Why patients prefer high-level healthcare facilities: a qualitative study using focus groups in rural and urban China

Healthcare preferences of chronic disease patients under China's hierarchical medical system: an empirical study of Tianjin's reform practice

To alleviate the contradiction in healthcare resources, the Chinese government formally established the framework of a hierarchical medical system in 2015, which contains the following brief generalities: " separate treatment of emergencies and slows, first-contact care at the primary, two-way referral, and upper and lower linkage, ". This study systematically summarizes and models the connotations of China's hierarchical medical system and a sample of 11,200 chronic disease patients in Tianjin, the largest port city in northern China, was selected for the empirical study to investigate the relationship between chronic disease patients' policy perceptions of the hierarchical medical system and their preference for healthcare. We found that under the strategy of separate treatment, improving the healthcare accessibility, drug supply, and lowering the cost of medical care would have a positive impact on increasing the preference of patients with chronic diseases to go to the primary hospitals. Under the two-way triage strategy, improving the level of physician services, referral convenience and treatment Standards have a positive impact on chronic disease patients' preference for primary care; The impact of the hierarchical medical system on the preference for healthcare differed between groups, focusing on differences in health literacy level, age and household type; The role of " upper and lower linkage " is crucial in the hierarchical medical system and it plays a part in mediating the influence of the " separate treatment of emergencies and slows" design and the "two-way referral " order on the treatment preferences of chronic disease patients. The results of the study provide a reference for the further development of a scientific and rational hierarchical medical system in the future.

Does a GP service package matter in addressing the absence of health management by the occupational population? A modelling study

OBJECTIVE

To assess the influence of supply and demand factors on the contract behavior of occupational populations with general practitioner (GP) teams.

METHODS

We employed a system dynamics approach to assess and predict the effect of the general practitioner service package (GPSP) and complementary incentive policies on the contract rate for 2015-2030. First, the GPSP is designed to address the unique needs of occupational populations, enhancing the attractiveness of GP contracting services, including three personalized service contents tailored to demand-side considerations: work-related disease prevention (WDP), health education & counseling (HEC), and health-care service (HCS). Second, the complementary incentive policies on the supply-side included income incentives (II), job title promotion (JTP), and education & training (ET). Considering the team collaboration, the income distribution ratio (IDR) was also incorporated into supply-side factors.

FINDINGS

The contract rate is predicted to increase to 57.8% by 2030 after the GPSP intervention, representing a 15.4% increase on the non-intervention scenario. WDP and HEC have a slightly higher (by 2%) impact on the contract rate than that from HCS. Regarding the supply-side policies, II have a more significant impact on the contract rate than JTP and ET by 3-5%. The maximum predicted contract rate of 75.2% is expected by 2030 when the IDR is 0.5, i.e., the GP receives 50% of the contract income and other members share 50%.

CONCLUSION

The GP service package favorably increased the contract rate among occupational population, particularly after integrating the incentive policies. Specifically, for a given demand level, the targeted content of the package enhanced the attractiveness of contract services. On the supply side, the incentive policies boost GPs' motivation, and the income distribution motivated other team members.

Social Medical Insurances, Choices of Medical Institutions and the 'Siphon Effect' in the Health Service Market: Evidence from 2021 Yangtze River Delta Region of China

Purpose

The siphon effect in the health service market is notably pronounced in many countries. How to measure and identify the determinants contributing to the siphon effect presents a substantial challenge. This study aimed to analyse the effect of two different social medical insurances, the Basic Medical Insurance System for Urban Employees (BMISUE), and the Basic Medical Insurance System for Urban and Rural Residents (BMISURR), on the siphon effect in the health services market.

Methods

The data used in this study were from the 2021 Health Life Satisfaction Survey of Yangtze River Delta (HLSSYRD) conducted by Shanghai Jiao Tong University. The logistic model was used to evaluate the association between social medical insurances and individual choices of medical institutions, and the Propensity Score Matching method (PSM) was used to check the robustness of basic results.

Results

Residents covered by BMISUE were more likely to choose a general hospital when they first sought medical treatment (OR = 5.377, 95% CI: 4.887, 5.915) relative to those insured by BMISURR. Further analysis showed that BMISUE would accelerate the siphon effect of general hospitals, people insured by BMISUE were still more likely to choose general hospitals despite being close to primary hospitals compared to those insured by BMISURR (OR = 3.240, 95% CI: 2.945, 3.565). Heterogeneity analysis indicated BMISUE had a greater impact on residents aged 15-59 years and those with high income compared to older people and individuals with low income.

Conclusion

Different social medical insurances can substantially affect residents' first choice of medical institutions. BMISUE with higher benefits level could exacerbate the siphon effect in the health service market. More equitable medical security system should be strengthened to bridge the benefits gap between BMISUE and BMISURR.

Trends in antidiabetic drug use and expenditure in public hospitals in Northwest China, 2012-21: a case study of Gansu Province

BACKGROUND

Since the twenty-first century, the prevalence of diabetes has risen globally year by year. In Gansu Province, an economically underdeveloped province in northwest China, the cost of drugs for diabetes patients accounted for one-third of their total drug costs. To fundamentally reduce national drug expenditures and the burden of medication on the population, the relevant departments of government have continued to reform and improve drug policies. This study aimed to analyse long-term trends in antidiabetic drug use and expenditure in Gansu Province from 2012 to 2021 and to explore the role of pharmaceutical policy.

METHODS

Data were obtained from the provincial centralised bidding and purchasing (CBP) platform. Drug use was quantified using the anatomical therapeutic chemistry/defined daily dose (ATC/DDD) method and standardised by DDD per 1000 inhabitants per day (DID), and drug expenditure was expressed in terms of the total amount and defined daily cost (DDC). Linear regression was used to analyse the trends and magnitude of drug use and expenditure.

RESULTS

The overall trend in the use and expenditure of antidiabetic drugs was on the rise, with the use increasing from 1.04 in 2012 to 16.02 DID in 2021 and the expenditure increasing from 48.36 in 2012 to 496.42 million yuan in 2021 (from 7.66 to 76.95 million USD). Some new and expensive drugs changed in the use pattern, and their use and expenditure shares (as the percentage of all antidiabetic drugs) increased from 0 to 11.17% and 11.37%, but insulins and analogues and biguanides remained the most used drug class. The DDC of oral drugs all showed a decreasing trend, but essential medicines (EMs) and medical insurance drugs DDC gradually decreased with increasing use. The price reduction of the bid-winning drugs was over 40%, and the top three drugs were glimepiride 2mg/30, acarbose 50mg/30 and acarbose 100mg/30.

CONCLUSIONS

The implementation of pharmaceutical policies has significantly increased drug use and expenditure while reducing drug prices, and the introduction of novel drugs and updated treatment guidelines has led to changes in use patterns.

Inspecting the "health poverty trap" mechanism: self-reinforcing effect and endogenous force

INTRODUCTION

The term "health poverty trap" describes a vicious cycle in which developing countries or regions become trapped in low levels of health and poverty during the process of modernization. Although significant progress has been made in alleviating poverty in China, there is still a need to further enhance the living conditions of its impoverished population.

METHODS

This research utilizes the data of the three national representative panel surveys from 2014 to 2020. The primary objective is to gain a better understanding of the intricate relationship between health and poverty. To examine the self-reinforcing effects of the cumulative cycle between health and poverty, we employ unconditional quantile regression analysis.

RESULT

The low-income group exhibits lower overall health status compared to the average level. Economic constraints partially hinder the ability of low-income individuals to access healthcare resources, thereby reinforcing the cyclical relationship between health and poverty. Additionally, the unique psychological and behavioral preferences of individuals in health poverty act as indirect factors that further strengthen this cycle. Health poverty individuals can generate endogenous force to escape the "health poverty trap" by enhancing their confidence levels and digital literacy.

CONCLUSIONS

The research examines the coexistence of health gradients and economic inequality among Chinese residents. Additionally, the study explores the endogenous force mechanism of escaping the health poverty trap from psychological and behavioral perspectives. This research also offers insights into optimizing government poverty alleviation programs to effectively address this issue.

Use of Primary Healthcare Among Chinese Older Adults With Functional Limitations

The aim of this study was to assess the factors associated with primary healthcare (PHC) utilization among older adults with functional limitations, providing insights for improving the effectiveness of PHC for this population. We used the China Health and Retirement Longitudinal Study (CHARLS) dataset, which encompasses 28 provinces in China. Logistic regression was used to analyze the people-related, care context-related, and linkage-related factors associated with PHC utilization. Approximately 55.61% of older adults with functional limitations utilized PHC in the past month, regardless of visit frequency or extent. Participants with lower educational attainment, those reporting more pain, and those living in rural areas had a higher likelihood of PHC utilization. Participants who received inpatient care in the past year had a lower likelihood of PHC utilization. We recommend that policymakers complement existing PHC health programs with increased health and social welfare support for this population.

