Two-part Regression Research Articles

Growing exports through ISO 9001 quality certification: Firm-level evidence from Chinese agri-food sectors

The adoption of ISO 9001 quality certification for agri-food products may promote China’s relatively weak competitiveness in agri-food exports compared with industrial sectors. To explore this, we construct a panel data set of Chinese listed firms in agri-food sectors from 2000 to 2016 and use staggered Difference-in-Difference (DID) method to investigate the causal relationship between the adoption of ISO 9001 quality certification and agri-food exports. Three main findings are obtained in this study. First, we find that the adoption of ISO 9001 certification is positively associated with exports for agri-food listed firms. Second, we find that ISO 9001 certification promotes firms’ exports by increasing their innovation activities. Third, the export effects are greater for food (vs. non-food) manufacturing firms and non-SOEs (vs. SOEs). Identification problems are addressed by utilizing randomly generated certification status, two-part fractional regression model, controlling and excluding other quality certifications, etc. This study provides important implications for China’s food and agricultural development strategy, which emphasises the transition from quantity expansion to quality enhancement.

Employment status, productivity loss, and associated factors among people with multiple sclerosis

Background: Multiple Sclerosis (MS) affects people in their most productive years of life. Consequently, MS can substantially affect employment and work-related outcomes. Objectives: This study characterizes productivity loss and employment status of people with multiple sclerosis (pwMS) and investigates associated factors. Methods: We used baseline data collected as part of the Canadian Prospective Cohort Study to Understand Progression in Multiple Sclerosis (CanProCo). Using the Valuation of Lost Productivity questionnaire, we measured MS-related paid work productivity loss for those employed, productivity losses incurred by those unemployed (i.e. lost employment time), and unpaid work productivity losses for all. A set of sociodemographic, disease, and performance-related factors were investigated using a two-part regression model for productivity loss and a multinomial logistic model for employment status. Results: From the cohort of 888 pwMS enrolled at baseline (mostly showing mild to moderate disability), 75% were employed, and of those unemployed, 69% attributed their unemployment to health-related issues. Total productivity loss over a 3-month period averaged 64 and 395 hours for those employed and unemployed, respectively. Some factors that affected productivity loss and employment status included use of disease-modifying therapies, fatigue, and performance indicators such as cognitive processing speed. Conclusion: Productivity loss experienced by employed and unemployed pwMS is substantial. Targeting the identified modifiable factors is likely to improve work productivity and permanence of MS patients in the workforce.

Psycho-Social Correlates of Cyberbullying among Polish Adolescents.

Cyberbullying has recently attracted attention due to its increasing prevalence and serious consequences for both victims and perpetrators. The objective of this population-based study was to examine the determinants of a person becoming a perpetrator of cyberbullying, including personal resources (emotional self-regulation, self-esteem, internal locus of control, optimism), social skills (prosocial behavior, assertiveness, cognitive empathy, cooperation), peer relationships (peer support, threats from peers, peer rejection, dislike of peers), and problematic Internet use (excessive Internet use, impulsive reactions to Internet deprivation). Participants (N = 541) were students at elementary schools (age 14-15) in Ostroleka, a city in central-eastern Poland. Two-part regression was used to explore protective/risk factors of the likelihood of an individual using cyberviolence (dichotomous part: involvement in violence) and how often it is used (continuous part: frequency of cyberbullying). The results showed that the emotional component is crucial to cyberbullying, as indicated by the importance of emotional self-control, which reduces the frequency of cyberbullying. Other important factors are assertiveness, impulsive response to limited Internet access (which increases the likelihood of engaging in cyberbullying) and fear of peers (which reduces its frequency). In turn, the importance of pro-sociality (which inhibits engagement) and peer support (which promotes engagement) points to the second important component of cyberbullying-that is, group mechanisms. At the same time, the results indicate that while the importance of Internet addiction as a risk factor for cyberbullying should not be underestimated, the amount of time spent online cannot be seen as the source of the problem. The study leads to the conclusion that effective interventions targeting cyberbullying should focus on the development of more adaptive styles of coping with emotions.

