Miao Cai

Technical efficiency and productivity of Chinese county hospitals: an exploratory study in Henan province, China

Objectives Chinese county hospitals have been excessively enlarging their scale during the healthcare reform since 2009. The purpose of this paper is to examine the technical efficiency and productivity of county hospitals during the reform process, and to determine whether, and how, efficiency is affected by various factors. Setting and participants 114 sample county hospitals were selected from Henan province, China, from 2010 to 2012. Outcome measures Data envelopment analysis was employed to estimate the technical and scale efficiency of sample hospitals. The Malmquist index was used to calculate productivity changes over time. Tobit regression was used to regress against 4 environmental factors and 5 institutional factors that affected the technical efficiency. Results (1) 112 (98.2%), 112 (98.2%) and 104 (91.2%) of the 114 sample hospitals ran inefficiently in 2010, 2011 and 2012, with average technical efficiency of 0.697, 0.748 and 0.790, respectively. (2) On average, during 2010–2012, productivity of sample county hospitals increased by 7.8%, which was produced by the progress in technical efficiency changes and technological changes of 0.9% and 6.8%, respectively. (3) Tobit regression analysis indicated that government subsidy, hospital size with above 618 beds and average length of stay assumed a negative sign with technical efficiency; bed occupancy rate, ratio of beds to nurses and ratio of nurses to physicians assumed a positive sign with technical efficiency. Conclusions There was considerable space for technical efficiency improvement in Henan county hospitals. During 2010–2012, sample hospitals experienced productivity progress; however, the adverse change in pure technical efficiency should be emphasised. Moreover, according to the Tobit results, policy interventions that strictly supervise hospital bed scale, shorten the average length of stay and coordinate the proportion among physicians, nurses and beds, would benefit hospital efficiency.

A Systematic Review and Meta-Analysis of the Relationship Between Hospital Volume and the Outcomes of Percutaneous Coronary Intervention.

Abstract Previous reviews have suggested that hospital volume is inversely related to in-hospital mortality. However, percutaneous coronary intervention (PCI) practices have changed substantially in recent years, and whether this relationship persists remains controversial. A systematic search was performed using PubMed, Embase, and the Cochrane Library to identify studies that describe the effect of hospital volume on the outcomes of PCI. Critical appraisals of the methodological quality and the risk of bias were conducted independently by 2 authors. Fourteen of 96 potentiality relevant articles were included in the analysis. Twelve of the articles described the relationship between hospital volume and mortality and included data regarding odds ratios (ORs); 3 studies described the relationship between hospital volume and long-term survival, and only 1 study included data regarding hazard ratios (HRs). A meta-analysis of postoperative mortality was performed using a random effects model, and the pooled effect estimate was significantly in favor of high volume providers (OR: 0.79; 95% confidence interval [CI], 0.72–0.86; P < 0.001). A systematic review of long-term survival was performed, and a trend toward better long-term survival in high volume hospitals was observed. This meta-analysis only included studies published after 2006 and revealed that postoperative mortality following PCI correlates significantly and inversely with hospital volume. However, the magnitude of the effect of volume on long-term survival is difficult to assess. Additional research is necessary to confirm our findings and to elucidate the mechanism underlying the volume–outcome relationship.

Efficiency and productivity measurement of rural township hospitals in China: a bootstrapping data envelopment analysis

Objective Township hospitals (THs) are important components of the three-tier rural healthcare system of China. However, the efficiency and productivity of THs have been questioned since the healthcare reform was implemented in 2009. The objective of this study is to analyse the efficiency and productivity changes in THs before and after the reform process. Setting and participants A total of 48 sample THs were selected from the Xiaogan Prefecture in Hubei Province from 2008 to 2014. Outcome measures First, bootstrapping data envelopment analysis (DEA) was performed to estimate the technical efficiency (TE), pure technical efficiency (PTE) and scale efficiency (SE) of the sample THs during the period. Second, the bootstrapping Malmquist productivity index was used to calculate the productivity changes over time. Results The average TE, PTE and SE of the sample THs over the 7-year period were 0.5147, 0.6373 and 0.7080, respectively. The average TE and PTE increased from 2008 to 2012 but declined considerably after 2012. In general, the sample THs experienced a negative shift in productivity from 2008 to 2014. The negative change was 2.14%, which was attributed to a 23.89% decrease in technological changes (TC). The sample THs experienced a positive productivity shift from 2008 to 2012 but experienced deterioration from 2012 to 2014. Conclusions There was considerable space for TE improvement in the sample THs since the average TE was relatively low. From 2008 to 2014, the sample THs experienced a decrease in productivity, and the adverse alteration in TC should be emphasised. In the context of healthcare reform, the factors that influence TE and productivity of THs are complex. Results suggest that numerous quantitative and qualitative studies are necessary to explore the reasons for the changes in TE and productivity.

