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A Literature review on the Identification of Variables for Measuring Hospital

Efficiency in the Data Envelopment Analysis (DEA)

Article  in  Unnes Journal of Public Health · January 2021

DOI: 10.15294/ujph.v10i1.38253

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 Unnes Journal of Public Health 1 (1) (2017)

Unnes Journal of Public Health

http://journal.unnes.ac.id/sju/index.php/ujph

IDENTIFICATION OF VARIABLES FOR MEASURING HOSPITAL

EFFICIENCY IN DATA ENVELOPMENT ANALYSIS (DEA): LITERATURE
REVIEW

Nokky Farra Fazria1 *, Inge Dhamanti123

1
Departement of Health Administration and Policy, Faculty of Public Health, Universitas Airlangga

2
Center for Patient Safety Research, Universitas Airlangga

3
School of Psychology and Public Health, La Trobe University

Info Artikel Abstract

________________ ___________________________________________________________________
Sejarah Artikel:

Choosing input and output usually become a problem when doing efficiency assessment in
Diterima hospital. Data Envelopment Analysis (DEA) is an instrument that often used for calculate
efficiency of hospital using some inputs and outputs. This study purposed to identificate most
Disetujui used hospital inputs and outputs from existing paper to assist hospital management staff to
choosing relevan variables that can represent available of input, asses easily, and knowing
Dipublikasikan which variables that need to improve. This literature review using keywords such as “hospital
efficiency” and “DEA for hospital” to search peer-reviewed journal in PubMed and Open
Knowledge Maps around 2014-2020. From 586 articles, there were 51 samples with total 5 to
________________
3504 of many types of hospitals been analyzed from 23 countries. There were five most used
Keywords:
Efisiensi; DEA; Kesehatan;
inputs such as number of beds, number of medical personnel, number of non-medical staff,
Rumah Sakit
operational cost, and number of medical technician staf with most used outputs such as
____________________
number of inpatient, number of outpatient service, number of surgery, days of inpatient, and
number of emergency visit often used for hospital efficiency assessment in DEA application.

© 2020 Universitas Negeri Semarang

* Alamat korespondensi: pISSN 2252-6781

eISSN 2548-7604
Kampus C Universitas Airlangga, Surabaya, Indonesia

E-mail: [email protected]

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INTRODUCTION

Resources of hospital are demanded to fulfil what patient wants. But in the reality, there are
many hospital have not the same resources of each other so that makes uneffiecient resources of each
hospital (Abdurachman et al., 2019). Efficiecy assesment in hospital are rarely conducted like the other
sector because of resources setting and limited control of outputs (Shettian, 2017). Beside that, raising
efficiency are needed especially for health care in a low or medium human development index
countries. One of health care efficiency assessment problem is on methodological step
(Vivekanantham et al., 2014). Efficiency is a condition when existing resources could make an usefull
result. Hospital efficiency is about a hospital capacity to make a qualified result such as a well treated
patient and have recovered discharged patient by using resources such as medical staff, non-medical
staff, and finance. While unefficiency is a sign of low quality services which could affect a late
treatment even an addition therapy (OECD, 2019). There are two type of efficiency, the first one is
technical efficiency by combining or reducing input at certain level and economic efficiency by setting
hospital finance (Samudro and Pratama, 2018).
There is a most used efficiency assessment method called Data Envelopment Analysis
(DEA). A. Charnes, W. W. Cooper and Rhodes are the first who introduced DEA to public (1978)
(Samudro and Pratama, 2018). DEA can be used in DEAP 2.1 (Tim Coelli Inc.) and to knowing its
interpretation can be used SPSS (SPSS Inc., USA) and Frontier Analyst fourth version (Banxia
Software Ltd, UK). There are some important term form DEA (Soares et al., 2017): Decision-Making
Unit (DMU) is a main unit which efficiency is analyzed. In the case of hospital efficiency assessment,
the DMU is hospital; Input is an available resources in the DMU; Output is an impact or result of the
process of running the DMU; The efficiency score is a calculated value as a result of an efficiency
assessment. The value often on a scale of 0 to 1, with means 0 is the minimum and 1 is the maximum
value of efficiency.
The proper use of DEA can be used as a reference for considering DMU resources, as long
as the used data could represent the DMU process and could be compared with othe DMU (Kang &
Kaipornsak, 2014). Lack of information about relevant factors from variables makes it difficult to
calculate hospital efficiency, therefore it is important to consider the selection of appropriate and
effective inputs and outputs (Hsiao et al., 2018) and even become a source of hospital evaluation
(Omrani et al., 2018) . This study aims to identify the most used input and ouput in calculating hospital
efficiency using DEA. This study purposes to guide hospital management staff to find the relevant
hospital input and output so that the efficiency assessment will be easier, right on target representing
the available resources and it can be seen which part which need more attention to evaluate the
hospital. This study also describe the form of each variable that can be generated in DEA.

