Panel data analysis of the impact of economic level (GDP, health expenditure, unemployment, and poverty) on SCI.
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It is believed that we need to know the neuropsychological foundations of learning for transmitting teaching.
Fonseca [1] describes that, although learning capacity is inherent to several species, the human is the only species that transmits teaching intentionally.
The literature reports that difficulties in learning conditional relationships between stimuli and concepts can lead to restrictions on an individual’s life and limit their social interaction.
Communication plays an important role in integration of auditory and visual stimuli. This way, the understanding of the environment arises from the interaction between people, and learning is a result of the relationship created through sensory stimuli.
It is known that language occurs mostly by meaningful experiences and situations. Although it depends on cognitive development, physiological integrity, and linguistic abilities, the environmental demands and support have an essential role in the child’s learning process. The construction of a socially shared code that leads to the assignment of meaning to the world’s various elements and experiences depends on the interaction with other significant persons. Language and memory are also dependent on meaningful situations and experiences. Abilities acquired through systematic training, despite frequently presenting fast results, are discarded as fast as they are acquired if they are not used or associated with meaningful contexts.
Based on these ideas, it seems reasonable to suppose that children with autism spectrum disorders present some disadvantage in the learning process because they have a social inability that is inherent to the ASD features, with varied degrees of impairment in social interactions. This way, it is accepted that language impairment of children with autism is not necessarily associated with linguistic structures, although they are affected in some children. Language impairments of children with ASD are essentially related to pragmatic abilities, also involving different levels of inabilities, from the lack of contact to subtle difficulties regarding interaction and conversation abilities. This is another reason why it is fundamental to understand the child’s context and environment, to assess the impact of each child’s inabilities and design intervention plans that address the most efficient and timely intervention.
Several recent studies show that including families in the therapeutic process of children with ASD increases better outcomes and prognosis than traditional one-on-one therapeutic approaches.
Authors like Winnicot [2] consider emotional health as the development’s “back bone,” allowing cognitive and linguistic development and therefore enabling successful learning processes. Regardless of the causal relation and of the hierarchy among these areas of development, the importance of emotional health to learning is unquestionable. Perceiving and processing sensorial information and positively assimilating and interpreting information in order to build and learn healthily and creatively—that is, so that cognitive processing really occurs—depend on emotional health.
Studies that focus on the importance of engaging parents and caregivers are increasing in number and impact, with results increasingly consistent showing that the quality of life of parents and caregivers as well as their involvement in the intervention processes with children with ASD has a positive influence in the outcomes of these processes.
The symptoms often found that ASD individuals also fit in the attention deficit hyperactivity disorder (ADHD) diagnosis, leading researches to compare learning performance between individuals with ASD and ADHD. Both diagnoses present significant impairments in cognitive performance, and it is important to make considerations from the neurocognitive perspective, raising questions and studies that involve tasks that require skills such as executive function (EF), theory of mind (ToM), language, and even correlations between them, seeking possible relations of causality.
EF is currently defined as a cognitive process necessary to define a goal and accomplish it, including the skills needed for it. Among them, working memory, inhibitory control, and cognitive flexibility are included. Working memory is the ability to rescue information previously stored to accomplish a task. Inhibitory control is the ability to suppress any actions or information that may interrupt or hinder the execution of the task or planning.
EF is closely linked to communicative skills, impacting learning, autonomy, and social life of the individual with ASD. This, in part, makes it difficult to understand the direct impact of EF impairment on children with ASD. Even the studies do not yet reach a consensus on impairments in EF in this population. Some studies indicate deficit and risk indicating the causal relationship between EF and other abilities, while others show that individuals with ASD do not present greater impairment than other groups with typical development (TD), developmental language disorder (DLD), and ADHD, indicating that this may not be the central impairment of the disorder.
Some researchers, including Kado and collaborators [3], report in their paper that the working memory performance of children with ASD and ADHD is similar, but their performance is below when compared with TD children, even when matched with IQ and school age. However, other researchers like Roleofs and collaborators did not find significant differences in working memory between adolescents and adults with ASD and intellectual disability when compared with individuals without ASD matched with IQ [4]. In an attempt to understand the interdependence of working memory with language, some studies separate the assessment of this cognitive ability between visual or spatial working memory and verbal working memory. A very interesting research that tries to understand the relation of working memory and language ability was Hill’s paper in 2015 [5]. The working memory was evaluated and compared in 5- to 8-year-old children with ASD and DLD. In this study, children with ASD were separated into two groups: children with and without language impairment. Children with proper language had better performances than children with language impairment. In addition, children with ASD and impaired language performed similarly to children with DLD in most verbal working memory tasks, but none of these groups differed in visual working memory tasks, suggesting their interdependence. This also happens with inhibition control.
The findings of inhibitory control studies in children with ASD are diverse. Some indicate significant losses, while others find no differences compared to ADHD and DT. A widely used test to verify this ability is Stroop, which requires a refined language skill. Corbett and his collaborators [6] performed several inhibitory control tests, with and without the need for verbal expressive language. In the test, requiring verbal ability, children with ASD and ADHD had worse performances than TD children. In the test where the verbal expressive ability was not required—children should heard or saw a certain number to answer or not—children with ASD performed worse than children with DT and ADHD. However, it is important to note that, even in the test of visual working memory, which supposed to not requiring expressive language, the task required a linguistic ability.
And the same pattern happens in researches that attempt to assess cognitive flexibility [7] using tasks that require some level of language, comprehensive or expressive.
The fact that neuropsychological assessments are intended to assess language and are not sensitive to these skills has been a frequent problem in most proposed assessments. In general, these assessments are made by psychologists who don’t have deep knowledge to determine language failures or even to distinguish or define the language structures required for that. Many misjudge language only as an expressive or verbal act, which is conceptually wrong, or disregard the cultural component of language, or even fail to evaluate language ability alone, often considering the cognitive strategies used by the child as language ability or otherwise. And as noted above, this knowledge is essential to clarify a possible causal relationship or to shed light on the possible association between cognitive and language areas, not only in children with ASD.
For children with typical development, learning to speak can naturally come out observing and participating in moments and situations of communication with their parents and their community.
In contrast, the act of learning to read and write is a complex task, composed of multiple interdependent processes, including understanding how the visual symbols correspond to spoken language [8].
There is a range of articles that discuss the importance and interdependence of good oral language development for the success of written code acquisition, since writing is considered a representation of language.
The literature of clinical neuropsychology reports that an assessment of cognitive strengths and weaknesses is useful for children with any developmental or learning disorder [9]. Considering the heterogeneity of the clinical settings of children with ASD, assessing and understanding the child’s individual strengths and weaknesses help better focus school plans and medical treatment and understand the possible areas of difficulty [9, 10].
Westerveld et al. [11] argue that learning to read is just another challenge for children with ASD. In their study, they found that approximately 30–60% of these children present some difficulty to develop literacy. It is important to highlight that even higher functioning children are also part of the statistics.
Jones et al. [12] described that the cognitive heterogeneity of children with ASD is an element that makes it difficult to characterize the academic difficulties of this population. In addition, they report that cognitive abilities may not be congruent with their writing operations.
In their paper, Fletcher and Miciak [9] argue the fact that some children have deficits in cognitive tests may not necessarily indicate causal direction in a child’s learning difficulties. A cognitive deficit does not indicate “why” a child has a learning problem.
Another possible justification found in the literature for this variation in the development of reading and writing in children with ASD is the individual differences in language skills in the areas of phonology, semantics, and syntax [11, 12].
Davidson and Weismer [10] describe that reading disabilities can be classified based on problems that arise in decoding or comprehension abilities. It’s important to know the history of reading instruction for children with exceptional educational needs to consider what is known about reading abilities in individuals with ASD [13].
Gabig [14] in her study with children with ASD, who reduced performance in areas such as vocabulary, may have negative influences on skills such as phonological processing. In addition, she found that some abilities related to decoding ability appear to be relatively intact.
Richardson and Heikki [8] discuss that the reasons for the phonological deficit in autism are still not clear but certainly interfere in the quality of mental representations and in the quality of the lexical, creating a poor link between the phonological awareness and reading skills.
Other authors question whether insufficient performance in reading skills are from specific verbal material defects or the consequence of perceptual, temporal, or long-term memory failure problems [15].
Overall, studies indicate that although the ability to recognize written words may be similar to that of typically developing learners, children with ASD tend to have deficits in integrating information. That is, they have difficulty retrieving and integrating meanings necessary for reading comprehension, including the ability to create connections between content read with prior knowledge and the ability to make inferences [16].
The literature describes that most children with autism show average ability to recognize words while reading and to accurately spell words for age and grade level. In contrast, what the literature cannot yet explain is whether phonological awareness accompanies the good performance of phonetic decoding presented by children with autism [14].
There are several studies that speculate if children with ASD would perform poorer when decoding pseudowords than when reading sight words because of a rote memorization of the visual shape of words. Most of their results indicated that children with autism do not show preference for the visual recognition of sight words over the decoding of pseudowords. It suggests that ASD children are capable of using visual and phonological recognition process to identify written words. Thus, studies lead us to believe that children with autism can benefit from other access channels to achieve good reading and writing performance.
