Managing the quality of primary health care in urban China: the impact of organizational and physician features.

BACKGROUND: Global health care quality improvement efforts have focussed on management practices. However, knowledge in primary care settings, especially in developing countries, such as China, is lacking. OBJECTIVE: To examine the organizational and physician features associated with health care quality in China's community health centres (CHCs). METHODS: We conducted a cross-sectional survey of 224 primary care physicians (PCPs) in 38 CHCs in Jinan, Tianjin, Shenzhen, and Shanghai. Clinical and prevention care quality with a 5-level scale (1 = never, 5 = always) reported by the PCPs were used to measure the quality of care. Two-level hierarchical linear models were estimated to examine the organization and physician-level variables associated with primary care quality. RESULTS: The average clinical care quality score was 4.08 and 3.59 for preventative care out of 5. At the organizational level, organizational culture and organizational support were the strongest predictors of physician-reported quality of care. At the physician level, professional fulfilment, psychological safety, and organizational citizenship behaviour were positively associated with care quality. CONCLUSIONS: Chinese CHCs clinical quality ranked high by PCPs, but the quality of preventative care provision required improvement. To improve primary care quality, managers of CHCs should implement optimal organizational structures, supportive organizational cultures, and strong organizational support at the organization level and cultivate high professional fulfilment, safe, and trustful relationships with colleagues at the physician level.

Older adults preferences for long-term caregivers in China: a discrete choice experiment.

OBJECTIVE: Understanding the preferences of old-age adults for their long-term caregivers can improve person-centred health care and the quality of long-term care (LTC). This study examines Chinese older adults' preferences for long-term caregivers. STUDY DESIGN: This is a cross-sectional study. METHODS: A national representative discrete choice experiment (DCE) surveyed 2031 adults aged 50-70 across 12 provinces in China. Each DCE scenario described five attributes: type of caregivers, place of LTC, contents of LTC, out-of-pocket payments, and quality of life (QoL). Preferences and the marginal willingness to pay (WTP) were derived using mixed-logit and latent class models. RESULTS: Older adults displayed higher preferences for long-term caregivers who improve their QoL, incur lower out-of-pocket payments, and provide medical LTC services at home, with the maximum WTP of $22.832 per month. QoL was rated as the most important LTC factor, followed by the place of LTC and the type of caregivers. When the level of QoL improved from poor to good, respondents would be willing to pay $18.375 per month more (95% confidence interval: 16.858 to 20.137), and the uptake rate increased by 76.47%. There was preference heterogeneity among older people with different sex, education, family size, and knowledge of LTC insurance. CONCLUSION: QoL was the most important factor in older Chinese adults' preference for caregivers. Home care and medical care from formal caregivers was preferred by older adults. We recommend training family caregivers, raising older people's awareness of LTC insurance, and guiding policymakers in developing people-oriented LTC and a multi-level LTC system.

Organisation-level and individual-level predictors of nurse-reported quality of care in primary care: A multilevel study in China.

OBJECTIVES: Knowledge of the predictors of nursing quality and safety remains a gap in global primary care research. This study examines organisational-level and nurse-level predictors of nurse-reported quality of care from a management perspective. METHODS: We recruited 175 primary care nurses in 38 community health centres (CHCs) varying by size and ownership in Jinan, Tianjin, Shenzhen and Shanghai. Guided by the Systems Engineering Initiative for Patient Safety model, the organisation-level predictors comprised organisational structure, organisational culture, psychological safety and organisational support, while the nurse-level predictors included organisational commitment and organisational citizenship behaviour. Nurse-reported quality of care was measured by two questions: "How do you rate the quality of care that you provide?" and "Do you often receive complaints from patients or their family members at work?" Multilevel linear regression models were used to examine the predictors of nurse-reported quality of care. RESULTS: Among the four organisation-level predictors, organisational structure, psychological safety and organisational support were positive predictors of nurse-reported quality of care. Nurses working in CHCs with highly hierarchical organisational structures (Coef. = 0.196, p = 0.000), a high level of organisational support (Coef. = 0.158, p = 0.017) and a high level of psychological safety (Coef. = 0.159, p = 0.035) were more likely to report high quality of care or less likely to receive medical complaints. In terms of nurse-level predictors, nurses willing to increase their knowledge through continuous education were more likely to report good quality of care (Coef. = 0.107, p = 0.049) and less likely to receive medical complaints from patients (Coef. = 0.165, p = 0.041). CONCLUSIONS: Potential management levers to improve quality of nursing care include formalised organisational structures, strong organisational support and a psychologically safe environment as well as the provision of training to facilitate continuous education. Implementing these recommendations is likely to enhance the nursing quality in primary care.

Impact of pension income on healthcare utilization of older adults in rural China.

