The equity of China's emergency medical services from 2010-2014

Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registry

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is an important global public health issue, but its epidemiology and outcomes in low-income and middle-income countries remain largely unknown. We aim to comprehensively describe the incidence, process of care, and outcomes of OHCA in China.

METHODS

In the prospective, multicentre, population-based Baseline Investigation of Out-of-hospital Cardiac Arrest (BASIC-OHCA) registry study, participating sites were selected from both urban and rural areas in all seven geographical regions across China. All patients with OHCA assessed by emergency medical service (EMS) staff were consecutively enrolled from Aug 1, 2019, to Dec 31, 2020. Patients with suspected cardiac arrest assessed by bystanders whose return of spontaneous circulation was achieved without the need for defibrillation or EMS personnel cardiopulmonary resuscitation were excluded. Patients with all key variables missing were excluded, including resuscitation attempt, age, sex, witnessed status, cause, all process of care indicators, and all outcome measures. In this analysis, we included data for EMS agencies serving 25 monitoring sites (20 urban and five rural) that included the entire serving population, data for the whole of 2020, and at least 50 OHCA patients in 2020. Data were collected and reported using the Utstein template. We calculated the crude incidence of EMS-assessed OHCA in 2020. We also report data on baseline characteristics (including sex, cause, location of OHCA, and presence of shockable rhythm), process of care (including EMS response time, cardiopulmonary resuscitation, defibrillation, and advanced life support), and outcomes of non-traumatic OHCA between Aug 1, 2019, and Dec 31, 2020, including survival and survival with favourable neurological outcomes at discharge or 30 days, and at 6 and 12 months.

FINDINGS

Of 115·1 million people served by the 25 participating sites, 132 262 EMS-assessed patients with OHCA were enrolled, and resuscitation was attempted for 42 054 (31·8%) patients between Aug 1, 2019, and Dec 31, 2020. The crude incidence of EMS-assessed OHCA was 95·7 per 100 000 population (95% CI 95·6-95·8) in 2020. Among 38 227 individuals with non-traumatic OHCA, 25 958 (67·9%) were male, 30 282 (79·2%) had a cardiac arrest at home, 32 523 (85·1%) had a presumed cardiac cause, and 2297 (6·0%) presented with an initial shockable rhythm. 4049 (11·5%) of 35 090 patients with an unwitnessed or bystander-witnessed OHCA received dispatcher-assisted cardiopulmonary resuscitation and 7121 (20·3%) received bystander cardiopulmonary resuscitation; only 14 (<0·1%) patients were assessed by bystanders with an automated external defibrillator. The median EMS response time was 12 min (IQR 9-16). At hospital discharge or 30 days, 441 (1·2%) of 38 227 survived, 304 (0·8%) survived up to 6 months, and 269 (0·7%) up to 12 months. At hospital discharge or 30 days, 309 (0·8%) survived with favourable neurological outcomes, 257 (0·7%) had favourable neurological outcomes at 6 months, and 236 (0·6%) at 12 months.

INTERPRETATION

Our findings revealed a high burden of EMS-assessed OHCA with a low proportion of resuscitation attempts. The suboptimal implementation of chain of survival and unsatisfactory prognosis call for national efforts to improve the care and outcomes of patients with OHCA in China.

FUNDING

The National Science & Technology Fundamental Resources Investigation Program of China, the State Key Program of the National Natural Science Foundation of China, Taishan Pandeng Scholar Program of Shandong Province, the Key Research & Development Program of Shandong Province, the Interdisciplinary Young Researcher Groups Program of Shandong University, the Clinical Research Center of Shandong University, the ECCM Program of Clinical Research Center of Shandong University, and the Natural Science Foundation of Shandong Province.

Equity and trends in general practitioners' allocation in China: based on ten years of data from 2012 to 2021

BACKGROUND

General practitioners (GP) are the gatekeepers of residents' health, 2021 is the 10th year of the establishment of the GP system in China. This study aims to assess the equity and trends of GP allocation in China from 2012 to 2021, summarize the efforts and progress of GPs in China during the decade, predict the development trend of GPs in mainland China in the next 5 years to provide a reference for regional health planning and rational allocation of GPs in China.

METHODS

Data from 2012 to 2021 on GPs in 22 provinces, 5 autonomous regions, and 4 municipalities directly under the central government in mainland China (excluding Hong Kong, Macao, and Taiwan) are collected by us. Gini coefficient, Lorenz curve and health resource agglomeration degree (HRAD) were used to analyze the equity of the allocation of GPs in China from different dimensions, a Grey prediction model was used to forecast the number of GPs in 2022-2026.

RESULTS

The number of GPs in mainland China increased from 109 794 to 434 868 from 2012 to 2021, with 3.08 GPs per 10 000 people in 2021. The Gini coefficient of GPs allocation by population in China decreased from 0.312 to 0.147 from 2012 to 2021, while the Gini coefficient of geographic dimension remained between 0.700 and 0.750. Compared with the degree of curvature of the Lorenz curve in the geographic dimension, the degree of curvature of the population and economic dimension were smaller. In 2021, the HRAD in the Eastern region was 4.618, the Central region was 1.493, with different degrees of imbalance among regions, the HRAD/PAD (population agglomeration degree) in the Eastern, Central and Western regions were 1.196, 0.880 and 0.821, respectively. GPs in the Eastern region is still concentrated, while the Central and Western regions were at a similar level, GPs were more scarce. The GM (1,1) model predicts that the number of GPs in mainland China will reach about 720 000 in 2026, the number of GPs per 10 000 people will reach 4.9.

