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1.  Preoperative Consultations for Medicare Patients Undergoing Cataract Surgery 
JAMA internal medicine  2014;174(3):380-388.
IMPORTANCE
Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service.
OBJECTIVE
To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure.
DESIGN, SETTING, AND PARTICIPANTS
Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556 637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89 817 individuals who underwent surgery from 2005 to 2006.
MAIN OUTCOMES AND MEASURES
Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery.
RESULTS
The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75–84 years vs 66–74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04–1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65–0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49–1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05–1.15]), anesthesia provider (anesthesiologist vs non–medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10–1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33–4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0–69%]), even after accounting for differences in patient-level, anesthesia provider–level, and facility-level characteristics.
CONCLUSIONS AND RELEVANCE
Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.
doi:10.1001/jamainternmed.2013.13426
PMCID: PMC4167873  PMID: 24366269
2.  Costs of medicines and health care: a concern for Australian women across the ages 
Background
Evidence from Australia and other countries suggests that some individuals struggle to meet the costs of their health care, including medicines, despite the presence of Government subsidies for low-income earners. The aim of our study was to elucidate women’s experiences with the day to day expenses that relate to medicines and their health care.
Methods
The Australian Longitudinal Study on Women’s Health (ALSWH) conducts regular surveys of women in three age cohorts (born 1973–78, 1946–51, and 1921–26). Our data were obtained from free text comments included in surveys 1 to 5 for each cohort. All comments were scanned for mentions of attitudes, beliefs and behaviours around the costs of medicines and health care. Relevant comments were coded by category and themes identified.
Results
Over 150,000 responses were received to the surveys, and 42,305 (27%) of these responses included free-text comments; 379 were relevant to medicines and health care costs (from 319 individuals). Three broad themes were identified: costs of medicines (33% of relevant comments), doctor visits (49%), and complementary medicines (13%). Age-specific issues with medicine costs included contraceptive medicines (1973–78 cohort), hormone replacement therapy (1946–51 cohort) and osteoporosis medications (1921–26 cohort). Concerns about doctor visits mostly related to reduced (or no) access to bulk-billed medical services, where there are no out-of-pocket costs to the patient, and costs of specialist services. Some women in the 1973–78 and 1946–51 cohorts reported ‘too much income’ to qualify for government health benefits, but not enough to pay for visits to the doctor. In some cases, care and medicines were avoided because of the costs. Personal feelings of embarrassment over financial positions and judgments about bulk-billing practices (‘good ones don’t bulk-bill’) were barriers to service use, as were travel expenses for rural women.
Conclusions
For some individuals, difficulty in accessing bulk-billing services and increasing out-of-pocket costs in Australia limit affordability of health services, including medications. At greatest risk may be those falling below thresholds for subsidised care such as self-funded retirees and those on low-middle incomes, in addition to those on very low incomes, who may find even small co-payments difficult to manage.
doi:10.1186/1472-6963-13-484
PMCID: PMC4225494  PMID: 24252248
Medicines; Affordability; Women’s health; Costs; Qualitative
3.  Billing Practices of Local Health Departments Providing 2009 Pandemic Influenza A (H1N1) Vaccine 
Context
In June 2009, the World Health Organization officially declared an influenza pandemic. In the United States, the federal government supplied 2009 H1N1 vaccine at no cost and provided funding for states to implement vaccination programs. Vaccine providers including health departments were permitted to bill insurance plans for administering 2009 H1N1 vaccine.
Objective
To determine the extent to which local health departments (LHDs) billed for administering 2009 H1N1 vaccine, specific billing practices of LHDs, and factors associated with LHD billing.
Design
Cross-sectional study using an Internet-based survey, and semistructured interviews.
Participants and Setting
Nationally representative stratified random sample of 527 LHDs in the United States. Interviews were conducted among a convenience sample of LHDs.
Main Outcome Measure
Proportion of LHDs reporting billing for administering 2009 H1N1 vaccine.
Results
A total of 308 health departments (58%) provided responses complete enough for analysis. Most LHDs (82%) had previous experience billing for seasonal influenza vaccination, but only 20% (n = 57) billed for administration of 2009 H1N1 vaccine. Medicare (74%) and Medicaid (80%) were the most commonly billed health care payers; more than half (55%) of LHDs billing for 2009 H1N1 vaccine administration sought reimbursement from one or more private insurance plans. Billing for 2009 H1N1 vaccine administration was more common among LHDs that previously offered seasonal influenza vaccination (P = .003), previously billed for seasonal influenza vaccination (P = .04), and conducted school-located influenza vaccination clinics prior to the 2009–2010 influenza season (P = .002).
Conclusions
Most LHDs elected not to bill for 2009 H1N1 vaccine administration despite prior experience billing for influenza vaccination. It is important to understand barriers to billing and resources needed by LHDs to facilitate billing for vaccination. Developing public health billing capacity will allow LHDs to recoup the costs of providing vaccines to insured persons and may also prepare them to conduct billing activities for other services or during future public health emergencies.
doi:10.1097/PHH.0b013e31825874c3
PMCID: PMC4632845  PMID: 23360957
human influenza; pandemic; public health practice; vaccination
4.  Australian primary care policy in 2004: two tiers or one for Medicare? 
The recent primary care policy debate in Australia has centred on access to primary medical (general practice) services. In Australia, access is heavily influenced by Commonwealth Government patient rebates that provide incentives for general practitioners not to charge copayments to patients (bulk billing). A steady decline in key access indicators (bulk billing) has led the Howard Government to introduce a set of changes that move Medicare from a universal scheme, to one increasingly targeted at providing services to more disadvantaged Australians. In doing so, another scene in the story of the contest between universal health care and selective provision in Australia has been written. This paper explores the immediate antecedents and consequences of the changes and sets them in the broader context of policy development for primary care in Australia.
doi:10.1186/1743-8462-1-2
PMCID: PMC544961  PMID: 15679930
5.  Variation in Chemotherapy Utilization in Ovarian Cancer: The Relative Contribution of Geography 
Health Services Research  2006;41(6):2201-2218.
Objective
This study investigates geographic variation in chemotherapy utilization for ovarian cancer in both absolute and relative terms and examines area characteristics associated with this variation.
Data Sources
Surveillance, Epidemiology, and End Results (SEER) Medicare data from 1990 to 2001 for Medicare patients over 65 with a diagnosis of ovarian cancer between 1990 and 1999. Chemotherapy within a year of diagnosis was identified by Medicare billing codes. The hospital referral region (HRR) represents the geographic unit of analysis.
Study Design
A logit model predicting the probability of receiving chemotherapy by each of the 39 HRRs. Control variables included medical characteristics (patient age, stage, year of diagnosis, and comorbidities) and socioeconomic characteristics (race, income, and education). The variation among HRRs was tested by the χ2 statistic, and the relative contribution was measured by the ω statistic. HHR market characteristic are then used to explain HRR-level variation.