OBJECTIVE: In China, rural residents experience poorer health conditions and a higher disease burden compared to urban residents but have lower healthcare services utilization. Rather than an insurance focus on enhanced healthcare services utilization, we aim to examine that whether an income shock, in the form of China's New Rural Pension Scheme (NRPS), will affect outpatient, inpatient and discretionary over-the-counter drug utilization by over 60-year-old rural NRPS residents. METHODS: Providing a monthly pension of around RMB88 (USD12.97), NRPS covered all rural residents over 60 years old. Fuzzy regression discontinuity design (FRDD) was employed to explore the NRPS causal effect on healthcare services utilization, measured by outpatient and inpatient visits and discretionary over-the-counter drug purchases. The nationwide China Health and Retirement Longitudinal Study (CHARLS) 2018 provided the data. RESULTS: Without significant changes in health status and medication needs, 60-plus-year-old NRPS recipients significantly increased the probability of discretionary OTC drug purchases by 33 percentage points. NRPS had no significant effect on the utilization of outpatient and inpatient utilization. The increase in the probability of discretionary OTC drug purchases from the NRPS income shock was concentrated in healthier and low-income rural residents. Robustness tests confirmed that FRDD was a robust estimation method and our results are robust. CONCLUSION: NRPS was an exogenous income shock that significantly increased the probability of discretionary over-the-counter drug purchases among over 60-year-old rural residents, but not the utilization of inpatient or outpatient healthcare services. Income remains an important constraint for rural residents to improve their health. We recommend policymakers consider including commonly used over-the-counter drugs in basic health insurance reimbursements for rural residents; provide health advice for rural residents to make discretionary over-the-counter drug purchases; and to mount an information campaign on over-the-counter drug purchasing in order to increase the health awareness of rural residents.

Structuring healthcare advance directives: Evidence from Chinese end-of-life cancer patients' treatment preferences.

BACKGROUND: Patients' treatment decisions may be influenced by the ways in which treatment options are presented. There is little evidence on how patients with advanced cancer choose preferences for advance directives (ADs) in China. Informed by behavioural economics, we assess whether end-of-life (EOL) cancer patients held deep-seated preferences for their health care and whether default options and order effects influenced their decision-making. METHODS: We collected data on 179 advanced cancer patients who were randomly assigned to complete one of the four types of ADs: comfort-oriented care (CC) AD (comfort default AD); a life extension (LE)-oriented care option (LE default AD); CC (standard CC AD) and LE-oriented (standard LE AD). Analysis of variance test was used. RESULTS: In terms of the general goal of care, 32.6% of patients in the comfort default AD group retained the comfort-oriented choice, twice as many as in the standard CC group without default options. Order effect was significant in only two individual-specific palliative care choices. Most patients (65.9%) appointed their children to make EOL care decisions, but patients choosing the CC goal were twice as likely to ask their family members to adhere to their choices than patients who chose the LE goal. CONCLUSION: Patients with advanced cancer did not hold deep-seated preferences for EOL care. Default options shaped decisions between CC and LE-oriented care. Order effect only shaped decisions in some specific treatment targets. The structure of ADs matters and influence different treatment outcomes, including the role of palliative care. PATIENT OR PUBLIC CONTRIBUTION: Between August and November 2018, from 640 cancer hospital medical records fitting the selection criteria at a 3A level hospital in Shandong Province, we randomly selected 188 terminal EOL advanced cancer patients using a random generator programme to ensure all eligible patients had an equal chance of selection. Each respondent completes one of the four AD surveys. While respondents might require support in making their healthcare choices, they were informed about the purpose of our research study, and that their survey choices would not affect their actual treatment plan. Patients who did not agree to participate were not surveyed.

Medical insurance payment schemes and patient medical expenses: a cross-sectional study of lung cancer patients in urban China.

