Universal Health Insurance System Research Articles

Selling pharmaceuticals ethically in resource-limited settings: the case of Sofosbuvir

In countries without universal health insurance systems, is it ethically acceptable for pharmaceutical companies to sell their products only to the relatively small segment of the population that can afford private insurance coverage or to pay for medications out of pocket? Are there certain drugs that companies should be expected to sell in these economies even if they are unable to do so profitably? Within a human rights framework, this paper identifies these and related ethical challenges and proposes some responses. The paper begins by considering general ethical responsibilities that arise from commitment to the Universal Health Coverage initiative as a Sustainable Development Goal. It then discusses ethical responsibilities on the part of pharmaceutical companies as distinct from those of national governments or the broader international community. Some proposals follow for thinking through specific ethical challenges that arise when making decisions about whether, and on what terms, to introduce a new drug into a particular setting. Finally, the paper considers a number of these issues and responses in the context of the sale of sofosbuvir in the Asia-Pacific region.

Ethical Considerations in Selling Pharmaceuticals in Emerging Economies

International research-based pharmaceutical companies are increasingly selling their products in less economically developed countries, commonly referred to as “emerging economies” or “emerging markets.” While the introduction of new drugs in these settings has the potential to bring significant health benefits for individuals and populations, it also raises a host of difficult ethical questions. For example, in countries without universal health insurance systems, is it ethically acceptable for companies to sell their products only to the relatively small segment of the population that can afford private insurance coverage or to pay for medications out of pocket? Are there certain drugs that companies should be expected to sell in emerging markets even if they are unable to do so profitably? What ethical responsibilities do companies have in settings where, because of lax regulatory controls, individuals are able to purchase virtually any medication they want without a prescription? This white paper is designed to help companies identify and respond to these and related ethical challenges. Developed with input from an international group of experts and stakeholders, the white paper begins by considering the sources of companies’ ethical responsibilities within emerging markets, as distinct from the responsibilities of national governments or the broader international community. It then provides guidance for thinking through specific ethical challenges that arise when making decisions about whether, and on what terms, to introduce a new drug into a particular setting.

INOVASI JAMINAN KESEHATAN SEMESTA DALAM USAHA MENINGKATKAN KUALITAS PELAYANAN KESEHATAN BAGI PESERTA JAMINAN PENYANGGA DI DAERAH ISTIMEWA YOGYAKARTA

This research aims to know and understand about the implementation of the innovation of Universal Health Insurance (Jamkesta) system in an effort to improve health care quality for participants buffer in Yogyakarta. This reseach used descriptive qualitative method. Data collected by interview and observation. Data validity checking is done through a method of triangulation. The process of data analysis include data reduction, data presentation, and conclusion. The results showed that the element of human resources, processes, financing, location, response to suggestions for improvements innovation, law, and social supports the implementation of Universal Health Insurance for participant buffer and newborns. However, there are still some deficiencies that need to be corrected when viewed from the elements of socialization, culture and technology. Meanwhile, elements of the results showed that as many as 45% of the total number of participants for eligibility letter (SEP) printed out by Bapel Jamkesos is for the class buffer without ID cards and newborns. This indicates that the Jamkesta vision and mandate of the Governor of Yogyakarta has been reached.Keywords: Innovation, Universal Health Insurance, and Health Care.

Income-Related Inequalities in Access to Dental Care Services in Japan.

Background: This study aimed to evaluate whether income-related inequalities in access to dental care services exist in Japan. Methods: The subjects included beneficiaries of the National Health Insurance (NHI) in Chiba City, Japan, who had been enrolled from 1 April 2014 to 31 March 2015. The presence or absence of dental visits and number of days spent on dental care services during the year were calculated using insurance claims submitted. Equivalent household income was calculated using individual income data from 1 January to 31 December 2013, declared for taxation. Results: Of the 216,211 enrolled subjects, 50.3% had dental care during the year. Among those with dental visits, the average number of days (standard deviation) spent on dental care services per year was 7.7 (7.1). Low income was associated with a decreased rate of dental care utilization regardless of age and sex. However, there was a significant inverse linear association between the number of days spent on dental care services and income levels for both sexes. Conclusions: There were income-related inequalities in access to dental care services, regardless of the age group or sex, within the Japanese universal health insurance system.

