Measuring Hospital Efficiency: A Comparison of Two Approaches

Objective. To compare the results of scoring hospital efficiency by means of two new types of frontier models, Data Envelopment Analysis (DEA) and stochastic frontier regression (SFR).

Study Setting. Financial records of Florida acute care hospitals in continuous operation over the period 1982-1993.

Study Design. Comparable DEA and SFR models are specified, and these models are then estimated to obtain the efficiency indexes yielded by each. The empirical results are subsequently examined to ascertain the extent to which they serve the needs of hospital policymakers.

Data Collection. A longitudinal or panel data set is assembled, and a common set of output, input, and cost indicators is constructed to support the estimation of comparable DEA and SFR models.

Principal Findings. DEA and SFR models yield convergent evidence about hospital efficiency at the industry level, but divergent portraits of the individual characteristics of the most and least efficient facilities.

Conclusions. Hospital policymakers should not be indifferent to the choice of the frontier model used to score efficiency relationships. They may be well advised to wait until additional research clarifies reasons why DEA and SFR models yield divergent results before they introduce these methods into the policy process.

Key Words. Hospital efficiency, Data Envelopment Analysis, stochastic frontier regression, hospital cost containment

Until recently, the efficiency of hospitals has been measured by estimating cost or production functions by means of ordinary regression methods. Cost studies, for instance, typically regressed operating expenses against various measures of hospital "output," input prices, and control variables such as case mix of the patient population to draw inferences about efficiency differentials across hospitals (Cowing, Holtmann, and Powers 1983). Although these regression studies produced many useful insights, they were unavoidably subject to the limitation that the estimated equation represented the average as opposed to the best-practice cost-output relationship. The error term in such regressions has a mean of zero, so deviations from the estimated "line" (hyperplane) are not only as likely to raise costs as reduce them, but are assumed to be entirely attributable to chance factors. It is intuitively clear that some observations below the regression "line" in cost equations are systematically more efficient in the sense that, for a given set of factor prices and patient characteristics, they produce more output per unit of input. However, ordinary regression methods cannot distinguish between these systematic variations and those truly due to statistical noise. In an industry where inefficiencies are thought to be widespread, this methodological gap seriously limits the use of such statistical inferences for policy purposes.

Recent years have witnessed technical developments in the field of management science and econometrics that hold out the promise of enabling analysts to identify best-practice output-input (cost) relationships as well as to gauge how much efficiency levels of given decision-making units or providers deviate from these frontier values (Bauer 1990). One of these developments is Data Envelopment Analysis (DEA), a nonparametric programming technique that pieces together an efficiency frontier by maximizing (a seriatim) the weighted output/input (cost) ratio of each provider, subject to the condition that this ratio can equal, but never exceed, unity for any other provider in the data set (Charnes, Cooper, and Rhodes 1978). DEA then yields several measures of the relative distance of any provider's efficiency ratio from the piecewise linear frontier, the most common being the proportional reduction in input or cost levels that could be achieved were the provider delivering services in the most efficient manner po ssible. Another was the development of stochastic frontier regression (SFR) methods. Unlike its classical OLS counterpart, SFR models the error term in two parts, one reflecting systematic deviations from a frontier (cost or output) level and the other from more conventional statistical noise (Aigner, Knox Lovell, and Schmidt 1977). SFR uses this composable error, as it is called, to estimate the overall efficiency level across any sample of providers and then, in what may be characterized as a second step, computes efficiency deviations of each sample observation from the industry frontier by taking the expected value of the disturbance of each observation, conditional on the estimated parameters of the underlying distribution of the composable error (Jondrow et al. 1982; Greene 1992). Like DEA, these SFR provider-specific efficiency values are also cast as the proportional difference between the costs (output) of any provider and the frontier level of costs (output).

