Emeritus Professor Stephen Nicholas

Part of the underlying motivation for writing and reading business histories of individual firms has been the promise to gain understanding of general factors in the growth of the industry or the whole economy. In assessing the significance of business history, Barry Supple argued that company histories should provide insights about the wider economic world.1 More specifically, Leslie Hannah has suggested that ¿business history has an important part to play in the explanation of economic growth¿ and Roy Church has endorsed Peter Payne¿s view that business history is the ¿grass roots approach to economic history¿.2 Asa Briggs included amongst his reasons for writing business history the illumination of many general points both in economic and social history 3.

Background: Continuing Medical Education (CME) is an important part of the training process for health workers worldwide. In China, training in Traditional Chinese Medicine (TCM) not only improves the expertise of medical workers, but also supports the Chinese Government¿s policy of promoting TCM as an equal treatment to western medicine. CME, including learning Traditional Chinese Medicine Technologies (TCMTs), perform poorly and research into the motivation of health workers to engage in CME is urgently required. Using a discrete choice experiment, this study assessed the CME learning preferences of primary health workers, using TCMT as a case study of CME programs. Methods: We conducted a discrete choice experiment among health workers in Shandong Province, Guizhou Province, and Henan provinces from July 1, 2021 to October 1, 2022 on the TCMT learning preferences of primary health workers. The mixed logit model and latent class analysis model were used to analyze primary health workers¿ TCMT learning preferences. Results: A total of 1,063 respondents participated in this study, of which 1,001 (94.2%) passed the consistency test and formed the final sample. Our key finding was that there were three distinct classes of TCMT learners. Overall, the relative importance of the seven attributes impacting the learning of TCMTs were: learning expenses, expected TCMT efficacy, TCMT learning difficulty, TCMT mode of learning, TCMT type, time required to learn, and expected frequency of TCMT use. However, these attributes differed significantly across the three distinct classes of TCMT learners. Infrequent users (class 1) were concerned with learning expenses and learning difficulty; workaholics (class 2) focused on the mode of learning; and pragmatists (class 3) paid more attention to the expected TCMT efficacy and the expected frequency of TCMT use. We recommend targeted strategies to motivate TCMT learning suited to the requirements of each class of TCMT learners. Conclusion: Rather than a single TCMT medical education program for primary health workers, CME programs should be targeted at different classes of TCMT learners.

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

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

Objective: In China, rural residents experience poorer health conditions and a higher disease burden compared to urban residents but have lower healthcare services utilization. Rather than an insurance focus on enhanced healthcare services utilization, we aim to examine that whether an income shock, in the form of China¿s New Rural Pension Scheme (NRPS), will affect outpatient, inpatient and discretionary over-the-counter drug utilization by over 60-year-old rural NRPS residents. Methods: Providing a monthly pension of around RMB88 (USD12.97), NRPS covered all rural residents over 60¿years old. Fuzzy regression discontinuity design (FRDD) was employed to explore the NRPS causal effect on healthcare services utilization, measured by outpatient and inpatient visits and discretionary over-the-counter drug purchases. The nationwide China Health and Retirement Longitudinal Study (CHARLS) 2018 provided the data. Results: Without significant changes in health status and medication needs, 60-plus-year-old NRPS recipients significantly increased the probability of discretionary OTC drug purchases by 33 percentage points. NRPS had no significant effect on the utilization of outpatient and inpatient utilization. The increase in the probability of discretionary OTC drug purchases from the NRPS income shock was concentrated in healthier and low-income rural residents. Robustness tests confirmed that FRDD was a robust estimation method and our results are robust. Conclusion: NRPS was an exogenous income shock that significantly increased the probability of discretionary over-the-counter drug purchases among over 60-year-old rural residents, but not the utilization of inpatient or outpatient healthcare services. Income remains an important constraint for rural residents to improve their health. We recommend policymakers consider including commonly used over-the-counter drugs in basic health insurance reimbursements for rural residents; provide health advice for rural residents to make discretionary over-the-counter drug purchases; and to mount an information campaign on over-the-counter drug purchasing in order to increase the health awareness of rural residents.

Objectives: Knowledge of the predictors of nursing quality and safety remains a gap in global primary care research. This study examines organisational-level and nurse-level predictors of nurse-reported quality of care from a management perspective. Methods: We recruited 175 primary care nurses in 38 community health centres (CHCs) varying by size and ownership in Jinan, Tianjin, Shenzhen and Shanghai. Guided by the Systems Engineering Initiative for Patient Safety model, the organisation-level predictors comprised organisational structure, organisational culture, psychological safety and organisational support, while the nurse-level predictors included organisational commitment and organisational citizenship behaviour. Nurse-reported quality of care was measured by two questions: ¿How do you rate the quality of care that you provide?¿ and ¿Do you often receive complaints from patients or their family members at work?¿ Multilevel linear regression models were used to examine the predictors of nurse-reported quality of care. Results: Among the four organisation-level predictors, organisational structure, psychological safety and organisational support were positive predictors of nurse-reported quality of care. Nurses working in CHCs with highly hierarchical organisational structures (Coef.¿=¿0.196, p¿=¿0.000), a high level of organisational support (Coef.¿=¿0.158, p¿=¿0.017) and a high level of psychological safety (Coef.¿=¿0.159, p¿=¿0.035) were more likely to report high quality of care or less likely to receive medical complaints. In terms of nurse-level predictors, nurses willing to increase their knowledge through continuous education were more likely to report good quality of care (Coef.¿=¿0.107, p¿=¿0.049) and less likely to receive medical complaints from patients (Coef.¿=¿0.165, p¿=¿0.041). Conclusions: Potential management levers to improve quality of nursing care include formalised organisational structures, strong organisational support and a psychologically safe environment as well as the provision of training to facilitate continuous education. Implementing these recommendations is likely to enhance the nursing¿quality in primary care.

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

Ambient air pollution is a major public health concern impacting all aspects of human health. There is a lack of studies on the impact of ambient air pollution on health-related quality of life (HRQoL) of older Chinese adults. Our study answers two questions: How concentrations of ambient air pollutants are associated with HRQoL among older adults in China and, second, what are the possible mechanisms through which ambient air pollution affects HRQoL. From the 2018 National Health Service Survey, we sampled 5717 aged 65 years or older residents for the eastern province of Shandong, China. Data on individual exposures to PM2.5 and PM10 (particulate matter with diameter less than or equal to 2.5 µm and 10 µm) and sulfur dioxide (SO2) were collected from the ChinaHighAirPollutants (CHAP) datasets. Mixed-effects Tobit regression models and mixed-effects ordered Probit regression models were employed to examine the associations of long-term exposure to ambient air pollution with the European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) scale comprising mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Socioeconomic, demographic and behavioral factors relating to HRQoL were also examined. The results show that for each 1 µg/m3 increase, EQ-5D-3L scores fell 0.002 for PM2.5; 0.001 for PM10 and 0.002 for SO2. Long term exposure to PM2.5, PM10 and SO2 were also associated with increased prevalence of pain/discomfort and anxiety/depression. The reduced HRQoL effects of ambient air pollution were exacerbated by higher socioeconomic status (affluent, urban and higher level of education). Our findings suggested that HRQoL of older Chinese adults was not only associated with demographic, socioeconomic, and health-related factors, but also negatively correlated with air pollution, especially through increased pain/discomfort and anxiety/depression. The paper proposes policy recommendations.

