Background: China experienced a rapid increase in hospitalisation over the past decade, yet the relative associations of healthcare demand and supply remain unclear. We examined long-term trends in hospitalisation and quantified the model-based contribution of hospital bed expansion to hospitalisation growth across provinces in China. Methods: We conducted a provincial panel study of 31 mainland Chinese provinces, 2011–2024. Hospitalisation rate was the primary outcome. Demand-side and supply-side factors were analysed using two-way fixed-effects models. Regression-based decomposition quantified model-based contributions. Subgroup analyses assessed heterogeneity by region, economic development, and bed density. Findings: The hospitalisation rate increased from 11.37% in 2011 to 22.62% in 2024, with persistent regional disparities. Hospital bed density was positively associated with hospitalisation after adjustment for demand-side factors and physician density (β=0.992, p<0.01). Bed density had the largest model-based contribution to this growth (3.44 percentage points, 30.6%), exceeding economic development (22.8%) and population ageing (7.2%). This association was stronger in central (β=1.505, p<0.01) and western provinces (β=2.453, p<0.01) but was not statistically significant in eastern provinces. Measured demand-side and supply-side factors together explained 38.6% of the total increase; the remaining 61.4% was unexplained. Interpretation: Long-term hospitalisation growth in China is associated with both rising healthcare needs and supply expansion, yet a substantial proportion remains unexplained by conventional frameworks. Hospital bed expansion showed the largest model-based contribution, but this association was context-dependent. Future reforms should prioritise resource optimisation over capacity expansion. Funding : None

ABSTRACT Background Knee osteoarthritis with medial‐compartment varus deformity is common in middle‐aged adults, and the optimal surgical strategy for this group remains debated, with open‐wedge high tibial osteotomy (OWHTO) and total knee arthroplasty (TKA) representing joint‐preserving and joint‐replacing options whose comparative long‐term value is uncertain. Objective To compare the cost‐effectiveness and long‐term outcomes of open‐wedge high tibial osteotomy (OWHTO) versus total knee arthroplasty (TKA) in middle‐aged patients with varus knee osteoarthritis: Methods This multicenter retrospective cohort study analyzed registry data from three Chinese university affiliated hospitals. A total of 825 patients aged 45–65 who underwent OWHTO or TKA between 2005 and 2015 were included, with follow‐up through 2025. Outcomes included Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, EQ‐5D‐5L utilities, range of motion (ROM), mechanical axis deviation (MAD), muscle strength, and total healthcare costs. Costs were assessed from a societal perspective (direct medical, direct non‐medical, and indirect productivity costs), and both costs and health outcomes were discounted at 3% annually. The EQ‐5D‐5L–based quality‐adjusted life year (QALY) was the primary outcome; clinical and functional measures were secondary. Multivariate regression models were used to compare outcomes between groups, and 1000‐bootstrap simulations were used to estimate incremental cost‐effectiveness ratios (ICERs). ICERs were interpreted against a willingness‐to‐pay threshold of one to three times China's 2024 gross domestic product per capita (CNY 95,749–287,247 per QALY). Robustness was assessed with inverse‐probability‐of‐treatment‐weighting (IPTW) and age‐stratified (45–54 vs. 55–65 years) sensitivity analyses. Results Clinical outcomes at final follow‐up did not differ significantly between OWHTO and TKA groups. OWHTO was associated with a lower cumulative cost (mean CNY 121,784) than TKA (CNY 160,075; p < 0.001). In cost‐effectiveness analyses, OWHTO was associated with better outcomes in WOMAC pain, mechanical alignment (MAD), ROM, and dynamic strength at a lower cost than TKA. Quality‐adjusted life year outcomes (EQ‐5D‐5L utility) slightly favored TKA (71.9% of bootstrap samples), yielding an ICER of CNY 5,441,410.25 per QALY for TKA relative to OWHTO, approximately 19 times the upper willingness‐to‐pay threshold (3× GDP per capita, CNY 287,247 per QALY), indicating that the marginal utility gain with TKA was not cost‐effective. The reoperation/revision rate did not differ between groups (OWHTO 0.95% [3/316] vs. TKA 0.59% [3/509]; p = 0.687), and findings were consistent in IPTW‐weighted and age‐stratified sensitivity analyses. Other ICERs were 146,719.91 CNY (WOMAC function), 53,934.07 CNY (WOMAC stiffness), 115,812.43 CNY (isometric strength), and 167,518.20 CNY (sit‐to‐stand power). Results were robust to sensitivity analyses. Conclusion Over more than 10 years of follow‐up, OWHTO provided outcomes equivalent to TKA while substantially reducing costs. These findings support OWHTO as a cost‐effective option for selected middle‐aged patients with varus knee osteoarthritis. Level of Evidence Level III, retrospective cohort study.

