Improving the performance of surgery-based clinical pathways: a simulation-optimization approach.

This paper aims to improve the performance of clinical processes using clinical pathways (CPs). The specific goal of this research is to develop a decision support tool, based on a simulation-optimization approach, which identify the proper adjustment and alignment of resources to achieve better performance for both the patients and the health-care facility. When multiple perspectives are present in a decision problem, critical issues arise and often require the balancing of goals. In our approach, meeting patients' clinical needs in a timely manner, and to avoid worsening of clinical conditions, we assess the level of appropriate resources. The simulation-optimization model seeks and evaluates alternative resource configurations aimed at balancing the two main objectives-meeting patient needs and optimal utilization of beds and operating rooms.Using primary data collected at a Department of Surgery of a public hospital located in Genoa, Italy. The simulation-optimization modelling approach in this study has been applied to evaluate the thyroid surgical treatment together with the other surgery-based CPs. The low rate of bed utilization and the long elective waiting lists of the specialty under study indicates that the wards were oversized while the operating room capacity was the bottleneck of the system. The model enables hospital managers determine which objective has to be given priority, as well as the corresponding opportunity costs.

An examination of competition and efficiency for hospital industry in Turkey.

The two particular reforms that have been undertaken under the Health Transformation Program in Turkey are enhancing efficiency and increasing competition. However, there is a lack of information about the relationship between competition and hospital efficiency. The purpose of this paper is to analyze the effect of competition on technical efficiency for the hospital industry in Turkey. The target population included all public and private general hospitals that were open in 2010 in Turkey (n = 1,224). From these, 1,103 hospitals met the selection criteria and were included in the study. Data were obtained from the Turkish Statistical Institute, the Ministry of Health, and through a field survey. Technical efficiency of hospitals was estimated using Data Envelopment Analysis with five outputs and five inputs. The intensity of competition among hospitals was measured by objective and subjective measures. Objective competition was measured using the Hirschman-Herfindahl Index, and subjective competition was measured based on the perceptions of top level hospital managers. Multivariate Tobit regression was used to investigate the relationship between competition and efficiency while controlling the effects of demand and supply characteristics of the market and the hospital traits. Efficiency results showed that 17% of hospitals were technically efficient. Regression analyses portrayed that the degree of competition among general hospitals did not have a statistically significant relationship with hospitals' technical efficiency. To conclude, hospital efficiency in Turkey does not seem to be affected by the intensity of competition among hospitals.

The Efficiency of Ophthalmic Ambulatory Surgery Centers.

Ambulatory surgery centers (ASCs) are important providers of ambulatory surgeries. However, little research exists examining the efficiency of ASCs in providing ambulatory surgical services. This study examined the technical efficiency of ASCs that concentrated on performing cataract surgeries, which are among the surgeries most commonly performed in the outpatient setting. This study, based on data from all active ASCs that provided the two most common cataract surgeries in California, found that a large proportion of ophthalmic ASCs were operating at low technical efficiency levels. The amount of slacks in input and output variables was estimated for each ASC, and the mean slacks were reported. The numbers of cataract surgery patients and operating rooms were found to significantly affect the efficiency of ophthalmic ASCs.

Quality outcomes among efficient and inefficient nursing homes: a national study.

