Mortality rates would decline if hospitals had separate units for routine and complex procedures along with more effective routing of patients, says a new study co-authored by Professor Stefan Scholtes of Cambridge Judge based on 250,000 patient episodes at 60 German hospitals.
Hospital patients with both routine and complex conditions would benefit from splitting hospitals into separate units for routine procedures and for emergency or non-routine elective services, says a new study co-authored by Professor Stefan Scholtes of Cambridge Judge Business School.
The study published in
the journal Management Science and based
on data of more than 250,000 patient episodes in 60 German hospitals, also finds
that hospitals can reduce mortality rates for emergency patients with complex
conditions by adopting a disease-based rather than specialty-based “routing”
system for newly admitted emergency patients.
The research focused
on 39 disease groups with significant in-hospital mortality risks, ranging from
breast, bowel and prostate cancers to renal failure and metabolic disorders. While
hospitals with a relatively high volume within a disease had lower seven-day
in-hospital mortality, this effect could largely be explained by a selection
effect, with high volume hospitals attracting healthier patients on average.
After controlling for selection with an appropriate statistical model, the data
showed no significant seven-day in-hospital mortality effect of a hospital’s
volume for routine patients. In fact, mortality for complex emergency patients was
higher in hospitals with a high volume of patients in their disease group,
suggesting that these patients are not well served in high-volume hospitals.
that splitting a hospital’s volume in a disease segment across two
organisationally separated units for routine and non-routine services, thereby
lowering the absolute volume of patients in the two units relative to the
hospital as a whole, will not harm routine services and may improve outcomes
for complex patients,” the study says.
Routing patients is
often a “difficult decision to make”, particularly for emergency
patients or those with multiple chronic illnesses. But hospitals that route
more patients with illnesses in the same broad disease group into the same
department, rather than scattering them across several departments with diverse
medical specialties, have “significantly lower mortality rates” for
complex patients in that disease group.
“In summary, our
findings support a reorganisation of general hospitals into a multi-specialty
hub for emergency and non-routine elective services, complemented by
organisationally separate disease-specific hospitals-within-hospitals, which
are ring-fenced from the hub and focus on routine elective care. The hub
hospital itself would further benefit from a disease-based rather than specialty-based
departmental structure and routing strategy.”
Based on an analysis
of the patient sample, the study estimates that such a reorganisation would
have reduced mortality rates by 13.43 per cent for routine patients and between
7.79 per cent and 11.67 per cent for complex emergency patients at the sample
hospitals, depending on the degree of disease-based routing.
deliberately looked at two important factors side by side: the separation of
routine and complex situations, and how hospitals are organised internally for
specific diseases,” says co-author Stefan Scholtes, Dennis Gillings
Professor of Health Management at Cambridge Judge Business School.
“We found that the
routine patient with a specific disease benefits from better service quality
when treated apart from too many admissions of patients with different diseases,
while complex emergency patients benefit from a hospital’s higher degree of
concentration in which patients within a broad disease area are mostly admitted
to the same clinical department rather than being distributed among various
departments. Cambridge University Hospitals has recently acted on this advice
by dedicating a group of wards to concentrate elderly emergency admissions and
avoid scattering them across the hospital’s specialty wards. The evaluation of
this intervention will provide additional evidence for the proposed organisational
The study acknowledges
the economic issues that must be overcome for the sort of reorganisation
proposed; currently, general hospitals often use profits from routine patients
to cover losses from more complex patients. Such a change would also require an
effective “gatekeeping” system to identify routine and complex
patients, as well as procedures for routing decisions.