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    Publication date: June 2018
    Source:Health Policy, Volume 122, Issue 6
    Author(s): Mahmut S. Yardim, Sarp Uner
    Objective To evaluate access to healthcare from an equity perspective on the way toward Universal Health Coverage in Turkey. Methods The country representative data from 2006 to 2013 Turkey Income and Living Conditions Surveys were analyzed. Private household residents aged fifteen and older were asked for self-reported unmet need for medical care in the past twelve months. The dependent variable had three categories: no unmet need, unmet need due to cost, and unmet need due to availability (waiting list and distance problems). Predictors of unmet need were assessed by a multinomial logistic regression analysis. Findings The prevalence of unmet need declined between 2006 and 2013. While educational inequalities in declared unmet need also decreased, the income gradient becomes more important. In 2013, controlling for other factors, the propensity to report unmet need was 10 times higher for those in the poorest-income quintile compared to the richest (versus 7 times in 2006). Conclusion Overall access to healthcare has gradually improved in Turkey in the health reform process, but 9% of people still declared unmet need due to cost in 2013, after the implementation of Universal Health Insurance. This was nearly four times the EU average. Unfavourable economic and labour market conditions can be challenges for effective universal health coverage.


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    Publication date: June 2018
    Source:Health Policy, Volume 122, Issue 6
    Author(s): Monica Otto, Patrizio Armeni, Claudio Jommi
    This paper analyses the determinants of cross-regional variations in expenditure and consumption for non-prescription drugs using the Italian Health Care Service as a case study. This research question has never been posed in other literature contributions. Per capita income, the incidence of elderly people, the presence of distribution points alternative to community pharmacies (para-pharmacies and drug corners in supermarkets), and the disease prevalence were included as possible explanatory variables. A trade-off between consumption of non-prescription and prescription-only drugs was also investigated. Correlation was tested through linear regression models with regional fixed-effects. Demand-driven variables, including the prevalence of the target diseases and income, were found to be more influential than supply-side variables, such as the presence of alternative distribution points. Hence, the consumption of non-prescription drugs appears to respond to needs and is not induced by the supply. The expected trade-off between consumption for prescription-only and non-prescription drugs was not empirically found: increasing the use of non-prescription drugs did not automatically imply savings on prescription-only drugs covered by third payers. Despite some caveats (the short period of time covered by the longitudinal data and some missing monthly data), the regression model revealed a high explanatory power of the variability and a strong predictive ability of future values.


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    Publication date: June 2018
    Source:Health Policy, Volume 122, Issue 6
    Author(s): Ines Niehaus, Charalabos-Markos Dintsios
    The early benefit assessment of pharmaceuticals in Germany and their preceding market authorization pursue different objectives. This is reflected by the inclusion of varying confirmatory endpoints within the evaluation of oncology drugs in early benefit assessment versus market authorization, with both relying on the same evidence. Data from assessments up to July 2015 are used to estimate the impact of explorative in comparison to confirmatory endpoints on market authorization and early benefit assessment by contrasting the benefit-risk ratio of EMA and the benefit-harm balance of the HTA jurisdiction. Agreement between market authorization and early benefit assessment is examined by Cohen’s kappa (k). 21 of 41 assessments were considered in the analysis. Market authorization is more confirmatory than early benefit assessment because it includes a higher proportion of primary endpoints. The latter implies a primary endpoint to be relevant for the benefit-harm balance in only 67% of cases (0.078). Explorative mortality endpoints reached the highest agreement regarding the mutual consideration for the risk-benefit ratio and the benefit-harm balance (0.000). For explorative morbidity endpoints (−0.600), quality of life (−0.600) and side effects (−0.949) no agreement is ascertainable. To warrant a broader confirmatory basis for decisions supported by HTA, closer inter-institutional cooperation of approval authorities and HTA jurisdictions by means of reliable joint advice for manufacturers regarding endpoint definition would be favorable.


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    Publication date: June 2018
    Source:Health Policy, Volume 122, Issue 6
    Author(s): J. Torrent-Farnell, M. Comellas, J.L. Poveda, I. Abaitua, L.G. Gutiérrez-Solana, J. Pérez-López, J. Cruz, J. Urcelay, L. Lizán
    Objectives To reach a consensus amongst experts on the most feasible actions to be undertaken to facilitate patient access to specialised care and orphan drugs (OD) in the public health sector in Spain. Methods Two Delphi rounds were completed. The questionnaire was based on a literature review and 2 focus groups. Agreement was sought on the desire (D) and prognosis (P) for the implementation within the next 5 years, on a 5-point Likert scale. Consensus was reached when ≥75% participants chose agreement (1–2) or disagreement options (4–5). Results 82 experts on rare disease (RD) participated. Agreement on the D and P was reached in 66.07% statements: OD pricing review [absence of clinical effectiveness (D:85.37%; P:85.90%), target population increase (D:79.27%; P:91.03%)]; reference team definition of referral protocols and clinical practice guidelines (D: 97.56%; P: 89.74%); and a unified, usable, etiology-based registry (D:97.56%; P:84.62%). D and P assessment diverged in 32.14% items: creation of a specific funding system for OD (D: 97.56%; P: 60.25%); and a network of medical teams to coordinate the care of RD patients (D: 99%; P: 62%). Conclusions The results have shown the need to promote dialogue between stakeholders, introduce European recommendation to national and regional Spanish policies and set up priorities and undertake actions to drive relevant changes in current medical practice in managing RD patients.


