International
Call for Papers
Lessons from Abroad: The Value of
International Comparisons
Chair: Nick Black, London School of Hygiene
& Tropical Medicine
Monday, June 27 • 11:00 am – 12:30 pm
●Government Health Expenditures and Health Outcomes
Farasat Bokhari, Ph.D., Pablo Gottret, Ph.D., Yunwei Gai, MA
Presented By: Farasat Bokhari, Ph.D., Assistant Professor,
Economics, Florida State University, 288 Bellamy Boulevard,
FSU, Tallahassee, FL 32306-2180; Tel: (850) 644-7098; Fax:
(850) 644-4535; Email: fbokhari@fsu.edu
Research Objective: The Millennium Development Goals
(MDGs) which have specific targets to be met by year 2015,
call for a reduction in the under-five mortality (U5M) by 75%
and maternal mortality (MM) by 65% of their 1990 levels.
Prior studies show that the impact of government health
expenditures (GHE) on health outcomes may be insignificant
after controlling for income effects and projections indicate
that with reasonable assumptions about income growth rates
many countries will fall short of meeting these targets. Using
new data and modern techniques of estimation, this study
aims to estimate if GHE reduce maternal and under-five
mortality significantly and if so by how much.
Study Design: Based on instrumental variables techniques
(GMM-H2SL), we estimate the elasticity of U5M and MM with
respect to GHE and income while treating both variables as
endogenous. Other control variables include measures of
education, roads and sanitation as well as the level of donor
funding available to the countries. Our identifying
instruments include military budged of neighboring countries,
own investment to consumption ratios and annual
assessment by the World Bank of the quality of polices and
institutions in 4 broad areas countries borrowing from
International Bank for Reconstruction and Development
(IBRD) and from International Development Association
(IDA).
Population Studied: The sample consists of observations
from 131 countries for the calendar year 2000.
Principal Findings: Our elasticity estimates are larger in
magnitude than those reported previously in the literature.
The elasticity of U5M with respect to GHE ranges from -.28
(high income countries or countries with no donor funding)
to -.51 (low income countries with large donor funding) with
the mean value of -.31. For MM the elasticity ranges from -.36
(high income countries with low donor funding) to -.81 (again
low income countries with large donor funding) with the mean
value of -.44. Additionally we find that donor funding has no
direct impact on these health outcomes, but it makes a
significant marginal contribution to the impact of GHE on
health outcomes. Specifically, countries receiving large
amount of donor funding are also the countries with larger
magnitude of elasticity of maternal mortality with respect to
government health expenditures.
Conclusions: Government health expenditures have a
significant impact on health outcomes and that donor funding
makes a marginal contribution to the impact of government
health expenditures on these outcomes.
Implications for Policy, Delivery, or Practice: First,
increases in government health expenditures do generate
improved outcomes in terms of U5M and MM. Yet the
impact will vary depending not only on the outcome being
measured but also on the quality of policies and institutions
such as budgeting procedures at the country level. Second,
and as shown in the literature, outcomes are influenced by
factors outside health alone such as road infrastructure,
education and others. Given each government's budget
constraint, a careful analysis must be made regarding the best
allocation of scarce resources to produce improved outcomes.
We see that a large donor presence has a marginal impact by
increasing the impact that GHE has on outcomes, specially in
the case of maternal mortality. This may be because of: (i) the
large volatility of donor funding at the country level which
diminishes the direct impact on health outcomes; and (ii) the
incentives that donor funding of primary care generate on
governments which may use their own resources to provide a
more stable source of funding for secondary and tertiary care
services required to make an impact in maternal mortality.
This certainly implies donors must exercise care in analyzing
the impact of their own resources and may not actually attain
the outcomes initially intended.
Primary Funding Source: World Bank (BNPP Trust Fund)
●Welfare State Matters: A Multilevel Approach
Haejoo Chung, RPh, MS, Carles Muntaner, M.D., Ph.D.
Presented By: Haejoo Chung, RPh, MS, Ph.D. Student,
Health Policy and Management, The Johns Hopkins
Bloomberg School of Public Health, 645 North Broadway
Street Hampton House 708, Baltimore, MD 21205; Tel: (443)
527 6298; Email: hachung@jhsph.edu
Research Objective: Building on the social science literature,
we hypothesized that population health indicators in wealthy
industrialized countries are ‘clustered’ around welfare state
regime-types. We tested this hypothesis during a period of
welfare state expansion from 1960 to 1994.
Study Design: We categorized data from 19 wealthy countries
into 4 different types of welfare state regimes (Social
Democratic, Christian Democratic, Liberal and Wage Earner
welfare states). Outcome variables were the infant mortality
rate (IMR) and the low birth weight rate (LBW), obtained from
the Organization of Economic Co-operation and Development
(OECD) Health Data 2000 and from the United Nations
Common Statistical Database (UNCSD). A 3-level multilevel
model with regime-type as the level 3 random variable was
statistically significant for the whole 35 years, as well as for its
four constituent decades (60s, 70s, 80s, and 90s) separately.
Population Studied: 19 Wealthy Countries from North
America, Europe, Asia, and Oceania.
Principal Findings: The variance explained by welfare regimetype level was 20-40% of the total for IMR and 40-50% for
LBW. The proportion of the variance explained by regime-type
level was highest in the 1960s, at a minimum in the 1970s,
and increased thereafter. Social Democratic regimes had
significantly better health indicators than other countries,
while the remaining 3 types of welfare state regimes were not
significantly different from one another. There was a stronger
divergence between the Social Democratic regimes and the
other countries in terms of child health indicators during the
“neo-liberal” era (1980s-1990s).
Conclusions: Our analysis indicates that in order to account
for regime-type variability, comparative international studies of
health indicators should use regime-type level fixed effects in
their analysis.
Implications for Policy, Delivery, or Practice: Thus, future
studies on international health comparisons of political and
economic factors may not be adequate in assuming that
countries are independent. Rather, supranational social policy
regimes seem to account for a substantial portion of the
variation in health indicators between rich countries.
Primary Funding Source: No Funding
●Picking Out the Pieces: Ethics and Morality in Global
Nurse Migration Policy
Sat Ananda Hayden, MSN, RN, HSA, Lutchmie Narine, Ph.D.,
Rosie O. Tong, Ph.D.
Presented By: Sat Ananda Hayden, MSN, RN, HSA, Doctoral
Student, Ph.D. Program in Public Policy, University of North
Carolina at Charlotte, 9201 University City Boulevard,
Charlotte, NC 28223; Tel: (704)687-6272; Fax: (704)583-4467;
Email: sahayden@uncc.edu
Research Objective: This study explores the extent ethical
and moral arguments are considered in policy discussions
about international nurse recruitment. International nurse
recruitment can seem a morally neutral phenomenon but
there is growing recognition that it in fact may have significant
moral and ethical impacts. For developing countries, the
losses of large numbers of highly skilled workers represents
investment losses in human capital and have the potential to
threaten their ability to establish and maintain basic public
health measures. In this study we look at the ethics of a
tradeoff between access to health care and freedom of
movement by health care professionals; dilemmas created
when one group of highly skilled professionals is treated
differently than others; and the ethical and moral implications
of brain drain.
Study Design: This research is a meta-synthesis of existing
studies. Studies were identified using major key search terms
on Medline, CINHAL, social science citation index, and other
health care databases. Published and unpublished papers
addressing ethical recruitment of nurses by national and
international professional nursing organizations and major
institutions were also reviewed.
Population Studied: Previous studies on nurse immigrants,
migration of medical professionals, and issues of globalization
related to brain drain.
Principal Findings: Few studies on nurse recruitment have
considered the ethical implications of international nurse
recruitment. It is not known what effects recent ethical
statements from international agencies may have as
recruitment efforts are conducted by private employment
agencies that are external to government and professional
organizations. There are currently no mechanisms to monitor
recruitment methods and approaches. Few ethical standards
for nurse recruitment addressed the health care access and
quality of care problems that may arise in source countries.
Nor has there been explicit examination of the ethics
associated with the loss of capital investment experienced by
these countries.
