Health care utilization in older people with cardiovascular disease in China

Healthcare utilization and its association with socioeconomic status in China: Evidence from the 2011-2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Healthcare utilization often favors the higher-socioeconomic status (SES) and having chronic diseases may exacerbate this inequality. This study aims to examine the trends in health service use over time, the effect of SES on healthcare utilization, and the role of chronic diseases in this association.

METHODS

Data used in this study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018, which is the first nationally representative survey of the middle-aged and older. The sample included people aged 45 years and older who responded to all the waves. A total of 10,922 adults were included in this study. Healthcare utilization was categorized into outpatient and inpatient service use and SES was measured by per-capita household expenditure. A multilevel zero-inflated negative binomial regression model was performed to analyze outpatient and inpatient service use, separately.

RESULTS

The rates of outpatient service use in 2011, 2013, 2015, and 2018 were 19.11%, 21.45%, 20.12%, and 16.32%, respectively, while the rates of inpatient service use were 8.40%, 13.04%, 14.17%, and 18.79%, respectively. Compared to individuals in the lowest quintile of per-capita household expenditure, those in higher quintiles had higher odds of outpatient service use (Q2: odds ratio = 1.233, p < 0.0001; Q3: 1.416, p < 0.0001; Q4: 1.408, p < 0.0001; or Q5: 1.439, p < 0.0001) and higher rates of inpatient service use (Q2: incidence rate ratio = 1.273, p < 0.0001; Q3: 1.773, p < 0.0001; Q4: 2.071, p < 0.0001; or Q5: 1.992, p < 0.0001). Additionally, having morbidity generally increased healthcare utilization, but did not play a significant role in moderating the relationship between SES and healthcare utilization.

CONCLUSIONS

Healthcare utilization rates were overall low in China, but relatively high for people in higher quintiles of per-capita household expenditure or those with morbidity, compared to their counterparts. Policy actions are required to provide more health education to the public, to further optimize health insurance schemes targeting outpatient services, especially for the low-SES, and to establish new health delivery models for NCD management in the primary health care setting.

Comparison of Health Care Utilization in Different Usual Sources of Care Among Older People With Cardiovascular Disease in China: Evidence From the Study on Global Ageing and Adult Health

Objectives: To compare the health care utilization in different usual sources of care (USCs) among the elderly population with cardiovascular disease in China. Methods: Cross-sectional data for 3,340 participants aged ≥50 years with cardiovascular disease from Global AGEing and Adult Health (2010)-China were used. Using the inverse probability of treatment weighting on the propensity score with survey weighting, combined with negative binomial regression and logistic regression models, the correlation between USCs and health care utilization was assessed. Results: Patients using primary care facilities as their USC had fewer hospital admissions (IRR = 0.507, 95% CI = 0.413, 0.623) but more unmet health needs (OR = 1.657, 95% CI = 1.108, 2.478) than those using public hospitals. Patients using public clinics as their USC had higher outpatient visits (IRR = 2.188, 95% CI = 1.630, 2.939) than the private clinics' group. Conclusion: The difference in inpatient care utilization and unmet health care needs between public hospitals and primary care facilities, and the difference in outpatient care utilization between public and private clinics were significant. Using primary care facilities as USCs, particularly public ones, appeared to increase care accessibility, but it still should be strengthened to better address patients' health care needs.

The action logic of the older adults about health-seeking in South Rural China

BACKGROUND

The Chinese government has invested significant resources to build many rural healthcare stations. However, in the face of convenient medical paths and accessible medical resources, the utilization rate of health services for older adults in rural areas is surprisingly low. This study explored why health-seeking behavior among older adults in rural China was not active.

METHODS

Data were collected through participatory rural appraisal (PRA) with 108 participants in 12 villages in southern China. Daily schedule and social and resource mapping were employed to outline the range of activities and the routine of the older adults, as well as in-depth interviews to understand the logic of their healthcare choices. Data collected were analyzed by content analysis.

RESULTS

Three themes were generated: (1) perceptions of health status (being healthy or sick): the rural older adults used the ability to handle routine chores as a measure of health status; (2) prioritization of solving symptoms over curing diseases: the older adults preferred the informal self-medication to cope with diseases, as long as there were no symptoms and no pain; (3) 'unpredictable' troubles: they tended to favor the 'optimal' solution of keeping their lives in order rather than the best medical treatment options.

