Post universal health coverage trend and geographical inequalities of mortality in Thailand

BACKGROUND: Thailand has achieved remarkable improvement in health status since the achievement of universal health coverage in 2002. Health equity has improved significantly. However, challenges on health inequity still remain.This study aimed to determine the trends of geographical inequalities in disease specific mortality in Thailand after the country achieved universal health coverage. METHODS: National vital registration data from 2001 to 2014 were used to calculate age-adjusted mortality rate and standardized mortality ratio (SMR). To minimize large variations in mortality across administrative districts, the adjacent districts were systematically grouped into “super-districts” by taking into account the population size and proximity. Geographical mortality inequality among super-districts was measured by the coefficient of variation. Mixed effects modeling was used to test the difference in trends between super-districts. RESULTS: The overall SMR steadily declined from 1.2 in 2001 to 0.9 in 2014. The upper north and upper northeast regions had higher SMR whereas Greater Bangkok achieved the lowest SMR. Decreases in SMR were mostly seen in Greater Bangkok and the upper northern region. Coefficient of variation of SMR rapidly decreased from 20.0 in 2001 to 12.5 in 2007 and remained close to this value until 2014. The mixed effects modelling revealed significant differences in trends of SMR across super-districts. Inequality in mortality declined among adults (≥15 years old) but increased in children (0–14 years old). A declining trend in inequality of mortality was seen in almost all regions except Greater Bangkok where the inequality in SMR remained high throughout the study period. CONCLUSIONS: A decline in the adult mortality inequality across almost all regions of Thailand followed universal health coverage. Inequalities in child mortality rates and among residents of Greater Bangkok need further exploration

Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE):an international observational study

Background: Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels. Methods: We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month. Findings: We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14–1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12–1·72) irrespective of other patient and service characteristics. Interpretation: Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes