Caesarean section rate and cost control effectiveness of case payment reform in the new cooperative medical scheme for delivery: evidence from Xi County, China

Economic evaluation of GnRH-agonist long protocol and GnRH-antagonist protocol in IVT/ICSI among the Chinese population: using pharmacoeconomic models

OBJECTIVE

This paper uses health economics methods to discuss the cost-effectiveness value of long protocol and antagonist protocol for in vitro fertilisation and embryo transfer (ET) in the Chinese population.

DESIGN

Health economic evaluation study.

SETTING

The data needed to construct the model for this study were derived from published studies and other secondary sources in China.

PARTICIPANTS

No patients participated in the study.

MEASURES

The main outcomes were live birth rate (LBR) and cost. From the societal perspective, we considered the direct and indirect costs over the course of the treatment cycles. A cost-effectiveness was measured using the incremental cost-effectiveness ratio and the probability that a protocol has higher net monetary benefit. Sensitivity analysis was carried out to verify the reliability of the simulation results.

RESULTS

For the Chinese population, the long protocol resulted in a higher LBR than the antagonist protocol (29.33% vs 20.39%), but at the same time, it was more expensive (￥29 146.26 (US$4333.17) vs ￥23 343.70 (US$3470.51)), in the case of considering only one fresh ET cycle. It was the same when considering subsequent frozen ET (FET) cycles (51.78% vs 42.81%; ￥30 703.02 (US$4564.62) vs ￥24 740.95 (US$3678.24)). The results of most subgroups were consistent with the results of the basic analysis. However, for certain populations, the long protocol was the inferior protocol (less effective and more expensive).

CONCLUSION

For the Chinese population, when the monetary value per live birth was greater than ￥65 420 (US$9726) and ￥66 400 (US$9872), respectively, considering only one fresh cycle and considering subsequent frozen cycles, the long protocol is the preferred protocol. This threshold also varies for women of different ages and ovarian response capacities. For women in POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) group 2, group 3 and group 4, antagonist protocol is recommended as the preferred protocol. The results of this study need to be verified by further large-scale randomised controlled trials.

The impacts of diagnosis-intervention packet payment on the providers' behavior of inpatient care-evidence from a national pilot city in China

Background

In 2020, the Chinese government developed and implemented an innovative case-based payment method under the regional global budget called the diagnosis-intervention packet (DIP) payment to pay for inpatient care. This study aims to assess the changes to inpatient care provision in hospitals after the DIP payment reform was implemented.

Methods

This study used inpatient medical costs per case, the proportion of the out-of-pocket (OOP) expenditure in inpatient medical costs, and the average length of stay (LOS) of inpatient care as outcome variables, and conducted an interrupted time series analysis to evaluate changes after the DIP payment reform. January 2021 was taken as the intervention point when a national pilot city of the DIP payment reform in the Shandong province began using the DIP payment to pay for inpatient care of secondary and tertiary hospitals. The data used in this study were obtained from the aggregated monthly claim data of inpatient care of secondary and tertiary hospitals.

Results

Compared to the pre-intervention trend, the inpatient medical costs per case, the proportion of the OOP expenditure in inpatient medical costs both in tertiary and secondary hospitals significantly decreased after the intervention. After the intervention, the reduction in the inpatient medical costs per case, the proportion of the OOP expenditure in inpatient medical costs in tertiary hospital were both higher than those in secondary hospital (p < 0.001). The average LOS of inpatient care in secondary hospital significantly increased after the intervention, and it immediately increase 0.44 day after intervention (p = 0.211). Moreover, the change of average LOS of inpatient care in secondary hospital after intervention was opposite to that in tertiary hospital, it had no statistical difference (p = 0.269).

Conclusion

In the short term, the DIP payment reform could not only effectively regulate provider behavior of inpatient care in hospitals, but also improves the rational allocation of the regional healthcare resources. However, the long-term effects of the DIP payment reform need to be investigated in the future.

Impact of maternal nationality on caesarean section rate variation in a high-income country

BACKGROUND

Caesarean section (CS) rates have been reported to differ between immigrants and native-born women in high-income countries.

