Outcomes and Healthcare Utilization Among New Persistent Opioid Users and Nonopioid Users After Curative-intent Surgery for Cancer.

OBJECTIVE: The aim of the study was to compare the health outcomes and resource use of cancer patients who were new persistent opioid users with those who were not, after undergoing curative intent surgery for cancer. BACKGROUND: Little is known about long-term health outcomes (overdose, mortality) and resource utilization of new persistent opioid users among cancer patients undergoing curative-intent surgery. METHODS: This retrospective cohort study included all adults with a diagnosis of solid cancers who underwent curative-intent surgery during the study period (2011-2015) in Alberta, Canada and were opioid-naïve before surgery, with a follow-up period until December 31, 2019. The key exposure, "new persistent opioid user," was defined as a patient who was opioid-naive before surgery and subsequently filled at least 1 opioid prescription between 60 and 180 days after surgery. The primary outcome was opioid overdose that occurred within 3 years of surgery. All-cause death, noncancer caused death, and department visit (yes vs. no), and hospitalization (yes vs. no) in the follow-up periods were also included as outcomes. RESULTS: In total, 19,219 patients underwent curative intent surgery with a median follow-up of 47 months, of whom 1530 (8.0%) were identified as postoperative new persistent opioid users. In total, 101 (0.5%) patients experienced opioid overdose within 3 years of surgery. Compared with nonopioid users, new persistent opioid users experienced a higher rate of opioid overdose (OR = 2.37, 95% CI: 1.44-3.9) within 3 years of surgery. New persistent opioid use was also associated with a greater likelihood of being hospitalized (OR = 2.03, 95% CI: 1.76-2.33) and visiting an emergency room (OR = 1.83, 95% CI: 1.62-2.06) in the first year after surgery, and a higher overall (HR = 1.28, 95% CI: 1.1-1.49) and noncancer caused mortality (HR = 1.33, 95% CI: 1.12-1.58), when compared with nonopioid users. CONCLUSION: Postoperative new persistent opioid use among cancer patients undergoing curative-intent surgery is associated with subsequent opioid overdose, worse survival, and more health resource utilization.

New method for determining breast cancer recurrence-free survival using routinely collected real-world health data.

BACKGROUND: In cancer survival analyses using population-based data, researchers face the challenge of ascertaining the timing of recurrence. We previously developed algorithms to identify recurrence of breast cancer. This is a follow-up study to detect the timing of recurrence. METHODS: Health events that signified recurrence and timing were obtained from routinely collected administrative data. The timing of recurrence was estimated by finding the timing of key indicator events using three different algorithms, respectively. For validation, we compared algorithm-estimated timing of recurrence with that obtained from chart-reviewed data. We further compared the results of cox regressions models (modeling recurrence-free survival) based on the algorithms versus chart review. RESULTS: In total, 598 breast cancer patients were included. 121 (20.2%) had recurrence after a median follow-up of 4 years. Based on the high accuracy algorithm for identifying the presence of recurrence (with 94.2% sensitivity and 79.2% positive predictive value), the majority (64.5%) of the algorithm-estimated recurrence dates fell within 3 months of the corresponding chart review determined recurrence dates. The algorithm estimated and chart-reviewed data generated Kaplan-Meier (K-M) curves and Cox regression results for recurrence-free survival (hazard ratios and P-values) were very similar. CONCLUSION: The proposed algorithms for identifying the timing of breast cancer recurrence achieved similar results to the chart review data and were potentially useful in survival analysis.

Supervised consumption site enables cost savings by avoiding emergency services: a cost analysis study.

