The impact of Chinese volume-based procurement on pharmaceutical market concentration.

Objectives: Optimizing the pharmaceutical industrial structure is the key mission of China's healthcare reform. From the industrial structure perspective, this study empirically evaluated the impact of China's national volume-based procurement (NVBP) policy on market concentration in the hospital-end drug market. Methods: This study used drug procurement data of China's public medical institutions which obtained from the national database. A quasi-natural experiment was designed involving eleven pairs of matched treatment-control region combinations, with NVBP policy as the intervention measure. The market was defined by drug name (molecular boundary) and city/province (geographical boundary). Market changes were measured from three dimensions: the number of enterprises and products, market share, and Herfindahl-Hirschman index (HHI). Dual comparison approach and difference-in-difference (DID) method with fixed effect model were applied to quantify policy impacts. Results: The number of enterprises and products decreased by 18 and 83 in pilot regions after NVBP policy, far more than the decreases in control regions (6 and 21). The accumulative market share of 15 bid-winning enterprises increased by 53.67% in volume and 18.79% in value, among which the increment of enterprises with low baseline market share was more prominent (66.64% and 36.40%). Among three enterprise types, the market share of generic consistency evaluation (GCE) certificated generics significantly increased, GCE uncertificated generics significantly decreased, and originators slightly decreased. DID models indicated significantly positive impact of NVBP policy on market concentration, with HHI-volume and HHI-value increasing by 49.33% (ß = 0.401, p < 0.01) and 21.05% (ß = 0.191, p < 0.01). Conclusion: The implementation of NVBP promoted the intensive drug circulation and supply of Chinese public hospitals, intensifying the exit of GCE uncertificated generics from the hospital-end market. NVBP combined with GCE standards significantly improved market concentration, which brought a positive signal of pharmaceutical industrial structure optimization in China. In the future context of normalized and institutionalized NVBP, the balance should be further sought between low drug prices and reliable hospital drug supply, sustainable industry development.

Influencing factors, gender differences and the decomposition of inequalities in cognitive function in Chinese older adults: a population-based cohort study.

BACKGROUND: Evidence remains limited and inconsistent for assessing cognitive function in Chinese older adults (CFCOA) and inequalities in cognitive function in Chinese older adults (ICFCOA) and exploring their influencing factors and gender differences. This study aimed to identify influencing factors and inequality in CFCOA to empirically explore the existence and sources of gender differences in such inequality and analyse their heterogeneous effects. METHODS: Based on data from the China Health and Retirement Longitudinal Study (CHARLS) for three periods from 2011 to 2015, recentered influence function unconditional quantile regression (RIF-UQR) and recentered influence function ordinary least squares (RIF-OLS) regression were applied to assess influencing factors of CFCOA, while grouped treatment effect estimation, Oaxaca-Blinder decomposition, and propensity score matching (PSM) methods were conducted to identify gender differences in ICFCOA and influencing factors, respectively. RESULTS: The results showed heterogeneous effects of gender, age, low BMI, subjective health, smoking, education, social interactions, physical activity, and household registration on CFCOA. Additionally, on average, ICFCOA was about 19.2-36.0% higher among elderly females than among elderly males, mainly due to differences in characteristic effects and coefficient effects of factors such as marital status and education. CONCLUSIONS: Different factors have heterogeneous and gender-differenced effects on CFCOA and ICFCOA, while the formation and exacerbation of ICFCOA were allied to marital status and education. Considering the severe ageing and the increasing incidence of cognitive decline, there is an urgent need for the government and society to adopt a comprehensive approach to practically work for promoting CFCOA and reducing ICFCOA.

A quasi-experimental study of the volume-based procurement (VBP) effect on antiviral medications of hepatitis B virus in China.

