Over- and under-treatment of TB patients in Eastern China: an analysis based on health insurance claims data

Differences Between the Local and Migrant Populations in Healthcare Service Use and Direct Cost of Tuberculosis Treatment - Shanghai Municipality, China, 2020-2021

What is already known about this topic?

Tuberculosis (TB) disproportionately affects socially vulnerable populations, particularly the migrant population. Shanghai has implemented a policy providing additional reimbursement for TB diagnosis and treatment beyond standard health insurance coverage for residents. However, comprehensive evidence on TB care utilization patterns and treatment costs remains limited, especially on the disparities between local and migrant populations.

What is added by this report?

From 2020 to 2021, local and migrant TB patients in Shanghai demonstrated comparable outpatient visit frequencies with an overall hospitalization rate of 85.7%. Migrant TB patients without resident permits are ineligible for government reimbursement, resulting in over half of the patients encountering out-of-pocket costs that exceed 20% of their annual household income for TB treatments.

What are the implications for public health practice?

The government's reimbursement policy should be expanded to include the most vulnerable populations, specifically migrant patients without residency permits, to strengthen the financial risk protection for TB patients.

Factors Associated with Non-Adherence to Treatment Among Migrants with MDR-TB in Wuhan, China: A Cross-Sectional Study

Background

Multidrug resistant tuberculosis (MDR-TB) has attracted increasing attention in achieving the global goal of tuberculosis (TB) control. China has the second largest TB burden worldwide and has been experiencing large-scale domestic migration. This study aims to explore the effect of migrants on non-adherence to MDR-TB treatment.

Materials and Methods

A cross-sectional study was carried out in Wuhan, China. The exposure cases were migrants who were not locally registered in the residence registration system. The control cases were local residents. Non-adherence cases were patients who were lost follow-up or refused treatment. Chi-square and t-test were used to compare variables between migrants and local residents. Logistic regression models using enter method were used to determine the relationship between migration and non-adherence to treatment. Moderation and medication effects on the association between migrant status and non-adherence were also explored.

Results

We studied 73 migrants and 219 local residents. The migrants, who did not to adhere to treatment (55, 75.3%), was far higher than that of local residents (89, 40.6%). Migrants with MDR-TB had 10.38-times higher difficulty in adhering to treatment (adjusted OR = 10.38, 95% CI 4.62-25.28) than local residents. This additional likelihood was moderated by age and treatment registration group. Migration had an indirect association with non-adherence to treatment via social medial insurance (adjusted OR = 1.05, 95% CI 1.01-1.13).

Conclusion

There a significant increased likelihood of non-adherence to treatment among migrants with MDR-TB, highlighting the importance of improving treatment adherence in this population. Migration prevented migrants from gaining access to social medical insurance and indirectly reduced their likelihood of adherence to treatment.

Overuse of medications in low- and middle-income countries: a scoping review

Objective

To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions.

Methods

We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions.

Findings

We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives.

Conclusion

Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

Differences in medical costs among urban lung cancer patients with different health insurance schemes: a retrospective study

Background

Health insurance plays a significant role in reducing the financial burden for lung cancer patients. However, limited research exists regarding the differences in medical costs for lung cancer patients with different insurance schemes across different cities. We aimed to assess disparities in lung cancer patients’ costs by insurance type and city–specific insurance type.

Methods

Claim data of China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) between 2010 and 2016 were employed to investigate differences in medical costs. This study primarily applied descriptive analysis and a generalized linear model with a gamma distribution and a log link.

