Health insurance and inequalities in catastrophic health spending in cancer patients. A cross-sectional study in China.

OBJECTIVE: To determine the role of social health insurance programs in reducing inequality in the incidence and intensity of catastrophic health expenditure (CHE) of cancer patients in China. METHOD: A convenient sample of 2534 cancer patients treated in nine hospitals in 2015 and 2016 were followed up through face-to-face interviews in March-December 2018. The incidence and intensity (mean positive overshoot) of CHE (≥ 40% household consumption) were calculated. RESULTS: About 72% of cancer patients experienced CHE events after insurance compensation, with the catastrophic mean positive overshoot amounting to 28.27% (SD: 15.83%) of the household consumption. Overall, social insurance contributed to a small percentage of drop in CHE events. Income-related inequality in CHE persisted before and after insurance compensation. Richer patients benefit more than poorer ones. CONCLUSIONS: Cancer treatment is associated with high incidence of CHE events in China. The alleviating effect of social health insurance on CHE events is limited.

Effects of 625 nm light-emitting diode irradiation on preventing ER stress-induced apoptosis via GSK-3ß phosphorylation in MC3T3-E1.

Prolonged endoplasmic reticulum (ER) stress contributes to cell apoptosis and interferes with bone homeostasis. Although photobiomodulation (PBM) might be used for ER stress-induced diseases, the role of PBM in relieving cell apoptosis remains unknown. During ER stress, glycogen synthase kinase-3ß (GSK-3ß) is critical; however, its functions in PBM remain uncertain. Thus, this study aimed to investigate the role of GSK-3ß in 625 nm light-emitting diode irradiation (LEDI) relieving tunicamycin (TM)-induced apoptosis. Based on the results, pre-625 nm LEDI (Pre-IR) phosphorylated GSK-3ß via ROS production. Compared with the TM group, Pre-IR + TM group reduced the phosphorylation of the α-subunit of eukaryotic translation initiation factor 2 (eIF-2α) and B-cell lymphoma protein 2 (Bcl-2)-associated X (Bax)/Bcl-2 ratio through regulating GSK-3ß. Furthermore, a similar tendency was observed between Pre-IR + TM and Pre-LiCl+TM groups in preventing TM-induced early and late apoptosis. In summary, this study suggests that the Pre-IR treatment in TM-induced ER stress is beneficial for preventing cell apoptosis via GSK-3ß phosphorylation.

625 nm Light Irradiation Prevented MC3T3-E1 Cells from Accumulation of Misfolded Proteins via ROS and ATP Production.

Osteoblasts must acquire a considerable capacity for folding unfolded and misfolded proteins (MPs) to produce large amounts of extracellular matrix proteins and maintain bone homeostasis. MP accumulation contributes to cellular apoptosis and bone disorders. Photobiomodulation therapy has been used to treat bone diseases, but the effects of decreasing MPs with photobiomodulation remain unclear. In this study, we explored the efficacy of 625 nm light-emitting diode irradiation (LEDI) to reduce MPs in tunicamycin (TM) induced-MC3T3-E1 cells. Binding immunoglobulin protein (BiP), an adenosine triphosphate (ATP)-dependent chaperone, is used to evaluate the capacity of folding MPs. The results revealed that pretreatment with 625 nm LEDI (Pre-IR) induced reactive oxygen species (ROS) production, leading to the increased chaperone BiP through the inositol-requiring enzyme 1 (IRE1)/X-box binding protein 1s (XBP-1s) pathway, and then restoration of collagen type I (COL-I) and osteopontin (OPN) expression relieving cell apoptosis. Furthermore, the translocation of BiP into the endoplasmic reticulum (ER) lumen might be followed by a high level of ATP production. Taken together, these results suggest that Pre-IR could be beneficial to prevent MP accumulation through ROS and ATP in TM-induced MC3T3-E1cells.

Integrated Analysis Revealing the Senescence-Mediated Immune Heterogeneity of HCC and Construction of a Prognostic Model Based on Senescence-Related Non-Coding RNA Network.

