Association between health insurance cost-sharing and choice of hospital tier for cardiovascular diseases in China: a prospective cohort study
Muriel LevyJohn BuckellRobert ClarkeNina WuPei PeiDianjianyi SunDaniel AveryHua ZhangJun LvCanqing YuLiming LiZhengming ChenWinnie YipYiping ChenBorislava MihaylovaJunshi ChenZhengming ChenRobert ClarkeRory CollinsLiming LiChen WangJun LvRichard PetoRobin G. WaltersDaniel AveryMaxim BarnardDerrick BennettRuth BoxallKahung ChanYiping ChenZhengming ChenJohnathan ClarkeRobert ClarkeHuaidong DuAhmed Edris MohamedHannah FrySimon GilbertPek Kei ImAndri IonaMaria KakkouraChristiana KartsonakiHubert LamKuang LinJames H. LiuMohsen MazidiIona Y. MillwoodSam MorrisQunhua NieAlfred PozarickiPaul RyderSaredo SaidDan SchmidtBecky StevensIain TurnbullRobin G. WaltersBaihan WangLin WangNeil WrightLing YangXiaoming YangPang YaoXiao HanCan HouQingmei XiaChao LiuJun LvPei PeiDianjianyi SunCanqing YuNaying ChenDuo LiuZhenzhu TangNingyu ChenQilian JiangJian LanMingqiang LiYun LiuFanwen MengJinhuai MengRong PanYulu QinPing WangSisi WangLiuping WeiLiyuan ZhouCaixia DongPengfei GeXiaolan RenZhongxiao LiEnke MaoTao WangHui ZhangXi ZhangJinyan ChenXimin HuXiaohuan WangZhendong GuoHuimei LiYilei LiMin WengShukuan WuShichun YanMingyuan ZouXue ZhouZiyan GuoQuan KangYanjie LiBo YuQinai XuLiang ChangLei FanShixian FengDing ZhangGang ZhouYulian GaoTianyou HePan HeChen HuHuarong SunXukui ZhangBiyun ChenZhongxi FuYuelong HuangHuilin LiuQiaohua XuLi YinHuajun LongXin XuHao ZhangLibo ZhangJian SuRan TaoMing WuJie YangJinyi ZhouYonglin ZhouYihe HuYujie HuaJianrong JinFang LiuJingchao LiuYan LuLiangcai MaAiyu TangJun ZhangLiang ChengHuaidong DuRuqin GaoFeifei LiShanpeng LiYongmei LiuFeng NingZengchang PangXiaohui SunXiaocao TianShaojie WangYaoming ZhaiHua ZhangWei HouJun LvJunzheng WangXiaofang ChenXianping WuNingmei ZhangXiaoyu ChangXiaofang ChenJianguo LiJiaqiu LiuGuojin LuoQiang SunXunfu ZhongWeiwei GongRuying HuHao WangMeng WangMin YuLingli ChenQijun GuDongxia PanChunmei WangKaixu XieXiaoyi ZhangHong‐Yuan ChenLiyang LiuHaiyan GouX. WangJing DingNing ZhangYueshi MaoShanshan ZhouLirong JinXin ChengYun LuLi ChenZilong HaoXiaona XingLei WangNaixin JuYiting MaoShuya LiPeng DuDeren WangXiaojia SunShihao YouWeizhi WangYanmei ZhuXiaojiu LiYi Dong
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BackgroundHospitals in China are classified into tiers (1, 2 or 3), with the largest (tier 3) having more equipment and specialist staff. Differential health insurance cost-sharing by hospital tier (lower deductibles and higher reimbursement rates in lower tiers) was introduced to reduce overcrowding in higher tier hospitals, promote use of lower tier hospitals, and limit escalating healthcare costs. However, little is known about the effects of differential cost-sharing in health insurance schemes on choice of hospital tiers.MethodsIn a 9-year follow-up of a prospective study of 0.5 M adults from 10 areas in China, we examined the associations between differential health insurance cost-sharing and choice of hospital tiers for patients with a first hospitalisation for stroke or ischaemic heart disease (IHD) in 2009–2017. Analyses were performed separately in urban areas (stroke: n = 20,302; IHD: n = 19,283) and rural areas (stroke: n = 21,130; IHD: n = 17,890), using conditional logit models and adjusting for individual socioeconomic and health characteristics.FindingsAbout 64–68% of stroke and IHD cases in urban areas and 27–29% in rural areas chose tier 3 hospitals. In urban areas, higher reimbursement rates in each tier and lower tier 3 deductibles were associated with a greater likelihood of choosing their respective hospital tiers. In rural areas, the effects of cost-sharing were modest, suggesting a greater contribution of other factors. Higher socioeconomic status and greater disease severity were associated with a greater likelihood of seeking care in higher tier hospitals in urban and rural areas.InterpretationPatient choice of hospital tiers for treatment of stroke and IHD in China was influenced by differential cost-sharing in urban areas, but not in rural areas. Further strategies are required to incentivise appropriate health seeking behaviour and promote more efficient hospital use.FundingWellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and National Natural Science Foundation of China.Keywords:
Reimbursement
Cost sharing
Overcrowding
Stroke
