Technical Efficiency of Public and Private Hospitals in Beijing, China: A Comparative Study

Evaluating private hospital performance before and during COVID-19 in China

The coronavirus disease 2019 (COVID-19) pandemic had a tremendous impact on the global medical system. The development of private hospitals is an important measure to deepen the reform of China's medical and health system, and an important driving force to improve the effective supply of medical services. This study aims to compare the performance of China's private hospitals before and during COVID-19 and determine the factors that affect hospital profitability between the 2 periods. Data are collected from 10 private listed hospitals from 2017 to 2022, and ratio analysis is used to measure hospital performance in 5 aspects, namely profitability, liquidity, leverage, activity (efficiency), and cost coverage. Multiple regression analysis is used to determine the influencing factors of hospital profitability. The results show a negative impact of COVID-19 on private hospital performance. Specifically, regardless of region, hospital profitability, liquidity, and cost coverage were reduced due to COVID-19, while hospital leverage was increased. COVID-19 had also an impact on hospital efficiency. In addition, before COVID-19, current ratio and cost coverage ratio were the determinants of hospital profitability, while only cost coverage ratio affected hospital profitability during the COVID-19 outbreak. We provide evidence that COVID-19 had an impact on China private hospitals, and the findings will aid private hospitals in improving their performance in the post-COVID-19 era.

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.

Bridging the gap: coordinating equity and efficiency in older people care resource allocation in China

BACKGROUND

With the increasing global aging population, how to allocate older people care resources reasonably has become an increasingly urgent international issue. China, as the largest developing country, has made many efforts to actively respond to the challenges of an aging population. However, there are still problems with uneven allocation of older people care resources and low efficiency of allocation. Therefore, this study evaluates the regional differences and dynamic evolution of the equity and efficiency of older people care resource allocation in China from 2009 to 2020, and explores ways to change the current situation.

METHODS

The data used in this study were derived from the "China Statistical Yearbook" and the "China Civil Affairs Statistical Yearbook" for the period of 2010-2021. Firstly, the equity of older people care resource allocation was measured using the Gini coefficient, the Theil index, the Older People Care Resource Density Index, and the Older People Care Resource Agglomeration Degree. Secondly, the dynamic Slack-Based Measure data envelopment analysis method was adopted to evaluate efficiency. Lastly, the Z-score is used to normalize the equity index and perform classification matching with the efficiency value. Spatial autocorrelation analysis and hotspot analysis were conducted using GIS technology to examine the dynamic evolution process of older people care resource allocation equity and efficiency, as well as their spatial distribution patterns and coordination across provinces from 2009 to 2020.

RESULTS

The equity analysis showed that the spatial distribution of various types of older people care resources was uneven, and the differences were mainly due to internal differences within each region, with the largest equity differences observed in western provinces. Currently, older people care resources are mainly concentrated in eastern regions, while the total amount of older people care resources in western regions and some central regions is relatively small, which cannot meet the older people care needs of residents. The efficiency analysis results showed that the efficiency of older people care resource allocation has been improving over the past 12 years, and in 2020, 77.42% of provinces were located on the efficiency frontier with an average efficiency value of 0.9396. Finally, the coordination analysis results showed that there were significant spatiotemporal differences in the equity and efficiency of older people care resources allocation.

CONCLUSION

With the development of society and economy, the total amount and service capacity of older people care resources in China have greatly improved. However, there are still significant spatiotemporal differences in the equity and efficiency of older people care resource allocation. The development of older people care services in central and eastern provinces is unbalanced, and there is a polarization trend in terms of equity and efficiency of older people care resource allocation. Most provinces in western regions face the dual dilemma of inadequate older people care resources and low utilization efficiency. It is recommended that policymakers comprehensively consider population and geographic factors in different provinces, establish relevant allocation standards according to local conditions, improve the redistribution system, and focus on increasing the total amount of older people care resources in underdeveloped provinces while promoting resource flow.

Incentive policy for the comprehensive development of young medical talents: an evolutionary game study

Introduction

Currently in China, there is a lack of well-defined and viable incentive mechanisms at the governmental and hospital levels to support the development of young medical talents, thereby hindering their growth Existing studies primarily investigate the current state and trajectory of incentives, yet they inadequately address the distinctive characteristics of various stakeholders involved in medical talent incentive processes, particularly the lack of research on incentive mechanisms with Chinese attributes.

