Karen Eggleston

All Publications

• Perspectives of Digital Health Innovations in Low- and Middle-Income Health Care Systems From South and Southeast Asia. Journal of medical Internet research Yi, S., Yam, E. L., Cheruvettolil, K., Linos, E., Gupta, A., Palaniappan, L., Rajeshuni, N., Vaska, K. G., Schulman, K., Eggleston, K. N. 2024; 26: e57612

  Abstract

  Digital health innovations have emerged globally as a transformative force for addressing health system challenges, particularly in resource-constrained settings. The COVID-19 pandemic underscored the critical importance of these innovations for enhancing public health. In South and Southeast Asia, a region known for its cultural diversity and complex health care landscape, digital health innovations present a dynamic interplay of challenges and opportunities. We advocate for ongoing research built into system development and an evidence-based strategy focusing on designing and scaling national digital health infrastructures combined with a vibrant ecosystem or "marketplace" of local experiments generating shared experience about what works in which settings. As the global digital health revolution unfolds, the perspectives drawn from South and Southeast Asia-including the importance of local partnerships-may provide valuable insights for shaping future strategies and informing similar initiatives in low- and middle-income countries, contributing to effective digital health strategies across diverse global health contexts.

  View details for DOI 10.2196/57612

  View details for PubMedID 39586089

• Health Insurance and Subjective Well-being: Evidence from Integrating Medical Insurance across urban and rural areas in China. Health policy and planning Zhou, Q., Eggleston, K., Liu, G. G. 2024

  Abstract

  Health insurance coverage and the risk protection it provides may improve enrollees' subjective well-being (SWB), as demonstrated for example by Oregon Medicaid's randomized expansion significantly improving enrollees' mental health and happiness. Yet little evidence from low- and middle-incomen countries documents the link between insurance coverage and SWB. We analyze individual-level data on a large natural experiment in China: the integration of the rural and urban resident health insurance programs. This reform, expanded nationally since 2016, is recognized as a vital step toward attaining the goal of providing affordable and equitable basic healthcare in China, because integration raises the level of healthcare coverage for rural residents to that enjoyed by their urban counterparts. This study is the first to investigate the impact of urban-rural health insurance integration on the SWB of the Chinese population. Analyzing 2011-2018 data from the China Health and Retirement Longitudinal Study in a difference-in-difference (DID) framework with variation in the treatment timing, we find that the integration policy significantly improved the life satisfaction of rural residents, especially among low-income and elderly individuals. The positive impact of the integration on SWB appears to stem from the improvement of rural residents' mental health (decrease in depressive symptoms) and associated increases in some health behaviors, as well as a mild increase in outpatient care utilization and financial risk protection. There was no discernible impact of the integration on SWB among urban residents, suggesting that the reform reduced inequality in healthcare access and health outcomes for poorer rural residents without negative spillovers on their urban counterparts.

  View details for DOI 10.1093/heapol/czae031

  View details for PubMedID 38648378

• Patient Preferences for Telemedicine Among Individuals With Chronic Conditions in South Korea During the Early COVID-19 Pandemic. Asia-Pacific journal of public health Chang, A., Liang, R., Eggleston, K., Kim, D. 2023: 10105395231204994

  View details for DOI 10.1177/10105395231204994

  View details for PubMedID 37837284

• Potential health and economic impact associated with achieving risk factor control in Chinese adults with diabetes: amicrosimulation modelling study. The Lancet regional health. Western Pacific Quan, J., Zhao, Z., Wang, L., Ng, C. S., Kwok, H. H., Zhang, M., Zhou, S., Ye, J., Ong, X. J., Ma, R., Leung, G. M., Eggleston, K., Zhou, M. 2023; 33: 100690

  Abstract

  Background: The prevalence of diabetes has risen sharply in China. Improving modifiable risk factors such as glycaemia and blood pressure could substantially reduce disease burden and treatment costs to achieve a healthier China by2030.Methods: We used a nationally representative population-based survey of adults with diabetes in 31 provinces in mainland China to assess the prevalence of risk factor control. We adopted a microsimulation approach to estimate the impact of improved control of blood pressure and glycaemia on mortality, quality-adjusted life-years (QALYs), and healthcare cost. We applied the validated CHIME diabetes outcomes model over a 10-year time horizon. Baseline scenario of status quo was evaluated against alternative strategies based on World Health Organization and Chinese Diabetes Society guidelines.Findings: Among 24,319 survey participants with diabetes (age 30-70), 69.1% (95% CI: 67.7-70.5) achieved optimal diabetes control (HbA1c <7% [53mmol/mol]), 27.7% [26.1-29.3] achieved blood pressure control (<130/80mmHg) and 20.1% (18.6-21.6) achieved both targets. Achieving 70% control rate for people with diabetes could reduce deaths before age 70 by 7.1% (5.7-8.7), reduce medical costs by 14.9% (12.3-18.0), and gain 50.4 QALYs (44.8-56.0) per 1000 people over 10 years compared to the baseline status quo. The largest health gains were for strategies including strict blood pressure control of 130/80mmHg, particularly in rural areas.Interpretation: Based on a nationally representative survey, few adults with diabetes in China achieved optimal control of glycaemia and blood pressure. Substantial health gains and economic savings are potentially achievable with better risk factor control especially in rural settings.Funding: Chinese Central Government, Research Grants Council of the Hong Kong Special Administrative Region, China [27112518].

  View details for DOI 10.1016/j.lanwpc.2023.100690

  View details for PubMedID 37181534

• Family physician services and blood pressure control in China: A population-based retrospective cohort study JOURNAL OF HEALTH SERVICES RESEARCH & POLICY Jing, R., Eggleston, K., Lai, X., Fang, H. 2023: 13558196221149929

  Abstract

  Given the importance of continuous family physician (FP) care in the management of hypertension, we explored the effects of such care among hypertensive patients in China, a country where such care is generally underutilized. We examined the longitudinal association between the use and continuity of FP services and health outcomes including blood pressure (BP) control rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP).We conducted a population-based cohort study using data from the retrospective regional electronic health record database in Xiamen City, China. The study considered 18,119 hypertensive patients aged over 18 years who had at least two visits to a health center in the preceding 12 months. The generalized estimating equation model was adopted to estimate the longitudinal association between FP service utilization and health outcomes.Hypertensive patients treated by their own FPs had a higher BP control rate (OR = 1.14, 95% CI: 1.02-1.28) and lower DBP (-0.36 mmHg, 95% CI: -0.52 to -0.20) than those without a FP or those with a FP but treated by a general community physician (GCP). Compared with hypertensive patients treated exclusively by GCPs, patients treated continuously and exclusively by a FP were 45% more likely to have their BP under control (OR = 1.45, 95% CI: 1.32-1.60), and their SBP and DBP were lower by 0.6 mmHg (95% CI: -0.78 to -0.39) and 0.6 mmHg (95% CI: -0.79 to -0.47), respectively.Hypertensive patients continuously treated by their own FPs performed better in terms of BP control rate, SBP and DBP values. In addition, the number and continuity of FP visits were associated with better BP control.

  View details for DOI 10.1177/13558196221149929

  View details for Web of Science ID 000913844400001

  View details for PubMedID 36630298

• Association between the quality of primary care, insurance coverage, and diabetes-related health outcomes in a cohort of older adults in China: results from the China Health and Retirement Longitudinal Study. BMJ open Zhang, A., Quan, J., Eggleston, K. 2022; 12 (9): e059756

  Abstract

  This study aims to identify the association between diabetes diagnosis, health outcomes, insurance scheme, and the quality of county-level primary care in a cohort of older Chinese adults.Data from the China Health and Retirement Longitudinal Study, a nationally-representative panel survey of people aged 45 and over in China.Among participants with valid diabetes-related and hypertension-related medical history and biomarkers (n=8207), participants with diabetes (n=1318) were identified using biomarkers and self-reported medical history. Individual models were run using complete case analysis.Among 1318 individuals with diabetes in 2011, 59.8% were unaware of their disease status. Diagnosis rates were significantly higher among participants with more generous public health insurance coverage (OR 3.58; 95% CI 2.15 to 5.98) and among those with other comorbidities such as dyslipidemia (OR 2.88; 95% CI 2.03 to 4.09). After adjusting for demographics, individuals with more generous public health insurance coverage did not have better glucose control at 4 years follow-up (OR 0.55; 95% CI 0.26 to 1.18) or fewer inpatient hospital admissions at 4 years (OR 1.29; 95% CI 0.72 to 2.33) and 7 years follow-up (OR 1.12; 95% CI 0.62 to 2.05). Individuals living in counties with better county-level primary care did not have better glucose control at 4 years follow-up (OR 0.69; 95% CI 0.01 to 33.36), although they did have fewer inpatient hospital admissions at 4 years follow-up (OR 0.03; 95% CI 0.00 to 0.95). Diabetes diagnosis was a significant independent predictor of both better glucose control at 4 years follow-up (OR 13.33; 95% CI 8.56 to 20.77) and increased inpatient hospital stays at 4 years (OR 1.72; 95% CI 1.20 to 2.47) and 7 years (OR 1.82; 95% CI 1.28 to 2.58) follow-up.These findings suggest that participants with diabetes are often diagnosed concurrently with other comorbid disease conditions or after diabetes-related complications have already developed, thus leading to worse health outcomes in subsequent years despite improvements in health associated with better primary care. These findings suggest the importance of strengthening primary care and insurance coverage among older adults to focus on diagnosing and treating diabetes early, in order to prevent avoidable health complications and promote healthy aging.

  View details for DOI 10.1136/bmjopen-2021-059756

  View details for PubMedID 36167393

• Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach. The European journal of health economics : HEPAC : health economics in prevention and care Lu, J. R., Chen, Y. I., Eggleston, K., Chen, C., Chen, B. 2022

  Abstract

  Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.

  View details for DOI 10.1007/s10198-022-01504-3

  View details for PubMedID 35995886

• Projecting prevalence of frailty and dementia and the economic cost of care in Japan from 2016 to 2043: a microsimulation modelling study. The Lancet. Public health Kasajima, M., Eggleston, K., Kusaka, S., Matsui, H., Tanaka, T., Son, B., Iijima, K., Goda, K., Kitsuregawa, M., Bhattacharya, J., Hashimoto, H. 2022; 7 (5): e458-e468

  Abstract

  BACKGROUND: Dementia and frailty often accompany one another in older age, requiring complex care and resources. Available projections provide little information on their joint impact on future health-care need from different segments of society and the associated costs. Using a newly developed microsimulation model, we forecast this situation in Japan as its population ages and decreases in size.METHODS: In this microsimulation modelling study, we built a model that simulates an individual's status transition across 11 chronic diseases (including diabetes, coronary heart disease, and stroke) as well as depression, functional status, and self-reported health, by age, sex, and educational strata (less than high school, high school, and college and higher), on the basis of nationally representative health surveys and existing cohort studies. Using the simulation results, we projected the prevalence of dementia and frailty, life expectancy with these conditions, and the economic cost for formal and informal care over the period 2016-43 in the population of Japan aged 60 years and older.FINDINGS: Between 2016 and 2043, life expectancy at age 65 years will increase from 23·7 years to 24·9 years in women and from 18·7 years to 19·9 years in men. Years spent with dementia will decrease from 4·7 to 3·9 years in women and 2·2 to 1·4 years in men. By contrast, years spent with frailty will increase from 3·7 to 4·0 years for women and 1·9 to 2·1 for men, and across all educational groups. By 2043, approximately 29% of women aged 75 years and older with a less than high school education are estimated to have both dementia and frailty, and so will require complex care. The expected need for health care and formal long-term care is anticipated to reach costs of US$125 billion for dementia and $97 billion for frailty per annum in 2043 for the country.INTERPRETATION: Japan's Government and policy makers should consider the potential social challenges in caring for a sizable population of older people with frailty and dementia, and a widening disparity in the burden of those conditions by sex and by educational status. The future burden of dementia and frailty should be countered not only by curative and preventive technology innovation, but also by social policies to mitigate the health gap.FUNDING: Japan Society for the Promotion of Science, Hitachi - the University of Tokyo Laboratory for a sustainable society, and the National Institute of Ageing.

