Impact of medical insurance access negotiation on the utilization of innovative anticancer drugs in China: an interrupted time series analysis

BACKGROUND

The high costs of innovative anticancer drugs hinder a number of cancer patients' access to these drugs in China. To address this problem, in 2018, the medical insurance access negotiation (MIAN) policy was implemented, when the prices of 17 innovative anticancer drugs were successfully negotiated and they were therefore included in the reimbursement list. This study aimed to explore the impact of the MIAN policy on the utilization of innovative anticancer drugs.

METHODS

With monthly data on drug expenditures and defined daily doses (DDDs) of each innovative anticancer drug from January 2017 to December 2019, interrupted time series analysis was employed to estimate both the instant (change in the level of outcome) and long-term (change in trends of outcomes) impacts of the MIAN policy on drug utilization in terms of drug expenditures and DDDs. Our sample consists of 12 innovative anticancer drugs.

RESULTS

From January 2017 to December 2019, the monthly drug expenditures and DDDs of 12 innovative anticancer drugs increased by about 573% (from US$8,931,809.30 to US$51,138,331.09) and 1400% (from 47,785 to 668,754), respectively. Overall, the implementation of the MIAN policy led to instant substantial increases of US$8,734,414 in drug expenditures and 158,192.5 in DDDs. Moreover, a sharper upward trend over time was reported, with increases of US$2,889,078 and 38,715.3 in the monthly growth rates of drug expenditures and DDDs, respectively. Regarding individual innovative anticancer drugs, the most prominent instant change and trend change in drug utilization were found for osimertinib, crizotinib, and ibrutinib. In contrast, the utilization of pegaspargase was barely affected by the MIAN policy.

CONCLUSIONS

The MIAN policy has effectively promoted the utilization of innovative anticancer drugs. To ensure the continuity of the effects and eliminate differentiation, supplementary measures should be carried out, such as careful selection of drugs for medical insurance negotiations, a health technology assessment system and a multichannel financing mechanism.

Efficacy and Safety of Local Radiotherapy Combined with Chemotherapy ± Bevacizumab in the Treatment of Patients with Advanced and Recurrent Metastatic Cervical Cancer

PURPOSE/OBJECTIVE(S)

To observe the efficacy and safety of local radiotherapy combined with chemotherapy ± bevacizumab in the treatment of patients with advanced or recurrent metastatic cervical cancer.

MATERIALS/METHODS

A total of 53 patients with advanced and recurrent metastatic cervical cancer who had received local radiotherapy combined with chemotherapy ± bevacizumab in Affiliated Cancer Hospital of Guizhou Medical University from July 2018 to October 2021 were collected. The recurrence types included 21 patients of pelvic recurrence, 7 patients of distant metastasis, 14 patients of complex pelvic recurrence and distant metastasis, and 11 patients of advanced stage (initial diagnosis stage IVB). The primary endpoints were objective response rate (ORR) and disease control rate (DCR). The secondary endpoints were progression-free survival (PFS), overall survival (OS) and incidence of adverse reactions.

RESULTS

(1) Complete response (CR) was achieved in 4 patients (7.5%), partial response (PR) in 34 patients (64.2%), stable disease (SD) in 12 patients (22.6%), and disease progression (PD) in 3 patients (5.7%), ORR was 71.7%, DCR was 94.3%. (2) The follow-up time was 5.3 to 45.7 months, the median OS was 29.3 months, the median PFS was 15.7 months, the one-year and two-year OS were 83.0% and 59.2%, and the 1-year and two-year PFS were 62.2% and 34.4%. (3) Recurrence type, tumor size at the time of recurrence, and efficacy after radiotherapy were significant factors for PFS and OS rates in multivariate analysis. (4) The main adverse reactions were myelosuppression, gastrointestinal reaction and urinary reaction. Grade IV leukopenia occurred at 13.2%, grade IV neutropenia at 11.3%, grade IV thrombocytopenia at 15.1%, and grade IV anemia at 5.7%, all of which were tolerable. The gastrointestinal and urinary reactions were mainly grade I-II, and the incidence of vesical or rectovaginal fistulas was about 7.5% (2 patients had rectovaginal fistulas and 2 patients had vesto-vaginal fistulas).

CONCLUSION

Local radiotherapy combined with chemotherapy ± bevacizumab can improve the efficacy and survival of patients with advanced and recurrent metastatic cervical cancer. Adverse reactions are tolerable and may provide survival benefits in these patients.

Factors and key problems influencing insured's poor perceptions of convenience of basic medical insurance: a mixed methods research of a northern city in China

BACKGROUND

This study aimed to explore the factors that affect insured's perceptions of convenience of the basic medical insurance (PCBMI) in Harbin, China and to diagnose the key problems to further propose corresponding measures. The findings provide evidence-based support for the reform of convenience of the basic medical insurance system (BMIS) and the cultivation of public literacy.

METHODS

We adopted a mixed methods design composing a multivariate regression model using the data from a cross-sectional questionnaire survey (n = 1045) of residents who were enrolled for BMIS in Harbin to identify the factors influencing the PCBMI. A quota sampling method was further adopted. Semi-structured interviews were then conducted with 30 important information providers selected by convenience sampling. Interpretative phenomenological analysis was employed to summarize and analyze the key problems.

RESULTS

Overall, approximately 51% of respondents reported poor PCBMI. The logistic regression model showed that insured without outpatient experience within two weeks (OR = 2.522, 95% CI = 1.267-5.024), had poorer levels of understanding of basic medical insurance information (OR = 2.336, 95% CI = 1.612-3.386), lived in rural areas (OR = 1.819, 95% CI = 1.036-3.195), had low levels of annual out-of-pocket medical expenses (OR = 1.488, 95% CI = 1.129-1.961), and were more likely to give the PCBMI a worse evaluation than their counterparts. The results of the qualitative analysis showed that the key problem areas of the PCBMI were the design of the BMIS, the cognitive biases of the insured, publicity information about the BMIS, and the health system environment.

CONCLUSIONS

This study found that in addition to the design of BMIS, the cognition of the insured, the BMIS information publicity and the health system environment are also the key problems hindering PCBMI. While optimizing system design and implementation, Chinese policymakers need to focus on the insured with low PCBMI characteristics. Moreover, it is necessary to focus on exploring effective BMIS information publicity methods, supporting public policy literacy and improving the health system environment.

Perceptions of the benefits of the basic medical insurance system among the insured: a mixed methods research of a northern city in China

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.

Perspectives and evaluation on the effect of financial burden relief of medical insurance for people with catastrophic diseases and its influencing factors

Background

Catastrophic disease sufferers face a heavy financial burden and are more likely to fall victim to the "illness-poverty-illness" cycle. Deeper reform of the medical insurance system is urgently required to alleviate the financial burden of individuals with catastrophic diseases.

Methods

Data were obtained from a cross-sectional questionnaire survey conducted in Heilongjiang in 2021, and logistic regression and restricted cubic spline model was used to predict the core factors related to medical insurance that alleviate the financial burden of people with catastrophic diseases.

Results

Overall, 997 (50.92%) medical insurance-related professionals negatively viewed financial burden relief for people with catastrophic diseases. Factors influencing its effectiveness in relieving the financial burden were: whether or not effective control of omissions from medical insurance coverage (OR = 4.04), fund supervision (OR = 2.47) and degree of participation of stakeholders (OR = 1.91). Besides, the reimbursement standards and the regional and population benefit package gap also played a role. The likelihood of financial burden relief increased by 21 percentage points for each unit increase in the level of stakeholder discourse power in reform.

