Hospital Management Models and Cancer Care Outcomes in Brazil: Evidence From a Staggered Difference-in-Differences Study in São Paulo.

Abstract

Background: The state of São Paulo pioneered the adoption of Social Health Organisations (SHOs) under Complementary Law No. 846/1998 that would allow private non-profit organisations to manage hospitals and health services under government contracts with the aim of gaining efficiency and improving quality of care. Our study evaluates whether the management of hospitals by SHOs is associated with improvements in system performance for patients diagnosed with breast, prostate and colorectal cancer.

Methods: We analysed 652,734 registered breast, prostate, and colorectal cancer cases diagnosed from 2000 to 2023 across an 80-hospital analytic roster. The primary staggered difference-in-differences analysis compared SHO adopters with directly administered public hospitals, used hospital-quarter observations with equal hospital weighting, and applied outcome-specific mortality follow-up restrictions.

Results: The restricted primary analyses included 23-24 public hospitals, depending on the outcome. SHO adoption was associated with imprecise changes in diagnosis-to-treatment time (-155.3 days; 95% CI -350.0 to 39.4), consultation-to-diagnosis time (-96.3 days; 95% CI -237.7 to 45.1), 30-day mortality (0.8 percentage points; 95% CI -4.0 to 5.5), 1-year mortality (2.5 percentage points; 95% CI -21.7-26.8), and 5-year mortality (29.6 percentage points; 95% CI -3.6 to 62.8). Estimates changed materially with the control group and weighting approach.

Conclusion: The study did not provide precise evidence that SHO adoption improved cancer-care processes or mortality. However, the small number of hospitals, incomplete long-term follow-up, sensitivity to weighting and control definitions, and the inability to estimate a joint pre-trends test mean that clinically important effects in either direction cannot be excluded.