Prevalence and associated factors of inappropriate hospital admissions and days of children in a secondary hospital in Shanghai, China.

BACKGROUND: Although the appropriateness of hospital utilization of adults and the elderly in China was audited by several studies, the appropriateness of hospital use by children in Shanghai remains to be determined. This study aims to assess the level of inappropriate hospital admissions and hospital days, to detect factors associated with inappropriateness, and to elucidate reasons for inappropriateness. METHODS: A retrospective review of the records of 291 admissions and 1449 hospital days of children inpatients from a secondary hospital in Shanghai was performed by two reviewers using the Chinese version Pediatric Appropriateness Evaluation Protocol (C-PAEP). Demographics, socio-economic characteristics, and other admission- or hospital stay-related information were collected and analyzed to determine factors associated with inappropriateness utilizing multivariate regression models. RESULTS: 38.5% (n = 112) of admissions and 9.5% (n = 137) of hospital days were categorized as inappropriate, according to the C-PAEP. Children who were non-Shanghai residents (p < 0.001), admitted through the emergency sector (p = 0.030), and/or received services in a surgical ward (p < 0.001) had a higher risk of being admitted inappropriately. Payment method (p = 0.006), service type (p < 0.001), comorbidity (p = 0.016), length of stay (p = 0.007), and appropriateness of admission (p < 0.001) were found to be associated with prevalence of inappropriate hospital days. Approximately three-fourths of the inappropriate admissions were premature admissions (75.9%, n = 85). The most frequent reasons for inappropriate hospital days were awaiting test results (34.3%, n = 47), awaiting surgery (19.7%, n = 27), awaiting test execution (10.9%, n = 15), and family unprepared for home care (10.9%, n = 15). CONCLUSIONS: Although the extent of inappropriate hospital days was moderate compared with that found by previous investigations, the prevalence of inappropriateness of admission was considerable. To enhance the appropriateness of hospital care for children, interventions could be implemented according to the associated factors and identified causes.

Well-being losses by providing informal care to elderly people: Evidence from 310 caregivers in Shanghai, China.

A series of policies aimed toward rational resource allocation of long-term care have being actively discussed since the launch of the social long-term care insurance in Shanghai, and it is important to take a societal perspective for informed decision-making. This study aims to explore factors that are associated with well-being of informal caregivers in Shanghai, and to provide empirical evidence of application of an established well-being valuation method to monetise informal caregivers' well-being losses in a developing country. 310 informal caregivers of applicants for social long-term care insurance in Shanghai were interviewed. Univariate and multivariate analyses were conducted to explore the associated factors with life satisfaction of the caregivers. The monetary values of an additional hour of caregiving with and without specification of care tasks were estimated by the well-being valuation method. Life satisfaction was consistently associated with monthly income, health status, and caring hours of the caregivers. The money needed to compensate one additional hour of caring per week was 12.58 CNY (0.3% of the monthly income), and 96.95 CNY (2.0% of the monthly income) for activities of daily living (ADL) tasks. Income, health status, and caregiving are significantly associated with well-being of informal caregivers. Caregivers in relatively poor health condition and/or involved in more ADL tasks should be particularly considered in supporting policies in Shanghai.

Retrospective analysis of medical malpractice claims in tertiary hospitals of China: the view from patient safety.

OBJECTIVES: The study analysed medical malpractice claims to assess patient safety in hospitals. The information derived from malpractice claims reflects potential risks and could help lead to reducing medical errors and improving patient safety. DESIGN, SETTING: We analysed 4380 medical malpractice claims from 351 grade-A tertiary hospitals in China for 2008-2017. We examined the characteristics of medical errors and patient safety, including the types of medical errors, proportionate liabilities and payments for medical malpractice in different clinical specialties. MAIN OUTCOME MEASURES: We assessed claim characteristics, payment amounts and liability. RESULTS: Our data analysis demonstrated that 72.5% of the claims involved medical errors, with average payments of US$31 430. The hospital's errors in medical malpractice resulted in 41.4% average liability in patient injury payments. Most medical malpractice cases occurred in Shanghai (817 claims, 18.7%) and Beijing (468 claims, 10.7%). The highest risks for medical error and malpractice claims were related to orthopaedics (11.3% of all claims, 72.8% with medical errors) and obstetrics and gynaecology (10.0% of all claims, 76.0% with medical errors). The highest rates related to proportionate liabilities were observed in otolaryngology (51.9%) and endocrinology (47.7%). Respiratory medicine had the highest proportion of claims in death rates (77.3%). Medical technology errors accounted for 91.8% of the claims and medical ethics errors for 5.8%. The highest average payment was found in cardiovascular surgery (US$41 733) and the lowest in stomatology (US$8822). CONCLUSIONS: A previous study found that grade-A tertiary hospitals in China have similar medical error rates to general Chinese hospitals. 36Different specialties had different risk characteristics regarding medical errors, payments and proportionate liabilities. Orthopaedics had the highest number of malpractices claims and higher proportionate liability but lower death rates.

