Effect of the catastrophic medical insurance on household catastrophic health expenditure: evidence from China / El efecto del seguro médico para enfermedades catastróficas o de alto coste sobre el gasto doméstico en salud: la evidencia en China

OBJECTIVE: China launched an innovative program of catastrophic medical insurance (CMI) to protect households from catastrophic health expenditure (CHE) and impoverishment. This article assesses the effect of CMI on relieving CHE and impoverishment from catastrophic illnesses in urban and rural China. METHOD: In total, 8378 cases are included in the analysis. We employed descriptive statistical analysis to compare the incidence and intensity of CHE at five health expenditure levels, from 1 June 2014 to 31 May 2015. To illustrate the different protection of the policy, we analyzed the data in two lines, the covered medical expenses and the total medical expenses. RESULTS: CMI drop down CHE incidence from 4.8% to 0.1% and the mean catastrophic payment gap from 7.9% to zero when only considering covered medical expenses. CMI drop down CHE incidence from 15.5% to 7.9% and the mean catastrophic payment gap from 31.2% to 14.7% when considering total medical expenses. If CMI reimburse uncovered medical expenses at 30%, the mean catastrophic payment gap could be 7.9% and insured person's annual premium will increase US$2.19. CONCLUSIONS: China CMI perfectly meet the pursued policy objectives when only considering the covered medical expenses. However, when considering the total medical expenses, the CMI is only partially effective in protecting households from CHE. The considerable gap is the result of the limitation of CMI list

OBJETIVO: China lanzó un innovador programa de Seguro Catastrófico de Salud (SCS) para proteger a los hogares del gasto sanitario catastrófico (GSC) y el empobrecimiento. Este artículo evalúa el efecto del SCS para aliviar el GSC y el empobrecimiento a causa de las enfermedades catastróficas en zonas urbanas y rurales de China. MÉTODO: En total, se incluyen 8378 casos en el análisis. Se emplearon análisis estadísticos descriptivos para comparar la incidencia y la intensidad del GSC en cinco niveles de gastos de salud, del 1 de junio de 2014 al 31 de mayo de 2015. Para ilustrar la diferente protección de la política se analizaron los datos en dos líneas: los gastos sanitarios cubiertos por el seguro y los gastos sanitarios totales. RESULTADOS: Considerando los gastos cubiertos por el seguro, se redujeron los hogares con gastos catastróficos del 4,8% al 0,1%, y la brecha de pago catastrófico media cayó del 7,9% al 0,0% en promedio. Cuando consideramos el gasto sanitario total, los hogares con gasto catastrófico se redujeron del 15,5% al 7,9%, y la brecha de pago catastrófico media cayó del 31,2% al 14,7% en promedio. Esta cantidad podría reducirse al 7,9% si se reembolsara el 30% a los gastos no cubiertos por el SCS, lo que supondría un aumento de la prima del seguro por persona de US$ 2,19. CONCLUSIONES: El SCS de China cumple perfectamente los objetivos de la política perseguida cuando solo se consideran los gastos cubiertos por el seguro. Si se consideran los gastos totales, el SCS solo es parcialmente efectivo para proteger a los hogares del gasto sanitario catastrófico. El motivo de este desfase es la limitación existente en la lista de servicios cubiertos por el SCS

Proton beam therapy utilization in adults with primary brain tumors in the United States.

