How to detect hospitals where quality would not be jeopardized by health cost savings? A methodological approach using DEA with SBM analysis.

BACKGROUND: In Spain the health care cuts have been the norm after the international economic crisis. The aim of this study is fourfold: (1) to measure hospital performance analysing two different perspectives: technical efficiency and quality; (2) to determine how technically efficient hospitals operate when faced with undesirable production; (3) to determine whether a potential trade-off between efficiency and quality exists or not; and (4) to propose a methodology to detect which hospitals could reduce their running costs without jeopardizing the quality of the services provided. Budget cutbacks imposed in Spain should focus solely on these hospitals, unless an increase in undesirable production is considered acceptable. METHODS: In this paper a SBM (slacks-based measure) of efficiency model is employed incorporating undesirable outputs using the case-mix adjusted deaths of patients. The study is carried out using information from 232 general hospitals in Spain. FINDINGS: We find four different groups of hospitals based on the relationship between efficiency and undesirable outputs. CONCLUSION: We show that undesirable outputs affect the measurement of technical efficiency, proposing a tool that allows the identification of hospitals where efficiency can be increased, that is, where budget cuts and/or more production outputs can be implemented without necessarily increasing the undesirable output.

Análisis multinivel de la eficiencia técnica de los hospitales del Sistema Nacional de Salud español por tipo de propiedad y gestión / Multilevel analysis of the technical efficiency of hospitals in the Spanish National Health System by property and type of management

Objetivo: Analizar la eficiencia técnica por tipo de propiedad y gestión de los hospitales generales del Sistema Nacional de Salud español (2010-2012) y sus variables explicativas hospitalarias y regionales. Método: Se estudian 230 hospitales combinando el análisis envolvente de datos y modelos transversales de regresión lineal multinivel de efectos fijos. Con el análisis envolvente de datos se miden la eficiencia técnica global, pura y de escala, y con los modelos multinivel, las variables explicativas de eficiencia. Resultados: El índice medio de eficiencia técnica global de los hospitales sin personalidad jurídica es inferior al de los hospitales con personalidad jurídica (0,691 y 0,876 en 2012). Existe una importante variabilidad en eficiencia técnica pura (ETP) por formas de gestión directa, indirecta y mixta. Un 29% de la variabilidad en la ETP es atribuible a diferencias entre comunidades autónomas. La dotación de personalidad jurídica del hospital aumenta en 11,14 puntos la ETP. Por otra parte, la mayoría de las formas de gestión alternativas al modelo tradicional aumentan en porcentajes variables la ETP. En el ámbito regional, según el escenario considerado, la insularidad y la renta media por hogar son variables explicativas de la ETP. Discusión: Tener personalidad jurídica favorece la eficiencia técnica. El marco de regulación y gestión de los hospitales, más que la propiedad pública o privada, parecen explicar la eficiencia técnica. Las características regionales explican de forma relevante la variabilidad en la ETP

Objective: To analyze technical efficiency by type of property and management of general hospitals in the Spanish National Health System (2010-2012) and identify hospital and regional explanatory variables. Method: 230 hospitals were analyzed combining data envelopment analysis and fixed effects multilevel linear models. Data envelopment analysis measured overall, technical and scale efficiency, and the analysis of explanatory factors was performed using multilevel models. Results: The average rate of overall technical efficiency of hospitals without legal personality is lower than hospitals with legal personality (0.691 and 0.876 in 2012). There is a significant variability in efficiency under variable returns (TE) by direct, indirect and mixed forms of management. The 29% of the variability in TE es attributable to the Region. Legal personality increased the TE of the hospitals by 11.14 points. On the other hand, most of the forms of management (different to those of the traditional hospitals) increased TE in varying percentages. At regional level, according to the model considered, insularity and average annual income per household are explanatory variables of TE. Discussion: Having legal personality favours technical efficiency. The regulatory and management framework of hospitals, more than public or private ownership, seem to explain technical efficiency. Regional characteristics explain the variability in TE

[Multilevel analysis of the technical efficiency of hospitals in the Spanish National Health System by property and type of management]. / Análisis multinivel de la eficiencia técnica de los hospitales del Sistema Nacional de Salud español por tipo de propiedad y gestión.

OBJECTIVE: To analyze technical efficiency by type of property and management of general hospitals in the Spanish National Health System (2010-2012) and identify hospital and regional explanatory variables. METHOD: 230 hospitals were analyzed combining data envelopment analysis and fixed effects multilevel linear models. Data envelopment analysis measured overall, technical and scale efficiency, and the analysis of explanatory factors was performed using multilevel models. RESULTS: The average rate of overall technical efficiency of hospitals without legal personality is lower than hospitals with legal personality (0.691 and 0.876 in 2012). There is a significant variability in efficiency under variable returns (TE) by direct, indirect and mixed forms of management. The 29% of the variability in TE es attributable to the Region. Legal personality increased the TE of the hospitals by 11.14 points. On the other hand, most of the forms of management (different to those of the traditional hospitals) increased TE in varying percentages. At regional level, according to the model considered, insularity and average annual income per household are explanatory variables of TE. DISCUSSION: Having legal personality favours technical efficiency. The regulatory and management framework of hospitals, more than public or private ownership, seem to explain technical efficiency. Regional characteristics explain the variability in TE.

