Striving towards efficiency in the Greek hospitals by reviewing case mix classifications

Do hospitals need to establish multiple hospital districts? A hospital-based perspective on the benefits of scale

Background

During the fight against COVID-19, China's public hospitals played the main role in taking on the most urgent, dangerous and arduous medical treatment and work. Therefore, in order to promote the high-quality development of hospitals, it is necessary to support some potential public hospitals to build and develop a "One Hospital with Multiple Campuses System" (OHMC) based on controlling the size of single hospitals, and to quickly convert their functions in the event of a severe epidemic.

Methods

The Cobb-Douglas production function and log-transformed production function were used to measure the appropriate hospital size for 22 public hospitals in a region of China.

Results

The eight OHMC hospitals that planned to be build are basically qualified to handle the conditions and potential of multi-districts from the perspective of economy of scale. The OHMC hospitals in operation appear to have weakened incremental scale rewards, because they are in the process of development, but they are still higher than the overall level of single-campus hospitals.

Conclusion

The expansion of hospital scale may bring the advantages of group development, but it may also bring about problems including rising hospital cost, increasing management and operation cost, inefficient allocation of medical resources and unbalanced development.

Bootstrapping data envelopment analysis of efficiency and productivity of county public hospitals in Eastern, Central, and Western China after the public hospital reform

China implemented the public hospital reform in 2012. This study utilized bootstrapping data envelopment analysis (DEA) to evaluate the technical efficiency (TE) and productivity of county public hospitals in Eastern, Central, and Western China after the 2012 public hospital reform. Data from 127 county public hospitals (39, 45, and 43 in Eastern, Central, and Western China, respectively) were collected during 2012-2015. Changes of TE and productivity over time were estimated by bootstrapping DEA and bootstrapping Malmquist. The disparities in TE and productivity among public hospitals in the three regions of China were compared by Kruskal-Wallis H test and Mann-Whitney U test. The average bias-corrected TE values for the four-year period were 0.6442, 0.5785, 0.6099, and 0.6094 in Eastern, Central, and Western China, and the entire country respectively, with average non-technical efficiency, low pure technical efficiency (PTE), and high scale efficiency found. Productivity increased by 8.12%, 0.25%, 12.11%, and 11.58% in China and its three regions during 2012-2015, and such increase in productivity resulted from progressive technological changes by 16.42%, 6.32%, 21.08%, and 21.42%, respectively. The TE and PTE of the county hospitals significantly differed among the three regions of China. Eastern and Western China showed significantly higher TE and PTE than Central China. More than 60% of county public hospitals in China and its three areas operated at decreasing return scales. There was a considerable space for TE improvement in county hospitals in China and its three regions. During 2012-2015, the hospitals experienced progressive productivity; however, the PTE changed adversely. Moreover, Central China continuously achieved a significantly lower efficiency score than Eastern and Western China. Decision makers and administrators in China should identify the causes of the observed inefficiencies and take appropriate measures to increase the efficiency of county public hospitals in the three areas of China, especially in Central China.

Association of low back pain on physical, sociodemographic and lifestyle factors across a general population sample within Greece

BACKGROUND

Although low back pain (LBP) is a debilitating problem internationally, there is not a lot of research on its impact on physical, psychosocial and lifestyle factors. Especially in mediterranean countries, such as Greece, it is not sufficiently explored whether physical (pain location, activity limitation etc.), sociodemographic (education, smoking etc.) or lifestyle factors (i.e. quality of life or anxiety) are influenced by LBP.

OBJECTIVE

To estimate LBP prevalence in the Greek general population and explore its association with particular sociodemographic, physical and lifestyle factors.

METHOD

A sample of 3125 people of the Greek adult population was randomly selected by stratified sampling encompassing rural and urban representation within the Greek mainland. An extended survey form was developed entailing three sections; personal (sociodemographic) information, questions on symptomatology and physical factors (i.e. pain characteristics, recurrence, physical disability etc.) and 3 self-administered questionnaires (including mostly lifestyle factors); Hospital Anxiety and Depression (HAD) scale for anxiety and depression, SF-12 for quality of life (QoL) and Roland-Morris for disability.

RESULTS

A total of 471 (15%) people reported LBP (210 males, mean age: 47.04 ± 15.03). Amongst them 60% reported sciatica, 76% suffered recurrent LBP and 70% received specialist care. Low disability levels, moderate to high pain intensity, gender differences and good self-reported QoL and psychosocial status were reported. Sociodemographic characteristics (income, smoking, marital status etc.) were not associated with LBP physical factors, apart from age which correlated with physical disability and wellness (r being 0.446 and 0.405, respectively, p< 0.001). Physical factors (particularly pain intensity and location) correlated with lifestyle factors (QoL) and disability (r ranging between 0.396 and 0.543, p< 0.001). Mental wellness, anxiety and depression (as lifestyle factors) were not associated with sociodemographic or physical factors.

CONCLUSIONS

Physical parameters were amongst the most prevalent characteristics of the Greek sample, thus offering a direction towards a more targeted treatment and rehabilitation planning. Unlike previous literature, most sociodemographic characteristics were not correlated with any LBP physical or lifestyle factors, thus possibly indicating a different socioeconomic background and aetiology domain to that of the usual non-specific LBP spectrum.

