Experience-based health state valuation using the EQ VAS: a register-based study of the EQ-5D-3L among nine patient groups in Sweden.

BACKGROUND: The EQ VAS component of the EQ-5D questionnaire has been used to assess patients' valuation of their own health besides its use for self-reporting of overall health status. The objective of the present study was to identify patients' valuation of EQ-5D-3L health states using the EQ VAS in different patient groups over time and in comparison to the general population. METHODS: Data were obtained from patients from nine National Quality Registers (n = 172,070 patients) at baseline and at 1-year follow-up and compared with data from the general population (n = 41,761 participants). The correlation between EQ VAS scores and EQ-5D-3L index based on the Swedish experience-based VAS value set was assessed. Ordinary least squares (OLS) regression models were used to determine the association between EQ-5D-3L dimensions and EQ VAS valuation. RESULTS: EQ VAS scores showed consistency with severity of health states both at baseline and at 1-year follow-up in the nine selected EQ-5D-3L health states. The regression models showed mostly consistent decrements by severity levels in each dimension at both time points and similar to the general population. The dimension mainly associated with inconsistency was the self-care severity level three. Problems in the anxiety/depression dimension had the largest impact on overall health status in most of the patient groups and the general population. CONCLUSION: The study has demonstrated the important role EQ VAS can play in revealing patients' valuation of their health and showed the variation in valuation of EQ-5D-3L dimensions and levels of severity across different patient groups.

Use of the visual analogue scale for health state valuation: a scoping review.

OBJECTIVES: The visual analogue scale (VAS) has been used in the context of health and healthcare for various purposes, for example, to measure pain and to provide a single-index measure of health-related quality of life (HRQoL). This scoping review aims to describe how the VAS has been used for health state valuation in the published literature. METHODS: The search was carried out in Medline, Web of Science and PsycInfo. The findings of the included articles were tabulated and presented descriptively using frequencies and proportions. RESULTS: The database search yielded 4856 unique articles, out of these, 308 were included. In 83% of the articles, the main purpose for using a VAS was to value health states. The two most common perspectives when valuing health states with a VAS were hypothetical (44%) and own health (34%). Some (n = 14) articles used the VAS in the context of economic evaluations, including calculating quality-adjusted life years (QALYs). A large variation in the design of the VAS was found, including the description of the lower and upper anchors. Advantages and disadvantages with using a VAS were mentioned in 14% of the included articles. CONCLUSION: The VAS has been a common method for valuing health states, both as a stand-alone method and in combination with other valuation methods. Despite its widespread use, the design of the VAS has been inconsistent which makes comparison of results across studies challenging. Further research on the role of using the VAS in economic evaluations is warranted.

'Like holding the axe on who should live or not': adolescents' and adults' perceptions of valuing children's health states using a standardised valuation protocol for the EQ-5D-Y-3L.

PURPOSE: There is an increasing interest for using qualitative methods to investigate peoples' cognitive process when asked to value health states. A standardised valuation protocol for the EQ-5D-Y-3L instrument was recently developed. Little is known regarding how people think, reason, and feel when asked to value health states for children. The aim was to explore how adolescents and adults perceive the task of valuing children's health states using the standardised valuation protocol. METHODS: This was a qualitative study where adults (n = 10) and adolescents (n = 10) from the general population participated in individual video-interviews. Initially, participants reported their own health with the EQ-5D-3L instrument. Then they were asked to complete several valuations tasks for a 10-year-old child according to the standardised valuation protocol, followed by a semi-structured interview with open-ended questions to further explore participants' perceptions. A qualitative content analysis was performed. RESULTS: The two main categories that emerged from the data were 'Thoughts and feelings when valuing children's health states' and 'Strategies when valuing children's health states'. Participants expressed feeling doubt, awfulness and being reluctant to trade-off life years, and questioned who has the right to value health states for children. Experience and point of view were strategies participants used to complete the valuation tasks. CONCLUSION: The findings from the present study can contribute to the understanding and interpretation of quantitative results where the standardised valuation protocol has been used to derive values for the EQ-5D-Y-3L. Furthermore, results of the study support the feasibility of including adolescents in valuation studies.

Inequality and heterogeneity in health-related quality of life: findings based on a large sample of cross-sectional EQ-5D-5L data from the Swedish general population.