BACKGROUND:The health of the populace is a fundamental pillar for China's sustainable economic growth. Health production efficiency refers to the ability to maximize the health outcomes of residents given a certain level of resource inputs. It reflects the efficiency of resource utilization in the process of health production. This paper evaluates health production efficiency in China, analyzes regional disparities, and explores influencing factors. METHODS:After constructing an evaluation index system for residents' health production efficiency, this study employs the undesired output-SBM super-efficiency model to measure health production efficiency. Regional disparities in health production efficiency are analyzed using the Dagum Gini coefficient, while a dynamic spatial Durbin model is applied to investigate the influencing factors and spatial spillover effects. RESULTS:The findings show: (1) Health production efficiency is generally on the rise nationwide, with eight major economic zones experiencing an increase in provinces with high efficiency and a decrease in those with low efficiency, except for a downturn in 2020 caused by the pandemic. (2) The overall disparity in health production efficiency has been steadily narrowing. Intra-regional disparities among the eight major economic zones vary, while inter-regional disparities have gradually declined but continue to represent the primary source of the overall gap. (3) Health production efficiency exhibits significant and positive spatial spillover effects both temporally and spatially. Per capita GDP exerts strong negative direct and spillover effects on health production efficiency. Residents' income demonstrates a positive spillover effect, while population density shows a significant negative overall effect. CONCLUSIONS:This study conducts a comprehensive evaluation of health production efficiency through the construction of an index system, revealing an overall upward trend in health production efficiency. Intra-regional disparities remain the primary source of the overall differences in health production efficiency across China. Policymakers need to address the challenges posed by per capita GDP and population density on health production efficiency while leveraging the positive impact of residents' income levels to promote sustainable and balanced regional development. This study can assist the government in optimizing the allocation of healthcare resources, reducing regional health disparities, and formulating more equitable health policies.

Endoscopic submucosal dissection (ESD) is a minimally invasive therapy for early gastrointestinal neoplasms, but patients may experience reduced functional capacity and delayed recovery post-procedure. Prehabilitation, has shown benefits in major surgery by improving physical fitness and recovery. We hypothesized that a structured prehabilitation regimen before ESD would enhance postoperative functional recovery and patient outcomes compared to standard care. Single-center, assessor-blinded randomized controlled trial of 100 adults undergoing elective ESD, randomized to 4-week prehabilitation (supervised aerobic/resistance training 3×/week, individualized nutrition with protein supplementation, and psychological support) or usual care (standard instructions without structured exercise or nutrition). The primary outcome was change in six-minute walk distance (6MWD) from baseline to 1 month. Secondary outcomes included handgrip strength, quality of life (SF-36), psychological health (HADS), postoperative complications, length of stay, and 90-day readmissions. Baseline characteristics were similar between groups. At 1-month post-ESD, six-minute walk distance had decreased in both groups with no significant between-group difference (mean change from baseline − 40.9 m in prehabilitation vs. − 53.3 m in controls, p = 0.439). By 3 months, the prehabilitation group surpassed their baseline walking distance (18.9 m), whereas controls remained below baseline (− 14.1 m), indicating superior functional recovery with prehabilitation (p = 0.022). Prehabilitation also led to greater improvements in early postoperative strength and patient-reported outcomes. At 1 month, handgrip strength increased more in the prehabilitation group (mean 5.6 kg vs. 4.1 kg, p = 0.001). Anxiety symptoms improved significantly with prehabilitation (HADS anxiety score change − 1.17 vs. − 0.22, p = 0.003), with a parallel significant reduction in depression scores (p = 0.002). Prehabilitation patients reported higher gains in mental quality-of-life by 3 months (SF-36 mental component + 15.4 vs. + 11.4 points, p < 0.001). There were no significant differences in perioperative safety outcomes, average hospital stay, and 90-day readmission rates. A 4-week multimodal prehabilitation program for ESD patients significantly improved postoperative functional capacity and psychological well-being without increasing complication rates or hospital stay. Prehabilitation is a safe and effective strategy to enhance recovery and patient-centered outcomes in ESD. This trial was retrospectively registered in the Chinese Clinical Trial Registry (ChiCTR) (registration number: ChiCTR2500103062) on May 23, 2025. Level I (Randomized Controlled Trial).

