Referral of Paediatric Patients Follows Geographic Borders of Administrative Units

Dan Med Bul ϧϪ/Ϩ June ϤϢϣϣ DANISH MEDICAL BULLETIN ϣ Referral of paediatric patients follows geographic borders of administrative units Poul-Erik Kofoed1, Erik Riiskjær2 & Jette Ammentorp3 ABSTRACT e ffect of economic incentives rooted in local govern- ORIGINAL ARTICLE INTRODUCTION: This observational study examines changes ment’s interest in maximizing the number of patients 1) Department in paediatric hospital-seeking behaviour at Kolding Hospital from their own county/region who are treated at the of Paediatrics, in The Region of Southern Denmark (RSD) following a major county/region’s hospitals in order not to have to pay the Kolding Hospital, change in administrative units in Denmark on 1 January higher price at hospitals in other regions or in the pri- 2) School of 2007. vate sector. Treatment at another administrative unit is Economics and MATERIAL AND METHODS: Data on the paediatric admis- Management, usually settled with 100% of the diagnosis-related group University of sions from 2004 to 2009 reported by department of paedi- (DRG) value, which is not the case for treatment per - Aarhus, and atrics and municipalities were drawn from the Danish formed at hospitals within the same administrative unit. 3) Health Services National Hospital Registration. Patient hospital-seeking On 1 January 2007, the 13 Danish counties were Research Unit, behaviour was related to changes in the political/admini s- merged into five regions. The public hospitals hereby Kolding Hospital/ trative units. Changes in number of admissions were com- Institute of Regional became organized in bigger administrative units, each pared with distances to the corresponding departments. Health Services with more hospitals than in the previous counties [7]. If RESULTS: From 2006 to 2009, the number of acute and Research, University of the political paradigm holds true that patients are cap- Southern Denmark planned admissions at the Department of Paediatrics in able of evaluating the quality of the health services and Kolding for children living in the RSD increased by 46.1% are aware of their right to select the hospital at which Dan Med Bul and 65.0%, respectively. The corresponding changes for 2011;58(6):A4281 children living in the neighboring region, the Central Den- they wish to be treated [8], one would expect no change mark Region, were –69.9% and –78.6%. in patients’ hospital-seeking behaviour following the CONCLUSION: The geographical location of the department change in administrative borders. under study and the changes in administrative units created The Department of Paediatrics at Kolding Hospital is a “natural experiment” that showed major changes in pae di- situated near the old borders of the three counties of atric hospital-seeking behaviour. Within the RSD, the free Sønderjylland, Ribe and Fyn, which were merged with choice of hospitals seemed to work, whereas the new bound- the southern part of Vejle County to form The Region of ary between The Central Denmark Region (CDR) and the RSD Southern Denmark (RSD). Moreover, the Department meant that paediatric patients were admitted at hospitals lies just south of the border between the new regions situated in the CDR even though the distances to these hos- RSD and The Central Denmark Region (CDR) (Figure 1). pitals were considerably longer than those to other hos- Approximately 30% of the population traditionally pitals. One could question whether patients really have a ser ved by the Department lived in the northern part of free choice across administrative borders as political and the County of Vejle, i.e. within the municipalities of economic concerns seemed to outweigh free patient choice. Horsens and Hedensted, which became a part of the FUNDING: not relevant. CDR. Furthermore, the former municipality of Christians- TRIAL REGISTRATION: not relevant. feld, previously situated in the County of Sønderjylland, became a part of Kolding municipality, which belonged to the County of Vejle (Figure 1, Figure 2). This geo- Treatment at public Danish hospitals is free of charge gra phical location combined with the change in admini- and the patients are entitled to choose the hospital (at strative units created a ‘‘natural experiment’’ in which a the same level of specialization) at which they wish to possible influence of economic/political priorities on be treated [1]. A comparative study of the three Scandi- paediatric hospital-seeking behaviour could be studied navian countries found that only few patients had actu- in an observational study [9]. ally chosen their hospital themselves despite of the fact that only few formal, legislative and economic barriers MATERIAL AND METHODS exist [2]. Previous studies indicate that distance is an The study was performed in the RSD at the Department important factor determining patients’ choice of hos- of Paediatrics at Kolding Hospital. pital [3-6]. However, other factors may be at