Medical insurance benefits and health inequality: evidence from rural China.

Alleviating health inequality among different income groups has become a significant policy goal in China to promote common prosperity. Based on the data from the China Health and Retirement Longitudinal Study (CHARLS) covering the period from 2013 to 2018, this study empirically examines the impact of Integrated Medical Insurance System (URRBMI) on the health and health inequality of older adult rural residents. The following conclusions are drawn: First, URRBMI have elevated the level of medical security, reduced the frailty index of rural residents, and improved the health status of rural residents. Second, China exhibits "pro-rich" health inequality, and URRBMI exacerbates health inequality among rural residents with different incomes. This result remains robust when replacing the frailty index with different health modules. Third, the analysis of influencing mechanisms indicates that the URRBMI exacerbate inequality in the utilization of medical services among rural residents, resulting in a phenomenon of "subsidizing the rich by the poor" and intensifying health inequality. Fourth, in terms of heterogeneity, URRBMI have significantly widened health inequality among the older adult and in regions with a higher proportion of multiple-tiered medical insurance schemes. Finally, it is suggested that China consider establishing a medical financing and benefit assurance system that is related to income and age and separately construct a unified public medical insurance system for the older adult population.

Does the increase in health insurance benefits have different effects on the health of middle-aged and older people individuals in rural areas? Analysis based on quantile difference-in-differences method.

In the context of healthy aging, enhancing health performance is an intrinsic requirement for the development and reform of the health insurance system. This paper mainly discusses the health effects of increasing medical insurance benefits on people with different levels of health. So this paper utilizes multiple rounds of data from the China Health and Retirement Longitudinal Study (CHARLS) and employs the quantile difference-in-differences method to systematically investigate the impact effects of the integration of urban and rural residents' health insurance on the frailty levels of rural middle-aged and older people individuals. The research findings are as follows: Firstly, the integration of urban and rural resident health insurance has mitigated the frailty level of rural older people individuals, with a more pronounced impact on those with poorer health statuses. Secondly, in terms of heterogeneity analysis, the health performance effects of the urban-rural health insurance integration policy are more significant among the older people population and in the western regions. Thirdly, the integration of urban and rural resident health insurance primarily improves health by reducing the burden of medical expenses, with a greater impact on the older people population with poorer health statuses. Based on the research findings, we recommend addressing the disparities in healthcare benefits across various insurance systems, alleviating the financial burden of healthcare for impoverished individuals, and consistently improving the coordination of healthcare insurance policies for both urban and rural residents.

[Characteristic Analysis of SWAT Model Parameter Values Based on Assessment of Model Research Quality].

The soil and water assessment tool (SWAT) model is currently one of the most widely used watershed models in China. Since the model has been developed with distributed parameters and is customized to satisfy the environmental characteristics of the U.S.A., determining appropriate parameter values that reflect local features for model application in China is crucial. Some studies have proposed parameter values for the SWAT model by summarizing reported values in the literature; however, these studies neither differentiate the literature with respect to its quality nor consider non-uniformity in parameter values and the impact of extreme values. To address this, an indicator system for assessing the quality of SWAT model research was established, taking into account the process of model development, parameter calibration, and model validation as well as model performance. This screening approach was applied to a total of 428 journal articles on SWAT model research published between 2015 and 2017 were retrieved from the China National Knowledge Infrastructure database. The reported values of 15 model parameters involved in hydrology and sediment and nutrient simulation were extracted from highly credible articles and analysed in terms of statistical distributions, differences among geographic regions, and discrepancies between calibrated and default values. Results showed that the 129 highly credible journal articles screened generally followed good modelling practice and consisted of case studies from different regions across China. The statistical distributions of the 15 model parameters derived from the SWAT model studies exhibited a range of features including positive and negative skewness, and those of 4 parameters showed significant differences among regions where the watersheds are located. Furthermore, the calibrated values of 12 out of 15 parameters were significantly different from their default values. Considering the statistical characteristics of these model parameters, recommended parameter values for SWAT model application in China are proposed in the form of confidence intervals, and specific suggestions are also provided based on data availability.

