Health Policy RSS feed: Current Issue. Health Policy is intended to be a vehicle for the exploration and discussion of health policy and health system issues and is aimed in particular at enhancing communication between health policy and system researchers, legislators, decision-makers and professionals concerned with developing, implementing, and analysing health policy, health systems and health care reforms, primarily in high-income countries outside the U.S.A. Health care policies and reforms are made at an ever-increasing pace in countries around the world - and policy-makers are increasingly looking to other countries for solutions to their own problems. Health Policy is committed to support this international dialogue to ensure that policies are not just copied but used and adapted based on the specific problems and objectives as well as the respective context. The journal encourages the submission of short, full-length, comparative and review articles (as well as groups of articles in "special sections") which address: 1. What is happening in terms of policies, reforms, regulation etc. of health systems; 2. Where the ideas are coming from, i.e. whether they are "imported" from another country or developed within the country, and how innovative they are they in comparison to other countries; 3. Why it is happening, e.g. as a consequence of a change in government, popular dissatisfaction or (perceived) unsustainable cost increases, and what are the objectives; 4. The actors involved (both governmental as well as non-governmental), incl. their roles, their opinions and their strength in the decision and implementation process; 5. Intended and, especially, unintended effects of these policies or reforms on the health system in terms of access, appropriateness, costs, effectiveness, quality, patient experience and equity etc.; and 6. Their final consequences in terms of health outcomes, financial protection and responsiveness to the population's legitimate expectations, i.e. a performance assessment of reforms and health systems. To achieve the journal's objectives, authors are encouraged to write in a non-technical style, which is understandable to health policy practitioners and specialists from other disciplines and in other countries. Electronic usage: An increasing number of readers access the journal online via ScienceDirect, one of the world's most advanced web delivery systems for scientific, technical and medical information. Average monthly article downloads for this journal: 35,538 * Figure is an average based on full text articles downloaded monthly via ScienceDirect between July 2010 and July 2011 http://www.healthpolicyjrnl.com/?rss=yesElsevier Inc.en © 2013 Elsevier Ireland Ltd. All rights reserved. Health Policy0168-85101102-3May 2013 © 2013 Elsevier Ireland Ltd. All rights reserved. healthpermissions@elsevier.comhttp://www.healthpolicyjrnl.com/article/PIIS0168851013000201/abstract?rss=yesAbstract: Objectives: To explore the literature for the definitions of informal payments in healthcare and critically analyze the proposed definitions. This will serve in the process of getting to a coherent definition of informal payments, which will further support acknowledging and addressing them globally.Methods: A search strategy was developed to identify papers addressing informal payments on PubMed, ScienceDirect, Econlit, EconPapers and Google Scholar.Results: 2225 papers were identified after a first search. 61 papers were included in the systematic review. Out of all definitions provided, we selected three definitions as being original. All other definitions either cite these definitions or do not provide new insight into the topic of informal payments. Although informal payments have been nominated by various terms over the years, there is a tendency in recent years towards an agreement to use this singular term. Definitions differ in terms of the relation of informal payments with other informal activities, their legality and the motivation behind them.Conclusions: The variety of forms which informal payments may take makes it difficult to define them in a comprehensive manner. However, we identified a definition that could serve as a beginning in this process. More effort is needed to build on it and get to a commonly accepted and shared definition of informal payments.Defining informal payments in healthcare: A systematic reviewRăzvan M. Cherecheş, Marius I. Ungureanu, Petru Sandu, Ioana A. Rus10.1016/j.healthpol.2013.01.010Health Policy 110, 2 (2013)2013-02-13Health Policy2013-02-131102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations105114http://www.healthpolicyjrnl.com/article/PIIS0168851013000183/abstract?rss=yesAbstract: Background: A vast amount of literature on effects of pay-for-performance (P4P) in health care has been published. However, the evidence has become