Measuring efficiency of long-term care units in Finland

Data Envelopment Analysis (DEA) was used to measure the nursing care efficiency of 64 long-term care units in Finland. New approaches introduced for evaluating efficiency were unit/ward level analysis, and the case-mix classification Resource Utilization Groups (RUG-III). Efficiency determinations were based on four DEA measures: cost, technical, allocative, and scale efficiency. The results indicated considerable variation in efficiency between units, suggesting that efficiency could be improved through better management and allocation of resources. Larger units seemingly operated more efficiently than smaller units. Allocative inefficiency resulted from using too many registered nurses and aides, and too few licensed practical nurses.     

Impact of Medicare Advantage penetration and hospital competition on technical efficiency of nursing care in US intensive care units

This study aimed to evaluate technical efficiency of US intensive care units and determine the effects of environmental factors on technical efficiency in providing quality of nursing care. Data were obtained from the 2014 National Database of Nursing Quality Indicators and the Centers for Medicare and Medicaid Services. Data envelopment analysis was used to estimate technical efficiency for each intensive care unit. Multilevel modeling was used to determine the effects of environmental factors on technical efficiency. Overall, Medicare Advantage penetration and hospital competition in a market did not create pressure for intensive care units to become more efficient by reducing their inputs. However, these 2 environmental factors showed positive influences on technical efficiency in intensive care units with certain levels of technical efficiency. The implications of the study results for management strategies and health policy may vary according to the levels of technical efficiency in intensive care units. Further studies are needed to examine why and how intensive care units with particular levels of technical efficiency are differently affected by certain environmental factors.     

Modeling efficiency at the process level: an examination of the care planning process in nursing homes

Objective. To examine the efficiency of the care planning process in nursing homes.
Methods: We collected detailed primary data about the care planning process for a stratified random sample of 107 nursing homes from Kansas and Missouri. We used these data to calculate the average direct cost per care plan and used data on selected deficiencies from the Online Survey Certification and Reporting System to measure the quality of care planning. We then analyzed the efficiency of the assessment process using corrected ordinary least squares (COLS) and data envelopment analysis (DEA).
Results: Both approaches suggested that there was considerable inefficiency in the care planning process. The average COLS score was 0.43; the average DEA score was 0.48. The correlation between the two sets of scores was quite high, and there was no indication that lower costs resulted in lower quality. For-profit facilities were significantly more efficient than not-for-profit facilities.
Conclusions. Multiple studies of nursing homes have found evidence of inefficiency, but virtually all have had measurement problems that raise questions about the results. This analysis, which focuses on a process with much simpler measurement issues, finds evidence of inefficiency that is largely consistent with earlier studies. Making nursing homes more efficient merits closer attention as a strategy for improving care. Increasing efficiency by adopting well-designed, reliable processes can simultaneously reduce costs and improve quality.     

Technical efficiency in the clinical management of critically ill patients

The purpose of this paper is to obtain empirical measures of performance in the management of critical patients treated in intensive care units (ICUs) and to evaluate the factors associated with performance, in a two stage approach. In the first stage, this paper uses an extended version of Data Envelopment Analysis (non-discretionary and categorical variables, and weight constraints under consideration) to obtain measures of technical efficiency in the treatment of 993 critical care patients in intensive care units in Catalonia (Spain) in 1991–92. The model incorporates accurate individual measures of illness severity from Mortality Probability Models (MPM II₀) and quality outcome measures in the input–output set to obtain non-biased efficiency measures. In the second stage, a loglinear regression model is applied to test a number of hypothesis about the role of different environmental factors—such as ownership, market structure, dimension, internal organization, diagnostic, mortality risk, etc.—to explain differences in the efficiency scores. © 1998 John Wiley & Sons, Ltd.     

The measurement of efficiency and productivity of health care delivery

The measurement of efficiency and productivity of health service delivery has become a small industry. This is a review of 317 published papers on frontier efficiency measurement. The techniques used are mainly based on non-parametric data envelopment analysis, but there is increasing use of parametric techniques, such as stochastic frontier analysis. Applications to hospitals and other health care organizations and areas are reviewed and summarised, and some meta-type analysis undertaken. Cautious conclusions are that public provision may be potentially more efficient than private, in certain settings. The paper also considers conceptualizations of efficiency, and points to dangers and opportunities in generating such information. Finally, some criteria for assessing the use and usefulness of efficiency studies are established, with a view to helping both researchers and those assessing whether or not to act upon published results. Copyright (c) 2008 John Wiley & Sons, Ltd.     

Functional status outcomes for assessment of quality in long-term care.