Principal Findings
The average chemotherapy rate was 56.6 percent, with a range by HRR from 33 percent to 67 percent. There were large and significant differences in chemotherapy use between HRRs, reflected by a χ2 for HRR of 146 (df=38, p<.001). HRR-level variation in chemotherapy use can be partially explained by higher chemotherapy rates in HRRs with a higher percentage of hospitals with oncology services. However, an ω analysis indicates that, by about 15 to one, the variation between patients in use of chemotherapy reflects variations in patient characteristics rather than unexplained variation among HRRs.
Conclusions
While absolute levels of chemotherapy variation between geographic areas are large and statistically significant, this analysis suggests that the role of geography in determining who gets chemotherapy is small relative to individual medical characteristics. Nevertheless, while variation by medical characteristics can be medically justified, the same cannot be said for geographic variation. Our finding that density of oncology hospitals predicts chemotherapy use suggests that provider supply is positively correlated with geographic variation.
doi:10.1111/j.1475-6773.2006.00596.x
PMCID: PMC1955308  PMID: 17116116
Geographic variations; chemotherapy treatment; ovarian cancer
6.  Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals? 
Background
In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.
Results
Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.
Conclusion
The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.
doi:10.1186/1743-8462-5-24
PMCID: PMC2588611  PMID: 18990236
7.  Patterns of Childhood Obesity Prevention Legislation in the United States 
Preventing Chronic Disease  2007;4(3):A56.
Introduction
Because of the public's growing awareness of the childhood obesity epidemic, health policies that address obesogenic environments by encouraging healthy eating and increased physical activity are gaining more attention. However, there has been little systematic examination of state policy efforts. This study identified and described state-level childhood obesity prevention legislation introduced and adopted from 2003 through 2005 and attempted to identify regional geographic patterns of introduced legislation.
Methods
A scan of legislation from all 50 states identified 717 bills and 134 resolutions that met study inclusion criteria. Analyses examined patterns in the introduction and adoption of legislation by time, topic area, and geography.
Results
Overall, 17% of bills and 53% of resolutions were adopted. The amount of legislation introduced and adopted increased from 2003 through 2005. The topic areas with the most introduced legislation were school nutrition standards and vending machines (n = 238); physical education and physical activity (n = 191); and studies, councils, or task forces (n = 110). Community-related topic areas of walking and biking paths (37%), farmers' markets (36%), and statewide initiatives (30%) had the highest proportion of bills adopted, followed by model school policies (29%) and safe routes to school (28%). Some regional geographic patterns in the introduction of legislation were observed. There was no statistical association between state-level adult obesity prevalence and introduction of legislation.
Conclusion
Public health and health policy practitioners can use this information to improve advocacy efforts and strengthen the political climate for establishing childhood obesity prevention legislation within state governments. Expanded surveillance (including standardized identification and cataloging) of introduced and adopted legislation will enhance the ability to assess progress and identify effective approaches. Future policy research should examine determinants, implementation, and effectiveness of legislation to prevent childhood obesity.
PMCID: PMC1955401  PMID: 17572960
8.  The construction of a decision tool to analyse local demand and local supply for GP care using a synthetic estimation model 
Background
This study addresses the growing academic and policy interest in the appropriate provision of local healthcare services to the healthcare needs of local populations to increase health status and decrease healthcare costs. However, for most local areas information on the demand for primary care and supply is missing. The research goal is to examine the construction of a decision tool which enables healthcare planners to analyse local supply and demand in order to arrive at a better match.
Methods
National sample-based medical record data of general practitioners (GPs) were used to predict the local demand for GP care based on local populations using a synthetic estimation technique. Next, the surplus or deficit in local GP supply were calculated using the national GP registry. Subsequently, a dynamic internet tool was built to present demand, supply and the confrontation between supply and demand regarding GP care for local areas and their surroundings in the Netherlands.
Results
Regression analysis showed a significant relationship between sociodemographic predictors of postcode areas and GP consultation time (F [14, 269,467] = 2,852.24; P <0.001). The statistical model could estimate GP consultation time for every postcode area with >1,000 inhabitants in the Netherlands covering 97% of the total population. Confronting these estimated demand figures with the actual GP supply resulted in the average GP workload and the number of full-time equivalent (FTE) GP too much/too few for local areas to cover the demand for GP care. An estimated shortage of one FTE GP or more was prevalent in about 19% of the postcode areas with >1,000 inhabitants if the surrounding postcode areas were taken into consideration. Underserved areas were mainly found in rural regions.
Conclusions
The constructed decision tool is freely accessible on the Internet and can be used as a starting point in the discussion on primary care service provision in local communities and it can make a considerable contribution to a primary care system which provides care when and where people need it.
doi:10.1186/1478-4491-11-55
PMCID: PMC4231547  PMID: 24161015
Health workforce planning; Local population demand; Synthetic estimation method; General practitioner care; Spatial microsimulation model; Decision tool
9.  A matrix model for valuing anesthesia service with the resource-based relative value system 
Background
The purpose of this study was to propose a new crosswalk using the resource-based relative value system (RBRVS) that preserves the time unit component of the anesthesia service and disaggregates anesthesia billing into component parts (preoperative evaluation, intraoperative management, and postoperative evaluation). The study was designed as an observational chart and billing data review of current and proposed payments, in the setting of a preoperative holing area, intraoperative suite, and post anesthesia care unit. In total, 1,195 charts of American Society of Anesthesiology (ASA) physical status 1 through 5 patients were reviewed. No direct patient interventions were undertaken.
Results
Spearman correlations between the proposed RBRVS billing matrix payments and the current ASA relative value guide methodology payments were strong (r=0.94–0.96, P<0.001 for training, test, and overall). The proposed RBRVS-based billing matrix yielded payments that were 3.0%±1.34% less than would have been expected from commercial insurers, using standard rates for commercial ASA relative value units and RBRVS relative value units. Compared with current Medicare reimbursement under the ASA relative value guide, reimbursement would almost double when converting to an RBRVS billing model. The greatest increases in Medicare reimbursement between the current system and proposed billing model occurred as anesthetic management complexity increased.
Conclusion
The new crosswalk correlates with existing evaluation and management and intensive care medicine codes in an essentially revenue neutral manner when applied to the market-based rates of commercial insurers. The new system more highly values delivery of care to more complex patients undergoing more complex surgery and better represents the true value of anesthetic case management.
doi:10.2147/JMDH.S68671
PMCID: PMC4199848  PMID: 25336964
payment reform; billing; crosswalk
10.  Overview of States’ Use of Telehealth for the Delivery of Early Intervention (IDEA Part C) Services 
Background:
Early intervention (EI) services are designed to promote the development of skills and enhance the quality of life of infants and toddlers who have been identified as having a disability or developmental delay, enhance capacity of families to care for their child with special needs, reduce future educational costs, and promote independent living (NECTAC, 2011). EI services are regulated by Part C of the Individuals with Disabilities Education Improvement Act (IDEA); however, personnel shortages, particularly in rural areas, limit access for children who qualify. Telehealth is an emerging delivery model demonstrating potential to deliver EI services effectively and efficiently, thereby improving access and ameliorating the impact of provider shortages in underserved areas. The use of a telehealth delivery model facilitates inter-disciplinary collaboration, coordinated care, and consultation with specialists not available within a local community.
