Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that ...cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.
Older people utilise more healthcare services and are likely to incur higher healthcare expenditure, however, data on their healthcare financing mechanisms are scarce in low-and middle- income ...countries including Ghana. In this study, we aimed at exploring how poor older people finance their healthcare in rural Ghana.
We conducted in-depth interviews and focus group discussions with 60 study participants comprising 30 poor older people, 15 healthcare providers and 15 caregivers in Atwima Nwabiagya District of Ghana. Data were analysed using thematic analytical framework and presented based on an a posteriori inductive reduction approach.
The study revealed that poor older people finance their healthcare through personal income, family support, Livelihood Empowerment Against Poverty grants and National Health Insurance Scheme subscription. It was also found that poor older people spent between GH¢ 20 and 250 on drugs, laboratory test and hospitalisation anytime they access a healthcare facility.
The findings contribute to our understanding of how poor older people finance their healthcare in rural Ghana. We argue that health stakeholders should strengthen healthcare financing mechanisms for poor older people for optimal healthcare use.
Abstract
Background
People who inject drugs (PWID) are a medically and socially vulnerable population with a high incidence of overdose, mental illness, and infections like HIV and hepatitis C. ...Existing literature describes social and economic correlations to increased health risk, including stigma. Injection drug use stigma has been identified as a major contributor to healthcare disparities for PWID. However, data on this topic, particularly in terms of the interface between enacted, anticipated, and internalized stigma, is still limited. To fill this gap, we examined perspectives from PWID whose stigmatizing experiences impacted their views of the healthcare system and syringe service programs (SSPs) and influenced their decisions regarding future medical care.
Methods
Semi-structured interviews conducted with 32 self-identified PWID in New York City. Interviews were audio recorded and transcribed. Interview transcripts were coded using a grounded theory approach by three trained coders and key themes were identified as they emerged.
Results
A total of 25 participants (78.1%) reported at least one instance of stigma related to healthcare system engagement. Twenty-three participants (71.9%) reported some form of enacted stigma with healthcare, 19 participants (59.4%) described anticipated stigma with healthcare, and 20 participants (62.5%) reported positive experiences at SSPs. Participants attributed healthcare stigma to their drug injection use status and overwhelmingly felt distrustful of, and frustrated with, medical providers and other healthcare staff at hospitals and local clinics. PWID did not report internalized stigma, in part due to the availability of non-stigmatizing medical care at SSPs.
Conclusions
Stigmatizing experiences of PWID in formal healthcare settings contributed to negative attitudes toward seeking healthcare in the future. Many participants describe SSPs as accessible sites to receive high-quality medical care, which may curb the manifestation of internalized stigma derived from negative experiences in the broader healthcare system. Our findings align with those reported in the literature and reveal the potentially important role of SSPs. With the goal of limiting stigmatizing interactions and their consequences on PWID health, we recommend that future research include explorations of mechanisms by which PWID make decisions in stigmatizing healthcare settings, as well as improving medical care availability at SSPs.
eHealth potentially enhances quality of care and may reduce health care costs. However, a review of systematic reviews published in 2010 concluded that high-quality evidence on the benefits of ...eHealth interventions was still lacking.
We conducted a systematic review of systematic reviews and meta-analyses on the effectiveness/cost-effectiveness of eHealth interventions in patients with somatic diseases to analyze whether, and to what possible extent, the outcome of recent research supports or differs from previous conclusions.
Literature searches were performed in PubMed, EMBASE, The Cochrane Library, and Scopus for systematic reviews and meta-analyses on eHealth interventions published between August 2009 and December 2012. Articles were screened for relevance based on preset inclusion and exclusion criteria. Citations of residual articles were screened for additional literature. Included papers were critically appraised using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement before data were extracted. Based on conclusions drawn by the authors of the included articles, reviews and meta-analyses were divided into 1 of 3 groups: suitable, promising, or limited evidence on effectiveness/cost-effectiveness. Cases of uncertainty were resolved by consensus discussion. Effect sizes were extracted from papers that included a meta-analysis. To compare our results with previous findings, a trend analysis was performed.
Our literature searches yielded 31 eligible reviews, of which 20 (65%) reported on costs. Seven papers (23%) concluded that eHealth is effective/cost-effective, 13 (42%) underlined that evidence is promising, and others found limited or inconsistent proof. Methodological quality of the included reviews and meta-analyses was generally considered high. Trend analysis showed a considerable accumulation of literature on eHealth. However, a similar percentage of papers concluded that eHealth is effective/cost-effective or evidence is at least promising (65% vs 62%). Reviews focusing primarily on children or family caregivers still remained scarce. Although a pooled (subgroup) analysis of aggregate data from randomized studies was performed in a higher percentage of more recently published reviews (45% vs 27%), data on economic outcome measures were less frequently reported (65% vs 85%).
The number of reviews and meta-analyses on eHealth interventions in patients with somatic diseases has increased considerably in recent years. Most articles show eHealth is effective/cost-effective or at least suggest evidence is promising, which is consistent with previous findings. Although many researchers advocate larger, well-designed, controlled studies, we believe attention should be given to the development and evaluation of strategies to implement effective/cost-effective eHealth initiatives in daily practice, rather than to further strengthen current evidence.
