Michael K. Gusmano

An evaluation of the policy on community health organizations in China: Will the priority of new healthcare reform in China be a success?

Abstract Objectives The objective of this paper is to assess historical and recent health reform efforts in China. We provide a brief history of the Chinese healthcare system since 1949 as context for the current healthcare; examine the factors that led to recent efforts to reestablish community-based care in China; and identify the challenges associated with attaining a sustainable and quality community healthcare system. Methods Based on literature review and publicly available data in China, the paper will present a historical case study analysis of health policy change of CHOs in China and provide policy evaluation, and the paper provided policy suggestions. Results We find that the governments recent efforts to emphasize the significance of community healthcare services in China have started to change patterns of healthcare use, but many problems still inhibit the development of CHOs, including unsustainable governmental roles, issues of human resource inadequacy and laggard GP practice, poorly designed payment schemes, patients trust crisis and continue to inhibit the development of community-based primary care. Conclusions Additional policy efforts to help CHOs’ development are needed. Recent government investments in public health and primary care alone are not sufficient and could not be sustainable. It will not until long-term self-sustaining mechanisms to relieve an omnipotent government are established, including competent community doctors (GP) system, supportive social insurance reimbursement, appropriate financial incentives to providers, better transparency and accountability, as well as a more regulated referral system, a legitimate, sustainable and quality community health system could be attained.

Gender and the Treatment of Heart Disease in Older Persons in the United States, France, and England: A Comparative, Population-Based View of a Clinical Phenomenon

BACKGROUND Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities. OBJECTIVE This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged > or =65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London. METHODS This was an ecological study based on a retrospective analysis of comparable administrative data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients. Differences in rates were examined by univariate analysis using the Student t test for statistical differences in mean values. RESULTS Despite differences in health system characteristics, including health insurance coverage, availability of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units. The rate of interventional treatment in women with CAD was less than half that in men. This difference persisted after adjustment for the prevalence of heart disease. CONCLUSIONS A consistent pattern of gender disparity in the interventional treatment of CAD was seen across 3 national health systems with known differences in patterns of medical practice. This finding is consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD are due at least in part to the underdiagnosis of CAD in women.

The world cities project: Rationale, organization, and design for comparison of megacity health systems

This article provides an overview of the World Cities Project (WCP), our rationale for it, our framework for comparative analysis, and an overview of current studies in progress. The WCP uses New York, London, Paris, and Tokyo as a laboratory in which to study urban health, particularly the evolution and current organization of public health infrastructure, as well as the health status and quality of life in these cities. Comparing world cities in wealthier nations is important because of (1) global trends in urbanization, emerging health risks, and population aging; (2) the dominant influence of these cities on “megacities” of developing nations; and (3) the existence of data and scholarship about these world cities, which provides a foundation for comparing their health systems and health. We argue that, in contrast to nation-states, world cities provide opportunities for more refined comparisons and cross-national learning. To provide a framework for WCP, we define an urban core for each city and examine the similarities and differences among them. Our current studies shed light on inequalities in health care use and health status, the importance of neighborhoods in protecting population health, and quality of life in diverse urban communities.

Policy Feedback and Public Opinion: The Role of Employer Responsibility in Social Policy

This study extends the literature on policy feedback and explores the extent to which public attitudes reflect learning from past government initiatives. We analyze the ways in which feedback mechanisms affecting public attitudes may differ from those earlier identified in the literature. We apply this general analytic framework to help explain variation in public attitudes toward private employer involvement in health care, explore possible causal pathways, and offer some preliminary empirical tests of these hypotheses. There are different levels of public support for the notion of employer obligation involving medical care, long-term care, and the treatment of substance abuse. Our evidence suggests that lessons about the performance of institutions in each of these policy domains represent the most important effect of existing policy on public attitudes. Furthermore, these differences correspond to what one would expect based on our model of policy feedback and cannot be explained by other plausible sources of policy legitimacy.

Life course vaccination and healthy aging

The authors notice the low vaccine coverage rate among European citizens and inventory the multiple reasons leading to the non-use of preventable infectious diseases vaccines in adults whose mortality consequences represent an important and unexpected burden of diseases. These facts are in close relation with the disruption of vaccine recommendations after the childhood vaccine program, the poor literacy knowledge concerning vaccines among the general population, but also unfortunately among physicians and other health care workers. Popular beliefs, fear of side-effects, fear of needles facilitated the constitution of active non-vaccine groups which conduct to the reappearance in non-vaccinated adults and with dramatic consequences of preventable childhood infectious diseases. This careful analysis of the current preventable infectious disease vaccine coverage in old adults leads to propose a life course vaccine programme including adult vaccinations as part of healthy aging as well as old adults’ vaccine guidelines integrated in health prevention programs.

