The Efficiency Measurement And Its Determinants In The Tertiary Public General Hospitals Under The Constraints Of Resource And Quality

[Purpose]This study aims to incorporate medical resource and quality into the measurement of hospital technical efficiency(TE),and analyze its determinants under the constraints of resource and quality,and provide empirical evidence and policy suggestions for the efficiency improvement in hospitals.[Methods]This study investigated 30 tertiary public general hospitals during 2013-2017 in Shanxi Province.Our data sources included the front page of inpatients medical records from 2013 to 2017 of the sample hospitals,operation data of the sample hospitals in the summary statistics table 1-1,Shanxi Statistical Yearbook 2014-2018,and policy documents from official websites.In the section of model building,based on the results of literature review concerning the hospital eff-iciency research,we chose the in-hospital mortality of acute myocardial infarction,heart failure and pneumonia to capture the medical quality of the sample hospitals.We chose 12 experts and conducted two rounds of experts’ consultation to determine the input and output indicators for the efficiency measurement under the constrains of resource and quality.Based on the risk adjustment model,Slack-based Directional Distance Function(SBM-DDF),and Tobit quantile regression,we built the framework for hospital efficiency measurement and determinants analysis under the constraints of resource and quality.In the section of empirical study,two-level logistic regressions were applied to calculate the risk-adjusted mortality rates following acute myocardial infarction(N=56258),heart failure(N=21336)and pneumonia(N=45338)in each hospital during 2013-2017,adjusting for the patient-level confounders.SBM-DDF was used to measure hospital inefficiency scores.σ andβ convergence tests were used to analyze the convergence of hospital TEs.Panel Tobit regression with random effect and Bayesian Tobit quantile regression were used to analyze the determinants of hospital efficiency.[Results]1.The framework for hospital efficiency measurement and determinants analysis under the constraints of resource and qualityBased on the literature review and experts’ advice,we built a framework for hospital efficiency measurement and determinants analysis under the constraints of resource and quality.First,the risk adjusted mortalities for patients with acute myocardial infarction,heart failure and pneumonia were treated as output variables.SBM-DDF model was used to incorporate the constraints of resource and quality into the framework of hospital efficiency measurement.Second,based on Tobit regression with panel data,we built the Bayesian Tobit Quantile regression to further analyze the determinants of hospital efficiencies.This model extended the determinants analysis of hospital efficiency from mean regression to quantile regression,and solved the methodological problems of traditional quantile regression,such as the truncated data and the failed convergence.2.Risk adjustment of mortalityWe made the mortality risk adjustment models for patients with acute myocardial infarction(N=56258),heart failure(N=21336)and pneumonia(N=45338),respectively.The C-statistics for all mortality risk adjustment models were over 0.8,which suggested that these models have good predictability and our results are reliable.After the risk adjustment,the disease mortality of each hospital changed significantly,which can reflect the variations in quality of care and was in favor of the fair comparison of the quality between hospitals.3.Hospital efficiency measurement and convergence test(1)The average inefficiency score of our sample hospitals under resource constraint was 0.227,while the average inefficiency score under resource and quality constraints was 0.143.After incorporating the quality constraint,we found that the rank of hospital efficiencies changed significantly(P<0.001),and the main source of hospital inefficiency changed from the outpatient and emergency visits(51.5%)to the medical quality represented by the mortalities of typical diseases(38.5%).(2)Overall,the sample hospitals with resource and quality constraints had σ convergence,absolute and conditional β convergence,suggesting that the efficiency gap between hospitals will gradually shrink.However,under the resource constraint,they had absolute and conditional β convergence but no σ convergence,which indicated that the efficiency gap between hospitals will not shrink.4.Efficiency determinants analysis(1)From the perspective of mean regression,bed occupancy rate(P=0.001),doctor-nurse ratio(P=0.057)and population density(P=0.074)had statistically significant and positive effects on hospital TEs,while length of stay(P=0.004)and hospital beds per 1000 populations(P=0.015)had significant and negative effects on TEs.(2)From the perspective of quantile regression,the positive effect size of bed occupancy rate and the negative effect sizes of length of stay increased gradually as the quantile of hospital TE increases.The outpatient-inpatient ratio,doctor-nurse ratio,and hospital beds per 1000 populations were associated with hospital TEs significantly at the<0.1 quantiles,>0.7 quantiles and>0.8 quantiles,respectively.[Conclusion]1.The outputs of hospital operation include both quantity and quality of medical services.Measuring hospital efficiency under the constraints of medical resource and quality could reflect the medical services better and get more accurate efficiency scores.2.Under the constraints of resource and quality,medical quality is the key factor influencing the technical inefficiencies of the tertiary public general hospitals in Shanxi.Continuous quality improvement is the key direction to improve hospital efficiency.3.The efficiency convergence of the tertiary public general hospitals in Shanxi may be associated with the connotation of hospital efficiency.The efficiency score under the constraints of resource and quality accounted for both quantity and quality of medical services and the efficiency gap between hospitals would gradually shrink.4.Under the constraints of resource and quality,the effect of each determinant on hospital efficiency is related to hospital’s own efficiency level.5.The following policy measures are recommended for improving hospital efficiency:(1)turn the model and idea of efficiency measurement,and guide hospitals to the connotative development path;(2)enhance the management of medical quality,and improve the utilization efficiency of high quality resource;(3)promote scientific evaluation of medical quality,and improve quality and efficiency simultaneously;(4)promote supply-side structural reforms and promote hospital efficiency.[Innovation and limitation]1.Innovations(1)This is the first study that introduces SBM-DDF into the efficiency measurement in healthcare industry.We build a research framework for hospital efficiency measurement under the constraints of resource and quality,which enriches the connotation of hospital efficiency.Additionally,the idea of quantile regression and Bayesian inference technique were introduced into the analysis of hospital efficiency determinants,which shifted the research attention of hospital efficiency determinants analysis from "mean regression" to "quantile regression".It could enrich people’s understanding of the differences in hospital efficiencies and provide valuable suggestions for policymakers.(2)Our results revealed that medical quality is the main source of hospital inefficiency and suggested that continuous improvement of medical quality is an important direction to improve hospital efficiency.In addition,we found that the effects of determinants on hospital efficiency varied by hospital efficiency level,suggesting that hospital managers should consider their own efficiency level when they make the strategy for efficiency improvement.2.LimitationsFirst,we only included 30 tertiary public general hospitals from Shanxi Province.The results based on the data from Shanxi may not be generalized into other areas in China.Second,the selected quality indicators may only partially reflect the medical quality in hospital,further research is warranted to investigate how to reflect comprehensive hospital quality.Third,due to the data unavailability,this study could not analyze the effects of some important internal and external determinants on hospital efficiency,such as hospital financial factors,hospital management system,and medical service price regulation.Lastly,although the association between hospital efficiency and its determinants was analyzed in this study,we cannot identify the underlying mechanism.