fragmented and it has become challenging to grasp the information included in it.Objectives: To provide a comprehensive overview of effects of P4P in a broad sense by synthesizing findings from published systematic reviews.Methods: Systematic literature search in five electronic databases for English, Spanish, and German language literature published between January 2000 and June 2011, supplemented by reference tracking and Internet searches. Two authors independently reviewed all titles, assessed articles’ eligibility for inclusion, determined a methodological quality score for each included article, and extracted relevant data.Results: Twenty-two reviews contain evidence on a wide variety of effects. Findings suggest that P4P can potentially be (cost-)effective, but the evidence is not convincing; many studies failed to find an effect and there are still few studies that convincingly disentangled the P4P effect from the effect of other improvement initiatives. Inequalities among socioeconomic groups have been attenuated, but other inequalities have largely persisted. There is some evidence of unintended consequences, including spillover effects on unincentivized care. Several design features appear important in reaching desired effects.Conclusion: Although data is available on a wide variety of effects, strong conclusions cannot be drawn due to a limited number of studies with strong designs. In addition, relevant evidence on particular effects may have been missed because no review has explicitly focused on these effects. More research is necessary on the relative merits of P4P and other types of incentives, as well as on the long-term impact on patient health and costs.Effects of pay for performance in health care: A systematic review of systematic reviewsFrank Eijkenaar, Martin Emmert, Manfred Scheppach, Oliver Schöffski10.1016/j.healthpol.2013.01.008Health Policy 110, 2 (2013)2013-02-04Health Policy2013-02-041102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations115130http://www.healthpolicyjrnl.com/article/PIIS0168851012003314/abstract?rss=yesAbstract: Objective: To explore trends and income related differences in out-of-pocket (OOP) costs for prescription and over-the-counter medicines in Finland in 1985–2006.Methods: Cross-sectional data collected in Household Budget Surveys conducted in 1985, 1990, 1995, 2001 and 2006 were used to calculate trends in household OOP payments in absolute and relative terms. Covariance analyses were used to evaluate age-adjusted OOP costs across income groups.Results: Mean OOP costs per household increased 2.7 fold over inflation from 1985 to 2006. The growth was steepest (60%) in 1990–1995 and slowest (10%) in 1995–2001. The mean costs, in 2006 currency value, increased from €138 to €373 and the average share of household total consumption spent on medicines increased from 0.8% to 1.6%. After adjusting by age, the lowest income quintile had the lowest mean OOP costs for all types of medicines at every time point, although the overall differences were small. In 1985/2006, the age-adjusted estimated marginal means for household medicinal costs were €121/€332 for the lowest income quintile and €138/€449 for the highest quintile, and for the share of household consumption 1.1%/2.2% for the lowest and 0.5%/1.1% for the highest quintile.Conclusions: All patients faced increasing OOP payments for medicines throughout the study period, but the relative growth was largest for the lowest income groups. Our results suggest that savings achieved by increasing the patients’ share of costs coincided with steep growth in OOP costs and wider differences between income groups. Cost containment measures targeted at prices, on the other hand, coincided with stabilised OOP costs and decreasing dispersion between the income quintiles. More research is needed to evaluate whether differences in OOP costs reflect differences in patterns of use.Trends and income related differences in out-of-pocket costs for prescription and over-the-counter medicines in Finland from 1985 to 2006Katri Aaltonen, Mikko Niemelä, Pauline Norris, J. Simon Bell, Sirpa Hartikainen10.1016/j.healthpol.2012.12.004Health Policy 110, 2 (2013)2013-02-04Health Policy2013-02-041102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations131140http://www.healthpolicyjrnl.com/article/PIIS0168851013000249/abstract?rss=yesAbstract: Introduction: Despite first-dollar public coverage for hospital and physician services, Canadians spend more privately on health care than citizens of most other developed countries. We quantified recent growth in private payments by Canadian households for health care.Methods: Using data from 163,081 respondents to Statistics Canada's annual Survey of Household Spending from 1998 to 2009, we calculated inflation-adjusted per-household spending on private health insurance premiums and