3.2 Findings on private elective surgical provision within public health systems
Access to health care is defined as the extent to which financial, organizational, geographical, and cultural barriers are minimized for patients 29. Eleven papers from the UK, Australia, Denmark, Canada, Netherlands and Italy discussed the accessibility of services for cataract, hip, and knee patients and compared the private and public provision of these surgical procedures 3, 6, 9, 10, 12, 13, 21, 25–28. Among these studies, only two12, 13 looked at accessibility related to patient preoperative/ general health status or symptom severity, and neither reached a definite conclusion about the relevance of these factors.
Reforms in the UK introduced in 2006 allowed Independent Sector Treatment Centres (ISTCs) to operate within the UK health system. From 2006 onward, private hospitals were also allowed to enter the existing elective surgical treatment system and compete with the ISTCs and public hospitals25 for publicly funded treatments. Kelly and Stoye 21 examined private providers’ access to the market for elective hip replacement in the UK between April 2002 and March 2011. They found that waiting times did not depend on the nearest ISTC; however, the introduction of the private sector providers reduced waiting times at National Health Service (NHS) hospitals without any effect on surgical volumes. In a second paper, Kelly and Stoye25 evaluated different aspects of the impacts of private hospitals' entry on the publicly funded elective hip replacement surgery market. The authors found a 12% annual expansion in the size of the publicly funded elective hip surgeries and a decrease in wait times in public hospitals from 239 days (2002-03) to 92 (2012-13) days. In 2012-13, median wait times were significantly lower at private hospitals than in public hospitals at 63 days and 92 days, respectively.
Kirkwood and Pollock9 conducted an ecological study of 154,766 patients receiving publicly funded primary hip arthroplasty (105,872 elective and 48,894 emergency cases) in Scotland between April 1993 and March 2013. They evaluated how the policy of commercial contracting to tackle waiting times impacted direct NHS provision and treatment inequalities. Inequalities by age and socioeconomic deprivation were found to increase with a private provision especially for the patients aged 85 years and over and those living in more socioeconomically deprived areas. Thus, they warned about the negative consequences of private sector provision on equitable access to care.
Fitzpatrick et al. 6 surveyed five English regions for 12 months and explored sociodemographic and health status factors associated with waiting times. Study results showed that publicly funded patients were 5.28 (95% Confidence Interval [CI] 4.22-6.59) more likely to report a wait time greater than three months for an outpatient appointment and 12.80 (95% CI 9.81-16.68) times more likely to report a wait time longer than six months for total hip replacement (THR) than the privately funded ones.
Pager and McCluskey 12 compared day-case cataract surgery patients’ priorities and satisfaction levels in Australia, surveying 42 public and 39 private patients. Results showed that mean surgery wait times for patients at public hospitals were nine times longer (38.2 vs 4.4 weeks, p<0.001) than the private centre patients.
Koehoorn et al. 10 assessed the effect of expedited surgical fees paid to physicians in reducing wait time and patient return to work time in public and private facilities in British Columbia. The study cohort consists of workers who accepted workers' compensation claims for meniscal injury and underwent knee surgery between 2001 and 2005. Study results showed that the median wait time for surgery was 22 and 24 days for expedited operations (public hospital and private clinic, respectively), compared to 37 days for non-expedited surgeries (public hospital only), a difference of almost two weeks.
Two studies from Denmark investigated access for cataract and hip operations. The first study by Solborg Bjerrum et al. 13 researched the epidemiology and mortality of patients who had cataract surgery in public hospitals and private facilities between 2004 and 2012. Using data from 243,856 patient registries (411,140 cataract operations), the researchers showed that private facilities offer second eye surgery sooner than public facilities. The median time interval was seven days shorter for cataract surgery patients in private clinics, and with a statistically significant difference between groups (95% CI [6.65, 7.35]; p<0.001).
A second study by Andersen and Jakobsen 3 compared private and public hip clinics using a Danish Registry from 2007 to 2008. The researchers evaluated the wait times from 36 public and 20 private hip replacement clinics and found that private clinics reduce wait times more than public clinics.
To evaluate differences in cataract surgery cost, quality of care, and efficiency, Kruse et al. 26 conducted a comparative multilevel analysis using 2013-15 reimbursement claim data and quality indicators. They found that ISTCs cataract surgery volume is slightly higher than the general hospitals, with an average of 0.91 and 0.84 cataract operations per care pathway, respectively.