BACKGROUND: As the main cause of cancer death, lung cancer imposes seriously health and economic burdens on individuals, families, and the health system. In China, there is no national study analyzing the hospitalization expenditures of different payment methods by lung cancer inpatients. Based on the 2010-2016 database of insured urban resident lung cancer inpatients from the China Medical Insurance Research Association (CHIRA), this paper aims to investigate the characteristics and cost of hospitalized lung cancer patient, to examine the differences in hospital expenses and patient out-of-pocket (OOP) expenses under four medical insurance payment methods: fee-for-service (FFS), per-diem payments, capitation payments (CAP) and case-based payments, and to explore the medical insurance payment method that can be conducive to controlling the cost of lung cancer. METHOD: This is a 2010-2016, 7-year cross-sectional study. CHIRA data are not available to researchers after 2016. The Medical Insurance Database of CHIRA was screened using the international disease classification system to yield 28,200 inpatients diagnosed with lung cancer (ICD-10: C34, C34.0, C34.1, C34.2, C34.3, C34.8, C34.9). The study includes descriptive analysis and regression analysis based on generalized linear models (GLM). RESULTS: The average patient age was 63.4 years and the average length of hospital stay (ALOS) was 14.2 day; 60.7% of patients were from tertiary hospitals; and 45% were insured by FFS. The per-diem payment had the lowest hospital expenses (RMB7496.00/US$1176.87), while CAP had the lowest OOP expenses (RMB1328.18/US$208.52). Compared with FFS hospital expenses, per-diem was 21.3% lower (95% CI = -0.265, -0.215) and case-based payment was 8.4% lower (95% CI = -0.151, -0.024). Compared with the FFS, OOP expenses, per-diem payments were 9.2% lower (95% CI = -0.130, -0.063) and CAP was 15.1% lower (95% CI = -0.151, -0.024). CONCLUSION: For lung cancer patients, per-diem payment generated the lowest hospital expenses, while CAP meant patients bore the lowest OOP costs. Policy makers are suggested to give priority to case-based payments to achieve a tripartite balance among medical insurers, hospitals, and insured members. We also recommend future studies comparing the disparities of various diseases for the cause of different medical insurance schemes.

Continuing medical education in China: evidence from primary health workers' preferences for continuing traditional Chinese medicine education.

BACKGROUND: Continuing Medical Education (CME) is an important part of the training process for health workers worldwide. In China, training in Traditional Chinese Medicine (TCM) not only improves the expertise of medical workers, but also supports the Chinese Government's policy of promoting TCM as an equal treatment to western medicine. CME, including learning Traditional Chinese Medicine Technologies (TCMTs), perform poorly and research into the motivation of health workers to engage in CME is urgently required. Using a discrete choice experiment, this study assessed the CME learning preferences of primary health workers, using TCMT as a case study of CME programs. METHODS: We conducted a discrete choice experiment among health workers in Shandong Province, Guizhou Province, and Henan provinces from July 1, 2021 to October 1, 2022 on the TCMT learning preferences of primary health workers. The mixed logit model and latent class analysis model were used to analyze primary health workers' TCMT learning preferences. RESULTS: A total of 1,063 respondents participated in this study, of which 1,001 (94.2%) passed the consistency test and formed the final sample. Our key finding was that there were three distinct classes of TCMT learners. Overall, the relative importance of the seven attributes impacting the learning of TCMTs were: learning expenses, expected TCMT efficacy, TCMT learning difficulty, TCMT mode of learning, TCMT type, time required to learn, and expected frequency of TCMT use. However, these attributes differed significantly across the three distinct classes of TCMT learners. Infrequent users (class 1) were concerned with learning expenses and learning difficulty; workaholics (class 2) focused on the mode of learning; and pragmatists (class 3) paid more attention to the expected TCMT efficacy and the expected frequency of TCMT use. We recommend targeted strategies to motivate TCMT learning suited to the requirements of each class of TCMT learners. CONCLUSION: Rather than a single TCMT medical education program for primary health workers, CME programs should be targeted at different classes of TCMT learners.

Ambient air pollution and the health-related quality of life of older adults: Evidence from Shandong China.

Ambient air pollution is a major public health concern impacting all aspects of human health. There is a lack of studies on the impact of ambient air pollution on health-related quality of life (HRQoL) of older Chinese adults. Our study answers two questions: How concentrations of ambient air pollutants are associated with HRQoL among older adults in China and, second, what are the possible mechanisms through which ambient air pollution affects HRQoL. From the 2018 National Health Service Survey, we sampled 5717 aged 65 years or older residents for the eastern province of Shandong, China. Data on individual exposures to PM2.5 and PM10 (particulate matter with diameter less than or equal to 2.5 µm and 10 µm) and sulfur dioxide (SO2) were collected from the ChinaHighAirPollutants (CHAP) datasets. Mixed-effects Tobit regression models and mixed-effects ordered Probit regression models were employed to examine the associations of long-term exposure to ambient air pollution with the European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) scale comprising mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Socioeconomic, demographic and behavioral factors relating to HRQoL were also examined. The results show that for each 1 µg/m3 increase, EQ-5D-3L scores fell 0.002 for PM2.5; 0.001 for PM10 and 0.002 for SO2. Long term exposure to PM2.5, PM10 and SO2 were also associated with increased prevalence of pain/discomfort and anxiety/depression. The reduced HRQoL effects of ambient air pollution were exacerbated by higher socioeconomic status (affluent, urban and higher level of education). Our findings suggested that HRQoL of older Chinese adults was not only associated with demographic, socioeconomic, and health-related factors, but also negatively correlated with air pollution, especially through increased pain/discomfort and anxiety/depression. The paper proposes policy recommendations.