CONCLUSION

After a decade of development, the number of GPs in China has increased significantly. It has reached the goal of the GP system when it was first established. However, the equity of the geographical dimension, both in terms of Gini coefficient and HRAD, has great differences between different regions. The average Gini coefficient at the geographic dimension is 0.723. The average HRAD index was 4.969 in the East and 0.293 in the West. The Western region has the problem of insufficient GP allocation in both population and geographical dimension. In the future, the number of GPs in China will continue to grow rapidly with the support of policies. The "2030" goal, proposed in 2018, is expected to be achieved by 2026. Due to certain factors (such as COVID-19), the actual situation may be different from the predicted results.

Ambulance referral of more than 2 hours could result in a high prevalence of medical-device-related pressure injuries (MDRPIs) with characteristics different from some inpatient settings: a descriptive observational study

BACKGROUND

Medical device-related pressure injuries(MDRPI) are prevalent and attracting more attention. During ambulance transfer, the shear force caused by braking and acceleration; extensive medical equipment crowed in a narrow space add external risk factors for MDRPIs. However, there is insufficient research on the relationship between MDRPIs and ambulance transfers. This study aims to clarify the prevalence and characteristics of MDRPI during ambulance transfer.

METHOD

A descriptive observational study was conducted with convenience sampling. Before starting the study, six PI specialist nurses certified by the Chinese Nursing Association trained emergency department nurses for three MDRPI and Braden Scale sessions, one hour for each session. Data and images of PIs and MDRPIs are uploaded via the OA system by emergency department nurses and reviewed by these six specialist nurses. The information collection begins on 1 July 2022 and ends on 1 August 2022. Demographic and clinical characteristics and a list of medical devices were collected by emergency nurses using a screening form developed by researchers.

RESULTS

One hundred one referrals were eventually included. The mean age of participants was (58.3 ± 11.69) years, predominantly male (67.32%, n = 68), with a mean BMI of 22.48 ± 2.2. The mean referral time among participants was 2.26 ± 0.26 h, the mean BRADEN score was 15.32 ± 2.06, 53.46% (n = 54) of participants were conscious, 73.26% (n = 74) were in the supine position, 23.76% (n = 24) were in the semi-recumbent position, and only 3 (2.9%) were in the lateral position. Eight participants presented with MDRPIs, and all MDRPIs are stage 1. Patients with spinal injuries are most prone to MDRPIs (n = 6). The jaw is the area most prone to MDRPIs, caused by the cervical collar (40%, n = 4), followed by the heel (30%, n = 3) and nose bridge (20%, n = 2) caused by the respiratory devices and spinal board.

CONCLUSION

MDRPIs are more prevalent during long ambulance referrals than in some inpatient settings. The characteristics and related high-risk devices are also different. The prevention of MDRPIs during ambulance referrals deserves more research.

The allocation and fairness of health human resources in Chinese maternal and child health care institutions: a nationwide longitudinal study

BACKGROUND

In response to an aging population, the Chinese government implemented the three-child policy in 2021 based on the comprehensive two-child policy. With the implementation of the new birth policy, people's maternal and child health (MCH) needs will also increase. The allocation and fairness of MCH human resources directly affect people's access to MCH services. The purpose of this study is to analyze the allocation of health human resources in Chinese maternal and child health care institutions, evaluate the fairness of the allocation, to provide a reference for the rational allocation of MCH human resources.

METHODS

The data of health technicians, licensed (assistant) physicians, and registered nurses in maternal and child health care institutions nationwide from 2016 to 2020 were included. The health resource density index (HRDI) is used to evaluate the allocation level of MCH human resources. The Gini coefficient (G) and Theil index (T) are used to evaluate the fairness of the allocation of MCH human resources from the perspectives of population and geographic area.

RESULTS

From 2016 to 2020, the average annual growth rate of the number of health technicians, licensed (assistant) physicians, and registered nurses in Chinese maternal and child health care institutions was 7.53, 6.88, and 9.12%, respectively. The Gini coefficient (G) of the three types of MCH human resources allocated by population were all below 0.23, and the Gini coefficient (G) allocated by geographical area were all above 0.65. The Theil index (T) of the three types of MCH human resources allocated by population was all lower than 0.06, and the Theil index (T) allocated by geographical area was all higher than 0.53. In addition, the three types of MCH human resources allocated by population and geographic area contributed more than 84% of the Theil index within the group (T_intra) to the Theil index (T).

CONCLUSIONS

China's MCH human resources were fair in terms of population allocation, but unfair in terms of geographical area allocation. In the future, more attention should be paid to the geographical accessibility of MCH human resources, and the allocation of resources should comprehensively consider the two factors of serving the population and geographical area.

