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Objective: To assess the impact of geographic access to surgical center on readmission risk and burden in children after congenital heart surgery., Study Design: Children <6 years old at discharge after congenital heart surgery (Risk Adjustment for Congenital Heart Surgery-1 score 2-6) were identified using Pediatric Health Information System data (46 hospitals, 2004-2015). Residential distance from the surgery center, calculated using ZIP code centroids, was categorized as <15, 15-29, 30-59, 60-119, and ≥120 miles. Rurality was defined using rural-urban commuting area codes. Geographic risk factors for unplanned readmissions to the surgical center and associated burden (total hospital length of stay [LOS], costs, and complications) were analyzed using multivariable regression., Results: Among 59 696 eligible children, 19 355 (32%) had ≥1 unplanned readmission. The median LOS was 9 days (IQR 22) across the entire cohort. In those readmitted, median total costs were $31 559 (IQR $90 176). Distance from the center was inversely related but rurality was positively related to readmission risk. Among those readmitted, increased distance was associated with longer LOS, more complications, and greater costs. Compared with urban patients, highly rural patients were more likely to have an unplanned readmission but had fewer average readmission days., Conclusions: Geographic measures of access differentially affect readmission to the surgery center. Increased distance from the center was associated with fewer unplanned readmissions but more complications. Among those readmitted, the most isolated patients had the greatest readmission costs. Understanding the contribution of geographic access will aid in developing strategies to improve care delivery to this population., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This article proposes a combined mixed methods approach to categorising GP practices. It looks not only at location but also at differences in the nature of the work that rural GPs perform. A data analysis was conducted of the largest health insurance company in the Czech Republic (5.9 million patients, 60% of the population, 100% coverage within the Czech Republic). We performed two data analyses, one for 2014-2015 and one for 2016, and divided GP practices into urban, intermediate, and rural groups (taking into account the OECD methodology). We compared groups in terms of the total annual cost in CZK per adult registered insurance holders. The total volume of data indicated the financial costs of €1.52 billion and €2.57 billion respectively. Both analysis showed differences between all groups of practises which confirmed the assumption that the work of the GP is influenced by regionality. A multidisciplinary hospital is the main factor that fundamentally affects the way a GP's work in that area. The proposed principle of categorising general practices combines geographical and cost characteristics. This requires knowledge of the cost data of healthcare payer and on the basic demographic knowledge of the area. We suggest this principe may be transferrable and particularly suitable for categorising general practice.

Little is known about how health insurance policies, particularly in developing countries, influence breast cancer prognosis. Here, we examined the association between individual health insurance and breast cancer-specific mortality in China. We included 7436 women diagnosed with invasive breast cancer between 2009 and 2016, at West China Hospital, Sichuan University. The health insurance plan of patient was classified as either urban or rural schemes and was also categorized as reimbursement rate (ie, the covered/total charge) below or above the median. Breast cancer-specific mortality was the primary outcome. Using Cox proportional hazards models, we calculated hazard ratios (HRs) for cancer-specific mortality, contrasting rates among patients with a rural insurance scheme or low reimbursement rate to that of those with an urban insurance scheme or high reimbursement rate, respectively. During a median follow-up of 3.1 years, we identified 326 deaths due to breast cancer. Compared to patients covered by urban insurance schemes, patients covered by rural insurance schemes had a 29% increased cancer-specific mortality (95% CI 0%-65%) after adjusting for demographics, tumor characteristics and treatment modes. Reimbursement rate below the median was associated with a 42% increased rate of cancer-specific mortality (95% CI 11%-82%). Every 10% increase in the reimbursement rate is associated with a 7% (95% CI 2%-12%) reduction in cancer-specific mortality risk, particularly in patients covered by rural insurance schemes (26%, 95% CI 9%-39%). Our findings suggest that underinsured patients face a higher risk of breast cancer-specific mortality in developing countries., (© 2020 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Background: Worldwide, peripheral arterial disease (PAD) is a disease with high morbidity, affecting more than 200 million people. Our objective was to analyze the surgical treatment for PAD performed in the Unified Health System of the city of São Paulo during the last 11 years based on publicly available data., Methods: The study was conducted with data analysis available on the TabNet platform, belonging to the DATASUS. Public data (government health system) from procedures performed in São Paulo between 2008 and 2018 were extracted. Sex, age, municipality of residence, operative technique, number of surgeries (total and per hospital), mortality during hospitalization, mean length of stay in the intensive care unit and amount paid by the government system were analyzed., Results: A total of 10,951 procedures were analyzed (either for claudicants or critical ischemia-proportion unknown); 55.4% of the procedures were performed on males, and in 50.60%, the patient was older than 65 years. Approximately two-thirds of the patients undergoing these procedures had residential addresses in São Paulo. There were 363 in-hospital deaths (mortality of 3.31%). The hospital with the highest number of surgeries (n = 2,777) had lower in-hospital mortality (1.51%) than the other hospitals. A total of $20,655,272.70 was paid for all revascularizations., Conclusions: Revascularization for PAD treatment has cost the government system more than $20 million over 11 years. Endovascular surgeries were performed more often than open surgeries and resulted in shorter hospital stays and lower perioperative mortality rates., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Maternal and newborn mortality rates are high in peri-urban areas in cities in Kenya, yet little is known about what drives women's decisions on where to deliver. This study aimed at understanding women's preferences on place of childbirth and how sociodemographic factors shape these preferences., Methods: This study used a Discrete Choice Experiment (DCE) to quantify the relative importance of attributes on women's choice of place of childbirth within a peri-urban setting in Nairobi, Kenya. Participants were women aged 18-49 years, who had delivered at six health facilities. The DCE consisted of six attributes: cleanliness, availability of medical equipment and drug supplies, attitude of healthcare worker, cost of delivery services, the quality of clinical services, distance and an opt-out alternative. Each woman received eight questions. A conditional logit model established the relative strength of preferences. A mixed logit model was used to assess how women's preferences for selected attributes changed based on their sociodemographic characteristics., Results: 411 women participated in the Discrete Choice Experiment, a response rate of 97.6% and completed 20,080 choice tasks. Health facility cleanliness was found to have the strongest association with choice of health facility (β = 1.488 p<0.001) followed respectively by medical equipment and supplies availability (β = 1.435 p<0.001). The opt-out alternative (β = 1.424 p<0.001) came third. The attitude of the health care workers (β = 1.347, p<0.001), quality of clinical services (β = 0.385, p<0.001), distance (β = 0.339, p<0.001) and cost (β = 0.0002 p<0.001) were ranked 4th to 7th respectively. Women who were younger and were the main income earners having a stronger preference for clean health facilities. Older married women had stronger preference for availability of medical equipment and kind healthcare workers., Conclusions: Women preferred both technical and process indicators of quality of care. DCE's can lead to the development of person-centered strategies that take into account the preferences of women to improve maternal and newborn health outcomes., Competing Interests: The authors have declared that no competing interests exist.

