An ethical framework for hemodialysis nurses: A qualitative study.

BackgroundChronic Kidney Disease affects 13% of China’s population, with hemodialysis consuming 1–3% of national healthcare expenditure. Hemodialysis patients face complex physical-psychological burdens, while physicians in Traditional Chinese Medicine (TCM) hospitals navigate unique ethical dilemmas arising from dual Western-TCM practice paradigms, cultural expectations, and systemic healthcare pressures. This study employed Social-Ecological Systems Theory to analyze these multilayered challenges and developed a structured ethical model.MethodsThis study followed a qualitative phenomenological research design. Maximum variation purposive sampling was employed to recruit 28 hemodialysis physicians from six TCM hospitals across five cities in Shandong Province, China. Data were collected through focus group and in-depth individual interviews with 28 hemodialysis physicians from November 2024 to January 2025, and were analyzed following Colaizzi’s descriptive analysis framework. The framework of the Society Ecosystems Theory was applied to analyze how multilevel systemic interactions shape ethical challenges, thereby constructing a multidimensional conceptual model.ResultsEthical challenges encountered by hemodialysis physicians were categorized into three themes with seven subthemes and 17 subcategories. Based on these findings, a three-tiered model was developed: macro-system challenges involving policy, organizational, and cultural dimensions; meso-system challenges emerging from interprofessional dynamics, particularly doctor-doctor, doctor-nurse, and doctor-patient relationships; and micro-system challenges pertaining to individual difficulties.ConclusionThe conceptual model reveals the multi-level nature of ethical challenges in hemodialysis practice, spanning systemic policies, interprofessional relationships, and individual dilemmas. The findings specifically call for targeted interventions at each level: policy reforms to address resource constraints, team-based strategies to improve clinical collaborations, and support systems to alleviate practitioners’ ethical distress. These evidence-based insights empower stakeholders to develop comprehensive solutions addressing the interconnected challenges identified.

BackgroundAs a key part of the new round of health reform, the zero-markup drug policy (ZMDP) removed the profit margins of drug sales at public health care facilities, and had some effects to the operation of these institutions. This study aims to assess whether the ZMDP has different impacts between county general and traditional Chinese medicine (TCM) hospitals.MethodsWe obtained longitudinal data from all county general and TCM hospitals of Shandong province in 2007–2017. We used difference-in-difference (DID) method to identify the overall and dynamic effects of the ZMDP.ResultsOn average, after the implementation of the ZMDP, the share of revenue from medicine sales reduced by 16.47 and 10.42%, the revenue from medicine sales reduced by 24.04 and 11.58%, in county general and TCM hospitals, respectively. The gross revenue reduced by 5.07% in county general hospitals. The number of annual outpatient visits reduced by 11.22% in county TCM hospitals. Government subsidies increased by 199.22 and 89.3% in county general and TCM hospitals, respectively. The ZMDP reform was not significantly associated with the revenue and expenditure surplus, the number of annual outpatient visits and the number of annual inpatient visits in county general hospitals, the gross revenue, the revenue and expenditure surplus and the number of annual inpatient visits in county TCM hospitals. In terms of dynamic effects, the share of revenue from medicine sales, revenue from medicine sales, and gross revenue decreased by 20.20, 32.58 and 6.08% respectively, and up to 28.53, 63.89 and 17.94% after adoption, while government subsidies increased by around 170 to 200% in county general hospitals. The number of annual outpatient visits decreased by 9.70% and up to 18.84% in county TCM hospitals.ConclusionThe ZMDP achieved its some initial goals of removing the profits from western medicines in county hospitals’ revenue without disrupting the normal operation, and had different impacts between county general and TCM hospitals. Meanwhile, some unintended consequences were also recognized through the analysis, such as the decline of the utilization of the TCM.

