China has a population of more than 1.4 billion, and rural population takes up more than 40% of the whole country based on the statistics in 2016 [4]. Rural hospitals are a critical component of health system across the whole country due to their significant contributions to overall community well-being. In the present study, we found that, while rural hospitals were bearing a heavy burden of respiratory health service, their healthcare resources were significantly underdeveloped in terms of basic facilities and equipment, clinical staffing and medical techniques. This imbalance was extremely serious in those rural hospitals which had not established an independent RMS.
Since the enforcement of health reform in 2009, Chinese government has achieved great accomplishments, including the expansion of social health insurance, the reform of public hospitals, and the strengthening of primary care [5]. However, respiratory healthcare in rural areas of China are still facing challenges. Healthcare resource allocation imbalance is the key problem. Unlike America and Europe, hospitals in China are organized according to government administration and strictly hierarchized based on their scales, available armamentarium and techniques [4]. Generally, rural hospitals, which are small-scale, have less facilities and equipment, and lower-quality healthcare staffs, could not meet the basic needs of all local people. But meanwhile, more financial support from the government is flowing to high-grade hospitals in urban areas instead of rural ones. Therefore, urban-to-rural disparity of resource allocation has been increasing, resulting in a vicious circle. Most rural residents do not have easy access to comprehensive and high-quality respiratory health service. These patients may substitute local primary care providers for specialists or they may decide to postpone or forego healthcare from a respiratory specialist due to the heavy financial burdens and long travel time, which at least partially contributes to the low patient satisfaction in rural hospitals [6].
In this study, 48 rural hospitals provided respiratory health services across the continuum of care from primary care to long-term care for a total population of about 40 million in rural China. Our data showed that 42.7% of these hospitals did not establish an independent department of respiratory medicine due to the lack of financial support and medical resources. Under such a condition, meeting the needs of patients for specialty care remains challenging. Physicians and nurses in these hospitals must deal with a wide variety of general diseases every day, instead of concentrating on respiratory diseases. While they get comprehensive knowledge and skills of general internal medicine, they lose the opportunity to be trained as an outstanding respiratory specialist, which is obviously not good to provide high-quality subspecialty health service. Moreover, a considerable proportion of rural hospitals do not have basic facilities and equipment, including PFT laboratories, atomization room, bronchoscopes and ventilators, which strongly suggests that some common respiratory diseases, such as COPD and lung cancer, cannot be accurately diagnosed and treated until patients go to higher-grade hospitals in urban areas. Besides, less than 15% of rural hospitals have set up sleep laboratories, indicating that sleep disorders is a weak point of respiratory health system in rural hospitals.
Based on our data, the overall PBR in rural hospitals is 1:11.1, and the overall NBR is 1:13.6, which is significantly lower compared with most hospitals in urban areas of China and other developed countries [7-9]. Heavy workload directly causes fatigue, which is associated with increased medical errors [10, 11]. It has been reported that up to 98, 000 patients die each year in hospitals as a result of preventable medical errors, in which excess clinical workload is a main cause [12]. Consistently, a higher PBR or NBR is associated with a better clinical outcomes in patients with pneumonia and malignancies [7, 9, 13]. On the other hand, the fact that a low proportion of respiratory healthcare staffs in rural hospitals have received professional clinical training is also worrying. Most physicians and nurses have not undertaken any formal training on respiratory intensive care, respiratory therapy or PFT. As a result, these clinical procedures may not be correctly performed. It has been reported that an internship in a PFT laboratory significantly improved the technical and diagnostic skills of respiratory trainees [14]. Thus, in order to improve the knowledge and skills of rural healthcare workers, more opportunities must be provided to those who are willing to participate clinical training on respiratory medicine. Furthermore, application of respiratory medical techniques are also very limited in rural hospitals based on our data. Common diagnostic tools, including percutaneous lung biopsy, TBNA and thoracoscopy are not applicable in more than 79% of rural hospitals. Without a comprehensive diagnostic system for respiratory diseases, it is extremely difficult to promote health service quality and patient satisfaction. A simple and convincing example is that, without PFT, there is no way for standardized diagnosis, treatment and long-term management for COPD and bronchial asthma, two of the most common respiratory diseases in rural hospitals.
A lack of specialist physicians has been a long-term problem in rural hospitals. Cultivation of more specialists is important to reduce the urban-to-rural disparity in high-quality health service. Currently, Chinese government is implementing the "Health China" strategy, with the aim of providing all-round health services through more medical reform. In a response to the nation's call to integrate healthcare resources, with the joint effort of a group of leading Chinese and American pulmonary specialists, the formal subspecialty training program in the combined fields of pulmonary and critical care medicine (PCCM) throughout China was designed in 2014 [15]. Subsequently, the Chinese Thoracic Society proposed collaborating with the American College of Chest Physicians to establish PCCM fellowship training program in China [16]. So far, the Chinese Thoracic Society keeps enhancing and expanding PCCM training in urban and rural China, hopefully which will contribute to providing more specialists for rural hospitals. However, it is still too far to conclude on the beneficial effects of PCCM training program on rural hospitals due to the following issues. Firstly, the engagement of respiratory physicians from rural hospitals needs to be promoted. Till now, more than 300 fellows have enrolled and been trained with common curricula, educational activities, and assessment measures. But the proportion of trainees from rural hospitals is less than 10% overall. Furthermore, almost all the PCCM fellows from rural hospitals chose to work in higher-level hospitals after finishing the training program, which could lead to a brain drain in rural hospitals instead. Additionally, the final assessment examination for Chinese PCCM training fellows has been held in English so far, which is a big challenge for physicians from rural hospitals and directly reduce their enthusiasm to participate in this program. Thus, there is an urgent need to better adjust this training program to Chinese healthcare system instead of completely copying the American pattern.