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Neumann A. Stakeholders' Perceived Barriers and Successes of Quality Improvement Programs for Patients With Diabetes Comment on "Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China". Int J Health Policy Manag 2023; 12:7831. [PMID: 38618776 PMCID: PMC10843251 DOI: 10.34172/ijhpm.2023.7831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/02/2023] [Indexed: 04/16/2024] Open
Abstract
Rasooly et al performed a qualitative evaluation to characterize the experiences of 26 stakeholders with the implementation of diabetes-related quality and performance measures delivered in primary healthcare to patients with diabetes in metropolitan China. Results from this cross-sectional investigation identified relevant gaps in primary care delivery for people with diabetes from one major center in China. As diabetes is a prevalent condition worldwide, lessons learned from this research can be useful to guide, refine, and improve quality measurement evaluations in primary care in China and other countries. In this commentary, we comment on the strengths and weaknesses of the study, suggest future directions, and discuss how lessons learned from this research can be helpful to guide, refine, and improve the quality measurement of diabetes care in other countries.
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Affiliation(s)
- Ana Neumann
- Department of General Practice and Dental Public Health, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Lin YT, Zhou CC, Xu K, Zhang MD, Li X. Cost-effectiveness analysis of serplulimab in combination with cisplatin plus 5-fluorouracil chemotherapy compared to cisplatin plus 5-fluorouracil chemotherapy as first-line treatment for advanced or metastatic esophageal squamous cell carcinoma in China. Ther Adv Med Oncol 2023; 15:17588359231213621. [PMID: 38028139 PMCID: PMC10666699 DOI: 10.1177/17588359231213621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Background This study evaluated the cost-effectiveness of serplulimab plus chemotherapy versus chemotherapy alone in treating advanced/metastatic esophageal squamous cell carcinoma (ESCC) within the Chinese health care system. Methods A partitioned survival model based on ASTRUM-007 trial patient characteristics was developed. Efficacy, safety, and medical/economic data were obtained from the trial and real-world clinical practice. Costs, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs) were calculated for both treatment strategies. Sensitivity, subgroup, and scenario analyses were performed to assess the uncertainty impact. Results Serplulimab combined with chemotherapy yielded an ICER of US$ 53,538.27/QALY. Deterministic sensitivity analysis identified patient survival and serplulimab price as influential parameters. Probabilistic sensitivity analysis showed a 47.33% probability of cost-effectiveness at a willingness-to-pay (WTP) threshold of US$ 53,541/QALY and 0.05% at three times China's GDP per capita. Subgroup analysis revealed that patients with a programmed death-ligand 1 (PD-L1) expression combined positive score (CPS) ⩾10 had a lower hazard ratio (0.59) and ICER (US$ 29,935.23/QALY), with a 95.36% probability of cost-effectiveness. Scenario analysis demonstrated that the drug donation discount policy significantly increased the likelihood of cost-effective serplulimab-chemotherapy combinations in Jiangsu, Fujian, and Guangdong at 99.99%, 99.90%, and 94.16%, respectively. Conclusion Compared to chemotherapy alone, serplulimab combined with chemotherapy is currently not a cost-effective first-line treatment for advanced/metastatic ESCC in China. However, as serplulimab plus chemotherapy regimens evolve and price competition among programmed death 1 (PD-1) inhibitors intensifies, this combination may become a cost-effective treatment option.
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Affiliation(s)
- Ying-Tao Lin
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Drug Clinical Trial Institution, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chong-Chong Zhou
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Kai Xu
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Meng-Die Zhang
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xin Li
- Center for Global Health, School of Public Health, Nanjing Medical University, No.101 Longmian Avenue, Nanjing, Jiangsu 210029, China
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, No.101 Longmian Avenue, Nanjing, Jiangsu, China
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Wang W, Zhang J, Loban K, Wei X. High performing primary health care organizations from patient perspective: a qualitative study in China. Glob Health Res Policy 2023; 8:31. [PMID: 37544999 PMCID: PMC10405398 DOI: 10.1186/s41256-023-00315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND There is a global call to build people-centred primary health care (PHC) systems. Previous evidence suggests that without organization-level reform efforts, the full potential of policy reforms may be limited. This study aimed to generate a profile of high performing PHC organizations from the perspective of patients. METHODS We conducted semi-structured interviews with 58 PHC users from six provinces (Shandong, Zhejiang, Shaanxi, Henan, Shanxi, Heilongjiang) in China using purposive and snowball sampling techniques. Transcription was completed by trained research assistants through listening to the recordings of the interviews and summarizing them in English by 30-s segments to generate the narrative summary. Informed by the Classification System of PHC Organizational Attributes, thematic analysis aimed to identify domains and attributes of high performing PHC organizations. RESULTS A profile of a high performing PHC organization with five domains and 14 attributes was generated. The five domains included: (1) organizational resources including medical equipment, human and information resource; (2) service provision and clinical practice including practice scope, internal integration and external integration; (3) general features including location, environment and ownership; (4) quality and cost; and (5) organizational structure including continuous learning mechanism, administrative structure and governance. CONCLUSIONS A five-domain profile of high performing PHC organizations from the perspective of Chinese PHC users was generated. Organizational resources, service delivery and clinical practices were most valued by the participants. Meanwhile, the participants also had strong expectation of geographical accessibility, high quality of care as well as efficient organizational structure. These organizational elements should be reflected in further reform efforts in order to build high performing PHC organizations.