BackgroundCompare changes in types of hospital service revenues between traditional Chinese medicine (TCM) hospitals and Western-medicine based general hospitals.Methods97 TCM hospitals and 103 general hospitals were surveyed in years of 2000 and 2004. Six types of medical service revenue between the two types of hospitals were compared overtime. The national statistics from 1999 to 2008 were also used as complementary evidence.ResultsFor TCM hospitals, the percentage of service revenue from Western medicine increased from 44.3% to 47.4% while the percentage of service revenue from TCM declined from 26.4% to 18.8% from 1999 to 2004. Percentages of revenue from laboratory tests and surgical procedures for both types of hospitals increased and the discrepancy between the two types of hospitals was narrowed from 1999 to 2004. For TCM hospitals, revenues from laboratory tests increased from 3.64% to 5.06% and revenues from surgical procedures increased from 3.44% to 7.02%. General hospitals' TCM drug revenue in outpatient care declined insignificantly from 5.26% to 3.87%, while the decline for the TCM hospitals was significant from 19.73% to 13.77%. The national statistics from 1999 to 2008 showed similar trends that the percentage of revenue from Western medicine for TCM hospitals increased from 59.6% in 1999 to 62.2% in 2003 and 66.1% in 2008 while the percentage of revenue from TCM for TCM hospitals decreased from 18.0% in 1999, 15.4% in 2003, and 13.7% in 2008.ConclusionWestern medicine has become a vital revenue source for TCM hospitals in the current Chinese health care environment where government subsidies to health care facilities have significantly declined. Policies need to encourage TCM hospitals to identify their own special and effective services, improve public perception, increase demand, strengthen financial sources, and ultimately make contributions to preserving one of the national treasures.

Background Traditional, complementary, and alternative medicine (TCAM) has attracted increasing attention in developed countries, but its mainstream status in China, the home of TCAM, is unclear. Over the period of 2004–2016, we analyze the health resources and health resource utilization of traditional medicine in traditional Chinese medicine (TCM) hospitals in China. Methods Over 2004–2016, we obtained data from all TCM hospitals in all Chinese provinces to create a hospital-based, longitudinal dataset. TCM health resources and their utilization were measured by two outcome variables: (1) primary outcome variables comprising the proportion of TCM physicians, TCM pharmacists, revenue from TCM drugs, and TCM prescriptions and (2) the secondary outcome variables, as proxies of westernization for TCM hospitals, comprising the number of medical equipment above RMB 10,000 and the proportion of surgery in inpatient visits. We used linear regression models with hospital-fixed effects to analyze time trends for the outcome variables. Results The number of public TCM hospitals remained stable from 2004 to 2016, while the number of private TCM hospitals increased from 294 in 2004 to 1560 in 2016. There was a small percentage increase in the proportion of TCM physicians (0.280%), TCM pharmacists (0.298%), and revenue from Chinese medicines (0.331%) and TCM prescriptions (1.613%) per hospital per year. Chinese drugs accounted for less than a half of the total drug prescriptions, and accordingly, just one-third of the drug revenue was from Chinese medicines at TCM hospitals. The proportions of physicians, pharmacists, revenue from Chinese drug sales, and traditional medicine prescriptions never reach the 60% benchmark target for mainstream in TCM hospitals. As proxies for Western medicine practices in TCM hospitals, the number of medical equipment above RMB 10,000 rapidly rose by over 13 percent per hospital per year, but the proportion of inpatient surgeries declined by 0.830 percentage points per hospital per year, reflecting a mixed trend in the use of Western medicine practices. Conclusion For the 2004–2016 period, traditional medicine, although making progress towards the mainstream benchmark of 60% TCM services, was still not mainstream at TCM hospitals.

