The basic social medical insurance is associated with clinical outcomes in the patients with ST-elevation myocardial infarction: a retrospective study from Shanghai, China

Insurance status and traumatized patients' outcomes: a report from the national trauma registry of Iran

BACKGROUND

Trauma care is one of the most expensive medical procedures that is significantly affected by factors like insurance status. Providing medical care to injured patients has a significant impact on patients' prognosis. This study examined whether insurance status was associated with different outcomes, including hospital length of stay (HLOS), mortality, and Intensive Care Unit (ICU) admission.

METHODS

This prospective study analyzed the data of traumatized patients who had been registered in the National Trauma Registry of Iran (NTRI), and hospitalized at Sina Hospital, Tehran, Iran, from March 22, 2016, to February 8, 2021. Given the type of insurance, the insured patients were classified as basic, road traffic, and foreign nationality. The outcomes of in-hospital death, ICU admission, and HLOS between insured and uninsured patients, and then different insurance statuses, were compared using regression models.

RESULT

A total of 5014 patients were included in the study. 49% of patients (n = 2458) had road traffic insurance, 35.2% (n = 1766) basic insurance, 10.5% (n = 528) were uninsured, and 5.2% (n = 262) had foreign nationality insurance. The mean age of patients with basic, road traffic insurance, foreign nationality, and uninsured patients was 45.2 (SD = 22.3), 37.8 (SD = 15.8), 27.8 (SD = 13.3), and 32.4 (SD = 11.9) years, respectively. There was a statistically significant association between insurance status and mean age. Based on these results, the mean age of patients with basic insurance was higher than other groups (p < 0.001). Additionally, 85.6% of the patients were male, with male to female ratio of 9.64 in road traffic insurance, 2.99 in basic insurance, 14.4 in foreign nationality, and 16 in uninsured patients. There was no statistically significant difference between in-hospital mortality in insured and uninsured patients, 98 (2.3%) vs. 12 (2.3%), respectively. The odds of in-hospital mortality in uninsured patients were 1.04 times the odds of in-hospital death in insured patients [Crude OR: 1.04, 95%CI: 0.58 to 1.90]. Multiple logistic regression showed that after adjusting for age, sex, ISS, and Cause of trauma, the odds of in-hospital death in uninsured patients were 2.97 times the odds of in-hospital death in insured patients [adjusted OR: 2.97, 95%CI: 1.43 to 6.21].

CONCLUSION

This study shows that having insurance can change the ICU admission, death, and HLOS in traumatized patients. The results of this study can provide essential data for national health policy for minimizing the disparities among different insurance statuses and proper use of medical resources.

Impact of reimbursement rates on the length of stay in tertiary public hospitals: a retrospective cohort study in Shenzhen, China

OBJECTIVE

To examine the association between reimbursement rates and the length of stay (LOS).

DESIGN

A retrospective cohort study.

SETTING

The study was conducted in Shenzhen, China by using health administrative database from 1 January 2015 to 31 December 2017.

PARTICIPANTS

6583 patients with acute myocardial infarction (AMI), 12 395 patients with pneumonia and 10 485 patients who received percutaneous coronary intervention (PCI) surgery.

MEASURES

The reimbursement rate was defined as one minus the ratio of out-of-pocket to the total expenditure, multiplied by 100%. The outcome of interest was the LOS. Multilevel negative binomial regression models were constructed to control for patient-level and hospital-level characteristics, and the marginal effect was reported when non-linear terms were available.

RESULTS

Each additional unit of the reimbursement rate was associated with an average of an additional increase of 0.019 (95% CI, 0.015 to 0.023), 0.011 (95% CI, 0.009 to 0.014) and 0.013 (95% CI, 0.010 to 0.016) in the LOS for inpatients with AMI, pneumonia and PCI surgery, respectively. Adding the interaction term between the reimbursement rate and in-hospital survival, the average marginal effects for the deceased inpatients with AMI and PCI surgery were 0.044 (95% CI, 0.031 to 0.058) and 0.034 (95% CI, 0.017 to 0.051), respectively. However, there was no evidence that higher reimbursement rates prolonged the LOS of the patients who died of pneumonia (95% CI, -0.013 to 0.016).

CONCLUSIONS

The findings indicate that the higher the reimbursement rate, the longer the LOS; and implementing dynamic supervision and improving the service capabilities of primary healthcare providers may be an important strategy for reducing moral hazard in low-income and middle-income countries including China.

Patient-level and system-level barriers associated with treatment delays for ST elevation myocardial infarction in China

OBJECTIVE

This study aims to understand the current ST elevated myocardial infarction (STEMI) treatment process in Guangdong Province and explore patient-level and system-level barriers associated with delay in STEMI treatment, so as to provide recommendations for improvement.

