COYNE VERSUS MESSINA 1

Coyne Vs. Messina

Dayron Elias

Grand Canyon University

HLT-540

06/06/18
COYNE VERSUS MESSINA 2

Coyne Vs. Messina

In complex systems it is generally difficult if not impossible to find a direct correlation

between one specific variable and another. Such is the case in healthcare, particularly in

hospitals, which are not only extremely sophisticated organizations as individual entities but vary

greatly from one installation to the next. Hospital size, hospital ownership type, clientele,

location, types of services offered and designation as a teaching or non-teaching hospital all are

confounding variables even when trying to calculate the simplest relationships such as a possible

correlation between hospital size and patient outcome, or hospital ownership type and efficiency

as measured against industry averages. Both “Hospital Cost and Efficiency: Do Hospital Size

and Ownership Type Really Matter” by Coyne & et al., and “The Relationship Between Inpatient

Admissions across Teaching and Non-Teaching Hospitals” by Messina & et. al., attempt to

quantify the relationship between several of the measures mentioned above in order to help to

better inform healthcare executives, particularly when questions such as hospital mergers,

construction, and designation as teaching faculties is concerned. Both papers are relatively well

supported but illustrate in detail the difficulty in ascertaining the actual performance of a hospital

and underscore the need to continue to study the problem of hospital performance in the future so

that patient outcomes and satisfaction can be optimized at the best possible cost for the providers.

The two studies do not ask nor answer the same questions. Coyne’s study asks, “Do size

and ownership type make a difference in the efficiency and cost results of hospitals in

Washington state?” (2009, p. 163). Messina on the other hand asks two questions, “First, what is

the nature of the relationship between patient satisfaction (as measured by scored instruments)
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and inpatient admissions in acute care hospitals? Second, does the relationship between patient

satisfaction (as measured by scored instruments) and inpatient admissions differ between

teaching hospitals and nonteaching hospitals?” (2009, p. 177). These are very different concepts,

and very different locales since Messina’s study took place in a small number of hospitals in

New Jersey (Messina, Scotti, Driscoll & et al., 2009). Both studies are relatively small in

participants, and thus may or may not be generalizable. This fact however, is noted in both

papers. That being said, these two papers do relate to one another because the sets of variables

measured in the studies interact with each other, even if there is not a direct correlation measured

by either Coyne or Messina.

Coyne’s study was built on a previous study conducted to evaluate efficiency using two

cost-measures between multi-unit and single-facility hospitals (2009). The research cited by

Coyne indicated that although a variety of variables had been measured, the association between

hospital size and ownership type and efficiency was still poorly understood. This was the

rationale for the follow-up work presented in 2009. Messina grounds the basis for study in the

evolution of healthcare in the 1980’s when hospitals could no longer simply increase the price of

services to produce revenue, but had to learn to control costs a well (Messina, 2009). According

to Messina, it was at this point that executives became interested in patient satisfaction and its

relationship to revenue, particularly as represented by admissions volume (Messina, 2009). The

idea of correlating patient satisfaction with hospital revenue has continued, as evidenced by

additional, studies that have been performed since 2009 such as Kerry Ellis’s “A Quantitative,

Correlational Study on the Impact of Patient Satisfaction on a Rural Hospital” (Ellis, 2011).

Since the two papers were not answering the same question, it is logical that they also did

not have the same set of variable. In both studies, the independent variables were categorical. For
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Coyne they were the type of hospital ownership and the size of the hospital in questions, and for

Messina they were teaching and non-teaching hospitals (2009, 2009). Messina however, added a

second independent variable, patient satisfaction scores, that vary continuously (2009). In all

cases, the dependent variables were continuous. Coyne measured five different efficiency and

five different cost ratios, while Messina measured the ration between patient satisfaction and

admissions volume and then further evaluated whether there was a statistically relevant

difference in this ratio between teaching and non-teaching hospitals (2009, 2009). The sample

size for Coyne was 96 institutions, spilt roughly evenly into small, middle, and large sized

hospitals (2009). There is an admission here that the sample size is not sufficient, and in

particular may not adequately represent the variation in large sized hospitals >150 beds (Coyne,

