INTRODUCTION
Human echinococcosis is caused by Echinococcus infection. It is prevalent in rural areas of underdeveloped countries and is considered a neglected tropical disease by World Health Organization (WHO). There are two major types: cystic echinococcosis (the most common form, caused by Echinococcus granulosus) and alveolar echinococcosis (the less common form, caused by Echinococcus multilocularis). Treatment requires extensive surgery and prolonged drug therapy, which can financially burden patients. If left untreated, the lesion might expand and cause severe complications; alveolar echinococcosis is a tumor-like lesion that can be lethal. Currently, at least 270 million people (58% of the total population) in Central Asia are at risk of human echinococcosis based on their close contact with infectious vectors, domestic animals, and livestock. The annual rate of surgical treatment ranges from 0.8% to 11.9% in western China.1 The disease also spread to nonendemic areas by wild animals and immigrant population, resulting in social and personal financial burdens. In both undeveloped and developed countries, the control of human echinococcosis turns out not cost-effective.2 According to an analysis by the WHO, cystic echinococcosis results in the loss of at least 1 million (potentially up to 3 million) disability-adjusted life years (DALY) annually.3
Human echinococcosis is especially prevalent in the Xinjiang, China, one of seven provinces with the highest human echinococcosis prevalence as well as the most underdeveloped area in China (Inner Mongolia, Tibet, Gansu, Qinghai, Ningxia, Xinjiang, and Sichuan). According to a national survey in 2004, approximately 66 million Chinese are at a risk of infection. The average prevalence in endemic areas was 1.08%. From 2004 to 2008, 27 of 31 provinces in China had reported human echinococcosis cases and approximately 50 million infected livestock every year. Human echinococcosis has become a serious public health problem and the leading cause of poverty in Xinjiang.4
Echinococcosis control requires a comprehensive effort, for example, monthly deworming of domestic dogs, improvement of slaughterhouse hygiene, identification of human cases, treatment of patients, and prevention education in the community. Control of echinococcosis in China has faced difficulties, especially in undeveloped areas. Infected animals distribute in pastures and mountains, which cover 40% of the area of China. Poor hygiene, sanitation conditions, and insufficient tap water have contributed to the increasing prevalence.5–7 Although Xinjiang has similar problems of resource constraints, chronic fund shortages, and “brain drain” in basic medical units, the local perceptions of public hospitals on human echinococcosis impact the treatment outcomes. Beyond the contribution of public health professionals from the Centers for Disease Control and Prevention (CDC), surgeons take a very active role in the parasite control program. The central teaching hospital, The First Affiliated Hospital of Xinjiang Medical University, has 65 years of experience with human echinococcosis surgery. The surgeon-orientated surgery network helps increase the patient processing efficiency and reduce the medical cost. Electronic databases and networks have been demonstrated effective in such an undeveloped area with limited resources, vast territory, sparse population, and poor traffic conditions.
MATERIALS AND METHODS
Study design.
Surgery data from a multicenter network during 2008–2013 were retrospectively analyzed from a surgery network shared database. The 2,544 human echinococcosis surgeries from 28 designated hospitals were included. The period from 2008 to 2013 was chosen because full medical records, financial reimbursements, and follow-up information were completed. The 2,544 reported surgeries from the database were retrieved, and important information were extracted, including the type, stage, and classification of the disease; registration and processing of patients; patient characteristics; surgical procedures; medical cost; and reimbursement. These large-scale data were compared and analyzed using SPSS Statistics for Windows, version 17.0 (SPSS Inc., Chicago, IL).
Treatment guidelines.
The diagnosis, staging, and treatments followed the Guidelines for the Treatment of Cystic and Alveolar Echinococcosis in Humans, which were approved by the WHO Informal Working Group on Echinococcosis.8–10 The patient processing flowchart is shown in Figure 1. The suspected of human echinococcosis cases take the screening tests (ultrasound and serological exams). The confirmed patients receive free medication from community hospitals. Patients with surgery indications (confirmed echinococcosis with a lesion larger than 8 cm or with complications) are transferred in the network for further surgical intervention.