Under the chest pain center mechanism, whether the nursing handover affects the nursing efficiency and the outcomes of patients with STEMI in the emergency department? A retrospective study

BACKGROUND

The introduction of chest pain centers (CPC) in China has achieved great success in shortening the duration of nursing operations to significantly improve the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The nursing handover period is still considered the high incidence period of adverse events because of the distractibility of nurses' attention, potential interruption, and unclear responsibilities. Under the CPC mechanism, the nursing efficiency and patients' outcome, whether affected by the nursing handover, is still a knowledge gap in research. This is also the aim of this study.

METHODS

A retrospective study was conducted with data from STEMI patients from a tertiary hospital in the north of Sichuan Province from January 2018 to December 2019 through the Chinese CPC database. Patients are divided into handover and non-handover groups according to the time they presented in the Emergency Department. D2FMC, FMC2FE, FMC2BS, FMC2CBR, FMC2FAD, and D2W were selected to measure nursing efficiency. The occurrence of major adverse cardiovascular events, the highest troponin values within 72 h of hospitalization, and the length of hospitalization were selected to measure the patient outcomes. Continuous variables are summarized as mean ± SD, and t-tests of the data were performed. P-values < 0.05 (two-tailed) were considered statistically significant.

RESULTS

A total of 231 cases were enrolled, of which 40 patients (17.3%) were divided into the handover period group, and 191 (82.6%) belonged to the non-handover period group. The results showed that the handover period group took significantly longer on items FMC2BS (P < 0.001) and FMC2FAD (P < 0.001). Still, there were no significant differences in D2FMC and FMC2FE, and others varied too little to be clinically meaningful, as well as the outcomes of patients.

CONCLUSION

This study confirms that nursing handover impacts the nursing efficiency of STEMI patients, especially in FMC2BS and FMC2FAD. Hospitals should also reform the nursing handover rules after the construction of CPC and enhance the triage training of nurses to assure nursing efficiency so that CPC can play a better role.

Regional disparities and influencing factors of high quality medical resources distribution in China

BACKGROUND

With the gradual increase of residents' income and the continuous improvement of medical security system, people's demand for pursuing higher quality and better medical and health services has been released. However, so far little research has been published on China's high quality medical resources (HQMR). This study aims to understand the spatiotemporal variation trend of HQMR from 2006 to 2020, analyze regional disparity of HQMR in 2020, and further explore the main factors influencing the distribution of HQMR in China.

METHODS

The study selected Class III level A hospitals (the highest level medical institutions in China) to represent HQMR. Descriptive statistical methods were used to address the changes in the distribution of HQMR from 2006 to 2020. Lorentz curve, Gini coefficient (G), Theil index (T) and High-quality health resource density index (HHRDI) were used to calculate the degree of inequity. The geographical detector method was used to reveal the key factors influencing the distribution of HQMR.

RESULTS

The total amount of HQMR in China had increased year by year, from 647 Class III level A hospitals in 2006 to 1580 in 2020. In 2020, G for HQMR by population was 0.166, while by geographic area was 0.614. T was consistent with the results for G, and intra-regional contribution rates were higher than inter-regional contribution rates. HHRDI showed that Beijing, Shanghai, and Tianjin had the highest allocated amounts of HQMR. The results of the geographical detector showed that total health costs, government health expenditure, size of resident populations, GDP, number of medical colleges had a significant impact on the spatial distribution of HQMR and the q values were 0.813, 0.781, 0.719, 0.661, 0.492 respectively. There was an interaction between the influencing factors.

CONCLUSIONS

China's total HQMR is growing rapidly but is relatively inadequate. The distribution of HQMR by population is better than by geography, and the distribution by geography is less equitable. Population size and geographical area both need to be taken into account when formulating policies, rather than simply increasing the number of HQMR.

Social health insurance consolidation and urban-rural inequality in utilization and financial risk protection in China

Universal health care is a long-term policy goal for health care reform in China. In 2016, China consolidated its urban and rural resident social health insurance programs into one program with a goal to reduce disparities between rural and urban populations. Using a nationally-representative sample of 14,967 individuals from the China Family Panel Studies surveys (2012-2018), we investigate whether the consolidation reduced gaps in total and out-of-pocket medical expenditure, and reimbursement between rural and urban residents. Our identification approach relies on an augmented difference-in-differences analysis whereby we compare the two programs that were consolidated to a different program that was not consolidated, before and after the consolidation. We find no evidence that the urban-rural gaps in these measures have narrowed as a result of the consolidation, at least in the near term. This surprising result may be partly explained by urban-rural inequality in access to care and provincial fiscal spending on health care. While these findings need to be confirmed with additional data and research, we call for continued efforts on addressing supply-side challenges, particularly in under-served areas.

Effect of Rural Clinical Placements on Intention to Practice and Employment in Rural Australia: A Systematic Review

BACKGROUND

Supporting the provision of clinical placement (CP) experiences in rural areas is a strategy used worldwide to promote the rural health workforce. While there is international evidence for this intervention in medicine, there is limited understanding of the influence of rural CP for nursing, midwifery, allied health, and dentistry health professions in Australia, which have received substantial federal investment. This review examined the relationship between rural CP and non-medicine health students' future rural practice intentions and workforce outcomes.

