IHEA 2025 Abstract Descriptions with Chinese Translations
IHEA 2025 摘要描述及中文翻译
1. Continuity and Switching in Primary Care
1. 基层医疗中的连续性与转换
People: Mr. Tor Iversen, "Institute of Health and Society, University of Oslo", Norway, عvind Snilsberg, "Institute of Health and Society, University of Oslo", Norway, Anne Karen Jenum, University of Oslo, Norway and Yuting Zhang, The University of Melbourne, Australia
Abstract (English):
This paper examines how continuity and discontinuity in patient-GP relationships relate to the provision of guideline-recommended healthcare services, focusing on patients with type 2 diabetes (T2D) in Norway. Using nationwide registry data from 2018 to 2023, we analyse how relationship duration and switching to a higher-performing GP are associated with the provision of recommended services. Consistent with previous research, we find that longer relationships with the same GP are associated with higher provision rates, with progressively stronger associations beyond 10 years. We also find that switching to a higher-performing GP is linked to an increased likelihood of receiving recommended care. By comparing estimates from the two analyses, we show that, in some cases, switching to a high-performing GP may be associated with greater improvements than extended continuity. These findings highlight the importance of both long-term GP-patient relationships and GP-level differences in the delivery of care. While policy efforts often emphasize continuity, our findings suggest that switching can also be beneficial when it involves a move to a higher-performing GP, indicating policies supporting informed switching as a way to improve care.
本文探讨了患者-全科医生关系中的连续性和不连续性如何与指南推荐医疗服务的提供相关，重点关注挪威的2型糖尿病患者。利用2018年至2023年的全国登记数据，我们分析了关系持续时间和更换为绩效更高的全科医生与推荐服务提供之间的关联。与以往研究一致，我们发现与同一全科医生保持更长时间的关系与更高的服务提供率相关，且这种关联在超过10年后逐渐增强。我们还发现更换为绩效更高的全科医生与获得推荐护理的可能性增加相关。通过比较两种分析的结果，我们表明，在某些情况下，更换为绩效高的全科医生可能比延长连续性带来更大的改善。这些发现突出了长期全科医生-患者关系以及全科医生层面差异在医疗服务提供中的重要性。 尽管政策努力通常强调连续性，但我们的研究结果表明，当涉及转向更高绩效的家庭医生时，转换也可能是有益的，这表明支持基于信息的转换可以作为改善护理的一种方式。
摘要（中文翻译预览）:
【翻译内容预览】This paper examines how continuity and discontinuity in patient-GP relationships relate to the provi...
【翻译内容预览】本文探讨了患者与家庭医生关系的连续性和不连续性如何与护理提供...
2. Assessing the Effectiveness of Hospital Discharge Planning Synthesis of Empirical Evidence and Literature Findings
2. 评估医院出院计划的有效性：实证证据和文献发现的综合
People: Lena Imhof, "University of Hamburg, Hamburg Center for Health Economics", Germany, Jonas Schrey?? "Hamburg Center for Health Economics, University of Hamburg", Germany, Vera Winter, Bergische Universit䴠Wuppertal, Germany and Robin Heber, German Hospital Association, Germany
Abstract (English):
Background/ research gap: Patient transitions between inpatient and outpatient settings represent a critical point in care, often associated with adverse events such as avoidable hospital readmissions or emergency department (ED) visits. Hospital discharge planning (DP) is a process designed to smooth the transition process and ensure continuity of care. Despite growing evidence on the effectiveness of DP practices, uncertainties remain regarding the specific interventions encompassed under the term “discharge planning”. Furthermore, large-scale observational studies are limited and primarily focus on readmission rates, overlooking other meaningful patient and system-level outcomes. Research question: To address this gap, we conducted an umbrella review (“review of reviews”) to categorize DP interventions and provide a comprehensive overview of studied outcomes, including their magnitude of effectiveness. We then used our literature findings to assess the effectiveness of DP on a variety of identified outcomes in a large-scale observational study. Our quantitative analysis particularly focuses on cardiovascular patients, a patient group often characterized by complex care needs and substantial healthcare utilization. Methods: For our umbrella review, we searched five databases. The methodological quality of each included review was determined using the AMSTAR 2 tool. DP interventions were summarized narratively and the strength of evidence was derived for all identified outcomes. In our quantitative analysis, we linked claims data from the largest German sickness fund with hospital quality data, which contain structural and quality-related metrics for all German hospitals. From this data, we derived hospital-level DP scores. We applied multilevel regression models with hospital random effects to assess associations between DP scores and outcomes such as readmission rates and length of stay. The models were adjusted for patient and hospital-level characteristics. Results: Our literature search yielded a total of 1,779 records of which n=34 reviews met our inclusion criteria. We identified 25 outcomes investigated by at least two reviews. Results indicate strong evidence that DP interventions reduce 180-day readmission and increase patient knowledge, moderate evidence for positively affecting quality of life and patient satisfaction, and low evidence for reducing mortality and ED-visits. Our data sample comprises 668,414 individual hospital cases between 2021 and 2024 with a cardiovascular diagnosis (ICD-10 I00-I99). Preliminary findings indicate a positive association between DP and several outcomes, but limited effects on other outcomes, such as mortality. Further subgroup analyses are planned to investigate whether the association between DP and outcomes differs across patient (e.g., disease type, case severity) and hospital (e.g., size, specialization) characteristics. The empirical findings align with the main results from our literature review. Conclusion: This study provides a comprehensive synthesis of the existing literature on hospital DP and presents new empirical evidence on the impact of DP on diverse patient outcomes. The findings offer valuable insights for researchers, policymakers, and professionals seeking to optimize care transitions and improve patient outcomes through strategic DP. The variability in effectiveness across outcomes highlights the need for tailored DP processes that align with patient and system priorities.
背景/研究差距：患者从住院转至门诊是一个关键的护理环节，常与可避免的再入院或急诊科（ED）就诊等不良事件相关。医院出院计划（DP）是一个旨在使转诊过程更顺畅并确保护理连续性的流程。尽管关于 DP 实践有效性的证据日益增多，但关于“出院计划”这一术语所涵盖的具体干预措施仍存在不确定性。此外，大规模观察性研究有限，且主要关注再入院率，忽视了其他有意义的患者和系统层面的结果。研究问题：为填补这一空白，我们进行了一项"综述的综述"（umbrella review），对 DP 干预措施进行分类，并提供对研究结果的全面概述，包括其有效性的程度。然后，我们利用文献研究结果，在一个大规模观察性研究中评估 DP 对各种已识别结果的有效性。 我们的定量分析特别关注心血管患者，这一患者群体通常具有复杂的护理需求和大量的医疗资源利用。方法：在我们的系统评价中，我们检索了五个数据库。使用 AMSTAR 2 工具评估了每项纳入评价的方法学质量。对 DP 干预措施进行了叙述性总结，并针对所有已识别的结果推导了证据强度。在定量分析中，我们将德国最大健康保险公司的理赔数据与医院质量数据相结合，这些数据包含德国所有医院的机构和质量相关指标。从这些数据中，我们推导出医院层面的 DP 评分。我们应用具有医院随机效应的多水平回归模型，以评估 DP 评分与再入院率和住院时间等结果之间的关联。模型调整了患者和医院层面的特征。结果：我们的文献检索共获得 1,779 条记录，其中 n=34 项评价符合我们的纳入标准。我们识别出至少有两项评价调查的 25 个结果。 结果表明，出院计划干预措施能有效降低 180 天再入院率并提升患者知识水平，对生活质量及患者满意度有中等程度的影响，但对降低死亡率和急诊就诊次数的影响证据较弱。我们的数据样本包括 2021 年至 2024 年间 668,414 例心血管疾病诊断（ICD-10 I00-I99）的个体医院病例。初步研究显示，出院计划与多种结果呈正相关，但对其他结果（如死亡率）的影响有限。我们计划进行进一步亚组分析，以探究出院计划与结果之间的关联是否因患者（如疾病类型、病情严重程度）和医院（如规模、专科）特征而异。实证研究结果与文献综述的主要结论一致。结论：本研究对现有医院出院计划文献进行了全面综合，并提出了关于出院计划对不同患者结果影响的新的实证证据。研究结果为寻求通过战略性的出院计划优化护理过渡、改善患者结果的科研人员、政策制定者和专业人士提供了宝贵的见解。 不同结果的有效性差异突出了需要与患者和系统优先事项相一致的定制化出院计划流程。
摘要（中文翻译预览）:
【翻译内容预览】Background/ research gap: Patient transitions between inpatient and outpatient settings represent a ...
【翻译内容预览】背景/研究差距：患者在不同住院和门诊环境之间的过渡代表了……
3. Effects of Medicare Advantage on Healthcare Use and Outcomes: Evidence from Public Retiree Health Benefits
3. 医疗保险优势对医疗使用和结果的影响：来自公共退休人员健康福利的证据
People: Jose Escarce, University of California at Los Angeles, United States, Victoria Shier, University of Southern California, United States, Rushil Zutshi, University of Southern California, United States, Peter Huckfeldt, University of Minnesota, United States, Tyler Boese, University of Minnesota, United States, Neeraj Sood, University of Southern California, United States and Helen Parsons, University of Minnesota, United States
人员：Jose Escarce，加利福尼亚大学洛杉矶分校，美国，Victoria Shier，南加州大学，美国，Rushil Zutshi，南加州大学，美国，Peter Huckfeldt，明尼苏达大学，美国，Tyler Boese，明尼苏达大学，美国，Neeraj Sood，南加州大学，美国和 Helen Parsons，明尼苏达大学，美国
Abstract (English):
摘要（英文）：
Medicare beneficiaries choose to receive coverage from traditional Medicare (TM) or through private Medicare Advantage (MA) plans. Starting in 2023, a majority (51%) of Medicare beneficiaries were enrolled in MA rather than TM. The Centers for Medicare and Medicaid Services (CMS) pays MA plans fixed monthly capitated payments to cover nearly all health care for enrollees. As MA plans keep the portion of payments not used on to provide health care (or lose money if spending is above the capitated payment), they have financial incentives to reduce health care use. In addition, MA plans have tools to reduce spending that are not present in traditional Medicare, such as establishing restricted provider networks and requiring prior authorization for services. However, financial incentives under capitation could lead to reductions in needed care. Prior research has found that MA enrollees have lower healthcare spending than TM enrollees, with fewer admissions for hospital and post-acute care but more preventive care visits, and mixed evidence on quality of care. However, recent research has been primarily cross-sectional and could be subject to selection bias, especially given that MA enrollees have been shown to be healthier than TM enrollees, even conditioning on observed health. ` `We investigate the causal effects of MA on healthcare use and patient outcomes utilizing a natural experiment. We studied 221,000 retired state employees in five states (AL, AZ, CO, CT, NJ) where retiree health benefits were shifted from state-sponsored supplemental “Medigap” plans (covering the extensive cost sharing in TM) to mandatory MA plans between 2017 and 2019. This natural experiment creates variation in MA enrollment that is independent of health status and thus avoids selection bias. State workforces include a diverse set of occupations and are broadly representative of older adults enrolled in Medicare. As a comparison group, we use retired state employees in ten states that continuously offered Medigap plans over this period. We estimate synthetic difference-in-difference models which assign weights to each comparison state to match the pre-policy trends of each “treatment” state. ` `After states shifted retiree health benefits from Medigap plans to MA, we find that 77% to 98% of retired state employees enrolled in MA across the 5 states in our sample. We find consistent evidence that MA enrollment led to higher rates of home evaluation visits and reductions in inpatient rehabilitation facility use. Other effects vary more across states: for example, MA enrollment increased annual wellness visits in two states but reduced them in two other states. We find mostly small and/or statistically insignificant effects for evaluation and management visits, hospital admissions, and patient outcomes (institutional days and mortality) across states. Overall, our results show that MA increased use of certain outpatient services and reduced use of post-acute care without affecting the patient outcomes we observed, suggesting greater efficiency. However, future work should focus on outcome measures with greater sensitivity. The heterogeneous effects across states imply that no two MA plans are the same and that average effects may mask substantial variation.
医疗保险受益人选择从传统医疗保险（TM）或通过私人医疗保险优势（MA）计划获得保障。从 2023 年开始，超过一半（51%）的医疗保险受益人参加了 MA 计划而不是 TM 计划。医疗保险和医疗补助服务中心（CMS）向 MA 计划支付固定的每月按人头付费，以覆盖参保人几乎所有的医疗费用。由于 MA 计划保留未用于提供医疗服务的部分付款（或在支出超过按人头付费的情况下亏损），它们有减少医疗使用的经济激励。此外，MA 计划拥有传统医疗保险中不存在的减少支出的工具，例如建立限制性医疗服务提供者网络，并要求对服务进行预先授权。然而，按人头付费下的经济激励可能导致必要护理的减少。先前研究表明，MA 计划参保人的医疗支出低于 TM 计划参保人，住院和急性后期护理的入院次数较少，但预防性护理就诊次数较多，且医疗质量方面的证据不一致。 然而，近期研究主要采用横断面设计，可能存在选择偏差，特别是考虑到已有研究表明，参与 MA 计划的人员健康状况优于参与 TM 计划的人员，即便在控制观察到的健康状况后也是如此。
我们利用一项自然实验来研究 MA 对医疗保健使用和患者结局的因果效应。我们研究了五个州（AL、AZ、CO、CT、NJ）的 22.1 万名退休公务员，这些州的退休人员健康福利在 2017 年至 2019 年间从州政府资助的补充“Medigap”计划（覆盖 TM 中广泛的共付费用）转向强制 MA 计划。这项自然实验创造了独立于健康状况的 MA 参保率变化，从而避免了选择偏差。这些州的工作队伍包括多样化的职业，并广泛代表了参加 Medicare 的老年人。作为对照组，我们使用了在这段时间内持续提供 Medigap 计划的十个州的退休公务员。我们估计了合成双重差分模型，该模型为每个比较州分配权重，以匹配每个“处理”州的政策实施前的趋势。 ` `在州将退休人员健康福利从补充医疗保险计划转移到医疗保险计划后，我们发现样本中的5个州有77%至98%的退休州雇员参加了医疗保险计划。我们发现一致的证据表明，参加医疗保险计划导致家庭评估访问率提高，住院康复设施使用率降低。其他影响在不同州之间差异较大：例如，在两个州，参加医疗保险计划增加了年度健康检查次数，但在另外两个州则减少了。我们发现评估和管理访问、住院和患者结果（机构天数和死亡率）在不同州之间的影响大多较小和/或统计上不显著。总体而言，我们的结果表明，医疗保险计划增加了某些门诊服务的使用，减少了急性期后护理的使用，而没有影响我们观察到的患者结果，这表明效率更高。然而，未来的研究应关注更敏感的结果指标。各州之间异质性的影响表明没有两个医疗保险计划是相同的，平均效果可能掩盖了显著的差异。
摘要（中文翻译预览）:
【翻译内容预览】Medicare beneficiaries choose to receive coverage from traditional Medicare (TM) or through private ...
【翻译内容预览】医疗保险受益人选择从传统医疗保险（TM）或通过私人...
4. Impact of Remuneration Scheme on General Practitioners' Antibiotic Prescribing Practices for Respiratory Tract Infections
4. 薪酬制度对全科医生呼吸道感染抗生素处方实践的影响
People: Ms. Yana Zykova, Cluster for Health Service Research, Norwegian Institute of Public Health, Norway; 2. School of Business and Economics, UiT The Arctic University of Norway, Norway
人员：Yana Zykova 女士，挪威公共卫生研究所医疗服务研究中心，挪威；2.挪威北极大学商学院，挪威
Abstract (English):
摘要（英文）：
** **Abstract:** While careful use of antibiotics is crucial to reduce growth in antibiotic resistance, there is widespread prescribing of antibiotics even when their effect is minimal or nonexistent. This is especially relevant for respiratory tract infections (RTIs) in primary care. Antibiotic prescriptions might be valued by patients and perceived as an indicator of quality. We hypothesize that, compared to a fixed salary, the GP remuneration scheme based on the number of provided services (fee-for-service (FFS)) and the number of registered patients (capitation (CAP)) may motivate GPs to prescribe antibiotics for RTIs more often because it allows keeping patients on the list, attracting new patients, and saving time by avoiding discussions and finding alternative solutions with the patient. To our knowledge, there is only one study about the effect of the GP remuneration scheme on antibiotic prescription behaviour. Hutchinson and Foley (1999) found that in 1996 in Newfoundland, Canada, GPs paid by FFS, compared to their salaried counterparts, prescribed more antibiotics per unique patient receiving antibiotic treatment than their salaried colleagues. However, the study design could not account for the frequency of infections among patients and cases when a GP abstained from antibiotic treatment. In our paper, we study a link between the GP remuneration type and the likelihood of antibiotic prescription during patient contacts with RTI. We compare FFS and a mix of FFS and CAP with a fixed salary. We also study whether GPs choose broad- or narrow-spectrum antibiotics when providing antibiotic treatment. Broad-spectrum antibiotics increase the chance of treating an infection from the first attempt (which patients may consider a quality of care mark) but contribute much more to the development of antibiotic resistance since they kill a wider range of bacteria species. We use data on all antibiotic prescriptions in Norway made by GPs in the period 2015-2019 combined with data on patient contacts with the GPs for RTIs and other relevant information about patients and GPs from several nationwide registers. The analysis of regular GPs allows for comparing GPs paid by fixed salary and a mix of FFS and CAP, while the analysis of locum GPs allows for the study of the difference between fixed salary and FFS. We use a linear probability model and show that the results are robust using logit and probit models. We find that the probability of antibiotic prescription for RTI for GPs remunerated by FFS and CAP was, in relative terms, 13-15% higher than for salaried GPs. When antibiotics are prescribed, GPs paid by FFS and CAP had an 10-11% higher probability of prescribing a broader-spectrum antibiotic. The findings are consistent when analysing within-subject effects on the subset of GPs switching remuneration types. We did not find any significant difference between FFS and fixed salary. Our findings suggest that it is important to provide GPs with incentives to follow guidelines for antibiotic prescriptions, especially when the share of contracts based on CAP and FFS is high.
