Care Appropriateness and Health Productivity Evolution: A Non-Parametric Analysis of the Italian Regional Health Systems

Efficiency evaluation, regional technological heterogeneity and determinant of total factor productivity change in China's healthcare system

Enhancing efficiency and productivity in countries' healthcare systems is a global challenge. The Chinese government invested huge resources to improve the efficiency and productivity of the healthcare system across the country. To assess the success of the mission above, this research utilized DEA-SBM Meta frontier analysis alongside the Malmquist Productivity Index. These methodologies were employed to gauge Efficiency, production technology heterogeneity, and productivity of healthcare systems change across 31 mainland Chinese provinces and four distinct geographical regions throughout the study period spanning from 1997 to 2022. Results revealed that the mean efficiency score of China's healthcare system is 0.7672. It indicates a growth potential of 23.28 percent in the operational efficiency of healthcare systems. The eastern region's efficiency level (0.86917) is higher among all four regions. Zhejiang, Shandong, and Guangdong are the top three healthcare-efficiency performers. The technology gap ratio indicates that eastern regions witnessed a high TGR (0.9909), showing the country's attainment of superior healthcare technologies. Beijing, Guangdong, Shanghai, Tianjin, and Zhejiang witnessed higher TGR values among all 31 mainland Chinese provinces. The total factor productivity index of the healthcare system witnessed a slight growth of 0.33%, with an average MI score of 1.0033. Efficiency change (EC) was found to be the main determinant of TFPC as technology change TC is less than EC. Moreover, the MI score of the Western region (1.033) is higher than the corresponding Eastern, northeastern, and central regions. Guizhou, Anhui, and Yunnan were found to be the top three performers in TFPC growth. Finally, the Kruskal-Wallis test confirmed the statistically significant difference among 4 Chinese regions for the healthcare system's efficiency, TFPC, and TGR.

Applications of data envelopment analysis in acute care hospitals: a systematic literature review, 1984-2022

This study reviews scholarly publications on data envelopment analysis (DEA) studies on acute care hospital (ACH) efficiency published between 1984 and 2022 in scholarly peer-reviewed journals. We employ systematic literature review (SLR) method to identify and analyze pertinent past research using predetermined steps. The SLR offers a comprehensive resource that meticulously analyzes DEA methodology for practitioners and researchers focusing on ACH efficiency measurement. The articles reviewed in the SLR are analyzed and synthesized based on the nature of the DEA modelling process and the key findings from the DEA models. The key findings from the DEA models are presented under the following sections: effects of different ownership structures; impacts of specific healthcare reforms or other policy interventions; international and multi-state comparisons; effects of changes in competitive environment; impacts of new technology implementations; effects of hospital location; impacts of quality management interventions; impact of COVID-19 on hospital performance; impact of teaching status, and impact of merger. Furthermore, the nature of DEA modelling process focuses on use of sensitivity analysis; choice of inputs and outputs; comparison with Stochastic Frontier Analysis; use of congestion analysis; use of bootstrapping; imposition of weight restrictions; use of DEA window analysis; and exogenous factors. The findings demonstrate that, despite several innovative DEA extensions and hospital applications, over half of the research used the conventional DEA models. The findings also show that the most often used inputs in the DEA models were labor-oriented inputs and hospital beds, whereas the most frequently used outputs were outpatient visits, followed by surgeries, admissions, and inpatient days. Further research on the impact of healthcare reforms and health information technology (HIT) on hospital performance is required, given the number of reforms being implemented in many countries and the role HIT plays in enhancing care quality and lowering costs. We conclude by offering several new research directions for future studies.

