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Zhang Z. Survey and analysis on the resource situation of primary health care institutions in rural China. Front Public Health 2024; 12:1394527. [PMID: 38919917 PMCID: PMC11196621 DOI: 10.3389/fpubh.2024.1394527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
Background China's rural population is immense, and to ensure the well-being of rural residents through healthcare services, it is essential to analyze the resources of rural grassroots healthcare institutions in China. The objective is to examine the discrepancies and deficiencies in resources between rural grassroots healthcare institutions and the national average, providing a basis for future improvements and supplementation of rural healthcare resources. Methodology The study analyzed data from 2020 to 2022 on the number of healthcare establishments, the capacity of hospital beds, the number of healthcare professionals, and the number of physicians in both rural and national settings. Additionally, it examined the medical service conditions and ratios of township health centers in rural areas to assess the resource gap between rural areas and the national average. Results Healthcare establishments: On average, there were 2.2 fewer healthcare institutions per 10,000 persons in rural areas compared to the national average over three years. Hospital beds: On average, there were approximately 36 fewer hospital beds per 10,000 persons in rural areas compared to the national average over three years. Healthcare professionals and physicians: On average, there were about 48 fewer healthcare technical personnel and 10 fewer practicing (including assistant) physicians per 10,000 persons in rural areas compared to the national average over three years. Conclusion Compared to the national average, there are significant discrepancies and deficiencies in grassroots healthcare resources in rural China. This underscores the necessity of increasing funding to progressively enhance the number of healthcare institutions in rural areas, expand the number of healthcare personnel, and elevate medical standards to better align with national benchmarks. Improving rural healthcare resources will strategically equip these institutions to cater to rural communities and effectively handle public health emergencies. Ensuring that the rural population in China has equal access to healthcare services as the rest of the country is crucial for promoting the well-being of rural residents and achieving health equity.
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Affiliation(s)
- Zhaoting Zhang
- School of Public Policy and Management, China University of Mining and Technology, Xuzhou, China
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Gao Q, Zhang B, Zhou Q, Lei C, Wei X, Shi Y. The impact of provider-patient communication skills on primary healthcare quality and patient satisfaction in rural China: insights from a standardized patient study. BMC Health Serv Res 2024; 24:579. [PMID: 38702670 PMCID: PMC11069204 DOI: 10.1186/s12913-024-11020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 04/21/2024] [Indexed: 05/06/2024] Open
Abstract
OBJECTIVES In middle-income countries, poor physician-patient communication remains a recognized barrier to enhancing healthcare quality and patient satisfaction. This study investigates the influence of provider-patient communication skills on healthcare quality and patient satisfaction in the rural primary healthcare setting in China. METHODS Data were collected from 504 interactions across 348 rural primary healthcare facilities spanning 21 counties in three provinces. Using the Standardized Patient method, this study measured physician-patient communication behaviors, healthcare quality, and patient satisfaction. Communication skills were assessed using the SEGUE questionnaire framework. Multivariate linear regression models and multivariate logistic regression models, accounting for fixed effects, were employed to evaluate the impact of physicians' communication skills on healthcare quality and patient satisfaction. RESULTS The findings indicated generally low provider-patient communication skills, with an average total score of 12.2 ± 2.8 (out of 24). Multivariate regression models, which accounted for physicians' knowledge and other factors, demonstrated positive associations between physicians' communication skills and healthcare quality, as well as patient satisfaction (P < 0.05). Heterogeneity analysis revealed stronger correlations among primary physicians with lower levels of clinical knowledge or more frequent training. CONCLUSION This study emphasizes the importance of prioritizing provider-patient communication skills to enhance healthcare quality and patient satisfaction in rural Chinese primary care settings. It recommends that the Chinese government prioritize the enhancement of provider-patient communication skills to improve healthcare quality and patient satisfaction.
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Affiliation(s)
- Qiufeng Gao
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, 710119, China
| | - Bin Zhang
- School of Economics and Finance, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Qian Zhou
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, 710119, China
| | - Cuiyao Lei
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, 710119, China
| | - Xiaofei Wei
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, 710119, China
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, 710119, China.
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Chen J, Bai T, Liu J, Xiong L, Wang W, Wang H, Wang R, Hou X. Significant improvement of physicians' knowledge and clinical practice: an opportune, effective, and convenient continuing medical education program on functional dyspepsia. Front Med (Lausanne) 2024; 11:1338206. [PMID: 38660419 PMCID: PMC11039830 DOI: 10.3389/fmed.2024.1338206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/07/2024] [Indexed: 04/26/2024] Open
Abstract
Aims This cohort study aimed to explore the effect of a one-day online continuing medical education (CME) on the improvement of physicians' knowledge and clinical practice on functional dyspepsia (FD). Methods Physicians were invited to participate in this CME via medical education applications. FD training videos made in advance were sent to participants via a weblink. Before and after training, participants were required to finish the FD knowledge test and provide case information of FD patients. McNemar test, Wilcoxon rank-sum test, Freidman test, Chi-square test, quantile regression, and generalized estimating equations (GEE) were used to perform statistical analysis. Results There were 397 of 430 (92.33%) physicians finished this CME program. The total score of the FD knowledge test after training was significantly higher compared with before training [488.3 (468.3-510.0) vs. 391.7 (341.7-450.0), p < 0.001]. Particularly, physicians from primary hospitals show more increase in total scores than physicians from secondary and tertiary hospitals. According to the GEE model, receiving this online training was an independent predictor of physicians' choice of upper gastrointestinal endoscopy in patients with FD [OR 1.73, 95%CI (1.09-2.73), p = 0.020], especially in PDS. Also, it was an independent predictor of physicians' choice of acid-suppressive drugs in patients with FD [OR 1.30, 95%CI (1.03-1.63), p = 0.026], especially in EPS and PDS overlapping EPS. Conclusion This one-day online CME program effectively and conveniently improved physicians' knowledge and clinical practice, providing new ideas for future CME and facilitating precise clinical management of FD patients with different subtypes especially in primary hospitals.
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Affiliation(s)
- Jie Chen
- Division of Gastroenterology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Bai
- Division of Gastroenterology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinsong Liu
- Division of Gastroenterology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lishou Xiong
- Division of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Weifeng Wang
- Division of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Huahong Wang
- Division of Gastroenterology, The First Hospital of Peking University, Beijing, China
| | - Rongquan Wang
- Division of Gastroenterology, The Southwest Hospital of Third Military Medical University, Chongqing, China
| | - Xiaohua Hou
- Division of Gastroenterology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Yang Y, Gong X, Song F, Guo R. Evidence-Do Gap in Quality of Direct-To-Consumer Telemedicine: Cross-Sectional Standardized Patient Study in China. Telemed J E Health 2024; 30:e1126-e1137. [PMID: 38039353 DOI: 10.1089/tmj.2023.0473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023] Open
Abstract
Background: The evidence-do gap between the availability of clinical guidelines and provider practice is well documented, resulting in low health care quality. With the rapid development of telemedicine worldwide, this study aimed to investigate the evidence-do gap and explore the factors for the evidence versus practice deficits as well as low quality in direct-to-consumer telemedicine. Methods: We adopted the standardized patient approach to evaluate the health worker performance and calculate the evidence-do gap in quality of the consultation process, diagnosis, and treatment in telemedicine based on China's national clinical guidelines. Moreover, we further explored the factors associated with the gap through multiple linear regression and logistic regressions. Results: Validated physician-patient interactions (N = 321) were included. On the one hand, the consultation process and treatment quality are less commendable with the huge evidence-do gap. More than three-quarters of the physicians provided low-quality care, as against standard clinical guidelines. On the other hand, the level I, specialized hospitals, doctor, associate chief physicians, and attending physicians, sponsored by Internet enterprises, more times of provider's responses and words were associated with high-quality processes; More total times of provider's responses, urticaria, and nonoffice hours of the visit were associated with high-quality diagnosis; Sponsored by Internet enterprises, more total words of provider's all responses, and urticaria were associated with high-quality treatment. Conclusions: Our findings have important implications in an era in which to better comprehend the evidence-do gap. Efforts to bridge the evidence-do gap should be focused on the important role of institutions and physicians.
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Affiliation(s)
- Yuting Yang
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
| | - Xue Gong
- Department of Quality and Efficiency, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Faying Song
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
| | - Rui Guo
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
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Si Y, Xue H, Liao H, Xie Y, Xu D(R, Smith MK, Yip W, Cheng W, Tian J, Tang W, Sylvia S. The quality of telemedicine consultations for sexually transmitted infections in China. Health Policy Plan 2024; 39:307-317. [PMID: 38113375 PMCID: PMC11423847 DOI: 10.1093/heapol/czad119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 12/06/2023] [Accepted: 12/16/2023] [Indexed: 12/21/2023] Open
Abstract
The burden of sexually transmitted infections (STIs) continues to increase in developing countries like China, but the access to STI care is often limited. The emergence of direct-to-consumer (DTC) telemedicine offers unique opportunities for patients to directly access health services when needed. However, the quality of STI care provided by telemedicine platforms remains unknown. After systemically identifying the universe of DTC telemedicine platforms providing on-demand consultations in China in 2019, we evaluated their quality using the method of unannounced standardized patients (SPs). SPs presented routine cases of syphilis and herpes. Of the 110 SP visits conducted, physicians made a correct diagnosis in 44.5% (95% CI: 35.1% to 54.0%) of SP visits, and correctly managed 10.9% (95% CI: 5.0% to 16.8%). Low rates of correct management were primarily attributable to the failure of physicians to refer patients for STI testing. Controlling for other factors, videoconference (vs SMS-based) consultation mode and the availability of public physician ratings were associated with higher-quality care. Our findings suggest a need for further research on the causal determinants of care quality on DTC telemedicine platforms and effective policy approaches to promote their potential to expand access to STI care in developing countries while limiting potential unintended consequences for patients.
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Affiliation(s)
- Yafei Si
- Centre for International Studies on Development and Governance, Zhejiang University, No. 688 Yuhangtang Road, Hangzhou, Zhejiang 310058, China
- School of Risk & Actuarial Studies and CEPAR, The University of New South Wales, 223 Anzac Parade, Kensington, NSW 2033, Australia
- Global Health Research Center, Duke Kunshan University, No. 8 Duke Avenue Kunshan, Jiangsu 215316, China
- University of North Carolina Project-China, No313 Huanshizhong Road Guangzhou, Guangdong 510000, China
| | - Hao Xue
- Stanford Center for China’s Institutions and Economy, Stanford University, 616 Jane Stanford Way, Stanford, CA 94305, USA
| | - Huipeng Liao
- University of North Carolina Project-China, No313 Huanshizhong Road Guangzhou, Guangdong 510000, China
| | - Yewei Xie
- University of North Carolina Project-China, No313 Huanshizhong Road Guangzhou, Guangdong 510000, China
- Programme for Health Services & Systems Research, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Dong (Roman) Xu
- Center for World Health Organization Studies and Department of Health Management, School of Health Management of Southern Medical University, 1023 South Shatai Road, Guangzhou, Guangdong 510515, China
- Acacia Labs, SMU Institute for Global Health (SIGHT), Dermatology Hospital of Southern Medical University (SMU), 1023 South Shatai Road, Guangzhou, Guangdong 510515, China
| | - M Kumi Smith
- Division of Epidemiology and Community Health, University of Minnesota Twin Cities, 1300 South 2nd Street, Minneapolis, MN 55454, USA
| | - Winnie Yip
- Department of Global Health and Population, Harvard University, 665 Huntington Ave, Cambridge, MA 02115, USA
| | - Weibin Cheng
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, No. 466 Xingangzhong Road, Guangzhou, Guangdong 510330, China
- School of Data Science, City University of Hong Kong, Tat Chee Avenue Kowloon, Hong Kong 0000, China
| | - Junzhang Tian
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, No. 466 Xingangzhong Road, Guangzhou, Guangdong 510330, China
| | - Weiming Tang
- University of North Carolina Project-China, No313 Huanshizhong Road Guangzhou, Guangdong 510000, China
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, No. 466 Xingangzhong Road, Guangzhou, Guangdong 510330, China
- Institute for Global Health and Infectious Disease, University of North Carolina at Chapel Hill, 123 W Franklin St, Chapel Hill, NC 27516, USA
| | - Sean Sylvia
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 1101 McGavran-Greenberg Hall, Chapel Hill, NC 27516, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, 123 W Franklin St, Chapel Hill, NC 27516, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 25 M.L.K. Jr Blvd, Chapel Hill, NC 27516, USA
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Zhao N, Gu M, Li J, Zhang H, Yang J. Factors influencing contracting of residents with family doctors in China: a national cross-sectional survey. BMC Health Serv Res 2024; 24:213. [PMID: 38360648 PMCID: PMC10870580 DOI: 10.1186/s12913-024-10606-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Family doctor contract services (FDCS) have been introduced in China in 2009 [1] and rapidly expanded recently. This study sought to investigate factors that influenced the willingness of Chinese residents to use FDCS. METHODS We employed multistage stratified and convenience sampling to administer questionnaires to 1455 Beijing, Qinghai, and Fujian residents. The willingness of residents in each province to contract family doctors was analyzed using the chi-square test and binary logistic regression. RESULTS The analysis in this study found that the signing rate of family doctors in China was about 27.77%, with differences in the signing up levels in Beijing (13.68%), Fujian (64.49%) and Qinghai (11.22%). In addition, the binary logistic regression results emphasized the relative importance of age, education, medical preference and policy knowledge on the willingness to sign up. Distrust of family doctors' medical skills (65.7%), not knowing how to contract (47.8%), and not knowing what medical problems can be solved (41.1%) were the top three reasons accounting for the reluctance of residents to contract with family doctors. CONCLUSION Residents from different backgrounds have different willingness to sign up, so the specific circumstances and needs of different groups should be taken into account. In order to increase the signing-up rate, consideration can be given to promoting the family doctor model in Fujian throughout the country. Individual hesitation can be eliminated by increasing the reimbursement rate of health insurance, reducing the out-of-pocket expenses of contracted patients, and providing incentives of certain discounts for consecutive contracted patients.