A Research on the Medical Professionalss Resistance of Telemedicine: Utilizing the Delphi Study

Background: The constructions of the infrastructure for information and communication technology (ICT) and a universal health insurance system are necessary for a smooth execution of telemedicine. However, despite the fulfilment of such necessary conditions, there are situations where the telemedicine still fails to settle as a system due to low receptivity of stakeholders. Introduction: This study plans to first analyse the stakeholders’ resistance to an organisation’s implementation of telemedicine. By focusing on the medical professionals’ interests, we aim to propose a strategy to minimise their conflicts and improve their acceptance. Materials and methods: The Delphi study was carried out on 190 telemedicine professionals, whom have been recommended by 480 telemedicine-related personnel in South Korea. Results: Out of 190 professionals, 60% of enrolled participants completed the final questionnaires. The stakeholders were categorised into groups including policy making officials, medical professionals, patients and industrialists. Amongst these, the majority of the medical professionals opposed to the execution of telemedicine. The main causes of such opposition were found to be the lack of medical delivery system and the threat of disruption of the primary care units. The consensus amongst stakeholders revealed low and in order to facilitate the smooth agreements, each expert presented the similar conditions such as the financial support by the government and the guarantee of medical autonomy. Conclusion: The analysis of the causes of the resistance of telemedicine, extracted from the concerned parties, has important implications for the policy-makers to derive strategies for an appropriate consensus.

Using administrative data to look at changes in the level and distribution of out-of-pocket medical expenditure: An example using Medicare data from Australia

ObjectivesAustralia’s universal health insurance system Medicare generates very large amounts of data on out-of-pocket expenditure (OOPE), but only highly aggregated statistics are routinely published. Our primary purpose is to develop indices from the Medicare administrative data to quantify changes in the level and distribution of OOPE on out-of-hospital medical services over time. MethodsData were obtained from the Australian Hypertension and Absolute Risk Study, which involved patients aged 55 years and over (n=2653). Socio-economic and clinical information was collected and linked to Medicare records over a five-year period from March 2008. The Fisher price and quantity indices were used to evaluate year-to-year changes in OOPE. The relative concentration index was used to evaluate the distribution of OOPE across socio-economic strata. ResultsOur price index indicates that overall OOPE were not rising faster than inflation, but there was considerable variation across different types of services (e.g. OOPE on professional attendances rose by 20% over a five-year period, while all other items fell by around 14%). Concentration indices, adjusted for demographic factors and clinical need, indicate that OOPE tends to be higher among those on higher incomes. ConclusionsA major challenge in utilizing large administrative data sets is to develop reliable and easily interpretable statistics for policy makers. Price, quantity and concentration indices represent statistics that move us beyond the average.

Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy.

Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient’s factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon’s skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.

Socioeconomic Disparities in the Prevalence, Diagnosis, and Control of Hypertension in the Context of a Universal Health Insurance System.

A lower use of preventive intervention in low socioeconomic populations has been described in countries with universal coverage health care systems, but little is known about the possible socioeconomic inequalities in secondary prevention in a universal health insurance system. Data from the 2010-2013 Korea National Health and Nutrition Examination Survey, a nationwide survey, were analyzed. A total of 20,044 subjects older than 30 years of age were included after excluding subjects with missing data. Prevalence ratios were calculated using Poisson regression models with robust variance to explore factors associated with the prevalence, unawareness, and inappropriate control of hypertension. Hypertension prevalence decreased with increasing education and income level. We observed an inverse association between education level and undiagnosed hypertension among women, but not men. Socioeconomic level was not associated with inadequate control of hypertension among men or women. Future interventions should include primary prevention efforts targeted at lower socioeconomic populations to reduce disparities. There is substantial room for improvement in secondary prevention efforts. Monitoring strategies may highlight gaps in the preventive and care services offered to the most vulnerable individuals and encourage governments and practitioners to address these gaps.