China is advancing Diagnosis Related Group (DRG)-based health insurance reforms to address rising healthcare costs, with traditional Chinese medicine (TCM) hospitals as a key focus. Evaluating the impact of TCM DRG reforms is crucial for China to leverage its unique medical practices in reducing the economic burden of disease. We collected 535,886 hospitalization records regarding length of stay and hospitalization costs from TCM hospitals in Qingyang City and Tianshui City, Gansu Province, for the period from January 2017 to June 2022 (313,823 from Qingyang and 222,062 from Tianshui). A comparative analysis of the DRG reform's implementation effects in secondary and tertiary TCM hospitals in Qingyang was conducted using descriptive statistics and two groups interrupted time-series (ITS) model. In Qingyang's secondary TCM hospitals, there were no significant changes in the length of stay and hospitalization costs before the DRG reform (p > 0.05). However, post-reform, both metrics exhibited a notable increase, averaging 0.02 days and CNY 34.54 per month (p < 0.05). Conversely, the length of stay in tertiary TCM hospitals showed no significant changes before the reform (p > 0.05), while hospitalization costs exhibited a significant upward trend (p < 0.05). After the implementation of the DRG reform, both length of stay and hospitalization costs significantly declined, with monthly reductions of 0.06 days and CNY 60.47 (p < 0.05). DRG reform has positively influenced the length of stay and hospitalization costs in TCM hospitals, with tertiary facilities showing better outcomes than secondary ones. To improve the effectiveness of DRG health insurance payment reforms in China, it is essential to enhance the qualifications of medical personnel and advance information technology infrastructure in TCM hospitals. Furthermore, implementing differentiated reforms across TCM hospitals and strengthening the systematic development of health insurance payment structures are critical.

AimThis study aimed to evaluate the operational efficiency of traditional Chinese medicine (TCM) hospitals in China.MethodsPearson’s analysis was used to test the correlation between the input and output variables. Data envelopment analysis (DEA) was utilized to analyze the input and output variables of 16 TCM hospitals, and each hospital efficiency score was computed by Deap 2.1, assuming variable return to scale (VRS), which is an input-oriented model. t tests were conducted to confirm the significant difference of efficiency scores at the hospital level and by hospital type, and ANOVA was used to test for significant differences in efficiency scores according to hospitals’ size.ResultsThe correlation coefficient of the input and output indicators was between 0.613 and 0.956 (p < 0.05). The difference in number of doctors (ND) and numbers of pharmacists (NP) were statistically significant (p < 0.05) at the hospital level. The mean efficiency scores for technical efficiency (TE), pure technical efficiency (PTE), and scale efficiency (SE) in secondary TCM hospitals were 0.766, 0.919, and 0.838, respectively. Additionally, the lowest TE, PTE, and SE were 0.380, 0.426, and 0.380, respectively. Eight TCM hospitals in this study were DEA efficient, with an efficiency score of 1. There were no statistically significant differences in TE, PTE, and SE among hospital levels, hospital types or hospital sizes groups (p > 0.05).ConclusionThis study revealed that tertiary TCM hospitals had a greater level of efficiency than secondary TCM hospitals. In our study, 50% of TCM hospitals had inefficient management. Therefore, to activate the new development power of TCM hospitals, it is necessary to reform and improve the management system and mechanism of TCM hospitals, optimize the development environment of TCM hospitals and formulate development plans and measures based on local conditions.

To evaluate the present development and status of quality control for intensive care unit (ICU) in Sichuan Provincial traditional Chinese medicine (TCM) hospitals including integrated traditional Chinese and western medicine hospitals and ethnic hospitals, and to provide practical references for improving the service quality of ICU. Supervisory Group of Sichuan Provincial Critical Care Medicine Quality Control Center of TCM was established in September 2018. From September 8th to 17th, 2018, according to the Scoring Criteria of Quality Control and Supervision Project of TCM for Critical Care Medicine, a 10-day quality control professional guidance was hand out to TCM hospitals with independent ICU in Sichuan Province. The service level of different aspects of hospital quality control was evaluated and ranked from equipment and resource support, medical team, service capacity and level, ward quality, completion of critical care core indicators, completion of quality control of TCM, development of new technologies, diagnosis and treatment schemes for dominant diseases. There were 52 TCM hospitals across the province that had an ICU. Thirty-three hospitals were third-class (63.5%), while the rest 19 hospitals were second-class (36.5%). Province-level, city-level and county-level hospitals were accounted for 9.6% (5/52), 38.5% (20/52), and 51.9% (27/52), respectively. Average bed ratio of ICU was 1.8%. Doctor-bed and guard-bed ratios were 0.71:1 and 2.0:1, respectively. The average annual admission rate of patients and the average daily admission rate of beds were higher, which were basically 1%. Ward quality was high; the incidence of nosocomial infection was controlled below 10%. Compliance rate of septic shock bundle treatment was high. The incidences of ventilator-associated pneumonia (VAP), catheter-related bloodstream infection (CRBSI) and catheter-associated urinary tract infection (CAUTI) were 0.45%, 0.22%, and 0.30%, respectively. Participation rate of TCM was about 83.4%. Average number of new technologies was about 4.4. Average number of disease schemes was about 2.62. ICU of Sichuan Provincial TCM hospitals reaches the standard level in service capacity and level, ward quality, critical medicine quality control, and participation rate of TCM treatment. Improvements are required for other prospects, including department scale, medical personnel allocation, new technical development, diagnosis and treatment schemes of dominant diseases.