Background: Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related mortality worldwide. Non-coding RNAs play an important role in HCC. This study aims to identify a senescence-related non-coding RNA network-based prognostic model for individualized therapies for HCC. Methods: HCC subtypes with senescence status were identified on the basis of the senescence-related genes. Immune status of the subtypes was analyzed by CIBERSORT and ESTIMATE algorithm. The differentially expressed mRNAs, microRNAs (miRNAs), and long non-coding RNAs (lncRNAs) were identified between the two HCC subtypes. A senescence-based competing endogenous RNA (ceRNA) co-expression network in HCC was constructed. On the basis of the ceRNA network, Lasso Cox regression was used to construct the senescence-related prognostic model (S score). The prognosis potential of the S score was evaluated in the training dataset and four external validation datasets. Finally, the potential of the prognostic model in predicting immune features and response to immunotherapy was evaluated. Results: The HCC samples were classified into senescence active and inactivate subtypes. The senescence active group showed an immune suppressive microenvironment compared to the senescence inactive group. A total of 2,902 mRNAs, 19 miRNAs, and 308 lncRNAs were identified between the two subtypes. A ceRNA network was constructed using these differentially expressed genes. On the basis of the ceRNA network, S score was constructed to predict the prognosis of patients with HCC. The S score was correlated with immune features and can predict response to immunotherapy of cancer. Conclusion: The present study analyzed the biological heterogeneity across senescence-related subtypes and constructed a senescence-related ceRNA-network-based prognostic model for predicting prognosis and immunotherapy responsiveness.

Surgical career choices of medical students in China: does gender bias play a role?

BACKGROUND: Gender bias in career choices has always been a matter of great concern, including in the field of medicine. This study reports on the current situation in this regard in China, including the reasons for Chinese medical students' willingness to engage in surgical careers; investigates their accounts of gender bias; and analyzes the effect of gender bias on their surgical career choices. METHODS: This study invited medical students from Harbin Medical University to fill out a non-mandatory questionnaire on whether they had witnessed gender bias, their surgical career intentions, and factors influencing their career intentions. A one-way analysis of variance was used to compare the differences between continuous variables. Pearson's chi-squared test was used to compare the differences between the categorical variables, the Kendall correlation coefficient (tau) was used to assess the correlation between the reasons rankings reported by gender, and a multiple regression analysis was conducted by logit model. RESULTS: A total of 643 students responded to the questionnaire. Of them, 63.76% expressed a willingness for a surgical career, with "interest" being a key driving factor (73.41%). Almost all respondents (96.27%) answered that there were more male leaders in the surgical departments they had rotated through or had contacted. Only a few respondents reported gender barriers influencing recruitment (32.19%). However, witnessing gender bias (recruitment of male required) was correlated to choice of surgical career (P < 0.05). Females were less willing to pursue a career in surgery if they had witnessed gender barriers in surgical recruitment. Male dominance also correlated to the choice of a surgical career (P < 0.1). Of the respondents, 53.19% believed that surgery was not suitable for females; among female respondents, this number was 56.12%, higher than for male respondents. When females think that the surgical profession is not suitable for them, it reduces the possibility of their pursuing a career in surgery. CONCLUSION: Most medical students were interested in surgical care. Witnessing gender bias decreases females' willingness to pursue a career in surgery. It is necessary to stimulate medical students' interest in surgery when formulating strategies to promote surgical career choices, as well as to reduce gender bias in surgery; in this way, females' surgical careers should be ensured.

Catastrophic health expenditure and its determinants in households with lung cancer patients in China: a retrospective cohort study.

BACKGROUND: Numerous studies have examined catastrophic health expenditures (CHE) worldwide, mostly focusing on general or common chronic populations, rather than particularly vulnerable groups. This study assessed the medical expenditure and compensation of lung cancer, and explored the extent and influencing factors of CHE among households with lung cancer patients in China. METHODS: During 2018-2019, a hospital-based multicenter retrospective survey was conducted in seven provinces/municipalities across China as a part of the Cancer Screening Program of Urban China. CHE was measured according to the proportion of out-of-pocket (OOP) health payments of households on non-food expenditures. Chi-square tests and logistic regression analysis was adjusted to determine the factors that significantly influenced the likelihood of a household with lung cancer patient to incur in CHE. RESULTS: In total, 470 households with lung cancer patients were included in the analysis. Health insurance was shown to protect some households from the impact of CHE. Nonetheless, CHE incidence (78.1%) and intensity (14.02% for average distance and 22.56% for relative distance) were still relatively high among households with lung cancer patients. The incidence was lower in households covered by the Urban Employee Basic Medical Insurance (UEMBI) insurance, with higher income level and shorter disease course. CONCLUSION: More attention is needed for CHE incidence among vulnerable populations in China. Households with lung cancer patients were shown to be more likely to develop CHE. Therefore, policy makers should focus on improving the financial protection and reducing the economic burden of this disease.

