Background
Over the past two decades, governments have tried to reduce costs in health care while improving access and reducing wait times. Although health systems and funding types vary between countries, a common challenge is dealing with increasing demand and healthcare expenses while providing efficient and high-quality care (Reference Gaynor, Moreno-Serra and Propper1). Quality improvement interventions, which redesign access to services, make changes to market structures, and create a competitive environment, are advocated for in many countries, including Canada, the United Kingdom (UK), and Australia (Reference Bachelet, Goyenechea and Carrasco2). These improvements have been particularly important in the context of elective surgeries (Reference Gaynor, Moreno-Serra and Propper1–Reference Rotenberg3). Although the use of private providers within the publicly funded health system has always been controversial, delivery-side market-oriented reforms in health care have been adopted widely. Under typical reforms, universality of coverage through taxation remains, but a competitive environment has been introduced on the supply side. Independent Sector Treatment Centres (ISTC) were introduced by the UK government in the 2000s with the primary aim of providing high-volume elective surgeries, such as cataract surgeries, hip and knee replacements (Reference Cooper, Gibbons and Skellern4;Reference Moscelli, Gravelle and Siciliani5).
With increasing pressures on public health systems internationally, there is a need to develop evidence based on the effects of private elective surgical provision within public health systems. Many studies have been produced to investigate the various effects of private elective surgical provision (Reference Adie, Dao, Harris, Naylor and Mittal6–Reference Vanhegan, Hakmi, de Roeck and Rumian19), and systematic reviews (Reference Tynkkynen and Vrangbaek20) and overviews (Reference Herrera, Rada, Kuhn-Barrientos and Barrios21) have provided evidence on public health outcomes compared to private provision of health services. Our focus was cataract and orthopedic surgeries as they persistently have long waitlists in many jurisdictions (22;Reference Karnon, Haghighi, Sajjad, Yem, Gamage and Thorpe23). As far back as 2004, hip and knee replacement and cataract surgery were listed as priority procedures in Canada, and Canadian Institute for Health Information (CIHI) was mandated to collect wait time information. According to a CIHI report, almost half of the Canadians who received a hip, knee replacement, or cataract surgery waited longer than recommended (22). Cataract lens insertion, and knee and hip replacement are the top three high-volume implantable medical device procedures in Canada (24). The CIHI 2020 report states that cataract lens insertion is the most common surgical procedure with 413, 202 procedures performed in 2018–19, followed by knee replacement and hip replacement with 75, 220 and 65, 645 procedures, respectively (24). To the best of our knowledge, no systematic reviews focus on the role of private provision of these elective surgeries in publicly funded health systems.
This systematic review aimed to identify differences in outcomes between public- and private-sector provision of cataract and orthopedic surgical procedures within publicly funded health systems. Our goal is to understand the benefits and drawbacks of both public and private provision of care, and to help inform policy makers of the trade-offs associated with different policy options.
Materials and methods
The systematic review was carried out using predefined protocol. Following inclusion and exclusion criteria and using data extraction form, each step was conducted by two reviewers independently.
Data sources and search strategy
The literature search was designed to identify studies that investigated the accessibility, acceptability, safety, clinical effectiveness, efficiency, and cost-effectiveness of private surgical facilities. Relevant bibliographic databases (Ovid MEDLINE, OVID Embase, and EBSCO EconLit) and gray literature sources (Google Advanced, The King’s Fund, OECD, European Observatory, Commonwealth Fund, Conference Board of Canada, Fraser Institute, INAHTA, nd CADTH) were searched by an information specialist (DC) between 14 and 21 May 2019. The first search update was performed by a second information specialist (LT) between 26 March and 6 April 2021 on the same sources, and a second search update was performed (DC) between 3 and 9 October 2022. Relevant studies published from January 2000 onwards were identified using a combination of controlled vocabulary (MeSH and EMTREE terms) and keywords relating to private non-hospital surgical facilities and the contracting out of services to them by the public health sector. Full details of the search strategy can be found in Additional file 1.
Inclusion and exclusion criteria
Studies were included if they met the following criteria:
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• Study design: Primary studies and systematic reviews
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• Population: Adult patients who had a cataract or orthopedic surgery
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• Setting: Publicly funded health systems non-hospital/hospital private surgical facilities and surgical facilities (both private and public hospital settings) operated by public sector health providers (e.g., national or regional health authorities)
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• Intervention: cataract and orthopedic surgeries operated in non-hospital/ hospital public facilities
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• Comparator: cataract and orthopedic surgeries operated in non-hospital/hospital private facilities
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• Outcome measures: Accessibility (waiting times, availability of health professionals or centers), acceptability (public/patient perceptions), safety/quality of care (readmission and complication rates), clinical effectiveness (need for revision), efficiency and cost/cost–benefit/cost-effectiveness of private/public surgical facilities
Studies that did not report data on any of the pre-defined outcomes were excluded.
