Governance structure reform and antibiotics prescription in community health centres in Shenzhen, China

Claiming or abdicating medical authority: Treatment recommendation actions, doctor-patient relationship, and antibiotic overprescription in Chinese paediatrics

Antibiotic overprescription in China has long been considered a problem on the supply side, linked to the financial incentives of physicians. Based on the conversation analysis of 187 video-recorded naturally occurring medical consultations in Chinese paediatric primary care settings, this study finds that the driving force behind the problem of antibiotic overprescription in China has changed. Physicians use a low-authority communication style to recommend treatment, displaying a low level of medical authority and a willingness to accommodate caregivers' preferences in antibiotic prescribing decisions. The problem is now attributed to physician-caregiver interaction, doctor-patient relationship and the antibiotic-saturated prescribing culture. Practice implications involve deepening the understanding of the evolving nature of the antibiotic overprescription problem in China, building trust between physicians and patients/caregivers in order to facilitate the physicians' role as the gatekeeper of antibiotics and providing training programmes to help physicians develop effective communication skills.

Health and health system impacts of China's comprehensive primary healthcare reforms: a systematic review

China's comprehensive primary healthcare (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality healthcare services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In 13 August 2022, international databases and three Chinese databases were searched for randomized controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group and assessed impacts on expenditures, utilization, care quality and health outcomes. Study quality was assessed using Risk of Bias In Non-randomized Studies of Interventions, and results were synthesized narratively. From 49 174 identified records, 42 studies were included-all with quasi-experimental designs, except for one randomized control trial. Nine studies were assessed as at low risk of bias. Only five low- to moderate-quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilization, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N = 15) and financing reforms (N = 11) were the most studied policies, whilst policies on primary care provision (i.e. family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilization (N = 17) and improved health outcomes in people with non-communicable diseases (N = 8). Evidence on healthcare costs was unclear, and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups that accrued greater benefits (N = 8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilization, improving some health outcomes and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance universal health coverage.

Reliability and validity evaluation of the appropriate antibiotic use self-efficacy scale for Chinese adults

BACKGROUND

Antibiotic resistance is one of the greatest threats to global public health. Inappropriate use of antibiotics can lead to an increase in antibiotic resistance. Individual self-efficacy in the appropriate use of antibiotics plays a key role, especially in China where the population has easy access to antibiotics. However, there are no tools available to assess the self-efficacy of appropriate antibiotic use for Chinese adults. We aimed to translate and develop a Chinese version of the Appropriate Antibiotic Use Self-Efficacy Scale (AAUSES), and validate its reliability and validity.

METHODS

A total of 659 adults were recruited to participate in the questionnaire. The original version scale was first translated into Chinese using the backward and forward translation procedures. The internal consistency reliability of the scale was measured by the Cronbach alpha coefficient, the test-retest reliability, and the corrected item-total correlation. The validity of the scale was assessed by the content validity index, exploratory factor analysis, and confirmatory factor analysis.

RESULTS

The content validity index of the scale was 0.96. Exploratory factor analysis (EFA) supported a 4-factor structure of the translated questionnaire, and the discriminant validity of the scale was good. Confirmatory factor analysis (CFA) showed in the model fitness index, the chi-square degree of freedom was 2.940, the goodness-of-fit index(GFI) was 0.929, the incremental fit index (IFI) was 0.908, the comparative fit index(CFI) was 0.906, root mean square error of approximation(RMSEA) was 0.077, and standardized root mean residual (SRMR) was 0.0689, and the model fitting indexes were all in the acceptable range. Cronbach alpha coefficient for the scale was 0.910. The test-retest reliability was 0.947, and the corrected item-total correlations for the items ranged from 0.488 to 0.736. Self-efficacy for appropriate antibiotic use in adults varied by education, occupation, income, place of residence, and whether or not they had heard of antibiotic resistance.

CONCLUSIONS

The results indicated that the Chinese version of the AAUSES had good reliability and validity. Therefore, it can be considered a tool to evaluate the appropriate antibiotic use self-efficacy of adults in China.

Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis

INTRODUCTION

The inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China.

METHODS

Searches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only).

RESULTS

Intervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies.

CONCLUSIONS

Interventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.

The Impact of Antimicrobial Stewardship in Children in Low- and Middle-income Countries: A Systematic Review

BACKGROUND

Antimicrobial stewardship (AMS) is central to the World Health Organisation Global Action Plan against antimicrobial resistance (AMR). If antibiotics are used without restraint, morbidity and mortality from AMR will continue to increase. In resource-rich settings, AMS can safely reduce antibiotic consumption. However, for children in low- and middle-income countries (LMIC), the impact of different AMS interventions is unknown.