BACKGROUND: With an anticipated increased use of nursing homes to serve an aging population in the United States, questions regarding the quality and cost of nursing home services come to the fore. Such questions are the concern of nursing home residents, their families, private and public payers, policy makers, regulators, and nursing home operators. PURPOSES: The purpose of this study was to examine the relationship between quality of care and efficiency of nursing homes to determine the characteristics of facilities that achieve high quality and high efficiency. The study sought also to determine the extent to which nursing homes can provide high-quality services and do so with a high level of efficiency. METHODOLOGY/APPROACH: This was a cross-sectional study of a 10% random sample of U.S. nursing homes, excluding those in hospitals and also those with fewer than 20 beds or more than 360 beds. Data sources were the Online Survey Certification and Reporting, the Area Resource File database, the U.S. Bureau of Labor Statistics, and the U.S. Bureau of Economic Analysis. Data envelopment analysis was employed in the analysis of data. FINDINGS: The average efficiency of nursing homes was 0.869 (SD = 0.1362), with a statistically significant higher average efficiency for nursing homes in urban areas; in counties with a higher level of competition, higher average income, or higher number of home health agencies; and in not-for-profit and governmental facilities. Quality measures were compared between efficient and inefficient nursing homes, showing mostly favorable quality outcomes for efficient nursing homes. PRACTICE IMPLICATIONS: Families and residents evaluating or in search of nursing homes can be confident that high-quality, efficient nursing homes exist. Legislators, policy makers, regulators, payers, and administrators can be confident that the setting of standards that encourage striving for both quality and efficiency simultaneously is indeed realistic.

Benchmarking urban acute care hospitals: efficiency and quality perspectives.

BACKGROUND: Over the last couple of decades, hospitals in the United States are facing pressures to maximize performance in terms of production efficiency and quality. An increasing emphasis on value-based purchasing on the part of third-party payers as well as the prevalence of pay for performance initiatives create an imperative for more accurate assessments of health care provider performance. PURPOSES: The objectives of this study were to measure hospital performance in terms of both technical efficiency and quality using data envelopment analysis (DEA) models in urban acute care hospitals. METHODOLOGY/APPROACH: In this observational cross-sectional study of a nationally representative sample of 371 urban acute care hospitals, hospital performance was assessed using slack-based additive DEA models. The technical inputs included in the DEA models were total number of beds setup and staffed, nonphysician full-time equivalent staffing, and nonpayroll operating expenses. The technical outputs were adjusted patient days, total number of outpatient visits, and training full-time equivalent, obtained from the American Hospital Association 2008 database. The quality measures used for the quality of care dimension of performance were survival rates for acute myocardial infarction, congestive heart failure, and pneumonia obtained from the Nationwide Inpatient Sample 2008 data. FINDINGS: Less than 20% of the sample hospitals were optimally performing for both quality and efficiency. Tobit regression analysis of the DEA scores found that public, small, teaching hospitals had higher DEA efficiency and quality scores. PRACTICE IMPLICATIONS: DEA is a promising tool for benchmarking both aspects of performance: efficiency and quality of hospitals. Because quality is a multidimensional construct, the choice of an appropriate composite quality measure has to be addressed in future research. However, incorporating quality into the DEA models would be a better reflection of the hospital product.

Assessment of physician performance for diabetes: a bias-corrected data envelopment analysis model.

BACKGROUND: In most national health systems, especially when universal coverage is provided, family physicians act as gatekeepers, because most healthcare services are only delivered if there is a formal prescription provided by a primary care physician. Although the consumption of healthcare resources is initiated by prescriptions coming from family physicians, studies that evaluate their performance, especially those using a consolidated methodology (e.g.quality and efficiency) are limited in the literature. The specific aim of this paper is to propose a method for assessing primary care performance. METHODS: The novelty of the proposed model is twofold. First, physician performance is assessed following a clinical pathway that focuses on homogeneous groups of patients, in this case, diabetes patients. Second, we argue that performance should not be limited to efficiency, but should encompass clinical effectiveness. Performance assessment is not based on the physician practice as a whole, but on a single disease, in this paper, diabetes. Data were collected from a sample of family physician practices in Italy, and Data Envelopment Analysis (DEA) is used to evaluate their efficiency performance. RESULTS: We found that 35 of 96 practices were efficient based on the standard DEA model. The number of efficient practices decreased based on three restricted models that explored various behavioural preferences of physicians in relation to patient visits, medication administration and referrals to hospitals. CONCLUSION: The efficiency assessment is completed by a post-hoc evaluation of effectiveness, which in this study is defined as patient care adherence to the prescribed guideline. This study identified best practices both in terms of efficiency and effectiveness. The methods used in this paper are generalisable and could be applied to many other chronic conditions, which may constitute the prevalent activities within the primary care.

