Disparities in utilisation of combined oral contraceptives in Aotearoa New Zealand: A cross-sectional whole-of-population study.

AIMS: The combined oral contraceptive (COC) is the most commonly used hormonal contraceptive in Aotearoa New Zealand (Aotearoa/NZ). Currently there is limited data available on who uses COC in Aotearoa/NZ. The aims were to (i) define the population of reproductive-aged females in Aotearoa/NZ in 2018 and identify the rate of COC use among this group and (ii) describe the sociodemographic and geographic characteristics of the population of COC users compared to the general population of reproductive-aged females in 2018. METHODS: This whole-of-population cross-sectional study used the Integrated Data Infrastructure, a large research database managed by Statistics New Zealand. Females aged 16-50 years with complete sociodemographic and geographic information in 2018 from Aotearoa/NZ's estimated resident population were included. COC dispensing records to this cohort were identified from the national Pharmaceutical Collection. This paper reports descriptive counts of COC use and employs generalised linear regression with a binomial distribution and a log link to estimate adjusted risk ratios (aRR) of COC use for key sociodemographic and geographic subgroups. RESULTS: Of 1 113 750 individuals in the study, 159 789 (14.3%) were dispensed as COC in 2018. European/other individuals were most likely to use COC (aRR: 2.72, 2.67-2.78), and Pacific Peoples were least likely (aRR: 0.56, 0.55-0.58) to use COC. Individuals residing in the most deprived quintile had less COC use than individuals in the least deprived quintile (aRR: 0.73, 0.72-0.74). CONCLUSION: Our study is able to highlight significant disparities in use by ethnicity, area-level deprivation, and geographic factors.

Why the US spends more treating high-need high-cost patients: a comparative study of pricing and utilization of care in six high-income countries.

One of the most pressing challenges facing most health care systems is rising costs. As the population ages and the demand for health care services grows, there is a growing need to understand the drivers of these costs across systems. This paper attempts to address this gap by examining utilization and spending of the course of a year for two specific high-need high-cost patient types: a frail older person with a hip fracture and an older person with congestive heart failure and diabetes. Data on utilization and expenditure is collected across five health care settings (hospital, post-acute rehabilitation, primary care, outpatient specialty and drugs), in six countries (Canada (Ontario), France, Germany, Spain (Aragon), Sweden and the United States (fee for service Medicare) and used to construct treatment episode Purchasing Power Parities (PPPs) that compare prices using baskets of goods from the different care settings. The treatment episode PPPs suggest other countries have more similar volumes of care to the US as compared to other standardization approaches, suggesting that US prices account for more of the differential in US health care expenditures. The US also differs with regards to the share of expenditures across care settings, with post-acute rehab and outpatient speciality expenditures accounting for a larger share of the total relative to comparators.

A methodology for identifying high-need, high-cost patient personas for international comparisons.

OBJECTIVE: To establish a methodological approach to compare two high-need, high-cost (HNHC) patient personas internationally. DATA SOURCES: Linked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. STUDY DESIGN: We outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, home-health care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries. DATA COLLECTION/EXTRACTION METHODS: Data collected by ICCONIC partners. PRINCIPAL FINDINGS: Across 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries. CONCLUSION: Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries.

International comparison of spending and utilization at the end of life for hip fracture patients.