2009). The sample size for Messina is even smaller, with only 14 total hospitals involved, seven

each of teaching and non-teaching (2009). As mentioned above, this does give some cause for

concern when the results are generalized. Neither experiment used a control group, although in

this sort of comparative study the lack there of is not a particular problem. In both cases, the

studies provided adequate support for the measurement criteria, which should be deemed both

reliable and valid. Coyne had a greater depth of resources from which to choose, at least judging

by the works cited (Coyne, 2009). Statistically, both used the standard p-value testing to ascribe

statistical significance, with Coyne using 2-way variance (ANOVA) and Messina used the

Spearman coefficient of rank-order correlation to generate the data (2009, 2009).

Both studies seemed to reach appropriate conclusions. Coyne found that both size and

ownership correlated with efficiency (Coyne, 2009). In general, not-for-profits were deemed

more efficient or at least developed better efficiency scores statistically than government run

hospitals (Coyne, 2009). Larger not-for-profit hospitals seemed to have an efficiency advantage
COYNE VERSUS MESSINA 5

as well (Coyne, 2009). In terms of cost efficiency, Medium sized hospitals had the advantage.

With acceptable p values listed for each assertion, the conclusions are not suspect excepting for

the previously mentioned problem with sample size and diversity which might have led to some

inadvertent selection bias (Coyne, 2009). Messina makes equally well-reasoned assertions. The

study found that there was no support for a correlation between admissions volume and customer

satisfaction in non-teaching hospitals. In fact, the data weakly suggested that there might be a

negative correlation between increased admissions and patient experience surveys (Messina,

2009). In teaching hospitals however, there was a statistically relevant positive correlation

between patient satisfaction surveys and hospital admissions (Messina, 2009). Once again these

findings are supported by adequate p values. The weakness in the Messina study is that there is

not a particularly adequate hypothesis as to why this is so. This may not be a significant concern,

since the Messina group admits that future studies are still required, as does the Coyne group

(2009, 2009).

As previous studies by Magnussen in 1998 and later studies by Ellis in 2011 have shown,

the correlation between hospital environment, patient outcomes, and efficiency and profit has

been and will most likely continue to be studied for many years (Magnussen, 1998, & Ellis,

2011). What is important to note here, is that the interplay between hospital type, teaching

designation, efficiency, cost control and overall patient satisfaction is dynamic and multi-

factorial. No one study can inform a healthcare executive on the direction in which to take his or

her organization. What these studies and others like them suggest is that each hospital is a

dynamic entity that must be evaluated in situ. Although there both Coyne and Messina found

correlational between the variables in their studies, there still exist far too many confounding

variables to present the results as definitive. Further, when the correlation between revenue and
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patient satisfaction is also considered, as it was by Ellis, yet another dimension of complexity is

added. In any event, all are valued studies and if successful in no other way, indicate the need for

more evaluation.
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References

Coyne, J. S., Richards, M.T., Short, R., Shultz, K. & Singh, S. (2009). Hospital Cost and

Efficiency: Do Hospital Size and Ownership Type Really Matter? Journal of Healthcare

Management, 54(3), 163.

Ellis, K. M. (2011). A quantitative, correlational study on the impact of patient satisfaction on a

rural hospital (Order No. 3533764). Available from ABI/INFORM Collection; ProQuest

Dissertations & Theses Global. (1223517188). Retrieved from

http://ezproxy.library.unlv.edu/login?url=https://search.proquest.com/docview/12235171

88?accountid=3611

Mobley L.R. & Magnussen, J. (1998). An international comparison of hospital efficiency: does

institutional environment matter?, Applied Economics, 30:8, 1089-1100, DOI:

10.1080/000368498325255

Messina, D.J., Scotti, D.J., Driscoll, A.E., Ganey, R. & G.P. Zipp. (2009) The Relationship

Between Inpatient Admissions across Teaching and Non-Teaching Hospitals. Journal of

Healthcare Management, 54(3), 177-190.