The utilization of proton beam therapy (PBT) as the primary treatment of adults with primary brain tumors (APBT) was evaluated through query of the National Cancer Database (NCDB) between the years 2004 and 2015. International Classification of Diseases for Oncology code for each patient was stratified into six histology categories; high-grade gliomas, medulloblastomas, ependymomas, other gliomas, other malignant tumors, or other benign intracranial tumors. Demographics of the treatment population were also analyzed. A total of 1,296 patients received PBT during the 11-year interval for treatment of their primary brain tumor. High-grade glioma, medulloblastoma, ependymoma, other glioma, other malignant, and other benign intracranial histologies made up 39%, 20%, 13%, 12%, 13%, and 2% of the cohort, respectively. The number of patients treated per year increased from 34 to 300 in years 2004 to 2015. Histologies treated with PBT varied over the 11-year interval with high-grade gliomas comprising 75% and 45% at years 2004 and 2015, respectively. The majority of the patient population was 18-29 years of age (59%), Caucasian race (73%), had median reported income of over $63,000 (46%), were privately insured (68%), and were treated at an academic institution (70%). This study characterizes trends of malignant and benign APBT histologies treated with PBT. Our data from 2004 through 2015 illustrates a marked increase in the utilization of PBT in the treatment of APBT and shows variability in the tumor histology treated over this time.

Individual vs household: How do different calculation patterns of catastrophic health expenditure matter? New evidence from China's critical illness insurance programme.

Reducing the incidence and severity of catastrophic health expenditure (CHE) has been considered to be one of the most fundamental goals of the global health care financing system. China, the second largest economy and the most populous country in the world, established a critical illness insurance (CII) programme in 2012 in an effort to protect Chinese residents from CHE shocks. This paper attempts to address whether the different calculation patterns (namely, individuals vs household) of CHE matter under China's CII programme. We compare two CII models built with the World Health Organization's (WHO's) standard and the Chinese standard. Exploiting the latest China family panel studies (CFPS) dataset, we demonstrate that using household as the calculation pattern is more effective in alleviating CHE under a tight premium budget, which is consistent with the international view. This finding raises concerns about the appropriate calculation pattern of CHE in policy making.

High risk of gastrointestinal hemorrhage in patients with systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc), a life-threatening autoimmune disease characterized by vasculopathy. Numerous SSc patients demonstrate gastrointestinal (GI) involvement but the delicate GI bleeding risk remains sparse. We aimed to explore the role of SSc in determining the long-term risk of GI bleeding, including bleedings of upper (peptic and non-peptic ulcers) and lower GI tracts. METHODS: Patients with SSc diagnosis were identified from the Catastrophic Illness Patient Database and the National Health Insurance Research Database from 1998 to 2007. Each SSc patient was matched with five SSc-free individuals by age, sex, and index date. All individuals (case = 3665, control = 18,325) were followed until the appearance of a GI bleeding event, death, or end of 2008. A subdistribution hazards model was assessed to evaluate the GI bleeding risk with adjustments for age, sex, and time-dependent covariates, comorbidity, and medications. RESULTS: The incidence rate ratios of GI bleeding were 2.38 (95% confidence interval [CI], 2.02-2.79), 2.06 (95% CI, 1.68-2.53), and 3.16 (95% CI, 2.53-3.96) for over-all, upper, and lower GI bleeding events in SSc patients. In the competing death risk in the subdistribution hazards model with time-covariate adjustment, SSc was an independent risk factor for over-all GI bleeding events (subdistribution hazard ratio [sHR] 2.98, 95% CI, 2.21-4.02), upper GI bleeding events (sHR 2.80, 95% CI, 1.92-4.08), and lower GI bleeding events (sHR 3.93, 95% CI, 2.52-6.13). CONCLUSION: SSc patients exhibited a significantly higher risk of over-all and different subtype GI bleeding events compared with the SSc-free population. The prevention strategy is needed for these high GI bleeding risk groups.

Patterns and predictors of off-label prescription of psychiatric drugs.