Hyperlexia is frequently one condition presented by children with ASD. It is characterized by a child’s precocious ability to read (far above what would be expected at their age). As with all individuals, children with hyperlexia have a wide range of skills and deficits. The high abilities to decode do not exclude the possibility that children may have a cognitive, language learning and/or social disorder.
What experts argue is that content that can be “formally” taught can be more easily learned by children with ASD. Already “intuitive” content such as phonological awareness skills would be less understood by this population.
Corso et al. [17] tested the correlation between reading tasks and different neuropsychological functions. They concluded that the strongest significant correlations occurred during executive functions tasks.
Pellicano [18] pointed out that there are no studies that explicitly investigate the nature of executive functions in autism, arguing that there are only researches with the fractionation of these functions, that is, as if just one of these components can be specifically affected in autism.
It is also often possible to find studies that compare the performance of children with ASD in theory of mind abilities (ToM). Some studies report that children with executive function deficits but with intact theory of mind abilities are hardly found.
Since the use of theory of mind abilities is essential to the mental and behavioral functioning, understanding the nature of these skills cannot be discarded during the assessment of reading and writing skills [19].
One of the reasons why individuals with ASD may have difficulties in representing situations involving theory of mind may be explained by the fact that they have difficulty integrating clues that are relevant to the context and self-representation.
This would be a justification for the text comprehension difficulties so often observed in this population, especially the difficulties related to understanding pragmatic and nonliteral aspects of language.
Deficits in the functioning of EF and literacy may differ between disturbances. Assessing them and identifying their deficits can provide information on which systems may be impaired and, most importantly, what can be done to stimulate them.
The intervention approach may consider all areas of oral or written language where the children have deficits. It’s important to associate information about the student’s facilitating routes, whether auditory, visual, or motor. This way, the therapist should investigate whether the influence of several processing modalities obtain a more comprehensive understanding of the child’s potential perceptual abilities.
Bosseler and Massaro [20] describe that technology is also being used in educational settings as an effective method of getting children engaged.
Some authors argue that if we guarantee the use of materials that address the different routes, learning can occur simply due to multiple exposures without necessarily having feedback and formal interference from the therapist. Although Bosseler and Massaro observed that children profited from seeing and hearing, spoken language can better guide language learning than modality alone.
What we should expect is that stimulated content must be learned operatively, processed, stored, and related to a set of experience to apply functionality and use it in a meaningful way.
Currently, there are already some available therapeutic methods that can be developed by parents at home. However, there are not yet numerous clinical articles that allow a more accurate interpretation of the results. Thus, there are limitations in measuring the effectiveness of these approaches in treating autistic children, especially in the long-term.
There are authors who emphasize how important it is to encourage these types of family-based therapeutic approaches as key interveners; however, understand that caregiver training should be done very carefully so that such interventions are not inadequately developed and reinforce difficulties and changes in child development.
As we have seen, environmental support plays an essential role in the child’s learning process. The findings suggest that children with autism spectrum disorders (ASD) have some disadvantage in the learning process due to their inherent social disability to ASD characteristics.
The literature describes that parental support and engagement in intervention processes with children with ASD positively influence the outcomes of these processes. Therefore, the intervention process should encompass all the possibilities and resources of oral and written language stimulation, associated with the information and collaboration presented by the caregivers.
The learning disabilities of children with autism exist, and our ultimate goal for these children is to create a connection between learning and functionality.
Answers regarding the value of a medical system can vary depending on various considerations and degrees of interest. Even when considering the universal values of human life and health, their implications are presumed to depend both on the sense of individual values and a country’s history, culture, national character, and surrounding socioeconomics [1, 2]. Meanwhile, if we discuss human dignity’s ethical and moral aspects, the fundamental values of health and life typically exhibit a consensus within the minimum necessary basic range. In other words, the value of the medical system can be considered a mechanism for stable supply (cultivation of a sense of security) that guarantees basic human rights. Given the socio-economic background, the significance of discussing the medical insurance systems of countries from this perspective has recently been increasing. Under these circumstances, the World Health Organization (WHO) has promoted universal health coverage (UHC).
UHC refers to universal access to all people for necessary healthcare services—irrespective of time, place, and their financial condition. UHC, a goal that the healthcare system must strive to achieve, includes basic health services: promotion, prevention, treatment, rehabilitation, and palliative care. This goal takes the civic perspective. Given this background, the understanding and contribution of all members of society (citizens) is essential to the realization of UHC. Its promotion requires a balance between the benefits and burdens at the citizen level. The aforementioned value trends were involved in discussing this balance. In other words, the choices and decisions of individuals and groups are influenced by values. However, issues related to equity and efficiency exist in allocating resources for public goods. The significance of applying value theory and market principles, although limited, has been discussed for a long time [3].
Therefore, the political dimension is also important when considering UHC progress. To promote UHC, some issues regarding evaluating the medical insurance system must be resolved. The increasing importance of socio-economic measures in medical insurance systems has attracted considerable attention. In general, the following three issues have been addressed: (1) The perspective through which the medical insurance system’s outcomes (goals and significance) must be discussed and evaluated. (2) The measurement and analysis of the impact of socio-economic factors on health insurance system outcomes. (3) Determining the operation of the medical insurance system (e.g., benefits and burdens, allocation of resources) based on the aforementioned issues. Each issue has a broad and complex context; thus, consistent effort is required.
The development of public medical resources, especially the financial investment system (national burden and insured burden), is indispensable for the sustainable operation of the medical system. Therefore, an analysis of the characteristics of each country’s political systems is required. As rational policy decision-making is imperative for discussing the financial burden, analytical tools such as those presented in this chapter are necessary. For example, in future studies, a cost-effectiveness analysis (CEA) could be conducted. Additionally, adopting a longitudinal research design (panel data analysis) would make it possible to account for the effects of fluctuations in external factors—such as the real economy—with high accuracy. For example, a report suggests that it is important to optimize resource allocation from the perspective of public interest rather than simply increasing the medical expenses per capita to develop the medical insurance system [4].
Based on the above, harmonizing the public and private sectors is a theme in healthcare insurance systems. This coincides with harmonizing the benefits and burdens of healthcare policy between individuals and society. This requires a macroeconomic analysis of the relationship between health sector outcomes and socio-economic factors. Therefore, this approach also involves financial aspect and discusses the relationship between the real economy and public interest activities. Regarding healthcare services, there is a lot of discussion about payment formulas and price levels in the relationship between stakeholders (economic payers, providers, and service recipients) [5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16]. In other words, there are themes related to the proper allocation of social security funds and the improvement of inefficiencies in the public market. Therefore, a microanalysis is essential in the discussion of healthcare insurance systems. From this perspective, utility theory and welfare economics are applied to elucidate the mechanisms of price formation and treatment selection behavior.
In particular, these themes are becoming more important in the quasi-public medical market, such as Japan’s universal health insurance system, medical resources consisting of social premiums, general taxes (including subsidies), and patient out-of-pocket expenses. For example, rising drug prices and procedure fees have a structure that rebounds from social and individual burdens. Therefore, the significance of comprehensively discussing phenomena and issues that straddle both macro- and micro-aspects has been emphasized (Figure 1). For example, high expectations for cost-effectiveness evidence can be applied to macro- and micro-issues to ensure the sustainability of the system and the appropriateness of resource allocation. From the above, three closely-related perspectives will be discussed: an examination of UHC considering socio-economic factors, examination of the significance of citizens’ value in resource allocation, and examination of price formation considering patients’ economic burden.
Three closely related perspectives are examined: An examination of UHC considering socio-economic factors, the significance of citizens’ value in resource allocation, and price formation considering the economic burden of patients. Note: UHC, universal health coverage.
This chapter explains the concept of the approach required to address the aforementioned issues and introduces examples of related research reports as a guidepost for discussions in the areas concerned. In the first section, the socio-economic factors that affect UHC are examined, and examples of quantitatively evaluating these relationships and their analysis results are provided. Subsequently, the concepts of medical value and methodology, which are indispensable to the ideal development of the medical insurance system, are summarized. Research cases related to the significance of lifesaving and drug discovery are introduced, considering the possibility of allocating public resources. In the final section, the concept of price (fee, charge) formation, which also considers medical value, is organized based on the characteristics of economics and medicine. For example, a report that analyzes the mechanism of price levels, focusing on Japanese private practice (out-of-pocket), is introduced.
Sustainable Development Goal (SDG) 3 comprises 13 targets related to “health and welfare for all.” The other 16 goals were either related—or indirectly contributed—to health. The SDGs aim to “leave no one behind” and are international objectives applicable to developing and advanced countries. UHC is a concept that includes 1) protection from financial risks for all, 2) access to quality primary health services, and 3) access to essential medicines and effective, high-quality, and inexpensive vaccines. Target 3.8 SDG 3, which involves achieving UHC and health improvement worldwide, is considered the most crucial task of the WHO [17].
The measurement approaches and definitions of the UHC index evolved between 2015 and 2019, and the index is now used in every global monitoring report [18]. UHC progress between regions and countries can be compared. Additionally, the UHC service coverage index (SCI) has been calculated as a single number (i.e., score) since the late 2010s, thereby improving comparability between nations. Although the performance of different countries can now be compared, global monitoring alone is insufficient to guide policymaking [19]. Therefore, each country should be encouraged to develop a country-specific global framework. The relationship between the environmental factors surrounding medical care and progress toward UHC should be analyzed to achieve this.