The systemic immune-inflammation index was non-linear associated with all-cause mortality in individuals with nonalcoholic fatty liver disease

Objective Systemic immune-inflammation index (SII), a novel inflammatory indicator based on platelets, neutrophils and lymphocytes, has been shown to be associated with prognostic value in several solid tumors. However, its prognostic value in nonalcoholic fatty liver disease (NAFLD) has not been reported yet. Therefore, the present study aimed to investigate the prognostic value of SII in individuals with NAFLD. Methods Data was collected from the 2005 to 2014 National Health and Nutrition Examination Survey (NHANES, https://www.cdc.gov/nchs/nhanes/index.htm), and vital status was derived from the National Death Index (NDI) up to 31 December 2015. NAFLD was diagnosed based on Hepatic Steatosis Index (HSI). Multivariate Cox regression and Kaplan–Meier survival curves were performed to measure the hazard ratios (HRs) and 95% confidence interval (CI). Our study investigated the relationship between SII and all-cause mortality by using two-part linear regression models with penalized splines, as well as Cox models with penalized splines. Results A total of 10,787 NAFLD participants (44.14% men) aged ≥20 years old were enrolled. There were 776 deaths from all causes after a mean follow-up period of 5.6 years. According to the full adjusted Cox regression analysis, the low log2-SII group (quartile 1) and the highest log2-SII group (quartile 4) were significantly associated with increased mortality from all causes (aHR =1.86; 95% CI: 1.47–2.37; p < 0.0001). After controlling for confounders, an increase in log2-SII was associated with an increased all-cause mortality risk of 41% for every unit raised (aHR = 1.41; 95% CI: 1.26–1.57; p < 0.0001). After adjusting for multiple potential confounders, the association between log2-SII and all-cause mortality was nonlinear, and the threshold value was 8.8. There was no association between an increase of one unit in log2-SII and all-cause mortality below the threshold (aHR = 0.90, 95% CI: 0.71–1.15, p = 0.419). However, a higher log2-SII was associated with a higher risk of death from any cause when it exceeded the threshold (aHR = 1. 73, 95% CI: 1.49–2.02, p < 0.001). Conclusion Based on a study of US NAFLD patients, it was found that the baseline log2-SII is associated with all-cause mortality. Elevated SII is associated with poor survival among NAFLD patients. KEY MESSAGES Using a large nationally representative survey of individuals among US adults, the study demonstrated that log2-SII was J-shaped and associated with all-cause death among individuals with NAFLD. Spline analyses demonstrated that the association between log2-SII and all-cause mortality was non-linear after adjusting for multiple potential confounders, and the threshold value was 8.8. Higher log2-SII associated with poor survival in NAFLD.

Desire and cravingmeasured using behavioral ratings and brain network topology differ significantly among moderate to heavy alcohol consumers.

"Craving" is a central concept in alcohol research, but the semantic interpretation of craving as a concept varies. Multiple studies that have investigated differences in operational definitions of craving have demonstrated a lack of agreement among them. This study investigated whether moderate to heavy drinkers would rate craving and "desire" for alcohol similarly and explored potential neurobiological differences underpinning feelings of craving and desire. Thirty-nine individuals who consumed an average of at least 7 drinks/week for females and 14 drinks/week for males were studied across 3-day periods of their typical alcohol consumption and imposed abstinence. Ratings of desire and craving for alcohol were collected approximately every three hours during waking periods across the two experimental periods (n = 35, 17 males). At the end of each period, participants underwent functional MRI scanning during neutral and alcohol image viewing (n = 39, 17 males) followed by ratings of desire and craving for alcohol (n = 32, 16 males). Survey responses were analyzed using 2-level nested hierarchical modeling, image ratings were compared using a hierarchical mixed-effects regression, and brain networks constructed from fMRI data were assessed with a two-part mixed-effect regression (α = 0.05 in all analyses). Ratings of desire and craving differed significantly from one another in the survey data and in the ratings collected during image viewing. The strength of the desire experience was higher overall than craving, but the fluctuations over time were similar. Results for desire and craving differed on brain network attributes associated with distributed processing and those regional specific within the default mode network. Significant associations were found between ratings of desire and connection strength and between ratings of craving and connection probability. These results demonstrate that the difference between ratings of craving for alcohol and desire for alcohol is not trivial. The different ratings and their association with alcohol consumption or abstinence experiences may have significant biological and clinical implications.