Off-label prescribing of psychiatric drugs is common, despite lacking strong scientific evidence of efficacy and potentially increasing risk for adverse events. The goal of this study was to characterize prevalence of off-label prescriptions of psychiatric drugs and examine patient and clinician predictors of off-label use. This manuscript presents a retrospective, cross-sectional study using data from the 2012 and 2013 National Ambulatory Medical Care Surveys (NAMCS). The study examined all adult outpatient visits to psychiatric practices for chronic care management with a single listed visit diagnosis in which at least one psychiatric drug was prescribed. The main outcome measure was off-label prescribing of at least one psychiatric drug, defined as prescription for a condition for which it has not been approved for use by the FDA. Among our sample representative of 1.85 billion outpatient visits, 18.5 million (1.3%) visits were to psychiatrists for chronic care management in which at least one psychiatric drug was prescribed. Overall, the rate of off-label use was 12.9% (95% CI: 12.2-15.7). The most common off-label uses were for manic-depressive psychosis treated with citalopram and primary insomnia treated with trazodone. Several patient and clinician characteristics were positively associated with off-label prescribing, including seeing a psychiatrist (OR: 1.06, 95% CI, 1.01-1.12; p = 0.03) instead of another type of clinician, the office visit taking place in the Western region of the country (OR: 1.09, 95% CI, 1.01-1.17; p = 0.02), and the patient having 3 or more chronic conditions (OR: 1.12, 95% CI, 1.02-1.14; p = 0.003). In contrast, having Medicare coverage (OR: 0.93, 95% CI, 0.84-0.97; p = 0.04) and receiving payment assistance from a medical charity (OR: 0.91, 95% CI, 0.88-0.96; p = 0.03) instead of private insurance were negatively associated with off-label prescribing. These results suggest that certain classes of psychiatric medications are being commonly prescribed to treat conditions for which they have not been determined by the FDA to be clinically efficacious and/or safe.

Membership In Seguro Popular In Mexico Linked To A Small Reduction In Catastrophic Health Expenditure.

In 2004 the government of Mexico initiated an ambitious program, Seguro Popular, to extend health insurance coverage to poor and informal-sector workers. While the program had a protective effect during its early stages, its impact on out-of-pocket health spending over time is unclear. This study used two waves of the Encuesta Nacional de Salud y Nutricion (from 2006 and 2012) to analyze the protective effects of Seguro Popular and social security programs on out-of-pocket and catastrophic health spending. While, given the endogeneity of Seguro Popular enrollment, we found no link between membership and out-of-pocket health care spending in the study period, we did find a robust, albeit small, link between membership and a reduction in catastrophic health spending. A significant part of overall out-of-pocket health spending goes to purchase medications. Policy decisions are necessary to address gaps in coverage and access to medicines. Improving the quality of care as well as including more clinically effective and cost-effective medicines in the Seguro Popular package could significantly reduce out-of-pocket health care spending in Mexico.

Private health insurance and catastrophic health expenditures of households with cancer patients in South Korea.

This study examines the effects of private health insurance (PHI) on the incidence of catastrophic health expenditures (CHE) for households with a patient with cancer. This study uses 1-year data from 2013 and households with cancer patients as the unit of research rather than individual household members. The sample thus includes 468 households with members with cancer who also used emergency, outpatient and hospitalisation services. Households with PHI had a lower incidence of CHE for all thresholds than those without did. At the 10% threshold, the incidence became significantly lower, by 0.59 and 0.60 times, respectively, if householders had higher education and income levels. Moreover, the incidence of CHE was higher by 8.71 times if the householders are female, and lower by 0.84 times if the householders did not have a spouse at the 20% threshold. From the analysis of households with cancer patients that hold PHI as the key variable, these households showed a lower incidence of CHE than the others did. PHI provides healthcare payments not secured through national health insurance (NHI) and protects households from health expenditures, thereby complementing NHI to a certain degree.

Health-related quality of life of African-American female breast cancer survivors, survivors of other cancers, and those without cancer.