**摘要：** 虽然谨慎使用抗生素对于减少抗生素耐药性增长至关重要，但在其效果微弱或不存在的情况下，抗生素的处方仍然普遍存在。这在初级保健中的呼吸道感染（RTI）尤其相关。患者可能重视抗生素处方，并将其视为质量指标。我们假设，与固定工资相比，基于提供服务的数量（按服务收费（FFS））和注册患者数量（按人头付费（CAP））的全科医生（GP）报酬方案可能会激励 GP 更频繁地为呼吸道感染开具抗生素处方，因为它允许将患者保留在名单上，吸引新患者，并通过避免与患者讨论和寻找替代解决方案来节省时间。据我们所知，关于 GP 报酬方案对抗生素处方行为影响的研究只有一项。Hutchinson 和 Foley（1999）发现，在 1996 年的加拿大纽芬兰，按服务收费的全科医生，与他们的拿固定工资的同行相比，为每位接受抗生素治疗的独特患者处方的抗生素数量更多。 然而，研究设计无法考虑全科医生（GP）在避免使用抗生素治疗时患者和病例的感染频率。在我们的研究中，我们研究了 GP 薪酬类型与在患者接触呼吸道感染（RTI）期间开具抗生素处方可能性之间的联系。我们比较了固定薪酬、固定薪酬与按人头付费（CAP）混合支付以及固定薪酬。我们还研究了 GP 在提供抗生素治疗时选择广谱或窄谱抗生素的情况。广谱抗生素增加了首次治疗感染的机会（患者可能将其视为护理质量的标志），但由于它们能杀死更广泛的细菌种类，因此对抗生素耐药性的发展影响更大。我们使用了 2015 年至 2019 年期间挪威所有由 GP 开具的抗生素处方数据，结合 GP 与患者接触 RTI 和其他相关信息的患者接触数据，以及来自几个全国性登记处的关于患者和 GP 的相关信息。常规 GP 的分析允许比较固定薪酬和固定薪酬与按人头付费混合支付的 GP，而临时 GP 的分析则允许研究固定薪酬与按人头付费之间的差异。 我们使用线性概率模型，并通过 logit 和 probit 模型证明结果具有稳健性。我们发现，对于由 FFS 和 CAP 支付报酬的家庭医生，其开具抗生素治疗呼吸道感染的概率，相对于领取固定薪水的医生，在相对意义上高出 13-15%。当开具抗生素时，由 FFS 和 CAP 支付的医生开具广谱抗生素的概率高出 10-11%。在分析转为不同报酬类型医生子集的个体内效应时，这一发现依然成立。我们没有在 FFS 和固定薪水之间发现显著差异。我们的研究表明，提供激励措施以促使家庭医生遵循抗生素处方指南非常重要，尤其是在基于 CAP 和 FFS 的合同份额较高的情况下。
摘要（中文翻译预览）:
【翻译内容预览】** **Abstract:** While careful use of antibiotics is crucial to reduce growth in antibiotic resistan...
5. Evaluating an Integrated Care Model Targeted with Predictive Models to Reduce Readmission, Mortality, and Nursing Home Admission in Elderly Patients
5. 评估基于预测模型的一体化护理模式，以减少老年患者的再入院率、死亡率和养老院入住率
People: April Yushan WU, "Centre for Health Systems and Policy Research, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong", Hong Kong, Xia Nan, "Sau Po Centre for Ageing, The University of Hong Kong", Hong Kong, Eng-kiong Yeoh, "Centre for Health Systems and Policy Research, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong", Hong Kong, Susan Zi-may Yau, "Centre for Health Systems and Policy Research, JC School of Public Health and Primary Care, The Chinese University of Hong Kong", Hong Kong, Evora Hailin Zhu, "JC School of Public Health, The Chinese University of Hong Kong", Hong Kong, Vivian Lou, The University of Hong Kong, Hong Kong and Yingyao Chen, "School of Public Health, Fudan University", China
人员：四月鱼山吴，“香港中文大学联合书院公共卫生与初级保健学院健康系统与政策研究中心，香港”，香港，夏南，“香港大学寿保中心”，香港，杨永康，“香港中文大学联合书院公共卫生与初级保健学院健康系统与政策研究中心，香港”，香港，尤子美，“香港中文大学联合书院公共卫生与初级保健学院健康系统与政策研究中心”，香港，朱海林，“香港中文大学联合书院公共卫生学院”，香港，刘薇，“香港大学”，香港和陈英瑶，“复旦大学公共卫生学院”，中国
Abstract (English):
摘要（英文）：
Introduction: As populations age and healthcare needs become more complex, health and social care systems are restructuring services to better accommodate patients with both poor functional status and significant healthcare needs. Hong Kong's public hospitals have introduced a territory-wide program called Integrated Care Management (ICM) to provide comprehensive medical-social care for discharged vulnerable elderly patients. This program encompasses thorough discharge planning, post-discharge rehabilitation, home support services, and caregiver training, all coordinated by link nurses and a multidisciplinary team. Additionally, a validated readmission risk prediction model is employed to identify high-risk patients and target them for the program. All elders aged 65 years and above with a risk score above 0.2, or those referred by clinicians, who are discharged from Hong Kong's public hospitals will be included in the program. Objective: To evaluate the association of ICM with hospital readmissions, emergency department (ED) visits, mortality, length of stay, and institutionalization in residential care homes among elderly patients post-discharge in Hong Kong. Methods: A population-based matched cohort study using propensity score matching was conducted to compare outcomes among community-dwelling patients aged 60 or above who received ICM services post-discharge from public hospitals in Hong Kong from 2012 to 2019.** Primary outcomes included post-discharge readmissions, mortality, and ED visits at 30-, 90-, and 180-days post-discharge. Secondary outcomes included the length of stay of index admissions and subsequent institutionalization in residential care homes. Results: A total of 47,190 ICM patients were matched with 1,182,129 non-ICM patients. The ICM program was associated with significant reductions in 30-day readmissions (adjusted OR = 0.45; 95% CI 0.43-0.46) and ED visits (adjusted OR = 0.53; 95% CI 0.51-0.55), but not in 30-day mortality (adjusted OR = 1.03; 95% CI 1.01-1.04). Significant reductions in mortality were observed at 90 days (adjusted OR = 0.87; 95% CI 0.82-0.92) and 180 days (adjusted OR = 0.84; 95% CI 0.80-0.87). The program also resulted in a slight increase in the length of stay (IRR = 1.03; 95% CI 1.01-1.04) and a lower incidence of institutionalization in residential care homes within six months post-discharge (adjusted OR = 0.73; 95% CI 0.71-0.75). Subgroup analyses indicated that mortality benefits were primarily observed in patients aged 80 and above. Conclusions: The medical-social integrated transitional care program was associated with reductions in healthcare utilization, institutionalization in nursing homes, and mortality within six months. The comprehensive design, involving coordinated social and health services and targeted interventions for high-risk patients, likely contributes to these outcomes. Further research with quasi-experimental design is warranted to further validate these findings, and compare the ability of healthcare professionals and predictive models in identifying the patients most in need.
引言：随着人口老龄化加剧和医疗需求日益复杂，健康和社会护理系统正在重构服务，以更好地满足功能状态差且医疗需求显著的患者的需要。香港公立医院已推出一项全地域性计划——整合照护管理（ICM），为出院的脆弱老年患者提供全面的医疗-社会照护。该计划包括全面的出院计划、出院后康复、居家支持服务以及照护者培训，均由联络护士和多学科团队协调。此外，还采用经验证的再入院风险预测模型来识别高风险患者，并将他们纳入该计划。所有年龄在 65 岁及以上、风险评分高于 0.2 的老年人，或由临床医生转介的、从香港公立医院出院的患者都将被纳入该计划。目标：评估 ICM 与香港老年患者出院后医院再入院、急诊科（ED）就诊、死亡率、住院时长以及入住养老院的比例之间的关系。 方法：采用倾向得分匹配方法进行一项基于人群的匹配队列研究，比较 2012 年至 2019 年期间在香港公立医院出院后接受 ICM 服务的 60 岁及以上社区居住患者之间的结果。**主要结果包括出院后 30 天、90 天和 180 天的再入院、死亡和急诊就诊。次要结果包括首次入院住院时长和后续在养老院入住情况。结果：共匹配了 47,190 名 ICM 患者与 1,182,129 名非 ICM 患者。 ICM 项目与 30 天再入院率显著降低相关（调整后 OR=0.45；95% CI 0.43-0.46）和急诊就诊次数减少（调整后 OR=0.53；95% CI 0.51-0.55），但对 30 天死亡率无显著影响（调整后 OR=1.03；95% CI 1.01-1.04）。90 天时观察到死亡率显著降低（调整后 OR=0.87；95% CI 0.82-0.92），180 天时也观察到（调整后 OR=0.84；95% CI 0.80-0.87）。该项目的实施还导致住院时间略有延长（IRR=1.03；95% CI 1.01-1.04），并降低了出院后六个月内入住养老院的比例（调整后 OR=0.73；95% CI 0.71-0.75）。亚组分析表明，死亡率的降低主要在 80 岁及以上的患者中观察到。结论：该医疗-社会整合的过渡照护项目与六个月内医疗资源利用减少、养老院入住率降低和死亡率降低相关。其综合设计，包括协调社会和医疗服务以及针对高危患者的精准干预，可能促成了这些结果。 有必要进行进一步的研究，采用准实验设计来验证这些发现，并比较医疗专业人员和预测模型在识别最需要帮助的患者方面的能力。
摘要（中文翻译预览）:
【翻译内容预览】Introduction: As populations age and healthcare needs become more complex, health and social care sy...
【翻译内容预览】引言：随着人口老龄化和医疗保健需求的日益复杂，健康和社会照护系...
6. The Causal Impact of Obesity on Labour Market Outcome: Evidence from Mendelian Randomisation Analyses Using UK Biobank Data.
6. 肥胖对劳动力市场结果因果影响：基于英国生物样本库数据的孟德尔随机化分析证据。
People: Aharon Katz, University of York, United Kingdom
人员：Aharon Katz，约克大学，英国
Abstract (English):
Obesity is one of the most pressing public health challenges of our time, with widespread implications for individual well-being, healthcare systems, and economic productivity. Its prevalence has risen dramatically in recent decades, accompanied by increasing evidence of its adverse impact on labour market outcomes such as employment probabilities, wages, and absenteeism. However, establishing a causal relationship between obesity and labour market performance is challenging due to confounding factors, reverse causality, and measurement biases. This study explores the causal impact of obesity on labour market outcomes using data from the UK Biobank, a comprehensive dataset combining genetic, health, and socioeconomic information. We apply a Mendelian randomisation (MR) approach, using a genetic risk score (GRS) for higher body mass index (BMI) as an instrumental variable. This method leverages genetic predispositions determined at conception, enabling us to isolate the exogenous variation in obesity while addressing key endogeneity concerns, such as omitted variable bias and reverse causation. To account for the heterogeneity in obesity's impact across diverse demographic and socioeconomic subgroups, we apply a combination of IV techniques and the person-centered treatment effect (PeT) framework. This methodological approach extends beyond traditional average treatment effect estimations, uncovering nuanced, subgroup-specific impacts that reflect the complex relationship between obesity and employment probabilities. Our findings consistently demonstrate a significant and negative causal effect of obesity on employment across all methods included. Furthermore, the marginal effect of obesity on employment probability varies notably by the approach applied and by sex, age, and socioeconomic status. These results highlight the broader economic burden of obesity, revealing its impact not only on healthcare costs but also on labour market performance and the deepening of economic inequalities. This research makes several key contributions. It enhances the methodological robustness of causal inference in the obesity-labour market literature by integrating genetic instruments and advanced econometric techniques. It also provides actionable insights for policymakers and public health stakeholders, emphasising the need for targeted interventions to mitigate the economic and social consequences of obesity. Policies promoting healthy weight management could have far-reaching effects, not only improving public health but also enhancing workforce productivity and reducing economic disparities. By drawing on the rich UK Biobank data and applying innovative analytical approaches, this study offers a comprehensive examination of the intersection between obesity and labour market outcomes, bridging gaps in existing research and contributing to a deeper understanding of the economic ramifications of obesity.
肥胖是我们这个时代最紧迫的公共卫生挑战之一，对个人福祉、医疗保健系统和经济生产力具有广泛影响。近年来，其患病率急剧上升，同时越来越多的证据表明它对就业概率、工资和缺勤率等劳动力市场结果产生不利影响。然而，由于混杂因素、反向因果关系和测量偏差，建立肥胖与劳动力市场表现之间的因果关系具有挑战性。本研究利用英国生物样本库的数据，探索肥胖对劳动力市场结果的因果影响，该数据集是一个综合数据集，结合了遗传、健康和社会经济信息。我们采用孟德尔随机化（MR）方法，使用高体重指数（BMI）的遗传风险评分（GRS）作为工具变量。这种方法利用在受精时确定的遗传倾向，使我们能够隔离肥胖的外生变化，同时解决关键的内生性问题，如遗漏变量偏差和反向因果关系。 为了考虑肥胖对不同人口统计和社会经济子群体的影响差异，我们应用了多种工具变量技术和以人为中心的处理效应（PeT）框架。这种方法论超越了传统的平均处理效应估计，揭示了反映肥胖与就业概率之间复杂关系的细致、子群体特定的影响。我们的研究结果一致表明，在所有包含的方法中，肥胖对就业存在显著且负面的因果效应。此外，肥胖对就业概率的边际效应因所采用的方法、性别、年龄和社会经济地位而异。这些结果突出了肥胖更广泛的经济负担，不仅揭示了其对医疗保健成本的影响，还揭示了其对劳动力市场表现和经济不平等加剧的影响。这项研究做出了几项关键贡献。通过整合遗传工具和先进的计量经济学技术，它增强了肥胖-劳动力市场文献中因果推理的方法论稳健性。 它还为政策制定者和公共卫生利益相关者提供了可行的见解，强调了需要有针对性的干预措施来减轻肥胖带来的经济和社会后果。促进健康体重管理的政策可能产生深远的影响，不仅改善公共健康，还提高劳动力生产率并减少经济差距。通过利用丰富的英国生物样本库数据并应用创新的分析方法，这项研究对肥胖与劳动力市场结果之间的交叉进行了全面考察，填补了现有研究的空白，并有助于更深入地理解肥胖的经济影响。
摘要（中文翻译预览）:
【翻译内容预览】Obesity is one of the most pressing public health challenges of our time, with widespread implicatio...
【翻译内容预览】肥胖是我们这个时代最紧迫的公共卫生挑战之一，具有广泛的影响...
7. Effects of Integrating Primary Care and Specialist Physician Practices
7. 整合初级保健和专科医生实践的影响
People: Laurence Baker, Stanford University, Gabriel Sekeres, Cornell University, United States, Kate Bundorf, Duke University and Anne Royalty, University of North Carolina Greensboro, United States
Abstract (English):
Background: The organization of physician practices may affect the cost and quality of care delivered. In the U.S., primary care physicians (PCPs) may work in practices that also include specialists (“multi-specialty’), or in practices with only primary care physicians. There have been significant shifts toward PCPs working in multi-specialty practices. Economic theory suggest that reduced frictions and improved information flow between primary and specialty care from having PCPs in multi-specialty practices could reduce costs and improve quality. On the other hand, theory also suggests the potential for delivering primary care in multi-specialty practices to increase incentives for inefficient specialist referrals. Understanding whether and how this dimension of practice organization affects care delivery is increasingly important, but relatively little literature examines this question. We investigate effects of having PCPs in multi-specialty practices on the cost and quality of care. Data: We focus on the U.S. Medicare program, the government-operated health insurance program primarily for the elderly. Following methods developed by Finkelstein, Gentzkow, and Williams, we identify 181,075 individuals age 65-99 in “traditional” Medicare who move from one Hospital Referral Region (HRR) to another between 2007 and 2019, tracking each for up to 13 years before and after the move (1.9m person-years). When individuals move, they must change PCPs. We identify each mover’s source of primary care in the pre- and post-move periods and identify those who switch between primary-care-only and multi-specialty groups and those who do not. We measure each mover’s total annual spending (including physician, inpatient and outpatient facility, prescription drug, skilled nursing, home health, hospice, and equipment spending), spending and utilization by categories, and ambulatory care sensitive admissions as a quality measure. Methods: We estimate stacked event study models to determine the impact of practice type on a range of outcome variables, identifying effects from those who switch relative to those who stay in the same type of practice, including individual and calendar time fixed effects and controlling for characteristics of the origin and destination HRRs. The stacked event study models account for heterogeneous treatment timing and allow investigation of possibly heterogenous treatment effects. We emphasize results from models that separately examine those who begin in primary-care only practices, some of whom switch to multi-specialty, and those who begin in multi-specialty practices, some of whom switch to primary-care only. Results: Switchers and non-switchers have similar demographic characteristics. Event study models find no evidence of pre-trends. Receiving primary care in a multi-specialty practice is associated with a decrease of $300-$400 per year in total spending, about 4% (p<.01). Multi-specialty patients have 0.41 fewer primary care visits per person per year, 0.06 more specialist visits, and 0.01 fewer hospitalizations (all p<.01). Quality of care measures are not changed. A broad range of specification tests yields generally stable results. Changes in health status do not appear to differentially lead movers to switch to or from multi-specialty practices. Conclusions: Primary care delivered in multi-specialty practices leads to increased efficiency. Policies that would affect the further development of multi-specialty practices should account for this.