Healthcare systems generally help improve clinical outcomes by increasing public financial investment [20, 21]. Meanwhile, declining birth rates, aging populations, and the maturation of medical systems generally tend to reduce the baseline performance of medical systems. Some reports mention that unemployment and poverty, which are distant causes of catastrophic health costs, are factors that reduce service coverage index levels [22]. Therefore, there is room for countermeasures, including population policies and economic measures. For example, future economic growth strategies could include the promotion of healthcare and life sciences industries. Improvements in health care programs include disease prevention and medical insurance policies.
Problems regarding medical financial systems constitute a significant challenge to achieving UHC. According to the WHO, a healthcare financial system that eliminates the financial constraints of access to health services is crucial [23, 24]. Several previous studies have suggested that UHC is more likely to be achieved when patients’ out-of-pocket medical costs are low [25]. As rational policy decision-making is imperative for discussing the financial burden, analytical aspects, such as UHC and socio-economic factor relationships, are necessary. For example, CEA, a performance analysis of medical functions, is the most common approach for assessing the health benefits for each spent or the cost for each additional health unit. CEA is a tool used to enhance the sustainability of medical systems.
This section introduces an example of the relationship between SCI and major socio-economic indicators to establish UHC levels and economic factors [25]. This study used SCI as a proxy for progress toward UHC in 11 Asian countries. A fixed-effects regression model was employed to analyze panel data from 2015 to 2017, and to explain the interrelationship between the SCI and major socio-economic indicators (health expenditure, unemployment, etc.) Performance analysis (to determine the ratio of the achieved SCI level to gross domestic product or health expenditure displacement) was also conducted. This analysis examines the balance between the degree of achievement related to UHC and a country’s economic level.
The gross domestic product (GDP) and SCI had a significant positive correlation (Spearman’s rank correlation coefficient [Rs] = 0.716, p < 0.01). Health expenditure and SCI were significantly and positively correlated (Rs = 0.743, p < 0.01). When both GDP and SCI indicators were transformed using logarithms, the abovementioned trend did not change significantly (Rs = 0.731, p < 0.01; Figure 2). The results of the panel data analysis showed that GDP per capita significantly contributed to SCI (standardized partial regression coefficient, 1.6129; partial regression coefficient, 0.0049; 95% Confidence interval [CI], 0.0025–0.0074; Table 1). The total population, governmental health expenditure, unemployment, and poverty rates were statistically significant, whereas health expenditure was not significant. The unemployment and poverty rates show a negative trend, and the entire model is statistically significant (R2 = 0.991, F-test: p < 0.001). The ROC curve for health expenditure per GDP for SCI showed a cutoff of 3.7% (p < 0.01) for the Youden index and 4.9% (p < 0.01) for the shortest distance (AUC = 0.8125, 95% CI: 0.6350–0.9899, p < 0.05; Figure 3).
Relationship between economic level (GDP) and SCI (logarithmic transformation, 2017). Note: UHC, universal health coverage; SCI, service coverage index [
UHC index of service coverage (SCI) | Partial regression coefficient | Standardized partial regression coefficient | SE | p-value | 95% CI |
---|---|---|---|---|---|
Population (total: million people) | 0.0049 | 0.1921 | 0.0012 | 0.0001 | 0.0025–0.0074 |
GDP per capita (current USD) | 0.0017 | 1.6129 | 0.0002 | < 0.001 | 0.0013–0.0021 |
Health expenditure (% of GDP) | 2.3481 | 0.4116 | 1.5748 | 0.136 | −0.7386–5.4347 |
Government health expenditures (% of general government expenditures) | 1.4511 | 0.6575 | 0.2804 | < 0.001 | 0.9015–2.0006 |
Unemployment rate (%: ratio of unemployed persons) | −1.4764 | −0.2253 | 0.7105 | 0.0377 | −2.8689–0.0838 |
Poverty rate (%: poverty gap) | −1.6736 | −0.2303 | 0.4674 | 0.0003 | −2.5897–0.7575 |
Model: R2 = 0.991, F test: p < 0.001 |
Panel data analysis of the impact of economic level (GDP, health expenditure, unemployment, and poverty) on SCI.
Note: GDP, gross domestic product; UHC, universal health coverage; SCI, service coverage index; SE, standard error; CI, confidence interval [21].
ROC curve of health expenditure (per GDP: %) for SCI (criterion: Score 70) [
From the results of the performance analysis after the logarithmic transformation of each index, South Korea (high-income country: HIC) scored the lowest (GDP: 0.12 SCI score/USD per capita, health expenditure: 0.07 SCI score/USD per capita; Figure 4), followed by Vietnam (lower-middle-income country: LMIC) and India (LMIC). Japan’s (HIC) performance was moderate, while Indonesia (UMIC), Thailand (UMIC), and Cambodia (LMIC) had relatively high performance. The Philippines (LMIC) had the highest performance (GDP: 1.84 SCI score/USD per capita, health expenditure: 1.04 SCI score/USD per capita). Myanmar (LMIC) was marked as the “dominant quadrant.” The more effective but less expensive quadrant exhibited the best performance in the cost-effectiveness analysis. When the relationship between the proportion of the population aged 65 and above was organized without logarithmic conversion, the SCI score increased with age (Rs = 0.779, p < 0.01), and the performance value decreased (Rs = − 0.830, p < 0.01; Figure 5).
Performance status by country (broad cost-effectiveness analysis based on displacement from 2015 to 2017). Note: SCI, service coverage index. *1: Dominant is positioned in a more cost-effective dimension with increasing outcomes (SCI) even if the economy (GDP) declines. *2: Performance was a cost-effectiveness analysis (difference in outcome “SCI” ÷ difference in the economy “GDP”; displacement from 2015 to 2017). Both indices were logarithmically transformed to consider the elasticity [
Trends in SCI and performance (economic level: GDP) with respect to the aging rate (percentage of the population aged 65 years and above). Note: UHC, universal health coverage; SCI, service coverage index. (†) Myanmar has a different quadrant (dimension) because it is “dominant” [
Each of the four SCI components had a different level of achievement (Figure 6). LMICs were most countries with SCI levels of 60 or below (i.e., Bangladesh, India, Indonesia, and Cambodia), where “infectious diseases” and “service capacity and access” were more widely dispersed. This was compared to the group of countries with SCIs of more than 80 (i.e., South Korea, Japan, Thailand, and China), HIC, and UMIC. Multiple regression analysis used SCI’s annual rate of change as the objective variable and SCI components as the explanatory variable. The results indicate that “service capacity and access” significantly contributed to the SCI level (standardized partial regression coefficient, 0.9209; partial regression coefficient, 0.3581; 95% CI, 0.3142–0.4019). Furthermore, when the GDP per capita and “service capacity and access” values of each country were relatively arranged, with Japan as the standard, a positive correlation was observed between the two indicators (i.e., single correlation: Rs = 0.901, p < 0.01) (Figure A1).
Distribution composition of SCI components according to SCI level (≥ 60 and ≥ 80). Note: SCI, service coverage index [
The present study used SCI as a proxy for the progress of UHC. Currently available service coverage metrics focused on infectious diseases and reproductive, neonatal, maternal, and child health [26]. In this study, the indicators for SCI-related data (Figure A2) were “reproductive, maternal, newborn and child health,” “infectious diseases,” “noncommunicable diseases,” and “service capacity and access.” In addition, the country-by-country socio-economic indicators included “total population,” “population aged 65 and above,” “gross domestic product (GDP) per capita,” “health expenditure per GDP/per capita,” “government health expenditures,” “unemployment rate,” and “poverty rate.” All data were converted into a panel from 2015 to 2017; SCI-related and socio-economic data were also compiled [27, 28, 29].
According to the analysis results derived by applying these data, UHC progress tends to increase as the share of the healthcare domain in government spending increases. Future studies on UHC development measures are important to discuss the appropriate form of resource allocation (public finance) according to sustainability-based productivity and efficiency or value evaluation (national consensus). Based on the statistical analysis results, some cases exist wherein SCI achievement levels differ even among countries at the same economic level. Furthermore, SCI improvement is small, even in countries with high economic investment levels. Exploring these factors and considering improvement measures are assumed to promote UHC progress. This study examined the influences of the maturity of the medical system as an additional country-specific factor (rather than the social system, national character, and culture).
The results showed that when aging and health expenditure exceed a certain level, UHC performance decreases as a country’s need to raise its goal increases. Additionally, the weight of “service capacity and access” to SCI was considerable. This secondary index, which embodies the environment of the healthcare system, can be considered a surrogate index that predicts the maturity of social and medical care. The considerable impact of these factors on UHC implies that stable development cannot be expected simply by expanding the expenditure scale due to the mechanisms related to economic conditions. As a result, policymakers must implement countermeasures based on indicators that can estimate the economic status of the UHC approach, such as its cost-effectiveness.
