What motivates individuals to share information with governments when adopting health technologies during the COVID-19 pandemic?

BACKGROUND

While digital governance has been adopted by governments around the world to assist in the management of the COVID-19 pandemic, the effectiveness of its implementation relies on the collection and use of personal information. This study examines the willingness of individuals to engage in information-sharing with governments when adopting health technologies during the COVID-19 pandemic.

METHODS

Data were obtained from a cross-sectional survey of 4,800 individuals drawn from 16 cities in China in 2021. Tobit regression models were used to assess the impacts of an array of determinants on an individual's willingness to share information with governments when adopting health technologies.

RESULTS

Individuals who perceived a higher level of helpfulness, risk, expectations from others, weariness toward privacy issues, and were sensitive to positive outcomes were more willing to share information with governments when adopting health technologies during the COVID-19 pandemic. Across all the subgroups, self-efficacy only reduced the willingness to share information with governments for individuals who spent more than seven hours per day online. The negative impacts of being sensitive to negative outcomes on the willingness to share information were only found among females and the less educated group.

CONCLUSIONS

This study revealed the seemingly paradoxical behavior of individuals who perceived high risks of sharing information and a sense of fatigue toward privacy issues yet continued to be willing to share their information with their governments when adopting health technologies during the COVID-19 pandemic. This work highlighted significant differential motivations for sharing information with governments when using health technologies during a pandemic. Tailored policies that resonate with population sub-groups were suggested to be proposed to facilitate crisis management in future situations.

Association Between Online Health Information-Seeking Behaviors by Caregivers and Delays in Pediatric Cancer: Mixed Methods Study in China

BACKGROUND

Pediatric cancer patients in China often present at an advanced stage of disease resulting in lower survival and poorer health outcomes. One factor hypothesized to contribute to delays in pediatric cancer has been the online health information-seeking (OHIS) behaviors by caregivers.

OBJECTIVE

This study aims to examine the association between OHIS behaviors by caregivers and delays for Chinese pediatric cancer patients using a mixed methods approach.

METHODS

This study used a mixed methods approach, specifically a sequential explanatory design. OHIS behavior by the caregiver was defined as the way caregivers access information relevant to their children's health via the Internet. Delays in pediatric cancer were defined as any one of the following 3 types of delay: patient delay, diagnosis delay, or treatment delay. The quantitative analysis methods included descriptive analyses, Student t tests, Pearson chi-square test, and binary logistic regression analysis, all performed using Stata. The qualitative analysis methods included conceptual content analysis and the Colaizzi method.

RESULTS

A total of 303 pediatric cancer patient-caregiver dyads was included in the quantitative survey, and 29 caregivers completed the qualitative interview. Quantitative analysis results revealed that nearly one-half (151/303, 49.8%) of patients experienced delays in pediatric cancer, and the primary type of delay was diagnosis delay (113/303, 37.3%), followed by patient delay (50/303, 16.5%) and treatment delay (24/303, 7.9%). In this study, 232 of the 303 (76.6%) caregiver participants demonstrated OHIS behaviors. When those engaged in OHIS behaviors were compared with their counterparts, the likelihood of patient delay more than doubled (odds ratio=2.21; 95% CI 1.03-4.75). Qualitative analysis results showed that caregivers' OHIS behaviors impacted the cancer care pathway by influencing caregivers' symptom appraisal before the first medical contact and caregivers' acceptance of health care providers' diagnostic and treatment decisions.

CONCLUSIONS

Our findings suggest that OHIS among Chinese pediatric caregivers may be a risk factor for increasing the likelihood of patient delay. Our government and society should make a concerted effort to regulate online health information and improve its quality. Specialized freemium consultations provided by health care providers via online health informatic platforms are needed to shorten the time for caregivers' cancer symptom appraisal before the first medical contact.

The Association Between Work Environment, Work Attitudes, and Turnover Intentions Among Geriatric Social Workers in China

The psychological state of geriatric social workers affects the intention to leave and thus the quality of services provided to older adults. This study explored the relationship between the work environment, work attitudes, and turnover intentions of geriatric social workers. This study obtained an analytic sample comprising 999 geriatric social workers from the 2019 Longitudinal Study of Social Work in China. Multivariate regression techniques combined with a mediation analysis was performed to explore the relationships. The study results provided preliminary evidence on the complex associations between and among work environment, work attitudes, and turnover intentions of geriatric social workers in China. We demonstrated that perceived organizational support reduced the turnover intentions of geriatric social workers through increased collective psychological ownership and reduced burnout. Regular inter- and intra-agency communication between social workers and their supervisors and colleagues have important roles in reducing turnover by enhancing support and emotional commitment to organizations. Policy decision-makers are suggested to clearly define the roles and responsibilities of geriatric social works to release their administrative burdens, which may help to reduce their burnout level and improve the stability of the geriatric social work force.

A cost-utility analysis of thrombopoietin receptor agonists for treating pediatric immune thrombocytopenia purpura after failure of first-line therapies

BACKGROUND

Thrombopoietin receptor agonists (TPO-RAs) have emerged as a recommended treatment for children with persistent and/or chronic immune thrombocytopenic purpura (ITP). The purpose of this study was to evaluate the cost-effectiveness of TPO-RAs relative to treatment without TPO-RAs (non-TPO-RAs/usual care) for ITP in children who do not respond to first-line therapy and in whom splenectomy is not recommended in Ontario, Canada, from a hospital payer perspective.

PROCEDURE

A 2-year Markov model with an embedded decision tree was used. Data on medications used, dose, response rate, bleeding, and emergency treatment events were collected from the Hospital for Sick Children in Toronto. The health outcomes were described in quality-adjusted life-years (QALYs). Health-state utilities were derived from the peer-reviewed literature. Scenario analyses, deterministic, and probabilistic sensitivity analyses were conducted. Economic costs were measured in 2021 Canadian dollars ($1.00 = US$0.80) RESULTS: TPO-RAs are estimated to result in an increased cost of $27,118 and a QALY gain of 0.21 compared to non-TPO-RAs over a 2-year horizon, resulting in an incremental cost-effectiveness ratio (ICER) of $129,133. In a 5-year scenario analysis, the ICER fell to $76,403. In the probabilistic sensitivity analysis, TPO-RAs exhibit a 40.0% probability of being cost-effective at a conventional ($100,000) willingness-to-pay threshold per QALY gained.

CONCLUSIONS

Further assessment of the long-term efficacy of TPO-RAs is warranted to obtain more precise long-term estimates. As the costs of TPO-RAs decline with the introduction of generic formulations, TPO-RAs may be increasingly cost-effective.

The Effect of a Long-Term Care Insurance Program on Subjective Well-Being of Older Adults with a Disability: Quasi-Experimental Evidence from China

China launched its long-term care insurance (LTCI) program for older adults in 2016. Although the scheme has shown some promising outcomes, little is known about whether it improves subjective well-being. This study explored this topic among older persons with a disability and identified the underlying mechanisms associated with the channel of this effect using data from a national survey. The LTCI program was shown to improve the subjective well-being among older persons with a disability and this effect increased over time. The LTCI program has great positive effect among women and those who lived alone compared to their counterparts. Mechanism analysis revealed that the main channel by which the LTCI program has positive effect occurred through the satisfaction of long-term care needs and improved self-reported health. This study suggests promising benefits of the LTCI program for older Chinese adults.

Impact of the Health Gym Program on hospital admissions for stroke in the state of Pernambuco, Brazil

This study aimed to evaluate the impact of the Health Gym Program (HGP) on hospital admissions for stroke in the state of Pernambuco, Brazil. This policy impact evaluation used a quasi-experimental approach consisting of a difference-in-differences estimator, weighted by propensity score matching to deal with potential confounding variables. The study comprised socioeconomic, demographic, and epidemiological data from official Brazilian databases from 2010 to 2019. The treatment group was composed of the 134 municipalities that implemented the HGP since 2011. The 51 municipalities that did not were allocated to the comparison group. The nearest neighbor algorithm (N5) was used to pair treatment and comparison group municipalities and create the weights to evaluate the average treatment effect on the treated (ATT) in the difference-in-differences estimator. In 2010, 2,771 people were hospitalized for stroke (0.51% of all hospitalizations) and in 2019, 11,542 (2%). Municipalities that implemented the HGP had 18.37% fewer hospitalizations than their counterparts in the comparison group. The program's impact in reducing hospitalization rates was incrementally greater among men (ATT: -0.1932) and those aged 71 to 80 years (ATT: -0.1911). All results were statistically significant at the 5% level. The HGP reduced hospitalization for stroke in several population groups, but primarily in those whose underlying prevalence of stroke is highest, reinforcing the importance of public investments in health promotion policies designed to encourage lifestyle changes.