[Application of lean management in cost control of cerebral infarction single disease in stroke center].

OBJECTIVE: To explore the effect of lean management on cost control of single disease in patients with acute cerebral infarction (ACI) in stroke center. METHODS: A retrospective study was conducted. The patients with ACI who underwent intravenous thrombolysis in the stroke center of Taizhou Central Hospital in Zhejiang Province were enrolled. Thirty patients adopted traditional management procedures from July 2016 to September 2017 were enrolled in the control group, and 32 patients received lean management from October 2017 to December 2018 were enrolled in the lean group. The patients in the control group were treated with traditional intravenous thrombolysis, and the patients were sent to the neurology ward for intravenous thrombolysis. The patients in the lean group applied lean management value stream to optimize process management, the lean management team of the stroke center was established, and the green channel for stroke treatment was established to eliminate the waiting time as far as possible. The location of thrombolysis was changed from neurology ward to the neurological intensive care unit (NICU) in emergency department. The patients in the two groups were compared in terms of intravenous thrombolytic door-to-needle time (DNT), admission time to the neurologist's visit time (T1), CT examination time to neurology ward or NICU admission time (T2), neurology ward/NICU visit time to medication time (T3), and the proportion of patients with DNT controlled within 40 minutes, recovery of neurological impairment 7 days after thrombolysis [national institutes of health stroke scale (NIHSS) score], activity of daily living assessment (Barthel index), length of hospital stay, cost of hospital stay and patient satisfaction. At the same time, the main process quality and the implementation rate of easily missed indexes of cerebral infarction single disease were recorded. RESULTS: Compared with the control group, DNT, T1 and T2 in the lean group were significantly shortened [DNT (minutes): 39.56±11.12 vs. 63.03±19.63, T1 (minutes): 16.23±6.79 vs. 33.48±12.63, T2 (minutes): 13.45±3.84 vs. 17.47±5.56, all P < 0.01], T3 was slightly shortened (minutes: 9.88±1.95 vs. 10.95±2.69, P > 0.05), and the proportion of DNT control within 40 minutes was significantly increased [75.0% (24/32) vs. 16.7% (5/30), P < 0.01], the 7-day NIHSS score was decreased significantly (8.66±4.12 vs. 13.00±5.63, P < 0.01), 7-day Barthel index was increased significantly (71.6±16.7 vs. 54.7±17.1, P < 0.01), the length of hospital stay was significantly shortened (days: 9.69±4.06 vs. 12.47±3.83, P < 0.01), the hospital costs were significantly reduced (Yuan: 16 338±5 481 vs. 19 470±5 495, P < 0.05), the satisfaction of patients was improved significantly [(91.38±2.69)% vs. (86.53±2.78)%, P < 0.01]. In terms of the implementation rate of quality indicators such as pre-application evaluation of thrombolytic drugs, evaluation of dysphagia, and evaluation of vascular function, health education of ACI, rehabilitation evaluation and implementation within 24 hours, etc., the lean group was significantly improved as compared with the control group [(87.5% (28/32) vs. 53.3% (16/30), 96.9% (31/32) vs. 73.3% (22/30), 78.1% (25/32) vs. 43.3% (13/30), 100.0% (32/32) vs. 76.7% (23/30), 75.0% (24/32) vs. 33.3% (10/30), all P < 0.05]. CONCLUSIONS: Lean thinking can realize the standardization of stroke center process, effectively utilize medical resources, improve medical quality and reduce the cost of cerebral infarction single disease.

Development of a SNP array and its application to genetic mapping and diversity assessment in pepper (Capsicum spp.).

