Factors influencing the hospitalization cost for stroke patients in J district, Shanghai. / 上海市JåŒºè„‘å’ä¸­æ‚£è€ ä½é™¢è´¹ç”¨çš„å½±å“å› ç´ .

OBJECTIVES: Stroke is the main cause of death in Chinese residents, bringing a heavy economic burden to patients. This study aims to explore the characteristics and the factors influencing the hospitalization cost for stroke, and to provide scientific evidence for reducing the economic burden on stroke patients. METHODS: The data were mainly obtained from the Shanghai Statistics Center for Health. Using the coding system of International Classification of Diseases (ICD)-10, we retrospectively collected the stroke-related first hospitalization records of stroke patients in J district, Shanghai during January 1, 2016 to December 31, 2019 whose main diagnostic disease codes were I61-I63. After cleaning and arranging the data, we counted the first hospitalization cost and length of hospital stay (LOS) of the patients. Univariate analysis was performed using non-parametric tests, and the factors influencing stroke hospitalization cost were further analyzed by multiple linear regression fitting path model. RESULTS: A total of 3 901 stroke patients were included. Ischemic and hemorrhagic stroke patients accounted for 92.59% and 7.41%, respectively, of which the mean hospitalization cost per patient were 12 397.35 yuan and 28 814.72 yuan, respectively, and the mean LOS per patient were 13 days and 19 days, respectively. Hospitalization cost for ischemic stroke mainly consisted of medicine fees, diagnosis fees, and service fees, accounting for 44.70%, 29.92%, and 15.42%, respectively, and hospitalization cost for hemorrhagic stroke mainly consisted of medicine fees, diagnosis fees, consumables fees, and service fees, accounting for 38.76%, 18.33%, 17.59%, and 15.38%, respectively. From 2016 to 2019, the proportion of medicine fees for ischemic stroke was decreased by 19.38 percentage points, and the diagnosis fees and service fees were increased by 8.43 percentage points and 9.04 percentage points, respectively; the proportions of medicine fees and consumables fees for hemorrhagic stroke were decreased by 7.54 percentage points and 13.43 percentage points, respectively, and the proportions of diagnostic fees and service fees were increased by 6.87 percentage points and 10.15 percentage points, respectively. Path analysis results showed that the main direct factors influencing hospitalization cost were the LOS, hospital level, operation, and year, and the main indirect factors were age and hospital level (all P<0.05). CONCLUSIONS: The cost burden of stroke patients in Shanghai is relatively heavy, and we should continue to promote the medical reform policy and consolidate the achievements of medical reform. Hospitals should strengthen clinical pathway management and patient health education to improve medical efficiency and reduce invalid hospitalization days. Government departments should continue to improve the medical insurance system, enhance the supervision to medical insurance, and promote health equity.

Effect of stroke screening survey on intravenous thrombolysis and long-term outcomes in acute ischemic stroke patients: the real-world evidence from Shanghai, China.

BACKGROUND: The stroke screening survey (SSS) is an essential strategy for stroke prevention. However, previous studies rarely discussed the effect of SSS on the acute phase treatment procedure for acute ischemic stroke (AIS) and the long-term prognosis outcomes. This study aims to investigate the effect of SSS on intravenous thrombolysis and long-term outcomes in AIS patients. METHODS: The stroke patients included were collected from Jiading Residences Community Health Records and Shanghai Stroke Service System database, from January 2017 to December 2019. Patients were divided into two groups, according to whether they have been screened before the event (onset and death). Demographic characteristics and treatment information of patients in the two groups were compared by the Mann-Whitney test and Chi-square test. The demographic differences between groups were adjusted with Propensity Score Matching (PSM) to evaluate the effect of SSS on door-to-needle time (DNT). The Kaplan-Meier survival curve with a log-rank test and multiple Cox regression model were used to evaluate the effect of SSS on long-term lifetime. RESULTS: A total of 1,236 patients with AIS were collected, including 468 (37.86%) female, 126 (10.19%) patients with intravenous thrombolysis, 241 (23.30%) patients died from all-cause mortality by January 8, 2020. A total of 124 (10.03%) patients have been screened before AIS onset, and 261 (21.17%) patients had undergone SSS after AIS onset. The baseline information indicated that patients with previous screening were older than the patients without at the time of onset [75 (70, 83) vs. 73 (65, 82), P=0.017], as well as more likely to have a history of hypertension (90.32% vs. 78.51%, P=0.002) and diabetes (50.00% vs. 25.81%, P<0.001). PSM results showed that patients with previous screening were associated with less severe onset situation [3 (1, 9) vs. 3 (1, 5), P=0.001] and shorter DNT [30 (24, 49) vs. 44 (31.5, 49), P=0.037] when compared to patients without. Additionally, patients with SSS had a lower hazard ratio of 0.567 (95% CI: 0.380-0.847, P=0.006) on all-cause mortality. CONCLUSIONS: For AIS patients, the SSS is associated with less severe onset situation, shorter DNT, and longer long-term lifetime.

