Commentary: A systematic review of health care efficiency measures

Hospitals' efficiency in Iran: A systematic review and meta-analysis

BACKGROUND

Given that the need to pay attention to measuring efficiency is considered as one of the main pillars of improving the level of efficiency in hospitals, so this study was carried out aimed to determine the mean technical efficiency (The technical efficiency is bound by zero and one and a score of less than one means that the theatre is inefficient as it could) score in terms of type and activity of the hospital, input-oriented and output-oriented attitude, returns to scale (In economics, returns to scale and economies of scale are related but different concepts that describe what happens as the scale of production increases in the long run, when all input levels including physical capital usage are variable (chosen by the firm). The concept of returns to scale arises in the context of a firm's production function. It explains the behavior of the rate of increase) in hospitals of Iran using data envelopment analysis (DEA) (DEA is a nonparametric method in operations' research and economics for the estimation of production frontiers. It is used to empirically measure productive efficiency of decision-making units) and stochastic frontier analysis (SFA) (SFA is a method of economic modeling. It has its starting point in the stochastic production frontier models simultaneously introduced by Aigner, Lovell and Schmidt^[1977] and Meeusen and Van den Broeck^[1977].

MATERIALS AND METHODS

The present study was carried out with a systematic review of all studies conducted on measuring efficiency of hospitals in Iran from March 21, 2001 to December 21, 2017 using DEA and SFA. Eleven databases were searched using appropriate keywords and 470 articles were found and evaluated using a checklist, and finally, 24 articles were entered into the meta-analysis process. Meta-analysis was performed using random effect model and fixed-effect model, and study heterogeneity was investigated using Q-Cochran test and I ² index. Furthermore, the main reasons of study heterogeneity were identified due to meta-regression.

RESULTS

The average technical efficiency score of hospitals using DEA and SFA method was obtained equal to 0.885 and 0.809, respectively. Furthermore, with regard to the DEA method, 0.885, 0.891.0.952 and 0.913 was obtained for input-oriented and output-oriented, general and specialized care hospitals and constant returns respectively. With regard to SFA method, 0.733, 0.664, 0.641, 0.802, was obtained, and the inputs and outputs affect measuring the efficiency.

DISCUSSION

In contrast, the DEA method can investigate several input and output simultaneously and is used as an effective and flexible tool in order to measure the efficiency of the hospital. DEA can be easily used for calculating efficiency scores based on the proper selection of input and output indicators. The data envelopment analysis method and different input and output variables have been used in most studies conducted in Iran, and Stochastic Frontier Analysis has been less considered. In the present study, the DEA method in governmental educational hospitals showed a higher efficiency than SFA method in the hospitals under study. But in general, due to lack of optimal efficiency level in the hospital, it is suggested that policymakers determine the hospital efficiency indices in order to evaluate their efficiency from different dimensions.

CONCLUSION

The average technical efficiency score of hospitals using DEA and SFA method was obtained equal to 0.885 and 0.809, respectively. Also, the mean technical efficiency score in terms of input-oriented and output-oriented, general and specialized care hospitals and constant returns to scale using the DEA method was obtained equal to 0.885, 0.891.0.952 and 0.913 and using the SFA method, respectively, it was equal to 0.733, 0.664, 0.641, 0.802, and the inputs and outputs affecting measuring the efficiency. There is no significant difference between the mean efficiency score between the two methods, but the data envelopment analysis method is used more. It is suggested that the hospitals efficiency indicators to be determined in order to more accurately evaluate the hospitals efficiency.

The training contents, problems and needs of doctors in urban community health service institutions in China

Background

The Chinese government offered various types of training programs for strengthening the role of doctors working in community health service institutions (CHSIs). The study intended to investigate the current training programs and training needs of doctors nationally in urban CHSIs in China, and to provide propositions for training more qualified doctors in the future.

Methods

Total 3098 doctors in 192 urban CHSIs were chosen from 9 provinces (Hebei, Liaoning, Shandong, Zhejiang, Fujian, Hunan, Guangxi, Guizhou, Ningxia) and one municipality (Beijing) among 31 provinces in eastern, central, and western regions by stratified sampling methods in Mainland China. All doctors in the selected CHSIs were investigated in this study. We discharged 3073 questionnaires, and the response rate was 98.0%. Descriptive statistics were used to describe the characteristics, training contents, problems and needs of doctors. Differences in training contents, problems and needs between eastern, central and western regions were analyzed with chi-square tests.