Diabetes is a major global health concern. However, with proper treatment and management, individuals can lead healthy and fulfilling lives. Shared medical appointment (SMA), an integrated health service, effectively improves the clinical and behavioral outcomes of people living with diabetes (PLWD). Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, this review aimed to evaluate the impact of SMA on PLWD treatment and management to inform the feasibility, sustainability, scalability, and equity of future SMA implementation. Eight electronic databases were searched for randomized controlled trials, non-randomized grouped controlled trials, pre/post studies, and interrupted time series model studies published in English and Chinese until February 2024. The information extraction was guided by the framework for outcome evaluation in implementation science, the RE-AIM framework. We performed meta-analyses for all randomized controlled trials (RCTs) using a random-effects model and presented Forrest plots and test statistics (Cochran's Q and I2) for heterogeneity analysis. Other results that did not lend themselves to quantitative analysis were summarized qualitatively. Forty-seven studies were included in the review. The studies were evaluated according to the RE-AIM framework, and most studies reported effectiveness well, while all other dimensions were poorly reported. Most studies demonstrated that SMA effectively improved patients' Hemoglobin A1c (HbA1c) and Systolic Blood Pressure (SBP) levels and reduced healthcare costs. However, the SMA was a highly resource-demanded and complex intervention package. The available evidence suggests that the SMA was beneficial in improving PLWD management and health outcomes among PLWD. However, its complexity would constrain its feasibility and scalability. Future research should assess the effect size of each intervention component and evaluate the implementation process, costs, and maintenance of SMA intervention, especially in resource-limited settings, to improve its sustainability, scalability, and equity. • What is already known about this topic? Current studies demonstrated that shared medical appointments (SMA) effectively improved clinical and behavioral outcomes for people living with diabetes (PLWD) in experimental settings, which contained adequate resources. However, there was a notable gap in the research regarding the comprehensive evaluation of the implementation outcome using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework, which would constrain the scale-up of the SMA and affect equity in resource-limited communities. • What this study adds - This systematic review innovatively evaluates the impact of SMA on diabetic treatment and management by using the RE-AIM framework. It highlights the gap between effectiveness and implementation research, including long-term sustainability, scalability, and equity, particularly in resource-limited settings. The multidimensional results of SMA provide insights into the study's effectiveness and inform the research design, practical applications, and subsequent policy development by considering all implementation-relevant dimensions. • How this study might affect research, practice, or policy - This study demonstrated the specific impact of SMA on biochemical markers and healthcare costs, supporting the effectiveness of SMA in primary healthcare (PHC) settings, mainly reflected in improved HbA1c and SBP levels. However, the resource-intensive SMA healthcare service would affect its scale-up and equity in various PHC settings. More precise experiments would be needed to validate the main and interaction effects of SMA intervention components and inform the selection of effective, appropriate, resource-affordable components for future implementation practices and policy-making.

