Objective To analyze the dynamic efficiency of township hospitals. Methods Based on the DEA-Malmquist index, this research analyzed the change of the total factor productivity indices and the decomposition items of 281 township hospitals in Hunan province with panel data from 2000 to 2008. Results Among 281 township hospitals, less than half increased their scale efficiency, while more than half increased their total factor productivity, technology, whole efficiency and technical efficiency. Increasing technology and whole efficiency was the best way to improve total factor productivity. Besides, increasing technical efficiency and scale efficiency was the best way to improve whole efficiency. Conclusions The improvement of scale efficiency is key to developing the central township hospitals, while the improvement of technology is the key to developing general township hospitals.
Objective To evaluate and select essential medicine for acute exacerbation of chronic bronchitis (AECB) using evidence-based methods based on the burden of disease. Methods By means of the approaches, criteria, and workflow set up in the second article of this series, we referred to the recommendations of evidence-based or authority guidelines from inside and outside China, collected relevant evidence from domestic clinical studies, and recommended essential medicine based on evidence-based evaluation. Data were analyzed by Review Manager (RevMan) 5.1 and GRADE profiler 3.6 to evaluate quality of evidence. Results (1) Five guidelines were included (four foreign guidelines, one domestic guideline; three based on evidence, two based on expert consensus). (2) Medicines recommended at least twice by the National Essential Medicine List (NEML, 2009 version) and Chinese National Formulary (CNF) contained: ipratropium bromide (four times), amoxicillin amp; clavulanate potassium (three times), and corticosteroid (three times), cefuroxime (twice), ciprofloxacin (twice), levofloxacin (twice), salbutamol (twice) and dextromethorphan (twice). (3) As for domestic study evidence, a result of one RCT indicated that amoxicillin amp; clavulanate potassium had efficiencies of 92.3% to 94.7% (n=77, low quality). A result of three RCTs (n=275, low quality) indicated that cefuroxime had efficiencies of 67.6% to 90% and an incidence of 5% as to adverse reaction that mainly included skin rashes, diarrhea, etc. A result of two RCTs (n=120, low quality) indicated that ciprofloxacin had efficiencies of 78.3% to 86.6%, bacterial clearance rates of 72.7% to 86.5% and the incidences of 8.7% to 16.2% as to adverse reaction that mainly included gastrointestinal reaction, skin rashes, etc. A result of seven RCTs (n=523, low quality) indicated that levofloxacin had efficiencies of 72.5% to 94.5%, bacterial clearance rates of 82.1% to 95.8% and the incidences of 5% to 7.5% as to adverse reaction. A result of two RCTs (n=239, low quality) indicated that salbutamol had efficiencies of 85.4% to 96.7%. A result of one RCT (n=95, low quality) indicated that ipratropium bromide had efficiencies of 98%. A result of five RCTs (n=466, low quality) indicated that the combined use of budesonide and bronchodilators had efficiencies of 93.4% to 97.8%. Conclusion (1) We offer a b recommendation for cefuroxime, amoxicillin amp; clavulanate potassium, ciprofloxacin and levofloxacin used in the treatment of AECB. (2) We offer a b recommendation for glucocorticoid (budesonide, aerosol) and anticholinergic bronchodilator (ipratropium bromide) and a weak recommendation for short-acting β2-agonist bronchodilator (salbutamol) and antitussive agent (dextromethorphan) for alleviating symptoms due to AECB. (3) We make a recommendation against mucolytic agents and theophylline as routine use. (4) More large-scale, multi-center, double-blinded RCTs are needed in clinical and pharmacoeconomic studies on AECB and outcome indicator should be improved in order to produce high-quality local evidence.