The different working assignment within the network. The full system covers government, Centers for Disease Control and Prevention (CDC), and public hospitals. In hospital section, there are hospitals in different levels: community hospitals, regional hospitals, and central hospitals, which offer free albendazole medicine. Only the 28 designated public hospitals which provide the professional echinococcosis surgery were included in surgery reimbursement (hospital list: Aletai, Bayingolin, Bortala, Chabuchaer, Changji, Emin, Fuhai, Habahe, Hami, Hefeng, Hejing, Jimsar, Jinghe, Kizilsu, Kuitun, Nilka, Qitai, Shawan, Shihezi, Tacheng, Toksun, UrumqiFriendship, Wusu, First Teaching hospital of Xiingjiang Medical University, Xinyuan, Yanqi, Yili Friendship, and Yili Xinhua). In the network, patients were identified and processed from community to regional hospitals with supervision of central hospital, financial support from government, and continuity with CDC. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The different working assignment within the network. The full system covers government, Centers for Disease Control and Prevention (CDC), and public hospitals. In hospital section, there are hospitals in different levels: community hospitals, regional hospitals, and central hospitals, which offer free albendazole medicine. Only the 28 designated public hospitals which provide the professional echinococcosis surgery were included in surgery reimbursement (hospital list: Aletai, Bayingolin, Bortala, Chabuchaer, Changji, Emin, Fuhai, Habahe, Hami, Hefeng, Hejing, Jimsar, Jinghe, Kizilsu, Kuitun, Nilka, Qitai, Shawan, Shihezi, Tacheng, Toksun, UrumqiFriendship, Wusu, First Teaching hospital of Xiingjiang Medical University, Xinyuan, Yanqi, Yili Friendship, and Yili Xinhua). In the network, patients were identified and processed from community to regional hospitals with supervision of central hospital, financial support from government, and continuity with CDC. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The different working assignment within the network. The full system covers government, Centers for Disease Control and Prevention (CDC), and public hospitals. In hospital section, there are hospitals in different levels: community hospitals, regional hospitals, and central hospitals, which offer free albendazole medicine. Only the 28 designated public hospitals which provide the professional echinococcosis surgery were included in surgery reimbursement (hospital list: Aletai, Bayingolin, Bortala, Chabuchaer, Changji, Emin, Fuhai, Habahe, Hami, Hefeng, Hejing, Jimsar, Jinghe, Kizilsu, Kuitun, Nilka, Qitai, Shawan, Shihezi, Tacheng, Toksun, UrumqiFriendship, Wusu, First Teaching hospital of Xiingjiang Medical University, Xinyuan, Yanqi, Yili Friendship, and Yili Xinhua). In the network, patients were identified and processed from community to regional hospitals with supervision of central hospital, financial support from government, and continuity with CDC. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
Disease classification and staging.
We follow WHO classification10 for diagnosis, staging, and treatment.11–13 In the classification, CE1 and CE2 are regarded as “active,” CE3 as “transitional,” and CE4 and CE5 as “inactive” cyst stages. The uncomplicated patients were treated in the community hospitals with albendazole. The advanced cyst cases (CE4 and CE5) were placed on the recheck list for further watch. The complicated CE2 and CE3b cases were transferred to regional hospitals. Patients with serious complications were transferred to the central hospital.
The classification and transfer indications for alveolar echinococcosis are different from cystic echinococcosis. Alveolar echinococcosis frequently infiltrates liver, acting as a malignant tumor with remote metastases. Alveolar echinococcosis was staged I to IV by the PNM system proposed by the WHO. The PNM system adopts a tumor classification conception: P represents the parasitic mass in the liver, N represents the involvement of neighboring organs, and M represents metastasis.13 Because alveolar echinococcosis is rare, all suspected alveolar echinococcosis cases found in community hospitals are transferred to regional hospitals for further confirmatory diagnosis with computed tomography or magnetic resonance imaging exams. Depending on the lesion stage and the patients’ general conditions, the confirmed alveolar echinococcosis patients are given albendazole therapy alone or hepatic resection followed by long-term adjuvant albendazole treatment. The end-stage cases with liver failure are transferred to the central hospital for liver transplantation.
