Prevalence and Determinants of Stunting-Anemia and Wasting-Anemia Comorbidities and Micronutrient Deficiencies in Children Under 5 in the Least-Developed Countries: A Systematic Review and Meta-analysis.

CONTEXT: Despite shifting from addressing isolated forms of malnutrition to recognizing its multifaceted nature, evidence on the prevalence and determinants of micronutrient deficiencies, and their coexistence with undernutrition in children under 5, remains insufficient, unsystematic, and incohesive. OBJECTIVE: The aim of this systematic review and meta-analysis was to assess the prevalence and determinants of stunting-anemia and wasting-anemia comorbidities and micronutrient deficiencies in children under 5 in the least-developed countries (LDCs). DATA SOURCES: Electronic searches took place from January 15, 2023, to February 14, 2024, across multiple databases, including PubMed, Embase, Web of Science, SCOPUS, African Index Medicus (AIM), World Health Organization's Institutional Repository for Information Sharing (IRIS), and African Journals Online. The search spanned the years 2000 to 2024, yet it yielded eligible full-text English research articles from only 2005 to 2021 conducted in LDCs. Studies lacking quantitative data on malnutrition types and their determinants were excluded. DATA EXTRACTION: Two independent authors assessed articles for bias and quality using Hoy et al's 10-item scale and Newcastle-Ottawa Scale (NOS) criteria. Prevalence and other details were extracted using a Joanna Briggs Institute Excel template. Authors extracted adjusted odds ratios (aORs) for determinant factors such as sex and vitamin A and iron supplementation. DATA ANALYSIS: The search yielded 6248 articles from 46 LDCs. Sixty-nine articles, with a total sample size of 181 605, met inclusion criteria for the final meta-analysis. Vitamin A deficiency affected 16.32% of children, and iodine deficiency affected 43.41% of children. The pooled prevalence of wasting-anemia and stunting-anemia comorbidity was 5.44% and 19.47%, respectively. Stunting was associated with vitamin A deficiency (aOR: 1.54; 95% CI: 1.01-2.37), and not taking vitamin A supplementation was associated with iron-deficiency anemia (aOR: 1.37; 95% CI: 1.21-1.55). CONCLUSION: A significant proportion of children under 5 in LDCs experienced stunting-anemia and wasting-anemia comorbidities and micronutrient deficiencies. This study underscores the urgent need to address factors driving these burdens. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42023409483.

Using a LOng peripheral intraVEnous catheter with retractable guidewire to optimize first-insertion success for patients with Difficult IntraVenous Access in the emergency department (LOVE-DIVA): a study protocol for a randomized controlled trial.

INTRODUCTION: First-insertion success rates for peripheral vascular access devices (PVADs) in patients with difficult venous access (DIVA) are low, which negatively affects staff workload, patient experience, and organizational cost. There is mixed evidence regarding the impact of a peripheral vascular access device with retractable coiled tip guidewire (GW; AccuCath™, BD) on the first-insertion success rate. The aim of this study is to investigate whether the use of long GW-PVADs, compared with standard PVADs, reduces the risk of first-time insertion failure, in patients admitted to emergency departments (EDs). METHODS AND ANALYSIS: A parallel-group, two-arm, randomized controlled trial will be carried out in two Australian EDs to compare long GW-PVADs (5.8 cm length) against standard care PVADs (short or long). Patients ≥18 years of age meeting DIVA criteria will be eligible for the trial. The sample size is 203 participants for each arm. Web-based central randomization will be used to ensure allocation concealment. Neither clinicians nor patients can be blinded to treatment allocation. Primary outcome is the first-insertion success rate. Secondary outcomes include the number of insertion attempts, time to insert PVAD, all-cause failure, dwell-time, patient-reported pain, serious adverse events, complications, subsequent vascular access devices required, patient satisfaction, staff satisfaction, and healthcare costs. Differences between the two groups will be analyzed using Cox proportional hazards regression. Cost-effectiveness analysis will also be conducted. Intention-to-treat analysis will be used. ETHICS AND DISSEMINATION: The study is approved by Metro South Ethics Committee (HREC/2022/QMS/82264) and Griffith University (2022/077). The findings will be published in a peer-reviewed journal. TRIAL REGISTRATION: ACTRN12622000299707.

