Effect of integrated urban and rural residents medical insurance on the utilisation of medical services by residents in China: a propensity score matching with difference-in-differences regression approach

Patient preferences and willingness to pay for central venous access devices in breast cancer: A multicenter discrete choice experiment

BACKGROUND

Despite being a significant management decision in clinical or nursing practice, there is limited understanding of the preferences regarding risks, benefits, costs, and other attributes of patients with breast cancer when selecting peripherally inserted central catheters or totally implanted ports. The objective of this study is to investigate the preferences of patients with breast cancer who require chemotherapy when selecting an optimal central venous access device.

METHODS

Data on patients' preferences for central venous access devices were collected using a face-to-face discrete choice experiment from the oncology departments of three public hospitals in China representing the eastern (Zhejiang province), central (Henan province), and western (Sichuan province) regions. The study used six attributes to describe the preferences of breast cancer patients for central venous access devices, including out-of-pocket cost, limitations in activities of daily living, catheter maintenance frequency, risk of catheter-related thrombosis, risk of catheter-related infection, and size of incision. Data were analyzed using a conditional logit model and mixed logit model. The marginal willingness to pay (mWTP) was calculated by assessing the ratio of the preference for other attributes to the preference for out-of-pocket cost.

RESULTS

A total of 573 respondents completed the survey. The discrete choice experiment results showed that respondents strongly preferred a central venous access device with a catheter maintenance frequency of one time a month (vs four times a month, β = 1.188, p < 0.001), the lower risk of catheter-related thrombosis (2 % vs 10 %, β = 1.068; p < 0.001) and lower risk of catheter-related infection (2 % vs 8 % risk: β = 0.824; p < 0.001). Respondents were willing to pay CNY ¥11,968.1 (US$1776.5) for a central venous access device with a catheter maintenance frequency of one time a month rather than four times a month, ¥10,753.6 (US$1596.2) for a central venous access device with 2 % thrombosis risk over one with 10 %, and ¥8302.0 (US$1232.3) for a central venous access device with 2 % infection risk over one with 8 %. Respondents with longer travel time to the hospital, younger than 50 years old, and with urban employee basic medical insurance were willing to pay more for an improvement in the attributes.

CONCLUSIONS

These findings suggest that patients with breast cancer were mainly concerned with the out-of-pocket cost, catheter maintenance frequency, risk of catheter-related thrombosis and risk of catheter-related infection when choosing a central venous access device for the delivery of chemotherapy. In clinical or nursing practice, when making central venous access device recommendation for young patients and those who live far from hospitals, totally implanted ports may be a preferable choice.

Patients' and Care Professionals' Evaluation of the Effect of a Hospital Group on Integrated Care in Chinese Urban Health Systems: A Propensity Score Matching and Difference-in-differences Regression Approach

BACKGROUND

A hospital group is an organizational integration strategy that has recently been widely implemented in Chinese urban health systems to promote integrated care. This study aims to evaluate the effect of hospital group on integrated care from the perspectives of both patients and care professionals.

METHODS

Two cross-sectional surveys were conducted in Shenzhen city of China, in June 2018 and July 2021. All thirty Community Health Stations (CHSs) in the hospital group were included in the intervention group, with 30 CHSs in the same district selected as the control group by simple random sampling. All care professionals within both the intervention and the control groups were invited to participate in the surveys. Twelve CHSs were selected from 30 CHSs in the intervention and the control groups by simple random sampling, and 20 patients with type 2 diabetes mellitus (T2DM) were selected from each of these selected CHSs to participate in the survey by systematic sampling. The Rainbow Model of Integrated Care-Measurement Tool (Chinese version) was used to assess integrated care. Propensity score matching and difference-in-differences regression (PSM-DID) were used to evaluate the effect of the hospital group on integrated care.

RESULTS

After matching, 528 patients and 1896 care professionals were included in the DID analysis. Results from care professionals indicated that the hospital group significantly increased technical competence of the health system by 0.771 points, and cultural competence by 1.423 points. Results from patients indicated that the hospital group significantly decreased organizational integration of the health system by 0.649 points.

CONCLUSION

The results suggests that the effect of the hospital group on integrated care over and above routine strategies for integrated care is limited. Therefore, it is necessary to pay attention to implementing professional, clinical and other integration strategies beyond establishing hospital groups, in urban Chinese health systems.

Does the integration of urban and rural health insurance influence the functional limitations of the middle-aged and elderly in rural China?

In January 2016, the Chinese government integrated the two systems of urban resident basic medical insurance and new rural cooperative medical system to establish a unified Urban and Rural Resident Medical Insurance. The integration of medical insurance is purported to enhance access for the rural population; however, a dearth of literature exists regarding its effect on functional impairment among middle-aged and elderly residing in rural areas. This study aims to evaluate the impact of urban-rural health insurance integration on functional limitation among middle-aged and elderly individuals in rural China. A longitudinal survey was conducted among 7855 middle-aged and elderly individuals in rural China. Using a nonequivalent control group pretest-posttest design, we exploit these policy changes to evaluate their impact on middle-aged and elderly individuals' functional limitation. The results showed that the integration of urban and rural health insurance systems was significantly associated with reduced functional limitation (Odds ratio .742; 95%CI 0.603, 0.914) among middle-aged and elderly individuals in rural China. Our findings also indicate that prevalent behaviors such as tobacco use, and alcohol consumption may exacerbate functional limitation among middle-aged and elderly individuals. These findings suggest that the integration of urban and rural health insurance systems can have a positive impact on the functional limitation of middle-aged and elderly individuals in rural China and could be an important factor in improving the health and well-being of middle-aged and elderly individuals in rural areas.

