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Objective 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.

Design Bivariate and multiple regression analyses of data from a cross-sectional health survey.

Setting A nationally representative and population-based survey, the 2005 Korea National Health and Nutrition Examination Survey.

Participants Respondents aged 40 or older who self-reported prior diagnosis with diabetes (n= 1418).

Main Outcome Measures 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.

Results 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.

Conclusion 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.

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International Journal for Quality in Health Care
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Young Kyung Do
Young Kyung Do
Karen Eggleston
Karen Eggleston
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The Shorenstein Asia-Pacific Research Center and its Asia Health Policy Program have joined with other centers and programs across the university as collaborative partners for the new Stanford Center for Population Research (SCPR). Supporting population research among faculty and students throughout Stanford, the SCPR is led by Professor Shripad Tuljapurkar, co-editor with Karen Eggleston of the book Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea.

The Stanford Center for Population Research, based in the Institute for Research in Social Sciences, has leadership and involvement across campus including the Humanities, Natural Sciences, Environmental programs, and the Medical School. The goal is to promote, support and develop population studies through collaboration among researchers and training for undergraduate and graduate students, serving as both a resource and nexus for faculty at Stanford across disciplines with interests in population studies, broadly defined.  

The Asia Health Policy Program will work with the Stanford Center for Population Research in studying the implications of demographic change in the Asia-Pacific region. For example, Karen Eggleston is undertaking comparative study of population health trends in China and India with other Stanford faculty associated with SCRP.

AHPP will also support the mission of strengthening the teaching of population studies at the undergraduate, graduate and postdoctoral levels, by helping to make connections for students studying demographic change in Asia. The 2011 postdoctoral fellow in Asia health policy, Qiulin Chen, will be studying population aging in China in comparative perspective. Shorenstein APARC’s affiliation with the SCRP will also help to reinforce the new Shorenstein APARC initiative studying policy responses to population aging in East Asia, kicking off with a workshop in January 2011.

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In April, China announced an ambitious health care reform plan that aims to provide universal access to basic care for all Chinese while enhancing population health initiatives, strengthening service delivery, improving risk pooling, and significantly increasing government funding for the health sector. China Radio International interviewed Karen Eggleston, Asia Health Policy Program Director, about China's health care reform for the radio program "People in the Know." The program, aired on August 21, can be heard online.
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As part of health reforms announced in April 2009, China plans to expand and strengthen primary care (i.e., provision of first contact, person-focused, ongoing care over time, and coordinating care when people receive services from other providers). Other nations of Asia continue to grapple with how to promote population health and constrain healthcare spending. What is the evidence about the effectiveness of primary care in improving population health and making healthcare accessible and affordable?

In this talk, Dr. Starfield will speak about the robust evidence of the association between primary care and better health outcomes at lower cost; ways of measuring the effectiveness of primary care; how selected Asian countries compare in such rankings; and the broader implications of primary care research for health policy in Asia.

Dr. Starfield, a physician and health services researcher, is internationally known for her work in primary care; her books, Primary Care:  Concept, Evaluation, and Policy and Primary Care: Balancing Health Needs, Services, and Technology, are widely recognized as the seminal works in the field.  She has been instrumental in leading projects to develop important methodological tools, including the Primary Care Assessment Tool, the CHIP tools (to assess adolescent and child health status), and the Johns Hopkins Adjusted Clinical Groups (ACGs) for assessment of diagnosed morbidity burdens reflecting degrees of  co-morbidity.   She was the co-founder and first president of the International Society for Equity in Health, a scientific organization devoted to furthering knowledge about the determinants of inequity in health and ways to eliminate them.  Her work thus focuses on quality of care, health status assessment, primary care evaluation, and equity in health. She is a member of the Institute of Medicine and has been on its governing council, and has been a member ofthe National Committee on Vital and Health Statistics and many other government and professional committees and groups. She has a BA from Swarthmore College, an MD from the State University of New York, Downstate Medical Center, and an MPH from Johns Hopkins University School of Public Health.

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Barbara Starfield University distinguished professor and professor of health policy and pediatrics Speaker Johns Hopkins University
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The Asia Health Policy Program hosted meetings of the Association of Pacific Rim Universities World Institute (AWI, www.apru.org/awi) public health research project, February 24-25 at the Shorenstein Asia-Pacific Research Center. Stanford University is a member of the Association of Pacific Rim Universities, and the Asia Health Policy Program coordinates with others on the steering committee for the AWI public health project. The project brings together scholars from leading Pacific Rim universities to focus on comparative study of chronic non-communicable disease – the number one cause of premature death worldwide – in selected Pacific Rim cities (Beijing, Danang, Hangzhou, Hong Kong, Singapore, Jakarta, Makassar, Nanjing, Sydney, Taipei, Vientiane and Wuhan).