PURPOSE: The purpose of this study was to compare differences in health-related quality of life (HRQOL) between African-American female breast cancer survivors, African-American female survivors of other cancers, and African-American women with no history of cancer. METHODS: Using data from the 2010 National Health Interview Survey (NHIS), the HRQOL of African-American women aged 35 years or older was compared by cancer status. Physical and mental health items from the Patient-Reported Outcomes Measurement Information System (PROMIS) global health scale were used to assess differences in HRQOL. RESULTS: For summary physical and mental health measures, no significant differences were found between breast cancer survivors and women with no history of cancer; survivors of other cancers reported poorer physical and mental health than did women with no history of cancer. Similar differences were found at the item level. When we examined the two African-American female cancer survivor groups, we found that cancer survivors whose cancer was being treated reported substantially poorer physical health and mental health than did those whose cancer was not being treated. Survivors who had private insurance and were cancer free reported better physical and mental health than did those who did not have private insurance and those who were not cancer free. Breast cancer survivors reported slightly better physical and mental health than did survivors of other cancers. CONCLUSIONS: Our findings highlight the need for public health agencies to adopt practices to improve the mental and physical health of African-American female survivors of cancer.

Incidence and clinical characteristics of Guillain-Barré syndrome before the introduction of Zika virus in Puerto Rico.

BACKGROUND: Zika virus has been associated with increases in Guillain-Barré syndrome (GBS) incidence. A GBS incidence estimation and clinical description was performed to assess baseline GBS epidemiology before the introduction of Zika virus in Puerto Rico. METHODS: Hospitalization administrative data from an island-wide insurance claims database and U.S. Census Bureau population estimates provided a crude GBS incidence for 2013. This estimate was adjusted using the proportion of GBS cases meeting Brighton criteria for confirmed GBS from nine reference hospitals. Characteristics of confirmed GBS cases in the same nine hospitals during 2012-2015 are described. RESULTS: A total of 136 GBS hospitalization claims were filed in 2013 (crude GBS incidence was 3.8 per 100,000 population). The adjusted GBS incidence was 1.7 per 100,000 population. Of 67 confirmed GBS cases during 2012-2015, 66% had an antecedent illness. Median time from antecedent illness to GBS onset was 7days. Most cases (67%) occurred during July-September. CONCLUSIONS: Puerto Rico's GBS incidence for 2013 was estimated using a combination of administrative data and medical records review; this method could be employed in other regions to monitor GBS incidence before and after the introduction of GBS infectious triggers.

Gasto catastrófico en salud en México y sus factores determinantes, 2002-2014.

OBJECTIVE: To assess the financial protection of public health insurance by analyzing the percentage of households with catastrophic health expenditure (HCHE) in Mexico and its relationship with poverty status, size of locality, federal entity, insurance status and items of health spending. METHOD: Mexican National Survey of Income and Expenditures 2002-2014 was used to estimate the percentage of HCHE. Through a probit model, factors associated with the occurrence of catastrophic spending are identified. Analysis was performed using Stata-SE 12. RESULTS: In 2014 there were 2.08% of HCHE (1.82-2.34%; N = 657,474). The estimated probit model correctly classified 98.2% of HCHE (Pr (D) ≥ 0.5). Factors affecting the catastrophic expenditures were affiliation, presence of chronic disease, hospitalization expenditure, rural condition and that the household is below the food poverty line. CONCLUSIONS: The percentage of HCHE decreased in recent years, improving financial protection in health. This decline seems to have stalled, keeping inequities in access to health services, especially in rural population without affiliation to any health institution, below the food poverty line and suffering from chronic diseases.

Hospitalization and mortality in Mexico due to breast cancer since its inclusion in the catastrophic expenditures scheme.

OBJECTIVE: To compare trends in hospital discharges and mortality due to breast cancer (BC) in Mexico from 2004 to 2012 by insurance condition before and after incorporating BC comprehensive treatment into the System of Social Protection in Health (Sistema de Protrección Social en Salud, SPSS) in 2007. MATERIALS AND METHODS: Data on BC hospital discharges and mortality reported in women aged 25 years and over were obtained from the National Health Information System. Mortality rates were adjusted by age and state. RESULTS: At the national level, a growing tendency in hospital discharges was observed, mainly for women without social security, while mortality rate remained constant. Mortality rates by state show that lower marginalization index corresponded to higher mortality. CONCLUSIONS: A differential behavior was observed among women according to insurance condition, partly due to the inclusion of BC treatment in the SPSS.