Re-analysis of ventilator-free days (VFD) in acute respiratory distress syndrome (ARDS) studies

BackgroundOver recent decades, improvements in healthcare have reduced mortality and morbidity rates in many conditions. This has resulted, in part, from the identification of effective interventions in randomised trials, and in conducting such trials, a composite outcome measure (COM) with multiple components will increase event rates, which allows study completion with a smaller sample size. In critical care research, the COM “ventilator-free days” (VFD) combines mortality and duration of mechanical ventilation (MV) into a single continuous measure, which can be analysed in a variety of ways. This study investigates the usefulness of Poisson and two-part Poisson models compared to t-distribution for the analysis of VFD.MethodsData from four studies (ALbuterol for the Treatment of ALI (ALTA), Early vs. Delayed Enteral Nutrition (EDEN), Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute Lung Injury (ALI) to reduce pulmonary dysfunction (HARP-2), Statins for Acutely Injured Lungs from Sepsis (SAILS)) were used for analysis, with the VFD results summarised using mean, standard deviation (SD), median, interquartile range (25th and 75th percentiles) and minimum and maximum values. The statistical analyses that are compared used the t-test, Poisson, zero-inflated Poisson (ZIP) and two-part Logit-Poisson hurdle models. The analyses were exploratory in nature, and the significance level for differences in the estimates was set to 0.05.ResultsIn HARP-2, which compared simvastatin and placebo, the mean (SD) VFD for all patients was 12.0 (10.2), but this mean value did not represent the data distribution as it falls in a zone between two peaks, with the lowest frequency of occurrence. The mean (SD) VFD after excluding patients who died before day 28 and patients who did not achieve unassisted breathing were 15.9 (8.7) and 18.2 (6.6), respectively. The mean difference (95% CI) between the two groups was 1.1 (95% CI: 0.7 to 2.8; p = 0.20) based on an independent t-test. However, when the two-part hurdle model was used, the simvastatin arm had a significantly higher number of non-zero values compared to the placebo group, which indicated that more patients were alive and free of mechanical ventilation in the simvastatin group. Similarly, in ALTA, this model found that significantly more patients were alive and free of MV in the control group. In EDEN and SAILS, there was no significant difference between the control and intervention groups.ConclusionOur analyses show that the t-test and Poisson model are not appropriate for bi-modal data (such as VFD) where there is a large number of zero events. The two-part hurdle model was the most promising approach. There is a need for future research to investigate other analysis techniques, such as two-part quantile regression and to determine the impact on sample size requirements for comparative effectiveness trials.

The use of hotels/motels to address homelessness among veterans during the COVID-19 pandemic: lessons from the supportive services for veteran families program

ABSTRACT The objective of this exploratory mixed methods study is to assess the use of hotels/motels among Veterans experiencing housing instability during the COVID-19 pandemic to inform policy and programmatic responses to homelessness during such emergencies. We analyzed qualitative interviews conducted with national-level homeless services leadership and Supportive Services for Veteran Families (SSVF) program providers during October 2020–May 2021 and quantitative data for Veterans who enrolled in SSVF during March–August 2020. A multivariable two-part regression model identified factors associated with receiving hotel/motel-specific financial assistance and associated costs. Qualitative interviews indicated that the use of hotels/motels during COVID-19 offered protection from a contagious disease and a novel mechanism to accommodate high-need Veterans who may have previously been unsheltered or resistant to services. Quantitative analyses found that Veteran households’ stays in hotels/motels increased sharply following the onset of the COVID-19 pandemic; this assistance tended to flow to a more vulnerable group (i.e. older, no income, and extensive histories of homelessness). COVID-19 and homelessness are ongoing public health concerns; strategies such as the use of hotels/motels to reduce homelessness and ensure safe options for isolation and quarantine are needed to prevent poor health outcomes for a vulnerable population.