Empathy and burnout in medical staff: mediating role of job satisfaction and job commitment.

BACKGROUND: Burnout is a growing problem among medical staff worldwide and empathy has been described as an essential competence to attenuate burnout. Previous studies found job satisfaction and job commitment were affected by the empathy and associated with burnout. This study explores the effect and mechanism of empathy on burnout on medical staff and investigates the mediating role of job satisfaction and job commitment in the relationship between empathy and burnout among medical staff. METHODS: Based on a self-administered questionnaire which included the Maslach Burnout Inventory (MBI) to measure burnout, 335 responses from medical staff in Tianjin City, China, yielded data on socio-demographic characteristics, empathy, burnout, job satisfaction and job commitment. Bivariate correlation and structured equation modeling (SEM) analyzed the relationships between empathy, job satisfaction, job commitment and burnout multi-group invariant analysis was used to evaluate whether the model was consistent across different type and level of hospitals and different job and employment type subgroups. RESULTS: A total of 202 (60.3%) medical staff had low level burnout, 115 (34.3%) staff had the moderate level and 18 (5.4%) staff had the high level burnout. The results of the SEM showed that empathy not only had a direct negative effect on burnout ([Formula: see text], but also had an indirect impact through job satisfaction ([Formula: see text] and job commitment ([Formula: see text]. Job commitment was negatively associated burnout ([Formula: see text] but, unexpectedly, job satisfaction was positively associated with burnout ([Formula: see text]. The results also indicated the model was consistent across employment type ([Formula: see text] = 5.904, p > 0.05) and hospital type ([Formula: see text] = 7.748, p > 0.05), but was inconsistent across hospital level ([Formula: see text] = 42.930, p < 0.05) and job type ([Formula: see text] = 52.912, p < 0.05). CONCLUSIONS: Our results pointed out the important role that empathy plays in addressing burnout and revealed that managing job satisfaction and increasing the job commitment attenuated burnout. We recommend that the government should accelerate the reform of the resourcing of different hospital levels; facilitate hospital managers to implement additional training; and support hospitals to strengthen psychological testing and counseling to reduce medical staff burnout.

High-cost users: drivers of inpatient healthcare expenditure concentration in urban China.

BACKGROUND: Total healthcare expenditures are concentrated among a small number of patients. To date, studies on the concentration of health care expenditures in developing countries are limited, mainly focusing on concentration measures and the demographic, clinical and socioeconomic characteristics of high-cost users (HCU). The drivers of the skewed overall distribution of health care expenditures are opaque. Using inpatient administrative claims data, this study provides new evidence on the concentration of healthcare expenditures in China; the demographic and clinical characteristics of high-cost users; and the drivers of the overall distribution of healthcare expenditures. METHODS: Utilizing administrative claims data for hospitalization in a prefecture-level city in China, we investigated the concentration of healthcare expenditure. We used recentered influence function (RIF) regression to examine the drivers of healthcare expenditure concentration, decomposing and estimating the effects of demographic and disease characteristics on the overall distribution of health care expenditures. RESULTS: Using a sample of 87,841 adults, we found extreme skewness in the distribution of inpatient medical expenditures in China, with approximately 49% of annual medical expenditures generated by the top 10% of inpatient groups. HCUs tend to be elderly and male, with high-frequency hospitalizations and long lengths of stay. In addition, healthcare expenditure concentration was related to diseases of the circulatory system, malignant neoplasms, diseases of the musculoskeletal system and connective tissue, diseases of the digestive system, injury and poisoning, and diseases of the respiratory system. Malignant and major diseases reinforced the concentration of healthcare spending, and a 10% increase in the prevalence of malignancy would result in a predicted Gini coefficient increase of 7.2%, heart disease of 0.92% and cerebrovascular disease of 1.5%. The above significant positive effects were not observed for hypertension and diabetes mellitus. CONCLUSIONS: Our study provides new insights into the concentration of inpatient medical expenditures in China, including the precise picture of HCU expenditure concentration, the drivers of HCU expenditure concentration and the magnitude of their impact. With the aging of China's population and the profound shift in the disease spectrum, policymakers need to strengthen the early detection and intervention management of specific chronic diseases and high-risk populations, especially the early diagnosis and treatment of key cancers.

The challenge of healthcare big data to China's commercial health insurance industry: evaluation and recommendations.