Hospitalization and mortality in Mexico due to breast cancer since its inclusion in the catastrophic expenditures scheme / Hospitalización y mortalidad en México por cáncer de mama a partir de su inclusión en el esquema de gastos catastróficos

Abstract Objective: To compare trends in hospital discharges and mortality due to breast cancer (BC) in Mexico from 2004 to 2012 by insurance condition before and after incorporating BC comprehensive treatment into the System of Social Protection in Health (Sistema de Protrección Social en Salud, SPSS) in 2007. Materials and methods: Data on BC hospital discharges and mortality reported in women aged 25 years and over were obtained from the National Health Information System. Mortality rates were adjusted by age and state. Results: At the national level, a growing tendency in hospital discharges was observed, mainly for women without social security, while mortality rate remained constant. Mortality rates by state show that lower marginalization index corresponded to higher mortality. Conclusions: A differential behavior was observed among women according to insurance condition, partly due to the inclusion of BC treatment in the SPSS.

Resumen Objetivo: Comparar las tendencias de egresos hospitalarios y mortalidad por cáncer de mama (CaMa) en México de 2004 a 2012, según esquema de aseguramiento, antes y después de la incorporación del tratamiento integral del CaMa al Sistema de Protección Social en Salud (SPSS) en 2007. Material y métodos: Los egresos hospitalarios y de mortalidad por CaMa en mujeres de 25 años o más se obtuvieron del Sistema Nacional de Información en Salud. Las tasas de mortalidad se ajustaron por edad y entidad federativa. Resultados: A nivel nacional, hubo una tendencia creciente de los egresos hospitalarios, principalmente para mujeres sin seguridad social, mientras que la tasa de mortalidad se mantuvo constante. Las tasas de mortalidad fueron mayores en estados con menor índice de marginación. Conclusiones: Se observó un comportamiento diferencial entre las mujeres según esquema de aseguramiento en salud debido, en parte, a la inclusión del tratamiento de CaMa al SPSS.

Utilization of Comprehensive Health Insurance Scheme, Kerala: A Comparative Study of Insured and Uninsured Below-Poverty-Line Households.

We aimed to compare the sociodemographics, health care utilization pattern, and out-of-pocket (OOP) expenses of 149 insured and 147 uninsured below-poverty-line households insured under the Comprehensive Health Insurance Scheme, Kerala, through a comparative cross-sectional study. Family size more than 4 (odds ratio [OR] = 2.34; 95% confidence interval [CI] = 1.13-4.82), family member with chronic disease (OR = 2.05; 95% CI = 1.18-3.57), high socioeconomic status (OR = 2.95; 95% CI = 1.74-5.03), and an employed household head (OR = 2.69; 95% CI = 1.44-5.02) were significantly associated with insured households. Insured households had higher inpatient service utilization (OR = 1.57; 95% CI = 1.05-2.34). Only 40% of inpatient service utilization among the insured was covered by insurance. The mean OOP expenses for inpatient services among insured (INR 448.95) was higher than among uninsured households (INR 159.93); P = .003. These findings show that urgent attention of the government is required to redesign and closely monitor the scheme.

Having Private Cancer Insurance in Korea: Gender Differences.

