Vassilis Aletras

A comparison of hospital scale effects in short-run and long-run cost functions.

Numerous estimates of economies of scale in the hospital setting have been obtained since the early 1980s from both flexible long-run and short-run cost functions. Although the theoretical superiority of the latter approach is widely recognized, it has been previously suggested that the two cost specifications yield quite similar econometric findings regarding scale effects. This paper utilizes a new data set consisting of 91 Greek NHS hospitals in order to empirically examine this proposition by comparing economies of scale estimates derived from both translog total and variable cost functions. The results indicate that the use of long-run equations might seriously mislead policy makers and that constant returns to scale prevail in Greek public hospitals.

The effect of environmental factors on technical and scale efficiency of primary health care providers in Greece

BackgroundThe purpose of this study was to compare technical and scale efficiency of primary care centers from the two largest Greek providers, the National Health System (NHS) and the Social Security Foundation (IKA) and to determine if, and how, efficiency is affected by various exogenous factors such as catchment population and location.MethodsThe sample comprised of 194 units (103 NHS and 91 IKA). Efficiency was measured with Data Envelopment Analysis (DEA) using three inputs, -medical staff, nursing/paramedical staff, administrative/other staff- and two outputs, which were the aggregated numbers of scheduled/emergency patient visits and imaging/laboratory diagnostic tests. Facilities were categorized as small, medium and large (<15,000, 15,000–30,000 and >30,000 respectively) to reflect catchment population and as urban/semi-urban or remote/island to reflect location. In a second stage analysis, technical and scale efficiency scores were regressed against facility type (NHS or IKA), size and location using multivariate Tobit regression.ResultsRegarding technical efficiency, IKA performed better than the NHS (84.9% vs. 70.1%, Mann-Whitney P < 0.001), smaller units better than medium-sized and larger ones (84.2% vs. 72.4% vs. 74.3%, Kruskal-Wallis P < 0.01) and remote/island units better than urban centers (81.1% vs. 75.7%, Mann-Whitney P = 0.103). As for scale efficiency, IKA again outperformed the NHS (89.7% vs. 85.9%, Mann-Whitney P = 0.080), but results were reversed in respect to facility size and location. Specifically, larger units performed better (96.3% vs. 90.9% vs. 75.9%, Kruskal-Wallis P < 0.001), and urban units showed higher scale efficiency than remote ones (91.9% vs. 75.3%, Mann-Whitney P < 0.001). Interestingly 75% of facilities appeared to be functioning under increasing returns to scale. Within-group comparisons revealed significant efficiency differences between the two primary care providers. Tobit regression models showed that facility type, size and location were significant explanatory variables of technical and scale efficiency.ConclusionVariations appeared to exist in the productive performance of the NHS and IKA as the two main primary care providers in Greece. These variations reflect differences in primary care organization, economical incentives, financial constraints, sociodemographic and local peculiarities. In all technical efficiency comparisons, IKA facilities appeared to outperform NHS ones irrespective of facility size or location. In respect to scale efficiency, the results were to some extent inconclusive and observed differences were mostly insignificant, although again IKA appeared to perform better.

Developing and testing an instrument for identifying performance incentives in the Greek health care sector

BackgroundIn the era of cost containment, managers are constantly pursuing increased organizational performance and productivity by aiming at the obvious target, i.e. the workforce. The health care sector, in which production processes are more complicated compared to other industries, is not an exception. In light of recent legislation in Greece in which efficiency improvement and achievement of specific performance targets are identified as undisputable health system goals, the purpose of this study was to develop a reliable and valid instrument for investigating the attitudes of Greek physicians, nurses and administrative personnel towards job-related aspects, and the extent to which these motivate them to improve performance and increase productivity.MethodsA methodological exploratory design was employed in three phases: a) content development and assessment, which resulted in a 28-item instrument, b) pilot testing (N = 74) and c) field testing (N = 353). Internal consistency reliability was tested via Cronbachs alpha coefficient and factor analysis was used to identify the underlying constructs. Tests of scaling assumptions, according to the Multitrait-Multimethod Matrix, were used to confirm the hypothesized component structure.ResultsFour components, referring to intrinsic individual needs and external job-related aspects, were revealed and explain 59.61% of the variability. They were subsequently labeled: job attributes, remuneration, co-workers and achievement. Nine items not meeting item-scale criteria were removed, resulting in a 19-item instrument. Scale reliability ranged from 0.782 to 0.901 and internal item consistency and discriminant validity criteria were satisfied.ConclusionOverall, the instrument appears to be a promising tool for hospital administrations in their attempt to identify job-related factors, which motivate their employees. The psychometric properties were good and warrant administration to a larger sample of employees in the Greek healthcare system.

