Competition and physician-induced demand in a healthcare market with regulated price: evidence from Ghana

Using panel data of administrative claims spanning 36 months (2017–2019) and an instrumental variable method, this study examines whether physician-induced demand for hypertension disease care exists in Ghana’s healthcare system where price is regulated, and there is no co-payment. We find that an increase in competition—measured as a high doctor-to-population ratio at the district level—leads to an increase in the number of physician visits, suggesting physician-induced demand exists, and that effects are greater for large hospitals and public health providers. This result is further supported by alternative measures and specifications showing that physicians’ revenue from medication and gross revenue increase as the physician density increases. These pattern suggest that physicians in high density areas, faced with a decrease in number of patients per physician, make up for the decline in income by inducing more patient visits.

International Socioeconomic Predictors of Colon and Rectal Cancer Mortality: Is Colorectal Cancer a First World Problem?

PURPOSE Colorectal cancer (CRC) is a leading cause of international morbidity and is the second highest cause of cancer-related mortality in the world. The purpose of this study was to investigate the relationship between international health care spending on CRC mortality over time. METHODS This is a retrospective study using a publicly available data from the WHO Global Health Observatory database. General estimating equations were used to analyze the relationship between total health care expenditure per capita (THEpc) and CRC mortality at the country level. The primary predictors of interest were quartiles of THEpc. Other exposure variables included gross domestic product per capita (GDPpc), smoking (% of adult population smoking), physician density (per 10,000), and time. RESULTS Mortality decreased significantly from 2000 to 2016 (coefficient [95% CI], −2.2 [−3.3 to −1.1]; P < .001). THEpc, GDPpc, time, and percentage of adult population smoking were significant predictors of CRC mortality. Patients in the top two quartiles of THEpc had 3% higher rates of CRC mortality compared with countries in Q1 THEpc (Q3: 3.4 [1.9-4.8], P < .001; Q4: 3.2 [1.4-5.0], P = .001). Similar trends were seen in GDPpc (Q4: 3.2 [1.4-5.0], P = .001; Q3: 3.4 [1.9-4.8], P < .001; Q2: 1.7 [0.7-2.6], P < .001; Q1: reference). CONCLUSION Overall, mortality decreased significantly over the study period. Countries with higher health expenditures and higher gross domestic products experienced higher rates of CRC mortality. Further research will be necessary to determine the cause for this, but we postulate that it may be a result of more robust diagnostic and follow-up methods in countries with more resources.

444. County-level COVID-19 Case Fatality Rate in Medicaid Expansion States Compared to Non-Expansion States

Background Medicaid expansion has been adopted by 38 states and the District of Columbia,1,2 contributing to lower rates of uninsured individuals in the US.3 During the COVID-19 pandemic, Medicaid enrollment offset employer-based insurance losses precipitated by the recession.4 The aim of this study was to evaluate whether Medicaid expansion may have impacted COVID-19 mortality. Methods We conducted an ecologic study that included all US counties in the 50 states and District of Columbia. County-specific Medicaid expansion status was based on whether expansion was adopted within the state. COVID-19 cases and deaths for each county were obtained from the Centers of Disease Control (CDC). Unadjusted and multivariable negative binomial regression with robust standard errors to account for clustering of counties within each state were used to evaluate the association of COVID-19 case fatality rate and Medicaid expansion status. Adjusted models included the addition of four sets of county-level covariates thought to influence the association of Medicaid status and COVID-19 fatality rate: demographics, comorbidities, economic indicators, and physician density. These analyses were then performed in subgroups of counties defined by urbanicity (metro, suburban or rural) and quartiles of poverty rates. Incidence Rate Ratios (IRR) and 95% confidence intervals (CI) are reported. Results A total of 1,814 Medicaid expansion and 1,328 non-expansion counties were included in the analysis. Crude case fatality rates were 2.1% (non-expansion) and 1.8% (expansion). Medicaid expansion was not associated with a significantly lower COVID-19 case fatality rate in either the unadjusted (IRR: 0.86; 95% CI: 0.74, 1.01) or fully adjusted (IRR: 1.02; 95% CI: 0.90, 1.16) models. In adjusted models, Medicaid expansion status was also not associated with differences in COVID-19 case fatality rate when counties were stratified by either urbanicity or percent of individuals living below the poverty line. Conclusion In this county-level analysis, Medicaid expansion status was not associated with a significant difference in county-level COVID-19-related case fatality rates among people of all ages. Future individual-level studies are needed to better characterize the effect of Medicaid on COVID-19 mortality. Disclosures All Authors: No reported disclosures

Geographic disparities in Saskatchewan prostate cancer incidence and its association with physician density: analysis using Bayesian models

