Adaptation strategies in transnational education: a case study of an australian Master of Health Administration Course offered to chinese managers.

BACKGROUND: Management decisions in health influence patient care outcomes; however, health management development courses in China are rare. This study aims to document and evaluate a transnational Master of Health Administration (MHA) course launched in 2000 for the benefit of Chinese health managers. METHODS: A case study of the MHA program jointly run by an Australian university and a Chinese Medical University was conducted. We reviewed the development of the MHA course through a document analysis (key events recorded in achieves, minutes, and audits) followed by reflection (by two course coordinators), extracting key themes related to adaptative strategies. We then conducted a questionnaire survey of 139 graduates seeking their views on relevance, satisfaction and challenges associated with each subject within the course, the relevance of key management skills (as determined by the Australasian College of Health Service Management competency framework), and the impact of the course on their personal career trajectories. Chi-square tests identified differences in the responses by age, gender, pre-training position, and current workplace. RESULTS: The curriculum pedagogy followed the principles of practice-based reflective learning. Research findings and student feedback shaped the curriculum design and subject content, to enhance management practices of the students. Survey participants expressed high levels of satisfaction and confirmed the relevance of all study subjects. Two subjects, health economics and data management, were perceived as being the most challenging. Of the ten management skills we assessed, relatively low self-rated confidence was found in "strategic thinking" and "planning". Younger and less experienced graduates were more likely to report learning challenges (p < 0.05). Frontline managers were least likely to obtain promotion by changing employers (χ2 = 6.02, p < 0.05) or being seconded to another position (χ2 = 9.41, p < 0.01). CONCLUSIONS: This case study illustrates the suitability of cross-country partnerships in health management training, which offers opportunities for managers to systematically explore and acquire a comprehensive set of management skills applicable to their career needs. Opportunities for developing training aligned to career development opportunities are critical for attracting and developing a competent and well-prepared health service management workforce in China.

Effects of prescription restrictive interventions on antibiotic procurement in primary care settings: a controlled interrupted time series study in China.

BACKGROUND: The overuse of antibiotics has been identified as a major challenge in regard to the rational prescription of medicines in low and middle income countries. Extensive studies on the effectiveness of persuasive interventions, such as guidelines have been undertaken. There is a dearth of research pertaining to the effects of restrictive interventions. This study aimed to evaluate the impacts of prescription restrictions in relation to types and administration routes of antibiotics on antibiotic procurement in primary care settings in China. METHODS: Data were drawn from the monthly procurement records of medicines for primary care institutions in Hubei province over a 31-month period from May 2011 to November 2013. We analyzed the monthly procurement volume and costs of antibiotics. Interrupted time series analyses with a difference-in-difference approach were performed to evaluate the effect of the restrictive intervention (started in August 2012) on antibiotic procurement in comparison with those for cardiovascular conditions. Sensitivity tests were performed by replacing outliers using a simple linear interpolation technique. RESULTS: Over the entire study period, antibiotics accounted for 33.65% of the total costs of medicines procured for primary care institutions: mostly non-restricted antibiotics (86.03%) and antibiotics administered through parenteral routes (79.59%). On average, 17.14 million defined daily doses (DDDs) of antibiotics were procured per month, with the majority (93.09%) for non-restricted antibiotics and over half (52.38%) for parenteral administered antibiotics. The restrictive intervention was associated with a decline in the secular trend of costs for non-restricted oral antibiotics (- 0.36 million Yuan per month, p = 0.029), and for parenteral administered restricted antibiotics (- 0.28 million Yuan per month, p = 0.019), as well as a decline in the secular trend of procurement volume for parenteral administered non-restricted antibiotics (- 0.038 million DDDs per month, p = 0.05). CONCLUSIONS: Restrictive interventions are effective in reducing the procurement of antibiotics. However, the effect size is relatively small and antibiotic consumptions remain high, especially parenteral administered antibiotics.

Inequality in the distribution of health resources and health services in China: hospitals versus primary care institutions.

