Provision Of Health Care Resources Research Articles

Spatial and social inequality of hierarchical healthcare accessibility in urban system: A case study in Shanghai, China

Urbanization is intensifying in cities, accompanied by burgeoning inequalities, notably in the healthcare sector. Limited research offers a granular examination of healthcare resource accessibility across diverse population groups. In this study, we employ census data from all 6164 communities in Shanghai to investigate the relationship between multi-scalar spatial dimensions and the socio-economic (dis)advantage of populations concerning healthcare resource accessibility. Distinct from previous studies, this research quantifies social inequality by considering the demographics of community residents and their interactions with healthcare facilities. We elucidate the stratified spatial distribution of healthcare accessibility across various spatial scales in Shanghai, leveraging Web Application Programming Interface (API) technology and examine the pervasive social inequalities across sub-district, district, and the central urban-suburban divide, focusing on specific population subgroups including gender, age, education level, wealth, household registration, ethnicity, occupation, and housing living facilities. Findings reveal that disparities in healthcare accessibility correlate with the quality of healthcare facilities, the socio-spatial attributes of localities, and the socio-economic and demographic profiles of the populations. The insights from this research will aid policymakers in enhancing the distribution and provision of healthcare resources, thereby promoting spatial and social equity in public healthcare system planning and implementation.

The paradox of the COVID-19 pandemic: The impact on patient demand in Japanese hospitals

Analyzing data from a large, nationally distributed group of Japanese hospitals, we found a dramatic decline in both inpatient and outpatient volumes over the three waves of the COVID-19 pandemic in Japan from February to December 2020. We identified three key reasons for this fall in patient demand. First, COVID-19-related hygiene measures and behavioral changes significantly reduced non-COVID-19 infectious diseases. Second, consultations relating to chronic diseases fell sharply. Third, certain medical investigations and interventions were postponed or cancelled. Despite the drop in hospital attendances and admissions, COVID-19 is said to have brought the Japanese health care system to the brink of collapse. In this context, we explore longstanding systematic issues, finding that Japan's abundant supply of beds and current payment system may have introduced a perverse incentive to overprovide services, creating a mismatch between patient needs and supply of health care resources. Poor coordination among medical providers and the highly decentralized governance of the health care system have also contributed to the crisis. In order to ensure the long-term sustainability of the Japanese health care system beyond COVID-19, it is essential to promote specialization and differentiation of medical functions among hospitals, to strengthen governance, and to introduce appropriate payment reform.

The Structural Characteristics of Economic Network and Efficiency of Health Care in China

With the rapid development of the economy of China, the interactivity between provinces and the mobility of the population is increasing. Some patients who could have received the same treatment in their residential areas still choose to receive services in areas with higher economic development and concentrated high-quality medical resources, resulting in a huge waste of medical resources. Blindly increasing medical resources everywhere does not necessarily increase the output effectively. In this study, the data envelopment analysis (DEA) model, social network analysis (SNA), cluster analysis, and regression analysis are used to analyze the structural characteristics of the economic network structure and efficiency of health care in China. The results show that indegree and eigenvector centrality have a significant positive correlation with the efficiency of health care, and the clustering coefficient has a significant negative correlation with the efficiency of health care in China. This study uses a k-means algorithm to classify 31 provinces into three groups and extract their characteristics. As for the supply of health care resources, the government should command and dispatch the resources in the whole country through a top-down design based on the characteristics of each province.

What county-level factors influence COVID-19 incidence in the United States? Findings from the first wave of the pandemic

Effective control of the COVID-19 pandemic via appropriate management of the built environment is an urgent issue. This study develops a research framework to explore the relationship between COVID-19 incidence and influential factors related to protection of vulnerable populations, intervention in transmission pathways, and provision of healthcare resources. Relevant data for regression analysis and structural equation modeling is collected during the first wave of the pandemic in the United States, from counties with over 100 confirmed cases. In addition to confirming certain factors found in the existing literature, we uncover six new factors significantly associated with COVID-19 incidence. Furthermore, incidence during the lockdown is found to significantly affect incidence after the reopening, highlighting that timely quarantining and treating of patients is essential to avoid the snowballing transmission over time. These findings suggest ways to mitigate the negative effects of subsequent waves of the pandemic, such as special attention of infection prevention in neighborhoods with unsanitary and overcrowded housing, minimization of social activities organized by neighborhood associations, and contactless home delivery service of healthy food. Also worth noting is the need to provide support to people less capable of complying with the stay-at-home order because of their occupations or socio-economic disadvantage.

