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.

Predicting future vaccination habits: The link between influenza vaccination patterns and future vaccination decisions among old aged adults in China.

BACKGROUND: Annual influenza vaccination is crucially recommended for the elderly to maintain humoral immunity. Insufficient coverage requires us to understand the determinants of their influenza behaviors and how these patterns impact vaccination choices. METHODS: Data from 540 Beijing residents aged over 65 were collected through interviews, capturing vaccination history and sociodemographic details. Individual influenza vaccination records from 2016 to 2020 were obtained from China's Immunization Information Systems. A latent class model identified three vaccination patterns. Multinomial logistic regression assessed relative risk ratios (RRRs) for vaccination based on sociodemographic factors. Vaccination patterns were used to predict future vaccination likelihood. RESULTS: The analysis revealed three groups: sporadically vaccinated (63.33%), occasionally vaccinated (18.71%), and frequently vaccinated (17.96%). Factors associated with frequent vaccination included age over 70 (RRR = 2.81), lower income (RRR = 0.39), higher vaccine hesitancy (RRR = 3.10), multiple chronic conditions (RRR = 2.72), and rural residence (RRR = 2.48). The frequently vaccinated group was more likely to sustain regular vaccination habits in subsequent years compared to the occasionally vaccinated group. CONCLUSIONS: Only 17.96% of Beijing's older population exhibited a consistent influenza vaccination pattern. Older age, rural residency, and chronic diseases correlated with repeated influenza vaccination. Segmenting the population based on past vaccination behavior can aid in designing targeted interventions to improve vaccination rates.

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.

Effectiveness of financial incentives on influenza vaccination among older adults in China: a randomized clinical trial.

OBJECTIVES: To investigate the short-term and long-term effectiveness of different levels of financial incentives on increasing the willingness to vaccinate and vaccine uptake. METHODS: A randomized controlled trial was conducted to investigate the effectiveness of financial incentives of three groups with monetary incentives (CNY 20, CNY 40, and CNY 60; 1 CNY = 0.13 EUR) vs. a control group-CNY 0-on influenza vaccine uptake among 720 older adults (≥60 years) in Beijing, China. The primary outcome was vaccine uptake, and the secondary outcomes were intention to vaccinate and length of time to immunization. RESULTS: Financial incentive significantly promoted higher intention to influenza vaccination (120/178 [67.42%] vs. 442/542 [81.55%]; Relative Risk [RR], 1.21; 95% CI, 1.02-1.42) and higher vaccination participation (74/178 [41.57%] vs. 316/542 [58.30%]; RR, 1.39; 95% CI, 1.10-1.75). CNY 60 had the largest impact on the intention to vaccinate (15.00% vs. 13.48% and 13.90%) and vaccination uptake (19.42% vs. 14.05% and 16.67%) compared with CNY 20 and CNY 40. Time to vaccination was significantly lower among participants receiving incentives than those without ([37.21 days; 95% CI, 34.33-39.99] vs. [48.27 days; 95% CI, 43.47-53.07]; Hazard Ratio [HR] 1.57, 95% CI 1.22-2.03). We found no long-term influence of financial incentives on vaccination decisions in the following year (217/542, 40.04% vs. 65/178, 36.52%; RR 1.08, 95% CI 0.82-1.42). DISCUSSION: Our study suggests that modest financial incentives will boost short-term influenza vaccination rates and shorten the length of time to immunization in China. No one single-time financial incentive had a long-term effect on future vaccination behaviours or helped establish regular vaccination behaviours.

Regional catastrophic health expenditure and health inequality in China.

Background: Catastrophic health expenditures (CHE) can trigger illness-caused poverty and compound poverty-caused illness. Our study is the first regional comparative study to analyze CHE trends and health inequality in eastern, central and western China, exploring the differences and disparities across regions to make targeted health policy recommendations. Methods: Using data from China's Household Panel Study (CFPS), we selected Shanghai, Henan and Gansu as representative eastern-central-western regional provinces to construct a unique 5-year CHE unbalanced panel dataset. CHE incidence was measured by calculating headcount; CHE intensity was measured by overshoot and CHE inequality was estimated by concentration curves (CC) and the concentration index (CI). A random effect model was employed to analyze the impact of household head socio-economic characteristics, the household socio-economic characteristics and household health utilization on CHE incidence across the three regions. Results: The study found that the incidence and intensity of CHE decreased, but the degree of CHE inequality increased, across all three regions. For all regions, the trend of inequality first decreased and then increased. We also revealed significant differences across the eastern, central and western regions of China in CHE incidence, intensity, inequality and regional differences in the CHE influencing factors. Affected by factors such as the gap between the rich and the poor and the uneven distribution of medical resources, families in the eastern region who were unmarried, use supplementary medical insurance, and had members receiving outpatient treatment were more likely to experience CHE. Families with chronic diseases in the central and western regions were more likely to suffer CHE, and rural families in the western region were more likely to experience CHE. Conclusions: The trends and causes of CHE varied across the different regions, which requires a further tilt of medical resources to the central and western regions; improved prevention and financial support for chronic diseases households; and reform of the insurance reimbursement policy of outpatient medical insurance. On a regional basis, health policy should not only address CHE incidence and intensity, but also its inequality.

