Medical costs and out-of-pocket expenditures associated with multimorbidity in China: quantile regression analysis

Interrelationships between physical multimorbidity, depressive symptoms and cognitive function among older adults in China, India and Indonesia: A four-way decomposition analysis

OBJECTIVE

This paper explores the role of depressive symptoms (mediator/moderator) in the association between physical multimorbidity (exposure) and cognitive function (outcome) among older adults in the three most populous middle-income countries.

METHODS

This study used cross-sectional data from China (2015 China Health and Retirement Longitudinal Study), India (2017/2018 Longitudinal Ageing Study in India), and Indonesia (2014/2015 Indonesian Family Life Survey), with a total sample of 73,199 respondents aged ≥ 45 years. Three domains of cognitive tests were harmonised across surveys, including time orientation, word recall, and numeracy. The four-way decomposition analysis assessed the mediation and interaction effects between exposure, mediator/moderator, and outcome, adjusted for covariates.

RESULTS

The mean age of the respondents (in years) was slightly younger in Indonesia (56.0, SD = 8.8) than in China (59.5, SD = 9.3) and India (60.0, SD = 10.5). The proportion of male respondents was 49.3 % in China, 47.3 % in India, and 47.5 % in Indonesia. Respondents in China had the highest mean cognitive function z scores (54.7, SD = 19.9), followed by India (51.1, SD = 20.0) and Indonesia (51.0, SD = 18.4). Physical multimorbidity was associated with lower cognitive function in China and India (p < 0.0001), with 48.4 % and 40.0 % of the association explained by the mediating effect of depressive symptoms ('overall proportion due to mediation'). The association was not found in Indonesia.

CONCLUSION

Cognitive functions were lower among individuals with physical multimorbidity, and depressive symptoms mainly explained the association. Addressing depressive symptoms among persons with physical multimorbidity is likely to have not only an impact on their mental health but could prevent cognitive decline.

Out-of-pocket expenditures associated with double disease burden in Pakistan: a quantile regression analysis

BACKGROUND

Pakistan is currently experiencing a double burden of disease. Families with members having both communicable and noncommunicable diseases are at a greater risk of impoverishment due to enormous out-of-pocket payments. This study examines the percentile distribution of the determinants of the out-of-pocket expenditure on the double disease burden.

METHOD

The study extracted a sample of 6,775 households with at least one member experiencing both communicable and noncommunicable diseases from the Household Integrated Economic Survey 2018-19. The dataset is cross-sectional and nationally representative. Quantile regression was used to analyze the association of various socioeconomic factors with the OOP expenditure associated with double disease burden.

RESULTS

Overall, 28.5% of households had double disease in 2018-19. The households with uneducated heads, male heads, outpatient healthcare, patients availing public sector healthcare services, and rural and older members showed a significant association with the prevalence of double disease. The out-of-pocket expenditure was higher for depression, liver and kidney disease, hepatitis, and pneumonia in the upper percentiles. The quantile regression results showed that an increased number of communicable and noncommunicable diseases was associated with higher monthly OOP expenditure in the lower percentiles (10th percentile, coefficient 312, 95% CI: 92-532), and OOP expenditure was less pronounced among the higher percentiles (75th percentile, coefficient 155, 95% CI: 30-270). The households with older members were associated with higher OOP expenditure at higher tails (50th and 75th percentiles) compared to lower (10th and 25th percentiles). Family size was associated with higher OOPE at lower percentiles than higher ones.

CONCLUSION

The coexistence of communicable and noncommunicable diseases is associated with excessive private healthcare costs in Pakistan. The results call for addressing the variations in financial costs associated with double diseases.