Background: Total healthcare expenditures are concentrated among a small number of patients. To date, studies on the concentration of health care expenditures in developing countries are limited, mainly focusing on concentration measures and the demographic, clinical and socioeconomic characteristics of high-cost users (HCU). The drivers of the skewed overall distribution of health care expenditures are opaque. Using inpatient administrative claims data, this study provides new evidence on the concentration of healthcare expenditures in China; the demographic and clinical characteristics of high-cost users; and the drivers of the overall distribution of healthcare expenditures. Methods: Utilizing administrative claims data for hospitalization in a prefecture-level city in China, we investigated the concentration of healthcare expenditure. We used recentered influence function (RIF) regression to examine the drivers of healthcare expenditure concentration, decomposing and estimating the effects of demographic and disease characteristics on the overall distribution of health care expenditures. Results: Using a sample of 87,841 adults, we found extreme skewness in the distribution of inpatient medical expenditures in China, with approximately 49% of annual medical expenditures generated by the top 10% of inpatient groups. HCUs tend to be elderly and male, with high-frequency hospitalizations and long lengths of stay. In addition, healthcare expenditure concentration was related to diseases of the circulatory system, malignant neoplasms, diseases of the musculoskeletal system and connective tissue, diseases of the digestive system, injury and poisoning, and diseases of the respiratory system. Malignant and major diseases reinforced the concentration of healthcare spending, and a 10% increase in the prevalence of malignancy would result in a predicted Gini coefficient increase of 7.2%, heart disease of 0.92% and cerebrovascular disease of 1.5%. The above significant positive effects were not observed for hypertension and diabetes mellitus. Conclusions: Our study provides new insights into the concentration of inpatient medical expenditures in China, including the precise picture of HCU expenditure concentration, the drivers of HCU expenditure concentration and the magnitude of their impact. With the aging of China's population and the profound shift in the disease spectrum, policymakers need to strengthen the early detection and intervention management of specific chronic diseases and high-risk populations, especially the early diagnosis and treatment of key cancers.

Background: Over 26 million recovered COVID-19 patients will suffer from discrimination in work, education and social interactions. We analyzed the determinants of discrimination against recovered COVID-19 patients and suggest policy recommendations to reduce such discrimination. Methods: Twenty-seven Chinese cities were selected randomly based on their geographical location and GDP rank. One hundred adults were interviewed in each city with an equal number of men and women and three urban residents for every two rural residents. A multiple ordered logistic regression model was used to assess the associations between potential determinants and the COVID-19 discrimination level. Results: Of 2377 participants, 79.76% displayed discrimination toward recovered COVID-19 patients. The female discrimination level was 1.25 times that of males; the discrimination level increased with age; and was occupation-specific, with physicians¿ (OR¿=¿0.352) and students¿ (OR¿=¿0.553) discrimination level lower than that of farmers. The discrimination level of participants from the central regions was 1.828 times, and the eastern region 1.504 times, that of participants from western region. The participants¿ discrimination level was lower when they scored higher in transmission knowledge, prevention knowledge and other COVID-19 knowledge, treatment methods and quarantine time. Conclusion: Sex, age, occupation, infections of relatives and friends, regions and scores on COVID-19 knowledge were determinants of discrimination level against recovered COVID-19 patients. In contrast with qualitative studies, our quantitative study recommends targeted education campaigns, focusing on physicians, women, older people and certain occupations. Only the COVID-19 vaccination program for the whole population will resolve the COVID-19 discrimination problem.

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

Importance: In China, little is known about end-of-life (EOL) care preferences of patients with terminal cancer. Understanding these patients' treatment preferences is needed to improve patient-centered health care, better inform surrogates and medical staff about patient preferences, and enhance the quality of EOL care. Objective: To examine preferences for EOL care among patients with terminal cancer in China. Design, Setting, and Participants: In this survey study, patients older than 50 years who had terminal cancer were randomly selected from medical records at a single hospital in China. Data on patients' EOL care preferences were collected by discrete choice experiment (DCE) from August to November 2018 and were analyzed from October 2020 to March 2021. Main Outcomes and Measures: The main outcome was patient preferences in EOL care, derived using a mixed logit model. Each DCE scenario described 6 attributes: hospitalization days, life extension, quality of life, adverse treatment events, place-of-death preference, and out-of-pocket costs. The marginal willingness to pay (WTP) in US dollars was estimated from regression coefficients. Results: Of 188 patients selected for the survey, 183 participated (97.3%). Among the respondents, the mean [SD] age was 61 [8.4] years, and 128 (69.8%) were male. Patients' preferences for moderate increase in survival time, better quality of life, death at home, and lower out-of-pocket costs were significantly associated with their choices between treatment models. Extending life by 10 months (vs 4 months: ß, 1.63; 95% CI, 0.81-2.44) and a better quality of life (very good vs poor: ß, 1.79; 95% CI, 0.96-2.62) were the most important attributes to patients. The uptake rate for a treatment scenario increased by 61.6% when the quality of life improved from poor to very good, and when life extension increased from 4 months to 10, the uptake rate increased by 57.2%. The uptake increased by 12.5% when the place of death changed from hospital to home. However, it decreased by 31.4% when the costs increased to $21174. The study found a WTP of $38854 (95% CI, $19468-$95096) to improve quality of life from a poor to a very good level, substantially higher than the WTP for a life extension of 6 months ($35308; 95% CI, $17745-$80279) or 1 year ($27572; 95% CI, $16389-$58027) compared with the baseline scenario of a 4-month extension. Patients were willing to pay $8860 (95% CI, $621-$26474) to die at home rather than in a hospital. Conclusions and Relevance: The findings suggest that in addition to extending life moderately for patients with terminal cancer, improving quality of life during EOL care and supporting home deaths may deserve greater attention. The findings also suggest that physicians and surrogates should ask about patients' care preferences and better inform them of their choices to improve EOL care outcomes.

Background: Hemophilia care in mainland China has been greatly improved since the establishment of the Hemophilia Treatment Center Collaborative Network of China (HTCCNC), and most of drugs for hemophilia have been covered by basic medical insurance schemes. This study assesses whether medical costs and hospital utilization disparities exist between hemophilia A and hemophilia B urban inpatients in China and, second, whether the prescription of coagulation factor concentrates for hemophilia A and hemophilia B inpatients was optimal, from the third payer perspective. Methods: We conducted a retrospective nationwide analysis based on a 5% random sample from claims data of China Urban Employees¿ Basic Medical Insurance (UEBMI) and Urban Residents¿ Basic Medical Insurance (URBMI) schemes from 2010 to 2016. Univariate analysis and multiple regression analysis based on a generalized linear model were conducted. Result: A total of 487 urban inpatients who had hemophilia were identified, including 407 inpatients with hemophilia A and 80 inpatients with hemophilia B. Total medical cost for hemophilia B inpatients was significantly higher than for hemophilia A inpatients (USD 2912.81 versus USD 1225.60, P <¿0.05), and hemophilia B inpatients had a significantly longer length of hospital stay than hemophilia A inpatients (9.00 versus 7.00, P <¿0.05). Total medical costs were mostly allocated to coagulation factor products (76.86-86.68%), with coagulation factor cost of hemophilia B significantly higher than hemophilia A (P <¿0.05). Both hemophilia cohorts utilized greatest amount of plasma-derived Factor VIII, followed by recombinant Factor VIII and prothrombin complex concentrates. Conclusions: Patients with hemophilia B experienced significantly higher inpatient cost, coagulation factor cost and longer length of hospital stay than patients with hemophilia A. Our findings revealed the suboptimal use of coagulation factor concentrate drugs and a higher drug cost burden incurred by hemophilia B than hemophilia A inpatients. Our results call for efforts to strengthen drug regulatory management for hemophilia and to optimize medical insurance schemes according to hemophilia types.

Background: In this study, we examined the length of stay (LoS)-predictive comorbidities, hospital costs-predictive comorbidities, and mortality-predictive comorbidities in immobile ischemic stroke (IS) patients; second, we used the Charlson Comorbidity Index (CCI) to assess the association between comorbidity and the LoS and hospitalization costs of stroke; third, we assessed the magnitude of excess IS mortality related to comorbidities. Methods: Between November 2015 and July 2017, 5114 patients hospitalized for IS in 25 general hospitals from six provinces in eastern, western, and central China were evaluated. LoS was the period from the date of admission to the date of discharge or date of death. Costs were collected from the hospital information system (HIS) after the enrolled patients were discharged or died in hospital. The HIS belongs to the hospital¿s financial system, which records all the expenses of the patient during the hospital stay. Cause of death was recorded in the HIS for 90 days after admission regardless of whether death occurred before or after discharge. Using the CCI, a comorbidity index was categorized as zero, one, two, and three or more CCI diseases. A generalized linear model with a gamma distribution and a log link was used to assess the association of LoS and hospital costs with the comorbidity index. Kaplan¿Meier survival curves was used to examine overall survival rates. Results: We found that 55.2% of IS patients had a comorbidity. Prevalence of peripheral vascular disease (21.7%) and diabetes without end-organ damage (18.8%) were the major comorbidities. A high CCI=3+ score was an effective predictor of a high risk of longer LoS and death compared with a low CCI score; and CCI=2 score and CCI=3+ score were efficient predictors of a high risk of elevated hospital costs. Specifically, the most notable LoS-specific comorbidities, and cost-specific comorbidities was dementia, while the most notable mortality-specific comorbidities was moderate or severe renal disease. Conclusion: CCI has significant predictive value for clinical outcomes in IS. Due to population aging, the CCI should be used to identify, monitor and manage chronic comorbidities among immobile IS populations.