  View details for DOI 10.1016/S2468-2667(22)00044-5

  View details for PubMedID 35487231

• Projecting prevalence of frailty and dementia and the economic cost of care in Japan from 2016 to 2043: a microsimulation modelling study LANCET PUBLIC HEALTH Kasajima, M., Eggleston, K., Kusaka, S., Matsui, H., Tanaka, T., Son, B., Iijima, K., Goda, K., Kitsuregawa, M., Bhattacharya, J., Hashimoto, H. 2022; 7 (5): E458-E468

  View details for Web of Science ID 000844229800015

• The Association between Health Workforce and Health Outcomes: A Cross-Country Econometric Study. Social indicators research Liu, J., Eggleston, K. 2022: 1-24

  Abstract

  This study investigates the strength and significance of the associations of health workforce with multiple health outcomes and COVID-19 excess deaths across countries, using the latest WHO dataset. Multiple log-linear regression analyses, counterfactual scenarios analyses, and Pearson correlation analyses were performed. The average density of health workforce and the average levels of health outcomes were strongly associated with country income level. A higher density of the health workforce, especially the aggregate density of skilled health workers and density of nursing and midwifery personnel, was significantly associated with better levels of several health outcomes, including maternal mortality ratio, under-five mortality rate, infant mortality rate, and neonatal mortality rate, and was significantly correlated with a lower level of COVID-19 excess deaths per 100K people, though not robust to weighting by population. The low density of the health workforce, especially in relatively low-income countries, can be a major barrier to improving these health outcomes and achieving health-related SDGs; however, improving the density of the health workforce alone is far from enough to achieve these goals. Our study suggests that investment in health workforce should be an integral part of strategies to achieve health-related SDGs, and achieving non-health SDGs related to poverty alleviation and expansion of female education are complementary to achieving both sets of goals, especially for those low- and middle-income countries. In light of the strains on the health workforce during the current COVID-19 pandemic, more attention should be paid to health workforce to strengthen health system resilience and long-term improvement in health outcomes.Supplementary Information: The online version contains supplementary material available at 10.1007/s11205-022-02910-z.

  View details for DOI 10.1007/s11205-022-02910-z

  View details for PubMedID 35310535

• Educational Gradients in Disability among Asia's Future Elderly: Projections for the Republic of Korea and Singapore ASIAN DEVELOPMENT REVIEW Chen, C., Lim, J., Chia, N., Kim, D., Park, H., Wang, L., Tysinger, B., Zhao, M., Cook, A. R., Chong, M., Yuan, J., Ma, S., Tan, K., Ng, T., Koh, W., Yoong, J., Bhattacharya, J., Eggleston, K. 2022; 39 (01): 51-89

  View details for DOI 10.1142/S0116110522500056

  View details for Web of Science ID 000923231500003

• Impact of the COVID-19 Pandemic on Chronic Disease Care in India, China, Hong Kong, Korea, and Vietnam. Asia-Pacific journal of public health Singh, K., Xin, Y., Xiao, Y., Quan, J., Kim, D., Nguyen, T., Kondal, D., Yan, X., Li, G., Ng, C. S., Kang, H., Minh Nam, H., Mohan, S., Yan, L. L., Shi, C., Chen, J., Thi Hong Hanh, H., Mohan, V., Kong, S., Eggleston, K., Research Group on COVID-19 and Chronic disease care in Asia, Prabhakaran, D., Tandon, N., Narayan, K. V., Ali, M. K., Ranjit Mohan, A., Mohan, D., Jagannathan, S., Venkateshmurthy, N. S., Jarhyan, P., Gong, E., Xiong, S., Chen, X., Ostbye, T., Duman, E. K., Cowling, B. J., Ng, T. W., Xiao, J., Leung, G. M., Chang, A., Liang, R. 1800: 10105395211073052

  Abstract

  This study aims to provide evidence on how the COVID-19 pandemic has impacted chronic disease care in diverse settings across Asia. Cross-sectional surveys were conducted to assess the health, social, and economic consequences of the pandemic in India, China, Hong Kong, Korea, and Vietnam using standardized questionnaires. Overall, 5672 participants with chronic conditions were recruited from 5 countries. The mean age of the participants ranged from 55.9 to 69.3 years. A worsened economic status during the COVID-19 pandemic was reported by 19% to 59% of the study participants. Increased difficulty in accessing care was reported by 8% to 24% of participants, except Vietnam: 1.6%. The worsening of diabetes symptoms was reported by 5.6% to 14.6% of participants, except Vietnam: 3%. In multivariable regression analyses, increasing age, female participants, and worsened economic status were suggestive of increased difficulty in access to care, but these associations mostly did not reach statistical significance. In India and China, rural residence, worsened economic status and self-reported hypertension were statistically significantly associated with increased difficulty in access to care or worsening of diabetes symptoms. These findings suggest that the pandemic disproportionately affected marginalized and rural populations in Asia, negatively affecting population health beyond those directly suffering from COVID-19.

  View details for DOI 10.1177/10105395211073052

  View details for PubMedID 35067078

• Urban-rural health insurance integration in china: impact on health care utilization, financial risk protection, and health status APPLIED ECONOMICS Zhou, Q., He, Q., Eggleston, K., Liu, G. G. 2021

  View details for DOI 10.1080/00036846.2021.1998323

  View details for Web of Science ID 000715724100001

• The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China. Journal of health economics Ding, H., Chen, Y., Yu, M., Zhong, J., Hu, R., Chen, X., Wang, C., Xie, K., Eggleston, K. 2021; 80: 102539

  Abstract

  Health systems globally face increasing morbidity and mortality from chronic diseases, yet many - especially in low- and middle-income countries - lack strong chronic disease management in primary health care (PHC). We provide evidence on China's efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% lower likelihood of having an inpatient admission, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program.

  View details for DOI 10.1016/j.jhealeco.2021.102539

  View details for PubMedID 34740053

• The Impact of Catastrophic Medical Insurance in China: A five-year patient-level panel study LANCET REGIONAL HEALTH-WESTERN PACIFIC Yu, M., Zhong, J., Hu, R., Chen, X., Wang, C., Xie, K., Guzman, M., Gui, X., Kong, S., Qu, T., Eggleston, K. 2021; 13

  View details for DOI 10.1016/j.lanwpc.2021.100174

  View details for Web of Science ID 000690384700020

• The Impact of Catastrophic Medical Insurance in China: A five-year patient-level panel study. The Lancet regional health. Western Pacific Yu, M., Zhong, J., Hu, R., Chen, X., Wang, C., Xie, K., Guzman, M., Gui, X., Kong, S. T., Qu, T., Eggleston, K. 2021; 13: 100174

  Abstract

  Background: In an effort to provide greater financial protection from the risk of large medical expenditures, China has gradually added catastrophic medical insurance (CMI) to the various basic insurance schemes. Tongxiang, a rural county in Zhejiang province, China, has had CMI since 2000 for their employee insurance scheme, and since 2014 for their resident insurance scheme. Methods: Compiling and analysing patient-level panel data over five years, we use a difference-in-difference approach to study the effect of the 2014 introduction of CMI for resident insurance beneficiaries in Tongxiang. In our study design, resident insurance beneficiaries are the treatment group, while employee insurance beneficiaries are the control group. Findings: We find that availability of CMI significantly increases medical expenditures among resident insurance beneficiaries, including for both inpatient and outpatient spending. Despite the greater financial protection, out-of-pocket expenditures increased, in part because patients accessed treatment more often at higher-level hospitals. Interpretation: Better financial coverage for catastrophic medical expenditures led to greater access and expenditures, not only for inpatient admissions-the category that most often leads to catastrophic expenditures-but for outpatient visits as well. These patterns of expenditure change with CMI may reflect both enhanced access to a patient's preferred site of care as well as the influence of incentives encouraging more care under fee-for-service payment. Funding: Stanford University's Freeman Spogli Institute for International Studies' Policy Implementation Lab and a Shorenstein Asia Pacific Research Center faculty research award provided funding for this project. Chinese translation of the abstract (Appendix 1).

  View details for DOI 10.1016/j.lanwpc.2021.100174

  View details for PubMedID 34527979

  View details for PubMedCentralID PMC8358690

• Healthcare utilization at retirement in China. Health economics Zhou, Q., Eggleston, K., Liu, G. G. 2021

  Abstract

  Previous studies, mostly analyzing data from high-income economies, present mixed evidence on the relationship between retirement and healthcare utilization. This study leverages administrative data for over 80,000 urban Chinese workers to explore the effect of retirement on outpatient and inpatient care utilization using a fuzzy regression discontinuity design. The analyses of medical claims from a large city in China complement and extend the current literature by providing evidence of potential mechanisms underlying increased short-run utilization. In this relatively well-insured population, annual total healthcare expenditures significantly increase primarily because of more intensive use of outpatient care at retirement, especially at the right tail of the distribution of outpatient visits. This increase in outpatient care appears to stem from a decline in the patient cost-sharing rate and the reduced opportunity cost of time upon retirement, interacting with supplier-induced demand, not from any sudden impact on health. We do not find evidence of change in inpatient care at retirement. The results hold for both females and males, and are robust to a number of sensitivity analyses.

  View details for DOI 10.1002/hec.4400

  View details for PubMedID 34322936

• Patient experiences and perceptions of chronic disease care during the COVID-19 pandemic in India: a qualitative study. BMJ open Singh, K., Kaushik, A., Johnson, L., Jaganathan, S., Jarhyan, P., Deepa, M., Kong, S., Venkateshmurthy, N. S., Kondal, D., Mohan, S., Anjana, R. M., Ali, M. K., Tandon, N., Narayan, K. M., Mohan, V., Eggleston, K., Prabhakaran, D. 2021; 11 (6): e048926

  Abstract

  OBJECTIVE: People with chronic conditions are known to be vulnerable to the COVID-19 pandemic. This study aims to describe patients' lived experiences, challenges faced by people with chronic conditions, their coping strategies, and the social and economic impacts of the COVID-19 pandemic.DESIGN, SETTING AND PARTICIPANTS: We conducted a qualitative study using a syndemic framework to understand the patients' experiences of chronic disease care, challenges faced during the lockdown, their coping strategies and mitigators during the COVID-19 pandemic in the context of socioecological and biological factors. A diverse sample of 41 participants with chronic conditions (hypertension, diabetes, stroke and cardiovascular diseases) from four sites (Delhi, Haryana, Vizag and Chennai) in India participated in semistructured interviews. All interviews were audio recorded, transcribed, translated, anonymised and coded using MAXQDA software. We used the framework method to qualitatively analyse the COVID-19 pandemic impacts on health, social and economic well-being.RESULTS: Participant experiences during the COVID-19 pandemic were categorised into four themes: challenges faced during the lockdown, experiences of the participants diagnosed with COVID-19, preventive measures taken and lessons learnt during the COVID-19 pandemic. A subgroup of participants faced difficulties in accessing healthcare while a few reported using teleconsultations. Most participants reported adverse economic impact of the pandemic which led to higher reporting of anxiety and stress. Participants who tested COVID-19 positive reported experiencing discrimination and stigma from neighbours. All participants reported taking essential preventive measures.CONCLUSION: People with chronic conditions experienced a confluence (reciprocal effect) of COVID-19 pandemic and chronic diseases in the context of difficulty in accessing healthcare, sedentary lifestyle and increased stress and anxiety. Patients' lived experiences during the pandemic provide important insights to inform effective transition to a mixed realm of online consultations and 'distanced' physical clinic visits.