Relationship between the health poverty vulnerability and multimorbidity patterns identified with latent class analysis aged 45 years or more adults in Northwestern China: A cross-section study

This study aims to identify multimorbidity patterns and examine whether health poverty vulnerability (HPV) varies among adults aged 45 years or more. Data from 4338 participants were extracted from a Chinese cross-sectional study. Latent class analysis was used to identify multimorbidity patterns based on 11 self-reported chronic diseases. A 3-stage feasible generalized least-squares method was used to measure the HPV. The associations and influencing factors were analyzed using the Tobit model. The mean HPV values were 0.105 ± 0.225 and 0.329 ± 0.357, based on extreme poverty and those of low- and middle-income countries' poverty line, respectively. Four latent multimorbidity patterns were identified, comprising hypertension (57.33%), cardiovascular diseases (19.94%), the musculoskeletal system (13.09%), and spine (9.64%). The HPV value from hypertension (coefficient [Coef] =0.03, 95% confidence interval (CI) = 0.00-0.05) was significantly higher than that of the musculoskeletal system based on extreme poverty. In addition, the HPV values for hypertension (Coef =0.08, 95% CI = 0.05-0.11), spine (Coef =0.06, 95% CI = 0.02-0.11), and cardiovascular diseases (Coef =0.07, 95% CI = 0.03-0.11) were significantly high based on low- and middle-income countries' poverty line. Age ≥75 years, registered poor households, catastrophic medical expenditure, and toilet style were major risk factors. Although the multimorbidity pattern-induced HPV has been significant improved on extreme poverty, it still poses a very serious challenge with regard to low- to middle-income countries' poverty line. The sensitivity analysis proved the robustness of the results. Policymakers should focus on adults with 3 multimorbidity patterns, namely, registered poor households, age ≥75 years, and catastrophic health expenditure, to adopt targeted interventions to prevent and eliminate HPV.

Heart failure: a prevalence-based and model-based cost analysis

Introduction

Heart failure (HF) imposes a heavy economic burden on patients, their families, and society as a whole. Therefore, it is crucial to quantify the impact and dimensions of the disease in order to prioritize and allocate resources effectively.

Methods

This study utilized a prevalence-based, bottom-up, and incidence-based Markov model to assess the cost of illness. A total of 502 HF patients (classes I-IV) were recruited from Madani Hospital in Tabriz between May and October 2022. Patients were followed up every two months for a minimum of two and a maximum of six months using a person-month measurement approach. The perspective of the study was societal, and both direct and indirect costs were estimated. Indirect costs were calculated using the Human Capital (HC) method. A two-part regression model, consisting of the Generalized Linear Model (GLM) and Probit model, was used to analyze the relationship between HF costs and clinical and demographic variables.

Results

The total cost per patient in one year was 261,409,854.9 Tomans (21,967.21 PPP). Of this amount, 207,147,805.8 Tomans (17,407.38 PPP) (79%) were indirect costs, while 54,262,049.09 Tomans (4,559.84 PPP) (21%) were direct costs. The mean lifetime cost was 2,173,961,178 Tomans. Premature death accounted for the highest share of lifetime costs (48%), while class III HF had the lowest share (2%). Gender, having basic insurance, and disease class significantly influenced the costs of HF, while comorbidity and age did not have a significant impact. The predicted amount closely matched the observed amount, indicating good predictive power.

Conclusion

This study revealed that HF places a significant economic burden on patients in terms of both direct and indirect costs. The substantial contribution of indirect costs, which reflect the impact of the disease on other sectors of the economy, highlights the importance of unpaid work. Given the significant variation in HF costs among assessed variables, social and financial support systems should consider these variations to provide efficient and fair support to HF patients.

Effects of private health insurance on medical expenditure and health service utilization in South Korea: a quantile regression analysis

BACKGROUND

Despite universal health insurance, South Korea has seen a sharp increase in the number of people enrolled in supplemental private health insurance (PHI) during the last decade. This study examined how private health insurance enrollment affects medical expenditure and health service utilization.

METHODS

Unbalanced panel data for adults aged 19 and older were constructed using the 2016-2018 Korea Health Panel Survey. Quantile regression for medical cost, and quantile count regression for health service utilization were utilized using propensity score-matched data. We included 17 variables representing demographic, socioeconomic, and health information, as well as medical costs and use of outpatient and inpatient care.