OBJECTIVE

We assessed the CS rate and its relationship with the CS rate in country of nationality and other explanatory factors among women of different nationalities including Qatari women who underwent deliveries at our hospital to generate evidence that will quantify and help explain the observed CS rates in our hospital.

METHODS

In this retrospective cross-sectional study conducted at the second-largest public maternity hospital in Qatar, Al-Wakra Hospital (AWH), data for all births delivered in 2019 were retrieved from the hospital's electronic medical records. The CS rates and the crude and adjusted risks of Caesarean delivery for mothers from each nationality were determined, and the common indications for CS were analyzed based on nationality. The association between nationality and Caesarean delivery was examined using binomial logistic regression analysis, with Qatari women as the reference group. The correlation between CS rate in country of nationality and observed CS rates in Qatar was also examined using Pearson's correlation.

RESULTS

The study population consisted of 4816 births by women of 68 nationalities, of which 4513 births were by women from 25 countries. The highest proportion of deliveries (n-1247, 25.9%) was by Indian women. The frequency of CS was the highest and lowest among Egyptian (49.6%) and Yemeni women (17.9%), respectively. Elective CS was predominantly performed in women of Arab nationalities; the most common indication was a history of previous multiple CSs. Emergency CS was primarily performed in women of Asian and Sub-Saharan African nationalities; the most common indications were failure to progress and fetal distress. For most nationalities, the CS rate in Qatar was associated with those of the countries of nationality.

CONCLUSIONS

The observed CS rates varied widely among women of different nationalities. The variation was influenced by maternal factors and medical indications as well as the CS rates in the country of nationality. We posit that cultural preferences, acculturation, and patient expectations influenced observed findings. More efforts are required to reduce primary CS rates and to help women make the most informed decisions regarding modes of delivery. Key Message: CS rates varied widely among women of different nationalities. The variation was influenced by medical indications, maternal preferences, and CS rate in countries of nationality. The solution to reducing CS rates should be a culturally informed response.

Association between service scope of primary care facilities and patient outcomes: a retrospective study in rural Guizhou, China

BACKGROUND

Extending service scope of primary care facilities (PCFs) has been widely concerned in China. However, no current data about association between service scope of PCFs with patient outcomes are available. This study aims to investigate association between service scope of PCFs and patient outcomes.

METHODS

A multistage, stratified clustered sampling method was used to collect information about service scope of PCFs from rural Guizhou, China. Claim data of 299,633 inpatient cases covered by 64 PCFs were derived from local information system of New Rural Cooperation Medical Scheme. Service scope of PCFs was collected with self-administrated questionnaires. Primary outcomes were (1) level of inpatient institutions, (2) length of stay, (3) per capita total health cost, (4) per capita out-of-pocket cost, (5) reimbursement ratio, (6) 30-day readmission. A total of 64 PCFs were categorized into five groups per facility-level service scope scores. Generalized linear regression models, logistic regression model, and ordinal regression model were conducted to identify association between service scope of PCFs and patient outcomes.

RESULTS

On average, the median service scope score of PCFs was 20, with wide variation across PCFs. After controlling for demographic and clinical characteristics, patients living in communities with PCFs of greatest service scope (Quintile V vs. I) tended to have smaller rates of admission by county-level hospitals (-6.2 % [-6.5 %, -5.9 %], city-level hospitals (-1.9 % [-2.0 %, -1.8 %]), and provincial hospitals (-2.1 % [-2.2 %, -2.0 %]), smaller rate of 30-day readmission (-0.5 % [-0.7 %, -0.2 %]), less total health cost (-201.8 [-257.9, -145.8]) and out-of-pocket cost (-210.2 [-237.2, -183.2]), and greater reimbursement ratio (2.3 % [1.9 %, 2.8 %]) than their counterparts from communities with PCFs of least service scope.

CONCLUSIONS

Service scope of PCFs varied a lot in rural Guizhou, China. Greater service scope was associated with a reduction in secondary and tertiary hospital admission, reduced total cost and out-of-pocket cost, and 30-day readmission and increased reimbursement ratio. These results raised concerns about access to care for patients discharged from hospitals, which suggests potential opportunities for cost savings and improvement of quality of care. However, further evidence is warranted to investigate whether extending service scope of PCFs is cost-effective and sustainable.