Abstract
In sub-Saharan African countries, out-of-pocket payments can be a major barrier to accessing appropriate healthcare services. Community-based health insurance (CBHI) has emerged as a ...context-appropriate risk-pooling mechanism to provide some financial protection to populations without access to formal health insurance. The aim of this rapid review was to examine the peer-reviewed literature on the impact of CBHI on the use of healthcare services as well as its capacity to improve equity in the use of healthcare between different socio-economic groups. A systematic search of three electronic databases (Pubmed, Cochrane Library and Littérature en Santé) was performed. Data were extracted on scheme and study characteristics, as well as the impact of the schemes on relevant outcomes. Sixteen publications met the inclusion criteria, studying schemes from seven different countries. They provide strong evidence that community-based health insurance can contribute to improving access to outpatient care and weak evidence that they improve access to inpatient care. There was low evidence on their capacity to improve equity in access to healthcare among insured members. In the absence of sufficient public spending for healthcare, such schemes may be able to provide some valuable benefits for communities with limited access to primary-level care in sub-Saharan Africa. The overall high risk of bias of the studies and the wide existing variety of insurance arrangements suggest caution in generalizing these results. These findings need to be validated and further developed by rigorous studies.
BackgroundPrimary care providers must understand the use patterns, clinical complexity, and primary care needs of cancer survivors to provide quality health care services. However, to the authors' ...knowledge, little is known regarding the prevalence and health care needs of this growing population, particularly in safety net settings.MethodsThe authors identified adults with a history of cancer documented in primary care electronic health records within a network of community health centers (CHCs) in 19 states. The authors estimated cancer history prevalence among >1.2 million patients and compared sex‐specific site distributions with national estimates. Each survivor was matched to 3 patients without cancer from the same set of clinics. The demographic characteristics, primary care use, and comorbidity burden then were compared between the 2 groups, assessing differences with absolute standardized mean differences (ASMDs). ASMD values >0.1 denote meaningful differences between groups. Generalized estimating equations yielded adjusted odds ratios (aORs) for select indicators.ResultsA total of 40,266 cancer survivors were identified (prevalence of 3.0% of adult CHC patients). Compared with matched cancer‐free patients, a higher percentage of survivors had ≥6 primary care visits across 3 years (62% vs 48%) and were insured (83% vs 74%) (ASMD, >0.1 for both). Cancer survivors had excess medical complexity, including a higher prevalence of depression, asthma/chronic obstructive pulmonary disease, and liver disease (ASMD, >0.1 for all). Survivors had higher odds of any opioid prescription (aOR, 1.23; 95% CI, 1.19‐1.27) and chronic opioid therapy (aOR, 1.27; 95% CI, 1.23‐1.32) compared with matched controls (P < .001 for all).ConclusionsIdentifying cancer survivors and understanding their patterns of utilization and physical and mental comorbidities present an opportunity to tailor primary health care services to this population.
The current large, observational study using primary care electronic health record data demonstrates several important findings regarding adult cancer survivors, including substantial differences in primary care use and health insurance patterns, excess comorbidity, and disparities in chronic pain and opioid use compared with matched cancer‐free counterparts. As more patients continue to survive cancer, the role of primary care providers in providing long‐term, comprehensive follow‐up care is increasing.
Abstract
Obesity is a major risk factor for many chronic diseases and disabilities, with severe implications on morbidity and mortality among older adults. With an increasing prevalence of obesity ...among older adults in Ghana, it has become necessary to develop cost-effective strategies for its management and prevention. However, developing such strategies is challenging as body mass index (BMI)-specific utilization and costs required for cost-effectiveness analysis are not available in this population. Therefore, this study examines the associations between health services utilization as well as direct healthcare costs and overweight (BMI ≥25.00 and <30.00 kg/m2) and obesity (BMI ≥30.00 kg/m2) among older adults in Ghana. Data were used from a nationally representative, multistage sample of 3350 people aged 50+ years from the World Health Organization’s Study on global AGEing and adult health (WHO-SAGE; 2014/15). Health service utilization was measured by the number of health facility visits over a 12-month period. Direct costs (2017 US dollars) included out-of-pocket payments and the National Health Insurance Scheme (NHIS) claims. Associations between utilization and BMI were examined using multivariable zero-inflated negative binomial regressions; and between costs and BMI using multivariable two-part regressions. Twenty-three percent were overweight and 13% were obese. Compared with normal-weight participants, overweight and obesity were associated with 75% and 159% more inpatient admissions, respectively. Obesity was also associated with 53% additional outpatient visits. One in five of the overweight and obese population had at least one chronic disease, and having chronic disease was associated with increased outpatient utilization. The average per person total costs for overweight was $78 and obesity was $132 compared with $35 for normal weight. The NHIS bore approximately 60% of the average total costs per person expended in 2014/15. Overweight and obese groups had significantly higher total direct healthcare costs burden of $121 million compared with $64 million for normal weight in the entire older adult Ghanaian population. Compared with normal weight, the total costs per person associated with overweight increased by 73% and more than doubled for obesity. Even though the total prevalence of overweight and obesity was about half of that of normal weight, the sum of their cost burden was almost doubled. Implementing weight reduction measures could reduce health service utilization and costs in this population.