Mapping Access to Children's Hospitals in Texas

Vehicle access, travel time, and distance to hospitals and emergency rooms with sufficient patient beds are critical healthcare accessibility measures, especially for children who require specific pediatric services. In a large state like Texas with vast rural areas and limited public transit infrastructure, 75% of the children live over an hour from the closest facility that provides pediatric emergency services or specialty care. In view of this challenge, this study first sought to map the prevailing geographical accessibility to children's hospitals and, second, to model the hospital beds per capita for each hospital's service area within the state of Texas. The results showed disparities in accessing emergency pediatric care, especially in rural areas. However, despite major metro areas recording better geographical accessibility to pediatric healthcare, residents in these areas may experience limited hospital bed availability. The findings indicate an urgent need for more pediatric healthcare services in rural Texas. Given the increasing population growth in metro areas and their surroundings, there is also a need for the expansion of healthcare infrastructure in these areas.

Optimizing the management of electrophysiology labs in Chinese hospitals using a discrete event simulation tool

BACKGROUND

The growing demand for electrophysiology (EP) treatment in China presents a challenge for current EP care delivery systems. This study constructed a discrete event simulation (DES) model of an inpatient EP care delivery process, simulating a generalized inpatient journey of EP patients from admission to discharge in the cardiology department of a tertiary hospital in China. The model shows how many more patients the system can serve under different resource constraints by optimizing various phases of the care delivery process.

METHODS

Model inputs were based on and validated using real-world data, simulating the scheduling of limited resources among competing demands from different patient types. The patient stay consists of three stages, namely: the pre-operative stay, the EP procedure, and the post-operative stay. The model outcome was the total number of discharges during the simulation period. The scenario analysis presented in this paper covers two capacity-limiting scenarios (CLS): (1) fully occupied ward beds and (2) fully occupied electrophysiology laboratories (EP labs). Within each CLS, we investigated potential throughput when the length of stay or operative time was reduced by 10%, 20%, and 30%. The reductions were applied to patients with atrial fibrillation, the most common indication accounting for almost 30% of patients.

RESULTS

Model validation showed simulation results approximated actual data (137.2 discharges calculated vs. 137 observed). With fully occupied wards, reducing pre- and/or post-operative stay time resulted in a 1-7% increased throughput. With fully occupied EP labs, reduced operative time increased throughput by 3-12%.

CONCLUSIONS

Model validation and scenario analyses demonstrated that the DES model reliably reflects the EP care delivery process. Simulations identified which phases of the process should be optimized under different resource constraints, and the expected increases in patients served.

Effects of the Implementation of Transport-Driven Poverty Alleviation Policy on Health Care-Seeking Behavior and Medical Expenditure Among Older People in Rural Areas: Quasi-Experimental Study

BACKGROUND

Improving the rural residents' accessibility to and affordability of health care is recognized as a common target globally. The Health in All Policies approach, from the Declaration of Helsinki to the United Nations' Decade Of Healthy Ageing, strengthened the far-reaching effect of large-scale public policies on health care-seeking behavior; however, the effects of national transport policy on health care-seeking behavior is unclear.

OBJECTIVE

This quasi-experimental study aimed to examine the effects of the implementation of transport-driven poverty alleviation (TPA) policy on health care-seeking behavior and medical expenditure among older adults in rural areas and the mechanism underlying these effects.

METHODS

We designed a quasi-experiment to estimate the effects of TPA policy implementation on health care-seeking behavior and medical expenditure among older adults in rural areas through a difference-in-differences (DID) analysis based on data from the China Health and Retirement Longitudinal Study in 2011, 2013, 2015, and 2018. The underlying mechanism was analyzed and effect modification patterns were further investigated by poor households, health status, and age.

RESULTS

Our findings validated a positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas. After the implementation of TPA policy, the number of inpatient visits increased by annually 0.35 times per person, outpatient medical expenditure increased by 192% per month, and inpatient medical expenditure increased by 57% annually compared with those of older adults in rural areas without the implementation of TPA policy. Further, there was a significant modification effect, with a positive effect among poor households, healthier older adults, and those aged 60-80 years. Additionally, the policy improved the patients' capabilities to seek long-distance care (β=23.16, 95% CI -0.99 to 45.31) and high-level hospitals (β=.08, 95% CI -0.02 to 0.13), and increased individual income to acquire more medical services (β=4.57, 95% CI -4.46 to 4.68).

CONCLUSIONS

These findings validate the positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas; however, the medical expenditure incurred was also high. Concerted efforts are needed to address health care-seeking dilemmas in rural areas, and attention must be paid to curbing medical expenditure growth for older adults in rural areas during TPA policy implementation.

Current status of and future perspectives on care for cancer survivors in China

Cancer is currently a major public health issue faced by countries around the world. With the progress of medical science and technology, the survival rate of cancer patients has increased significantly and the survival time has been effectively prolonged. How to provide quality and efficient care for the increasingly large group of cancer survivors with limited medical resources will be a key concern in the field of global public health in the future. Compared to developed countries, China's theoretical research and practical experience in care for cancer survivors are relatively limited and cannot meet the multi-faceted and diverse care needs of cancer patients. Based on the existing models of care worldwide, the current work reviews care for cancer survivors in China, it proposes considerations and suggestions for the creation of models of cancer care with Chinese characteristics in terms of optimizing top-level system design, enhancing institutional mechanisms, accelerating human resource development, and enhancing self-management and social support for patients.

High performing primary health care organizations from patient perspective: a qualitative study in China

BACKGROUND

There is a global call to build people-centred primary health care (PHC) systems. Previous evidence suggests that without organization-level reform efforts, the full potential of policy reforms may be limited. This study aimed to generate a profile of high performing PHC organizations from the perspective of patients.

METHODS

We conducted semi-structured interviews with 58 PHC users from six provinces (Shandong, Zhejiang, Shaanxi, Henan, Shanxi, Heilongjiang) in China using purposive and snowball sampling techniques. Transcription was completed by trained research assistants through listening to the recordings of the interviews and summarizing them in English by 30-s segments to generate the narrative summary. Informed by the Classification System of PHC Organizational Attributes, thematic analysis aimed to identify domains and attributes of high performing PHC organizations.

RESULTS

A profile of a high performing PHC organization with five domains and 14 attributes was generated. The five domains included: (1) organizational resources including medical equipment, human and information resource; (2) service provision and clinical practice including practice scope, internal integration and external integration; (3) general features including location, environment and ownership; (4) quality and cost; and (5) organizational structure including continuous learning mechanism, administrative structure and governance.

CONCLUSIONS

A five-domain profile of high performing PHC organizations from the perspective of Chinese PHC users was generated. Organizational resources, service delivery and clinical practices were most valued by the participants. Meanwhile, the participants also had strong expectation of geographical accessibility, high quality of care as well as efficient organizational structure. These organizational elements should be reflected in further reform efforts in order to build high performing PHC organizations.

Experiences of referral with an obstetric emergency: voices of women admitted at Mbarara Regional Referral Hospital, South Western Uganda

BACKGROUND

Life-threatening obstetric complications usually lead to the need for referral and constitute the commonest direct causes of maternal deaths. Urgent management of referrals can potentially lower the maternal mortality rate. We explored the experiences of women referred with obstetric emergencies to Mbarara Regional Referral Hospital (MRRH) in Uganda, in order to identify barriers and facilitating factors.

METHODS

This was an exploratory qualitative study. In-depth interviews (IDIs) were conducted with 10 postnatal women and 2 attendants as key informants. We explored health system and client related factors to understand how these could have facilitated or hindered the referral process. Data was analyzed deductively employing the constructs of the Andersen Healthcare Utilization model.

RESULTS

Women experienced transport, care delays and inhumane treatment from health care providers (HCPs). The obstetric indications for referral were severe obstructed labor, ruptured uterus, and transverse lie in advanced labor, eclampsia and retained second twin with intrapartum hemorrhage. The secondary reasons for referral included; non-functional operating theatres due to power outages, unsterilized caesarian section instruments, no blood transfusion services, stock outs of emergency drugs, and absenteeism of HCPs to perform surgery. Four (4) themes emerged; enablers, barriers to referral, poor quality of care and poor health facility organization. Most referring health facilities were within a 30-50 km radius from MRRH. Delays to receive emergency obstetric care (EMOC) led to acquisition of in-hospital complications and eventual prolonged hospitalization. Enablers to referral were social support, financial preparation for birth and birth companion's knowledge of danger signs.

CONCLUSION

The experience of obstetric referral for women was largely unpleasant due to delays and poor quality of care which contributed to perinatal mortality and maternal morbidities. Training HCPs in respectful maternity care (RMC) may improve quality of care and foster positive postnatal client experiences. Refresher sessions on obstetric referral procedures for HCPs are suggested. Interventions to improve the functionality of the obstetric referral pathway for rural south-western Uganda should be explored.

Preferences of patients with diabetes mellitus for primary healthcare institutions: a discrete choice experiment in China

OBJECTIVES

To quantify the preference of patients with diabetes mellitus (DM) for primary healthcare (PHC) institutions in China to redirect the patient flow and improve health outcomes.