Federalism and Australia’s National Health and Health Insurance System

While health reform in Australia has been marked by piecemeal, incremental changes, the overall trend to increasing Commonwealth involvement has not been accidental or driven by power-hungry centralists: it has been shaped by broader national and international developments including technological change and the maturing of our nation and its place internationally, and by a widespread desire for a national universal health insurance system. In many respects the Australianhealth system performs well, but the emerging challenges demand a more integrated, patient-oriented system. This is likely to require a further shift towards the Commonwealth in terms of financial responsibility, as the national insurer. But it also requires close cooperation with the States, who could play a firmer role in service delivery and in supporting regional planning and coordination. The likelihood of sharing overall responsibility for the health system also suggests thereis a need to involve the States more fully in processes for setting national policies.
 This article draws heavily on a lecture presented at the Australian National University in October 2015. It includes an overview of Australia’s evolving federal arrangements and the context within which the current Federalism Review is being conducted. It suggests Australia will not return to ‘coordinate federalism’ with clearly distinct responsibilities, and that greater priority should be given to improving how we manage shared responsibilities.
 There is a long history of Commonwealth involvement in health, and future reform should build on that rather than try to reverse direction. While critical of the proposals from the Commission of Audit and in the 2014 Budget, the lecture welcomed the more pragmatic approaches that seemed to be emerging from the Federalism Review discussion papers and contributions from some Premiers which could promote more sensible measures to improve both the effectiveness and the financial sustainability of Australia’s health and health insurance system.
 The Commonwealth’s new political leadership in 2015 seemed interested in such measures and in moving away from the Abbott Government’s approach. But the legacy of that approach severely damaged the Turnbull Government in the 2016 federal election as it gave traction to Labor’s ‘Mediscare’ campaign. In addition to resetting the federalism debate as it affects health, the Turnbull Government now needs to articulate the principles of Medicare and to clarify the role of the private sector, including private health insurance, in Australia’s universal health insurance system. Labor also needs to address more honestly the role of the private sector and develop a more coherent policy itself.
 Abbreviations: COAG – Council of Australian Governments; NHHRC – National Health and Hospitals Reform Commission; PHI – Private Health Insurance; VFI – Vertical Fiscal Imbalance.

Survival and complication rates in patients with thalassemia major in Taiwan.

While transfusion and iron chelation therapy for thalassemia major (TM) has improved dramatically in recent years, the consequences of this improvement (current rates of survival and TM-related complications) remain unknown. This nationwide population-based cohort study analyzed 2007-2011 data obtained from the Taiwanese National Health Insurance Research Database. After excluding those patients receiving hematopoietic stem cell transplantation, we enrolled 454 patients with TM who received transfusion and chelation therapy (median age, 17.2 years). Among these patients, the mortality rate was 2.9% in 2007, 2.3% in 2008, 2.9% in 2009, 2.6% in 2010, and 0.7% in 2011. Heart was the most common target organ of TM-related complications. There were 80 patients (17.6%) with arrhythmia and 86 patients (18.9%) with congestive heart failure. Dysfunction of endocrine organs was common, and the most common endocrinopathy was hypogonadism (23.1%), followed by diabetes (21.2%). There were 75 patients (16.5%) with liver cirrhosis and 79 patients (17.4%) with osteoporosis. Adequate red blood cell transfusion and iron chelation is available to all patients with TM in Taiwan under the universal health insurance system, and has resulted in reduction of TM-related mortality to very low levels. As these patients get older, early detection of complications and adequate intervention are important to quality-of-life improvement.

Factors involved in the delay of treatment initiation for cervical cancer patients: A nationwide population-based study.

Cervical cancer ranks as the fourth leading cause of cancer death in women worldwide. In Taiwan, although the universal health insurance system has achieved 99.9% coverage and ensured easy access to medical care, some cervical cancer patients continue to delay initiation of definitive treatment after diagnosis. This study focused on cervical cancer patients who delayed treatment for at least 4 months, and examined the characteristics, related factors, and survival in these patients.Data on patients with a new confirmed diagnosis of cervical cancer by the International Federation of Gynecology and Obstetrics (FIGO) staging system between 2005 and 2010 were obtained from the National Health Insurance Research Database and the Taiwan Cancer Registry. Logistic regression analysis was performed to analyze the association of various factors with treatment delay. The Cox proportional hazards model was used to analyze the effects of various factors on mortality risk.The rate of treatment delay for cervical cancer decreased steadily from 6.46% in 2005 to 2.48% in 2010. Higher rates of treatment delay were observed among patients who were aged ≥75 years (9.91%), had severe comorbidity, had stage IV (9.50%), diagnosing hospital level at nonmedical center, or at public hospital ownership. Factors that correlated with treatment delay were age ≥75 years (odds ratio [OR] = 2.42), higher comorbidity Charlson comorbidity index (CCI) 4–6, or ≥7 (OR = 1.60, 2.00), cancer stage IV (OR = 2.60), the diagnosing hospital being a regional, district hospital, or other (OR = 3.00, 4.01, 4.60), and at public hospital ownership. Those who delayed treatment had 2.31 times the mortality risk of those who underwent timely treatment (P < 0.05).Delayed cervical cancer treatment in Taiwan was associated with age, comorbidity, cancer stage, diagnosing hospital level, and hospital ownership. Delaying treatment for ≥4 months substantially raised mortality risk in cervical cancer patients.