Development Of a Chronic Stress Diagnosis.

This study discusses a novel diagnosis, “stress- related exhaustion disorder”, which was introduced in Sweden in 2005. An International Classification of Diseases 10th revision (ICD-10) code, F43.8A, was specified for exhaustion disorder. Since then, there has been a remarkable increase in the number of patients diagnosed with exhaustion disorder in Sweden. The scientific basis of the diagnosis, and the putative mechanisms behind its increase, are discussed. It is hypothesized that the following factors may have promoted the increase in exhaustion disorder diagnosis: (i) the widespread perception of exhaustion disorder as a medical condition with physiological impairment of the endocrine and nervous systems, caused by external stressors; (ii) provision of healthcare resources and social insurance benefits for exhaustion disorder, without having firm evidence or guidelines on its management; (iii) highly inclusive diagnostic criteria for exhaustion disorder that overlap with the criteria for several other diagnoses (depression, anxiety disorders, chronic pain disorders), leading to possible bias towards exhaustion disorder diagnosis. The increase in exhaustion disorder does not necessarily reflect an increased stress-related morbidity in society. It is also important to consider factors related to the concept of stress as a disease, the availability and organization of healthcare and social insurance benefits, and diagnostic bias.LAY ABSTRACTMany of us will experience “stress”, at least at some time in our lives. It is a common view that stress sometimes becomes so severe that it causes “burnout” or “exhaustion”. While these concepts are frequently used in everyday language, their mechanisms are poorly understood, especially regarding whether and how stress might cause exhaustion. In a single country, Sweden, an initiative was undertaken in 2005 to introduce a novel diagnosis: “stress-related exhaustion disorder”. Since then, a remarkable increase in exhaustion disorder has taken place, and it has become a major cause of disability. The question arises as to whether this reflects a true increase in stressrelated disease in the population? This paper explores this question, and proposes that there are several other factors that may explain the increase in exhaustion disorder. The analysis also highlights the risks involved in creating a novel diagnosis for which solid scientific data are lacking.

Social Determinants of Health and Geographic Variation in Medicare per Beneficiary Spending

Despite substantial geographic variation in Medicare per beneficiary spending in the US, little is known about the extent to which social determinants of health (SDoH) are associated with this variation. To determine the associations between SDoH and county-level price-adjusted Medicare per beneficiary spending. This cross-sectional study used county-level data on 2017 Medicare fee-for-service (FFS) spending, patient demographic characteristics (eg, age and gender) and clinical risk score, supply of health care resources (eg, number of hospital beds), and SDoH measures (eg, median income and unemployment rate) from multiple sources. Multivariable regressions were used to estimate the association of the variation in spending across quintiles with SDoH. 2017 county-level price-adjusted Medicare Parts A and B spending per beneficiary. SDoH measures included socioeconomic position, race/ethnicity, social relationships, and residential and community context. Among 3038 counties with 33 495 776 Medicare FFS beneficiaries (18 352 336 [54.8%] women; mean [SD] age, 72 [1.5] years), mean Medicare price-adjusted per beneficiary spending for counties in the highest spending quintile was $3785 (95% CI, $3706-$3862) higher, or 49% higher, than spending for bottom-quintile counties (mean [SD] spending per beneficiary, $11 464 [735] vs $7679 [522]; P < .001). The total contribution (including through both direct and indirect pathways) of SDoH was 37.7% ($1428 of $3785) of this variation, compared with 59.8% ($2265 of $3785) by patient clinical risk, 14.5% ($549 of $3785) by supply of health care resources, and 19.8% ($751 of $3785) by patient demographic characteristics. When all factors were included within the same model, the direct contribution of SDoH was associated with 5.8% of the variation, compared with 4.6% by supply, 4.7% by patient demographic characteristics, and 62.0% by patient clinical risk. These findings suggest social determinants of health are associated with considerable proportions of geographic variation in Medicare spending. Policies addressing SDoH for disadvantaged patients in certain regions have the potential to contain health care spending and improve the value of health care; patient SDoH may need to be accounted for in publicly reported physician performance, and in value-based purchasing incentive programs for health care professionals.

