Health and Management Laboratory (MeS Lab), Institute of Management, Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy.
Int J Equity Health. 2018 Nov 20;17(1):169. doi: 10.1186/s12939-018-0878-x.
Equity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems. However, systematic performance management strategies for achieving equity are still weaker than those aimed at achieving financial sustainability and quality of care. Using a vertical equity perspective, the overarching aim of this paper is to examine how improving equity in quality of care impacts on financial sustainability. We applied a simulation to indicators of the heart failure clinical pathway in Tuscany (central Italy), in order to quantify the equity gaps and financial resources that could be reallocated in the absence of performance inequities.
The analysis included all patients hospitalized for heart failure as a principal diagnosis in 2014. We selected five indicators: hospitalization rate, 30-day readmission, cardiology visits, and the utilization of beta-blockers, and ACE inhibitors and sartans. For each indicator, the simulation followed three steps: 1) stratification by socioeconomic status (SES), using education as a proxy for SES; 2) computation of the vertical equity indicator; and 3) assessment of the financial value of the equity gap.
All indicators showed performance gaps regarding inequities across SES-groups. For the hospitalization rate and 30-day readmission, resources could have been reallocated, if the performance of patients with a low SES had been equal to the performance of patients with a high SES, which amounted to €2,144,422 and €892,790 respectively. In contrast, limited additional resources would have been required for prescriptions and cardiology visits.
Reducing equity gaps by improving the performance of low-SES patients may be a crucial strategy to achieving financial sustainability in universal coverage healthcare systems. Universal healthcare systems, which aim to pursue financial sustainability and quality of care, are thus urged to develop performance management actions to improve equity. This approach should not only include the measurement and public disclosure of equity indicators but be part of a comprehensive evidence-based strategy for the management of chronic conditions along the clinical pathway.
公平、医疗保健的财务可持续性和质量是全民健康系统所追求的关键目标。然而，实现公平的系统绩效管理策略仍弱于实现财务可持续性和护理质量的策略。本文从垂直公平的角度出发，旨在考察提高医疗服务质量公平性对财务可持续性的影响。我们应用了一种模拟方法来衡量意大利托斯卡纳（中部）心力衰竭临床路径的指标，以量化在不存在绩效不平等的情况下，重新分配公平性差距和财务资源的情况。
该分析包括 2014 年因心力衰竭作为主要诊断住院的所有患者。我们选择了五个指标：住院率、30 天再入院率、心脏病学就诊次数，以及β受体阻滞剂、ACE 抑制剂和沙坦类药物的使用率。对于每个指标，模拟都遵循三个步骤：1）按社会经济地位（SES）分层，使用教育作为 SES 的代理变量；2）计算垂直公平指标；3）评估公平差距的财务价值。
所有指标都显示出 SES 群体之间存在绩效差距。对于住院率和 30 天再入院率，如果低 SES 患者的表现与高 SES 患者的表现相等，那么可以重新分配资源，分别为 2144422 欧元和 892790 欧元。相比之下，对于处方和心脏病学就诊，所需的额外资源有限。
通过提高低 SES 患者的绩效来缩小公平差距，可能是实现全民覆盖医疗保健系统财务可持续性的关键策略。因此，旨在追求财务可持续性和护理质量的全民健康系统，被敦促制定绩效管理行动来改善公平性。这种方法不仅应包括公平性指标的衡量和公开披露，还应成为沿着临床路径管理慢性病的全面循证战略的一部分。
