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Death and profit

Review
Results
Comment

Most healthcare payment and delivery is through organisations with no profit motive. In some parts of the world, some hospitals are run on a 'for-profit' basis. A new systematic review suggests that these hospitals have higher mortality rates than not-for-profit institutions [1].

Review


This review is part of a larger study exploring the effects of the profit motive in healthcare. A complex search strategy examined multiple databases for studies examining hospital mortality in hospitals run for profit, and not for profit. Both observational and randomised studies were looked for. Mortality, types of patients, and adjustment for potential confounding criteria were among information extracted from the studies.

Results


Fifteen observational studies were included. All were in the United States, and in most patient care was publicly funded through Medicare. Most included medical, surgical and general acute care, with one specifically examining maternity services. The studies, between 1982 and 1995, looked at 26,000 hospitals, and with data on 38 million patients.

Fourteen studies evaluated adult populations. When adjusted for potential confounders, six had a significantly higher risk of death in for-profit hospitals, and one a significantly lower risk of death in for-profit hospitals. The pooled relative risk showed that private for-profit hospitals were associated with a higher risk of death. The relative risk was 1.020 (95% confidence interval 1.003 to 1.038). One study on perinatal mortality with 1.6 million patients in 243 hospitals also demonstrated an increased risk of death in private for-profit hospitals.

Comment


The first thing to take on board is that this review is not about ownership. Hospitals could be private or public. This is about whether the private hospitals were administered so that they had to make a profit. Those that did, compared with those that did not, had a higher death rate. Is the result credible? David Naylor [2] makes a good argument that it is. The excessive mortality is found in most of the studies, and there may be good reasons to treat conservatively the one study that went the other way. The reasons for the excess mortality are obvious. For-profit hospitals have to make a profit, and probably pay more to senior executives. The result is less resource at the front line.

References:

  1. PJ Devereaux et al. A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. Canadian Medical Association Journal 2002 166: 1399-1406.
  2. CD Naylor. Your money and/or your life? Canadian Medical Association Journal 2002 166: 1416-1417.
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