Assessing the excess costs of the in-hospital adverse events covered by the AHRQ's Patient Safety Indicators in Switzerland.

There currently exists no comprehensive and up-to date overview on the financial impact of the different adverse events covered by the Patient Safety Indicators (PSIs) from the Agency for Healthcare Research and Quality. We conducted a retrospective case-control study using propensity score matching on a national administrative data set of 1 million inpatients in Switzerland to compare excess costs associated with 16 different adverse events both individually and on a nationally aggregated level. After matching 8,986 cases with adverse events across the investigated PSIs to 26,931 controls, we used regression analyses to determine the excess costs associated with the adverse events and to control for other cost-related influences. The average excess costs associated with the PSI-related adverse events ranged from CHF 1,211 (PSI 18, obstetric trauma with instrument) to CHF 137,967 (PSI 10, postoperative acute kidney injuries) with an average of CHF 27,409 across all PSIs. In addition, adverse events were associated with 7.8-day longer stays, 2.5 times more early readmissions (within 18 days), and 4.1 times higher mortality rates on average. At a national level, the PSIs were associated with CHF 347 million higher inpatient costs in 2019, which corresponds to about 2.2% of the annual inpatient costs in Switzerland. By comparing the excess costs of different PSIs on a nationally aggregated level, we offer a financial perspective on the implications of in-hospital adverse events and provide recommendations for policymakers regarding specific investments in patient safety to reduce costs and suffering.

Ambient Temperature Effects on Hospitalization Risk Among Farmers: A Time-Series Study on Multiple Diseases in Vietnam.

OBJECTIVE: The aim of the study is to assess the effect of high temperatures on hospitalization for all causes and heat-sensitive diseases among Vietnamese farmers. METHODS: The Poisson generalized linear model and distributed lag nonlinear model were used to investigate the temperature-hospitalization association for all causes and seven cause-specific disease groups. RESULTS: Every 1°C increase in daily mean temperature above the threshold increased the estimated relative risk (95% CI) of all-cause hospitalization by 1.022 (0.998-1.047) at the country level, 1.047 (1.007-1.089) in the south, and 0.982 (0.958-1.006) in the north. Infectious disease hospitalization was most affected by high temperatures (1.098 [1.057-1.140]). High temperatures significantly increased the risk of all-cause hospitalization for farmers 60 years and younger in three of the six provinces. CONCLUSIONS: The findings emphasized the need for health promotion programs to prevent heat-related health issues.

Health-related quality of life in people with different diabetes-related foot ulcer health states: A cross-sectional study of healed, non-infected, infected, hospitalised and amputated ulcer states.

AIMS: Diabetes-related foot ulcers (DFU) are a leading cause of infection, hospitalisation and amputation. However, to our knowledge no studies have compared the health-related quality of life (HRQoL) of people with DFU that were infected, hospitalised or amputated. This study aimed to investigate and compare the HRQoL of different groups of people with healed, non-infected, infected, hospitalised, or amputated DFU. METHODS: This was a multi-centre cross-sectional study measuring the HRQoL of patients, attending one of 18 Diabetic Foot Services across Queensland, Australia, with one of five DFU health states: healed, non-infected, infected, hospitalised, amputated. HRQoL was measured using the EQ-5D-5L to estimate age-sex adjusted utility values. RESULTS: Of 376 included patients (mean age 63 (12) years, 75% male), age-sex adjusted HRQoL utility estimates (95% CIs) were: healed DFU 0.57 (0.51-0.64), non-infected DFU 0.55 (0.49-0.62), infected DFU 0.45 (0.36-0.55), hospitalised DFU 0.53 (0.42-0.64), and amputated DFU 0.55 (0.46-0.63). CONCLUSION: People in any DFU health state have considerably reduced HRQoL, with greatest reductions in those with infected DFU. These findings provide valuable HRQoL estimates and comparisons for several different important DFU health states, adding to our understanding of the impact of DFU on HRQoL and facilitating future economic evaluations.