out-of-pocket payments on six types of health care services. Further, we estimated the prevalence and some socio-economic determinants of households spending over 10% of after-tax income on health care using logistic regression.Results: We found that Canadian households spent $19.8 billion on private payments for health care in 2009. This represents an average of $1523 per household—a 37% increase over 1998. The top three spending categories in 2009 were private health insurance premiums ($5.9 billion), dental ($4.9 billion) and prescription drugs ($4.2 billion). Even after adjusting for inflation, expenditure on every category of health care spending increased between 1998 and 2009. The proportion of households spending more than 10% of after-tax income on health care increased by 56% (from 3.3% to 5.2%). Households including a senior, with a low income, and in British Columbia or the Atlantic Provinces were significantly more likely to reach this threshold.Interpretation: Over the period studied, the burden of private health care expenditures increased substantially for Canadian households. As direct charges reduce the use of necessary health care services, investigation into the health consequences of these increases is warranted.Growth in private payments for health care by Canadian householdsMichael R. Law, Jamie R. Daw, Lucy Cheng, Steven G. Morgan10.1016/j.healthpol.2013.01.014Health Policy 110, 2 (2013)2013-02-18Health Policy2013-02-181102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations141146http://www.healthpolicyjrnl.com/article/PIIS0168851013000626/abstract?rss=yesAbstract: Background: Like in many other high-income jurisdictions, the public drug program in Ontario, Canada provides comprehensive coverage of prescription drugs to the 65 years and older population with some cost sharing. The objective of this study was to examine the marginal impact of holding private drug coverage on the use of publicly funded medicines among the senior population in Ontario.Methods: We drew on linked survey and administrative data sources to examine the impact of private drug coverage first on total spending and utilization of medications, and second, on clinically recommended medications for individuals with a diagnosis of diabetes.Results: Approximately 27% of Ontario seniors reported having private prescription drug insurance from a current or prior employer. The population-level analysis of all seniors found that individuals with private insurance coverage, on average, took about a quarter of an additional drug and incurred 16% more in costs to the public program in a year compared to those without additional coverage. The disease-specific analysis of seniors with a diagnosis of diabetes found that private coverage was associated with two-fold higher odds of taking an anti-hypertensive drug, but it had no association with the use of statins or anti-diabetic medications.Discussion: The results of this study provide some evidence that seniors in Ontario are sensitive to the price of drugs. These findings raise equity concerns relating to the cost sharing arrangements in the public system and our policy of allowing private plans to “top-up” the public plan.How does complementary private prescription drug insurance coverage affect seniors’ use of publicly funded medications?Sara Allin, Michael R. Law, Audrey Laporte10.1016/j.healthpol.2013.02.010Health Policy 110, 2 (2013)2013-03-21Health Policy2013-03-211102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations147155http://www.healthpolicyjrnl.com/article/PIIS0168851013000432/abstract?rss=yesAbstract: Drawing upon role theory and the literature concerning unintended consequences of financial pressure, this study investigates the effects of health care decision pressure from the hospital's administration and from the professional peer group on physician's inclination to engage in up coding. We explore two kinds of up coding, information-related and action-related, and develop hypothesis that connect these kinds of data manipulation to the sources of pressure via the intermediate effect of role conflict. Qualitative data from initial interviews with physicians and subsequent questionnaire evidence from 578 physicians in 14 French hospitals suggest that the source of pressure is a relevant predictor of physicians’ inclination to engage in data-manipulation. We further find that this effect is partly explained by the extent to which these pressures create role conflict. Given the concern about up coding in treatment-based reimbursement systems worldwide, our analysis adds to understanding how the design of the hospital's management control system may enhance this undesired type of behavior.Sources of financial pressure and up coding behavior in French public hospitalsIrène Georgescu, Frank G.H. Hartmann10.1016/j.healthpol.2013.02.003Health Policy 110, 2 (2013)2013-03-14Health Policy2013-03-141102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations156163http://www.healthpolicyjrnl.com/article/PIIS0168851013000213/abstract?rss=yesAbstract: Episode-based payment, commonly referred to as bundled payment, has emerged as a key component of U.S. health care payment reform. Bundled payments are appealing as they share the financial risk of treating patients between payers and providers, encouraging the delivery of cost-effective care. A closely watched example is the U.S. End Stage Renal Disease (ESRD) Prospective Payment System, known as the ‘expanded ESRD bundle.’ In this paper we consider the expanded ESRD bundle 2 years after its implementation. First, we discuss emerging lessons, including how implementation has changed dialysis care with respect to the use of erythropoietin stimulating agents, how implementation has led to an increase in the use of home-based peritoneal dialysis, and how it may have contributed to the market consolidation of dialysis providers. Second, we use the expanded ESRD bundle to illustrate the importance of accounting for stakeholder input and staging policy implementation. Third, we highlight the need to consider system-wide consequences of implementing bundled payment policies. Fourth, we suggest how bundled payments may create research opportunities. Bundled payment policies offer opportunities and challenges. Their success will be determined not only by impacts on cost containment, but also to the extent they encourage high quality care.What can we learn from the U.S. expanded end-stage renal disease bundle?James D. Chambers, Daniel E. Weiner, Sarah K. Bliss, Peter J. Neumann10.1016/j.healthpol.2013.01.011Health Policy 110, 2 (2013)2013-02-18Health Policy2013-02-181102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations164171http://www.healthpolicyjrnl.com/article/PIIS0168851013000651/abstract?rss=yesAbstract: Background: Treatment costs of end-stage renal disease with dialysis are high and vary between dialysis modalities. Public healthcare payers aim at stimulating the use of less expensive dialysis modalities, with maintenance of healthcare quality.Objectives: This study examines the effects of Belgian financial incentive mechanisms for the use of low-cost dialysis treatments.Methods: First, the costs of different dialysis modalities were calculated from the hospital's perspective. Data were obtained through a hospital survey. The balance between costs and revenues was simulated for an average Belgian dialysis programme. Incremental profits were calculated in function of the proportion of patients on alternative dialysis modalities.Results: Hospital haemodialysis is the most expensive modality per patient year, followed by peritoneal dialysis and finally satellite haemodialysis. Under current reimbursement rules mean profits of a dialysis programme are maximal if about 28% of patients are treated with a low-cost dialysis modality. This is only slightly lower than the observed percentage in Belgian dialysis centres in the same period.Conclusions: In Belgium, the financial incentives for the use of low-cost dialysis modalities only had a modest impact due to the continuing profits that could be generated by high-cost dialysis. Profit neutrality is crucial for the success of any financial incentive mechanism for low-cost dialysis modalities.Analysis of the costs of dialysis and the effects of an incentive mechanism for low-cost dialysis modalitiesIrina Cleemput, Chris De Laet10.1016/j.healthpol.2013.03.001Health Policy 110, 2 (2013)2013-03-25Health Policy2013-03-251102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations172179http://www.healthpolicyjrnl.com/article/PIIS0168851013000171/abstract?rss=yesAbstract: This paper proposes the framing of disinvestment strategies as the “value for money” approach suitable for the current situation of acute budget restrictions. Building on the experiences from other countries, it first reviews the instruments already available for implementing this approach within the Spanish National Health Service (SNS) namedThese three elements have been in place in the SNS for some years now. However their effective alignment in supporting a disinvestment strategy has met with several hurdles. Components of organisational incentives as well as the “technological fascination” affecting professionals’ and public perceptions have played a role in Spain as elsewhere. In addition, some idiosyncratic political factors lead to weak mechanisms for the channelling of available evidence into decision-making and the existing SNS technical bodies capped to issue only non-binding recommendations.Sadly, the “cuts across the board” strategy adopted in facing the financial crisis might have finally triggered the required political clime to overcome these obstacles to disinvestment. In the