DESIGN

Cross-sectional study. Discrete choice experiment (DCE) surveys asked patients with DM to choose between hypothetical institutions that differed in the medical service capacity, out-of-pocket (OOP) medical costs per month, travel time, the attitude of medical staff and the availability of diabetes drugs.

SETTING

Shandong province, China.

PARTICIPANTS

The participants were 887 patients with DM from 36 urban communities and 36 rural villages in Shandong province. One participant did not provide any DCE answers and a further 57 patients failed the internal consistency test. 829 fully completed surveys were included in the final data analysis.

MAIN OUTCOMES AND MEASURES

A mixed logit model was used to calculate the willingness to pay and predict choice probabilities for PHC institution attributes. Preference heterogeneity was also investigated.

RESULTS

All five attributes were associated with the preferences of patients with DM. The OOP medical costs and the medical service capacity were the most influential attributes. Improvements simultaneously in the attitude of medical staff, drug availability and travel time increased the likelihood of a patient's PHC institution choice. Preferences differed by region, annual household income and duration of diabetes.

CONCLUSIONS

Our patient preference data may help policymakers improve health services and increase acceptance of choosing PHC institutions. The OOP medical costs and medical service capacity should be regarded as a priority in decision-making.

One Pandemic, Two Solutions: Comparing the U.S.-China Response and Health Priorities to COVID-19 from the Perspective of "Two Types of Control"

After three years of global rampage, the COVID-19 epidemic, the most serious infectious disease to occur worldwide since the 1918 influenza pandemic, is nearing its end. From the global experience, medical control and social control are the two main dimensions in the prevention and control of COVID-19. From the perspective of "two types of control", namely medical control and social control, this paper finds that the political system, economic structure, and cultural values of the United States greatly limit the government's ability to impose social control, forcing it to adopt medical control to fight the virus in a single dimension. In contrast, China's political system, economic structure, and cultural values allow its government to adopt stringent, extensive, and frequent social control, as well as medical control to fight the virus. This approach departs from the traditional pathway of fighting the epidemic, i.e., "infection-treatment-immunization", thereby outpacing the evolution of the virus and controlling its spread more rapidly. This finding helps explain why the Chinese government adopted a strict "zeroing" and "dynamic zeroing" policy during the first three years, at the cost of enormous economic, social, and even political legitimacy. It was not until late 2022, when the Omicron variant with the waning virulence became prevalent, that China chose to "coexist" with the virus, thus avoiding a massive epidemic-related death. While the United States adopted a pulsed-style strategy at the beginning of the epidemic, i.e., "relaxation-suppression-relaxation-suppression", and began to "coexist" with the virus in just one year, resulting in a large number of excess deaths associated with the epidemic. The study contributes to explaining the difference in the interplay between public health priorities and COVID-19 response strategies in China and the United States, based on the specific public health context and the perspective of "medical control" and "social control".

Explaining the intention and behaviours of interinstitutional collaboration in chronic disease management among health care personnel: a cross-sectional study from Fujian Province, China

BACKGROUND

The increasing number of chronic diseases consumes a large amount of health resources and puts a huge burden on health service system. The integrated management of chronic diseases in Sanming City aims to improve the efficiency and quality of chronic disease management through the collaboration between different levels of medical institutions.

AIM

The aim of the present study was to use the theory of planned behaviour (TPB) to examine the intention and behaviours of interinstitutional collaboration in chronic disease management (ICCDM) among healthcare personnel.

METHODS

A cross-sectional study of 274 health care personnel was conducted in medical institutions in Fujian Province, China, from March 2022 to April 2022. A self-administered questionnaire based on TPB theory was applied to measure the participants' ICCDM behaviours.

RESULTS

The proposed TPB model revealed that attitude was significantly and positively associated with behaviour intention, and behaviour intention and perceived behavioural control were significant predictors of ICCDM behaviour.

CONCLUSION

TPB provides insights into ICCDM behaviour. Due to the fact that attitude, perceived behavioural control, and behavioural intention towards ICCDM behaviour were demonstrated to be significant predictors of ICCDM behaviour, these factors may be a promising focus of ICCDM interventions in the integrated management of chronic diseases in China.

Examining clinical capability of township healthcare centres for rural health service planning in Sichuan, China: an administrative data analysis

OBJECTIVE

This study aimed to examine the clinical capability of township healthcare centres (THCs), the main primary care providers in rural China, as a basis for rural health service planning.

DESIGN

Observational study of quantitative analysis using administrative data.

SETTING

Three counties with low, middle and high social economic development level, respectively, in Sichuan province western China.

PARTICIPANTS

9 THCs and 6 county hospitals (CHs) were purposively selected in the three counties. Summary of electronic medical records of 31 633 admissions from 1 January 2015 to 30 December 2015 of these selected health institutions was obtained from the Health Information Centre of Sichuan province.

MAIN OUTCOME MEASURES

Six indicators in scope of inpatient services related to diseases and surgeries in the THCs as proxy of clinical capability, were compared against national standard of capability building of THCs, among counties, and between THCs and CHs of each county.

RESULTS

The clinical capability of THCs was suboptimal against the national standard, though that of the middle-developed county was better than that in the rich and the poor counties. THCs mainly provided services of infectious or inflammatory diseases, of respiratory and digestive systems, but lacked clinical services related to injuries, poisoning, pregnancy, childbirth and surgeries. A large proportion of the top 20 diseases of inpatients were potentially avoidable hospitalisations (PAHs) and were overlapped between THCs and CHs.

CONCLUSIONS

The clinical capability of THCs was generally suboptimal against national standard. It may be affected by the economics, population size, facilities, workforce and the share of services of THCs in local health systems. Identification of absent services and PAHs may help to identify development priorities of local THCs. Clarification of the roles of THCs and CHs in the tiered rural health system in China is warranted to develop a better integrated health system.

Does increasing physician volume in primary healthcare facilities under the hierarchical medical system help reduce hospital service utilisation in China? A fixed-effects analysis using province-level panel data

OBJECTIVE

To examine whether increases in physician volume in primary healthcare facilities are associated with reduced utilisation of hospital outpatient and inpatient services after China facilitated the establishment of the hierarchical medical system.

DESIGN

We used a two-way fixed-effects regression to examine the association between the annual number of physicians in primary healthcare facilities and that of patient visits per physician, inpatient admissions and total expenses per outpatient visit in public hospitals during 2010-2014 and 2015-2019. Variables were log transformed to ensure the normal distribution of the data.

SETTING

Province-level data of all 31 provinces in mainland China from 2010 to 2019 were collected from the China Health Statistics Yearbook published by the China Health Commission.

PARTICIPANTS

All 31 provinces in mainland China.

PRIMARY AND SECONDARY OUTCOME MEASURES

The annual number of outpatient visits per physician, hospital admission and total expenses per outpatient visit in public hospitals.

RESULTS

During 2015-2019, we found that, on average, a 1% increase in the number of primary healthcare physicians was accompanied by a 0.19% (95% CI -0.33% to -0.05%) reduction in the annual number of visits per physician in public hospitals, and a 0.31% (95% CI -0.52% to -0.10%) reduction in patient visits in city-administered hospitals. No significant associations were found between 2010 and 2014. We also did not observe any significant associations between primary healthcare physician volume and hospital admissions or outpatient expenses during neither 2010-2014 and 2015-2019.

CONCLUSIONS

In the context of the hierarchical medical system, enhancing physician volume in primary healthcare facilities helps reduce outpatient visits in public hospitals, especially city-administered hospitals. However, more efforts are required to be continuously made to improve primary healthcare capacity to avoid preventable hospital admissions and outpatient expenses.

Analyzing the efficiency of Chinese primary healthcare institutions using the Malmquist-DEA approach: Evidence from urban and rural areas

Background

China has been increasing the investment in Primary Health Care Institutions (PHCIs) since the launch of the New Health Care System Reform in 2009. It is a crucial concern whether the PHCIs can meet residents' need both in urban and rural with the limited government finance, especially encountering the challenge of the COVID-19. This study aimed to reveal the trend of the primary health service efficiency in the past decade, compare the urban-rural differences, and explore relevant factors.

Methods

DEA and Malmquist models were applied to calculate the health service efficiency of PHCIs among 28 provinces in China, with the input variables including the number of institutions, number of beds, number of health technicians, and the outputs variables including the number of outpatients and emergency visits, number of discharged patients. And the Tobit model was used to analyze the factors on the efficiency in urban and rural. A sensitivity analysis for model validations was also carried out.

Results

The average technical efficiency (TE) of urban PHCIs fluctuated from 63.3% to 67.1%, which was lower than that in rural (75.8-82.2%) from 2009 to 2019. In terms of dynamic efficiency, the urban PHCIs performed better than the rural, and the trends in the total factor productivity change were associated with favorable technology advancement. The population density and dependency ratio were the key factors on TE in both of the urban and rural PHCIs, and these two factors were positively correlated to TE. In terms of TE, it was negatively correlated with the proportion of total health expenditure as a percentage of GDP in urban PHCIs, while in rural it was positively correlated with the urbanization rate and negatively correlated with GDP per capita. Besides, the tests of Mann-Whitney U, and Kruskal-Wallis H indicated the internal validity and robustness of the chosen DEA and Malmquist models.