Not surprisingly, the efficiency vectors yielded by DEA and SFR techniques find ready uses by policymakers, nowhere more so than in the hospital sector. Indicators of the relative efficiency of hospitals are needed to gauge whether hospital cost-containment efforts are succeeding; they are also needed to evaluate the effect of more extensive managed care arrangements in local healthcare markets and to prepare "report cards" and other quality assessments of hospital service delivery. Such indicators may also have a prescriptive role to play in establishing criteria for selective contracting purposes and in pegging reimbursement levels in hospital rate-setting programs; see Batavia et al. (1993), Hadley and Zuckerman (1994), and Newhouse (1994) for differing views on these potential uses. Yet, whether frontier methods actually live up to their policy promise is untested at the moment. The recent literature includes a number of DEA hospital applications but only one published SFR study. [1] The knowledge base m ust be expanded before we can judge if, and how well, frontier methods serve the needs of hospital policymakers.

http://findarticles.com/p/articles/mi_m4149/is_6_34/ai_59629773/

Flu Robot Displayed in Tokyo

A robot that displays symptoms of swine flu was among the exhibits at a Tokyo trade fair. The robot sweats, moans and cries. It's designed to help health care workers diagnose and treat the flu. (Oct 22)

Planning for tomorrow

By Tod Moore, RCDD

It takes teamwork to build the modern OR

It takes teamwork to build the modern OR

One of the greatest challenges faced by OR managers, hospital administrators and facility design teams is determining which technologies should be deployed on the first day of a facility’s opening, which technologies should be prepared for the future and how they should all fit together. The key to successfully working through these crucial issues is early planning by the entire design team.

OR technology planning

From the medical equipment perspective, knowing which ORs will be configured for which type of procedure will determine the equipment and configuration. But, as it relates to the audiovisual and information technology systems, it is a little more difficult to nail down.

Granted, almost all medical equipment today requires connectivity to the data network, and that is primarily an infrastructure-related issue that is accomplished through coordination with the medical equipment planner, architect and the technology consultant. However, as it relates to what type of communication systems, displays and applications to use, consideration must be given to how procedures are performed, organizational and operational efficiencies, flexibility and due diligence to determine the return on investment for various systems.

First steps in this process begin at the OR stakeholders meeting with the facility’s information technology department, the technology consultant and the architect to plot the strategic plan for OR operation and organization in regard to technology systems. From this visioning process, clear guidelines, systems selection and cost models should be determined. The results of this process become a road map for technology deployment for the project.

The resulting road map is not a static document. Due to the nature of the design and construction process, combined with the fast-paced, changing world of communication technologies, it must be a flexible plan that allows for adaptation throughout the life of the project. One key to success for any OR technology deployment, or any health care technology deployment for that matter, is future-thinking for infrastructure flexibility, adaptability and growth.

Perhaps various systems are desired that will not be deployed when the OR opens but may be installed several years down the road. The better the team can anticipate future needs and provide for a more plug-and-play infrastructure to accommodate future deployments, the lower the cost, time and inconvenience associated with new systems integration.

The integrated OR

One emerging technological trend is the integrated or “context aware” OR, an environment that links changes in the OR environment with the computer systems in use, which are otherwise static. This environment is achieved with systems that take advantage of technologies such as radio-frequency identification (RFID) and integrates them with other systems such as telemetry, medical vitals, electronic medical records (EMR), picture archiving and communications systems (PACS), and other software applications to provide a real-time, interactive monitoring platform.

When using RFID on staff, surgical tools, medications and more, movement of these items can be monitored and OR staff can be notified that a given item that was scheduled as part of the procedure has not been used, like an early warning system. RFID can provide essential, location-based information throughout the entire procedure, including who entered and exited the OR or what surgical tools were used, for historical record keeping and procedure review for educational purposes.

All this information can be displayed on the patient dashboard for the surgeon and the OR staff. Systems such as the LiveData OR Dashboard™ from LiveData Inc. (www.livedata.com), Cambridge, Mass., captures, synthesizes and automatically displays essential patient information in real-time throughout the patient procedure.

Robotics in the OR

Futuristic technologies that are becoming more and more of a reality in the operating room, although in limited numbers, are robotic surgical tools.

