Rural Cooperative Medical Scheme Research Articles

Does Medical Insurance Integration Reduce Frailty Risk? Evidence From Rural Older Adults in China.

This study aimed to assess the impacts of China's health insurance integration reform on frailty among rural older adults. Nationally representative longitudinal data with 2,751 adults aged ≥60 years were analyzed from the China Health and Retirement Longitudinal Study 2011-2015. The integration of the rural New Cooperative Medical Scheme and urban Resident Basic Medical Insurance into the unified Urban and Rural Resident Basic Medical Insurance (URRBMI). Frailty Index (FI) summarizes 32 health deficits, quantifying frailty severity with a range of 0-1. Frailty is defined as FI ≥ 0.25, prefrailty as FI: 0.10-0.25, and robustness as FI < 0.10. Frailty worsening, stability, and improvement from 2011 to 2015 were assessed. Difference-in-differences and propensity score matched difference-in-differences models assessed URRBMI integration effects on frailty severity and risk (FI ≥ 0.25) among rural older adults. URRBMI integration significantly reduced frailty severity by 15.16% and risk by 9.60% points among rural older adults. Reductions were greatest among initially prefrail individuals, with 27.49% lower frailty severity and a 17.62% point reduction in subsequent frailty onset risk after URRBMI integration. In contrast, no significant benefits were observed for initially robust or frail subgroups following integration. Analyses of frailty transitions corroborated selective benefits, with URRBMI integration lowering the risks of worsening frailty among prefrail but no significant reversal of frailty status among those initially frail or prefrail. China's URRBMI integration selectively ameliorated frailty progression among rural older adults with prefrail status. Targeting integrated medical insurance policies toward high-risk populations may optimize frailty prevention effects.

Does supplemental private health insurance impact health care utilization and seeking behavior of residents covered by social health insurance? Evidence from China National Health Services Survey

BackgroundSupplemental private health insurance (PHI) plays a crucial role in complementing China’s social health insurance (SHI). However, the effectiveness of incorporating PHI as supplementary coverage lacks conclusive evidence regarding its impact on healthcare utilization and seeking behavior among SHI-covered individuals. Therefore, investigating the effects of supplementary PHI on health care utilization and seeking behavior of residents covered by social health insurance is essential to provide empirical evidence for informed decision-making within the Chinese healthcare system.MethodsData from the 2018 China National Health Services Survey were analyzed to compare outpatient and inpatient healthcare utilization and choices between PHI purchasers and non-purchasers across three SHI schemes: urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), and the new rural cooperative medical scheme (NRCMS). Using the Andersen Healthcare Services Utilization Behavior Model as the theoretical framework,binary logistic regression and multinomial logistic regression (MNL) models were employed to assess the impact of PHI on healthcare utilization and provider preferences.ResultsAmong UEBMI, URBMI, and NRCMS participants with PHI, outpatient visit rates were 17.9, 19.8, and 21.7%, and inpatient admission rates were 12.4, 9.9, and 12.9%, respectively. Participants without PHI exhibited higher rates for outpatient visits (23.6, 24.3, and 25.6%) and inpatient admissions (15.2, 12.8, and 14.5%). Binomial logistic regression analyses revealed a higher probability of outpatient visits and inpatient admissions among UEBMI participants with PHI (p < 0.05). NRCMS participants with PHI showed a lower probability of outpatient visits but a higher probability of inpatient admissions (p < 0.05). Multinomial logistic regression indicated that NRCMS participants with PHI were more likely to choose higher-level hospitals, with a 17% increase for county hospitals and 27% for provincial or higher-level hospitals compared to primary care facilities.ConclusionThe findings indicate that the possession of PHI correlated with increased utilization of outpatient and inpatient healthcare services among participants covered by UEBMI. Moreover, for participants under the NRCMS, the presence of PHI is linked to a proclivity for seeking outpatient care at higher-level hospitals and heightened utilization of inpatient services. These results underscore the nuanced influence of supplementary PHI on healthcare-seeking behavior, emphasizing variations across individuals covered by distinct SHI schemes.

