Assessing the Impact of Activity-Based Funding in the Irish Public Hospital System: A Comparison of Methods and Empirical Investigations
Creators: name: Valentelyte, Gintare
Publisher: name: Royal College of Surgeons in Ireland
Year: 2024
Subjects: classificationCode: 380108
subject: Health economics
classificationCode: 420306
subject: Health care administration

description: <strong>Aim: </strong>The aim of this PhD was to evaluate the impact of Activity-Based Funding introduction in the Irish public hospital system using empirical investigations and analytical methods comparison.
<strong>Methods and results: </strong>Four studies were carried out to meet this aim.
Study one was a scoping review of analytical methods used in research evaluating the impacts of Activity-Based Funding (ABF) on hospital outcomes. The systematic search and review identified nineteen relevant papers, which used quantitative methodologies in their assessment of causal effects of ABF. Findings showed that quasi-experimental methods comprising of different forms of Interrupted Time-Series analysis was one of the most commonly used analytical methods across most reviewed studies. Difference-in-Differences or similar methods comparing outcome changes over time relative to comparator groups were also used. Case numbers, length of stay, mortality and readmission were the main hospital performance outcomes measured.
Study two compared four of the identified (in study one) commonly used quasi-experimental methods in evaluating causal effects of ABF. Using a case study of elective hip replacements in Ireland the following methods were employed and compared: The Interrupted Time-Series analysis, Difference-in-Differences, Propensity Score Matching Difference-in-Differences and the Synthetic Control methods. The Interrupted Time-Series analysis produced statistically significant results different in magnitude and interpretation, relative to the control-treatment methods, which suggested no statistically significant ABF effect. The choice of analytical method used in the evaluation of policy interventions is important and can affect the estimated effects. More robust control-treatment designs that incorporate a counterfactual framework should be employed to provide a stronger evidence base to inform debates about impacts of policies such as ABF.
Study three evaluated the impact of two ABF mechanisms introduced for laparoscopic cholecystectomy surgery delivered across Irish public hospitals. Using a Propensity Score Matching Difference-in-Differences approach, the causal effect of these funding changes for public patients, across outcomes measuring the proportion of day-case admissions and length of stay was estimated. These outcomes were compared between public patients, subject to ABF reimbursement, and private patients, not subject to ABF reimbursement, treated in the same public hospitals over time. No significant effects were found for any of the outcomes associated with either of the ABF mechanisms across Irish public hospitals. 
Finally, study four evaluated the impact of ABF across several commonly performed elective procedures in Irish public hospitals across three specialties: Orthopaedics, general surgery, cardiology. Using the Propensity Score Matching Difference-in-Differences approach, the causal effect of ABF was estimated across three outcomes: Volume of activity, proportion of day-case admissions and length of stay. Changes in these outcomes were compared between public patients (subject to ABF reimbursement) and private patients (not subject to ABF reimbursement). Overall, no significant effects were identified for any of the outcome measures linked to ABF across Irish public hospitals.
<strong>Conclusion: </strong>This PhD has generated in-depth empirical research evidence of the impacts of ABF post introduction across public hospitals in Ireland using robust analytical methods. The empirical research found no significant causal effects linked to ABF, across outcomes measuring hospital volume of activity, the proportion of day-case admissions and length of stay. This thesis provides insights that choice of analytical method can impact the estimated effects of ABF. Additionally, the empirical research highlights that continued engagement and collaboration between key Irish public hospital stakeholders is required, if the ABF mechanism should be strengthened in the future.