AIM

To determine the impact of different AMS interventions on antibiotic use and clinical and microbiologic outcomes in children in LMIC.

METHODS

MEDLINE, Embase and PubMed were searched for studies of AMS interventions in pediatric population in LMIC settings. Controlled trials, controlled before-and-after studies and interrupted time series studies were included. Outcomes assessed were antibiotic use, multidrug-resistant organism (MDRO) rates, clinical outcomes and cost.

RESULTS

Of 1462 studies, 34 met inclusion criteria including a total population of >5,000,000 in 17 countries. Twenty were in inpatients, 2 in ED, 10 in OPD and 2 in both. Seven studies were randomized controlled trials. All types of interventions reported a positive impact on antibiotic prescribing. AMS bundles with education, and clinical decision tools appeared more effective than guidelines alone. AMS interventions resulted in significantly decreased clinical infections (4/4 studies) and clinical failure (2/2) and reduced MDRO colonization rate (4/4). There was no concomitant increase in mortality (4/4 studies) or length of stay (2/2).

CONCLUSION

Multiple effective strategies exist to reduce antibiotic consumption in LMIC. However, marked heterogeneity limit conclusions regarding the most effective approach, particularly regarding clinical outcomes. Overall, AMS strategies are important tools in the reduction of MDRO-related morbidity in children in LMIC.

Willingness to use and satisfaction of primary care services among locals and migrants in Shenzhen, China

The Chinese government has been reforming the health care system by developing a primary care system. The objectives of this study were to compare the willingness to use and satisfaction with community health care centres (CHCs), a component within the Chinese primary care system, between locals and migrants living in Luohu, Shenzhen, China. A 2019 cross-sectional survey data that interviewed 1,205 adult residents living in Luohu district were used for secondary data analysis. Two identifications of migrants were used for analysis, Shenzhen hukou status and urban village status. Linear probability models were used to determine relationship between migrants' status and the outcome variable of willingness to use CHCs and order logistic regression were used to determine the association between migrants' status and the outcome variable of satisfaction with CHCs. Among participants, 37.6% of the participants had Shenzhen hukou. Using the classification of urban village status, 29.1% of participants were urban villagers. Urban villagers were less likely to know the location of nearest CHCs and less likely to select CHCs as their frequently used health care institutions. No statistically significant difference was found on willingness to use CHCs or satisfaction with CHCs between Shenzhen hukou and non-Shenzhen hukou. But urban villagers were more satisfied with attitude and medical skills of health care workers. Our findings indicated that policymakers and social professionals need to adjust the organization and functioning of primary care institutions in the community to increase awareness and utilization of primary care services.

Improving antibiotic use through behaviour change: a systematic review of interventions evaluated in low- and middle-income countries

Antibiotic resistance (ABR) has been identified as a critical threat to global health at the highest policy fora. A leading cause of ABR is the inappropriate use of antibiotics by both patients and healthcare providers. Although countries around the world have committed to developing and implementing national action plans to tackle ABR, there is a considerable gap in evidence about effective behaviour change interventions addressing inappropriate use of antibiotics in low- and middle-income countries (LMICs), where ABR is growing at an alarming rate. We conducted a systematic review to synthesize evidence about the effectiveness and cost-effectiveness of behaviour change interventions to reduce inappropriate use of antibiotics in LMICs. Three databases were searched using a set of predefined search terms and exclusion criteria. The search identified 43 relevant articles. A narrative synthesis of results was conducted using the Behaviour Change Wheel framework to categorize intervention components. The majority of the reviewed studies were set in lower-middle-income or low-income countries located in Sub-Saharan Africa or East Asia and the Pacific. Twenty-four articles evaluated multi-faceted interventions over a period of 12 months or less. Despite the widespread use of antibiotics in the community, interventions were primarily implemented in public health facilities, targeting health professionals such as doctors, nurses, and other allied medical staff. Although education for providers was the most widely used strategy for influencing antibiotic use, it was shown to be most effective when used in conjunction with training or other enabling and supportive measures to nudge behaviour. Six articles included an evaluation of costs of interventions and found a reduction in costs in inpatient and outpatient settings, and one article found a training and guidelines implementation-based intervention to be highly cost-effective. However, the small number of articles conducting an economic evaluation highlights the need for such analyses to be conducted more frequently to support priority setting in resource-constrained environments.