Post-traumatic elbow stiffness (PTES) severely limits elbow function, often necessitating surgical intervention after conservative measures fail. Although open arthrolysis (OA) is traditionally preferred, arthroscopic release (AR), being less invasive, could offer comparable or superior clinical outcomes with potentially lower complication rates. However, evidence from rigorous randomized trials directly comparing AR and OA for PTES remains scarce. This prospective randomized controlled trial aimed to evaluate and compare clinical outcomes, safety, and cost-effectiveness of arthroscopic release (AR) versus open arthrolysis (OA) in patients with PTES. From November 2016 to December 2022, 192 patients diagnosed with PTES, unresponsive to non-operative treatment, were randomized equally into AR and OA groups. Surgical interventions followed standardized techniques, including routine ulnar nerve management. Postoperative rehabilitation protocols were identical for both groups. Primary outcomes assessed were elbow flexion-extension and forearm rotation range of motion (ROM) at one year post-surgery. Secondary outcomes included flexion strength, endurance, patient-reported outcome measures (PROMs), cost analysis, and adverse event incidence. Statistical analyses used linear mixed-effects models and incremental cost-effectiveness ratios (ICER). At 1-year follow-up, both AR and OA produced substantial improvements in elbow motion and patient function and exceeded thresholds for clinically important gains. The between-group difference favoured AR (p < 0.05) but was very small in magnitude and below the minimal clinically important difference (25°). AR incurred higher intraoperative costs, but these were offset by significantly lower postoperative rehabilitation and follow-up care costs, resulting in similar total costs between groups and indicating that AR was cost-effective overall. Adverse event rates were similar (AR 32.3 https://www.chictr.org.cn/ ).

Providers have intended and unintended responses to payment reforms, such as China's new case-based payment system, i.e. Diagnosis-Intervention Packet (DIP) under global budget, that classified patients based on the combination of principal diagnosis and procedures. Our study explores the impact of DIP payment reform on hospital selection of patients undergoing total hip/knee arthroplasty (THA/TKA) or with arteriosclerotic heart disease (AHD) from July 2017 to June 2021 in a large city. We used a difference-in-differences approach to compare the changes in patient age, severity reflected by the Charlson Comorbidity Index (CCI), and a measure of treatment intensity [relative weight (RW)] in hospitals that were and were not subject to DIP incentives before and after the DIP payment reform in July 2019. Compared with non-DIP pilot hospitals, trends in patient age after the DIP reform were similar for DIP and non-DIP hospitals for both conditions, while differences in patient severity grew because severity in DIP hospitals increased more for THA/TKA (P = 0.036) or dropped in non-DIP hospitals for AHD (P = 0.011) following DIP reform. Treatment intensity (measured via RWs) for AHD patients in DIP hospitals increased 5.5% (P = 0.015) more than in non-DIP hospitals after payment reform, but treatment intensity trends were similar for THA/TKA patients in DIP and non-DIP hospitals. When the DIP payment reform in China was introduced just prior to the pandemic, hospitals subject to this reform responded by admitting sicker patients and providing more treatment intensity to their AHD patients. Policymakers need to balance between cost containment and the unintended consequences of prospective payment systems, and the DIP payment could also be a new alternative payment system for other countries.

