International Journal of Health Policy and Management最新文献

Background: Low-value care (LVC) is a critical issue in terms of patient safety and fiscal policy; however, little has been known in Asia. For the purpose of better understanding the extent of LVC on a national level, the utilization, costs, and associated characteristics of selected international recommendations were assessed in this study.

Methods: This retrospective cohort study used the National Health Insurance (NHI) claims data during 2013-2017 to evaluate the LVC utilization. Adult beneficiaries who enrolled in the NHI program and received at least one of the low-value services in hospitals were included. We measured seven procedures derived from the international recommendations at the hospital level, and a composite measure was created by summing the total utilization of selected services to determine the overall prevalence and corresponding cost. The generalized estimating equation (GEE) model was adopted to estimate the association.

Results: A total of 1 970 496 episodes of LVC was identified among 1 218 146 beneficiary-year observations and 2054 hospital-year observations. Overall, the utilization rate of the composite measure increased from 150.70 to 186.23 episodes per 10 000 beneficiaries with the growth in cost from US$ 5.40 to US$ 6.90 million. LVC utilization was proportional to the volume of outpatient visits and length of stay. Also, hospitals with a large volume of outpatient visits (adjusted odds ratio [aOR]: 95% CI, 2.10: 1.26 to 3.49 for Q2-Q3, 2.88: 1.45 to 5.75 for ≥Q3) and a higher proportion of older patients (aOR: 95% CI, 1.06: 1.02 to 1.11) were more likely to have high costs.

Conclusion: The utilization and corresponding cost of LVC appeared to increase annually despite the relatively lower prevalence compared to other countries. Multicomponent interventions such as recommendations, de-implementation policies and payment reforms are considered effective ways to reduce LVC. Repeated measurements would be needed to evaluate the effectiveness of interventions.

Background: Various features in health insurance schemes may lead to variation in healthcare. Unwarranted variations raise concerns about suboptimal quality of care, differing treatments for similar needs, or unnecessary financial burdens on patients and health systems. This realist review aims to explore insurance features that may contribute to healthcare variation in Asian countries; and to understand influencing mechanisms and contexts.

Methods: We undertook a realist review. First, we developed an initial theory. Second, we conducted a systematic review of peer-reviewed literature in Scopus, MEDLINE, EMBASE, and Web of Science to produce a middle range theory for Asian countries. The Mixed Methods Appraisal Tool (MMAT) was used to appraise the methodological quality of included studies. Finally, we tested the theory in Thailand by interviewing nine experts, and further refined the theory.

Results: Our systematic search identified 14 empirical studies. We produced a middle range theory in a context-mechanism-outcome configuration (CMOc) which presented seven insurance features: benefit package, cost-sharing policies, beneficiaries, contracted providers, provider payment methods, budget size, and administration and management, that influenced variation through 20 interlinked demand- and supply-side mechanisms. The refined theory for Thailand added eight mechanisms and discarded six mechanisms irrelevant to the local context.

Conclusion: Our middle range and refined theories provide information about health insurance features associated with healthcare variation. We encourage policy-makers and researchers to test the CMOc in their specific contexts. Appropriately validated, it can help design interventions in health insurance schemes to prevent or mitigate the detrimental effects of unwarranted healthcare variation.

The COVID-19 pandemic in Italy is a stark reminder of the necessity of incorporating the social, economic, and political context in planning responses to public health emergencies. During the ongoing global COVID-19 crisis, it is not just crucial but a shared responsibility to supplement epidemiological approaches with insights from the social sciences. This ensures effective and equitable policies, and it is a responsibility that each of us in the field shares. This discussion is relevant and timely, relating directly to the current global crisis and its potential implications for future public health strategies. This comment underscores the key points of Masino and Enria's paper, illuminating the importance of integrating social sciences into public health strategies, the pivotal role of inequalities in shaping pandemic experiences, and, most importantly, the profound and urgent implications for future epidemic preparedness and response. The urgency of these implications cannot be overstated, and we must act on them swiftly and decisively.

