Assessing quality of primary diabetes care in South Korea and Taiwan using avoidable hospitalizations

Framework for responsive financing of district hospitals of India

Introduction

The current financing of public-sector district hospitals in India relies on historical budget allocations rather than actual utilization or healthcare needs. We utilized empirical data on healthcare delivery costs to develop the financing framework for these hospitals using a blended payment approach.

Methods

The primary data on cost of delivering services in 27 district hospitals across nine states of India was analysed along with indicators influencing the demand and supply of health services. Payment for outpatient, inpatient, and indirect services was assessed using the risk adjusted global budget, case-based bundled payment, and per-bed-global budget, respectively. Risk adjustment weights were computed by regressing the cost of outpatient care with demand and supply side factors which are likely to influence the utilization or the prices. Budget impact analysis was conducted to assess the fiscal implications of this payment approach, accounting for current care standards and two scenarios: upgrading district hospitals to Indian Public Health Standards (IPHS) or medical colleges.

Results

The average annual budget for a district hospital in India is estimated at ₹326 million (US$3.35 million), ranging from ₹66 million to ₹2.57 billion (US$0.8-31.13 million). Inpatient care comprises the largest portion (78%) of the budget. Upgrading to IPHS-compliant secondary hospitals or medical colleges would increase average budgets by 131 and 91.5%, respectively.

Conclusion

Implementing a blended payment approach would align funding with healthcare needs, enhance provider performance, and support ongoing financing reforms aimed at strategic purchasing and universal health coverage.

Reflection on 30 years of Taiwanese national health insurance: Analysis of Taiwanese health system progress, challenges, and opportunities

On the eve of Taiwan's National Health Insurance's 30th birthday, this study reviews the policy and performance trajectory of the Taiwanese health system. Taiwan has controlled their health spending well and grown increasingly reliant on private financing. The floating-point global budget payment preferentially rewards outpatient-based services, but this has not affected the hospital-centric market composition, which persists despite several primary-care friendly developments. The outcomes suggest improving health care workforce and resource availability, good patient-centredness, respectable technical efficiency, and impressive patient care satisfaction. However, there are worrisome trends for financial barriers to access and allocative efficiency. Evidence on clinical quality suggests that hospitals are performing well though the primary care setting might not be. Overall, the public remains satisfied despite signs of lagging improvement in health outcomes, worsening maternal mortality rate, and persistently incomplete financial risk protection. Identifying what drives the worsening financial barriers of access and persistent financial risk is necessary for further discussions on potential financing adjustments. Improving allocative efficiency could draw on a combination of supporting the functions and quality of primary care alongside patient-oriented education and incentives. Further data on causes of slow health status improvement and rebounding maternal mortality rate is necessary.

[Determinants of avoidable hospitalization for type2 diabetes. Narrative review]

OBJECTIVE

To identify the structural and intermediate determinants associated with avoidable hospitalizations (AH) of patients with type2 diabetes mellitus (T2DM).

DESIGN

Literature review based on narrative synthesis.

DATA SOURCES

Databases: PubMed, Science Direct, and Latin American and Caribbean Literature in Health Sciences (LILACS).

STUDY SELECTION

Documents were selected and analyzed under a critical literature review, considering inclusion and exclusion criteria.

DATA EXTRACTION

Information extracted from each selected article was synthesized based on the countries' income levels and the social determinants of health framework.

RESULTS

A total of 4,166 articles were relevant, 36 were selected for review. From this selection, 21 were publications conducted in high-income countries, 14 in upper-middle-income countries, and one in lower-middle-income countries. The review identified that the coverage of health services -mainly primary health care- and health insurance contribute to reducing the risk of AH for T2DM, while social inequalities tend to increase the risk.

CONCLUSIONS

The AH due to T2DM are susceptible to reduction through policies that contribute to increasing effective access to health services (availability, insurance), since they express social inequality, occurring to a greater extent in socioeconomically vulnerable populations. This review also provides evidence of the need to expand research on this topic in middle and low-income countries.

Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program

Most patients are diagnosed as having diabetes only after experiencing diabetes complications. Educational attainment might have a positive relationship with diabetes prognosis. The diabetes pay-for-performance (P4P) program-providing comprehensive, continuous medical care-has improved diabetes prognosis in Taiwan. This retrospective cohort study investigated how educational attainment affects the presence of diabetes complications at diabetes diagnosis and mortality risk in patients with diabetes enrolled in the P4P program. From the National Health Insurance Research Database, we identified patients aged >45 years who had received a new diagnosis of type 2 diabetes during 2002-2015; they were followed up until the end of 2017. We next used logistic regression analysis to explore whether the patients with different educational attainments had varied diabetic complication risks at diabetes diagnosis. The Cox proportional hazard model was employed to examine the association of different educational attainments in people with diabetes with mortality risk after their enrollment in the P4P program. The results indicated that as educational attainment increased, the risk of diabetes complications at type 2 diabetes diagnosis decreased gradually. When type 2 diabetes with different educational attainments joined the P4P program, high school education had the highest effect on reducing mortality risk; however, those with ≤ 6th grade education had the lowest impact.

Expanding outpatient benefits package can reduce diabetes-related avoidable hospitalizations

Objective

To evaluate the policy effect of replacing hospitalization service with outpatient service and reducing diabetes-related avoidable hospitalizations by improving outpatient benefits package.

Methods

A database of hospital discharge from 2015 to 2017 in City Z was used. All diabetic inpatient cases enrolled in Urban Employee Basic Medical Insurance were selected as the intervention group, and diabetic inpatient cases enrolled in Urban and Rural Resident Basic Medical Insurance were selected as the control group. The Difference-in-Difference model was used to analyze the effect of improving outpatient benefits package level of diabetes from 1800 yuan (about $252.82) to 2400 yuan (about $337.09) per capita per year on avoidable hospitalization rate, average hospitalization cost and average length of stay.

Results

The avoidable hospitalization rate of diabetes mellitus decreased by 0.21 percentage points (P < 0.01), the average total cost of hospitalization increased by 7.89% (P < 0.01), and the average length of stay per hospitalization increased by 5.63% (P < 0.01).

Conclusions

Improving the outpatient benefits package of diabetes can play a role in replacing hospitalization service with outpatient service, reducing diabetes-related avoidable hospitalizations, and reducing the disease burden and financial burden.

The ecology of medical care in Korea: the association of a regular doctor and medical care utilization

BACKGROUNDS

There is no registered regular doctor system in Korea, but people voluntarily select regular doctors for medical services. This study aims to study the ecology of medical care in Korea according to the presence and type of a regular doctor.

METHODS

This study was conducted using Korean Health Panel survey in 2018. The proportion of people who had health problems and received medical care in various settings was analyzed per 1,000 people according to the following groups: without a regular doctor, having a clinic physician as a regular doctor, and having a hospital physician as a regular doctor. The adjusted odds ratio for usage of medical services was calculated.

RESULTS

Health problems and medical care use increased in the groups in this order: group without a regular doctor, group with a clinic physician as a regular doctor, the group with a hospital physician a regular doctor. Having a hospital physician as a regular doctor was associated with higher odds of inpatient care and emergency room visits, and having a clinic physician as a regular doctor was not associated with odds of inpatient care and emergency room visits when adjusting demographic and health-related variables.

CONCLUSION

Depending on whether having a regular doctor and a regular doctor's type, different ecology of medical care was observed. The position and role of a regular doctor in the context of the Korea health care system should be considered from the perspective of primary care.

