Table 1.
Summary of reviewed studies
| Author | Year | Country | Hospital type | Number of hospitals | Method used to calculate efficiency | Input and outputs | Source of inefficiency |
|---|---|---|---|---|---|---|---|
| Al-Shammari [19] | 1999 | Jordan | Hospitals of MoH* | 15 | DEA |
Inputs: Numbers of bed-days, physicians, health workforce Outputs: Numbers of inpatient days, minor operations, major operations |
Excess resources |
| Ramanathan [20] | 2005 | Oman | Regional and Wilayat hospitals (MoH), Sultan Qaboos University Hospital, Hospital of the Royal Oman Police | 20 | DEA (Malmquist index) |
Inputs: Numbers of beds, physicians, and other medical workforces. Outputs: Number of visits, in-patient services, surgical operations |
Partial utilization of inputs, lack of full compliance with technological changes |
| Hajialiafzali [21] | 2007 | Iran | Hospitals affiliated with the Social Security Organization | 53 | DEA (frontier-based methods) |
Inputs: Total numbers of FTE* medical doctors, of FTE nurses, of other FTE workforces, number of beds Outputs: Numbers of outpatient visits and emergency visits, ratio of major surgeries to total surgeries, total numbers of medical interventions and surgical procedures |
Partial utilization of inputs |
| Hatam [15] | 2008 | Iran | Hospitals affiliated with the Social Security Organization | 18 | DEA (frontier-based methods) |
Inputs: Numbers of beds, FTE, total expense Outputs: Patient-days, BOR*, BTR,* ALS*, ratio of available beds to constructed beds, hoteling expense, bed-day costs, workforce costs |
Unused beds |
| Goshtasebi [22] | 2009 | Iran | MoH hospitals | 6 | Pabon Lasso | Output: ALS, BOR, BTR | Underutilization of resources, high BOR |
| Jandaghi [23] | 2010 | Iran | Public and private hospitals | 8 | DEA (frontier-based methods) |
Inputs: Numbers of physicians, nurses, medical workforce, official workforce, annual costs of hospital Outputs: Numbers of clinical visits, emergency visits, and bed-days |
Excess resources |
| Hatam [24] | 2010 | Iran | General public hospitals | 21 | DEA (frontier-based methods) |
Inputs: Numbers of hospital beds, FTE physicians, nurses, and other workforces Outputs: BOR, patient–day admissions, bed-days, ALS, BTR |
Lack of motivation to select inputs to minimize expenses caused by the fact that hospitals are public and therefore do not seek profitability. |
| Shahhoseini [25] | 2011 | Iran | Provincial hospitals | 12 | DEA (frontier-based methods) |
Inputs: Numbers of active beds, nurses, physicians, and other professionals Outputs: Number of surgeries, outpatients visits, BOR, ALS, inpatient days |
Excess resources |
| Ketabi [26] | 2011 | Iran | Hospitals in Isfahan | 23 | DEA |
Inputs: Average numbers of active beds, medical equipment, workforce (such as doctors, nurses and technicians) Outputs: BOR (%), ALS, total percentage of survival, performance ratio |
Excess medical equipment, workforce and technology for teaching and private hospitals. Teaching hospitals are less efficient because of bureaucratic processes and private hospitals have lower BORs. |
| Bahadori [27] | 2011 | Iran | Hospitals affiliated with Urmia University of Medical Sciences | 23 | Pabon Lasso | Output: ALS, BOR, BTR | Poor performance in BOR and/or BTR in 60.87% of hospitals. |
| Al-Shayea [28] | 2011 | Saudi Arabia | Khalid University Hospital | 1 (9 departments) | DEA |
Inputs: doctors’ total salary, nurses’ total salary Outputs: Numbers of in-patients, outpatients, bed and average turnover rate |
High costs of inputs |
| Kiadaliri [29] | 2011 | Iran | General hospitals affiliated with Ahvaz Jondishapour University of Medical Sciences | 19 | DEA (frontier-based methods) |
Inputs: beds, human resources Outputs: inpatient days, outpatient days, number of surgeries, BOR |
Inappropriate hospital sizes |
| Osmani [30] | 2012 | Afghanistan | District Hospitals | 68 | DEA and Tobit regression analysis model |
Inputs: Numbers of physicians, midwives, nurses, non-medical workforce, and beds Outputs: Numbers of outpatient visits, inpatient admissions, and patient days, ALS, BOR, number of hospital beds (proxy for hospital size), bed-physician and outpatient physician ratio, number of physicians |
Excess numbers of doctors, nurses, and beds |
| Farzianpour [31] | 2012 | Iran | Teaching hospitals of Tehran University of Medical Sciences | 16 | DEA (frontier-based methods) |
Inputs: Numbers of physicians, practicing nurses in health facilities, and active beds Outputs: Numbers of inpatients, outpatients, ALS |