Method:
A survey sent by the National Early Childhood Technical Assistance Center (NECTAC) to IDEA Part C coordinators assessed their utilization of telehealth within states’ IDEA Part C programs. Reimbursement for provider type and services and barriers to implement a telehealth service delivery model were identified.
Results:
Representatives from 26 states and one jurisdiction responded to the NECTAC telehealth survey. Of these, 30% (n=9) indicated that they are either currently using telehealth as an adjunct service delivery model (n=6) or plan to incorporate telehealth within the next 1–2 years (n=3). Identified telehealth providers included developmental specialists, teachers of the Deaf/Hard of Hearing (DHH), speech-language pathologists, occupational therapists, physical therapists, behavior specialists, audiologists, and interpreters. Reimbursement was variable and included use of IDEA Part C funding, Medicaid, and private insurance. Expressed barriers and concerns for the implementation of telehealth as a delivery model within Part C programming included security issues (40%; n=11); privacy issues (44%; n=12); concerns about quality of services delivered via telehealth (40%; n=11); and lack of evidence to support the effectiveness of a telehealth service delivery model within IDEA Part C programming (3%; n=1). Reimbursement policy and billing processes and technology infrastructure were also identified as barriers impacting the implementation of telehealth programming.
Conclusions:
Provider shortages impact the quantity and quality of services available for children with disabilities and developmental delay, particularly in rural areas. While many states are incorporating telehealth within their Early Intervention (IDEA Part C) services in order to improve access and overcome personnel shortages, barriers persist. Policy development, education of stakeholders, research, utilization of secure and private delivery platforms, and advocacy may facilitate more widespread adoption of telehealth within IDEA Part C programs across the country.
doi:10.5195/IJT.2012.6105
PMCID: PMC4296829  PMID: 25945202
Telehealth; tele-intervention; telerehabilitation; Individuals with Disabilities Education Improvement Act (IDEA); early intervention services
11.  Inequities in accessibility to and utilisation of maternal health services in Ghana after user-fee exemption: a descriptive study 
Introduction
Inequities in accessibility to, and utilisation of maternal healthcare services impede progress towards attainment of the maternal health-related Millennium Development Goals. The objective of this study is to examine the extent to which maternal health services are utilised in Ghana, and whether inequities in accessibility to and utilization of services have been eliminated following the implementation of a user-fee exemption policy, that aims to reduce financial barriers to access, reduce inequities in access, and improve access to and use of birthing services.
Methods
We analyzed data from the 2007 Ghana Maternal Health Survey for inequities in access to and utilization of maternal health services. In measuring the inequities, frequency tables and cross-tabulations were used to compare rates of service utilization by region, residence and selected socio-demographic variables.
Results
Findings show marginal increases in accessibility to and utilisation of skilled antenatal, delivery and postnatal care services following the policy implementation (2003–2007). However, large gradients of inequities exist between geographic regions, urban and rural areas, and different socio-demographic, religious and ethnic groupings. More urban women (40%) than rural, 53% more women in the highest wealth quintile than women in the lowest, 38% more women in the best performing region (Central Region) than the worst (Upper East Region), and 48% more women with at least secondary education than those with no formal education, accessed and used all components of skilled maternal health services in the five years preceding the survey. Our findings raise questions about the potential equity and distributional benefits of Ghana’s user-fee exemption policy, and the role of non-financial barriers or considerations.
Conclusion
Exempting user-fees for maternal health services is a promising policy option for improving access to maternal health care, but might be insufficient on its own to secure equitable access to maternal health services in Ghana. Ensuring equity in access will require moving beyond user-fee exemption to addressing wider issues of supply and demand factors and the social determinants of health, including redistributing healthcare resources and services, and redressing the positional vulnerability of women in their communities.
doi:10.1186/s12939-014-0089-z
PMCID: PMC4318433  PMID: 25388288
User-fee exemption; Maternal health; Access; Inequity; Ghana
12.  Analysis of Services Received Under Medicare by Specialty of Physician 
Health Care Financing Review  1981;3(1):89-116.
This paper examines use of physicians' services by Medicare beneficiaries according to the specialty of the physician providing care. The major objectives of this study were to determine which types of physicians are most frequently used, the average charge per service by specialty, the mix of physicians (by specialty) that patients saw during the year, and the amount Medicare reimburses in relation to total physician income. Data were studied for the total Medicare population and by age, sex, race, and geographic area.
Claims data for 1975 and 1977 were used from the Part B Bill Summary System. This system collects information from bills for a 5 percent sample of Medicare enrollees.
Major findings from this study indicate: (1) Physicians in general practice and internal medicine provided about the same number of services and each far outranked all other types of physicians in numbers of Medicare beneficiaries with reimbursed services. (2) There were marked differences by census region in the use of certain specialists, particularly pathologists, podiatrists, dermatologists, and the specialty group otology, laryngology, rhinology. (3) Average charges per service varied considerably by specialty. Internists' charges averaged 35 percent higher per service than charges by general practitioners. Charges submitted by the surgical specialties far outranked all others and showed the greatest increase during the period under study. (4) Of the total persons with reimbursed physicians' services in 1977, 85 percent saw a primary care physician during the year, while the remaining 15 percent received services from specialists only. (5) Of the total reimbursements made by Medicare, internists received 20 percent, general practitioners received 14 percent, and general surgeons 12 percent. Medicare's payments were estimated to be 21 percent of total gross income for internists, 20 percent for anesthesiologists, and 18 percent for surgical specialties.
PMCID: PMC4191236  PMID: 10309476
13.  Patterns and predictors of state adult obesity prevention legislation enactment in US states: 2010–2013 
Preventive medicine  2015;74:117-122.
Objective
This study examined bill- and state-level factors associated with enactment of adult obesity prevention legislation in US states.
Methods
A review of bills in the Rudd Center for Food Policy and Obesity’s legislative database identified 487 adult obesity prevention bills, or proposed legislation, introduced between 2010 and 2013. Multilevel models were constructed to examine bill- and state-level characteristics associated with enactment.
Results
From 2010 to 2013, 81 (17%) of obesity prevention bills introduced were enacted across 35 states and the District of Columbia. Bills introduced in 2010 were more likely to be enacted than in 2013 (OR = 9.49; 95% CI: 2.61–34.5). Bills focused on access to healthy food, physical activity, general and educational programs, as well as modifying rules and procedures (e.g., preemption) had greater odds of enactment relative to food and beverage taxes (OR = 8.18; 95% CI: 2.85–23.4 healthy food; OR = 17.3; 95% CI: 4.55–65.7 physical activity; OR = 15.2; 95% CI: 4.80–47.9 general; OR = 13.7; 95% CI: 3.07–61.5 rules).
Conclusion
The year of bill introduction and overall bill enactment rate were related to adult obesity prevention legislation enactment in states. This study highlights the importance of a bill’s topic area for enactment and provides insights for advocates and policymakers trying to address enactment barriers.
doi:10.1016/j.ypmed.2015.02.013
PMCID: PMC4422336  PMID: 25735604
Obesity; Policy; Legislation
14.  Malaria Burden and Artemisinin Resistance in the Mobile and Migrant Population on the Thai–Myanmar Border, 1999–2011: An Observational Study 
PLoS Medicine  2013;10(3):e1001398.