Patient-reported experience is associated with higher future revenue and lower costs of hospitals.

BACKGROUND: Despite the established positive association between patient experience and patient volume, the relationship between patient experience and the financial performance of hospitals has not been studied thoroughly. METHODS: To investigate this relationship, we used longitudinal data from 132 Swiss acute-care hospitals from 2016 to 2019 to examine the associations between patient experience and the proportion of elective patients, revenue, costs, and profits of hospitals. To account for a potential time lag effect, we utilized annual patient experience data and employed multilevel mixed-effects regression modeling to investigate its association with the aforementioned financial performance indicators for the following year. RESULTS: Data for private and public hospitals were analyzed both separately and in combination, to account for the different proportions of elective patients in these types of hospitals. The resulting mixed models, revealed that for each year studied, the previous year's patient experience was positively associated with the current year's proportion of elective patients (ß = 0.09, p = 0.004, all hospitals) and revenue (ß = 1789.83, p = 0.037, private hospitals only), and negatively associated with costs (ß = - 1191.13, p = 0.017, all hospitals); but not significantly associated with future profits (ß = 629.12, p = 0.240, all hospitals). CONCLUSIONS: This analysis showed that better patient experience is associated with a higher proportion of elective patients, greater revenue, and lower costs. Our findings may assist hospital managers and regulators in identifying strategies to increase revenue and reduce costs.

Climate change and human health in Vietnam: a systematic review and additional analyses on current impacts, future risk, and adaptation.

This study aims to investigate climate change's impact on health and adaptation in Vietnam through a systematic review and additional analyses of heat exposure, heat vulnerability, awareness and engagement, and projected health costs. Out of 127 reviewed studies, findings indicated the wider spread of infectious diseases, and increased mortality and hospitalisation risks associated with extreme heat, droughts, and floods. However, there are few studies addressing health cost, awareness, engagement, adaptation, and policy. Additional analyses showed rising heatwave exposure across Vietnam and global above-average vulnerability to heat. By 2050, climate change is projected to cost up to USD1-3B in healthcare costs, USD3-20B in premature deaths, and USD6-23B in work loss. Despite increased media focus on climate and health, a gap between public and government publications highlighted the need for more governmental engagement. Vietnam's climate policies have faced implementation challenges, including top-down approaches, lack of cooperation, low adaptive capacity, and limited resources.

Economic burden and financial vulnerability of injuries among the elderly in Vietnam.

Falls are a leading cause of death among elderly people. However, research on the cost of fall-related injuries is limited in Vietnam. We estimated treatment costs and associated factors among 405 elderly patients in Thai Binh hospitals. Costs were estimated through self-reported data on medical and non-medical expenses. Logistic regression and GLM were used to identify payment and affordability factors. Inpatient and outpatient care costs for fall-related injuries were US$98.06 and US$8.53, respectively. 11.85% of participants couldn't pay for treatment. Payment ability and cost decline were linked to family income, medical history, and hospital stay length. Elderly with fall-related injuries in Vietnam experienced high costs and severe health issues. Primary healthcare services and communication campaigns should be strengthened to reduce disease burden and develop effective fall injury prevention strategies.

A global perspective on the governance-health nexus.

BACKGROUND: This study raises two key arguments: First, government health expenditure (GHE) and per capita out-of-pocket expenditures on healthcare (OPEH) are sensitive to contemporary good governance practices, giving policy importance to the exogeneity of healthcare determinants, i.e., governance for health rather than health governance. Second, it is the income level of countries that reflects the volatility of the governance spillovers on the subject. METHODS: The present study constructs a composite governance index (CGI) and employs a set of panel data for 144 countries over the period from 2002 to 2020. To allow comparability and extract specific policy implications, the countries are classified as full, high-, middle-, and low-income panels. Meanwhile to delve into the short- and long-run effects of CGI on GHE and OPEH, the study employs the cross-sectionally augmented autoregressive distributed lags (CS-ARDL) model. Further, to establish a causal link between the variables, it uses the Dumitrescu-Hurlin panel causality technique. RESULTS: The results indicate that CGI is significantly cointegrated with GHE and OPEH in all recipient panels. It indicates that while CGI has significantly positive impacts on GHE and OPEH, its effects vary according to the income level of the underlying economies. The findings support the idea of governance for health and show that CGI drives the stabilization and enhancement of GHE and OPEH in the long run. Furthermore, the findings reveal that economic growth, the age dependency ratio, and tax revenue have positive effects, while the crude death rate and the child mortality rate exert negative impacts on the subject. Finally, the results highlight a unidirectional causality running from CGI to GHE and OPEH, while no feedback response is evident. CONCLUSIONS: Although an increase in GHE and OPEH is associated with the improvement of the population's healthcare, the results suggest the recognition of the importance and institutionalization of good governance to streamline this improvement through effective channelization, outreach, and social environment development for extensive health inclusion.

