Comparing the Efficiency of Hospitals in Northern Iran Before and After the Covid-19 Pandemic Using the Pabon Lasso Model

doi:10.21203/rs.3.rs-2502495/v1

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Comparing the Efficiency of Hospitals in Northern Iran Before and After the Covid-19 Pandemic Using the Pabon Lasso Model

https://doi.org/10.21203/rs.3.rs-2502495/v1

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Background

The Pabon Lasso Model is often used to assess the efficiency of hospitals as the most important component of the health system. The present study sought to evaluate and compare the efficiency of hospitals in northern Iran before and after the COVID-19 pandemic using the Pabon Lasso Model.

Methods

This descriptive study was conducted in 40 public, private, and social security hospitals in northern Iran from 2019 to 2020. The data were collected using the forms approved by the Ministry of Health and Education. Besides, the three indices of bed occupancy rate, bed turnover frequency, and the average length of stay were calculated and plotted using the Pabon Lasso graphs. The collected data were analyzed using the paired samples t-test.

Results

The average bed occupancy rates in 2019 and 2020 were equal to 67.72% and 52.28%, lower than the national standard rate. Moreover, the average lengths of stay were 2.58 and 2.83 days and the bed turnover rates were 96.7 and 77.94, higher than the national standard rate. Of the total 36 hospitals in 2019, 33.3% of hospitals were in the first quarter (low efficiency), and 16.6% in the third quarter (high efficiency). Furthermore, the data for 2020 indicated that 38.8% of hospitals were in the first quarter (low efficiency), showing an increase compared to 2019 and 19.4% of hospitals were in the third quarter, indicating a decrease compared to 2019.

Conclusion

The data confirmed that the average length of stay and bed turnover in the studied hospitals were favorable. In addition, unlike private hospitals, the number of efficient units in public hospitals decreased during the COVID-19 pandemic. Thus, hospital managers need to pay more attention to improving performance indicators and increasing productivity in these hospitals.

Efficiency

Hospitals

Bed Occupancy

Bed Turnover

Hospitals are among the most expensive economic sectors in countries. They also play a vital role as the outcome of their activities is protecting people’s lives. Besides, the provision of community health depends on their correct and accountable performance(1). Moreover, hospitals account for 50–80% of the health sector’s expenses. Thus, the provision of efficient services has always been a public demand and a function to be fulfilled by authorities(2–4).

In recent years, the health sector in most countries has faced a significant increase in healthcare and hospital costs(5). Given the shortage of resources allocated to the health sectors in most developing countries(6), resources are not allocated and used through efficient planning, and the efficiency of the health sector is often lower than expected(7, 8). Demographic and epidemiological changes, advanced technology, and insufficient information available to service recipients also increase healthcare costs(5). Evaluating the performance of a complex organization such as a hospital, by estimating its efficiency and productivity, is considered the most important and common measurement tool(9, 10).

Several methods have been proposed to evaluate efficiency. However, one of the most important and useful models for evaluating hospital performance is the Pabon Lasso Model. This graphic model was introduced in 1986 (11) and three indicators, bed occupancy rate (BOR), bed turnover (BTO), and the average length of stay (ALS), are used to evaluate the performance of a hospital(12). The hospital’s performance is evaluated in this model using a diagram that is divided into four quarters by two intersecting lines representing the average bed occupancy rate and bed occupancy turnover. The longitudinal axis (X) shows the average bed occupancy rate and the transverse axis (Y) shows the bed occupancy turnover. Depending on its location in one of these quarters, a hospital can have special characteristics, and the performance of the hospital can be analyzed following these characteristics. This model provides hospital management with a logical tool for decision-making(13).

In December 2019, the spread of a viral disease was reported in the Chinese city of Wuhan. The cause of this disease was a new type of genetically modified virus from the family of coronaviruses called SARS-2-CoV, which was named COVID-19(14). COVID-19, which is caused by an RNA virus, mostly affects the respiratory system of the patient and is spreading catastrophically(15). The sharp growth of the costs of medical services has focused the attention of managers, policymakers, and researchers on the distribution of resources and the performance of hospitals, as one of the main elements of providing medical services and the most important resource-consuming unit in the health system(7). Given that improving economic performance can significantly contribute to the allocation of financial and human resources as the most important assets of the health system, improving the performance of hospitals can lead to an important step in controlling and maintaining the costs of the health sector(16).