Ethics statement.
The database was approved by the Administer of Health, China. Ethics terms were approved by Ethics Committee of The First Affiliated Hospital of Xinjiang Medical University. Hospitals in the network and participating patients signed the written informed consent to share the data. Among all participants, there were 12 children under 18 years of age and their parents provided written consent on behalf of the child participants. The data available in the database are shown with real names and the patient’s written informed consent to have their identifiable data to be shared.
Patient financial support solution.
The maximum financial subsidy RMB8000 (USD$1200) was directly reimbursed to every patient who underwent surgery. The funding was provided by government. The Health Ministry performed the accreditation and then authorized 28 qualified public hospitals to perform surgery. The government financial support had no bias and was equally available to any confirmed human echinococcosis patients with surgery indications. The 28 public hospitals within the network were qualified to perform surgery. The patients’ assignment to a hospital was based on the shortest distance.
RESULTS
Part 1: The establishment of the multicenter network, structure of the institutions, and connections.
The establishment of the multicenter network of 28 public hospitals.
A network of 28 public hospitals was established. The hospitals include Aletai, Bayingolin, Bortala, Chabuchaer, Changji, Emin, Fuhai, Habahe, Hami, Hefeng, Hejing, Jimsar, Jinghe, Kizilsu, Kuitun, Nilka, Qitai, Shawan, Shihezi, Tacheng, Toksun, Urumqi Friendship, Wusu, First Teaching hospital of Xinjiang Medical University (XMU), Xinyuan, Yanqi, Yili Friendship, and Yili Xinhua. The leading hospital is the First Teaching hospital of XMU. Figure 1 also shows the significance of the network. The network can facilitate patient surgery completion and establish a regional collaboration that integrates health administrators, health-care providers, financial aid, and the public health system.
Public hospital distribution is based on the geography and prevalence.
The geography of Xinjiang and echinococcosis prevalence helps to illustrate the significance of the database and the network. Xinjiang is the country’s most remote region of China, bordering Central Asia and covering an area of over 1,600,000 m2, approximately the size of one Iran or three Frances. Its geography is characterized by a high altitude and complex landforms. It is divided into the Dzungarian Basin in the north and Tarim Basin in the south with extremely rugged Karakoram, Kunlun, and Tian Shan mountains, making road and rail transportation difficult. The long distance makes patient transfer time consuming and expensive. Currently, 28 designated public hospitals have been certificated to provide qualified surgery. These hospitals cover the major endemic area (Figure 1).
The structure of the institutions and the connections.
As shown in Figure 2, the network built up a reasonable three-level surgery referral and treatment system to optimize the limited medical resources among different tiers of medical institutions. Different hospitals had level-matched assignments. The previous system suffered from chronic low funding. Patients bypassed the local hospitals and flooded into the central hospital for skilled surgeons. Consequently, patients’ financial burden increased. The medical resources in higher ranked hospitals were insufficient to handle the overwhelming patients. The underused facilities in community hospitals were worsened in this vicious circle. The surgery network was established and led by the central teaching hospital, the First Teaching Hospital of XMU. Altogether, 28 public hospitals are designated to offer the surgery and subsidies. The database and teleconsulting help to standardize the diagnosis, surgical treatment, chemotherapy, and postoperation follow-up based on the WHO guidelines. This protocol dramatically optimized the surgery register procedure, transfer, and ensured patients could be efficiently treated with shorter time and lower cost.