Conclusions: Current discourse regarding international nurse
recruitment fails to address the issue in terms of professional
ethics and values. While they address exploitation and
mistreatment of nurse immigrants, ethical statements fail to
consider the financial and social exploitation of source
countries. The impact of equity and efficiency tradeoffs
between Northern and Southern countries remains largely
unexplored. The failure to take into account ethical
implications limits the policy discussion taking place about
international recruitment and so may hinder attempts to fully
understand what the phenomenon involves, its effects, and
what might be the best options available to address the
problem.
Implications for Policy, Delivery, or Practice: Elucidation of
the ethical and moral dilemmas inherent in international
nurse recruitment can help researchers and policy makers to
identify a way to better understanding this topic as both a
domestic and foreign policy issue. For healthcare
administrators this new understanding provides a framework
for thinking about the tradeoffs between using domestic or
foreign prepared nurses. For policymakers and nurse
educators, this information will assist in decision-making
about increasing domestic production of professional nurses.
Professional nursing organizations, professional associations,
and nursing leaders can use these findings to help them better
integrate professional ethics and values in their approaches to
international nurse recruitment
Primary Funding Source: No Funding
●Chronic Diseases as Tracer Conditions in International
Benchmarking of Health Systems: the Example of Diabetes
Ellen Nolte, MPH, Ph.D., Chris Bain, M.D., MSc, Martin
McKee, MBBS, MPH, MS
Presented By: Ellen Nolte, MPH, Ph.D., Senior Lecturer,
Public Health & Policy, London School of Hygiene & Tropical
Medicine, Keppel Street, London, WC1E 7HT; Tel:
+442076127809; Fax: +442076127812; Email:
ellen.nolte@lshtm.ac.uk
Research Objective: Recognition of the limitations of
composite measures of health system performance has
highlighted the need for a battery of measures that capture
different aspects of health systems, and in particular issues
such as the ability to respond to chronic diseases that are not
easily measured. This paper proposes the use of tracer
conditions as a means to overcome some of the limitations
inherent in current approaches to performance assessment,
such as that used in the 2000 World Health Report.
Study Design: We selected diabetes as a tracer condition as
there is an explicit, internationally agreed, case definition and
data are available on incidence and outcome (mortality) in
industrialized countries. We generated a measure of “casefatality” among young people with diabetes using the
mortality/incidence ratio (M/I ratio). Standardized incidence
rates for ages 0-14 years were extracted from the WHO
DiaMond study for the period 1990-1994; data on death from
diabetes for ages 0-39 years were obtained from the World
Health Organization mortality database and converted into
age-standardized death rates using the European standard
population for the period 1994-1998.
Population Studied: 29 industrialized countries with
published data on diabetes incidence and mortality.
Principal Findings: We show a more than 10-fold variation in
the M/I ratio across industrialized countries, with highest
ratios in former communist countries of central and eastern
Europe as well as in Japan and the United States. These
relative differences are similar to those observed in cohort
studies of mortality among young people with type 1 diabetes
in five countries. An sensitivity analysis showed that, using the
plausible range of assumptions about potential
overestimation of diabetes as a cause of death and an
underestimation of incidence rates in the USA yields a M/I
ratio that would still be twice as high as in the United
Kingdom or Canada. This indicates that the observed
differences are unlikely to be explicable by data problems.
Conclusions: The ratio of mortality to incidence for diabetes
provides a means of differentiating countries that provide
differing quality of care to people with diabetes and potentially,
by extension, other chronic diseases. Although only an
indicator of potential problems, it should stimulate more
detailed assessments that can identify whether such problems
exist and what they are.
Implications for Policy, Delivery, or Practice: Many
international comparisons of health systems have focused on
what can most readily be measured such as rates of elective
surgery. This paper is an attempt to show how to shift the
agenda on performance assessment practically to those
disorders such as chronic disease that, while less visible, are
critically important.
Primary Funding Source: The Nuffield Trust
●Public Involvement in Health Care: Examples from
Europe
Suzanne Wait, MPH, Ph.D., Ellen Nolte, MPH, Ph.D.
Presented By: Suzanne Wait, MPH, Ph.D., Nuffield Trust
Fellow, The Judge Institute, Cambridge University,
Trumpington Street, Cambridge, CB2 1AG; Tel:
+441223766639; Fax: +441223339701; Email:
s.wait@jims.cam.ac.uk
Research Objective: Public involvement policies are
increasingly advocated as a means to enhance health system
responsiveness. Yet the evidence base of whether such
policies achieve this aim is weak. Most policies aimed at
enhancing public involvement in health (care) policy are
recent and the objectives, rationale and evaluative criteria
against which to measure their impact are rarely specified.
Also, there is little understanding of the confounding factors
that may enable or hinder public involvement policies within
different health care contexts. This study aims to identify
contextual factors that influence the adoption and/or
implementation of public involvement in health policy by
examining the experience of five European countries.
Study Design: Review of the academic and grey literature on
public involvement policies in England, Finland, France,
Germany and Italy. Relevant work was identified from a
systematic search of Embase and PubMed for the years 1980
to the present, complemented by an iterative search of the
World Wide Web using common search engines, using
designated keywords.
Population Studied: England, Finland, France, Germany, Italy
Principal Findings: The rationale for enhancing public
involvement policies has differed between countries. In
England, public involvement is expected to restore trust and
accountability within the health system whereas in France,
policies are driven by a need to enhance responsiveness and
quality. In Italy, a grassroots active citizen engagement
movement has taken responsibility for ensuring that quality
targets and policy objectives are adhered to, holding the
government accountable for system responsiveness. Finland
has taken the legislative route to protect patients’ rights and
public participation in governance structures. In Germany, the
discussion seems largely centered on the democratic
legitimacy of public and patient bodies as representatives of
‘the public’.
Conclusions: Public involvement has received considerable
attention in health policy over the past decade. Yet the scope,
objectives and desired outcomes of existing public
involvement policies remain poorly defined. Whether and how
the various initiatives will achieve the implicit aim to enhance
health system responsiveness remains to be elucidated, as
does the development of appropriate measures of the impact
of given initiatives. What is clear from past experience is that
challenges remain beyond the creation of formal structures.
Implications for Policy, Delivery, or Practice: True public
involvement will have significant implications for the
governance of health systems and may require redistribution
of power between the various stakeholders. More research is
needed to better understand the expectations and motivations
behind different roles assumed by individuals and the impact
of different health system contexts.
Primary Funding Source: The Nuffield Trust
Related Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Determinants of Global Ratings and Recommendation by
Patients in the Dutch Hospital CAHPS Pilot
Onyebuchi A. Arah, M.D., D.Sc., MPH, Guus ten Asbroek,
MSc, Aldien Poll, MSc, Piet Stam, MSc, Johan de Koning,
MPH, Ph.D., Niek S. Klazinga, M.D., Ph.D.
Presented By: Onyebuchi A. Arah, M.D., D.Sc., MPH, ,
Department of Social Medicine, Academic Medical Center of
the University of Amsterdam, Meibergdreef 9, PO Box 22700,
Amsterdam, 1100 DE; Tel: (00)31-20-5665049; Fax: (00)31-206972316; Email: o.a.arah@amc.uva.nl
Research Objective: As a result of the increasing competition
in Dutch healthcare, patient experience surveys have become
even more important in guiding choice and highlighting
performance of insurers, providers and hospitals. Studies
suggest that patient experiences of care may be very important
determinants of their satisfaction and ratings. It is not very
clear, however, which care experiences are the most important
determinants of the global ratings that patients give providers
and their hospitals. This study estimates the effect of patient
experiences on global ratings and their likelihood to
recommend the hospital to family and friends.
Study Design: We use the sample adult file from the 2004
Dutch hospital pilot study which used the United States
hospital CAHPS (Consumer Assessment of Health Plans
Study) instrument. We estimate separate joint models of
patient care experience, on the one hand, and global ratings
(of the nurses, doctor and hospital) and likelihood to
recommend the hospital to family and friends, on the other
hand. Patient care experiences are calculated as the composite
scores of 7 core domains of hospital performance, namely
doctor’s communication, nursing services, nurses’
communication, hospital physical environment, pain control,
communication about medication, and discharge information.
All models are adjusted for patients’ age, education, gender,
and self-reported general health status and mental health
status.
