Research On Approriate Size Of County Hospitals Of Hunan Province

Background:County hospitals are a bond linking township hospitals, provincial hospitals and municipal hospitals. They are also the medical treatment and public health centers and the business guidance centers. They play a leading and core role in the rural health service system. County hospitals construction and function performance directly influence the general public’s immediate interests and is important for the development of rural economy. There is a lack of beds and blind expansion in county hospitals at present. According to social an economic development, local population characteristics, population health and demand and utilization, conforming with functional orientation and scientific construction and development, which is a vital and realistic subject.The data from home and abroad have shown that the size of a hospital is based on the number of beds, involving internal factors and external factors. While understanding of appropriate size of a hospital hasn’t formed a comparatively uniform viewpoint in the academia and each school has its own theoretical presentation. The current empirical research is confined to the scale economy within a hospital, then tend to treat a hospital’s appropriate size as the optical scale or the scale economy within a hospital, thus reducing the content of appropriate size of a hospital. The study of appropriate size of county hospitals hasn’t taken into account the locational characteristics and functional characteristics. Therefore, it is necessary to make a systematic analysis of size of county hospitals.Objectives:Through the analysis of demand trend of rural residents medical service and supply status, health resources allocation within a county and the operational state of county and township medical institutions, propose a mathematical model of proper construction scale of county hospitals, make relevant measures guiding the hospitals’scientific planning and construction, and provide a reference for the government’s scientific decision-making.Methods:The county hospitals of this study refer to the largest hospitals sponsored by the governments within a county/city/district.1.Objects and samples There are two samples involved in this study. One is population-based sample, the other samples of medical institutions. The research samples of residents medical service demand trend are the population determined by multi-stage stratified cluster.About determination of the research samples of health services in rural areas,the First thing is to establish the regional category indicators using dimensionless method according to the screened area classification index, and divide87counties/cities/districts in compliancewith standards from the123counties in divided into four categories of regions in termsof the given exclusion criteria. A total of16sample counties were extracted by stratified random sampling in proportion to20%of the first, second, or third types of regions and15%of the four. All the county level medical institutions and the rural township hospitals in the sample counties were regrard as the research samples of the countryside medical and health services. The research objects is16county hospitals in accordance with principle of sampling extraction.2. Research contents and tools(1) Sample rural residents medical service demands and needs and utilization:adopting four-times national health service investigation data from Hunan provincial rural sample population questionnaire. Main indicators are prevalence rate of chronic diseases, two-week prevalence rate, two-week consultation rate of patients, two-week prevalence rate of self-treatment, hospitalization rate, clinical expenditure of out-patient average hospitalization expense of each time, health care spending per year and health care coverage.(2) The equity of the current situation of health resource allocation of the sample area:using the self-made questionnaire data, the author analyzed and compared the number of beds, nurses and doctors’ average of1,000people of the sample areas, Theil index and Gini coefficients.(3) The resource allocation and operational characteristics of sample county and townships medical institutions:adopting self-made questionnaire data to make statistical analysis, it covers eight indicators of resource allocation, nine indicators of financial operation and eleven indicators of medical service.(4) The input and output performance of sample county hospitals: Using CCR model in DEA base model and BCC model, the author calculated EDA efficiency scores on the basis of the overall performance and the medical service performance evaluation and analyzed the scale revenue status.(5)The theoretical models of sample county hospitals:adopting multivariable regression analysis, the author established the scale model of county hospitals. Multivariate regression analysis includes3types and20items. Among them social-economic indicators include:the household registration population,65y and older population, GDP per capita, crude death rate, maternal mortality rate, seven items in total. Resource-allocation indicators include:actual number of beds (or the total health technical personnel), business occupancy area, total cost of the equipment, Y10,000-worth equipment units, four items in total. Operational indicators include:fixed assets, long-term liability, medical income, medical expenditure, outpatients and emergency visits, inpatient amount, actual available bed days, bed utilization rate, average length of stay. There are nine items in total3. Data-collecting methodSecond-hand