CONCLUSION

This study showed that the medical practices of the rural elderly were profoundly influenced by their perceptions of health and their life experiences. In the face of diseases, they tended to keep their lives in order, preferring self-treatment practices that address symptoms or selectively following medical advice rather than medical and science-based clinical solutions. In the future, the construction of rural health care should focus on changing the 'inaccessibility' of healthcare resources at the subjective level of the rural elderly and develop culturally adaptable health education.

Gender differentials in the choice of in-patient healthcare services among the older adults in India: A cross-sectional study

India is presently undergoing a rapid demographic transition and experiencing a gradual increase in an ageing population. As a result, the households were continuously exposed to catastrophic economic impacts, ultimately influencing the healthcare utilisation of older people. The study examined the gender differentials in the choice of in-patient private and public hospitalisation among Indian elderly using Andersen's Health Behaviour Model. The database was acquired from the nationally representative cross-sectional survey (NSSO, 2017-18). Bivariate chi-square and binomial logistic regression techniques were used to fulfill the objective. In addition, the poor-rich ratio and concentration index was used to understand the inherent socioeconomic inequalities in healthcare preferences. The findings suggest that aged men were 27 percent more prone to avail private healthcare facilities than aged women. Further, older adults, who are married, belong to the upper caste, have higher education and gone through surgery, and primarily reside in an affluent society were more likely to prefer private in-patient hospitalisation. It represents negligence of older women in access to better healthcare who had financial strain and economically dependent. The study can be used to reframe existing public health policies and programs, particularly focusing on the older women, to avail cost-effective treatment.

Differentials in private and public healthcare service utilization in later life: do gender and marital status have any association?

The present study investigates whether the differentials in private and public inpatient healthcare utilization are associated with marital status for men and women aged 60 years and above in India. Binary logistic regression was applied to examine the association of private and public inpatient healthcare utilization with the marital status of the elderly. The study found that widowed men and women generally used public healthcare for hospitalization, while married men and women preferred private healthcare. Our findings also indicated that private inpatient health services expenditure was higher for married elderly than widowed elderly. After controlling all covariates, widowhood was significantly associated with higher use of public healthcare services for women but not for men. India's current health care policy and program may be required to focus on improving the infrastructure quality of current public healthcare systems. It also needs to be favorable for vulnerable sections of society, especially widowed women, to avail better treatment at an affordable cost.

Determinants of choice of usual source of care among older people with cardiovascular diseases in China: evidence from the Study on Global Ageing and Adult Health

BACKGROUND

Cardiovascular diseases (CVD) are emerging as the leading contributor to death globally. The usual source of care (USC) has been proven to generate significant benefits for the elderly with CVD. Understanding the choice of USC would generate important knowledge to guide the ongoing primary care-based integrated health system building in China. This study aimed to analyze the individual-level determinants of USC choices among the Chinese elderly with CVD and to generate two exemplary patient profiles: one who is most likely to choose a public hospital as the USC, the other one who is most likely to choose a public primary care facility as the USC.

METHODS

This study was a secondary analysis using data from the World Health Organization's Study on Global AGEing and Adult Health (SAGE) Wave 1 in China. 3,309 individuals aged 50 years old and over living with CVD were included in our final analysis. Multivariable logistic regression was built to analyze the determinants of USC choice. Nomogram was used to predict the probability of patients' choice of USC.

RESULTS

Most of the elderly suffering from CVD had a preference for public hospitals as their USC compared with primary care facilities. The elderly with CVD aged 50 years old, being illiterate, residing in rural areas, within the poorest income quintile, having functional deficiencies in instrumental activities of daily living and suffering one chronic condition were found to be more likely to choose primary care facilities as their USC with the probability of 0.85. Among those choosing primary care facilities as their USC, older CVD patients with the following characteristics had the highest probability of choosing public primary care facilities as their USC, with the probability of 0.77: aged 95 years old, being married, residing in urban areas, being in the richest income quintile, being insured, having a high school or above level of education, and being able to manage activities living.

CONCLUSIONS

Whilst public primary care facilities are the optimal USC for the elderly with CVD in China, most of them preferred to receive health care in public hospitals. This study suggests that the choice of USC for the elderly living with CVD was determined by different individual characteristics. It provides evidence regarding the choice of USC among older Chinese patients living with CVD.