The COVID-19 outbreak led to a fundamental change in the management of hospitals, and most managers focused on the treatment of the disease, and most medical centers have dedicated their departments to treating COVID-19 patients. Since no study has compared hospital efficiency as an important issue before and after the COVID-19 pandemic, this study aims to use the Pabon Lasso Model to compare the efficiency of hospitals in northern Iran before and after the COVID-19 pandemic.

This descriptive-analytical cross-sectional study was conducted in 2021 in 36 hospitals with a total of 4000 active beds in Mazandaran Province, northern Iran. The hospitals were selected using the census method. The data were collected using the monthly hospital activity report approved by the Ministry of Health of Iran, which is used in all hospitals across the country. The data for hospital bed indicators were collected from April 2019 to February 2020 before the COVID-19 outbreak and from April 2020 to February 2021 after the COVID-19 outbreak. The three indicators (bed occupancy, bed turnover, and average length of stay) were extracted and plotted using the Pabon Lasso graphs. To obtain more reliable and consistent data and results, the three indicators were estimated as follows: The bed occupancy rate was estimated as the ratio of occupied day beds in a certain period to normal day beds in the same period multiplied by 100, the bed turnover rate was calculated as the number of patients discharged and died in a given period to the average number of beds ready for use in the same period, and the average length of stay was also calculated as the total number of the beds occupied in a given period to the number of patients discharged or died in the same period. Finally, using the above three indicators, the Pabon Lasso hospital efficiency graph was plotted. In this graph, the X-axis shows the average bed occupancy rate, the Y-axis shows the average annual discharge per bed (the bed turnover rate), and the Z-axis shows the average length of stay. Given the existence of a mathematical relationship between the indicators of bed occupancy rate, bed turnover, and the average length of stay, a line from the zero point (starting point of the model) that passes through every point in the model indicates the average length of stay and the figure is divided into four quarters. The hospitals are placed in one of the four quarters in the Pabon Lasso graph. The inclusion criterion was the hospitals located in Mazandaran Province and the exclusion criteria were the unavailability of the data and the non-cooperation of the hospital officials.

The indicators were assessed using descriptive statistics and the data for 2019 (before the COVID-19 outbreak) and 2020 (after the COVID-19 outbreak). The data were analyzed with SPSS software (version 22) using paired samples t-test to determine the relationship between the performance indicators before and after the COVID-19 outbreak. All statistical procedures were performed at the significance level of 0.05 (p < 0.05).

The highest bed occupancy rates in 2019 and 2020 were found in teaching hospitals with the corresponding values of 76.08% and 65.58%. The lowest occupancy rate (61.95%) was related to private hospitals and public non-teaching hospitals (66.23%). The highest average length of stay was related to teaching hospitals with values of 4.92 and 5.32, and the lowest was related to private hospitals with values of 1.33 and 1.55, respectively (Table 1).