Excess inputs or insufficient outputs |
| Chaabouni [32] | 2012 | Tunisia | Public hospitals | 10 | DEA and The Bootstrap Approach |
Inputs: Numbers of physicians, nurses, dentists and pharmacists, other workforces, and beds Outputs: Numbers of outpatient visits, admissions, post-admission days |
High hospital expenditures |
| Barati Marnani [33] | 2012 | Iran | Affiliated with Shahid Beheshti University of Medical Sciences | 23 | Pabon Lasso model and DEA (frontier-based methods) |
Pabon Lasso: ALS, BOR, BTR DEA: Inputs: Numbers of physicians, nurses, other workforces, and active beds Outputs: BOR, numbers of patients and surgeries |
Excess resources |
| Sheikhzadeh [34] | 2012 | Iran | Elected public and private hospitals of East Azerbaijani Province | 6 | DEA (frontier-based methods) |
Inputs: Numbers of specialist physicians, general physicians, nurses, residents, medical team workforce with a degree (Bachelor’s), medical team, nonmedical and support workforce, and active beds Outputs: Numbers of emergency patients, outpatients, and inpatients, average daily inpatients residing in hospital |
Excess and inefficient inputs: lack of medical services for the amount of resources used. |
| Yusefzadeh [35] | 2013 | Iran | Public hospitals | 23 | DEA |
Inputs: Numbers of active beds, doctors, and other workforces Outputs: Number of outpatients’ admissions and day-beds |
Excess inputs or insufficient outputs |
| Gholipour [36] | 2013 | Iran | Obstetrics and gynaecology teaching hospitals | 2 | Pabon Lasso | Output: ALS, BOR, BTR | Low BOR |
| Arfa [37] | 2013 | Tunisia | Public hospitals | 101 | DEA |
Five fixed inputs: Numbers of physicians, dentists, mid-wives, nurses or equivalents, and beds. One variable input: budget Outputs: Numbers of outpatient visits and admissions |
Hospitals are not operating at full capacity |
| Ajlouni [38] | 2013 | Jordan | Public hospitals | 15 | DEA and Pabon-Lasso |
Pabon Lasso: ALS, BOR, BTR DEA: Inputs: Numbers of bed-days, physicians per year, and health workforce per year Outputs: Patient days, numbers of minor operations and major operations |
Poor management, treatment of diseases requiring long patient stays |
| Abou El-Seoud [39] | 2013 | Saudi Arabia | Public hospitals that have been reformed to operate under private sector management through the full operating system in Saudi Arabia | 20 | DEA |
Inputs: Numbers of specialists, nurses, allied workforce, and beds Outputs: Numbers of visits, patient hospital admissions, laboratory tests, and beneficiaries of radiological imaging |
Administrative weakness to overcome external environmental factors rather than inability to manage internal operations |
| Bastani [40] | 2013 | Iran | Hospitals affiliated to the MoH | 139 | Four hospital performance indicators | Output: ALS, BOR, BTR | Inappropriate hospital sizes |
| Younsi [41] | 2014 | Tunisia | 30 public and 10 private hospitals | 40 | Pabon Lasso | Output: ALS, BOR, BTR | Low bed density which may not match population hospital needs. Hospital bed numbers should be increased or maintained. |
| Torabipour [42] | 2014 | Iran | Teaching and non-teaching hospitals of Ahvaz County | 12 | DEA (Malemquist index) |
Inputs: Numbers of nurses, beds, and physicians. Outputs: Numbers of outpatients and inpatients, ALS, number of major operations |
Lack of familiarity of managers with advanced hospital technologies, lack of equipment and inappropriate use of technology in diagnosis, care and treatment. |
| Syed Aziz Rasool [43] | 2014 | Pakistan | Non-profit private organization (branches of LRBT hospitals) | 16 | DEA |
Inputs: Numbers of beds, specialists, nurses Outputs: Numbers of outpatient visits, inpatient admissions, and total numbers of surgeries |
Lack of government funds to hospitals run by non-profit organizations. |
| Pourmohammadi [44] | 2014 | Iran | All hospitals affiliated with the Social Security Organization | 64 | The Cobb-Douglas model |
Inputs: Numbers of physicians, nurses, other workforces, and active beds Outputs: Number of outpatients and inpatients |
Excess workforce |
| Mehrtak [45] | 2014 | Iran | All general hospitals located in Iranian Eastern Azerbijan Province | 18 | Pabon Lasso and DEA |
Pabon Lasso: ALS, BOR, BTR DEA: Inputs: Numbers of active beds, physicians, nurses, discharged patients Outputs: Number of surgeries and discharged patients, BOR |
Excess inputs: larger hospitals are more efficient than smaller hospitals. |
| Lotfi [46] | 2014 | Iran | All hospitals of Ahvaz (8 hospitals affiliated with Jundishapur University of Medical Sciences and 8 non-affiliated hospitals) | 16 | Pabon Lasso and DEA |
