Modeling the overdetection of screen-identified cancers in population-based cancer screening with the Coxian phase-type Markov process

Modeling overdetection resulting from screening often uses the conventional competing risk model. This model assigns screen-detected cases dying from other causes as overdetection modeled by a one-jump process, which may not be true for the censored overdetected cases. To relax this restrictive assumption, accommodate a finite Markov process for overdetection, and dispense with long-term follow-up until death, we propose a generalized Coxian phase-type Markov process to distinguish the progressive latent multistate pathway from the nonprogressive (overdetected) latent multistate pathway. Various new likelihood functions were developed to estimate the transition parameters with the available data accrued at the time of diagnosis. The proportion of overdetected cancers by the cured model was further estimated by using parameters with and without distinguishing between the two latent pathways. While perturbation analyses were conducted by changing their parameters to assess their effects on overdetection, the results, including of asymptotic analyses, were very robust for an overdetection rate higher than 20% but not for low overdetection rates. These two scenarios were demonstrated by applying the Coxian phase-type model to prostate cancer and breast cancer screening, yielding a substantial proportion of overdetected prostate cancer (60%) attributed to the prostate specific antigen test and a small fraction of overdetected breast cancer (3%) detected by mammography. This kind of variation in overdetection elucidated by the Coxian phase-type Markov process provides new insights into the quantitative mechanisms producing overdetection, which is informative for evaluating the benefits and risks of various types of population-based cancer screening programs.     

Modeling hospital length of stay by Coxian phase-type regression with heterogeneity

Hospital length of stay (LOS) is an important measure of healthcare utilization and is generally positively skewed and heterogeneous. We fit a Coxian phase-type distribution to LOS and identify the hidden states of the underlying latent homogeneous Markov model. We demonstrate that selecting an appropriate number of phases and a regression model for hazard rates can account for some heterogeneity in LOS. Reversible jump MCMC method enables us to dynamically uncover the hidden stochastic Markov structure. A classification method is used to assign patients to different LOS groups. The methodology is illustrated with application to hospital admissions for acute myocardial infarction in the 2003 Nationwide Inpatient Sample from the Healthcare Utilization Project.     

Geographic distribution of healthcare resources,healthcare service provision,and patient flow in Japan: A cross sectional study

Healthcare systems in developed countries are facing the challenge of dealing with changing social structures as a result of rapidly aging populations. This study examines the relationship among the geographical distribution of healthcare resources, healthcare service provision, and interregional patient flow in Japan. A cross-sectional study was performed using data from healthcare-related public surveys conducted in 2008, together with social, economic, and environmental variables. The geographical units of analysis were 348 Secondary Healthcare Service Areas, which provide and manage most healthcare services in Japan. The equity of the distribution of physicians among hospitals and clinics was evaluated using the Lorenz curve and the Gini coefficient. Multiple regression analysis was used to examine the relationships between the inpatient flow ratio and selected variables. Next, the 348 Secondary Healthcare Service Areas were divided into tertiles according to the inpatient flow ratio, and differences among these variables were examined using Bonferroni's correction for multiple comparisons. The Gini coefficient for physician distribution among hospitals was 0.209 and was 0.165 among clinics. Multiple regression analysis showed that hospital physician density, the elderly ratio, and hospital bed density were all correlated with the inpatient flow ratio (β = 0.396, −0.576, 0.425, respectively; R² = 0.622, all ps < 0.001). Healthcare resources were significantly more scarce in the lowest tertile (outflow group) than in other groups in both hospitals and clinics. The provision of healthcare services was also imbalanced among tertiles. Our results imply that there is a need for reconstituting the geographical distribution of healthcare resources in Japan. Further research and healthcare-related databases are also needed to facilitate the creation of a more balanced geographical distribution and of a more effective healthcare system in Japan.     