Francois Nosten and colleagues evaluate malaria prevalence and incidence in the mobile population on the Myanmar side of the border with Thailand between 1999 and 2011, and also assess resistance to artemisinin.
Background
The Shoklo Malaria Research Unit has been working on the Thai–Myanmar border for 25 y providing early diagnosis and treatment (EDT) of malaria. Transmission of Plasmodium falciparum has declined, but resistance to artesunate has emerged. We expanded malaria activities through EDT and evaluated the impact over a 12-y period.
Methods and Findings
Between 1 October 1999 and 30 September 2011, the Shoklo Malaria Research Unit increased the number of cross-border (Myanmar side) health facilities from two to 11 and recorded the number of malaria consultations. Changes in malaria incidence were estimated from a cohort of pregnant women, and prevalence from cross-sectional surveys. In vivo and in vitro antimalarial drug efficacy were monitored. Over this period, the number of malaria cases detected increased initially, but then declined rapidly. In children under 5 y, the percentage of consultations due to malaria declined from 78% (95% CI 76–80) (1,048/1,344 consultations) to 7% (95% CI 6.2–7.1) (767/11,542 consultations), p<0.001. The ratio of P. falciparum/P. vivax declined from 1.4 (95% CI 1.3–1.4) to 0.7 (95% CI 0.7–0.8). The case fatality rate was low (39/75,126; 0.05% [95% CI 0.04–0.07]). The incidence of malaria declined from 1.1 to 0.1 episodes per pregnant women-year. The cumulative proportion of P. falciparum decreased significantly from 24.3% (95% CI 21.0–28.0) (143/588 pregnant women) to 3.4% (95% CI 2.8–4.3) (76/2,207 pregnant women), p<0.001. The in vivo efficacy of mefloquine-artesunate declined steadily, with a sharp drop in 2011 (day-42 PCR-adjusted cure rate 42% [95% CI 20–62]). The proportion of patients still slide positive for malaria at day 3 rose from 0% in 2000 to reach 28% (95% CI 13–45) (8/29 patients) in 2011.
Conclusions
Despite the emergence of resistance to artesunate in P. falciparum, the strategy of EDT with artemisinin-based combination treatments has been associated with a reduction in malaria in the migrant population living on the Thai–Myanmar border. Although limited by its observational nature, this study provides useful data on malaria burden in a strategically crucial geographical area. Alternative fixed combination treatments are needed urgently to replace the failing first-line regimen of mefloquine and artesunate.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
According to latest figures, the World Health Organization estimates that there are over 200 million cases of malaria each year, with over three-quarters of a million deaths. Several Plasmodium parasites cause malaria (the most serious being Plasmodium falciparum) and are transmitted to people through the bites of infected night-flying mosquitoes. Malaria transmission can be prevented by using insecticides to control the mosquitoes and by sleeping under insecticide-treated bed nets. However, in Southeast Asia the effectiveness of these measures is limited. Treating infected people with antimalarial drugs, particularly with artemisinin-based combination treatments (ACTs), is a key strategy in reducing the deaths and disability caused by malaria. However, progress is now threatened by the emergence in Southeast Asia of P. falciparum isolates that are resistant to artesunate (a common component of ACT). This development is concerning, as resistance to the artemisinin family of drugs, of which artesunate is a member, could trigger a resurgence in malaria in many parts of the world and compromise the progress made in the treatment of severe malaria.
Why Was This Study Done?
P. falciparum resistance to artemisinin has been confirmed in the area around the border between Thailand and Myanmar. Malaria control in this border area is particularly challenging, as there is a reservoir of malaria in Myanmar (where the disease burden is higher than in Thailand), frequent population movement, and differences in adequate control measures on the two sides of the border. In this study the authors evaluated malaria prevalence and incidence in the mobile population on the Myanmar side of the border between 1 October 1999 and 30 September 2011 to assess whether increasing access to early diagnosis and treatment with ACT was associated with a decline in the malaria burden.
What Did the Researchers Do and Find?
The Shoklo Malaria Research Unit (SMRU) has been working on the Thai–Myanmar border for 25 years providing early diagnosis and treatment of malaria and has extended its services from two to 11 health care facilities (health posts) on the Myanmar side of the border over the past few years. In order to evaluate any changes in the malaria burden since the expansion of services, the researchers recorded the number of consultations in all SMRU clinics and health posts with confirmed malaria diagnosis and tracked changes in the prevalence of malaria in the population on the Myanmar side of the border (via cross-sectional surveys in villages). The researchers also assessed the incidence of malaria in a cohort of pregnant women living on both sides of the border and monitored antimalarial drug efficacy over this time period.
The researchers found that although the mobile population on the Thai side of the border remained constant, the population in villages covered by the clinics and health posts in the border area increased four-fold. Over the time period, the researchers found that the number of confirmed malaria cases (P. falciparum) increased initially, rising from just over 5,000 in 2000 to a peak of 13,764 in 2006, and then declined to just over 3,500 in 2011. A striking finding was the predominance of infections in young adult males (50,316/90,321; 55.7%). Encouragingly, the percentage of consultations due to malaria in children under five years fell from 78% to 7%, and the incidence of malaria declined from 1.1 to 0.1 episodes per pregnant woman-year. In addition, the proportion of patients admitted to hospital with severe disease was stable, and the number of deaths from malaria remained extremely low, with an overall case fatality rate of 0.05%. The researchers also found that the ratio of P. falciparum to P. vivax infections declined from 1.4 to 0.7, and the prevalence of P. falciparum decreased from 24.3% to 3.4%. However, worryingly, in the small number of patients undertaking drug efficacy tests, the drug efficacy of artesunate declined steadily, with the proportion of patients still infected with malaria at day 3 of treatment increasing from 0% in 2000 to 28% in 2011.
What Do These Findings Mean?
These findings indicate that despite the emergence of resistance to artesunate in P. falciparum, and the decline in the efficacy of ACT, the strategy of early diagnosis and treatment with ACTs has been associated with a reduction in malaria in the population living on the Thai–Myanmar border. Furthermore, these findings suggest that an aggressive strategy based on early detection and treatment of cases, combined with vector control and information, could be the way forward to eliminate malaria. Although there were only a small number of patients involved in drug efficacy tests in 2011, this study shows that alternative fixed combination treatments are needed urgently to replace the failing first-line regimen of mefloquine and artesunate.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001398.
More information about the Shoklo Malaria Research Unit is available
The World Health Organization website has more information about antimalarial drug efficacy and drug resistance
The Bill & Melinda Gates Foundation website tells the malaria resistance story
doi:10.1371/journal.pmed.1001398
PMCID: PMC3589269  PMID: 23472056
15.  Primary care physician supply and other key determinants of health care utilisation: the case of Switzerland 
Background
The Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland.
Methods
The data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data.
Results
Models within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care.
