The impacts of national centralized drug procurement policy on drug utilization of medical institutions: an empirical study in a county-level hospital in China.

PURPOSE: Under the background of the regular implementation of the National Centralized Drug Procurement (NCDP) policy, this study aimed to assess the impacts of the NCDP policy on drug utilization of county-level medical institutions, and probe into the influencing factors of the changes in drug utilization. METHOD: A pre-post study was applied using inpatient data from a county-level medical institution in Nanjing. Drug utilization behavior of medical institutions of 88 most commonly used policy-related drugs (by generic name, including bid-winning and bid-non-winning brands) was analyzed, and the substitution of bid-winning brands for brand-name drugs after policy intervention was evaluated. RESULTS: After policy intervention, 43.18% of policy-related drugs realized the substitution of bid-winning brands for bid-non-winning brands (6.82% of complete substitution, 36.36% of partial substitution). Meanwhile, 40.90% of policy-related drugs failed to realize brand substitution. Multiple factors affected brand substitution, including: (1) Policy effect: brand substitution was more obvious after the intervention of the first and third round of NCDP. (2) Drug market competition: the greater the price reduction of bid-non-winning brands, the more the drugs for the same indication, the more likely that medical institutions keep using the same brands as they did before policy intervention. (3) Previous drug utilization of medical institutions: brand substitution was more obvious in drugs with large number of prescriptions and weak preference for brand-name drugs. CONCLUSION: The NCDP policy promoted the substitution of bid-winning brands for bid-non-winning brands. However, the NCDP policy remained to be further implemented in county-level medical institutions. Policy implememtation efforts, drug market competition and drug utilization of medical institutions would affect the implementation of the NCDP policy.

The impact of the pandemic on the presentation and treatment of head and neck squamous cell carcinoma at a county hospital.

INTRODUCTION: In March 2020, the World Health Organization declared COVID-19 a pandemic, initiating stay-at-home orders which delayed cancer care and screening. The impact on head and neck cancer care in populations at risk has yet to be elucidated. The objective of this investigation is to evaluate how the presentation, diagnosis, and treatment of head and neck squamous cell carcinoma cancer patients at a county hospital were affected by the pandemic. METHODS: A retrospective review of patients with head and neck squamous cell carcinoma that were diagnosed at a county hospital 365 days before and after stay-at-home orders were initiated. The primary outcomes were duration between diagnosis from imaging and initiation of treatment. Secondary outcomes included mortality, stage, nodal status, and distant metastasis at presentation. RESULTS: There was a total of 105 diagnoses. Sixty-five (62 %) head and neck squamous cell carcinoma diagnoses were diagnosed before the stay-at-home orders were initiated, and 40 (38 %) after. Eighty percent (32/40) of diagnoses presenting after had stage IV disease compared to 58 % (38/65) in those before (p < 0.05). A higher percentage of patients who presented later had a >30-day delay to biopsy (43 % v. 20 %, OR: 3.0, p < 0.05). This difference was exacerbated by those with laryngeal, oral cavity, or oropharyngeal cancer (45 % v. 15 %, OR: 4.5, p < 0.05). There was a larger delay from diagnosis to treatment after the orders were initiated (68 v. 53, p < 0.05) however there was no difference in one-year mortality (25 % v. 23 %, p > 0.05). This investigation found a 14 % loss to follow-up. CONCLUSIONS AND RELEVANCE: In this cohort of head and neck squamous cell carcinoma diagnoses at a county hospital, those diagnosed after the stay-at-home orders were initiated presented with more advanced disease. They also had more delays in diagnosis and initiation of treatment. There was no difference in one-year mortality rates between the two groups however there was a significant loss to follow-up, limiting prognostication. These findings serve to better prepare healthcare providers to implement optimized care during future shutdowns related to public health crises. LEVEL OF EVIDENCE: III.

Outcomes of Exeter cemented total hip arthroplasty in a county hospital: survivorship of eight hundred and ninety four hips with a minimum ten-year follow up.

