The impact of hospital attributes on patient choice for first visit

The underutilization of primary care in urban China threatens the efficiency and effectiveness of the Chinese health system. To guide patient flow to primary care, the Chinese government has rolled out a sequence of health care reforms which improve the affordability, the infrastructure and workforce of the primary care system. However, these measures have not yielded the desired effect on the utilization of primary care, which is lowest in urban areas. It is unclear how the factors identified to influence facility choice in urban China are actually impacting choice behaviour. We conducted a discrete choice experiment to elicit the quantitative impact of facility attributes when choosing a health care facility for first visit and analysed how the stated choice varies with these attributes. We found that the respondents placed different weights on the identified attributes, depending on whether they perceived their condition to be minor or severe. For conditions perceived as minor, the respondents valued visit time, equipment and medical skill most. For conditions perceived as severe, they placed most importance on equipment, travel time and facility size. We found that for conditions perceived as minor, only 14% preferred visiting a facility over opting out, a percentage which would more than double to 37% if community health centres were maximally improved. For conditions perceived as severe, improvements in community health centres may almost double first visits to primary care, mostly from patients who would otherwise choose higher-level facilities. Our findings suggest that for both severity conditions, improvements to medical equipment and medical skill at community health centres in urban China can effectively direct patient flow to primary care and promote the efficiency and effectiveness of the urban health system

Why patients prefer high-level healthcare facilities

__Introduction__ Despite policy measure to strengthen and promote primary care, Chinese patients increasingly choose to access higher level hospitals. The resulting overcrowding at higher level hospitals and underutilisation of primary care are viewed to diminish the effects of the continuing health system investments on population health. We explore the factors that influence the choice of healthcare facility level in rural and urban China and aim to reveal the underlying choice processes. __Methods__ We conducted eight semistructured focus group discussions among the general population and the chronically ill in a rural area in Chongqing and an urban area in Shanghai. Respondents’ discussions of (evidence-based) factors and how they influenced their facility choices were analysed using qualitative analysis techniques, from which we elicited choice process maps to capture the partial order in which the factors were considered in the choice process. __Results__ The factors considered, after initial illness perception, varied over four stages of health service utilisation: initial visit, diagnosis, treatment and treatment continuation. The factors considered per stage differed considerably between the rural and urban respondents, but less so between the general population and the chronically ill. Moreover, the rural respondents considered the township health centres as default and prefer to continue in primary care, yet access higher levels when necessary. Urban respondents chose higher levels by default and seldom moved down to primary care. __Conclusions__ Disease severity, medical staff, transportation convenience, equipment and drug availability played important roles when choosing healthcare facilities in China. Strengthening primary care correspondingly may well be effective to increase primary care utilisation by the rural population but insufficient for the urban population. The developed four-stage process maps are general enough to serve as the basis for (partially) ordering factors influencing facility level choices in other contexts

Ventricular flow analysis and its association with exertional capacity in repaired tetralogy of Fallot: 4D flow cardiovascular magnetic resonance study

Background: Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) allows quantification of biventricular blood flow by flow components and kinetic energy (KE) analyses. However, it remains unclear whether 4D flow parameters can predict cardiopulmonary exercise testing (CPET) as a clinical outcome in repaired tetralogy of Fallot (rTOF). Current study aimed to (1) compare 4D flow CMR parameters in rTOF with age- and gender-matched healthy controls, (2) investigate associations of 4D flow parameters with functional and volumetric right ventricular (RV) remodelling markers, and CPET outcome. Methods: Sixty-three rTOF patients (14 paediatric, 49 adult; 30 ± 15 years; 29 M) and 63 age- and gender-matched healthy controls (14 paediatric, 49 adult; 31 ± 15 years) were prospectively recruited at four centers. All underwent cine and 4D flow CMR, and all adults performed standardized CPET same day or within one week of CMR. RV remodelling index was calculated as the ratio of RV to left ventricular (LV) end-diastolic volumes. Four flow components were analyzed: direct flow, retained inflow, delayed ejection flow and residual volume. Additionally, three phasic KE parameters normalized to end-diastolic volume (KEi EDV), were analyzed for both LV and RV: peak systolic, average systolic and peak E-wave. Results: In comparisons of rTOF vs. healthy controls, median LV retained inflow (18% vs. 16%, P = 0.005) and median peak E-wave KEi EDV (34.9 µJ/ml vs. 29.2 µJ/ml, P = 0.006) were higher in rTOF; median RV direct flow was lower in rTOF (25% vs. 35%, P < 0.001); median RV delayed ejection flow (21% vs. 17%, P < 0.001) and residual volume (39% vs. 31%, P < 0.001) were both greater in rTOF. RV KEi EDV parameters were all higher in rTOF than healthy controls (all P < 0.001). On multivariate analysis, RV direct flow was an independent predictor of RV function and CPET outcome. RV direct flow and RV peak E-wave KEi EDV were independent predictors of RV remodelling index. Conclusions: In this multi-scanner multicenter 4D flow CMR study, reduced RV direct flow was independently associated with RV dysfunction, remodelling and, to a lesser extent, exercise intolerance in rTOF patients. This supports its utility as an imaging parameter for monitoring disease progression and therapeutic response in rTOF. Clinical Trial Registrationhttps://www.clinicaltrials.gov. Unique identifier: NCT03217240

Direct Observation of Inhomogeneous Solid Electrolyte Interphase on MnO Anode with Atomic Force Microscopy and Spectroscopy

<p class="articleBody_abstractText">Solid electrolyte interphase (SEI) is an in situ formed thin coating on lithium ion battery (LIB) electrodes. The mechanical property of SEI largely defines the cycling performance and the safety of LIBs but has been rarely investigated. Here, we report quantitatively the Young&rsquo;s modulus of SEI films on MnO anodes. The inhomogeneity of SEI film in morphology, structure, and mechanical properties provides new insights to the evolution of SEI on electrodes. Furthermore, the quantitative methodology established in this study opens a new approach to direct investigation of SEI properties in various electrode materials systems.</p