Increased Health Service Research Articles

A controlled pilot trial of a nurse-led intervention (Mini-AFTERc) to manage fear of cancer recurrence in patients affected by breast cancer

BackgroundFear of cancer recurrence (FCR) is common in people affected by breast cancer. FCR is associated with increased health service and medication use, anxiety, depression and reduced quality of life. Existing interventions for FCR are time and resource intensive, making implementation in a National Health Service (NHS) setting challenging. To effectively manage FCR in current clinical practice, less intensive FCR interventions are required. Mini-AFTERc is a structured 30-min counselling intervention delivered over the telephone and is designed to normalise moderate FCR levels by targeting unhelpful behaviours and misconceptions about cancer recurrence.This multi-centre non-randomised controlled pilot trial will investigate the feasibility of delivering the Mini-AFTERc intervention, its acceptability and usefulness, in relation to specialist breast cancer nurses (SBCNs) and patients. This protocol describes the rationale, methods and analysis plan for this pilot trial of the Mini-AFTERc intervention in everyday practice.MethodsThis study will run in four breast cancer centres in NHS Scotland, two intervention and two control centres. SBCNs at intervention centres will be trained to deliver the Mini-AFTERc intervention. Female patients who have completed primary breast cancer treatment in the previous 6 months will be screened for moderate FCR (FCR4 score: 10‑14). Participants at intervention centres will receive the Mini-AFTERc intervention within 2 weeks of recruitment. SBCNs will audio record the intervention telephone discussions with participants. Fidelity of intervention implementation will be assessed from audio recordings. All participants will complete three separate follow-up questionnaires assessing changes in FCR, anxiety, depression and quality of life over 3 months. Normalisation process theory (NPT) will form the framework for semi-structured interviews with 20% of patients and all SBCNs. Interviews will explore participants’ experience of the study, acceptability and usefulness of the intervention and factors influencing implementation within clinical practice. The ADePT process will be adopted to systematically problem solve and refine the trial design.DiscussionFindings will provide evidence for the potential effectiveness, fidelity, acceptability and practicality of the Mini-AFTERc intervention, and will inform the design and development of a large randomised controlled trial (RCT).Trial registrationClinicalTrials.gov: NCT0376382. Registered 4th December 2018, https://clinicaltrials.gov/ct2/show/NCT03763825

What drives utilization of primary care facilities?: Evidence from a national facility survey

ABSTRACT This analysis aims to assess the association between commune health station (CHS) service availability/readiness and health service utilization. Data from the 2015 Vietnam District and Commune Health Facility Survey was used to build a series of multivariate negative binomial regressions to measure the association between domains of service availability/readiness and CHS's average number of visits per capita. Three domains of service availability/readiness are significantly associated with higher utilization rates: health infrastructure, basic equipment availability, and capacity to deliver services for non-communicable diseases. If all three modifiable CHS characteristics were to be improved from their current level, the predicted utilization rate of the CHS would be 3.3–3.7 times as high as current levels. Investments in improving facility infrastructure, making available essential equipment items, and enabling the CHS to provide hypertension and diabetes services would all likely increase health service utilization at CHS level.

Increasing health service access by expanding disease coverage and adding patient navigation: challenges for patient satisfaction

BackgroundCancer control programs have added patient navigation to improve effectiveness in underserved populations, but research has yielded mixed results about their impact on patient satisfaction. This study focuses on three related research questions in a U.S. state cancer screening program before and after a redesign that added patient navigators and services for chronic illness: Did patient diversity increase; Did satisfaction levels improve; Did socioeconomic characteristics or perceived barriers explain improved satisfaction.MethodsRepresentative statewide patient samples were surveyed by phone both before and after the program design. Measures included satisfaction with overall health care and specific services, as well as experience of eleven barriers to accessing health care and self-reported health and sociodemographic characteristics. Multiple regression analysis is used to identify independent effects.ResultsAfter the program redesign, the percentage of Hispanic and African American patients increased by more than 200% and satisfaction with overall health care quality rose significantly, but satisfaction with the program and with primary program staff declined. Sociodemographic characteristics explained the apparent program effects on overall satisfaction, but perceived barriers did not. Further analysis indicates that patients being seen for cancer risk were more satisfied if they had a patient navigator.ConclusionsHealth care access can be improved and patient diversity increased in public health programs by adding patient navigators and delivering more holistic care. Effects on patient satisfaction vary with patient health needs, with those being seen for chronic illness likely to be less satisfied with their health care than those being seen for cancer risk. It is important to use appropriate comparison groups when evaluating the effect of program changes on patient satisfaction and to consider establishing appropriate satisfaction benchmarks for patients being seen for chronic illness.