CEA is often applied to medical-economic evaluations, such as high-priced medicines and health programs, but can also be applied to macro issues, such as medical systems [30]. Cost-effectiveness is an instrument widely used in Western health systems. The instrument provides the information needed to reach a consensus among stakeholders in allocating medical resources and setting medical prices. As UHC progress requires country-specific efforts, as discussed in the introduction, estimating the coefficients that define each country’s UHC progress and socio-economic status is also necessary. Hence, a country-specific performance analysis (CEA: country-specific coefficient calculations) was conducted. In the present study, CEA was performed using economic level as a cost index and SCI level as an effective index.
This approach suggests that regardless of the maturity of the system or the size of the economy, the status of UHC activities in each country can be evaluated based on the displacement of economic and SCI levels achieved.
This section summarizes the conditions and mechanisms of the link between value and price discussion in a medical system.
In a private economy, where the market principle works, goods (and services) are demanded and supplied in the market based on people’s decision-making (free choice and action) depending on changes in price levels. If the market works well, supply and demand will be balanced, and various goods will be properly distributed. The relationship between benefits and burdens in this market is easy to explain. Meanwhile, in a public economy, where the government is the main operator, the market principle works in a limited way. Taxes that enforce the burden are a receiver of supply costs for the demand of goods.
Therefore, public needs and expenditures (including reallocation) are generally determined by the government’s judgment. However, price levels in the public economy are often formed by costs (e.g., size of spending budget), which are both inefficient and inconsistent with market utility (i.e., consumer satisfaction). Additionally, the allocation of public resources may deviate from the balance between supply and demand, and inequity among participants within a group may be promoted. Thus, issues related to Use-value, Marginal utility, and Pareto optimization become apparent in the public economy [31, 32].
Subsequently, the concept of verifying the economic appropriateness of the market function and product price (among others) arises by balancing the number of resources consumed and the results obtained (e.g., cost-effectiveness and performance) [2]. As an example of its widespread use, considering large-scale public investments (e.g., the construction of dams and bridges), the desirability of the project’s implementation is evaluated based on its cost-effectiveness. Additionally, in the private economy, where technological innovation is active, and consumers have numerous choices, the concept of cost-effectiveness is used more actively to incorporate activities and stimulate product appeal. Consequently, the basic and broad concept of cost-effectiveness has developed in social policy decision-making and resource management fields. Its know-how has been cultivated in contract society and management activities and used in social consensus-building and decision-making.
Meanwhile, the provision of medical services is characterized by information asymmetry and restrictions on opportunity costs (options) against the background of health and life. Therefore, healthcare markets differ from common markets that exhibit typical demand and supply; this market has three parties (citizens, insurance, and providers) and faces asymmetric information that creates several market problems (i.e., common equilibrium market laws do not apply), including problems in defining prices. Although this is inherently unfair (bias) in the health sector from the perspective of citizens’ financial burden, the system is based on medical needs such that the needs of the patient, regardless of the outcomes, receive the same medical care. Since such a tendency threatens the system’s sustainability, there have been attempts to improve it as much as possible by utilizing cost-effectiveness and utility theory.
By their very nature, public goods are non-competitive; therefore, the role of price tends to be smaller. Medical care has restrictions on individual choice. However, CEA (including cost-utility analysis [CUA]) is widely used to evaluate medical technology in high-income countries, and prices are determined according to this evaluation. Recently, pricing has become more common with evidence-based or value-based approaches. In this method, a consumer’s natural internal decision-making regarding consumption behavior is externally substituted by other stakeholders under certain conditions (typically advocating the maximization of group benefits) for a certain group or system based on the law of equal marginal utility and expected utility theory. These methods will be considered along with the uncertainty of outcomes and limited rationality of human beings.
The medical systems of many countries have historically operated as part of the social security system, as they gather high public interest from the necessity for all people. Further, against the background of stable supply, the pricing of medical services has often been based on costs. As described in the previous section, numerous developed countries face structural issues, such as declining birth rates, aging populations, and rising costs of medical services; thus, verification of price levels has become an urgent concern [25]. Therefore, the need to build a social consensus on the economic burden of the value of medical services has been increasing, and the verification of price levels while considering cost-effectiveness has further expanded [33]. Against this background, discussions on value evaluation and price levels in the medical field are being conducted using various approaches to consider cost-effectiveness.
Utility refers to the degree of subjective satisfaction or demand fulfillment that each consumer obtains when consuming a certain good or service and is considered a fundamental concept in economics [34]. When interpreted broadly, human economic activities and all human behaviors (including the selection of medical services) aim to maximize the utility to be acquired as the background. Thus, this concept can explain the background of stakeholder behavior changes (e.g., decisions and choices) in the field of health care [35]. Furthermore, a method supported by varied theories related to utility was assumed as an approach to value evaluation.
In summary, “value” is regarded as the meaning of the existence (usefulness or significance in a narrow sense) of an object regardless of whether it is “tangible or intangible.” For example, in the public sector, meaning is often organized using exchange value and use-value. A value is diverse and difficult to quantify in general; however, it should be explained to the parties concerned (Figure 7) [36] when discussing it as part of a social system. This perspective is even more important for the effective utilization (fair distribution) of public properties. Aspects related to life and health should first be discussed from the perspective of “use-value” in developing society. Furthermore, medical care is expected to be provided to everyone at a fairly low cost (public aspect).
The conception of value assessment in the quasi-public healthcare system: The balance of the valuation of technical innovations and the guarantee that all patients have access. The public medical marketplace requires a system that considers both use and exchange values [
Therefore, several countries worldwide have more or less developed the medical field as a public system, following the lead of the 1978 Alma Ata Declaration. Specifically, Japan’s universal health insurance system is assumed to have experienced this trend (see Figure 8). However, highly specialized professionals and therapeutic materials require large investments in developing medical resources, and their supply is restricted. Therefore, to operate and develop medical care as a social system—considering the “exchange value” content that accompanies scarcity and building a system that incorporates certain market principles (economic aspect)—are crucial [2]. This perspective is also important in discussing consistency within the real economy.
Significance and key characteristics of value measurement in the public economy (decision-making and resource allocation) [
Thus, in a quasi-public healthcare market such as Japan, it is desirable to provide mature and widespread medical care at low-cost while guaranteeing a high economic level for innovative (or effective) medical care and specialized resources. Moreover, a system that balances the use and exchange of values is necessary. As previously mentioned, assessing value in the medical field involves various restrictions. Value evaluation can be performed in several ways, which are inadequate for consistency with the real economy or developed as a theory of price setting. The approach to value evaluation that contributes to the discussion of economic activities and official prices in the healthcare system is as follows:
Generally, in microeconomics, prices converge based on supply and demand equilibrium with the background of utility theory, and efficiency is thus maximized. Incorporating herein the perspective of equity (well-being), public interest value is discussed based on the balance between patient utility value (preference, willingness to pay) and medical finance (income reallocation, finance balance) (Figure 9). The balance between increasing utility and cost per health program unit while weaving individuals and society is thus considered. As a result, if utility is maximized in a certain budget range, the higher performance increases the utility in a total of the entire population, and the stakeholders’ “value” increases. Compared to the conceptual discussion of value, it is relatively possible to discuss consistency with a real economy or a general value; hence, it is considered suitable for examining the medical price of the public sector.
Concept of value evaluation of health care based on utility theory and cost-effectiveness considering welfare economics.
The value of medical services can be indirectly evaluated in the public sector by applying the marginal utility theory and scales based on preferences while considering different conditions and objectives from those in the private sector [37]. Incidentally, in the medical field, a method for measuring and analyzing patient utility values as a type of health-related quality of life has been developed. The application of this concept to CEA is CUA, which is a type of CEA. Based on the above, the medical value is calculated as “health recovery (patient outcomes such as utility)/resource consumption (direct medical cost) ⇒ medical performance = medical, economic value” [38] (Figure 10). A related concrete methodology is cost-effectiveness analysis, which considers health programs’ medical and economic position.
Concept of economic performance: One of the methods used to discuss the economic value of healthcare. “Value” in social activities is determined by the balance between capital investment and its returns. If a certain amount of money is paid to use a certain service (function), its value is determined by performance, equal to the amount of service (function) divided by the cost. For the consumption of one budget item, the greater the result, the higher is the value. The amount in terms of “restoration of health” is used as an index of “function” in the medical field [
This explains the socio-economic significance of the medical services provided by balancing public costs and earned utility in the medical market. It is believed that the higher the performance, the greater the utility (clinical outcomes for patients) as part of the value of the budget range.
This section introduces reports that discuss the socio-economic significance of the spread of lifesaving medical devices and the research and development (R&D) of expensive pharmaceuticals (at the time of 2010).
First, a case of microeconomic valorization of end-stage renal failure is discussed [39]. With the progression of renal impairment in patients with chronic kidney disease, the dysregulation of electrolyte and water metabolism and retention of uremic toxins can significantly impact health status and even threaten life [40]. Treatment with hemodialysis (HD) should target maintaining the amount and composition of body fluids within the normal range. The study subjects were aged >20 years and had received HD for at least 6 months. HD patients were prospectively observed for 36 months, and patient utility was assessed based on the EQ-5D, from which quality-adjusted life years (QALYs) were estimated. Medical costs were calculated based on the medical service fees. Cost-effectiveness, defined as the incremental cost-utility ratio (ICUR), was analyzed socially. A total of 29 patients (mean age; 59.9 ± 13.1 years) undergoing 437 dialysis sessions were analyzed.