Conclusions

It needs to reduce the health resource wastes and increase service provision in urban PHCIs. Meanwhile, it is necessary to strengthen medical technology and gaining greater efficiency in rural PHCIs by technology renovation.

Challenges in moving toward universal health coverage: rising cost of outpatient care among Vietnam's insured rural residents, 2006-2018

OBJECTIVES

The aim of this study was to assess temporal trends in out-of-pocket (OOP) expenditures per outpatient contact by the insured residents in rural Vietnam.

STUDY DESIGN

This was a repeated cross-sectional study.

METHODS

Seven biennial waves from the Vietnam's Household Living Standard Survey covering the period 2006-2018 and a two-part model were used to assess temporal trends in OOP expenditures and its variations across various health facilities while controlling for a wide array of individual- and household-specific characteristics.

RESULTS

The pattern of health facility utilization shifted steadily from commune health centers toward higher level government hospitals and private health facilities between 2006 and 2018. The regression results indicated an upward trend in the amount of OOP expenditures, with the amount of OOP expenditures incurred per outpatient contact being 40.3% higher in 2010-2012 than in 2006-2008 and by as much as 155.5% higher in 2018. These high-cost pressures were attenuated by 63%-65% when accounting for the types of health facility contacted. The cost inflation was more pronounced for care sought at higher level government hospitals and private hospitals than at other health facilities.

CONCLUSION

The cost of accessing outpatient care rose sharply between 2006 and 2018, particularly for visits involving higher level government hospitals and private hospitals. These findings suggest that beside expanding the coverage over the transition path to universal coverage, efforts should be directed at reforming Vietnam's hospital-centric and fragmented delivery system as a way of containing costs and ensuring financial sustainability of social health insurance system.

Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study adaptations in lung cancer screening delivery in the Veterans Health Administration: a cohort study

BACKGROUND

Lung cancer screening is a complex clinical process that includes identification of eligible individuals, shared decision-making, tobacco cessation, and management of screening results. Adaptations to the delivery process for lung cancer screening in situ are understudied and underreported, with the potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for a systematic enumeration of adaptations to implementation of evidence-based practices. We applied FRAME to study adaptations in lung cancer screening delivery processes implemented by lung cancer screening programs in a Veterans Health Administration (VHA) Enterprise-Wide Initiative.

METHODS

We prospectively conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMCs) between 2019 and 2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, documented, and mapped to FRAME categories.

RESULTS

We conducted a total of 16 interviews across 10 VHA lung cancer screening programs (n=6 in year 1, n=10 in year 2) to collect adaptations. In year 1 (2020), six programs were operational and eligible. Of these, three reported adaptations to their screening process that were planned or in response to COVID-19. In year 2 (2021), all 10 programs were operational and eligible. Programs reported 14 adaptations in year 2. These adaptations were planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to the identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 60% of programs to improve the data collection and tracking of Veterans in the screening process.

CONCLUSIONS

Using FRAME, we found that adaptations occurred primarily in the areas of patient identification and communication of results due to increased workload. These findings highlight navigator time and resource considerations for sustainability and scalability of existing and future lung cancer screening programs as well as potential areas for future intervention.

Long-term trend of antibiotic use at public health care institutions in northwest China, 2012-20 -- a case study of Gansu Province

BACKGROUND

Over the past 20 years, excessive antibiotic use has led to serious antimicrobial resistance (AMR) worldwide, and the phenomenon is particularly serious in China. To this end, the Chinese health sector took a series of measures to promote rational antibiotic use. In this study, to reveal the impact of policies on antibiotic use, we explored the long-term trend and patterns of antibiotic use at public health care institutions from 2012 to 2020 in northwest China, taking Gansu Province as an example.

METHODS

Antibiotic procurement data were obtained from the provincial centralized bidding procurement (CBP) platform between 2012 and 2020. Antibiotic use was quantified using the Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology and standardized using the DDD per 1000 inhabitants per day (DID). Twelve relevant quality indicators were calculated for comparison with the European Surveillance of Antimicrobial Consumption (ESAC) project monitoring results.

RESULTS

Total antibiotic use increased from 18.75 DID to 57.07 DID and then decreased to 19.11 DID, a turning point in 2014. The top three antibiotics used were J01C (beta-lactam antibacterials, penicillins), J01F (macrolides, lincosamides and streptogramins), and J01D (other beta-lactam antibacterials, cephalosporins), accounting for 45.15%, 31.40%, and 11.99% respectively. The oral antibiotics used were approximately 2.5 times the parenteral antibiotics, accounting for 71.81% and 28.19%, respectively. Different use preferences were shown in public hospitals and primary health care centres (PHCs), and the latter accounted for more than half of total use. The absolute use of all classes of antibiotics in Gansu is almost higher than any of the 31 European countries included in the ESAC, but the relative use of some focused antibiotics is lower than theirs.

CONCLUSIONS

The intervention policies of the health department reduced antibiotic use in Gansu Province, but the proportion of broad-spectrum and parenteral antibiotics was still high. It is necessary to further improve the quality of antibiotic prescriptions and pay more attention to the rationality of antibiotic use in PHCs.

Capturing What Matters with Patients' Bypass Behavior? Evidence from a Cross-Sectional Study in China

BACKGROUND

In China, bypassing is becoming increasingly prevalent. Such behavior, as going directly to upper-level health-care facilities without a primary care provider (PCP) referral when facing non-critical diseases, contrasts to "expanding the role of PCPs as the first-contact of care", may cause unneglectable damage to the healthcare system and people's physical health.

OBJECTIVE

To examine the relationship between patient experience in primary health-care clinics (PHCs) and their bypass behavior.

METHODS

A cross-sectional study was designed for data collection. From July 2021 to August 2021, we conducted a questionnaire survey nationally. Fifty-three investigators were dispatched to 212 pre-chosen PHCs, around which 1060 interviewees were selected to gather information, using a convenience sampling. The primary independent variable was scores measured by Chinese Primary Care Assessment Tool (PCAT-C) to quantify patients' experience at PHCs. The dependent variable was a binary variable measured by a self-developed instrument to identify whether participants actually practiced bypassing. Covariates were well-screened determinants of patients' bypass behavior including socio-demographic factors, policy factors, and health-care suppliers. Binary logistic regression analysis was employed to evaluate the association of patients' experience with their bypass behavior.

FINDINGS

A total of 928 qualified questionnaires were obtained. The first contact dimension (OR 0.961 [95% CI 0.934 to 0.988], P = 0.005) and continuity dimension (OR 1.034 [95% CI 1.000 to 1.068], P = 0.047) of patients' experience were significantly associated with patients' bypass behavior (P < 0.05). In addition, age (OR 1.072, [95% CI 1.015-1.132], P = 0.013) and gender (OR 2.044, [95% CI 1.139-3.670], P = 0.017) also made a statistically significant difference.

CONCLUSION

Enhancement in patient experience at PHCs may help reduce their bypass behavior. Specifically, efforts are needed to improve primary care accessibility and utilization. The positive correlation between bypassing rates and continuity scores may require more attention on strengthening PCPs' technical quality besides the quality of interpersonal interactions.

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

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.

Associations between short-term exposure of ambient particulate matter and hemodialysis patients death: A nationwide, longitudinal case-control study in China

BACKGROUND

Long-term exposure to particulate air pollutants can lead to an increase in mortality of hemodialysis patients, but evidence of mortality risk with short-term exposure to ambient particulate matter is lacking. This study aimed to estimate the association of short-term exposure to ambient particulate matter across a wide range of concentrations with hemodialysis patients mortality.

METHODS

We performed a time-stratified case-crossover study to estimate the association between short-term exposures to PM_2.5 and PM₁₀ and mortality of hemodialysis patients. The study included 18,114 hemodialysis death case from 279 hospitals in 41 cities since 2013. Daily particulate matter exposures were calculated by the inverse distance-weighted model based on each case's dialysis center address. Conditional logistic regression were implemented to quantify exposure-response associations. The sensitivity analysis mainly explored the lag effect of particulate matter.

RESULTS

During the study period, there were 18,114 case days and 61,726 control days. Of all case and control days, average PM_2.5 and PM₁₀ levels were 43.98 μg/m³ and 70.86 μg/m³, respectively. Each short-term increase of 10 μg/m³ in PM_2.5 and PM₁₀ were statistically significantly associated with a relative increase of 1.07 % (95 % confidence interval [CI]: 0.99 % - 1.15 %) and 0.89 % (95 % CI: 0.84 % - 0.94 %) in daily mortality rate of hemodialysis patients, respectively. There was no evidence of a threshold in the exposure-response relationship. The mean of daily exposure on the same day of death and one-day prior (Lag 01 Day) was the most plausible exposure time window.

CONCLUSIONS

This study confirms that short-term exposure to particulate matter leads to increased mortality in hemodialysis patients. Policy makers and public health practices have a clear and urgent opportunity to pass air quality control policies that care for hemodialysis populations and incorporate air quality into the daily medical management of hemodialysis patients.

