Educational Inequalities in Hospital Use Among Older Adults in England, 2004-2015.

Policy Points US policymakers considering proposals to expand public health care (such as "Medicare for all") as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well-funded universal health care systems are already in place. In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity. Based on England's experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups. CONTEXT: Expanding access to health care is once again high on the US political agenda, as is concern about those who are being "left behind." But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education-level-defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use. METHODS: Novel linkage of data from six waves (2004-2015) of the English Longitudinal Study of Ageing (ELSA) with participants' hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004-2005 to 2008-2009 and 2010-2011 to 2014-2015 to examine whether potential education-related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010. FINDINGS: For the study period, our sample of ELSA respondents in the low-education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high-education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11-0.47). Additional outpatient health care use in the high-education group was driven by follow-up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high-education group made 0.48 (95% CI, 0.21-0.74) more annual outpatient visits than those in the low-education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high-education group made 0.04 (95% CI, -0.075 to 0.001) fewer annual ED visits than the low-education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period. CONCLUSIONS: After controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high-education group using more outpatient care and less ED care than peers in the low-education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use.

Clinical phenotypes of US level I trauma centers: use of clustering methodology.

BACKGROUND: American College of Surgeons Level I Trauma Centers (ACSL1TCs) meet the same personnel and structural requirements but serve different populations. We hypothesized that these nuanced differences may amenable to description through mathematical clustering methodology. METHODS: The National Trauma Data Bank 2014 was used to derive information on ACSL1TCs. Explorative cluster hypothesis generation was performed using Ward's linkage to determine expected number of clusters based on patient and injury characteristics. Subsequent k-means clustering was applied for analysis. Comparison between clusters was performed using the Kruskal-Wallis or chi-square test. RESULTS: In 2014, 113 ACSL1TCs admitted 267,808 patients (median = 2220 patients, range: 928-6643 patients). Three clusters emerged. Cluster I centers (n = 53, 47%) were more likely to admit older, Caucasian patients who suffered from falls (P < 0.05) and had higher proportions of private (31%) and Medicare payers (29%) (P = 0.001). Cluster II centers (n = 18, 16%) were more likely to admit younger, minority males who suffered from penetrating trauma (P < 0.05) and had higher proportions of Medicaid (24%) or self-pay patients (19%) (P = 0.001). Cluster III centers (n = 42, 37%) were similar to cluster I with respect to racial demographic and payer status but resembled cluster II centers with respect to injury patterns (P < 0.05). CONCLUSIONS: Our analysis identified three unique, mathematically definable clusters of ACSL1TCs serving three broadly different patient populations. Understanding these mathematically definable clusters should have utility when assessing an institution's financial risk profile, directing prevention and outreach programs, and performing needs and resource assessments. Ultimately, clustering allows for more meaningful direct comparisons between phenotypically similar trauma centers.

An analysis of the federal funding for mental health care in Brazil.

This article analyzes spending on mental health by the Brazilian Ministry of Health between 2001 and 2014. It is documental research of the Brazilian Ministry of Health's databases. It analyzes the data using descriptive statistical analysis. Total spending on mental health for the period 2001 to 2014 shows a percentage increase in resources destined for outpatient care, but this increase is a reallocation from hospital services to community-based services and total resources for the mental health program remain at an average of 2.54% of the total health budget. Within outpatient expenditure, spending on medications remains high. Professionals committed to psychiatric reform fight to guarantee that a small fraction of the surplus appropriated by the state is directed towards social policies.

Funding renal replacement therapy in southeast Asia: building public-private partnerships in Singapore, Malaysia, Thailand, and Indonesia.

The provision of renal replacement therapy (RRT) in developing economies is limited by lack of financial and other resources. There are no national reimbursement policies for RRT in many countries in Asia. The Southeast Asia countries of Singapore, Malaysia, Thailand, and Indonesia have adopted a strategy of encouraging public-private partnerships to increase the RRT rates in their respective countries. The private organizations include both for-profit and philanthropic bodies. The latter raise funds from ordinary citizens, corporations, and faith-based groups, as well as receive subsidies from the government to support RRT for patients in need. The kidney foundations of these countries play a leadership role in this public-private partnership. Many of the private organizations that support RRT are providers of treatment in addition to offering financial assistance to patients, with hemodialysis being the most frequently supported modality. Public-private partnership in funding RRT is sustainable over the long term with proper organization and facilitated by support from the government.

