China should reduce the overuse of intravenous infusionBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1262 (Published 04 February 2014) Cite this as: BMJ 2014;348:g1262
- Sanying Yuan, nurse, Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
Intravenous infusion of drugs or fluid is normally reserved for patients whose condition cannot be effectively treated by injection or drugs taken orally. Potential overuse of intravenous infusion is a controversial topic in mainland China, in large part because reliable statistics on the consumption are difficult to find. At a 2011 conference to reform the country’s healthcare system, Zhu Zhixin, deputy director of the Chinese National Development and Reform Commission, reported that the country consumed 10.4 billion bottles of infusion fluid in 2009—roughly eight bottles on average for each inhabitant.
Other countries, in contrast, rarely show consumption as high as 2.5 to 3 bottles per person.1 In September 2013, Haiping Deng, spokesman for the Chinese National Health and Family Planning Commission, clarified that the 10.4 billion bottles of infusion fluid mentioned referred to the production, not consumption, of infusion fluid in 2009.2 Despite the difficulties in putting numbers to the problem, both commissions agree that improper use of infusion in Chinese medical institutions needs to be tackled.
According to the Pharmaceutical Industry Association of China, fewer than two bottles of intravenous fluid were consumed per person in 1998, and many factories rushed to increase production to fulfil national needs after this.3 In a remarkably short time, the country met and exceeded Western standards. Indeed, the growing trend in intravenous infusion is part of a larger trend in increasing spending on drugs in China in general.
This overuse occasionally gives rise to so called “infusion forests,” with bags and tubes visible throughout the hospital. These forests are usually observed during cold weather, when many children fall ill.4 As one clinician, Yang Xia, commented about a recent infusion forest in Beijing Today, most of those patients “didn’t need IV medication. Pills and good rest would have been enough.”1
The high use of intravenous infusion is taking its toll on the Chinese healthcare system in several ways. For example, in one tertiary hospital in China in 2009, four nurses in the paediatric infusion room performed an average of 65 infusions every day. Over the year, 10 medical disputes arose at the hospital because of disagreements about infusion, including complaints of failed venepuncture.5 Intravenous infusion also makes up a disproportionate part of a nurse’s workload. In our recent survey of 287 nurses from 40 hospitals in Sichuan province, 78% of nurses described themselves as overworked and complained that more than 50% of their daily work was performing such infusions. They reported having to cut back on time spent on other nursing duties as a result.
Several factors help to explain the high use of intravenous infusion in China. One possible factor is poor investment in the healthcare system and relatively low salaries for doctors, leading them to prescribe infusion drugs in return for compensation from drug manufacturers.6 However, evidence from a governmental evaluation indicates that relatively few of China’s 8.6 million doctors deliberately overprescribe infusion treatments to earn more or boost their performance evaluation.7 Indeed, Chinese doctors and nurses have tried their best to fulfil their healthcare duty. A recent survey by Beijing University and the Chinese Ministry of Health, involving some 200 000 people in 31 provinces and autonomous regions, found 95% of people to be satisfied with the care they received from doctors and 94% with the care they received from nurses.7 8
Another factor may be pressure from patients, many of whom think that they can recover faster if they receive their drugs intravenously rather than orally. Some patients become difficult if their doctors do not prescribe infusion, leading them to decide that their doctors are irresponsible.
Such a decision is more likely than ever in the currently tense relationship between patient and doctor in China, which is worsened by occasional accounts of poor medical practice. Patients are often suspicious about whether a doctor is doing his or her utmost to manage or cure disease, and they can quickly turn antagonistic if they think their suspicions are justified. If a patient’s condition worsens, the family often accuses the medical staff of inadequate care or negligence. Since legal channels for pursuing malpractice claims are widely perceived to be inefficient and biased in favour of medical institutions,9 10 aggrieved patients often choose to take matters into their own hands. The results have been several highly publicised attacks by patients on doctors and nurses, some of which have ended in death.11 12 Under such circumstances, it is no surprise that doctors sometimes prescribe intravenous drugs simply because patients prefer them.
To help combat potential overuse of intravenous infusion, the Chinese government has adopted several measures. Hospitals in China supervise how many intravenous drugs are prescribed by their doctors. Those who prescribe infusions with unusually high frequency are investigated and asked to justify their decisions. In 2012 the Ministry of Health rolled out a “zero profit” policy for some drugs, including intravenous infusion fluid; the policy was implemented first in rural hospitals and later extended to Beijing and Shenzhen.13 This policy forbids doctors and hospitals from profiting from drug sales, removing the incentive associated with prescribing. Critics argue, however, that this policy may simply shift the incentive from overprescribing drugs to ordering excessive numbers of tests and examinations, for which hospitals and individual doctors can still earn extra compensation.14 15
These measures, while a step in the right direction, should go hand in hand with additional interventions. Firstly, the government should invest more in the healthcare sector, and in particular it should increase doctors’ and nurses’ salaries to reduce pressure to earn money from prescribing drugs. After the economic reforms of 1985, the Chinese government dedicated relatively little funding to healthcare. According to the country’s own Ministry of Health, China has 20% of the world’s population but accounts for only 3% of global healthcare spending.7 Doctors fare no better than the rest of the healthcare system: 80% of clinicians in secondary and tertiary facilities describe themselves as overworked and underpaid. Even doctors in cities earn as little as ¥5000 (£500; €609; $825) a month. Senior doctors at most hospitals earn just ¥7 for a consultation.16 The government should also educate the public. Such campaigns have proved effective for helping to modify public perceptions about antibiotics, reducing unwarranted use.17
Cite this as: BMJ 2014;348:g1262
I thank Professor Yanli Luo for her support.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare that I have no conflicts of interest.
Provenance and peer review: Not commissioned; externally peer reviewed.