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Affiliation(s)
- Wenhua Wang
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, People's Republic of China.
| | - Jinnan Zhang
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Katya Loban
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Tang C, Fang P, Bai X, Min R, Liu C. Patient experience in community health services and first choice for medical attention: A cross-sectional study in Wuhan, China. PLoS One 2023; 18:e0288164. [PMID: 37490476 PMCID: PMC10368283 DOI: 10.1371/journal.pone.0288164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 06/21/2023] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVES In China, it is up to the patients to choose between hospitals and primary care facilities to initiate their medical care. This study aimed to determine the association between patient experience with community health centres (CHCs, a predominant provider of community-based primary care) and patient preference of taking community-based primary care facilities as a first choice for medical attention. METHODS A questionnaire survey was conducted on 1919 patients who sought medical care in 55 CHCs in Wuhan, China. Respondents were asked to identify their preferred first choice for medical attention and rate their satisfaction with eight aspects of CHCs (basic facility, medical equipment, medical services, nursing services, treatment process, courtesy and responsiveness, time spent with medical doctor, pharmacy services). Multivariate logistic regression models were established to determine the association between the CHC experience and the first choice of providers after adjustment for variations in sociodemographic characteristics. RESULTS Over 90% of respondents were satisfied or very satisfied with the eight aspects of CHCs; but only 75% preferred to take community-based primary care facilities as their first choice for medical attention. Those who were older and had a lower income were more likely to choose community-based primary care facilities. Geographic proximity and higher levels of satisfaction with the basic facility, courtesy and responsiveness, and pharmacy services in the CHCs were associated with a higher likelihood of taking community-based primary care facilities as a first choice for medical attention. CONCLUSION The consumers of CHCs are generally satisfied with the services they received. However, one quarter of the CHC patients are yet to be convinced to accept community-based primary care facilities as a preferred first provider for medical care. Geographic proximity and patient experience with CHCs are associated with the patient choice.
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Affiliation(s)
- Changmin Tang
- School of Management, Hubei University of Chinese Medicine, Wuhan, Hubei, China
- Key Research Institute of Humanities and Social Sciences of Hubei Province, Wuhan, Hubei, China
| | - Pengqian Fang
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xue Bai
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Rui Min
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
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Wang P, Li S, Wang Z, Jiao M, Zhang Y, Huang W, Ning N, Gao L, Shan L, Li Y, Wu Q. Perceptions of the benefits of the basic medical insurance system among the insured: a mixed methods research of a northern city in China. Front Public Health 2023; 11:1043153. [PMID: 37139382 PMCID: PMC10149763 DOI: 10.3389/fpubh.2023.1043153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
Background The perceptions of the benefits of the basic medical insurance system among the insured not only reflect the system's performance but also the public's basic medical insurance policy literacy, valuable information for countries that have entered the stage of deepening reform. This study aims to examine the factors that affect the perceptions of the benefits of the basic medical insurance system in China, diagnose the key problems, and propose corresponding measures for improvement. Methods A mixed method design was used. Data for the quantitative study were obtained from a cross-sectional questionnaire survey (n = 1,045) of residents of Harbin who had enrolled for basic medical insurance system. A quota sampling method was further adopted. A multivariate logistic regression model was then employed to identify the factors influencing the perceptions of the benefits of the basic medical insurance system, followed by semi-structured interviews with 30 conveniently selected key informants. Interpretative phenomenological analysis was used to analyze the interview data. Results Approximately 44% of insured persons reported low perceptions of benefits. The logistic regression model showed that low perceptions of the benefits of the basic medical insurance system was positively correlated with the experience of daily drug purchases (OR = 1.967), perceptions of recognition with basic medical insurance system (OR = 1.948), perceptions of the financial burden of participation costs (OR = 1.887), perceptions of the convenience of using basic medical insurance for medical treatment (OR = 1.770), perceptions of the financial burden of daily drug purchases costs (OR = 1.721), perceptions of the financial burden of hospitalization costs (OR = 1.570), and type of basic medical insurance system (OR = 1.456). The results of the qualitative analysis showed that the key problem areas of perceptions of the benefits of the basic medical insurance system were: (I) system design of basic medical insurance; (II) intuitive cognition of the insured; (III) rational cognition of the insured; and (IV) the system environment. Conclusions Improving the perceptions of the benefits of the basic medical insurance system of the insured requires joint efforts in improving system design and implementation, exploring effective publicity methods of basic medical insurance system information, supporting public policy literacy, and promoting the health system environment.