OBJECTIVE: To identify and explore differences in spending and utilization of key health services at the end of life among hip fracture patients across seven developed countries. DATA SOURCES: Individual-level claims data from the inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC). STUDY DESIGN: We retrospectively analyzed utilization and spending from acute hospital care, emergency department, outpatient primary care and specialty physician visits, and outpatient drugs. Patterns of spending and utilization were compared in the last 30, 90, and 180 days across Australia, Canada, England, Germany, New Zealand, Spain, and the United States. We employed linear regression models to measure age- and sex-specific effects within and across countries. In addition, we analyzed hospital-centricity, that is, the days spent in hospital and site of death. DATA COLLECTION/EXTRACTION METHODS: We identified patients who sustained a hip fracture in 2016 and died within 12 months from date of admission. PRINCIPAL FINDINGS: Resource use, costs, and the proportion of deaths in hospital showed large variability being high in England and Spain, while low in New Zealand. Days in hospital significantly decreased with increasing age in Canada, Germany, Spain, and the United States. Hospital spending near date of death was significantly lower for women in Canada, Germany, and the United States. The age gradient and the sex effect were less pronounced in utilization and spending of emergency care, outpatient care, and drugs. CONCLUSIONS: Across seven countries, we find important variations in end-of-life care for patients who sustained a hip fracture, with some differences explained by sex and age. Our work sheds important insights that may help ongoing health policy discussions on equity, efficiency, and reimbursement in health care systems.

International comparison of health spending and utilization among people with complex multimorbidity.

OBJECTIVE: The objective of this study was to explore cross-country differences in spending and utilization across different domains of care for a multimorbid persona with heart failure and diabetes. DATA SOURCES: We used individual-level administrative claims or registry data from inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States (US). DATA COLLECTION/EXTRACTION METHODS: Data collected by ICCONIC partners. STUDY DESIGN: We retrospectively analyzed age-sex standardized utilization and spending of an older person (65-90 years) hospitalized with a heart failure exacerbation and a secondary diagnosis of diabetes across five domains of care: hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. PRINCIPAL FINDINGS: Sample sizes ranged from n = 1270 in Spain to n = 21,803 in the United States. Mean age (standard deviation [SD]) ranged from 76.2 (5.6) in the Netherlands to 80.3 (6.8) in Sweden. We observed substantial variation in spending and utilization across care settings. On average, England spent $10,956 per person in hospital care while the United States spent $30,877. The United States had a shorter length of stay over the year (18.9 days) compared to France (32.9) and Germany (33.4). The United States spent more days in facility-based rehabilitative care than other countries. Australia spent $421 per person in primary care, while Spain (Aragon) spent $1557. The United States and Canada had proportionately more visits to specialist providers than primary care providers. Across almost all sectors, the United States spent more than other countries, suggesting higher prices per unit. CONCLUSION: Across 11 countries, there is substantial variation in health care spending and utilization for a complex multimorbid persona with heart failure and diabetes. Drivers of spending vary across countries, with the United States being the most expensive country due to high prices and higher use of facility-based rehabilitative care.

Within and across country variations in treatment of patients with heart failure and diabetes.

OBJECTIVE: To compare within-country variation of health care utilization and spending of patients with chronic heart failure (CHF) and diabetes across countries. DATA SOURCES: Patient-level linked data sources compiled by the International Collaborative on Costs, Outcomes, and Needs in Care across nine countries: Australia, Canada, England, France, Germany, New Zealand, Spain, Switzerland, and the United States. DATA COLLECTION METHODS: Patients were identified in routine hospital data with a primary diagnosis of CHF and a secondary diagnosis of diabetes in 2015/2016. STUDY DESIGN: We calculated the care consumption of patients after a hospital admission over a year across the care pathway-ranging from primary care to home health nursing care. To compare the distribution of care consumption in each country, we use Gini coefficients, Lorenz curves, and female-male ratios for eight utilization and spending measures. PRINCIPAL FINDINGS: In all countries, rehabilitation and home nursing care were highly concentrated in the top decile of patients, while the number of drug prescriptions were more uniformly distributed. On average, the Gini coefficient for drug consumption is about 0.30 (95% confidence interval (CI): 0.27-0.36), while it is, 0.50 (0.45-0.56) for primary care visits, and more than 0.75 (0.81-0.92) for rehabilitation use and nurse visits at home (0.78; 0.62-0.9). Variations in spending were more pronounced than in utilization. Compared to men, women spend more days at initial hospital admission (+5%, 1.01-1.06), have a higher number of prescriptions (+7%, 1.05-1.09), and substantially more rehabilitation and home care (+20% to 35%, 0.79-1.6, 0.99-1.64), but have fewer visits to specialists (-10%; 0.84-0.97). CONCLUSIONS: Distribution of health care consumption in different settings varies within countries, but there are also some common treatment patterns across all countries. Clinicians and policy makers need to look into these differences in care utilization by sex and care setting to determine whether they are justified or indicate suboptimal care.