The tertiary structure and different role of public hospitals. The central function of surgery network is to ensure the right tertiary structure and different role of public hospitals. As a result, patients can get qualified surgery nearby. The surgery register database was set up among 28 designated and was led by the central teaching hospital, the First Teaching Hospital of Xinjiang Medical University. The database and teleconsulting helped to standardize diagnosis and treatment. The community–regional–central hospital stepwise consultation optimized the surgery register procedure, keeping the patients to be treated in the local hospital, decreased the disordered transfer, and ensured complicated cases to be efficiently transferred and treated in central hospital. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The tertiary structure and different role of public hospitals. The central function of surgery network is to ensure the right tertiary structure and different role of public hospitals. As a result, patients can get qualified surgery nearby. The surgery register database was set up among 28 designated and was led by the central teaching hospital, the First Teaching Hospital of Xinjiang Medical University. The database and teleconsulting helped to standardize diagnosis and treatment. The community–regional–central hospital stepwise consultation optimized the surgery register procedure, keeping the patients to be treated in the local hospital, decreased the disordered transfer, and ensured complicated cases to be efficiently transferred and treated in central hospital. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The tertiary structure and different role of public hospitals. The central function of surgery network is to ensure the right tertiary structure and different role of public hospitals. As a result, patients can get qualified surgery nearby. The surgery register database was set up among 28 designated and was led by the central teaching hospital, the First Teaching Hospital of Xinjiang Medical University. The database and teleconsulting helped to standardize diagnosis and treatment. The community–regional–central hospital stepwise consultation optimized the surgery register procedure, keeping the patients to be treated in the local hospital, decreased the disordered transfer, and ensured complicated cases to be efficiently transferred and treated in central hospital. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
Hospital admission process.
The network coordinates the surgery services for echinococcosis patients. A specially designed information technology solution was deployed within the 28 designated public hospitals. The system included a hospital administration system as well as a complete electronic medical record database. During 2008–2013, the system registered 2,544 echinococcosis patients and assigned them to the nearest local public hospital to undergo surgery. Diagnosis and treatment were supervised by a highly ranked hospital. The complicated cases were discussed by remote online consulting. The responsibility of different levels of hospitals is different, as illustrated in Figure 2. The flowchart shows the patient transfer procedure and health provider’s assignment in the network.
Hardware and software infrastructure.
Both wireless and wired Internet infrastructure were used, so that the network can share patients’ graphical textual and numerical medical history information, including admissions, discharges, surgical operations, radiology examinations, albendazole doses, follow-up record, and in-hospital costs. The hardware and computer system were established and maintained by the hospital’s medical information team. The central hospital, The First Affiliated Hospital of XMU, is responsible for maintaining the database. The hospital has been certified by Health-care Information and Management Systems Society.
Network operation and management.
During 2008–2013, 2,544 surgeries were performed in the 28 hospitals. Patients were assigned a unique tracking number. The patient’s medical condition, follow-up information, pharmaceutical therapy, radiographic images, laboratory results, and medical costs were updated, maintained and shared by the surgeons, radiologists, physicians, nurses, pharmaceutics, and clinical researchers. The registered patients in the database were also reported to the local CDC. The postsurgery patients were followed up routinely. Their family and community were also tracked. Field surveys, free physical exams, and education books on prevention were offered.
Part 2: Results from the network: epidemiological and clinical data.
The total surgeries increased yearly, and more patients were covered.
Network helps patients without complications to be treated locally. The total surgery cases increased annually compared with previous decades, when patients from all parts of Xinjiang flooded into XMU to undergo the surgery. As shown in Figure 3, from 2008 to 2013, a total of 2,544 human echinococcosis surgeries were performed. As a comparison with previous years, XMU itself could only finish 1,425 surgeries in 10 years (from 1991 to 2001, most echinococcosis patients from all parts of Xinjiang went to XMU for surgery). After applying the echinococcosis surgery registry system, patients were assigned to the nearest hospital, and surgeries could be performed in all 28 designated public hospitals (Figure 3).