BACKGROUND: China's social medical insurance system faces challenges in financing, product coverage, patient health responsibility sharing and data security, which commercial health insurance companies can help address. Confronting accelerated population aging, the rapid increase of patients with chronic diseases and the maternal and child healthcare needs created by the three-child policy, the Chinese government has encouraged the development of commercial health insurance. But China's commercial health insurance companies face financial sustainability problems, limited product ranges and high operating costs. At the same time, the informatization level of China's healthcare industry, and the value of healthcare big data, is increasing. We analyze and describe the potential application of healthcare big data in the life cycle of China's commercial health insurance system and provide specific action plans for Chinese commercial health insurance companies; identify the challenges to commercial health insurers; and make recommendations for the application of big health data by commercial health insurers. Our recommendations inform healthcare policy makers on the development of commercial health insurance and the improvement of the healthcare financing system. We not only verify the value of healthcare big data, but also identify specific ways that healthcare big data plays in the development of commercial health insurance. Based on the research results, we recommend new policies for government and new uses of healthcare big data for commercial health insurance institutions. The benign development of commercial health insurance will improve the level of health services in China. METHODS: By interviewing health insurance managers (including actuaries, product managers, business executives, information technology medical workers, and commercial health insurance personnel) and by accessing research papers, industry reports, news reports and public information disclosure documents about commercial health insurance, we describe the impact of healthcare big data on the life cycle of commercial health insurance products and processes. RESULTS: We identify the issues and challenges of commercial health insurers in the use of healthcare big data, and advance specific strategies to expand the use of healthcare big data. In the life cycle of commercial health insurance products, healthcare big data can improve premium income, control medical costs and increase operational efficiency. First, healthcare big data can increase premiums, products and services by attenuating moral hazard and adverse selection problems, where high quality clients over-pay and high-risk clients underpay for health insurance. Second, healthcare big data can reduce medical expenses compensation pay-outs by promoting the establishment of a management medical system. Finally, the use of healthcare big data improves operational efficiency by increasing payment speeds, identifying fraud and increasing claim verification processes through automating payments and reducing offline processes. We discuss the obstacles to obtain healthcare big data confronting commercial health insurance companies. The sharing and data mining of healthcare big data brings privacy risks to the insured and there are significant differences in data standards and quality of healthcare big data that limit the application of healthcare big data in commercial health insurance. We recommend that national, regional and local government departments coordinate policies to facilitate the cooperation between commercial health insurance companies and regional healthcare big data platforms. In terms of technology, we recommend the establishment of data sharing platforms and data exchange mechanism across institutions and regions according to nation-wide standards and specifications. Government management departments should establish healthcare big data standards and specification system, promote the construction of healthcare big data and ensure the integrity, authenticity and reliability of health data. We recommend data quality continuous improvement and management mechanisms that combine technology and management. Government regulation should oversee commercial health insurance institutions and establish data security management systems to monitor and supervise the privacy of personal data. CONCLUSIONS: Healthcare big data can play an important role in the development of China's commercial health insurance industry. Healthcare big data can increase commercial health insurers' financial viability while providing improved, and cost-effective, products and services. By providing more and better information to insurers, healthcare big data attenuates the asymmetric information problem, addressing moral hazard and adverse selection problems. By combining hospital and medical organization management information systems with insurers' data management, healthcare big data can help insurers set sustainable premiums, control medical costs and promote operational efficiency. At present, the informatization degree of China's healthcare industry remains limited. To improve the performances, products and services of commercial health insurers, we recommend government reforms in healthcare big data, such as expanding medical industry cooperation; further developing the processes of applying healthcare big data; augmenting data sharing; addressing privacy risks; setting data standards; and improving data quality.

Medical costs and hospital utilization for hemophilia A and B urban inpatients in China: a national cross-sectional study.

BACKGROUND: Hemophilia care in mainland China has been greatly improved since the establishment of the Hemophilia Treatment Center Collaborative Network of China (HTCCNC), and most of drugs for hemophilia have been covered by basic medical insurance schemes. This study assesses whether medical costs and hospital utilization disparities exist between hemophilia A and hemophilia B urban inpatients in China and, second, whether the prescription of coagulation factor concentrates for hemophilia A and hemophilia B inpatients was optimal, from the third payer perspective. METHODS: We conducted a retrospective nationwide analysis based on a 5% random sample from claims data of China Urban Employees' Basic Medical Insurance (UEBMI) and Urban Residents' Basic Medical Insurance (URBMI) schemes from 2010 to 2016. Univariate analysis and multiple regression analysis based on a generalized linear model were conducted. RESULT: A total of 487 urban inpatients who had hemophilia were identified, including 407 inpatients with hemophilia A and 80 inpatients with hemophilia B. Total medical cost for hemophilia B inpatients was significantly higher than for hemophilia A inpatients (USD 2912.81 versus USD 1225.60, P < 0.05), and hemophilia B inpatients had a significantly longer length of hospital stay than hemophilia A inpatients (9.00 versus 7.00, P < 0.05). Total medical costs were mostly allocated to coagulation factor products (76.86-86.68%), with coagulation factor cost of hemophilia B significantly higher than hemophilia A (P < 0.05). Both hemophilia cohorts utilized greatest amount of plasma-derived Factor VIII, followed by recombinant Factor VIII and prothrombin complex concentrates. CONCLUSIONS: Patients with hemophilia B experienced significantly higher inpatient cost, coagulation factor cost and longer length of hospital stay than patients with hemophilia A. Our findings revealed the suboptimal use of coagulation factor concentrate drugs and a higher drug cost burden incurred by hemophilia B than hemophilia A inpatients. Our results call for efforts to strengthen drug regulatory management for hemophilia and to optimize medical insurance schemes according to hemophilia types.