Conclusion

China's current medical insurance policies have not yet fully addressed the needs of vulnerable populations, especially the need to reduce their financial burden continuously. Future reform should focus on addressing core issues by reducing the uninsured, enhancing the width and depth of medical insurance coverage, improving the level and capacity of medical insurance governance that provides more discourse power for the vulnerable population, and building a more responsive and participatory medical insurance governance system.

Global attributed burden of death for air pollution: Demographic decomposition and birth cohort effect

BACKGROUND

To identify the high-risk pollutants and evolving patterns of attributed mortality burden, more detailed evidence is needed to examine the contribution of different air pollutants to death across the disease spectrum, particularly considering population change as well as the context of the era.

METHODS

We explored the evolving patterns of all-cause and disease-specific deaths attributed to overall air pollution and its main subcategories by using the estimated annual percentage change and additionally assessing the contribution of population growth and ageing to death burden using the decomposition method. Age-period-cohort model and Joinpoint analysis were used to evaluate birth cohort effects specific-disease death burden owing to high-risk air pollution subcategories.

FINDINGS

The number of deaths caused by air pollution increased by 2.62 %, which was driven by ambient particulate matter pollution and ambient ozone pollution, whereas household air pollution decreased. Population ageing contributed 28.88 % of the deaths increase change for air pollution. Compared with other subcategories, the age-standardized mortality rate (ASMR) attributed to ambient particulate matter pollution remained the heaviest attributed death burden, comprehensively considering of bivariate burden. In 2019, ischemic heart disease attributed to ambient particulate matter pollution exhibited the highest ASMR, which may be impacted by a rapid increase era from 1950 to 1980 birth cohort in woman and 1970 to 1990 birth cohort in man. Diabetes mellitus attributed to ambient particulate matter pollution showed the largest increase for ASMR, which was driven primarily by men born 1910-1975 and women born 1950-1975.Uzbekistan showed the highest ASMR for ischemic heart disease, with Equatorial Guinea showing the fastest increase for diabetes mellitus.

CONCLUSION

Priority intervention targets for air pollution and health should emphasize the susceptibility of the elderly population as well as the structural factors of the era, in particular sensitive diseases to the ambient particulate matter pollution.

Creep Behavior of A356 Aluminum Alloy Reinforced with Multi-Walled Carbon Nanotubes by Stir Casting

Lightweight aluminum alloy components are often used to manufacture a variety of engineering components in many industries. In recent years, researchers have studied the effect of improving the mechanical properties of metal alloys by incorporating nano-carbon into its structure. In this study, the effect of the addition of 0.2, 0.5, and 1 wt% of multi-walled carbon nanotubes (MWCNTs) on the stress-strain behavior and creep phenomenon of an A356 aluminum alloy were studied. The effect of nickel coating on 0.2 wt% MWCNTs was also investigated. Samples were prepared using the stir-casting method. The results revealed that the grain size became finer when MWCNT nano-particulates were introduced. Although the MWCNTs were distributed homogeneously in the A356 matrix, as confirmed by FESEM analysis, there were some agglomerations observed in a specific area with dimensions smaller than 100 nm. Nevertheless, the addition of MWCNTs was found to be beneficial in enhancing the hardness of alloys containing 0.2 wt%, 0.2 wt% nickel-coated, 0.5 wt%, and 1 wt% MWCNTs by 9%, 24%, 32%, and 15%, respectively, as compared with the unreinforced A345 matrix. It was also found that the 0.5 wt% MWCNT-A356 matrix exhibited an improvement in the creep lifetime by more than two orders of magnitude.

Epidemiological trend in scarlet fever incidence in China during the COVID-19 pandemic: A time series analysis

Objective

Over the past decade, scarlet fever has caused a relatively high economic burden in various regions of China. Non-pharmaceutical interventions (NPIs) are necessary because of the absence of vaccines and specific drugs. This study aimed to characterize the demographics of patients with scarlet fever, describe its spatiotemporal distribution, and explore the impact of NPIs on the disease in the era of coronavirus disease 2019 (COVID-19) in China.

Methods

Using monthly scarlet fever data from January 2011 to December 2019, seasonal autoregressive integrated moving average (SARIMA), advanced innovation state-space modeling framework that combines Box-Cox transformations, Fourier series with time-varying coefficients, and autoregressive moving average error correction method (TBATS) models were developed to select the best model for comparing between the expected and actual incidence of scarlet fever in 2020. Interrupted time series analysis (ITSA) was used to explore whether NPIs have an effect on scarlet fever incidence, while the intervention effects of specific NPIs were explored using correlation analysis and ridge regression methods.

Results

From 2011 to 2017, the total number of scarlet fever cases was 400,691, with children aged 0-9 years being the main group affected. There were two annual incidence peaks (May to June and November to December). According to the best prediction model TBATS (0.002, {0, 0}, 0.801, {<12, 5>}), the number of scarlet fever cases was 72,148 and dual seasonality was no longer prominent. ITSA showed a significant effect of NPIs of a reduction in the number of scarlet fever episodes (β2 = -61526, P < 0.005), and the effect of canceling public events (c3) was the most significant (P = 0.0447).

Conclusions

The incidence of scarlet fever during COVID-19 was lower than expected, and the total incidence decreased by 80.74% in 2020. The results of this study indicate that strict NPIs may be of potential benefit in preventing scarlet fever occurrence, especially that related to public event cancellation. However, it is still important that vaccines and drugs are available in the future.

Spatial effects of air pollution on the economic burden of disease: implications of health and environment crisis in a post-COVID-19 world

Background

Air pollution has been identified as related to the diseases of susceptible population, but the spatial heterogeneity of its economic burden and its determinants are rarely investigated. The issue is of great policy significance, especially after the epidemic of COVID-19, when human are facing the joint crisis of health and environment, and some areas is prone to falling into poverty.

Methods

The geographical detector was adopted to study the spatial distribution characteristics of the incidence of catastrophic health expenditure (ICHE) for older adults in 100 rural areas in China at the prefecture-city level. The health factors, sociological factors, policy factors and environmental factors and their interactions are identified.

Results

First, most health service factors had strong explanatory power for ICHE whether it interacts with air pollution. Second, 50 single-factor high-risk areas of ICHE were found in the study, but at the same time, there were 21 areas dominated by multiple factors.

Conclusion

The different contributions and synergy among the factors constitute the complex mechanism of factors and catastrophic health expenditure. Moreover, during this process, air pollution aggravates the contribution of health service factors toward ICHE. In addition, the leading factors of ICHE are different among regions. At the end, this paper also puts forward some policy suggestions from the perspective of health and environment crisis in the post-COVID-19 world: environmental protection policies should be combined with the prevention of infectious diseases; advanced health investment is the most cost-effective policy for the inverse health sequences of air pollution and infectious diseases such as coronavirus disease 2019 (COVID-19); integrating environmental protection policy into healthy development policy, different regions take targeted measures to cope with the intertwined crisis.