Study selection
Titles and abstracts were screened by two reviewers (IA and EK) and full-texts of the potentially relevant articles were retrieved. Disagreements over eligibility and study quality were resolved by discussion. A third (JR) reviewer helped resolve uncertainty when needed.
To be eligible for inclusion, a study must have (i) evaluated the impact of private surgical facilities within publicly funded health systems, (ii) included at least one of the outcomes described above, and (iii) the provision of elective cataract and orthopedic services only.
Data extraction
The following data were extracted from studies: author(s) name, country of the study, year of publication, title, objective, surgery type, setting, population, outcome measures, results, and conclusion. Two reviewers (IA and EK) extracted data in duplicate from the selected primary studies. We extracted data separately for cataract and orthopedic surgeries. Systematic reviews were not included for analysis if they did not adequately address our scope on cataract and orthopedic surgery. Owing to the heterogeneity of study designs we did not undertake formal evidence synthesis, and instead report the results of each study.
Quality assessment
Studies were assessed by author AI against relevant JBI quality appraisal checklists (25–29) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 (Reference Husereau, Drummond, Augustovski, de Bekker-Grob, Briggs and Carswell30) reporting checklist as appropriate. We report the proportion of checklist items that were met for each study (Tables 1–5, Additional File 1).
Studies evaluating accessibility, acceptability, and safety
Results
Description of selected studies
Using the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram, Figure 1 indicates the total number of articles through the identification and selection process. The initial and updated main literature search identified 1710 citations (746 citations from MEDLINE, and 964 from EMBASE and EconLit electronic databases). A total of 328 gray literature results were identified. After duplicates were removed, 1377 unique studies appeared relevant. The list of titles and abstracts was reviewed, and 69 studies were selected for full-text review. Twenty-nine articles, from Canada, the UK, Australia, Austria, Denmark, Italy, Netherlands, and Norway, were analyzed for a critical narrative summary report (Reference Cooper, Gibbons and Skellern4;Reference Adie, Dao, Harris, Naylor and Mittal6–Reference Vanhegan, Hakmi, de Roeck and Rumian19;Reference Karnon, Haghighi, Sajjad, Yem, Gamage and Thorpe23;Reference Koehoorn, McLeod, Fan, McGrail, Barer and Cote31–Reference Heath, Ackerman, Holder, Lorimer, Graves and Harris43). Included studies are described in Tables 1–4. Adherence to JBI quality checklists for all studies is presented in Table 5. The data extracted from each study are reported in additional file 2, and described in detail in the following section. Reporting quality of the single cost–utility analysis (Reference Karnon, Haghighi, Sajjad, Yem, Gamage and Thorpe23) was additionally assessed using the CHEERS 2022 (Reference Husereau, Drummond, Augustovski, de Bekker-Grob, Briggs and Carswell30) checklist and results presented in Additional File 3.
PRISMA 2020 flow diagram.
From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/.
We report the findings of the quality assessment in Table 5. Of the cohort studies, adherence ranged from 73 to 91 percent of checklist items. Only one study reported strategies to deal with confounding factors, and none of the studies reported strategies to address incomplete follow-up. The only economic evaluation reported 91 percent of JBI Checklist for Economic Evaluations items, lacking generalizability of the findings to other health systems. Of the qualitative research studies, adherence ranged from 80 to 100 percent, with studies not reporting of cultural location of the researchers, or the influence of the researcher on the research. Of the three cross-sectional studies, one study met each of the quality criteria, whereas the other two studies did not identify confounding factors, or state strategies to deal with them. Only one quasi-experimental study was included, which did not clearly state the control group. These quality appraisal findings are also reported alongside the extracted information provided in Tables 1–4.
Summary of findings on private elective surgical provision by outcome
Here we present the results of the review by the outcomes of interest – accessibility, acceptability, safety, efficiency, clinical effectiveness, and cost-effectiveness. We note that several studies did not provide detailed patient information such as ethnic group and case severity, even though this information is important to evaluate accessibility, patient selection issues, effectiveness of the treatment, and complications. This limits the generalizability of some studies and limits the conclusions that can be drawn when considering the relevance of the evidence to local decision making.
Accessibility
Access to health care is defined as the extent to which financial, organizational, geographical, and cultural barriers are minimized for patients (Reference Gulliford, Figueroa-Munoz, Morgan, Hughes, Gibson and Beech44). 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 (Reference Bannister, Ahmed, Bannister, Bray, Dillon and Eastaugh-Waring7;Reference Fitzpatrick, Norquist, Reeves, Morris, Murray and Gregg12;Reference Kelly and Stoye15–Reference Tulp, Kruse, Stadhouders and Jeurissen18;Reference Koehoorn, McLeod, Fan, McGrail, Barer and Cote31;Reference Pager and McCluskey33;Reference Solborg Bjerrum, Mikkelsen and la Cour34;Reference Kelly and Stoye39;Reference Moscone, Siciliani, Tosetti and Vittadini41). Among these studies, only two (Reference Pager and McCluskey33;Reference Solborg Bjerrum, Mikkelsen and la Cour34) 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. Included studies focused on accessibility are summarized by surgery type in Table 1.
