Health Value of China’s Long-term Care Insurance in Older Disabled People: Role of Institutional Care

doi:10.21203/rs.3.rs-1819880/v1

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Health Value of China’s Long-term Care Insurance in Older Disabled People: Role of Institutional Care

https://doi.org/10.21203/rs.3.rs-1819880/v1

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Background

Since the public long-term care insurance (LTCI) system was piloted in Chengdu, China in July 2017, there has been a considerable growth of LTC institutions in China. This study aimed to evaluate the health value effect of LTCI in older patients with severe disabilities in an LTC institution.

Methods

This study was based on data from 985 severe disability patients with or without LTCI from July 2017 to October 2020 in the Eighth People's Hospital, Chengdu, China. The Cox proportional hazard model estimated LTCI’s health value, including survival probability and risk of pneumonia/pressure ulcers. Subgroup analysis was performed for sex, age, Charlson Comorbidity Index (CCI), and the number of drugs.

Outcome

In the analysis 519 and 466 patients in LTCI and non-LTCI groups, respectively, were included. In adjusted Cox analyses, the LTCI group had a significantly elevated survival rate compared at 12 months (P<0.001, OR=1.758, 95% CI 1.300-2.376). At 40 months, the adjusted survival rate was 62.6% in the LTCI group, which was significantly higher (53.7%; P=0.003, OR=1.438, 95% CI 1.131-1.831). The subgroups of patients aged 60 to 79 years (interaction P=0.007) and CCI≥3 (interaction P=0.026) were more significantly associated with survival improvement than those aged >80 years and CCI< 3. The LTCI group was also at lower risk for hospital-acquired pneumonia (P=0.016, HR 0.622, 95% CI 0.422-0.917) and pressure ulcers (P=0.008, HR 0.695, 95% CI 0.376-0.862). The improved survival of LTCI remained stable in sensitivity analyses.

Conclusion

For older patients with severe disabilities, in a long-term care institution, LTCI significantly improved their health profile and longevity after a year, suggesting the large role and development potentiality of institution care in the LTCI system of China.

Long-term care insurance

older adults

disability

China

institutional care

China's population is aging rapidly, with approximately 144 million people aged 65 years or older in 2015, and their number will more than double by 2050 to a projected 366 million [1]. The combination of an aging population and associated multimorbidity results in impairment of daily activity ability, increased hospitalization, mortality, and care burden [2, 3]. Therefore, in China, the demand for long-term care (LTC) for frail and disabled older people is huge and increasing rapidly. Over the past few years, the Chinese government strived to develop a modern long-term care insurance (LTCI) system that is high quality, affordable, and suitable for the needs of the aging population [4].

The LTCI system, first established in developed countries in the 1990s, is a policy used to share nursing expenditures of individuals who are unable to care for themselves due to chronic illness or physical and psychological disabilities [4, 5]. The public LTCI system in China was piloted in 15 cities in 2017, including Qingdao, Chengdu, and Chongqing. The beneficiaries must be severely disabled for at least six months, determined by a measure of activities of daily living (ADLs) which is based on the Barthel score or variations of it developed by the cities [5, 6]. Most LTCI pilots covered a combination of three types of LTC services, including home, community, and institutional or hospital care.

Studies in developed countries such as the Germany, Japan and Korea found that LTCI significantly affected beneficiaries’health conditions, medical expenses and utilization, satisfaction, and caregivers' informal care burdens [7, 8, 9]. Similarly, early data from China showed that it contributes to a reduction in the burden of family care and medical expenditures [10, 11, 12] and an improvement in the health outcomes of older adults with home care [10]. However, as economic development proceeds and the aging population expands, traditional family informal care offered by relatives is far from meeting the multilevel care needs of the current older disabled population in China [13, 14]. Meanwhile, national LTC institution promotion policies with corresponding fiscal subsidies caused considerable growth of institutions [14, 15]. The number of beds for every 1,000 people aged 65 and older more than doubled from 2008 to 2018 in China [15]. To date, there is limited evidence regarding the effect of the LTCI on older disabled adults in LTC institutions. What role did the LTC institution play in the implementation of LTCI’s pilot policies? An empirical study was conducted with older disabled patients admitted to the Eighth People's Hospital of Chengdu, an LTC institution, to investigate the health value of LTCI.