Factors associated with child delivery expenditure during the transition to the national implementation of the two-child policy in China

BACKGROUND

This study aimed to analyze the status of birthrates and the characteristics of child delivery expenditure under the Chinese two-child policy's transition period. We evaluated the socioeconomic factors associated with child delivery and provide evidence for decisions relating to health support for childbirth.

METHODS

Child delivery expense data were obtained from 2015 to 2017 in Dalian, China. A total of 13,535 obstetric records were enrolled using stratified random sampling and the proportional probability to size method. First, we calculated the current curative expenditure of child delivery and health financing in childbirth costs based on the System of Health Accounts 2011 (SHA 2011). Second, univariate analysis of variance and generalized linear modeling were performed to examine factors associated with child delivery expenditure. Third, we classified the included hospitals into the county, district, and municipal hospitals and compared maternal characteristics between these categories.

RESULTS

Overall, out-of-pocket payments accounted for more than 35% of the total expenditure on child delivery. Median (interquartile range) delivery expenditure at the county and district level hospitals [county-level: 5128.50 (3311.75-5769.00) CNY; district-level: 4064.00 (2824.00-6599.00) CNY] was higher than that at the municipal level hospitals: 3824.50 (2096.50-5908.00) CNY. The increase of child delivery expenditure was associated with an increased ratio of reimbursement, admissions to county and district level hospitals, cesarean sections, and length of stay, as well as a decline in average maternal age (p < 0.05).

CONCLUSIONS

Health financing for childbirth expenditure was not rational during the transition period of the family planning policy in China. Higher delivery expenditure at county and district level hospitals may indicate variations in medical professionalism. Poorly managed hospitalization expenditure and/or nonstandard medical charges for childbirth, all of which may require the development of appropriate public health policies to regulate such emerging phenomena.

Determinants of length of stay after cesarean sections in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Since Italy has the highest cesarean section (CS) rate (38.1%) among all European countries, the containment of health care costs associated with CS is needed, along with control of length of hospital stay (LOS) following CS. This population based cross-sectional study aims to investigate LoS post CS (overall CS, OCS; planned CS, PCS; urgent/emergency CS, UCS), in Friuli Venezia Giulia (a region of North-Eastern Italy) during 2005-2015, adjusting for a considerable number factors, including various obstetric conditions/complications. Maternal and newborn characteristics (health care setting and timeframe; maternal health factors; child's size factors; child's fragility factors; socio-demographic background; obstetric history; obstetric conditions) were used as independent variables. LoS (post OCS, PCS, UCS) was the outcome measure. The statistical analysis was conducted with multivariable linear (LoS expressed as adjusted mean, in days) as well as logistic (adjusted proportion of LoS > 4 days vs. LoS ≤ 4 days, using a 4 day cutoff for early discharge, ED) regression. An important decreasing trend over time in mean LoS and LoS > ED was observed for both PCS and UCS. LoS post CS was shorter with parity and history of CS, whereas it was longer among non-EU mothers. Several obstetric conditions/complications were associated with extended LoS. Whilst eclampsia/pre-eclampsia and preterm gestations (33-36 weeks) were predominantly associated with longer LoS post UCS, for PCS LoS was significantly longer with birthweight 2.0-2.5 kg, multiple birth and increasing maternal age. Strong significant inter-hospital variation remained after adjustment for the major clinical conditions. This study shows that routinely collected administrative data provide useful information for health planning and monitoring, identifying inter-hospital differences that could be targeted by policy interventions aimed at improving the efficiency of obstetric care. The important decreasing trend over time of LoS post CS, coupled with the impact of some socio-demographic and obstetric history factors on LoS, seemingly suggests a positive approach of health care providers of FVG in decision making on hospitalization length post CS. However, the significant role of several obstetric conditions did not influence hospital variation. Inter-hospital variations of LoS could depend on a number of factors, including the capacity to discharge patients into the surrounding non-acute facilities. Further studies are warranted to ascertain whether LoS can be attributed to hospital efficiency rather than the characteristics of the hospital catchment area.