Pabon Lasso: ALS, BOR, BTR DEA: Inputs: Numbers of physicians, nurses, other workforces, and active beds Outputs: BOR, numbers of patients and surgeries |
Underuse of resources, excess hospital inputs |
| Kalhor [47] | 2014 | Iran | Hospitals affiliated with Qazvin University | 6 | Pabon Lasso | Output: ALS, BOR, BTR | Poor managerial decisions |
| Goudarzi [48] | 2014 | Iran | Teaching hospitals affiliated with Tehran University of Medical Sciences | 12 | DEA (frontier-based methods) |
Inputs: Numbers of medical doctors, nurses, and other workforces, active beds, and outpatient admissions Outputs: Number of inpatient admissions |
Excess numbers of nurses and active beds |
| Askari [49] | 2014 | Iran | Hospitals affiliated with Yazd University of Medical Sciences | 13 | DEA |
Inputs: Numbers of active beds, nurses, physicians, and non-clinical workforce Outputs: hospitalization admissions, BOR (%), and number of surgeries |
High excess inputs, particularly the excess number of nurses. |
| Adham [50] | 2014 | Iran | Teaching and non-teaching hospitals | 14 | Pabon Lasso | Output: ALS, BOR, BTR | Low BOR |
| Imamgholi [51] | 2014 | Iran | Hospitals affiliated to Busheher University of Medical Sciences | 7 | Pabon Lasso | Output: ALS, BOR, BTR | Non-optimal hospital sizes |
| Shetabi [52] | 2015 | Iran | Hospitals affiliated to Kermanshah University of Medical Sciences | 7 | DEA |
Inputs: Numbers of active beds, doctors, nurses, and other workforces Outputs: Numbers of accepted inpatients, outpatients and BOR (%) |
Excess inputs |
| Masoompourb [53] | 2015 | Iran | Teaching Hospital | 1 | Pabon Lasso | ALS, BOR, BTR | Decrease in ALS |
| Chaabouni [54] | 2016 | Tunisia | Public Hospitals | 10 | DEA (frontier-based methods) |
Inputs: Numbers of physicians, nurses, dentists, pharmacists, and beds, total cost Outputs: Numbers of outpatient visits, admissions, and post-admission days, price of labor |
large hospital sizes |
| Safdar [55] | 2016 | Pakistan | A large public hospital | 1 | DEA |
Inputs: Waiting time at the pharmacy, length of waiting line Outputs: Consultation time at the pharmacy |
High waiting times: low efficiency levels (less than 50% efficiency) are associated with high waiting times. |
| Mohammadi [56] | 2016 | Iran | Public hospitals | 67 | Cobb-Douglas production function | Inputs: Human resources (including net working hours of specialized workforce) and bed numbers (including the number of active beds) | Insufficient inputs: Inpatient service production levels were lower than expected in 40% of hospitals. A 10% increase in net working hours of specialized human resources would generate a 8.8% increase in average inpatient service production levels. A 10% increase in the number of active beds would generate a 1.1% increase in average inpatient service production levels. |
| Mahate [57] | 2016 | United Arab Emirates | Private and public hospitals in the UAE | 96 | DEA |
Inputs: Numbers of beds, doctors, dentists, nurses, pharmacists and allied health workforce, and administrative workforce Outputs: Numbers of treated inpatients, outpatients, ALS |
Waste of 41 to 52% of inputs during service delivery. |
| Kalhor [58] | 2016 | Iran | Tehran city general hospitals | 54 | DEA |
Inputs: Total numbers of FTE medical doctors, and nurses, numbers of supporting medical workforce including ancillary service workforce, and beds Outputs: Numbers of patient days, outpatient visits, patients receiving surgery, ALS |
Ownership type (lower efficiency of university hospitals because of more expenditures) |
| Kakemam [59] | 2016 | Iran | Hospitals of public, private, or social security ownership types in Tehran | 54 | DEA |
Inputs: Numbers of active beds, physicians, nurses, and other medical workforces Outputs: Numbers of outpatient visits, surgeries, and hospitalized days, ALS |
Lack of resource optimization. Poor adaptation of the sizes, types of practices, and ownerships of hospitals, affecting their technical efficiency. Approximately 70% of the hospitals were inefficient. |
| Hassanain [60] | 2016 | Saudi Arabia | Hospitals affiliated to the MoH | 12 | Lean | On-time start, room turnover times, percent of overrun cases, average weekly procedure volume and OR utilization | Ppoor hospital infrastructure, old technology, suboptimal management of human resources, the absence of employee engagement, frequent scheduling changes, inefficient process flow |
