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Separate and concentrate

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.

Three surgeons at work operating in surgical theatre. Resuscitation medicine team wearing protective masks saving patient. Surgery and emergency concept.
Stefan Scholtes
Professor Stefan Scholtes

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.

“This suggests 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.

“Our study 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 principle.”

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.

The study – entitled “Separate and concentrate: accounting for patient complexity in general hospitals” – is co-authored by Professor Ludwig Kuntz of the University of Cologne, Professor Stefan Scholtes of Cambridge Judge Business School, and Dr Sandra Sülz of Erasmus University in Rotterdam.