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Lu PJ, Liu JY, Ma H, Chen TJ, Chou LF, Hwang SJ. Characteristics of Clinics without National Health Insurance Contracts: A Nationwide Survey in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031517. [PMID: 35162539 PMCID: PMC8835185 DOI: 10.3390/ijerph19031517] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 01/25/2023]
Abstract
Based on the 1978 Alma-Ata Declaration, the key to achieving health for all is primary health care, and many countries have established various comprehensive health care systems. Because of the financial toll of a public health care system, government-sponsored public health insurance is not universally accepted. This study used Taiwan as the backdrop to understand why many health clinics have chosen not to accept the National Health Insurance (NHI), despite it covering 99.93% of the country’s population. The clinics’ operational details were garnered from the datasets of Taiwan’s open government data platforms and checked against the list of contracting clinics within the NHI. Of 10,907 Western medicine primary care clinics in 2016, as many as 9846 (90.3%) clinics had signed contracts with the NHI. The remaining 1061 noncontracting clinics were distributed in urban (94.5%, n = 1003), suburban (4.9%, n = 52), and rural/remote areas (0.6%, n = 6). The NHI did not have contracts with 183 plastic surgery, 88 internal medicine, and 85 surgery clinics. In conclusion, nearly one-tenth of clinics practiced independently of the NHI in Taiwan. Their reasons for declining the contract and practices for delivering their services deserve further studies.
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Affiliation(s)
- Pei-Jyun Lu
- Department of Medical Education, Taipei Veterans General Hospital, Taipei 112, Taiwan;
| | - Jui-Yao Liu
- Department of Family Medicine, National Yang Ming Chiao Tung University Hospital, Yilan 260, Taiwan;
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan;
| | - Hsin Ma
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan;
| | - Tzeng-Ji Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan;
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan;
- Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Big Data Center, Department of Medical Research, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Correspondence:
| | - Li-Fang Chou
- Department of Public Finance, National Chengchi University, Taipei 116, Taiwan;
| | - Shinn-Jang Hwang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan;
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan;
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Cookson R, Dusheiko M, Hardman G. Socioeconomic inequality in small area use of elective total hip replacement in the English National Health Service in 1991 and 2001. J Health Serv Res Policy 2016; 12 Suppl 1:S1-10-7. [PMID: 17411502 DOI: 10.1258/135581907780318365] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives To compare socioeconomic inequality in small area use of elective total hip replacement in the English National Health Service (NHS) in 1991 and 2001. Methods Hospital Episode Statistics and Census data were aggregated to a common geography of ‘frozen’ 1991 English electoral wards. The Townsend deprivation score was used as the primary indicator of socioeconomic status for each ward, and the sensitivity analysis used other Census indicators. Two main measures of inequality were examined: the indirectly age-sex standardized utilization rate ratio between most and least deprived quintile groups, and the concentration index of deprivation-related inequality in age-sex standardized utilization ratios between small areas. Each standardized utilization ratio is the observed use divided by the expected use, if each age and sex group in the study population had the same use rate as the national population. Results In both years, observed use was below expected use for the bottom third of areas by socioeconomic status. The standardized utilization rate ratio between top and bottom Townsend quintiles fell from 1.41 (95% confidence interval [CI] 1.36-1.47) in 1991 to 1.27 (95% CI 1.23-1.32) in 2001. The proportionate increase in use required to bring the bottom quintile to the level of top thus fell significantly from 41% to 27%. The Town-send-based concentration index also fell from 0.069 (95% CI 0.059-0.079) in 1991 to 0.060 (95% CI 0.050-0.071) in 2001, although this fall was not statistically significant (P=0.085). Other socioeconomic indicators yielded a similar pattern. Conclusions Socioeconomic small area inequality in use of total hip replacement appears to have fallen between 1991 and 2001. One possible explanation is that increased hip replacement rates in the 1990s may have lowered barriers to access, thus allowing this health technology to diffuse further among lower socio-economic groups.
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Affiliation(s)
- Richard Cookson
- Department of Social Policy and Social Work, Centre for Health Economics, University of York, York YO10 5DD, UK.