Unmet eye care needs among a homeless youth population

ObjectiveTo assess the rate of visual impairment and quantify the unmet eye care needs within Toronto’s homeless youth community. DesignProspective and cross sectional. ParticipantsNinety randomly selected homeless youth aged 16–24 years. MethodsFrom each of 9 participating homeless youth shelters and drop-in centres in Toronto, 10 English-speaking youths between ages 16 and 24 were randomly recruited. Information regarding sociodemographics, medical history, subjective visual acuity, and access to eye care was collected. Comprehensive visual screening and undilated direct fundoscopy were also performed. ResultsThe median age of participants was 21 years (interquartile range = 19–23 years), and 62.2% were male. Most participants were homeless for less than 5 years (90%) and earning less than $500 monthly (57.8%). Despite 51.1% of participants having previously owned corrective lenses, only 20% of participants currently owned them when assessed/at study time. When analyzing the better-seeing eye, presenting visual acuity was 20/50 or worse in 18.9% (95% CI 10.8%–27.0%) of participants. Pinhole occlusion decreased the number to 2.2% (95% CI 0%–5.3%). The most common cause of visual impairment was uncorrected refractive error. Ocular pathology was observed in 8 participants. Compared to adults, youth have similar functional visual impairment (adults 24.0%, youth 18.9%) but less impairment uncorrectable by pinhole occlusion (adults 11.0%, youth 2.2%) and are less dissatisfied with their vision (adults 70.0%, youths 36.7%). Although a higher proportion of homeless youths have visited an eye specialist in the past year (adults 14.0%; youths 17.8%), neither group is visiting as frequently as the Canadian average (41%) (p < 0.01). ConclusionsHomeless youth have a high prevalence of visual impairment, even when living within a system of universal health insurance. Ongoing vision-screening programs, readily accessible free eye clinics, and particularly low-cost glasses may help address this need.

The reform of the medical welfare system and health equity for the elderly in China: a study in Zhejiang

Health equity is the basic theory of universal health insurance and the objective of reform of the medical welfare system. Based on health equity theory with the perspective of giving priority to disadvantaged groups, this article takes Zhejiang province as an example and adopts a mixed-method approach to explore the effects of the reform of the medical welfare system on health equity for older people. The structural equation model (SEM)-based nonrecursive path analysis demonstrates an improvement of health equity for insured elders of the Basic Medical Insurance for Employees (BMIE) and the Urban Basic Medical Insurance for Residents (UBMIR) as a result of an increased utilization of healthcare. However, there is little difference in terms of the utilization of healthcare and health outcomes between old people insured by the New Rural Cooperative Medical System (NRCMS) and those without medical insurance. This results from the low-level benefits of the insurance policy and defective policy design. A qualitative analysis further discovers the insufficient protection of health equity for several types of vulnerable aged groups in the process of healthcare delivery. Finally, this study advocates the perspective of health equity for vulnerable groups, a transition from emphasizing opportunity equity to stressing outcome equity, and the construction of universal health insurance and long-term care system for the disabled elderly.

Racial-Ethnic Differences in Health Service Use in a Large Sample of Homeless Adults With Mental Illness From Five Canadian Cities.

This study examined factors associated with health care use in an ethnically diverse Canadian sample of homeless adults with mental illness, a particularly disadvantaged group. Baseline survey data were available from five sites across Canada for 2,195 At Home/Chez Soi demonstration project participants. Negative binomial regression models examined the relationship between racial-ethnic or cultural group membership (white, N=1,085; Aboriginal, N=476; black, N=244; and other ethnoracial minority groups, N=390) and self-reported emergency department (ED) visits and hospitalizations in the past six months and past-month visits to a medical, other clinical, or social service provider. Adjusted models included other predisposing, enabling, and need factors, based on Andersen's behavioral model for vulnerable populations. Compared with white participants, black participants had a lower rate of ED visits (adjusted rate ratio [ARR]=.54, 95% confidence interval [CI]=.43-.69) and Aboriginal participants had a lower rate of medical visits (ARR=.84, CI=.71-.99) and a higher rate of visits to social service providers (ARR=1.54, CI=1.18-2.01). Participants in other ethnoracial minority groups had a higher rate of social service provider visits than white participants (ARR=1.44, CI=1.10-1.89). Access to a family physician, having at least high school education, and high needs for mental health services were associated with greater use of ED and medical visits and hospitalizations. Rates of ED and medical visits were lower with increased age and better physical health. In a system of universal health insurance that prioritizes access to and quality of care, the presence of racial-ethnic disparities experienced by this vulnerable population merits further attention.

