Analysis And Evaluation On The Size And Layout Of Hospitals In Shanghai

1Background1.1Construction progress and effectiveness of hospital size and layout should be summarized and evaluated under the background of health care reformIn our country, the difficulty and high cost of seeing a doctor had been positioned as a major livelihood issues. In order to dissolve this issues, central government had launched a new round reform on the medical and health system, improving the accessibility of fundamental health care is one of the reform immediate goals, promote public hospital reform pilot program is one of five key elements of reform in recently (2009-2011). The significance of the public hospital reform pilot program is "’to improve the standard of service of public medical institutions, make great efforts to dissolve the problem of curing the diseases,"moderate scale", and" rational layout" were basic guiding ideology and demand of public hospital reform pilot program Under the background of the new medical reform, at least two points need in-depth study around hospital size and layout, the first was how about hospital size and layout building progress in all regions, the second was how to evaluate "moderate scale","rational distribution".1.2Shanghai hospital size and layout building is unique, the urgent need for evaluation of the construction effectsShanghai hospital building had more special external environment. In Shanghai as early as in1997, government had explicated the objectives to establish urban medical service system composing with community health centers and urban medical centers. From then on, Shanghai government integrated the medical resources and adjusted the layout of hospital uninterrupted within the region, the action of construct scale and layout of the area hospitals continuous. The impact and repercussions of the largestwas was "5+3+1" suburbs three hospital building projects.To implement the country’s spirit of the new round of medical reform, Shanghai proposed to improve the health care system to optimize the layout and structure of health care resources, and promote the integration of health care resources, the formation of the "1560" medical circles "to improve basic medical services accessibility as it reform and development goals. Shanghai hospital size and layout building analysis and evaluation were more urgent.1.3Domestic study on hospital size and layout evaluation perspective and method need to be developed to serve the health practiceThe measurement of scale economies is appropriate method of study scale. In recent year, the study of scale economies effective of hospital was getting active in our country, variety of methods had been used, but there were some problems, such as the cases of some point of view was scare, the study and model used by cost function was not abundant, the scale economies study using DEA often were assistant product of technology efficacy measurement, some important problem conclusions were not inconformity, the region of hospital were finitude, etc. The scale economies of hospital were influenced by the inside and outside environment of hospital, the study of other country and region can’t substitute the study of our country, preciously study can’t not substitute study at present.Traditional method of study of hospital layout included provider-population ratio and equity measurement of health resources, those methods had limitations. The measurement of spatial accessibility was a good method for studying this problem. In western country the study of health care spatial accessibility had very matured, there were a lot of models and study cases, had a very widely practical application. In recent year, our country had some study cases with applying the methods of health care spatial accessibility, but the number of cases was small and the types of study model was limited, the study scale often little, the academic significance exceeded the practical significance, this situation can’t satisfy the demand of hospital layout decision in the practices environment.2ObjectivesThis study would explored and developed methods of evaluation on the hospitals individual size and layout within the region, empirical analyzed and evaluated the development of hospital size and layout in Shanghai, put forward some advice on the development of hospital size and layout in Shanghai. In order to get this goal, the study would summarize hospital size and layout’s theories and methods of firstly, the study would also summarize and describe hospital size and layout development’s environment, background, procedure and status in quo In Shanghai secondly, and most important parts of this study were the study would be to measure the hospital scale economies and analyze theirs influencing factors effect, would be to measure hospital spatial accessibilities and evaluate theirs influences on equity. Finality, the study would put forward some advice on the development of hospital size and layout in Shanghai.3Content and Methods3.1Overall Characteristic of the StudyOverall characteristic of