Essays on quality of care: economic and public health approaches.

Summary This thesis examines several issues related to the quality of hospital care through the disciplinary prisms of economics and public health.The first chapter introduces the notion of quality of care in public health and economics. An examination of the traditional treatment of this notion in the two disciplines highlights the convergence of the definitions of quality of care proposed and the complementarity of the approaches to regulation promoted by the two disciplines.Competition at fixed prices, such as that induced by activity-based pricing, should lead to an improvement in the quality of care if demand is sensitive to quality. In the second chapter, we use data on the public dissemination of hospital rankings to estimate the elasticity of demand for care with respect to quality, for the public and private sectors, based on a panel of French hospitals and for several clinical situations. We show an impact of the rankings on the activity of private hospitals, for one of the clinical situations considered. On the other hand, the demand on the public sector does not seem to be influenced by the publication of the rankings. These results question the hypothesis of competition in quality in the public sector in France. The third chapter focuses on the cost of strategies for the control of nosocomial infections, from a hospital perspective. We evaluated the costs associated with interventions promoting general hygiene measures or targeted screening for multidrug-resistant bacteria in two European multi-center clinical trials in intensive care and surgery. Our results highlight the greater variability in costs for comprehensive promotion strategies and, for interventions shown to be effective in these studies, a cost of implementation consistent with the assumption that these interventions are cost-effective.