PURPOSE: This study aimed to investigate inequality and heterogeneity in health-related quality of life (HRQoL) and to provide EQ-5D-5L population reference data for Sweden. METHODS: Based on a large Swedish population-based survey, 25,867 respondents aged 30‒104 years, HRQoL is described by sex, age, education, income, economic activity, health-related behaviours, self-reported diseases and conditions. Results are presented by EQ-5D-5L dimensions, respondents rating of their overall health on the EQ visual analogue scale (EQ VAS), VAS index value and TTO (time trade-off) index value allowing for calculation of quality-adjusted life years (QALYs). Ordinary Least Squares and multivariable logistic regression analyses were used to study inequalities in observed EQ VAS score between socioeconomic groups and the likelihood to report problems on the dimensions, respectively, adjusted for confounders. RESULTS: In total, 896 different health states were reported; 24.1% did not report any problems. Most problems were reported with pain/discomfort. Women reported worse HRQoL than men, and health deteriorated with age. The strongest association between diseases and conditions and EQ VAS score was seen for depression and mental health problems. There was a socioeconomic gradient in HRQoL; adjusting for health-related behaviours, diseases and conditions slightly reduced the differences between educational groups and income groups, but socioeconomic inequalities largely remained. CONCLUSION: EQ-5D-5L population reference (norms) data are now available for Sweden, including socioeconomic differentials. Results may be used for comparisons with disease-specific populations and in health economic evaluations. The observed socioeconomic inequality in HRQoL should be of great importance for policy makers concerned with equity aspects.

Validation of the patient-reported experience measure for care in Chinese hospitals (PREM-CCH).

BACKGROUND: A psychometrically validated instrument to measure patient experience in Chinese public hospitals would be useful and is currently lacking. Our research team developed the Patient-Reported Experience Measure for Care in Chinese Hospitals (PREM-CCH). We aimed to validate this PREM-CCH in the present study. METHODS: Data were drawn from a cross-sectional patient survey in 2016. Complete responses from 2293 outpatients and 1510 inpatients were included. Separate psychometric evaluation was carried out on outpatient and inpatient PREM-CCHs in terms of exploratory factor analysis, internal consistency, construct validity and criterion validity. RESULTS: The validated outpatient PREM-CCH contained 22 items and five Factors, i.e. Communication and information, Professional competence, Medical costs, Efficiency, and Hospital recommendation. The validated inpatient PREM-CCH contained 19 items and six Factors, i.e. Communication and information, Professional competence, Medical costs, Efficiency, Health outcomes, and Hospital recommendation. The PREM-CCH showed satisfactory internal consistency, construct validity and criterion validity. CONCLUSIONS: The PREM-CCH is one of the first validated instruments capturing patient experience of care in the context of Chinese public hospitals. It performed well in the psychometric evaluation. It consists of a basic set of items important to patients that could be applicable to public hospitals in China and actionable to inform quality improvement initiatives.

Acceptability of the health-related quality of life instrument EQ-5D-Y-5L among patients in child and adolescent psychiatric inpatient care.

AIM: The generic EuroQol 5 Dimensions Youth 5 Level (EQ-5D-Y-5L) measures health-related quality of life among children from 8 years. Respondents report their health on five dimensions with five severity levels and rate their overall health on a visual analogue scale (EQ VAS). The aim of the study was to explore acceptability of the EQ-5D-Y-5L instrument among patients in child and adolescent psychiatric inpatient care. METHODS: A convenience sample of patients within a psychiatric inpatient care clinic in Region Stockholm, Sweden, was used. Follow-up questions were answered directly after filling in the EQ-5D-Y-5L. Conventional qualitative content analysis was chosen to analyse the open-ended questions on how they perceived answering the instrument. RESULTS: In total, 52 patients (83% girls), mean age 15.4 years (range 13-17), were included. Three themes emerged: generic content of the EQ-5D-Y-5L descriptive system; design and wording of the EQ-5D-Y-5L descriptive system and the EQ VAS; self-reporting health with the EQ-5D-Y-5L descriptive system and the EQ VAS. CONCLUSION: The inclusion of physical health dimensions was perceived as positive, but some patients considered the descriptive system too generic. The results indicate that these patients in general could self-report their health in a meaningful way with the EQ-5D-Y-5L instrument.