Utilizing data from the nationally representative China Health and Retirement Longitudinal Study, this study analyzed the effect of intensity and duration of adverse childhood experiences on depression in middle aged and older aged adults in China. The mediating effect of cumulative health risk and personal factors were validated through the Karlson¿Holm¿Breen method. The results showed a significant dose-response relationship between adverse childhood experiences and adult depression. The elevated health risks of chronic diseases, disabilities, and physical pain, as well as the disadvantages in education, employment, and economic status caused by the adverse childhood experiences indirectly worsen adult depression.

Background: Productivity losses due to diabetes are increasing in China, but research about the impact of diabetes on productivity in urban and rural areas requires further in-depth study. This article provides the first estimate of the cost of productivity losses attributed to diabetes in individuals 20¿69 years old in urban and rural areas of China. Methods: The human capital approach is employed to measure the productivity losses attributed to absenteeism, presenteeism, labor force dropout, and premature deaths due to diabetes of the 20¿69-year-old population of males and females in urban and rural areas of China. Based on the life table modelling, we calculate the years of potential life lost and working years of life lost of people with diabetes. Results: In 2017, we estimated that there were 100.46 million people with diabetes, with the total cost of productivity losses being USD 613.60 billion, comprising USD 326.40 billion from labor force dropout, USD 186.34 billion from premature death, USD 97.71 billion from absenteeism, and USD 27.04 billion from presenteeism. Productivity loss was greater in urban (USD 490.79 billion) than rural areas (USD 122.81 billion), with urban presenteeism (USD 2.54 billion) greater than rural presenteeism (USD 608.55 million); urban absenteeism (USD 79.10 billion) greater than rural absenteeism (USD 18.61 billion); urban labor force dropout (USD 261.24 billion) greater than rural labor force dropout (USD 65.15 billion); and urban premature death (USD 147.90 billion) greater than rural premature death (USD 38.44 billion). Conclusions: Diabetes has a large and significant negative impact on productivity in urban and rural China. Productivity loss is significantly higher in urban versus rural regions. Further investment is required in the prevention, diagnosis, and control of diabetes in under-resourced health services in rural locations as well as in urban areas, where most diabetes cases reside. Specifically, targeted and effective diabetes prevention and management actions are urgently required.

Background: China¿s social medical insurance system faces challenges in financing, product coverage, patient health responsibility sharing and data security, which commercial health insurance companies can help address. Confronting accelerated population aging, the rapid increase of patients with chronic diseases and the maternal and child healthcare needs created by the three-child policy, the Chinese government has encouraged the development of commercial health insurance. But China's commercial health insurance companies face financial sustainability problems, limited product ranges and high operating costs. At the same time, the informatization level of China's healthcare industry, and the value of healthcare big data, is increasing. We analyze and describe the potential application of healthcare big data in the life cycle of China's commercial health insurance system and provide specific action plans for Chinese commercial health insurance companies; identify the challenges to commercial health insurers; and make recommendations for the application of big health data by commercial health insurers. Our recommendations inform healthcare policy makers on the development of commercial health insurance and the improvement of the healthcare financing system. We not only verify the value of healthcare big data, but also identify specific ways that healthcare big data plays in the development of commercial health insurance. Based on the research results, we recommend new policies for government and new uses of healthcare big data for commercial health insurance institutions. The benign development of commercial health insurance will improve the level of health services in China. Methods: By interviewing health insurance managers (including actuaries, product managers, business executives, information technology medical workers, and commercial health insurance personnel) and by accessing research papers, industry reports, news reports and public information disclosure documents about commercial health insurance, we describe the impact of healthcare big data on the life cycle of commercial health insurance products and processes. Results: We identify the issues and challenges of commercial health insurers in the use of healthcare big data, and advance specific strategies to expand the use of healthcare big data. In the life cycle of commercial health insurance products, healthcare big data can improve premium income, control medical costs and increase operational efficiency. First, healthcare big data can increase premiums, products and services by attenuating moral hazard and adverse selection problems, where high quality clients over-pay and high-risk clients underpay for health insurance. Second, healthcare big data can reduce medical expenses compensation pay-outs by promoting the establishment of a management medical system. Finally, the use of healthcare big data improves operational efficiency by increasing payment speeds, identifying fraud and increasing claim verification processes through automating payments and reducing offline processes. We discuss the obstacles to obtain healthcare big data confronting commercial health insurance companies. The sharing and data mining of healthcare big data brings privacy risks to the insured and there are significant differences in data standards and quality of healthcare big data that limit the application of healthcare big data in commercial health insurance. We recommend that national, regional and local government departments coordinate policies to facilitate the cooperation between commercial health insurance companies and regional healthcare big data platforms. In terms of technology, we recommend the establishment of data sharing platforms and data exchange mechanism across institutions and regions according to nation-wide standards and specifications. Government management departments should establish healthcare big data standards and specification system, pr...

Background:As a common medical emergency in individuals with diabetes, hypoglycemia events can impose significant demands on hospital resources. Based on diabetes patients with and without hypoglycemia, we assess the cost of hypoglycemic events on China's hospital system.Method:Our study sample comprised 7110 diabetes episodes, including 1417 patients with hypoglycemia (297 patients with severe and 1120 with non-severe hypoglycemia) and 5693 diabetes patients without hypoglycemia. Data on patient social-demographics, length of hospital stay, and hospitalization costs were collected on each patient from Health Information System in Shandong province, China. The additional hospital costs caused by hypoglycemia were assessed by the cost difference between diabetes patients with and without hypoglycemia, including severe and non-severe hypoglycemia. China-wide hospital costs of hypoglycemia were estimated based on adjusted additional hospital costs, comprising inspection, treatment, drugs, materials, nursing, general medical costs, and other costs, caused by hypoglycemia, the prevalence of diabetes and hypoglycemia events, and the rates of hospitalization. Multiple sensitivity analyses were conducted to assess the impact of variations in the key input parameters on the primary estimates.Results:Total hospital costs for patients with hypoglycemia (US$3020.61) were significantly higher than that of patients without hypoglycemia (US$1642.91). The average additional cost caused by hypoglycemia was US$1377.70, with higher average costs of US$1875.89 for severe hypoglycemia and lower average costs of US$1244.76 for non-severe hypoglycemia. The additional hospital cost caused by severe and non-severe hypoglycemia patients was higher for the 60 to 75 year old group, married patients and patients accessing free medical services. Generally, hypoglycemic patients with Urban and Rural Resident Basic Medical Insurance incurred higher additional hospital costs than patients with Urban Employees Basic Medical Insurance. Based on these estimates, the total annual additional hospital costs arising from hypoglycemia events in China were estimated to be US$67.52 million. Sensitivity analyses suggested that the costs of hypoglycemia events ranged up to US$49.99 million to 67.52 million.Conclusion: Hypoglycemic events imposed a substantial cost on China's hospital system, with certain subgroups of patients, such as older patients and those with free health insurance, using medical resources more intensively to treat hypoglycemia events. We recommend more effective planning of prevention and treatment regimes for hypoglycemia patients; further reform to China's health insurance schemes; and better hospital cost control for those accessing free hospital services.