| Hamidi [61] | 2016 | Palestine | 22 government hospitals | 22 | DEA (frontier-based methods) |
Inputs: Numbers of beds, doctors, nurses, and non-medical workforce Outputs: Numbers of admitted patients, hospital days, operations, outpatient visits, ALS |
Mismanagement of available resources, shortage of the numbers of doctors and nurses and excess number of non-medical staff |
| Nabilou [62] | 2016 | Iran | Hospitals affiliated to Tehran University of Medical Sciences | 17 | DEA (Malmquist index) |
Inputs: Active beds, nurses, doctors and other workforces Outputs: outpatient admissions, bed-days, number of surgical operations |
Due to hospitals’ technological changes, a lack of knowledge of hospital workforce on proper applications of technology for patient treatment became the main cause of low hospital productivity and inefficiency. |
| Rezaei [63] | 2016 | Iran | Kurdistan teaching hospitals | 12 | DEA (frontier-based methods) |
Inputs: Numbers of active beds, nurses, physicians, and other workforce members Outputs: Inpatient admissions |
Waste of inputs during service delivery |
| Farzianpour [64] | 2017 | Iran | Training and non-training hospitals of Tabriz city | 19 | DEA |
Inputs: Numbers of physicians, total workforce, and active beds Outputs: Number of outpatients and BOR |
Poor management of human and financial resources. |
| Arfa [65] | 2017 | Tunisia | Public district hospitals | 105 | DEA |
Inputs: Numbers of physicians, surgical dentists, midwives, nurses and equivalents, and beds, operating budget Outputs: Outpatient visits in stomatology wards, outpatient visits in emergency wards, outpatient visits in external wards, numbers of admissions, and admissions in maternity wards |
Inadequate number of workforce, equipment, beds, and medical supply, health quality and lack of fitting operating budgets: tackling these sources of inefficiency would reduce net user needs and the bypassing of the public district hospitals, to increase their capacity utilization. Social health insurance should be turned into a direct purchaser of curative and preventive care for the public hospitals. |
| Aly Helal [66] | 2017 | Saudi Arabia | Public hospitals | 270 | DEA |
Inputs: Numbers of beds, doctors, nurses, and allied medical workforce Outputs: Numbers of individuals visiting admitted patients, radiography service beneficiaries, laboratory testing beneficiaries, and inpatients |
Excess inputs |
| Mousa [67] | 2017 | Saudi Arabia | Public hospitals | 270 | DEA |
Inputs: Numbers of physicians, nurses, pharmacists, allied health professionals, beds Outputs: Numbers of outpatient visits, inpatients, laboratory investigations, X-rays patients, X-rays films, total number of surgical operations |
Inadequate resources: some resources should be switched between regions to improve efficiency. |
| Moradi [68] | 2017 | Iran | Public hospitals | 11 | Pabon Lasso | ALS, BOR, BTR | Low number of hospital beds, and need for hospital expansion |
| Sultan [69] | 2017 | Jordan | General public hospitals | 27 | DEA |
Inputs: Numbers of beds, physicians, healthcare workforce, administrative workforce Outputs: Inpatient days, outpatient visits, emergency departments, and ambulances |
Diseconomies of scale affect the operational efficiency, poor management, poor productivity in outpatient services and low numbers of physicians. |
| Kassam [70] | 2017 | Iraq | Hospitals in Baghdad | 3 | DEA and Luenberger Productivity Indicator (LPI) |
Inputs: Numbers of doctors, nurses, and other health workforces Outputs: Numbers of outpatients, laboratory tests, radiology tests, sonar tests, emergency visits |
The cause of the inefficiencies is undetermined. |
| Rezaee [71] | 2018 | Iran | Hospitals affiliated with Kermanshah University of Medical Sciences | 15 | Pabon Lasso | Output: ALS, BOR, BTR | Excess inputs |
| Yazan Khalid Abed-Allah Migdadi [72] | 2018 | Jordan | Public hospitals | 15 | DEA |
Inputs: Numbers of physicians, nurses, and beds Outputs: ALS, number of Surgeries, BOR |
Low BOR |
| Sajadi [73] | 2018 | Iran | All hospitals in Isfahan City | 54 | Cross-sectional descriptive study comparing performance indicators | Outputs: BOR, BTR, bed-days, inpatients visits, number of surgeries in all types of hospitals, outpatient visits in all non-private hospitals, emergency visits in public and social security hospitals, and natural deliveries in public and semi-public hospitals | Inefficient use of limited resources |
*BOR bed occupancy rate, BTR bed turnover rate, ALS average length of stay, FTE Full Time Employee, MoH Ministry of Health