The development and application of single nucleotide polymorphisms (SNPs) is in its infancy for pepper. Here, a set of 15,000 SNPs were chosen from the resequencing data to develop an array for pepper with 12,720 loci being ultimately synthesized. Of these, 8,199 (~64.46%) SNPs were found to be scorable and covered ~81.18% of the whole genome. With this array, a high-density interspecific genetic map with 5,569 SNPs was constructed using 297 F2 individuals, and genetic diversity of a panel of 399 pepper elite/landrace lines was successfully characterized. Based on the genetic map, one major QTL, named Up12.1, was detected for the fruit orientation trait. A total of 65 protein-coding genes were predicted within this QTL region based on the current annotation of the Zunla-1 genome. In summary, the thousands of well-validated SNP markers, high-density genetic map and genetic diversity information will be useful for molecular genetics and innovative breeding in pepper. Furthermore, the mapping results lay foundation for isolating the genes underlying variation in fruit orientation of Capsicum.

Quantitative assessment of the association between MTHFR rs1801131 polymorphism and risk of liver cancer.

Methylenetetrahydrofolate reductase (MTHFR) is one of the most important enzymes for folate metabolism which plays a key role in cell metabolism. MTHFR rs1801131 (A1298C) polymorphism can decrease in vitro MTHFR enzyme activity and has been hypothesized to be associated with liver cancer risk. This study aimed to quantify the strength of the association between MTHFR rs1801131 polymorphism and liver cancer risk by performing a meta-analysis. We searched the PubMed and Wanfang databases for studies relating on the association between MTHFR rs1801131 polymorphism and risk of liver cancer. Seven studies with 2,030 cases of liver cancer and 3,096 controls were finally included into the meta-analysis. Meta-analysis of a total of seven studies showed that the homozygote genotype CC of MTHFR rs1801131 polymorphism was significantly associated with decreased risk of liver cancer (for CC versus AA: odds ratio (OR) = 0.65, 95% confidence interval (CI) 0.47-0.89, P = 0.007; for CC versus AA + AC: OR = 0.65, 95% CI 0.48-0.89, P = 0.006). Subgroup by race showed that the homozygote genotype CC of MTHFR rs1801131 polymorphism was significantly associated with decreased risk of liver cancer in Asians (CC versus AA: OR = 0.64, 95% CI 0.46-0.90, P = 0.010; for CC versus AA + AC: OR = 0.63, 95% CI 0.45-0.88, P = 0.007). However, the association in Caucasians was still unclear owing to the limited data available now. Thus, Asian individuals with the homozygote genotype CC of MTHFR rs1801131 polymorphism are significantly associated with decreased risk of liver cancer. The association in Caucasians needs further studies.

Health economic assessment for screening of gastric cancer in a high risk population in northeastern china.

OBJECTIVE: To assess economic cost-effects for the screening programs of gastric cancer in a high risk population in northeastern China. METHODS: The data were collected from November 2001 to December 2003. The multi-stage sampling to define the screening group and the control group was applied in this study. Two stage screening programs were used in the study. An epidemiological survey and serum PG test were carried out in the first stage. The endoscopy and pathological examination were performed in the second stage screening. Effectiveness was assessed by the increased quality adjusted life-year (QALY) because of reduced gastric cancer deaths in screening. RESULTS: A total of 27,970 participants (n=7,128 screening group, n=20,842 control group) were enrolled in the survey. Twenty nine gastric cancer cases were detected in the screening group with 20 cases in the early stage and 9 cases in the advanced stage, respectively. Eighty six gastric cancer cases were detected in the control group, all of whom were in the advanced stage and had died before the study finished. The screening and treatment of 29 cases cost $152,227 and $5,249 per each case, respectively. The costs were $459 to gain per QALY. CONCLUSION: The screening program of gastric cancer used in our study is an economic and society-beneficial measure to detect gastric cancer in high risk area. The methods fit China's present economic development level.

Variation between last-menstrual-period and clinical estimates of gestational age in vital records.