Linking governance with environmental quality: a global perspective.

Sustainable environmental quality is a global concern, and a concrete remedy to overcome this challenge is a policy priority. Therefore, this study delves into the subject and examines the effects of governance on environmental quality in 180 countries from 1999 to 2021. To maintain comparability and precision, we first classify countries into full and income-level panels and then, innovatively, construct a composite governance index (CGI) to capture the extensive effects of governance on CO2 emissions. Complementing the stationarity properties of the variables, we employ the cross-sectionally augmented autoregressive distributed lags model to analyze the data. Our survey yields four key findings. First, a long-run nexus between CGI, CO2 emissions, and other control variables is confirmed. Second, the findings indicate that CGI is crucial to improving environmental quality by reducing CO2 emissions across all panels. Third, we find that while CGI maintains a similar magnitude, the size of its effects substantially varies according to the income level of the underlying countries. Fourth, the findings reveal that energy consumption, population growth rate, trade openness, and urbanization contribute to environmental degradation, while financial development and the human development index are significant in reducing CO2 emissions. Our findings suggest specific policy implications, summing up that one common policy is not a good fit for all environmental quality measures.

Economic evaluations of whole-genome sequencing for pathogen identification in public health surveillance and health-care-associated infections: a systematic review.

Whole-genome sequencing (WGS) has resulted in improvements to pathogen characterisation for the rapid investigation and management of disease outbreaks and surveillance. We conducted a systematic review to synthesise the economic evidence of WGS implementation for pathogen identification and surveillance. Of the 2285 unique publications identified through online database searches, 19 studies met the inclusion criteria. The economic evidence to support the broader application of WGS as a front-line pathogen characterisation and surveillance tool is insufficient and of low quality. WGS has been evaluated in various clinical settings, but these evaluations are predominantly investigations of a single pathogen. There are also considerable variations in the evaluation approach. Economic evaluations of costs, effectiveness, and cost-effectiveness are needed to support the implementation of WGS in public health settings.

One-stage revision versus debridement, antibiotics, and implant retention (DAIR) for acute prosthetic knee infection: an exploratory cohort study.

INTRODUCTION: Studies have shown that debridement, antibiotics, and implant retention (DAIR) is an effective procedure for acute infection of total knee arthroplasty (TKA). This study aimed to explore DAIR and one-stage revision for homogenous cohorts with acute postoperative and acute hematogenous infection of TKA, without compelling indications to perform a staged revision. MATERIALS AND METHODS: This study was an exploratory analysis that used retrospective data from Queensland Health, Australia, for DAIR and one-stage revision of TKA between June 2010 and May 2017 (3-year average follow-up). The re-revision burden, mortality rate, and the cost of the interventions were explored. Costs were expressed in 2020 Australian dollars. RESULTS: There were 15 (DAIR) and 142 (one-stage) patients with homogenous characteristics in the sample. The re-revision burden for DAIR was 20%, while for one-stage revision it was 12.68%. Two deaths were associated with a one-stage revision and no death was associated with DAIR. The total cost since the index revision of DAIR, $162,939, was higher than for one-stage revision $130,924 (p value = 0.501), due to higher re-revision burden. CONCLUSIONS: This study would suggest the use of one-stage revision over DAIR for acute postoperative and acute hematogenous infection of TKA. It suggests that there could be other potential criteria which have not been ascertained that need to be considered for optimal DAIR selection. The study indicates the need for more research and, of note, high-quality randomized controlled trials to provide a well-defined treatment protocol with high level of evidence to guide patient selection for DAIR.