Análisis de la eficiencia técnica en los hospitales del Sistema Nacional de Salud español / Analysis of the technical efficiency of hospitals in the Spanish National Health Service

Objetivo: Analizar la eficiencia técnica y la productividad de los hospitales generales del Sistema Nacional de Salud (SNS) español (2010-2012) e identificar variables hospitalarias y regionales explicativas. Métodos: Se estudian 230 hospitales del SNS mediante análisis envolvente de datos midiendo la eficiencia técnica global, pura, de escala, y el índice de Malmquist. La robustez del análisis se evalúa con modelos input-output alternativos. Se emplean modelos multinivel lineales transversales de efectos fijos para analizar las variables explicativas de eficiencia. Resultados: El índice medio de eficiencia técnica global (ETG) es de 0,736 en 2012, con una importante variabilidad por comunidades autónomas. El índice de Malmquist (2010-2012) es de 1,013. Un 23% de la variabilidad en ETG es atribuible a la comunidad autónoma. Las variables exógenas estadísticamente significativas (residentes por cada 100 facultativos, índice de envejecimiento, renta media anual por hogar, gasto en servicios públicos fundamentales y gasto público sanitario per cápita) explican el 42% de la variabilidad de ETG entre hospitales y el 64% entre comunidades autónomas. El número de residentes es estadísticamente significativo. En todas las comunidades autónomas existe una relación lineal directa significativa entre la ETG y la renta anual per cápita y el gasto en servicios públicos fundamentales, e indirecta con el índice de envejecimiento y el gasto público sanitario per cápita. Discusión El importante margen de mejora en eficiencia de los hospitales está condicionado por características específicas de cada comunidad autónoma, particularmente el envejecimiento, la riqueza y las políticas de gasto público de cada una (AU)

Objective: To analyse the technical efficiency and productivity of general hospitals in the Spanish National Health Service (NHS) (2010-2012) and identify explanatory hospital and regional variables. Methods: 230 NHS hospitals were analysed by data envelopment analysis for overall, technical and scale efficiency, and Malmquist index. The robustness of the analysis is contrasted with alternative input-output models. A fixed effects multilevel cross-sectional linear model was used to analyse the explanatory efficiency variables. Results: The average rate of overall technical efficiency (OTE) was 0.736 in 2012; there was considerable variability by region. Malmquist index (2010-2012) is 1.013. A 23% variability in OTE is attributable to the region in question. Statistically significant exogenous variables (residents per 100 physicians, aging index, average annual income per household, essential public service expenditure and public health expenditure per capita) explain 42% of the OTE variability between hospitals and 64% between regions. The number of residents showed a statistically significant relationship. As regards regions, there is a statistically significant direct linear association between OTE and annual income per capita and essential public service expenditure, and an indirect association with the aging index and annual public health expenditure per capita. Discussion: The significant room for improvement in the efficiency of hospitals is conditioned by region-specific characteristics, specifically aging, wealth and the public expenditure policies of each one (AU)

[Analysis of the technical efficiency of hospitals in the Spanish National Health Service]. / Análisis de la eficiencia técnica en los hospitales del Sistema Nacional de Salud español.

OBJECTIVE: To analyse the technical efficiency and productivity of general hospitals in the Spanish National Health Service (NHS) (2010-2012) and identify explanatory hospital and regional variables. METHODS: 230 NHS hospitals were analysed by data envelopment analysis for overall, technical and scale efficiency, and Malmquist index. The robustness of the analysis is contrasted with alternative input-output models. A fixed effects multilevel cross-sectional linear model was used to analyse the explanatory efficiency variables. RESULTS: The average rate of overall technical efficiency (OTE) was 0.736 in 2012; there was considerable variability by region. Malmquist index (2010-2012) is 1.013. A 23% variability in OTE is attributable to the region in question. Statistically significant exogenous variables (residents per 100 physicians, aging index, average annual income per household, essential public service expenditure and public health expenditure per capita) explain 42% of the OTE variability between hospitals and 64% between regions. The number of residents showed a statistically significant relationship. As regards regions, there is a statistically significant direct linear association between OTE and annual income per capita and essential public service expenditure, and an indirect association with the aging index and annual public health expenditure per capita. DISCUSSION: The significant room for improvement in the efficiency of hospitals is conditioned by region-specific characteristics, specifically aging, wealth and the public expenditure policies of each one.