'Hybrid' top down bottom up health system innovation in rural China: A qualitative analysis

Introduction

China has made considerable progress with health system reforms in recent years. Rural China, however, has lagged behind as the diversity of needs of China’s 3,000 rural counties were not always well addressed by national top-down reforms. China’s Rural Health Reform Project Health XI (HXI) piloted a hybrid process of top down and bottom up implementation of health system reforms which were tailored to rural county level needs and covered a population of more than 21 million. Different studies provide evidence that HXI counties have achieved substantial benefits given the relatively limited investment. The Effectiveness of HXI subsequently raises the question how the hybrid approach may have resulted in effective implementation of interventions. We answer this question to advance understanding of hybrid approaches in general and in the rural Chinese context in particular, where the bottom-up elements might match poorly with the traditional organisational culture and learning style.

Materials & methods

We conducted an in-depth qualitative analysis in three ‘best practice’ counties, performing document-analyses, observations, semi-structured individual and group interviews. In alignment with the research question, this study is of an explorative nature and follows a sequence of deductive and inductive steps

Results

HXI struggled initially as counties had difficulties to take initiative and autonomously select and adapt their own reforms. The initial reforms required multiple improvement iterations before achieving the planned results. The effectiveness of these bottom up reform processes has been aided by tight top down supervision and extensive domestic expert involvement. County level leadership is seen as essential to align the top down and bottom up structures and processes. Where successful, HXI has changed mind-sets and counties developed generic health improvement capabilities.

Conclusion

Tailoring innovations to fit local needs formed a severe challenge for the three ‘best practice’ counties studied. A ‘change of mindset’ to actively take initiative and assume autonomy was needed to advance. Top down supervision and extensive support of experts was required to overcome the barriers. The studied counties finally achieved sustainable improvements and developed double loop learning capabilities beyond HXI objectives. Taken together, the above findings suggest that the continuum of healthcare reform implementation approaches in which hybrid approaches reside—from bottom up to top down—has two dimensions: a content dimension and a procedural dimension. Enabled by top down procedures, counties were able to bottom up tailor the content of best practice innovations to fit local needs.

Association between direct government subsidies and service scope of primary care facilities: a cross-sectional study in China

Background

Comprehensive primary care practices, through preconception, preventive, curative, and rehabilitative care, have been a global priority in the promotion of health. However, the scope of primary care services has still been in decline in China. Studies on the factors for primary care service scope have centred on human resources and infrastructure; the role of direct government subsidies (DGS) on services scope of primary care facilities were left unanswered. This study aimed to explore the association between the DGS and services scope of primary care facilities in China.

Methods

A multi-stage, clustered cross-sectional survey using self-administrated questionnaire was conducted among primary care facilities of 36 districts/counties in China. A total of 770 primary care facilities were surveyed with 757 (98.3%) valid respondents. Of the 757 primary care facilities, 469 (62.0%) provided us detailed information of financial revenue and DGS from 2009 to 2016. Therefore, 469 primary care facilities from 31 counties/districts were included in this study. Sasabuchi-Lind-Mehlum tests and multivariate regression models were used to examine the inverted U-shaped relationship between the DGS and service scope.

Results

Of 469 PCFs, 332 (70.8%) were township health centres. Proportion of annul DGS to FR arose from 26.5% in 2009 to 50.5% in 2016. At the low proportion of DGS to financial revenue, an increase in DGS was associated with an increased service scope of primary care facilities, whereas the proportion of DGS to financial revenue over 42.5% might cause narrowed service scope (P = 0.023, 95% CI 11.59–51.74%); for the basic medical care dimension, the cut point is 42.6%. However, association between DGS and service scope of public health by primary care facilities is statistically insignificant.

Conclusion

While the DGS successfully achieved equalization of basic preventive and public health services, the disproportionate proportion of DGS to financial revenue is associated with narrowed service scope, which might cause underutilization of primary care and distorted incentive structure of primary care. Future improvements of DGS should focus on the incentive of broader basic medical services provision, such as clarifying service scope of primary care facilities and strategic procurement with a performance-based subsidies system to determine resource allocation.