The impact of the global economic crisis on HIV and AIDS programmes directed at women and children in Zambia.

This investigation sought to ascertain the extent to which the global economic crisis of 2008-2009 affected the delivery of HIV/AIDS-related services directed at pregnant and lactating mothers, children living with HIV and children orphaned through HIV in Zambia. Using a combined macroeconomic analysis and a multiple case study approach, the authors found that from mid-2008 to mid-2009 the Zambian economy was indeed buffeted by the global economic crisis. During that period the case study subjects experienced challenges with respect to the funding, delivery and effectiveness of services that were clearly attributable, directly or indirectly, to the global economic crisis. The source of funding most often compromised was external private flows. The services most often compromised were non-medical services (such as the delivery of assistance to orphans and counselling to HIV-positive mothers) while the more strictly medical services (such as antiretroviral therapy) were protected from funding cuts and service interruptions. Impairments to service effectiveness were experienced relatively equally by (HIV-positive) pregnant women and lactating mothers and children orphaned through HIV. Children living with AIDS were least affected because of the primacy of ARV therapy in their care.

Evolution of postanesthesia care units: a legacy of politics, funding, and patient safety concerns.

Postanesthesia care units or PACUs (earlier called recovery rooms) flourished after World War II as social, political, and economic influences advanced enormous changes in health care expectations and delivery in the United States. Innovations in science and technology, facilitated by increased federal funding of scientific research in the years preceding and during the war, heralded a postwar need for greater complexity of hospital care safely delivered by trained personnel. PACUs began to open in new and modernized postwar hospitals as a means to safely provide more complex postoperative care during a time of persistent nursing shortages. PACUs proved to be an effective and cost-efficient means of decreasing the significantly high incidence of contemporary postoperative morbidity and mortality. Continuous and skilled observation by the recovery room nurses was credited with the improved patient outcomes. Once firmly established, PACUs have remained vital to the delivering of safe and cost-effective postoperative and postprocedural care.

A Good Investment: Expanding Capacity to Care for Older Adults in the Home and Community Care Sector Through Increased Personal Support Worker Wages.

Most older adults prefer to age in place, which for many will require home and community care (HCC) support. Unfortunately, HCC capacity is insufficient to meet demand due in part to low wages, particularly for personal support workers (PSWs) who provide the majority of paid care. Using Ontario as a case study, this paper estimates the cost and capacity impacts of implementing wage parity between PSWs employed in HCC and institutional long-term care (ILTC). Specifically, we consider the cost of increased HCC PSW wages versus expected savings from avoiding unnecessary ILTC placement for those accommodated by HCC capacity growth. The expected increase in HCC PSW retention would create HCC capacity for approximately 160,000 people, reduce annual health system costs by approximately $7 billion, and provide an 88 per cent return on investment. Updating wage structures to reduce turnover and enable HCC capacity growth is a cost-efficient option for expanding health system capacity.

Medical debt during epidemics: A case for resolving the situation in low- and middle-income countries such as Kenya.

This paper evaluates the problem of medical debt in Kenya during the COVID-19 pandemic. The medical debt problem is compounded during pandemics such as COVID-19 when patients seek treatment and end up in insurmountable debt because illnesses related to the pandemic are not covered by the Kenyan National Health Insurance Fund (NHIF), the public health coverage body under government control. As a result, discharged patients may be detained in hospitals and dead bodies are locked away in mortuaries, until relatives and friends fundraise and clear the bills. Apart from causing vulnerability, fear, and emotional stress among the poor, this practice leads to a growing lack of trust in the healthcare system, with patients deliberately avoiding hospitals whenever they suspect they have COVID-19. The resulting vicious cycle makes healthcare more inaccessible by limiting the choices that people may have. User fees, which were introduced in all public health facilities by the Kenyan government as part of a World Bank prescription for cost-sharing, normally affect more women than men. Although Kenya has implemented a general waiver system in public hospitals for those who cannot pay their medical bills, the process of obtaining this waiver can be burdensome, demeaning, and dangerous for the health of the patients. This undermines the government's commitment to the provision of equitable and affordable health care for the citizens. In this article, the problem of medical debt in Kenya is addressed as a multi-faceted problem drawing on issues of justice and fairness, human dignity, good governance, the interplay between global and local policies, as well as politics and law. It argues that it is in the best interest of Kenya and other African countries to ensure that public health coverage covers pandemics so that the majority poor can afford and access healthcare.