Impacts of unifying urban and rural residents' medical insurance on the hospitalisation expenses of rural patients in eastern China: an interrupted time series analysis

OBJECTIVES

This study evaluated the impact of the Urban and Rural Residents' Basic Medical Insurance scheme on hospitalisation expenses of rural patients in eastern China, which unified separate healthcare systems for urban and rural residents.

DESIGN

Monthly hospitalisation data from municipal and county hospitals were collected from the local Medicare Fund Database, covering the period from January 2018 to December 2021. The unification of insurance between urban and rural patients was implemented at different times for county and municipal hospitals. An interrupted time series analysis was used to assess the immediate and gradual effects of the integrated policy on the total medical expenses, out-of-pocket (OOP) expenses and effective reimbursement rate (ERR) among rural patients.

SETTING AND PARTICIPANTS

This study included 636 155 rural inpatients over 4 years in Xuzhou City, Jiangsu Province, China.

RESULTS

In January 2020, the policy of urban and rural medical insurance was initially integrated in county hospitals, after which the ERR decreased at a monthly rate of 0.23% (p=0.002, 95% CI -0.37% to -0.09%) compared with the preintervention period. After the insurance systems were unified in municipal hospitals in January 2021, OOP expenses decreased by ¥63.54 (p=0.002, 95% CI -102.48 to -24.61) and the ERR increased at a monthly rate of 0.24% (p=0.029, 95% CI 0.03% to 0.045%).

CONCLUSIONS

Our results suggest that the unification of urban and rural medical insurance systems was an effective intervention to reduce the financial burden of illness for rural inpatients, especially OOP expenses for hospitalisation in municipal hospitals.

Does the immediate reimbursement of medical insurance reduce the socioeconomic inequality in health among the floating population? Evidence from China

BACKGROUND

Enhancing health intervention for floating populations has become an essential aspect of public health around the world. China launched a policy reform aimed at implementing immediate reimbursement for trans-provincial inpatient treatments. The objective of this study was to investigate the effects of this policy change on socioeconomic inequality in health among the floating population.

METHODS

This study used two waves of individual-level data from the China Migrants Dynamic Survey (CMDS) collected in 2017 and 2018 as well as administrative hospital data at the city level. The sample included 122061 individuals and 262 cities. Under a quasi-experimental research design, we built up the framework to employ the generalized and multi-period difference-in-differences estimation strategy. We used the number of qualified hospitals that could provide immediate reimbursement to represent the degree and intensity of the implementation of this policy change. We also calculated the Wagstaff Index (WI) to measure socioeconomic inequality in health.

RESULTS

This policy change and income level had a negative joint impact on the health status of floating population (odds ratio = 0.955, P < 0.01), that is, the lower the income, the better the number of qualified hospitals' effect on health improvement. Furthermore, as the number of qualified tertiary hospitals increased, the health inequality would decrease significantly on average at the city level (P < 0.05). In addition, inpatient utilization as well as total expenditure and reimbursement significantly improved after the policy change, and the magnitude of increase was greater in the relatively lower-income group (P < 0.01). Finally, only inpatient spending could obtain immediate reimbursement in the early stage, thus, compared with primary care, these impacts were greater in tertiary care.

CONCLUSIONS

Our study revealed that after the implementation of immediate reimbursement, the floating population could obtain greater and more timely reimbursement, which significantly increased its inpatient utilization, promoted health, and reduced the health inequality caused by socioeconomic factors. These results suggest that a more accessible and friendly medical insurance scheme should be promoted for this group.

The impact of integrated urban and rural resident basic medical insurance on health service equity: Evidence from China

Background

Many countries and regions worldwide are improving their healthcare systems through the integration and unification of health insurance programs covering different groups of people. In China, the past 10 years has been the time when Chinese government promote the Urban and Rural Residents Basic Medical Insurance (URRBMI) by integrating the Urban Residents' Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS).

Objectives

To evaluate the impact of the URRBMI on equity in relation to health services.

Methods

The quantitative data used in this study were obtained from the CFPS 2014–2020 database, and all respondents with health insurance type UEBMI, URBMI, and NRCMS were included. UEBMI respondents were set as the control group and URBMI or NRCMS as the intervention group, and a DID method model was used to analyze the impact of integrating health insurance on health service utilization, costs and health status. Heterogeneity analysis was also conducted after stratifying the sample according to income level and chronic disease status. This was done to investigate whether there were differences in the effects of the integrated health insurance program across different social groups.

Results

The implementation of URRBMI is found to be associated with a significant increase in inpatient service utilization (OR = 1.51, P &lt; 0.01) among rural Chinese residents. Regression results by income stratum show that the utilization of inpatient services increased in rural areas for high-, middle- and low-income groups, with the fastest increase (OR = 1.78, P &lt; 0.05) emerging for low-income groups. Analysis by chronic disease status shows that rural residents with chronic disease are associated with a higher increase in hospitalization rates (OR = 1.64, P &lt; 0.01).

Conclusion

The implementation of URRBMI is found to have improved health insurance's ability to withstand risks and effectively improve access to health services for rural residents. In this regard, it can be considered as playing a positive role in bridging the gap in health service utilization between rural and urban areas and in improving regional equity.