Investigating the Impact of E-Cigarette Price and Tax on E-Cigarette Use Behavior

Although the relationship between tax and price and youth cigarette use is well established, little is known about these associations and youth e-cigarette use. This research examines U.S. youth sensitivity to changes in e-cigarette prices and tax using standardized measures of e-cigarette taxes and prices. This analysis uses national data on past 30-day use and the number of days using e-cigarettes (i.e., the intensity of use) from the repeat cross-sectional 2015-2019 Youth Risk Behavior Survey, in combination with inflation-adjusted standardized e-cigarette price and tax data to understand whether changes in e-cigarette price and tax were associated with changes in e-cigarette use. Two-part demand regression models controlling for demographics and e-cigarette restriction policies were conducted to calculate price and tax elasticities of demand, in addition to $0.50 and $1.00 price and tax increase simulations. Increased e-cigarette prices and taxes were associated with significant reductions in past 30-day use. Prices were also significantly associated with decreases in the intensity of use. A $0.50 and $1.00 tax increase leads to a 6.3% and 12.2% decrease in past 30-day use and a 4.7% and 9.3% decrease in intensity, respectively. A $0.50 and $1.00 price increase leads to a 4.1% and 8.2% decrease in past 30-day use and a 4.2% and 8.3% decrease in intensity, respectively. Higher prices and taxes reduce youth current e-cigarette use and days using e-cigarettes. Policies increasing e-cigarette prices, such as excise taxes, can reduce youth current e-cigarette use and days using e-cigarettes.

Caregivers’ willingness to pay for digital support services: Comparative survey

BackgroundConsidering the substantial information needs experienced by informal caregivers, the increased availability of digital support services for caregivers as well as the potential they offer, further understanding of caregivers’ willingness to pay for digital support services is needed. ObjectiveThe aim of this study is to identify associations between informal caregiver's characteristics and their willingness to pay for digital support services in two countries: Italy and Sweden. MethodsA sample of 378 respondents participated in a cross-sectional survey. Respondents were recruited by the Italian National Institute of Health and Science on Ageing and the Swedish Family Care Competence Centre. A two-part regression model was used. In the first part, logistic regression analysis was applied to investigate the association between willingness to pay and sets of independent variables (caregiver’s demographics, caregiver’s socioeconomic resources and caregiving context). In the second part, a generalized linear model (log-link and gamma distribution) was applied to determine the adjusted mean willingness to pay. ResultsMore than half of the participants from both countries of our study were willing to pay out of pocket for digital support services. A recommendation by a healthcare professional was the top factor that may motivate caregivers’ willingness to pay an additional amount for a paid version of a digital support service. In both countries, the majority of the respondents believe that the government should allocate more funds for digital support services and for improving digital infrastructures. Caregiver' s gender, care recipient relationship to the caregiver, care duration, the total household income and the amount spent per month on professional caregiving services are all associated with willingness to pay. For every additional 10 Euro increase in the amount spent per month on professional caregiving services, the odds of willingness to pay an additional Euro for a digital support service increased by 0.60 % in the Italian sample (p= 0.002, 95% CI: 1.002, 1.009) and 0.31% in the Swedish sample (p=0.015, 95% CI: 1.006, 1.057). ConclusionsFactors such as demographics, socioeconomic resources and the caregiving context may play a role in caregivers’ willingness to pay for digital support services. The digital and social divide may negatively affect caregivers’ willingness to pay for digital support services. Policy makers and insurance providers should consider innovative policies to fund digital support services that have been shown to be effective at supporting and improving caregivers’ health outcomes via subsidies or other incentives. Future research that evaluates the cost-effectiveness of digital support services is needed in a context of a growing number of informal caregivers and ever scarcer resources.