Clinical application of Ultracontrol®: infusion volume and use with different dialyzers.

INTRODUCTION: Recent studies indicate that the survival benefit with post-dilution on line hemodiafiltration (OL-HDF-post) are achieved if the infusion volume (Vinf) is greater than 20L per session, a goal that is not easily achieved due to hemoconcentration problems. Today we have automated techniques to achieve higher performance minimizing the number of alarms as Ultracontrol® (Ultrac). The objective in the first part of study was to evaluate the UltraC performance (expressed as the filtration fraction (FF) and Vinf) and which problems it presents, and in the second part, to study its performance with four different dialyzers. MATERIAL AND METHODS: 1st period. Nine patients were transferred to OL-HDF-post with UltraC. The first 3 months on OL-HDF all sessions were recorded and compared with hemodialysis sessions in the previous month. 2nd part: 18 patients on chronic OL-HDF-post were dialyzed for a week with each of these dialyser: FX1000, FX800, Elisio210H and Polyflux210. RESULTS: 1st period: In 3 patients, problems associated with inappropriate pressures emerged. In 3 patients there were problems associated with inadequate PTM and Psist that resolved changing to pressure control. Mean values were: maximum Qb 441 (21) (range 350-490) ml/min, Vinf 26.3 (3.3) l/session, FF 30.6 (2.5)%, KT 59.9 (5) l/session. KT increase of 12% compared to HD. 2nd part: Polyflux210 required less UltraC withdrawals than the others. Different PTM or Psist were found and determined the need for removal of the system. The KT was adequate. a) The UltraC system reaches FF of 30% with minimal alarms and Vinf higher than 20 l. b) Structural characteristics of dialysers can limit their use with UltraC although they managed to desirable KT and Vinf in a manual way.

Sistema Ultracontrol® en la clínica diaria de la hemodiafiltración en línea posdilucional: volumen de infusión alcanzado y aplicabilidad con distintos dializadores / Clinical application of Ultracontrol®: infusion volume and use with different dialyzers

Introducción: Estudios recientes indican que los beneficios en la supervivencia con hemodiafiltración en línea posdilucional (HDFOL-post) se logran si el volumen de infusión (Vinf) es superior a 20 l por sesión, cifra que no es fácil lograr por los problemas que genera la hemoconcentración. Hoy día contamos con técnicas automáticas que logran un mayor rendimiento minimizando el número de alarmas como el Ultracontrol® (UltraC). Objetivo: El objetivo ha sido, en una primera parte, evaluar el UltraC para conocer qué rendimiento logra (expresado como la fracción de filtración [FF] y el Vinf) y los problemas que presenta y, en una segunda parte, estudiar su funcionamiento con cuatro dializadores diferentes. Material y métodos: Primera parte. Nueve pacientes fueron transferidos a HDFOL-post con UltraC. Se recogieron todas las sesiones correspondientes a los tres primeros meses con HDF-OL y al mes previo en HD. Segunda parte. 18 pacientes en tratamiento crónico con HDFOL-post fueron sometidos a diálisis una semana con cada uno de estos dializadores: FX1000, FX800, Polyflux210 y Elisio 210H. Resultados: Primera parte. En 3 pacientes surgieron problemas asociados a PTM y Psist inadecuadas que se (..) (AU)

Introduction: Recent studies indicate that the survival benefit with post-dilution on line hemodiafiltration (OL-HDF-post) are achieved if the infusion volume (Vinf) is greater than 20L per session, a goal that is not easily achieved due to hemoconcentration problems. Today we have automated techniques to achieve higher performance minimizing the number of alarms as Ultracontrol® (Ultrac). The objective in the first part of study was to evaluate the UltraC performance (expressed as the filtration fraction (FF) and Vinf) and which problems it presents, and in the second part, to study its performance with four different dialyzers. Material and methods: 1st period. Nine patients were transferred to OL-HDF-post with UltraC. The first 3 months on OL-HDF all sessions were recorded and compared with hemodialysis sessions in the previous month. 2nd part: 18 patients on chronic OL-HDF-post were dialyzed for a week with each of these dialyser: FX1000, FX800, Elisio210H and Polyflux210. Results: 1st period: In 3 patients, problems associated with inappropriate pressures emerged. In 3 patients there (..) (AU)

Evaluación de la eficacia de la darbepoetina alfa subcutánea administrada en dosis única mensual en el tratamiento de la anemia en pacientes con insuficiencia renal crónica prediálisis / Evaluation of efficacy of darbepoetin alfa administered once monthly as treatment of anemia in predialysis patients with chronic kidney disease