Multidimensional poverty of persons with disabilities in China: An analysis of poverty reduction effect of employment services

Introduction

Disability is a global public health problem, and poverty due to illness and disability has always been a major problem and challenge for global poverty governance. In order to eradicate poverty, China has carried out a series of welfare reforms and employment interventions for people with disabilities. The purpose of this study is to examine the levels of multidimensional poverty of persons with disabilities aged 16-59 in China and the poverty reduction effect of employment services.

Methods

The Alkire-Foster (AF) method is applied to measure and decompose the multidimensional poverty index (MPI) of people with disabilities in this study. In order to make the results more robust, ordinary least squares (OLS) regression and the combination of propensity score matching and difference-in-differences (PSM-DID) are used to study the effect of employment services on multidimensional poverty of the disabled.

Results

The results show that among persons with disabilities aged 16-59, about 90% are deprived in at least one dimension, and about 30% are in a state of severe multidimensional poverty until 2019. The contributions of deprivation in the dimensions of education and social participation are remarkably higher than dimensions of economy, health and insurance. In addition, employment services have a significant improvement effect on multidimensional poverty, which is reflected not only in the economic dimension, but also in the dimensions of education, insurance and social participation.

Conclusion

People with disabilities are generally in multidimensional poverty in China, and their abilities in learning and social integration are seriously inadequate. Employment services have played a great role in improving poverty, but the improvement has been different in different dimensions and different disability categories. These findings provide important evidence for recognizing multidimensional poverty of persons with disabilities and the poverty reduction effect of employment services, which will help to formulate more reasonable public policies to eradicate poverty.

Effects of Urban and Rural Resident Basic Medical Insurance on Healthcare Utilization Inequality in China

Objectives: This study aims to evaluate the effects of Urban and Rural Resident Basic Medical Insurance (URRBMI) integration on healthcare utilization and explore the contribution of URRBMI to healthcare utilization inequality among middle-aged and older adults. Methods: Using data from the China Health and Retirement Longitudinal Study (CHARLS) 2011-2018. The difference-in-difference model, concentration index (CI), and decomposition method were adopted. Results: The results suggested that the probability of outpatient visits and the number of outpatient visits had decreased by 18.2% and 10.0% respectively, and the number of inpatient visits had increased by 3.6%. However, URRBMI had an insignificant effect on the probability of inpatient visits. A pro-poor inequality for the treatment group was observed. The decomposition revealed that the URRBMI contributed to the pro-poor inequality in healthcare utilization. Conclusion: The findings suggest that URRBMI integration has decreased outpatient care utilization and improved the number of inpatient visits. While the URRBMI has improved healthcare utilization inequality, some challenges still exist. Comprehensive measures should be taken in the future.

Trends in Socio-economic Inequality in Smoking Among Middle-aged and Older Adults in China: Evidence From the 2011 and 2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Socio-economic inequalities in smoking and related health problems are a public health concern worldwide. To support the development of effective tobacco control policies, this study examines trends in smoking rates according to socio-economic status (SES) in China.

AIMS AND METHODS

We analyzed data from repeated cross-sectional China Health and Retirement Longitudinal Study (CHARLS) on adults aged ≥45 years for the years 2011 and 2018, which involved 16 471 participants in 2011 and 19 367 in 2018. We then estimated the SES of individuals based on four types of wealth-related variables, namely, education, occupation, household characteristics, and durable consumer goods. Principal-component analysis was conducted to measure SES, and the Erreygers normalised concentration index (ECI) was used to calculate socio-economic inequality in current smoking by gender, age, and region.

RESULTS

The overall ECI (95% confidence interval) for women was -0.042 (-0.054 to -0.031) and -0.038 (-0.047 to -0.029) for 2011 and 2018, respectively. The ECI (95% confidence interval) for men was -0.077 (-0.101 to -0.050) and -0.019 (-0.042 to 0.005) for 2011 and 2018, respectively. The inequality in smoking by SES for adults aged < 60 years in the Northeast region increased during 2011-2018, from -0.069 (-0.144 to 0.006) to -0.119 (-0.199 to -0.038) for women and from 0.009 (-0.115 to 0.132) to -0.164 (-0.296 to -0.032) for men.

CONCLUSIONS

smoking inequality by socio-economic among adults aged ≥45 years declined in recent years in China. However, smoking inequality by SES increased in other population groups.

IMPLICATIONS

Our research indicated that socio-economic inequality of current smoking among residents aged 45 years and older declined in 2018 when compared with 2011 numbers, particularly for men aged ≥ 60 years. Women in the Northeast region displayed more significant smoking inequality by SES than women in other regions did. During the study period, there was an increase in inequality in smoking by SES for adults aged < 60 years in the Northeast region. Thus, tobacco control policies and interventions should be targeted at high-risk subpopulations with lower SES, particularly in Northeast China.

The impacts of the National Medication Price-Negotiated Policy on the financial burden of cancer patients in Shandong province, China: an interrupted time series analysis

BACKGROUND

In order to further regulate the price of anticancer medication and alleviate the financial burden of cancer patients, the Chinese government implemented the National Medication Price-Negotiated Policy (NMPNP) in 2017. This study aims to assess the impacts of implementation of the NMPNP on the access of anticancer medication and the financial burden for cancer patients in Shandong province, and to provide evidence to inform the design of similar policies in other developing countries.