Background: The Pilot Plan of National Centralized Volume-Based Procurement (NCVBP) was adopted to cope with the rapid increase in drug expenditures. This research aimed to quantitatively evaluate the impact of the NCVBP on antiviral medications for the hepatitis B virus. Methods: Data on nucleoside analogs (NAs) medications of hepatitis B virus monthly procurement records in the pilot cities from January 2018 to December 2019 were extracted from the China Drug Supply Information Platform (CDSIP). The impacts of the NCVBP on purchased volumes, expenditures, and pre-defined daily dose costs were evaluated by interrupted time-series (ITS) analysis using Stata 16.0. We constructed two segments with one interruptive point (March 2019). Results: Compared to the same period between pre-and post-intervention, the purchased volume of NAs medications were increased by 92.85%, and selected medications were increased by 119.09%. Analysis of changes in the level of NAs medication followed a decrease in purchased expenditure (coefficient: 5364.88, p < 0.001), meanwhile, the purchased volume was increased with statistical significance (coefficient:605.49, p < 0.001). The Defined Daily Dose cost (DDDc) of NAs medication followed a decrease (coefficient: 8.90, p < 0.001). The NCVBP reform was followed by an increase of 618.41 ten thousand Defined Daily Dose (DDD) (p < 0.001) in purchased volume and a reduction of 5273.84 ten thousand Chinese Yuan (CNY) (p < 0.001) in the purchased expenditure of selected medications in the level. The DDDc of selected medications decreased in the level (coefficient: 9.87, p < 0.001), while the DDDc of alternative medications increased in the slope (coefficient:0.07, p = 0.030). The purchased volume and expenditure of bid-winning products increased by 964.08 ten thousand DDD and 637.36 ten thousand CNY in the level (p < 0.001). An increase of 633.46 ten thousand DDD (p < 0.001) in purchased volume and a reduction of 4285.32 ten thousand CNY (p < 0.001) in the purchased expenditure of generic drugs in the level was observed. Conclusion: The NCVBP reduced the DDDc of NAs medication, improved the utilization of the selected medications, and promoted the usage of generic products.

The effect of informal social support on the health of Chinese older adults: a cross-sectional study.

BACKGROUND: This study aimed to assess the effect of informal social support (ISS) on the health of Chinese older adults, identify channels of the association between the two, and assess the magnitude of this effect in different groups of older adults. METHODS: Based on the data from the 2018 China Longitudinal Aging Social Survey (CLASS), we first used both the Quality of Well-Being (QWB) scale and the analytic hierarchy process (AHP) method to construct the QWB score that can objectively measure the health status of Chinese older adults. Next, we conducted an econometric equation controlling for various high-dimensional fixed effects, estimated the effects using the Tobit model, and used various robustness check strategies and the propensity score matching (PSM) method to ensure reliability and deal with the potential endogeneity, respectively. Finally, we performed staging and grouping regression for mechanism and heterogeneity analysis. RESULTS: The mean QWB score of Chinese older adults was 0.778. ISS has a significant positive effect on the health of older adults (P < 0.001), and there were similar patterns of findings for the effects of SE (P < 0.001), PSS (P < 0.001), and ES (P < 0.001). Additionally, the health promotion effect is higher in older adults who are male (P < 0.001), under the age of 80 (P < 0.001), with agricultural household registration (P < 0.001), or with high income (P < 0.001) than in the control group. CONCLUSION: ISS, including SE, PSS, and ES, had significant promotion effects on the health of older adults, especially on those who are male, under the age of 80, with agricultural household registration, or with high income. Meanwhile, these effects could be reflected through two channels: alleviating loneliness and improving the positive emotional status of older adults.

The impact of key monitoring policy on the usage of policy-related drugs in Hubei Province, China.

Introduction: This study evaluated quantitatively the impact of the first batch of the catalog of Key Monitoring and Rational Use Drugs (KMRUD) in Hubei Province on policy-related drug use and expenditures. Methods: This study is aimed to provide a basis for the successful implementation of subsequent catalogs of KMRUD, which may promote the standardization of clinical application of related drugs and effectively reduce drug expenses of the patients. Data on the procurement records of policy-related drugs from January 2018 to June 2021 were obtained from the Drug Centralized Procurement Platform of the Public Resources Trading Center in Hubei Province. Interrupted time-series (ITS) analysis was used in this study. Results: After the implementation of the first batch of the catalog of KMRUD, the consumption of policy-related drugs decreased by 83.29% in 2020. The spending on policy-related drugs decreased by 83.93% in 2020. The introduction of the first batch of the catalog of KMRUD was associated with a significant decrease in the spending on policy-related drugs in the level (p = 0.001). Before the implementation of the KMRUD catalog policy, the Defined Daily Doses (DDDs) (ß1 = -32.26 p < 0.001) and spending (ß1 = -3662.19 p < 0.001) on policy-related drugs showed a downward trend. In the aggregated ITS analysis, the Defined Daily Dose cost (DDDc) of policy-related drugs decreased significantly in the trend (p < 0.001). After the implementation of the KMRUD catalog policy, the monthly procurement volume of 10 policy-related drugs have a significant downward trend (p < 0.05), and 4 policy-related drugs have a significant upward trend (p < 0.05). Conclusion: After the policy intervention, the total DDDc on policy-related drugs indicated sustained reductions. The KMRUD policy overall achieved the goal of limiting policy-related drug use and controlling cost increases. And it is recommended that the health department quantify the usage indicator of adjuvant drugs, uniform standards, and apply prescription reviews and dynamic supervision, and other measures to strengthen supervision.

Quantitative evaluation of traditional Chinese medicine development policy: A PMC index model approach.