Conclusion
The study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss language regions and may be rooted in the different cultural backgrounds of the served populations.
doi:10.1186/1472-6963-8-8
PMCID: PMC2242783  PMID: 18190705
16.  Out-of-pocket expenditures for primary health care in Tajikistan: a time-trend analysis 
Background
Aligned with the international call for universal coverage of affordable and quality health care, the government of Tajikistan is undertaking reforms of its health system aiming amongst others at reducing the out-of-pocket expenditures (OPE) of patients seeking care. Household surveys were conducted in 2005, 2007, 2008 and 2011 to explore the scale and determinants of OPE of users in four district of Tajikistan, where health care is legally free of charge at the primary level.
Methods
Using the data from four cross-sectional household surveys conducted between 2005 and 2011, time trends in OPE for consultation fees, drugs and transport costs of adult users of family medicine services were analysed. To investigate differences along the economic status, an asset index was constructed using principal component analysis.
Results
Adjusted for inflation, OPE for primary care have substantially increased in the period 2005 to 2011. While the proportion of patients reporting the payment of informal consultation fees to providers and their amount were constant over time, the proportion of patients reporting expenditures for drugs has increased, and the median amounts have doubled from 5.3 US$ to 10.7 US$. Thus, the expenditures on medicine represent the biggest financial burden for patients accessing a primary care facility. Regression models showed that in 2011 patients from the most remote district with spread-out villages reported significant higher expenditures on medicine. Besides the steady increase in the median amount for OPE, the proportion of patients reporting making an informal payment to their care provider showed great variations across district of residence (between 20% and 73%) and economic status (between 33% among the ‘worst-off’ group and 68% among the ‘better-off’ group).
Conclusions
In a context of limited governmental funds allocated to health and financing reforms aiming to improve financial access to primary care, the present paper indicates that in Tajikistan OPE – especially in relation to expenditures for drugs – have increased over time, and vary substantially across geographical areas and economic status. The fact that better-off households report disbursing more and in higher proportions hints towards a discrimination along the capacity to pay from providers. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies to improve access of patients to services.
doi:10.1186/1472-6963-13-103
PMCID: PMC3614449  PMID: 23505990
Tajikistan; Informal payments; Out-of-pocket expenditure; Family medicine; Health reforms
17.  High-billing general practitioners and family physicians in Ontario: how do they do it? An analysis of practice patterns of GP/FPs with annual billings over $400,000. 
BACKGROUND: To better understand the reasons why some fee-for-service physicians have high billing levels, the authors compared the practice and demographic characteristics of general practitioners and family physicians (GP/FPs) who submitted over $400,000 in annual Ontario Health Insurance Plan (OHIP) fee-for-service claims in 1994-95 with those of GP/FPs who billed between $35,000 and $400,000. METHODS: The authors describe the OHIP billing and physician characteristic data for fiscal year 1994-95. They used multivariate logistic regression to determine factors independently associated with high billing status. RESULTS: A total of 219 GP/FPs (2.5% of the GP/FPs in Ontario) billed over $400,000 in 1994-95. Of these, 14 had billing patterns similar to those of specialists, and 27 billed predominantly for diagnostic and therapeutic procedures (particularly physiotherapy). The remaining 178 (81.3%) billed for a mix of services similar to that of other GP/FPs but on average had 2.6 times the volume of patient assessments and a greater share of their total billings derived from diagnostic and therapeutic procedures (9.1% v. 5.6%). Multivariate analysis indicated that these high-volume GP/FPs were less likely than GP/FPs who billed between $35,000 and $400,000 to be 60 years of age or older (odds ratio [OR] 0.09, p < 0.05) and female (OR 0.21) and were more likely to be foreign graduates (OR 1.85) and practising in a region with low physician supply (OR 0.45 for each increase of 1 physician per 1000 population). Metropolitan Toronto was an outlier to the latter relation and was more likely to have high-volume GP/FPs (OR 16.89). INTERPRETATION: High-billing GP/FPs attained their high billing levels by maintaining large numbers of patient visits and by performing procedures. Further research is needed to determine the time spent per patient and the quality of care delivered by these physicians as well as the appropriateness of the procedures that they perform.
PMCID: PMC1229097  PMID: 9538852
18.  Medicare Assignment Rates of Physicians: Their Responses to Changes in Reimbursement Policy 
Health Care Financing Review  1980;1(3):75-89.
A physician's Medicare assignment rate is one measure of his or her willingness to participate in the Medicare program. The assignment rate reflects the proportion of services provided to Medicare beneficiaries for which the physician accepts the Medicare reasonable fee as payment in full. Generally, Medicare reasonable fees are lower than the payment which a physician receives from providing the same service to a private patient or to a Medicare patient who is not treated on assignment. Because Medicare eligibles not treated on an assigned basis are financially liable for the difference between the physician's charge and the Medicare reasonable fee, the assignment rate is an indication of the out-of-pocket costs borne by Medicare eligibles.
One factor which may affect the willingness of physicians to accept patients on assignment is the difference between the reimbursement which he or she may receive in the private market and the fee received from treating Medicare eligibles on assignment. Throughout this paper we assume that the physician's private price or billed charge is equivalent to the level of reimbursement received from treating privately insured patients and Medicare non-assigned patients. Since the level of reimbursement is generally no greater than the billed charge and may be less, this assumption may overstate the actual reimbursement received by the physician. In all instances, reimbursement refers to the aggregate amount received by the physician from all sources for a given service. The lower a physician's Medicare reasonable fee relative to the private market fee the less willing he/she may be to participate in Medicare assignment. This paper examines the effect of changes in Medicare reimbursement on the assignment rates of physicians. It also predicts Medicare assignment rates under a policy option which would increase Medicare reasonable fees to the level of prevailing fees.
PMCID: PMC4191123  PMID: 10309135
19.  Geographical Inequalities in Use of Improved Drinking Water Supply and Sanitation across Sub-Saharan Africa: Mapping and Spatial Analysis of Cross-sectional Survey Data 
PLoS Medicine  2014;11(4):e1001626.
Using cross-sectional survey data, Rachel Pullan and colleagues map geographical inequalities in use of improved drinking water supply and sanitation across sub-Saharan Africa.
Please see later in the article for the Editors' Summary
Background
Understanding geographic inequalities in coverage of drinking-water supply and sanitation (WSS) will help track progress towards universal coverage of water and sanitation by identifying marginalized populations, thus helping to control a large number of infectious diseases. This paper uses household survey data to develop comprehensive maps of WSS coverage at high spatial resolution for sub-Saharan Africa (SSA). Analysis is extended to investigate geographic heterogeneity and relative geographic inequality within countries.
Methods and Findings
Cluster-level data on household reported use of improved drinking-water supply, sanitation, and open defecation were abstracted from 138 national surveys undertaken from 1991–2012 in 41 countries. Spatially explicit logistic regression models were developed and fitted within a Bayesian framework, and used to predict coverage at the second administrative level (admin2, e.g., district) across SSA for 2012. Results reveal substantial geographical inequalities in predicted use of water and sanitation that exceed urban-rural disparities. The average range in coverage seen between admin2 within countries was 55% for improved drinking water, 54% for use of improved sanitation, and 59% for dependence upon open defecation. There was also some evidence that countries with higher levels of inequality relative to coverage in use of an improved drinking-water source also experienced higher levels of inequality in use of improved sanitation (rural populations r = 0.47, p = 0.002; urban populations r = 0.39, p = 0.01). Results are limited by the quantity of WSS data available, which varies considerably by country, and by the reliability and utility of available indicators.
