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CMAJ • May 28, 2002; 166 (11)
© 2002 Canadian Medical Association or its licensors

Research
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A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals

P.J. Devereaux*, Peter T.L. Choi{dagger}{ddagger}, Christina Lacchetti{ddagger}, Bruce Weaver{ddagger}, Holger J. Schünemann§, Ted Haines{ddagger}, John N. Lavis{ddagger}**, Brydon J.B. Grant§{dagger}{dagger}{ddagger}{ddagger}, David R.S. Haslam§§, Mohit Bhandari¶¶, Terrence Sullivan***, Deborah J. Cook*{ddagger}, Stephen D. Walter{ddagger}, Maureen Meade*{ddagger}, Humaira Khan{ddagger}, Neera Bhatnagar{dagger}{dagger}{dagger} and Gordon H. Guyatt*{ddagger}

From the Departments of *Medicine, {dagger}Anesthesia, {ddagger}Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the {dagger}{dagger}{dagger}Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and {dagger}{dagger}Physiology and Biophysics, University at Buffalo, and the {ddagger}{ddagger}Veterans Affairs Medical Center, Buffalo, NY; the **Institute for Work and Health and the Population Health Program, Canadian Institute for Advanced Research, Toronto, and the ***Department of Health Policy Management and Evaluation, University of Toronto, Toronto, Ont.

Correspondence to: Dr. P.J. Devereaux, Department of Clinical Epidemiology & Biostatistics, McMaster University, Rm. 2C12, 1200 Main St. W, Hamilton ON L8N 3Z5; fax 905 524-3841; philipj@mcmaster.ca

Background: Canadians are engaged in an intense debate about the relative merits of private for-profit versus private not-for-profit health care delivery. To inform this debate, we undertook a systematic review and meta-analysis of studies comparing the mortality rates of private for-profit hospitals and those of private not-for-profit hospitals.

Methods: We identified studies through an electronic search of 11 bibliographical databases, our own files, consultation with experts, reference lists, PubMed and SciSearch. We masked the study results before determining study eligibility. Our eligibility criteria included observational studies or randomized controlled trials that compared private for-profit and private not-for-profit hospitals. We excluded studies that evaluated mortality rates in hospitals with a particular profit status that subsequently converted to the other profit status. For each study, we calculated a relative risk of mortality for private for-profit hospitals relative to private not-for-profit hospitals and pooled the studies of adult populations that included adjustment for potential confounders (e.g., teaching status, severity of illness) using a random effects model.

Results: Fifteen observational studies, involving more than 26 000 hospitals and 38 million patients, fulfilled the eligibility criteria. In the studies of adult populations, with adjustment for potential confounders, private for-profit hospitals were associated with an increased risk of death (relative risk [RR] 1.020, 95% confidence interval [CI] 1.003–1.038; p = 0.02). The one perinatal study with adjustment for potential confounders also showed an increased risk of death in private for-profit hospitals (RR 1.095, 95% CI 1.050–1.141; p < 0.0001).

Interpretation: Our meta-analysis suggests that private for-profit ownership of hospitals, in comparison with private not-for-profit ownership, results in a higher risk of death for patients.




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