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2.
Med Care ; 58(3): 257-264, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32106167

RESUMO

BACKGROUND: Medical care overuse is a significant source of patient harm and wasteful spending. Understanding the drivers of overuse is essential to the design of effective interventions. OBJECTIVE: We tested the association between structural factors of the health care delivery system and regional differences systemic overuse. RESEARCH DESIGN: We conducted a retrospective analysis of deidentified claims for 18- to 64-year-old adults from the IBM MarketScan Commercial Claims and Encounters Database. We calculated a semiannual Johns Hopkins Overuse Index for each of the 375 Metropolitan Statistical Areas in the United States, from January 2011 to June 2015. We fit an ordinary least squares regression to model the Johns Hopkins Overuse Index as a function of regional characteristics of the health care system, adjusted for confounders and time. RESULTS: The supply of regional health care resources was associated with systemic overuse in commercially insured beneficiaries. Regional characteristics associated with systemic overuse included number of physicians per 1000 residents (P=0.001) and higher Medicare malpractice geographic price cost index (P<0.001). Regions with a higher density of primary care physicians (P=0.008) and a higher proportion of hospital-based providers (P=0.016) had less systemic overuse. Differences in hospital and insurer market power were inversely associated with systemic overuse. CONCLUSIONS: Systemic overuse is associated with observable, structural characteristics of the regional health care system. These findings suggest that interventions that aim to improve care efficiency via reductions in overuse should focus on the structural drivers of this phenomenon, rather than on the eradication of individual overused procedures.


Assuntos
Geografia , Mau Uso de Serviços de Saúde , Benefícios do Seguro , Setor Privado , Adulto , Assistência à Saúde/economia , Assistência à Saúde/tendências , Feminino , Mau Uso de Serviços de Saúde/economia , Mau Uso de Serviços de Saúde/tendências , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/tendências , Masculino , Medicare/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
3.
J Stroke Cerebrovasc Dis ; 29(2): 104559, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31836360

RESUMO

OBJECTIVES: This study aimed to examine the temporal trend of 30-day and 1-year mortality among U.S. Medicare beneficiaries who were hospitalized for ischemic stroke, with special focus on the mortality among subgroup of patients in relation to acute reperfusion therapies including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). METHODS: We evaluated Medicare fee-for-service beneficiaries age 65 years or older who were hospitalized for ischemic stroke between 2009 and 2013. Multivariable Cox proportional hazards models were generated to analyze the trend of adjusted mortality. RESULTS: A total of 1,070,574 patients were included in the study. The 30-day mortality did not change among patients who were not treated with IVT or EVT. It decreased by 13% among patients treated with IVT but not EVT (HR = .87, 95% CI .82-.92), 25% among patients treated with EVT but not IVT (HR = .75, 95% CI .59-.95), and 37% among patients treated with both IVT and EVT (HR = .63, 95% CI .52-.77). One-year mortality decreased by 19% among patients who were not treated with IVT nor EVT (HR = .81, 95% CI .80-.83), 22% among those treated with IVT but not EVT (HR = .78, 95% CI .75-.81), 33% among those treated with EVT but not IVT (HR = .67, 95% CI .55-.81), and 38% among those treated with both IVT and EVT (HR = .62, 95% CI .53-.73). CONCLUSIONS: From 2009 to 2013, the 30-day stroke case fatality decreased only among the patients received reperfusion therapy. The 1-year mortality declined among all the stroke patients, with the greatest decline among those treated with both IVT and EVT.


Assuntos
Isquemia Encefálica/mortalidade , Benefícios do Seguro/tendências , Medicare/tendências , Acidente Vascular Cerebral/mortalidade , Trombectomia/mortalidade , Terapia Trombolítica/mortalidade , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Terapia Combinada , Feminino , Humanos , Masculino , Mortalidade/tendências , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
4.
Food Chem ; 311: 126023, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-31864189

RESUMO

The effects of boiling and in vitro human simulated digestion on phenolic compounds and bioactivity of the African leafy green vegetable, Bidens pilosa, known as Blackjack in South Africa, was investigated and compared to the leafy green vegetable Spinacia oleracea (Spinach). Metabolites such as 3-caffeoylquinic acid, catechin, 4-caffeoylquinic acid, quercetin-3-O-robinobioside, rutin and quercetin-3-O-glucoside were dominant in the boiled methanolic compared with the raw methanolic extracts of the Blackjack. The total phenolic and flavonoid content generally decreased after in vitro complete digestion for both raw and boiled extracts, indicating that pH and environment associated with digestion alters the bioactivity of the extracted phenolics. Both leafy green vegetables had beneficial effects, but all Blackjack extracts were more effective in preventing the AAPH-mediated oxidation of Caco-2 cells, low-density lipoprotein and deoxyribonucleic acid than those of the spinach. This study identified the health benefits of eating Blackjack and therefore, the cultivation and consumption of this leafy green vegetable should be promoted.


