Impact of Changes to Concealed-Carry Weapons Laws on Fatal and Nonfatal Violent Crime, 1980-2019.

The United States faces rapidly rising rates of violent crime committed with firearms. In this study, we sought to estimate the impact of changes to laws that regulate the concealed carrying of weapons (concealed-carry weapons (CCW) laws) on violent crimes committed with a firearm. We used augmented synthetic control models and random-effects meta-analyses to estimate state-specific effects and the average effect of adopting shall-issue CCW permitting laws on rates of 6 violent crimes: homicide with a gun, homicide by other means, aggravated assault with a gun, aggravated assault with a knife, robbery with a gun, and robbery with a knife. The average effects were stratified according to the presence or absence of several shall-issue permit provisions. Adoption of a shall-issue CCW law was associated with a 9.5% increase in rates of assault with a firearm during the first 10 years after law adoption and was associated with an 8.8% increase in rates of homicide by other means. When shall-issue laws allowed violent misdemeanants to acquire CCW permits, the laws were associated with higher rates of gun assaults. It is likely that adoption of shall-issue CCW laws has increased rates of nonfatal violent crime committed with firearms. Harmful effects of shall-issue laws are most clear when provisions intended to reduce risks associated with civilian gun-carrying are absent.

Is the healthy start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom?

BACKGROUND: Healthy Start is a food assistance programme in the United Kingdom (UK) which aims to provide a nutritional safety-net and enable low-income families on welfare benefits to access a healthier diet through the provision of food vouchers. Healthy Start was launched in 2006 but remains under-evaluated. This study aims to determine whether participation in the Healthy Start scheme is associated with differences in food expenditure in a nationally representative sample of households in the UK. METHODS: Cross-sectional analyses of the Living Costs and Food Survey dataset (2010-2017). All households with a child (0-3 years) or pregnant woman were included in the analysis (n = 4869). Multivariable quantile regression compared the expenditure and quantity of fruit and vegetables (FV), infant formula and total food purchases. Four exposure groups were defined based on eligibility, participation and income (Healthy Start Participating, Eligible Non-participating, Nearly Eligible low-income and Ineligible high-income households). RESULTS: Of 876 eligible households, 54% participated in Healthy Start. No statistically significant differences were found in FV or total food purchases between participating and eligible non-participating households, but infant formula purchases were lower in Healthy Start participating households. Ineligible higher-income households had higher purchases of FV. CONCLUSION: This study did not find evidence of an association between Healthy Start participation and FV expenditure. Moreover, inequalities in FV purchasing persist in the UK. Higher participation and increased voucher value may help to improve programme performance and counteract the harmful effects of poverty on diet.

Impact of public hospital pricing reform on medical expenditure structure in Jiangsu, China: a synthetic control analysis.

BACKGROUND: The synthetic control method (SCM) is a useful tool in providing unbiased analysis on the policy effect in real-world health policy evaluations. Through controlling for a few confounding factors, we aim to apply SCM in analyzing the impact of the pricing reform on medical expenditure structure in Jiangsu Province, China. METHODS: We constructed a synthetic control for Zhenjiang, a city where the reform was piloted in Jiangsu, by selecting weights on those potential control units to define a linear combination of the control outcomes to replicate the counterfactual as if the intervention is in absence. The policy effect was measured by the differences in the percentage of drug expenditure among average outpatient and inpatient care cost per visit in the post-policy period between Zhenjiang and its synthetic control. We also examined the significance of the estimated results by performing placebo tests, and cross-validated the results with a difference-in-differences analysis. RESULTS: The medical pricing reform was found to be effective in reducing the drug expenditure proportions in both outpatient and inpatient care by an estimated mean level of 7.7 and 3.2% (or 16.3 and 9.2% relative decrease to their 2012 levels) respectively. This reform effect was estimated to be significant in the placebo tests and was further confirmed by a cross-validation. CONCLUSION: We conclude that the pricing reform in public hospitals has significantly reduced drug expenditure incurred in both outpatient and inpatient care. This study also highlights the applicability of SCM method as an effective tool for health policy evaluation using publicly available data in the context of Chinese healthcare system.

Centralisation of acute stroke services in London: Impact evaluation using two treatment groups.