Acceptability
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 (Reference Sekhon, Cartwright and Francis45). From a healthcare perspective, the primary acceptability indicator is satisfaction level. In seven papers, two from the UK (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Perotin, Zamora, Reeves, Bartlett and Allen37), three from Australia (Reference Adie, Dao, Harris, Naylor and Mittal6;Reference Naylor, Descallar, Grootemaat, Badge, Harris and Simpson32;Reference Pager and McCluskey33), one from Denmark (Reference Andersen and Jakobsen7), and one from the Netherlands (Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17), the acceptability of surgical services was discussed. Studies that included an assessment of acceptability are summarized in Table 1.
Safety
Factors impacting patient safety in the outpatient surgery population include surgical preparedness, patient education, and clinically appropriate and accurate surgical procedures (Reference Hundt, Carayon, Springman, Smith, Florek, Sheth, Henriksen, Battles, Marks and Lewin46). Several papers addressed safety considerations for elective surgical procedures: four from the UK (Reference Bannister, Ahmed, Bannister, Bray, Dillon and Eastaugh-Waring8;Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Kelly and Stoye15), two from Australia (Reference Naylor, Descallar, Grootemaat, Badge, Harris and Simpson32;Reference Li, Morlet, Ng, Semmens and Knuiman38), three from Denmark (Reference Andersen and Jakobsen7;Reference Solborg Bjerrum, Mikkelsen and la Cour34;Reference Solborg Bjerrum, Kiilgaard, Mikkelsen and la Cour35), one from Norway (Reference Holom and Hagen14), and one from Italy (Reference Moscone, Siciliani, Tosetti and Vittadini41). Results are summarized by surgery type in Table 1.
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 eight studies (Reference Adie, Dao, Harris, Naylor and Mittal6; Reference Bannister, Ahmed, Bannister, Bray, Dillon and Eastaugh-Waring8;Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Harris, Cuthbert, Lorimer, de Steiger, Lewis and Graves13;Reference Tulp, Kruse, Stadhouders and Jeurissen18;Reference Pager and McCluskey33;Reference Chhabra, Perriman, Phillips, Parkinson, Glasgow and Douglas42). The most extensive research on the correlation between clinical effectiveness and care provider types was conducted in the UK (Reference Bannister, Ahmed, Bannister, Bray, Dillon and Eastaugh-Waring8;Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11) and Australia (Reference Adie, Dao, Harris, Naylor and Mittal6;Reference Harris, Cuthbert, Lorimer, de Steiger, Lewis and Graves13;Reference Pager and McCluskey33;Reference Chhabra, Perriman, Phillips, Parkinson, Glasgow and Douglas42). Results of included studies are summarized by surgery type in Table 2.
Studies evaluating clinical effectiveness and efficiency
Efficiency
Efficiency refers to how to use resources effectively to achieve an objective (47). Surgical service efficiency was examined in ten studies (Reference Cooper, Gibbons and Skellern4;Reference Barbieri, Schmid, Ulmer and Pfeiffer9;Reference Kelly and Stoye15;Reference Tulp, Kruse, Stadhouders and Jeurissen18;Reference Vanhegan, Hakmi, de Roeck and Rumian19;Reference Koehoorn, McLeod, Fan, McGrail, Barer and Cote31;Reference Siciliani, Sivey and Street36;Reference Li, Morlet, Ng, Semmens and Knuiman38–Reference Street, Sivey, Mason, Miraldo and Siciliani40). 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 (Reference Cooper, Gibbons and Skellern4;Reference Barbieri, Schmid, Ulmer and Pfeiffer9;Reference Kelly and Stoye15;Reference Siciliani, Sivey and Street36;Reference Kelly and Stoye39), and a number of the surgical procedures completed in a year (Reference Kelly and Stoye15;Reference Vanhegan, Hakmi, de Roeck and Rumian19;Reference Li, Morlet, Ng, Semmens and Knuiman38). Studies on efficiency are reported in Table 2.
Cost and cost-effectiveness
Goodacre and McCabe define a cost-effective intervention as an intervention that represents good value for money (Reference Goodacre and McCabe48). One cost–utility analysis (Reference Karnon, Haghighi, Sajjad, Yem, Gamage and Thorpe23) and one costing study (Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17) included in this review and presented in Table 3. The evidence on cost-effectiveness of introducing private providers into the publicly funded market is highly limited.
Studies evaluating cost and cost-effectiveness.
