Health Policy

Access to, use of and satisfaction with health services among adults enrolled in Brazil’s Family Health Strategy: evidence from the 2008 National Household Survey

Access to, use of and satisfaction with health services among adults enrolled in Brazil’s Family Health Strategy: evidence from the 2008 National Household Survey
Tropical Medicine & International Health, Vol. 17, no. 1, pp. 36-42. 10.1111/j.1365-3156.2011.02866.x

Macinko, J., and M.F. Lima Costa
01/01/2012

Objective  To assess the effects of participation in Brazil’s primary healthcare programme (the Family Health Strategy or FHS) on access, use and satisfaction with health services among adults.

Methods  Data are from the 2008 National Household Survey (PNAD) on 264 754 adults. This cross-sectional analysis compares FHS enrollees to both non-enrollees and those with private health plans. We calculated predicted probabilities of each outcome stratified by household wealth quintile, rural/urban location and sex using robust Poisson regression. We performed propensity score analysis to assess the differences in access among FHS enrollees and the rest of the population, once relevant socio-demographic characteristics and other determinants of access were balanced.

Results  Compared to families with neither FHS enrolment nor private health plans, adult FHS enrollees were generally more likely to have a usual source of care, to have visited a doctor or dentist in the past 12 months, to have access to needed medications and to be satisfied with the care they received. The FHS effect was largest among urban dwellers and the poorest.

Conclusions  The FHS appears to be associated with enhanced access to and utilization of health services in Brazil. However, it has not yet been able to match levels of access experienced by those with private health plans, perhaps because the population served by the FHS is among the poorest, most rural and least healthy in the country.

The Population Level Prevalence and Correlates of Appropriate and Inappropriate Imaging to Stage Incident Prostate Cancer in the Medicare Population

The Population Level Prevalence and Correlates of Appropriate and Inappropriate Imaging to Stage Incident Prostate Cancer in the Medicare Population
Journal of Urology, Vol. 187, no. 1, pp. 97-102. DOI: 10.1016/j.juro.2011.09.042

Makarov, D.V., R.A. Desai, J.B. Yu, R. Sharma, N. Abraham, P.C. Albertsen, D.F. Penson, and C.P. Gross
01/01/2012

Purpose: According to guidelines most men with incident prostate cancer do not require staging imaging. We determined the population level prevalence and correlates of appropriate and inappropriate imaging in this cohort.

Materials and Methods: We performed a cross-sectional study of men 66 to 85 years old who were diagnosed with prostate cancer in 2004 and 2005 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. Low risk (no prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or clinical stage greater than T2) and high risk (1 or more of those features) groups were formed. Inappropriate imaging was defined as any imaging for men at low risk and appropriate imaging was defined as bone scan for men at high risk as well as pelvic imaging as appropriate. Logistic regression modeled imaging in each group.

Results: Of 18,491 men at low risk 45% received inappropriate imaging while only 66% of 10,562 at high risk received appropriate imaging. For patients at low risk inappropriate imaging was associated with increasing clinical stage (T2 vs T1 OR 1.35, 95% CI 1.27–1.44), higher Gleason score (7 vs less than 7 OR 1.80, 95% CI 1.69–1.92), increasing age and comorbidity as well as decreasing education. Appropriate imaging for men at high risk was associated with lower stage (T4, T3 and T2 vs T1 OR 0.63, 95% CI 0.48–0.82, OR 0.67, 95% CI 0.60–0.80 and OR 0.87, 95% CI 0.80–0.86) and with higher Gleason score (greater than 8 and 7 vs less than 7 OR 2.18, 95% CI 1.92–2.48 and 1.51, 95% CI 1.35–1.70, respectively) as well as with younger age, white race, higher income, lower stage and more comorbidity.

Conclusions: We found poor adherence to imaging guidelines for men with incident prostate cancer. Understanding the patterns by which clinicians use imaging for prostate cancer should guide educational efforts as well as research to suggest evidence-based guideline improvements.

Trajectories of cognitive decline over 10 years in a Brazilian elderly population: the Bambuí Cohort Study of Aging

Trajectories of cognitive decline over 10 years in a Brazilian elderly population: the Bambuí Cohort Study of Aging
Cadernos de Saude Publica, Vol. 27, supp. 3. 10.1590/S0102-311X2011001500003

Macinko, J., V. Camargos, J.O.A. Firmo, and M.F. Lima Costa
12/01/2011

We use data from a population-based cohort of elderly Brazilians to assess predictors of hospitalizations during ten years of follow-up. Participants were 1,448 persons aged 60 years and over at baseline (1997). The outcome was self-reported number of hospitalizations per year. Slightly more than a fifth (23%) experienced no hospitalizations during the 10 year follow-up. About 30% had 1-2 events, 31% had between 3 and 7 events, and about 18% had 8 or more events during this time. Results of multivariable hurdle and Cox proportional hazards models showed that the risk of hospitalization was positively associated with male sex, increased age, chronic conditions, and visits to the doctors in the previous 12 months. Underweight was a predictor of any hospitalization, while obesity was an inconsistent predictor of hospitalization.