Differences in health outcomes for high-need high-cost patients across high-income countries.

OBJECTIVE: This study explores variations in outcomes of care for two types of patient personas-an older frail person recovering from a hip fracture and a multimorbid older patient with congestive heart failure (CHF) and diabetes. DATA SOURCES: We used individual-level patient data from 11 health systems. STUDY DESIGN: We compared inpatient mortality, mortality, and readmission rates at 30, 90, and 365 days. For the hip fracture persona, we also calculated time to surgery. Outcomes were standardized by age and sex. DATA COLLECTION/EXTRACTION METHODS: Data was compiled by the International Collaborative on Costs, Outcomes and Needs in Care across 11 countries for the years 2016-2017 (or nearest): Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. PRINCIPAL FINDINGS: The hip sample across ranged from 1859 patients in Aragon, Spain, to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia, and the majority of hip patients across countries were female. The congestive heart failure (CHF) sample ranged from 742 patients in England to 21,803 in the United States. Mean age ranged from 77.2 in the United States to 80.3 in Sweden, and the majority of CHF patients were males. Average in-hospital mortality across countries was 4.1%. for the hip persona and 6.3% for the CHF persona. At the year mark, the mean mortality across all countries was 25.3% for the hip persona and 32.7% for CHF persona. Across both patient types, England reported the highest mortality at 1 year followed by the United States. Readmission rates for all periods were higher for the CHF persona than the hip persona. At 30 days, the average readmission rate for the hip persona was 13.8% and 27.6% for the CHF persona. CONCLUSION: Across 11 countries, there are meaningful differences in health system outcomes for two types of patients.

Differences in health care spending and utilization among older frail adults in high-income countries: ICCONIC hip fracture persona.

OBJECTIVE: This study explores differences in spending and utilization of health care services for an older person with frailty before and after a hip fracture. DATA SOURCES: We used individual-level patient data from five care settings. STUDY DESIGN: We compared utilization and spending of an older person aged older than 65 years for 365 days before and after a hip fracture across 11 countries and five domains of care as follows: acute hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. Utilization and spending were age and sex standardized.. DATA COLLECTION/EXTRACTION METHODS: The data were compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries as follows: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. PRINCIPAL FINDINGS: The sample ranged from 1859 patients in Spain to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia. The majority of patients across countries were female. Relative to other countries, the United States had the lowest inpatient length of stay (11.3), but the highest number of days were spent in post-acute care rehab (100.7) and, on average, had more visits to specialist providers (6.8 per year) than primary care providers (4.0 per year). Across almost all sectors, the United States spent more per person than other countries per unit ($13,622 per hospitalization, $233 per primary care visit, $386 per MD specialist visit). Patients also had high expenditures in the year prior to the hip fracture, mostly concentrated in the inpatient setting. CONCLUSION: Across 11 high-income countries, there is substantial variation in health care spending and utilization for an older person with frailty, both before and after a hip fracture. The United States is the most expensive country due to high prices and above average utilization of post-acute rehab care.

Social impacts and costs of schizophrenia: a national cohort study using New Zealand linked administrative data.