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Affiliation(s)
- Peng Wang
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Shuyi Li
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Zhizhen Wang
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Mingli Jiao
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- Research Center of Health Policy and Management, School of Health Management, Harbin Medical University, Harbin, China
| | - Yuchao Zhang
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Weiqi Huang
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ning Ning
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Lijun Gao
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Linghan Shan
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ye Li
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- Research Center of Health Policy and Management, School of Health Management, Harbin Medical University, Harbin, China
| | - Qunhong Wu
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
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Lovis C, Hefner J, Chen C, Huang Y, Wang X, Yang Q, Zhu X, Zhang X, Hao M, Shui L. Developing a Capsule Clinic-A 24-Hour Institution for Improving Primary Health Care Accessibility: Evidence From China. JMIR Med Inform 2023; 11:e41212. [PMID: 36622737 PMCID: PMC9871876 DOI: 10.2196/41212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/18/2022] [Accepted: 12/08/2022] [Indexed: 01/10/2023] Open
Abstract
Telehealth is an effective combination of medical service and intelligent technology. It can improve the problem of remote access to medical care. However, an imbalance in the allocation of health resources still occurs. People spend more time and money to access higher-quality services, which results in inequitable access to primary health care (PHC). At the same time, patients' usage of telehealth services is limited by the equipment and their own knowledge, and the PHC service suffers from low usage efficiency and lack of service supply. Therefore, improving PHC accessibility is crucial to narrowing the global health care coverage gap and maintaining health equity. In recent years, China has explored several new approaches to improve PHC accessibility. One such approach is the capsule clinic, an emerging institution that represents an upgraded version of the internet hospital. In coordination with the United Nations, the Yinzhou district of Ningbo city in Zhejiang, China, has been testing this new model since 2020. As of October 2022, the number of applications in Ningbo was 15, and the number of users reached 12,219. Unlike internet hospitals, the entire process-from diagnosis to prescription services-can be completed at the capsule clinic. The 24-hour telehealth service could also solve transportation problems and save time for users. Big data analysis can accurately identify regional populations' PHC service needs and improve efficiency in health resource allocation. The user-friendly, low-cost, and easily accessible telehealth model is of great significance. Installation of capsule clinics would improve PHC accessibility and resolve the uneven distribution of health resources to promote health equity.
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Affiliation(s)
| | | | - Chun Chen
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Yunyun Huang
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Xiaoyi Wang
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Qingren Yang
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Xuebo Zhu
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Xiangyang Zhang
- Engineering Research Center of Intelligent Medicine (2016E10011), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mo Hao
- School of Public Health, Fudan University, Shanghai, China
| | - Liming Shui
- Yinzhou District Health Bureau, Ningbo, China
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Cao W, Feng H, Ma Y, Zhao D, Hu X. Long-term trend of antibiotic use at public health care institutions in northwest China, 2012-20 -- a case study of Gansu Province. BMC Public Health 2023; 23:27. [PMID: 36604660 PMCID: PMC9814306 DOI: 10.1186/s12889-022-14944-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Over the past 20 years, excessive antibiotic use has led to serious antimicrobial resistance (AMR) worldwide, and the phenomenon is particularly serious in China. To this end, the Chinese health sector took a series of measures to promote rational antibiotic use. In this study, to reveal the impact of policies on antibiotic use, we explored the long-term trend and patterns of antibiotic use at public health care institutions from 2012 to 2020 in northwest China, taking Gansu Province as an example. METHODS Antibiotic procurement data were obtained from the provincial centralized bidding procurement (CBP) platform between 2012 and 2020. Antibiotic use was quantified using the Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology and standardized using the DDD per 1000 inhabitants per day (DID). Twelve relevant quality indicators were calculated for comparison with the European Surveillance of Antimicrobial Consumption (ESAC) project monitoring results. RESULTS Total antibiotic use increased from 18.75 DID to 57.07 DID and then decreased to 19.11 DID, a turning point in 2014. The top three antibiotics used were J01C (beta-lactam antibacterials, penicillins), J01F (macrolides, lincosamides and streptogramins), and J01D (other beta-lactam antibacterials, cephalosporins), accounting for 45.15%, 31.40%, and 11.99% respectively. The oral antibiotics used were approximately 2.5 times the parenteral antibiotics, accounting for 71.81% and 28.19%, respectively. Different use preferences were shown in public hospitals and primary health care centres (PHCs), and the latter accounted for more than half of total use. The absolute use of all classes of antibiotics in Gansu is almost higher than any of the 31 European countries included in the ESAC, but the relative use of some focused antibiotics is lower than theirs. CONCLUSIONS The intervention policies of the health department reduced antibiotic use in Gansu Province, but the proportion of broad-spectrum and parenteral antibiotics was still high. It is necessary to further improve the quality of antibiotic prescriptions and pay more attention to the rationality of antibiotic use in PHCs.