BACKGROUND: Equity is one of the major goals of China's recent health system reform. This study aimed to evaluate the equality of the distribution of health resources and health services between hospitals and primary care institutions. METHODS: Data of this study were drawn from the China Health Statistical Year Books. We calculated Gini coefficients based on population size and geographic size, respectively, for the indicators: number of institutions, number of health workers and number of beds; and the concentration index (CI) for the indicators: per capita outpatient visits and annual hospitalization rates. RESULTS: The Gini coefficients against population size ranged between 0.17 and 0.44 in the hospital sector, indicating a relatively good equality. The primary care sector showed a slightly higher level of Gini coefficients (around 0.45) in the number of health workers. However, inequality was evident in the geographic distribution of health resources. The Gini coefficients exceeded 0.7 in the geographic distribution of institutions, health workers and beds in both the hospital and the primary care sectors, indicating high levels of inequality. The CI values of hospital inpatient care and outpatient visits to primary care institutions were small (ranging from -0.02 to 0.02), indicating good wealth-related equality. The CI values of outpatient visits to hospitals ranged from 0.16 to 0.21, indicating a concentration of services towards the richer populations. By contrast, the CI values of inpatient care in primary care institutions ranged from -0.24 to -0.22, indicating a concentration of services towards the poorer populations. The eastern developed region also had a high internal inequality compared with the other less developed regions. CONCLUSION: Significant inequality in the geographic distribution of health resources is evident, despite a more equitable per capita distribution of resources. Richer people are more likely to use well-resourced hospitals for outpatient care. By contrast, poorer people are more likely to use poorly-resourced primary care institutions for inpatient care. There is a risk of the emergence of a two-tiered health care delivery system.

Distribution of essential medicines to primary care institutions in Hubei of China: effects of centralized procurement arrangements.

BACKGROUND: Poor distribution of essential medicines to primary care institutions has attracted criticism since China adopted provincial centralized regional tendering and procurement systems. This study evaluated the impact of new procurement arrangements that limit the number of distributors at the county level in Hubei province, China. METHODS: Procurement ordering and distribution data were collected from four counties that pioneered a new distribution arrangement (commencing September 2012) compared with six counties that continued the existing arrangement over the period from August 2011 to September 2013. The new arrangement allowed primary care institutions and/or suppliers to select a local distributor from a limited panel (from 3 to 5) of government nominated distributors. Difference-in-differences analyses were performed to assess the impact of the new arrangements on delivery and receipt of essential medicines. RESULTS: Overall, the new distribution arrangement has not improved distribution of essential medicines to primary care institutions. On the contrary, we found a 7.78-19.85 percentage point (p < 0.01) decrease in distribution rates to rural primary care institutions. Similar results were demonstrated using the indicator of received rates, with a 7.89-19.65 percentage point (p < 0.01) decrease. CONCLUSIONS: Simply limiting the number of distributors does not offer a solution to the poor performance of delivery of essential medicines for primary care institutions, especially those located in rural areas. Procurement arrangements need to consider the special characteristics of rural facilities. In a county, there are more rural primary care institutions than urban ones. On average, rural primary care institutions demand more and are more geographically dispersed compared to their urban counterparts, which may impose increased distribution costs.

Challenges in China's health system reform: lessons from other countries.

We are very pleased to have been invited to edit the inaugural virtual special issue for the Australian Journal of Primary Health. This virtual issue will present a set of recently published papers from the Australian Journal of Primary Health that have been selected for their relevance to issues faced in China. It will be launched on 11 September 2017. We have written this Editorial to set the scene for the special issue, and as a general overview of issues affecting one of our most influential neighbours in the region.

Urban-rural inequality regarding drug prescriptions in primary care facilities - a pre-post comparison of the National Essential Medicines Scheme of China.

OBJECTIVE: To assess the impact of the National Essential Medicines Scheme (NEMS) with respect to urban-rural inequalities regarding drug prescriptions in primary care facilities. METHODS: A stratified two-stage random sampling strategy was used to sample 23,040 prescriptions from 192 primary care facilities from 2009 to 2010. Difference-in-Difference (DID) analyses were performed to test the association between NEMS and urban-rural gaps in prescription patterns. Between-Group Variance and Theil Index were calculated to measure urban-rural absolute and relative disparities in drug prescriptions. RESULTS: The use of the Essential Medicines List (EML) achieved a compliance rate of up to 90% in both urban and rural facilities. An overall reduction of average prescription cost improved economic access to drugs for patients in both areas. However, we observed an increased urban-rural disparity in average expenditure per prescription. The rate of antibiotics and glucocorticoids prescription remained high, despite a reduced disparity between urban and rural facilities. The average incidence of antibiotic prescription increased slightly in urban facilities (62 to 63%) and reduced in rural facilities (67% to 66%). The urban-rural disparity in the use of parenteral administration (injections and infusions) increased, albeit at a high level in both areas (44%-52%). CONCLUSION: NEMS interventions are effective in reducing the overall average prescription costs. Despite the increased use of the EML, indicator performances with respect to rational drug prescribing and use remain poor and exceed the WHO/INRUD recommended cutoff values and worldwide benchmarks. There is an increased gap between urban and rural areas in the use of parenteral administration and expenditure per prescription.