Utility-based EQ-5D score was 0.75 ± 0.21, and the estimated total medical cost for 1 year of maintenance HD (MHD) treatment was 45,200 ± 8800 USD. On average, the ICUR was 68,800 ± 44,700 USD/QALY (Figure 11). When comparing the ICUR based on the causes of kidney failure, the value for diabetic nephropathy was higher than that for glomerulonephritis (81,700 ± 62,800 vs. 68,200 ± 40,700). The ICUR after 36 months of observation increased mainly in patients below 65 years of age (all P < 0.05; <65, P < 0.01; ≥ 65, not significant) (Figure 12). MHD could improve the socio-economic status of older-adult patients with end-stage kidney disease; however, the ICUR for diabetic nephropathy was higher than that for glomerulonephritis (Table 2). However, the ICUR does not deteriorate in older-adult patients. Therefore, measures to prevent malnutrition and establish the optimum time per session and frequency of dialysis (i.e., optimal dialysis volume) are necessary to further improve MHD’s cost-effectiveness.
Utility values (EQ-5D score) during the first 4 weeks of observation and the 36th week. Four-week interval after the classification of primary diseases for end-stage kidney disease (glomerulonephritis, diabetes mellitus, and the whole) [
Change in cost-effectiveness (ICUR) between the first 4 weeks of observation and the 36th four-week interval. *p < 0.05, **p < 0.01 [
Parameter | All Subjects | Glomerulonephritis | Diabetic nephropathy | Others | ||
---|---|---|---|---|---|---|
Utility(QALYs) | ||||||
Mean ± SD | 0.75 ± 0.21 | 0.73 ± 0.17 | 0.68 ± 0.23 | 0.83 ± 0.22 | ||
Median | 0.73 | 0.71 | 0.60 | 1.00 | ||
* | ** | ** | ||||
Mean ± SD | 45,200 ± 8800 | 45,300 ± 8800 | 51,100 ± 10,700 | 41,100 ± 4100 | ||
Median | 43,300 | 44,100 | 43,500 | 41,900 | ||
** | ** | ** | ||||
Mean ± SD | 68,800 ± 44,700 | 68,200 ± 40,700 | 81,700 ± 52,800 | 54,600 ± 27,400 | ||
Median | 58,700 | 60,900 | 81,100 | 44,400 | ||
** | ** | ** | ||||
Dialysis time (hour per intervention) | ||||||
Mean ± SD | 4.35 ± 0.50 | 4.19 ± 0.39 | 4.08 ± 0.43 | |||
95%CI(two-sample population mean) | 0.16(0.01.0.28) | 0.11(-0.01.0.23) 0.27(0.16, 0.37) | ||||
Cr(mg/dL) | ||||||
Mean ± SD | 9.93 ± 2.11 | 9.47 ± 2.39 | 10.97 ± 3.24 | |||
95%CI(two-sample population mean) | 0.45(-0.78, 1.70) | 1.50(-0.09, 3.09) 1.04(-0.29, 2.38) | ||||
BUN(mg/dL) | ||||||
Mean ± SD | 67.09 ± 15.62 | 69.43 ± 16.92 | 72.43 ± 12.38 | |||
95%CI(two-sample population mean) | 2.34(-4.87, 9.56) | 2.99(-4.20, 10.20) 5.34(0.02, 10.65) | ||||
Age(years) | ||||||
Mean ± SD | 63.59 ± 12.30 | 63.78 ± 4.27 | 51.78 ± 14.08 | |||
95%CI(two-sample population mean) | 0.18(-1.88, 2.26) | 12.00(9.19, 14.81) 11.81(8.63, 14.99) |
Cost-effectiveness by utility and cost in patients on maintenance hemodialysis (MHD).
*p<0.05. **p<0.01. The data source for this analysis was the mean value over 4 weeks in 2011. BUN. blood urea nitrogen: CI. Confidence interval: Cr. creatinine: SD. Standard deviation: QALYs. Quality-adjusted life years. These values were analyzed by distinguishing between the primary disease of end-stage kidney disease (ESKD), glomerulonephritis, diabetic nephropathy, and others during the first 4 weeks of observation [39].
The present findings may contribute to the reexamination of the socio-economic value of MHD therapy, which is a lifesaving medical treatment.
Subsequently, a case of socio-economic valuation of a (then) new drug for the refractory nephrotic syndrome was discussed [41]. Nephrotic syndrome is the generic name for the pathological conditions associated with proteinuria (≥3.5 g/day), hypoproteinemia, and generalized edema. The disorder is further classified as a primary nephrotic syndrome (caused by primary glomerular disease) or secondary nephrotic syndrome (caused by systemic disorders). The syndrome rapidly improves with steroid (e.g., prednisolone) and immunosuppressant (e.g., cyclosporine) treatment. Refractory cases (frequent relapse type, steroid dependence, or steroid resistance) may also occur, requiring steroid therapy for prolonged periods, for which side effects become a major issue. Therefore, there is a need for novel medical strategies to suppress relapse while reducing reliance on steroids. The regimen has not been clinically verified regarding the use of rituximab in patients with steroid-dependent nephrotic syndrome and frequently relapsing nephrotic syndrome. Still, there is a lack of evidence in health economics [42].
Therefore, we conducted a prospective clinical study of 30 patients before (with steroids and immunosuppressants) and after introducing rituximab therapy (Figure A3). Relapse rates and total medical expenses were selected as the primary endpoints for treatment effectiveness and treatment costs, respectively. As a secondary endpoint, cost-effectiveness was compared before and after rituximab administration in relation to previous pharmacotherapy. The observation period was 24 months before and after rituximab initiation. The authors demonstrated a statistically significant improvement in the relapse rate, from a mean of 4.30 events before administration to a mean of 0.27 events after administration. Furthermore, a significantly better prognosis emerged in the cumulative avoidance of relapse rate by Kaplan–Meier analysis (p < 0.01) (Figure 13). Finally, the total medical costs decreased from 2923 USD to 1280 USD per month, and pre-post cost-effectiveness was confirmed to be dominant (Figure 14). Thus, treatment with rituximab may be superior to previous pharmacological treatments from a health economics perspective (Table 3). Although this study did not directly observe patient utility, the excellent results in recurrence rates suggest an improvement in HRQOL.
Kaplan–Meier curves of the cumulative avoidance rate of the first relapse [
Mutual relationship between urinary protein levels and total medical cost (before and after rituximab therapy) [
Items | Pre-administration | Post-administration | Difference (after-before) |
Medical cost difference (points/24 months) | 725,403 | 317,707 | -407,696 |
(USD/24 months) | (70,155) | (30,726) | (-39,429) |
Relapse difference (times/24 months) | 4.30 | 0.27 | -4.03 |
Pre-post CEA (points/24 months/times) | 101,082 | ||
(USD/24 months/times) | (9776) | ||
Reference: pre-post CEA with a case in which the analysis was restricted to 17 months (points/17 months/times) | 50,982 | ||
(USD/17 months/times) | (4931) | ||
Items | Pre-administration | Post-administration | Difference (after-before) |
Medical cost difference (points/24 months) | 725,403 | 401,539 | -323,864 |
(USD/24 months) | (70,155) | (38,833) | (-31,321) |
Number of relapses (times/24 months) | 4.30 | 0.27 | -4.03 |
Pre-post CEA (points/24 months/times) | 80,297 | ||
(USD/24 months/times) | (7766) | ||
Reference: pre-post CEA with a case in which the analysis was restricted to 17 months (points/17 months /times) | 29,445 | ||
(USD/17 months/times) | (2848) |
Medical economics analysis (pre-post-CEA) accounting for the medical costs of rituximab.
The analysis has been corrected for the number of months. Pre-post CEA was calculated as [medical cost (post-pre)/medical effectiveness (post-pre)] (suppression amount for medical costs accumulated over 24 months per one-time reduction[avoid] in relapses). Expressed as points per 24 months per time. Analyzing the cost-effectiveness (the ratio of total medical costs and a number of relapses, after correction for the number of months) before and after rituximab therapy revealed that cost-effectiveness improved in medical, economic terms. This was 317,707 points (30,726 USD) per 24 months (0.27 times) after rituximab therapy compared with 725,403 points (70,155 USD) per 24 months (4.30 times) before therapy [41].
As this study indicates the superior cost-effectiveness of rituximab against refractory nephrotic syndrome, health economics is expected to be actively applied to the valuation of technical innovations such as drug discovery.
The discussion of value covers the whole range of activities related to the health and welfare field, such as examinations and diagnoses provided by medical facilities, surgery, and hospitalization, as well as medication, therapeutic materials, and care provided by caregivers. Prices (i.e., official prices in Japan) are attached to several services. Professionals who typically work in clinical or long-term care sites may not be very aware of these prices. However, the financial resources for the operation of medical and long-term care facilities are based on the price of services provided to patients/family members and long-term care recipients, who are the so-called beneficiaries. The medical institution charges to insurer for various services provided to the assured patient, which become the source of salary payments and reinvestment for the parties concerned. Therefore, if the price, value to be generated, and amount of resources consumed are not well balanced, the motivation for the employment of professionals and profitability assumedly decreases, thus making sustainable facility management difficult.