Understanding the health care utilization behavior to achieve the sustainable development goals—a comparative study of Malda District, India

The Sustainable Development Goals were finalized in September 2015 by following and expanding Millennium Development Goals with newer targets under the principle of ‘leaving no one behind’. One of the 17 goals is devoted to health (Goal number 3). Understanding the health care utilization behavior is essential to attain the health goal by providing adequate and quality health services. The study seeks to understand the health care utilization behavior and its determinants in Malda district, India. For this study, the primary data are collected through a household survey with a pre-designed schedule. For that, for a comparative discussion, Englishbazar and Chanchal- II blocks have been chosen by purposive sampling considering the best and worst health conditions, respectively. The sample size was 100 families for each block. Analytical methods like chi-square, correlation, and regression analysis are used for the study. The four categories of treatment patterns that have been recognized in the study area; are self-treatment, government institution, qualified doctors and private institution, and the presence of quack doctors. People’s education and income were the confounding factors of such treatment patterns. Many of the respondents are getting treatment from quack doctors or rely on self-treatment based on their very little knowledge of medicine, resulting from a lack of awareness among local communities. It may be concluded that besides socio-economic factors, the availability of insufficient health care facilities influences the health care utilization behavior in the study area.

Impact of Tobacco Smoking on Health Care Utilization and Medical Costs in Chronic Obstructive Pulmonary Disease, Coronary Heart Disease and Diabetes

OBJECTIVE

To determine the impact of smoking on disease-specific health care utilization and medical costs in patients with chronic non-communicable diseases (NCDs).

METHODS

Participants were middle-aged and elderly adults with chronic NCDs from a prospective cohort in China. Logistic regressions and linear models were used to assess the relationship between tobacco smoking, health care utilization and medical costs.

RESULTS

Totally, 1020 patients with chronic obstructive pulmonary disease (COPD), 3144 patients with coronary heart disease (CHD), and 1405 patients with diabetes were included in the analysis. Among patients with COPD, current smokers (β: 0.030, 95% CI: -0.032-0.092) and former smokers (β: 0.072, 95% CI: 0.014-0.131) had 3.0% and 7.2% higher total medical costs than never smokers. Medical costs of patients who had smoked for 21-40 years (β: 0.028, 95% CI:-0.038-0.094) and ≥41 years (β: 0.053, 95% CI: -0.004β0.110) were higher than those of never smokers. Patients who smoked ≥21 cigarettes (β: 0.145, 95% CI: 0.051-0.239) per day had more inpatient visits than never smokers. The association between smoking and health care utilization and medical costs in people with CHD group was similar to that in people with COPD; however, there were no significant associations in people with diabetes.

CONCLUSION

This study reveals that the impact of smoking on health care utilization and medical costs varies among patients with COPD, CHD, and diabetes. Tobacco control might be more effective at reducing the burden of disease for patients with COPD and CHD than for patients with diabetes.

Gender Differences in Health Care Utilization Among the Elderly

The unstoppable process of demographic aging of population has profound consequences on the economic, health, social and political spheres of society, because of the specific and diverse needs of the older population. The aim of the study was to examine gender differences of health care utilization among elderly in Serbia. The survey was conducted as a part of the national study "Health Survey of the Serbian population" in 2013. In the past year, 87.4% of the older population visited their chosen doctor. Women were significantly more likely to use primary health care compared to men, while the frequency of hospitalization is significantly higher in men. When it comes to female population, age, region of residence and financial situation stood out as the most important predictors of primary care services usage. In men, the residence stood out as the most important predictor of primary health care services usage. Multivariate binary logistic regression distinguishes gender, education and region of residence as the most important factors associated with hospital treatment.

Epidemiological Features of Cardiovascular Disease in Asia

Cardiovascular disease (CVD) is the leading cause of death in Asia. To combat the harmful impacts of CVD on public health in Asian countries with more effective strategies and actions, it is crucial to understand the current epidemiologic features of CVD in Asia. Through a systematic study and analysis of various timely data on CVD epidemiology in Asian countries from multiple sources, this state-of-the-art review provides an overview of the important epidemiologic features of CVD in Asia. Current and future challenges in CVD prevention implied by the epidemiologic features in Asian countries are highlighted and discussed in this review.

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Comprehensive data for the current features of CVD epidemics in Asia are lacking.

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This review provides an overview of the epidemiologic features of CVD in Asia.

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Current and future challenges and requirements for CVD prevention in Asian countries are addressed.

The association between childhood conditions and heart disease among middle-aged and older population in China: a life course perspective

Background

Heart disease is a severe health problem among adult populations in China. The prevalence rates of heart disease increase with age. The pathogenic causes of heart disease are often related to conditions in early life. Using a nationally representative sample of adults aged 45 or older in China, we examined the association between childhood conditions and heart disease in later life from a life course perspective.