Background Saskatchewan has one of the highest incidence of prostate cancer (PCa) in Canada. This study assesses if geographic factors in Saskatchewan, including location of where patients live and physician density are affecting the PCa incidence. First, the objective of this study is to estimate the PCa standardized incidence ratio (SIRs) in Saskatchewan stratified by PCa risk-level. Second, this study identifies clusters of higher than and lower than expected PCa SIRs in Saskatchewan. Lastly, this study identifies the association (if any) between family physician density and estimated PCa SIRs in Saskatchewan. Methods First, using Global Moran’s I, Local Moran’s I, and the Kuldorff’s Spatial Scan Statistic, the study identifies clusters of PCa stratified by risk-levels. Then this study estimates the SIRs of PCa and its association with family physician density in Saskatchewan using the Besag, York, and Mollie (BYM) Bayesian method. Results Higher than expected clusters of crude estimated SIR for metastatic PCa were identified in north-east Saskatchewan and lower than expected clusters were identified in south-east Saskatchewan. Areas in north-west Saskatchewan have lower than expected crude estimated SIRs for both intermediate-risk and low-risk PCa. Family physician density was negatively associated with SIRs of metastatic PCa (IRR: 0.935 [CrI: 0.880 to 0.998]) and SIRs of high-risk PCa (IRR: 0.927 [CrI: 0.880 to 0.975]). Conclusions This study identifies the geographical disparities in risk-stratified PCa incidence in Saskatchewan. The study identifies areas with a lower family physician density have a higher-than-expected incidences of metastatic and high-risk PCa. Hence policies to increase the number of physicians should ensure an equitable geographic distribution of primary care physicians to support early detection of diseases, including PCa.

Socioeconomic Factors Contributing to Antibiotic Resistance in China: A Panel Data Analysis

The relationship between socioeconomic factors and antibiotic resistance (ABR) prevalence remains a knowledge gap in China. In this study, our aim was to examine the association between ABR prevalence and socioeconomic factors across 30 provinces in mainland China. We used two measures of level of ABR: the proportion of methicillin-resistant Staphylococcus aureus (MRSA), third-generation cephalosporin-resistant Escherichia coli (3GCREC), and third-generation cephalosporin-resistant Klebsiella pneumoniae (3GCRKP), and the aggregate resistance. The data of ABR prevalence, education, gross domestic product (GDP) per capita, out-of-pocket (OOP) health expenditure, physician density, hospital bed density, and public toilet density during 2014 and 2018 in 30 provinces in mainland China were included. We examined the association between ABR prevalence and potential contributing socioeconomic factors using panel data modeling. In addition, we explored this relationship in the eastern, central, and western economic zones. Our results indicated that GDP per capita was significantly positively correlated with ABR in mainland China and the eastern economic zone; however, significantly positive associations did not exist in the central and western economic zones. Surprisingly, both higher GDP per capita and higher OOP health expenditure were associated with a higher level of MRSA, but a lower level of 3GCREC; higher physician density was associated with a lower level of MRSA, but a higher level of 3GCREC. In addition, ABR prevalence presented a decline trend during 2014 and 2018. Our study highlights that intervention measures tackling the development and spread of ABR in mainland China must better recognize and address the importance of social and economic determinants.

Physician distribution across China’s cities: regional variations

Background Distribution of physicians is a key component of access to health care. Although there is extensive research on urban-rural disparities in physician distribution, limited attention has been directed to the heterogeneity across urban areas. This research depicts variations in physician density across over 600 cities in the context of China’s rapid urbanization. Methods Data came from National Census Surveys and China statistical yearbooks, 2000–2003, and 2010–2013. Cities were characterized in terms of not only administrative level but also geographic regions and urban agglomerations. We analyzed variations in physician supply by applying generalized estimating equations with an ordinal logistic linking function. Results Although overall physician density increased between 2003 and 2013, with population and socioeconomic attributes adjusted, physician density declined in urban China. On average, urban districts had a higher physician density than county-level cities, but there were regional variations. Cities in urban agglomerations and those outsides did not differ in physician density. Conclusion Despite the reduced inequality between 2003 and 2013, the growth in physician density did not appear to be commensurate with the changes in population health demand. Assessment in physician distribution needs to take into account heterogeneity in population and socioeconomic characteristics.

Geographic Disparities in Saskatchewan Prostate Cancer Incidence and its Association with Physician Density: Analysis Using Bayesian Models.