Public reporting improves antibiotic prescribing for upper respiratory tract infections in primary care: a matched-pair cluster-randomized trial in China.

BACKGROUND: Inappropriate use and overuse of antibiotics is a serious concern in the treatment of upper respiratory tract infections (URTIs), especially in developing countries. In recent decades, information disclosure and public reporting (PR) has become an instrument for encouraging good practice in healthcare. This study evaluated the impact of PR on antibiotic prescribing for URTIs in a sample of primary care institutions in China. METHODS: A matched-pair cluster-randomized trial was undertaken in QJ city, with 20 primary care institutions participating in the trial. Participating institutions were matched into pairs before being randomly assigned into a control and an intervention group. Prescription statistics were disclosed to patients, health authorities, and health workers monthly within the intervention group, starting from October 2013. Outpatient prescriptions for URTIs were collected from both groups before (1st March to 31st May, 2013) and after the intervention (1st March to 31st May, 2014). A total of 34,815 URTI prescriptions were included in a difference-in-difference analysis using multivariate linear or logistic regression models, controlling for patient attributes as well as institutional characteristics. RESULTS: Overall, 90% URTI prescriptions required antibiotics and 21% required combined use of antibiotics. More than 77% of URTI prescriptions required intravenous (IV) injection or infusion of drugs. PR resulted in a 9 percentage point (95% CI -17 to -1) reduction in the use of oral antibiotics (adjusted RR = 39%, P = 0.027), while the use of injectable antibiotics remained unchanged. PR led to a 7 percentage point reduction (95% CI -14 to 0; adjusted RR = 36%) in combined use of antibiotics (P = 0.049), which was largely driven by a significant reduction in male patients (-7.5%, 95% CI -14 to -1, P = 0.03). The intervention had little impact on the use of IV injections or infusions, or the total prescription expenditure. CONCLUSIONS: The results suggest that PR could improve prescribing practices in terms of reducing oral antibiotics and combined use of antibiotics; however, the impacts were limited. We suggest that PR would probably be enhanced by provider payment reform, management and training for providers, and health education for patients.

Effects of public reporting of prescription indicators on patient choices: evidence from propensity scores matching.

Background: Public reporting on health providers' performance (PRHPP) is increasingly used for empowering patients. This study aimed to test the effect of PRHPP using the theory of the consumer choice model. Methods: The study was conducted in 10 primary care institutions in Hubei province, China. Information related to the percentage of prescriptions requiring antibiotics, the percentage of prescriptions requiring injections, and average costs per prescription for each prescriber was calculated, ranked and displayed in a public place on a monthly basis. A questionnaire survey was undertaken on 302 patients 10 months after the initiation of the PRHPP, tapping into patient awareness, understanding, perceived value and use of the information in line with the theory of the consumer choice model. The fitness of data with the model was tested using structural equation modelling. The patients who were aware of the PRHPP were compared with those who were unaware of the PRHPP. The propensity score method (considering differences between the two groups of patients in age, gender, education, health and income) was used for estimating the effects of the PRHPP. Results: About 22% of respondents were aware of the PRHPP. Overall, the patients showed limited understanding, perceived value and use of the disclosed information. The data fit well into the consumer choice model. Awareness of the PRHPP was found to be associated with increased understanding of the antibiotic (p = 0.028) and injection prescribing indictors (p = 0.030). However, no significant differences in perceived value and use of the information (p > 0.097) were found between those who were aware and those who were unaware of the PRHPP. Conclusion: Although PRHPP may improve patient understanding of the prescribing performance indicators, its impacts on patient choices are limited due to low levels of perceived value and use of information from patients. Additional support is needed to enable patients to make informed choices using the PRHPP.

Examining clinical capability of township healthcare centres for rural health service planning in Sichuan, China: an administrative data analysis.