An equity evaluation in stroke inpatients in regard to medical costs in China: a nationwide study.

BACKGROUND: Stroke has always been a severe disease and imposed heavy financial burden on the health system. Equity in patients in regard to healthcare utilization and medical costs are recognized as a significant factor influencing medical quality and health system responsiveness. The aim of this study is to understand the equity in stroke patients concerning medical costs and healthcare utilization, as well as identify potential factors contributing to geographic variation in stroke patients' healthcare utilization and costs. METHODS: Covering 31 provinces in mainland China, our main data were a 5% random sample of stroke claims from Urban Employees Basic Medical Insurance (UEBMI) and Urban Residents Basic Medical Insurance (URBMI) from 2013 to 2016. The Theil index was employed to evaluate the equity in stroke patients in regard to healthcare utilization and medical costs, and the random-effect panel model was used to explore the impact of province-level factors (health resource factors, enabling factors, and economic factors) on medical costs and health care utilization. RESULTS: Stroke patients' healthcare utilization and medical costs showed significant differences both within and between regions. The UEBMI scheme had an overall lower Theil index value than the URBMI scheme. The intra-region Theil index value was higher than the inter-region Theil index, with the Theil index highest within eastern China, China's richest and most developed region. Health resource factors and enabling factors (represented by reimbursement rate and education attainment years) were identified significantly associated with medical costs (P < 0.05), but have no impact on average length of stay. CONCLUSIONS: China's fragmented urban health insurance schemes require further reform to ensure better equity in healthcare utilization and medical costs for stroke patients. Improving education attainment, offering equal access to healthcare, allocating health resources reasonably and balancing health services prices in different regions also count.

The Sharing Economy in China's Aging Industry: Applications, Challenges, and Recommendations.

BACKGROUND: All aging societies face the challenge of allocating limited resources for the highest value of use. The sharing economy provides one method to address the imbalance between the demand and supply of health services to the older adult population. With a substantial aging population, China's practices in the sharing aging industry may set examples for other "getting old before getting rich" countries. OBJECTIVE: There is a gap in both the data and research on China's aging industry sharing economy. This paper addresses these data and research lacunae by constructing a framework for the application of a sharing model in China's aging industry, by assessing the current state of the aging industry sharing economy, by setting out the challenges to the sharing aging health care and service economy, and by making recommendations for the development of the aging industry sharing economy. METHODS: This paper constructs a sharing economy framework in the aging industry covering four aspects (people, facilities, capital, and information) to test the current state and future prospects of China's aging industry sharing economy. RESULTS: In people sharing, we analyzed the sharing of emotional companionship, doctors, nurses, nursing attendants, and domestic helpers. We discussed facility sharing models from the point of land and housing, medical devices, and other items such as pensioner meals and shared medicine bins. We acknowledge that crowdfunding platforms have developed fast in China, but many older adult users faced problems in their operation. Information sharing is a developing field, which can optimize users' experiences and should help older adults filter out misinformation, but China currently does not have adequate sharing information platforms for older adults. CONCLUSIONS: We identified four major challenges in China's aging industry sharing economy: poor adaptability to technology for older adults, mediocre quality of shared services, one-size-fits-all and the concept of the useless elderly, and shortage of qualified practitioners. We make recommendations for specific measures by governments, communities, and enterprises to improve the sharing economy in the aging industry.

Development, Status Quo, and Challenges to China's Health Informatization During COVID-19: Evaluation and Recommendations.

By applying advanced health information technology to the health care field, health informatization helps optimize health resource allocation, improve health care services, and realize universal health coverage. COVID-19 has tested the status quo of China's health informatization, revealing challenges to the health care system. This viewpoint evaluates the development, status quo, and practice of China's health informatization, especially during COVID-19, and makes recommendations to address the health informatization challenges. We collected, assessed, and evaluated data on the development of China's health informatization from five perspectives-health information infrastructure, information technology (IT) applications, financial and intellectual investment, health resource allocation, and standard system-and discussed the status quo of the internet plus health care service pattern during COVID-19. The main data sources included China's policy documents and national plans on health informatization, commercial and public welfare sources and websites, public reports, institutional reports, and academic papers. In particular, we extracted data from the 2019 National Health Informatization Survey released by the National Health Commission in China. We found that China developed its health information infrastructure and IT applications, made significant financial and intellectual informatization investments, and improved health resource allocations. Tested during COVID-19, China's current health informatization system, especially the internet plus health care system, has played a crucial role in monitoring and controlling the pandemic and allocating medical resources. However, an uneven distribution of health resources and insufficient financial and intellectual investment continue to challenge China's health informatization. China's rapid development of health informatization played a crucial role during COVID-19, providing a reference point for global pandemic prevention and control. To further promote health informatization, China's health informatization needs to strengthen top-level design, increase investment and training, upgrade the health infrastructure and IT applications, and improve internet plus health care services.

