Congestion analysis to evaluate the efficiency and appropriateness of hospitals in Sicily

Applications of data envelopment analysis in acute care hospitals: a systematic literature review, 1984-2022

This study reviews scholarly publications on data envelopment analysis (DEA) studies on acute care hospital (ACH) efficiency published between 1984 and 2022 in scholarly peer-reviewed journals. We employ systematic literature review (SLR) method to identify and analyze pertinent past research using predetermined steps. The SLR offers a comprehensive resource that meticulously analyzes DEA methodology for practitioners and researchers focusing on ACH efficiency measurement. The articles reviewed in the SLR are analyzed and synthesized based on the nature of the DEA modelling process and the key findings from the DEA models. The key findings from the DEA models are presented under the following sections: effects of different ownership structures; impacts of specific healthcare reforms or other policy interventions; international and multi-state comparisons; effects of changes in competitive environment; impacts of new technology implementations; effects of hospital location; impacts of quality management interventions; impact of COVID-19 on hospital performance; impact of teaching status, and impact of merger. Furthermore, the nature of DEA modelling process focuses on use of sensitivity analysis; choice of inputs and outputs; comparison with Stochastic Frontier Analysis; use of congestion analysis; use of bootstrapping; imposition of weight restrictions; use of DEA window analysis; and exogenous factors. The findings demonstrate that, despite several innovative DEA extensions and hospital applications, over half of the research used the conventional DEA models. The findings also show that the most often used inputs in the DEA models were labor-oriented inputs and hospital beds, whereas the most frequently used outputs were outpatient visits, followed by surgeries, admissions, and inpatient days. Further research on the impact of healthcare reforms and health information technology (HIT) on hospital performance is required, given the number of reforms being implemented in many countries and the role HIT plays in enhancing care quality and lowering costs. We conclude by offering several new research directions for future studies.

COVID-19 health policy evaluation: integrating health and economic perspectives with a data envelopment analysis approach

The COVID-19 pandemic is a global challenge to humankind. To improve the knowledge regarding relevant, efficient and effective COVID-19 measures in health policy, this paper applies a multi-criteria evaluation approach with population, health care, and economic datasets from 19 countries within the OECD. The comparative investigation was based on a Data Envelopment Analysis approach as an efficiency measurement method. Results indicate that on the one hand, factors like population size, population density, and country development stage, did not play a major role in successful pandemic management. On the other hand, pre-pandemic healthcare system policies were decisive. Healthcare systems with a primary care orientation and a high proportion of primary care doctors compared to specialists were found to be more efficient than systems with a medium level of resources that were partly financed through public funding and characterized by a high level of access regulation. Roughly two weeks after the introduction of ad hoc measures, e.g., lockdowns and quarantine policies, we did not observe a direct impact on country-level healthcare efficiency, while delayed lockdowns led to significantly lower efficiency levels during the first COVID-19 wave in 2020. From an economic perspective, strategies without general lockdowns were identified as a more efficient strategy than the full lockdown strategy. Additionally, governmental support of short-term work is promising. Improving the efficiency of COVID-19 countermeasures is crucial in saving as many lives as possible with limited resources.

Financial Performance and Profile of Brazilian Hospitals

The literature on data envelopment analysis (DEA) of hospital efficiency has used absolute data to approach financial and operating indicators, either separate or combined. This study stratifies a sample of Brazilian hospitals using financial and operating indicators to investigate their performance, based on financial liquidity ratios and levels of indebtedness against their profitability and return on investments. The models obtained in the analysis show that the level of indebtedness and the operating margin are determinants of efficiency, but they may be overrun by debt capital and return on investments, depending on installed capacity.

Inequality in Healthcare Utilization in Italy: How Important Are Barriers to Access?

With the ageing population, equitable access to medical care has proven to be paramount for the effective and efficient management of all diseases. Healthcare access can be hindered by cost barriers for drugs or exams, long waiting lists or difficult access to the place where the needed healthcare service is provided. The aim of this paper is to investigate whether the probability of facing one of these barriers varies among individuals with different socio-economic status and care needs, controlling for geographical variability.

METHODS

The sample for this study included 9629 interviews with Italian individuals, aged 15 and over, from the second wave (2015) of the European Health Interview Survey, which was conducted in all EU Member States. To model barriers to healthcare, two-level variance components of logistic regression models with a nested structure given by the four Italian macro-areas were considered.