data come from the official annual statistical data; medical institutions survey data come from16sample counties’s survey data spanning from May through July,2009. Population data come from the country-wide fourth medial service field investigation data provided by Hunan Health Information Center (Hunan Province) as well as series data from Hunan four-times medical service investigation (conducted in1993,1998,2003and2008respectively (aggregation data from3similar units)4. Quality controlThis study is designed to carry out quality control in the process mainly through pre-survey, investigation personnel training, data collection review, double data entry.5. Data analysis methodEstablish a databank with Excel entry and calculate in the corresponding software package according to different methods. Statistical analysis is finished in SPSS13.0statistical software package. Adopting inspection level0.05and using descriptive analysis, one-way analysis of variance, multi-factor regression analysis, Gini coefficient and Theil index calculation is finished by Excel programming. Performance analysis adopts the basic models in data envelopment analysis method CCR and BCC; calculation will be finished in DEAP version2.1software package.Results:1.Sample population medical service needs and demands and utilization changes Two-week prevalence rate for the sample population in2008in135.45‰, up21.91‰than in2003; the top five kinds of diseases, in comparison with those surveyed in2008and2003, the proportion of the chronic diseases is increasing. The patients with chronic diseases which lasts two weeks are increasing from39.70%in2003to55.00%in2008. The sample population with chronic diseases is on the rise. The proportion is135.07%o in2008, up to9.96%population appear to be on the decline, down from58.58%o in2003to49.10%o in2008. The two-week consultation medical institutions are in townships and villages. The proportion of consultation in the two levels increased from72.22%to78.6%. The two-week non-consultation rate of sample population increased from51.60%in2003to63.80%in2008. Due to financial difficulties, the proportion of two-week patients without being treated decreased from48.38%to29.60%. The pure self-treatment rate of sample population is29.09%, down8.00%than in2003. The hospitalization rate within a year is increasing considerably, with investigation population hospitalization rate up from35.62%o in2003to72.76%o in2008, increasing by104%. The one-year non-hospitalization. Due to financial difficulties, the non-hospitalization rate decreased by10.35%compared with that in2003. The proportion of the hospitalized patients who asked to be discharged from hospital halfway decreased compared with that in2003. The social medical coverage took a reverse furn. Among the sample population of the year2003, only2.55%of the residents had different forms of social medical security, which rose to94.45%in2008.2. The equity of health resource allocation in sample areasThe Gini Coefficient of resource allocation in sample areas is below0.3, the Gini coefficient of the number of beds, nurses and doctors was between0.036and0.186, according to population distribution; the Gini coefficient of the number of the number of beds, nurses and doctors was between0.040and0.257according to geographical distribution; the Theil index of sample areas in2008was from0.0011to0.0320according to population distribution; the Theil index of the number of beds, nurses and doctors was from0.0013to0.0500according to geographical distribution.3. The resource allocation and operational changes of sample medical institutions(1) The resource allocation and operational changes of sample medical institutions in sample county and townships. From2000to2008, in16sample counties and districts, the overall resource allocation increased by295.71%in terms of special equipment. The total number of on-the job workers, actual sick bed number,business occupancy area, total health technical personnel, the number of doctors increased by21.05%,71.07%,69.62%,25.35%and48.52%respectively. During the eight years from2000to2008, the fixed assets, long-term liability, debt growth rate was295.06%,274.28%,644.90%,495.70%respectively. The total revenue and expenditure grew in step by about276%, financial subsidy revenue growth rate reached263.36%. Operational indicator shows:during the eight-year period, the number of patients who were discharged from hospital, outpatient visits, the patients occupancy bed days, the actual available bed days, the actual open bed days increased by188.26%,49.8%,165.03%,155.77%,63.34%respectively. The total hospitalization and outpatients cost increased by409.26%and204.09%respectively.(2) The resource allocation and operational changes of sample county hospitals. From2000to2008, the pattern of hospital beds stuff size on the job-workers increased by38.01%,45.27%,13.42%and20.66% respectively. Building area per bed decreased by13.84%. Bed average business occupancy area increased by37.59%. Total equipment per bed and10,000yuan or over, worth equipment unit, bed average fixed assets, bed average assets, bed1average long-term liabilities, and bed average liabilities increased by137.91%,211.76%203.70%,178.41%,630.70%,468.99%respectively. Total income per bed and expenditure per bed increased by139.6%and146.61%; balance of financial revenue and expenditure per bed, financial subsidy decreased by17.95and36.36%respectively. Doctors’daily hospitalization, The amount of daily diagnosis and treatment, daily hospitalization, sickbed usage appears decreasing tendency in hospitals increased by73.97%,36.08%, and60.61%respectively. Average hospitalization days decreased by2.63%. Outpatient visits costs per-capita, inpatient daily expense per bed increased by80.78%and49.3%respectively.