PURPOSE: A total of 894 hips were evaluated to describe the survivorship of Exeter cemented femoral stems and report the outcomes and complications of our 'Exeter- era', and there is no study from Central or Eastern Europe demonstrating similar results. METHODS: Between January 2000 and December 2009, a total of 894 hips were included who underwent Exeter universal and V40 femoral stems with a mean follow up of 13 years. Cemented Exeter low profile polyethylene cups were used in 889 patients (99.4%) cups. Harris hip score (HHS) was used and statistical outcome measures were calculated with revision as an endpoint for aseptic loosening of the stem, aseptic loosening of any component, all-cause revision of the stem, and all-cause revision of the hip. RESULTS: A total of 103 patients died and 129 (14.4%) operated hips were lost to follow-up before ten years. Out of the 662, ten stems (1.5%) were revised for aseptic loosening. Aseptic loosening of any component was the reason for revision in 43 cases (6.5%), consisting of 40 cup revisions and ten stem exchanges. Periprosthetic fracture occurred in 17 cases (1.9%) Periprosthetic joint infection occurred in 18 cases (2.01%). Three cups were exchanged for recurrent dislocation, and two stems had broken. CONCLUSION: Exeter hip system has provided reproducible results across different centres worldwide, as it did in our series. Thorough surgical and cementing technique is of utmost importance for achieving these results. The cup is the weak point of the system and use of a hybrid system is worth considering.

[A survey on the practice of bronchoscopy in county-level hospitals of China].

Objective: To investigate the bronchoscopy resource allocation and technology application in county-level hospitals in China. Methods: A cross-sectional survey was conducted. In 2021, 12 provinces were sampled from all provinces in China according to the regional Gross Domestic Product (GDP) and the number of counties, in which a total of 291 county-level hospitals were randomly enrolled. Two county-level hospitals which carried out bronchoscopy technology in each province were randomly sampled to investigate the status of bronchoscopy resources, technical application, decontamination and anesthesia by using questionnaires. Independent sample t test or two related sample nonparametric test were used for comparison between groups. Spearman correlation analysis was used to explore the correlation. Bilateral P<0.05 was considered statistically significant. Results: According to the sampling results, it was estimated that in the county-level hospitals, the proportion of those performing bronchoscopy was 11.4% (9.9%, 13.8%), which was significantly correlated with the population in the province (r=0.64, P=0.025) and the regional GDP (r=0.65, P=0.025).The 24 county-level hospitals interviewed were equipped with (1.6±1.0) bronchoscopes on average, and the number of hospitals with electronic bronchoscopes and fiberoptic bronchoscopes was 22 (91.7%) and 6 (25.0%), respectively. Six (25.0%) hospitals performed bronchoscopy every working day. Twelve (50.0%) hospitals had relatively permanent physicians and nurses. All operating doctors had received special training. There was a significant increase in the number of bronchoscopy cases per hospital in 2020 compared to 2019 [140(70, 335) vs. 100(29, 254), P=0.001]. All hospitals used standard cleaning and sterilization workbenches, cleaning agents and disinfectants. Surface anesthesia was available in 24 hospitals, and bronchoscopy techniques under sedation and analgesia were performed in 10 (41.7%) hospitals. Atropine was still used to prevent airway secretions in 2 (8.3%) hospitals,although not recommended by guidelines. Conclusions: There was a large gap between the current status of bronchoscopy technology in county-level hospitals and the standards of the National Health Commission, together with regional disparities. Bronchoscopist training in the standardization and the decontamination work met the requirements. In some hospitals, the use of complementary medicines was not standardized or the sedatives were not given routinely according to the guidelines. We should promote the popularization and standardization of bronchoscopy technology, and strengthen the allocation of related resources in China's county hospitals.

Changes in Epidemiology of Acetaminophen Overdoses in an Urban County Hospital After 20 Years.