Background: In the United States, there are nearly 1,400 Health Resources and Services Administration-funded health centers (HCs) serving low-income and underserved populations and more than 600 of these HCs are located in rural areas. Disparities in quality of medical care in urban vs. rural areas exist but data on such differences between urban and rural HCs is limited in the literature. We examined whether urban and rural HCs differed in their performance on clinical quality measures before and after controlling for patient, organizational, and contextual characteristics., Methods and Findings: We used the 2017 Uniform Data System to examine performance on clinical quality measures between urban and rural HCs (n = 1,373). We used generalized linear regression models with the logit link function and binomial distribution, controlling for confounding factors. After adjusting for potential confounders, we found on par performance between urban and rural HCs in all but one clinical quality measure. Rural HCs had lower rates of linking patients newly diagnosed with HIV to care (74% [95% CI: 69%, 80%] vs. 83% [95% CI: 80%, 86%]). We identified control variables that systematically accounted for eliminating urban vs. rural differences in performance on clinical quality measures. We also found that both urban and rural HCs had some clinical quality performance measures that were lower than available national benchmarks. Main limitations included potential discrepancy of urban or rural designation across all HC sites within a HC organization., Conclusions: Findings highlight HCs' contributions in addressing rural disparities in quality of care and identify opportunities for improvement. Performance in both rural and urban HCs may be improved by supporting programs that increase the availability of providers, training, and provision of technical resources., Competing Interests: The authors have read the journal’s policy, and the authors of this manuscript have the following competing interests to declare: HH and AS are employees of the U.S. Government, U.S. Department of Health and Human Services, which funded this study. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Objective: To examine the association of health insurances on catastrophic health expenditure (CHE), and compares that among different health insurances in the last two decades in China., Methods: The systematic review was conducted according to the Cochrane Handbook and reported according to PRISMA. We searched English and Chinese literature databases including PubMed, EM base, web of science, CNKI, Wan fang, VIP and CBM (Sino Med) for empirical studies on the association between health insurance and CHE from January 2000 to June 2020. Study selection, data extraction and quality appraisal were conducted by two reviewers. The secular trend of CHE rate and comparisons between population with different health insurances were conducted using meta-analysis, subgroup analysis and meta-regression., Results: A total of 4874 citations were obtained, and finally 30 eligible studies with 633917 participants were included. The overall CHE rate was 13.6% (95% CI: 13.1% - 14.0%) from Jan 2000 to June 2020, 12.8% (95% CI: 12.2% - 13.3%) for people with health insurance compared with 16.2% (95% CI:15.4% - 16.9%) for people without health insurance. For types of insurance, the CHE rate was 13.0% (95% CI: 12.4% - 13.6%) for people with new rural cooperative medical scheme (NCMS), 11.9% (95% CI: 9.3% - 14.5%) for urban employees health insurance (UEBMI), 12.0% (95% CI: 8.3% - 15.6%) for urban residents health insurance (URBMI), and 18.0% (95% CI: - 4.5% - 31.5%) for commercial insurance. However, the CHE rate in China has increased in the past 20 years, even adjusted for other factors. The CHE rate of people with NCMS has increased significantly more than people with UEBMI and URBMI., Conclusion: In the past 20 years, the basic health insurance plan has reduce the rate of CHE to a certain extent, but due to the rapid increase in medical costs and the release of health needs in recent years, it masks the role of health insurance. More efforts are needed to control unreasonable medical demand and rising costs., Competing Interests: The authors have declared that no competing interests exist.

Objectives. To investigate differences in funding and service delivery between rural and urban local health departments (LHDs) in the United States. Methods. In this repeated cross-sectional study, we examined rural-urban differences in funding and service provision among LHDs over time using 2010 and 2016 National Association of County and City Health Officials data. Results. Local revenue among urban LHDs (41.2%) was higher than that in large rural (31.3%) and small rural LHDs (31.2%; P  < .05). Small (20.9%) and large rural LHDs (19.8%) reported greater reliance on revenue from Center for Medicare and Medicaid Services than urban LHDs (11.5%; P  < .05). All experienced decreases in clinical revenue between 2010 and 2016. Urban LHDs provided less primary care services in 2016; rural LHDs provided more mental health and substance abuse services ( P  < .05). Conclusions. Urban LHDs generated more revenues from local sources, and rural LHDs generated more from the Center for Medicare and Medicaid Services and clinical services. Rural LHDs tended to provide more clinical services. Given rural LHDs' reliance on clinical revenue, decreases in clinical services could have disproportionate effects on them. Public Health Implications. Differences in financing and service delivery by rurality have an impact on the communities. Rural LHDs rely more heavily on state and federal dollars, which are vulnerable to changes in state and national health policy.

Introduction: Accompanying rapid urbanization in Bangladesh are inequities in health and healthcare which are most visibly manifested in slums or low-income settlements. This study examines socioeconomic, demographic and geographic patterns of self-reported chronic illness and healthcare seeking among adult slum dwellers in Bangladesh. Understanding these patterns is critical in designing more equitable urban health systems and in enabling the country's goal of Universal Health Coverage by 2030., Methods: This descriptive cross-sectional study compares survey data from slum settlements located in two urban sites in Bangladesh, Tongi and Sylhet. Reported chronic illness symptoms and associated healthcare-seeking strategies are compared, and the catastrophic impact of household healthcare expenditures are assessed., Results: Significant differences in healthcare-seeking for chronic illness were apparent both within and between slum settlements related to sex, wealth score (PPI), and location. Women were more likely to use private clinics than men. Compared to poorer residents, those from wealthier households sought care to a greater extent in private clinics, while poorer households relied more on drug shops and public hospitals. Chronic symptoms also differed. A greater prevalence of musculoskeletal, respiratory, digestive and neurological symptoms was reported among those with lower PPIs. In both slum sites, reliance on the private healthcare market was widespread, but greater in industrialized Tongi. Tongi also experienced a higher probability of catastrophic expenditure than Sylhet., Conclusions: Study results point to the value of understanding context-specific health-seeking patterns for chronic illness when designing delivery strategies to address the growing burden of NCDs in slum environments. Slums are complex social and geographic entities and cannot be generalized. Priority attention should be focused on developing chronic care services that meet the needs of the working poor in terms of proximity, opening hours, quality, and cost., Competing Interests: The study PI and corresponding author of this manuscript received funding from the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ- https://www.giz.de/en/html/index.html) and the Department for International Development (DFID - https://www.gov.uk/government/organisations/department-for-international-development) to conduct this study. Support from GIZ, a commercial funder, was used to cover the costs of research, such as human resources, travel, the purchase tablets for survey administration as well as institutional overhead. GIZ had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Funding from GIZ in no way affects or alters our adherence to PLOS ONE policies on sharing data or materials. On behalf of other co-authors, there are no other financial or nonfinancial, professional, or personal interests to report.

Background: In 2015, the American College of Surgeons Committee on Trauma introduced the Needs-Based Assessment of Trauma Systems (NBATS) tool to quantify the optimal number of trauma centers for a region. While useful, more focus was required on injury population, distribution, and transportation systems. Therefore, NBATS-2 was developed utilizing advanced geographical modeling. The purpose of this study was to evaluate NBATS-2 in a large regional trauma system., Methods: Data from all injured patients from 2016 to 2017 with an Injury Severity Score greater than 15 was collected from the trauma registry of the existing (legacy) center. Injury location and demographics were analyzed by zip code. A regional map was built using US census data to include hospital and population demographic data by zip code. Spatial modeling was conducted using ArcGIS to estimate an area within a 45-minute drive to a trauma center., Results: A total of 1,795 severely injured patients were identified across 54 counties in the tri-state region. Forty-eight percent of the population and 58% of the injuries were within a 45-minute drive of the legacy trauma center. With the addition of another urban center, injured and total population coverage increased by only 1% while decreasing the volume to the existing center by 40%. However, the addition of two rural trauma centers increased coverage significantly to 62% of the population and 71% of the injured (p < 0.001). The volume of the legacy center was decreased by 25%, but the self-pay rate increased by 16%., Conclusion: The geospatial modeling of NBATS-2 adds a new dimension to trauma system planning. This study demonstrates how geospatial modeling applied in a practical tool can be incorporated into trauma system planning at the local level and used to assess changes in population and injury coverage within a region, as well as potential volume and financial implications to a current system., Level of Evidence: Care management/economic, level V.