These medical curiosities range from surgical tools and medication dispensers to state-of-the-art remote surgical procedure robots, such as the da Vinci® Surgical System by Intuitive Surgical Inc. (www.intuitivesurgical.com), Sunnyvale, Calif., which allows a surgeon to perform surgery from outside the OR, or even in another city or country. As of 2000, the da Vinci system has been cleared by the Food and Drug Administration (FDA) for general laparoscopic surgery and, since then, the FDA cleared the da Vinci surgical system for thoracoscopic (chest) surgery for cardiac procedures performed with adjunctive incisions and urologic and gynecologic procedures.

Many medical futurists believe that one way to improve efficiency in the OR and help combat the nurse shortages will be to utilize more robotic surgical devices. Imagine freeing available staff for other vital patient-related tasks and replacing the scrub nurse or the circulating nurse with a robotic system that never tires and is always available, such as the Penelope™ Surgical Instrument Server (SIS) from Robotic Systems & Technologies Inc. (www.roboticsystech.com), Bronx, N.Y.

Combine robotics with a truly context aware OR, and the possibilities for unmanned surgical procedures are possible. An example of this is the unmanned OR lab at the Scientific Research Institute (SRI) (www.sri.com) in Menlo Park, Calif. Presently focusing on surgical procedures for soldiers in the battlefield to conduct unmanned medical treatment, this technology and the use of the “trauma pod” can stabilize injured soldiers within minutes after a trauma, and administer life-saving medical and surgical care prior to evacuation and during transport. This innovative technology also has the potential to be used in civilian hospitals when trauma centers are too far away to save a patient’s life.

Remote monitoring

In addition to remote surgical procedures is remote monitoring. With tremendous advances in telemedicine, the ability to accurately view and remotely interact real-time with a surgical team is here today. High-definition video combined with new camera technology has created the telepresence environment, allowing for accurate remote consultative surgical procedures, as well as detailed medical educational tools.

Telepresence solutions such as the MedPresence conference room being used at St. Joseph’s Hospital and Medical Center’s Barrow Neurological Institute in Phoenix allows physicians and students to remotely observe surgeries being performed in real-time from the physician’s office or the classroom. Participants feel as if they are in the operating room with the ability to view all aspects of a given operation. The benefits of the solutions like the MedPresence Surgical Training Theatre by Human Productivity Lab (www.humanproductivitylab.com), Ashburn, Va., are significant in all aspects of the medical-surgical field through increased productivity, reduced travel and improved distance learning. This leads to dramatic return on investment (ROI) for medical organizations. For instance, a physician who is required to be in the OR with his or her patient throughout a surgical procedure, although not physically performing the procedure, can now be face-to-face in surgery from a few doors down in his or her own office space. This allows the physician to be productive on other tasks while still being involved in the surgery. By the same token, high-dollar procedures that are performed at only three or four institutions throughout the world can be observed by a wide network of medical colleagues, surgical residents and medical students. These real-time participants can take advantage of the knowledge to be gained from renowned experts using emerging surgical techniques without traveling long distances.

Practice makes perfect

In another trend, preoperative planning and surgical rehearsal of complex procedures in an interactive visualization environment can be created to allow the production of 3-D surgical planning data sets. Image review and analysis tools allow the surgical review of computed tomography, magnetic resonance imaging and angiographic examinations in an interactive 2-D and 3-D environment.

Surgery simulators can be classified into three categories. The first-generation simulators display only the anatomy, in particular the geometry of the structures involved in a surgical procedure. With this, the user can essentially navigate within a virtual representation of the patient, with limited detail.

A number of these simulators have been developed in recent years and are available today. These systems are generally used as diagnostic tools, and also to assist with surgery planning, but are limited in their complexity.

Second-generation simulators not only include the geometric modeling of the body anatomy, but also the modeling of the physical properties of the living tissues. This provides for realistic interactions between surgical instruments and the actual tissues. A few of these systems are available today, including such surgical simulators as LAP Mentor™ by Simbionix™ USA (www.simbionix.com), Cleveland, or the ProMIS™ by Haptica Inc. (www.haptica.com), Boston.

Third-generation simulators combine anatomical, physical and physiological modeling. There is a greater degree of complexity with these models because they are combining the physiological and physical properties of the patient. Some third-generation models exist, but no commercially available product is currently on the market.

