Victor G. Rodwin

The use of revascularization (coronary artery bypass surgery [CABG] and percutaneous coronary intervention [PCI]) in the United States is declining, but they remain important procedures for the treatment of patients with coronary artery disease. There are large and long‐standing disparities in the use of revascularization among patients hospitalized with heart disease. In this article, we investigate whether the implementation of the Patient Protection and Affordable Care Act (ACA) is associated with a reduction in disparities in the use of revascularization. We use data from the Agency for Healthcare Research and Quality (AHRQ)'s National Inpatient Sample (NIP) of the Healthcare Cost and Utilization Project (HCUP) project to compare the use of revascularization among patients 45 years and older in the United States in 2012 and 2018. For both years, we conducted multiple logistic regression analysis to assess the factors associated with coronary revascularization among patients hospitalized with heart disease. Hospitalizations for heart disease and the use of revascularization both fell between 2012 and 2018 at a rate that was greater than the reduction in heart disease deaths in the country. These findings are consistent with the clinical literature on the growth of medical management of heart disease. Disparities in the use of revascularization, by gender, insurance status, neighborhood, and race/ethnicity, were just as large after the implementation of the ACA in 2014. The expansion of insurance by the ACA, alone, was insufficient to reduce disparities in the use of revascularization in patients with diagnosed coronary heart disease in the United States.

Interview of Victor Rodwin by Anaïs Fossier

The Swiss healthcare system is well known for the quality of its healthcare and population health but also for its high cost, particularly regarding out-of-pocket expenses. We conduct the first national study on the association between socioeconomic status and access to community-based ambulatory care (CBAC). We analyze administrative and hospital discharge data at the small area level over a four-year time period (2014 – 2017). We develop a socioeconomic deprivation indicator and rely on a well-accepted indicator of potentially avoidable hospitalizations as a measure of access to CBAC. We estimate socioeconomic gradients at the national and cantonal levels

with mixed effects models pooled over four years. We compare gradient estimates among specifications without control variables and those that include control variables for area geography and physician availability. We find that the most deprived area is associated with an excess of 2.80 potentially avoidable hospitalizations per 1,000 population (3.01 with control variables) compared to the least deprived area. We also find significant gradient variation across cantons with a difference of 5.40 (5.54 with control variables) between the smallest and largest

canton gradients. Addressing broader social determinants of health, financial barriers to access, and strengthening CBAC services in targeted areas would likely reduce the observed gap.

The Patient Protection and Affordable Care Act (ACA) was signed into law by U.S. President Obama in 2010 and fully implemented in 2014. The ACA expanded health insurance by expanding the Medicaid program, creating health insurance exchanges (now called “marketplaces”) in which people with incomes between 139% and 400% of the federal poverty level, could purchase subsidized insurance coverage, and by regulating health insurance to eliminate practices such as denying coverage to people with pre‐existing conditions, or basing premiums on health status. We investigate the effects of the ACA's implementation on access to ambulatory health services in New York City by comparing rates of hospitalizations for ambulatory care‐sensitive conditions (ACSC) before and after the full implementation of the law. Although the ACA was associated with a significant decrease in the rate of ACSC in NYC, we find that there continue to be systemic inequalities by gender, race, ethnicity, income, and insurance status. We argue that the broader social and economic inequalities at the national and state levels, including tax and spending policies that have led to increased income and wealth inequalities, help explain why we see persistent inequalities in hospitalizations for ACSC.

Background/Purpose 
In 2014, New York City implemented the Afordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.

Methods 
We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011–2013 (pre-ACA) and 2014–2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.

Results 
Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45–64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.

Conclusions 
Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Anthropologists are well-known for their tendency to think small (by focusing on local communities), engage in what Clifford Geertz (1973) called “thick description,” and grasp for broader insights and conclusions. In this respect, Mara Buchbinder’s ethnographic research on how patients, caregivers, health care providers, legislators, and activists have responded to Vermont’s 2013 Patient Choice and Control at End of Life Act is exem- plary. As she explains, “One of the strengths of ethnography is its refusal to compromise between specificity and generality” (15). That is Buchbinder’s rationale for studying Vermont as a “microcosm of a larger national story, offering insights into cultural ideals, fears, and debates that will resonate across the United States” (15). She interviewed 144 Vermonters and participated, as an observer, in advocacy and educational events and profes-xsional medical conferences. Her book uncovers layers of complexity and depth in the area of medical aid in dying, otherwise known as death with dignity or physician-assisted suicide. It is well written and serves as a good example of how a wide range of concepts in the social sciences can be useful for interpreting detailed empirical material.

France's system of universal health insurance (UHi) offers more equitable access to outpatient care than the patchwork system in the U.S., which does not have a UHi system. We investigate the degree to which the implementation of the Patient Protection and Affordable Care Act (ACA) has narrowed the gap in access to outpatient care between France and the U.S. To do so, we update a previous comparison of access to outpatient care in Manhattan and Paris as measured by age-adjusted rates of hospital discharge for avoidable hospital conditions (AHCs). We compare these rates immediately before and after the implementation of the ACA in 2014. We find that AHC rates in Manhattan declined by about 25% and are now lower than those in Paris. Despite evidence that access to outpatient care in Manhattan has improved, Manhattanites continue to experience greater residence-based neighborhood inequalities in AHC rates than Parisians. In Paris, there was a 3% increase in AHC rates and neighborhood-level inequalities increased significantly. Our analysis highlights the persistence of access barriers to outpatient care in Manhattan, particularly among racial and ethnic minorities, even following the expansion of health insurance coverage. 

Health financing by which we mean financing to promote health, including healthcare, is a core function of a health system. In addition to making decisions on investing to promote population health and improve healthcare, governments also have to consider spending in other areas, including social protection, education, defence, public order and safety, housing and environment, transportation, agriculture and employment. Health financing is therefore part of the resource allocation process in which advocates for NCDs must find a voice. While there will always be trade-offs in government spending priorities across sectors, this does not mean that public finance is a zero-sum game.

Universal health coverage (UHC) is a central part of the 2030 Sustainable Development Agenda and the WHO Global NCD Action Plan. Achieving UHC means that all people would have access to the health services they need, when and where they need them, without financial hardship. UHC includes health protection and promotion, as well as disease prevention, treatment, rehabilitation and palliative care, across the life-course.

There will always be trade-offs in allocating resources between each of the UHC dimensions (i.e. population covered, services provided, and direct costs to patients) (Figure 38.1). What levels of coverage can be provided for the population? Or should more services be covered by enlarging the benefits package to include other health services and if so which ones? Or should cost sharing and fees for patients be reduced?

This article examines the factors affecting Americans’ trust in their federal government and its health agencies during the COVID-19 public health crisis. More specifically, we examine the evolution of Americans’ trust in their government and health system and how, in the context of the COVID-19 pandemic response, it has been affected by multiple factors. Several academic journals, government policy recommendations and public health polls were evaluated to understand the public’s trust in the federal government and its health institutions. Public trust in institutions during a global pandemic is essential in influencing adherence to a pandemic response (both nonpharmaceutical and medical interventions). Americans’ trust in institutions is built and maintained by a variety of factors. We focus on: political polarization and involvement, media influence and health communications, history of systemic racism and socioeconomic inequalities, and pandemic fatigue. Based on the interplay of these factors, we conclude with recommendations for future pandemic response strategies.

Objectives: To determine the level of neighbourhood ine-qualities in infant mortality (IM) rates in the urban core of four world cities and to examine the association betweenneighbourhood-level income and IM. We compare our findings with those published in 2004 to better understand how these city health systems have evolved.

Methods: We compare IM rates among and within the four cities using data from four periods: 1988–1992; 1993–1997; 2003–2008 and 2012–2016. Using a maximum-likelihood negative binomial regression model that controls for births, we predict the relationship between neighbourhood-level income and IM.

Results: IM rates have declined in all four cities. Neighbourhood-level income is statistically significant for New York and, for the two most recent periods, in Paris. In contrast, there is no significant relationship between neighbourhood income and IM in London or Tokyo.

Conclusions: Despite programmes to reduce IM inequalities at national and local levels, these persist in New York. Until the early part of this century, none of the other cities experienced a relationship between neighbourhood income and IM, but growing income inequalities within Paris have changed this situation.

