Zhaohui Cheng

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.

The Costs and Their Determinant of Cesarean Section and Vaginal Delivery: An Exploratory Study in Chongqing Municipality, China

Objectives. This study aims to analyze the cesarean section (CS) rates and vaginal delivery rates in tertiary hospitals of China, explore the costs of two different deliveries, and examine the relative influencing factors of the costs in both CS and vaginal deliveries. Methods. 30,168 anonymized obstetric medical cases were selected from three sample tertiary hospitals in Chongqing Municipality from 2011 to 2013. Chi-square test was used to compare the distributions of CS and vaginal deliveries under different indicators. Mann–Whitney test and Kruskal-Wallis test were adopted to analyze the differences under different items. Multiple linear regression was used to determine the influencing factors of the costs of different delivery modes. Results. (1) The rates of CS were 69%, 65.5%, and 59.2% in the three sample tertiary hospitals in Chongqing from 2011 to 2013. (2) The costs and the length of stay of CS were greater than those of vaginal delivery, which had significant differences (P < 0.005). (3) The areas, length of stay, age, medical insurance, and modes of delivery were the influencing factors of both CS and vaginal delivery costs. Discussion. The high CS rates in China must be paid significant attention. The indicators of two modes of delivery should be regulated strictly. CS rate reduction and saving medical resources will be the benefits if vaginal delivery is chosen by pregnant women.

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.

Factors Associated with the Competencies of Public Health Workers in Township Hospitals: A Cross-Sectional Survey in Chongqing Municipality, China

Purpose: This study aimed to explore the competencies of public health workers (PHWs) of township hospitals in Chongqing Municipality (China), and determine the related impact factors of the competencies of PHWs; Methods: A cross-sectional research was conducted on 314 PHWs from 27 township hospitals in three districts in Chongqing Municipality (China), from June to August 2014. A self-assessment questionnaire was established on the basis of literature reviews and a competency dictionary. The differences in competencies among the three districts were determined by adopting the chi-square test, t-test, analysis of variance (ANOVA) method, and the impact factors of the competencies of PHWs were determined by adopting stepwise regression analysis. Results: (1) Results of the demographic characteristics of PHWs in three sample districts of Chongqing Municipality showed that a significant difference in age of PHWs (p = 0.021 < 0.05) and the majors of PHWs (p = 0.045 < 0.05); (2) In terms of the self-evaluation competency results of PHWs in township hospitals, seven among the 11 aspects were found to have significant differences in the three districts by the ANOVA test; (3) By adopting the t-test and ANOVA method, results of the relationship between the characteristics of PHWs and their competency scores showed that significant differences were found in the economic level (p = 0.000 < 0.05), age (p = 0.000 < 0.05), years of working (p = 0.000 < 0.05) and title of PHWs (p = 0.000 < 0.05); (4) Stepwise regression analysis was used to determine the impact factors of the competencies of PHWs in township hospitals, including the economic level (p = 0.000 < 0.001), years of working (p = 0.000 < 0.001), title (p = 0.001 < 0.005), and public health major (p = 0.007 < 0.01). Conclusions: The competencies of the township hospital staff in Chongqing Municipality (China), are generally insufficient, therefore, regulating the medical education and training skills of PHWs is crucial to improve the competencies of PHWs in the township hospitals of Chongqing Municipality. The results of this study can be mirrored in other areas of China.

The differences between doctors' and nurses' attitudes toward adverse event reporting and assessments of factors that inhibit reporting.

To the editor, Adverse events (AEs) are frequent occurrences in health care systems that not only threaten patients’ safety but also cause huge economic losses. Thus, if they were prevented or reduced, it would save numerous lives as well as costs. In China, AEs are also an emerging issue that influences health care quality. To improve AE reporting, professionals’ attitudes about AE reporting and views regarding factors that discourage AE reporting should be known; these may be different from those in other foreign countries. Doctors and nurses—with different levels of education, working experience, and health care provision responsibilities—may have different attitudes toward AE reporting and different views about the factors that inhibit reporting. Little research has examined these differences between doctors and nurses. Therefore, we conducted research to determine the differences between doctors’ and nurses’ attitudes toward AE reporting and assessments of factors that inhibit reporting. A cross-sectional survey using anonymous questionnaires was administered between March and December 2011. Respondents included 326 doctors and 467 nurses from 13 hospitals in Jiangsu, Hubei, and Zhejiang provinces in China. All the respondents joined the study voluntarily and provided informed consent. The questionnaire assessed 3 areas of daily medical practice: (1) socioeconomic characteristics, (2) awareness and use of AE reporting, and (3) factors that discourage doctors and nurses from reporting AEs. Following review by a panel of professionals to assess content validity, the questionnaire was piloted with 24 doctors and 30 nurses. Test-retest reliability was determined using a κ-statistic, and only questions for which there was at least moderate reproducibility (κ > 0.4) were used. The results showed that most doctors and nurses (80.1%) were aware of the AE reporting in their hospitals. Nurses were more aware of AE reporting than doctors (88.0% vs 71.7%; relative risk = 1.23; P < .001). For doctors, the major inhibiting factors to reporting were the fear of having their bonuses reduced, the belief that it is not their responsibility to report others’ mistakes, and the fear of consequences for their future career (Table 1). For nurses, the major inhibiting factors were the belief that it is not their responsibility to report others’ mistakes, the fear that their bonuses would be reduced, and the fear of acquiring a negative reputation (Table 1). Doctors and nurses differed in their opinions about whether reporting AEs had consequences for their future career (P = .001), whether they recognized that an AE had occurred (P < .05), whether there was a supportive environment for reporting AEs in the department (P < .001), and whether the feedback from AE reporting was lacking (P < .001), among other factors (Table 1). In China and other countries with underdeveloped AE reporting systems, the person who caused the AE is unfairly punished. Therefore, the culture of blame makes medical health care professionals reluctant to report AEs. Doctors were significantly more concerned than nurses that AEs may have consequences for their careers. One potential explanation for the difference is that there are different opportunities for promotion for doctors and nurses. In China, the opportunities for nurses to be promoted are very rare, whereas doctors can obtain a senior title relatively easily. In contrast to doctors, nurses were significantly less likely to agree that they did not recognize that an AE had occurred. Most AEs happen while patients are receiving nursing care, which also might explain why nurses are more familiar with the AE reporting system than doctors. The nurses were significantly more concerned about feedback, which can contribute to positive change (eg, improve the quality of nursing care in the future). Learning from AEs is essential for improving health care quality. To enhance learning and improve quality, there should be additional clarification about responsibilities for 505197 AJMXXX10.1177/1062860613505197American Journal of Medical QualityShu et al. research-article2013

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.