背景：医师诊所的组织方式可能影响所提供护理的成本和质量。在美国，家庭医生（PCP）可能在一个同时包含专科医生（“多专科”）的诊所工作，也可能在一个只有家庭医生的诊所工作。近年来，家庭医生在多专科诊所工作的趋势显著增加。经济理论表明，在多专科诊所中拥有家庭医生可以减少初级护理和专科护理之间的摩擦，改善信息流通，从而降低成本并提高质量。另一方面，理论也表明，在多专科诊所中提供初级护理可能会增加不合理的专科转诊的激励。了解诊所组织方式这一维度如何影响护理提供变得越来越重要，但相对较少的文献研究这个问题。我们研究了在多专科诊所中拥有家庭医生对护理成本和质量的影响。数据：我们重点关注美国的医疗保险计划，这是一个主要由老年人使用的政府运营的健康保险计划。 根据 Finkelstein、Gentzkow 和 Williams 开发的方法，我们在“传统”医疗保险中识别出 181,075 名 65 至 99 岁的个体，他们在 2007 年至 2019 年间从一个医院转诊区（HRR）搬迁至另一个 HRR，并追踪他们在搬迁前后的长达 13 年（1.9 百万年）的数据。当个体搬迁时，他们必须更换家庭医生（PCP）。我们识别出每位搬迁者在搬迁前后的主要护理来源，并区分出那些在单一专科组和多专科组之间转换的个体以及未转换的个体。我们测量每位搬迁者的年度总支出（包括医生、住院和门诊设施、处方药、专业护理、家庭护理、临终关怀和设备支出），按类别划分的支出和使用情况，以及作为质量指标的门诊护理敏感入院情况。方法：我们估计堆叠事件研究模型，以确定不同实践类型对一系列结果变量的影响，识别出在相同类型实践中停留的个体与转换个体之间的效应，包括个体和日历时间固定效应，并控制源 HRR 和目标 HRR 的特征。 堆叠事件研究模型考虑了异质的治疗时间，并允许研究可能异质的治疗效果。我们强调那些分别检查仅在初级保健实践中开始的患者（其中一些人转诊至多专科实践）以及那些在多专科实践中开始的患者（其中一些人转诊至仅在初级保健实践中的模型的结果）。结果：转诊者和未转诊者具有相似的 demographics 特征。事件研究模型未发现预趋势的证据。在多专科实践中接受初级保健与每年总支出减少 300-400 美元相关，约 4%（p<.01）。多专科患者每人每年减少0.41次初级保健就诊，增加0.06次专科就诊，减少0.01次住院（所有p<.01）。护理质量指标未发生变化。广泛的规格检验产生了总体上稳定的结果。健康状况的变化似乎并未导致患者差异化地转诊至或离开多专科实践。结论：在多专科实践中提供的初级保健提高了效率。 影响多专科诊所进一步发展的政策应当考虑这一点。
摘要（中文翻译预览）:
【翻译内容预览】Background: The organization of physician practices may affect the cost and quality of care delivere...
【翻译内容预览】背景：医师诊所的组织方式可能会影响医疗服务的成本和质量...
8. Implementation Costs and Benefits of Innovative Payment Models: An Assessment of Four Case Studies in Europe
8. 创新支付模式的实施成本与效益：欧洲四个案例研究评估
People: Matthias Hofer, The Office of Health Economics, London, United Kingdom, Mikel Berdud, Office of Health Economics, United Kingdom, Mireia Jofre-Bonet, Office of Health Economics, United Kingdom, Amanda Cole, Office of Health Economics, United Kingdom and Sian Hodgson, Office of Health Economics, United Kingdom
Abstract (English):
摘要（英文）：
Background: Member States in the EU are struggling to balance sustainability of health innovation with sustainability of health care systems. Central to this challenge is the role of pricing and payment models for pharmaceutical innovation, as they influence affordability, affect access to products, and provide incentives for directing efforts towards areas of the highest societal value. Therefore, it is important that policymakers have a thorough understanding of Innovative Pricing and Payment Model (IPM) implementation experiences aimed at providing market access solutions to breakthrough pharmaceutical innovation. A key feature of IPM to understand for policy makers is their cost and benefit of implementation. Objectives: We aimed to evidence costs and benefits of IPMs along all phases of implementation for key stakeholders (e.g. payers/HTAs, innovators, providers, patients). Methods: We developed an IPM cost-benefit evaluation framework adapting implementation assessment models from implementation science literature. The framework breaks down the implementation stages into design, implementation, maintenance, closing. We selected four case studies, which covered four distinct families of IPM: instalments, revenue guarantees, outcomes-based agreements, and portfolio agreements. We conducted semi-structured interviews with relevant stakeholders involved in the implementation of IPMs. Based on interviews, we collected additional data to quantify, estimate and document IPM implementation costs and benefits. Results: In all case studies, IPMs were considered as solutions to specific issues that otherwise cannot be addressed with simple discounts in ‘a conventional’ contract. These issues included the long-term uncertainty on the product effectiveness, the uncertainty on the use and expected return, or the lack of an existing sufficient market. In some cases (e.g., outcomes-based agreements) the IPM solved the issue and were considered temporary approaches, while in others (e.g., revenue guarantees) the IPM seemed to have a more permanent role in providing access to innovation. All implemented IPM involved increased complexity and a proportional increase in the cost of their implementation for all stakeholders, though to different degrees. We documented significant costs, which are spread over all phases of implementation and included human resources costs, opportunity costs, and transaction costs. We also documented benefits for all stakeholders, which were mainly associated with access and early access to pharmaceutical innovation including health related benefits, anticipated revenue, cost savings and certainty on expected returns. Overall, such benefits are primarily realised during implementation and maintenance phases. Conclusion: IPMs help mitigating issues related with access or early access to pharmaceutical innovation in “conventional” agreements, and offer benefits for payers (cost savings and risk-sharing), patients (health-related benefits) and pharmaceutical industry (revenue and risk-sharing). Despite these benefits, IPMs were deemed more complex and more costly than “conventional” agreements and not all stakeholders experience costs and benefits in the same degree, leading to potential implementation conflicts and incentive incompatibilities. The best strategy when implementing an IPM is to make IPMs a win-win for all stakeholders by reducing the burden of IPM implementation and limiting their duration until the issue that motivates its implementation is addressed and benefits have been realised.
背景：欧盟成员国正努力平衡医疗创新的可持续性与医疗保健系统的可持续性。这一挑战的核心在于药品创新定价和支付模式的作用，因为它们影响可负担性、影响产品可及性，并为将努力方向引导至最具社会价值领域提供激励。因此，政策制定者需要全面了解旨在为突破性药品创新提供市场准入解决方案的创新定价和支付模式（IPM）实施经验。政策制定者需要理解 IPM 的一个关键特征是其实施的成本和效益。目标：我们的目标是证明 IPM 在实施所有阶段对主要利益相关者（例如支付方/卫生技术评估机构、创新者、提供者、患者）的成本和效益。方法：我们开发了一个 IPM 成本效益评估框架，借鉴了实施科学文献中的实施评估模型。该框架将实施阶段分解为设计、实施、维护、关闭。 我们选择了四个案例研究，涵盖了四种不同的知识产权管理（IPM）类型：分期付款、收入保证、基于结果的协议和投资组合协议。我们与参与实施 IPM 的相关利益相关者进行了半结构化访谈。基于访谈，我们收集了额外数据，以量化、估算和记录 IPM 实施成本和收益。结果：在所有案例研究中，IPM 被视为解决特定问题的方案，而这些问题无法通过传统合同中的简单折扣来解决。这些问题包括产品长期有效性的不确定性、使用和预期回报的不确定性，或现有市场不足。在某些情况下（例如基于结果的协议），IPM 解决了问题，并被视为临时方法，而在其他情况下（例如收入保证），IPM 似乎在提供创新访问方面具有更永久的作用。所有实施的 IPM 都增加了复杂性，并导致所有利益相关者实施成本成比例增加，尽管程度不同。 我们记录了显著的成本，这些成本分布在实施的各个阶段，包括人力资源成本、机会成本和交易成本。我们还记录了所有利益相关者的收益，这些收益主要与获得和提前获得药物创新有关，包括与健康相关的收益、预期收入、成本节约和对预期回报的确定性。总体而言，这些收益主要在实施和维护阶段实现。结论：知识产权管理计划（IPMs）有助于缓解与获得或提前获得药物创新相关的“传统”协议中的问题，并为付款人（成本节约和风险分担）、患者（健康相关收益）和制药行业（收入和风险分担）提供收益。尽管有这些收益，但 IPMs 被认为比“传统”协议更复杂、成本更高，并非所有利益相关者都以相同程度体验到成本和收益，这可能导致潜在的实施方案冲突和激励不兼容。 实施 IPM 的最佳策略是通过减轻 IPM 实施的负担并限制其持续时间，使 IPM 成为所有利益相关者的双赢局面，直到促使其实施的问题得到解决并实现收益。
摘要（中文翻译预览）:
【翻译内容预览】Background: Member States in the EU are struggling to balance sustainability of health innovation wi...
【翻译内容预览】背景：欧盟成员国正努力平衡健康创新的可持续性与...
9. Integrating Virtual Primary Care: Evidence and Learnings from Lower-Middle Income Countries
9. 整合虚拟初级保健：来自低收入和中等收入国家的证据和学习
People: Divya Srivastava, City St George's University of London, United Kingdom and Anooj Pattnaik, ThinkWell, United States
人员：Divya Srivastava，城市圣乔治大学，英国，以及 Anooj Pattnaik，ThinkWell，美国
Abstract (English):
摘要（英文）：
Background Digital health communication technology in primary care (also termed virtual primary care, VPC)) allows patients to interact with health practitioners remotely through email, text, online chat, video or phone. Use of VPC grew exponentially in lower-and-middle-income countries (LMICs) during Covid-19. However, they grew within health systems that were not set up for this type of service delivery, from the regulatory and financing side to the underlying infrastructure and information systems. A question also remains on whether the growth of VPC contributes to persisting digital exclusion for underserved populations. This paper reviews the evidence and challenges LMICs faced when trying to set up these virtual primary care systems in the face of increasing demand but intransigent legacy health systems. Methods We apply an adapted novel framework, built on the World Health Organization building blocks for health systems functions. First, we conduct a targeted literature review that includes PubMed, CINAHL, EBSCO, Web of Science, Scopus, Cochrane Review, Google Scholar, between 2013 and 2023. We then map LMIC findings from three illustrative countries which have had significant activity in virtual primary care in recent years: Indonesia, Kenya,Thailand against the adapted WHO’s framework. The targeted review is complemented with a three-round Delphi consensus building exercise which is currently underway. The Delphi exercise involves an international group of experts focussed along seven themes to examine virtual primary care systems: (1) stated policy objectives, (2) regulation and governance, (3) financing and reimbursement, (4) delivery and integration, (5) workforce training and support, (6) IT systems and data sharing, and (7) patient involvement. Results Preliminary results, indicate that the deployment of VPC in LMICs was largely in the private sector with little regulation or policy guidance. Common challenges include lack of basic infrastructure (especially in rural areas), non-existent governance, legal, and regulatory systems for digital health, fragmented and often paper-based information systems, and nascent or limited national health insurance schemes for providers to contract with and be incentivized by. This is in the face of growing public demand for virtual primary care systems coupled with real equity and access barriers around infrastructure and costs associated with private provision. Conclusions LMIC experiences highlight how the intense need for digital alternatives during the pandemic led to the rapid and innovative growth of VPC primarily in the private sector. We found that LMIC governments struggled to keep up with this rapid deployment, with little effective regulation or policy change to integrate this private VPC into the health system, protect the privacy and data of citizens, or ensure access to those in most need. The standardized framework itself proved valuable in allowing a comparative approach to facilitate the assessment of VPC in LMICs. 2
背景 基层医疗中的数字健康沟通技术（也称为虚拟基层医疗，VPC）允许患者通过电子邮件、短信、在线聊天、视频或电话与医疗从业者进行远程互动。在新冠疫情期间，VPC 在低收入和中等收入国家（LMICs）的使用呈指数级增长。然而，它们的增长是在尚未为这种服务提供方式做好准备的健康系统内进行的，从监管和融资方面到基础基础设施和信息系统。一个仍然存在的问题是，VPC 的增长是否导致了服务不足人群持续存在的数字排斥。本文回顾了证据，并探讨了 LMICs 在面临需求增加但传统医疗系统固执己见的情况下，试图建立这些虚拟基层医疗系统时所面临的挑战。方法 我们应用了一个基于世界卫生组织健康系统功能构建模块的改进新型框架。首先，我们进行了有针对性的文献综述，包括 PubMed、CINAHL、EBSCO、Web of Science、Scopus、Cochrane Review、Google Scholar，时间范围从 2013 年到 2023 年。 然后我们将三个近年来在虚拟初级保健领域有显著活动的国家（印度尼西亚、肯尼亚、泰国）的低收入和中等收入国家（LMIC）的研究结果与调整后的世界卫生组织（WHO）框架进行对比。目标综述通过正在进行的三轮德尔菲共识构建活动得到补充。德尔菲活动涉及一个专注于七个主题的国际专家小组，以考察虚拟初级保健系统：（1）政策目标，（2）监管和治理，（3）筹资和报销，（4）交付和整合，（5）劳动力培训和支持，（6）IT 系统和数据共享，以及（7）患者参与。结果初步结果表明，在低收入和中等收入国家部署虚拟初级保健（VPC）主要在私营部门进行，监管或政策指导不足。常见挑战包括缺乏基本基础设施（尤其是在农村地区）、数字健康治理、法律和监管体系不存在、碎片化且通常基于纸质的信息系统，以及为提供者提供合同和激励的初步或有限的国家医疗保险计划。 面对公众对虚拟初级保健系统日益增长的需求，以及围绕基础设施和私人提供相关成本的真实公平性和可及性障碍，情况是这样的。结论 LMIC 的经验突显了疫情期间对数字替代方案的强烈需求如何导致了虚拟初级保健（VPC）在私人部门快速而创新的增长。我们发现，LMIC 政府难以跟上这种快速部署，缺乏有效的监管或政策变化来将私人 VPC 整合到卫生系统中，保护公民的隐私和数据，或确保最需要的人获得服务。标准化的框架本身被证明是有价值的，它允许采用比较方法，以促进对 LMIC 中 VPC 的评估。2
摘要（中文翻译预览）:
【翻译内容预览】Background Digital health communication technology in primary care (also termed virtual primary care...
【翻译内容预览】背景初级保健中的数字健康通信技术（也称为虚拟初级保健...
10. Team Incentives and Primary Health Care Team Performance in India
10. 团队激励与印度初级卫生保健团队绩效
People: Akriti Mehta, Johns Hopkins University, India, Krishna D. Rao, Johns Hopkins University, United States and Harsha Joshi, Johns Hopkins University, India
人员：Akriti Mehta，约翰霍普金斯大学，印度，Krishna D. Rao，约翰霍普金斯大学，美国，以及 Harsha Joshi，约翰霍普金斯大学，印度
Abstract (English):
Background: High-performing primary health care (PHC) is widely recognized as the foundation for achieving universal health coverage. Team based approaches to delivering primary care services is widely acknowledged as important for comprehensive and coordinated services. To address concerns about PHC team productivity, many low and middle-income countries like India have provide performance incentives to public sector PHC teams. In India, PHC teams - comprised of Community Health Officers, auxiliary nurses, and community health workers - receive team-based financial incentives for achieving benchmarks on a set of fifteen process and service coverage indicators sourced from routine information systems like outpatient visits, pregnancies and births registered, screening and treatment for hypertension and diabetes. Objective: This study aims to understand if team-based financial incentives are associated with improved facility service readiness and service delivery outcomes of vaccination coverage and hypertension screening. These outcomes require coordinated action among members of the PHC teams. A second aim, is to understand if there are unintended consequences of team incentives – principally, if non-incentivized services Methods: This study is located in the district of Bhavnagar in the state of Gujarat in India, where a sample of 40 primary health care facilities were surveyed in 2024 to evaluate facility readiness to provide a range of health services. The service readiness measures are based on WHO’s Service Availability and Readiness Assessment tool. Catchment population information on service coverage and immunization was sourced from routine data systems. Service readiness and coverage indicators that are incentivized and non-incentivized are compared using regression analysis to understand their relative performance. Bivariate and multivariate analysis is used to understand the association between team incentives and facility service readiness. Findings: Our preliminary results suggest that there is a weak association between receipt of team incentives and the outcomes of facility service readiness. Further, no significant association was found between services that required coordinated action by PHC teams (i.e. hypertension screening coverage and immunization) and receipt of team incentives. Further, we find that teams underperformed on un-incentivized indicators. Both design and implementation issues are responsible for why team incentives may not have their invented effects. For example, while health workers receive incentives based on a common set of indicators, they are individually paid through different budget lines at differential times, which does not provide a collective sense of accomplishment. Conclusions: Team performance incentives are an important policy tool to improve team performance. However, in scaled programs team incentives need to be carefully designed and calibrated to avoid attenuation of their effects on team performance, as well as, unintended consequences by depressing performance on non-incentivized activities.
背景：高效的基本医疗服务（PHC）被广泛认可为实现全民健康覆盖的基础。团队化方式提供基本医疗服务被广泛认为对提供全面协调的服务至关重要。为解决 PHC 团队生产率问题，许多低收入和中等收入国家如印度已向公共部门 PHC 团队提供绩效激励。在印度，由社区卫生官员、辅助护士和社区卫生工作者组成的 PHC 团队，通过实现基于一系列十五个流程和服务覆盖指标（这些指标源自门诊就诊、登记的孕产妇和出生、高血压和糖尿病筛查和治疗等常规信息系统）的基准来获得团队化财务激励。目标：本研究旨在了解团队化财务激励是否与改善设施服务准备度和疫苗接种覆盖率和高血压筛查的服务提供结果相关。这些结果需要 PHC 团队成员之间的协调行动。 第二个目标是了解团队激励是否存在未预料到的后果——主要是非激励性服务方法。方法：这项研究位于印度古吉拉特邦的巴文纳加尔地区，在2024年对该地区40个初级卫生保健设施进行了调查，以评估这些设施提供一系列卫生服务的准备情况。服务准备度指标基于世界卫生组织的《服务可及性和准备度评估工具》。服务覆盖和免疫接种的辖区人口信息来源于常规数据系统。通过回归分析比较激励性服务和非激励性服务的准备度指标，以了解它们的相对表现。使用双变量和多变量分析来了解团队激励与设施服务准备度之间的关联。结果：我们的初步结果表明，团队激励的获得与设施服务准备度的结果之间只有微弱的关联。 此外，未发现需要社区卫生团队协调行动的服务（即高血压筛查覆盖率和免疫接种）与团队获得激励之间存在显著关联。此外，我们发现团队在未激励指标上的表现不佳。设计和实施问题共同导致了团队激励可能无法达到预期效果的原因。例如，虽然卫生工作者根据一套共同的指标获得激励，但他们通过不同的预算项目在不同时间获得个人报酬，这无法提供集体成就感。结论：团队绩效激励是提高团队绩效的重要政策工具。然而，在规模化项目中，团队激励需要精心设计和校准，以避免其对团队绩效的影响减弱，以及因抑制非激励活动绩效而产生的不良后果。
摘要（中文翻译预览）:
【翻译内容预览】Background: High-performing primary health care (PHC) is widely recognized as the foundation for ach...
【翻译内容预览】背景：高绩效的初级卫生保健（PHC）被广泛认为是...