Population Studied: Adult patients aged 18 years or older
who were discharged, within the previous 2 months, from
hospital admission in selected Dutch cities in 2003 and 2004.
Principal Findings: We find that nurses’ communication is
the most significant determinant for giving higher global
ratings of nurses and hospitals. Although doctor’s
communication is the most positively associated with the
doctor’s ratings, its postive influence on hospital rating is only
50% that of the nurses’communication (p=0.002). Nurses’
communication is also the most important determinant of
patients’ likelihood to recommend a hospital. Getting
discharge information had the least influence on patients’
ratings of the nurses, doctors and hospitals as well as on their
recommendation of the hospital to family and friends.
Physical environment, pain control, communication about
medication and nursing have varying low-to-moderate impact
on ratings and recommendation.
Conclusions: Nurses’ and doctor’s communication and care
exert the most influence on patients’ ratings of nurses, doctor
and hospital as well as their likelihood to recommend the
hospital in question. Nurse-patient interactions are particularly
important to patients’ likelihood to recommend a hospital.
Implications for Policy, Delivery, or Practice: Current
minimal interests in the role of nurses in Dutch hospitals
performance need re-evaluation. Like Donabedian pointed,
and as this study shows, focusing on the interpersonal care
component of quality is very important, and may trump an
overemphasis on technical performance. Hospitals in the
Netherlands that want to stay competitive in the new
healthcare market will do well to strengthen the
communication and caring skills of their nurses and doctors
in a balanced manner. Policymakers, purchasers and insurers
need high quality information on interpersonal care, and not
just the technical, performance of hospitals. Using the
hospital CAHPS instrument also encourages international
comparative learning between the United States and the
Netherlands.
Primary Funding Source: Agis Health Insurance, Amsterdam
●The Importance of Access to Effective Care: Lessons
From the Former Soviet Union
Dina Balabanova, Ph.D., MSc, Martin McKee, M.D., Ph.D.
Presented By: Dina Balabanova, Ph.D., MSc, Lecturer, Health
Policy, Public Health and Policy, London School of Hygiene
and Tropical Medicine, Keppel Street, London, WC1E 7HT;
Email: dina.balabanova@lshtm.ac.uk
Research Objective: In the past decade, the countries that
emerged from the Soviet Union have experienced major
changes in the inherited Soviet model of health care that was
centrally planned and provided universal, free access to basic
care. Our research programme aimed to explore to what
extent the underlying principle of universality is retained under
the new funding and delivery systems.
Study Design: The paper draws on the findings of a series of
studies conducted by the authors: cross sectional
representative surveys conducted in eight FSU countries in
2001, an analysis of mortality statistics (avoidable mortality) in
Russia between 1965 and 2002, analysis of the Russian
Longitudinal Monitoring Survey, and rapid appraisal studies of
diabetes care in Ukraine and Kyrgyzstan.
Population Studied: The populations of Armenia, Belarus,
Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania,
Moldova, Russia, and Ukraine.
Principal Findings: While the USSR was able to implement a
system of universal coverage, it was unable, from the 1970s
onwards, to respond to the challenge of growing complexity of
health care. Yet while lagging behind western countries in
sophistication of care, it was able to maintain a basic service
for all. Following the collapse of the USSR, only a few
countries were able to make an effective transition to new
systems of financing and delivery. In Russia, a new health
insurance system was introduced, achieving about 90%
coverage; those excluded share many of the characteristics of
the uninsured in the USA. In some other countries, especially
in Georgia and Armenia, families face major financial barriers
to obtaining care, which often leads to necessary help being
deterred. In contrast, in Russia and Belarus, access has largely
been maintained. In all countries, the already disadvantaged
have suffered most. Where systems collapsed, the most
striking finding was the increase in death rates from chronic
diseases, such as diabetes, condition for which outcomes are
especially poor among the uninsured in the USA. Rapid
appraisal studies demonstrate how the presence of chronic
disease in the absence of an effective health system leads to a
downward spiral of impoverishment and premature death.
Conclusions: Political transformation and health sector
reform in the FSU has had adverse consequences for access
to health care, manifested through endemic informal
payments, underinsurance, and inability of the health systems
to respond to complex chronic disease. There are widening
inequalities between population groups and countries,
affecting health outcomes.
Implications for Policy, Delivery, or Practice: The break-up
of the USSR provides a series of natural experiments in which
it is possible to assess the impact of political and economic
change on population health. In particular, the varying extent
to which countries have been able to maintain universal health
care coverage, and the health consequences associated with
these efforts, provide new insights on the consequences of the
failure to provide coverage. Although the scale and nature of
the problems facing the ex USSR countries are very different
from those in western countries, they do offer some lessons,
in particular about the consequences of inadequate health
care coverage.
Primary Funding Source: UK Department for International
Development
●Integrating Stakeholder Needs with Telecare Service
Development: Lessons From the UK
James Barlow, Ph.D., BA, Hazel Aldred, Steffen Bayer, Ph.D.,
MSc, BA, Simon Brownsell, Ph.D., BA, Richard Curry, BA, BSc,
Mark Hawley, Ph.D., BSc
Presented By: James Barlow, Ph.D., BA, Chair in Technology
& Innovation Management, Tanaka Business School, Imperial
College London, South Kensington Campus, London, SW7
2AZ; Tel: 020 7594 5928; Fax: 020 7594 5915; Email:
j.barlow@imperial.ac.uk
Research Objective: The UK government wishes to provide
home telecare services to all those who need them by 2011.
Around $150m is available to pump prime schemes, but policy
makers are unclear about which user groups and services
should be prioritised. This paper shows how detailed user
needs analysis and simulation modelling can inform telecare
policy and investment decisions.
Study Design: We draw on findings from two major research
projects on the implementation of telecare aimed at
maintaining older people’s independence. One project
analysed stakeholder needs (end users and care providers) as
a precursor to telecare service development. We addressed
this from two perspectives. We explored attitudes towards
telecare in 19 focus groups (183 older people and carers).
Second, we conducted a detailed evaluation of factors
triggering increasing levels of care (through an extensive
literature review and further focus groups) and mapped these
against telecare to explore its role in supporting independence
and quality of life (QOL). This enabled us to link an
understanding of changes in user needs to current provision
of services and an exploration of how telecare might enhance
them.
The second project used systems dynamics modelling to
investigate how telecare impacts on patient flows within a
local care system. By segmenting the older population
according to degree of frailty and including different flow rates
between these segments and institutional care settings, we
captured policy relevant effects of new telecare enhanced care
paths. Data were based on estimates from national statistics,
adapted to the situation within a local care authority, and
informed by a telecare trial conducted in the same area.
Population Studied: Older people, stakeholders from local
social and health care services within the UK.
Principal Findings: We identified 107 factors triggering
increased levels of care and prioritised the 36 most important.
Mapping telecare against these showed that existing systems
can impact on 66% of factors (86% if emerging systems
prove successful). Factors commonly regarded as
underpinning QOL correspond with 33 of the priority trigger
factors. Together, this allowed us to develop a perspective on
areas where telecare could support the independence and
QOL of older people by altering their care paths. However,
policy and investment decisions also need to be made on the
basis of their costs and benefits. Simulation modelling
suggested that the time required for benefits (e.g. a reduction
of the residential care home population) to become effective
may be long compared to the typical time horizons of decision
makers in health and social care.
Conclusions: Research on the links between user needs, QOL
and factors triggering increased levels of care provides a
baseline to inform the development of new telecare services,
but simulation modelling is needed to explore their wider
impact.
Implications for Policy, Delivery, or Practice: To meet
government aspirations for mainstreaming telecare it is vital
to identify areas where it is likely to deliver the greatest benefit.
Work is now needed to identify which trigger factors and
corresponding telecare interventions provide the greatest
benefit in meeting user needs, helping more people remain
independent and simultaneously containing the increase in
demand for care services.
Primary Funding Source: EPSRC (UK)
●Italian Mental Health Care Reform and Psychiatric
Deinstitutionalization in Anthropological, Political, and
Historical Perspective
Sara Bergstresser, Ph.D.