Factors associated with selection of practice in primary care and rural health among medical and nursing students in China

BACKGROUND

China has a shortage of physicians and nurses in primary care and rural health. This study explores factors that influence the choices of medical and nursing students in China to select a career in primary care, or in rural health.

METHODS

A total of 3826 medical students and 1771 nursing students were surveyed in China. Data were analysed using descriptive statistics, Chi-squared tests, and logistic regression models.

RESULTS

The majority of medical and nursing students were willing to practice primary care (55% and 59%, respectively). Yet, only 16% and 5% of medical and nursing students, respectively, desired to work in a village or small city. The most common reasons cited to not practice primary care is the lack of opportunities for clinical skills improvement, academic and personal development, and networking. Medical students who were living in a rural residence between ages 1 and 15years were more likely to report a willingness to work in a rural location (OR: 2.18, 95% CI: 1.33-3.58) or in primary care (OR: 1.72, 95% CI: 1.31-2.25).

CONCLUSION

More efforts are needed to understand how preferences among medical and nursing students influence their career choices and change in choices over time. Understanding the concerns of students can help to tailor interventions in healthcare education and training to increase student satisfaction with their career choice and enrolment counts in medical and nursing fields.

Mobile Health in China: Well Integrated or a New Divide?

The application of mobile health holds promises of achieving greater accessibility in the evolving health care sector. The active engagement of private actors drives its growth, while the challenges that exist between health care privatization and equitable access are a concern. This article selects the private internet hospital in China as a case study. It indicates that a market-oriented regulatory mechanism of private mobile health will contribute little to improving health equity from the perspectives of egalitarians and libertarians. By integrating the capability approach and the right to health, it is claimed that mobile health is a means of accessing health care for everyone, where substantive accessibility should be emphasized. With this view, this article provides policy recommendations that reinforce private sector engagement for mobile health, recognizing liberty, equity, and collective responsibility in the Chinese context.

How to Make Primary Healthcare More Popular: Evidence from the Middle-Aged and Elderly in China

Since 2001, China has been an aging society; it is expected to become superaged by 2033. This rapid aging trend poses a challenge to the elderly regarding their pension services and healthcare. Primary healthcare has great potential for serving older adults in the community, yet it is not popular. This study used 1977 samples from the 2018 China Health and Retirement Longitudinal Study database to explore the use of outpatient services in primary care institutions among the middle-aged and elderly. Using a structural equations model, we constructed a framework to explore pathways leading to primary outpatient use. We discovered that the supply of primary health services had a significant direct and mediating effect on the utilization of primary outpatient services, and that community pension services may indirectly discourage it. In addition, the supply of primary health services has a suppressor effect between medical insurance and primary outpatient utilization. Health insurance directly promotes primary outpatient utilization, while the supply of primary care institutions suppresses the positive influence of medical insurance on the utilization of primary outpatient services. Therefore, community pension services should pay attention to differentiated services. Moreover, adjusting the coordinated development of medical insurance and the supply of primary healthcare could enhance the positive effects of medical insurance for outpatients.

Effects of Vertical Integration Reform on Primary Healthcare Institutions in China: Evidence From a Longitudinal Study

BACKGROUND

Integrated care is a global trend in international healthcare reform, particularly for piloting vertical integration involving hospitals and primary healthcare institutions (PHIs). However, evidence regarding the impact of vertical integration on primary healthcare has been mixed and limited. Our study aims to evaluate the empirical effects of vertical integration reform on PHIs in China, and examines variations across integration intensity (tight integration vs. loose collaboration).

METHODS

This study used a longitudinal design. The time-varying difference-in-difference (DID) method with a fixed-effect model for panel data was adopted. A total of 370 PHIs in the eastern, central, and western areas of China from 2009 to 2018 were covered. Outcome measures included the indicators at three dimensions regarding inpatient and outpatient service volume, patient flow between PHIs and hospitals and quality of chronic disease care (hypertension and diabetes).

RESULTS

Significant increases in absolute (the number) and relative (the ratio between PHIs and hospitals) volume of inpatient admissions have been found after reform under tight integration, peaking at 183% and 15.0% respectively, in the third reform year. The quality of hypertension and diabetes care (by indicators of control rate of blood pressure and blood glucose) showed significant improvements under both types of vertical integration after reform. It was much more distinct for the PHIs under tight integration, which had the most significant increase of 34.0% and 22.8% under tight integration for the control rate of hypertension and diabetes compared to the peak of 21.2% and 22.1% respectively under loose collaboration.

CONCLUSION

Our findings suggest that vertical integration (especially tight integration) in China significantly contributed to strengthening primary healthcare in terms of inpatient services and quality of hypertension and diabetes care, providing empirical evidence to other countries on integrating primary healthcare-based health systems.

Illness Perceptions and Self-Management among People with Chronic Lung Disease and Healthcare Professionals: A Mixed-Method Study Identifying the Local Context

Self-management interventions (SMIs) may fail if they misalign with the local context. To optimize the implementation of SMIs in Chinese people with chronic lung disease (CLD), the local context was identified in Chinese primary care (PC) and secondary care (SC). A mixed-method study using semi-structured interviews and quantitative surveys was conducted on people with CLD and healthcare professionals (HCPs). The qualitative data was collected until data saturation was reached, and participants were invited to complete the survey after the interview. The qualitative data—analyzed with the framework approach—was triangulated with the quantitative data. A total of 52 participants completed the interviews, and 48 also finished the survey. Four themes were identified; (a) illness perceptions (e.g., patients had poor CLD knowledge and SM, inadequate resources lead to suboptimal disease control in PC); (b) self-management skills (e.g., most patients delayed exacerbation recognition and action, and some were admitted at the crisis point); (c) factors influencing self-management skills (e.g., (in)adequate disease knowledge and medical expenditure affordability); and (d) needs for self-management (e.g., increased disease knowledge, individualized self-management plan, eHealth, (healthcare insurance) policy support). Identified themes were dependent on each other and should be leveraged when implementing SMIs. Ultimately, such SMIs can optimize patient health outcomes.

Medical information seeking behavior of urban patients in Zhejiang Province, China: a cross-sectional study

Background

Health information seeking behavior (HISB) is a prevalent research topic. However, little is known about sociodemographic factors of HISB in China. This study aimed to examine the HISB of urban patients in China and identify predictors of source preference, online information seeking, and the timing of online seeking.

Methods

Based on the Health Information National Trends Survey (HINTS), this study conducted a cross-sectional survey of 1653 participants in different types of hospitals in 3 cities of different income levels within Zhejiang Province, China. Binary logistic regression analysis and multinomial logistic regression analysis were used to identify predictors of source preference, online medical information seeking, and the timing of online seeking for urban patients.

Results

The offline was the primary source of medical information for 58.61% of adult urban patients, while 78.19% had ever sought medical information online. 36.81% of online medical information seekers sought information before the medical visit, 8.65% sought information after the visit, and 54.54% sought information before and after the visit. China’s urban patients with higher education levels, higher income levels, young, active in internet use, and living in high-income cities were more likely to be active online medical information seekers (using the internet as the primary source) and online medical information seekers (having ever sought medical information online). Except for gender and age, most sociodemographic characteristics were not significantly associated with the timing of online medical information seeking.

Conclusions

Significant predictors of active online medical information seekers and online medical information seekers in China were almost the same. Regional economic development had a significant direct impact on medical information seekers. Most sociodemographic characteristics were not significantly associated with the timing of online medical information seeking. The findings of this study imply that China’s health information technology industry has Chinese characteristics.

The effect of basic medical insurance on the changes of primary care seeking behavior: An application of hierarchical age-period-cohort analysis

In order to encourage residents to go to primary care facilities, China has set up differentiated basic medical insurance reimbursement ratios. The study aims to use the dynamic point of view of longitudinal data to examine the changes in the impact of basic medical insurance on primary care. The data for this study comes from the Chinese Family Panel Study (CFPS) in 2010, 2012, 2014, 2016, and 2018. We adopted Hierarchal Age-period-cohort-Cross-Classified Random Effects Models (HAPC-CCREM) to examine the changes in the impact of basic medical insurance on primary care. Compared with non-insured groups, participants of the New Rural Cooperative Medical System (coefficient = 0.730) have a relatively high incidence of primary care seeks, while Urban Residents' Basic Medical Insurance (coefficient = −0.482) and Urban Employees' Basic Medical Insurance (coefficient = −0.663) are lower, respectively. Age, period over time and cohort have a more obvious moderating effect on primary care seeks. The study of primary care behavior is an important direction for the construction of a hierarchical medical system. As basic medical insurance is the source of power for the hierarchical medical system, we can provide certain direction for policy formulation on the changes of basic medical insurance in primary care behavior.

Would you zoom with your doctor? A discrete choice experiment to identify patient preferences for video and in-clinic consultations in German primary care

INTRODUCTION

The popularity of video consultations in healthcare has accelerated during the COVID-19 pandemic. Despite increased availability and obvious benefits, many patients remain hesitant to use video consultations. This study investigates the relative importance of the consultation mode compared to other attributes in patients' appointment choices in Germany.