Improving the productivity and relative efficiency of traditional Chinese medicine (TCM) hospitals is pivotal for hospital managers and policymakers to optimize the utilization of TCM resources in China. This study aimed to measure the productivity and relative efficiency of public tertiary TCM hospitals in Hubei Province. The input and output indicators data were extracted from the Health Commission of Hubei Province (HCHP) from 2019 to 2021. The Bootstrap-Malmquist-DEA model was employed to measure the productivity and relative efficiency of the hospitals. The statistical significance was set at P < .05. The numbers of total diagnostic patients and discharged patients declined by 23.44% and 28.34% from 2019 to 2020, and then increased by 25.76% and 20.44% respectively from 2020 to 2021. The average bias-corrected technical efficiency (TE) scores of the TCM hospitals from 2019 to 2021 were 0.8391, 0.8048, and 0.8559, indicating good efficiency. The average total factor productivity (TFP) in 2020 and 2021 decreased compared to that in 2019, with scores of 0.7479 and 0.8996, respectively. Between 2019 and 2020, the TFP changes among 19 out of 21 (90.48%) TCM hospitals and the technological changes (TC) among 20 out of 21 (95.24%) were less than 1.0000 (P < .05). The TFP changes of 17 out of 21 (80.95%) TCM hospitals and the TC of 20 out of 21 (95.24%) were less than 1.0000 (P < .05) between 2019 and 2021. COVID-19 might have constrained the provision of healthcare services by the public tertiary TCM hospitals in Hubei Province. Priority should be given to the utilization of healthcare resources, performance evaluation, information system strengthening, and internal hospital management to boost technical efficiency. TCM hospitals need to focus further on technology innovation to improve their technological progress.

ObjectiveIn the context of medical insurance payment reform, this study aims to evaluate the impact of the Diagnosis-Intervention Packet (DIP) payment policy on hospitalization costs across different types and levels of hospitals. In order to provide empirical evidence to support the high-quality collaboration between hospitals and medical insurance, while reducing the economic burden on patients.MethodOur study collected medical insurance reimbursement data from January 2019 to December 2022 in S city, covering 2,467,746 patients. Based on the intervention time point of the DIP reform implementation in 2021, an interrupted time series analysis was conducted on a monthly basis to compare the trend changes in hospitalization costs between traditional Chinese medicine hospitals (TCMHs) and general hospitals (GHs), as well as to examine the differences in impacts across hospitals of various levels.ResultsFirstly, our study found that tertiary hospitals had the highest average hospitalization costs (), followed by secondary hospitals (), and primary hospitals, which had the lowest costs (). Secondly, after the implementation of the DIP reform, the average hospitalization costs immediately decreased in both TCMHs and GHs, with a more significant reduction observed in GHs (= − 0.023, p = 0.059, = − 0.016, p = 0.039). Thirdly, when further categorized by hospital level, we found that the instantaneous effect of the reform on average hospitalization costs was most significant in primary TCMHs (= − 0.080, p = 0.008), followed by tertiary TCMHs (= − 0.033, p = 0.012), while the effect in secondary TCMHs was not significant (= − 0.024, p = 0.087). In GHs, the most significant instantaneous effect was observed in tertiary hospitals (= − 0.046, p = 0.004), while no significant changes were observed in secondary and primary hospitals (= − 0.026, p = 0.077, = − 0.022, p = 0.201). In terms of the long-term effects of the DIP reform, both TCMHs and GHs showed significant changes in average hospitalization costs, with a larger reduction observed in GHs, indicating better reform outcomes (= − 0.006, p < 0.001, = − 0.010, p < 0.001).ConclusionThe government should adjust policies in a differentiated and refined manner based on the type and level of hospitals to achieve the goals of controlling medical costs and improving the incentive mechanisms. Meanwhile, optimizing the healthcare service structure can improve quality and efficiency, as well as better meet patient needs.

