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Walsan R, Mitchell RJ, Braithwaite J, Westbrook J, Hibbert P, Mumford V, Harrison R. Is there an association between out-of-pocket hospital costs, quality and care outcomes? A systematic review of contemporary evidence. BMC Health Serv Res 2023; 23:984. [PMID: 37705006 PMCID: PMC10500869 DOI: 10.1186/s12913-023-09941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 08/21/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Out of pocket (OOP) costs vary substantially by health condition, procedure, provider, and service location. Evidence of whether this variation is associated with indicators of healthcare quality and/or health outcomes is lacking. METHODS The current review aimed to explore whether higher OOP costs translate into better healthcare quality and outcomes for patients in inpatient settings. The review also aimed to identify the population and contextual-level determinants of inpatient out-of-pocket costs. A systematic electronic search of five databases: Scopus, Medline, Psych Info, CINAHL and Embase was conducted between January 2000 to October 2022. Study procedures and reporting complied with PRISMA guidelines. The protocol is available at PROSPERO (CRD42022320763). FINDINGS A total of nine studies were included in the final review. A variety of quality and health outcomes were examined in the included studies across a range of patient groups and specialities. The scant evidence available and substantial heterogeneity created challenges in establishing the nature of association between OOP costs and healthcare quality and outcomes. Nonetheless, the most consistent finding was no significant association between OOP cost and inpatient quality of care and outcomes. INTERPRETATION The review findings overall suggest no beneficial effect of higher OOP costs on inpatient quality of care and health outcomes. Further work is needed to elucidate the determinants of OOP hospital costs. FUNDING This study was funded by Medibank Better Health Foundation.
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Affiliation(s)
- Ramya Walsan
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Rebecca J Mitchell
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Peter Hibbert
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Virginia Mumford
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Reema Harrison
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
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Coste M, Bousmah MAQ. Predicting health services utilization using a score of perceived barriers to medical care: evidence from rural Senegal. BMC Health Serv Res 2023; 23:263. [PMID: 36927564 PMCID: PMC10018867 DOI: 10.1186/s12913-023-09192-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 02/16/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Ensuring access to healthcare services is a key element to achieving the Sustainable Development Goal 3 of "promoting healthy lives and well-being for all" through Universal Health Coverage (UHC). However, in the context of low- and middle-income countries, most studies focused on financial protection measured through catastrophic health expenditures (CHE), or on health services utilization among specific populations exhibiting health needs (such as pregnancy or recent sickness). METHODS This study aims at building an individual score of perceived barriers to medical care (PBMC) in order to predict primary care utilization (or non-utilization). We estimate the score on six items: (1) knowing where to go, (2) getting permission, (3) having money, (4) distance to the facility, (5) finding transport, and (6) not wanting to go alone, using individual data from 1787 adult participants living in rural Senegal. We build the score via a stepwise descendent explanatory factor analysis (EFA), and assess its internal consistency. Finally, we assess the construct validity of the factor-based score by testing its association (univariate regressions) with a wide range of variables on determinants of healthcare-seeking, and evaluate its predictive validity for primary care utilization. RESULTS EFA yields a one-dimensional score combining four items with a 0.7 Cronbach's alpha indicating good internal consistency. The score is strongly associated-p-values significant at the 5% level-with determinants of healthcare-seeking (including, but not limited to, sex, education, marital status, poverty, and distance to the health facility). Additionally, the score can predict non-utilization of primary care at the household level, utilization and non-utilization of primary care following an individual's episode of illness, and utilization of primary care during pregnancy and birth. These results are robust to the use of a different dataset. CONCLUSION As a valid, sensitive, and easily documented individual-level indicator, the PBMC score can be a complement to regional or national level health services coverage to measure health services access and predict utilization. At the individual or household level, the PBMC score can also be combined with conventional metrics of financial risk protection such as CHE to comprehensively document deficits in, and progress towards UHC.
