China Health Statistics Research Articles

Effect of health insurance on direct hospitalisation costs for in-patients with ischaemic stroke in China

Objectives The aim of the present study was to determine the direct medical costs of hospitalisations for ischaemic stroke (IS) in-patients with different types of health insurance in China and to analyse the demographic characteristics of hospitalised patients, based on data supplied by the China Health Insurance Research Association (CHIRA). Methods A nationwide and cross-sectional sample of IS in-patients with International Classifications of Diseases 10th Revision (ICD-10) Code I63 who were ensured under either the Basic Medical Insurance Scheme for Employees (BMISE) or the Basic Medical Insurance Scheme for Urban Residents (BMISUR) was extracted from the CHIRA claims database. A retrospective analysis was used with regard to patient demographics, total hospital charges and costs. Results Of the 49588 hospitalised patients who had been diagnosed with IS in the CHIRA claims database, 28850 (58.2%) were men (mean age 67.34 years) and 20738 (41.8%) were women (mean age 69.75 years). Of all patients, 40347 (81.4%) were insured by the BMISE, whereas 8724 (17.6%) were insured by the BMISUR; the mean age of these groups was 68.55 and 67.62 years respectively. For BMISE-insured in-patients, the cost per hospitalisation was RMB10131 (95% confidence interval (CI) 10014-10258), the cost per hospital day was RMB787 (95% CI 766-808), the out-of-pocket costs per patient were RMB2346 (95% CI 2303-2388) and the reimbursement rate was 74.61% (95% CI 74.48-74.73%). For BMISUR-insured in-patients the cost per hospitalisation was RMB7662 (95% CI 7473-7852), the cost per hospital day was RMB744 (95% CI 706-781), the out-of-pocket costs per patient were RMB3356 (95% CI 3258-3454) and the reimbursement rate was 56.46% (95% CI 56.08-56.84%). Conclusions Costs per hospitalisation, costs per hospital day and the reimbursement rate were higher for BMISE- than BMISUR-insured in-patients, but BMISE-insured patients had lower out-of-pocket costs. The financial burden was higher for BMISUR- than BMISE-insured in-patients. For BMISUR-insured in-patients, the out-of-pocket payment was 43.54% of total expenses, which means the government should increase the financial investment, raise reimbursement rates and set up differential reimbursements to meet the health needs of in-patients with different income levels. What is known about the topic? Cardiovascular and cerebrovascular diseases are major non-communicable diseases affecting the health of the Chinese population. The China Health Statistics Yearbook (2013) reported that across all in-patients, 195million (5.82%) had been discharged with a diagnosis of cerebrovascular disease. Of these, 118million had IS, accounting for 60.51% of all in-patients with cerebrovascular disease and 54.97% of hospitalisation costs for all cerebrovascular disease in-patients. After the two basic insurance systems, namely the BMISE and BMISUR, had been established, the out-of-pocket expenses for patients were reduced. However, to date there have been no studies investigating how the different types of health insurance (i.e. the BMISE and the BMISUR) affected the costs of treatment of IS in-patients in China. What does this paper add? This paper reports the direct costs for patients diagnosed with IS based on data supplied by the CHIRA. Direct hospitalisation costs depending on the type of insurance cover, age and gender were also evaluated. What are the implications for practitioners? The present study found that the personal financial burden of disease treatment was higher for in-patients insured under the BMISUR than BMISE. For in-patients insured under the BMISUR, the out-of-pocket payment was 43.54% of total expenses, which means the government should increase the financial investment, raise reimbursement rates and set up differential reimbursement rates to meet the health needs of patients with different incomes.