Methods

This study adopts evolutionary game theory to investigate the dynamics of replication and the strategies for achieving evolutionary stability in the comprehensive development of young medical talents, considering both scenarios with and without supportive policies.

Results

In the absence of any supportive policy measures, the evolutionarily stable strategy (ESS) point is O(0,0), the unstable equilibrium point is C(1,1), and the saddle points are A(0,1), B(1,0). The initial state of the system is at the unstable equilibrium point C(1,1), which means that the young medical talents and medical institutions adopt a combination of strategies (actively seeking comprehensive development and taking incentive measures). Under the scenario with supportive policies, the ESS point is C(1,1), the unstable equilibrium point is O(0,0), and the saddle points are A(0,1), B(1,0). The initial state of the system is at the unstable equilibrium point O(0,0), which means that young medical talents and medical institutions adopt (N,N) strategy combinations (inactively seeking comprehensive development, implementing no incentive measure).

Discussion

(1) Government incentives play a crucial role in motivating young medical talents to seek comprehensive development. (2) The level of government incentive support for young medical talents should exceed the cost increment of individual efforts. Additionally, the policy support provided by the government to medical institutions should surpass the incentive support offered by these institutions to young medical talents. This will enhance the motivation and encouragement efforts of medical institutions in actively promoting comprehensive development among young medical talents. (3) With the backing of certain government incentive policies, medical institutions implementing incentive measures and young medical talents actively seeking comprehensive development will establish a virtuous cycle of mutual promotion.

Efficiency trends of essential public health services and possible influencing factors since the new round health reform in China: a case study from Hainan Province

Objective

This article aimed to evaluate the efficiency trends and influencing factors of essential public health services in Hainan Province after the healthcare reform launched in 2009 in China.

Methods

The efficiency of essential public health services (EPHS) at primary health institutions was assessed using data envelopment analysis (DEA), and the efficiency change was analyzed by employing the Malmquist productivity index (MPI). We used Tobit regression to identify the influence of environmental factors on the efficiency of public health services. The bootstrap method was adopted to reduce the impact of random errors on the result.

Results

The bootstrapping bias-corrected efficiency revealed that the average values of technical efficiency, pure technical efficiency, and scale efficiency were 0.7582, 0.8439, and 0.8997, respectively, which meant that the EPHS in Hainan Province were not at the most effective state. The average bias-corrected MPI was 1.0407 between 2010 and 2011 and 1.7404 between 2011 and 2012. MPIs were less than 1.0000 during other periods investigated, ranging from 0.8948 to 0.9714, indicating that the efficiency of EPHS has been decreasing since 2013. The Tobit regression showed that the regression coefficients of per capita GDP, population density, the proportion of older people aged over 65, and the proportion of ethnic minority population were 0.0286, -0.0003, -0.0316, and - 0.0041 respectively, which were statistically significant (p < 0.05).

Conclusion

There was a short-term improvement in the efficiency of EPHS in Hainan after the launch of the new round of health reform. However, this trend has not been sustained after 2013. In particular, equalized financial investment in essential public health could not fulfill the needs of poor counties. This has resulted in the inability to improve scale efficiency in some counties, which in turn has affected the improvement of overall EPHS efficiency. Therefore, to promote EPHS efficiency sustainably, it is suggested that under this model of provincial control of counties, the equity of resource allocation should be effectively improved while further advancing the technology of service delivery.

Functions, advantages and challenges facing private healthcare organisations in China's healthcare system: a qualitative analysis through open-ended questionnaires

OBJECTIVES

The medical reform in 2009 stimulated the growth of private healthcare organisations in China, but there is still room for their further development in the healthcare market. The objectives of the study were to provide more information about the healthcare market in China and to explore the challenges private healthcare organisations faced.

DESIGN

Qualitative descriptive study using a web-based open-ended questionnaire and thematic content analysis. Data were collected between 12 February and 20 February 2020.

SETTING

This study was conducted in China.

PARTICIPANTS

124 respondents from private healthcare organisations across 20 provinces in China.

RESULTS

Our content analysis identified three themes: (1) functioning and positioning of the healthcare institutions: current private healthcare organisations generally serve as a supplement to public hospitals and focus more on specialised medical and high-end services; (2) institutions' advantages: private healthcare organisations can flexibly respond to market demands, formulate effective strategies, introduce advanced management concepts and methods, provide personalised and diversified services, and introduce new technologies which can stimulate market vitality and promote healthy competition; and (3) institutions' challenges: private healthcare organisations face difficulties in professional development and talent cultivation, branding and establishing a reputation, and the policies for institution establishment, tax and medical insurance pose drawbacks to their development.

