Income inequality and cause-specific mortality during economic development.

PURPOSE: Life expectancy is strongly related to national income, whether there is an additional contribution of income inequality is unclear. METHODS: We used negative binomial regression to examine the association of neighborhood-level Gini, adjusted for age, sex, and income, with mortality rates in Hong Kong from 1976 to 2006. RESULTS: The association of neighborhood Gini with all-cause mortality varied over time (p-value for interaction < .01). Neighborhood Gini was positively associated with nonmedical mortality in 1976 to 1986; incident rate ratio (IRR) 1.09, 95% confidence interval (95% CI) 1.02-1.16 per 0.1 change and in 1991 to 2006, IRR 1.24, 95% CI 1.13-1.36, adjusted for age, sex and absolute income. Similarly adjusted, Gini was not associated with all-cause mortality in 1976 to 1986 (IRR 0.96, 95% CI 0.93-1.00) but was in 1991 to 2006 (IRR 1.25, 95% CI 1.20-1.29), when Gini was also positively associated with death from cardiovascular diseases, respiratory diseases and some cancers. CONCLUSIONS: Independent of income, income inequality was positively associated with nonmedical mortality rates at a low level of spatial aggregation, indicating the consistent harms of social disharmony. However, the impact on medical mortality was less consistent, suggesting the relevance of contextual factors.

Social disparities and cause-specific mortality during economic development.

Social patterning of disease is pervasive and persistent. Disease patterns change with economic development and the attendant epidemiological transition. It is becoming evident that social patterns of disease are epidemiologically stage specific. In a population with a recent history of rapid economic development we examined social patterns of all-cause and cause-specific mortality over time to elucidate how economic development impacts disparities in health. We used concentration indices to provide a summary measure of disparities by income in potential years of life lost (PYLL) for the Hong Kong population from 1976 to 2006. For all-cause mortality and for each of the specific causes considered the concentration curve in 2006 dominated the 1976 concentration curve. The concentration index for all-cause PYLL was negligible in 1976, but increased over the period. PYLL attributable to injury and poisoning was fairly consistently associated with lower income, but PYLL attributable to cardiovascular diseases and cancer reversed from an association with higher income in 1976 to an association with lower income in 2006. Social disparities in health are not universal or homogeneous in origin. Attention should be focused on disease-specific causes of disparities, so that contextually specific prevention strategies can be implemented. This is of particular relevance to China and other emerging economies where there may be a window of opportunity to prevent disparities in cancer and cardiovascular diseases occurring.

Long-term care cost drivers and expenditure projection to 2036 in Hong Kong.

BACKGROUND: Hong Kong's rapidly ageing population, characterised by one of the longest life expectancies and the lowest fertility rate in the world, is likely to drive long-term care (LTC) expenditure higher. This study aims to identify key cost drivers and derive quantitative estimates of Hong Kong's LTC expenditure to 2036. METHODS: We parameterised a macro actuarial simulation with data from official demographic projections, Thematic Household Survey 2004, Hong Kong's Domestic Health Accounts and other routine data from relevant government departments, Hospital Authority and other LTC service providers. Base case results were tested against a wide range of sensitivity assumptions. RESULTS: Total projected LTC expenditure as a proportion of GDP reflected secular trends in the elderly dependency ratio, showing a shallow dip between 2004 and 2011, but thereafter yielding a monotonic rise to reach 3.0% by 2036. Demographic changes would have a larger impact than changes in unit costs on overall spending. Different sensitivity scenarios resulted in a wide range of spending estimates from 2.2% to 4.9% of GDP. The availability of informal care and the setting of formal care as well as associated unit costs were important drivers of expenditure. CONCLUSION: The "demographic window" between the present and 2011 is critical in developing policies to cope with the anticipated burgeoning LTC burden, in concert with the related issues of health care financing and retirement planning.

Redistribution or horizontal equity in Hong Kong's mixed public-private health system: a policy conundrum.

We examine the distributional characteristics of Hong Kong's mixed public-private health system to identify the net redistribution achieved through public spending on health care, compare the income-related inequality and inequity of public and private care and measure horizontal inequity in health-care delivery overall. Payments for public care are highly concentrated on the better-off whereas benefits are pro-poor. As a consequence, public health care effects significant net redistribution from the rich to the poor. Public care is skewed towards the poor in part not only because of allocation according to need but also because the rich opt out of the public sector and consume most of the private care. Overall, there is horizontal inequity favouring the rich in general outpatient care and (very marginally) inpatient care. Pro-rich bias in the distribution of private care outweighs the pro-poor bias of public care. A lesser role for private finance may improve horizontal equity of utilisation but would also reduce the degree of net redistribution through the public sector.