Disease burden of famale breast cancer in China

To analyze the data on burden of female breast cancer in China. The data from Chinese Cancer Registry Annual Report 2012, three national death cause surveys in China, Disease Surveillance Points system(DSP), China Health Statistics Yearbook, GLOBOCAN 2012, Cancer Incidence in Five Continents(CI5), WHO Mortality Database and Global Burden of Disease(GBD)2013 were used to extract the incidence, mortality and disability-adjusted life years(DALY)of female breast cancer and analyze related trends in China. The data from three national death cause surveys showed that the crude mortality of breast cancer doubled from year 1973-1975 to year 2004-2005, the increase was higher in urban area(127.4%)than in rural area(75.2%). WHO Mortality Database showed that average annual percentage change(AAPC)of breast cancer crude mortality increased by 3.1%(P<0.05)from 1987 to 2000, and China Health Statistics Yearbook showed that the AAPC in urban females increased by 2.7% from 2002 to 2013(P<0.05), whereas the AAPC in rural females showed no significant change(P>0.05). It was estimated by GLOBOCAN 2012 that in 2012 the age-standardized incidence and age-standardized mortality of breast cancer in China was 22.1 per 100 000 and 5.4 per 100 000, respectively. The age-specific incidence began to increase obviously at age of 40 years and peaked at age 45-59 years(GLOBOCAN 2012). Chinese Cancer Registry Annual Report 2012 showed that breast cancer incidence and mortality were 2-fold and 1.5-fold higher in urban females than in rural females in 2009. It was estimated that the breast cancer case number and death number in females in China would increase to 251 600 and 75 900, respectively, more increose in age group ≥65 years. Only GBD 2013 reported DALY, the DALY caused by breast cancer in China was 1 666.0 thousand in 2013, accounting for 12.7% of global DALY, and increased by 56.7% from 1990(1 062.6 thousand), the peak age-specific DALY rate was at 50 to 59 years, and national average ratio of years lived with disability(YLD)was 8.7%(ranging from 8.1% to 9.0% at provincial level). Burden of disease caused by female breast cancer is becoming increasingly severe in China, especially in urban areas. It is necessary to strengthen the population-based prevention and control programs and further studies may focus on DALY.

National equity of health resource allocation in China: data from 2009 to 2013.

BackgroundThe inequitable allocation of health resources is a worldwide problem, and it is also one of the obstacles facing for health services utilization in China. A new round of health care reform which contains the important aspect of improving the equity in health resource allocation was released by Chinese government in 2009. The aim of this study is to understand the changes of equity in health resource allocation from 2009 to 2013, and make a further inquiry of the main factors which influence the equity conditions in China.MethodsData resources are the China Health Statistics Yearbook (2014) and the China Statistical Yearbook (2014). Four indicators were chosen to measure the trends in equity of health resource allocation. Data were disaggregated by three geographical regions: west, central, and east. Theil index was used to calculate the degree of unfairness.ResultsThe total amount of health care resources in China had been increasing in recent years. However, the per 10, 000 km2 number of health resources showed a huge gap in different regions, and per 10, 000 capita health resources ownership showed a relatively small disparities at the same time. The index of health resources showed an overall downward trend, in which health financial investment the most unfair from 2009 to 2012 and the number of health institutions the most unfair in 2013. The equity of health resources allocation in eastern regions was the worst except for the aspect of health technical personnel allocation. The regional contribution rates were lower than that of the inter-regional contribution rates which were all beyond 60 %.ConclusionThe equity of health resource allocation improved gradually from 2009 to 2013. However, the internal differences within the eastern region still have a huge impact on the overall equity in health resource allocation. The tough issues of inequitable in health resource allocation should be resolved by comprehensive measures from a multidisciplinary perspective.

Does Rapid and Sustained Economic Growth Lead to Convergence in Health Resources: The Case of China From 1980 to 2010.

China’s rapid and sustained economic growth offers an opportunity to ask whether the advantages of growth diffuse throughout an economy, or remain localized in areas where the growth has been the greatest. A critical policy area in China has been the health system, and health inequality has become an issue that has led the government to broaden national health insurance programs. This study investigates whether health system resources and performance have converged over the past 30 years across China’s 31 provinces. To examine geographic variation of health system resources and performance at the provincial level, we measure the degree of sigma convergence and beta convergence in indicators of health system resources (structure), health services utilization (process), and outcome. All data are from officially published sources: the China Health Statistics Year Book and the China Statistics Year Book. Sigma convergence is found for resource indicators, whereas it is not observed for either process or outcome indicators, indicating that disparities only narrowed in health system resources. Beta convergence is found in most indicators, except for 2 procedure indicators, reflecting that provinces with poorer resources were catching up. Convergence found in this study probably reflects the mixed outcome of government input, and market forces. Thus, left alone, the equitable distribution of health care resources may not occur naturally during a period of economic growth. Governmental and societal efforts are needed to reduce geographic health variation and promote health equity.

Inequality trends of health workforce in different stages of medical system reform (1985-2011) in China.

IntroductionThe aim of this study was to identify whether policies in different stages of medical system reform had been effective in decreasing inequalities and increasing the density of health workers in rural areas in China between 1985 and 2011.MethodsWith data from China Health Statistics Yearbooks from 2004 to 2012, we measured the Gini coefficient and the Theil L index across the urban and rural areas from 1985 to 2011 to investigate changes in inequalities in the distributions of health workers, doctors, and nurses by states, regions, and urban-rural stratum and account for the sources of inequalities.ResultsWe found that the overall inequalities in the distribution of health workers decreased to the lowest in 2000, then increased gently until 2011. Nurses were the most unequally distributed between urban-rural districts among health workers. Most of the overall inequalities in the distribution of health workers across regions were due to inequalities within the rural-urban stratum.Discussions and conclusionsDifferent policies and interventions in different stages would result in important changes in inequality in the distribution of the health workforce. It was also influenced by other system reforms, like the urbanization, education, and employment reforms in China. The results are useful for the Chinese government to decide how to narrow the gap of the health workforce and meet its citizens’ health needs to the maximum extent.

