Hong Kong domestic health spending: financial years 1989/90 to 2011/12.

This report presents the latest estimates of Hong Kong domestic health spending for financial years 1989/90 to 2011/12, cross-stratified and categorized by financing source, provider, and function. Total expenditure on health (TEH) was HK$101 985 million in financial year 2011/12, which represents an increase of HK$8580 million or 9.2% over the preceding year. TEH grew faster relative to gross domestic product (GDP) leading to a rise in TEH as a percentage of GDP from 5.1% in 2010/11 to 5.2% in 2011/12. During the period 1989/90 to 2011/12, total health spending per capita (at constant 2012 prices) grew at an average annual rate of 4.8%, which was faster than the average annual growth rate of per capita GDP by 1.8 percentage points. In 2011/12, public and private expenditure on health increased by 8.3% and 10.0% when compared with 2010/11, reaching HK$49,262 million and HK$52,723 million respectively. Consequently, public share of total health expenditure dropped slightly from 48.7% to 48.3% over the year. Of private spending, the most important source of health financing was out-of-pocket payments by households (34.9% of TEH), followed by employer-provided group medical benefits (7.5%) and private insurance (7.4%). It is worth noting that private insurance will likely take over employers as the second largest private payer if the insurance market continues to expand at the current rate. Of the HK$101,985 million total health expenditure in 2011/12, current expenditure comprised HK$96,572 million (94.7%), whereas HK$5413 million (5.3%) was for capital expenses (ie investment in medical facilities). Analysed by health care function, services of curative care accounted for the largest share of total health spending (65.2%), which was made up of ambulatory services (33.6%), in-patient curative care (26.9%), day patient hospital services (4.1%), and home care (0.5%). Notwithstanding its small share, the total spending for day patient hospital services shows an increasing trend over the period 1989/90 to 2011/12, likely as a result of policy directives to shift the emphasis from in-patient to day patient care. Hospitals accounted for an increasing share of total spending, from 28.2% in 1989/90 to 46.8% in 2002/03 and then dropped slightly to 42% to 44% during the period 2005/06 to 2011/12, which was primarily driven by reduced expenditure of Hospital Authority. As a result of the epidemics which are of public health importance (eg avian flu, SARS, swine flu) and the expansion of private health insurance market in the last two decades, spending on provision and administration of public health programmes, and general health administration and insurance accounted for increasing, though less significant, shares of total health spending over the period. Without taking into account capital expenses (ie investment in medical facilities), public current expenditure on health amounted to HK$45,321 million (46.9% of total current expenditure) in 2011/12 with the remaining HK$51,251 million made up of private sources of funds. Public current expenditure was mostly incurred at hospitals (74.1%), whereas private current expenditure was mostly incurred at providers of ambulatory health care (51.2%). Although both public and private spending were mostly expended on personal health care services and goods (91.1% of total current spending), the distributional patterns among functional categories differed. Public expenditure was targeted at in-patient care (47.3%) and substantially less on out-patient care (27.4%). In comparison, private spending was mostly concentrated on out-patient care (42.7%), whereas in-patient care (24.7%) and medical goods outside the patient care setting (19.9%) comprised the majority of the remaining share. Compared to the Organisation for Economic Co-operation and Development countries, Hong Kong has devoted a relatively low percentage of GDP to health care in the last decade. As a share of total spending, public funding (either general government revenue or social security funds) was also lower than those in most economies with comparable economic development and public revenue collection base. Nonetheless, Hong Kong health care system achieved service quality and health outcome that fared well by global standards, indicating cost efficiency and effectiveness.

Refining the Apgar score cut-off point for newborns at risk.