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Odeyemi IAO, Nixon J. The role and uptake of private health insurance in different health care systems: are there lessons for developing countries? CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:109-18. [PMID: 23494071 PMCID: PMC3593711 DOI: 10.2147/ceor.s40386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Social and national health insurance schemes are being introduced in many developing countries in moving towards universal health care. However, gaps in coverage are common and can only be met by out-of-pocket payments, general taxation, or private health insurance (PHI). This study provides an overview of PHI in different health care systems and discusses factors that affect its uptake and equity. METHODS A representative sample of countries was identified (United States, United Kingdom, The Netherlands, France, Australia, and Latvia) that illustrates the principal forms and roles of PHI. Literature describing each country's health care system was used to summarize how PHI is utilized and the factors that affect its uptake and equity. RESULTS In the United States, PHI is a primary source of funding in conjunction with tax-based programs to support vulnerable groups; in the UK and Latvia, PHI is used in a supplementary role to universal tax-based systems; in France and Latvia, complementary PHI is utilized to cover gaps in public funding; in The Netherlands, PHI is supplementary to statutory private and social health insurance; in Australia, the government incentivizes the uptake of complementary PHI through tax rebates and penalties. The uptake of PHI is influenced by age, income, education, health care system typology, and the incentives or disincentives applied by governments. The effect on equity can either be positive or negative depending on the type of PHI adopted and its role within the wider health care system. CONCLUSION PHI has many manifestations depending on the type of health care system used and its role within that system. This study has illustrated its common applications and the factors that affect its uptake and equity in different health care systems. The results are anticipated to be helpful in informing how developing countries may utilize PHI to meet the aim of achieving universal health care.
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Affiliation(s)
- Isaac AO Odeyemi
- Senior Director and Head of Health Economics and Outcomes Research, Astellas Pharma UK Ltd, Chertsey, UK
| | - John Nixon
- Teaching Associate in Health Economics, Department of Economics and Related Studies, University of York, York, UK
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Armstrong MEG, Spencer EA, Cairns BJ, Banks E, Pirie K, Green J, Wright FL, Reeves GK, Beral V. Body mass index and physical activity in relation to the incidence of hip fracture in postmenopausal women. J Bone Miner Res 2011; 26:1330-8. [PMID: 21611971 DOI: 10.1002/jbmr.315] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Hip fracture risk is known to increase with physical inactivity and decrease with obesity, but there is little information on their combined effects. We report on the separate and combined effects of body mass index (BMI) and physical activity on hospital admissions for hip fracture among postmenopausal women in a large prospective UK study. Baseline information on body size, physical activity, and other relevant factors was collected in 1996-2001, and participants were followed for incident hip fractures by record linkage to National Health Service (NHS) hospital admission data. Cox regression was used to calculate adjusted relative risks of hip fracture. Among 925,345 postmenopausal women followed for an average of 6.2 years, 2582 were admitted to hospital with an incident hip fracture. Hip fracture risk increased with decreasing BMI: Compared with obese women (BMI of 30+ kg/m(2) ), relative risks were 1.71 [95% confidence interval (CI) 1.47-1.97)] for BMI of 25.0 to 29.9 kg/m(2) and 2.55 (95% CI 2.22-2.94) for BMI of 20.0 to 24.9 kg/m(2). The increase in fracture risk per unit decrease in BMI was significantly greater among lean women than among overweight women (p < .001). For women in every category of BMI, physical inactivity was associated with an increased risk of hip fracture. There was no significant interaction between the relative effects of BMI and physical activity. For women who reported that they took any exercise versus no exercise, the adjusted relative risk of hip fracture was 0.68 (95% CI 0.62-0.75), with similar results for strenuous exercise. In this large cohort of postmenopausal women, BMI and physical activity had independent effects on hip fracture risk.