RESULTS

Of the barriers considered in this study, only two were found to be significantly associated with healthcare utilization. Specifically, they are long waiting lists for specialist service accessibility (adjOR = 1.20, 95% CI (1.07; 1.35)) and very expensive exams for dental visit accessibility (adjOR = 0.84, 95% CI (0.73; 0.96)). Another important result was the evidence of an increasing north-south gradient for all of the considered barriers.

CONCLUSION

In Italy, healthcare access is generally guaranteed for all of the services, except for specialist and dental visits that face a waiting time and financial barriers. However, barriers to healthcare were differentiated by income and sex. The north-south gradient for healthcare utilization could be explained through the existing differences in organizational characteristics of the several regional healthcare services throughout Italy.

The efficiency of provincial government health care expenditure after China's new health care reform

OBJECTIVE

We aim to estimate the total factor productivity and analyze factors related to the Chinese government's health care expenditure in each of its provinces after its implementation of new health care reform in the period after 2009.

MATERIALS AND METHODS

We use the Malmquist DEA model to measure efficiency and apply the Tobit regression to explore factors that influence the efficiency of government health care expenditure. Data are taken from the China statistics yearbook (2004-2020).

RESULTS

We find that the average TFP of China's 31 provincial health care expenditure was lower than 1 in the period 2009-2019. We note that the average TFP was much higher after new health care reform was implemented, and note this in the eastern, central and western regions. But per capita GDP, population density and new health care reform implementation are found to have a statistically significant impact on the technical efficiency of the provincial government's health care expenditure (P<0.05); meanwhile, region, education, urbanization and per capita provincial government health care expenditure are not found to have a statistically significant impact.

CONCLUSION

Although the implementation of the new medical reform has improved the efficiency of the government's health expenditure, it is remains low in 31 provinces in China. In addition, the government should consider per capita GDP, population density and other factors when coordinating the allocation of health care input.

SIGNIFICANCE

This study systematically analyzes the efficiency and influencing factors of the Chinese government's health expenditure after it introduced new health care reforms. The results show that China's new medical reform will help to improve the government's health expenditure. The Chinese government can continue to adhere to the new medical reform policy, and should pay attention to demographic and economic factors when implementing the policy.

Multilevel Analysis of the Relationship between Ownership Structure and Technical Efficiency Frontier in the Spanish National Health System Hospitals

Objective: To evaluate the relationship between the ownership structure of hospitals and the possibility of their being positioned on the frontier of technical efficiency in the economic crisis period 2010–2012, adjusting for hospital variables and regional characteristics in the areas where the Spanish National Health System (SNHS) hospitals are located. Methods: 230 National Health System hospitals were studied over the two-year period 2010–2012 according to their ownership structure—public hospitals, private hospitals and public–private partnership (PPP)—data envelopment analysis orientated to inputs was used to measure the overall technical efficiency, pure efficiency and efficiency of scale. A generalised linear mixed model (GLMM) with binomial distribution and logit link function was used to analyse the hospital and regional variables associated with positioning on the frontier. Results: There are substantial differences between the average pure technical efficiency of public, private and PPP hospitals, as well as a greater number of PPP models being positioned on the efficiency frontier (91.67% in 2012). The odds of being positioned on the frontier are 41.7 times higher in PPP models than in public hospitals. The average annual household income per region is related to the greater odds of hospitals being positioned on the frontier of efficiency. Conclusions: During the most acute period of recession in the Spanish economy, PPP formulas favoured hospital efficiency, by increasing the odds of being positioned on the frontier of efficiency when compared to private and public hospitals. The position on the frontier of efficiency of a hospital is related to the wealth of its region.

Assessing the Efficiency of Health-care Facilities in Sub-Saharan Africa: A Systematic Review

Background:

The provision of health-care services is dependent on the effective and efficient functioning of various components of a health-care system. It is therefore important to evaluate the functioning of these various components. Hence, the aim of this study was to review studies on health-care facilities efficiency in sub-Saharan Africa (SSA) with respect to the methodologies used as well as outcomes and factors influencing efficiency.

Methods:

The review was conducted through a comprehensive search of electronic databases which included PubMed, Web of science, academic search complete via EBSCOhost, Science Direct, and Google scholar. A search was also conducted by looking into citations in the reference list of selected articles and through gray literature. Studies were screened by examining their titles, abstracts, and full-text based on stated inclusion and exclusion criteria. The concurrent screening and data extraction were conducted by the two authors.

Results:

A total of 40 studies were shortlisted for the review. The majority (90.0%) of the studies employed the data envelopment analysis technique for their efficiency measurements. The input and output variables utilized by most of the studies were predominantly human resources and health-related services respectively. The outcome from majority of the studies showed that less than 40% of the studied facilities were efficient. The leading influencing factors reported by the studies were catchment population, facility ownership, and location.