METHODS

A quasi-experiment design of an interrupt time series analysis was conducted. The month of September 2017 was taken as the intervention point when the Shandong Provincial Reimbursement Drug Lists was updated based on the result of the NMPNP in 2017. The data used were the aggregated monthly claim data of cancer patients from 2016 to 2021, which were obtained from four cities in Shandong province. The outpatient and inpatient care visits per capita, proportion of OOP expenditure and medication costs in outpatient and inpatient medical costs were used as outcome variables. A segmented regression model was used to analyze the change of the access of anticancer medication and the financial burden for cancer patients.

RESULTS

The outpatient care visits per capita significantly decreased after the intervention. Compared to preintervention trend, the proportion of OOP expenditure in outpatient medical costs decreased by average 0.25 percentage point per month (p <  0.0001) after the intervention, however the proportion of OOP expenditure in inpatient medical costs increased by 0.02 percentage point per month (p = 0.76). Since the intervention, the proportion of medication costs in outpatient medical costs averagely rose by 0.28 percentage point (p <  0.0001), and its implementation caused the proportion of medication costs in inpatient medical costs averagely decreased 0.2 percentage point (p <  0.0001).

CONCLUSIONS

The NMPNP improved the access of anticancer medication, and relieved the financial burden of outpatient care. However, it did not effectively alleviate the financial burden of inpatient care. Additionally, the NMPNP impacted the behavior of the healthcare providers. The policymakers should closely monitor the change of providers behaviors, and dynamically adjust financial incentives policies of healthcare providers during the implementation of similar medication price negotiated policies.

Multimorbidity and catastrophic health expenditure: Evidence from the China Health and Retirement Longitudinal Study

Background

Population aging accompanied by multimorbidity imposes a great burden on households and the healthcare system. This study aimed to determine the incidence and determinants of catastrophic health expenditure (CHE) in the households of old people with multimorbidity in China.

Methods

Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2018, with 3,511 old people (≥60 years) with multimorbidity responding to the survey on behalf of their households. CHE was identified using two thresholds: ≥10% of out-of-pocket (OOP) health spending in total household expenditure (THE) and ≥40% of OOP health spending in household capacity to pay (CTP) measured by non-food household expenditure. Logistic regression models were established to identify the individual and household characteristics associated with CHE incidence.

Results

The median values of THE, OOP health spending, and CTP reached 19,900, 1,500, and 10,520 Yuan, respectively. The CHE incidence reached 31.5% using the ≥40% CTP threshold and 45.6% using the ≥10% THE threshold. It increased by the number of chronic conditions reported by the respondents (aOR = 1.293-1.855, p < 0.05) and decreased with increasing household economic status (aOR = 1.622-4.595 relative the highest quartile, p < 0.001). Hospital admissions over the past year (aOR = 6.707, 95% CI: 5.186 to 8.674) and outpatient visits over the past month (aOR = 4.891, 95% CI: 3.822 to 6.259) of the respondents were the strongest predictors of CHE incidence. The respondents who were male (aOR = 1.266, 95% CI: 1.054 to 1.521), married (OR = 1.502, 95% CI: 1.211 to 1.862), older than 70 years (aOR = 1.288-1.458 relative to 60-69 years, p < 0.05), completed primary (aOR = 1.328 relative to illiterate, 95% CI: 1.079 to 1.635) or secondary school education (aOR = 1.305 relative to illiterate, 95% CI: 1.002 to 1.701), lived in a small (≤2 members) household (aOR = 2.207, 95% CI: 1.825 to 2.669), and resided in the northeast region (aOR = 1.935 relative to eastern, 95% CI: 1.396 to 2.682) were more likely to incur CHE.

Conclusion

Multimorbidity is a significant risk of CHE. Household CHE incidence increases with the number of reported chronic conditions. Socioeconomic and regional disparities in CHE incidence persist in China.

Changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes in Beijing, China

BACKGROUND

China expanded health coverage to residents in informal economic sectors by the rural new cooperative medical scheme (NCMS) for rural population and urban resident basic medical insurance scheme (URBMI) for non-working urban residents. Fragmentation of resident social health insurance schemes exacerbated the health inequity and China started the integration of urban and rural resident medical insurance schemes since 2016. Beijing finished the insurance integration in 2017 and has been implementing a unified urban and rural resident basic medical insurance scheme (URRBMI) since the beginning of 2018. This study aims to examine changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes.

METHODS

We used household survey data from Beijing Health Services Survey in 2013 and 2018. Respondents who were 15 or older and covered by URBMI, NCMS or URRBMI were included in this study. Our study finally included 8,554 individuals in 2013 and 6,973 individuals in 2018, about 70% of which were rural residents in each year. Descriptive analysis was used to compare the healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure between different groups. A series of two-part regression models were used to analyze the changes of healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure.

RESULTS

From 2013 to 2018, urban-rural disparity in outpatient care utilization seemed widened because urban residents' utilization of outpatient care increased 131% while rural residents' utilization only increased 72%; both rural and urban residents' spending on outpatient care increased about 50%. Utilization of inpatient care changed little and poor residents still used significantly less inpatient care compared with the rich residents. Poor residents still suffered heavily catastrophic health expenditures.