RESULTS

We discovered that PHI enrollees' socioeconomic and health status is more likely to be better than PHI non-enrollees'. Results showed that private health insurance had a greater effect on the lower quantiles of the conditional distribution of outpatient costs (coefficient 0.149 at the 10th quantile and 0.121 at the 25th quantile) and higher quantiles of inpaitent care utilization (coefficient 0.321 at the 90th quantile for days of hospitalization and 0.076 at the 90th quantile for number of inpatient visits).

CONCLUSIONS

PHI enrollment is positively correlated with outpatient costs and inpatient care utilization. Government policies should consider these heterogeneous distributional effects of private health insurance.

Association between multimorbidity and informal long-term care use in China: a nationwide cohort study

BACKGROUND

The impact of multimorbidity on long-term care (LTC) use is understudied, despite its well-documented negative effects on functional disabilities. The current study aims to assess the association between multimorbidity and informal LTC use in China. We also explored the socioeconomic and regional disparities.

METHODS

The study included 10,831 community-dwelling respondents aged 45 years and older from the China Health and Retirement Longitudinal Study in 2011, 2015, and 2018 for analysis. We used a two-part model with random effects to estimate the association between multimorbidity and informal LTC use. Heterogeneity of the association by socioeconomic position (education and income) and region was explored via a subgroup analysis. We further converted the change of informal LTC hours associated with multimorbidity into monetary value and calculated the 95% uncertainty interval (UI).

RESULTS

The reported prevalence of multimorbidity was 60·0% (95% CI: 58·9%, 61·2%) in 2018. We found multimorbidity was associated with an increased likelihood of receiving informal LTC (OR = 2·13; 95% CI: 1·97, 2·30) and more hours of informal LTC received (IRR = 1·20; 95% CI: 1·06, 1·37), ceteris paribus. Participants in the highest income quintile received more hours of informal LTC care (IRR = 1·62; 95% CI: 1·31, 1·99). The estimated monetary value of increased informal LTC hours among participants with multimorbidity was equivalent to 3·7% (95% UI: 2·2%, 5·4%) of China's GDP in 2018.

CONCLUSION

Our findings substantiate the threat of multimorbidity to LTC burden. It is imperative to strengthen LTC services provision, especially among older adults with multimorbidity and ensure equal access among those with lower income.

Out-of-Pocket Health Expenditures Associated with Chronic Health Conditions and Disability in China

The objective of this study is to estimate the extra costs of living associated with chronic health conditions and disabilities in China. Leveraging the 2018 China Health and Retirement Longitudinal Study involving 13,530 respondents aged 50 and over, we apply both an ordinary least squares linear regression model and a logistic model to analyze the correlation between medical out-of-pocket expenditures (OOPEs) and chronic health conditions, as well as disabilities measured by Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) limitations. This paper bridges the gap in the literature on OOPEs and their association with disabilities and chronic health conditions, respectively. We find that ADL limitations, IADL limitations, and chronic health conditions are consistently associated with higher OOPEs. The odds that older persons with disabilities and chronic health conditions incur OOPEs are two to three times higher than for persons without disabilities and chronic health conditions, respectively. Persons with disabilities and chronic health conditions have the highest OOPEs. The findings suggest that more policy and research attention is necessary to improve the financial protection of those with chronic health conditions and disabilities, including through access to comprehensive health insurance coverage.

Catastrophic health expenditure of households with hypertension: a comparative study in China

Objectives

The aim of this study was to understand the impact of multimorbidity on catastrophic health expenditures for people with hypertension.

Methods

Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) in 2018, 8,342 adults were included in our analysis. Propensity score matching method was used to compare the risk of catastrophic health expenditures between the hypertension patients (treatment group) and those without any chronic disease (control group) in middle-aged and older adults. Patients with hypertension were also divided into two groups: only hypertension and multimorbidity.

Results

Hypertension increased the likelihood of CHE by 11.3% in older adults. Further analysis showed that hypertension alone does not increase the risk of CHE, and the risk of CHE in hypertension patients with multimorbidity was 12.9% higher than those without chronic disease.

Conclusion

Our study highlights the importance of healthy management of patients with only hypertension and preventing them from developing multimorbidity.