Book Review

This article uses an ecological study design to explore intraurban health inequality in São Paulo by examining neighborhood-level changes in mortality amenable to medical care. We use 2003–2013 data for 95 city districts of São Paulo and apply a random coefficient growth curve modeling approach. We find that improved access to health-care services is associated with reduced amenable mortality. Despite these overall improvements, the magnitude of population health disparities, as measured by amenable mortality, did not diminish. The effects of social, economic, and health system factors on amenable mortality depend on the income level of the district. Persistent disparities in amenable mortality within São Paulo suggests that neighborhood-level differences in social determinants of health and access to health services require further investment from the Brazilian government.

Background: Many studies explore the clinical and ethical dimensions of care at the end-of-life, but fewer use administrative data to examine individual and geographic differences, including the use of palliative care.

Aim: Provide a population-based perspective on end-of-life and hospital palliative care among local authorities and hospitals in France.

Design: Retrospective cohort study of care received by 17,928 decedents 65 and over (last 6 months of life), using the French national health insurance database

Results: 55.7% of decedents died in acute-care hospitals; 79% were hospitalized in them at least once; 11.7% were admitted at least once for hospital palliative care. Among 31 academic medical centers, intensive care unit admissions ranged from 12% to 67.4%; hospital palliative care admissions, from 2% to 30.6%. Across local authorities, for intensive care unit days and hospital palliative care admissions, the ratios between the values at the third and the first quartile were 2.4 and 1.5. The odds of admission for hospital palliative care or to an intensive care unit for more than 7 days were more than twice as high among people ⩽85 years (aOR = 2.11 (1.84–2.43) and aOR = 2.59 (2.12–3.17), respectively). The odds of admission for hospital palliative care were about 25% lower (p = 0.04) among decedents living in local authorities with the lowest levels of education than those with the highest levels.

Conclusion: The variation we document in end-of-life and hospital palliative care across different categories of hospitals and 95 local authorities raises important questions as to what constitutes appropriate hospital use and intensity at the end-of-life.

This title is part of UC Press's Voices Revived program, which commemorates University of California Press’s mission to seek out and cultivate the brightest minds and give them voice, reach, and impact. Drawing on a backlist dating to 1893, Voices Revived makes high-quality, peer-reviewed scholarship accessible once again using print-on-demand technology. This title was originally published in 1984.

Book Chapter

Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement. The parties involved, the frequency of fee schedule updates, and the scope of the negotiations vary, but all three countries attempt to balance the interests of payers with those of physician associations. Instead of looking for policy importation, this analysis demonstrates the benefits of structuring negotiations and standardizing fee-for-service payments independent of any specific reform proposal, such as single-payer reform and public insurance buy-ins.

This article uses an ecological study design to explore intraurban health inequality in São Paulo by examining neighborhood‐level changes in mortality amenable to medical care. We use 2003–2013 data for 95 city districts of São Paulo and apply a random coefficient growth curve modeling approach. We find that improved access to health‐care services is associated with reduced amenable mortality. Despite these overall improvements, the magnitude of population health disparities, as measured by amenable mortality, did not diminish. The effects of social, economic, and health system factors on amenable mortality depend on the income level of the district. Persistent disparities in amenable mortality within São Paulo suggests that neighborhood‐level differences in social determinants of health and access to health services require further investment from the Brazilian government.

Objectives: We investigate the reliability of a survey question on forgone healthcare services for financial reasons, based on analysis of actual healthcare use over the 3-year period preceding response to the question. We compare the actual use of different health services by patients who report having forgone health care to those who do not.

Methods: Based on a prospective cohort study (CONSTANCES), we link survey data from enrolled participants to the Universal Health Insurance (UHI) claims database and compare use of health services of those who report having forgone health care to controls. We present multivariable logistic regression models and assess the odds of using different health services.

Results: Compared to controls, forgoing care participants had lower odds of consulting GPs (OR = 0.83; 95% CI 0.73, 0.93), especially specialists outside hospitals (gynecologists: 0.74 (0.69, 0.78); dermatologists: 0.81 (0.78–0.85); pneumologists 0.82 (0.71–0.94); dentists 0.71 (0.68, 0.75)); higher odds of ED visits (OR = 1.25; 95% CI 1.19, 1.31); and no difference in hospital admissions (OR = 1.02; 95% CI 0.97, 1.09). Participants with lower occupational status and income had higher odds of forgoing health care.

Conclusions: The perception of those who report having forgone health care for financial reasons is consistent with their lower actual use of community-based ambulatory care (CBAC). While UHI may be necessary to improve healthcare access, it does not address the social factors associated with the population forgoing health care for financial reasons.

An epidemic is like a fire: its origin and the conditions under which it spreads determine the extent of damage. The initial outbreak and epidemic of Covid-19 began in China in November, 2019, before spreading to the rest of the planet. It seems to us, therefore, that a responsible blog in HEPL would not gloss over the lack of transparency and the cover-up before the recognition of human-to-human transmission and the lockdown, which is well described in this blog. We admire the conscientious work of Chinese scientists and the healthcare workforce in responding to the epidemic. However, we are concerned by the political response to the pandemic in many nations, including China, at the beginning of the outbreak. In responding to your blog on China, we feel compelled to remind readers of some important facts that strike us as essential for understanding and assessing the Chinese response to the epidemic, in Wuhan, before January 20th.

Switzerland, a wealthy and multilingual nation (8.6 million population) with private universal health insurance (UHI) by federal mandate, is known for its decentralized federalism, direct democracy and comparatively high level of trust in its governments, healthcare system and medical profession. Covid-19 prevalence varies between the most affected cantons – Italian-speaking Ticino and French-speaking Geneva and Vaud – and the less affected German-speaking cantons (Covid-19-CH, 2020). Given Switzerland’s institutional context and regional variation, we present a brief chronology of the federal government’s response to the pandemic and our preliminary assessment.

This paper examines changes in infant mortality (IM) in Moscow, Russia's largest and most affluent city. Along with some remarkable improvements in Moscow's health system over the period between 2000 and 2014, the overall IM rate for Moscow's residents decreased substantially between 2000 and 2014. There remains, however, substantial intra-city variation across Moscow's 125 neighborhoods. Our regression models suggest that in higher-income neighborhoods measured by percent of population with rental income as a primary source, the IM rate is significantly lower than in lower-income neighborhoods measured by percent of population with transfer income as primary source (housing and utility subsidies and payments to working and low-income mothers, single mothers and foster parents). We also find that the density of physicians in a neighborhood is negatively correlated with the IM rate, but the effect is small. The density of nurses and hospital beds has no effect. We conclude that overall progress on health outcomes and measures of access does not, in itself, solve the challenge of intra-urban inequalities.

China’s estimated 114 million people with diabetes pose a massive challenge for China’s health policy-makers who have significantly extended health insurance coverage over the past decade. What China is doing now, what it has achieved, and what remains to be done should be of interest to health policy-makers, worldwide. We identify the challenges posed by China’s two principal strategies to tackle diabetes: (1) A short-term pilot strategy of health promotion, detection and control of chronic diseases in 265 national demonstration areas (NDAs); and (2) A long-term strategy to extend health promotion and strengthen primary care capacity and health system integration throughout China. Finally, we consider how Chinese innovations in artificial intelligence (AI) and Big Data may contribute to improving diagnosis, controlling complications and increasing access to care. Health system integration in China will require overcoming the fragmentation of a system that still places excessive reliance on local government financing. Moreover, what remains to be done resembles deeper challenges faced by healthcare systems worldwide: the need to upgrade primary care and reduce inequalities in access to health services.

Purpose: To quantify and compare citywide disparities in the performance of coronary revascularization procedures in New York residents diagnosed with ischemic heart disease (IHD) by the characteristics of the patients and their neighborhood of residence in 2000–2002 and 2011–2013.

Methods: We identify the number of hospitalizations for patients with diagnoses of IHD and/or congestive heart failure (CHF) and the number of revascularization procedures performed on the population 45 years and older, relying on hospital administrative data for New York City, by area of residence, from the Statewide Planning and Research Cooperative System (SPARCS). We conduct multiple logistic regressions to analyze the factors associated with revascularization for hospitalized patients admitted with IHD and CHF over the two time periods.