Upscaling policy pilots: Four tales in Chinese health governance

Governments have widely applied policy pilots to test new policy initiatives before their full rollout. However, little is known about their upscaling styles. In this contribution, in relation to two attributes of the issues that policy pilots attempt to resolve – ambiguity and salience – we construct an analytic framework consisting of four policy-pilot upscaling styles: command replication, refinement by doing, waiting by doing, and putting on hold. Four representative cases in Chinese health governance, namely, the Sanming healthcare reform, the New Rural Cooperative Medical Scheme, medical staff’s salary reform in public hospitals, and income–expenditure two-line management in primary healthcare institutions, have been investigated to exemplify them. Our study contributes to the existing governance and policy literature by adding new building blocks to the upscaling of policy pilots.

Public expenditure on health care and the incidence of non-communicable diseases (NCDs) in China from 2008 to 2018

ObjectivesThis study investigates whether differences in individual-level and provincial-level health funding could explain or mitigate health inequalities among older people in terms of non-communicable diseases within a population served by fragmented health insurance schemes. Study designA national repeated cross-sectional analysis was done of the 2008, 2011, 2014, and 2018 Chinese Longitudinal Healthy Longevity Surveys. These provided a total of 44,623 persons aged 60 and over. Main outcome measuresRespondents were asked whether they had been diagnosed with any types of non-communicable diseases by doctors. A dichotomous outcome variable was constructed to indicate whether older people had any diagnosed non-communicable diseases. ResultsCompared with uninsured older persons, those who were enrolled in social health insurance schemes designed for civil servants as cadres, urban employees and urban residents were more likely to report a higher incidence of non-communicable diseases. There were no significant differences in the prevalence of non-communicable diseases between uninsured older people and those in the New Rural Cooperative Medical Scheme. Although the incidence of non-communicable diseases among older persons increased over the study period, greater health expenditure was significantly associated with a lower risk of non-communicable diseases. The interaction results between individual social health insurance schemes and public health expenditure indicate that disparities in the incidence of non-communicable diseases among different health insurance schemes diminish as public health expenditure increases. Older individuals with Public Free Medical Services benefited the most in provinces with higher public health expenditure compared with other health insurance schemes. ConclusionsGiven the evidence of the beneficial effects of universal health coverage on non-communicable diseases among older persons, these results should encourage policy makers to increase public health funding and to raise the overall benefit packages for social health insurance schemes.

Temporal-spatial distribution characteristics and associated socioeconomic factors of visiting frequency for rural patients with hypertension in Fujian Province, Southeast China

BackgroundRegular follow-up and medication can effectively reduce the risk of adverse outcomes for patients with hypertension. This study aimed to explore the temporal-spatial distribution characteristics and associated socioeconomic factors of visiting frequency for rural patients with hypertension in Fujian province from 2011 to 2016.MethodsThe medical records of patients with hypertension were abstracted from the database of New Rural Cooperative Medical Scheme. Geographically and temporally weighted regression model was used to analyze the associations between percentage of patients whose visiting frequency ≥ 4 times within a year and seven socioeconomic factors at the county level.ResultsThe visiting rate of rural patients with hypertension was 0.79%, 1.27%, 1.87%, 2.29%, 2.78%, 3.43% over the six-year study period, respectively. The percentage of patients whose visiting frequency ≥ 4 times within a year gradually increased over time and the percentage ranged from 61 to 80% in a half of the counties by 2016. In general, there was positive association between Gross Domestic Product per capita and the percentage of patients whose visiting frequency ≥ 4 times within a year. The percentage of female patients, percentage of patients who aged ≥ 60 years, percentage of low-income patients, carbon emission intensity, percentage of savings and number of health technicians per 10,000 persons were negatively correlated with the percentage of patients whose visiting frequency ≥ 4 times within a year in most of counties of Fujian Province. In the sensitivity analysis, the percentage of outpatients whose visiting frequency ≥ 4 times within a year was higher than that of all patients. There was positive association between percentage of outpatients who aged ≥ 60 years and the percentage of outpatients whose visiting frequency ≥ 4 times.ConclusionsThe visiting rate and the visiting frequency within a year for rural patients with hypertension in Fujian province need to be improved. Female and elderly patients should be the focus of health management. Effectively implementing the family doctor services, providing several kinds of free antihypertensive drugs, improving energy utilization efficiency and reasonably allocating the health resources may be the effective strategies to improve the follow-up compliance of patients.