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.

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.

Online medical consultation in China: Evidence from obesity doctors.

Objective: Online medical consultation (OMC) is increasingly used in China, but there have been few in-depth studies of consultation arrangements and fee structures of online doctors in China. This research assessed the consultation arrangements and fee structure of OMC in China by undertaking a case study of obesity doctors from four representative OMC platforms. Methods: Detailed information, including fees, waiting time and doctor information, was collected from four obesity OMC platforms and analyzed using descriptive statistical analysis. Results: The obesity OMC platforms in China shared similarities in the use of big data and artificial intelligence (AI) but differed across service access, specific consultation arrangements and fees. Big data search and AI response technologies were used by most platforms to match users with doctors and reduce doctors' pressure. The descriptive statistical analysis showed that the higher the rank of the online doctor, the higher the online fee and the longer the wait time. Through a comparison with offline hospitals, we found online doctors' fees exceeded offline hospital doctors' fees by up to 90%. Conclusions: OMC platforms can gain competitive advantages over offline medical institutions through the following measures: make fuller use of big data and AI technologies to provide users with longer duration, lower cost and more efficient consultation services; provide better user experience than offline medical institutions; use big data and fee advantages to screen doctors to match users' consultation needs instead of screening by the rank of doctors only; and cooperate with commercial insurance providers to provide innovative health care packages.

Coping with COVID: Performance of China's hierarchical medical system during the COVID-19 pandemic.

Objective: The COVID-19 pandemic has challenged the health system worldwide. This study aimed to assess how China's hierarchical medical system (HMS) coped with COVID-19 in the short-and medium-term. We mainly measured the number and distribution of hospital visits and healthcare expenditure between primary and high-level hospitals during Beijing's 2020-2021 pandemic relative to the 2017-2019 pre-COVID-19 benchmark period. Methods: Hospital operational data were extracted from Municipal Health Statistics Information Platform. The COVID-19 period in Beijing was divided into five phases, corresponding to different characteristics, from January 2020 to October 2021. The main outcome measures in this study include the percentage change in inpatient and outpatient emergency visits, and surgeries, and changing distribution of patients between different hospital levels across Beijing's HMS. In addition, the corresponding health expenditure in each of the 5 phases of COVID-19 was also included. Results: In the outbreak phase of the pandemic, the total visits of Beijing hospitals declined dramatically, where outpatient visits fell 44.6%, inpatients visits fell 47.9%; emergency visits fell 35.6%, and surgery inpatients fell 44.5%. Correspondingly, health expenditures declined 30.5% for outpatients and 43.0% for inpatients. The primary hospitals absorbed a 9.51% higher proportion of outpatients than the pre-COVID-19 level in phase 1. In phase 4, the number of patients, including non-local outpatients reached pre-pandemic 2017-2019 benchmark levels. The proportion of outpatients in primary hospitals was only 1.74% above pre-COVID-19 levels in phases 4 and 5. Health expenditure for both outpatients and inpatients reached the baseline level in phase 3 and increased nearly 10% above pre-COVID-19 levels in phases 4 and 5. Conclusion: The HMS in Beijing coped with the COVID-19 pandemic in a relatively short time, the early stage of the pandemic reflected an enhanced role for primary hospitals in the HMS, but did not permanently change patient preferences for high-level hospitals. Relative to the pre-COVID-19 benchmark, the elevated hospital expenditure in phase 4 and phase 5 pointed to hospital over-treatment or patient excess treatment demand. We suggest improving the service capacity of primary hospitals and changing the preferences of patients through health education in the post-COVID-19 world.

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.

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.

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.

Costs of traditional Chinese medicine treatment for inpatients with lung cancer in China: a national study.

BACKGROUND: Traditional Chinese Medicine (TCM) has long been a widely recognized medical approach and has been covered by China's basic medical insurance schemes to treat lung cancer. But there was a lack of nationwide research to illustrate the impact of the use of TCM on lung cancer patients' economic burden in mainland China. Therefore, we conduct a nationwide study to reveal whether the use of TCM could increase or decrease the medical expenditure of lung cancer inpatients in mainland China. METHODS: This is a 7-year cross-sectional study from 2010 to 2016. The data is a random sample of 5% from lung cancer claims data records of Chinese Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI). Mann-Whitney test was used to compare inpatient cost data with positive skewness. Ordinary least squares regression analysis was performed to compare the total TCM users' hospitalization cost with TCM nonusers', to examine whether TCM use is the key factor inducing relatively high medical expenditure. RESULT: A total of 47,393 lung cancer inpatients were included in this study, with 38,697 (81.7%) of them at least using one kind of TCM approach. The per inpatient medical cost of TCM users was RMB18,798 (USD2,830), which was 65.2% significantly higher than that of TCM nonusers (P < 0.001). The medication cost, conventional medication cost, and nonpharmacy cost of TCM users were all higher than TCM nonusers, illustrating the higher medical cost of TCM users was not induced by TCM only. With confounding factors fixed, there was a positive correlation between TCM cost and conventional medication cost, nonpharmacy cost (Coef. = 0.283 and 0.211, all P < 0.001), indicting synchronous increase of TCM costs and conventional medication cost for TCM users. CONCLUSION: The use of TCM could not offset the utilization of conventional medicine, demonstrating TCM mainly played a complementary role but not an alternative role in the inpatient treatment of lung cancer. A joint Clinical Guideline that could balance the use of TCM and Conventional medicine should be developed for the purpose of reducing economic burden for lung cancer inpatients.

