Comparative performance of public and private sector delivery of BCG vaccination: Evidence from Sub-Saharan Africa

Background

The private sector is an important source of health care in the developing world. However, there is limited evidence on how private providers compare to public providers, particularly for preventive services such as immunizations. We used data from Sub-Saharan Africa (SSA) to assess public–private differences in Bacillus Calmette–Guérin (BCG) vaccine delivery.

Methods and findings

We used demographic and health surveys from 102,629 children aged 0–59 months from 29 countries across SSA to measure differences in BCG status for children born at private versus public health facilities (BCG is recommended at birth). We used a probit model to estimate public–private differences in BCG delivery, while controlling for key confounders. Next, we estimated how differences in BCG status evolved over time for children born at private versus public facilities. Finally, we estimated heterogeneity in public–private differences based on wealth and rural–urban residency. We found that children born at a private facility were 7.1 percentage points less likely to receive BCG vaccine in the same month as birth than children born at a public facility (95% CI 6.3–8.0; p < 0.001). Most of this difference was driven by for-profit private providers (as opposed to NGOs) where the BCG provision rate was 10.0 percentage points less than public providers (95% CI 9.0–11.2; p < 0.001) compared to only 2.4 percentage points for NGOs (95% CI 1.0–3. 8; p < 0.01). Moreover, children born at private for-profit facilities remained less likely to be vaccinated up to 59 months after birth. Finally, public–private differences were more pronounced for poorer children and children in rural areas.

Conclusions

The for-profit private sector performed substantially worse than the public sector in providing BCG vaccine to newborns, resulting in a longer duration of vulnerability to tuberculosis. This disparity was greater for poorer children and children in rural areas.     

Findings from a hepatitis B birth dose assessment in health facilities in the Philippines: Opportunities to engage the private sector

Background

Hepatitis B vaccination in the Philippines was introduced in 1992 to reduce the high burden of chronic hepatitis B virus (HBV) infection in the population; in 2007, a birth dose (HepB-BD) was introduced to decrease perinatal HBV transmission. Timely HepB-BD coverage, defined as doses given within 24 h of birth, was 40% nationally in 2011. A first step in improving timely HepB-BD coverage is to ensure that all newborns born in health facilities are vaccinated.

Methods

In order to assess ways of improving the Philippines’ HepB-BD program, we evaluated knowledge, attitudes, and practices surrounding HepB-BD administration in health facilities. Teams visited selected government clinics, government hospitals, and private hospitals in regions with low reported HepB-BD coverage and interviewed immunization and maternity staff. HepB-BD coverage was calculated in each facility for a 3-month period in 2011.

Results

Of the 142 health facilities visited, 12 (8%) did not provide HepB-BD; seven were private hospitals and five were government hospitals. Median timely HepB-BD coverage was 90% (IQR 80%–100%) among government clinics, 87% (IQR 50%–97%) among government hospitals, and 50% (IQR 0%–90%) among private hospitals (p = 0.02). The private hospitals were least likely to receive supervision (53% vs. 6%–31%, p = 0.0005) and to report vaccination data to the national Expanded Programme on Immunization (36% vs. 96%–100%, p < 0.0001).

Conclusions

Private sector hospitals in the Philippines, which deliver 18% of newborns, had the lowest timely HepB-BD coverage. Multiple avenues exist to engage the private sector in hepatitis B prevention including through existing laws, newborn health initiatives, hospital accreditation processes, and raising awareness of the government's free vaccine program.     

EMERGENCY ADMISSIONS AND ELECTIVE SURGERY WAITING TIMES

An average patient waits between 2 and 3 months for an elective procedure in Australian public hospitals. Approximately 60% of all admissions occur through an emergency department, and bed competition from emergency admission provides one path by which waiting times for elective procedures may be lengthened. In this article, we investigated the extent to which public hospital waiting times are affected by the volume of emergency admissions and whether there is a differential impact by elective patient payment status. The latter has equity implications if the potential health cost associated with delayed treatment falls on public patients with lower ability to pay. Using annual data from public hospitals in the state of New South Wales, we found that, for a given available bed capacity, a one standard deviation increase in a hospital's emergency admissions lengthens waiting times by 19 days on average. However, paying (private) patients experience no delay overall. In fact, for some procedures, higher levels of emergency admissions are associated with lower private patient waiting times. Copyright © 2012 John Wiley & Sons, Ltd.     