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 (Reference Cooper, Gibbons and Skellern4;Reference Bannister, Ahmed, Bannister, Bray, Dillon and Eastaugh-Waring8–Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Holom and Hagen14;Reference Pager and McCluskey33–Reference Solborg Bjerrum, Kiilgaard, Mikkelsen and la Cour35;Reference Street, Sivey, Mason, Miraldo and Siciliani40;Reference Heath, Ackerman, Holder, Lorimer, Graves and Harris43).
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 (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Solborg Bjerrum, Mikkelsen and la Cour34). Dumping occurs when patients from private facilities are referred to public facilities in the event of adverse surgical outcomes (Reference Solborg Bjerrum, Kiilgaard, Mikkelsen and la Cour35).
Fourteen papers compared the characteristics of patients. They found that patients who have surgery in private hospitals are healthier (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Solborg Bjerrum, Mikkelsen and la Cour34) and younger (Reference Holom and Hagen14;Reference Solborg Bjerrum, Mikkelsen and la Cour34;Reference Street, Sivey, Mason, Miraldo and Siciliani40) than those who have surgery in public hospitals. Private hospital patients also have fewer comorbidities (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Holom and Hagen14) and less severe preoperative symptoms (Reference Cooper, Gibbons and Skellern4;Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Pager and McCluskey33;Reference Heath, Ackerman, Holder, Lorimer, Graves and Harris43). The included studies are summarized by surgery type in Table 4.
Studies evaluating patient selection issues
The quality measures of included studies based on the Joanna Briggs Institute quality appraisal checklist
“1” indicates the study does fulfill the specified criteria, whereas “0” indicates the study does not fulfill the stated criteria. NA indicates that the criteria were not applicable to the study.
Summary of findings on private elective surgical provision by country
Austria
One study from Austria (Reference Barbieri, Schmid, Ulmer and Pfeiffer9) compared the LOS and found that private hospitals had a significantly shorter average LOS than public hospitals. The authors explained the difference by stating that public hospitals often performed additional procedures during one admission. Study results showed that the rates for cataract intervention in both eyes were nearly three times higher in public hospitals.
Australia
There are eight Australian studies that looked at various outcomes to compare the public and private surgical facilities for cataract and orthopedic surgeries. One study (Reference Li, Morlet, Ng, Semmens and Knuiman38) compared surgical volumes found that more cataract surgeries were performed in private hospitals than in public hospitals.
The only Australian study (Reference Pager and McCluskey33) assessed surgical wait times and found that public hospitals were nine times longer than private center patients. Studies that evaluate patient satisfaction levels have conflicting results. In some studies, public-sector patients were less satisfied overall than private-sector patients (Reference Pager and McCluskey33), in others (Reference Adie, Dao, Harris, Naylor and Mittal6) private patients were less likely to be satisfied due to their higher expectations, whereas some did not find a statistically significant difference Naylor et al (Reference Naylor, Descallar, Grootemaat, Badge, Harris and Simpson32).
Similar to patient satisfaction, postoperative outcome results were mixed. In some studies, procedures performed in private hospitals had a significantly higher risk of postoperative complication (Reference Li, Morlet, Ng, Semmens and Knuiman38) and revision rates (Reference Harris, Cuthbert, Lorimer, de Steiger, Lewis and Graves13) than those performed in public hospitals, whereas others show that both groups achieved the same level of postoperative outcomes (Reference Adie, Dao, Harris, Naylor and Mittal6;Reference Pager and McCluskey33). One study (Reference Naylor, Descallar, Grootemaat, Badge, Harris and Simpson32) states the complication rates were different for hip arthroplasty but were the same for knee arthroplasty. It is worth noting that the variation in revision rates after hip and knee surgeries could be mainly due to differences in prosthesis selection (Reference Harris, Cuthbert, Lorimer, de Steiger, Lewis and Graves13). One study found that following total knee arthroplasty, public patients were significantly more likely to be readmitted within 30 days compared with private patients and the authors concluded that these higher readmission rates might be explained by several contributing factors such as socioeconomic status, longer waiting times resulting in increased impairment and disease complexity (Reference Chhabra, Perriman, Phillips, Parkinson, Glasgow and Douglas42). A recently published study evaluated the preoperative symptom severity and found that patients who underwent primary total hip replacement or total knee replacement for osteoarthritis had significantly worse preoperative symptom severity if their surgery was performed at a public hospital which may reflect variation in access to surgery, and surgeon and patient preferences between these groups (Reference Heath, Ackerman, Holder, Lorimer, Graves and Harris43).
The only study accessed the cost-effectiveness of contracting with the private sector for TKR and 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 (Reference Karnon, Haghighi, Sajjad, Yem, Gamage and Thorpe23).