this study lied the united use of theories analysis and practices study, the combination of history reviews and status in quo descriptions, the united use of qualitative and quantitative analysis, the incorporation of statistical description and statistical inference, studying those problems with multi-dimension and various kinds of methods comprehensively.3.1Content and Definite Methods3.1.1Reviews on the hospital size and layout’s theories and methods. In this part, the maternities were domestic and overseas literature on the hospital size and layout’s theories and methods, author would read and review them.3.1.2Analysis on the environment, background of the development of hospital size and layout. In this part, the data including city planning of Shanghai, all kinds of yearbooks and scholarly literature were analyzed, the situation of Shanghai city development on city planning, physical geography, economic social population and health status in quo were summarized.3.1.3Analysis on the procedure and status in quo of the development of hospital size and layout. In this part, the data from all kinds of yearbooks, scholarly literature and website of hospital and government health department on the procedure and status in quo of the development of hospital size and layout were analyzed and summarized.3.1.4Measurement on the scale economies of secondary and tertiary hospitals in Shanghai and the analysis on theirs influencing factors effect. In this part, the data of50secondary and tertiary hospitals on the economic operation from Shanghai health economic society were analyzed. The study content and methods including:Statistical description and grouping comparative on hospitals input and output scale; Indicator statistical description and grouping comparative on hospitals economic operation efficiency; Comprehensive evaluation on hospitals economic operation efficiency by factor analysis method and the analysis on theirs influencing factors effect; Measurement the scale economies of hospitals by cost function coefficient evaluating and calculating marginal cost indicators and scale economies indicators based on cost function coefficient and the analysis on theirs influencing factors effect; Measurement the scale economies of hospitals by calculating scale economies, technology efficiency and cost efficiency indicators through DEA models of CRS、VRS、NIRS、 Malmquist productivity index, etc. And analyzing on theirs influencing factors effect. All the analysis no the influences factors effect including single factor analysis and multivariate analysis.3.1.5Measurement on the hospital spatial accessibilities and the assessment of theirs influences on equity. This part of data comes from the Shanghai Health Bureau of Health supervision official website, government documents and news reports. The study measured and assessed hospitals spatial accessibilities by making use of the API that is, application of procedures programming interface provided by the Internet map service providers (Sogou Map) and JavaScript program code carried Address Resolution, distance calculation, applying three models of spatial accessibilities that were, the closest distance, the cumulative opportunities, gravity index based on European straight-line distance. After that, Authors calculated coefficient of variation, the Gini Coefficient, Lorenz Curve and Their s index using the calculation results of spatial accessibilities.3.1.6Recommendations to further optimize Shanghai hospital size and layout. In this part, author synthesize theoretical analysis of hospital size and layout, background and environmental analysis of shanghai hospital size and layout, process and status quo analysis of shanghai hospital size and layout, hospital economies of scale and spatial accessibility and fairness of hospital layout, put forward some recommendations to further optimize Shanghai hospital size and layout.4Major findings, conclusions4.1Urban development orientation and economic and social development situation calls for hospital total resources and layout to make adjustments4.1.1Shanghai urban development orientation, and economic and social development situation calls for increased total hospital resource allocationShanghai’s Urban Planning orientation was to build "a modern international metropolis "," international economic, financial, trade and shipping center ". Shanghai city was the "core" and "leading" in the Yangtze River Delta region. Its population base was large,23,026,600resident population in2010. The immigrant population proportion was high, with38.67%in2010. Population dense was high,3632people/square kilometers in2010. Its convenient transportation favored travelling. Health development is lagging behind population and economic development.2005-2010cumulative growth rate of doctors, number of beds were about16%, with resident population21.82%and for GDP85.63%, fiscal revenue and expenditure of around100%, urban per capita disposable income of71%,65%in rural areas, the health systems work volume287-434%, significantly higher than the investment of