  View details for DOI 10.1136/bmjopen-2021-048926

  View details for PubMedID 34145019

• False alarm? Estimating the marginal value of health signals & nbsp; JOURNAL OF PUBLIC ECONOMICS Iizuka, T., Nishiyama, K., Chen, B., Eggleston, K. 2021; 195

  View details for DOI 10.1016/j.jpubeco.2021.104368

  View details for Web of Science ID 000632254900005

• Health, psychosocial, and economic impacts of the COVID-19 pandemic on people with chronic conditions in India: a mixed methods study. BMC public health Singh, K., Kondal, D., Mohan, S., Jaganathan, S., Deepa, M., Venkateshmurthy, N. S., Jarhyan, P., Anjana, R. M., Narayan, K. M., Mohan, V., Tandon, N., Ali, M. K., Prabhakaran, D., Eggleston, K. 2021; 21 (1): 685

  Abstract

  BACKGROUND: People with chronic conditions are disproportionately prone to be affected by the COVID-19 pandemic but there are limited data documenting this. We aimed to assess the health, psychosocial and economic impacts of the COVID-19 pandemic on people with chronic conditions in India.METHODS: Between July 29, to September 12, 2020, we telephonically surveyed adults (n=2335) with chronic conditions across four sites in India. Data on participants' demographic, socio-economic status, comorbidities, access to health care, treatment satisfaction, self-care behaviors, employment, and income were collected using pre-tested questionnaires. We performed multivariable logistic regression analysis to examine the factors associated with difficulty in accessing medicines and worsening of diabetes or hypertension symptoms. Further, a diverse sample of 40 participants completed qualitative interviews that focused on eliciting patient's experiences during the COVID-19 lockdowns and data analyzed using thematic analysis.RESULTS: One thousand seven hundred thirty-four individuals completed the survey (response rate=74%). The mean (SD) age of respondents was 57.8years (11.3) and 50% were men. During the COVID-19 lockdowns in India, 83% of participants reported difficulty in accessing healthcare, 17% faced difficulties in accessing medicines, 59% reported loss of income, 38% lost jobs, and 28% reduced fruit and vegetable consumption. In the final-adjusted regression model, rural residence (OR, 95%CI: 4.01,2.90-5.53), having diabetes (2.42, 1.81-3.25) and hypertension (1.70,1.27-2.27), and loss of income (2.30,1.62-3.26) were significantly associated with difficulty in accessing medicines. Further, difficulties in accessing medicines (3.67,2.52-5.35), and job loss (1.90,1.25-2.89) were associated with worsening of diabetes or hypertension symptoms. Qualitative data suggest most participants experienced psychosocial distress due to loss of job or income and had difficulties in accessing in-patient services.CONCLUSION: People with chronic conditions, particularly among poor, rural, and marginalized populations, have experienced difficulties in accessing healthcare and been severely affected both socially and financially by the COVID-19 pandemic.

  View details for DOI 10.1186/s12889-021-10708-w

  View details for PubMedID 33832478

• Development and validation of the CHIME simulation model to assess lifetime health outcomes of prediabetes and type 2 diabetes in Chinese populations: A modeling study. PLoS medicine Quan, J., Ng, C. S., Kwok, H. H., Zhang, A., Yuen, Y. H., Choi, C. H., Siu, S. C., Tang, S. Y., Wat, N. M., Woo, J., Eggleston, K., Leung, G. M. 2021; 18 (6): e1003692

  Abstract

  Existing predictive outcomes models for type 2 diabetes developed and validated in historical European populations may not be applicable for East Asian populations due to differences in the epidemiology and complications. Despite the continuum of risk across the spectrum of risk factor values, existing models are typically limited to diabetes alone and ignore the progression from prediabetes to diabetes. The objective of this study is to develop and externally validate a patient-level simulation model for prediabetes and type 2 diabetes in the East Asian population for predicting lifetime health outcomes.We developed a health outcomes model from a population-based cohort of individuals with prediabetes or type 2 diabetes: Hong Kong Clinical Management System (CMS, 97,628 participants) from 2006 to 2017. The Chinese Hong Kong Integrated Modeling and Evaluation (CHIME) simulation model comprises of 13 risk equations to predict mortality, micro- and macrovascular complications, and development of diabetes. Risk equations were derived using parametric proportional hazard models. External validation of the CHIME model was assessed in the China Health and Retirement Longitudinal Study (CHARLS, 4,567 participants) from 2011 to 2018 for mortality, ischemic heart disease, cerebrovascular disease, renal failure, cataract, and development of diabetes; and against 80 observed endpoints from 9 published trials using 100,000 simulated individuals per trial. The CHIME model was compared to United Kingdom Prospective Diabetes Study Outcomes Model 2 (UKPDS-OM2) and Risk Equations for Complications Of type 2 Diabetes (RECODe) by assessing model discrimination (C-statistics), calibration slope/intercept, root mean square percentage error (RMSPE), and R2. CHIME risk equations had C-statistics for discrimination from 0.636 to 0.813 internally and 0.702 to 0.770 externally for diabetes participants. Calibration slopes between deciles of expected and observed risk in CMS ranged from 0.680 to 1.333 for mortality, myocardial infarction, ischemic heart disease, retinopathy, neuropathy, ulcer of the skin, cataract, renal failure, and heart failure; 0.591 for peripheral vascular disease; 1.599 for cerebrovascular disease; and 2.247 for amputation; and in CHARLS outcomes from 0.709 to 1.035. CHIME had better discrimination and calibration than UKPDS-OM2 in CMS (C-statistics 0.548 to 0.772, slopes 0.130 to 3.846) and CHARLS (C-statistics 0.514 to 0.750, slopes -0.589 to 11.411); and small improvements in discrimination and better calibration than RECODe in CMS (C-statistics 0.615 to 0.793, slopes 0.138 to 1.514). Predictive error was smaller for CHIME in CMS (RSMPE 3.53% versus 10.82% for UKPDS-OM2 and 11.16% for RECODe) and CHARLS (RSMPE 4.49% versus 14.80% for UKPDS-OM2). Calibration performance of CHIME was generally better for trials with Asian participants (RMSPE 0.48% to 3.66%) than for non-Asian trials (RMPSE 0.81% to 8.50%). Main limitations include the limited number of outcomes recorded in the CHARLS cohort, and the generalizability of simulated cohorts derived from trial participants.Our study shows that the CHIME model is a new validated tool for predicting progression of diabetes and its outcomes, particularly among Chinese and East Asian populations that has been lacking thus far. The CHIME model can be used by health service planners and policy makers to develop population-level strategies, for example, setting HbA1c and lipid targets, to optimize health outcomes.

  View details for DOI 10.1371/journal.pmed.1003692

  View details for PubMedID 34166382

• Cost-effective interventions to prevent non-communicable diseases: increasing the evidence base in India and other low- and middle-income settings. BMC medicine Eggleston, K., Jain, R. 2020; 18 (1): 379

  View details for DOI 10.1186/s12916-020-01850-0

  View details for PubMedID 33292216

• Future projection of the health and functional status of older people in Japan: A multistate transition microsimulation model with repeated cross-sectional data. Health economics Kasajima, M., Hashimoto, H., Suen, S., Chen, B., Jalal, H., Eggleston, K., Bhattacharya, J. 2020

  Abstract

  Accurate future projections of population health are imperative to plan for the future healthcare needs of a rapidly aging population. Multistate-transition microsimulation models, such as the U.S. Future Elderly Model, address this need but require high-quality panel data for calibration. We develop an alternative method that relaxes this data requirement, using repeated cross-sectional representative surveys to estimate multistate-transition contingency tables applied to Japan's population. We calculate the birth cohort sex-specific prevalence of comorbidities using five waves of the governmental health surveys. Combining estimated comorbidity prevalence with death record information, we determine the transition probabilities of health statuses. We then construct a virtual Japanese population aged 60 and older as of 2013 and perform a microsimulation to project disease distributions to 2046. Our estimates replicate governmental projections of population pyramids and match the actual prevalence trends of comorbidities and the disease incidence rates reported in epidemiological studies in the past decade. Our future projections of cardiovascular diseases indicate lower prevalence than expected from static models, reflecting recent declining trends in disease incidence and fatality.

  View details for DOI 10.1002/hec.3986

  View details for PubMedID 32662080

• Are quality-adjusted medical prices declining for chronic disease? Evidence from diabetes care in four health systems. The European journal of health economics : HEPAC : health economics in prevention and care Eggleston, K. n., Chen, B. K., Chen, C. H., Chen, Y. I., Feenstra, T. n., Iizuka, T. n., Lam, J. T., Leung, G. M., Lu, J. R., Rodriguez-Sanchez, B. n., Struijs, J. N., Quan, J. n., Newhouse, J. P. 2020

  Abstract

  Improvements in medical treatment have contributed to rising health spending. Yet there is relatively little evidence on whether the spending increase is "worth it" in the sense of producing better health outcomes of commensurate value-a critical question for understanding productivity in the health sector and, as that sector grows, for deriving an accurate quality-adjusted price index for an entire economy. We analyze individual-level panel data on medical spending and health outcomes for 123,548 patients with type 2 diabetes in four health systems: Japan, The Netherlands, Hong Kong and Taiwan. Using a "cost-of-living" method that measures value based on improved survival, we find a positive net value of diabetes care: the value of improved survival outweighs the added costs of care in each of the four health systems. This finding is robust to accounting for selective survival, end-of-life spending, and a range of values for a life-year or fraction of benefits attributable to medical care. Since the estimates do not include the value from improved quality of life, they are conservative. We, therefore, conclude that the increase in medical spending for management of diabetes is offset by an increase in quality.

  View details for DOI 10.1007/s10198-020-01164-1

  View details for PubMedID 32078719

• Smoking, life expectancy, and chronic disease in South Korea, Singapore, and the United States: A microsimulation model. Health economics Kim, D., Chen, C., Tysinger, B., Park, S., Chong, M. Z., Wang, L., Zhao, M., Yuan, J., Koh, W., Yoong, J., Bhattacharya, J., Eggleston, K. 2019

  Abstract

  The substantial social and economic burden attributable to smoking is well-known, with heavy smokers at higher risk of chronic disease and premature mortality than light smokers and nonsmokers. In aging societies with high rates of male smoking such as in East Asia, smoking is a leading preventable risk factor for extending lives (including work-lives) and healthy aging. However, little is known about whether smoking interventions targeted at heavy smokers relative to light smokers lead to disproportionately larger improvements in life expectancy and prevalence of chronic diseases and how the effects vary across populations. Using a microsimulation model, we examined the health effects of smoking reduction by simulating an elimination of smoking among subgroups of smokers in South Korea, Singapore, and the United States. We found that life expectancy would increase by 0.2 to 1.5 years among light smokers and 2.5 to 3.7 years among heavy smokers. Whereas both interventions led to an increased life expectancy and decreased the prevalence of chronic diseases in all three countries, the life-extension benefits were greatest for those who would otherwise have been heavy smokers. Our findings illustrate how smoking interventions may have significant economic and social benefits, especially for life extension, that vary across countries.

  View details for DOI 10.1002/hec.3978

  View details for PubMedID 31802569

• Enhancing financial protection under China's social health insurance to achieve universal health coverage. BMJ (Clinical research ed.) Fang, H., Eggleston, K., Hanson, K., Wu, M. 2019; 365: l2378

  View details for DOI 10.1136/bmj.l2378

  View details for PubMedID 31227485

• Economic Impact of Diabetes in South Asia: the Magnitude of the Problem. Current diabetes reports Singh, K., Narayan, K. M., Eggleston, K. 2019; 19 (6): 34

  Abstract

  PURPOSE OF REVIEW: To critically assess and identify gaps in the current literature on the economic impact of diabetes in South Asia.RECENT FINDINGS: The total annual (direct medical and non-medical and indirect) costs for diabetes care in South Asia range from $483-$2637 per patient, and on an average 5.8% of patients with diabetes suffer catastrophic spending i.e. when households reduce basic expenditure by 40% to cope with healthcare costs. The mean direct costs per patient are positively associated with a country's gross domestic product (GDP) per capita, although there is wide heterogeneity across South Asian countries. With an estimated 84 million people suffering from diabetes in South Asia, diabetes imposes a substantial economic burden on individuals, families, and society. Since the disease burden increasingly occurs in the most productive midlife period, it adversely affects workforce productivity and macroeconomic development. Diabetes-related complications lead to markedly higher treatment costs, causing catastrophic medical spending for many households, thus underscoring the importance of preventing diabetes-related complications.