Background: Saskatchewan has one of the highest incidence of prostate cancer (PCa) in Canada. This study assesses if geographic factors in Saskatchewan, including location of where patients live and physician density are affecting the PCa incidence. First, the objective of this study is to estimate the PCa standardized incidence ratio (SIRs) in Saskatchewan stratified by PCa risk-level. Second, this study identifies clusters of higher than and lower than expected PCa SIRs in Saskatchewan. Lastly, this study identifies the association (if any) between family physician density and estimated PCa SIRs in Saskatchewan. Methods: First, using Global Moran’s I, Local Moran’s I, and the Kuldorff’s Spatial Scan Statistic, the study identifies clusters of PCa stratified by risk-levels. Then this study estimates the SIRs of PCa and its association with family physician density in Saskatchewan using the Besag, York, and Mollie (BYM) Bayesian method.Results: Higher than expected clusters of crude estimated SIR for metastatic PCa were identified in north-east Saskatchewan and lower than expected clusters were identified in south-east Saskatchewan. Areas in north-west Saskatchewan have lower than expected crude estimated SIRs for both intermediate-risk and low-risk PCa. Family physician density was negatively associated with SIRs of metastatic PCa (IRR: 0.935 [CrI: 0.880 to 0.998]) and SIRs of high-risk PCa (IRR: 0.927 [CrI: 0.880 to 0.975]). Conclusions: This study identifies the geographical disparities in risk-stratified PCa incidence in Saskatchewan. The study identifies areas with a lower family physician density have a higher-than-expected incidences of metastatic and high-risk PCa. Hence policies to increase the number of physicians should ensure an equitable geographic distribution of primary care physicians to support early detection of diseases, including PCa.

Socioeconomic factors contributing to antibiotic resistance in China: a panel data analysis

Background The relationship between socioeconomic factors and ABR remains a knowledge gap in China. In this study, our aim was to examine the association between ABR proportion and socioeconomic factors across 30 provinces in mainland China. Methods We used two measures of ABR: the proportion of carbapenem-resistant Pseudomonas aeruginosa (CRPA), 3rd generation cephalosporin-resistant Klebsiella pneumoniae (3GCRKP), 3rd generation cephalosporin-resistant Escherichia coli (3GCREC), methicillin-resistant Staphylococcus aureus (MRSA); and the aggregate resistance. ABR proportion, education, gross domestic product (GDP) per capita, out-of-pocket (OOP) health expenditure, physician density, hospital bed density, access to water source, and number of public toilets per 10,000 population data during 2014 and 2018 in 30 provinces in mainland China were included. We examined the association between ABR level and potential contributing factors using panel data modelling. In addition, we explored this relationship from eastern, central, and western economic zone, respectively. Results Our results indicated that higher hospital bed density and physician density were significantly associated with lower levels of ABR. The issue of ABR was also related to socioeconomic factors such as GDP per capita, OOP health expenditure, education, which might depend on different resistant bacteria or different economic zones. GDP per capita was negatively associated with CRPA level, but positively associated with MRSA level. Higher OOP health expenditure was associated higher CRPA level. In addition, we only found that ABR prevalence was significantly negatively associated with education, and positively associated with OOP health expenditure in central economic zone, but not found in eastern and western economic zone. Conclusions Our study highlights that measures increasing hospital beds and physicians allocation to curb ABR should be implemented. Besides, intervention measures tackling the development and spread of ABR in China must better recognize and address the importance of social and economic determinants.

Variation in the use of percutaneous coronary interventions among older patients with acute coronary syndromes: a multilevel study in Fukuoka, Japan

Background Variation in health care delivery among regions and hospitals has been observed worldwide and reported to have resulted in health inequalities. Regional variation of percutaneous coronary intervention (PCI) was previously reported in Japan. This study aimed to assess the small-area and hospital-level variations and to examine the influence of patient and hospital characteristics on the use of PCI. Methods Data provided by the Fukuoka Prefecture Latter-stage Elderly Insurance Association was used. There were 11,821 patients aged ≥65 years with acute coronary syndromes who were identified from 2015 to 2017. Three-level multilevel logistic regression analyses were performed to quantify the small-area and hospital variations, as well as, to identify the determinants of PCI use. Results The results showed significant variation (δ2 = 0.744) and increased PCI use (MOR = 2.425) at the hospital level. After controlling patient- and hospital-level characteristics, a large proportional change in cluster variance was found at the hospital level (PCV 14.7%). Fixed-effect estimation results showed that females, patients aged ≥80 years old, hypertension and dyslipidemia had significant association with the use of PCI. Hospitals with high physician density had a significantly positive relationship with PCI use. Conclusions Patients receiving care in hospitals located in small areas have equitable access to PCI. Hospital-level variation might be originated from the oversupply of physicians. A balanced number of physicians and beds should be taken into consideration during healthcare allocation. A treatment process guideline on PCI targeting older patients is also needed to ensure a more equitable access for healthcare resources.