EQ-5D-Y-5L as a patient-reported outcome measure in psychiatric inpatient care for children and adolescents - a cross-sectional study.

BACKGROUND: Psychiatric disorders have a major individual and societal impact. Until now, the association between health-related quality of life and physical disorders has been far more investigated than the association with psychiatric disorders. Patient-reported outcome measures makes it possible to capture the patient perspective to improve treatments and evaluate treatment outcomes. The aim of this study is to measure health-related quality of life with the EQ-5D-Y-5L among patients in child and adolescent psychiatric inpatient care and to test the instrument's psychometric properties in terms of feasibility and construct validity. METHODS: Data were collected at the child and adolescent psychiatric inpatient facility in Region Stockholm. A questionnaire including the EQ-5D-Y-5L instrument, the Strengths and Difficulties Questionnaire with an impact supplement and a self-rated health question, was administered for self-completion using paper and pencil, with an interviewer present. The Chi-square test was used to investigate differences in proportion of reported problems in the EQ-5D-Y-5L dimensions and the Mann-Whitney U test was used for differences in mean EQ VAS scores. Feasibility was assessed by investigating proportion of missing and ambiguous answers and Spearman's and Pearson's correlation were used to examine construct validity. RESULTS: In total 52 adolescents participated in the study and the majority were girls. The most common diagnosis at admission was depressive episode/recurrent depressive disorder. All participants reported problems on at least one dimension. Most problems were reported in the dimension 'feeling worried, sad or unhappy', where 64% reported severe or extreme problems. Mean EQ VAS score was 29.2. Feasibility was supported and construct validity indicated as some of the hypothesised correlations between the EQ-5D-Y-5 L and the Strengths and Difficulties Questionnaire were found, however, for 'doing usual activities' and 'having pain or discomfort' the correlations were weaker than hypothesised. CONCLUSIONS: This is the first study where the newly developed EQ-5D-Y-5L instrument has been used in psychiatric inpatient care for youth. Participants reported problems in all severity levels in most of the EQ-5D-Y-5L dimensions; mean EQ VAS score was considerably low. Feasibility of the EQ-5D-Y-5L was supported, however other psychometric properties need to be further tested in a larger sample.

Reporting and valuing one's own health: a think aloud study using EQ-5D-5L, EQ VAS and a time trade-off question among patients with a chronic condition.

BACKGROUND: The EQ-5D-5L, the EQ VAS, and the time trade-off (TTO) are commonly used to report and value health. Still, there is a need to better understand how these questionnaires and methods are perceived by the respondents, as well as the thoughts and motives behind their responses. The aim of this study was to increase knowledge of how individuals think and reason when reporting and valuing their own current health, using EQ-5D-5L, EQ VAS, and an open-ended TTO question. METHODS: Twenty patients with type 1 diabetes participated in qualitative individual think aloud interviews in Stockholm, Sweden. Participants were asked to describe their thoughts when responding to three assessments. The interviews were transcribed verbatim and analyzed using thematic analysis. RESULTS: The analysis showed that participants conducted the assessments by contextualizing and interpreting instructions, relating the questions to their own health, using different recall periods and time perspectives, and using personal, interpersonal, or normative comparators. It was challenging to reduce the experience of everyday life into a response option, and the thoughts behind the responses differed between the assessments. Before deciding on what to include, participants thought of the purpose and context of the assessments. Current health or past experiences of health were applied in the EQ-5D descriptive system and in EQ VAS, while participants focused on the future in the TTO. Thoughts about the impact on others, personal goals, and expectations on future health were more clearly integrated in the TTO assessment. All participants considered the trade-off between life years and health. However, despite the use of different comparators, the concept of 'full health' was found difficult to imagine or relate to. CONCLUSIONS: This study provides insights as to how responses to the EQ-5D-5L, EQ VAS, and TTO assessments are complementary and where these assessments differ in adults with a chronic condition. The findings may contribute to a better understanding when interpreting the quantitative results and contribute to the literature pertaining to possible explanations for differences in health state values depending on the valuation method.

Influence of elicitation procedure and phrasing on health state valuations in experience-based time trade-off tasks among diabetes patients in China.