Going shopping or consulting in medical visits: Caregivers' roles in pediatric antibiotic prescribing in China

Antimicrobial Resistance (AMR) is one of the gravest global public health crises today. Over-prescription in clinical settings is a primary driver. Despite its magnitude and scale, the problem of antibiotic over-prescription in China has not been understood adequately nor addressed effectively. Based on a corpus of 183 video-recorded medical conversations in the Chinese pediatric setting, we show that patient caregivers frequently challenge the physician's medical authority by resisting treatment recommendations, displaying a high level of entitlement to influence the treatment decision. As a result, even when the physicians do not recommend antibiotics based on their professional judgment, they prescribe in response to caregiver pressure. We argue that the relatively low level of medical authority is a significant contributor to the problem. Under this consumerist model of doctor-patient relationship, antibiotics are oriented to by the caregivers as a negotiable commodity and physicians are unable to fulfill their role as gatekeepers. Educational campaigns are needed to promote rational use of antibiotics among patients and caregivers, and serious efforts are called for to protect physicians' professional authority in China.

The Effectiveness of an Educational Intervention on Knowledge, Attitudes and Reported Practices on Antibiotic Use in Humans and Pigs: A Quasi-Experimental Study in Twelve Villages in Shandong Province, China

Our aim was to evaluate the effectiveness of an intervention for residents in rural China on knowledge, attitudes and reported practices (KAP) on antibiotic use in humans and pigs. A quasi-experimental study was conducted in 12 villages in rural Shandong province, divided into intervention and control groups, covering a two-year period from July 2015 to June 2017. A package of health education-based interventions including training sessions, speakerphone messages, posters and handbooks for residents was developed and implemented over a one-year period to improve the use of antibiotics in humans and pigs. The intervention net effects were evaluated by Difference-in-Difference (DID) analysis based on responses to a questionnaire concerning KAP towards antibiotic use in humans and pigs. A total of 629 participants completed both baseline and post-trial questionnaires, including 127 participants with backyard pig farms. Significant improvements were found in KAP towards antibiotic use in humans, but changes related to antibiotic use for pigs were not significant. Participants who were in the intervention group (p < 0.001) were more likely to have improved their knowledge on antibiotic use in humans. Participants who had higher attitude scores were less likely to report self-medicating with stored antibiotics in the previous year (p < 0.001). Our results suggest that our health education-based intervention was effective in improving KAP on human antibiotic use, but it had little effect regarding antibiotic use for pigs.

Characteristics of prescriptions and costs for acute upper respiratory tract infections in Chinese outpatient pediatric patients: a nationwide cross-sectional study

BACKGROUND

To understand the characteristics of prescriptions and costs in pediatric patients with acute upper respiratory infections (AURI) is important for the regulation of outpatient care and reimbursement policy. This study aims to provide evidence on these issues that was in short supply.

METHODS

We conducted a retrospective cross-sectional study based on data from National Engineering Laboratory of Application Technology in Medical Big Data. All outpatient pediatric patients aged 0-14 years with an uncomplicated AURI from 1 January 2015 to 31 December 2017 in 138 hospitals across the country were included. We reported characteristics of patients, the average number of medications prescribed per encounter, the categories of medication used and their percentages, the cost per visit and prescription costs of drugs. For these measurements, discrepancies among diverse groups of age, regions, insurance types, and AURI categories were compared. Kruskal-Wallis nonparametric test and Student-Newman-Keuls test were performed to identify differences among subgroups. A multinomial logistic regression was conducted to examine the independent effects of those factors on the prescribing behavior.

RESULTS

A total of 1,002,687 clinical records with 2,682,118 prescriptions were collected and analyzed. The average number of drugs prescribed per encounter was 2.8. The most frequently prescribed medication was Chinese traditional patent medicines (CTPM) (36.5% of overall prescriptions) followed by antibiotics (18.1%). It showed a preference of CPTM over conventional medicines. The median cost per visit was 17.91 USD. The median drug cost per visit was 13.84 USD. The expenditures of antibiotics and CTPM per visit (6.05 USD and 5.87 USD) were among the three highest categories of drugs. The percentage of out-of-pocket patients reached 65.9%. Disparities were showed among subgroups of different ages, regions, and insurance types.

CONCLUSIONS

The high volume of CPTM usage is the typical feature in outpatient care of AURI pediatric patients in China. The rational and cost-effective use of CPTM and antibiotics still faces challenges. The reimbursement for child AURI cases needs to be enhanced.