Methods

The data used in this study were derived from the life history module and 2015 wave of China Health and Retirement Longitudinal Study (CHARLS). Missingness were handled by multiple imputation, generating 20 complete datasets with a final sample of 19,800. Doctor-diagnosed heart disease was the main dependent variable. Respondents’ conditions in childhood, adulthood, and older age were the independent variables (e.g., socioeconomic status, health, and health resources). Random-effects logistic regression models were conducted to test the hypotheses.

Results

A total of 16.6% respondents reported being diagnosed with heart disease by doctors. Regarding childhood socioeconomic status, 8.2% of the respondents considered that they were (a lot) better off than their neighbors, and 31.1% considered that their health status in childhood was better than their peers. More than 90% of respondents did not have severe illnesses during their childhood, and around 80.3% had access to health resources nearby in childhood. Lower socioeconomic status and poorer health conditions in childhood were associated with a greater likelihood of reporting doctor-diagnosed heart diseases, even after controlling for conditions in adulthood and older age (socioeconomic status: odds ratio (OR) = 0.947; self-rated health: OR = 0.917; severe illnesses: OR = 1.196).

Conclusions

Along with chronic diseases (e.g., hypertension, diabetes, and dyslipidemia), unhealthy behaviors, overweight and obesity, poor childhood conditions should be considered as screening criteria to identify populations at risk of heart disease. Relevant preventive strategies and interventions should be developed from a life course perspective and conducted in communities by providing health education program among older population with low socioeconomic status, and encouraging early detection and treatment.

Unmet Needs of Healthcare Services and Associated Factors among a Cohort of Ghanaian Adults: A Nationally Stratified Cross-Sectional Study Design

We estimated the prevalence of unmet needs of healthcare services (UNHS) and its associated factors among a cohort of older Ghanaian adults. World Health Organization (WHO) Study on Global AGEing and Adult Health for Ghana was used with a total of 4735 participants. Logistics regression analysis was performed using Stata 16 to assess associated factors. The overall UNHS was 3.7% (95% CI = 2.7-4.8) and the prevalence was significantly high amongst older adults aged 60 to 69 years (5.9%). Could not afford the healthcare (56.4%) was the main contender for UNHS. UNHS was influenced by; those aged 60 to 69 years [OR (95% CI) = 1.86 (1.19-2.91)]; no formal educational [aOR (95% CI) = 4.71 (1.27-17.38)], and no NHIS [OR (95% CI) = 1.78 (1.03-3.09)]. Participants needed care for joint pain (25.4%), and communicable diseases (19.1%). The inability to access healthcare was relatively higher for older adults more advanced in age, with low education, and for those without health insurance. Health system strengthening including financial protection by expanding the National Health Insurance Scheme to all Ghanaians in line with Ghana's Universal Health Coverage Roadmap would reduce the unmet healthcare needs of older adults.

Reduction in inequalities in health insurance coverage and healthcare utilization among older adults in the Philippines after mandatory national health insurance coverage: trend analysis for 2003-2017

BACKGROUND

Health policies in the Philippines have evolved in response to increasing health demands of older adults. However, there is a lack of research on equity among the ageing population in low-middle income countries. The objective of this study was to identify the trends in National Health Insurance Program (NHIP) coverage and healthcare utilization among older adults in the Philippines for the period from 2003 to 2017, during which NHIP expansion policies were implemented, focusing on reductions in socio-economic inequalities.

METHODS

A literature search of policies for older adults and an analysis of four Philippine National Demographic and Health Surveys (2003, 2008, 2013, and 2017) with data from 25,217 older adults who were 60 years or older were performed. The major outcome variables were NHIP coverage, self-reported illness, outpatient healthcare utilization, and inpatient healthcare utilization. Inequalities in NHIP coverage and healthcare utilization according to wealth were evaluated by calculating the concentration index for individual years, followed by a regression-based decomposition analysis.

RESULTS

NHIP coverage among older adults increased from 9.4 (2003) to 87.6% (2017). Although inequalities according to wealth quintile were observed in all four surveys (all P < 0.001), the concentration index declined from 0.3000 (2003) to 0.0247 (2017), showing reduced inequalities in NHIP coverage over time as observed for self-reported illness and healthcare utilization. NHIP coverage expansion for older adults in 2014 enabled equal opportunity for access to healthcare.