PURPOSE: Open-ended and iteration-based time trade-off (TTO) tasks can both be used for valuation of health states. It has so far not been examined how the elicitation procedure affects the valuation of experience-based health states. The purpose of this study is to investigate the influence of elicitation procedure on experience-based health state values elicited by the TTO method. METHODS: 156 Chinese adults with type 2 diabetes participated in face-to-face interviews with an open-ended or an iteration-based TTO task. The association between the type of TTO task and the valuation of health states was investigated through multiple linear regression analyses. A modified open-ended TTO task was also developed (n = 33) to test whether different phrasings of open-ended TTO tasks influence TTO values. RESULTS: Higher TTO values were observed in the original open-ended TTO task compared to the iteration-based task, which indicates that the elicitation procedure influences the valuation of health states. When the modified open-ended task was introduced, the difference between the two elicitation procedures was no longer statistically significant, suggesting that the phrasing and/or visual presentation of the TTO task may influence the valuation of health states. CONCLUSIONS: The choice of elicitation procedure as well as the description of experience-based TTO tasks may influence the valuation of health states. Further research is warranted, also in other cultural contexts, to further explore these findings.

Whom should we ask? A systematic literature review of the arguments regarding the most accurate source of information for valuation of health states.

PURPOSE: To determine and critically evaluate the arguments in the published literature regarding the most accurate source of information for valuation of health states: values based on experienced health states (patient values) or values based on described health states (general public values).

Healthcare utilisation and measles, mumps and rubella vaccination rates among children with an extended postnatal home visiting programme in a disadvantaged area in Stockholm, Sweden-A 3-year follow-up.

AIM: To follow up healthcare utilisation and measles, mumps and rubella (MMR) vaccination rates among children 0-36 months, receiving an extended postnatal home visiting programme in a disadvantaged area with poorer child health, and in control groups, in Stockholm, Sweden. METHODS: We analysed electronic child health records regarding outpatient visits, inpatient episodes and MMR vaccination for children 0-36 months receiving the home visiting programme (Intervention Group) and in control groups (Control Group and Rinkeby Comparison Group). RESULTS: Children in the Intervention Group had significantly higher MMR vaccination rate than children in the Rinkeby Comparison Group. Healthcare utilisation was similar in the Intervention Group and the control groups. In stratified analyses by number of home visits received, children receiving the recommended six home visits had significantly fewer inpatient episodes and somewhat fewer emergency visits than those receiving fewer home visits. CONCLUSION: The extended home visiting programme had a positive impact on the MMR vaccination rate. Children receiving the recommended six home visits had lower use of inpatient care. In addition to being positively perceived by parents in an area with greater healthcare needs, the programme may have a positive impact on their children's healthcare utilisation.

Predictive ability of the American Society of Anaesthesiologists physical status classification system on health-related quality of life of patients after total hip replacement: comparisons across eight EQ-5D-3L value sets.

BACKGROUND: American Society of Anaesthesiologists (ASA) physical status classification system and its association with postoperative outcomes has been studied in different diseases. However, there is a paucity of studies on the relationship between ASA class and postoperative health-related quality of life (HRQoL) outcomes following total hip replacement (THR). The aim of this study was to assess the discriminative abilities of EQ-5D-3L value sets from Sweden, Germany, Denmark and the United Kingdom in relation to ASA classes and these value sets' abilities to show the predictive performance of ASA classes on HRQoL among THR patients in Sweden. METHODS: A longitudinal study was conducted using data of patients in the Swedish Hip Arthroplasty Register who underwent THR between 2008 and 2016. We included 69,290 pre- and 1-year postoperative records and 21,305 6-year postoperative records. The study examined three experience-based EQ-5D-3L value sets (the Swedish VAS and TTO and the German VAS) and five hypothetical value sets (TTO from Germany and VAS and TTO value sets from Denmark and the UK each). Using linear models, the abilities of the value sets to discriminate among ASA classes and to show the predictive performance of ASA classes on HRQoL score were assessed. RESULTS: All value sets differentiated among ASA classes and showed the predictive effect of ASA classes on HRQoL. ASA classes were found to predict HRQoL consistently for all value sets investigated, with small variations in prediction error among the models. CONCLUSION: ASA classes of patients undergoing THR predicted HRQoL scores significantly and consistently, indicating their importance in tailoring care for patients.

How do EQ-5D-3L and EQ-5D-5L compare in a Swedish total hip replacement population?