Presented By: Sara Bergstresser, Ph.D., NIMH Postdoctoral
Fellow, Health Care Policy, Harvard Medical School, 180
Longwood Ave., Boston, MA 02115; Tel: (617) 432-3137(617)
432-3137; Email: bergstre@hcp.med.harvard.edu
Research Objective: The process of health reform can be
better understood and evaluated when examined within
specific historical, political, and cultural contexts. This study
objective was to examine the Italian experience of mental
health care reform and psychiatric deinstitutionalization from
before the 1978 law through its aftermath with a focus on the
longer-term processes of implementation. Following reform
goals of community participation and stigma reduction,
interaction between community health center users and the
general public of the surrounding community was also
examined in relation to the successful performance of
everyday local life and the potential for stigma reduction
through interpersonal interaction.
Study Design: The approach used in this study is
anthropological. At one level, it involves intensive
ethnographic case study of the day-to-day life within a
community mental health center and surrounding town as
well as its place within the broader national system. This level
was based on fieldwork conducted in the study area for a total
of 16 months within 2000 and 2001-2. At the broader
contextual level, this qualitative case study is framed within
relevant political, cultural, and historical contexts as well as in
comparison to an historical examination of
deinstitutionalization in the US.
Population Studied: Ethnographic portions of the study were
conducted primarily within a local community mental health
center situated within a Northern Italian town of
approximately 6000 inhabitants.
Principal Findings: The history of the reform, including
elements of a social movement and political contexts, allowed
the allocation of many resources to the plan. Realities of the
Italian political and legal systems made it difficult to change
these reforms once established, helping to provide continuity,
Difficulties in implementation of ideological law that are still
being addressed in some areas until the present day.
Participation in the local patterns of everyday life have
therapeutic value; positive attitudes were expressed towards
the utility of performing everyday tasks as well as social
interaction with a broad range of individuals within and
beyond the center itself. Evidence of the reduction of social
stigma as related to mental illness was expressed in interviews
addressing self-reported attitudes towards mental illness and
the presence of the community center among members of the
surrounding community.
Conclusions: The long-term investment of resources and
attention is a key component of the implementation of a
community mental health system. The political and historical
contexts of reform played a key role in the ability of the Italian
system to take adequate time to address emerging problems
and to form a strong community mental health infrastructure.
Community participation for mental health center clients,
particularly in the areas of interpersonal interaction, the
scheduling of everyday life according to local norms, and work,
simultaneously plays a therapeutic role as well as leading to
some reduction of social stigma.
Implications for Policy, Delivery, or Practice: The
implementation of a community mental health system must
involve long term investment, not decreasing or eliminating
resources if improvement is not immediately evident. A
community model is best conceptualized with substantial
attention paid to local practices, expectations, and interaction
patterns. The Italian system, involving a national system
implemented locally, provides an instructive model program
where resources are nationally dedicated to community
mental health centers while retaining focus on the needs of
local populations.
Primary Funding Source: NIMH NRSA Funding
●Health Disparities in the U.S. and Canada
Jean-Marie Berthelot, BSc, Nancy A Ross, Ph.D.
Presented By: Jean-Marie Berthelot, BSc, Manager, Statistics
Canada, Health Analysis and Measurement Group, Ottawa
(Ontario), K1A 0T6; Tel: (613)951-3760; Fax: (613)951-3959;
Email: berthel@statcan.ca
Research Objective: It is now widely accepted that higher
socio-economic position is associated with better health. This
relationship is found across most disease outcomes, and
across places and through time, regardless of how social
position is measured.
Study Design: Using the Joint Canada/U.S. Survey of Health,
we examined the size of the health disparities across the two
countries. The analysis looked not only at income but also at
gradients in health status related to wealth. We also compared
health status of individuals in the two countries at different
points along the income and wealth scales so that we might
directly compare, for example, the health status of poorer
Americans and Canadians.
Principal Findings: Almost one-third (31%) of Americans in
the lowest income group reported fair or poor health,
compared with only 23% among their Canadian counterparts.
Significant differences were also noted for the lowest income
group with regard to severe mobility limitations, smoking,
obesity and unmet health care needs. No systematic
differences for these outcomes were observed among the
most affluent households on either side of the border.
Conclusions: The social gradient in health and health care
services is steeper in the U.S. than it is in Canada for many
outcomes.
Primary Funding Source: Canadian Institute for Health
Research
●Use of Mental Health Care Services in the United States
and Canada: Findings from the Joint Canada/United
States Survey of Health
Debra L Blackwell, Ph.D., Jane F. Gentleman, Ph.D., Michael E.
Martinez, MPH
Presented By: Debra L Blackwell, Ph.D., Senior analyst,
Division of Health Interview Statistics, National Center for
Health Statistics, 3311 Toledo Road, room 2326, Hyattsville,
MD 20782; Tel: (301)458-4103; Email: ZDF1@CDC.GOV
Research Objective: As for other health care services, Canada
and the United States have different approaches to financing
mental health services care for their residents. Canada has a
single payer plan in which all residents have governmentsponsored health insurance coverage for most mental health
care services. In contrast, in the U.S., limited funding for
mental health care services comes from health insurance
providers.
Study Design: The Joint Canada/United States Survey of
Health (JCUSH) was used to examine differences in the
utilization of mental health care services between the two
countries, with particular focus on the effects of health
insurance coverage. In order to properly control for selection
effects, we first predicted the probability of being depressed
among all respondents. Then utilization of mental health care
services among depressed respondents is predicted, while
controlling for various demographic, socio-economic
(including health insurance coverage), and health status
factors.
●An Exploratory Analysis of Nonprofit Approaches to
Health Services Delivery in Bulawayo Zimbabwe
Martha Conkling, MSPH
Presented By: Martha Conkling, MSPH, Graduate assistant,
Health Policy and Management, School of Rural Public health,
3000 Briarcrest, Suite 300, Bryan, TX 77802; Tel: (979)-4583031; Email: mctromp@srph.tamhsc.edu
Research Objective: Zimbabwe has a high prevalence of
HIV/AIDS with up to 25 percent of the population from 18-46
years are infected with the virus. Approximately 3800 people
die every week of AIDS. The life expectancy for males has
fallen to 36 years. Record inflation and unemployment fuel
the epidemic. This study was undertaken to explore the role of
nongovernmental organizations (NGOs) in the provision of
health services in Bulawayo, Zimbabwe at this juncture. The
goals of the study were to provide a better understanding of
the reasons and resources that are implemented by NGO’s to
carry out their mandates.
Study Design: A qualitative research design with 45 minute
face to face, taped interviews was employed. An interview
protocol was designed and followed in each of the interviews.
Questions varied slightly depending on the type of
organization interviewed, i.e. health service delivery or health
policy/donor. The interview was based on questions
concerning organization background and operational
information, resource dependencies, accountability and interrelationships with other NGOs in the city.
Population Studied: Fifteen non-profit, health delivery
organizations in Bulawayo, Zimbabwe in July and August of
2004 and 5 non-profit health policy organizations that
supported some of the Bulawayo NGOs in Harare, Zimbabwe
in August 2004. The people who were interviewed held upper
administration positions in the organization they represented.
Principal Findings: Small locally founded NGOs struggle to
find resources and training to build capacity. All
organizations, large, small, local and international, are
involved in home based care. The need is so extreme that all
other projects have been put on hold. A desire to coordinate
services and create some form of communication among the
NGOs serving Bulawayo, in order to work effectively and
efficiently among the infected and the affected, are key
responses to questions of NGO inter-relationships. Standards
for home based care have been identified nationally and
training has begun to implement those standards. Antiretrovirals are being introduced in Zimbabwe for the first time
to individuals who have a t-cell count below 200. The one
NGO that has historically dealt with TB is struggling to keep
one office in Zimbabwe open, the one in Bulawayo.
Conclusions: Health services are being delivered in
households throughout Zimbabwe. The government health
service system cannot respond to the demand for even the
most basic medicines for HIV/AIDS patients. Expertise and
manpower are limited but do exist, as does the knowledge of
how to adequately deal with the HIV/AIDS crisis. While donor
NGOs are no longer able to work in Zimbabwe, support and
new strategies do exist, particular in the volunteer sector.