The inpatient costs and hospital service use associated with invasive meningococcal disease in South Australian children

Background

Invasive meningococcal disease (IMD) remains a serious public health concern due to a sustained high case fatality rate and morbidity in survivors. This study aimed to estimate the hospital service costs associated with IMD and variables associated with the highest costs in Australian children admitted to a tertiary paediatric hospital.

Methods

Clinical details were obtained from medical records and associated inpatient costs were collected and inflated to 2011 Australian dollars using the medical and hospital services component of the Australian Consumer Price Index. Both unadjusted and adjusted analyses were undertaken. Multivariate regression models were used to adjust for potential covariates and determine independent predictors of high costs and increased length of hospital stay.

Results

Of 109 children hospitalised with IMD between May 2000 and April 2011, the majority were caused by serogroup B (70.6%). Presence of sequelae, serogroup B infection, male gender, infants less than one year of age, and previous medical diagnosis were associated with higher inpatient costs and length of stay (LOS) in hospital (p < 0.001) during the acute admissions. Children diagnosed with septicaemia had a longer predicted LOS (p = 0.033) during the acute admissions compared to those diagnosed with meningitis alone or meningitis with septicaemia. Serogroup B cases incurred a significantly higher risk of IMD related readmissions (IRR: 21.1, p = 0.008) for patients with sequelae. Serogroup B infection, male gender, diagnosis of septicaemia, infants less than one year of age, and no previous medical diagnosis were more likely to have higher inpatient costs and LOS during the IMD related readmissions for patients with sequelae (p < 0.05).

Conclusion

Although IMD is uncommon, the disease severity and associated long-term sequelae result in high health care costs, which should be considered in meningococcal B vaccine funding considerations.     

Comorbidity scores for administrative data benefited from adaptation to local coding and diagnostic practices

Objective

The Charlson and Elixhauser indices are the most commonly used comorbidity indices with risk prediction models using administrative data. Our objective was to compare the original Charlson index, a modified set of Charlson codes after advice from clinical coders, and a published modified Elixhauser index in predicting in-hospital mortality.

Study Design and Setting

Logistic regression using two separate years of administrative hospital data for all acute nonspecialist public hospitals in England.

Results

For all admissions combined, discrimination was similar for the Charlson index using the original codes and weights and the Charlson index using the original codes but England-calibrated weights (c = 0.73), although model fit was superior for the latter. The new Charlson codes improved discrimination (c = 0.76), model fit, and consistency of recording between admissions. The modified Elixhauser had the best performance (c = 0.80). For admissions for acute myocardial infarction and chronic obstructive pulmonary disease, the weights often differed, although the patterns were broadly similar.

Conclusion

Recalibration of the original Charlson index yielded only modest benefits overall. The modified Charlson codes and weights offer better fit and discrimination for English data over the original version. The modified Elixhauser performed best of all, but its weights were perhaps less consistent across the different patient groups considered here.     

Hospital type and patient outcomes: an empirical examination using AMI readmission and mortality records

This paper investigates whether there are differences in patient outcomes across different types of hospitals using patient‐level data on readmission and mortality associated with acute myocardial infarction (AMI). Hospitals are grouped according to their ownership type (private, public teaching, public non‐teaching) and their location (metropolitan, country and remote country). Using data collected from 130 Victorian hospitals on 19 000 patients admitted to a hospital with their first AMI between January 2001 and December 2003, we consider how the likelihood of unplanned re‐admission and mortality varies across hospital type. We find that there are significant differences across hospital types in the observed patient outcomes – private hospitals persistently outperform public hospitals. Copyright © 2009 John Wiley & Sons, Ltd.     

Private patients in NHS hospitals: comparison of two sources of information.