Objective To evaluate and select essential medicine for acute cholecystitis using evidence-based methods based on the burden of disease. Methods By means of the approaches, criteria, and workflow set up in the second article of this series, we referred to the recommendations of evidence-based or authority guidelines from inside and outside China, collected relevant evidence from domestic clinical studies, and recommended essential medicine based on evidence-based evaluation. Data were analyzed by Review Manager (RevMan) 5.1 and GRADE profiler 3.6 to evaluate quality of evidence. Results (1) Three guidelines were included (two foreign guidelines, one domestic guideline; two based on evidence, one based on expert consensus). (2) Results of two RCTs (n=200, low quality) and two CCTs (n=230, low quality) indicated efficiencies of ampicillin/sulbactam, piperacillin/tazobactam, ciprofloxacin combined with metronidazole, and ceftazidime combined with metronidazole were 92.5%, 92.6%, 92.5% and 91.3%. A result of three RCTs (n=661, low quality) indicated that lavofloxacin had efficiencies of 82.2% to 95.8% which were 84.4% to 94.7% when combined with metronidazole. A result of three RCTs (n=553, low quality) indicated that for acute cholecystitis, ceftriaxone had an efficiency of 90.0%, cefuroxime 73.7% and cefoperazone/sulbactam 95.6% (Efficiency: ceftriaxone 93.3%, cefuroxime 82.5% and cefoperazone/sulbactam 92.3%, when combined with metronidazole). A result of one RCT (n=72, low quality) indicated that cephazoline had an efficiency of 70.9% with bacteria resistance rates of 70% for G+ and 87% for G. Conclusion (1) We offer a b recommendation for piperacillin/tazobactam and cefoperazone/sulbactam used in the treatment of acute cholecystitis (mild, moderate and severe). We offer a b recommendation for meropenem, imipenem/cilastatin and metronidazole as alternatives for severe acute cholecystitis. (2) We offer a weak recommendation for ceftazidime and cefepime used in the treatment of severe acute cholecystitis and a weak recommendation for cefotiam, ampicillin/sulbactam and cefuroxime used in the treatment of acute cholecystitis (mild and moderate). We offer a weak recommendation for lavofloxacin and ciprofloxacin used in the treatment of acute cholecystitis (mild and severe) and a weak recommendation for ceftriaxone used in the treatment of acute cholecystitis (mild, moderate and severe). (3) We make a recommendation against cephazoline as routine use. (4) More large-scale, multi-center, double-blinded RCTs are needed in clinical and pharmacoeconomic studies of acute cholecystitis and outcome indicator should be improved in order to produce high-quality local evidence.
Abstract Objective To investigate the disease constitution and hospitalization expenses in Songqiao Central Township Health Center (SqC) in Gaoyou City of Jiangsu Province in 2010, so as to provide the baseline data of disease burden for further study. Methods The inpatient records of SqC in 2010 were collected. The first discharge diagnoses were classified according to the International Classification of Disease 10 (ICD-10). The general information of the inpatients, discharge diagnosis, hospitalization expenses, disease category, age, gender, and reimbursement of expenses were described and analyzed by using Microsoft Excel 2003 and SPSS 13.0 software. Results a) The total number of inpatients was 1036 in 2010, and the gender ratio was about 1.0 (50.7% vs. 49.3%); b) The disease spectrum included 17 categories. The cumulative percents of the top 5 systematic diseases were 81.2%, including the respiratory, digestive, neoplasm, circulatory diseases, and injury, poisoning amp; external causes; c) The top 15 diseases were pneumonia, fracture, malignant neoplasm, benign neoplasm, acute bronchitis, cerebral infarction, hypertension, acute appendicitis, emphysema, cholecystolithias accompanied with cholecystitis, inguinal hernia, coronary heart disease, diabetes mellitus, chronic bronchitis and superficial injury; d) The patients suffering from pneumonia and acute bronchitis were mainly over 65 years old and younger than 5; e) The number of chronic diseases significantly increased with age, especially after the age of 35 years old, and reached the peak at the age over 65 years old; while the acute diseases were mainly distributed at the age younger than 15 yeas old and older than 65 years old. The average length of stay, the total hospitalization and out-of-pocket expenses per capita of the chronic diseases were more than those of the acute ones (13.8 days vs. 9.9 days, ? 3 082 vs. ? 2 615; ? 417 vs. ? 371, respectively); f)The length of stay and total hospitalization per capita were quite higher than the other township health centers (11.6 days vs. 5.2 days, ? 3 001.4 vs. ? 1 004.6); and g) Both of the total reimbursement and out-of-pocket expenses per capita accounted for 44%-57% of the total hospitalization expenses. Among the total reimbursement, the payment from New Cooperative Medical Scheme (NCMS) accounted for over 99%, while that from Medical Aid Scheme only accounted for less than 2%. Conclusion a) The top 3 systematic diseases of SqC are seen in respiratory system, digestive system and neoplasm. The acute diseases are mainly pneumonia and fracture; b) The number of acute or chronic diseases increases significantly with age, especially after 35 years old. Both adolescents and the aged suffer from the heaviest burden of diseases; c) The average length of stay and hospitalization expenses pre capita of SqC are much higher than those of the other township health centers; and d) NCMS is the major source of reimbursement. However, the proportion of out-of-pocket expenses and the burden of diseases are still very high and heavy. Thus the policy of NCMS needs to be adjusted step by step in future.