The burden of surgical site infections in Australia: A cost-of-illness study.

OBJECTIVE: To estimate the cost of surgical site infections in Australian public hospitals in 2018-19, to demonstrate the economic burden of hospital-associated infection in a well-resourced health system. METHODS: A cost-of-illness analysis was conducted over a 1-year time horizon based on data from published literature extrapolated using simulation techniques. The direct and indirect costs of SSI were estimated for Australia and each of its states and territories. RESULTS: An estimated 16,541 cases of SSI occurred in Australian public hospitals in 2018-19, resulting in a total direct cost of A$323.5 million. The average cost per case was A$18,814, which was 2.5 times the average per capita spending on health. The indirect costs of absenteeism and premature death were valued at A$23.0 million and A$2 948.1 million per annum, respectively. CONCLUSION: SSI is a significant but preventable cost with most of the financial burden coming from premature deaths but underreporting means our costs are likely underestimated.

Are joint replacement registries associated with burden of revision changes? A real-world panel data regression analysis.

OBJECTIVES: The association of joint replacement registries with outcomes such as revision burden is uncertain. This study aimed to evaluate whether joint replacement registries are associated with the burden of revision changes while controlling for confounders that could affect the association. DESIGN: A longitudinal study involving a combination of cross-sectional and time series data from 1980 to 2018. The study was a panel regression analysis using the difference-in-difference method. SETTING: Data from countries with joint replacement registries and countries without joint replacement registries were used. Registry data were obtained from joint replacement registries' annual reports, while non-registry data were obtained from each included country's pooled hospitals' annual revision burden reported in the literature. OUTCOME MEASURES: Changes in revision burden from 1980 to 2018 was the outcome measure. The revision burden in the registry periods of registry countries was compared with the non-registry periods of registry and non-registry countries. RESULTS: Data were obtained from 12 registry periods and 8 non-registry periods. The average difference in revision burden in the registry periods of registry countries relative to the non-registry periods of registry and non-registry countries was statistically significant for hip, -3.80 (95% CI (-2.50 to -5.10); p<0.001) percentage points and knee, -1.63 (95% CI (-1.00 to -2.30); p<0.001) percentage points. This translates to a 19.30%, and 21.85% reduction in revision burden for hip and knee registries, for the whole sampling period. CONCLUSION: Joint replacement registries are associated with a significant reduction in the burden of revision. Although revision burden reduces over time even without the registries, the establishment of joint replacement registries is associated with an increased reduction. The establishment of joint replacement registries in non-registry countries would be a worthwhile decision as it will further improve the outcomes of arthroplasty surgeries.

Does affirmative action reduce disparities in healthcare use by Indigenous peoples? Evidence from Australia's Indigenous Practice Incentives Program.

Globally, Indigenous populations experience poorer health but use less primary healthcare than their non-Indigenous counterparts. In 2010, the Australian government introduced a targeted reform aimed at reducing these disparities. The reform reduced, or abolished prescription medicine co-payments and provided financial incentives for GPs to better manage chronic disease care for Indigenous peoples. Exploiting the framework of a natural experiment, we investigate how the reform affected these health disparities in primary and specialist healthcare utilization using longitudinal administrative data from 75,826 Australians, including 1896 Indigenous peoples, with cardiovascular disease. The differences-in-differences estimates indicate that the reform increased primary healthcare use among Indigenous peoples, including 12.9% more prescription medicines, 6.6% more GP services, and 34.0% more chronic disease services, but also reduced specialist attendances by 11.8%. Increases in primary care were larger for those who received the largest co-payment relief and lived in metropolitan regions, whereas the reduction in specialist attendances was concentrated among lower income Indigenous patients. Affirmative action can reduce inequalities in Indigenous use of primary healthcare, albeit careful design is required to ensure that benefits are equitable and do not lead to substitution away from valuable, or necessary, care.

Proactive Detection (PROTECT) and Safety Planning to Shorten Emergency Department Stays for Psychiatric Patients.