BACKGROUND: As coverage of public insurance is not sufficient to cover diagnosis or treatment of cancer, having private health insurance is important to prepare for unexpected expenses of cancer. The purpose of this study was to assess factors associated with having private cancer insurance, considering gender among the socio- demographic factors and health behavior. MATERIALS AND METHODS: We used data from the 2011 Korea Health Panel, which included 10,871 participants aged 20 years and older. Socio-demographics, health behavior, and perceived cancer risk were the independent variables and having private cancer insurance was the dependent variable. Multivariable logistic regression analysis was used to identify factors associated with having private cancer insurance. RESULTS: The variables relating to middle age, higher education, higher household income, married men, and the perceived cancer risk groups of 1-10% and 11-30% were significantly associated with having private cancer insurance. Additionally, females who had private non-cancer health insurance were positively associated with the dependent variables (OR=1.36; 95% CI=1.17-1.57). Education, smoking status, exercise, and perceived cancer risk possibility were significantly associated with having private cancer insurance only among women. The men lowered the overall percentages of those having private cancer insurance (OR=0.53, 95% CI=0.45-0.63). CONCLUSIONS: We found that there were significant differences between men and women who had private cancer insurance. Women with private cancer insurance are more likely to follow precautionary health behavior than men. This could be interpreted as resulting from masculine ideologies. It is important to make males recognize the seriousness of the cancer risk. In general, household income was highly associated with private cancer insurance. These results reveal an inequity among the buyers of private cancer insurance in terms of economic status level, education level, and health condition.

Investigating determinants of catastrophic health spending among poorly insured elderly households in urban Nigeria.

BACKGROUND: In the absence of functional social security mechanisms for elderly people in Nigeria, elderly households are solely responsible for geriatric healthcare costs, which can lead to catastrophic health expenditures (CHE) - particularly among the poor. This study investigates the key determinants of CHE among poorly insured elderly households in Nigeria. We also offer some policy options for reducing the risk of CHE. METHODS: Data on out-of pocket payments and self-reported health status were sourced from the Nigerian General Household Panel Survey (NGHPS) in Nigeria, conducted by the National Bureau of Statistics in 2010, with technical support from the World Bank. CHE was defined at the 10% of total consumption expenditure threshold. The determinants of CHE and their marginal effects were investigated using probit regressions. An elderly household is defined as a household with at least one elderly member ≥ 50 years old. RESULTS: The proportion of elderly households with CHE is 9.6%. Poorer and smaller elderly households were most at risk of CHE. Female-headed households were less likely to incur CHE compared to male-headed households (p < 0.01). Conversely, households with informal health financing arrangements were less likely to incur CHE (p < 0.001). Education and utilising a health promoting tool, such as treated bednets increased the probability of incurring CHE in Urban Nigeria. CONCLUSION: Findings from this paper should prompt policy action to financially support poor elderly households at risk of CHE in Urban Nigeria. The Nigerian government should enhance the national health insurance scheme to provide better coverage for elderly people, thereby protecting elderly households from incurring CHE.

Racial Differences in Clostridium difficile Infection Rates Are Attributable to Disparities in Health Care Access.

This study confirms previously reported racial differences in Clostridium difficile infection (CDI) rates in the United States and explores the nature of those differences. We conducted a retrospective study using the 2010 Nationwide Inpatient Sample, the largest all-payer database of hospital discharges in the United States. We identified hospital stays most likely to include antibiotic treatment for infections, based on hospital discharge diagnoses, and we examined how CDI rates varied, in an attempt to distinguish between genotypic and environmental racial differences. Logistic regressions for the survey design were used to test hypotheses. Among patients likely to have received antibiotics, white patients had higher CDI rates than black, Hispanic, Asian, and Native American patients (P < 0.0001). CDI rates increased with higher income levels and were higher for hospitalizations paid by private insurance versus those paid by Medicaid or classified as self-pay or free care (P < 0.0001). Among patients admitted from skilled nursing facilities, where racial bias in health care access is less, racial differences in CDI rates disappeared (P = 1.0). Infected patients did not show racial differences in rates of complicated CDI or death (P = 1.0). Although white patients had greater CDI rates than nonwhite patients, racial differences in CDI rates disappeared in a population for which health care access was presumed to be less racially biased. This provides evidence that apparent racial differences in CDI risks may represent health care access disparities, rather than genotypic differences. CDI represents a deviation from the paradigm that increased health care access is associated with less morbidity.

Catastrophic health expenditure and rural household impoverishment in China: what role does the new cooperative health insurance scheme play?

