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Health Care Management Science

, Volume 20, Issue 4, pp 565–576 | Cite as

Using nonparametric conditional approach to integrate quality into efficiency analysis: empirical evidence from cardiology departments

  • Yauheniya Varabyova
  • Carl Rudolf Blankart
  • Jonas Schreyögg
Article

Abstract

Health care providers are under pressure to improve both efficiency and quality. The two objectives are not always mutually consistent, because achieving higher levels of quality may require additional resources. The aim of this study is to demonstrate how the nonparametric conditional approach can be used to integrate quality into the analysis of efficiency and to investigate the mechanisms through which quality enters the production process. Additionally, we explain how the conditional approach relates to other nonparametric methods that allow integrating quality into efficiency analysis and provide guidance on the selection of an appropriate methodology. We use data from 178 departments of interventional cardiology and consider three different measures of quality: patient satisfaction, standardized mortality ratio, and patient radiation exposure. Our results refute the existence of a clear trade-off between efficiency and quality. In fact, the impact of quality on the production process differs according to the utilized quality measure. Patient satisfaction does not affect the attainable frontier but does have an inverted U-shaped effect on the distribution of inefficiencies; mortality ratio negatively impacts the attainable frontier when the observed mortality more than doubles the predicted mortality; and patient radiation exposure is not associated with the production process.

Keywords

Quality Technical efficiency Cardiology department Conditional approach Data envelopment analysis (DEA) 