CONCLUSION

From 2013 to 2018, residents' utilization of healthcare, especially outpatient care, increased in Beijing. Health insurance reforms increased residents' utilization of healthcare but failed to reduce their healthcare financial burden, especially for poor people. Our study advocates more pro-poor insurance policies and more efforts on the efficiency of health system.

Did the Integrated Urban and Rural Resident Basic Medical Insurance Improve Benefit Equity in China?

OBJECTIVES

The reform of merging 2 major health insurance schemes into Urban and Rural Resident Basic Medical Insurance (URRBMI) is recognized as a vital step to safeguard equal healthcare and benefit to each enrollee in China. Against this backdrop, this article aims to evaluate the impact of URRBMI integration on benefit and its contribution to benefit equity.

METHODS

The data of this study were derived from the China Health and Retirement Longitudinal Study 2011 and 2015. A total of 11 383 individuals were included in the final sample. Coarsened exact matching with difference-in-difference approach was firstly adopted to investigate the treatment effects of URRBMI on benefits. Next, the decomposition of concentration index (CI) was conducted to explore the contribution of URRBMI to benefit equity.

RESULTS

The coarsened exact matching with difference-in-difference results revealed that the consolidation of URRBMI has significantly improved outpatient benefit. The decomposition results showed that the contribution rates of URRBMI scheme to outpatient benefit rate (CI -0.0114), benefit probability (CI 0.0673), compensation fee (CI 0.0076), and reimbursement ratio (CI 0.0483) were 11.26%, -3.38%, -7.67%, and -0.81%, suggesting that this reform makes contribution to the propoor inequity in the outpatient benefit rate and relieves the prorich inequity in outpatient benefit probability and the degree of benefits.

CONCLUSIONS

The findings of this study provide novel evidence of enhanced benefits and benefit equity for outpatient care with the integration of URRBMI. Further efforts should be made to the expansion of URRBMI coverage and the elimination of income disparities that affecting benefit equity.

The Impact of the Consistency Evaluation Policy of Generic Drugs on R&D Investment Intensity of Pharmaceutical Companies-An Empirical Study Based on the Difference-in-Differences Model

In 2016, China began to execute the consistency evaluation policy of generic drugs. Many scholars believed that the policy would stimulate pharmaceutical firms to increase R&D investment with a theoretical perspective, but few have conducted empirical studies. Therefore, we conduct a difference-in-differences (DID) model and use panel data of 111 A-share listed pharmaceutical firms from 2012 to 2020 to empirically study the impact of the consistency evaluation policy of generic drugs on pharmaceutical firms' R&D investment intensity. The result shows that the policy has a significant positive impact on the R&D investment intensity of firms with chemical generics, robust under the test for parallel trend test, placebo test, and the propensity score matching and difference-in-differences (PSM-DID) test. In addition, we further analyzed the impact of this policy on the R&D intensity of pharmaceutical firms according to the heterogeneity of enterprise's operational nature, regional distribution and profitability. From the perspective of time changes and the average effect, the R&D investment intensity of private pharmaceutical firms is more affected by the policy than state-owned enterprises; the R&D investment intensity of pharmaceutical firms in the eastern region is more affected by this policy than those in the central and the western; the R&D investment intensity of high-profitability pharmaceutical firms is more affected by the policy than those with low-profitability. The consistency evaluation policy is still being implemented, and its impact on pharmaceutical firms needs to be studied from different empirical research perspectives in the future.

Multi-dimensional vulnerability analysis on catastrophic health expenditure among middle-aged and older adults with chronic diseases in China

OBJECTIVE

Middle-aged and older adults are more likely to suffer from chronic diseases because of their particular health characteristics, which lead to a high incidence of catastrophic health expenditure (CHE). This study plans to analyse the different factors affecting CHE in middle-aged and older adults with chronic diseases, target the vulnerable characteristics, and suggest groups that medical insurance policies should pay more attention to.

METHODS

The data used in this study came from the 2018 China Health and Retirement Longitudinal Study (CHARLS) database. The method of calculating the CHE was adopted from the World Health Organization (WHO). The logistic regression was used to determine the family characteristics of chronic disease in middle-aged and older adults with a high probability of incurring CHE.

RESULTS

The incidence of CHE in middle-aged and older adults with chronic disease was highest in sub-poverty level families (26.20%) was lowest in wealthier level families (20.07%). Households with malignant tumours had the highest CHE incidence under any circumstances, especially if the householder had been using inpatient service in the past year. Among the comparison of CHE incidence in different types of medical insurance, the Urban and Rural Residents' Basic Medical Insurance (URRBMI) was the highest (27.46%). The incidence of CHE was 2.73 times (95% CI 2.30-3.24) and 2.16 times (95% CI 1.81-2.57) higher among people who had used inpatient services in the past year or outpatient services in the past month than those who had not used them.

CONCLUSIONS

Relatively wealthy economic conditions cannot significantly reduce the financial burden of chronic diseases in middle-aged and older adults. For this particular group with multiple vulnerabilities, such as physical and social vulnerability, the high demand and utilization of health services are the main reasons for the high incidence of CHE. After achieving the goal of lowering the threshold of universal access to health services, the medical insurance system in the next stage should focus on multiple vulnerable groups and strengthen the financial protection for middle-aged and older adults with chronic diseases, especially for patients with malignant tumours.