Results

In total, 92,856 lung cancer patients with inpatient records were identified, with Renminbi (RMB) 11,276 [6322–20,850] (median [interquartile range]) medical costs for the UEBMI group and RMB 8303 [4492–14,823] for the URBMI group. Out–of–pocket (OOP) expenses for the UEBMI group was RMB 2143 [1108–4506] and RMB 2975 [1367–6275] for the URBMI group. The UEBMI group also had significantly higher drug costs, medical service costs, and medical consumable costs, compared to the URBMI group. Regarding city-specific insurances, medical costs for the UEBMI and the URBMI lung cancer patients in Shanghai were RMB 9771 [5183–16,623] and RMB 9741 [5924–16,067], respectively. In Xianyang, the medical costs for UEBMI and URBMI patients were RMB 11,398 [6880–20,648] and RMB 9853 [5370–24,674], respectively. The regression results showed that the UEBMI group had 27.31% fewer OOP expenses than the URBMI group did, while patients in Xiangyang and Xianyang had 39.53 and 35.53% fewer OOP expenses, respectively, compared to patients in Shanghai.

Conclusions

Compared with the URBMI patients, the UEBMI lung cancer patients obtained more or even better health services and had reduced financial burden. The differences in insurances among cities were greater, compared to those among insurances within cities, and the differences in OOP expenses between cities were greater compared to those between UEBMI and URBMI. Our results called for further reform of China’s fragmented insurance schemes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07957-9.

How to Effectively Identify Patients With Rifampin-Resistant Tuberculosis in China: Perspectives of Stakeholders Among Service Providers

To evaluate China's current rifampin-resistant tuberculosis (RR-TB) screening strategy from stakeholders' perspectives, the perceptions, attitudes, and interests of 245 stakeholders from three eastern, central, and western China provinces on RR-TB screening strategies, were investigated through stakeholder survey and interview. The attitudes toward three RR-TB screening strategies were statistically different: inclination to choose who to screen (Z = 98.477; P < 0.001), funding for rapid diagnostic technology screening either by reimbursed health insurance or directly subsidized financial assistance (Z = 4.142, P < 0.001), and respondents' attitude during RR-TB screening implementation levels (Z = 2.380, P = 0.017). In conclusion, RR-TB screening scope could be expanded by applying rapid diagnostic technologies. Provinces with different economic status could adjust their screening policies accordingly.

Equity in Healthcare Financing Following the Introduction of the Unified Residents' Health Insurance Scheme in China

This study sought to explore whether there are significant disparities in the financing of healthcare between urban and rural populations following the introduction in 2016 of the Urban and Rural Resident Basic Medical Insurance (URRBMI) scheme in China. We used household survey data from Heilongjiang province to estimate separate concentration curves in the financing burden and the resultant Kakwani indices (KIs) for urban and rural populations. This enabled assessment of the progressivity (or otherwise) of this burden. The results show that in urban areas indirect taxes were proportional (KI = 0.0009, p = 0.8449), while indirect taxes in rural areas were progressive (KI = 0.0284, p = 0.0002). In both urban and rural areas, direct taxes were found to be progressive (urban: KI = 0.4628, p < 0.0001; rural: KI = 0.4087, p = 0.0064), while URRBMI was regressive (urban: KI = -0.6236, p < 0.0001; rural: KI = -0.4325, p < 0.0001). Out-of-pocket payments were proportional in urban areas (KI = -0.0064, p = 0.7490); in contrast, they were regressive in rural areas (KI = -0.1078, p = 0.0012). Overall, the burden of healthcare finance in urban China was found to be neither regressive nor progressive (KI = -0.0142, p = 0. 1397), whereas in rural China it was found to be regressive (KI = -0.1208, p < 0.0001). This result is driven by high reliance on regressive forms of funding, namely, fixed contributions to URRBMI, out-of-pocket costs and private health insurance. It is concluded that achieving equity in health financing in China will require strong measures to reduce the regressivity of financing, particularly for rural populations. This can be achieved through a shift towards means-adjusted URRBMI contributions, a greater reliance on tax-based financing and reducing the reliance on out-of-pocket payments and private health insurance.

Access to quality diagnosis and rational treatment for tuberculosis: real-world evidence from China-Gates Tuberculosis Control Project Phase III

Background

China has successfully reduced tuberculosis (TB) incidence rate over the past three decades, however, challenges remain in improving the quality of TB diagnosis and treatment. In this paper, we assess the effects of the implementation of “China National Health Commission (NHC) and Gates Foundation TB Prevention and Control Project” on the quality of TB care in the three provinces.

