Health care systems face resource scarcity that may jeopardise their financial sustainability as well as the quality of delivered health care. In view of that, the association between technical efficiency, access, and quality of services should be investigated, despite some past attempts that led to mixed, unclear, and perhaps biased results. We use a dataset composed of financial resources, hospital services, appropriateness and timeliness of care, patients’ clinical safety, access to health care services, demographics, and epidemiology variables to study the aforementioned link regarding the Portuguese public hospitals (operating between 2013 and 2016). Quality and access data are aggregated into three main composite indicators, through Grey Relational Analysis (GRA). Bias- and environmentally corrected efficiency scores are estimated via bootstrap-based directional Data Envelopment Analysis. A double bootstrap algorithm is employed, using GRA-based quality indicators as predictors of technical efficiency. Evidence suggests that (1) Portuguese public hospitals exhibit low performance in terms of quality, while the different indicators present considerable correlation among them and with hospital size and patients’ complexity characteristics; (2) patients’ clinical safety, appropriateness and timeliness, as well as access to health care services are consistent and significant predictors of technical efficiency; and (3) the association between efficiency, quality, and access depends on the interaction between appropriateness, timeliness, and access. Therefore, quality and access can be improved with no efficiency sacrifice and vice versa.

中文翻译：

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运营效率与临床安全性，护理适当性，及时性以及获得医疗保健的关系

卫生保健系统面临资源短缺，这可能会损害其财务可持续性以及所提供的卫生保健的质量。有鉴于此，尽管过去的一些尝试导致了结果混合，不明确甚至可能带有偏见，但仍应研究技术效率，获取和服务质量之间的关联。我们使用由财务资源，医院服务，护理的适当性和及时性，患者的临床安全性，医疗服务的可及性，人口统计学和流行病学变量组成的数据集来研究上述有关葡萄牙公立医院的链接（2013年至2016年运营）。通过灰色关联分析（GRA），质量和访问数据汇总为三个主要的综合指标。通过基于引导程序的定向数据包络分析估算出经偏差和环境校正的效率得分。采用双引导算法，使用基于GRA的质量指标作为技术效率的预测指标。有证据表明：（1）葡萄牙公立医院在质量方面表现不佳，而不同的指标之间却表现出很大的相关性，并与医院规模和患者的复杂性特征有关；（2）患者的临床安全性，适当性和及时性以及获得医疗保健服务是技术效率的一致且重要的预测指标；（3）效率，质量和获取之间的关联取决于适当性，及时性和获取之间的相互作用。因此，