Medical insurance and healthcare utilization among the middle-aged and elderly in China: evidence from the China health and retirement longitudinal study 2011, 2013 and 2015.

BACKGROUND: In response to China's rapidly aging population and increasing healthcare service demands, the Chinese government is developing a universal medical insurance system. This study aimed to assess healthcare utilization patterns and analyze the impacts of medical insurance schemes on healthcare utilization among the middle-aged and elderly in China. METHODS: Data was extracted from the China Health and Retirement Longitudinal Study in 2011, 2013 and 2015. Healthcare utilization was measured by outpatient and inpatient service utilization. Univariate analysis was deployed to examine the impacts of different medical insurance schemes on healthcare utilization. The factors associated with healthcare utilization were estimated using a random-effects logistic regression model. RESULTS: During the study period, the number of individuals involved was 17,250, 18,195 and 19,842, respectively. The proportion of individuals who received outpatient service was 18.6, 20.7 and 18.7% and those who used inpatient service was 9.6, 13.8 and 14.3%, respectively. We identified that medical insurance was a major protective factor for improving healthcare utilization but different medical insurance schemes exerted various impacts on the middle-aged and the elderly. CONCLUSIONS: Despite the growing population coverage, the Chinese government should make every effort to bridge the gap among people with different medical insurance schemes. Further evaluation is needed to assess whether the expanded medical insurance schemes could protect the middle-aged and elderly households from catastrophic health expenditure.

The Impact of Sanming Healthcare Reform on Antibiotic Appropriate Use in County Hospitals in China.

Background: The excessive use of resources and poor quality of care are great concerns worldwide, particularly in China. In 2013, a model of systematic reforms was developed in Sanming to address the inefficiency and waste in public hospitals. However, limited empirical studies have evaluated the effect of Sanming healthcare reform on antibiotic appropriate use. This study aims to evaluate the impact of the healthcare reform on the appropriate use of antibiotics in county-level public hospitals in Sanming, China. Methods: We conducted a retrospective observational study exploring trends in antibiotic use with an interrupted time series design. We selected three county-level hospitals in Sanming and extracted outpatient prescriptions of the Departments of Internal Medicine and the Department of Pediatrics between January 2011 and December 2017. Acute Upper Respiratory Tract Infection (AURI), Acute Bronchitis (AB) and Community Acquired Pneumonia (CAP) were selected as the sample diseases for our analysis. The primary outcome was the percentage of prescriptions conformed with standard treatment guidelines (STGs). Results: A total of 142,180 prescriptions were included in the analysis. During the study period, the percentage of antibiotics prescriptions conformed with STGs boosted from 32.4% in 2011 to 82.3% in 2017. Moreover, after the reform, the rate of prescriptions that conformed with STGs showed significant increasing trends in children with AURI (ß = 1.624, p < 0.001), children with AB (ß = 3.123, p < 0.001), adult with AB (ß = 1.665, p < 0.001), children with CAP (ß = 3.123, p < 0.001), adult with CAP (ß = 4.385, p < 0.001), but not in adult patients with AURI (ß = -0.360, p = 0.022). Conclusion: Our study confirmed that the Sanming healthcare reform helped to promote the appropriate use of antibiotics in county-level hospitals. This systematic approach to healthcare reform, characterized by an effective governance structure, dynamic financial compensation mechanisms, and specialized drug stewardship, is promising for future public hospital reforms.

Association Between Physicians' Workload and Prescribing Quality in One Tertiary Hospital in China.

