| Background and PurposeThe stroke mainly including ischemic stroke and hemorrhagic stroke is a non-infectious chronic disease,which threaten Chinese patient's life seriously.A study indicates that for Chinese patients,stroke is at the top of disease spectrum whose prevalence rate and death rate is far higher than other diseases.In 2016,the number of discharged patients with cerebrovascular disease(CVD)in China reached 4.7 million and the hospitalization expenses were RMB 47.2 billion;as the main cerebrovascular disease,the stroke cost 75.24%of discharged patients within CVD and 79.67%of expenses accordingly.Therefore,it is very meaningful to do the research on the cost and influence factors of cerebral stoke patients and the proposal raised based on the study will be benefit for the cost controlling and patients'disease burden saving.Currently the main problems in stroke expenditures studies are as follows:(1)Limited data coverage.The studies mainly focused on several hospitals or medical services data from some provinces or cities with cross-section data,small sample size or limited region that cannot be a typical model to reflect the comprehensive situation of national patients.(2)Limited variables.Most of the studies only take considerations on some single variable but lack of comprehensive variables based on the big data.(3)Lack of studies on the different kinds of stroke but only see it as a whole.(4)Few studies on the stoke expenditures and its influence factors for outpatients until now.As a word,the conclusion of formal studies is not that comprehensive to some extent and there is no scientific study on the expenditures and influences factors of stroke national wide.Based on the above considerations,this study takes the core information of stroke including the cost and relevant influence data during 2010-2015 based on The National Survey Database on Use of Basic Medical Insurances and Medical Services released by China Health Insurance Research Association(CHIRA)to organize a model to make deeply analysis on the national stroke expenditures and identify the comprehensive influences factors for both inpatients and outpatients.Moreover,in order to put forward useful proposals on the government decision making to control the unexpected cost raising and reduce patients'disease burden.Research MethodsThe National Survey Database on Use of Basic Medical Insurances and Medical Services is a national survey executed by CHIRA,which randomly selected the medical services information of inpatients and outpatients from 80 cities' medical insurance agencies within 31provinces and The Xinjiang Production and Construction Corps.This study takes the pooled cross-sectional data of patients diagnosed as stroke(160-164),including 343870 person-times ischemic stroke and 33925 person-times hemorrhagic stroke.This study firstly use descriptive statistics to make analysis on the medical expenditures,drug cost and self-pay status and its variation trend by different years,genders and insurances,and secondly take multivariable statistics method to build up a influencing factors model on the inpatients total cost,drug cost and self-pay of stroke patients,lastly make a deeply discussion based on the models.Research Results1.Basic status of inpatientsThe study extracted 228669 people times' stroke patients in total during 2010-2015,of which the ratio of hemorrhagic stroke and ischemic stroke is 13.5%and 86.5%.(1)The hemorrhagic stroke64.8%of the patients are male and 35.2%are female with statistical significance(P<0.05);The average age is 62.84 years(SD 14.43);Ratio of the Basic Medical Insurance Scheme for Employees(BMISE)and the Basic Medical Insurance Scheme for Urban Residents(BMISUR)is 69.38%and 30.62%with statistical significance(P<0.05);Ratio of East,Central and West region is 41.9%29.98%and 28.12%,with statistical significance(P<0.05);Patients ratio in basic medical institutions,second-grade hospitals and third-grade hospitals is 7.39%,35.81%and 56.80%with statistical significance(P<0.05)(2)The ischemic stroke58.39%of the patients are male and 41.61%are female with statistical significance(P<0.05);The average age is 68.23 years(SD 11.47);Ratio of BMISE and BMISUR is 73.77%and 26.22%with statistical significance(P<0.05);Ratio of East,Central and West region is 41.69%?37.29%and 21.02%with statistical significance(P<0.05);Patients ratio in basic medical institutions,second-grade hospitals and third-grade hospitals is 16.82%.40.65%and 42.52%with statistical significance(P<0.05)2.Medical cost status and trend for different kinds of stroke(1)The hemorrhagic strokeThe average medical cost per time is ?27558(SD 48244)and 67.32%reimbursed by medical insurance.Differ in male and female,the cost per time is ?27550(SD 50620)and?27565(SD 43696).For BMISE and BMISUR patients,it costs ?30881(SD 53670)with 71.67%reimbursed and ?20139(SD 32059)with 51.93%reimbursed respectively.The cost per time in the third-grade hospital,the second-grade hospital and basic medical institutions is?35152(SD 53455),?18881(SD 38856)and ?11697(SD 34946),with the reimbursement ratio of 66.37%,68.72%and 77.41%.Cost per time of East,Central and West region is?29788(SD 45543),?26982(SD 58354)and ?24858(SD 39258)of which 67.65%,64.02%and 70.54%reimbursed.All above analysis have statistical significance(P<0.05).The drug to total medical cost ratio is decreasing from 50.19%to 39.79%and the medical devices and treatment items cost ratio increasing from 36.17%-43.41%(P<0.05).Increase with age,the drug cost ratio is increasing from 40.78%to 47.14%and services cost ratio decreasing from 21.32%to 9.70%(P<0.05);the cost ratio of western drugs and Chinese traditional drugs is 89.5%and 10%.The western drug cost ratio in the third-grade hospitals,the second-grade hospitals and basic medical institutions are 90.95%,88.87%and 77.45%(P<0.05)(2)The ischemic strokeThe average medical cost per time is ?10025(SD 13712)and 73.38%reimbursed by medical insurance.Differ in male and female,the