Methods

We conducted the baseline study in 2016 and the final evaluations in 2019 in the 12 selected project counties. We obtained TB patients’ information from the TB Information Management System and reviewed medical records of TB cases in the TB designated hospitals. We compared TB diagnosis and treatment services with the national practice guideline and used Student’s t-test and Pearson χ² tests or Fisher’s exact tests to compare the difference before and after the project implementation.

Results

The percentage of sputum smear-negative (SS–) patients taking culture or rapid molecular test (RMT) doubled between 2015 and 2018 (from 35% to 87%), and the percentage of bacteriologically confirmed pulmonary TB cases increased from 36% to 52%. RMT has been widely used and contributed an additional 20% of bacteriologically confirmed TB cases in 2018. The percentage of TB patients taking drug susceptibility tests (DST) also doubled (from 40% in 2015 to 82% in 2018), and the proportion of TB patients receiving adequate diagnosis services increased from 85% to 96%. Among all SS– TB patients, over 86% received the recommended diagnostic services at the end of the study period, an improvement from 75% prior to the project implementation. However, the proportion of TB patients treated irrationally using second-line anti-TB drugs (SLDs) increased from 12.6% in 2015 to 19.9% in 2018. The regional disparities remained within the project provinces, albeit the gaps between them narrowed down for almost all indicators.

Conclusions

The quality of TB diagnosis services has been improved substantially, which is attributable to the coverage of new diagnosis technology. However, irrational use of SLDs remains a concern after the project implementation.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00875-8.

Implementing a new tuberculosis surveillance system in Zhejiang, Jilin and Ningxia: improvements, challenges and implications for China's National Health Information System

BACKGROUND

China is still faced with the public health challenge of tuberculosis (TB), and a robust surveillance system is critical for developing evidence-based TB control policies. The Tuberculosis Information Management System (TBIMS), an independent system launched in 2005, has encountered several challenges in meeting the current needs of TB control. The Chinese government also planned to establish the National Health Information System (NHIS) aggregating data in different areas. The China National Health Commission-Gates TB Project Phase III launched a new TB surveillance system to address these challenges and also as a pilot for the countrywide implementation of the NHIS. This commentary highlights the improvements and challenges in implementing the new TB system and also discusses the implications for the roll-out of the NHIS.

MAIN TEXT

The new TB surveillance system piloted in each prefecture of the project provinces was designed based on the local information system under the unified principle of organizing patient information under a unique ID and realizing the function of data exchange. Upon mid-2019, the data exchange successful rate reached almost 100%, and the system showed good performance in data completeness. Major improvements of the new system included achieving automatic data extraction instead of manual entry, assisting clinical service provision, and the augmented statistical functions. The major challenges in the implementation and scale-up of the new system were the licensing issue and the diversities of infrastructures that hinder the promotion of the new system at a low cost. This pilot also accumulated experiences for the roll-out of the NHIS regarding the technical solutions of reforming current information systems as well as effective training approaches for the developers and users of the new system.

CONCLUSIONS

The successful implementation of the new TB surveillance system in the three TB designated medical institutions demonstrated how the diverse infrastructures of the information system could be reformed to achieve the functions of automatic data extraction and data exchange and better cater to the needs of healthcare workers. This pilot also accumulated rich experiences and lessons learnt for developing technical solutions and personnel training for the scale-up of the NHIS.

Spatiotemporal characteristics and the epidemiology of tuberculosis in China from 2004 to 2017 by the nationwide surveillance system

Background

China has always been one of the countries with the most serious Tuberculosis epidemic in the world. Our study was to observe the Spatial-temporal characteristics and the epidemiology of Tuberculosis in China from 2004 to 2017 with Joinpoint regression analysis, Seasonal Autoregressive integrated moving average (SARIMA) model, geographic cluster, and multivariate time series model.

Methods

The data of TB from January 2004 to December 2017 were obtained from the notifiable infectious disease reporting system supplied by the Chinese Center for Disease Control and Prevention. The incidence trend of TB was observed by the Joinpoint regression analysis. The Seasonal autoregressive integrated moving average (SARIMA) model was used to predict the monthly incidence. Geographic clusters was employed to analyze the spatial autocorrelation. The relative importance component of TB was detected by the multivariate time series model.