  View details for DOI 10.1007/s11892-019-1146-1

  View details for PubMedID 31098775

• Financing longevity: The economics of pensions, health, and long-term care: Introduction to the special issue JOURNAL OF THE ECONOMICS OF AGEING Eggleston, K. N., Mukherjee, A. 2019; 13: 1–6

  View details for DOI 10.1016/j.jeoa.2018.10.001

  View details for Web of Science ID 000468800600001

• Direct medical cost of diabetes in rural China using electronic insurance claims data and diabetes management data JOURNAL OF DIABETES INVESTIGATION Wu, H., Eggleston, K. N., Zhong, J., Hu, R., Wang, C., Xie, K., Chen, Y., Chen, X., Yu, M. 2019; 10 (2): 531–38

  Abstract

  To evaluate the annual direct medical cost attributable to type 2 diabetes mellitus according to socioeconomic factors, medical conditions and complications categories.We created uniquely detailed data from merging datasets of the local diabetes management system and the social security system in Tongxiang, China. We calculated the type 2 diabetes mellitus-related total cost and out-of-pocket cost for inpatient admissions and outpatient visits, and compared the cost for patients with or without complications by different healthcare items.A total of 16,675 patients were eligible for analysis. The type 2 diabetes mellitus-related cost accounted for 40.6% of the overall cost. The cost per patient was estimated to be a median of 1,067 Chinese Yuan, 7,114 Chinese Yuan and 969 Chinese Yuan for inpatient and outpatient cost, respectively. The median total cost for hospital-based care was 3.69-fold higher than that for primary care. The median cost of patients with complications was 3.46-fold higher than that of those without complications. The median cost for a patient with only macrovascular, only microvascular or both macrovascular and microvascular complications were 3.13-, 3.79- and 10.95-fold higher than that of patients without complications. Pharmaceutical expenditure accounted for 51.8 and 79.7% of the total cost for patients with or without complications, respectively.Although the type 2 diabetes mellitus-related cost per patient was relatively low, it accounted for a great proportion of the overall cost. Complications obviously aggravated the economic burden of type 2 diabetes mellitus. Proper management and the prevention of diabetes and its complications are urgently required to curtail the economic burden.

  View details for PubMedID 29993198

• How do type 2 diabetes mellitus (T2DM)-related complications and socioeconomic factors impact direct medical costs? A cross-sectional study in rural Southeast China BMJ OPEN Wu, H., Eggleston, K. N., Zhong, J., Hu, R., Wang, C., Xie, K., Chen, Y., Chen, X., Yu, M. 2018; 8 (11)

  View details for DOI 10.1136/bmjopen-2017-020647

  View details for Web of Science ID 000454740400011

• How do type 2 diabetes mellitus (T2DM)-related complications and socioeconomic factors impact direct medical costs? A cross-sectional study in rural Southeast China. BMJ open Wu, H., Eggleston, K. N., Zhong, J., Hu, R., Wang, C., Xie, K., Chen, Y., Chen, X., Yu, M. 2018; 8 (11): e020647

  Abstract

  OBJECTIVE: To evaluate type 2 diabetes mellitus (T2DM)-related direct medical costs by complication type and complication number, and to assess the impacts of complications as well as socioeconomic factors on direct medical costs.DESIGN: A cross-sectional study using data from the region's diabetes management system, social security system and death registry system, 2015.SETTING: Tongxiang, China.PARTICIPANTS: Individuals diagnosed with T2DM in the local diabetes management system, and who had 2015 insurance claims in the social security system. Patients younger than 35 years and patients whose insurance type changed in the year 2015 were excluded.MAIN OUTCOME MEASURES: The mean of direct medical costs by complication type and number, and the percentage increase of direct medical costs relative to a reference group, considering complications and socioeconomic factors.RESULTS: A total of 19015 eligible individuals were identified. The total cost of patients with one complication was US$1399 at mean, compared with US$248 for patients without complications. The mean total cost for patients with 2 and 3+ complications was US$1705 and US$2994, respectively. After adjustment for socioeconomic confounders, patients with one complication had, respectively, 83.55% and 38.46% greater total costs for inpatient and outpatient services than did patients without complications. The presence of multiple complications was associated with a significant 44.55% adjusted increase in total outpatient costs, when compared with one complication. Acute complications, diabetic foot, stroke, ischaemic heart disease and diabetic nephropathy were the highest cost complications. Gender, age, education level, insurance type, T2DM duration and mortality were significantly associated with increased expenditures of T2DM.CONCLUSIONS: Complications significantly aggravated expenditures on T2DM. Specific kinds of complications and the presence of multiple complications are correlated with much higher expenditures. Proper management and the prevention of related complications are urgently needed to reduce the growing economic burden of diabetes.

  View details for PubMedID 30389755

• The impact of social pensions on intergenerational relationships: Comparative evidence from China JOURNAL OF THE ECONOMICS OF AGEING Chen, X., Eggleston, K., Sun, A. 2018; 12: 225–35

  Abstract

  China launched a new rural pension scheme (hereafter NRPS) for rural residents in 2009, now covering almost all counties with over 400 million people enrolled. This implementation of the largest social pension program in the world offers a unique setting for studying the economics of intergenerational relationships during development, given the rapidity of China's population aging, traditions of filial piety and co-residence, decreasing number of children, and dearth of formal social security, at a relatively low income level. We draw on rich household surveys from two provinces at distinct development stages - impoverished Guizhou and relatively well-off Shandong - to better understand heterogeneity in the impact of pension benefits. Employing a fuzzy regression discontinuity design, we find that around the pension eligibility age cut-off, the NRPS significantly reduces intergenerational co-residence, especially between elderly parents and their adults sons; promotes pensioners' healthcare service consumption; and weakens (but does not supplant) non-pecuniary and pecuniary transfers across three generations. These effects are much larger in less developed Guizhou province.

  View details for PubMedID 30534523

  View details for PubMedCentralID PMC6286058

• The Impact of Rural Pensions in China on Labor Migration WORLD BANK ECONOMIC REVIEW Eggleston, K., Sun, A., Zhan, Z. 2018; 32 (1): 64–84

  View details for DOI 10.1093/wber/lhw032

  View details for Web of Science ID 000427151500004

• INNOVATION AND SHORTAGE: THE YIN AND YANG OF THE HEALTH SECTOR ACTA OECONOMICA Eggleston, K. 2018; 68: 99–114

  View details for DOI 10.1556/032.2018.68.S.8

  View details for Web of Science ID 000418746400008

• Avoidable Hospital Admissions From Diabetes Complications In Japan, Singapore, Hong Kong, And Communities Outside Beijing HEALTH AFFAIRS Quan, J., Zhang, H., Pang, D., Chen, B. K., Johnston, J. M., Jian, W., Lau, Z., Iizuka, T., Leung, G. M., Fang, H., Tan, K. B., Eggleston, K. 2017; 36 (11): 1896–1903

  Abstract

  Improving the quality of primary care may reduce avoidable hospital admissions. Avoidable admissions for conditions such as diabetes are used as a quality metric in the Health Care Quality Indicators of the Organization for Economic Cooperation and Development (OECD). Using the OECD indicators, we compared avoidable admission rates and spending for diabetes-related complications in Japan, Singapore, Hong Kong, and rural and peri-urban Beijing, China, in the period 2008-14. We found that spending on diabetes-related avoidable hospital admissions was substantial and increased from 2006 to 2014. Annual medical expenditures for people with an avoidable admission were six to twenty times those for people without an avoidable admission. In all of our study sites, when we controlled for severity, we found that people with more outpatient visits in a given year were less likely to experience an avoidable admission in the following year, which implies that primary care management of diabetes has the potential to improve quality and achieve cost savings. Effective policies to reduce avoidable admissions merit investigation.

  View details for PubMedID 29137504

• Village senior centres and the living arrangements of older people in rural China: considerations of health, land, migration and intergenerational support AGEING & SOCIETY Liu, H., Eggleston, K. N., Min, Y. 2017; 37 (10): 2044–73

  View details for DOI 10.1017/S0144686X16000714

  View details for Web of Science ID 000413163400004

• Mortality In Rural China Declined As Health Insurance Coverage Increased, But No Evidence The Two Are Linked HEALTH AFFAIRS Zhou, M., Liu, S., Bundorf, M., Eggleston, K., Zhou, S. 2017; 36 (9): 1672–78

  Abstract

  Health insurance holds the promise of improving population health and survival and protecting people from catastrophic health spending. Yet evidence from lower- and middle-income countries on the impact of health insurance is limited. We investigated whether insurance expansion reduced adult mortality in rural China, taking advantage of differences across Chinese counties in the timing of the introduction of the New Cooperative Medical Scheme (NCMS). We assembled and analyzed newly collected data on NCMS implementation, linked to data from the Chinese Center for Disease Control and Prevention on cause-specific, age-standardized death rates and variables specific to county-year combinations for seventy-two counties in the period 2004-12. While mortality rates declined among rural residents during this period, we found little evidence that the expansion of health insurance through the NCMS contributed to this decline. However, our relatively large standard errors leave open the possibility that the NCMS had effects on mortality that we could not detect. Moreover, mortality benefits might arise only after many years of accumulated coverage.

  View details for PubMedID 28874497

• The Educational Gradient in Health in China CHINA QUARTERLY Chen, Q., Eggleston, K., Zhang, W., Zhao, J., Zhou, S. 2017; 230: 289–322

  Abstract

  It has been well established that better educated individuals enjoy better health and longevity. In theory, the educational gradients in health could be flattening if diminishing returns to improved average education levels and the influence of earlier population health interventions outweigh the gradient-steepening effects of new medical and health technologies. This paper documents how the gradients are evolving in China, a rapidly developing country, about which little is known on this topic. Based on recent mortality data and nationally representative health surveys, we find large and, in some cases, steepening educational gradients. We also find that the gradients vary by cohort, gender and region. Further, we find that the gradients can only partially be accounted for by economic factors. These patterns highlight the double disadvantage of those with low education, and suggest the importance of policy interventions that foster both aspects of human capital for them.

  View details for PubMedID 29056815

  View details for PubMedCentralID PMC5650237

• Patient Copayments, Provider Incentives, and Income Effects: Theory and Evidence From the Essential Medications List Under China's 2009 Healthcare Reform WORLD MEDICAL & HEALTH POLICY Chen, B. K., Yang, Y., Eggleston, K. 2017; 9 (1): 24–44

  Abstract

  Expanding access through insurance expansion can increase healthcare utilization through moral hazard. Reforming provider incentives to introduce more supply-side cost sharing is increasingly viewed as crucial for affordable, sustainable access. Using both difference-in-differences and segmented regression analyses on a panel of 1,466 hypertensive and diabetic patients, we empirically examine Shandong province's initial implementation of China's 2009 Essential Medications List policy. The policy reduced drug sale markups to providers but also increased drug coverage benefits for patients. We find that providers appeared to compensate for lost drug revenues by increasing office visits, for which no fee reduction occurred. At the same time, physician agency (yielding to patient demand for pharmaceuticals) may have tempered provider incentives to reduce drug expenditures at the visit level. Taken together, the policy may have increased total spending or total out-of-pocket expenditures. Mandating payment reductions in a service that comprises a large portion of provider income may have unintended consequences.