OBJECTIVE: This study aimed to examine the clinical capability of township healthcare centres (THCs), the main primary care providers in rural China, as a basis for rural health service planning. DESIGN: Observational study of quantitative analysis using administrative data. SETTING: Three counties with low, middle and high social economic development level, respectively, in Sichuan province western China. PARTICIPANTS: 9 THCs and 6 county hospitals (CHs) were purposively selected in the three counties. Summary of electronic medical records of 31 633 admissions from 1 January 2015 to 30 December 2015 of these selected health institutions was obtained from the Health Information Centre of Sichuan province. MAIN OUTCOME MEASURES: Six indicators in scope of inpatient services related to diseases and surgeries in the THCs as proxy of clinical capability, were compared against national standard of capability building of THCs, among counties, and between THCs and CHs of each county. RESULTS: The clinical capability of THCs was suboptimal against the national standard, though that of the middle-developed county was better than that in the rich and the poor counties. THCs mainly provided services of infectious or inflammatory diseases, of respiratory and digestive systems, but lacked clinical services related to injuries, poisoning, pregnancy, childbirth and surgeries. A large proportion of the top 20 diseases of inpatients were potentially avoidable hospitalisations (PAHs) and were overlapped between THCs and CHs. CONCLUSIONS: The clinical capability of THCs was generally suboptimal against national standard. It may be affected by the economics, population size, facilities, workforce and the share of services of THCs in local health systems. Identification of absent services and PAHs may help to identify development priorities of local THCs. Clarification of the roles of THCs and CHs in the tiered rural health system in China is warranted to develop a better integrated health system.

Conditions required to ensure successful detection and management of mild cognitive impairment in primary care: A Delphi consultation study in China.

Objective: Detection and management of mild cognitive impairment (MCI) in primary care has been recognized internationally as one of the strategies that can be employed to delay the development of dementia. However, little is known about what role primary care should play. This study aimed to develop a checklist of conditions necessary for successfully detecting and managing mild cognitive impairment in primary care in China. Methods: This study employed the Delphi method to establish expert consensus on the conditions required for successfully detecting and managing MCI in primary care in China. Twenty-four experts who specialized in general practice, public health, neuropsychology, or community health service management rated the importance of pre-defined conditions (44 items measuring providers' preparedness, patient engagement, and system support in line with the Chronic Care Model). The degree of consensus among the experts was measured using four indicators: median ≥ 4, mean ≥3.5, Co-efficient of Variance < 0.25, and retention in the checklist required ≥ 80% agreement with a rating of important or essential. The checklist and descriptions of the conditions were revised according to the experts' feedback and then sent out for repeated consultations along with a summary of the results of the previous round of consultations. Consensus was achieved after the second round of consultations, which was completed by 22 of the experts. Results: The experts endorsed a checklist of 47 conditions required for successful detection and management of MCI in primary care in China. These conditions were categorized into four domains: prepared general practitioners (17 items), engaged patients (15 items), organizational efforts (11 items), and environmental support (4 items). Conclusions: Successful detection and management of MCI in primary care in China requires a dedicated and competent workforce of general practitioners, as well as the engagement of patients and family caregivers. Adequate support from healthcare organizations, health system arrangements, and the broader society is needed to enable effective interactions between general practitioners and patients and efficient delivery of the services required to detect and manage MCI.

Perceived Quality of Traditional Chinese Medicine Care in Community Health Services: A Cross-Sectional Survey in Hangzhou of China.

Background: Traditional Chinese medicine (TCM) is an integral part of the mainstream health care system in China. Public community health services are required by the government to deliver TCM services. This study aimed to assess patient perceived quality of TCM care in community health services. Methods: A cross-sectional questionnaire survey was conducted on 471 TCM users in four community health centers in Hangzhou. Respondents were asked to rate their experiences on a Likert scale about tangibility, reliability, responsiveness, assurance and empathy of the TCM services they received. Linear regression models were established to determine the sociodemographic and services factors associated with the ratings. Results: Average ratings on the five aspects of the TCM care ranged from 78 to 88 out of a possible 100, with assurance attracting the highest and empathy attracting the lowest score. Overall, higher perceived quality of TCM care (except for assurance) was associated with a choice of TCM in preference to western medicine. Those who reported higher cost (≥100 yuan) of TCM care rated higher on responsiveness and empathy of the care. But higher frequency of visits to community TCM services was associated with lower ratings on reliability, assurance and empathy. Those who received two or more TCM modalities also perceived lower tangible care. In addition, higher ratings on reliability and responsiveness were found in women. The respondents with a university qualification gave higher ratings on reliability and responsiveness; by contrast, those with a highest education of senior high school rated lower on assurance and empathy. Lower perceived tangibility and assurance was also associated with rural residency. Compared with those working in the public sector, the respondents from the retail and services sector gave a higher rating on assurance but a lower rating on empathy. Conclusion: Overall, the TCM users perceived high quality of TCM care in community health services in Hangzhou. However, there is a need to further improve TCM care from all quality perspectives in order to attract and maintain consumer trust in TCM.