Antibiotic Consumption Trends in China: Evidence From Six-Year Surveillance Sales Records in Shandong Province

Background

The overuse of antibiotics is a serious public health problem in China, causing a high rate of antimicrobial resistance. This study identified the trends of antibiotic consumption in China to provide evidence for further intervention.

Method

The six-year surveillance data on antibiotic sales from 2012 to 2017, which served as a proxy for consumption, were collected from 39 public health care facilities in Shandong province, including three tertiary hospitals, six secondary hospitals, and 30 primary health centers. Based on the Anatomical Therapeutic Chemical (ATC)/DDD methodology, antibiotic consumption was formulated in defined daily doses (DDD) per 1,000 inhabitants per day (DID).

Results

The total antibiotic consumption among all health care settings increased from 16.07 DID in 2012 to a peak of 17.44 DID in 2015 and then decreased to 11.35 DID in 2017 with a 34.90% reduction. J01C (beta-lactam antimicrobials, penicillin), the most frequently used antibiotic class, accounted for 36.32% of the total DID. Consumption of carbapenems increased from 0.029 DID in 2012 to 0.08 DID in 2017. Parenteral antibiotics accounted for nearly 40% of the total consumption. Compared with the 2012 figures, the 2017 consumption showed a small increase in hospital sector that was compensated by the decrease in community care.

Conclusion

A substantial reduction in total antibiotic consumption was observed in China from 2012 to 2017. However, the extensive consumption of broad-spectrum antimicrobials, high proportion of parenteral antibiotic use, and increased use of last-resort antibiotics attracted public health concerns.

Advanced neonatal medicine in China: Is newborn ward capacity associated with inpatient antibiotic usage?

Previous surveys of neonatal medicine in China have not collected comprehensive information on antibiotic use in newborns. The goal of the present study was to assess the trends in antibiotic use in inpatient newborns from advanced hospitals in mainland China and to evaluate the contributing factors. We extracted retrospective data on newborn clinical units from a database containing key clinical subspecialty area indicators from provincial or ministerial (Class A level III) hospitals over three consecutive years (2008–2010) and in 25 of 31 provincial districts of mainland China. Fifty-five newborn units were included in the study. The results showed that two thirds (65.7% ± 23.1%) of inpatient newborns were prescribed antibiotic products. Antibiotic use rates were significantly different by newborn ward bed capacity (p = 0.023; 60.6% for d capacity (ficant65.7% ± 23–100 beds group, and 77.1% for (ficant65.7% ± 23.1%) of inpatient newb significantly different by type of hospital, geographic area, admission to physician or nurse ratio, or physician or nurse academic degree. Factors contributing significantly to antibiotic use included ward bed capacity, physician to nurse ratio, average hospital stay, and pneumonia to preterm infant ratio. Our data suggested that the use of antibiotics among inpatient newborns in advanced hospitals in mainland China was prevalent and should be subject to rigorous monitoring, and highlighted the need to explore how newborn ward bed capacity potentially impacts antibiotic use.

The inappropriate use of antibiotics in hospitalized dengue virus-infected children with presumed concurrent bacterial infection in teaching and private hospitals in Bandung, Indonesia

BACKGROUND

Dengue virus infection (DVI) among children is a leading cause of hospitalization in endemic areas. Hospitalized patients are at risk of receiving unnecessary antibiotics.

METHODS

A retrospective medical review analysis study was conducted to evaluate the prevalence, indication, and choice of antibiotics given to hospitalized patients less than 15 years of age with DVI in two different hospital settings (teaching and private hospitals) in the Municipality of Bandung. Epidemiological, clinical, and laboratory data were obtained using a pre-tested standardized questionnaire from patients' medical records admitted from January 1 to December 31, 2015.

RESULTS

There were 537 (17.5%) out of 3078 cases who received antibiotics. Among 176 cases admitted to the teaching hospitals, presumed bacterial upper respiratory tract infection (URTI) and typhoid fever were found in 1 (0.6%) case and 6 (0.3%) cases. In private hospitals among 2902 cases, presumed bacterial URTI was found in 324 (11.2%) cases, typhoid fever in 188 (6.5%) cases and urinary tract infection (UTI) in 18 (0.6%) cases. The prevalence of URTI and typhoid fever were significantly lower in the teaching hospitals compared to the private hospitals (p<0.0001 and p<0.05 respectively). The diagnosis of URTI in both teaching and private hospitals was merely based on clinical findings. Amoxicillin was given to 1 patient in the teaching hospitals; the 3rd generation of cephalosporins, mostly intravenous, were given in 247 (67%) cases in private hospitals. The diagnosis of typhoid fever in the teaching hospitals was based on culture in 1 (16.7%) and reactive IgM anti-Salmonella in 5 (83.3%) cases while in the private hospitals, they were based on reactive IgM anti-Salmonella in 13 (6.5%) cases, single Widal test in 61 (32.5%), and without laboratory confirmation in 114 (60.6%) cases. Most of the cases in both hospital settings were treated mostly with 3rd generation cephalosporin. The diagnosis of UTI was based on positive leucocyte esterase and nitrite in urine dipstick test in 7 (38.9%) and leucocyturia alone in 11 (61.1%) cases and was treated with 3rd generation in 15 (83.3%) cases, amoxicillin, chloramphenicol and clarithromycin, each in 1 (5.6%) case.