Data source and study population

This was a prospective observational cohort study of older adults with severe disabilities from the Eighth People's Hospital of Chengdu, China. It is a geriatric specialist hospital, older services demonstration training center, and the first hospital to implement LTCI in Chengdu. This LTCI pilot policy is led and regulated by Chengdu Healthcare Security Administration. Overall survival of older disabled patients was the main study outcome. The incidence of hospital-acquired pneumonia and pressure ulcers were the secondary outcomes.

Participants were recruited over 40 months from July 2017 to October 2020. The inclusion criteria were: (1) patients aged 60 years or above and (2) assessed as severely disabled. The assessment of disability included ADLs (Barthel score), cognitive ability, and perception ability (vision, hearing, and social communication) performed by trained assessors, including the preliminary evaluation and revaluation. Severe disability was defined as severely impaired ADL (Barthel score < 40 for at least 6 months) with or without altered cognitive and perception abilities. Patients younger than 60 years or without baseline disability assessment were excluded.

We conducted this study in compliance with the principles of the Declaration of Helsinki. The Ethics Committee of the Eighth People’s Hospital of Chengdu (approval No. 2017-CBYEC-004) approved the study design and exempted written informed consent for participants.

Grouping method

The patients were divided into LTCI and non-LTCI groups based on eligibility. Severe disability patients with Urban Employee Basic Medical Insurance (UEBMI) were eligible to receive LTCI. The patients with LTCI can apply for institutional care subsidies of 1006–1676 RMB/person/month. The rest covered by Urban-Rural Resident Basic Medical Insurance (URRBMI) were not covered by LCTI due to the policy pilot.

Definition of variables

The Charlson Comorbidity Index (CCI) score was used to assess multimorbidities, a method of predicting mortality by classifying or weighting multifocal conditions [16]. The Mini-mental State Examination (MMSE) is a dementia screening tool that consists of 30 questions with a maximum score of 30. Higher scores indicate better cognition.

Statistical analyses.

The quantitative variables with a normal distribution are presented as the mean ± standard deviation and categorical variables are described as absolute (n) and relative frequencies (%). For betweengroup comparisons, Pearson’s chisquare test was used for categorical variables, according to the sample number. Survival analysis was performed using univariate and multivariate Cox proportional hazards regression analyses. Adjustments for covariates included age and sex, polypharmacy, MMSE, and CCI score. The incidence rate of hospital-acquired pneumonia and pressure ulcers were described as the number of events per 100 person-years.

Baseline characteristics

Figure 1 showed the study flow diagram. There were 519 patients with LTCI and 446 patients without LTCI included in the analysis. The baseline characteristics of the patients are shown in Table 1. There were 214 (41.2%) males in LTCI group with a mean age of 81.63 (SD, 7.48) years and 188 (40.09%) males in non-LTCI group with a mean age of 80.79 (SD, 13.94) years. More than half of the patients in both groups had CCI ≥ 3 and received > 5 drugs. There were no statistically significant differences in demographic characteristics between the study groups.

Table 1

Characteristics of LTCI* group and non-LTCI group at baseline.
	LTCI group (n = 519)	Non-LTCI group (n = 466)	P value
Age (years)	81.63 ± 7.48	80.79 ± 13.94	0.282
Gender (male), n (%)	216(41.62%)	188(40.09%)	0.722
Educational Level, n (%)			0.869
Primary school or below	149(28.71%)	136(29.18%)
Middle school or above	370(71.29%)	330(70.81%)
Marriage status, n (%)			0.709
In marriage	323(62.23%)	284(60.94%)
Never married, widowed, or divorce	196(37.77%)	181(38.84%)
The number of children, n (%)			0.373
≥2	305(57.77%)	299(64.16%)
༜2	214(41.23%)	187(40.13%)
MMSE^a score	25.88 ± 3.46	25.56 ± 3.92	0.270
Received > 5 drugs, n (%)	374(72.06%)	360(77.25%)	0.065
CCI^b≥3, n (%)	460(88.63%)	401(86.05%)	0.223
Chronic life-limiting illness, n (%)
Hypertension	355(68.40%)	321(68.88%)	0.070
Coronary heart disease	183(35.26%)	140(30.04%)	0.082
Chronic heart failure	185(35.65%)	183(39.27%)	0.240
Chronic obstructive pulmonary disease	214(41.23%)	185(39.69%)	0.624
Type 2 Diabetes	223(42.97%)	195(41.85%)	0.814
Sequelae of cerebral infarction	98(18.88%)	90(19.31%)	0.864
Chronic renal failure	71(13.68%)	63(13.52%)	0.941
Malignancy	43(8.28%)	50(10.72%)	0.190
*LTCI: Long-Term Care Insurance
^aMMSE: Mini-mental State Examination (MMSE) score;
^bCCI: Charlson Comorbidity Index