The bundling of clinical expertise in centralised treatment centres is considered an effective intervention to improve quality and efficiency of acute stroke care. In 2010, 8 London Trusts were converted into Hyper Acute Stroke Units. The intention was to discontinue acute stroke services in 22 London hospitals. However, in reality, provision of services declined only gradually, and 2 years later, 15% of all patients were still treated in Trusts without a Hyper Acute Stroke Unit. This study evaluates the impact of centralising London's stroke care on 7 process and outcome indicators using a difference-in-difference analysis with two treatment groups, Hyper Acute and discontinued London Trusts, and data on all stroke patients recorded in the hospital episode statistics database from April 2006 to April 2014. The policy resulted in improved thrombolysis treatment and lower rates of pneumonia in acute units. However, 6 indicators worsened in the Trusts that were meant to discontinue services, including deaths within 7 and 30 days, readmissions, brain scan rates, and thrombolysis treatment. The reasons for these results are difficult to uncover and could be related to differences in patient complexity, data recording, or quality of care. The findings highlight that actual implementation of centralisation policies needs careful monitoring and evaluation.

Effects of a Diagnosis-Related Group Payment Reform on Length and Costs of Hospitalization in Sichuan, China: A Synthetic Control Study.

Background: Diagnosis-related group (DRG) payment policies are increasingly recognized as crucial instruments for addressing health care overprovision and escalating health care costs. The synthetic control method (SCM) has emerged as a robust tool for evaluating the efficacy of health policies worldwide. Methods: This study focused on Panzhihua city in Sichuan Province, a pilot city for DRG payment reform implementation, serving as the treatment group. In contrast, 20 nonpilot cities within the province were utilized as potential control units. A counterfactual control group was constructed to evaluate the changes in average inpatient stay duration and health care organization costs following the DRG payment reform initiated in 2018. Results: Focusing on Panzhihua, Sichuan Province, the analysis reveals that following the reform in March 2018, the average length of hospital stay in Panzhihua decreased by 1.35 days during 2019-2021. Additionally, the average cost per hospitalization dropped by 855.48 RMB, the average cost of medication per hospitalization decreased by 68.51 RMB, and the average cost of diagnostic and therapeutic procedures per hospitalization declined by 136.37 RMB. While global evidence backs DRGs for efficiency and cost reduction, challenges persist in addressing emerging issues like new conditions. Conclusion: Since its introduction in 2018, the DRG payment reform in Sichuan Province has effectively reduced both the duration of hospital stays and the operational costs of health care facilities. However, potential drawbacks include compromised service quality and an elevated risk of patient readmission, indicating a need for further refinement in the implementation of DRG payment reforms in China.

Evaluating health policies with subnational disparities: a text-mining analysis of the Urban Employee Basic Medical Insurance Scheme in China.

Subnational disparities in most health systems often defy 'one-size-fits-all' approach in policy implementation. When local authorities implement a national policy in a decentralized context, they behave as a strategic policy actor in specifying the central mandates, selecting appropriate tools and setting key implementation parameters. Local policy discretion leads to diverse policy mixes across regions, thus complicating evidence-based evaluations of policy impacts. When measuring complex policy reforms, mainstream policy evaluation methodologies have tended to adopt simplified policy proxies that often disguise distinct policy choices across localities, leaving the heterogeneous effects of the same generic policy largely unknown. Using the emerging 'text-as-data' methodology and drawing from subnational policy documents, this study developed a novel approach to policy measurement through analysing policy big data. We applied this approach to examine the impacts of China's Urban Employee Basic Medical Insurance (UEBMI) on individuals' out-of-pocket (OOP) spending. We found substantial disparities in policy choices across prefectures when categorizing the UEBMI policy framework into benefit-expansion and cost-containment reforms. Overall, the UEBMI policies lowered enrollees' OOP spending in prefectures that embraced both benefit-expansion and cost-containment reforms. In contrast, the policies produced ill effects on OOP spending of UEBMI enrollees and uninsured workers in prefectures that carried out only benefit-expansion or cost-containment reforms. The micro-level impacts of UEBMI enrolment on OOP spending were conditional on whether prefectural benefit-expansion and cost-containment reforms were undertaken in concert. Only in prefectures that promulgated both types of reforms did UEBMI enrolment reduce OOP spending. These findings contribute to a comprehensive text-mining measurement approach to locally diverse policy efforts and an integration of macro-level policy analysis and micro-level individual analysis. Contextualizing policy measurements would improve the methodological rigour of health policy evaluations. This paper concludes with implications for health policymakers in China and beyond.