Consequently, the supply of medical and long-term care will decline, which is a significant problem for residents, including patients and their families [43, 44, 45]. Therefore, the price levels at which service recipients and providers are mutually satisfied (or convinced) should be discussed. However, determining the characteristics and effects of the target market is necessary to discuss the appropriateness of the price, considering the theory related to human choice and behavior (outlined in the previous section). In particular, as the field of health and welfare has service characteristics that are different from those in other fields, it is necessary to consider and interpret the mechanism of the market. Against this background, this section explains the basic price and its calculation methods.
The behavior and motivation of market economic agents and the pricing mechanism for goods and services, including resource allocation and income distribution, should be considered for price optimization. Overall, the general economic approach is limited because of various uncertainties related to highly specialized technologies in medical science. Thus, examining price settings in the medical field is generally difficult because of the complex involvement of various factors. A price-setting approach in medical treatment can be divided into two major categories: “market-based” and “input-based” [46]. The “market-based” approach determines the price level by considering the actual market price of medical treatment, while the “input-based” approach is based on the consumption of goods and services. Generally, prices are presumed to have been formed in the public medical market using these approaches in countries with a mature medical system.
Approaches to explain the public price of individual medical technologies (services) have also been discussed. For example, from the standpoint of a medical provider (supply approach), “technical difficulty” and “medical cost” are often selected from the viewpoint of quality evaluation and business management. Furthermore, for the payer (or beneficiary), the methods of “patient outcome,” “economic performance,” and “willingness to pay” are often selected from the perspective of market and value evaluation (Figure 15) [48, 49, 50]. Additionally, cases exist in which certain preconditions are set to use these indicators. For example, in Japan’s universal health insurance system, most prices charged to public insurers by medical institutions are centered on direct medical costs, based on the consumption of medical resources—considering their clinical usefulness and hospital operability. Technical fees (e.g., surgery fees), influenced by doctors’ specialties, are considered technical difficulties. Furthermore, overseas (developed countries) market prices are referred to when determining the public prices for pharmaceutical resources and medical devices.
Theory of the price-setting approach (in general and within the range of this examination) [
As the socio-economic environment surrounding the medical system becomes more severe, even public prices that follow the theory of the public economy are expected to play a role in improving the system’s performance and increasing its sustainability. In other words, verifying the structure of price formation and the appropriateness of its level has become a major concern for medical stakeholders. Based on this, an analysis of factors that affect prices is also expected. However, when developing official price research in the medical field, the following must be noted: There are not enough research reports to study the analytical model required for factor analysis. This condition is especially true in Japan. In addition, the formation of official prices involves various subsidy programs (politics), and thus, the analytical approach becomes too complicated. Therefore, in this chapter, as an initial study on medical prices, we introduce a survey on price differences between Japan and overseas and price factors in the private market.
This study examines the mechanism of market price reference and the influence of the real economy (citizens’ economic burden) on the public price, contributing to the arrangement of public price discussions in the future.
This section presents a method for setting the price level based on the analysis of medical expenses of Japanese medical institutions for foreign visitors (FVs). Furthermore, international comparisons of price levels for Japanese tourists (patients) in foreign countries have been conducted previously [47]. This section elucidates the “market-based” and “input-based” approaches discussed in 4.1, and discusses the “foreign price reference system,” which is part of the setting of public prices in Japan. In recent years, the supply of medical services centered on pharmaceutical products has been based on global R&D, manufacturing, and sales systems. In addition, some patient groups also exhibit cross-border consultation behaviors. In other words, it is inferred that discussions with a view to the globalization of medical care are indispensable for the progress of UHC, even if they are indirect.
The costs were analyzed based on socio-economic ranges in this calculation, considering clinical characteristics and economic activities. The costs related to general medical care and public investment in hospital management and healthcare infrastructure through the insurance system and various taxation systems that support Japan’s medical system are also considered. For example, social insurance burdens (e.g., insurance contributions and subsidies, such as operational grants to medical institutions) and additional expenses for FVs (e.g., interpretation, coordinator, equipment, and risk management costs) were used as calculation items.
Three medical institutions with more than 400 beds were chosen as target facilities, and their locations (urban or rural) were considered. Additional factors (such as the occupancy and profit rate of each facility) were considered in the calculation. Data collection involved medical practice and medical institution management surveys. The medical practice survey used time study (i.e., occupation time of medical staff and institutional equipment) and medical records (i.e., electronic and management ledgers): Some were self-reported alternatives based on their professional experience. The medical institution management survey collected financial statements (profit and loss balance sheets), number of patients and medical treatments, number of staff and equipment, unit purchase price, and the area of each department.
The medical expenses for FVs were broadly divided into “additional expenses of foreign medical treatment” and “increased expenses of regular medical treatment.” The following definitions for additional and increased expenses were applied: additional expenses for new and additional services (e.g., interpretation and transportation) for non-locally insured patients. The increased expenses for medical services were similarly offered to the locally-insured patients. However, for non-locally-insured patients, the unit price and quantity increased (e.g., consultation hours and staff). Profit was included in this calculation as a necessary resource for reinvestment by medical institutions to realize sustainable management while appropriately responding to the medical needs of FVs. However, when determining profit margins, the historical average of each institution was adopted to avoid the distortion of price levels and the expensive economic burden on FVs owing to excessive profits. The profits gained from FVs were essentially the same as those from Japanese patients.
Compared with the medical expenses (point system) of Japanese patients, those for FVs were 1.31 times (1 point 0.12 dollars) higher for pharyngitis, 1.56 times (1 point 0.14 dollars) higher for urticaria with allergies, 2.21 times (1 point 0.20 dollars) higher for hemorrhagic cystitis, 3.66 times (1 point 0.34 dollars) higher for in patients with severe pneumonia, 1.22 times (1 point 0.11 dollars) higher for general appendicitis, and 2.92 times (1 point 0.27 dollars) higher for endoscopic cholangitis treatment (Figure 16). Moreover, the operating expense for trochanteric fractures of the femur was 3.59 times (1 point 0.33 dollars) higher. Figure 17 shows the amount billed when providing medical treatment to Japanese overseas travelers (overseas FVs) in each country. The survey indicated that although the total number of patients was 18 (one in each country, except for the USA, Australia, Italy, and China), the actual medical payment was approximately USD 20.32–158.75/bill (medical expenditures for medical examination and drug cost) in 12 countries. The highest price was in the USA, at USD 158.75/bill (medical fees may be partially unknown), followed by Austria with USD 79.38 (purchasing power parity 86.28)/bill and Belgium with USD 73.93 (purchasing power parity 73.93)/bill. In summary, including additional research, the medical expenses for FV patients were 1.22–3.66 times higher than those for Japanese patients, 1.31–2.21 times higher for outpatients (pharyngitis, urticaria, and cystitis), and 1.22–3.66 times higher for inpatients (e.g., with severe pneumonia, appendicitis, cholangitis, and femoral fractures).
Calculation of price levels for foreign visitors (seven diseases) [
International comparison of medical expenses (pharyngitis and outpatients) [
The concept of factors that form the parturition price operated by the private medical care system (out-of-pocket) and the actual situation of the difference in price level due to regional characteristics [51] is introduced. This approach spans both “market-based” and “input-based” approaches, as discussed in Section 4.1. For the sustainable operation of the medical system, it is important to consider the stability of hospital management and the financial burden on citizens. In other words, it is presumed that discussions that consider the relationship between economic factors and medical treatment behavior are indispensable for the progress of UHC. This study has the advantage of developing purely causal inferences on that subject, considering the bias of other social support (subsidies). It is useful to indirectly re-recognize how the ratio of out-of-pocket expenses to the official price of public medical insurance affects the choice of consultation.
In Japan, parturition (normal childbirth), which differs from injury and illness, is not covered by the medical insurance system. This service is self-financed medical care. However, as financial support for childbirth expenditures, the Health Insurance Act provides a lump-sum childbirth and childcare allowance of JPY 420,000 per child (2021). As this system aims to reduce the financial burden of childbirth, it is also important from the perspective of measures against declining birth rates. However, the average price of childbirth is rising, and the actual cost of childbirth often exceeds JPY 420,000. Therefore, while an increase in the amount of lump-sum childbirth and childcare payments has been requested, the out-of-pocket price structure of childbirth is unclear; that is, actual costs have not been understood. Therefore, the government considers the appropriate amount of lump-sum childbirth and childcare payments to realistically grasp the situation of childbirth expenditures with services and prices.
Against the background of these trends, Japan’s regional levels of parturition prices and the factors that helped inform them were analyzed. First, a hypothesis that market principles would have a greater effect on the level formation was proposed; then, the factors that affect childbirth expenditures were structured. Consequently, price formation was considered to involve delivery costs, outcomes, supply/demand, solvency, and official (public) prices. From the provider’s perspective, “guarantee of provision cost (from a stable management viewpoint),” “overall market level and internal harmony (operation of facility),” “guarantee of quality (characteristics of the medical field),” and “competitiveness of regions (balance between supply and demand)” were selected. From the perspective of pregnant women, the elements of “interest in security (from the outcome perspective),” “interest in added value (from the amenity perspective),” “interest in the brand (from the perspective of other added values),” “restrictions on solvency (from an economic perspective),” and “access conditions (from the various types of burden)” were selected. Generally, childbirth expenditure is affected by various factors, including different factors related to facility type (e.g., general hospital, clinic, and maternity home), delivery method (e.g., natural childbirth, cesarean section, and painless delivery), timing (weekdays/daytime, night/holidays, year-end/new year), region (prefectures, cities/regions), and others (e.g., optional services such as attending a birth with family).