Association Between Work Absence and Health Services Utilization and Costs Among Employed Individuals With Arthritis.

To evaluate whether work absence is associated with increased health services utilization and health care costs among employed individuals with arthritis. This was a retrospective cross-sectional study using pooled data from the 2011 to 2015 Medical Expenditure Panel Survey (MEPS). Employed individuals with arthritis were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes and Clinical Classification code. Generalized linear models were used to analyze utilization and costs outcomes. Individuals with arthritis who reported work absences had greater odds of having a hospitalization event (odds ratio [OR]: 9.198, P < 0.001), higher number of ambulatory care visits (β = 0.549, P < 0.001), and had higher total health care costs (β = 0.40, P < 0.001) and arthritis-related costs (β = 0.035, P < 0.0002) compared with individuals without work absences. Among employed individuals with arthritis, self-reported work absence is associated with significantly higher health care utilization and health care costs.

Cost-Effectiveness of Pharmacist-Led Deprescribing of NSAIDs in Community-Dwelling Older Adults.

Older adults are often prescribed potentially inappropriate medications associated with adverse health outcomes and increased health services utilization. Developing Pharmacist-led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly (D-PRESCRIBE), a pragmatic randomized clinical trial, demonstrated how a community pharmacist-led evidence-based educational intervention successfully empowered community-dwelling older adults and their physicians to reduce chronic use of inappropriate medications. The objective of this study was to evaluate the cost-effectiveness of the D-PRESCRIBE intervention for discontinuing nonsteroidal anti-inflammatory drugs (NSAIDs). Cost-effectiveness analysis. Canada. Community-dwelling adults aged 65 years and older. Decision analysis combining decision tree and Markov state transition modeling was developed to estimate the cost-effectiveness of D-PRESCRIBE (NSAIDs) compared with usual care from a Canadian healthcare system perspective with a time horizon of 1 year. Data from the D-PRESCRIBE trial and published literature were used to calculate effectiveness, utilities, and costs. Reference case and scenario analyses were conducted using probabilistic modeling. Sensitivity analyses assessed the robustness of the reference case model. D-PRESCRIBE (NSAIDs) was less costly (-$1008.61) and more effective (.11 quality-adjusted life-years [QALYs]) than usual care and was the dominant strategy. At willingness-to-pay thresholds of $50 000 per QALY and $100 000 per QALY, D-PRESCRIBE (NSAIDs) incurred a positive incremental net benefit compared with usual care, suggesting it is cost-effective. Compared with the reference case, scenario analyses gave comparable QALYs with modest variation in cost estimates. For community-dwelling older adults, D-PRESCRIBE (NSAIDs) provides greater benefits at lower system costs, making it a compelling strategy to reduce the use and harms associated with chronic NSAID consumption. Our findings support reimbursing community pharmacists' clinical professional services for deprescribing inappropriate NSAIDs in community-dwelling older adults. J Am Geriatr Soc 68:1090-1097, 2020.

Effectiveness of Task Sharing and Task Shifting on the Uptake of Family Planning in Kenya

Background: Contraception is an inexpensive and cost-effective intervention, but health workforce shortages and restrictive policies on the roles of mid and lower-level cadres limit access to effective contraceptive methods in many settings. Task sharing and task shifting are strategies that can be adopted to increase uptake of health services including family planning. Methods: We collected data through online survey, key informant interviews and focused grouped discussions with an intervention group and that implemented the task sharing and task shifting policy guidelines and a control group that did not implement the policy. A total of 434 questionnaires were filled by health workers’ in primary health care facilities to assess effectiveness of task sharing and task shifting on the uptake of family planning services including its strengths and challenges. The questionnaire was designed with the aim of getting data on services provided by the cadres on effectiveness (number of clients, increase in use of methods, access to services), how they perceive these tasks, the bottlenecks and facilitating factors associated with the practice of task sharing and task shifting. Results: We found out that the task sharing and task shifting can expand and increase access to services as stated by 95% of the respondents. Most community health workers provided more of the family planning services at 45% with only 5% of the services of family planning being provided by medical officers. 98% of family planning services were integrated with other services. Task shifting was beneficial to the health care providers as well as the clients and the success of task sharing and task shifting depended on training, supportive supervision and a regulated environment through policies. Conclusion: The study shows that formalized task sharing and task shifting can increase health service uptake especially when community health workers are involved to provide services in the community. This leads to increased service provision, equivalent health professional performance across cadres and patient outcomes in the provision of family planning services.