Catastrophic Health Expenditure and Its Determinants Among Households With Breast Cancer Patients in China: A Multicentre, Cross-Sectional Survey.

Background: Although numerous studies have examined catastrophic health expenditures (CHE) worldwide, most focus on the general population, not on specific vulnerable groups. We aimed to analyse the extent and the influencing factors of CHE in households with breast cancer patients in China, and explore the ability of different insurances to protect these households from CHE. Methods: A multicentre, cross-sectional interview surveys was conducted in households with breast cancer patients across seven provinces/municipalities in China. CHE were defined as out-of-pocket expenditures ≥ 40% of households' non-food expenditures. Chi-square tests and logistic regression analysis were performed to identify the determinants of CHE in household with breast cancer patients. Results: In the 639 participating households with breast cancer patients, the mean out-of-pocket (OOP) expenditure accounted for ~55.20% of the mean households' non-food expenditures. The overall incidence of CHE was 87.95 and 66.28% before and after insurance compensation, respectively. The logistic regression model revealed that education, disease course, health insurance, treatment method, and income were significant predictors of CHE. Conclusions: The results indicated that medical insurance protects some households with breast cancer patients from the impact of CHE. However, their reimbursement rates were relatively low. Therefore, breast cancer still had a significant catastrophic effect on the economy of households. Policy efforts should focus on improving insurance compensation rates and relieving the economic burden of critical illnesses such as breast cancer.

Effects of cancer treatment on household impoverishment: a multicentre cross-sectional study in China.

OBJECTIVES: To determine the incidence and intensity of household impoverishment induced by cancer treatment in China. DESIGN: Average income and daily consumption per capita of the households and out-of-pocket payments for cancer care were estimated. Household impoverishment was determined by comparing per capita daily consumption against the Chinese poverty line (CPL, US$1.2) and the World Bank poverty line (WBPL, US$1.9) for 2015. Both pre-treatment and post-treatment consumptions were calculated assuming that the households would divert daily consumption money to pay for cancer treatment. PARTICIPANTS: Cancer patients diagnosed initially from 1 January 2015 to 31 December 2016 who had received cancer treatment subsequently. Those with multiple cancer diagnoses were excluded. DATA SOURCES: A household questionnaire survey was conducted on 2534 cancer patients selected from nine hospitals in seven provinces through two-stage cluster/convenience sampling. FINDINGS: 5.89% (CPL) to 12.94% (WBPL) households were impoverished after paying for cancer treatment. The adjusted OR (AOR) of post-treatment impoverishment was higher for older patients (AOR=2.666-4.187 for ≥50 years vs <50 years, p<0.001), those resided in central region (AOR=2.619 vs eastern, p<0.01) and those with lower income (AOR=0.024-0.187 in higher income households vs the lowest 20%, p<0.001). The patients without coverage from social health insurance had higher OR (AOR=1.880, p=0.040) of experiencing post-treatment household impoverishment than those enrolled with the insurance for urban employees. Cancer treatment is associated with an increase of 5.79% (CPL) and 12.45% (WBPL) in incidence of household impoverishment. The median annual consumption gap per capita underneath the poverty line accumulated by the impoverished households reached US$128 (CPL) or US$212 (WBPL). US$31 170 395 (CPL) or US$115 238 459 (WBPL) were needed to avoid household impoverishment induced by cancer treatment in China. CONCLUSIONS: The financial burden of cancer treatment imposes a significant risk of household impoverishment despite wide coverage of social health insurance in China.