The use of IVF/ICSI and risk of postpartum hemorrhage: A retrospective cohort study of 153,765 women in China

Objective

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. Identifying women who are at high risk of PPH is crucial for implementing early preventive and interventive strategies. This study aimed to examine whether there is an association between the use of in vitro fertilization (IVF) /intracytoplasmic sperm injection (ICSI) and increased risk of PPH.

Method

This retrospective cohort study was conducted using medical record data from women who delivered at a tertiary hospital in Shanghai, China, between January 1, 2013 and April 30, 2019. Logistic regression analysis was used to estimate the associations between the use of IVF/ICSI and the risk of PPH.

Results

A total of 153,765 pregnant women were included, of which 6,484 conceived through IVF/ICSI and147,281 conceived naturally. The incidence of PPH was 1.9% in this cohort. The incidence of PPH in women who conceived through IVF/ICSI was significantly higher than those in women who conceived naturally (3.4% vs. 1.7%, p < 0.01). The use of IVF/ICSI was associated with an increase in the amount of postpartum blood loss. Compared to women who conceived naturally, the average amount of postpartum blood loss increased by 42.1 mL (β = 42.1, 95% CI, 38.2-46.0) for women who conceived through IVF/ICSI. In addition, women who conceived through IVF/ICSI were at higher risk of maternal PPH. The adjusted odds ratio (OR) of PPH in women who conceived through ART was 2.7 (OR = 2.7, 95% CI, 2.3-3.1).

Conclusion

Our findings demonstrated that women who conceived through IVF/ICSI were at higher risk of PPH and suggested to obstetricians and midwives to identify and implement early preventative strategies for PPH among pregnant women who conceived through IVF/ICSI.

The impact of provincial lockdown policies and COVID-19 case and mortality rates on anxiety in Canada

AIM

COVID-19 has had significant mental health impacts internationally and anxiety rates are estimated to have tripled during the pandemic, but the specific causes remain underexplored. This study's purpose was to investigate the associations of sociodemographic factors, COVID-19-related policies, and COVID-19 case/mortality rates with levels of anxiety among Canadians during the pandemic.

METHODS

This study used linear regression models populated with three integrated sources of data: a repeated cross-sectional survey (n = 7008), Oxford COVID-19 Government Response Tracker data, and COVID-19 case/mortality rates. Sociodemographic factors included were age, gender, race, province, income, education, rurality, household composition, and factors related to employment.

RESULTS

Local COVID-19 case and mortality rates and stay-at-home orders were positively associated with anxiety symptom severity. Anxiety was most severe among those who: were female, Indigenous, or Middle Eastern; had postsecondary education; lived with others; and became unemployed or had working hours altered during the pandemic. Anxiety was less severe among: older adults; male, Caucasians, and black individuals; those with high incomes, and; those for whom employment did not change during the pandemic.

CONCLUSION

Anxiety was primarily driven by socioeconomic factors among Canadians during the COVID-19 pandemic. Policies that alleviate socioeconomic uncertainty for groups that are most vulnerable may reduce the long-term harm of the pandemic and associated lockdown policies.

The Relationship between the Unmet Needs of Chinese Family Caregivers and the Quality of Life of Childhood Cancer Patients Undergoing Inpatient Treatment: A Mediation Model through Caregiver Depression

A large proportion of the global burden of childhood cancer arises in China. These patients have a poor quality of life (QoL) and their family caregivers have high unmet needs. This paper examined the association between the unmet needs of family caregivers and the care recipient’s QoL. A total of 286 childhood cancer caregivers were included in this cross-sectional study. Unmet needs and depression among caregivers were assessed by the Comprehensive Needs Assessment Tool for Cancer Caregivers (CNAT-C) and the Patient Health Questionnaire (PHQ-9), respectively. The patient’s QoL was proxy-reported by the Pediatric Quality of Life Inventory Measurement Models (PedsQL 3.0 scale Cancer Module). Descriptive analyses, independent Student’s t-tests, one-way ANOVA, and mediation analyses were performed. The mean scores (standard deviations) for unmet needs, depression, and QoL were 65.47 (26.24), 9.87 (7.26), and 60.13 (22.12), respectively. A caregiver’s unmet needs (r = −0.272, p < 0.001) and depression (r = −0.279, p < 0.001) were negatively related to a care recipient’s QoL. Depression among caregivers played a mediating role in the relationship between a caregiver’s unmet needs and a care recipient’s QoL. As nursing interventions address depression among caregivers, it is important to standardize the programs that offer psychological support to caregivers.

Healthcare utilization and costs for musculoskeletal disorders in Ontario, Canada

OBJECTIVE

To examine the magnitude and costs of ambulatory primary and specialist physician care and hospital service use for musculoskeletal disorders (MSDs) in Canada's largest province, Ontario.

METHODS

Administrative health databases were analyzed for fiscal year 2013-2014 for adults 18+ years, including data on physician services, emergency department (ED) visits and hospitalizations. ICD diagnostic codes were used to identify MSD services. A validated algorithm was used to estimate direct medical costs. Person visit rates and numbers of persons and visits were tabulated by care setting, age and sex, and physician specialty. Data were examined for all MSDs combined as well as specific diagnostic groupings.

RESULTS

Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs. These included 5.6 million primary care visits. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, 8.5% to day surgery and 61.2% of total costs associated with inpatient hospitalizations. Costs due to arthritis accounted for 40% of total MSD care costs ($639 million). MSD-related imaging costs were $169 million. Including these costs yields a total estimate of $1.8 billion for all MSDs combined.

CONCLUSION

MSDs place a significant and costly burden on the health care system. Health system planning needs to consider the large and escalating demand for care to reduce both the individual and population burden.

The impact of environmental pollution on the physical health of middle-aged and older adults in China

While several studies have demonstrated the negative impacts of environmental pollution on population health, in general, few studies have examined the potential differential effects on the physical health of middle-aged and older populations, i.e., 45 years and older. Given the twin concerns of environmental pollution and population aging in China, this article employed a fixed effects model to infer the impact of environmental pollution on public health with a particular focus on middle-aged and older adults. The analyses were based on data from the 2011 to 2018 waves of the CHARLS and pollutant data from prefecture-level cities. The results showed that both the level and intensity of environmental pollution significantly increased the risk of chronic diseases and negatively impacted the physical health of middle-aged and older adults. Environmental pollution had its greatest negative effect on the physical health of the elderly, urban residents, residents of the Eastern region, and those with lower incomes than their counterparts. We further found that the potential channels of health effect were through reduced physical exercise and sleep duration and an increase in depressive symptoms, and the pollution prevention actions alleviated the health deterioration of environmental pollution for the middle-aged and the elderly. It is imperative for the government to urgently reinforce policy enforcement to decrease air and water pollution and enhance the ability to circumvent pollution for the lower socioeconomic groups.

Cost-utility analysis of transcranial direct current stimulation therapy with and without virtual illusion for neuropathic pain for adults with spinal cord injury in Canada

OBJECTIVE

To undertake a cost-utility analysis comparing virtual illusion (VI) and transcranial direct current stimulation (tDCS) combination therapy, tDCS alone and standard pharmacological care in Ontario, Canada from a societal perspective over a three-month time horizon.

DESIGN

Cost-utility analysis using Markov model methods.

SETTING

Community setting in Ontario, Canada.

PARTICIPANTS

Individuals with spinal cord injury and neuropathic pain (NP) resistant to pharmacological therapy.

INTERVENTIONS

Virtual illusion and transcranial direct current stimulation, transcranial direct current stimulation alone and standard pharmacological therapy.

OUTCOME MEASURES

Incremental costs, quality adjusted life years (QALY) and incremental cost effectiveness ratio.