Effects of Diabetes Quality Assessment on Diabetes Management Behaviors Based on a Nationwide Survey

Improved diabetes management in primary care is essential for reducing the public health burden of diabetes, and various programs are being implemented in Korea for this purpose. Although the Health Insurance Review and Assessment (HIRA) evaluates the quality of type 2 diabetes management in primary care clinics and hospitals, it is unclear whether the implementation of these evaluations is related to the adequate management of complications in diabetic patients. We evaluated the association between the proportion of clinics managing diabetes well and lifestyles and uptake of screening for complications in 24,620 diabetic participants of the 2019 Korean Community Health Survey (KCHS). Multivariate multilevel logistic regression was performed to evaluate the fixed effect of the district-level variable and the heterogeneity among districts. The proportion of clinics with good diabetes management per 10,000 inhabitants was positively related to screening for diabetes complications. Furthermore, this district variable was significantly related to engaging in walking activity (Odds ratio: 1.39, 95% CI: 1.10-1.76) and sufficiently explained the heterogeneity among districts. However, current smoking and weight control were not associated with the proportion of clinics with good diabetes management. The financial incentives to primary care clinics would improve the primary prevention of diabetic complications.

National Trends in Hospitalization for Ambulatory Care Sensitive Conditions among Korean Adults between 2008 and 2019

PURPOSE

This study aimed to examine 12-year trends in hospitalization rates for ambulatory care sensitive conditions (ACSC) and factors affecting hospitalization.

MATERIALS AND METHODS

This study used data on Korean National Health Insurance and Medical Aid patients aged 19 and over who used medical services at least once between January 2008 and December 2019 with an ACSC as their major diagnosis. As of 2019, a total of 12324071 patients were included. To check for any changes in hospitalization, age- and sex-standardized hospitalization rates were obtained for each condition and insurance type, and multiple logistic regression was performed to identify factors affecting hospitalization.

RESULTS

The collective average ACSC hospitalization rate decreased from 5.0% in 2008 to 4.2% in 2019. Specifically, hospitalization rates for hypertension (1.4% in 2008; 0.8% in 2019), diabetes (5.8% in 2008; 3.3% in 2019), and chronic obstructive pulmonary disease and asthma (4.1% in 2008; 3.2% in 2019) decreased, while rates for pneumonia (24.5% in 2008; 28.1% in 2019) and urinary tract infection (UTI) (5.7% in 2008; 6.4% in 2019) increased. The rate for heart failure decreased 2.3% between 2008 and 2012 and then rebounded. The odds of hospitalization among Medical Aid patients were 1.45-4.20 times higher than those of National Health Insurance patients.

CONCLUSION

Differences in trends were confirmed for ACSC hospitalization rates among different conditions and insurance types in Korea. These results suggest the need for policy reforms aimed at reducing hospitalization for heart failure, pneumonia, and UTI, especially among Medical Aid patients.

Disparities in diabetes-related avoidable hospitalization among diabetes patients with disability using a nationwide cohort study

Diabetes is an ambulatory care sensitive condition that quality of care can prevent complications development and hospitalization needs. However, diabetes patients with disability face greater challenges with receiving quality diabetes care than those without disabilities. This study examined diabetes-related avoidable hospitalizations (DRAH) focusing on the association with disability. We used nationally representative health insurance cohort data from 2002 to 2013. The study population is people who were newly diagnosed with type 2 diabetes. We measured the cumulated number of DRAH using the Prevention Quality Indicators (PQIs). The variables of interest were disability severity and type. We performed a recurrent events analysis using Cox proportional hazard regression model. Among 49,410 type 2 diabetes patients, 12,231 (24.8%) experienced DRAHs at least once during the follow-up period. Among the total population, 5924 (12.0%) diabetes patients were registered as disabled. The findings report that disability severity was significantly associated with higher risks for DRAH, where severely disabled diabetes patients showed the highest hazard ratio of 2.24 (95% CI 1.80-2.79). Among three DRAH indicators, severely disabled diabetes patients showed increased risks for long-term (AHR 2.21, 95% CI 1.89-2.60) and uncontrolled (AHR 2.28, 95% CI 1.80-2.88) DRAH. In addition, intellectual (AHR 5.52, 95% CI 3.78-8.05) and mental (AHR 3.97, 95% CI 2.29-6.89) disability showed higher risks than other types of disability. In conclusion, diabetes patients with disability are at higher risk for DRAH compared to those without disabilities, and those with intellectual and mental disabilities were more likely to experience DRAH compared to those with physical or other types of disability. These findings call for action to find the more appropriate interventions to improve targeted diabetes primary care for patients with disability. Further research is needed to better understand determinants of increasing risks of DRAH.