Degree of protection provided by poverty alleviation policies for the middle-aged and older in China: evaluation of effectiveness of medical insurance system tools and vulnerable target recognition

Background

China’s medical insurance schemes and poverty alleviation policy at this stage have achieved population-wide coverage and the system's universal function. At the late stage of the elimination of absolute poverty task, how to further exert the poverty alleviation function of the medical insurance schemes has become an important agenda for targeted poverty alleviation. To analyse the risk of catastrophic health expenditure (CHE) occurrence in middle-aged and older adults with vulnerability characteristics from the perspectives of social, regional, disease, health service utilization and medical insurance schemes.

Methods

We used data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) database and came up with 9190 samples. The method for calculating the CHE was adopted from WHO. Logistic regression was used to determine the different characteristics of middle-aged and older adults with a high probability of incurring CHE.

Results

The overall regional poverty rate and incidence of CHE were similar in the east, central and west, but with significant differences among provinces. The population insured by the urban and rural integrated medical insurance (URRMI) had the highest incidence of CHE (21.17%) and health expenditure burden (22.77%) among the insured population. Integration of Medicare as a medical insurance scheme with broader benefit coverage did not have a significant effect on the incidence of CHE in middle-aged and older people with vulnerability characteristics.

Conclusions

Based on the perspective of Medicare improvement, we conducted an in-depth exploration of the synergistic effect of medical insurance and the poverty alleviation system in reducing poverty, and we hope that through comprehensive strategic adjustments and multidimensional system cooperation, we can lift the vulnerable middle-aged and older adults out of poverty.

Factors that dynamically affect provincial incidences of catastrophic health expenditure among middle-aged and elderly Chinese population-transition of disease financial risk protection from global to local

Background

The high incidence of catastrophic health expenditure (ICHE) among middle-aged and elderly population is a major deterrent for reducing the financial risk of disease. Current research is predominantly based on the assumption of spatial homogeneity of nationwide population characteristics, ignoring the differences in regional characteristics. Thus, our study aimed to explore the impact of various influencing factors on the ICHE from a spatiotemporal perspective.

Methods

We used data from the China Health and Retirement Longitudinal Study (waves 1 to 4), to conduct a retrospective cohort study across 28 provinces, from 2011 to 2018. We measured regional incidences of catastrophic health expenditure using methods recommended by the World Health Organization. Ordinary least squares (OLS) and geographical and temporal weighted regression (GTWR) were used as the global and local estimation models, respectively. The Fortheringham method was used to test the spatiotemporal non-stationarity.

Results

National ICHE showed a gradual increase from 2011 to 2015, but suddenly decreased from 2015 to 2018, also showing the spatial heterogeneity. And the southwest area and Hebei showed persistently high ICHE (Qinghai even reached the highest value of 27.5% in 2015). Out-of-pocket payment, gross domestic product, PM_2.5, ageing, incidence of non-communicable diseases and disabilities, number of nurses, and health insurance coverage in the global estimation passed the significance test, and the GTWR model showed a better model fit (0.769) than the OLS model (0.388). Furthermore, except for health insurance coverage, all seven variables had spatiotemporal non-stationarity among their impacts on ICHE.

Conclusion

In this longitudinal study, we found spatiotemporal non-stationarity among the variable relationships, supporting regional governments’ adoption of regional-target policies. First, after the completion of universal health insurance coverage, the spatiotemporal non-stationarity of the prevalence of non-communicable diseases and disability and ageing should be the focus of the next phase of health insurance design, where improvements to compensation coverage and benefit packages are possible policy instruments. Second, the governance and causes of catastrophic health expenditure need to be laid out from a macro perspective rather than only from the individual/household perspective, especially for the potential impact of economic development, air pollution and nursing resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03432-6.

What fragile factors hinder the pace of China's alleviation efforts of the poverty-stricken population? A study from the perspective of impoverishment caused by medical expenses

OBJECTIVE

China has made remarkable achievements in poverty alleviation. However, with the change in economic development and age structure, the population stricken by poverty due to medical expenses and disability accounted for 42.3 and 14.4% of the total poverty-stricken population, respectively. Accordingly, it is crucial to accurately pinpoint the characteristics of people who are about to become poor due to illness. In this study, we analyzed the incidence of impoverishment by medical expense at the provincial, family, and different medical insurance scheme levels to identify the precise groups that are vulnerable to medical-related poverty.

METHOD

Data were extracted from the Fifth National Health Service Survey in China in 2013 through a multi-stage, stratified, and random sampling method, leaving 93,570 households (273,626 people) for the final sample. The method recommended by World Health Organization (WHO) was adopted to calculate impoverishment by medical expense, and logistic regression was adopted to evaluate its determinants.

RESULTS

The poverty and impoverishment rate in China were 16.2 and 6.3% respectively. The poverty rate in western region was much higher than that of central and eastern regions. The rate of impoverishment by medical expense (IME) was higher in the western region (7.2%) than that in the central (6.5%) and eastern (5.1%) regions. The New Cooperative Medical Scheme (NCMS) was associated with the highest rate (9.1%) of IME cases. The top three diseases associated with IME were malignant tumor, congenital heart disease, and mental disease. Households with non-communicable disease members or hospitalized members had a higher risk on IME. NCMS-enrolled, poorer households were more likely to suffer from IME.

CONCLUSION

The joint roles of economic development, health service utilization, and welfare policies result in medical impoverishment for different regions. Poverty and health service utilization are indicative of households with high incidence of medical impoverishment. Chronic diseases lead to medical impoverishment. The inequity existing in different medical insurance schemes leads to different degrees of risk of IME. A combined strategy to precise target multiple vulnerabilities of poor population would be more effective.

The superposition effects of air pollution on government health expenditure in China- spatial evidence from GeoDetector

Background

As the fifth-largest global mortality risk factor, air pollution has caused nearly one-tenth of the world’s deaths, with a death toll of 5 million. 21% of China’s disease burden was related to environmental pollution, which is 8% higher than the US. Air pollution will increase the demand and utilisation of Chinese residents’ health services, thereby placing a greater economic burden on the government. This study reveals the spatial impact of socioeconomic, health, policy and population factors combined with environmental factors on government health expenditure.

Methods

Spearman’s correlation coefficient and GeoDetector were used to identify the determinants of government health expenditure. The GeoDetector consist of four detectors: factor detection, interaction detection, risk detection, and ecological detection. One hundred sixty-nine prefecture-level cities in China are studied. The data sources are the 2017 data from China’s Economic and Social Big Data Research Platform and WorldPOP gridded population datasets.

Results

It is found that industrial sulfur dioxide attributed to government health expenditure, whose q value (explanatory power of X to Y) is 0.5283. The interaction between air pollution factors and other factors will increase the impact on government health expenditure, the interaction value (explanatory power of × 1∩× 2 to Y) of GDP and industrial sulfur dioxide the largest, whose values is 0.9593. There are 96 simple high-risk areas in these 169 areas, but there are still high-risk areas affected by multiple factors.

Conclusion

First, multiple factors influence the spatial heterogeneity of government health expenditure. Second, health and socio-economic factors are still the dominant factors leading to increased government health expenditure. Third, air pollution does have an important impact on government health expenditure. As a catalytic factor, combining with other factors, it will strengthen their impact on government health expenditure. Finally, an integrated approach should be adopted to synergisticly governance the high-risk areas with multi-risk factors.

