Medical waste management in three areas of rural China

<div><p>Objective</p><p>The purpose of this paper is to describe current practices of medical waste management, including its generation, investments, collection, storage, segregation, and disposal, and to explore the level of support from upper tiers of the government and health care system for medical waste management in rural China.</p><p>Methods</p><p>The authors draw on a dataset comprised of 209 randomly selected rural township health centers (THCs) in 21 counties in three provinces of China: Anhui, Shaanxi and Sichuan. Surveys were administered to health center administrators in sample THCs in June 2015.</p><p>Results</p><p>The results show that the generation rate of medical waste was about 0.18 kg/bed, 0.15 kg/patient, or 0.13 kg/person per day on average. Such per capita levels are significant given China’s large rural population. Although investments of medical waste facilities and personnel in THCs have improved, results show that compliance with national regulations is low. For example, less than half of hazardous medical waste was packed in sealed containers or containers labeled with bio-hazard markings. None of the THCs segregated correctly according to the categories required by formal Chinese regulations. Many THCs reported improper disposal methods of medical waste. Our results also indicate low levels of staff training and low rates of centralized disposal in rural THCs.</p><p>Conclusions</p><p>Medical waste is a serious environmental issue that is rising on the agenda of policymakers. While a large share of THCs has invested in medical waste facilities and personnel, it appears that actual compliance remains low. Using evidence of low rates of training and centralized disposal, we surmise that a lack of support from upper tiers of management is one contributing factor. Given these findings, we recommend that China’s policymakers should enhance support from upper tiers and improve monitoring as well as incentives in order to improve medical waste management.</p></div

Medical waste facilities, specialist personnel and staff awareness in sample township health centers.

<p>Medical waste facilities, specialist personnel and staff awareness in sample township health centers.</p

Support from upper tiers: medical waste training and centralized disposal of medical waste in sample township health centers.

<p>Support from upper tiers: medical waste training and centralized disposal of medical waste in sample township health centers.</p

Characteristics of sample township health centers.

<p>Characteristics of sample township health centers.</p

Know-do gap: Comparison of data from vignettes versus SP interaction among the same providers.

<p>For all items, the prefix "E" indicates examinations and laboratory evaluations; the prefix "Q" indicates history questions. The gap calculation is the result of a <i>t</i> test comparing the average vignette performance with the average SP performance. <i>P</i> values are in brackets. AFB, acid-fast bacillus; SP, standardized patient; TB, tuberculosis.</p

Tuberculosis detection and the challenges of integrated care in rural China: A cross-sectional standardized patient study

<div><p>Background</p><p>Despite recent reductions in prevalence, China still faces a substantial tuberculosis (TB) burden, with future progress dependent on the ability of rural providers to appropriately detect and refer TB patients for further care. This study (a) provides a baseline assessment of the ability of rural providers to correctly manage presumptive TB cases; (b) measures the gap between provider knowledge and practice and; (c) evaluates how ongoing reforms of China’s health system—characterized by a movement toward “integrated care” and promotion of initial contact with grassroots providers—will affect the care of TB patients.</p><p>Methods/Findings</p><p>Unannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms were deployed in 3 provinces of China in July 2015. The SPs successfully completed 274 interactions across all 3 tiers of China’s rural health system, interacting with providers in 46 village clinics, 207 township health centers, and 21 county hospitals. Interactions between providers and standardized patients were assessed against international and national standards of TB care. Using a lenient definition of correct management as at least a referral, chest X-ray or sputum test, 41% (111 of 274) SPs were correctly managed. Although there were no cases of empirical anti-TB treatment, antibiotics unrelated to the treatment of TB were prescribed in 168 of 274 interactions or 61.3% (95% CI: 55%–67%). Correct management proportions significantly higher at county hospitals compared to township health centers (OR 0.06, 95% CI: 0.01–0.25, <i>p</i> < 0.001) and village clinics (OR 0.02, 95% CI: 0.0–0.17, <i>p</i> < 0.001). Correct management in tests of knowledge administered to the same 274 physicians for the same case was 45 percentage points (95% CI: 37%–53%) higher with 24 percentage points (95% CI: −33% to −15%) fewer antibiotic prescriptions. Relative to the current system, where patients can choose to bypass any level of care, simulations suggest that a system of managed referral with gatekeeping at the level of village clinics would reduce proportions of correct management from 41% to 16%, while gatekeeping at the level of the township hospital would retain correct management close to current levels at 37%. The main limitations of the study are 2-fold. First, we evaluate the management of a one-time new patient presenting with presumptive TB, which may not reflect how providers manage repeat patients or more complicated TB presentations. Second, simulations under alternate policies require behavioral and statistical assumptions that should be addressed in future applications of this method.</p><p>Conclusions</p><p>There were significant quality deficits among village clinics and township health centers in the management of a classic case of presumptive TB, with higher proportions of correct case management in county hospitals. Poor clinical performance does not arise only from a lack of knowledge, a phenomenon known as the “know-do” gap. Given significant deficits in quality of care, reforms encouraging first contact with lower tiers of the health system can improve efficiency only with concomitant improvements in appropriate management of presumptive TB patients in village clinics and township health centers.</p></div

Estimated patient pathways under status quo (patients freely selecting into tiers).

<p>Percentages at bottom of figure show the percentage of patients selecting into each health system tier based on survey responses (<a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1002405#pmed.1002405.s006" target="_blank">S5 Table</a>). For each referral pathway, figure shows percentage of total patient population following each path calculated using SP results for subsample of complete health systems.</p

Main outcomes of interactions with SPs.

<p>Presaging our simulation results, in the 13 of 46 cases (28%, 95% CI 17%–43%) when village providers (verbally) referred SPs, 5 of 13 (38%, 95% CI 18%–64%) referred to the THC and 6 of 13 (46%, 95% CI 23%–71%) referred directly to the county. Of the 36 (18%, 95% CI 13%–24%) township providers who referred SPs to an upper level provider, a small majority referred to the county hospital (18 of 36; 51%, 95% CI 36%–67%), and the rest referred directly to the CCDC (14 of 36; 39%, 95% CI 25%–55%) or a city level provider (4 of 36; 11%, 95% CI 4%–25%). CXR, chest X-ray; ISTC, international standards for tuberculosis care; SP, standardized patient; THC, township health center.</p

STROBE flowchart.

<p>SPs were randomly assigned to facilities and within each facility, SPs visited the doctor following the normal procedures for any walk-in patient. Given a choice of which doctor to visit, SPs randomly chose a doctor following a pre-determined randomization protocol. In county hospitals, where patients can choose doctors by specialty, SPs visited generalists. Our results, therefore, are designed to approach the care a walk-in patient would receive at each of the sampled facilities.</p

Simulation of system-level management outcomes with and without managed referrals.

<p>Simulation of system-level management outcomes with and without managed referrals.</p