Does integrated care mean fewer hospitalizations? An evaluation of a French field experiment.

This study aims to evaluate the impact of an experimental healthcare policy on hospital use among elderly patients. From 2015 to 2017, French public authorities implemented an integrated care model, the Digital Health Territories (Territoire de Soins Numérique (TSN)) programme designed to improve healthcare coordination and sustain the use of health information (HI) technologies. The TSN programme was expected to reduce hospital healthcare utilization. In the Aquitaine region, the TSN programme was implemented in part of the Landes district and primarily consisted of the creation of a support platform (PTA). Part of the Lot-et-Garonne district was chosen as a "control area" due to its similarities to the experimental district in terms of the population structure and healthcare supply characteristics. In the control area, no integrated care model innovation was implemented over the study period. Using claims data from the French National Health Insurance (Système National d'Information Inter-Régimes de l'Assurance Maladie (SNIIRAM)), the healthcare utilization of the populations living in the experimental and control areas was tracked from 2012 to 2017. To estimate the impact of the TSN programme on three hospitalization outcomes, we used a combination of matching and difference-in-differences (DiD) approaches. The TSN programme shows a significant but weak negative impact on emergency department (ED) visits and no significant impact on 30-day re-hospitalizations (R30) or potentially avoidable hospitalizations (PAHs).

Can case-based payment contain healthcare costs? - A curious case from China.

We adopted a difference-in-difference (DID) design to evaluate the impact of a case-based payment pilot in Tianjin, China on hospital admission, utilization of varied therapeutic regimes, and the associated costs. We used claim data of all admissions of angina and acute myocardial infarction during July 2015 to June 2018, 18 months before and after the program. Our analyses were supported by convincing common trends tests and a couple of sensitivity analyses. As intended, for patients who received percutaneous coronary stenting (PCS) and were counted in the case-based payment system, we showed that the program decreased length-of-stay, per-admission spending, and out-of-pocket spending by 20.8%, 14.2%, and 95.5%, respectively, but did not increase readmissions. However, when considering all patients who suffered from the two types of coronary heart diseases, we found that the program otherwise increased per-admission spending by nearly 11%. As a result, the program took a perverse effect in increasing monthly spending for the health insurance scheme and the society by 1005.6 thousand USD (47·5%) and 1095·7 thousand USD (34·7%), respectively. Increases in hospital admissions, and proportion of performing PCS accounted for 66·7% and 39·2% of the rise, respectively. In addition, our analysis provided evidence of health providers' cream-skimming behaviors, including selecting younger patients with lower CCI in the case-based system, up-coding complications, and keeping higher cost patients in the fee-for-service payment system. We draw lessons that case-based payment may make an unintended impact that increases healthcare costs when incentives are not properly designed.

Chronic Opioid Therapy Utilization Following an Acute Pain Prescription Supply Restriction Law: An Interrupted Time Series Analysis.

BACKGROUND: Florida House Bill 21 (HB21) was implemented in July 2018 to limit Schedule II opioids prescriptions for patients with acute pain to a 3-day supply. Little is known about the potential unintended effects that such opioid restriction policies may have on chronic pain patients, who are exempt from the law. OBJECTIVE: We aimed to evaluate the effect of HB21 on opioid utilization measures among a cohort of chronic opioid therapy (COT) patients. STUDY DESIGN: A quasi-experimental design with interrupted time series analyses. SETTING: Pharmacy claims from January 1, 2015 to June 31, 2019 from a large employer-based health plan in Florida. METHODS: COT patients were those who received a ≥ 70 days' supply of opioids in the prior 90 days, representing 15,310 patients. Interrupted time series analyses were conducted to compare the following monthly measures among COT patients before and after HB21 implementation: 1) number of COT patients, 2) daily Morphine Milligram Equivalents [MMEs], 3) days' supply of prescriptions. RESULTS: There was a significant 25% reduction in the trend (pre-HB21 RR: 0.95, 95% CI: 0.93, 0.96 versus post-HB21 RR: 0.70, 95% CI: 0.65, 0.76) and an 8% immediate decrease (RR: 0.92, 95% CI: 0.88, 0.97) in the monthly prevalence of COT patients after HB21 implementation. However, no significant change was observed in trends for monthly number of days supplied per prescription, monthly MMEs per COT patient-day, or total MMEs per prescription. LIMITATIONS: Our study used data from employer-based private health insurance and did not include a longer post-policy period to adjust for implementation lag. CONCLUSION: Fewer patients received COT after HB21; however, patients who continued to receive COT experienced no significant changes in their regimen. The study did not assess whether COT patients were appropriately tapered or if therapeutic alternatives were initiated for new chronic pain patients.