Application of Big Data Technology for COVID-19 Prevention and Control in China: Lessons and Recommendations.

BACKGROUND: In the prevention and control of infectious diseases, previous research on the application of big data technology has mainly focused on the early warning and early monitoring of infectious diseases. Although the application of big data technology for COVID-19 warning and monitoring remain important tasks, prevention of the disease's rapid spread and reduction of its impact on society are currently the most pressing challenges for the application of big data technology during the COVID-19 pandemic. After the outbreak of COVID-19 in Wuhan, the Chinese government and nongovernmental organizations actively used big data technology to prevent, contain, and control the spread of COVID-19. OBJECTIVE: The aim of this study is to discuss the application of big data technology to prevent, contain, and control COVID-19 in China; draw lessons; and make recommendations. METHODS: We discuss the data collection methods and key data information that existed in China before the outbreak of COVID-19 and how these data contributed to the prevention and control of COVID-19. Next, we discuss China's new data collection methods and new information assembled after the outbreak of COVID-19. Based on the data and information collected in China, we analyzed the application of big data technology from the perspectives of data sources, data application logic, data application level, and application results. In addition, we analyzed the issues, challenges, and responses encountered by China in the application of big data technology from four perspectives: data access, data use, data sharing, and data protection. Suggestions for improvements are made for data collection, data circulation, data innovation, and data security to help understand China's response to the epidemic and to provide lessons for other countries' prevention and control of COVID-19. RESULTS: In the process of the prevention and control of COVID-19 in China, big data technology has played an important role in personal tracking, surveillance and early warning, tracking of the virus's sources, drug screening, medical treatment, resource allocation, and production recovery. The data used included location and travel data, medical and health data, news media data, government data, online consumption data, data collected by intelligent equipment, and epidemic prevention data. We identified a number of big data problems including low efficiency of data collection, difficulty in guaranteeing data quality, low efficiency of data use, lack of timely data sharing, and data privacy protection issues. To address these problems, we suggest unified data collection standards, innovative use of data, accelerated exchange and circulation of data, and a detailed and rigorous data protection system. CONCLUSIONS: China has used big data technology to prevent and control COVID-19 in a timely manner. To prevent and control infectious diseases, countries must collect, clean, and integrate data from a wide range of sources; use big data technology to analyze a wide range of big data; create platforms for data analyses and sharing; and address privacy issues in the collection and use of big data.

Comparison of patient perceived primary care quality in public clinics, public hospitals and private clinics in rural China.

BACKGROUND: In rural China, patients have free choice of health facilities for outpatient services. Comparison studies exploring the attributes of different health facilities can help identify optimal primary care service models. Using a representative sample of Chinese provinces, this study aimed to compare patients' rating of three primary care service models used by rural residents (public clinics, public hospitals and private clinics) on a range of health care attributes related to responsiveness. METHODS: This was a secondary analysis using the household survey data from World Health Organization (WHO) Study on global AGEing and adult health (SAGE). Using a multistage cluster sampling strategy, eight provinces were selected and finally 3435 overall respondents reporting they had visited public clinics, public hospitals or private clinics during the last year, were included in our analysis. Five items were used to measure patient perceived quality in five domains including prompt attention, communication and autonomy, dignity and confidentiality. ANOVA and Turkey's post hoc tests were used to conduct comparative analysis of five domains. Separate multivariate linear regression models were estimated to examine the association of primary care service models with each domain after controlling for patient characteristics. RESULTS: The distribution of last health facilities visited was: 29.5% public clinics; 31.2% public hospitals and; 39.3% private clinics. Public clinics perform best in all five domains: prompt attention (4.15), dignity (4.17), communication (4.07), autonomy (4.05) and confidentiality (4.02). Public hospitals perform better than private clinics in dignity (4.03 vs 3.94), communication (3.97 vs 3.82), autonomy (3.92 vs 3.74) and confidentiality (3.94 vs 3.73), but equivalently in prompt attention (3.92 vs 3.93). Rural residents who are older, wealthier, and with higher self-rated health status have significantly higher patient perceived quality of care in all domains. CONCLUSIONS: Rural public clinics, which share many characteristics with the optimal primary care delivery model, should be strongly strengthened to respond to patients' needs. Better doctor-patient interaction training would improve respect, confidentiality, autonomy and, most importantly, health care quality for rural patients.