CONCLUSION

The use of antibiotics in private hospitals was inappropriate in most cases while the use of antibiotics in the teaching hospital was more accountable. This study indicated that interventions, such as the implementation of the antibiotics stewardship program, are needed especially in private hospitals to reduce inappropriate use of antibiotics.

Effects of the performance management information system in improving performance: an empirical study in Shanghai Ninth People’s Hospital

Improving the performance of clinical departments is not only the significant content of the healthcare system reform in China, but also the essential approach to better satisfying the Chinese growing demand for medical services. Performance management is vital and meaningful to public hospitals in China. Several studies are conducted in hospital internal performance management, but almost none of them consider the effects of informational tools. Therefore, we carried out an empirical study on effects of using performance management information system in Shanghai Ninth People’s Hospital. The main feature of the system is that it provides a real-time query platform for users to analyze and dynamically monitor the key performance indexes, timely detect problems and make adjustments. We collected pivotal medical data on 35 clinical departments of this hospital from January 2013 until December 2014, 1 year before and after applying the performance management information system. Comparative analysis was conducted by statistical methods. The results show that the system is beneficial to improve performance scores of clinical departments and lower the proportion of drug expenses, meanwhile, shorten the average hospitalized days and increase the bed turnover rate. That is to say, with the increasing medical services, the quality and efficiency is greatly improved. In a word, application of the performance management information system has a positive effect on improving performance of clinical departments.

Addressing antimicrobial resistance in China: policy implementation in a complex context

The effectiveness of antibiotics in treating bacterial infections is decreasing in China because of the widespread development of resistant organisms. Although China has enacted a number of regulations to address this problem, but the impact is very limited. This paper investigates the implementation of these regulations through the lens of complex adaptive systems (CAS). It presents the findings from reviews of relevant policy documents and published papers. The paper identifies different types of agent and explores their interaction with regard to the use of antibiotics and their responses to changes of the regulations. It focuses particularly on the impact of perverse financial incentives on overall patterns of use of antibiotics. Implications for the possibilities of nonlinear results, interactive relationships, and new pathways of policy implementation are discussed. The paper concludes that policy-makers need to better understand the objectives, incentives and potential adaptive behaviors of the agents when they implement interventions to improve antibiotic use and reduce the risk of emergence of resistant organisms.

Protocol for a pragmatic cluster randomised controlled trial for reducing irrational antibiotic prescribing among children with upper respiratory infections in rural China

INTRODUCTION

Irrational use of antibiotics is a serious issue within China and internationally. In 2012, the Chinese Ministry of Health issued a regulation for antibiotic prescriptions limiting them to <20% of all prescriptions for outpatients, but no operational details have been issued regarding policy implementation. This study aims to test the effectiveness of a multidimensional intervention designed to reduce the use of antibiotics among children (aged 2-14 years old) with acute upper respiratory infections in rural primary care settings in China, through changing doctors' prescribing behaviours and educating parents/caregivers.

METHODS AND ANALYSIS

This is a pragmatic, parallel-group, controlled, cluster-randomised superiority trial, with blinded evaluation of outcomes and data analysis, and un-blinded treatment. From two counties in Guangxi Province, 12 township hospitals will be randomised to the intervention arm and 13 to the control arm. In the control arm, the management of antibiotics prescriptions will continue through usual care via clinical consultations. In the intervention arm, a provider and patient/caregiver focused intervention will be embedded within routine primary care practice. The provider intervention includes operational guidelines, systematic training, peer review of antibiotic prescribing and provision of health education to patient caregivers. We will also provide printed educational materials and educational videos to patients' caregivers. The primary outcome is the proportion of all prescriptions issued by providers for upper respiratory infections in children aged 2-14 years old, which include at least one antibiotic.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the Ethics Committee of Guangxi Provincial Centre for Disease Control and Prevention, China. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, local and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN14340536; Pre-results.