Migrants and healthcare: investigating patient mobility among migrants in Ireland

Drawing on detailed interviews with 60 recent migrants to Ireland, we discuss the extent and nature of patient mobility. The paper is framed by the typology of patient mobility outlined by Glinos et al. (2010), which highlights patient motivation and funding. We pay particular attention to four key areas: availability of health care for migrants living in Ireland; affordability of care as a push factor for patient mobility; how migrants' perceptions of care affect their decision about where to avail of care; and the impact of familiarity on patient mobility. We provide empirical support for this typology. However, our research also highlights the fact that two factors – availability and familiarity – require further elaboration. Our research demonstrates the need for greater levels of awareness of culture specificity on the part of both migrants and healthcare providers. It also highlights the need to investigate the social and spatial activities of migrants seeking health care, both within and beyond national boundaries.     

我国医疗服务竞争机制的优化策略——建立纵向整合的医疗服务体系

新医改时期,我国医疗服务提供引入市场机制已成必然选择,但如何完善当前的竞争机制需要进一步深入研究。本研究首先给出了衡量竞争机制有效性的评价标准;辨析了我国目前的竞争机制是医疗服务机构间在＂机构水平＂上相互竞争、以机构完成医疗服务量作为激励机制,并结合医疗服务特征,阐述了这是一种低效的竞争机制。提出＂系统水平＂上的竞争是今后我国新医改医疗服务竞争机制的选择,即在区域内构建多个纵向整合的医疗服务体系,竞争在系统与系统之间进行、以服务人群的健康改善作为激励机制。最后,对全球医疗服务竞争机制的演变进行了回顾,从经验上验证了上述理论分析的结论。     

Estimating the costs for a group of geriatric patients using the Coxian phase-type distribution

The length of stay in hospital of geriatric patients may be modelled using the Coxian phase-type distribution. This paper examines previous methods which have been used to model health-care costs and presents a new methodology to estimate the costs for a cohort of patients for their duration of stay in hospital, assuming there are no further admissions. The model, applied to 1392 patients admitted into the geriatric ward of a local hospital in Northern Ireland, between 2002 and 2003, should be beneficial to hospital managers, as future decisions and policy changes could be tested on the model to investigate their influence on costs before the decisions were carried out on a real ward.     

北京市居民对各级医疗卫生机构满意度调查分析

目的:通过分析2013年北京市卫生服务调查数据,了解北京市居民对各级医疗机构医疗服务的满意度情况,为相关政策提供决策依据。方法:在全市范围内进行抽样入户问卷调查,问卷使用"第五次国家卫生服务调查表"中的"家庭调查表",对其中就诊和住院满意度问题按照不同医疗机构级别分组进行描述,并采用!2检验进行分析。结果:北京市居民对基层医疗卫生机构就诊的总体满意度为84.5%,显著高于区县级(67.9%)和市级及以上医疗机构(61.4%),候诊时间等各项具体指标的满意程度也均高于区县级和市级及以上医疗机构,区县级和市级及以上医疗机构各有优劣。住院满意度情况则没有太大差别。与区县级及以上医疗卫生机构相比,基层医疗卫生机构门诊最主要的不满意原因分别为药品种类少和技术水平低;住院最主要的不满意原因分别为技术水平低,而市级及以上医疗机构则为服务态度差和医疗费用高。结论:北京市居民对基层医疗卫生机构的就诊满意度情况要显著优于区县级和市级及以上医疗机构。基层医疗卫生机构需增加药品种类,提高技术水平;区县级和市级及以上医疗机构要降低医疗费用,缩短等候时间。     

基于患者调查的深圳市罗湖医院集团化改革的成效初探

目的:从患者的角度对深圳市罗湖区医院集团改革实施后的成效进行探索。方法:采用问卷调查法,对罗湖区医院集团内的3家区属医院和23家社康中心的患者进行调查。结果:发放问卷990份,回收有效问卷936份,有效回收率为94.55%。认为家庭医生技术水平、服务态度、转诊服务以及解释和沟通能力等方面较好或非常好的患者占总调查人数的90%以上;给予社康中心服务水平、转诊便捷性、转诊流程、专家坐诊机制等较好或非常好评价的患者占总调查人数的80%以上。结论:罗湖医院集团建设初期成果有所显现,患者对家庭医生和社康中心的满意度较高,患者生病后通常所选的医疗机构中,选择社康中心的比例较集团成立前明显增加;未来应进一步发挥医疗集团优势,完善相关配套政策,长期成效值得进一步观察。     