Assuntos
Antioxidantes/metabolismo , Bidens/química , Flavonoides/análise , Fenóis/análise , Antioxidantes/isolamento & purificação , Antioxidantes/farmacologia , Células CACO-2 , Culinária , DNA/efeitos adversos , Digestão , Flavonoides/metabolismo , Flavonoides/farmacologia , Temperatura Alta , Humanos , Concentração de Íons de Hidrogênio , Benefícios do Seguro , Lipoproteínas LDL/efeitos adversos , Metanol , Oxirredução/efeitos dos fármacos , Fenóis/metabolismo , Fenóis/farmacologia , Folhas de Planta/química , Spinacia oleracea/química , Verduras/química
5.
J Stroke Cerebrovasc Dis ; 28(12): 104399, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31611168

RESUMO

OBJECTIVE: To examine racial/ethnic disparities in 30-day all-cause readmission after stroke. METHODS: Thirty-day all-cause readmission was compared by race/ethnicity among Medicare fee-for-service beneficiaries discharged for ischemic stroke from hospitals in the Florida Stroke Registry from 2010 to 2013. We fit a Cox proportional hazards model that censored for death and adjusted for age, sex, length of stay, discharge home, and comorbidities to assess racial/ethnic differences in readmission. RESULTS: Among 16,952 stroke patients (54% women, 75% white, 8% black, and 15% Hispanic), 30-day all-cause readmission was 15% (17.2% for blacks, 16.7% for Hispanics, 14.4% for whites, and 14.7% for others; P = .003). There was a median of 11 days between discharge and first readmission. In adjusted analyses, there was no significant difference in readmission for blacks (hazard ratio 1.15, 95% confidence interval 0.99-1.33), Hispanics (1.00, .90-1.13), and those of other race/ethnicity (.91, .71-1.16) compared with whites. Nearly 1 in 4 readmissions were attributable to acute cerebrovascular events: 16.6% ischemic stroke or transient ischemic attack, 1.5% hemorrhagic stroke, and 5.2% cerebral artery interventions. Interventions were more common among whites and those of other race than blacks and Hispanics (P = .029). Readmission due to pneumonia or urinary tract infection was 8.2%. CONCLUSIONS: Readmissions attributable to acute cerebrovascular events were common and generally occurred within 2 weeks of hospital discharge. Racial/ethnic disparities were present in readmissions for arterial interventions. Our results underscore the importance of postdischarge transitional care and the need for better secondary prevention strategies after ischemic stroke, particularly among minority populations.


Assuntos
Afro-Americanos , Isquemia Encefálica/terapia , Grupo com Ancestrais do Continente Europeu , Disparidades em Assistência à Saúde/etnologia , Hispano-Americanos , Benefícios do Seguro , Medicare , Readmissão do Paciente , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etnologia , Feminino , Florida/epidemiologia , Humanos , Masculino , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Prevenção Secundária , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etnologia , Fatores de Tempo , Cuidado Transicional , Estados Unidos/epidemiologia
8.
Matern Child Health J ; 23(12): 1595-1603, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31363887

RESUMO

OBJECTIVES: Provision of long-acting reversible contraception (LARC) after delivery and prior to discharge is safe and advantageous, yet few Texas hospitals offer this service. Our study describes experiences of Texas hospitals that implemented immediate postpartum LARC (IPLARC) programs, in order to inform the development of other IPLARC programs and guide future research on system-level barriers to broader adoption. METHODS: Eight Texas hospitals that had implemented an IPLARC program were identified, and six agreed to participate in the study. Interviews with 19 key hospital staff covered (1) factors that led the development of an IPLARC program; (2) billing, pharmacy, and administrative operations related to implementation; (3) patient demand and readiness; (4) the consent process; (5) staff training; and (6) hospital plans for monitoring and evaluation of IPLARC services. RESULTS: Most hospitals in this study primarily served Medicaid and un- or under-insured populations. Participants from all six hospitals perceived high levels of patient demand for IPLARC and provider interest in providing this service. The major challenges were related to financing IPLARC programs. Participants from half of the hospitals reported that leadership had concerns about financial viability of providing IPLARC. The hospitals with the longest-running IPLARC programs were safety net hospitals with family planning training programs. CONCLUSIONS FOR PRACTICE: We found that hospitals with IPLARC programs all had strong support from both providers and hospital leadership and had funding sources to offset costs that were not reimbursed. Strategies to reduce the financial risks related to IPLARC provision could provide the impetus for new programs to launch and support their sustainability.


