Socioeconomic Status of Newborns and Hospital Efficiency: Implications for Hospital Payment Methods.

OBJECTIVES: Studies have shown a consistent impact of socioeconomic status at birth for both mother and child; however, no study has looked at its impact on hospital efficiency and financial balance at birth, which could be major if newborns from disadvantaged families have an average length of stay (LOS) longer than other newborns. Our objective was therefore to study the association between socioeconomic status and hospital efficiency and financial balance in that population. METHODS: A study was carried out using exhaustive national hospital discharge databases. All live births in a maternity hospital located in mainland France between 2012 and 2014 were included. Socioeconomic status was estimated with an ecological indicator and efficiency by variations in patient LOS compared with different mean national LOS. Financial balance was assessed at the admission level through the ratio of production costs and revenues and at the hospital level by the difference in aggregated revenues and production costs for said hospital. Multivariate regression models studied the association between those indicators and socioeconomic status. RESULTS: A total of 2 149 454 births were included. LOS was shorter than the national means for less disadvantaged patients and longer for the more disadvantaged patients, which increased when adjusted for gestational age, birth weight, and severity. A 1% increase in disadvantaged patients in a hospital's case mix significantly increased the probability that the hospital would be in deficit by 2.6%. CONCLUSIONS: Reforms should be made to hospital payment methods to take into account patient socioeconomic status so as to improve resource allocation efficiency.

An updated assessment of utilization of interventional pain management techniques in the Medicare population: 2000 - 2013.

BACKGROUND: The rapid increase in the prevalence of chronic pain and disability, and the explosion of interventional pain management associated health care costs are a major concern for our community. Further, the increasing utilization of numerous modalities of treatments in managing chronic pain, continue to escalate at a pace which may not be sustainable. There are multiple regulations in place to control the growth of health care expenditures which seem to have been largely ineffective. Among the various modalities utilized in managing chronic pain, interventional techniques have shown a significant increase in their utilization in the face of continued debate with respect to the accuracy of diagnostic interventions and the efficacy of therapeutic interventions. OBJECTIVE: To update and assess the utilization of interventional techniques in chronic pain management in fee-for-service Medicare population. STUDY DESIGN: An updated analysis of the growth of interventional techniques in managing chronic pain in fee-for-service Medicare beneficiaries from 2000 through 2013. METHODS: The data were derived and analyzed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master Data from 2000 through 2013. RESULTS: From 2000 through 2013, in fee-for-service Medicare beneficiaries, the overall utilization of interventional techniques services increased 236% at an annual average growth of 9.8%, whereas the per 100,000 Medicare population utilization increased 156% with an annual average growth of 7.5%. During this period, the US population increased 12% with an annual average increase of 0.9%, whereas those above 65 years of age increased 27% with an annual average increase of 1.9%. Total Medicare beneficiaries increased 31% with an annual average increase of 2.1%, with an overall increase of 64% for those above 65 years of age, an increase of 26%, constituting 17% of the US population in 2013. The overall increases in epidural and adhesiolysis procedures were 165% compared to 102% per 100,000 fee-for-service population with annual average increases of 7.8% and 5.6%. Facet joint and sacroiliac joint injections increased 417% for services with an annual average increase of 13.5%, whereas the rate per 100,000 fee-for-service Medicare beneficiaries increased 295% with an annual average increase of 11.1%. LIMITATIONS: Limitations of this assessment include the lack of inclusion of participants from Medicare Advantage plans, lack of appropriate available data for state-wide utilization, and potential errors in documentation, coding, and billing. CONCLUSION: This update once again shows a significant increase in interventional techniques in fee-for-service Medicare beneficiaries from 2000 through 2013 with an increase of 156% per 100,000 Medicare population with an annual average increase of 7.5%. During this period the Medicare population increased 31% with an annual average increase of 2.1%.

Sodium content and labelling of processed and ultra-processed food products marketed in Brazil.

OBJECTIVE: To analyse the Na content and labelling of processed and ultra-processed food products marketed in Brazil. DESIGN: Cross-sectional study. SETTING: A large supermarket in Florianopolis, southern Brazil. SUBJECTS: Ingredient lists and Na information on nutrition labels of all processed and ultra-processed pre-prepared meals and prepared ingredients, used in lunch or dinner, available for sale in the supermarket. RESULTS: The study analysed 1416 products, distributed into seven groups and forty-one subgroups. Five products did not have Na information. Most products (58.8 %; 95 % CI 55.4, 62.2 %) had high Na content (>600 mg/100 g). In 78.0 % of the subgroups, variation in Na content was at least twofold between similar products with high and low Na levels, reaching 634-fold difference in the 'garnishes and others' subgroup. More than half of the products (52.0 %; 95 % CI 48.2, 55.6 %) had at least one Na-containing food additive. There was no relationship between the appearance of salt on the ingredients list (first to third position on the list) and a product's Na content (high, medium or low; P=0.08). CONCLUSIONS: Most food products had high Na content, with great variation between similar products, which presents new evidence for reformulation opportunities. There were inconsistencies in Na labelling, such as lack of nutritional information and incomplete ingredient descriptions. The position of salt on the ingredients list did not facilitate the identification of high-Na foods. We therefore recommend a reduction in Na in these products and a review of Brazilian legislation.