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Affiliation(s)
- Wenxuan Cao
- grid.32566.340000 0000 8571 0482School of Public Health, Lanzhou University, Lanzhou, 730000 China
| | - Hu Feng
- grid.32566.340000 0000 8571 0482School of Public Health, Lanzhou University, Lanzhou, 730000 China
| | - Yongheng Ma
- Division of Pharmaceutical Procurement, Gansu Public Resources Trading Center, Lanzhou, 730000 China
| | - Defang Zhao
- Division of Pharmaceutical Procurement, Gansu Public Resources Trading Center, Lanzhou, 730000 China
| | - Xiaobin Hu
- grid.32566.340000 0000 8571 0482School of Public Health, Lanzhou University, Lanzhou, 730000 China
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Luo X, Yu S, Zeng Z, Zhou X, Liu Y, Wang L, Hu J, Chang Y. Systemic glucocorticoid prescriptions pattern and factors of inappropriate use in primary care institutions of Southwest China. Front Public Health 2022; 10:952098. [PMID: 36172212 PMCID: PMC9510701 DOI: 10.3389/fpubh.2022.952098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/24/2022] [Indexed: 01/24/2023] Open
Abstract
Background Inappropriate use of glucocorticoids in primary care institutions is serious. It not only causes economic burden, but leads to many adverse reactions. The purpose of this study is to explore systemic glucocorticoid prescription pattern and factors of inappropriate use in primary care institutions. Methods This is a retrospective study. Systemic glucocorticoids prescribed in 58 primary care institutions in Guizhou province of Southwest China in 2020 were selected from the Health Information System. All prescriptions were classified as appropriate or inappropriate use. Inappropriate use was classified into the following two categories: (a) Inappropriate indications; (b) Inappropriate selection of glucocorticoids. Multivariate analysis was used to explore the factors associated with inappropriate use of systemic glucocorticoids. Results A total of 63,315 glucocorticoid prescriptions were included in the analysis. Diseases of the respiratory system (60.8%) and diseases of the skin and subcutaneous tissue (23.1%) were the most common indications for use. Injections (89.8%) predominated and dexamethasone (86.5%) was the most prescribed glucocorticoid. 68.2% of all prescriptions were inappropriate. Compared to physicians with a college degree, physicians with a junior college (OR: 1.12, 95% CI: 1.08-1.17) and technical secondary education (OR: 1.12, 95% CI:1.05-1.19) were more likely to prescribe glucocorticoids inappropriately as were attending physicians (OR: 1.12, 95% CI: 1.01-1.25) and resident physicians (OR: 1.31, 95% CI: 1.15-1.48) compared to associate chief physicians. The risk of inappropriate glucocorticoid use was highest in patients 65 years of age and older (OR: 6.00, 95% CI: 5.62-6.40). In contrast, prescriptions given by injection were more likely to be used inappropriately than those given orally (OR: 0.44, 95% CI: 0.41-0.46). Conclusion Inappropriate use of systemic glucocorticoids without appropriate indications was extremely prominent in primary care institutions of Guizhou Province, especially in diseases of the respiratory system and among the elderly. The risk of inappropriate glucocorticoid use was highest in patients 65 years of age and older. It is important to note that physicians younger than 33, with more than 40 years of service, and attending or residents were more likely to inappropriately prescribe glucocorticoids.
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Affiliation(s)
- Xiaobo Luo
- School of Public Health, Guizhou Medical University, Guiyang, China
| | - Shitao Yu
- Guiyang Public Health Clinical Center, Guiyang, China
| | - Zhen Zeng
- Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Xunrong Zhou
- Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China,Xunrong Zhou
| | - Yuxi Liu
- School of Humanities and Management, Institute for Health Law and Policy, Guangdong Medical University, Dongguan, China,Yuxi Liu
| | - Lei Wang
- Primary Health Department of Guizhou Provincial Health Commission, Guiyang, China
| | - Jiaqi Hu
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, China
| | - Yue Chang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, China,*Correspondence: Yue Chang
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Lim AH, Ng SW, Teh XR, Ong SM, Sivasampu S, Lim KK. Conjoint analyses of patients’ preferences for primary care: a systematic review. BMC PRIMARY CARE 2022; 23:234. [PMID: 36085032 PMCID: PMC9463739 DOI: 10.1186/s12875-022-01822-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
While patients’ preferences in primary care have been examined in numerous conjoint analyses, there has been little systematic effort to synthesise the findings. This review aimed to identify, to organise and to assess the strength of evidence for the attributes and factors associated with preference heterogeneity in conjoint analyses for primary care outpatient visits.
Methods
We searched five bibliographic databases (PubMed, Embase, PsycINFO, Econlit and Scopus) from inception until 15 December 2021, complemented by hand-searching. We included conjoint analyses for primary care outpatient visits. Two reviewers independently screened papers for inclusion and assessed the quality of all included studies using the checklist by ISPOR Task Force for Conjoint Analysis. We categorized the attributes of primary care based on Primary Care Monitoring System framework and factors based on Andersen’s Behavioural Model of Health Services Use. We then assessed the strength of evidence and direction of preference for the attributes of primary care, and factors affecting preference heterogeneity based on study quality and consistency in findings.
Results
Of 35 included studies, most (82.4%) were performed in high-income countries. Each study examined 3–8 attributes, mainly identified through literature reviews (n = 25). Only six examined visits for chronic conditions, with the rest on acute or non-specific / other conditions. Process attributes were more commonly examined than structure or outcome attributes. The three most commonly examined attributes were waiting time for appointment, out-of-pocket costs and ability to choose the providers they see. We identified 24/58 attributes with strong or moderate evidence of association with primary care uptake (e.g., various waiting times, out-of-pocket costs) and 4/43 factors with strong evidence of affecting preference heterogeneity (e.g., age, gender).