Hospital electronic medical record enterprise application strategies: do they matter?

BACKGROUND: Successful implementations and the ability to reap the benefits of electronic medical record (EMR) systems may be correlated with the type of enterprise application strategy that an administrator chooses when acquiring an EMR system. Moreover, identifying the most optimal enterprise application strategy is a task that may have important linkages with hospital performance. PURPOSE: This study explored whether hospitals that have adopted differential EMR enterprise application strategies concomitantly differ in their overall efficiency. Specifically, the study examined whether hospitals with a single-vendor strategy had a higher likelihood of being efficient than those with a best-of-breed strategy and whether hospitals with a best-of-suite strategy had a higher probability of being efficient than those with best-of-breed or single-vendor strategies. A conceptual framework was used to formulate testable hypotheses. METHODOLOGY: A retrospective cross-sectional approach using data envelopment analysis was used to obtain efficiency scores of hospitals by EMR enterprise application strategy. A Tobit regression analysis was then used to determine the probability of a hospital being inefficient as related to its EMR enterprise application strategy, while moderating for the hospital's EMR "implementation status" and controlling for hospital and market characteristics. FINDINGS: The data envelopment analysis of hospitals suggested that only 32 hospitals were efficient in the study's sample of 2,171 hospitals. The results from the post hoc analysis showed partial support for the hypothesis that hospitals with a best-of-suite strategy were more likely to be efficient than those with a single-vendor strategy. PRACTICE IMPLICATIONS: This study underscores the importance of understanding the differences between the three strategies discussed in this article. On the basis of the findings, hospital administrators should consider the efficiency associations that a specific strategy may have compared with another prior to moving toward an enterprise application strategy.

Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-Associated Infections in United States Hospitals.

OBJECTIVE: Healthcare-associated infections (HAIs) pose a challenge to patient safety. Although studies have explored individual level, few have focused on organizational factors such as a hospital's safety infrastructure (indicated by Leapfrog Hospital Safety Score) or workplace quality (Magnet recognition). The aim of the study was to determine whether Magnet and hospitals with better Leapfrog Hospital Safety Scores have fewer HAIs. METHODS: Ordered probit regression analyses tested associations between Safety Score, Magnet status, and standardized infection ratios, depicting whether a hospital had a Clostridium difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection standardized infection ratio that was "better," "no different," or "worse" than a National Benchmark as per Centers for Disease Control and Prevention's National Healthcare Safety Network definitions. RESULTS: Accounting for confounders, relative to "A" hospitals, "B" and "C" hospitals had significant and negative relationships with CDI (-0.16, P < 0.01, and -0.14, P < 0.05, respectively) but not MRSA bacteremia. Magnet hospitals had a significant and positive relationship with MRSA bloodstream infections (0.74, P < 0.001) but a significant negative relationship with CDI (-0.21, P < 0.01) compared with non-Magnet. CONCLUSIONS: A hospitals performed better on CDI but not MRSA bloodstream infections. In contrast, Magnet designation was associated with fewer than expected MRSA infections but more than expected CDIs. These mixed results indicate that hospital global assessments of safety and workplace quality differentially and imperfectly predict its level of HAIs, suggesting the need for more precise organizational measures of safety and more nuanced approaches to infection prevention and reduction.

The efficiency of hospital-based clusters: evaluating system performance using data envelopment analysis.

