Research on Current Curative Expenditure and Inuencing Factors Among Cardiovascular and Cerebrovascular Diseases Based on “System of Health Accounts 2011”

13 Background: This study aims to research the total current curative expenditure (CCE) of 14 cardiovascular and cerebrovascular diseases (CVDs) and their influencing factors in Xinjiang, China. 15 Methods: Through multistage stratified cluster sampling, the sample information of patients with 16 CVDs in Xinjiang, in 2017, was collected. Under the framework of “System of Health Accounts 17 2011,” the top -down allocation method was used to calculate the CCE of CVDs. Multiple linear 18 regression was used to analyze the influencing factors. 19 Results: The CCE of CVDs in Xinjiang was 10.574 billion yuan; 86.81% of the CCE was spent in 20 hospitals, of which 67.22% went to general hospitals. Coronary heart disease, hypertension, and 21 cerebral infarction were the top three diseases among the treatment cost of CVDs, accounting for 22 74.20% of the total treatment cost. The CCE of older adults aged 65 years and above accounted for 23 43.51%. The main factors affecting the hospitalization cost were length of stay, grade of the medical 24 institution, operation, age, payment method, and gender. 25 Conclusions: CVDs consume numerous health funds in Xinjiang; prevention and control work focus 26 on older adults. Further, the flow of treatment cost institutions is unreasonable; thus, the role of 27 primary medical institutions in the prevention and treatment of chronic diseases should be 28 strengthened. Reducing the length of hospital stay can effectively control the CCE. 29

74.20% of the total treatment cost. The CCE of older adults aged 65 years and above accounted for 23 43.51%. The main factors affecting the hospitalization cost were length of stay, grade of the medical 24 institution, operation, age, payment method, and gender. hemorrhagic diseases of the heart, brain, and systemic tissues caused by hyperlipidemia, blood 36 5 to five counties (districts) were selected according to the working foundation and information 88 construction of health and family planning medical institutions. Five streets, communities, and 89 townships were chosen in the selected districts and counties, and one to three villages or 90 neighborhood committees were selected as samples in each township. After determining the survey 91 area, sampling was conducted according to the level and classification of health institutions. Three 92 hundred and fifty-two health institutions were investigated. The  institutions. The proportion of preventive outpatient income in the total income and the proportion of 127 preventive outpatient visits in the total outpatient visits are all derived from the data of the sample 128 institutions. 129

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The main factors influencing hospitalization expenses of CVDs were determined through the 131 analysis of hospitalization expenses. Spearman correlation analysis was used to test the correlation 132 among hospitalization expenses whether surgery, length of stay, insurance status, institution level, 133 admission season, gender, or age. Since the length of hospital stay and the total cost were positively 134 skewed to the peak distribution, the logarithmic transformation was performed before the analysis.  In the CCE of CVDs, the top three were coronary heart disease, hypertension, and cerebral 151 infarction, accounting for 74.20% of the total CCE. From the perspective of disease service function 152 distribution, the CCE of hypertension was mainly outpatient service, accounting for more than half of 153 the outpatient CCE. In the inpatient service, cardiovascular diseases accounted for nearly 70%, and 154 cerebrovascular diseases accounted for 23.55% (Figure 1 in middle-aged and elderly people aged 45-84 years, with a CCE of 9.096 billion yuan, accounting for 160 86.02%. It is worth noting that this was spent by 43.51% of elderly people aged 65 years and above, 161 while the proportion of the population they accounted for was only 6.48%, and the proportion of CCE 162 was significantly higher than that of the population. Moreover, inpatient service was the main group 163 for CVDs in all age groups, and the proportion of inpatient service cost was more than 60% ( Figure  164 2). 165