Conclusions:

The review showed that there was a marked degree of inefficiency across the health-care facilities. Consequently, due to severe resource constraints facing SSA, there is a need to determine how to use the available resources optimally to improve health systems performance.

Assessment of technical efficiency of public hospitals in Turkey

BACKGROUND

Turkish public hospitals have been subjected to health care reform because of increasing cost pressure, inequities in access to health care, poor quality of care and limited patient responsiveness in the last three decades. This study investigates the impact of recent hospital reforms on the efficiency of public hospitals.

METHODS

The study provides a comprehensive evaluation of the efficiency of Turkish hospitals by using Data Envelopment Analysis (DEA). The estimation of efficiency of 669 public hospitals of Turkey is performed by an output-oriented model of DEA under the assumption of variable return-to-scale by using data collected from the Ministry of Health (MoH) over the period 2013-17.

RESULTS

The average efficiency score is equal to 0.83 for all MoH hospitals. Considering the hospital type, the efficiency scores of training and research hospitals are higher than those of the general and branch hospitals. In addition, considering the hospital size, huge-scale hospitals have the highest efficiency score in all years. Moreover, overcrowded regions such as Marmara and South-eastern Anatolia regions had higher efficiency scores than other geographical regions.

CONCLUSIONS

The results indicate that recent health reforms did not significantly enhance hospital efficiency. Thus, policymakers and managers should take the necessary precautions to increase hospital efficiency.

Sustainable efficiency assessment of private diagnostic laboratories under uncertainty

Purpose

Assessing the performance of medical laboratories plays an important role in the quality of health services. However, because of imprecise data, reliable results from laboratory performance cannot be obtained easily. The purpose of this paper is to illustrate the use of interval network data envelopment analysis (INDEA) based on sustainable development indicators under uncertainty.

Design/methodology/approach

In this study, each medical diagnostic laboratory is considered as a decision-making unit (DMU) and an INDEA model is used for calculating the efficiency of each medical diagnostic laboratory under imprecise inputs and outputs. The proposed model helps provide managers with effective performance scores for deficiencies and business improvements. The proposed model with realistic efficiency scores can help administrators manage their deficiencies and ultimately improve their business.

Findings

The results indicate that uncertainty can lead to changes in performance scores, rankings and performance classifications. Therefore, the use of DEA models under certainty can be potentially misleading.

Originality/value

The contribution of this study provides useful insights into the use of INDEA as a modeling tool to aid managerial decision-making in assessing efficiency of medical diagnostic laboratories based on sustainable development indicators under uncertainty.

Road map for progress and attractiveness of Iranian hospitals by integrating self-organizing map and context-dependent DEA

Hospitals play an important role in healthcare systems and usually stay on the end node of the healthcare chain. Thus, determining their road map to get close to the desired efficiency frontier and developing short-term and long-term plans could help to manage costs and resources, efficiently. As the efficiency frontier depends on the size of the hospital and the complexity of its structure, the homogeneity in benchmarking must be considered. For tackling this problem, the self-organizing map (SOM) is used to create homogeneous groups. On the other hand, data envelopment analysis (DEA) is a well-known methodology for evaluating decision-making units. Each unit obtains the efficiency score based on the ratio of weighted outputs to weighted inputs, where each unit can take the desirable weights for inputs and outputs to provide the maximum value. One of the problems of DEA is the selection of the reference set and distinguishing between the efficient hospitals. To overcome these problems, the context-depended DEA has been applied and the progress and attractiveness of hospitals are obtained. To evaluate the capability of the proposed approach, data of 288 Iranian hospitals are utilized. By applying SOM the hospitals are clustered into appropriate homogeneous groups and by applying context-dependent DEA, the road map for progress and attractiveness of each hospital is determined. In other words, using the proposed approach the hospitals are able to determine the short and long-term goals according to their strategic plans.

Assessing congestion in emergency obstetric care in public hospitals in Tamil Nadu

Purpose

The purpose of this paper is to assess congestion as the simultaneous occurrence of desirable health output (e.g. maternal admissions) along with undesirable output (e.g. still births (SB)), in emergency obstetric care settings of public hospitals in Tamil Nadu.