The association between obesity, health service use, and work productivity in Australia: a cross-sectional quantile regression analysis

The burden of disease attributable to obesity is rapidly increasing and becoming a public health challenge globally. Using a nationally representative sample in Australia, this study aims to examine the association of obesity with healthcare service use and work productivity across outcome distributions. We used Household, Income and Labour Dynamics Australia (HILDA) Wave 17 (2017-2018), including 11,211 participants aged between 20 and 65 years. Two-part models using multivariable logistic regressions and quantile regressions were employed to understand variations in the association between obesity levels and the outcomes. The prevalence of overweight and obesity was 35.0% and 27.6%, respectively. After adjusting for socio-demographic factors, low socioeconomic status was associated with a higher probability of overweight and obesity (Obese III: OR = 3.79; 95% CI 2.53-5.68) while high education group was associated with a lower likelihood of being high level of obesity (Obese III OR = 0.42, 95% CI 0.29-0.59). Higher levels of obesity were associated with higher probability of health service use (GP visit Obese, III: OR = 1.42 95% CI 1.04-1.93,) and work productivity loss (number of paid sick leave days, Obese III: OR = 2.40 95% CI 1.94-2.96), compared with normal weight. The impacts of obesity on health service use and work productivity were larger for those with higher percentiles compared to lower percentiles. Overweight and obesity are associated with greater healthcare utilisation, and loss in work productivity in Australia. Australia's healthcare system should prioritise interventions to prevent overweight and obesity to reduce the cost on individuals and improve labour market outcomes.

Association between multimorbidity and memory-related diseases among middle-aged and older adults: Evidence from the China Health and Retirement Longitudinal Study

Objectives

This study aimed to examine the cross-sectional and longitudinal association between multimorbidity and memory-related diseases (MDs) among Chinese middle-aged and older adults.

Methods

This study included 8,338 subjects who participated in the China Health and Retirement Longitudinal Study (CHARLS). Logistic regression and Cox proportional hazards regression models were used to explore the association and effect of multimorbidity on MDs.

Results

The overall prevalence of MDs was 2.52%, and the mean multimorbidity number was 1.87. In a cross-sectional analysis, compared with the no multimorbidity group, groups of multimorbidity with four or more non-communicable diseases (NCDs) were more likely to have MDs (OR: 6.49, 95%CI: 4.35–9.68). Within 2.7 years of follow-up, 82 cases of MDs (1.12%) were reported, and participants with multimorbidity were more likely to have new-onset MDs than participants without multimorbidity (HR: 2.93, 95%CI: 1.74–4.96).

Conclusion

Multimorbidity is associated with MDs among Chinese middle-aged and older adults. This relationship gradually strengthens with the severity of multimorbidity, which indicates that early prevention for people with multimorbidity may reduce the risk of MDs.

Hospitalization costs of injury in elderly population in China: a quantile regression analysis

BACKGROUND

Trauma in the elderly is gradually growing more prevalent as the aging population increases over time. The purpose of this study is to assess hospitalization costs of the elderly trauma population and analyze the association between those costs and the features of the elderly trauma population.

METHODS

In a retrospective analysis, data on trauma patients over 65 who were admitted to the hospital for the first time due to trauma between January 2017 and March 2022 was collected from a tertiary comprehensive hospital in Baotou. We calculated and analyzed the hospitalization cost components. According to various therapeutic approaches, trauma patients were divided into two subgroups: non-surgical patients (1320 cases) and surgical patients (387 cases). Quantile regression was used to evaluate the relationship between trauma patients and hospitalization costs.

RESULTS

This study comprised 1707 trauma patients in total. Mean total hospitalization costs per patient were ¥20,741. Patients with transportation accidents incurred the highest expenditures among those with external causes of trauma, with a mean hospitalization cost of ¥24,918, followed by patients with falls at ¥19,809 on average. Hospitalization costs were dominated by medicine costs (¥7,182 per capita). According to the quantile regression results, all trauma patients' hospitalization costs were considerably increased by length of stay, surgery, the injury severity score (16-24), multimorbidity, thorax injury, and blood transfusion. For non-surgical patients, length of stay, multimorbidity, and the injury severity score (16-24) were all substantially linked to higher hospitalization costs. For surgical patients, length of stay, injury severity score (16-24), and hip and thigh injuries were significantly associated with greater hospitalization costs.