In a cross-sectional study from the Netherlands, Tulp et al. 28 examined the differences in healthcare quality and cost for five elective surgeries between the ISTCs and general hospitals, using 2017 data. Their analysis showed that cataract (1855.22 ±965.50 vs 1180.81 ±640.65), hip (379.51 ± 184.63 vs 127.92 ± 130.68), and knee surgeries (315.00 ± 149.90 vs 163.07 ± 182.84) were performed more frequently in public hospitals.
Moscone et al.27 compared healthcare quality between public and private hospitals treating publicly funded patients who received elective (hip or knee replacement) or emergency care (hip fracture) in the Lombardy region, Italy. Study results showed that even though there were more public than private hospitals (64 vs 46), private hospitals treat more hip and knee replacement patients. Ordinary least square (OLS) regression analysis results indicated that hip and knee surgery wait times are shorter in private hospitals by about 25 to 35%. Comparing the OLS with an instrumental variable (IV) approach, the authors showed that unobserved factors such as patient morbidity were also important. OLS indicated lower wait times in private facilities, but this result was not significant using the IV approach.
Although the included studies offer little information on defining or assessing acceptability, a theoretical framework defines the concept as a patient’s cognitive and emotional responses to the intervention 30. From a health care perspective, the primary acceptability indicator is satisfaction level, and the included studies provide information on retrospective acceptability using satisfaction levels. In seven papers, two from the UK 17, 23, three from Australia 2, 11, 12, one from Denmark 3 and one from the Netherlands 26, the acceptability of surgical services was discussed.
Browne et al. 23 conducted a prospective cohort study of 769 patients treated in six ISTCs and 20 NHS providers to compare the case-mix and patient reported outcomes of surgery. They assessed the change in patient-reported health status and health-related quality of life after three months for cataract surgery patients and after six months for hip and knee patients. In this study, roughly equivalent proportions of patients treated at ISTCs and NHS facilities (cataract surgery 97% versus 91%; hip replacement 98% versus 92%; and knee replacement 85% versus 87%, respectively) described their operation results as excellent, very good, or good, irrespective of where they were treated.
Using survey data, Perotin et al. 17 studied the effects of hospital ownership on the quality of information, care, privacy, dignity, hospitality, and procedural delays. Results showed that public sector hospitals provided better information and more choice, while private sector facilities offered a more comfortable, friendly, and clean environment. The authors stated that the results varied across patient groups and explained that differences in the quality of information between these two sectors were due to patient selection and other unobserved hospital characteristics, and not due to hospital ownership 17.
Australian survey results for patients who received cataract care within the private and public sectors show that 90% of private sector patients were satisfied with the information they received, whereas 45% of public sector patients wanted more information. Public sector patients were less satisfied overall than private sector patients, although the level of satisfaction between groups was similar 12.
Assessing satisfaction rates, Adie et al. 2 conducted a prospective observational study on 331 hip and knee replacement patients in two public and two private high-volume joint replacement centres in Australia. They found almost 90% satisfaction rates in public and private patients at six and 12 months after surgery. After adjusting for the effect of patient expectation (expectations met in 76% of private centres and 64% of public centres at 12 months), private patients were less likely to be satisfied due to their higher expectations (adjusted odds ratio [aOR] for satisfaction at 12 months: 0.16 private vs public).
Naylor et al. 11 surveyed satisfaction in Australian patients who underwent arthroplasty in eight public and seven private high-volume arthroplasty centres. The odds ratio (OR) for satisfaction was higher in public (1.78) but not statistically significant (p= 0.26). Private sector did better in hospitality (46.7% vs 35.6%) and frequency of surgeon visitation (76.4% vs 65.8%).
A Danish study used survey results from 36 public and 20 private hip replacement clinics, Andersen and Jakobsen 3 reported higher patient satisfaction with private clinics.
Using patient-reported data from a questionnaire given to Dutch cataract surgery patients from 2013-14, Kruse et al.26 compared patient satisfaction between ISTCs and public hospitals. They used the Net Promoter Score to measure patient satisfaction and identified significantly higher scores among ISTC patients compared with public hospital patients.
Factors impacting patient safety in the outpatient surgery population include surgical preparedness, patient education, and clinically appropriate and accurate surgical procedures 31. Several papers addressed safety considerations for elective surgical procedures: four from the UK 5, 23–25, two from Australia 11, 19, three from Denmark 3, 13, 14, one from Norway 18, and one from Italy 27.