Background: Traditional Chinese medicine development policies (TCMDPs) are essential in improving the sustainable development of TCM undertakings, of which transmissions of policy information are closely related to the actual policy effectiveness. However, the inherent components of TCMDPs had not been explored from the structural dimension of policy design. Methods: Based on the policy modeling consistency (PMC) index model, we constructed a comprehensive evaluation system, including ten first-level and 40 second-level indicators, and focused on the TCMDPs released by the Chinese central government in the past 42 years (1980-2022) to conduct multi-dimensional inspections to TCMDPs by analyzing the overall policy quality, individual scoring performance, and indicators distribution characteristics. Results: This study pointed out that four policies were rated as "perfect," 35 were rated as "superb," 50 were rated as "excellent," 28 were rated as "good," and four were rated as "acceptable," with total mean values of the PMC index being 7.530 ± 0.835. Although most TCMDPs had appropriate policy structure and consistency, the potential weaknesses in the design of TCMDPs also needed our attention through careful checks on the outlier policy samples. Besides, the existing TCMDPs had room for improvement regarding policy areas, guarantees and incentives, objects included, and issuing agencies. Conclusions: We emphasized that the policy evaluation method used in this current study, the PMC index model, is scarce in the TCMDPs. These findings are helpful for fully understanding the strengths and weaknesses of TCMDPs and provide theoretical references for further studies optimizing TCMDPs.

Multiple chronic conditions among older adults in China: differences in socio-demographic characteristics.

Objective: There are relatively few studies on multiple chronic conditions (MCC) among older adults in China. This study sought to assess the potential differences in the risk of MCC among different elderly populations, and thus to identify the most vulnerable populations at higher risk of developing the MCC. Methods: A sample of 5320 adults aged 60 years or above from the China's Health-Related Quality of Life Survey for Older Adults 2018 (CHRQLS-OA 2018) were included in this study. Descriptive statistics frequencies and proportions were used to summarize the sample characteristics, and logistic regression models were conducted to identify the differences in the risk of having MCC among different populations. Results: Overall, 52.6% of respondents had been clearly diagnosed with at least one chronic disease with 25.3% having MCC. The males ((adjusted odds ratio [AOR] = 0.84; 95% confidence interval [CI] = 0.73-0.98) were less likely to have MCC. This was also true among female elderly with a non-agricultural hukou (AOR = 0.75; 95% CI = 0.57-0.99). The elderly with a non-agricultural hukou aged 60-64 (AOR = 0.55; 95% CI = 0.34-0.88) had a lower risk of having MCC. Those whose average annual household income per capita were 15,000-30,000 RMB (AOR = 1.42; 95% CI = 1.03-1.96) were more likely to suffer from MCC. The odds ratios of having MCC were smaller as the personal savings increases in total samples (all P < 0.05). Conclusions: The findings suggest that different policies or approaches should target these specific populations who are most in need and are most likely to suffer from MCC.

Relationship between physical activity, screen-related sedentary behaviors and anxiety among adolescents in less developed areas of China.

This study aimed to explore the association between physical activity, screen-related sedentary behaviors, and anxiety. The current study used latent profile analysis (LPA) to identify homogenous subtypes of anxiety among adolescents in less-developed areas of China. Data were aggregated from 6 schools in the less-developed areas of China in September 2018. In total, 900 students were evaluated using the 100-item Mental Health Test (MHT) and Youth Risk Behavior Surveillance System (YRBSS) questionnaire. The LPA was conducted to explore the potential classification of anxiety, which makes full use of all the sample data and explore heterogeneous classifications within groups. Logistic regression was used for the multifactor analysis. A P value <.05 was considered statistically significant. The entropy value suggested that the model with 3 latent profile was the best choice. There were 223 adolescents in the severe anxiety group, accounting for 24.78%. Logistics regression analysis of anxiety revealed that the risk of severe anxiety in boys was lower (odds ratio [OR] = 0.317, P < .001) than in girls. Students had a significantly lower probability of suffering from severe anxiety in using cellphones or computers ≤ 2 hours/day than those used cellphones or computers＞2 hours/day (OR = 0.391, P = .004). Decreasing screen-related sedentary behaviors should be a target of community and school-based interventions, because high screen-related sedentary behaviors were associated with higher odds of anxiety among adolescents in less developed area of China.

The change of drug utilization in China's public healthcare institutions under the "4 + 7" centralized drug procurement policy: Evidence from a natural experiment in China.

Background: Improving drug accessibility and rational drug use are major challenges for China's healthcare reform. In 2018, the Chinese government introduced a novel nationwide policy of centralized drug procurement for off-patent drugs, focusing on improving drug utilization patterns of public medical institutions. Objective: To estimate the impacts of the Chinese centralized drug procurement policy (the so-called "4 + 7" policy) on drug utilization in public medical institutions. Methods: A retrospective natural experimental design and difference-in-difference method were applied using cross-region data extracted from the national procurement database. Eleven "4 + 7" pilot cities (intervention group) and eleven non-pilot provinces (control group) were matched. In addition, "4 + 7" policy-related drugs (n = 116) were selected as study samples, including 25 drugs in the 4 + 7" procurement List ("4 + 7" List drugs) and their alternative drugs (n = 91) that have not yet been covered by centralized procurement policy. Then, the "4 + 7" List drugs were divided into bid-winning and non-winning drugs according to the bidding results, and they were sorted into generic and original drugs. Defined daily dose (DDD) was used to standardize the quantity of drugs used. Results: In the 1-year procurement period, the overall completion rate of agreed procurement volume reached 191.4% in pilot cities. Owing to policy impact, the consumption increased by 405.31% in bid-winning drugs (ß = 1.62, p < 0.001) and decreased by 62.28% (ß = -0.98, p < 0.001) in non-winning drugs. The overall use proportion of bid-winning drugs increased from 17.03% to 73.61% with statistical significance (ß = 1.48, p < 0.001), and increments were also detected in all healthcare settings, regions, and anatomical therapeutic chemical (ATC) categories (all p-values < 0.05). Generics and originators were detected with 67.53% increment (ß = 0.52, p < 0.001) and 26.88% drop (ß = -0.31, p = 0.006) in consume volume. The use proportion of generics increased from 59.23% to 78.44% with significance (ß = 0.24, p < 0.001), as well as in tertiary hospitals (ß = 0.31), secondary hospitals (ß = 0.23), and primary healthcare centers (ß = 0.11) (all p-values < 0.001). The use proportion of relatively quality-guaranteed drugs (i.e. bid-winning and original drugs) increased from 56.69% to 93.61% with significance (ß = 0.61, p < 0.001), and similar increments were also detected in all healthcare settings, regions, and ATC categories (all p-values < 0.05). Conclusion: Healthcare providers demonstrated good compliance with the "4 + 7" policy in completing contracted procurement volume. Centralized drug procurement policy promoted drug consumption gradually concentrated on bid-winning drugs, generic drugs, and more importantly, quality-guaranteed drugs.

The impacts of the "4+7" pilot policy on the volume, expenditures, and daily cost of Serotonin-Specific Reuptake Inhibitors (SSRIs) antidepressants: A quasi-experimental study.

Objectives: The purpose of this study was to quantitatively evaluate the impacts of the"4 + 7" pilot policy on purchase volume, purchase expenditures, and daily cost and to find the changes in the use of SSRIs. Methods: Data was collected covering 31 months, before, during, and after the "4 + 7" pilot policy was implemented in Shenzhen. Interrupted time-series (ITS) analysis was used to examine whether there had been a significant effect with the onset of the "4 + 7" pilot policy in March 2019. Findings: The daily cost of policy-related drugs had a substantial drop of 2.93 yuan under the "4 + 7" pilot policy. The result has shown a 76.70% increase in volume and a 3.39% decrease in the expenditure on policy-related drugs. This study found that the "4 + 7" pilot policy increased the proportion of purchasing winning drugs, with an increment of 85.60 percent. After the implementation of the "4 + 7" pilot policy, policy-related drugs decreased by 443.55thousand Chinese yuan. The study indicated that volume of winning products significantly increased as shown in the regression with a level coefficient (ß 2 ) of -224.17 (p < 0.001) and trend coefficient (ß 3 ) of 15.74 (p < 0.001). The result revealed that both volume and expenditures on branded products showed a significant decrease in the regression in the post-intervention period (level coefficient of volume: ß 2 = -57.65, p < 0.01, trend coefficient of volume: ß 3 = -3.44, p < 0.01; level coefficient of expenditure: ß 2 = -712.98, p < 0.01, trend coefficient of expenditure: ß 3 = -40.10, p < 0.01). Conclusion: The volume-based procurement has successfully led to price reductions and improved the affordability of medicines, especially for those with chronic diseases. The volume-based procurement has demonstrated initial success in reshaping the composition of the Chinese pharmaceutical market in favor of generics with high quality and low prices.

Changing Characteristics of Pharmaceutical Prices in China Under Centralized Procurement Policy: A Multi-Intervention Interrupted Time Series.