Traumatic brain injury in homeless and marginally housed individuals: a systematic review and meta-analysis

Homelessness is a global public health concern, and traumatic brain injury (TBI) could represent an underappreciated factor in the health trajectories of homeless and marginally housed individuals. We aimed to evaluate the lifetime prevalence of TBI in this population, and to summarise findings on TBI incidence and the association between TBI and health-related or functioning-related outcomes. For this systematic review and meta-analysis, we searched without date restrictions for original research studies in English that reported data on the prevalence or incidence of TBI, or the association between TBI and one or more health-related or function-related outcome measures. Studies were included if they had a group or clearly identifiable subgroup of individuals who were homeless, marginally housed, or seeking services for homeless people. With use of random-effects models, we calculated pooled estimates of the lifetime prevalence of any severity of TBI and the lifetime prevalence of moderate or severe TBI. We used meta-regression and subgroup analysis to evaluate potential moderators of prevalence estimates and the leave-one-out method for sensitivity analyses. We then summarised findings from all studies that evaluated TBI incidence and the association between TBI and health-related or functioning-related outcomes. All statistical analyses were done using R version 3.5.1. The study is registered with PROSPERO, number CRD42019119678. Of 463 potentially eligible studies identified by the search, 38 studies were included in the systematic review and 22 studies were included in the meta-analysis. The lifetime prevalence of any severity of TBI in homeless and marginally housed individuals (18 studies, n=9702 individuals) was 53·1% (95% CI 46·4-59·7; I2=97%) and the lifetime prevalence of moderate or severe TBI (nine studies, n=5787) was 22·5% (13·5-35·0; I2=99%). The method used to ascertain TBI history, the age of the sample, and the sample size significantly moderated estimated lifetime prevalence of any severity of TBI. TBI was consistently associated with poorer self-reported physical and mental health, higher suicidality and suicide risk, memory concerns, and increased health service use and criminal justice system involvement. The lifetime prevalence of TBI is high among homeless and marginally housed individuals, and a history of TBI is associated with poorer health and general functioning. Health-care providers and public health officials should have an increased awareness of the burden of TBI in this population. Prospective and longitudinal studies are needed to better understand how the health of this population is affected by TBI. Canadian Institutes of Health Research.

Do welfare benefit reassessments of people with mental health conditions lead to worse mental health? A prospective cohort study.

There have been cases of suicide following the Work Capability Assessment (WCA), a questionnaire and interview for those claiming benefits due to ill health or disability in the United Kingdom. To examine whether experiencing problems with welfare benefits, including WCA, among people with pre-existing mental health conditions was associated with poorer mental health and wellbeing and increased health service use and costs. A prospective cohort study of an exposed group (n = 42) currently seeking help from a Benefits Advice Service in London and a control group (n = 45) who had recently received advice from the same service. Questionnaires at baseline and 3-, 6- and 12-month follow-ups. The exposed group had higher mean scores for anxiety (p = .008) and depression (p = .016) at baseline and the control group higher mean scores for wellbeing at baseline (p = .034) and 12 months (p = .035). However, loss to follow-up makes overall results difficult to interpret. The control group had higher incomes throughout the study, particularly at the 12-month follow-up (p = .004), but the differences could have been accounted for by other factors. Health service costs were skewed by a few participants who used day-care services intensively or had inpatient stays. Over the study period the proportion of exposed participants engaged in benefits reassessment ranged from 50% to 88%, and 40% to 76% of controls. The hardship of living with financial insecurity and a mental health condition made it difficult for our participants to sustain involvement in a 12-month study and the frequency of benefit reviews meant that the experiences of our controls were similar to our exposed group. These limitations limit interpretation but confirm the relevance of our research. The control data raise the question of whether people with mental health conditions are being disproportionately reassessed.

INEQUALITY IN COMMUNITY HEALTH SERVICES USE IN ISRAEL: A COMPARISON BETWEEN ELDER JEWS AND ARABS

Population aging is an important social and public health issue globally. However, increase in longevity causes physical frailty and disability for many elders, which might lead to independence loss and impact quality of life. This increases health services usage and leads to higher costs of medical treatments. Data show that higher socio-economic status and accessibility to health services might reduce inequality in service use and impact mortality rates and quality of life. Also, that improved socio-economic status and population accessibility to Health services may stem from inner health system factors, as well as those related to the patients. Among minorities lower usage of formal professional services, including health services, are often related to cultural differences and many times to lower technological level, which are not considered by service providing organizations. Thus, lack of attention to service using minorities’ needs may cause a gap between potential consumers to services use. Israel is a multi-cultural society with mixed population of Jews and Arabs. Currently, Arabs comprise 20.9% and Jews 74.3%. However, the rate of disabled Jews is 16% compared to 31% among older Arabs.