Consequences of a decentralized healthcare governance model: measuring regional authority support for patient choice in Sweden

What are the implications of a decentralized model of healthcare governance? This case study on patient choice in Sweden is an attempt to shed light on this issue. Due to decentralization and constitutional rights of self-determination, the regional authorities in Sweden, called County Councils (CCs), have far-reaching rights to manage the healthcare sector. The fact that patient choice is considered to be a soft law or a soft governance regulation, opens it up to regional variation. To examine the CCs level of support of patient choice, an index is presented. The Patient Choice Index (PCI) shows that there is extensive variation among the CCs. To explain the causes of these variations, a number of hypotheses are tested. The analyses imply that ideology and economy, and more specifically the CCs' governing majorities and running net profits, are major explanations for the level of support.     

Using Coxian Phase-Type Distributions to Identify Patient Characteristics for Duration of Stay in Hospital

Coxian phase-type distributions are a special type of Markov model that describes duration until an event occurs in terms of a process consisting of a sequence of latent phases. This paper considers the use of Coxian phase-type distributions for modelling patient duration of stay for the elderly in hospital and investigates the potential for using the resulting distribution as a classifying variable to identify common characteristics between different groups of patients according to their (anticipated) length of stay in hospital. The identification of common characteristics for patient length of stay groups would offer hospital managers and clinicians possible insights into the overall management and bed allocation of the hospital wards.     

卫生体系分类方法的创新

本文研究的是卫生体系分类问题,希望得到比以往分析的卫生组织模式更深入的成果。从卫生服务的筹资方式看,可在标准三分法(据此可将卫生体系分为三类:自愿保险、社会医保和全民医保)基础上增加两种类型:强制国民医保和特殊人群医保计划。从保险方和服务提供方之间的服务提供和关系来看,有必要对垂直整合和独立的体系加以区分。本文与以往大部分研究的不同之处在于其潜在的逻辑。本文假设所有体系均为混合体系,主张抛开传统的卫生体系分类逻辑(即根据现行体系将各个国家分入不同类别),转而采用拼图逻辑。细分卫生服务或人口的概念,被证明对这一目标非常有用。     

Reflections on the influenza vaccination of healthcare workers

Despite all that is known about the dangers of nosocomial transmission of influenza to the vulnerable patient populations in our healthcare facilities, and the benefits of the influenza vaccination, the low rates of influenza vaccination among healthcare workers (HCWs) internationally shows no sign of significant improvement. With the current voluntary 'opt-in' programmes clearly failing to adequately address this issue, the time has undoubtedly come for a new approach to vaccination to be implemented. Two different approaches to vaccination delivery have been suggested to rectify this situation, mandatory vaccination and 'opt-out' declination forms. It is suggested, however, that these two approaches are inadequate when used by themselves. In order to protect the most vulnerable patients in our healthcare facilities as best we can from serious harm or death caused by nosocomial transmission of influenza, while at the same time respecting HCWs autonomy, and in many jurisdictions, the related legal right to refuse medical treatment, it is recommended that 'op-out' declination forms should be used in conjunction with restricted mandatory vaccination. This 'combined' approach would allow any HCW to refuse the influenza vaccination, but would make the influenza vaccination a mandatory requirement for working in areas where the most vulnerable patients are cared for. Those HCWs not willing to be vaccinated should be required to work in other areas of healthcare.     