Objective: To build a deprivation index for the assignation of the budgets of the primary healthcare teams in Catalonia (Spain) valid for both urban and rural environments and updatable with greater frequency than indices built from census variables., Method: Starting from a review of the most common deprivation indices, variables were selected from sources that allow frequent updating and are representative at the territorial level of primary care. The correlations were calculated between the chosen variables and variables of need for healthcare and morbidity. principal components analysis was applied. Finally, the correlations of the index built with the MEDEA index and with variables of use of healthcare resources and morbidity was calculated stratifying by geographical dispersion., Results: The variables of income, occupation and education are the ones with the highest correlation with the need for healthcare and morbidity. The composed socioeconomic index (CSI) ranges from -.01 to 5.68, with an average value of 2.60 and a standard deviation of .91. The correlation between the CSI and the MEDEA index is .89. The CSI correlates with use for healthcare in both urban and rural environments, although in rural environments the association is lower., Conclusions: The CSI was built with data that allow frequent updating and was integrated in the model for allocating resources to primary healthcare starting in 2017., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To estimate the costs and mortality reductions of a package of essential health interventions for urban populations in Bangladesh and India., Methods: We used population data from the countries' censuses and United Nations Population Division. For causes of mortality in India, we used the Indian Million Death Study. We obtained cost estimates of each intervention from the third edition of Disease control priorities . For estimating the mortality reductions expected with the package, we used the Disease control priorities model. We calculated the benefit-cost ratio for investing in the package, using an analysis based on the Copenhagen Consensus method., Findings: Per urban inhabitant, total costs for the package would be 75.1 United States dollars (US$) in Bangladesh and US$ 105.0 in India. Of this, prevention and treatment of noncommunicable diseases account for US$ 36.5 in Bangladesh and U$ 51.7 in India. The incremental cost per urban inhabitant for all interventions would be US$ 50 in Bangladesh and US$ 75 in India. In 2030, the averted deaths among people younger than 70 years would constitute 30.5% (1027/3362) and 21.2% (828/3913) of the estimated baseline deaths in Bangladesh and India, respectively. The health benefits of investing in the package would return US$ 1.2 per dollar spent in Bangladesh and US$ 1.8 per dollar spent in India., Conclusion: Investing in the package of essential health interventions, which address health-care needs of the growing urban population in Bangladesh and India, seems beneficial and could help the countries to achieve their 2030 sustainable development goals., ((c) 2020 The authors; licensee World Health Organization.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed.

Background: The inequity of healthcare utilization in rural China is serious, and the urban-rural segmentation of the medical insurance system intensifies this problem. To guarantee that the rural population enjoys the same medical insurance benefits, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) nationwide in 2016. Against this backdrop, this paper aims to compare the healthcare utilization inequity between URRBMI and New Cooperative Medical Schemes (NCMS) and to analyze whether the inequity is reduced under URRBMI in rural China., Methods: Using the data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which was conducted in 2015, a binary logistic regression model was applied to analyze the influence of income on healthcare utilization, and the decomposition of the concentration index was adopted to compare the Horizontal inequity index (HI index) of healthcare utilization among the individuals insured by URRBMI and NCMS., Results: There is no statistically significant difference in healthcare utilization between URRBMI and NCMS, but in outpatient utilization, there are significant differences among different income groups in NCMS; high-income groups utilize more outpatient care. The Horizontal inequity indexes (HI indexes) in outpatient utilization for individuals insured by URRBMI and NCMS are 0.024 and 0.012, respectively, indicating a pro-rich inequity. Meanwhile, the HI indexes in inpatient utilization under the two groups are - 0.043 and - 0.028, respectively, meaning a pro-poor inequity. For both the outpatient and inpatient care, the inequity degree of URRBMI is larger than that of NCMS., Conclusions: This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. More chronic diseases should be covered and moral hazard should be avoided in URRBMI. For the vulnerable groups, special policies such as reducing the deductible and covering these groups with catastrophic medical insurance could be considered.

Objective: This study aimed to define the end-of-life (EOL) healthcare utilisation and its cost and determinants for cancer patients and to proactively inform related strategies in mainland China., Design: A population-based retrospective study., Setting and Participants: Data from 894 cancer patients were collected in urban Yichang, China from 01 July 2015 to 30 June 2017., Outcome Measures: Emergency department (ED) visits, outpatient and inpatient hospitalisation services, intensive care unit (ICU) admission and total costs were used as the main outcomes., Results: In this study, 66.8% of the 894 patients were male, and the average age was 60.4 years. Among these patients, 37.6% died at home, and patients had an average of 4.86 outpatient services, 2.23 inpatient hospitalisation services and 1.44 ED visits. Additionally, 5.9% of these patients visited the ICU at least once. During the EOL periods, the costs in the last 6 months, 3 months, 1 month and 1 week were US$18 234, US$13 043, US$6349 and US$2085, respectively. The cost increased dramatically as death approached. The estimation results of generalised linear regression models showed that aggressive care substantially affected expenditure. Patients with Urban Employee Basic Medical Insurance spent more than those with Urban Resident-based Basic Medical Insurance or the New Rural Cooperative Medical Scheme. The place of death and the survival time are also risk factors for increased EOL cost., Conclusion: The findings suggested that the EOL cost for cancer patients is associated with aggressive care, insurance type and survival time. Timing palliative care is urgently needed to address ineffective and irrational healthcare utilisation and to reduce costs., Ethics and Dissemination: This study was approved by the Ethics Committee of the Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571). All the data used in this study were de-identified., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cost-effectiveness in healthcare is being increasingly scrutinized. Data regarding claims variability for vascular operations are lacking. Herein, we aim to describe variability in charges and payments for aortoiliac (AI) and infrainguinal (II) revascularizations., Methods: We analyzed 2012-2014 claims data from a statewide claims database for procedures grouped by Current Procedural Terminology codes into II-open (II-O), II-endovascular (II-E), AI-open (AI-O), and AI-endovascular interventions (AI-E). We compared charges and payments in urban (≥50,000 people, UAs) versus rural areas (<50,000 people, RAs). Amounts are reported in $US as median with interquartile range. Cost-to-charge ratios (CCRs) as a measure of reimbursement were calculated as the percentage of the charges covered by the payments. Wilcoxon rank-sum tests were performed to determine significant differences., Results: A total of 5,239 persons had complete claims data. There were 7,239 UA and 6,891 RA claims, and 1,057 AI claims (AI-E = 879, AI-O = 178) and 4,182 II claims (II-E = 3,012, II-0 = 1,170). Median charges were $5,357 for AI [$1,846-$27,107] and $2,955 for II [$1,484-$9,338.5] (P < 0.0001). Median plan payment was $454 for AI [$0-$1,380] and $454 for II [$54-$1,060] (P = 0.67). For AI and II, charges were significantly higher for UA than RA (AI: UA $9,875 [$2,489-$34,427], RA $3,732 [$1,450-$20,595], P < 0.0001; II: UA $3,596 [$1,700-$21,664], RA $2,534 [$1,298-$6,169], P < 0.0001). AI-E charges were higher than AI-O (AI-E $7,960 [$1,699-$32,507], AI-O $4,774 [$2,636-$7,147], P < 0.0001), but AI-O payments were higher (AI-E $424 [$0-$1,270], AI-O $869 [$164-$1,435], P = 0.0067). II-E charges were higher (II-E $2,994 [$1,552-$22,164], II-O $2,873 [$1,108-$5,345], P < 0.0001), but II-O payments were higher (II-E $427 [$50-$907], II-O $596 [$73-$1,299], P < 0.0001). CCRs were highest for II operations and UAs., Conclusions: Wide variability in claim charges and payments exists for vascular operations. AI procedures had higher charges than II, without any difference in payments. UA charged more than RA for both AI and II operations, but RA had higher payments and CCRs. Endovascular procedures had higher charges, while open procedures had higher payments. Charge differences may be related to endovascular device costs, and further research is necessary to determine the reasons behind consistent claims variability between UA and RA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: General practice (GP) has historically been central to the prevention and treatment of childhood illnesses. In Ireland, this role has recently expanded with the introduction of free GP care for children aged under six years in 2015. The Republic of Ireland has the only health system in the European Union which does not offer universal coverage for primary care. This study aims to analyse general practice records to investigate the effect of point of care consultation fees on childhood attendances., Methods: GPs affiliated to the medical school (n = 72) were invited to participate. 100 children aged 1 to 14 years were randomly sampled from each. Data was collected on service utilisation in the previous 12 months, specifically: age, gender, eligibility for free care and whether they had consulted their GP in the 12 month period., Results: Sixty-four practices participated, producing data on 6007 eligible children. The median age of children was seven years; 3688(62%) were 'fee-paying'. GMS patients aged under six years had a median of three consultations/year, with a quarter attending six times a year or more, while fee paying patients had a median of two consultations/year with a quarter attending four times a year or more., Conclusions: Children eligible for free care attend more often with a subgroup attending very frequently. This study provides important information on the possible impact of fees on healthcare utilisation for countries considering co-payment.