The Core of Healthcare Efficiency: A Comprehensive Bibliometric Review on Frontier Analysis of Hospitals

Parametric and non-parametric frontier applications are typical for measuring the efficiency and productivity of many healthcare units. Due to the current COVID-19 pandemic, hospital efficiency is the center of academic discussions and the most desired target for many public authorities under limited resources. Investigating the state of the art of such applications and methodologies in the healthcare sector, besides uncovering strategical managerial prospects, can expand the scientific knowledge on the fundamental differences among efficiency models, variables and applications, drag research attention to the most attractive and recurrent concepts, and broaden a discussion on the specific theoretical and empirical gaps still to be addressed in future research agendas. This work offers a systematic bibliometric review to explore this complex panorama. Hospital efficiency applications from 1996 to 2022 were investigated from the Web of Science base. We selected 65 from the 203 most prominent works based on the Core Publication methodology. We provide core and general classifications according to the clinical outcome, bibliographic coupling of concepts and keywords highlighting the most relevant perspectives and literature gaps, and a comprehensive discussion of the most attractive literature and insights for building a research agenda in the field.

The residential healthcare for the elderly in Italy: some considerations for post-COVID-19 policies

In Italy, the COVID-19 pandemic and the death of many elderly people have put in evidence the uneven territorial distribution of nursing homes, which have amplified the spread and severity of the pandemic. By applying a pooled OLS model to the Italian regions, over the 2010-18 period, we investigate the demand factors, market forces and institutional drivers of the spatial distribution of residential healthcare for the elderly. Using a fine-grained approach that considers specific regional and age-related elements and the market environment, which can reduce or increase the pressure on regional governments to provide formal assistance, we find that the financial resources and the availability of unemployed women as potential caregivers explain the distribution of expenditure better than the health needs of the elderly. As a result, the expenditure is concentrated in richer and more financially autonomous regions and it is not congruent with the distribution of chronicity, health and frailty factors or income among the elderly. These critical issues of the care services for frail elderly people, related to a highly decentralized governance and resulting in fragmented, market-driven provision, could be attacked only by a national reform.

Supporting efficiency improvement in public health systems: a rapid evidence synthesis

BACKGROUND

Public health systems internationally are under pressure to meet increasing demand for healthcare in the context of increasing financial resource constraint. There is therefore a need to maximise health outcomes achieved with public healthcare expenditure. This paper aims to establish and synthesize the contemporary evidence base for approaches taken at a system management level to improve efficiency.

METHODS

Rapid Evidence Assessment (REA) methodology was employed. A search strategy was developed and applied (PUBMED, MEDLINE) returning 5,377 unique titles. 172 full-text articles were screened to determine relevance with 82 publications included in the final review. Data regarding country, study design, key findings and approaches to efficiency improvement were extracted and a narrative synthesis produced. Publications covering health systems from developed countries were included.

RESULTS

Identified study designs included policy reviews, qualitative reviews, mixed methods reviews, systematic reviews, literature reviews, retrospective analyses, scoping reviews, narrative papers, regression analyses and opinion papers. While findings revealed no comprehensive frameworks for system-wide efficiency improvement, a range of specific centrally led improvement approaches were identified. Elements associated with success in current approaches included dedicated central functions to drive system-wide efficiency improvement, managing efficiency in tandem with quality and value, and inclusive stakeholder engagement.

CONCLUSIONS

The requirement for public health systems to improve efficiency is likely to continue to increase. Reactive cost-cutting measures and short-term initiatives aimed only at reducing expenditure are unlikely to deliver sustainable efficiency improvement. By providing dedicated central system-wide efficiency improvement support, public health system management entities can deliver improved financial, health service and stakeholder outcomes.

Forecasting national and regional level intensive care unit bed demand during COVID-19: The case of Italy

Given the pressure on healthcare authorities to assess whether hospital capacity allows properly responding to outbreaks such as COVID-19, there is a need for simple, data-driven methods that may provide accurate forecasts of hospital bed demand. This study applies growth models to forecast the demand for Intensive Care Unit admissions in Italy during COVID-19. We show that, with only some mild assumptions on the functional form and using short time-series, the model fits past data well and can accurately forecast demand fourteen days ahead (the mean absolute percentage error (MAPE) of the cumulative fourteen days forecasts is 7.64). The model is then applied to derive regional-level forecasts by adopting hierarchical methods that ensure the consistency between national and regional level forecasts. Predictions are compared with current hospital capacity in the different Italian regions, with the aim to evaluate the adequacy of the expansion in the number of beds implemented during the COVID-19 crisis.