Conclusions
This study identifies important geographic inequalities in use of WSS previously hidden within national statistics, confirming the necessity for targeted policies and metrics that reach the most marginalized populations. The presented maps and analysis approach can provide a mechanism for monitoring future reductions in inequality within countries, reflecting priorities of the post-2015 development agenda.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Access to a safe drinking-water supply (a water source that is protected from contamination) and to adequate sanitation facilities (toilets, improved latrines, and other facilities that prevent people coming into contact with human urine and feces) is essential for good health. Unimproved drinking-water sources and sanitation are responsible for 85% of deaths from diarrhea and 1% of the global burden of disease. They also increase the transmission of parasitic worms and other neglected tropical diseases. In 2000, world leaders set a target of reducing the proportion of the global population without access to safe drinking water and basic sanitation to half of the 1990 level by 2015 as part of Millennium Development Goal (MDG) 7 (“Ensure environmental sustainability”; the MDGs are designed to improve the social, economic, and health conditions in the world's poorest countries). Between 1990 and 2010, more than 2 billion people gained access to improved drinking-water sources and 1.8 billion gained access to improved sanitation. In 2011, 89% of the world's population had access to an improved drinking-water supply, 1% above the MDG target, and 64% had access to improved sanitation (the MDG target is 75%).
Why Was This Study Done?
Despite these encouraging figures, the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) estimates that, globally, 768 million people relied on unimproved drinking-water sources, 2.5 billion people did not use an improved sanitation facility, and more than 1 billion people (15% of the global population) were defecating in the open in 2011. The JMP estimates for 2011 also reveal national and sub-national inequalities in drinking-water supply and sanitation coverage but a better understanding of geographic inequalities is needed to track progress towards universal coverage of access to improved water and sanitation and to identify the populations that need the most help to achieve this goal. Here, the researchers use cross-sectional household survey data and modern statistical approaches to produce a comprehensive map of the coverage of improved drinking-water supply and improved sanitation at high spatial resolution for sub-Saharan Africa and to investigate geographic inequalities in coverage. Cross-sectional household surveys collect health and other information from households at a single time-point, including data on use of safe water and improved sanitation.
What Did the Researchers Do and Find?
The researchers extracted data on reported household use of an improved drinking-water supply (for example, a piped water supply), improved sanitation facilities (for example, a flushing toilet), and open defecation from 138 national household surveys undertaken between 1991 and 2012 in 41 countries in sub-Saharan Africa. They developed statistical models to fit these data and used the models to estimate coverage at the district (second administrative) level across sub-Saharan Africa for 2012. For ten countries, the estimated coverage of access to improved drinking water at the district level within individual countries ranged from less than 25% to more than 75%. Within-country ranges of a similar magnitude were estimated for coverage of access to improved sanitation (21 countries) and for open defecation (16 countries). Notably, rural households in the districts with the lowest coverage of access to improved water supply and sanitation within a country were 1.5–8 times less likely to access improved drinking water, 2–18 times less likely to access improved sanitation, and 2–80 times more likely to defecate in the open than rural households in districts with the best coverage. Finally, countries with high levels of inequality in improved drinking-water source coverage also experienced high levels of inequality in improved sanitation coverage.
What Do These Findings Mean?
These findings identify important geographic inequalities in the coverage of access to improved water sources and sanitation that were previously hidden within national statistics. The accuracy of these findings depends on the accuracy of the data on water supplies and sanitation provided by household surveys, on the researchers' definitions for improved water supplies and sanitation, and on their statistical methods. Nevertheless, these findings confirm that, to achieve universal coverage of access to improved drinking-water sources and sanitation, strategies that target the areas with the lowest coverage are essential. Moreover, the maps and the analytical approach presented here provide the means for monitoring future reductions in inequalities in the coverage of access to improved water sources and sanitation and thus reflect a major priority of the post-2015 development agenda.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001626.
A PLOS Medicine Collection on water and sanitation is available
The World Health Organization (WHO) provides information on water, sanitation, and health (in several languages)
The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation is the official United Nations mechanism tasked with monitoring progress toward MDG7, Target 7B; the JMP 2013 update report is available online (also available in French and Spanish through the JMP website)
The sub-national predictions resulting from this study and the final sub-national maps are available as a resource for researchers and planners
doi:10.1371/journal.pmed.1001626
PMCID: PMC3979660  PMID: 24714528
20.  Healthcare service providers’ and facility administrators’ perspectives of the free maternal healthcare services policy in Malindi District, Kenya: a qualitative study 
Reproductive Health  2015;12:59.
Background
Globally, there are increasing efforts to improve maternal health outcomes including the reduction in maternal mortality rates. Improved access to skilled care utilisation during pregnancy and delivery has been one of the strategies employed to improve maternal health outcomes. In Kenya, more than half of the women deliver without the assistance of a skilled attendant and this has contributed to high maternal mortality rates. The free maternal healthcare services policy in all public facilities was initiated as a strategy to improve access to skilled care and reduce poor maternal health outcomes. This study aimed to explore the perspectives of the service providers and facility administrators of the free maternal health care service policy that was introduced in Kenya in 2013.
Methods
A qualitative inquiry using semi-structured one-on-one interviews was conducted in Malindi District, Kenya. The participants included maternal health service providers and facility administrators recruited from five different healthcare facilities. Data were analysed using a thematic framework analysis.
Results
Free maternal healthcare service provision was perceived to boost skilled care utilisation during pregnancy and delivery. However, challenges including; delays in the reimbursement of funds by the government to the facilities, stock outs of essential commodities in the facilities to facilitate service provision, increased workload amidst staff shortage and lack of consultation and sensitisation of key stakeholders were perceived as barriers to effective implementation of this policy.
Conclusion
Free maternal healthcare services can be one of the strategies to improve a range of maternal health outcomes. However, the implementation of this policy would be more effective if; the healthcare facilities were upgraded, equipped with adequate supplies, funds and staff; the community are continually sensitized on the importance of seeking skilled care during pregnancy and delivery; and inclusivity and collaboration with other key stakeholders be fostered in addressing poor maternal health outcomes in the country.
doi:10.1186/s12978-015-0048-1
PMCID: PMC4482051  PMID: 26116432
Free maternal healthcare service policy; Healthcare providers; Facility administrators; Malindi District; Kenya
21.  Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study 
PLoS Medicine  2010;7(6):e1000297.
Blustein and colleagues examine the associations between changes in hospital performance and their local economic resources. Locationally disadvantaged hospitals perform poorly on key indicators, raising concerns that pay-for-performance models may not reduce inequality.
Background
Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.
Methods and Findings
We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare's “Value-Based Purchasing” program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p<0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p<0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.