Using a two-stage data envelopment analysis to estimate the efficiency of county hospitals in China: a panel data study

Abstract Background Chinese county hospitals have substantially enlarged their scale and service volume since the new health-care reform in 2009. In the context of scale expansion, continuously efficient operations are important considerations. In this study, we aimed to estimate the efficiency of Chinese county hospitals after such expansion and to establish whether and how efficiency is affected by various factors. Methods We studied three kinds of efficiency: pure technical efficiency, scale efficiency, and technical efficiency (=pure technical efficiency × scale efficiency). We included 140 county hospitals from Henan province and 100 county hospitals from Jiangsu province during 2010–12. A two-stage data envelopment analysis was used. In the first stage, the efficiencies of county hospitals were estimated using data envelopment analysis. In the second stage, overall technical inefficiencies were regressed against two environmental factors and five institutional factors using Tobit regression. The Health and Family Planning Commission of Jiangsu and Henan province, China, provided us the data for hospital efficiency estimation. No patient information was involved in the study. Findings 20 (2·8%) of 720 sample hospital units were technically efficient overall, with a mean efficiency of 0·573 (SD 0·188). 39 (5·4%) were only technically efficient, and 94 (13·1%) were efficient in scale, with mean efficiencies of 0·615 (0·184) and 0·932 (0·132), respectively. Scatter plot of the relation between scale efficiency and hospital beds showed that Chinese county hospitals were likely to be efficient at roughly 200–600 beds. Tobit regression analysis showed that hospital size and average length of stay had negative associations with technical efficiency, whereas occupancy rate, bed-to-nurse ratio, and nurse-to-physician ratio are positively associated with technical efficiency. Moreover, hospitals in Jiangsu province are more efficient than those in Henan province. Interpretation The Chinese county hospitals sampled were technical inefficient, and pure technical inefficiency was the driving force. Useful ways to improve efficiency in these hospitals could include taking measures to improve pure technical efficiency, controlling hospital bed scale to balance efficiency with quality, coordinating the ratio of physicians, nurses, and beds, and improving the hospital management ability to reduce average length of stay and enhance bed usage. Funding This work was supported by the National Natural Science Foundation of China grant number 71173081. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

What Does a Hospital Survey on Patient Safety Reveal About Patient Safety Culture of Surgical Units Compared With That of Other Units

AbstractThe objective of this study was to examine the strengths and weaknesses of surgical units as compared with other units, and to provide an opportunity to improve patient safety culture in surgical settings by suggesting targeted actions using Hospital Survey on Patient Safety Culture (HSOPSC) investigation.A Hospital Survey on Patient Safety questionnaire was conducted to physicians and nurses in a tertiary hospital in Shandong China. 12 patient safety culture dimensions and 2 outcome variables were measured.A total of 23.5% of respondents came from surgical units, and 76.5% worked in other units. The “overall perceptions of safety” (48.1% vs 40.4%, P < 0.001) and “frequency of events reported” (63.7% vs 60.7%, P = 0.001) of surgical units were higher than those of other units. However, the communication openness (38.7% vs 42.5%, P < 0.001) of surgical units was lower than in other units. Medical workers in surgical units reported more events than those in other units, and more respondents in the surgical units assess “patient safety grade” to be good/excellent. Three dimensions were considered as strengths, whereas 5 other dimensions were considered to be weaknesses in surgical units. Six dimensions have potential to aid in improving events reporting and patient safety grade. Appropriate working times will also contribute to ensuring patient safety. Medical staff with longer years of experience reported more events.Surgical units outperform the nonsurgical ones in overall perception of safety and the number of events reported but underperform in the openness of communication. Four strategies, namely deepening the understanding about patient safety of supervisors, narrowing the communication gap within and across clinical units, recruiting more workers, and employing the event reporting system and building a nonpunitive culture, are recommended to improve patient safety in surgical units in the context of 1 hospital.