CONCLUSION

This study illustrates that private healthcare organisations need more government support for further development, such as providing a fairer insurance strategy and taxation policy, affording ground for a more equitable scientific research environment and promotion opportunities, and evaluating reputation score for healthcare institutions.

Technical Efficiency Evaluation of Primary Health Care Institutions in Shenzhen, China, and Its Policy Implications under the COVID-19 Pandemic

(1) Background: Primary health care institutions (PHCI) play an important role in reducing health inequities and achieving universal health coverage. However, despite the increasing inputs of healthcare resources in China, the proportion of patient visits in PHCI keeps declining. In 2020, the advent of the COVID-19 pandemic further exerted a severe stress on the operation of PHCI due to administrative orders. This study aims to evaluate the efficiency change in PHCI and provide policy recommendations for the transformation of PHCI in the post-pandemic era. (2) Methods: Data envelope analysis (DEA) and the Malmquist index model were applied to estimate the technical efficiency of PHCI in Shenzhen, China, from 2016 to 2020. The Tobit regression model was then used to analyze the influencing factors of efficiency of PHCI. (3) Results: The results of our analysis reflect considerable low levels of technical efficiency, pure technical efficiency, and scale efficiency of PHCI in Shenzhen, China, in 2017 and 2020. Compared to years before the epidemic, the productivity of PHCI decreased by 24.6% in 2020, which reached the nadir, during the COVID-19 pandemic along with the considerable reduction of technological efficiency, despite the significant inputs of health personnel and volume of health services. The growth of technical efficiency of PHCI is significantly affected by the revenue from operation, percentage of doctors and nurses in health technicians, ratio of doctors and nurses, service population, proportion of children in the service population, and numbers of PHCI within one kilometer. (4) Conclusion: The technical efficiency significantly declines along with the COVID-19 outbreak in Shenzhen, China, with the deterioration of underlying technical efficiency change and technological efficiency change, regardless of the immense inputs of health resources. Transformation of PHCI such as adopting tele-health technologies to maximize primary care delivery is needed to optimize utilization of health resource inputs. This study brings insights to improve the performances of PHCI in China in response to the current epidemiologic transition and future epidemic outbreaks more effectively, and to promote the national strategy of Healthy China 2030.

The effects of provider contract types and fiscal decentralization on the efficiency of the Polish hospital sector: A data envelopment analysis across 16 health regions

BACKGROUND

Expenditures on hospitals constitute a large proportion of total health expenditures. In Poland the share of hospital spending is higher than the European Union average. The efficiency of the Polish hospital sector merits investigation.

RESEARCH GOAL

The goal of this study is to estimate the relative technical efficiencies of Polish hospital regions, and to measure the impacts of provider contract types, fiscal decentralization, and the 2017 reform on the relative efficiencies.

METHODS

Using data from 16 hospital regions in Poland for the years 2007 to 2019, we estimate relative technical efficiencies and their determinants using a two-stage approach. In the first stage, we apply Data Envelopment Analysis, in which we assume variable returns to scale and an output orientation. In the second stage we use a truncated regression with double bootstrapping.

RESULTS

Our findings are threefold. First, fiscal decentralization may reduce technical efficiency, but the results was not statistically significant. Second, efficiency tended to be higher in regions where a greater proportion of nurses and midwives were offered employment as opposed to consulting contracts. Contract types offered to physicians were not statistically significant. Third, the 2017 reforms seem to have had a positive impact on efficiency to date.

CONCLUSION

Policy makers may wish to consider offering less fiscal autonomy and control to regions and encouraging employment contracts with nurses and midwives.

Measuring the efficiency of public hospitals: A multistage data envelopment analysis in Fujian Province, China

Objective

The present study aimed to evaluate the operational efficiency of public hospitals in Fujian Province and the factors responsible for the inefficiency of these hospitals and provide relevant suggestions for health policymakers in allocating service resources.

Method

In the first stage of the research, the variables affecting the efficiency of hospitals were extracted by qualitative and quantitative methods, including literature optimization, gray related analysis and gray clustering evaluation. In the second stage, the data envelopment analysis (DEA) method was used to evaluate the operational efficiency of 49 hospitals of different levels and types selected by sampling in 2020. Finally, a Tobit regression model with introduced institutional factors and background factors was established to study the main influencing factors of hospital inefficiency.