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Affiliation(s)
- Ning Zhao
- School of Public Health, Capital Medical University, Beijing, China
| | - Mei Gu
- School of Public Health, Capital Medical University, Beijing, China
| | - Jin Li
- School of Public Health, Capital Medical University, Beijing, China
| | - Haiyan Zhang
- Department of Health Education, Beijing Huairou Hospital of University of Chinese Academy of Sciences, Beijing, China
| | - Jia Yang
- School of Public Health, Capital Medical University, Beijing, China.
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Wang N, Li Y, Wu S, Liu Y, Nie J, Wu J, Reheman Z, Ye J, Yang J. Effect of no eyeglasses sales on the quality of eye care: an experimental evidence from China. BMC Public Health 2024; 24:422. [PMID: 38336621 PMCID: PMC10858552 DOI: 10.1186/s12889-024-17882-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Eye examinations and eyeglasses acquisition are typically integrated into a cohesive procedure in China. We conducted a randomized controlled trial using incognito standardized patient (SP) approach to evaluate the impact of separating eyeglasses sales on the accuracy of final prescription. METHODS 52 SPs were trained to provide standardized responses during eye examinations, and undergoing refraction by a senior ophthalmologist at a national-level clinical center. SPs subsequently received eye examinations at 226 private optical shops and public hospitals in Shaanxi, northwestern China. The visits were randomly assigned to either control group, where SPs would typically purchase eyeglasses after refraction, or treatment group, where SPs made an advance declaration not to purchase eyeglasses prior to refraction. The dioptric difference between the final prescriptions provided by local refractionists and expert in the better-seeing eye was determined using the Vector Diopteric Distance method, and the completeness of exams was assessed against national standards. Multiple regressions were conducted to estimate the impact of no eyeglasses sales on the accuracy of the final prescription of local refractionists, as well as the completeness of examinations. RESULTS Among 226 eye exams (73 in public hospitals, 153 in private optical shops), 133 (58.8%) were randomized to control group and 93 (41.2%) to no eyeglasses sales group. The inaccuracy rate of final prescriptions provided by local refractionists (≥ 1.0 D, experts' final prescription as the reference) was 25.6% in control group, while 36.6% in no-sale group (P = 0.077). The likelihood of providing inaccurate final prescriptions was significantly higher in no-sale group compared to control group (OR = 1.607; 95% CI: 1.030 to 2.508; P = 0.037). This was particularly evident in private optical shops (OR = 2.433; 95% CI: 1.386 to 4.309; P = 0.002). In terms of process quality, the no-sale group performed significantly less subjective refraction (OR = 0.488; 95% CI: 0.253 to 0.940; P = 0.032) and less testing SP's own eyeglasses (OR = 0.424; 95% CI: 0.201 to 0.897; P = 0.025). The duration of eye exams was 3.917 min shorter (95% CI: -6.798 to -1.036; P = 0.008) in no-sale group. CONCLUSIONS Separating eyeglasses sales from optical care could lead to worse quality of eye care. Policy makers should carefully consider the role of economic incentives in healthcare reform.
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Affiliation(s)
- Nan Wang
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
| | - Yangyuan Li
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
| | - Shichong Wu
- Department of Statistics, School of Economics, Xiamen University, Xiamen, China
| | - Yunjie Liu
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
| | - Jingchun Nie
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China.
| | - Junhao Wu
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
| | - Zulihumaer Reheman
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
| | - Jinbiao Ye
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
| | - Jie Yang
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
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8
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Xu T, Loban E, Wei X, Zhou Z, Wang W. Comparison of Health Care Utilization in Different Usual Sources of Care Among Older People With Cardiovascular Disease in China: Evidence From the Study on Global Ageing and Adult Health. Int J Public Health 2024; 68:1606103. [PMID: 38234446 PMCID: PMC10792126 DOI: 10.3389/ijph.2023.1606103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 12/14/2023] [Indexed: 01/19/2024] Open
Abstract
Objectives: To compare the health care utilization in different usual sources of care (USCs) among the elderly population with cardiovascular disease in China. Methods: Cross-sectional data for 3,340 participants aged ≥50 years with cardiovascular disease from Global AGEing and Adult Health (2010)-China were used. Using the inverse probability of treatment weighting on the propensity score with survey weighting, combined with negative binomial regression and logistic regression models, the correlation between USCs and health care utilization was assessed. Results: Patients using primary care facilities as their USC had fewer hospital admissions (IRR = 0.507, 95% CI = 0.413, 0.623) but more unmet health needs (OR = 1.657, 95% CI = 1.108, 2.478) than those using public hospitals. Patients using public clinics as their USC had higher outpatient visits (IRR = 2.188, 95% CI = 1.630, 2.939) than the private clinics' group. Conclusion: The difference in inpatient care utilization and unmet health care needs between public hospitals and primary care facilities, and the difference in outpatient care utilization between public and private clinics were significant. Using primary care facilities as USCs, particularly public ones, appeared to increase care accessibility, but it still should be strengthened to better address patients' health care needs.
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Affiliation(s)
- Tiange Xu
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Ekaterina Loban
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Wenhua Wang
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
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Li H, Guo Z, Yang W, He Y, Chen Y, Zhu J. Perceptions of medical error among general practitioners in rural China: a qualitative interview study. BMJ Open Qual 2023; 12:e002528. [PMID: 38160021 PMCID: PMC10759142 DOI: 10.1136/bmjoq-2023-002528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Medical error (ME) is a serious public health problem and a leading cause of death. The reported adverse incidents in China were much less than western countries, and the research on patient safety in rural China's primary care institutions was scarce. This study aims to identify the factors contributing to the under-reporting of ME among general practitioners in township health centres (THCs). METHODS A qualitative semi-structured interview study was conducted with 31 general practitioners working in 30 THCs across 6 provinces. Thematic analysis was conducted using a grounded theory approach. RESULTS The understanding of ME was not unified, from only mild consequence to only almost equivalent to medical malpractice. Common coping strategies for THCs after ME occurs included concealing and punishment. None of the participants reported adverse events through the National Clinical Improvement System website since they worked in THCs. Discussions about ME always focused on physicians rather than the system. CONCLUSIONS The low reported incidence of ME could be explained by unclear concept, unawareness and blame culture. It is imperative to provide supportive environment, patient safety training and good examples of error-based improvements to rural primary care institutions so that ME could be fully discussed, and systemic factors of ME could be recognised and improved there in the future.
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Affiliation(s)
- Hange Li
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
| | - Ziting Guo
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Wenbin Yang
- Department of Oral and Maxillofacial Surgery, Department of Medical Affairs, Sichuan University West China Hospital of Stomatology, Chengdu, Sichuan, China
- Sichuan University State Key Laboratory of Oral Diseases, Chengdu, Sichuan, China
| | - Yanrong He
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Yanhua Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
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10
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Si Y, Chen G, Su M, Zhou Z, Yip W, Chen X. The Impact of Physician-Patient Gender Match on Healthcare Quality: An Experiment in China. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.03.23296202. [PMID: 37873451 PMCID: PMC10592995 DOI: 10.1101/2023.10.03.23296202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Despite growing evidence of gender disparities in healthcare utilization and health outcomes, there is a lack of understanding of what may drive such differences. Designing and implementing an experiment using the standardized patients' approach, we present novel evidence on the impact of physician-patient gender match on healthcare quality in a primary care setting in China. We find that, compared with female physicians treating female patients, the combination of female physicians treating male patients resulted in a 23.0 percentage-point increase in correct diagnosis and a 19.4 percentage-point increase in correct drug prescriptions. Despite these substantial gains in healthcare quality, there was no significant increase in medical costs and time investment. Our analyses suggest that the gains in healthcare quality were mainly attributed to better physician-patient communications, but not the presence of more clinical information. This paper has policy implications in that improving patient centeredness and incentivizing physicians' efforts in consultation (as opposed to treatment) can lead to significant gains in the quality of healthcare with modest costs, while reducing gender differences in care.
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Affiliation(s)
- Yafei Si
- School of Risk & Actuarial Studies, University of New South Wales, Australia
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Australia
| | - Gang Chen
- Centre for Health Economics, Monash Business School, Monash University, Australia
| | - Min Su
- School of Public Administration, Inner Mongolia University, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi’an Jiaotong University, China
| | - Winnie Yip
- Harvard T.H. Chan School of Public Health, Harvard University, USA
| | - Xi Chen
- Department of Health Policy and Management, Yale School of Public Health, USA
- Department of Economics, Yale University, USA
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11
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Zhang X, Sun B, Tian Z, Yu B, Wei C, Zhang Y, Zheng C, Chen X, Liu Q. Relationship between honesty-credit, specialty identity, career identity, and willingness to fulfill the contract among rural-oriented tuition-waived medical students of China: a cross-sectional study. Front Public Health 2023; 11:1089625. [PMID: 37529424 PMCID: PMC10388187 DOI: 10.3389/fpubh.2023.1089625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
Background The fulfillment of contractual obligations by rural-oriented tuition-waived medical students (RTMSs) to work in rural medical institutions after graduation directly impacts the improvement of rural health quality. This study aimed to not only quantitatively measure the direct impact of honesty-credit, specialty identity, and career identity on willingness to fulfill the contract of RTMSs but also to quantify the intermediary role of specialty identity and career identity between honesty-credit and willingness to fulfill the contract. The research results provided recommendations for the rural-oriented tuition-waived medical education (RTME) program to achieve its goal of training rural primary healthcare personnel. Methods From March to May 2022, 1162 RTMSs were selected as the research objects. The honesty-credit, specialty identity, career identity, and willingness to fulfill the contract were quantitated using a self-completed questionnaire. Pearson's correlation analysis and structural equation modeling were used for statistical analysis and mediating effect evaluation. Results A total of 455 (42.3%) RTMSs had high willingness to fulfill the contract, and honesty-credit had a significant direct positive effect on willingness (β = 0.198, P < 0.001), specialty identity (β = 0.653, P < 0.001), and career identity (β = 0.180, P < 0.001). In the intermediary path between honesty-credit and willingness, career identity [95% confidence interval (CI): 0.007-0.051] had significant mediating effects. Career identity (95% CI: 0.030-0.149) also had significant mediating effects between specialty identity and willingness, and specialty identity (95% CI: 0.465-0.760) had significant mediating effects between honesty-credit and career identity. These results strongly confirmed that honesty-credit, specialty identity, and career identity are early and powerful predictors of the willingness to fulfill the contract of RTMSs. Conclusion The honesty-credit of RTMSs can predict their willingness to fulfill the contract early, significantly and positively. For the students who fail to pass the credit assessment for many times and have a strong tendency to default, their training qualifications should be canceled in time, so that students who are truly willing to serve rural areas can enter the project, and finally achieve the policy goal of "strengthening the rural primary medical and health system".