  View details for PubMedID 29075552

• Forecasting Trends in Disability in a Super-Aging Society: Adapting the Future Elderly Model to Japan. Journal of the economics of ageing Chen, B. K., Jalal, H., Hashimoto, H., Suen, S., Eggleston, K., Hurley, M., Schoemaker, L., Bhattacharya, J. 2016; 8: 42-51

  Abstract

  Japan has experienced pronounced population aging, and now has the highest proportion of elderly adults in the world. Yet few projections of Japan's future demography go beyond estimating population by age and sex to forecast the complex evolution of the health and functioning of the future elderly. This study estimates a new state-transition microsimulation model - the Japanese Future Elderly Model (FEM) - for Japan. We use the model to forecast disability and health for Japan's future elderly. Our simulation suggests that by 2040, over 27 percent of Japan's elderly will exhibit 3 or more limitations in IADLs and social functioning; almost one in 4 will experience difficulties with 3 or more ADLs; and approximately one in 5 will suffer limitations in cognitive or intellectual functioning. Since the majority of the increase in disability arises from the aging of the Japanese population, prevention efforts that reduce age-specific morbidity can help reduce the burden of disability but may have only a limited impact on reducing the overall prevalence of disability among Japanese elderly. While both age and morbidity contribute to a predicted increase in disability burden among elderly Japanese in the future, our simulation results suggest that the impact of population aging exceeds the effect of age-specific morbidity on increasing disability in Japan's future.

  View details for DOI 10.1016/j.jeoa.2016.06.001

  View details for PubMedID 28580275

• Mortality outcomes for Chinese and Japanese immigrants in the USA and countries of origin (Hong Kong, Japan): a comparative analysis using national mortality records from 2003 to 2011. BMJ open Hastings, K. G., Eggleston, K., Boothroyd, D., Kapphahn, K. I., Cullen, M. R., Barry, M., Palaniappan, L. P. 2016; 6 (10)

  Abstract

  With immigration and minority populations rapidly growing in the USA, it is critical to assess how these populations fare after immigration, and in subsequent generations. Our aim is to compare death rates and cause of death across foreign-born, US-born and country of origin Chinese and Japanese populations.We analysed all-cause and cause-specific age-standardised mortality rates and trends using 2003-2011 US death record data for Chinese and Japanese decedents aged 25 or older by nativity status and sex, and used the WHO Mortality Database for Hong Kong and Japan decedents in the same years. Characteristics such as age at death, absolute number of deaths by cause and educational attainment were also reported.We examined a total of 10 458 849 deaths. All-cause mortality was highest in Hong Kong and Japan, intermediate for foreign-born, and lowest for US-born decedents. Improved mortality outcomes and higher educational attainment among foreign-born were observed compared with developed Asia counterparts. Lower rates in US-born decedents were due to decreased cancer and communicable disease mortality rates in the US heart disease mortality was either similar or slightly higher among Chinese-Americans and Japanese-Americans compared with those in developed Asia counterparts.Mortality advantages in the USA were largely due to improvements in cancer and communicable disease mortality outcomes. Mortality advantages and higher educational attainments for foreign-born populations compared with developed Asia counterparts may suggest selective migration. Findings add to our limited understanding of the racial and environmental contributions to immigrant health disparities.

  View details for DOI 10.1136/bmjopen-2016-012201

  View details for PubMedID 27793837

  View details for PubMedCentralID PMC5093623

• Prevalence and determinants of diabetes and prediabetes among Vietnamese adults. Diabetes research and clinical practice Pham, N. M., Eggleston, K. 2016; 113: 116-124

  Abstract

  We estimated the prevalence of diabetes and prediabetes among Vietnamese adults, and quantitatively evaluated association with known risk factors.Subjects were 5602 men and 10,680 women in North Vietnam aged 30-69 years participating in community diabetes screening programs during 2011-2013. We calculated standardized prevalence rates and demographic projections for 2035, and used multinomial regression analysis to examine the associations of multiple risk factors with diabetes and prediabetes.The age-, sex- and area of residence-standardized prevalence of diabetes was 6.0% and of prediabetes was 13.5%, with higher prevalence among men than women. Population aging is projected to raise the prevalence of diabetes to 7.0% and of prediabetes to 15.7% by 2035. Older age, obesity, large waist-to-hip ratio and hypertension were each associated with higher prevalence of diabetes, whereas the opposite direction of association was observed for underweight and minority ethnicity. In addition, diabetes was positively associated with family history of diabetes in women, but inversely related to physically heavy work among men.One in 17 and one in 7 adults had diabetes and prediabetes, respectively, in Vietnam. Urbanization, population aging, increased adiposity, hypertension and sedentary work are associated with the increasing prevalence of diabetes.

  View details for DOI 10.1016/j.diabres.2015.12.009

  View details for PubMedID 26795973

• The weaker sex? Vulnerable men and women's resilience to socio-economic disadvantage. SSM - population health Cullen, M. R., Baiocchi, M. n., Eggleston, K. n., Loftus, P. n., Fuchs, V. n. 2016; 2: 512–24

  Abstract

  Sex differences in mortality vary over time and place as a function of social, health, and medical circumstances. The magnitude of these variations, and their response to large socioeconomic changes, suggest that biological differences cannot fully account for sex differences in survival. Drawing on a wide swath of mortality data across countries and over time, we develop a set of empiric observations with which any theory about excess male mortality and its correlates will have to contend. We show that as societies develop, M/F survival first declines and then increases, a "sex difference in mortality transition" embedded within the demographic and epidemiologic transitions. After the onset of this transition, cross-sectional variation in excess male mortality exhibits a consistent pattern of greater female resilience to mortality under socio-economic adversity. The causal mechanisms underlying these associations merit further research.

  View details for PubMedID 29349167

• Disparities in health and health care in Myanmar. Lancet (London, England) Zaw, P. P., Htoo, T. S., Pham, N. M., Eggleston, K. 2015; 386 (10008): 2053

  View details for DOI 10.1016/S0140-6736(15)00987-3

  View details for PubMedID 26700385

  View details for PubMedCentralID PMC4672190

• Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis LANCET INFECTIOUS DISEASES Alsan, M., Schoemaker, L., Eggleston, K., Kammili, N., Kolli, P., Bhattacharya, J. 2015; 15 (10): 1203-1210

  View details for DOI 10.1016/S1473-3099(15)00149-8

  View details for PubMedID 26164481

• Diabetes prevalence and risk factors among vietnamese adults: findings from community-based screening programs. Diabetes care Pham, N. M., Eggleston, K. 2015; 38 (5): e77-8

  View details for DOI 10.2337/dc14-3093

  View details for PubMedID 25908162

• Leading Causes of Death among Asian American Subgroups (2003-2011) PLOS ONE Hastings, K. G., Jose, P. O., Kapphahn, K. I., Frank, A. T., Goldstein, B. A., Thompson, C. A., Eggleston, K., Cullen, M. R., Palaniappan, L. P. 2015; 10 (4)

  Abstract

  Our current understanding of Asian American mortality patterns has been distorted by the historical aggregation of diverse Asian subgroups on death certificates, masking important differences in the leading causes of death across subgroups. In this analysis, we aim to fill an important knowledge gap in Asian American health by reporting leading causes of mortality by disaggregated Asian American subgroups.We examined national mortality records for the six largest Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) and non-Hispanic Whites (NHWs) from 2003-2011, and ranked the leading causes of death. We calculated all-cause and cause-specific age-adjusted rates, temporal trends with annual percent changes, and rate ratios by race/ethnicity and sex. Rankings revealed that as an aggregated group, cancer was the leading cause of death for Asian Americans. When disaggregated, there was notable heterogeneity. Among women, cancer was the leading cause of death for every group except Asian Indians. In men, cancer was the leading cause of death among Chinese, Korean, and Vietnamese men, while heart disease was the leading cause of death among Asian Indians, Filipino and Japanese men. The proportion of death due to heart disease for Asian Indian males was nearly double that of cancer (31% vs. 18%). Temporal trends showed increased mortality of cancer and diabetes in Asian Indians and Vietnamese; increased stroke mortality in Asian Indians; increased suicide mortality in Koreans; and increased mortality from Alzheimer's disease for all racial/ethnic groups from 2003-2011. All-cause rate ratios revealed that overall mortality is lower in Asian Americans compared to NHWs.Our findings show heterogeneity in the leading causes of death among Asian American subgroups. Additional research should focus on culturally competent and cost-effective approaches to prevent and treat specific diseases among these growing diverse populations.

  View details for DOI 10.1371/journal.pone.0124341

  View details for Web of Science ID 000353659100048

  View details for PubMedID 25915940

  View details for PubMedCentralID PMC4411112

• An exploration of China's mortality decline under Mao: A provincial analysis, 1950-80 POPULATION STUDIES-A JOURNAL OF DEMOGRAPHY Babiarz, K. S., Eggleston, K., Miller, G., Zhang, Q. 2015; 69 (1): 39-56

  Abstract

  Between 1950 and 1980, China experienced the most rapid sustained increase in life expectancy of any population in documented global history. We know of no study that has quantitatively assessed the relative importance of the various explanations proposed for this gain in survival. We have created and analysed a new, province-level panel data set spanning the decades between 1950 and 1980 by combining historical information from China's public health archives, official provincial yearbooks, and infant and child mortality records contained in the 1988 National Survey of Fertility and Contraception. Although exploratory, our results suggest that gains in school enrolment and public health campaigns together are associated with 55-70 per cent of China's dramatic reductions in infant and under-5 mortality during our study period. These results underscore the importance of non-medical determinants of population health, and suggest that, in some circumstances, general education of the population may amplify the effectiveness of public health interventions. Supplementary material for this article (Babiarz et al. 2014, Suppl.) is available at: http://dx.doi.org/10.1080/00324728.2014.972432.

  View details for DOI 10.1080/00324728.2014.972432

  View details for Web of Science ID 000349446200001

  View details for PubMedID 25495509

  View details for PubMedCentralID PMC4331212

• Cardiovascular Disease Mortality in Asian Americans JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Jose, P. O., Frank, A. T., Kapphahn, K. I., Goldstein, B. A., Eggleston, K., Hastings, K. G., Cullen, M. R., Palaniappan, L. P. 2014; 64 (23): 2486-2494

  Abstract

  Asian Americans are a rapidly growing racial/ethnic group in the United States. Our current understanding of Asian-American cardiovascular disease mortality patterns is distorted by the aggregation of distinct subgroups.The purpose of the study was to examine heart disease and stroke mortality rates in Asian-American subgroups to determine racial/ethnic differences in cardiovascular disease mortality within the United States.We examined heart disease and stroke mortality rates for the 6 largest Asian-American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) from 2003 to 2010. U.S. death records were used to identify race/ethnicity and cause of death by International Classification of Diseases-10th revision coding. Using both U.S. Census data and death record data, standardized mortality ratios (SMRs), relative SMRs (rSMRs), and proportional mortality ratios were calculated for each sex and ethnic group relative to non-Hispanic whites (NHWs).In this study, 10,442,034 death records were examined. Whereas NHW men and women had the highest overall mortality rates, Asian Indian men and women and Filipino men had greater proportionate mortality burden from ischemic heart disease. The proportionate mortality burden of hypertensive heart disease and cerebrovascular disease, especially hemorrhagic stroke, was higher in every Asian-American subgroup compared with NHWs.The heterogeneity in cardiovascular disease mortality patterns among diverse Asian-American subgroups calls attention to the need for more research to help direct more specific treatment and prevention efforts, in particular with hypertension and stroke, to reduce health disparities for this growing population.

  View details for DOI 10.1016/j.jacc.2014.08.048

  View details for Web of Science ID 000345962400007

  View details for PubMedID 25500233

  View details for PubMedCentralID PMC4274749

• An observational study of socioeconomic and clinical gradients among diabetes patients hospitalized for avoidable causes: evidence of underlying health disparities in China? INTERNATIONAL JOURNAL FOR EQUITY IN HEALTH Chen, B., Eggleston, K., Li, H., Shah, N., Wang, J. 2014; 13

  Abstract

  Diabetes is an ambulatory care sensitive condition that can generally be managed in outpatient settings with little or no need for inpatient care. As a preliminary step to investigate whether health disparities can be detected in the inpatient setting in China, we study how diabetic patients hospitalized without prior primary care contact or with greater severity of illness differ from other diabetic inpatients along socioeconomic and clinical dimensions.We conduct an observational study using three years of clinical data for more than 1,800 adult patients with diabetes at two tertiary hospitals in East China. Univariate analysis and probit regression are used to characterize the differences in socioeconomic and clinical factors between patients hospitalized for diabetes with no prior primary care contact and those hospitalized with previous treatment experience. Secondarily, we use ordinary least squares regression to estimate the socioeconomic and clinical differences associated with poor serum glucose control at admission.We find that compared with patients hospitalized after prior treatment experience, inpatients with no previous primary care contact for diabetes have worse clinical laboratory values, are more likely to be young and male, to have lower education attainment, and to have poorer blood sugar control. Insurance, urban residence, and previous use of diabetic medication are in turn negatively correlated with HbA1c levels upon admission.Among hospitalized diabetic patients, socioeconomic factors such as lower education attainment, rural residence and lack of full insurance are associated with avoidable hospitalizations or worse indicators of health. Although we cannot definitively rule out selection bias, these findings are consistent with health disparities observable even at the inpatient level. Future studies should study the underlying mechanism by which traditionally vulnerable groups are more likely to be hospitalized for avoidable causes and with greater severity of illness.