Results

In the first stage, 10 input variables and 10 output variables necessary from the mangers' point of view were identified to test efficiency. In the second stage, the average comprehensive TE, PTE, and SE of 49 sample hospitals was 0.802, 0.888, and 0.902, respectively. 22.45% of these hospitals met the effective criteria, i.e., the overall effective rate was 22.45%. The low SE value of the hospital was the main reason hindering the improvement of the comprehensive efficiency value. The overall effective rate of secondary public hospitals (30.77%) was higher than that of tertiary public hospitals (19.44%), and the overall effective rate of public specialized hospitals (30%) was higher than that of general public hospitals (18.92%). Based on the third stage results, the bed occupancy rate (BOR) and the proportion of beds (POB) were major factors affecting the operation efficiency of grade III hospitals (p < 0.01). However, the operating efficiency of grade II hospitals was significantly affected by POB and regional per capita GDP(GDPPC) (p < 0.05). Moreover, the impact of BOR and GDPPC was positive, and POB was negatively correlated with hospital operation efficiency.

Conclusions

The study results indicated that the overall operation efficiency of public hospitals in Fujian Province is low. This study revealed that intervention should be strengthened from a policy and management perspective to improve the operation efficiency of public hospitals.

Equity and efficiency of public hospitals' health resource allocation in Guangdong Province, China

Background

To better meet people’s growing demand for medical and health services, 21 cities in Guangdong Province were involved in the reform of public hospitals in 2017. This paper evaluates the equity and efficiency of public hospitals’ health resource allocation in Guangdong Province and explores ways to change the current situation.

Methods

Data were collected from the Guangdong Health Statistical Yearbook 2016–2020 and Guangdong Statistical Yearbook 2017–2021. The Gini coefficient (G), Theil index (T), and health resource density index (HRDI) were used to measure the equity of health resource allocation. An improved three-stage DEA method was applied in efficiency evaluation. The entropy weight method was employed to calculate the weight of different indicators to obtain a comprehensive indicator representing the overall volume of health resources in each city. A two-dimensional matrix was drawn between the HRDI of the comprehensive indicator and efficiency and the per capita government financial subsidies and efficiency to observe the coordination of equity and efficiency across regions.

Results

From 2016 to 2020, the G of public hospital, bed, and health technician allocation by population remained below 0.2, while that by geographical area ranged from 0.4 to 0.6; the G of government financial subsidies by population was above 0.4, while that by geographical area was greater than 0.7. The results for T showed that inequality mainly comes from intraregional differences, and the Pearl River Delta contributes most to the overall differences. Although the HRDI of the Pearl River Delta is far greater than that of other regions, obvious differences exist across cities in the region. Only 38.1% of cities were found to be efficient in 2020. The Pearl River Delta was in the first quadrant, and the other three regions were in the third quadrant, accounting for a large proportion.

Conclusion

The equity of government financial subsidies allocation was the worst, and there were distinct regional differences in the geographical distribution of health resources. The development of healthcare within the Pearl River Delta was highly unbalanced. The development of healthcare was uneven between the Pearl River Delta, eastern, western, and mountainous regions. In addition, most cities in the eastern, western, and mountainous regions bore the dual pressures of relatively insufficient health resources and inefficiency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01741-1.

Levels, trends, and determinants of effectiveness on the hierarchical medical system in China: Data envelopment analysis and bootstrapping truncated regression analysis

Background

The hierarchical medical system (HMS) refers to the classification of treatment according to disease priorities based on severity and difficulty to promote the fairness of medical services for residents, which is regarded as the key to the success of medical reform in China.

Methods

In the past decade of "New Medical Reform," the efficiency of HMS, including secondary and tertiary hospitals and primary healthcare centers (PHCs), was measured horizontally and vertically by employing the combination of an output-oriented superefficiency slack-based model-data envelopment analysis (SE-SBM-DEA) model with the Malmquist total factor productivity index (MTFP). In the second stage, the overall technical efficiency (OTE) scores were regressed against a set of environmental characteristics and several managerial factors through bootstrapping truncated regression.