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Affiliation(s)
- Xuewen Zhang
- School of Integrated Traditional Chinese and Western Medicine, Jining Medical University, Jining, China
| | - Bing Sun
- School of Integrated Traditional Chinese and Western Medicine, Jining Medical University, Jining, China
| | - Zhuang Tian
- School of Public Health, Jining Medical University, Jining, China
| | - Bin Yu
- School of Integrated Traditional Chinese and Western Medicine, Jining Medical University, Jining, China
| | - Chao Wei
- School of Integrated Traditional Chinese and Western Medicine, Jining Medical University, Jining, China
| | - Ying Zhang
- School of Integrated Traditional Chinese and Western Medicine, Jining Medical University, Jining, China
| | - Canlei Zheng
- School of Integrated Traditional Chinese and Western Medicine, Jining Medical University, Jining, China
| | - Xuejun Chen
- School of Integrated Traditional Chinese and Western Medicine, Jining Medical University, Jining, China
| | - Qing Liu
- School of Integrated Traditional Chinese and Western Medicine, Jining Medical University, Jining, China
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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Do private providers initiate anti-tuberculosis therapy on the basis of chest radiographs? A standardised patient study in urban India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100152. [PMID: 37383564 PMCID: PMC10306035 DOI: 10.1016/j.lansea.2023.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 06/30/2023]
Abstract
Background The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations. Methods This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results. Findings Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21-28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19-26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10-16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing. Interpretation One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories. Funding This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment, Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Use of standardised patients to assess tuberculosis case management by private pharmacies in Patna, India: A repeat cross-sectional study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001898. [PMID: 37235550 PMCID: PMC10218738 DOI: 10.1371/journal.pgph.0001898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023]
Abstract
As the first point of care for many healthcare seekers, private pharmacies play an important role in tuberculosis (TB) care. However, previous studies in India have showed that private pharmacies commonly dispense symptomatic treatments and broad-spectrum antibiotics over-the-counter (OTC), rather than referring patients for TB testing. Such inappropriate management by pharmacies can delaye TB diagnosis. We assessed medical advice and OTC drug dispensing practices of pharmacists for standardized patients presenting with classic symptoms of pulmonary TB (case 1) and for those with sputum smear positive pulmonary TB (case 2), and examined how practices have changed over time in an urban Indian site. We examined how and whether private pharmacies improved practices for TB in 2019 compared to a baseline study conducted in 2015 in the city of Patna, using the same survey sampling techniques and study staff. The proportion of patient-pharmacist interactions that resulted in correct or ideal management, as well as the proportion of interactions resulting in antibiotic, quinolone, and corticosteroid are presented, with standard errors clustered at the provider level. To assess the difference in case management and the use of drugs across the two cases by round, a difference in difference (DiD) model was employed. A total of 936 SP interactions were completed over both rounds of survey. Our results indicate that across both rounds of data collection, 331 of 936 (35%; 95% CI: 32-38%) of interactions were correctly managed. At baseline, 215 of 500 (43%; 95% CI: 39-47%) of interactions were correctly managed whereas 116 of 436 (27%; 95% CI: 23-31%) were correctly managed in the second round of data collection. Ideal management, where in addition to a referral, patients were not prescribed any potentially harmful medications, was seen in 275 of 936 (29%; 95% CI: 27-32%) of interactions overall, with 194 of 500 (39%; 95% CI: 35-43%) of interactions at baseline and 81 of 436 (19%; 95% CI: 15-22%) in round 2. No private pharmacy dispensed anti-TB medications without a prescription. On average, the difference in correct case management between case 1 vs. case 2 dropped by 20 percent points from baseline to the second round of data collection. Similarly, ideal case management decreased by 26 percentage points between rounds. This is in contrast with the dispensation of medicines, which had the opposite effect between rounds; the difference in dispensation of quinolones between case 1 and case 2 increased by 14 percentage points, as did corticosteroids by 9 percentage points, antibiotics by 25 percentage points and medicines generally by 30 percentage points. Our standardised patient study provides valuable insights into how private pharmacies in an Indian city changed their management of patients with TB symptoms or with confirmed TB over a 5-year period. We saw that overall, private pharmacy performance has weakened over time. However, no OTC dispensation of anti-TB medications occurred in either survey round. As the first point of contact for many care seekers, continued and sustained efforts to engage with Indian private pharmacies should be prioritized.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | | | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jishnu Das
- Georgetown University, Washington, DC, United States of America
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Ontario, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Miranda-Novales MG, Flores-Moreno K, Rodríguez-Álvarez M, López-Vidal Y, Soto-Hernández JL, Solórzano Santos F, Ponce-de-León-Rosales S. The Real Practice Prescribing Antibiotics in Outpatients: A Failed Control Case Assessed through the Simulated Patient Method. Antibiotics (Basel) 2023; 12:antibiotics12050915. [PMID: 37237818 DOI: 10.3390/antibiotics12050915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
The first level of medical care provides the largest number of consultations for the most frequent diseases at the community level, including acute pharyngitis (AP), acute diarrhoea (AD) and uncomplicated acute urinary tract infections (UAUTIs). The inappropriate use of antibiotics in these diseases represents a high risk for the generation of antimicrobial resistance (AMR) in bacteria causing community infections. To evaluate the patterns of medical prescription for these diseases in medical offices adjacent to pharmacies, we used an adult simulated patient (SP) method representing the three diseases, AP, AD and UAUTI. Each person played a role in one of the three diseases, with the signs and symptoms described in the national clinical practice guidelines (CPGs). Diagnostic accuracy and therapeutic management were assessed. Information from 280 consultations in the Mexico City area was obtained. For the 101 AP consultations, in 90 cases (89.1%), one or more antibiotics or antivirals were prescribed; for the 127 AD, in 104 cases (81.8%), one or more antiparasitic drugs or intestinal antiseptics were prescribed; for the scenarios involving UAUTIs in adult women, in 51 of 52 cases (98.1%) one antibiotic was prescribed. The antibiotic group with the highest prescription pattern for AP, AD and UAUTIs was aminopenicillins and benzylpenicillins [27/90 (30%)], co-trimoxazole [35/104 (27.6%)] and quinolones [38/51 (73.1%)], respectively. Our findings reveal the highly inappropriate use of antibiotics for AP and AD in a sector of the first level of health care, which could be a widespread phenomenon at the regional and national level and highlights the urgent need to update antibiotic prescriptions for UAUTIs according to local resistance patterns. Supervision of adherence to the CPGs is needed, as well as raising awareness about the rational use of antibiotics and the threat posed by AMR at the first level of care.
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Affiliation(s)
- María Guadalupe Miranda-Novales
- Unidad de Investigación en Análisis y Síntesis de la Evidencia, Instituto Mexicano del Seguro Social, Centro Médico Nacional Siglo XXI, Mexico City 06720, Mexico
| | - Karen Flores-Moreno
- Laboratorio de Microbioma, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Mauricio Rodríguez-Álvarez
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Yolanda López-Vidal
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - José Luis Soto-Hernández
- Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City 14269, Mexico
| | - Fortino Solórzano Santos
- Unidad de Investigación en Enfermedades Infecciosas, Hospital Infantil de México Federico Gómez, Secretaría de Salud, Mexico City 06720, Mexico
| | - Samuel Ponce-de-León-Rosales
- Programa Universitario de Investigación Sobre Riesgos Epidemiológicos y Emergentes, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
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Si Y, Bateman H, Chen S, Hanewald K, Li B, Su M, Zhou Z. Quantifying the financial impact of overuse in primary care in China: A standardised patient study. Soc Sci Med 2023; 320:115670. [PMID: 36669284 DOI: 10.1016/j.socscimed.2023.115670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
Overuse of health care is a potential factor in explaining the rapid increase in health care expenditure in many countries; however, it is difficult to measure overuse. This study employed the novel method of using unannounced standardised patients (SPs) to identify overuse, document its patterns and quantify its financial impact on patients in primary care in China. We trained 18 SPs to present consistent cases of two common chronic diseases and recorded 492 physician-patient interactions in 63 public and private primary hospitals in a capital city in western China in 2017 and 2018. Overuse, defined as the provision of unnecessary medical tests and drugs, was identified by a panel of medical experts based on national clinical guidelines. We estimated linear regression models to investigate how hospital, physician and patient characteristics were associated with overuse and to quantify the financial impact of overuse after controlling for a series of fixed effects. We found overuse in 72.15% of the SP visits. The high prevalence of overuse was similar among public and private hospitals, low-competence and high-competence physicians, male and female physicians, junior and senior physicians and male and female patients, but it varied between patients presenting different diseases. Compared to the non-overuse group, overuse significantly increased the total cost by 117.8%, the test cost by 58.8% and the drug cost by 100.3%. The financial impact of overuse was consistent across the aforementioned hospital, physician and patient characteristics. We suggest that the overuse observed in this study is unlikely to be attributable to physician incompetence but rather to the financing framework for primary care in China. These findings illuminate the cost escalation of primary care in China, which is a form of medical inefficiency that should be urgently addressed.
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Affiliation(s)
- Yafei Si
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia.
| | - Hazel Bateman
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Shu Chen
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Katja Hanewald
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Bingqin Li
- Social Policy Research Centre, University of New South Wales, Sydney, Australia
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China.
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16
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King JJC, Powell-Jackson T, Hargreaves J, Makungu C, Goodman C. Does increased provider effort improve quality of care? Evidence from a standardised patient study on correct and unnecessary treatment. BMC Health Serv Res 2023; 23:190. [PMID: 36823637 PMCID: PMC9948477 DOI: 10.1186/s12913-023-09149-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Poor quality of care, including overprovision (unnecessary care) is a global health concern. Greater provider effort has been shown to increase the likelihood of correct treatment, but its relationship with overprovision is less clear. Providers who make more effort may give more treatment overall, both correct and unnecessary, or may have lower rates of overprovision; we test which is true in the Tanzanian private health sector. METHODS Standardised patients visited 227 private-for-profit and faith-based facilities in Tanzania, presenting with symptoms of asthma and TB. They recorded history questions asked and physical examinations carried out by the provider, as well as laboratory tests ordered, treatments prescribed, and fees paid. A measure of provider effort was constructed on the basis of a checklist of recommended history taking questions and physical exams. RESULTS 15% of SPs received the correct care for their condition and 74% received unnecessary care. Increased provider effort was associated with increased likelihood of correct care, and decreased likelihood of giving unnecessary care. Providers who made more effort charged higher fees, through the mechanism of higher consultation fees, rather than increased fees for lab tests and drugs. CONCLUSION Providers who made more effort were more likely to treat patients correctly. A novel finding of this study is that they were also less likely to provide unnecessary care, suggesting it is not simply a case of some providers doing "more of everything", but that those who do more in the consultation give more targeted care.
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Affiliation(s)
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
| | - James Hargreaves
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
| | - Christina Makungu
- Ifakara Health Instiute, Plot 463, Kiko Avenue, P.O. Box 78 373, Mikocheni, Dar es Salaam, Tanzania
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
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17
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Wu Y, Ye R, Sun C, Meng S, Cai Z, Li L, Sylvia S, Zhou H, Pappas L, Rozelle S. Using standardized patients to assess the quality of type 2 diabetes care among primary care providers and the health system: Evidence from rural areas of western China. Front Public Health 2022; 10:1081239. [PMID: 36620284 PMCID: PMC9815030 DOI: 10.3389/fpubh.2022.1081239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Background Improving type 2 diabetes (T2D) care is key to managing and reducing disease burden due to the growing prevalence of diabetes worldwide, but research on this topic, specifically from rural areas, is limited. This study uses standardized patients (SPs) to assess T2D care quality among primary care providers to access the healthcare system in rural China. Methods Using multi-stage random sampling, health facilities, providers, and households were selected. SPs were used to evaluate providers' T2D care quality and a questionnaire survey was used to collect patient sorting behaviors from households. Logistic regression was used to explore factors correlated with T2D care quality. Provider referral and treatment rates were combined with patient sorting behaviors to assess the overall quality of T2D management by rural China's healthcare system. Results A total of 126 providers, 106 facilities, and 750 households were enrolled into this study. During SP interactions, 20% of rural providers followed the national guidelines for T2D consultation, 32.5% gave correct treatment, and 54.7% provided lifestyle suggestions. Multi-variable regression results showed that providers who had earned practicing certificates (β = 1.56, 95% CI: 0.44, 2.69) and saw more patients (β = 0.77, 95%: 0.25, 1.28) were more likely to use a higher number of recommended questions and perform better examinations, whereas providers who participated in online training were less likely to practice these behaviors (β = -1.03, 95%: -1.95, -0.11). The number of recommended questions and examination (NRQE) was the only significant correlated factor with correct treatment (marginal effect = 0.05, 95%: 0.01, 0.08). Throughout the rural healthcare system, 23.7% of T2D patients were treated correctly. Conclusion The quality of T2D care in rural western China, especially throughout the consultation and treatment process during a patient's first visit, is poor. Online training may not improve T2D care quality and low patient volume was likely to indicate poor care quality. Further research is needed to explore interventions for improving T2D care quality in rural China's healthcare system.
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Affiliation(s)
- Yuju Wu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruixue Ye
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chang Sun
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sha Meng
- Department of Operation Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhengjie Cai
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Linhua Li
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Huan Zhou
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China,*Correspondence: Huan Zhou ✉
| | - Lucy Pappas
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
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Leung T, Cai Y, Cao J, He Q, Wang X, Lu Y, Liang H, Xu D, Liao J. The Agreement Between Virtual Patient and Unannounced Standardized Patient Assessments in Evaluating Primary Health Care Quality: Multicenter, Cross-sectional Pilot Study in 7 Provinces of China. J Med Internet Res 2022; 24:e40082. [PMID: 36459416 PMCID: PMC9758641 DOI: 10.2196/40082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/27/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The unannounced standardized patient (USP) is the gold standard for primary health care (PHC) quality assessment but has many restrictions associated with high human and resource costs. Virtual patient (VP) is a valid, low-cost software option for simulating clinical scenarios and is widely used in medical education. It is unclear whether VP can be used to assess the quality of PHC. OBJECTIVE This study aimed to examine the agreement between VP and USP assessments of PHC quality and to identify factors influencing the VP-USP agreement. METHODS Eleven matched VP and USP case designs were developed based on clinical guidelines and were implemented in a convenience sample of urban PHC facilities in the capital cities of the 7 study provinces. A total of 720 USP visits were conducted, during which on-duty PHC providers who met the inclusion criteria were randomly selected by the USPs. The same providers underwent a VP assessment using the same case condition at least a week later. The VP-USP agreement was measured by the concordance correlation coefficient (CCC) for continuity scores and the weighted κ for diagnoses. Multiple linear regression was used to identify factors influencing the VP-USP agreement. RESULTS Only 146 VP scores were matched with the corresponding USP scores. The CCC for medical history was 0.37 (95% CI 0.24-0.49); for physical examination, 0.27 (95% CI 0.12-0.42); for laboratory and imaging tests, -0.03 (95% CI -0.20 to 0.14); and for treatment, 0.22 (95% CI 0.07-0.37). The weighted κ for diagnosis was 0.32 (95% CI 0.13-0.52). The multiple linear regression model indicated that the VP tests were significantly influenced by the different case conditions and the city where the test took place. CONCLUSIONS There was low agreement between VPs and USPs in PHC quality assessment. This may reflect the "know-do" gap. VP test results were also influenced by different case conditions, interactive design, and usability. Modifications to VPs and the reasons for the low VP-USP agreement require further study.