A critical analysis of Peru's HIV grant proposals to the Global Fund.

Peru has applied to six of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) rounds for funding, achieving success on four occasions. The process of proposal development has, however, been criticised, especially concerning the use of evidence, relevance/consistency and performance indicators. We aimed to analyse the Peruvian Global Fund proposals according to those dimensions, providing feedback to improve future local efforts and inform global discussions around Global Fund procedures. We analysed the content of four HIV-focused proposals (rounds 2, 5, 6 and 8) regarding epidemic context, needs identification and prioritisation and monitoring and evaluation systems. Peruvian proposals submitted after round 1 were described as resulting from collaborative inputs involving formerly unrepresented sectors, principally 'vulnerable populations'. However, difficulties arose regarding the amount and quality of evidence about the epidemiological context; limited consideration of social determinants of the epidemic; lack of theory-driven interventions, and little synergy across projects and the inclusion of weak monitoring and evaluation systems, with poor indicators and measurement procedures. Prioritising the development of analytical and technical skills to generate Global Fund proposals would enhance the country's capacity to produce and utilise evidence, improve the technical-political interface, strengthen information systems and lead to more informed decision making and accountability.

Resumen de levantamiento de necesidades de investigación en evaluaciones económicas: subsecretaría de salud pública / Summary of research needs survey in economic evaluations: undersecretary of public health

El siguiente resumen fue preparado a partir de la respuesta recibida a los Memorándum Nº 781 y 782 de parte de la División de Prevención y Control de Enfermedades (DIPRECE) y la División de Políticas Públicas Saludables y Promoción (DIPOL), ambas pertenecientes a la Subsecretaría de Salud Pública del Ministerio de Salud.\r\nLos Memorándum antes mencionados fueron enviados por la Jefa de la División de Planificación Sanitaria, con la finalidad de recoger información para el levantamiento de necesidades Ministeriales de Investigación en Evaluaciones Económicas.

A saúde na percepção do adolescente / Health in the adolescent's viewpoint

Na fase da adolescência, o indivíduo experimenta os melhores índices de saúde, os quais podem ser mantidos e/ou melhorados, dependendo da percepção e valorização dos mesmos, influenciando na sua qualidade de vida. O estudo avaliou a opinião de adolescentes (n=493) da Fundação Mirim do Município de Araçatuba - SP, quanto à saúde geral e bucal, bem como sua percepção sobre elas, por meio questionário semiestruturado, durante o ano letivo de 2006, já que os mesmos possuem acesso à atenção à saúde bucal e palestras sobre saúde. Dentre os entrevistados 34,5 por cento conceituaram a saúde como coisa ou algo que precisa(mos) cuidar; 26,6 por cento, como bem-estar; 18,1 por cento, como a própria existência; e 14,5 por cento, como ausência de doença. Em relação aos conceitos de saúde bucal, 68,4 por cento definiram como higiene; 16,2 por cento, como aparência; e 15,5 por cento, como ausência de doenças bucais. A percepção desses jovens quanto a sua saúde em geral foi para 46,5 por cento, ótima, e 44,1 por cento, boa, enquanto que a da sua saúde bucal foi para 53,6 por cento, boa, e 24 por cento, ótima. Pode-se concluir que os adolescentes têm uma ideia tanto sobre saúde geral como saúde bucal, porém a classificação é menor no que tange à saúde bucal, pois envolve aspectos afetivos, estéticos e sociais. Ademais, percebe-se a necessidade de programas educativo-preventivos direcionados a esse grupo.

During adolescence, the individual experiences the best health indexes, which can be maintained and/or improved, depending on their perception and valorization influencing their quality of life. The study assessed the opinion of adolescents (n=493) from the Mirim Foundation of the Araçatuba county in São Paulo State, Brazil, about their oral and general health, as well as their perception about them, through a semi-structured questionnaire, in the school year period of 2006, since they have access to information on oral health care and speeches about health in general. Among the interviees, 34.5 percent referred to health as something to be cared of; 26.6 percent defined it as well-being;ç 18.1 percent, as related to their very existence, and 14.5 percent, as an absence of disease. In relation to the concepts of oral health, 68.4 percent defined it as hygiene; 16.2 percent, as physical appearance and 15.5 percent, as to the absence of oral diseases. The perception of these youngsters about their health in general was excellent for 46.5 percent, and good for 44.1 percent. Concerning their oral health, for 53.6 percent it was good, and for 24 percent, excellent. One can conclude that the adolescents have an idea about general health, as well as oral health, but the oral health classification is lower, since it involves emotional, esthetic and social aspects. Moreover, the need of prevention-educative programs designed for this group is indubitable.