The influence of socioeconomic status on health resource utilization in pediatric epilepsy in a universal health insurance system.

It is unknown if there is a disparity in health resource utilization (HRU) among children with epilepsy in a universal health insurance system. The aims of this study were to evaluate whether socioeconomic status (SES) influenced the pattern of HRU among children with epilepsy, and to determine if neurology visits were associated with emergency department (ED) visits and hospitalizations. Health administrative databases were used to identify HRU among children with epilepsy in Ontario, Canada. The frequency of neurology visits, ED visits, and hospitalizations were assessed for 1 year. SES was measured using dissemination area income and deprivation index. The association between SES and HRU was evaluated, adjusting for age, sex, residence, and comorbidities. Subsequently, we assessed whether neurology visits influenced ED visits and hospitalizations, adjusting for age, sex, residence, comorbidities, and SES. Deprivation index was a more sensitive measure of disparity in HRU than dissemination area income. Status epilepticus-related ED visits and hospitalizations were most expensive but accounted for a small proportion of total costs. Higher deprivation was associated with fewer neurology visits (relative risk [RR] 0.85-0.89), more frequent ED visits (RR 1.08-1.36), and hospitalizations (RR 1.27). Increased neurology visits were associated with more frequent ED visits (RR 1.10) and hospitalizations (RR 1.15). The associations between neurology visits and ED visits as well as hospitalizations varied by deprivation index, in that neurology visits were associated with increased ED visits and hospitalizations and the increase was higher in the most deprived relative to the least deprived (all p < 0.0001). We found disparity in HRU by SES despite the universal health insurance system. More frequent neurology visits were associated with more frequent ED visits and hospitalizations after adjusting for SES, probably related to epilepsy severity. Our study identified an at-risk population for high resource use that may require additional support to reduce ED visits and hospitalizations.

Gambling and problem gambling in Switzerland.

To provide an overview of gambling and problem gambling in Switzerland, including historical aspects, past and current legislation and policies, treatment options and the research base. A literature search was conducted on two databases (PubMed and PsycINFO), and official government and statistical reports selected from the official websites of four sources (Federal Office of Justice; Federal Gambling Board; Federal Office of Statistics; Swiss Lottery and Betting Board). After a history of banning or partial banning, Swiss gambling became regulated at the beginning of the 20th century through successive laws. The current system is characterized by important differences in the law and policies for casinos and lotteries, and contradictions in the regulation of these two areas are still under debate in order to develop new legislation. Gambling is widespread in Switzerland, and the prevalence of problem gambling in this country was comparable to that in other European countries in 2014. Most gambling treatment facilities are integrated into mental health treatment services that have out-patient programmes, and treatment for problem gambling is covered by a universal compulsory Swiss health insurance system. The availability of public funding for gambling research is still limited. Switzerland needs to develop a more coherent regulatory and prevention policy approach to gambling, overcoming conflicts in the current dual system of federal and cantonal regulation. Recent efforts to enhance funding for gambling research are promising, and could lead to a more systematic analysis of the efficacy of prevention and treatment programmes.

Wealth-related versus income-related inequalities in dental care use under universal public coverage: a panel data analysis of the Japanese Study of Aging and Retirement.

BackgroundThere is a substantial body of evidence of income-related inequalities in dental care use, attributed to the fact that dental care is often not covered by public health insurance. Wealth-related inequalities have also been shown to be greater than income-related inequalities. Japan is one of the exceptions, as the the universal pubic health insurance system has covered dental care. The aim of this study was therefore to compare wealth- and income-related inequalities in dental care use among middle-aged and older adults in Japan to infer the mechanisms of wealth-related inequalities in dental care use.MethodsData were derived from the Japanese Study of Aging and Retirement, a survey of community-dwelling middle-aged and older adults living in five municipalities in eastern Japan. Of the participants in the second wave conducted in 2009, we analyzed 2581 residents. Dental care use was measured according to whether the participant had been seen by a dentist or a dental hygienist in the past year. The main explanatory variables were income and wealth (financial assets, real assets and total wealth). The need for dental care was measured using age, the use of dentures and chewing ability. The concentration indices for the distribution of actual and need-standardized dental care use were calculated.ResultsAmong the respondents, 47.9 % had received dental care in the past year. The concentration index of actual dental care use (CI) showed a pro-rich inequality for both income and wealth. The CIs for all three wealth measures were larger than that for income. A broadly comparable pattern was seen after need-standardization (income: 0.020, financial assets: 0.035, real assets: 0.047, total wealth: 0.050).ConclusionsThe results showed that wealth-related inequalities in dental care use were greater than income-related inequalities in Japan, where most dental care is covered by the public health insurance system. This suggests that wealth-related inequalities in dental care use cannot be explained by economic budget constraints alone. Further studies should investigate the mechanisms of wealth-related inequalities in dental care use.