Objective To evaluate and select essential medicine for acute and chronic gastritis using evidence-based approaches based on the burden of disease for township health centers located in eastern, central and western regions of China. Methods By means of the approaches, criteria, and workflow set up in the second article of this series, we referred to the recommendations of evidence-based or authority guidelines from inside and outside China, collected relevant evidence from domestic clinical studies, and recommended essential medicine based on evidence-based evaluation. Data were analyzed by Review Manager (RevMan) 5.1 and GRADE profiler 3.6 to evaluate quality of evidence. Results (1) Five guidelines for acute gastritis and seven guidelines for chronic gastritis were included. The recommended included omeprazole, ranitidine and domperidone. (2) A result of three CCTs (n=315, low quality) indicated that omeprazole was superior to famotidine and ranitidine in alleviating symptoms of chronic gastritis such as pain or discomfort in the upper abdomen, regurgitation, a burning sensation in the heart, distention and fullness in the upper abdomen (71.2% vs. 47.3%, 94.4% vs. 84.3%, Plt;0.05). A result of one RCT (n=100, low quality) and two CCTs (n=213, low quality) indicated that in HP eradication rates, omeprazole triple therapy and the control intervention had no significant difference (OR=1.09, 95%CI 0.44 to 2.70, Pgt;0.05). A result of one RCT (n=100, low quality) indicated that omeprazole caused no adverse reaction. A result of five CCTs (n=528, low quality) indicated that adverse reaction of omeprazole included poor appetite (two cases), nausea and vomiting (four cases), headache or vertigo (one case) and increased transaminase (one case). Omeprazole cost eight yuan (tablet) or four yuan (capsule) daily. (3) HP eradication rates of ranitidine bismuth citrate was higher than the control group (OR=2.05, 95%CI 1.29 to 3.25, P=0.002). A result of 15 RCTs (n=3 638, high quality) indicated adverse reaction of ranitidine bismuth citrate mainly included symptoms in the digestive system. A result of one RCT (n=100, low quality) indicated ranitidine bismuth citrate and omeprazole triple therapy had no significant difference (Pgt;0.05) and ranitidine bismuth citrate caused no adverse reaction. Ranitidine cost 0.36 yuan (tablet), 0.40 yuan (capsule) or 2.7 to 5.4 yuan (injection) daily. (4) A result of two CCTs (n=133, low quality) indicated that compared with the control intervention, domperidone was more efficient without adverse reaction in improving indigestion, promoting gastric emptying effect, and alleviating pain and distention in the upper abdomen, belching and regurgitation. Domperidone cost 1 to 1.3 yuan daily. (5) All kinds of recommended medicines are listed and legalized in China Pharmacopoeia (2010) and CNF (2010). (6) In clinical setting, above-recommended medicines should be applied strictly according to the CNF (2010) and the National Clinical Prescription Guidelines for Essential Medicine. Conclusion For acute and chronic gastritis, indigestion and HP eradication: (1) We offer a b recommendation for omeprazole (immediate release tablet/capsule for oral use, 10 mg/tablet) which should be cautiously used in children, elderly people, and women during pregnancy or lactation. (2) We offer a b recommendation for ranitidine (immediate release tablet/capsule for oral use, 150 mg/tablet) which should be cautiously used in patients with severe insufficiency in the liver or kidney, women in the pregnancy or lactation, and children under eight years of age.