A systematic review of the budget impact analyses for antitumor drugs of lung cancer.

BACKGROUND: Budget impact analyses (BIAs) are used for reimbursement decisions and drug access medical insurance, as a supplement to cost-effectiveness analyses (CEAs). OBJECTIVES: We systematically reviewed BIAs for antitumor drugs of lung cancer to provide reference for high-value drug budget impact analyses and decision making. METHODS: We conducted a literature search on PubMed, EMbase, The Cochrane Library, China National Knowledge Infrastructure and Wanfang Data Knowledge Service Platform from 2010 to 2019. The methodological indicators and result information of the budget impact analyses were extracted and evaluated for quality. RESULTS: A total of 14 studies on the budget impact for antitumor drugs of lung cancer were included, and the overall quality was good. Half of studies were from developed countries. Nine of the studies were designed using the BIA cost calculation model, and two were simulated using the Markov model Monte Carlo model. From all studies, only 14.3% reported model validation. The budget impact results of the same drug in different countries were inconsistent. CONCLUSIONS: Included studies evaluating budget impact analyses for anti-tumor drugs of lung cancer showed variability in the methodological framework for BIAs. The budget impact analyses of high-value drugs need to be more stringent to ensure the accuracy of the parameters, and should provide reliable results based on real data to decision-making departments, which should carefully consider access to lung cancer drugs.

Integrative Analysis for Elucidating Transcriptomics Landscapes of Glucocorticoid-Induced Osteoporosis.

Osteoporosis is the most common bone metabolic disease, characterized by bone mass loss and bone microstructure changes due to unbalanced bone conversion, which increases bone fragility and fracture risk. Glucocorticoids are clinically used to treat a variety of diseases, including inflammation, cancer and autoimmune diseases. However, excess glucocorticoids can cause osteoporosis. Herein we performed an integrated analysis of two glucocorticoid-related microarray datasets. The WGCNA analysis identified 3 and 4 glucocorticoid-related gene modules, respectively. Differential expression analysis revealed 1047 and 844 differentially expressed genes in the two datasets. After integrating differentially expressed glucocorticoid-related genes, we found that most of the robust differentially expressed genes were up-regulated. Through protein-protein interaction analysis, we obtained 158 glucocorticoid-related candidate genes. Enrichment analysis showed that these genes are significantly enriched in the osteoporosis related pathways. Our results provided new insights into glucocorticoid-induced osteoporosis and potential candidate markers of osteoporosis.

Assessing health-related quality of life of patients with colorectal cancer using EQ-5D-5L: a cross-sectional study in Heilongjiang of China.

AIM: This study aimed to assess the health-related quality of life (HRQoL) of patients with colorectal cancer (CRC) and its determinants. METHODS: A cross-sectional questionnaire survey was conducted on 300 newly diagnosed patients with CRC in China's Heilongjiang province, measuring HRQoL using the EuroQol five-dimension five-level (EQ-5D-5L). Kruskal-Wallis analyses were performed to identify the independent variables associated with the EQ-5D-5L utility scores. Predictors of the utility scores were confirmed using a Tobit regression model. RESULTS: The respondents had a mean EQ-5D-5L utility score of 0.617 (SD=0.371) and a median of 0.740 (range: -0.348 to 1.000). Pain/discomfort and anxiety/depression were major concerns of the respondents, with a prevalence of over 60% (all levels inclusive). The Kruskal-Wallis analyses found lower utility scores in those who were not married, worked as a farmer, enrolled with the new rural cooperative medical scheme and had lower household income (p<0.05). Those who were at a later stage of CRC, underwent surgical only therapy and had a stoma also had lower EQ-5D-5L scores than others (p<0.05). The Tobit regression model confirmed these predictors, except for occupation and marital status. CONCLUSION: Patients with CRC have poor HRQoL, with pain/discomfort and depression/anxiety as the most frequently reported problems. The poor HRQoL is associated with the seriousness of the disease condition, as well as the low socioeconomic status of the patients.

Health utility scores of family caregivers for leukemia patients measured by EQ-5D-3L: a cross-sectional survey in China.