Effects of Drug Price Changes on Patient Expenditure: Evidence from China’s Zero Markup Drug Policy

Global society is dedicated to lowering healthcare costs. In China, the rapid growth in drug expenditure has been a major factor in the surge in patient expenditure. To alleviate the negative effect of this phenomenon, China launched the zero markup drug policy (ZMDP) in 2009. However, there is limited direct evidence of its effectiveness in reducing patient costs. Using claims data from January 2012 through May 2016 for enrollees in China’s New Rural Cooperative Medical Scheme (NRCMS) in 25 counties, we investigated the changes in patient expenditure before and after the ZMDP’s implementation. We found that the ZMDP significantly reduced outpatients’ total expenditure (23.66%), reimbursable expenses (24.42%), out-of-pocket (OOP) costs (54.62%), and the OOP costs ratio (14%). Compared with outpatients, the ZMDP’s implementation significantly reduced inpatients’ total expenditure (5.82%) and reimbursable expenses (8.61%) but showed no significant relationship between OOP costs and the OOP costs ratio. Thus, it is important to distinguish outpatients from inpatients, as the ZMDP only significantly reduces outpatients’ OOP costs. We believe that the difference between outpatients and inpatients in the share of drug expenditure (in the total expenditure) when visiting doctors and the shift from drug expenditure to other expenditure categories can explain the ineffectiveness of the policy for inpatients. Therefore, future reforms should focus on reducing inpatient costs.

Growing up without health insurance: Evidence from rural China.

This paper examines the long-term effects of health insurance on children's educational attainment in a developing country. Utilizing the county-by-county rollout of the New Rural Cooperative Medical Scheme in rural China, we find that exposure to the health insurance program in early life leads to improved educational attainment in adulthood. Empirical tests suggest that a short-term increase in health care utilization is unlikely to be a potential channel. We provide some evidence for the channel that health insurance reduces household financial burdens and increases household expenditure on children's nutrition.

How are policy pilots managed? Findings from the New Rural Cooperative Medical Scheme in China

AbstractPolicy piloting has become a popular form of organization in implementing public policies. However, the current literature surprisingly discusses little about its management. This study investigates how two policy-pilot attributes – ambiguity and compatibility – shape policy-pilot management. To accomplish this, we developed an analytic framework consisting of four management strategies: experimentation, refinement, upscaling, and institutionalization. We chose a representative policy pilot in Chinese health governance, the New Rural Cooperative Medical Scheme, to examine the adoption of these four strategies. Our finding that, at various junctures, the Chinese state adopted these four strategies to manage policy piloting demonstrates the applicability of the analytic framework constructed in this study. This study contributes to the existing public policy literature by providing new insights into policy implementation in temporary organizing settings.