Primary care quality between Traditional Tibetan Medicine and Western Medicine Hospitals: a pilot assessment in Tibet.

INTRODUCTION: This paper assesses both patients' perspectives on the differences in primary care quality between traditional Tibetan medicine (TTM) hospitals and western medicine (WM) hospitals and the efficacy of the government's investment in these two Prefecture-level primary care structures in Tibet. METHOD: A validated Tibetan version of the Primary Care Assessment Tool (PCAT-T) was used to collect data on 692 patients aged over 18 years old, who reported the sampling site was their regular source of health care. T-tests were performed to compare the separate and total primary care attributes between WM hospitals and TTM hospitals. Multiple linear regression analysis was conducted to examine the association of the health care setting with primary care attributes while controlling for socio-demographic, health service use and health status characteristics. RESULTS: Compared to WM hospitals, the results showed that TTM hospitals had patients who were older (15.8 % versus 8.4 % over 60 years); with lower education levels (66.0 % versus 35.8 % with below junior high school ) and income levels (46.9 % versus 26.5 % with annual household income below 30,000RMB); more likely to be married (79.2 % versus 60.5 %); made less frequent health care visits; and had higher self-rated health status. Overall, patients assessed the primary care performance in TTM hospitals significantly higher (80.0) than WM hospitals (74.63). There were no differences in health care assessment by patient gender, age, income, education, marital status and occupation. CONCLUSIONS: TTM patients reported better primary care experiences than patients using WM hospitals, which validated the government's investment in traditional Tibetan medicine.

Contribution of primary care to health: an individual level analysis from Tibet, China.

INTRODUCTION: There have been significant improvements in health outcomes in Tibet, health disparities between Tibet and the rest of China has been greatly reduced. This paper tests whether there was a positive association between good primary care and better health outcomes in Tibet. METHOD: A validated Tibetan version of the Primary Care Assessment Tool (PCAT-T) was used to collect data on 1386 patients aged over 18 years old accessing primary care. Self-rated health (SRH) was employed to measure health outcomes. A multiple binary logistic regression model was used to explore the association between primary care quality and self-rated health status after controlling for socio-demographic and lifestyle variables. RESULTS: This study found that primary care quality had a significant positive association with self-rated health status. Among the nine domains of PCAT-T, family centeredness domain had the highest Odds Ratio (OR = 1.013) with SRH. Patients located in rural area, with higher education levels, without depression, and less frequent drinking were more likely to self-rate as "good health" compared with the reference group. CONCLUSIONS: In Tibet, higher quality primary care was associated with better self-rated health status. Primary care should be much strengthened in future health system reform in Tibet.

Cost-effectiveness of endovascular treatment for acute ischemic stroke in China: evidence from Shandong Peninsula.

BACKGROUND: Recently, the endovascular treatment (EVT) of acute ischemic stroke has made significant progress in many aspects. Intravenous thrombolysis (IVT) is usually recommended before endovascular treatment in clinical practice, but the value of the practice is controversial. The latest meta-analysis evaluation was that the effect of EVT versus EVT plus IVT did not differ significantly. The cost-effectiveness analysis of EVT plus IVT needs further analysis. This study assesses the health benefits and economic impact of EVT plus IVT in Shandong Peninsula of China. METHOD: We followed a cross-section design using the Chinese-Shandong Peninsula public hospital database between 2013 and 2023. The real-world costs and health outcomes were collected through the Hospital Information System (HIS) and published references. We calculated incremental cost-effectiveness ratios (ICERs) from the perspective of Chinese healthcare using the complex decision model to compare the costs and effectiveness between EVT versus EVT + IVT. One-way and Monte Carlo probabilistic sensitivity analyses were performed to assess the robustness of the economic evaluation model. RESULTS: EVT alone had a lower cost compared with EVT + IVT whether short-term or long-term. Until 99% dead of AIS patients, the ICER per additional QALY was RMB696399.30 over the willingness-to-pay (WTP) threshold of 3× gross domestic product (GDP) per capita in Shandong. The probabilistic sensitivity analysis of 3 months, 1 year and long-term horizons had a 97.90%, 97.43% and 96.89% probability of cost-effective treatment under the WTP threshold (1×GDP). The results of the one-way sensitivity analysis showed that direct treatment costs for EVT alone and EVT + IVT were all sensitive to ICER. CONCLUSIONS: EVT alone was more cost-effective treatment compared to EVT + IVT in the Northeast Coastal Area of China. The data of this study could be used as a reference in China, and the use of the evaluation in other regions should be carefully considered.