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Sweetland S, Green J, Liu B, Berrington de González A, Canonico M, Reeves G, Beral V. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ 2009; 339:b4583. [PMID: 19959589 PMCID: PMC2788913 DOI: 10.1136/bmj.b4583] [Citation(s) in RCA: 291] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To examine the duration and magnitude of increased risk of venous thromboembolism after different types of surgery. DESIGN Prospective cohort study (Million Women Study). SETTING Questionnaire data from the Million Women Study linked with hospital admission and death records. PARTICIPANTS 947 454 middle aged women in the United Kingdom recruited in 1996-2001 and followed by record linkage to routinely collected NHS data on hospital admissions and deaths. During follow-up 239 614 admissions were for surgery; 5419 women were admitted, and a further 270 died, from venous thromboembolism. MAIN OUTCOME MEASURES Adjusted relative risks and standardised incidence rates for hospital admission or death from venous thromboembolism (pulmonary embolism or deep vein thrombosis), by time since and type of surgery. RESULTS Compared with not having surgery, women were 70 times more likely to be admitted with venous thromboembolism in the first six weeks after an inpatient operation (relative risk 69.1, 95% confidence interval 63.1 to 75.6) and 10 times more likely after a day case operation (9.6, 8.0 to 11.5). The risks were lower but still substantially increased 7-12 weeks after surgery (19.6, 16.6 to 23.1 and 5.5, 4.3 to 7.0, respectively). This pattern of risk was similar for pulmonary embolism (n=2487) and deep venous thrombosis (n=3529). The postoperative risks of venous thromboembolism varied considerably by surgery type, with highest relative risks after inpatient surgery for hip or knee replacement and for cancer-1-6 weeks after surgery the relative risks were, respectively, 220.6 (187.8 to 259.2) and 91.6 (73.9 to 113.4). CONCLUSION The risk of deep vein thrombosis and pulmonary embolism after surgery is substantially increased in the first 12 postoperative weeks, and varies considerably by type of surgery. An estimated 1 in 140 middle aged women undergoing inpatient surgery in the UK will be admitted with venous thromboembolism during the 12 weeks after surgery (1 in 45 after hip or knee replacement and 1 in 85 after surgery for cancer), compared with 1 in 815 after day case surgery and only 1 in 6200 women during a 12 week period without surgery.
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Affiliation(s)
- Siân Sweetland
- Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Oxford OX3 7LF
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Banks E, Reeves GK, Beral V, Balkwill A, Liu B, Roddam A. Hip fracture incidence in relation to age, menopausal status, and age at menopause: prospective analysis. PLoS Med 2009; 6:e1000181. [PMID: 19901981 PMCID: PMC2766835 DOI: 10.1371/journal.pmed.1000181] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 10/02/2009] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Bone mineral density is known to decrease rapidly after the menopause. There is limited evidence about the separate contributions of a woman's age, menopausal status and age at menopause to the incidence of hip fracture. METHODS AND FINDINGS Over one million middle-aged women joined the UK Million Women Study in 1996-2001 providing information on their menopausal status, age at menopause, and other factors, which was updated, where possible, 3 y later. All women were registered with the UK National Health Service (NHS) and were routinely linked to information on cause-specific admissions to NHS hospitals. 561,609 women who had never used hormone replacement therapy and who provided complete information on menopausal variables (at baseline 25% were pre/perimenopausal and 75% postmenopausal) were followed up for a total of 3.4 million woman-years (an average 6.2 y per woman). During follow-up 1,676 (0.3%) were admitted to hospital with a first incident hip fracture. Among women aged 50-54 y the relative risk (RR) of hip fracture risk was significantly higher in postmenopausal than premenopausal women (adjusted RR 2.22, 95% confidence interval [CI] 1.22-4.04; p = 0.009); there were too few premenopausal women aged 55 y and over for valid comparisons. Among postmenopausal women, hip fracture incidence increased steeply with age (p<0.001), with rates being about seven times higher at age 70-74 y than at 50-54 y (incidence rates of 0.82 versus 0.11 per 100 women over 5 y). Among postmenopausal women of a given age there was no significant difference in hip fracture incidence between women whose menopause was due to bilateral oophorectomy compared to a natural menopause (adjusted RR 1.20, 95% CI 0.94-1.55; p = 0.15), and age at menopause had little, if any, effect on hip fracture incidence. CONCLUSIONS At around the time of the menopause, hip fracture incidence is about twice as high in postmenopausal than in premenopausal women, but this effect is short lived. Among postmenopausal women, age is by far the main determinant of hip fracture incidence and, for women of a given age, their age at menopause has, at most, a weak additional effect. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Emily Banks
- National Centre for Epidemiology and Population Health, The Australian National University, Acton, Australia.