Results: Despite any decline in population health status, both the age-adjusted rates of inpatient hospital discharges for acute myocardial infarction, for IHD and for CHF, decreased as did the rates of revascularization procedures. Racial and ethnic disparities were much smaller in the later period than those documented earlier. However, there were persistent gender, insurance status, and neighborhood-level disparities in the treatment of heart disease.

Conclusions: With the declines in rates of heart disease, our findings point to the need for more clinical and population-based research to improve the understanding of why race/ethnicity, gender, insurance status, and neighborhood-level disparities persist in the treatment of heart disease.

This paper examines changes in infant mortality (IM) in Moscow, Russia’s largest and most affluent city. Along with some remarkable improvements in Moscow’s health system over the period between 2000 and 2014, the overall IM rate for Moscow’s residents decreased substantially between 2000 and 2014. There remains, however, substantial intra-city variation across Moscow’s 125 neighborhoods. Our regression models suggest that in higher-income neighborhoods measured by percent of population with rental income as a primary source, the IM rate is significantly lower than in lower-income neighborhoods measured by percent of population with transfer income as primary source (housing

and utility subsidies and payments to working and low-income mothers, single mothers and foster parents). We also find that the density of physicians in a neighborhood is negatively correlated with the IM rate, but the effect is small. The density of nurses and hospital beds has no effect. We conclude that overall progress on health outcomes and measures of access does not, in itself, solve the challenge of intra-urban inequalities.

Comparative policy analysis sometimes relies on the use of metrics to foster policy learning. We compare health care for patients at the end of life (EOL) in the U.S. and France. The analysis aims to enable policy makers in both nations to re-examine their own health systems in light of how their counterparts are responding to common concerns about the intensity, quality and cost of. EOL care. We find that a higher percentage of French decedents 65 years and over, are hospitalized, yet they spend fewer days in intensive care units (ICUs) than their counterparts for whom we have data (Medicare beneficiaries) in the U.S. In addition, decedents in the U.S. consult with a higher number of different physicians than their French counterparts. We also compare patterns of hospital use for decedents in EOL care among academic medical centers (AMCs) in the U.S. and France. We find greater variation among French AMCs than among their counterparts in the U.S.

There is strong evidence that housing conditions affect

population health, but evidence is limited on the extent to which housing

with supportive social services can maintain population health and

reduce the use of expensive hospital services. We examined a nonprofit,

community-based program in Queens, New York, that supplied affordable

housing with supportive social services to elderly Medicare beneficiaries.

We evaluated whether this program reduced hospital use, including

hospital discharges for ambulatory care–sensitive conditions (ACSCs).

We compared hospital use among an intervention group residing in six

high-rise buildings in two neighborhoods to that among their Medicare

counterparts living in the same neighborhoods but in different buildings.

We found that hospital discharge rates were 32 percent lower, hospital

lengths-of-stay one day shorter, and ACSC rates 30 percent lower among

residents in the intervention group than among people in the

comparison group. This suggests that investments in housing with

supportive social services have the potential to reduce hospital use and

thereby decrease spending for vulnerable older patients.

Link to JHPPL conference at Columbia University June 20, 2017

0:00 - Introduction by Michael Sparer

1:44 - Commentary by Miriam Laugesen 

20:27 - Commentary by Victor Rodwin

Although eliminating financial barriers to care is a necessary condition for improving access to health services, it is not sufficient. Given the contrasting health systems with regard to financing and organization of health insurance in the United States and Canada, there is a long history of comparing these countries. We extend the empirical studies on the Canadian and US health systems by comparing access to ambulatory care as measured by hospitalization rates for ambulatory care sensitive conditions (ACSC) in Montreal and New York City. We find that, in New York, ACSC rates were more than twice as high (12.6 per 1000 population) as in Montreal (4.8 per 1000 population). After controlling for age, sex, and number of diagnoses, significant differences in ACSC rates are present in both cities, but are more pronounced in New York. Our findings are consistent with the hypothesis that universal, first-dollar health insurance coverage has contributed to lower ACSC rates in Montreal than New York. However, Montreal’s surprisingly low ACSC rate calls for further research.

The French health care system is a model of national health insurance (NHI) that provides health care coverage to all legal residents. It is an example of public social security and private health care financing, combined with a public-private mix in the provision of health care services. The French health care system reflects three underlying political values: liberalism, pluralism and solidarity. This article provides a brief overview of how French NHI evolved since World War II; its financing health care organization and coverage; and most importantly, its overall performance.

OBJECTIVES:

To determine whether implementation of a case-based payment system changed all-cause readmission rates in the 30 days following discharge after surgery, we analysed all surgical procedures performed in all hospitals in France before (2002-2004), during (2005-2008) and after (2009-2012) its implementation.

SETTING:

Our study is based on claims data for all surgical procedures performed in all acute care hospitals with >300 surgical admissions per year (740 hospitals) in France over 11 years (2002-2012; n=51.6 million admissions).

INTERVENTIONS:

We analysed all-cause 30-day readmission rates after surgery using a logistic regression model and an interrupted time series analysis.

RESULTS:

The overall 30-day all-cause readmission rate following discharge after surgery increased from 8.8% to 10.0% (P<0.001) for the public sector and from 5.9% to 8.6% (P<0.001) for the private sector. Interrupted time series models revealed a significant linear increase in readmission rates over the study period in all types of hospitals. However, the implementation of case-based payment was only associated with a significant increase in rehospitalisation rates for private hospitals (P<0.001).

CONCLUSION:

In France, the increase in the readmission rate appears to be relatively steady in both the private and public sector but appears not to have been affected by the introduction of a case-based payment system after accounting for changes in care practices in the public sector.

Rehospitalization after acute myocardial infarction (AMI) is common in elderly patients. It increases morbimortality and health care expenditures. The association between ambulatory care after discharge forAMI and rehospitalization has never been studied in France. We analyzed the impact of ambulatory care on rehospitalization of elderly patients (≥65 years) within 30 days after hospital discharge. 

We conducted a nationwide population-based study of elderly patients hospitalized with a main diagnosis of AMI in France between 2011 and 2013. We excluded patients hospitalized for AMI in the previous year and those who died during the index hospitalization or within 30 days after discharge. The primary outcome was the first all-cause 30-day rehospitalization in an acute care hospital. Individual and neighborhood-level variables were compared among rehospitalized and nonrehospitalized patients. Determinants of 30-day rehospitalization were identified using logistic regression models. 

Among the 624 eligible patients, 137 (22.0%) were rehospitalized within 30 days after discharge. In multivariate analyses, chronic kidney failure (odds ratio [OR] 1.88; 95% confidence interval [CI], 1.01–3.53) was an independent predictor of 30-day rehospitalization. We found no association among deprivation and spatial accessibility measures and 30-day rehospitalization. The purchase of lipid-lowering drugs prescription within 7 days after discharge was associated with a reduced risk of 30-day rehospitalization (OR 0.53; 95% CI, 0.36–0.79).

This study highlights the role of coordination among hospital and primary care physicians in post-AMI discharge and follow-up among elderly patients. Specifically, targeted interventions to reduce 30-day rehospitalizations should focus on patients with comorbidities and use of prescription drugs after hospital discharge.

In Manhattan, the rate of hospital discharges for avoidable hospital conditions (AHC), a measure of access to timely and effective ambulatory care, fell by nearly 50 percent between 1999 and 2013. Despite this remarkable improvement, there has been virtually no change in racial, ethnic, or neighborhood-level differences in rates of AHC. This is surprising given New York City's emphasis on public health and its efforts to reduce health and health-care inequalities. We discuss the policy implications of these findings and argue that growing income and wealth inequalities have limited the ability of New York City to address inequalities in population health and health-care access. Unless there are substantial changes in federal and state policy, designed to reduce economic inequalities, it will be difficult to achieve the goal of eliminating health and health-care inequalities.