CONCLUSION

The passage of mandatory NHIP coverage for older Filipino adults in 2014 was followed by a reduction in inequality in NHIP coverage and healthcare utilization according to wealth.

Factors Associated with Utilization of Primary and Specialist Healthcare Services by Elderly Cardiovascular Patients in the Republic of Serbia: A Cross-Sectional Study from the National Health Survey 2013

The European Health Interview Survey (EHIS) is run every 5 years to examine how people experience and rank their health, how they care about their health, and to what extent they use the healthcare services. We identified the sub-population of special interest, i.e., cardiovascular disease (CVD) patients older than 65 years, in this cross-sectional study from the Serbian national survey of population health (2568 persons from a total of 15,999 subjects surveyed). We performed univariable and multivariable logistic regression analysis to assess the correlation between the healthcare system utilization and identified demographic, geographic, socio-economic, and self-rated factors. The most important factor for the utilization of the primary and the specialist healthcare services by elderly CVD patients is the region where one lives (Southern and Eastern Serbia OR = 2.44, 95% CI = 1.58-3.77/Belgrade OR = 1.75, 95% CI = 1.32-2.30). Age is another factor, where the 65 to 74 years old CVD patients utilize healthcare services the most. Higher education (OR = 1.80, 95% CI = 1.31-2.47), being a part of the highest Wealth Index group (OR = 1.62, 95% CI = 1.10-2.40), having very poor health status (OR = 3.02, 95% CI = 1.41-6.47), and presence of long-term illness (OR = 1.49, 95% CI = 1.16-1.92), play an important role in the utilization of the specialist care only.

Predictors of healthcare utilisation among poor older people under the livelihood empowerment against poverty programme in the Atwima Nwabiagya District of Ghana

BACKGROUND

Like many other low- and middle-income countries (LMICs), the Ghanaian healthcare system remains poor which is likely to affect the utilisation of healthcare services, especially among poor older people who are faced with multiple health problems. Yet, factors that explain healthcare use among poor older people in LMICs, particularly Ghana remain largely unexplored. Understanding the predictors of healthcare use among poor older people could have a huge impact on health policies in LMICs including Ghana. This study, therefore, examined factors associated with healthcare use among poor older people under the Livelihood Empowerment Against Poverty (LEAP) programme in the Atwima Nwabiagya District of Ghana.

METHODS

Cross-sectional data were obtained from an Ageing, Health, Lifestyle and Health Services (AHLHS) study conducted between 1 and 20 June 2018 (N = 200) in Atwima Nwabiagya District, Ghana. Sequential logistic regression models were performed to estimate the variables that predict healthcare use among poor older people. All test results were considered significant at 0.05 or less.

RESULTS

The fully adjusted model showed that respondents aged 85-89 years (AOR = 0.094, CI: 0.007-1.170), acquired basic education (AOR =0.251, CI: 0.085-0.987), received no family support (AOR = 0.771, CI: 0.120-0.620), with no past illness records (AOR = 0.236, CI: 0.057-0.197) and who were not diagnosed of chronic non-communicable diseases (AOR = 0.418, CI: 0.101-0.723) were significantly less likely to utilise health facility compared with their respective counterparts. Moreover, those with no disability (AOR = 19.245, CI: 2.415-29.921) and who consumed low fruits (AOR = 1.435 = CI: 0.552-8.740) and vegetables (AOR = 1.202 = CI: 0.362-10.20) had a higher likelihood to use healthcare.

CONCLUSION

The study has outlined multiple factors influencing utilisation of healthcare among poor older people under the LEAP programme in Ghana. The results, therefore, validate the importance of social and behavioural determinants of healthcare use in the Ghanaian poor older population. We highlight the need for health planners and stakeholders to consider demographic, socio-economic, health-related and lifestyle factors when formulating health policy for poor older people in Ghana.

Effect of Physical Activity on Hospital Service Use and Expenditures of Patients with Coronary Heart Disease: Results from Dongfeng-Tongji Cohort Study in China

The intervention of behaviors, including physical activity (PA), has become a strategy for many hospitals dealing with patients with chronic diseases. Given the limited evidence available about PA and healthcare use with chronic diseases, this study explored the association between different levels of PA and annual hospital service use and expenditure for inpatients with coronary heart disease (CHD) in China. We analyzed PA information from the first follow-up survey (2013) of the Dongfeng-Tongji cohort study of 1460 CHD inpatients. We examined factors such as PA exercise volume and years of PA and their associations with the number of inpatient visits, number of hospital days, and inpatient costs and total medical costs. We found that the number of hospital days and the number of inpatient visits were negatively associated with intensity of PA level. Similarly, total inpatient and outpatient costs declined when the PA exercise volume levels increased. Furthermore, there were also significant associations between the number of hospital days, inpatient costs or total medical costs and levels of PA years. This study provides the first empirical evidence about the effects of the intensity and years of PA on hospital service use and expenditure of CHD in China. It suggests that the patients' PA, especially the vigorous PA, should be promoted widely to the public and patients in order to relieve the financial burden of CHD.