Primary care models for community-dwelling adults with long-term conditions: a scoping review protocol.

This scoping review aims to map primary care models designed to support adults with long-term conditions. The review will analyze the following in relation to the models identified: characteristics, impact reported, implications for practice and outcome measures. Robust solutions to support individuals with long-term conditions need to be established in order to increase health service capacity and provide cost-effective solutions while, most importantly, ensuring they receive the best services to live meaningful and productive lives. The concept to be mapped is primary care models used to support adults living with long-term conditions. This may also encompass services not solely designed for people with long-term conditions; however, they will be services that may be the first port of call for this group. Operational a priori criteria have been designed to assist with distinguishing appropriate literature. Due to the nature of the scoping review, literature from a range of published and unpublished sources will be utilized from 1995 to 2019. Databases to be searched will include: MEDLINE, Embase, PsycINFO, HMIC, CINAHL, Cochrane Database of Systematic Reviews and Web of Science. Appropriate gray literature will be searched, alongside hand searching selected primary care journals, conference abstracts and professional and government bodies. Articles will be restricted to English. Titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria. Charting of the data will include details about the population, concept, context, study methods and key findings relevant to the review objective.

Epidemiology of Alcohol Use in Late Adolescence in Greece and Comorbidity with Depression and Other Common Mental Disorders.

Background The aim of the current study was to examine the prevalence and associations of hazardous alcohol use with sociodemographic variables and its comorbidity with depression and other common mental disorders in a sample of Greek adolescents between 16 and 18 year old. MethodsWe recruited 2431 adolescents attending 25 senior high schools in Greece. We assessed depressive and anxiety disorders using the computerized version of a fully-structured psychiatric interview (the revised Clinical Interview Schedule / CIS-R). Alcohol use was assessed using questions taken from a previous WHO school survey. ResultsApproximately one-third of adolescents (overall: 30.7%, boys: 39.2%, girls: 21.9%, p < 0.001) consumed alcohol on a weekly basis. The experience of excessive consumption, leading to drunkenness at least two or more times in their lifetime, was reported by 15.39% of the adolescents (19.42% for the boys and 11.24% for the girls, p < 0.001). Frequent alcohol consumption and drunkenness were strongly associated with the presence of depression, all other anxiety disorders except panic disorder, current smoking, and lifetime cannabis use, lower school performance, bad or fair relationship with parents, and increased health services use. Conclusion Alcohol use is highly prevalent among Greek adolescents. Special attention for the development of more focused preventive strategies should be paid to adolescents suffering from depression or other common mental disorders.

Oral Complications of Chronic Graft-Versus-Host Disease.

The increasing clinical indications for hematopoietic stem cell transplantation (HSCT) and improved clinical care throughout and following HSCT have led to not only long-term survival but also to an increasing incidence and prevalence of graft-versus-host disease (GVHD). Chronic GVHD (cGVHD) affects almost 50% of adult patients post-HSCT, with increasing incidence in pediatric patients as well. Oral cGVHD specifically has a reported prevalence ranging from 45% to 83% in patients who develop cGVHD and is more extensive in adult patients than in children. Oral cGVHD affects patients through clinically significant oral symptoms that may lead to significantly decreased caloric intake, oral infections, and increased health service utilization, and may thus affect overall health and survival. The most commonly used therapy for mucosal involvement of oral cGVHD is topical high-dose and ultra-high potency corticosteroids, and calcineurin inhibitors. This review of oral complications of cGVHD presents the clinical significance of oral cGVHD to HSCT survivors, our current understanding of the pathobiology of oral cGVHD and gaps in this evidence, and the global targeted interdisciplinary clinical research efforts, including the National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease. Current challenges regarding the management of oral cGVHD and strategies to advance our scientific understanding of this clinically significant chronic oral disease are presented.

