Differences in medical costs between TCM users and TCM nonusers in inpatients with thalassemia

Thalassemias are a group of inherited hematologic disorders caused by defects in the synthesis of one or more of the hemoglobin chains [1], α thalassemia and β thalassemia are most common clinically. There were about 399 million thalassemia carriers in 2019 worldwide [2], mainly in sub-Saharan Africa, the Mediterranean region, and East and South-East Asia, and thalassemia is becoming more common in Europe and North America due to migration factors [3, 4]. The increased morbidity of thalassemia has resulted in serious health threats and heavy economic burdens to the patients [5], especially in low and middle-income countries [4]. It was estimated that the global cost of treatment for thalassemia was approximately USD842 million in 2017 and is expected to increase by 7.9% from 2018 to 2026 [2]. In the 2017 Global Burden of Disease report, thalassemia has resulted in 582,000 disability-adjusted life-years (DALYs) [6]. Given the importance of preventing hemoglobinopathy, WHO has declared hemoglobinopathy control, especially β-thalassemia, a priority for the developing world [7].

Thalassemia is prevalent in tropical and subtropical areas regions [3]. Due to geographical and genetic factors, thalassemia is most common in southern regions of China such as Guangdong, Guangxi, Hainan, and other provinces [8]. A meta-analysis displayed that the combined overall prevalence of α, β, and α + β was 7.88%, 2.21%, and 0.48%, respectively [9]. Lin et al. collected data from 45 patients with thalassemia in Guangdong Province in 2012 and found that the per capita annual direct economic burden of patients was RMB43,058.66 (USD6,482), the per capita annual indirect economic burden was RMB20,474.51 (USD3,082), and the per capita intangible economic burden was RMB302,466.67 (USD45,536) [10]. The annual direct economic burden alone exceeded the per capita disposable income of Guangdong Province (RMB30,226.71(USD4,551)) in that year. In 2016, a study on the cost of rare diseases in Fujian Province showed that the average annual medical cost of thalassemia patients was RMB79,200 (USD11,924), of which the out-of-pocket cost was RMB44,600 (USD6,715), and the proportion of households with catastrophic expenditure was as high as 94.12% [11], the annual treatment cost exceeded the per capita disposable income of RMB36,014.26 (USD5,422) in Fujian Province. The economic burdens and health threats faced by patients in China are in a very serious situation.

The recommended treatment for thalassemia patients with severe conditions includes regular lifelong blood transfusions and iron chelation, and there is no sovereign remedy for patients with severe thalassemia except hematopoietic stem cell transplantation [12]. Most patients could hardly afford the highly expenses, so they had to struggle to seek other approaches, such as complementary and alternative medicine (CAM). A survey conducted in Iran showed that 68.5% of thalassemia respondents had used CAM at least once in their lifetime [13]. In Turkey, 82.5% of parents of children with thalassemia reported that they had used multiple CAM to treat their children [14]. The proportion of people with thalassemia in Malaysia who use CAM even exceeds cancer patients [15, 16]. Traditional Chinese medicine (TCM) is typical of CAM and plays an important role in the healthcare system both in China and in many other East Asian countries [17]. The Chinese government has always attached great importance to the development of TCM, and in 2016 issued the Outline of Strategic Planning for the Development of Traditional Chinese Medicine (2016–2030), the government emphasized “attached equal importance to TCM and Western medicine”, and encouraged the joint research of TCM and western medicine for major and difficult diseases, and form a unique strategy for integrating TCM and western medicine.

With the broad use of TCM, more and more research have emerged to examine the role of TCM on disease treatment and the influence of using TCM on patients’ economic burdens. Some studies showed that the treatment of thalassemia with TCM can improve the hematopoietic function, reduce the damage of red blood cells, alleviate the symptoms of anemia, and enhance the quality of life [18‐20]. Lin et al. found that in Dementia, TCM users could lower inpatient medical cost and length of stay compared to TCM nonusers [21]. Liao et al., using Taiwan’s 2005 Longitudinal Health Insurance Database, found that the TCM insurance cost was consistently lower than those covering biomedicine in patients with liver cancer [17]. Huang et al. concluded that TCM mainly played a complementary role to conventional medicine in the treatment of Chinese mainland ischemic stroke [22]. The above researches demonstrated the influence of TCM using either on treatment effect or on the economic burdens of other diseases. It is noteworthy that although TCM has been used in the treatment of thalassemia, there is no research illustrating the effect of TCM use on the economic burdens of thalassemia inpatients. However, as a significant approach for curing thalassemia, the role of TCM is worthy of attention, the economic burdens of TCM use on thalassemia inpatients need to examine. To explore the above issues, we used cross-sectional data from 2010 to 2016 for research, and further evaluate the correlation between TCM use and TCM cost.

To our knowledge, this is the first national study in China based on Medicare data to examine the economic influence of using TCM on thalassemia inpatients, and to analyze the reason of the influence. A nationally representative sample of the Chinese mainland population was used to ensure robust estimations of the cost to inpatients with thalassemia. We found that TCM users had 67.4% higher hospitalization costs than TCM nonusers, but the use of TCM was not the main reason for higher hospitalization costs.