METHOD
This study conducted a literature review method of several articles with inclusion criteria of
search keywords such as "hospital efficiency" and "DEA for hospitals". Selected articles are published
articles from peer-reviewed journals from the literature database PubMed and Open Knowledge
Maps. The articles that appear are being reviewed from the title which states the elements of the
keywords, the language used is English, the year the article was published around 2014-2020, the
purpose of the article is to calculate hospital efficiency, the calculation method using DEA application
and mentioning the use of input and output for calculation. The exclusion criteria for articles to be
analyzed were articles obtained other than the specified keywords and articles that calculated the
efficiency of the part of hospital unit. The articles reviewed were not limited to the type of hospital,
city or country of origin, the combination of the DEA model used, and the type of efficiency that was
calculated. After the relevant articles selected, the variables were collected and calculated by the turus
method to see their frequency of used. The results of the literature review will be presented in a table
that contains the name of the author of the article, the number of DMU used in the calculation, and
the input and output mentioned. The five most used input and five output variables from the relevant
article will be discussed further in the results and discussion section.

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RESULT AND DISCUSSION

From the search results through the literature database based on keywords and year, the total
number of searches was 586 articles. The articles are then reviewed according to the appropriate title
and language getting 69 articles. Furthermore, the articles were examined according to their objectives,
the method used, the DMU used and the input and output variables mentioned so that there were 51
articles which most relevant to be analyzed in this study. Of the 54 relevant articles, it was found that
the number of DMUs was calculated starting from the smallest number DMUs was 5 to the largest
number was 3,504 DMUs. The DMUs that are calculated by the DEA in the relevant article come
from various types of hospitals such as public hospitals, private hospitals, university hospitals, regional
hospitals, veteran hospitals, institutions or ministry-bound hospitals. The relevant article calculates the
DMU of many countries such as Germany, China, Iran, Canada, Brazil, United States, Turkey,
Uganda, Bohemia, Greece, Italy, Ethiopia, Taiwan, Norway, Spain, Bangladesh, Poland, Japan,
Portugal, South Korea, Saudi Arabia, Malaysia and Palestine. Technical efficiency, economic
efficiency, scale efficiency, managerial efficiency and operational efficiency are the aims in calculating
the DEA of the relevant articles. The additional approaches or combinations of DEA calculations used
in relevant articles are vary such as the use of Tobit regression, the Malmquist index, integrated K-
means clustering, dynamic network DEA, bootstrap DEA, fuzzy DEA, slack-based DEA, window-
based, two-level DEA, and the four-tier DEA. Several variables from the results of the review on the
application of DEA in hospitals are more clearly shown in Table 1

Table 1. Literature Review of Hospital Variables in Data Envelopment Analysis (DEA)