Impact of the National Reimbursement Drug List Negotiation Policy on Accessibility of Anticancer Drugs in China: An Interrupted Time Series Study

Objective

Since 2016, the Chinese government has been regularly implementing the National Reimbursement Drug List Negotiation (NRDLN) to improve the accessibility of drugs. In the second round of NRDLN in July 2017, 18 anticancer drugs were included. This study analyzed the impact of the NRDLN on the accessibility of these 18 anticancer drugs in China.

Methods

National hospital procurement data were collected from 2015 to 2019. As measurements of drug accessibility, monthly average of drug availability or defined daily dose cost (DDDc) was calculated. Interrupted time series (ITS) analysis was employed to evaluate the impact of NRDLN on drug accessibility. Multilevel growth curve models were estimated for different drug categories, regions or levels of hospitals.

Results

The overall availability of 18 anticancer drugs increased from about 10.5% in 2015 to slightly over 30% in 2019. The average DDDc dropped from 527.93 CNY in 2015 to 401.87 CNY in 2019, with a reduction of 23.88%. The implementation of NRDLN was associated with higher availability and lower costs for all 18 anticancer drugs. We found an increasing level in monthly drug availability (β2 = 2.1126), which ascended more sharply after the implementation of NRDLN (β3 = 0.3656). There was a decreasing level in DDDc before July 2017 (β2 = −108.7213), together with a significant decline in the slope associated with the implementation of NRDLN (β3 = −4.8332). Compared to Traditional Chinese Medicines, the availability of Western Medicines was higher and increased at a higher rate (β3 = 0.4165 vs. 0.1108). Drug availability experienced a larger instant and slope increase in western China compared to other regions, and in secondary hospitals than tertiary hospitals. Nevertheless, regional and hospital-level difference in the effect of NRDLN on DDDc were less evident.

Conclusion

The implementation of NRDLN improves the availability and reduces the cost of some anticancer drugs in China. It contributes to promoting accessibility of anticancer drugs, as well as relieving regional or hospital-level disparities. However, there are still challenges to benefit more patients sufficiently and equally. It requires more policy efforts and collaborative policy combination.

Developing a scale measuring the doctor-patient relationship in China from the perspective of doctors

OBJECTIVES

The doctor-patient relationship is usually measured in line with patient needs and demands. This study aimed to develop a scale measuring such a relationship from the perspective of doctors.

METHODS

A draft scale was developed and adapted to the hospital context of China based on several existing scales, with an intention to measure how medical doctors view and manage their relationship with patients beyond episodic clinical encounters. Two rounds of Delphi consultations involving 14 experts were conducted to seek their consensus on the inclusion and descriptions of items. This resulted in a 19-item scale measuring four domains of the relationship. The scale was validated through a survey of 1,712 medical doctors selected from 27 public hospitals in Heilongjiang province of China. The internal consistency of the scale was assessed using Cronbach's α coefficients of the four domains. Confirmatory factor analyses were performed to test the construct validity of the scale. Linear regression analyses were performed to assess the known-group validity of the scale.

RESULTS

The scale measures four domains. The Cronbach's α of the scale reached an acceptable level, ranging from 0.61 to 0.78 for its four domains. Good fitness of data into the four-domain structure of the scale was confirmed by the confirmatory factor analysis. Known-group differences were demonstrated in the regression analyses.

CONCLUSION

The doctor-patient relationship scale developed in this study is a psychometrically valid tool assessing how medical doctors view and manage their relationship with patients in the hospital setting in China.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Inequity in Health Services Utilization in Economically Underdeveloped Regions of Northeast China

Background

The Chinese health system has long been committed to eliminating inequalities in health services utilization. However, few studies have analyzed or measured these inequalities in economically underdeveloped regions in China.

Methods

A total of 6,627 respondents from 3,000 households in Heilongjiang Province were extracted from the Sixth National Health Services Survey. We measured horizontal inequity in both 2-week outpatient rate and annual inpatient rate, and then identified the factors contributing to inequality.

Results

The horizontal inequity indices of the 2-week outpatient and annual impatient rates in Heilongjiang Province were 0.0586 and 0.1276, respectively. Household income, health status, place of residence, basic medical insurance, and commercial health insurance were found to be the main factors affecting inequality in health services utilization. The contributions of household income to these two indices were 184.03 and 253.47%, respectively. Health status factors, including suffering from chronic disease, limitations in daily activities, and poor self-rated health, played positive roles in reducing inequality in these two indices. The contributions of place of residence to these two indices were 27.21 and −28.45%, respectively. Urban Employee Basic Medical Insurance made a pro-rich contribution to these two indices: 56.25 and 81.48%, respectively. Urban and Rural Resident Basic Medical Insurance, Urban Resident Basic Medical Insurance, New Rural Cooperative Medical Scheme, and other basic medical insurance made a pro-poor contribution to these two indices: −73.51 and −54.87%, respectively. Commercial health insurance made a pro-rich contribution to these two indices: 20.79 and 7.40%, respectively. Meanwhile, critical illness insurance made a slightly pro-poor contribution to these two indices: −4.60 and −0.90%, respectively.

Conclusions

The findings showed that the “equal treatment in equal need” principle was not met in the health services utilization context in Heilongjiang Province. To address this issue, the government could make policy changes to protect low-income populations from underused health services, and work to improve basic medical insurance, critical illness insurance, and social security systems.

Attitudes of medical professionals towards patient-centredness: a cross-sectional study in H City, China

OBJECTIVES

Patient-centred communication improves patient experiences and patient care outcomes. This study aimed to assess the preference of medical professionals in China towards patient-centred communication under the context of the deteriorating doctor-patient relationship.

METHODS

A cross-sectional survey of medical professionals was conducted in January and February 2018 in H City of Heilongjiang province, the northeast of China. The Chinese-Revised Patient-Practitioner Orientation Scale (CR-PPOS) was adopted to measure the individual preference of respondents towards patient-centredness in clinical communication. Multivariate logistic regression models were established to identify the sociodemographic (gender, age, marital status and educational attainment) and work experience (years of working, seniority, satisfaction with income, daily workload and perceived doctor-patient relationship) predictors of the preference towards patient-centredness.

PATIENT AND PUBLIC INVOLVEMENT

Not applicable.

RESULTS

A total of 618 valid questionnaires were returned. The CR-PPOS demonstrated acceptable reliability and validity. Overall, a low level of preference towards patient-centredness in clinical communication was found. Relatively higher scores on 'caring for patients' (20.42±4.42) was found compared with those on 'information/responsibility sharing' (15.26±4.21). Younger age, higher educational attainment, lower daily workload and a perception of harmonious doctor-patient relationship were associated with a higher preference towards patient-centredness in clinical communication.

CONCLUSIONS

A low level of preference towards patient-centredness in clinical communication was found in medical professionals in the northeast of China, which may further jeopardise the efforts to improve doctor-patient relationship.

Assessing knowledge and self-report intention from COVID-19 symptoms based on the Health Belief Model among international students in Heilongjiang, China: a cross-sectional study

BACKGROUND

A COVID-19 outbreak has been contained in China through effective prevention measures with the collaboration of the citizens. However, there is resistance to self-reported symptoms as required in the international student community. This study explored knowledge level and symptoms reporting behaviours toward COVID-19 among international students.