By applying advanced health information technology to the health care field, health informatization helps optimize health resource allocation, improve health care services, and realize universal health coverage. COVID-19 has tested the status quo of China¿s health informatization, revealing challenges to the health care system. This viewpoint evaluates the development, status quo, and practice of China¿s health informatization, especially during COVID-19, and makes recommendations to address the health informatization challenges. We collected, assessed, and evaluated data on the development of China¿s health informatization from five perspectives¿health information infrastructure, information technology (IT) applications, financial and intellectual investment, health resource allocation, and standard system¿and discussed the status quo of the internet plus health care service pattern during COVID-19. The main data sources included China¿s policy documents and national plans on health informatization, commercial and public welfare sources and websites, public reports, institutional reports, and academic papers. In particular, we extracted data from the 2019 National Health Informatization Survey released by the National Health Commission in China. We found that China developed its health information infrastructure and IT applications, made significant financial and intellectual informatization investments, and improved health resource allocations. Tested during COVID-19, China¿s current health informatization system, especially the internet plus health care system, has played a crucial role in monitoring and controlling the pandemic and allocating medical resources. However, an uneven distribution of health resources and insufficient financial and intellectual investment continue to challenge China¿s health informatization. China¿s rapid development of health informatization played a crucial role during COVID-19, providing a reference point for global pandemic prevention and control. To further promote health informatization, China¿s health informatization needs to strengthen top-level design, increase investment and training, upgrade the health infrastructure and IT applications, and improve internet plus health care services.

Background: Stroke is a devastating disease and a major cause of death and disability in China. While existing studies focused mainly on differences in stroke patients¿ health care utilization by insurance type, this study assesses whether health utilization and medical costs differed by insurance type across four cities in China. Methods: A 5% random sample from the 2014¿2016 China Urban Employees¿ Basic Medical Insurance (UEBMI) and Urban Residents¿ Basic Medical Insurance (URBMI) claims data were collected across four cities, Beijing, Shanghai, Tianjin, and Chongqing. Descriptive statistics and ordinary least squares regression were employed to analyze the data. Results: We found that differences in healthcare utilization and inpatient and outpatient medical expenses varied more by city-specific insurance type than they did between the UEBMI and URBMI schemes. For example, the median UEBMI medical outpatient costs in Beijing (RMB500.2) were significantly higher than UEBMI patients in Shanghai (RMB260.8), Tianjin (RMB240.8), and Chongqing (RMB293.0), and Beijing URBMI patients had significantly higher outpatient medical costs (RMB356.9) than URBMI patients in Shanghai (RMB233.4) and Chongqing (RMB211.0), which were significantly higher than Tianjin (RMB156.2). Patients in Chongqing had 66.4% (95% CI: - 0.672, - 0.649) fewer outpatient visits, 13.0% (95% CI: - 0.144, - 0.115) fewer inpatient visits, and 34.2% (95% CI: - 0.366, - 0.318) shorter length of stay than patients in Beijing. The divergence of average length of stay and out-of-pocket (OOP) expenses by insurance type was also greater between cities than the UEMBI-URBMI mean difference. Conclusions: Significant city-specific differences in stroke patients¿ healthcare utilization and medical costs reflected inequalities in health care access. The fragmented social health insurance schemes in China should be consolidated to provide patients in different cities equal financial protection and benefit packages and to improve the equity of stroke patient access to health care.

Background: Evidence-based policy making for delivering affordable lung cancer care relies on the breadth, depth and quality of knowledge of its treatment costs. This study estimates the annual prevalence, medical service utilization and direct treatment costs of lung cancer in urban China. Materials and Methods: Using claim data from China's urban basic medical insurance between 2013 and 2016, we constructed a nationally representative sample of lung cancer patients in urban China. Weighted descriptive analyses, Poisson regressions and generalized linear modelling were used to analyse lung cancer medical service utilization and costs and their associations with patient characteristics. Results: In urban China, the annual prevalence of lung cancer was 87.65/100000, with nearly 0.65% of total health expenditures of urban residents spent on lung cancer treatments. Weighted average annual total medical costs of lung cancer was RMB33.78 (US$5.36) thousand, with annual out-of-pocket costs of RMB10.26 (US$1.63) thousand. The average yearly number of lung cancer-related outpatient visits was 2.42 and inpatient admissions was 2.07, with an average cost of RMB0.75 (US$0.12) thousand for outpatients and RMB 15.67 (US$2.49) thousand for inpatients. Inpatient expenses were the major component (95%) of lung cancer medical costs, with roughly 67% of inpatient services occurring in high-level tertiary hospitals. Medical care utilization and direct medical costs were associated with sex, age and insurance status. Western medicine costs were the major contributor (39.4%) to average lung cancer-related medical costs. Conclusion: Lung cancer imposed a significant economic burden on China's health system and a financial cost on lung cancer sufferers and their families. Specific policies are required to efficiently allocate health resources, contain health expenditure and decrease the individual financial burden of lung cancer.

Background: Stroke has always been a severe disease and imposed heavy financial burden on the health system. Equity in patients in regard to healthcare utilization and medical costs are recognized as a significant factor influencing medical quality and health system responsiveness. The aim of this study is to understand the equity in stroke patients concerning medical costs and healthcare utilization, as well as¿identify potential factors contributing to geographic variation in stroke patients¿ healthcare utilization and costs. Methods: Covering 31 provinces in mainland China, our main data were a 5% random sample of stroke claims from Urban Employees Basic Medical Insurance (UEBMI) and Urban Residents Basic Medical Insurance (URBMI) from 2013 to 2016. The Theil index was employed to evaluate the equity in stroke patients in regard to healthcare utilization and medical costs, and the random-effect panel model was used to explore the impact of province-level factors (health resource factors, enabling factors, and economic factors) on medical costs and health care utilization. Results: Stroke patients¿ healthcare utilization and medical costs showed significant differences both within and between regions. The UEBMI scheme had an overall lower Theil index value than the URBMI scheme. The intra-region Theil index value was higher than the inter-region Theil index, with the Theil index highest within eastern China, China¿s richest and most developed region. Health resource factors and enabling factors (represented by reimbursement rate and education attainment years) were identified significantly associated with medical costs (P < 0.05), but have no impact on average length of stay. Conclusions: China¿s fragmented urban health insurance schemes require further reform to ensure better equity in healthcare utilization and medical costs for stroke patients. Improving education attainment, offering equal access to healthcare, allocating health resources reasonably and balancing health services prices in different regions also count.

To control and prevent the risk of diabetes, diabetes studies have identified the need to better understand and evaluate the associations between influencing indicators and the prevalence of diabetes. One constraint has been that influencing indicators have been selected mainly based on subjective judgment and tested using traditional statistical modeling methods. We proposed a framework new to diabetes studies using data-driven and spatial methods to identify the most significant influential determinants of diabetes automatically and estimated their relationships. We used data from diabetes mellitus patients' health insurance records in Shandong province, China, and collected influencing indicators of diabetes prevalence at the county level in the sociodemographic, economic, education, and geographical environment domains. We specified a framework to identify automatically the most influential determinants of diabetes, and then established the relationship between these selected influencing indicators and diabetes prevalence. Our autocorrelation results showed that the diabetes prevalence in 12 Shandong cities was significantly clustered (Moran's I¿=¿0.328, p¿<¿0.01). In total, 17 significant influencing indicators were selected by executing binary linear regressions and lasso regressions. The spatial error regressions in different subgroups were subject to different diabetes indicators. Some positive indicators existed significantly like per capita fruit production and other indicators correlated with diabetes prevalence negatively like the proportion of green space. Diabetes prevalence was mainly subjected to the joint effects of influencing indicators. This framework can help public health officials to inform the implementation of improved treatment and policies to attenuate diabetes diseases.

(1) Background: China will provide free coronavirus disease 2019 (COVID-19) vaccinations for the entire population. This study analyzed the COVID-19 vaccination willingness rate (VWR) and its determinants under China¿s free vaccination policy compared to a paid vaccine. (2) Methods: Data on 2377 respondents were collected through a nationwide questionnaire survey. Multivariate ordered logistic regression models were specified to explore the correlation between the VWR and its determinants. (3) Results: China¿s free vaccination policy for COVID-19 increased the VWR from 73.62% to 82.25% of the respondents. Concerns about the safety and side-effects were the primary reason for participants¿ unwillingness to be vaccinated against COVID-19. Age, medical insurance and vaccine safety were significant determinants of the COVID-19 VWR for both the paid and free vaccine. Income, occupation and vaccine effectiveness were significant determinants of the COVID-19 VWR for the free vaccine. (4) Conclusions: Free vaccinations increased the COVID-19 VWR significantly. People over the age of 58 and without medical insurance should be treated as the target intervention population for improving the COVID-19 VWR. Contrary to previous research, high-income groups and professional workers should be intervention targets to improve the COVID-19 VWR. Strengthening nationwide publicity and education on COVID-19 vaccine safety and effectiveness are recommended policies for decision-makers.