(3) Comparison of the sample area resource allocation with its present operation status. From medical resources allocation situation of four area county and township within2008, variance analysis showed extremely significantly different in the mean values of the actual hospital bed number, the utility area, the medical and technical personnel number, the licensed/assistant physician number, and the professional equipment gross (p＜0.01), and significant differences in those of the registered nurse number, and the health hospital bed number (p<0.05). From the current financial operation indicators, there was no significant difference in drug costs between the four regions. The total assets, the liabilities, the total income, the medical income, the drug income, the total expenditure, and the medical expenditure revealed very significantly different by the analysis of variance (p<0.01). The financial subsidy income displayed significant different through variance analysis (p<0.05). From the service indicators, variance analysis showed extremely significantly different in the mean values of the total clinic visit number, the outpatient and emergency number, the total bed days actually opened, the total bed days actually occupied, the number of the patients observed in the health center, the number of the patients discharged from hospital, the number of the patients cured and discharged from hospital, and the hospitalized patient number between the four regions (p<0.01). Results of Variance analysis on the mean values of the total bed days of dischargee occupied in hospital and the number of the hospitalized patients showed significantly different among the four regions (p<0.05).(4) The component ratios of the county medical institutions and township hospitals from the sample areas. The resource allocation of township health centers, and their operation From the prepared case beds, the actual case beds, the floor area, the utility area, the total number of all on-the-job workers, the medical and technical personnel number, and the licensed/assistant physician number, the constituent ratios of the county hospitals accounted from20.99%to26.67%. The constituent ratio of other county-level medical institutions accounted from20.28%to27.89%, and that of the township hospitals accounted from46.92%to55.57%. From professional equipment gross, the constituent ratio of the county hospitals, other county-level medical institutions, and township hospitals were43.46%,30.88%, and25.67%, respectively. The constituent ratios of the total assets, the fixed assets, the total income, and the total expenditure accounted accounted from39.45%to46.60%in the county hospitals, from24.26%to26.20%in other county-level hospitals, from29.13%to35.82%in the township hospitals, respectively. The constituent ratio of liabilities and long-term liabilities accounted for52.17%and59.07%in the county hospitals,26%and23.06%in the other county-level medical institutions, and21.83%and17.87%in the township hospitals, respectively. The composition ratio of financial subsidy income accounted for15.99%in the county hospitals,31.24%in the other county-level medical institutions, and52.78%in the township hospitals. The constituent ratios of total clinic visits and discharged patients accounted for22.19%and26.53%in the county hospital,19.58%and20.44%in the other county-level medical institutions, and58.22%and53.02%in the township hospitals, respectively. The constituent ratios of hospital surgery accounted for36.66%,26.57%and36.77%in the county hospitals, the other county-level medical institutions, and the township hospitals, respectively. The constituent ratios for the total out-patient cost, the in-patient cost accounted for41.39%and43.75%,23.68%and25.39%in the other county-level medical institutions, and34.93%and30.86%in the township hospitals, respectively.4. Evaluation of the scales and achievements in the sample county hospitals(1) Evaluation of the scales of the sample county hospitals. The number of the case beds from16the sample county hospitals was from160to756, which was in line with the basic standard of case beds required in the second-level hospitals according to General Hospital Hierarchical Management Standard (draft) in1989. The ratios of the daily outpatient or emergency visits and prepared case beds in the county hospitals was in the range of0.14-1.9:1, which were less than those of3:1required in the second-level hospitals according to General Hospital Hierarchical Management Standard (draft) in2008. According to the basic standard requirement for the ratio of the daily outpatient or emergency visits and prepared case beds for the second-level hospitals in the General Hospital Hierarchical Management Standard (draft) in1989, the ratio of case beds and hospital formal workers is1:1.3-1.5.37.5%of the16county hospitals met this requirement,50%exceeded1:1.3-1.5, and12.5%lowered1:1.3-1.5. Moreover, the standard ratio of the health technical staff accounted for the whole hospital employees is not less than75%required by in the General Hospital Hierarchical Management Standard (draft) in1989.81.25%of the16county hospitals reached this standard ratio, and18.75%did not meet this standard. The Basic Standards for the Medical Institutions require at least0.88medical technical personnel per case bed in the second-level hospitals. Thus,93.75%of the16county hospitals accorded with this requirement,6.25%did not meet it. The Basic