CONCLUSIONS

Using quantile regression to identify factors associated with hospitalization costs could be helpful for addressing the burden of injury in the elderly population. Policymakers may find these findings to be insightful in lowering hospitalization costs related to injury in the elderly population.

Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians

OBJECTIVES

In 2019, the Centers for Medicare & Medicaid Services began implementing the Patients Over Paperwork (POP) initiative in response to clinicians reporting burdensome documentation regulations. To date, no study has evaluated how these policy changes have influenced documentation burden.

METHODS

Our data came from the electronic health records of an academic health system. Using quantile regression models, we assessed the association between the implementation of POP and clinical documentation word count using data from family medicine physicians in an academic health system from January 2017 to May 2021 inclusive. Studied quantiles included the 10th, 25th, 50th, 75th, and 90th quantiles. We controlled for patient-level (race/ethnicity, primary language, age, comorbidity burden), visit-level (primary payer, level of clinical decision making involved, whether a visit was done through telemedicine, whether a visit was for a new patient), and physician-level (sex) characteristics.

RESULTS

We found that the POP initiative was associated with lower word counts across all of the quantiles. In addition, we found lower word counts among notes for private payers and telemedicine visits. Conversely, higher word counts were observed in notes that were written by female physicians, notes for new patient visits, and notes involving patients with greater comorbidity burden.

CONCLUSIONS

Our initial evaluation suggests that documentation burden, as measured by word count, has declined over time, particularly following implementation of the POP in 2019. Additional research is needed to see whether the same occurs when examining other medical specialties, clinician types, and longer evaluation periods.

Association between multimorbidity patterns and healthcare costs among middle-aged and older adults in China

BACKGROUND

This study investigated multimorbidity patterns among middle-aged and older Chinese people and whether healthcare costs varied among different multimorbidity patterns.

METHODS

Data were from the 2011-2018 waves of the China Health and Retirement Longitudinal Study (CHARLS). We included 20,855 unique observations with information coming from their last wave of interviews and aged at least 45 years or older. Latent class analysis (LCA) was performed to classify individuals with common multimorbidity clusters based on 14 self-reported chronic diseases. Healthcare costs were from participants' self-reports and categorized into outpatient, inpatient, and self-treatment. Two-part regression was performed to analyze the association of multimorbidity patterns with healthcare costs.

RESULTS

Five multimorbidity clusters were identified: minimal disease, arthritis, cardiovascular disease (CVD), lung/asthma, and multisystem morbidity. The multisystem morbidity group had the highest use in all three types of healthcare and the highest self-treatment cost. Compared with the minimal disease group, the other four groups did not show significant differences in outpatient costs. Relative to the minimal disease group, the lung/asthma group reported lower inpatient costs.

CONCLUSION

Healthcare use and costs varied across multimorbidity patterns among middle-aged and older Chinese people. Implementing an integrated care plan for multimorbidity is suggested to improve the cost-effectiveness of healthcare provision and reduce the financial burden of the healthcare system. Reimbursement policy design should also take multimorbidity patterns into account.

Real price of health-experiences of out-of-pocket costs in Australia: protocol for a systematic review

INTRODUCTION

Australians have substantial out-of-pocket (OOP) health costs compared with other developed nations, even with universal health insurance coverage. This can significantly affect access to care and subsequent well-being, especially for priority populations including those on lower incomes or with multimorbidity and chronic illness. While it is known that high OOP healthcare costs may contribute to poorer health outcomes, it is not clear exactly how these expenses are experienced by people with chronic illnesses. Understanding this may provide critical insights into the burden of OOP costs among this population group and may highlight policy gaps.

