Someyah
Someyah
Someyah
Website:
www.jehp.net Abstract:
DOI: BACKGROUND: Given that the need to pay attention to measuring efficiency is considered as
10.4103/jehp.jehp_393_18 one of the main pillars of improving the level of efficiency in hospitals, so this study was carried
out aimed to determine the mean technical efficiency (The technical efficiency is bound by zero
and one and a score of less than one means that the theatre is inefficient as it could) score in
terms of type and activity of the hospital, input‑oriented and output‑oriented attitude, returns to
scale (In economics, returns to scale and economies of scale are related but different concepts
that describe what happens as the scale of production increases in the long run, when all input
levels including physical capital usage are variable (chosen by the firm). The concept of returns
to scale arises in the context of a firm’s production function. It explains the behavior of the rate
of increase) in hospitals of Iran using data envelopment analysis (DEA) (DEA is a nonparametric
method in operations’ research and economics for the estimation of production frontiers. It is
used to empirically measure productive efficiency of decision‑making units) and stochastic frontier
analysis (SFA) (SFA is a method of economic modeling. It has its starting point in the stochastic
production frontier models simultaneously introduced by Aigner, Lovell and Schmidt[1977] and
Meeusen and Van den Broeck[1977]
MATERIALS AND METHODS: The present study was carried out with a systematic review
of all studies conducted on measuring efficiency of hospitals in Iran from March 21, 2001 to
December 21, 2017 using DEA and SFA. Eleven databases were searched using appropriate
keywords and 470 articles were found and evaluated using a checklist, and finally, 24 articles
were entered into the meta‑analysis process. Meta‑analysis was performed using random effect
Management of Health model and fixed‑effect model, and study heterogeneity was investigated using Q‑Cochran
Services, School of Public test and I2 index. Furthermore, the main reasons of study heterogeneity were identified due
Health, Shahid Sadoughi to meta‑regression.
University of Medical RESULTS: The average technical efficiency score of hospitals using DEA and SFA method
Sciences, 1Statistics and was obtained equal to 0.885 and 0.809, respectively. Furthermore, with regard to the DEA
Epidemiology, School of method, 0.885, 0.891.0.952 and 0.913 was obtained for input‑oriented and output‑oriented,
Public Health, Shahid general and specialized care hospitals and constant returns respectively. With regard to SFA
Sadoughi University method, 0.733, 0.664, 0.641, 0.802, was obtained, and the inputs and outputs affect measuring
of Medical Sciences, the efficiency.
2
Department of Health
DISCUSSION: In contrast, the DEA method can investigate several input and output simultaneously
Economics, School of
and is used as an effective and flexible tool in order to measure the efficiency of the hospital. DEA
Public Health, Shahid
can be easily used for calculating efficiency scores based on the proper selection of input and
Sadoughi University of
output indicators. The data envelopment analysis method and different input and output variables
Medical Sciences,
have been used in most studies conducted in Iran, and Stochastic Frontier Analysis has been less
Yazd, Iran
considered. In the present study, the DEA method in governmental educational hospitals showed a
Address for higher efficiency than SFA method in the hospitals under study. But in general, due to lack of optimal
correspondence: efficiency level in the hospital, it is suggested that policymakers determine the hospital efficiency
Dr. Roohollah Askari, indices in order to evaluate their efficiency from different dimensions.
Associate Professor,
Management of Health
Services, School of Public This is an open access journal, and articles are
Health, Shahid Sadoughi distributed under the terms of the Creative Commons
University of Medical Attribution‑NonCommercial‑ShareAlike 4.0 License, which
Sciences, Yazd, Iran. allows others to remix, tweak, and build upon the work
E-mail: r.asqari@gmail. non‑commercially, as long as appropriate credit is given and How to cite this article: Mahdiyan S, Dehghani A,
com the new creations are licensed under the identical terms. Tafti AD, Pakdaman M, Askari R. Hospitals' efficiency
in Iran: A systematic review and meta-analysis. J Edu
Received: 17‑11‑2018 Health Promot 2019;8:126.