We compare health improvements among three megacities in BRIC nations as measured by declines in amenable mortality (AM). Although there have been studies of AM in Brazil and the Russian Federation using different definitions and age cohorts, this indicator has never been used to compare these cities. During the period 2000–10, age-adjusted rates of all leading causes of AM fell in all three cities. In São Paulo, it dropped from 1.57 to 1.19 per 1,000 population. In Moscow, it fell from 2.10 to 1.40, and in Shanghai, from 0.72 to 0.54. The rate of decrease was highest in Moscow (33 percent), followed by Shanghai (30 percent), and São Paulo (24 percent). All three cities experienced large reductions in chronic cardiovascular diseases in the form of IHD and stroke, but they remain the leading causes of premature death. Our finding of the decline of AM deaths in São Paulo, Moscow, and Shanghai suggests that all three health systems made significant improvements over the 2000–10 period. It will be important to monitor this indicator as economic growth in these countries and cities has slowed considerably since 2010.

Policymakers in the US and France are struggling to improve coordination among

hospitals and other health care providers. A comparison of hospital readmission rates, and the factors that may explain them, can provide important insights about the French and US health care systems. In addition, it illustrates a methodological approach to comparative research: how an empirical inquiry along a single indicator can reveal broader issues about system-wide differences across health care systems and policy. Using data from three French regions, the article extends a

previous national-level comparison indicating that rates of hospital readmission for the population aged 65+ are lower in France than in the US. In addition, we extend the range of variables available in the national comparison by drawing on neighborhood-level income data available from a previous study of access to primary care among three French regions. Within France, the odds of surgical hospital readmission are significantly lower in private for-profit hospitals compared with public hospitals. Patients who live in lower income neighborhoods are also more likely to be readmitted for medical and surgical conditions than are patients living in higher income neighborhoods, but this income effect is weaker than in the US. The article concludes with a discussion of how these findings reflect broader system-wide differences between the US and French health systems and the ways in which policymakers attempt to coordinate hospitals and community based services.

We compare health improvements among three megacities in BRIC nations as measured by declines in amenable mortality (AM). Although there have been studies of AM in Brazil and the Russian Federation using different definitions and age cohorts, this indicator has never been used to compare these cities. During the period 2000–10, age‐adjusted rates of all leading causes of AM fell in all three cities. In São Paulo, it dropped from 1.57 to 1.19 per 1,000 population. In Moscow, it fell from 2.10 to 1.40, and in Shanghai, from 0.72 to 0.54. The rate of decrease was highest in Moscow (33 percent), followed by Shanghai (30 percent), and São Paulo (24 percent). All three cities experienced large reductions in chronic cardiovascular diseases in the form of IHD and stroke, but they remain the leading causes of premature death. Our finding of the decline of AM deaths in São Paulo, Moscow, and Shanghai suggests that all three health systems made significant improvements over the 2000–10 period. It will be important to monitor this indicator as economic growth in these countries and cities has slowed considerably since 2010.

Over half of the world’s population lives in cities and United Nations (UN) demographers project an increase of 2.5 billion more urban dwellers by 2050. Yet there is too little systematic comparative research on the practice of urban health policy and management (HPAM), particularly in the megacities of middle-income and developing nations. We make a case for creating a global database on cities, population health and healthcare systems. The expenses involved in data collection would be difficult to justify without some review of previous work, some agreement on indicators worth measuring, conceptual and methodological considerations to guide the construction of the global database, and a set of research questions and hypotheses to test. We, therefore, address these issues in a manner that we hope will stimulate further discussion and collaboration.

Obamacare is the most important reform in the American healthcare system since 1965. Its introduction provoked unprecedented controversy between republicans and democrats. Whilst much remains to be done, it has already helped extend health insurance coverage, change the way the healthcare system is funded, establish federal regulations for private insurance, and above all, promote innovation and experiments to modernize the healthcare delivery. Seen from France, it is interesting to follow the array of ongoing experiments in the United States intended to modernize the healthcare system: adaptations to the payment systems for hospitals and doctors and organizational innovations to improve healthcare delivery.

A response to two commentaries:

Hunter, D. J. (2015). Health Policy and Management: In praise of political science Comment on "On Health Policy and Management (HPAM): Mind the theory-policy-practice gap" International Journal of Health Policy and Management Int J Health Policy Manag, 4(6), 391-394.

Kervasdoué, J. D. (2015). An American plague: Pro-market believers in health policy Comment on "On Health Policy and Management (HPAM): Mind the theory-policy-practice gap" International Journal of Health Policy and Management Int J Health Policy Manag, 4(2), 107-109. doi:10.15171/ijhpm.2015.15

Les hospitalisations potentiellement évitables (HPE), nécessaires au moment de l’admission à l’hôpital, pourraient être évitées par une prise en charge appropriée des soins de premier recours. Quel est l’apport de l’indicateur des HPE dans un diagnostic territorial et dans l’évaluation des parcours de soins?

Link to 2 page abstract

Available on SSRN database here.

The largest cities in the wealthy nations all face an unprecedented challenge: how to meet the needs of a population that lives longer, has a declining birth rate, is generally healthier, but also increasingly beset by the rise of chronic illness. The World Cities Project (WCP) has produced two books and numerous articles based on comparisons among, and within five of the world's most dynamic cities: New York, Paris, London, Tokyo and Hong Kong. These cities are centres of economic growth and finance, culture and media, sophisticated transportation systems and innovations of all kinds. They are renowned for their centres of excellence in medical care, top-ranking medical schools, institutes of bio-medical research, and public health infrastructure. Likewise, they attract some of the wealthiest, as well as the poorest populations of their nations, which forces their health care systems to confront the challenge of confronting glaring inequalities and redesigning their health care systems.

We reflected on why the field of HPAM has had little impact on the basic arrangements within which most physicians practice. We argued that this failure reflects four dimensions of a theory-policy-practice gap: 1) The dominance of microeconomic thinking; 2) The lack of learning from comparative case studies in healthcare management; 3) The separation of HPAM from frontline medical providers; and 4) The failure to expose medical students to issues of HPAM with respect to the organizational and regulatory environments in which they will ultimately work.

Windows can sometimes be mirrors. A look at health systems abroad can enable us to develop a better understanding of our health system in the United States. An international perspective suggests that the United States has the most expensive health care system in the world, but unlike other wealthy countries, we fail to provide universal health insurance coverage and experience large inequities in access to primary and specialty care. Health care costs are often a source of financial strain, even bankruptcy, for people with serious illness (Hacker, 2006), and Americans suffer from high rates of mortality that could have been avoided with timely and appropriate access to a range of effective health care services (Nolte & McKee, 2012). There is also evidence that the U.S. health care system squanders resources and fails to address many of its population’s health care needs. Not surprisingly, public opinion polls regularly find that medical professionals and the public are dissatisfied with the system and believe major change is necessary (Blendon, Benson, & Brulé, 2012). 

Over the past two decades, Shanghai, the largest megacity in China, has been coping with unprecedented growth of its economy and population while overcoming previous underinvestment in the health system by the central and local governments. We study the evolution of Shanghai’s healthcare system by analyzing “Avoidable Mortality” (AM) – deaths amenable to public health and healthcare interventions, as previously defined in the literature. Based on analysis of mortality data, by cause of death, from the Shanghai Municipal Center for Disease Control and Prevention, we analyze trends over the period 2000–10 and compare Shanghai’s experience to other mega-city regions – New York, London and Paris. Population health status attributable to public health and healthcare interventions improved dramatically for Shanghai’s population with permanent residency status. The age-adjusted rate of AM, per 1,000 population, dropped from 0.72 to 0.50. The rate of decrease in age-adjusted AM in Shanghai (30%) was comparable to New York City (30%) and Paris (25%), but lower than London (42%). Shanghai’s establishment of the Municipal Center for Disease Control and Prevention and its upgrading of public health and health services are likely to have contributed to the large decrease in the number and rate of avoidable deaths, which suggests that investments in public health infrastructure and increasing access to health services in megacities – both in China and worldwide – can produce significant mortality declines. Future analysis in Shanghai should investigate inequalities in avoidable deaths and the extent to which these gains have benefitted the significant population of urban migrants who do not have permanent residency status.