A Systematic Evaluation of Hospital Performance of Childbirth Delivery Modes and Associated Factors in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Cesarean sections (CS) have become increasingly common in both developed and developing countries, raising legitimate concerns regarding their appropriateness. Since improvement of obstetric care at the hospital level needs quantitative evidence, using routinely collected health data we contrasted the performance of the 11 maternity centres (coded with an alphabetic letter A to L) of an Italian region, Friuli Venezia Giulia (FVG), during 2005-15, after removing the effect of several factors associated with different delivery modes (DM): spontaneous vaginal delivery (SVD), instrumental vaginal delivery (IVD), overall CS (OCS) and urgent/emergency CS (UCS). A multivariable logistic regression model was fitted for each individual DM, using a dichotomous outcome (1 = each DM; 0 = rest of hospital births) and comparing the stratum specific estimates of every term with their respective reference categories. Results were expressed as odds ratios (OR) with 95% confidence intervals (95%CI). The Benjamini-Hochberg (BH) false discovery rates (FDR) approach was applied to control alpha error due to the large number of statistical tests performed. In the entire FVG region during 2005-2015, SVD were 75,497 (69.1% out of all births), IVD were 7,281 (6.7%), OCS were 26,467 (24.2%) and UCS were 14,106 (12.9% of all births and 53.3% out of all CS). SVD were more likely (in descending order of statistical significance) with: higher number of previous livebirths; clerk/employed occupational status of the mother; gestational age <29 weeks; placentas weighing <500 g; stillbirth; premature rupture of membranes (PROM). IVD were predominantly more likely (in descending order of statistical significance) with: obstructed labour, non-reassuring fetal status, history of CS, labour analgesia, maternal age ≥35 and gestation >40 weeks. The principal factors associated with OCS were (in descending order of statistical significance): CS history, breech presentation, non-reassuring fetal status, obstructed labour, multiple birth, placental weight ≥ 600 g, eclampsia/pre-eclampsia, maternal age ≥ 35 and oligohydramnios. The most important risk factors for UCS were (in descending order of statistical significance): placenta previa/abruptio placenta/ antepartum hemorrage; non-reassuring fetal status, obstructed labour; breech presentation; PROM, eclampsia/pre-eclampsia; gestation 33-36 weeks; gestation 41+ weeks; oligohydramnios; birthweight <2,500 g, maternal age ≥ 35 and cord prolapse. After removing the effects of all other factors, we found great variability of DM rates across hospitals. Adjusting for all risk factors, all hospitals had a OCS risk higher than the referent (hospital G). Out of these 10 hospitals with increased adjusted risk of OCS, 9 (A, B, C, D, E, F, I, J, K) performed less SVD and 5 (A, C, D, I, J) less IVD. In the above 5 centres CS was therefore probably overused. The present study shows that routinely collected administrative data provide useful information for health planning and monitoring. Although the overall CS rate in FVG during 2005-15 was 24.2%, well below the corresponding average Italian national figure (38.1%), the variability of DM rates across FVG maternity centres could be targeted by policy interventions aimed at reducing the recourse to unnecessary CS. In some clinical conditions such as obstructed labor, non-reassuring fetal status, breech presentation, history of CS, higher maternal age and multiple birth, consideration may be given to more conservative DM. The overuse of CS in nulliparas and repeat CS (RCS) should be carefully monitored and subject to audit.

The impact of the "Health Transformation Plan" and related policies on the prevalence rate of cesarean section in Iran: Insights from an interrupted time series analysis

BACKGROUND

The high prevalence of cesarean section represents a major public health challenge worldwide. In 2014, the Iranian Health Transformation Plan (HTP) included programs promoting vaginal delivery.

AIM

The aim of this study was to investigate the effect of the HTP on the rate of cesarean section in Iran.

METHOD

The interrupted time series analysis (ITSA) was used. Cesarean section- and vaginal delivery-related monthly data were collected from eight public hospitals affiliated with the Lorestan University of Medical Sciences, from March 2012 to February 2019. The autocorrelation plots and the Durbin-Watson test were used for evaluating the autocorrelation between data points in the generalized least squares regression model.

