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Background We have previously validated administrative data algorithms to identify patients with rheumatoid arthritis (RA) using rheumatology clinic records as the reference standard. Here we reassessed the accuracy of the algorithms using primary care records as the reference standard. Methods We performed a retrospective chart abstraction study using a random sample of 7500 adult patients under the care of 83 family physicians contributing to the Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Using physician-reported diagnoses as the reference standard, we computed and compared the sensitivity, specificity, and predictive values for over 100 administrative data algorithms for RA case ascertainment. Results We identified 69 patients with RA for a lifetime RA prevalence of 0.9%. All algorithms had excellent specificity (>97%). However, sensitivity varied (75-90%) among physician billing algorithms. Despite the low prevalence of RA, most algorithms had adequate positive predictive value (PPV; 51-83%). The algorithm of “[1 hospitalization RA diagnosis code] or [3 physician RA diagnosis codes with ≥1 by a specialist over 2 years]” had a sensitivity of 78% (95% CI 69–88), specificity of 100% (95% CI 100–100), PPV of 78% (95% CI 69–88) and NPV of 100% (95% CI 100–100). Conclusions Administrative data algorithms for detecting RA patients achieved a high degree of accuracy amongst the general population. However, results varied slightly from our previous report, which can be attributed to differences in the reference standards with respect to disease prevalence, spectrum of disease, and type of comparator group.

ObjectivesThis study considers whether, in an easy access single-payer health care system, patients placed on outpatient commitment—community treatment orders (CTOs) in Victoria Australia—are more likely to access acute medical care addressing physical illness than voluntary patients with and without severe mental illness.MethodFor years 2000 to 2010, the study compared acute medical care access of 27,585 severely mentally ill psychiatrically hospitalized patients (11,424 with and 16,161 without CTO exposure) and 12,229 never psychiatrically hospitalized outpatients (individuals with less morbidity risk as they were not considered to have severe mental illness). Logistic regression was used to determine the influence of the CTO on the likelihood of receiving a diagnosis of physical illness requiring acute care.ResultsValidating their shared and elevated morbidity risk, 53% of each hospitalized cohort accessed acute care compared to 32% of outpatients during the decade. While not under mental health system supervision, however, the likelihood that a CTO patient would receive a physical illness diagnosis was 31% lower than for non-CTO patients, and no different from lower morbidity-risk outpatients without severe mental illness. While, under mental health system supervision, the likelihood that CTO patients would receive a physical illness diagnosis was 40% greater than non-CTO patients and 5.02 times more likely than outpatients were. Each CTO episode was associated with a 4.6% increase in the likelihood of a member of the CTO group receiving a diagnosis.ConclusionMental health system involvement and CTO supervision appeared to facilitate access to physical health care in acute care settings for patients with severe mental illness, a group that has, in the past, been subject to excess morbidity and mortality.

This study aimed to evaluate the impact of the PharmaCloud program, a health information exchange program implemented in 2013, on medication duplication under a single-payer, universal health insurance program in Taiwan. This study employed a retrospective pre-post study design and used nationwide health insurance claim data from 2013 to 2015. A difference-in-difference analysis was conducted to evaluate the effects of inquiry rate on the probability of receiving duplicate medications and on the number of days of overlapping medication prescriptions after implementation of the PharmaCloud program. The study subjects included patients receiving medications in 7 categories: antihypertension drugs, 217,200; antihyperlipidemic drugs, 69,086; hypoglycemic agents, 103,962; antipsychotic drugs, 15,479; antidepressant drugs, 12,057; sedative and hypnotic drugs, 56,048; and antigout drugs, 18,250. Up to 2015, the overall PharmaCloud inquiry rate has increased to 55.36%-69.16%. Compared with subjects in 2013, subjects in 2014 and 2015 had a significantly lower likelihood of receiving duplicate medication in all 7 medication groups; for instance, for antihypertension drug users, the odds ratio (OR) was 0.91 with 95% confidence interval (CI)=0.90-0.92 in 2014, and the OR was 0.81 with 95% confidence interval=0.81-0.82 in 2015. However, a higher inquiry rate led to a lower likelihood of receiving duplicate medication and shorter periods of overlapping medications only in some of the medication groups. The health information exchange program has reduced medication duplication, yet the reduction was not entirely associated with record inquiries. The hospitals have responded to the challenge of medication duplication by enhancing internal prescription control via a prescription alert system, which may have contributed to the reduction in duplicate medications and is a positive, unintended consequence of the intervention.