Utilization of basic medical insurance data in cancer-related researches in China

Objective: To explore the utilization of cancer-related data from basic medical insurance databases in China, and promote the application of medical insurance data in cancer prevention and treatment. Methods: Database PubMed, Web of Science, Wanfang, and CNKI were used to select related research papers using data from basic medical insurance system in China published by December 2021. Descriptive analysis was conducted in terms of the number of publications, types of cancer, primary research contents and author affiliations. Results: A total of 65 papers were included in the study. The number of publications increased rapidly after 2016. The most studied cancer type was lung cancer, and healthcare costs were the most common research contents. Fujian, Beijing, and Anhui have made a better use of cancer-related medical insurance databases compared to other provincial regions. The accessibility of the New Rural Cooperative Medical Scheme data was limited due to the high regional barriers, while the accessibility of the urban basic medical insurance data was relatively high. The researchers from Peking University and Fudan University had higher utilization of basic medical insurance data compared with those from other institutions. Conclusions: The utilization of cancer-related data from basic medical insurance databases in China is limited because of poor accessibility, insufficient data sharing, and regional restrictions. Thus, it is urgent to improve data accessibility and promote the integration and utilization of regional medical insurance data.

Effects of basic medical insurance integration on subjective wellbeing of residents in China: empirical evidence from a quasi-experiment.

Enhancing the wellbeing of residents through universal health coverage (UHC) is a long-term policy goal for China. In 2016, China integrated the New Rural Cooperative Medical Scheme (NRCMS) and the Urban Resident Basic Medical Insurance (URBMI) into the Urban and Rural Resident Basic Medical Insurance (URRBMI) to address the problem of fragmentation. The objective of this study was to investigate whether the integration of basic medical insurance had an impact on the subjective wellbeing of Chinese residents. Using the China Household Finance Survey data of 2015 and 2019, we empirically estimated the influence of the integration of basic medical insurance on Chinese residents through the difference-in-difference method based on propensity score matching (PSM-DID). Our findings indicate that the integration of basic medical insurance improved the subjective wellbeing of the insured population. Additionally, through heterogeneity testing, we validated that the integration increased the subjective wellbeing of residents from less developed regions in West China and rural areas, as well as those with older adult dependents. However, the subjective wellbeing of low-income groups, who were expected to benefit more from the URRBMI, did not improve significantly, at least in the short term. According to our research, the integration of basic medical insurance in China supports the country's objective of achieving equality and providing universal benefits for its residents. The introduction of the URRBMI has had a positive impact on the subjective wellbeing of insured individuals. This is particularly beneficial for disadvantaged groups in less developed regions, as well as for residents with older adult dependents. However, the subjective wellbeing of the middle-income group has improved significantly, whereas that of the low-income group, despite being the intended beneficiaries of the integration, did not show significant improvement. From a funding perspective, we recommend establishing a dynamic adjustment funding system that links residents' medical insurance funding standards with their disposable income. Regarding the utilization of the URRBMI, the benefit packages should be expanded, particularly by covering more outpatient services through risk pooling. We call for further research with additional data and continued efforts on improving wellbeing of residents, particularly for disadvantaged populations.

Evidence From the China Family Panel Studies Survey on the Effect of Integrating the Basic Medical Insurance System for Urban and Rural Residents on the Health Equity of Residents: Difference-in-Differences Analysis.