Application

Variabel
No Penulis DMU
Input Output
1 (Büchner et al., 833 hospitals in Jerman - Full-time equivalent - Weighted inpatient cases by
2014) workers length of stay
- Medical supplying cost
- Other operational
supplying cost
- Staff service price
- Number of beds
2 (Chowdhury et al., 113 acute hospital - Staff hours - Number of outpatient visits
2014) Ontario, Canada - Nursing hours - Total number of inpatient
- Number of Staffed beds days
- Medical surgical supply - Case-mix adjusted weighted
cost inpatient days
- Non-medical surgical - Case-mix
supply cost
- Total equipment expense
3 (Kang & 128 public hospital dan - Number of beds - Outpatient visits
Kaipornsak, 2014) 69 traditional medicine - Number of physicians - Average of bed days
in Wilayah Mongolia - Number of nurses - Emergency visits
Dalam, Cina - Area of hospital - Surgery on ipatients
4 (Cheng et al., 2015) 114 township hospital - Number of physicians - Outpatient and emergency
in Province of Henan, - Number of nurses visits
Cina - Number of beds - Days of inpatient
5 (Gholami et al., 187 hospitals in United - Administrative and - Net patient revenue
2015) States general direct expenses - Total inpatient revenue
and salaries - Total number of admissions
- Salaries wages and fees - Total number of patient days
payable
- Total number of full-time
employees
- Sum of total current and
total long-term assets
- Total number of beds

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Variabel
No Penulis DMU
Input Output
6 (Li & Dong, 2015) 14 third-grade public - Number of beds - Number of diagnostic visits
general hospitals in - Number of staff - Number of discharged
Tianjin, Cina inpatients
7 (Narcı et al., 2015) 1.103 hospitals di Turki - Number of beds - Number of inpatients
- Number of specialist - Days of inpatients
physician - Number of surgeries
- Number of general - Number of outpatient and
physicians emergency visits
- Number of nurses and
other employee
8 (Rezaee & 288 hospitals from 31 - Number of staff - Number of inpatients
Karimdadi, 2015) Province in Iran - Number of medical - Number of outpatients
equipments - Number of patients with
- Number of operational special disease
beds - Number of operational beds
in a month
- Bed ocuupancy rate
9 (Xu et al., 2015) 51 tertiary hospital in - Medical personnel - Economic output
Beijing, Cina - Equipment - Bed occupancy
- Construction - services
- Finance
10 (Cheng et al., 2016) 48 township hospitals - Number of medical - Number of outpatients and
from Xiaogan, personnel emergency visits
Province of Hubei, - Number of medical - Number of inpatients
Cina technicians - Number of electronic medical
- Number of non-medical record
staff - Number of patients with
- Number of beds chronic disease
11 (Jiang et al., 2016) 7 pilot group hospitals - Number of beds - Person-time outpatient
dan 7 non-pilot group - Number of medical staff - Discharged patients
hospitals di Guangxi, - Hospital expenditure - Revenue from health services
China - Fixed asset
12 (Kalhor et al., 25 university hospitals, - Number of full-time - Days of inpatients
2016) 19 private hospitals, 10 doctors - Number of outpatients
social security hospitals - Number of full-time - Number of surgeries
Tehran, Iran nurses - Average Length of Stay
- Number of other medical
personnel
- Number of beds
13 (Lobo et al., 2016) 31 federal public - Number of beds - Outpatient visits weighted by
hospital guided by - Number of equipment disease seriousness
Minictry of Education - Human resources (except
Brazil doctor)
14 (Mujasi et al., 17 hospitals in Uganda - Number of beds - Days of inpatient
2016) - Number of medical - Number of outpatients
personnel
15 (Papadaki & 5 hospitals part of - Operational cost - Number of beds
Stankova, 2016) Central Bohemian - Number of inpatients
Holding and 7 - Bedc occupancy days
independent hospitals
16 (Samsudin et al., 25 public hospitals in - Number of doctors - Number of inpatients
2016) Kedah, Perlis, Pulau - Number of nurses - Number of outpatients
Pinang, Perak, - Number of beds - Number of surgeries
Malaysia - Total services
17 (Ali et al., 2017) 12 hospitals in East - Number of health staff - Outpatient visits
Ethiopia - Medicine supplying cost - Days of inpatient
- Number of beds - Number of surgeries
18 (Anthun et al., Somatic hospital which - Operational cost - Elective inpatients and
2017) provide emergency emergency services
service on 1999-2014 in - Day care services
Norwegia - Outpatient services

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Variabel
No Penulis DMU
Input Output
19 (Campanella et al., 50 public hospitals in - Number of beds - 30 days death risk of acute
2017) Italia - Number of doctors miokard infark case
- Number of nurses - 30 days death risk of
congestive heart failure case
- 30 days death risk of
pneumonia
20 (Flokou et al., 107 NHS hospitals in - Beds - Inpatient cases
2017) Greek - Doctors - Number of surgeries
- Other professional - Outpatient visits
employee
21 (Guo et al., 2017) 18 hospitals from 7 - Number of Full-Time - Days of inpatients
hospital clusters in Equivalents Staff - Emergency visit
Hong Kong, Cina - Number of beds - Outpatients visit
- Inpatient discharged rate
22 (Jia & Yuan, 2017) 5 high level public - Number of beds - Number of outpatients
hospitals in Shanghai, - Number of staff - Number of emergency patient
Cina - Number of discharged patient
- Average length of stay
23 (Jiang et al., 2017) 1105 hospitals from 31 - Open beds - Oupatients and emergency
province in Cina - Doctors visits
- Nurses - Days of inpatients
- Medical technician
24 (Li et al., 2017) 12 hospitals in Province - Number of beds - Number of emergency visits
of Anhui, Cina - Number of nurses - Inpatient discharged
- Number of beds - Number of inpatients
- Total expenditure
25 (Soares et al., 2017) 18 federal hospitals and - Number of medical and - Number of outpatient visits
3 government hospitals non-medical personnels - Number of inpatients
in Brazil - Yearly revenue - Number of surgeries
- Number of beds - Number of examinations
- Average length of stay
26 (Wang et al., 2017) 127 region general - Number of employee - Number of outpatients and
hospitals East Cina, (doctors, nurses, emergency visits
Middle Cina, and West technician) - Days of inpatients
Cina - Number of active beds
27 (Giancotti et al., 41 public hospitals in - Number of beds - Number of discharged
2018) Italia - Number of staff inpatients
- Days of inpatients
- Average length of stay
28 (Hsiao et al., 2018) 182 hospitals in Taiwan - Number of beds - Number of inpatients
- Human resources - Number of outpatients
- Number of physicians - Number of emergency visits
- Number of nurses - Inpatients revenue
- Number of other medical - Outpatients revenue
personnel
29 (Kiani et al., 2018) 8 hospitals affiliated - Number of doctors - Occupancy rate
University of Medical - Number of beds - Number of surgeries
Science Boshehr, Iran - Number of nurses - Number of discharged patient
- Admission per bed
30 (Kocisova et al., Hospitals from 16 - Average length of stay - Average number of patients
2018) province in Polandia - Average costs of care - Share of accredited hospitals
- Net profit per doctors
31 (Leleu et al., 2018) 1847 hospitals in - Case-mix Index - Volume of surgeries
United States - Staff - Volume of visits
- Beds - 30 days of re-admission rate
- 30 days of death rate
32 (Miguel et al., All of general hospital - Number of doctors - Number of discharges
2019) of Health Service - Number of beds - Number of outpatient
Madrid (SERMAS) - Goods and services consultations
Spain expenditure - Number of emergency
consultations

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- Number of non-admission
surgeries

