeholders, Many Values: Measuring Value In A Diverse Healthcare” featured expert economists, epidemiologists, and patient […]

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Medical school with no lectures?

Med students in Vermont rejoice!  The Washington Post reports: When the University of Vermont’s medical school opens for the year in the summer of 2019, it will be missing something that all but one of its peer institutions have: lectures. The Larner College of Medicine is scheduled to become the first U.S. medical school to […]

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Economic Burden of ACPA+ patients with Rheumatoid Arthritis

That is the topic of my most recent article in the Journal of Managed Care & Specialty Pharmacy along with co-authors Mahlet Gizaw Tebeka, Kwanza Price, Chad Patel, and Kaleb Michaud.  The abstract of the article–titled “The Economic Burden of ACPA-Positive Status Among Patients with Rheumatoid Arthritis“–is below. BACKGROUND: Anticitrullinated protein antibodies (ACPAs) are serological […]

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Quality of your (Social) Life

Many metrics purport to measure individuals quality of life.  Tools such as the EQ-5D and SF-36 do so largely based on functional status.  Using other surveys on individual preferences, one can estimate patient utility for any given functional status level (i.e,. EQ-5D or SF-36 score).  What these scores ignore, however, is the social component of […]

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Quotation of the Day

On this Fourth of July, I will actually quote a British man to describe the state of a country. “Healthy citizens are the greatest asset any country can have.” ― Winston S. Churchill

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Are multiple sclerosis treatments worth the cost? Comparing how treatment “value” is determined by five cost effectiveness analyses

by Daniel Kantor, Michelle Brauer and Jason Shafrin As drug prices continue to rise, many patients, payers and policymakers are asking whether the treatment benefits justify the cost. One method favored by health technology assessment (HTA) bodies for making this decision in a formal manner is to conduct a cost effectiveness analyses (CEA).  However, there […]

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Overview of the American Health Care Act (a.k.a. “Repeal and Replace”)

Before we get into the details of how the American Health Care Act bill will proposed to change the current system, let’s first talk about what is not changing.  In fact, while “repeal and replace” has a catchy ring to it, there is a lot that is staying the same.  As Ezra Klein of Vox notes, […]

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Links to start the week

Obamacare replacement? My drug problem. Do ACOs reduce post acute care use? Eating with 4 ingredients. MD Anderson benches Watson? Patient = partner.

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