Percentage Point Increase In Coverage Research Articles

Contribution of primary care expansion to Sustainable Development Goal 3 for health: a microsimulation of the 15 largest cities in Brazil

ObjectivesAs middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities...

The Contribution of Primary Care Expansion to Sustainable Development Goal Three for Health: A Microsimulation of the Fifteen Largest Cities in Brazil

Background: As middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities in mortality. We estimated the potential impact of primary care expansion on cause-specific mortality in the 15 largest Brazilian cities. Methods: We obtained hazard ratios of death by cause and by demographic group, from a national administrative database linked to the Estrategia de Saude da Familia (Family Health Strategy, FHS) electronic health and death records among 1.2 million residents of Rio de Janeiro (2010-2016). We incorporated these hazard ratios into a microsimulation to estimate the impact of changing primary care coverage. Findings: Increased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1,000 between the highest- and lowest-mortality city, given a 40 percentage point increase in coverage), between welfare recipients and non-recipients (from 1.3 to 1.0 deaths per 1,000), and among race/ethnic groups (between Black and White Brazilians from 1.0 to 0.8 deaths per 1,000). A 40 percentage point increase in coverage would be insufficient to reach SDG targets --reducing premature mortality from non-communicable diseases by 20% (versus the target of 33%), and communicable diseases by 15% (versus 100%). Interpretation: Primary care coverage may be critically beneficial to reducing within-country health inequalities, but reaching SDG targets will likely require coordination between primary care and other sectors. Funding Statement: This work was supported by a grant from the Health Systems Research Initiative with funding from the Foreign, Commonwealth and Development Office, the UK Medical Research Council and Wellcome Trust, in collaboration with the UK Economic and Social Research Council (grant no. MR/P014593/1).DR acknowledges support from the Spanish Ministry of Science and Innovation through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018- 000806-S), and support from the Generalitat de Catalunya through the CERCA Program. Declaration of Interests: None. Ethics Approval Statement: Approval for this study was obtained from the Brazilian National Commission for Ethics in Research (Comissao Nacional de Etica em Pesquisa [CONEP]; number 2.689.528) and Imperial College London’s Ethical Comittee.

School Entry Requirements and Coverage of Nontargeted Adolescent Vaccines.

Low human papillomavirus (HPV) vaccination coverage is an urgent public health problem requiring action. To identify policy remedies to suboptimal HPV vaccination, we assessed the relationship between states' school entry requirements and adolescent vaccination. We gathered data on states' school entry requirements for adolescent vaccination (tetanus, diphtheria, and pertussis [Tdap] booster; meningococcal; and HPV) from 2007 to 2012 from Immunization Action Coalition. The National Immunization Survey-Teen provided medical record-verified vaccination data for 99 921 adolescents. We calculated coverage (among 13- to 17-year-olds) for individual vaccinations and concomitant vaccination. HPV vaccination outcomes were among female adolescents. Analyses used weighted longitudinal multivariable models. States with requirements for Tdap booster and meningococcal vaccination had 22 and 24 percentage point increases in coverage for these vaccines, respectively, compared with other states (both P < .05). States with HPV vaccination requirements had <1 percentage point increase in coverage for this vaccine (P < .05). Tdap booster and meningococcal vaccination requirements, respectively, were associated with 8 and 4 percentage point spillover increases for HPV vaccination coverage (both P < .05) and with increases for concomitant vaccination (all P < .05). Ensuring all states have meningococcal vaccination requirements could improve the nation's HPV vaccination coverage, given that many states already require Tdap booster but not meningococcal vaccination for school entry. Vaccination programs and clinicians should capitalize on changes in adolescent vaccination, including concomitant vaccination, that may arise after states adopt vaccination requirements. Additional studies are needed on the effects of HPV vaccination requirements and opt-out provisions.

Increasing Health Insurance Costs and the Decline in Insurance Coverage

To determine the impact of rising health insurance premiums on coverage rates. Our analysis is based on two cohorts of nonelderly Americans residing in 64 large metropolitan statistical areas (MSAs) surveyed in the Current Population Survey in 1989-1991 and 1998-2000. Measures of premiums are based on data from the Health Insurance Association of America and the Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits. Probit regression and instrumental variable techniques are used to estimate the association between rising local health insurance costs and the falling propensity for individuals to have any health insurance coverage, controlling for a rich array of economic, demographic, and policy covariates. More than half of the decline in coverage rates experienced over the 1990s is attributable to the increase in health insurance premiums (2.0 percentage points of the 3.1 percentage point decline). Medicaid expansions led to a 1 percentage point increase in coverage. Changes in economic and demographic factors had little net effect. The number of people uninsured could increase by 1.9-6.3 million in the decade ending 2010 if real, per capita medical costs increase at a rate of 1-3 percentage points, holding all else constant. Initiatives aimed at reducing the number of uninsured must confront the growing pressure on coverage rates generated by rising costs.