Background: Hepatitis B (HB) is the most serious and common viral hepatitis in China. Previous studies on HB discrimination mainly have focussed on stratified analysis, and there has been no consideration of the impact of geographical-environmental factors on HB discrimination from a spatial perspective. Objective: This study conducted a large nationwide village-based survey to test whether there were significant regional differences in HB discrimination, and to explore the relationship between different socio-economic geographical factors and HB discrimination. Methods: The sample comprised 22618 rural adults, aged over 18¿years old, from villages in seven provinces, representing central, southern, and eastern coastal regions of China. Using face-to-face interviews, we surveyed participants¿ discrimination against HB patients or carriers. Chi-square tests were used to analyze the effects of the region on differences in proportions between three discrimination levels (low, medium, and high). A geographical detector was used to explore the relationship between different socio-economic and geographical-environmental factors and HB discrimination. Results: The distribution of HB discrimination levels across the 42 villages was statistically significant. The level of HB discrimination in the central and southern regions was generally low, and the level of HB discrimination in the eastern coastal regions was higher. Both socio-economic and geographic-environmental factors had a significant relationship with HB discrimination. Most of these relationships were not linear. Conclusions: Developing the economy and accelerating urbanization did not automatically eliminate discrimination against HB. We recommend government HB publicity and education campaigns to inform the population of HB causes and effects, and strengthen the education of students so that they can have a clear and correct understanding of HB from a young age, both of which will address HB discrimination.

Drawing on team innovation and mood-as-information theories, this paper develops a moderated mediation model to explain the effect of environmental dynamism on team innovative capability. We argue that this effect occurs through an increase in cognitive diversity and is contingent on positive mood, which engenders a more expansive and flexible approach to problem solving. Data collected through a survey-based study of 63 US healthcare teams generates support for our arguments that environmental dynamism increases innovative capability and does so through cognitive diversity. Further, our data suggest that this path only exists when teams are characterized by positive mood. Overall, we find support for a moderated mediation model in which environmental dynamism increases innovative capability through cognitive diversity contingent on positive mood, which allows us to contribute significantly to literature on team innovative capability and mood-as-information.

Objectives We assess whether China's diabetes pilot hierarchical diagnosis and treatment reforms shifted patient healthcare-seeking behaviour towards primary health institutions (PHIs) and away from secondary and tertiary hospitals. From the patients' perspective, we evaluate whether the hierarchical system saw the decline of average hospital cost, out-of-pocket (OOP) expenses and the increase of reimbursement rate in PHIs. From the health system's perspective, we also assessed whether the share of PHIs in total costs, total visits and reimbursement rate increased and the share of secondary and tertiary hospitals decreased. Methods Data were collected from the health insurance bureau of 11 cities in Shandong Province, China between 2015 and 2017, which included 9 118 518 outpatient visits and 622 739 inpatient visits. For both inpatients and outpatients and the health system, we analysed health services-seeking characteristics including hospital costs, hospital visits, OOP expense and reimbursements of hospital costs. Binary logistic regression was conducted to analyse the influencing factors of seeking PHI health services. Results PHIs remained the lowest hospital cost provider, but average hospital costs declined across all three healthcare levels of PHIs, secondary hospitals and tertiary hospitals from 2015 to 2017. The hierarchical system aimed to shift patients to PHIs, increasing PHIs' share of total hospital costs. However, the PHI share of total outpatient costs declined 12.0%, while rising 15.0% in secondary hospitals, the opposite of the goal of the hierarchical medical system. Average outpatient visits rose roughly at the same rate in PHIs (5.1%) as secondary hospitals (6.8%), with no evidence of a shift in patient visits between hospital levels over 2015-2017. Average inpatient visits fell across all levels of hospitals, with no significant difference in the rate of decline between PHIs (9.4%) and secondary (7.5%) and tertiary (7.8%) hospitals. For outpatient and inpatient services, the binary logistic regression showed that over the 2015-2017 period patients with diabetes increasingly used higher level hospitals rather than PHIs (p<0.05). The only success of the hierarchical medical system was the relative fall of OOP outpatient expenses, which fell more rapidly in PHIs (13.7%) than secondary (5.0%) and tertiary (3.5%) hospitals. However, inpatient OOP expenses fell only 2.2% for PHIs, less than half that of secondary (5.5%) and tertiary (7.4%) hospitals, the opposite of the aim of the hierarchical system reform. Conclusions The implementation of the hierarchical medical system for patients with diabetes did not achieve its goal of increasing PHI utilisation and decreasing secondary and tertiary hospital utilisation. Enhancing the utilisation of PHIs for diabetes and other patients requires further health reform, including educating patients on PHI use, further reforming the health insurance schemes, improving PHI facilities and encouraging referrals to PHIs from higher level hospitals.

(1) Background: The management of multiple chronic diseases challenges China¿s health system, but current research has neglected how multimorbidity is associated with poor health-related quality of life (HRQOL) and high health service demands by middle-aged and older adults. (2) Methods: A cross-sectional study was conducted in Shandong province, China in 2018 across three age groups: Middle-aged (45 to 59 years), young-old (60 to 74 years), and old-old (75 or above years). The information about socio-economic, health-related behaviors, HRQOL, and health service utilization was collected via face-to-face structured questionnaires. The EQ-5D-3L instrument, comprising a health description system and a visual analog scale (VAS), was used to measure participants¿ HRQOL, and ¿2 tests and the one-way ANOVA test were used to analyze differences in socio-demographic factors and HRQOL among the different age groups. Logistic regression models estimated the associations between lifestyle factors, health service utilization, and multimorbidity across age groups. (3) Results: There were 17,867 adults aged 45 or above in our sample, with 9259 (51.82%) female and 65.60% living in rural areas. Compared with the middle-aged adults, the young-old and old-old were more likely to be single and to have a lower level of education and income, with the old-old having lower levels than the young-old (P < 0.001). We found that 2465 (13.80%) suffered multimorbidities of whom 75.21% were older persons (aged 60 or above). As age increased, both the mean values of EQ-5D utility and the VAS scale decreased, displaying an inverse trend to the increase in the number of chronic diseases (P < 0.05). Ex-smokers and physical check-ups for middle or young-old respondents and overweight/obesity for all participants (P < 0.05) were positively correlated with multimorbidity. Drinking within the past month for all participants (P < 0.001), and daily tooth-brushing for middle (P < 0.05) and young-old participants (P < 0.001), were negatively associated with multimorbidity. Multimorbidities increased service utilization including outpatient and inpatient visits and taking self-medicine; and the probability of health utilization was the lowest for the old-old multimorbid patients (P < 0.001). (4) Conclusions: The prevalence and decline in HRQOL of multimorbid middle-aged and older-aged people were severe in Shandong province. Old patients also faced limited access to health services. We recommend early prevention and intervention to address the prevalence of middle-aged and old-aged multimorbidity. Further, the government should set-up special treatment channels for multiple chronic disease sufferers, improve medical insurance policies for the older-aged groups, and set-up multiple chronic disease insurance to effectively alleviate the costs of medical utilization caused by economic pressure for outpatients and inpatients with chronic diseases.

(1) Background: The association between multimorbidity and mental health is well established. However, the role of gender in different populations remains unclear. Currently, China is facing an increased prevalence of multimorbidity, especially in its disease-causing poverty population. The present study explores the gender-based differences in the relationship between multimorbidity and mental health using data from the rural, disease-causing poverty, older-age population in Shandong province, China, as a case study. (2) Methods: The data were obtained from the survey on the health and welfare of disease-causing poverty households in rural Shandong province. We identified 936 rural participants who were over 60 years old from disease-causing poverty households. The mental health status was measured using the Kessler Psychological Distress Scale (K10) instrument. Using a multivariable linear regression model, including the interaction of gender and multimorbidity, gender differences in the association between multimorbidity and mental health were explored. (3) Results: Multimorbidity was a serious health problem in rural, disease-causing poverty, older-age households, with the prevalence of multimorbidity estimated as 40% for women and 35.4% for men. There was a strong association between multimorbidity and mental health, which was moderated by gender. Women had higher K10 scores than men, and the mean K10 score was highest in women with three or more chronic diseases. Compared with men, women with multimorbidity had a higher risk of mental health problems. (4) Conclusions: The prevalence of multimorbidity in older-age rural disease-causing poverty subpopulations is a severe public health problem in China. The association between multimorbidity and mental health differed by gender, where multimorbid women suffered an increased mental health risk compared with men. Gender differences should be addressed when delivering effective physical and mental healthcare support to disease-causing poverty, older-age, rural households.