Browne et al. 23 compared patient-reported outcomes of cataract surgery in six ISTC and 20 NHS providers from 2006 to 2007. They found that patients treated in ISTCs were less likely to report postoperative problems than those treated in NHS facilities (aOR: 0.35; 95% CI [0.17, 0.70]), and improvements were greater in patients treated in private centres. The authors highlighted that private centres tend to treat less severe primary cataract cases.
Bannister et al. 24 and Chard et al. 5 examine safety issues between the private and public facilities after hip and knee surgeries. Bannister et al. 24 reported on readmission, reoperation, dislocation rates, and wound problems, while Chard et al. 5 presented complication rates as a safety criterion. Chard et al. 5 found that patients undergoing joint replacements in public facilities reported complications more often and hypothesized that this could be due to patient selection. Bannister et al. 24 compared short-term complications of THR and total knee replacement (TKR) at one NHS hospital with two ISTCs. Their study reported lower complication rates for surgeries performed in the NHS hospital, in contrast to Chard et al 5.
Kelly and Stoye 25 stated that after the introduction of private hospitals on the public market for elective hip replacements, the 30-day emergency readmission rate dropped from 6.1% (2002-03) to 5.6% (2012-13) in public hospitals, but these changes were not statistically significant. In 2012-13, 30-day emergency readmission rates following hip replacement were lower at private hospitals: 5.6% and 3.5% respectively. The authors concluded that readmission rates were unaffected by the reforms.
Li et al. 19 studied the sociodemographic, environmental, and clinical risk factors for postoperative endophthalmitis, using administrative data from Western Australia. The results showed that procedures performed in private hospitals had a significantly higher risk of postoperative infection (OR 2.38; 95% CI 1.32–4.27; p 0.003) than those performed in public hospitals.
Naylor et al. 11 conducted a telephone survey of Australian arthroplasty patients at eight public and seven private high-volume providers on the 35th postoperative day. Cohort analysis by arthroplasty type and sector showed that the rate of complications was different for hip arthroplasty (public 23% vs private 37%, p<0.01) but were the same for knee arthroplasty (16%).
Two studies 13, 14 were conducted in Denmark to compare elective surgeries in private versus public hospitals. The first study showed that overall mortality in patients who had cataract surgery in public hospitals was 62% (IRR: 1.62, 95% CI: 1.59–1.66, p < 0.001) higher than patients who had cataract surgery in private clinics between 2002 and 2010 13. Patient selection could contribute to this difference, as patients treated in public facilities were more deprived than those in private clinics. The second study addressed the risk of cataract surgery complication (endophthalmitis) in private clinics versus public health care centres between 2004 and 2012 and showed that endophthalmitis risk is two times as high (0.73 per 1,000 procedures compared with 0.36 per 1,000 procedures) in private surgical centres 14. This finding reinforces findings from earlier research by Li et al. 19 and others.
A third Dutch study by Andersen and Jakobsen 3 examined complication rates as a safety criterion after hip and knee surgeries. They found that patients undergoing joint replacements in public facilities reported complications more often. The reason could be patient selection as patients undergoing surgery in private centres were healthier and were less prone to complications relative to those undergoing surgery through public providers.
Like Kelly and Stoye 25, Moscone et al.27 evaluated 30-day emergency readmission rates for publicly funded hip and knee replacement patients to investigate the difference between the public and private providers using an IV approach. Using 2012-14 administrative data on patients admitted to 189 hospitals in Italy, they found that the risk of readmission following hip replacement in private facilities was 3.6% higher than in public facilities (p=0.032).
Holom and Hagen 18 evaluated publicly financed primary total hip (37,897) and total knee arthroplasty (25,802) patients for six years in Norway. They concluded that private non-profit hospitals had significantly lower rates for 30-day readmission due to complications (0.049 ±0.217 for private not-for-profit hospitals and 0.080 ±0.272 for public hospitals), despite finding that quality differences between hospital types (private for-profit hospitals, private not-for-profit hospitals, and public hospitals) were minor. The authors suggest that this may be because public hospitals receive more readmissions and play a critical role in the care of more complex cases.
3.2.4 Clinical effectiveness
Clinical effectiveness can be assessed by many outcomes, such as improvements life-years gained, symptom relief, patient-reported outcomes, or cure. Researchers explored postoperative outcomes, readmission rates, reoperation rates, or short-term complications of surgical procedures as a clinical effectiveness factor in seven studies 2, 5, 7, 12, 23, 24, 28.