RESULTS

The incremental cost effectiveness ratio of VI and tDCS therapy cost is $3,396 per QALY (2020 Canadian dollars) when compared to standard care. The incremental cost per QALY of tDCS therapy alone is $33,167. VI and tDCS therapy had lower incremental costs (-$519) and higher incremental QALYs (0.026) compared to tDCS alone. From a public healthcare payer perspective, there is a 74% probability that VI and tDCS therapy and 54% probability that tDCS alone would be cost effective at a $50,000 per QALY willingness-to-pay threshold. Our findings remained relatively robust in various scenario analyses.

CONCLUSION

Our findings suggest that at three-months after therapy, VI and tDCS combination therapy may be more cost effective than tDCS therapy alone. Based on conventional health technology funding thresholds, VI and tDCS combination therapy merits consideration for the treatment of NP in adults with spinal cord injuries.

Did the universal zero-markup drug policy lower healthcare expenditures? Evidence from Changde, China

Background

The zero-markup drug policy (also known as the universal zero-markup drug policy (UZMDP)) was implemented in stages beginning with primary healthcare facilities in 2009 and eventually encompassing city public hospitals in 2016. This policy has been a central pillar of Chinese health reforms. While the literature has examined the impacts of this policy on healthcare utilization and expenditures, a more comprehensive and detailed assessment is warranted. The purpose of this paper is to explore the impacts of the UZMDP on inpatient and outpatient visits as well as on both aggregate healthcare expenditures and its various components (including drug, diagnosis, laboratory, and medical consumables expenditures).

Methods

A pre-post design was applied to a dataset extracted from the Changde Municipal Human Resource and Social Security Bureau comprising discharge data on 27,246 inpatients and encounter data on 48,282 outpatients in Changde city, Hunan province, China. The pre-UZMDP period for the city public hospitals was defined as the period from October 2015 to September 2016, while the post-UZMDP period was defined as the period from October 2016 to September 2017. Difference-in-Difference negative binomial and Tobit regression models were employed to evaluate the impacts of the UZMDP on healthcare utilization and expenditures, respectively.

Results

Four key findings flow from our assessment of the impacts of the UZMDP: first, outpatient and inpatient visits increased by 8.89 % and 9.39 %, respectively; second, average annual inpatient and outpatient drug expenditures fell by 4,349.00 CNY and 1,262.00 CNY, respectively; third, average annual expenditures on other categories of healthcare expenditures increased by 2,500.83 CNY, 417.10 CNY, 122.98 CNY, and 143.50 CNY for aggregate inpatient, inpatient diagnosis, inpatient laboratory, and outpatient medical consumables expenditures, respectively; and fourth, men and older individuals tended to have more inpatient and outpatient visits than their counterparts.

Conclusions

Although the UZMDP was effective in reducing both inpatient and outpatient drug expenditures, it led to a sharp rise in other expenditure categories. Policy decision makers are advised to undertake efforts to contain the growth in total healthcare expenditures, in general, as well as to evaluate the offsetting effects of the policy on non-drug components of care.

The impacts of pollution and its associated spatial spillover effects on ill-health in China

While the adverse health effects of air pollution and its associated spatial spillovers have been extensively explored, there are a paucity of studies examining and comparing the effects of air pollution, water pollution, and their associated spatial spillover consequences for health. This study aims to evaluate and compare the impacts of water pollution, air pollution, and their associated spillover effects on ill-health. This study combined individual-level health data acquired from three waves of the China Health and Retirement Longitudinal Study (CHARLS) for 25,504 residents from 28 Chinese provinces with provincial-level pollution data for 2011, 2013 and 2015. We used Moran's I statistic to examine the existence and direction of the spatial spillover effects of pollution. The Spatial Durbin Model was then employed to assess the impacts of pollution and its associated spatial spillover effects on ill-health. A province's ill-health score increased by 6.649 for every 1 ton per capita per annum increase in the average amount of soot/dust discharged by its adjacent provinces. For every 1 ton per capita per annum increase in wastewater discharged, a province's ill-health score increased by 0.004. Targeted actions through the construction of cooperative action with adjacent provinces are suggested by our study to improve the efficiency of policy interventions.

Determinants of primary and non-primary informal care-giving to home-based palliative care cancer care-recipients in Ontario, Canada

Informal care plays an important role in the care of care-recipients. Most of the previous studies focused on the primary caregivers and ignored the importance of non-primary caregivers. Moreover, little is known about the provision of informal care in the context of home-based palliative care. The purpose of this study was to examine the provision of primary and non-primary informal care-giving and their respective determinants. Primary caregivers assume the main responsibility for care, while non-primary caregivers are those other than the primary caregiver who provide care-giving. A longitudinal, prospective cohort design was conducted and data were drawn from two palliative care programs in Canada between November 2013 and August 2017. A total of 273 caregivers of home-based palliative care cancer care-recipients were interviewed biweekly until the care recipient died. The outcomes were the propensity and intensity of informal care-giving. Regression analysis with instrumental variables was used. About 90% of primary caregivers were spouses and children, while 53% of non-primary caregivers were others rather than spouses and children. The average number of hours of primary and non-primary informal care-giving reported for each 2-week interview period was 83 hr and 23 hr, respectively. Hours of home-based personal support workers decreased the intensity of primary care-giving and the likelihood of non-primary care-giving. Home-based nursing visits increased the propensity of non-primary care-giving. The primary care-giving and non-primary care-giving complement each other. Care recipients living alone received less primary informal care-giving. Employed primary caregivers decreased their provision of primary care-giving, but promoted the involvement of non-primary care-giving. Our study has clinical practices and policy implications. Suitable and targeted interventions are encouraged to make sure the provision of primary and non-primary care-giving, to balance the work of the primary caregivers and their care-giving responsibility, and to effectively arrange the formal home-based palliative care services.

Can integrated care improve the efficiency of hospitals? Research based on 200 Hospitals in China

Background

The shift towards integrated care (IC) represents a global trend towards more comprehensive and coordinated systems of care, particularly for vulnerable populations, such as the elderly. When health systems face fiscal constraints, integrated care has been advanced as a potential solution by simultaneously improving health service effectiveness and efficiency. This paper addresses the latter. There are three study objectives: first, to compare efficiency differences between IC and non-IC hospitals in China; second, to examine variations in efficiency among different types of IC hospitals; and finally, to explore whether the implementation of IC impacts hospital efficiency.

Methods

This study uses Data Envelopment Analysis (DEA) to calculate efficiency scores among a sample of 200 hospitals in H Province, China. Tobit regression analysis was performed to explore the influence of IC implementation on hospital efficiency scores after adjustment for potential confounding. Moreover, the association between various input and output variables and the implementation of IC was investigated using regression techniques.

Results

The study has four principal findings: first, IC hospitals, on average, are shown to be more efficient than non-IC hospitals after adjustment for covariates. Holding output constant, IC hospitals are shown to reduce their current input mix by 12% and 4% to achieve optimal efficiency under constant and variable returns-to-scale, respectively, while non-IC hospitals have to reduce their input mix by 26 and 20% to achieve the same level of efficiency; second, with respect to the efficiency of each type of IC, we show that higher efficiency scores are achieved by administrative and virtual IC models over a contractual IC model; third, we demonstrate that IC influences hospitals efficiency by impacting various input and output variables, such as length of stay, inpatient admissions, and staffing; fourth, while bed density per nurse was positively associated with hospital efficiency, the opposite was shown for bed density per physician.

Conclusions

IC has the potential to promote hospital efficiency by influencing an array of input and output variables. Policies designed to facilitate the implementation of IC in hospitals need to be cognizant of the complex way IC impacts hospital efficiency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-021-00314-3.

A Cost Analysis of Pulse Oximetry as a Determinant in the Decision to Admit Infants With Mild to Moderate Bronchiolitis

OBJECTIVES

A previous randomized controlled trial showed that artificially elevating the pulse oximetry display resulted in fewer hospitalizations with no worse outcomes. This suggests that management decisions based mainly on pulse oximetry may unnecessarily increase health care costs. This study assessed the incremental cost of altered relative to true oximetry in infants with mild to moderate bronchiolitis.

