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

Professor Belanger indicates that Statistics Canada identifies Canadian hospitals as public institutions. However, leading health policy experts, health economists, and the Royal Commission on the Future of Health Care in Canada clearly indicate that Canadian hospitals are private not-for-profit institutions.[1,2] In Ontario the last example of public hospitals were the psychiatric hospitals, all of which have either become or are in the process of becoming private not-for-profit hospitals. The mechanics of this transition highlight the differences between public institutions with centralized administration and control, and private not- for-profit institutions with local administration and control. The latter structure characterizes the majority of Canadian hospitals (i.e. private not-for-profit institutions) that are owned and controlled by religious organizations, communities, regional health authorities or the hospital boards.

Even if one were to disagree with these experts and believe that our Canadian hospitals are public institutions our systematic review would still provide a compelling guide for health care policy. There are only three types of hospitals: public, private for-profit, and private not-for- profit. If one believes our hospitals are public and that we need a change there is only one reasonable choice (i.e. moving from public ownership and administration to the private not-for-profit ownership and administration which we found was associated with lower mortality rates in comparison to private for-profit ownership and administration).

Professor Deber’s contribution to the Romanow Commission, while valuable, is not a systematic review but rather a traditional narrative review article. A systematic review is a study that addresses a focused question, and minimizes bias through the use of explicit eligibility criteria and a structured, comprehensive search to identify all potentially relevant studies.[3] Our study that demonstrated higher risk adjusted mortality rates in private for-profit hospitals relative to private not-for-profit hospitals is a systematic review and meets these criteria,[4] while Professor Deber’s does not. One crucial limitation of a traditional narrative review is that it remains open to a biased selection of the available evidence.

Professor Deber states, “the quality differences between private for- profit and private not-for-profit organizations appear to be less pronounced when clinicians are able to influence the care they give, without direct pressures to balance their clinical judgement against the return to shareholders.” This may be the case. However, our systematic review demonstrated that private for-profit hospitals employed less highly skilled health professionals and there is a demonstrable association between health professionals’ skill level and patient mortality. Therefore, even if the private for-profit hospitals do not pressure their health professionals to balance their clinical judgement against the return to shareholders, the lower skill level provides one explanation for the largely consistent higher mortality rates in private for-profit hospitals.

References: [1]Lewis S, Donaldson C, Mitton C, Currie G. The future of health care in Canada. BMJ 2001;323:926-9. [2]Commission on the future of health care in Canada, Minister of Public Works and Government. Shape the future of health care. Consultation workbook. 2002 p. 1-29. Available:www.healthcarecommission.ca/Suite247/Common/GetMedia_WO.asp?MediaID=604&Filename=consultation_workbook.pdf (accessed 2002 Apr 18). [3]Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med. 1997; 126: 376-380. [4]Devereaux PJ, Choi PT-L, Lacchetti C, et al. A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. CMAJ. 2002; 166: 1399-1406.