Background and purpose - To better detect small changes in postoperative outcome following total hip replacement (THR), the Swedish Hip Arthroplasty Register (SHAR) has decided to change from the EQ-5D-3L (3L) to the EQ-5D-5L (5L). To enable comparison of results obtained with use of the 2 versions of EQ-5D, transferal of results between the questionnaires used is necessary. We assessed the measurement properties of the EQ-5D-5L compared with the EQ-5D-3L, preoperatively and 1-year postoperatively in a Swedish THR population.Patients and methods - Patients eligible for elective THR during 2015 in Western Sweden were invited to the study. With a 2-week separation, the 3L and 5L questionnaires were administered to patients before and 1 year after surgery. Comparing the 2 versions of the EQ-5D, we investigated redistribution of responses, ceiling and floor effects, EQ VAS correlations (Spearman's rank correlation coefficient, rs), and EQ VAS scores for different severity levels by dimension (univariable ordinary least square regression).Results - The additional severity levels of the 5L version were frequently used on both measurement occasions (preoperative mobility 5%, self-care 17%, usual activities 20%, pain 5% and anxiety 3%, postoperative mobility 6%, self-care 5%, usual activities 8%, pain 9%, and anxiety 5%). Ceiling effects of the 3L version diminished overall by 7% using the 5L version. The correlations between the 2 EQ VAS scores obtained with the 3L and 5L instruments were strong both pre- (rs = 0.71) and postoperatively (rs = 0.87). Estimated EQ VAS scores for different levels of severity were consistent for all dimensions except for the mobility dimension of the preoperative 5L version and the anxiety dimension in the postoperative 5L version.Interpretation - Our findings support that the 5L has a higher resolution than the 3L version regarding description of health-related quality of life in patients undergoing THR in Sweden. The EQ VAS scores for different levels of severity agree well between the EQ-5D versions. This could potentially be used to develop a crosswalk value set for transforming 3L to 5L responses in this patient group.

Exploring pathways to outpatients' satisfaction with health care in Chinese public hospitals in urban and rural areas using patient-reported experiences.

BACKGROUND: This study aimed to measure outpatients' general satisfaction with and experiences of different aspects of health care in Chinese public hospitals and to investigate to what extent general satisfaction could be explained by patients' experiences in public hospitals located at urban and rural areas. METHODS: Data on 4782 outpatients were derived from a patient survey in 9 city-level (urban) and 16 county-level (rural) public hospitals across China in 2016. According to Donabedian's model, questions on patients' experiences were categorized into six aspects under "structure" and "process", with general satisfaction representing "outcome". The Chi-square tests were used to test the differences in patients' experiences and general satisfaction between urban and rural areas. The Partial Least Squares Structural Equation Modeling (PLS-SEM) was used to estimate effects of patients' experiences on general satisfaction. RESULTS: Compared with respondents in rural areas, there were significantly higher percentages of respondents in urban areas reporting satisfaction and positive experiences in most aspects. As manifested by the path coefficients in PLS models, the positive effect of professional competence (0.197) on general satisfaction was the most significant in respondents at urban areas, followed by communication and information (0.183), and caring attitudes and emotional support (0.174). Among respondents at rural areas, the positive effect of environment facilities (0.199) was the most significant, followed by caring attitudes and emotional support (0.188), and professional competence (0.179). The PLS models explained 44.9 and 46.0% of variations in patient satisfaction at urban and rural areas, respectively. CONCLUSIONS: Levels of patient satisfaction and experiences at Chinese public hospitals were higher in urban than in rural areas. Outpatients' experiences of professional competence, caring attitudes and emotional support were strongly related to their satisfaction in both settings. However, among respondents in urban areas, experiences of communication and information were more strongly related to satisfaction, whereas among respondents in rural areas, experiences of environment and facilities were more strongly related to satisfaction.

EQ-5D-Y-5L: developing a revised EQ-5D-Y with increased response categories.