OBJECTIVE: A literature gap exists for interventions to decrease average length of stay (ALOS) for patients with psychiatric presentations at the emergency department (ED). Long ALOSs are often related to sequential assessments of patients with high suicide risk or patients awaiting an inpatient bed. Safety planning may provide opportunities for diverting patients to the community and for reducing ED ALOS. This study reports on the impact of a safety-planning approach based on the PROTECT (proactive detection) framework for suicide prevention. METHODS: A complex intervention (comprising leadership, governance, and innovation) was instrumental in embedding a new clinical culture of proactive detection and positive risk management through safety planning at Princess Alexandra Hospital in Brisbane, Queensland, Australia. Practice as usual continued at a comparator nonintervention site (NIS). In total, 24,515 psychiatric presentations over 24 months were grouped into monthly averages for key outcomes, providing a sample size of 24 at each site. A difference-in-differences analysis across sites, preintervention (January-November 2019) and postimplementation (December 2019-December 2020), was used to estimate the intervention's impact. RESULTS: ED ALOS for psychiatric presentations, patients with an ALOS >12 hours, patients with an ALOS >24 hours, and inpatient psychiatric admissions decreased significantly compared with NIS (p<0.01) pre- and postimplementation of the safety-planning intervention. CONCLUSIONS: Embedding a recovery-oriented culture of safety significantly reduced ED ALOS for psychiatric evaluations. Leadership, governance, and innovative practices that shift the focus of assessment and care from a mindset of risk prediction to one of prevention through collaborative safety planning as outlined in the PROTECT framework may have far-reaching benefits for patient care.

The Prevalence of Heat-related Illnesses and Associated Factors among Rice Farmers in Vietnam.

Objective: The aim of this study was to examine the prevalence of heat-related illnesses (HRI) and their associated factors among rice farmers in Central Vietnam. Methods: A cross-sectional study was conducted using a sample of 379 farmers from August to September 2021 in Ha Tinh province on the north-central coast of Vietnam. A structured questionnaire was used to collect demographic information, farming activities, heat exposure, and health issues. Multivariable logistic regression was used to identify the factors associated with HRI. Results: At least one HRI symptom was experienced by 83.4% of farmers, and two or more HRI symptoms were experienced by 55.1% of farmers during the last harvesting season (the summer-autumn rice season, 2021). Factors significantly associated with HRI were age, having chronic diseases, type of farming tasks, the number of hours working in the heat, and water intake. Farmers working outdoors for more than 4 hours in the heat were 2.3 times [95%CI: 1.14-4.69] more likely to experience HRI than those working fewer than 2 hours. A higher risk of HRI was also associated with heavy farming tasks (OR = 2.35, [1.34-4.14]), having hypertension (OR = 3.75, [1.90-7.81]), cardiovascular diseases (OR = 2.53, [1.03-6.93]), and other chronic conditions (OR = 2.51, [1.51-4.25]). In contrast, a lower risk of HRI was found in the older group (OR = 0.44, [0.22-0.87]) and increased water intake (OR = 0.46, [0.27-0.77]). Conclusions: Hot weather is a significant occupational health risk for farmers in Vietnam. Changing the working schedule, working in shorter intervals, and remaining well-hydrated should be considered in HRI prevention strategies.

Is 2-Stage Septic Revision Worth the Money? A Cost-Utility Analysis of a 1-Stage Versus 2-Stage Septic Revision of Total Knee Arthroplasty.