References

  1. 1.
    Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, Sermeus W (2010) Systematic review: effects, design choices, and context of pay-for-performance in health care. BMC Health Serv Res 10(1):247CrossRefGoogle Scholar
  2. 2.
    Hollingsworth B (2008) The measurement of efficiency and productivity of health care delivery. Health Econ 17(10):1107–1128CrossRefGoogle Scholar
  3. 3.
    Chang S-J, Hsiao H-C, Huang L-H, Chang H (2011) Taiwan quality indicator project and hospital productivity growth. Omega 39(1):14–22CrossRefGoogle Scholar
  4. 4.
    Garavaglia G, Lettieri E, Agasisti T, Lopez S (2011) Efficiency and quality of care in nursing homes: an Italian case study. Health Care Manag Sci 14(1):22–35CrossRefGoogle Scholar
  5. 5.
    Mark BA, Jones CB, Lindley L, Ozcan YA (2009) An examination of technical efficiency, quality, and patient safety in acute care nursing units. Policy Politics Nur Pract 10(3):180–186CrossRefGoogle Scholar
  6. 6.
    Nayar P, Ozcan YA (2008) Data envelopment analysis comparison of hospital efficiency and quality. J Med Syst 32(3):193–199CrossRefGoogle Scholar
  7. 7.
    Tiemann O, Schreyögg J (2009) Effects of ownership on hospital efficiency in Germany. Bus Res 2(2):115–145CrossRefGoogle Scholar
  8. 8.
    Varabyova Y, Schreyögg J (2013) International comparisons of the technical efficiency of the hospital sector: panel data analysis of OECD countries using parametric and non-parametric approaches. Health Policy 112(1):70–79CrossRefGoogle Scholar
  9. 9.
    Yang J, Zeng W (2014) The trade-offs between efficiency and quality in the hospital production: some evidence from Shenzhen, China. China Econ Rev 31:166–184CrossRefGoogle Scholar
  10. 10.
    Du J, Wang J, Chen Y, Chou S-Y, Zhu J (2014) Incorporating health outcomes in Pennsylvania hospital efficiency: an additive super-efficiency DEA approach. Ann Oper Res 221(1):161–172CrossRefGoogle Scholar
  11. 11.
    Ferrier GD, Trivitt JS (2013) Incorporating quality into the measurement of hospital efficiency: a double DEA approach. J Prod Anal 40(3):337–355CrossRefGoogle Scholar
  12. 12.
    Simar L, Wilson PW (2015) Statistical approaches for non-parametric frontier models: a guided tour. Int Stat Rev 83(1):77–110CrossRefGoogle Scholar
  13. 13.
    Färe R, Grosskopf S (1983) Measuring output efficiency. Eur J Oper Res 13(2):173–179CrossRefGoogle Scholar
  14. 14.
    Fare R, Grosskopf S, Lovell CK (1994) Production frontiers. Cambridge University PressGoogle Scholar
  15. 15.
    Clement JP, Valdmanis VG, Bazzoli GJ, Zhao M, Chukmaitov A (2008) Is more better? An analysis of hospital outcomes and efficiency with a DEA model of output congestion. Health Care Manage Sci 11(1):67–77CrossRefGoogle Scholar
  16. 16.
    Mutter R, Valdmanis V, Rosko M (2010) High versus lower quality hospitals: a comparison of environmental characteristics and technical efficiency. Health Serv Outcome Res Methodol 10(3–4):134–153CrossRefGoogle Scholar
  17. 17.
    Valdmanis VG, Rosko MD, Mutter RL (2008) Hospital Quality, Efficiency, and Input Slack Differentials. Health Serv Res 43(5p2):1830–1848. doi: 10.1111/j.1475-6773.2008.00893.x CrossRefGoogle Scholar
  18. 18.
    Prior D (2006) Efficiency and total quality management in health care organizations: a dynamic frontier approach. Ann Oper Res 145(1):281–299CrossRefGoogle Scholar
  19. 19.
    Wu C-H, Chang C-C, Chen P-C, Kuo K-N (2013) Efficiency and productivity change in Taiwan’s hospitals: a non-radial quality-adjusted measurement. CEJOR 21(2):431–453CrossRefGoogle Scholar
  20. 20.
    Anderson R, Weeks H, Hobbs B, Webb J (2003) Nursing home quality, chain affiliation, profit status and performance. J Real Estate Res 25(1):43–60Google Scholar
  21. 21.
    Bates LJ, Mukherjee K, Santerre RE (2006) Market structure and technical efficiency in the hospital services industry: a DEA approach. Med Care Res Rev 63(4):499–524CrossRefGoogle Scholar
  22. 22.
    Gok MS, Sezen B (2013) Analyzing the ambiguous relationship between efficiency, quality and patient satisfaction in healthcare services: the case of public hospitals in Turkey. Health Pol 111(3):290–300CrossRefGoogle Scholar
  23. 23.
    Kooreman P (1994) Nursing home care in the Netherlands: a nonparametric efficiency analysis. J Health Econ 13(3):301–316CrossRefGoogle Scholar
  24. 24.
    Laine J, Finne-Soveri UH, Björkgren M, Linna M, Noro A, Häkkinen U (2005) The association between quality of care and technical efficiency in long-term care. Int J Qual Health Care 17(3):259–267CrossRefGoogle Scholar
  25. 25.
    Lee RH, Bott MJ, Gajewski B, Taunton RL (2009) Modeling efficiency at the process level: an examination of the care planning process in nursing homes. Health Serv Res 44(1):15–32CrossRefGoogle Scholar
  26. 26.
    Nyman JA, Bricker DL (1989) Profit incentives and technical efficiency in the production of nursing home care. Rev Econ Stat 71(4):586–594CrossRefGoogle Scholar
  27. 27.
    Bădin L, Daraio C, Simar L (2012) How to measure the impact of environmental factors in a nonparametric production model. Eur J Oper Res 223(3):818–833CrossRefGoogle Scholar
  28. 28.
    Simar L, Wilson PW (2011) Two-stage DEA: caveat emptor. J Prod Anal 36(2):205–218CrossRefGoogle Scholar
  29. 29.
    Simar L, Wilson PW (2007) Estimation and inference in two-stage, semi-parametric models of production processes. J Econ 136(1):31–64CrossRefGoogle Scholar
  30. 30.
    Daraio C, Simar L, Wilson PW (2015) Testing the" separability" condition in two-stage nonparametric models of production. LEM Working Paper Series,Google Scholar
  31. 31.
    Jones J, Sanderson C, Black N (1992) What will happen to the quality of care with fewer junior doctors? A Delphi study of consultant physicians' views. J R Coll Physicians Lond 26(1):36–40Google Scholar