Increased risks of tic disorders in children with epilepsy: A nation-wide population-based case–control study in Taiwan

Both epilepsy and tic disorders may share common mechanisms with the involvement of abnormal cortical-basal ganglion circuit connection and dopaminergic dysfunction. However, the association between epilepsy and tic disorders has never been studied. This study investigated the risks of developing tic disorders among children with epilepsy using databases of a universal health insurance system in Taiwan.The data analyzed in this study were retrieved from the National Health Insurance Research Database in Taiwan. The study cohort included children with epilepsy between 2001 and 2007 (n=2629) and a three-fold age- and gender-matched controls (n=7887). All subjects were followed up for 3 years from the date of cohort entry to identify their admissions due to tic disorders (ICD-9-CM codes 307.2, 307.20–307.23). Cox hazard regression analysis was performed to estimate the effect of epilepsy on the occurrence of tics.The epilepsy cohort had a higher prevalence of tics (1.7% vs. 0.2%), and a 8.70-fold increased risk of developing a tic disorder compared with the controls (adjusted hazard ratio (AHR) 8.70, 95% confidence interval (CI) 4.26–16.37, p<0.001). Male patients were observed to have a higher risk of developing a tic disorder (AHR 1.90, 95% CI=1.04–3.46, p<0.001) compared to female individuals. Patients with multiple antiepileptic drugs treatment also exhibited higher crude OR for developing tic disorders.This nationwide population-based cohort study, for the first time, demonstrated that there is a significantly increased risk for tic disorders among children with epilepsy. We also found males, attention deficit disorder and the use of multiple AEDs to be independent risk factors of tic disorders. Closely evaluating possible tic disorders would be crucial for improving the outcome and life quality in children with epilepsy.

Output congestion leads to compromised care in Peruvian public hospital neonatal units

Peru is moving toward a universal health insurance system, and it is facing important challenges in the provision of public health services. As more citizens gain access to health insurance, the flow of patients exceeds the capacity of public hospitals to provide care with quality. In this study we explore the relationship between technical efficiency and patient safety events in neonatal care units of Peru's public hospitals. We use Data Envelope Analysis (DEA) with output congestion to assess the association between technical efficiency and patient safety events. We study 35 neonatal care units of public hospitals in Peru's Social Security Health System, and identify two undesirable (risk-adjusted) safety outcomes: neonatal mortality and near-miss neonatal mortality. We found that for about half of hospital's neonatal care units, technical efficiency is affected by output congestion. For those hospitals, patient safety is being compromised by receiving too many patients. Our results are consistent with public reports indicating that hospitals in the Peru's Social Security Health System are overcrowded, affecting efficiency and jeopardizing quality of care. We found that most congested hospitals are located in the capital city and suburban areas, and are more likely to be hospitals with the lowest and the highest level of care. Our results call for improvements in the patient referral system and capacity expansion.

The additional costs of catheter-related bloodstream infections in intensive care units

The additional costs of health care-associated infections vary depending on the reimbursement systems of different countries. We estimated the additional costs of central venous catheter-related bloodstream infections (CVC-CRBSI) in Japan, which has a universal health insurance system covering all citizens. We conducted a retrospective matched case-control study. Twenty-two patients with CVC-CRBSI were identified among 2,148 patients treated between October 2011 and May 2014 in the intensive care unit of Tokyo Medical University Hospital (1,015 beds). Twenty-two matched controls were selected on the basis of 5 criteria. The drug and medical material costs and technical fees incurred from the date of catheter insertion until hospital discharge were examined using a fee-for-service system. The additional costs of CVC-CRBSI were calculated as the difference between the costs of cases and controls. The contribution of antimicrobial drugs and the causative microorganism to the additional drug costs were also assessed. The additional costs of CVC-CRBSI were estimated at $57,090 per case. Antimicrobial agents comprised only about 10% of the additional drug costs. The additional costs of Candida infection were almost twice those of CVC-CRBSI caused by other microorganisms. The additional costs of CVC-CRBSI in Japan were estimated at $57,090 per case.