Conclusions
Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare's hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
These days, many people are rewarded for working hard and efficiently by being given bonuses when they reach preset performance targets. With a rapidly aging population and rising health care costs, policy makers in many developed countries are considering ways of maximizing value for money, including rewarding health care providers when they meet targets, under “pay-for-performance.” In the UK, for example, a major pay-for-performance initiative—the Quality and Outcomes Framework—began in 2004. All the country's general practices (primary health care facilities that deal with all medical ailments) now detail their achievements in terms of numerous clinical quality indicators for common chronic conditions (for example, the regularity of blood sugar checks for people with diabetes). They are then rewarded on the basis of these results.
Why Was This Study Done?
In the US, the government is poised to implement a nationwide pay-for-performance program in hospitals within Medicare, the government program that provides health insurance to Americans aged 65 years or older, as well as people with disabilities. However, some observers are concerned about the effect that the proposed pay-for-performance program might have on the distribution of health care resources in the US. Pay-for-performance assumes that health care providers have the economic and human resources that they need to perform or to improve their performance. But, if a hospital's capacity to perform depends on local resources, payment based on performance might worsen existing health care inequalities because hospitals in under-resourced areas might lose funds to hospitals in more affluent regions. In other words, the government might act as a reverse Robin Hood, taking from the poor and giving to the rich. In this study, the researchers examine the association between hospital performance and local economic and human resources, to explore whether this scenario is a plausible result of the pending change in US hospital reimbursement.
What Did the Researchers Do and Find?
US hospitals have voluntarily reported their performance on indicators of clinical care (“process-of-care measures”) for acute myocardial infarction (AMI, heart attack), heart failure (HF), and pneumonia under the Hospital Quality Alliance (HQA) program since 2004. The researchers identified 2,705 hospitals that had fully reported process-of-care measures for AMI and HF in both 2004 and 2007. They then used the “Performance Assessment Model” (a methodology developed by the US Centers for Medicare and Medicaid Services to score hospital performance) to calculate scores for each hospital. Finally, they looked for associations between these scores and measures of the hospital's local economic and human resources such as population poverty levels and the percentage of college graduates in the workforce. Hospital performance was associated with local and economic workforce capacity, they report. Thus, hospitals in counties with longstanding poverty had lower average performance scores for HF and AMI than hospitals in affluent counties. Similarly, hospitals in counties with a low percentage of college graduates in the workforce had lower average performance scores than hospitals in counties where more of the workforce had been to college. Finally, although performance improved generally over the study period, hospitals in disadvantaged areas still lagged behind hospitals in advantaged areas in 2007.
What Do These Findings Mean?
These findings indicate that hospital performance (as measured by the clinical process measures considered here) is associated with the quantity and quality of local human and economic resources. Thus, the proposed Medicare hospital pay-for-performance program may exacerbate existing US health care inequalities by leading to the transfer of funds from hospitals in disadvantaged locations to those in advantaged locations. Although further studies are needed to confirm this conclusion, these findings have important implications for pay-for-performance programs in health care. They suggest that US policy makers may need to modify how they measure performance improvement—the current Performance Assessment Model gives hospitals that start from a low baseline less credit for improvements than those that start from a high baseline. This works against hospitals in disadvantaged locations, which start at a low baseline. Second and more generally, they suggest that there may be a tension between the efficiency goals of pay-for-performance and other equity goals of health care systems. In a world where resources vary across regions, the expectation that regions can perform equally may not be realistic.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000297.
KaiserEDU.org is an online resource for learning about the US health care system. It includes educational modules on such topics as the Medicare program and efforts to improve the quality of care
The Hospital Quality Alliance provides information on the quality of care in US hospitals
Information about the UK National Health Service Quality and Outcomes Framework pay-for-performance initiative for general practice surgeries is available
doi:10.1371/journal.pmed.1000297
PMCID: PMC2893955  PMID: 20613863
22.  Health systems research in the time of health system reform in India: a review 
Background
Research on health systems is an important contributor to improving health system performance. Importantly, research on program and policy implementation can also create a culture of public accountability. In the last decade, significant health system reforms have been implemented in India. These include strengthening the public sector health system through the National Rural Health Mission (NRHM), and expansion of government-sponsored insurance schemes for the poor. This paper provides a situation analysis of health systems research during the reform period.
Methods
We reviewed 9,477 publications between 2005 and 2013 in two online databases, PubMed and IndMED. Articles were classified according to the WHO classification of health systems building blocks.
Results
Our findings indicate the number of publications on health systems progressively increased every year from 92 in 2006 to 314 in 2012. The majority of papers were on service delivery (40%), with fewer on information (16%), medical technology and vaccines (15%), human resources (11%), governance (5%), and financing (8%). Around 70% of articles were lead by an author based in India, the majority by authors located in only four states. Several states, particularly in eastern and northeastern India, did not have a single paper published by a lead author located in a local institution. Moreover, many of these states were not the subject of a single published paper. Further, a few select institutions produced the bulk of research. Of the foreign author lead papers, 77% came from five countries (USA, UK, Canada, Australia, and Switzerland).
Conclusions
The growth of published research during the reform period in India is a positive development. However, bulk of this research is produced in a few states and by a few select institutions Further strengthening health systems research requires attention to neglected health systems domains like human resources, financing, and governance. Importantly, research capacity needs to be strengthened in states and institutions that have a scarcity of researchers, as well as states that have been the focus of little research. While more funding for health systems research is required, this funding needs to be targeted at deficient health systems domains, geographical areas, and institutions.
doi:10.1186/1478-4505-12-37
PMCID: PMC4134119  PMID: 25106759
23.  A review of rural and remote health service indexes: are they relevant for the development of an Australian rural birth index? 
Background
Policy informs the planning and delivery of rural and remote maternity services and influences the perinatal outcomes of the 30 per cent of Australian women and their babies who live outside the major cities. Currently however, there are no planning tools that identify the optimal level of birthing services for rural and remote communities in Australia. To address this, the Australian government has prioritised the development of a rigorous methodology in the Australian National Maternity Services Plan to inform the planning of rural and remote maternity services.
Methods
A review of the literature was undertaken to identify planning indexes with component variables as outlined in the Australian National Maternity Services Plan. The indexes were also relevant if they described need associated with a specific type and level of health service in rural and remote areas of high income countries. Only indexes that modelled a range of socioeconomic and or geographical variables, identified access or need for a specific service type in rural and remote communities were included in the review.
Results
Four indexes, two Australian and two Canadian met the inclusion criteria. They used combinations of variables including: geographical placement of services; isolation from services and socioeconomic vulnerability to identify access to a type and level of health service in rural and remote areas within 60 minutes. Where geographic isolation reduces access to services for high needs populations, additional measures of disadvantage including indigeneity could strengthen vulnerability scores.