Agricultural competitiveness is an important indicator for measuring the level of local agricultural development, and high-quality agricultural development is the future development trend of agriculture. This paper analyzes the changes and factors of agricultural competitiveness in Shandong Province, and makes a comprehensive evaluation, and puts forward measures and suggestions to promote the development of high-quality agriculture in Shandong Province. In this paper, relevant agricultural data of 16 prefecture-level cities in Shandong Province are selected, and factor analysis is used to assess the level of agricultural competitiveness of prefecture-level cities in Shandong Province. The results show that the overall distribution of agricultural competitiveness in Shandong Province is uneven, with large gaps and low values. The geographical distribution shows the trend of "high in the middle and low around", and the input-output and economic factors, planting output, fruit and vegetable output, fishery output all affect the competitiveness of Shandong's agriculture. Therefore, the future development direction of Shandong Province's agriculture should be based on the actual development situation, and the competitiveness of agriculture in each prefecture-level city should be improved according to local conditions.

BackgroundThe efficiency of public hospitals, particularly Traditional Chinese Medicine (TCM) hospitals, has emerged as a critical issue in China's healthcare reform, compounded by challenges such as low diagnostic revenue, regional disparities, and increasing adoption of Western medicine practices. As traditional Chinese medicine plays an indispensable role in managing chronic conditions among older adults, this study addresses critical healthcare challenges within China's aging population context. Therefore, this study aims to systematically analyze the technical efficiency of public TCM hospitals in Hebei Province.MethodsThis research employs an integrated three-stage analytical framework using advanced efficiency measurement techniques to assess the technical efficiency of 21 public TCM hospitals in Hebei Province from 2014 to 2018. The methodology combines static efficiency evaluation with dynamic efficiency analysis, while regression modeling identifies key efficiency determinants. Specifically, data were collected from hospital records and analyzed using Data Envelopment Analysis, Stochastic Frontier Analysis, and Super Slack-Based Measure models.ResultsFindings reveal that average technical efficiency of TCM hospitals in Hebei is suboptimal, primarily driven by insufficient pure technical efficiency rather than scale inefficiency. Environmental factors, including geographic location and local TCM practitioner training, significantly influence efficiency levels. Dynamic analysis indicates declining technological progress, counteracting marginal improvements in managerial efficiency. Furthermore, operational and financial factors show varied impacts: bed utilization rates, personnel expenditure ratios, and total asset turnover rates correlate positively, while depreciation costs, management expense ratios, and bed capacity demonstrate negative effects. Consequently, the research emphasizes that internal management optimization should take precedence over scale expansion.ConclusionsThis research contributes to deeper understanding of efficiency dynamics in TCM hospitals through advanced analytical techniques. Most critically, policymakers should prioritize enhancing operational management and targeted resource distribution to achieve sustainable improvements in TCM hospital performance. Additionally, hospital management can benefit from adopting commitment-based practices to improve efficiency performance and optimize healthcare delivery outcomes.

Background: This paper aims to investigate the development trend of traditional Chinese medicine (TCM) hospitals in China and explore their medical service innovations, with special reference to the changing co-existence with western medicine (WM) at TCM hospitals. Methods: Quantitative data at macro level was collected from official databases of China Health Statistical Yearbook and Extracts of Traditional Chinese Medicine Statistics. Qualitative data at micro level was gathered through interviews and second-hand material collection at two of the top-level TCM hospitals. Results: In both outpatient and inpatient sectors of TCM hospitals, drug fees accounted for the biggest part of hospital revenue. Application of WM medical exanimation increased in both outpatient and inpatient services. Even though the demand for WM drugs was much higher in inpatient care, TCM drugs was the winner in the outpatient. Also qualitative evidence showed that TCM dominated the outpatient hospital service with WM incorporated in the assisting role. However, it was in the inpatient medical care that WM prevailed over TCM which was mostly applied to the rehabilitation of patients. Conclusion: By drawing on WM while keeping it active in supporting and strengthening the TCM operation in the TCM hospital, the current system accommodates the overriding objective which is for TCM to evolve into a fully informed and more viable medical field.