INTRODUCTION: Acetaminophen (APAP) toxicity is the main cause of acute liver failure in the United States. A prior series (1992-1995) identified 71 hospitalized adults with APAP toxicity through the International Statistical Classification of Disease and Related Health Problems, 9th revision (ICD-9) code at Parkland Hospital, Dallas, TX. METHODS: We used a laboratory database search of serum APAP levels from 2011 to 2015 to identify patients with APAP toxicity in the same hospital. RESULTS: We identified 140 patients hospitalized for APAP toxicity from 27,143 APAP levels obtained; 35 required Intensive Care Unit (ICU) admission, and there were no deaths. APAP toxicity/100,000 admissions was similar between eras. DISCUSSION: APAP toxicity continues unabated after 20 years but with improved overall outcomes.

Association between headache and suicidality: An analysis of universal suicide screening data at a large urban county hospital.

BACKGROUND: Identifying individuals at increased risk of suicide is important, particularly those who present for treatment for nonpsychiatric chief complaints who may go undetected. It has been found that pain symptoms, such as headache, are associated with suicide, although this association requires further characterization. This study examined specific components of suicidality in relation to headache subtypes. METHODS: This study retrospectively reviewed 2,832,835 nonpsychiatric adult clinical encounters at a large county hospital, where a standardized suicide risk screening tool, the Columbia-Suicide Severity Rating Scale (C-SSRS), was universally implemented. The C-SSRS assesses specific components of suicidality: wish to be dead and suicidal ideation, method, intent, plan, and action. Multivariate logistic regressions were performed to assess the association between headache, as well as headache subtype (migraine, tension, or cluster), and each component of suicidality. RESULTS: There were significant positive associations between presenting with a headache and 2 specific components of suicidality: wish to be dead and suicidal action. Individuals with tension headache may have a lower risk of wishing to be dead compared to those with migraine and cluster headaches. CONCLUSIONS: The association of headaches with specific elements of sui-cidality demonstrates the potential yield of identification of suicide risk among individuals with nonpsychiatric presentations.

Characteristics, safety and cost-effectiveness analysis of self-administered outpatient parenteral antibiotic therapy via a disposable elastomeric continuous infusion pump at two county hospitals in Houston, Texas, United States.

WHAT IS KNOWN AND OBJECTIVE: Outpatient parenteral antibiotic therapy (OPAT) is an attractive option for patients who require parenteral antimicrobials as outpatients. Few OPAT studies have assessed the impact of IV antibiotic therapy via elastomeric continuous pumps, with most having been conducted outside the United States and few in county hospitals. The OPAT program in Harris Health system, the county hospital system of Houston, Texas, United States, has implemented a disposable elastomeric continuous infusion pump (eCIP) for self-administered intravenous antibiotics (s-OPAT) since December 2018. Our goal was to describe the clinical characteristics of patients discharged with an eCIP, as well as the safety and cost-effectiveness of this pump. METHODS: We retrospectively analysed patients discharged from Harris Health hospitals between 12/2018 and 02/2021 with s-OPAT via eCIP at home. We extracted various patient characteristics and outcomes related to OPAT. RESULTS AND DISCUSSION: Among 481 OPAT patients during the study period, 91 patients received s-OPAT via eCIP. A total of 1925 days of s-OPAT were administered at home, with a median duration of 12 days. Eighty-three patients (93.4%) achieved a cure from infection, six patients (6.6%) had side effects, and nine patients (9.9%) experienced 30-day hospital readmission. Twenty-two patients (24.2%) presented to the ED during s-OPAT, with 13 patients (14.3%) presenting with PICC line concerns. We estimated that s-OPAT via eCIP saved $2,360,500 to $3,503,900 compared to inpatient-only therapy. WHAT IS NEW AND CONCLUSION: Our study showed that patients with s-OPAT via eCIP had a high cure rate with a relatively low incidence of side effects and 30-day hospital readmission. ED visits during therapy were relatively high, which indicates the necessity of close patient monitoring via the OPAT program. eCIP appears to be a good option to facilitate an early disposition of patients in county hospitals.

Hospital management practices in county-level hospitals in rural China and international comparison.