Purpose: Hearing loss has not received sufficient attention, especially in low-and middle-income countries where more than 80% of the people with hearing loss reside. Little is known about the preference for hearing aids among people with hearing loss in developing countries. The aim of this study is to elicit the preferences for hearing aid attributes among rural Chinese adults with moderate or greater hearing loss and examine how preferences vary across different individual socioeconomic characteristics. Patients and Methods: We interviewed 125 adults in two rural counties in Shandong province in China. A discrete choice experiment (DCE) with eight attributes, comprising out-of-pocket (OOP) costs, hearing aid style, effective in quiet settings and noisy settings, feedback (whistling), connectivity, water/sweat resistance and battery life, were employed to examine participants¿ preference for hearing aids. Mixed logit models were used for the statistical analyses. Results: While OOP costs, effectiveness in quiet settings, water/sweat resistance and battery life were significantly associated with choosing a hearing aid, rural Chinese adults with moderate or greater hearing loss valued effectiveness in noisy settings above other attributes of hearing aids, followed closely by lack of feedback. The preference of the attributes of OOP costs, in the canal hearing aids, effectiveness in noisy settings, connectivity and battery life varied across individual socioeconomic characteristics including sex, marriage, employ-ment, income and education level. Conclusion: Our study supported the view that the development of noise suppression and feedback cancellation systems remained the main challenge for the hearing aid industry. Since OOP costs were also associated with choosing a hearing aid, the policy advice is to improve reimbursements from insurance schemes and/or reduce the costs of hearing aids.

Objectives This study investigates the disparities in the utilisation of patient health services for patients who had a stroke covered by different urban basic health insurance schemes in China. Design We conducted descriptive analysis based on a 5% random sample from claims data of China Urban Employees' Basic Medical Insurance (UEBMI) and Urban Residents' Basic Medical Insurance (URBMI) in 2015, supplied by the China Health Insurance Research Association. Setting Chinese urban social insurance system. Participants A total of 56 485 patients who had a stroke were identified, including 36 487 UEBMI patients and 19 998 URBMI patients. Primary and secondary outcome measures The primary outcome measures include annual number of hospitalisations, average length of stay (ALOS) and average hospitalisation cost. Out-of-pocket (OOP) cost is the secondary outcome measure. Results The annual mean number of hospitalisations of UEBMI patients was 1.21 and 1.15 for URBMI patients. The ALOS was significantly longer for UEBMI than for URBMI patients (13.93 vs 10.82, p<0.001). Hospital costs were significantly higher for UEBMI than for URBMI patients (US1724.02 vs US986.59 (p<0.001), while the OOP costs were significantly higher for URBMI than for UEBMI patients (US423.17 vs US407.81 (p<0.001). Patients with UEBMI had higher reimbursement rate than URBMI patients (79.41% vs 66.92%, p<0.001) and a lower self-paid ratio than URBMI patients (23.65% vs 42.89%, p<0.001). Conclusions Significant disparities were found in the utilisation of hospital services between UEBMI and URBMI patients. Our results call for a systemic strategy to improve the fragmented social health insurance system and narrow the gaps in China's health insurance schemes.

Under 60 year olds represent a rapidly growing segment of the cancer population. They often face longer hospital stays, higher treatment intensity, and hospitalization costs. In this background, we aim to assess the impact of the 2009 reforms on the hospital expenses of younger cancer inpatients. Our study sample included 11 791 young and middle age stomach, lung, colorectal, esophageal, and breast cancer inpatients hospitalized during 2013 to 2017. Hospitalization treatment costs of under 60 cancer inpatients increased, but it fell in 2017 under the impact of the health reforms. However, out-of-pocket expenditures rose, which partly reflected the failure of the health insurance scheme to adequately cover cancer inpatient cost, potentially imposing financial hardships on cancer inpatients and their families. To continue to reduce the economic burden of cancer patients, early screening and diagnosis among younger populations and enhanced hospice care integrated with the ongoing primary health care reform are important.

Background: Disease-causing poverty is a serious problem in rural China, where social capital can mediate the disease - poverty relationship. However, there is no generally accepted reliable, robust and viable measure of social capital for China's unique socio-cultural context. This study adapts for China the widely used Onyx and Bullen social capital measurement scale and tests the validity and reliability of a modified Chinese Onyx-Bullen general scale, the Chinese Onyx-Bullen health scale, for a disease-causing-poverty subpopulation in rural China. Methods: We conducted the forward and backward translation procedure and cross-cultural adaptation process to derive the 34 item Chinese Onyx-Bullen general scale. Next we collected through face-to face interviews a sample of disease-causing poverty population in rural Shandong province in China to test a 29 item modified Chinese Onyx-Bullen general scale for a health subpopulation. Most of the rural respondents had no formal work, so 5 work-related items in the Onyx-Bullen general scale were deleted in the Chinese Onyx-Bullen health scale. Exploratory factor analysis was conducted to evaluate the structure, validity, internal consistency and reliability of the Chinese Onyx-Bullen health scale. SPSS21.0 software was used for data analysis. Results: A total of 467 people completed the scale. For the 29-item scale, a better simple structure was found when the number of factors was limited to 8. The absolute values of inter-factor correlations were in the range of 0.004 to 0.213 and the Kaiser-Meyer-Olkin value was 0.834. All the eight factors explain a total of 59.51% of the variance. The total scale had a Cronbach's alpha = 0.868, in which seven of the eight factors had Cronbach's a greater than 0.5. Conclusion: The Chinese health version of the Onyx-Bullen general social capital scale showed an adequate reliability and validity in a rural disease-causing poverty subpopulation in Shandong province, providing the first general, robust, consistent and reliable measure of social capital in China. The Chinese Onyx-Bullen general social capital scale provides a scale for testing social capital in China or for modification along the lines of the Chinese Onyx-Bullen health scale.

The zero-markup drug policy (ZMDP) was heralded as the biggest reform to China's modern health system. However, there have been a very limited number of investigations of the ZMDP at county hospital level, and those limited county hospital studies have several limitations in terms of sample representativeness and study design. We investigated the overall and dynamic effects of ZMDP at traditional Chinese medicine (TCM) county hospitals. We obtained longitudinal data from all TCM county hospitals in 2004-16 and the implementation year of ZMDP for each hospital. We used differences-in-difference methods to identify the overall and dynamic effects of ZMDP. On average, the ZMDP reform was associated with the reduction in the share of revenue from drug sales (3.1%), revenue from western medicines sales (12.7%), revenue from medical care services (3.6%) and gross hospital revenue (3.4%), as well as increased government subsidies (24.4%). The ZMDP reform was not significantly associated with the number of annual outpatient and inpatient visits. In terms of dynamic effects, the share of revenue from drug sales decreased by 2.5% in the implementation year and by about 5% in the subsequent years. Revenue from western medicine sales fell substantially in the short term and continued to drop in the long term. Government subsidies went up strikingly in the short term and long term, and revenue from medical care services and gross revenue decreased only in the implementation year. The ZMDP achieved its stated goal through reducing the share of revenue from drug sales without disrupting the availability of healthcare services at TCM county hospitals. The success of ZMDP was mainly due to the huge growth in the government's financial investment in TCM hospitals.

Objective: While diabetes links with comorbidity of depression, there is no evidence in China regarding whether health behaviors modified the effect of depressive symptoms on diabetes. This study examined the influence of depressive symptoms on the incident diabetes, and investigated whether health behavior was a moderator in the depression-diabetes relationship in Chinese mid-aged and older adults. Methods: Using data from the China Health and Retirement Longitudinal 2011¿2015 Study, the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) short form was used to measure depressive symptoms in 47,671 Chinese mid-aged and older adults. Diabetes was diagnosed through self-reported measures. We used random effect logistic regression models to examine the effect of depressive symptoms on the incidence of depressive symptoms. Results: Participants with depressive symptoms were more likely to suffer from diabetes than their non-depressive symptoms counterparts, with an odds ratio (OR) of 1.33 (95% CI: 1.13, 1.58). We found that unhealthy behaviors moderated the influence of depressive symptoms on risk of diabetes (OR = 1.01, 95% CI = 1.01, 1.02), indicating that depressive symptoms patients with two or more unhealthy behaviors had a higher risk of diabetes compared with their peers without unhealthy behaviors. Conclusion: Our findings suggested that depressive symptoms were a risk factor in developing diabetes, and that response to this factor varied by individuals¿ health behaviors. Clinicians should be aware of increased risk of elevated diabetes in population with depressive symptoms and consider routine screening for depressive symptoms among them.