Canada
Some workers’ compensation systems in Canada pay higher fees to expedited surgeries to reduce surgery wait times, disability costs and improve return-to-work outcomes. Policies vary among provinces, but in this approach, clinics are expected to perform expedited operations within 21 days of surgery decision. A study (Reference Koehoorn, McLeod, Fan, McGrail, Barer and Cote31) assessed the effect of expedited surgical fees and revealed that the public expedited group had the shortest disability duration from surgical consult to return to work around one workweek.
Denmark
Studies from Denmark show that private clinics reduce wait times more than public clinics (Reference Andersen and Jakobsen7), and private facilities offer second eye surgery sooner than public facilities (Reference Solborg Bjerrum, Mikkelsen and la Cour34). One study (Reference Andersen and Jakobsen7) reported higher patient satisfaction with private clinics after hip replacements. On the other hand, due to high complication (Reference Andersen and Jakobsen7;Reference Solborg Bjerrum, Kiilgaard, Mikkelsen and la Cour35), and overall mortality rates (Reference Solborg Bjerrum, Mikkelsen and la Cour34) in public hospitals, dumping and patient selection are concerns that are mentioned in almost all studies (Reference Andersen and Jakobsen7;Reference Solborg Bjerrum, Mikkelsen and la Cour34;Reference Solborg Bjerrum, Kiilgaard, Mikkelsen and la Cour35).
Italy
A study from Italy (Reference Moscone, Siciliani, Tosetti and Vittadini41) showed that private hospitals treat more hip and knee replacement patients with a shorter wait time, but with higher 30-day emergency readmission rates. Similar to studies from Denmark, this study also highlighted that severe patients were less likely to be admitted to private facilities either due to a lack of facilities to treat the patients with a high comorbidity index, specialization in routine cases, or a combination of dumping and cherry-picking (Reference Moscone, Siciliani, Tosetti and Vittadini41).
The Netherlands
Two studies from the Netherlands had information on the predefined outcomes. One study found that ISTCs cataract surgery volume is slightly higher than in general hospitals. They identified significantly higher patient satisfaction scores among ISTC patients compared with public hospital patients with a lower cost (Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17). The main reasons for the lower cost were to perform less severe patients’ cataract surgeries and claim the fewer care activities, more intense optometrist use, and lower overhead costs (Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17). In contrast, Tulp et al. (Reference Tulp, Kruse, Stadhouders and Jeurissen18) showed that cataract, hip, and knee surgeries were performed more frequently in public hospitals, but revision surgery after THR was performed more frequently in private facilities than in public hospitals. It is important to note that these quality differences were not consistent over all elective surgery types and providers. ISTCs performed worse for both TKR and THR, yet outperformed public hospitals for cataract treatment.
Norway
Holom and Hagen (Reference Holom and Hagen14) evaluated publicly financed primary total hip and total knee replacement patients and found that private hospitals had significantly lower rates for 30-day readmission due to complications. 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.
The United Kingdom
Reforms in the UK introduced in 2006 allowed 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 hospitals (Reference Kelly and Stoye15) for publicly funded treatments.
The introduction of private-sector providers reduced waiting times at National Health Service (NHS) hospitals without any effect on surgical volumes (Reference Kelly and Stoye39), with significantly lower median wait times at private hospitals than in public hospitals (Reference Fitzpatrick, Norquist, Reeves, Morris, Murray and Gregg12;Reference Kelly and Stoye15). One study warned about the negative consequences of private-sector provision on equitable access to care (Reference Kirkwood and Pollock16) as the results showed that 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.
Patient satisfaction levels were mixed in the UK studies. Some studies reported roughly equivalent satisfaction levels (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10), whereas others (Reference Perotin, Zamora, Reeves, Bartlett and Allen37) showed that public sector hospitals provided better information and more choice, whereas private-sector facilities offered a more comfortable, friendly, and clean environment.
Studies also show mixed results for postoperative outcomes and complication rates. Some studies found that patients treated in ISTCs were less likely to report postoperative problems than those treated in NHS facilities (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11), and improvements were greater in patients treated in private centers (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11) which could be due to patient selection (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Chard, Kuczawski, Black, van der Meulen and Committee11). In contrast, some studies reported lower complication and reoperation rates for surgeries performed in the NHS hospital (Reference Bannister, Ahmed, Bannister, Bray, Dillon and Eastaugh-Waring8). Similar to studies form other countries, UK studies also state that 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 (Reference Chard, Kuczawski, Black, van der Meulen and Committee11).
Studies from the UK on efficiency also report varied results. Some studies (Reference Kelly and Stoye39) did not find any effect of independent sector provider exposure on preoperative LOS, others (Reference Cooper, Gibbons and Skellern4;Reference Kelly and Stoye15) found that hospitals located in more competitive markets were more successful in decreasing LOS.