ObjectiveThe objectives of this study are to refine the measurement of appropriate emergency department (ED) use and to provide a natural observation of appropriate ED use rates based on professional versus patient perspectives.SettingTaiwan has a population of 23 million, with one single-payer universal health insurance scheme. Taiwan has no limitations on ED use, and a low barrier to ED use may be a surrogate for natural observation of users’ perspectives in ED use.ParticipantsIn 7 years, there were 1 835 860 ED visits from one million random samples of the National Health Insurance Database.MeasuresAppropriate ED use was determined according to professional standards, measured by the modified Billings New York University Emergency Department (NYU-ED) algorithm, and further analysed after the addition of prudent patient standards, measured by explicit process-based and outcome-based criteria.Statistical analysesThe area under the receiver operating characteristic curve (AUC) was used to reflect the performance of appropriate ED use measures, and sensitivity analyses were conducted using different thresholds to determine the appropriateness of ED use. The generalised estimating equation model was used to measure the associations between appropriate ED use based on process and outcome criteria and covariates including sex, age, occupation, health status, place of residence, medical resources area, date and income level.ResultsAppropriate ED use based on professional criteria was 33.5%, which increased to 63.1% when patient criteria were added. The AUC, which combines both professional and patient criteria, was high (0.85).ConclusionsThe appropriate ED use rate nearly doubled when patient criteria were added to professional criteria. Explicit process-based and outcome-based criteria may be used as a supplementary measure to the implicit modified Billings NYU-ED algorithm when determining appropriate ED use.

Background Care-seeking behavior is widely acknowledged to have strong influences on health outcomes among individuals with chronic conditions including diabetes. Despite its dynamic nature, care seeking behavior are often considered as time invariant in most studies. The likelihood of patients changing their regularity and source of chronic care over time is often neglected. This study aimed to determine the long-term trajectories of care-seeking patterns of both care-seeking regularity and health provider choices; and their associated factors among patients with type 2 diabetes under the National Health Insurance (NHI) program in Taiwan. Methods We utilized population-based data from the National Health Insurance Research Database (NHIRD) in Taiwan. Three thousand, nine hundred and eighty-seven adult patients with newly diagnosed type 2 diabetes in 1999 were enrolled in the cohort. We assessed their trajectories of regular care visits and sources of diabetes care from 2000 to 2010. A group-based trajectory model was applied. Results Seven distinct groups of long-term care-seeking patterns were identified. Only 51.44% of patients with newly diagnosed diabetes had regularly visited their providers over time. Among them, 56.41 and 16.09% had persistently sought care from generalized and specialized providers, respectively. 27.50% had sought care from different levels of providers. Patients who were male, elderly, low-income, and had a higher baseline diabetes severity were significantly more likely to either continue with their irregular care-seeking behavior or fail to maintain their regular care seeking behavior over time. Those who were younger, had a higher socioeconomic status, and lived in an urban area were significantly more likely to persistently seek care from specialized care settings. Conclusions This study is the first population-based assessment of long-term care-seeking behaviors of type 2 diabetes patients under a single-payer system with a comprehensive benefit coverage. The most alarming finding was that, despite the existence of the comprehensive universal health insurance coverage in Taiwan, almost 50% of patients did not seek or maintain regular visits to providers over time as recommended. Understanding variations in the long-term trajectories of care adherence and sources of care may help to identify gaps in diabetes care management.

The Turkish healthcare system has been subject to major reforms since 2003. During the reform process, access to public healthcare providers was eased and private providers were included in the insurance package for public insurees. This study analyzes data on out-of-pocket (OOP) healthcare expenditures to look into the impact of reforms on the size of OOP health expenditures for premium-based public insurees. The study uses Household Budget Surveys that provide a range of individual-and household-level data as well as healthcare expenditures for the years 2003, before the reforms, and 2006, after the reforms. Results show that with the reforms ratio of households with non-zero OOP expenditure has increased. Share and level of OOP expenditures have decreased. The impact varies across income levels. A semi-parametric analysis shows that wealthier individuals benefited more in terms of the decrease in OOP health expenditures.