Table 1

The descriptive statistics for the efficiency indicators of the selected hospitals
Hospital type	Hospital code	Bed occupancy rate		The average length of study		Bed turnover
Hospital type	Hospital code	2019	2020	2019	2020	2019	2020
Public	1	78.67	57.67	3.16	3.56	85.62	58.55
	2	55	67	3.48	3.08	56.58	80.04
	3	79.15	71.23	2.89	2.53	67.24	58.47
	4	75	55	12.35	12.72	38.47	34.46
	5	92.6	77	2.7	4.7	125.24	59.31
Public teaching		76.08	65.58	4.92	5.32	74.63	58.16
Public	6	58	36.62	3.13	2.44	62	47.25
	7	83.4	44.4	2.07	2.73	145.47	60.19
	8	63	43.37	2.17	1.89	92.1	64.00
	9	70	52	2.8	2.9	91.95	66.05
	10	66	42	3.5	4	67.42	38.23
	11	75	55	2.96	3.05	90.92	65.12
	12	60.4	57.5	3.05	4.09	76.35	37.42
	13	77.6	63.48	3.03	3.17	78.61	60.92
	14	85	75	3.03	3.16	75.08	68.95
	15	54.88	28.73	3.35	3.89	58.09	26.66
	16	57.2	57.7	2.14	2.1	75.4	58.5
	17	26.83	26.15	2.25	2	43.50	48.10
	18	58.7	45.3	2.4	2.83	59.9	79.5
	19	52.3	45.99	1.65	2.13	116.19	78.90
	20	52.62	38.78	1.79	2.05	107.65	69.53
	21	69.4	46.12	2.12	2.38	115.10	70.97
	22	90.0	22.1	1.33	2.4	58.1	68.17
	23	95.00	44.00	1.49	1.73	78.9	88.11
	24	63.61	42	1.46	1.66	105.25	62.96
	25	65.83	32.6	2.53	2.6	94.84	47.06
Public non-teaching hospitals		66.23	44.94	2.41	2.66	84.64	60.32
Social security	26	74.52	65.54	3.52	3.94	81.95	58.02
	27	72.01	47	3.32	3.19	78.79	52.95
	28	60.49	48.66	2.11	2.73	91.72	57.32
	29	92.3	73.1	1.99	1.75	219.32	166.22
Social security		74.83	58.57	2.73	2.90	117.94	83.63
Private	30	80.84	86.39	1.38	1.42	189.32	189.15
	31	56.08	51.45	0.91	0.96	103.2	93.8
	32	88.47	60.83	0.61	1.53	198.76	195.08
	33	58	57	1.96	2.35	108.51	88.84
	34	37.46	50.41	1.79	1.52	62.52	108.94
	35	66.45	57.3	1.56	1.67	123.54	108.98
	36	46.39	57.68	1.13	1.15	157.73	189.2
Private		61.95	60.15	1.33	1.51	134.79	139.41
Total		67.72	52.28	2.58	2.83	96.70	77.94

Table 1: The descriptive statistics for the efficiency indicators of the selected hospitals

An analysis of the Pabon Lasso graphs shows that out of a total of 36 hospitals in 2019, 12 hospitals (33.3%) were in the first quarter, 7 hospitals (19.4%) in the second quarter, 6 hospitals (16.6%) in the third quarter, and 11 hospitals (30.7%) were in the fourth quarter (Fig. 1). Furthermore, an assessment of hospital ownership indicated that in 2019, non-teaching public hospitals were in the first quarter, private hospitals were in the second quarter, and social welfare and teaching hospitals were in the fourth quarter (Fig. 2).

However, in 2020, 14 hospitals (38.8%) were located in the first quarter, 5 hospitals (13.8%) were located in the second quarter, 7 hospitals (19.4%) were located in the third quarter, and 10 hospitals (28%) were located in the fourth quarter (Fig. 3). In addition, in 2020, public non-teaching hospitals were located in the first quarter, private hospitals were located in the third quarter, and teaching and social security hospitals were located in the fourth quarter (Fig. 4).

Of a total of 36 hospitals in 2019, 27.8% of hospitals were placed in the first quarter (low efficiency), and 36.1% of hospitals in the third quarter (high efficiency). Besides, the 2020 data indicated that 36.1% of hospitals were located in the first quarter (low efficiency), showing an increase compared to 2019 and 27.8% of hospitals were in the third quarter, showing a decrease compared to 2019.

Figure 1. The efficiency of hospitals affiliated with Mazandaran University of Medical Sciences in 2019

Figure 2. The efficiency of hospitals affiliated with Mazandaran University of Medical Sciences in terms of ownership in 2019

Figure 3. The efficiency of hospitals affiliated with Mazandaran University of Medical Sciences in 2020

Figure 4. The efficiency of hospitals affiliated with Mazandaran University of Medical Sciences in terms of ownership in 2020

A comparison of Figs. 2 and 4 showed that the educational public hospitals were located in the fourth quarter in 2019 and 2020. Private hospitals moved from the second quarter (the low bed occupancy rate, high bed turnover rate, and short length of stay) in 2019 to the third quarter in 2020. In 2019 and 2020, non-teaching public hospitals were located in the first quarter. Social security hospitals were moved from the third quarter in 2019 to the fourth quarter in 2020. The data from the paired samples t-test indicated that the bed occupancy rate and bed turnover showed significant differences in 2019 and 2020 (P-value < 0.05)(Table 2).