Design/methodology/approach

The study is based on a cross-sectional data set of 97 public hospitals collected by the statistical cell of Tamil Nadu Health Systems Project for the year 2013–2014. The study uses three inputs – beds, doctors and nurses; three desirable outputs – maternal admissions, neonatal admission and live births; and four undesirable outputs – SB, intra-uterine deaths, neonatal deaths and maternal deaths. Congestion analysis, a variant of the data envelopment analysis (DEA) method and slack analysis, has been applied to detect an excessive use of some inputs or a shortfall in some outputs across these hospitals. Furthermore, the association between congestion and some contextual factors has been examined.

Findings

On an average, the hospitals in our sample can increase the total amount of outputs by 62.8 percent by improving overall efficiency, and about 34.2 percent of this inefficiency can be attributed to congestion. Analysis of sub-samples showed that government hospitals at the taluk level have higher congestion than district headquarter hospitals. Congestion seems to decrease with greater hospital volume up to a limit; beyond that, it increases in obstetric care settings.

Originality/value

Hospital-based efficiency studies in the Indian context, so far, have estimated relative efficiency among hospitals using the classical DEA method, but ignoring adverse health outcomes. Congestion analysis, an advance in the DEA method, considers how much the desirable outputs can be increased as also how much undesirable outputs affect efficiency.

Efficiency Measurement in Health Facilities: A Systematic Review in Low- and Middle-Income Countries

BACKGROUND

Limited healthcare resources in low- and middle-income countries (LMICs) have led policy-makers to improve healthcare efficiency. Therefore, it is essential to understand how efficiency has been measured in the LMIC setting.

OBJECTIVE

This paper reviews methodologies used for efficiency studies in health facilities in LMICs.

METHODS

We searched MEDLINE, Embase, Global Health, EconLit and ProQuest Dissertations and Theses databases to Week 6 in 2018. We included all types of quantitative analysis studies relating to the measurement of the efficiency of services at health facilities in LMICs. We extracted data from eligible studies, and assessed the validity for each study. Because of the substantial heterogeneity of the studies, results were presented narratively.

RESULTS

A total of 137 papers were eligible for inclusion. These articles covered a wide range of health facility types, with more than half of the studies relating to hospitals. Our systematic review showed that there is an increasing trend in efficiency measurements in LMICs using various methods. Most studies employed data envelopment analysis as an efficiency measurement method. The studies typically included physical inputs and health services as outputs. Sixty-one percent of the studies analysed the contextual variables of the health facility efficiency.

CONCLUSION

This review highlights the potential for methodological improvement and policy impacts in efficiency measurements.

Integrated Analysis of Healthcare Efficiency: A Systematic Review

Data Envelopment Analysis (DEA) has been used as a performance measurement tool in efficiency assessment of healthcare systems. However, over the years, researchers and health practitioners presented the theoretical and methodological limitations of DEA that limits the full view of healthcare efficiency. To address these limitations, a commonly used strategy is to integrate other statistical methods and techniques with DEA to provide better efficiency evaluation. This paper reviews 57 studies with DEA applications in the healthcare industry to illustrate the integrated analysis of healthcare efficiency. With DEA as the central method, regression models in conjunction with statistical tests are commonly used. Input-oriented radial DEA models using predominantly capacity-related inputs and activity-related outputs and following either constant return to scale or variable return to scale assumptions are mostly applied to measure healthcare efficiency.

Identifying congestion levels, sources and determinants on intensive care units: the Portuguese case

Healthcare systems are facing a resources scarcity so they must be efficiently managed. On the other hand, it is commonly accepted that the higher the consumed resources, the higher the hospital production, although this is not true in practice. Congestion on inputs is an economic concept dealing with such situation and it is defined as the decreasing of outputs due to some resources overuse. This scenario gets worse when inpatients' high severity requires a strict and effective resources management, as happens in Intensive Care Units (ICU). The present paper employs a set of nonparametric models to evaluate congestion levels, sources and determinants in Portuguese Intensive Care Units. Nonparametric models based on Data Envelopment Analysis are employed to assess both radial and non-radial (in)efficiency levels and sources. The environment adjustment models and bootstrapping are used to correct possible bias, to remove the deterministic nature of nonparametric models and to get a statistical background on results. Considerable inefficiency and congestion levels were identified, as well as the congestion determinants, including the ICU specialty and complexity, the hospital differentiation degree and population demography. Both the costs associated with staff and the length of stay are the main sources of (weak) congestion in ICUs. ICUs management shall make some efforts towards resource allocation to prevent the congestion effect. Those efforts shall, in general, be focused on costs with staff and hospital days, although these congestion sources may vary across hospitals and ICU services, once several congestion determinants were identified.