Univariate survival analysis

As shown in Table 2, following univariate Cox regression analysis, males (P = 0.016, OR = 1.442, 95% CI 1.072–1.941), patients with LTCI (P = 0.025, OR = 1.435, 95% CI 1.047–1.966) and those who received > 5 drugs (P = 0.034, OR = 1.285 95%, 95% CI 1.019–1.619), were significantly positively correlated with long survival. The MMSE score (P < 0.001, OR = 0.963, 95% CI 0.935–0.991) and CCI ≥ 3 (P < 0.001, OR = 0.141, 95%, CI 0.070–0.287) were significantly negatively correlated with overall survival.

Table 2

Univariate Cox regression analysis to identify factors of survival
	P value	Odds rate	95%CI
Gender (male)	0.016	1.442	1.072–1.941
Age (years)	0.776	1.002	0.987–1.017
In marriage	0.587	0.918	0.675–1.249
Number of children < 2	0.732	0.949	0.705–1.279
With LTCI	0.025	1.435	1.047–1.966
MMSE ^a score	< 0.001	0.963	0.935–0.991
Received > 5 drugs	0.034	1.285	1.019–1.619
CCI^b≥3	< 0.001	0.141	0.070–0.287
^aMMSE: Mini-mental State Examination (MMSE) score;
^bCCI: Charlson Comorbidity Index

Multivariate survival analysis

The LTCI group tended to have a better survival rate after one month, three months, and six months of admission before or after adjustments. The LTCI group had a significantly elevated survival rate at 12 months (P < 0.001, OR = 1.758, 95% CI 1.300-2.376) in the multivariate-adjusted Cox model. Furthermore, this difference persisted at 18 (P = 0.003, OR = 1.507, 95% CI 1.149–1.976), 24 (P < 0.001, OR = 1.642, 95% CI 1.264–2.088), and 36 months (P = 0.004, OR = 1.443, 95% CI 1.1.121–1.832). After 40 months, the LTCI group was characterized by a significantly higher survival (P = 0.003, OR = 1.438, 95% CI 1.131–1.831; Table 3) (Fig. 2).

Table 3

Crude and adjusted Cox regression analysis: Association of LTCI^*with cumulative survival rate at 1, 3, 12, 18, 24, 36 and 40 months after hospital admission in patients with severe disability.
Time after Admission (months)	Model	LTCI group (n = 519)		Non-LTCI group (n = 466)		P value	OR	95%CI
Time after Admission (months)	Model	Survival (n)	Survival rate (%)	Survival (n)	Survival rate (%)	P value	OR	95%CI
1	Crude	514	99.03	461	96.78	0.187	1.979	0.718–5.458
	Adjusted					0.853	1.006	0.974–1.038
3	Crude	485	93.4	427	91.63	0.723	1.11	0.612–2.01
	Adjusted					0.986	1.005	0.755–1.838
6	Crude	459	88.43	403	86.48	0.314	1.25	0.810–1.928
	Adjusted					0.463	1.179	0.759–1.831
12	Crude	411	88.4	315	67.59	< 0.001	1.852	1.378–2.489
	Adjusted					< 0.001	1.758	1.300-2.376
18	Crude	380	73.2	262	56.22	0.001	1.562	1.196–2.04
	Adjusted					0.003	1.507	1.149–1.976
24	Crude	351	67.6	254	54.50	< 0.001	1.751	1.370–2.337
	Adjusted					< 0.001	1.625	1.264–2.088
36	Crude	326	62.8	250	53.64	0.007	1.383	1.090–1.753
	Adjusted					0.004	1.433	1.121–1.832
40	Crude	325	62.6	250	53.64	0.002	1.461	1.153–1.853
	Adjusted					0.003	1.438	1.131–1.831
*LTCI: Long-Term Care Insurance