resourcesgrowth, the space of the medical and health facilities efficiency enhance would be small.4.1.2Urban development orientation and economic and social development situation requires to improve the allocation of the suburbs (County) HospitalsThe proportion of urban population in Shanghai in2009was88.6%this meaned high level of urbanization. Shanghai has formulated the development planning of urban and rural integration, multi-center metropolitan area. Its suburban population concentred, its momentum of economic development was strong. Suburbs (counties) resident population in2010was11,322,000; its proportion was69.7%,42.7%and6.5%growth over2005. Since2005, its every year GDP growth rate had been greater than10%, Higher than urban. With the advance of the process of suburbanization, suburban population size would be increase, the trend of economic development also be better.4.2Shanghai hospital size and layout adjust constantly, made great achievements, but the problem persists4.2.1Shanghai hospital size and layout building process and featuresSince1997, Shanghai hospital size and layout building had blend into Shanghai medical and health reform process in the background of the construction of new urban medical service system, this building process were influenced and promoted by a lot of reform action such as the localization reform of enterprise hospital, medical institutions consolidation and reorganization in particular the hospital group movement, classified management of medical institutions, medical institutions counterpart support, the Regional Medical Commonwealth pilot and other work. Its main features are:government-led and market-oriented co-exist, government-led is major; compatible with the overall urban development and layout building; combination of hospital micro-scale construction and the overall adjustment of layout; hospital size and layout the building main body is the public tertiary hospitals; tends to close links between the different regions, different levels of hospitals.4.2.2Shanghai hospital expansion was evident, the layout has improved Shanghai hospital’s doctors and beds were increased year by year in absolute numbers and in relative proportion. In the2000-2010decade, cumulative growth rate of beds was48.46%, doctors was19.41%. In2010, the proportions of hospital doctors, beds were80.72%and61.81%respectively. Hospitals proportions more than800beds of hospitals more than one hundred beds accounted for from7.14%in2003to15.06%in2010. Hospitals proportion more than500beds accounted for36.75%, only slightly lower than the39.13%level in Beijing. Numbers of Tertiary (municipal) hospitals and theirs practice point were increasing both. Tertiary (municipal) hospital’s influence over other medical establishment increased by way of hospital group and other ways, the numbers of Hospital Branch and out-patient department having tertiary (municipal) hospital name in their title increased."5+3+1" construction projects, and the earlier some individual tertiary hospitals relocation, setting Branch, etc. improved the hospital, especially tertiary hospital’s layout.4.2.3Shanghai hospital size and layout construction process problemsProminent problem was hospitals resources especially three hospitals resource in suburbs (counties) was inadequate.The emphasis of city construction transfering from the city center to the suburbs brought the population distribution pattern changed,2010suburbs population was11.322million,69.7%percent,42.7%and6.5%growth over2005. the number of beds per million population in the central city hospital in2010were52.53-209.69, higher than18.62-49.41in suburbs (counties), Index in the central city were increase, Index in suburbs (counties) were are on the decline. Tertiary (municipal) hospital practice points are mainly distributed in the central city. Other issues include:the Shanghai hospital size and the layout were still lagging behind Shanghai Urban Planning and positioning requirements; tertiary hospitals had a deeper level of monopolization of the market; Shanghai hospital size and layout construction exacerbated the complexity of the property right’s relationship and management’s relationship, difficult to manage; should pay attention to dilution of the old brand, new brand-building; constraints from the Medicare prospective payment; untouched hospital compensation mechanism reform, the masses benefit was limited; issue of contributing to the existing medical orderly.4.3The hospital has economies of scale, too big might occur decreasing returns to scale4.3.1Input-output scale analysis and comparison of sample hospitals The size of the municipal sample hospitals was significantly greater than the scale of district hospitals.2008-2010. the hospital fixed assets, service provided, income and expenditure expansion were more obvious, especially the municipal hospital, hospital staff and beds investment increase is not obvious. Proportion of the drug incomes were45-47%,"drugs to support medical’"s compensation mechanism remains unchanged in2008-2010.4.3.2The economic operation efficiency