Organizational influences on diabetes related hospitalization
Degree GrantorUniversity of Canterbury
Degree NameDoctor of Philosophy
This thesis develops the concept of managerialism in health care through the investigation of patterns of diabetes related hospitalization. It is argued that individual health care behaviour is conditioned by the organizational and societal frameworks in which care is sought and used. Two dominant themes are investigated: firstly, the applicability of Roemer's Law of supply induced demand in explaining area variations in hospital use; and secondly, organizational influences on hospital utilization via doctor gate-keeping functions and interaction between available health services. These are respectively studied at the regional and local levels. These themes are explored through a case study of the disorder Diabetes Mellitus. Diabetes is a chronic health problem which through its complications leads to increased levels of morbidity and premature death. The philosophy of diabetes care and the allocation and organization of resources to diabetes are identified, and a methodology for measuring diabetes related hospitalization developed. Considerable variation was found to occur between regional hospital board populations in their rates of hospitalization for diabetes. Positive relationships were observed between per capita rates of diabetes hospitalization and area hospital bed supplies, even after controlling for differences in socio-demographic characteristics of the area populations. These results confirm the existence of Roemer's Law in diabetes hospitalization. The impact of the organization of health services on patterns of hospitalization at the local level was examined through the establishment of the population based Canterbury Register of Insulin Treated Diabetic (ITDM) Persons. This provided essential epidemiological data and facilitated the measurement of hospitalization of this diabetic population over the three year period 1 January 1984 to 31 December 1986. Considerable heterogeneity was observed in the characteristics of the ITDM individuals admitted to hospital during the study period. Admission spanned all age groups and durations of diabetes. Hospitalization was prompted by a spectrum of conditions with a significant proportion being caused by the potentially preventable acute disorders of diabetes control. Hospital utilization by the Canterbury ITDM population was mediated through the referral system operating between primary care, community based diabetes educational, specialist diabetes outpatient clinical, and hospital inpatient services. General practitioners were the main gatekeepers to care. Patterns of hospitalization varied by individual patient characteristics, general practitioner characteristics, and patient attendance at specialist ambulatory diabetes services.