RESULTS

The ITSA showed that the rate of cesarean section decreased immediately after the HTP, by -0.002 per 1000 persons (95% CI, -0.004 to -0.001; P = .069). After the HTP, a significant decreasing trend of cesarean section per month was computed (-0.003; 95% CI, -0.005 to 0.012; P = .043).

CONCLUSION

The present study showed that the implementation of the HTP policy was effective in reducing the rate of cesarean section. This policy should continue, involving relevant stakeholders, raising mothers' awareness and motivation, and providing financial support.

10 years of health-care reform in China: progress and gaps in Universal Health Coverage

In 2009, China launched a major health-care reform and pledged to provide all citizens with equal access to basic health care with reasonable quality and financial risk protection. The government has since quadrupled its funding for health. The reform's first phase (2009-11) emphasised expanding social health insurance coverage for all and strengthening infrastructure. The second phase (2012 onwards) prioritised reforming its health-care delivery system through: (1) systemic reform of public hospitals by removing mark-up for drug sales, adjusting fee schedules, and reforming provider payment and governance structures; and (2) overhaul of its hospital-centric and treatment-based delivery system. In the past 10 years, China has made substantial progress in improving equal access to care and enhancing financial protection, especially for people of a lower socioeconomic status. However, gaps remain in quality of care, control of non-communicable diseases (NCDs), efficiency in delivery, control of health expenditures, and public satisfaction. To meet the needs of China's ageing population that is facing an increased NCD burden, we recommend leveraging strategic purchasing, information technology, and local pilots to build a primary health-care (PHC)-based integrated delivery system by aligning the incentives and governance of hospitals and PHC systems, improving the quality of PHC providers, and educating the public on the value of prevention and health maintenance.

The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review

Background

The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness.

Methods

The sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software.

Results

Nine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate.

Conclusions

The effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders’ characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies’ outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7265-4) contains supplementary material, which is available to authorized users.

The effect of the health poverty alleviation project on financial risk protection for rural residents: evidence from Chishui City, China

Background

Illness is the leading cause (44%) of poverty in China. Since 2016, The health poverty alleviation project, an integral component of the Targeted Poverty Alleviation in China, was implemented in 2016 to strengthen financial risk protection against illness for financially backward segments of the population. However, the effects of the health poverty alleviation project on financial risk protection have not been explored in the literature, this paper aims to bridge the gap.

Methods

Using panel data on 63,426 rural households in Chishui City, China, from 2014 to 2017, the difference-in-differences with propensity score matching method was employed.

Results

The health poverty alleviation project reduces out-of-pocket payments by 15% on average and decreases the probability of catastrophic health expenditure (annual out-of-pocket payments exceeding 10% of annual household income) and impoverishing health spending occurrence (out-of-pocket payments are forcing a household into poverty or into deeper poverty) by 7.7 and 11.7%, respectively. Additionally, the project increases the number of annual hospitalizations per household by 0.035.

Conclusion

Our study demonstrates that the health poverty alleviation project significantly improves financial risk protection by reducing out-of-pocket payments and decreasing the probability of incurring catastrophic or impoverishing levels of health expenditure. Our study has implications for the poverty reduction policies and reform of the Chinese health financing system.

Cesarean delivery rates, costs and readmission of childbirth in the new cooperative medical scheme after implementation of an episode-based bundled payment (EBP) policy

BACKGROUND

In the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong'an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS.

METHODS

Data from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong'an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method.

RESULTS

The EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates.

CONCLUSIONS

These results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.

Length of stay following cesarean sections: A population based study in the Friuli Venezia Giulia region (North-Eastern Italy), 2005-2015

BACKGROUND

Births by cesarean section (CS) usually require longer recovery time, and as a result women remain hospitalized longer following CS than vaginal delivery (VD). A number of strategies have been proposed to reduce avoidable health care costs associated with childbirth. Among these, the containment of length of hospital stay (LoS) has been identified as an important quality indicator of obstetric care and performance efficiency of maternity centres. Since improvement of obstetric care at hospital level needs quantitative evidence, we compared the maternity services of an Italian region on LoS post CS.