 

Ambassador Michael H. Armacost, Acting Director of the Shorenstein Asia-Pacific Research Center, welcomed the participants -- researchers and deans of schools of public health from China, Hong Kong, Japan, Korea, Singapore, Vietnam, Malaysia, Indonesia, and Australia. During the deliberations, the participants agreed to establish a program of research and development to prepare tools for use by health systems worldwide to implement best practice in chronic disease prevention and management through four areas of research: risk factor surveillance; assessment of costs and organization of services; change management to implement best practice; and monitoring and evaluation.

 

The previous meeting of the AWI public health project was held in November 2008 in Singapore. The next meeting will be held in June 2009 at Johns Hopkins University (an Invited Member of the Association of Pacific Rim Universities World Institute).

 

On February 23, prior to the public health project meetings, the Asia Health Policy Program also hosted the planning meetings for the AWI 2009 public health workshop, to be held at Johns Hopkins University June 24-26, 2009.

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Why do community-based education and social persuasion programs for promoting healthy lifestyle and preventing chronic disease sometimes fall short of our expectations? Why are population effects so difficult to engineer and why are they so ephemeral? This research carried out at USC, the Claremont Graduate University, and collaborating institutions in China integrates across social, behavioral, and neurocognitive sciences to address those questions.

We conclude tentatively that the answer to each of the questions may lie in individual and context variability relative to program response, and that in order to more fully address the question of prevention program response variability requires engagement and integration across several levels of science to consider the roles of social groupings, environmental selection and design, social influence processes, and brain biology. What works in one social, cultural or organizational setting may not be so effective in another. What works for persons with certain genetic and experiential backgrounds may be totally ineffective for persons with different dispositional or personality characteristics. In a series of community/school based prevention trials carried out in markedly different southern California and central China settings, we have uncovered domains of consistent response, and other domains of substantial environment- and disposition-based response variability. A social influences based smoking prevention program framed in collectivist values and objectives worked to prevent smoking in one cultural setting but not another. And an individualist framed social influences program worked in the setting where the collectivist program did not. But the characteristics of the particular settings which defined program success or failure were different from what conventional (e.g., cultural psychology) wisdom would have led us to expect. Furthermore, both within and across cultural settings, the same individual dispositional characteristics moderated or determined program effectiveness, again in ways not predicted by the common cultural and behavioral science wisdom. In recent studies carried out both in China and the U.S. we have found affective decision deficits, with known neural underpinnings, to account for rapid progression to regular smoking and binge drinking. These deficits are akin to the dispositional characteristics found earlier to moderate prevention program effects. Subsequent brain imaging studies confirm the hypothesized regions of neural involvement. Together these findings hold promise for more effective – situation and phenotype specific – approaches to engendering and sustaining more optimal individual and population health behavior.

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Carl Anderson Johnson Dean & Professor Speaker School of Community & Global Health, Claremont Graduate School
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Karen Eggleston
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Demographic change and long-term care in Japan, chronic non-communicable disease in China, national health insurance in South Korea, TB control in North Korea, pharmaceutical policy in the region and global safety in drug supply chains -- these are some of the topics explored in a new Stanford course: East Asian Studies 117 and 217,  "%course1%." Taught in fall 2008 by Karen Eggleston, Director of the Asia Health Policy Program, the course has enrolled students not only of East Asian studies but also other undergraduate majors as well as graduate students from the School of Education, School of Medicine, and Graduate School of Business.

 

The course discusses population health and healthcare systems in contemporary China, Japan, and Korea (north and south). Using primarily the lens of social science, especially health economics, participants analyze recent developments in East Asian health policy. In addition to seminar discussions, students engage in active exploration of selected topics outside the classroom, culminating in individual research papers and group projects that present findings in creative ways. For example, several students prepared an overview of health and healthcare in North Korea; three MBA students prepared a proposal for a healthcare venture in China (+PPT+ 1.2MB); and others attended related colloquia, interviewed researchers, and prepared summaries for public posting, such as the article on gender imbalance in China.

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