Variabel
No Penulis DMU
Input Output
33 (Pirani et al., 2018) 17 general hospital - Number of admissions - Average length of stay
affiliated by University - Number of nurses - Bed turn-over interval
of Medical Science - Number of available beds
Ahvaz, Iran
34 (Omrani et al., 288 hospitals of 31 - Number of employees - Number of inpatients
2018) province in Iran - Number of surgery - Number of outpatients
equipments - Number of specific patients
- Number of active beds - Bed occupancy per day
35 (Şahin & İlgün, 865 hospitals guided by - Number of beds - Number of policlinic
2018) Ministry of Health in - Number of physicians admission
81 provvice in Turkey - Number of nurses and - Number of inpatients
midwives - Number of surgeries
- Number of other medical - Crude death rate
personnel
36 (Sultan & Crispim, 11 general hospital - Number of beds - Days of inpatients
2018) from West Bank in - Number of doctors - Oupatients visit
2010 to 2015 with 66 - Number of - Emergency visit
examination target in administration staf
Palestine - Number of medicine and
technology
37 (Zhang et al., 2018) 213 hospital in Japan - Number of doctors - Number of outpatients per
with adjusted criteria - Number of nurses day
- Number of other staff - Average of admission
- Number of beds - Discharges per year
- Region areas - Number of emergency beds
38 (Zheng et al., 2018) 84 general hospital in - Number of staff - Number of outpatients and
Chongqing, Cina - Government financial emergency visits
subsidiary - Number of discharged patient
- Number of beds - Health and medical services
- Fixed assets revenue
- Bed occupancy rate
39 (Ahmed et al., 62 district hospitals in - Number of beds - Number of mother who
2019) Bangladesh - Number of doctors received 4 ANC services
- Number of nurses - Number of normal services
- Number of caesar services
- Number of mother who
received PNC servicea
- Number of outpatient
services
- Number of inpatients
40 (Cinaroglu, 2019) 688 general hospitals in - Number of staff beds - Number of admissions
Turkey - Number of full-time - Number of inpatients
doctors - Number of surgeries
- Number of full-time
nurses and midwives
41 (Ferreira & Nunes, 27 centered hospital in - Services cost - Number of inpatients
2019) Portugal - Number of beds - Number of examination
- Number of full-time appointment
medical personnel - Number of emergency visit
- Number of surgeries
42 (Fuentes et al., 9 general acute hospital - Number of beds - Average length of stay
2019) from Health Services - Number of surgery room - Turn-over rate
Murcia, Spanyol - Personnel cost - Case-mix considered
- Operational cost discharged
- Number of emergency visits
- Number of surgeries

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Variabel
No Penulis DMU
Input Output
43 (Küçük et al., 2019) 669 of Health Ministry - Number of doctors - Number of outpatients
Hospital in Turki - Number of beds - Total inpatients
- Number of CT Scanners - Number of emergency
and MRI units department visit
- Total expenditures - Number of outpatients visit
per physician
- Number of surgeries
- Total revenue
44 (Li et al., 2019) Chinese township - Number of medical - Number of outpatient visit
hospital of 29 personnel - Number of inpatients
provincial areas in Cina - Number of medical beds - Medical bed utilization rate
- Number of township
hospital
45 (Lin et al., 2019) 15 veteran hospitals in - Number of physicians - Number of patient days
Taiwan - Number of patient beds - Number of patients receiving
- Number of other medical surgery
personnel - Net inpatient survivors
- Number of nurses
- Equipment
- Floor area
46 (Liu et al., 2019) 72 hospitals in - Physical area of hospital - Total income
Chingqing, China - Actual number of open - Number of hospital bed
beds rotations
- Total fixed assets - Number outpatient and
- Number of healthcare emergency visits
technicians - Number of discharged
patients
47 (Park et al., 2019) 1185 hospitals in Korea - Number of doctors - Number of hospitalized
Selatan - Number of nurses patients
- Number of beds - Number of operations
- Medical revenues

48 (Saquetto & 98 hospitals of National - Operational hospital beds - Number of consultations in

Araujo, 2019) Association of Private - Registered physician the emergency room
Hospitals (ANAHP) - Number of active - Number of hospitalizations
Brazil employees - Number of surgeries

49 (Alatawi et al.,, 91 public hospitals in - Number of beds - Outpatients visit

2020) Arab Saudi - Number of doctors - Discharged patients
- Number of nurses - Number of surgical
- Number of allied health operations
personnel - Number of radiological
investigations
- Number of laboratory tests
- Hospital mortality rate
50 (Botega et al., 3504 general hospitals - Human resources - Number of hospitalizations
2020) in Brazil (doctors, nurses, nursing according to five groups of
assitants, and ICD-10 and two age groups.
technicians)
- Infrrastructure (number
of beds, number medical
equipment)
51 (Jing et al., 2020) 154-232 hospitals from - Number of beds - Outpatients and emergency
“Beijing’s Health and - Number of helath visit
Family Planning technicians - Inpatient discharges
Statictical Yearbooks” - Revenue
in Beijing, China

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From Table 1, there are many terms included in the input and output variables. The terms and
how many times it have been used shown in Table 2.