Willingness-to-pay and willingness-to-accept of informal caregivers of dependent elderly people in Shanghai, China.

BACKGROUND: In order to make optimal long-term care-related decisions, it is important to take a societal perspective. Shanghai is one of the pilot cities of social long-term care insurance in China. However, little knowledge exists about the economic value of the informal care provided to dependent elderly people in China. This paper aims to evaluate the economic value of informal caregiving in Shanghai using the contingent valuation method by their least-preferred care tasks, and identify the associated factors of willingness-to-pay (WTP) and willingness-to-accept (WTA) of the informal caregivers. METHODS: This study employed the contingent valuation method to elicit 371 informal caregivers' WTP and WTA for 1 hour of reduction or increase of least-preferred caring tasks in Shanghai. Univariate and multivariate analyses were conducted to explore the associated factors with the WTP and WTA values. RESULTS: The average WTP and WTA were 25.31 CNY and 38.66 CNY, respectively. The associated factors with WTP include caregiver's income and caregiver's relationship to the recipient. Care recipient's age, income, least-preferred task by the caregiver, and subscales of Caregiver Reaction Assessment were found to be associated with WTA. The non-responsiveness rates were 26.1 and 33.2% for WTP and WTA questions, respectively. CONCLUSIONS: The findings of the current study demonstrated that decision-makers and researchers should take the economic valuation results of informal care into account to make more informed and effective long-term care-related policies and analyses.

Impacts of Hospital Payment Based on Diagnosis Related Groups (DRGs) with Global Budget on Resource Use and Quality of Care: A Case Study in China.

BACKGROUND: China has implemented numerous pilots to shift its hospital payment mechanism from the traditional retrospective cost-based system to prospective diagnosis-related-group (DRG) -based system. This study investigated the impact of the DRG payment reform with global budget in Zhongshan, China. METHODS: A total of 2895 patients diagnosed with acute myocardial infarction (AMI) were selected from local two largest tertiary hospitals, among which 727 were discharged prior to the payment reform and 2168 afterwards. Difference-in-difference (DID) regression models were used to evaluate the policy effects on patients' percutaneous coronary intervention (PCI) use, hospital expenditures, in-hospital mortality, and readmission rates within 30 days after discharge. RESULTS: Patients' PCI use and hospital expenditures increased quickly after the payment reform. With patients with no local insurance scheme as reference, PCI use for local insured patients decreased significantly by 4.55 percent (95 percent confidence interval [CI]: 0.23, 0.72), meanwhile the total hospital expenses decreased significantly by US$986.10 (b=-0.15, P=0.0037) after reform. No changes were observed with patients' hospital mortality and readmission rates in our study. CONCLUSION: The innovative DRG-based payment reform in Zhongshan suggested a positive effect on AMI patient's cost containment but negative effect on encouraging resource use. It had no impacts on patients' care quality. Cost shifting consequence from the insured to the uninsured was observed. More evidence of the impacts of the DRG-based payment in China's health scenario is needed before it is generalized nationwide.

Inappropriate admissions of the cardiology and orthopedics departments of a tertiary hospital in Shanghai, China.

