| [Purpose]The overall objective of this study was to estimate tertiary public general hospital efficiency based on hospital medical service quality and quantity,and to provide references and basis for hospital quality and efficiency improvement.Specific objectives include:to estimate the hospital disease quality based on risk adjustment theory.To eastimate the hospital efficiency with desirable outputs by applying modified hospital efficiency evaluation model,and explore the relationship between hospital quality and efficiency.To establish the hospital efficiency evaluation model considering hospital medical quality and quantity in assessing the hospital comprehensive efficiency.[Methods]This study selected 31 tertiary public general hospitals in Shanxi Province from 2013 to 2015 as the research objects.Sample hospitals operation data and patients electronic medical records data were mainly collected from hospitals Health Information Systems.Hospitals external data were mainly collected from China Health Statistics Yearbook and Shanxi Statistics Yearbook.This study used SPSS 21.0,Stata 14.0,R studio,MaxDEA Pro 6.18,DEAP 2.1 software in data descriptive analysis,statistical tests,hospitals quality and efficiency calculation,and so on.Literature research method was used to systematically arrange the medical quality and efficiency evaluation theories,the evaluation methods and models,and the research progress and trends.Experts’ consultation and focus group discussion methods were employed to determine the typical diseases,quality indicators,input-output indicators and efficiency estimation model.Descriptive statistical analysis,chi-square test and nonparametric test were used to analyze the changes of hospitals input and output indicators,the statistically significant difference of efficiency among different hospital size.Multilevel logistic regression model was applied to standardize medical quality indicators among sample hospitals.A modified three-stage DEA efficiency evaluation model was used to evaluate hospital efficiency with desirable outputs.Quadrant grouping analysis and clustering analysis were used to analyze the relationship between hospital quality and efficiency.A modified three-stage SBM-Undesirable efficiency evaluation model with considering hospital medical service quality and quantity was used to evaluate hospital comprehensive efficiency.[Results]1.Risk-adjusted quality analysis results in sample hospitals(1)The AUC indexes,under the ROC curves,of the 4 typical disease(AMI,HF,stroke and pneumonia)risk-adjustment quality regression model were greater than 0.7,indicating a good predictive effect can obtain reliable quality scores.(2)The model results showed that:advanced age.more times of hospitalization,emergency and severe condition,higher CCI index are major risk factors for adverse outcomes,while the increase number of doctors and nurses per hundred beds and higher disease services volume are main protection factors for patients to get adverse outcome.(3)The diseases quality changed obviously before and after risk-adjustment in sample hospitals.The quality risk-adjustment was in favor of the fair comparison of the quality between hospitals.2.The hospital efficiency evaluation results with desirable outputs,and the relationship between quality and efficiency of sample hospitals(1)The sample hospitals efficiency is influenced by regional population scale,GDP per capita and government fiscal subsidies.The sample hospitals operated with low technical efficiency and scale inefficiency were the main reason after eliminating this influence factors.(2)The sample hospitals can obtain a high level of scale efficiency when hospital beds range from 1200 to 1800.(3)According to the quality-efficiency quadrant grouping analysis results,during 2013-2015,the sample hospitals quality improved gradually but appeared a downward trend in efficiency.Hospital resources allocation,medical service load and medical resources utilization are closely related to hospital quality-efficiency.(4)The samples hospitals can clustered into four groups by applying clustering analysis.The ordinal logistic regression results indicated that the number of hospital doctors,hospital beds,the proportion among doctors,nurses and beds,and the average length of stay had a significant effect on the quality and efficiency of the sample hospitals(P<0.05).3.The comprehensive efficiency results of samples hospitals based on quality(1)A significant difference in hospital efficiency before and after hospital medical quality was treated as undesirable output(P<0.001).Hospital efficiency became lower and hospital ranks changed after hospital quality was considered in the model.(2)Following the hospital medical quality was considered,the suitable beds scale for tertiary public general hospitals is 800-1600.which is narrowed comparing to the previous results.(3)According to the Malmquist-luenberger index results,the total factor productivity change(TFPC)in sample hospitals obtained growth at an average annual rate of 0.14%during 2013-2014 with non-significant(P>0.05),and retrogress at an average annual rate of 1.96%during 2014-2015(P<0.05).TFPC overall deteriorated at an average annual rate of 0.92%in the three years(P<0.05).There is significant difference in TFPC among the different hospital scale(P<0.05).In addition,except for the hospital with 500-1000 beds obtained TFPC improved,all other hospitals presented deterioration in TFPC,of which the main reason was the technological change(TC)retrogression.[Conclusions and Policy Implications]1.Conclusions:(1)During 2013-2015,the sample hospitals experienced a steady development with hospital inputs and outputs improvement.(2)The efficiency of the sample hospitals was influenced by environmental factors and random errors,eliminating this influence factors can help the hospital managers to get true hospital efficiency and make accurate decisions.(3)Risk adjustment model can improve the accuracy of hospital medical quality evaluation and the comparison fairness between hospitals.The risk and protect factors of the medical quality analyzed in the risk-adjustment model can provide directions and references for hospitals quality improvement.(4)There is a trade-off between quality and efficiency in the sample hospitals.The hospital resource allocation,service load,and resources utilization are closely related to hospital quality and efficiency.Measures that coordinate the proportion among doctors,nurses and beds,reasonably regulate medical services load and shorten the average length of stay would benefit the hospital efficiency and quality.(5)The hospital efficiency evaluation model,based on medical quality,can obtain more comprehensive and accurate efficiency scores.There is a significant difference between hospital efficiency after medical quality was considered as output.(6)From 2013 to 2015,the scale inefficiency was the main cause of the overall technical inefficiency,which suggested managers to pay attention to hospital scale.The sample hospitals experienced the total factor productivity change(TFPC)deterioration during 2013-2015.The main reason was the technological change(TC)retrogression,indicating the hospitals to innovate medical technology and management.(7)After considering hospital medical quality in the efficiency evaluation model,the suitable bed scale for tertiary public general hospitals is 800-1600.The suitable bed scale research method based on hospital quality can provide reference for future related studies.2.Suggestions:(1)To reasonablely regulate and control tertiary general hospital beds scale.(2)To promote the evaluation of the hospital efficiency scientifically,and make public the evaluation results.(3)To guide patient to obtain reasonable medical treatment.(4)To evaluate the hospital quality reasonably.facilitating continuous improvement of medical service quality.(5)To reasonably regulate the hospital fixed assets investment,improve hospital resource utilization.(6)To innovate hospital quality and efficiency management,and strengthen adverse event management.[Innovation and Limitation]Research Innovation:(1)This study applied multilevel logistic regression model risk-adjusted the medical quality indicators of the sample hospitals,which can help managers to obtain an impartial quality evaluation results.(2)A modified three-stage DEA efficiency evaluation model was established and first introduced to evaluate hospital efficiency.The model can eliminate the environmental and random error influences to obtain impartial and robust evaluation results.(3)A modified three-stage SBM-Undesirable efficiency evaluation model was established and first introduced to evaluate hospital efficiency.The model can take hospital service quality and quantity both into consideration to obtain comprehensive and accurate hospital efficiency scores.Research Limitation:This study selected 31 tertiary public general hospitals in Shanxi Province as sample hospitals,and the future studies need to bring into more hospitals.This study focus on the technical quality of sample hospitals,but patients perceived quality was excluded.Due to the differences of the medical records quality among the sample hospitals,indictors of readmission rate and the incidence of adverse events were not taken into consideration in the quality evaluation scheme. |
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