current context, the SNS stakeholders (professionals and the public) may regard the disinvestment proposal of informed local decisions about how best to spend the shrinking amount of resources, getting rid of low value care, as a shielding rationale, rather than a thread.Disinvestment in the age of cost-cutting sound and fury. Tools for the Spanish National Health SystemSandra García-Armesto, Carlos Campillo-Artero, Enrique Bernal-Delgado10.1016/j.healthpol.2013.01.007Health Policy 110, 2 (2013)2013-02-04Health Policy2013-02-041102-3S0168-8510(13)X0005-3Financing Health Care: Definitions, Effects, and Innovations180185http://www.healthpolicyjrnl.com/article/PIIS0168851013000614/abstract?rss=yesAbstract: Objectives: A scoping review was conducted to synthesise the findings of evaluations of voluntary agreements between business and government. It aimed to summarise the types of agreements that exist, how they work in practice, the conditions for their success and how they had been evaluated.Methods: Voluntary agreements were included if they involved a transparent signing-up process and where businesses agreed to carry out specific actions or to achieve specific outcomes. Studies of any design published in English were included.Results: 47 studies were identified. Voluntary agreements may help to improve relationships between government and business, and can help both parties agree on target-setting and data-sharing. Governments may also use the experience to help develop subsequent legislation. For voluntary agreements to be successful, targets should be ambitious and clearly defined, with robust independent monitoring. Public knowledge of agreements can help encourage participation and ensure compliance.Conclusions: If properly implemented and monitored, voluntary agreements can be an effective policy approach, though there is little evidence on whether they are more effective than compulsory approaches. Some of the most effective voluntary agreements include substantial disincentives for non-participation and sanctions for non-compliance. Many countries are moving towards these more formal approaches to voluntary agreements.Voluntary agreements between government and business—A scoping review of the literature with specific reference to the Public Health Responsibility DealAnna Bryden, Mark Petticrew, Nicholas Mays, Elizabeth Eastmure, Cecile Knai10.1016/j.healthpol.2013.02.009Health Policy 110, 2 (2013)2013-03-18Health Policy2013-03-181102-3S0168-8510(13)X0005-3Public Health Policies186197http://www.healthpolicyjrnl.com/article/PIIS0168851012003351/abstract?rss=yesAbstract: Objective: To analyse the trends and characteristics of international health issues through agenda items of the World Health Assembly (WHA) from 1970 to 2012.Methods: Agendas in Committees A/B of the WHA were classified as Administrative or Technical and Health Matters. Agenda items of Health Matters were sorted into five categories by the WHO reform in the 65th WHA. The agenda items in each category and sub-category were counted.Results: There were 1647 agenda items including 423 Health Matters, which were sorted into five categories: communicable diseases (107, 25.3%), health systems (81, 19.1%), noncommunicable diseases (59, 13.9%), preparedness surveillance and response (58, 13.7%), and health through the life course (36, 8.5%). Among the sub-categories, HIV/AIDS, noncommunicable diseases in general, health for all, millennium development goals, influenza, and international health regulations, were discussed frequently and appeared associated with the public health milestones, but maternal and child health were discussed three times. The number of the agenda items differed for each Director-General's term of office.Conclusions: The WHA agendas cover a variety of items, but not always reflect international health issues in terms of disease burden. The Member States of WHO should take their responsive roles in proposing more balanced agenda items.World Health Assembly Agendas and trends of international health issues for the last 43 years: Analysis of World Health Assembly Agendas between 1970 and 2012Tomomi Kitamura, Hiromi Obara, Yoshihiro Takashima, Kenzo Takahashi, Kimiko Inaoka, Mari Nagai, Hiroyoshi Endo, Masamine Jimba, Yasuo Sugiura10.1016/j.healthpol.2012.12.008Health Policy 110, 2 (2013)2013-01-07Health Policy2013-01-071102-3S0168-8510(13)X0005-3Public Health Policies198206http://www.healthpolicyjrnl.com/article/PIIS0168851013000596/abstract?rss=yesAbstract: Exposure to second-hand tobacco smoke is a serious public health concern and while all EU Member States have enacted some form of regulation aimed at limiting exposure, the scope of these regulations vary widely and many countries have failed to enact comprehensive legislation creating smoke-free workplaces and indoor public places. To gauge the effectiveness of