See five commentaries on the article

We argue that the field of health policy and management (HPAM) ought to confront the gap between theory, policy, and practice. Although there are perennial efforts to reform health care systems, the conceptual barriers are considerable and reflect the theory-policy-practice gap. We highlight four dimensions of the gap (1) the dominance of microeconomic thinking in health policy analysis and design; (2) the lack of learning from management theory and comparative case studies; (3) the separation of HPAM from the rank and file of health care; and (4) the failure to expose medical students to issues of HPAM. We conclude with suggestions for rethinking the field of HPAM by embracing broader perspectives, e.g. ethics, urban health, systems analysis and cross-national analyses of health care systems.

See two commentaries on the article

Hunter, D. J. (2015). Health Policy and Management: In praise of political science Comment on "On Health Policy and Management (HPAM): Mind the theory-policy-practice gap" International Journal of Health Policy and Management Int J Health Policy Manag, 4(6), 391-394.

Kervasdoué, J. D. (2015). An American plague: Pro-market believers in health policy Comment on "On Health Policy and Management (HPAM): Mind the theory-policy-practice gap" International Journal of Health Policy and Management Int J Health Policy Manag, 4(2), 107-109. doi:10.15171/ijhpm.2015.15

Objective: To compare rates of 30-day all-cause rehospitalization in France and the US among patients aged 65 years and older and explain any difference between the countries.

Methods: To calculate rehospitalization rates in France, we use an individual identifying variable in the national hospital administrative dataset to track unique individuals aged 65 years or more hospitalized in France in 2010. To calculate the proportion of rehospitalized patients (65þ) who received outpatient visits between the time of initial discharge and rehospitalization, we linked the hospital database with a database that includes all medical and surgical admissions. We used step by step regression models to predict rehospitalization.

Results: Rates of rehospitalization in France (14.7%) are lower than among Medicare beneficiaries in the US (20%). We find that age, sex, patient morbidity and the ownership status of the hospital are all correlated with rehospitalization in France.

Conclusions: Lower rates of rehospitalization in France appear to be due to a combination of better access to primary care, better health among the older French population, longer lengths of stay in French hospitals and the fact that French nursing homes do not face the same financial incentive to rehospitalize residents.

To learn from health care systems abroad, we must move beyond simplistic characterizations and compare different systems with respect to salient performance measures. Despite findings from recent cross-national studies suggesting that many health care systems outperform the United States, claims by U.S. public officials often fail to acknowledge the actual accomplishments of health care systems abroad. We document significant variation among the United States and France, Germany, and England, which provide universal coverage, albeit in different ways. As previously documented, the United States has the highest rate of mortality amenable to health care. We extend this work by adding two indicators: (a) access to timely and effective primary care as measured by hospital discharges for avoidable hospital conditions; and (b) use of specialty services as indicated by coronary revascularization (bypass surgery and angioplasty), adjusted for the burden of coronary artery disease. Our findings indicate that: (a) the United States suffers the gravest consequences of financial barriers to primary care; (b) in all four countries, older people (65+) receive fewer revascularizations than their younger counterparts once we account for disease burden; and (c) in France, patients receive the most revascularizations, after adjusting for the burden of disease.

The field of health policy and management (HPAM) faces a gap between theory, policy and practice. Despite decades of efforts at reforming health policy and health care systems, prominent analysts state that the health system is ‘‘stuck’’ and that models for change remain ‘‘aspirational.’’ We discuss four reasons for the failure of current ideas and models for redesigning health care: (1) the dominance of microeconomic thinking; (2) the lack of comparative studies of health care organizations and the limits of health management theory in recognizing the importance of local contexts; (3) the separation of HPAM from the rank and file of health care, particularly physicians; and (4) the failure to expose medical students to issues of HPAM. We conclude with suggestions for rethinking how the field of HPAM might generate more promising policies for health care providers and managers by abandoning the illusion of context-free theories and, instead, seeking to facilitate the processes by which organizations can learn to improve their own performance.

This article presents an indicator used in the United States and other OECD nations (hospitalizations for ambulatory-care sensitive conditions – ACSC) to assess access to primary care services and their capacity to handle a set of medical conditions before they require acute hospital treatment. Based on a study of Ile de France, which relies on residence-based hospital discharge data on patient diagnoses and treatments, the indicator identifies areas where hospitalizations for ACSC appear particularly high. Such hospital stays are considered potentially avoidable. Based on data from the Programme de m.dicalisation des syst.mes d’information (PMSI), disparities are measured. We rely on logistic regression analysis to identify a range of individual factors and neighborhood-level factors that explain these disparities. Access to primary care appears to be worse among residents in areas with average household income in the lowest quartile and among those hospitalized in public hospitals. This raises an important question for the future of health policy. Should areas with higher hospital discharge rates of ACSC be understood as having populations with poor health-seeking behaviors or health care systems not well enough organized to target higher-risk populations?

Based on the number of hospitalizations for ambulatory-care sensitive conditions in the Paris region (Ile-de-France), and the DRG-based rates for these hospital stays, we estimate the hospital expenditures that could be avoided if patients had access to primary care services that successfully manage their chronic conditions and avoid exacerbations that lead to necessary hospitalizations when they occur. In addition, we caution policymakers about what inferences can legitimately be drawn from such estimates for the expenditures averted on hospital care do not represent a net gain as there would likely be additional expenditures needed to upgrade ambulatory care to manage a host of complex chronic diseases.

Objectives: This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d’Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.

Methods: To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age- adjusted hospital discharge rates for revascularization – bypass surgery and angioplasty – among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization. Results: In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.

Conclusions: Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.

With population aging and increasing urbanization, it is important to examine the quality of life of older people living in cities, in particular world cities. However, few comparative studies of world cities examine their health, long-term care systems, or the characteristics of their older populations. To assess how well world cities are addressing the challenges associated with aging populations, it is helpful to review comparable data on the economic and health status of older persons, as well as the availability and use of health, social, and long-term care services. By extending the work of the “CADENZA: A Jockey Club Initiative for Seniors” Project and the World Cities Project, this chapter compares three world cities—Hong Kong, New York City, and London. The three world cities are similar in the size and proportion of their older populations, but the characteristics of older people and the health and long-term care systems available to them differ in significant ways. These comparisons reveal how Hong Kong, New York City, and London are responding to a rapidly aging population. They should be valuable to other cities that face the challenges of population aging.

We investigate avoidable hospital conditions (AHC) in three world cities as a way to assess access to primary care. Residents of Hong Kong are healthier than their counterparts in Greater London or New York City. In contrast to their counterparts in New York City, residents of both Greater London and Hong Kong face no financial barriers to an extensive public hospital system. We compare residence-based hospital discharge rates for AHC, by age cohorts, in these cities and find that New York City has higher rates than Hong Kong and Greater London. Hong Kong has the lowest hospital discharge rates for AHC among the population 15–64, but its rates are nearly as high as those in New York City among the population 65 and over. Our findings suggest that in contrast to Greater London, older residents in Hong Kong and New York face significant barriers in accessing primary care. In all three cities, people living in lower socioeconomic status neighborhoods are more likely to be hospitalized for an AHC, but neighborhood inequalities are greater in Hong Kong and New York than in Greater London.

We investigate avoidable hospital conditions (AHC) in three

world cities as a way to assess access to primary care. Residents of Hong Kong

are healthier than their counterparts in Greater London or New York City.

In contrast to their counterparts in New York City, residents of both Greater

London and Hong Kong face no financial barriers to an extensive public hospital

system. We compare residence-based hospital discharge rates for AHC, by age

cohorts, in these cities and find that New York City has higher rates than Hong

Kong and Greater London. Hong Kong has the lowest hospital discharge rates

for AHC among the population 15–64, but its rates are nearly as high as those in

New York City among the population 65 and over. Our findings suggest that in

contrast to Greater London, older residents in Hong Kong and New York face

significant barriers in accessing primary care. In all three cities, people living in

lower socioeconomic status neighborhoods are more likely to be hospitalized for

an AHC, but neighborhood inequalities are greater in Hong Kong and New York

than in Greater London.