BACKGROUND: The rapid increase in the number of hospitals becoming members of multihospital systems in recent decades has led to the formation of local and regional clusters that have the potential to function as regional systems, a model long advocated as a policy strategy for improving health system performance. PURPOSE: This study addresses both cluster efficiency and the hierarchical configuration with which hospitals are grouped into clusters. METHODOLOGY/APPROACH: This study uses 2004 data from the American Hospital Association Annual Survey multihospital system designations updated to 2005. Efficiencies are measured using data envelopment analysis. PRINCIPAL FINDINGS: The data envelopment analysis results show that 20 clusters or 5.8% of the sample of 343 clusters are highly efficient; the remaining 323 or 94.2% of the clusters received lesser efficiency scores, averaging 0.73 on the data envelopment analysis measure. The study found the number of beds in the primary hospitals and the percentage of hospitals in the clusters that were urban, two of three variables that reflect patterns of regional model service configurations, to be significantly correlated with cluster efficiency. CONCLUSION: Results suggest that many hospital clusters have evolved service configurations that are consistent with historically conceptualized regional organizational forms and that the particular regional pattern of distributing service capacities across cluster members might contribute to measured performance. The study also confirms the applicability of data envelopment analysis for assessing the performance of complex, multiunit organizations.

Performance evaluation of ambulatory surgery centres: an efficiency approach.

This paper evaluates the performance of 198 ambulatory surgery centres (ASCs) operating in the State of Pennsylvania during the fiscal year 2006. Performance is assessed from technical efficiency view using data envelopment analysis (DEA). Multi-input/output model included two inputs: number of operating rooms and labour, and patient surgical visits differentiated by age groups: 0-17, 18-64, 65+ as three outputs. Input oriented models were employed to assess various DEA efficiency models. Results show that about 48 (24%) of ASCs are efficient with a mean efficiency score of 0.60. The results also indicate that appropriate utilization of operating rooms and labour inputs are the main determinants of ASC efficiency.

An examination of technical efficiency, quality, and patient safety in acute care nursing units.

Using an innovative statistical approach-data envelopment analysis-the authors examined the technical efficiency of 226 medical, surgical, and medical-surgical nursing units in 118 randomly selected acute care hospitals. The authors used the inputs of registered nurse, licensed practical nurse, and unlicensed hours of care; operating expenses; and number of beds on the unit. Outputs included case mix adjusted discharges, patient satisfaction (as a quality measure), and the rates of medication errors and patient falls (as measures of patient safety). This study found that 60% of units were operating at less than full efficiency. Key areas for improvement included slight reductions in labor hours and large reductions in medication errors and falls. The study findings indicate the importance of improving patient safety as a mechanism to simultaneously improve nursing unit efficiency.

Do hospitals with electronic medical records (EMRs) provide higher quality care?: an examination of three clinical conditions.

This study investigates how hospital electronic medical record (EMR) use influences quality performance. Data include nonfederal acute care hospitals in the United States. Sources of the data include the American Hospital Association, Hospital Quality Alliance, the Healthcare Information and Management Systems Society, and the Centers for Medicare and Medicaid Services case-mix index sets. The authors use a retrospective cross-sectional format with linear regression to assess the relationship between hospital EMR use and quality performance. Quality performance is measured using 10 process indicators related to 3 clinical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. The authors also use a propensity score adjustment to control for possible selection bias. After this adjustment, the authors identify a positive significant relationship between EMR use and 4 of the 10 quality indicators. They conclude that there is limited evidence of the relationship between hospital EMR use and quality.

A national study of efficiency for dialysis centers: an examination of market competition and facility characteristics for production of multiple dialysis outputs.