The old age health security in rural China: where to go?

IntroductionThe huge number of rural elders and the deepening health problems (e.g. growing threats of infectious diseases and chronic diseases etc.) place enormous pressure on old age health security in rural China. This study aims to provide information for policy-makers to develop effective measures for promoting rural elders’ health care service access by examining the current developments and challenges confronted by the old age health security in rural China.MethodsSearch resources are electronic databases, web pages of the National Bureau of Statistics of China and the National Health and Family Planning Commission of China on the internet, China Population and Employment Statistics Yearbook, China Civil Affairs’ Statistical Yearbook and China Health Statistics Yearbooks etc. Articles were identified from Elsevier, Wiley, EBSCO, EMBASE, PubMed, SCI Expanded, ProQuest, and National Knowledge Infrastructure of China (CNKI) which is the most informative database in Chinese. Search terms were “rural”, “China”, “health security”, “cooperative medical scheme”, “social medical assistance”, “medical insurance” or “community based medical insurance”, “old”, or “elder”, “elderly”, or “aged”, “aging”. Google scholar was searched with the same combination of keywords.ResultsThe results showed that old age health security in rural China had expanded to all rural elders and substantially improved health care service utilization among rural elders. Increasing chronic disease prevalence rates, pressing public health issues, inefficient rural health care service provision system and lack of sufficient financing challenged the old age health security in rural China.ConclusionsIncreasing funds from the central and regional governments for old age health security in rural China will contribute to reducing urban–rural disparities in provision of old age health security and increasing health equity among rural elders between different regions. Meanwhile, initiating provider payment reform may contribute to improving the efficiency of rural health care service provision system and promoting health care service access among rural elders.

National Health Insurance Development in China from 2004 to 2011: Coverage versus Benefits.

BackgroundThe simultaneous improvement of the security capability of China Health Insurance System and its development in the last decade remains uncertain. This study measures the status and trends of reimbursement levels of the China Health Insurance System, as well as to offer policy advice to subsequent insurance reforms.MethodsThe National Reimbursement Ratio was created to determine the reimbursement level of the national health insurance system based on total health expenditure and the covered population. Chinese total health expenditure data from 2004 to 2011 were extracted from China’s Health Statistics according to the standards of the International Classification for Health Accounts by Healthcare Financing.ResultsIn 2011, the medical expenditure per capita in China was USD 130.95 and the National Reimbursement Ratio was 26.39%. The National Reimbursement Ratio showed an intense transition from 2004 to 2011, with a sharp decrease from 98.51% in 2004 to 22.44% in 2009, and then a small increase to 26.39% in 2011.ConclusionThe National Reimbursement Ratio was effective in revealing the reimbursement level of the national health insurance system and in predicting its trends. The challenge to China’s healthcare reform is to switch from increasing insurance coverage to guaranteeing a steady increase in government input and building a powerful supervision mechanism.

China's three-year health reform program and equity in sanitation improvement: a panel analysis.

BackgroundAccessible improved sanitation is critical to child health, and inequities in improved sanitation can be interpreted as health inequities across socio-economic groups. From 2009 to 2011, the Chinese government invested 4.448 billion yuan for rural sanitation improvement through a 3-year health reform program. This study assesses the inequity of sanitation improvement in rural China from 2003 to 2011 and examines whether the 3-year health reform program promoted equity in sanitation improvement.MethodsData from the China Health Statistics Yearbooks of 2004 to 2012 and the National Bureau of Statistics of China were used to create the concentration curve (CC), concentration index (CI), and absolute concentration index (ACI) of improved sanitation. Data of central investment for sanitation improvement in each province of China for 2009, 2010, and 2011 was gained through correspondence and used to create the CC and CI for investment.ResultsAlthough the CIs of improved sanitation are lower than the CIs of the net income of rural residents, the latter have an obvious downtrend. The CIs of improved sanitation increased from 2003 until 2008 and started to drop in 2009. As a result, by 2011, the CIs of improved sanitation had reached their 2003 levels. The ACI of improved sanitation decreased slightly from 2003 to 2008, but declined sharply from 2009 to 2011. The CIs of central investment for 2009, 2010, and 2011 are negative and the CCs of central investment are above the line of absolute equality, indicating that investments had been concentrated more on poorer provinces and regions.ConclusionsThe equality of rural residents’ net income has been improving each year, whereas equity in sanitation improvement deteriorated from 2003 to 2008. However, equity in sanitation improvement has increased since 2009 due to central investment in sanitation improvement during the 3-year health reform program that benefits low-income areas more. It is clear that the 3-year health reform program played an important role in promoting the level and equity of sanitation improvement.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-1364-7) contains supplementary material, which is available to authorized users.