Weighing patient attributes in antibiotic prescribing for upper respiratory tract infections: A discrete choice experiment on primary care physicians in Hubei Province, China.

Objectives: This study aimed to determine how primary care physicians weigh intervenable patient attributes in their decisions of antibiotic prescribing for upper respiratory tract infections (URTIs). Methods: A discrete choice experiment (DCE) was conducted on 386 primary care physicians selected through a stratified cluster sampling strategy in Hubei province, China. The patient attributes tested in the DCE were identified through semi-structured interviews with 13 primary care physicians, while the choice scenarios were determined by a D-efficient design with a zero prior parameter value. Conditional logit models (CL) and mixed logit models (MXL) were established to determine the preference of the study participants in antibiotic prescribing for URTI patients with various attributes. Relative importance (RI) was calculated to reflect the influence of each attribute. Results: In addition to age and duration of symptoms, the interventionable patient attributes were also considered by the primary care physicians in their antibiotic prescribing decisions. They preferred to prescribe antibiotics for URTI patients with difficulties to schedule a follow-up appointment (p < 0.001) and for those without a clear indication of refusal to antibiotics (p < 0.001). Patient request for antibiotics had an RI ranging from 15.2 to 16.3%, compared with 5.1-5.4% for easiness of follow-up appointment. The influence of these two interventionable patient attributes was most profound in the antibiotic prescribing decisions for patients aged between 60 and 75 years as indicated by their interaction effects with age (ß = 0.69 for request for antibiotics, p < 0.01; ß = -1.2 for easiness of follow-up, p < 0.001). Conclusion: Reducing patient pressure and improving accessibility and continuity of care may help primary care physicians make rational antibiotic prescribing decisions for URTIs.

Health-related quality of life of young academics: A cross-sectional survey of universities in Wuhan, China.

Objective: This study aimed to assess the health-related quality of life (HRQoL) of young academics in Wuhan, China, and its determinants. Methods: A multistage stratified cluster sampling strategy was employed to recruit study participants (young academics <40 years old) from 12 universities in Wuhan. A total of 301 respondents returned a self-complete questionnaire that contained the EQ-5D-5L. Multivariate linear and Tobit regression models were established to determine the sociodemographic and job predictors of the visual analogue scale (VAS) score and the EQ-5D utility index, respectively. Results: The study participants reported a mean VAS value of 79.42 (SD = 10.51) and a mean EQ-5D utility index of 0.915 (SD = 0.090). Anxiety/depression was the most frequently reported problem (65.12%), followed by pain/discomfort (43.52%). Transitioning towards a full professorship in national key universities (p < 0.001), lower income (p < 0.05) and too much pressure for academic promotion (p < 0.001) were significant predictors of lower HRQoL; whereas, maintaining routines in physical activities (p < 0.001), sleep (p < 0.001) and meals (p < 0.001), a good relationship with colleagues and family members (p < 0.001), and social activities (p < 0.01) were significant predictors of higher HRQoL. Conclusion: Low HRQoL of young academics in China is evident, as indicated by the 7.08 and 0.049 gap in VAS and utility index, respectively, compared to the general population at the same age. Work and career pressures are associated with the low HRQoL of young academics. The findings of this study highlight the importance of work-life balance in promoting HRQoL of young academics in universities in China.

Defining timeliness in care for patients with lung cancer: a scoping review.