BACKGROUND: Two-stage exchange arthroplasty remains the gold standard for the management of prosthetic joint infection (PJI) of the knee, but several studies have demonstrated that 1-stage exchange is as effective as 2-stage exchange. This study aimed to support decision-making via an economic evaluation of 1-stage compared to 2-stage exchange for total knee arthroplasty septic revision in patients who did not have compelling indication PJI (ie, Methicillin-resistant Staphylococcus aureus, multiorganism, systemic sepsis, comorbidities, culture negative, resistant organism, and immunocompromised) to undergo a 2-stage exchange. METHODS: A cost-utility analysis was performed using a Markov cohort model from the health care provider perspective using Australia data. One-stage septic knee revisions were compared with 2-stage exchange procedures for chronic PJI using a patient-lifetime horizon. Health outcomes were expressed as quality-adjusted life-years (QALY), whereas costs were presented in 2020 Australian dollars. Sensitivity analyses, population expected values of perfect information, and the perfect information for parameters (EVPPI) were assessed to estimate the opportunity costs surrounding the decision made at a willingness-to-pay threshold of $50,000 per QALY. RESULTS: The incremental cost-effectiveness ratio of 2-stage exchange compared with 1-stage exchange was $231,000 per QALY, with 98.5% of the probabilistic sensitivity simulations above the willingness-to-pay threshold. The population expected value of perfect information was $882,000, whereas the expected value of perfect information for parameters for the "cost parameters" was $207,000. CONCLUSION: The adoption of 1-stage septic knee revision is the optimal choice for patients who have a PJI and who do not have a compelling need for a 2-stage exchange arthroplasty. One-stage exchange for PJI should be advocated in patients who meet the eligibility criteria.

Testing for selection bias and moral hazard in private health insurance: Evidence from a mixed public-private health system.

Separating selection bias from moral hazard in private health insurance (PHI) markets has been a challenging task. We estimate selection bias and moral hazard in Australia's mixed public-private health system, where PHI premiums are community-rated rather than risk-rated. Using longitudinal cohort data, with fine-grained measures for medical services predominantly funded by PHI providers, we find consistent and robust estimates of advantageous selection among hospitalized cardiovascular disease (CVD) patients. Specifically, we show that in addition to their risk-averse attributes, CVD patients who purchase PHI use fewer services that are not covered by PHI providers (e.g., general practitioners and emergency departments) and have fewer comorbidities. Finally, unlike previous studies, we show that ex-post moral hazard exists in the use of specific "in-hospital" medical services such as specialist and physician services, miscellaneous diagnostic procedures, and therapeutic treatments. From the perspective of PHI providers, the annual cost of moral hazard translates to a lower bound estimate of $707 per patient, equivalent to a 3.03% reduction in their annual profits.

Application of a risk-guided strategy to secondary prevention of coronary heart disease: analysis from a state-wide data linkage in Queensland, Australia.

OBJECTIVE: This study sought whether higher risk patients with coronary heart disease (CHD) benefit more from intensive disease management. DESIGN: Longitudinal cohort study. SETTING: State-wide public hospitals (Queensland, Australia). PARTICIPANTS: This longitudinal study included 20 426 patients hospitalised in 2010 with CHD as the principal diagnosis. Patients were followed-up for 5 years. PRIMARY AND SECONDARY OUTCOMES AND MEASURES: The primary outcome was days alive and out of hospital (DAOH) within 5 years of hospital discharge. Secondary outcomes included all-cause readmission and all-cause mortality. A previously developed and validated risk score (PEGASUS-TIMI54) was used to estimate the risk of secondary events. Data on sociodemography, comorbidity, interventions and medications were also collected. RESULTS: High-risk patients (n=6573, risk score ≥6) had fewer DAOH (∆=-142 days (95% CI: -152 to -131)), and were more likely to readmit or die (all p<0.001) than their low-risk counterparts (n=13 367, risk score <6). Compared with patients who were never prescribed a medication, those who consumed maximal dose of betablockers (∆=39 days (95% CI: 11 to 67)), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (∆=74 days (95% CI: 49 to 99)) or statins (∆=109 days (95% CI: 90 to 128)) had significantly greater DAOH. Patients who received percutaneous coronary intervention (∆=99 days (95% CI: 81 to 116)) or coronary artery bypass grafting (∆=120 days (95% CI: 92 to 148)) also had significantly greater DAOH than those who did not. The effect sizes of these therapies were significantly greater in high-risk patients, compared with low-risk patients (interaction p<0.001). Analysis of secondary outcomes also found significant interaction between both medical and interventional therapies with readmission and death, implicating greater benefits for high-risk patients. CONCLUSIONS: CHD patients can be effectively risk-stratified, and use of this information for a risk-guided strategy to prioritise high-risk patients may maximise benefits from additional resources spent on intensive disease management.