Background A good health care system and, especially, the provision of efcient hospital care are the goals of national and regional health policies. However, the scope of general hospital care in the 16 federal states in Germany varies considerably from region to region. The objectives of this paper are to evaluate the technical efciencies of all general hospitals of the 16 federal states for the period from 2015 to 2020, to fnd out the relation between the exogenous factors and score of efciency, and also the infuence of the COVID-19 pandemic on the results of the technical efciency of hospital care in the German states. Methods A two-step approach was used. First, an input-oriented Data Envelopment Analysis model with constant returns to scale and variable returns to scale was applied for the 6-year period from 2015 to 2020. The calculation of technical efciency according to the input-oriented DEA model contains the three components-total technical efciency (TTE), pure technical efciency (PTE) and scale efciency (SE). In the second stage, the infuence of exogenous variables on the previously determined technical efciency was evaluated by applying the tobit regression analysis. Results Although the level of average technical efciency of about 90% is high, total technical efciency deteriorated steadily from 2015 to 2020. Its lowest point at around 78%, was in the year 2020. The deterioration of the average technical efciency is notably infuenced by the lower results in the years 2019 and 2020. The decomposition of technical efciency also revealed that the deterioration of overall average efciency was infuenced by both pure technical efciency (PTE) and scale efciency (SE). Based on the tobit regression analysis performed, it was possible to conclude that the change in the efciency score can be explained by the infuence of exogenous factors only from 6.4% for overall efciency and from 7.1% for scale efciency. Conclusions The results of the analysis of the overall technical efciency reveal that the aggregated data of all general hospitals of all 16 federal states show a steadily worsening total technical efciency every year since 2015. Although, especially, the deterioration of the year 2020 with the occurrence of COVID-19 pandemic, contributes to a deteriorated efciency average, the deterioration of the efciency values, based on the analysis performed, is also observable between the years 2016 and 2019. Considering the output generated, for inefcient units and the relevant policy authorities in the hospital sector, it can be recommended that the number of beds and in particular the number of physicians, should be reduced as inputs. Based on this study, it is also recommended that decisions to increase the efciency of general hospitals should be made with consideration of exogenous factors such as the change in the number of general hospitals or the population density in the respective state, as these had explanatory value in connection with the increase in efciency values. Due to the wide variation in the size of the federal states, the recommendation is more appropriate for federal states with low population density.