Background: Immobility complications, including pressure injuries (PIs), deep vein thrombosis (DVT), pneumonia, and urinary tract infections (UTIs), affect the clinical outcomes of stroke patients. A standardized nursing intervention model (SNIM) was constructed and implemented to improve the quality of care and clinical outcomes among immobile patients with stroke. Aims: To assess the benefit of SNIM for immobility complication rates, including PIs, DVT, pneumonia, and UTIs, and mortalities in immobile patients with stroke. Methods: A before and after study design was used. Patients were divided into a pre- and post-SNIM training original cohort and matched for socioeconomic, demographic, and disease characteristics using propensity score. We fitted logistic regression models to examine the effect of SNIM, and whether the benefit differed between tertiary and non-tertiary hospitals. Results: In the original cohort, the rate of pneumonia, UTIs, and mortality was lower after SNIM training. Furthermore, in the matched cohort, the difference in PI rates was significant. Logistic regression analysis revealed that the probability of PIs, pneumonia, UTIs, and mortality were significantly reduced after SNIM training in the original cohort and this estimated value changed little in the matched cohort. Our results show that the decreased rates of pneumonia, UTIs, and mortality were mainly among non-tertiary hospitals. Conclusions: A structured and systematic SNIM benefited immobile stroke patients¿ clinical outcomes, but mainly in non-tertiary hospitals in China. Standardized nursing training is needed in non-tertiary hospitals.

SIGNIFICANCE Myopia is a major health issue in East Asian countries, especially in China. By identifying Chinese patients' motivations for laser in situ keratomileusis (LASIK) surgery, our results are expected to help clinicians counsel patients before LASIK surgery and to maximize patients' post-operative LASIK surgery satisfaction, improving the quality of LASIK surgery services. PURPOSE Laser in situ keratomileusis has become a popular type of refractive surgery for the correction of myopia worldwide. This study uses qualitative inquiry approaches to understand the motives and processes of patients' LASIK surgery decision making. METHODS A purposive sample of 45 patients who had decided to undergo LASIK was recruited. Our qualitative study used in-depth interviews and used content analysis to interpret the data. RESULTS Among 45 participants, 48.9% reported that career requirements were the most important reason for seeking LASIK surgery. The inconvenience of wearing glasses or lenses during activities of daily life was also a primary motive. Improving facial appearance was a main reason for female but not male respondents. Potential complications of spectacles and contact lenses in addition to maturation of LASIK technology were also reported motives to seek surgery. Participants gave multiple, overlapping reasons for LASIK surgery. CONCLUSIONS These findings suggest that motives to seek LASIK surgery are not only a desire to correct refractive error but also social factors and confidence in improved surgical technology. The implications for clinicians are to be aware of these multiple motives for LASIK to improve the quality and effectiveness of health services for myopia patients.

Purpose: To evaluate the quality of life (QoL) and social support among family caregivers of a family member with a mental illness and to identify factors associated with the QoL. Methods: This is a cross-sectional study, where participants were recruited and independently interviewed using a questionnaire, consisting of demographic characteristics, the Medical Outcome Survey SF-36 form, and social support rating scales. Multiple stepwise regression analysis was used to analyse the factors related to QoL. Results: 181 family caregivers were recruited in Shandong province, China. On a composite QoL score, family caregivers perceived that their QoL was poor (68.3), especially in the aspects of role-physical (61.3), role-emotional (57.6) and mental health (63.0). We also found family caregivers received low social support, especially in objective support and utilization of social support. Patient's illness state, care time, financial burden and objective support were significantly correlated to caregivers¿ QoL in the physical component score (PCS). Patient's illness state, patient's marital status, family monthly income, caregiver's knowledge about the illness, caregivers coordinating caring, life and work, subjective support received and utility of support were significantly associated with caregivers¿ QoL in the mental component score (MCS). Conclusions: Social support had a significant correlation with caregivers¿ QoL. Caregivers should be encouraged to request assistance from other family members and friends in providing care, especially when caregivers are unemployed or long-time carers. Mental health education campaigns and helping families to maintain and enhance a supportive social network may provide useful means to improve caregivers¿ QoL.

Background: Co-morbid diabetes and depression is common; however, little evidence was regarding the effect of education on this association. This study aimed to investigate the role of education in the effect of diabetes on depressive symptoms in China. Methods: We used data from the China Health and Retirement Longitudinal Study, including 6,921 participants free from depressive symptoms in three waves of cohort study from 2011. We assessed the depressive symptoms based on Center for Epidemiological Studies¿Depression scale. We fitted Cox proportional hazards regression models to examine the effect of baseline diabetes on the subsequent depressive symptoms. Results: Participants with diagnosed diabetes were more likely than their nondiabetic peers to develop depressive symptoms only in 45¿64 years group, with a hazard ratio of 1.30 (95% CI: 1.05, 1.61). In addition, the effect of diagnosed diabetes on depressive symptoms only occurred in participants with a diploma of primary school or below. Limitations: Information was unavailable may offer additional explanatory power. Conclusion: Our findings suggested that diagnosed diabetes was a chronic stressor in developing depressive symptoms, and that response to this stressor varied by individuals¿ educational attainment. Action to prevent and treat diabetes may contribute to the fight against depressive symptoms, especially in the lower-education population.

Background: Given the health and welfare impacts of haze, haze reduction governance challenges Chinese policy-makers. Surprisingly, there have been no studies of the differences in the public¿s willingness to pay (WTP) for haze governance within a province. Yet haze reduction policies are implemented at the provincial level. Based on the contingent valuation method, data on WTP for haze governance across four industrial cities in Shandong province were collected using a questionnaire survey. Method: A combination of stratified sampling and non-probability sampling methods were used, yielding a valid sample of 1006 respondents. The Heckman sample selection model was used to analyze factors determining WTP and WTP amount. Results: 53% of respondents were unwilling to pay for haze reduction, while less than 1% of these respondents were satisfied with Shandong¿s air quality. About half (47%) of the respondents were willing to pay, on average, US$14.14 per household per year for haze governance. We found that there were significant inter-city differences in the WTP and WTP amounts: those with a higher income, education, haze knowledge, and haze concern were WTP; age, marital status, and subjective indicators displayed a negative relationship with WTP amount. About two thirds of the non-payers, and those with poor environmental knowledge, argued that air quality improvement was mainly the responsibility of governments (39.3%) and polluters (25.6%), instead of ordinary citizens. Further, 27% of non-payers said that their income was too low to contribute to a pollution tax and 6.3% claimed that they did not believe the funds would be used effectively for environmental conservation. Conclusions: City-specific differences in WTP may caution against ¿one size fits all¿ policies. The study indicates that the government may need to target policies to specific cities and the characteristics of residents in those cities by age, education, and income groups and residents¿ subjective evaluation of the government and the haze problem and those responsible for pollution.

Hepatitis B (HB) vaccination is the most effective way to prevent HB virus infection. While measures taken to control the prevalence of HB have achieved significant results, HB prevalence in rural China among adults remains problematic. This study sheds new light on the determinants of HB vaccine uptake and its inequality according to socioeconomic status in rural areas of China. We interviewed 22,283 adults, aged 18¿59¿years, from 8444 households, in 48 villages from 8 provinces. Vaccination status was modeled by using two logistic models: whether take at least one HB vaccine and whether to complete the entire vaccination regime. The Erreygers' concentration index (ECI) was used to quantify the degree of inequality and the decomposition approach was used to uncover the determinants of inequality in vaccine uptake. We found that the coverage rate of HB vaccination is 20.2%, and the completion rate is 16.0%. The ECI of at least one dose (0.081) and three doses (0.076) revealed a substantial pro-rich inequality. Income contributed the largest percentage to HB vaccination inequalities (52.17% for at least one dose and 52.03% for complete vaccinations). HB awareness was another important cause of inequality in HB vaccination (around 30%). These results imply that rich had a greater tendency to vaccinate and inequality favouring the rich was almost equal for the complete three doses. While the factors associated with HB vaccination uptake and inequalities were multifaceted, income status and HB awareness were the main barriers for the poor to take HB vaccine by adults in rural China.