Factors influencing healthcare use among poor older females under the Livelihood Empowerment Against Poverty programme in Atwima Nwabiagya District, Ghana

Objective

While studies show that females utilise more healthcare services in later life, data on their healthcare use predictions are limited in Ghana. This study therefore fills this gap by examining the predictors of healthcare use among poor older females under the Livelihood Empowerment Against Poverty (LEAP) programme in Atwima Nwabiagya District of Ghana. A sample of 156 poor older females was extracted from an Ageing, Health, Lifestyle and Health Services Survey which was conducted between 1 and 20 June 2018 in Atwima Nwabiagya District. Sequential logistic regression models were used to analyse the data.

Results

The fully adjusted model showed that respondents aged 85–89 years (AOR = 0.007, CI 0.001–0.958), those without past illness records (AOR = 0.027, CI 0.002–0.346) and not diagnosed of chronic non-communicable diseases (AOR = 0.003, CI 0.001–0.313) were significantly less likely to utilise a health facility compared with their respective counterparts. Non-vegetables consumers (AOR = 1.2, CI 0.23–2.45) were found to be more likely to utilise healthcare services. These findings have implications for policies towards healthcare use among poor older females in developing countries including Ghana.

Determinants of Overall Satisfaction with Public Clinics in Rural China: Interpersonal Care Quality and Treatment Outcome

The primary health care quality factors determining patient satisfaction will shape patient-centered health reform in China. While rural public clinics performed better than hospitals and private clinics in terms of patient perceived quality of primary care in China, there is little information about which quality care aspects drove patients’ satisfaction. Using a World Health Organization database on 1014 rural public clinic users from eight provinces in China, our multiple linear regression model estimated the association between patient perceived quality aspects, one treatment outcome, and overall primary health care satisfaction. Our results show that treatment outcome was the strongest predictor of overall satisfaction (β = 0.338 (95% CI: 0.284 to 0.392); p < 0.001), followed by two interpersonal care quality aspects, Dignity (being treated respectfully) (β = 0.219 (95% CI: 0.117 to 0.320); p < 0.001) and Communication (clear explanation by the physician) (β = 0.103 (95% CI: 0.003 to 0.203); p = 0.043). Prompt attention (waiting time before seeing the doctor) and Confidentiality (talking privately to the provider) were not correlated with overall satisfaction. The treatment outcome focus, and weak interpersonal primary care aspects, in overall patient satisfaction, pose barriers towards a patient-centered transformation of China’s primary care rural clinics, but support the focus of improving the clinical competency of rural primary care workers.

Public Hospitals in China: Is There a Variation in Patient Experience with Inpatient Care

In China, public hospitals are the main provider of inpatient service. The Chinese public hospital reform has recently shifted towards health care organizations and delivery to improve health care quality. This study analyzes the variation of one of the dimensions of health care quality, patient-centeredness, among inpatients with different socioeconomic status and geographical residency in China. 1471 respondents who received inpatient care in public hospitals were included in our analysis. Patient-centeredness performance was assessed on the dimensions of Communication, Autonomy, Dignity, and Confidentiality. Variations of inpatient experience were estimated using binary logistic regression models according to: residency, region, age, gender, education, income quintile, self-rated health, and number of hospital admissions. Our results indicate that older patients, and patients living in rural areas and Eastern China are more likely to report positive experience of their public hospital stay according to the care aspects of Dignity, Communication, Confidentiality and Autonomy. However, there remains a gap between China and other countries in relation to inpatient experience. Noticeable disparities in inpatient experience also persist between different geographical regions in China. These variations of patient experience pose a challenge that China's health policy makers would need to consider in their future reform efforts.