The most extensive research on the correlation between clinical effectiveness and care provider types was conducted in the UK 5, 23, 24 and Australia 2, 7, 12.
Browne et al. 23 evaluated 769 patients treated in six ISTCs, and 1,895 patients treated in 20 NHS facilities in England. They found that functional status and quality of life improvement were more significant for the patients who had cataract surgery or hip replacement in ISTCs than those had surgery in NHS facilities. After adjusting for preoperative characteristics, they found favourable and statistically significant differences persisted for patients treated at ISTCs. The study outcomes are reported as follows: Visual Function 14 (VF-14) scores were 2.6 points higher (p=0.005) and the EQ-5D 0.03 points higher (p=0.01) for cataract surgery patients at ISTCs, and for hip replacement patients, Oxford Hip Scores (OHS) were 2.4 points higher (p=0.03) and the EQ-5D scores were 0.06 points higher (p=0.03) for ISTC patients.
Bannister et al.24 examined short-term complications after total hip and knee arthroplasties at an NHS hospital and two ISTCs. They found that after total hip arthroplasty, the NHS facility had a lower rate of complications requiring reoperation than ISTCs. After total knee arthroplasties, readmission rates at a private hospital (13%) were 12 times higher than a regional orthopedic hospital and 13 times greater than NHS (1.1% and 1% respectively; chi-square test: 108; p=0.000). After total hip arthroplasty, reoperation rates at the regional orthopedic hospital were at 0.6%, NHS 1.4%, and private hospital 9%.
A study by Chard et al. 5 provided information on clinical outcomes after hip and knee surgery. The authors evaluated the characteristics of patients undergoing hip and knee replacement (5,671 in ISTCs and 14,292 in NHS), inguinal hernia repair, or varicose vein surgery. The comparison of symptoms and health-related quality of life scores showed that hip and knee replacements performed by ISTC surgeons had better outcomes than the procedures undertaken by the physicians who work at the public hospitals (difference of 1.7 in OHS and 1.4 for Oxford knee score). The authors stated that these differences were minor, thus, unlikely to be clinically significant. Chard et al. 5 suggested a possible reason for the better outcomes could be that these facilities admitted healthier patients or patients who had less severe conditions than those undergoing surgery in NHS providers.
Pager and McCluskey 12 looked at 42 public and 39 private day-surgery cataract patients’ priorities, satisfaction levels, and postoperative outcomes. Comparing preoperative and postoperative VF-14 (Visual Function Index) scores, results showed that both groups achieved the same level of postoperative outcomes. Preoperative VF-14 scores were 86.5 (Standard Deviation [SD] ±11.7) for private patients and 79.0 (SD ±19) for public patients, and after the procedure, the VF-14 scores reached 91.5 (SD ±13) and 92.8 (SD ±14), for private and public patients, respectively.
Other studies from Australia 2, 7 evaluate the clinical effectiveness of hip and knee replacement. Adie et al. 2 found similar outcomes (magnitude and rate of improvement in Oxford score or quality of life) for patients treated in public and private hospitals, while Harris et al. 7 reported higher revision rates for THR (17.4% private vs 4.4% public) and TKR (19.6% private vs 10.0% public) in private hospitals. The authors highlighted that this variation was mainly due to differences in prosthesis selection.
Tulp et al. 28 compared ISTCs with public hospitals on quality and price for five elective surgeries (cataract, THR, TKR, anterior cruciate ligament, and carpal tunnel surgery). They found that revision surgery after THR was performed more frequently in private facilities than in public hospitals. A regression analysis estimated a 1.44% higher revision rate in private facilities. These quality differences were not consistent over all elective surgery types and providers. ISTCs performed on worse for both TKR and THR, yet outperformed public hospitals for cataract treatment.
Efficiency refers to how to use resources effectively to achieve an objective 32. Surgical service efficiency was examined in ten studies 4, 10, 15, 16, 19–22, 25, 28. Most of the research adopted the technical efficiency perspective, so the authors evaluated length of stay (LOS), defined as from admission to discharge or preoperative only 4, 16, 18, 20, 21, 25, and a number of the surgical procedures completed in a year 15, 19, 25.