METHODS

Four databases were systematically searched; papers were screened using defined criteria and appraised using the mixed-methods appraisal tool (MMAT). Findings were synthesized using a critical narrative approach.

RESULTS

The methodological quality of the 29 eligible studies (13 quantitative non-randomized, 10 mixed method, 4 qualitative, 2 quantitative description) was appraised. Ten high-quality studies were identified. The review found that positive CP experiences may influence intention to practice rurally amongst undecided students and serve as a reinforcing experience for those students already interested in rural practice. There were mixed findings regarding the influence of CP length. The review also found that there is currently only evidence for the short-term effects of CP on students' future practice outcomes in rural areas with focus thus far on early practice outcomes.

CONCLUSIONS

Those looking to use rural CP to promote the rural health workforce should focus on supporting the quality of a large number of CP experiences that are undertaken in rural areas, as there are currently differing findings on the role of rural CP length. Future studies of rural CP should consider greater use of social and educational theories to guide them.

The Right to Accessible COVID-19 Testing in the Post-Epidemic Period under the Urban–Rural Integration: Haishu District, Ningbo City, China

The reasonable distribution of COVID-19 testing facilities is a crucial public necessity to protect the civil right of health and the proper functioning of society in the post-epidemic period. However, most of the current COVID-19 testing facilities are in large hospitals in China, partially overlooking the COVID-19 testing needs of rural dwellers. This paper used shortest-path analysis and the improved potential model to measure the accessibility of current and potential COVID-19 testing facilities, superimposing this with the testing demands of residents, as calculated by the population demand index, so as to comprehensively evaluate the equity of the spatial allocation of the current and potential testing facilities, with a particular focus on Haishu District, Ningbo City, China. The results revealed that the overall accessibility of the current testing facilities in Haishu District was high, while the internal spatial differentiation was considerable. The comprehensive accessibility of testing facilities gradually declined from the downtown areas towards the rural areas. Moreover, roughly half of the rural population needing COVID-19 tests encountered hindrances due to poor access to testing agencies. However, after fully exploiting the potential testing facilities, the comprehensive accessibility of testing facilities was significantly improved, and the inequity in the accessibility to testing facilities was effectively alleviated, which significantly improved the equity of the allocation of testing facilities in Haishu District. The leveraging of current medical facilities to boost the number of testing facilities in rural areas could eliminate the disparity of resource distribution caused by urban and rural binary opposition, and could quickly identify external sources of COVID-19 in rural areas in the post-epidemic period. Moreover, efficient COVID-19 testing combined with the travel records of infection carriers can effectively identify unknown infection cases and obviate large-scale infection outbreaks.

Ten years of China's new healthcare reform: a longitudinal study on changes in health resources

BACKGROUND

China launched a new round of healthcare-system reform in 2009 and proposed the goal of equal and guaranteed essential medical and health services for all by 2020. We aimed to investigate the changes in China's health resources over the past ten years after the healthcare reform.

METHODS

Data were collected from the China Statistical Yearbook and China Health Statistics Yearbook from 2009 to 2018. Four categories and ten indicators of health resources were analyzed. A descriptive analysis was used to present the overall condition. The Health Resource Density Index was applied to showcase health-resource distribution in demographic and geographic dimensions. The global and local Moran's I were used to assess the spatial autocorrelation of health resources. Concentration Index (CI) was used to quantify the equity of health-resource distribution. A Geo-Detector model and Geographic Weighted Regression (GWR) were applied to assess the association between gross domestic product (GDP) per capita and health resources.

RESULTS

Health resources have increased over the past ten years. The global and local Moran's I suggested spatial aggregation in the distribution of health resources. Hospital beds were concentrated in wealthier areas, but this inequity decreased yearly (from CI=0.0587 in 2009 to CI=0.0021 in 2018). Primary medical and health institutions (PMHI) and their beds were concentrated in poorer areas (CI remained negative). Healthcare employees were concentrated in wealthier areas (CI remained positive). In 2017, the q-statistics indicated that the explanatory power of GDP per capita to beds, health personnel, and health expenditure was 40.7%, 50.3%, and 42.5%, respectively. The coefficients of GWR remained positive with statistical significance, indicating the positive association between GDP per capita and health resources.

CONCLUSIONS

From 2009 to 2018, the total amount of health resources in China has increased substantially. Spatial aggregation existed in the health-resources distribution. Health resources tended to be concentrated in wealthier areas. When allocating health resources, the governments should take economic factors into account.

Changes in ST segment elevation myocardial infarction hospitalisations in China from 2011 to 2015

Objective

Access to acute cardiovascular care has improved and health services capacity has increased over the past decades. We assessed national changes in (1) patient characteristics, (2) in-hospital management and (3) patient outcomes among patients presenting with ST segment elevation myocardial infarction (STEMI) in 2011–2015 in China.

Methods

In a nationally representative sample of hospitals in China, we created two random cohorts of patients in 2011 and 2015 separately. We weighted our findings to estimate nationally representative numbers and assessed changes from 2011 to 2015. Data were abstracted from medical charts centrally using standardised definitions.