Background Achieving universal health coverage (UHC) is a crucial target shared by the Sustainable Development Goals (SDGs). As UHC levels are influenced by factors such as the regional economy and resource allocation, subnational evidence in China is urgently needed. This study aimed to monitor provincial progress from 2016 to 2021, thereby informing the development of region -specific strategies. Methods Based on the UHC monitoring framework proposed by the World Health Organization, a UHC index was constructed comprising the service coverage dimension (16 indicators) and financial protection dimension (four indicators). In this observational study, routinely collected health data from 25 provinces (autonomous regions and municipalities) in mainland China were obtained from statistical yearbooks, relevant literature, and nationally representative surveys. The indices were calculated using geometric means. Socioeconomic inequalities among provinces were quantified using the slope index of inequality (SII) and relative index of inequality (RII). Results From 2016 to 2021, China made laudable progress towards achieving UHC, with the index rising from 56.94 in 2016 to 63.03 in 2021. Most provinces demonstrated better performance in service coverage. Western provinces generally presented faster rates of progress, which were attributed to more substantial increases in financial protection. Despite significant disparities, with the UHC index ranging from 77.94 in Shanghai to 54.61 in Fujian in 2021, the overall equity of UHC has improved across the 25 provinces. SII decreased from 17.78 (95% confidence interval (CI) = 11.64, 23.93) to 12.25 (95% CI = 5.86, 18.63) and RII from 1.38 (95% CI = 1.29, 1.46) to 1.22 (95% CI = 1.16, 1.29). However, the non -communicable disease (NCD) domain experienced a drop in both index score and equity, underscoring the need for prioritised attention. Conclusions In the context of SDGs and the 'Healthy China 2030' initiative, China has made commendable progress towards UHC, and inter -provincial equity has improved. However, substantial differences persisted. The equitable realisation of UHC necessitates prioritising the enhancement of service capacity and financial protection in less developed regions, particularly by addressing shortages in the general practitioner workforce and mitigating catastrophic payments. Developed regions should focus on preventing NCDs through effective interventions targeting key risk factors. This study provides insights for other countries to adopt comprehensive monitoring frameworks, identify subnational disparities, and introduce targeted policy initiatives.

BACKGROUND:China has developed a novel case-based payment method called the DiagnosisIntervention Packet (DIP) to regulate healthcare providers' behavior. G city, a metropolis in southeast China, has shifted its payment policy from fixed rate per admission to DIP under regional global budget since 2018. This study examined the immediate and trend changes in provider behavior after this payment reform. METHODS:Discharge data in G city between 2016 and 2019 was used, covering more than 10 million inpatient cases in 320 hospitals. A counterfactual scenario was developed to assign insured and uninsured inpatients across the study period to specific DIP groups under consistent rules. Controlled interrupted time-series (ITS) analyses were performed, with uninsured inpatients as control. Outcomes included inpatient volume, average DIP weight (similar to case-mix index in Diagnosis-Related Groups), and two innovative indicators (average diagnostic weight and average treatment weight) to decompose the changes in DIP weight. Subgroup analyses were conducted for different hospital levels and 21 major disease categories. RESULTS:After the DIP reform, monthly trend of inpatient volume decreased (-1085.34, P=0.052), while monthly growth of average DIP weight increased (2.17, P=0.02). No significant changes in average diagnostic weight were observed. Monthly trend of average treatment weight increased (2.38, P=0.001) after the reform. Secondary and tertiary hospitals experienced insignificantly decreased inpatient volume and elevated average DIP weight, accompanied by negligible change in average diagnostic weight and significant increase in average treatment weight. Primary hospitals experienced reduced inpatient volume and stable average DIP weight, along with increase in average diagnostic weight and decrease in average treatment weight. CONCLUSION:By differentiated payments for severity, DIP induced hospitals to shift their focus from volume to weight of inpatients. Instead of diagnostic upcoding, hospitals responded to the DIP reform primarily by increasing treatment intensity. Primary hospitals may face financial risks under regional competition.

Purpose: China has developed and widely piloted a new case-based payment, ie, the "Diagnosis-Intervention Packet" (DIP) payment, which has a granular classification system. We evaluated the impact of DIP payment on the quality of care in a large pilot city in China and explored potential mechanisms of quality change. Methods: The city started to implement DIP payment with a hospital-level cap on July 1, 2019. Using a 5% random sample of discharge records from July 2017 to June 2021, we employed a difference-in-differences approach to compare two mortality measures (in-hospital mortality, mortality of surgical patients), two readmission measures (all-cause readmission within 30 days, readmission with the same principal diagnosis within 30 days) and a patient safety measure (operation associated complications or adverse event) in 13 pilot hospitals and 27 non-pilot hospitals before and after DIP payment reform. Results: Of 122,637 discharge records included, 43,023 (35.1%) were from pilot hospitals. After DIP payment, the readmission rate within 30 days and readmission rate with the same principal diagnosis in pilot hospitals decreased significantly by 3.2 percentage points (P <0.001) and 1.8 percentage points (P <0.001), respectively. The in-hospital mortality rate, the mortality rate of surgical patients, and the rate of operation-associated complications or adverse events did not have significant changes. The decrease in quality measures was primarily driven by tertiary hospitals, was more obvious over time after the policy adoption, and was more pronounced in groups with higher intensity of care. Conclusion: This study indicated that DIP payment with a cap in the study city was associated with improved quality of care among patients in pilot hospitals. The provider's behavior of increasing the intensity of care, especially for more severe patients, may partially contribute to the results.