Assuntos
Anticoncepção/economia , Benefícios do Seguro/legislação & jurisprudência , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Medicaid/legislação & jurisprudência , Demandas Administrativas em Assistência à Saúde , Anticoncepção/métodos , Serviços de Planejamento Familiar , Feminino , Gastos em Saúde , Hospitais , Humanos , Benefícios do Seguro/economia , Medicaid/economia , Período Pós-Parto , Gravidez , Avaliação de Programas e Projetos de Saúde , Mecanismo de Reembolso , Texas , Estados Unidos
10.
Med Care ; 57(10): 830-835, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31453892

RESUMO

BACKGROUND: The Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey includes items about chronic conditions, health history, and self-rated health. Questions remain about the concordance between patient reports and administrative sources on questions related to health history. OBJECTIVE: To validate CAHPS measures of chronic conditions against claims-based measures from the Medicare Chronic Conditions Warehouse (CCW). METHODS: We linked CAHPS responses from 301,050 fee-for-service Medicare beneficiaries in 2010-2012 with summaries of their claims in the CCW and identified nearest equivalent measures of conditions across sources. We calculated sensitivities and specificities for conditions and estimated regression models to assess the effects of patient characteristics on the sensitivity. RESULTS: The sensitivity of CAHPS measures differed across conditions, ranging from 0.513 for history of stroke to 0.773 for history of cancer. Sensitivity was generally lower for older beneficiaries, those reporting good self-rated health, and those with fair or poor mental health. Specificity was 0.904 or greater for all conditions, up to 0.961 for stroke. CONCLUSIONS: Despite difference in timeframes and definitions of conditions, the measured sensitivities demonstrated reasonable validity. Variation in sensitivity is consistent with covariates that either directly measure health severity within a diagnosis or can be construed as a proxy for severity of illness.


Assuntos
Doença Crônica , Pesquisas sobre Serviços de Saúde/normas , Benefícios do Seguro/estatística & dados numéricos , Medicare/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , Estados Unidos
11.
J Ment Health Policy Econ ; 22(2): 43-59, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31319375

RESUMO

BACKGROUND: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted. RESULTS: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.


Assuntos
Custo Compartilhado de Seguro , Dedutíveis e Cosseguros , Benefícios do Seguro , Programas de Assistência Gerenciada/organização & administração , Transtornos Mentais/economia , Serviços de Saúde Mental/economia , Saúde Mental , Adolescente , Adulto , Idoso , Gastos em Saúde , Humanos , Programas de Assistência Gerenciada/economia , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
12.
Inquiry ; 56: 46958019861554, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31271082

RESUMO

While the traditional Medicare program does not cover dental, vision, and hearing services, Medicare Advantage (MA) plans have been given the flexibility to do so. However, it is not known how many MA enrollees are in plans that cover these services. The 2016 Medicare Current Beneficiary Survey linked to MA plan benefit data is used to examine enrollment levels in plans that cover dental, vision, and/or hearing services in MA. Medicaid beneficiaries are excluded from this analysis as coverage of supplemental benefits is largely determined by the state. The highest coverage of supplemental services is vision, followed by hearing and dental (71%, 56%, and 41%, respectively). Across all supplemental services, coverage for supplemental benefits is highest among low-income beneficiaries and those who have not completed high school. Hispanic Medicare beneficiaries had the highest enrollment in plans that offered a supplemental benefit, and white Medicare beneficiaries tended to have the lowest enrollment in these plans. Unlike in traditional Medicare, MA enrollees have access to health plans that offer supplemental benefits, including dental, vision, and/or hearing services. This analysis shows that enrollment in these plans is highest among low-income MA enrollees who may not have the means to purchase stand-alone insurance for these services in traditional Medicare. More analysis is warranted to examine the generosity of the coverage of these services in MA plans. However, for federal policy makers to consider offering supplemental coverage in traditional Medicare, the MA experience suggests this type of benefit would be valuable.