Results

While the proportion of patients with STEMI among all patients with acute myocardial infarction decreased over time from 82.5% (95% CI 81.7 to 83.3) in 2011 to 68.5% (95% CI 67.7 to 69.3) in 2015 (p<0.0001), the weighted national estimate of patients with STEMI increased from 210 000 to 380 000. The rate of reperfusion eligibility among patients with STEMI decreased from 49.3% (95% CI 48.1 to 50.5) to 42.2% (95% CI 41.1 to 43.4) in 2015 (p<0.0001); ineligibility was principally driven by larger proportions with prehospital delay exceeding 12 hours (67.4%–76.7%, p<0.0001). Among eligible patients, the proportion receiving reperfusion therapies increased from 54% (95% CI 52.3 to 55.7) to 59.7% (95% CI 57.9 to 61.4) (p<0.0001). Crude and risk-adjusted rates of in-hospital death did not differ significantly between 2011 and 2015.

Conclusions

In this most recent nationally representative study of STEMI in China, the use of acute reperfusion increased, but no significant improvement occurred in outcomes. There is a need to continue efforts to prevent cardiovascular diseases, to monitor changes in in-hospital treatments and outcomes, and to reduce prehospital delay.

Terrorism in China and the Emerging Needs for Counter- Terrorism Medicine Following a Decade of Deaths and Injuries

BACKGROUND

China is ranked 42nd on the Global Terrorism Index (2019), a scoring system of terrorist activities. While China has a relatively low terrorism risk, events globally have wide-ranging repercussions for future attacks, putting first responders and emergency health workers at risk. This study aims to provide the epidemiological context for the past decade detailing the unique injury types responders are likely to encounter and to develop training programs utilizing these data.

METHODS

The Global Terrorism Database (GTD) was searched for all attacks in China between the years 2008-2018. Attacks met inclusion criteria if they fulfilled the terrorism-related criteria as set by the GTD's Codebook. Ambiguous events, as defined by the GTD's Codebook, were excluded. English language grey literature was searched to ensure no events meeting these criteria were missed. A focused search of online English language newspaper articles was also performed for any terrorist events between 2008-2018.

RESULTS

One-hundred and eight terrorist events occurred in the study time period. Of the 108 incidents, forty-seven (43.5%) involved Explosives/Bombs/Dynamite (E/B/D) only, with an average fatality count of 2.9 and injury count of 7.5 per event. Twenty-seven (25.0%) used bladed or blunt weapons in melees with an average fatality count of 9.7 and an injury count of 8.8 per event. Five (4.6%) involved incendiary weapons with an average fatality count of 2.4 and an injury count of 7.2 per event. Two used only chemical weapons (1.8%) with no recorded deaths and an injury count of 27.0 per event. Two events had unknown weapon types (1.8%) with one recorded death and no injury count. One event used a firearm (0.9%) and led to one death and no injuries. One event used a vehicle (0.9%), which also led to one death and no recorded injuries. Twenty-three attacks used a mix of weapons (21.2%) with an average fatality count of 17.1 and an injury count of 12.0 per event.

CONCLUSIONS

One-hundred and eight terrorist attacks were recorded between 2008-2018 on Chinese soil using well-understood modalities. This resulted in a total of 809 recorded fatalities with 956 non-fatal injuries. The most commonly chosen methodology was E/B/D, followed by melees and the use of bladed weapons. Three events individually recorded a combined casualty toll of over 100 people.

Regional Disparity and Patients Mobility: Benefits and Spillover Effects of the Spatial Network Structure of the Health Services in China

BACKGROUND

The distribution of medical resources in China is seriously imbalanced due to imbalanced economic development in the country; unbalanced distribution of medical resources makes patients try to seek better health services. Against this backdrop, this study aims to analyze the spatial network characteristics and spatial effects of China's health economy, and then find evidence that affects patient mobility.

METHODS

Data for this study were drawn from the China Health Statistical Yearbooks and China Statistical Books. The gravitational value of China's health spatial network was calculated to establish a network of gravitational relationships. The social network analysis method was used for centrality analysis and spillover effect analysis.

RESULTS

A gravity correlation matrix was constructed among provinces by calculating the gravitational value, indicating the spatial relationships of different provinces in the health economic network. Economically developed provinces, such as Shanghai and Jiangsu, are at the center of the health economic network (centrality degree = 93.333). These provinces also play a strong intermediary role in the network and have connections with other provinces. In the CONCOR analysis, 31 provinces are divided into four blocks. The spillover effect of the blocks indicates provinces with medical resource centers have beneficial effects, while provinces with insufficient resources have obvious spillover effects.

CONCLUSION

There is a significant gap in the geographical distribution of medical resources, and the health economic spatial network structure needs to be improved. Most medical resources are concentrated in economically developed provinces, and these provinces' positions in the health economic spatial network are becoming more centralized. By contrast, economically underdeveloped regions are at the edge of the network, causing patients to move to provinces with medical resource centers. There are health risks of the increasing pressure to seek medical treatment in developed provinces with abundant medical resources.