Association between multimorbidity patterns and healthcare costs among middle-aged and older adults in China

BackgroundThis study investigated multimorbidity patterns among middle-aged and older Chinese people and whether healthcare costs varied among different multimorbidity patterns. MethodsData were from the 2011–2018 waves of the China Health and Retirement Longitudinal Study (CHARLS). We included 20,855 unique observations with information coming from their last wave of interviews and aged at least 45 years or older. Latent class analysis (LCA) was performed to classify individuals with common multimorbidity clusters based on 14 self-reported chronic diseases. Healthcare costs were from participants' self-reports and categorized into outpatient, inpatient, and self-treatment. Two-part regression was performed to analyze the association of multimorbidity patterns with healthcare costs. ResultsFive multimorbidity clusters were identified: minimal disease, arthritis, cardiovascular disease (CVD), lung/asthma, and multisystem morbidity. The multisystem morbidity group had the highest use in all three types of healthcare and the highest self-treatment cost. Compared with the minimal disease group, the other four groups did not show significant differences in outpatient costs. Relative to the minimal disease group, the lung/asthma group reported lower inpatient costs. ConclusionHealthcare use and costs varied across multimorbidity patterns among middle-aged and older Chinese people. Implementing an integrated care plan for multimorbidity is suggested to improve the cost-effectiveness of healthcare provision and reduce the financial burden of the healthcare system. Reimbursement policy design should also take multimorbidity patterns into account.

Mitigating donor interests in the case of COVID-19 vaccine: the implication of COVAX and DAC membership

IntroductionThe COVID-19 vaccine donation process allegedly prioritised national interests over humanitarian needs. We thus examined how donors allocated vaccines by recipient country needs versus donor national interests and how such...

Obtaining EQ-5D-3L utility index from the health status scale of traditional Chinese medicine (TCM-HSS) based on a mapping study

BackgroundAlmost all traditional Chinese medicine (TCM) quality of life measures are non-preference-based measures (non-PBMs), which do not provide utilities for cost-utility analysis in pharmacoeconomic evaluation. Whereas the mapping has become a new instrument to obtain utilities, which builds a bridge between non-PBMs and PBMs.PurposeTo develop mapping algorithms from the health status scale of traditional Chinese medicine (TCM-HSS) onto the three-level EuroQol five-dimensional questionnaire (EQ-5D-3L).MethodsThe cross-sectional data were collected by questionnaire survey from a tertiary hospital visit population and community residents in China, and randomly divided into training and validation set by 2:1. Based on the training set, direct and indirect mapping methods (7 regression methods and 4 model specifications) were conducted to establish alternative models, which were comprehensively evaluated based on the validation set by mean absolute error, root mean square error, and Spearman correlation coefficient between predicted and observed values. Based on the whole sample, the preferred mapping algorithm was developed.ResultsA total of 639 samples were included, with an average age of 45.24 years and 61.66% of respondents were female. The mean EQ-5D-3L index was 0.9225 [SD = 0.1458], and the mean TCM-HSS index was 3.4144 [SD = 3.1154]. The final mapping algorithm was a two-part regression model including the TCM-HSS subscales, interaction terms, and demographic covariates (age and gender). The prediction performance was good. The mean error was 0.0003, the mean absolute error was 0.0566, the root mean square error was 0.1039, and 83.10% of the prediction errors were within 0.1; the Spearman correlation coefficient between predicted and observed EQ-5D-3L values was 0.6479.ConclusionIt is the first study to develop a mapping algorithm between the TCM-HSS and EQ-5D-3L, which demonstrates excellent prediction accuracy and estimates utility value for economic evaluation from TCM quality of life measures.