The Transforming Clinical Practice Initiative prioritized the delivery of free practice transformation assistance by Practice Transformation Networks (PTNs) to small and rural practices that may otherwise lack the resources needed to succeed in Medicare's value-based payment (VBP) programs. We assessed the enrollment of rural practices in PTNs using 2016 TCPI enrollment data and American Board of Family Medicine recertification examination registration data from 2013 to 2016. PTNs enrolled a higher proportion of rural family medicine practices than are represented across the general workforce ( P < .0001). We await more comprehensive data releases to fully understand enrollment to this important initiative., Competing Interests: Conflict of interest: none declared., (© Copyright 2018 by the American Board of Family Medicine.)

Background: Essential medicines are those drugs that satisfy the priority health care needs of the population and help with functioning healthcare systems. Although many countries have formulated an essential medicine list, almost half of the global population still lack regular access to essential medicines. Research about the initiation of National Essential Medicines Policy in Chinese secondary and tertiary hospitals is inadequate, and the long-term effect on access after the reform is still unknown. This study's objective was to investigate the access to essential medicines in mainland China's secondary and tertiary hospitals., Methods: Data on the access to 30 essential medicines from China's National Essential Medicine List were obtained from China Medicine Economic Information database covering 396 secondary hospitals and 763 tertiary hospitals. We improved the standard methodology developed by the World Health Organization and the Health Action International to measure the availability, median price ratio (MPR) and the incidence of catastrophic drug expenditure (CDE)., Results: Five essential medicines had > 50% availability and the nationwide availability kept steady; availability of drugs in eastern regions of China was significantly higher than the central and western regions. The median MPR of 30 drugs nationwide kept steady approximately 5; MPR of drugs in the eastern regions was significantly higher than the central and western regions and the ratio of MPR of innovator brands to generics increased from 3.66 to 6.32 during the study period. The incidence of CDE caused by essential medicines decreased from 2011 to 2014; brand name medicines were more likely to cause CDE than generics and rural patients have a greater tendency to fall into CDE., Conclusions: After the implementation of National Essential Medicines Policy, the MPR of essential medicines was well controlled and became more affordable in the context of steady availability. This has highlighted the problems associated with region disparity and inequity between rural and urban areas in the delivery of essential medicines and sustainable mechanisms are needed to deepen the National Essential Medicines Policy in mainland China.

Background: The payment system is pivotal in implementing policies in the health sector. Equitable access to healthcare is the main principle of the payment system., Aims: This study aimed to investigate aspects of the payment system in the urban family physician programme (FPP) in the Islamic Republic of Iran., Methods: This was a qualitative study. We obtained data from key informants and both formal and grey literature. We used content analysis for data analysis., Results: A range of concepts was explored related to the payment system of the FPP. By merging similar expressions, we categorized the findings into four main themes including: payment method, payment criteria and incentives, payment process and amount of payment., Conclusions: FPP is required to follow convenient implementation methods. The mechanisms of payment in the health sector are weak and have no transparency. A blurred combination of criteria makes an unclear process for determining the payment mechanisms. It is recommended that the opinions of key stakeholders be taken into consideration prior to developing payment mechanisms and financial incentives., (Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

The aims of this study were to describe health insurance reforms initiated by the Chinese government over the past two decades, to review their achievements in reducing the medical economic burden, and to summarize the challenges that still exist regarding a further reduction in out-of-pocket expenditures in this country. China has successfully attained the goal of providing health insurance coverage to almost the entire population by developing a mixed health insurance system, which consists of Urban Employees Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NCMS), and supplementary Catastrophic Health Insurance. Despite this achievement, China is still facing the challenges of a disparity in the medical economic burden by region and by health insurance scheme, relatively little protection from financial risk compared to developed countries, as well as low efficiency and quality of care under current payment systems. To further reduce the disparity in the medical economic burden and to increase the overall protection from financial risk in China, the Government should increase central government transfers to NCMS and URBMI enrollees in poor regions and increase the total amount of government subsidies to NCMS. In addition, China should improve the efficiency and quality of health insurance by further reforming the payment system.

Objective: To analyze the equity of outpatient service utilization for hypertensive patients (HPs) under 3 kinds of social medical insurance, and to explore its influential factors.
 Methods: A total of 8 670 HPs (aged at 15 years old from 28 sub-centers) in 14 provinces were selected. Indirectly standardized method and concentration index were used to analyze the equity of outpatient utilization in HPs, and decomposition analysis was used to explore the impact factors of outpatient treatment among the whole sample population, population with urban employees' basic medical insurance (UEBMI), and population with urban residents' basic medical insurance (URBMI) and new rural cooperative medical systems (NCMS).
 Results: The overall concentration index (CI) for the whole sample population was 0.2378. After the standardizing "need" variable, horizontal inequity (HI) was 0.2360, indicating that the outpatient service of HPs was inequity and that the higher economic level, the more outpatient services received. The decomposition of overall CI results showed that the positive factors for contribution were gross domestic product (GDP) level, retired, UEBMI and URBMI, and the negative factors for contribution were NCMS. The CI of UEBMI, URBMI and NCMS was 0.2017, 0.1208 and 0.0288, respectively; the HI was 0.1889, 0.1215 and 0.0219, respectively. The inequity in UEBMI is the most serious, followed by NRCMS and URBMI. The economic level was the main factor that caused inequity in the outpatient services utilization in three social medical insurance. In addition to the economic level, a common positive factor for the contribution to UEBMI and URBMI was district of residence, and the age was the positive factor to UEBMI as well.
 Conclusion: There are different levels of inequity in the HPs covered by 3 kinds of social medical insurance, and the inequity of UEBMI is the highest one among 3 kinds social medical insurance. The economic level is the main factor that affects the equity of outpatient in the HPs under 3 kinds of social medical insurance.

Background: Over the last decade, Ethiopia has made impressive national improvements in health outcomes, including reductions in maternal, neonatal, infant, and child mortality attributed in large part to their Health Extension Program (HEP). As this program continues to evolve and improve, understanding the unit cost of health extension worker (HEW) services is fundamental to planning for future growth and ensuring adequate financial support to deliver effective primary care throughout the country., Methods: We sought to examine and report the data needed to generate a HEW fee schedule that would allow for full cost recovery for HEW services. Using HEW activity data and estimates from national studies and local systems we were able to estimate salary costs and the average time spent by an HEW per patient/community encounter for each type of services associated with specific users. Using this information, we created separate fee schedules for activities in urban and rural settings with two estimates of non-salary multipliers to calculate the total cost for HEW services., Results: In the urban areas, the HEW fees for full cost recovery of the provision of services (including salary, supplies, and overhead costs) ranged from 55.1 birr to 209.1 birr per encounter. The rural HEW fees ranged from 19.6 birr to 219.4 birr., Conclusion: Efforts to support health system strengthening in low-income settings have often neglected to generate adequate, actionable data on the costs of primary care services. In this study, we have combined time-motion and available financial data to generate a fee schedule that allows for full cost recovery of the provision of services through billable health education and service encounters provided by Ethiopian HEWs. This may be useful in other country settings where managers seek to make evidence-informed planning and resource allocation decisions to address high burden of disease within the context of weak administrative data systems and severe financial constraints., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Acute malnutrition is currently divided into severe (SAM) and moderate (MAM) based on level of wasting. SAM and MAM currently have separate treatment protocols and products, managed by separate international agencies. For SAM, the dose of treatment is allocated by the child's weight. A combined and simplified protocol for SAM and MAM, with a standardised dose of ready-to-use therapeutic food (RUTF), is being trialled for non-inferior recovery rates and may be more cost-effective than the current standard protocols for treating SAM and MAM., Method: This is the protocol for the economic evaluation of the ComPAS trial, a cluster-randomised controlled, non-inferiority trial that compares a novel combined protocol for treating uncomplicated acute malnutrition compared to the current standard protocol in South Sudan and Kenya. We will calculate the total economic costs of both protocols from a societal perspective, using accounting data, interviews and survey questionnaires. The incremental cost of implementing the combined protocol will be estimated, and all costs and outcomes will be presented as a cost-consequence analysis. Incremental cost-effectiveness ratio will be calculated for primary and secondary outcome, if statistically significant., Discussion: We hypothesise that implementing the combined protocol will be cost-effective due to streamlined logistics at clinic level, reduced length of treatment, especially for MAM, and reduced dosages of RUTF. The findings of this economic evaluation will be important for policymakers, especially given the hypothesised non-inferiority of the main health outcomes. The publication of this protocol aims to improve rigour of conduct and transparency of data collection and analysis. It is also intended to promote inclusion of economic evaluation in other nutrition intervention studies, especially for MAM, and improve comparability with other studies., Trial Registration: ISRCTN 30393230 , date: 16/03/2017.