The time distribution and the hospital distribution of 2,544 surgeries registered in the database. From year 2008 to 2013, a total of 2,544 human echinococcosis surgeries were completed. Annual surgery cases varied from 2008 to 2012 (156, 173, 284, 617, 754, and 560, respectively). As a comparison of previous years, most human echinococcosis surgeries were done in XMU, from 1991 to 2001, the annual surgery cases completed by Xinjiang Medical University were 122, 129, 118, 188, 138, 119, 120, 125, 128, 124, and 114, respectively during 10 years. After application of echinococcosis surgery register database patients were assigned to the nearest hospitals and so surgeries can be done in all of 28 designated public hospitals. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The time distribution and the hospital distribution of 2,544 surgeries registered in the database. From year 2008 to 2013, a total of 2,544 human echinococcosis surgeries were completed. Annual surgery cases varied from 2008 to 2012 (156, 173, 284, 617, 754, and 560, respectively). As a comparison of previous years, most human echinococcosis surgeries were done in XMU, from 1991 to 2001, the annual surgery cases completed by Xinjiang Medical University were 122, 129, 118, 188, 138, 119, 120, 125, 128, 124, and 114, respectively during 10 years. After application of echinococcosis surgery register database patients were assigned to the nearest hospitals and so surgeries can be done in all of 28 designated public hospitals. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The time distribution and the hospital distribution of 2,544 surgeries registered in the database. From year 2008 to 2013, a total of 2,544 human echinococcosis surgeries were completed. Annual surgery cases varied from 2008 to 2012 (156, 173, 284, 617, 754, and 560, respectively). As a comparison of previous years, most human echinococcosis surgeries were done in XMU, from 1991 to 2001, the annual surgery cases completed by Xinjiang Medical University were 122, 129, 118, 188, 138, 119, 120, 125, 128, 124, and 114, respectively during 10 years. After application of echinococcosis surgery register database patients were assigned to the nearest hospitals and so surgeries can be done in all of 28 designated public hospitals. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
Clinical characteristics of the 2,544 patients in the network from 2008 to 2013.
An analysis of surgical records in the human echinococcosis surgery registry database was performed as shown in Figure 3. The hospital distribution is quite uneven, and the surgery case number is associated with the hospital location and capacity. XMU is the central hospital in Xinjiang, at the top of the scale (Grade 3 hospital), and the other 27 hospitals are regional hospitals. From 2008 to 2013, a total of 2,544 patients (52.75% male and 47.25% female) were hospitalized for human echinococcosis surgeries. The overwhelming majority had cystic human echinococcosis. Young and middle-aged patients mostly affected (666 patients in their 30s and 544 in their 40s); the ethnic group division is consistent with the local population composition (Han: 888, Kazakh: 681, and Uighur: 529, accounting for the majority of patients) (Figure 4).
The clinical characters of 2,544 echinococcosis patients with surgeries in Xinjiang during 2008–2013. From year 2008 to 2013, a total of 2,544 patients (52.75% male and 47.25% female), were hospitalized for human echinococcosis-related surgeries. The overwhelming major type is cystic human echinococcosis. The young and middle-aged are mostly affected (666 patients in 30s and 544 in 40s); in ethnic group division is coherent to the local population composition (Han: 888, Kazakh: 681, Uighur: 529, account the majority of patients). The hospital stay varied in different hospitals and affected the direct medical cost. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The clinical characters of 2,544 echinococcosis patients with surgeries in Xinjiang during 2008–2013. From year 2008 to 2013, a total of 2,544 patients (52.75% male and 47.25% female), were hospitalized for human echinococcosis-related surgeries. The overwhelming major type is cystic human echinococcosis. The young and middle-aged are mostly affected (666 patients in 30s and 544 in 40s); in ethnic group division is coherent to the local population composition (Han: 888, Kazakh: 681, Uighur: 529, account the majority of patients). The hospital stay varied in different hospitals and affected the direct medical cost. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The clinical characters of 2,544 echinococcosis patients with surgeries in Xinjiang during 2008–2013. From year 2008 to 2013, a total of 2,544 patients (52.75% male and 47.25% female), were hospitalized for human echinococcosis-related surgeries. The overwhelming major type is cystic human echinococcosis. The young and middle-aged are mostly affected (666 patients in 30s and 544 in 40s); in ethnic group division is coherent to the local population composition (Han: 888, Kazakh: 681, Uighur: 529, account the majority of patients). The hospital stay varied in different hospitals and affected the direct medical cost. This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
Government subsidy can relieve individual patients’ direct medical costs.