Table 2

The results of paired samples t-test
Variable	Year	Mean difference	Std. Deviation	t	df	P-value
Bed occupancy rate	2019–2020	14.09	12.06	5.611	35	< 0.0001
Bed turnover	2019–2020	18.45	26.9	3.831	35	< 0.0001
The average length of stay	2019–2020	2.97	17.3	1.125	35	0.268

Table 1. The results of paired samples t-test

This study investigated the performance indicators (bed occupancy rate, bed turnover, and average length of stay) of hospitals affiliated with Mazandaran University of Medical Sciences before (2019) and after the COVID-19 pandemic (2020). The findings of this study have some scientific implications for managers to optimize the utilization of resources and facilities in hospitals.

According to the standard set by the Ministry of Health of Iran, whereby the ideal bed occupancy rate was considered to be more than 70%(5), the bed occupancy rates estimated in this study were 67.72% and 52.28% in 2019 and 2020, indicating inadequate and inefficient use of the beds available in medical centers. Moreover, this index was lower than the standard in 2019 except for teaching hospitals (76.08%) and social security hospitals (74.27%). The bed occupancy rates for all hospitals in the province in 2020 were lower than the standard limits, indicating inefficient use of available beds in the hospitals.

The average length of stay in 2019 and 2020 was 2.58 and 2.83 days, respectively. The highest value was related to teaching hospitals (4.92 and 5.32) and the lowest value was related to private hospitals (1.33 and 1.51). If the optimal average length of stay of patients is considered to be less than 4.1 days(5), the average length of stay in teaching hospitals shows the undesirability of this index in the studied hospitals. However, this index was desirable in other social security, public, and private hospitals before and after the COVID-19 pandemic.

If the standard bed turnover is considered more than 24 times(5), all the hospitals under study were efficient in terms of bed turnover. However, public (teaching and non-teaching) hospitals and social security hospitals faced a significant drop in bed turnover after the COVID-19 pandemic. Nevertheless, this index increased in private hospitals, confirming an increase in their efficiency after the COVID-19 pandemic possibly due to the policy of the Iranian Ministry of Health to admit COVID-19 patients in public hospitals. However, this requirement was less frequently considered in private and social security hospitals and only during COVID-19 peaks.

Miraki et al. found that the average bed turnover rate, length of stay, and bed occupancy rate in the medical centers were 79 times, 3.4 days, and 62.5%, respectively, indicating the optimal bed turnover rate, nearly optimal average length of stay, and low bed occupancy rate(17). In line with the present study, Shahri et al. (2017) stated that the performance indicators in Shiraz hospitals were lower than the standard levels(18). However, Teymourzadeh et al. (2019) reported that the bed occupancy rate (71%), bed turnover, and average length of stay (2.5 days) of hospitals affiliated with the army were satisfactory compared to national standards(19). Furthermore, Iswanto (2015) reported that the average length of stay was 2 to 3 days and bed turnover was 42 to 47 times, indicating the high efficiency of the medical center(20).

The data in the present study revealed of the total 36 hospitals in 2019, 33.3% of hospitals were in the first quarter (low efficiency), and 16.6% in the third quarter (high efficiency). In addition, the data for 2020 indicated that 38.8% of hospitals were in the first quarter (low efficiency), showing an increase compared to 2019 and 19.4% of hospitals were in the third quarter, indicating a decrease compared to 2019. Dopeykar and Amiri (2020) showed that only 24% of inpatient departments had full efficiency (third quarter) and many departments did not have an optimal level of efficiency(9). Moreover, other studies (e.g. Haghi et al., 2018) showed that 20% of the studied hospitals in Tehran were located in the first quarter and 20% in the third quarter(5). Erfani et al. (2018) also reported that only about a third of hospitals in Iran were in the third quarter (high efficiency)(21), as confirmed in the present study. However, Na'emani et al. (2018) found the effective performance of military hospitals compared to other hospitals in Iran. Their findings indicated that 37% of military hospitals in Iran had a good performance, 37% of them had poor performance, and 26% of them had average performance(7). Moreover, Ajlouni et al. (2013) stated that 8 of 15 public hospitals studied in Jordan in 2008 were efficient(22). This finding was not in line with the results of the present study possibly due to the number of hospitals and their ownership. The present study examined teaching, public, social security, and private hospitals, so the performance indicators in the present study were different from those used in the above study.

