Hospital and patient predictors of healthcare disparities among type 2 diabetes inpatients in tertiary and county hospitals of inner mongolia, China

Abstract

Background: To eliminate healthcare disparities is one of the important goals of healthcare systems all over the world. Disparities on accessibility to healthcare for diabetes patients have been reported by many population-based studies. As a chronic disease with high prevalence, high admission rate and long length of stay, type 2 diabetes inpatients have more chance to encounter inequitable healthcare during their stay in hospital. However, evidence on equity of actual healthcare received from hospitals is limited, especially in low and middle-income countries. Objectives: To examine the disparities of inpatient care among type 2 diabetes inpatients treated in county and tertiary hospitals in Inner Mongolia, China, with regards to: length of stay, hospitalization charge, treatment schemes, treatment decision making process. To identify the hospital and individual predictors on disparities of hospitalization care among type 2 diabetes inpatients treated in county and tertiary hospitals in Inner Mongolia, China. To put forward relevant policy recommendation on eliminating healthcare disparities to local health system and surveyed hospitals. Methods: A cross-sectional, hospital-based survey using a cluster sampling technique was conducted in three tertiary hospitals and three county hospitals in Inner Mongolia, China. Inpatients with a principal diagnosis of type 2 diabetes mellitus (ICD code E11.2 to E11.9) and discharged from October 2013 to January 2014 were eligible to join this study. Data collection consisted of two stages. In the first stage individual face-to-face interviews were conducted using a structured questionnaire one day before patient discharge from hospital to obtain demographic data such as economic status and duration of diabetes. In the second stage, medical records were reviewed one week after patient discharge from hospital. A self-designed data collection form was used in this stage to collect data on inpatient care of each participant. All the research tools were pre-tested and revised before the main study was conducted. Hospitalization care for T2DM inpatients was measured by length of stay, hospitalization charge, treatment schemes, and treatment decision-making process. Independent variables regarding to hospital governance and hospital characristics from provider side and socio-demographics from patient side were potiential predictors for the healthcare disparities. Weighted multivariate regression models were used to explore the association between independent variables and outcome variables. Results: A total of 771 eligible participants were recruited into this study. 80% of T2DM inpatients were aged 50 years and above. 6.4% attained a bachelor degree study or above. Minority groups were rare (3.7%). More than half of the participants (59.5%) were living in urban areas. Although the national health insurance system (Urban Employee's Basic Medical Insurance, Urban Resident's Basic Medical Insurance and New Rural Cooperative Medical System) covered most of the participants, 21.2% of the participants covered the cost of their hospitalization. Healthcare disparities were explored by comparing hospitalizaiton care between urban and rural T2DM inpatients, since rural-urban disparities is the most concerned issue in China. This study has found that more healthcare resources were allocated to urban T2DM inpatients after adjusted by the healthcare needs. Both hospital and patient factors were found accociated with healthcare disparities for T2DM inpatients, independently of their healthcare needs. However, hospital factors stood out of the results. Hospitals from different regions have different treatment patterns. Implementation of reform was shown to be associated with controlling medication use and length of hospital stay for T2DM inpatients. Increased government input was asscociated with longer length of hospital stay. However, the causation between these factors and healthcare disparities should be explored in further studies. Conclusions: The results of this study suggest that hospitals factors mainly accounted for the healthcare disparities. Hospitals located in different regions have different treatment patterns, which tends to increase the healthcare disparities and should be eliminated by carrying out clinical pathways and further policy strategies. Healthcare reform in pilot hospital was found having effect on controlling medication use and reducing average length of hospital stay, which needs further evidence to make sure the effective policy. Increased government input tended to decrease hospital efficiency in terms of longer length of stay. It is important to develop policies on achieving reasonable length of stay for chronic disease like T2DM.