OBJECTIVE: Although decline in functional status has been recommended as a quality indicator in long-term care, studies examining its use provide no consensus on which definition of functional status outcome is the most appropriate to use for quality assessment. We examined whether different definitions of decline in functional status affect judgments of quality of care provided in Department of Veterans Affairs (VA) long-term care facilities. METHODS: Six measures of functional status outcome that are prominent in the literature were considered. The sample consisted of 15 409 individuals who resided in VA long-term care facilities at any time from 4/1/95 to 10/1/95. Activities of daily living variables were used to generate measures of functional status. Differences between residents' baseline and semi-annual assessments were considered and facility performance using the various definitions of functional status were described. RESULTS: The percentage of residents seen as declining in functional status ranged from 7.7% to 31.5%, depending upon the definition applied. The definition of functional status also affected rankings, z-scores, and 'outlier' status for facilities. CONCLUSION: Judgments of facility performance are sensitive to how outcome measures are defined. Careful selection of an appropriate definition of functional status outcome is needed when assessing quality in long-term care.     

Analyzing the ambiguous relationship between efficiency,quality and patient satisfaction in healthcare services: The case of public hospitals in Turkey

Objective

This paper empirically analyzes the effects of efficiency and structural quality on patient satisfaction in Turkish public hospitals. It also investigates the controversial relationship between hospital efficiency and structural quality for small, medium and large size hospitals in a comparative perspective.

Methods

Data envelopment analysis (DEA) is used to analyze the efficiencies of hospitals. Data concerning 523 public hospitals is obtained from Turkish Ministry of Health. Due to the missing data of some hospitals, the sample of this study is composed of the remaining 348 observations. Multiple regression analysis is used to evaluate the relationship between patient satisfaction as a dependent variable and structural quality, hospital efficiency and institutional factors as independent variables. Furthermore, stepwise process multiple regression analysis is used to analyze the moderator effects of hospital efficiency on the form of the relationship between quality and satisfaction.

Findings

The findings indicate that hospital efficiency changes the form of the relationship between structural quality and patient satisfaction as a moderator variable. The trade-off between quality and efficiency is found to vary depending on the hospital size. Negative correlation is found between quality and efficiency for small-size hospitals. However, positive correlation between efficiency and quality is found significant as indicated by Total Quality Management (TQM) approach for large-size hospitals. This study also provides the empirical evidence on the negative relationship between patient satisfaction and hospital size.

Conclusions

The effect of hospital efficiency on patient satisfaction might be improved for inefficient small and medium size hospitals by taking successful large hospitals as role models.     

The association between culture, climate and quality of care in primary health care teams

BACKGROUND: Culture and climate represent shared beliefs and values that may influence quality of care in health care teams, and which could be manipulated for quality improvement. However, there is a lack of agreement on the theoretical and empirical relationships between climate and culture, and their relative power as predictors of quality of care. This study sought to examine the association between self-report measures of climate and culture in primary care teams and comprehensive measures of quality of care. METHODS: The data were derived from a cross-sectional survey of 492 professionals in 42 general practices in England. Self-report measures of culture (the Competing Values Framework) and climate (the Team Climate Inventory) were used, together with validated measures of quality of care from medical records and self-report. RESULTS: The majority of practices could be characterized as 'clan' culture type. Practices with a dominant clan culture scored higher on climate for participation and teamwork. There were no associations between culture and quality of care, and only limited evidence of associations between climate and quality. CONCLUSIONS: The current analysis would not support the hypothesis that culture and climate are important predictors of quality of care in primary care. Although larger studies are required to provide a definitive test, the results may suggest the need for a more complex model of the associations between culture, climate and outcomes, and further research may be required into the interaction between culture and climate with other determinants of behaviour such as internal and external incentives.     

The quantile regression approach to efficiency measurement: insights from Monte Carlo simulations

In the health economics literature there is an ongoing debate over approaches used to estimate the efficiency of health systems at various levels, from the level of the individual hospital - or nursing home - up to that of the health system as a whole. The two most widely used approaches to evaluating the efficiency with which various units deliver care are non-parametric data envelopment analysis (DEA) and parametric stochastic frontier analysis (SFA). Productivity researchers tend to have very strong preferences over which methodology to use for efficiency estimation. In this paper, we use Monte Carlo simulation to compare the performance of DEA and SFA in terms of their ability to accurately estimate efficiency. We also evaluate quantile regression as a potential alternative approach. A Cobb-Douglas production function, random error terms and a technical inefficiency term with different distributions are used to calculate the observed output. The results, based on these experiments, suggest that neither DEA nor SFA can be regarded as clearly dominant, and that, depending on the quantile estimated, the quantile regression approach may be a useful addition to the armamentarium of methods for estimating technical efficiency.     