Breakthroughs in lighting

Finally, there have been different ways of focusing light in the OR, different ways of directing the light or creating a spot, but for over 70 years the light source itself has been the halogen bulb. This light source is known for its high-quality bright light, but not for its efficiency in terms of lamp life or heat.

Advanced surgical lighting uses light-emitting diode (LED) technology that utilizes both white and color LEDs to create a very high level of almost shadow-free illumination.

The most important features in surgical lighting—intensity, color temperature, heat control, shadow control, maneuverability and flexibility—are inherent in this technology. Surgeons can even use voice commands to adjust the intensity or color of the light.

Detailed due diligence

Determining which systems to consider and deploying them in the OR is a daunting process that requires due diligence by the design team as it relates to process, culture, services and cost.

Gathering the appropriate stakeholders and technical experts to look at strategic plans, ROI, future trends and facility impacts are crucial to successful OR suite design and implementation.

Tod Moore, RCDD, is principal of technology consulting at Sparling, Seattle. His e-mail address is tomoore@sparling.com.

This article 1st appeared in the April 2008 issue of HHN Magazine.

How the Predator UAV Works - Under the Hood

Under the Hood

The Predator UAV is a medium-altitude, long-range aircraft that operates much like any other small plane.

Photo courtesy U.S. Air Force An airman works on the Predator's Rotax 914 engine.

A Rotax 914, four-cylinder, four-stroke, 101-horsepower engine, the same engine type commonly used on snowmobiles, turns the main drive shaft. The drive shaft rotates the Predator's two-blade, variable-pitch pusher propeller. The rear-mounted propeller provides both drive and lift. The remote pilot can alter the pitch of the blades to increase or decrease the altitude of the plane and reach speeds of up to 135 mph (120 kts). There is additional lift provided by the aircraft's 48.7-foot (14.8-meter) wingspan, allowing the Predator to reach altitudes of up to 25,000 feet (7,620 meters). The slender fuselage and inverted-V tails help the aircraft with stability, and a single rudder housed beneath the propeller steers the craft.

The fuselage of the Predator is a mixture of carbon and quartz fibers blended in a composite with Kevlar. Underneath the fuselage, the airframe is supported by a Nomex, foam and wood laminate that is pressed together in layers. Between each layer of laminate, a sturdy fabric is sandwiched in to provide insulation to internal components. The rib work of the structure is built from a carbon/glass fiber tape and aluminum. The sensor housing and wheels are also aluminum.

The edges of the wings are titanium and are dotted with microscopic weeping holes that allow an ethylene glycol solution to seep out of internal reservoirs and breakdown ice that forms on the wings during flight.

The Predator UAV uses run-of-the-mill mechanical systems. A 3-kilowatt starter/alternator supplies the craft's electronics with power; this is supplemented with auxiliary battery power. Forward and aft fuel tanks house rubberized fuel bladders that are easy to fill through gas caps located at the top of the fuselage. An operator starts the engine by attaching the umbilical cord of a Starter/Ground Power Cart to the aircraft's starter-control connector, located in the ground panel on the outside of the plane. An operator stops the engine by hitting a kill switch just behind one of the wings on the side of the plane.

For the Engine

• The Predator's two fuel tanks combined carry up to 600 pounds of 95-octane to 100-octane reciprocating aircraft engine fuel.
• The Predator uses 7.6 liters of standard motor oil for lubrication.
• In addition to venting, conventional automotive antifreeze is used to cool the engine.
• Two 8-pound, 14-amp-hour Ni-Cad battery packs are housed in the fuselage for backup power in case the engine or alternator fails.

Making more milk - Breastfeeding.

