Trends Of Healthcare Equity And Factors Influencing Healthcare Utilization And Cost Burden Of Shanghai Civilians

Backgrounds and Objectives: Equity is one of the key performance indicators ofhealth system. This investigation aimed to evaluate the trends in the equity of health careof Shanghai civilians from2008to2013, explore the factors that influence the utilizationof health services and the burden of costs and provide reference for deepening the newreform of healthcare system reform in Shanghai.Contents:(1)trends of equity of health status of civilians of Shanghai city from2008to2013;(2)trends of equity of health care delivery of Shanghai city from2008to2013;(3)trends of equity of health financing of Shanghai city from2008to2013;(4)trends ofequity of health service utilization of Shanghai city from2008to2013;(5) factors thatinfluence the utilization of outpatient and inpatient services in2013;(6) factors thatinfluence the costs of outpatient and inpatient in2013.Methods: We analyzed data from the2008and2013health services survey in thethree districts (counties) in Shanghai, which used multistage stratified random sampling.Four sets of indicators were chosen to measure trends in equity of health service. Thechanges in equity were examined by the concentration index, slope index and Kakwaniindex. The factors that influence the utilization of health services and the burden of costswere explored by logistic regression and multiple stepwise regression or sample selectionmodel respectively.Findings:(1)The last-two-week prevalence rate, chronic illness prevalence rate andself-assessed health score was higher while the duration of last-two-week bed restdecreased in2013. The age-related C of the chronic illness prevalence rate was positiveand the income-related/education level related/health insurance-related Cs of the chronicillness prevalence rate were positive. The absolute value of the age-relatedincome-related/education level related Cs of the chronic illness prevalence rate declined.The absolute value of the income-related Cs and SIIs of the bed rest duration declined. Theabsolute value of the age-related/income-related/education level related Cs and SIIs of theself-assessed health score declined.(2) The Cs and SIIs of the rate of household withphysical distance <1km from the house to the nearest medical facility were all positive in2013with the absolute value less than that in2008.(3) There was no difference betweenthe rate of patients who considered the waiting time for medical consultation short or veryshort in2013and that in2008. The absolute value of the age-related/educational-levelrelated Cs of the rate of patients who considered the waiting time for medical consultation increased.(4) There was no difference between the self-paid hospitalization expense perinpatient in2013and that in2008（adjusted by CPI） while the ratio of self-paidhospitalization expense to annual per-capital income in2013is lower than that in2008.The Kakwani Index of self-paid hospitalization expense in2013was negative with theabsolute value less than that in2008.(5) There was no difference between the rate ofhousehold with catastrophic health expense in2013and that in2008. The C and SII werenegative with the absolute value not more or less than that in2008.(6) The last-two-weekmedical consultation rate ascended while the rate of patient that should but did not consultdescended. The absolute value of the education level-related/age-related Cs and SIIs of therate of last-two-week medical consultation and the rate of patient that should but did notconsultate inclined. The absolute value of the health insurance-related C of last-two-weekmedical consultation declined. The absolute value of income-related/gender-related CI andSII of last-two-week medical consultation rate declined in2013.(7) The hospitalizationrate in2013was higher than that in2008and there was no difference between the rate ofpatients that should hospitalize but not admitted in2013and that in2008. The age-relatedhospitalization rate and the rate of patients that should hospitalize but not admitted wereboth positive while the education level-related/income-related hospitalization rate and therate of patients that should hospitalize but not admitted were all negative．The absolutevalue of the age-related/education level-related/income-related SIIs of the rate of patientsthat should hospitalize but not admitted decreased. The absolute value of theincome-related Cs of the hospitalization rate dramatically decreased.(8) The independentvariables that entered the logistic regression function of outpatient service utilizationincluded age, chronic illness, income，district (county) and physical distance from thehouse to the nearest medical facility.(9) The independent variables that entered the logisticregression function of inpatient service utilization included age, gender, marital status,chronic illness and self-assessed health score.(10) The independent variables that enteredthe multiple stepwise regression function of self-paid outpatient medical expense includedEngel’s coefficient, gender, times of consultation, the physical distance from the house tothe nearest medical facility and the degree of hospital.(11) The independent variables thatentered the sample selection model function of self-paid inpatient medical expenseincluded Engel’s coefficient, the length of hospitalization, surgery, the type of medicalinsurance, the kind of diseases and the degree of hospital.(12) The independent variablesthat entered the sample selection model function of total inpatient medical expense included Engel’s coefficient，the length of hospitalization, surgery, district (county), thekind of diseases and the degree of hospital.Conclusions：(1) The chronic illness prevalence rate were less pro the population withdisadvantaged socioeconomic conditions and the equity of self-assessed health score andbed rest duration was improved in2013.（2）Although there was a positive correlationbetween the physical access and income, the physical access was less pro to the wealthyhousehold.(3) There was a negative correlation between income and the rate of patientswho considered the waiting time for medical consultation short or very short and the equityof subjective waiting time feeling became worse among civilians with different ages oreducation levels in2013.(4) The cost burden of hospitalization was lightened and theequity of health financing for hospitalization was improved in2013.(5) The rate ofhousehold with catastrophic health expense in2013was pro to the lower-incomehousehold in2013. There was no difference in the equtity of the rate of household withcatastrophic health expense between2008and2013.(6) The equity of last-two-weekmedical consultation among civilians with different health insurance or gender or incomewas improved. The equity of suppression of consultation among civilians with differentages or education levels declined.(7) The income-related equity of hospitalization wasimproved in2013. The equity of suppression of hospitalization among civilians withdifferent ages or education levels or income was improved in2013.(8) Age, chronic illness,income, district (county) and physical distance from the house to the nearest medicalfacility influence the outpatient service utilization in2013.(9) Age, gender, marital status,chronic illness and self-assessed health score influence the inpatient service utilization in2013.(10) Engel’s coefficient, gender, times of consultation, the physical distance from thehouse to the nearest medical facility and the degree of hospital influenced self-paidoutpatient medical expense in2013.(11) Engel’s coefficient, the length of hospitalization,surgery, the type of medical insurance, the kind of diseases and the degree of hospitalinfluenced self-paid inpatient medical expense in2013.(12) Engel’s coefficient，the lengthof hospitalization, surgery, district (county), the kind of diseases and the degree of hospitalinfluenced the total inpatient medical expense in2013.Suggestions：(1)Further prevent and control the chronic diseases to improve thehealth status.(2) Further help the aged population to get high-quality healthcare.(3) Furtherimprove the medical aid system to better the health care for the disadvantaged members.(4)Further perfect the medical insurance system to improve protection standard.(5) Further invest more in public health to develop community health services.