METHODS

A cost analysis was undertaken from the health care system and societal perspectives using patient-level data from the randomized controlled trial, with a 5-day time horizon after emergency department visit. Infants aged 4 weeks to 12 months with mild to moderate bronchiolitis were randomized to pulse oximetry measurements with true or altered saturation values displayed by artificially increasing saturation 3% points above true values. Direct and indirect health care costs were measured. Sensitivity analyses were performed to assess parameter uncertainty.

RESULTS

From the health care system perspective, the average cost per patient was Can $1155 for altered oximetry and $1967 for true oximetry, with a net savings of $812. From a societal perspective, the average cost per patient was $1559 for altered oximetry and $2473 for true oximetry, with a net savings of $914. Probabilistic analyses demonstrated that altered oximetry remained the less costly study group, with an average savings of $810 (95% confidence interval, $748-$872) from the health care system perspective and $910 (95% confidence interval, $848-$973) from the societal system perspective.

CONCLUSIONS

Reliance on oximetry as a major determinant in the decision to hospitalize infants with mild to moderate bronchiolitis is associated with significantly greater costs.

Lifetime incremental cost-utility ratios for minimally invasive surgery for degenerative lumbar spondylolisthesis relative to failed medical management compared with total hip and knee arthroplasty for osteoarthritis

Background:

The objective of this study was to compare the cost-effectiveness of minimally invasive surgery (MIS) for patients with degenerative lumbar spondylolisthesis (DLS) relative to failed medical management with the cost-effectiveness of hip and knee arthroplasty for matched cohorts of patients with osteoarthritis.

Methods:

A cohort of patients with DLS undergoing MIS procedures with decompression alone or decompression and instrumented fusion between 2008 and 2014 was matched to cohorts of patients with hip osteoarthritis (OA) and knee OA undergoing total joint replacement. Incremental cost–utility ratios (ICURs) were calculated from the perspective of the Ontario Ministry of Health, using prospectively collected Short Form–6 Dimension utility data. Costs and quality-adjusted life years (QALYs) were discounted at 3% and sensitivity analyses were performed.

Results:

Sixty-six patients met the inclusion criteria for the DLS cohort (n = 35 for decompression alone), with a minimum follow-up time of 1 year (mean 1.7 yr). The mean age of patients in the DLS cohort was 64.76 years, and 45 patients (68.2%) were female. For each cohort, utility scores improved from baseline to follow-up and the magnitude of the gain did not differ by group. Lifetime ICURs comparing surgical with nonsurgical care were Can$7946/QALY, Can$7104/QALY and Can$5098/QALY for the DLS, knee OA and hip OA cohorts, respectively. Subgroup analysis yielded an increased ICUR for the patients with DLS who underwent decompression and fusion (Can$9870/QALY) compared with that for the patients with DLS who underwent decompression alone (Can$5045/QALY). The rank order of the ICURs by group did not change with deterministic or probabilistic sensitivity analyses.

Conclusion:

Lifetime ICURs for MIS procedures for DLS are similar to those for total joint replacement. Future research should adopt a societal perspective and potentially capture further economic benefits of MIS procedures.

The relationship between internal migration and the likelihood of high-risk pregnancy: Hukou system and high-risk pregnancies in China

BACKGROUND

China has one of the world's largest internal migrant populations. The Chinese Hukou system is a unique household registration system that limits internal migrants in their access to basic urban public services, such as public health insurance and social assistance of their host city. In the case of female internal migrants, this may lead to high-risk pregnancies. The objective of this study is to assess the relationship between internal migrant status (Hukou) and the likelihood of high-risk pregnancies that occur in one large municipal-level obstetrics hospital in Shanghai, China.

METHODS

Medical records data from the Shanghai First Maternity and Infant Hospital from January 1, 2013, to May 31, 2018, were used to analyze 133,358 live births for Shanghai natives (n = 83,872) and internal migrant women (n = 49,486). A propensity score matching approach was used in conjunction with logistic regression analysis to identify the role of internal migrant status (Hukou) on the likelihood of high-risk pregnancies.

RESULTS

A greater likelihood of high-risk pregnancies were found among internal migrant women who moved from other parts of China to Shanghai. This effect was more obvious for women who gave birth for the first time and internal migrant women who were employed.

CONCLUSION

The results show the effects of internal migrant status (Hukou) and the elevated likelihood of high-risk pregnancies among internal migrant women relative to their urban counterparts in Shanghai even after accounting for self-selection by employing the propensity score matching method. China's unique Hukou household registration system limits access to public services for internal migrant women and accordingly may account for the elevated likelihood of high-risk pregnancies.

Bridging the Gap between Symptom Onset and Diagnosis in Axial Spondyloarthritis

OBJECTIVE

To evaluate a stratified screening process for early identification of axial spondyloarthritis (axSpA) considering: 1) wait times from primary care to rheumatology screen; 2) incremental precision and accuracy from primary care to rheumatology screen; and 3) diagnostic delay.

METHODS

Adults with low back pain (LBP) attending primary care LBP clinics prospectively underwent a primary standardized clinical screen. Patients with LBP >3 months and onset age <50 years were referred for a comprehensive secondary screen by a physiotherapist with advanced rheumatology training. At secondary screening, patients with inflammatory features were deemed to have a low, medium, or high risk of axSpA vs. no risk. Precision and accuracy of this screening strata were measured against a rheumatologist with axSpA expertise.

RESULTS

In all, 405 patients underwent primary and secondary screening. Mean age was 36.9 years (±9.9); 55% were female. HLA-B27 was present in 14.4%. Median wait time from primary to secondary screen was 15 days. AxSpA risk assignment by rheumatologist was: 64.9% (none or low risk axSpA) and 35.1% (medium or high risk axSpA). The best combination of sensitivity (68%), specificity (90%), positive (80%) and negative (84%) predictive values was evident with the secondary screen. 15.6% of patients received a final diagnosis of axSpA. Median LBP duration from onset to diagnosis was: 2 years (non-radiographic axSpA) and 7 years (ankylosing spondylitis).

CONCLUSION

A stratified interprofessional screening process can facilitate rapid diagnosis of persistent LBP, with high precision and accuracy, in patients with axSpA.

"Not Just Anybody Can Do It": A Qualitative Study of the Lived Experience of Inpatient Palliative Care Professionals in China's Mainland

Background: Over the past 5 years, China has invested substantially in palliative care programs to meet the rising demand for such services. In China's mainland, most palliative care programs are embedded within an established hospital unit, but a small subset of providers practice exclusively in a stand-alone inpatient palliative care department.

Objective: To explore the lived experience of professionals at an independently operating palliative care hospital department in China's mainland.

Design: We used purposive sampling to select palliative care physicians and nurses. Semistructured in-depth interviews were conducted in person. Thematic analysis was used to elicit key themes that pertained to participants' lived experience.

Setting/Subjects: Ten palliative care physicians and seven nurses at the palliative medicine department in the West China Fourth Hospital of Sichuan University in Chengdu, Sichuan Province, participated in the interviews.

Results: Three themes related to participants' lived experience were (1) interactions with patients and families (e.g., frequent encounters with death, communication difficulties, witnessing family struggles, and developing mutually trusting relationships); (2) factors influencing their work life (e.g., supportive working environment, unmet training needs, policy restrictions, and lack of public awareness); and (3) perceived nature of work (e.g., complex and demanding, underappreciation, encroachment of work stress into personal life, deriving accomplishment from work, and personal growth).

Conclusion: This study helps fill the void in the palliative care literature regarding the lived experience of inpatient palliative care professionals in China's mainland. Our findings revealed factors influencing the well-being of palliative care professionals that are meaningful to policymakers.

Does Unpaid Caregiving Erode Working Hours Among Middle-Aged Chinese Adults?