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    Publication date: June 2018
    Source:Health Policy, Volume 122, Issue 6
    Author(s): A. Leu, H. Wepf, B. Elger, T. Wangmo
    On the 1st of January 2012, Switzerland introduced the diagnosis-related group hospital tariff structure (SwissDRG). It was recognised that healthcare provided to the most vulnerable patient groups would be a challenge for the new SwissDRG. Coincident with the implementation of SwissDRG, we explored hospital experts' perceptions of which patient groups are vulnerable under the SwissDRG system, what has changed for this group, as well as solutions to ensure adequate access to health care for them. We interviewed 43 experts from 40 Swiss hospitals. Participating experts named several vulnerable patient groups who share some common characteristics. These hospital experts were concerned about the patient groups that are not financially profitable and questioned the practicability of the current regulation. At the same time, they highlighted the complexity associated with caring for this group under the new SwissDRG and reported measures at the macro, meso, and micro levels to protect vulnerable patient groups from negative effects. To curb negative outcomes for vulnerable patient groups after the introduction of the SwissDRG, the Swiss legislation has introduced various instruments including the acute and transitional care (ATC) measures. We conclude that ATC measures do not produce the expected effect the legislators had hoped for. More health data is needed to identify situations where vulnerable patient groups are more susceptible to inadequate health care access in Switzerland.


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    Publication date: June 2018
    Source:Health Policy, Volume 122, Issue 6
    Author(s): Séverine Schusselé Filliettaz, Peter Berchtold, Dimitri Kohler, Isabelle Peytremann-Bridevaux
    Introduction Due to fragmentation of care delivery, health systems are under pressure and integrated care is advocated for. Compared to the numerous existing integrated care initiatives in Europe and elsewhere, Switzerland seems to lag behind. Methods The objective of the survey was to produce a comprehensive overview of integrated care initiatives in Switzerland. To be included, initiatives needed to meet four criteria: present some type of formalization, consider >2 different groups of healthcare professionals, integrate >2 healthcare levels, be ongoing. We systematically contacted major health system organizations at federal, cantonal and local level. Between 2015 and 2016, we identified 172 integrated care initiatives and sent them a questionnaire. We performed descriptive analyses. Results Integrated care initiatives in Switzerland are frequent and increasing. The implementation of initiatives over time, their distribution between linguistic areas, the number of healthcare levels integrated, and the number of professionals involved vary according to the type of initiatives. Discussion Despite Switzerland's federalist structure and organization of healthcare, and only recent incentives to develop integrated care, initiatives are frequent and diverse. Stakeholders should support existing initiatives and facilitate their development. They should also promote innovative avenues, experiment alternative payment models for integrated care, foster people-centeredness and incentivize interprofessional models. This will require systems thinking and contributions from all actors of the healthcare system.


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    Publication date: June 2018
    Source:Health Policy, Volume 122, Issue 6
    Author(s): Wilm Quentin, Reinhard Busse



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  • 06/23/18--21:04: Editorial Board
  • Publication date: June 2018
    Source:Health Policy, Volume 122, Issue 6




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    Publication date: Available online 18 June 2018
    Source:Health Policy
    Author(s): Eline M. Bunnik, Nikkie Aarts, Suzanne van de Vathorst
    Background Today, public and private bodies around the world are trying to facilitate and increase expanded access to unapproved, investigational drugs for patients with unmet medical needs. Methods This paper discusses three major shifts in the field of expanded access and presents an argumentative account of ethical issues connected with those shifts, based on a literature study and unstructured interviews with 35 stakeholders in the Netherlands. Results and discussion Traditionally, expanded access has been based on three key principles: 1) it is exceptional, 2) it is done ‘out of compassion’, and 3) it has a therapeutic aim. Current efforts to facilitate expanded access affect these key principles, rendering expanded access a default option, allowing companies to charge for investigational drugs and gather data on its outcomes. These shifts may generate new ethical issues, including false hope, safety concerns and funding issues, which must be anticipated by physicians, pharmaceutical companies, payers and policymakers. Conclusion Healthcare systems allow for the use of promising unapproved drugs in exceptional circumstances, but do not always assist patients with unmet medical needs in getting access. It is time to replace the current patchwork of practices with systems for expanded access in which criteria are clearly described, responsibilities are assigned and arrangements are made, so that patients will know what (not) to expect from expanded access.


