Analysing the results of the program of intervention in ophthalmology.
Researcher: Gisele Braun
Waiting lists’ management – a painful problem
The management of waiting lists is a problem to be solved in many countries with National Health Service (NHS). The waiting time for treatment can be quite long. In Spain, for example, the waiting time for knee or hip replacement surgery may take up to six months. Waiting lists are very important for the evaluation of the NHS as a whole. They are easily judged by the citizens and reflect the result of the combination of investment, productivity and health status of the population. Short-term programs, with the aim of reducing waiting lists through the financing of extra activity, have been commonly used in European countries with NHS. The Programa Específico de Resolução de Lista de Espera, the Programa de Promoção de Acesso and the Programa Especial de Combate às Listas de Espera Cirúrgicas are examples of such programs in Portugal. They were implemented in the late 90's and early 2000. However, the results were below expectations as regards the effective reduction of waiting lists and waiting times.
Ophthalmology – a critical area identified
The Portuguese Sistema Integrado de Gestão de Inscritos para Cirurgia, a system for managing surgery waiting lists, was created in 2004, aiming to improve the management of waiting lists for consultations and surgical procedures. Among the several indicators that can be obtained, the data related to ophthalmology services require special attention given their low quality when compared to other European countries.
Among the reasons for the shortage of supply, we can list the limited number of doctors, the low levels of productivity and poor management of health facilities as the main factors, whereas ageing population associated with a greater awareness of the technological developments and facilities available to correct sight problems are responsible for the constant increase in the demand for health care. In fact, the cataract is an eye condition that can drastically reduce the quality of life and even lead to blindness if not treated properly.
The Program of Intervention in Ophthalmoloy or Programa de Intervenção em Oftalmologia (PIO), conducted between 2008 and 2009, was designed precisely to reduce the size of the list and waiting time for access to eye care.
The public intervention program under different lenses
Previous evaluations of the program included descriptive analyses that didn´t apply specific statistical techniques to evaluate it. The analysis from Administração Central do Sistema de Saúde (ACSS) focused exclusively on the volume of hospital activity after the completion of the program (with some intermediate evaluations). This analysis concluded to the success of the program. On the other hand, the national Tribunal de Contas evaluated the program as not satisfactory, given that the final records have not reached the minimum targets set in the program.
However, none of these reviews provides an economic analysis of the program, which was performed in the study, which constitutes a chapter of Gisele Braun’s doctoral thesis advised by Professor Pedro Pita Barros, and defended in December 2014 at Nova SBE.
After analysing the data, the study provides evidence of success of the program. The results reveal a statistically significant impact of the PIO on the volume of first consultations and eye-related surgical procedures and also on the mean waiting time for these health care services. Furthermore, there is a longer term impact of the programme on mean waiting time to receive medical care.
A richer methodology, improved policy decisions
The databases analysed, Diagnosis-Related Groups and Lista de Inscritos para Cirurgia, were provided by the ACSS. The information used includes the episodes between the years 2006 to 2010. These data were organized into two panels, in order to isolate fixed effects over time, which could change the size of waiting lists or waiting time on the list, but which are not direct consequences of ophthalmology program.
The estimated coefficients indicate a positive impact of PIO on the average number of surgeries performed each month of the program. These results are robust to the inclusion of annual dummies and control variables of the characteristics of hospitals.
For the analysis of the average waiting time, the PIO has a negative impact, as expected, for the period in which the program was active, and also for the months following completion of the PIO. We also estimated models of simultaneous equations to accommodate the fact that random forces may affect the level of activity and the waiting time simultaneously (the results were essentially the same).
Previous analyses have been insufficient from the economic point of view to assess the health benefits from the public health spending. By adding other variables and incorporating the randomness of the data this study can contribute to inform on better policy decisions such as the decision for a next intervention program.