Trends in all-cause mortality among people with diagnosed diabetes in high-income settings: a multicountry analysis of aggregate data

BACKGROUND

Population-level trends in mortality among people with diabetes are inadequately described. We aimed to examine the magnitude and trends in excess all-cause mortality in people with diabetes.

METHODS

In this retrospective, multicountry analysis, we collected aggregate data from 19 data sources in 16 high-income countries or jurisdictions (in six data sources in Asia, eight in Europe, one from Australia, and four from North America) for the period from Jan 1, 1995, to Dec 31, 2016, (or a subset of this period) on all-cause mortality in people with diagnosed total or type 2 diabetes. We collected data from administrative sources, health insurance records, registries, and a health survey. We estimated excess mortality using the standardised mortality ratio (SMR).

FINDINGS

In our dataset, there were approximately 21 million deaths during 0·5 billion person-years of follow-up among people with diagnosed diabetes. 17 of 19 data sources showed decreases in the age-standardised and sex-standardised mortality in people with diabetes, among which the annual percentage change in mortality ranged from -0·5% (95% CI -0·7 to -0·3) in Hungary to -4·2% (-4·3 to -4·1) in Hong Kong. The largest decreases in mortality were observed in east and southeast Asia, with a change of -4·2% (95% CI -4·3 to -4·1) in Hong Kong, -4·0% (-4·8 to -3·2) in South Korea, -3·5% (-4·0 to -3·0) in Taiwan, and -3·6% (-4·2 to -2·9) in Singapore. The annual estimated change in SMR between people with and without diabetes ranged from -3·0% (95% CI -3·0 to -2·9; US Medicare) to 1·6% (1·4 to 1·7; Lombardy, Italy). Among the 17 data sources with decreasing mortality among people with diabetes, we found a significant SMR increase in five data sources, no significant SMR change in four data sources, and a significant SMR decrease in eight data sources.

INTERPRETATION

All-cause mortality in diabetes has decreased in most of the high-income countries we assessed. In eight of 19 data sources analysed, mortality decreased more rapidly in people with diabetes than in those without diabetes. Further longevity gains will require continued improvement in prevention and management of diabetes.

FUNDING

US Centers for Disease Control and Prevention, Diabetes Australia Research Program, and Victoria State Government Operational Infrastructure Support Program.

Hospitalization for ambulatory care sensitive conditions: What conditions make inter-country comparisons possible?

Hospitalizations for ambulatory care sensitive conditions have been extensively used in health services research to assess access, quality and performance of primary health care. Inter-country comparisons can assist policy-makers in pursuing better health outcomes by contrasting policy design, implementation and evaluation. The objective of this study is to identify the conceptual, methodological, contextual and policy dimensions and factors that need to be accounted for when comparing these types of hospitalizations across countries. A conceptual framework for inter-country comparisons was drawn based on a review of 18 studies with inter-country comparison of ambulatory care sensitive conditions hospitalizations. The dimensions include methodological choices; population's demographic, epidemiologic and socio-economic profiles and features of the health services and system. Main factors include access and quality of primary health care, availability of health workforce and health facilities, health interventions and inequalities. The proposed framework can assist in designing studies and interpreting findings of inter-country comparisons of ambulatory care sensitive conditions hospitalizations, accelerating learning and progress towards universal health coverage.