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Affiliation(s)
| | - Yiyuan Cai
- Department of Epidemiology and Medical Statistics, School of Public Health, Guizhou Medical University, Guiyang, China
| | - Jin Cao
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Qianyu He
- Department of Medical Statistics & Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Xiaohui Wang
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Lu
- Department of Preventive Medicine & Maternal and Child Health, School of Public Health, Guizhou Medical University, Guiyang, China
| | - Huijuan Liang
- Research Institute for Health Policy of Inner Mongolia, Inner Mongolia Medical University, Hohhot, China
| | - Dong Xu
- Center for World Health Organization Studies, Department of Health Management, School of Health Management of Southern Medical University, Guangzhou, China.,ACACIA Lab for Implementation Research, Southern Medical University Institute for Global Health, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Jing Liao
- Department of Medical Statistics & Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
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Tang W, Si Y, Xue H, Liao H, Xie Y, Xu D(R, Smith MK, Yip W, Cheng W, Tian J, Sylvia S. The quality of direct-to-consumer telemedicine consultations for sexually transmitted infections in China: An analysis of visits by standardized patients (Preprint). Interact J Med Res 2022. [DOI: 10.2196/44190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Xu W, Zheng J, Huang Y, Zhang M. Quality improvement and patient safety in China, present and future. Paediatr Anaesth 2022; 32:1201-1208. [PMID: 36029166 DOI: 10.1111/pan.14550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 11/27/2022]
Abstract
With continued political support and increased health financing, China has achieved great progress in medical and health quality during the two decades. The strategy to improve health in China is built on reliable cross-sectoral information and data sharing along with quality improvement science and safety analytics balancing equitability, accessibility, quality outcomes, and safety in healthcare for everyone. As part of the healthcare system, pediatric anesthesiology has made great efforts to align with the China healthcare strategy to achieve quality outcomes, accessibility, and patient safety, but it still faces many problems such as unbalanced regional development, lack of awareness and relevant knowledge, and increased workload due to insufficient number of anesthesiologists. To address these problems, the Chinese Society of Anesthesiology and Chinese Society for Pediatric Anesthesiology supported by the Chinese hospital associations are strengthening interregional cooperation and international collaboration. In our experience, quality improvement can be successfully implemented at major centers through collaboration with experienced international institutions. In turn, the major centers educate and collaborate with the district hospitals to empower local improvements in safety and quality. Since the science in QI and patient safety is relatively new to anesthesiology in China, such collaborations must be greatly scaled up to reach the large geography and patient population in China. While the future is promising, there is still a long way to go.
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Affiliation(s)
- Wenyan Xu
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jijian Zheng
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Huang
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mazhong Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Chen Y, Sylvia S, Dill SE, Rozelle S. Structural Determinants of Child Health in Rural China: The Challenge of Creating Health Equity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13845. [PMID: 36360724 PMCID: PMC9654689 DOI: 10.3390/ijerph192113845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 06/16/2023]
Abstract
Over the past two decades, the literature has shown a clear gradient between child health and wealth. The same health-wealth gradient is also observed among children in China, with a large gap in health between rural and urban children. However, there are still unanswered questions about the main causes of China's rural-urban child health inequality. This paper aims to review the major factors that have led to the relatively poor levels of health among China's rural children. In addition to the direct income effect on children's health, children in rural areas face disadvantages compared with their urban counterparts from the beginning of life: Prenatal care and infant health outcomes are worse in rural areas; rural caregivers have poor health outcomes and lack knowledge and support to provide adequate nurturing care to young children; there are large disparities in access to quality health care between rural and urban areas; and rural families are more likely to lack access to clean water and sanitation. In order to inform policies that improve health outcomes for the poor, there is a critical need for research that identifies the causal drivers of health outcomes among children. Strengthening the pediatric training and workforce in rural areas is essential to delivering quality health care for rural children. Other potential interventions include addressing the health needs of mothers and grandparent caregivers, improving parenting knowledge and nurturing care, improving access to clean water and sanitation for remote families, and most importantly, targeting poverty itself.
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Affiliation(s)
- Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sarah-Eve Dill
- Stanford Center on China’s Economy and Institutions, Stanford University, Stanford, CA 94305, USA
| | - Scott Rozelle
- Stanford Center on China’s Economy and Institutions, Stanford University, Stanford, CA 94305, USA
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22
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Daniels B, Shah D, Kwan AT, Das R, Das V, Puri V, Tipre P, Waghmare U, Gomare M, Keskar P, Das J, Pai M. Tuberculosis diagnosis and management in the public versus private sector: a standardised patients study in Mumbai, India. BMJ Glob Health 2022; 7:e009657. [PMID: 36261230 PMCID: PMC9582305 DOI: 10.1136/bmjgh-2022-009657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/13/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There are few rigorous studies comparing quality of tuberculosis (TB) care in public versus private sectors. METHODS We used standardised patients (SPs) to measure technical quality and patient experience in a sample of private and public facilities in Mumbai. RESULTS SPs presented a 'classic, suspected TB' scenario and a 'recurrence or drug-resistance' scenario. In the private sector, SPs completed 643 interactions. In the public sector, 164 interactions. Outcomes included indicators of correct management, medication use and client experience. Public providers used microbiological testing (typically, microscopy) more frequently, in 123 of 164 (75%; 95% CI 68% to 81%) vs 223 of 644 interactions (35%; 95% CI 31% to 38%) in the private sector. Private providers were more likely to order chest X-rays, in 556 of 639 interactions (86%; 95% CI 84% to 89%). According to national TB guidelines, we found higher proportions of correct management in the public sector (75% vs 35%; (adjusted) difference 35 percentage points (pp); 95% CI 25 to 46). If X-rays were considered acceptable for the first case but drug-susceptibility testing was required for the second case, the private sector correctly managed a slightly higher proportion of interactions (67% vs 51%; adjusted difference 16 pp; 95% CI 7 to 25). Broad-spectrum antibiotics were used in 76% (95% CI 66% to 84%) of the interactions in public hospitals, and 61% (95% CI 58% to 65%) in private facilities. Costs in the private clinics averaged rupees INR 512 (95% CI 485 to 539); public facilities charged INR 10. Private providers spent more time with patients (4.4 min vs 2.4 min; adjusted difference 2.0 min; 95% CI 1.2 to 2.9) and asked a greater share of relevant questions (29% vs 43%; adjusted difference 13.7 pp; 95% CI 8.2 to 19.3). CONCLUSIONS While the public providers did a better job of adhering to national TB guidelines (especially microbiological testing) and offered less expensive care, private sector providers did better on client experience.
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Affiliation(s)
- Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Daksha Shah
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Ada T Kwan
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Varsha Puri
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Pranita Tipre
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Upalimitra Waghmare
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Mangala Gomare
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Padmaja Keskar
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Québec, Canada
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Nayak PR, Oswal K, Pramesh CS, Ranganathan P, Caduff C, Sullivan R, Advani S, Kataria I, Kalkonde Y, Mohan P, Jain Y, Purushotham A. Informal Providers-Ground Realities in South Asian Association for Regional Cooperation Nations: Toward Better Cancer Primary Care: A Narrative Review. JCO Glob Oncol 2022; 8:e2200260. [PMID: 36315923 PMCID: PMC9812474 DOI: 10.1200/go.22.00260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/04/2022] [Accepted: 09/13/2022] [Indexed: 01/06/2023] Open
Abstract
PURPOSE South Asian Association for Regional Cooperation (SAARC) nations are a group of eight countries with low to medium Human Development Index values. They lack trained human resources in primary health care to achieve the WHO-stated goal of Universal Health Coverage. An unregulated service sector of informal health care providers (IPs) has been serving these underserved communities. The aim is to summarize the role of IPs in primary cancer care, compare quality with formal providers, quantify distribution in urban and rural settings, and present the socioeconomic milieu that sustains their existence. METHODS A narrative review of the published literature in English from January 2000 to December 2021 was performed using MeSH Terms Informal Health Care Provider/Informal Provider and Primary Health Care across databases such as Medline (PubMed), Google Scholar, and Cochrane database of systematic reviews, as well as World Bank, Center for Global Development, American Economic Review, Journal Storage, and Web of Science. In addition, citation lists from the primary articles, gray literature in English, and policy blogs were included. We present a descriptive overview of our findings as applicable to SAARC. RESULTS IPs across the rural landscape often comprise more than 75% of primary caregivers. They provide accessible and affordable, but often substandard quality of care. However, their network would be suitable for prompt cancer referrals. Care delivery and accountability correlate with prevalent standards of formal health care. CONCLUSION Acknowledgment and upskilling of IPs could be a cost-effective bridge toward universal health coverage and early cancer diagnosis in SAARC nations, whereas state capacity for training formal health care providers is ramped up simultaneously. This must be achieved without compromising investment in the critical resource of qualified doctors and allied health professionals who form the core of the rural public primary health care system.
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Affiliation(s)
- Prakash R. Nayak
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | | | | | - Priya Ranganathan
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Carlo Caduff
- Department of Global Health and Social Medicine, King's College London, United Kingdom
| | - Richard Sullivan
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
| | | | - Ishu Kataria
- Public Health Centre for Global Non-communicable Diseases, RTI International, New Delhi, India
| | - Yogeshwar Kalkonde
- Sangwari-People's Association for Equity and Health, Ambikapur, Chhattisgarh, India
| | | | | | - Arnie Purushotham
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
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Gong X, Hou M, Guo R, Feng XL. Investigating the relationship between consultation length and quality of tele-dermatology E-consults in China: a cross-sectional standardized patient study. BMC Health Serv Res 2022; 22:1187. [PMID: 36138410 PMCID: PMC9493166 DOI: 10.1186/s12913-022-08566-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022] Open
Abstract
Background Consultation length, the time a health provider spend with the patient during a consultation, is a crucial aspect of patient-physician interaction. Prior studies that assessed the relationship between consultation length and quality of care were mainly based on offline visits. Research was lacking in E-consults settings, an emerging modality for primary health care. This study aims to examine the association between consultation length and the quality of E-consults services. Methods We defined as standardized patient script to present classic urticaria symptoms in asynchronous E-consults at tertiary public hospitals in Beijing and Hangzhou, China. We appraised consultation length using six indicators, time waiting for first response, time waiting for each response, time for consultation, total times of provider’s responses, total words of provider’s all responses, and average words of provider’s each response. We appraised E-consults services quality using five indicators building on China’s clinical guidelines (adherence to checklist; accurate diagnosis; appropriate prescription; providing lifestyle modification advice; and patient satisfaction). We performed ordinary least squares (OLS) regressions and logistic regressions to investigate the association between each indictor of consultation length and E-consults services quality. Results Providers who responded more quickly were more likely to provide lifestyle modification advice and achieve better patient satisfaction, without compromising process, diagnosis, and prescribing quality; Providers who spent more time with patients were likely to adhere to clinical checklists; Providers with more times and words of responses were significantly more likely to adhere to the clinical checklist, provide an accurate diagnosis, appropriate prescription, and lifestyle modification advice, which achieved better satisfaction rate from the patient as well. Conclusions The times and words that health providers provide in E-consult can serve as a proxy measure for quality of care. It is essential and urgent to establish rules to regulate the consultation length for Direct-to-consumer telemedicine to ensure adequate patient-provider interaction and improve service quality to promote digital health better. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08566-2.
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Affiliation(s)
- Xue Gong
- School of Public Health, Capital Medical University, Beijing, China
| | - Mengchi Hou
- China Aerospace Science & Industry Corporation 731 Hospital, Beijing, China
| | - Rui Guo
- School of Public Health, Capital Medical University, Beijing, China.
| | - Xing Lin Feng
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China.
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Fang Y, Jiang S, Jiang P, Zhou H, Yang M. Are Rural Primary Care Providers Able to Competently Manage Common Illnesses? A Cross-Sectional Study in Rural Sichuan, Western China. Healthcare (Basel) 2022; 10:healthcare10091750. [PMID: 36141362 PMCID: PMC9498850 DOI: 10.3390/healthcare10091750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/25/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Strengthening primary care is a key focus of the latest healthcare reforms in China. However, many challenges, including the workforce competence, still exist. This study aimed to evaluate the common disease management competency of rural primary care providers in Sichuan Province, western China. Methods: A cross-sectional study was conducted in 9 township health centers and 86 village clinics in 3 counties. Diarrhea and respiratory infection were selected as the evaluation cases. General partitioners were assessed through their abilities to (1) take history; (2) make diagnoses; (3) propose treatment; and (4) deal with clinical cases. Results: In total, 362 healthcare workers were surveyed, and 130 general practitioners were enrolled into our study. On average, rural primary care providers could only answer 46.4% of questions absolutely correctly, with 29.7% partly correctly and 23.8% incorrectly. Conclusion: We suggest strengthening training to improve rural primary care providers’ competencies, especially their capacities of history taking. Policy action is also needed to address regional disparities.