METHODS

An online cross-sectional investigation was conducted among 119 international students across Heilongjiang province and questionnaires implemented through WeChat between 1 and 25 March 2020. The results were explained using descriptive Χ2 test and binary logistic regression analysis using SPSS V.20.

RESULTS

In total, 119 international students participated, with a response rate of 90.16%. Of the 119 respondents, 96 (80.7%) knew COVID-19 symptoms, 109 (91.6%) took cognisance of questions on the importance of the maintenance of wearing masks and 113 (95%) on questions regarding hand hygiene in the prevention of disease transmission. However, results show that there were still large gaps in knowledge about questions regarding the virus and the treatment methods (many participants incorrectly believed that the virus could be kill by drinking alcohol or smoking). In addition, more than half of the participants declared compliance with positive health behaviours, however 27.7% did not agree with vaccination (if any), and 31.1% did not agree to be quarantined after being diagnosed with COVID-19. Furthermore, 20 participants (16, 80%) expressed an inclination to deliberately withhold symptoms. Variables in the Health Belief Model showed a significant association with behavioural change.

CONCLUSION

From our study, we found that there is evident knowledge about COVID-19 among international students, although orientation and sensitisation are still required. Those who were aware of the benefits of reporting, the severity of COVID-19 and the legal consequences of deliberately concealing information showed a greater willingness to report; conversely, those who believed reporting is very inconvenient and feared being quarantined after reporting showed less willingness to report. A study focusing on international students' knowledge and behaviour amid the pandemic will provide information for countries to cut off the chain of disease transmission of all variants of COVID-19.

Ten-Year Poverty Alleviation Effect of the Medical Insurance System on Families With Members Who Have a Non-communicable Disease: Evidence From Heilongjiang Province in China

Aims: Non-communicable diseases (NCD) drag the NCD patients' families to the abyss of poverty. Medical insurance due to weak control over medical expenses and low benefits levels, may have actually contributed to a higher burden of out-of-pocket payments. By making a multi-dimensional calculation on catastrophic health expenditure (CHE) in Heilongjiang Province over 10 years, it is significant to find the weak links in the implementation of medical insurance to achieve poverty alleviation.

Methods: A logistic regression was undertaken to predict the determinants of catastrophic health expenditure.

Results: The average CHE of households dropped from 18.9% in 2003 to 14.9% in 2013. 33.2% of the households with three or more NCD members suffered CHE in 2013, which was 7.2 times higher than the households without it (4.6%). The uninsured households with cardiovascular disease had CHE of 12.0%, which were nearly 10% points lower than insured households (20.4–22.4%). For Medical Insurance for Urban Employees Scheme enrolled households, the increasing number of NCD members raised the risk of impoverishment from 3.4 to 20.0% in 2003, and from 0.3 to 3.1% in 2008. Households with hospital in-patient members were at higher risk of CHE (OR: 3.10–3.56).

Conclusions: Healthcare needs and utilization are one of the most significant determinants of CHE. Households with NCD and in-patient members are most vulnerable groups of falling into a poverty trap. The targeting of the NCD groups, the poorest groups, uninsured groups need to be primary considerations in prioritizing services that are contained in medical insurance and poverty alleviation.

Prevalence and Factors Associated With Burnout of Frontline Healthcare Workers in Fighting Against the COVID-19 Pandemic: Evidence From China

OBJECTIVES

The sudden outbreak of the novel coronavirus disease (COVID-19) plunged healthcare workers (HCWs) into warfare. This study aimed to determine the prevalence of burnout and the factors associated with it among frontline HCWs fighting COVID-19.

METHODS

A cross-sectional survey was conducted among frontline HCWs fighting against the COVID-19 in Wuhan, Harbin, and Shenzhen during the period from February 18 to March 4. Finally, HCWs were recruited using cluster sampling, 1,163 HCWs were included in the final analysis. Burnout was measured using a 22-item Maslach Burnout Inventory scale (MBI scale).

RESULTS

Of the participants, 48.6% suffered from burnout, and 21.8% showed a high degree of burnout. Doctors (b = 3.954, P = 0.011) and nurses (b = 3.067, P = 0.042) showed higher emotional exhaustion (EE) than administrators. Participants who worked continuously for more than 8 h a day (b = 3.392, P = 0.000), those who were unable to eat three regular daily meals (b = 2.225, P = 0.008), whose daily water intake was no more than 800 ml (b = 3.007, P = 0.000), who slept for no more than 6 h (b = 1.609, P = 0.036), and who were infected or had colleagues who were infected with COVID-19 (b = 4.182, P = 0.000) experienced much higher levels of EE, while those who could adhere to infection control procedures (b = -5.992, P = 0.000), who were satisfied with their hospital's infection control measures(b = -3.709, P = 0.001), and who could receive sufficient psychological crisis intervention (b = -1.588, P = 0.039) reported lower levels of EE.

CONCLUSION

The study reveals that burnout is prevalent among frontline HCWs and that the known factors associated with burnout, such as workload, and the factors directly associated with COVID-19, such as having insufficient protection, can affect burnout symptoms in frontline HCWs. Synergized and comprehensive interventions should be targeted at reducing its occurrence among frontline HCWs fighting COVID-19.

Economic burden and health related quality of life of ultra-rare Gaucher disease in China

Background

The diagnosis and health care of patients with rare diseases present a tremendous challenge worldwide. This study described the health care service utilization through participants’ perspective and estimated the cost of illness (COI), and patients with Gaucher disease (GD)’s/caregivers’ health-related quality of life in China.

Method

An online retrospective survey of patients with GD and their caregivers was conducted during May–June 2018. Socio-demographic, health service utilization, disease-related expenses, social support, sleep quality (Pittsburgh Sleep Quality Index [PSQI]), and the Short Form Health Survey (SF-36) were investigated. Using self-reported information, we estimated the annual COI, including direct healthcare, direct non-healthcare, and indirect costs.

Results

Forty patients and their 49 caregivers were surveyed. The patients’ onset age of GD was 9.3 ± 10.9; their disease course was 3.5 ± 3.1 years. 21 (42.9%) patients had ≥ 2 caregivers, but 35 (71.4%) caregivers reported have no experience as a caregiver. 79.6% caregivers have stopped working, and 87.8% changed weekly working schedule. Before final diagnosis, patients visited 3.9 ± 3.1 (max = 20) hospitals and took 1.2 ± 1.7 (max = 6.6) years for confirmed diagnosis. On average, 5.0 ± 9.6 misdiagnoses occurred, and the per-patient diagnoses cost was USD ($) 7576. After GD confirmation, 8 (16.3%) patients received no treatment, 40 (81.6%) received pharmacotherapy, 10 (20.4%) received surgery, 38 (77.6%) received outpatient service (8.8 ± 9.1 times/annually), and 37 (77.5%) received inpatient service (4.0 ± 3.5 times/annually). Annual per-patient COI was USD ($) 49,925 (95% confidence interval: 29,178, 70,672). Average direct healthcare cost was $41,816, including pharmaceutical ($29,908), inpatient ($7,451), and outpatient ($1,838). Productivity loss per-caregiver was $1,980, and their Zarit Burden Inventory score was moderate-severe (48.6 ± 19.6). Both patients/caregivers reported lower social support (32.4 ± 7.4, 34.9 ± 7.6), two times higher PSQI (7.9 ± 2.9, 8.7 ± 3.6), and half lower SF-36 (41.3 ± 18.6, 46.5 ± 19.3) than those reported for healthy Chinese individuals.