Introducción y objetivo: Hasta el momento se ha demostrado la eficacia de ladarbepoetina alfa en el tratamiento de la anemia asociada a la enfermedad renalcrónica (ERC) en administración subcutánea (sbc) con una frecuencia semanal oquincenal. El objetivo de este estudio es evaluar la eficacia de la darbepoetina alfasbc administrada en dosis única mensual en el tratamiento de la anemia en pacientescon insuficiencia renal crónica (IRC) avanzada (estadios IV y V) prediálisisque mantenían niveles estables de hemoglobina (Hb) con darbepoetina alfa sbcadministrada en dosis quincenal.Material y métodos: Se seleccionaron para el estudio 15 pacientes que teníanniveles de Hb > 11 g/dl y recibían desde al menos 4 meses darbepoetina alfa sbcadministrada quincenalmente. En ellos se mantuvo la dosis equivalente de darbepoetinaalfa por vía sbc pero en administración mensual durante un año, sin modificaciónde la dosis. Durante el seguimiento se perdieron 8 pacientes por diferentesmotivos, manteniéndose 12 pacientes a los 3 meses de seguimiento yquedando la muestra reducida a 7 pacientes al finalizar el estudio.Resultados: A los 3 meses de seguimiento se objetiva una disminución estadísticamentesignificativa de la Hb y el hematocrito (Hto), aunque todos los pacientesmantuvieron Hb > 11 g/dl, así como una elevación estadísticamente significativade la creatinina (Cr) y de la paratohormona (PTH) plasmáticas, permaneciendoel resto de las variables sin modificaciones. Al final del estudio, tras un año de seguimiento,no se aprecian cambios significativos en ninguna de las variables, manteniendotodos los pacientes Hb > 11 g/dl.Conclusión: La darbepoetina alfa sbc mensual es una opción eficaz en el tratamientode la anemia asociada a la IRP. La administración de una dosis de1 mcg/kg/mes permitió en todos los pacientes mantener una adecuada correcciónde la anemia según las guías clínicas (Hb > 11 g/dl)

Background: Darbepoetin alfa has demonstrated its efficacy when is administeredsubcutaneously once-weekly and once every 2 weeks as treatment of anemiain patients with chronic kidney disease (CKD). The aim of this study is to assessthe efficacy of subcutaneus darbepoetin alfa administered once monthly in patientswith progressive CKD who maintained stable levels of Hb treated on onceevery other week dosing.Methods: Patients included in the study maintained hemoglobin (Hb) > 11 g/dland were receiving darbepoetin alfa once every other week during at least 4months. We studied a frecuency interval dose change: once every other week frecuencywas converted to once monhly at equivalent dose. The study completerswere 12 patients over the third month and 7 at the end of one year evaluationperiod.Results: A statistic significant decrease in Hb and hematocrit (Hto) was observedover the third month, although all patients maintain Hb levels higher than 11g/dl. At the same time it was appreciated a statistic significant increased on creatinine(Cr) and parathyroid hormone levels (PTH). At the end of one year evaluationperiod no differences were observed in any of variables.Conclusion: Darbepoetin alfa administered once monthly is an efficacious optionas treatment of anemia for patientes with CKD. With a dose of 1 mcg/kg/month,all patientes maintain Hb > 11 g/dl

[Evaluation of efficacy of darbepoetin alfa administered once monthly as treatment of anemia in predialysis patients with chronic kidney disease]. / Evaluación de la eficacia de la darbepoetina alfa subcutánea administrada en dosis única mensual en el tratamiento de la anemia en pacientes con insuficiencia renal crónica prediálisis.

BACKGROUND: Darbepoetin alfa has demonstrated its efficacy when is administered subcutaneously once-weekly and once every 2 weeks as treatment of anemia in patients with chronic kidney disease (CKD). The aim of this study is to assess the efficacy of subcutaneus darbepoetin alfa administered once monthly in patients with progressive CKD who maintained stable levels of Hb treated on once every other week dosing. METHODS: Patients included in the study maintained hemoglobin (Hb) > 11 g/dl and were receiving darbepoetin alfa once every other week during at least 4 months. We studied a frequency interval dose change: once every other week frequency was converted to once monthly at equivalent dose. The study completers were 12 patients over the third month and 7 at the end of one year evaluation period. RESULTS: A statistic significant decrease in Hb and hematocrit (Hto) was observed over the third month, although all patients maintain Hb levels higher than 11 g/dl. At the same time it was appreciated a statistic significant increased on creatinine (Cr) and parathyroid hormone levels (PTH). At the end of one year evaluation period no differences were observed in any of variables. CONCLUSION: Darbepoetin alfa administered once monthly is an efficacious option as treatment of anemia for patientes with CKD. With a dose of 1 mcg/kg/month, all patientes maintain Hb > 11 g/dl.