Development and preliminary validation of a questionnaire to measure satisfaction with home care in Greece: an exploratory factor analysis of polychoric correlations

BackgroundThe primary aim of this study was to develop and psychometrically test a Greek-language instrument for measuring satisfaction with home care. The first empirical evidence about the level of satisfaction with these services in Greece is also provided.MethodsThe questionnaire resulted from literature search, on-site observation and cognitive interviews. It was applied in 2006 to a sample of 201 enrollees of five home care programs in the city of Thessaloniki and contains 31 items that measure satisfaction with individual service attributes and are expressed on a 5-point Likert scale. The latter has been usually considered in practice as an interval scale, although it is in principle ordinal. We thus treated the variable as an ordinal one, but also employed the traditional approach in order to compare the findings. Our analysis was therefore based on ordinal measures such as the polychoric correlation, Kendalls Tau b coefficient and ordinal Cronbachs alpha. Exploratory factor analysis was followed by an assessment of internal consistency reliability, test-retest reliability, construct validity and sensitivity.ResultsAnalyses with ordinal and interval scale measures produced in essence very similar results and identified four multi-item scales. Three of these were found to be reliable and valid: socioeconomic change, staff skills and attitudes and service appropriateness. A fourth dimension -service planning- had lower internal consistency reliability and yet very satisfactory test-retest reliability, construct validity and floor and ceiling effects. The global satisfaction scale created was also quite reliable. Overall, participants were satisfied -yet not very satisfied- with home care services. More room for improvement seems to exist for the socio-economic and planning aspects of care and less for staff skills and attitudes and appropriateness of provided services.ConclusionsThe methods developed seem to be a promising tool for the measurement of home care satisfaction in Greece.

Comparative validation of the WOMAC osteoarthritis and Lequesne algofunctional indices in Greek patients with hip or knee osteoarthritis

AbstractPurposeTo comparatively evaluate the reliability and validity of the Western Ontario and McMaster (WOMAC) and the Lequesne algofunctional indices in Greek patients with hip or knee osteoarthritis (OA). MethodsThe Greek versions of WOMAC LK 3.1 and Lequesne indices were administered to 97 outpatients with OA. Internal consistency reliability was assessed by Cronbach’s alpha and item–scale correlations. Test–retest reliability was examined with intraclass correlations. Patients were also asked to complete the Short Form 36 (SF-36) and a Visual Analog Scale capturing strength of pain, in order to assess construct validity. Additional demographic and clinical data were also recorded to evaluate further associations. ResultsCronbach’s alpha values of the WOMAC ranged between 0.92 and 0.98 for hip and 0.89–0.97 for knee OA. The respective values for Lequesne were 0.63–0.74 and 0.74–0.80. Item–scale correlations confirmed the superiority of WOMAC with respect to internal consistency reliability. Intraclass correlations were 0.79–0.97 and 0.57–0.98 for hip and 0.86–0.97 and 0.82–0.97 for knee OA, for WOMAC and Lequesne, respectively. The two indices showed high correlations with comparable subscales of SF-36 and the Visual Analog Scale. Significant relationships were identified for age, body mass index, duration of disease, duration of stiffness and radiographic classification.ConclusionsOur findings, in samples of knee and hip OA patients, indicate that the WOMAC index demonstrates better internal consistency reliability than the Lequesne counterpart, as well as equivalent test–retest reliability and construct validity.

Valuation and Preliminary Validation of the Greek 15D in a Sample of Patients with Coronary Artery Disease

OBJECTIVE To replicate, using the Greek version of the 15D instrument, the three-stage valuation procedure, using a sample of coronary artery disease patients; to assess on a preliminary basis the psychometric properties of the instrument in the Greek health-care environment; to evaluate the health-related quality of life of patients with coronary artery disease. METHODS The generic instrument 15D was translated and culturally adapted into the Greek language and setting. It was then administered during October 2005 to May 2006 to 420 coronary artery disease patients. The three-stage valuation procedure was employed and, with the use of elicited preference weights, a single health-related quality of life index score for the patients was derived. Scores were also calculated using the original Finnish valuation system and compared with the previously derived utilities. Sensitivity, reliability, and validity were assessed by examining response distributions, floor and ceiling effects, item-scale correlations, Cronbachs alpha coefficients, and hypothesized relationships between sociodemographic variables and health-related quality of life. RESULTS The Greek valuation systematically generated higher 15D utilities than the Finnish one. Nevertheless, the utilities derived with the original Finnish valuation algorithm differed significantly with respect to sex, age, and education, just as they did using the Greek valuation system. In most cases, the full range of possible responses has been used satisfactorily and floor and ceiling effects were generally moderate. In general, internal consistency reliability was also satisfactory. CONCLUSION The valuation system generated results demonstrating satisfactory psychometric properties. Further research should validate the 15D in the general Greek population.