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    Publication date: Available online 18 June 2018
    Source:Health Policy
    Author(s): M. Obucina, N. Harris, J.A. Fitzgerald, A. Chai, K. Radford, A. Ross, L. Carr, N. Vecchio
    The Triple Aim framework is an increasingly popular tool for designing and assessing quality improvements in the health care sector. We systematically reviewed the empirical evidence on the application of the Triple Aim framework within primary healthcare settings since its inception almost a decade ago. Results show that primary healthcare providers varied in their interpretation of the Triple Aim framework and generally struggled with a lack of guidance and an absence of composite sets of measures for performance assessment. Greater clarity around application of the Triple Aim framework in primary healthcare is needed, especially around the selection and implementation of purposeful measures from locally available data. This review highlights areas for improvement and makes recommendations intended to guide future applications of the Triple Aim in the context of primary healthcare.


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    Publication date: Available online 19 June 2018
    Source:Health Policy
    Author(s): Cornelis van Mosseveld, Vincent van Polanen Petel, Patricia Hernández-Peña, Piet Verbiest
    Compatibility of statistical frameworks and comparability of data are aspects of statistical quality. This paper explores comparability of data from National Accounts (NA) and Care Accounts/health accounts (CA&HA) of the Netherlands. Although based on the same sources, differences result from specificities of each framework, making data adjustments necessary. Data comparison of major aggregates and household spending is a means for verification and for triangulation of sources. Monitoring household spending on health is one of the Sustainable Development Goals. The usability of NA data for household consumption estimates is key to judge plausibility of household spending levels. However, definitions, coverage and valuation in NA and CA&HA should be understood to benefit from the use of NA data for HA. More than in the concepts used the strength of NA is the way NA are usually produced compared with HA. Key is the integrated analysis including supply and demand to verify the comprehensiveness and consistency. It is concluded that SUT data of NA on consumption of human health and social care can be used for judging plausibility of HA household spending estimates, and, in the absence of the latter, NA data can directly be used. The case of the Netherlands shows that policy measures can have a large impact on the validity of using NA for the estimation of household spending.


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    Publication date: Available online 27 June 2018
    Source:Health Policy
    Author(s): Eric Andrew Finkelstein, Semra Ozdemir, Chetna Malhotra, Tazeen H. Jafar, Lina Choong Hui Lin, Sheryl Gan Shien Wen
    Background Despite literature suggesting conservative management (CM) is a viable option for elderly comorbid ESRD patients, the vast majority in Singapore receive dialysis. We hypothesized that the high demand for dialysis is driven by 1) lack of knowledge of CM and relative benefits of dialysis to CM, 2) adherence to physician recommendations which favour dialysis, and 3) high subsidies for haemodialysis (HD). Methods We tested these hypotheses via a survey, including a discrete choice experiment (DCE), administered to 151 elderly pre-dialysis kidney patients and their family caregivers. Results Results are consistent with the hypotheses: 40% (95% Confidence Interval (CI) 32-48) of patients and 46% (CI 38-55) of caregivers reported not being aware of CM, and 43% (CI 35-51) of patients and 24% (CI 17-31) of caregivers could not provide information on expected survival for dialysis or CM. Yet, once aware of CM as an option, 54% of patients and 42% of caregivers chose CM. However, if their physician recommended dialysis, 49% (CI 40-58) of patients and 68% (CI 59-77) of caregivers switched their choice. Subsidies on HD further reduced demand for CM by 6 percentage points. Conclusions These results reveal that the high demand for dialysis is driven mostly by lack of awareness of CM as an option and by physician recommendations for dialysis over CM.


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    Publication date: Available online 28 June 2018
    Source:Health Policy
    Author(s): Marshall H. Chin, Paula T. King, Rhys G. Jones, Bryn Jones, Shanthi N. Ameratunga, Naoko Muramatsu, Sarah Derrett
    Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries’ approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country’s culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples’ self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.