Objective To provide baseline datum for further evidence-based selecting essential health technology or essential medicine by comparing the top 15 inpatient diseases in the three pilot township clinics in western China from 2008 to 2010. Methods With the key words as disease spectrum, constitution of disease, inpatient disease category, inpatient diseases and so on, such databases as CBM, CNKI, VIP, WanFang and official websites of Ministry of Health were searched on computer, and the manual search was also conducted in combination to extract the related datum of provinces where the pilot township health centers were situated. The Excel software was used for data classification and analyses. Results (1) Among the 16 included literatures including 15 journal papers and 1 master thesis, 4 scored from zero to 3.5, 9 scored from 3.5 to 6.75, and the left 3 scored 7 or more than 7; (2) The common inpatient diseases in the township health centers in eastern, central and western regions in China were different. The upper respiratory tract infection, acute/chronic bronchitis, acute/chronic gastritis and appendicitis were the common inpatient diseases in the township health centers throughout China. The pneumonia, emphysema, cholelithiasis, cholecystitis, and acute/chronic gastroenteritis were the common inpatient diseases in the township health centers in southwest and northwest regions. The top 15 inpatient diseases in the three pilot township clinics in this study covered all the common inpatient diseases in the township health centers in southwest and northwest regions in China; (3) The total number of the top 15 inpatient diseases of the three pilot township health centers in western China between 2008 and 2010 was 35, including 20 chronic and 15 acute diseases. The chronic diseases were chronic bronchitis, chronic gastritis, hypertension, lumbar/cervical disease, cholelithiasis or cholecystitis, coronary heart disease, chronic pulmonary heart disease, urinary calculi, pelvic inflammation, vertebrobasilar insufficiency, arthritis, acute exacerbation of chronic bronchitis, Meniere’s disease, chronic obstructive emphysema, myocardial ischemia, prostatitis, etc.. The acute diseases were upper respiratory tract infection, pulmonary infection, fracture, superficial injury, acute appendicitis, acute bronchitis, urinary tract infection, acute gastritis, acute gastroenteritis, delivery amp; cesarean section, soft tissue injury, acute urticaria, etc.; and (4) While the common inpatient disease categories were relatively centralized and stable, but some of them were different in regions, inpatients’ age and sex structure. Conclusion (1) There are some differences in the common inpatient diseases in the township health centers among eastern, central and western regions in China, thus it is necessary to select essential health technology and essential medicine according to local conditions; (2) As a good representation, the common inpatients diseases in the three pilot township health centers in western China can provide the baseline evidence for selecting essential health technology and essential medicine for the township health centers in western China; (3) There are lack of national/regional statistics, survey data and evidence-based research on disease spectrum of the township health centers currently. While the investigation methods or statistics measurements/quality of these included studies are variable without standard regulation; and (4) It suggests that the state and every provinces should implement and improve the statistic analysis of disease spectrum of the township health centers, train staffs and fulfill the construction of information system.