Objective: National centralized drug procurement organized by the Chinese government currently represents the largest group purchasing organization worldwide, to establish a reasonable price formation mechanism. This study aimed to evaluate the effects of centralized procurement policy on drug price and price ratio in China. Method: Monthly drug procurement data of public medical institutions were extracted from the national procurement database, including 11 pilot cities and 36 months from January 2018 to December 2020. Centralized procured INNs (International Nonproprietary Names) (n = 25) and their alternative INNs (n = 96) were selected as study samples. Centralized procured INNs were divided into bid-winning and non-winning products according to the bidding results. Drug price, price distribution, and price ratio were measured. Multi-intervention interrupted time series analysis was performed to estimate the policy impacts in two centralized procurement periods. Results: The price of centralized procured INNs showed an immediate drop of 44.57% (ß = -0.59, p < 0.001) at the policy implementation, among which bid-winning drugs decreased by 61.71% (ß = -0.96, p < 0.001). No significant change in the price level or trends was found for non-winning products and alternative drugs in the first-year procurement period (all p-values > 0.05). During the second-year procurement period, alternative drugs in four therapeutic categories detected significant increases in the price level (all p-values < 0.05). The overall coefficient of variation of price distribution exhibited upward trends after policy implementation. Among the most centralized procured INNs, the price ratio between certificated generics (generics that have passed the consistency evaluation) and original drugs declined significantly after policy intervention (p < 0.05), whereas the price ratio between uncertificated and certificated generics increased significantly (p < 0.05). Conclusion: Chinese government-organized group purchasing resulted in prominent price reduction of bid-winning drugs. The policy observed a short-term "spillover" effect of synergistic price reduction, while the effect wore off after 1-year procurement period. The extremely dispersed price distribution, as well as unreasonable price ratios, requires further effective price regulation means.

A Cross-National Comparison on Life Expectancy of Non-Hispanic White Americans.

Objectives: Taking the life expectancy (LE) of Non-Hispanic White (NHW) Americans as an example to provide potential references for improving LE globally. Methods: We collected complete data from the United States (US) CDC, Office for National Statistics in the United Kingdom (UK), and the OECD publications, and described LE changes of NHW Americans by cross-national comparison and Arriaga's method. Results: LE of NHW Americans was not as optimistic as European countries from 2006 to 2018. The LE annual average growth rate was 0.04% for NHW Americans, 0.19% for the UK population, and the median of 25 countries was 0.24%. Compared with the other age groups, the age group 30-34 revealed an inferior impact on the LE of NHW people, of which accidents and intentional self-harm were likely to be the top two direct causes. Conclusion: Finding out the direct causes that affect the LE growth in different age groups is conducive to making a targeted intervention or solving the LE growth bottleneck.

Antibiotic Use in China's Public Healthcare Institutions During the COVID-19 Pandemic: An Analysis of Nationwide Procurement Data, 2018-2020.

Background: The overuse of antibiotics is a serious public health problem and a major challenge in China, and China lacks up-to-date evidence on the nationwide antibiotic use in different healthcare settings. The changes of China's antibiotic use under the COVID-19 pandemic are still unknown. Objective: This study aimed to investigate the use of antibiotics in China's public medical institutions based on a three-year nationwide surveillance and to examine the impact of the COVID-19 pandemic on China's antibiotic consumption. Methods: This study used nationwide drug procurement data from the China Drug Supply Information Platform (CDSIP). We retrospectively analyzed antibiotic procurement data of 9,176 hospitals and 39,029 primary healthcare centers (PHCs) from 31 provinces in mainland China from January 2018 to December 2020. Antibiotic utilization was measured by defined daily doses (DDDs) and DDD per 1,000 inhabitants per day (DID). Generalized linear regression models were established to quantify the impact of the COVID-19 pandemic on antibiotic use. Results: The total antibiotic consumption among all healthcare settings increased from 12.94 DID in 2018 to 14.45 DID in 2019, and then dropped to 10.51 DID in 2020. More than half of antibiotics were consumed in PHCs, especially in central regions (59%-68%). The use of penicillins (J01C) and cephalosporins (J01D) accounted for 32.02% and 28.86% of total antibiotic consumption in 2020. During 2018-2020, parenteral antibiotics accounted for 31%-36% of total antibiotic consumption; the proportion is more prominent in central and western regions and the setting of hospitals. Access category antibiotics comprised 40%-42% of the total utilization. Affected by COVID-19, the antibiotic consumption was significantly dropped both in hospitals (ß = -.11, p < .001) and PHCs (ß = -.17, p < .001), as well as in total (ß = -.14, p < .001). Significant increments were observed in the proportion of total antibiotics (ß = .02, p = .024) consumed in hospitals (against the consumption in all healthcare settings), as well as parenteral antibiotics (ß = 1.73, p = .001). Conclusion: The consistent preferred use of penicillin and cephalosporin, as well as injections, among China's public healthcare institutions should draw concern. China's antibiotic consumption significantly declined during the COVID-19 pandemic, which brings opportunities for antibiotic use management in China.

Impact of '4+7' volume-based drug procurement on the use of policy-related original and generic drugs: a natural experimental study in China.