Improved treatment capacity and quality of care: the effectiveness of the stroke prevention and treatment system in Shanghai, China from 2012-2017.

Because of the high mortality, recurrence, and rate of disability of stroke, a stroke prevention and treatment system was instituted in Shanghai in 2012; this system includes 11 municipal hospitals, 25 district hospitals, and 240 community health centers. Community health centers focus on early screening in the community, health management of high-risk individuals, and secondary prevention and rehabilitation of stroke patients. Residents' health profiles are utilized by community health centers to proactively identify the population at higher risk. District hospitals are responsible for screening for vascular lesions in high-risk individuals, including carotid artery and intracranial artery screening, and standardized treatment of stroke patients. Municipal hospitals concentrate on complex and emergency care for acute onset stroke. The system specifies care for all stages of stroke management. The development of the system has improved the capacity of and quality of care for stroke patients. The rate at which patients undergo intravenous thrombolysis and the percentage of patients with a door-to-needle time of less than 60 minutes have increased significantly. However, the primary and secondary prevention of stroke is insufficient, the stroke rehabilitation system is incomplete, and the quality of care in primary healthcare facilities is limited. An evaluation system and payment mechanisms are needed to incentivize healthcare personnel to fulfill their responsibilities and to ensure the system's operation.

An Exploratory Study of the Use of the Electronic Health Records of Hypertensive Patients to Support the Primary Prevention of Stroke in Shanghai.

BACKGROUND: The value of identifying and targeting population demographics at high risk of stroke based on patient-reported outcomes (PROs) with electronic health records (EHRs) in Shanghai is largely undiscovered. AIM: To test the hypothesis that establishing an evidence-based support system composed of PROs integrated with EHRs could be effective at identifying individuals at high risk of suffering from stroke. METHODS: The patients included in this study joined the hypertensive patient management system from 2014 to 2018. We merged the Hypertension Patients Management Database and the Diabetes Mellitus Patients Management Database of Shanghai Jiading district, then kept the hypertension patients with or without diabetes. We subsequently performed a screen analysis utilizing EHRs to target the population with any risk factor for stroke, namely, hypertension, diabetes mellitus, obesity, smoking and physical inactivity. We also calculated the distribution of each risk factor and the combinations of risk factors. RESULTS: In the Jiading District of Shanghai, 46,580 hypertensive patients with complete baseline information joined the hypertensive patient management system from 2014 to 2018. The majority of the patients were aged above 60 years old. Physical inactivity (83.24%), smoking (24.07%), diabetes (16.87%), and obesity (12.23%) were highly prevalent in hypertensive participants. Approximately 4377 patients were diagnosed with hypertension exclusively, accounting for 9.70% of the total number of patients in this study. Meanwhile, approximately 52.47% of the patients were diagnosed with two concurrent risk factors, and 38.13% of the patients had hypertension, meaning that 17,762 patients could be labeled as the high-risk population for stroke according to the criteria established by the National Stroke Screening Survey. CONCLUSION: Our exploratory findings demonstrate the feasibility of pinpointing and targeting populations at high risk of stroke using the EHRs of hypertensive patients.

[Influential factors for hospitalization costs regarding the final phase of malignant tumor patients in Shanghai].

OBJECTIVE: To explore the influential factors for hospitalization costs regarding the final phase of malignant tumor patients in Shanghai, and to explore the relevant policy for reasonable control of hospitalization costs.
 Methods: A total of 10 065 patients with malignant tumors were enrolled in this study. The multiple linear regression analysis was used to seek the determinants for hospitalization cost of malignant tumor patients during the final phase.
 Results: The median length of hospital stay was 43 days for the patients, with an average age of (70.73±12.87) years. Among them 61.66% of hospitalized patients were male and the median hospitalization cost of malignancy was 55 447.84 yuan. Hospitalization cost showed the linear regression relationship with type of health care, hospital level, hospital types, tumor types, length of hospital stay, surgery, age, gender, and time from hospital admission to death.
 Conclusion: Proximity to death in malignant tumor patients is an important factor for the hospitalization cost. Medical resources should be allocated rationally, and the comprehensive measures should be taken to control the cost reasonably.

Disease burden of COPD in China: a systematic review.

Chronic obstructive pulmonary disease (COPD) is one of the main contributors to the global burden of disease. The aim of this systematic review was to quantify the disease burden of COPD in China and to determine the risk factors of the disease. The number of studies included in the review was 47 with an average quality assessment score of 7.70 out of 10. Reported COPD prevalence varied between 1.20% and 8.87% in different provinces/cities across China. The prevalence rate of COPD was higher among men (7.76%) than women (4.07%). The disease was more prevalent in rural areas (7.62%) than in urban areas (6.09%). The diagnostic rate of COPD patients in China varied from 23.61% to 30.00%. The percentage of COPD patients receiving outpatient treatment was around 50%, while the admission rate ranged between 8.78% and 35.60%. Tobacco exposure and biomass fuel/solid fuel usage were documented as two important risk factors of COPD. COPD ranked among the top three leading causes of death in China. The direct medical cost of COPD ranged from 72 to 3,565 USD per capita per year, accounting for 33.33% to 118.09% of local average annual income. The most commonly used scales for the assessment of quality of life (QoL) included Saint George Respiratory Questionnaire, Airways Questionnaire 20, SF-36, and their revised versions. The status of QoL was worse among COPD patients than in non-COPD patients, and COPD patients were at higher risks of depression. The COPD burden in China was high in terms of economic burden and QoL. In view of the high smoking rate and considerable concerns related to air pollution and smog in China, countermeasures need to be taken to improve disease prevention and management to reduce disease burdens raised by COPD.