11. Accounting for Morbidity in Capitation Payments: A Person-Based Model for Primary Medical Care in England
11. 考虑病人在按人头付费中的发病率：英格兰初级医疗保健的人本模型
People: Ms. Laura Anselmi, University of Manchester, United Kingdom; The University of Manchester, United Kingdom, Shaolin Wang, University of Manchester, United Kingdom, Evangelos Kontopantelis, University of Manchester, United Kingdom, Michael Anderson, University of Manchester, United Kingdom, Matt Sutton, University of Manchester, United Kingdom and Yiu-Shing Lau, University of Manchester, United Kingdom
Abstract (English):
Background: Accurate needs-based capitation is key to effective and equitable primary care funding. Most existing capitation formulae use only basic demographic and area characteristics. Payment to general practices in England are informed by capitation weights based on a formula developed and are now outdated and unlikely to reflect the additional needs of general practices serving more deprived populations. We developed needs-based capitation weights for England using alternative sets of morbidity indicators recorded in primary and secondary care. Methods: We used nationally representative data on 12,667,755 million patients registered with 1,397 general practices in England on 1 April 2018 from the Clinical Practice Research Datalink (CPRD) linked with secondary care records from the Hospital Episode Statistics (HES). We used linear regression to estimate the association between cost-weighted We used linear regression to estimate the effects of age and gender, ethnicity, area-level deprivation, new registration and morbidity on cost-weighted consultations with primary care staff. We measured morbidity using three sets of indicators recorded in primary or secondary care, covering 20 to 209 conditions. We computed relative expected workload by applying the regression coefficients to person level data in CPRD and to available national data on registered populations for all 6,892 practices in England. Results: Workload was on average £110 per patient per year, varying between £7 and £882 for patients with at least one appointment and between £47 and £179 across practices.** Workload increased with age and with deprivation, but these gradients halved when morbidity was included. When primary and secondary diagnoses were included, the range of average relative workload per patient widened from 0.84-1.14 to 0.73-1.20 between practices at the 5th and 95th percentiles, and from 0.96-1.03 to 0.94-1.06 between the least and most deprived deciles. Alternative sets of diagnoses produced similar patterns. Conclusion: The inclusion of morbidity represents needs more accurately and re-directs resources toward practices in more deprived areas. Strengthening of routine diagnostic recording and data linkage is recommended to support the practical use of more refined, complete and comprehensive morbidity indicators. Further analysis and discussion on implementation aspects will be presented.
背景：基于需求的按人头付费是有效且公平地资助初级保健的关键。大多数现有的按人头付费公式仅使用基本的人口统计和地区特征。英格兰对全科诊所的支付是基于一个已开发和过时的公式计算的按人头付费权重，现在不太可能反映服务于更贫困人口的全科诊所的额外需求。我们使用初级保健和二级保健中记录的替代疾病指标集，为英格兰开发了基于需求的按人头付费权重。方法：我们使用了 2018 年 4 月 1 日注册在英格兰 1,397 家全科诊所的 12,667,755 万名患者的全国代表性数据，这些数据来自临床实践研究数据链接（CPRD），并与医院就诊统计（HES）的二级保健记录链接。我们使用线性回归来估计年龄和性别、种族、地区贫困程度、新注册和疾病对成本加权初级保健人员咨询的影响。 我们使用在初级或次级保健中记录的三组指标来衡量发病率，涵盖 20 至 209 种疾病。我们通过将回归系数应用于 CPRD 中的人级数据，以及英格兰所有 6,892 个医疗机构的注册人口可用国家数据，来计算相对预期工作量。结果：平均每位患者每年的工作量为 110 英镑，对于至少预约一次的患者，工作量在 7 至 882 英镑之间；不同医疗机构的工作量在 47 至 179 英镑之间。**工作量随年龄和贫困程度的增加而增加，但当发病率被纳入时，这些梯度减半。当纳入初级和次级诊断时，5%和 95%分位数之间每位患者的平均相对工作量范围从 0.84-1.14 扩大到 0.73-1.20，最贫困和最不贫困的十分位数之间从 0.96-1.03 扩大到 0.94-1.06。不同的诊断组产生了相似的模式。结论：纳入发病率能更准确地反映需求，并将资源重新导向更贫困的地区。 加强常规诊断记录和数据关联性，以支持更精细、完整和全面的疾病指标的实际应用。将就实施方面进行进一步分析和讨论。
摘要（中文翻译预览）:
【翻译内容预览】Background: Accurate needs-based capitation is key to effective and equitable primary care funding. ...
【翻译内容预览】背景：基于需求的准确人头费是有效和公平的基本医疗资金的关键。...
12. Primary Healthcare Investment Case for Jordan
12. 约旦基本医疗投资案例
People: Iryna Kurinna, Palladium, Ukraine, Mr. Robert Kolesar, Palladium, United States and Eduardo Gonzalez Pier, Palladium, Mexico
Abstract (English):
摘要（英文）：
Background: High-performing primary healthcare (PHC) is critical for achieving better health outcomes, improving health system efficiency, promoting equity, and enhancing resilience. Globally, health systems with a strong PHC focus consistently outperform those emphasizing hospital-based care at comparable expenditure levels. However, Jordan’s healthcare system faces persistent challenges, including fragmented and poorly harmonized health insurance schemes, overuse of the exemption program, and suboptimal PHC service quality. Only 22.4% of Jordan’s health budget is allocated to PHC, significantly below the international benchmark of one-third. The health system remains skewed toward curative care, with limited support for preventive services, health promotion, early detection, and palliative care. Recent analyses by the Jordan Strategy Forum, the World Bank, and the International Monetary Fund underscore the need to prioritize PHC within the country’s broader health reform agenda. This study fills a critical gap by generating economic evidence to catalyze policy action and mobilize resources for PHC strengthening in Jordan. Research aims: The Jordan PHC Investment Case aims to: 1. Summarize health expenditure trends and develop an investment case framework. 1. Estimate potential system savings and economic benefits of PHC strengthening through improved technical efficiencies, reduced hospital referrals, and enhanced health outcomes. 1. Quantify the PHC financing gap and calculate the return on investment (ROI) of increased PHC spending. 1. Provide actionable recommendations for governance, financing, health workforce development, and other targeted strategies to strengthen PHC. Methods: The study employs a mixed quantitative approach based on an extensive literature review, health expenditure analyses, and econometric modelling. Data envelopment analysis (DEA) was used to benchmark technical efficiency, estimate the Malmquist Productivity Index, and construct an efficiency frontier for a reference set of countries. Cost savings related to containing hospital emergency visits and reduction in Ministry of Health (MOH) hospital referrals are estimated based on the operation and cost data from Jordan's MOH. We also apply the Synthetic Control Method (SCM) and assess potential health gains from PHC reforms, monetized using standard values per statistical life year. Finally, we compare PHC expenditure benchmarks with current spending to calculate potential economic returns on investment. Key Results: Preliminary results indicate that Jordan’s PHC system operates below efficiency benchmarks observed in peer countries, with substantial room for improvement. DEA analysis reveals significant technical inefficiencies, while SCM modelling suggests that reversing historical underinvestment in PHC could lead to measurable health gains. Initial ROI estimates demonstrate that increased PHC investment can yield system-wide savings through reduced hospitalizations and referrals, alongside economic benefits from improved population health outcomes. Conclusions: Strengthening PHC in Jordan offers a transformative opportunity to improve health system efficiency, equity, and sustainability. The evidence generated highlights the urgency of reorienting health sector priorities toward PHC and mobilizing domestic and international investments. Policymakers should act on the recommendations provided to close the PHC financing gap and harness the potential health and economic returns of a strengthened PHC system. These findings support Jordan’s health reform agenda and provide a replicable model for other middle-income countries aiming to achieve UHC.
背景：高效的一级保健（PHC）对于实现更好的健康结果、提高卫生系统效率、促进公平以及增强韧性至关重要。在全球范围内，注重一级保健的卫生系统在同等支出水平上始终优于那些强调医院护理的系统。然而，约旦的卫生系统面临持续挑战，包括碎片化且协调不力的医疗保险计划、免税计划的过度使用以及一级保健服务质量欠佳。约旦只有 22.4%的医疗预算分配给一级保健，远低于国际标准的 1/3。卫生系统仍然偏向于治疗性护理，对预防性服务、健康促进、早期发现和姑息护理的支持有限。约旦战略论坛、世界银行和国际货币基金组织的最新分析强调了在国家更广泛的卫生改革议程中优先考虑一级保健的必要性。本研究通过生成经济证据来填补关键空白，以推动政策行动并为约旦一级保健的加强动员资源。研究目标：约旦一级保健投资案例旨在：1. 总结医疗卫生支出趋势并制定投资案例框架。1. 估算通过提高技术效率、减少医院转诊和改善健康结果来加强初级卫生保健的潜在系统节约和经济效益。1. 量化初级卫生保健融资缺口，并计算增加初级卫生保健支出的投资回报率（ROI）。1. 提供关于治理、融资、卫生人力发展和其他针对性策略的可操作建议，以加强初级卫生保健。方法：本研究采用混合定量方法，基于广泛的文献综述、医疗卫生支出分析和计量经济模型。使用数据包络分析（DEA）进行技术效率基准测试，估算马尔姆奎斯特生产率指数，并为参考国家集建立效率前沿。基于约旦卫生部（MOH）的运营和成本数据，估算与控制医院急诊就诊和减少卫生部医院转诊相关的成本节约。 我们还应用了合成控制法（SCM）并评估了初级保健改革可能带来的潜在健康收益，使用标准值按统计生命年进行货币化。最后，我们将初级保健支出基准与当前支出进行比较，以计算潜在的投资回报。主要结果：初步结果表明，约旦的初级保健系统运行效率低于同行国家观察到的效率基准，有巨大的改进空间。数据包络分析揭示了显著的技术效率低下，而合成控制法建模表明，扭转对初级保健的历史性投资不足可能导致可衡量的健康收益。初步的投资回报估计表明，增加初级保健投资可以通过减少住院和转诊来获得全系统的节省，同时从改善人口健康结果中获得经济效益。结论：加强约旦的初级保健提供了一个转型机会，以改善卫生系统的效率、公平性和可持续性。产生的证据突出了将卫生部门优先事项转向初级保健以及动员国内和国际投资的紧迫性。 政策制定者应采取行动落实建议，以缩小初级卫生保健融资差距，并利用强化初级卫生保健系统的潜在健康和经济回报。这些发现支持约旦的健康改革议程，并为其他旨在实现全民健康覆盖的中等收入国家提供了一个可复制的模式。
摘要（中文翻译预览）:
【翻译内容预览】Background: High-performing primary healthcare (PHC) is critical for achieving better health outcome...
【翻译内容预览】背景：高性能的初级保健（PHC）对于实现更好的健康结果至关重要...
13. Does the Formation of Interprofessional Primary Care Teams Promote Preventive Cancer Screening? Results of a Stacked DID Analysis
13. 跨专业初级保健团队的形成是否促进预防性癌症筛查？堆叠 DID 分析的结论
People: Sisira Sarma, Western University, Canada, Sisira Sarma, Western University, Canada, Rose Anne Devlin, University of Ottawa, Canada, Steven Habbous, "Ontario Health, Toronto, ON, Canada", Canada and Liisa Jaakkimainen, University of Toronto, Canada
人员：Sisira Sarma，加拿大西大学，Sisira Sarma，加拿大西大学，Rose Anne Devlin，加拿大渥太华大学，Steven Habbous，“加拿大安大略省健康，多伦多，ON，加拿大”，加拿大和 Liisa Jaakkimainen，加拿大多伦多大学
Abstract (English):
摘要（英文）：
Background and Aims: Interprofessional team-based primary care approaches have been implemented in many jurisdictions worldwide to deliver comprehensive primary care services on a continuing basis. Canada’s most populous province, Ontario, rolled out an interprofessional team approach called the Family Health Team (FHT) in a staggered manner beginning in 2006 within a universal health insurance system, where physicians are remunerated by age- and sex-adjusted capitation method while allied health professionals are salaried. Limited evidence exists on the causal effect of interprofessional team-based care on preventive health care, which our study addresses. Preventive screening for cancer, particularly breast, cervical, and colorectal cancer, is important for early detection and reducing cancer-related morbidity and mortality. Methods: Utilizing retrospective Ontario health administrative data on physicians and patients from 2005–2023, we analyzed cancer screenings among patients enrolled with an FHT who were eligible for colorectal (N=3,494,098), cervical (N= 4,386,583), and breast (N=1,540,176) cancer screenings. We used a stacked difference-in-differences approach, where we included cohorts of patients enrolled with an FHT physician from 2006 to 2022, along with corresponding control cohorts of patients enrolled with an FHT physician five years later. We used entropy balancing in the pre-FHT period to address physician selection into FHTs using observable patient and physician factors. Our control group for each stack minimizes unobservable selection into FHT as physicians with strong preferences and a proclivity to practice in teams are included. Patient selection into FHT is not feasible in Ontario as only physicians can decide whether to form a team, subject to availability by the Ontario Ministry of Health. We conducted event-study analyses to tease out the causal effect of FHT on cancer screening over time, adjusting for patient demographics, physician characteristics, and patient-fixed effects. We also investigated the effects across various marginalized populations based on area-level characteristics. Results: Our preliminary results of aggregate treatment effects revealed that patients enrolled with FHTs experienced an increase in the probability of colon cancer screening of 1.1% (p<0.05), cervical cancer screening of 1.9% (p<0.001) and breast cancer screening of 1.2% (p<0.001). Dynamic effect results of time to treatment indicate that the effect increased after three years of physician practice in teams. For example, colon cancer screening probabilities rose by 0.8% (p <0.001) in the first year and by 2% (p<0.001) after four years. Stratified analyses revealed that the effects were more pronounced among patients living in economically disadvantaged areas (colon: 1.8%, p<0.001; cervical 2%, p<0.001; breast: 1.4% p<0.05). Conclusions and Implications for Policy and Practice: We found that the rollout of interprofessional primary care teams within a capitated physician payment system in Ontario, Canada, improved preventive cancer screening rates. Our findings underscore the potential of employing interprofessional team-based care to improve preventive healthcare and mitigate disparities in access to preventive cancer screening. Policymakers may consider these findings as supporting interprofessional team-based primary care to optimize preventive care. Future research could explore other preventive care outcomes in teams using our analytical approach to obtain broader insights into primary health care system efficiency and equity.
背景与目的：跨专业团队式基层医疗模式已在全球许多地区实施，以持续提供全面的基层医疗服务。加拿大人口最多的省份安大略省，自 2006 年起在全民医保体系内分阶段推行了一种名为家庭健康团队（FHT）的跨专业团队式医疗模式，其中医师按年龄和性别调整的总额预付方式获得报酬，而其他医疗专业人员则领取固定薪水。目前关于跨专业团队式医疗对预防性医疗保健的因果效应的证据有限，本研究旨在探讨这一问题。癌症的预防性筛查，特别是乳腺癌、宫颈癌和结直肠癌的筛查，对于早期发现和降低癌症相关发病率和死亡率至关重要。方法：利用 2005 年至 2023 年安大略省医师和患者回顾性医疗行政数据，我们分析了已注册 FHT 且符合结直肠癌（N=3,494,098）、宫颈癌（N=4,386,583）和乳腺癌（N=1,540,176）筛查资格的患者癌症筛查情况。 我们采用了堆叠双重差分方法，其中包含了从 2006 年至 2022 年注册了家庭医生团队（FHT）的病人队列，以及相应地，五年后注册了家庭医生团队的控制队列。我们在家庭医生团队（FHT）成立前使用熵平衡法，通过可观察的患者和医生因素来解决医生选择加入家庭医生团队的问题。每个堆叠的控制组最小化了不可观察的选择加入家庭医生团队的情况，因为偏好强烈且倾向于团队执业的医生被包括在内。在安大略省，患者选择加入家庭医生团队是不可行的，因为只有医生可以决定是否组建团队，并且需要遵守安大略省卫生部的可用性规定。我们进行了事件研究分析，以揭示家庭医生团队对癌症筛查随时间的因果效应，同时调整了患者人口统计特征、医生特征和患者固定效应。我们还根据地区层面的特征调查了不同边缘化人群的影响。 结果：我们初步的汇总治疗效果结果显示，接受家庭医生团队（FHTs）治疗的患者的结肠癌筛查概率增加了 1.1%（p<0.05），宫颈癌筛查概率增加了1.9%（p<0.001），乳腺癌筛查概率增加了1.2%（p<0.001）。治疗时间动态效应结果显示，在医生团队执业三年后，该效应有所增加。例如，第一年结肠癌筛查概率上升了0.8%（p <0.001），四年后的上升了2%（p<0.001）。分层分析表明，在经济欠发达地区居住的患者受益更为明显（结肠癌：1.8%，p<0.001；宫颈癌：2%，p<0.001；乳腺癌：1.4% p<0.05）。结论及对政策与实践的意义：我们发现，在加拿大安大略省实施按人头付费的医生支付制度下，推行跨专业初级保健团队改善了预防性癌症筛查率。我们的研究结果强调了采用跨专业团队护理来提高预防性医疗保健和减少预防性癌症筛查机会不平等的可能性。 政策制定者可以考虑这些发现作为支持跨专业团队式基层医疗以优化预防性护理的依据。未来研究可以探索使用我们的分析方法在团队中研究其他预防性护理结果，以更全面地了解初级卫生保健系统的效率和公平性。
摘要（中文翻译预览）:
【翻译内容预览】Background and Aims: Interprofessional team-based primary care approaches have been implemented in m...
【翻译内容预览】背景和目的：跨专业团队式基层医疗方法已在...
14. Cost Control, Healthcare Provision, and Quality of Care in Chinese Primary Health Care Instutions under Capitation-Based Payment Schemes
14. 在按人头付费方案下中国基层医疗机构中的成本控制、医疗服务和护理质量
People: Yangling Ren, Southwestern University of Finance and Economics, China, Yafei Si, "University of New South Wales, Sydney", Australia, Chi Shen, Xi an Jiaotong University, China, Zhongliang Zhou, Xi'an Jiaotong University, China and Dan Cao, Xi an university of architecture and technology, China
人员：杨凌，西南财经大学，中国， Si Yafei，“新南威尔士大学，悉尼”，澳大利亚，沈驰，西安交通大学，中国，周钟亮，西安交通大学，中国和曹丹，西安建筑科技大学，中国
Abstract (English):
摘要（英文）：
Health systems worldwide face the dual challenge of containing rising costs while ensuring access to high-quality care, particularly in primary care settings. Capitation-based payment reforms have been proposed as a solution to balance these demands, yet empirical evidence on their impact in low- and middle-income countries remains limited. This study evaluates the effects of a capitation payment pilot, where financial risk is shared between healthcare providers and patients and implemented in western China, on service provision, healthcare cost and care quality. Utilizing a differences-in-differences approach, we find that at the hospital level, the capitation reform led to positive impacts on public health service delivery and outpatient visits. The reform resulted in a significant reduction in monthly drug costs per visit, despite no changes in test cost and total cost per visit. Survey analysis using standardized patients (SPs) further revealed a significant improvement in the process quality such as doctors’ adherence to recommended questions and exams and patient centredness, despite no significant changes in providing a correct diagnosis or correct treatment. The SP survey also finds a significant decrease in total cost. These findings underscore the potential of capitation to contain healthcare cost inflations without compromising overall care quality.