different smoke-free models we compared fine particles from second-hand smoke in hospitality venues before and after the implementation of smoking bans in France, Greece, Ireland, Italy, Portugal, Turkey, and Scotland.Data on PM2.5 fine particle concentration levels were recorded in 338 hospitality venues across these countries before and after the implementation of smoke-free legislation. Changes in mean PM2.5 concentrations during the period from pre- to post-legislation were then compared across countries.While a reduction in PM2.5 was observed in all countries, those who had enacted and enforced more fully comprehensive smoke-free legislation experienced the greatest reduction in second-hand tobacco smoke.Comprehensive smoke-free laws are more effective than partial laws in reducing exposure to second-hand tobacco smoke. Also, any law, regardless of scope must be actively enforced in order to have the desired impact. There is continued need for surveillance of smoke-free efforts in all countries.The efficacy of different models of smoke-free laws in reducing exposure to second-hand smoke: A multi-country comparisonMark Ward, Laura M. Currie, Zubair Kabir, Luke Clancy10.1016/j.healthpol.2013.02.007Health Policy 110, 2 (2013)2013-03-18Health Policy2013-03-181102-3S0168-8510(13)X0005-3Public Health Policies207213http://www.healthpolicyjrnl.com/article/PIIS0168851013000316/abstract?rss=yesAbstract: Italy has a monitoring system for genetic testing, consisting in a periodic census of clinical and laboratory activities performed in the country. The experience is limited, however, concerning the translation of genomic testing for complex diseases into clinical practice. For the first time the Italian Ministry of Health has introduced a policy strategic plan on genomics and predictive medicine within the 2010–2012 National Prevention Plan. This achievement was supported by the Italian Network for Public Health Genomics (GENISAP) and will likely contribute to the integration of public health genomics into health care in the country. Our experience might be of interest not only in Italy, but in other high-income countries, struggling to keep a healthy economy and healthy citizens.The policy of public health genomics in ItalyBenedetto Simone, Walter Mazzucco, Maria Rosaria Gualano, Antonella Agodi, Domenico Coviello, Francesca Dagna Bricarelli, Bruno Dallapiccola, Emilio Di Maria, Antonio Federici, Maurizio Genuardi, Liliana Varesco, Walter Ricciardi, Stefania Boccia, for the GENISAP Network10.1016/j.healthpol.2013.01.015Health Policy 110, 2 (2013)2013-03-06Health Policy2013-03-061102-3S0168-8510(13)X0005-3Public Health Policies214219http://www.healthpolicyjrnl.com/article/PIIS0168851013000353/abstract?rss=yesAbstract: Introduction: The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries.Methods: We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation.Results: We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors.Conclusions: This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies.Reported barriers to evaluation in chronic care: Experiences in six European countriesCécile Knai, Ellen Nolte, Matthias Brunn, Arianne Elissen, Annalijn Conklin, Janice Pedersen Pedersen, Laura Brereton, Antje Erler, Anne Frølich, Maria Flamm, Birgitte Fullerton, Ramune Jacobsen, Robert Krohn, Zuleika Saz-Parkinson, Bert Vrijhoef, Karine Chevreul, Isabelle Durand-Zaleski, Fadila Farsi, Antonio Sarría-Santamera, Andreas Soennichsen10.1016/j.healthpol.2013.01.019Health Policy 110, 2 (2013)2013-03-01Health Policy2013-03-011102-3S0168-8510(13)X0005-3International Comparisons220228http://www.healthpolicyjrnl.com/article/PIIS016885101300002X/abstract?rss=yesAbstract: This article investigates the impact of legal determinants of cadaveric and living donor organ transplantation rates using panel data on legislative, procedural and managerial aspects of organ transplantation and procurement, government health expenditures, enrollment rates, religious beliefs, legal systems and civil rights and liberties for 62 countries over a 2-year period. Under living donor organ transplantation, we found that guaranteeing traceability of organs by law or performing psychiatric evaluation to living donors has a sizeable, negative impact on living transplant rates once the remaining determinants of living transplantation have been controlled for. Under cadaveric transplantation, our findings do not suggest an unequivocal and positive association between presumed consent, donor registries and cadaveric transplant rates. However, legally requiring family consent or maintaining written procurement standards for deceased donors has a sizeable, negative impact on cadaveric transplant rates. The latter finding suggests that informing families rather than asking for consent may be an effective strategy to raise procurement rates while respecting