The introduction of ISTCs resulted in a reduction in departmental efficiency and financial productivity (Reference Vanhegan, Hakmi, de Roeck and Rumian19). Postoperative LOS for those receiving hip and knee replacement surgeries in public facilities was longer than for those treated in private treatment centers (Reference Siciliani, Sivey and Street36;Reference Street, Sivey, Mason, Miraldo and Siciliani40).
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 centers took on less problematic patients and left the others to the public healthcare providers (Reference Cooper, Gibbons and Skellern4). As a result, the public sector had to deal with more complex cases, comorbidities, and complications with fewer staff. Case selection issues were evaluated by Bannister et al. (Reference Bannister, Ahmed, Bannister, Bray, Dillon and Eastaugh-Waring8). In contrast to previous studies (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10), they found that one ISTC rejected referred surgical cases due to either the complexity of the surgery or associated co-morbidities. Studies found that patients treated in public centers were younger, more likely to have come from deprived areas, and tended to have more diagnostic and procedure codes than those treated in private centers (Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Kelly and Stoye15;Reference Street, Sivey, Mason, Miraldo and Siciliani40). Discussions around the potential for shifting such patients to the public system raise another concern regarding private-sector provision.
Summary of findings on private elective surgical provision by surgery type
Cataract surgery
Four papers from Australia, Denmark, and Netherlands discussed the accessibility of services for cataract patients and compared the private and public provision of these surgical procedures (Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17;Reference Tulp, Kruse, Stadhouders and Jeurissen18;Reference Pager and McCluskey33;Reference Solborg Bjerrum, Mikkelsen and la Cour34). Among these studies, only two (Reference Pager and McCluskey33;Reference Solborg Bjerrum, Mikkelsen and la Cour34) 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. Two studies looked at the surgery volume and one found that the average number of surgeries is higher within private facilities (Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17), and the other study stated that cataract surgeries were performed more frequently in public hospitals (Reference Tulp, Kruse, Stadhouders and Jeurissen18). The average number of surgeries is higher within private facilities than in general hospitals (Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17). Private hospitals have shorter wait times than public hospitals (Reference Pager and McCluskey33;Reference Solborg Bjerrum, Mikkelsen and la Cour34). Patient satisfaction levels are higher for private clinics than public clinics (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17;Reference Pager and McCluskey33).
Studies assessed safety found that procedures performed in private hospitals had a significantly higher risk of postoperative infection than did those performed in public hospitals (Reference Solborg Bjerrum, Kiilgaard, Mikkelsen and la Cour35;Reference Li, Morlet, Ng, Semmens and Knuiman38), whereas overall mortality in patients who had regular cataract surgery in public hospitals was higher compared to patients who had cataract surgery in private hospitals (Reference Solborg Bjerrum, Mikkelsen and la Cour34). Only one study evaluated the postoperative outcomes and did not find any difference between the public and private facilities (Reference Pager and McCluskey33), whereas another study showed that after adjustments for preoperative characteristics private facilities achieved significantly better outcomes (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10). Private facilities were more efficient with a lower LOS (Reference Barbieri, Schmid, Ulmer and Pfeiffer9) and a higher number of surgical procedures completed in a year than the public facilities (Reference Li, Morlet, Ng, Semmens and Knuiman38). Private facility’s costs were 7 percent lower compared to public facilities (Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17). Patients undergoing day surgery in private facilities were healthier, younger, and had a less severe primary condition than those in public facilities (Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10;Reference Kruse, Groenewoud, Atsma, van der Galien, Adang and Jeurissen17;Reference Pager and McCluskey33;Reference Solborg Bjerrum, Mikkelsen and la Cour34;Reference Street, Sivey, Mason, Miraldo and Siciliani40).