OBJECTIVE: To examine market competition and facility characteristics that can be related to technical efficiency in the production of multiple dialysis outputs from the perspective of the industrial organization model. STUDY SETTING: Freestanding dialysis facilities that operated in 1997 submitted cost report fonns to the Health Care Financing Administration (HCFA), and offered all three outputs--outpatient dialysis, dialysis training, and home program dialysis. DATA SOURCES: The Independent Renal Facility Cost Report Data file (IRFCRD) from HCFA was utilized to obtain information on output and input variables and market and facility features for 791 multiple-output facilities. Information regarding population characteristics was obtained from the Area Resources File. STUDY DESIGN: Cross-sectional data for the year 1997 were utilized to obtain facility-specific technical efficiency scores estimated through Data Envelopment Analysis (DEA). A binary variable of efficiency status was then regressed against its market and facility characteristics and control factors in a multivariate logistic regression analysis. PRINCIPAL FINDINGS: The majority of the facilities in the sample are functioning technically inefficiently. Neither the intensity of market competition nor a policy of dialyzer reuse has a significant effect on the facilities' efficiency. Technical efficiency is significantly associated, however, with type of ownership, with the interaction between the market concentration of for-profits and ownership type, and with affiliations with chains of different sizes. Nonprofit and government-owned Facilities are more likely than their for-profit counterparts to become inefficient producers of renal dialysis outputs. On the other hand, that relationship between ownership form and efficiency is reversed as the market concentration of for-profits in a given market increases. Facilities that are members of large chains are more likely to be technically inefficient. CONCLUSIONS: Facilities do not appear to benefit from joint production of a variety of dialysis outputs, which may explain the ongoing tendency toward single-output production. Ownership form does make a positive difference in production efficiency, but only in local markets where competition exists between nonprofit and for-profit facilities. The increasing inefficiency associated with membership in large chains suggests that the growing consolidation in the dialysis industry may not, in fact, be the strategy for attaining more technical efficiency in the production of multiple dialysis outputs.

The influence of previous breast cancer upon mammography utilization.

Women with a previous history of breast cancer are at increased risk for developing cancer in the opposite breast. However, the literature is inconsistent regarding whether a previous history of breast cancer is associated positively with mammography utilization. Some studies indicate that women with a previous history of breast cancer are less likely to utilize mammography, although behavioral models of health care theorize that women with a history of breast cancer may be more vigilant regarding the disease. We analyzed responses from 830 women > or =50 years who participated in the 1998 National Health Interview Survey. A significantly greater proportion of women with breast cancer reported had a mammogram in the previous year (73.13%) as compared with women who did not have breast cancer (56.69%). Although a previous history of breast cancer was found to be associated positively with mammography use, women with public sources of health insurance are less likely to report mammography use. Results indicate that women with a previous history of breast cancer appear aware of the necessity for continued screening. However, enabling factors such as type of health insurance continue to exert an influence upon the utilization of mammography.

Use of data envelopment analysis to quantify opportunities for antibacterial targets for reduction of health care-associated Clostridium difficile infection.

Clostridium difficile infection (CDI) is an important health care-associated infection that leads to increased morbidity and mortality. Antibacterial medications used in hospitals serve as targets for antibacterial stewardship programs to reduce C difficile. The objective was to create a benchmark strategy targeting high-risk antibacterials for C difficile. This was a retrospective cross-sectional study using claims data from 58 hospitals. The Data Envelopment Analysis Technique was used to identify best-practice hospitals in terms of less use of 5 classes of antibacterials and fewer CDIs. Of 58 hospitals, 17 (29%) were identified as best-practice hospitals. Antibacterial classes requiring the greatest percentage reduction in use in non-best-practice hospitals versus best-practice hospitals were clindamycin (31%), ß-lactam/ß-lactamase combinations (30%), and carbapenems (29%). This study suggests that there are areas of improvement in high-risk antibacterial use that could lead to decreased CDIs.

Freestanding inpatient rehabilitation facility performance following the 60 percent rule: a matter of fit.

The 60 percent rule has served as a controversial policy change within the postacute care sector since its revision in 2004, requiring inpatient rehabilitation facilities (IRFs) to admit no less than 60% of patients according to 1 of 13 specific conditions or else risk the loss of IRF designation according to Medicare's prospective payment system. Using a contingency theory framework, this study proposes that the 60 percent rule introduced considerable uncertainty into freestanding IRFs' operational environment, and as a result, IRFs' operational performance varied according to their "fit" between certain structural characteristics and the pervasive environmental uncertainty. The results suggest that operational performance, as measured by facility Malmquist Index scores, decreased on average for freestanding IRFs following the 60 percent rule's enforcement in 2005. In contrast, organizations possessing structural characteristics that better "fit" the heightened environmental uncertainty exhibited improved performance on average during the study's 6-year time period.