Objectives: To explore the future implications of diabetes for urban centres, we projected the prevalence and cost of diabetes from 2015 to 2040 in three very different North American cities: Houston, Mexico City and Vancouver., Study Design: We use a simple demographic transition model using existing sources to project future prevalence and financial burden of diabetes., Methods: Based on data from each individual city, projections of the diabetes prevalence and financial burden were created through a three-stage transition model where the likelihood of moving across stages is based on incidence rates for age and gender groups., Results: According to our projections from 2015 to 2040, diabetes prevalence will approximately double in Houston to 1,051,900 people and in Vancouver to 379,778 people and increase by >1 million to 3,080,013 people in Mexico City. Prevalence rates will increase from 8.5% to 11.7% in Houston, from 9.1% to 11.9% in Mexico City and from 7.2% to 11.3% in Vancouver. Associated costs will rise 1.9-fold to $11.5 billion (in US dollars) in Houston, 1.6-fold to $2.8 billion in Mexico City and 2.1-fold to $2.6 billion in Vancouver., Conclusions: Unless actions are taken to decrease its incidence, diabetes is expected to increasingly contribute to the societal and financial burden, particularly for urban areas. Resources and policy actions are needed immediately to promote healthy lifestyles and to implement secondary prevention of diabetes complications., (Copyright © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: New payments from Medicare encourage behavioral health services to be integrated into primary care practice activities., Objective: To evaluate the financial impact for primary care practices of integrating behavioral health services., Design: Microsimulation model., Participants: We simulated patients and providers at federally qualified health centers (FQHCs), non-FQHCs in urban and rural high-poverty areas, and practices outside of high-poverty areas surveyed by the National Association of Community Health Centers, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, and National Health Interview Survey., Interventions: A collaborative care model (CoCM), involving telephone-based follow-up from a behaviorist care manager, or a primary care behaviorist model (PCBM), involving an in-clinic behaviorist., Main Measures: Net revenue change per full-time physician., Key Results: When behavioral health integration services were offered only to Medicare patients, net revenue was higher under CoCM (averaging $25,026 per MD in year 1 and $28,548/year in subsequent years) than PCBM (-$7052 in year 1 and -$3706/year in subsequent years). When behavioral health integration services were offered to all patients and were reimbursed by Medicare and private payers, only practices adopting the CoCM approach consistently gained net revenues. The outcomes of the model were sensitive to rates of patient referral acceptance, presentation, and therapy completion, but the CoCM approach remained consistently financially viable whereas PCBM would not be in the long-run across practice types., Conclusions: New Medicare payments may offer financial viability for primary care practices to integrate behavioral health services, but this viability depends on the approach toward care integration.

Background: China is in the process of integrating the new cooperative medical scheme (NCMS) and the urban residents' basic medical insurance system (URBMI) into the urban and rural residents' basic medical insurance system (URRBMI). However, how to integrate the financing policies of NCMS and URBMI has not been described in detail. This paper attempts to illustrate the differences between the financing mechanisms of NCMS and URBMI, to analyze financing inequity between urban and rural residents and to identify financing mechanisms for integrating urban and rural residents' medical insurance systems., Methods: Financing data for NCMS and URBMI (from 2008 to 2015) was collected from the China health statistics yearbook, the China health and family planning statistics yearbook, the National Handbook of NCMS Information, the China human resources and social security statistics yearbook, and the China social security yearbook. "Ability to pay" was introduced to measure inequity in health financing. Individual contributions to NCMS and URBMI as a function of per capita disposable income was used to analyze equity in health financing between rural and urban residents., Results: URBMI had a financing mechanism that was similar to that used by NCMS in that public finance accounted for more than three quarters of the pooling funds. The scale of financing for NCMS was less than 5% of the per capita net income of rural residents and less than 2% of the per capita disposable income of urban residents for URBMI. Individual contributions to the NCMS and URBMI funds were less than 1% of their disposable and net incomes. Inequity in health financing between urban and rural residents in China was not improved as expected with the introduction of NCMS and URBMI. The role of the central government and local governments in financing NCMS and URBMI was oscillating in the past decade., Conclusions: The scale of financing for URRBMI is insufficient for the increasing demands for medical services from the insured. The pooling fund should be increased so that it can better adjust to China's rapidly aging population and epidemiological transitions as well as protect the insured from poverty due to illness. Individual contributions to the URBMI and NCMS funds were small in terms of contributors' incomes. The role of the central government and local governments in financing URRBMI was not clearly identified. Individual contributions to the URRBMI fund should be increased to ensure the sustainable development of URRBMI. Compulsory enrollment should be required so that URRBMI improves the social medical insurance system in China.

Objectives: Population-based screening for glaucoma has been demonstrated to be cost-effective if targeted at high-risk groups such as older adults and those with a family history of glaucoma, and through use of a technician for conducting initial assessment rather than a medical specialist. This study attempts to investigate the cost-effectiveness of a hypothetical community screening and subsequent treatment programme for glaucoma in comparison with current practice (i.e. with no screening programme but with some opportunistic case finding) in the urban areas of India., Study Design: A hypothetical screening programme for both primary open-angle glaucoma and angle-closure disease was built for a population aged between 40 and 69 years in the urban areas of India., Methods: Screening and treatment costs were obtained from an administrator of a tertiary eye hospital in India. The probabilities for the screening pathway were derived from published literature and expert opinion. The glaucoma prevalence rates for urban areas were adapted from the Chennai Glaucoma Study findings. A decision-analytical model using TreeAge Pro 2015 was built to model events, costs and treatment pathways. One-way sensitivity analyses were conducted., Results: The introduction of a community screening programme for glaucoma is likely to be cost-effective, the estimated incremental cost-effectiveness ratio (ICER) values being 10,668.68 when compared with no screening programme and would treat an additional 4443 cases and prevent 1790 person-years of blindness over a 10-year period in the urban areas of India. Sensitivity analyses revealed that glaucoma prevalence rates across various age groups, screening uptake rate, follow-up compliance after screening, treatment costs and utility values of health states associated with medical and surgical treatment of glaucoma had an impact on the ICER values of the screening programme., Conclusions: In comparison with current practice (i.e. without a screening programme but with some opportunistic case finding), the introduction of a community screening programme for glaucoma for the 40-69 years age group is likely to be relatively cost-effective if implemented in the urban areas of India., (Copyright © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Estimates of those living in rural counties vary from 46.2 to 59 million, or 14% to 19% of the U.S., Population: Rural communities face disadvantages compared with urban areas, including higher poverty, lower educational attainment, and lack of access to health services. We aimed to demonstrate rural-urban disparities in cancer and to examine NCI-funded cancer control grants focused on rural populations. Estimates of 5-year cancer incidence and mortality from 2009 to 2013 were generated for counties at each level of the rural-urban continuum and for metropolitan versus nonmetropolitan counties, for all cancers combined and several individual cancer types. We also examined the number and foci of rural cancer control grants funded by NCI from 2011 to 2016. Cancer incidence was 447 cases per 100,000 in metropolitan counties and 460 per 100,000 in nonmetropolitan counties ( P < 0.001). Cancer mortality rates were 166 per 100,000 in metropolitan counties and 182 per 100,000 in nonmetropolitan counties ( P < 0.001). Higher incidence and mortality in rural areas were observed for cervical, colorectal, kidney, lung, melanoma, and oropharyngeal cancers. There were 48 R- and 3 P-mechanism rural-focused grants funded from 2011 to 2016 (3% of 1,655). Further investment is needed to disentangle the effects of individual-level SES and area-level factors to understand observed effects of rurality on cancer. Cancer Epidemiol Biomarkers Prev; 26(7); 992-7. ©2017 AACR ., (©2017 American Association for Cancer Research.)