OBJECTIVES: Admission rates have increased in China, despite the fact that accessibility to primary care is improving. Hospital care could be cost-inefficient, and little is currently known about the appropriateness of admissions to tertiary hospitals in China. This study aims to measure the extent of inappropriate admissions in the cardiology and orthopedics departments of a tertiary hospital in Shanghai, to explore the factors associated with inappropriateness for each department, and to identify the causes of inappropriate admissions. METHODS: The records of inpatients discharged on randomly sampled two days each week during March 2013 to February 2014 from the two departments were extracted. Two reviewers were recruited to assess the records according to the Chinese version of the Appropriateness Evaluation Protocol (C-AEP). Demographic, socio-economic, and other admissions-related variables were collected. Logistic regression analysis was adopted to determine the associated factors of inappropriateness. RESULTS: 35.0% (N = 120) of the 343 admissions and 38.7% (N = 179) of the 463 admissions of the cardiology and orthopedics departments were not justified by the C-AEP, respectively. Age (OR = 0.717), self-pay (OR = 3.752), admission via outpatient sector (OR = 5.332), and readmission (OR = 2.501) were identified as factors affecting the appropriateness of admissions in the cardiology department. Age (OR = 0.930), self-pay (OR = 2.597), admission during 12:00-17:59 (OR = 3.211), and admission via outpatient sector (OR = 7.060) were determined to be associated with appropriateness of admission in the orthopedics department. The main reason for inappropriateness was premature admission for both departments. CONCLUSIONS: The magnitude of inappropriate admissions was considerable in the departments. To improve appropriateness, the results suggest that further interventions should be focused on both external and internal factors.

Extent and cost of inappropriate use of tumour markers in patients with pulmonary disease: a multicentre retrospective study in Shanghai, China.

OBJECTIVES: The currently implemented healthcare reform in China requires substantial capital investment. Although overtreatment results in serious waste, inappropriate laboratory use is widespread, and overuse of tumour markers (TMs) has attracted increasing attention. DESIGN: Retrospective study. SETTING: The respiratory, thoracic surgery and oncology departments of three hospitals in Shanghai from 2014 to 2015. PARTICIPANTS: Patients with chronic obstructive pulmonary disease (COPD) and primary bronchogenic lung cancer (PLC). Based on clinical guidelines and physician experience, the criteria of suitability of TM examinations were determined, and the number, cost and proportion of inappropriate TM requests were analysed. RESULTS: The area under the receiver operating characteristic curve for carcinoembryonic antigen+cytokeratin fragment 21-1+squamous cell carcinoma antigen+neuron-specific enolase in patients with COPD and PLC was 0.813, in accordance with the cost-effectiveness principle, indicating good clinical and health economics values. In the 2706 patients, 12 496-16 956 (58.27%-79.06%) of TM requests were inappropriate. Furthermore, the involved expense was 650 200-1 014 156 yuan, accounting for 7.69%-12.00% of examination expenses and 1.35%-2.11% of hospitalisation costs. CONCLUSIONS: We found that the inappropriate use of TMs was widespread for patients with pulmonary disease. Clinicians should use TMs strictly according to the guidelines to effectively manage laboratory resources and control costs.

Inappropriate hospital days of a tertiary hospital in Shanghai, China.

OBJECTIVE: This study aims to evaluate the prevalence of inappropriate hospital stays in a tertiary hospital in Shanghai, identify the causes for the inappropriateness and analyze the predictors. DESIGN: A retrospective review of medical records. SETTING: The cardiology and the orthopedics departments of a tertiary hospital in Shanghai, China. PARTICIPANTS: About 806 patients discharged from the cardiology or the orthopedics department of a tertiary hospital from March 2013 to February 2014. INTERVENTIONS: Two reviewers audited 8396 hospital days of the cardiology department (n = 3606) and the orthopedics department (n = 4790) by adopting the Chinese Version of the Appropriateness Evaluation Protocol. Univariate and multivariate analysis were adopted to identify the predictors of higher levels of inappropriateness produced by internal causes. MAIN OUTCOME MEASURE: The prevalence of inappropriate hospital days. RESULTS: It was found that 910 (25.2%) and 1940 (40.5%) hospital days were judged to be inappropriate in the cardiology and the orthopedics departments, respectively; and 753 (20.9%) and 1585 (33.1%) of these inappropriate hospital days were due to internal reasons, respectively. Awaiting tests, surgery or discharge were determined to constitute the main causes of inappropriateness for both departments. The predictors of higher levels of inappropriateness in the cardiology department were younger age, self-pay, outpatient admission and inappropriate admission. Self-pay, surgical and/or first-time admission patients exhibited the highest levels of inappropriateness in the orthopedics department. CONCLUSIONS: The rates of inappropriateness in the involved departments were relatively high. Further interventions should be designed and implemented, accordingly.

Reliability and Validity of the Chinese Version Appropriateness Evaluation Protocol.