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Affiliation(s)
- Yian Fang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
- School of Public Health, Peking University, Beijing 100191, China
| | - Shaohua Jiang
- The First Affiliated Hospital, Xinjiang Medical University, Urumqi 833054, China
| | - Pei Jiang
- School of Public Health, North Sichuan Medical College, Nanchong 637100, China
| | - Huan Zhou
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Min Yang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
- Faculty of Health, Design and Art, Swinburne University of Technology, Melbourne 3122, Australia
- Correspondence:
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26
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Meng S, Wang Q, Wu Y, Xue H, Li L, Ye R, Chen Y, Pappas L, Akhtar M, Dill SE, Sylvia S, Zhou H, Rozelle S. The know-do gap in quality of health for chronic non-communicable diseases in rural China. Front Public Health 2022; 10:953881. [PMID: 36062129 PMCID: PMC9435052 DOI: 10.3389/fpubh.2022.953881] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/25/2022] [Indexed: 01/24/2023] Open
Abstract
Proper management of non-communicable diseases (NCDs) is a severe challenge to China's rural health system. This study investigates what influences the poor medical treatment of NCDs (diabetes and angina) by evaluating the "know-do gap" between provider knowledge and practice. To determine whether low levels of provider knowledge low quality of patient care is the primary constraint on the quality of NCDs diagnosis and treatment in rural China. Providers from Village Clinics (VC) and Township Health Centers (THC), and Standardized Patients (SP) were selected by a multi-stage random sampling method. Clinical vignettes were administered to 306 providers from 103 VCs and 50 THCs in rural Sichuan Province. SPs presented diabetes symptoms completed 97 interactions with providers in 46 VCs and 51 THCs; SPs presented angina symptoms completed 100 interactions with providers in 50 VCs and 50 THCs. Process quality, diagnosis quality, and treatment quality were assessed against national standards for diabetes and angina. Two-tailed T-tests and tests of proportions for continuous outcomes and tests of proportions for binary dependent variables were used to compare vignette and SP results. Differences between vignette and SP data calculated the know-do gap. Regression analyses were used to examine the providers/facility characteristics and knowledge/practice associations. THC providers demonstrated significantly more knowledge in vignettes and better practices in SP visits than VC providers. However, levels of knowledge were low overall: 48.2% of THC providers and 28.2% of VC providers properly diagnosed type 2 diabetes, while 23.8% of THC providers and 14.7% of VC providers properly diagnosed angina. With SPs, 2.1% of THC providers and 6.8% of VC providers correctly diagnosed type 2 diabetes; 25.5% of THC providers and 12.8% of VC providers correctly diagnosed angina. There were significant know-do gaps in diagnosis process quality, diagnosis quality, and treatment quality for diabetes (p < 0.01), and in diagnosis process quality (p < 0.05) and treatment quality for angina (p < 0.01). Providers in rural China display low levels of knowledge when treating diabetes and angina. Despite low knowledge, evidence of the know-do gap indicates that low-quality healthcare is the primary constraint on the quality of NCD diagnosis and treatment in rural China. Our research findings provide a new perspective for the evaluation of the medical quality and a technical basis for the development of new standardized cases in the future.
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Affiliation(s)
- Sha Meng
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China,Department of Operation Management, West China Hospital, Sichuan University, Chengdu, China
| | - Qingzhi Wang
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yuju Wu
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Linhua Li
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Ruixue Ye
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lucy Pappas
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Muizz Akhtar
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Sarah-Eve Dill
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Huan Zhou
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Huan Zhou
| | - Scott Rozelle
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
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Patient satisfaction and its health provider-related determinants in primary health facilities in rural China. BMC Health Serv Res 2022; 22:946. [PMID: 35883080 PMCID: PMC9316702 DOI: 10.1186/s12913-022-08349-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 07/18/2022] [Indexed: 12/17/2022] Open
Abstract
Background Patient satisfaction is an important outcome measure of health service and is one of the main reasons for the gradual deterioration of doctor–patient relationships in China. This study used the standardized patient (SP) method to explore patient satisfaction and its health provider-related determinants among primary health facilities in rural China. Methods The dataset comprised 1138 clinic cases in 728 rural primary health facilities in 31 counties, spread across four provinces. Information regarding the consultation interaction between the unannounced SPs and primary physicians was recorded. Patient satisfaction was gathered from the feedback of SPs after the visit. Results The overall average score of SP satisfaction with rural primary health facilities was only 13.65 (SD = 3.22) out of 20. The SP scores were found to be consistent with those of real patients. After controlling variances in patient population via the SP method, the regression analysis demonstrated that health provider-related factors, such as physician-level characteristics, consultation process, affordability, and convenience, have a significant correlation with patient satisfaction among primary physicians. Among factors relating to physician-level characteristics, affordability, convenience and the consultation process of the visit, the quality of the consultation process (e.g., consultation time, proactively providing necessary instructions and other crucial information) were found to be the prominent determinants. Conclusions This study revealed the need to improve patient satisfaction in primary health facilities in rural China. To solve this issue, we recommend that policies to increase medical service quality be implemented in rural primary healthcare systems. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08349-9.
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Ni XF, Yang CS, Zeng LN, Li HL, Diao S, Li DY, Wu J, Liu YC, Jia ZJ, Cheng G, Zhang LL. Drug-Related Problems of Children With Chronic Diseases in a Chinese Primary Health Care Institution: A Cross-Sectional Study. Front Pharmacol 2022; 13:874948. [PMID: 35924066 PMCID: PMC9342849 DOI: 10.3389/fphar.2022.874948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Drug-related problems (DRPs) refer to events or circumstances involving drug therapy that actually or potentially interfere with desired health outcomes. DRPs might be severe for children with chronic diseases managed at primary health care institutions, but the relevant research is scarce. Objective: In this cross-sectional study, we aimed to explore the prevalence, types, causes, and influencing factors of DRPs in children with chronic diseases in a Chinese primary health care institution. Methods: We recruited children with chronic diseases who visited the pediatric outpatient department in a primary health care institution from July 1 to 12 October 2021. Clinical pharmacists identified DRPs through medication therapy reviews, classified the types and causes of DRPs, and distinguished the manifested DRPs that affected the outcome and potential DRPs that were going to affect the outcome. Results: A total of 188 children with chronic diseases was included, and 584 DRPs were identified in 89.89% of participants. The most common type of DRPs was "treatment effectiveness" (a manifested problem or potential problem with the effect of the pharmacotherapy; 83.56%), of which 67.29% were potential DRPs. The second common type was "treatment safety" (patient suffers or could suffer from an adverse drug event; 14.21%), of which 89.16% were potential DRPs. The most common cause of DRPs was related to the process of use (42.24%), such as "patient uses/takes less drug than prescribed or does not take the drug at all," "patient stores drug inappropriately," and "patient administers/uses the drug in a wrong way." The second common cause was related to the process of dispensing (29.83%), such as "necessary information not provided or incorrect advice provided" and "prescribed drug is not available." The third common cause was related to the process of prescribing (26.21%), such as "drug dose is too low" and "no or incomplete drug treatment despite an existing indication." The number of combined medications was an influencing factor for the frequency of DRPs (p < 0.05). Conclusion: This cross-sectional study showed that the current situation regarding DRPs among children with chronic diseases managed in the primary health care institution was serious. The types of DRPs were mainly related to treatment effectiveness, and improper usage of medications was one of the main causes of DRPs. The number of combined drugs was the influencing factor for the frequency of DRPs. In the future, pharmacists should consider formulating pharmaceutical intervention strategies for this specific group according to the characteristics of DRPs.
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Affiliation(s)
- Xiao-Feng Ni
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Chun-Song Yang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
| | - Li-Nan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
| | - Hai-Long Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
| | - Sha Diao
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
| | - De-Yuan Li
- Pediatric Intensive Care, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jin Wu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yuan-Chun Liu
- Zigong Da’an Maternity and, Child Health Care Hospital, Zigong, China
| | - Zhi-Jun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Guo Cheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Translational Medicine, Center for Translational Medicine, Sichuan University, Chengdu, China
| | - Ling-Li Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
- China Center for Evidence-based Medicine, West China Hospital, Sichuan University, Chengdu, China
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Zhao X, Zhang Y, Yang Y, Pan J. Diabetes-related avoidable hospitalisations and its relationship with primary healthcare resourcing in China: A cross-sectional study from Sichuan Province. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e1143-e1156. [PMID: 34309097 DOI: 10.1111/hsc.13522] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 06/13/2023]
Abstract
The reduction of diabetes-related avoidable hospitalisations (AHs) can be achieved via the provision of timely and effective primary healthcare (PHC), which has made diabetes AHs rate a widely adopted indicator for evaluating the performances of PHC systems. This study reported the AHs rate of diabetes and further explored its relationship with PHC resourcing in China. Hospital discharge data of the fourth quarters of 2016 and 2017 in Sichuan Province, China were used. The number of PHC doctors per 10,000 population and the proportion of PHC doctors on all doctors were used as indicators reflective of PHC resourcing. Linear regression models were used to explore the associations between PHC resourcing and AHs of diabetes. Age-standardised rates of diabetes-related AHs in Sichuan province, China were found to be 248.102 and 272.368 per 100,000 population in 2016 and 2017, respectively. A 10% increase in the number of PHC doctors per 10,000 population was associated with a reduction of 2.574 per 100,000 population in the age-standardised AHs rate of diabetes. In addition, 10% increase in the proportion of PHC doctors on all doctors was associated with a reduction of 10.839 diabetes-related AHs per 100,000 population. Based on subgroup analysis, PHC resourcing demonstrated to have a stronger impact on AHs of diabetes with long-term complications than on that of uncontrolled diabetes. Our findings reported that the diabetes AHs rates in Sichuan Province were prevalently high. We also found that increased PHC resourcing was associated with decreased diabetes-related AHs rates.
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Affiliation(s)
- Xiaoshuang Zhao
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Yumeng Zhang
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Yili Yang
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
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30
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Xu DR, Cai Y, Wang X, Chen Y, Gong W, Liao J, Zhou J, Zhou Z, Zhang N, Tang C, Mi B, Lu Y, Wang R, Zhao Q, He W, Liang H, Li J, Pan J. Improving Data Surveillance Resilience Beyond COVID-19: Experiences of Primary heAlth Care quAlity Cohort In ChinA (ACACIA) Using Unannounced Standardized Patients. Am J Public Health 2022; 112:913-922. [PMID: 35483014 PMCID: PMC9137008 DOI: 10.2105/ajph.2022.306779] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2022] [Indexed: 12/02/2023]
Abstract
We analyzed COVID-19 influences on the design, implementation, and validity of assessing the quality of primary health care using unannounced standardized patients (USPs) in China. Because of the pandemic, we crowdsourced our funding, removed tuberculosis from the USP case roster, adjusted common cold and asthma cases, used hybrid online-offline training for USPs, shared USPs across provinces, and strengthened ethical considerations. With those changes, we were able to conduct fieldwork despite frequent COVID-19 interruptions. Furthermore, the USP assessment tool maintained high validity in the quality checklist (criteria), USP role fidelity, checklist completion, and physician detection of USPs. Our experiences suggest that the pandemic created not only barriers but also opportunities to innovate ways to build a resilient data collection system. To build data system reliance, we recommend harnessing the power of technology for a hybrid model of remote and in-person work, learning from the sharing economy to pool strengths and optimize resources, and dedicating individual and group leadership to problem-solving and results. (Am J Public Health. 2022;112(6):913-922. https://doi.org/10.2105/AJPH.2022.306779).
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Affiliation(s)
- Dong Roman Xu
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yiyuan Cai
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Xiaohui Wang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yaolong Chen
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Wenjie Gong
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jing Liao
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jifang Zhou
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Zhongliang Zhou
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Nan Zhang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Chengxiang Tang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Baibing Mi
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yun Lu
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Ruixin Wang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Qing Zhao
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Wenjun He
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Huijuan Liang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jinghua Li
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jay Pan
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
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Chen Y, Sylvia S, Wu P, Yi H. Explaining the declining utilization of village clinics in rural China over time: A decomposition approach. Soc Sci Med 2022; 301:114978. [PMID: 35461080 DOI: 10.1016/j.socscimed.2022.114978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/19/2022]
Abstract
With a goal of improving health system quality and efficiency, reforms of China's health system over the past decade have sought to strengthen primary healthcare in lower-level clinics and health centers. Despite these wide-ranging reforms and initiatives, population-based studies have documented dramatic declines in patients' use of primary care facilities during this period. In this paper, we explore the determinants of this trend in China's rural areas using detailed longitudinal data following a nationally-representative sample of rural households and village clinics from 2011 to 2018. We estimate that between 2011 and 2018, the probability that individuals sought care at village clinics when ill dropped by 44%. At the same time, the utilization of outpatient services in county hospitals increased by 56% and patient self-treatment increased by 20%. Detailed Kitagawa-Oaxaca-Blinder decompositions suggest four primary drivers of this trend: the shifting burden of disease in rural areas, changes in how patients choose to seek care given different disease conditions, declining drug inventory in village clinics, and the decreasing importance of remoteness as a determinant of healthcare seeking behavior. Our results highlight the deteriorating role of village clinics in the rural healthcare system and the increasing importance of self-treatment and higher-tier primary care services.