Continuous quality improvement (CQI) has grown in the U.S. since the 1970s, yet little is known about the costs to implement CQI in substance abuse treatment facilities. This paper is part of a larger group randomized control trial in a large urban county evaluating the impact of Plan-Study-Do-Act (PDSA)-CQI designed for community service organizations (Hunter, Ober, Paddock, Hunt, & Levan, 2014). Operated by one umbrella organization, each of the eight facilities of the study, four residential and four outpatient substance abuse treatment facilities, selected their own CQI Actions, including administrative- and clinical care-related Actions. Using an activity-based costing approach, we collected labor and supplies and equipment costs directly attributable to CQI Actions over a 12-month trial period. Our study finds implementation of CQI and meeting costs of this trial per facility were approximately $2000 to $10,500 per year ($4500 on average), or $10 to $60 per admitted client. We provide a description of the sources of variation in these costs, including differing intensity of the CQI Actions selected, which should help decision makers plan use of PDSA-CQI., (Copyright © 2017. Published by Elsevier Inc.)

Introduction: Medical schools are in general over-represented by students from high socio-economic status backgrounds. The University of Western Australia Medical School has been progressively widening the participation of students from a broader spectrum of the community both through expanded selection criteria and quota-based approaches for students of rural, indigenous and other socio-educationally disadvantaged backgrounds. We proposed that medical students entering medical school from such backgrounds would ultimately be more likely to practice in areas of increased socio-economic disadvantage., Methods: The current practice address of 2829 medical students who commenced practice from 1980 to 2011 was ascertained from the Australian Health Practitioner Regulation Agency (AHPRA) Database. Logistic regression was utilised to determine the predictors of the likelihood of the current practice address being in the lower 8 socio-economic deciles versus the top 2 socio-economic deciles., Results: Those who were categorised in the lower 8 socio-economic deciles at entry to medical school had increased odds of a current practice address in the lower 8 socio-economic deciles 5 or more years after graduation (OR 2.05, 95% CI 1.72, 2.45, P < 0.001). Other positive univariate predictors included age at medical degree completion (for those 25 years or older vs those 24 years or younger OR 1.53, 95% CI 1.27, 1.84, P < 0.001), being female (OR 1.26, 95% CI 1.07, 1.48, P = 0.005) and having a general practice versus specialist qualification (OR 4.16, 95% CI 3.33, 5.19, P < 0.001). Negative predictors included having attended an independent school vs a government school (OR 0.77, 95% CI 0.64, 0.92, P < 0.001) or being originally from overseas vs being born in Oceania (OR 0.80, 95% CI 0.67, 0.96, P = 0.017). After adjustment for potential confounders in multivariate logistic regression, those in the lower 8 socio-economic deciles at entry to medical school still had increased odds of having a current practice address in the lower 8 socio-economic deciles (OR 1.63, 95% CI 1.34, 1.99, P < 0.001)., Conclusion: Widening participation in medical school to students from more diverse socio-educational backgrounds is likely to increase the distribution of the medical workforce to ultimate service across areas representative of a broader socio-economic spectrum.

Since 2014, when the Health Insurance Marketplaces (HIMs) authorized by the Patient Protection and Affordable Care Act (ACA) were implemented, considerable premium changes have been observed in the marketplaces across the 50 states and the District of Columbia. This policy brief assesses the changes in average HIM plan premiums from 2014 to 2016, before accounting for subsidies, with an emphasis on the widening variation across rural and urban places. Since this brief focuses on premiums without accounting for subsidies, this is not intended to be an analysis of the "affordability" of ACA premiums, as that would require assessment of premiums, cost-sharing adjustments, and other factors.

Aim This article aims to evaluate access to prenatal care according to the dimensions of availability, affordability and acceptability in the SUS microregion of southeastern Brazil. Methods A cross-sectional study conducted in 2012-2013 that selected 742 postpartum women in seven hospitals in the region chosen for the research. The information was collected, processed and submitted to the chi-square test and the nonparametric Spearman's test, with p-values less than 5% (p < 0.05). Results Although the SUS constitutionally guarantees universal access to health care, there are still inequalities between pregnant women from rural and urban areas in terms of the availability of health care and among families earning up to minimum wage and more than one minimum wage per month in terms of affordability; however, the acceptability of health care was equal, regardless of the modality of the health services. Conclusion The location, transport resources and financing of health services should be reorganised, and the training of health professionals should be enhanced to provide more equitable health care access to pregnant women.

Background: Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system., Methods and Results: We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30-day and 1-year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11-0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30-day mortality (P=0.008) but no significant difference for 1-year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients., Conclusion: Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30-day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low-income nonmetropolitan communities., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Aim: To analyze one-year typical management practice in outpatients with type 2 diabetes mellitus (T2DM) in cities, towns, and villages., Subjects and Methods: 438 records of T2DM outpatients regularly visiting their physicians during 2009 were retrospectively analyzed. Group 1 included 221 outpatients from 7 polyclinics of the Kirov Regional Center; Group 2 consisted of 227 patients from 36 districts of the Kirov Region. VEN-, ABC-, and frequency analyses were made; the costs of drug therapy and hospitalization for the included patients were calculated., Results: The investigation revealed the low efficiency of sugar-lowering therapy (SLT), insufficient glycated hemoglobin testing rates (15% in Group 2 during a year), inadequate correction of SLT. During one year the number of patients with fixed target office blood pressure levels in Group 1 increased from 16.6 to 34.1% (р<0.001) and that in Group 2 was statistically significantly unchanged (21.6% vs 25.1%; p=0.05). In Group 2, the use frequency of statins was lower (20.3% by the end of the year versus 49.3% in Group 1; р<0.001); the examination quality was worse; the drugs with unproven efficacy, the cost of which was higher than that of statins/disaggregants, were used more often. In Groups 1 and 2, there were 50 (23.7%) and 95 (41.9%) patients who were more commonly hospitalized for T2DM-related causes; Group 2 patients had a higher rate of hospitalizations and longer inpatient treatment., Conclusion: The worse outpatient care quality in the towns and villages was followed by increases in a need for inpatient treatment and in direct drug (2.36-fold) and non-drug direct and indirect (2.77-fold) costs.

Background: As per the vaccine management policy of the Government of India all vaccine vials opened for an immunization session were discarded at the end of that session, irrespective of the type of vaccine or the number of doses remaining in the vial prior to 2013. Subsequently, open vial policy (OVP) was introduced in 2013 and should reduce both vaccine wastage as well as governmental healthcare costs for immunization. This study evaluates the vaccine wastage after introduction of the OVP and its comparison with the previous study of vaccine wastage in Surat city before implementation of OVP. It needs to mention that the vaccine policy for this period under comparison was uniform except for the OVP., Methods: Information regarding vaccine doses consumed and children vaccinated during immunization sessions of 24 urban health centers (UHCs) of Surat city were retrieved for the period of January 1st, 2014 to March 31st, 2014. The data were analyzed to estimate vaccine wastage rate (WR) and vaccine wastage factor (WF). In order to assess the impact of OVP, vaccine WR of this study was compared with that of previous study conducted in Surat city during January 1st, 2012 to March 31st, 2012., Results: The vaccine WR for oral polio vaccine (OPV) has decreased from 25% to 13.62%, while the WRs for DPT, hepatitis B virus (HBV) and the pentavalent vaccine combinedly have decreased from 17.94% to 8.05%. Thus, by implementation of OVP, an estimated 747 727 doses of OPV and 343 725 doses of diphtheria, pertussis and tetanus toxoid vaccine (DPT), HBV and the pentavalent vaccines combinedly have been saved in Surat city of India in a year., Conclusion: The implementation of the OVP in Surat city has led to a significant lowering in the vaccine wastage, leading to savings due to lower vaccine requirements., (© 2016 by Kerman University of Medical Sciences.)