Ubels and van Raaij provide a valuable account of the operation of novel hospital/medical specialist enterprise (MSE) contracts in a Dutch healthcare system shaped by market reform. However, their analytical distinction between the separate domains of contractual and relational governance frames the contractual domain more narrowly than does the relational contract theory widely deployed in socio-legal studies. The authors' conclusion that contract plays little or no part in governing relations between hospitals and MSEs leads them to underplay a wider realm of contractual practices that develop in the shadow of the written contract. Apparent non-use of contracts in favour of shared planning, compromise and extra-legal solutions only takes the form it does because of the potential application of the available legal framework. Larger qualitative field studies involving a more extensive combination of interviews and observations may be needed to gain fuller insights into the relational dimensions of the contracting process.

This response critically examines the editorial by Engebretsen and Baker, emphasizing the colonial underpinnings of global health as it pertains to Gaza. We argue that global health is not merely ineffective but complicit in perpetuating settler colonial structures that exacerbate health disparities. The health crisis in Gaza is intricately linked to Israeli occupation, challenging the reductionist frames of "conflict health" and "refugee health" often employed by global health institutions. The presence of non-governmental organizations (NGOs) in Gaza exemplifies how international health efforts can depoliticize the crisis, as they often operate within constraints that do not challenge the underlying power dynamics. Our call for localization and self-determination highlights the complexities of achieving these goals in a context where the state is unrecognized. To effect meaningful change, global health must confront and dismantle the colonial structures underpinning health inequities in Gaza, moving beyond superficial humanitarian approaches to advocate for justice and autonomy.

Background: An updated version of the Short-Form 6-Dimension (SF-6D) Classification System has been developed. This new version (SF-6Dv2) with improved consistency and dimension descriptors is now requiring the development of new utility value sets. The aim of this study was to estimate an SF-6Dv2 value set from a general population in Quebec, Canada.

Methods: A discrete choice experiment with time trade-off (DCE_TTO) was conducted using two designs: binary choice sets (Design 1) and best-worst choice sets (Design 2). Design 1 consisted of binary choice sets along with an associated duration, and Design 2 included Design 1 and a third scenario describing "immediate death." Various logit model specifications were employed to estimate value sets separately for Design 1 and in combination with Design 2. Heterogeneity in preferences was assessed using a mixed logit model.

Results: The survey was completed online by 1208 participants and 1153 were included for analysis. The model combining Design 1 and 2 data was considered as the best fitting model for estimating the final value set. It provided a value set with logical consistent coefficients and showed the lowest standard errors. Values ranged from -0.683 for the worst health state (555655) to 1 for full health (111111), with 13.01% of the values being negative. Preference values were the most affected by pain dimension and the least by vitality dimension. Preference heterogeneity existed for all the most severe levels of dimensions.

Conclusion: This study provided the SF-6Dv2 value set for use in Quebec, Canada. The recommended value set is the anchored consistent model combining data from Design 1 and 2 using a conditional logit.

Background: In the context of a broader vision for primary healthcare (PHC) informed health systems, Sweden is following international trends by introducing the national "Good Quality and Local Health Care" reform. This reform seeks to establish a health system with primary care (PC) at the centre by emphasising aspects such as interorganisational collaboration and e-Health innovation. Since translating policy into practice may be challenging in rural areas due to resource constrains and normatively urban perspectives in national policy-making, this study explores how rural PC actors navigate the PHC vision in the context of a sparsely populated area of the Swedish north.

Methods: This was a single case study, focusing on a rural municipality in northern Sweden. Thematic analysis was applied to data collected through interviews and observations, resulting in the development of three themes.