Does Level of Hospital Matter? A Study of Mortality of Acute Myocardial Infarction Patients in Shanxi, China:

This study compares risk-standardized mortality rates (RSMRs) of patients with acute myocardial infarction among tertiary A (typically, advanced urban hospitals with more than 800 beds), tertiary B (urban hospitals with more than 500 beds), and secondary A hospitals (rural and urban hospitals with less than 500 beds) in Shanxi, China. In all, 43 500 acute myocardial infarction inpatient records from 93 hospitals were included. Hierarchical logistic regression was used to estimate RSMRs, and Dunn’s post hoc test was used to make pairwise comparisons of RSMR between hospital levels. It was found that the median RSMRs of secondary A hospitals were significantly lower than those of tertiary A and tertiary B hospitals (at 1% and 10% significance level, respectively), while there was no significant difference between the median RSMRs in tertiary A and tertiary B hospitals. The reasons for significant disparity in quality of care among different hospital levels requires further exploration.

Bootstrapping data envelopment analysis of efficiency and productivity of county public hospitals in Eastern, Central, and Western China after the public hospital reform

China implemented the public hospital reform in 2012. This study utilized bootstrapping data envelopment analysis (DEA) to evaluate the technical efficiency (TE) and productivity of county public hospitals in Eastern, Central, and Western China after the 2012 public hospital reform. Data from 127 county public hospitals (39, 45, and 43 in Eastern, Central, and Western China, respectively) were collected during 2012–2015. Changes of TE and productivity over time were estimated by bootstrapping DEA and bootstrapping Malmquist. The disparities in TE and productivity among public hospitals in the three regions of China were compared by Kruskal–Wallis H test and Mann–Whitney U test. The average bias-corrected TE values for the four-year period were 0.6442, 0.5785, 0.6099, and 0.6094 in Eastern, Central, and Western China, and the entire country respectively, with average non-technical efficiency, low pure technical efficiency (PTE), and high scale efficiency found. Productivity increased by 8.12%, 0.25%, 12.11%, and 11.58% in China and its three regions during 2012–2015, and such increase in productivity resulted from progressive technological changes by 16.42%, 6.32%, 21.08%, and 21.42%, respectively. The TE and PTE of the county hospitals significantly differed among the three regions of China. Eastern and Western China showed significantly higher TE and PTE than Central China. More than 60% of county public hospitals in China and its three areas operated at decreasing return scales. There was a considerable space for TE improvement in county hospitals in China and its three regions. During 2012–2015, the hospitals experienced progressive productivity; however, the PTE changed adversely. Moreover, Central China continuously achieved a significantly lower efficiency score than Eastern and Western China. Decision makers and administrators in China should identify the causes of the observed inefficiencies and take appropriate measures to increase the efficiency of county public hospitals in the three areas of China, especially in Central China.SummaryChina implemented the public hospital reform in 2012. This study utilized bootstrapping data envelopment analysis (DEA) to evaluate the technical efficiency (TE) and productivity of county public hospitals in Eastern, Central, and Western China after the 2012 public hospital reform. Data from 127 county public hospitals (39, 45, and 43 in Eastern, Central, and Western China, respectively) were collected during 2012–2015. Changes of TE and productivity over time were estimated by bootstrapping DEA and bootstrapping Malmquist. The disparities in TE and productivity among public hospitals in the three regions of China were compared by Kruskal–Wallis H test and Mann–Whitney U test. The average bias-corrected TE values for the four-year period were 0.6442, 0.5785, 0.6099, and 0.6094 in Eastern, Central, and Western China, and the entire country respectively, with average non-technical efficiency, low pure technical efficiency (PTE), and high scale efficiency found. Productivity increased by 8.12%, 0.25%, 12.11%, and 11.58% in China and its three regions during 2012–2015, and such increase in productivity resulted from progressive technological changes by 16.42%, 6.32%, 21.08%, and 21.42%, respectively. The TE and PTE of the county hospitals significantly differed among the three regions of China. Eastern and Western China showed significantly higher TE and PTE than Central China. More than 60% of county public hospitals in China and its three areas operated at decreasing return scales. There was a considerable space for TE improvement in county hospitals in China and its three regions. During 2012–2015, the hospitals experienced progressive productivity; however, the PTE changed adversely. Moreover, Central China continuously achieved a significantly lower efficiency score than Eastern and Western China. Decision makers and administrators in China should identify the causes of the observed inefficiencies and take appropriate measures to increase the efficiency of county public hospitals in the three areas of China, especially in Central China.