Background: Pneumonia is a frequent lung infection and a serious illness, which is often diagnosed among patients hospitalized with acute exacerbations of COPD. The aim of this study was to estimate the attributable costs due to pneumonia among patients hospitalized with pneumonia compared to a matched general population control group without pneumonia hospitalization., Methods: This study includes citizens older than 18 years from three municipalities (n=142,344). Based on national registers and municipal data, the health and social care costs of pneumonia in the second half of 2013 are estimated and compared with propensity score-matched population controls., Results: The average health care costs of 383 patients hospitalized with pneumonia in the second half of 2013 were US$34,561 per patient. Among pneumonia patients with COPD, the costs were US$35,022. The attributable costs of patients with pneumonia compared to the population control group for the 6-month period were US$24,155 per case. Overall, the attributable costs for the 383 pneumonia cases amounted to US$9.25 million. Subgroup analyses showed that costs increased with age. The attributable costs due to pneumonia were highest among the 18-59-year-old and the 70-79-year-old patients. This difference is likely to reflect an increased risk of mortality among the pneumonia patients. Men have higher costs than women in the pneumonia group., Conclusion: The costs of pneumonia are considerable. In three Danish municipalities, the attributable costs due to pneumonia were US$24,155 per case or US$64,992 per 1,000 inhabitants in the second half of 2013. Similar high health care and social care costs were found for pneumonia patients with COPD - the largest group having pneumonia episodes. The municipalities are responsible for 49% of the costs, while a closer focus on the prevention of pneumonia may be advisable, eg, starting with citizens having COPD.

Objective: To investigate patients' experiences of a new payment system for dental care in Sweden., Methods: Twenty interviews, with 12 women and 8 men, were analysed by thematic content analysis. The interviewees were all regularly attending patients, strategically selected from five general Public Dental Service clinics in urban Gothenburg, Sweden, who had chosen a new payment system based on capitation rather than the traditional fee-for-service system. Conducted by two clinical psychologists/researchers independent of dental profession, the interviews were guided by a semi-structured schedule, which included questions about the new payment system and about dental care and oral health. All interviews were audio-recorded and transcribed verbatim., Results: Two themes emerged from the analysis: "Choice" and "Commitment". The sub-themes defined patients as having chosen the new capitation scheme on their own initiative or after being influenced by relatives or by their dentist, and that the change of payment system was occasioned by previous bad (dental) experiences or in the hope of future (dental health) gain. The commitment was perceived as affording economic security and, through the contractual relationship with the provider, regular calls to attend the clinic., Conclusions: Patients were generally in favour of the new payment system for dentistry in Sweden; however, important arguments were raised to improve the system, such as better communication concerning the contract and risk assessment.

We previously reported the financial data for the first 5 years of one of the author's medical toxicology practice. The practice has matured; changes have been made. The practice is increasing its focus on office-based encounters and reducing hospital-based acute care encounters. We report the reimbursement rates and other financial metrics of the current practice. Financial records from October 2009 through September 2013 were reviewed. This is a period of 4 fiscal years and represents the currently available financial data. Charges, payments, and reimbursement rates were recorded according to the type and setting of the medical toxicology encounter: forensic consultations, outpatient clinic encounters, nonpsychiatric inpatient consultations, emergency department (ED) consultations, and inpatient psychiatric consultations. All patients were seen regardless of ability to pay or insurance status. The number of billed Current Procedural Terminology (CPT) codes for office-based encounters increased over the study period; the number of billed CPT codes for inpatient and ED consultations reduced. Office-based encounters demonstrate a higher reimbursement rate and higher payments. In the fiscal year (FY) of 2012, office-based revenue exceeded hospital-based acute care revenue by over $140,000 despite a higher number of billed CPT encounters in acute care settings, and outpatient payments were 2.39 times higher than inpatient, inpatient psychiatry, observation unit, and ED payments combined. The average payment per CPT code was higher for outpatient clinic encounters than inpatient encounters for each fiscal year studied. There was an overall reduction in CPT billing volume between FY 2010 and FY 2013. Despite this, there was an increase in total practice revenue. There was no change in payor mix, practice logistics, or billing/collection service company. In this medical toxicology practice, office-based encounters demonstrate higher reimbursement rates and overall payments compared to inpatient and ED consultations. While consistent with our previous studies, these differences have been accentuated. This study demonstrates the results of changes to the practice--reduced inpatient/ED consultations and increased outpatient encounters. These practice changes resulted in higher overall revenue despite a lower patient volume. In this analysis, the office-based practice of medical toxicology has higher reimbursement rates, nearly 2.5 times higher, when compared to hospital-based acute care consultations.

Background: Smoking crack involves the risk of transmitting diseases such as HIV and hepatitis C (HCV). The current study determines whether the formerly unsanctioned supervised smoking facility (SSF)-operated by the grassroot organization, Vancouver Area Network of Drug Users (VANDU) for the last few years-costs less than the costs incurred for health-care services as a direct consequence of not having such a program in Vancouver, Canada., Methods: The data pertaining to the attendance at the SSF was gathered in 2012-2013 by VANDU. By relying on this data, a mathematical model was employed to estimate the number of HCV infections prevented by the former facility in Vancouver's Downtown Eastside (DTES)., Results: The DTES SSF's benefit-cost ratio was conservatively estimated at 12.1:1 due to its low operating cost. The study used 70% and 90% initial pipe-sharing rates for sensitivity analysis. At 80% sharing rate, the marginal HCV cases prevented were determined to be 55 cases. Moreover, at 80% sharing rate, the marginal cost-effectiveness ratio ranges from $1,705 to $97,203. The results from both the baseline and sensitivity analysis demonstrated that the establishment of the SSF by VANDU on average had annually saved CAD$1.8 million dollars in taxpayer's money., Conclusions: Funding SSFs in Vancouver is an efficient and effective use of financial resources in the public health domain; therefore, Vancouver Coastal Health should actively participate in their establishment in order to reduce HCV and other blood-borne infections such as HIV within the non-injecting drug users.

Background and Objective: To determine whether tele-ophthalmology screening for proliferative diabetic retinopathy (PDR) can be cost-saving., Patients and Methods: Adults with diabetes presenting for routine medical care underwent non-mydriatic fundus photography with remote grading. Direct medical costs were estimated using the Medicare fee schedule in the base case, with Medicaid and commercial insurance rates used for low and high values, respectively. One-way and probabilistic sensitivity analyses were performed., Results: Of 99 participants, at least mild retinopathy was found in 24 (24.2%). Urgent consultation was recommended for eight participants (8.1%) for possible vision-threatening diabetic retinopathy, including two participants (three eyes) with PDR. In the base case, screening saved $36 per patient. A Monte Carlo simulation indicated that screening saved a median of $48 per patient., Conclusion: A substantial burden of diabetic retinopathy was identified, most of which was undiagnosed. In a closed system, tele-ophthalmology screening for PDR is likely to be cost-saving across the range of scenarios explored., (Copyright 2014, SLACK Incorporated.)

Objective: Social and economic barriers can hinder access to quality palliative and end-of-life care for patients living in inner-city communities. Using a community-based participatory research (CBPR) approach, we investigated the stresses associated with living with a chronic disease and barriers to access and utilization of palliative care resources experienced by low-income patients and caregivers in five inner-city communities., Methods: Four focus groups (N = 33) were conducted with community stakeholders, including healthcare professionals (social workers and nurses), persons living with chronic illnesses (e.g., HIV/AIDS, cardiovascular disease, and cancer), and caregivers. Focus group responses were analyzed using thematic analyses., Results: Patients' and caregivers' stresses centered around five themes: lack of family support, communication barriers with healthcare professionals, minority stress, caregiver burden, and lack of spiritual support. The community stakeholders identified resources and services to improve access to care and the quality of life of underserved, low-income populations living with chronic illnesses., Significance of Results: A CBPR approach enabled us to develop an interdisciplinary and culturally sensitive intervention to begin addressing the palliative and end-of-life needs of the patients and caregivers of the inner-city community.

