Abstract
ObjectiveRecent evidence on the Spanish National Health System (SNHS) reveals a considerable margin for hospital efficiency and quality improvement. However, those studies do not consider both dimensions together. This study aims at jointly studying both technical efficiency (TE) and quality, classifying the public SNHS hospitals according to their joint performance.MethodsStochastic frontier analysis is used to estimate TE and multilevel logistic regressions to build a low-quality composite measure (LQ), which considers in-hospital mortality and safety events. All hospitalizations discharged in Spain in 2003 and 2013, in 179 acute-care general hospitals, were studied. Four scenarios of resulting performance were built setting yearly medians as thresholds for the overall sample, and according to hospital-complexity strata.ResultsOverall, since 2003, median TE improved and LQ reduced -from TE2003:0.89 to TE2013:0.93 and, from LQ2003:42.6 to LQ2013:27.7 per 1,000 treated patients. The time estimated coefficient showed technical progress over the period. TE across hospitals showed scarce variability (CV2003:0.08 vs. CV2013:0.07), not so the rates of LQ (CV2003:0.64 vs. CV2013:0.76). No correlation was found between TE values and LQ rates. When jointly considering technical efficiency and quality, hospitals dealing with the highest clinical complexity showed the highest chance to be placed in optimal scenarios, also showing lesser variability between hospitals.ConclusionsEfficiency and quality have improved in Spanish public hospitals. Not all hospitals experiencing improvements in efficiency equally improved their quality. The joint analysis of both dimensions allowed identifying those optimal hospitals according to this trade-off.
Highlights
Health systems performance assessment (HSPA) has become a major priority in Europe as a way to strengthen health systems effectiveness [1]
Efficiency and quality have improved in Spanish public hospitals
In Spain, HSPA is getting momentum as a reaction to the deep financial crisis endured by the Spanish National Health System (SNHS) since 2010 [2]
Summary
Health systems performance assessment (HSPA) has become a major priority in Europe as a way to strengthen health systems effectiveness [1]. The most prevalent HSPA conceptual framework [3] suggests monitoring a set of dimensions such as equity in access, sufficiency in terms of financial endowment and quality as central focus, considering this last one as a nested matrix of the sub-dimensions patient-centred care, efficiency and patient safety. HSPA dimensions are measured as if they were independent phenomena when, on the contrary, multiple trade-offs are possible; for example, quality and efficiency are usually reported separately when both, are closely related when aiming the maximization of healthcare value (i.e., increasing efficiency while improving quality) [4]. One of the major concerns when measuring and reporting technical efficiency (TE) lays on the frequent coexistence of hospitals efficient exhibiting differences in quality [5,6,7]. Some authors found that lower TE was associated with poorer quality outcomes [8] while others found that technically efficient hospitals were performing well with regard to quality [9], remaining unclear whether hospitals that successfully improve quality necessarily sacrifice production efficiency [10,11]
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