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Affiliation(s)
- Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paiou Wu
- School of Advanced Agricultural Sciences, Peking University, Beijing, China.
| | - Hongmei Yi
- School of Advanced Agricultural Sciences, Peking University, Beijing, China; Institute for Global Health and Development, Peking University, Beijing, China.
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Wang Q, Adhikari SP, Wu Y, Sunil TS, Mao Y, Ye R, Sun C, Shi Y, Zhou C, Sylvia S, Rozelle S, Zhou H. Consultation length, process quality and diagnosis quality of primary care in rural China: A cross-sectional standardized patient study. PATIENT EDUCATION AND COUNSELING 2022; 105:902-908. [PMID: 34391601 DOI: 10.1016/j.pec.2021.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Consultation length, the time spent between patient and health care provider during a visit, is an essential element in measuring quality of health care patients receive from a primary care facility. However, the linkage between consultation length and process quality and diagnosis quality of primary care is still uncertain. This study aims to examine the role consultation length plays in delivering process quality and diagnosis quality, two central components of overall primary care quality, in rural China. METHODS We recruited unannounced standardized patients (SPs) to present classic symptoms of angina and tuberculosis in selected healthcare facilities in three provinces of China. The consultation length and primary care quality of SPs were measured and compared with both international and national standards of care. Ordinary Least Squares (OLS) regressions for process quality (continuous dependent variable) and Logistic regressions for diagnosis quality (binary dependent variable) were performed to investigate the relationship between consultation length and primary care quality. RESULTS The average consultation lengths among patients with classic symptoms of angina and those with symptoms of tuberculosis were approximately 4.33 min and 6.28 min, respectively. Providers who spent more time with patients were significantly more likely to complete higher percentage of recommended checklist items of both questions and examinations for angina (β = 1.39, 95%CI 1.01-1.78) and tuberculosis (β = 0.89, 95%CI 0.69-1.08). Further, providers who spent more time with patients were more likely to make correct diagnosis for angina (marginal effect = 0.014, 95%CI 0.002-0.026) and for tuberculosis (marginal effect = 0.013, 95%CI 0.005-0.021). CONCLUSIONS The average consultation length is extremely short among primary care providers in rural China. The longer consultation leads to both better process and diagnosis quality of primary care. PRACTICE IMPLICATIONS We recommend primary care providers to increase the length of their communication with patients. To do so, government should implement healthcare reforms to clarify the requirements of affordable and reliable consultation length in medical care services. Moreover, such an experience can also be extended to other developing countries.
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Affiliation(s)
- Qingzhi Wang
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Sasmita Poudel Adhikari
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yuju Wu
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Thankam S Sunil
- Department of Public Health, University of Tennessee, TN, USA
| | - Yuping Mao
- Department of Communication Studies, California State University, California, USA
| | - Ruixue Ye
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Chang Sun
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
| | - Chengchao Zhou
- Institute of Social Medicine and Health Administration, School of Public Health, Shandong University, Jinan, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Scott Rozelle
- Freeman Spogli Institute, Stanford University, California, USA
| | - Huan Zhou
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
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Kwan A, Boone CE, Sulis G, Gertler PJ. Do private providers give patients what they demand, even if it is inappropriate? A randomised study using unannounced standardised patients in Kenya. BMJ Open 2022; 12:e058746. [PMID: 35304401 PMCID: PMC8935168 DOI: 10.1136/bmjopen-2021-058746] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Low and varied quality of care has been demonstrated for childhood illnesses in low-income and middle-income countries. Some quality improvement strategies focus on increasing patient engagement; however, evidence suggests that patients demanding medicines can favour the selection of resistant microbial strains in the individual and the community if drugs are inappropriately used. This study examines the effects on quality of care when patients demand different types of inappropriate medicines. METHODS We conducted an experiment where unannounced standardised patients (SPs), locally recruited individuals trained to simulate a standardised case, present at private clinics. Between 8 March and 28 May 2019, 10 SPs portraying caretakers of a watery diarrhoea childhood case scenario (in absentia) conducted N=200 visits at 200 private, primary care clinics in Kenya. Half of the clinics were randomly assigned to receive an SP demanding amoxicillin (an antibiotic); the other half, an SP demanding albendazole (an antiparasitic drug often used for deworming), with other presenting characteristics the same. We used logistic and linear regression models to assess the effects of demanding these inappropriate medicines on correct and unnecessary case management outcomes. RESULTS Compared with 3% among those who did not demand albendazole, the dispensing rate increased significantly to 34% for those who did (adjusted OR 0.06, 95% CI 0.02 to 0.22, p<0.0001). Providers did not give different levels of amoxicillin between those demanding it and those not demanding it (adjusted OR 1.73, 95% CI 0.51 to 5.82). Neither significantly changed any correct management outcomes, such as treatment or referral elsewhere. CONCLUSION Private providers appear to account for both business-driven benefits and individual health impacts when making prescribing decisions. Additional research is needed on provider knowledge and perceptions of profit and individual and community health trade-offs when making prescription decisions after patients demand different types of inappropriate medicines. TRIAL REGISTRATION NUMBERS American Economic Association Registry (#AEARCTR-0000217) and Pan African Clinical Trial Registry (#PACTR201502000770329).
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Affiliation(s)
- Ada Kwan
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Division of Health Policy and Management, University of California Berkeley School of Public Health, Berkeley, California, USA
| | - Claire E Boone
- Division of Health Policy and Management, University of California Berkeley School of Public Health, Berkeley, California, USA
| | - Giorgia Sulis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Paul J Gertler
- University of California Berkeley Haas School of Business, Berkeley, California, USA
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Kovacs R, Lagarde M. Does high workload reduce the quality of healthcare? Evidence from rural Senegal. JOURNAL OF HEALTH ECONOMICS 2022; 82:102600. [PMID: 35196633 PMCID: PMC9023795 DOI: 10.1016/j.jhealeco.2022.102600] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 06/14/2023]
Abstract
There is a widely held perception that staff shortages in low and middle-income countries (LMICs) lead to excessive workloads, which in turn worsen the quality of healthcare. Yet there is little evidence supporting these claims. We use data from standardised patient visits in Senegal and determine the effect of workload on the quality of primary care by exploiting quasi-random variation in workload. We find that despite a lack of staff, average levels of workload are low. Even at times when workload is high, there is no evidence that provider effort or quality of care are significantly reduced. Our data indicate that providers operate below their production possibility frontier and have sufficient capacity to attend more patients without compromising quality. This contradicts the prevailing discourse that staff shortages are a key reason for poor quality primary care in LMICs and suggests that the origins likely lie elsewhere.
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Affiliation(s)
- Roxanne Kovacs
- Department of Economics and Centre for Health Governance, University of Gothenburg, Vasagatan 1, Gothenburg, Sweden.
| | - Mylene Lagarde
- London School of Economics and Political Science, Department of Health Policy, Houghton Street, London, UK
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35
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Sylvia S, Ma X, Shi Y, Rozelle S. Ordeal mechanisms, information, and the cost-effectiveness of strategies to provide subsidized eyeglasses. JOURNAL OF HEALTH ECONOMICS 2022; 82:102594. [PMID: 35193056 PMCID: PMC9811338 DOI: 10.1016/j.jhealeco.2022.102594] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 05/14/2023]
Abstract
The cost-effectiveness of policies providing subsidized health goods is often compromised by limited use of the goods provided. Through a randomized trial involving 251 primary schools in western China, we tested two approaches to improve the cost-effectiveness of a program distributing free eyeglasses to myopic children. Relative to delivery of free eyeglasses to schools, we find that providing vouchers redeemable in local optical shops modestly improved the targeting of eyeglasses to those who would use them without reducing effective coverage. Information provided through a health education campaign increased eyeglass use when eyeglasses were delivered to schools, but had no effect when requiring voucher redemption or when families were only given a prescription for eyeglasses to be purchased on the market. Though most expensive, free delivery to schools with a health education campaign was the most socially cost-effective approach tested and increased effective coverage of eyeglasses by 18.5 percentage points after seven months.
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Affiliation(s)
- Sean Sylvia
- University of North Carolina at Chapel Hill, 135 Dauer Drive, 1101 McGavran-Greenberg Hall, CB #7411, Chapel Hill, NC 27599, United States.
| | - Xiaochen Ma
- Peking University, 112 Shu Wahh Building, 38 XueYuan Road, Haidian District, Beijing 100191, China.
| | - Yaojiang Shi
- Shaanxi Normal University, 620 Chang'an Road West, Xi'an 710119, China.
| | - Scott Rozelle
- Stanford University, 616 Serra Street, Encina Hall East Wing, Room 401, Stanford, CA 94305, United States.
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Kovacs RJ, Lagarde M, Cairns J. Can patients improve the quality of care they receive? Experimental evidence from Senegal. WORLD DEVELOPMENT 2022; 150:105740. [PMID: 35115735 PMCID: PMC8651629 DOI: 10.1016/j.worlddev.2021.105740] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 06/14/2023]
Abstract
Providers in many low and middle-income countries (LMICs) often fail to correctly diagnose and treat their patients, even though they have the clinical knowledge to do so. Against the backdrop of many failed attempts to increase provider effort, this study examines whether quality of care can be improved by encouraging patients to be more active during consultations. We design a simple experiment with undercover standardised patients who randomly vary how much information they disclose about their symptoms. We find that providers are 27% more likely to correctly manage a patient who volunteers several key symptoms of their condition at the start of the consultation, compared to a typical patient who shares less information. Lower performance in the control group is not due to providers' lack of knowledge, an incapacity to ask the right questions, or a response to time or resource constraints. Instead, providers' low motivation seems to limit their ability to adapt their effort to patients' inputs in the consultation. Our findings provide proof-of-concept evidence that interventions making patients more active in their consultations could significantly improve the quality of care in LMICs.
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Affiliation(s)
- Roxanne J. Kovacs
- Department of Economics and Centre for Health Governance, University of Gothenburg, Sweden
| | - Mylene Lagarde
- London School of Economics and Political Science, Department of Health Policy, United Kingdom
| | - John Cairns
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, United Kingdom
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37
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Huang H, Hua W, Chen R, Hu Y, Ying S, Chi C, Zhang M, Huang K, Liu H, Shen H, Lai K. Perspectives and Management of Atypical Asthma in Chinese Specialists and Primary Care Practitioners-A Nationwide Questionnaire Survey. Front Med (Lausanne) 2021; 8:727381. [PMID: 34778289 PMCID: PMC8582351 DOI: 10.3389/fmed.2021.727381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background and objective: To evaluate the awareness/knowledge and clinical practice for the treatment of atypical asthma among respiratory specialists and primary care practitioners (PCPs) in China. Methods: A total number of 1,997 physicians participated in the survey via WeChat. The questionnaire included six main items: physician demographic characteristics, awareness, diagnosis, medical prescription, assessment/education, and proposal. Results: Cough variant asthma (CVA) was recognized by 97.51% of physicians (1,166 respiratory specialists and 799 PCPs), followed by chest tightness variant asthma (CTVA, 83.72%) and occult asthma (73.54%). Specialists were more likely to follow diagnostic recommendations than PCPs (P < 0.01); however, 34.15% of physicians reported the utility of bronchodilation tests, airway provocation tests, and peak expiratory flow monitoring. A total of 91.70% and 92.01% of physicians prescribed inhaled corticosteroids (ICS) or ICS plus long-acting beta-agonists (LABA) for CVA and CTVA, respectively. Physicians prescribed an ICS or ICS/LABA for 4 (2–8) or 8 (4–12) weeks for CVA and 4 (2–8) or 5 (4–12) weeks for CTVA, and the prescription durations were significantly shorter for PCPs than for specialists (P < 0.01). Further, 52.42% and 35.78% reported good control of CVA and CTVA, respectively, with significantly lower control rates for PCPs than for specialists (P < 0.01). Additionally, specialists exhibited better assessment and educational habits than PCPs. Conclusion: While atypical asthma was identified by most specialists and PCPs, there remains a gap between management in real clinical practice and guideline recommendations, especially for PCPs. Further training of PCPs and clinical studies of atypical asthma are required to improve practice.