Assessing the impact of more doctors’ program on healthcare indicators in Brazil

This paper aimed to assess the short term effects of the More Doctors Program, launched by the Brazilian federal government in 2013. Using a differences-in-differences approach with municipal data collected between 2010 and 2015, we confirmed that MDP has two correlated impacts. First, it has increased health service attendance in treated municipalities. We documented that appointments, consults, referrals, and home visits have increased by 5.9%, 9.4%, 12.3%, and 29.7%, respectively. Second, we found a negative impact on hospitalization. We argue that intensification of health service access has reduced general hospitalization (4.6%). However, it does not seem to have been able to reduce mortality in the municipalities, in line with the previous literature. We believe that increases in referrals and appointments with specialists can be interpreted as a quality improvement, since a more precise diagnosis can reduce hospitalization due to faster health recovery but without any impact on mortality.

Clinical and economic burden of infections in hospitalized solid organ transplant recipients compared with the general population in Canada - a retrospective cohort study.

Infections continue to be a major cause of post-transplant morbidity and mortality, requiring increased health services utilization. Estimates on the magnitude of this impact are relatively unknown. Using national administrative databases, we compared mortality, acute care health services utilization, and costs in solid organ transplant (SOT) recipients to nontransplant patients using a retrospective cohort of hospitalizations in Canada (excluding Manitoba/Quebec) between April-2009 and March-2014, with a diagnosis of pneumonia, urinary tract infection (UTI), or sepsis. Costs were analyzed using multivariable linear regression. We examined 816324 admissions in total: 408352 pneumonia; 328066 UTI's; and 128275 sepsis. Unadjusted mean costs were greater in SOT compared to non-SOT patients with pneumonia [(C$14923±C$29147) vs. (C$11274±C$18284)] and sepsis [(C$23434±C$39685) vs. (C$20849±C$36257)]. Mortality (7.6% vs. 12.5%; P<0.001), long-term care transfer (5.3% vs. 16.5%; P<0.001), and mean length of stay (11.0±17.7days vs. 13.1±24.9days; P<0.001) were lower in SOT. More SOT patients could be discharged home (63.2% vs. 44.3%; P<0.001), but required more specialized care (23.5% vs. 16.1%; P<0.001). Adjusting for age and comorbidities, hospitalization costs for SOT patients were 10% (95% CI: 8-12%) lower compared to non-SOT patients. Increased absolute hospitalization costs for these infections are tempered by lower adjusted costs and favorable clinical outcomes.

Review on the Current Status of Poverty and Its Determinants in Ethiopia

The study was mainly focused on assessing current poverty status and its determinants in Ethiopia. Specifically aims to review the level of poverty status, causes of poverty and determinants of poverty in Ethiopia. However, its total population is more than100 million; agriculture is the foundation of its economic growth. Poverty is still a big obstacle to overcome in Ethiopia. Poverty in Ethiopia is caused population pressure, illiteracies, and natural factors like drought, famine etc. Disease, shortage of land, poor use of technology, weak basic services, political instability, inflation, high unemployment rate and etc. Based on generalized results of we reviewed documents the major determinants of poverty were age of household heads, family size per adult equivalent, access to credit service, dependency ratio, and access to health service. Hence, promoting equitable economic growth, family planning, increasing land productivity, increasing credit service, increasing health service, and promoting research extension farmer linkage are indispensable policy interventions to better reduce rural poverty. Key words : Poverty, Determinants, Ethiopia DOI : 10.7176/JPID/50-04 Publication date :June 30 th 2019

1311-P: Machine Learning (ML) Application to Predict Patient Risk of Nonadherence in Type 2 Diabetes Management Using U.S. Claims Databases

Medication non-adherence is one of the common leading public health challenges facing the U.S. Poor medication adherence in patients with diabetes, especially type 2 diabetes mellitus (T2DM), may be associated with inadequate glycemic control, increased morbidity and mortality and lead to increased health services utilization and hospital admissions. The use of predictive models based on ML using “big” healthcare data can help identify and predict a subpopulation with high risk of nonadherence, thus providing a scope for improving value in health care and reducing the cost burden. In this study, we extracted 111,180 T2DM patients initiating metformin monotherapy (index date) from the Truven database to train the ML models and predict patients’ level of adherence to metformin monotherapy. Patients must have had at least 6 months of pre-index (baseline) and at least 2 years of post-index (follow-up) data available. Adherence was measured as proportion of days covered (PDC) for metformin in the second year after the index date with PDC &amp;gt;= 0.8 labeled as high-adherence and &amp;lt; 0.8 labeled as low-adherence. A total of 120 variables were extracted including patients’ demographic information, T2DM-related medication and procedure use, comorbidities, and metformin usage information. In the preliminary analysis, random forest classifiers with 80% random split training set and validated with the 20% test set has reached 0.73 accuracy and 0.73 sensitivity. Due to the high dimensionality and sparsity of the features, we will apply further feature engineering and additional non-linear ML models such as XGboosting, BART and super learner to compare with logistic regression model and to optimize the accuracy and sensitivity. A T2DM cohort from Optum claims database will be used for cross-validation to ensure the generalization of the model. This ML model could also be adapted for other therapeutic areas. Disclosure X. Chen: Employee; Self; Merck &amp; Co., Inc. G. Fernandes: None. J. Chen: None. Z. Liu: Employee; Self; Merck &amp; Co., Inc. R. Baumgartner: None.

