Hospital quality interdependence in a competitive institutional environment: Evidence from Italy

In this paper we explore the geographical scope of hospital competition on quality, using Italian data on over 207,000 patients admitted to 174 hospitals located in the Lombardy region in the years 2008–2014. We propose an economic framework that incorporates both local and global forms of quality competition among hospitals, the latter emerging from periodically released hospital performance rankings. Under this framework, we derive the hospital reaction functions and, accordingly, we characterize the structure of interdependence among hospital qualities. We employ recent methods from the graphical modelling literature to estimate the set of local rivals for each hospital, as well as the degree of global interdependence among hospitals. Consistently with our micro-founded framework, our results show a significant positive degree of short- and long-range dependence, suggesting the existence of forms of local and global competition amongst hospitals with relevant implications for health care policy.