OBJECTIVE: To evaluate the impact of the first round of the National Centralized Drug Procurement pilot (so-called '4+7' policy) on the use of policy-related original and generic drugs. METHODS: A retrospective natural experimental design was adopted. Drug procurement data from the China Drug Supply Information Platform database were used, involving 9 '4+7' pilot cities in intervention group and 12 non-pilot provinces in control group. '4+7' policy-related drugs were selected as study samples, including 25 drugs in the '4+7' procurement list and their alternative drugs that have not yet been covered by the policy. '4+7' List drugs were divided into bid-winning and non-winning products according to the bidding results. Included drugs were sorted into original and generic products. Difference-in-difference method was employed to estimate the net effect of policy impact. RESULTS: After policy intervention, the DDDs (defined daily doses) of '4+7' List original drugs significantly reduced (ß=-39.10, p<0.001), while generic drugs increased (ß=40.43, p<0.01). 17.08% of the original drugs in DDDs were substituted by generic drugs. Prominent reduction was observed in the monthly expenditure of '4+7' List drugs (¥726.40 million) and overall policy-related drugs (¥654.47 million). The defined daily drug cost (DDDc) of bid-winning original and generic drugs, as well as non-winning original drugs, decreased by 44.44%, 79.00% and 15.10% (all p<0.01), while the DDDc of non-winning generic drugs increased by 64.81% (p<0.001). The use proportion of higher-quality drugs raised prominently from 39.66% to 91.93%. CONCLUSIONS: '4+7' policy is conducive to generic substitution, drug price reduction and pharmaceutical cost-containment in China. The overall quality level of drug use of the Chinese population increased after policy intervention, especially in primary healthcare settings. However, the increased DDDc of non-winning generic drugs and alternative drugs should draw the importance of further policy monitoring.

The impact of National Centralised Drug Procurement policy on the use of policy-related original and generic drugs in China.

AIMS: To evaluate the effects of the first round of National Centralised Drug Procurement pilot (so-called '4+7' policy) on the use of policy-related original and generic drugs. METHODS: This study used drug purchasing order data from the Centralised Drug Procurement Survey in Shenzhen 2019, covering 24 months from January 2018 to December 2019. '4+7' policy-related drugs were selected as study samples, including 25 drugs in the '4+7' procurement list and 69 alternative drugs that have an alternative relationship with '4+7' List drugs in clinical use. '4+7' List drugs were then divided into bid-winning and bid-non-winning products according to the bidding results. Included drugs were sorted into original and generic drugs. Purchase volume, expenditures, and daily costs were selected as outcome variables, and were measured using Defined Daily Doses (DDDs), Chinese Yuan (CNY), and Defined Daily Drug cost (DDDc). A single-group Interrupted Time Series analysis was adopted to quantify policy effect. RESULTS: After policy intervention, the overall policy-related original drugs significantly decreased by 0.39 CNY (95% CI: -0.62 to -0.17, p < 0.01) in DDDc, 5949.36 thousand DDDs (95% CI: -8276.67 to -3622.05, p < 0.001) in volume, and 31,575.08 thousand CNY (95% CI: -41,812.68 to -21,337.49, p < 0.001) in expenditures. The volume proportion of generic drugs increased from 78.6% to 91.0%, and the expenditure proportion of increased from 30.9% to 49.8%. CONCLUSION: '4+7' policy promoted the substitution use of domestic generics against original branded drugs and played positive effects on drug price cut and medication burden reduction. The proportion of original branded drugs and generics that passed generic consistency evaluation significantly increased after policy intervention, indicating the improvement of the overall quality level of drug use in China.

The effects of pursed lip breathing combined with diaphragmatic breathing on pulmonary function and exercise capacity in patients with COPD: a systematic review and meta-analysis.

BACKGROUND: Pursed lip breathing (PLB) and diaphragmatic breathing (DB) are physical therapy interventions frequently adopted by patients with chronic obstructive pulmonary disease (COPD). This systematic review aimed to investigate the effects of PLB combined with DB on pulmonary function and exercise capacity in patients with COPD. METHODS: Six databases were searched to collect relevant studies published before August 30, 2019 in English and Chinese. Randomized controlled trials (RCTs) with PLB combined with DB training as the exclusive intervention for COPD were identified. Mean difference (MD) or standardized mean difference (SMD) with 95% confidence interval (CI) was calculated. Heterogeneity was assessed by Cochran's Q test and I2 statistics. RESULTS: A total of 15 RCTs were included, involving 1098 patients with COPD (570 in treatment groups and 528 in control groups). Significant improvements were found in forced expiratory volume in 1 s (FEV1) (SMD = 0.47, 95% CI = 0.27-0.67, P < .001), forced vital capacity (FVC) (SMD = 0.87, 95% CI = 0.59-1.15, P < .001), FEV1 as a proportion of FVC (FEV1/FVC) (MD = 8.30, 95% CI = 1.17-15.43, P = .02), and 6-min walk test (6MWT) distance (MD = 29.09, 95% CI = 19.35-38.83, P < .001). CONCLUSIONS: The intervention of PLB combined with DB effectively promotes pulmonary function and exercise capacity in patients with COPD. The combined application of PLB and DB is an easy and low-cost physical therapy intervention, which should be promoted as a daily essential practice of COPD.