METHODS

This is a qualitative study. Data were collected using semistructured, face-to-face individual interviews from April 2018 to January 2019. Participants included patients with STEMI, cardiologists and nurses from hospitals, emergency department doctors, primary healthcare providers, local health governors, and coordinators at the emergency medical system (EMS). An inductive thematic analysis was adopted to generate overarching themes and subthemes for potential causes of STEMI treatment delay. The WHO framework for people-centred integrated health services was used to frame recommendations for improving the health system.

RESULTS

Thirty-two participants were interviewed. Patient-level barriers included poor knowledge in recognising STEMI symptoms and not calling EMS when symptoms occurred. Limited capacity of health professionals in hospitals below the tertiary level and lack of coordination between hospitals of different levels were identified as the main system-level barriers. Five recommendations were provided: (1) enhance public health education; (2) strengthen primary healthcare workforce; (3) increase EMS capacity; (4) establish an integrated care model; and (5) harness government's responsibilities.

CONCLUSIONS

Barriers associated with delay in STEMI treatment were identified at both patient and system levels. The results of this study provide a useful evidence base for future intervention development to improve the quality of STEMI treatment and patient outcomes in China and other countries in a similar situation.

The Effects of Private Health Insurance on Universal Health Coverage Objectives in China: A Systematic Literature Review

BACKGROUND

We conducted a systematic review on the role of private health insurance to complement the social health insurance system towards achieving universal health coverage in China. This review presents the impacts of private health insurance on expanding coverage, increasing access to healthcare, and financial protection.

METHODS

A systematic review was conducted by searching peer-reviewed articles published between January 2000 and March 2018 in Web of Science, PubMed, and China Knowledge Resource Integrated Database. The search terms included coverage prevalence, access and financial protection related to private health insurance in China. A total of 31 studies were selected.

RESULTS

Coverage prevalence of private health insurance gradually increased but it was unequally distributed across regions and populations. The expansion of social health insurance has enhanced the total aggregate premium of private health insurance but has had a mixed impact on the take-up of private health insurance. Private insurance beneficiaries were found to limit their utilisation of healthcare services and there was no evidence that it ensured financial protection.

CONCLUSION

The role of private health insurance (PHI) in extending universal health coverage in China was limited and therefore should not be overstated.

The Effects of Private Health Insurance on Universal Health Coverage Objectives in China: A Systematic Literature Review

BACKGROUND

We conducted a systematic review on the role of private health insurance to complement the social health insurance system towards achieving universal health coverage in China. This review presents the impacts of private health insurance on expanding coverage, increasing access to healthcare, and financial protection.

METHODS

A systematic review was conducted by searching peer-reviewed articles published between January 2000 and March 2018 in Web of Science, PubMed, and China Knowledge Resource Integrated Database. The search terms included coverage prevalence, access and financial protection related to private health insurance in China. A total of 31 studies were selected.

RESULTS

Coverage prevalence of private health insurance gradually increased but it was unequally distributed across regions and populations. The expansion of social health insurance has enhanced the total aggregate premium of private health insurance but has had a mixed impact on the take-up of private health insurance. Private insurance beneficiaries were found to limit their utilisation of healthcare services and there was no evidence that it ensured financial protection.

CONCLUSION

The role of private health insurance (PHI) in extending universal health coverage in China was limited and therefore should not be overstated.

Insurance status and 1-year outcomes of stroke and transient ischaemic attack: a registry-based cohort study in China

OBJECTIVE

Although more than 95% of the population is insured by urban or rural insurance programmes in China, little research has been done on insurance-related outcome disparities for patients with acute stroke and transient ischaemic attack (TIA). This study aimed to examine the relationship between insurance status and 1-year outcomes for patients with stroke and TIA.

METHODS

We abstracted 24 941 patients with acute stroke and TIA from the China National Stroke Registry II. Insurance status was categorised as Urban Basic Medical Insurance Scheme (UBMIS), New Rural Cooperative Medical Scheme (NRCMS) and self-payment. The relationship between insurance status and 1-year outcomes, including all-cause death, stroke recurrence and disability, was analysed using the shared frailty model in the Cox model or generalised estimating equation with consideration of the hospital's cluster effect.

RESULTS

About 50% of patients were covered by UBMIS, 41.2% by NRCMS and 8.9% by self-payment. Compared with patients covered by UBMIS, patients covered by NRCMS had a significantly higher risk of all-cause death (9.7% vs 8.6%, adjusted HR: 1.32 (95% CI 1.17 to 1.48), p<0.001), stroke recurrence (7.2% vs 6.5%, adjusted HR: 1.12 (95% CI 1.11 to 1.37), p<0.001) and disability (32.0% vs 26.3%, adjusted OR: 1.29 (95% CI 1.21 to 1.39), p<0.001). Compared with patients covered by UBMIS, self-payment patients had a similar risk of death and stroke recurrence but a higher risk of disability.