The purpose of this study is to explore the applicability of the current CHS-DRG grouping and payment scheme in Traditional Chinese Medicine (TCM) hospitals by grouping the discharged cases in TCM hospitals. It also aims to provide a method reference for discussing the related grouping of TCM disease and syndrome diagnosis. The first-page data of inpatient medical records in some TCM hospitals above the county level, from 2015 to 2020, were taken as the research object. The first-page data of inpatient medical records from 2015 to 2017 were grouped according to the CHS-DRG grouping rules, and the grouping results were obtained. Subsequently, two-stage clustering methodology was used to further group the bad groups, and the TCM disease grouping model was preliminarily formed. The model was verified by the first-page data of inpatient medical records from 2018 to 2020. The results showed that under the CHS-DRG grouping model, 494,150 cases were divided into 359 DRG groups. Only 92 cases with CV < 1 and cases > 100 were grouped poorly. After adding TCM diagnostic codes into the grouping model, the grouping effect of the disease group with CV > 1 was significantly increased, and the grouping results met the CHS-DRG grouping criteria. To fully leverage the benefits of Traditional Chinese Medicine and provide simple, convenient, empirical, and inexpensive medical services, TCM hospitals can explore TCM case grouping models that conform to the characteristics of TCM. In case grouping, TCM characteristic diagnosis and treatment elements should be included, and the study of medical insurance payment mode suitable for TCM hospitals should be conducted. Additionally, improving the hospital hardware facilities and providing an intelligent, automatic medical record management system should be prioritized. Further standardizing TCM diagnosis and code filling in the medical record information system and strengthening the study of TCM medical record management and coding will improve the quality of medical record.

Correctly understanding and handling the relationship of tourism industry, ecological environment, and regional economy is an important prerequisite and foundation for realizing regional ecological protection and high-quality development. Based on the entropy method and the coupling coordination model, this paper conducts quantitative research on the coupling coordination relationship and development law of tourism industry–ecological environment–regional economic (TEE) in various cities in Shandong Province. First, a coupling coordination evaluation system of TEE was constructed to evaluate the comprehensive development level of the three systems in each city in Shandong Province from 2010 to 2017; secondly, based on the coupling coordination model, the relationship among the three systems of each city was analyzed using spatial and temporal dimensions; finally, the gray GM (1, 1) model was used to predict the future coupling coordination degree of the three systems in Shandong Province. The research results show that: (1) the development of the economy and tourism industry of cities in Shandong Province is highly correlated, and the overall trend is increasing. The ecological environment mainly changes first, and then rises. (2) From the perspective of time, the changes in the coupling coordination degree of the three systems are mainly to maintain stability and increase fluctuations, and generally develop in the direction of benign coordination. From a spatial perspective, the coupling coordination degree of the three systems shows significant regional integrity and differences, showing a pattern of high in the east and low in the west. (3) In the next few years, the coupling coordination degree of the three systems will roughly continue the characteristics of changes from 2010 to 2017.

Objective To know the status of organizational culture in traditional Chinese medicine (TCM) hospital and provide construction suggestions for nursing managers. Methods A total of 300 registered nurses in TCM hospitals in Tianjin were investigated with the self-designed general information questionnaire and NCAT on nursing organizational culture. Unifactor variance analysis was used to analyze the influencing factors. Results The score of organizational culture of nursing in TCM hospital was (61.72±8.19), and was in the medium level. The team cooperation and communication dimension scored the highest, which was (23.34±3.21); satisfaction dimension scored lowest, and was (6.42±2.00). Unifactor analysis found that the scores of satisfaction and professional commitment of nursing organizational culture was statistically significant with different age (P<0.05). Conclusions Nursing organizational culture is in the medium level. Nursing managers should strengthen the TCM hospital culture construction from the following three aspects: material, institute and spirit culture. Key words: Nursing management research; Organizational culture; Traditional Chinese medicine hospital