BACKGROUND: Alarming increasing trends in physician workload have attracted much attention in recent years. Heavy workload may compromise the quality of medication use. Previous studies have identified a series of factors contributing to inappropriate prescribing; however, there is no demonstrated evidence supporting an association between workload and the appropriateness of physicians' prescriptions in China. This study aimed to investigate the relationship between physician workload and prescription quality in a tertiary hospital in Beijing, China. METHODS: Our study was a single-center, retrospective study, with all outpatient electronic health records extracted from hospital information system of a tertiary hospital in Beijing from July 1 to November 30, 2015. We used outpatient volume in each 5-hour shift as the measure of physician workload. The evaluation of prescribing quality was based on the Rational Drug Use System. Generalized linear models with a γ distribution and a log link were used to explore factors associated with inappropriate prescribing, and we undertook a series of robustness tests with respect to different exclusion criteria. RESULTS: A total of 457,784 prescriptions from 502 physicians were included in the study. Physicians had an average workload of 34.3 (±19.8) patients per shift, and the mean rate of inappropriate prescribing per shift was 14.1% (±14.6%). Higher rates of inappropriate prescribing were associated with heavier workloads (P < 0.001). Physicians who worked in the afternoon, chief physicians, those working in surgical department, males, and those with more than 20-year experience had higher rates of inappropriate prescribing with increasing workload. CONCLUSIONS: Heavier workload was associated with higher risk of prescribing inappropriately. It requires great efforts to determine optimal physician workloads and mitigate the potential adverse effects on the prescription quality.

The Impact of Physicians' Working Hours on Inappropriate Use of Outpatient Medicine in a Tertiary Hospital in China.

BACKGROUND: Inappropriate prescribing is an important health system problem in China. Several studies have identified critical factors influencing prescription quality, but the impact of physicians' working hours remains unknown. In China, tertiary hospitals face ever-increasing outpatient volumes. Physicians are asked to work long hours and the impact of shift duration on prescription quality is unknown. OBJECTIVE: We aimed to investigate the association between consecutive working hours and the quality of physicians' prescriptions in a Chinese tertiary hospital. METHODS: We obtained all outpatient electronic health records from the hospital information system (HIS) of a tertiary hospital in Beijing, China from 1 July to 30 November 2015. Prescriptions made during two periods were analyzed: a morning shift from 7:30 to 12:30, and an afternoon shift from 13:30 to 18:30. The time when a physician issued the first prescription was considered the beginning of the work shift and prescriptions within the next 4 consecutive hours were included. Potentially inappropriate prescriptions were based on the Rational Drug Use (RDU) system that was developed and validated for this study. We used multivariable logistic regression to examine the impact of shift duration and other clinical and physician factors on potentially inappropriate prescribing. RESULTS: Of the total 560,529 prescriptions, 15.3% were classified as inappropriate by the RDU system. Physicians' inappropriate prescribing increased in the last hour in each work shift (odds ratio (OR) for the fourth hour compared to the first = 1.12 (95% CI, 1.09-1.15)). We also found that physicians who worked all day had a higher rate of inappropriate prescribing than those who only worked half a day (OR = 1.05 (95% CI, 1.04-1.07)). CONCLUSIONS: Longer working hours are a risk factor for inappropriate prescribing. Relevant interventions are urgently needed to establish working hour limits in China to reduce the likelihood of inappropriate prescribing by physicians.

How Far Have We Come? Challenges to Orphan Drug Access in China, 2011-2017.

Rare diseases are an important global public health issue. One significant challenge is to ensure the access to orphan drugs for patients with rare disease. This study aims to evaluate the accessibility of orphan drugs in China. Information pertaining to the availability and costs of each orphan drug in each hospital was obtained from the Chinese Medicine Economic Information database during 2011-2017. We measured the accessibility of orphan drugs from 3 aspects: availability, daily costs, and affordability to patients.The market availability rate of orphan drugs in China was 28.8% by June 30, 2017. The median availability rate at the hospital level was less than 15% but was increasing over time. The cost of a defined daily dose of orphan drugs varied significantly with a decreasing trend in all areas. Less than half of all surveyed orphan drugs had a cost of a defined daily dose no more than residents' average daily income.This study reveals the challenges of access to orphan drugs in China. The availability of marketed orphan drugs in China was relatively low and most orphan drugs placed a heavy financial burden on patients with rare disease. It is necessary to develop legislation for orphan drugs and encourage domestic generics.