BACKGROUND:Root caries are prevalent issues that affect dental health, particularly among elderly individuals with exposed root surfaces. Fluoride therapy has shown effectiveness in preventing root caries, but limited studies have addressed its cost-effectiveness in elderly persons population. This study aimed to evaluate the cost-effectiveness of a fluoride treatment program for preventing root caries in elderly persons within the context of Chinese public healthcare.METHODS:A Markov simulation model was adopted for the cost-effectiveness analysis in a hypothetical scenario from a healthcare system perspective. A 60-year-old subject with 23 teeth was simulated for 20 years. A 5% sodium fluoride varnish treatment was compared with no preventive intervention in terms of effectiveness and cost. Tooth years free of root caries were set as the effect. Transition probabilities were estimated from the data of a community-based cohort and published studies, and costs were based on documents published by the government. The incremental cost-effectiveness ratio (ICER) was calculated to evaluate cost-effectiveness. Univariate and probabilistic sensitivity analyses were performed to evaluate the influence of data uncertainty.RESULTS:Fluoride treatment was more effective (with a difference of 10.20 root caries-free tooth years) but also more costly (with a difference of ¥1636.22). The ICER was ¥160.35 per root caries-free tooth year gained. One-way sensitivity analysis showed that the risk ratio of root caries in the fluoride treatment group influenced the result most. In the probabilistic sensitivity analysis, fluoride treatment was cost-effective in 70.5% of the simulated cases.CONCLUSIONS:Regular 5% sodium fluoride varnish application was cost-effective for preventing root caries in the elderly persons in most scenarios with the consideration of data uncertainty, but to a limited extent. Improved public dental health awareness may reduce the incremental cost and make the intervention more cost-effective. Overall, the study shed light on the economic viability and impact of such preventive interventions, providing a scientific basis for dental care policies and healthcare resource allocation.

Background In 2013, the Shanghai Hospital Development Center issued a policy to advocate public hospitals to report their information about costs on diseases. The objective was to evaluate the impact of interhospital disclosure of costs on diseases on medical costs and compare costs per case following information disclosure between hospitals of different rankings. Methods The study uses the hospital-level performance report issued by Shanghai Hospital Development Center in the fourth quarter of 2013, which covers quarterly aggregated hospital-level discharge data from 14 tertiary public hospitals participating in thyroid malignant tumors and colorectal malignant tumors information disclosure from the first quarter of 2012 to the third quarter of 2020. An interrupted time series model with segmented regression analysis is employed to examine changes in quarterly trends with respect to costs per case and length of stay before and after information disclosure. We identified high- and low-cost hospitals by ranking them on a costs per case basis per disease group. Results This research identified significant differences in cost changes for thyroid malignant tumors and colorectal malignant tumors between hospitals after disclosing information. A hospital’s discharge costs per case for thyroid malignant tumors increased significantly among top-cost hospitals (1629.251 RMB, P = 0.019), while decreased for thyroid and colorectal malignant tumors among low-cost hospitals (-1504.189 RMB, P = 0.003; -6511.650 RMB, P = 0.024, respectively). Conclusion Our findings indicate that information disclosure of costs on diseases results in changes in discharge costs per case. And low-cost hospitals continued to maintain their leading edge, whereas the high-cost hospitals changed their position in the industry by reducing discharge costs per case after information disclosure.