Incidence of hospital-acquired pneumonia and pressure ulcers

During the 40-month follow-up, the LTCI group was significantly less likely to have hospital-acquired pneumonia (5.30 per 100 person-years) than the non-LTCI group (9.78 per 100 person-years; P = 0.016, HR 0.622, 95% CI 0.422–0.917; Table 4). The adjusted incidence risk of pressure ulcers in the LTCI group was 4.64 per 100 person-years, which was lower than that in the non-LTCI group (8.76 per 100 person-years; P = 0.008, HR 0.695, 95% CI 0.376–0.862; Table 4).

Table 4

Risk of pneumonia and pressure ulcers among patients in LTCI^* group and non-LTCI group
	LTCI group (n = 519)			Non-LTCI group (n = 466)			Crude		Adjusted
	Person-years	Number of events	IDR^a (95%CI)	Person-years	Number of events	IDR^a (95%CI)	HR (95%CI)	P value	HR (95%CI)	P value
Pneumonia	754.75	40	5.30 (3.706–6.905)	553.42	54	9.75 (7.286–12.230)	0.608 (0.414–0.894)	0.011	0.622 (0.422–0.917)	0.016
Pressure ulcers	754.75	35	4.64 (3.137–6.137)	553.42	48	8.67 (6.238–11.018)	0.563 (0.371–0.855)	0.007	0.569 (0.376–0.862)	0.008
*LTCI: Long-Term Care Insurance
^aIDR: Incidence density rate = number of incidence cases /person-years ×100

Subgroup analyses

The survival improvement for the LTCI group was consistent across all subgroups (Supplementary Tables 2–5). In the subgroup of patients aged ≥ 80 years, the survival advantage of LTCI was displayed from 12 to 24 months but lost significance at three years.

In the test for subgroup interaction, as shown in Supplementary Table 6, patients aged 60 to 79 years (interaction P = 0.007) and CCI ≥ 3 (interaction P = 0.026) were more significantly associated with survival improvement than those aged > 80 years and CCI < 3. There were no significant interactions in subgroups of sex and medication conditions.

Sensitivity analyses

Sensitivity analysis indicated a stable result of survival improvement in the LTCI group at one year (P < 0.001, OR = 1.752, 95% CI 1.278–2.404) and remained significant over the remainder of the follow-up period (Supplementary table 1).

The pilot implementation of the LTCI policy is important for the current reform of China’s aged care system [17, 18]. In this prospective observational cohort study from an LTC institution, we revealed that LTCI significantly improved the longevity of older disabled people in China (P = 0.003, OR = 1.438, 95% CI 1.131–1.831) and their health profile by reducing the incidence of hospital-acquired pneumonia (P = 0.016, HR 0.622, 95% CI 0.422–0.917) and pressure ulcers (P = 0.008, HR 0.695, 95% CI 0.376–0.862).

Consistent with previous studies in Britain [19], South Korea [20], Japan [21], and a recent study from Qingdao [10], the LTCI policy was associated with lower mortality risk among care beneficiaries. The study in Qingdao [10] showed that it lowered the one-year mortality risk by 15% among older adults with a baseline need for care. In our study, LTCI coverage improved one-year survival by approximately 20% in older patients with severe disabilities in an LTC institution. Institutional care seems to have more technological advantages than home care regarding professional physicians, caregivers, and equipment, allowing older disabled people to live well with 24h support staff. Furthermore, our study found the prolonged survival effect of LTCI becomes more pronounced after a year, suggesting that improving the health value of LTCI is a stepwise process. Notably, further analysis observed that patients aged 60 to 79 years and CCI > 3 might benefit more from LTCI. This might be because the longer life expectancy of relatively younger patients and the high potential of serious multimorbidity could benefit more from LTCI.