Accepted: 31‑12‑2018 For reprints contact: [email protected]
© 2019 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow 1
Mahdiyan, et al.: Hospitals’ efficiency in Iran: A systematic review and meta‑analysis
CONCLUSION: The average technical efficiency score of hospitals using DEA and SFA method was obtained equal to 0.885
and 0.809, respectively. Also, the mean technical efficiency score in terms of input-oriented and output-oriented, general and
specialized care hospitals and constant returns to scale using the DEA method was obtained equal to 0.885, 0.891.0.952 and
0.913 and using the SFA method, respectively, it was equal to 0.733, 0.664, 0.641, 0.802, and the inputs and outputs affecting
measuring the efficiency. There is no significant difference between the mean efficiency score between the two methods, but
the data envelopment analysis method is used more. It is suggested that the hospitals efficiency indicators to be determined in
order to more accurately evaluate the hospitals efficiency.
Keywords:
Data envelopment analysis, efficiency improvement, stochastic frontier analysis, systematic review
The results of preliminary studies from databases and the search engine: 470
{ Pubmed=13 , civilica=2 , sid=26, isi=9 ,google scholar=343 , irandoc=34, iranmedex=31, magiran=12}
the WHO site between March 21, 2001 and December from Cochran methodology). Finally, 24 articles entered
21, 2017, and the search strategy has been mainly the meta‑analysis process (With reference to Figure 1).
performed based on Persian and English keywords
using the Mesh system, with the possible combination Statistical analysis
of important, original, and sensitive words. The search Random effect model and fixed‑effect model were used
has been done using Persian keywords of Efficiency, to perform meta‑analysis and the study heterogeneity
Hospital technical efficiency, DEA, SFA, efficiency was investigated using Q‑Cochran test and I2 index. The
improvement, and English keywords of DEA and SFA agreement level between the two browsers (Cohen’s kappa
and Iranian hospital with And and OR Operators. coefficient (κ) [Cohen’s kappa coefficient is a statistic
Also, the list of reference in the studies published has which measures inter‑rater agreement for qualitative
been reviewed to increase sensitivity and select more items. It is generally thought to be a more robust measure
numbers of studies. than simple percent agreement calculation, as κ takes
into account the possibility of the agreement occurring
Selection of studies by chance]) was determined using the Cohen test. The
Of 470 articles, 344 studies were repetitive and removed. DerSimonian and Laird method was used to calculate the
Then, 12 nonrelated studies were removed using effects of community indicators (Pooled Effect Muser)
exclusion criteria, such as studies that did not use the for random models, and inverse variance method was
SFA and DEA methods to measure the efficiency level, used for fixed and forest plot models. The funnel plot
the studies which have reported the level of efficiency was used to identify the publication bias qualitatively
qualitatively and the articles’ letter to the editor. One and Egger’s regression test was used to identify the
hundred and fourteen articles were extracted for the publication bias quantitatively. Furthermore, the main
study of full text, of which 26 articles were removed reasons for the study heterogeneity were identified using
because of nonpublication of articles, the impossibility of meta‑regression. Meta‑analysis was performed using
the chart drawing with comprehensive meta‑analysis
contacting writers, and the limitations on the purchase of
V2 (CMAV2) software.