Who pays for health care in Asia?

We estimate the distributional incidence of health care financing in 13 Asian territories that account for 55% of the Asian population. In all territories, higher-income households contribute more to the financing of health care. The better-off contribute more as a proportion of ability to pay in most low- and lower-middle-income territories. Health care financing is slightly regressive in three high-income economies with universal social insurance. Direct taxation is the most progressive source of finance and is most so in poorer economies. In universal systems, social insurance is proportional to regressive. In high-income economies, the out-of-pocket (OOP) payments are proportional or regressive while in low-income economies the better-off spend relatively more OOP. But in most low-/middle-income countries, the better-off not only pay more, they also get more health care.

Health care consequences of cesarean birth during the first 18 months of life.

OBJECTIVE: Elective cesarean delivery is increasingly common. The potential effects of surgical delivery in an unselected sample of infants beyond the immediate neonatal period remain poorly defined. METHODS: We carried out an 18-month follow-up of a population-based cohort of 8327 Hong Kong Chinese infants born in 1997. The main outcome measures were utilization of outpatient visits and hospitalizations, categorized by doctor-diagnosed causes as reported by parents. RESULTS: Among term singleton infants, there was no association of cesarean (compared with vaginal) birth with subsequent hospital admission (adjusted odds ratio = 0.92; 95% confidence interval = 0.79-1.08) or with above versus below the median number of outpatient episodes (1.10; 0.96-1.26) in the first 18 months of life. There were weak positive associations with afebrile gastrointestinal, respiratory, skin and a few other conditions. CONCLUSION: Cesarean birth is not associated with hospitalization or outpatient care overall during the first 18 months after adjustment for confounders. We cannot rule out isolated associations with minor morbidities.

Catastrophic payments for health care in Asia.

Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. We estimate the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. We focus on payments that are catastrophic, in the sense of severely disrupting household living standards, and approximate such payments by those absorbing a large fraction of household resources. Bangladesh, China, India, Nepal and Vietnam rely most heavily on OOP financing and have the highest incidence of catastrophic payments. Sri Lanka, Thailand and Malaysia stand out as low to middle income countries that have constrained both the OOP share of health financing and the catastrophic impact of direct payments. In most low/middle-income countries, the better-off are more likely to spend a large fraction of total household resources on health care. This may reflect the inability of the poorest of the poor to divert resources from other basic needs and possibly the protection of the poor from user charges offered in some countries. But in China, Kyrgyz and Vietnam, where there are no exemptions of the poor from charges, they are as, or even more, likely to incur catastrophic payments.

Hong Kong's health spending projections through 2033.

OBJECTIVE: To derive actuarial projection estimates of Hong Kong's total domestic health expenditure to the year 2033. METHODS: Disaggregating health expenditure by age, sex, unit cost and utilisation level, we estimated future health spending by projecting utilisation (by public/private, inpatient/outpatient care) to reflect demographic changes and associated increase in demand (from higher expectations and greater intensity of care), and then multiplying such by the projected unit costs (incorporating the impact of key cost drivers such as public expectations, technological changes and potential productivity gains) to obtain total expenditure estimates. RESULTS: The model was most sensitive to the excess health care price inflation rate, i.e. the annual price/cost growth of medical goods and services over and above per capita GDP growth. Population ageing and growth per se, without taking into account related technologic innovation for chronic conditions that particularly afflict older adults, contribute relatively little to overall spending growth. Given the model assumptions, it is possible to limit total health spending to below 10% of GDP by 2033, where the public share would gradually decline from the current 57% to between 46% and 49%. CONCLUSIONS: Expenditure control through global budgeting, technology assessment and demand-side constraints should be considered although their effectiveness remains inconclusive.

Horizontal equity in health care utilization evidence from three high-income Asian economies.

This paper compares the extent to which the principle of "equal treatment for equal need"(ETEN) is maintained in the health care delivery systems of Hong Kong, South Korea and Taiwan. Deviations in the degree to which health care is distributed according to need are measured by an index of horizontal inequity. Income-related inequality in utilization is split into four major sources: (i) direct effect of income; (ii) need indicators (self-assessed health status, activity limitation, and age and gender interaction terms); (iii) non-need variables (education, work status, private health insurance coverage, employer-provided medical benefits, Medicaid status (low-income medical assistance), geographic region and urban/rural residency and (iv) a residual term. Service types studied include western doctor, licensed traditional medicine practitioner (LTMP), dental and emergency room (ER) visits, as well as inpatient admissions. Violations of the ETEN principle are observed for physician and dental services in Hong Kong . There is pro-rich inequity in western doctor visits. Unusually, this inequity exists for general practitioner but not specialist care. In contrast, South Korea appears to have almost comprehensively maintained ETEN although the better-off have preferential access to higher levels of outpatient care. Taiwan shows intermediate results in that the rich are marginally more likely to use outpatient services, but quantities of western doctor and dental visits are evenly distributed while there is modest pro-rich bias in the number of LTMP episodes. ER visits and inpatient admissions in Taiwan are either proportional or slightly pro-poor. Future work should focus on the evaluation of policy interventions aimed at reducing the observed unequal distributions.

Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data.

BACKGROUND: Conventional estimates of poverty do not take account of out-of-pocket payments to finance health care. We aimed to reassess measures of poverty in 11 low-to-middle income countries in Asia by calculating total household resources both with and without out-of-pocket payments for health care. METHODS: We obtained data on payments for health care from nationally representative surveys, and subtracted these payments from total household resources. We then calculated the number of individuals with less than the internationally accepted threshold of absolute poverty (US1 dollar per head per day) after making health payments. We also assessed the effect of health-care payments on the poverty gap--the amount by which household resources fell short of the 1 dollar poverty line in these countries. FINDINGS: Our estimate of the overall prevalence of absolute poverty in these countries was 14% higher than conventional estimates that do not take account of out-of-pocket payments for health care. We calculated that an additional 2.7% of the population under study (78 million people) ended up with less than 1 dollar per day after they had paid for health care. In Bangladesh, China, India, Nepal, and Vietnam, where more than 60% of health-care costs are paid out-of-pocket by households, our estimates of poverty were much higher than conventional figures, ranging from an additional 1.2% of the population in Vietnam to 3.8% in Bangladesh. INTERPRETATION: Out-of-pocket health payments exacerbate poverty. Policies to reduce the number of Asians living on less than 1 dollar per day need to include measures to reduce such payments.

Non-attendance and effective equity of access at four public specialist outpatient centers in Hong Kong.

This study tests whether socio-economic status (SES), at either the individual or ecologic levels, exerts a direct impact on non-attendance or an indirect impact on attendance through longer waiting time for appointments and/or doctor-shopping behavior at four public specialist outpatient centers in Hong Kong. We collected information through three main sources, namely patients' referral letters, telephone interviews with both open- and closed-ended questions (e.g. doctor-shopping data) and hospital administrative databases from a total of 6495 attenders and non-attenders enrolled from July 2000 through October 2001. Individual-level SES was measured by education, occupation and monthly household income. Tertiary planning unit (TPU)-level SES data consisted of proportion unemployed, proportion with tertiary education, median income and Gini coefficient. Direct effects of SES on non-attendance were examined by logistic regression. Indirect contributions mediated through waiting time and doctor-shopping were analyzed by structural equation modeling. We found that SES, at the individual or ecologic level, did not exert a direct effect on non-attendance. Instead, TPU-level SES contributed positively to waiting time (beta=0.06+/-0.03, p=0.048), i.e. worse-off neighborhoods (and those with greater income inequality) had a shorter waiting time. Individual-level SES was also directly associated with the likelihood of doctor-shopping (beta=0.16+/-0.02, p<0.001), i.e. the poor were less likely to doctor-shop. Both waiting time (beta=0.12+/-0.02, p<0.001) and doctor-shopping (beta=0.37+/-0.02, p<0.001) were significantly related to non-attendance. Our findings suggest a highly equitable specialist ambulatory care public system in Hong Kong. Health care resources are appropriately targeted at the socially indigent, and the poor are not discriminated against and pushed to seek alternative sources of care by the system. These results should be confirmed using a prospective design.

Prepayment was superior to postpayment cash incentives in a randomized postal survey among physicians.

OBJECTIVE: Improving response rates, particularly among physicians, is important to minimize nonresponder bias and increase the effective sample size in epidemiologic research. We conducted a randomized trial to examine the impact of prepayment vs. postpayment incentives on response rates. STUDY DESIGN AND SETTING: Self-completion postal questionnaires were mailed to 949 physicians who were respondents to an earlier survey and representative of the general physician population in Hong Kong. These physicians were randomly allocated to receive a HK dollar 20 cash prepayment incentive that accompanied the survey (n=474) or a postpayment reward of the same amount on receipt of the completed questionnaire (n=475). RESULTS: The final prepayment response rate was 82.9%, compared with 72.5% in the postpayment arm (P < .001). Of the eight alternative incentive and follow-up strategies evaluated, three lie on the efficiency frontier (i.e., not dominated), including postpayment with three mailings at HK dollar 42.7, prepayment with three mailings at HK dollar 66.5 and prepayment with three mailings and telephone follow-up at HK dollar 112.1 per responder recruited (US dollar 1=HK dollar 7.8). CONCLUSION: The findings demonstrate that prepayment cash incentives are superior to postpayment of the equivalent amount in improving response rates among a representative sample of Hong Kong physicians. Further research should concentrate on confirming the generalizability of these findings in other health care occupation groups and settings.