Risk Factors of Undiagnosed Diabetes Mellitus among Korean Adults: A National Cross-Sectional Study Using the KNHANES Data

In this cross-sectional study, we investigated the baseline risk factors of diabetes mellitus (DM) in patients with undiagnosed DM (UDM). We utilized the Korean National Health and Nutrition Examination Survey (KNHANES) 2010–2017 data. Data regarding the participants’ demographic characteristics, health status, health determinants, healthcare accessibility, and laboratory tests were gathered to explore the differences between the DM, UDM, and without-DM groups. Among the 64,759 individuals who participated in the KNHANES 2010–2017, 32,611 individuals aged ≥20 years with fasting plasma glucose levels of <100 or ≥126 mg/dL were selected. The odds ratios (ORs) regarding family history of diabetes and the performance of national health and cancer screening tests were lower in the UDM group than in the DM group (adjusted OR: 0.54; 95% confidence interval (CI): 0.43, 0.66; adjusted OR: 0.74; 95% CI: 0.62, 0.89; adjusted OR: 0.71; 95% CI: 0.60, 0.85). The ORs of hypertension and obesity were higher in the UDM group than in the DM group (adjusted OR: 1.32; 95% CI: 1.06, 1.64; adjusted OR: 1.80; 95% CI: 1.37, 2.36, respectively). Patients with UDM were more likely to be exposed to DM-related risk factors than those with and without DM. Public health interventions to prevent UDM development are necessary.

Defining ambulatory care sensitive conditions for adults in Portugal

BACKGROUND

Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which adequate management, treatment and interventions delivered in the ambulatory care setting could potentially prevent hospitalization. Which conditions are sensitive to ambulatory care varies according to the scope of health care services and the context in which the indicator is used. The need for a country-specific validated list for Portugal has already been identified, but currently no national list exists. The objective of this study was to develop a list of Ambulatory Care Sensitive Conditions for Portugal.

METHODS

A modified web-based Delphi panel approach was designed, in order to determine which conditions can be considered ACSCs in the Portuguese adult population. The selected experts were general practitioners and internal medicine physicians identified by the most relevant Portuguese scientific societies. Experts were presented with previously identified ACSC and asked to select which could be accepted in the Portuguese context. They were also asked to identify other conditions they considered relevant. We estimated the number and cost of ACSC hospitalizations in 2017 in Portugal according to the identified conditions.

RESULTS

After three rounds the experts agreed on 34 of the 45 initially proposed items. Fourteen new conditions were proposed and four achieved consensus, namely uterine cervical cancer, colorectal cancer, thromboembolic venous disease and voluntary termination of pregnancy. In 2017 133,427 hospitalizations were for ACSC (15.7% of all hospitalizations). This represents a rate of 1685 per 100,000 adults. The most frequent diagnosis were pneumonia, heart failure, chronic obstructive pulmonary disease/chronic bronchitis, urinary tract infection, colorectal cancer, hypertensive disease atrial fibrillation and complications of diabetes mellitus.

CONCLUSIONS

New ACSC were identified. It is expected that this list could be used henceforward by epidemiologic studies, health services research and for healthcare management purposes. ACSC lists should be updated frequently. Further research is necessary to increase the specificity of ACSC hospitalizations as an indicator of healthcare performance.

Disease management in diabetes care: When involving GPs improves patient compliance and health outcomes

Although the study of the association between interventions in primary care and health outcomes continues to produce mixed findings, programs designed to promote the greater compliance of General Practitioners and their diabetic patients with guidelines have been increasingly introduced worldwide, in an attempt to achieve better quality diabetes care through the enhanced standardisation of patient supervision. In this study, we use clinical data from the Diabetes Register of one large Local Health Authority (LHAs) in Italy's Emilia-Romagna Region for the period 2012-2015. Firstly, we investigate whether GPs' participation in the local Diabetes Management Program (DMP) leads to improved patient compliance with regional guidelines. Secondly, we test whether the monitoring activities prescribed for diabetics by the Regional diabetes guidelines have a positive impact on patients' health outcomes and increase appropriateness in health care utilization. Our results show that such a Program, which aims to increase GPs' involvement and cooperation in following the Regional guidelines, achieves its goal of improved patient compliance with the prescribed actions. In turn, through the implementation of the DMP and the greater involvement of physicians, Regional policies have succeeded in promoting better health outcomes and improved appropriateness of health care utilization.