Standards for the Medical Institutions also require at least0.4nurse per case bed. On the view of the prepare case beds,87.5%of the16county hospital complied with this requirement,13.5%did not meet it. According to the clinical department set requirements for the second-level hospitals in the Basic Standards for the Medical Institutions, only one hospital was in accordance with the establishment requirement, accounting for6.25%.93.75%of the county hospitals have some mismanagement of the department sets. In contrast with the requirements about the construction land index in the General Hospital Construction Standards in2008,12.5%of these county hospitals conformed to the national case bed using land index,62.5%lowered this index, and25%exceeded it. From the analysis of the building area index per preparaed case bed, there were8.25%of the ounty hospitals meeting the construction land index in the General Hospital Construction Standards in2008,50%lower than the national building area index per preparaed case bed, and41.75%over it. Moreover,91.75%of the county hospitals reached the basic standard of the building area index per preparaed case bed required in the second-level hospitals according to General Hospital Hierarchical Management Standard, and8.25%did not.(2) Evaluation of the achievements of the sample county hospitals. Adoption of the DEA CCR model and BCC model, under the overall achievement model, the overall efficiency was equal to1in the81.25% of the16county hospitals. In the constant returns to scale stage, it results in the the optimal production scale.6.25%of the hospitals were in the stage of increasing returns to scale, and12.5%were in the stage of decreasing returns to scale. Under the medical service-achievement model, the overall efficiency was equal to1in43.75%of the county hospitals. In the constant returns to scale stage, it results in the the optimal production scale.43.75%of the hospitals were in the stage of increasing returns to scale, and18.75%were in the stage of decreasing returns to scale.5. Regression model of approriate size of county hospitalsThe multiple linear regression model was established by taking the7social economic indicators including the household registration population etc, the4resource allocation indexes such as the utility area, and9operation index of outpatient and emergency number etc as the independent variables, and the number of medical technical personnel and the real beds as the dependent variables. The results showed that, county hospital Health Professionals related impact factors were included:The counties’per capita disposable income of urban residents, crude death rate, the counties’actual medical beds, business occupancy, professional equipment value, the number of devices valued above10,000yuan, fixed assets, long-term debt, medical income, medical expenses, outpatient and emergency visits, hospital visits, actual available bed days, rate of utilization of hospital beds; county hospital beds related impact factor were included:the population of aged65and above in the counties, disposable income of urban residents, medical personnel of medical institutions in county area, business occupancy, the total value of professional equipment, fixed assets, long-term debt, medical income, medical expenses, outpatient and emergency visits, hospital visits, actual available bed days, utilization of hospital beds, average dates of hospitalization. Conclusions:1. The number of the beds of county hospitals of hunan province was from160to756. Although the present scales of the county hospital sets did not exactly match the current national standards, they met the medical needs of county residents. According to the national policy orientation, analysis of the five aspects in the health service needs of county residents, the functional orientation, financial affordability, and the microeconomic efficiency of the county hospitals, we consider that the present scales of the county hospitals in Hunan province were appropriate.2. The main factor determining the county hospital approriate size is the county hospital internal, especially the operation of hospital, such as: actual available bed days and medical expenses.3. In the external factors, the population number of age65and above and the urban residents’ disposable income and crude death rate also has some influence on approriate scale of the county hospital.The value and innovation of this research:1. When the rural medical care security in fully covered, the rural health service system construction is enhanced and the county hospitals comprehensive reform is in full swing, the author puts forward the suggestions on how to construct and develop county hospital on an appropriate and scientific scale, through analysis of supply and demand conditions of Hunan county hospitals medical and health service. These suggestions will be of real and academic value.2. It adopts macro and micro, static and dynamic, theoretical and practical, qualitative and quantitative factors combined to make a systematic analysis of influenced elements of county hospital size. It establishes a multi-factor regressive model according to areas. 3. It proposes the definition of hospitals’appropriate size on the basis of theoretical analysis and data review, that is, hospitals’ appropriate size means that hospitals’size conforms with the orientation of state policy macroscopically, suited to health service demands of residents in the region, matching with the niche tasks and demands of hospitals’ function. Hospitals’size is financially acceptable, and it has the efficiency of scale economy.