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Affiliation(s)
- Marion Coste
- Aix Marseille University, CNRS, AMSE, Marseille, France. .,Aix Marseille University, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France.
| | - Marwân-Al-Qays Bousmah
- Aix Marseille University, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France.,Université Paris Cité, IRD, Inserm, Ceped, Paris, F-75006, France
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Sudhinaraset M, Landrian A, Mboya J, Golub G. The Economic Toll of
COVID
‐19: A Cohort Study of Prevalence and Economic Factors Associated with postpartum depression in Kenya. Int J Gynaecol Obstet 2022; 158:110-115. [PMID: 35152420 PMCID: PMC9087701 DOI: 10.1002/ijgo.14142] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
Objective The aim of the study is to examine the risk of postpartum depression (PPD) among women who delivered during the COVID‐19 pandemic compared to women who delivered before the COVID‐19 pandemic and how economic challenges are associated with PPD. Methods Data were collected from 2332 women. This includes 1197 women from healthcare facilities in 2019 who were followed up at 2–4 and 10 weeks postpartum. Additionally, we recruited 1135 women who delivered from March 16, 2020 onward when COVID‐19 restrictions were mandated in Kenya in the same catchment areas as the original sample to compare PPD rates. Results Adjusting for covariates, women who delivered during COVID‐19 had 2.5 times higher odds of screening positive for PPD than women who delivered before COVID‐19 (95% confidence interval [CI] 1.92–3.15). Women who reported household food insecurity, required to pay a fee to cover the cost of PPE during labor and delivery and/or postnatal visit(s), and those who reported COVID‐19 employment‐related impacts had a higher likelihood of screening for PPD compared to those who did not report these experiences. Conclusion The COVID‐19 pandemic has greatly increased the economic vulnerability of women, resulting in increases in PPD. The COVID‐19 pandemic has greatly increased the economic vulnerability of women and has increased PPD.
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Affiliation(s)
- May Sudhinaraset
- Fielding School of Public Health University of California Los Angeles USA
| | - Amanda Landrian
- Fielding School of Public Health University of California Los Angeles USA
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Afulani PA, Ogolla BA, Oboke EN, Ongeri L, Weiss SJ, Lyndon A, Mendes WB. Understanding disparities in person-centred maternity care: the potential role of provider implicit and explicit bias. Health Policy Plan 2021; 36:298-311. [PMID: 33491086 DOI: 10.1093/heapol/czaa190] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 12/17/2022] Open
Abstract
Studies in low-resource settings have highlighted disparities in person-centred maternity care (PCMC)-respectful and responsive care during childbirth-based on women's socioeconomic status (SES) and other characteristics. Yet few studies have explored factors that may underlie these disparities. In this study, we examined implicit and explicit SES bias in providers' perceptions of women's expectations and behaviours, as well as providers' general views regarding factors influencing differential treatment of women. We conducted a convergent mixed-methods study with 101 maternity providers in western Kenya. Implicit SES bias was measured using an adaptation of the Implicit Association Test (IAT) and explicit SES bias assessed using situationally specific vignettes. Qualitative data provided additional details on the factors contributing to disparities. Results provide evidence for the presence of both implicit and explicit bias related to SES that might influence PCMC. Differential treatment was linked to women's appearance, providers' perceptions of women's attitudes, assumptions about who is more likely to understand or be cooperative, women's ability to advocate for themselves or hold providers accountable, ability to pay for services in a timely manner, as well as situational factors related to stress and burnout. These factors interact in complex ways to produce PCMC disparities, and providing better care to certain groups does not necessarily indicate preference for those groups or a desire to provide better care to them. The findings imply the need for multilevel approaches to addressing disparities in maternity care. This should include provider training on PCMC and their biases, advocacy for women of low SES, accountability mechanisms, and structural and policy changes within health care settings.