BACKGROUND: Although management is important in healthcare, low- and middle-income countries (LMICs) have little experience measuring the competence of hospital management. While improving hospital management is the main focus of hospital reform in China, few studies have empirically documented the baseline situation to inform policy design. METHODS: We assessed the management practices of county-level hospitals in Guizhou in southwest China during 2015. We used the Development World Management Survey (D-WMS) instrument to interview 273 managers in 139 hospitals. We scored the management practices of the sampled hospitals, overall and in four dimensions (operations, monitoring, targets, personnel management) and three processes (implementation, usage, monitoring). We then converted the scores to the WMS scale and compared these with data from two other LMICs and seven high-income countries (HICs). RESULTS: On a scale of 1 ('worst practice') to 5 ('best practice'), the mean (SD) hospital D-WMS scores were 2.57 (0.46) overall; 2.71 (0.48), 2.64 (0.58), 2.40 (0.64), and 2.56 (0.40) for operation, monitoring, target, and personnel, respectively; and 2.43 (0.48), 2.62 (0.48), and 2.66 (0.47) for implementation, usage, and monitoring, respectively. After conversion to WMS scores, China ranked seventh of 10 countries, after six HICs and higher than one HIC and two other LMICs (Brazil and India). China ranked higher than the two LMICs in each of the four dimensional scores. CONCLUSIONS: Chinese county-level hospitals should improve their low quality of management by prioritizing target-setting and process implementation, particularly in personnel management. Meanwhile, modern management training should be given to most clinical managers.

Assessing the cost-effectiveness of contraceptive methods from a health provider perspective: case study of Kiambu County Hospital, Kenya.

BACKGROUND: Kenya's contraceptive prevalence rate at 53% is low, with wide disparity among the 47 counties that make up the country (2-76%). Significant financial investment is required to maintain this level of contraceptive use and increase it to levels seen in more developed countries. This is in the context of a growing population, declining donor funding, limited fiscal space and competing health challenges. Studies have shown that long-term contraceptive methods are more cost-effective than short-term methods. However, it is unclear if this applies in Sub-Saharan Africa; with limited financial resources, lower social economic status among users, and publicly managed commodity supply chains, in vertical programs largely dependent on donor funding. This study assessed the cost-effectiveness of contraceptive methods used in Kenya. METHODS: A cross-sectional study was undertaken in a county referral hospital in mid-2018. Purposive sampling of 5 family planning clinic providers and systematic sampling of 15 service delivery sessions per method was done. Questionnaire aided interviews were done to determine inputs required to provide services and direct observation to measure time taken to provide each method. Cost per method was determined using activity based costing, effectiveness via couple year protection conversion factors, and cost-effectiveness was expressed as cost per couple year protection. RESULTS: The intra-uterine copper device was most cost-effective at 4.87 US dollars per couple year protection followed by the 2-Rod Implant at 6.36, the 1-Rod Implant at 9.50, DMPA at 23.68, while the combined oral contraceptive pills were least cost-effective at 38.60 US dollars per couple year protection. Long-term methods attracted a higher initial cost of service delivery when compared to short-term methods. CONCLUSION: Long-term contraceptive methods are more cost-effective. As such, investing in long-term contraceptives would save costs despite higher initial cost of service delivery. It is recommended, therefore, that Sub-Saharan Africa countries allocate more domestic financial resources towards availability of contraceptive services, preferably with multi-year planning and budget commitment. The resources should be invested in a wide range of interventions shown to increase uptake of long-term methods, including reduction of cost barriers for the younger population, thereby increasing contraceptive prevalence rates.