Modelling bounded health scores with censored skew-normal distributions

Health care interventions that use quality of life or health scores often provide data which are skewed and bounded. The scores are typically formed by adding up numerical responses to a number of questions. Different questions might have different weights, but the scores will be bounded, and are often scaled to the range 0-100. If improvement in health over time is measured, scores will tend to cluster near the 'healthy' or 'good' boundary as time progresses, leading to a skew distribution. Further, some patients will drop-out as time progresses, hence the scores reflect a selected population.We fit models based on the skew-normal distribution to data from a randomized controlled trial of treatments for sprained ankles, in which scores were recorded at baseline and at 1, 3 and 9 months after injury. We consider the extent to which skewness in the data can be explained by clustering at the boundary via a comparison between a censored normal and a censored skew-normal model.As this analysis is based on the complete data only, a formula for the bias of the treatment effects due to informative drop-out is given. This allows us to assess under what conditions the conclusions drawn from the complete data might be either reinforced or reversed, when the informative drop-out process is taken into account.     

Five types of OECD healthcare systems: Empirical results of a deductive classification

This article classifies 30 OECD healthcare systems according to a deductively generated typology by Rothgang and Wendt [1]. This typology distinguishes three core dimensions of the healthcare system: regulation, financing, and service provision, and three types of actors: state, societal, and private actors. We argue that there is a hierarchical relationship between the three dimensions, led by regulation, followed by financing and finally service provision, where the superior dimension restricts the nature of the subordinate dimensions. This hierarchy rule limits the number of theoretically plausible types to ten. To test our argument, we classify 30 OECD healthcare systems, mainly using OECD Health Data and WHO country reports. The classification results in five system types: the National Health Service, the National Health Insurance, the Social Health Insurance, the Etatist Social Health Insurance, and the Private Health System. All five types belong to the group of healthcare system types considered theoretically plausible. Merely Slovenia does not comply with our assumption of a hierarchy among dimensions and typical actors due to its singular transformation history.     

以科学态度在卫生系统发展中构建与评价激励约束机制——兼评宁夏盐池与海原两县支付制度改革与研究

本文结合宁夏回族自治区盐池与海原两县支付制度改革与研究实践,阐述了如下观点:构建合理的激励约束机制是卫生系统可持续发展的支撑;合理激励约束机制的设计应以卫生系统目标改进为导向,兼顾各方和短长期利益;机制切换重在实施过程中利益相关方的配合协调与改革主导部门的实施推进;没有严谨科学的研究为依据的机制创建与评价难以令人信服。     

Vaccination of healthcare personnel: Spotlight on groups with underlying conditions

Healthcare personnel (HCP) are at increased risk of acquiring vaccine-preventable diseases (VPDs). Vaccination protects HCP and their patients from nosocomial transmission of VPDs. HCP who have underlying diseases (e.g., immunocompromised, HIV-infected, or those with chronic diseases) and HCP in particular phases of life (e.g., pregnant, elderly) require special consideration in regards the provision of vaccines. On the one hand, live virus vaccines may be contraindicated (e.g., pregnant HCP, immunocompromised HCP), while on the other hand, vaccines not routinely recommended (e.g., pneumococcal) may be indicated (e.g., elderly or immunocompromised HCP). It is not known how many HCP with underlying conditions require special consideration in the healthcare setting. This is an important issue, because the risk for serious morbidity, complications and mortality for HCP with underlying conditions will only increase. The prevention of nosocomial infections requires comprehensive occupational safety programs. The healthcare system must engage HCP and occupational physicians to ensure sufficient vaccination rates as part of an effective nosocomial infection prevention and HCP safety strategy.     

Medication supply,healthcare outcomes and healthcare expenses: Longitudinal analyses of patients with type 2 diabetes and hypertension

Introduction

Patients with chronic conditions largely depend on proper medications to maintain health. This study aims to examine, for patients with diabetes and hypertension, whether the appropriateness of the quantity of drug obtained is associated with favorable healthcare outcomes and lower expenses.

Methods

This study utilized a longitudinal design with a seven-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. The patients under study were those aged 18 years or older and newly diagnosed with type 2 diabetes or hypertension in 2002. Generalized estimating equations were performed to examine the relationship between medication supply and health outcomes as well as expenses.

Results

The results indicate that while compared with patients with an appropriate medication supply, patients with either an undersupply or an oversupply of medications tended to have poorer healthcare outcomes. The study also found that an excess supply of medications for patients with diabetes or hypertension resulted in higher total healthcare expenses.