When women get together and start swapping stories of the days
when their babies were small and the subject of breastfeeding
comes up, chances are at least one woman will say, “I couldn’t
make enough (or my doctor said I didn’t have enough) milk, so I
had to quit nursing.” If the subject changes quickly, no one gets to
hear the sadness behind those words or the questions that could be
asked: “What happened? Did anyone give you a reason?” That’s
where this book comes in. When there’s another baby on the hori-
zon, that same woman will grab this book right out of your hand.
She wants answers, and The Breastfeeding Mother’s Guide to Making
More Milk has them. She needs to know she didn’t fail; the prob-
lem was that the answers weren’t there for her before. And there is
plenty she can do to make more milk for the next baby.
Breastfeeding problems of one sort or another have been
around forever, but good help for the complicated problems is still
evolving. Many doctors, nurses, and even midwives haven’t yet
heard of all the advances in the fi eld of lactation, so women are still
being told they can’t make more milk or shouldn’t even consider
breastfeeding at all. One example close to my heart is how moth-
ers of babies with Down syndrome are often discouraged from
breastfeeding. When I gave birth to Stephen eighteen years ago,
his pediatrician thought I was being “heroic” for sticking with it
through four long weeks of weight los s before he turned the corner
and learned how to suck without hurting me. Until our culture is
convinced that breastfeeding and breast milk make a difference, it
is likely that this attitude wil l continue.
The fi rst wave of breastfeeding help came from the founding
mothers of La Leche League in 1956. The second wave, which
resulted in the fi eld of lactation science, began with passionate La
Leche League Leaders who helped one mother and then another
and then another, moving past the “easy” cases to the ones that
needed more time and attention, more research, and more persis-
tence. These are the cases you’ll read about in this book, and you’ll
see the work of these pioneers listed in the References.
Now we see the third wave of breastfeeding help: the creden-
tialed lactation consultants whose numbers have mushroomed,
medical researchers and practitioners who are advancing the fi eld,
and the Academy of Breastfeeding Medicine as a formal organiza-
tion. The Breastfeeding Mother’s Guide to Making More Milk com-
bines all these resources for mothers who may otherwise never
fi nd their way past the hurdles of low self-confi dence and inexpe-
rienced helpers. As the fi eld of lactation has come into its own as
a specialty, more and more of the previously “hopeless” cases have
been successfully addressed and remedied, many of them com-
pletely, and many mothers, no longer hopeless, are able to achieve
a full milk supply for their babies. The ones that don’t get a full
supply usual ly exper ience enough of an improvement to make the
effort well worthwhile.
Whatever the circumstances are, or whatever the root problem,
you can fi nd your situation in this book and, detective-style and
systematically, alone or with support from your health care profes-
sionals, make the changes necessary to turn the problem around.
This book shows us how almost anyone can make more milk.