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Liu B, Beral V, Balkwill A. Childbearing, breastfeeding, other reproductive factors and the subsequent risk of hospitalization for gallbladder disease. Int J Epidemiol 2008; 38:312-8. [DOI: 10.1093/ije/dyn174] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Liu B, Beral V, Balkwill A, Green J, Sweetland S, Reeves G. Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women: prospective cohort study. BMJ 2008; 337:a386. [PMID: 18617493 PMCID: PMC2500203 DOI: 10.1136/bmj.a386] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether transdermal compared with oral use of hormone replacement therapy reduces the risk of gallbladder disease in postmenopausal women. DESIGN Prospective cohort study (Million Women Study). SETTING Women registered with the National Health Service (NHS) in England and Scotland. PARTICIPANTS 1,001,391 postmenopausal women (mean age 56) recruited between 1996 and 2001 from NHS breast screening centres and followed by record linkage to routinely collected NHS hospital admission data for gallbladder disease. MAIN OUTCOME MEASURES Adjusted relative risk and standardised incidence rates of hospital admission for gallbladder disease or cholecystectomy according to use of hormone replacement therapy. RESULTS During follow-up 19 889 women were admitted for gallbladder disease; 17 190 (86%) had a cholecystectomy. Compared with never users of hormone replacement therapy, current users were more likely to be admitted for gallbladder disease (relative risk 1.64, 95% confidence interval 1.58 to 1.69) but risks were substantially lower with transdermal therapy than with oral therapy (relative risk 1.17, 1.10 to 1.24 v 1.74, 1.68 to 1.80; heterogeneity P<0.001). Among women using oral therapy, equine oestrogens were associated with a slightly greater risk of gallbladder disease than estradiol (relative risk 1.79, 1.72 to 1.87 v 1.62, 1.54 to 1.70; heterogeneity P<0.001) and higher doses of oestrogen increased the risk more than lower doses: for equine oestrogens >0.625 mg, 1.91 (1.78 to 2.04) v <or=0.625 mg, 1.76 (1.68 to 1.84); heterogeneity P=0.02; estradiol >1 mg, 1.68 (1.59 to 1.77) v <or=1 mg, 1.44 (1.31 to 1.59); heterogeneity P=0.003. The risk of gallbladder disease decreased with time since stopping therapy (trend P=0.004). Results were similar taking cholecystectomy as the outcome. Standardised hospital admission rates per 100 women over five years for cholecystectomy were 1.1 in never users, 1.3 with transdermal therapy, and 2.0 with oral therapy. CONCLUSION Gallbladder disease is common in postmenopausal women and use of hormone replacement therapy increases the risk. Use of transdermal therapy rather than oral therapy over a five year period could avoid one cholecystectomy in every 140 users.
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Affiliation(s)
- Bette Liu
- Epidemiology Unit, University of Oxford, Oxford OX3 7LF.
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Liu B, Sweetland S, Beral V, Green J, Balkwill A, Casabonne D. Self-reported information on joint replacement and cholecystectomy agrees well with that in medical records. J Clin Epidemiol 2007; 60:1190-4. [PMID: 17938062 DOI: 10.1016/j.jclinepi.2007.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 02/02/2007] [Accepted: 02/15/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine the validity of self-reported primary hip replacement, primary knee replacement, and cholecystectomy. STUDY DESIGN AND SETTING The data from 28,524 participants in the Million Women Study who were recruited from Scotland were linked with routinely collected Scottish hospital admission data. We compared the reporting of three operations by the study participants on a postal questionnaire with that recorded in the hospital admission database. RESULTS Annual incidence rates for the three operations were similar using hospital admission and self-reported data at: 2.1 (n=220) and 2.3 (n=247) per 1,000 women, respectively, for hip replacement; 1.1 per 1,000 women from both sources for knee replacement (n=118 and n=116, respectively); and 3.4 (n=357) and 3.2 (n=344) per 1,000 women, respectively, for cholecystectomy. Agreement between self-report and the hospital admission records was good for all three operations with agreements of 99.8%, 99.9%, and 99.6% for hip replacement, knee replacement, and cholecystectomy, respectively. CONCLUSION In middle-aged women who answered postal questionnaires, self-reporting of primary hip replacement, primary knee replacement, and cholecystectomy was found to agree well with information held in a medical record database.