Allocation of health care resources in the neonatal and perinatal area -CPS Symposium 1996.

There have been publically expressed concerns about the costs and allocation of neonatal and perinatal health care resources in Canada and elsewhere for the past 15 years. This paper reports information from a symposium held during the 1996 Canadian Paediatric Society (CPS) annual meeting sponsored by the CPS Section on Perinatal Medicine. Experts in perinatal epidemiology, health care economics, public policy and finance, and consumer perspectives on the outcomes of neonatal and perinatal intensive care explored the following questions: How should the need for health care resources in the neonatal and perinatal area be objectively determined? When there are competing needs between the maternal-newborn area and other areas, how should these be rationalized? What evidence should be used (or should be available) to support the present use of resources? What evidence should be available (or is needed) to change or introduce new uses of resources? The conclusions indicated that there are no generally accepted methods to determine the allocation of health care resources but that considerations need to include population characteristics, desired outcomes, achievable results, values, ethics, legalities, cost-benefit analyses and political objectives. Information from families and adolescents who required the use of high technology and/or high cost programs will contribute individual, family and societal values that complement cost-efficacy analyses.

The integrated management for renal replacement therapy in Portugal.

Portugal was the first European country to introduce an integrated management of end-stage renal disease (IM ESRD). This new program integrates various dialysis services and products, which are reimbursed at a fixed rate/patient/week called "comprehensive price payment." This initiative restructured the delivery of dialysis services, the monitoring of outcomes, and the funding of renal replacement therapy. This article described the implementation of a new model of comprehensive provision of hemodialysis (HD) services and aimed to assess its impact on dialysis care. Quality assessments and reports of patient satisfaction, produced by the Ministry of Health since 2008, as well as national registries and reports, provided the data for this review. Indicators of HD services in all continental facilities show positive results that have successively improved along the period of 2009-2011, in spite of an average annual growth of 3% of the population under HD treatment. Mortality rates for HD patients were 12.7%, 12%, and 11%, respectively in 2009, 2010, and 2011; annual hospitalization rates were 4.9%, 3.8%, and 4.4% for the same years; key performance indicators showed averages above the reference values such as hemoglobin, serum phosphorus, eKt/V, water quality, number of days of hospitalization per patient per year, and number of weekly dialysis sessions. The financing analysis of IM ESRD demonstrates a sustained control of global costs, without compromising quality. The IM ERSD program is an innovative and quality-driven approach that benefits both dialysis patients and providers, contributing toward the rationalization of service provision and the efficient use of resources.

Financiamento público para a saúde de municípios paranaenses em região de fronteiras (2000 - 2016) / Financiación pública para la salud de municipios de Paraná en la región de fronteras (2000 - 2016) / Public funding for health care in municipalities of the state of Paraná located in the border region (2000 - 2016)

RESUMO Objetivo: analisar a trajetória do financiamento público com ações e serviços de saúde em quatro municípios fronteiriços do Paraná/Brasil, no período de 2000 a 2016. Método: pesquisa quantitativa desenvolvida com dados do Sistema de Informação sobre Orçamentos Públicos em Saúde, analisados por meio de estatística descritiva simples. Resultados: os resultados mostram crescimento dos valores absolutos e relativos aplicados em ações e serviços de saúde ao longo do período; maior participação dos municípios no financiamento; e certo reconhecimento da problemática da fronteira pelos governos federal e estadual por meio de programas específicos. Conclusão: o problema do financiamento da saúde em municípios de fronteira não está equacionado no período posterior à promulgação da Emenda Constitucional nº 29, em 2000, face ao subfinanciamento crônico do sistema e da interrupção de programas específicos. Os resultados contribuem para melhor compreensão acerca do direito à saúde dos residentes na fronteira.

