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.

The measurement of efficiency and productivity of health care delivery

Coronary revascularization, comprising coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI), is among the most common major medical procedures provided by the U.S. healthcare system, with over 1 million procedures performed annually.1 It is also among the most costly: Medicare inpatient payments to hospitals for coronary revascularizations exceeded $3.2 billion in fiscal year 2006,2 an amount larger than the reimbursement for any other medical or surgical procedure except for hip/knee replacement.

Several innovations in coronary revascularization, such as drug-eluting stents, minimally invasive CABG, and "off-pump" CABG, have been adopted widely in the past decade,3–5 with the promise of improved clinical outcomes compared to older revascularization technologies and techniques.5–7 In addition, publication of randomized controlled trial results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial (2007)8 and the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial (2009)9 have provided important new information about both the potential clinical value of revascularization compared to pharmacotherapy, as well as the outcomes of CABG compared to PCI in the drug-eluting stent era. In addition, during the past decade updated appropriateness criteria for coronary revascularization have been issued and/or revised by the major cardiovascular societies.10–14

During this period of technological innovation, new published evidence, and updated guidelines, it is not well known whether or how the volume of coronary revascularization and its constituent types changed in the United States. Substantial changes in the overall volume of revascularizations and/or the relative use of CABG versus PCI would have important ramifications on clinical outcomes, healthcare costs, and the future organization and delivery of hospital-based cardiovascular care. Therefore, the goal of this study was to use a representative national sample of hospitalization claims to estimate temporal trends in the annual volume of coronary revascularization procedures during 2001–2008.

https://jamanetwork.com/journals/jama/articlepdf/899648/joc15039_1769_1776.pdf

Coronary Revascularization Trends in the United States, 2001-2008

Meta-governance – or governance of governance – is a concept that raises questions regarding how values, norms and principles underpin governance systems and governing approaches. Values, norms and principles pertain both to substantive governance issues, for instance, related to sustainable resource use, and to governance system issues in themselves, for instance, regarding their institutional design. This article deals primarily with the latter. Thus the interactive perspective serves as basis for developing a coherent set of meta-governance principles. We argue that an explicit, deliberated and decided upon set of meta-governance principles as an integral part of governance can help in making hard substantive governance choices easier. Interactive learning plays a key role in governance processes when public and private governing actors have to make such hard choices. In the article, examples from natural resource governance will serve as illustrations for the more conceptual argumentation and reasoning.

Meta-governance: values, norms and principles, and the making of hard choices

Throughout the book, my colleagues and I have endeavored to address the DEA theory needed by the end-users, key model design issues, correct interpretation of DEA results, and advanced concepts of current research focused on further development of DEA. The examples are chosen from the service sector. Specifically represented areas are banking, education, property management, hospitality, tourism, health insurance, socially responsible investments, public transportation, pension funds, information technology, public hospitals, Olympics, telecommunications, public library, police stations, energy, retail, and research centers. Chapter titles follow the naming convention of providing the topic or purpose of the chapter first, followed by the listing of the industries or areas where illustrations have been set.

https://papers.ssrn.com/sol3/Delivery.cfm/SSRN_ID2627576_code562976.pdf?abstractid=2627576&mirid=1

Productivity Analysis in the Service Sector with Data Envelopment Analysis

We investigated the effects of privatization on hospital efficiency in Germany. To do so, we obtained bootstrapped data envelopment analysis (DEA) efficiency scores in the first stage of our analysis and subsequently employed a difference-in-difference matching approach within a panel regression framework. Our findings show that conversions from public to private for-profit status were associated with an increase in efficiency of between 2.9 and 4.9%. We defined four alternative post-privatization periods and found that the increase in efficiency after a conversion to private for-profit status appeared to be permanent. We also observed an increase in efficiency for the first three years after hospitals were converted to private non-profit status, but our estimations suggest that this effect was rather transitory. Our findings also show that the efficiency gains after a conversion to private for-profit status were achieved through substantial decreases in staffing ratios in all analyzed staff categories with the exception of physicians and administrative staff. It was also striking that the efficiency gains of hospitals converted to for-profit status were significantly lower in the diagnosis-related groups (DRG) era than in the pre-DRG era. Altogether, our results suggest that converting hospitals to private for-profit status may be an effective way to ensure the scarce resources in the hospital sector are used more efficiently.

/pdf/changes-in-hospital-efficiency-after-privatization-xdk7o28lt8.pdf

Changes in hospital efficiency after privatization

This study evaluates the technical efficiency of federal hospitals in the United States using a variable returns to scale, input-oriented, data envelopment analysis (DEA) methodology. Hospital executives, health care policy-makers, taxpayers, and other stakeholders, benefit from studies that improve the efficiency of federal hospitals. Data for 280 federal hospitals in 1998 and 245 in 2001 were analyzed using DEA to measure hospital efficiency. Results indicate overall efficiency in federal hospitals improved from 68% in 1998 to 79% in 2001. However, based upon 2001 spending of d42.5 billion for federal hospitals potential savings of d2.0 billion annually are possible through more efficient management of resources. From a policy perspective, this study highlights the importance of establishing more specific policies to address inefficiency in the federal health care industry.

Mark Wakefield

Papers

Efficiency of Federal Hospitals in the United States