BACKGROUND: The use of National Health Service (NHS) hospitals to treat private patients is debatable on the grounds of equity of access. Hospital Episodes Statistics (HES) annual reports are the only routine source of information on the scale of this activity. The accuracy of the information is doubted. This enquiry tested the completeness of HES data against information obtained directly from private patient unit managers. METHOD: Managers of the 71 pay bed units in NHS hospitals in England were asked to supply from local registers and accounts the numbers of in-patients and day cases admitted in 1995-1996. Their reports were matched with the numbers of first consultant episodes for private in-patients and day cases shown for those hospitals in the HES data file for that year. RESULTS: Of the 71 units 62 responded; 53 of these gave usable data. The 53 included, and 18 excluded from the comparison, matched on median and range of bed numbers. Managers identified 16 per cent more total admissions than did HES, 62,572 against 54,131; 13 per cent more in-patient admissions, 39,776 against 35,319; and 21 per cent more day cases, 22,796 against 18,812. More total admissions were reported by managers of 38 pay bed units than were recorded in HES, fewer by 12, and equal numbers by three. Similar sized discrepancies were noted for in-patient admissions and day cases. Reasons for the under-reporting of private patients in HES included the use of separate patient administration systems for private patients with a failure to feed data to HES, and the omission of some provider units altogether by a minority of trusts from the returns made to the Department of Health. CONCLUSION: Overall, HES underestimates the amount of private patient activity reported directly by NHS hospitals. No method of validating private patient data is currently available. An amendment to an existing statistical return would provide a check on numbers. Central guidance on the inclusion of private patient activity in data transmitted by providers to the HES processing agency should be reinforced.     

Impact of 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) on childhood pneumonia hospitalizations in Brazil two years after introduction

Introduction

Pneumococcal disease is a major public health problem worldwide. From March to September of 2010, 10-valent pneumococcal non-typeable Haemophilus influenzae protein conjugate vaccine (PHiD-CV) was introduced in the Brazilian childhood National Immunization Program (NIP) in all 27 Brazilian states. The aim of the present study is to report national time-trends in incidence of hospital admissions for childhood pneumonia in Brazil before and after two years of introduction of this new pneumococcal conjugate vaccine.

Methods

Analysis of hospitalization data of children aged 0–4 years in Brazilian public health system with an admission diagnosis of pneumonia from 2002 to 2012 was performed comparing pre (2002–2009) and post-vaccination periods (2011–2012). Hospital number of admission due to pneumonia and all non-respiratory diseases were obtained from DATASUS, the Brazilian government open-access public health database system. Incidence of pneumonia hospitalization was compared to incidence of all non-respiratory admissions.

Results

Admission rates for pneumonia decreased steadily from 2010 to 2012. In children aged less than four years, incidence of pneumonia hospitalizations decreased 12.65% when pre (2002–2009) and post-vaccination introduction periods (2011–2012) were compared and adjusted for seasonality and secular-trend (p < 0.001). On the other hand, non-respiratory admission rates remained stable comparing both periods (p = 0.39).

Conclusion

Childhood pneumonia hospitalization rates were fluctuating prior to 2010 and decreased significantly in the two years after PHiD-CV introduction. Conversely, rate of non-respiratory admissions has shown no decrease. These data are an evidence of the effectiveness and public health impact of this new pneumococcal vaccine.     

Increasing appropriateness of hospital admissions in the Emilia-Romagna region of Italy

OBJECTIVES: The Emilia-Romagna region of Italy has reduced the number of available hospital beds and introduced financial incentives to curb hospital use. The goal of this study was to assess the impact of these policies on changes over time in the number of acute hospital admissions classified in diagnosis related groups (DRGs) that could be treated safely and effectively in alternative, less costly settings. METHODS: The assessment of the appropriate site of care was based on analysis of hospital discharge data for all hospitals for the selected diagnosis related groups in the Emilia-Romagna region for 2001 to 2005. The necessity for acute hospital admission was based on the severity of a patient's principal diagnosis, co-morbid diseases and, for surgical admissions, procedure performed. RESULTS: From 2001 to 2005, potentially inappropriate medical admissions of more than one day decreased from 20,076 to 11,580, a 42% decrease. Inappropriate admissions decreased in both public and private hospitals but there remained a higher rate of inappropriate admissions to private hospitals. Potentially inappropriate medical admissions accounted for 128,319 bed-days in 2001 and 68,968 bed-days in 2005, a reduction of 59,351 bed-days. Potentially inappropriate surgical admissions decreased from 7383 in 2001 to 4349 in 2005, a 41% decrease. Bed-days consumed by inappropriate surgical admissions decreased from 23,181 in 2001 to 13,660 in 2005. CONCLUSIONS: The Emilia-Romagna region has succeeded in reducing the use of acute hospital beds for patients in selected diagnosis related groups. However, there are still substantial numbers of admissions that could potentially be treated in less costly settings.     