Impact of Social Participation Types on Depression in the Elderly in China: An Analysis Based on Counterfactual Causal Inference

Objectives

Depression is the leading cause of ill health and disability worldwide, and has become one of the key issues in the public health sector. Social participation is one of the most important measures to support the rapidly aging population and can reduce the risk of depression in the elderly. This study aims to explore the causal relationship between different types of social participation and depression in the elderly, and reduce the level of depression in the elderly by promoting social participation.

Methods

In order to accurately evaluate the causal relationship between participation in different types of social activities and depression in the elderly, this paper uses propensity score matching (PSM) for analysis based on counterfactual framework. The specific matching methods used are: k-nearest neighbor matching method, kernel matching method and radius matching method.

Results

In this study, 31.4% of the elderly have depression, and the proportion of female elderly is significantly higher. Participation in different social activities has different effects on depression in the elderly. Taking into account sample selection bias, participation in friend-making, exercise, and recreational activities can effectively reduce the risk of depression in the elderly. Compared with other social activities, participation in exercise and recreational activities are more helpful to reduce the risk of depression in the elderly. Participating in exercise activities only reduces the risk of depression in 60–69-year-olds, while participating in economic activities increases the risk of depression in the elderly aged 70 and over. Compared with the male elderly, participation in friend-making, exercise, and recreational activities results in the female elderly having stronger resistance to the risk of depression.

Conclusions

Depression was prevalent among the elderly. Through PSM analysis, different types of social participation have different effects on depression in the elderly. In order to maximize the positive effects of different types of social participation on depression in the elderly, it is necessary to provide differentiated social support environment for the elderly. Expanding the research on the relationship between social participation and depression of the elderly will help to formulate more reasonable public health policies and improve the mental health of the elderly.

What is the major driver of China's hospital medical expenditure growth? A decomposing analysis

OBJECTIVES

This study aimed to quantify increases in the medical expenditures of public hospitals associated with changes in service use and prices, which could inform policy efforts to curb the future growth of hospital medical expenditures.

DESIGN

Nationwide and provincial data regarding service volume, service price and intensity of public hospitals' outpatient and inpatient care from 2008 to 2018 were extracted from the China Health Statistical Yearbooks, and population size data were obtained from the 2019 China Statistical Yearbook.

METHODS

A decomposition analysis was performed to measure the relative effects of changes in service use (volume or its subcomponent factors) and service price and intensity on the increase in the inpatient and outpatient total medical expenditures of public hospitals from 2008 to 2018.

RESULTS

After adjusting for price inflation, the total medical expenditure of public hospitals increased by approximately threefold from 2008 to 2018. During this period, the increase in service volume was associated with 67.4% of the observed increase in the total medical expenditures in the inpatient sector and 57.2% of the observed increase in the total medical expenditures in the outpatient sector. Most of the service volume effect is due to an increase in the hospital utilisation rate. The growth in the utilisation rate was associated with 73.7% of the observed growth in the total medical expenditures in the inpatient sector and 60.3% of the observed growth in the total medical expenditures in the outpatient sector.

CONCLUSION

Service use, rather than price, appears to be the major driver of increases in medical expenditures in Chinese hospitals. An important policy implication for China and other countries with similar drivers is that the effect of controlling price and intensity growth on containing medical costs could be limited and controlling service utilisation growth could be essential.

Equity in Healthcare Financing Following the Introduction of the Unified Residents' Health Insurance Scheme in China

This study sought to explore whether there are significant disparities in the financing of healthcare between urban and rural populations following the introduction in 2016 of the Urban and Rural Resident Basic Medical Insurance (URRBMI) scheme in China. We used household survey data from Heilongjiang province to estimate separate concentration curves in the financing burden and the resultant Kakwani indices (KIs) for urban and rural populations. This enabled assessment of the progressivity (or otherwise) of this burden. The results show that in urban areas indirect taxes were proportional (KI = 0.0009, p = 0.8449), while indirect taxes in rural areas were progressive (KI = 0.0284, p = 0.0002). In both urban and rural areas, direct taxes were found to be progressive (urban: KI = 0.4628, p < 0.0001; rural: KI = 0.4087, p = 0.0064), while URRBMI was regressive (urban: KI = -0.6236, p < 0.0001; rural: KI = -0.4325, p < 0.0001). Out-of-pocket payments were proportional in urban areas (KI = -0.0064, p = 0.7490); in contrast, they were regressive in rural areas (KI = -0.1078, p = 0.0012). Overall, the burden of healthcare finance in urban China was found to be neither regressive nor progressive (KI = -0.0142, p = 0. 1397), whereas in rural China it was found to be regressive (KI = -0.1208, p < 0.0001). This result is driven by high reliance on regressive forms of funding, namely, fixed contributions to URRBMI, out-of-pocket costs and private health insurance. It is concluded that achieving equity in health financing in China will require strong measures to reduce the regressivity of financing, particularly for rural populations. This can be achieved through a shift towards means-adjusted URRBMI contributions, a greater reliance on tax-based financing and reducing the reliance on out-of-pocket payments and private health insurance.

Inflammatory indicator levels in patients undergoing aortic valve replacement via median sternotomy with preoperative anxiety and postoperative complications: a prospective cohort study

OBJECTIVE

This study was performed to evaluate the association of preoperative anxiety with inflammatory indicators and postoperative complications in patients undergoing scheduled aortic valve replacement surgery.