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Affiliation(s)
- Bette Liu
- Cancer Research UK Epidemiology Unit, University of Oxford, Richard Doll Building, Oxford, UK.
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Dixon T, Shaw ME, Dieppe PA. Analysis of regional variation in hip and knee joint replacement rates in England using Hospital Episodes Statistics. Public Health 2006; 120:83-90. [PMID: 16198381 DOI: 10.1016/j.puhe.2005.06.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Revised: 05/10/2005] [Accepted: 06/28/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Total hip and knee joint replacements are effective interventions for people with severe arthritis, and demand for these operations appears to be increasing as our population ages. This study explores regional variations in health care and inequalities in the provision of these expensive interventions, which are high on the UK Government's health agenda. STUDY DESIGN The Hospital Episode Statistics (HES) for England were analysed. The HES database holds information on patients who are admitted to National Health Service (NHS) hospitals in England. METHODS Age-standardized procedure rates were calculated using 5-year age groups with the English mid-year population of 2000 as the reference. Univariate associations between age-standardized operation rates and regional characteristics were assessed using Pearson's correlation coefficient. RESULTS Age and sex-standardized surgery rates vary by 25-30%. For both hip and knee replacement, rates are highest in the South West and Midlands and lowest in the North West, South East and London regions. In the case of knee replacement, there are also marked differences in the sex ratios between regions. The variable that explained most variation in hip replacement rates was the proportion of older people in the region. In the case of knee replacement, the number of NHS centres offering surgery in the region was the main explanatory variable, with regions with fewer centres having the highest provision rates. CONCLUSION These data can help to inform planning of services. They suggest that there may be inequities as well as inequalities in the provision of primary joint replacement surgery in England.
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Affiliation(s)
- T Dixon
- National Centre for Monitoring Diabetes, Australian Institute of Health and Welfare, Canberra, Australia
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Oliver SE, Donovan JL, Peters TJ, Frankel S, Hamdy FC, Neal DE. Recent trends in the use of radical prostatectomy in England: the epidemiology of diffusion. BJU Int 2003; 91:331-6; discussion 336. [PMID: 12603408 DOI: 10.1046/j.1464-410x.2003.04083.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe recent trends in the use of radical prostatectomy (RP) in England, as there is currently no consensus on the most effective treatment for localized prostate cancer, although RP is the treatment of choice among urological surgeons for men aged < 70 years. METHODS Routine data were assessed to establish the number of RPs performed in England in 1991-99. Age-standardized operation rates were compared by region and socio-economic group, and the geographical spread of use mapped. RESULTS The number of RPs performed annually increased nearly 20-fold between 1991 and 1999. Rates of surgery were greatest in the London National Health Service (NHS) regions and lowest in the Trent region. Outside London, the risk of surgery in a NHS hospital was significantly greater for men living in the least deprived areas; in London this trend was reversed. CONCLUSION Rapid increases in the use of RP showed marked regional variations, most likely related to access to prostate-specific antigen testing and the location of surgeons able to carry out radical surgery. By 1999, a third of procedures were still being undertaken in 'low-volume' hospitals, with implications for the quality of care and outcomes. Crucially, these developments occurred in the absence of robust information about the effectiveness of RP. Recent funding of a randomized trial of treatment options in this area is welcome, but wider questions remain about the timing of the evaluation of surgical technologies.
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Affiliation(s)
- S E Oliver
- Department of Health Sciences, University of York, York, UK.
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