The proportion of women of reproductive age using a contraceptive method in Kenya, at 53% is low. More funding is required to ensure women who need contraceptives have access and continue using them. Previous research has shown that contraceptives that protect a woman from getting pregnant for an extended period utilize less resources. This study assessed the potential of contraceptives used in Kenya to produce results at less cost.This study was undertaken in a sub-national referral hospital in mid-2018. A sample of 5 family planning clinic providers were interviewed while 15 contraceptive service sessions per method were observed. The interviews were conducted to determine the supplies required to offer services. Observation was used to measure time taken to provide each contraceptive method. The cost associated with providing each contraceptive per year was determined using activity based costing. Effectiveness of each method was determined using the rate of protection from pregnancy during one-year. Cost-effectiveness was the money utilized to achieve protection from pregnancy in one year of use.The Copper-T coil was found to achieve greater results at a lesser cost of 4.87 US dollars for one year of protection from pregnancy, followed by the 2-Rod Implant at US dollars 6.36, the 1-Rod Implant at 9.50, DMPA at 23.68, and The Pill at 38.60 US dollars.Contraceptive methods that protect a woman from getting pregnant for a longer period utilize less resources. Investing in such would save costs despite requiring higher initial cost of service provision.

Microorganisms and Antibiotic Resistance of Bacterial Keratitis at a Rural County Hospital in Seville.

PURPOSE: To review the incidence, resistance patterns, and management of bacterial keratitis during the past 4 years. METHODS: We retrospectively reviewed the clinical records of microbiological isolates from patients with a clinical diagnosis of bacterial keratitis. RESULTS: A total of 159 patients were analyzed, and 102 microorganisms were isolated from 129 cultures. In these cultures, 23.7% of the microorganisms were gram positive, 60.8% were gram negative, and 15.5% were fungi. Pseudomonas aeruginosa was the most common bacteria (9.2%), followed by Serratia marcescens (4.4%) and Staphylococcus aureus (4%). Resistance to fluoroquinolones and aminoglycosides was found to be 23.1% and 53.1% in gram-positive and 2.8% and 13.9% in gram-negative bacteria, respectively. Resistance to ceftazidime against gram-negative bacteria was 13.9%. No resistance to vancomycin was observed. CONCLUSIONS: A high resistance rate to aminoglycosides and fluoroquinolones was observed in gram-positive bacteria. We concluded that fluoroquinolones or aminoglycosides may not be suitable for initial monotherapy in patients with severe bacterial keratitis.

Guadalupe County Hospital: Facing Unique Social Challenges.

Social determinants of health (SDOHs) are the "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks" (Healthy People 2030 2021). These conditions include economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. Ultimately, social determinants affect health status and outcomes to a greater degree than direct clinical care. Although these factors are experienced at a personal level, their impact can be seen on a community level. Also, while SDOHs vary, they tend to be more negatively impactful in rural communities-which then experience more harmful effects on health outcomes than their urban or suburban counterparts (National Advisory Committee on Rural Health and Human Services 2017). The unique experiences and challenges of rural communities require unique solutions. Guadalupe County Hospital in Santa Rosa, New Mexico, collaborates with community partners to address SDOHs. These efforts have a positive impact on their communities and can be replicated in other rural settings.

The Impact of Burnout Syndrome on Job Satisfaction among Emergency Department Nurses of Emergency Clinical County Hospital "Sfântul Apostol Andrei" of Galati, Romania.

Background and Objectives: Burnout syndrome is caused by a number of factors, including personal, organizational, and professional problems. Data from the literature reported a strong relationship between burnout syndrome and job satisfaction among emergency medical personnel. Materials and Methods: We studied a sample of 80 nurses working in the Emergency Department of Emergency Clinical County Hospital "Sfântul Apostol Andrei" of Galati Romania. Participants signed an informed consent and then completed a socio-demographic questionnaire and the MBI-HSS (Maslach Burnout Inventory-Human Services Survey) questionnaire to assess the level of burnout and JSS (Job Satisfaction Survey) to assess the level of professional satisfaction. The aim of this study was to measure the levels of burnout and satisfaction among nurses in the Emergency Department as well as the relationship between these two variables and a group of selected socio-demographic characteristics. Results: This study found that 36.25% of nurses reported a high level of burnout. Additionally, emotional exhaustion is directly proportional to professional experience and age. Participants also reported a sense of ambivalence and satisfaction with the workplace, but were satisfied with the nature of their work. Conclusions: The results of this study suggest the relationship between variables and this could be used to implement psychoactive intervention strategies at both individual and organizational levels, which could lead to a decrease in burnout levels. Burnout is a predictor of job satisfaction for Emergency Department nurses. Personal achievement was relatively commensurate with the nature of the work. Additionally, the increase in burnout among nurses is directly proportional to the nature of the work.