Conclusions
We found 35 conjoint analyses examining 58 attributes of primary care and 43 factors that potentially affect the preference of these attributes. The attributes and factors, stratified into evidence levels based on study quality and consistency, can guide the design of research or policies to improve patients’ uptake of primary care. We recommend future conjoint analyses to specify the types of visits and to define their attributes clearly, to facilitate consistent understanding among respondents and the design of interventions targeting them.
Word Count: 346/350 words.
Trial registration
On Open Science Framework: https://osf.io/m7ts9
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Ge L, Zhang X, Huang Y, Xu T, Zhao Q, Zhu T, Pan J, Chen C. Can a multitiered copayment system affect people's healthcare-seeking behavior? A case study of Wenzhou, China. BMC Health Serv Res 2022; 22:630. [PMID: 35545782 PMCID: PMC9097063 DOI: 10.1186/s12913-022-08031-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 04/25/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Facilitating the primary health care (PHC) system and maintaining people's reasonable healthcare-seeking behavior are key to establishing a sustainable healthcare system. China has employed a multitiered copayment system/medical insurance differentiated payment policies to incentivize the public to utilize PHC services through its hierarchical medical care system; however, most people still prefer visiting tertiary care hospitals. We question whether the quality gap in healthcare services reduces the effect of the multitiered copayment system, which is considered an important factor in the lack of reform in the Chinese healthcare system. Thus, we explore the effect and influencing factors of the multitiered copayment system that drives primary healthcare-seeking behavior under the current situation with a large quality gap. We also consider the hypothetical situation of a reduced gap in the future. METHODS This study used the hypothetical quality improvement scenario to elicit people's hypothetical behaviors, and a multistage stratified cluster random sampling method. This preliminary study was conducted in 2016 using 1829 individuals from four regions of Wenzhou in Zhejiang Province: Ouhai, Ruian, Yongjia, and Taishun. A descriptive statistical analysis, chi-square analysis, Fisher's exact test, and multinomial logistic regression model were performed to introduce the effect of the multitiered copayment system, and to explore the factors affecting the selection of PHC institutions at pre- and post-change phases. RESULT The results show that compared with the large quality gap phase, the number of respondents who believed the multitiered copayment system had an effect on their selection of PHC institutions after the equalization of healthcare services quality increased threefold (from 14.0% to 50.8%). Moreover, the main determinants in people's selection of PHC institutions changed from age and needs variables (self-rated health status) to age, needs variables (self-rated health status) and enabling variables (distance to a medical care facility). CONCLUSION The results indicate limited initial effects of the multitiered copayment system. However, they become more pronounced after the equalization of healthcare services quality. This study confirms that changes in the quality gap in healthcare services influence the effect of the multitiered copayment system. Hence, reducing this gap can help achieve the intended outcome of the tiered healthcare insurance schedule.
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Affiliation(s)
- Lizheng Ge
- School of Public Health and Management, Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China
| | - Xiangyang Zhang
- First Affiliated Hospital of Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China
| | - Yunyun Huang
- School of Innovation and Entrepreneurship, Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Tingke Xu
- School of Public Health and Management, Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China
| | - Qianru Zhao
- School of Public Health and Management, Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China
| | - Tingting Zhu
- School of Public Health and Management, Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China
| | - Jingye Pan
- First Affiliated Hospital of Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China.
| | - Chun Chen
- School of Public Health and Management, Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China.
- Center for Health Assessment, Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
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11
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Liu S, Lin J, He Y, Xu J. The Service Capability of Primary Health Institutions under the Hierarchical Medical System. Healthcare (Basel) 2022; 10:healthcare10020335. [PMID: 35206949 PMCID: PMC8872352 DOI: 10.3390/healthcare10020335] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/29/2022] [Accepted: 02/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Primary health institutions (PHIs) are the foundation of the whole health system and the basic link to achieve the goal of all people enjoying primary health care. However, the service capability of primary health institutions is not under the hierarchical medical system. Method: Data were collected from the China Health Statistics Yearbook between 2014 and 2020. PHIs included community health centres, community health stations, and township hospitals in our study. The service capability of primary health institutions was analysed from the perspective of structure, process, and results. Structure capability was evaluated using the number of beds, number of personnel, number of health technicians, and proportion of the number of personnel in PHIs accounting for the total number of health personnel. Process capability was evaluated using the number of general practitioners. The number of outpatients and inpatients, medical income, the proportion of drug income, and the average number of patients and beds served by physicians in PHIs per day were employed to evaluate the resulting capability. Results: From 2014 to 2020, the number of community health service centres/stations increased, while the number of township health centres decreased. In the aspect of structure capability, the total number of personnel and health technicians in community health centres/stations and township hospitals both increased during 2014 and 2020. However, the increasing rate in PHIs was a little bit less than that of general medical institutions. The proportion of male health technicians in community health centres and township hospitals both decreased, while the proportion of female technicians in both increased. From 2014 to 2020, the number of beds in PHIs also increased from 138.12 × 104 to 164.94 × 104. However, the proportion of beds in PHIs accounting for the total number of beds in medical institutions decreased. For the resulting capability, from 2014 to 2019, the proportion of diagnosis and treatment times in PHIs decreased from 57.41% to 51.96%, although it increased in 2020. The proportion of inpatients in PHIs decreased from 20.03% to 16.11%. From 2014 to 2020, the utilisation rate of hospital beds in PHIs decreased (from 55.6% to 34% for community health centres and 60.5% to 53.6% for township hospitals). The average daily bed days of doctors in township hospitals was higher than that of doctors in community health service centres. However, the average medical cost of outpatients and the per capita medical cost of inpatients in community health service centres were higher than in township hospitals. Conclusion: In recent years, although the service capability showed an increasing trend in PHIs, the growth rate was lower than the general health institutions. The utilisation rates of PHIs, including beds and physicians, were decreased. Among PHIs, the utilisation in township hospitals was higher than in community health centres with a relatively low price. Under the hierarchical medical system and normalisation period of the COVID-19 epidemic, it is important to improve the service capability to achieve its goal of increasing PHI utilisation and decreasing secondary and tertiary hospital utilisation.