Cities are critical sites for enquiry and action in relation to health and well-being. With up to 70 per cent of the world’s population estimated to be living in urban areas by 2050 1 , global health will be determined increasingly in cities. As Africa and Asia become the locus of urbanisation, researchers and policy-makers are increasingly contextualising, questioning or even moving beyond the urban health knowledge and approaches we have developed over the past century mainly in Western Europe and North America. The existence of significant urban health inequalities even within rich cities, often stubbornly resisting the efforts of public policy to reduce them, also continue to demand our attentions. In response to these challenges, the 2011 Urban Age Hong Kong conference, organized by the London School of Economics and Political Science and the Alfred Herrhausen Society in partnership with the University of Hong Kong, brought together over 170 planners, architects, sociologists, medical doctors, public health experts and economists from 36 cities and 22 countries to help identify the routes through which new meanings, methods and interventions for health and well-being might be developed for greater effect in today’s cities.

Hong Kong stands out among wealthy megacities as having some of the best indicators of population health. Infant mortality is 3.0 per 1,000 births in Hong Kong compared to 6.2 in New York City and 4.0 in Paris, while life expectancy at birth is 78.0 years compared to 77.7 years in Tokyo and 76.1 years in Greater London (Table 1). Such indicators are too broad, however, to draw useful inferences about the performance of Hong Kong’s health care system, let alone the effects of Hong Kong, as a city, on its population’s health. It is difficult to disentangle the relative importance of health systems and diverse city characteristics, such as population density, levels of environmental pollution or the nature of the built environment, from the multiple determinants of health, including the sociocultural factors and the neighbourhood context of the population whose health is measured.

While the growth of urbanization, worldwide, has improved the lives of migrants from the hinterland, it also raises health risks related to population density, concentrated poverty and the transmission of infectious disease. Will megacity regions evolve into socially infected breeding grounds for the rapid transmission of disease, or can they become critical spatial entities for the protection and promotion of population health? We address this question for the Pearl River Delta Region (PRD) based on recent data from Chinese sources, and on the experience of how New York, Greater London, Tokyo and Paris have grappled with the challenges of protecting population health and providing their populations with access to health care services. In some respects, there are some important lessons from comparative experience for PRD, notably the importance of covering the entire population for health care services and targeting special programs for those at highest risk for disease. In other respects, PRD's growth rate and sheer scale make it a unique megacity region that already faces new challenges and will require new solutions.

Patient safety, and more broadly the quality of care, is typically discussed with reference to the reduction of preventable adverse events within hospitals and adherence to practice guidelines on care processes. We call it the ‘care-centered approach’ and recognize that the United States is a leader in the field. Another face of patient safety and care quality may be defined as the ‘system-centered approach’. It focuses on access to a timely and effective continuum of health-care services – clinical prevention, primary care and appropriate referral to and receipt of specialty care. Although France's efforts to pursue a care-centered approach to patient safety are limited, its system-centered approach yields some benefits. Based on the evidence we have reviewed for access to primary care (hospital discharges for avoidable hospital conditions), mortality amenable to medical intervention and consumer satisfaction, in the United States and France, there appear to be good grounds for bolstering the system-centered approach in the United States.

The article presents a review of an individual approach to emergency preparedness for socially isolated elderly city dwellers. It cites crisis instances highlighting older persons' vulnerability and the importance of neighborhood characteristics as the isolated elderly had reportedly higher mortality rates in poor neighborhoods and abandoned lots than in equally poor but more socially-connected neighborhoods. It suggests a population-based case management requiring information dissemination and outreach strategies for finding and assisting older persons.

New York. London. Paris. Although these cities have similar sociodemographic characteristics, including income inequalities and ethic diversity, they have vastly different health systems and services. This book compares the three and considers lessons that can be applied to current and future debates about urban health care.

Highlighting the importance of a national policy for city health systems, the authors use well-established indicators and comparable data sources to shed light on urban health policy and practice. Their detailed comparison of the three city health systems and the national policy regimes in which they function provides information about access to health care in the developed world's largest cities.

The authors first review the current literature on comparative analysis of health systems and offer a brief overview of the public health infrastructure in each city. Later chapters illustrate how timely and appropriate disease prevention, primary care, and specialty health care services can help cities control such problems as premature mortality and heart disease.

In providing empirical comparisons of access to care in these three health systems, the authors refute inaccurate claims about health care outside of the United States.

Click here for a brief excerpt of the content.

Book review in Journal of Health Politics, Policy and Law.

A major effort to introduce new vaccines into poor nations of the world was initiated in recent years with the help of the GAVI alliance. The first vaccines introduced have been the Haemophilus influenzae type B (Hib) and the hepatitis B (Hep B) vaccines. The introduction of these vaccines during the first phase of GAVI's operations demonstrated considerable variability. We set out to study the factors affecting the introduction of these vaccines. The African Region (AFRO), where new vaccines were introduced to a substantial number of countries during the first phase of GAVI's funding, was selected for this study.

Victor G. Rodwin, qui tiendra une conférence à Marseille le 22 janvier prochain, explique en quoi la réforme
du système de santé est si difficile à mettre en oeuvre aux États-Unis. Si le Président Obama a surmonté
les premières difficultés, la course d'obstacles n'est pas pour autant terminée. Rodwin reconnaît l'excellence
du système médical français tout en contestant la première place attribuée par l'OMS à notre pays.

The question posed in this paper is whether single-payer health care systems

are more likely to provide equal treatment for equal need (horizontal equity) than are multipayer systems. To address this question, we compare access to primary and specialty health care services across selected neighborhoods, grouped by average

household income, in a single-payer system (the English NHS), a multiple-payer system with universal coverage (French National Health Insurance), and the U.S. multiple-payer system characterized by large gaps in health insurance coverage. We find that Paris residents, including those with low incomes, have better access to health care than their counterparts in Inner London and Manhattan. This finding casts doubt on the notion that the number of payers influences the capacity of a health care system to provide equitable access to its residents. The lesson is to worry less about the number of payers and more about the system’s ability to assure access to primary and specialty care services.

A collection of writings by leading experts and newer researchers on the SARS outbreak and its relation to infectious disease management in progressively global and urban societies.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

Background: Access to timely and effective medical services can reduce rates of premature mortality attributed to certain conditions. We investigate rates of total and avoidable mortality (AM) and the percentage of avoidable deaths in France, England and Wales and the United States, three wealthy nations with different health systems, and in the urban cores of their world cities, Paris, Inner London and Manhattan. We examine the association between AM and an income-related variable among neighbourhoods of the three cities. Methods: We obtained mortality data from vital statistics sources for each geographic area. For two time-periods, 1988–90 and 1998–2000, we assess the correlation between area of residence and age- and gender-adjusted total and AM rates. In our comparison of world cities, regression models are employed to analyse the association of a neighbourhood income-related variable with AM. Results: France has the lowest mortality rates. The US exhibits higher total, but similar AM rates compared to England and Wales. Rates of AM are lowest in Paris and highest in London. Avoidable mortality rates are higher in poor neighbourhoods of all three cities; only in Manhattan is there a correlation between the percentage of deaths that are avoidable and an income related variable. Conclusions: Beyond the well-known association of income and mortality, persistent disparities in AM exist, particularly in Manhattan and Inner London. These disparities are disturbing and should receive greater attention from policy makers.

Climate change and human health are intertwined.  The heat waves in Chicago, in 1995, and in Paris, in 2003, followed by Hurricane Katrina_s destruction of New Orleans, raised awareness of the risks faced by vulnerable older people. Many cities have responded by announcing emergency preparedness plans; some of these plans have already been tested. Last summer, from July 27 to August 5, New York City suffered a mild heat wave with temperatures reaching 100-F. Paris, as well, was hit by another heat wave from July 17 to July 29, with maximum temperatures reaching 104-F, which was considerably milder than in 2003 when they often exceeded 110-F. In New York, there were 100 "excess deaths," an increase of 8% over past trends. In Paris, the number of excess deaths in 2006 (42), also an increase of 8%, was considerably lower than the 1,294 deaths registered in 2003-an increase of 190% compared to the preceding three-year average. Given existing surveillance capacity, it is impossible to know whether the reduction in excess deaths in Paris was due, partly, to its enhanced preparedness or whether it reflects no more than the effects of a far milder heat wave. Nevertheless, the milder heat wave of 2006 does provide an opportunity to examine the actual implementation of the heat wave preparedness plan. In light of ongoing efforts to develop such plans in cities worldwide and completed studies on the effects of the 2003 heat wave in Paris, what may be learned to promote urban health and improve understanding of the factors that put vulnerable older people at greatest risk?