The impact of "4 + 7" volume-based drug procurement on the volume, expenditures, and daily costs of antihypertensive drugs in Shenzhen, China: an interrupted time series analysis.

BACKGROUND: In 2019, Chinese government launched a nationwide volume-based drug procurement aiming at reducing drug prices and saving drug costs through economies of scale, which aroused widespread attention. The first round of the policy pilot was implemented in 4 municipalities and 7 sub-provincial cities, referred to as "4 + 7" policy. In the "4 + 7" policy, 7 antihypertensive drugs were included. This study was conducted to evaluate the impact of "4 + 7" policy on the use of policy-related antihypertensive drugs. METHOD: This study applied single-group Interrupted Time Series (ITS) design. We used drug purchasing data from the Centralized Drug Procurement Survey in Shenzhen 2019, covering 24 months from January 2018 to December 2019. Antihypertensive drugs related to "4 + 7" policy were selected as study samples, including 7 drugs in the "4 + 7" List and 17 alternative drugs. Alternative drugs refer to antihypertensive drugs that have an alternative relationship with "4 + 7" List drugs in clinical use and have not yet been covered by the policy. "4 + 7" List drugs were then divided into bid-winning and bid-non-winning products according to the bidding results. Purchase volume, expenditures, and daily costs were selected as outcome variables, and were measured using Defined Daily Doses (DDDs), Chinese Yuan (CNY), and Defined Daily Drug cost (DDDc). RESULTS: After "4 + 7" policy intervention, the procurement volume of bid-winning antihypertensive drugs significantly increased (3.12 million DDD, 95 % CI = 2.14 to 4.10, p < 0.001), while the volume of non-winning drugs decreased (-2.33 million DDD, 95 % CI= -2.83 to -1.82, p < 0.01). The use proportion of bid-winning antihypertensive drugs increased from 12.31 to 87.74 % after policy intervention. The overall costs of the seven "4 + 7" List antihypertensive drugs significantly declined (-5.96 million CNY, 95 % CI= -7.87 to -4.04, p < 0.001) after policy intervention, with an absolute reduction of 36.37 million CNY compared with the pre-"4 + 7" period. The DDDc of bid-winning antihypertensive drugs significantly decreased (-1.30 CNY, 95 % CI= -1.43 to -1.18, p < 0.001), while the DDDc of non-winning (0.28 CNY, 95 % CI = 0.11 to 0.46, p < 0.01) and alternative (0.14 CNY, 95 % CI = 0.03 to 0.25, p < 0.05) antihypertensive drugs increased markedly. CONCLUSIONS: The implementation of "4 + 7" policy promoted the drug use hypertensive patients gradually concentrated on the quality-guaranteed bid-winning drugs, which might be conducive to improve the overall quality level of drug use of Chinese hypertensive patients. Besides, a preliminary positive policy effect of price cut and cost-saving was observed in the antihypertensive drug category. In the future, price monitoring and drug use management regarding policy-related drugs should also be strengthened.

The Effects of the National Centralized Drug Purchasing Pilot Program on Nucleos(t)ide Analogs in Shenzhen City: An Interrupted Time Series Analysis.

Objectives: To assess the effects of the National Centralized Drug Purchasing Pilot Program on nucleos(t)ide analogs (NAs) in Shenzhen city. Methods: Drugs procurement records in medical institutions were analyzed covering the period from January 2018 to December 2019. An interrupted time series (ITS) analysis was used to evaluate the impact of the "4+7" pilot policy on NAs in Shenzhen city. The outcome measures were usage volume, expenditures, daily cost, and distribution structure of NAs. Findings: After the introduction of the "4+7" pilot policy, the defined daily doses (DDDs) of NA drugs increased by 76.48%, the expenditures and defined daily dose cost (DDDc) of NAs decreased by 45.43 and 69.08%, respectively. The proportion of winning products in Entecavir and Tenofovir Fumarate DDDs was increased by 64.21 and 19.20%, respectively. The post-intervention period witnessed a significant increase in the regression level for NAs DDDs (level coefficient: ß2 = 631.87, p < 0.05). The expenditures (trend coefficient: ß3 = 392.24, p < 0.05) and DDDc (level coefficient: ß2 = -6.17, p < 0.001; trend coefficient: ß3 = -0.21, p < 0.05) of NAs showed decreasing trend in the post-intervention period. The expenditures of original products and generic products both showed a decreasing trend in the post-intervention period (trend coefficient: ß3 = -372.78, p < 0.05, trend coefficient: ß3 = -130.78, p < 0.05, respectively). The DDDc of original products in the policy-related varieties was a significant decrease in the regression slope and level (level coefficient: ß2 = -2.18, p < 0.05; trend coefficient: ß3 = -0.32, p < 0.01). Conclusion: After the implementation of the"4+7" policy, the DDDc of NAs decreased, the accessibility of policy-related drugs was improved, and the usage of generic medicine was promoted.

