Availability, cost, and prescription patterns of antihypertensive medications in primary health care in China: a nationwide cross-sectional survey

doi:10.1016/S0140-6736(17)32476-5

The Lancet

Volume 390, Issue 10112, 9–15 December 2017, Pages 2559-2568

https://doi.org/10.1016/S0140-6736(17)32476-5 Get rights and content

Summary

Background

Around 200 million adults in China have hypertension, but few are treated or achieve adequate control of their blood pressure. Available and affordable medications are important for successfully controlling hypertension, but little is known about current patterns of access to, and use of, antihypertensive medications in Chinese primary health care.

Methods

We used data from a nationwide cross-sectional survey (the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project primary health care survey), which was undertaken between November, 2016 and May, 2017, to assess the availability, cost, and prescription patterns of 62 antihypertensive medications at primary health-care sites across 31 Chinese provinces. We surveyed 203 community health centres, 401 community health stations, 284 township health centres, and 2474 village clinics to assess variation in availability, cost, and prescription by economic region and type of site. We also assessed the use of high-value medications, defined as guideline-recommended and low-cost. We also examined the association of medication cost with availability and prescription patterns.

Findings

Our study sample included 3362 primary health-care sites and around 1 million people (613 638 people at 2758 rural sites and 478 393 people at 604 urban sites). Of the 3362 sites, 8·1% (95% CI 7·2–9·1) stocked no antihypertensive medications and 33·8% (32·2–35·4) stocked all four classes that were routinely used. Village clinics and sites in the western region of China had the lowest availability. Only 32·7% (32·2–33·3) of all sites stocked high-value medications, and few high-value medications were prescribed (11·2% [10·9–11·6] of all prescription records). High-cost medications were more likely to be prescribed than low-cost alternatives.

Interpretation

China has marked deficiencies in the availability, cost, and prescription of antihypertensive medications. High-value medications are not preferentially used. Future efforts to reduce the burden of hypertension, particularly through the work of primary health-care providers, will need to improve access to, and use of, antihypertensive medications, paying particular attention to those with high value.

Funding

CAMS Innovation Fund for Medical Science, the Entrusted Project from the China National Development and Reform Commission, and the Major Public Health Service Project from the Ministry of Finance of China and National Health and Family Planning Commission of China.

Introduction

An estimated 200 million adults in China have hypertension but fewer than 15% are treated.1, 2, 3, 4 Moreover, among those who are treated, about two-thirds do not achieve adequate control of their blood pressure.5, 6, 7, 8 Inadequate management of patients with hypertension might have substantial health and economical consequences; the sequelae of hypertension, including stroke and heart disease, are the leading causes of morbidity and mortality in China,9, 10 and are associated with substantial expense to patients and the health system.

The successful management of hypertension in China requires, in addition to lifestyle and behavioural modifications, affordable and widely available antihypertensive medications prescribed appropriately in primary health-care settings, a main point of contact with the health system in China. Findings from studies have suggested low availability and high costs as major barriers to optimum use and adherence to essential antihypertensive medications, especially in low-income rural areas in China.3, 11

The Chinese health reform in 2009 strengthened the role of primary health care that serves as gatekeeper to the health-care system.¹² The reform also introduced the National Essential Medicine Program that was designed to provide affordable and equitable basic health care for all by 2020. Pharmaceutical policy has also evolved quickly, such as allowances for primary health-care sites to procure non-essential medicines in 2014 and abolishment of the government price ceiling in 2015 (appendix). Although availability of medications increased after the National Essential Medicine Policy was launched,13, 14, 15 little is known about current patterns of access to antihypertensive medications across Chinese primary health-care settings, where higher financial burdens and few medication choices might result in lower treatment and control rates. This information is essential for developing targets for interventions that are designed to improve national hypertension treatment and control.