Middle-aged adults are commonly confronted with the burden of paid work and multiple caregiving roles. This paper examines the relationship between weekly hours of unpaid caregiving and hours of work using data from the baseline survey of the China Health and Retirement Longitudinal Study. The analysis was conducted on a nationally representative sample of 3645 working-age Chinese adults aged 45-60 years who were not farming and had a young grandchild and/or a parent/parent-in-law. For women and men separately, we combined the use of a Heckman selection procedure and instrumental variables to estimate the relationship between weekly caregiving hours and hours of work. A caregiving threshold was also identified for women and men separately to allow for the testing of a kink and/or a discontinuity in this relationship. We found that for women, their working hours were initially unrelated to hours of caregiving before the threshold of 72 caregiving hours per week; then, their working hours experienced an almost two-fold increase at the caregiving threshold before falling by 2.02 percent for each additional hour of caregiving beyond the threshold. For men, their hours of work fell by 2.74 percent for each hourly increment in caregiving. Although a caregiving threshold of 112 h was identified for men, there was insufficient evidence for a statistically significant kink or discontinuity in this relationship. These findings provide support for a range of fiscal and human resource policies that target employed family caregivers in order to advance their well-being while also maintaining their work productivity.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11205-021-02692-w.

How Do Middle-Aged Chinese Men and Women Balance Caregiving and Employment Income?

Unpaid family caregivers might suffer losses in income as a result of care provision. Here we used data from the baseline survey of the China Health and Retirement Longitudinal Study to assess the relationship between hours of weekly caregiving provided to grandchildren/parents/parents-in-law and individual's monthly employment income. Our study sample comprised 3718 middle-aged Chinese adults who were of working age (45-60 years). For women and men separately, we used a likelihood-based method to determine a caregiving threshold in a two-stage Heckman selection procedure. Instrumental variables were used to rule out the endogeneity of caregiving hours. Our analysis revealed a negative association between caregiving and income for women that depended on a caregiving threshold of 63 h per week. There was an absence of caregiving-income relationship among men. These results offer new insights into the opportunity costs of unpaid caregiving and support tailored policies to protect the financial well-being of female caregivers.

Economic Consequences of Adult Living Kidney Donation: A Systematic Review

OBJECTIVES

Current guidelines mandate organ donation to be financially neutral such that it neither rewards nor exploits donors. This systematic review was conducted to assess the magnitude and type of costs incurred by adult living kidney donors and to identify those at risk of financial hardship.

METHODS

We searched English-language journal articles and working papers assessing direct and indirect costs incurred by donors on PubMed, MEDLINE, Scopus, the National Institute for Health Research Economic Evaluation Database, Research Papers in Economics, and EconLit in 2005 and thereafter. Estimates of total costs, types of costs, and characteristics of donors who incurred the financial burden were extracted.

RESULTS

Sixteen studies were identified involving 6158 donors. Average donor-borne costs ranged from US$900 to US$19 900 (2019 values) over the period from predonation evaluation to the end of the first postoperative year. Less than half of donors sought financial assistance and 80% had financial loss. Out-of-pocket payments for travel and health services were the most reported items where lost income accounted for the largest proportion (23.2%-83.7%) of total costs. New indirect cost items were identified to be insurance difficulty, exercise impairment, and caregiver income loss. Donors from lower-income households and those who traveled long distances reported the greatest financial hardship.

CONCLUSIONS

Most kidney donors are undercompensated. Our findings highlight gaps in donor compensation for predonation evaluation, long-distance donations, and lifetime insurance protection. Additional studies outside of North America are needed to gain a global prospective on how to provide for financial neutrality for kidney donors.

Childhood Nutrition in Rural China: What Impact Does Public Health Insurance Have?

OBJECTIVES

To investigate the impact of public health insurance coverage, specifically the New Cooperative Medical Scheme (NCMS), on childhood nutrition in poor rural households in China, and to identify the mechanisms through which health insurance coverage affects nutritional intake.

METHODS

Longitudinal data on 3291 children were taken from four time periods (2004, 2006, 2009, and 2011) from the China Health and Nutrition Survey (CHNS). Panel data analysis was performed with the fixed-effect model and the propensity score matching with difference-in-differences (PSM-DID) approach.

RESULTS

The introduction of the NCMS was associated with a decline in calories, fat, and protein intake, and an increase in the intake of carbohydrates. The NCMS had the greatest negative effect on children aged 0 to 5 years, particularly girls. Out-of-pocket medical expenses were identified as the main channel through which the NCMS affected the nutritional intake of children.

CONCLUSIONS

The study showed that the NCMS neither significantly improved the nutritional status of children nor enhanced intake of high-quality nutrients among rural poor households. These findings were attributed to the way in which health-seeking behavior was modified in the light of NCMS coverage. Specifically, NCMS coverage tended to increase healthcare utilization, which in turn increased out-of-pocket medical expenditures. This encouraged savings to aid financial risk protection and resulted in less disposable income for food consumption.

The determinants of the intensity of home-based informal care among cancer patients in receipt of home-based palliative care

BACKGROUND

Understanding the determinants of the intensity of informal care may assist policy makers in the identification of supports for informal caregivers. Little is known about the utilization of informal care throughout the palliative care trajectory.

AIM

The purpose of this study was to analyze the intensity and determinants of the use of informal care among cancer patients over the palliative care trajectory.

DESIGN

This was a longitudinal, prospective cohort design conducted in Canada. Regression analysis using instrumental variables was applied.

SETTING/PARTICIPANTS

From November 2013 to August 2017, a total of 273 caregivers of cancer patients were interviewed biweekly over the course of the care recipient's palliative care trajectory. The outcome was the number of hours of informal care provided by unpaid caregivers, that is, hours of informal care.

RESULTS

The number of hours of informal care increased as patients approached death. Home-based nursing care complemented, and hence, increased the provision of informal care. Patients living alone and caregivers who were employed were associated with the provision of fewer hours of informal care. Spousal caregivers provided more hours of informal care. Patient's age, sex, and marital status, and caregiver's age, sex, marital status, and education were associated with the number of hours of informal care.

CONCLUSIONS

The intensity of informal care was determined by predisposing, enabling, and needs-based factors. This study provides a reference for the planning and targeting of supports for the provision of informal care.

Measurement and determinants of catastrophic health expenditure among elderly households in China using longitudinal data from the CHARLS

BACKGROUND

Catastrophic health expenditure (CHE) among the Chinese elderly warrants attention. However, the incidence, intensity and determinants of CHE have not been fully investigated. This study explores the incidence, intensity and determinants of CHE among elderly Chinese citizens, i.e., those aged 60 years or older.

METHODS

Data were obtained from three waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013 and 2015. The cut-off points used in this study for CHE were 10% of the total expenditures and 40% of non-food expenditure. Under the guidance of Andersen's model of health services utilization, this study used logistic regression analysis to explore the determinants of CHE.

RESULTS

The incidence of CHE defined as more than 40% of non-food expenditure rose over the study period, 2011-2015, from 20.86% (95% CI: 19.35 to 22.37%) to 31.00% (95% CI: 29.28 to 32.72%). The intensity of CHE also increased. The overshoot (O) based on non-food expenditure rose from 3.12% (95% CI: 2.71 to 3.53%) to 8.75% (95% CI: 8.14 to 9.36%), while the mean positive overshoot (MPO) rose from 14.96% (95% CI: 12.99 to 16.92%) to 28.23% (95% CI: 26.26 to 30.19%). Thus, the problem of CEH was even more serious in 2015 than in 2011. Logistic regression revealed that households were more likely to face CHE if they had a spouse as a household member, reported an inpatient event in the last year, reported an outpatient visit in the last month, were disabled, were members of a poor expenditure quartile, lived in the middle and western zones or resided in an urban area. In contrast, CEH was not significantly affected by respondents being older than 75 years or having a chronic health condition, by household size or by insurance type.

CONCLUSIONS

Key policy recommendations include the gradual improvement of medical assistance and the expansion of the use of health insurance to reduce household liability for health expenditures.

Unpaid Caregiving and Labor Force Participation among Chinese Middle-Aged Adults

Unpaid family caregivers must consider the economic trade-off between caregiving and paid employment. Prior literature has suggested that labor force participation (LFP) declines with caregiving intensity, but no study has evaluated this relationship by accounting for the presence of both kinks and discontinuities. Here we used respondents of the China Health and Retirement Longitudinal Study baseline survey who were nonfarming, of working age (aged 45-60) and had a young grandchild and/or a parent/parent-in-law. For women and men separately, a caregiving threshold-adjusted probit model was used to assess the association between LFP and weekly unpaid caregiving hours. Instrumental variables were used to rule out the endogeneity of caregiving hours. Of the 3718 respondents in the analysis, LFP for men was significantly and inversely associated with caregiving that involved neither discontinuities nor kinks. For women, a kink was identified at the caregiving threshold of eight hrs/w such that before eight hours, each caregiving hour was associated with an increase of 0.0257 in the marginal probability of LFP, but each hour thereafter was associated with a reduction of 0.0014 in the marginal probability of LFP. These results have implications for interventions that simultaneously advance policies of health, social care and labor force.