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Affiliation(s)
- Huaqiong Huang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Hua
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ruchong Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yue Hu
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Songmin Ying
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Chunhua Chi
- Department of General Practice, Peking University First Hospital, Beijing, China
| | - Min Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kewu Huang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Huiguo Liu
- Key Laboratory of Pulmonary Diseases of Health Ministry, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huahao Shen
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Kefang Lai
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Yan C, Liao H, Ma Y, Wang J. The Impact of Health Care Reform Since 2009 on the Efficiency of Primary Health Services: A Provincial Panel Data Study in China. Front Public Health 2021; 9:735654. [PMID: 34746081 PMCID: PMC8569255 DOI: 10.3389/fpubh.2021.735654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Primary health care (PHC) is an important part of health systems in the world and in China. To improve the efficiency of PHC institutions (PHCIs), many countries have implemented reforms, including China's health care reform since 2009. This study aims to evaluate the impact of this reform on the efficiency of PHCIs from the perspective of the whole health system. Methods: Data were collected from China Health Statistical Yearbooks and China Statistical Yearbooks published from 2005 to 2019. By taking the number of beds, health technicians and PHCIs as inputs and the proportion of diagnosis, treatment and admission in PHCIs as outputs, Malmquist DEA was used to evaluate the efficiency change of PHCIs, and panel data regression was performed to analyze the impact of the reform and other factors on such efficiency. The interaction between reform and economic level was also estimated. Results: The MPI in Beijing, Tianjin, Shanghai, Hunan, and Guangdong improved after the reform. The efficiency improvement in Beijing, Tianjin and Shanghai is mainly reflected in the growth of TC, whereas the efficiency improvement in Guangdong and Hunan is mainly reflected in the growth of EC. Meanwhile, the EC and TC in Hebei, Heilongjiang, Shandong, and other provinces deteriorated. The deterioration of MPI in Shanxi, Inner Mongolia and Jilin was mainly attributed to EC. while the deterioration of MPI in Liaoning, Anhui, and Fujian provinces is mainly attributed to TC. Since 2009, the reform exerted a negative impact on MPI (β = -0.06; P < 0.01), TC (β = -0.048; P < 0.01) and EC (β = -0.03; P < 0.01). And such negative impact was weaker in economically developed areas (β = 0.076; P < 0.01). Conclusions: Attention should be paid to future reforms: China should continue investing in PHCIs, establish a structurally integrated and functionally complementary delivery system and promote the coordination of reform policies to avoid the adverse impacts of other reform policies on PHCIs.
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Affiliation(s)
- Chaoyang Yan
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Liao
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Ma
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Wang
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,The Key Research Institute of Humanities and Social Science of Hubei Province, Huazhong University of Science and Technology, Wuhan, China.,Health Poverty Alleviation Center, Institute for Poverty Reduction and Development, Huazhong University of Science and Technology, Wuhan, China
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39
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Rao S, Xue H, Teuwen DE, Shi H, Yi H. Measurements of quality of village-level care and patients' healthcare-seeking behaviors in rural China. BMC Public Health 2021; 21:1873. [PMID: 34657604 PMCID: PMC8520638 DOI: 10.1186/s12889-021-11946-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background Although the progress in global health initiatives has improved the availability of primary health care (PHC), unqualified healthcare remains a serious challenge in low- and middle-income countries, where PHC is often underutilized. This study examines factors associated with patients’ healthcare-seeking behaviors in rural Chin—seeking healthcare at village-level PHC providers, at higher-level health facilities, self-medicating, and refraining from seeking medical help. We focus on provider-side factors, including (1) the unobservable quality indicator, (2) the observable quality indicator, and (3) the observable signal indicator. Methods We analyzed 1578 episodes of healthcare-seeking behaviors of patients with diarrhea or cough/runny nose symptom from surveys conducted in July 2017 and January 2018 in 114 villages of the Yunnan province. We investigated the correlation between quality-related factors with patients’ healthcare-seeking behaviors by multinomial logit regression. Results We found that rural patients were insensitive to the unobservable quality of healthcare providers, as measured by standardized clinical vignettes, which might be attributable to the credence nature of PHC. The observable quality indicator, whether the clinician has received full-time junior college formal medical education, was associated with patients’ healthcare choices. Patients, however, were more likely to select healthcare based on the observable signal indicator, which was measured by the availability of medicines. Additionally, the observable signal indicator had no significant association with two quality indicators. Notably, socioeconomically-disadvantaged patients relied more on the village-level PHC, which emphasized the role of PHC in promoting the welfare of rural populations. Conclusions Our study found an inconsistency between objective quality of healthcare provided by providers and subjective quality perceived by patients. Patients could not identify the actual quality of PHC precisely, while they were more likely to make decisions based on the observable signal indicator. Therefore, the quality of PHC should be more observable to patients. This study not only supplements the literature on healthcare-seeking choices by examining four types of behaviors simultaneously but also clarifies rural patients’ perceptions of the quality of PHC for policy decision-making on increasing the utilization of PHC and improving the medical welfare of the vulnerable. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11946-8.
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Affiliation(s)
- Sihang Rao
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Room 408B, Wangkezhen Building, No. 5, Yiheyuan Road, Haidian, Beijing, 100871, China
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Stanford University, California, USA
| | - Dirk E Teuwen
- Medical Sustainability, UCB, Brussels, Belgium.,Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Haonan Shi
- Business Development Center, Red Cross Society of China, Beijing, China
| | - Hongmei Yi
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Room 408B, Wangkezhen Building, No. 5, Yiheyuan Road, Haidian, Beijing, 100871, China.
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Zheng W, Kämpfen F, Huang Z. Health-seeking and diagnosis delay and its associated factors: a case study on COVID-19 infections in Shaanxi Province, China. Sci Rep 2021; 11:17331. [PMID: 34462494 PMCID: PMC8405662 DOI: 10.1038/s41598-021-96888-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/17/2021] [Indexed: 12/17/2022] Open
Abstract
This time-to-event study examines social factors associated with health-seeking and diagnosis of 165 COVID-19 cases in response to the pandemic spread in Shaanxi Province, China. In particular, we investigate the differential access to healthcare in terms of delayed time from symptom onset to first medical visit and subsequently to diagnosis by factors such as sex, age, travel history, and type of healthcare utilization. We show that it takes more time for patients older than 60 (against those under 30) to seek healthcare after developing symptoms (+ 2.5 days, [Formula: see text]), surveillance on people with living or travel history to Wuhan helps shorten the time to the first doctor visit (- 0.8 days) and diagnosis (- 2.2 days, [Formula: see text]). A delay cut is associated with the adoption of intermediary and large hospitals rather than community-based care as primary care choices (- 1.6 days, [Formula: see text] and - 2.2 days, [Formula: see text]). One unit increase of healthcare workers per 1000 people saves patients 0.5 days ([Formula: see text]) for diagnosis from the first doctor visit and 0.6 days ([Formula: see text]) in total. Our analysis of factors associated with the time delay for diagnosis may provide a better understanding of the health-seeking behaviors of patients and the diagnosis capacity of healthcare providers during the COVID-19 pandemic.
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Affiliation(s)
- Wenyuan Zheng
- School of Insurance, Southwestern University of Finance and Economics, Chengdu, 611130, China
| | - Fabrice Kämpfen
- Population Studies Center, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Zhiyong Huang
- Center of Health Governance and Policy, Southwestern University of Finance and Economics, Chengdu, 611130, China.
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Influence of the Integrated Delivery System on the Medical Serviceability of Primary Hospitals. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:9950163. [PMID: 34394901 PMCID: PMC8356014 DOI: 10.1155/2021/9950163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022]
Abstract
Objective To explore the change in the medical serviceability of primary hospitals since the establishment of the Huzhou No. 1 People's Hospital medical care group incorporating the integrated delivery system. Methods With reference to the “Grade Evaluation Standard of General Hospitals in Zhejiang Province” and the “Guidelines for Service Capacity Evaluation of Township Hospitals (2019 Edition),” we analyzed the influence of the integrated delivery system on the capacity of primary medical services and selected the targeted core indicators. From the four dimensions of diagnosis and treatment breadth, diagnosis and treatment efficiency, surgical ability, and patient satisfaction, an index evaluation system was established to explore the changes in the medical serviceability in primary hospitals. Results The measurements were aimed at four specific issues, that is, the low medical technology level of grassroots personnel, the poor information communication among medical institutions, the difficulty in recruiting people, and the imperfect training mechanism in primary hospitals. After establishing a series of measurements related to the problems faced by the primary healthcare sector in China, the score of breadth of diagnosis and treatment, efficiency of diagnosis and treatment ability, surgical ability, and patient satisfaction of the primary hospitals in our medical group have greatly increased. Conclusion The integrated delivery system improved the primary hospitals' medical health ability obviously. Our study also provides various useful and operable suggestions for primary healthcare.
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King JJC, Powell-Jackson T, Makungu C, Hargreaves J, Goodman C. How much healthcare is wasted? A cross-sectional study of outpatient overprovision in private-for-profit and faith-based health facilities in Tanzania. Health Policy Plan 2021; 36:695-706. [PMID: 33851694 DOI: 10.1093/heapol/czab039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 02/25/2021] [Accepted: 03/25/2021] [Indexed: 12/11/2022] Open
Abstract
Overprovision-healthcare whose harm exceeds its benefit-is of increasing concern in low- and middle-income countries, where the growth of the private-for-profit sector may amplify incentives for providing unnecessary care, and achieving universal health coverage will require efficient resource use. Measurement of overprovision has conceptual and practical challenges. We present a framework to conceptualize and measure overprovision, comparing for-profit and not-for-profit private outpatient facilities across 18 of mainland Tanzania's 22 regions. We developed a novel conceptualization of three harms of overprovision: economic (waste of resources), public health (unnecessary use of antimicrobial agents risking development of resistant organisms) and clinical (high risk of harm to individual patients). Standardized patients (SPs) visited 227 health facilities (99 for-profit and 128 not-for-profit) between May 3 and June 12, 2018, completing 909 visits and presenting 4 cases: asthma, non-malarial febrile illness, tuberculosis and upper respiratory tract infection. Tests and treatments prescribed were categorized as necessary or unnecessary, and unnecessary care was classified by type of harm(s). Fifty-three percent of 1995 drugs prescribed and 43% of 891 tests ordered were unnecessary. At the patient-visit level, 81% of SPs received unnecessary care, 67% received care harmful to public health (prescription of unnecessary antibiotics or antimalarials) and 6% received clinically harmful care. Thirteen percent of SPs were prescribed an antibiotic defined by WHO as 'Watch' (high priority for antimicrobial stewardship). Although overprovision was common in all sectors and geographical regions, clinically harmful care was more likely in for-profit than faith-based facilities and less common in urban than rural areas. Overprovision was widespread in both for-profit and not-for-profit facilities, suggesting considerable waste in the private sector, not solely driven by profit. Unnecessary antibiotic or antimalarial prescriptions are of concern for the development of antimicrobial resistance. Option for policymakers to address overprovision includes the use of strategic purchasing arrangements, provider training and patient education.
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Affiliation(s)
- Jessica J C King
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Christina Makungu
- Health Systems Research Group, Ifakara Health Institute, Plot 463, Kiko Avenue, Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - James Hargreaves
- Department of Public Health and Environments, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Acharya Y, James N, Thapa R, Naz S, Shrestha R, Tamang S. Content of antenatal care and perception about services provided by primary hospitals in Nepal: a convergent mixed methods study. Int J Qual Health Care 2021; 33:6175215. [PMID: 33730154 DOI: 10.1093/intqhc/mzab049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 01/24/2021] [Accepted: 03/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Nepal has made significant strides in maternal and neonatal mortality over the last three decades. However, poor quality of care can threaten the gains, as maternal and newborn services are particularly sensitive to quality of care. Our study aimed to understand current gaps in the process and the outcome dimensions of the quality of antenatal care (ANC), particularly at the sub-national level. We assessed these dimensions of the quality of ANC in 17 primary, public hospitals across Nepal. We also assessed the variation in the ANC process across the patients' socio-economic gradient. METHODS We used a convergent mixed methods approach, whereby we triangulated qualitative and quantitative data. In the quantitative component, we observed interactions between providers (17 hospitals from all 7 provinces) and 198 women seeking ANC and recorded the tasks the providers performed, using the Service Provision Assessments protocol available from the Demographic and Health Survey program. The main outcome variable was the number of tasks performed by the provider during an ANC consultation. The tasks ranged from identifying potential signs of danger to providing counseling. We analyzed the resulting data descriptively and assessed the relationship between the number of tasks performed and users' characteristics. In the qualitative component, we synthesized users' and providers' narratives on perceptions of the overall quality of care obtained through focus group discussions and in-depth interviews. RESULTS Out of the 59 tasks recommended by the World Health Organization, providers performed only 22 tasks (37.3%) on average. The number of tasks performed varied significantly across provinces, with users in province 3 receiving significantly higher quality care than those in other provinces. Educated women were treated better than those with no education. Users and providers agreed that the overall quality of care was inadequate, although providers mentioned that the current quality was the best they could provide given the constraints they faced. CONCLUSION The quality of ANC in Nepal's primary hospitals is poor and inequitable across education and geographic gradients. While current efforts, such as the provision of 24/7 birthing centers, can mitigate gaps in service availability, additional equipment, infrastructure and human resources will be needed to improve quality. Providers also need additional training focused on treating patients from different backgrounds equally. Our study also points to the need for additional research, both to document the quality of care more objectively and to establish key determinants of quality to inform policy.