Research in context

Evidence before this study

To assess treatment and control of hypertension in China, we searched PubMed for English-language published articles and the China National Knowledge Infrastructure for Chinese-language articles, published before May, 2016, using the terms “primary health care”, “pharmaceutical policy”, “essential medication”, “essential medicine”, “hypertensive medication”, OR “hypertension”. We also reviewed references from the identified articles and other relevant articles and reports. Awareness, treatment, and control of hypertension were found to be low. The Chinese National Essential Medicine Program, a zero mark-up policy for essential medications, was implemented by all primary health-care sites in 2009 to meet residents' medication needs and reduce their out-of-pocket costs. However, we noted conflicting results for availability and cost, and few studies reported prescription patterns of antihypertensive medications. Previous studies were limited to specific regions, populations, and data sources.

Added value of this study

We used data from a national primary health-care study and a screening study of high risks for cardiovascular disease in China to depict the current status of availability, cost, and prescription patterns of antihypertensive medications in primary health-care settings in China. We collected the data directly from primary health-care sites, rather than analysing secondary data from other reports. We noted marked deficiencies in availability, cost, and prescription of hypertensive medications, and a few health-care pharmacies did not stock any antihypertensive medications. Village clinics and sites in the western region of China had the lowest availability. High-cost medications were more likely to be prescribed than low-cost medications, and high-value medications, those that are guideline-recommended and low-cost, were not preferentially prescribed.

Implications of all the available evidence

Our findings suggest that interventions to improve hypertension treatment and control in China will need to ensure that low-cost antihypertensive medications are adequately available in primary health-care settings. Implementation of the essential medicines policy at the local level is currently inadequate. Use of high-value medications might help to reduce patients' cost burden of hypertension treatment.

Accordingly, to address the need for information about the availability, cost, and prescription of antihypertensive medications in primary health-care settings across China, we analysed data from a national, government-funded study of the primary health-care system and a large national cardiovascular screening project.¹⁶ Our study focused on all four types of primary health-care sites in China—community health centres and community health stations in urban areas, and township health centres and village clinics in rural areas—and also examined how the costs of antihypertensive medications were associated with the availability and prescription of antihypertensive medications, with a particular focus on lower-cost, guideline-recommended treatments.

Section snippets

Data source and study sample

We derived data on the availability, cost, and prescription of antihypertensive medications from the nationwide China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) Million Persons Project (MPP) primary health-care survey, undertaken from November, 2016 through May, 2017. The design of this survey has been described previously.¹⁷ Briefly, we established a nationwide epidemiological collaborative network of the China PEACE MPP, which consisted of 141 county or district-level

Results

The study sample included 3362 primary health-care sites (18·0% urban, 82·0% rural) across China (appendix). Township health centres constituted 8·4% of sites, village clinics 73·6%, community health centres 6·0%, and stations 11·9% (table 1). The 435 townships or communities, which collectively enrolled 1·09 million people in the China PEACE MPP, served as the study sample for determining hypertension treatment and control rates. The median sample size of participants at the township or

Discussion

This national study of antihypertensive medications in China revealed marked deficiencies in their availability, cost, and prescription. First, hypertension medications are inconsistently available in primary health-care pharmacies across China, and one in 12 did not stock any antihypertensive medications. Second, despite the availability of low-cost antihypertensive medications, higher-cost medications were more often prescribed. In fact, the higher the cost of the medication, the more likely

References (43)

Y Li et al.
Burden of hypertension in China: a nationally representative survey of 174 621 adults
Int J Cardiol
(2017)
D Li et al.
Hypertension burden and control in mainland China: analysis of nationwide data 2003–2012
Int J Cardiol
(2015)
M Zhou et al.
Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013
Lancet
(2016)
G Yang et al.
Emergence of chronic non-communicable diseases in China
Lancet
(2008)
Z Chen
Launch of the health-care reform plan in China
Lancet
(2009)
Y Fang et al.
Access to affordable medicines after health reform: evidence from two cross-sectional surveys in Shaanxi Province, western China
Lancet Glob Health
(2013)
L Yang et al.
Organizational barriers associated with the implementation of national essential medicines policy: a cross-sectional study of township hospitals in China
Soc Sci Med
(2015)
WC Yip et al.
Early appraisal of China's huge and complex health-care reforms
Lancet
(2012)
HV Hogerzeil et al.
Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration
Lancet
(2013)
L Jiang et al.
Achieving best outcomes for patients with cardiovascular disease in China by enhancing the quality of medical care and establishing a learning health-care system
Lancet
(2015)

Q Meng et al.

Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study

Lancet

(2012)

S Lewington et al.

The burden of hypertension and associated risk for cardiovascular mortality in China

JAMA Intern Med

(2016)

JG Wang

Chinese hypertension guidelines

Pulse

(2015)

X Guan et al.

An analysis of China's national essential medicines policy

J Public Health Policy

(2011)

XL Feng et al.

Health system strengthening and hypertension awareness, treatment and control: data from the China Health and Retirement Longitudinal Study

Bull World Health Organ

(2014)

L Yang et al.

Prevalence, awareness, treatment, control and risk factors associated with hypertension among adults in southern China, 2013

PLoS One

(2016)

J Lu et al.

Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project

Lancet

(2017)

Y Song et al.

The impact of China's national essential medicine system on improving rational drug use in primary health care facilities: an empirical study in four provinces

BMC Health Serv Res

(2014)

Q Liu et al.

Evaluation of the effects of comprehensive reform on primary healthcare institutions in Anhui Province

BMC Health Serv Res

(2014)

X Xi et al.

A survey of the availability, prices and affordability of essential medicines in Jiangsu Province, China

BMC Health Serv Res

(2015)

J Lu et al.

Protocol for the China PEACE (Patient-centered Evaluative Assessment of Cardiac Events) million persons project pilot

BMJ Open

(2016)