Consequently, the average parturition price by region in Japan was investigated. First, when the actual situation of childbirth expenditure by prefecture was analyzed using national birth-related statistical data (around 2016) [52, 53], the national average was 505,759 ± 41,906 JPY/case. A difference of approximately 1.5 times was confirmed between the highest (Tokyo City: No.1 in Figure 18) and lowest (Tottori Prefecture: No.48 in Figure 18) areas. Subsequently, multivariate analysis (multiple regression analysis) was performed to analyze the factors that differed depending on regional characteristics. Based on the factor structure described above, the objective variable was the parturition price. The explanatory variables were citizen income (solvency), “public medical expense (hospitalization unit price),” “pregnant woman’s age (risk factor),” “birth population (childbirth demand),” and “obstetric facility (supply capacity),” and “specialized equipment (maternal-fetal intensive care unit). The statistical software SPSS (IBM) was used for analysis, and the significance level was set at 5%. The results indicate that prefectural income, age at parturition, number of births, and density of equipment (facilities) affect parturition prices (Table 4). In particular, the citizen income (standard partial regression coefficient: 0.561, p < 0.001) tended to be highly related to parturition prices. The standard partial regression coefficient of birth population was negative (−0.628, p = 0.014), but the simple regression coefficient was positive (0.721, p < 0.01).
Distribution of parturition prices by region (prefecture). Note: The data source was “mean and median of childbirth costs by prefecture” (All-Japan Federation of National Health Insurance Organizations, announced in 2017).
Childbirth expenditures (normal childbirth, yen / case, FY2016) | Standardized partial regression coefficient | F-value | p-value | VIF |
---|---|---|---|---|
Annual income per citizen of the prefecture (yen / year) | 0.561 | 17.588 | 0.000 | 2.68 |
1-day hospitalization unit public price for all beds (overall: yen / day) | 0.281 | 4.106 | 0.054 | 2.88 |
Pregnant woman age (years) | 0.331 | 4.384 | 0.047 | 3.74 |
Total number of births (cases) | −0.628 | 7.011 | 0.014 | 8.42 |
Average number of births per hospital facility (number of deliveries: cases) | 0.312 | 3.272 | 0.083 | 4.46 |
Maternal and fetal intensive care unit per birth population (MFICU: number of beds) | −0.257 | 5.162 | 0.032 | 1.91 |
Decentralized analysis of the model: p < 0.001 | ||||
Socio-economic factors are affecting parturition price levels (multiple regression analysis).
Note: MFICU, maternal-fetal intensive care unit.
This chapter discussed the macroscopic mechanisms of the relationship between UHC progress and socio-economic factors to promote the sustainable development of health insurance systems. Against that background, the clinical economic considerations were presented to discuss the relationship between value and price from a micro perspective (e.g., health technology assessment).
Examining the effects of socio-economic factors of GDP and governmental health expenditures on the development of UHC showed a statistically significant positive correlation between these factors and UHC service coverage index. Furthermore, it was understood that the declining birth rate, aging population, and maturing healthcare system impacted the progress of UHC. Unemployment and poverty, distant causes of catastrophic healthcare costs, reduced the service coverage index level because of the mechanisms related to vital statistics and economic conditions. Thus, policymakers must implement countermeasures based on indicators that can estimate the economic status of the UHC approach, such as its cost-effectiveness. The sufficiency of public healthcare resources was considered important in addressing this issue. Furthermore, it was inferred that sharing healthcare values among stakeholders would be meaningful for this purpose.
Assuming that it contributes to the discussion of the real economy and official prices related to the medical field, the medical value should be evaluated by applying the marginal utility theory and cost-utility analysis. Despite some limitations, the benefits and burdens based on the value of medical care should be discussed when designing a system related to the operation of medical insurance. In this chapter, valuation research cases related to the significance of lifesaving and drug discovery were introduced, considering the possibility of allocating public resources. Furthermore, present chapter presented the price formation mechanism in the clinical field based on medical value. The price level was organized with reference to the case (childbirth) of private medical care in Japan. Factors such as the age at parturition, income level, and facility utilization rate have a price impact.
Promoting harmonization with socio-economic trends and improving explanatory power for those who bear the economic burden are key points for the future development of medical insurance systems. Long-term research using a broader range of socio-economic indicators is needed for a more accurate interpretation and deeper analysis of the obtained findings.
This study was funded by the Government of Japan Health and Labor Sciences Research Grant (grant no. JP19DA1004).
The author declares no conflicts of interest associated with this manuscript.
Trends in the country-specific economic level (GDP) and SCI components (service capacity and access). Note: UHC, universal health coverage; SCI, service coverage index [
The UHC service coverage index (SCI): Summary of tracer indicators and computation [
Overview of the regimen used (images). In this study, rituximab was administered four times every 6 months. For the first 6 months after the first dose of rituximab, the dosage of prednisolone and cyclosporine was reduced each month and stopped [
The authors gratefully acknowledge Ms. Naoko Tsukamoto and Ms. Noriko Yoshida for their contributions to the chart adjustment.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. He has contributed in stochastic estimation of control area especially, in the Multiple Target Tracking and Interactive Multiple Model (IMM) research, Ball & Beam Control Problem, Robotics, Levitation Control. He has contributed in developing Algorithms for Fingerprint Matching, Computer Vision and Face Recognition. He has been supervising Pattern Recognition, Formal Languages and Distributed Processing projects for several years. He has reviewed many books on Management, Computer Science. Currently, he is an active and permanent reviewer for many international conferences and symposia and the program committee member for many international conferences.\nIn teaching he has taught the core computer science subjects like, Digital Design, Real Time Embedded System Programming, Operating Systems, Software Engineering, Data Structures, Databases, Compiler Construction. 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This cognitive impairment affects the long-term prognosis and has been shown to be associated with long-term disability, higher health care costs, and even increased mortality. On the other hand, clinical research on POCD is in its infancy, the condition has not been clarified, and since no strategy for management is currently available, it is imperative to develop specific methods for prevention and management. Although its pathogenesis involves various factors, accumulating evidence suggests that surgery elicits an inflammatory response in the hippocampus, a brain area closely related to cognitive function, playing a key role in the development of POCD. Several studies suggest that age-related phenotypic change of microglia is associated with pathogenic neuroinflammation, and more importantly it may be modifiable. In this chapter, we discuss the current overview and preclinical highlights regarding POCD. 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Liposuction is a procedure to improve the body contour and not a surgery to reduce weight, although recently people who have failed in their plans to lose weight look at liposuction as a means to contour their body figure. Tumescent liposuction of large volumes requires a meticulous selection of each patient; their preoperative evaluation and perioperative management are essential to obtain the expected results. The various techniques of general anesthesia are the most recommended and should be monitored in the usual way, as well as monitoring the total doses of infiltrated local anesthetics to avoid systemic toxicity. The management of intravenous fluids is controversial, but the current trend is the restricted use of hydrosaline solutions. The most feared complications are deep vein thrombosis, pulmonary thromboembolism, fat embolism, lung edema, hypothermia, infections and even death. The adherence to the management guidelines and prophylaxis of venous thrombosis/thromboembolism is mandatory.",book:{id:"6221",slug:"anesthesia-topics-for-plastic-and-reconstructive-surgery",title:"Anesthesia Topics for Plastic and Reconstructive Surgery",fullTitle:"Anesthesia Topics for Plastic and Reconstructive Surgery"},signatures:"Sergio Granados-Tinajero, Carlos Buenrostro-Vásquez, Cecilia\nCárdenas-Maytorena and Marcela Contreras-López",authors:[{id:"273532",title:"Dr.",name:"Sergio Octavio",middleName:null,surname:"Granados Tinajero",slug:"sergio-octavio-granados-tinajero",fullName:"Sergio Octavio Granados Tinajero"}]},{id:"53389",title:"Anesthesia for Urological Surgery",slug:"anesthesia-for-urological-surgery",totalDownloads:3545,totalCrossrefCites:0,totalDimensionsCites:1,abstract:"Because of the variable techniques and patients’ positions used in urological surgery, anesthesia for urologic surgery requires advanced knowledge and special transactions. In this matter, it is important to follow current approaches for anesthesiologists. Different surgical procedures and complications due to different positions or anesthesia were evaluated separately to be more concise. We have researched recent literature and created this chapter about new technologies in urological surgery and development in anesthesia for urological