METHODS

A prospective cohort study was performed. The Hamilton Anxiety Scale was used to assess preoperative anxiety. The serum white blood cell (WBC) count and concentrations of C-reactive protein, interleukin (IL)-6, and IL-8 were measured 1 day preoperatively and 3 and 7 days postoperatively. Postoperative complications were also recorded.

RESULTS

Seventy-three patients were included. The incidence of preoperative anxiety was 30.1% (22/73). The payment source was the only independent risk factor for preoperative anxiety. The incidence of postoperative complications was lowest in the mild anxiety group. The WBC count 3 days postoperatively was significantly lower in the mild than moderate-severe anxiety group. The IL-8 concentration 1 day preoperatively was highest in the no anxiety group.

CONCLUSIONS

Mild preoperative anxiety might help to improve clinical outcomes. However, further investigations with more patients are warranted. Patients with different degrees of anxiety may have different levels of inflammatory cytokines.

Effect of Social Participation on the Physical Functioning and Depression of Empty-Nest Elderly in China: Evidence from the China Health and Retirement Longitudinal Survey (CHARLS)

This study aimed to explore the impact of social participation (SP) on physical functioning and depression among empty-nest elderly taking part in the fourth wave of the China Health and Retirement Longitudinal Survey (CHARLS, 2018). The instrumental variable (IV) method and propensity score matching (PSM) method were used to analyse the impact of SP. The two-stage regression results of the IV method showed that SP has a significant negative impact on the physical functioning scores of empty-nest elderly (β = −3.539, p < 0.001) and non-empty-nest elderly (β = −4.703, p < 0.001), and SP has a significant negative impact on the depression scores of empty-nest elderly (β = −2.404, p < 0.001) and non-empty-nest elderly (β = −1.957, p < 0.001). The results of the PSM method were basically consistent with the IV method. Compared with non-empty-nest elderly, SP had more positive effects on the depression of empty-nest elderly (Wald χ² = 6.62, p = 0.010). Providing a friendly and supportive environment for the SP of empty-nest elderly was an important measure to promote healthy ageing. Targeted SP may be one of the greatest opportunities to improve the mental health of empty-nest elderly.

Disparities in end-of-life care, expenditures, and place of death by health insurance among cancer patients in China: a population-based, retrospective study

Background

Disparities in the utilization, expenditures, and quality of care by insurance types have been well documented. Such comparisons have yet to be investigated in end-of-life (EOL) settings in China, where public insurance covers over 95% of the Chinese population. This study examined the associations between health insurance and EOL care in the last six months of life: outpatient visits, emergency department (ED) visits, inpatient services, intensive care unit (ICU) admissions, expenditures, and place of death among the cancer patients.

Methods

A total of 398 patients diagnosed with cancer who survived more than 6 months after diagnosis and died from July 2015 to June 2017 in urban Yichang, China, were included. Descriptive analysis and multivariate regression models were used to investigate the bivariate and independent associations, respectively, between health insurance with EOL healthcare utilization, expenditures and place of death.

Results

Urban Employee Basic Medical Insurance (UEBMI) beneficiaries visited EDs more frequently than Urban Resident-based Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS) beneficiaries (marginal effects [95% Confidence Interval]: 2.15 [1.81–2.48] and 1.92 [1.59–2.26], respectively). NRCMS and UEBMI beneficiaries had more hospitalizations than URBMI beneficiaries (1.01 [0.38–1.64] and 0.71 [0.20–1.22], respectively). Compared to URBMI beneficiaries, NRCMS beneficiaries and UEBMI beneficiaries had ¥15,722 and ¥43,241 higher expenditures. Similarly, UEBMI beneficiaries were most likely to die in hospitals, followed by NRCMS (UEBMI vs. NRCMS: 0.23 [0.11–0.36]) and URBMI (UEBMI vs. URBMI: 0.67 [0.57–0.78]) beneficiaries.

Conclusions

The disproportionately lower utilization of EOL care among NRCMS and URBMI beneficiaries, compared to UEBMI beneficiaries, raised concerns regarding quality of EOL care and financial burdens of NRCMS and URBMI beneficiaries. Purposive hospice care intervention might be warranted to address EOL care for these beneficiaries in China.

Is There A Non-Essential Hospitalization Day In Inpatients With Diabetes Under Medical Insurance? Evidence From An Observational Study In China

PURPOSE

Non-essential hospitalization day of inpatient diabetes threatens health seriously and contributes to great economic burden on individuals and the society. Studying the essential utilization of hospitalization services is conducive to the reduction in the burden of diabetes. The purpose of this study is to identify the existence of non-essential hospitalization days during hospitalization in diabetic patients through exploring the use of health care in different types of insured patients.

PATIENTS AND METHODS

A sample of 6731 admission records from 5929 hospitalized patients was studied. Binary logistic regression was performed to estimate the adjusted effects of health insurance status on readmission. Multiple stepwise linear regression was performed to estimate the adjusted effects of health insurance status on length of stay (LOS), direct medical expenses (DME), out-of-pocket (OOP) expenditures, and percentage of individual payment after reimbursement (PIPAR). Adjusted odds ratios (with 95% CI) were reported as the results of logistic regression models and linear regression models, respectively.