Physicians' perceptions towards the impact of and willingness to pay for clinical computerization in Hong Kong.

BACKGROUND AND OBJECTIVES: We evaluated factors associated with physicians' perceptions towards the effects of computers on health care and on current levels of computerization in their practice. We also performed a contingent valuation to quantify physicians' perceived benefits from computerization in a hypothetical ambulatory, solo clinic. METHODS: We surveyed 949 representative physicians in Hong Kong by post. Factor analysis was performed to summarize similar items into categories. Multivariable log-linear regression models were employed to assess the relationships between different factor scores and the number of functions computerized. We elicited their willingness-to-pay (WTP) for three defined computer systems using contingent valuation techniques. WTP values were estimated using econometric modeling by both, parametric and geometric methods. Sociodemographic, attitudinal, and practice-related predictors of WTP were estimated through regression analyses. RESULTS: Factor analysis revealed a three-factor solution which explained 53% of total variance. The overall mean score (mean = 3.51 +/- 0.45) showed a generally positive attitude towards the effects of computers on health care. Respondents with a higher level of computer knowledge had significantly higher mean overall (P = 0.002) and factor scores for all three factors (P < 0.01). Higher factor scores on the effects of computers on patient care and clinicians (P = 0.006) and on the health system (P = 0.032) were associated with a higher number of functions computerized. The parametric median WTP values for computerizing administrative, clinical, and both sets of functions were HK dollars 21205 (US dollars 2719), HK dollars 34231 (US dollars 4389), and HK dollars 45720 (US dollars 5862), respectively, which were lower than the estimates obtained from demand curves using the geometric method [HK dollars 43286 (US dollars 5549), HK dollars 59570 (US dollars 7637), and HK dollars 84623 (US dollars 10849), respectively]. Doctors with higher incomes were willing to pay more to computerize the clinic, with strong dose-response gradients demonstrated. Those who worked in corporate settings were also more likely to accept higher WTP values. CONCLUSIONS: Our findings confirm that better knowledge about computers is contributory to a more positive attitude towards the effects of computers on health care, which is in turn significantly associated with higher levels of actual computerization in clinical practice. WTP values represent the likelihood, in monetary terms, of translating doctors' perceived benefits from computerization into investment action.

Evaluation of a handheld clinical decision support tool for evidence-based learning and practice in medical undergraduates.

INTRODUCTION: Handheld computers (PDAs) uploaded with clinical decision support software (CDSS) have the potential to facilitate the adoption of evidence-based medicine (EBM) at the point-of-care among undergraduate medical students. Further evaluation of the usefulness and acceptability of these tools is required. METHODS: All 169 Year 4 undergraduate medical students at the University of Hong Kong completed a post-randomised controlled trial survey. Primary outcome measures were CDSS/PDA usefulness, satisfaction, functionality and utilisation. Focus groups were also conducted to derive complementary qualitative data on the students' attitudes towards using such new technology. RESULTS: Overall, the students found the CDSS/PDA useful (mean score = 3.90 out of 6, 95% confidence interval (CI) = 3.78, 4.03). They were less satisfied with the functional features of the CDSS (mean score = 3.45, 95% CI = 3.32, 3.59) and the PDA (mean score = 3.51 95% CI = 3.40, 3.62). Utilisation was low, with the average frequency of use less than once per week. Although students reported a need for information in patient care at least once daily, they infrequently used the CDSS in a clinical setting (20.4 +/- 10.4% of the time), with an average information retrieval success rate of 37.6 +/- 22.1% requiring 63.7 +/- 86.1 seconds. Multivariable regression shows that higher perceived CDSS/PDA usefulness was associated with more supportive faculty attitudes, greater knowledge of EBM, better computer literacy skills and increased use in a clinical setting. Greater satisfaction with the CDSS/PDA was associated with increased use in a clinical setting and higher successful search rates. Qualitative results were consistent with these quantitative findings and yielded additional information on students' underlying feelings that may explain the observations. CONCLUSIONS: While PDAs uploaded with the CDSS are able to provide students with better access to high quality information, improvements in faculty attitudes, students' knowledge of EBM and computer literacy skills, and having the CDSS specially designed for undergraduate use are essential to increasing student adoption of such point-of-care tools.