Variation in tests for people with type 2 diabetes, hypertension, or chronic kidney disease in UK primary care

BackgroundRates of pathology testing are rising in the UK, with significant geographical variability. Around 50% of overall GP laboratory testing represents monitoring for chronic conditions such as high blood pressure, type 2 diabetes, and chronic kidney disease (CKD). Overuse of tests for monitoring chronic conditions may be a potential source of harm; causing patient anxiety, downstream tests/referrals, overdiagnosis, increase GP workload and increase health service costs. On the other hand, failure to test may lead to missed diagnoses, complications, patient harm and litigation.AimThis study aims to use an open cohort to examine current variation in the use of tests for individuals with type 2 diabetes, hypertension, and CKD&gt;2 across the UK.MethodClinical Practice Research Datalink (CPRD) data will be used to consider what tests have been ordered for people with these conditions and look at variation over time, and by region, age, sex, ethnicity, and socioeconomic position using age–sex-standardised utilisation rates, descriptive statistics, and multilevel Poisson regression.ResultsAn estimated 1.2 million patients within the CPRD database have previously been diagnosed with any of the chronic conditions with over 11 million tests. Some 1 029 496 patients have hypertension, 344 613 with diabetes, and 271 897 with CKD&gt;2, with much overlap. The results from this study will help to find what tests are currently used among patients with these conditions and to quantify variation in testing.ConclusionThis work will be used to inform the development of testing algorithms for patients with these conditions in primary care.

Health literacy of nursing students and its effective factors.

The insufficiency of health literacy negatively affects the national economy as it leads to increased health service expenditure. It is very important for individuals to have accurate health-related information to reduce these negative effects. The aim of the study is to examine the health literacy of nursing students and its effective factors. This descriptive study was carried out with students from the nursing department of a vocational school of health sciences between September and October 2018 in Turkey. A semi-structured questionnaire regarding the descriptive features of the participants and the European Health Literacy Scale were used for data collection. The study included 283 nursing students; 29.3% had a problematic-limited health literacy level. The study found a statically significant difference between student year, high school graduation and family's income level and the total mean score of the HLS-EU scale. The subject of health literacy should be integrated into the educational program of nursing students. The nurses are the most important workforce in health services, and awareness about this subject should be raised.

Simulation-based training for increasing health service board members’ effectiveness: protocol for a cluster-randomised controlled trial

IntroductionResearch indicates that health service boards can influence quality of care. However, government reviews have indicated that board members may not be as effective as possible in attaining this goal....

Effect of a medical subsidy on health service utilization among schoolchildren: A community-based natural experiment in Japan

Reducing out-of-pocket medical payments for children can reduce financial barriers to healthcare, but may increase health service expenditure. Efficient schemes of patient cost-sharing are needed to address this. We explored the impacts of a medical subsidy for children (MSC), which contained two schemes for cost-sharing of medical expenditure and health service utilization. The first is a monthly stop-loss policy, or caps on out-of-pocket payments, for outpatient/inpatient services; this reduces out-of-pocket payments for those who use greater amounts of health services. The second is a free prescription policy, which eliminates out-of-pocket payments regardless of the amount of drug expenditure. Expansion of the MSC was used as a natural experiment in a Japanese prefecture. We analyzed Japanese National Health Insurance claims data covering April 2013 to January 2017, and found no significant effect of the stop-loss policy on outpatient/inpatient service expenditures, regardless of the children’s baseline health status. The free prescription policy, however, significantly increased prescription drug expenditure to 116% in the total sample and 121% among children with good health status, but not among children with poor health status. Increased health expenditure among healthy, low-volume users was found to cause increased overall expenditure. The stop-loss policy for children is potentially efficient because it selectively reduced out-of-pocket payments in high-volume users and did not increase overall expenditure.