OBJECTIVE: To adapt the Appropriateness Evaluation Protocol (AEP) to the specific settings of health care in China and to validate the Chinese version AEP (C-AEP). METHODS: Forward and backward translations were carried out to the original criteria. Twenty experts participated in the consultancy to form a preliminary version of the C-AEP. To ensure applicability, tests of reliability and validity were performed on 350 admissions and 3,226 hospital days of acute myocardial infraction patients and total hip replacement patients in two tertiary hospitals by two C-AEP reviewers and two physician reviewers. Overall agreement, specific agreement, and Cohen's Kappa were calculated to compare the concordance of decisions between pairs of reviewers to test inter-rater reliability and convergent validity. The use of "overrides" and opinions of experts were recorded as measurements of content validity. Face validity was tested through collecting perspectives of nonprofessionals. Sensitivity, specificity, and predictive values were also reported. RESULTS: There are 14 admission and 24 days of care criteria in the initial version of C-AEP. Kappa coefficients indicate substantial agreement between reviewers: with regard to inter-rater reliability, Kappa (κ) coefficients are 0.746 (95% confidence interval [CI] 0.644-0.834) and 0.743 (95% CI 0.698-0.767) of admission and hospital days, respectively; for convergent validity, the κ statistics are 0.678 (95% CI 0.567-0.778) and 0.691 (95% CI 0.644-0.717), respectively. Overrides account for less than 2% of all judgments. Content validity and face validity were confirmed by experts and nonprofessionals, respectively. According to the C-AEP reviewers, 18.3% of admissions and 28.5% of inpatient days were deemed inappropriate. CONCLUSIONS: The C-AEP is a reliable and valid screening tool in China's tertiary hospitals. The prevalence of inappropriateness is substantial in our research. To reduce inappropriate utilization, further investigation is needed to elucidate the reasons and risk factors for this inappropriateness.

Impacts of health insurance benefit design on percutaneous coronary intervention use and inpatient costs among patients with acute myocardial infarction in Shanghai, China.

BACKGROUND: Currently, the most popular hospital payment method in China is fee-for-service (FFS) with a global budget cap. As of December 2009, a policy change means that heart stents are covered by public health insurance, whereas previously they were not. This policy change provides us an opportunity to study how a change in insurance benefit affected the quantity and quality of hospital services. The new policy introduced incentives for both patients and providers: it encourages patient demand for percutaneous coronary intervention (PCI) services and stent use (moral hazard effect), and discourages hospital supply due to the financial pressures of the global cap (provider gaming effect). If the provider's gaming effect dominates the moral hazard effect, actual utilisation and costs might go down, and vice versa. Our hypothesis is that patients in the higher reimbursement groups will have fewer PCIs and lower inpatient costs. OBJECTIVE: We aimed to examine the impact of health insurance benefit design on PCI and stent use, and on inpatient costs and out-of-pocket expenses for patients with acute myocardial infarction (AMI) in Shanghai. METHODS: We included 720 patients with AMI (467 before the benefit change and 253 after) from a large teaching tertiary hospital in Shanghai. Data were collected via review of hospital medical charts, and from the hospital billing database. Patient information collected included demographic characteristics, medical history and procedure information. All patients were categorised into four groups according to their actual reimbursement ratio: high (90-100 %), moderate (80-90 %), low (0-80 %) and none (self-paid patients). Multiple regression and difference-in-difference (DID) models were used to investigate the impacts of the health insurance benefit design on PCI and stent use, and on total hospital costs and patients' out-of-pocket expenses. RESULTS: After the change in insurance benefit policy, compared with the self-paid group, PCI rates for the moderate and low reimbursement groups increased by 22.2 and 20.3 %, respectively, and decreased by 48.7 % for the high reimbursement group. The change in insurance benefit policy had no impact on the number of stents used. The high reimbursement group had the lowest hospital costs, and the low reimbursement group had the highest hospital costs, regardless of benefit policy change. The general linear regression results showed that the high reimbursement group had higher total hospital costs than the self-paid group, but were the lowest among all reimbursement groups after the benefit policy change (DIDh = 1,202.21, P = 0.0096). There were no significant changes in the other two groups, and there were no differences in the out-of-pocket costs across any of the insured groups. CONCLUSIONS: Our results suggest that the benefit policy change did not impact life-saving procedures or reduce patients' burden of disease among AMI patients. The effect of 'provider gaming' was the strongest for the high reimbursement group as a result of the global budget cap pressure. The current FFS with a global budget cap is of low efficiency for cost containment and equity improvement. Payment method reforms with alignment of financial incentives to improve provider behaviour in practicing evidence-based medicine are needed in China.