Where Do Cancer Patients in Receipt of Home-Based Palliative Care Prefer to Die and What Are the Determinants of a Preference for a Home Death?

Understanding the preferred place of death may assist to organize and deliver palliative health care services. The study aims to assess preference for place of death among cancer patients in receipt of home-based palliative care, and to determine the variables that affect their preference for a home death. A prospective cohort design was carried out from July 2010 to August 2012. Over the course of their palliative care trajectory, a total of 303 family caregivers of cancer patients were interviewed. Multivariate regression analysis was employed to assess the determinants of a preferred home death. The majority (65%) of patients had a preference of home death. The intensity of home-based physician visits and home-based personal support worker (PSW) care promotes a preference for a home death. Married patients, patients receiving post-graduate education and patients with higher Palliative Performance Scale (PPS) scores were more likely to have a preference of home death. Patients reduced the likelihood of preferring a home death when their family caregiver had high burden. This study suggests that the majority of cancer patients have a preference of home death. Health mangers and policy makers have the potential to develop policies that facilitate those preferences.

Dialysis Initiation and All-Cause Mortality Among Incident Adult Patients With Advanced CKD: A Meta-analysis With Bias Analysis

Rationale & Objectives

Due to unmeasured confounding, observational studies have limitations when assessing whether dialysis initiation reduces mortality compared with conservative therapy among adults with advanced chronic kidney disease (CKD). We addressed this issue in this meta-analysis.

Study Design

Meta-analysis with bias analysis for unmeasured confounding.

Setting & Study Population

Adults with stage 4 or 5 CKD who had initiated dialysis or conservative treatment.

Selection Criteria for Studies

Prospective or retrospective cohort studies comparing survival of dialysis versus conservatively managed patients were searched on MEDLINE and Embase from January 2009 to March 20, 2019.

Data Extraction

HRs of all-cause mortality associated with dialysis initiation compared with conservative treatment.

Analytical Approach

We pooled HRs using a random-effects model. We estimated the percentage of effect sizes more protective than HRs of 0.80 and severity of unmeasured confounding that could reduce this percentage to only 10%. Subgroup analysis was performed for studies with only older patients (aged ≥ 65 years).

Results

12 studies were included that involved 16,609 dialysis patients and 3,691 conservatively managed patients. A random-effects model suggested that dialysis initiation was associated with a mean mortality HR of 0.47 (95% CI, 0.34-0.64), in which 92% (95% CI, 50%-100%) of the true effects were more protective than HRs of 0.80. To reduce the percentage of HRs < 0.80 to 10%, unmeasured confounder(s) would need to be associated with both dialysis initiation and mortality by relative risks of 4.05 (95% CI, 2.39-4.15), which is equivalent to shifting each study's estimated HR by 2.31-fold (95% CI, 1.51-2.36). Restricting studies to include only older patients did not modify the results.

Limitations

Limited number of studies and evidence on the absence of publication bias.

Conclusions

Our findings suggest that dialysis initiation considerably reduces mortality among adults with advanced CKD. Future bias-adjusted meta-analyses need to assess outcomes beyond mortality.

Transitions in Labour Force Participation over the Palliative Care Trajectory

BACKGROUND

Home-based palliative programs rely on family caregivers, who often miss time from employment. This article identified changes in caregivers' labour force participation over the palliative trajectory.

METHODS

Family caregivers (n = 262) were interviewed biweekly to measure transitions across four employment categories.

RESULTS

More than half of the caregivers had one employment transition and 29% had three or more. The highest proportion of transitions occurred for caregivers who were employed part-time.

INTERPRETATION

Understanding these transitions is critical to the development of strategies tailored to caregivers to contain labour force losses and to support caregivers during a time of high caregiving demands.

Healthcare utilization and costs of pediatric home mechanical ventilation in Canada

BACKGROUND

Children using home mechanical ventilation (HMV) live at home with better quality of life, despite financial burden for their family. Previous studies of healthcare utilization and costs have not considered public and private expenditures, including family caregiver time. Our objective was to examine public and private healthcare utilization and costs for children using HMV, and variables associated with highest costs.

METHODS

Longitudinal, prospective, observational cost analysis study (2012-2014) collecting data on public and private (out-of-pocket, third-party insurance, and caregiving) costs every 2 weeks for 6 months using the Ambulatory Home Care Record. Functional Independence Measure (FIM), WeeFIM, and Caregiving Impact Scale (CIS) were measured at baseline and study completion. Regression modeling examined a priori selected variables associated with monthly costs using Andersen and Newman's framework for healthcare utilization, relevant literature, and clinical expertise. Data are reported in 2015 Canadian dollars ($1CAD = $0.78USD).

RESULTS

Forty two children and their caregivers were enrolled. Overall median (interquartile range) monthly healthcare cost was $12 131 ($8159-$15 958) comprising $9929 (89%) family caregiving hours, $996 (9%) publicly funded, and $252 (2%) out-of-pocket (<1% third-party insurance) costs. With higher FIM score (lower dependency), median costs were reduced by 4.5% (95% confidence interval: 8.3%-0.5%), adjusted for age, sex, tracheostomy, and daily ventilation duration. Note: since the three cost categories did not sum to the total statistically derived median cost, the percentage of each category used the sum of median public + caregiver lost time + private out-of-pocket + third-party insurance as the denominator.

CONCLUSIONS

For HMV children, most healthcare costs were due to family caregiving costs. More dependent children incur highest costs. The financial burden to family caregivers is substantial and needs to considered in future policy decisions related to pediatric HMV.

Temporal trends in place of death for end-of-life patients: Evidence from Toronto, Canada

Understanding the temporal trends in the place of death among patients in receipt of home-based palliative care can help direct health policies and planning of health resources. This paper aims to assess the temporal trends in place of death and its determinants over the past decade for patients receiving home-based palliative care. This paper also examines the impact of early referral to home-based palliative care services on patient's place of death. Survey data collected in a home-based end-of-life care program in Toronto, Canada from 2005 to 2015 were analysed using a multivariate logistic model. The results suggest that the place of death for patients in receipt of home-based palliative care has changed over time, with more patients dying at home over 2006-2015 when compared to 2005. Also, early referral to home-based palliative care services may not increase a patient's likelihood of home death. Understanding the temporal shifts of place of death and the associated factors is essential for effective improvements in home-based palliative care programs and the development of end-of-life care policies.

A cost-utility analysis of atezolizumab in the second-line treatment of patients with metastatic bladder cancer

Background

Despite initial promising results, the IMvigor211 clinical trial failed to demonstrate an overall survival (os) benefit for atezolizumab compared with chemotherapy as second-line treatment for metastatic bladder cancer (mbc). However, given lessened adverse events (aes) and preserved quality of life (qol) with atezolizumab, there might still be investment value. To evaluate that potential value, we conducted a cost-utility analysis (cua) of atezolizumab compared with chemotherapy from the perspective of the Canadian health care payer.

Methods

A partitioned survival model was used to evaluate atezolizumab compared with chemotherapy over a lifetime horizon (5 years). The base-case analysis was conducted for the intention-to-treat (itt) population, with additional scenario analyses for subgroups by IMvigor-defined PD-L1 status. Health outcomes were evaluated through life-year gains and quality-adjusted life-years (qalys). Cost estimates in 2018 Canadian dollars for systemic treatment, aes, and end-of-life care were incorporated. The incremental cost-effectiveness ratio (icer) was used to compare treatment strategies. Parameter and model uncertainty were assessed through sensitivity and scenario analyses. Per Canadian guidelines, cost and effectiveness were discounted at 1.5%.