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Although socioeconomic inequality in cardiovascular health has long been a public health focus, the differences in cardiovascular-disease burden and mortality between people with different socioeconomic statuses has yet to be adequately addressed. We aimed to assess the effects of socioeconomic status, measured via three socioeconomic-status indicators (ie, education, occupation, and household wealth and a composite socioeconomic-status disparity index, on mortality and cardiovascular-disease burden (ie, incidence, mortality, and admission to hospital) in China.
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Of 47 931 participants enrolled in the PURE-China study, 47 278 (98·6%) had complete information on sex and follow-up. After excluding 1189 (2·5%) participants with missing data on education, household wealth, and occupation at baseline, 46 089 participants were included in this analysis. Median follow-up was 11·9 years (IQR 9·5–12·6); 26 860 (58·3%) of 46 089 participants were female and 19 229 (41·7%) were male. Having no or primary education, unskilled occupation, or being in the lowest third of household wealth was associated with a higher risk of all-cause mortality, cardiovascular-disease mortality, non-cardiovascular-disease mortality, major cardiovascular disease, and cardiovascular-disease admission to hospital compared with having higher education, a professional or managerial occupation, or more household wealth. After adjustment for confounders, people categorised as having low integrated socioeconomic status based on the index had a higher risk of all-cause mortality (HR 1·65 [95% CI 1·42–1·92]), cardiovascular-disease mortality (2·19 [1·68–2·85]), non-cardiovascular disease mortality (1·43 [1·18–1·72]), major cardiovascular disease (1·43 [1·27–1·61]) and cardiovascular-disease admission to hospital (1·14 [1·01–1·28]) compared with people categorised as having high integrated socioeconomic status.
Socioeconomic-status inequalities in mortality and cardiovascular-disease outcomes exist in China. Targeted policies of equal health-care resource allocation should be promoted to equitably benefit people with fewer years of education and less household wealth.
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Citation Excerpt :
Availability of antihypertensive medications other than angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers were associated with higher treatment proportions. The relatively high cost of these drugs might influence long-term treatment adherence of patients, and this might be one of the reasons for absence of association.25,26 Nevertheless, none of the associations with medication availability remained significant after adjusting for other institutional characteristics, indicating that they might have been confounded by other factors related to resources.
Since 2010, China has made vast financial investments and policy changes to the primary care system. We aimed to assess how hypertension awareness, treatment, and control might be used to assess quality of primary care systems, which reflect the outcomes of public health services and medical care.
We used The China Patient-centred Evaluative Assessment of Cardiac Events Million Persons Project, a government-funded public health project that focuses on cardiovascular disease risk in China. We linked primary care institution characteristics that were captured in the survey between 2016 and 2017 to the participant-level data gathered in baseline visits between 2014 and 2021. Participants were included if they had hypertension and lived in the towns or streets that took part in the primary care survey. Participants were excluded if they had missing data for blood pressure measurement, history of hypertension, sex, or age. Primary care institutions were excluded if the catchment area had fewer than 100 participants with hypertension. Hypertension awareness was defined as the proportion of participants with hypertension who self-reported a hypertension diagnosis. Hypertension treatment was defined as the proportion of participants who currently use antihypertensive medications among those who were aware. Hypertension control was defined as the proportion of participants with an average systolic blood pressure less than 140 mm Hg and an average diastolic blood pressure less than 90 mm Hg over two readings among those who were treated during the study. All patients were included in the analysis. This trial was registered at ClinicalTrials.gov, NCT02536456.
Between Sept 15, 2014, and March 16, 2021, we assessed 503 township-level primary care institutions for eligibility. 70 institutions were excluded as they could not be linked with individual data or because their catchment area had fewer than 100 participants with hypertension. We analysed 433 township-level primary care institutions across all 31 provinces of mainland China, including 660 565 individuals with hypertension in their catchment areas. Across townships, age-sex standardised hypertension awareness varied from 8·2% to 81·0%, treatment varied from 2·6% to 96·5%, and control proportions varied from 0% to 62·4%. Hypertension awareness, treatment, and control were significantly associated with the following institutional characteristics: government funding through balance allocation (ie, institutions have their human resources funded by local government, but need to be self-supporting in other aspects; awareness odds ratio 0·88, 95% CI 0·78–0·99; p=0·027), having financial problems that interrupted routine service delivery (awareness 0·81, 0·72–0·92; p=0·0007, control 0·84; 0·75–0·94, p=0·0034), setting performance-based bonus (treatment 1·39, 1·07–1·80; p=0·013), basic salary defined by number of patient visits (control 0·85, 0·76–0·95; p=0·0053), using electronic referrals (treatment 1·41, 1·14–1·73; p=0·0012, control 1·17; 1·03–1·33, p=0·014), implementing family physician contract services (awareness 1·13, 1·00–1·28; p=0·045, control 1·30; 1·15–1·46, p<0·0001), and proportion of physicians who are formally licensed (awareness per 10% increase 1·04, 1·01–1·08; p=0·019, treatment 1·08; 1·02–1·14, p=0·0077; control per 10% increase 1·07, 1·03–1·10; p=0·0006).
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^†: Joint senior authors

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ArticlesAvailability, cost, and prescription patterns of antihypertensive medications in primary health care in China: a nationwide cross-sectional survey

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Data source and study sample

Results

Discussion

Int J Cardiol

Int J Cardiol

Lancet

Lancet

Lancet

Lancet Glob Health

Soc Sci Med

Lancet

Lancet

Lancet

Lancet

The burden of hypertension and associated risk for cardiovascular mortality in China

JAMA Intern Med

Chinese hypertension guidelines

Pulse

An analysis of China's national essential medicines policy

J Public Health Policy

Health system strengthening and hypertension awareness, treatment and control: data from the China Health and Retirement Longitudinal Study

Bull World Health Organ

Prevalence, awareness, treatment, control and risk factors associated with hypertension among adults in southern China, 2013

PLoS One

Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project

Lancet

The impact of China's national essential medicine system on improving rational drug use in primary health care facilities: an empirical study in four provinces

BMC Health Serv Res

Evaluation of the effects of comprehensive reform on primary healthcare institutions in Anhui Province

BMC Health Serv Res

A survey of the availability, prices and affordability of essential medicines in Jiangsu Province, China

BMC Health Serv Res

Protocol for the China PEACE (Patient-centered Evaluative Assessment of Cardiac Events) million persons project pilot

BMJ Open

Articles
Availability, cost, and prescription patterns of antihypertensive medications in primary health care in China: a nationwide cross-sectional survey