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12
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Chiwire P, Beaudart C, Evers SM, Mahomed H, Hiligsmann M. Enhancing Public Participation in Public Health Offerings: Patient Preferences for Facilities in the Western Cape Province Using a Discrete Choice Experiment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19010590. [PMID: 35010867 PMCID: PMC8744715 DOI: 10.3390/ijerph19010590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/23/2021] [Accepted: 12/29/2021] [Indexed: 02/01/2023]
Abstract
Understanding patients’ preferences for health facilities could help decision makers in designing patient-centered services. Therefore, this study aims to understand how patients’ willingness to trade for certain attributes affects the choice of public health facilities in the Western Cape province of Cape Town, South Africa. A discrete choice experiment was conducted in two community day centers (CDCs). Patients repetitively chose between two hypothetical health facilities that differed in six attributes: distance to facility, treatment by doctors vs. nurses, confidentiality during treatment, availability of medication, first visit (drop-in) waiting times, and appointment waiting times. The sample consisted of 463 participants. The findings showed that availability of medication (50.5%), appointment waiting times (19.5%), and first visit waiting times (10.2%) were the most important factors for patients when choosing a health facility. In addition, respondents preferred shorter appointment and first visit waiting times (<2 h). These results identified important characteristics in choosing public health facilities in Cape Town. These public health facilities could be improved by including patient voices to inform operational and policy decisions in a low-income setting.
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Affiliation(s)
- Plaxcedes Chiwire
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, 6200 MD Maastricht, The Netherlands; (C.B.); (S.M.E.); (M.H.)
- Correspondence:
| | - Charlotte Beaudart
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, 6200 MD Maastricht, The Netherlands; (C.B.); (S.M.E.); (M.H.)
| | - Silvia M. Evers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, 6200 MD Maastricht, The Netherlands; (C.B.); (S.M.E.); (M.H.)
| | - Hassan Mahomed
- Metro Health Services, Western Cape Government: Health and Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch 7505, South Africa;
| | - Mickaël Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, 6200 MD Maastricht, The Netherlands; (C.B.); (S.M.E.); (M.H.)
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13
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Chiwire P, Evers SM, Mahomed H, Hiligsmann M. Identification and Prioritization of Attributes for a Discrete Choice Experiment Using the Nominal Group Technique: Patients' Choice of Public Health Facilities in Cape Town, South Africa. Value Health Reg Issues 2021; 27:90-98. [PMID: 34891111 DOI: 10.1016/j.vhri.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 04/29/2021] [Accepted: 06/21/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To date, there has been scant research on patient input regarding the desirable characteristics of healthcare facilities. This study uses the nominal group technique (NGT) to develop a discrete choice experiment (DCE) aimed at identifying and prioritizing, from the patient's perspective, essential characteristics for choosing public health facilities in Cape Town, South Africa. METHODS Four focus group discussions were conducted, including a total of 21 patients or their parents/companion at Bothasig and Goodwood community day centers (which offer primary care within substructure) in Cape Town. The group discussions followed the steps of NGT guidelines. At each facility, the frequency of an attribute being within the top 5 was determined, a weighted ranking was calibrated, and a subgroup analysis was performed. RESULTS The 6 most important attributes in choosing a facility were "treatment by a doctor/(family physician)" (66.7%), "distance to the community day center" (61.7%), "availability of medication" (61.7%), "confidentiality during treatment" (57.7%), and "waiting time" and "treatment by a nurse." The weighted results showed that distance was the most important, followed by treatment by the doctors, treatment confidentiality, availability of medication, and waiting time and treatment by a nurse. CONCLUSION This study confirms the feasibility and value of the NGT in identifying and prioritizing the attributes for a DCE. The NGT can be used to elicit patient preferences and, when used together with a DCE, can enhance information quality and quantity for decision making in tandem with patient satisfaction and experiences.