The fragmentation of the medical insurance system is a major challenge to achieving health equity. In response to this problem, the Chinese government is pushing to establish the unified Urban and Rural Resident Basic Medical Insurance (URRBMI) system by integrating the New Rural Cooperative Medical Scheme and the Urban Resident Basic Medical Insurance. By the end of 2020, URRBMI had been implemented almost entirely across China. Has URRBMI integration promoted health equity for urban and rural residents? This study aims to examine the effect of URRBMI integration on the health level of residents and whether the integration can contribute to reducing health disparities and promoting health equity. We used the staggered difference-in-differences method based on the China Family Panel Studies survey from 2014 to 2018. Our study had a nationally representative sample of 27,408 individuals from 98 cities. We chose self-rated health as the measurement of health status. In order to more accurately discern whether the sample was covered by URRBMI, we obtained the exact integration time of URRBMI according to the official documents issued by local governments. Finally, we grouped the sample by urban and rural areas, regions, and household income to examine the impact of the integration on health equity. We found that overall, the URRBMI integration has improved the health level of Chinese residents (B=0.066, 95% CI 0.014-0.123; P=.01). In terms of health equity, the results showed that first, the integration has improved the health level of rural residents (B=0.070, 95% CI 0.012-0.128; P=.02), residents in western China (B=0.159, 95% CI 0.064-0.255; P<.001), and lower-middle-income groups (B=0.113, 95% CI 0.004-0.222, P=.04), so the integration has played a certain role in narrowing the health gap between urban and rural areas, different regions, and different income levels. Through further mechanism analysis, we found that the URRBMI integration reduced health inequity in China by facilitating access to higher-rated hospitals and increasing reimbursement rates for medical expenses. However, the integration did not improve the health of the central region and low-income groups, and the lack of access to health care for low-income groups was not effectively reduced. The role of URRBMI integration in promoting health equity among urban and rural residents was significant (P=.02), but in different regions and income groups, it was limited. Focusing on the rational allocation of medical resources between regions and increasing the policy tilt toward low-income groups could help improve the equity of health insurance integration.

A spatiotemporal analysis of the association between carbon productivity, socioeconomics, medical resources and cardiovascular diseases in southeast rural China.

With China's rapid industrialization and urbanization, China has been increasing its carbon productivity annually. Understanding the association between carbon productivity, socioeconomics, and medical resources with cardiovascular diseases (CVDs) may help reduce CVDs burden. However, relevant studies are limited. The study aimed to describe the temporal and spatial distribution pattern of CVDs hospitalization in southeast rural China and to explore its influencing factors. In this study, 1,925,129 hospitalization records of rural residents in southeast China with CVDs were analyzed from the New Rural Cooperative Medical Scheme (NRCMS). The spatial distribution patterns were explored using Global Moran's I and Local Indicators of Spatial Association (LISA). The relationships with influencing factors were detected using both a geographically and temporally weighted regression model (GTWR) and multiscale geographically weighted regression (MGWR). In southeast China, rural inpatients with CVDs increased by 95.29% from 2010 to 2016. The main groups affected were elderly and women, with essential hypertension (26.06%), cerebral infarction (17.97%), and chronic ischemic heart disease (13.81%) being the leading CVD subtypes. The results of LISA shows that central and midwestern counties, including Meilie, Sanyuan, Mingxi, Jiangle, and Shaxian, showed a high-high cluster pattern of CVDs hospitalization rates. Negative associations were observed between CVDs hospitalization rates and carbon productivity, and positive associations with per capita GDP and hospital beds in most counties (p < 0.05). The association between CVDs hospitalization rates and carbon productivity and per capita GDP was stronger in central and midwestern counties, while the relationship with hospital bed resources was stronger in northern counties. Rural hospitalizations for CVDs have increased dramatically, with spatial heterogeneity observed in hospitalization rates. Negative associations were found with carbon productivity, and positive associations with socioeconomic status and medical resources. Based on our findings, we recommend low-carbon development, use of carbon productivity as an environmental health metric, and rational allocation of medical resources in rural China.

Income-related equity in inpatient care utilization and unmet needs between 2013 and 2018 in Tibet, China