Assuntos
Auxiliares de Audição/estatística & dados numéricos , Benefícios do Seguro/estatística & dados numéricos , Seguro Odontológico/estatística & dados numéricos , Seguro Oftalmológico/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Humanos , Cobertura do Seguro , Medicaid , Estados Unidos
13.
Inquiry ; 56: 46958019862120, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31282241

RESUMO

There is increasing recognition of the role of social determinants of health (SDOH) in the ability of Medicare Advantage (MA) enrollees to obtain needed care. The 2018 CHRONIC Care Act established Special Supplemental Benefits for the Chronically Ill (SSBCI), which for the first time gives MA plans the flexibility to provide supplemental benefits to enrollees to address SDOH. Given the role of SDOH in chronic disease, this represents an opportunity for MA plans to address underlying issues not strictly health care related with which MA enrollees struggle and that affect their overall health. MA plans have experimented with different approaches to address SDOH but have been limited by the lack of ability to offer services as part of covered benefits and reliance on partnerships, grants, and other funding sources to support the provision of these services. The effect of this policy and how it may evolve before implementation begins in 2020 remains uncertain as we wait to see how MA plans will interpret eligibility criteria and services offered without any additional allotted funding.


Assuntos
Doença Crônica/legislação & jurisprudência , Benefícios do Seguro/legislação & jurisprudência , Medicare Part C/legislação & jurisprudência , Determinantes Sociais da Saúde , Disparidades em Assistência à Saúde , Humanos , Medicare Part C/economia , Estados Unidos
15.
Intellect Dev Disabil ; 57(3): 234-241, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31120407

RESUMO

Nonelderly disabled Medicare beneficiaries have a higher prevalence of chronic conditions, higher utilization of prescription medications, and increased demand for clinical services when compared to beneficiaries 65 years of age and older who are not disabled. Out-of-pocket costs and medication-related problems are major barriers to medication compliance and achievement of therapeutic goals. A school of pharmacy partnered with a nonprofit organization that provides care to individuals with developmental disabilities. The present study highlights outcomes resulting from (a) providing Medicare Part D plan optimization services to lower prescription drug costs and (b) Medication Therapy Management services to evaluate safe and effective medication use in this beneficiary population. Provided interventions were shown to reduce overall medication costs and identify significant medication-related problems.


Assuntos
Deficiências do Desenvolvimento/economia , Gastos em Saúde , Medicare Part D/economia , Medicamentos sob Prescrição/economia , Adulto , Idoso , Redução de Custos , Deficiências do Desenvolvimento/tratamento farmacológico , Custos de Medicamentos , Feminino , Humanos , Benefícios do Seguro/economia , Masculino , Conduta do Tratamento Medicamentoso/economia , Pessoa de Meia-Idade , Projetos Piloto , Estados Unidos
17.
Occup Med (Lond) ; 69(4): 279-282, 2019 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-31094424

RESUMO

BACKGROUND: Seafarers enable 90% of global commerce, working in isolation from social support and medical care. While occupational conditions of isolation may suggest possible excess risk of mental illness and suicide, research on seafarer mental illness is limited. AIMS: To describe seafarers with mental illness and associated incidence rates in a large population of international seafarers. METHODS: We used mental illness claims data from a large international marine insurance provider arising from working seafarers during the years 2007-15. We used descriptive statistics and calculated mental illness incidence rates in this seafarer population. RESULTS: There were 278 seafarer mental illness claims in the study data. Claims were more often reported in deck workers (46%) and ratings (58%). The crude mental illness rate was 3.9 per 100 000 person-years. CONCLUSIONS: Using objective data on a large seafaring population, our analysis highlights the important issue of mental illness in this isolated and underserved international workforce. The low observed mental illness claims rate is likely due to the high threshold for claims reporting.


Assuntos
Transtornos Mentais/epidemiologia , Navios , Adulto , Humanos , Incidência , Benefícios do Seguro/estatística & dados numéricos , Pessoa de Meia-Idade , Medicina Naval , Ocupações/estatística & dados numéricos
18.
Artigo em Inglês | MEDLINE | ID: mdl-31118599