Results: The results indicate that the policies were suboptimally aligned with the needs of the rural municipality. The results highlighted enduring collaborations that predated the reform. These local alliances led to a resource allocation challenge, rendering the existing networks and reform efforts concurrently understaffed. Moreover, the reform's efforts to digitise healthcare faced impediments due to challenges associated with scaling up e-Health technology. Although key reform concepts such as person-centeredness and integrated care had already been put into practice, they were insufficiently acknowledged as such by external stakeholders.

Conclusion: Subjecting national health policy-making to scrutiny by different stakeholders through the use of rural proofing can lead to a more deliberate and impactful implementation of policies. Rural proofing facilitates the pre-emptive identification of potential shortcomings, thereby enabling the formulation of necessary adjustments that resonate with local needs. This study shows apparent misalignments between the national vision and the practical reality in rural areas, therefore calling for greater efforts to include rural perspectives in national policy-making.

Bennett and colleagues' paper aims to synthesize the existing frameworks to identify and monitor unhealthy commodity industry's (UCI's) influence on health "to create a template surveillance system to be used by national governments across industries." In this commentary, we argue that to achieve a robust government-led national surveillance system, some challenges should be considered, such as (a) addressing power asymmetries between government and UCIs involved in policy-making, (b) evaluating competing interests among government constituencies to achieve policy coherence around health issues, and (c) contemplate whether governments rely on private or corporate donors and partners that may threaten financing and operationalization of the surveillance. Suggestions on how to overcome these challenges are beyond the scope of this commentary, but we discuss some cases of bottom-up approaches from organized groups aiming to hold UCIs accountable. We consider them to be emerging effective ways to support government-led initiatives and counter the long-lasting corporate power and negative impacts on public health.

Background: Most the Organization for Economic Co-operation and Development (OECD) countries are currently facing the challenges of the health transition, the aging of their populations and the increase in chronic diseases. Effective and comprehensive primary healthcare (PHC) services are considered essential for establishing an equitable, and cost-effective healthcare system. Developing care coordination and, on a broader scale, care integration, is a guarantee of quality healthcare delivery. The development of healthcare systems at the meso-level supports this ambition and results in a process of territorial structuring of PHC. In France, the Health Territorial and Professional Communities (HTPC) constitute meso-level organizations in which healthcare professionals (HCPs) from the same territory gather. We conducted a study to determine, in a qualitative step, the key elements of the territorial structuring of PHC in France and, then, to develop, in a quantitative step, a typology of this structuring.

Methods: A sequential-exploratory mixed-method study with a qualitative step using a multiple case approach and a quantitative step as a hierarchical clustering on principal components (HCPC) from a multiple correspondence analysis (MCA).

Results: A total of 7 territories were qualitatively explored. Territorial structuring appears to depend on: past collaborations at the micro-level, meso-level coordination among HCPs and multiprofessional structures, diversity of independent professionals, demographic dynamics attracting young professionals, and public health investment through local health contracts (LHCs). The typology identifies 4 clusters of mainland French territories based on their level of structuring: under or unstructured (38.6%), with potential for structuring (34.7%), in the way for structuring (25.3%) and already structured territories (1.4%).

Conclusion: Interest in territorial structuring aligns with challenges in meso-level healthcare organization and the need for integrated care. Typologies of territorial structuring should be used to understand its impact on access, care quality, and medical resources.

The pharmaceutical industry has a long history of prioritizing the research and sale of medicines that will yield the largest amount of revenue and placing the health of people second. This gap is especially prevalent in countries of the Global South. This article first explores the dichotomy in research between the Global North and the Global South and then looks at examples of how access to key medicines used in diseases such as HIV, oncology and hepatitis C is limited in the latter group of countries. The role of pharmaceutical companies during the COVID-19 pandemic prompted negotiations for a pandemic accord that would ensure more equity in both research and access when the next pandemic comes. However, efforts by a combination of the pharmaceutical industry and some high-income countries (HICs) are creating serious obstacles to achieving the goal of an accord that would place health over profits.