BACKGROUND AND AIMS: We report on a cost analysis study, using population level data to determine the emergency service costs avoided from emergency overdose management at supervised consumption services (SCS). DESIGN: We completed a cost analysis from a payer's perspective. In this setting, there is a single-payer model of service delivery. SETTING: In Calgary, Canada, 'Safeworks Harm Reduction Program' was established in late 2017 and offers 24/7 access to SCS. The facility is a nurse-led service, available for client drop-in. We conducted a cost analysis for the entire duration of the program from November 2017 to January 2020, a period of 2 years and 3 months. METHODS: We assessed costs using the following factors from government health databases: monthly operational costs of providing services for drug consumption, cost of providing ambulance pre-hospital care for clients with overdoses who could not be revived at the facility, cost of initial treatment in an emergency department, and benefit of costs averted from overdoses that were successfully managed at the SCS. RESULTS: The proportion of clients who have overdosed at the SCS has decreased steadily for the duration of the program. The number of overdoses that can be managed on site at the SCS has trended upward, currently 98%. Each overdose that is managed at the SCS produces approximately $1600 CAD in cost savings, with a savings of over $2.3 million for the lifetime of the program. CONCLUSION: Overdose management at an SCS creates cost savings by offsetting costs required for managing overdoses using emergency department and pre-hospital ambulance services.

Psychometric evaluation of a Canadian version of the Seattle Angina Questionnaire (SAQ-CAN).

BACKGROUND: The Seattle Angina Questionnaire (SAQ) is a widely-used patient-reported outcomes measure in patients with heart disease. This study assesses the validity and reliability of the SAQ in a Canadian cohort of individuals with stable angina. METHODS AND RESULTS: Data are from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, a population-based registry of patients who received cardiac catheterization in Alberta, Canada. The cohort consists of 4052 patients undergoing cardiac catheterization for stable angina and completed the SAQ within 2 weeks. Exploratory factor analysis and confirmatory factor analysis (CFA) were used to assess the factorial structure of the SAQ. Internal and test-retest reliabilities of a new measure (i.e., SAQ-CAN) was measured using Cronbach α and intraclass correlation coefficient, respectively. CFA model fit was assessed using the root mean square error of approximation (RMSEA) and comparative fit index (CFI). Construct validity of the SAQ-CAN was assessed in relation to Hospital Anxiety and Depression Scales (HADS), Euro Quality of life 5 dimension (EQ5D), and original SAQ. Of the 4052 patients included in this analysis, 3281 (80.97%) were younger than 75 years old, while 3239 (79.94%) were male. Both exploratory and confirmatory factor analyses revealed a four-factorial structure consisting of 16 items that provided a better fit to the data (RMSEA = 0.049 [90% CI = (0.047, 0.052)]; CFI = 0.975). The 16-item SAQ demonstrated good to excellent internal reliability (Cronbach's α range from 0.77 to 0.90), moderate to strong correlation with the Original SAQ and EQ5D but negligible correlations with HADS. CONCLUSION: The SAQ-CAN has acceptable psychometric properties that are comparable to the original SAQ. We recommend its use for assessing coronary health outcomes in Canadian patients with Coronary Artery Disease.

Trajectories of perceived social support in acute coronary syndrome.

PURPOSE: Perceived social support is known to be an important predictor of health outcomes in patients with acute coronary syndrome (ACS). This study investigates patterns of longitudinal trajectories of patient-reported perceived social support in individuals with ACS. METHODS: Data are from 3013 patients from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry who had their first cardiac catheterization between 2004 and 2011. Perceived social support was assessed using the 19-item Medical Outcomes Study Social Support Survey (MOS) 2 weeks, 1 year, and 3 years post catheterization. Group-based trajectory analysis based on longitudinal multiple imputation model was used to identify distinct subgroups of trajectories of perceived social support over a 3-year follow-up period. RESULTS: Three distinct social support trajectory subgroups were identified, namely: "High" social support group (60%), "Intermediate" social support group (30%), and "Low" social support subgroup (10%). Being female (OR = 1.67; 95% CI = [1.18-2.36]), depression (OR = 8.10; 95% CI = [4.27-15.36]) and smoking (OR = 1.70; 95% CI = [1.23-2.35]) were predictors of the differences among these trajectory subgroups. CONCLUSION: Although the majority of ACS patients showed increased or fairly stable trajectories of social support, about 10% of the cohort reported declining social support. These findings can inform targeted psycho-social interventions to improve their perceived social support and health outcomes.

How to practice person-centred care: A conceptual framework.