Implications for Policy, Delivery, or Practice: Among
Zimbabwe NGOs the struggle to communicate, share
information and continue working is dependent on consensus
building. Donor NGOs are asked to contribute to teaching
proposal writing, report writing skills, and professional
development. Volunteers entering the country for short
periods of time are a possible option considering the current
economic and political crisis.
Primary Funding Source: No Funding Source
●The Role of CAHPS in the Dutch Health Care System:
Developing Disease-specific Patient Questionnaires
Diana Delnoij, Ph.D., Niek S. Klazinga, Professor, Guus ten
Asbroek, MSc, Jolanda Groenendijk, MSc, Hugo M. Smeets,
MSc, Aldien Poll, MSc
Presented By: Diana Delnoij, Ph.D., research coordinator,
NIVEL, PO Box 1568, Utrecht, 3500BN; Tel: +31-30-2729847;
Fax: +31-30-2729847; Email: d.delnoij@nivel.nl
Research Objective: In the past decade, in the Dutch health
care system managed competition has been introduced.
Regulated competition between health plans provides them
with a business case to act as strategic purchasers of care.
Selective contracting of care -common in the US- is an
important new tool for Dutch health plans. To avoid that
selective contracting takes place only on the basis of costs,
thereby neglecting differences in the quality of care, the
Netherlands Organisation for Health Research and
Development has issued an extensive research programme for
the development of instruments and indicators that measure
the quality of care. Consumer Assessment of Health Plan
Surveys (CAHPS) developed in the United States are
promoted as state-of-the-art instruments for measuring
responsiveness and client orientation of providers. Using
CAHPS as an example, a whole series of new patient
questionnaires are being developed around several diseases
and/or procedures, e.g. for patients with diabetes, patients
with dyspepsia, and patients who underwent cataract surgery,
or total hip or knee arthroplasty.
Study Design: The questionnaires are developed following a
standardized procedure that consists of: - Selecting relevant
core questions from the CAHPS modules; - Forward/backward
translation of those questions into Dutch/English; - Choosing
the translation that resembles the American original most; Adding disease-specific questions that are based on
qualitative research (focus group discussions with patients;
concept mapping); - Adding questions about disease-specific
outcomes (e.g. complications, or emergency hospital
admissions).
Population Studied: The various disease-specific
questionnaires are in different stages of development. The
questionnaires for diabetes and acid surpressive drugs have
been tested in pilot studies commissioned by Agis, a large
Dutch health plan. Questionnaires were mailed to samples of
enrollees (n=983 for diabetes, n=777 for dyspepsia). The
respons rates were 63% for diabetes and 60% for dyspepsia.
For the other questionnaires the qualitative research has taken
place and the pilot versions of the questionnaires are currently
under construction.
Principal Findings: The patient questionnaire on diabetes
and acid surpressive drugs display good psychometric
properties. The instruments consist of several reliable scales
reflecting respectful treatment and courtesy of providers,
doctor-patient communication, and provision of information
(alpha's between .70 and .90). Patients' experiences with
courtesy and with doctor-patient communication are generally
very well. But particularly the frequency with which family
doctors provide good information about the patient's disease,
is disappointing. Between 30% and 60% of the respondents
report that they (almost) never receive adequate information
e.g. about the causes of their complaints, coping with the
disease in their daily life, or life style. At the conference more
results can be presented from the other questionnaires.
Conclusions: The internal validity of the disease-specific
patient questionnaires based on CAHPS is very good. More
research needs to be done concerning the external validity of
the instruments. Also, close monitoring will take place of the
role of these patient questionnaires in the governance of the
Dutch health care system, which will come to rely more and
more on managed competition and regulated markets.
Implications for Policy, Delivery, or Practice: The
questionnaires have been developed for the Dutch health care
market with the ultimate purpose of generating information
that health plans need to be able to act as strategic purchasers
of care. The first results are promising. The information that
their enrollees have provided through the questionnaires is
already being used by Agis in their contract negotiations with
providers of diabetes care.
Primary Funding Source: Agis Zorgverzekeringen
●The U.S. State Legislatures: International, Sub-national,
National Counter-terrorism Activities
Victoria A. Doyon, MS,
Presented By: Victoria A. Doyon, MS, Senor Research Analyst,
George Mason University, Center for Health Policy Research
and Ethics, 2710 Hemlock Avenue, Alexandria, VA 22305; Tel:
(703)993-1953; Fax: (703)993-1953; Email: vdoyon@gmu.edu
Research Objective: Recent studies have shed light on the
increasing role of the U.S. state legislatures in international
policy making. Moreover, some analysts suggest that the
empirical evidence demonstrates a shift in the focus of state
legislatures from traditional matters such as international
trade as it pertains to their state or region to more wideranging global issues such as healthcare or the environment.
It tests three hypotheses: (1) that U.S. states that were early
innovators were leaders in the international counterbioterrorism arena; (2) that the innovator states were among
the first to enact sub-national counter-bioterrorism legislation;
and (3) states that adopted and/or adapted these legislative
initiatives subsequently assumed a leadership role in crafting
U.S. national counter bio-terrorism policy.
Study Design: The paper uses a case study methodology that
draws on state legislation emerging from 1994 -2004.
Population Studied: This paper explores the U.S. state
legislatures' engagement in counter bioterrorism legislation
between 1994-2004. In particular, the paper examines the U.S.
states as innovators, adopters and adapters of counterbioterrorism legislation.
Principal Findings: It examines the relationship between
international and sub-national counter-bioterrorism state
legislation and U.S. national policy as it pertains to the public
health components of the Homeland Security Act.
Additionally, the paper discusses state legislation
contributions to closely related laws including the Model State
Emergency Health Powers Act, and the Model State Public
Health Act. Careful attention will be given to identify unique
contributions of select innovator states in the design,
development, and implementation of models for counterbioterrorism legislation.
Conclusions: The success of the state legislative models
provides a counter factual example of the critical role for
retaining the basic federal-state partnership inherent to the
U.S. public health system.
Implications for Policy, Delivery, or Practice: The paper has
significance for current debates federal reorganization.
Primary Funding Source: No Funding Source
●International Developments in For-Profit Health Care
Patrick Jeurissen, MPA
Presented By: Patrick Jeurissen, MPA, health economist, ,
Dutch Council for Public Health and Health Care, Plein van de
Verenigde Naties 21, Zoetermeer, 2719 EG; Tel:
0031(79)3687323; Fax: 0031(79)3621487; Email:
p.jeurissen@rvz.net
Research Objective: The objective of this research is to
explain the (possible) growth of for-profit hospital care in
different western countries and the specific patterns in which
for-profit hospital care develops. Why is this different in
different nations?
Study Design: This study is a comparative historical analysis,
which consists of three critical case studies. In a pilot we
found that traditional welfare economic analysis were not very
helpful in explaining our research question. Thus, we looked at
three other competing theoretical perspectives to structure the
research. These are centered around institutionalist(1),
(micro)economic(2) and actorist(3) explanations. For each of
these perspectives a set of working hypothesis was formed.
Then we used literature and secondary research as well as
interviewing to check the robustness of the theoretical
framework within a narrative approach.
Population Studied: We studied the developments of forprofit hospital care since the ending of World War II. The
countries we investigated were the UK (National Health
Service), Germany (Bischmark system) and the US (pluralist
system). We choose the hospital sector, because of its
significance and the availability of adequate sources.
Principal Findings: The approach proved to be useful
because, the complex interactions and dynamics between the
different hypothesis became clear. The evidence supports the
thesis that institutions matter, especially for explaining the
typical and specific developments in individual countries.
However, at the same time growth as such is better explained
by broader and more general developments in the market
structure which favour for-profit hospitals and corporization.
Important aspects are the interwoveness with public
performance of health service delivery, path dependency
patterns especially on the position and remuneration structure
of the doctors, the growing attractiveness of the health care
market, the structural weakening of the non-profit sector and
the growing capital intensity of the sector.
Conclusions: More research is needed to validate these
findings for a more broader set of countries. This can be done
by depending less on qualitative methods and by using a
limited set of key hypothesis and test them with quantitative
techniques.
Implications for Policy, Delivery, or Practice: There are
strong but mostly indirect policy and institutional influences
on for-profit hospital care. Governments should consider a
more direct policy approach, since for-profit health care will be
an important aspect of future health service delivery systems.
