This a response to the comments posted by James D Shelton on our study that evaluated the impact of Vajpayee Aarogyashree Scheme (VAS). We agree with the posted comments on several dimensions including:
1. We agree that our study and its conclusions would be strengthened if we had detailed information on the procedures performed during a hospitalization. In addition to data on procedures performed we would also have liked to have detailed data on the clinical history of patients and presenting conditions. For example, a bypass surgery can be life saving for someone with severe coronary artery disease but can have little effect on health for someone with mild disease. Without such detailed information on procedures, clinical history and presenting conditions for patients in the treatment and comparison areas it is not possible to judge the clinical reasonableness of the study findings. We did not collect such information as it is difficult to collect such information using household surveys and a full blown medical record abstraction was beyond the scope of the current study.
2. We also agree that measurement error in the cause of death is a limitation of this study. A fuller discussion of this issue is presented in the paper and online appendix. However, we note that it is not appropriate to compare the age of death distribution in the comparison area with estimates of the all India age of death distribution for several reasons. First, we survey rural households and government reports suggest large urban-rural disparities in death rates in Karnataka, with death rate for rural residents being about 50% higher than death rate for urban residents. We also survey poor or BPL households and prior studies suggest higher rates of premature mortality for poor households. Finally, in the treatment area, roughly half the deaths occurred below age 60 which matches well with mortality data from Karnataka as reported the government of India.
3. We agree with the comment that a program that supports only tertiary care and does not have a well-functioning system for referring patients to tertiary care would have a much smaller impact on health. As we note in the paper the effects of the program we observe arise from the combination of outreach via health camps and free access to tertiary care at public and private hospitals. Also, outreach via health camps is part of other government sponsored programs in India. The outreach via health camps might lead to greater and potentially earlier diagnosis of disease. Some of the diagnosed patients would seek medical management of their health conditions while others would be appropriate for tertiary care. The program also had a pre-authorization process to screen patients and reduce inappropriate use of care. Patients with better access to tertiary care might be more likely to seek formal medical care for diagnosis of symptoms potentially requiring tertiary care. So the program could benefit patient health through multiple channels including greater access to tertiary care, reduction in undiagnosed disease, earlier diagnosis and treatment, and changes in appropriate use of tertiary care or quality of care more broadly.
4. We also agree and note in the paper that the effects we observe might be larger than true longer term effects of the program due to “pent up” demand for tertiary care. In the long run, the effects would be smaller as the program would target incident rather than prevalent cases. However, we believe that the burden of incident cases of non-communicable diseases is non-trivial and a well-functioning health care system should address this burden of illness.
Although we agree with several comments in the rapid response, not surprisingly, we do not agree with the assessment that the results of our study are implausible. We think it is certainly plausible that a program that provides access to expensive tertiary care (and access to specialists via health camps) for life threatening conditions to poor patients can have meaningful impact on patient health. However, this does not imply that we should adopt this or other similar programs at the expense of primary care interventions. In fact, instead of pitting primary care versus tertiary care the right question is: what is the optimal portfolio of primary, secondary and tertiary care interventions for addressing the burden of illness of a population? The answer to this question is difficult and would require cost-benefit or cost-effectiveness analysis of alternate portfolio of strategies. Future research should focus on this important question.
Competing interests:
No competing interests
29 October 2014
Neeraj Sood
Prof
Eran Bendavid, Arnab Mukherji, Zachary Wagner
USC
University of Southern California, 635 Downey Way, VPD, Los Angeles CA 90089 USA
Rapid Response:
This a response to the comments posted by James D Shelton on our study that evaluated the impact of Vajpayee Aarogyashree Scheme (VAS). We agree with the posted comments on several dimensions including:
1. We agree that our study and its conclusions would be strengthened if we had detailed information on the procedures performed during a hospitalization. In addition to data on procedures performed we would also have liked to have detailed data on the clinical history of patients and presenting conditions. For example, a bypass surgery can be life saving for someone with severe coronary artery disease but can have little effect on health for someone with mild disease. Without such detailed information on procedures, clinical history and presenting conditions for patients in the treatment and comparison areas it is not possible to judge the clinical reasonableness of the study findings. We did not collect such information as it is difficult to collect such information using household surveys and a full blown medical record abstraction was beyond the scope of the current study.
2. We also agree that measurement error in the cause of death is a limitation of this study. A fuller discussion of this issue is presented in the paper and online appendix. However, we note that it is not appropriate to compare the age of death distribution in the comparison area with estimates of the all India age of death distribution for several reasons. First, we survey rural households and government reports suggest large urban-rural disparities in death rates in Karnataka, with death rate for rural residents being about 50% higher than death rate for urban residents. We also survey poor or BPL households and prior studies suggest higher rates of premature mortality for poor households. Finally, in the treatment area, roughly half the deaths occurred below age 60 which matches well with mortality data from Karnataka as reported the government of India.
3. We agree with the comment that a program that supports only tertiary care and does not have a well-functioning system for referring patients to tertiary care would have a much smaller impact on health. As we note in the paper the effects of the program we observe arise from the combination of outreach via health camps and free access to tertiary care at public and private hospitals. Also, outreach via health camps is part of other government sponsored programs in India. The outreach via health camps might lead to greater and potentially earlier diagnosis of disease. Some of the diagnosed patients would seek medical management of their health conditions while others would be appropriate for tertiary care. The program also had a pre-authorization process to screen patients and reduce inappropriate use of care. Patients with better access to tertiary care might be more likely to seek formal medical care for diagnosis of symptoms potentially requiring tertiary care. So the program could benefit patient health through multiple channels including greater access to tertiary care, reduction in undiagnosed disease, earlier diagnosis and treatment, and changes in appropriate use of tertiary care or quality of care more broadly.
4. We also agree and note in the paper that the effects we observe might be larger than true longer term effects of the program due to “pent up” demand for tertiary care. In the long run, the effects would be smaller as the program would target incident rather than prevalent cases. However, we believe that the burden of incident cases of non-communicable diseases is non-trivial and a well-functioning health care system should address this burden of illness.
Although we agree with several comments in the rapid response, not surprisingly, we do not agree with the assessment that the results of our study are implausible. We think it is certainly plausible that a program that provides access to expensive tertiary care (and access to specialists via health camps) for life threatening conditions to poor patients can have meaningful impact on patient health. However, this does not imply that we should adopt this or other similar programs at the expense of primary care interventions. In fact, instead of pitting primary care versus tertiary care the right question is: what is the optimal portfolio of primary, secondary and tertiary care interventions for addressing the burden of illness of a population? The answer to this question is difficult and would require cost-benefit or cost-effectiveness analysis of alternate portfolio of strategies. Future research should focus on this important question.
Competing interests: No competing interests