A total of 2,544 patients who had human echinococcosis surgeries in 28 echinococcosis designated hospitals in Xinjiang from 2008 to 2013 were included to calculate their direct surgery costs. As shown in Figure 5, the average direct medical cost of an echinococcosis surgery is RMB18890 yuan ($2,998). The average reimbursement of government subsidy is RMB7249 ($1,150). The average medical insurance coverage is RMB5938 ($942). The average self-payment is RMB11185 ($1,775). The medical cost mentioned earlier is the direct cost related to the surgery. Of note, the localized surgery approach also reduced indirect costs that are not included in the chart, such as travel, nursing, family lost labor, and so on. The direct medical cost was reduced compared with the previous cost by approximately $1,500 per case.14
Direct medical cost for individual patient analysis. The total 2,544 patients who had the human echinococcosis surgeries in 28 echinococcosis designated hospitals in Xinjiang from 2008 to 2013 were included to calculate their average direct cost for surgery. As shown in this figure, the mean direct medical cost of an echinococcosis surgery showed RMB18890 yuan ($2,998). The mean reimbursement of government subside is RMB7249 ($1,150), mean medical insurance coverage is RMB5938 ($942), mean self-payment is RMB11185 ($1,775). This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
Direct medical cost for individual patient analysis. The total 2,544 patients who had the human echinococcosis surgeries in 28 echinococcosis designated hospitals in Xinjiang from 2008 to 2013 were included to calculate their average direct cost for surgery. As shown in this figure, the mean direct medical cost of an echinococcosis surgery showed RMB18890 yuan ($2,998). The mean reimbursement of government subside is RMB7249 ($1,150), mean medical insurance coverage is RMB5938 ($942), mean self-payment is RMB11185 ($1,775). This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
Direct medical cost for individual patient analysis. The total 2,544 patients who had the human echinococcosis surgeries in 28 echinococcosis designated hospitals in Xinjiang from 2008 to 2013 were included to calculate their average direct cost for surgery. As shown in this figure, the mean direct medical cost of an echinococcosis surgery showed RMB18890 yuan ($2,998). The mean reimbursement of government subside is RMB7249 ($1,150), mean medical insurance coverage is RMB5938 ($942), mean self-payment is RMB11185 ($1,775). This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
Network saves medical expenses from social security.
The surgery network has organized 30,000 teleconsultations, helping 92% of patients undergo treatment at the local hospitals. The direct savings in hospitalization cost is over 248.7 million yuan ($40 million). According to the current situation, in Urumqi, the capital of Xinjiang, the average inpatient hospitalization cost is RMB 12,000 yuan ($1,900), which is much higher than the regional hospital RMB 4,600 yuan ($730) or the community hospital RMB 2,300 yuan ($365).14 Our previous study on the direct and indirect economic burden of human echinococcosis in Xinjiang was US $1,493.12. The DALY lost was approximately 1.03 DALY/person.15
The surgery network improves efficiency and treats more people.
To observe the greatest improvement in the patient processing efficiency, the central hospital (XMU) was evaluated. Its annual human echinococcosis cases, transfer cases, and inpatient costs were reviewed and compared in Figure 6.