BackgroundProviding equitable access to health care for all populations is an important sustainable development goal. China has made significant progress in achieving equity in healthcare utilization. However, research on equity in healthcare utilization in Tibet is sparse. This study aims to evaluate changes in income-related inequity in inpatient care utilization and unmet needs between 2013 and 2018 among the Tibetan population and identify the inequity source.MethodsData for this cross-sectional study were obtained from the fifth and sixth waves of the National Health Services Survey in 2013 and 2018. After excluding observations with missing values for key variables, 11,092 and 10,397 respondents were included in this study, respectively. The outcome variables of interest were inpatient service utilization and unmet hospitalization needs. The concentration index and horizontal inequity index (HI) were used to assess income-related inequity. Non-linear decompositions were performed to identify the main contributors to inequity. In the decomposition method, need variables included sex, age, chronic diseases, and the EuroQol-Visual Analog Scale; non-need variables consisted of income, education, employment status, marital status, and health insurance schemes.ResultsThe probability of inpatient care utilization increased from 6.40% in 2013 to 8.50% in 2018. The HI for inpatient care utilization was 0.19 (P < 0.001) in 2013, whereas it decreased to 0.07 (P < 0.001) in 2018. The contribution of income to inequity in inpatient care utilization decreased from 87.09% in 2013 to 59.79% in 2018. As for unmet inpatient care needs, although its probability increased from 0.76 to 1.48%, the percentage of reasons for financial hardship decreased from 47.62 to 28.57%. The HI for unmet hospitalization need was − 0.07 in 2013 and − 0.05 in 2018, and neither was statistically significant. The New Rural Cooperative Medical Scheme made majority contributions to promote equity in unmet hospitalization need. Moreover, the female respondents reporting low EuroQol-Visual Analog Scale scores and patients with chronic disease were not only more likely to seek for inpatient care, but also have more unmet need than the reference groups.ConclusionsThe inequity in inpatient care utilization in Tibet narrowed from 2013 to 2018, and there was no inequity in unmet hospitalization needs in 2013 and 2018. Income and the New Rural Cooperative Medical Scheme are the main drivers of equity promotion. To promote access to inpatient care utilization and decrease the probability of unmet hospitalization need in future, policymakers should target high-need residents in Tibet to improve accessibility, availability, and acceptability.

Spatial patterns and the associated factors for breast cancer hospitalization in the rural population of Fujian Province, China

BackgroundDespite the known increasing incidence of breast cancer in China, evidence on the spatial pattern of hospitalization for breast cancer is scarce. This study aimed to describe the disparity of breast cancer hospitalization in the rural population of Southeast China and to explore the impacts of socioeconomic factors and heavy metal pollution in soil.MethodsThis study was conducted using the New Rural Cooperative Medical Scheme (NRCMS) claims data covering 20.9 million rural residents from 73 counties in Southeast China during 2015–2016. The associations between breast cancer hospitalization and socioeconomic factors and soil heavy metal pollutants were evaluated with quasi-Poisson regression models and geographically weighted Poisson regressions (GWPR).ResultsThe annual hospitalization rate for breast cancer was 101.40/100,000 in the studied area and the rate varied across different counties. Overall, hospitalization for breast cancer was associated with road density (β = 0.43, P = 0.02), urbanization (β = 0.02, P = 0.002) and soil cadmium (Cd) pollution (β = 0.01, P = 0.02). In the GWPR model, a stronger spatial association of Cd, road density and breast cancer hospitalization was found in the northeast regions of the study area while breast cancer hospitalization was mainly related to urbanization in the western regions.ConclusionsSoil Cd pollution, road density, and urbanization were associated with breast cancer hospitalization in different regions. Findings in this study might provide valuable information for healthcare policies and intervention strategies for breast cancer.

Socioeconomic Inequality and Associated Factors Affecting Health Care Utilization among the Elderly: Evidence from the China Health and Retirement Longitudinal Study

Background: Elderly population is particularly vulnerable to socioeconomic disparities. This study assessed inequalities in health care utilization among the elderly in China and identified contributing factors. Methods: This study used data from the 2018 China Health and Retirement Longitudinal Study survey. A non-linear probit regression model based on the Andersen Health Care Utilization Model was used to identify determinants of health care utilization among the elderly. The concentration index (CI) and the decomposition of the CI were calculated to evaluate inequalities in health care utilization among the elderly and identify related contributors. Results: The CI for actual and standardized outpatient visits was 0.0889 and 0.0945, respectively, and the corresponding values for inpatient service utilization were 0.1134 and 0.1176, respectively. Factors that contributed to greater inequalities in the utilization of outpatient and inpatient service included income (73.68% for outpatient service; 85.20% for inpatient service), Urban Employee Basic Medical Insurance (UEBMI) (40.75% for outpatient service; 32.03% for inpatient service) and non-agricultural Hukou status (12.63% for outpatient service; 18.73% for inpatient service). New Rural Cooperative Medical Scheme (NRCMS) (−34.30% for outpatient service; −33.18% for inpatient service) and poor health status (−7.36% for outpatient service; −8.30% for inpatient service) reduced inequalities in outpatient and inpatient utilization. Conclusions: This study found that a key contributor to these inequalities was income, followed by UEBMI coverage. Meanwhile, health care coverage through NRCMS was associated with fewer disparities in health care utilization.