AIM: To evaluate the Apgar score predictive power for mortality during different periods in the first year of life in a population with a very low mortality rate. METHODS: The records of all singleton live births without severe congenital malformations and length of gestation >25 wk (n = 976635) were collected from the Swedish Medical Birth Registry, 1990 to 1998. Receiver operating characteristic (ROC) analysis was utilized. RESULTS: Both the 1-min and the 5-min Apgar scores were shown to be good discriminators for early mortality, with the area under the ROC curve >0.85. For babies at risk of early death, the selected cut-off values for the 1-min Apgar score was <8 for preterm (true-positive (TP) rate: 83.9%; false-positive (FP) rate: 17.7%) and term babies (TP rate: 69.4%; FP rate: 6.7%). At 5 min, the analysis revealed that newborns with an Apgar score <9 were at risk for early death (preterm babies: TP rate: 79.8%; FP rate: 13.3%; term babies: TP rate: 73.8%; FP rate: 3.4%). CONCLUSIONS: Our analysis did not support the common practice in the clinic or in research of grouping infants at risk in Apgar score groups, i.e. a score below 4 or a score below 7. However, the data presented here allow the clinicians and researchers to identify and define a suitable cut-off point in relation to the quality of neonatal care and resources available, rather than adhering to a historical cut-off value that has not been studied in depth.

Maternal smoking: an increasing unique risk factor for sudden infant death syndrome in Sweden.

AIM: To assess the change of risk factors that are specific to sudden infant death syndrome (SIDS) after the initialization of a campaign to reduce the risk (RTR) of SIDS compared to non-SIDS postneonatal deaths. METHODS: Data were extracted from the Swedish Medical Birth Registry, 1982-1991 and 1993-1998. 1105 infants died from SIDS during the postneonatal period. 2115 postneonatal deaths were from other causes and 11,050 live birth controls were selected. Risk factors previously identified to be related to SIDS were defined as high parity, prematurity, young maternal age, low Apgar score, birth during the night, single motherhood, multiple births, maternal smoking, male gender, short length standard deviation score (SDS) and small weight-to-length SDS. RESULTS: Non-SIDS deaths were more significantly related to a low 5-min Apgar score, smaller weight-to-length SDS, and/or short length SDS values; while SIDS deaths were more closely related to mothers with higher parity or multiple births, mothers who smoked during pregnancy and single-parent (mother) families. Maternal smoking was even more prominent among SIDS deaths in the post-campaign period. The adjusted odds ratios, compared with non-SIDS deaths, increased from 1.84 (95% CI: 1.48, 2.28) in the pre-campaign period to 4.11 (95% CI: 2.72, 6.21) in the post-campaign period. CONCLUSIONS: Maternal smoking during pregnancy remains the most important modifiable risk factor for SIDS in the post-campaign period in comparison with non-SIDS postneonatal deaths. Other than putting babies in a supine sleeping position, maternal smoking should be the next most important issue to be considered, if there is to be a second campaign.

Do men have a higher case fatality rate of severe acute respiratory syndrome than women do?

Severe acute respiratory syndrome (SARS) has been reported in 30 countries and regions, with a cumulative total of 8,099 probable cases and 774 deaths as of July 31, 2003, according to the World Health Organization. In Hong Kong, People's Republic of China, 1,755 SARS cases and 299 deaths had occurred as of September 22, 2003. The authors analyzed data from the Department of Health, Hong Kong SAR. The data series includes details regarding sex, age, and chronic disease history. Using data from early March to September 22, 2003, the authors found that males had a significantly (p < 0.0001) higher case fatality rate than females did, 21.9% versus 13.2%; the relative risk was 1.66 (95% confidence interval (CI): 1.35, 2.05), and it was 1.62 (95% CI: 1.21, 2.16) after adjustment for age. Subgroup analysis was conducted by excluding health care workers (n = 386) from the analysis. The overall crude relative risk of mortality was 1.41 (95% CI: 1.15, 1.74), and the adjusted relative risk was 1.48 (95% CI: 1.10, 2.00). Thus, among SARS patients, males may be more severely affected by the disease than females are. This finding could be related to a nonuniform case definition of SARS disease, a different treatment regimen, a past smoking history, work-environment factors, or gender-specific immune-defense factors, for instance.