indicators characterization analysis and comparisonDescription from the efficiency and workload of hospital services, the money invested and the income and expenditure ratio, the ratio of operating income, and elements of compensation ratio, the level of assets and surplus development capacity, the service unit costs, the economic and operational benefits of the sample hospitals indicators showed that City level hospital had an advantage in-patient services efficiency, financial compensation and return on assets, district hospitals has more cheap on unit costs, higher on the net asset growth.4.3.3Factor analysis of the economic operational benefits and influencing factors analysisHospital economic operation efficiency and scale were height correlated, factor total score and the approved number of beds correlation coefficient is0.784. Municipal tertiary hospital’s score were higher than the district-level, namely secondary hospitals’. Comprehensive analysis outcomes from single factor and multi-factor, factor total score was unrelated with factors such as Roemer index, whether Affiliated Hospital, West hospital or not,(district hospitals) naming a municipal hospital or not, the hospital is in the urban areas or not,(municipal hospitals) whether having suburbs branch and so on.4.3.4Cost function method hospital evaluation of the economies of scale and analysis of influencing factorsThe marginal cost of the sample of hospital in2010of outpatient and emergency, marginal costs of in-patient short-term returns to scale, long-term economies of scale in turn was310.28yuan,14146.29yuan,0.99,0.84, with the former two were increasing and the latter two were in the fall. In2010the proportion of hospital’s short-term returns to scale, long-term economies of scale greater than1are44%and24%respectively in50hospitals. The study supports the conclusions that if the hospital size is too lager may lead to diseconomies of scale, diseconomies of scale happened more in hospital marginal costs, long-term economies of scale, in2010. District-level hospital position and title had statistical significance on marginal cost of outpatient and emergency.4.3.5Hospital economies of scale evaluation by data envelopment analysis and impact factor analysisSample hospitals in2010the DEA scale efficiency, the CRS cost efficiency, cost efficiency average in turn were0.970,0.837.0.741, number of hospitals decreasing returns to scale was33.2008-2010, returns to scale change index was1.0113, and the total factor productivity Malmquist index was1.0301. Hospital scale efficiency value was the parabolic shape. Hospital size had related with CRS technical efficiency, cost efficiency, but not a simple linear relationship. Scale is too large to cause decreasing returns to scale. The Roemer Index affected the CRS technical efficiency. The time was the influence factor on the cost-efficiency, returns to scale range.Comprehensive analysis on findings from factor analysis evaluation, cost function and DEA confirmed the existence of economies of scale, but the findings from cost function and DEA does not support the assumption of infinite existence of hospital scale, confirmed that the scale is too large to produce decreasing returns to scale. Its turning point of the short-term balance of the cost function method and DEA method were500approved beds, the long-run equilibrium and the marginal cost of the cost function method were1000approved beds.4.4Shanghai hospital accessibility, fairness had improved, but still had large regional differences4.4.1The results and conclusions based on nearest distance methodTo compared with2007, the city’s half of the street, township nearest distance to tertiary (municipal) hospitals would be reduced by2012expected, involving11.57million population,. Chongming County, Fengxian District, Jiading District, Pudong New Area, nearest distance dropped most obvious, followed by the other suburbs, finally were urban five districts. Expected by the end of2012, nearest distance of the streets, villages and towns to the tertiary (municipal) hospital ranged169.43-35169.87m, an average of6666.47m, the nearest distance mean of suburbs (county) is6.36times the urban, the nearest distance mean of Pudong district, Expansion area, Suburban and Chongming county area in turn were5.43,3.02,1.17,2.32to urban ones.4.4.2The results and conclusions based on cumulative opportunity method To compared with2007, in2012expected city’s the cumulative opportunity mean growth in the threshold level of5000m,10000m,20000m,50000m and100,000meters to tertiary (municipal) hospitals followed by0.45,1.63.4.62,12.2914.98. Regional cumulative opportunity growth were different, urban area’s cumulative opportunity growth in the20,000m threshold significantly higher than the suburbs (counties), cumulative opportunities in the regional degree of dispersion was not declining, but increasing, especially in the20,000m threshold. Expected by the end of2012the city’s cumulative opportunity mean in the threshold level of5000m,10,000m,20,000m.50,000m and100,000m in turn