ANALYSIS OF CIGARETTE DEMAND AMONG POOR HOUSEHOLDS IN INDONESIA: AN ISLAMIC ECONOMIC APPROACH

Increasing Indonesia’s health and economic burdens generated by smoking habit require immediate stakeholder responses to reduce cigarette consumption. This study aims to examine and compare the changes in smoking behavior (i.e., the smoking status and the number of cigarettes consumed monthly) among zakat recipients (mustahik) and zakat payers (muzaki) caused by cigarette prices and income changes. Using a dataset from SUSENAS 2018 and conducted under kifayah approach (a poverty line approach in Islamic economics that will allow the observers to differentiate between muzaki and mustahik), this study employed two-part regression models. Results showed that an increasing income escalated cigarette consumption (ß = 0.761; 95% CI = 0.761, 0.762), but increasing cigarette prices reduced cigarette consumption (ß = -0.682; 95% CI = -0.683, -0.682). Mustahik household is more responsive toward changes as compared to muzaki ones. Mustahik household sensitivity towards cigarettes has important implications for zakat institutions in ensuring and monitoring zakat funds utilization among mustahik.

Out-of-pocket payments and loss of income among long-term breast cancer survivors in Germany: a multi-regional population-based study

PurposeThis study aims to examine the magnitude of out of pocket (OOP) payments and income loss, as well as to identify socioeconomic and clinical factors among long-term breast cancer (BC) survivors in Germany.MethodsWe examine data from 2654 long-term BC survivors in Germany that participated in the “CAncEr Survivorship – A multi-Regional population-based study” (CAESAR) and who were at least 5 years post diagnosis. BC-related OOP payments and income loss both within the 12 months prior to the survey were analyzed. Two-part regression models were performed to identify socioeconomic and clinical factors.ResultsOOP payments were incurred by 51.9% of survivors with a total mean spending of 566 euros. Income loss was present among 9.6% of survivors and averaged 5463 euros among those reporting such. Socioeconomic and clinical factors associated with higher OOP payments (p ≤ 0.05) included age at time of diagnosis (65–79 years), education (10–11 years), (early) retirement, stage of diagnosis (stage III), time from diagnosis (more than 10 years), comorbidities (at least 1), and the use of rehabilitation services. Regarding income loss, age at time of diagnosis (50–59 years), (early) retirement, stage of diagnosis (stage II), time from diagnosis (5–7 years), comorbidities (at least 1), and receiving chemotherapy treatment were associated with higher losses.ConclusionsFor some survivors in Germany, financial burden can be considerably high despite comprehensive healthcare and support from social security.Implications for Cancer SurvivorsOOP payments related to domestic help and nursing staff as well as to outpatient care are most frequent.

Healthcare costs associated with comorbid cardiovascular and renal conditions among persons with diabetes, 2008–2019

BackgroundThere is paucity of data examining healthcare costs among persons with comorbid diabetes and cardiorenal conditions.ObjectiveTo elucidate the longitudinal trends and quantify the incremental healthcare costs associated with the following cardiorenal conditions: atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and kidney disease, among persons with diabetes.MethodsMedical Expenditure Panel Survey data (2008–2019) were used to identify adults with diabetes and comorbid cardiorenal conditions. Overall, medical and pharmaceutical costs were ascertained (in 2019 US dollars). Analyses were adjusted for 14 variables using a two-part regression model.ResultsAmong 32,519 adults with diabetes, the mean (standard error [SE]) annual healthcare costs were $13,829 ($213), with medical and prescription components contributing $9301 ($172) and $4528 ($98), respectively. Overall healthcare costs rose by 26.8% from $12,791 (2008–2009) to $16,215 (2018–2019) over the study period, driven by 42.5% and 20.3% increase in pharmaceutical and medical spending, respectively. Similar trends were observed for subgroup of persons with cardiorenal conditions. Compared to their counterparts without cardiorenal conditions and prior to adjustment, persons with ASCVD, HF and kidney disease incurred healthcare costs that were approximately 2.2, 3.3, and 2.7 times greater. After adjustment, comorbid ASCVD, HF and kidney disease were associated with annual excess spending of $8651 (95% CI $7729–$9573), $9373 (95% CI $9010–$9736), and $9995 (95% CI $8781–$11,209), respectively.ConclusionsStudy results are generalizable to non-institutionalized US persons. Healthcare costs associated with the management of diabetes are high—especially among those with comorbid cardiorenal conditions, and have risen in recent years.