METHODS

A discrete choice experiment was conducted to examine the influence of appointment attributes on preferences for video over in-clinic consultations. A total of 350 participants were included in the analysis.

RESULTS

The level of continuity of care (46%) and the waiting time until the next available appointment (22%) were shown to have higher relative importance than consultation mode (18%) and other attributes. Participants with fewer data privacy concerns, higher technology proficiency, and more fear of COVID-19 tended to prefer video over in-clinic consultations. The predicted choice probability of a video over a typical in-clinic consultation and opting out increased from <1% to 40% when the video consultation was improved from the worst-case to the best-case scenario.

CONCLUSION

This study provides insight into the effect of the consultation mode on appointment choice at a time when telemedicine gains momentum. The results suggest that participants preferred in-clinic over video consultations. Policymakers and service providers should focus on increasing the level of continuity of care and decreasing the time until the next available appointment to prompt the adoption of video consultations. Although participants preferred to talk to their physician in person over consulting via video per se, the demand for video consultations can be increased significantly by improving the other appointment attributes of video consultations such as the level of continuity of care.

Patient satisfaction and its health provider-related determinants in primary health facilities in rural China

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.

Predictors of Healthcare Utilization Among Older Adults with Moderate to Severe Cognitive Limitations in Ghana: A Cross-Sectional Analysis of the WHO Study on Global Ageing and Adult Health (SAGE) Wave 1

BACKGROUND

As the number of older adults in Ghana keeps increasing, so does the prevalence of aging-related diseases and conditions that tend to lead to cognitive decline. However, knowledge on the predicting factors of healthcare utilization among older adults with cognitive limitations is still scarce.

OBJECTIVE

This study examines the predictive factors of healthcare-seeking behavior among older adults with moderate-to-severe cognitive limitations in Ghana.

METHODS

Based on Andersen's behavioral model of health service utilization, the study analyzed data from 3106 older adults with moderate to severe cognitive limitations in Ghana aged 50+ using Bivariate Probit Regression and the Heckman Selection Model.

RESULTS

Results showed that individuals who were aged 75+, living in urban settlements, educated, higher income levels and parents who had some level of education, pension benefits, and both mandatory and voluntary health insurance were more likely to seek inpatient care. Enabling resources such as the national health insurance scheme and other types of medical insurance, household income, pension benefits, and predisposition factors like education influenced outpatient and inpatient healthcare consumption for older adults with moderate to severe cognitive limitations but had little influence on the choice of healthcare facility except for health insurance.

CONCLUSION

Since the healthcare-seeking behavior of older adults with moderate-to-severe cognitive limitations is driven by an amalgamation of several internal and external factors, there is a need for policy change to understand and cautiously incorporate these factors into the decision to improve equitable access to healthcare services for these individuals, as not all sizes fit all in providing quality care for them.

The Preferences for Attributes of Initial COVID-19 Diagnosis in the US and China during the Pandemic: A Discrete Choice Experiment with Propensity Score Matching

Background

China and the United States play critical leading roles in the global effort to contain the COVID-19 virus. Therefore, their population’s preferences for initial diagnosis were compared to provide policy and clinical insights.

Objective

We aim to quantify and compare the public’s preferences for medical management of fever and the attributes of initial diagnosis in the case of presenting symptoms during the COVID-19 pandemic in China and the United States.

Methods

We conducted a cross-sectional study from January to March 2021 in China and the United States using an online discrete choice experiment (DCE) questionnaire distributed through Amazon Mechanical Turk (MTurk; in the United States) and recruited volunteers (in China). Propensity score matching (PSM) was used to match the 2 groups of respondents from China and the United States to minimize confounding effects. In addition, the respondents’ preferences for different diagnosis options were evaluated using a mixed logit model (MXL) and latent class models (LCMs). Moreover, demographic data were collected and compared using the chi-square test, Fisher test, and Mann-Whitney U test.

Results

A total of 9112 respondents (5411, 59.4%, from China and 3701, 40.6%, from the United States) who completed our survey were included in our analysis. After PSM, 1240 (22.9%) respondents from China and 1240 (33.5%) from the United States were matched for sex, age, educational level, occupation, and annual salary levels. The segmented sizes of 3 classes of respondents from China were 870 (70.2%), 270 (21.8%), and 100 (8.0%), respectively. Meanwhile, the US respondents’ segmented sizes were 269 (21.7%), 139 (11.2%), and 832 (67.1%), respectively. Respondents from China attached the greatest importance to the type of medical institution (weighted importance=40.0%), while those from the United States valued the waiting time (weighted importance=31.5%) the most. Respondents from China preferred the emergency department (coefficient=0.973, reference level: online consultation) and fever clinic (a special clinic for the treatment of fever patients for the prevention and control of acute infectious diseases in China; coefficient=0.974, reference level: online consultation), while those from the United States preferred private clinics (general practices; coefficient=0.543, reference level: online consultation). Additionally, shorter waiting times, COVID-19 nucleic acid testing arrangements, higher reimbursement rates, and lower costs were always preferred.

Conclusions

Improvements in the availability of COVID-19 testing and medical professional skills and increased designated health care facilities may help boost potential health care seeking during COVID-19 and prevent unrecognized community spreading of SARS-CoV-2 in China and the United States. Moreover, to better prevent future waves of pandemics, identify undiagnosed patients, and encourage those undiagnosed to seek health care services to curb the pandemic, the hierarchical diagnosis and treatment system needs improvement in China, and the United States should focus on reducing diagnosis costs and raising the reimbursement rate of medical insurance.

Development trend of primary healthcare after health reform in China: a longitudinal observational study

OBJECTIVES

Reconstructing the primary healthcare system is the focus of the new round of Chinese health reform. Nevertheless, there have been few studies focusing on the strengthening of primary healthcare in Chinese health system.

DESIGN

This study was a longitudinal observational study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The data of this study came from China Health Statistical Yearbook (2009-2018). We evaluated the development of primary healthcare based on the absolute values of health resources allocation and health service provision and evaluated the status of primary healthcare throughout the health system based on the composition ratios of the indicators across the health system. The Cochran-Armitage trend test and linear trend test were used to identify the indicators' trends over time.

RESULTS

From 2009 to 2018, the amounts of health resources allocation and health service provision of Chinese primary healthcare institutions showed a significant upward trend (p<0.001). However, compared with the indicators in 2009, excepting that the proportion of grants from the government in the whole health system has an upward trend, the proportions of other indicators had an escalating trend in 2018 by 3.66% for practicing (assistant) physicians, by 2.69% for nurses, by 3.99% for total revenues, by 5.87% for beds, by 8.39% for outpatient visits.

CONCLUSION

The primary healthcare system has developed rapidly, but its development speed lagged behind the entire health system, resulting in the weakening of its actual functions, which is not in line with the goal of health reform. The government should be more aware of the importance of primary healthcare at all levels of local governments and ensure adequate financial input.

Patient preferences and attitudes towards first choice medical services in Shenzhen, China: a cross-sectional study

OBJECTIVE

This study aimed to explore the characteristics of Shenzhen residents' preferences and influencing factors regarding their first choice of medical institution at various medical levels, and to understand their attitudes towards community health services.

DESIGN

Cross-sectional survey.

PARTICIPANTS

A total of 1612 participants at least 18 years of age were randomly sampled with stratification among 10 districts in Shenzhen. Data were gathered through a self-designed questionnaire. The effective questionnaire response rate was 93.05%. All patients participated in the study voluntarily, provided written informed consent and were able to complete the questionnaire.

MAIN OUTCOME MEASURES

We measured and compared the participants' expected and actual preferences and influencing factors regarding their first choice of medical service at various medical levels.

RESULTS

More than 50% of the participants preferred municipal and district hospitals as their first choice, and 27.5% chose medical institutions according to specific circumstances. Univariate analysis indicated that age, education, income, medical insurance, housing conditions and registered permanent residence were significantly associated with the actual and expected preferred first medical institution. The main factors influencing participants' actual and expected preferred medical institution differed. With the actual preferred first medical institution as the dependent variable, education, monthly income, medical technology, convenience and providers' service attitude and medical ethics were the main factors (χ²=212.63, p<0.001), whereas with the expected preferred first medical institution as the dependent variable, occupation, Shenzhen registered permanent residence, education and medical technology were the main factors (χ²=78.101, p<0.001).

CONCLUSION

The main factors influencing participants' preferred medical institution and their actual first visit differed. Patients with high education or income or registered permanent residence preferred high-level medical institutions for the first visit.