全球卫生系统面临着控制成本上升和确保获得高质量护理的双重挑战，尤其是在初级护理环境中。基于人头付费的支付改革被提议作为平衡这些需求的解决方案，然而关于其在低收入和中等收入国家影响的实证证据仍然有限。本研究评估了在中国西部地区实施的基于人头付费试点的影响，该试点在医疗服务提供者和患者之间共享财务风险，对服务提供、医疗成本和护理质量的影响。采用双重差分法，我们发现医院层面，基于人头付费改革对公共卫生服务提供和门诊就诊产生了积极影响。尽管检测成本和每次就诊总成本没有变化，该改革导致每次就诊的月药品成本显著降低。使用标准化患者（SP）进行的调查分析进一步显示，尽管正确诊断或正确治疗没有显著变化，但流程质量显著改善，例如医生对推荐问题和检查的依从性以及以患者为中心的服务。 SP 调查还发现总成本显著下降。这些发现强调了按人头付费在控制医疗成本上涨的同时，不会影响整体护理质量的潜力。
摘要（中文翻译预览）:
【翻译内容预览】Health systems worldwide face the dual challenge of containing rising costs while ensuring access to...
【翻译内容预览】全球卫生系统面临双重挑战：控制不断上升的成本，同时确保...
15. Does Health Insurance Protect Against High Cost of Maternal Care? Evidence from Ethiopia, Kenya, and India
15. 医疗保险能否抵御高昂的孕产妇护理费用？来自埃塞俄比亚、肯尼亚和印度的证据
People: Catherine Arsenault, The George Washington University Milken Institute School of Public Health, Aleksandra Jakubowski, Northeastern University, United States, Sein Kim, Harvard University, United States, Sailesh Mohan, Public Health Foundation of India, India, Brian Arwah, KEMRI Wellcome Trust, Kenya, Anagaw Derseh Mebratie, Addis Ababa University School of Public Health, Ethiopia, Theodros Zemedu, Harvard T. H. Chan School of Public Health, United States, Margaret Kruk, Harvard T.H. Chan School of Public Health, United States, Monica Chaudry, PHFI, India and Jacinta Nzinga, "Liverpool School of Tropical Medicine, Liverpool, United Kingdom ", Kenya
Abstract (English):
Background Governments in LMICs are expanding the enrollment in national health insurance schemes to improve financial protections for their citizens. The extent to which these schemes reduce out-of-pocket (OOP) expenditures for maternal care remains underexplored. We used a unique longitudinal dataset that tracks women’s real-time experiences with health system along the maternal care continuum. Methods The eCohorts study tracked the experiences of 3,032 pregnant women in Ethiopia, Kenya, and India. Women were enrolled at first antenatal care (ANC) visit and were called repeatedly during pregnancy, after delivery, and during postnatal care (PNC) period. We grouped OOP spending to direct costs (fees, medicines, test, laboratories) and indirect costs (transportation, food, accommodation) and assessed whether health insurance mitigates expenditures along the care continuum. We also assessed the relationship between OOP spending, healthcare quality, and user experience. Models controlled for facility type, delivery type (vaginal vs. C-section), delivery complications, primiparity, rural residence, marital status, education, and wealth. Results Most women (>95%) in Ethiopia and Kenya incurred some OOP costs of maternal care, while 28% of women in India received completely free care. The median (IQR) cost of maternal care was $43.6 (16.6, 99.1) in Ethiopia, $48.2 (12.0, 169.9) in India, and $36.2 (16.3, 69.9) in Kenya. The largest contributor to OOP spending were direct costs of deliveries, particularly C-sections and births in private facilities. Health insurance did not significantly reduce the probability of OOP expenses in Ethiopia or Kenya. In India, women were 14pp (p<.01) less likely to pay direct costs and 11 pp (p<.05) less likely to have indirect costs for ANC. Insurance did not affect direct OOP cost of delivery and increased indirect OOP costs by 12 pp (p<.05) in India. Insurance did not affect the level of spending in Ethiopia and India. In contrast, insurance significantly increased spending in Kenya: $6.5 (p<0.001) more on direct ANC costs, $2.5 (p<0.001) more on indirect ANC costs, and $0.80 more on PNC (p<0.05). OOP costs were catastrophic (>10% of annual income) for 24% of women in Ethiopia and 23% of women in Kenya (data collection is ongoing in India) and insurance was not protective from catastrophic costs. Higher OOP spending on ANC was associated with better quality in all countries. For delivery services, the relationship between OOP spending and quality varied: higher spending was associated with improved quality in Ethiopia but lower quality in Kenya. In Ethiopia, higher delivery costs correlated with better user experience, while no such associations were found in India or Kenya. Conclusion Significant gaps remain in the financial protection offered by insurance schemes in LMICs, potentially slowing enrollment growth. Having insurance did not protect from incurring high OOP costs of maternal care. Along the care continuum, women spent most on direct costs of delivery services, particularly C-sections. Using private facilities may be an effort to receive better care, but we found no consistent evidence that paying more translates to better quality or user experience.
背景 发展中国家政府正在扩大国家医疗保险计划的覆盖范围，以改善其公民的财务保护。这些计划在减少孕产妇护理自付费用方面的程度仍需深入探讨。我们使用了一个独特的纵向数据集，跟踪了妇女在孕产妇护理全过程中的实时健康系统体验。方法 eCohorts 研究追踪了埃塞俄比亚、肯尼亚和印度 3,032 名孕妇的经历。妇女在第一次产前护理（ANC）访问时被纳入研究，并在怀孕期间、分娩后和产后护理（PNC）期间反复被联系。我们将自付费用分为直接成本（费用、药品、检测、实验室）和间接成本（交通、食物、住宿），并评估了医疗保险是否减轻了护理全过程中的支出。我们还评估了自付费用、医疗质量和用户体验之间的关系。模型控制了设施类型、分娩方式（阴道分娩与剖宫产）、分娩并发症、初产、农村居住、婚姻状况、教育程度和财富。 结果埃塞俄比亚和肯尼亚的大多数女性（>95%）在孕产妇保健方面承担了部分自付费用，而印度有 28%的女性接受了完全免费的护理。埃塞俄比亚孕产妇保健的中位数（IQR）费用为 43.6 美元（16.6, 99.1），印度为 48.2 美元（12.0, 169.9），肯尼亚为 36.2 美元（16.3, 69.9）。自付费用中最大的支出是分娩的直接费用，尤其是剖腹产和私立机构的分娩。在埃塞俄比亚和肯尼亚，医疗保险并未显著降低自付费用的概率。在印度，女性直接费用支付的可能性降低了 14 个百分点（p<.01），产前护理间接费用的可能性降低了11个百分点（p<.05）。医疗保险并未影响分娩的直接自付费用，但在印度增加了12个百分点的间接自付费用（p<.05）。医疗保险并未影响埃塞俄比亚和印度的支出水平。 相比之下，保险显著增加了肯尼亚的医疗支出：直接产前护理成本增加了 6.5 美元（p<0.001），间接产前护理成本增加了2.5美元（p<0.001），产后护理成本增加了0.80美元（p<0.05）。在埃塞俄比亚和肯尼亚，24%和23%的女性自付费用是灾难性的（占年收入超过10%）（印度数据收集仍在进行中），而保险并不能防止灾难性费用。在所有国家，自付产前护理费用较高与更好的质量相关。对于分娩服务，自付费用与质量之间的关系有所不同：在埃塞俄比亚，高支出与质量改善相关，而在肯尼亚则与质量下降相关。在埃塞俄比亚，较高的分娩成本与更好的用户体验相关，而在印度或肯尼亚则未发现此类关联。结论：在低收入和中等收入国家，保险计划提供的财务保障仍存在显著差距，可能减缓参保增长。有保险并不能防止承担高昂的自付孕产妇护理费用。在整个护理过程中，女性在分娩服务的直接成本上花费最多，尤其是剖腹产。 使用私人设施可能是为了获得更好的护理，但我们没有发现一致的证据表明支付更多费用能转化为更好的质量或用户体验。
摘要（中文翻译预览）:
【翻译内容预览】Background Governments in LMICs are expanding the enrollment in national health insurance schemes to...
【翻译内容预览】背景：低收入和中等收入国家的政府正在扩大国家医疗保险计划的参保人数...
16. How Fee-for-Service Price Change Incurs Cost Shifting to Prospective Payment System: Evidence from China
16. 如何服务价格变化导致成本转嫁给预付费系统：来自中国的证据
People: Lai Yi, Central university of Finance and Economics, China, Fu Hongqiao, Peking University, China and Ma Chao, Southeast University, China
Abstract (English):
Background: The existence and impacts of “cost shifting” have been examined in existing theoretical and empirical literature but with mixed results (Aghamolla et al., 2024; Chernew et al., 2021; Clemens and Gottlieb, 2017; Dranove et al., 2017; Frakt, 2011; McGuire and Pauly, 1991; Rizzo and Zeckhauser, 2003; Wagner, 2016; White and Wu, 2014). Minimal studies focused on cost shifting behavior in developing countries. The highly segregated regional health insurance system and heavily skewed distribution of high-quality medical resources in developing countries brings an important payer for local providers in resource-rich cities --- the nonlocal patients who move outside their usual residence to seek healthcare in these cities. Providers can cost shift between local patients and non-local patients. This study investigates the existence of this kind of cost shifting behavior in developing countries. Method and Results: Taking an FFS Price-Cutting in a large southern city of China as a natural experiment, this study examined the responses of public hospitals and whether cost shifting existed. In China, the nonlocal patients who move outside their residences to seek healthcare in resource-rich cities pay by fee-for-service, while the local-insured patients mainly pay by the prospective payment system, giving hospitals room to cost shift. The FFS Price-Cutting eliminated the markup of medical consumables fee (5%-10% markup) since 2019 without changing the local prospective payment system. This study utilized the continuous difference-in-difference method and leverage variation in the exposure to the Price-Cutting across different hospitals (pre-reform consumables ratio) to identify the effects. Moreover, we supplement a heterogeneous analysis to detect cost-shifting. We obtained a random sampling claim data of both local-insured and nonlocal-insured patients from the administration in G city, with 200 thousand observations for local-insured and 360 thousand for nonlocal-insured. We found that the Price-Cutting has increased medical service expenditures and the likelihood of receiving procedures for both types of patients as expected. For nonlocal-insured patients, we found a decrease in both consumable expenditures and total expenditures, causing hospital revenue loss. In contrast, for local-insured patients, we found no measurable change in consumables expenditures, an increase in total expenditures and reimbursement, and even a reduction in illness severity. Further analysis showed that public hospitals relied more on revenue from patients who pay purely by Fee-for-Service, like nonlocal patients, experienced a larger increase in reimbursement of local-insured patients by conducting more procedures, suggesting that hospitals offset the income loss from nonlocal patients by inducing more demand from local-insured patients. We found fiscal subsidies to public hospitals can alleviate strategic response. Discussion and Implication: Our study extends this line of literature on cost shifting by investigating an important local/nonlocal setting in developing countries and showing whether the price change in FFS payers influences the PPS payers. These findings implied the importance of monitoring the cost shifting between local and nonlocal patients, and the coordination of their payment methods matters. Keywords: Cost Shifting, Price Regulation, Provider Behavior, Interregional Patients, Case-based Payment
背景：“成本转移”的存在及其影响在现有的理论和实证文献中已被探讨，但结果不一（Aghamolla 等人，2024；Chernew 等人，2021；Clemens 和 Gottlieb，2017；Dranove 等人，2017；Frakt，2011；McGuire 和 Pauly，1991；Rizzo 和 Zeckhauser，2003；Wagner，2016；White 和 Wu，2014）。对发展中国家成本转移行为的研究很少。发展中国家高度分割的区域医疗保险体系和优质医疗资源严重不均的特点，为资源丰富的城市的本地医疗服务提供者带来了一位重要支付方——那些离开常住地到这些城市寻求医疗服务的非本地患者。医疗服务提供者可以在本地患者和非本地患者之间进行成本转移。本研究调查了发展中国家是否存在这种成本转移行为。方法与结果：以中国南部某大城市的一次 FFS 价格削减为自然实验，本研究考察了公立医院的反应以及是否存在成本转移。 在中国，非本地患者到资源丰富的城市寻求医疗服务时按服务项目付费，而本地参保患者主要通过按预付费制度支付，这为医院提供了成本转嫁的空间。自 2019 年起，按服务项目付费价格削减消除了医疗耗材费用的加价（5%-10%的加价），但未改变本地预付费制度。本研究采用持续双重差分法，并利用不同医院在价格削减政策下的暴露程度差异（改革前耗材比率）来识别其影响。此外，我们还补充了异质性分析以检测成本转嫁现象。我们从 G 市管理部门获取了本地参保和非本地参保患者的随机抽样理赔数据，其中本地参保患者有 20 万观察值，非本地参保患者有 36 万观察值。我们发现，价格削减政策如预期般增加了两种类型患者的医疗服务支出和接受手术的可能性。对于非本地参保患者，我们发现其耗材支出和总支出均有所下降，导致医院收入减少。 相比之下，对于本地参保患者，我们发现消耗品支出没有可测量的变化，总支出和报销额增加，甚至疾病严重程度降低。进一步分析显示，公立医院更依赖纯按项目付费的患者收入，例如非本地患者，通过进行更多手术，导致本地参保患者的报销额大幅增加，这表明医院通过吸引更多本地参保患者需求来弥补非本地患者的收入损失。我们发现对公立医院的财政补贴可以缓解策略性反应。讨论与启示：我们的研究通过调查发展中国家一个重要的本地/非本地设置，扩展了成本转嫁的文献，并展示了按项目付费者的价格变化是否影响按病例付费者。这些发现表明监测本地与非本地患者之间的成本转嫁的重要性，以及协调他们的支付方式至关重要。关键词：成本转嫁、价格监管、提供者行为、跨区域患者、按病例付费
摘要（中文翻译预览）:
【翻译内容预览】Background: The existence and impacts of “cost shifting” have been examined in existing theoretical ...
【翻译内容预览】背景：现有理论已对“成本转嫁”的存在及其影响进行了考察...
17. General Practitioners Remuneration and Impact on Patients' Health, Health Care Use and Mortality
17.全科医生的报酬及其对病人健康、医疗使用和死亡率的影响
People: Kjartan Sarheim Anthun, SINTEF, Norway
人员：Kjartan Sarheim Anthun，挪威 SINTEF
Abstract (English):
Abstract **Background and aim** General practitioner (GP) organisation and remuneration have been studied for some years (Scott&Hall 1995; Flodgren et al 2011; Abelsen&Olsen 2012; Barham & Milliken 2015; Brekke et al 2020; Skovsgaard et al 2023). Since differences in remuneration are often invariant within a health system, and endogeneity is a concern, there is a gap in knowledge regarding the effects of remuneration that could be addressed by well-designed studies. This study aims to examine the impact of remuneration schemes on the treatment decisions of GPs in Norway. We compare two distinct schemes employed in Norway: one involving independent physicians compensated by municipalities through a combination of capitation and fee-for-service, and another where physicians are employed and salaried. The comparison is complicated by the fact that municipalities and GPs may select their funding scheme, potentially with differences in patient populations. To mitigate this endogeneity, we analyse GPs transitioning between remuneration schemes and instances of random patient assignment to GPs with differing funding structures. By assessing patients on a GP's list before and after a transition, we evaluate the effects on patient outcomes. Additionally, we match patients exposed to funding changes with those who were not, allowing us to estimate effects that are less prone to confounding. This approach will yield significant health economic insights into how GPs' remuneration influences patient health, healthcare utilization, and mortality. **Methods and approach** We employ a difference-in-differences design to analyse changes over time. The treated group includes patients whose GPs underwent a funding scheme change, while the control group consists of patients with GPs that did not. By comparing outcome trends between these groups, we can estimate the effects of the funding changes. We also match across groups (on age, sex, immigrant background, GP age, GP list size, and follow-up duration) to control for confounding factors. To prevent spill-over effects, we ensured that matched GPs did not practice in the same municipality. We use Poisson regression with high-dimensional fixed effects to compare outcome rate changes within the matched groups. **Current status and results** To conduct our analysis, we utilize data from multiple complete Norwegian registries covering all health care use and all GPs. Our primary outcomes are a) contacts and costs with primary care physicians, b) contacts and costs with acute hospital services in somatic and mental health specialist care, and c) rate of deaths per year during the follow-up period. Preliminary results indicate mixed results.
摘要 **背景和目的** 全科医生（GP）的组织和薪酬体系已有数年研究（Scott&Hall 1995; Flodgren 等人 2011; Abelsen&Olsen 2012; Barham & Milliken 2015; Brekke 等人 2020; Skovsgaard 等人 2023）。由于薪酬差异在医疗系统中往往保持不变，且内生性问题值得关注，因此关于薪酬影响的知识存在空白，可通过精心设计的研究加以解决。本研究旨在考察薪酬体系对挪威全科医生治疗决策的影响。我们比较了挪威采用的两种不同体系：一种涉及独立医生由市镇通过包干制和按服务收费相结合的方式补偿，另一种则是医生被雇佣并领取固定薪水。由于市镇和全科医生可能选择不同的资金方案，且患者群体可能存在差异，这种比较变得复杂。为缓解内生性问题，我们分析了全科医生在不同薪酬体系间的转换，以及随机分配给具有不同资金结构医生的患者案例。 通过在过渡前后评估全科医生的病人名单，我们评估了这对病人结果的影响。此外，我们将接触资金变化的病人与未接触的病人进行匹配，使我们能够估计受混杂因素影响较小的效果。这种方法将为全科医生的报酬如何影响病人健康、医疗保健利用和死亡率提供重要的卫生经济见解。**方法和途径**我们采用双重差分设计来分析随时间变化的情况。处理组包括全科医生经历了资金方案变化的病人，而对照组由全科医生未发生变化的患者组成。通过比较这些组之间的结果趋势，我们可以估计资金变化的效果。我们还通过年龄、性别、移民背景、全科医生年龄、全科医生名单大小和随访持续时间等指标进行组间匹配，以控制混杂因素。为了防止溢出效应，我们确保匹配的全科医生不在同一市执业。我们使用具有高维固定效应的泊松回归来比较匹配组内的结果率变化。 **当前状态和结果** 为了进行我们的分析，我们利用了多个完整的挪威登记数据，涵盖所有医疗保健使用和所有全科医生。我们的主要结果是：a) 与全科医生的接触和费用，b) 与急症医院服务的接触和费用（在躯体和心理健康专家护理中），以及 c) 在随访期间每年的死亡率。初步结果表明结果不一。
摘要（中文翻译预览）:
【翻译内容预览】Abstract **Background and aim** General practitioner (GP) organisation and remuneration have been st...