An accurate assessment of gestational age is vital to population-based research and surveillance in maternal and infant health. However, the quality of gestational age measurements derived from birth certificates has been in question. Using the 2002 US public-use natality file, the authors examined the agreement between estimates of gestational age based on the last menstrual period (LMP) and clinical estimates in vital records across durations of gestation and US states and explored reasons for disagreement. Agreement between the LMP and the clinical estimate of gestational age varied substantially across gestations and among states. Preterm births were more likely than term births to have disagreement between the two estimates. Maternal age, maternal education, initiation of prenatal care, order of livebirth, and use of ultrasound had significant independent effects on the disagreement between the two measures, regardless of gestational age, but these factors made little difference in the magnitude of gestational age group differences. Information available on birth certificates was not sufficient to understand this disparity. The lowest agreement between the LMP and the clinical estimate was observed among preterm infants born at 28-36 weeks' gestation, who accounted for more than 90% of total preterm births. This finding deserves particular attention and further investigation.

Infant mortality trends and differences between American Indian/Alaska Native infants and white infants in the United States, 1989-1991 and 1998-2000.

OBJECTIVES: To describe changes in infant mortality rates, including birthweight-specific rates and rates by age at death and cause. METHODS: We analyzed US linked birth/infant-death data for 1989-1991 and 1998-2000 for American Indians/Alaska Native (AIAN) and White singleton infants at > or =20 weeks' gestation born to US residents. We calculated birthweight-specific infant mortality rates (deaths in each birthweight category per 1000 live births in that category), and overall and cause-specific infant mortality rates (deaths per 100000 live births) in infancy (0-364 days) and in the neonatal (0-27 days) and postneonatal (28-364 days) periods. RESULTS: Birthweight-specific infant mortality rates declined among AIAN and White infants across all birthweight categories, but AIAN infants generally had higher birthweight-specific infant mortality rates. Infant mortality rates declined for both groups, yet in 1998-2000, AIAN infants were still 1.7 times more likely to die than White infants. Most of the disparity was because of elevated post-neonatal mortality, especially from sudden infant death syndrome, accidents, and pneumonia and influenza. CONCLUSIONS: Although birthweight-specific infant mortality rates and infant mortality rates declined among both AIAN and White infants, disparities in infant mortality persist. Preventable causes of infant mortality identified in this analysis should be targeted to reduce excess deaths among AIAN communities.

The Asian birth outcome gap.

Asians are often considered a single group in epidemiological research. This study examines the extent of differences in maternal risks and birth outcomes for six Asian subgroups. Using linked birth/infant death certificate data from the State of California for the years 1992-97, we assessed maternal socio-economic risks and their effect on birthweight, preterm delivery (PTD), neonatal, post-neonatal and infant mortality for Filipino (87,120), Chinese (67,228), Vietnamese (45,237), Korean (23,431), Cambodian/Laotian (21,239) and Japanese (18,276) live singleton births. The analysis also included information about non-Hispanic whites and non-Hispanic blacks in order to give a sense of the magnitude of risks among Asians. Logistic regression models explored the effect of maternal risk factors and PTD on Asian subgroup differences in neonatal and post-neonatal mortality, using Japanese as the reference group. Across Asian subgroups, the differences ranged from 2.5- to 135-fold for maternal risks, and 2.2-fold for infant mortality rate. PTD was an important contributor to neonatal mortality differences. Maternal risk factors contributed to the disparities in post-neonatal mortality. Significant differences in perinatal health across Asian subgroups deserve ethnicity-specific interventions addressing PTD, teen pregnancy, maternal education, parity and access to prenatal care.

[Study on health economics regarding the screening of gastric cancer in Zhuanghe high risk area].