Abstract Emergency departments (EDs) face several challenges in maintaining consistent quality care in the face of steadily increasing public demand. Improvements in the survival rate of critically ill patients in the ED are directly related to the advancement of early recognition and treatment. Frequent episodes of overcrowding and prolonged waiting times force EDs to operate beyond their capacity and threaten to impact upon patient care. The objectives of this review are as follows: (a) to establish overcrowding as a threat to patient outcomes, person-centered care, and public safety in the ED; (b) to describe scenarios in which point-of-care testing (POCT) has been found to ameliorate factors thought to contribute to overcrowding; and (c) to discuss how POCT can be used directly, and indirectly, to expedite patient care and improve outcomes. Various studies have shown that overcrowding in the ED has profound effects on operational efficiency and patient care. Several reports have quantified overcrowding in the ED and have described a relationship between heightened periods of overcrowding and delays in treatment, increased incidence of adverse events, and an even greater probability of mortality. In certain scenarios, POCT has been found to increase the number of patients discharged in a timely manner, expedite triage of urgent but non-emergency patients, and decrease delays to treatment initiation. This review concludes that POCT, when used effectively, may alleviate the negative impacts of overcrowding on the safety, effectiveness, and person-centeredness of care in the ED.
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Overcrowding in Emergency Departments (ED) is a common phenomenon worldwide, especially in metropolitan areas. The main reason for overcrowding is not inappropriate emergency department use by patients but rather a shortage of available hospital beds which results in extended ED stays for patients who need emergency admission. The aims of this study, conducted at the San Giovanni Battista (Molinette) University hospital in Turin (Italy), were a) to verify the existence of overcrowding in the hospital ED and b) to test whether, as stated in the literature, overcrowding is due to restricted access to hospital beds for patients needing emergency admission, and to identify contributing factors. Results show the existence of overcrowding and confirm the hypothesized cause.
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Emergency department (ED) overcrowding has been an international phenomenon for more than 10 years. It is important to understand that ED overcrowding is a measure of health system efficiency and is not strictly related to ED volumes or capacity. ED overcrowding is defined as a situation in which the demand for emergency services exceeds the ability of physicians and nurses to provide quality care within a reasonable time. The major factor resulting in ED overcrowding is the presence of admitted patients in the ED for prolonged periods of time, not a high volume of low-acuity patients. While limited data are available for paediatric EDs, winter respiratory illnesses set the stage for ED overcrowding, which are epidemic in adult or general EDs. Prehospital-, ED- and hospital-related factors are described in the present article, and these may help prevent or manage this important patient safety problem.
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Abstract Background Emergency department (ED) overcrowding is among the biggest and most important problems experienced by ED staff. The number of ED visits is on the increase and remains an unresolved problem. Emergency department overcrowding has become an important problem for emergency care services worldwide. There is a relationship between overcrowding and patients’ negative experiences of using ED and therefore reporting reduced patients’ satisfaction. This study aimed to identify the causes of ED overcrowding, determine the reasons for people’s use of EDs, and develop solutions for reducing ED overcrowding. Methods This study used quantitative methods using a descriptive approach. The participants were patients who visited the ED. A questionnaire was administered to 296 participants between December 2021 and February 2022. The study included 5 different hospitals in Turkey. The data were analyzed using descriptive statistics. Results This study identified the most common presenting medical problems in the ED and why patients used the ED. Reasons for using the ED included patients perceiving their condition as really urgent (62.8%), the ED being open for 24 hours (36.1%), and receiving faster care in the ED (31.4%). This study also developed recommendations for alleviating ED overcrowding. Conclusion This study identified causes of ED overcrowding and some solutions for alleviating the issue. Emergency department overcrowding should be perceived as an international problem, and initiatives for solutions should be implemented quickly.