Orthopedic surgery
Eight papers from Canada, Denmark, Italy, Netherlands, and the UK discussed the accessibility of services for orthopedic patients and compared the private and public provision of these surgical procedures (Reference Andersen and Jakobsen7;Reference Fitzpatrick, Norquist, Reeves, Morris, Murray and Gregg12;Reference Kelly and Stoye15;Reference Kirkwood and Pollock16;Reference Tulp, Kruse, Stadhouders and Jeurissen18;Reference Koehoorn, McLeod, Fan, McGrail, Barer and Cote31;Reference Kelly and Stoye39;Reference Moscone, Siciliani, Tosetti and Vittadini41). Six studies used wait times to evaluate accessibility (Reference Andersen and Jakobsen7;Reference Fitzpatrick, Norquist, Reeves, Morris, Murray and Gregg12;Reference Kelly and Stoye15;24;Reference Koehoorn, McLeod, Fan, McGrail, Barer and Cote31;Reference Kelly and Stoye39;Reference Moscone, Siciliani, Tosetti and Vittadini41), other studies used treatment inequalities (Reference Kirkwood and Pollock16) and surgery volume (Reference Tulp, Kruse, Stadhouders and Jeurissen18). Hip and knee surgeries were performed more frequently in public hospitals (Reference Tulp, Kruse, Stadhouders and Jeurissen18). Increased use of private-sector provision was associated with a significant decrease in direct NHS provision with widening inequalities by age or socio-economic deprivation (Reference Kirkwood and Pollock16). Except for one study (Reference Koehoorn, McLeod, Fan, McGrail, Barer and Cote31), private facilities have shorter wait times than public clinics (Reference Andersen and Jakobsen7;Reference Fitzpatrick, Norquist, Reeves, Morris, Murray and Gregg12;Reference Kelly and Stoye15;Reference Moscone, Siciliani, Tosetti and Vittadini41). Patient satisfaction levels are higher for private clinics than public clinics (Reference Andersen and Jakobsen7;Reference Browne, Jamieson, Lewsey, van der Meulen, Copley and Black10). Public sector hospitals provided better information and more choice, whereas private-sector facilities offered a more comfortable, friendly, clean environment (Reference Perotin, Zamora, Reeves, Bartlett and Allen37)and more frequent surgeon visitation (Reference Naylor, Descallar, Grootemaat, Badge, Harris and Simpson32). Patients undergoing joint replacements in public hospitals more often reported complications (Reference Andersen and Jakobsen7;Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Naylor, Descallar, Grootemaat, Badge, Harris and Simpson32). We found mixed results for 30-day readmission dates and quality of life improvement after orthopedic surgeries. According to two study results, private hospitals had significantly lower rates for 30-day readmission than the public hospitals (Reference Holom and Hagen14;Reference Kelly and Stoye15), whereas three studies reported high readmission rates for private hospitals compared to the public ones (Reference Andersen and Jakobsen7;Reference Bannister, Ahmed, Bannister, Bray, Dillon and Eastaugh-Waring8;Reference Moscone, Siciliani, Tosetti and Vittadini41). The revision rates were higher in private facilities both for hip (Reference Harris, Cuthbert, Lorimer, de Steiger, Lewis and Graves13;Reference Tulp, Kruse, Stadhouders and Jeurissen18) and knee surgeries (Reference Harris, Cuthbert, Lorimer, de Steiger, Lewis and Graves13). Private facilities have shorter LOS than public facilities (Reference Siciliani, Sivey and Street36;Reference Street, Sivey, Mason, Miraldo and Siciliani40). A cost–utility study showed that with the purchase of private services, additional QALYs could be gained at an incremental cost of less than 40,000 2016 Australian Dollars (Reference Karnon, Haghighi, Sajjad, Yem, Gamage and Thorpe23). Patients in private facilities were healthier (Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Holom and Hagen14;Reference Kelly and Stoye15;Reference Street, Sivey, Mason, Miraldo and Siciliani40;Reference Moscone, Siciliani, Tosetti and Vittadini41)and younger (Reference Street, Sivey, Mason, Miraldo and Siciliani40) than those in public ones, had less severe preoperative symptoms (Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Heath, Ackerman, Holder, Lorimer, Graves and Harris43), and were more affluent (Reference Chard, Kuczawski, Black, van der Meulen and Committee11;Reference Street, Sivey, Mason, Miraldo and Siciliani40).
Discussion
In this review, we evaluated the three main dimensions of healthcare quality alongside efficiency and cost considerations: safety, clinical effectiveness, and patient experience (Reference Doyle, Lennox and Bell49). The results of the primary studies provide a mixed picture of the outcomes for private and public provision. Some results suggest that private-sector provision has a positive impact on public health system providers’ outcomes primarily due to competition (Reference Cooper, Gibbons and Skellern4), and higher degrees of competition are associated with greater improvements in quality (Reference Cooper, Gibbons, Jones and McGuire50). Studies also show the increased quality of care in hospitals located in more competitive areas than hospitals located in less competitive areas, without increased expenditures (Reference Cooper, Gibbons, Jones and McGuire50;Reference Gaynor, Moreno-Serra and Propper51). Although the evidence suggests that competition increases health system quality (Reference Gaynor, Moreno-Serra and Propper1), price regulation mechanisms are also important. Private surgical clinics generally refuse to disclose their financial statements, making it difficult to know the extent to which inappropriate or unnecessary surgeries occur in the private sector. Theoretical models show that when delivery side competition is combined with price regulation, wait times are reduced, and patient’s quality of care increases (Reference Propper52). Although the included studies used various methods, only four (Reference Holom and Hagen14;Reference Kelly and Stoye15;Reference Kelly and Stoye39;Reference Moscone, Siciliani, Tosetti and Vittadini41) applied causal inference methods rather than regression-based approaches with controls.