OBJECTIVES: Early diagnosis and reducing the time taken to achieve each step of lung cancer care is essential. This scoping review aimed to examine time points and intervals used to measure timeliness and to critically assess how they are defined by existing studies of the care seeking pathway for lung cancer. METHODS: This scoping review was guided by the methodological framework for scoping reviews by Arksey and O'Malley. MEDLINE, EMBASE, CINAHL and PsycINFO electronic databases were searched for articles published between 1999 and 2019. After duplicate removal, all publications went through title and abstract screening followed by full text review and inclusion of articles in the review against the selection criteria. A narrative synthesis describes the time points, intervals and measurement guidelines used by the included articles. RESULTS: A total of 2113 articles were identified from the initial search. Finally, 68 articles were included for data charting process. Eight time points and 14 intervals were identified as the most common events researched by the articles. Eighteen different lung cancer care guidelines were used to benchmark intervals in the included articles; all were developed in Western countries. The British Thoracic Society guideline was the most frequently used guideline (20%). Western guidelines were used by the studies in Asian countries despite differences in the health system structure. CONCLUSION: This review identified substantial variations in definitions of some of the intervals used to describe timeliness of care for lung cancer. The differences in healthcare delivery systems of Asian and Western countries, and between high-income countries and low-income-middle-income countries may suggest different sets of time points and intervals need to be developed.

Identifying Antibiotic Prescribing Patterns Through Multi-Level Latent Profile Analyses: A Cross-Sectional Survey of Primary Care Physicians.

Background: Overuse of antibiotics significantly fuels the development of Antimicrobial resistance, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants. Methods: A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n = 501,072) made by the participants from 1 January to March 31, 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO "Watch and Reserve" list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns. Results: On average, each primary care physician issued 909 (ranging from 100 to 11,941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD = 17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD = 15.83%) contained broad-spectrum antibiotics; 71.92% (SD = 21.42%) contained parenteral administered antibiotics; 23.52% (SD = 19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD = 20.98%) contained antibiotics listed in the WHO "Watch and Reserve" list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers. Conclusion: Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

Evaluating Traditional Chinese Medicine Interventions on Chronic Low Back Pain Using Goal Attainment Scaling.

BACKGROUND: Extensive studies have been conducted to evaluate the pain relief effect of traditional Chinese medicine (TCM) interventions on patients with low back pain, including in China. However, there is a dearth in the literature documenting the diverse goals of TCM interventions, let alone the overall effect of such interventions. In this study, the goal attainment scaling (GAS) method was adopted to evaluate individualised TCM interventions on chronic low back pain. METHODS: A pre-post intervention study was conducted on patients with chronic low back pain who received individualised TCM interventions in community health services. The study was undertaken in three community health centres in Hangzhou of China. A total of 165 eligible patients were invited, and 150 participated in the study, including 136 who completed both pre- and postintervention surveys. Each participant was asked to identify three to five intended goals from a pool of 26 outcome indicators and their corresponding expectations of these goals prior to the TCM interventions. Their conditions were rated against the selected indicators on a self-report five-point Likert scale before and after the TCM interventions, respectively. Gaps between the actual conditions and the expected goals were summed up for each participant and converted into a standardised GAS score, with a higher score indicating higher achievements, and 50 indicting patient expectations were met. Linear regression models were established to determine the factors associated with the pre-post GAS changes after adjustment for variations in other variables. RESULTS: On average, an increase of 14.99 (SD = 9.81) in the GAS scores was achieved. This resulted in a mean GAS score of 48.33 (SD = 9.74) after the TCM interventions, falling slightly short (<2) of patient expectations. The multivariate linear regression models revealed that local residents, the retired, and those who perceived lower professional competency of their attending doctors had a smaller increase in the GAS scores after adjustment for variations in other variables. CONCLUSION: The individualised TCM interventions can help patients with low back pain to achieve their expected goals as measured by the GAS. Further studies are needed to better understand how patients set up their goals and the professional competency requirements to meet patient expectations.

Antibiotic Sales in Primary Care in Hubei Province, China: An Analysis of 2012-2017 Procurement Records.

