Configurational Paths to Higher Efficiency in County Hospital: Evidence From Qualitative Comparative Analysis.

Background: The efficient operation of county-level medical institutions is a significant guarantee in constructing Chinese rural tertiary care service networks. However, it is still unclear how to increase the efficiency of county hospitals under the interaction of multiple factors. In this study, 35 county general hospitals in China were selected to explore the configuration paths of county hospitals' high and poor efficiency status under the Environment-Structure-Behavior (ESB) framework and provide evidence-based recommendations for measures to enhance its efficiency. Methods: Data envelopment analysis with the bootstrapping procedure was used to estimate the technical efficiency value of case hospitals. A fuzzy-set qualitative comparative analysis approach was carried out to explore the configuration of conditions to the efficiency status. Results: Antecedent configurations affecting the efficiency status of county hospitals were identified based on the ESB analytical framework. Three high-efficiency configuration paths can be summarized as structural optimization, capacity enhancement, and government support. Another three types of paths, namely insufficient capacity, aggressive expansion, and poor decision-making, will lead to inefficient configurations. Conclusion: Qualitative comparative analysis is necessary when exploring complex causality. The efficiency situation of county hospitals results from a combination of influencing factors instead of the effect of a single one. There is no solitary configuration for high efficiency that applies to all healthcare units. Any measures aimed at efficiency promotion should be discussed within the framework of a case-specific analysis.

Impact of reimbursement rates on the length of stay in tertiary public hospitals: a retrospective cohort study in Shenzhen, China.

OBJECTIVE: To examine the association between reimbursement rates and the length of stay (LOS). DESIGN: A retrospective cohort study. SETTING: The study was conducted in Shenzhen, China by using health administrative database from 1 January 2015 to 31 December 2017. PARTICIPANTS: 6583 patients with acute myocardial infarction (AMI), 12 395 patients with pneumonia and 10 485 patients who received percutaneous coronary intervention (PCI) surgery. MEASURES: The reimbursement rate was defined as one minus the ratio of out-of-pocket to the total expenditure, multiplied by 100%. The outcome of interest was the LOS. Multilevel negative binomial regression models were constructed to control for patient-level and hospital-level characteristics, and the marginal effect was reported when non-linear terms were available. RESULTS: Each additional unit of the reimbursement rate was associated with an average of an additional increase of 0.019 (95% CI, 0.015 to 0.023), 0.011 (95% CI, 0.009 to 0.014) and 0.013 (95% CI, 0.010 to 0.016) in the LOS for inpatients with AMI, pneumonia and PCI surgery, respectively. Adding the interaction term between the reimbursement rate and in-hospital survival, the average marginal effects for the deceased inpatients with AMI and PCI surgery were 0.044 (95% CI, 0.031 to 0.058) and 0.034 (95% CI, 0.017 to 0.051), respectively. However, there was no evidence that higher reimbursement rates prolonged the LOS of the patients who died of pneumonia (95% CI, -0.013 to 0.016). CONCLUSIONS: The findings indicate that the higher the reimbursement rate, the longer the LOS; and implementing dynamic supervision and improving the service capabilities of primary healthcare providers may be an important strategy for reducing moral hazard in low-income and middle-income countries including China.