Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel data

Abstract

Background Multimorbidity, the presence of two or more mental or physical chronic non-communicable diseases, is a major challenge for the health system in China, which faces unprecedented ageing of its population. Here we examined the distribution of physical multimorbidity in relation to socioeconomic status; the association between physical multimorbidity, health-care service use, and catastrophic health expenditures; and whether these associations varied by socioeconomic group and social health insurance schemes. MethodsIn this population-based, panel data analysis, we used data from three waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS) for 2011, 2013, and 2015. We included participants aged 50 years and older in 2015, who had complete follow-up for the three waves. We used 11 physical non-communicable diseases to measure physical multimorbidity and annual per-capita household consumption spending as a proxy for socioeconomic status. Findings Of 17 708 participants in CHARLS, 11 817 were eligible for inclusion in our analysis. The median age of participants was 62 years (IQR 56-69) in 2015, and 5766 (48•8%) participants were male. 7320 (61•9%) eligible participants had physical multimorbidity in China in 2015. The prevalence of physical multimorbidity was increased with older age (odds ratio 2•93, 95% CI 2•71-3•15), among women (2•70, 2•04-3•57), within a higher socioeconomic group (for quartile 4 [highest group] 1•50, 1•24-1•82), and higher educational level (5•17, 3•02-8•83); however, physical multimorbidity was more common in poorer regions than in the more affluent regions. An additional chronic non-communicable disease was associated with an increase in the number of outpatient visits (incidence rate ratio 1•29, 95% CI 1•27-1•31), and number of days spent in hospital as an inpatient (1•38, 1•35-1•41). We saw similar effects in health service use of an additional chronic non-communicable disease in different socioeconomic groups and among those covered by different social health insurance programmes. Overall, physical multimorbidity was associated with a significantly increased likelihood of catastrophic health expenditure (for the overall population: odds ratio 1•29, 95% CI 1•26-1•32, adjusted for sociodemographic variables). The effect of physical multimorbidity on catastrophic health expenditures persisted even among the higher socioeconomic groups and across all health insurance programmes.Interpretation Concerted efforts are needed to reduce health inequalities that are due to physical multimorbidity, and its adverse economic effect in population groups in China. Social health insurance reforms must place emphasis on reducing out-of-pocket spending for patients with multimorbidity to provide greater financial risk protection.

Urban–rural disparity in prevalence of multimorbidity in China: a cross-sectional nationally representative study

“…The other four papers reported national prevalence of multimorbidity among middle-aged and elderly Chinese. [18][19][20][21] These papers all used the same data set from the China Health and Retirement Longitudinal Study and reported consistently higher prevalence of multimorbidity among urban population than rural population. Zhao et al, for example, reported that rurality was associated with an OR of 0.76 of multimorbidity in people above 50 years old.…”

“…Zhao et al, for example, reported that rurality was associated with an OR of 0.76 of multimorbidity in people above 50 years old. 21 These studies have two important limitations. First, measurement of multimorbidity was all based on selfreport.…”

“…This is likely to cause underreporting that disproportionally affects rural population for whom healthcare is usually less accessible than urban population. 22 Second, these studies had neglected depression, [19][20][21] a most prevalent mental health condition among Chinese 23 and a condition widely covered in previous international multimorbidity studies. 24 25 As Lei et al reported, prevalence of depressive symptoms in 2011/2012 was also found to be much higher among rural middle-aged and elderly (35% for men and 49% for women) than among urban ones (23% for men and 35% for women), 26 though other estimation arrived at a range between 6.3% and 53.6%.…”

The Associations Between Mental Disorders and Cascade of Care in Managing Hypertension, Diabetes, Dyslipidemia, Chronic Kidney Disease in China: A Pooled Cross-Sectional Analysis

“…40,41 However, our study utilized clinical measurement for all physical NCDs as well as mental disorder which can mitigate under-reporting of NCDs. 42 Additionally, this survey only asked if subjects were taking treatment (medicines, lifestyle changes), but did not measure self-reported treatment adherence (i.e. dosage, frequency, duration, etc).…”

<p>Cross-Cultural Adaptation and Reliability Testing of Chinese Version of the Living with Medicines Questionnaire in Elderly Patients with Chronic Diseases</p>

“…4,5 One study found the prevalence of multi-morbidity in an urban community-dwelling elderly to be 49.4%, 6 while data from the China Health and Retirement Longitudinal Study showed that multi-morbidity of physical conditions increased with age and was more common in poorer regions. 7 Elderly patients often need to use polypharmacy because of multiple chronic diseases. 8 A study in western China showed that older people's use of medicines was higher in urban than rural areas, with 17.5% and 11.5% of residents in these areas, respectively, using five or more medicines.…”