BACKGROUND: Globally, health-care systems and organizations are looking to improve health system performance through the implementation of a person-centred care (PCC) model. While numerous conceptual frameworks for PCC exist, a gap remains in practical guidance on PCC implementation. METHODS: Based on a narrative review of the PCC literature, a generic conceptual framework was developed in collaboration with a patient partner, which synthesizes evidence, recommendations and best practice from existing frameworks and implementation case studies. The Donabedian model for health-care improvement was used to classify PCC domains into the categories of "Structure," "Process" and "Outcome" for health-care quality improvement. DISCUSSION: The framework emphasizes the structural domain, which relates to the health-care system or context in which care is delivered, providing the foundation for PCC, and influencing the processes and outcomes of care. Structural domains identified include: the creation of a PCC culture across the continuum of care; co-designing educational programs, as well as health promotion and prevention programs with patients; providing a supportive and accommodating environment; and developing and integrating structures to support health information technology and to measure and monitor PCC performance. Process domains describe the importance of cultivating communication and respectful and compassionate care; engaging patients in managing their care; and integration of care. Outcome domains identified include: access to care and Patient-Reported Outcomes. CONCLUSION: This conceptual framework provides a step-wise roadmap to guide health-care systems and organizations in the provision PCC across various health-care sectors.

Comparison of risk adjustment methods in patients with liver disease using electronic medical record data.

BACKGROUND: Risk adjustment is essential for valid comparison of patients' health outcomes or performances of health care providers. Several risk adjustment methods for liver diseases are commonly used but the optimal approach is unknown. This study aimed to compare the common risk adjustment methods for predicting in-hospital mortality in cirrhosis patients using electronic medical record (EMR) data. METHODS: The sample was derived from Beijing YouAn hospital between 2010 and 2014. Previously validated EMR extraction methods were applied to define liver disease conditions, Charlson comorbidity index (CCI), Elixhauser comorbidity index (ECI), Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), MELD sodium (MELDNa), and five-variable MELD (5vMELD). The performance of the common risk adjustment models as well as models combining disease severity and comorbidity indexes for predicting in-hospital mortality was compared using c-statistic. RESULTS: Of 11,121 cirrhotic patients, 69.9% were males and 15.8% age 65 or older. The c-statistics across compared models ranged from 0.785 to 0.887. All models significantly outperformed the baseline model with age, sex, and admission status (c-statistic: 0.628). The c-statistics for the CCI, ECI, MELDNa, and CTP were 0.808, 0.825, 0.849, and 0.851, respectively. The c-statistic was 0.887 for combination of CTP and ECI, and 0.882 for combination of MELDNa score and ECI. CONCLUSIONS: The liver disease severity indexes (i.e., CTP and MELDNa score) outperformed the CCI and ECI for predicting in-hospital mortality among cirrhosis patients using Chinese EMRs. Combining liver disease severity and comorbidities indexes could improve the discrimination power of predicting in-hospital mortality.

Does the new cooperative medical scheme reduce inequality in catastrophic health expenditure in rural China?

BACKGROUND: In 2003, the New Cooperative Medical Scheme (NCMS) was introduced in China to re-establish health insurance for the country's vast rural population. In addition, the coverage of NCMS has been expanding after the new health care reform launched in 2009. This study aims to examine whether the NCMS and its recent expansion have reached the goal of reducing the risk and inequality of catastrophic health spending for rural residents in China. METHODS: We conducted a face-to-face household survey in three counties of the Shandong province in 2009 and 2012. Using this unique panel data, we examined the changes in the incidence and intensity of catastrophic health expenditures (CHEs) before and after NCMS reimbursement. We used concentration index (CI) and decomposition method to study the changes in inequality in CHEs. RESULTS: We found that NCMS reimbursement played a role of reducing both the incidence and intensity of CHEs, and that this impact was stronger after the new health care reform was launched. After reimbursement, the concentration indices for CHEs were 0.073 and 0.021 in 2009 and 2012, indicating that the rich had a greater tendency to incur CHEs and there existed less inequality in the incidence of CHEs after reimbursement in 2012 compared with 2009. The decomposition analysis results suggested that changes in CHE inequality between 2009 and 2012 were attributed to changes in economic status and household size rather than reimbursement levels. CONCLUSIONS: Our results indicated that inequality was shrinking from 2009 to 2012, which could be a result of fewer rich people having CHEs in 2012 compared with 2009. The impact of NCMS in alleviating the financial burden of rural residents was still limited, especially among the poor. Health care reform policies in China that aim to reduce CHEs must continue to place an emphasis on improving reimbursement, cost containment, and reducing income inequalities.