Conclusions

The high misdiagnosis rate, together with delayed diagnosis, substantial costs, and deteriorated health-related quality of life of GD patients as well as their heavy care burden, calls for extreme attention from policymakers in China. Further efforts of government and society are urgently demanded, including pharmaceutical reimbursement, screening newborns, developing precise diagnostic tools, and training doctors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01963-6.

Minimizing the Risk of Catastrophic Health Expenditure in China: A Multi-Dimensional Analysis of Vulnerable Groups

Background: In moving toward universal health coverage in China, it is crucial to identify which populations should be prioritized for which interventions rather than blindly increasing welfare packages or capital investments. We identify the characteristics of vulnerable groups from multiple perspectives through estimating catastrophic health expenditure (CHE) and recommend intervention priorities. Methods: Data were from National Health Service Survey conducted in 2003, 2008, and 2013. According to the recommendation of WHO, this study adopted 40% as the CHE threshold. A binary regression was used to identify the determinants of CHE occurrence; a probit model was used to obtain CHE standardized incidence under the characteristics of single and two dimensions in 2013. Results: The total incidence of CHE in 2013 was 13.9%, which shows a general trend of growth from 2003 to 2013. Families in western and central regions and rural areas were more at risk. Factors related to social demography show that households with a female or an unmarried head of household or with a low socioeconomic status were more likely to experience CHE. Households with older adults aged 60 and above had 1,524 times higher likelihood of experiencing CHE. Among the health insurance schemes, the participants covered by the New Rural Cooperative Medical Scheme had the highest risk compared with the participants of all basic health insurance schemes. Households with several members seeking outpatient, inpatient care or with non-communicable diseases were more likely to experience CHE. Households with members not seeing a doctor or hospitalized despite the need for it were more likely to experience CHE. Characteristics such as a household head with characteristics related to low socioeconomic status, having more than two hospitalized family members, ranked high. Meanwhile, the combination of having illiterate household heads and with being covered by other health insurance plans or by none ranked the first place. Cancer notably caused a relatively high medical expenditure among households with CHE. Conclusion: In China, considering the vulnerability of the population across different dimensions is conducive to the alleviation of high CHE. Furthermore, people with multiple vulnerabilities should be prioritized for intervention. Identifying and targeting them to offer help and support will be an effective approach.

Comparative and quantitative analysis of COVID-19 epidemic interventions in Chinese provinces

A mathematical model was developed to evaluate and compare the effects and intensity of the coronavirus disease 2019 prevention and control measures in Chinese provinces. The time course of the disease with government intervention was described using a dynamic model. The estimated government intervention parameters and area difference between with and without intervention were considered as the intervention intensity and effect, respectively. The model of the disease time course without government intervention predicted that by April 30, 2020, about 3.08% of the population would have been diagnosed with coronavirus disease 2019 in China. Guangdong Province averted the most cases. Comprehensive intervention measures, in which social distancing measures may have played a greater role than isolation measures, resulted in reduced infection cases. Shanghai had the highest intervention intensity. In the context of the global coronavirus disease 2019 pandemic, the prevention and control experience of some key areas in China (such as Shanghai and Guangdong) can provide references for outbreak control in many countries.

Does the medical insurance system play a real role in reducing catastrophic economic burden in elderly patients with cardiovascular disease in China? Implication for accurately targeting vulnerable characteristics

BACKGROUND

The vulnerability of cardiovascular disease (CVD) patients' health abilities, combined with the severity of the disease and the overlapping risk factors, leads such people to bear the economic burden of the disease due to the medical services. We estimated the economic burden of CVD and identified the weak link in the design of the medical insurance.

METHODS

Data from 5610 middle-aged and elderly with CVD were drawn from the 2015 wave of "China Health and Retirement Longitudinal Study" (CHARLS). The recommended method of the "World Health Organization" (WHO) was adopted to calculate "catastrophic health expenditure" (CHE), "impoverishment by medical expenses" (IME), and applied the treatment-effect model to analyze the determinants of CHE.

RESULTS

The incidence of CHE was 19.9% for the elderly families with CVD members, which was 3.6% higher than for uninsured families (16.3%). Families with CVD combined with > 3 other chronic diseases (38.88%) were the riskiest factor for the high CHE in the new rural cooperative medical system (NCMS). Moreover, families with members > 75 years old (33.33%), having two chronic disease (30.74%), and families having disabled members (33.33%), hospitalization members (32.41%) were identified as the high risky determinants for the high CHE in NCMS.

CONCLUSIONS

Elderly with physical vulnerabilities were more prone to CHE. The medical insurance only reduced barriers to accessing health resources for elderly with CVD; however it lacked the policy inclination for high-utilization populations, and had poorly accurate identification of the vulnerable characteristics of CVD, which in turn affects the economic protection ability of the medical insurance. The dispersion between the multiple medical security schemes leads to the existence of blind spots in the economic risk protection of individuals and families.

Targeting vulnerable groups of health poverty alleviation in rural China- what is the role of the New Rural Cooperative Medical Scheme for the middle age and elderly population?

Background

In light of the health poverty alleviation policy, we explore whether the New Rural Cooperative Medical System (NRCMS) has effectively reduced the economic burden of medical expenses on rural middle-aged and elderly people and other impoverished vulnerable groups. The study aims to provide evidence that can be used to improve the medical insurance system.

Methods

Data were obtained from the 2015 China Health and Retirement Longitudinal Study (CHARLS). The method of calculating the catastrophic health expenditure (CHE) and impoverishment by medical expense (IME) was adopted from the World Health Organization (WHO). The treatment effect model was used to identify the determinants of CHE for rural middle-aged and elderly people.

Results

The incidence of CHE in rural China for middle-aged and elderly people is 21.8%, and the IME is 8.0%. The households that had enrolled in the NRCMS suffered higher CHE (21.9%) and IME (8.0%), than those that had not enrolled (CHE: 20.6% and IME: 7.7%). The NRCMS did not provide sufficient economic protection from CHE for households with three or more chronic diseases, inpatients, or households with members aged over 65 years. Key risk factors for the CHE included education levels, households with inpatients, households with members aged over 65 years, and households with disabilities.

Conclusions

Although the NRCMS has reduced barriers to the usage of household health services by reducing people’s out-of-pocket payments, it has not effectively reduced the risk of these households falling into poverty. Our research identifies the characteristics of vulnerable groups that the NRCMS does not provide enough support for, and which puts them at a greater risk of falling into poverty due to health impoverishment.

The medical insurance system's weakness to provide economic protection for vulnerable citizens in China: A five-year longitudinal study

OBJECTIVES

Little is known about the magnitude of catastrophic health expenditure (CHE) attributable to critical disease, especially in the middle-aged and elderly population. This research aimed to exploring the key aspects of how the health insurance fails to protect the middle-aged and elderly against CHE in the past five years. And propose corresponding measures to improve.

METHODS

Data were obtained from the 2011 to 2015 China Health and Retirement Longitudinal Study. The method was adapted from WHO to calculate the catastrophic health expenditure (CHE) and impoverishment by medical expense (IME), and use Generalized Linear Mixed Models (GLMMs) to comprehensively analyze the risk factors that cause middle-aged and elderly people to fall into CHE.

