Causal Variance Decompositions for Evaluating Healthcare Provider Performance

There has been a growing interest in striving for accountability and transparency in healthcare by quantifying and comparing the performance of providers. This requires measuring the quality of care provided to patients, which is often done using disease-specific quality indicators (QIs). Before considering intervening and improving quality gaps identified by using QIs, the chosen indicator has to demonstrate existing differences in the quality of care. Therefore, the overarching aim of this thesis is to develop metrics that assess the usefulness of QIs in identifying existing differences in the quality of care provided between providers. This can be achieved by decomposing and quantifying the overall variation between providers in a causal inference framework. The first objective is to develop a three-way causal variance decomposition to attribute observed variation in care received into that causally explained by hospitals’ performance, the patient case-mix itself, and unexplained variation. In the context of surgical cancer treatments, the performance variations can be due to hospital and/or surgeon level differences, creating a hierarchical clustering. The second objective is to generalize the causal variance decomposition for several exposure hierarchies. For this purpose, I derive a decomposition of the observed variation in care received into four parts, explained by patient case- mix, causally explained by hospitals’ performance, causally explained by surgeons’ performance, and unexplained variation. While the use of variance decompositions can demonstrate differences in quality of care, causal mediation analysis can be used to investigate the care pathways that lead to these differences in performance between hospitals. Combining these two approaches enables decomposing between-hospital variation in an outcome-type indicator into two parts: the part that is mediated through a specific process of care and the part that is due to all other pathways. The third objective is to derive a causal mediation analysis decomposition of the between-hospital variance into three parts, the natural indirect effects, the natural direct effects, and a covariance-type term. Model-based estimators are formulated for the variance decompositions, and their performance are investigated through simulation studies. All methods are demonstrated in real data applications in Ontario kidney cancer data.

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