Time Trends and Determinants of Pharmaceutical Expenditure in China (1990–2009)

Pharmaceutical policy reform is currently one of the primary areas of health reform in China. The national pharmaceutical policy of China has multiple objectives: to develop the domestic pharmaceutical industry and encourage innovation, to control escalation of total pharmaceutical expenditures (TPE) which constitute a substantial component of total health expenditures (THE), and to ensure access to essential medicines for poor and uninsured patients. The current pharmaceutical system has been criticized for its high costs, questionable prescribing practices, and poor regulation of drug quality. This study aims to examine the time trends and influential factors of TPE in China. Data from the 2010 China National Health Accounts Report and the 2010 China Health Statistics Year Book were used in the analysis. Time trends of TPE as a share of THE (TPE/THE), of gross domestic product [GDP] (TPE/GDP), and the relationship between TPE/THE and GDP were examined. The growth of TPE was examined after adjusting for health care utilization and GDP. The determinants of the TPE/THE and the TPE/GDP between 1990 and 2009 were investigated by two time-series regression models including the amount of prescriptions dispensed (using proxy variables of health utilization), the price indices of medical services, and the price indices of pharmaceuticals during that time period. Descriptive analyses showed that TPE and THE grew consistently during the years 1990-2009. The ratio of the THE/GDP increased more rapidly in recent years than the TPE/GDP. Furthermore, outpatient pharmaceutical expenditures (PEs) per visit and hospital PEs per admission grew throughout the study period. The amount of outpatient visits did not show a significant growth pattern during the 1990s, despite rapid GDP growth during that period. The time-series models showed that the TPE/THE was negatively associated with GDP during the same year (p = 0.039), as well as the medical consumer price index [CPI] (p = 0.021). The TPE/GDP was influenced by the price index of prescriptions (p < 0.001) and the amount of health services utilization, including inpatient admissions (p = 0.012) and outpatient visits (p = 0.003). The cost escalations in PEs and health expenditures were concurrent with GDP growth. TPE has been the major source of financial burden for patients. Even though the rapid growth in China's economy may ameliorate the overall TPE burden, control of PEs is still a key for successful health system reform.

A Cost-Effectiveness Analysis between Amlodipine and Angiotensin II Receptor Blockers in Stroke and Myocardial Infarction Prevention among Hypertension Patients in China

ObjectiveUncontrolled hypertension (HTN) results in strokes, myocardial infarction (MI), and other complications, which are the leading cause of disability, death, and severe economic consequence. We conducted an economic evaluation to determine the costs and quality-adjusted life-years (QALYs) associated with amlodipine (Norvasc) and the angiotensin II receptor blockers (ARBs) in preventing stroke and MI among Chinese HTN patients. MethodsA cost-utility analysis was conducted from the third-party payer perspective. A Markov model was constructed to estimate 5-year costs and health consequences of amlodipine and valsartan. Effectiveness data were based on a published meta-analysis. Utility data were retrieved from the published literature. Costs of MI were retrieved from China Health Statistics Yearbook. Costs of stroke were obtained from retrospective chart review and follow-up interviews in Chinese tertiary hospitals. Costs included costs of drugs, direct medical costs of HTN management, stroke/MI treatment, and follow-up management. Discounting rate used for costs and QALYs was 3%. ResultsTotal direct medical and drug costs of amlodipine and valsartan (ARB) users were ¥111,731,716 and ¥132,058,611, respectively; total QALYs of amlodipine and valsartan users were 30,648.5 and 30,520.8, respectively. Amlodipine is dominant with lower costs and higher QALYs. This demonstrated that compared with valsartan, amlodipine is a cost-saving therapy with better QALY outcome. When irbesartan data were used in the comparison, the magnitude of cost saving changed but the overall conclusion remained the same. ConclusionAmlodipine is a cost-saving therapy compared with ARBs in preventing stroke and MI for Chinese HTN patients.

Social, economic, political and health system and program determinants of child mortality reduction in China between 1990 and 2006: A systematic analysis.