Results

On average, the OTE score in tertiary hospitals was 0.93, which was higher than that in secondary hospitals and PHCs (0.9 and 0.92, respectively). In terms of trend, the OTE of tertiary hospitals declined at first and then increased. The opposite was true of secondary hospitals, in which the APC of the OTE was 10.82 and -3.11% in early and late 2012, respectively. The PHCs generally showed a fluctuating downward trend. In the aspects of productivity, all institutions showed a downturn by an annual average rate of 2.73, 0.51, and 2.70%, respectively. There was a significant negative relationship between the ratio of outpatients to inpatients and tertiary hospitals. Additionally, the medical technical personnel per 1,000 population negatively affected PHCs. In contrast, the GDP per capita had a significantly positive effect on tertiary hospitals, and the number of beds per 1,000 population positively influenced PHCs.

Conclusion

The efficiency of medical institutions at various levels in HMS was unbalanced and took the form of an "inverted pyramid." Multilateral factors influence the efficiency of HMS, and to address it, multi-intervention packages focusing on sinking high-quality medical resources and improving healthcare capacity, and guiding hierarchical medical practice should be adopted.

A Multi-Criteria Approach to Assess the Performance of the Brazilian Unified Health System

Brazil's Unified Health System (SUS) provides universal free access to health services and is considered a model for the rest of the world. One of the tools used by the Brazilian government to assess this system is the Index of Unified Health System Performance (IDSUS). However, this method has a number of limitations, such as disregarding the opinion of healthcare decision makers. Thus, the aim of the present study was to propose a model based on the R-TOPSIS in order to assess the performance of the SUS. Methodologically, the main steps for proposing multi-criteria models were followed, and to validate the model, a real case study with a set of six cities (alternatives) of the state of São Paulo was used. The results provide a clearer picture of the differences in terms of potential and obtained access, as well as the effectiveness of health services in the cities analyzed. Likewise, the proposal of integrating multiple criteria as well as considering healthcare decision makers proved to be decisive for the results obtained, even in comparison with the other approaches. It was concluded that the proposed method provides a robust and adequate analysis of health systems performance.

How is the medical service efficiency in China? An empirical analysis using stochastic frontier approach and gravity models

The COVID-19 has heightened the focus of medical services. Scientifically evaluating the efficiency of medical services and defining their spatial transmission relationship is crucial for the rational allocation of health resources and the accomplishment of balanced regional medical service growth. We used a Stochastic Frontier Model to calculate medical service performance in Chinese provinces and the Gravity Model to study the spatial relationship of medical service performance across provinces using data from 2009 to 2018. We discover that: (1) population density and proportion of technical personnel are significantly positively correlated with the efficiency of regional medical services, whereas health institution density has a significantly negative influence. Their respective influence coefficients were 1.717, 0.647, and 0.407. (2) In China, the regional development of medical service efficiency is unbalanced. The east, middle, and west multi-year average medical service efficiency were 0.65, 0.46, and 0.53, respectively, and their gaps were narrowing; the south and north average efficiency were 0.591, 0.516, respectively, and their gaps were widening. (3) Our medical efficiency network is not yet widespread in the country. Hubei, Henan, Shandong, Jiangsu, Zhejiang, and Beijing were at the centre of the medical efficiency network, driving and connecting the nation's medical service. Our findings offer specific recommendations for better understanding and improving the efficiency of medical services.

Selecting the most suitable organizational structure for hospitals: an integrated fuzzy FUCOM-MARCOS method

Background

Previous studies mentioned four organizational structures for hospitals, which are budgetary, autonomous, corporate, and private. Nevertheless, healthcare decision-makers are still required to select the most organizational structure specific to their circumstances. The present study aims to provide a framework to prioritize and select the most suitable organizational structure using multicriteria decision-making (MCDM) methods in Iranian hospitals.

Methods

First, a multicriteria decision-making model consisted of the respective criteria, and alternatives were developed. The pertinent criteria were identified through a systematic literature review. The coefficient weights of the identified criteria were then calculated using FUCOM-F. Finally, organizational structures were prioritized in accordance with the identified criteria using FMARCOS.

Results

The findings reveal that income is the most significant criterion in selecting organizational structures for hospitals whereas the number of outpatient visits is the least important. Also, the private structure is the most appropriate, and budgetary style is the least suitable organizational structure for Iranian hospitals.

Conclusion

Providing a framework in order to select the most appropriate organizational structure could help managers and policymakers of the healthcare sector in Iran and other countries, mainly similar developing countries.