Development and validation of method for defining conditions using Chinese electronic medical record.

BACKGROUND: The adoption of the electronic medical record (EMR) is rapidly growing in China. Constantly evolving, Chinese EMRs contain vast amounts of clinical and financial data, providing tremendous potential for research and policy use; however, they are only partially standardized and contain free text or unstructured data. To utilize the information contained in Chinese EMRs, the development of data extraction methodology is urgently needed. The purpose of this study is to develop and validate methods to extract clinical information from the Chinese EMR for research use. METHODS: Using 2010 to 2014 EMR data from YouAn Hospital, a large teaching hospital affiliated with Capital Medical University in Beijing, China, we developed extraction methods including 40 EMR definitions for defining 6 liver disease, 5 disease severity conditions, and 29 comorbidities and treatments. We conducted a chart review of 450 randomly selected EMRs. Using physician chart review results as a reference, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to validate each EMR definition. RESULTS: The sensitivity of the 6 EMR definitions for liver diseases ranged from 78.9 to 100.0 %, and PPV ranged from 82.1 to 100.0 %. The sensitivity of the 5 definitions on disease severity conditions ranged from 91.0 to 100.0 %, and PPV ranged from 79.2 to 100.0 %. Among the 29 EMR definitions for comorbidities and treatments, 23 had sensitivity over 90.0 % and 25 had PPV over 80.0 %. The specificity and NPV for all 40 EMR definitions were over 90.0 %. CONCLUSION: The extraction method developed is a valid way of extracting information on liver diseases, comorbidities and related treatments from YouAn hospital EMRs. Our method should be modified for application to other Chinese EMR systems, following our framework for extracting conditions.

Systematic review of risk adjustment models of hospital length of stay (LOS).

BACKGROUND: Policy decisions in health care, such as hospital performance evaluation and performance-based budgeting, require an accurate prediction of hospital length of stay (LOS). This paper provides a systematic review of risk adjustment models for hospital LOS, and focuses primarily on studies that use administrative data. METHODS: MEDLINE, EMBASE, Cochrane, PubMed, and EconLit were searched for studies that tested the performance of risk adjustment models in predicting hospital LOS. We included studies that tested models developed for the general inpatient population, and excluded those that analyzed risk factors only correlated with LOS, impact analyses, or those that used disease-specific scales and indexes to predict LOS. RESULTS: Our search yielded 3973 abstracts, of which 37 were included. These studies used various disease groupers and severity/morbidity indexes to predict LOS. Few models were developed specifically for explaining hospital LOS; most focused primarily on explaining resource spending and the costs associated with hospital LOS, and applied these models to hospital LOS. We found a large variation in predictive power across different LOS predictive models. The best model performance for most studies fell in the range of 0.30-0.60, approximately. CONCLUSIONS: The current risk adjustment methodologies for predicting LOS are still limited in terms of models, predictors, and predictive power. One possible approach to improving the performance of LOS risk adjustment models is to include more disease-specific variables, such as disease-specific or condition-specific measures, and functional measures. For this approach, however, more comprehensive and standardized data are urgently needed. In addition, statistical methods and evaluation tools more appropriate to LOS should be tested and adopted.

Administrative health data in Canada: lessons from history.

BACKGROUND: Health decision-making requires evidence from high-quality data. As one example, the Discharge Abstract Database (DAD) compiles data from the majority of Canadian hospitals to form one of the most comprehensive and highly regarded administrative health databases available for health research, internationally. However, despite the success of this and other administrative health data resources, little is known about their history or the factors that have led to their success. The purpose of this paper is to provide an historical overview of Canadian administrative health data for health research to contribute to the institutional memory of this field. METHODS: We conducted a qualitative content analysis of approximately 20 key sources to construct an historical narrative of administrative health data in Canada. Specifically, we searched for content related to key events, individuals, challenges, and successes in this field over time. RESULTS: In Canada, administrative health data for health research has developed in tangent with provincial research centres. Interestingly, the lessons learned from this history align with the original recommendations of the 1964 Royal Commission on Health Services: (1) standardization, and (2) centralization of data resources, that is (3) facilitated through governmental financial support. CONCLUSIONS: The overview history provided here illustrates the need for longstanding partnerships between government and academia, for classification, terminology and standardization are time-consuming and ever-evolving processes. This paper will be of interest to those who work with administrative health data, and also for countries that are looking to build or improve upon their use of administrative health data for decision-making.