METHOD AND ANALYSIS

A systematic review of qualitative studies will be conducted using Pubmed, CINAHL Complete (EBSCO), Cochrane Library, PsycINFO (Ovid) and EconLit from date of inception to June 2022. Primary outcomes will include people's experiences of OOP costs such as their preferences, priorities, trade-offs and other decision-making considerations. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and methodological appraisal of included studies will be assessed using the Critical Appraisal Skills Programme. A narrative synthesis will be conducted for all included studies.

ETHICS AND DISSEMINATION

Ethics approval was not required given this is a systematic review that does not include human recruitment or participation. The study's findings will be disseminated through conferences and symposia and shared with consumers, policymakers and service providers, and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022337538.

The impact of depression and physical multimorbidity on health-related quality of life in China: a national longitudinal quantile regression study

The co-occurrence of mental and physical chronic conditions is a growing concern and a largely unaddressed challenge in low-and-middle-income countries. This study aimed to investigate the independent and multiplicative effects of depression and physical chronic conditions on health-related quality of life (HRQoL) in China, and how it varies by age and gender. We used two waves of the China Health and Retirement Longitudinal Study (2011, 2015), including 9227 participants aged ≥ 45 years, 12 physical chronic conditions and depressive symptoms. We used mixed-effects linear regression to assess the effects of depression and physical multimorbidity on HRQoL, which was measured using a proxy measure of Physical Component Scores (PCS) and Mental Component Scores (MCS) of the matched SF-36 measure. We found that each increased number of physical chronic conditions, and the presence of depression were independently associated with lower proxy PCS and MCS scores. There were multiplicative effects of depression and physical chronic conditions on PCS (- 0.83 points, 95% CI - 1.06, - 0.60) and MCS scores (- 0.50 points, 95% CI - 0.73, - 0.27). The results showed that HRQoL decreased markedly with multimorbidity and was exacerbated by the presence of co-existing physical and mental chronic conditions.

What is the impact of multimorbidity on out-of-pocket healthcare expenditure among community-dwelling older adults in Ireland? A cross-sectional study

OBJECTIVES

Individuals with multimorbidity use more health services and take more medicines. This can lead to high out-of-pocket (OOP) healthcare expenditure. This study, therefore, aimed to assess the association between multimorbidity (two or more chronic conditions) and OOP healthcare expenditure in a nationally representative sample of adults aged 50 years or over.

DESIGN

Cross-sectional analysis of data collected in 2016 from wave 4 of The Irish Longitudinal Study on Ageing.SettingIreland.ParticipantsCommunity-dwelling adults aged 50 years and over.MethodA generalised linear model with log-link and gamma distributed errors was fitted to assess the association between multimorbidity and OOP healthcare expenditure (including general practitioner, emergency department, outpatients, specialist consultations, hospital admissions, home care and prescription drugs).

RESULTS

Overall, 3453 (58.5%) participants had multimorbidity. Among those with any OOP healthcare expenditure, individuals with multimorbidity spent more on average per annum (€806.8 for two conditions, €885.8 for three or more conditions), than individuals with no conditions (€580.3). Pharmacy-dispensed medicine expenditure was the largest component of expenditure. People with multimorbidity on average spent more of their equivalised household income on healthcare (7.1% for two conditions, 9.7% for three or more conditions), than people with no conditions (5.0%). A strong positive association was found between number of conditions and OOP healthcare expenditure (p<0.001) and between having private health insurance and OOP healthcare expenditure (p<0.001). A strong negative association was found between eligibility for free primary/hospital care and heavily subsidised medicines and OOP healthcare expenditure (p<0.001).

CONCLUSIONS

This study suggests that having multimorbidity in Ireland increases OOP healthcare expenditure, which is problematic for those with more conditions who have lower incomes. This highlights the need for this financial burden to be considered when designing healthcare/funding systems to address multimorbidity, so that access to essential healthcare can be maximised for those with greatest need.

Using Bayesian networks with Max-Min Hill-Climbing algorithm to detect factors related to multimorbidity

Objectives

Multimorbidity (MMD) is a medical condition that is linked with high prevalence and closely related to many adverse health outcomes and expensive medical costs. The present study aimed to construct Bayesian networks (BNs) with Max-Min Hill-Climbing algorithm (MMHC) algorithm to explore the network relationship between MMD and its related factors. We also aimed to compare the performance of BNs with traditional multivariate logistic regression model.