these articles. After determining the studies, to assess the
quality of the documentation, a checklist was prepared; Results
so that, the aim of each research, study method, sample
size, sampling method, data collection tool, measurement According to Table 1 and based on most studies
status of variables, target group, and status of analysis conducted in 2013, the DEA method is more investigated
were investigated using twelve questions (extracted compared to SFA method to measure the efficiency of
Journal of Education and Health Promotion | Volume 8 | June 2019 3
4
Table 1: Specifications of studies in meta‑analysis and metaragiosis
No.of No.of Input Standard Standard error Standard Mean Mean Mean technical No.of Estimation City studied Publication Author(s) No
output variable error scale management error scale management efficiency hospital method year
variable technical efficiency efficiency
2 4 0/025 0/01 0/032 0/9 0/97 0/87 19 DEA Tehran 2015 Rezapur et al.[1] 1
4 4 0/026 0/826 54 DEA Tehran 2016 Kakman et al.[14] 2
5 3 0/215 0/78 16 DEA Tehran 2009 Alamtabriz 3
et al.[5]
3 3 0/165 0/855 12 DEA Yazd 2008 Mohamadi 4
ardekani et al.[15]
4 4 0/052 0/965 12 DEA Tehran 2009 Purreza et al.[16] 5
4 4 0/015 0/901 65 DEA Iranian 2012 Sepehrdoost 6
hospital et al.[17]
4 5 0/167 0/861 22 DEA Tehran 2013 Adelazar et al.[18] 7
3 4 0/055 0/958 13 DEA Yazd 2012 Askari et al.[19] 8
4 4 0/125 0/893 25 DEA Tehran 2006 Ghaderi et al.[20] 9
4 4 0/082 0/98 0/961 0/943 19 DEA Gilan 2013 Mohebifar 10
et al.[21]
4 4 0/157 0/92 7 DEA Kermanshah 2014 Ghasemi 11
et al.[22]
2 3 0/169 0/056 0/165 0/89 0/95 0/85 12 DEA kordestan 2016 Rezaei et al. .[23] 12
3 5 0/045 0/044 0/074 0/957 0/971 0/933 31 DEA Iranian 2016 Mehraban 13
hospital et al.[24]
5 6 0/193 0/593 12 SFA Tehran 2013 Godarzi et al.[25] 14
1 4 0/184 0/68 12 SFA kordestan 2016 Rezaei et al.[26] 15
1 4 0/173 0/624 9 SFA kerman 2012 Godarzi et al.[3] 16
4 4 0/115 0/73 13 DEA Lorestan 2014 Godarzi et al.[27] 17
4 4 0/099 0/95 13 SFA Lorestan 2014 Godarzi et al.[27] 18
3 2 0/321 0/63 13 DEA Tehran 2015 Khodabakhshi 19
et al.[28]
2 2 0/013 0/88 11 DEA Khorasan 2013 kazemi et al.[29] 20
jonoobi
Mahdiyan, et al.: Hospitals’ efficiency in Iran: A systematic review and meta‑analysis
Iranian hospitals more than other cities. Also, in terms and other hospital staff, and four output variables
of 4 variables, input and output variables have been including the number of admissions of outpatients
used to measure the efficiency. Four variables have and number of hospitalized patients, bed occupancy
been used as input and output variables for measuring rate (The occupancy rate is calculated as the number
efficiency. of beds effectively occupied [bed‑days] for curative
care [HC.1 in SHA classification] divided by the
Figure 2 shows the mean technical efficiency of hospitals’ number of beds available for curative care multiplied by
inverse variance by size, using DEA and SFA methods. 365 days, with the ratio multiplied by 100), and number
In this figure, the efficiency estimation for DEA‑based of surgeries were identified as the most important and
studies is closer to one, indicating a higher efficiency of effective variables in measuring efficiency. Meta‑analysis
these hospitals than hospitals which use the SFA method. and meta‑regression and the study of the number of
variables have not been addressed in previous studies.
Discussion For example, Mosadeghrad et al. during a study entitled
“The efficiency of Iranian Hospitals: A Systematic Review
In the present study, 24 articles were reviewed using and Meta‑Analysis of Two Decades of Research,” in 2016,
systematic, meta‑analysis, and meta‑regression methods. 91 articles which used DEA and SFA and Pabon Lasso
Of these, 16 articles using DEA method and 8 articles methods during 2016–2017 to measure the efficiency of
using the SFA method have measured the efficiency of hospitals were evaluated and analyzed.[13] However,
governmental hospitals, and 3 articles have measured meta‑analysis and meta‑regression were not performed,
the efficiency of nongovernmental hospitals evaluated but important variables such as the number of beds and
using DEA method Thirteen studies using DEA method hospital staff were identified as input variables, and
and 2 studies using SFA have measured the efficiency of the number of surgeries, the number of admissions of
noneducational hospitals; 9 studies using DEA method outpatients and number of hospitalized patients, and bed
and 5 studies using SFA method have measured the occupancy rate were identified as the most important
efficiency of specialized hospitals; 14 studies using DEA output variables.