CONCLUSIONS

Patients with stroke and TIA demonstrated differences in 1-year mortality, stroke recurrence and disability between urban and rural insurance groups in China.

Insurance status, inhospital mortality and length of stay in hospitalised patients in Shanxi, China: a cross-sectional study

OBJECTIVES

To determine insurance-related disparities in hospital care for patients with acute myocardial infarction (AMI), heart failure (HF) and pneumonia.

SETTING AND PARTICIPANTS

A total of 22 392 patients with AMI, 8056 patients with HF and 17 161 patients with pneumonia were selected from 31 tertiary hospitals in Shanxi, China, from 2014 to 2015 using the International Classification of Diseases, Tenth Revision codes. Patients were stratified by health insurance status, namely, urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), new cooperative medical scheme (NCMS) and self-payment.

OUTCOME MEASURES

Inhospital mortality and length of stay (LOS).

RESULTS

The highest unadjusted inhospital mortality rate was detected in NCMS patients independent of medical conditions (4.7%, 4.4% and 11.1% for AMI, HF and pneumonia, respectively). The lowest unadjusted inhospital mortality rate and the longest LOS were observed in UEBMI patients. After controlling patient-level and hospital-level covariates, the adjusted inhospital mortality was significantly higher for NCMS and self-payment among patients with AMI, for NCMS among patients with HF and for URBMI, NCMS and self-payment among patients with pneumonia compared with UEBMI. The LOS of the URBMI, NCMS and self-payment groups was significantly shorter than that of the UEBMI group.

CONCLUSION

Insurance-related disparities in hospital care for patients with three common medical conditions were observed in this study. NCMS patients had significantly higher adjusted inhospital mortality and shorter LOS compared with UEBMI patients. Policies on minimising the disparities among different insurance schemes should be established by the government.

The influence of individual socioeconomic status on the clinical outcomes in ischemic stroke patients with different neighborhood status in Shanghai, China

Objective: Socioeconomic status (SES) is being recognized as an important factor in both social and medical problems. The aim of present study is to examine the relationship between SES and ischemic stroke and investigate whether SES is a predictor of clinical outcomes among patients with different neighborhood status from Shanghai, China. Methods: A total of 471 first-ever ischemic stroke patients aged 18-80 years were enrolled in this retrospective study. The personal SES of each patient was evaluated using a summed score derived from his or her educational level, household income, occupation, and medical reimbursement rate. Clinical adverse events and all-cause mortality were analyzed to determine whether SES was a prognostic factor, its prognostic impact was then assessed based on different neighborhood status using multivariable Cox proportional hazard models after adjusting for other covariates. Results: The individual SES showed a significant positive correlation with neighborhood status (r = 0.370; P < 0.001). The incidence of clinical adverse events and mortality were significantly higher in low SES patients compared with middle and high SES patients (P = 0.001 and P = 0.037, respectively). After adjusting other risk factors and neighborhood status, Kaplan-Meier analysis showed clinical adverse events and deaths were still higher in the low SES patients (all P < 0.05). Multivariate Cox regression analysis demonstrated that both personal SES and neighborhood status are independent prognostic factors for ischemic stroke (all P < 0.05). Besides, among patients with low and middle neighborhood status, lower individual SES was significantly associated with clinical adverse events and mortality (all P < 0.05). Conclusion: Both individual SES and neighborhood status are significantly associated with the prognosis after ischemic stroke. A lower personal SES as well as poorer neighborhood status may significantly increase risk for adverse clinical outcomes among ischemic stroke patients.

Consolidating the social health insurance schemes in China: towards an equitable and efficient health system

Fragmentation in social health insurance schemes is an important factor for inequitable access to health care and financial protection for people covered by different health insurance schemes in China. To fulfil its commitment of universal health coverage by 2020, the Chinese Government needs to prioritise addressing this issue. After analysing the situation of fragmentation, this Review summarises efforts to consolidate health insurance schemes both in China and internationally. Rural migrants, elderly people, and those with non-communicable diseases in China will greatly benefit from consolidation of the existing health insurance schemes with extended funding pools, thereby narrowing the disparities among health insurance schemes in fund level and benefit package. Political commitments, institutional innovations, and a feasible implementation plan are the major elements needed for success in consolidation. Achievement of universal health coverage in China needs systemic strategies including consolidation of the social health insurance schemes.