Mental health inpatient treatment expenditure trends in China, 2005-2012: evidence from Shandong.

BACKGROUND: Mental health is increasingly becoming a huge public health issue in China. Yet for various cultural, healthcare system, and social economic reasons, people with mental health need have long been under-served in China. In order to inform the current on-going health care reform, empirical evidences on the economic burden of mental illnesses in China are urgently needed to contribute to health policy makers' understanding of the potential benefits to society from allocating more resources to preventing and treating mental illness. However, the cost of mental illnesses and particularly its trend in China remains largely unknown. AIMS OF THE STUDY: To investigate the trend of health care resource utilization among inpatients with mental illnesses in China, and to analyze what are the factors influencing the inpatient costs. METHOD: Our study sample included 15,721 patients, both adults and children, who were hospitalized over an eight-year period (2005-2012) in Shandong Center for Mental Health (SCMH), the only provincial psychiatric hospital in Shandong province, China. Data were extracted from the Health Information System (HIS) at SCMH, with detailed and itemized cost data on all inpatient expenses incurred during hospitalization. The identification of the patients was based on the ICD-10 diagnoses recorded in the HIS. Descriptive analysis was done to analyze the trend of hospitalization cost and length of stay during the study period. Multivariate stepwise regression analysis was conducted to assess the factors that influence hospitalization cost. RESULTS: Among the inpatients in our sample, the most common mental disorders were schizophrenia, schizotypal and delusional disorders. The disease which had the highest per capita hospital expense was behavioral and emotional disorders with onset usually occurring in childhood and adolescence (RMB 8,828.4; US$ 1,419.4, as compared to the average reported household annual income of US$ 2,095.3 in China). The average annual growth rate of per capita hospitalization cost was 23.6%, with the inpatient cost reaching RMB 11,949 (US$ 1921.1) in 2012. The hospitalization cost was found to be strongly associated with hospital length of stay, level of care, age, employment status, admission diagnoses, and frequency of hospitalization. DISCUSSION: Our study found that mental health inpatient resources use, particularly hospitalization cost, has been growing at an increasing rate. In our sample, hospitalization cost nearly tripled from 2005 to 2012. Mental illnesses and the related economic burden on the population will continue to grow, making mental health a major public health issue in China. Hospital length of stay was found to be increasing in our sample, and positively correlated with hospitalization cost. Childhood and adolescence behavioral and emotional disorders were found to be significantly associated with higher inpatient cost. IMPLICATIONS FOR HEALTH POLICIES AND FUTURE RESEARCH: The policy implications generated from the results of this study are two-fold: first of all, in order to meet the growing need of mental health care in China, the government needs to significantly increase its spending in preventing and treating mental illnesses. Second, cost containment in inpatient care would become a major challenge for mental health policy makers in China. Government support, clinical practices and guideline development, as well as research are urgently needed to promote mental health prevention and improve the efficiency of mental health system in China. The current mental health system, like the overall healthcare system in China, relies heavily on hospital inpatient care. In order to build a sustainable mental health care system to meet increasing population need in China, it is crucial to integrate mental health care reform with the ongoing primary health care reform. Future mental health policy reform and research in China should put more focus on how to strengthen primary care system as well as community support, establish effective two-tier referring mechanism between hospital and primary care system, and to ensure continuity of care.

Direct economic burden of hepatitis B virus related diseases: evidence from Shandong, China.