These policies should address the combination of market
reforms and the normality of monopolistic or oliogopolistic
market structures.
Primary Funding Source: Research is done for a Ph.D thesis
in the Netherlands and is supported by the employer
●Ultrasonography in the Diagnosis of Appendicitis:
Evaluation by Meta-analysis
Chun-Bae Kim, M.D., Ph.D., Seung-Hum Yu, M.D., Ph.D.,
Joong Wha Park, M.D., Myoung Soo Kim, M.D., David M.
Radosevich, Ph.D.
Presented By: Chun-Bae Kim, M.D., Ph.D., Associate
Professor, Department of Preventive Medicine, Yonsei
University Wonju College of Medicine, 1180 Cushing Circle
Apartment #108, St. Paul, MN 55108; Tel: (612)625-7417; Fax:
(612)624-8448; Email: kimxx360@umn.edu
Research Objective: To review the usefulness of
ultrasonography (US) for the diagnosis of appendicitis and to
evaluate the diagnostic accuracy of US according to patient’s
and researcher’s characteristics.
Study Design: Relevant Korean articles published between
1985 and 2003 were included if patients had clinical symptoms
of acute appendicitis, histopathologic findings were the
reference standard, and data were presented for 2 x 2 tables;
articles were excluded if patients had not sonographic signs of
appendicitis by graded-compression US. Two reviewers
independently extracted data on study characteristics.
Hasselblad method was used to obtain combining estimates
of sensitivity and specificity for performance of US.
Population Studied: Quantitative meta-analysis about 2,643
symptomatic Korean patients in 22 studies was done.
Principal Findings: The estimate of d calculated combining of
sensitivity and specificity was 2.0054 [95% confidence interval
(CI): 1.8553, 2.1554] by a random effects model. Overall
sensitivity, specificity, positive and negative predictive value
was 86.7%, 90.0%, 90.9%, and 85.5%, respectively. According
to subgroup meta-analysis by patient’s characteristics, the d
estimate (95% CI) of dominantly younger age, male, and
highly clinical suggestive group for US was 2.2388 (1.8758 to
2.6019), 2.7131 (2.2493 to 3.1770), 2.4582 (1.7387 to 3.1777),
respectively. Also, according to subgroup meta-analysis by
researcher’s characteristics, the d value (95% CI) for US done
by diagnostic radiologists and gray-scale was 2.0195 (1.7942 to
2.2447) and 2.2630 (1.8444 to 2.6815).
Conclusions: This evidence suggests that US may be useful
in the diagnosis of acute appendicitis, especially when
patients are younger age, male, and clinically highly
suggestive.
Implications for Policy, Delivery, or Practice: To our
knowledge, this study is a cornerstone in which the estimate
formula of d for assessing the accuracy of a new diagnostic
test was used and provides an evidence-based clinical
outcome for medical education and health insurance policy.
Primary Funding Source: Other, 2001 Health Policy Project,
Ministry of Health & Welfare, Republic of Korea
●Equal Access to Health Care: Experience from Taiwan's
National Health Insurance
Ying-Chun Li, Ph.D., Winnie Yip, Ph.D.
Presented By: Ying-Chun Li, Ph.D., Research Associate,
Health Policy and Management, Harvard School of Public
Health, 124 Mount Auburn Street, South 410, Cambridge, MA
02138; Tel: (617) 496-8851; Fax: (617) 496-8833; Email:
ycli@hsph.harvard.edu
Research Objective: International studies of health care
indicate that despite decades of universal and fairly
comprehensive coverage, utilization patterns suggest that rich
and poor are not treated equally in European countries.
Taiwan launched the National Health Insurance (NHI)
program in 1995. The major goals of NHI are to provide
comprehensive universal coverage and equal access to care.
However, few studies have systematically and empirically
evaluated the equality of health care utilization under NHI by
applying nationally representative data sets. The objective of
this study is to test the hypothesis that gaps of health care
utilization between people with different socioeconomic status
will narrow down under NHI over time.
Study Design: Using longitudinal data, this study estimated
individual access to care as a function of income status, preNHI insured status, and their interactions by applying logistic
and OLS models. The models also controlled individual
characteristics and supply of medical care. By examining the
coefficient of the interaction term, we tested whether there is
significant difference between the group that was uninsured
before NHI (treatment) and those that was insured (control)
in the average difference of access to care between the highest
and lowest income groups. Both income and pre-NHI
insured status were further interacted with year variable to
examine the trend changes of NHI effects. In addition, we
conducted the propensity score matching method to test the
robustness of our results to the comparability of study
samples.
Population Studied: From a database of all NHI enrollees,
100,000 samples were randomly selected and followed from
1996 to 2000. Access to care is measured as the probability
of having a western doctor visit, frequency of visits and total
expenditures, conditioned on having a positive physician
contact in past 12 months. The studied population was
divided into three groups: the working population, elderly
persons, and children.
Principal Findings: The results indicate that higher income
status is associated with a higher probability of visiting a
western doctor. The newly insured group utilized fewer
services than previously insured group, but this disparity
shrank over time. Income related differences in access to care
between newly and previously insured groups were equalized
over time under NHI. Moreover, the propensity score
matching results validated the comparability of our study
samples.
Conclusions: The empirical results support our hypothesis
that NHI improves equality in access to health care among
those who were newly and previously insured. The NHI also
reduces disparities of access to care among individuals with
different income status over time.
Implications for Policy, Delivery, or Practice: Our results
suggest that Taiwan's NHI has improved access to health care
for people with lower socioeconomic status. However,
variations in access to care among different age groups imply
that there may be some underlying factors such as individual
preferences on health care utilization beyond the influences of
NHI.
Primary Funding Source: Bureau of National Health
Insurance, Taiwan
●Do Drug Reimbursement Rate Reductions Work?
Evidence from Taiwan's Outpatient Hypertension
Treatments in the Elderly
Shuen-Zen Liu, Ph.D., James Romeis, Ph.D., Hsuan-Lien Chu,
Ph.D.
Presented By: Shuen-Zen Liu, Ph.D., Professor, Accounting,
National Taiwan University, Room 1009, Building II, College of
Management, Taipei, 106; Tel: 011 886 2 27377817; Fax: 011
886 2 27385108; Email: sliu@mba.ntu.edu.tw
Research Objective: This study investigates the initial effects
of Taiwan’s prescription drug reimbursement rate reduction
policy (a supply-side cost control mechanism) in the elderly
with hypertension based on outpatient treatment data.
Study Design: We use regression analysis to examine whether
average prescription drug cost decreases as a result of the
nation’s drug reimbursement rate reduction program. The
probit model is invoked to investigate changes in prescribing
behavior for drugs with and without reimbursement rate
reductions. In addition, we further investigate whether or not
the drug rate reduction policy results in potential adverse
effects on health status.
Population Studied: About 137,000 patients aged 65 and
older with hypertension were drawn from 21 hospitals in the
Taipei area for the study.
Principal Findings: We found that average drug cost per
prescription increased slightly despite the implementation of
the rate reduction policy after controlling for relevant variables
in regression analyses. About 8,900 items of drugs (roughly
45% of the total) experienced rate reductions in the National
Health Insurance [NHI] formulary. Those drugs, however,
appeared only in about 3% of prescriptions. Thus, the policy
had limited impact on total outpatient drug expenditures. As
expected, in the probit model, we found evidence that
physicians substituted drugs experiencing rate reductions with
drug experiencing no rate reductions.
Conclusions: Physicians appeared to be reluctant in reducing
the use of essential drugs even when facing rate reductions,
possibly attempting to avoid an adverse health outcome. The
result may suggest less concern over the quality of health
service because of the policy. Overall, the National Health
Insurance reimbursement rate reduction policy offers a
mechanism to change prescription behavior of physicians by
reducing excessive profits on certain drug items based upon
reliable database of reported drug transaction prices.