BACKGROUND: This study assessed the health related quality of life of family caregivers (FCs) of leukemia patients by using the health utility scores derived from the EuroQol five-dimensional (EQ-5D) questionnaire. METHODS: A cross-sectional survey was undertaken on 306 family caregivers of leukemia patients to assess their health utility using the EQ-5D-3L. Participants were recruited from three hospitals in China's Heilongjiang province. The health utility scores of the participants were estimated based on the Chinese EQ-5D-3L value set and compared with those of the local general population. Factors predicting the health utility scores were identified through the Kruskal-Wallis analysis of variance and median regression analyses. RESULTS: FCs had lower health utility scores than the general population (p < 0.001). The participants with a lower socioeconomic status had lower utility scores and reported more problems than those with a higher socio-economic status. Better family function and higher social support were associated with higher health utility scores. The type of leukemia, household income, and social support are significant predictors of health utility scores of the FCs. Chronic lymphocytic leukemia, low socio-economic status, and low social support are associated with lower health utility scores of the FCs. CONCLUSIONS: FCs for leukemia patients have lower health utility scores than the local general population, as measured by the EQ-5D-3L. There is an immediate need to address the health concerns of FCs, who play an important role in the Chinese health care system.

Factors associated with the quality of life of family caregivers for leukemia patients in China.

BACKGROUND: The leukemia affects not only the quality of life (QOL) of patients with the disease but also that of their family caregivers (FCs). The research studies on QOL of FCs for leukemia patients are limited. This study aimed to evaluate the QOL of FCs for leukemia patients in Heilongjiang province, China. METHODS: A cross-sectional questionnaire survey was undertaken with 309 FCs for leukemia patients recruited from three hospitals in Heilongjiang province. The QOL of the participants was assessed using the Chinese version of WHOQOL-BREF. Multivariate regression models were established to determine the predictors of the QOL of FCs, including the socio-economic characteristics of patients and FCs, and the emotional distress, social support and family functions of FCs. RESULTS: The FCs had low QOL scores in all four domains: 12.7 ± 2.8 for physical, 12.2 ± 2.5 for psychological, 13.2 ± 2.9 for social and 11.3 ± 2.5 for environment. Social support is a major predictor of the QOL of FCs, with a standardized ß coefficient of "high support" ranging from 0.41 to 0.58 for the four domains, followed by family function (ß = 0.37 ~ 0.44 for psychological, social and environmental domains). The FCs who were older, highly educated, had no religious belief, suffered from a higher level of emotional distress, and provided care to younger patients and the patients without insurance coverage had lower QOL than the others. CONCLUSION: The study provides some important insights into the QOL of FCs for leukemia patients. The QOL of FCs for leukemia patients is low and low levels of support to FCs are a major predictor of low QOL of FCs.

Economic Burden for Lung Cancer Survivors in Urban China.

BACKGROUND: With the rapid increase in the incidence and mortality of lung cancer, a growing number of lung cancer patients and their families are faced with a tremendous economic burden because of the high cost of treatment in China. This study was conducted to estimate the economic burden and patient responsibility of lung cancer patients and the impact of this burden on family income. METHODS: This study uses data from a retrospective questionnaire survey conducted in 10 communities in urban China and includes 195 surviving lung cancer patients diagnosed over the previous five years. The calculation of direct economic burden included both direct medical and direct nonmedical costs. Indirect costs were calculated using the human capital approach, which measures the productivity lost for both patients and family caregivers. The price index was applied for the cost calculation. RESULTS: The average economic burden from lung cancer was $43,336 per patient, of which the direct cost per capita was $42,540 (98.16%) and the indirect cost per capita was $795 (1.84%). Of the total direct medical costs, 35.66% was paid by the insurer and 9.84% was not covered by insurance. The economic burden for diagnosed lung cancer patients in the first year following diagnosis was $30,277 per capita, which accounted for 171% of the household annual income, a percentage that fell to 107% after subtracting the compensation from medical insurance. CONCLUSIONS: The economic burden for lung cancer patients is substantial in the urban areas of China, and an effective control strategy to lower the cost is urgently needed.

[Accuracy of immunochemical faecal occult blood test for colorectal cancer: meta-analysis].