Gender-Specific Risk Factors for Reflux Esophagitis in a Predominantly Hispanic Population of a Large Safety-Net Hospital.

BACKGROUND: Defining factors associated with severe reflux esophagitis allows for identification of subgroups most at risk for complications of strictures and esophageal malignancy. We hypothesized there might be unique clinical features in patients with reflux esophagitis in a predominantly Hispanic population of a large, safety-net hospital. AIM: Define clinical and endoscopic features of reflux esophagitis in a predominantly Hispanic population of a large, safety-net hospital. METHODS: This is retrospective comparative study of outpatients and hospitalized patients identified with mild (Los Angeles Grade A/B) and severe (Los Angeles Grade C/D) esophagitis through an endoscopy database review. The electronic medical record was reviewed for demographic and clinical data. RESULTS: Reflux esophagitis was identified in 382/5925 individuals: 56.5% males and 79.8% Hispanic. Multivariable logistic regression model adjusted for age, gender, race, body mass index (BMI), tobacco and alcohol use, and hospitalization status with severity as the outcome showed an interaction between gender and BMI (p ≤ 0.01). Stratification by gender showed that obese females had decreased odds of severe esophagitis compared to normal BMI females (OR = 0.18, 95% CI = 0.07-0.47; p < 0.01). In males, the odds of esophagitis were higher in inpatient status (OR = 2.84, 95% CI = 1.52 - 5.28; p < 0.01) and as age increased (OR = 1.37, 95% CI = 1.03 - 1.83; p = 0.03). CONCLUSIONS: We identify gender-specific associations with severe esophagitis in a predominantly Hispanic cohort. In females, obese BMI appears to be protective against severe esophagitis compared to normal BMI, while in men inpatient status and increasing age were associated with increased odds of severe esophagitis.

Signet Ring Cell Gastric Carcinoma: Clinical Epidemiology and Outcomes in a Predominantly Latino County Hospital Population.

BACKGROUND: Gastric signet ring cell carcinoma (GSRC) is a rare but increasingly prevalent tumor histotype whose clinical features and natural history are poorly understood, particularly in the USA and minorities. AIMS: To examine the occurrence, clinico-demographic characteristics, oncologic features, treatment, and outcomes of GSRC in a predominantly minority county hospital setting and benchmark them against data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. METHODS: We queried biopsy-proven GSRC cases at a Los Angeles County hospital, from 2004 to 2017. Clinical characteristics, treatment, and survival data were collected and compared to SEER data. RESULTS: We identified 63 patients with GSRC. Compared to SEER, our cohort was significantly younger (52.6 vs. 63.5 years, p < 0.01), Hispanic/Latino predominant (81% vs. 20%, p < 0.01), had higher overall stage (86% vs. 69% with stage III/IV, p < 0.01), and more frequent node involvement (89% vs. 49%, p < 0.01). Lower tumor stage, Helicobacter pylori positivity, and surgical intervention were associated with significantly longer median survival (all p < 0.05), which was similar in our study compared to SEER (median 12.6 vs. 9.0 months, p = 0.26). CONCLUSIONS: Patients with GSRC within the Los Angeles County population have different clinical characteristics compared to what has been reported in SEER. Our cohort was younger, and despite having more advanced disease, did not have shorter survival. Further study is needed to better identify protective and risk factors in this population and improve understanding of the etiopathogenesis and natural history of this malignancy.

The hospital management practices in Chinese county hospitals and its association with quality of care, efficiency and finance.