The over-use of antibiotics has been identified as a major global challenge, where there is insufficient knowledge about the use of antibiotics in primary healthcare settings, especially at a population level. This study aims to investigate the trends and patterns of antibiotic sales in primary care in Hubei, China over a six-year period from 2012 to 2017. Antibiotic sales were expressed with Defined Daily Doses per 1000 inhabitants per day (DIDs) and compared with European countries using the 12 quality indicators proposed by the scientific advisory board of the European Surveillance of Antimicrobial Consumption (ESAC) project. Antibiotic sales increased from 12.8 DID in 2012 to 15.3 DID in 2013, and then declined afterwards. The most commonly used antibiotics, J01C (beta-lactam antimicrobials, penicillins), accounted for 40.5% of total antibiotic sales. Parenteral administration of antibiotics accounted for over 50% of total antibiotic sales. Total antibiotic sales were almost on a par with the 31 European countries monitored by the ESAC project, but cephalosporin sales were higher than at least three quarters of the compared countries, resulting in a significant higher proportion of third-generation cephalosporin consumption (13.8-19.43%). The relative consumption of Fluoroquinolone (9.26-9.89%) was also higher than at least half of the compared countries. There is a lack of robust evidence to show that antibiotic consumption in primary care is lower in Hubei compared with other countries. The preference of clinicians in China to use broad-spectrum and parenteral antibiotics deserves further study and policy attention.

Delivery of Essential Medicines to Primary Care Institutions and its Association with Procurement Volume and Price: A Case Study in Hubei Province, China.

BACKGROUND: The low availability of essential medicines is a worldwide issue of concern. In 2009, China introduced a National Essential Medicines List (NEML), with NEML medicines being purchased in bulk at contracted prices established by tenders conducted at the provincial level. The availability of essential medicines in the public sector largely relies on commercial supply chains. OBJECTIVES: The objectives of this paper were to analyze the delivery performance of essential medicines under NEML provincial procurement arrangements, and to determine whether the procurement volume and price of medicines are associated with the delivery performance of suppliers. METHODS: We reviewed 9390 recorded orders of 1099 essential medicines in Hubei province from August 2011 to April 2012. The reliability of medicine delivery in-full and on-time (DIFOT) was considered the performance indicator, and we used Spearman correlation analyses to explore whether there were any associations between DIFOT and procurement price and volume. Quantile regressions were performed to determine such associations. RESULTS: The DIFOT had positive correlations with procurement price and volume. The Spearman rank correlation coefficients between price and DIFOT were 0.114, 0.34 and 0.25 for medicines with low one-third, middle one-third and high one-third procurement volumes, respectively. The quantile regression analysis revealed a positive association between price and DIFOT across all quantiles of DIFOT, and although significant positive associations between volume and DIFOT were only found at the 25th percentile of DIFOT, volume showed significant interactions with price for both the 25th and 50th percentiles of DIFOT. CONCLUSIONS: Higher procurement price is associated with better delivery performance of essential medicines; however, it is important to link procurement price with procurement volume. Increasing procurement volume may alleviate the negative effect of low price on delivery performance. Variation in volumes of repeated orders imposes uncertainties and may jeopardize the delivery of essential medicines.

Measuring patient safety culture in maternal and child health institutions in China: a qualitative study.

INTRODUCTION: Patient safety culture (PSC) plays a critical role in ensuring safe and quality care. Extensive PSC studies have been undertaken in hospitals. However, little is known about PSC in maternal and child health (MCH) institutions in China, which provide both population-based preventive services as well as individual care for patients. OBJECTIVES: This study aimed to develop a theoretical framework for conceptualising PSC in MCH institutions in China. METHODS: The study was undertaken in six MCH institutions (three in Hebei and three in Beijing). Participants (n=118) were recruited through stratified purposive sampling: 20 managers/administrators, 59 care providers and 39 patients. In-depth interviews were conducted with the participants. The interview data were coded using both inductive (based on the existing PSC theory developed by the Agency for Healthcare Research and Quality) and deductive (open coding arising from data) approaches. A PSC framework was formulated through axial coding that connected initial codes and selective coding that extracted a small number of themes. RESULTS: The interviewees considered patient safety in relation to six aspects: safety and security in public spaces, safety of medical services, privacy and information security, financial security, psychological safety and gap in services. A 12-dimensional PSC framework was developed, containing 69 items. While the existing PSC theory was confirmed by this study, some new themes emerged from the data. Patients expressed particular concerns about psychological safety and financial security. Defensive medical practices emerged as a PSC dimension that is associated with not only medical safety but also financial security and psychological safety. Patient engagement was also valued by the interviewees, especially the patients, as part of PSC. CONCLUSIONS: Although there are some common features in PSC across different healthcare delivery systems, PSC can also be context specific. In MCH settings in China, the meaning of 'patient safety' goes beyond the traditional definition of patients. General well-being, health and disease prevention are important anchor points for defining PSC in such settings.