Continuity of Care and Healthcare Costs among Patients with Chronic Disease: Evidence from Primary Care Settings in China.

Background:Though critical to primary care, continuity of care has rarely been examined in China. This study aims to assess the relationship between continuity of care and healthcare costs among patients with chronic diseases within primary care settings in China.Methods:In this cross-sectional study, we used a social health insurance claims dataset of 1406 patients with hypertension and/or diabetes in Yuhuan City, Zhejiang Province collected in 2017–2019. We measured continuity of care using the Bice-Boxerman Continuity of Care (COC) Index, Herfindahl Index (HI), Sequential Continuity of Care (SECON) Index, Usual Provider of Care (UPC), and a binary variable indicating whether a patient’s UPC was a primary care provider. We examined the associations between continuity of care and healthcare costs in the same period and the subsequent year, using ordinary least squares regression for the outpatient costs and two-part regression for the inpatient costs. Based on the regression coefficients, we predicted costs saved if each continuity measure was set to 1 from the status quo.Results:When optimum continuity were to be achieved, 7.12–27.29% of total outpatient costs and 55.38–73.35% of total inpatient costs could be saved compared to the status quo during the two-year study period. If optimum continuity were to be achieved in the first year, 7.47%–21.78% of total outpatient costs and 8.84–40.22% of total inpatient costs could be saved in the second-year.Conclusions:Care continuity indicators were consistently associated with reduced outpatient costs and hospitalization risks. Future health reform in China should further enhance continuity of care in primary care.

Changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes in Beijing, China

BackgroundChina expanded health coverage to residents in informal economic sectors by the rural new cooperative medical scheme (NCMS) for rural population and urban resident basic medical insurance scheme (URBMI) for non-working urban residents. Fragmentation of resident social health insurance schemes exacerbated the health inequity and China started the integration of urban and rural resident medical insurance schemes since 2016. Beijing finished the insurance integration in 2017 and has been implementing a unified urban and rural resident basic medical insurance scheme (URRBMI) since the beginning of 2018. This study aims to examine changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes.MethodsWe used household survey data from Beijing Health Services Survey in 2013 and 2018. Respondents who were 15 or older and covered by URBMI, NCMS or URRBMI were included in this study. Our study finally included 8,554 individuals in 2013 and 6,973 individuals in 2018, about 70% of which were rural residents in each year. Descriptive analysis was used to compare the healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure between different groups. A series of two-part regression models were used to analyze the changes of healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure.ResultsFrom 2013 to 2018, urban–rural disparity in outpatient care utilization seemed widened because urban residents’ utilization of outpatient care increased 131% while rural residents’ utilization only increased 72%; both rural and urban residents’ spending on outpatient care increased about 50%. Utilization of inpatient care changed little and poor residents still used significantly less inpatient care compared with the rich residents. Poor residents still suffered heavily catastrophic health expenditures.ConclusionFrom 2013 to 2018, residents’ utilization of healthcare, especially outpatient care, increased in Beijing. Health insurance reforms increased residents’ utilization of healthcare but failed to reduce their healthcare financial burden, especially for poor people. Our study advocates more pro-poor insurance policies and more efforts on the efficiency of health system.