  32. 32.
    Jha AK, Li Z, Orav EJ, Epstein AM (2005) Care in U.S. Hospitals — The Hospital Quality Alliance Program. N Engl J Med 353(3):265–274. doi: 10.1056/NEJMsa051249 CrossRefGoogle Scholar
  33. 33.
    Cazals C, Florens J-P, Simar L (2002) Nonparametric frontier estimation: a robust approach. J Econ 106(1):1–25CrossRefGoogle Scholar
  34. 34.
    Ozcan YA (2014) Health care benchmarking and performance evaluation an assessment using data envelopment analysis (DEA), 2nd edn. Springer, Newton, MAGoogle Scholar
  35. 35.
    Bădin L, Daraio C, Simar L (2014) Explaining inefficiency in nonparametric production models: the state of the art. Ann Oper Res 214(1):5–30CrossRefGoogle Scholar
  36. 36.
    Daraio C, Simar L (2007) Conditional nonparametric frontier models for convex and nonconvex technologies: a unifying approach. J Prod Anal 28(1–2):13–32CrossRefGoogle Scholar
  37. 37.
    Daraio C, Simar L (2005) Introducing environmental variables in nonparametric frontier models: a probabilistic approach. J Prod Anal 24(1):93–121CrossRefGoogle Scholar
  38. 38.
    Bădin L, Daraio C, Simar L (2010) Optimal bandwidth selection for conditional efficiency measures: a data-driven approach. Eur J Oper Res 201(2):633–640CrossRefGoogle Scholar
  39. 39.
    G-BA (2016) Qualitätsbericht der Krankenhäuser.Google Scholar
  40. 40.
    Gehrlach C, Altenhöner T, Schwappach D (2009) Der patients’ experience questionnaire. Patientenerfahrungen vergleichbar machen Bertelsmann Stiftung, GüterslohGoogle Scholar
  41. 41.
    Bramesfeld A, Willms G Gesetzliche Qualitätssicherung in der medizinischen Versorgung: Stand und Weiterentwicklung–Sektorenübergreifende Qualitätssicherung nach § 137a SGB V. In: Public Health Forum, 2014. vol 2. Elsevier, pp 14. e11–14. e13Google Scholar
  42. 42.
    Herr A (2008) Cost and technical efficiency of German hospitals: does ownership matter? Health Econ 17(9):1057–1071CrossRefGoogle Scholar
  43. 43.
    Varabyova Y, Blankart CR, Torbica A, Schreyögg J (2016) Comparing the Efficiency of Hospitals in Italy and Germany: Nonparametric Conditional Approach Based on Partial Frontier. Health Care Manag Sci:1–16Google Scholar
  44. 44.
    Doyle C, Lennox L, Bell D (2013) A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ open 3(1)Google Scholar
  45. 45.
    AQUA (2013) Beschreibung der Qualitätsindikatoren für das Erfassungsjahr 2012: Koronarangiographie und Perkutane Koronarintervention (PCI). Indikatoren 2012Google Scholar
  46. 46.
    van Ineveld M, van Oostrum J, Vermeulen R, Steenhoek A, van de Klundert J (2015) Productivity and quality of Dutch hospitals during system reform. Health Care Manage Sci:1–12Google Scholar
  47. 47.
    Navarro-Espigares JL, Torres EH (2011) Efficiency and quality in health services: a crucial link. Serv Ind J 31(3):385–403CrossRefGoogle Scholar
  48. 48.
    Martínez-Costa M, Martínez-Lorente AR, Choi TY (2008) Simultaneous consideration of TQM and ISO 9000 on performance and motivation: an empirical study of Spanish companies. Int J Prod Econ 113(1):23–39CrossRefGoogle Scholar
  49. 49.
    Zhang NJ, Unruh L, Wan TT (2008) Has the Medicare prospective payment system led to increased nursing home efficiency? Health Serv Res 43(3):1043–1061CrossRefGoogle Scholar
  50. 50.
    Khan N, Abboudi H, Khan MS, Dasgupta P, Ahmed K (2014) Measuring the surgical ‘learning curve’: methods, variables and competency. BJU Int 113(3):504–508CrossRefGoogle Scholar
  51. 51.
    Kristensen SR, Bech M, Lauridsen JT (2015) Who to pay for performance? The choice of organisational level for hospital performance incentives. Eur J Health Econ:1–8Google Scholar
  52. 52.
    Suñol R, Arah O, Wagner C, Groene O (2013) Relationships between the implementation of quality management strategies and clinical outcomes in European hospitals. The International Society for Quality in Health CareGoogle Scholar
  53. 53.
    Worthington AC (2004) Frontier efficiency measurement in health care: a review of empirical techniques and selected applications. Med Care Res Rev 61(2):135–170CrossRefGoogle Scholar
  54. 54.
    Ludwig M, Van Merode F, Groot W (2010) Principal agent relationships and the efficiency of hospitals. Eur J Health Econ 11(3):291–304CrossRefGoogle Scholar
  55. 55.
    Busse R, Blümel M (2014) Germany. Health system review Health Systems in Transition (2)Google Scholar
  56. 56.
    Hannöver W, Dogs CP, Kordy H (2000) Patientenzufriedenheit–ein Maß für Behandlungserfolg? Psychotherapeut 45(5):292–300CrossRefGoogle Scholar
  57. 57.
    AQUA (2014) Indikatoren in den Strukturierten Qualitätsberichten. Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH.Google Scholar
  58. 58.
    Ali AI, Seiford LM (1990) Translation invariance in data envelopment analysis. Oper Res Lett 9(6):403–405CrossRefGoogle Scholar
  59. 59.
    Blank R, Krusenbaum S, Steven M (2015) Effizienzanalyse mittels data envelopment analysis unter Berücksichtigung von Emissionen. WiSt-Wirtschaftswissenschaftliches Studium 44(11):613–622CrossRefGoogle Scholar
  60. 60.
    Simar L, Wilson PW (2002) Non-parametric tests of returns to scale. Eur J Oper Res 139(1):115–132CrossRefGoogle Scholar
  61. 61.
    Banker RD (1996) Hypothesis tests using data envelopment analysis. J Prod Anal 7(2–3):139–159CrossRefGoogle Scholar
  62. 62.
    Smith P (1997) Model misspecification in data envelopment analysis. Ann Oper Res 73:233–252CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Yauheniya Varabyova
    • 1
  • Carl Rudolf Blankart
    • 1
    • 2
  • Jonas Schreyögg
    • 1
  1. 1.Hamburg Center for Health EconomicsUniversität HamburgHamburgGermany
  2. 2.Center for Gerontology and Health Care Research, School of Public HealthBrown UniversityProvidenceUSA

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