There is limited evidence that private-sector contracts within the publicly funded health system will address existing problems of capacity and waiting times in healthcare delivery. Even though there were statistically significant reductions in wait times for patients treated in private facilities in most studies, the evidence on the importance of wait times on patient preferences is controversial. A recent Australian study (Reference Gilbert, Keay, Palagyi, Do, McCluskey and White53) identified the five most important attributes that patients consider when making decisions about cataract surgery in an urban setting are surgical wait time, cost, travel time, hospital reputation, and surgeon experience. This qualitative study has two main limitations. First, it does not reflect the preferences of individuals seeking cataract surgery in rural areas of Australia. They may prioritize distance over surgical wait time. Secondly, non-English speaking participants’ results are different than those of English-speaking participants. Non-English-speaking participants indicated that they were content to wait for surgery on the condition that they did not have to pay (Reference Gilbert, Keay, Palagyi, Do, McCluskey and White53). As described above, the evidence so far remains mixed. Private-sector providers are expected to be more efficient due to their ability to treat patients more quickly, but some available evidence challenges this view (Reference Kruse, Stadhouders, Adang, Groenewoud and Jeurissen54–Reference Vengberg, Fredriksson and Winblad56). Even if private-sector providers treat more patients in a given time period, implications for the relative quality, cost-effectiveness, and efficiency of such services are unclear. Opponents of private-sector provision remain concerned that private centers would engage in patient selection strategies, cherry-picking, cream-skimming, and dumping (Reference Cooper, Gibbons and Skellern4).
Tynkkynen and Vrangbaek (Reference Tynkkynen and Vrangbaek20) conducted a scoping review on public and private provision in Europe, and included four of the same studies as this review (Reference Andersen and Jakobsen7;Reference Solborg Bjerrum, Mikkelsen and la Cour34;Reference Solborg Bjerrum, Kiilgaard, Mikkelsen and la Cour35;Reference Perotin, Zamora, Reeves, Bartlett and Allen37) as well as an overview of other systematic reviews (Reference Herrera, Rada, Kuhn-Barrientos and Barrios21). Their findings are partially consistent with ours. The authors found that although public hospitals treat patients with more comorbidities and complications who are older and more socioeconomically deprived, they consistently have better economic performance than the private ones. The review concluded that several studies addressing the economic effects of the private compared with the public provision of health care fail to consider quality and other operational dimensions, a critical blind spot that may influence results.
In an overview of systematic reviews, Herrera et al. (Reference Herrera, Rada, Kuhn-Barrientos and Barrios21) reviewed 5,918 studies to identify systematic reviews on the impact of different types of ownership on economic, administrative, and health-related outcomes. The authors analyzed nine systematic reviews and found that for-profit healthcare providers seem to have worse mortality outcomes than their not-for-profit and public counterparts. They concluded that substantial evidence gaps in the literature remain in the comparison between public and private-sector providers. The number of economic evaluation studies was considerably smaller, so future research could substantially contribute to the economic impacts of introducing private surgical facilities in publicly funded healthcare systems.
Limitations
This systematic review has several limitations. We have restricted our search to studies published after January 2000 and only included English language publications. Although limiting searches to English-only studies is common, this could cause “English-language bias” and limit the generalizability of the results. Also, detailed patient information such as ethnic group and case severity was not given in all included studies, even though this information is important to evaluate accessibility, patient selection issues, effectiveness of the treatment, and complications. Although this is a limitation of the evidence, rather than our study design, it does limit the conclusions that can be drawn. Finally, this study is limited to a relatively narrow set of procedures - future studies could be designed to evaluate other surgical interventions or systems with a broader mix of public and private healthcare delivery options to provide a broader perspective.
It is important to note that system structure and payment models have a role to play in determining how private providers participate in a given market, but this is outside of the aim of this review. Our aim is to identify evidence for differences in outcomes between public and private providers, given that a public payer commissions services from both public and privately operated care providers. Providing recommendations on how private capacity can be used in any given health system, payment models, or health system financing was out of scope, but could be valuable for future research.
Conclusions
The evidence we identified on accessibility, acceptability, safety, efficiency, and clinical effectiveness does not show a clear advantage of one delivery model over another. Rather there are strengths and weaknesses for both models. Decision-makers should take into account the evidence presented above and assess it against current and anticipated system needs when considering the role of private providers in publicly funded settings. The use of privately operated facilities to perform publicly funded services is sometimes proposed as an alternative way to deliver health care more efficiently in resource-constrained systems, though in our review the outcomes with the most limited evidence base were costs and cost-effectiveness. As economic arguments are often used in public debates on the use of private providers, further research on these outcomes is warranted.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/S0266462323000120.
Acknowledgements
Alberta Health Services had no input into the design or conduct of the review, interpretation of results, or decision to submit the manuscript for publication.
Funding
This work was in part supported by funding from Alberta Health Services (Research Funding Agreement between IHE and AHS, 1 April 2018 to 31 March 2021, IHE grant number: 11–038).
Competing interest
None.
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