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Objective: the purpose of this study was to compare the technical efficiency of Italian hospitals at a regional level and to examine if differences could be explained by organisational and contextual factors. Technical efficiency was defined as the ability of the operating units evaluated to use optimal resource levels for their level of output. Methods: the effect of external factors was explored through a second stage Data Envelopment Analysis (DEA). Efficiency scores were calculated for each hospital using the DEA method (Stage I). Through Tobit regression analysis, the estimated efficiency scores were regressed against a set of organisational and contextual characteristics beyond managerial control, which reflected differences in the population demographics and regional health expenditure (Stage II). Stage I and Stage II efficiency scores were compared in order to indirectly assess managerial contribution in relation to hospital efficiency. Results: the highest efficiency (M±SD) was observed in hospitals in the North-West (75.7±15.1), followed by those in the North-East (75.5±15.1), Central Italy (73.9±16.4) and then Southern Italy (70.6±17.9). Hospital Trusts (HTs) were shown to be more technically efficient than Local Public Hospitals (LPHs). Organisational and contextual indicators were statistically significantly different at Tobit regression analysis for HTs and LPHs. Emilia Romagna and Lombardia were the regions whose management contributed to increased efficiency. Conclusions: in our study, the distribution of regions according to technical efficiency only partly reflected the North-South gradient shown by other studies regarding the gap of expenditure. The important role of organisation and environment in establishing efficiency differences among hospitals was demonstrated.

Background. Sicilian government has developed a very ambitious Reform through the Regional Law n. 5 (14th April 2009). Hospitals were requested to ensure the quality of care through monitoring of appropriateness and quality of service. The aim of this study was to assess variations of efficiency and organizational appropriateness of healthcare delivery before and after this Reform and to show patterns associated to different types of healthcare delivery organizations. Methods. This study was based on repeated cross-sectional data for 118 (out of 129) short-term, acute-care, non teaching-and-research Sicilian hospitals, in 2008 and 2010. Congestion and slacks analysis was used, with four inputs, two desirable outputs and two undesirable outputs of healthcare delivery. Results. The loss of desirable output increased between 2008 (23%) and 2010 (31%). Most of the variation between two years in the measured inefficiency could be attributed to congestion due to inappropriate care (p=0.009) and scale inefficiency (p=0.028). Hospitals that have undergone an organizational transformation did not show congestion in the study period. Conversely, hospitals with no variations in their organization were congested in association to the shortfall in the ODs (p=0.019) and in DHs (p=0.018). Conclusion. This study has shown the general worsening of efficiency of acute-care Sicilian hospitals from 2008 and 2010 and, in particular, has suggested that the reduction of efficiency was due to hospitals that have not undergone an organizational transformation. They are medium-low sized and low-complexity public hospitals and for-profits, while larger and high-complexity organizations resulted the least congested ones.