Methods

The data was downloaded from the Online Open Database of CHARLS 2018, a population-based longitudinal survey. In this study, we included 10 variables from data on demographic background, health status and functioning, and lifestyle. Missing value imputation was first performed using Random Forest. Afterward, the variables were included into logistic regression model construction and BNs model construction. The structural learning of BNs was achieved using MMHC algorithm and the parameter learning was conducted using maximum likelihood estimation.

Results

Among 19,752 individuals (9,313 men and 10,439 women) aged 64.73 ± 10.32 years, there are 9,129 ones without MMD (46.2%) and 10,623 ones with MMD (53.8%). Logistic regression model suggests that physical activity, sex, age, sleep duration, nap, smoking, and alcohol consumption are associated with MMD (P < 0.05). BNs, by establishing a complicated network relationship, reveals that age, sleep duration, and physical activity have a direct connection with MMD. It also shows that education levels are indirectly connected to MMD through sleep duration and residence is indirectly linked to MMD through sleep duration.

Conclusion

BNs could graphically reveal the complex network relationship between MMD and its related factors, outperforming traditional logistic regression model. Besides, BNs allows for risk reasoning for MMD through Bayesian reasoning, which is more consistent with clinical practice and thus holds some application prospects.

The influence of the National Health Insurance scheme of the Lao People's Democratic Republic on healthcare access and catastrophic health expenditures for patients with chronic renal disease, and the possibility of integrating organ transplantation into the health financing system

Citizens of the Lao People’s Democratic Republic have difficulties in obtaining proper health services compared to more developed countries, due to the lack of available health facilities and health financing programmes. Haemodialysis (HD) is currently included under the coverage of the National Health Insurance (NHI) scheme. However, there are several technical barriers related to health service utilization. This study aims to analyse the effects of the Lao NHI on issues of accessibility and the possibility of encountering catastrophic health expenditures for patients with chronic kidney disease. In addition, the study provides policy recommendations for policy-makers regarding the provision of organ transplantation under NHI in the future. Savannakhet Province was purposively selected as a study site, where 342 respondents participated in the study. Two logistic regression models are used to assess the effectiveness of the NHI in terms of accessibility and financial protection against catastrophic health expenditures. The Andersen behavioural model is applied as a guideline to identify factors that affect accessibility and economic catastrophe. NHI is found to improve accessibility to health service utilization for household members with chronic kidney disease. However, due to the limited HD services, there are barriers to accessing health services and a risk of financial hardship due to nonmedical expenditures. Chronic conditions, in addition to kidney issues, dramatically increase the chances of suffering catastrophic health expenditures. In the short run, collaboration with neighbouring countries’ hospitals through copayment programmes is strongly recommended for NHI’s policy-makers. For long-term policy guidelines, the government should move forward to include kidney transplantation in the NHI healthcare system.

How much do government and households spend on an episode of hospitalisation in India? A comparison for public and private hospitals in Chhattisgarh state

BACKGROUND

Improvements in the financing of healthcare services are important for developing countries like India to make progress towards universal health coverage. Inpatient-care contributes to a big share of total health expenditure in India. India has a mixed health-system with a sizeable presence of private hospitals. Existing studies show that out-of-pocket expenditure (OOPE) incurred per hospitalisation in private hospitals was greater than public facilities. But, such comparisons have not taken into account the healthcare spending by government.

METHODS

For a valid comparison between public and for-profit private providers, this study in Indian state of Chhattisgarh assessed the combined spending by government and households per episode of hospitalisation. The supply-side and demand-side spending from public and private sources was taken into account. The study used two datasets: a) household survey for data on hospital utilisation, OOPE, cash incentives received by patients and claims raised under publicly funded health insurance (PFHI) schemes (n = 903 hospitalisation episodes) b) survey of public facilities to find supply-side government spending per hospitalisation (n = 64 facilities).