The Effect of Medical Choice on Health Costs of Middle-Aged and Elderly Patients with Chronic Disease: Based on Principal-Agent Theory

(1) Background: The discussion on how to reduce the health costs of chronic disease patients has become an important public health issue. Limited research has been conducted on how chronic disease patients’ medical choice of public and private medical institutions affect health costs. (2) Methods: This study used the panel data composed of the China Health and Retirement Longitudinal Survey (CHARLS) from 2011 to 2018, adopted the quasi-natural experimental research method, and set up a control group and an experimental group that chose public medical institutions and private medical institutions, to analyze the association between the medical choice and health costs of chronic disease patients. (3) Results: Compared with chronic disease patients who chose private medical institutions, patients who chose public medical institutions increased their total cost by 44.9%, total out-of-pocket cost by 22.9%, and decreased the total out-of-pocket ratio by 0.117%, total drug cost out-of-pocket ratio by 0.075%, and drug cost ratio by 0.102%. (4) Conclusions: According to the triple principal-agent relationships, the resource advantages given by the government to public medical institutions, the salary incentive system of medical institutions, and the information asymmetry advantage held by physicians may be important factors for the increase in health costs for chronic disease patients.

Do China rural traditional Chinese medicine hospitals provide efficient healthcare to the people? Empirical study from 2013 to 2018 using data envelopment analysis

Rural traditional Chinese medicine hospitals bear responsibilities of providing efficient medical services for rural residents. Efficiency assessments have previously been conducted in single province. This study aimed to investigate the technical efficiency of rural traditional Chinese medicine hospitals across China from 2013 to 2018, with the application of super slack-based measure data envelopment analysis. In total, 1219 hospitals covering 28 provinces were included as sample hospitals. Overall, hospitals performed technically less efficiently but presented with an increasing trend. Redundancy and insufficiency existed in health input and output variables, respectively. Notably, optimizing input variables was found to make more substantial improvement in hospital efficiency. Provincial and regional disparities were also observed in hospital efficiency. In conclusion, rural traditional Chinese medicine hospitals have experienced slight improvement in efficiency during the study period, however, their efficiency was still in a relatively low level with ample room for improvement. Meanwhile, regional coordinated development should also be noticed in this process.

Association between hospital and ICU structural factors and patient outcomes in China: a secondary analysis of the National Clinical Improvement System Data in 2019

Background

Hospital and ICU structural factors are key factors affecting the quality of care as well as ICU patient outcomes. However, the data from China are scarce. This study was designed to investigate how differences in patient outcomes are associated with differences in hospital and ICU structure variables in China throughout 2019.

Methods

This was a multicenter observational study. Data from a total of 2820 hospitals were collected using the National Clinical Improvement System Data that reports ICU information in China. Data collection consisted of a) information on the hospital and ICU structural factors, including the hospital type, number of beds, staffing, among others, and b) ICU patient outcomes, including the mortality rate as well as the incidence of ventilator-associated pneumonia (VAP), catheter-related bloodstream infections (CRBSIs), and catheter-associated urinary tract infections (CAUTIs). Generalized linear mixed models were used to analyse the association between hospital and ICU structural factors and patient outcomes.

Results

The median ICU patient mortality was 8.02% (3.78%, 14.35%), and the incidences of VAP, CRBSI, and CAUTI were 5.58 (1.55, 11.67) per 1000 ventilator days, 0.63 (0, 2.01) per 1000 catheter days, and 1.42 (0.37, 3.40) per 1000 catheter days, respectively. Mortality was significantly lower in public hospitals (β =  − 0.018 (− 0.031, − 0.005), p = 0.006), hospitals with an ICU-to-hospital bed percentage of more than 2% (β =  − 0.027 (− 0.034, -0.019), p < 0.001) and higher in hospitals with a bed-to-nurse ratio of more than 0.5:1 (β = 0.009 (0.001, 0.017), p = 0.027). The incidence of VAP was lower in public hospitals (β =  − 0.036 (− 0.054, − 0.018), p < 0.001). The incidence of CRBSIs was lower in public hospitals (β =  − 0.008 (− 0.014, − 0.002), p = 0.011) and higher in secondary hospitals (β = 0.005 (0.001, 0.009), p = 0.010), while the incidence of CAUTIs was higher in secondary hospitals (β = 0.010 (0.002, 0.018), p = 0.015).

Conclusion

This study highlights the association between specific ICU structural factors and patient outcomes. Modifying structural factors is a potential opportunity that could improve patient outcomes in ICUs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03892-7.