Hierarchical two-step floating catchment area (2SFCA) method: measuring the spatial accessibility to hierarchical healthcare facilities in Shenzhen, China

BackgroundSpatial accessibility to healthcare facilities has drawn much attention in health geography. In China, central and local governments have aimed to develop a well-organized hierarchical system of healthcare facilities in recent years. However, few studies have focused on the measurement of healthcare accessibility in a hierarchical service delivery system, which is crucial for the assessment and implementation of such strategies.MethodsBased on recent improvements in 2SFCA (two-step floating catchment area) method, this study aims to propose a Hierarchical 2SFCA (H2SFCA) method for measuring spatial accessibility to hierarchical facilities. The method considers the varied catchment area sizes, distance decay effects, and transport modes for facilities at various levels. Moreover, both the relative and absolute distance effects are incorporated into the accessibility measurement.ResultsThe method is applied and tested in a case study of hierarchical healthcare facilities in Shenzhen, China. The results reveal that the general spatial accessibility to hierarchical healthcare facilities in Shenzhen is unevenly distributed and concentrated. The disparity of general accessibility is largely caused by the concentrated distribution of tertiary hospitals. For facilities at higher levels, average accessibility of demanders is higher, but there are also larger disparities in spatial accessibility. The comparison between H2SFCA and traditional methods reveals that traditional methods underestimate the spatial disparity of accessibility, which may lead to biased suggestions for policy making.ConclusionsThe results suggest that the supply of healthcare resources at primary facilities is far from sufficient. To improve the spatial equity in spatial accessibility to hierarchical healthcare facilities, various actions are needed at different levels. The proposed H2SFCA method contributes to the modelling of spatial accessibility to hierarchical healthcare facilities in China and similar environments where the referral system has not been well designed. It can also act as the foundation for developing more comprehensive measures in future studies.

Racial/Ethnic Residential Segregation, the Distribution of Physician’s Offices and Access to Health Care: The Case of Houston, Texas

Previous research has demonstrated the impacts of racial/ethnic residential segregation on access to health care, but little work has been conducted to tease out the mechanisms at play. I posit that the distribution of health care facilities may contribute to poor access to health care. In a study of the Houston area, I examine the association between residential segregation, the distribution of physician’s offices, and two health care access outcomes of having a personal physician, as well as the travel time to their office location. Using the 2010 Health of Houston Survey combined with several census products, I test these relationships in a series of spatial and multilevel models. I find that Black segregation is related to a lower density of physician’s offices. However, I find that this distribution is not related to having a personal physician, but is related to travel times, with a greater number of facilities leading to shorter travel times to the doctor. I also find that Black segregation is positively associated with travel times, and that the distribution of physician’s offices partially mediates this relationship. In sum, these findings suggest that a more equitable provision of health care resources across urban neighborhoods would mitigate some of the negative effects of segregation.