Objective To evaluate and select essential medicine for community-acquired pneumonia (CAP) using evidence-based methods based on the burden of disease. Methods By means of the approaches, criteria, and workflow set up in the second article of this series, we referred to the recommendations of evidence-based or authority guidelines from inside and outside China, collected relevant evidence from domestic clinical studies, and recommended essential medicine based on evidence-based evaluation. Data were analyzed by Review Manager (RevMan) 5.1 and GRADE profiler 3.6 to evaluate quality of evidence. Results (1) Eleven guidelines were included (nine foreign guidelines, two domestic guidelines; nine based on evidence, two based on expert consensus). For CAP, amoxicillin amp; clavulanate potassium had efficiencies of 77.1% and an incidence of 18.8% as to adverse reaction that mainly included gastrointestinal reaction, skin rashes, etc. Piperacillin/tazobactam had an efficiency of 92.1% and a bacterial clearance rate of 88.9%. Cefuroxime had an efficiency of 89% and a bacterial clearance rate of 85.5%. There was no statistical significance between azithromycin and cefuroxime for CAP (RR=0.98, 95%CI 0.9 to 1.06); however, azithromycin was superior to cefuroxime in shortening fever-relief time (MD=–0.98, 95%CI –1.24 to –0.55) and cough-relief time (MD=–1.36, 95%CI –1.94 to –0.78). Efficiencies of ceftriaxone, cefotaxime, moxifloxacin and lavofloxacin were all more than 80% and among the three, moxifloxacin was the most efficient (RR=1.08, 95%CI 1.02 to 1.13, P=0.004). Meropenem had an efficiency of 90%, a bacterial clearance rate of 83.3% and an incidence of 3.33% as to adverse reaction that mainly included diarrhea. Conclusion (1) We offer a b recommendation for antibiotics such as amoxicillin, amoxicillin amp; clavulanate potassium, ampicillin/sulbactam, piperacillin/tazobactam, doxycycline, azithromycin, clarithromycin, cefuroxim, ceftriaxone, cefotaxime, lavofloxacin, moxifloxacin, ertapenem, meropenem, imipenem and vancocin. (2) We offer a weak recommendation for penicillin G, ciprofloxacin and erythromycin. (3) We propose that doctor should choose optimal antibiotics based on commonly-seen pathogenic bacteria that cause CAP, local criteria of antibiotic susceptibility, severity of CAP, and risk factors of patients.
Objective To establish standards, methods and processes for evidence-based evaluation and selection of essential medicine that meet the needs of the 8 pilot township health centers in China. Methods A descriptive analysis was conducted to compare the similarities/differences and the advantages/disadvantages of the standards, methods and processes between the World Health Organization (WHO) essential medicines evaluation and selection, and the GRADE evidence quality and recommend intensity. In combination with the former outcomes of this series of study, the standards, methods and processes of evidence-based evaluation and selection of essential medicines in the domestic pilot township health centers were optimized, restructured and improved. Softwares such as GRADEprofiler were used to assess the quality of evidence. Results a) Localized standards, methods and processes for evidence-based evaluation and selection of essential medicine were established, and the evaluation tool was ascertained; and b) Disease and drug names, guidelines and searching processes for evaluation and selection of essential medicine were developed with standardized, systematic and transparent approaches. Conclusion a) Standards, methods and processes for searching, evaluating and recommending the best evidence are preliminarily established, through comparative analysis on the effectiveness, safety, cost-effectiveness and applicability of the candidate medicines for diagnosing, treating and preventing diseases in township health centers in China; b) Following the principle of “utilizing the best existing evidences and developing the urgently-needed but lacking evidence”, a good exploration was done for the localization, standardization and transparency of the standards, methods and processes of evidence-based evaluation and selection of essential medicine for pilot township health centers.
Objective To provide baseline data for further evidence-based evaluation and selection of essential medicine by analyzing the inpatient disease constitution in 8 pilot township health centers located in eastern, central and western China in 2010. Methods The analysis was performed to compare the similarities and differences of both systematic diseases and top 15 single diseases of inpatients in 8 pilot township health centers located in eastern, central and western China in 2010. The Microsoft Excel 2003 and SPSS 13.0 softwares were used for data classification and analysis, and the frequency and composition were used as describing statistical indicators. Results a) The top 5 systematic diseases were respiratory, digestive, circulatory, urinary tract and urogenital systems, as well as the trauma and toxicosis, with accumulative constituent ratio accounting for 71.0%-81.6%; b) The inpatients suffering from top 15 systematic diseases were 10 630, accounting for 61.10%. Each of the respiratory and digestive system contained 6 single diseases including 4 acute and 2 chronic ones, with inpatients accounting for 99.2% and 93.8%, respectively; the circulatory system contained 3 single diseases which were all chronic with inpatient ratio of 84.6%; and c) The chronic diseases were in majority within the top 15 single diseases, which were most commonly seen rather than acute diseases in the pilot township health centers in eastern and central China. The inpatients’ acute diseases were more often seen than chronic diseases in well-off and fundamental township health centers. Conclusion a) The top 5-6 systematic diseases are stable in the pilot township health centers in eastern, central and western China in 2010. The common single inpatient diseases are centralized, which benefits the selection and adjustment of essential medicine for the pilot township health centers in China; b) The capacity building of the western, fundamental and well-off township health centers to diagnose and treat inpatients suffering acute diseases should be promoted; c) The capacity building of the central and general township health centers to diagnose and manage inpatients suffering chronic diseases should be promoted; d) The capacity building of the eastern and well-off township health centers to provide outpatient service should be promoted. The function of the eastern township health centers needs further clarification and improvement; and e) More attention should be paid to diseases prevention, control and treatment for women, children, the elderly and the population with high burden of diseases.