The impact of integrated urban and rural resident basic medical insurance on health service equity: Evidence from China.

Many countries and regions worldwide are improving their healthcare systems through the integration and unification of health insurance programs covering different groups of people. In China, the past 10 years has been the time when Chinese government promote the Urban and Rural Residents Basic Medical Insurance (URRBMI) by integrating the Urban Residents' Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS). To evaluate the impact of the URRBMI on equity in relation to health services. The quantitative data used in this study were obtained from the CFPS 2014-2020 database, and all respondents with health insurance type UEBMI, URBMI, and NRCMS were included. UEBMI respondents were set as the control group and URBMI or NRCMS as the intervention group, and a DID method model was used to analyze the impact of integrating health insurance on health service utilization, costs and health status. Heterogeneity analysis was also conducted after stratifying the sample according to income level and chronic disease status. This was done to investigate whether there were differences in the effects of the integrated health insurance program across different social groups. The implementation of URRBMI is found to be associated with a significant increase in inpatient service utilization (OR = 1.51, P < 0.01) among rural Chinese residents. Regression results by income stratum show that the utilization of inpatient services increased in rural areas for high-, middle- and low-income groups, with the fastest increase (OR = 1.78, P < 0.05) emerging for low-income groups. Analysis by chronic disease status shows that rural residents with chronic disease are associated with a higher increase in hospitalization rates (OR = 1.64, P < 0.01). The implementation of URRBMI is found to have improved health insurance's ability to withstand risks and effectively improve access to health services for rural residents. In this regard, it can be considered as playing a positive role in bridging the gap in health service utilization between rural and urban areas and in improving regional equity.

Ambient nitrogen dioxide and cardiovascular diseases in rural regions: a time-series analyses using data from the new rural cooperative medical scheme in Fuyang, East China.

Most of studies relating ambient nitrogen dioxide (NO2) exposure to hospital admissions for cardiovascular diseases (CVDs) were conducted among urban population. Whether and to what extent these results could be generalizable to rural population remains unknown. We addressed this question using data from the New Rural Cooperative Medical Scheme (NRCMS) in Fuyang, Anhui, China. Daily hospital admissions for total CVDs, ischaemic heart disease, heart failure, heart rhythm disturbances, ischaemic stroke, and haemorrhagic stroke in rural regions of Fuyang, China, were extracted from NRCMS between January 2015 and June 2017. A two-stage time-series analysis method was used to assess the associations between NO2 and CVD hospital admissions and the disease burden fractions attributable to NO2. In our study period, the average number (standard deviation) of hospital admissions per day were 488.2 (117.1) for total CVDs, 179.8 (45.6) for ischaemic heart disease, 7.0 (3.3) for heart rhythm disturbances, 13.2 (7.2) for heart failure, 267.9 (67.7) for ischaemic stroke, and 20.2 (6.4) for haemorrhagic stroke. The 10-μg/m3 increase of NO2 was related to an elevated risk of 1.9% (RR: 1.019, 95% CI: 1.005 to 1.032) for hospital admissions of total CVDs at lag0-2days, 2.1% (1.021, 1.006 to 1.036) for ischaemic heart disease, and 2.1% (1.021, 1.006 to 1.035) for ischaemic stroke, respectively, while no significant association was observed between NO2 and hospital admissions for heart rhythm disturbances, heart failure, and haemorrhagic stroke. The attributable fractions of total CVDs, ischaemic heart disease, and ischaemic stroke to NO2 were 6.52% (1.87 to 10.94%), 7.31% (2.19 to 12.17%), and 7.12% (2.14 to 11.85%), respectively. Our findings suggest that CVD burdens in rural population are also partly attributed to short-term exposure to NO2. More studies across rural regions are required to replicate our findings.