The burden and trend of gastric cancer and possible risk factors in five Asian countries from 1990 to 2019

The burdens and trends of gastric cancer are poorly understood, especially in high-prevalence countries. Based on the Global Burden of Disease Study 2019, we analyzed the incidence, death, and possible risk factors of gastric cancer in five Asian countries, in relation to year, age, sex, and sociodemographic index. The annual percentage change was calculated to estimate the trends in age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR). The highest ASIR per 100,000 person-years in 2019 was in Mongolia [44 (95% uncertainty interval (UI), 34 to 55)], while the lowest was in the Democratic People’s Republic of Korea (DPRK) [23 (95% UI, 19 to 29)]. The highest ASDR per 100,000 person-years was in Mongolia [46 (95% UI, 37 to 57)], while the lowest was in Japan [14 (95% UI, 12 to 15)]. Despite the increase in the absolute number of cases and deaths from 1990 to 2019, the ASIRs and ASDRs in all five countries decreased with time and improved sociodemographic index but increased with age. Smoking and a high-sodium diet were two possible risk factors for gastric cancer. In 2019, the proportion of age-standardized disability-adjusted life-years attributable to smoking was highest in Japan [23% (95% UI, 19 to 28%)], and the proportions attributable to a high-sodium diet were highest in China [8.8% (95% UI, 0.21 to 33%)], DPRK, and the Republic of Korea. There are substantial variations in the incidence and death of gastric cancer in the five studied Asian countries. This study may be crucial in helping policymakers to make better decisions and allocate appropriate resources.

Patients' Willingness of First Visit in Primary Medical Institutions and Policy Implications: A National Cross-Sectional Survey in China

Background

The Chinese hierarchical treatment system expects patients to first visit primary medical institutions (PMIs), and patients' willingness determined their utilization of primary health care. The aim of this study was to explore the factors associated with patients' willingness to make their first visit to PMIs.

Methods

We employed multistage stratified sampling and convenience sampling to administer questionnaires to 1,507 patients in Beijing, Qinghai, and Fujian. Patients' willingness of first visit in PMIs was analyzed using Chi-square test and binary logistic regression.

Results

Of the 1,507 participants in the survey, 55.1% were willing to make their first visit in PMIs. Fewer patients in Beijing (17.6%) are willing to make their first visit in PMIs than those in Qinghai (71.9%) and Fujian provinces (72.0%). Binary logistic regression analysis revealed that higher recognition of the community first visit policy and higher satisfaction with the medical technology of PMIs are associated with patients' willingness of first visit in PMIs.

Conclusions

Due to differences in local economic conditions, medical resources, and policy formulation, there are differences among provinces in patients' willingness of first visit in PMIs. To increase patients' rate of visits in PMIs, it is important to improve service capacity and quality of PMIs and change residents' attitudes for PMIs.

Analysis on the willingness and influencing factors of choosing primary healthcare institutions among patients with chronic conditions in China: a cross-sectional study

OBJECTIVE

To assess the willingness and factors influencing the choice of primary healthcare (PHC) institutions among patients with chronic conditions in China.

DESIGN

A nationwide population-based study with binary logistic regression was conducted and used to estimate the ORs of the influencing factors of health-seeking at PHC institutions using the Anderson model as a theoretical framework.

SETTING

The China Family Panel Studies (CFPS) database.

PARTICIPANTS

The study sample included 7967 patients with chronic conditions identified from the 2016 and 2018 CFPS databases.

RESULTS

From 2016 to 2018, the rate of choosing PHC institutions for patients with chronic conditions dropped from 51.0% to 47.7%. The logistic regression results showed that patients with low family income (OR value of >60 000 group was 0.57, 95% CI 0.43 to 0.74), low education level (OR value of bachelor degree or above was 0.54, 95% CI 0.35 to 0.83;), older age (OR value of >65 group was 1.31, 95% CI 1.08 to 1.60;), hypertension and diabetes (OR 1.26, 95% CI 1.13 to 1.41), living in rural areas (OR value of urban was 0.47, 95% CI 0.38 to 0.60), immigrating from rural to urban areas (OR 1.64, 95% CI 1.26 to 2.13), reporting good health (OR value of very good was 1.33, 95% CI 1.05 to 1.68) and those from areas with a high proportion of PHC institutions (OR 1.05, 95% CI 1.02 to 1.07) were more inclined to choose PHC institutions. Conversely, patients with urban employee health insurance (OR 0.62, 95% CI 0.49 to 0.80) and more than one chronic disease (OR 0,83, 95% CI 0.75 to 0.92) preferred choosing a hospital.

CONCLUSIONS

The patients' willingness to choose PHC institutions was low. The health-seeking preference of patients with chronic conditions is derived from medical needs and is influenced by the predisposing factors and tendencies of enabling resources. Measures should be taken to improve the capacity of PHC institutions.

A contextual exploration of healthcare service use in urban slums in Nigeria

Introduction

Many urban residents in low- and middle-income countries live in unfavorable conditions with few healthcare facilities, calling to question the long-held view of urban advantage in health, healthcare access and utilization. We explore the patterns of healthcare utilization in these deprived neighborhoods by studying three such settlements in Nigeria.

Methods

The study was conducted in three slums in Southwestern Nigeria, categorized as migrant, indigenous or cosmopolitan, based on their characteristics. Using observational data of those who needed healthcare and used in-patient or out-patient services in the 12 months preceding the survey, frequencies, percentages and odds-ratios were used to show the study participants’ environmental and population characteristics, relative to their patterns of healthcare use.

Results

A total of 1,634 residents from the three slums participated, distributed as 763 (migrant), 459 (indigenous) and 412 (cosmopolitan). Residents from the migrant (OR = 0.70, 95%CI: 0.51 to 0.97) and indigenous (OR = 0.65, 95%CI: 0.45 to 0.93) slums were less likely to have used formal healthcare facilities than those from the cosmopolitan slum. Slum residents were more likely to use formal healthcare facilities for maternal and perinatal conditions, and generalized pains, than for communicable (OR = 0.50, 95%CI: 0.34 to 0.72) and non-communicable diseases (OR = 0.61, 95%CI: 0.41 to 0.91). The unemployed had higher odds (OR = 1.45, 95%CI: 1.08 to 1.93) of using formal healthcare facilities than those currently employed.

Conclusion

The cosmopolitan slum, situated in a major financial center and national economic hub, had a higher proportion of formal healthcare facility usage than the migrant and indigenous slums where about half of families were classified as poor. The urban advantage premise and Anderson behavioral model remain a practical explanatory framework, although they may not explain healthcare use in all possible slum types in Africa. A context-within-context approach is important for addressing healthcare utilization challenges in slums in sub-Saharan Africa.

Stated preferences for family doctor contract services: a survey of the rural elderly in Anhui Province, China

OBJECTIVE

A number of factors contribute to the utilisation of family doctor contract services (FDCS) in China. This study aims to measure the preferences of the elderly for the FDCS and identify the key factors (and their relative importance) that may guide policymakers in more accurately providing the FDCS.

PARTICIPANTS AND METHODS

A discrete choice experiment was performed to elicit the preferences for FDCS among the rural elderly in China. Attributes and levels were established based on qualitative methods. Four attributes were included: service type, service package, physician's reputation and annual contract costs. A D-efficient design was used to create a set of profiles that represented FDCS. The survey was conducted face to face using a sample of participants aged 60 and above in rural areas of Anhui Province. The data were analysed using a latent class logit (LCL) model.

RESULTS

A total of 545 valid questionnaires were included in the analysis. The average age of the participants was 69.44 (SD 5.80). Two latent classes were identified with the LCL model. All four attributes proved statistically significant at the level of both the population mean and the two classes. The rural elderly showed a preference for FDCS with a relatively good reputation, lower annual contract costs, the basic service with the add-on of chronic disease service and home visit. Age, gender, education, self-reported health status and the number of chronic diseases were found to be associated with latent class membership.

CONCLUSION

In this study, the physician's reputation had the largest impact on the rural elderly's choice of FDCS. Policy recommendations included the need to strengthen family doctor team training, devote greater attention to improving the family doctor's medical skills and service approaches, and increased FDCS efficiency for the care of the rural elderly.

Judicial judgment and media sensation of violence against medical staff in China: A fuzzy set qualitative comparative analysis (fsQCA)

INTRODUCTION

Violence against medical staff has been prevalent in China over the past two decades. Although Chinese authorities have released many laws and regulations to protect medical staff from violence since 2011, the legal approach alone is unlikely to resolve this complex issue. In particular, several cases of violence against medical staff in China have caused great media sensation.

METHOD

This paper proposes an integrated model that combines the environmental stimuli theory, broken windows theory, and rational choice theory. It adopts the fuzzy set qualitative comparative analysis (fsQCA) to untangle the causal relationship between violence against medical staff, media sensation, and judicial judgment. We examined reports of medical violence on media and news websites from January 1, 2010, to January 31, 2020, and selected 50 cases with detailed information for this study.

RESULTS

The results show that each condition is not sufficient for the absence of judicial judgment, but when combined, they are conducive to the outcome. The conditions of hospital level, medical cost, and media sensation play important roles. The providers, patients, and environmental factors are indicators of inadequate or lack of judicial judgment, which corresponds to previous expectations.

CONCLUSIONS

The integrated model greatly enriches the extant theories and literature, and also yields implications for preventing violence against medical staff in China. We suggest that sustainable and innovative healthcare reform should be initiated. For example, public hospitals should remain the cornerstone of national public health security. Medical staff in public hospitals must be regarded as "civil servants". Therefore, the current legal system should be improved. The media should objectively report events concerning medical staff and improve public healthcare knowledge.