Results

49.3% of doctors in CHSIs had Bachelor’s degree and beyond. 12.9% of doctors had senior professional titles. The most frequent training topics for the doctors in eastern, central and western regions were “basic clinical theory knowledge” (52.4%), “community health service competency” (59.6%), “clinical practice skills” (45.9%) respectively. The most serious problem for doctors was “insufficient training time” in eastern (36.8%), central (36.5%) and western (39.6%). The biggest knowledge need for doctors both in eastern (79.8%) and central region (79.1%) was “the updated international medical knowledge”, in western region it was “the updated domestic medical knowledge” (73.2%). The biggest skill-related training need for doctors in eastern region (84.1%) and central region (82.6%) was “communication skills”, and “diagnosis and differential diagnosis” in western region (78.2%).

Conclusion

Government should design proper training contents according to the knowledge and skill needs of different design. Furthermore, a uniform, rigorous training and evaluation system focus on practicability should be established to promote community health service system in Mainland China.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0867-6) contains supplementary material, which is available to authorized users.

Detrimental Effects of "Stretch" Goals in Specialty Substance Use Disorder Treatment Organizations

BACKGROUND

"Stretch" goals, a rarely examined concept that represents seemingly impossible, highly ambitious organizational goals ostensibly established to fill performance gaps and motivate employees, are examined within a sample of substance use disorder (SUD) treatment centers in the United States in terms of their prevalence and effects on organizational behavior. Stretch goals are defined as "seemingly impossible" goals intended to motivate employees to achieve high performance. In light of the high level of environmental change and unpredictability faced by SUD treatment centers in recent decades, we theorize that stretch goals would be both common and often detrimental (in terms of capacity utilization rate and efficiency) in these settings.

METHODS

In a temporally lagged analysis of data from leaders of a representative U. S. national sample of 219 SUD treatment centers characterized by entrepreneurial management structures, we examined the prevalence of stretch goals and their impact on key outcome variables of capacity utilization rate and efficiency.

RESULTS

Widespread adoption of stretch goals was found, with 43% of our sample falling within the stretch category. Stretch goals had a negative main effect on capacity utilization rate as compared to less ambitious challenging goals. Stretch and prior performance interacted to further predict capacity utilization rate, whereas stretch and slack resource availability interacted to predict center efficiency.

DISCUSSION

Although stretch goals are frequently used in the SUD treatment industry, we find them mostly detrimental to performance. Stretch goals may enhance the efficiency of treatment centers with prior limited resource availability, but they are negatively associated with capacity utilization, especially in centers with a record of already strong performance. Despite the high prevalence of such goals and positive values centered on aspirational behavior, these results strongly suggest caution in such goal setting in SUD treatment centers.

Variation of fee-for-service specialist direct care work effort with patient overall illness burden

OBJECTIVE

To explore whether a common industry measure of overall patient illness burden, used to assess the total costs of members in a health plan, would be suitable to describe variation in a summary metric of utilization that assesses specialist physician direct patient care services not grouped into clinical episodes, but with exclusion criteria applied to reduce any bias in the data. Data sources/study setting Calendar year 2006 administrative data on 153,557 commercial members enrolled in a non-profit single-state statewide Health Maintenance Organization (HMO) and treated by 4356 specialists in 11 specialties. The health plan's global referral process and specialist fee-for-service reimbursement likely makes these results applicable to the non-managed care setting, as once a global referral was authorized there was no required intervention by the HMO or referring primary care provider for the majority of any subsequent specialist direct clinical care. Study design Specialty-specific correlations and ordinary least-squares regression models to assess variations in specialist direct patient care work effort with patient overall illness burden, after the application of exclusion criteria to reduce potential bias in the data. Principle findings Statistically significant positive correlations exist between specialist direct patient care work effort and patient overall illness burden for all studied specialties. Regression models revealed a generally monotonic increasing relationship between illness burden categories and aggregate specialist direct patient care work effort. Almost all regression model differences from the reference category across specialties are statistically significant (P ≤ 0.012). Assessment of additional results demonstrates the relationship has more substantive significance in some specialties and less in others. The most substantive relationships in this study were found in the specialties of orthopaedic surgery, general surgery and interventional cardiology.

CONCLUSIONS

For many specialties, specialists do vary physician direct patient care utilization with patient overall illness burden. Accounting for patient overall health status is important to fairly compare specialists of certain specialties on utilization for health plan specialist network management. Additional study is required to evaluate health plan application of this methodology.