The development and validation of a knowledge, attitude and behaviour questionnaire to assess undergraduate evidence-based practice teaching and learning.

OBJECTIVES: Most evidence-based practice (EBP) educational assessment tools evaluated to date have focused on specific knowledge components or technical skills. Other important potential barriers to the adoption of EBP, such as attitudinal, perceptual and behavioural factors, have yet to be studied, especially in the undergraduate setting. Therefore, we developed and validated a knowledge, attitude and behaviour questionnaire designed to evaluate EBP teaching and learning in an undergraduate medical curriculum. METHODS: We derived the questionnaire from a comprehensive literature review, informed by international and local experts and a Year 5 student focus group. We determined its factor structure and refined and validated the questionnaire according to the responses of a cohort of Year 5 and a combined group of Years 2 and 3 students using principal components factor analysis with varimax rotation. Factor reliability was computed using Cronbach's alpha coefficient. We assessed construct validity by correlating the factors with other measures of EBP activity and examined responsiveness through paired t-test of the pre/post factor mean scores. RESULTS: A 43-item questionnaire was developed. Four factors were identified from both student groups. The overall questionnaire as well as each factor had high construct validity (Cronbach's alpha > 0.7 for each scale). No significant correlations were found between the 4 factors, confirming their orthogonality. Positive correlations, however, resulted between factor mean scores and other EBP activities. The responsiveness of the questionnaire was satisfactory. CONCLUSION: A reliable knowledge, attitude and behaviour measure of EBP teaching and learning appropriate for undergraduate medical education has been developed and validated.

Randomised controlled trial of clinical decision support tools to improve learning of evidence based medicine in medical students.

OBJECTIVE: To assess the educational effectiveness on learning evidence based medicine of a handheld computer clinical decision support tool compared with a pocket card containing guidelines and a control. DESIGN: Randomised controlled trial. SETTING: University of Hong Kong, 2001. PARTICIPANTS: 169 fourth year medical students. MAIN OUTCOME MEASURES: Factor and individual item scores from a validated questionnaire on five key self reported measures: personal application and current use of evidence based medicine; future use of evidence based medicine; use of evidence during and after clerking patients; frequency of discussing the role of evidence during teaching rounds; and self perceived confidence in clinical decision making. RESULTS: The handheld computer improved participants' educational experience with evidence based medicine the most, with significant improvements in all outcome scores. More modest improvements were found with the pocket card, whereas the control group showed no appreciable changes in any of the key outcomes. No significant deterioration was observed in the improvements even after withdrawal of the handheld computer during an eight week washout period, suggesting at least short term sustainability of effects. CONCLUSIONS: Rapid and convenient access to valid and relevant evidence on a portable computing device can improve learning in evidence based medicine, increase current and future use of evidence, and boost students' confidence in clinical decision making.

Incentives and barriers that influence clinical computerization in Hong Kong: a population-based physician survey.

OBJECTIVE: Given the slow adoption of medical informatics in Hong Kong and Asia, we sought to understand the contributory barriers and potential incentives associated with information technology implementation. DESIGN AND MEASUREMENTS: A representative sample of 949 doctors (response rate = 77.0%) was asked through a postal survey to rank a list of nine barriers associated with clinical computerization according to self-perceived importance. They ranked seven incentives or catalysts that may influence computerization. We generated mean rank scores and used multidimensional preference analysis to explore key explanatory dimensions of these variables. A hierarchical cluster analysis was performed to identify homogenous subgroups of respondents. We further determined the relationships between the sets of barriers and incentives/catalysts collectively using canonical correlation. RESULTS: Time costs, lack of technical support and large capital investments were the biggest barriers to computerization, whereas improved office efficiency and better-quality care were ranked highest as potential incentives to computerize. Cost vs. noncost, physician-related vs. patient-related, and monetary vs. nonmonetary factors were the key dimensions explaining the barrier variables. Similarly, within-practice vs external and "push" vs "pull" factors accounted for the incentive variables. Four clusters were identified for barriers and three for incentives/catalysts. Canonical correlation revealed that respondents who were concerned with the costs of computerization also perceived financial incentives and government regulation to be important incentives/catalysts toward computerization. Those who found the potential interference with communication important also believed that the promise of improved care from computerization to be a significant incentive. CONCLUSION: This study provided evidence regarding common barriers associated with clinical computerization. Our findings also identified possible incentive strategies that may be employed to accelerate uptake of computer systems.