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Affiliation(s)
- Plaxcedes Chiwire
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.
| | - Silvia M Evers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands; Trimbos Institute, National Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Hassan Mahomed
- Metro Health Services, Western Cape Government: Health and Division of Health Systems and Public Health, Faculty of Medicine and Health Sciences, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Mickaël Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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14
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Lai Y, Chen S, Li M, Ung COL, Hu H. Policy Interventions, Development Trends, and Service Innovations of Internet Hospitals in China: Documentary Analysis and Qualitative Interview Study. J Med Internet Res 2021; 23:e22330. [PMID: 34283025 PMCID: PMC8335616 DOI: 10.2196/22330] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/22/2020] [Accepted: 05/25/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Internet hospitals have been encouraged by the Chinese government to develop an innovative medical service model that mainly uses new internet-based technologies to increase access to health care and improve the quality and efficiency of health care delivery. However, the academic exploration of the institutional and sectoral development of internet hospitals in China is scarce in the existing literature. OBJECTIVE This study aimed to investigate the policy interventions, development trends, and service innovations of internet hospitals in China. It is expected that the findings from this study will contribute to the further innovation of internet hospitals in China and provide references for the international development of internet hospitals for personalized digital health and patient-centric services. METHODS This study analyzed official policies related to internet hospitals that were implemented by the government in China since 2005. The data of formally approved internet hospitals were collected from official websites to analyze development trends. In-depth semistructured interviews were conducted with 58 key stakeholders who represented comprehensive viewpoints about the service innovations of internet hospitals between March and November 2019. RESULTS In total, 25 policies that promoted the development of internet hospitals in China were identified. These policies encompassed informatization infrastructure construction, medical resource integration, development model design, service model design, and payment model design. Of the 268 internet hospitals that had received an official license from the government, 153 public internet hospitals had been built mainly by medical institutions. Public tertiary hospitals were the main actors in founding internet hospitals that were created to provide services that targeted patients with common diseases or chronic diseases or patients living in remote and rural areas. Promoting convenient access to high-quality medical resources and saving patients' and their families' time were the key values of internet hospitals. CONCLUSIONS The policy interventions strongly promoted the development of internet hospitals in China. Public tertiary hospitals led the development of internet hospitals. However, internet hospitals in China have mainly played roles that are complementary to those of physical medical institutions. The service model of internet hospitals needs more distinguished innovations to provide personalized digital health and patient-centric services.
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Affiliation(s)
- Yunfeng Lai
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Shengqi Chen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Meng Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
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15
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Jia H, Cao P, Yu J, Zhang J, Jiang H, Zhao Q, Yu X. A New Perspective for Improving the Human Resource Development of Primary Medical and Health Care Institutions: A Structural Equation Model Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:2560. [PMID: 33806526 PMCID: PMC7967509 DOI: 10.3390/ijerph18052560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/27/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022]
Abstract
In some countries, including China, primary health care is rarely utilized because of medical personnel shortages at primary medical and health care institutions (PMHCIs). Several studies suggest that the most effective solution is to guide qualified doctors and medical graduates to work in PMHCIs, but the studies and measures have been formulated only from the perspective of the government and PMHCIs; few have considered the subjective willingness of medical personnel. Therefore, it is necessary to explore the measures to develop human resources of PMHCIs from the guiding object. This research was divided into two parts based on implicit theory and a lexical approach. The first part collected the factors affecting their choosing PMHCIs for employment, and the second part used exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and structural equation modeling (SEM) to explore the dimensions and paths of the influencing factors. At last, seven factors were obtained from the EFA, and the SEM hypothesis fit the data well. Internal Organization Development, Patient Factor, Remuneration and Development, and Family Support had a significantly positive effect on the Sense of Gain of medical personnel seeking employment at PMHCIs, whereas both Job Responsibilities and Condition of the City Where the PMHCI Is Located had no significant effect. In addition, the indirect effects of Internal Organization Development and Condition of the City Where the PMHCI Is Located on the Sense of Gain were significant. The Patient Factor, Family Support, and Remuneration and Development significantly mediated the relationship between the internal and external environment of the institution and the Sense of Gain, whereas the mediating effect of Job Responsibilities was not significant. The improvement of family support, remuneration and development, and patient factors increase the willingness of medical personnel to seek employment at PMHCIs. In addition, the internal and external environments of a PMHCI play a vital role in guiding medical personnel to PMHCIs for employment. This research provides theoretical support for improving the development of human resources, guiding medical personnel to work in PMHCIs, and promoting the use of primary care services.
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Affiliation(s)
- Huanhuan Jia
- School of Public Health, Jilin University, Changchun 130000, China; (H.J.); (P.C.); (J.Y.); (J.Z.); (H.J.)
| | - Peng Cao
- School of Public Health, Jilin University, Changchun 130000, China; (H.J.); (P.C.); (J.Y.); (J.Z.); (H.J.)
| | - Jianxing Yu
- School of Public Health, Jilin University, Changchun 130000, China; (H.J.); (P.C.); (J.Y.); (J.Z.); (H.J.)
| | - Jingru Zhang
- School of Public Health, Jilin University, Changchun 130000, China; (H.J.); (P.C.); (J.Y.); (J.Z.); (H.J.)
| | - Hairui Jiang
- School of Public Health, Jilin University, Changchun 130000, China; (H.J.); (P.C.); (J.Y.); (J.Z.); (H.J.)
| | - Qize Zhao
- Jilin Province Healthcare Security Administration Management Center, Changchun 130000, China;
| | - Xihe Yu
- School of Public Health, Jilin University, Changchun 130000, China; (H.J.); (P.C.); (J.Y.); (J.Z.); (H.J.)