Data Envelopment Analysis Applications on Primary Health Care Using Exogenous Variables and Health Outcomes

A data envelopment analysis was used to evaluate the efficiency of 18 primary healthcare centres in a health district of the Valencian Community, Spain. Factor analysis was used as a first step in order to identify the most explanatory variables to be incorporated in the models. Included as variable inputs were the ratios of general practitioners, nurses, and costs; as output variables, those included were consultations, emergencies, avoidable hospitalisations, and prescription efficiency; as exogenous variables, those included were the percentage of population over 65 and a multimorbidity index. Confidence intervals were calculated using bootstrapping to correct possible biases. Efficient organisations within the set were identified, although the results depend on the models used and the introduction of exogenous variables. Pharmaceutical expenditure showed the greatest slack and room for improvement in its management. Data envelopment analysis allows an evaluation of efficiency that is focussed on achieving better results and a proper distribution and use of healthcare resources, although it needs the desired goals of the healthcare managers to be clearly identified, as the perspective of the analysis influences the results, as does including variables that measure the achievements and outcomes of the healthcare services.

Convergence, decentralization and spatial effects: An analysis of Italian regional health outcomes

Fiscal decentralization has been a key component of many health sector reforms. Nevertheless, the actual effects of greater financial accountability by regional governments on reducing geographical health disparities are still debatable. The existing empirical literature is highly fragmented, focusing either on the effect of fiscal decentralization on health outcomes (without considering convergence) or on the convergence process in health (without considering decentralization). This paper aims to make a step forward by disentangling the role played by fiscal decentralization on the convergence dynamics of infant mortality rate and life expectancy at birth, considering also spatial effects. To this purpose, a panel of 20 Italian regions over the period 1996-2016 is investigated. For both our health outcomes, the results point towards no reduction in dispersion levels but evidence of a "catching-up" effect among regions. Exploiting the panel dimension of the data, fiscal decentralization seems to favour the rate of convergence of the Italian regions. However, the fiscal decentralization-growth rate relationship is sensitive to the regional level of health outcome: once high performance levels are reached, more consistent improvements require giving up a certain degree of fiscal accountability. Finally, spatial interactions appear statistically relevant for explaining the regional convergence process.

Health Expenditure and All-Cause Mortality in the 'Galaxy' of Italian Regional Healthcare Systems: A 15-Year Panel Data Analysis

BACKGROUND

The sustainability of healthcare systems is a topic of major interest. During periods of economic instability, policy makers typically reallocate resources and execute linear cuts in different areas of public spending, including healthcare.

OBJECTIVES

The aim of this paper was to examine whether and how per capita public healthcare expenditure (PHE) in the Italian regions was related to the all-cause mortality rate (MR) between 1999 and 2013 and to determine which expenditure item most affected mortality in the short and very short term.

METHODS

We conducted a pooled cross-sectional time series study. Secondary data were extracted from 'Health for All', a database released periodically by the Italian National Institute of Statistics. PHE is subdivided into directly provided services (DPS), pharmaceutical care, general practitioner care, specialist medical care, privately delivered hospital care, other privately delivered medical services, and psychiatric support and rehabilitation. We used a fixed-effects regression to assess the effects of PHE items on the MR after controlling for a number of socioeconomic and supply variables.

RESULTS

Higher spending on DPS was associated with a lower MR. Other expenditure variables were not significantly associated with the MR.

CONCLUSIONS

The results highlight the importance of medical services and goods provided directly by public services (i.e. hospital-based general and specialized wards and offices, emergency departments, etc.). DPS represents the driving force of the system and should be considered a determinant of the health of the Italian population. Our results suggest that the context and financing methods of a healthcare system should be carefully analysed before linear cuts are made or resources are reallocated.