The Efficiency Evaluation of Municipal-Level Traditional Chinese Medicine Hospitals Using Data Envelopment Analysis After the Implementation of Hierarchical Medical Treatment Policy in Gansu Province, China

Background: Efficiency evaluation is an integral part of new medical reform and is necessary to solve the problem of limited and unbalanced medical resources. This study evaluated the efficiency of municipal-level Traditional Chinese Medicine hospitals by Data Envelopment Analysis application after a hierarchical medical treatment policy was implemented. We propose solutions to the problems existing in hospital operations and promote the utilization efficiency of medical resources in those hospitals. Methods: The sample included all municipal-level TCM hospitals in Gansu province from 2017 to 2019. The DEA-BCC model was employed to evaluate the relative efficiency of hospital operations, and the Manny-Whitney test was used to compare the input and output variables of technical efficiency efficient and inefficient hospitals. Results: From 2017 to 2019, the growth in the number of staff in secondary hospitals (25.88%) was lower than that in tertiary hospitals (31.98%). However, the increase in the number of beds (16.52%) in secondary hospitals was higher than that in tertiary hospitals (−0.30%). 5 (38.46%) achieved DEA efficient in secondary hospitals and 2 (40.00%) in tertiary hospitals. The means of technical efficiency, pure technical efficiency, and scale efficiency in secondary hospitals were 0.812, 0.887, and 0.908, respectively. The means in tertiary hospitals were 0.868, 0.926, and 0.935, respectively. The hospital areas were statistically different between the TE efficient and inefficient hospitals (P<0.05) in secondary hospitals. However, the number of outpatients between the two groups was statistically different (P<0.05) in tertiary hospitals. Conclusion: In this study, the medical and health services of municipal TCM hospitals in Gansu Province have made great progress. Due to the backward economy of Gansu Province, the classification of diagnosis and treatment of diseases was still based on Western medicine, resulting in the slow medical development of some municipal TCM hospitals. TCM hospitals should improve management efficiency, optimize hospital operation scale, improve the utilization efficiency of medical resources and promote efficient hospital development.

Efficiency and Productivity of Public Hospitals in Serbia Using DEA-Malmquist Model and Tobit Regression Model, 2015-2019

Improving productivity within health systems using limited resources is a matter of great concern. The objectives of the paper were to evaluate the productivity, efficiency, and impact of environmental factors on efficiency in Serbian hospitals from 2015-2019. Data envelopment analysis, Malmquist index and Tobit regression were applied to hospital data from this period, and public hospitals in Serbia exhibited a great variation regarding their capacity and performance. Between five and eight hospitals ran efficiently from 2015 to 2019, and the productivity of public hospitals increased whereas technical efficiency decreased in the same period. Tobit regression indicated that the proportion of elderly patients and small hospital size (below 200 beds) had a negative correlation with technical efficiency, while large hospital size (between 400 and 600 beds), the ratio of outpatient episodes to inpatient days, bed turnover rate and the bed occupation rate had a positive correlation with technical efficiency. Serbian public hospitals have considerable space for technical efficiency improvement and public action must be taken to improve resource utilization.

Governmental Investments in Hospital Infrastructure Among Regions and Its Efficiency in China: An Assessment of Building Construction

Hospital infrastructure has been addressed as the prerequisite of healthcare delivery which intensively affects medical quality. Over the past decade, China has proposed a series of investment plans for hospital infrastructure in order to promote healthcare development in underdeveloped regions. Focusing on the construction of hospital buildings as the key component of hospital infrastructure, this study aims to examine whether the investment efficiency is lower where a government prioritizes equity and to explore what kind of geographical predispositions should be embedded in governmental investment plans for hospital infrastructures from the perspectives of both investment equity and efficiency. Relevant data from 330 governmental-invested hospital building construction projects in Sichuan province, China, from 2009 to 2018 were collected. Concentration index was used to evaluate the equity in the distribution of the investments. Tobit model was employed to explore the relationship between regional economic development and investment efficiency measured by an integrated approach of principal component analysis and data envelopment analysis. The results demonstrated a slight concentration of governmental investments in economically developed regions, while a negative association with regional economic development was identified with investment efficiency. Our study illustrated the investment efficiency was higher where a government prioritized equity and provided empirical evidences on switching governmental investment predisposition in the aspect of healthcare infrastructure construction toward less developed regions in China from the perspectives of both investment allocation equity and efficiency, which would further assist in the formulation of region-specific policies and strategies for underdeveloped regions.