Supplementary private health insurance: The impact of physician financial incentives on medical practice

In the French diagnosis-related group (DRG)-based payment system, both private and public hospitals are financed by a public single payer. Public hospitals are overcrowded and have no direct financial incentives to choose one procedure over another. If a patient has a strong preference, they can switch to a private hospital. In private hospitals, the preference does come into play, but the patient has to pay for the additional cost, for which they are reimbursed if they have supplementary private health insurance. Do financial incentives from the fees received by physicians for different procedures drive their behavior? Using French exhaustive data on delivery, we find that private hospitals perform significantly more cesarean deliveries than public hospitals. However, for patients without private health insurance, the two sectors differ much less in terms of cesareans rate. We determine the impact of the financial incentive for patients who can afford the additional cost. Affordability is mainly ensured by the reimbursement of costs by private health insurance. These findings can be interpreted as evidence that, in healthcare systems where a public single payer offers universal coverage, the presence of supplementary private insurance can contribute to creating incentives on the supply side and lead to practices and an allocation of resources that are not optimal from a social welfare perspective.     

Épidémiologie de la tuberculose en Bretagne : les cas déclarés entre 2000 et 2007

The authors studied the reported cases of tuberculosis diseases in Brittany between 2000 and 2007 via the mandatory notification scheme. One thousand nine hundred and seventy-five cases were notified during the study period. The incidence in French Brittany (eight cases per 100,000) was the third highest in France. A statistically significant negative trend was observed later, mainly attributable to a decrease between 2000 and 2001. The mean patient age at notification was 55 in Brittany versus 46 years of age for the rest of France (p < 0.001). Eighty per cent of the patients were born in France versus 46% for the rest of the country. The rate of multiresistance to antibiotics was 1.3% versus 4.6% for the rest of France (p < 0.001). The estimated completeness of notification was 80% compared to 70% for the whole country. Despite a decrease of tuberculosis incidence in Brittany, the withdrawal of mandatory vaccination suggests strengthening tuberculosis monitoring in the future.     

Adverse events in older patients admitted to acute care: A preliminary cost description

The financial costs associated with Adverse Events (AEs) for older patients (=65 years) in Canadian hospitals are unknown. The objective of this paper is to describe and compare costs between patients who experienced an AE and those who did not during an acute hospital admission to a tertiary care facility. Patients with an AE had twice the hospital length of stay (20.2 versus 9.8 days, p < 0.00001), resulting in 1,400 extra days at a cost of approximately $7,500/patient.     

Source of admission and cost: public hospitals face financial risk.

We studied all admissions to the 11 acute care hospitals of the New York City Health and Hospitals Corporation (April 1983-September 1984) matching emergency room (ER) admitted diagnostic related group (DRG) subgroups in each hospital with at least five non-ER admitted patients (N = 222,961). Mean cost per ER patient ($8,385) was greater than non-ER mean cost per patient ($4,386) for Medicare and non-Medicare. Our data suggest that public hospitals with a high proportion of ER admissions may be at a financial disadvantage under DRG reimbursement.     

Anti-hepatitis B core positivity as a risk factor for hepatocellular carcinoma in alcoholic cirrhosis: A case–control study