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.

Student COVID-19 vaccination preferences in China: A discrete choice experiment.

Objective: This study uses a discrete choice experiment (DCE) questionnaire to investigate student vaccination preferences for both intrinsic and extrinsic attributes. Methods: A two-part DCE questionnaire was distributed to 1,138 students through face-to-face interviews at vaccination centers in Qingdao, China. Conditional logit models were used to understand student preference trade-offs. Mixed logit models (MLM) and sub-group analysis were conducted to understanding student preference heterogeneity. Results: We found that students preferred vaccines with fewer side effects (ß = 0.845; 95% CI, 0.779-0.911), administered through third level health facilities (ß = 0.170; 95% CI, 0.110-0.230), and had at least 1 year duration of protection (ß = 0.396; 95% CI, 0.332-0.461. Higher perception of COVID-19 risks (ß = 0.492; 95% CI, 0.432-0.552) increased the likelihood of student vaccination uptake. Surprisingly, vaccine effectiveness (60%) and percentages of acquaintances vaccinated (60%) reduced vaccination utility, which points to free-rider problems. In addition, we find that student study majors did not contribute to preference heterogeneity, and the main disparities in preferences were attributed to student risk tolerances. Conclusion: Both intrinsic and extrinsic attributes were influential factors shaping student preferences for COVID-19 vaccines. Our results inform universities and local governments across China on targeting their vaccination programs.

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.

Preferences for private health insurance in China: A discrete choice experiment.

Introduction: There is limited evidence on the sustainability and optimal design of China's private health insurance market, especially from the demand-side. With the increasing medical cost burden on both patients and the social security system, policy makers need data on potential clients' demand for private health insurance. Methods: A discrete choice experiment was conducted to explore potential clients' preferences for a type of government-involved private supplementary health insurance, Huimin Insurance, in China. A mixed logit model was used to evaluated participants' preferences for six attributes. Willingness to pay, subgroup analysis and interaction effects were estimated based on the initial model. Results: Among the 947 participants, 883 (93.2%) were aged 18 to 59 years and 578 (61.0%) were female. Participants had a strong preference for government involvement, extensive benefit packages, high reimbursement ratio and compensation for pre-existing conditions. With respect to the attribute of deductible, participants were indifferent between the level of CNY15,000 and CNY18,000 but had strong and significant preference for the level of CNY15,000 than CNY20,000. The premium was significantly correlated with a decline in the utility of PHI. Conclusions: All attributes had a significant impact on participants' preference for Huimin Insurance. Providing a reference point for the development of private health insurance in China, our results inform the optimal design of PHI, especially Huimin Insurance's products.

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.

The Economic Burden of Hospital Costs on Families With Type 1 Diabetes Mellitus Children: The Role of Medical Insurance in Shandong Province, China.

Objective: This study estimates the economic burden imposed on families by comparing the hospitalization costs of T1DM children with and without medical insurance in Shandong province. Methods: Our data comprised 1,348 T1DM inpatient records of patients aged 18 years or younger from the hospitalization information system of 297 general hospitals in 6 urban districts of Shandong Province. Descriptive statistics are presented and regression analyses were conducted to explore the factors associated with hospitalization costs. Results: Children with medical insurance had on average total hospitalization expenditures of RMB5,833.48 (US$824.02) and a hospitalization stay of 7.49 days, compared with the children without medical insurance who had lower hospitalization expenditures of RMB4,021.45 (US$568.06) and an average stay of 6.05 days. Out-of-pocket expenses for insured children were RMB3,036.22 (US$428.89), which is significantly lower than that of the uninsured children (P < 0.01). Out-of-pocket (OOP) expenditures accounted for 6% of the annual household income of insured middle-income families, but rose to a significant 25% of the annual income for low-income families. These OOP expenditures imposed a heavy economic burden on families, with some families experiencing long-term financial distress. Both insured and uninsured families, especially low-income families, could be tipped into poverty by hospitalization costs. Conclusion: Hospitalization costs imposed a significant economic burden on families with children with T1DM, especially low-income insured and uninsured families. The significantly higher hospitalization expenses of insured T1DM children, such as longer hospitalization stays, more expensive treatments and more drugs, may reflect both excess treatment demands by parents and over-servicing by hospitals; lower OOP expenses for uninsured children may reflect uninsured children from low-income families forgoing appropriate medical treatment. Hospital insurance reform is recommended.