Influence of Chinese National Centralized Drug Procurement on the price of policy-related drugs: an interrupted time series analysis.

BACKGROUND: The Chinese government implemented the first round of National Centralized Drug Procurement (NCDP) pilot (so-called "4 + 7" policy) in mainland China in 2019. This study aims to examine the impact of "4 + 7" policy on the price of policy-related drugs. METHODS: This study used drug purchasing order data from the Centralized Drug Procurement Survey in Shenzhen 2019, covering 24 months from January 2018 to December 2019. "4 + 7" policy-related drugs were selected as study samples, including 25 drugs in the "4 + 7" procurement list and 57 alternative drugs that have an alternative relationship with "4 + 7" List drugs in clinical use. "4 + 7" List drugs were then divided into bid-winning and bid-non-winning products according to the bidding results. Single-group Interruption Time Series (ITS) analysis was adopted to examine the change of Drug Price Index (DPI) for policy-related drugs. RESULTS: The ITS analysis showed that the DPI of winning (- 0.183 per month, p < 0.0001) and non-winning (- 0.034 per month, p = 0.046) products significantly decreased after the implementation of "4 + 7" policy. No significant difference was found for the immediate change of DPI for alternative drugs (p = 0.537), while a significant decrease in change trend was detected in the post-"4 + 7" policy period (- 0.003 per month, p = 0.014). The DPI of the overall policy-related drugs significantly decreased (- 0.261 per month, p < 0.0001) after "4 + 7" policy. CONCLUSIONS: These findings indicate that the price behavior of pharmaceutical enterprises changed under NCDP policy, while the price linkage effect is still limited. It is necessary to further expand the scope of centralized purchased drugs and strengthen the monitoring of related drugs regarding price change and consumption structure.

The impacts of Chinese drug volume-based procurement policy on the use of policy-related antibiotic drugs in Shenzhen, 2018-2019: an interrupted time-series analysis.

BACKGROUND: In 2019, Chinese government implemented volume-based procurement of 25 drugs in 4 municipalities and 7 sub-provincial cities, i.e. "4 + 7" policy. Competitive bidding was conducted by the government based on the annual agreed procurement volume submitted by each public medical institution in pilot cities. Pilot cities were required to implement bid winning results in March 2019 and the use volume of bid winning products was examined to ensure the completion of agreed procurement volume. In the policy, an oral antibiotic (cefuroxime) was included. Given the current condition of the irrational use of antibiotics in China, this study aims to evaluate the impact of "4 + 7" policy on the use of policy-related antibiotics. METHODS: This study used drug purchase data from the Centralized Drug Procurement Survey in Shenzhen 2019, covering 24 months from January 2018 to December 2019. Oral antibiotic drugs related to "4 + 7" policy were selected as study samples, including cefuroxime and 12 antibiotic drugs that have an alternative relationship with cefuroxime in clinical use. Purchase volume and expenditures were selected as outcome variables, and were measured using Defined Daily Doses (DDDs) and Chinese yuan, respectively. Segmented linear regression analysis with interrupted time series was adopted to examine the effect of "4 + 7" policy. RESULTS: After the implementation of "4 + 7" policy, the overall volume of cefuroxime and its alternative drugs increased from 9.47 million DDDs to 13.42 million DDDs, with an increase of 41.8 %. The results of segmented linear regression showed that the volume of cefuroxime significantly increased 161.16 thousand DDDs after "4 + 7" policy (95 % CI: 59.43 to 262.90, p-value = 0.004). The volume of alternative drugs significantly increased 273.65 thousand DDDs (95 % CI: 90.17 to 457.12, p-value = 0.006). The overall "4 + 7" policy-related antibiotics significantly increased 436.31 thousand DDDs (95 % CI: 190.81 to 681.81, p-value = 0.001) after "4 + 7" policy. CONCLUSIONS: This study provides evidence that the implementation of "4 + 7" volume-based procurement policy was associated with significant increases in the volume of policy-related antibiotic drugs. The increase in antibiotic use after the policy needs special attention and vigilance.