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    Publication date: Available online 28 June 2018
    Source:Health Policy
    Author(s): Brett Scholz, Julia Bocking, Chris Platania-Phung, Michelle Banfield, Brenda Happell
    Contemporary health policies require consumers be involved at all stages of health service planning, implementation, delivery, and evaluation. The extent to which this policy is met, however, varies widely across the sector. One barrier to meeting policy requirements is power imbalances within systemic partnerships between consumers and other health professionals. Between September 2016 and February 2017, interviews were conducted with health care managers, clinicians, and consumers working on partnerships across various health service departments in one hospital. An exploratory, qualitative approach was used. Data were analysed using principles of discursive psychology, which focuses on the way power is constructed through participants' accounts of partnerships. The findings suggest providers have significant power over consumers in partnerships at the systematic level of health services. Managers were responsible for setting the parameters for partnerships, and consumers were seen more as a resource to be used by health services rather than as equal partners to work with. The findings suggest that although contemporary health policies require partnership with consumers, better guidelines are needed to specifically address and challenge power imbalances within these partnerships.


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    Publication date: Available online 30 June 2018
    Source:Health Policy
    Author(s): Irina Cleemput, Stephan Devriese, Laurence Kohn, René Westhovens
    Early temporary reimbursement (ETR) schemes for new interventions targeting high unmet needs are increasingly applied in pharmaceutical policy. Crucial for these schemes is the assessment of unmet healthcare needs of patients and society. This study develops and tests a multi-criteria decision approach (MCDA) for assessing therapeutic and societal needs. The Belgian unmet needs commission, responsible for creating a list of unmet needs for the ETR programme, has tested this methodology to assess the needs in eight health conditions. For therapeutic need, three criteria were included (impact of the condition on quality of life and on life expectancy and inconvenience of current treatment); for societal need two criteria (condition-related healthcare expenditures per patient, prevalence). The results show that the proposed MCDA is feasible and acceptable for the unmet needs commission. Clear definitions of the criteria and regular repetition of these is needed to avoid variable interpretation of the criteria by the commission members. Quality assessment of the evidence is desired. Rankings resulting from the application have face validity. Considering therapeutic need separately from societal need is considered appropriate. Policy makers should consider the use of MCDA in assessing healthcare needs. MCDA improves the transparency and accountability of the decision making processes and is practical and feasible.


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    Publication date: Available online 30 June 2018
    Source:Health Policy
    Author(s): Lisa Vermeulen, Willemijn Schäfer, Danica Rotar Pavlic, Peter Groenewegen
    General practitioners (GPs) are frontline health workers. They should be sensitive to the health needs of the community in addition to caring for patients that visit their practice. Due to changes in demography, epidemiology, ecology and healthcare policy, a community orientation becomes more important. Our research question is: to what extent does community orientation of GPs vary between countries and GPs and how can this variation be explained? We use cross-sectional survey data from the QUALICOPC study, conducted among over 7,000 GPs in 34 countries. Community orientation was measured through a scale constructed from three survey questions on whether GPs would take action when confronted with: repeated accidents in an industrial setting, frequent respiratory problems in patients living near a certain industry, and repeated cases of food poisoning in the local community. Independent variables are at healthcare system level and GP or practice level. Data were analysed using linear multilevel regression analysis. Community orientation varies between GPs and countries. Community orientation is more frequent in healthcare systems with a list system, among self-employed GPs, those using medical records to make overviews, and those more active in prevention and multidisciplinary cooperation. GPs in rural areas and areas with more people from ethnic minorities are more community oriented. Based on the variation between countries and GPs, we would like to raise awareness and underline the importance of multidisciplinary cooperation.


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    Publication date: Available online 3 July 2018
    Source:Health Policy
    Author(s): Mohammad Hajizadeh, Min Hu, Amy Bombay, Yukiko Asada
    Using three nationally representative Aboriginal Peoples Surveys (2001, 2006 and 2012, n = 68,060), we examined income-related inequalities in self-perceived poor/fair general health status among Indigenous adults (18+) living off-reserve in Canada. We used the relative and absolute concentration indices (RC and AC, respectively) to quantify income-related inequalities in health for men and women, within the three Indigenous populations (First Nations, Métis, and Inuit), and in different geographic regions. Moreover, we performed decomposition analysis to determine factors that explain income-related inequality in health within the Indigenous peoples living off-reserve in Canada. The prevalence of poor/fair health status among the Indigenous population living off-reserve increased from 18% in 2001 to 22% in 2012. The extent of pro-rich relative (absolute) income-related inequalities in health increased by 23% (42%) from 2001 to 2012. Income-related inequalities in health increased statistically significantly within First Nations and Métis populations as well as in Atlantic provinces, Ontario, Alberta, British Columbia and Territories. Decomposition analyses indicated that, besides income itself, occupational status and educational attainment were the most important factors contributing to the pro-rich distribution of health among Indigenous peoples living off-reserve. Growing socioeconomic inequalities in health among Indigenous peoples should warrant more attention. Policies designed to address the broader array of social determinants of health may mitigate the continuing inequalities in health among Indigenous peoples living off-reserve in Canada.


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