Background: China's health system has shown remarkable progress in health provision and health outcomes in recent decades, however inequality in health care utilization persists and poses a serious social problem. While government pro-poor health policies addressed affordability as the major obstacle to equality in health care access, this policy direction deserves further examination. Our study examines the issue of health care inequalities in China, analyzing both regional and individual socioeconomic factors associated with the inequality, and provides evidence to improve governmental health policies. Methods: The China Health and Nutrition Survey (CHNS) 1991-2011 data were used to analyze the inequality of health care utilization. The random effects logistic regression technique was used to model health care utilization as the dependent variable, and income and regional location as the independent variables, controlling for individuals' age, gender, marital status, education, health insurance, body mass index (BMI), and period variations. The dynamic trend of 1991-2011 regional disparities was estimated using an interaction term between the regional group dummy and the wave dummy. Results: The probability of using outpatient service and inpatient services during the previous 4 weeks was 8.6 and 1.1% respectively. Compared to urban residents, suburban (OR: 0.802, 95% CI: 0.720-0.893), town (OR: 0.722, 95% CI: 0.648-0.804), rich (OR: 0.728, 95% CI: 0.656-0.807) and poor village (OR: 0.778, 95% CI: 0.698-0.868) residents were less likely to use outpatient service; and rich (OR: 0.609, 95% CI: 0.472-0.785) and poor village (OR: 0.752, 95% CI: 0. 576-0.983) residents were less likely to use inpatient health care. But the differences between income groups were not significant, except the differences between top and bottom income group in outpatient service use. Conclusion: Regional location was a more important factor than individual characteristics in determining access to health care. Besides demand-side subsidies, Chinese policy makers should pay enhanced attention to health care resource allocation to address inequity in health care access.

Introduction: This paper assesses both patients' perspectives on the differences in primary care quality between traditional Tibetan medicine (TTM) hospitals and western medicine (WM) hospitals and the efficacy of the government's investment in these two Prefecture-level primary care structures in Tibet. Method: A validated Tibetan version of the Primary Care Assessment Tool (PCAT-T) was used to collect data on 692 patients aged over 18 years old, who reported the sampling site was their regular source of health care. T-tests were performed to compare the separate and total primary care attributes between WM hospitals and TTM hospitals. Multiple linear regression analysis was conducted to examine the association of the health care setting with primary care attributes while controlling for socio-demographic, health service use and health status characteristics. Results: Compared to WM hospitals, the results showed that TTM hospitals had patients who were older (15.8 % versus 8.4 % over 60 years); with lower education levels (66.0 % versus 35.8 % with below junior high school ) and income levels (46.9 % versus 26.5 % with annual household income below 30,000RMB); more likely to be married (79.2 % versus 60.5 %); made less frequent health care visits; and had higher self-rated health status. Overall, patients assessed the primary care performance in TTM hospitals significantly higher (80.0) than WM hospitals (74.63). There were no differences in health care assessment by patient gender, age, income, education, marital status and occupation. Conclusions: TTM patients reported better primary care experiences than patients using WM hospitals, which validated the government's investment in traditional Tibetan medicine.

The results of research on diversity in teams suggest that it offers both a great opportunity for organisations as well as an enormous challenge. However, current research is plagued by a lack of overall consistency, indicating that the relationship between diversity and team performance is not well understood. This study examines the components of cognitive conflict in order to assess whether construct operationalisation may explain this inconsistency. Analysis of the existing operationalisations of cognitive conflict reveals that it incorporates both disagreement about information and reasoning, and debate of rival hypotheses or recommendations. We propose that functional diversity leads to cognitive disagreement but not debate, and that debate enhances knowledge creation, with which cognitive disagreement shows no relationship. Our results support these hypotheses, which provide a powerful explanation for the contrary results found by researchers investigating cognitive conflict. Given that extant measures of cognitive conflict include scale items which measure both debate and cognitive disagreement, cognitive conflict may be viewed as an aggregate measure of these two distinct constructs. This study contributes to research on diversity and conflict by providing an explanation for contrary results, and by providing and a detailed operationalisation of cognitive conflict and its component constructs. It also contributes to research into creativity and innovation by providing insight into the dynamics underpinning knowledge sharing and creation.

This paper contributes to our understanding of the process of knowledge creation in organisations. Based on a process model, the paper develops propositions relating to factors facilitating knowledge creation in cross-functional work teams. These propositions relate to the constructs of cognitive diversity, transactional memory, trans-specialist knowledge and their contribution to new knowledge development through knowledge boundary spanning. © 2006 Operational Research Society Ltd. All rights reserved.

This paper contributes to our understanding of knowledge creation by developing a comprehensive model of the knowledge creating process in organisational work teams. It subsequently synthesises contemporary theory across research streams to develop hypotheses relating to three factors capable of facilitating the knowledge development process - cognitive diversity, transactional memory and openmindedness norms. In combination, the conceptual rationale and empirical support act to substantiate three key relationships in the knowledge creation process.

Knowledge transfer and learning within non-equity strategic alliances is an under-researched area. Based on interview data, this paper studies knowledge transfer, replication and learning in contractual joint ventures (CJVs), a major form of foreign investment in China. Using a quasi-hierarchical organization structure, CJVs replicated part of their Hong Kong parent's know-how, which depended on local Chinese managers' learning intent and learning ability. Hong Kong partners also learned from managing the CJV and operating in China's local environment. © Gabler Verlag 2005.

This paper provides a methodology for identifying the dynamics of international firm expansion, demonstrating systematic evidence of both 'toe in the water' and concentrated bursts of internationalization by US multinational enterprises. We use the methodology of statistical process control to analyze initial investments in host countries and develop a numerical measure of temporal clustering or bunching. Using this measure, we identify two distinct patterns of growth; whereas some firms cluster their investments over time, others do not cluster their investments. For firms that cluster, three types of clustering strategy are identified: concentrating, hibernating, and hybrid. Arguments based on internal firm architecture, experience, and learning are advanced to explain these findings. © 2005 Academy of International Business All rights reserved.

This paper develops a new model for testing the role of incentives in FDI location choice by integrating the theory of the MNE with new approaches to location theory. From the theory our paper derives four testable hypotheses related to the role of policy variables in the location choice of Japanese MNEs in Singapore. Specifically we test for the existence of regional investment clusters and national tournaments as key elements in the FDI location decision. We also test for differences in the incentive preferences of export-oriented versus market-oriented investors and for first investments compared to reinvestments. Using survey data from 134 Japanese MNEs our study confirmed the existence of a Southeast Asian regional investment cluster and a location tournament between regional states. Our study also found that different incentives attracted export-oriented and market-oriented investors, but there were no significant differences in the incentive preferences of first investors compared to reinvestors. The policy implications of these findings are discussed. © 2001 Kluwer Academic Publishers.

This paper tests whether Japanese subsidiaries in Australia were learning organisations. Two strands of MNE theory are presented: dynamic capability and organisational learning models. Japanese MNEs transferred both work and subcontracting practices to their Australian subsidiaries. Statistical tests showed that there were no significant deepening in work practices or subcontracting relationships between 1993 and 1997. Our tests also revealed no long-term learning, measured by changes in work practices and subcontracting relationships for firms who had operated in Australia for more than 10 and less than 10 years. The paper advances explanations of the absence of short-term and long-term learning.

This paper examines management and HRM practices adopted by Japanese multinational enterprises (MNEs) and the transferability of Japanese HRM in the Australian host-country situation. It also compares HRM practices of Japanese MNEs in Australia with the experience in North America and Europe and attempts to map the typology of the human resource management utilized by a range of Japanese firms operating in Australia, including large and small firms; manufacturing and non-manufacturing companies; firms with differing levels of Japanese equity and with different levels of operational experience. This paper is based on survey data from sixty-nine Japanese subsidiaries operating in the Australian manufacturing and service sectors in 1994.