RESULTS

Taking into account all relevant demand and supply side expenditures, the average total spending per day of hospitalisation was INR 2833 for public hospitals and INR 6788 for private hospitals. Adjusted model for logarithmic transformation of OOPE while controlling for variables including case-mix showed that a hospitalisation in private hospitals was significantly more expensive than public hospitals (coefficient = 2.9, p < 0.001). Hospitalisations in private hospitals were more likely to result in a PFHI claim (adjusted-odds-ratio = 1.45, p = 0.02) and involve a greater amount than public hospitals (coefficient = 0.27, p < 0.001). Propensity-score matching models confirmed the above results. Overall, supply-side public spending contributed to 16% of total spending, demand-side spending through PFHI to 16%, cash incentives to 1% and OOPE to 67%. OOPE constituted 31% of total spending per episode in public and 86% in private hospitals.

CONCLUSIONS

Government and households put together spent substantially more per hospitalisation in private hospitals than public hospitals in Chhattisgarh. This has important implications for the allocative efficiency and the desired public-private provider-mix. Using public resources for purchasing inpatient care services from private providers may not be a suitable strategy for such contexts.

Effect of Family Practice Contract Services on the Perceived Quality of Primary Care among Patients with Multimorbidity: A Cross-Sectional Study in Guangdong, China

Family practice contract services, an important primary-care reform policy for improving primary healthcare quality in China, incorporate patients with multiple chronic conditions into the priority coverage groups and focus on their management. This study aims to explore the family practice contract services' effectiveness in improving the quality of primary care experienced by this population. A cross-sectional study using a three-stage sampling was conducted from January to March 2019 in Guangdong, China. A multivariable linear regression, including interaction terms, was applied to examine the associations between the contract services and primary care quality among people with different chronic conditions. The process quality of primary care was measured in six dimensions using the validated assessment survey of primary care (ASPC) scale. People with contract services scored higher in terms of quality of primary care than those without contract services. Contract services moderated the association between chronic condition status and primary care quality. Significantly positive interactions were observed in the patient-centred care dimension and negative interactions were reflected in the accessibility dimension. Our findings suggest that family practice contract services play a crucial role in improving patient-perceived primary care quality and provide emerging evidence that patients with multimorbidity tend to benefit more from the services, especially in patient-centred care.

Urban-rural differences in the impacts of multiple chronic disease on functional limitations and work productivity among Chinese adults

BACKGROUND

Chronic disease multimorbidity has become a major challenge for health systems. While a lot of research has evaluated the direct economic burden of multimorbidity on health care utilization and cost, little attention has been given to the impacts on work productivity and functional limitations, as indirect indicators of disease burden.

OBJECTIVES

This study aims to examine the prevalence of multimorbidity among Chinese adults and its impact on functional disability and work productivity. It also investigates urban-rural differences in these relationships.

METHOD

This study utilized the data from the China Health and Retirement Longitudinal Study (CHARLS) in 2015, including 11,176 participants aged 45 years and older. Multivariable logistic regression models were used to estimate the effect of multimorbidity on functional disability (i.e. ADL: activities of daily life; IADL: instrumental activities of daily life), and work productivity loss due to health problems. Negative binomial regression models were used to assess the association of multimorbidity with sickness absences from agricultural work and employed non-agricultural work.

RESULTS

68.8% of total participants in CHARLS had multimorbidity in China in 2015. Rural residents with multimorbidity reported higher proportions of physical functions and days of sick leave than urban residents. Multimorbidity was positively associated with ADL limitation (odds ratio 1.924, 95% CI 1.656-2.236), IADL limitation (1.522, 1.326-1.748), limited work due to health problems (1.868, 1.601-2.178) and days of sick leave (for agricultural work, incidence rate ratio 1.676, 95% CI 1.390-2.020; for employed non-agricultural work, 2.418, 1.245-4.696). For the rural group, the impact of multimorbidity on functional limitations and work productivity loss (except for early retirement), was less than the urban group.

CONCLUSIONS

Multimorbidity poses significant challenges for functional health and work productivity These have significant negative economic consequences for individuals, the Chinese health system and the society.