Factors affecting the choice of health care utilisation between private and public services among the elderly population in India

India is experiencing rapid population ageing in recent years. One of the most concomitant issues is the choice of health care services among the elderly, leading to its impact on the magnitude of health expenditure. Applying Andersen's Health Behavioural Model, this study identifies the predictors of the choice of inpatient health care services among the Indian elderly between private and public services. It also examines the nature of interregional disparity in the choice of health care services. Using NSSO data, the results suggest that the elderly belonging to upper caste and having higher levels of education, higher incomes, larger family size, and needing surgery are likely to choose private health care, while those experiencing higher economic dependence, chronic diseases, and higher duration of hospitalisation tend to prefer public inpatient services. The magnitude and significance of these factors, however, vary across regions. The findings of the study provide an understanding of the preferences of the India's geriatric population over hospital services, which may help policymakers better understand their health care needs.

Does insurance enrolment increase healthcare utilisation among rural-dwelling older adults? Evidence from the National Health Insurance Scheme in Ghana

INTRODUCTION

This paper examines the relationship between national health insurance enrolment and the utilisation of inpatient and outpatient healthcare for older adults in rural areas in Ghana. The Ghanaian National Health Insurance Scheme (NHIS) aims to improve affordability and increase the utilisation of healthcare. However, the system has been criticised for not being responsive to the needs of older adults. The majority of older adults in Ghana live in rural areas with poor accessibility to healthcare. With an ageing population, a specific assessment of whether the scheme has benefitted older adults, and also if the benefit is equitable, is needed.

METHODS

Using the Ghanaian Living Standards Survey from 2012 to 2013, this paper uses propensity score matching to estimate the effect of enrolment within the NHIS on the utilisation of inpatient and outpatient care among older people aged 50 and over.

RESULTS

The raw results show higher utilisation of healthcare among NHIS members, which persists after matching. NHIS members were 6% and 9% more likely to use inpatient and outpatient care, respectively, than non-members. When these increases were disaggregated for outpatient care, the non-poor and females were seen to benefit more than their poor and male counterparts. For inpatient care, the benefits of enrolment were equal by poverty status and sex. However, overall, poor older adults use health services much less than the non-poor older adults even when enrolled.

CONCLUSION

The results indicate that NHIS coverage does increase healthcare utilisation among rural older adults but that inequalities remain. The poor are still at a great disadvantage in their use of health services overall and benefit less from enrolment for outpatient care. The receipt of healthcare is significantly influenced by a set of auxiliary barriers to access to healthcare even where insurance should remove the financial burden of ad hoc out of pocket payments.

Exploring the characteristics of the high-cost population from the family perspective: a cross-sectional study in Jiangsu Province, China

BACKGROUND

Across a range of healthcare settings, 5% of the population accounts for half of healthcare spending: these patients are identified as a 'high-cost population'. Characterising high-cost users is essential for predicting potential high-cost patients and the development of appropriate interventions to improve the management and financing of these patients.

OBJECTIVE

This cross-sectional study aimed to explore the characteristics of this high-cost population from a family perspective in China and provide suggestions for social health insurance policy development.

METHODS

This study used data from the Fifth Health Service Investigation of Jiangsu Province (2013), and 12 600 families were enrolled for analysis. Households whose medical expenditures were among the top 5% were identified to be high-cost families. A t-test, a Χ² test, and a binary logistic regression were used.

RESULTS

High-cost families (n=631, 5%) accounted for 44.9% of the total medical expenditure of sampled families. High-cost families had 3.2 members and 1.2 chronic disease patients per household, which is significantly more than the 2.9 members and 0.7 people in the remaining families, respectively (p<0.05). Bi-weekly emergency department visits and annual hospitalisations preceding the household investigation of high-cost families were 1.19 and 0.98 per household, which is significantly more than the 0.68 and 0.17 of the remaining families, respectively (p<0.05). A binary logistic regression indicated that the number of family members (OR 1.152), the number of chronic disease patients (OR 1.508), bi-weekly emergency department visits (OR 1.218), and annual hospitalisations (OR 4.577) were associated with high costs.

CONCLUSION

The 5% high-cost families in Jiangsu Province accounted for approximately half of medical expenditures. The effectiveness of Chinese Social Health Insurance in lowering high-cost families' risk of catastrophic health expenditure was modest. Policymakers need to ascertain the priority of lowering the burden of high-cost families' out-of-pocket expenses through improving the reimbursement proportion and reducing avoidable medical services.

Comparison of patient perceived primary care quality in public clinics, public hospitals and private clinics in rural China

Background

In rural China, patients have free choice of health facilities for outpatient services. Comparison studies exploring the attributes of different health facilities can help identify optimal primary care service models. Using a representative sample of Chinese provinces, this study aimed to compare patients’ rating of three primary care service models used by rural residents (public clinics, public hospitals and private clinics) on a range of health care attributes related to responsiveness.