Effects of Activity-Based Hospital Payments in Israel: A Qualitative Evaluation Focusing on the Perspectives of Hospital Managers and Physicians.

BACKGROUND: Since 2010, Israel has expanded the adoption of procedure-related group (PRG) based payments for hospitals. While there is a rich quantitative literature that assesses the effects of payment reforms on efficiency or quality of care, very few qualitative studies have focused on the impacts of diagnosis-related group (DRG)-like payments on hospitals from the perspective of hospital workers as change agents. METHODS: We used a qualitative, thematic analysis based on 33 semi-structured in-depth interviews with chief executive officers (CEOs), chief financial officers (CFOs), ward directors and physicians conducted in five public hospitals in Israel, sampled by maximum variation according to hospital characteristics. RESULTS: Interviewees reported that the payment reform led to organizational changes such as increased transparency and enhanced supervision. Interviewees also reported several actions in response to the economic incentives of PRG-based payment. These included (1) shifting activities to afterhours and using operating rooms (ORs) more efficiently to enable increased surgical volumes; (2) reducing costs by shortening lengths of stay and increasing cost-consciousness in procurement; and (3) increasing revenues by improving coding and selecting procedures. Moderating factors reduced the effects of the reform. For example, organizational factors such as the public nature of hospitals or the (un)availability of healthcare resources did not always allow hospitals to increase the number of cases treated. Also, conflicting incentives such as multiple payment mechanisms or underpricing of procedures blurred the incentives of the reform. Finally, managers and physicians have many other considerations that outweigh the economic ones. CONCLUSION: PRG payments affected the organizational dynamics of hospitals and changed decision-making about admission and treatment policies. However, such effects were moderated by many other factors that should be considered when shaping and analyzing hospital payment reforms.

Population-based organized screening by faecal immunochemical testing and colorectal cancer mortality: a natural experiment.

BACKGROUND: Population-based organized screening programmes for colorectal cancer (CRC) are underway worldwide, with many based on the faecal immunochemical test (FIT). No clinical trials assessing FIT compared with no screening are planned, and few studies have assessed the population impact of such programmes. METHODS: Before 2010, 11 out of 50 Spanish provinces initiated population-based organized screening programmes with FIT for an average-risk population aged 50-69 years. We used a quasi-experimental design across Spanish provinces between 1999 and 2016 to evaluate their impact on population age-standardized mortality and incidence rates due to CRC. Difference-in-differences and synthetic control analyses were performed to test for validation of statistical assumptions and to assess the dynamics of screening-associated changes in outcomes over time. RESULTS: No differences in outcome trends between exposed (n = 11) and control (n = 36) provinces were observed for up to 7 years preceding the implementation of screening. Relative to controls, exposed provinces experienced a mean increase in age-standardized incidence of 10.08% [95% confidence interval (CI) (5.09, 15.07)] 2 years after implementation, followed by a reduction in age-standardized mortality rates due to CRC of 8.82% [95% CI (3.77, 13.86)] after 7 years. Results were similar for both women and men. No associated changes were observed in adjacent age bands not targeted by screening, nor for 10 other major causes of death in the exposed provinces. CONCLUSIONS: FIT-based organized screening in Spain was associated with reductions in population colorectal cancer mortality. Further research is warranted in order to assess the replicability and external validity of our findings, and on gender-specific use of FIT in organized screening.