Assessment of Patients’ Perception of Telemedicine Services Using the Service User Technology Acceptability Questionnaire

Introduction: The purpose of this paper is to assess if similar telemedicine services integrated in the management of different chronic diseases are acceptable and well perceived by patients or if there are any negative perceptions. Theory and methods: Participants suffering from different chronic diseases were enrolled in Veneto Region and gathered into clusters. Each cluster received a similar telemedicine service equipped with different disease-specific measuring devices. Participants were patients with diabetes (n = 163), chronic obstructive pulmonary disease (n = 180), congestive heart failure (n = 140) and Cardiac Implantable Electronic Devices (n = 1635). The Service User Technology Acceptability Questionnaire (SUTAQ) was initially translated, culturally adapted and pretested and subsequently used to assess patients’ perception of telemedicine. Data were collected after 3 months and after 12 months from the beginning of the intervention. Data for patients with implantable devices was collected only at 12 months. Results: Results at 12 months for all clusters are similar and assessed a positive perception of telemedicine. The SUTAQ results for clusters 2 (diabetes), 5 (COPD) and 7 (CHF) after 3 months of intervention were confirmed after 12 months. Conclusions: Telemedicine was perceived as a viable addition to usual care. A positive perception for telemedicine services isn’t a transitory effect, but extends over the course of time.

A window-DEA based efficiency evaluation of the public hospital sector in Greece during the 5-year economic crisis

The main objective of this study was to apply the non-parametric method of Data Envelopment Analysis (DEA) to measure the efficiency of Greek NHS hospitals between 2009–2013. Hospitals were divided into four separate groups with common characteristics which allowed comparisons to be carried out in the context of increased homogeneity. The window-DEA method was chosen since it leads to increased discrimination on the results especially when applied to small samples and it enables year-by-year comparisons of the results. Three inputs -hospital beds, physicians and other health professionals- and three outputs—hospitalized cases, surgeries and outpatient visits- were chosen as production variables in an input-oriented 2-year window DEA model for the assessment of technical and scale efficiency as well as for the identification of returns to scale. The Malmquist productivity index together with its components (i.e. pure technical efficiency change, scale efficiency change and technological scale) were also calculated in order to analyze the sources of productivity change between the first and last year of the study period. In the context of window analysis, the study identified the individual efficiency trends together with “all-windows” best and worst performers and revealed that a high level of technical and scale efficiency was maintained over the entire 5-year period. Similarly, the relevant findings of Malmquist productivity index analysis showed that both scale and pure technical efficiency were improved in 2013 whilst technological change was found to be in favor of the two groups with the largest hospitals.

Decomposition of potential efficiency gains from hospital mergers in Greece

This paper evaluates the technical efficiency of 71 Greek public hospitals and examines potential efficiency gains from 13 candidate mergers among them. Efficiency assessments are performed using bootstrapped Data Envelopment Analysis (DEA) whilst merger analysis is conducted by applying the Bogetoft and Wang methodology which allows the overall potential merger gains to be decomposed into three main components of inefficiency, namely technical (or learning), scope (or harmony) and scale (or size) effects. Thus, the analysis provides important insights not only on the magnitude of the potential total efficiency gains but also on their sources. The overall analysis is conducted in the context of a complete methodological framework where methods for outlier detection, returns to scale identification, and bias corrections for DEA estimations are also applied. Mergers are analyzed under the assumptions of constant, variable and non-decreasing returns to scale in an input oriented DEA model with three inputs and three outputs. The main finding of the study indicates that almost all mergers show substantial potential room for efficiency improvement, which is mainly attributed to the pre-merger technical inefficiencies of the individual hospitals and therefore it might be possible to be achieved without the need of implementing full-scale mergers. The same -though, at a lower extent- applies to the harmony effect whilst the size effect shows marginal or even negative gains.

Eliciting the Monetary Value of a Quality-Adjusted Life Year in a Greek Outpatient Department in Times of Economic Austerity

Background and objectiveContingent valuation is widely used to determine individuals’ willingness to pay (WTP) for a health gain. Our study aimed to elicit an empirical estimate of the monetary value of a quality-adjusted life year (QALY) in a Greek outpatient setting in times of economic austerity and assess the impact of patients’ characteristics on their valuations.MethodsWe used a questionnaire as a survey tool to determine the maximum WTP for a health gain of a hypothetical therapy and to evaluate patients’ health-related quality of life (EuroQoL-5D-3L) and demographic and socioeconomic characteristics. EuroQoL tariffs were used to estimate health utilities. Mean WTP values were computed and ordinary least squares regressions performed on transformed Box-Cox and logarithmic dependent WTP per QALY variables to remedy observed skewness problems.ResultsAnalyses were performed for 167 patients with utility values less than unity. Mean WTP per QALY reported was similar for both payment vehicles examined: payments made out-of-pocket (€2629) and payments made through new tax imposition (€2407). Regression results showed that higher net monthly family income was associated with higher WTP per QALY for both payment vehicles. Moreover, the presence of a chronic condition and higher level of education were associated with higher out-of-pocket WTP per QALY and WTP per QALY through taxes, respectively.ConclusionThe very low WTP per QALY estimates could be explained by the recent severe economic depression and austerity in Greece. In fact, family income was found to be a significant predictor of WTP per QALY. Since these estimates deviate significantly from the cost-effectiveness thresholds still employed in economic evaluations in this country, research should be undertaken promptly to further examine this important issue using a nationwide representative sample of the general population along with WTP and other methodologies.