Robert F. Elliott

Global variation in renal replacement therapy for end-stage renal disease

BACKGROUND Incidence rates of renal replacement therapy (RRT) for end-stage renal disease vary considerably worldwide. This study examines the independent association between the general population, health care system and renal service characteristics and RRT incidence rates. METHODS RRT incidence data (2003-2005) were obtained from renal registries; general population age and health and macroeconomic indices were collected from secondary sources. Renal service organization and resource data were obtained through interviews and questionnaires. Linear regression models were built to establish the factors independently associated with RRT incidence, stratified by the Human Development Index where required. False discovery rate (FDR) correction was adjusted for multiple testing. RESULTS Across the 46 countries (population 1.25 billion), RRT incidence rates ranged from 12 to 455 (median 130) per million population. Gross domestic product (GDP) per capita [incidence rate ratio (IRR): 1.02 per

Advances in health economics

1000 increase, P(FDR) = 0.047], percentage of GDP spent on health care (IRR: 1.11 per % increase, P(FDR) = 0.006) and dialysis facility reimbursement rate relative to GDP (IRR: 0.76 per GDP per capita-sized increase in reimbursement rate, P(FDR) = 0.007) were independently associated with RRT incidence. In more developed countries, the private for-profit share of haemodialysis facilities was also associated with higher incidence (IRR: 1.009 per % increase, P(FDR) = 0.003). CONCLUSIONS Macroeconomic and renal service factors are more often associated with RRT incidence rates than measured demographic or general population health status factors.

Unions and Risk: Their Impact on the Level of Compensation for Fatal Risk

List of Contributors. About the Authors. Preface. Workshop Participants. Acknowledgements. Willingness to Pay for Health Care (C. Donaldson and P. Shackley). Using Discrete Choice Experiments in Health Economics: Moving Forward (M. Ryan and K. Gerard). Methods for Eliciting Time Preferences Over Future Health Events (M. van der Pol and J. Cairns). Economic Evaluation for Decision making (A. Gray and L. Vale). Incentives in Health Care (A. Scott and S. Farrar). The Nursing Labour Market (R. Elliott, et al.). The Economics of the Hospital: Issues of Asymmetry and Uncertainty as they Affect Hospital Reimbursement (A. McGuire and D. Hughes). Measuring Efficiency in Dental Care (D. Parkin and N. Devlin). Ageing, Disability and Long term Care Expenditures (P. McNamee and S. Stearns). Economic Challenges in Primary Care (A. Maynard and A. Scott). Equity in Health Care: The Need for a New Economics Paradigm? (G. Mooney and E. Russell). Economics of Health and Health Improvement (A. Ludbrook and D. Cohen). Index.

Relative Earnings in the UK Public Sector: The Impact of Pay Reform on Pay Structure

This paper distinguishes between the premia for fatal risk in jobs covered by union-negotiated terms and conditions and the premia in uncovered jobs. It employs a model which allows for the endogeneity of both covered status and fatal job risk. Values of a life in both the covered and uncovered sectors are computed. Copyright 1996 by The London School of Economics and Political Science.

Exploring the Association between Macroeconomic Indicators and Dialysis Mortality

The manner in which pay is determined has undergone fairly substantial changes in parts of the UK public sector in the last 15 years. The provision of some services has been subject to ‘market testing’ while other services are no longer provided by the public sector and have been contracted out. In still other areas of the public sector, most noticeably the civil service, decisions over pay have been decentralised and pay advances have been increasingly linked to individual performance. The thrust of reform has been to ensure that the same disciplines which influence pay in the private sector of the economy come to bear on pay in the public sector.

Sociodemographic and health characteristics, rather than primary care supply, are major drivers of geographic variation in preventable hospitalizations in Australia.

BACKGROUND AND OBJECTIVES Mortality on dialysis varies greatly worldwide, with patient-level factors explaining only a small part of this variation. The aim of this study was to examine the association of national-level macroeconomic indicators with the mortality of incident dialysis populations and explore potential explanations through renal service indicators, incidence of dialysis, and characteristics of the dialysis population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Aggregated unadjusted survival probabilities were obtained from 22 renal registries worldwide for patients starting dialysis in 2003-2005. General population age and health, macroeconomic indices, and renal service organization data were collected from secondary sources and questionnaires. Linear modeling with log-log transformation of the outcome variable was applied to establish factors associated with survival on dialysis. RESULTS Two-year survival on dialysis ranged from 62.3% in Iceland to 89.8% in Romania. A higher gross domestic product per capita (hazard ratio=1.02 per 1000 US dollar increase), a higher percentage of gross domestic product spent on healthcare (1.10 per percent increase), and a higher intrinsic mortality of the dialysis population (i.e., general population-derived mortality risk of the dialysis population in that country standardized for age and sex; hazard ratio=1.04 per death per 10,000 person years) were associated with a higher mortality of the dialysis population. The incidence of dialysis and renal service indicators were not associated with mortality on dialysis. CONCLUSIONS Macroeconomic factors and the intrinsic mortality of the dialysis population are associated with international differences in the mortality on dialysis. Renal service organizational factors and incidence of dialysis seem less important.