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An emergency department (ED) is considered to be "overcrowded" when the number of patients exceeds its treatment capacity and it does not have the conditions to meet the needs of the next patient to be treated. This study evaluates overcrowding in the emergency department of a hospital in Colombia.To compare the objective NEDOCS scale with a subjective evaluation by ED health staff in order to evaluate the differences between the two.The NEDOCS scale was applied and a subjective overcrowding survey was administered to the medical staff and the charge nurse on duty 6 times per day (6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m. and 9:00 p.m.) for three consecutive weeks. The results were evaluated with a correlation analysis and measurement of agreement.A median NEDOCS score of 137 was obtained for the total data. There was a moderately positive correlation between the NEDOCS and the subjective scales, with a rho of 0.58 (p (0.001). During times when the ED was the most crowded, 87% of the total subjective health staff evaluations underestimated the level of overcrowding.Health staff do not perceive a risk due to ED overcrowding when the NEDOCS scores correspond to overcrowding categories equal to or over 5 (severely crowded and dangerously crowded), which poses a risk to patient safety and care.Se considera "Aglomeración" cuando un servicio de urgencias excede el número de pacientes que tiene capacidad de atender o no cuenta con las condiciones para cubrir las necesidades del próximo paciente a ser atendido. Este estudio evalúa el sobrecupo del servicio de urgencias en un hospital de Colombia.Comparar la escala objetiva de NEDOCS con la escala subjetiva del personal de salud en el departamento de urgencias para evaluar la diferencia entre ambas.Se aplicó la escala NEDOCS y una escala subjetiva de sobrecupo en el servicio de urgencias al personal médico y enfermera jefe de turno durante 3 semanas seguidas, 6 veces al día (6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.). Se realizaron análisis de correlación y medida de concordancia para evaluar los diferentes resultados.La mediana de NEDOCS para el total de datos fue de 137, se presentó una correlación moderadamente positiva entre la escala NEDOCS objetiva con respecto a la subjetiva Rho 0.58 (p <0.001), del total de respuestas en los momentos de mayor congestión el 87% de las valoraciones subjetivas del personal de salud fueron subestimar el nivel de Sobrecupo.Cuando los niveles de sobrecupo clasificados por NEDOCS son iguales o superiores a nivel 5 (Severamente congestionado y peligrosamente congestionado) el personal de salud no tiene una percepción del riesgo por sobrecupo del departamento de urgencias, lo que conlleva a un riesgo en la seguridad y atención del paciente.
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Increase in demand for health services in HED (Hospital Emergency Department) and their increasing this greater overcrowding is known from the English language as overcrowding. The concept of overcrowding is also inherently related to the notion of frequent use of assistance in the SOR. However, no uniform criterion for defining this concept has been developed so far. The aim of this study is to present the causes of the phenomenon of overcrowding and the related issues of patients’ functioning in the health care system. The main reasons for this phenomenon are the demographic aspect, i.e. the extension of the average age of many societies, but also the tendency of patients to omit medical assistance at the primary health care level and go directly to the HED as facilities with greater diagnostic and therapeutic possibilities. The consequences of the overcrowding phenomenon are, above all, an increase in the costs of HED functioning, longer waiting times for health services provided in the HED and excessive workload of the staff employed there. Currently, overcrowding has been recognized as a global public health problem.
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Overcrowding in Emergency Departments (EDs) is a significant concern worldwide. The number of ED visits is increasing, and this problem has become an important public health problem both in Turkey and in the world. ED overcrowding is associated with many negative consequences, including increased workload, caused staff distress and burnout, decreased satisfaction of ED healthcare staff and patients, delay in treatment of patients most in need of emergency care, decreased quality of care, and increased healthcare cost. Therefore, there is an urgent need to address ED overcrowding in Turkey. The effectice solutions were discussed in this letter.
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Overcrowding in emergency departments is a problem in many countries around the world, including the United States and Chile. Emergency department (ED) overcrowding causes problems for patients and staff, including increased waiting times, increased ambulance diversion, increased length of stay, increased medical errors, increased patient mortality, and increased harm to hospitals due to financial losses. This article aims to describe the etiology of ED overcrowding and potential solutions through an examination of the evidence. Ultimately, ED overcrowding originates from hospital overcrowding and thus the solutions to this complex problem lie in the ED itself as well as outside of the ED.
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The overcrowding of Emergency Departments compromises their critical function and the safety of patients and staff. This study asked the patients how the wait in overcrowded conditions impacted on them and the care they received and what they believed the reasons for the overcrowding were. A prospective questionnaire based structured interview study was performed. Over half (57.7%) of patients felt that the lack of inpatient beds and wards was the main reason that they experienced delays. An overwhelming 85.9% felt that the Health Authorities were not doing enough to address the overcrowding issue. Overcrowding of Emergency Departments has been identified as a major problem the solution is to be found in increasing the capacity of the acute hospital system according to the majority of our study population.
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