What Drives Outpatient Care Costs in Kenya? An Analysis With Generalized Estimating Equations

Objective: This study aimed to identify the factors associated with outpatient expenses incurred by households in Kenya.

Background: The problem of outpatient healthcare expenses incurred by citizens in countries with limited resources has received little attention. Thus, this study aimed to determine the predictors of household spending on outpatient expenses in Kenya.

Method: We conducted a cross-sectional analysis on households in Kenya using data from the 2018 Kenya Household Health Expenditure and Utilization Survey. We applied the generalized estimating equations method to determine the best subset of predictors of outpatient care cost.

Findings: The best predictors of outpatient care expenses in Kenya are age, wealth index, and education level of the household head.

Conclusions: There were no differences regarding age in the mean spending on outpatient care. Moreover, we found that the cost of outpatient care changes with age in a sinusoidal manner. We observed that rich households spent more on outpatient care, mostly owing to their financial ability. Households whose heads reported primary or secondary school education level spent less on outpatient costs than households headed by those who never went to school.

Application of the DEA Model in Tourism SMEs: An Empirical Study from Slovakia in the Context of Business Sustainability

Slovak spa services are not given sufficient attention directly following the support and sustainable development. The paper focuses on the evaluation of the overall development and current level of efficiency of the Slovak spas in 2013–2018, through the application of DEA models. Input variables (total number of beds, employees, medical staff) and output variables (use of bed capacity, number of treated clients) within the structure of DEA models analyzed (CCR-I, CCR-O, BCC-I, BCC-O) are determined by results of the correlation analysis. The data were obtained from the annual reports of the spa enterprises. By the results, the average efficiency score for all enterprises reached 0.7527, i.e., the average spa enterprise would need only 75.27% of currently used inputs for a given output production to move to the efficiency frontier. The development of the average efficiency score confirmed a positive growing trend until 2015; however, the efficiency decreased by 1.84% in a year-to-year comparison in 2016–2018. In each year of the analyzed period, the number of inefficient enterprises (66.67%) exceeded that of the efficient ones (33.33%). Through research carried out in spa facilities, the authors contributed to expanding the application of the DEA method in another tourism sector.

Technical Efficiency of Regional Public Hospitals in China Based on the Three-Stage DEA

Many countries are facing the increasing cost of healthcare services and the low efficiency of public hospitals. These issues are also evident in China. This paper offers a comprehensive assessment of the efficiency of public hospitals operating in China’s 31 regions. The impact of the third round of reform of the health system in 2009 is assessed based on the three-stage data envelopment analysis procedure. The time period from 2011 to 2018 is covered in this study. Due to different functions performed by the public hospitals and other ones, the number of patients with infectious diseases is incorporated as an output variable reflecting the social function. The outpatient visits and inpatient visits are considered to reflect the outputs related to the private functions. The results imply an increase in the mean efficiency of public hospitals from 0.927 to 0.981 after taking the impact of environmental variables and statistic noise into account. These results indicate that the efficiency of public hospitals is dependent in the operational environment. There are 11 regions whose hospitals operate on the efficiency frontier during the whole period covered. Therefore, the Chinese government should reasonably design and apply the regulatory tools to improve the efficiency of public hospitals.

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.

Healthcare and Welfare Policy Efficiency in 34 Developing Countries in Asia

The healthcare and welfare policies of nations, as well as the amount of investments put into these areas, vary across countries. Investments in healthcare and welfare have been increasing worldwide which brings the question of assessing the efficiency of these investments. There are, however, difficulties in evaluating the effectiveness of such investments due to differences in countries’ economic development levels and due to the differences in data definition issues. There are only a limited number of studies in the literature that employ consistent and comparable indicators across countries. This study evaluates the healthcare investment efficiency and health competitiveness efficiency of 34 developing countries in Asia using a two-stage dynamic data envelopment analysis approach. Furthermore, we employ a broader measure of indicators on national healthcare and welfare policies and outcomes, in addition to the investment data on healthcare and welfare expenditures. Our findings indicate that the establishment of an investment environment with a consolidated approach and management is an important factor that increases the efficiency of investments in healthcare and welfare sectors. A consistent delivery of the national policy strategy is also crucial for reaching the medium-and long-term targets for each country. For example, if a country establishes healthcare and welfare policies that focus on improving its indicators with low efficiencies, the output will be improved and a better return on investment will be ensured in a long-term perspective.