surgery.",book:{id:"5490",slug:"current-topics-in-anesthesiology",title:"Current Topics in Anesthesiology",fullTitle:"Current Topics in Anesthesiology"},signatures:"Zeki Tuncel Tekgül, Burcu Özalp Horsanali and Mustafa Ozan\nHorsanali",authors:[{id:"59702",title:"Dr.",name:"Mustafa Ozan",middleName:null,surname:"Horsanali",slug:"mustafa-ozan-horsanali",fullName:"Mustafa Ozan Horsanali"},{id:"190164",title:"Dr.",name:"Zeki Tuncel",middleName:null,surname:"Tekgül",slug:"zeki-tuncel-tekgul",fullName:"Zeki Tuncel Tekgül"},{id:"195091",title:"Dr.",name:"Burcu Özalp",middleName:null,surname:"Horsanalı",slug:"burcu-ozalp-horsanali",fullName:"Burcu Özalp Horsanalı"}]},{id:"61712",title:"Functional Anatomy and Physiology of Airway",slug:"functional-anatomy-and-physiology-of-airway",totalDownloads:3739,totalCrossrefCites:1,totalDimensionsCites:5,abstract:"In this chapter, we scope the importance of functional anatomy and physiology of the upper airway. The upper airway has an important role in transporting air to the lungs. Both the anatomical structure of the airways and the functional properties of the mucosa, cartilages, and neural and lymphatic tissues influence the characteristics of the air that is inhaled. The airway changes in size, shape, and position throughout its development from the neonate to the adults. Knowledge of the functional anatomy of the airway in these forms the basis of understanding the pathological conditions that may occur. The upper airway extends from the mouth to the trachea. It includes the mouth, the nose, the palate, the uvula, the pharynx, and the larynx. This section also describes the functional physiology of this airway. Managing the airway of a patient with craniofacial disorders poses many challenges to the anesthesiologist. Anatomical abnormalities may affect only intubation, only airway management, or both. This section also focuses on the abnormal airways in obesity, pregnancy, children and neonate, and patients with abnormal facial defects.",book:{id:"6495",slug:"tracheal-intubation",title:"Tracheal Intubation",fullTitle:"Tracheal Intubation"},signatures:"Aslı Mete and İlknur Hatice Akbudak",authors:[{id:"237495",title:"Dr.",name:"Asli",middleName:null,surname:"Mete",slug:"asli-mete",fullName:"Asli Mete"},{id:"237882",title:"Dr.",name:"Ilknur",middleName:"Hatice",surname:"Akbudak",slug:"ilknur-akbudak",fullName:"Ilknur Akbudak"}]},{id:"60582",title:"Indications for Endotracheal Intubation",slug:"indications-for-endotracheal-intubation",totalDownloads:3689,totalCrossrefCites:1,totalDimensionsCites:0,abstract:"Endotracheal intubation may be required when respiratory distress or airway integrity cannot be achieved or maintained for any reason. It should be considered that intubation may be required when evaluating the patient, and that in the long term, airway protection will be needed or that the problem cannot be solved by noninvasive ventilation via airway aids and devices. Identifying the problem causing the patient’s respiratory failure helps in making the decision to intubate. In fact, the clinician must be fast and self-confident when deciding on intubation. It is difficult to decide in some complex situations. It is very important to evaluate the patient, according to clinical status, age, and comorbidity, and to determine urgent intubation need. In non-diagnostic cases, further research is needed to investigate the causes of the condition such as hypoxia/hypercapnia resulting in patient respiratory distress. Different voice tone, swallowing difficulties, coughing attacks, stridor, dyspnea can be a sign of upper airway obstruction. Arterial blood gas analysis will facilitate our decision to make intubation. Non-invasive pulse oximetry and continuous capnography values may also be a guide, but the most important thing is that delayed intubation decision may bring life-threatening situations.",book:{id:"6495",slug:"tracheal-intubation",title:"Tracheal Intubation",fullTitle:"Tracheal Intubation"},signatures:"Yeliz Şahiner",authors:[{id:"236458",title:"Dr.",name:"Yeliz",middleName:null,surname:"Şahiner",slug:"yeliz-sahiner",fullName:"Yeliz Şahiner"}]},{id:"64750",title:"Perioperative Complications in Plastic Surgery",slug:"perioperative-complications-in-plastic-surgery",totalDownloads:1398,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Anesthetic complications in the perioperative period in plastic surgery are extremely rare, although they can be catastrophic and sometimes fatal. The proper selection and correct preoperative assessment of patients are the key to stay away from unwanted events. Preanesthesia evaluation is mandatory in each patient and must include clinical history, complete physical examination, and routine and special laboratory tests in patients with associated pathologies. Anesthetic management is based on these results, type of surgery, experience of the anesthesiologist, and the operating environment. The anesthetic technique can be local, regional, or general with standard noninvasive monitoring. It is recommended that an anesthesiologist be present in all plastic surgery procedures. Complications are usually the result of moving away from the guidelines already established for an excellent practice or the result of sentinel events rather than human errors. Pulmonary embolism is probably the most feared complication, with soft tissue infections being the most frequent complication in plastic surgery. Less common complications include arrhythmias, overhydration, allergies, bleeding, skin necrosis, dehiscence of wounds, brain damage, and dead. Anesthesiologists, surgeons, nurses, and all personnel involved in the care of these patients must work as a team of highly qualified and updated professionals.",book:{id:"6221",slug:"anesthesia-topics-for-plastic-and-reconstructive-surgery",title:"Anesthesia Topics for Plastic and Reconstructive Surgery",fullTitle:"Anesthesia Topics for Plastic and Reconstructive Surgery"},signatures:"Víctor M. Whizar-Lugo, Jaime Campos-León and Alejandro\nMoreno-Guillen",authors:[{id:"169249",title:"Prof.",name:"Víctor M.",middleName:null,surname:"Whizar-Lugo",slug:"victor-m.-whizar-lugo",fullName:"Víctor M. 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At the Ministry of Justice of Slovenia, she is a member of examination boards for court expert candidates and judicial appraisers in the following areas: economy/finance, valuation of companies, banking, and forensic investigation of economic operations/accounting. 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The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}},{id:"338856",title:"Mrs.",name:"Nur Alvira",middleName:null,surname:"Pascawati",slug:"nur-alvira-pascawati",fullName:"Nur Alvira Pascawati",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universitas Respati Yogyakarta",country:{name:"Indonesia"}}},{id:"441116",title:"Dr.",name:"Jovanka M.",middleName:null,surname:"Voyich",slug:"jovanka-m.-voyich",fullName:"Jovanka M. Voyich",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Montana State University",country:{name:"United States of America"}}},{id:"330412",title:"Dr.",name:"Muhammad",middleName:null,surname:"Farhab",slug:"muhammad-farhab",fullName:"Muhammad Farhab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"349495",title:"Dr.",name:"Muhammad",middleName:null,surname:"Ijaz",slug:"muhammad-ijaz",fullName:"Muhammad Ijaz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}}]}},subseries:{item:{id:"20",type:"subseries",title:"Animal Nutrition",keywords:"Sustainable Animal Diets, Carbon Footprint, Meta Analyses",scope:"An essential part of animal production is nutrition. Animals need to receive a properly balanced diet. One of the new challenges we are now faced with is sustainable animal diets (STAND) that involve the 3 P’s (People, Planet, and Profitability). We must develop animal feed that does not compete with human food, use antibiotics, and explore new growth promoters options, such as plant extracts or compounds that promote feed efficiency (e.g., monensin, oils, enzymes, probiotics). These new feed options must also be environmentally friendly, reducing the Carbon footprint, CH4, N, and P emissions to the environment, with an adequate formulation of nutrients.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/20.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11416,editor:{id:"175967",title:"Dr.",name:"Manuel",middleName:null,surname:"Gonzalez Ronquillo",slug:"manuel-gonzalez-ronquillo",fullName:"Manuel Gonzalez Ronquillo",profilePictureURL:"https://mts.intechopen.com/storage/users/175967/images/system/175967.png",biography:"Dr. Manuel González Ronquillo obtained his doctorate degree from the University of Zaragoza, Spain, in 2001. He is a research professor at the Faculty of Veterinary Medicine and Animal Husbandry, Autonomous University of the State of Mexico. He is also a level-2 researcher. He received a Fulbright-Garcia Robles fellowship for a postdoctoral stay at the US Dairy Forage Research Center, Madison, Wisconsin, USA in 2008–2009. He received grants from Alianza del Pacifico for a stay at the University of Magallanes, Chile, in 2014, and from Consejo Nacional de Ciencia y Tecnología (CONACyT) to work in the Food and Agriculture Organization’s Animal Production and Health Division (AGA), Rome, Italy, in 2014–2015. He has collaborated with researchers from different countries and published ninety-eight journal articles. He teaches various degree courses in zootechnics, sheep production, and agricultural sciences and natural resources.\n\nDr. Ronquillo’s research focuses on the evaluation of sustainable animal diets (StAnD), using native resources of the region, decreasing carbon footprint, and applying meta-analysis and mathematical models for a better understanding of animal production.",institutionString:null,institution:{name:"Universidad Autónoma del Estado de México",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,series:{id:"13",title:"Veterinary Medicine and Science",doi:"10.5772/intechopen.73681",issn:"2632-0517"},editorialBoard:[{id:"175762",title:"Dr.",name:"Alfredo J.",middleName:null,surname:"Escribano",slug:"alfredo-j.-escribano",fullName:"Alfredo J. 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