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Affiliation(s)
- Yubraj Acharya
- Department of Health Policy and Administration, The Pennsylvania State University, 601L Ford Building, University Park, PA 16802, USA
| | - Nigel James
- Department of Health Policy and Administration, The Pennsylvania State University, 601L Ford Building, University Park, PA 16802, USA
| | - Rita Thapa
- Nick Simons Institute, Box 8975, EPC 1813, Lalitpur, Nepal
| | - Saman Naz
- Department of Health Policy and Administration, The Pennsylvania State University, 601L Ford Building, University Park, PA 16802, USA
| | | | - Suresh Tamang
- Nick Simons Institute, Box 8975, EPC 1813, Lalitpur, Nepal
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Shen M, He W, Yeoh EK, Wu Y. The association between an increased reimbursement cap for chronic disease coverage and healthcare utilization in China: an interrupted time series study. Health Policy Plan 2021; 35:1029-1038. [PMID: 32869090 DOI: 10.1093/heapol/czaa087] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2020] [Indexed: 11/14/2022] Open
Abstract
Hypertension and diabetes are highly prevalent in China and pose significant health and economic burdens, but large gaps in care remain for people with such conditions. In this article, drawing on administrative insurance claim data from China's Urban Employee Basic Medical Insurance (UEBMI), we use an interrupted time series design to examine whether an increase in the monthly reimbursement cap for outpatient visits using chronic disease coverage affects healthcare utilization. The cap was increased by 50 yuan per chronic disease on 1 January 2016, in one of the largest cities in China. Compared with the year before the increase, patients with only hypertension increased their spending using chronic disease coverage by 17.8 yuan (P < 0.001) or 11.6%, and those with only diabetes increased their spending using chronic disease coverage by 19.5 yuan (P < 0.001) or 10.6%, with the differences almost entirely driven by spending on drugs. In addition, these two groups of patients reduced their spending using standard outpatient coverage by 13.9 yuan (P < 0.001) or 5.7% and 14.9 yuan (P = 0.03) or 5.2%, respectively, and thus had no changes in total outpatient spending. Patients with both hypertension and diabetes, meanwhile, increased their spending using chronic disease coverage by 54.8 yuan (P < 0.001) or 18.1% and decreased their spending using standard outpatient coverage by 16.1 yuan (P = 0.002) or 6.1%, with no changes in their probability of hospitalization. Among patients with both hypertension and diabetes who had fewer-than-average outpatient visits in 2015, the hospitalization rate decreased after the 2016 reimbursement cap increase (adjusted odds ratio = 0.702, P = 0.01). These findings suggest that increasing financial protection for patients with hypertension and diabetes may be an important strategy for reducing adverse health events, such as hospitalization, in China.
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Affiliation(s)
- Menghan Shen
- Center for Chinese Public Administration Research, School of Government, Sun Yat-sen University, No. 135 Xin Gang Xi Road, Guangzhou, 510275, China
| | - Wen He
- School of Public Administration, Hunan University, Lushan Road (S), Yuelu District, Changsha,410082, China
| | - Eng-Kiong Yeoh
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Yushan Wu
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
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Sulis G, Daniels B, Kwan A, Gandra S, Daftary A, Das J, Pai M. Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya. BMJ Glob Health 2021; 5:bmjgh-2020-003393. [PMID: 32938614 PMCID: PMC7493125 DOI: 10.1136/bmjgh-2020-003393] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Determining whether antibiotic prescriptions are inappropriate requires knowledge of patients’ underlying conditions. In low-income and middle-income countries (LMICs), where misdiagnoses are frequent, this is challenging. Additionally, such details are often unavailable for prescription audits. Recent studies using standardised patients (SPs) offer a unique opportunity to generate unbiased prevalence estimates of antibiotic overuse, as the research design involves patients with predefined conditions. Methods Secondary analyses of data from nine SP studies were performed to estimate the proportion of SP–provider interactions resulting in inappropriate antibiotic prescribing across primary care settings in three LMICs (China, India and Kenya). In all studies, SPs portrayed conditions for which antibiotics are unnecessary (watery diarrhoea, presumptive tuberculosis (TB), angina and asthma). We conducted descriptive analyses reporting overall prevalence of antibiotic overprescribing by healthcare sector, location, provider qualification and case. The WHO Access–Watch–Reserve framework was used to categorise antibiotics based on their potential for selecting resistance. As richer data were available from India, we examined factors associated with antibiotic overuse in that country through hierarchical Poisson models. Results Across health facilities, antibiotics were given inappropriately in 2392/4798 (49.9%, 95% CI 40.8% to 54.5%) interactions in India, 83/166 (50.0%, 95% CI 42.2% to 57.8%) in Kenya and 259/899 (28.8%, 95% CI 17.8% to 50.8%) in China. Prevalence ratios of antibiotic overuse in India were significantly lower in urban versus rural areas (adjusted prevalence ratio (aPR) 0.70, 95% CI 0.52 to 0.96) and higher for qualified versus non-qualified providers (aPR 1.55, 95% CI 1.42 to 1.70), and for presumptive TB cases versus other conditions (aPR 1.19, 95% CI 1.07 to 1.33). Access antibiotics were predominantly used in Kenya (85%), but Watch antibiotics (mainly quinolones and cephalosporins) were highly prescribed in India (47.6%) and China (32.9%). Conclusion Good-quality SP data indicate alarmingly high levels of antibiotic overprescription for key conditions across primary care settings in India, China and Kenya, with broad-spectrum agents being excessively used in India and China.
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Affiliation(s)
- Giorgia Sulis
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada.,McGill International TB Centre, McGill University, Montreal, Québec, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Ada Kwan
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, York University, Toronto, Ontario, Canada.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA.,Centre for Policy Research, New Delhi, Delhi, India
| | - Madhukar Pai
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada .,McGill International TB Centre, McGill University, Montreal, Québec, Canada.,Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Comparing the Quality of Primary Care between Public and Private Providers in Urban China: A Standardized Patient Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105060. [PMID: 34064733 PMCID: PMC8151428 DOI: 10.3390/ijerph18105060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022]
Abstract
Previous studies have been limited by not directly comparing the quality of public and private CHCs using a standardized patient method (SP). This study aims to evaluate and compare the quality of the primary care provided by public and private CHCs using a standardized patient method in urban China. We recruited 12 standardized patients from the local community presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi'an, China. We measured the quality of primary care on seven criteria: (1) adherence to checklists, (2) correct diagnosis, (3) correct treatment, (4) number of unnecessary exams and drugs, (5) diagnosis time, (6) expense of visit, (7) patient-centered communication. Significant quality differences were observed between public CHCs and private CHCs. Private CHC physicians performed 4.73 percentage points lower of recommended questions and exams in the checklist. Compared with private CHCs, public CHC providers were more likely to give a higher proportion of correct diagnosis and correct treatment. Private CHCs provided 1.42 fewer items of unnecessary exams and provided 0.32 more items of unnecessary drugs. Private CHC physicians received a 9.31 lower score in patient-centered communication. There is significant quality inequality in different primary care models. Public CHC physicians might provide a higher quality of service. Creating a comprehensive, flexible, and integrated health care system should be considered an effective approach towards optimizing the management of CHC models.
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Fang Y, Zhang F, Zhou C, Chen M. Governance Capability of the Public Health System: A Comparative Analysis of the Control of COVID-19 in the Different Provinces of China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4210. [PMID: 33921152 PMCID: PMC8071522 DOI: 10.3390/ijerph18084210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022]
Abstract
At the beginning of 2020, the global outbreak of the novel coronavirus COVID-19 posed a huge challenge to the governance capabilities of public health in various countries. In this paper, the SEIR model is used to fit the number of confirmed cases in each province in China, and the reduction rate of the basic reproduction number is used to measure the actual score of the control effect of COVID-19. The potential capacity of prevention and control of epidemics, in theory, is constructed, and we use the difference between theoretical ability and actual score to measure the ability of governance of public health. We found that there were significant differences between actual effect and theoretical ability in various regions, and governance capabilities were an important reason leading to this difference, which was not consistent with the level of economic development. The balance of multiple objectives, the guiding ideology of emphasizing medical treatment over prevention, the fragmentation of the public health system, and the insufficiency of prevention and control ability in primary public health systems seriously affected the government's ability to respond to public health emergencies.
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Affiliation(s)
- Yingfeng Fang
- School of Economics and Management, Wuhan University, Wuhan 430072, China; (F.Z.); (C.Z.); (M.C.)
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Green C, Hollingsworth B, Yang M. The impact of social health insurance on rural populations. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:473-483. [PMID: 33638010 PMCID: PMC7954739 DOI: 10.1007/s10198-021-01268-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/16/2021] [Indexed: 06/12/2023]
Abstract
Improving health outcomes of rural populations in low- and middle-income countries represents a significant challenge. A key part of this is ensuring access to health services and protecting households from financial risk caused by unaffordable medical care. In 2003, China introduced a heavily subsidised voluntary social health insurance programme that aimed to provide 800 million rural residents with access to health services and curb medical impoverishment. This paper provides new evidence on the impact of the scheme on health care utilisation and medical expenditure. Given the voluntary nature of the insurance enrolment, we exploit the uneven roll-out of the programme across rural counties as a natural experiment to explore causal inference. We find little effect of the insurance on the use of formal medical care and out-of-pocket health payments. However, there is evidence that it directed people away from informal health care towards village clinics, especially among patients with lower income. The insurance has also led to a reduction in the use of city hospitals among the rich. The shift to village clinics from informal care and higher-level hospitals suggests that the NRCMS has the potential to improve efficiency within the health care system and help patients to obtain less costly primary care. However, the poor quality of primary care and insufficient insurance coverage for outpatient services remains a concern.
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Affiliation(s)
- Colin Green
- Present Address: Department of Economics, Norweigian University of Science and Technology, Trondheim, Norway
| | | | - Miaoqing Yang
- Department of Economics, Lancaster University Management School, Lancaster University, Lancaster, LA2 0PF UK
- Present Address: National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF UK
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王 志, 郭 岩. [Association between community socioeconomic status and adults' self-rated health in China]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2020; 53:314-319. [PMID: 33879904 PMCID: PMC8072415 DOI: 10.19723/j.issn.1671-167x.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To examine whether community socioeconomic status is associated with self-rated health independent of individual socioeconomic status for urban and rural residents, and to provide policy implications for improving the health status of the socioeconomically underdeveloped communities in China. METHODS Based on the baseline data of China Family Panel Studies (CFPS) in 2010, principal component analysis was used to construct community socioeconomic index (SEI) based on average years of schooling, average income and average wealth at the community level. Community SEI was defined as the standardized first principal component score. In combination with the adult data from CFPS 2012 follow-up data, the multilevel Logistic regression model was used to analyze whether the community socioeconomic status had an independent contextual effect on the self-rated health of urban residents and rural residents after controlling individual-level socioeconomic status. RESULTS In the final analysis, 31 321 adult residents in 577 communities were included, of whom 8 423 were urban residents and 22 898 were rural residents. Community SEI ranged from -2.41 to 3.16, with a mean of 0 and a stan-dard deviation of 1. As the community SEI increased, the incidence of deprivations in different dimensions decreased, indicating the community socioeconomic status increased. The multilevel Logistic model controlling for both individual sociodemographic factors and community socioeconomic status showed that as the community SEI increased, the probability of poor self-rated health decreased, which indicated community SEI had a contextual effect on poor self-rated health. The contextual effect of community SEI on poor self-rated health was statistically significant for the rural residents (OR=0.84, 95%CI: 0.76-0.94) but not statistically significant for the urban adults (OR=0.94, 95%CI: 0.83-1.06). CONCLUSION After controlling for individual socioeconomic status, community socioeconomic status was associa-ted with poor self-rated health for rural residents independent of individual socioeconomic status. Therefore, in order to improve the health status of the rural population, it needs not only individual-based health interventions, but also community-based health interventions.
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Affiliation(s)
- 志成 王
- />北京大学公共卫生学院卫生政策与管理学系,北京 100191Department of Health Policy and Management, Peking University School of Public Health, Beijing 100191, China
| | - 岩 郭
- />北京大学公共卫生学院卫生政策与管理学系,北京 100191Department of Health Policy and Management, Peking University School of Public Health, Beijing 100191, China
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Han X, Li X, Cheng L, Wu Z, Zhu J. Performance of China's new medical licensing examination for rural general practice. BMC MEDICAL EDUCATION 2020; 20:314. [PMID: 32943039 PMCID: PMC7499991 DOI: 10.1186/s12909-020-02234-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/09/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND To evaluate the performance of China's new medical licensing examination (MLE) for rural general practice, which determines the number of qualified doctors who can provide primary care for China's rural residents, and to identify associated factors. METHODS Data came from all 547 examinees of the 2017 MLE for rural general practice in Hainan province, China. Overall pass rates of the MLE and pass rates of the MLE Step 1 practical skills examination and Step 2 written exam were examined. Chi-square tests and multivariable logistic regression were used to identify examinee characteristics associated with passing Step 1 and Step 2, respectively. RESULTS Of the 547 examinees, 68% passed Step 1, while only 23% of Step 1 passers passed Step 2, yielding an 15% (82 of 547) overall pass rate of the whole examination. Junior college medical graduates were 2.236 (95% CI, 1.127-4.435) times more likely to pass Step 1 than secondary school medical graduates. Other characteristics, including age, gender, forms of study and years of graduation, were also significantly associated with passing Step 1. In contrast, examinees' vocational school major and Step 1 score were the only two significant predictors of passing Step 2. CONCLUSIONS Our study reveals a low pass rate of China's new MLE for rural general practice in Hainan province, indicating a relatively weak competency of graduates from China's alternative medical education. An effective long-term solution might be to improve examinees' clinical competency through mandating residency training for graduates of China's alternative medical education.
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Affiliation(s)
- Xinxin Han
- School of Medicine, Tsinghua University, Beijing, China
| | - Xiaotong Li
- Institute for Hospital Management, Tsinghua Shenzhen International Graduate School, Shenzhen, China
| | - Liang Cheng
- Department of Science and Education, Hainan Health Commission, Haikou, China
| | - Zhuoqing Wu
- Hainan Provincial Medical Association, Haikou, China
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, 100084, PR China.
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