BackgroundBetween 1990 and 2006, China reduced its under-five mortality rate (U5MR) from 64.6 to 20.6 per 1000 live births and achieved the fourth United Nation’s Millennium Development Goal nine years ahead of target. This study explores the contribution of social, economic and political determinants, health system and policy determinants, and health programmes and interventions to this success.MethodsFor each of the years between 1990 and 2006, we obtained an estimate of U5MR for 30 Chinese provinces from the annual China Health Statistics Yearbook. For each year, we also obtained data describing the status of 8 social, 10 economic, 2 political, 9 health system and policy, and six health programmes and intervention indicators for each province. These government data are not of the same quality as some other health information sources in modern China, such as articles with primary research data available in Chinese National Knowledge Infrastructure (CNKI) and Wan Fang databases, or Chinese Maternal and Child Mortality Surveillance system. Still, the comparison of relative changes in underlying indicators with the undisputed strong general trend of childhood mortality reduction over 17 years should still capture the main effects at the macro-level. We used multivariate random effect regression models to determine the effect of 35 indicators individually and 5 constructs defined by factor analysis (reflecting effects of social, economic, political, health systems and policy, and health programmes) on the reduction of U5MR in China.ResultsIn the univariate regression applied with a one-year time lag, social determinants of health construct showed the strongest crude association with U5MR reduction (R2 = 0.74), followed by the constructs for health programmes and interventions (R2 = 0.65), economic (R2 = 0.47), political (R2 = 0.28) and health system and policy determinants (R2 = 0.26), respectively. Similarly, when multivariate regression was applied with a one-year time lag, the social determinants construct showed the strongest effect (beta = 11.79, P < 0.0001), followed by the construct for political factors (beta = 4.24, P < 0.0001) and health programmes and interventions (beta = −3.45, P < 0.0001). The 5 studied constructs accounted for about 80% of variability in U5MR reduction across provinces over the 17-year period.ConclusionVertical intervention programs, health systems strengthening or economic growth alone may all fail to achieve the desired reduction in child mortality when improvement of the key social determinants of health is lagging behind. To accelerate progress toward MDG4, low- and middle-income countries should undertake appropriate efforts to promote maternal education, reduce fertility rates, integrate minority populations and improve access to clean water and safe sanitation. A cross-sectoral approach seems most likely to have the greatest impact on U5MR.

The Imbalance between Patient Needs and the Limited Competence of Top-Level Health Providers in Urban China: An Empirical Study Based on a 2008 National Household Survey

Objective: To show the pattern of patient satisfaction with top-level delivery organizations (Level 2 and Level 3 hospitals), and using neo-institutionalism approach to explain the relatively low satisfaction and to explore the limitations with top providers, focusing on how to improve the competence of Level 2 and Level 3 hospitals at both the individual hospital level and the whole delivery system level.Data Sources/Study Setting: The household survey by the National Bureau of Statistics in China in 2008; China Health Statistics Yearbooks.Data Collection/Extraction Methods: The analysis uses a 2008 sample medical experiences of 5,036 residents from 17 provinces collected in a household survey by the National Bureau of Statistics in China. The linear regression model, the structural difference regression model, and the ordered probit model are used in our framework.Principal Findings: The imbalance between the needs of patients and the limited competence of top-level providers, and the conflict between the business expansion and the limited competence of those providers are deeply and widely influenced by patterns of patient needs, the top providers’ expansion, and the institutional environment.Conclusions: In order to effectively respond to patient needs, top and lower level providers need to set their own individual priorities. The government needs to improve institutional arrangements to respond to patient needs with the development of a fair and appropriate reimbursement and compensation pricing mechanism, and with further evaluation of top level providers’ advanced and limited health services.

Comparing road traffic mortality rates from police-reported data and death registration data in China

To compare death rates from road traffic injuries in China in 2002-2007 when derived from police-reported data versus death registration data. In China, police-recorded data are obtained from police records by means of a standardized, closed-ended data collection form; these data are published in the China statistical yearbook of communication and transportation. Official death registration data, on the other hand, are obtained from death certificates completed by physicians and are published in the China health statistics yearbook. We searched both sources for data on road traffic deaths in 2002-2007, used the χ(2) test to compare the mortality rates obtained, and performed linear regression to look for statistically significant trends in road traffic mortality over the period. For 2002-2007, the rate of death from road traffic injuries based on death registration data was about twice as high as the rate reported by the police. Linear regression showed a significant decrease of 27% (95% confidence interval, CI: 35-19) in the death rate over the period according to police sources but no significant change according to death registration data. The widely-cited recent drop in road traffic mortality in China, based on police-reported data, may not reflect a genuine decrease. The quality of the data obtained from police reports, which drives decision-making by the Government of China and international organizations, needs to be investigated, monitored and improved.