Measuring the productive efficiency and clinical quality of institutional long-term care for the elderly

The authors consider the association between productive efficiency and clinical quality in institutional long-term care for the elderly. Cross-sectional data were collected from 122 wards in health-centre hospitals and residential homes in Finland in 2001. Productive efficiency was measured in terms of technical efficiency, which was defined as the unit's distance from the (best practice) production frontier. The analysis employed stochastic production frontier estimation, where technical inefficiency in the production function was specified to be a function of ward characteristics and clinical quality of care. Several quality indicators based on the Resident Assessment Instrument, such as prevalence of pressure ulcers and depression with no treatment, were used in the analysis. The results did not reveal systematic association between technical efficiency and clinical quality of care. However, the prevalence of pressure ulcers, indicating poor quality of care was associated with technical efficiency, a fact which highlights the importance of including quality measures in the assessment of efficiency in long-term care.     

Family caregivers' viewpoints towards quality of long-term care services for community-dwelling elders in Taiwan

The population of elderly people in Taiwan is increasing rapidly, and long-term gerontology care has become an important issue in this greying society. The purpose of this study is to explore family caregivers' viewpoints and opinions regarding the long-term care services for community-dwelling older adults in Taiwan. A qualitative study was conducted between August and December of 2005. Fifty family caregivers agreed to participate in this study. Data were collected by focus group interviews, in order to obtain the experience and expectation of family caregivers concerning long-term care services in their daily lives. Through content analysis and peer discussion, the data were categorized into five major themes: (1) praise for the services; (2) flexibility of long-term care services; (3) comprehensiveness of long-term services; (4) linkage and extension of existing resources; and (5) activeness of service provision. Study findings from the family caregivers' viewpoints should contribute to the improvement of long-term care services and provide a basis for designing suitable programmes to enhance community-dwelling in situ elderly people care.     

数据包络分析模型在艾滋病母婴传播评价中应用

目的 以预防艾滋病母婴传播项目为例,探索数据包络分析方法在公共卫生项目技术效率评价中的应用.方法 采用包含不可控因素的数据包络分析(DEA)模型,以县为单位,测算85个项目县预防艾滋病母婴传播项目人类免疫缺陷病毒(HIV)检测工作的技术效率和规模效率.结果 85个预防艾滋病母婴传播项目县(HIV)检测工作的纯技术效率值平均为0.590,纯技术效率值为1的项目县共有11个,效率值最小为0.160,部分项目县属于技术效率较低的情况.85个项目县的规模效率值平均为0.884,规模效率值为1的项目县有6个,规模效率值最小为0.147,绝大多数项目县规模效率值>0.8.结论 包含不可控因素的DEA模型很好地解决了不可控因素对生产过程产生的影响及各决策单元(DMU)不可比的问题,消除了DEA在公共卫生应用领域的阻碍,可指导公共卫生项目管理尤其是绩效评价.     

Associations between technical quality of diabetes care and patient experience

Aims It has long been held that high‐quality care has both technical and interpersonal aspects. The nature and strength of any association between both aspects remain poorly explored. This study investigated the associations between diabetes patients’ reports of receiving recommended care (as measures of technical quality) and their experience and ratings (as measures of interpersonal care). Methods Using data from a cross section of 3096 patients with diabetes nested within 24 diabetes‐care‐networks, we conducted multilevel regression analysis of the relationships between nine indicators of receiving care recommended in practice guidelines and: six scales of patient experience and global ratings of general practitioner, nurses, and overall diabetes care. Results On average, reporting having received recommended care was associated with reporting better patient experience and ratings. The extent and frequencies of these associations varied across the different care processes. Receiving foot examination, physical activity advice, smoking status check, eye examination, and HbA_1c testing, but not nutritional advice, urine, cholesterol or blood pressure checks, were statistically associated with better patient experience and global ratings. Those who received HbA_1c testing rated their overall care 1.002 points higher (95% confidence interval: 0.726–1.278) on a scale of 0–10 than those who did not. Conclusions Higher self‐reported technical quality of care in diabetes appears to be frequently but not always associated with better experiences and ratings. It is possible that the former leads to the latter and/or that both share a common cause within providers. Both care aspects do not seem interchangeable during performance assessment.     