Results

For the itt population, the expected qalys for atezolizumab and chemotherapy were 0.75 and 0.56, with expected costs of $90,290 and $8,466 respectively. The resultant icer for atezolizumab compared with chemotherapy was $430,652 per qaly. Scenario analysis of patients with PD-L1 expression levels of 5% or greater led to a lower icer ($334,387 per qaly). Scenario analysis of observed compared with expected benefits demonstrated a higher icer, with a shorter time horizon ($928,950 per qaly).

Conclusions

Despite lessened aes and preserved qol, atezolizumab is not considered cost-effective for the second-line treatment of mbc.

Inequality of opportunity in healthcare expenditures: evidence from China

BACKGROUND

The theory of equality of opportunity attributes total inequality to effort levels and circumstance factors. Inequality attributable to circumstance is defined as inequality of opportunity (IOp), namely inequity. Many studies have been pursued in this area but few concerning health care, especially in China. Despite Chinese health system reforms, healthcare inequity remains. This study explores the extent and sources of IOp in outpatient and inpatient expenditures in China.

METHODS

We used three waves (2011, 2013 and 2015) of data from the China Health and Retirement Longitudinal Study that offer a nationally representative sample of Chinese residents aged 45 and older. Based on a pooled regression model, we estimated the contribution of circumstance factors to the inequality in outpatient and inpatient expenditures by defining a counterfactual distribution. The "circumstance-free effort" was introduced to deal with the correlation between circumstance and effort.

RESULTS

We report a decline in inequity from 2011 to 2015, and the IOp ratio to total inequality in outpatient and inpatient expenditures decreased 9.4% (from 28.6 to 25.9%) and 3.3% (from 49.1 to 47.5%), respectively. Social background, medical supply-side factors, including the type of basic medical insurance, region and community medical resources were important sources of IOp in outpatient and inpatient expenditures.

CONCLUSIONS

These findings provide information on which to base policies designed to reduce inequity in healthcare expenditures. It is necessary to transfer more subsidies to the New Co-operative Medical System, and to address the uneven regional distribution of medical resources. Additionally, increasing access to quality primary community clinics may be a pro-poor policy to alleviate inequity in the use of outpatient care. Compared to outpatient services, policies protecting vulnerable populations need to pay more attention to the financing and design of inpatient services.

Impacts of Absolute and Relative Income on Self-Rated Health in Urban and Rural China

This study aims to assess the impacts of absolute and relative income on self-rated health (SRH) of residents in rural and urban China. Data were derived from the China Health and Nutrition Survey. Three distinct measures of relative income were considered (Gini coefficient, Yitzhaki index, and Deaton index) and computed for 3 geographic units (nation, province, and community). Nonlinear dynamic models for panel data were employed to test the absolute and relative income hypotheses. Absolute income was significantly associated with SRH among urban and rural populations. Relative income, as measured by the Gini coefficient, the Yitzhaki index, and the Deaton index, had statistically significant and negative impacts on SRH among the rural population, regardless of the reference group. For the urban population, the Gini coefficient was associated with SRH regardless of the reference group. In contrast, only the Yitzhaki index and the Deaton index at the provincial level were associated with SRH among the urban population. Our findings may provide a reference for policymakers to implement health policies designed to improve population health.

Congruence between Preferred and Actual Place of Death for Those in Receipt of Home-Based Palliative Care

Background: Understanding the factors that affect the congruence between preferred and actual place of death may help providers offer clients customized end-of-life care settings. Little is known about this congruence for cancer patients in receipt of home-based palliative care. Objectives: This study aims to determine the congruence between preferred and actual place of death among cancer patients in home-based palliative care programs. Design: A longitudinal prospective cohort study was conducted. Congruence between preferred and actual place of death was measured. Both univariate and multivariate analyses were used to assess the determinants of achieving a preferred place of death. From July 2010 to August 2012, a total of 290 caregivers were interviewed biweekly over the course of their palliative care trajectory from entry to the program and death. Results: The overall congruence between preferred and actual place of death was 71.72%. Home was the most preferred place of death. The intensity of home-based nursing visits and hours of care from personal support workers (PSWs) increased the likelihood of achieving death in a preferred setting. Conclusions: The provision of care by home-based nurse visits and PSWs contributed to achieving a greater congruence between preferred and actual place of death. This finding highlights the importance of formal care providers in signaling and executing the preferences of clients in receipt of home-based palliative care.

Evaluating the Cost Effectiveness of a Suicide Prevention Campaign Implemented in Ontario, Canada

BACKGROUND

Although suicide-prevention campaigns have been implemented in numerous countries, Canada has yet to implement a strategy nationally. This is the first study to examine the cost utility of the implementation of a multidimensional suicide-prevention program that combines several interventions over a 50-year time horizon.

METHODS

We used Markov modeling to capture the dynamic changes to health status and estimate the incremental cost per quality-adjusted life-year gained over a 50-year period for Ontario residents for a suicide-prevention strategy compared to no intervention. The strategy consisted of a package of interventions geared towards preventing suicide including a public health awareness campaign, increased identification of individuals at risk, increased training of primary-care physicians, and increased treatment post-suicide attempt. Four health states were captured by the Markov model: (1) alive and no recent suicide attempt; (2) suicide attempt; (3) death by suicide; (4) death (other than suicide). Analyses were from a societal perspective where all costs, irrespective of payer, were included. We used a probabilistic analysis to test the robustness of the model results to both variation and uncertainty in model parameters.

RESULTS

Over the 50-year period, the suicide-prevention campaign had an incremental cost-effectiveness ratio (ICER) of $18,853 (values are in Canadian dollars) per QALY gained. In all one-way sensitivity analyses, the ICER remained under $50,000/QALY. In the probabilistic analysis, there was a probability of 94.8% that the campaign was cost effective at a willingness-to-pay of $50,000/QALY (95% confidence interval of ICER probabilistic distribution: 2650-62,375). Among the current population, the intervention was predicted to result in the prevention of 4454 suicides after 50 years (1033 by year 10; 2803 by year 25). A healthcare payer perspective sensitivity analysis showed an ICER of $21,096.14/QALY.

INTERPRETATION

These findings demonstrate that a suicide-prevention campaign in Ontario is very likely a cost-effective intervention to reduce the incidence of suicide and suggest suicide-prevention campaigns are likely to be cost effective for some other Canadian provinces and potentially other countries.

Cost-Utility Analysis of Electroconvulsive Therapy and Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression in Ontario

OBJECTIVES

To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT), and combining both treatments in a stepped care pathway for patients with treatment-resistant depression (TRD) in Ontario.

METHODS

A cost-utility analysis evaluated the lifetime costs and benefits to society of rTMS and ECT as first-line treatments for TRD using a Markov model, which simulates the costs and health benefits of patients over their lifetime. Health states included acute treatment, maintenance treatment, remission, and severe depression. Treatment efficacy and health utility data were extracted and synthesized from randomized controlled trials and meta-analyses evaluating these techniques. Direct costing data were obtained from national and provincial costing databases. Indirect costs were derived from government records. Scenario, threshold, and probabilistic sensitivity analyses were performed to test robustness of the results.

RESULTS

rTMS dominated ECT, as it was less costly and produced better health outcomes, measured in quality-adjusted life years (QALYs), in the base case scenario. rTMS patients gained an average of 0.96 additional QALYs (equivalent to approximately 1 year in perfect health) over their lifetime with costs that were $46,094 less than ECT. rTMS remained dominant in the majority of scenario and threshold analyses. However, results from scenarios in which the model's maximum lifetime allowance of rTMS treatment courses was substantially limited, the dominance of rTMS over ECT was attenuated. The scenario that showed the highest QALY gain (1.19) and the greatest cost-savings ($46,614) was when rTMS nonresponders switched to ECT.

CONCLUSION

From a societal perspective utilizing a lifetime horizon, rTMS is a cost-effective first-line treatment option for TRD relative to ECT, as it is less expensive and produces better health outcomes. The reduced side effect profile and greater patient acceptability of rTMS that allow it to be administered more times than ECT in a patient's lifetime may contribute to its cost-effectiveness.