Construction of a Medical Resource Sharing Mechanism Based on Blockchain Technology: Evidence from the Medical Resource Imbalance of China

Health equity is a very important part of social equity. The outbreak of the novel coronavirus pneumonia (COVID-19) in a short period of time exposed the problems existing in the allocation of medical resources and the response to major public health emergencies in China. By using Kernel density estimation and Data envelopment analysis (DEA), it is found that the allocation and imbalance of medical resources in China are greatly different among regions, and the polarization phenomenon is obvious. As an important part of the information technology system, blockchain technology is characterized by decentralization and non-tampering. It can realize sharing of medical resources through a mechanism of resource storage, circulation, supervision, and protection. The construction of a medical resource sharing mechanism under the condition of blockchain technology will greatly improve the degree of medical resource sharing, will narrow the differences in resource allocation between regions, and can effectively respond to an outbreak of major public health emergencies.

Increased recurrent risk did not improve cerebrovascular disease survivors' response to stroke in China: a cross-sectional, community-based study

Background

Cerebrovascular disease (CVD) survivors are at a high risk of recurrent stroke. Although it is thought that survivors with higher risk of stroke respond better to stroke onset, to date, no study has been able to demonstrate that. Thus, we investigated whether the intent to call emergency medical services (EMS) increased with recurrent stroke risk among CVD survivors.

Methods

A cross-sectional community-based survey was conducted from January 2017 to May 2017, including 187,723 adults (age ≥ 40 years) across 69 administrative areas in China. A CVD survivor population of 6290 was analyzed. According to the stroke risk score based on Essen Stroke Risk Score, CVD survivors were divided into three subgroups: low (0), middle (1–3) and high (4–7) recurrent risk groups. Multivariable logistic regression models were used to identify the association between the stroke risk and stroke recognition, as well as stroke risk and EMS calling.

Results

The estimated stroke recognition rate in CVD survivors with low, middle, and high risk was 89.0% (503/565), 85.2% (3841/4509), and 82.5% (1001/1213), respectively, while the rate of calling EMS was 66.7% (377/565), 64.3% (2897/4509), and 69.3% (840/1213), respectively. The CVD survivors’ knowledge of recognizing stroke and intent to call EMS did not improve with recurrent stroke risk, even after adjustment for multiple socio-demographic factors.

Conclusions

Despite being at a higher risk of recurrent stroke, Chinese CVD survivors showed poor knowledge of stroke, and their intent to call EMS did not increase with recurrent stroke risk. Enhanced and stroke risk-orientated education on stroke recognition and proper response is needed for all CVD survivors.

Characteristics and treatment of patients with epistaxis over the last 5 years in Guangzhou

Background:

Epistaxis is one of the most common emergencies in the department of otolaryngology, which gives a burden to the health care system.

Objectives:

This study aimed to investigate the patients’ characteristics of hospital admission with epistaxis and provide an optimized protocol.

Methods:

This study was a retrospective analysis of patients with epistaxis admitted to The Third Affiliated Hospital of Sun Yat-sen University in Guangzhou, China. The data were analyzed in terms of gender, age, seasonal differences, length and expenses of hospitalization, pathogenesis of epistaxis, primary medical management before hospital admission, bleeding sites, and treatment.

Results:

A total of 387 patients were included, which consisted of 270 males and 117 females with an average of 43 years. Most patients could be identified with underlying diseases, and the most commonly observed bleeding site was Little area (n = 164). Most patients received electrocauterization as a precision medical treatment (n = 288). The duration of hospitalization length ranged from a mean of 5.17–4.48 days, and the expenses of hospitalization ranged from a mean of RMB 4881–4951 yuan over the last 5 years.

Conclusion:

Most patients with epistaxis could be treated as outpatients by endoscopic electrocauterization, and hospitalization is indicated when patients need improvement of poor general condition, posterior packing, embolization, or surgery. This study enables to provide an optimized protocol for patient with epistaxis.

Cardiovascular surgery experience does not significantly improve patients' response to stroke

OBJECTIVES

Patients with a history of cardiovascular surgery are at risk of stroke, and immediately calling emergency medical services (EMS) after stroke onset is crucial to receiving effective reperfusion therapy. We aimed to determine the effect of a history of cardiovascular surgery on patients' ability to recognize stroke and intent to call EMS.

METHODS

We performed a cross-sectional community-based study from January 2017 to May 2017. A total population of 186,167 individuals, recruited from 69 administrative areas across China, was analyzed. Different multivariable logistic regression models were performed to identify the associations between cardiovascular surgical history and stroke recognition or intent to call EMS, respectively.

RESULTS

0.1% of the total population had a history of cardiovascular surgery. In the surgery group, the estimated stroke recognition rate (SRR) and correct action rate (CAR) were 84.9% and 74.7%, respectively. The prevalence of cardiovascular risk factors was significantly higher in the surgery group. Cardiovascular surgical history was not associated with recognition of stroke across different models. The surgery group was more likely to call EMS, but the difference was not significant after full adjustment (OR: 1.40, 95% CI: 0.99-1.98, p = .0572).

CONCLUSIONS

Cardiovascular surgical history does not influence patients' likelihood of calling EMS more often at stroke onset. Patients receiving cardiovascular surgeries should be counseled regarding stroke recognition, proper response to stroke, and the importance of controlling risk factors.