Relación entre el Currículum de la Facultad de Ciencias Médicas y las necesidades de salud del país / Relationship between the Curriculum, Faculty of Medical and health needs of the country

La formación profesional del médico que ocurre en la Facultad de Ciencias Médicas, obedece a un plan estructurado para ocho años de estudio y trabajo que ha evolucionado con elementos constitutivos de dos paradigmas de educación médica, los modelos "biomédico" y "social", en el afán de adaptar la enseñanza a la situación nacional. Para visualizar si el plan ha evolucionado acorde a las políticas y necesidades públicas en salud, se realizó este trabajo que involucró una búsqueda documental y una escuesta de percepción a informantes claves. Los anales registran que el currículo de la carrera de medicina nació con exclusivismo del modelo biomédico, pero a mediados del siglo xx incorporó importantes contenidos del modelo social, acorde al desarrollo en el país de los sistemas de salud en forma planificada. Un ensayo de aproximaciones mas cercanas con elaboración participante de perfiles de necesidades y respuestas, propuestos en los años 80's y con intentos de implementación en los 90's terminó con momentos de crisis superada hasta 2,002 con la puesta a punto de un último plan ahora vigente. pero, la percepción generalizada es que,a pesar de tener un planteamiento que incorpora fuertes componentes sde medicina preventiva y social, privilegia los preceptos biomédicos, abunda en regideces y desestructuraciones que conducen a la formación de un profesional con conocimientos fragmentados, escasa capacidad de conducción de procesos administrativos y de gerencia y escaso compromiso hacia la comnidad

[Economic evaluation of the demand of medical care for mental health in Mexico: schizophrenia and depression, 1996-2000]. / Evaluación económica de la demanda de atención médica para salud mental en México: esquizofrenia y depresión, 1996-2000.

Financing protection for both, users and providers of health care services is one of the main objectives of National Program of Health in Mexico, 2001-2006. In fact one of the elements of the present health care reform initiatives is need for the efficient allocation of financial resources, using resource allocation schemes by specific health care demands that combine both the economic, clinical and the epidemiological perspectives. The evaluation of such schemes has been approached in several ways; however, in the case of mental health services, there is dearth of studies that use economic assessment methods. Moreover, such studies are of limited scope, often a response to unmated health needs, disregarding the economic implication for health services production and financing and ensuing medical care market imbalances. This paper presents the results of an evaluative research work aimed to assess the average cost of depression and schizophrenia case management, the financial resources required to meet the health care demands by type of institution, period 1996-2000, in Mexico by type of health care provider. The case management average cost for schizophrenia was $211.00 US, and that for depression was $221.00 US. The demand of services for both conditions in each type of institution showed that the greatest relative demands (96% of the national total for depression and 94% of the national total for schizophrenia) occur in three institutions: IMSS, SSA and ISSSTE. The greatest demand of the health services for the two study condition corresponded to those insured by the IMSS, followed by those uninsured who use the SSA services, and those insured by the ISSSTE. The case management costs for mental conditions are in the middle range between hypertension and diabetes in the upper end, pneumonia and diarrhea in the lower end. The case managment costs of health care demands for the selected tracer conditions differ considerably among institutions for insure populations and those for uninsured populations, with a greater economic impact on-the former. Independent from differences found, these results allow the identification of economic evaluation indicators that could be used to design resource allocation schemes for each of the institutions included in this study.

Does managed mental health care reallocate resources to those with greater need for services?

Evidence points to the existence of two coexisting inefficiencies in mental health care resource allocation: those with need receive too limited or no care while those with no apparent need receive services. In addition to reducing costs, managed mental health care is expected to reallocate treatment resources to those with greater need for services. However, there are no empirical findings regarding this issue. This study tests whether managed mental health care has had a differential impact by level of need. Data consist of three waves of a community sample with a control group. The study finds that managed care has not succeeded in reallocating resources from the unlikely to the definite "needers."

Assessing community health among indigenous populations in Ecuador with a participatory approach: implications for health reform.

Health reform is an important movement in countries throughout the region of the Americas, which could profoundly influence how basic health services are provided and who receives them. Goals of health sector reform include to improve quality, correct inefficiencies, and reduce inequities in current systems. The latter may be especially important in countries with indigenous populations, which are thought to suffer from excess mortality and morbidity related to poverty. The purpose of this paper is to report the results of a community health assessment conducted in 26 indigenous communities in the Province of Cotopaxi in rural Ecuador. It is hoped that this information will inform the health reform movement by adding to the current understanding of the health and socioeconomic situation of indigenous populations in the region while emphasizing a participatory approach toward understanding the social forces impacting upon health. This approach may serve as a model for empowering people through collective action. Recommended health reform strategies include: 1) Develop a comprehensive plan for health improvement in conjunction with stakeholders in the general population, including representatives of minority groups; 2) Conduct research on the appropriate mix between traditional medicine, primary health care strategies, and high technology medical services in relation to the needs of the general population; 3) Train local health personnel and traditional healers in primary health care techniques; 4) Improve access to secondary and tertiary health services for indigenous populations in times of emergency; and 5) Advocate for intersectoral collaboration among government institutions as well as non-governmental organizations and the private sector.