BACKGROUND: Although the expenses of liver cirrhosis are covered by a critical illness fund under the current health insurance program in China, the economic burden associated with hepatitis B virus (HBV) related diseases is not well addressed. In order to provide evidence to address the economic disease burden of HBV, we conducted a survey to investigate the direct economic burden of acute and chronic hepatitis B, cirrhosis and liver cancer caused by HBV-related disease. METHODS: From April 2010 to November 2010, we conducted a survey of inpatients with HBV-related diseases and who were hospitalized for seven or more days in one of the seven tertiary and six secondary hospitals in Shandong, China. Patients were recorded consecutively within a three-to-five month time period from each sampled hospital; an in-person survey was conducted to collect demographic and socio-economic information, as well as direct medical and nonmedical expenses during the last month and last year prior to the current hospitalization. Direct medical costs included total outpatient, inpatient, and self-treatment expenditures; direct nonmedical costs included spending on nutritional supplements, transportation, and nursing. Direct medical costs during the current hospitalization were also obtained from the hospital financial database. The direct economic cost was calculated as the sum of direct medical and nonmedical costs. Our results call for the importance of implementing clinical guideline, improving system accountability, and helping secondary and smaller hospitals to improve efficiency. This has important policy implication for the on-going hospital reform in China. RESULTS: Our data based on inpatients with HBV-related diseases suggested that the direct cost in US dollars for acute hepatitis B, severe hepatitis B, chronic hepatitis B, compensated cirrhosis, decompensated cirrhosis and primary liver cancer was $2954, $10834, $4552, $7400.28, $6936 and $10635, respectively. These costs ranged from 30.72% (for acute hepatitis B) to 297.85% (for primary liver cancer) of the average annual household income in our sample. Even for patients with health insurance, direct out-of-pocket cost of all HBV-related diseases except acute hepatitis B exceeded 40.00% of the patient's disposable household income, making it a catastrophic expenditure for the household. CONCLUSION: Hepatitis B imposes considerable economic burden on a family. Our findings will help health policy makers' understanding of the magnitude of the economic burden of HBV-related diseases in China. Evidence from our study also contributes to our understanding of potential benefits to society from allocating more resources to preventing and treating HBV infection, as well as increasing insurance coverage in China. These findings have important policy implications for health care reform efforts currently underway in China focusing on how to reduce the burden of catastrophic disease for its citizens.

A systematic review of interventions to increase breast and cervical cancer screening uptake among Asian women.

BACKGROUND: The Asian population is one of the fastest growing ethnic minority groups in western countries. However, cancer screening uptake is consistently lower in this group than in the native-born populations. As a first step towards developing an effective cancer screening intervention program targeting Asian women, we conducted a comprehensive systematic review, without geographic, language or date limitations, to update current knowledge on the effectiveness of existing intervention strategies to enhance breast and cervical screening uptake in Asian women. METHODS: This study systematically reviewed studies published as of January 2010 to synthesize knowledge about effectiveness of cancer screening interventions targeting Asian women. Fifteen multidisciplinary peer-reviewed and grey literature databases were searched to identify relevant studies. RESULTS: The results of our systematic review were reported in accordance with the PRISMA Statement. Of 37 selected intervention studies, only 18 studies included valid outcome measures (i.e. self-reported or recorded receipt of mammograms or Pap smear). 11 of the 18 intervention studies with valid outcome measures used multiple intervention strategies to target individuals in a specific Asian ethnic group. This observed pattern of intervention design supports the hypothesis that employing a combination of multiple strategies is more likely to be successful than single interventions. The effectiveness of community-based or workplace-based group education programs increases when additional supports, such as assistance in scheduling/attending screening and mobile screening services are provided. Combining cultural awareness training for health care professionals with outreach workers who can help healthcare professionals overcome language and cultural barriers is likely to improve cancer screening uptake. Media campaigns and mailed culturally sensitive print materials alone may be ineffective in increasing screening uptake. Intervention effectiveness appears to vary with ethnic population, methods of program delivery, and study setting. CONCLUSIONS: Despite some limitations, our review has demonstrated that the effectiveness of existing interventions to promote breast and cervical cancer screening uptake in Asian women may hinge on a variety of factors, such as type of intervention and study population characteristics. While some studies demonstrated the effectiveness of certain intervention programs, the cost effectiveness and long-term sustainability of these programs remain questionable. When adopting an intervention program, it is important to consider the impacts of social-and cultural factors specific to the Asian population on cancer screening uptake. Future research is needed to develop new interventions and tools, and adopt vigorous study design and evaluation methodologies to increase cancer screening among Asian women to promote population health and health equity.

Growing old before growing rich: inequality in health service utilization among the mid-aged and elderly in Gansu and Zhejiang Provinces, China.