Effects of Migration on Infant and Maternal Health in China

We assess the association between maternal migrant status and health outcomes in China, which has one of the world’s largest migrant populations. Health records from the Shanghai First Maternity and Infant Hospital from January 1, 2013, to June 30, 2017, were used to analyze 104 681 live births for Shanghai native-born and migrant women based on International Classification of Diseases, Tenth Revision diagnosis codes and demographic data. Regression analysis including propensity score matching was conducted to investigate the association between maternal migrant status and adverse infant birth outcomes (fetal disease, congenital malformation, neonatal disease) and maternal health after controlling for pregnancy status and socioeconomic factors. The results demonstrate that migrant women had statistically significant increased odds (9.1%-10%, P < .001) of having infants with adverse health outcomes compared with their urban counterparts and that migrant mothers have less likelihood of pregnancy complications and gestational diabetes mellitus. Our results show the mixed effects of migration on infant and maternal health may be a possible outcome of China’s Hukou system that often represents an important barrier in accessing prenatal health care by migrant women. Current reforms that improve access to prenatal health care services for migrant women may enhance the health outcomes of their infants.

Does Public Health Insurance Coverage Lead to Better Health Outcomes? Evidence From Chinese Adults

This article examines the impacts of public health insurance on the health of adults through use of data from the China Health and Nutrition Survey. We use the endogenous treatment effects model to infer the causal effects of public health insurance on health. We find that public health insurance significantly improves the physical and mental health status of health insurance beneficiaries after controlling for other covariates. Among the 2 types of voluntary public health insurance, the Urban Resident Basic Medical Insurance has the greater impact in improving health than the New Cooperative Medical Scheme. Moreover, the health effect appears to be stronger for middle-aged individuals, the elderly, and those with lower incomes than for their counterparts. The positive health effects may result from few channels, including the increase of health care utilization, the improvement of health-related behaviors, and the fact that individuals with public health insurance are more likely to use higher level care providers. This study provides implications on reforming China's health care system.

The effects of compulsory health insurance on birth outcomes: evidence from China's UEBMI scheme

BACKGROUND

Despite extensive research concerning the impact of health insurance on the advancement of infant health in developed countries, few studies have adjusted their results for potential confounding due to adverse selection in insurance coverage, wherein those who anticipate a need for health services tend to be the ones that acquire insurance. The presence of compulsory health insurance in China, such as the Urban Employee Basic Medical Insurance (UEBMI) scheme may provide an opportunity to estimate the effect of health insurance on infant health, by reducing the endogeneity problem into insurance due to the adverse selection. The objective is to assess the relationship between UEBMI and infant health outcomes in one sizeable municipal-level obstetrics hospital in Shanghai, East China.

METHODS

Medical records data from the Shanghai First Maternity and Infant Hospital from January 1, 2013 to April 30, 2019 were used to form an analysis dataset of 160,429 live births which was comprised of Shanghai residents with UEBMI coverage (n = 101,153) and women without any insurance coverage (n = 59,276). A propensity score matching approach using conjoint quantile regression and probit regression models was used to eliminate latent endogeneity of UEBMI coverage in order to garner robust results. Further analysis stratified by maternal migrant status was conducted to further assess the sensitivity of the findings to distinct patient subgroups.

RESULTS

The UEBMI scheme was shown to be associated with improvements in infant birth outcomes. The scheme was associated with: an increase in birth weight of about 30 g (p <  0.001, 95% CI 23.908-35.295). This finding was evident in other five different birth outcomes (premature birth, low birth weight, very low birth weight, low Apgar score, and an abnormal health condition at birth). After stratifying by migrant status, the UEBMI was shown to have a greater effect on migrants compared to local residents of Shanghai.

CONCLUSIONS

Our findings suggest that health insurance coverage for pregnant women, especially for migrants, has the potential to significantly and directly improve infant health outcomes. Further research is required to determine whether these findings can be replicated for other Chinese jurisdictions.

Iron deficiency screening for children at 18 months: a cost-utility analysis

BACKGROUND

The peak prevalence of iron deficiency is in children 6 months to 3 years of age, a sensitive period for neurodevelopment. Our study objective was to examine the cost-utility of a proposed iron deficiency screening program for 18-month-old children.

METHODS

We used a decision tree model to estimate the costs in 2019 Canadian dollars and quality-adjusted life years (QALYs) associated with 3 iron deficiency screening strategies: no screening, universal screening and targeted screening for a high-risk population. We used a societal perspective and assessed lifetime QALY gains. We derived outcomes from the literature and prospectively collected data. We performed one-way and probabilistic sensitivity analyses to assess parameter uncertainty.

RESULTS

The incremental costs to society of universal and targeted screening programs compared to no screening were $2286.06/QALY and $1676.94/QALY, respectively. With a willingness-to-pay threshold of $50 000/QALY, both programs were cost-effective. Compared to a targeted screening program, a universal screening program would cost an additional $2965.96 to gain 1 QALY, which renders it a cost-effective option. The study findings were robust to extensive sensitivity analyses.

INTERPRETATION

A proposed universal screening program for iron deficiency would be cost-effective over the lifespan compared to both no screening (current standard of care) and a targeted screening program for children at high risk. Policy-makers and physicians may consider expanding the recommended 18-month enhanced well-baby visit to include screening for iron deficiency.

Impact of Predialysis Psychosocial Conditions on Kidney Transplant Recipient Survival: Evidence Using Propensity Score Matching

Background:

An increased number of end-stage renal disease patients suffer psychosocial conditions and may experience delayed access to transplantation due to listing restrictions. However, it remains to be shown whether preexisting psychosocial conditions confer an independent risk factor of poor posttransplant outcomes.

Objective:

We addressed this gap in knowledge by conducting a retrospective cohort study to investigate an independent association between the risk of death after transplant and having a diagnosis of psychosocial conditions 1 year prior to starting dialysis.

Methods:

All cases of adult deceased-donor kidney transplantation performed in Ontario, Canada, between April 1, 2002, and March 31, 2013, were used. Propensity score matching was applied to adjust for potential endogenous bias of using predialysis psychosocial status to predict posttransplant mortality. Survival analysis techniques, including Kaplan-Meier curves and Cox proportional hazards modeling, were also used.

Results:

Our results indicate a 49.4% (hazard ratio [HR] = 1.494 [95% confidence interval (CI) = 1.168-1.913]) increased relative risk of posttransplant death to be associated with predialysis psychosocial conditions, when other factors are held constant. The effect is significant (P = .001) and is independent of other known predictors of death including advanced age.

Conclusions:

Findings from this study offered strong support for the development of psychosocial evaluation to screen candidates prior to transplant listing and early interventions for transplant candidates with psychosocial concerns.

A cost analysis comparing telepsychiatry to in-person psychiatric outreach and patient travel reimbursement in Northern Ontario communities

Introduction

Residents of Northern Ontario have limited access to local psychiatric care. To address this, three program models exist: (1) telepsychiatry; (2) psychiatrists traveling to underserved areas; and (3) reimbursing patients for travel to a psychiatrist. Evidence shows that telepsychiatry has comparable outcomes to in-person consultations. The objective of this study was to determine the cost difference between programs.

Methods

A cost-minimization analysis estimating cost per visit from a public healthcare payer economic costing perspective was conducted. Data on fixed and variable costs were obtained. Evidence-based assumptions were made where relevant. Base-case scenarios and a break-even analysis were completed, as well as deterministic and probabilistic sensitivity analyses, to explore the effects of parameter variability on program costs.

Results

Costs per visit were lowest in telepsychiatry (CAD$360) followed by traveling physicians (CAD$558) and patient reimbursement (CAD$620). Among the 100,000 Monte Carlo simulations, results showed telepsychiatry was the least costly program in 71.2% of the simulations, while the reimbursement and outreach programs were least costly in 15.1% and 13.7% of simulations, respectively. The break-even analysis found telepsychiatry was the least costly program after an annual patient visit threshold of approximately 76 visits (compared to traveling psychiatrists) and 126 visits (compared to reimbursed patients).

Discussion

Our analyses support telepsychiatry as the least costly program. These results have important implications for program planning, including the prioritization of telepsychiatry, increased integration of telepsychiatry with other modalities of outreach psychiatry, and limiting use of the patient remuneration program to where medically necessary, to reduce overall cost.