title: Measuring the performance of Critical Access Hospitals in Missouri using data envelopment analysis.
abstract: OBJECTIVE
  Rural hospitals are critical for access to health care, and for their contributions to local economies. However, many rural hospitals, especially critical access hospitals (CAHs) need to strive for more efficiency for continued viability. Routinely evaluating their performance, and providing feedback to management and policy makers, is therefore important.
  
  
  METHODS
  Three measures of relative efficiency are estimated for CAHs in Missouri using an Input-oriented Data Envelopment Analysis with a variable returns to scale assumption and compared with the efficiency of other rural hospitals in Missouri using Banker's F-test. Using 30-day readmission rate as a measure of quality, CAHs are evaluated against efficiency-quality dimensions.
  
  
  RESULTS
  CAHs in Missouri had a slight decline in average technical efficiency, but they had a slight gain in average cost efficiency in 2009 compared to 2006. More than half of the CAHs were neither economically nor technically efficient in both years. The relative efficiency of other rural hospitals was statistically higher than that of CAHs in Missouri.
  
  
  CONCLUSIONS
  This study validates the finding of relative inefficiency of CAHs compared to other hospitals paid under the Prospective Payment System at a state level (Missouri). However, with considerable variation in socioeconomic as well as health care access indicators across states, a relative efficiency frontier may not be the only relevant indicator of value for the evaluation of the performance of CAHs. Access to health care and the impact on the local economy provided by these CAHs to the community are also critical indicators for more comprehensive performance evaluation.
authors.affiliation: Department of Geography, University of Missouri, Columbia, MO 65212, USA. sgm8f@mail.missouri.edu
authors.forename: Shriniwas
authors.initials: S
authors.lastname: Gautam
authors.forename: Lanis
authors.initials: L
authors.lastname: Hicks
authors.forename: Thomas
authors.initials: T
authors.lastname: Johnson
authors.forename: Bhawani
authors.initials: B
authors.lastname: Mishra
mesh_terms: D003362:Cost-Benefit Analysis; D017598:Efficiency, Organizational; D006297:Health Services Accessibility / Q000191:economics; D006780:Hospitals, Rural / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D006278:Medicare / Q000191:economics / Q000458:organization & administration*; D008923:Missouri; D010359:Patient Readmission / Q000706:statistics & numerical data*; D015397:Program Evaluation; D011445:Prospective Payment System / Q000191:economics; D011787:Quality of Health Care / Q000191:economics / Q000458:organization & administration*; D014481:United States