OBJECTIVE: Using the health economics methodology to assess the screening program on gastric cancer in Zhuanghe high risk area for gastric cancer, from 2001 to 2003 and to assess the feasibility on cost of the screening program and to provide a basis for the popularization of the two-time gastric cancer screening methodology. METHODS: Three major techniques of medical economics namely cost-effective analysis (CEA), cost-benefit analysis (CBA) and cost-utility analysis (CUA) were used to assess the screening program. The screening program was composed of two steps: (1) epidemiological survey and detection of blood pepsinogen; (2) gastroscopy and biopsy of membrane. 'Number of deaths reduced' was used to evaluate the effect during cost-effective analysis while cost-benefit analysis would include the evaluation on the direct cost and indirect cost, direct benefit and indirect benefit as well as the cost-benefit ratio (CBR). During CUA, a questionnaire of WHOQOL-BREF was used to assess the value of the utility while the number of quality adjusted life year (QALY) saved by the screening program was also computed. The direct cost of per saved QALY was also calculated. RESULTS: Dada from CEA showed that: investing every 8448 Yuan on screening program and treatment in Zhuanghe high risk area of gastric cancer, one gastric cancer patient could be avoided. Results from CBA showed that: direct cost was 1,260,000 Yuan while indirect cost was 40 621 Yuan with direct benefit as 101 500 Yuan and indirect benefit as 1 540 979 Yuan. The total cost however, was 1,300,621 Yuan with total benefit as 2,555,979 Yuan and CBR was 1:1.97. Data from CUA showed that: a total number of 331.44 QALY was saved, 11.43 QALY was saved by reducing one death, 3802 Yuan per QALY was saved in high risk area of gastric cancer, through this screening program. CONCLUSION: The screening program of gastric cancer appeared to be an economic and society-beneficial measure regarding primary prevention in high risk area of gastric cancer. We also suggested that in the future, evaluations through health economics methodologies on different screening programs be carried out in the same population to solve the problem of comparability.

Perinatal outcomes in two dissimilar immigrant populations in the United States: a dual epidemiologic paradox.

OBJECTIVE: Previous studies have addressed perinatal outcomes in Hispanic, black, and white non-Hispanic women and demonstrated that although foreign-born Mexican American women have many demographic and socioeconomic risk factors, their rates of low birth weight (LBW) infants and infant mortality are similar to those of white women. This phenomenon has been termed an epidemiologic paradox. There have been no population-based studies on women of Asian Indian origin, a relatively new, highly educated, and affluent immigrant group that has been reported to have a high rate of LBW infants. The objective of this study was to define the sociodemographic risk profile and perinatal outcomes in women of Asian Indian birth and to compare these outcomes to foreign-born Mexican American and US-born black and white women. METHODS: The vital records for self-reported foreign-born Asian Indian (0.8%) and Mexican women (26.7%) and US-born black (31.2%) and white women (31.2%) were extracted from California's 1 622 324 births, 1995-1997. Sociodemographic risk profiles; the percentage of LBW, very low birth weight (VLBW), prematurity, and intrauterine growth retardation (less than third percentile); and percentage of fetal, neonatal, and postneonatal death rates were compared. Logistic models were used to estimate the importance of selected sociodemographic and medical factors to the prediction of LBW infants in each racial/ethnic group. RESULTS: When compared with whites, US-born blacks and foreign-born Mexican mothers were at increased risk for adverse perinatal outcomes on the basis of higher levels of inadequate prenatal care, teen births, Medi-Cal paid delivery, and lower levels of maternal and paternal education. Foreign-born Asian Indian mothers had good prenatal care, were rarely teenagers, had dramatically higher levels of both maternal and paternal education, and had the lowest percentage of deliveries paid for by Medi-Cal. Black infants had the highest rates of prematurity; intrauterine growth retardation; LBW; and fetal, neonatal, and postneonatal mortality. Paradoxically, despite their high-risk profile, Mexicans did not have elevated levels of LBW or neonatal mortality. Conversely, Asian Indian infants, although seemingly of low sociodemographic risk, had high levels of LBW, growth retardation, and fetal mortality. Logistic regression analysis of independent risk factors for giving birth to an LBW infant showed higher maternal education, early access to prenatal care, and having private insurance to be protective in white non-Hispanic and black but not in Asian Indian and Mexican-born women. CONCLUSIONS: Despite their high socioeconomic status and early entry into care, foreign-born Asian Indian women have a paradoxically higher incidence of LBW infants and fetal deaths when compared with US-born whites. Factors that protect from giving birth to an LBW infant in white women were not protective among Asian Indian women. Current knowledge regarding factors that confer a perinatal advantage or disadvantage is unable to explain this new epidemiologic paradox. These findings highlight the need for additional research into both epidemiologic and biological risk factors that determine perinatal outcomes.