OBJECTIVE: To assess the accuracy of immunological fecal occult blood test (iFOBT) for detection of colorectal cancer (CRC). METHODS: A total of 1 197 studies published before June 2014 were selected from PubMed and Embase and 17 of which were finally included in this meta-analysis. A bivariate mixed-effects models was used for overall value merging and heterogeneity testing. In addition to the overall sensitivity and specificity, the analyses were also performed among certain subgroups, including a "colonoscopy group" (all were referred for colonoscopy diagnosis regardless screening results) and a "follow-up group" (only the screening positive were referred and all were then followed up), a qualitative group and a quantitative group (classified by the way of iFOBT result reading). RESULTS: A total of 161 502 subjects aged from 48 to 63 years were included in the analysis. IFOBT had an overall integrated sensitivity of 0.85 (95% CI: 0.79-0.89) (heterogeneity test: Q = 59.67, P < 0.001) and an overall integrated specificity of 0.93 (95% CI: 0.92-0.94) (heterogeneity test: Q = 1 722.53, P < 0.001) for detection of CRC. In the subgroup analysis, it was found that in the "colonoscopy group" and in the "follow-up group", the sensitivity were 0.81 (95%CI: 0.73-0.87) and 0.88 (95% CI: 0.81-0.92), respectively; the specificity were 0.92 (95% CI: 0.89-0.93) and 0.95 (95% CI: 0.94-0.96), respectively. It was also found that in the qualitative group and the quantitative group, the sensitivity were 0.84 (95% CI: 0.76-0.90) and 0.86 (95% CI: 0.78-0.92), respectively; the specificity were 0.94 (95% CI: 0.91-0.96) and 0.93 (95% CI: 0.91-0.94), respectively. CONCLUSION: IFOBT had high overall sensitivity and specificity for detecting colorectal cancer.

Socioeconomic inequities in health care utilization in China.

The study assessed the present degree of inequity in health care utilization as well as the contributions of the main determinants in the context of expending health insurance coverage in China. Data were obtained from the 2008 National Health Services Survey (NHSS) in China. A concentration index was used to quantify the degree of income-related inequity in health care utilization. The need-standardized concentration indexes of outpatient care and inpatient care were 0.015 and 0.197, respectively. Income made the largest contribution to inequity favoring the better-off in the use of health care. The impacts of health insurance schemes on overall inequity varied according to the insurance memberships as well as types of services. The study revealed a pro-rich distribution of the probability of health care across income groups in China. Increased financial protection ability of medical insurance system remains a vital cornerstone to tackle the health care utilization inequity.

Cost-effectiveness of colorectal cancer screening protocols in urban Chinese populations.

Colorectal cancer (CRC) takes a second and fourth position in the incidence and mortality lists respectively among all malignant tumors in urban populations in China. This study was designed to evaluate the cost-effectiveness of two different CRC screening protocols: faecal occult blood test (FOBT) alone, and FOBT plus a high-risk factor questionnaire (HRFQ) as the respective initial screens, followed by colonoscopy. We developed a Markov model to simulate the progression of a cohort of 100,000 average risk asymptomatic individuals moving through a defined series of states between the ages of 40 to 74 years. The parameters used for the modeling came from the CESP (Comparison and Evaluation of Screening Programs for Colorectal Cancer in Urban Communities in China) study and published literature. Eight CRC screening scenarios were tested in the Markov model. The cost-effectiveness of CRC screening under each scenario was measured by an incremental cost-effectiveness ratio (ICER) compared with a scenario without CRC screening. The study revealed that a combined use of FOBT and HRFQ is preferable in CRC screening programs as an initial screening instrument. Annual FOBT+HRFQ screening is recommended for those who have a negative initial result and those who have a positive result but have failed to continue to colonoscopic examination. Repeated colonoscopy (for those with a positive result in initial screening but a negative colonoscopy result) should be performed at a ten-year interval instead of one-year. Such a protocol would cost 7732 Yuan per life year saved, which is the most cost-effective option. In conclusion, the current Chinese Trial Version for CRC Screening Strategy should be revised in line with the most cost-effective protocol identified in this study.