Table 2. Details of The Amount of Use of Input and Output Variables to Calculate Hospital
Effiency in Data Envelopment Analysis (DEA) Application

Amount Amount
No. Input Output
of used of used
1 Number of beds 41 Number of inpatients 31
2 Number of medical personnel 39 Number of outpatient services 23
(doctor, nurse, dentist,
midwive)
3 Number of non-medical staff 15 Number of surgeries 17
4 Operational cost 16 Days of inpatient 12
5 Number of medical 9 Number of emergency visit 10
technician personnel
6 Area of hospital 4 Number of outpatient and 8
emergency services
7 Number of fixed assets 4 Hospital revenue 7
8 Number of medical 4 Utilization of beds 4
equipment
9 Number of equipments / 4 Number of patients with specific 3
technology treatment
10 Finance 2 services 3
11 Number of staff beds 2 Number of beds 2
12 Average Length of Stay 2 Income of inpatient 2
13 Staff working time 1 Crude Death Rate (CDR) 2
14 Construction 1 Net income of patient 1
15 Income per year 1 Case mix 1
Note: Due to the limit of space, the other term which can not be included in this table known
has 1 amount of used

In Table 2, it shown that five most used input to assess hospital efficiency in DEA application are
the number of beds, the number of medical personnel, the number of non-medical staff, operational
cost and the number of medical technicians.
1. The number of beds
The number of beds which can be included for hospital efficiency assessment were suitable
and available to use. The number of beds often considered as the capital of the hospital (Omrani et
al., 2018). The number of beds in this case are chronic care beds and special care beds (Soares et
al., 2017). An effective bed allocation planning, such as considering the number of beds by the size
of the hospital could have an impact on calculating efficiency and have a role for hospital
management (Kakeman et al., 2016).
2. The number of medical personnel
Human resources have the most important role in the health service system. The number of
doctors who are counted are doctors who work full time including dentists and Chinese medicine
doctors. The other medical personnel who are counted are nurses who work in hospital and nurses
who work in patient home (Soares et al., 2017) also midwives (Şahin & İlgün, 2018).
3. The number of non-medical staff
Non-medical personnel in this case were a staff who did not perform medical treatment on
patients in their work. The number of non-medical personnel included in the calculation are the
number of full-time staff or equivalent, social workers, researchers, non-professional workers
(Soares et al., 2017), full-time management staff (Hsiao et al, 2018), and logistics staff (Xu et al.,
2015).