Objectives: To determine the effect of home-based primary care (HBPC) on Medicare costs and mortality in frail elders., Design: Case-control concurrent study using Medicare administrative data., Setting: HBPC practice in Washington, District of Columbia., Participants: HBPC cases (n = 722) and controls (n = 2,161) matched for sex, age bands, race, Medicare buy-in status (whether Medicaid covers Part B premiums), long-term nursing home status, cognitive impairment, and frailty. Cases were eligible if enrolled in MedStar Washington Hospital Center's HBPC program during 2004 to 2008. Controls were selected from Washington, District of Columbia, and urban counties in Virginia, Maryland, and Pennsylvania., Intervention: HBPC clinical service., Measurements: Medicare costs, utilization events, mortality., Results: Mean age was 83.7 for cases and 82.0 for controls (P < .001). A majority of both groups was female (77%) and African American (90%). During a mean 2-year follow-up, in univariate analysis, cases had lower Medicare ($44,455 vs $50,977, P = .01), hospital ($17,805 vs $22,096, P = .003), and skilled nursing facility care ($4,821 vs $6,098, P = .001) costs, and higher home health ($6,579 vs $4,169; P < .001) and hospice ($3,144 vs. $1,505; P = .005) costs. Cases had 23% fewer subspecialist visits (P = .001) and 105% more generalist visits (P < .001). In a multivariate model, cases had 17% lower Medicare costs, averaging $8,477 less per beneficiary (P = .003) over 2 years of follow-up. There was no difference between cases and controls in mortality (40% vs 36%, hazard ratio = 1.06, P = .44) or in average time to death (16.2 vs 16.8 months, P = .30)., Conclusion: HBPC reduces Medicare costs for ill elders, with similar survival outcomes in cases and controls., (© 2014 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.)

Background: Preventive dental care use remains relatively low in Japan, especially among working-age adults. Universal health insurance in Japan covers curative dental care with an out-of-pocket payment limit, though its coverage of preventive dental care is limited. The aim of this study was to test the hypothesis that income inequality in dental care use is found in preventive, but not curative dental care among working-age Japanese adults., Methods: A cross-sectional survey was conducted using a computer-assisted, self-administered format for community residents aged 25-50 years. In all, 4357 residents agreed to participate and complete the questionnaire (valid response rate: 31.3%). Preventive dental care use was measured according to whether the participant had visited a dentist or a dental hygienist during the past year for dental scaling or fluoride or orthodontic treatments. Curative dental care use was assessed by dental visits for other reasons. The main explanatory variable was equivalent household income. Logistic regression analyses with linear trend tests were conducted to determine whether there were significant income-related gradients with curative or preventive dental care use., Results: Among the respondents, 40.0% of men and 41.5% of women had used curative dental care in the past year; 24.1% of men and 34.1% of women had used preventive care. We found no significant income-related gradients of curative dental care among either men or women (p = 0.234 and p = 0.270, respectively). Significant income-related gradients of preventive care were observed among both men and women (p < 0.001 and p = 0.003, respectively). Among women, however, income-related differences were no longer significant (p = 0.126) after adjusting for education and other covariates. Compared with men with the lowest income, the highest-income group had a 1.79-fold significantly higher probability for using preventive dental care., Conclusions: The prevalence of preventive dental care use was lower than that of curative care. The results showed income-related inequality in preventive dental care use among men, though there were no significant income-related gradients of curative dental care use among either men or women. Educational attainment had a positive association with preventive dental care use only among women.

Urban health authorities in the United States have been charged with developing plans for providing the infrastructure necessary to dispense prophylactic medications to their populations in the case of epidemic disease outbreak or bioterrorist attack. However, no specific method for such plans has been prescribed. This article formulates and demonstrates the use of an integer programming technique for helping to solve a part of the dispensing problem faced by cities, namely that of providing the federally required infrastructure at minimum cost, using their limited time and resources. Specifically, the technique minimizes the number of point-of-dispensing (POD) centers while covering every resident in all the census tracts within the city's jurisdiction. It also determines the optimal staffing requirement in terms of the number of nurses at each POD. This article includes a demonstration of the model using real data from Cleveland, OH, a mid-sized US city. Examples are provided of data and computational results for a variety of input parameter values such as population throughput rate, POD capacities, and distance limitations. The technique can be readily adapted to a wide range of urban areas.

Objectives: The study sought to determine barriers to accessing oral health services amongst the elderly residing in retirement villages in Johannesburg. The objectives were to determine the normative and perceived oral health needs, the barriers experienced and the predictors of oral health utilisation., Materials and Methods: This was a cross-sectional study. Three hundred and eight (n=308) participants were recruited from 10 retirement villages in Johannesburg. Data were collected from questionnaires and clinical oral examinations assessing the DMFT and CPITN scores., Results: The clinical findings of the oral health status indicated a caries experience of 46%, whilst 58% of participants suffered from periodontal conditions. Sixty four percent (64%) acknowledged the need to visit a dentist, however only 28% of the study population had utilised oral health care in the past 12 months, due to perceived barriers. The barriers most frequently reported included the belief that they were not able to afford dental treatment and the lack of transport availability. The multivariate analysis indicated that a significant positive predictor of utilisation was Perceived Need., Conclusion: Though oral health access was freely available in the public sector and normative and perceived need for oral health care were high, the barriers experienced prevented 72% of the participants from utilising oral health services.

Objectives: To determine the number of interventions made by pharmacy students at an urban family medicine clinic and the acceptance rate of these recommendations by the healthcare providers. The secondary objective was to investigate the cost avoidance value of the interventions., Methods: A prospective, unblinded study was conducted to determine the number and cost avoidance value of clinical interventions made by pharmacy students completing advanced pharmacy practice experiences (APPEs) in an urban family medicine clinic., Results: Eighteen students completed this experience in the 8 months studied. Of the 718 interventions performed, 77% were accepted by physicians, including 58% of the 200 interventions that required immediate action. Projected avoidance was estimated at $61,855., Conclusion: The clinical interventions by pharmacy students were generally well received by healthcare providers and resulted in significant cost savings. Pharmacy students can play an important role in a family medicine clinic.

Objective: In 2006, the incidence of unintended pregnancy among rural-to-urban migrant women (RUMW) in Shanghai was reported as 12.8 per 100 women-years during the first year postpartum. Among permanent residents of Shanghai, that same rate was 3.8 per 100 women-years. An intervention study was designed to address the unmet need for family planning services among this underserved population of RUMW and reduce their high postpartum unintended pregnancy incidence., Study Design: We enrolled 840 migrant women into an intervention study that provided free contraceptive counseling and a choice of methods. Subjects were recruited into the study during hospitalization for childbirth and offered a contraceptive method according to their choice prior to discharge. Counseling and further support were offered at 6 weeks and at 3, 6, 9 and 12 months postpartum via scheduled telephone calls and/or clinic visits., Results: Among all study participants, the median time to contraceptive initiation and sexual resumption was 2 months postpartum, respectively. The overall contraceptive prevalence at 12 months was 97.1%, and more than half of the women were using long-acting contraception. The incidence rate of unintended pregnancy during the first year postpartum was 2.2 per 100 women-years (95% confidence interval: 1.3-3.6)., Conclusions: Integrating free family planning services into existing childbirth delivery services in a maternity setting in Shanghai was effective in addressing the unmet need for family planning and reduced the risk of unintended pregnancy during the first year postpartum., Implications: The maternity setting at the time of early labor and prior to postpartum hospital discharge is a practical venue and an optimal time to provide contraception counseling and for postpartum women to initiate use of contraceptive methods. Supporting services during the first year postpartum are also essential to encourage women to continue contraceptive use and reduce the incidence of postpartum unintended pregnancy., (Copyright © 2014 Elsevier Inc. All rights reserved.)