OBJECTIVE: To determine whether the New Cooperative Medical Insurance Scheme (NCMS) is associated with decreased levels of catastrophic health expenditure and reduced impoverishment due to medical expenses in rural households of China. METHODS: An analysis of a national representative sample of 38,945 rural households (129,635 people) from the 2008 National Health Service Survey was performed. Logistic regression models used binary indicator of catastrophic health expenditure as dependent variable, with household consumption, demographic characteristics, health insurance schemes, and chronic illness as independent variables. RESULTS: Higher percentage of households experiencing catastrophic health expenditure and medical impoverishment correlates to increased health care need. While the higher socio-economic status households had similar levels of catastrophic health expenditure as compared with the lowest. Households covered by the NCMS had similar levels of catastrophic health expenditure and medical impoverishment as those without health insurance. CONCLUSION: Despite over 95% of coverage, the NCMS has failed to prevent catastrophic health expenditure and medical impoverishment. An upgrade of benefit packages is needed, and effective cost control mechanisms on the provider side needs to be considered.

Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance.

OBJECTIVE: To assess the degree to which the Chinese people are protected from catastrophic household expenditure and impoverishment from medical expenses and to explore the health system and structural factors influencing the first of these outcomes. METHODS: Data were derived from the Fourth National Health Service Survey. An analysis of catastrophic health expenditure and impoverishment from medical expenses was undertaken with a sample of 55 556 households of different characteristics and located in rural and urban settings in different parts of the country. Logistic regression was used to identify the determinants of catastrophic health expenditure. FINDINGS: The rate of catastrophic health expenditure was 13.0%; that of impoverishment was 7.5%. Rates of catastrophic health expenditure were higher among households having members who were hospitalized, elderly, or chronically ill, as well as in households in rural or poorer regions. A combination of adverse factors increased the risk of catastrophic health expenditure. Families enrolled in the urban employee or resident insurance schemes had lower rates of catastrophic health expenditure than those enrolled in the new rural corporative scheme. The need for and use of health care, demographics, type of benefit package and type of provider payment method were the determinants of catastrophic health expenditure. CONCLUSION: Although China has greatly expanded health insurance coverage, financial protection remains insufficient. Policy-makers should focus on designing improved insurance plans by expanding the benefit package, redesigning cost sharing arrangements and provider payment methods and developing more effective expenditure control strategies.

Persistence at 1 year of oral antiosteoporotic drugs: a prospective study in a comprehensive health insurance database.

OBJECTIVE: Treatments against osteoporosis have demonstrated fracture risk reduction but persistence to therapy remains a major issue. Intermittent regimens have been developed to improve persistence. The aim of this 1-year prospective study was to compare, in the general population, the persistence of various oral regimens of antiosteoporotic treatment. METHODS: We conducted this prospective study in the French comprehensive public health insurance database of the Rhône-Alpes region. Women aged 45 years or older who had a first reimbursement of an oral antiosteoporotic treatment during February 2007 composed the study cohort. Persistence was defined by the proportion of patients refilling a prescription in the pharmacist delivery register (ERASME). Using statistical analyses like Kaplan-Meier survival curves and log-rank tests, we compared the treatment persistence of strontium ranelate, raloxifene, and daily-, weekly-, and monthly bisphosphonates. RESULTS: Two thousand four hundred and nineteen patients were included over a period of 1 month and followed up for 12 months. Two hundred and eighty-nine (11.9%) patients were treated with monthly bisphosphonates, 1298 (53.7%) with weekly bisphosphonates, and 832 (34.4%) with daily treatments (526 strontium ranelate (21.7%), 296 raloxifene (12.2%), and 10 bisphosphonates (0.4%)). At 1 year, overall persistence was 34%. Fifty percent of patients on monthly bisphosphonates were still persistent while only 37% of patients on weekly bisphosphonates, 34% on raloxifene, and 16% on strontium ranelate were persistent. Therapy monitoring with biochemical markers or bone mineral density was associated with improved persistence. CONCLUSION: Overall persistence at 1 year was low, but intermittent regimens were associated with higher persistence rates, along with women who had therapy monitoring.