BACKGROUND: China's recent growth in income has been unequally distributed, resulting in an unusually rapid retreat from relative income equality, which has impacted negatively on health services access. There exists a significant gap between health care utilization in rural and urban areas and inequality in health care access due to differences in socioeconomic status is increasing. We investigate inequality in service utilization among the mid-aged and elderly, with a special attention of health insurance. METHODS: This paper measures the income-related inequality and horizontal inequity in inpatient and outpatient health care utilization among the mid-aged and elderly in two provinces of China. The data for this study come from the pilot survey of the China Health and Retirement Longitudinal Study in Gansu and Zhejiang. Concentration Index (CI) and its decomposition approach were deployed to reflect inequality degree and explore the source of these inequalities. RESULTS: There is a pro-rich inequality in the probability of receiving health service utilization in Gansu (CI outpatient = 0.067; CI inpatient = 0.011) and outpatient for Zhejiang (CI = 0.016), but a pro-poor inequality in inpatient utilization in Zhejiang (CI = -0.090). All the Horizontal Inequity Indices (HI) are positive. Income was the dominant factor in health care utilization for out-patient in Gansu (40.3 percent) and Zhejiang (55.5 percent). The non-need factors' contribution to inequity in Gansu and Zhejiang outpatient care had the same pattern across the two provinces, with the factors evenly split between pro-rich and pro-poor biases. The insurance schemes were strongly pro-rich, except New Cooperative Medical Scheme (NCMS) in Zhejiang. CONCLUSIONS: For the middle-aged and elderly, there is a strong pro-rich inequality of health care utilization in both provinces. Income was the most important factor in outpatient care in both provinces, but access to inpatient care was driven by a mix of income, need and non-need factors that significantly differed across and within the two provinces. These differences were the result of different levels of health care provision, different out-of-pocket expenses for health care and different access to and coverage of health insurance for rural and urban families. To address health care utilization inequality, China will need to reduce the unequal distribution of income and expand the coverage of its health insurance schemes.

Association of mental health with health care use and cost: a population study.

OBJECTIVE: To compare the health costs of groups with and without psychiatric diagnoses (PDs) using 9 years of physician billing data. METHODS: A dataset containing registration data for all patients receiving public mental health service was constructed and subsequently matched, on age and sex, in a final patient to comparison patient ratio of 1:8, with health care users who did not receive treatment in the mental health system. Three groups emerged: a patient PD group-patients with psychiatric disorders treated in public mental health care (n = 76 677); a comparison patient PD group-comparison patients with PDs treated in physicians only (n = 277 627); and a patient- comparison patient non-PD group-patients (treated in specialized publicly funded care or by their physician) without PDs (n = 329 177). Examining over 42 million billing records for all of these patients, we compared the average number of visits and the average health only (nonpsychiatric) billing cost per each patient during the 9-year study period across the groups. RESULTS: Among all health care users in the data, the health costs (Total Costs - Mental Health Costs) were greater on average for the patients with PD group ($3437) and the comparison patient PD group ($3265), compared with patient-comparison patient non-PD group ($1345). Forty-six percent of the comparison sample had a PD. CONCLUSIONS: Having a mental health problem is related to greater health-related expenditures. This has important policy implications on how mental health resources are constructed and rationed within the health care system.

Comparing public and private hospitals in China: evidence from Guangdong.

BACKGROUND: The literature comparing private not-for-profit, for-profit, and government providers mostly relies on empirical evidence from high-income and established market economies. Studies from developing and transitional economies remain scarce, especially regarding patient case-mix and quality of care in public and private hospitals, even though countries such as China have expanded a mixed-ownership approach to service delivery. The purpose of this study is to compare the operations and performance of public and private hospitals in Guangdong Province, China, focusing on differences in patient case-mix and quality of care. METHODS: We analyze survey data collected from 362 government-owned and private hospitals in Guangdong Province in 2005, combining mandatorily reported administrative data with a survey instrument designed for this study. We use univariate and multi-variate regression analyses to compare hospital characteristics and to identify factors associated with simple measures of structural quality and patient outcomes. RESULTS: Compared to private hospitals, government hospitals have a higher average value of total assets, more pieces of expensive medical equipment, more employees, and more physicians (controlling for hospital beds, urban location, insurance network, and university affiliation). Government and for-profit private hospitals do not statistically differ in total staffing, although for-profits have proportionally more support staff and fewer medical professionals. Mortality rates for non-government non-profit and for-profit hospitals do not statistically differ from those of government hospitals of similar size, accreditation level, and patient mix. CONCLUSIONS: In combination with other evidence on health service delivery in China, our results suggest that changes in ownership type alone are unlikely to dramatically improve or harm overall quality. System incentives need to be designed to reward desired hospital performance and protect vulnerable patients, regardless of hospital ownership type.