Integrated delivery of HIV and tuberculosis services in sub-Saharan Africa: a systematic review

Integrated delivery of HIV and tuberculosis services in sub-Saharan Africa: a systematic review
The Lancet Infectious Diseases, Vol. 11, no. 11. 10.1016/S1473-3099(11)70145-1

Uyei, J., D. Coetzee, J. Macinko, and S. Guttmacher
11/01/2011

Tuberculosis is a major cause of morbidity and mortality in people with HIV and about a quarter of HIV-related deaths are attributed to tuberculosis. In this Review we identify and synthesise published evidence for the effectiveness and cost-effectiveness of eight integrated strategies recommended by WHO that represent coordinated delivery of HIV and tuberculosis services. Evidence supports concurrent screening for tuberculosis and HIV, and provision of either co-trimoxazole during routine tuberculosis care or isoniazid during routine HIV care and at voluntary counselling and testing centres. Although integration of antiretroviral therapy into tuberculosis care has shown promise for improving health outcomes for patients, evidence is insufficient to make conclusive claims. Evidence is also insufficient on the accessibility of condoms at tuberculosis facilities, the benefits of risk reduction counselling in patients with tuberculosis, and the effectiveness of tuberculosis infection control in HIV health-care settings. The vertical response to the tuberculosis and HIV epidemics is ineffective and inefficient. Implications for policy makers and funders include further investments in implementing integrated tuberculosis and HIV programmes with known effectiveness, preferably in a way that strengthens health systems; evaluative research that identifies barriers to integration; and research on integrated strategies for which effectiveness, efficiency, and affordability are not well established.

An Intervention to Improve Care and Reduce Costs for High Risk Patients with Frequent Health Services Use

An Intervention to Improve Care and Reduce Costs for High Risk Patients with Frequent Health Services Use
BMC Health Serv Res. 2011; 11: 270.

Maria C Raven, Kelly M Doran, Shannon Kostrowski, Colleen C Gillespie and Brian D Elbel
10/13/2011

Background

A small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs.

Methods

Community and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach.

Results

Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient.

Conclusions

A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated.

Reducing Racial and Ethnic Disparities: The Action Plan from the Department of Health and Human Services

Reducing Racial and Ethnic Disparities: The Action Plan from the Department of Health and Human Services
Health Affairs, 2011. Volume 30 / Issue 10 / October 2011, pp 1822-1829, Published online

Howard K. Koh, Garth Graham and Sherry Glied
10/12/2011

The Department of Health and Human Services (HHS) recently unveiled the most comprehensive federal commitment yet to reducing racial and ethnic health disparities. The 2011 HHS Action Plan to Reduce Racial and Ethnic Health Disparities not only responds to advice previously offered by stakeholders around the nation, but it also capitalizes on new and unprecedented opportunities in the Affordable Care Act of 2010 to benefit diverse communities. The Action Plan advances five major goals: transforming health care; strengthening the infrastructure and workforce of the nation’s health and human services; advancing Americans’ health and well-being; promoting scientific knowledge and innovation; and upholding the accountability of HHS for making demonstrable progress. By mobilizing HHS around these goals, the Action Plan moves the country closer to realizing the vision of a nation free of disparities in health and health care.

The Influence of Primary Care and Hospital Supply on Ambulatory Care–Sensitive Hospitalizations Among Adults in Brazil, 1999–2007

The Influence of Primary Care and Hospital Supply on Ambulatory Care–Sensitive Hospitalizations Among Adults in Brazil, 1999–2007
American Journal of Public Health: October 2011, Vol. 101, No. 10, pp. 1963-1970. 10.2105/AJPH.2010.198887

Macinko, J., V.B. de Oliveira, M.A. Turci, F.C. Guanais, P.F. Bonolo, and M.F. Lima Costa
10/01/2011

Objectives. We assessed the influence of changes in primary care and hospital supply on rates of ambulatory care–sensitive (ACS) hospitalizations among adults in Brazil.

Methods. We aggregated data on nearly 60 million public sector hospitalizations between 1999 and 2007 to Brazil's 558 microregions. We modeled adult ACS hospitalization rates as a function of area-level socioeconomic factors, health services supply, Family Health Program (FHP) availability, and health needs by using dynamic panel estimation techniques to control for endogenous explanatory variables.

Results. The ACS hospitalization rates declined by more than 5% annually. When we controlled for other factors, FHP availability was associated with lower ACS hospitalization rates, whereas private or nonprofit hospital beds were associated with higher rates. Areas with highest predicted ACS hospitalization rates were those with the highest private or nonprofit hospital bed supply and with low (< 25%) FHP coverage. The lowest predicted rates were seen for areas with high (> 75%) FHP coverage and very few private or nonprofit hospital beds.

Conclusions. These results highlight the contribution of the FHP to improved health system performance and reflect the complexity of the health reform processes under way in Brazil.

Advancing Research Data Infrastructure for Patient-Centered Outcomes Research

Advancing Research Data Infrastructure for Patient-Centered Outcomes Research
JAMA: The Journal of the American Medical Association, 2011. Volume 306 / Issue 11 / September 2011, pp 1254-1255, Published online

Amol Navathe, Carolyn Clancy and Sherry Glied
09/21/2011

Patient-centered outcomes research, which aims to assist clinicians and patients in making informed decisions regarding prevention, diagnosis, and treatment, is essential for improving the delivery of quality health care. Much of patient-centered outcomes research relies on observational and quasi-experimental methods applied to data generated as a byproduct of providing care. While existing data sources have improved, there remain important data-related barriers to rapid, efficient research. Recent changes in the policy environment, coupled with significant technological progress, provide an opportunity to surmount some of these obstacles.

Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services Compared to Other Countries

Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services Compared to Other Countries
Health Affairs, 2011. Volume 30 / Issue 09 / September 2011, pp 1647-1656, Published online

Sherry Glied and Miriam Laugesen
09/08/2011

Higher health care prices in the United States are a key reason that the nation’s health spending is so much higher than that of other countries. Our study compared physicians’ fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians’ incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries’ national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians’ counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.

Pages

Subscribe to Health Policy