patient autonomy. Finally, we confirm that predominantly non-Christian countries have significantly higher living but lower cadaveric transplant rates.The effectiveness of transplant legislation, procedures and management: Cross-country evidenceFırat Bilgel10.1016/j.healthpol.2012.12.014Health Policy 110, 2 (2013)2013-01-23Health Policy2013-01-231102-3S0168-8510(13)X0005-3International Comparisons229242http://www.healthpolicyjrnl.com/article/PIIS0168851012003375/abstract?rss=yesAbstract: This paper is concerned with the cost-efficiency of Private Finance Initiatives (PFIs) in the delivery of hospital facilities in the UK. We outline a methodology for identifying the “fair” return on equity, based on the Weighted Average Cost of Capital (WACC) of each investor. We apply this method to assess the expected returns on a sample of 77 contracts signed between 1997 and 2011 by health care provider organisations in the UK. We show that expected returns are in general in excess of the WACC benchmarks. The findings highlight significant problems in current procurement practices and the methodologies by which bids are assessed. To minimise the financial impact of hospital investments on health care systems, a regulatory regime must ensure that expected returns are set at the “fair” rate.Does the private sector receive an excessive return from investments in health care infrastructure projects? Evidence from the UKVeronica Vecchi, Mark Hellowell, Stefano Gatti10.1016/j.healthpol.2012.12.010Health Policy 110, 2 (2013)2013-01-16Health Policy2013-01-161102-3S0168-8510(13)X0005-3Other Topics243270http://www.healthpolicyjrnl.com/article/PIIS0168851012003302/abstract?rss=yesAbstract: Objectives: To quantify dynamic availability of ambulatory care, and to examine possible associations with non-emergency treatments in emergency departments (EDs).Methods: Longitudinal data from the Taiwan National health Insurance Research Database were used to evaluate 749,584 emergency-medicine cases occurring between 2005 and 2010 according to a modified New York University algorithm. Multivariable-cumulative-logistic-regression analysis with generalized estimating-equation methods was used to determine associations between availability of ambulatory care and the urgency of patients’ medical needs during ED visits.Results: More than half (53.04%) of the ED visits that were evaluated in our study were classified as non-emergencies, and over half of these occurred despite a high availability of ambulatory care facilities (median > 96%). Compared with patients in areas with a low availability of ambulatory care, patients in areas of medium to high availability showed approximately 0.8 times lower odds ratios for associations with non-emergency ED visits.Conclusions: Non-emergency ED visits may be reduced by increasing the availability of ambulatory care facilities in areas with deficits in the availability of such facilities. However, increasing the availability of ambulatory care by raising the number of available ambulatory care physicians or the number of ambulatory care facilities may not reduce non-emergency ED visits in areas with medium to high availability of ambulatory care facilities.The association between the availability of ambulatory care and non-emergency treatment in emergency medicine departments: A comprehensive and nationwide validationChien-Lung Chan, Wender Lin, Nan-Ping Yang, Hsin-Tsung Huang10.1016/j.healthpol.2012.12.003Health Policy 110, 2 (2013)2013-01-04Health Policy2013-01-041102-3S0168-8510(13)X0005-3Other Topics271279http://www.healthpolicyjrnl.com/article/PIIS0168851013000420/abstract?rss=yesAbstract: Background: Much attention has been paid to patient access to emergency services, focusing on hospital reforms, yet very little is known about the characteristics of those presenting to emergency departments.Objectives: By exploiting linkage of emergency records and a representative survey of the 45 and older population in Australia, we provide unique insights into the role of lifestyle in predicting emergency presentations.Methods: A generalized linear regression model is used to estimate the impact of lifestyles on emergency presentations one year ahead. We control for extensive individual characteristics and area fixed-effects.Results: Not smoking, having healthy body weight, taking vitamins, and exercising vigorously and regularly can reduce emergency presentations and also prevent subsequent admissions from emergency. There is no evidence that heavy drinking leads to more frequent emergency visits, but we find a high tendency for heavy drinkers to smoke and be in poor health, which are both major predictors of emergency visits.Conclusions: Targeted public health interventions on smoking, body mass and exercise may reduce emergency visits. Effective public health interventions which target body