RESUMO

Objective: We investigated the impact of preexisting COPD and its subtypes, chronic bronchitis and emphysema, on overall survival among Medicare enrollees diagnosed with non-small-cell lung cancer (NSCLC). Methods: Using SEER-Medicare data, we included patients ≥66 years of age diagnosed with NSCLC at any disease stage between 2006 and 2010 and continuously enrolled in Medicare Parts A and B in the 12 months prior to diagnosis. Preexisting COPD in patients with NSCLC were identified using ICD-9 codes. Kaplan-Meier method and log-rank tests were used to examine overall survival by COPD status and COPD subtype. Multivariable Cox proportional hazards models were fit to assess the risk of death after cancer diagnosis. Results: We identified 66,963 lung cancer patients. Of these, 22,497 (33.60%) had documented COPD before NSCLC diagnosis. For each stage of NSCLC, median survival was shorter in the COPD compared to the non-COPD group (Stage I: 692 days vs 1,130 days, P<0.0001; Stage II: 473 days vs 627 days, P<0.0001; Stage III: 224 days vs 229 days; P<0.0001; Stage IV: 106 days vs 112 days, P<0.0001). For COPD subtype, median survival for patients with preexisting chronic bronchitis was shorter compared to emphysema across all stages of NSCLC (Stage I: 672 days vs 811 days, P<0.0001; Stage II 582 days vs 445 days, P<0.0001; Stage III: 255 days vs 229 days, P<0.0001; Stage IV: 105 days vs 112 days, P<0.0001). In Cox proportional hazard model, COPD patients exhibited 11% increase in risk of death than non-COPD patients (HR: 1.11, 95%CI: 1.09-1.13). Conclusion: NSCLC patients with preexisting COPD had shorter survival with marked differences in early stages of lung cancer. Chronic bronchitis demonstrated a greater association with time to death than emphysema.


Assuntos
Bronquite Crônica/epidemiologia , Benefícios do Seguro , Neoplasias Pulmonares/epidemiologia , Medicare , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Enfisema Pulmonar/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Bronquite Crônica/diagnóstico , Bronquite Crônica/mortalidade , Bronquite Crônica/terapia , Bases de Dados Factuais , Feminino , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/terapia , Masculino , Estadiamento de Neoplasias , Prognóstico , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/terapia , Enfisema Pulmonar/diagnóstico , Enfisema Pulmonar/mortalidade , Enfisema Pulmonar/terapia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Programa de SEER , Fatores de Tempo , Estados Unidos/epidemiologia
20.
BMJ Open ; 9(5): e025254, 2019 05 09.
Artigo em Inglês | MEDLINE | ID: mdl-31072851

RESUMO

OBJECTIVE: To estimate the effects of expanding outpatient benefit package on ameliorating the issues of over-reliance on inpatient services and seeking higher level medical services in rural China. DESIGN: A quasi-experimental design. SETTING AND PARTICIPANTS: 1673 pairs of patients with hypertension were selected after using propensity score matching from Dangyang county (intervention group) and Zhijiang (control group) county, Hubei province. INTERVENTION: The outpatient annual reimbursement capping line was expanding from ¥300 to ¥600, daily capping line from ¥10/12 to ¥150. The compensation scope and institution were also enlarged from January 2016. OUTCOME MEASURES: The difference-in-differences model was used to estimate the effects on medical service type selection. χ2 test was used to verify the effects on medical institution selection. We also examined the effects on health outcomes through the length of stay and blood pressure changes. RESULTS: The intervention was associated with 3.225 times (p=0.001) increase in total visits. Outpatient visits increased by 3.3 times (p=0.008), whereas the township level presented a maximum increase of 1.932 times (p=0.001). The inpatient visits declined by 0.075 times (p=0.000), whereas county-level inpatient visits reached a maximum decrease of 0.042 times (p=0.033). Meanwhile, the township level exhibited a maximum proportion growth of 14.8% in outpatient (p=0.000) and 13.3% in inpatient visits (p=0.048). Outpatient visits at the county level dropped at 13.2% (p=0.000), whereas inpatients visits declined by 7.7% (p=0.040). The length of stay and blood pressure were decreased, respectively, compared with the control group. CONCLUSION: Improving outpatient benefit package alleviated patient dependence on inpatient services through motivating outpatient service utilisation, consolidated the primacy of township health centres and guided patients to return to primary medical institutions. The health insurance reform should 'take the long view' in the future, and more attention should be paid to the rationality of medical service utilisation.


Assuntos
Assistência Ambulatorial/economia , Assistência à Saúde/economia , Hipertensão/terapia , Benefícios do Seguro/economia , Pacientes Ambulatoriais/estatística & dados numéricos , Serviços de Saúde Rural/economia , China/epidemiologia , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Hipertensão/economia , Hipertensão/epidemiologia , Benefícios do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão
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