【翻译内容预览】Abstract **背景和目的** 全科医生（GP）的组织和报酬...
18. Healthcare Providers Preferences for Capitation Payment Method Under Universal Health Insurance in Tanzania: A Discrete Choice Experiment
18. 坦桑尼亚全民健康保险下医疗服务提供者对按人头付费方式的偏好：一项离散选择实验
People: Francis Donard Ngadaya, Ifakara Health Institute, Dar es salaam, Tanzania; Ifakara Health Institute, Tanzania, Josephine Borghi, "Department of Global Health and Development, London School of Hygiene and Tropical Medicine", United Kingdom, John Joseph Maiba, Ifakara Health Institute, Tanzania, Gemini Mtei, Results for Development (R4D), Tanzania, United Republic of, Timothy Powell-Jackson, "London School of Hygiene and Tropical Medicine, LSHTM", United Kingdom and Peter Binyaruka, Ifakara Health Institute (IHI), Tanzania
人员：Francis Donard Ngadaya, Ifakara 健康研究所, 达累斯萨拉姆, 坦桑尼亚；Ifakara 健康研究所, 坦桑尼亚；Josephine Borghi, "全球健康与发展系, 伦敦卫生与热带医学院", 英国；John Joseph Maiba, Ifakara 健康研究所, 坦桑尼亚；Gemini Mtei, 发展成果 (R4D), 坦桑尼亚, 联合共和国；Timothy Powell-Jackson, "伦敦卫生与热带医学院, LSHTM", 英国；以及 Peter Binyaruka, Ifakara 健康研究所 (IHI), 坦桑尼亚
Abstract (English):
摘要（英文）：
背景：坦桑尼亚正在设计和准备实施全民健康保险（UHI）计划，以此实现全民健康覆盖目标。由于资源有限，UHI 计划需要通过激励高效和更优质的医疗服务来战略性地购买健康服务。服务提供方支付方式（PPMs）是医疗采购改革的关键组成部分。与按服务付费相比，按人头付费在成本控制和效率方面提供了机会，但其成功取决于设计，该设计应包含减少按人头付费下预测的医疗服务提供方负面行为的要素。其他关键方法是使按人头付费属性与医疗服务提供方的偏好保持一致，以确保可接受性和顺利实施。为了为 UHI 的按人头付费设计和实施提供信息，我们进行了一项离散选择实验（DCE），以了解初级卫生保健提供方中最偏好的按人头付费和实施属性，估算了接受意愿的权衡、偏好异质性和政策选项模拟。 方法：我们在坦桑尼亚辛吉达和马尼亚拉地区的 84 个设施中，对 240 名初级卫生保健提供者（最好是设施负责人）进行了一项选择实验调查。该选择实验使用了五个人头付费属性：支付金额的充足性、覆盖服务、支付计划、高绩效设施的额外支付以及支付及时性，每个属性都有不同的水平。人头付费属性和水平是通过文献综述和定性研究确定的，并通过专家意见和试点测试进行了完善和精简。我们使用 D-efficient 设计以及试点研究（n=28）的系数来生成两个区块，每个区块包含 12 个强制性的、无标签的选择集，其中包含两种假设的支付方式（人头付费 A 和人头付费 B）。将使用混合多项式 Logit 模型和条件 Logit 模型来估计主效应，然后使用更灵活的混合 MNL 模型来探索偏好异质性、接受意愿的权衡以及政策选项模拟。结果：虽然结果即将公布，但我们预计将估计出主效应，以显示基于它们如何影响提供者选择的最偏好属性。 试点结果显示，人们更倾向于及时支付、支付金额充足以及涵盖的服务范围。关于接受意愿的结果将被呈现，例如，医疗服务提供者如何评估基于绩效分配的增加相对于其他分类属性的价值。将考虑多种情景来模拟不同按人头付费属性如何影响医疗服务提供者的接受程度。最后，偏好异质性将展示按人头付费属性的偏好如何根据设施和卫生工作者特征而变化。结论：这些发现将为乌干达按人头付费方式的设计提供基于证据的见解，通过与其医疗服务提供者的偏好保持一致，并确保他们接受，从而在坦桑尼亚顺利实施。关键词：按人头付费、全民健康保险、医疗服务提供者、选择实验、坦桑尼亚
摘要（中文翻译预览）:
【翻译内容预览】背景：坦桑尼亚正在设计和准备全民健康保险的实施计划...
19. 不同支付系统对公立医院医疗服务的影响：来自中国多试点城市的证据
People: Yifan Yao, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, China, Yingbei Xiong, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, China and Li Xiang, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, China
人员：姚一帆，同济医科大学医学与健康管理学院，中国；熊英北，同济医科大学医学与健康管理学院，中国；向亮，同济医科大学医学与健康管理学院，中国
Abstract (English):
摘要（英文）：
Objective: To evaluate the effect of various payment systems, including Diagnosis-Related Groups-Prospective Payment System (DRG-PPS), Diagnosis-Related Groups under Regional Global Budget System (DRG-GBS), and Diagnosis-Intervention Packet under Regional Global Budget System (DIP-GBS), on cost and quality of healthcare in public hospitals. **Methods:** The study was conducted in one of China’s most economically developed regions, characterized by abundant medical resources and extensive patient data. The dataset included 9,297,452 inpatient records from 64 public hospitals in the city and aggregated at the hospital level. Among them, 9 tertiary hospitals implemented the DRG payment model, while 55 hospitals adopted the DIP model. This retrospective observational study analyzed data from all public hospitals in the study city between January 2018 and August 2023. The study periods were defined as follows: before DRG-PPS (January 2018-December 2018), during DRG-PPS (January 2019-December 2020), during DRG-GBS (January 2021-August 2023); before DIP-GBS (January 2018-February 2020), and during DIP-GBS (March 2020-August 2023). To assess the impact of different payment systems on public hospital services, we analyzed costs, cost composition and quality. Outcome variables include total cost as well as medication cost, consumables cost, diagnostic and laboratory test cost, and surgical cost. For each cost component, we examined its proportion of the total cost. For healthcare quality, the outcome variables include length of stay (LOS), hospital infection rate, and clinical pathway compliance rate. We conducted an interrupted time series (ITS) analysis to examine the impact on above-mentioned outcome variables before and after the implementation of DRG and DIP reforms. **Results** Total cost remained unchanged under DRG-PPS but decreased under DRG-GBS (-$18.78, 95% CI, –37.08 to –0.49) and DIP-GBS (-$23.47, 95% CI, –34.05 to –12.90). LOS remained stable under DRG-PPS and DRG-GBS, but slightly decreased under DIP-GBS (–0.04 days, 95% CI, –0.07 to 0.00). Infection rates declined after DRG-PPS (-0.02% per month, 95% CI, –0.04 to 0.00) and DIP-GBS (-0.01% per month, 95% CI, –0.02 to 0.00). Clinical pathway compliance rate remained stable under DRG-PPS and DIP-GBS but declined under DRG-GBS (–0.34% per month; 95% CI, –0.70 to 0.02). Medication cost declined under DIP-GBS (-$5.21, 95% CI, –8.30 to –2.11), while consumables cost decreased under both DRG-GBS and DIP-GBS. The proportion of diagnostic and laboratory test cost increased under both DRG-GBS and DIP-GBS. Surgical costs decreased after DRG-GBS and DIP-GBS by $3.29 (95% CI, –5.65 to –0.93) and $2.79 (95% CI, –4.12 to –1.46), respectively. The results of subgroup analysis showed that the effects of DIP-GBS in tertiary hospitals were consistent with the overall results, while most outcome changes in non-tertiary hospitals were not significant. Conclusion Findings suggest that the same DRG model produced different outcomes under different budget modes (GBS vs PPS), whereas DRG and DIP showed similar effects within the same budget mode (GBS). In China's dual-track payment system, rather than focusing on which grouping methods is superior, efforts should prioritize quality monitoring and improving hospital adaptability to ensure high-quality care under value-based payment systems.
摘要（中文翻译预览）:
【翻译内容预览】Objective: To evaluate the effect of various payment systems, including Diagnosis-Related Groups-Pro...
【翻译内容预览】目标：评估包括诊断相关分组（DRG）在内的各种支付系统的影响...
20. Impacts of Policies in Controlling Growth of Medical Expenses in China, 2010-2019
20. 政策对中国医疗费用增长的控制影响，2010-2019年
People: Xuechen Xiong, The University of Hong Kong, Hong Kong, Jianchao Quan, University of Hong Kong, Pokfulam, Hong Kong, Zhaohua Huo, Chinese University of Hong Kong, Hong Kong and Li Luo, Fudan University, China
人员：熊雪尘，香港大学，香港，全建超，香港大学，香港 Pokfulam，香港，霍兆华，香港中文大学，香港和罗立，复旦大学，中国
Abstract (English):
摘要（英文）：
Background Addressing the surge in medical expenses is a primary focus of Chinese healthcare reform. The annual growth rate of total health expenditure was 12.4% in 2019, surpassing the national GDP growth rate of 6.0%. A series of nationwide policies have been implemented to control the unreasonable growth of medical expenses in public hospitals, including enhancing financial support for healthcare facilities, adjusting service pricing of medical treatments, and implementing a zero-mark-up policy for medications. However, the effectiveness of these measures in controlling growth of medical expenses is unknown. Objectives To evaluate the impact of increased financial support for healthcare facilities, adjusted service pricing, and the zero-mark-up policy on curbing the growth of medical expenses in public hospitals in China from 2010 to 2019. Methods We utilized system dynamics theory to model the capital flow of hospitals. We analyzed the growth of medical expenses by considering: 1) the population growth and aging, 2) changes in disease spectrum and modern lifestyle, and 3) induced services provided by doctors. Data collection was facilitated by the Shanghai Municipal Health and Health Commission, providing information on public hospital expenditures, human resources, and health services. Results Population and disease changes are the primary drivers of medical cost growth in Shanghai, contributing to approximately 51% of the overall increase in medical expenses in public hospitals over the past decade. Induced costs have also played a significant role, accounting for around 36% of the rise in medical expenses. While the zero-mark-up policy does not impact total hospital funds or induced expenses, it does alter the distribution of capital flows. The medical service price adjustment policy reduced the proportion of induced costs by 3%, and increased fiscal investment reduced it by 8%. The comprehensive implementation of all three policies led to an 11% decrease in medical expense growth. Conclusion Comparing the three policies, solely implementing the zero-mark-up policy does not directly address induced costs. The fiscal investment policy shows better effectiveness in controlling growth of medical expenses compared to the service price adjustment policy. Keywords: public hospitals, medical expenses, induced cost, national policy
背景 控制医疗费用激增是中国医疗改革的主要焦点。2019 年，总医疗支出的年增长率为 12.4%，超过了 6.0%的国民生产总值增长率。一系列全国性政策已被实施以控制公立医院医疗费用的不合理增长，包括增强医疗机构的财政支持、调整医疗服务定价以及实施药品零加成政策。然而，这些措施在控制医疗费用增长方面的有效性尚不清楚。目的 评估 2010 年至 2019 年中国公立医院医疗费用增长方面的财政支持增加、服务定价调整和零加成政策的影响。方法 我们利用系统动力学理论对医院的资金流进行建模。我们通过考虑以下因素分析医疗费用的增长：1）人口增长和老龄化，2）疾病谱和现代生活方式的变化，3）医生提供的诱导性服务。 数据收集工作由上海市卫生健康委员会协助完成，提供了公立医院支出、人力资源和卫生服务方面的信息。结果人口和疾病变化是上海医疗费用增长的主要驱动因素，导致过去十年公立医院医疗费用总体增长约 51%。诱导费用也发挥了重要作用，约占医疗费用增长约 36%。虽然零加成政策不会影响医院总资金或诱导费用，但它会改变资金流动的分配。医疗服务价格调整政策使诱导费用占比降低了 3%，而增加财政投资使诱导费用占比降低了 8%。三项政策的全面实施导致医疗费用增长下降了 11%。结论比较这三项政策，单独实施零加成政策并不能直接解决诱导费用问题。与医疗服务价格调整政策相比，财政投资政策在控制医疗费用增长方面显示出更好的效果。 关键词：公立医院，医疗费用，诱导成本，国家政策
摘要（中文翻译预览）:
【翻译内容预览】Background Addressing the surge in medical expenses is a primary focus of Chinese healthcare reform....
【翻译内容预览】解决医疗费用激增问题是中国医疗改革的主要焦点……
21. Is Malawi's Health System Positioned to Achieve Universal Health Coverage Goals? An Assessment of Strategic Health Purchasing at Primary Health Care
21. 马拉维卫生系统是否具备实现全民健康覆盖目标的能力？对初级卫生保健战略采购的评估
People: Norah Mwase, Amref Health Africa, Malawi, Timange Banda, Ministry of Health, Malawi, Madalitso Tolani, Amref Health Africa, Malawi, Tisha King, Amref Health Africa, Kenya, Moses Zuze, Ministry of Health, Malawi, Shadrack Gikonyo, Amref Health Africa, Kenya, Boniface Mbuthia, Amref Health Africa, Kenya, Joyce Murerwa, Amref Health Africa, Kenya and Lizah Nyawira, Amref Health Africa, Kenya
Abstract (English):
Strategic Health Purchasing has potential to address health system inefficiencies and advance towards Universal Health Coverage. However, limited evidence exists on the progress made in strategic health purchasing in Malawi and how it can be enhanced. This study aims to assess the progress, gaps and opportunities in strategic health purchasing among major purchasers of health in Malawi to inform strategic purchasing reforms. We utilized the Strategic Health Purchasing Progress Tracking Framework to collect data on key domains of purchasing such as benefit specification, provider contracting, payment and performance monitoring arrangements, governance and financial management through analyses of relevant documents and key informant interviews. The findings revealed progress in: 1) Enabling policy frameworks that prioritize implementation of strategic purchasing reforms 2) Cost-effective benefit package accessible to all Malawians at no cost 3) Provider payment mechanisms include input-based payments, fee-for-service and global budgets 4) Selective contracting with some faith-based providers 5) Multiple performance monitoring arrangements like supportive supervision and information management systems exist. However, limitations persist including passive provider payment mechanisms, limited provider autonomy especially for primary health care facilities and rigid public financial management systems. Addressing these gaps is critical in achieving universal health coverage. Drawing lessons from SLA to strengthen direct facility financing, prioritizing PFM reform to allow recognition of primary health facilities as cost centers and strengthening performance monitoring arrangements to allow integration of health information systems are essential.
战略卫生采购有潜力解决卫生系统低效问题并推动全民健康覆盖。然而，目前关于马拉维战略卫生采购进展及其提升方式的研究证据有限。本研究旨在评估马拉维主要卫生采购方的战略卫生采购进展、差距和机遇，为战略采购改革提供参考。我们利用战略卫生采购进展追踪框架，通过分析相关文件和关键知情人访谈，收集关于采购关键领域的数据，如利益说明、服务提供者合同、支付和绩效监测安排、治理和财务管理等。 研究发现取得了以下进展：1）建立优先实施战略性采购改革的政策框架 2）为所有马拉维公民提供具有成本效益的福利包，且免费 3）提供者支付机制包括基于投入的支付、按服务收费和全球预算 4）与部分宗教机构提供者进行选择性签约 5）存在多种绩效监测安排，如支持性监督和信息管理系统。然而，仍存在局限性，包括被动的提供者支付机制、提供者自主权有限（尤其是初级卫生保健设施）以及僵化的公共财务管理体制。解决这些差距对于实现全民健康覆盖至关重要。借鉴 SLA 的经验以加强直接设施融资，优先进行公共财务管理改革以承认初级卫生保健设施为成本中心，以及加强绩效监测安排以实现卫生信息系统的整合，这些都是至关重要的。
摘要（中文翻译预览）:
【翻译内容预览】Strategic Health Purchasing has potential to address health system inefficiencies and advance toward...
【翻译内容预览】战略性健康采购有潜力解决卫生系统低效问题并朝着...