Studies from the UK on efficiency report varied results. Two studies 20, 21 evaluated the effect of private sector exposure on preoperative LOS in public facilities. Kelly and Stoye 21 evaluated geographic areas where the independent sector providers were closer to patients than the NHS hospitals, yet did not find any effect of independent sector provider exposure on preoperative LOS; however, the researchers reported that NHS funded hip replacement numbers increased annually by 0.5 procedures per Middle Layer Super Output Area (MSOA). The authors explained this increase by hypothesizing that independent sector providers operated on patients who would not otherwise have undergone a hip replacement.
Using a large dataset which covers 615,281 patients who had hip replacement surgery both in private and public facilities between April 2002 and March 2013, Kelly and Stoye 25 found a five day decrease in median LOS (from 9 to 4 days) at public hospitals over the study period. In 2012-13, the median LOS is the same for public and private providers. Study results also showed that private hospitals' entry into the publicly funded elective surgery market increased the total number of publicly funded hip replacements provided, without reducing the total number of cases in the public facilities.
Contrasting these results, Cooper et al.20 found that hospitals located in more competitive markets were more successful in decreasing LOS. They found the entry of for-profit specialty surgical centres led to a 16% reduction in pre-surgery LOS at nearby public hospitals, increasing the proportion of patients treated on the day of admission.
Vanhegan et al. 15 evaluated the effect of an ISTC on the provision of elective orthopedic surgery in England and found that the same surgeon operated on 66 patients in a public facility prior to the introduction of ISTCs, and just 32 patients in the ISTC after the introduction of the ISTC, a reduction in productivity of 51%. They found the introduction of the ISTC resulted in a reduction in departmental efficiency and financial productivity. The researchers reported a combined reduction in potential financial productivity of £128,677 over three months or £514,708 over a year, based on 2011 tariffs 15.
Another UK study, by Street et al.22, compared outcomes between hospitals and private treatment centres by applying six indicators to assess healthcare resource group (HRGs) intensity: age, LOS, number of diagnoses, number of procedures, income deprivation and transferred to other NHS providers. The study results showed very little difference in LOS (weighted mean difference -0.25 days, 99% CI -0.28 to -0.22) between patients treated in hospitals and treatment centres except for hip and knee replacements. Those receiving hip and knee replacement surgeries in public facilities had stayed longer than those treated in private treatment centres.
Siciliani et al. 16 evaluated whether provision of care in specialized treatment centres is more efficient than in hospital settings. They investigated differences in LOS for hip replacement patients and found the specialized public treatment centres (5.866±2.572) and private treatment centres (4.481±1.494) have 18% and 40% shorter LOS than public hospitals (7.455±4.780), respectively.
Barbieri et al. 4 compared the LOS and found that private hospitals had a significantly shorter average LOS than public hospitals (2.97 compared with 4.21 days). The authors explained the difference by stating that public hospitals often performed additional procedures during one admission.
Using population-based administrative data from Western Australia, Li et al. 19 compared public and private facilities and found that more cataract surgeries were performed in private hospitals than in public hospitals and hospitals in rural areas.
Tulp et al.28 compared ISTCs with general hospitals and provide efficiency information on five elective surgeries (cataract, total hip and knee replacement, anterior cruciate ligament, and carpal tunnel surgery). All procedures except anterior cruciate ligament surgery were performed more often in the public hospital setting, leading to lower list prices for procedures, although the effect is limited.
Koehoorn et al. 10 evaluated the effect of expedited surgical fees paid to physicians in reducing wait time and return to work time in public and private facilities in British Columbia, Canada. Aiming to reduce surgery wait times, disability costs and improve return-to-work outcomes, some workers’ compensation systems in Canada pay (higher) fees to expedited surgeries. Policies vary among provinces, but in this approach, clinics are expected to perform expedited operations within 21 days of surgery decision. Study results revealed that the public expedited group had the shortest disability duration from surgical consult to return to work around one workweek.
3.2.6 Cost and cost-effectiveness
Goodacre and McCabe define a cost-effective intervention as an intervention that represents good value for money33. A broader definition of cost-effectiveness is: “The achievement of results in the most economical way. This approach assesses efficiency by checking whether resources are being used to produce any given results at the lowest possible cost. Cost-effectiveness is most relevant as a concept of efficiency in cases such as the provision of defence, education, health care, policing, or environmental protection, where it is sometimes difficult to measure the monetary value of the results achieved.” 34
Karnon et al.8 assessed the cost-effectiveness of contracting with the private sector for TKR. Using secondary data, the authors developed a decision tree and a Markov model. The study population comprised of patients categorized as non-urgent. The authors used the Western Ontario and McMaster Universities Arthritis Index to represent patients' health status. The analysis was undertaken from the Australian health system perspective, and the authors found that with the purchase of private services, additional quality-adjusted life years (QALYs) could be gained at an incremental cost of less than 40,000 2016 Australian Dollars. They concluded that alternative options for increased government funding of TKR might be more cost-effective than many new publicly funded pharmaceuticals in Australia. To our knowledge, this is the only study that demonstrates the cost-effectiveness of contracting with the private sector for TKR.