Health care delivery restructuring and productivity change: assessing the Veterans Integrated Service Networks (VISNs) using the Malmquist approach.

This study evaluates the productivity changes for the Veterans Integrated Service Networks (VISNs) that the Veterans Health Administration (VHA) created, comparing performance in 1994 with that in 2004. This represents periods before and after the VHA in 1995 reconfigured provider units into 21 regionalized delivery systems and engaged in other important system innovations. Productivity is measured using the Malmquist Index approach (a longitudinal version of the data envelopment analysis [DEA]). Results indicate that the VISN restructuring generally produced improvements in overall productivity (Malmquist scores) and in VISN adaptations to structural/technological change. They also show that the VISNs overall did not produce "changes in efficiency," reflecting challenges they may have faced in making "technical change" through management adaptations. The findings are consistent with what would be expected, given the major changes that did occur within the VHA in recent years as well as the before and after design used in this study.

The economics of cancer care: longitudinal changes in provider efficiency.

Renewed debate over competition in healthcare suggests that greater specialization is good for the health economy. In essence, greater specialization is hypothesized to lead to lower average costs, due to learning curve effects, scale, or other operating efficiencies. This hypothesis was tested in oncology care, since this disease group is one of the few with existing specialized cancer centers already in place. Data envelopment analysis (DEA), and specifically a longitudinal Malmquist index over a 5-year period was applied to the major, specialized inpatient cancer centers to determine if these specialized centers achieve higher productivity over time, and if scale leads to higher operating efficiency. Results suggest policy and payer implications since these DRG-exempt hospitals may not be improving their technical efficiency over time. Despite advancements in technology and greater scale, the average efficiency of cancer care has marginally declined. Similarly, when compared to other hospitals with greater numbers of other service offerings, oncology care has not benefited from increasing returns to scale.

Data envelopment analysis comparison of hospital efficiency and quality.

Using a sample of Virginia hospitals, performance measures of quality were examined as they related to technical efficiency. Efficiency scores for the study hospitals were computed using Data Envelopment Analysis (DEA). The study found that the technically efficient hospitals were performing well as far as quality measures were concerned. Some of the technically inefficient hospitals were also performing well with respect to quality. DEA can be used to benchmark both dimensions of hospital performance: technical efficiency and quality. The results have policy implications in view of growing concern that hospitals may be improving their efficiency at the expense of quality.

Organizational and environmental determinants of hospital EMR adoption: a national study.

The recent focus on health care quality improvement and cost containment has led some policymakers and practitioners to advocate the adoption of health information technology. One such technology is the Electronic Medical Record (EMR), which is predicted to change and improve health care in the USA. Little is known about factors that influence hospital adoption of this relatively new technology. The purpose of this paper is to determine the national prevalence of EMR adoption in acute care hospitals while examining the organizational and environmental correlates using a Resource Dependence Theoretical Perspective. Significant predictors of hospital EMR use may indicate barriers to use for some hospitals and can be used to guide policy. This study uses a non-experimental cross sectional design to examine hospital EMR use in 2004. A logistic regression approach is used to determine the correlations between hospital EMR use and organizational and environmental characteristics. Hospital EMR use was identified using the HIMSS Analytics data. Organizational and environmental variables were measured using data from the AHA, CMS (financial and case mix) and ARF. Hospital EMR adoption is significantly associated with environmental uncertainty, type of system affiliation, size, and urbanness. The effects of competition, munificence, ownership, teaching status, public payer mix, and operating margin were not statistically significant. Significant predictors of hospital EMR adoption represent barriers that may prevent certain hospitals from obtaining and using EMRs. These hospitals include those that are smaller, more rural, non-system affiliated, and in areas of low environmental uncertainty. Since EMR adoption may be an organizational survival strategy for hospitals to improve quality and efficiency, hospitals that are at risk of missing the wave of implementation should be offered services and incentives to enable them to implement and maintain EMR systems.