Hepatocellular carcinoma (HCC) is occasionally developed in patients with alcoholic cirrhosis. Old age, male gender, lifetime quantity of alcohol, and presence of hepatitis C virus (HCV) infection are risk factors for HCC in alcoholic cirrhosis. In this study, we investigated whether anti-hepatitis B core (HBc) positivity or occult hepatitis B virus (HBV) infection is a risk factor for HCC in patients with alcoholic cirrhosis. Between January 2006 and August 2008, a total of 72 cirrhotic male patients with an initial diagnosis of HCC, hospitalized in three major hospitals in the Incheon area, were enrolled as cases. Another 72 cirrhotic male patients without HCC, who matched the cases by age (±3 years), were enrolled as controls. All cases and controls were negative for hepatitis B surface antigen and anti-HCV, but had history of chronic alcohol intake over 80 g per day. The clinical characteristics including presence of anti-HBc or serum HBV DNA (identified by nested polymerase chain reaction) were investigated. The mean age of both the cases and controls was 62 ± 10 years. The basal laboratory data, Child–Pugh scores, total lifetime alcohol intake (1459 ± 1364 versus 1641 ± 1045 kg), and detection rates of serum HBV DNA [31.7% (20/63) versus 29.9% (20/67)] of the cases and controls were not significantly different. However, the anti-HBc positivity rate was higher among the cases [86.1% (62/72)] than in the controls [66.7% (48/72); p = 0.005] and was the only significant risk factor for HCC (odds ratio; 3.1, 95% confidence interval; 1.354–7.098, p = 0.007). Anti-HBc positivity was identified as a risk factor for the development of HCC in patients with alcoholic cirrhosis.     

Risk factors for nosocomial rotavirus infection in a paediatric hospital: The potential role for rotavirus vaccine use

To analyze the incidence and risk factors (RF) of nosocomial infection (NI) in a paediatric teaching hospital, a retrospective cohort study was conducted in Salvador, Brazil. The Centres for Disease Control and Prevention definitions were used. The detection of the rotavirus antigen in stool was performed using a rapid latex agglutination test. The study group comprised 2978 admissions that accounted for 32,924 patient-days. The incidence of NI was 8.3/1000 patient-days and 9.2/100 admissions. Of the 274 NI episodes, the most common illness and causative agent were gastroenteritis (125; 45.6%) and rotavirus (59; 21.5%), respectively. The RF for rotavirus NI was young age (10 ± 8 months vs. 27 ± 33 months; mean difference 17 months, 95% CI 15–20 months, p < 0.001). The temporal distribution of community-acquired and NI rotavirus showed similar trends. The universal use of rotavirus vaccine is a potential tool to control NI among children.     

Effects of 7-valent pneumococcal conjugate 1 vaccine on the severity of adult 2 bacteremic pneumococcal pneumonia

Purpose

The introduction of a 7-valent conjugate pneumococcal vaccine (PCV7) in children largely affected the prevalence of adult pneumococcal pneumonia. In this study we investigated whether the clinical severity of adult bacteremic pneumococcal pneumonia has also altered following the introduction of pediatric PCV7 vaccination.

Methods

Adults hospitalized with bacteremic pneumococcal pneumonia between 2001 and June 2011 at two Dutch hospitals were included retrospectively. Clinical data on patient characteristics, comorbidities and severity of disease were obtained and pneumococcal serotypes were determined.

Results

Among 343 patients investigated, those infected with PCV7 serotypes had a higher PSI score (p = 0.0072) and mortality rate (p = 0.0083) compared with the remainder of the cohort. Since the introduction of PCV7 the proportion of pneumococcal pneumonias caused by serotypes 1 and 7F (p-values 0.037 and 0.025) increased, as well as the rate of pleural effusion and empyema (p-values 0.011 and 0.049). Whilst de proportion of adults infected with PCV7 serotypes decreased after the introduction of PCV7 (p = 0.015), PSI scores in these patients remained higher (p = 0.030), although mortality rates between PCV7 and non PCV7 types equalized. After the introduction of PCV7 a marked shortening in hospital stay was observed only among patients infected with non PCV7 serotypes (p = 0.019).

Conclusions

The introduction of pediatric PCV7 vaccination was accompanied by subtle changes in clinical severity of adult bacteremic pneumococcal pneumonia. Expansion of serotypes covered by pneumococcal vaccination may again influence the clinical presentation of disease.     