Kruse et al.26 compared the claim costs for cataract surgery between ISTCs and public facilities. They found that ISTCs costs were 7% lower compared to public facilities for both 2013 and 2014. The authors explained that with the fewer care activities claimed by ISTCs, lower costs in ISTCs were due to more intense optometrist use and lower overhead costs.
3.2.7 Patient characteristics and selection issues
Our review also identified additional important findings around the selection of patients receiving care in different facility types. Terms such as cherry-picking, cream-skimming, and dumping were used in several studies to describe approaches to patient selection by private providers 4, 5, 12–14, 18, 20, 22–24.
Generally, private facilities are alleged to cherry-pick or cream-skim by selecting less complex patients, which (i) increases postoperative LOS and costs for public facilities, (ii) restricts access to private facilities for certain groups of patients, and (iii) increases inequality within the health system 5, 13, 23. Dumping occurs when patients from private facilities are referred to public facilities in the event of adverse surgical outcomes 14.
Thirteen papers compared the characteristics of patients undergoing cataract, orthopedic surgery at private surgical clinics with public facilities. They found that patients who have surgery in private hospitals are healthier 5, 13, 23 and younger 13, 18, 22 than those who have surgery in public hospitals. Private hospital patients also have fewer comorbidities 18, 23 and less severe preoperative symptoms 5, 12, 20, 23.
In the 2000s, after the implementation of for-profit and not-for-profit healthcare providers in the UK, public sector providers faced a staff shortage. At the same time, private centres took on less problematic patients and left the others to the public health care providers 20. As a result, the public sector had to deal with more complex cases, comorbidities, and complications with fewer staff.
Case selection was also evaluated by Bannister et al. 24. In contrast to previous studies 18, 23, they found that one ISTC rejected 1% of referred surgical cases due to the complexity of the surgery and 4.2% due to associated co-morbidities. Discussions around the potential for shifting such patients to the public system raise another concern regarding private sector provision.
Street et al. 22 analyzed the UK hospital episode statistics and compared the characteristics of patients treated in ISTCs and hospitals in 2006. Of 3,334,535 patients, 2.3% were treated in private centres. They found that patients treated in public centres were younger, more likely to have come from deprived areas, and tended to have more diagnostic and procedure codes than those treated in private centres.
Barbieri et al. 4 detected differences in the hospitalization of cataract patients in Austria. They found that the rates for cataract intervention in both eyes were nearly three times higher in public hospitals (7.01% public compared with 2.47% private).
A UK study 5 compared characteristics of ISTC and public health care centre patients. A three- to six-month follow-up on outcomes after elective surgery showed that patients treated by ISTCs were healthier and admitted with less severe symptoms than the patients treated by the public health care providers, though the difference was small. The results of this study do not appear to support cherry-picking concerns.
Similarly, another UK study 25 showed that the mean age and the mean number of comorbidities are slightly lower for the patients treated at private hospitals in 2012-13 compared to the public hospitals. The mean number of comorbidities was 1.8 for patients treated in private facilities and 3.1 for the ones treated in NHS hospitals.
Kruse et al. 26 found that ISTCs generally perform less severe patients’ cataract surgeries. They attribute this finding to Dutch treatment guidelines which ISTCs must follow, requiring them to refrain from treating patients with severe systematic diseases according to American Society of Anesthesiologists Classification System (ASA type III).
Moscone et al. 27 also found that severe patients who require hip and knee surgery were less likely to be admitted to private facilities, consistent with some other studies26. They suggest this is due to either a lack of facilities to treat the patients with a high comorbidity index or specialization in routine cases, or a combination of dumping and cherry-picking.
A study from Denmark revealed a strong indicator of dumping, as the researchers found that all endophthalmitis cases after cataract surgery (36% performed at public hospitals and 64% performed at private hospitals) were treated in public hospitals between 2002 and 2010 14.