Population characteristics and geographic coverage of primary care facilities

BackgroundThe location of General Practitioner (GP) facilities is an important aspect in the design of healthcare systems to ensure they are accessible by populations with healthcare needs. A key consideration in the facility location decision involves matching the population need for the services with the supply of healthcare resources. The literature points to several factors which may be important in the decision making process, such as deprivation, transportation, rurality, and population age.MethodsThis study uses two approaches to examine the factors associated with GP accessibility in Northern Ireland. The first uses multinomial regression to examine the factors associated with GP coverage, measured as the proportion of people who live within 1.5 km road network distance from the nearest GP practice. The second focuses on the factors associated with the average travel distance to the nearest GP practice, again measured using network distance. The empirical research is carried out using population and geospatial data from Northern Ireland, across 890 Super Output Areas and 343 GP practices.ResultsIn 19% of Super Output Areas, all of the population live within 1.5 km of a GP practice, whilst in 24% none of the population live within 1.5 km. The regression results show that there are higher levels of population coverage in more deprived areas, smaller areas, and areas that have more elderly populations. Similarly, the average travel distance is related to deprivation, population age, and area size.ConclusionsThe results indicate that GP practices are located in areas with higher levels of service need, but also that care needs to be taken to ensure rural populations have sufficient access to services, whether delivered through GP practices or through alternative services where GP practices are less accessible. The methodology and results should be considered by policy makers and healthcare managers when making decisions about GP facility location and service provision.

Comment on “A Conceptual Framework for Quality Healthcare Accessibility: a Scalable Approach for Big Data Technologies”

ᅟFloating Catchment Area (FCA) metrics incorporate the supply of health care resources, potential population demand for those resources, and the distance separating people and supply locations to characterize the spatial accessibility of health care resources for populations. In this work, I challenge a number of assertions offered in a recently published FCA-based paper and provide a critique of the authors' proposed metric. Within my critique, I present a number of broad observations and recommendations regarding FCA metrics and their implementation in a Geographic Information System (GIS). In doing so, I aim to initiate a broader discussion of access to health care, spatial accessibility, and FCA metrics that transcends disciplinary boundaries.

Effects and consequences of caring for persons with heart failure: (ECCUPENIC study) a nested case-control study.

Primary: To report a research protocol to analyse the relationship between the degree of heart failure and the health-related quality of life of patients and their family caregivers. Secondary: To identify the characteristics of heart failure patients and their caregivers and the association between these characteristics and hospital admissions. Moreover, to conduct a longitudinal analysis of the relationship between patients' and that of their family caregivers. As heart failure progresses, it reduces the patient's quality of life and progressive functional deterioration requires hospital admission and the provision of healthcare resources. The availability of a family caregiver is a key element in addressing and managing this healthcare problem and some research results have associated this factor with the prognosis for heart failure. Multicentre cohort nested case-control study. Exploratory analysis: Descriptive statistics, measures of central tendency and dispersion or percentages. Bivariate analysis: Using Student's t-test and chi-square test, anova and non-parametric tests. Survival analysis: Kaplan-Meier curves. Multivariate analysis: Cox's proportional hazards model. All calculations performed with an alpha level of 0·05. Lack of family support for patients with HF or greater duration of care is associated with more hospitalizations and increased depression among caregivers. Further longitudinal studies with a large population sample are required.

Social determinants of hospitalizations for ambulatory care sensitive conditions in Guarulhos, São Paulo.

The study goals present an overview of Hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) in Guarulhos, SP, from 2008 to 2012. This is an ecological study based on secondary data obtained from the Brazilian Hospital Information System, and supported by the Praxical Theory of Intervention of Collective Health Nursing. Applied descriptive statistics for analysis. It was observed that Guarulhos shows an upward trend in hospitalizations by ACSC (20% increase), the most frequent causes of heart failure (11.8%), cerebrovascular disease (10.6%) and angina (9.7%), most frequently in the age group ≥ 65years old, for both sexes. The results are similar to other Brazilian studies, but their analysis should extrapolate the biological limits and the supply of healthcare resources, focusing on the social determinants of the health-disease process.

On the supply of China's healthcare resources in a decentralized healthcare system

The structure of China's current governance bears prominent features of fiscal decentralization. The supply of healthcare resources in China has clearly witnessed slower growth in the last two decades during which the fiscal decentralization process has taken place. Using China's provincial panel data, we examine the determinants of healthcare resource supply while paying particular attention to the role of fiscal decentralization. We find that the supply of healthcare resources is inversely related to the degree of decentralization, which, using spatial econometrics, is attributed to the presence of strategic substitutes in healthcare spending across city governments. These findings have important implications for policy makers in making fiscal arrangements among different government tiers.