Políticas de Promoção de Equidade em Saúde para grupos vulneráveis: o papel do Ministério da Saúde / Equity Promotion Policies in Health for vulnerable groups: the role of the Ministry of Health

Resumo Este artigo analisa as Políticas de Promoção de Equidade em Saúde implementadas pelo Ministério da Saúde para grupos vulneráveis, através da Coordenação da Secretaria de Gestão Estratégia e Participativa, em decorrência de marcadores de raça, etnia, gênero e modo de vida. São identificados os três elementos estruturantes destas políticas: gestão participativa, transversalidade e sensibilização/qualificação profissional. Para a realização do trabalho foram consultadas diversas fontes documentais: políticas, vídeos, conferências, e atas de conselhos e comissões de saúde. Os resultados apontam aspectos virtuosos e lacunas no processo de implementação destas políticas. Revelam ainda que as tensões permanentes entre políticas de igualdade e políticas de equidade colocam desafios à garantia dos direitos à saúde destas populações. Por fim, ressalta-se que somente em sociedades democráticas estes direitos podem ser reconhecidos e assegurados.

Abstract This article aims to analyze Equity Promotion Policies in Health implemented by the Ministry of Health for vulnerable groups, through the Department of Strategy and Participative Management based on race, ethnicity, gender and lifestyle markers. The three structural elements of these policies are identified as: participatory management, transversality and awareness / professional qualifications. In carrying out research for this article, different documental sources were used including: policies, videos, conferences and minutes from council meetings as well as information from health committees. The results showed positive aspects and shortcomings in the implementation process of these policies. Also, they revealed that there are permanent tensions between equality policies and equity policies which pose challenges to guaranteeing the right to health of these populations. Finally, it can be reaffirmed that only in democratic societies can these rights be recognized and guaranteed.

Monitoring and evaluation of the PAHO/WHO cooperation project, the Mais Médicos (More Doctors) Program: a mid-term assessment / Monitoramento e avaliação do Projeto de Cooperação da OPAS/OMS com o Programa Mais Médicos: reflexões a meio caminho

As relações de trabalho entre a Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/OMS) e as instituições de saúde do Brasil têm uma longa história de cooperação com benefícios mútuos que, em muitos casos, foram compartilhados com outras nações sob diversos enfoques de cooperação entre os países para o desenvolvimento da saúde. Um marco nesta relação é a cooperação técnica prestada ao Programa Mais Médicos (PMM). Esta cooperação agrega valor estratégico na redução das lacunas em matéria de igualdade de saúde e capitaliza a natureza única da experiência de cooperação Sul-Sul entre Cuba e Brasil, triangulada através da OPAS/OMS. Este artigo discute o papel da OPAS/OMS na avaliação da sua cooperação técnica com o PMM. Foi desenvolvido um marco de monitoramento e avaliação, visando identificar progressivamente os avanços na cobertura e qualidade dos serviços de atenção básica proporcionados pelo Sistema Único de Saúde (SUS) por meio do PMM. Especial atenção foi dedicada à identificação das melhores práticas nos serviços de saúde, à análise dos resultados e impactos do PMM, e à gestão e divulgação dos conhecimentos produzidos pela sua implementação, através de plataforma de conhecimento. Alguns resultados relevantes do PMM são sinteticamente apresentados e discutidos.

Working relations between the Pan- American Health Organization/World Health Organization (PAHO/WHO) and Brazilian health institutions accumulated a long history of cooperation with mutual benefits, which in many cases were shared with other nations under various cooperation frameworks among countries for health development. A milestone in this relationship is the technical cooperation provided by PAHO/WHO to the More Doctors Program (Programa Mais Médicos - PMM). This cooperation has added both strategic value in reducing gaps in health equality and has capitalized on the unique nature of the Cuba-Brazil South-South cooperation experience, triangulated through PAHO/WHO. This paper discusses PAHO/WHO’s role in the evaluation of its technical cooperation within PMM. A Monitoring and Evaluation (M&E) Framework has been developed in order to progressively identify the advances in coverage and quality of primary health care provided by the Unified Health System (Sistema Único de Saúde - SUS) through the PMM. Special attention was given to identify best practices in health services, to analyze results and impacts of the PMM, and to manage and share knowledge that has been produced by its implementation, through a web-based knowledge platform. Some relevant results of PMM are briefly presented and discussed.