RESULTS

The incidence of CHE of China's middle-aged and elderly population has been rose in the five years from 2011 (10.5 %) to 2013 (17.5 %) to 2015 (19.7 %). The CHE of richest families was almost 6 times from 2011 to 2015. Urban Employee Medical Insurance Scheme, the incidence of CHE was up 10 percentage from 2011 to 2015. According to the GLMMs, families have inpatient cares as the most important factor to CHE. The incidence of CHE increased by 2.25 times compared with those who did not use inpatient services.

CONCLUSIONS

The health system needs to control the irrational growth of health expenses and reduce residents' overuse of health services. Government should take supplementary measures to comprehensively strengthen the advantages of health insurance. Raise residents' awareness of health care, enhance citizens' physical fitness, and avoid unnecessary waste of health resources.

[Ovarian Sertoli-Leydig cell tumors: DICER1 hotspot mutations and associated clinicopathological features]

Objective: To investigate DICER1 hotspot mutations in ovarian Sertoli-Leydig cell tumor (SLCT) and its associated clinicopathological features. Methods: Forty-three SLCTs and 40 other sex cord-stromal tumors (SCSTs) diagnosed between 2010 and 2017 at Fudan University Shanghai Cancer Center were examined for somatic DICER1 hotspot mutations by Sanger sequencing. The associations between mutation status and clinicopathological features, including patient age, tumor differentiation and recurrence, were analyzed. Results: Somatic DICER1 mutations were found in 51% (22/43) of SLCTs, while none in the other 40 SCSTs. The most common mutation of DICER1 was p.D1709N in exon 24 (41%, 9/22) and the second most common mutation of DICER1 was p.E1813K in exon 25 (14%, 3/22). A novel frameshift mutation (c.5464delG, p.M1837fs*16) was identified in one SLCT with microcystic pattern. Mutations were more likely to occur in patients under forty years of age (P=0.046), whereas no significant associations were found between DICER1 mutations and clinical symptoms, morphology or tumor recurrence. Conclusions: Somatic DCIER1 hotspot mutations are specifically found in SLCT and may serve as an ancillary marker in differential diagnosis of SLCT from other SCST. The mutations occur more often in young patients (<40 years old). Additional studies are warranted to examine the associations between DICER1 mutations and clinicopathological features and prognosis of SLCT.

Does the medical insurance system really achieved the effect of poverty alleviation for the middle-aged and elderly people in China? Characteristics of vulnerable groups and failure links

BACKGROUND

We examined the physiological, household, and spatial agglomeration characteristics of the health poverty population in China. We identified weak links that affect the implementation of the medical insurance and further improve its effectiveness for health poverty alleviation.

METHODS

A national representative sample from the China Health and Retirement Longitudinal Study (CHARLS) was analyzed. The WHO recommended method was adopted to calculate catastrophic health expenditure (CHE) and impoverishment by medical expenses (IME). We created a binary indicator for IME as the outcome variable and applied the treatment-effect model to analyze the determinants of IME.

RESULTS

The incidence of IME was 7.2% of the overall population, compared to 20.3% of the sample households trapped in CHE. The incidence of IME enrolled in insurance schemes was 7.4% higher than that of uninsured families (4.8%). Economic level, living area, family size, age of household head, having hospitalized members, and participating in insurance were statistically significant for the occurrence of IME.

CONCLUSIONS

The original poverty-promoting policies has not reached the maximum point of convergence with China's current demand for health. The overlapped health vulnerabilities exacerbated the risk of poverty among the elderly and households with high health needs and utilization. In addition, the medical insurance schemes have proven to be insufficient for protection against economic burden of poor households. So, special health needs, age, and household capacity to pay should be comprehensively considered while strengthening the connection between the disease insurance scheme with supplementary insurance.

Can the reform of integrating health insurance reduce inequity in catastrophic health expenditure? Evidence from China

BACKGROUND

China's fragmentation of social health insurance schemes has become a key obstacle that hampers equal access to health care and financial protection. This study aims to explores if the policy intervention Urban and Rural Residents Basic Medical Insurance (URRBMI) scheme, which integrates Urban Resident Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NCMS), can curb the persistent inequity of catastrophic health expenditure (CHE) and further analyses the determinants causing inequity.

METHODS

Data were derived from the Fifth National Health Service Survey (NHSS). A total of 11,104 households covered by URRBMI and 20,590 households covered by URBMI or NCMS were selected to analyze CHE and the impoverishment rate from medical expenses. Moreover, the decomposition method based on a probit model was employed to analyse factors contributing CHE inequity.

RESULTS

The overall incidence of CHE under integrated insurance scheme was 15.53%, about 1.10% higher than the non-integrated scheme; however, the intensity of CHE and impoverishment among the poorest was improved. Although CHE was still concentrated among the poor under URRBMI (CI = -0.53), it showed 28.38% lower in the degree of inequity. For URRBMI households, due to the promotion of integration reform to the utilization of rural residents' better health services, the factor of residence (24.41%) turns out to be a major factor in increasing inequity, the factor of households with hospitalized members (- 84.53%) played a positive role in reducing inequity and factors related to social economic status also contributed significantly in increasing inequity.

CONCLUSION

The progress made in the integrated URRBMI on CHE equity deserves recognition, even though it did not reduce the overall CHE or the impoverishment rate effectively. Therefore, for enhanced equity, more targeted solutions should be considered, such as promoting more precise insurance intervention for the most vulnerable population and including costly diseases suitable for outpatient treatment into benefit packages. Additionally, comprehensive strategies such as favourable targeted benefit packages or job creation are required for the disadvantaged.

Financial Affordability, Health Insurance, and Use of Health Care Services by the Elderly: Findings From the China Health and Retirement Longitudinal Study

The rapidly growing aging population has attracted global attention. This study explores the associations between 3 basic health insurances, and it identifies factors associated with health care services among the elderly populations. This study is based on multistage stratified cluster sampling method from the 2013 China Health and Retirement Longitudinal Study (CHARLS) resulting in 7589 participants. Medical Insurance for Urban Employees (MIUE) members were more likely to use inpatient health care services. Health insurance programs were associated with inpatient services usage but not outpatient services usage. There are significant disparities in medical costs and health care service usage among the 3 insurance programs. Health insurance program is only associated with inpatient care. These findings may provide some suggestions to support improvements to the Chinese health care system.

Catastrophic health expenditure incidence and its equity in China: a study on the initial implementation of the medical insurance integration system

BACKGROUND

By 2013, several regions in China had introduced health insurance integration policies. However, few studies addressed the impact of medical insurance integration in China. This study investigates the catastrophic health expenditure and equity in the incidence of catastrophic health expenditure by addressing its potential determinants in both integrated and non-integrated areas in China in 2013.

METHODS

The primary data are drawn from the fifth China National Health Services Survey in 2013. The final sample comprises 19,788 households (38.4%) from integrated areas and 31,797 households (61.6%) from non-integrated areas. A probit model is employed to decompose inequality in the incidence of catastrophic health expenditure in line with the methodology used for decomposing the concentration index.