Race and Residence: Intercounty Variation in Black-White Differences in Hospice Use

ContextAlthough blacks use hospice at lower rates than whites in the U.S., racial differences in hospice use vary by geographic area. ObjectivesTo describe intercounty variability in black-white differences in hospice use and the association with the supply of health care resources. MethodsSubjects were a retrospective cohort of Medicare beneficiaries in North and South Carolina who died in 2008. Using Wilcoxon tests and logistic regression, we examined the differences in the supply of health care resources (hospital beds and physicians per population age 65 years and older, percentage of generalists, etc.) between counties with and without racial disparity in hospice use. Counties with a racial disparity had significantly (P < 0.05) higher rates of hospice use among whites than blacks. ResultsOf 76,283 decedents in 128 counties, 19.78% were black. In the 39 counties (30.47%) with racial disparity in hospice use, the mean proportion of whites who enrolled in hospice was 41.3% vs. 28.66% of blacks (P < 0.0001). Counties with more hospital beds per population age 65 years and older had a higher odds (OR, 1.39; 95% confidence interval [CI] 1.04–1.86) and those with a larger proportion of generalists had a lower odds (OR, 0.01; 95% CI 0.001–0.476) of having a racial disparity in hospice use. ConclusionIn most counties, the rates of hospice use were similar for blacks and whites. In counties with a racial disparity, there were more resources to deliver aggressive care (i.e., hospital beds and specialists). Because of a greater preference for life-sustaining therapies, blacks may be more likely to use acute care services at the end of life when resources for the delivery of these services are readily available.

An experimental investigation of mixed systems of public and private health care finance

This paper presents the results of a revealed-choice experiment testing the theoretical predictions of a model of a mixed system of public and private finance. We investigate behavioural responses in individuals’ willingnesses-to-pay for private health insurance to changes in the public sector allocation rule (needs-based vs. random), the supply of health care resources, and the size of the public health care budget. Of particular interest is how willingness-to-pay for private insurance feeds back into the determination of the equilibrium price of health care resources, the probability of public treatment and which individuals are left untreated. Our findings are generally consistent with the predictions of the theoretical model, although individuals consistently exhibit greater willingnesses-to-pay for private insurance than predicted resulting in a larger than predicted amount of private insurance being purchased. A commonly used risk-aversion measure only partially explains this observed deviation. We also find that, relative to a system of public financing only, a mixed system of health care finance results in higher health care prices and sicker, poorer people being left untreated.

Differences between younger and older individuals in their use of care and rehabilitation but not in self-perceived global recovery 1 year after stroke

BackgroundAlthough priorities in Swedish stroke care should be based on the ethical principles of equal care and greatest support to those in greatest need, being of working age (younger) or retired (older) might influence expectations on recovery and the provision of care and rehabilitation. MethodInformation regarding the use of care and rehabilitation during the 1st year after stroke was retrieved from the Stockholm County Council database and the medical data was taken from the medical records. The Barthel Index was used for self-ratings of dependence pre‐stroke, and the Stroke Impact Scale was used to assess self-perceived disability and a global rating of recovery at 12months. One hundred and ninety‐two individuals were included. ResultsResults showed that the younger group received more care and rehabilitation than the older group. In the older group, comorbid conditions and pre‐stroke dependence, estimated in accordance with the Barthel Index, were more common. The older group reported larger impact on self-perceived disability regarding strength, mobility, self-care and domestic life, while self-perceived global recovery did not differ between the groups. ConclusionYounger individuals received more care and rehabilitation, which indicates structural inequality in the provision of health care resources. However, as no difference in self-perceived global recovery was found between the groups; the disparity in the provision of health care may also be a consequence of greatest support being given to those in greatest need. By demonstrating the necessity of involving self-rated assessments of stroke impact at different points in time and in different age groups, the results of this study add to previous knowledge of age-related differences in the provision of health care and stroke outcome. Furthermore, this suggests a way to approach evaluation of equality in the provision of health care.