method and 7 studies using SFA method have measured
the efficiency of general hospitals; 14 studies using In 2016, Emanrezaei and Barun during a study entitled
input‑driven approach and 2 studies using output‑driven “Efficiency Analysis of Hospitals in Iran: A Systematic
approach and 5 studies using the DEA method and 3 Review” investigated 18 articles that used DEA and
studies using SFA method with constant returns to scale SFA methods during 2006–2014 to measure hospital
approach have measured the efficiency. efficacy[33] and concluded that most of the studies have
used the DEA method and the input‑oriented approach,
In this study, four input variables including number of which is consistent with the present study and the study
active beds, number of physicians, number of nurses, of Jahangiri entitled “Application of Data Envelopment
Journal of Education and Health Promotion | Volume 8 | June 2019 5
Mahdiyan, et al.: Hospitals’ efficiency in Iran: A systematic review and meta‑analysis
Analysis Technique in Iranian Hospitals: A Systematic outputs should be defined according to the goals of
Review” in 2015, which was carried out by examining 47 each hospital.[11] More input indicators are proposed
articles (regardless of the time of publication).[34] compared to this study.
The input and output variables introduced by Jahangiri Hussey et al. during a study entitled “A systematic review
who have used DEA method in their study is similar of measuring the health care efficiency” investigated
to this study, but both methods were investigated 172 English‑language articles from 1990 to 2008 and
by Emanrezaei and Baruni and the inputs affecting compared two methods of DEA and SFA in measuring
measuring efficiency included the number of full‑time the efficiency of the health system and investigated
physicians, full‑time nurses, and full‑time staff, the the number and type of selected input and outcomes.
number of active beds, the fixed bed, the annual cost, In the present study, the days of discharge, visits of
and the infrastructure and output variables included doctors, results of health measures, and therapeutic
the number of hospital admissions and outpatients, procedures were investigated as outputs.[7]Katharakis
the number of surgeries, bed occupancy rates, bed and Katostaras, during a study entitled “SFA, DEA
turnover rate (Hospital Bed Turnover Rate), (It is for Measuring Health Care efficiency: A Systematic
given by the formula: Hospital Bed turnover rate Review,” investigated 21 English‑language articles that
equals to Number of discharges (including deaths) had been accepted by various journals over the past
in a given time period divided to Number of beds in decade. In these articles, the inputs were analyzed using
the hospital during that time period), hospitalization meta‑analysis and the relationship between input and
day, the average length of stay in hospitals (ALOS), outputs was investigated by measuring more accurately
occupancy bed, hospital income, moreover, the the efficiency, better decision‑making, their effectiveness
number of discharged patients has been determined, on the efficiency, and selecting an appropriate model
by additional variables introduced by them, but as in to measure efficiency and proved that the accuracy
the study carried out by Jahangiri, meta‑analysis and of both methods depends on many factors, including
meta‑regression were not used in their study. Kiadaliri statistical methods, definition of inputs and outputs,
et al., in 2011–2012, in a study entitled “Stochastic and access to data.[36] Dong et al., during a study entitled
Frontier Analysis in Measuring the Efficiency of Iranian “Measuring the efficiency of Chinese hospitals using
Hospitals: A Systematic Review and meta‑regression data envelopment analysis for: a systematic review,”
Analysis,” examines both the DEA and SFA methods concluded that significant numbers of input and output
and its meta‑analysis and meta‑regression estimated were used in China, Europe, the United States, and other
the mean efficiency of hospitals at 0.846.[35] In addition, countries.
as in this study, they concluded that the most studies
in the field of measuring efficiency were carried out On the other hand, there are some shortcomings such
in 2012. as inappropriate selection of input and output indices
and unmodified errors on efficiency score in the studies
A number of systematic reviews were carried out on conducted on the efficiency of hospitals based on DEA.