22. Understanding Health Providers' Decision-making and Behavioural Responses to Case-based Payment Reform in China
22. 理解中国按病种付费改革中医疗服务提供者的决策和行为反应
People: Xiaoying Zhu, "Nossal Institute for Global Health, University of Melbourne", Australia; University of Melbourne, Australia, Daniel Strachan, "Nossal Institute for Global Health, University of Melbourne", Australia, Tiara Marthias, Nossal Institute for Global Health, Australia, Ajay Singh Mahal, university of Melbourne, Australia, Shenglan Tang, "Global Health Research Center, Duke Kunshan University", China and Barbara McPake, Nossal Institute for Global Health, University of Melbounre, Australia
人员：朱小英，"墨尔本大学诺萨尔全球健康研究所"，澳大利亚；墨尔本大学，澳大利亚；丹尼尔·斯特兰奇，"墨尔本大学诺萨尔全球健康研究所"，澳大利亚；蒂亚拉·马蒂亚斯，诺萨尔全球健康研究所，澳大利亚；阿杰·辛格·马哈尔，墨尔本大学，澳大利亚；唐胜兰，"杜克-昆山大学全球健康研究中心"，中国；芭芭拉·麦克佩克，诺萨尔全球健康研究所，墨尔本大学，澳大利亚
Abstract (English):
Abstract Background: To address rapidly increasing healthcare expenditures of social health insurance, the Chinese government has recently introduced provider payment reform, transitioning from a fee-for-service model to a case-based payment system. The case-based payment method transfers the risks associated with healthcare expenditures from the payer to the provider incentivising them for cost control. While existing studies have provided statistical evidence for some changes in healthcare practices following the payment method reforms, evidence for how providers understand the reforms and respond to them in their decision-making processes remains limited. Objective: Our study aims to investigate how hospital-based physicians have responded to case-based payment system reform in China and examine how this influences factors considered in clinical decision-making. Methods: Qualitative in-depth interviews with physicians were conducted in Nanjing, China in 2024. 22 physicians working in hospital inpatient departments were purposively sampled for interview while ensuring representation across different medical specialties and career stages. Thematic analysis was conducted on the verbatim transcriptions of digital recordings of face-to-face, semi-structured interviews with the informed consent of participants. Results: We find that physicians simultaneously serve as agents for health insurance, hospitals and patients, with their service delivery decisions shaped by awareness of the principals that underpin these priorities. Under the case-based payment methods, participants identified priorities of the health insurance authority as cost control, efficiency, and standardised clinical practice, the hospital’s priorities as revenue generation and institutional reputation, and patients’ priorities as care accessibility, financial burden reduction, and outcome optimisation. We identified five tensions across these agency relationships: clinical quality versus cost containment; professional autonomy versus regulatory constraints; policy compliance versus patient preferences; immediate benefits versus future sustainability; and information asymmetry across physicians, health insurers and patients and relatedly, physician’s perceived pressure to bridge gaps in policy awareness. These tensions have brought out stress reported by physicians attributed to concerns for vulnerable patients, potential for strained patient relationships, and perceptions of needing to expand their role and skillsets from physician to accountant. In their clinical decision making, physicians balance the priorities of all three agency roles while considering the cost-benefits trade off when managing the above tensions. They choose the levels of health service based on assessments of patient benefits relative to hospital profit. Insufficient services might be provided if their perceived patient benefits are relatively lower. Notably, when hospitals implement direct insurance payment-related income incentives, physicians show strong awareness of hospital profit considerations, leading to unintended behaviours such as treatment delays for secondary health issues, selective patient admission, unbundled medical procedures and strategic coding practices. However, mediating factors such as physician’s own interests, ethical considerations, risk aversion, professional values, and the design of monitoring schemes, influence how these impacts play out. Conclusions: Our study contributes to understanding of how hospital-based physicians in China respond to case-based payment reform and to broader theoretical application of agency theory. While standard agency theory often simplifies physician's motivation, our findings reveal physicians are bound by professional ethics and multiple agency relationships, suggesting policymakers should look beyond simple economic incentives.
摘要 背景：为应对社会医疗保险快速增长的医疗费用支出，中国政府近期推出了医疗服务支付改革，从按服务项目付费模式转变为按病例付费制度。按病例付费方式将医疗费用相关的风险从支付方转移至服务提供方，激励其进行成本控制。尽管现有研究已为支付方式改革后医疗实践的一些变化提供了统计证据，但关于医疗服务提供方如何理解改革并在其决策过程中做出响应的证据仍然有限。目的：本研究旨在调查中国医院医师如何响应按病例付费制度改革，并探讨这种响应如何影响临床决策中考虑的因素。方法：2024年在中国南京对医师进行了定性深度访谈。从医院住院部工作的22名医师中进行了目的性抽样，以确保不同医学专业和职业阶段医师的代表性。 对面对面、半结构化访谈的数字录音逐字转录进行了主题分析，访谈对象在知情同意下参与。结果：我们发现，医生同时作为健康保险、医院和患者的代理人，其服务决策受到支撑这些优先事项的委托人意识的影响。在按病例付费的方式下，参与者将健康保险机构的优先事项识别为成本控制、效率和标准化临床实践，医院的优先事项为收入生成和机构声誉，而患者的优先事项为护理可及性、减轻经济负担和结果优化。我们在这些代理关系中识别出五种张力：临床质量与成本控制之间的张力；专业自主与监管约束之间的张力；政策合规与患者偏好之间的张力；即时利益与未来可持续性之间的张力；以及医生、健康保险机构和患者之间信息不对称，以及与此相关地，医生感知到的政策认知差距的压力。 这些紧张关系凸显了医生所报告的压力，包括对脆弱患者的担忧、潜在的患者关系紧张，以及从医生扩展到会计师的角色和技能需求。在临床决策中，医生在管理上述紧张关系时，平衡三种代理角色的优先事项，同时考虑成本效益权衡。他们根据患者利益相对于医院利润的评估来选择健康服务的水平。如果他们感知的患者利益相对较低，可能会提供不足的服务。值得注意的是，当医院实施与直接保险支付相关的收入激励时，医生表现出对医院利润考虑的强烈意识，导致出现非预期的行为，如治疗次要健康问题的延迟、选择性患者入院、医疗程序拆分和策略性编码实践。然而，医生自身的利益、伦理考量、风险规避、职业价值观以及监控方案的设计等中介因素，影响了这些影响的具体表现。 结论：我们的研究有助于理解中国医院医师如何应对按病例付费改革，并拓展了代理理论在更广泛理论应用中的理解。虽然标准的代理理论常常简化医师的动机，但我们的研究发现医师受到职业道德和多重代理关系的约束，这表明政策制定者应超越简单的经济激励。
摘要（中文翻译预览）:
【翻译内容预览】Abstract Background: To address rapidly increasing healthcare expenditures of social health insuranc...
【翻译内容预览】摘要 背景：为应对社会医疗保险医疗费用快速增长的问题...
23. Primary Care as Substitute or Complement: Evaluating its Impact on Hospital Hierarchies in China
23. 基层医疗作为替代或补充：评估其对中国医院层级结构的影响
People: Jia Tang, Renmin University of China, China, Rize Jing, Renmin University of China, Beijing, China, Song Yueping, Renmin University of China, China and Chenxu Ni, University of Chinese Academy of Social Sciences, China
Abstract (English):
摘要（英文）：
This study investigates the substitution and complementary effects between outpatient and inpatient services across China’s tiered healthcare system. Leveraging an extensive dataset comprising over 1.5 million patients covering 2013–2019, we provide a nuanced understanding of how primary care utilization impacts higher-tier healthcare services. Employing fixed-effects regression models to account for regional and temporal variations, our analysis offers novel insights into the dynamics of healthcare service utilization. Our findings reveal significant substitution effects, demonstrating that increased primary care utilization reduces reliance on secondary and tertiary hospital services. Specifically, each additional primary care visit decreases the likelihood of secondary hospital visits by 12.7% and tertiary visits by 13.4%, illustrating the pivotal role of primary care in alleviating pressure on higher-level healthcare facilities. This substitution effect is more pronounced for outpatient services, indicating that enhanced primary care effectively absorbs demand traditionally managed at higher-tier hospitals. Such findings highlight the strategic importance of strengthening primary care to optimize resource allocation and reduce healthcare costs, aligning with global trends in health system reforms. Additionally, we identify a complementary relationship between outpatient and inpatient services within the same care level, driven by induced hospitalization. Our data show that each outpatient visit at secondary hospitals increases the likelihood of inpatient admissions at the same facility by 8.9%, reflecting financial incentives in China’s healthcare system that encourage unnecessary hospitalizations. This dynamic underscores systemic inefficiencies and calls for policy interventions to mitigate induced demand. Addressing these challenges is crucial for ensuring that primary care functions as a gatekeeper, preventing unnecessary hospital admissions while maintaining quality care. The study also highlights the homogeneity of outpatient services across different hospital levels, which facilitates substitution between these services. Patients increasingly perceive primary and secondary outpatient services as viable alternatives to tertiary care, supporting the efficacy of tiered healthcare reforms. However, disparities in service quality and capacity remain barriers to fully realizing the potential of primary care as a substitute, particularly in rural and under-resourced areas. Policymakers must prioritize investments in primary care infrastructure and workforce development to address these gaps. This research contributes significantly to the literature by offering the first large-scale empirical analysis of healthcare service substitution and complementarity in a developing country context. It provides actionable insights for policymakers seeking to enhance healthcare efficiency through targeted reforms. Our findings advocate for the recalibration of financial incentives to discourage induced hospitalization and promote equitable access to primary care, ensuring that patients receive the appropriate level of care. As China continues to implement its hierarchical medical system, this study serves as a critical resource for designing policies that optimize healthcare delivery and improve patient outcomes. **Key words:** Substitution effects; Complementarity; Tiered healthcare system; Induced hospitalization; Outpatient care; Inpatient care; Healthcare policy; China’s healthcare
本研究探讨了中国分级医疗体系中门诊和住院服务的替代与互补效应。利用包含2013-2019年超过150万患者的大型数据集，我们深入理解了基层医疗利用如何影响高等级医疗服务。通过固定效应回归模型分析区域和时间差异，我们的研究为医疗服务利用动态提供了新见解。研究发现存在显著的替代效应，表明基层医疗利用增加会减少对二级和三级医院服务的依赖。具体而言，每次基层医疗就诊使二级医院就诊可能性降低12.7%，三级医院就诊可能性降低13.4%，凸显了基层医疗在缓解高级别医疗机构压力中的关键作用。这种替代效应在门诊服务中更为明显，表明加强基层医疗能有效吸收传统上由高等级医院管理的需求。 这些发现突出了加强基层医疗的战略重要性，以优化资源配置和降低医疗成本，这与全球卫生系统改革的趋势相一致。此外，我们识别出同一护理水平下门诊和住院服务之间的互补关系，这种关系是由诱导住院驱动的。我们的数据显示，二级医院每增加一次门诊就诊，就会使该机构住院的可能性增加8.9%，这反映了中国医疗体系中存在的经济激励措施，这些措施鼓励不必要的住院。这种动态凸显了系统性低效，并呼吁政策干预以缓解诱导需求。解决这些挑战对于确保基层医疗能够发挥守门人的作用至关重要，既能防止不必要的住院，又能保持护理质量。该研究还强调了不同医院级别门诊服务的同质性，这促进了这些服务之间的替代。 患者越来越将初级和二级门诊服务视为替代三级医疗的可行选择，这支持了分级医疗改革的有效性。然而，服务质量和能力方面的差距仍然是充分发挥初级医疗作为替代品潜力的障碍，特别是在农村和资源匮乏地区。政策制定者必须优先投资于初级医疗基础设施和人才队伍建设，以解决这些差距。这项研究通过提供首个针对发展中国家背景下医疗服务替代和互补性的大规模实证分析，为寻求通过有针对性的改革提高医疗效率的政策制定者提供了有价值的见解。我们的研究倡导重新调整经济激励措施，以减少诱导住院并促进初级医疗的公平获取，确保患者获得适当级别的医疗护理。随着中国继续实施其分级医疗体系，这项研究为设计优化医疗服务和改善患者结局的政策提供了关键资源。 **关键词：** 替代效应；互补性；分级医疗体系；诱导住院；门诊医疗；住院医疗；医疗政策；中国医疗
摘要（中文翻译预览）:
【翻译内容预览】This study investigates the substitution and complementary effects between outpatient and inpatient ...
【翻译内容预览】本研究探讨了门诊医疗与住院医疗之间的替代效应和互补效应...
24. Reduced Mortality and Admissions Through Integrated Care: Evidence from Taiwan's Family Doctor Program
24. 通过整合医疗降低死亡率和入院率：来自台湾家庭医生项目的证据
People: Li-Lin Liang, "Institute of Public Health, National Yang Ming Chiao Tung University", Taiwan and Ms. Jui-fen Rachel Lu, Chang Gung University, Taiwan
人员：梁丽琳，“国立阳明交通大学公共卫生学院”，台湾和吕瑞芬女士，长庚大学，台湾
Abstract (English):
Background: Integrated care (IC) addresses fragmented health systems through a primary healthcare approach, targeting the triple aims of improving health outcomes, reducing costs, and enhancing patient experience. While its effectiveness is well-documented for single-disease management, its impact on multimorbid patients remains unclear. Over 70% of IC research focuses on North American and European models, where patient registration with family physicians is mandatory or incentivized. However, there is limited evidence on the design and implementation of IC in health systems where primary care delivery is weakly integrated into broader healthcare systems. This study addresses this gap by evaluating Taiwan's Family Doctor Program (FDP), a nationwide IC initiative introduced by the National Health Insurance (NHI) Administration to enhance care for high-cost, multimorbid chronic patients. Research question: What are the effects of the FDP on avoidable hospital admissions and all-cause mortality? Methods: We conducted survival analysis using nationwide data from the Taiwan NHI Research Database. Eligible patients were identified from the annual roster and assigned to FDP or non-FDP groups using a one-to-one matching method. Matching criteria included demographics, health status, healthcare utilization patterns, and attributes of the clinic most frequently visited. The study period spanned from 2013 to 2020, divided into baseline (2013–2016) and follow-up (2017–2020) phases. Analyses focused on hospital admissions and all-cause mortality, with final matched samples of 484,644 individuals for admissions and 826,996 for mortality. We employed multivariable modified Cox proportional hazards models and stratified analyses to assess FDP effectiveness. Results: FDP participants exhibited a 1.88% lower 4-year cumulative mortality incidence compared to non-participants (7.94% vs. 9.82%; P<0.001). After multivariable adjustments, FDP participants had a 3% lower risk of hospital admissions (adjusted hazard ratio [AHR]: 0.97; 95% CI: 0.95–0.98; P<0.001) and a 13% lower risk of death (AHR: 0.87; 95% CI: 0.86–0.89; P<0.001) than non-participants. The reduction in admission risk was most notable among patients under 65 and those with hyperlipidemia or diabetes (AHR: 0.95–0.96, P<0.05). All-cause mortality risk was significantly lower across all subgroups (AHR: 0.84–0.89, all P<0.005). Conclusion: The FDP’s multifaceted IC approach—comprising case management, clinic-hospital care pathways, and team-based care—may explain its association with improved outcomes. Performance payments in the FDP are directed to primary care teams, who may share these payments with hospitals, thereby incentivizing hospital engagement in IC initiatives. This mechanism highlights the critical role of primary care coordination in achieving improved outcomes while fostering hospital collaboration. Taiwan’s experience provides valuable insights for countries seeking to establish IC models in systems with less integrated primary care delivery.
摘要（中文翻译预览）:
【翻译内容预览】Background: Integrated care (IC) addresses fragmented health systems through a primary healthcare ap...
【翻译内容预览】背景：整合护理（IC）通过初级保健途径解决碎片化的卫生系统...
25. Assessing Health Care System Performance for Each US County Using the Triple Aim Framework
25. 使用 Triple Aim 框架评估美国各县医疗保健系统绩效
People: Azalea Thomson, "Institute for Health Metrics and Evaluation, University of Washington", United States, Haley Kathryn Lescinsky, Institute for Health Metrics and Evaluation, United States, Joseph Dieleman, "Institute for Health Metrics and Evaluation, University of Washington", Seattle, Maitreyi Sahu, University of Washington, SEATTLE, United States, Kayla Taylor, "Institute for Health Metrics and Evaluation, University of Washington", United States, Max Weil, Institute for Health Metrics and Evaluation, United States, Meera Beauchamp, Institute for Health Metrics and Evaluation, United States, Drew DeJarnatt, Institute for Health Metrics and Evaluation, United States and Sawyer Crosby, Institute for Health Metrics and Evaluation, United States
人员：Azalea Thomson, "华盛顿大学健康指标与评估研究所", 美国, Haley Kathryn Lescinsky, 健康指标与评估研究所, 美国, Joseph Dieleman, "华盛顿大学健康指标与评估研究所", 西雅图, Maitreyi Sahu, 华盛顿大学, 西雅图, 美国, Kayla Taylor, "华盛顿大学健康指标与评估研究所", 美国, Max Weil, 健康指标与评估研究所, 美国, Meera Beauchamp, 健康指标与评估研究所, 美国, Drew DeJarnatt, 健康指标与评估研究所, 美国, Sawyer Crosby, 健康指标与评估研究所, 美国
Abstract (English):
摘要（英文）：
The Triple Aim of healthcare systems is to provide patients with a good experience, achieve positive health outcomes, and spend relatively few resources. By many accounts, the United States health care system is failing the Triple Aim litmus test with high mortality, low healthcare access, and the highest rates of health spending per person in the world. However, there is much variation within the US. In this study, we (i) examine if any US counties are doing well by the triple aim standards, (ii) describe the populations living in exemplar counties, and (iii) identify health system characteristics and policies associated with positive county performance. We extracted county-specific estimates of life expectancy from the Global Health Data Exchange and direct health care spending per capita, adjusted for local prices and age structure, from our previous work (under review currently). We used previous literature to identify five subdomains of patient experience: accessibility, prevention, safety, appropriateness, and patient-centeredness. We extracted county-level measures for each of the subdomains from the CMS Hospital Patient Survey (HCAHPS), the Area Health Resource File, and Mapping Medicare disparities tool and made a composite measure of patient experience using principal components analysis. Then, we assessed each county on all three aims jointly to create an exemplar score for each county from 2014 to 2019. Exemplar counties were defined as counties who were in the top quartile for each of the three triple aim indicators, in each year. We assessed if exemplar counties had statistically different population characteristics than non-exemplar counties. Finally, we measured the association between exemplar scores and relevant policy variables at the state and county level with bivariate regressions controlling for key observed exemplar characteristics. We found that in 2019, 2% of US counties were in the top quantile of all 3 aims. The people who lived in these exemplar counties were more educated, wealthier, more urban, less black, and less obese than those who lived in non-exemplar counties. After adjusting for education, income, race, ruralness, and obesity, we found that places with higher rates of managed care for Medicaid and Medicare and places with lower market concentration of hospitals and insurers were more successful at making progress towards the triple aim. Additionally, we found that these results were robust to alternative definitions of patient experience, using all-cause mortality instead of life-expectancy, and not adjusting health expenditure for state purchasing power. The triple aim criterion is an ambitious target that few counties in the United States have achieved. Those that have are places with high relative privilege, suggesting that our health care system is performing strongest in the counties with the greatest means. We show that expanding managed care insurance plans and increasing market competition for hospitals and insurers could improve county health system’s progress towards the triple aim.
摘要（中文翻译预览）:
【翻译内容预览】医疗系统的三重目标是为患者提供良好的体验，实现积极的...