Historical Perspective - Immune System

The discipline of immunology grew out of the observation
that individuals who had recovered from certain infectious
diseases were thereafter protected from the disease. The
Latin term immunis, meaning “exempt,” is the source of the
English word immunity, meaning the state of protection
from infectious disease.
Perhaps the earliest written reference to the phenomenon
of immunity can be traced back to Thucydides, the great his-
torian of the Peloponnesian War. In describing a plague in
Athens, he wrote in 430 BC that only those who had recov-
ered from the plague could nurse the sick because they
would not contract the disease a second time.Although early
societies recognized the phenomenon of immunity, almost
two thousand years passed before the concept was success-
fully converted into medically effective practice.
The first recorded attempts to induce immunity deliber-
ately were performed by the Chinese and Turks in the fif-
teenth century. Various reports suggest that the dried crusts
derived from smallpox pustules were either inhaled into the
nostrils or inserted into small cuts in the skin (a technique
called variolation). In 1718, Lady Mary Wortley Montagu, the
wife of the British ambassador to Constantinople, observed
the positive effects of variolation on the native population
and had the technique performed on her own children. The
method was significantly improved by the English physician
Edward Jenner, in 1798. Intrigued by the fact that milkmaids
who had contracted the mild disease cowpox were subse-
quently immune to smallpox, which is a disfiguring and of-
ten fatal disease, Jenner reasoned that introducing fluid from
a cowpox pustule into people (i.e., inoculating them) might
protect them from smallpox. To test this idea, he inoculated
an eight-year-old boy with fluid from a cowpox pustule and
later intentionally infected the child with smallpox. As pre-
dicted, the child did not develop smallpox.
Jenner’s technique of inoculating with cowpox to protect
against smallpox spread quickly throughout Europe. How-
ever, for many reasons, including a lack of obvious disease
targets and knowledge of their causes, it was nearly a hun-
dred years before this technique was applied to other dis-
eases. As so often happens in science, serendipity in
combination with astute observation led to the next major
advance in immunology, the induction of immunity to
cholera. Louis Pasteur had succeeded in growing the bac-
terium thought to cause fowl cholera in culture and then had
shown that chickens injected with the cultured bacterium de-
veloped cholera.After returning from a summer vacation, he
injected some chickens with an old culture. The chickens be-
came ill, but, to Pasteur’s surprise, they recovered. Pasteur
then grew a fresh culture of the bacterium with the intention
of injecting it into some fresh chickens. But, as the story goes,
his supply of chickens was limited, and therefore he used the
previously injected chickens.Again to his surprise, the chick-
ens were completely protected from the disease. Pasteur
hypothesized and proved that aging had weakened the viru-
lence of the pathogen and that such an attenuated strain
might be administered to protect against the disease. He
called this attenuated strain a vaccine (from the Latin vacca,
meaning “cow”), in honor of Jenner’s work with cowpox
inoculation.
Pasteur extended these findings to other diseases, demon-
strating that it was possible to attenuate, or weaken, a
pathogen and administer the attenuated strain as a vaccine.
In a now classic experiment at Pouilly-le-Fort in 1881, Pas-
teur first vaccinated one group of sheep with heat-attenuated
anthrax bacillus (Bacillus anthracis); he then challenged the
vaccinated sheep and some unvaccinated sheep with a viru-
lent culture of the bacillus.All the vaccinated sheep lived, and
all the unvaccinated animals died. These experiments
marked the beginnings of the discipline of immunology. In
1885, Pasteur administered his first vaccine to a human, a
young boy who had been bitten repeatedly by a rabid dog
(Figure 1-1). The boy, Joseph Meister, was inoculated with a
series of attenuated rabies virus preparations. He lived and
later became a custodian at the Pasteur Institute.

New device could track tumor's growth

Surgical removal of a tissue sample is now the standard for diagnosing cancer. Such procedures, known as biopsies, are accurate but only offer a snapshot of the tumor at a single moment in time.

Monitoring a tumor for weeks or months after the biopsy, tracking its growth and how it responds to treatment, would be much more valuable, says Michael Cima, MIT professor of materials science and engineering, who has developed the first implantable device that can do just that.

Cima and his colleagues recently reported that their device successfully tracked a tumor marker in mice for one month. The work is described in a paper published online in the journal Biosensors & Bioelectronics in April.

Such implants could one day provide up-to-the-minute information about what a tumor is doing - whether it is growing or shrinking, how it's responding to treatment, and whether it has metastasized or is about to do so.

"What this does is basically take the lab and put it in the patient," said Cima, who is also an investigator at the David H. Koch Institute for Integrative Cancer Research at MIT.

The devices, which could be implanted at the time of biopsy, could also be tailored to monitor chemotherapy agents, allowing doctors to determine whether cancer drugs are reaching the tumors. They can also be designed to measure pH (acidity) or oxygen levels, which reveal tumor metabolism and how it is responding to therapy.

With current tools for detecting whether a tumor has spread, such as biopsy, by the time you have test results it's too late to prevent metastasis, said Cima.

"This is one of the tools we're going to need if we're going to turn cancer from a death sentence to a manageable disease," he said.

In the Biosensors & Bioelectronics study, human tumors were transplanted into the mice, and the researchers then used the implants to track levels of human chorionic gonadotropin, a hormone produced by human tumor cells.

The cylindrical, 5-millimeter implant contains magnetic nanoparticles coated with antibodies specific to the target molecules. Target molecules enter the implant through a semipermeable membrane, bind to the particles and cause them to clump together. That clumping can be detected by MRI (magnetic resonance imaging).

The device is made of a polymer called polyethylene, which is commonly used in orthopedic implants. The semipermeable membrane, which allows target molecules to enter but keeps the magnetic nanoparticles trapped inside, is made of polycarbonate, a compound used in many plastics.

Cima said he believes an implant to test for pH levels could be commercially available in a few years, followed by devices to test for complex chemicals such as hormones and drugs.