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The disease composition of the CCE of CVDs differed across age groups. Taking the results of 167 2017 as an example, the proportion of coronary heart disease and essential hypertension in all age 168 groups above 35 years old was significantly higher than that of other diseases. Among them, the age 169 group with the highest treatment cost for primary hypertension was 35-79 years old, accounting for 170 more than 30%. The treatment cost for coronary heart disease ranks first, after the age of 60, as this is 171 the main disease endangering the health of the older adults group (Figure 3).  (Table 2). There was a positive correlation 175 between hospitalization expenses and age (r = 0.115, P < 0.001), gender (r = 0.058, P < 0.001), length 176 of stay (r = 0.564, P < 0.001), type of insurance (r = 0.362, P < 0.001), institution level (r = 0.582, P < 177 0.001) and surgery (r = 0.232, P < 0.001). There was a negative correlation between age and gender, 178 insurance type and surgery (Table 2). 179 The hospitalization CCE was log-transformed to approximate normally distributed data; the 181 It is worth noting that older adults have become the main victims of CVDs, which is an important 203 factor influencing the growth of health costs. The regression analysis also confirmed that the impact 204 of adults over 65 years old on health expenditure is significantly greater than that of other age groups. 205 The treatment cost of this group accounted for 43.51% of the total treatment cost of CVDs. In the past 206 three population censuses, the proportion of adults over 65 years old in Xinjiang reached 3.91%, 207 4.67%, and 6.48%, respectively, showing an obvious acceleration and the serious aging problem. Due 208 to the continuous deterioration of physical functions, older adults often suffer from a variety of 209 complications concurrently, which undoubtedly creates a huge economic burden on older adults 210 whose income source is primarily family support [11]. It can be seen that strengthening the 211 intervention of risk factors for older adults and realizing healthy aging is the inevitable way to cope 212 with the changes in the population structure in Xinjiang. 213 In this study, it was noted that the top three diseases with the highest treatment cost were 214 coronary heart disease, hypertension, and cerebral infarction, with a total amount of 7.846 billion 215 yuan, accounting for three-quarters of the total cost of treatment of CVDs. Research should focus on 216 targeted prevention and control for these diseases. Studies have noted that more than 80% of the 217 incidence of ischemic cardiovascular disease can be attributed to dyslipidemia, hypertension, and 218 diabetes and 20% to lifestyle and other factors [12]. Therefore, the prevention and control of CVDs, 219 should focus on primary prevention by forming healthy eating habits and behavior. Further, the 220 outpatient control of hypertension, hyperlipidemia, and hyperglycemia according to the risk factors of 221 the disease to effectively prevent the occurrence of cardiovascular and cerebrovascular events should 222 be another focal point. At present, standardized management of hypertension and hyperglycemia has 223 been conducted steadily in Xinjiang. From 2011-2019, the standardized management of these two 224 chronic diseases in basic public health service projects increased by 212% and 181%, 225 respectively[13]. However, the prevention and control of dyslipidemia still lag behind hypertension 226 and diabetes. International studies have shown that for every 1 mmol/L decrease in LDL cholesterol, 227 the risk of cardiovascular disease decreased by 22% [14]. Therefore, strengthening the outpatient 228 control of dyslipidemia can effectively improve the cost-effectiveness of secondary prevention. 229 From the perspective of institutional flow, the cost of CVD treatment in Xinjiang is concentrated 230 in hospitals, accounting for 86.81%, and the proportion of primary medical institutions was low. 231 There is an "inverted triangle" phenomenon in the health resource allocation of the treatment cost of 232 CVDs, which is not consistent with the planning structure of chronic disease prevention and control 233 strategy and hierarchical diagnosis and treatment policy. We should further implement the 234 hierarchical diagnosis and treatment policy, improve the health service ability of grassroots 235 institutions, and realize the reasonable diversion of medical treatment. 236 The hospitalization expenses of patients with CVDs accounted for 70.09% of the treatment 237 expenses in Xinjiang. The rapid growth of inpatient services is the main driving force of the growth of 238 medical expenses [15]. According to the regression analysis of the influencing factors of 239 hospitalization expenses, the length of stay is the most important factor, which is consistent with other 240 research results [16]. Logically, the longer the length of hospital stay, the more medical resources 241 will be consumed, which leads to higher hospital costs [17]. Shortening hospital stays is the most 242 direct and effective way to reduce the total health cost of patients with CVDs. The level of medical 243 institutions is another key factor affecting hospitalization expenses. In this study, it was noted that the will not only increase the cost but also extend the length of the hospital stay [22]. In the study 257 sample, the average treatment cost of surgical patients was 3.18 times that of non-surgical patients. 258 The treatment cost of surgical patients is significantly higher than that of non-surgical patients 259 because cardiovascular surgery requires expensive stents and imported drugs. In this study, it was also 260 confirmed that the cost of medical insurance patients is higher than that of self-funded patients. Wang 261 Ting and other scholars found that the gradual improvement of the social basic medical security 262 system could lead to an increase in the total cost of healthcare [23]. It can be seen that the gradual 263 improvement of the medical security system not only promotes patients' ability to obtain better 264 medical services but also increases the total medical expenses. 265

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The research on the CCE of patients with CVDs in Xinjiang province shows that the economic 267 burden of patients with CVDs is relatively heavy. The top three influencing factors of hospitalization 268 expenses were length of stay, grade of medical institution, and whether or not surgery was performed. 269 It is suggested to promote the hierarchical diagnosis and treatment system, strengthen the role of The study was supported by Health Economics Association of Xinjiang Uygur Autonomous Region 281 and Ethics Committee of Shihezi University and they claimed that they approved this study. All 282 procedures performed in studies involving human participants were in accordance with the ethical 283 standards of the institutional and national research committee and with the Helsinki declaration and its 284 later amendments or compa-rable ethical standards. All the informed consent form and the data we 285 used have been informed to Ethics Committee of Shihezi University and got their permission. 286

Consent for publication 287
All of the data is allowed by patients and medical institutions. 288

Availability of data and materials 289
The datasets generated and/or analyzed during the current study are available from the corresponding 290 author on reasonable request. 291

Competing interests 292
The authors declare that they have no competing interests.

Author's Contributions 298
LZ had full access to all of the study and takes responsibility for the integrity of the data and the accuracy 299 of the data analysis; XL and LM was responsible for concept and design; XL and JY assisted in revision of 300 the manuscript. All authors read and approved the final manuscript. 301

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if it was and "0" otherwise; urban residents' basic medical insurance="1" if it was and "0" otherwise. As for urban 386 employees' basic medical insurance, setting to "0". 387 388