mass, exercise, current smoking and smoking initiation, may have the effect of reducing ED usage and subsequent admission.Individual-level data linking a survey of the population 45 and older in Australia with their emergency department (ED) records is exploited to provide unique insights into the role of lifestyle in predicting emergency care. Controlling for demographic and socioeconomic characteristics, as well as chronic conditions, we find that being a non-smoker, having a healthy body weight, taking vitamins, and doing a vigorous exercise at least once a week can prevent ED presentations. Being a non-smoker, taking vitamins and exercising also prevent subsequent admissions from ED. We do not find a similar protective effect from complying with dietary recommendations. There is no evidence that heavy drinking alone leads to more frequent ED visits, but we find a high tendency for heavy drinkers to smoke and be in poor health, which are both major predictors of ED visits. These results suggest that targeted public health interventions on smoking, body mass and exercise can reduce ED visits. The use of linked data provides important insight into the characteristics of potential ED users which in turn is valuable for the planning of health services.The effect of lifestyle choices on emergency department use in AustraliaMeliyanni Johar, Glenn Jones, Elizabeth Savage10.1016/j.healthpol.2013.02.002Health Policy 110, 2 (2013)2013-03-07Health Policy2013-03-071102-3S0168-8510(13)X0005-3Other Topics280290http://www.healthpolicyjrnl.com/article/PIIS0168851013000456/abstract?rss=yesAbstract: Social media (for example Facebook and YouTube) uses online and mobile technologies to allow individuals to participate in, comment on and create user-generated content. Twitter is a widely used social media platform that lets users post short publicly available text-based messages called tweets that other users can respond to. Alongside traditional media outlets, Twitter has been a focus for discussions about the controversial and radical reforms to the National Health Service (NHS) in England that were recently passed into law by the current coalition Government. Looking at over 120,000 tweets made about the health reforms, we have investigated whether any insights can be obtained about the role of Twitter in informing, debating and influencing opinion in a specific area of health policy. In particular we have looked at how the sentiment of tweets changed with the passage of the Health and Social Care Bill through Parliament, and how this compared to conventional opinion polls taken over the same time period. We examine which users appeared to have the most influence in the ‘Twittersphere’ and suggest how a widely used metric of academic impact – the H-index – could be applied to measure context-dependent influence on Twitter.Twitter and the health reforms in the English National Health ServiceDominic King, Daniel Ramirez-Cano, Felix Greaves, Ivo Vlaev, Steve Beales, Ara Darzi10.1016/j.healthpol.2013.02.005Health Policy 110, 2 (2013)2013-03-14Health Policy2013-03-141102-3S0168-8510(13)X0005-3Other Topics291297http://www.healthpolicyjrnl.com/article/PIIS0168851013000468/abstract?rss=yesAbstract: The dramatic growth of social media in recent years has not gone unnoticed in the health sector. Media such as Facebook and Twitter are increasingly being used to disseminate information among health professionals and patients but, more recently, are being seen as a source of data for surveillance and research, for example by tracking public concerns or capturing discourses taking place outside traditional media outlets. This raises ethical issues, in particular the extent to which postings are considered public or private and the right to anonymity of those posting on social media. These issues are not clear cut as social media, by their nature, blur the boundary between public and private. There is a need for further research on the beliefs and expectations of those using social media in relation to how their material might be used in research. In contrast, there are areas where the ethical issues are more clear cut, such as when individuals are active participants in research, where traditional considerations apply.Ethical issues in using social media for health and health care researchRebecca McKee10.1016/j.healthpol.2013.02.006Health Policy 110, 2 (2013)2013-03-14Health Policy2013-03-141102-3S0168-8510(13)X0005-3Other Topics298301http://www.healthpolicyjrnl.com/article/PIIS0168851013000894/abstract?rss=yesContents10.1016/S0168-8510(13)00089-4Health Policy 110, 2 (2013)2013-05-01Health Policy2013-05-011102-3S0168-8510(13)X0005-3CO3CO3http://www.healthpolicyjrnl.com/article/PIIS0168851013000900/abstract?rss=yesContents10.1016/S0168-8510(13)00090-0Health Policy 110, 2 (2013)2013-05-01Health Policy2013-05-011102-3S0168-8510(13)X0005-3CO4CO4