26. 无法合并数据的双重差分法（UNDID）
People: Erin Strumpf, McGill University, Canada, Sunny Karim, Carleton University, Canada, Matt Webb, Carleton University, Canada and Nichole Austin, Dalhousie University, Canada
人员：Erin Strumpf，麦吉尔大学，加拿大，Sunny Karim，卡尔顿大学，加拿大，Matt Webb，卡尔顿大学，加拿大和 Nichole Austin，达尔豪斯大学，加拿大
Abstract (English):
摘要（英文）：
双重差分法（DID）常用于估计处理效应，但在因隐私问题或数据共享的法律限制而无法合并数据的情况下不可行，尤其是在跨司法管辖区（如国家或州）的情况下。当处理或政策在国家级别变化时，处理组和控制组的数据可能无法合并。例如，不同保险商（如加拿大各省、私营和公共保险商、跨州的全部付款索赔数据库）的健康护理数据，在安全环境中持有的受限使用微观数据（如加拿大统计局或美国人口普查局研究数据中心的出生统计、所得税、商业数据），以及跨国家联盟的电子健康记录（如欧洲健康数据空间）。在本研究中，我们识别并放宽了 DID 估计中数据可合并性的假设。我们提出了一种创新方法，用于使用不可合并数据估计双重差分法（UN-DID），该方法可以容纳协变量、多个组和分阶段采用。 通过分析证明和蒙特卡洛模拟，我们表明在没有协变量的情况下，UN-DID 和传统 DID 对平均处理效应和标准误的估计是相等且无偏的。在有协变量的情况下，两种方法产生的估计都是无偏的、等价的，并收敛到真实值。估计值略有差异，但统计推断和实质性结论保持一致。两个基于真实世界数据的实证案例进一步突显了 UN-DID 的实用性。UN-DID 方法允许使用不可合并数据估计跨司法管辖区的处理效应，从而能够使用更好的反事实，并回答新的研究问题。
摘要（中文翻译预览）:
【翻译内容预览】双重差分法（DID）常用于估计处理效应，但在...的情况下不可行...
27. 检验支付机制对坦桑尼亚医疗质量和公平性的影响
People: Peter Binyaruka, Ifakara Health Institute (IHI), Tanzania, Timothy Powell-Jackson, "London School of Hygiene and Tropical Medicine, LSHTM", United Kingdom, John Joseph Maiba, Ifakara Health Institute, Tanzania, Josephine Borghi, "Department of Global Health and Development, London School of Hygiene and Tropical Medicine", United Kingdom, Francis Ngadaya, Ifakara Health Institute, Dar es salaam, Tanzania and Gemini Mtei, Result for Development, Tanzania
Abstract (English):
背景：战略医疗采购，包括设计良好的提供者支付机制（PPMs），对于实现全民健康覆盖（UHC）至关重要。每种 PPMs 都会创造不同的激励措施，影响提供者行为，并以预期或非预期的方式影响医疗服务提供。随着坦桑尼亚准备实施强制性全民健康保险（UHI），有效的 PPMs 设计对于支持战略采购目标至关重要。然而，关于不同 PPMs（如按服务收费或按人头付费）如何影响低收入环境中提供者行为、服务质量和护理公平性的证据很少。本研究旨在评估坦桑尼亚当前 PPMs 的影响，以指导 UHI 设计，实现高质量和公平的医疗服务。方法：本研究采用混合方法设计，收集定量和定性数据。定量数据通过在两个地区的 28 个初级医疗保健设施进行的客户退出调查收集，每个设施至少有 10 名门诊和产前护理部门的参保和未参保客户（n=280）。 我们测量了受支付方式和提供者行为（如等待和咨询时间、人际护理、产前护理内容、药物处方模式、剖腹产率、转诊实践、健康促进建议和自付费用）影响的护理质量指标。使用客户的社经地位来衡量护理质量分配的公平性。对有保险和无保险的客户进行了焦点小组讨论和深度访谈，以探索医患互动、满意度和整体护理体验。定量数据采用描述性分析，使用公平性指标（差距、比例和集中指数）来评估公平性，倾向得分匹配和回归分析来量化按项目付费和按人头付费方式对护理质量的影响，通过将护理结果对保险状况进行回归分析，同时采用主题内容分析来分析定性数据。结果：我们预期会观察到不同保险计划（不同支付方式）的客户和无保险客户在护理质量上的差异，特别是在等待时间、服务范围和自付费用等关键质量指标上存在变化。 公平性分析将揭示社会经济地位如何影响质量分配，而回归分析将量化按服务收费、按人头付费和自付费用对护理质量的影响。定性研究将提供更多关于患者-提供者互动和满意度的见解，突出 PPM 如何塑造整体护理体验。结论：研究结果将揭示 PPM 对坦桑尼亚医疗质量和公平性的影响，为 UHI 相关的 PPM 改革提供循证政策决策支持。这将有助于优化 PPM 设计，促进公平和高品质的护理，推动坦桑尼亚更公平、更高效的医疗体系发展。
摘要（中文翻译预览）:
【翻译内容预览】背景：战略性医疗采购，包括设计良好的提供者支付机制（PP...
28. 一种用于估计具有多重处理和相关性、交错时序的差异-差异模型的合并回归方法
人员：Partha Deb，纽约市亨特学院，美国
摘要（英文）：
双重差分法（DID）研究设计是经济学中因果推断的重要工具。近年来，关于如何在基于回归的双重差分法研究设计中获得 DID 估计的新理论论文数量异常之多。特别是，当存在错配的治疗时间和异质治疗效果时，具有恒定治疗效果的模型的二维固定效应估计器会产生有偏的治疗效果估计，这导致了处理错配时间和异质治疗效果的新方法（例如 Borusyak 等人，2024 年；Callaway 和 Sant'Anna，2021 年；Deb 等人，2024 年；以及 Sun 和 Abraham，2021 年）。然而，在许多应用中，研究者感兴趣的是在样本期内发生且时间相关但非同时发生的多个相关事件。在其他应用中，尽管研究者可能只关注一个事件，但他们担心存在时间相关的混杂事件。 在这种情况下，Chaisemartin 和 d'Haultfoeuille（2023）以及 Tsai（2024）表明，在存在混杂事件的情况下，具有多个事件指标的 TWFE 回归和为单个处理设计的交错 DID 估计量都是有偏的。他们各自开发了一种新方法，但两种方法都难以实施。在本文中，我扩展了 Deb 等人（2024）的框架到具有相关时间顺序的多个事件的情况。识别每种处理对组-时间层面的效应需要每个事件都存在尚未处理的单位。回归设定结果表明，这是 Deb 等人（2024）设定的一个直接扩展。可以对每个事件单独恢复平均处理效应，原则上也可以对所有事件组合恢复，尽管在只有少数几种事件类型的情况下，这些组合在有限样本中可能难以识别。我将此方法应用于检验惩罚性优先产前物质使用政策（PSUP）对孕妇心理健康结果的影响。我使用了 2005-2018 年行为风险因素监测系统的数据。 来自 34 个州的育龄女性代表性样本中至少有一个孩子的样本有 440,446 个观察值。各州政策启动时间存在显著差异。在 2007 年至 2018 年间，有 13 个州实施了惩罚性 PSUP。在 2008 年至 2016 年间，有 9 个州实施了优先 PSUP。有 4 个州实施了这两种类型的政策，但并非同时实施。最后，有 18 个州没有实施 PSUP。结果表明，仅允许考虑 2 项政策的 TWFE 估计器会对每项政策的效果以及同时实施两项政策的效果产生有偏估计。逐个处理的治疗效应动态差分估计器也会产生有偏估计（并且无法对两项政策同时实施的情况进行估计）。基于回归的估计器能对各种 ATET 产生直观的估计。
摘要（中文翻译预览）:
【翻译内容预览】双重差分（DID）研究设计是经济学因果推断的重要工具...
29. 一种结合工具变量和机器学习回归模型的新型观测数据评估方法
People: Mr. Stephen O'Neill, London School of Hygiene and Tropical Medicine, United Kingdom and Richard Grieve, LSHTM, United Kingdom
人员：Stephen O'Neill 先生，英国伦敦卫生与热带医学院，以及 Richard Grieve，LSHTM，英国
Abstract (English):
精确的亚组特异性估计对于指导针对性或个性化治疗决策至关重要，但当前生成政策相关证据的方法存在不足。随机对照试验（RCTs）通常对亚组研究力度不足，而观察性研究容易受到指示混杂（选择偏倚）的影响。如果存在有效的工具变量（IV），可以减少偏倚，但所得估计值往往高度不确定，尤其是在 IV 效应不强的情况下。此外，IV 估计值可能对模型设定的选择敏感，尤其是在关注估计异质性效应时。这些方法论挑战在评估手术或放射治疗（SORT 研究）对非小细胞肺癌（NSCLC）的相对有效性时得到体现，该研究使用了英国癌症登记数据。主要终点是 2 年全因死亡率。研究考虑了包括年龄、性别、癌症分期、虚弱程度和功能评分在内的亚组。由于样本量限制，工具变量（历史提供者偏好）对某些亚组预期相对较弱，从而加剧了关于精确性的担忧。 为应对这些挑战，我们基于先前结合 IV 和回归方法的成果，通过引入不易受模型设定偏差影响的机器学习方法进行扩展。具体而言，我们采用 Hansen-Stein 估计量（Hansen, 2017），该估计量通过平均 OLS 和 2SLS 估计来平衡偏差和效率，并将其应用于基于森林的方法。我们开发了一种新型估计量（Forest-Stein），该估计量结合了因果森林（CF）和 IV 森林（IVF），以增强模型在弱工具变量和小样本情况下的稳健性，同时允许更灵活的模型设定。我们通过蒙特卡洛模拟研究，评估了所提出的 Forest-Stein 估计量相对于 OLS、2SLS、Hansen-Stein、CF 和 IVF 估计量的相对性能。我们定义了一个简单的 DGP，包含八个观测协变量，其中一些影响处理、结果或两者，一个未观测混杂变量和一个二元工具变量（Z）。我们定义了一个子群指示变量 G，该变量影响处理和结果。真实效应被定义为在不同子群中存在差异。 我们估计了总体效应以及两个子组（G=0 和 G=1）的效应，样本量分别为{500, 1000, 5000}，工具变量强度从完全无关到非常强不等。我们报告了训练、测试和保留样本中的绝对偏差和 RMSE。结果表明，与使用 OLS 和 2SLS 的 Hansen-Stein 方法的研究结果一致，我们的 Forest-Stein 估计随着工具变量强度的减弱趋向于因果森林估计，而随着工具变量强度的增强趋向于工具森林估计，从而在小样本中防止了弱工具变量带来的不精确性。正在进行的工作将扩展模拟研究，以考虑非线性结果模型设定，我们预计 Forest-Stein 将优于 Hansen-Stein，并考虑不同形式的效果异质性和不同水平的未观察混杂和工具变量强度。最后，我们在 SORT 案例研究中说明了该方法的表现，以应对估计所有政策相关子组的异质效应的挑战，包括那些可能存在工具变量强度不足问题的子组。
摘要（中文翻译预览）:
【翻译内容预览】精确的亚组特异性估计对于指导针对性或个性化治疗至关重要...
30. 澳大利亚维多利亚州西部优先初级保健中心项目的评估
人员：Feby Savira，澳大利亚迪肯大学，Sean Randall，澳大利亚迪肯大学沃朗贡分校，Madison Frith，澳大利亚迪肯大学，Naomi White，澳大利亚西部维多利亚初级卫生网络，Andrew Giddy，澳大利亚西部维多利亚初级卫生网络，Anna Peeters，澳大利亚迪肯大学，Kirsty McLean，格兰皮恩斯医疗，Jamie Swann，澳大利亚西部维多利亚初级卫生网络，Suzanne Robinson，澳大利亚迪肯大学
摘要（英文）：
Introduction: The Victorian State Government of Australia has established Priority Primary Care Centers (PPCCs) to reduce the demand for Emergency Departments (EDs). PPCCs are general practitioner led, free of charge services that aim to provide care for conditions that require urgent attention, but do not require the high-acuity care of an ED. This study aims to evaluate the implementation and impact of the PPCC on ED demand in three sites within the Western region of Victoria, Australia. Methods: This is an observational mixed methods study. A scoping review was conducted to synthesise international literature on the effectiveness of PPCC-like services (i.e., urgent care centres). The quantitative component involved analysis of de-identified administrative data, comprising PPCC clinical records and ED presentation records, as well as patient survey. Qualitative data collection involved semi-structured interviews to understand the experiences of PPCC patients, clinical staff, managerial and administrative staff and ED clinical staff. Implementation science frameworks have been integrated within the study design. Results: Scoping review findings suggest while often context-specific, urgent care centres, particularly walk-in clinics and after-hour clinics, are associated with reduced ED visits and high patient satisfaction. Analysis of PPCC clinical records from 28 October 2022 until 8 June 2024 indicated 48,772 unique attendances. Most PPCC attendees in the region were either younger patients (31%) or older adults (20%), predominantly residing in regional centres (51%) and belonging to middle socioeconomic groups (33% in Quintile 3 and 26% in Quintile 4). Majority of attendances were appropriate low acuity presentations and resolved in-clinic (82%). There was no change in ED presentations across all sites, however, there was improvement in proportion of patients receiving treatment within one hour at the ED. Survey data showed that 1,161 of 2,351 respondents (49%) would have attended the ED if the PPCC were unavailable. Qualitative data suggests PPCC offers accessible, affordable, and convenient care. Facilitators to successful implementation of PPCC included experienced workforce, effective planning and resource management, and effective collaboration and leadership, while barriers included poor community awareness and interoperability issues. Conclusion: The PPCC has reached a broad range of patients with various demographic and socioeconomic backgrounds across the region.* There was limited evidence on its impact in reducing ED presentations, however this should be viewed in context of ever-increasing healthcare demand. Most attendances were resolved in the clinic, suggesting the PPCC is filling a gap of unmet need for urgent but low-acuity care.*
摘要（中文翻译预览）:
【翻译内容预览】引言：澳大利亚维多利亚州政府已建立优先初级保健中心...
31. 使用空气温度作为工具变量，重新审视应急医疗中响应时间对健康结果因果影响
人员：托马斯·佩洛昆，巴黎经济学院 - 法国公共卫生学院，法国和保琳·肖万，巴黎西岱大学，法国
摘要（英文）：
本文研究了紧急护理中的反应时间（RT），重点关注大血管闭塞（LVO），这是急性缺血性卒中（AIS）最严重的形式，而 AIS 是导致残疾和死亡的主要原因，预计到 2035 年，欧盟的卒中病例将增加 34%。针对 LVO 的最佳治疗方法（机械取栓术）稀有且地域受限，这凸显了在集中化效率与急性病症及时救治之间取得平衡的挑战。然而，由于严重程度偏差的内生性和截断数据（如患者和应急服务的响应速度，以及医院的可及性）等因素，将 RT 与结果联系起来十分困难。医疗服务的生产不仅依赖于时间，而且在不同个体之间存在巨大差异；这种异质性源于未观察到的或内生的变量，特别是病情的严重程度、健康衰退的速度或患者的健康素养。 本文利用原始的大规模个体数据，其中包含从症状出现开始计时的 15,467 例急性缺血性卒中（AIS）的精确时间测量，以及转化为效用指数的精确患者健康结果数据，以探讨这一复杂关系在完整响应时间段内的表现。通过选择一种原始工具——气温——进行非参数估计，我们识别了响应时间增加的平均处理效应（ATE）以及接受治疗的平均处理效应（ATT）。此外，还考察了患者减少响应时间回报的异质性。将使用工具变量法识别的关系估计值与临床文献中的现有结果进行比较，突出了稳健识别策略在纠正效应低估方面的价值。我们的方法表明，延迟与结果之间存在近似线性关系，挑战了在 AIS 管理中传统上认为的效应有界观点。 我们的 ATT 结果支持现有的临床建议，但与政策相关的治疗效果需要对患者受益的分布和健康损失评估进行更精确的说明。
摘要（中文翻译预览）:
【翻译内容预览】本文研究紧急护理中的反应时间（RT），重点关注大血管阻塞（LVO），...
32. 重组波哥大卫生系统对高血压患者健康结果和成本的影响
人员：达尼拉·Sᮣhez-Santiesteban，哥伦比亚国立大学，哥伦比亚，吉安卡洛·布特拉戈，哥伦比亚国立大学，哥伦比亚，黛安娜·皮诺，哥伦比亚国立大学，哥伦比亚，托马斯·霍恩，“伦敦帝国学院公共卫生政策评估单位”，英国和克里斯托弗·米利特，“伦敦帝国学院公共卫生政策评估单位”，英国
摘要（英文）：
Background: In 2015, Bogotá’s health system faced challenges from delays in paying providers, high administrative costs, financial instability, low quality infrastructure, service delivery inefficiencies, and poor care coordination. To address these challenges, the government in Bogotá implemented a public health sector reorganisation to improve comprehensive care, enhance health outcomes, and decrease fragmentation between actors. This study evaluates the impact of the Bogotá health reorganisation on health outcomes and costs in patients with hypertension. Methods: Administrative data and health records were linked using a unique identifier by the Ministry of Health in Colombia and cross-referenced to generate a cohort of individuals with data points for over 10 years. We employed a difference-in-differences analysis to evaluate the impact of the reorganisation in Bogotá between 2014 and 2018, using 2017 as the intervention year. Patients with hypertension in Bogotá in the subsidised scheme (exposed group) were compared to those in the contributory scheme (control group). We constructed a closed cohort to evaluate clinical outcomes and healthcare costs using fixed effects and a dynamic cohort to assess mortality in the population. Each outcome was measured yearly and at an individual level. Clinical outcomes evaluated included organ damage from hypertension, dialysis requirement, and myocardial revascularisation (myocardial infarction). We also included the number of outpatient and hospitalisation services and mortality. Economic outcomes evaluated total healthcare costs in million COP. Results: The reorganisation was associated with increased outpatient care services. Conversely, there were associated reductions in adverse outcomes, such as hospitalisations, myocardial revascularisation, dialysis, and mortality. Additionally, total healthcare costs in millions of COP, also reduced. There was a finding that the effects grew larger over time. Conclusions: The Bogotá health reorganisation positively impacted clinical and economic outcomes in patients with hypertension. These findings suggest that reforms focused on decreasing healthcare fragmentation can yield benefits for chronic conditions such as hypertension in resource-constrained settings.
摘要（中文翻译预览）:
【翻译内容预览】Background: In 2015, Bogotá’s health system faced challenges from delays in paying providers, high a...
【翻译内容预览】背景：2015年，波哥大卫生系统面临支付供应商延迟、高...的挑战。