The network increases the efficiency of central hospital. (A) From 2008 to 2013, the database was in function and the annual human echinococcosis processing efficiency increased. (B) During 2008–2013, 2,560 human echinococcosis cases were consulted by telemedicine in central hospital Xinjiang Medical University (XMU); only 204 cases were transferred, whereas the rest 2,356 stayed in the regional hospitals with the help of further treatment direction from central hospital by telemedicine. (C) The average inpatient cost comparison in XMU and regional hospitals (in central hospital is 12,167 yuan/case, whereas in regional hospital was only 5,895 yuan/case). This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The network increases the efficiency of central hospital. (A) From 2008 to 2013, the database was in function and the annual human echinococcosis processing efficiency increased. (B) During 2008–2013, 2,560 human echinococcosis cases were consulted by telemedicine in central hospital Xinjiang Medical University (XMU); only 204 cases were transferred, whereas the rest 2,356 stayed in the regional hospitals with the help of further treatment direction from central hospital by telemedicine. (C) The average inpatient cost comparison in XMU and regional hospitals (in central hospital is 12,167 yuan/case, whereas in regional hospital was only 5,895 yuan/case). This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
The network increases the efficiency of central hospital. (A) From 2008 to 2013, the database was in function and the annual human echinococcosis processing efficiency increased. (B) During 2008–2013, 2,560 human echinococcosis cases were consulted by telemedicine in central hospital Xinjiang Medical University (XMU); only 204 cases were transferred, whereas the rest 2,356 stayed in the regional hospitals with the help of further treatment direction from central hospital by telemedicine. (C) The average inpatient cost comparison in XMU and regional hospitals (in central hospital is 12,167 yuan/case, whereas in regional hospital was only 5,895 yuan/case). This figure appears in color at www.ajtmh.org.
Citation: The American Journal of Tropical Medicine and Hygiene 97, 3; 10.4269/ajtmh.17-0052
As the top hospital in Xinjiang, XMU treated most human echinococcosis cases. From 1957 to 1990, altogether 3,516 human echinococcosis cases were treated in XMU, which means the central hospital can process 103 echinococcosis patients per year with its best effort. The annual capacity for treating human echinococcosis stayed at approximately 130 cases from 1990 to 2001. From 2001 to 2008, the telemedicine and surgery network were under construction. From 2008 to 2013, the network was functioning, and the annual human echinococcosis processing efficiency dramatically increased (Figure 6A). As a beneficial result of the database and telemedicine, transfers from regional hospitals to the central hospital decreased. According to the 2,560 cases of human echinococcosis evaluated by telemedicine in the central hospital XMU during 2008–2013, only 204 cases were transferred, whereas the remaining 2,356 stayed at the regional hospitals while receiving further treatment direction from the central hospital through telemedicine (Figure 6B). The average inpatient cost in the central hospital is 12,167 yuan/case, whereas the cost in the regional hospitals was only 5,895 yuan/case (Figure 6C).
The surgery network decreased morbidity/mortality.
Although widely practiced, surgery for human echinococcosis is still associated with high mortality and morbidity. According the global data updated in April 2016 by the WHO (http://www.who.int/mediacentre/factsheets/fs377/en/) for cystic echinococcosis, there is an average of a 2.2% postoperative death rate for surgical patients, and approximately 6.5% of cases relapse after intervention. According to CDC data (https://www.cdc.gov/parasites/echinococcosis/disease.html), alveolar echinococcosis has a mortality rate between 50% and 75%. In our retrospective review of 6 years of data in the 2,544 cases in the network, the improved control of human echinococcosis has occurred with standardization protocols on serum immunological and imaging diagnosis, chemotherapeutic treatment, antihelminthic dosing, and surgery procedures.
Currently, as a benefit of the Xinjiang surgery network, for cystic echinococcosis, the advanced surgery procedures were introduced and standardized in the network: “radical,” “quasi-radical,” and “improved.” Quasi-radical “external cystectomy” can reduce the total recurrence rate of liver cystic echinocccosis from 2–25% to 0.4%, and the incidence of biliary fistula decreased from 37% to 3.2%.16
For alveolar echinococcosis, the palliative lesion slicing procedure has been applied to replace the traditional surgery that can otherwise cause refractory biliary fistula. The implementation of liver resection and biliary/vascular reconstruction made radical surgery possible. Currently, as a benefit of the Xinjiang surgery network, the radical resection rate increased from the previous rate of 11.0% to a current rate of 67.9%.16
Liver transplantation is the only solution for end-stage patients, but it was previously impossible to perform in Xinjiang. In 2008, the first liver transplantation for liver alveolar echinococcosis (AE) was completed in XMU. In 2010, the first autotransplantation for liver AE was completed in XMU. After network implementation, at this point, 54 inoperable AE patients have successfully received liver transplantation in XMU. They had reduced postoperative complications, which significantly improved the cure rate.
