Parameters of control when facing stochastic demand: a DEA approach applied to Bangladeshi vaccination sites.

An aim of vaccination programs is near-complete coverage. One method for achieving this is for health facilities providing these services to operate frequently and for many hours during each session. However, if vaccine vials are not fully used, the remainder is often discarded, considered as waste. Without an active appointment schedule process, there is no way for facility staff to control the stochastic demand of potential patients, and hence reduce waste. And yet reducing the hours of operation or number of sessions per week could hinder access to vaccination services. In lieu of any formal system of controlling demand, we propose to model the optimal number of hours and sessions in order to maximize outputs, the number and type of vaccines provided given inputs, using Data Envelopment Analysis (DEA). Inputs are defined as the amount of vaccine wastage and the number of full-time equivalent staff, size of the facility, number of hours of operation and the number of sessions. Outputs are defined as the number and type of vaccines aimed at children and pregnant women. This analysis requires two models: one DEA model with possible reallocations between the number of hours and the number of sessions but with the total amount of time fixed and one model without this kind of reallocation in scheduling. Comparing these two scores we can identify the "gain" that would be possible were the scheduling of hours and sessions modified while controlling for all other types of inefficiency. By modeling an output-based model, we maintain the objective of increasing coverage while assisting decision-makers determining optimal operating processes.

Comparing teaching and non-teaching hospitals: a frontier approach (teaching vs. non-teaching hospitals).

This paper compares teaching and non-teaching hospitals in terms of their provision of patient services. We proceed by comparing the frontiers of the teaching and non-teaching hospitals using a data envelopment (DEA) type approach, which we apply to a sample of 236 teaching hospitals and 556 non-teaching hospitals operating in the US in 1994. Our results suggest that only about 10% of the teaching hospitals can effectively "compete" with non-teaching hospitals based on the provision of patient services.

Productivity and economic burden associated with diabetes.

OBJECTIVES: This report assessed the cost and burden of diabetes in broad terms of economic status, underlying disability, and barriers to health care--that is, as reflected in employment, income, disability days, general health status, and access to medical care. METHODS: We used the 1990 to 1995 Behavioral Risk Factor Survey in Oklahoma to compare persons with diabetes with age-, sex-, and race/ethnicity-matched respondents without diabetes. RESULTS: Persons with diabetes were significantly and substantially worse off on all economic, disability, and access measures. CONCLUSIONS: Compared with nondiabetic persons, diabetic persons have fewer resources to deal with higher levels of disability and poorer health status.

Principal-agent problems in health care systems: an international perspective.

A central feature of all health care systems is the flow of finances from the population, via a variety of agencies, to the providers of health care. Each transfer of funds within the system involves a principal-agent problem, in the sense that a principal is entrusting funds to an agent with the intention that some desired aspect of health care delivery can be secured. This paper examines within the context of a principal-agent model three key elements of the health care system: the raising of finance, the transfer of funds to hospitals, and spending by hospitals. At each of these stages there is a danger that the objectives of society for the health care system are lost. In order to illustrate the issues involved, five mature systems of health care are examined: Austria, Germany, the United Kingdom, the Netherlands and the United States of America. The paper concludes that three aspects of the flow of funds are crucial to securing adequate control: the means of controlling patient entry to hospitals; the mechanism for remunerating hospitals for additional patients; and the control of physicians by hospital management.

Evaluating hospital performance with case-mix-adjusted outputs.

In this article, we compared hospital efficiency using a multiple input-output approach in two ways: one way used a straightforward count of inpatient days and outpatient services as outputs; and the second used a case mix-adjusted count of inpatient services and outpatient care as outputs. Our results show that there was no difference when we incorporated the case-mix index, either as a weighting device or as a separate output. However, this result may be due to our having a relatively homogeneous sample, (i.e., large metropolitan hospitals). Variations using this approach may occur when using a more heterogeneous sample, such as comparing hospitals of all sizes or rural versus urban hospitals.

Measuring hospital performance. A non-parametric approach.

In this paper a technique for assessing the relative performance of firms is introduced and applied to a sample of hospitals in California. Hospitals are compared on the basis of their relative technical efficiency. The reference technology is constructed from observed outputs and inputs (including physicians) using programming techniques, and efficiency is assessed relative to the frontier of the technology using measures similar to those suggested by Farrell. The technique used here imposes no prespecified functional form, allows for multiple outputs and inputs (allowing for differences in case mix), and yields information on the productive performance of individual hospitals. This technique can also be used to determine whether different types of hospitals use different technologies. Our results, although illustrative rather than definitive, suggest that ownership affects 'efficiency' as measured here: public and NFP hospitals have 'different' best practice frontiers, and public hospitals appear to use relatively fewer resources. These results could reflect differences in quality of care by ownership.