were4.91,13.35,26.22,50.47,57.92. Cumulative opportunity to urban areas had been higher than the suburbs (counties), expansion area was highest in suburbs (counties), following was Pudong area, Suburban and Chongming county was poorer.4.4.3The results and conclusions based on gravity model methodTo compared with2007, in2012expected city’s the accessibility index to tertiary (municipal) hospitals were almost100%increased. When P=1,2007,2011,2012’s gravity index mean in turn were1.24,1.39,1.70, cumulative growth rate was37.10%; when β=1.2,2007,2011,2012’s gravity index mean in turn were1.26,1.41,1.72, the accumulated growth rate was36.51%. When β=1, in2007,2011and2012, multiple relationship of urban and rural areas (counties)" s gravity index mean in turn were3.68,3.53,2.79, when β=1.2followed by4.76,4.52,3.32. The differences of the street and town’s gravity index to the tertiary (municipal) hospital in the suburbs (counties) regions were pulled large,2007,2011,2012’s standard deviation of the amount of cumulative growth in Pudong area, Expansion area, the suburbs, Chongming county in turn were0.09,0.02,0.06,0.25when β=1,0.11,0.02,0.05,0.50when β=1.2.4.4.4The results and conclusions of equity evaluation based on accessibilityIndicators including closest distance,10000m threshold’s cumulative opportunity,20000m threshold’s cumulative opportunity, gravity index when β=1and β=1.2were used to calculated the coefficient of variation, the Gini coefficient, Theil’s index and the Lorenz curve for the equity evaluation, Shanghai tertiary (municipal) hospital space layout fairness tended to improve, unfair derived from the differences between regions. Gove gravity index when β=1for example,2007、2011、2012’s variation coefficients were0.832,0.793,0.654respectively, Gini coefficients were0.510,0.496,0.413, the Theil’s index were0.149,0.145,0.101, Contribution rates of region differences to the total Theil index were75.17%,77.24%,72.28%, the2012Lorenz curve closest to the diagonal, followed in2011,2007.5Policy Significances5.1Compatible with the economic and socio-demographic developments, to improve the level of total hospital resources allocation;5.2Continue to improve the suburbs (county) level and quality of hospital resource allocation, to ameliorate hospital layout equity;5.3To control of hospital size properly, hospital expansion are compatible with hospital capacity and technology development;5.4To promote the medical and health system reform, making benefit of hospital size and layout adjustment to get greater efficiency.6Research Innovation6.1Evaluation methods on hospital size and layout are explored and applied:6.1.1The researchers applied a set of methods of evaluation on hospital economies of scale based on health statistics conventional data with multi-view. The methods including:Itemized description and comprehensive evaluation of the economic operation effect; Estimates of outpatient and emergency hospital services to marginal cost, short-term returns to scale, the scale of economic indicators based on the cost function method; Estimated scale efficiency index, the dynamic change index and other kind of efficiency indexs based on data envelopment analysis.6.1.2The researchers applied a set of methods with a scale of streets, towns, based on the geographic information system (GIS) access to distances information, of evaluation on the layout of the hospital based on spatial accessibility perspective. This method borrowing ideas from geography theory and methods, with the help of the Internet map service provider API function, based geographic information system (GIS) to obtain the distance information from settlements to hospitals, applying of a variety of models to measure spatial accessibility to the tertiary (municipal) hospitals in Shanghai, to evaluate layout fair based on these measurement.6.2This study systems analyzed the background and environmentof, process and status of Shanghai secondary, tertiary hospital’s size and layout, thematic evaluation on hospital’s size and layout were made, put forward some constructive suggestions based on research results.6.3This study analyzed whether there is contact between factors such as whether the district hospitals had municipal hospitals title, whether municipal hospitals seted suburbs branch and other factors and hospital indicators of the economies of scale, enriching the studys of hospital economies of scale.7Limitations7.1By sample size and data limitations, hospital economies of scale evaluation and impact factor analysis section, some analysis can not expand in depth, such as case mix differences in hospital economies of scale;7.2The indicators and weights determined based on the statistical method in comprehensive evaluation of hospital economies of scale, wether it was scientific and rational, yet to be applied in more practice, to accept the test of practice;7.3Shanghai hospital size and layout’s building are tertiary hospital-based, due to time constraints, study only evaluated the tertiary (municipal) hospital accessibility, two hospital evaluation to be next to continue.