  View details for DOI 10.1186/1475-9276-13-9

  View details for Web of Science ID 000332938900002

  View details for PubMedID 24479633

• Will Demographic Change Slow China's Rise? JOURNAL OF ASIAN STUDIES Eggleston, K., Oi, J. C., Rozelle, S., Sun, A., Walder, A., Zhou, X. 2013; 72 (3): 505-518

  View details for DOI 10.1017/S0021911813000557

  View details for Web of Science ID 000324763900002

• Contracting with private providers for primary care services: evidence from urban China. Health economics review Wang, Y., Eggleston, K., Yu, Z., Zhang, Q. 2013; 3 (1): 1-?

  Abstract

  Controversy surrounds the role of the private sector in health service delivery, including primary care and population health services. China's recent health reforms call for non-discrimination against private providers and emphasize strengthening primary care, but formal contracting-out initiatives remain few, and the associated empirical evidence is very limited. This paper presents a case study of contracting with private providers for urban primary and preventive health services in Shandong Province, China. The case study draws on three primary sources of data: administrative records; a household survey of over 1600 community residents in Weifang and City Y; and a provider survey of over 1000 staff at community health stations (CHS) in both Weifang and City Y. We supplement the quantitative data with one-on-one, in-depth interviews with key informants, including local officials in charge of public health and government finance.We find significant differences in patient mix: Residents in the communities served by private community health stations are of lower socioeconomic status (more likely to be uninsured and to report poor health), compared to residents in communities served by a government-owned CHS. Analysis of a household survey of 1013 residents shows that they are more willing to do a routine health exam at their neighborhood CHS if they are of low socioeconomic status (as measured either by education or income). Government and private community health stations in Weifang did not statistically differ in their performance on contracted dimensions, after controlling for size and other CHS characteristics. In contrast, the comparison City Y had lower performance and a large gap between public and private providers. We discuss why these patterns arose and what policymakers and residents considered to be the main issues and concerns regarding primary care services.

  View details for DOI 10.1186/2191-1991-3-1

  View details for PubMedID 23327666

  View details for PubMedCentralID PMC3599686

• Risk adjustment and prevention CANADIAN JOURNAL OF ECONOMICS-REVUE CANADIENNE D ECONOMIQUE Eggleston, K., Ellis, R. P., Lu, M. 2012; 45 (4): 1586-1607

  View details for DOI 10.1111/j.1540-5982.2012.01747.x

  View details for Web of Science ID 000314240700013

• Soil-Transmitted Helminth Infections and Correlated Risk Factors in Preschool and School-Aged Children in Rural Southwest China PLOS ONE Wang, X., Zhang, L., Luo, R., Wang, G., Chen, Y., Medina, A., Eggleston, K., Rozelle, S., Smith, D. S. 2012; 7 (9)

  Abstract

  We conducted a survey of 1707 children in 141 impoverished rural areas of Guizhou and Sichuan Provinces in Southwest China. Kato-Katz smear testing of stool samples elucidated the prevalence of ascariasis, trichuriasis and hookworm infections in pre-school and school aged children. Demographic, hygiene, household and anthropometric data were collected to better understand risks for infection in this population. 21.2 percent of pre-school children and 22.9 percent of school aged children were infected with at least one of the three types of STH. In Guizhou, 33.9 percent of pre-school children were infected, as were 40.1 percent of school aged children. In Sichuan, these numbers were 9.7 percent and 6.6 percent, respectively. Number of siblings, maternal education, consumption of uncooked meat, consumption of unboiled water, and livestock ownership all correlated significantly with STH infection. Through decomposition analysis, we determined that these correlates made up 26.7 percent of the difference in STH infection between the two provinces. Multivariate analysis showed that STH infection is associated with significantly lower weight-for-age and height-for-age z-scores; moreover, older children infected with STHs lag further behind on the international growth scales than younger children.

  View details for DOI 10.1371/journal.pone.0045939

  View details for Web of Science ID 000309517500047

  View details for PubMedID 23029330

  View details for PubMedCentralID PMC3459941

• The New Demographic Transition: Most Gains in Life Expectancy Now Realized Late in Life. The journal of economic perspectives : a journal of the American Economic Association Eggleston, K. N., Fuchs, V. R. 2012; 26 (3): 137-156

  Abstract

  The share of increases in life expectancy realized after age 65 was only about 20 percent at the beginning of the 20th century for the US and 16 other countries at comparable stages of development; but that share was close to 80 percent by the dawn of the 21st century, and is almost certainly approaching 100 percent asymptotically. This new demographic transition portends a diminished survival effect on working life. For high-income countries at the forefront of the longevity transition, expected lifetime labor force participation as a percent of life expectancy is declining. Innovative policies are needed if societies wish to preserve a positive relationship running from increasing longevity to greater prosperity.

  View details for DOI 10.1257/jep.26.3.137

  View details for PubMedID 25076810

  View details for PubMedCentralID PMC4112481

• The New Demographic Transition: Most Gains in Life Expectancy Now Realized Late in Life JOURNAL OF ECONOMIC PERSPECTIVES Eggleston, K. N., Fuchs, V. R. 2012; 26 (3): 137-156

  View details for DOI 10.1257/jep.26.3.137

  View details for Web of Science ID 000307405400007

• Prescribing institutions: Explaining the evolution of physician dispensing JOURNAL OF INSTITUTIONAL ECONOMICS Eggleston, K. 2012; 8 (2): 247-270

  View details for DOI 10.1017/S174413741100052X

  View details for Web of Science ID 000304892000005

• Socioeconomic Correlates of Inpatient Spending for Patients with Type 2 Diabetes Mellitus in China: Evidence from Hangzhou EXPERIMENTAL AND CLINICAL ENDOCRINOLOGY & DIABETES Li, H., Chen, B. K., Shah, N., Wang, Z., Eggleston, K. N. 2012; 120 (1): 35-44

  Abstract

  We evaluated the factors associated with inpatient costs including total costs, pharmaceutical costs and laboratory costs for diabetes-related admissions.Using data for 960 adult patients admitted between May 2005 and April 2008 with a primary or secondary diagnosis of type 2 diabetes mellitus (DM) at Sir Run Run Shaw Hospital affiliated with Zhejiang University Medical School (SRRSH) in Hangzhou, China, we evaluate the association between patient characteristics and inpatient costs with multivariable regression analyses.Total inpatient costs were positively associated with age, higher UKPDS stroke risk score, and presence of any complication. A regression that included patient socioeconomic and clinical characteristics explained 21.5% of the variation in total inpatient costs; regression estimates indicate that patients with coronary artery disease, retinopathy, nephropathy, neuropathy, and diabetic foot had inpatient costs that were respectively 93.7%, 14.0%, 17.5%, 11.5% and 89.0% higher than otherwise similar patients without those complications. Pharmaceutical costs did not differ by insurance coverage. Insured patients spent 7-16% more on laboratory tests than otherwise similar patients did.Clinical factors, especially presence of diabetes-related complications, appear to be the primary determinants of variation in inpatient costs for patients with type 2 DM in China. To mitigate the health costs increases associated with China's DM epidemic, policymakers should focus on cost-effective ways to manage patients in outpatient settings to prevent the complications associated with diabetes.

  View details for DOI 10.1055/s-0031-1291178

  View details for Web of Science ID 000299495600006

  View details for PubMedID 22237582

• Demographic Change, Intergeneration al Transfers, and the Challenges to Social Protection Systems in China Aging, Economic Growth, and Old - Age Security in Asia Chen, Q., Eggleston , K. Edward Elgar . 2012
• Health, Education, and China’s Demographic Tra nsition Since 1950 The Chinese Economy : A New Transition Eggleston , K. International Economics Association, Palgrave-MacMillian . 2012: 150–165
• Children of China's Future YaleGlobal Online Eggleston, K., Oi, J. C., Rozelle, S., Su, A., Zhou, X. 2012
• Educational disparities in quality of diabetes care in a universal health insurance system: evidence from the 2005 Korea National Health and Nutrition Examination Survey INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Do, Y. K., Eggleston, K. N. 2011; 23 (4): 397-404

  Abstract

  To investigate educational disparities in the care process and health outcomes among patients with diabetes in the context of South Korea's universal health insurance system.Bivariate and multiple regression analyses of data from a cross-sectional health survey.A nationally representative and population-based survey, the 2005 Korea National Health and Nutrition Examination Survey.Respondents aged 40 or older who self-reported prior diagnosis with diabetes (n= 1418).Seven measures of the care process and health outcomes, namely (i) receiving medical treatment for diabetes, (ii) ever received diabetes education, (iii) received dilated eye examination in the past year, (iv) received microalbuminuria test in the past year, (v) having activity limitation due to diabetes, (vi) poor self-rated health and (vii) self-rated health on a visual analog scale.Except for receiving medical care for diabetes, overall process quality was low, with only 25% having ever received diabetes education, 39% having received a dilated eye examination in the past year and 51% having received a microalbuminuria test in the past year. Lower education level was associated with both poorer care processes and poorer health outcomes, whereas lower income level was only associated with poorer health outcomes.While South Korea's universal health insurance system may have succeeded in substantially reducing financial barriers related to diabetes care, the quality of diabetes care is low overall and varies by education level. System-level quality improvement efforts are required to address the weaknesses of the health system, thereby mitigating educational disparities in diabetes care quality.

  View details for DOI 10.1093/intqhc/mzr035

  View details for Web of Science ID 000292834300006

  View details for PubMedID 21705771

• Quality Adjustment for Health Care Spending on Chronic Disease: Evidence from Diabetes Treatment, 1999-2009 AMERICAN ECONOMIC REVIEW Eggleston, K. N., Shah, N. D., Smith, S. A., Berndt, E. R., Newhouse, J. P. 2011; 101 (3): 206-211

  View details for DOI 10.1257/aer.101.3.206

  View details for Web of Science ID 000291150300040

• Quality Adjustment for Health Care Spending on Chronic Disease: Evidence from Diabetes Treatment, 1999–2009. The American economic review Eggleston, K. N., Shah, N. D., Smith, S. A., Berndt, E. R., Newhouse, J. P. 2011; 101 (3): 206-11

  Abstract

  US health care expenditures reached $2.5 trillion in 2009, representing 17.6 percent of gross domestic product (GDP) and $8,086 per person (US Department of Health and Human Services Centers for Medicare and Medicaid Services 2011). Since health care represents a large and growing share of the economy, and factors such as population aging imply that chronic disease treatment will continue to expand as a share of health expenditures, developing methods for assessing the value of quality improvement for chronic disease spending is of increasing importance for accurately measuring real economic activity. This paper develops a method for assessing the value of quality changes associated with health care for patients living with one important chronic disease, diabetes mellitus, using 11 years of detailed data on spending and quality of care for over 800 patients. We first provide an overview of measurement issues for health care quality, and then present our data, methods, results, and a brief discussion.