RESUMEN Objetivo: evaluar cómo ocurre la financiación pública con acciones y servicios de salud en cuatro municipios de frontera de Paraná/Brasil, en el periodo de 2000 a 2016. Método: investigación cuantitativa desarrollada con datos del Sistema de Información sobre Presupuestos Públicos en Salud, analizados por medio de estadística descriptiva simple. Resultados: los resultados apuntan crecimiento de los valores absolutos y relativos aplicados en acciones y servicios de salud a lo largo del periodo; mayor participación de los municipios en la financiación; y algún reconocimiento de la problemática de la frontera por los gobiernos federal y estadual por medio de programas específicos. Conclusión: el problema de la financiación de la salud en municipios de frontera no fue investigado en el periodo posterior a la promulgación de la Enmienda Constitucional nº 29, en 2000, considerando la subfinanciación crónica del sistema y la interrupción de programas específicos. Los resultados contribuyen para la comprensión acerca del derecho a la salud de las personas que viven en la frontera.

ABSTRACT Objective: To analyze the history of public funding of health actions and services in four bordering municipalities of Paraná/Brazil, from 2000 to 2016. Method: Quantitative study that uses data from the Information System on Public Health Budgets (SIOPS), analyzed through simple descriptive statistics. Results: The results show the growth of absolute and relative values applied in healthcare actions and services over the study period; greater participation of the municipalities in the funding, and a bit of recognition of the issues related to the border region by the federal and state governments, through the implementation of specific programs. Conclusion: The problem of health funding in border municipalities was not solved after the enactment of Constitutional Amendment No. 29, in 2000, due to the chronic underfunding of the system and the discontinuation of specific programs. The results contribute to a better understanding of the right to health of border residents.

Análise do financiamento e gasto do Sistema Único de Saúde dos municípios da região de saúde Rota dos Bandeirantes do estado de São Paulo, Brasil / Analysis of the Unified Health System funding and expenditure in the municipalities of the "Rota dos Bandeirantes" health region, State of São Paulo, Brazil

Resumo Diante do cenário nacional da falta de recursos no Sistema Único de Saúde (SUS), há diferenças importantes nos modelos de financiamento dos municípios. Desta forma, este estudo tem por objetivo analisar o financiamento e o gasto do SUS dos sete municípios da região de saúde Rota dos Bandeirantes do estado de São Paulo no período de 2009 a 2012. Para a análise foram coletados indicadores de despesa liquidada, disponibilizados pelo Sistema de Informações sobre Orçamentos Públicos em Saúde, apresentando dados descritivos com cálculos de frequências absoluta e relativa. Identificou-se que a receita disponível per capita de Barueri é quase dez vezes maior que a de Carapicuíba, e Barueri gasta em saúde, por habitante, mais que o dobro da média regional, e quase cinco vezes mais que Carapicuíba. A União, responde por 95,4% de todos os repasses realizados para os municípios. Grande parte da receita disponível dos municípios da região é composta por impostos próprios e repasses estaduais. Todos os municípios apresentaram uma evolução positiva significativa tanto da receita disponível quanto dos gastos em saúde. A média regional das receitas próprias aplicadas em saúde é de 27,3%, sendo que em Carapicuíba chegou a 37,5%, muito acima do mínimo exigido pela Constituição Federal que é de 15%.

Abstract The national scenario of lack of resources in the Brazilian Unified Health System (SUS) has led to major differences in the municipalities funding models. Thus, this study aims to analyze SUS funding and expenditure in seven cities of the Rota dos Bandeirantes health region, State of São Paulo, SP, Brazil, from 2009 to 2012. Settled expenditure indicators were collected from the Public Health Budgets Information System (SIOPS) for analysis, showing descriptive data with absolute and relative frequency calculations. We identified that the per capita income available for the city of Barueri is almost tenfold that of the city of Carapicuíba, and that Barueri's health expenditure per capita is more than double that of the regional average and almost fivefold that of Carapicuíba. The Federal Government is responsible for 95.4% of all funding to municipalities. Most of the available income of the municipalities in the region include their own taxes and state transfers. All the municipalities showed a significant positive trend, both for available income and health expenditure. The regional average of own revenue spent on health is 27.3%. Carapicuíba achieved a level of 37.5%, which is much higher than the minimum of 15% required by the Federal Constitution.