Implications for Policy, Delivery, or Practice: In the US,
chemotherapy concessions, referring to drug profits
oncologists earn in treating US Medicare patients, have
recently sparked heated criticisms as conflicts of interest that
create bad medicines. Some propose that US Medicare reduce
the rates so that doctors are reimbursed at prices much closer
to what is actually paid. The NHI in Taiwan has long
recognized potential conflicts of interest in the system and
determined to gradually decrease drug profits through large
scale reimbursement rate reduction initiatives. As little
empirical evidence is available concerning effects of such
regulatory initiatives on cost control and prescribing patterns,
results obtained from this study should help health service
researchers and health policy officials design similar policies
in the US or elsewhere.
Primary Funding Source: National Science Council, Taiwan
●Access to Health Care services in Canada and the United
States: The role of public versus private insurance
Debra L. Blackwell, Ph.D., Jane F. Gentleman, Ph.D., Michael
E. Martinez, Ph.D., Claudia Sanmartin, Ph.D., Jean-Marie
Berthelot, BSc
Presented By: Michael E. Martinez, Ph.D., Senior analyst,
Division of Health Interview Statistics, National Center for
Health Statistics, 3311 Toledo Road, Room 2326, Hyattsville,
MD 20782; Tel: 301-458-4103; Email: ZDF1@CDC.GOV
Research Objective: Canada and the US employ strikingly
different approaches to financing medical care for their
citizenry. Canada has a single payer plan in which all
residents have government-sponsored health insurance
coverage for physician visits and hospitalization. In contrast,
in the US, most funding for health care services comes from
insurance providers. The two countries are similar, however,
regarding dental care and prescription drugs for which
individuals depend on private insurance coverage.
Study Design: The Joint Canada/U.S. Survey of Health was be
used to examine differences in the determinants of health care
utilization between the two countries with a particular focus
on the effects of health insurance coverage. The analysis
focused on services for which private insurance plays a role in
the US but not in Canada (i.e. physician visits and
hospitalizations) and for services for which private insurance
plays a role in both countries (i.e. dental services and
prescription drugs). Descriptive statistics and multivariate
analyses (linear and logistic regression methods) were used to
describe and model health care service utilization.
Population Studied:
Principal Findings: For services where private health
insurance plays a role in access to health care services in both
countries, its association with the used of services is strikingly
similar between Canada and the U.S..
Conclusions: Furthermore, the Canadian results indicate than
in the presence of private health care insurance,
socioeconomic disparities in access to health care services are
much larger than in the context of universal health insurance
coverage.
Primary Funding Source: CDC
●Beyond Race: Comparing Health Outcomes in the USA
with Countries in Europe
Martin McKee, M.D. Msc, Ellen Nolte, MPH, Ph.D., Chris
Bain, MBBS, MPH, MS
Presented By: Martin McKee, M.D. Msc, Professor of
European Public Health, Public Health & Policy, London
School of Hygiene & Tropical Medicine, Keppel Street,
London, WC1E 7HT; Tel: +442079272229; Fax:
+442075808183; Email: martin.mckee@lshtm.ac.uk
Research Objective: Premature mortality from many
conditions is worse in the USA than in other advanced
industrialised countries. However mortality also differs by race
within the USA, with outcomes for the African-American
population somewhat poorer than for the white population.
However, while life expectancy at birth among the AfricanAmerican population is especially low in international terms,
comparable to Bulgaria, life expectancy for the white
population is also lower than expected given the economic
status of the USA. The reasons for these racial differences in
mortality have been discussed at length elsewhere. However,
so far, there have been few attempts to place them in an
international perspective. This study compares race and agespecific death rates from a range of common conditions in the
USA with age specific death rates in two European countries,
England and Wales and Sweden.
Study Design: Death rates from a range of common
conditions potentially amenable to health care (diabetes
mellitus, ischaemic heart disease, cerebrovascular disease,
asthma, hypertension, colorectal cancer, breast cancer,
cervical cancer) were studied using data for the year 2000 in
the USA, England & Wales, and Sweden (2000 & 2001
combined to produce more stable rates). Death rates from the
USA were extracted for the categories “white” and “black” as
defined by the National Centre for Health Statistics. Age (5
year age bands), sex (and in the USA, race) specific death
rates were compared in the three countries. Premature
mortality was defined as deaths occurring under age 75 (50 for
diabetes).
Population Studied: The populations of the USA, England &
Wales and Sweden.
Principal Findings: Death rates from all conditions were
highest at all ages among the black American population, with
rates among men especially high. However, for most
conditions, death rates among the white American population
were higher than among the populations of England & Wales
and Sweden. Especially large relative gaps between black and
white Americans were seen for diabetes, asthma,
hypertension, cerebrovascular disease, and cervical cancer.
Among the white American population, death rates at all ages
were substantially higher than in England & Wales and
Sweden in the case of diabetes, while for asthma,
hypertension, and ischaemic heart disease they were
somewhat higher than in Sweden at all ages. For many
conditions, the gap between the white American population
and the two European countries was widest at young ages,
narrowing or even reversing after 65.
Conclusions: Death rates from causes amenable to health
care are somewhat worse among both the black and white
populations of the USA than in other advanced industrialised
countries. The USA performs especially poorly in respect of
some chronic disorders where good outcomes require easy
access to high quality, integrated health care. Outcomes are
particularly poor at young ages; in many cases they improve
among Americans over 65, who are covered by Medicare.
Implications for Policy, Delivery, or Practice: The patterns
observed by country, race and age for each condition indicate
many specific areas where there is scope for learning from
international experience. In general, however, this study
highlights the importance of policies in the USA that will
improve access to care among young people.
Primary Funding Source: The Nuffield Trust
●Centralizing Assessment to Inform Drug Coverage
Decisions: An International Comparison
Steve Morgan, Ph.D., Craig Mitton, Ph.D., Meghan McMahon,
BA, Elizabeth Roughead, Ph.D., Panos Kanavos, Ph.D., Ray
Kirk, Ph.D.
Presented By: Steve Morgan, Ph.D., Assistant Professor,
Centre for Health Services and Policy Research, University of
British Columbia, 429 - 2194 Health Sciences Mall, Vancouver,
BC, V6T 1Z3; Tel: (604)822-7012; Fax: (604)822-5690; Email:
morgan@chspr.ubc.ca
Research Objective: Information requirements for drug
licensing decisions, such as those of the US FDA, are different
than requirements for drug coverage decisions. To promote
value through coverage policies, drug benefit providers require
quality information about comparative clinical- and costeffectiveness. Many countries have centralized the clinical and
economic assessments necessary for such evidence-based
policy. We analyze centralized assessment processes in
Australia, Canada, New Zealand and the United Kingdom, and
investigate their relationship to drug coverage decisions.
Study Design: We assembled comparable information
concerning assessment agency structures and processes. For
each country, we compiled coverage recommendations and
per capita expenditure and utilization data for the world's 20
top-selling drugs. Semi-structured telephone interviews were
conducted to elicit opinion regarding factors influencing
recommendations of assessment agencies, the relationship
between recommendations and subsequent drug coverage
decisions, and the perceived acceptability of the processes.
Population Studied: We identified and interviewed four key
informants from each country, including experts from the
centralized assessment agency, a major drug benefit plan, an
industry association, and academia. Sixteen interviews were
conducted, recorded, and analyzed.
Principal Findings: Centralized assessment processes for
drug coverage differ substantially across countries. Critical
differences appear to stem from the relationship between drug
assessment and drug funding decisions. In Australia and
New Zealand, assessment is connected to centralized drug
funding mechanisms. Agencies in these countries assess all
drugs to be covered by government, incorporate
pharmacoeconomic information, and integrate price
negotiations into the decision-making process. New Zealand
funded the fewest of the top-selling drugs, resulting in lowest
per capita expenditures. The centralized assessment agency
in the UK has authority over funding decisions implemented
by independent regional bodies. This agency assesses only a
minority of prescription drugs, chosen based on potential
cost, health system impact, or controversy. It placed no
national mandates on coverage for the top-selling drugs.
Canadian assessment is a coordinated effort of federal and
regional drug benefit programs. The assessment agency
reviews all new prescription drugs, but cedes coverage
decisions to each drug plan. Canada the highest per capita
expenditures on the top-selling drugs. All informants
supported the goals of centralized assessment efforts. Some
criticized the transparency of data or rationale behind
coverage recommendations. Informants also criticized the
quality and/or value of pharmacoeconomic information
available for consideration. Finally, informants in the UK and
Canada suggested that local capacity to incorporate evidence
into decision-making processes remains critical and often
lacking.