  View details for PubMedID 29517880

• Soft budget constraints and ownership: Empirical evidence from US hospitals ECONOMICS LETTERS Eggleston, K., Shen, Y. 2011; 110 (1): 7-11

  View details for DOI 10.1016/j.econlet.2010.09.016

  View details for Web of Science ID 000286561500003

• The Global Challenge of Antimicrobial Resistance: Insights from Economic Analysis INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Eggleston, K., Zhang, R., Zeckhauser, R. J. 2010; 7 (8): 3141-3149

  Abstract

  The prevalence of antimicrobial resistance (AR) limits the therapeutic options for treatment of infections, and increases the social benefit from disease prevention. Like an environmental resource, antimicrobials require stewardship. The effectiveness of an antimicrobial agent is a global public good. We argue for greater use of economic analysis as an input to policy discussion about AR, including for understanding the incentives underlying health behaviors that spawn AR, and to supplement other methods of tracing the evolution of AR internationally. We also discuss integrating antimicrobial stewardship into global health governance.

  View details for DOI 10.3390/ijerph7083141

  View details for Web of Science ID 000281411100011

  View details for PubMedID 20948953

  View details for PubMedCentralID PMC2954574

• Comparing public and private hospitals in China: Evidence from Guangdong BMC HEALTH SERVICES RESEARCH Eggleston, K., Lu, M., Li, C., Wang, J., Yang, Z., Zhang, J., Quan, H. 2010; 10

  Abstract

  The literature comparing private not-for-profit, for-profit, and government providers mostly relies on empirical evidence from high-income and established market economies. Studies from developing and transitional economies remain scarce, especially regarding patient case-mix and quality of care in public and private hospitals, even though countries such as China have expanded a mixed-ownership approach to service delivery. The purpose of this study is to compare the operations and performance of public and private hospitals in Guangdong Province, China, focusing on differences in patient case-mix and quality of care.We analyze survey data collected from 362 government-owned and private hospitals in Guangdong Province in 2005, combining mandatorily reported administrative data with a survey instrument designed for this study. We use univariate and multi-variate regression analyses to compare hospital characteristics and to identify factors associated with simple measures of structural quality and patient outcomes.Compared to private hospitals, government hospitals have a higher average value of total assets, more pieces of expensive medical equipment, more employees, and more physicians (controlling for hospital beds, urban location, insurance network, and university affiliation). Government and for-profit private hospitals do not statistically differ in total staffing, although for-profits have proportionally more support staff and fewer medical professionals. Mortality rates for non-government non-profit and for-profit hospitals do not statistically differ from those of government hospitals of similar size, accreditation level, and patient mix.In combination with other evidence on health service delivery in China, our results suggest that changes in ownership type alone are unlikely to dramatically improve or harm overall quality. System incentives need to be designed to reward desired hospital performance and protect vulnerable patients, regardless of hospital ownership type.

  View details for DOI 10.1186/1472-6963-10-76

  View details for Web of Science ID 000277049800001

  View details for PubMedID 20331886

  View details for PubMedCentralID PMC2858143

• PRESCRIBING CULTURES AND PHARMACEUTICAL POLICIES IN THE ASIA-PACIFIC (Book Review) HEALTH AFFAIRS Book Review Authored by: Zellmer, W. A. 2010; 29 (2): 329-330

  View details for DOI 10.1377/hlthaff.2009.1107

  View details for Web of Science ID 000274146400019

• Inpatient treatment of diabetic patients in Asia: evidence from India, China, Thailand and Malaysia DIABETIC MEDICINE Goldhaber-Fiebert, J. D., Li, H., Ratanawijitrasin, S., Vidyasagar, S., Wang, X. Y., Aljunid, S., Shah, N., Wang, Z., Hirunrassamee, S., Bairy, K. L., Wang, J., Saperi, S., Nur, A. M., Eggleston, K. 2010; 27 (1): 101-108

  Abstract

  The prevalence of Type 2 diabetes mellitus (DM) has grown rapidly, but little is known about the drivers of inpatient spending in low- and middle-income countries. This study aims to compare the clinical presentation and expenditure on hospital admission for inpatients with a primary diagnosis of Type 2 DM in India, China, Thailand and Malaysia.We analysed data on adult, Type 2 DM patients admitted between 2005 and 2008 to five tertiary hospitals in the four countries, reporting expenditures relative to income per capita in 2007.Hospital admission spending for diabetic inpatients with no complications ranged from 11 to 75% of per-capita income. Spending for patients with complications ranged from 6% to over 300% more than spending for patients without complications treated at the same hospital. Glycated haemoglobin was significantly higher for the uninsured patients, compared with insured patients, in India (8.6 vs. 8.1%), Hangzhou, China (9.0 vs. 8.1%), and Shandong, China (10.9 vs. 9.9%). When the hospital admission expenditures of the insured and uninsured patients were statistically different in India and China, the uninsured always spent less than the insured patients.With the rising prevalence of DM, households and health systems in these countries will face greater economic burdens. The returns to investment in preventing diabetic complications appear substantial. Countries with large out-of-pocket financing burdens such as India and China are associated with the widest gaps in resource use between insured and uninsured patients. This probably reflects both overuse by the insured and underuse by the uninsured.

  View details for DOI 10.1111/j.1464-5491.2009.02874.x

  View details for Web of Science ID 000273451900015

  View details for PubMedID 20121896

• "Kan Bing Nan, Kan Bing Gui": Challenges for China’s Healthcare System Thirty Years into Reform Growing Pains: Tensions and Opportunities in China’s Transformation Eggleston , K. Walter H. Shorenstein Asia - Pacif ic Research Center. 2010
• The Diabetes Epidemic in the Asia - Pacific Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea Eggleston , K., et al Walter H. Shorenstein Asia - Pacific Research Center series with Brookings Institution Press. 2010
• Introduction Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea Eggleston , K., Tuljapurkar , S. Walter H. Shorenstein Asia - Pacific Research Center series with Brookings Institution Press. 2010
• Aging Asia: The Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea Book Eggleston, K., Tuljapukar, S. Brooking Institution Press. 2010
• Jobs and Kids: Female Employment and Fertility in Rural China VoxEU.org Zeckhauser, R., Eggleston, K., Rizzo, J., Fang, H. 2010
• The Net Value of Health Care for Patients With Type 2 Diabetes, 1997 to 2005 ANNALS OF INTERNAL MEDICINE Eggleston, K. N., Shah, N. D., Smith, S. A., Wagie, A. E., Williams, A. R., Grossman, J. H., Berndt, E. R., Long, K. H., Banerjee, R., Newhouse, J. P. 2009; 151 (6): 386-W127

  Abstract

  The net economic value of increased health care spending remains unclear, especially for chronic diseases.To assess the net value of health care for patients with type 2 diabetes.Economic analysis of observational cohort data.Mayo Clinic, Rochester, Minnesota, a not-for-profit integrated health care delivery system.613 patients with type 2 diabetes.Changes in inflation-adjusted annual health care spending and in health status between 1997 and 2005 (with health status defined as 10-year cardiovascular risk), holding age and diabetes duration constant across the observation period ("modifiable risk"), and simulated outcomes for all diabetes complications based on the UKPDS (United Kingdom Perspective Diabetes Study) Outcomes Model. Net value was estimated as the present discounted monetary value of improved survival and avoided treatment spending for coronary heart disease minus the increase in annual spending per patient.Assuming that 1 life-year is worth $200,000 and accounting for changes in modifiable cardiovascular risk, the net value of changes in health care for patients with type 2 diabetes was $10,911 per patient (95% CI, -$8480 to $33,402) between 1997 and 2005, a positive dollar value that suggests the value of health care has improved despite increased spending. A second approach based on diabetes complications yielded a net value of $6931 per patient (CI, -$186,901 to $211,980).The patient population was homogeneous and small, and the wide CIs of the estimates are compatible with a decrease as well as an increase in value.The economic value of improvements in health status for patients with type 2 diabetes seems to exceed or equal increases in health care spending, suggesting that those increases were worth the extra cost. However, the possibility that society is getting less value for its money could not be statistically excluded, and there is opportunity to improve the value of diabetes-related health care.None.

  View details for Web of Science ID 000270390100003

  View details for PubMedID 19755364

• Human Resource Management Technology Diffusion through Global Supply Chains: Buyer-directed Factory-based Health Care in India WORLD DEVELOPMENT Brown, D. K., Downes, T., Eggleston, K., Kumari, R. 2009; 37 (9): 1484-1493

  View details for DOI 10.1016/j.worlddev.2009.01.004

  View details for Web of Science ID 000269614000005

• Provider payment incentives: international comparisons INTERNATIONAL JOURNAL OF HEALTH CARE FINANCE & ECONOMICS Eggleston, K. 2009; 9 (2): 113-115

  View details for DOI 10.1007/s10754-009-9065-3

  View details for Web of Science ID 000265963900001

  View details for PubMedID 19377868

• The effect of soft budget constraints on access and quality in hospital care INTERNATIONAL JOURNAL OF HEALTH CARE FINANCE & ECONOMICS Shen, Y., Eggleston, K. 2009; 9 (2): 211-232

  Abstract

  Given an increasingly complex web of financial pressures on providers, studies have examined how hospitals' overall financial health affects different aspects of hospital operations. In our study, we develop an empirical proxy for the concept of soft budget constraint (SBC, Kornai, Kyklos 39:3-30, 1986) as an alternative financial measure of a hospital's overall financial health and offer an initial estimate of the effect of SBCs on hospital access and quality. An organization has a SBC if it can expect to be bailed out rather than shut down. Our conceptual model predicts that hospitals facing softer budget constraints will be associated with less aggressive cost control, and their quality may be better or worse, depending on the scope for damage to quality from noncontractible aspects of cost control. We find that hospitals with softer budget constraints are less likely to shut down safety net services. In addition, hospitals with softer budget constraints appear to have better mortality outcomes for elderly heart attack patients.

  View details for DOI 10.1007/s10754-009-9066-2

  View details for Web of Science ID 000265963900008

  View details for PubMedID 19408114

• Soft budget constraints in China: Evidence from the Guangdong hospital industry INTERNATIONAL JOURNAL OF HEALTH CARE FINANCE & ECONOMICS Eggleston, K., Shen, Y., Lu, M., Li, C., Wang, J., Yang, Z., Zhang, J. 2009; 9 (2): 233-242

  Abstract

  Using data from 276 general acute hospitals in the Pearl River Delta region of Guangdong Province from 2002 and 2004, we construct a preliminary metric of budget constraint softness. We find that, controlling for hospital size, ownership, and other factors, a Chinese hospital's probability of receiving government financial support is inversely associated with the hospital's previous net revenue, an association consistent with soft budget constraints.

  View details for DOI 10.1007/s10754-009-9067-1

  View details for Web of Science ID 000265963900009

  View details for PubMedID 19399608

• Measuring Selection Incentives in Managed Care: Evidence From the Massachusetts State Employee Insurance Program JOURNAL OF RISK AND INSURANCE Eggleston, K., Bir, A. 2009; 76 (1): 159-175

  View details for DOI 10.1111/j.1539-6975.2009.01292.x

  View details for Web of Science ID 000263255900008

• Introduction Prescribing Cultures and Pharmaceutical Policy in the Asia - Pacific Eggleston , K. Walter H. Shorenstein Asia - Pacific Research Center series with Brookings Institution Press. 2009
• Physician s and pharmacists in comparative historical perspective: The ca se of South Korea Prescribing Cultures and Pharmaceutical Policy in the Asia Pacific Eggleston , K., Yang , B. Shorenstein Asia - Pacific Research Center series with Brookings Institution Press. 2009 : 267–280
• HOSPITAL OWNERSHIP AND QUALITY OF CARE: WHAT EXPLAIN'S THE DIFFERENT RESULTS IN THE LITERATURE? HEALTH ECONOMICS Eggleston, K., Shen, Y., Lau, J., Schmid, C. H., Chan, J. 2008; 17 (12): 1345-1362

  Abstract

  This systematic review examines what factors explain the diversity of findings regarding hospital ownership and quality. We identified 31 observational studies written in English since 1990 that used multivariate analysis to examine quality of care at nonfederal general acute, short-stay US hospitals. We find that pooled estimates of ownership effects are sensitive to the subset of studies included and the extent of overlap among hospitals analyzed in the underlying studies. Ownership does appear to be systematically related to differences in quality among hospitals in several contexts. Whether studies find for-profit and government-controlled hospitals to have higher mortality rates or rates of adverse events than their nonprofit counterparts depends on data sources, time period, and region covered. Policymakers should be aware of the underlying reasons for conflicting evidence in this literature, and the strengths and weaknesses of meta-analytic synthesis. The 'true' effect of ownership appears to depend on institutional context, including differences across regions, markets, and over time.