Clarifying Sources of Geographic Differences in Medicare Spending

Although geographic differences in Medicare spending are widely considered to be evidence of program inefficiency, policymakers need to understand how differences in beneficiaries' health and personal characteristics and specific geographic factors affect the amount of Medicare spending per beneficiary before formulating policies to reduce geographic differences in spending. We used Medicare Current Beneficiary Surveys from 2000 through 2002 to examine differences across geographic areas (grouped into quintiles on the basis of Medicare spending per beneficiary over the same period). We estimated multivariate-regression models of individual spending that included demographic and baseline health characteristics, changes in health status, other individual determinants of demand, and area-level measures of the supply of health care resources. Each group of variables was entered into the model sequentially to assess the effect on geographic differences in spending. Unadjusted Medicare spending per beneficiary was 52% higher in geographic regions in the highest spending quintile than in regions in the lowest quintile. After adjustment for demographic and baseline health characteristics and changes in health status, the difference in spending between the highest and lowest quintiles was reduced to 33%. Health status accounted for 29% of the unadjusted geographic difference in per-beneficiary spending; additional adjustment for area-level differences in the supply of medical resources did not further reduce the observed differences between the top and bottom quintiles. Policymakers attempting to control Medicare costs by reducing differences in Medicare spending across geographic areas need better information about the specific source of the differences, as well as better methods for adjusting spending levels to account for underlying differences in beneficiaries' health measures.

Multidisciplinary care needs in an Australian tertiary teaching hospital

The ageing of the Australian population is placing increasing demand on the nation's healthcare system. This study set out to describe the level of need for multidisciplinary care in an Australian tertiary hospital setting. A cross-sectional audit by case note review of all patients on acute medical and surgical wards in an Australian tertiary hospital. The primary outcome was an identified need for multidisciplinary assessment and intervention. A total of 60% of the 295 inpatients audited required multidisciplinary care. Of those who were admitted to geriatric and rehabilitation units, 84% required multidisciplinary care. Patients in acute medical and surgical units also had substantial multidisciplinary care needs. Age was a significant influence with 79% of those aged 86 and above having multidisciplinary care needs, whilst only 38% of those aged 55 or less required multidisciplinary care. Difficulties with mobility, need for assistance with self-care, and continence problems were associated with higher requirement for multidisciplinary care. In the hospital population, significant multidisciplinary care needs exist. These needs are not limited to inpatients that are elderly or admitted to geriatric or rehabilitation units. This has implications for planning, funding, provision of health care resources, and training of medical and allied health staff.

Primary care physician supply and other key determinants of health care utilisation: the case of Switzerland

BackgroundThe Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland.MethodsThe data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data.ResultsModels within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care.ConclusionThe study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss language regions and may be rooted in the different cultural backgrounds of the served populations.

Technical efficiency of district hospitals: Evidence from Namibia using Data Envelopment Analysis

BackgroundIn most countries of the sub-Saharan Africa, health care needs have been increasing due to emerging and re-emerging health problems. However, the supply of health care resources to address the problems has been continuously declining, thus jeopardizing the progress towards achieving the health-related Millennium Development Goals. Namibia is no exception to this. It is therefore necessary to quantify the level of technical inefficiency in the countries so as to alert policy makers of the potential resource gains to the health system if the hospitals that absorb a lion's share of the available resources are technically efficient.MethodAll public sector hospitals (N = 30) were included in the study. Hospital capacity utilization ratios and the data envelopment analysis (DEA) technique were used to assess technical efficiency. The DEA model used three inputs and two outputs. Data for four financial years (1997/98 to 2000/2001) was used for the analysis. To test for the robustness of the DEA technical efficiency scores the Jackknife analysis was used.ResultsThe findings suggest the presence of substantial degree of pure technical and scale inefficiency. The average technical efficiency level during the given period was less than 75%. Less than half of the hospitals included in the study were located on the technically efficient frontier. Increasing returns to scale is observed to be the predominant form of scale inefficiency.ConclusionIt is concluded that the existing level of pure technical and scale inefficiency of the district hospitals is considerably high and may negatively affect the government's initiatives to improve access to quality health care and scaling up of interventions that are necessary to achieve the health-related Millennium Development Goals. It is recommended that the inefficient hospitals learn from their efficient peers identified by the DEA model so as to improve the overall performance of the health system.