Insurance status, inhospital mortality and length of stay in hospitalised patients in Shanxi, China: a cross-sectional study

Objectives To determine insurance-related disparities in hospital care for patients with acute myocardial infarction (AMI), heart failure (HF) and pneumonia. Setting and participants A total of 22 392 patients with AMI, 8056 patients with HF and 17 161 patients with pneumonia were selected from 31 tertiary hospitals in Shanxi, China, from 2014 to 2015 using the International Classification of Diseases, Tenth Revision codes. Patients were stratified by health insurance status, namely, urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), new cooperative medical scheme (NCMS) and self-payment. Outcome measures Inhospital mortality and length of stay (LOS). Results The highest unadjusted inhospital mortality rate was detected in NCMS patients independent of medical conditions (4.7%, 4.4% and 11.1% for AMI, HF and pneumonia, respectively). The lowest unadjusted inhospital mortality rate and the longest LOS were observed in UEBMI patients. After controlling patient-level and hospital-level covariates, the adjusted inhospital mortality was significantly higher for NCMS and self-payment among patients with AMI, for NCMS among patients with HF and for URBMI, NCMS and self-payment among patients with pneumonia compared with UEBMI. The LOS of the URBMI, NCMS and self-payment groups was significantly shorter than that of the UEBMI group. Conclusion Insurance-related disparities in hospital care for patients with three common medical conditions were observed in this study. NCMS patients had significantly higher adjusted inhospital mortality and shorter LOS compared with UEBMI patients. Policies on minimising the disparities among different insurance schemes should be established by the government.

Health insurance and quality and efficiency of medical care for patients with acute myocardial infraction in tertiary hospitals in Shanxi, China: a retrospective study

BACKGROUND Previous studies have shown that health insurance type affects patient outcomes, but empirical research on the effect of health insurance on quality and efficiency of care in China is scarce. This study aimed to determine whether there are health insurance-related differences in hospital care for acute myocardial infraction. METHODS Patients with a principal diagnosis of acute myocardial infraction were identified from inpatient discharge records of 27 tertiary hospitals in Shanxi, China from September 1, 2013, to October 31, 2014. Patients were classified into four health insurance categories: Urban Employee Basic Medical Insurance (UEBMI), Urban Residents Basic Medical Insurance (URBMI), the New Rural Cooperative Medical Scheme (NCMS), or uninsured (out-of-pocket). The outcomes of interest were in-hospital mortality, length of stay, and total cost. Multilevel logistic regression was applied for in-hospital mortality, and multilevel linear regression for log transformed LOS and total cost. All models were adjusted for patient and hospital characteristics. Limited information from patient medical records was extracted from a database and all records were anonymised. As such, no ethical approval was required for this study. FINDINGS We analysed records for 9075 patients. Compared with UEBMI group, in-hospital mortality was significantly lower for NCMS group (OR 0·613 [95% CI 0·438-0·859]) and uninsured group (0·477 [0·281-0·810]). Excluding patients who died during hospitalisation, compared with UEBMI group length of stay was shorter in the URBMI (coefficient of variable, -0·074 [95% CI -0·115 to -0·034]), NCMS (-0·116 [-0·139 to -0·093]) and uninsured (-0·146 [-0·177 to -0·114]) groups and total cost was lower in the URBMI (-0·067 [-0·130 to -0·004]), NCMS (-0·118 [-0·154 to -0·082]) and uninsured (-0·115 [-0·165 to -0·066]) groups. INTERPRETATION For patients hospitalized for acute myocardial infarction, health insurance type is significantly associated with quality and efficiency of care under current health policies in Shanxi, China. The underlying mechanism justifying this association should be explored further. FUNDING None.

Does A Medical Consortium Influence Health Outcomes of Hospitalized Cancer Patients? An Integrated Care Model in Shanxi, China

Objective: To assess the effect of the medical consortium policy on the outcomes of cancer patients admitted to secondary hospitals in Shanxi, China. Method: Electronic medical records of lung cancer (n = 8,193), stomach cancer (n = 5,693) and esophagus cancer (n = 2,802) patients hospitalized in secondary hospitals were used. Propensity score matching was used to match each patient enrolled in medical consortium hospitals with a counterpart admitted in non-medical consortium hospitals. Cox proportional hazard models were used to estimate the hazard ratio of patients enrolled different categories of hospitals. Results: The hazards of lung, stomach and esophageal cancer patients admitted in medical consortium hospitals were consistently and significantly lower than those admitted in non-medical consortium hospitals after adjusting for a number of potential confounders. Lower hazard ratios were associated with lung (hazard ratio (HR) = 0.533, p < 0.001), stomach (HR = 0.494, p < 0.001), and esophagus (HR = 0.505, p < 0.001) cancer patients in medical consortium hospitals. Conclusion: The medical consortium provides an effective strategy to improve the outcomes of cancer patients in Shanxi, China. The partnerships between top-tier hospitals and grassroots medical services bridge the gap in resources and plays a critical role in the quality of care in China.