End-of-life care for patients with dementia in the United States: institutional realities

Few are satisfied with end-of-life care in the United States. For families and friends of people with dementia, end-of-life care is particularly frustrating. Providing better end-of-life care to people with dementia is urgent because the prevalence of the disease is increasing rapidly. Dementia is currently the seventh leading cause of death in the United States and fifth leading cause of death among people aged 65 years and older. By 2050, there will be around 19 million people with Alzheimers disease. This article reviews ethical and policy challenges associated with providing end-of-life care for people with dementia in the United States. I explain how disagreements about the meaning of futility lead to poor care for people with dementia. Most people agree that we should not provide care that is futile, but there is little agreement about how futility should be defined. US policies and politics clearly tip the balance in the direction of treatment, even in the face of strong evidence that such care does more harm than good. Although we may never reach a consensus, it is important to address these questions and think about how to develop policies that respect the different values.

Avoidable mortality pattern in a Chinese population—Hong Kong, China

BACKGROUND We examined the avoidable mortality pattern in Hong Kong, and the influence of age and gender. Comparison with Paris, Inner London and Manhattan was performed, and we discussed the findings in terms of prevention programmes, ethnicity and lifestyles. METHODS Mortality and population data by age and gender were obtained from vital statistics sources. Two periods, 1999-2003 and 2004-06, were selected for analysis. Negative binomial regression and logistic regression were used to model, respectively, the number and proportion of avoidable mortality, in relation to age and gender. RESULTS The standardized total mortality rates (per 1000 population) were 2.51 in the period 1999-2003 and 2.25 in the period 2004-06, whereas the standardized avoidable mortality rates (per 1000 population) were 0.85 and 0.77 for the two periods, respectively. Cerebrovascular disease (stroke) was the leading cause of avoidable mortality. Women in the age range of 65-74 years had the highest avoidable mortality proportion. In 1999-2003, Hong Kong had the second lowest standardized avoidable mortality rate among the four cities compared, whereas the avoidable mortality proportion was the highest. CONCLUSION There might be room for improvement in the primary care system in Hong Kong, particularly in the development of effective prevention programmes targeting the leading causes of avoidable mortality.

A new approach to the comparative analysis of health systems: invasive treatment for heart disease in the US, France, and their two world cities

Cross-national comparisons that assess dimensions of health system performance indicate that the US provides higher rates of revascularization procedures than France and other developed nations, but we believe these findings are misleading. In this paper, we compare the use of these procedures in the US, France and their two world cities, Manhattan and Paris. In doing so, we address a number of limitations associated with existing cross-national comparisons of heart disease treatment. After adjusting for the prevalence of disease in these nations and cities, we found that residents of France aged 45-64 years receive more revascularization procedures than residents of the US and that Parisians receive more revascularizations than residents of Manhattan. Older residents 65 years and over (65+) in the US receive more of these procedures than their French counterparts, but the differences are not nearly as great as previous studies suggest. Moreover, our data on Manhattan and Paris where the population and level of health resources are more comparable, indicate that older Parisians obtain more revascularization procedures than older Manhattanites. Finally, we found that the use of revascularization procedures is significantly lower in Manhattan among persons without private health insurance and among racial and ethnic minorities.

Deliberative Democracy in Theory and Practice: Connecticut's Medicaid Managed Care Council

Despite calls for greater deliberation among citizens on public policy, we have little information about how existing deliberation is structured or how well it works. We examine Connecticuts effort to put public deliberation to work in Medicaid policy-making. Findings from our participant-observation study and in-person interviews with 100 participants in this process suggest some important qualifications to literature on public deliberation. Greater inclusion of diverse social groups from the target population is important, but this should not replace the inclusion of professional advocates since the latter are often more willing than citizen representatives to challenge policy experts on technical issues. Incorporating public deliberation into the process at an early stage is ideal, but deliberation during the later stages of policymaking (including during implementation) can still produce useful results. Finally, the style and purpose of deliberation can shape the range of topics on the agenda, so it is important to understand how the structure of a deliberative forum can affect the style and purpose of deliberation. The essence of democracy itself is now widely taken to be deliberation, as opposed to voting, interest aggregation, constitutional rights, or even self-government. (Dryzek 2000, 1).

The Ethical Imperative And Moral Challenges Of Engaging Patients And The Public With Evidence

Engaging patients and the public with evidence is an ethical imperative because engagement is central to respect for persons and will likely improve health outcomes, facilitate the stewardship of resources, enhance prospects for justice, and build public trust. However, patient and public engagement is also morally complex, because evidence alone is never definitive. As patients and the public engage with evidence, value conflicts will arise and must be managed to achieve trustworthy decision making. We outline value conflicts likely to emerge in the following five settings: clinical care, health care organizations, public health, the regulatory context, and among payers. Using a variety of examples, we offer suggestions about how such conflicts may be managed, including providing more opportunities for democratic deliberation and having more explicit community discussion of how to balance personal choice and community well-being, transparent discussions of cost and quality outcomes, and greater patient engagement in community-based participatory research and the governance of learning health systems.