Batch effects removal for microbiome data via conditional quantile regression

Batch effects in microbiome data arise from differential processing of specimens and can lead to spurious findings and obscure true signals. Strategies designed for genomic data to mitigate batch effects usually fail to address the zero-inflated and over-dispersed microbiome data. Most strategies tailored for microbiome data are restricted to association testing or specialized study designs, failing to allow other analytic goals or general designs. Here, we develop the Conditional Quantile Regression (ConQuR) approach to remove microbiome batch effects using a two-part quantile regression model. ConQuR is a comprehensive method that accommodates the complex distributions of microbial read counts by non-parametric modeling, and it generates batch-removed zero-inflated read counts that can be used in and benefit usual subsequent analyses. We apply ConQuR to simulated and real microbiome datasets and demonstrate its advantages in removing batch effects while preserving the signals of interest.

Healthcare cost expenditures associated to frailty and sarcopenia

ObjectivesFrailty and sarcopenia have been related with adverse events, including hospitalization. However, its combined effect with hospitalization-related outcomes, including costs, has not been previously investigated. Our purpose was to explore how frailty, sarcopenia and its interaction could impact on healthcare expenditures.Methods1358 community-dwelling older adults from the Toledo Study of Healthy Ageing (TSHA) were included. Sarcopenia was measured using the Foundation for the National Institutes of Health criteria fitted to our cohort. Frailty was defined according to Frailty Trait Scale 5 (FTS5) and the Frailty Index fitted to the cut-off points of TSHA population. Hospitalization costs were taken from hospital records and costs were attributed according to Diagnostic-Related Groups, using as the cost base year 2015. Two-part regression models were used to analyze the relationship between frailty and sarcopenia and hospital admission, number of hospitalizations, length of stay and hospitalization costs.ResultsSarcopenia was associated only with the probability of being admitted to hospital. Frailty was also associated with higher hospital use, regardless of the frailty tool used, but in addition increased hospital admission costs at follow-up by 23.72% per year and by 19.73% in the full model compared with non-frail individuals. The presence of sarcopenia did not increase the costs of frailty but, by opposite, frailty significantly increased the costs in people with sarcopenia, reaching by 46–56%/patient/year at follow-up. Older adults with frailty and sarcopenia had a higher risk of hospitalization, disregarding the tool used to assess frailty, and higher hospitalization costs (FTS5) in the full model, at the cross-sectional and at the follow-up level.ConclusionsFrailty is associated with increased hospitalization costs and accounts for the potential effects of sarcopenia.

Comparable estimates of out-of-pocket payment on hospitalisation and outpatient services in India, 2004-18

BackgroundComparable estimates of household health spending and out-of-pocket (OOP) payment on health care in India are a daunting task. Often these estimates are provided for specific services such as maternal care, type of disease, hospitalisation, outpatient care, and an episode of hospitalisation. This paper presents comprehensive and comparable estimates of health spending and out-of-pocket payment on hospitalisation and outpatient care in India over the past 15 years. MethodsA total of 73,868 households in 2004, 65,932 households in 2014, and 113,823 households in 2018 surveyed in the 60th, 71st, and 75th rounds of NSSO health surveys, respectively, were used in the analysis. Descriptive statistics, concentration index, two-part regression, and logistic regression were used in the analysis. ResultsThe utilisation of hospitalisation services has increased over time. During 2004–18, the mean adjusted OOP payment on hospitalisation at 2018 prices was 308 US$ in 2004,353 US$ in 2014 and 332 US$ by 2018. Reimbursement on medical spending was only 2%, 7% and 11% of medical spending in 2004, 2014 and 2018 respectively. Both medical spending and OOP on inpatient and outpatient care showed large inter-state variations. The OOP payment on inpatient and outpatient care was significantly higher among richer households in urban households, households without health insurance, households having an elderly member and female-headed households. ConclusionThough the households OOP for outpatient and inpatient, in recent years had declined, OOP as a share of medical expenditure remained high over time and majority of the households are not yet covered under any health protection scheme in India.