Measurements of quality of village-level care and patients' healthcare-seeking behaviors in rural China

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.

Outpatient Antibiotic Prescribing Patterns and Appropriateness for Children in Primary Healthcare Settings in Beijing City, China, 2017-2019

(1) Background: Few studies have focused on antibiotic use and appropriateness in children in primary health institutions (PHIs). This study aimed to identify the patterns and appropriateness of antibiotic use for children in PHIs in Beijing, China. (2) Methods: Outpatient prescriptions of 327 PHIs from 2017 to 2019 for patients <18 years old were collected. Prescriptions were described using quantity indicators. Antibiotics were categorized according to ATC classification J01 and Access, Watch, Reserve grouping. Appropriateness was reviewed by experts using three subtypes of irrational prescriptions (irregular, inappropriate, and abnormal). (3) Results: 20,618 prescriptions were collected in total. The antibiotic prescription rate (APR) was 15.1% (N = 3113). Among antibiotic prescriptions, J01FA Macrolides were the most used (N = 1068, 34.9%). The Watch group constituted 89.0% (N = 2818) of total antibiotic use. Bronchitis (N = 1059, 35.2%) was the most common diagnosis. A total of 292 instances of irrational antibiotic use were identified, with inappropriate prescriptions being the most prevalent subtype (N = 233, 79.8%). (4) Conclusion: Although APR for children in PHIs in Beijing was relatively low, the pattern of antibiotic use differed from other countries. Further studies are needed to optimize antibiotic use for children in PHIs under different levels of economic development.

Cancer incidence, mortality, and burden in China: a time-trend analysis and comparison with the United States and United Kingdom based on the global epidemiological data released in 2020

BACKGROUND

Cancer is one of the leading causes of death and a main economic burden in China. Investigating the differences in cancer patterns and control strategies between China and developed countries could provide reference for policy planning and contribute to improving cancer control measures. In this study, we reviewed the rates and trends of cancer incidence and mortality and disability-adjusted life year (DALY) burden in China, and compared them with those in the United States (US) and the United Kingdom (UK).

METHODS

Cancer incidence, mortality, and DALY data for China, US and UK were obtained from the GLOBOCAN 2020 online database, Global Burden of Disease (GBD) 2019 study, and Cancer Incidence in Five Continents plus database (CI5 plus). Trends of cancer incidence and mortality in China, US, and UK were analyzed using Joinpoint regression models to calculate annual percent changes (APCs) and identify the best-fitting joinpoints.

RESULTS

An estimated 4,568,754 newly diagnosed cancer cases and 3,002,899 cancer deaths occurred in China in 2020. Additionally, cancers resulted in 67,340,309 DALYs in China. Compared to the US and UK, China had lower cancer incidence but higher cancer mortality and DALY rates. Furthermore, the cancer spectrum of China was changing, with a rapid increase incidence and burden of lung, breast, colorectal, and prostate cancer in addition to a high incidence and heavy burden of liver, stomach, esophageal, and cervical cancer.

CONCLUSIONS

The cancer spectrum of China is changing from a developing country to a developed country. Population aging and increase of unhealthy lifestyles would continue to increase the cancer burden of China. Therefore, the Chinese authorities should adjust the national cancer control program with reference to the practices of cancer control which have been well-established in the developed countries, and taking consideration of the diversity of cancer types by of different regions in China at the same time.

COVID-19 as an opportunity to reveal the impact of large hospital expansion on the healthcare delivery system: evidence from Shanghai, China

Background

The expansion of large hospitals on the medical service market's supply side has always been an intensely debated topic. In this study, we conducted statistical analysis on the natural shock of COVID-19 to investigate whether the large hospitals will draw health demand from the small hospitals when a supply capacity surplus is present, a phenomenon otherwise known as the "siphon effect".

Methods

We collected the monthly hospital income and service data, including outpatient income, inpatient income, number of visits, and discharges, from all public hospitals, from January 2018 to July 2020 in Shanghai. A difference-in-differences (DIDs) method was applied to analyze the existence of the large hospitals' siphon effect by identifying the differences in the healthcare service market share change between large and small hospital groups at the height of pandemic (February and March, 2020) and the postpandemic period (April and May, 2020). Case mix index (CMI) was used to verify whether the reduction in healthcare amount and market share of small hospitals was due to unnecessary care.

Results

In total, 156 public hospitals, including 46 large hospitals and 110 small hospitals, with an average number of beds of 1,079.21 and 345.25, respectively, were involved in this study. At the height of the pandemic, the healthcare service volume and revenue in public hospitals in Shanghai experienced a sharp decline, especially for large hospitals and inpatient services. Compared to small hospitals at the height of the COVID-19 pandemic, large hospitals' market share decreased significantly in outpatient and inpatient services for overall and nonlocal patients (P<0.05). During the postpandemic period, large hospitals' market share increased significantly in outpatient and inpatient services for overall and local patients (P<0.05). This increase was more substantial in inpatient services.

Conclusions

Under conditions of the COVID-19 pandemic of higher care-seeking costs in the large hospitals, some of the healthcare services typically provided by large hospitals were then supplied by small hospitals. Furthermore, the siphon effect of large hospitals could be clearly observed when a supply capacity surplus was present and external constraint on patients' care-seeking behavior was absent.

Impacts of the COVID-19 Pandemic on Public Hospitals of Different Levels: Six-Month Evidence from Shanghai, China

Purpose

Hospitals suffered from a precipitous loss of medical service globally due to COVID-19. The tragedy paradoxically produced an opportunity to investigate the patterns of change in medical services and revenue in hospitals at different levels when faced with a natural shock. This study aims to examine the effects of the COVID-19 pandemic in the first half of 2020 on hospital operation in Shanghai.

Methods

We obtained monthly characteristic and operational data of public hospitals (N=156) from January 1, 2018, to July 31, 2020, in Shanghai from the China Statistical Survey of Health Resources and Services Program. We constructed a set of difference-in-differences models to investigate the pandemic (from February 1 to March 31, 2020) and post-pandemic (from April 1 to July 31, 2020) effects on operational outcomes in hospitals of different levels, including outpatient and inpatient visits, outpatient and inpatient revenue, as well as the differential effects on local and nonlocal patients.

Results

There were 46 tertiary hospitals and 110 non-tertiary hospitals involved in this study. Compared to a non-tertiary hospital during the COVID-19 pandemic, a tertiary hospital averagely experienced substantially more significant losses in outpatient visits (57.91 thousand, p < 0.01), inpatient visits (1.93 thousand, p < 0.01), outpatient revenue (18.88 million RMB, p < 0.01), and inpatient revenue (30.65 million RMB, p < 0.01) monthly. Compared to a non-tertiary hospital in the post-pandemic period, a tertiary hospital averagely lost more outpatient visits (18.02 thousand, p < 0.01) from all patients and inpatient visits (0.15 thousand, p < 0.01) from nonlocal patients, but was associated with higher inpatient revenue (2.24 million RMB, p < 0.01) from all patients and outpatient revenue (0.87 million RMB, p < 0.01) from nonlocal patients monthly.

Conclusion

Medical service and revenue for public hospitals in Shanghai dropped precipitously during the COVID-19 pandemic, but mainly recovered after the pandemic. Compared to non-tertiary hospitals, medical services and revenue in tertiary hospitals experienced more substantial reduction during the pandemic but had a faster recovery that maintained longer during the post-pandemic period.

Bypassing primary care facilities: health-seeking behavior of middle age and older adults in China

BACKGROUND

With economic development, aging of the population, improved insurance coverage, and the absence of a formal referral system, bypassing primary healthcare facilities appear to have become more common. Chinese patients tend to visit the secondary or tertiary healthcare facilities directly leading to overcrowding at the higher-level facilities. This study attempts to analyze the factors associated with bypassing primary care facilities among patients of age 45 years or older in China.

METHODS

Random effects logistic models were used to examine bypassing of primary health facilities among rural-urban patients. Data from 2011 to 2015 waves of the China Health and Retirement Longitudinal Study were used.

RESULTS

Two in five older patients in China bypass primary health centers (PHC) to access care from higher-tier facilities. Urban patients were nearly twice as likely as rural patients to bypass PHC. Regardless of rural-urban residence, our analysis found that a longer travel time to primary facilities compared to higher-tier facilities increases the likelihood of bypassing. Patients with higher educational attainment were more likely to bypass PHCs. In rural areas, patients who reported their health as poor or those who experienced a recent hospitalization had a higher probability of bypassing PHC. In urban areas, older adults (age 65 years or older) were more likely to bypass PHC than the younger group. Patients with chronic conditions like diabetes also had a higher probability of bypassing.

CONCLUSIONS

The findings indicate the importance of strengthening the PHCs in China to improve the efficiency and effectiveness of the health system. Significantly lower out-of-pocket costs at the PHC compared to costs at the higher tiers had little or no impact on increasing the likelihood of utilizing the PHCs. Improving service quality, providing comprehensive person-centered care, focusing on family health care needs, and providing critical preventive services will help increase utilization of PHCs as well as the effectiveness and efficiency of the health system.