Methods

This was a secondary analysis using the household survey data from World Health Organization (WHO) Study on global AGEing and adult health (SAGE). Using a multistage cluster sampling strategy, eight provinces were selected and finally 3435 overall respondents reporting they had visited public clinics, public hospitals or private clinics during the last year, were included in our analysis. Five items were used to measure patient perceived quality in five domains including prompt attention, communication and autonomy, dignity and confidentiality. ANOVA and Turkey’s post hoc tests were used to conduct comparative analysis of five domains. Separate multivariate linear regression models were estimated to examine the association of primary care service models with each domain after controlling for patient characteristics.

Results

The distribution of last health facilities visited was: 29.5% public clinics; 31.2% public hospitals and; 39.3% private clinics. Public clinics perform best in all five domains: prompt attention (4.15), dignity (4.17), communication (4.07), autonomy (4.05) and confidentiality (4.02). Public hospitals perform better than private clinics in dignity (4.03 vs 3.94), communication (3.97 vs 3.82), autonomy (3.92 vs 3.74) and confidentiality (3.94 vs 3.73), but equivalently in prompt attention (3.92 vs 3.93). Rural residents who are older, wealthier, and with higher self-rated health status have significantly higher patient perceived quality of care in all domains.

Conclusions

Rural public clinics, which share many characteristics with the optimal primary care delivery model, should be strongly strengthened to respond to patients’ needs. Better doctor-patient interaction training would improve respect, confidentiality, autonomy and, most importantly, health care quality for rural patients.

Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana

BACKGROUND

Previous studies investigating factors associated with healthcare utilization by older Ghanaians lack distinction between public and private health services. The present study examined factors associated with public and private healthcare service use, and the resulting perceived health system responsiveness.

OBJECTIVES

To identify factors associated with public and private healthcare utilization among older adults aged 50 and older in Ghana; and to compare perceived differences in health system responsiveness between the private and public sectors.

METHODS

Cross-sectional data was analyzed from the World Health Organization Study on global AGEing and adult health (SAGE) Wave 1 in Ghana. Using Andersen's conceptual framework, public and private outpatient care utilization was examined using multinomial logistic regression to estimate and identify predictor variables associated with the type of outpatient healthcare facility accessed. Health system responsiveness was compared using chi-square tests.

RESULTS

Of 2517 respondents who used outpatient care in the 12 months preceding interview, 51.7% of respondents used a public facility, 17.8% a private facility, and 30.5% used other facilities. Older age group, higher education and higher wealth were associated with the use of private outpatient healthcare services. Using public outpatient care facilities was associated with having health insurance. Respondents with two or more chronic conditions were more likely to use public and private outpatient care than other facilities. Perceived health system responsiveness was better in private for-profit than in public and private not-for-profit healthcare facilities.

CONCLUSIONS

This study suggested that higher wealth and multimorbidity were significant predictors of public and private outpatient healthcare utilization; however, health insurance was a predictor only for the use of public facilities. Future mixed-method studies could further elucidate factors influencing the choice of public and private outpatient healthcare use.

Prevention and Control of Cardiovascular Disease in the Rapidly Changing Economy of China

With one-fifth of the world's total population, China's prevention and control of cardiovascular disease (CVD) may affect the success of worldwide efforts to achieve sustainable CVD reduction. Understanding China's current cardiovascular epidemic requires awareness of the economic development in the past decades. The rapid economic transformations (industrialization, marketization, urbanization, globalization, and informationalization) contributed to the aging demography, unhealthy lifestyles, and environmental changes. The latter have predisposed to increasing cardiovascular risk factors and the CVD pandemic. Rising CVD rates have had a major economic impact, which has challenged the healthcare system and the whole society. With recognition of the importance of health, initial political steps and national actions have been taken to address the CVD epidemic. Looking to the future, we recommend that 4 priorities should be taken: pursue multisectorial government and nongovernment strategies targeting the underlying causes of CVD (the whole-of-government and whole-of-society policy); give priority to prevention; reform the healthcare system to fit the nature of noncommunicable diseases; and conduct research for evidence-based, low-cost, simple, sustainable, and scalable interventions. By pursuing the 4 priorities, the pandemic of CVD and other major noncommunicable diseases in China will be reversed and the global sustainable development goal achieved.