PURPOSE: EQ-5D-Y is a generic measure of health status for children and adolescents aged 8-15 years. Originally, it has three levels of severity in each dimension (3L). This study aimed to develop a descriptive system of EQ-5D-Y with an increased number of severity levels and to test comprehensibility and feasibility. METHODS: The study was conducted in Germany, Spain, Sweden and the UK. In Phase 1, a review of existing instruments and focus group interviews were carried out to create a pool of possible labels for a modified severity classification. Participants aged 8-15 rated the severity of the identified labels in individual sorting and response scaling interviews. In Phase 2, preliminary 4L and 5L versions were constructed for further testing in cognitive interviews with healthy participants aged 8-15 years and children receiving treatment for a health condition. RESULTS: In Phase 1, a total of 233 labels was generated, ranging from 37 (UK) to 79 labels (Germany). Out of these, 7 to 16 possible labels for each dimension in the different languages were rated in 255 sorting and response scaling interviews. Labels covered an appropriate range of severity on the health continuum in all countries. In Phase 2, the 5L version was generally preferred (by 68-88% of the participants per country) over the 4L version. CONCLUSIONS: This multinational study has provided a version of the EQ-5D-Y with 5 severity levels in each dimension. This extended version (EQ-5D-Y-5L) requires testing its psychometric properties and its performance compared to that of the original EQ-5D-Y-3L.

Time Trade-Off Value Set for EQ-5D-3L Based on a Nationally Representative Chinese Population Survey.

OBJECTIVES: To obtain a nationally representative Chinese three-level EuroQol five-dimensional questionnaire value set based on the time trade-off (TTO) method. METHODS: A multistage, stratified, clustered random nationally representative Chinese sample was used. The study design followed an adapted UK Measurement and Valuation of Health protocol. Each respondent valued 11 random states plus state 33333 and "unconscious" using the TTO method in face-to-face interviews. Three types of models were explored: ordinary least squares, general least squares, and weighted least squares models. RESULTS: In total, 5939 inhabitants aged 15 years and older were interviewed. Of these, 5503 satisfactorily interviewed participants were included in constructing models. An ordinary least squares model including 10 dummies without constant and N3 had a mean absolute error of 0.083 and a correlation coefficient of 0.899 between the predicted and mean values. Goodness-of-fit indices of two models based on split subsample were similar. CONCLUSIONS: TTO values were higher in our study compared with those in a study carried out in urban areas, which is mirrored by the higher values in rural areas. Several other aspects, in addition to the valuation procedure, might have influenced the results, such as factors beyond demographic factors such as view on life and death and believing in an afterlife, which need further investigation. Future studies using the three-level EuroQol five-dimensional questionnaire should consider using this value set based on a nationally representative sample of the Chinese population.

Population health status based on the EQ-5D-Y-3L among adolescents in Sweden: Results by sociodemographic factors and self-reported comorbidity.

PURPOSE: The EQ-5D-Y-3L is a generic health-related quality of life (HRQoL) measure developed for youth from 8 years old. The aim of this study is to present population health status, based on the EQ-5D-Y-3L, among adolescents in Sweden, by sex, age, self-reported comorbidity and parents' occupational status. METHODS: Data were obtained from a cross-sectional total survey among students, aged 13-18 years, in a Swedish County year 2014. The survey included EQ-5D-Y-3L, questions regarding self-reported health, disease, functional impairment and mental distress. Parents' occupational status was used as a proxy for socio-economic status. RESULTS: A total of 6574 participants answered all the EQ-5D-Y-3L dimensions (mean age was 15.9 years, same proportion of boys and girls). Girls reported more problems than boys in the dimensions 'doing usual activities', 'having pain or discomfort' and 'feeling worried, sad or unhappy', and lower mean VAS score. Respondents with one or both parents unemployed reported more problems with usual activities, pain/discomfort and in the mood dimension than those with both parents employed. Those with comorbidity had in general more problems in all dimensions and lower mean VAS score. The highest impact on VAS score was found for adolescents who reported that they always felt depressed. CONCLUSIONS: Sex, age, self-reported comorbidity and parents' occupational status were associated with HRQoL determined by the EQ-5D-Y-3L in the general population of adolescents. The ability of EQ-5D-Y-3L to distinguish adolescents' health status based on these factors confirms the instrument's usefulness in assessment of HRQoL and as guidance for prioritization.

What do patients care most about in China's public hospitals? Interviews with patients in Jiangsu Province.