Technical,scale, and size efficiency in nursing home care: A nonparametric analysis of Connecticut homes

Maindiratta (1990) questioned the usefulness of the concept of scale efficiency in production as the most productive scale size (MPSS) usually requires altering the scale of output produced. If the decision making unit (DMU) is required to deliver a specific output bundle, then altering output along with the input scale to reach the MPSS is not a valid recommendation. He proposed a measure of the size efficiency of a DMU. In this paper, we apply Data Envelopment Analysis (DEA) to examine the levels of technical, scale, and size efficiency of individual nursing homes providing health care to the elderly. The data used relate to the operations of 140 nursing homes from Connecticut, USA during the year 1982–83. Maindiratta's model is input-oriented. By contrast, our study is output-oriented and we appropriately reformulate Maindiratta's model. The findings show that in several cases size efficiency is less than unity. This suggests that the most efficient production of output would require restructuring of the nursing home under investigation as more than one small unit. We also compare the efficiency levels of ‘for-profit’ homes with those of ‘not-for-profit’ homes.     

基于Network DEA模型的省际卫生资源配置效率动态分析与评价

  目的  基于31省市2007 — 2016年医疗卫生机构相关数据,分析资源配置效率,进一步对卫生资源进行回归预测,探讨各省市未来5年卫生资源投入产出规模与效率,为医疗卫生机构优化资源配置,提高效率提供依据,为卫生行政部门有效制定相关政策提供参考。  方法  采用网络DEA分析方法评价各省市效率,运用固定效应模型与随机效应模型进行回归预测,运用主成分分析对评价指标进行综合分析。  结果  31省市技术效率仅上海、河南和广东10年间均处于DEA有效;15个省市（占48.34 %）节点2效率高于节点1;东南部地区技术效率较高;西部地区10年间技术效率波动大;31省市5年预测效率均值达到0.95,高于10年效率均值;13个城市5年预测技术效率值均为DEA有效; 预测模型对各城市卫生资源投入规模有较好的指导作用。  结论  多数省市资源配置效率低下,省际差异大,东南地区技术效率较高;模型预测效率值有所提高,科学化定性定量的规划卫生资源投入规模与结构是必要的。     

Relationship between regulatory status,quality of care,and three-year mortality in Canadian residential care facilities: a longitudinal study

OBJECTIVES: To compare the mortality rate in regulated and unregulated facilities, controlling for confounding variables, and investigate the effect of care quality on residents' length of survival. DATA SOURCES/STUDY SETTING: At baseline, subjects were assessed in their living environment with respect to their functional autonomy, cognitive abilities, and quality of care. Vital status, disease-related information, and hospitalization data were retrieved three years later from the subjects' medical files. STUDY DESIGN: A three-year follow-up study of 299 residents from 88 long-term care facilities located in the province of Quebec, Canada. The effect of regulatory status and quality of care on length of survival was investigated by means of multivariable Cox proportional hazards regression models, from both traditional and competing risks perspectives. PRINCIPAL FINDINGS: Controlling for age, comorbidity, and baseline functional abilities, a resident's length of survival is not significantly influenced by the regulatory status of the facility in which he or she lived at baseline. However, residents with poor quality ratings at baseline had shorter survival times than those provided with good care. Median survival was 28 months among residents classified as receiving inadequate care compared to 41 months for those adequately cared for (p = 0.0217). CONCLUSIONS: The study suggests that quality of care has a much stronger influence on resident outcomes than regulation per se. This finding underscores the relevance of testing innovative interventions aimed at improving the quality of care provided in long-term care facilities, regardless of their regulatory status.     

Institutional arrangements and efficiency of health care delivery systems

This study examined the efficiency of health care delivery systems in 24 OECD countries. Practicing physicians, practicing nurses, inpatient beds, and pharmaceuticals were considered as inputs to treat populations of various age groups. Data envelopment analysis (DEA) was utilized to calculate efficiency. We also calculated input efficiency that should be helpful in determining excess number of physicians, nurses, inpatient beds, and pharmaceuticals consumed. Institutional arrangements affect efficiency: public-contract and public-integrated countries are more efficient than public-reimbursement countries. Countries in which physicians are paid in wages and salaries and countries with capitation have higher efficiency than fee-for-service countries. Countries in which a primary care physician acts as a gatekeeper are also more efficient than countries without gatekeepers.     

Managed care and technical efficiency

By focusing exclusively on consumer benefit, previous studies of the effects of managed care have ignored important hospital efficiency gains. This study uses the HCUP sample of hospitals for 1992-1996 to estimate a stochastic frontier model of hospital technical efficiency. After controlling for hospital and market area variables, the study finds strong evidence that increased managed care insurance in a given market is associated with improved technical efficiency in the area's hospitals, especially in tertiary cases. Using Battese and Coelli's one-stage method (1995), the coefficients estimates are more efficient than for two-stage methods found in the literature.