Cross-national comparisons that assess dimensions of health system performance indicate that the US provides higher rates of revascularization procedures than France and other developed nations, but we believe these findings are misleading. In this paper, we compare the use of these procedures in the US, France and their two world cities, Manhattan and Paris. In doing so, we address a number of limitations associated with existing cross-national comparisons of heart disease treatment. After adjusting for the prevalence of disease in these nations and cities, we found that residents of France aged 45–64 years receive more revascularization procedures than residents of the US and that Parisians receive more revascularizations than residents of Manhattan. Older residents 65 years and over (65+) in the US receive more of these procedures than their French counterparts, but the differences are not nearly as great as previous studies suggest. Moreover, our data on Manhattan and Paris where the population and level of health resources are more comparable, indicate that older Parisians obtain more revascularization procedures than older Manhattanites. Finally, we found that the use of revascularization procedures is significantly lower in Manhattan among persons without private health insurance and among racial and ethnic minorities.

An interdisciplinary examination of rates of avoidable hospitalizations in France and England to evaluate access to primary care and identify the extent to which these countries may be able to reduce hospital costs by investing in disease management and primary care. The policy brief was published under the Alliance for Health & the Future, a partnership between ILC-USA, ILC-UK and ILC-France.

Cross-national comparisons that assess dimensions of health system performance indicate that the US provides higher rates of revascularization procedures than France and other developed nations, but we believe these findings are misleading. In this paper, we compare the use of these procedures in the US, France and their two world cities, Manhattan and Paris. In doing so, we address a number of limitations associated with existing cross-national comparisons of heart disease treatment. After adjusting for the prevalence of disease in these nations and cities, we found that residents of France aged 45�64 years receive more revascularization procedures than residents of the US and that Parisians receive more revascularizations than residents of Manhattan. Older residents 65 years and over (65 ) in the US receive more of these procedures than their French counterparts, but the differences are not nearly as great as previous studies suggest. Moreover, our data on Manhattan and Paris where the population and level of health resources are more comparable, indicate that older Parisians obtain more revascularization procedures than older Manhattanites. Finally, we found that the use of revascularization procedures is significantly lower in Manhattan among persons without private health insurance and among racial and ethnic minorities.

Declining birthrates, increasing longevity and growing urbanization have created a new challenge for cities: how to respond to an aging population. The World Cities Project was designed to examine whether the four largest cities among the wealthiest nations of the world - New York, London, Paris and Tokyo - offer a model of what other cities will someday resemble as their populations grow older.

Perhaps the four world cities examined here will always be regarded as special cases; however, they share in common a host of important characteristics. Within them live the largest number of older people in their countries and in some neighborhoods the percent of elders 65 or older far exceeds what the census demographers project for their nations in 2030. Thus, these great cities may serve as laboratories to inquire about the implications of demographic change for health and quality of life, living arrangements and housing, and the provision of long-term care to older adults when they eventually become frail.

Based on a comparison of discharges for avoidable hospital conditions (AHCs), we find that Paris provides greater access to primary care than Manhattan. Ageadjusted AHC rates are more than 2.5 times as high in Manhattan as in Paris. In contrast, the difference in rates of hospital discharge for "marker conditions" are only about 20 percent higher in Manhattan. Rates of discharges for AHCs are higher among residents of low-income neighborhoods in both cities, but the disparity among high- and low-income neighborhoods is more than twice as great in Manhattan. Our analysis highlights the consequences of access barriers to care in Manhattan, particularly among vulnerable residents.

Population aging often provokes fears of impending social security deficits, uncontrollable medical expenditures, and transformations in living arrangements, but public policy could also stimulate social innovations. These issues are typically studied at the national level; yet they must be resolved where most people live—in diverse neighborhoods in cities. New York, London, Paris, and Tokyo are the four largest cities among the wealthiest, most developed nations of the world. The essays commissioned for this volume compare what it is like to grow older in these cities with respect to health care, quality of life, housing, and long-term care. The contributors look beyond aggregate national data to highlight the importance of how local authorities implement policies.

In France, American nostrums of unleashing market forces under the banner of "consumer-directed health care," and selective contracting by private health insurers, have gained little ground. That should not, however, lead one to conclude that the French health care system is irrelevant to the United States. The organization and financing of health care, in France, resembles, in many respects, that of the United States - more so, in fact, than do Britain's National Health Service or Canadian and German national health insurance (NHI). The French reliance on a public-private mix that includes a significant proprietary hospital sector, private fee-for-service medical practice, and enormous patient choice among a pluralistic organization of health care providers makes French NHI a model for what Senator Ted Kennedy and Congressman Pete Stark have called "Medicare for all."

Objective: We investigated the association between average income or deprivation and infant mortality rate across neighborhoods of four world cities.

Methods: Using a maximum likelihood negative binomial regression model that controls for births, we analyzed data for 1988-1992 and 1993-1997.

Results: In Manhattan, during both periods, we found a statistically significant association between income and infant mortality (.05 level) while in Tokyo there was none. In Paris and London, there was no association in period one. In period two, the association just misses statistical significance for Paris while in London association with a deprivation index is significant.

Conclusions: In contrast to Tokyo, Paris and London, the association of income and infant mortality rate is more strongly evident in Manhattan.

Health services research is, by nature, multidisciplinary, for it draws on the methods,concepts and theories of social sciences, which are relevant to the study of how the organization and financing of health services can improve the delivery of health care services (Gray, et al., 2003). While medicine and public health, too, are multidisciplinary enterprises drawing on such disciplines as molecular biology, physiology, anatomy, genetics, epidemiology and more, health services research departs from these disciplines in focusing not on the nature of disease and health but rather on the financing and organization of health systems.

So it is with urban health services research albeit that this field is more narrowly focused on health services in cities. The city focus has resulted in a large body of research on vulnerable groups, barriers to service access, public health clinics and community health centers. Likewise, it has led to important investigations of safetynet institutions, e.g. public hospitals and health centers, which serve a disproportionate share of uninsured and low-income patients. In addition, urban health services research has focused on a host of specific services associated with subpopulations suffering from TB, HIV/AIDS, drug addiction and other social pathologies that are typically associated with the "inner city."

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

The World Health Organization recently ranked the French health care system the best in the world.1 Although the methods and data on which this assessment was based have been criticized, there are good grounds for being impressed by the French system. Yet in August 2004, with the national health insurance (NHI) system facing a severe financial crisis, France enacted Minister of Health Philippe Douste-Blazy's reform plan. Like previous efforts at health care reform, this one seeks to preserve a system of comprehensive benefits, which is supported by the major stakeholders.

We examine, for residents in two nations (U.S. and France) and the hearts of two world cities (New York, and Paris), differences in rates of mortality and hospital discharge, by area of residence, for ischemic heart disease (IHD), acute myocardial infarction (AMI), and rates of revascularization. To assess the relationship between treatment rates and the prevalence of IHD, we introduce an index based on the ratio of procedure rates to AMI hospital discharge rates and mortality. After accounting for disease prevalence, we find that procedure rates are lower in Manhattan than in Paris for both age groups, and lower in the United States than France among the 45-64 year old cohort.

Background: Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.

Objective: This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged > 65 years by analyzing data from the United States, France, England and from their largest cities - New York City and its outer boroughs, Paris and its First Right, and Great London.

Conclusions: A consistent pattern of gender disparity in the interventional treatment of CAD was seen across 3 national health systems with known differences in patterns of medical practice. This finding is consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD are due at least in part to the underdiagnosis of CAD in women.

Background: Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.

Objective: This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged ≥65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London.

Methods: This was an ecological study based on a retrospective analysis of comparable administrative
data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest
cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between
treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients.
Differences in rates were examined by univariate analysis using the Student t test for statistical differences
in mean values.

Results: Despite differences in health system characteristics, including health insurance coverage, availability
of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous
transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units.
The rate of interventional treatment in women with CAD was less than half that in men. This difference
persisted after adjustment for the prevalence of heart disease.

Conclusions: A consistent pattern of gender disparity in the interventional treatment of CAD was seen
across 3 national health systems with known differences in patterns of medical practice. This finding is
consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD
are due at least in part to the underdiagnosis of CAD in women.