Conclusion

Either an undersupply or an oversupply of medication was associated with unfavorable healthcare outcomes, and that medication oversupply was associated with the increased consumption of health resources. Our findings suggest that improving appropriate medication supply is beneficial for the healthcare system.     

Modelling hospital length of stay using convolutive mixtures distributions

Length of hospital stay (LOS) is an important indicator of the hospital activity and management of health care. The skewness in the distribution of LOS poses problems in statistical modelling because it fails to adequately follow the usual traditional distribution of positive variables such as the log‐normal distribution. We present in this paper a model using the convolution of two distributions, a technique well known in the signal processing community. The specificity of that model is that the variable of interest is considered to be the resulting sum of two random variables with different distributions. One of the variables features the patient‐related factors in terms of their need to recover from their admission condition, while the other models the hospital management process such as the discharging process. Two estimation procedures are proposed. One is the classical maximum likelihood, while the other relates to the expectation–maximization algorithm. We present some results obtained by applying this model to a set of real data from a group of hospitals in Victoria (Australia). Copyright © 2016 John Wiley & Sons, Ltd.     

A conditional approach for modelling patient readmissions to hospital using a mixture of Coxian phase‐type distributions incorporating Bayes' theorem

The number of elderly patients requiring hospitalisation in Europe is rising. With a greater proportion of elderly people in the population comes a greater demand for health services and, in particular, hospital care. Thus, with a growing number of elderly patients requiring hospitalisation competing with non‐elderly patients for a fixed (and in some cases, decreasing) number of hospital beds, this results in much longer waiting times for patients, often with a less satisfactory hospital experience. However, if a better understanding of the recurring nature of elderly patient movements between the community and hospital can be developed, then it may be possible for alternative provisions of care in the community to be put in place and thus prevent readmission to hospital. The research in this paper aims to model the multiple patient transitions between hospital and community by utilising a mixture of conditional Coxian phase‐type distributions that incorporates Bayes' theorem. For the purpose of demonstration, the results of a simulation study are presented and the model is applied to hospital readmission data from the Lombardy region of Italy. Copyright © 2016 John Wiley & Sons, Ltd.     

Excess healthcare spending associated with fractures among adults with cerebral palsy

BackgroundFractures represent a triple threat to adults with cerebral palsy (CP): common, accumulate early in adulthood, and are consequential to health. An economic evaluation of fractures in CP is needed to highlight priorities for allocating resources to clinical and public health programs aimed at preventing fractures and their disease sequela.ObjectiveTo identify short-term healthcare costs associated with fractures among adults with CP.MethodsA retrospective cohort study was performed using Optum's de-identified Clinformatics® Data Mart Database from 01/01/2011-12/31/2017. The primary cohort included adults ≥ 18 years old with CP with an incident fracture (CP+Fx), and cost estimates were compared with: CP without fractures (CPw/oFx) and without CP+Fx (w/oCP+Fx). A difference-in-difference (DiD) analysis compared the change in pharmacy and medical costs between cohorts from the one-year baseline period through the one-year post-index period in three-month quarters.ResultsCP+Fx (n = 855) had higher mean costs in the baseline and follow-up periods compared with CPw/oFx (n = 5667) and w/oCP+Fx (n = 588,042). The first post-index quarter DiD estimate suggests that CP+Fx accumulated an excess $6462 (95%CI = $3810-$9021) compared with w/oCP+Fx and $17,197 (95%CI = $14,418-$19,833) compared with CPw/oFx. The CP+Fx cohort had higher DiD estimates in the other follow-up quarters, but they were not statistically significant compared with CPw/oFx. When stratified by fracture site, vertebral column fractures for CP+Fx vs. w/oCP+Fx accumulated an excess $25,226 (95%CI = $12,639-$37,417).ConclusionsFractures, especially of the vertebral column, were associated with high healthcare costs among adults with CP. Studies are needed to identify cost-effective opportunities to utilize available resources to prevent fractures and their costly sequela for CP.