Background Chronic obstructive pulmonary disease (COPD) imparts a substantial economic burden on western health systems. Our objective was to analyze the determinants of elevated healthcare utilization among patients with COPD in a single-payer health system. Methods Three-hundred eighty-nine adults with COPD were matched 1:3 to controls by age, gender and area of residency. Total healthcare cost 5 years prior recruitment and presence of comorbidities were obtained from a computerized database. Health related quality of life (HRQoL) indices were obtained using validated questionnaires among a subsample of 177 patients. Results Healthcare utilization was 3.4-fold higher among COPD patients compared with controls (p < 0.001). The \"most-costly\" upper 25% of COPD patients (n = 98) consumed 63% of all costs. Multivariate analysis revealed that independent determinants of being in the \"most costly\" group were (OR; 95% CI): age-adjusted Charlson Comorbidity Index (1.09; 1.01 - 1.2), history of: myocardial infarct (2.87; 1.5 - 5.5), congestive heart failure (3.52; 1.9 - 6.4), mild liver disease (3.83; 1.3 - 11.2) and diabetes (2.02; 1.1 - 3.6). Bivariate analysis revealed that cost increased as HRQoL declined and severity of airflow obstruction increased but these were not independent determinants in a multivariate analysis. Conclusion Comorbidity burden determines elevated utilization for COPD patients. Decision makers should prioritize scarce health care resources to a better care management of the \"most costly\" patients.

Choice is often touted as a means for change within health care systems. Yet ‘choice’, in this context, takes at least three distinct forms: choice between providers within a publicly funded health care system; choice between competing insurers within a universal plan; and, lastly, choice as between privately financed health care and universal public coverage. In Canada, it is this last form of choice that is under active debate; particularly in light of the Supreme Court of Canada’s decision in Chaoulli, which found a regulation banning private health insurance for medically necessary care was unconstitutional. The argument is frequently made that Canada is an outlier from other countries in having regulation that effectively precludes this kind of choice. This issue is likely to become of concern again in upcoming constitutional challenges where applicants are looking to overturn through judicial challenges Canada’s medicare system. This article tests that argument of whether Canada truly is ‘odd’ from a comparative policy perspective by exploring regulation of choice of privately financed health care in several European countries – the Netherlands, Germany, Sweden, England and France. We highlight commonalities as well as differences, showing the extent to which these countries employ regulation to fetter growth of a large privately financed sector. The article’s thesis is that Canada, in employing more intrusive forms of regulation, is not an outlier per se but at one point in a regulatory spectrum.

OBJECTIVES: Comparisons of cancer survival in Canadian and US metropolitan areas have shown consistent Canadian advantages. This study tests a health insurance hypothesis by comparing cancer survival in Toronto, Ontario, and Honolulu, Hawaii. METHODS: Ontario and Hawaii registries provided a total of 9190 and 2895 cancer cases (breast and prostate, 1986-1990, followed until 1996). Socioeconomic data for each person's residence at the time of diagnosis were taken from population censuses. RESULTS: Socioeconomic status and cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Honolulu, residents of low-income areas in Toronto experienced 5-year survival advantages for breast and prostate cancer. In support of the health insurance hypothesis, between-country differences were smaller than those observed with other state samples and the Canadian advantage was larger among younger women. CONCLUSIONS: Hawaii seems to provide better cancer care than many other states, but patients in Toronto still enjoy a significant survival advantage. Although Hawaii's employer-mandated health insurance coverage seems an effective step toward providing equitable health care, even better care could be expected with a universally accessible, single-payer system.

Objectives. The authors provide an overview of the hospital sector in Germany with a focus on the impact of recent reform legislation on this sector. Methods. Data from the Federal Statistics Office, the Ministry of Health, and the Federal Association of Physicians are synthesized with information obtained from a general review of the literature. Results. Before the implementation of recent health-care reforms, the German health-care system has been sharply divided into inpatient and ambulatory care sectors, resulting in a fragmented system of care delivery. All hospital operating costs were fully covered through per diem charges. The 1992 Health Care Structure Act and subsequent pieces of legislation have introduced new mechanisms to improve cost efficiency in the hospital sector and increase coordination between the inpatient and outpatient care. These measures notably include implementing an inpatient prospective payment system and permitting ambulatory surgery and care services to be offered in inpatient settings. Conclusions. Whereas prospective payments have greatly reduced the length of stay, hospitals were reluctant to offer ambulatory surgery due to budgetary constraints and the high level of ambulatory surgery by office-based physicians. The reforms passed have not yielded substantial cost savings. These reforms offer a natural experiment that could benefit from national and international studies on the impact of hospital sector redesign on management, financing, and patient outcomes.