BACKGROUND: County hospitals as the backbone of the China's healthcare system are providing services for over 70% of the total population. However, the hospital management practice (HMP) and its links with quality of care, efficiency and finance in these hospitals are unknown. METHODS: We did two cross-sectional surveys of HMP in 2013 and 2015 among 101 county hospitals across rural China. Three managing roles (hospital director, director of medical affairs office and director of cardiology) and a cardiologist were invited to the surveys. A novel HMP rating scale, with 100 as full score, was used to measure the HMP in 17 indicators under four dimensions (target, operation, performance, and talent management) for each hospital. We analyzed the association of HMP score with variables on quality of care, efficiency and finance using linear mixed models with and without adjustment for potential confounders. FINDINGS: A total of 95 hospitals participated in at least one survey and were included in the analysis. The overall mean HMP score varied dramatically across the hospitals and 84% of them scored less than 60. The dimension mean HMP score was 38.6 (target), 56.4 (operation), 53.2 (performance) and 55.7 (talent), respectively. The pattern of indicator mean HMP score, however, was almost identical between hospitals with high and low overall HMP score, showing the same 'strength' (staff satisfaction, staff performance appraisal, 'hard wares', patient-centered services, etc.) and 'weakness' (target balance, target setting, continuous quality improvement, penalties on staff with dissatisfied performance, etc.). The associations of overall mean HMP score with quality of care and efficiency variables and cost per hospitalization was not statistically significant. The statistical significance in the association with hospital annual total income disappeared after adjusting for region, teaching status, number of competitors, number of staff and number of beds in use. CONCLUSION: The HMP in Chinese county hospitals scores low in general and was not significantly associated with hospital care quality, efficiency and finance. The current healthcare reform in China should address the micro level issues in hospital management practices.

Impact of global budget combined with pay-for-performance on the quality of care in county hospitals: a difference-in-differences study design with a propaensity-score-matched control group using data from Guizhou province, China.

BACKGROUND: Provider payment system has a profound impact on health system performance. In 2016, a number of counties in rural Guizhou, China, implemented global budget (GB) for county hospitals with quality control measures. The aim of this study is to measure the impact of GB combined with pay-for-performance on the quality of care of inpatients in county-level hospitals in China. METHODS: Inpatient cases of four diseases, including pneumonia, chronic asthma, acute myocardial infarction and stroke, from 16 county-level hospitals in Guizhou province that implemented GB in 2016 were selected as the intervention group, and similar inpatient cases from 10 county-level hospitals that still implemented fee-for-services were used as the control group. Propensity matching score (PSM) was used for data matching to control for age factors, and difference-in-differences (DID) models were constructed using the matched samples to perform regression analysis on quality of care for the four diseases. RESULTS: After the implementation of GB, rate of sputum culture in patients with pneumonia, rate of aspirin at discharge, rate of discharge with ß-blocker and rate of smoking cessation advice in patients with acute myocardial infarction increased. Rate of oxygenation index assessment in patient with chronic asthma decreased 20.3%. There are no significant changes in other indicators of process quality. CONCLUSIONS: The inclusion of pay-for-performance in the global budget payment system will help to reduce the quality risks associated with the reform of the payment system and improve the quality of care. Future reform should also consider the inclusion of the pay-for-performance mechanism.

Effects of Chinese medical pricing reform on the structure of hospital revenue and healthcare expenditure in county hospital: an interrupted time series analysis.

BACKGROUND: China has initiated a medical pricing reform to combat the overuse of drugs and relieve the financial burden of patients. This paper aims to analyze the effect of medical pricing reform on revenue structure and healthcare expenditure of county public hospitals in Guangdong province. METHODS: Based on the monthly data from January 2013 to August 2019, we use interrupted time series design to evaluate the effects of medical pricing reform on healthcare expenditure in both outpatients and inpatients. A counterfactual is also established to examine the net effect of the policy. RESULTS: The proportion of drug revenue decreased from 35 % to 2015 to 29.7 % in 2019, and the revenue from medical services and inspection increased 3.2 and 3 % respectively. Meanwhile, the increasing trend of total expenditure and its main components is slowed down, especially the drug expense and medical consumable expense for inpatients after the Zero Mark-up Drug policy (coefficient = -18.76, p < 0.01; coefficient = -13.41, p < 0.01, respectively). However, the growth of inspection expense for outpatients continues to increase, while the healthcare expenditure for inpatients experiences an instant increase after the Zero Mark-up Medical Consumables policy. In terms of the net effect, most of healthcare expenditure in both outpatient and inpatient experienced a negative net growth from 2015 to 2019. CONCLUSIONS: The medical pricing reform is a valuable attempt in controlling the unreasonable increase of medical expenses. In the meantime, the unexpected increase in inspection expenditure and insufficient compensation from medical service adjustment should draw the attention of the policymakers.