Objective To evaluate and select essential medicine for middle-aged and elderly women with primary osteoporosis using evidence-based methods based on the burden of disease. Methods By means of the approaches, criteria, and workflow set up in the second article of this series, we referred to the recommendations of evidence-based or authority guidelines from inside and outside China, collected relevant evidence from domestic clinical studies, and recommended essential medicine based on evidence-based evaluation. Data were analyzed by Review Manager (RevMan) 5.1 and GRADE profiler 3.6 to evaluate quality of evidence. Results (1) 18 guidelines were included, 14 of which were evidence-based or based on expert consensus. Recommended medicines included bisphosphonates, calcitonin, estrogen, parathyroid hormone, selective estrogen receptor modulator, strontium and Chinese patent drug. (2) A result of one quasi-RCT (very low quality) indicated that caltrate D had a better effect on elderly women with primary osteoporosis than calcium gluconate in improving bone mineral density (BMD) (MD=0.04, 95%CI 0.02 to 0.06) and ameliorating bone ache ( RR=2.64, 95%CI 1.40 to 4.96). A few cases treated by caltrate D presented with adverse reaction such as gastrointestinal discomfort, poor appetite, constipation and nausea which disappeared later. Caltrate D (calcium carbonate D3) with good applicability cost 1.00 yuan daily. (3) A result of one RCT (low quality) indicated that alendronate had a better effect than caltrate D in improving L2-L4 BMD (MD=0.06, 95%CI 0.017 to 0.10) and ameliorating bone ache (RR=1.8, 95%CI 1.40 to 2.52). A result of two RCTs (moderate quality) indicated that alendronate plus calcium carbonate plus vitamin D6 had a better effect than calcium carbonate plus vitamin D in improving L2-L4 BMD (MD=0.05, 95%CI 0.02 to 0.08) and reducing blood alkaline phosphatase (MD=–31.9, 95%CI –54.99 to –8.81). There were slight adverse effects mainly including gastrointestinal reaction. Alendronate with fairly poor applicability cost 2.67 yuan daily. (4) A result of one RCT (moderate quality) indicated that after a 3-month treatment, Xian Ling Gu Bao Jiao Nang (name of a Chinese patent drug, abbreviated as XLGB) plus calcium preparation had a better effect than calcium preparation alone (MD=10, 95%CI 0.05 to 0.15). A result of one RCT (moderate quality) indicated that given for 3 to 6 months, XLGB plus calcium preparation was superior to calcium preparation alone in increasing the density of Ward’s triangle and the great femoral trochanter. A result of one RCT (low quality) indicated that XLGB plus calcitriol had a better effect than calcitriol alone in pain relief (RR=1.26, 95%CI 1.04 to 1.52). There were slight adverse effects mainly including reaction in the digestive system, the circulatory system and the skin. XLGB with good applicability cost 4.58 yuan daily. Conclusion We offer a weak recommendation for alendronate applied to middle-aged and elderly women with primary osteoporosis and pain and fracture caused by primary osteoporosis. We also offer a b recommendation for caltrate D and XLGB applied to middle-aged and elderly women with primary osteoporosis and pain and fracture caused by primary osteoporosis. In addition, we propose that the census on elder people with osteoporosis in rural areas should be carried out. More clinical and pharmacoeconomic studies of large-sample, high-quality on alendronate and its calcium preparation for adult osteoporosis are needed in China.