Short-term and long-term effects of Sanming healthcare system reform on drug-related expenditures for rural patients with cancer in public hospitals: an interrupted time series analysis using segmented regression model in China

ObjectivesTo assess the effects of ‘Sanming model’ on drug-related expenditures.DesignInterrupted time series analysis with two time points was conducted to analyse the effects of ‘Sanming model’ using segmented regression model.SettingTwo...

Income-related health inequality among rural residents in western China.

Health equality has drawn much public attention in both developed and developing countries. China, the largest developing country, has implemented a new round of health system reform to improve health equality since 2009. This study aims to examine the magnitude and sources of income-related health inequality in western rural regions of China. Data were obtained from the Survey of Rural Economic and Social Development in Western China conducted in 2014, in which 14,555 individuals from 5,299 households in 12 provinces were included. Health outcome variables of interest were self-rated health status, prevalence of chronic disease and four-week illness. Concentration index was calculated to assess magnitude of income-related health inequality, and nonlinear decomposition analysis was performed to identify the sources of health inequality. The Concentration indexes for poor self-rated health status, prevalence of chronic disease and four-week illness were -0.0898 (P<0.001),-0.0860 (P<0.001) and -0.1284 (P<0.001), respectively. Income and education were two main sources of health inequality, accounting for about 25-50% and 15% contribution to the inequality. Ethnicity made <10% contribution to income-related health inequality, and enrollment in New Rural Cooperative Medical Scheme contributed to <1%. This study found slight income-related health inequality among rural residents in western China, implying that although China has made substantial progress in economic development and poverty alleviation, health inequality in western rural region should still be concerned by the government. To achieve health equality further, the Chinese government should not only strengthen its reimbursement mechanism of the current health insurance scheme to improve affordability of primary healthcare for residents in western rural regions, but also implement health poverty alleviation policies targeting socioeconomically vulnerable population and ethnic minorities in future.

Drivers of high-cost persistence in rural China: A population-based retrospective study.

High-cost patients account for over 70% of total health expenditures in rural China and have become a key focus of health insurers. Persistently high-cost patients constitute a substantial proportion of medical resources. Hence, exploring high-cost persistence (HCP) and what drives it is considered meaningful and necessary. A population-based retrospective study was carried out. The annual healthcare utilization data of Dangyang New Rural Cooperative Medical Scheme from 2012 to 2017 were analyzed. Patients in the top 10% of spending in a given year were considered high-cost patients. Persistence level was estimated using Markov matrices. A total of 19,405 patients categorized as high-cost patients in 2016 were divided into two groups according to whether or not they kept high-cost status in 2017. Finally, a multilevel logistic regression model was used in examining the determinants of HCP. On average, about 31.48% of high-cost patients each year still maintained high-cost status in the subsequent year from 2012 to 2017. The elderly (OR = 2.150), families with more non-labor members (OR = 2.307), families applying for subsistence allowances (OR = 1.245), and patients with blood and immune diseases (OR = 2.614) or malignant tumors (OR = 2.077) were more likely to maintain high-cost status. Hospitalization frequency was found to be a mediator. About one-third of high-cost patients in a given year had persistently high cost status in the subsequent year. Health status and family support were considered the main drivers of HCP. High inpatient service utilization as a mediator was a prominent manifestation of persistently high-cost patients. The accurate identification of persistently high-cost patients is the basis for our management.