Background Health-care financing should be equitable. In many developing countries such as Kenya, changes to health-care financing systems are being implemented as a means of providing equitable ...access to health care with the aim of attaining universal coverage. Vertical equity means that people of dissimilar ability to pay make dissimilar levels of contribution to the health-care financing system. Vertical equity can be analysed by measuring progressivity. Objectives The aim of this study was to analyse progressivity by measuring deviations from proportionality in the relationship between sources of health-care financing and ability to pay using Kakwani indices applied to data from the Kenya Household Health Utilisation and Expenditure Survey 2007. Methods Concentration indices and Kakwani indices were obtained for the sources of healthcare financing: direct and indirect taxes, out of pocket (OOP) payments, private insurance contributions and contributions to the National Hospital Insurance Fund. The bootstrap method was used to analyse the sensitivity of the Kakwani index to changes in the equivalence scale or the use of an alternative measure of ability to pay. Results The overall health-care financing system was regressive. Out of pocket payments were regressive with all other payments being proportional. Direct taxes, indirect taxes and private insurance premiums were sensitive to the use of income as an alternative measure of ability to pay. However, the overall finding of a regressive health-care system remained. Conclusion Reforms to the Kenyan health-care financing system are required to reduce dependence on out of pocket payments. The bootstrap method can be used in determining the sensitivity of the Kakwani index to various assumptions made in the analysis. Further analyses are required to determine the equity of health-care utilization and the effect of proposed reforms on overall equity of the Kenyan health-care system.
This evaluation was designed to assess the impact of providing integrated primary and mental health care on utilization and costs for outpatient medical, inpatient hospital, and emergency department ...treatment among persons with serious mental illness.
Two safety-net, community mental health centers that received a Substance Abuse and Mental Health Services Administration Primary and Behavioral Health Care Integration (PBHCI) grant were the focus of this study. Clinic 1 had a ten-year history of providing integrated services whereas clinic 2 began integrated services with the PBHCI grant. Difference-in-differences (DID) analyses were used to compare individuals enrolled in the PBHCI programs (N=373, clinic 1; N=389, clinic 2) with propensity score-matched comparison groups of equal size at each site by using data obtained from medical records.
Relative to the comparison groups, a higher proportion of PBHCI clients used outpatient medical services at both sites following program enrollment (p<.003, clinic 1; p<.001, clinic 2). At clinic 1, PBHCI was also associated with a reduction in the proportion of clients with an inpatient hospital admission (p=.04) and a trend for a reduction in inpatient hospital costs per member per month of $217.68 (p=.06). Hospital-related cost savings were not observed for PBHCI clients at clinic 2 nor were there significant differences between emergency department use or costs for PBHCI and comparison groups at either clinic.
Investments in PBHCI can improve access to outpatient medical care for persons with severe mental illness and may also curb hospitalizations and associated costs in more established programs.
Artificial intelligence (AI) has the potential to improve the efficiency and effectiveness of health care service delivery. However, the perceptions and needs of such systems remain elusive, ...hindering efforts to promote AI adoption in health care.
This study aims to provide an overview of the perceptions and needs of AI to increase its adoption in health care.
A systematic scoping review was conducted according to the 5-stage framework by Arksey and O'Malley. Articles that described the perceptions and needs of AI in health care were searched across nine databases: ACM Library, CINAHL, Cochrane Central, Embase, IEEE Xplore, PsycINFO, PubMed, Scopus, and Web of Science for studies that were published from inception until June 21, 2021. Articles that were not specific to AI, not research studies, and not written in English were omitted.
Of the 3666 articles retrieved, 26 (0.71%) were eligible and included in this review. The mean age of the participants ranged from 30 to 72.6 years, the proportion of men ranged from 0% to 73.4%, and the sample sizes for primary studies ranged from 11 to 2780. The perceptions and needs of various populations in the use of AI were identified for general, primary, and community health care; chronic diseases self-management and self-diagnosis; mental health; and diagnostic procedures. The use of AI was perceived to be positive because of its availability, ease of use, and potential to improve efficiency and reduce the cost of health care service delivery. However, concerns were raised regarding the lack of trust in data privacy, patient safety, technological maturity, and the possibility of full automation. Suggestions for improving the adoption of AI in health care were highlighted: enhancing personalization and customizability; enhancing empathy and personification of AI-enabled chatbots and avatars; enhancing user experience, design, and interconnectedness with other devices; and educating the public on AI capabilities. Several corresponding mitigation strategies were also identified in this study.
The perceptions and needs of AI in its use in health care are crucial in improving its adoption by various stakeholders. Future studies and implementations should consider the points highlighted in this study to enhance the acceptability and adoption of AI in health care. This would facilitate an increase in the effectiveness and efficiency of health care service delivery to improve patient outcomes and satisfaction.
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