DISCUSSION
Echinococcosis is now a serious public health problem in China that affects both human health and the economy. In Xinjiang, echinococcosis patients mainly live in undeveloped mountain regions with poor traffic conditions. These low-income farmers and herdsmen have limited scientific and cultural knowledge, limiting their early diagnosis and treatment. A human echinococcosis prevention and control program should include government financial support, health education, a monitoring program, a livestock slaughtering management program, professional and technical staff training program, a drug treatment program, an evaluation program, and so on. Here, we report our experience with a surgery network that has been demonstrated as applicable in undeveloped areas.
The network helped to save time, money, energy, and medical resources in an otherwise time-consuming and poorly efficacious process. The establishment of the database promoted the adequacy of medical treatment and facilitated standard treatment and continuity of care. The medical record sharing within the network helped to track the full medical history, including digital radiography and laboratory exam results.
One of the major challenges facing parasite control is money, which can be from government investment or personal payment for the treatment. Because of the low income of the infected herdsmen and long travel to the higher ranked capital hospitals, a medical network within the clustered hospitals prevents the waste associated with disordered patient transfer. To achieve the maximum benefit for the population in need, standardized admission and discharge criteria, surgery, and drug treatment guidelines were defined and frequently reevaluated by XMU. A computerized hospital administration information system quickly and accurately gathered the medical history and then promptly presented the information to the consulting expert surgeons, enabling an informed decision-making process. Moreover, the use of an electronic medical record enabled rapid patient transit to the nearest network hospitals while also lowering the transfer cost. This had a special significance in Xinjiang because of the language discrepancies between patients and caregivers and the poor traffic conditions. In addition, an electronic medical record system contributes to effective patient discharge by producing a clear, concise, and easily readable discharge summary. These features are crucial to maintaining the continuity of care. XMU also supplied surgery suites with digital video transmission systems that can share real-time surgery procedures within networks. Further benefits of using the database in Xinjiang include the establishment of community education, parasite research projects, efficient management of the surgical waiting list, facilitation of the treatment of returning patients, and online consulting.
In May 2013, the 66th World Health Assembly adopted resolution WHA66.12, which calls on Member States to intensify and integrate measures and plan investments to improve the health and social well-being of affected populations. The surgery network contributes to the successful control of echinococcosis in Xinjiang. National and international health organizations are encouraged to consider developing a standardized global parasite control network for cooperation with higher efficiency.
In conclusion, our study showed surgery network is effective to promote regional human echinococcosis treatment. The network improves collaboration efficiency with lower medical cost. It can serve as a reference for other parasite disease control.
Acknowledgments:
We thank the effective coordination from 28 cooperation public hospitals (Aletai, Bayingolin, Bortala, Chabuchaer, Changji, Emin, Fuhai, Habahe, Hami, Hefeng, Hejing, Jimsar, Jinghe, Kizilsu, Kuitun, Nilka, Qitai, Shawan, Shihezi, Tacheng, Toksun, Urumqi Friendship, Wusu, First Teaching hospital of Xiingjiang Medical University, Xinyuan, Yanqi, Yili Friendship, and Yili Xinhua). We also thank the coworkers from Xinjiang Centers for Disease Control and Prevention, Xinjiang Academy of Animal Husbandry Sciences. In addition, we thank the Xinjiang Institute of Ecology and Geography of the Chinese Academy of Sciences for their Remote Sensing and Geography Information System.
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