cost per time is ?10422(SD 14308)and?9451(SD 12810).For BMISE and BMISUR patients,it costs ?11013(SD 14638)with 76.39%reimbursed and ?7371(SD 10060)with 54.84%reimbursed respectively.The cost per time in the third-grade hospital,the second-grade hospital and basic medical institutions is?14260(SD 17462),?7884(SD 8950)and ?4759(SD 8671),with the reimbursement ratio of 72.32%,74.07%and 78.80%.Cost per time of East,Central and West region is ?12131(SD 14887),?8006(SD 12585)and ?9271(SD 12439)of which 73.42%70.91%and 76.98%reimbursed.All above analysis have statistical significance(P<0.05).The drug to total medical cost ratio is decreasing from 56.26%to 49.45%and the medical devices and treatment items cost ratio increasing from 39.51%to 45.09%(P<0.05).Increase with age,the drug cost ratio is increasing from 45.08%to 51.60%and services cost ratio decreasing from 12.00%to 4.44%(P<0.05);the cost ratio of western drugs and Chinese traditional drugs is 72.82%and 25.86%.The western drug cost ratio in the third-grade hospitals,the second-grade hospitals and basic medical institutions are 78.52%,70.60%and 60.88%(P<0.05)3.Core influencing factors analysis on inpatientsThe conclusions of the comprehensive factors model indicate that the year,medical insurance type,gender,age,hospital grade,length of hospital stay,and the region of patients are almost all significant influencing factors on the cost of hemorrhagic stroke and ischemic stroke including the cost per time,drug cost and self-pay ratio(except that medical insurance class is not a significant influencing factor on hemorrhagic stroke).For hemorrhagic stroke,in the per time cost model R2=0.332,standardized regression coefficients of the length of stay,hospital grade,region,year,medical insurance type,age and gender are respectively 0.432?0.343?-0.103?0.071?-0.054 and 0.012;in the drug cost model R2=0.248,standardized regression coefficients of the length of stay,hospital grade,region,age,year,gender and medical insurance type are respectively 0.368,0.324,-0.074,0.014,-0.014 and-0.002(P=0.653);in the self-pay model R2=0.282,standardized regression coefficients of the hospital grade,length of stay,medical insurance type,region,age,year and gender are respectively 0.404,0.329,0.146,-0.130,0.030 and 0.062.All above standardized regression coefficients have statistical significance(P<0.05).For the ischemic stroke,in the per time cost model R2=0.443,standardized regression coefficients of the hospital grade,length of stay,region,medical insurance type,year,age and gender are respectively 0.366,-0.174,-0.099,0.064,0.046 and-0.016;in the drug cost model R2=0.275,standardized regression coefficients of the hospital grade,length of stay,region,medical insurance type,age,gender and year are respectively 0.376,0.270,0.154,-0.071,0.043,-0.023 and-0.011;in the self-pay model R2=0.343,standardized regression coefficients of the hospital grade,length of stay,region,medical insurance type,year,age and gender are respectively 0.515?0.229,-0.199,0.141,0.033,-0.032 and-0.007.All above standardized regression coefficients have statistical significance(P<0.05).4.Analysis on the outpatientThe study extracted 149126 people times' stroke outpatients in total during 2013-2015,of which the ratio of hemorrhagic stroke and ischemic stroke is 2.77%and 97.23%.For hemorrhagic stroke,64.64%of the patients are male with the average age of 62.81 years(SD 14.20),patient ratio in the third-grade hospital is 45.66%,the average cost per time is ?446(SD 546)and differ in BMISE and BMISUR,the cost per time for outpatient is ?458(SD 555)and ?376(SD 487),and the drug cost ratio is 95%.For ischemic stroke 57.49%of the patients are male with the average age of 66.30 years(SD 12.02),patient ratio in the third-grade hospital is 44.23%,the average cost per time is ?493(SD 632)and differ in UEBMI and URBMI,the cost per time for outpatient is ?498(SD 616)and ?421(SD 814),and the drug cost ratio is 86.37%(P<0.05)ConclusionsThe demographic characteristics,medical service utilizing and variation trend are different for outpatients and inpatients with hemorrhagic stroke and ischemic stroke;meanwhile,the expenditure distribution,characteristics and variation trend of outpatient expenses and hospitalization expenses are also different for patients with hemorrhagic stroke and ischemic stroke.See from the core influencing factors,seven factors have significant influence on the average cost per time,medicine expense and personal disease burden of stroke patients including years,insurance type,gender,age,hospital grade,length of hospital stay and region.The most important influencing factor of the average cost per time and drug cost of patients with hemorrhagic stroke is the length of hospital stay,while the most important influencing factor for patients with ischemic stroke is the hospital grade;and the hospital grade is the most important influencing factors of the personal disease burden of patients with hemorrhagic stroke and ischemic stroke.On medical cost controlling side,we could strengthen the disease pathway management to raise efficiency and shorten the length of hospital stay;guide the patients of recovery stage to basic medical institutions,reduce the pressure of third-grade hospitals and cut down the medical cost accordingly;on payer's side,it will be beneficial for ensuring the equity when taking actions to narrow the payment gap between different type of medical insurances,This study provides a whole picture analysis national wide on the demographic characteristics,service utilizing and variation trend on stroke including both hemorrhagic stroke and ischemic stroke,which will provide some basic macroscopic information for the epidemiological study of stroke.Meanwhile,study on the medical cost and the influencing factors of stroke and the cost controlling strategies raised based on the study will be benefit for the cost controlling and patients' disease burden saving. |
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