Conclusions: Centralizing the assessment of pharmaceuticals
can raise evidentiary standards and reduce duplication of
efforts in the drug coverage process. Establishing
transparency of data and rationale will be increasingly
important as centralized assessments become more
influential in either centralized or devolved decision-making
environments.
Implications for Policy, Delivery, or Practice: In a market
with devolved decision-making such as the US, centralizing
the review of clinical and economic data will provide
consistent evidence upon which to base coverage. This may
help to promote equitable access to medicines of proven
benefit. Centralized assessment will not, however, eliminate
the need for local expertise and decision-making capacity.
Primary Funding Source: CWF
●Equity in Health Care Financing in Low-Income
Countries. Evidence from India
Kakoli Roy, Ph.D., David H. Howard, Ph.D.
Presented By: Kakoli Roy, Ph.D., Economist, Office of
Workforce and Career Development, Centers for Disease
Control and Prevention, 1600 Clifton Road NE, MS E90,
Atlanta, GA 30333; Tel: (404)498-6298; Fax: (404)498-6145;
Email: kjr3@cdc.gov
Research Objective: To examine how well the Indian
healthcare system protects households of differing living
standards against the financial consequences of unanticipated
health shocks.
Study Design: We use regression analysis to estimate the
relationship between household consumption (proxy for
ability to pay) and out-of-pocket spending per hospitalization.
We also estimate the relationship between consumption and
the ratio of out-of-pocket spending to consumption.
Population Studied: The data is drawn from the 52nd round
of National Sample Survey, a nationally representative
socioeconomic and health survey conducted in 1995-1996. The
sample comprises 24,379 (3.84%) households where a
member was hospitalized during the one-year reference
period.
Principal Findings: Our results indicate that both overall
health care expenditure (absolute payments) and the
consequent financial burden (payment share) increases, with
increasing ability to pay, depicting a progressive healthcare
financing system. Comparisons across the groups, however,
indicate some horizontal inequity including differences both in
degrees of progressivity and the redistributive effect.
Conclusions: The Indian health care system is equitable, in
the sense that out-of-pocket payment shares for low income
households are not higher than those for upper income
households. We believe this finding reflects the prevailing
practice of “price discrimination” in the health care system,
where poor consumers pay lower prices for health care
services than upper income patients.
Implications for Policy, Delivery, or Practice: Our primary
policy conclusions are that 1) the spread of insurance in India
may not automatically lead to improvements in equity
compared to the current situation and 2) reform strategies
should explore the possibility of introducing formal user fees
that increase with ability to pay, allowing such price
discrimination to further enhance equity in financing, while
raising revenues to improve service delivery and access to
public facilities.
Primary Funding Source: No Funding Source
●Will France Save Its National Health Insurance System?
Paul Sorum, M.D., Ph.D.
Presented By: Paul Sorum, M.D., Ph.D., Professor, Medicine
and Pediatrics, Albany Medical College, 724 Watervliet-Shaker
Road, Latham, NY 12110; Tel: (518)783-0312; Fax: (518)7827485; Email: PaulSorum@cs.com
Research Objective: To understand if and how France can, as
a result of the new health reform law, maintain autonomous
sickness funds as the foundation of its national health
insurance system.
Study Design: Synthesis of the scholarly literature on French
health care; the daily reports and analyses of day-to-day events
in the newspaper Le Monde; the texts of the new law and of
other official documents and agreements, as found on the
web sites of the French government and of the insurance
system; and interviews with physicians, administrators, and
patients.
Population Studied: The major stakeholders in the French
health care system.
Principal Findings: France’s health care system has, since the
end of the Second World War, been based on one large and
several small sickness funds, financed largely through payroll
contributions and governed by representatives of the “social
partners,” labor unions and business groups (with labor union
officials as dominant). As health care coverage was extended
to all residents, as costs of services increased, and as France’s
economic growth slowed in the past two decades, the
government began to play an increasingly important role in
funding and supervising the health insurance system. Under
pressure from the European union to reduce France’s budget
deficit, premier Raffarin and minister of health Douste-Blazy
pushed through the National Assembly in August 2004 a
potentially sweeping set of health care reforms. The overall
issue will be whether these reforms can sufficiently reduce the
deficit in the health insurance system. The specific concern
here is their impact on the governing structure of the sickness
funds. The law unified the sickness funds as the National
Union of Health Insurance Funds. The general director,
appointed by the government, is now in charge of the funds'
policies and of negotiations with physicians and other
providers; in the past, the general director of the major fund
was subordinate to the elected president of its governing
council. The general director is appointed for a term of five
years (longer than the time in office of most ministers). In
principle, therefore, the general director’s authority is much
greater than before: the direct influence of labor unions and
businesses is diminished, and a government cannot dismiss a
general director of whom it disapproves. The first major
accomplishment of the new director general, Frédéric Van
Roekeghem, was to negotiate in December an agreement with
physicians on reimbursement and other issues; it was signed
by three of the five physicians’ unions. Immediately, however,
the less favored categories of physicians, the pediatricians and
the general practitioners, began to protest against the new
agreement and—in line with French labor traditions as well as
with physicians' recent actions—to threaten to resort to
strikes.
Conclusions: How the new governing structure of the
sickness funds responds to physicians’ strikes, government
pressure, and other challenges is likely to determine how
autonomous and powerful it will become in practice.
Implications for Policy, Delivery, or Practice: The fate of
France’s sickness funds is of great interest to advocates of a
national health insurance system in the United States.
Primary Funding Source: No Funding Source
●Using Comparative Performance Data to Improve Quality
Karol G. Wicker, MHS
Presented By: Karol G. Wicker, MHS, Director of Data
Analysis, , Center for Performance Sciences, 6820 Deerpath
Road, Elkridge, MD 21075; Tel: (410)540-5056; Fax: (410)3799558; Email: kwicker@mhaonline.org
Research Objective: Assess how a clinical performance
measurement system and use of comparative performance
data leads to quality improvement in a range of different
healthcare systems. Review how benchmarking initiatives
show how clinical performance measurement can serve as a
catalyst for local and regional collaboration for hospital quality
improvement efforts.
Study Design: Review implementation of performance
measurement in different health policy settings in the context
of internal and external accountability and accreditation, and
identify the challenges including local support, support from
hospital leadership, physician buy-in, expert support, and
adjusting to the local culture. Analyze the concepts of data
analysis and reporting. Review data of specific clinical
performance indicators from local, regional, and international
comparative analysis and critically assess comparative
analysis and non-comparative analysis and their application
for quality improvement and internal and external
accountability .
Population Studied: More than 1,000 hospitals in Asia,
Europe, and the USA that participate in the Quality Indicator
Project, a large performance measurement system
implemented in partnership with local organizations such as
academic institutions, ministries of health, hospital
association (e.g., in the USA), or accrediting bodies. The study
will focus on measures including readmissions, returns to the
intensive care unit, patient falls, and surgical prophylaxis.
Principal Findings: There is evidence of relationships
between different approaches to data analysis, including
internal data analysis, comparative reporting, and statistical
process control, and quality improvement efforts. There are
strengths and weaknesses of the different approaches to data
analysis. Use of benchmarking initiatives, specifically in the
field of patient falls and care processes in the ICU show that
clinical performance measurement can serve as a mechanism
for collaborative quality improvement efforts and supporting
agendas for internal and external accountability.
Conclusions: Clinical performance measurement systems
and use of comparative performance data can lead to quality
improvement in healthcare at the local hospital level or
regional and national level. Furthermore, implementation of
performance measurement systems and utilization of
comparative data can meet the agendas of internal and
external accountability and accreditation.
Implications for Policy, Delivery, or Practice: An agenda for
performance improvement in a broader health policy context
of “pay for performance,” internal and external accountability,
and public disclosure of data, already exist in countries
participating the performance measurement system and is
rapidly developing in others. This experience has given
valuable lessons regarding the operations and challenges of
linking performance measurement to those agendas. Since
this agenda can be expected to emerge in other countries, the
findings have important health policy implications about the
possible approaches that can be taken.