What is appropriate care? An integrative review of emerging themes in the literature

Background

Health care improvement efforts should be aligned in order to make a meaningful impact on health systems. Appropriate care delivery could be a unifying goal to help coordinate efforts to improve health outcomes and ensure system sustainability. A more complete understanding of how appropriate care is currently conceived in research and clinical practice could help inform a more integrated and holistic concept of appropriate care that could guide health care policy and delivery practices. We examined the current understanding of appropriate care by identifying its use and definitions in recently published literature.

Methods

An integrated review of the practices, goals and perspectives of appropriate care in English language peer-reviewed articles published from 2011 to 2016. Inductive content analysis was used to describe emerging themes of appropriate care in articles meeting inclusion criteria.

Results

This integrative review included empirical studies, reviews, and commentaries with various health care settings, cultural contexts, and perspectives. Conceptualizations of appropriate care varied, however most descriptions fell into five main categories: evidence-based care, clinical expertise, patient-centeredness, resource use, and equity. These categories were often used in combination, indicating an integrated understanding of appropriate care.

Conclusions

An understanding of how appropriate care is conceptualized in research and policy can help inform an integrated approach to appropriate care delivery in policy and practice according to the relevant priorities and circumstances.

The impact of economic crisis on the Greek hospitals' productivity

During the recent economic crisis, Greece implemented a comprehensive reform in the health care system. The 2010 health reform occurred under the constraints imposed by the memorandum of understanding that the Greek Government signed with its EU/International Monetary Fund creditors to control its deficit. The objective of the study is to examine the impact of the reform on the efficiency and productivity of public hospitals in Greece. We use the Malmquist productivity index to comparatively examine the potential changes before and after the reform years. We compare productivity, efficiency, and technological changes using panel data of 111 public acute hospitals operating in Greece throughout the recession period of 2009 to 2012. Bootstrapping methods are applied to allow for uncertainty owing to sampling error and for statistical inference for the Malmquist productivity index and its decompositions. The analysis indicates that the productivity has been increased following the policy changes. It appears that the expected benefits from the reform in general have been achieved, at least in the short-term. This result is examined in the light of management and operations activities, which are related with the reform process. Therefore, at a second stage, the Malmquist index is regressed on variables that may potentially be statistically associated with productivity growth.

Sustaining Gains in Health Programs: Technical Efficiency and its Determinants in Malaria Programs in Sub-Saharan Africa

BACKGROUND

Since the year 2000, Africa has made significant progress in the fight against malaria. Between 2000 and 2015, the incidence and death from malaria fell by 42 and 66%, respectively. However, the African region still accounts for most global cases of malaria. In 2015, the region was home to 89% of malaria cases and 91% of malaria death.

OBJECTIVE

This study aimed to evaluate efficiency of policies against malaria in 30 malaria-endemic Sub-Saharan African (SSA) countries, from the perspective of sustaining gains.

METHODS

The data came from World Malaria Report 2013. Data were analyzed using the double bootstrap method. We first estimated bootstrapped efficiency scores. Then, bootstrapped truncated regression was used to determine factors associated with malaria program efficiency.

RESULTS

This study showed that most malaria programs in SSA are technically inefficient. We also found that aid from international institutions and public expenditures on malaria programs do not significantly affect the efficiency of malaria programs. However, in an enhanced governance context, international aid and public expenditure impact positively on the efficiency of malaria programs. Moreover, intermittent preventive treatment for pregnant women is associated with a positive effect on the efficiency. Surprisingly, the free care policies-artemisinin-based combinations for under five-year-old children in the public facilities, rapid diagnostic tests, and distribution of insecticide-treated bed nets and long-lasting insecticide-impregnated nets-does not significantly affect the efficiency of malaria programs.

CONCLUSION

Financing alone does not ensure efficiency of malaria programs. Good governance and the targeting of the most vulnerable segments of the population are necessary to reduce malaria deaths and improve efficiency of malaria programs in SSA.