measuring efficiency of healthcare centers around the Therefore, it is necessary to investigate and select an
world, and inputs and outputs have been proposed. appropriate index for using the DEA method.[37] Binder
For example, a study entitled “A systematic review and Rudolph, in another study entitled “The systematic
of hospital input and output in measuring technical review of health care centers efficiency measurement”
efficiency using DEA” was carried out by Azreena and reviewed 21 studies and concluded that efficiency
Rosliza in 2018, in which the input and output used in measurement of healthcare organizations has direct
measuring efficiency were investigated, and the best effect on their policy. They found that the difference in
indicators were introduced. Input and outputs which efficiency determined by DEA and SFA methods is due
are usually used by researchers for the analysis of the to various factors such as statistical errors, input and
technical efficiency of a hospital using DEA include outputs definitions, and available data. However, the
the number of physicians, the number of nurses and views of the different models have different advantages
the number of beds, the number of other nonmedical and disadvantages, and selecting the most appropriate
staff and the total number of employees, the total cost, method depends on the type of organization under study
the total cost of nonstaff, the value of fixed capital, and available data.[38]
and the cost of drug storage and outputs include the
total number of admissions, mean daily admission, Hofmarcher, during a study entitled “Measuring
number of outpatients, number of surgeries, number of Australian Hospitals Efficiency Using the DEA Approach,”
deliveries, ALOS, bed occupancy rate, and total income. concluded that in most studies, the number of beds
Although the present study identified input and outputs, is considered as a input variable and the number of
the researchers believe that the selection of data and hospital staff, the rate of discharge, the length of stay, and
6 Journal of Education and Health Promotion | Volume 8 | June 2019
Mahdiyan, et al.: Hospitals’ efficiency in Iran: A systematic review and meta‑analysis
emergency visits are considered as output variables, but equal to 0.885, 0.891.0.952 and 0.913 and using the SFA
what is considered as a DEA advantage compared to other method, respectively, it was equal to 0.733, 0.664, 0.641,
methods is that several inputs and several outputs are 0.802, and the inputs and outputs affecting measuring
arisen in the process of efficiency measurement; but, on the the efficiency. There is no significant difference between
other hand, the selection of the most suitable inputs and the mean efficiency score between the two methods, but
outputs is concern of researchers in this field of studies.[39] the data envelopment analysis method is used more. It
is suggested that the hospitals efficiency indicators to
Chirikos and Sear during another study entitled be determined in order to more accurately evaluate the
“Measuring Hospital Efficiency: Comparing Two DEA, hospitals efficiency.
SFA approaches” compared two methods and concluded
that significant differences were observed over the years Research constraints
between the DEA and SFA approaches although there The lack of access to a number of articles due to access
is no clear relationship between the characteristics of restrictions on the university site is considered as one
different hospitals and DEA scores with SFA scores; but of the constraints in this study that the websites of
after comparing these two methods, it has been concluded other universities were used to solve this problem.
that different results are obtained due to the existence Furthermore, it is suggested that an appropriate method
of different methodologies and inputs in calculating the for efficiency measurement using systematic review and
efficiency using the two methods.[40] According to the meta‑analysis to be identified in future studies aimed to
results of comparing the studies carried out in abroad, we the optimal allocation of resources in Iranian hospitals.
conclude that the researchers agreed on the inputs and
outputs defined in the present study as the most effective Acknowledgments
indicators in calculating efficiency and emphasized that The present study is the result of the master thesis
input and output play an important role in the efficiency approved by the Faculty of Health of Shahid Sadoughi
rate, and it cannot be said decisively that a method is University of Medical Sciences, Yazd, with the ethics
better than another. Of course, DEA and SFA are widely code of IR. SSU. SPH. REC.1396.153. The authors of this
used in efficiency measurement. The SFA method is study would like to acknowledge the research staff of the
often used for analysis of no efficient hospitals although School of Health and the jury members, who helped us
this method has clear and important advantages; but, to conduct and improve the quality of this study.
the disadvantages of this method for hospital efficiency
measurement are also evident such as the need for Financial support and sponsorship
production functions estimation and the use of an output. This research was supported by the Vice‑Chancellor
of Research of Shahid Sadoughi University of Medical
In contrast, the DEA method can investigate several Sciences in Yazd.
input and output simultaneously and is used as an
effective and flexible tool to measure the efficiency of the Conflicts of interest
hospital. DEA can be easily used for calculating efficiency The article has not been registered elsewhere before and
scores based on the proper selection of input and output will not be published.
indicators.[37] The DEA method and different input
and output variables have been used in most studies References
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