Les villes de New York, Londres, Paris et Tokyo concentrent une part majeure de l'activité et de la richesse de leurs nations. Elles connaissent une forte densité de population, et notamment de personnes âgées. Elles disposent en outre d'un potentiel en équipement, réseaux et infrastructures de soins médicaux très important par rapport aux autres agglomérations.

Examiner le vieillissement de leur population et comparer les systèmes de santé et de soins dans ces quatre mégapoles est l'objet d'un programme de recherche international, qui vise à s'interroger sur les adaptations des systèmes sanitaires et sociaux à la longévité croissante de la population.

C'est parmi les quatre villes Tokyo qui présente la densité la plus élevée de personnes âgées de 65 ans et plus, mais Paris celle de personnes très âgées (85 ans et plus).

À Tokyo, les personnes âgées vivent également moins souvent seules que dans les autres mégapoles, les centres urbains de Manhattan, Paris et Londres concentrant en particulier une forte proportion de femmes très âgées et vivant seules.

Si ces quatre villes ont un équipement médical et hospitalier plus important en centre urbain qu'en périphérie, la densité en lits médicalisés et de long séjour apparaît inférieure à Londres et à Tokyo.

Les services d'aide à domicile, plus denses dans les centres urbains, sont plus difficiles à comparer mais semblent légèrement mieux assurés dans le centre de Londres.

A comparison of citywide infant mortality rates for Manhattan, Inner London, Paris, and Inner Tokyo during 1988–97 shows the Manhattan rate nearly always higher than those of the other cities. Differences in the neighborhood rate distributions of the four cities explain the citywide pattern. In contrast to the other cities, Manhattan has neighborhoods with rates substantially above its median neighborhood rate and these neighborhoods drag its citywide rate above those of the other cities.

This article provides an overview of the World Cities Project (WCP), our rationale for it, our framework for comparative analysis, and an overview of current studies in progress. The WCP uses New York, London, Paris, and Tokyo as a laboratory in which to study urban health, particularly the evolution and current organization of public health infrastructure, as well as the health status and quality of life in these cities. Comparing world cities in wealthier nations is important because of (1) global trends in urbanization, emerging health risks, and population aging; (2) the dominant influence of these cities on “megacities” of developing nations; and (3) the existence of data and scholarship about these world cities, which provides a foundation for comparing their health systems and health. We argue that, in contrast to nation-states, world cities provide opportunities for more refined comparisons and cross-national learning. To provide a framework for WCP, we define an urban core for each city and examine the similarities and differences among them. Our current studies shed light on inequalities in health care use and health status, the importance of neighborhoods in protecting population health, and quality of life in diverse urban communities.

The city is, at once, a center for disease and poor health and also a place for hope, cures and good health. From the earliest times, the city has attracted the poor and been the target of the plague, as well as war. Likewise, the health care industry has always been part of the economic base of cities - from Lourdes, in France, to Rochester, Minnesota, to megacities around the world. With its highly disproportionate share of health resources, e.g., hospitals, physicians, nurses and social services, the big city is a center of excellence in medicine. Yet, as Richard Horton, editor of The Lancet once noted, "For all of its rational efficiency and benevolent intent, the city is likely to be the death of us." Are cities socially infected breeding grounds for disease? Or do they represent critical spatial entities for promotion of population health? I propose to begin with a global view of urban health and disease and the challenge this poses for public health today. Next, I examine some evidence for the hypothesis that population health in cities is relatively poor. Finally, I suggest that the more pertinent question is not whether the city is unhealthy or healthy but rather the extent to which we can alleviate the problems posed by inequalities of income and wealth - in the city as well as outside of it.

Improvements in health care and declining birth rates have combined to create rapidly aging populations throughout the industrialized world. By 2020, for example, nearly seventeen percent of the US population is expected to be over the age of sixty-five. In Japan that mark has already been passed, with more than one-quarter of the population expected to be over sixty-five by 2020. At the same time, the world's population is increasingly concentrated in urban areas: the United Nations estimates that by 2025, sixty-one percent of the world's population will live in cities. As both urbanization and population aging increase, we will need models of how to accommodate this population shift and examples to emulate in dealing with these phenomena.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

Health care has emerged as perhaps the most urgent issue in America, and health care reform as the most ambitious initiative in domestic policy since the New Deal. Japan, on the other hand, already boasts the world's lowest infant mortality rate and longest life expectancy, while achieving more success than America at containing medical costs: in 1991, spending on health care accounted for a mere 6.6 percent of Japan's total gross domestic product versus 13.4 percent of America's. How does Japan do it? What aspects of the Japanese model might be applicable to the United States?

    To explore these questions, on Friday, April 30, 1993, the Japan Society organized a one-day conference entitled Making Universal Health Care Affordable: How Japan Does It. Three distinguished panels of Japanese and American health care specialists discussed the management of Japan's universal health care coverage, ways to balance quality care and cost containment, and how the United States might profit from Japan's experience. Professor Victor Rodwin was one of the conference participants (see Appendix 3) and agreed to draw on the conference discussions as a starting point for this more extensive monograph.

    The Japan Society is grateful to KPMG Peat Marwick; New York Pharma Forum; the International Leadership Center on Longevity and Society (U.S.) of The Mount Sinai School of Medicine, an affiliate of The City University of New York; the Japanese Ministry of Health and Welfare; and the New York Academy of Medicine for their generous support of the conference and this publication.

    We offer special thanks to the conference participants for their valuable presentations. We also thank John Campbell and Michael Reich for their close reading and comments on this manuscript; Toshihiko Takeda and Masaru Hiraiwa (JETRO-Ministry of Health and Welfare) for providing details on the Japanese health system and for reviewing key parts of the document; and Frank Schwartz for his diligent editorial assistance. Finally, we gratefully acknowledge David Forbes at New York University's Wagner Graduate School of Public Service for his secretarial assistance; Jennifer Capson McManus for proofreading the manuscript; and Donna Keyser and Lou Montesano for assisting in its publication.

This paper considers how American and Japanese policymakers might learn from

their mutual experience with health insurance and health policy. Each country views itself as a

health care leader in their respective areas of strength. Each country is characterized by

distinctive patterns of health care organization and financing. Yet, policy analysts on both sides

are intrigued and often envious of the other’s success. Americans can learn from the central

regulation of Japanese national health insurance and from Japan’s stellar health status and its

recent political commitment to long-term care. The Japanese can learn from the active role of

payers and other organizations in the United States in controlling volume, assuring quality of

care, and designing alternative health care delivery systems.

With sixteen hospitals and almost 10,500 beds, the New York City Health and Hospitals Corporation (HHC) is the largest municipal hospital system in the United States. With forty-seven hospitals and almost thirty-three thousand beds, the Paris Hospital Corporation, Assistance Publique-Hopitaux de Paris (AP), is three times as large, the biggest municipal hospital system in France.

This book compares these two vast systems. It analyzes staffing, outpatient and inpatient core, the desirability of private faculty a practice plans, budgeting, quality assurance, and the role of medical education in these two very different systems. In addition, it reviews how both HHC and AP plan to adapt their systems over the next decade and beyond. Aging populations, the development and diffusion of new medical technologies, and the growth of hospitals and physicians throughout the 1960s and 1970s have led to massive increases in health care costs in both the United States and in France. Both New York City and Paris have suffered the shock of the AIDS epidemic. Detailed, informed, and authoritative, this book will stand for years as the standard comparative study of two large municipal hospital systems.

The Advanced Management program for Clinicians (AMPC) was established in 1986 with the help of a grant from the W.K. Kellogg Foundation. It is designed for health care professionals who are currently in management positions and for those who seek career shifts in the direction of health care management and policy. The AMPC program represents New York University's response to some of the sweeping changes affecting the health sector: (1) the growth of large health care organizations; (2) pressures by payers to contain health care expenditures; (3) increasing intervention by government and corporations in the practice of medicine; and (4) disgruntlement among clinicians about their working environment. 

In this paper we briefly review these trends and discuss our goals in creating the AMPC program. Next, we describe the program's distinguishing characteristics. And we conclude with some reflections about the issues raised by two and a half years of experience training physicians in this program.