BACKGROUND: Evaluations on different aspects of the performance of public hospitals in China have been conducted, usually based on indicators developed by literature review and expert suggestions. The patient perspective was not always considered. This study aims to identify what patients care most about in China's public hospitals exclusively from a patient perspective. METHODS: A mix of stratified sampling and typical sampling was used to select 15 public hospitals in Jiangsu Province of China. In each sampled hospital, a convenient sample of six outpatients and six inpatients was selected to conduct face-to-face individual interviews. An interview guide consisting of six open-ended questions was designed. Donabedian's quality of care framework was applied to categorize themes and subthemes, which were generated from patients' interviews by using the conventional content analysis approach. Frequencies of themes and subthemes were counted. RESULTS: Nine key themes were identified regarding patients' concerns about hospital care, which were environment and facilities, professional competence, hospital reputation, and morals of medical staff in the "structure" category of Donabedian's framework, caring attitudes and emotional support, medical costs, communication and information, and efficiency and coordination of care in the "process" category, and health outcomes in the "outcome" category. CONCLUSIONS: This study has identified and prioritized the aspects that patients care most about in China's public hospitals in Jiangsu Province exclusively from a patient perspective. A measurement tool of patient-reported experiences in public hospitals could be built based on this study. Efforts should be made to represent the patient perspective to further improve the reform of public hospitals in China.

Equity aspects of the Primary Health Care Choice Reform in Sweden - a scoping review.

BACKGROUND: Good health and equal health care are the cornerstones of the Swedish Health and Medical Service Act. Recent studies show that the average level of health, measured as longevity, improves in Sweden, however, social inequalities in health remain a major issue. An important issue is how health care services can contribute to reducing inequalities in health, and the impact of a recent Primary Health Care (PHC) Choice Reform in this respect. This paper presents the findings of a review of the existing evidence on impacts of these reforms. METHODS: We reviewed the published accounts (reports and scientific articles) which reported on the impact of the Swedish PHC Choice Reform of 2010 and changes in reimbursement systems, using Donabedian's framework for assessing quality of care in terms of structure, process and outcomes. RESULTS: Since 2010, over 270 new private PHC practices operating for profit have been established throughout the country. One study found that the new establishments had primarily located in the largest cities and urban areas, in socioeconomically more advantaged populations. Another study, adjusting for socioeconomic composition found minor differences. The number of visits to PHC doctors has increased, more so among those with lesser needs of health care. The reform has had a negative impact on the provision of services for persons with complex needs. Opinions of doctors and staff in PHC are mixed, many state that persons with lesser needs are prioritized. Patient satisfaction is largely unchanged. The impact of PHC on population health may be reduced. CONCLUSIONS: The PHC Choice Reform increased the average number of visits, but particularly among those in more affluent groups and with lower health care needs, and has made integrated care for those with complex needs more difficult. Resource allocation to PHC has become more dependent on provider location, patient choice and demand, and less on need of care. On the available evidence, the PHC Choice Reform may have damaged equity of primary health care provision, contrary to the tenets of the Swedish Health and Medical Service Act. This situation needs to be carefully monitored.

Association between social capital and health-related quality of life among left behind and not left behind older people in rural China.

BACKGROUND: The association between social capital and health-related quality of life (HRQoL) has not been thoroughly studied among older persons in rural China, especially among those who were left behind or not. This study investigates the association between social capital and HRQoL and examines possible differences of this association between being left behind or not in rural China. METHODS: A cross-sectional survey of 825 people aged 60 years and older, residing in three rural counties in Jiangsu Province in China, was conducted in 2013. Factor analysis was performed to measure social capital. EQ-5D was used to measure HRQoL. Tobit regression analysis with upper censoring was conducted to explore the association between social capital and EQ-5D index. RESULTS: After controlling for individual characteristics, low social capital and being left behind were significantly associated with low HRQoL. Old people with low social capital had 0.055 lower EQ-5D index compared to those with high social capital. Old people being left behind had 0.040 lower EQ-5D index compared to those who were not left behind. For different dimensions of social capital, the main effects came from the domain of trust and reciprocity. There was a significant interaction between low social capital and being left behind on HRQoL, suggesting that low social capital was associated with low HRQoL among persons left behind. CONCLUSIONS: Our findings indicate that the left behind old people with low social capital were a potentially vulnerable group in rural China. Formulating and implementing initiatives and strategies which increase social capital may foster better HRQoL, especially for old people who were left behind.