AIM: To identify a national population of individuals living with schizophrenia in New Zealand, and to examine health, social support, justice, economic outcomes and estimated government costs compared to a matched comparison group. METHODS: Data were sourced from the Integrated Data Infrastructure. Individuals with a schizophrenia diagnosis in public hospital discharge or specialist secondary mental health service data, aged 18 to 64 and living in New Zealand were included in the schizophrenia population. Propensity score matching was used to select a comparison group of individuals without schizophrenia from the New Zealand resident population and compare outcomes and costs. RESULTS: In 2015 there were 18,096 people living with schizophrenia in New Zealand, a prevalence of 6.7 per 1,000 people. Compared to the matched comparison population, individuals with schizophrenia had higher hospitalisation rates for mental (OR=52.80) and physical (OR=1.18) health conditions. They were more likely to receive social welfare benefits (OR=17.64), less likely to be employed (OR=0.11) and had lower income ($26,226 lower). Per-person government costs were higher for the schizophrenia group across all domains, particularly health ($14,847 higher) and social support ($11,823 higher). CONCLUSION: Schizophrenia is associated with a range of adverse health, social and economic outcomes and considerably higher government costs compared to the general population.

Vision screening in New Zealand pre-school children: Is it equitable?

AIM: This study aimed to investigate the variability by ethnicity, socio-economic status and location in coverage and testability of the universal B4 School Check vision screening in children aged 4-5 years in New Zealand. METHODS: Aggregated data from 1 July 2011 to 30 June 2015 were sourced from the Statistics New Zealand Integrated Data Infrastructure. Sourced data were attendance at vision screening and record of visual acuity measurement stratified by ethnicity, socio-economic status and region. Children who attended screening were compared with the eligible population (n = 252 279) to calculate coverage. Testability was determined by comparing the children with a recorded visual acuity measurement in each eye with those who attended screening. RESULTS: Overall vision screening coverage was 89.5% and testability was 97.8%. Ethnic differences were evident for coverage (85.7% in Pacific children, 92.5% in European children) and testability (96.4% in Maori children, 98.4% in European children). Socio-economic differences were also observed for coverage (86.4% in most deprived areas, 92.4% in least deprived), testability (most deprived 96.3%, least deprived 98.7%) and by region (coverage range of 80.4-96.4% and testability range of 93.2-99.3%). CONCLUSIONS: Significant disparities exist in vision screening coverage and testability for New Zealand pre-school children. Equity-focused initiatives are required to improve outcomes for children from Maori and Pacific families, and those from households in lower socio-economic areas. Understanding region-specific challenges and successes could support more equitable access to vision screening between regions. Further research is required to determine sources of inequities and to investigate interactions between ethnicity, socio-economic status and location.

IDI trends in antidepressant dispensing to New Zealand children and young people between 2007/08 and 2015/16.

AIM: To examine trends in antidepressant dispensing to childred and young people in New Zealand aged 1-24 years between 2007/08 and 2015/16 using the national Integrated Data Infrastructure (IDI), and to determine whether these trends vary by age, sex, ethnicity and socioeconomic deprivation. METHODS: In a novel endeavour, data on antidepressant dispensing, age, sex, ethnicity and socioeconomic status were sourced from the IDI, a linked individual-level database containing New Zealand government and survey microdata. RESULTS: The total rate of dispensing of antidepressants to young people increased by 44% from 1,870 per 100,000 in 2007/08 to 2,694 per 100,000 in 2015/16. Increases were larger for the 13-17 age group than the 1-12- or 18-24-year age groups. New Zealand European/Other ethnicities had the highest dispensing rates (3,623 out of every 100,000 people received an antidepressant in 2015/16), followed by Maori (1,980/100,000), Asian (902/100,000) and Pasifika (819/100,000) had the lowest. Dispensing rates increased with increasing deprivation, except in the most deprived quintile, where rates were lower than all other quintiles. CONCLUSION: This study demonstrates the value of utilising IDI data for health research, while providing directions for future use, including further linkage of IDI datasets. Overall there was a trend towards an increase in the use of antidepressants across all age, sex and ethnic groups, but notable variation in dispensing between different ethnic and socioeconomic groups. Despite our inability to determine the clinical rationale for increased dispensing of antidepressants, the available data highlight some potentially significant improvements as well as disparities in healthcare.