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16
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Zhang L, Weng TP, Wang HY, Sun F, Liu YY, Lin K, Zhou Z, Chen YY, Li YG, Chen JW, Han LJ, Liu HM, Huang FL, Cai C, Yu HY, Tang W, Huang ZH, Wang LZ, Bao L, Ren PF, Deng GF, Lv JN, Pu YL, Xia F, Li T, Deng Q, He GQ, Li Y, Zhang WH. Patient pathway analysis of tuberculosis diagnostic delay: a multicentre retrospective cohort study in China. Clin Microbiol Infect 2021; 27:1000-1006. [PMID: 33421578 DOI: 10.1016/j.cmi.2020.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/13/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Delay in diagnosis of tuberculosis (TB) is an important but under-appreciated problem. Our study aimed to analyse the patient pathway and possible risk factors of long diagnostic delay (LDD). METHODS We enrolled 400 new bacteriologically diagnosed patients with pulmonary TB from 20 hospitals across China. LDD was defined as an interval between the initial care visit and the confirmation of diagnosis exceeding 14 days. Its potential risk factors were investigated by multivariate logistic regression and multilevel logistic regression. Hospitals in China were classified by increasing size, from level 0 to level 3. TB laboratory equipment in hospitals was also evaluated. RESULTS The median diagnostic delay was 20 days (IQR: 7-72 days), and 229 of 400 patients (57.3%, 95%CI 52.4-62.1) had LDD; 15% of participants were diagnosed at the initial care visit. Compared to level 0 facilities, choosing level 2 (OR 0.27, 95%CI 0.12-0.62, p 0.002) and level 3 facilities (OR 0.34, 95%CI 0.14-0.84, p 0.019) for the initial care visit was independently associated with shorter LDD. Equipping with smear, culture, and Xpert at initial care visit simultaneously also helped to avoid LDD (OR 0.28, 95%CI 0.09-0.82, p 0.020). The multilevel logistic regression yielded similar results. Availability of smear, culture, and Xpert was lower in level 0-1 facilities than in level 2-3 facilities (p < 0.001, respectively). CONCLUSIONS Most patients failed to be diagnosed at the initial care visit. Patients who went to low-level facilities initially had a higher risk of LDD. Improvement of TB laboratory equipment, especially at low-level facilities, is urgently needed.
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Affiliation(s)
- Lu Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Tao-Ping Weng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong-Yu Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Sun
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuan-Yuan Liu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ke Lin
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhe Zhou
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuan-Yuan Chen
- Department of Tuberculosis, Hangzhou Red Cross Hospital, Hangzhou, China
| | - Yong-Guo Li
- Department of Infectious Diseases, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Ji-Wang Chen
- Department of Tuberculosis, The Second Hospital of Daqing, Daqing, China
| | - Li-Jun Han
- Department of Tuberculosis, Changchun Hospital of Infectious Diseases, Changchun, China
| | - Hui-Mei Liu
- Department of Tuberculosis, Xuzhou Hospital of Infectious Diseases, Xuzhou, China
| | - Fu-Li Huang
- Department of Infectious Diseases, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Cui Cai
- Department of Tuberculosis, Guiyang Public Health Clinical Centre, Guiyang, China
| | - Hong-Ying Yu
- Department of Infectious Diseases, The First People's Hospital of Huaihua, Huaihua, China
| | - Wei Tang
- Provincial Key Laboratory for Respiratory Infectious Diseases in Shandong, Shandong Provincial Chest Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zheng-Hui Huang
- Department of Tuberculosis, Wuhan Jin Yin-Tan Hospital, Wuhan, China
| | - Long-Zhi Wang
- Department of Tuberculosis Xi'an Chest Hospital, Xi'an, China
| | - Lei Bao
- Department of Infectious Diseases, Anhui Provincial Hospital, Anhui, China
| | - Peng-Fei Ren
- Department of Tuberculosis, Henan Province Infectious Diseases Hospital, Zhengzhou, China
| | - Guo-Fang Deng
- Shenzhen Key Laboratory of Infection & Immunity, Shenzhen Third People's Hospital (The Second Affiliated Hospital of Shenzhen University), Shenzhen University School of Medicine, Shenzhen, China
| | - Jian-Nan Lv
- Department of Tuberculosis, Beihai Tuberculosis Hospital, Beihai, China
| | - Yong-Lan Pu
- Department of Infectious Diseases, The First People's Hospital of Taicang, Taicang, China
| | - Fan Xia
- Department of Infectious Diseases, 905th Military Hospital, Naval Medical University, Shanghai, China
| | - Tao Li
- Department of Infectious Diseases, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Qun Deng
- Department of Tuberculosis, Jiangxi Chest Hospital, Jiangxi, China
| | - Gui-Qing He
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
| | - Yang Li
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China.
| | - Wen-Hong Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China.
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