A qualitative evaluation of clinically coded data quality from health information manager perspectives.

BACKGROUND: It is essential that clinical documentation and clinical coding be of high quality for the production of healthcare data. OBJECTIVE: This study assessed qualitatively the strengths and barriers regarding clinical coding quality from the perspective of health information managers. METHOD: Ten health information managers and clinical coding quality coordinators who oversee clinical coders (CCs) were identified and recruited from nine provinces across Canada. Semi-structured interviews were conducted, which included questions on data quality, costs of clinical coding, education for health information management, suggestions for quality improvement and barriers to quality improvement. Interviews were recorded, transcribed and analysed using directed content analysis and informed by institutional ethnography. RESULTS: Common barriers to clinical coding quality included incomplete and unorganised chart documentation, and lack of communication with physicians for clarification. Further, clinical coding quality suffered as a result of limited resources (e.g. staffing and budget) being available to health information management departments. Managers unanimously reported that clinical coding quality improvements can be made by (i) offering interactive training programmes to CCs and (ii) streamlining sources of information from charts. CONCLUSION: Although clinical coding quality is generally regarded as high across Canada, clinical coding managers perceived quality to be limited by incomplete and inconsistent chart documentation, and increasing expectations for data collection without equal resources allocated to clinical coding professionals. IMPLICATIONS: This study presents novel evidence for clinical coding quality improvement across Canada.

Strategies for enhancing the initiation of cholesterol lowering medication among patients at high cardiovascular disease risk: a qualitative descriptive exploration of patient and general practitioners' perspectives on a facilitated relay intervention in Alberta, Canada.

OBJECTIVE: The objective of our study was to explore the perspectives of patients and general practitioners (GPs) regarding interventions to increase initiation of cholesterol lowering medication (or statins), including a proposed laboratory-based facilitated relay intervention. DESIGN: Qualitative descriptive study using interviews and focus groups for data collection, and thematic analysis for data analysis. SETTING: Primary care providers and patients in Calgary, Alberta, Canada. PARTICIPANTS: 17 GPs with primarily community-based, non-academic practices with at least 1 year of practice experience participated in semistructured interviews. 14 patients at high risk of cardiovascular disease participated in focus groups. MAIN OUTCOME MEASURES: Exploration of strategies that might be used to enhance the prescription of, and adherence to statin therapy for patients with statin-indicated conditions. RESULTS: GPs proposed a variety of interventions to improve statin prescription, including electronic record audit solutions, GP directed education, and patient-oriented campaigns. Patients expressed that they may benefit from being provided access to their laboratory test results, as well as targeted education. Both parties provided positive feedback on the proposed laboratory-based facilitated relay intervention, while pointing out areas for improvement. Notably, GPs were concerned that the patient-directed component of the intervention might jeopardise therapeutic relationships, and patients were concerned about accidental disclosure of personal health information. Important considerations for the design of facilitated relay messaging should include brevity, simplicity and the provision of contact information for inquiries. CONCLUSIONS: GPs and patients described several suggestions for increasing statin initiation and welcomed the proposal of a laboratory-based facilitated relay strategy. These findings support further testing of this intervention which may enhance GPs' ability to successfully engage patients in cardiovascular risk reduction through statin therapy.

Soft budget constraints in China: evidence from the Guangdong hospital industry.

Using data from 276 general acute hospitals in the Pearl River Delta region of Guangdong Province from 2002 and 2004, we construct a preliminary metric of budget constraint softness. We find that, controlling for hospital size, ownership, and other factors, a Chinese hospital's probability of receiving government financial support is inversely associated with the hospital's previous net revenue, an association consistent with soft budget constraints.