Results

We included 13,991,850 TB cases from January 2004 to December 2017, with a yearly average morbidity of 999,417 cases. The final selected model was the 0 Joinpoint model (P = 0.0001) with an annual average percent change (AAPC) of − 3.3 (95% CI: − 4.3 to − 2.2, P < 0.001). A seasonality was observed across the 14 years, and the seasonal peaks were in January and March every year. The best SARIMA model was (0, 1, 1) X (0, 1, 1)₁₂ which can be written as (1-B) (1-B¹²) X_t = (1–0.42349B) (1–0.43338B¹²) ε_t, with a minimum AIC (880.5) and SBC (886.4). The predicted value and the original incidence data of 2017 were well matched. The MSE, RMSE, MAE, and MAPE of the modelling performance were 201.76, 14.2, 8.4 and 0.06, respectively. The provinces with a high incidence were located in the northwest (Xinjiang, Tibet) and south (Guangxi, Guizhou, Hainan) of China. The hotspot of TB transmission was mainly located at southern region of China from 2004 to 2008, including Hainan, Guangxi, Guizhou, and Chongqing, which disappeared in the later years. The autoregressive component had a leading role in the incidence of TB which accounted for 81.5–84.5% of the patients on average. The endemic component was about twice as large in the western provinces as the average while the spatial-temporal component was less important there. Most of the high incidences (> 70 cases per 100,000) were influenced by the autoregressive component for the past 14 years.

Conclusion

In a word, China still has a high TB incidence. However, the incidence rate of TB was significantly decreasing from 2004 to 2017 in China. Seasonal peaks were in January and March every year. Obvious geographical clusters were observed in Tibet and Xinjiang Province. The relative importance component of TB driving transmission was distinguished from the multivariate time series model. For every provinces over the past 14 years, the autoregressive component played a leading role in the incidence of TB which need us to enhance the early protective implementation.

Determinants of Medication Adherence for Pulmonary Tuberculosis Patients During Continuation Phase in Dalian, Northeast China

PURPOSE

Medication adherence is crucial for decreasing the burden of tuberculosis, but few relevant studies have been conducted in northeast China. This study aimed to explore the level of medication adherence among pulmonary tuberculosis outpatients and the predictive factors based on the bio-psycho-social medical model.

PATIENTS AND METHODS

A cross-sectional multi-center survey was conducted in four tuberculosis medical institutions in Dalian, northeast China. Medication adherence was measured using the eight-item Chinese version of the Morisky Medication Adherence Scale, which divides adherence into three levels. The independent variables consisted of sociodemographic characteristics, treatment factors, knowledge about TB, mental health, and behavioral characteristics. Descriptive statistics, the chi-square test, and multivariate ordinal logistic regression were applied to analyze the data using Stata/MP 14.0.

RESULTS

Among the 564 eligible participants, 236 (41.84%) and 183 (32.45%) exhibited high and medium medication adherence, respectively, but 145 (25.71%) exhibited low medication adherence. Multivariate ordinal logistic regression showed that patients who were older (OR: 1.02, p=0.013) were employed (OR: 1.61, p=0.011), had better tuberculosis knowledge (OR: 1.34, p<0.001), and did not consume alcohol (OR: 1.84, p=0.032) exhibited higher medication adherence. However, patients who did not follow their doctors' advice to take adjuvant drugs (OR: 0.44, p=0.001), had a history of TB treatment (OR: 1.76, p=0.009), experienced adverse drug reactions (OR: 0.65, p=0.017), experienced stigma (OR: 0.67, p=0.032), and needed supervised treatment (OR: 0.66, p=0.012) exhibited lower medication adherence.

CONCLUSION

Tuberculosis patients' medication adherence was not very high and it was influenced by diverse and complex factors involving sociodemographic characteristics, treatment factors, knowledge about TB, mental health, and behavioral characteristics.