Global differences in dialysis modality mix: the role of patient characteristics, macroeconomics and renal service indicators

Background:Geographic rates of preventable hospitalization are used internationally as an indicator of accessibility and quality of primary care. Much research has correlated the indicator with the supply of primary care services, yet multiple other factors may influence these admissions. Objective:To quantify the relative contributions of the supply of general practitioners (GPs) and personal sociodemographic and health characteristics, to geographic variation in preventable hospitalization. Methods:Self-reported questionnaire data for 267,091 participants in the 45 and Up Study, Australia, were linked with administrative hospital data to identify preventable hospitalizations. Multilevel Poisson models, with participants clustered in their geographic area of residence, were used to explore factors that explain geographic variation in hospitalization. Results:GP supply, measured as full-time workload equivalents, was not a significant predictor of preventable hospitalization, and explained only a small amount (2.9%) of the geographic variation in hospitalization rates. Conversely, more than one-third (36.9%) of variation was driven by the sociodemographic composition, health, and behaviors of the population. These personal characteristics explained a greater amount of the variation for chronic conditions (37.5%) than acute (15.5%) or vaccine-preventable conditions (2.4%). Conclusions:Personal sociodemographic and health characteristics, rather than GP supply, are major drivers of preventable hospitalization. Their contribution varies according to condition, and if used for performance comparison purposes, geographic rates of preventable hospitalization should be reported according to individual condition or potential pathways for intervention.

Long-term Illness and Wages: The Impact of the Risk of Occupationally Related Long-term Illness on Earnings

BACKGROUND An increase in the dialysis programme expenditure is expected in most countries given the continued rise in the number of people with end-stage renal disease (ESRD) globally. Since chronic peritoneal dialysis (PD) therapy is relatively less expensive compared with haemodialysis (HD) and because there is no survival difference between PD and HD, identifying factors associated with PD use is important. METHODS Incidence counts for the years 2003-05 were available from 36 countries worldwide. We studied associations of population characteristics, macroeconomic factors and renal service indicators with the percentage of patients on PD at Day 91 after starting dialysis. With linear regression models, we obtained relative risks (RRs) with 95% confidence intervals (CIs). RESULTS The median percentage of incident patients on PD was 12% (interquartile range: 7-26%). Determinants independently associated with lower percentages of patients on PD were as follows: patients with diabetic kidney disease (per 5% increase) (RR 0.93; 95% CI 0.89-0.97), health expenditure as % gross domestic product (per 1% increase) (RR 0.93; 95% CI 0.87-0.98), private-for-profit share of HD facilities (per 1% increase) (RR 0.996; 95% CI 0.99-1.00; P = 0.04), costs of PD consumables relative to staffing (per 0.1 increase) (RR 0.97; 95% CI 0.95-0.99). CONCLUSIONS The factors associated with a lower percentage of patients on PD include higher diabetes prevalence, higher healthcare expenditures, larger share of private-for-profit centres and higher costs of PD consumables relative to staffing. Whether dialysis modality mix can be influenced by changing healthcare organization and funding requires additional studies.

Decentralization and Pay Reform in Central Government: a Study of Three Countries

Long-term illness (LTI) is a more prevalent workplace risk than fatal accidents but there is virtually no evidence for compensating differentials for a broad measure of LTI. In 1990 almost 3.4 percent of the U.K. adult population suffered from a LTI caused solely by their working conditions. This paper provides the first estimates of compensating differentials for a broad measure of work-related LTI. Using data on self-reported illnesses we find significant CDs for male manual workers but none for male nonmanual workers. These results are robust to the addition of variables for the risk of accidental at-work deaths.

Adam Smith may have been right after all: A new approach to the analysis of compensating differentials

Over the past decade central governments of the UK, Sweden and Australia have engaged in significant reforms in the way they pay their employees. These reforms have generally taken the form of the decentralization of pay bargaining and the individualization of pay. This paper details the policies that have been implemented in central government in these countries and presents some preliminary results on the effects of these. While the actual implementation has varied quite substantially across the countries and the analysis of the outcomes must be regarded as preliminary, there is some evidence that the reforms have led to an increase in earnings dispersion