RESULTS

The incidence of catastrophic health expenditure in integrated areas is higher than in non-integrated areas (13.87% vs. 13.68%, respectively). The concentration index in integrated areas and non-integrated areas is - 0.071 and - 0.073, respectively. Average household out-of-pocket health expenditure and average capacity to pay in integrated areas are higher than those in non-integrated areas. However, households in integrated areas have lower share of out-of-pocket expenditures in the capacity to pay than households in non-integrated areas. The majority of the observed inequalities in catastrophic health expenditure can be explained by differences in the health insurance and householders' educational attainment both in integrated areas and non-integrated areas.

CONCLUSIONS

The medical insurance integration system in China is still at the exploratory stage; hence, its effects are of limited significance, even though the positive impact of this system on low-income residents is confirmed. Moreover, catastrophic health expenditure is associated with pro-poor inequality. Medical insurance, urban-rural disparities, the elderly population, and use of health services significantly affect the equity of catastrophic health expenditure incidence and are key issues in the implementation of future insurance integration policies.

Determination of Minerals and Trace Elements in Milk, Milk Products, Infant Formula, and Adult Nutrition: Collaborative Study 2011.14 Method Modification

Official Method SM 2011.14/ISO 15151:2018/IDF 229:2018 uses microwave digestion of samples and inductively coupled plasma–atomic emission spectrometry for determination of nine elements, including Ca, Cu, Fe, K, Mg, Mn, Na, P, and Zn. The method was evaluated in a collaborative study of 25 products, including 13 fortified nutritional products (powders, ready-to-feed liquids, and liquid concentrates), five product placebos, six dairy products (liquids, powders, butter, and processed cheese), and the National Institute for Standards and Technology (NIST) Standard Reference Material (SRM) 1849a, in compliance with AOAC INTERNATIONAL Standard Method Performance Requirement (SMPR®) 2014.004. This study significantly expanded the applicability of Official Method 2011.14 beyond the original scope of chocolate milk powder, dietetic milk powder, infant cereal, peanut butter, and wheat gluten. The study included 14 collaborators from 11 countries, and results were compared to SMPR 2014.004. Accuracy of the method was demonstrated using NIST SRM 1849a, yielding recoveries across all laboratories of 98–101% for the nine elements. Precision for the 13 fortified nutritional product samples was 2.2–3.9% for repeatability (relative SD of repeatability) and 6.0–12.2% for reproducibility (RSDR). Excluding Mn, which was present at a wide range of concentrations, the reproducibility was 6.0–9.5%, meeting the performance requirements of SMPR 2014.004. Placebo samples (not fortified with Cu, Fe, Mn, or Zn) yielded acceptable repeatability of 1.8–2.9% for Ca, K, Mg, Na, and P (minerals) but 5.4–29.4% for the low levels of Cu, Fe, Mn, and Zn (trace elements). Reproducibility for the placebos showed the same pattern, with acceptable reproducibility (5.4–10.3%) for minerals but not for the low levels of the trace elements (13.2–82.8%). In the six dairy product samples, repeatability ranged from 1.6 to 3.6% for the minerals, Zn, and the low range of Mn but from 9.4 to 24.6% for Cu, Fe, and the high range of Mn, where concentrations were low as for the nutritional placebos. Reproducibility in the dairy samples was 5.3–8.8% for the minerals but 11.4–55.0% for the trace elements. The mean concentrations of Cu, Fe, and Zn in the dairy products were similar with those in the placebo products, while Zn was present at levels more similar with the fortified nutritional products. Thus, the method met the SMPR criteria except where the trace minerals were present at very low levels. Based on these results, the AOAC Stakeholder Panel for Infant Formula and Adult Nutritionals recommended Final Action status of the expanded applicability of the method. The method was adopted as Final Action by the AOAC Official Methods Board.

Insulin resistance and intestinal integrity in children with and without HIV infection in Uganda

OBJECTIVES

The risk of cardiometabolic complications in children with perinatally acquired HIV infection (PHIVs) and in perinatally HIV-exposed but uninfected children (HEUs) and its relationship to systemic inflammation and markers of gut integrity are not well established. In this current study, we assed insulin resitance in PHIV compared to HEUs and HIV unexposed uninfected children and explored potential association with intestinal damage biomarkers.

METHODS

This was a cross-sectional study in PHIVs, HEUs and HIV-unexposed, uninfected children (HUUs) aged 2-10 years enrolled in Uganda. PHIVs were on stable antiretroviral therapy (ART) with HIV viral load  < 400 HIV-1 RNA copies/mL. Insulin resistance was estimated using the homeostasis model assessment of insulin resistance (HOMA-IR). We measured markers of systemic inflammation, monocyte activation and gut integrity. Kruskal-Wallis tests were used to compare markers by HIV status; Pearson correlation and multiple linear regressions were used to assess associations of the HOMA-IR index with biomarkers of intestinal damage and translocation.

RESULTS

Overall, 172 participants were enrolled in the study (57 PHIVs, 59 HEUs and 56 HUUs). The median age was 7.8 [interquartile range (IQR) 6.39, 8.84] years, 55% were female and the median body mass index (BMI) was 15 (IQR 14.3, 15.8) kg/m² . Among PHIVs, the median CD4% was 37%, and 93% had viral load ≤ 20 copies/mL. PHIVs had higher waist:hip ratio, high-density lipoprotein (HDL) cholesterol, triglycerides and HOMA-IR index than the other groups (P ≤ 0.02). Factors correlated with insulin resistance included higher BMI and HDL cholesterol and lower soluble tumour necrosis factor receptor I (sTNFRI) (P ≤ 0.02). There was no correlation between any of the other inflammatory or gut biomarkers and HOMA-IR index (P ≥ 0.05). After adjusting for age and sTNFRI, BMI remained independently associated with the HOMA-IR index (β = 0.16; P < 0.01).

CONCLUSIONS

Despite viral suppression, Ugandan PHIVs have disturbances in glucose metabolism. Higher BMI, and not immune activation or alteration of gut integrity, was associated with insulin resistance in this population.

Can integration reduce inequity in healthcare utilization? Evidence and hurdles in China

BACKGROUND

Integration of medical insurance schemes has been prioritized as one of the key strategies to address inequity in China's health system. The first pilot attempt to integrate started in 2003 and later expanded nationwide. This study aims to assess its intended impact on inequity in inpatient service utilization and identify the main determinants contributing to its ineffectiveness.

METHODS

A total of 49,365 respondents in the pilot integrated area and 77,165 respondents in the non-integration area were extracted from the Fifth National Health Services Survey. A comparative analysis was conducted between two types of areas. We calculate a concentration index (CI) and horizontal inequity index (HI) in inpatient service utilization and decompose the two indices.

RESULTS

Insurance integration played a positive role in reducing inequality in inpatient service utilization to some extent. A 13.23% lower in HI, a decrease in unmet inpatient care and financial barriers to inpatient care in the pilot integrated area compared with the non-integration area; decomposition analysis showed that the Urban-Rural Residents Basic Medical Insurance, a type of integrated insurance, contributed 37.49% to reducing inequality in inpatient service utilization. However, it still could not offset the strong negative effect of income and other insurance schemes that have increased inequality.

CONCLUSIONS

The earlier pilot attempt for integrating medical insurance was not enough to counteract the influence of factors which increased the inequality in inpatient service utilization. Further efforts to address the inequality should focus on widening access to financing, upgrading the risk pool, reducing gaps within and between insurance schemes, and providing broader chronic disease benefit packages. Social policies that target the needs of the poor with coordinated efforts from various levels and agencies of the government are urgently needed.