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4. Operational cost
Total hospital expenditure counted as a part of the hospital’s economic investment (Li et al.,
2017). The expenses referred to the total of costs spent on purchasing goods and services to support
hospital services ( Miguel et al., 2019). The expenditure of goods and services commonly referred
as hospital operational costs (Fuentes et al., 2019). Operational costs often included in the
productivity analysis which can show good comparisons in terms of units and time (Anthun et al.,
2017). Expenses incurred by hospitals are usually in the term of cost allocations for medical services
(such as paroll, capital, and equipment depreciation costs) as well as non-medical supplies (Büchner
et al., 2014). In a study in China, large hospital expenditures affected by policy reforms did not lead
to raised hospital operational efficiency (Jiang et al., 2016). Hospital operational costs used in
calculating efficiency can be in a number of units of currency per year.
5. The number of medical technicians
Medical technician personnel referred to medical personnel other than doctors, nurses, and
not including hospital administrative staff (Lin et al., 2019). Medical technician including clinical
sosial workers, psychologists, hearing and speech therapists, and respiratory therapists (Hsiao et
al., 2018); pharmacists, pharmacist assistants, dietitians, physiotherapists, occupational therapists,
and radiology technicians (Kalhor et al., 2016) (Soares et al., 2017); clinical laboratory technicians
and medical imaging technicians (Cheng et al., 2016).
Beside of inputs, there were five most used outputs to assess hospital efficiency in DEA
application are the number of inpatients, the number of outpatient services, the number of surgeries,
days of inpatient, and the number of emergency visit.
1. The number of inpatients
Inpatient is a patient who are treated and need more treatment which requires a day or night
of stay or more in the hospital (Bateman et al., 2007). Inpatient could come form referrals from
other health facilities and or referrals from other unit within a hospital. In terms of efficiency, the
number of inpatients is usually espressed by the number of patients per year.
Many articles use the term “discharged patient” to represent the number of inpatients (Li &
Dong, 2015) (Narcı et al., 2015) (Jiang et al., 2016) (Jia & Yuan, 2017) (Li et al., 2017) (Giancotti
et al., 2018) (Kiani et al., 2018) (Zhang et al., 2018) (Zheng et al., 2018) (Fuentes et al., 2019)
(Miguel et al., 2019) (Liu et al., 2019) (Jing et al., 2020). From patients who have been discharged,
it can shows how was the capacity of services that have been used (Li et al., 2017). Patients who are
discharged consist of various results of treatment, such as recovered (Lin et al., 2019) or have died
(Narcı et al., 2015).
2. The number of oupatient services
Outpatients are patient who are hospitalized but do not require treatment that requires the
patient to stay overnight (Bateman et al., 2007). Outpatients usually only receive pre-admission
assessment or diagnostic procedures until consultation and can leave afterwards. In calculating
efficiency, outpatients were expressed by the number of patients per poly in one year (Soares et al.,
2017). As an output variable for calculating hospital efficiency, the number of outpatients often
combined with the number of emergency patients (Li & Dong, 2015) (Cheng et al., 2015) (Narcı et
al., 2015) (Cheng et al., 2016) (Wang et al., 2017) (Zheng et al., 2018) (Liu et al., 2019) (Jing et al.,
2020).
3. The number of surgeries
The number of operations are the number of treatments for a disease of disorder by means of
procedures that require some actions such as cutting, removing, or manipulating tissues, organs or
parts (Bateman et al., 2007). In efficiency calculations, the number of surgeries usually espressed
per year.
4. Days of inpatient
Days of inpatient is the cumulative length of stay of hospitalized patient or in emergency
department (Lin et al., 2019); including length of stay in general care, acute care, intensive care, dan
chronic care (Kalhor et al., 2016). Days of inpatient also referred as the specific duration of patient
admission and utilization of clinical and non-clinical inputs such as treatment, pharmacy,
paramedical support services, and administrative services (Sultan & Crispim, 2018). Realized that
ipatient services have different features and consume more resources that outpatients, the use of

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term “days of inpatient” is considered more medically homogenous than the term “number of
patients hospitalized” and can provide a more significant output (Wang et al., 2017). The use of
days of inpatient widely used in the form of the Average Lentgh of Stay (ALoS) (Fuentes et al.,
2019) (Pirani et al., 2018) (Giancotti et al., 2018) (Jia & Yuan, 2017) (Kalhor et al., 2016). But in
other hand, the varying length of days the hospitalized can be considered a distortion of ALoS
calculation because the level of use can be higher or lower wthin patient (Flokou et al., 2017). In
the calculation of efficiency, days of inpatient can be expressed by the number of days the patient
was treated per year.
5. The number of emergency visit
The number of emergency visit is the number of the arrival of patients in a condition that
urgently requires prompt treatment and care (Bateman et al., 2007). In calculating effeiciency, the
number of visits by emergency patients is counted in one year (Soares et al., 2017)

CONCLUSION

Each of the five most used input and output variables for the calculation of hospital efficiency
can be applied in the Data Envelopment Analysis (DEA). The hospital input variables that are often
used in the DEA application include the number of beds, the number of medical personnel, the
number of non-medical personnel staff, hospital expenses, and the number of medical technician
personnel. While the hospital output variables that are often used include the number of inpatients,
the number of outpatient services, the number of operations, days of inpatient and the number of
emergency department visits.

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