Exploring the determinants that influence end-of-life hospital costs of the elderly in Shanghai, China.

The aim of this study was to use data from the Information Center of the Shanghai Municipal Commission of Health and Family Planning (SMCHFP) to determine the factors affecting end-of-life hospital costs of patients. A total number of 43,806 decedents who died in medical facilities in 2015 were examined. These individuals, accounted for 34.85% of all deaths in 2015 in Shanghai. Descriptive analysis and multiple linear regression analysis were performed using STATA 13.0. Results indicated that 88.94% of the decedents who died in medical facilities were over age 60. Males accounted for 55.57% of decedents, and the insured were mostly covered by Urban Employee Basic Medical Insurance (UEBMI) (81.93%). Cancer and circulatory disease were the main causes of death, causing 34.53% and 26.19% of deaths. Hospital costs were higher for males (male vs. female: 9,013 USD vs. 7,844 USD), individuals insured by UEBMI (8,784 USD), and individuals with cancer (10,156USD). Twenty-nine-point-zero-three percent of admissions occurred in the month before death and accounted for 37.82% of costs. Multiple linear regression analysis indicated that hospital costs were correlated with gender, cause of death (cancer, circulatory disease, or respiratory disease), time-to-death, insurance schemes, level of medical facilities, and length of stay (LOS) (p < 0.05 for all). After controlling for other factors, age was not a significant factor (p > 0.05). A proximity-to-death (PTD) phenomenon was evident in Shanghai. This study suggested that the PTD should be considered when predicting medical cost. Primary medical care should be enhanced and gaps in insurance coverage should be reduced to improve the efficiency and equity of medical funding. More attention should be paid to the population with a heavier disease burden.

Tracking hospital costs in the last year of life - The Shanghai experience.

One aim of the current study was to track end-of-life care using individual data in Shanghai, China to profile hospital costs for decedents and those for the entire population. A second aim of this study was to clarify the effect of proximity to death. Data from the Information Center of the Shanghai Municipal Commission of Health and Family Planning (SMCHFP) were examined. For decedents who died in medical facilities in 2015, inpatient care was tracked for 1 year before death. A total of 43,765 decedents were included in the study, accounting for 35% of total deaths in 2015 in Shanghai. Hospital costs were higher for people who died before the age of 45 (14,228.62 USD) than for those aged 90 or older (8,696.34 USD). The ratio of costs for decedents to the entire population declined significantly with age. Women received less care than men in the last year of life (t = -15.1244, p < 0.05). Average tertiary hospital costs per decedent declined significantly with age, whereas average secondary hospital costs increased slightly with age. Among the top 14 causes of death classified using the ICD-10, rectal cancer incurred the greatest costs (13,973 USD per decedent). Over 43% of hospital costs were incurred during the month before death. Declining costs in the last year of life with age as well as with distance to death demonstrate the existence of a proximity to death phenomenon in health care expenses. Disease-specific studies should be conducted and attention should be paid to gender equity when examining end-of-life medical costs in the future.

The impact of population aging on medical expenses: A big data study based on the life table.

This study shed light on the amount and structure of utilization and medical expenses on Shanghai permanent residents based on big data, simulated lifetime medical expenses through combining of expenses data and life table model, and explored the dynamic pattern of aging on medical expenditures. 5 years were taken as the class interval, the study collected and did the descriptive analysis on the medical services utilization and medical expenses information for all ages of Shanghai permanent residents in 2015, simulated lifetime medical expenses by using current life table and cross-section expenditure data. The results showed that in 2015, outpatient and emergency visits per capita in the elderly group (aged 60 and over) was 4.1 and 4.5 times higher than the childhood group (aged 1-14), and the youth and adult group (aged 15-59); hospitalization per capita in the elderly group was 3.0 and 3.5 times higher than the childhood group, and the youth and adult group. People survived in the 60-64 years group, their expected whole medical expenses (105,447 purchasing power parity Dollar) in the rest of their lives accounted for 75.6% of their lifetime. A similar study in Michigan, US showed that the expenses of the population aged 65 and over accounted for 1/2 of lifetime medical expenses, which is much lower than Shanghai. The medical expenses of the advanced elderly group (aged 80 and over) accounted for 38.8% of their lifetime expenses, including 38.2% in outpatient and emergency, and 39.5% in hospitalization, which was slightly higher than outpatient and emergency. There is room to economize in medical expenditures of the elderly people in Shanghai, especially controlling hospitalization expenses is the key to saving medical expenses of elderly people aged over 80 and over.