The political economy of austerity and healthcare: Cross-national analysis of expenditure changes in 27 European nations 1995–2011

Why have patterns of healthcare spending varied during the Great Recession? Using cross-national, harmonised data for 27 EU countries from 1995 to 2011, we evaluated political, economic, and health system determinants of recent changes to healthcare expenditure. Data from EuroStat, the IMF, and World Bank (2013 editions) were evaluated using multivariate random- and fixed-effects models, correcting for pre-existing time-trends. Reductions in government health expenditure were not significantly associated with magnitude of economic recessions (annual change in GDP, p = 0.31, or cumulative decline, p = 0.40 or debt crises (measured by public debt as a percentage of GDP, p = 0.38 or per capita, p = 0.83)). Nor did ideology of governing parties have an effect. In contrast, each $100 reduction in tax revenue was associated with a $2.72 drop in health spending (95% CI: $1.03–4.41). IMF borrowers were significantly more likely to reduce healthcare budgets than non-IMF borrowers (OR = 3.88, 95% CI: 1.95 –7.74), even after correcting for potential confounding by indication. Exposure to lending from international financial institutions, tax revenue falls, and decisions to implement cuts correlate more closely than underlying economic conditions or orientation of political parties with healthcare expenditure change in EU member states.     

Improvement in attitudes toward influenza vaccination in medical students following an integrated curricular intervention

Introduction

Vaccination of health care workers (HCW) reduces transmission of influenza among patients, yet uptake of vaccination remains low. If vaccination education is integrated into the early medical school curriculum, will student attitudes toward the vaccine change? The objectives of the study were to: (1) Determine influenza vaccination rates among entering medical students; (2) Assess the attitudes toward influenza vaccination; (3) Evaluate the effects of a multifaceted educational intervention on attitudes to vaccination.

Methods

Entering medical students were surveyed before and after an intervention at the beginning of the influenza season. This intervention provided by an inter-professional team, included education about influenza, importance of vaccination for HCWs, followed by vaccination administration practice, and ended with students vaccinating consenting classmates.

Results

The pre-intervention surveys and intervention were completed by 124 of 125 (99%) students. Pre-intervention survey revealed 60 (48%) of students had been previously vaccinated. Of the vaccinated students 91% had been recommended vaccination by their healthcare provider compared to 43% of non-vaccinated students. More positive attitudes were noted in the vaccinated students compared to non-vaccinated students: importance of vaccination (p < 0.01); HCWs should be vaccinated (p < 0.01); recommendation of vaccine to family and friends (p < 0.01). 97 (78%) students completed post-intervention surveys. Significant improvement in these attitudes was noted post-intervention compared to pre-intervention: importance of vaccination 93% versus 71% (p < 0.01); HCWs should be vaccinated 95% versus 83% (p < 0.01); recommendation to family and friends 93% versus 73% (p < 0.01); comfort with vaccine counseling 92% versus 41%; comfort with vaccine administration 84% versus 22% (p < 0.01).

Conclusion

Educating medical students and promoting the importance of vaccination early in a medical student's career using such an intervention is relatively simple and easily integrated into the curriculum. This intervention was successful in vaccinating all students, and demonstrated a marked positive shift in attitudes toward influenza vaccination.     

Private health expenditure in the Greek health care system: Where truth ends and the myth begins

Greece today has the most “privatized” health care system among EU countries. Given the country's universal coverage by a public system this may be called “the Greek paradox”. The Objective of this paper is to analyze private health payments by provider and type of service in order to bring to light the reasons for and the nature of the extraordinary private expenditure in Greece. Methods: We used a randomized countrywide sample of 1616 households. Regression analysis was used to determine the extent to which social and economic household characteristics influence the frequency of use of certain health services and the size of household payments for such services. In all statistical analyses we used the p < 0.05 level of significance. Results: Out of the total private household health expenditure (€6141 million), 66% is for outpatient services, with the largest share for dental services, absorbing 31.1% (€1912 million or 1.5% of GDP) of the total out-of-pocket health expenditure. Rural dwellers seek private outpatient care more often, because of the understaffed public primary facilities. The hospital sector absorbs less than 15% (or €884 million) of household private health expenditure. A significant part (20%) of hospital care financed privately concerns informal payments within public hospitals, an amount almost equal with formal payments in the form of cost sharing. Admissions to private hospitals are only 16% of total admissions. Our results indicate that this is a result of the political emphasis in public hospitals and of the considerably high cost of private hospital care. Conclusions: The rise in private health expenditure and the development of the private sector during the last 20 years in Greece is associated with public under financing. The gap was filled by the private sector through increased investment, mostly in upgraded amenities and new technology. Today, the complementary nature of private care in Greece is no longer disputed, but is a matter of serious concern, as it undermines the constitutionally guaranteed free access and equitable distribution of health resources.