Efficiency and optimal size of hospitals: Results of a systematic search

Background

National Health Systems managers have been subject in recent years to considerable pressure to increase concentration and allow mergers. This pressure has been justified by a belief that larger hospitals lead to lower average costs and better clinical outcomes through the exploitation of economies of scale. In this context, the opportunity to measure scale efficiency is crucial to address the question of optimal productive size and to manage a fair allocation of resources.

Methods and findings

This paper analyses the stance of existing research on scale efficiency and optimal size of the hospital sector. We performed a systematic search of 45 past years (1969–2014) of research published in peer-reviewed scientific journals recorded by the Social Sciences Citation Index concerning this topic. We classified articles by the journal’s category, research topic, hospital setting, method and primary data analysis technique. Results showed that most of the studies were focussed on the analysis of technical and scale efficiency or on input / output ratio using Data Envelopment Analysis. We also find increasing interest concerning the effect of possible changes in hospital size on quality of care.

Conclusions

Studies analysed in this review showed that economies of scale are present for merging hospitals. Results supported the current policy of expanding larger hospitals and restructuring/closing smaller hospitals. In terms of beds, studies reported consistent evidence of economies of scale for hospitals with 200–300 beds. Diseconomies of scale can be expected to occur below 200 beds and above 600 beds.

Attitudes and diagnostic practice in low back pain: A qualitative study amongst Greek and British physiotherapists

AIM

To explore current diagnostic practice and attitudes of Greek and United Kingdom physiotherapists (PTs) on assessing low back pain (LBP) patients.

METHODS

Three focus groups were undertaken, followed by a structured questionnaire-type survey comprising 23 health professionals and a random stratified sample of 150 PTs, respectively. Twenty-nine themes relating to LBP diagnostic practice emerged. These were then given to 30 British PTs assessing their level of agreement with their Greek counterparts. Analysis was performed by percentage agreements and χ² tests.

RESULTS

The survey was divided into three subsections; PTs’ attitudes on LBP assessment, patients’ attitudes and diagnostic/healthcare issues, each constituting 14, 7 and 8 statements, respectively. Over half of the statements fell within the 30%-80% agreement between Greece and United Kingdom whereas, 5 statements reported low (< 10%) and 8 statements demonstrated high (> 90%) PT percentage agreement. Similarities across British and Greek PTs were detected in history taking methods and in the way PTs feel patients perceive physiotherapy practice whereas, re-assessment was undertaken less frequently in Greece. Diagnosis according to 91% of the Greek PTs is considered a “privilege” which is exclusive for doctors in Greece (only 17% British PTs agreed) and is accompanied with a great overuse of medical investigations. Forty percent of Greek PTs (compared to 0% of British) consider themselves as “executers”, being unable to interfere with treatment plan, possibly implying lack of autonomy.

CONCLUSION

Although similarities on history taking methods and on patients’ attitudes were detected across both groups, gross differences were found in re-assessment procedures and diagnostic issues between Greek and British physiotherapists, highlighting differences in service delivery and professional autonomy.

Managing for efficiency in health care: the case of Greek public hospitals

This paper evaluates the efficiency of public hospitals with two alternative conceptual models. One model targets resource usage directly to assess production efficiency, while the other model incorporates financial results to assess economic efficiency. Performance analysis of these models was conducted in two stages. In stage one, we utilized data envelopment analysis to obtain the efficiency score of each hospital, while in stage two we took into account the influence of the operational environment on efficiency by regressing those scores on explanatory variables that concern the performance of hospital services. We applied these methods to evaluate 96 general hospitals in the Greek national health system. The results indicate that, although the average efficiency scores in both models have remained relatively stable compared to past assessments, internal changes in hospital performances do exist. This study provides a clear framework for policy implications to increase the overall efficiency of general hospitals.

How efficient are Greek hospitals? A case study using a double bootstrap DEA approach

The purpose of this study was to measure Greek hospital performance using different input-output combinations, and to identify the factors that influence their efficiency thus providing policy makers with valuable input for the decision-making process. Using a unique dataset, we estimated the productive efficiency of each hospital through a bootstrapped data envelopment analysis (DEA) approach. In a second stage, we explored, using a bootstrapped truncated regression, the impact of environmental factors on hospitals' technical and scale efficiency. Our results reveal that over 80% of the examined hospitals appear to have a technical efficiency lower than 0.8, while the majority appear to be scale efficient. Moreover, efficiency performance differed with inclusion of medical examinations as an additional variable. On the other hand, bed occupancy ratio appeared to affect both technical and scale efficiency in a rather interesting way, while the adoption of advanced medical equipment and the type of hospital improves scale and technical efficiency, correspondingly. The findings of this study on Greek hospitals' performance are not encouraging. Furthermore, our results raise questions regarding the number of hospitals that should operate, and which type of hospital is more efficient. Finally, the results indicate the role of medical equipment in performance, confirming its misallocation in healthcare expenditure.