Sex-specific prevalence, inequality and associated predictors of hypertension, diabetes, and comorbidity among Bangladeshi adults: results from a nationwide cross-sectional demographic and health survey

OBJECTIVES

To determine the sex-specific prevalence, inequality and factors associated with healthcare utilisation for diabetes mellitus (DM), hypertension and comorbidity among the adult population of Bangladesh.

STUDY DESIGN

This study analysed cross-sectional nationwide Bangladesh Demographic and Health Survey data from 2011. Comorbidity was defined as the coexistence of both DM and hypertension. Several socioeconomic and demographic factors such as age, sex, education, geographic location, administrative division, employment status, education and wealth index were considered as major explanatory variables. Inequality in prevalence and healthcare utilisation was measured using the 'Lorenz curve'. Adjusted multiple logistic regression models were performed to observe the effects of different factors and reported as adjusted ORs (AORs) with 95% CIs. A p value of <0.05 was adopted as the level of statistical significance.

SETTING

The study was conducted in Bangladesh.

PARTICIPANTS

A total of 7521 adult participants with availability of biomarkers information were included.

RESULTS

The mean age of the study participants was 51.4 years (SD ±13.0). The prevalence of hypertension, diabetes and comorbidity were 29.7%, 11.0% and 4.5% respectively. Socioeconomic inequality was observed in the utilisation of healthcare services. A higher prevalence of hypertension and comorbidity was significantly associated with individuals aged >70 years (AOR 7.0, 95% CI 5.0 to 9.9; AOR 6.7, 95% CI 3.0 to 14.9). The risk of having hypertension, diabetes and comorbidity were significantly higher among more educated, unemployed as well as among individuals from Khulna division.

CONCLUSIONS

The study revealed a rising prevalence of hypertension, diabetes and comorbidity with inequality in service utilisation. A joint effort involving public, private and non-governmental organisations is necessary to ensure improved accessibility in service utilisation and to reduce the disease burden.

The comparison of healthcare utilization inequity between URRBMI and NCMS in rural China

BACKGROUND

The inequity of healthcare utilization in rural China is serious, and the urban-rural segmentation of the medical insurance system intensifies this problem. To guarantee that the rural population enjoys the same medical insurance benefits, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) nationwide in 2016. Against this backdrop, this paper aims to compare the healthcare utilization inequity between URRBMI and New Cooperative Medical Schemes (NCMS) and to analyze whether the inequity is reduced under URRBMI in rural China.

METHODS

Using the data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which was conducted in 2015, a binary logistic regression model was applied to analyze the influence of income on healthcare utilization, and the decomposition of the concentration index was adopted to compare the Horizontal inequity index (HI index) of healthcare utilization among the individuals insured by URRBMI and NCMS.

RESULTS

There is no statistically significant difference in healthcare utilization between URRBMI and NCMS, but in outpatient utilization, there are significant differences among different income groups in NCMS; high-income groups utilize more outpatient care. The Horizontal inequity indexes (HI indexes) in outpatient utilization for individuals insured by URRBMI and NCMS are 0.024 and 0.012, respectively, indicating a pro-rich inequity. Meanwhile, the HI indexes in inpatient utilization under the two groups are - 0.043 and - 0.028, respectively, meaning a pro-poor inequity. For both the outpatient and inpatient care, the inequity degree of URRBMI is larger than that of NCMS.

CONCLUSIONS

This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. More chronic diseases should be covered and moral hazard should be avoided in URRBMI. For the vulnerable groups, special policies such as reducing the deductible and covering these groups with catastrophic medical insurance could be considered.

Challenges for the surgical capacity building of township hospitals among the Central China: a retrospective study

BACKGROUND

China's rapid transition in healthcare service system has posed considerable challenges for the primary care system. Little is known regarding the capacity of township hospitals (THs) to deliver surgical care in rural China with over 600 million lives. We aimed to ascertain its current performance, barriers, and summary lessons for its re-building in central China.

METHODS

This study was conducted in four counties from two provinces in central China. The New Rural Cooperative Medical System (NRCMS) claim data from two counties in Hubei province was analyzed to describe the current situation of surgical care provision. Based on previous studies, self-administered questionnaire was established to collect key indicators from 60 THs from 2011 to 2015, and social and economic statuses of the sampling townships were collected from the local statistical yearbook. Semi-structured interviews were conducted among seven key administrators in the THs that did not provide appendectomy care in 2015. Determinants of appendectomy care provision were examined using a negative binominal regression model.

RESULTS

First, with the rapid increase in inpatient services provided by the THs, their proportion of surgical service provision has been nibbled by out-of-county facilities. Second, although DY achieved a stable performance, the total amount of appendectomy provided by the 60 THs decreased to 589 in 2015 from 1389 in 2011. Moreover, their proportion reduced to 26.77% in 2015 from 41.84% in 2012. Third, an increasing number of THs did not provide appendectomy in 2015, with the shortage of anesthesiologists and equipment as the most mentioned reasons (46.43%). Estimation results from the negative binomial model indicated that the annual average per capita disposable income and tightly integrated delivery networks (IDNs) negatively affected the amount of appendectomy provided by THs. By contrast, the probability of appendectomy provision by THs was increased by performance-related payment (PRP). Out-of-pocket (OOP) cost gap of appendectomy services between the two different levels of facilities, payment method, and the size of THs presented no observable improvement to the likelihood of appendectomy care in THs.