Conclusion
Current planning indexes are applicable for the development of an Australian rural birthing index. The variables in each of the indexes were relevant, however use of flexible sized catchments to accurately account for population births and weighting for extreme geographic isolation needs to be considered. Additionally, socioeconomic variables are required that will reflect need for services particularly for isolated high needs populations. These variables could be used with Australian data and appropriate cut-off points to confirm applicability for maternity services. All of the indexes used similar types of variables and are relevant for the development of an Australian Rural Birth Index.
doi:10.1186/s12913-014-0548-7
PMCID: PMC4265404  PMID: 25491346
Indexes; Maternity services; Rural and remote; National maternity services plan
24.  The Chilling Effect: How Do Researchers React to Controversy? 
PLoS Medicine  2008;5(11):e222.
Background
Can political controversy have a “chilling effect” on the production of new science? This is a timely concern, given how often American politicians are accused of undermining science for political purposes. Yet little is known about how scientists react to these kinds of controversies.
Methods and Findings
Drawing on interview (n = 30) and survey data (n = 82), this study examines the reactions of scientists whose National Institutes of Health (NIH)-funded grants were implicated in a highly publicized political controversy. Critics charged that these grants were “a waste of taxpayer money.” The NIH defended each grant and no funding was rescinded. Nevertheless, this study finds that many of the scientists whose grants were criticized now engage in self-censorship. About half of the sample said that they now remove potentially controversial words from their grant and a quarter reported eliminating entire topics from their research agendas. Four researchers reportedly chose to move into more secure positions entirely, either outside academia or in jobs that guaranteed salaries. About 10% of the group reported that this controversy strengthened their commitment to complete their research and disseminate it widely.
Conclusions
These findings provide evidence that political controversies can shape what scientists choose to study. Debates about the politics of science usually focus on the direct suppression, distortion, and manipulation of scientific results. This study suggests that scholars must also examine how scientists may self-censor in response to political events.
Drawing on interview and survey data, Joanna Kempner's study finds that political controversies shape what many scientists choose not to study.
Editors' Summary
Background.
Scientific research is an expensive business and, inevitably, the organizations that fund this research—governments, charities, and industry—play an important role in determining the directions that this research takes. Funding bodies can have both positive and negative effects on the acquisition of scientific knowledge. They can pump money into topical areas such as the human genome project. Alternatively, by withholding funding, they can discourage some types of research. So, for example, US federal funds cannot be used to support many aspects of human stem cell research. “Self-censoring” by scientists can also have a negative effect on scientific progress. That is, some scientists may decide to avoid areas of research in which there are many regulatory requirements, political pressure, or in which there is substantial pressure from advocacy groups. A good example of this last type of self-censoring is the withdrawal of many scientists from research that involves certain animal models, like primates, because of animal rights activists.
Why Was This Study Done?
Some people think that political controversy might also encourage scientists to avoid some areas of scientific inquiry, but no studies have formally investigated this possibility. Could political arguments about the value of certain types of research influence the questions that scientists pursue? An argument of this sort occurred in the US in 2003 when Patrick Toomey, who was then a Republican Congressional Representative, argued that National Institutes of Health (NIH) grants supporting research into certain aspects of sexual behavior were “much less worthy of taxpayer funding” than research on “devastating diseases,” and proposed an amendment to the 2004 NIH appropriations bill (which regulates the research funded by NIH). The Amendment was rejected, but more than 200 NIH-funded grants, most of which examined behaviors that affect the spread of HIV/AIDS, were internally reviewed later that year; NIH defended each grant, so none were curtailed. In this study, Joanna Kempner investigates how the scientists whose US federal grants were targeted in this clash between politics and science responded to the political controversy.
What Did the Researchers Do and Find?
Kempner interviewed 30 of the 162 principal investigators (PIs) whose grants were reviewed. She asked them to describe their research, the grants that were reviewed, and their experience with NIH before, during, and after the controversy. She also asked them whether this experience had changed their research practice. She then used the information from these interviews to design a survey that she sent to all the PIs whose grants had been reviewed; 82 responded. About half of the scientists interviewed and/or surveyed reported that they now remove “red flag” words (for example, “AIDS” and “homosexual”) from the titles and abstracts of their grant applications. About one-fourth of the respondents no longer included controversial topics (for example, “abortion” and “emergency contraception”) in their research agendas, and four researchers had made major career changes as a result of the controversy. Finally, about 10% of respondents said that their experience had strengthened their commitment to see their research completed and its results published although even many of these scientists also engaged in some self-censorship.
What Do These Findings Mean?
These findings show that, even though no funding was withdrawn, self-censoring is now common among the scientists whose grants were targeted during this particular political controversy. Because this study included researchers in only one area of health research, its findings may not be generalizable to other areas of research. Furthermore, because only half of the PIs involved in the controversy responded to the survey, these findings may be affected by selection bias. That is, the scientists most anxious about the effects of political controversy on their research funding (and thus more likely to engage in self-censorship) may not have responded. Nevertheless, these findings suggest that the political environment might have a powerful effect on self-censorship by scientists and might dissuade some scientists from embarking on research projects that they would otherwise have pursued. Further research into what Kempner calls the “chilling effect” of political controversy on scientific research is now needed to ensure that a healthy balance can be struck between political involvement in scientific decision making and scientific progress.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050222.
The Consortium of Social Science Associations, an advocacy organization that provides a bridge between the academic research community and Washington policymakers, has more information about the political controversy initiated by Patrick Toomey
Some of Kempner's previous research on self-censorship by scientists is described in a 2005 National Geographic news article
doi:10.1371/journal.pmed.0050222
PMCID: PMC2586361  PMID: 19018657
25.  Spatial analysis of elderly access to primary care services 
Background
Admissions for Ambulatory Care Sensitive Conditions (ACSCs) are considered preventable admissions, because they are unlikely to occur when good preventive health care is received. Thus, high rates of admissions for ACSCs among the elderly (persons aged 65 or above who qualify for Medicare health insurance) are signals of poor preventive care utilization. The relevant geographic market to use in studying these admission rates is the primary care physician market. Our conceptual model assumes that local market conditions serving as interventions along the pathways to preventive care services utilization can impact ACSC admission rates.
Results
We examine the relationships between market-level supply and demand factors on market-level rates of ACSC admissions among the elderly residing in the U.S. in the late 1990s. Using 6,475 natural markets in the mainland U.S. defined by The Health Resources and Services Administration's Primary Care Service Area Project, spatial regression is used to estimate the model, controlling for disease severity using detailed information from Medicare claims files. Our evidence suggests that elderly living in impoverished rural areas or in sprawling suburban places are about equally more likely to be admitted for ACSCs. Greater availability of physicians does not seem to matter, but greater prevalence of non-physician clinicians and international medical graduates, relative to U.S. medical graduates, does seem to reduce ACSC admissions, especially in poor rural areas.
Conclusion
The relative importance of non-physician clinicians and international medical graduates in providing primary care to the elderly in geographic areas of greatest need can inform the ongoing debate regarding whether there is an impending shortage of physicians in the United States. These findings support other authors who claim that the existing supply of physicians is perhaps adequate, however the distribution of them across the landscape may not be optimal. The finding that elderly who reside in sprawling urban areas have access impediments about equal to residents of poor rural communities is new, and demonstrates the value of conceptualizing and modelling impedance based on place and local context.
doi:10.1186/1476-072X-5-19
PMCID: PMC1482683  PMID: 16700904

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