In our study, LTCI reduced the incidence of hospital-acquired pneumonia and pressure ulcers, thus considerably lowering the disability-associated burden of disease. Previous studies indicated that disability is associated with a higher likelihood of developing pneumonia and infection-related mortality [22, 23, 24]. High-quality airway management is a fundamental and vital skill in the care of disabled patients [25]. Repeated episodes of pneumonia can be avoided by prevention of aspiration, timely sputum suction, suitable oral health care, gastroesophageal reflux management, and a head-up position during the night [26, 27, 28]. Pressure ulcers are frequent complications of disabled patients and are generally connected with poor prognosis [29, 30]. Therefore, their early risk assessment and management such as identification of malnutrition and nutritional supplementation, effective skincare (creams, dressings, and management of incontinence), various support surfaces, and regular turning strategies, are important for disabled people [29, 30, 31]. With the substitution effect of the LTCI policy, patients with institutional care could have obtained better disease management and individualized disability care plans, leading to an improved quality of life (QoL).

This is the study to demonstrate that LTC institutions played an important role in improving survival and lowering the disability-associated burden of disease for older disabled patients in China. Their construction benefits from China's policy of yi-yang-jie-he, which involves the combination of medical and older service resources. The Eighth People's Hospital of Chengdu is a typical yi-yang-jie-he institution, a combination of geriatric specialist hospital and LTC institution, providing acute treatment and multimorbidity management as well as LTC services and caregivers training. Nonetheless, LTC institutions worldwide have been hit by COVID-19, showing high rates of infection and mortality [32]. Simultaneously, LTC in China faced a shortage of trained professional caregivers, specifically for home care [3, 4]. In response to this challenge, Chengdu encouraged new forms of home care whereby professionals from LTC institutions visit older people at home. By integrating professional institutional and traditional family-centered care, LTC institutions may confer more technological advantages and become better incorporated into home and community-based services, which is worth further exploration.

This study has some limitations. First, this was a single-center study with a sample size of 935 patients. Further studies with larger sample sizes are required to validate the effect of China’s LTCI. Second, the study did not explore the impact of LTCI policy on the financial burden of families and health-related expenditures.

There was a statistically significant association between China LTCI and long survival with better QoL in severe disability patients, specifically for younger patients aged 60 to 79 years and patients with severe multimorbidity. LTCI policy implementation requires more than a year to show its significant effect. LTC institutions are important improving patient health profiles and longevity, and there is significant opportunity for LTC institution development and application in the future. As China is actively promoting the pilot work of LTCI by adding 14 new pilot cities, more relevant scientific evidence is required for future LTCI policy analysis and practice.

LTC: Long-Term Care

LTCI: Long-Term Care Insurance

MMSE: Mini-mental State Examination

CCI: Charlson Comorbidity Index

ADLs：activities of daily living

UEBMI: Urban Employee Basic Medical Insurance

URRBMI: Urban–Rural Resident Basic Medical Insurance

QoL：quality of life

Ethics approval and consent to participate

Consent for publication

Not applicable

Availability of data and materials:

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

The National Key R&D Program of China (project 2020YFC2008000); the National Key R&D Program of China (project 2018YFC2002400; subproject 2018YFC2002405); and the Regional Innovation Cooperation Program of Science and Technology Commission Foundation of Sichuan Province (2021YFQ0031).

Authors' contributions

DQ, BZ and BD were involved in the study conception and design; QZ and YY performed the data collection, data curation and formal analysis; QZ and BZ contributed to data interpretation and writing of the original draft. DQ, JW and BD were responsible for the funding acquisition, project administration, supervision, review and editing of the paper. All authors read, provided feedback and approved the final manuscript.

Acknowledgements

Not applicable

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No competing interests reported.

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Health Value of China’s Long-term Care Insurance in Older Disabled People: Role of Institutional Care

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Abstract

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Background

Methods

Data source and study population

Grouping method

Definition of variables

Results

Baseline characteristics

Univariate survival analysis

Multivariate survival analysis

Incidence of hospital-acquired pneumonia and pressure ulcers

Subgroup analyses

Sensitivity analyses

Discussion

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials:

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

Funding

Authors' contributions

Acknowledgements

References

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