The present study showed that the teaching hospitals were located in the fourth quarter (high bed occupancy rate, low bed turnover rate, and long length of stay) in 2019 and 2020, indicating that the hospitals had a low bed turnover but a high bed occupancy rate. This confirmed the long length of stay, inefficient use of available facilities, and high costs. The private hospitals were in the second quarter (low bed occupancy rate, high bed turnover rate, and short length of stay) in 2019. These hospitals had a bed occupancy rate lower than the average or at least acceptable but had a good and higher than average bed turnover and additional beds. Besides, there were a lot of vacant beds in these hospitals and a lot of unnecessary and hasty admissions. These hospitals were located in the third quarter (high bed occupancy rate, high bed turnover rate, and short length of stay) in 2020. Thus, they had both good bed turnover and a high bed occupancy rate, indicating the efficient use of facilities in these hospitals. Moreover, the public non-teaching hospitals were located in the first quarter (low bed occupancy rate, low bed turnover rate, and long length of stay) in 2019 and 2020, indicating that the number of beds in these hospitals exceeded the demand for them. The social security hospitals moved from the third quarter (high bed occupancy rate, high bed turnover rate, and short length of stay) in 2019 to the fourth quarter (high bed occupancy rate, low bed turnover rate, and long length of stay) in 2020 and after the COVID-19 epidemic. These hospitals had low occupancy rates and bed turnover, indicating that the number of beds in these hospitals was higher than the demanded level.

One of the disadvantages of the Pabon Lasso analysis is that the model does account for factors such as the type of hospital, ownership, the number of specialists and general physicians, and other variables that have a significant effect on the efficiency of the hospital. Thus, this type of analysis should be performed with caution and the effect of these factors should be taken into account.

The results of this study indicated that with the COVID-19 outbreak, the efficiency of the hospitals of Mazandaran Province decreased. The movement towards the northeast (the third quarter of the graph) confirmed the improvement in performance. Unlike private hospitals, the efficiency of public hospitals decreased after COVID-19 compared to the year before the COVID-19 pandemic, indicating that the number of efficient hospitals increased in the third quarter, but the number of inefficient centers increased in the first quarter. There was a shift of patients from public to private hospitals for many reasons, including the increased admissions of COVID-19 patients in public hospitals and as a result the lack of empty beds for other care, people’s concern about contracting COVID-19, and unwieldiness to go to public hospitals. Thus, planners can create constructive competition between public, private, and social security hospitals to continuously improve performance indicators and promote efficiency in these hospitals.

BOR: bed occupancy rate

BTO: bed turnover

ALS: average length of stay

Ethics approval and participation consent

The study procedure was approved by the Medical Ethics Committee of Mazandaran University of Medical Sciences [IR.MAZUMS..REC. 1399.8974]. The current study included hospitals who supplied their informed consent. For this, verbal informed consent was obtained from all hospitals before starting this study, and all hospitals completed an informed consent form after being explained the study's aims. All hospitals information was as private and nameless; there was no personal information that could link the answers with any of the hospitals in the present study.

Consent for publication : Not applicable.

Availability of data and materials

The datasets produced and analyzed throughout the present study are not publicly available in order to keep the participants' privacy but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No external funding sources were provided for this study.

Authors’ contribution

RM and GA designed the project and wrote the first draft of the manuscript.AA and RM did the statistical analysis. RM collected the data. RM and MT critically revised the final article. All Authors read and approved the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgments

We would like to appreciate all participants for their help and support. The authors would like to express their sincere gratitude to the officials at the research and treatment departments of the Mazandaran University of Medical Sciences.

Authors' Information

Ghasem Abedi , Department of Public Health, School of Health, Mazandaran University of Medical Sciences, Sari, Iran; Health Sciences Research Center, Addiction Research Institutes, Mazandaran University of Medical Sciences, Sari, Iran. Mozhgan Tavana, Ph.D Candidate of health services management, Sari Branch, Islamic Azad University, Sari, Iran. Roya Malekzadeh, Department of Public Health, School of Health, Mazandaran University of Medical Sciences, Sari, Iran. Ehsan Abedini, PhD in Health Services Management, Mazandaran University of Medical Sciences, Sari, Iran.

Conflict of interest: The authors reported no conflict of interest.

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No competing interests reported.

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Comparing the Efficiency of Hospitals in Northern Iran Before and After the Covid-19 Pandemic Using the Pabon Lasso Model

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