A comparative analysis of monthly out-of-pocket costs for patients with breast cancer as compared with other common cancers in Ontario, Canada.

BACKGROUND: Monthly out-of-pocket costs (oopc) for Ontario patients with cancer have previously been reported, but little detail has been provided on differences based on tumour type. METHODS: A questionnaire administered in cancer clinics in the province of Ontario, with a mix of urban and rural patients, was analyzed using descriptive statistics and a regression analysis of cross-sectional data. The dependent variable was oopc (Canadian dollars), analyzed separately for total oopc (excluding imputed travel costs), and for each of the individual cost categories. RESULTS: Compared with colorectal, lung, and prostate cancer patients combined, breast cancer patients had statistically significantly higher total oopc ($393 vs. $149, p = 0.02), device costs ($142 vs. $12, p = 0.018), and family care costs ($38 vs. $3, p = 0.01). By contrast, they trended toward lower costs for travel ($225 vs. $426, p = 0.055) and had lower costs for parking ($32 vs. $53, p = 0.0198). Compared with non-breast cancer patients, patients with breast cancer reported a greater perceived financial burden (31% vs. 17% p = 0.0133). INTERPRETATION: These findings highlight that financial burden for cancer patients can vary by tumour type, and that patients with breast cancer may require a different mix of supportive services than do patients with other common tumour types. Supportive care programs related to financial burden should consider the likelihood and nature of financial burden when counselling breast cancer patients.

Diferentes obstáculos financieros en la consulta con profesionales de la salud en Argentina / Different financial obstacles when consulting health professionals in Argentina / Diferentes obstáculos financeiros na consulta com profissionais da saúde na Argentina

En el artículo se analizan los obstáculos financieros que debe atravesar la población para acceder a la consulta con un médico, un odontólogo y un psicólogo o psiquiatra en las zonas urbanas de Argentina. El trabajo está basado en la Encuesta de Utilización y Gastos en Servicios de Salud realizada en el año 2010 de forma conjunta por el CEDOP (UBA) y la DEIS (MSAL). Como resultado se encuentra que existen obstáculos financieros diferenciales para la consulta con los distintos profesionales de la salud. Aquellos que consultan con un odontólogo, o con un psicólogo o psiquiatra tienen que gastar más dinero “de su bolsillo” que aquellos que se atienden con un médico. El principal motivo que explica estos gastos diferenciales es la distinta cobertura que el sistema argentino brinda a la consulta con los profesionales.

In this article we analyze the different financial obstacles the population has to go through in order to have access to a doctor, a dentist, a psychologist or a psychiatrist in urban areas in Argentina. The work is based on a Survey about Use and Expenditure on Health Services carried out in the year 2010 together by CEDOP (UBA) and DEIS (MSAL). As a result, we see that there are differential financial obstacles to make appointments with different health professionals. Those who see a dentist, a psychologist or a psychiatrist have to spend more of their “own” money than those who see a doctor. The main reason explaining this differential expenditure is the different coverage the Argentine system provides for the appointments with professionals.

Neste artigo são analisados os obstáculos financeiros com que a população deve se deparar na hora da consulta com um médico, um dentista e um psicólogo ou psiquiatra nas áreas urbanas da Argentina. O estudo baseia-se na Enquête de Utilização e Despesas nos Serviços de Saúde realizada em 2010 conjuntamente pelo CEDOP (UBA) e a DEIS (MSAL). Como resultado, achou-se-que existem obstáculos financeiros diferenciais para a consulta com diferentes profissionais da saúde. Aqueles que consultam com um dentista ou com um psicólogo ou psiquiatra devem gastar mais dinheiro, pela sua conta, que aqueles que-são atendidos por um médico. O motivo principal que explica estas despesas diferenciais é uma cobertura diferente que o sistema argentino oferece na consulta com os profissionais.