RESULTS

Adjusted 7-day readmission rate and 30-day readmission rate were not significantly different between urban and rural resident basic medical insurance (URRBMI) and urban employee basic medical insurance (UEBMI). Compared with inpatients under URRBMI, the adjusted LOS and DME were significantly higher for UEBMI inpatients (adjusted OR of 2.6, 95% CI=1.9-3.2, adjusted OR of 1870.85, 95% CI=1370.97-2370.73, respectively). Adjusted OOP and PIPAR were significantly lower for UEBMI inpatients (adjusted OR of－970.86, 95% CI =-1111.63--830.10, adjusted OR of -0.19, 95% CI=-0.20--0.18, respectively).

CONCLUSION

There was a non-essential hospitalization day existing in the treatment of diabetes. Moral hazard has been found in UEBMI which would trigger overtreatment in hospitalization of diabetics, and the lower PIPAR of UEBMI was one of the main causes of moral hazard.

Patient experience of hospital care in China: major findings from the Chinese Patient Experience Questionnaire Survey (2016-2018)

OBJECTIVES

China launched the National Healthcare Improvement Initiative (NHII) in 2015 to improve patient experiences in healthcare. This study aimed to generate evidence of hospital care quality from the patients' perspective.

DESIGN

This nationwide cross-sectional study interviewed participants from 31 provinces, municipalities and autonomous regions across China.

SETTING

A total of 117 tertiary hospitals in mainland China.

PARTICIPANTS

48 422 responses from outpatients and 35 957 responses from inpatients were included in this study.

PRIMARY OUTCOME MEASURE

The scores of six predefined domains in the Chinese Patient Experience Questionnaire, five of which were designed to reflect specific dimensions of care, and one of which indicated the overall rating.

RESULTS

More than 80% of the respondents viewed their care experiences as positive. The NHII seems to have had a positive impact, as indicated by the steady, although unremarkable, increase in the patient experience scores over the 2016-2018 period. The Chinese patients generally reported a positive experience with the clinical aspects of care, but reported a less positive experience with the environmental, interpersonal and social services aspects of care. The institutional factors, including region and type of hospital, and personal factors, such as gender, age, education and occupation, were factors affecting the patient experience in China. Humanistic care was the aspect of care with the greatest association with the overall patient experience rating in both the outpatient and inpatient settings.

CONCLUSIONS

The national survey indicated an overall positive patient perspective of care in China. Older age, higher education level and formal employment status were found to be correlated with positive care experiences, as were higher levels of economic development of the region, a more generous insurance benefits package and a higher degree of coordinated care. The interpersonal-related initiatives had substantial roles in the improvement of the patient experience. In the regions where farmers and users of traditional Chinese medicine services constitute a greater proportion of the population, improvement of patient experiences for these groups deserves special policy attention.

Burden of visual impairment associated with eye diseases: exploratory survey of 298 Chinese patients

OBJECTIVES

To explore the economic burden, prevalence of catastrophic healthcare expenditure (CHE) and the quality of life (QoL) of Chinese patients with visual impairment (VI) associated with eye diseases.

DESIGN

A questionnaire survey from March to May 2016 by structured face-to-face interviews of patients with VI.

PARTICIPANTS

302 patients who were diagnosed with moderate VI or worse in both eyes (visual acuity <6/18) were included, and 298 patients (98.7%) who completed the survey questionnaires were eligible for the study.

OUTCOME MEASURES

The economic burden was estimated by calculating participants' direct costs covered in 2015 and the definition of CHE was out-of-pocket (OOP) costs exceeding 30% of annual household income. QoL was weighed by health utility value using time-trade-off valuation techniques.

RESULTS

Annual average direct costs per patient caused by VI were US$6988.6±US$10 834.3, and 70.3% were direct medical costs of which only 26.9% were reimbursable by medical insurance. 32.2% of households that suffered from CHE, in particular, were less wealthy patients with VI living in rural areas and without medical insurance. The health utility value was rated at 0.65 on average, and patients with VI aged 51-57, living alone and insured by commercial medical insurance had relatively less QoL.

CONCLUSION

Our study explored the economic burden and QoL of VI associated with patients with eye diseases in China, indicating a substantial economic burden and poor QoL. Preferential medical insurance policies should be designed in relation to people with VI to further reduce the health inequalities, avoid CHE and promote QoL.

Is There a Difference in the Utilisation of Inpatient Services Between Two Typical Payment Methods of Health Insurance? Evidence from the New Rural Cooperative Medical Scheme in China

This study aimed to evaluate the effects of the differences between two typical payment methods for the new rural cooperative medical scheme (NRCMS) in China on the utilisation of inpatient services. Interrupted time-series analysis (ITSA) and propensity score matching (PSM) were used to measure the difference between two typical payment methods for the NRCMS with regard to the utilisation of inpatient services. After the reform was formally implemented, the level and slope difference after reform compared with pre-intervention (distribution of inpatients in county hospitals (DIC), distribution of inpatients in township hospitals (DIT) and the actual compensation ratio of inpatients (ARCI)) were not statistically significant. Kernel matching obtained better results in reducing the mean and median of the absolute standardised bias of covariates of appropriateness of admission (AA), appropriateness of disease (AD). The difference in AA and AD of the matched inpatients between two groups was −0.03 (p-value = 0.042, 95% CI: −0.08 to 0.02) and 0.21 (p-value < 0.001, 95% CI: −0.17 to 0.25), respectively. The differences in the utilisation of inpatient services may arise owing to the system designs of different payment methods for NRCMS in China. The causes of these differences can be used to guide inpatients to better use medical services, through the transformation and integration of payment systems.