Efficiency as a domain of health care systems: a phenomenographic approach

PURPOSE

This paper focuses on efficiency as a central theme of the Italian health care reforms, combining macrolevel policies with microlevel (i.e., operating room) perceptions of the concept.

DESIGN/METHODOLOGY/APPROACH

According to the phenomenographic approach, this analysis investigates how the components of a surgical team (22 semistructured interviews) experience efficiency in their daily workflows.

FINDINGS

The main findings show that the concept of efficiency is multidimensional. According to participants' perspective, several categories of efficiency collected in an outcome space emphasize an holistic view of efficiency driving health policies and strategies.

SOCIAL IMPLICATIONS

The suggestion of further relationships between perspectives and other constructs (i.e., quality, safety, patient focus, process) at micro and macro level could enhance the impact of health reforms.

ORIGINALITY/VALUE

A qualitative approach conducted at microlevel help to recognize the phenomenon (of efficiency), engaging the individual conception that practitioners have of the health efficiency.

Measuring Efficiency and Productivity Across Hospitals in the Regional Health Authority of Thessaly, in Greece

The aim of the article is to assess performance in seven homogenous specialty clinics across all National Health System (NHS) hospitals in the Regional Health Authority of Thessaly (RHAT), over the period 2002–2006. Data Envelopment Analysis by using the Malmquist Productivity Index and its decompositions has been applied in order to measure the technical efficiency and productivity. Clinics were considered to transform inputs labour (medical and nursing staff) and capital (hospital beds) into health services, approximated by the number of in-patient discharges and in-patient days, used as outputs. The model is output-oriented and assumes variable return to scale. Data were collected from hospitals’ records. Overall productivity progressed in all clinics. Technical change progressed except the general medicine clinics. Technical efficiency regressed in four clinics. Diachronically the size of the clinics influences the overall effects on hospital performance and the maximum level of outputs produced has not been achieved using the given labour and capital inputs, except orthopaedic clinics. Homogeneity in assessing hospitals’ performance provides evidence on the efficiency and productivity gains among clinics and suggests improvements in those which appear inefficient. The difficult economic situation Greece is facing nowadays makes the assessment of NHS hospitals’ performance a priority in the decision-making.

The short-term effect on technical and scale efficiency of establishing regional health systems and general management in Greek NHS hospitals

OBJECTIVES

The Greek National Health System has been subjected to a reform initiative in 2001. The new legislation required hospitals to operate as administrative and economic decentralized units, under the control of newly established Regional Health Systems. In addition, Professional Managers have been appointed and signed "efficiency contracts", which supposedly committed them to run the hospitals effectively and efficiently. The present study aims at estimating the efficiency impact of this reform.

METHODS

Data Envelopment Analysis was employed with included inputs being the number of medical staff employees, other hospital employees and staffed beds, whereas outputs were the case-mix adjusted inpatient cases, outpatient visits and surgical operations performed. The technical and scale efficiencies of a sample of 51 general acute National Health System hospitals have been comparatively examined before and after the reform.

RESULTS

The analysis surprisingly indicates that technical and scale efficiency has been reduced following the policy changes.

CONCLUSIONS

It appears that the expected benefits from the reform have not in general been achieved, at least in the short-run. This result is examined in light of coexisting administrative and organizational factors, which are impeding the reform process.

Balancing efficiency of health services and equity of access in remote areas in Greece

Data envelopment analysis (DEA) was used to investigate the efficiency of a set of small-scaled Greek hospitals known as hospital-health centers (HHCs). These facilities naturally provide primary and secondary care but are also expected to function as health centers addressing mostly preventive medicine, hygiene and other public health issues. They are located in remote rural areas and serve the relatively small local populations. This study aimed to obtain insight on their productive efficiency in light of their particular role. The sample consisted of 17 from the 18 units existing in the Greek NHS. Variables chosen to characterize production were numbers of doctors, nurses and beds as inputs, and admissions, outpatient visits and preventive medical services as outputs. The DEA model was input oriented, allowed for constant returns to scale and units were ranked according to a benchmarking approach. Analyses were performed with and without the preventive medicine variable and the results demonstrated technical inefficiencies 26.77 and 25.13%, respectively. Location appeared to affect performance, with remote units, e.g. on small islands, more inefficient. This raises the question if correcting reduced efficiency compromises equity of service access for highly dependent populations. Moreover, we observed superior performance of units additionally offering preventive medical services. This generates another question as to the role these facilities should play in our currently changing health care system.

Analysing the Greek health system: a tale of fragmentation and inertia

The Greek health system does not yet offer universal coverage and has fragmented funding and delivery. Funding is regressive, with a reliance on informal payments, and there are inequities in access, supply and quality of services. Inefficiencies arise from an over reliance on relatively expensive inputs, as evidenced by the oversupply of specialists and under-supply of nurses. Resource allocation mechanisms are historical and political with no relation to performance or output, therefore providers have little incentive to improve productivity. Some options for future health system reform include focusing on coordinating funding by developing a monopsony purchaser with the aim of improving quality of services and efficiency in the health system and changing provider incentives to improve productivity.