Theses and Dissertations from UMD
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Item AN ECONOMIC ANALYSIS OF FACTORS IMPACTING HOSPITAL PATIENT OUTCOMES IN THE UNITED STATES(2006-08-07) Wei, Heng; Evans, William N; Economics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This dissertation is two essays that examine the impact of two distinct structural changes in hospitals. The first essay examines whether legislated changes in the minimum postpartum length of stay improve health outcomes for newborns. The second essay examines the consequences of nurse unions in hospitals. Much of the previous research about the relationship between postpartum length of stay and patient outcomes are potentially subject to an omitted variable bias because sicker newborns usually stay longer in the hospital. We overcome this problem by using passages of early discharge laws as a quasi experiment that generated exogenous increase in length of postpartum stays. The California Newborn's and Mother's Health Act of 1997 effective on August 26, 1997, mandated that private insurance carriers provide coverage for at least 48-hour hospital stays for normal deliveries and 96-hour hospital stays for cesarean deliveries. A similar federal law went into effect on January1, 1998. Using an interrupted time series design, we demonstrate that early discharge laws reduced considerably the fraction of newborns and mothers who were discharged early. In two-stage least square models using the state and Federal law as instruments for the length of hospital stay, we find that an additional day in the hospital reduces the probability of readmission by about one percentage point for complicated vaginal deliveries and c-sections of all types. For uncomplicated vaginal deliveries, we find there was no statistically significant change in 28-day newborn readmission rates. The second essay examines the impact of nurse unionization in hospitals on wages, hours, staffing ratio of nursing personnel. Using hospital-level panel data merged with data on union elections from the National Labor Relations Board, we compare the outcomes of nursing personnel in hospitals that became unionized during the sample period with hospitals that did not change union status. The results indicate that unions have a small negative impact on nurse wage rates and they encourage hospitals to use a larger fraction of contract employees. These difference-in-difference estimates also indicate that cross-sectional regressions tend to overstate the wage gains of union because unions are more likely to appear in higher-wage hospitals.Item LEGISLATING HEALTHCARE QUALITY(2006-04-27) Kim, Beomsoo; Evans, William N; Economics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Health care market has often been regulated by government legislation. A California law passed in 1999 regulating minimum nurse to patient ratios in hospital units is one of them. This legislation was prompted by results from previous research showing higher adverse patient outcomes when hospital nurse/patient ratios are low. In the second chapter of my dissertation, I use a census of hospital discharges in California during 1996-2000 to estimate the impact of hospital staff levels on adverse events by examining whether outcomes are correlated with the number of admissions in the hospital over the next two days. I find quantitatively small and statistically insignificant effects of Friday and Saturday admission shocks on mortality rates of patients admitted on Thursdays. These results suggest that the portion of the California law designed to guarantee adequate staffing when the patient census increases unexpectedly should have little impact on patient outcomes. Another regulation which has been proposed by the government is federal tort reform. One frequent justification for tort reform proposals is the potential impact of liability on defensive medicine. There is however, scant and conflicting evidence on whether malpractice risk alters physician practices. In the third chapter of my dissertation, I examine whether malpractice risk alters the procedure choices of obstetricians, who face one of the highest rates of malpractice lawsuits and pay much larger malpractice premiums than most other specialties. By focusing on obstetricians, I can observe the impact of malpractice risk on the use of procedures such as cesarean sections, vaginal births after cesareans, prenatal care visits, the use of diagnostic tests such as ultrasound and amniocentesis, and the use of various equipment and techniques during the delivery such as fetal monitoring, forceps and vacuum extraction. Because the measured malpractice risk may signal something unobserved about physician quality or practice style, I use malpractice claims against non-OB/GYNs as an instrument for OB/GYN claims. I find that cesarean section rates and most other measures of physician behavior are not sensitive to medical malpractice risk.