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Affiliation(s)
- Patience A Afulani
- Epidemiology and Biostatistics Department, University of California, San Francisco (UCSF), San Francisco, CA 94158, USA.,UCSF Institute for Global Health Sciences, San Francisco, CA, USA
| | - Beryl A Ogolla
- Global Programs for Research and Training, Nairobi, Kenya
| | - Edwina N Oboke
- Global Programs for Research and Training, Nairobi, Kenya
| | | | - Sandra J Weiss
- UCSF Department of Community Health Systems, San Francisco, CA 94143, USA
| | - Audrey Lyndon
- NYU Rory Meyers College of Nursing, New York, NY, USA
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Neonatal care practices need to be further explored - Authors' reply. LANCET GLOBAL HEALTH 2021; 9:e754. [PMID: 34019830 PMCID: PMC8149298 DOI: 10.1016/s2214-109x(21)00095-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/24/2021] [Indexed: 11/27/2022]
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Saha R, Paul P. Institutional deliveries in India's nine low performing states: levels, determinants and accessibility. Glob Health Action 2021; 14:2001145. [PMID: 34914883 PMCID: PMC8682830 DOI: 10.1080/16549716.2021.2001145] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite the implementation of several national-level interventions, institutional delivery coverage remains unsatisfactory in India’s low performing states (LPS), leading to a high burden of maternal mortality. Objective This study investigates the levels, differentials, and determinants of institutional deliveries in LPS of India. The study also delineates a holistic understanding of barriers to delivery at health facilities and the utilization of the Janani Suraksha Yojana (JSY) specifically designed to improve maternal and child health of disadvantaged communities. Methods A cross-sectional study was conducted using data from the National Family Health Survey (NFHS)-4, 2015–16. The study was carried out over India’s nine LPS utilizing 112,518 women who had a living child in the past five years preceding the survey. Bivariate and multivariate regression analysis techniques were used to yield findings. Results Of the study sample, nearly three-quarters (74%) of women delivered in a health institution in the study area, with the majority delivered in public health facilities. The multivariate analysis indicates that women who lived in rural areas, belonged to disadvantaged social groups (e.g. Scheduled caste/tribes and Muslims), and those who married early (before 18 years) were less likely to utilize institutional delivery services. On the other hand, women’s education, household wealth, and exposure to mass media were found to be strong facilitators of delivering in a health facility. Meeting with a community health worker (CHW) during pregnancy emerged as an important predictor of institutional delivery in our study. Further, interaction analysis shows that women who reported the distance was a ‘big problem’ in accessing medical care had significantly lower odds of delivering at a health facility. Conclusions The study suggests emphasizing the quality of in-facility maternal care and awareness about the importance of reproductive health. Furthermore, strengthening sub-national policies specifically in underperforming states is imperative to improve institutional delivery coverage.
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Affiliation(s)
- Ria Saha
- Public Health Consultant, London, UK
| | - Pintu Paul
- Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India
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Montagu D, Giessler K, Nakphong MK, Green C, Roy KP, Sahu AB, Sharma K, Sudhinarset M. A comparison of intensive vs. light-touch quality improvement interventions for maternal health in Uttar Pradesh, India. BMC Health Serv Res 2020; 20:1121. [PMID: 33276773 PMCID: PMC7716449 DOI: 10.1186/s12913-020-05960-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/23/2020] [Indexed: 11/25/2022] Open
Abstract
Background Poor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and necessitate significant external input, making replication and scale difficult. This study compares the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch. Methods We use a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12 months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome Results Both Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a ‘halo’ effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed. Conclusions This study demonstrates that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a ‘halo’ effect, changing many other aspects of patient-provider interaction at the same time. Trial registration QI Phase 1 - NCT04208867. Retrospectively registered. December 19th, 2019. QI Phase 2 –NCT04208841. Retrospectively registered. December 23, 2019.
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Affiliation(s)
- Dominic Montagu
- University of California San Francisco, 550 16th St., San Francisco, CA, USA.
| | - Katie Giessler
- University of California San Francisco, 550 16th St., San Francisco, CA, USA
| | - Michelle Kao Nakphong
- University of California Los Angeles, 650 Charles E. Young Drive South, Los Angeles, CA, 90095-1772, USA
| | - Cathy Green
- Indepedent Improvement Consultant, 24 One Chapmans Peak Drive, Western Cape, Hout Bay, South Africa
| | - Kali Prosad Roy
- Population Services International, C-445 Chittranjan Park, New Delhi, 110019, India
| | - Ananta Basudev Sahu
- Population Services International. Nidhi Kamal Tower, 202, 2nd Floor, Plot - 37 & 38B, Barwara House, Ajmer Road, Jaipur, Rajasthan, India
| | - Kovid Sharma
- Population Services International, Lucknow, Uttar Pradesh, India
| | - May Sudhinarset
- University of California Los Angeles, 650 Charles E. Young Drive South, Los Angeles, CA, 90095-1772, USA
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