play, e.g. Before 2007 each of the four counties combined to Ϥ DANISH MEDICAL BULLETIN Dan Med Bul ϧϪ/Ϩ June ϤϢϣϣ form the RSD had one department of paediatrics. four counties in general, and in the County of Sønder- Patients had the right to choose a department in the jylland in particular. neighbouring county. After the creation of the new The number of acute and planned paediatric admis- regions, the RSD thus had four paediatric departments, sions in the RSD reported by departments of paediatrics and the patients were also free to select any of these or and the municipalities were drawn from “eSundhed”, any other department outside the RSD (at the same which is a part of the Danish National Hospital Regi s- level of specialization). There are no private hospitals tration [10]. We obtained data from three years before with in-patient paediatric services in the area. Kolding to three years after the reform, viz. 2004-2009. Hospital was located in the former County of Vejle. All residents and newborns in Denmark are given a Before the formation of the Danish regions, physicians unique 10-digit person identification number (CPR and patients were loyal towards their own county in all number) [11]. The CPR number was used to define the number of individual children admitted each year. The total population divided according to age groups and per municipality was registered from Statistics Denmark FIGURE 1 [12]. Distances to the departments of paediatrics were Before the reform. The four counties estimated as the distance from the centre of the muni- before they were merged to form the cipalities using the Krak internet site [13]. Region Southern Denmark with the department of paediatrics located in Kolding, Esbjerg, Sønderborg and Odense. Trial registration: not relevant. As from January 1 2007 Christiansfeld (shaded), which was previously situated in the County of Sønderjylland, became RESULTS part of the new Kolding Municipality. Table 1 shows the number of all acute paediatric admissions at the Department of Paediatrics at Kolding Hos- Vejle pital and at the three other paediatric departments in Ribe the RSD. From 2006, i.e. the last year before the new re- Kolding Esbjerg Odense gions were established, to 2009, the number of admissions at the Department in Kolding rose by 46.1% (from Fyn 3,376 to 4,931 admissions) for children living in the RSDAt the other departments, the number only rose Sønderjylland Sønderborg by 11.4% (from 11,398 to 12,698 admissions). The number of admissions to the department in Kolding of children from the CDR fell from 1,275 to 384 (69.9%). At the three other paediatric departments, the number increased slightly by 6.6% (from 243 to 259 admis- FIGURE 2 sions). From 2006 to 2009, the number of planned admis- After the reform. Region Southern sions at the Department in Kolding for children living in Denmark (light shaded) and Central Denmark Region (dark shaded) including the RSD increased by 65.0% (from 360 to 594 admis- the location of the paediatric depart- Randers sions), while at the three other paediatric departments ments. The two municipalities Horsens in the region, the number decreased by 5.2% (from and Hedensted previously situated in the County of Vejle became part of the 1,763 to 1,671 admissions) (Table 2). During the same Aarhus Central Denmark Region. Kolding’s period, the number of planned admissions to the Depart- neighbouring municipalities Vejen (previously Ribe County), Haderslev ment in Kolding of children from the CDR diminished by (previously Sønderjylland County) and Horsens 78.6% (from 159 to 34). Middelfart (previously Fyn County) Hedensted With regard to patients from Christiansfeld (located are indicated. in the former County of Sønderjylland) and from Kold- Esbjerg Kolding ing’s three neighboring municipalities (Vejen in the Vejen Middelfart Odense former County of Ribe, Haderslev in the former County Haderslev of Sønderjylland and Middelfart in the former County of Fyn), the number of admissions at the Department of Sønderborg Paediatrics in Kolding rose from 487 in 2006 to 828 in 2007, to 1,037 in 2008 and to 1,394 in 2009 (a total increase of 186.2%). For comparison, the corresponding numbers of all paediatric admissions of children from Dan Med Bul ϧϪ/Ϩ June ϤϢϣϣ DANISH MEDICAL BULLETIN ϥ the RSD were 16,897, 18,907, 18,634 and 19,894, re- TABLE 1 spectively (a total increase of 17.7%). From 2004 to 2006, approximately 22% of all Acute paediatric admissions in The Region of Southern Denmark and for all children at the Department of Paediatrics at Kolding Hospital and at the three other paediatric departments in The Region of South- paediatric admissions of children living in the RSD took ern Denmark. place at the Department of Paediatrics in Kolding. This Children from RSD Children from CDR All admissions increase d to 24.1% in 2007, to 26.4% in 2008 and to KH1 other2 all3 KH1 other2 all3 KH1 other2 all3 28.1% in 2009 (an increase of 27.7%).

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