Efficiency and productivity of county-level traditional Chinese medicine hospitals in Hubei Province, China: A retrospective study based on 17 years of panel data.

BACKGROUND: The county-level traditional Chinese medicine hospitals have significantly expanded in recent decades. This study aims to assess the changes in the efficiency and productivity of the county-level traditional Chinese medicine hospitals and explore the possible causes of such changes. METHODS: Sixty one hospitals spanning from 2001 to 2017 were selected as samples in this study. And a slacks-based measure of super-efficiency in Data Envelopment Analysis and Malmquist index were used to respectively measure the changes in the efficiency and productivity. RESULTS: The scale of sample hospitals in Hubei continuously expanded from 2001 to 2017. The mean values of technical efficiency, pure technical efficiency and scale efficiency in 2017 were 0.686, 0.74 and 0.933, respectively. The technical efficiency changes in 2017 was 1.97 times that of 2001, and the technological changes in 2017 was 1.45 times that of 2001. CONCLUSIONS: The medical environment and resources have been greatly improved due to the expansion of the sample hospitals, but the technical efficiency value indicates that the operation efficiency of sample hospitals still needs to be significantly improved. Decision-makers are advised to attach importance to the efficiency of operation management and consider the impact of multiple factors on the change in productivity.

Influenza Vaccination Coverage of Health Care Personnel in Los Angeles County Hospitals, 2016-2017.

The objective of the Los Angeles County, California (LAC), health care personnel (HCP) influenza vaccination improvement intervention was to increase HCP influenza vaccination coverage during the 2016-2017 influenza season via targeted outreach to LAC acute care hospitals. We selected 13 facilities for intervention and received tailored recommendations from a menu of evidence-based practices. Following the season, each hospital in the intervention group experienced a significant increase in vaccination coverage, which increased the LAC countywide average for all hospitals by 5%, from 74% to 79%.

Comparison of inpatient distribution amongst different medical alliances in a county: a longitudinal study on a healthcare reform in rural China.

BACKGROUND: China has launched the medical alliances (MAs) reform to drive the development of primary medical institutions and decrease health inequality in rural areas. Three different types of MAs were built to promote township hospitals in Y County. This study aims to evaluate the actual effect of China's MAs reform in rural areas on inpatient distribution especially amongst different types of MAs. METHODS: We obtain 2008-2015 claims data from the New Cooperative Medical Scheme (NCMS) in Y County, Hubei Province of China. We consider January 2008-December 2010 as the pre-reform period and January 2011-December 2015 as the post-reform period. We use independent sample t-test and single-group interrupted time series analysis (ITSA) to compare the number of inpatients per month in the three MAs, including three county and 10 township hospitals before and after the reform. We use paired t-test and multiple-group ITSA between seven township hospitals within MAs and seven township hospitals outside MAs. RESULTS: The MAs reform in Y County increased the number of inpatients in county and township hospitals within MAs. After the reform, the number of inpatients per month in county hospitals had an upward trend, with a slope of 31.01 person/month (P < 0.000). Approximately 19.99 new inpatients were admitted to township hospitals monthly after the reform (P < 0.000). Furthermore, township hospitals within MAs had a substantial increase in the number of inpatients (10.45 new inpatients monthly) compared with those outside MAs. CONCLUSION: The MAs reform in Y County significantly improved the capability of medical institutions within MAs. After the reform, township hospitals within MAs had greater development advantages than those outside MAs. However, it also caused further imbalance in the county region, which contained the new health inequality risk.