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Research article

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, Christina Lacchetti, Bruce Weaver, Holger J. Schünemann, Ted Haines, John N. Lavis, Brydon J.B. Grant, David R.S. Haslam, Mohit Bhandari, Terrence Sullivan, Deborah J. Cook, Stephen D. Walter, Maureen Meade, Humaira Khan, Neera Bhatnagar and Gordon H. Guyatt
CMAJ May 28, 2002 166 (11) 1399-1406;
P.J. Devereaux
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Peter T.L. Choi
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Christina Lacchetti
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Bruce Weaver
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Holger J. Schünemann
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Ted Haines
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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John N. Lavis
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Brydon J.B. Grant
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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David R.S. Haslam
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Mohit Bhandari
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Terrence Sullivan
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Deborah J. Cook
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Stephen D. Walter
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Maureen Meade
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Humaira Khan
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Neera Bhatnagar
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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Gordon H. Guyatt
From the Departments of *Medicine, †Anesthesia, ‡Clinical Epidemiology and Biostatistics, §§Psychiatry and Behavioral Neurosciences, and ¶¶Surgery and the †††Health Sciences Library, McMaster University, Hamilton, Ont.; the Departments of §Medicine, ¶Social and Preventive Medicine, and ††Physiology and Biophysics, University at Buffalo, and the ‡‡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.
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  • response to letters from Professor Belanger and Deber
    P.J. Devereaux
    Posted on: 06 August 2002
  • More about private delivery
    Raisa B. Deber
    Posted on: 02 July 2002
  • H�pitaux canadiens: priv�s ou publics?
    G�rard B�langer
    Posted on: 29 May 2002
  • Posted on: (6 August 2002)
    Page navigation anchor for response to letters from Professor Belanger and Deber
    response to letters from Professor Belanger and Deber
    • P.J. Devereaux, Cardiologist
    • Other Contributors:

    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 bec...

    Show More

    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.

    Show Less
    Competing Interests: None declared.
  • Posted on: (2 July 2002)
    Page navigation anchor for More about private delivery
    More about private delivery
    • Raisa B. Deber, Professor
    What are the implications of allowing for-profit delivery? Although I admire the courage of Devereaux et al in attempting a meta analysis of this literature, as they have noted, there is enormous variability within each category. All hospitals are not alike. In addition to the distinction they accurately make between private for-profit (FP) and private not-for-profit (NFP), the literature also suggests that there are ma...
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    What are the implications of allowing for-profit delivery? Although I admire the courage of Devereaux et al in attempting a meta analysis of this literature, as they have noted, there is enormous variability within each category. All hospitals are not alike. In addition to the distinction they accurately make between private for-profit (FP) and private not-for-profit (NFP), the literature also suggests that there are major differences between for-profit firms which are investor owned (FP/c), and those which operate as small businesses (FP/s). There may also be differences between organizations depending upon the degree of control by health professionals. Further compounding the difficulty in making comparisons, the for-profit hospitals in the studies they reviewed tend to occupy 'niche' markets, serving different target populations (and often performing different mixes of services) than do the not-for-profit organizations. Comparisons therefore often depend upon what (and how) various factors are controlled for, making precise point estimates even more tenuous. Regardless of the implications for costs (which are subject to similar "apples and oranges" difficulties), quality differences between FP and NFP 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.

    Readers interested in this topic might find useful a systematic review I have conducted for the Romanow Commission, which I have been informed should appear in the near future on their web site.

    Show Less
    Competing Interests: None declared.
  • Posted on: (29 May 2002)
    Page navigation anchor for H�pitaux canadiens: priv�s ou publics?
    H�pitaux canadiens: priv�s ou publics?
    • G�rard B�langer, professeur d'�conomique

    Les hôpitaux canadiens sont-ils des organisations privées à but non lucratif? Depuis 1961, Statistique Canada répond par la négative pour les données de la comptabilité nationale. Ils sont une composante de l'administration publique.

    Competing Interests: None declared.
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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, Christina Lacchetti, Bruce Weaver, Holger J. Schünemann, Ted Haines, John N. Lavis, Brydon J.B. Grant, David R.S. Haslam, Mohit Bhandari, Terrence Sullivan, Deborah J. Cook, Stephen D. Walter, Maureen Meade, Humaira Khan, Neera Bhatnagar, Gordon H. Guyatt
CMAJ May 2002, 166 (11) 1399-1406;

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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, Christina Lacchetti, Bruce Weaver, Holger J. Schünemann, Ted Haines, John N. Lavis, Brydon J.B. Grant, David R.S. Haslam, Mohit Bhandari, Terrence Sullivan, Deborah J. Cook, Stephen D. Walter, Maureen Meade, Humaira Khan, Neera Bhatnagar, Gordon H. Guyatt
CMAJ May 2002, 166 (11) 1399-1406;
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