Intended and unintended impacts of the comprehensive reform of urban public hospitals: A mixed-method study in Hangzhou, China.

Objectives: Public hospital reform is a key area in the Chinese healthcare system reform with the aim of controlling excessive growth of medical expenditures. This study aims to evaluate the impacts of two rounds of urban public hospital reforms respectively starting in 2018 and 2019. Method: A mixed-method method was conducted in Hangzhou. In the quantitative phase, monthly data covering 7 provincial, 12 municipal, and 35 district hospitals from March 2017 to June 2020 was analyzed using a panel-interrupted time-series. Thematic content analysis was conducted using qualitative data collected from 32 in-depth interviews. Results: Quantitative data showed a considerable reduction in the proportion of drug revenue (provincial hospitals: -4.937%; municipal hospitals: -2.765%; district hospitals: -2.189%) and an increase in the proportion of consumable (provincial hospitals: ß 2 = 2.025; municipal hospitals: ß 3 = 0.206) and examinations (provincial hospitals: ß 2 = 1.354, ß 3=0.159; municipal hospitals: ß 2 = 1.179) revenue after the first reform. In post-reform 2, The respective instant decrease and increase in the proportion of consumable (provincial hospitals: -2.395%; municipal hospitals: -0.898%) and medical services (provincial hospitals: 2.115%; municipal hospitals: -2.604%) revenue were observed. Additionally, quantitative and qualitative data indicated inpatient expenditures dropped considerably after the reform. However, insufficient compensation for medical services and increased financial pressure on hospitals were repeatedly mentioned as unintended consequences in qualitative interviews. Conclusions: Overall, the urban public hospital reforms in China created positive effects in adjusting hospital revenue structure and constraining soaring medical expenditures. Unintended consequences remind policymakers to establish rational and dynamic compensation mechanisms for public hospitals.

Impacts of a New Episode-Based Payment Scheme on Volume, Expenditures, and Efficiency in Public Hospitals: A Quasi-Experimental Interrupted Time-Series Study in Jinhua, China.

Purpose: Based on the diagnosis-related groups payment, China developed an innovative episode-based payment scheme, called "payment method by disease types with point counting", to control health expenditures inflation. This study aimed to investigate the impacts of this new payment method on volume, expenditures, and efficiency in Chinese public hospitals. Methods: The study sample consisted of 7 tertiary hospitals and 14 secondary hospitals in Jinhua (intervention group) and 4 tertiary hospitals and 14 secondary hospitals in Taizhou (control group). Monthly data points were collected for each sampled hospital from June 2016 to June 2019 using a self-administered questionnaire with impact evaluation indicators. Controlled interrupted time-series analysis was employed to estimate the effect of the new payment method. Results: The significant slowing trends in inpatient expenditures per visit (tertiary hospitals: ß7=-123.16, p=0.042; secondary hospitals: ß7=-89.24, p=0.021) and out-of-pocket payments (tertiary hospitals: ß7=-4.18, p=0.027; secondary hospitals: ß7=-4.87, p=0.019) were observed after policy intervention. However, outpatient expenditures per visit in tertiary (ß7=1.67, p=0.018) and secondary hospitals (ß7=1.24, p=0.003) rose faster with the new payment method. Additionally, payment reform also caused an increase in the number of inpatient visits (ß7=100.01, p=0.038) and reduced the length of stay (ß7=-0.10, p=0.036) in tertiary hospitals. Conclusion: The introduction of payment method by disease types with point counting causes the cost containment for inpatient care, whereas the increase in outpatient expenditures. The findings suggest this new payment scheme has the potential for rollout in other areas, but the cost-shifting from the inpatient to outpatient setting should be prevented.

How secondhand smoke exposure affects tobacco use and smoking susceptibility of adolescents: Sex and school differences.

INTRODUCTION: Secondhand smoke (SHS) exposure affects tobacco related health behaviors during adolescence and persists into adulthood. This study aimed to investigate the influence of SHS exposure on tobacco use among adolescents stratified by school and gender, and provide recommendations for controlling tobacco use in youth. METHODS: Through stratified random cluster sampling, 12278 selected students (aged 13-18 years) from schools in China were administered questionnaires. Multiple logistic regression was used to analyze whether SHS exposure would increase the smoking risk and susceptibility of adolescents. RESULTS: The prevalence of SHS exposure among the participating students was 74.8%. Adolescents exposed to SHS were at higher odds of being susceptible and currently smoking. Students with SHS exposure at both home and public places accounted for 36.6%, greatly increasing the current smoking risk and smoking susceptibility. Home SHS exposure had greater impact on the current tobacco use of boys (OR=2.13; 95% CI: 1.50-3.03) and junior school students (OR=4.67; 95% CI: 2.41-9.06). Exposure from public places increased the risk of current smoking in boys (OR=4.20; 95% CI: 2.31-7.65) and smoking susceptibility of vocational school students (OR=1.51; 95% CI: 1.07-2.15). Students with highlevel exposure to SHS had 2.25 times higher odds of e-cigarette use. CONCLUSIONS: The prevalence of SHS exposure is still high among adolescents in China and is associated with increased risk for tobacco use regardless of gender and school level. Effective smoke-free strategies should be developed and strictly implemented. Boys and junior school students constitute vulnerable populations exposed to SHS at home.