3.1 General information
In 2016, there were 13, 835 patients died from malignant tumor in medical institutions of Shanghai, among which male accounted for 62.49%. The average age was 70.42±12.70 years old. The leading types of malignant tumor were lung cancer (24.17%), gastric cancer (9.37%), colon cancer (7.05%), pancreatic cancer (5.98%) and liver cancer (5.83%). The number of admissions in the last 2 years of life amounted to 74, 500. The proportion of admissions to tertiary hospitals, secondary hospitals, first-level and unrated hospitals, community health service centers were 56.58%, 35.76%, 4.64% and 3.02% respectively. The median LOS were 7 days, 13 days and 15 days in tertiary, secondary, first-level and unrated hospitals respectively. Chi-squared test demonstrated that there was significant difference in constitution of gender and age among different levels of medical institutions (P<0.05). Women and those aged 65 and above were more likely to be hospitalized in lower level institutions.
Hospital services of terminal malignant tumor patients were concentrated in institutions located in central urban areas (Figure 2). Among the top 5 hospitals with the largest number of admissions, the first one was Pulmonary Hospital (accounted for 5.27% of the total number of admissions), followed by Zhongshan Hospital (4.42%), Chest Hospital (3.63%), the Tenth People’s Hospital (3.51%) and Shanghai East Hospital (2.85%). 15 of the top 20 medical institutions were tertiary hospitals, and the other 5 ones were secondary hospitals. Admissions to these 20 hospitals accounted for 53.52% of the total.
Among 13, 835 terminal malignant tumor patients in 2016, 44.87% patients were hospitalized in one single hospital and were not transferred to another hospital in the last 2 years of life, the majority of which chose tertiary hospitals. Around 90% of the patients were hospitalized in no more than three different medical institutions. Less than 1% of patients transferred to more than seven medical institutions.
At the municipal level, a large number of patients were transferred to tertiary hospitals. Hospitals in central urban areas were closely connected with each other, receiving a large number of patients transferred from other hospitals. That was probably due to the central geographic location therefore it was convenient for referral. While at the district level, the figure demonstrated different patterns. In suburbs like Jinshan, Fengxian and Qingpu District, patients were mainly hospitalized within the district, and the majority of patients were transferred into regional tertiary hospital in these suburbs.
3.2 Hospitalization expenditures of different levels of institutions
Medical services for malignant tumor patients were mainly provided by tumor hospitals and oncology departments of comprehensive hospitals. Among them, the number of beds in tertiary hospitals accounted for 55.55% of the total number of beds in Shanghai, while the proportion of admissions and hospitalization expenditures accounted for 56.58% and 56.94%. Per-admission hospitalization expenditures ranged from RMB 21, 000 to RMB 235, 000 Yuan among different levels of hospitals, while the number was RMB 7, 900 yuan in community health service centers. Per-day hospitalization expenditures of tertiary hospitals were 2.10 times of that of first-level and unrated hospitals, 9.96 times of that of community health service institutions (Figure 3).
The out-of-pocket payment in Shanghai includes the self-paid expenditures beyond the scope of medical insurance and copayment within the insurance coverage. The out-of-pocket payment rate of tertiary hospitals was the highest (30.58%), and the rate increased by level of institutions. The patients’ copayment rate ranged from 15.98% to 17.22% in the secondary and tertiary hospitals, and that of first-level hospitals and community health service centers ranged from 7.94% to 8.01%. However, self-paid rate beyond the scope of medical insurance of tertiary hospitals was 13.36%, which was much higher than that of first-level (5.52%) and secondary hospitals (8.23%). The rate of community health service centers was only 0.8% (Figure 4).
3.3 Correlation between service utilization and expenditures
In our research, the number of hospitalizations for each terminal malignant tumor patients varied from 1 to 51 times in the last 2 years of life, the median was 7 times. Patients’ number of admissions was positively correlated with total hospitalization expenditures (r=0.6927). The interval of hospitalization days ranged from 1 to 726 days, the median was 9 days. Patients’ hospitalization days were associated with the increase of hospitalization expenditures (r=0.7792). Thus the number of admissions and LOS were both correlated with total hospitalization expenditures.
3.4 Path analysis on influencing factors of terminal malignant tumor patients’ hospitalization expenditures
In the first equation, Y1 (lg hospitalization expenditure) was defined as dependent variable, Y2 (lg LOS) and other exogenous variables were defined as independent variables, multiple stepwise regression analysis was conducted (F=2556.576, P=0.000, Ra2=0.758). In the second equation that Y2 (lg LOS) was set as the dependent variable, test of the model also got a significant result (F=377.166, P=0.000, Ra2=0.303). Fitted path models were as follows:
Y1=3.417+0.676Y2+0.499X7+0.322X5-6+0.320X5-5+0.301X6+0.177X5-2+0.169X5-4-0.131X5-1+0.124X5-3-0.101X2-0.064X4-3-0.061X3-2+0.008X4-4-0.008X1+0.006X4-2-0.053X4-1-0.005X4-5 (1)
Y2=1.470+0.518X7+0.117X6-0.108X5-6-0.099X3-1-0.095X5-5-0.091X4-1-0.078X3-2+0.055X2-0.052X5-3-0.047X5-4+0.043X5-1-0.041X4-3+0.026X1-0.025X4-5-0.024X4-4-0.020X4-2 (2)
The standardized regression coefficient of model (1) showed that factors influencing malignant tumor patients’ hospitalization expenditures in order were LOS, number of admissions, level of medical institutions and with/without surgery. The effect of influencing factors in model (2) showed that number of admissions, level of medical institutions, with/without surgery, insurance scheme, type of malignant tumor, gender and age not only influenced hospitalization expenditures directly, but also affected hospitalization expenditures through their impact on LOS indirectly. The results suggested that demographic characteristics, namely age (-0.101), gender (-0.008), type of malignant tumor and insurance scheme (-0.061) had less impact on hospitalization expenditures compared with utilization factors. The impact of LOS ranked first, followed by number of admissions, level of institutions and with/without surgery. Those who were hospitalized only in tertiary hospitals and in both tertiary and secondary hospitals generated higher expenditures. As shown in Table 2 and Figure 5.