Objective To analyze the change of healthcare quality after the Diagnosis-Intervention Packet(DIP)payment system reform and provide evidence for improving payment system reform in China.Methods It collected discharge records of hospitalized patients with employee basic medical insurance scheme in first DIP pilot hospitals of a city from July 2017 to June 2021.It included three death-related measures and two readmission-related mea-sures,which were all risk-adjusted considering the patient mix.It used t test to compare their differences before and after the DIP reform in July 2019.Results After the risk-adjustment,mortality rate of surgical patients,mortality rate of patients in low-risk DIP groups,all-cause readmission rate within 30 days after discharge and readmission rate with the same principal diagnosis within 30 days after discharge declined 0.06 percentage points(P=0.031),0.15 percentage points(P=0.001),0.47 percentage points(P＜0.001)and 0.72 percentage points(P＜0.001),respectively.Conclusion No current evidences indicated negative impacts of the DIP payment reform on the quality of healthcare in the city.Case-based payment pilot cities should closely monitor the change of healthcare quality after the reform.

We analyzed COVID-19 influences on the design, implementation, and validity of assessing the quality of primary health care using unannounced standardized patients (USPs) in China. Because of the pandemic, we crowdsourced our funding, removed tuberculosis from the USP case roster, adjusted common cold and asthma cases, used hybrid online–offline training for USPs, shared USPs across provinces, and strengthened ethical considerations. With those changes, we were able to conduct fieldwork despite frequent COVID-19 interruptions. Furthermore, the USP assessment tool maintained high validity in the quality checklist (criteria), USP role fidelity, checklist completion, and physician detection of USPs. Our experiences suggest that the pandemic created not only barriers but also opportunities to innovate ways to build a resilient data collection system. To build data system reliance, we recommend harnessing the power of technology for a hybrid model of remote and in-person work, learning from the sharing economy to pool strengths and optimize resources, and dedicating individual and group leadership to problem-solving and results. (Am J Public Health. 2022;112(6):913–922. https://doi.org/10.2105/AJPH.2022.306779 )

目的 梳理上海市医疗保险(以下简称"医保")支付方式的演变过程及改革背景,理解其决策逻辑.方法 结合多源流分析与实施背景分析框架,分析上海医保支付改革形成的原因及特点.结果 各级政府均高度重视医保支付方式改革,为上海医保支付改革提供了政治支持.上海医保改革始终以政策问题为导向,早期面临基金失衡后采取总额预算管理,医院积极性不高便采取结余留用,基金效率低下而进行按疾病诊断相关分组/病种分值付费改革.上海"海派文化"中的"包容性"表现为"小步走、不停留"的改革理念,"精致性"表现为循证决策和数字化赋能的改革策略;上海较高的经济水平、较低的医保基金失衡风险,使其更多关注医院和患者利益,注重医疗服务质量,强调改革的连续性与一致性.结论 上海医保支付改革的演变是外部政策、当前问题、文化与经济环境等因素的综合产物.

结合国家部署和当地实际,上海市积极开展按疾病诊断相关分组(diagnosis-related groups,DRG)付费改革,形成了覆盖按DRG付费全过程的10个技术规范,包括数据上传与质量控制、分组策略与规则、权重设置与指标、费率测算与调整、特殊病例标准与处置、考核体系、监管办法、清算规则、付费激励,以及专家库建设与政策评估.在此基础上,进一步总结出了DRG工作闭环的5个关键环节:数据采集、病例入组、权重调整、过程监控、年度清算.在工作闭环的指导下,上海市按DRG付费改革已取得诸多初步成果,未来将继续稳步推进.

以DRG为代表的医保支付改革,关注支付单元同质化、价格与价值关联、预付制等,导致医院成为价格接受者,会引起医院降低患者治疗成本、改变编码、增加患者数量等的行为转变.药品使用受其影响,包括不必要用药减少、低价药替代高价药、药品费用向门诊和药店转移等.医保准入谈判和药品集中采购政策均可降低药品价格,但前者将为医生治疗医保患者时提供更多的用药选择,后者则限制医生治疗医保患者时的用药选择.医保支付及相关政策间存在联动,将协同影响药品使用,即医保准入谈判通过影响支付单元界定及药品价格而影响DRG分组及权重,药品集中采购通过改变价格而影响DRG权重,DRG通过引导成本最小化而可能促进医院对集采药品的使用.