METHODS

We conducted a population-based study in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from all its 12 maternity centres (coded from A to K) during 2005-2015. We fitted a multivariable logistic regression using LoS as a binary outcome, higher/lower than the international early discharge (ED) cutoffs for CS (4 days), controlling for hospitals as well as several factors related to the clinical conditions of the mothers and the newborn, the obstetric history and socio-demographic background. Results were expressed as adjusted odds ratios (aOR) with 95% confidence interval (95%CI). Population attributable risks (PARs) were also calculated as proportional variation of LoS>ED for each hospital in the ideal scenario of having the same performance as centre J (the reference) during calendar year 2015. Results were expressed as PAR with 95%CI. Differences in mean LoS were also investigated with a multivariable linear regression model including the same explanatory factors of the above multiple logistic regression. Results were expressed as adjusted regression coefficients (aRC) with 95%CI.

RESULTS

Although decreasing over the years (5.0 ± 1.7 days in 2005 vs. 4.4 ± 1.7 days in 2015), the pooled mean LoS in the whole FVG during these 11 years was still 4.7 ± 1.7 days, higher than respective international ED benchmark. The significant decreasing trend of LoS>ED over time in FVG (aOR = 0.89; 95%CI: 0.88; 0.90) was marginal as compared to the variability of LoS>ED observed among the various maternity services. Regardless it was expressed as aRC or aOR, LoS after CS was lowest in hospital C, highest in hospital D and intermediate in centres I, K, G, F, A, H, E, B and J (in descending order). The aOR of LoS being longer than ED ranged from 1.63 (95%CI:1.46; 1.81) in hospital B up to 32.09 (95%CI: 25.68; 40.10) in facility D. When hospitals were ranked by PAR the same pattern was found, even if restricting the analysis to low risk pregnancies.

CONCLUSIONS

Although significantly decreasing over time, the mean LoS in FVG during 2005-2015 was 4.7 days, higher than the international threshold recommended for CS. There was substantial variability in LoS by facility centre, suggesting that internal organizational processes of single hospitals should be improved by enforcing standardized guidelines and using audits, economic incentives and penalties if need be.

Medical Service Quality, Efficiency and Cost Control Effectiveness of Upgraded Case Payment in Rural China: A Retrospective Study

Background: As the principal means of reimbursing medical institutions, the effects of case payment still need to be evaluated due to special environments and short exploration periods, especially in rural China. Methods: Xi County was chosen as the intervention group, with 36,104, 48,316, and 59,087 inpatients from the years 2011 to 2013, respectively. Huaibin County acted as the control group, with 33,073, 48,122, and 51,325 inpatients, respectively, from the same period. The inpatients' information was collected from local insurance agencies. After controlling for age, gender, institution level, season fixed effects, disease severity, and compensation type, the generalised additive models (GAMs) and difference-in-differences approach (DID) were used to measure the changing trends and policy net effects from two levels (the whole county level and each institution level) and three dimensions (cost, quality and efficiency). Results: At the whole-county level, the cost-related indicators of the intervention group showed downward trends compared to the control group. Total spending, reimbursement fee and out-of-pocket expense declined by ¥346.59 (p < 0.001), ¥105.39 (p < 0.001) and ¥241.2 (p < 0.001), respectively (the symbol ¥ represents Chinese yuan). Actual compensation ratio, length of stay, and readmission rates exhibited ascending trends, with increases of 7% (p < 0.001), 2.18 days (p < 0.001), and 1.5% (p < 0.001), respectively. The intervention group at county level hospital had greater length of stay reduction (¥792.97 p < 0.001) and readmission rate growth (3.3% p < 0.001) and lower reimbursement fee reduction (¥150.16 p < 0.001) and length of stay growth (1.24 days p < 0.001) than those at the township level. Conclusions: Upgraded case payment is more reasonable and suitable for rural areas than simple quota payment or cap payment. It has successfully curbed the growth of medical expenses, improved the efficiency of medical insurance fund utilisation, and alleviated patients' economic burden of disease. However, no positive effects on service quality and efficiency were observed. The increase in readmission rate and potential hidden dangers for primary health care institutions should be given attention.