CONCLUSION

The county-level health system did not effectively respond to the continuously increasing surgical care need. The surgical capacity of THs declined with the surgical patterns' simplistic and quantity reduction. Deficits and critical challenges for surgical capacity building in central China were identified, including shortage of human resources and medical equipment and increasing income. Moreover, tight IDNs do not temporarily achieve capacity building. Therefore, the reimbursement rate should be further ranged, and physicians should be incentivized appropriately. The administrators, policy makers, and medical staff of THs should be aware of these findings owing to the potential benefits for the capacity building of the rural healthcare system.

Equity and efficiency of medical service systems at the provincial level of China's mainland: a comparative study from 2009 to 2014

BACKGROUND

The astonishing economic achievements of China in the past few decades have remarkably increased not only the quantity and quality of medical services but also the inequalities in health resources allocation across regions and inefficiency of the medical service delivery.

METHODS

A descriptive analysis was used to compare the inequities in inputs and outputs of the provincial medical service systems, a non-radial super-efficiency data envelopment analysis model was then used to estimate the efficiency, and a regression analysis of the panel data was used to explore the determinants.

RESULTS

The inputs and outputs of most provincial medical service systems increased gradually from 2009 to 2014. Overall, the eastern region allocated more human and capital resources than the other two regions, and produced more than 50% of the total outpatient and emergency room visits, whereas the western region produced more inpatient services (about 30% of the total volume of inpatient services) according to the distribution of the population. The average efficiency scores of the provincial medical systems in China's mainland were 0.895, 0.927, 0.929, 0.963, 0.977 and 0.968 from 2009 to 2014, with a slight average improvement of 1.60%. The efficiency score of each provincial medical service system varied greatly from one another: Tibet (1.475 ± 0.057) performed extremely well, whereas several others including Heilongjiang (0.579 ± 0.001) performed poorly. Furthermore, the proportion of high-class medical facilities was negatively associated with efficiency, whereas the proportion of the vulnerable population, the per capita Gross Domestic Product, the proportion of the illiterate population and the improvement of primary health care had positive effects on efficiency.

CONCLUSION

Inequity in health resources allocation and service provision existed across the regions, but not all the gaps have begun to narrow since 2009. The difference of efficiency was great among provincial medical service systems but minor across regions, and the score changed very little over time. More importantly, the central region held the lowest average efficiency score in the past 6 years, while the western region held the largest average efficiency score at the first 5 years, which should receive enough attention of the government and decision-makers. In practice, efficiency was related to many complicated factors, indicating that the improvement of efficiency is a complex and iterative process that requires the strong cooperation of many sectors.

Equality in the distribution of health material and human resources in Guangxi: evidence from Southern China

Objective

The aim of this study was to assess the equality in the distribution of health material and human resources in Guangxi, and put forward proposal to improve the equality status of the health material and human resources.

Results

We used concentration index to evaluate the degree of income-related equality of health material and human resources. The concentration index values of the five resources ranged from −0.0847 to 0.1416 from 2011 to 2015. Health institution was concentrated among the poorer populations, while other four resources were concentrated among the richer populations. Overall, the equality status of health institutions, health care beds, health technical personnel, and certified nurses got better from 2011 to 2015. However, the equality status of practicing physicians has got worse since 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2760-0) contains supplementary material, which is available to authorized users.

Evaluation on equality and efficiency of health resources allocation and health services utilization in China

Background

China is faced with a daunting challenge to equality and efficiency in health resources allocation and health services utilization in the context of rapid economic growth. This study sought to evaluate the equality and efficiency of health resources allocation and health services utilization in China.

Methods

Demographic, economic, and geographic area data was sourced from China Statistical Yearbook 2012–2016. Data related to health resources and health services was obtained from China Health Statistics Yearbook 2012–2016. Furthermore, we evaluated the equality of health resources allocation based on Gini coefficient. Concentration index was used to measure the equality in utilization of health services. Data envelopment analysis (DEA) was employed to assess the efficiency of health resources allocation.

Results

From 2011 to 2015, the Gini coefficients for health resources by population ranged between 0.0644 and 0.1879, while the Gini coefficients for the resources by geographic area ranged from 0.6136 to 0.6568. Meanwhile, the concentration index values for health services utilization ranged from −0.0392 to 0.2110. Moreover, in 2015, 10 provinces (32.26%) were relatively efficient in terms of health resources allocation, while 7 provinces (22.58%) and 14 provinces (45.16%) were weakly efficient and inefficient, respectively.

Conclusions

There exist distinct regional disparities in the distribution of health resources in China, which are mainly reflected in the geographic distribution of health resources. Furthermore, the people living in the eastern developed areas are more likely to use outpatient care, while the people living in western underdeveloped areas are more likely to use inpatient care. Moreover, the efficiency of health resources allocation in 21 provinces (67.74%) of China was low and needs to be improved. Thus, the government should pay more attention to the equality based on geographic area, guide patients to choose medical treatment rationally, and optimize the resource investments for different provinces.