  View details for DOI 10.1002/hec.1333

  View details for Web of Science ID 000261635300003

  View details for PubMedID 18186547

• From plan to market in the health sector?: China's experience. Journal of Asian economics Eggleston, K., Wang, J., Rao, K. 2008; 19 (5): 400-412

  Abstract

  Countries worldwide confront the challenge of defining and achieving appropriate roles for government and market forces in the health sector. China-as both a developing and a transitional economy-represents an important case. This paper uses an international comparative perspective to examine how the health of China's population and other aspects of health system performance changed during the reform era. We draw on standard public finance and health economics theory, as well as the more recent incomplete-contracting theory of property rights, to summarize the comparative advantages of government and market for financing and delivery of health services, particularly in developing and transitional economies. We then describe and analyze against this theoretical background the transformation of China's health sector and recent commitment of government funds to move toward universal coverage.

  View details for DOI 10.1016/j.asieco.2008.09.002

  View details for PubMedID 32288456

  View details for PubMedCentralID PMC7129661

• Soft budget constraints and the property rights theory of ownership ECONOMICS LETTERS Eggleston, K. 2008; 100 (3): 425-427

  View details for DOI 10.1016/j.econlet.2008.03.010

  View details for Web of Science ID 000259438700030

• Pharmaceutical policy in China HEALTH AFFAIRS Sun, Q., Santoro, M. A., Meng, Q., Liu, C., Eggleston, K. 2008; 27 (4): 1042-1050

  Abstract

  Contradictory goals plague China's pharmaceutical policy. The government wants to develop the domestic pharmaceutical industry and has used drug pricing to cross-subsidize public hospitals. Yet the government also aims to control drug spending through price caps and profit-margin regulations to guarantee access even for poor patients. The resulting system has distorted market incentives, increased consumers' costs, and financially rewarded inappropriate prescribing, thus undermining public health. Pharmaceuticals account for about half of total health spending in China, representing 43 percent of spending per inpatient episode and 51 percent of spending per outpatient visit. Yet some essential medicines are unavailable or of questionable quality.

  View details for DOI 10.1377/hlthaff.27.4.1042

  View details for Web of Science ID 000257635900018

  View details for PubMedID 18607039

• Emerging health economics and outcomes research in the Asia-Pacific region VALUE IN HEALTH Liu, G. G., Eggleston, K., Hu, T. 2008; 11: S1-S2

  View details for DOI 10.1111/j.1524-4733.2008.00360.x

  View details for Web of Science ID 000255205600001

  View details for PubMedID 18387052

• Health service delivery in China: A literature review HEALTH ECONOMICS Eggleston, K., Ling, L., Meng Qingyue, Q. Y., Lindelow, M., Wagstaff, A. 2008; 17 (2): 149-165

  Abstract

  We report the results of a review of the Chinese- and English-language literatures on service delivery in China, asking how well China's health-care providers perform and what determines their performance. Although data and methodological limitations suggest caution in drawing conclusions, a critical reading of the available evidence suggests that current health service delivery in China leaves room for improvement, in terms of quality, responsiveness to patients, efficiency, cost escalation, and equity. The literature suggests that these problems will not be solved by simply shifting ownership to the private sector or by simply encouraging providers -- public and private -- to compete with one another for individual patients. By contrast, substantial improvements could be (and in some places have already been) made by changing the way providers are paid -- shifting away from fee-for-service and the distorted price schedule. Other elements of 'active purchasing' by insurers could further improve outcomes. Rigorous evaluations, based on richer micro-level data, could considerably strengthen the evidence base for service delivery policy in China.

  View details for DOI 10.1002/hec.1306

  View details for Web of Science ID 000253239400001

  View details for PubMedID 17880024

• Developing Commercial Health Insurance in China Field Note in Perspectives: China and the World Morrison, J., Eggleston, K. 2008; 10 (3): 141-155
• From Plan to Market in the Health Sector? China's Experience Journal of Asian Economics Eggleston, K., Wang, J., Kequin Rao 2008; 19: 400-412
• Healthcare Reforms in Central and Eastern Europe: Overview and Possible Implications of China Bijao (Comparative Studies) Eggleston, K. 2007; 32: 119-132
• Physician dual practice HEALTH POLICY Eggleston, K., Bir, A. 2006; 78 (2-3): 157-166

  Abstract

  Physicians employed in government clinics and hospitals also frequently have private practices. The economic theory of such dual practice is relatively limited and recent. We provide a summary and comparison of five models of dual practice, including one we have developed based on total compensation theory and contracting limitations. We also discuss whether theoretical predictions are consistent with empirical evidence from developed and developing countries. We argue that the social trade-off between the benefits and costs of dual practice hinge on the quality of a country's contracting institutions. The conclusion outlines a proposed research agenda for better understanding this widespread phenomenon in the health sector and in other segments of society.

  View details for DOI 10.1016/j.healthpol.2005.09.007

  View details for Web of Science ID 000240837500005

  View details for PubMedID 16253383

• Provider choice of quality and surplus. International journal of health care finance & economics Miller, N., Eggleston, K., Zeckhauser, R. 2006; 6 (2): 103-117

  Abstract

  We study the quality choices of institutional health-care providers, such as hospitals, assuming that the utility function of the key organizational decision maker includes both quality of care and financial surplus. We are primarily concerned with how changes in outside claims--particularly proportional outside claims--on the provider's financial surplus affect his choice of quality. We use the term "rate of surplus retention" to refer to the fraction of surplus remaining after deducting all such claims. Using the Arrow-Pratt coefficient of relative risk aversion as a measure of curvature of the provider's utility-from-money function, we show that increasing the surplus retention rate increases (decreases) quality if the provider's coefficient of relative risk aversion is greater than (less than) 1.

  View details for PubMedID 16783504

• Ownership and performance of health service organizations: Evidence from hospitals Global Forum Update on Research for Health Eggleston, K., Shen, Y. 2006; 3: 142-145
• Antibiotic resistance as a global threat: Evidence from China, Kuwait and the United States GLOBALIZATION AND HEALTH Zhang, R., Eggleston, K., Rotimi, V., Zeckhauser, R. J. 2006; 2

  View details for DOI 10.1186/1744-8603-2-6

  View details for Web of Science ID 000208157200006

• Multitasking and mixed systems for provider payment JOURNAL OF HEALTH ECONOMICS Eggleston, K. 2005; 24 (1): 211-223

  Abstract

  The problem of multitasking refers to the challenge of designing incentives to motivate appropriate effort across multiple tasks when the desired outcomes for some tasks are more difficult to measure than others. Multitasking is pervasive in health care. I use a simple model to show that the problem of multitasking further strengthens conventional arguments for mixed payment systems such as partial capitation. When pay-for-performance metrics are imperfect for rewarding service-specific quality efforts, using mixed payment helps to balance incentives for quality effort across services.

  View details for DOI 10.1016/j.jhealeco.2004.09.001

  View details for Web of Science ID 000226272400010

  View details for PubMedID 15617795

• Hospital competition under regulated prices: application to urban health sector reforms in China. International journal of health care finance & economics Eggleston, K., Yip, W. 2004; 4 (4): 343-368

  Abstract

  We develop a model of public-private hospital competition under regulated prices, recognizing that hospitals are multi-service firms and that equilibria depend on the interactions of patients, hospital administrators, and physicians. We then use data from China to calibrate a simulation model of the impact of China's recent payment and organizational reforms on cost, quality and access. Both the analytic and simulation results show how providing implicit insurance through distorted prices leads to over/under use of services by profitability, which in turn fuels cost escalation and reduces access for those who cannot afford to self-pay for care. Simulations reveal the benefits of mixed payment and expanded insurance cover for mitigating these distortions.

  View details for PubMedID 15467409

• Addressing government and market failures with payment incentives: Hospital reimbursement reform in Hainan, China SOCIAL SCIENCE & MEDICINE Yip, W., Eggleston, K. 2004; 58 (2): 267-277

  Abstract

  This paper examines the role of provider payment policy as an instrument for addressing government and market failures and controlling costs in the health sector, particularly in developing countries. We empirically evaluate the impact of provider payment reform in Hainan province, China, on expenditures for different categories of services that had been subject to distorted prices under fee-for-service. Using a pre-post study design with a control group, we analyze two years of claims data to assess the impact of a January 1997 change to prospective payment for a sub-sample of the hospitals. This difference-in-difference empirical strategy allows us to isolate the supply-side payment reform effects from demand-side policy interventions. We find that prepayment is associated with a slower increase in spending on expensive drugs and high technology services, compared to fee-for-service. The fact that payment reform is associated with reduced growth in spending on the most expensive drugs is particularly encouraging, given that drugs account for a remarkably high percentage of both the level and growth of aggregate health expenditure in China. Payment reform can be an effective policy instrument for correcting market failures and adverse side effects of government health sector interventions (such as distorted prices to assure access to basic services), both of which can lead to excessive health care expenditure growth. Such health spending growth can have a particularly high opportunity cost for developing countries.

  View details for DOI 10.1016/S0277-9536(03)00010-8

  View details for Web of Science ID 000187743100006

  View details for PubMedID 14604613

• Healthcare payment incentives: a comparative analysis of reforms in Taiwan, South Korea and China. Applied health economics and health policy Eggleston, K., Hsieh, C. 2004; 3 (1): 47-56

  Abstract

  Payment incentives to both consumers and providers have significant consequences for the equity and efficiency of a healthcare system, and have recently come to the fore in health policy reforms. This review first discusses the economic rationale for the apparent international convergence toward payment systems with mixed demand- and supply-side cost sharing. The recent payment reforms undertaken in Taiwan, South Korea and China are then summarised. Available evidence clearly indicates that payment incentives matter, and, in particular, that supply-side cost sharing can improve efficiency without undermining equity. Further study and monitoring of health service quality and risk selection is warranted.

  View details for PubMedID 15702940

• Zhuangui Zhong De Fuli, Xuanze He Yizhixing (Welfare, Choice and Solidarity in Transition -- Chinese edition) Kornai, J., Eggleston, K. CITIC Publishing House. 2003
• Provider payment reform in China: The case of hospital reimbursement in Hainan Province HEALTH ECONOMICS Yip, W., Eggleston, K. 2001; 10 (4): 325-339

  Abstract

  This paper develops a simple model of payment incentives and empirically evaluates provider payment reform in Hainan Province, China. We use a pre-post study design with a control group to analyse two years of claims data to assess the impact of a January 1997 change to prospective payment for a sub-sample of the hospitals. This difference-in-difference empirical strategy allows us to isolate the supply-side payment reform effects from demand-side changes, in contrast with previous studies of China's reforms. Our results validate the theory that Chinese providers' behavioural response to payment incentives is similar to that reported in the literature derived from the experience of industrialized countries. We find that prepayment is associated with a slower rate of growth of overall expenditures, programme spending and patient co-payments per inpatient admission, compared to fee-for-service (FFS). These findings suggest cautious optimism regarding the effectiveness of prospective payment for controlling costs and should be encouraging for policymakers in developing and transitional economies considering replacement of FFS with more aggregated forms of provider payment.

  View details for Web of Science ID 000169548000006

  View details for PubMedID 11400255

• Welfare, Choice and Solidarity in Transition: Reforming the Health Sector in Eastern Europe Kornai, J., Eggleston, K. Cambridge University Press. 2001
• The design and interpretation of contracts: Why complexity matters NORTHWESTERN UNIVERSITY LAW REVIEW Eggleston, K., Posner, E. A., Zeckhauser, R. 2000; 95 (1): 91-132

  View details for Web of Science ID 000165397100002