In general, patients with minor thalassemia are in a mild condition and do not need to be hospitalized, but patients with moderate to severe thalassemia require hospitalization. After a long time of therapy, those severe thalassemia inpatients might seek alternative treatments to alleviate their pain, and TCM would be their best choice in China. Previous studies have shown that TCM is effective in relieving the symptoms of thalassemia [18‐20]. We found that 37.8% of thalassemia inpatients chose to use one or more TCM approaches to treat their diseases while in hospital, which indicates that TCM has a certain degree of trust, objective demand rate, and application space, and has a good mass base in the treatment of inpatients with thalassemia in mainland China.

We found that the cost of TCM users is significantly higher than that of TCM nonusers. The TCM users have to burden 67.4% higher medical costs than TCM nonusers with other confounding factors fixed. Previous studies had shown that complementary and alternative medicine is cheaper than conventional medicines [24‐26], and using TCM might alleviate the economic burdens of patients, which seems to be contrary to our results. Hence, we examined why TCM users have to burden more than TCM nonusers. From the results of the composition of medical costs in Table 4, we found that the conventional medication cost and nonpharmacy cost of TCM users accounted for the majority of the total medical cost (95.6%). The median cost of conventional medication (RMB2,259/USD340) for TCM users was significantly higher than TCM nonusers (RMB469/USD71). The median nonpharmacy cost of TCM users, such as medical treatment fees, blood transfusion fees, examination fees, and other costs (RMB5,966/USD898), were also higher than that of TCM nonusers (RMB1,304/USD196). Hence, we conclude higher conventional medication and nonpharmacy cost is the major cause of higher total inpatient costs for TCM users. The cost of TCM only accounts for a small proportion of the total medical costs and has less impact on the total medical costs. This is consistent with the results of previous studies. Huang et al. concluded that medical costs for hospitalized TCM users were 32.5% higher than for TCM nonusers, and that the cost of TCM increased significantly with increasing prescriptions of conventional medicine, which suggesting that TCM treatments were complements, rather than substitutes, to conventional treatment [22]. Nie et al. concluded that medication costs, conventional medication costs and nonpharmacy costs for TCM users were higher than for TCM nonusers, revealing that the higher medical costs for TCM users were not just to do with TCM treatments [27]. Four reasons could contribute to explaining this phenomenon.

First of all, the disease severity of TCM users might be more serious than that of TCM nonusers. Although we used the number of comorbidities as a control variable when comparing the inpatient cost of TCM users with nonusers, we also noted that the number of comorbidities was insufficient to represent the severity of the disease. In fact, the clinical outcome indicators were not included in the medical insurance database in China. When all kinds of inpatient costs for TCM users grow together, it could indicate a more serious disease situation. Patients with serious illnesses need to consume more drugs and treatment, and the serious illness will lead to a high cost of hospitalization. Second, it may also be related to people’s medical behaviors. Chinese people have a preference for the TCM culture, they believe that TCM is cheap and has few side effects [28‐30]. TCM is used to choosing as an auxiliary treatment when treating diseases [31, 32]. The use of TCM is an additional treatment based on conventional treatment, so TCM cost becomes an additional financial part, and the cost of TCM users is higher than TCM nonusers. Third, after adjusting the confounding factors, we found that TCM cost was positively correlated with conventional medication and nonpharmacy cost. The increase of TCM cost is accompanied by the increase of conventional medication cost and nonpharmacy cost, which do not offset each other. This may have to do with the prescribing behavior of physicians. Doctors who are used to prescribing more western medicines also tend to prescribe more TCM, which might result in synchronous growth of both TCM costs and other costs. Last but not least, TCM plays a more complementary role but not an alternative role in the treatment of thalassemia due to the lack of combined Chinese and Western medical treatment guidelines for thalassemia diseases. In China, there are only clinical guidelines for the use of conventional treatments for thalassemia [33, 34], no guidelines for the use of TCM methods of treatment, much less for the combination of TCM and Western medicine for treatment. In clinical practice, there is no pathway for combining TCM and Western medicine, so it is not possible to achieve an alternative with better efficacy for both sides, and there is no alternative application of synergistic means, which leads to high treatment costs. Previous studies have shown that the combination of Chinese and Western medicine is clinically effective in treating diseases and can reduce the economic burden of patients [35‐37], such as the treatment of acute cerebral infarction and rheumatoid arthritis. A study of hospitalization expenses for patients with acute cerebral infarction found that the cost of combined Chinese and Western medical treatment was superior to Western medical treatment, meaning that medical costs were lower for TCM users than for TCM nonusers [36]. The above may also explain the preference of some physicians to use both TCM and Western medicine. However, in the absence of a comprehensive Chinese and Western medicine treatment plan for thalassemia, doctors cannot refer to the corresponding clinical guidelines and can only prescribe based on their own experience, which is subjective and insufficient on the control over the dosage of drugs and non-drug means. Conventional methods still play a dominant role in treatment, and the addition of TCM could not balance the relationship with conventional drugs, and the arbitrary prescription of drugs might even increase the financial burdens of patients. Jianying Pan randomly divided cirrhotic ascites patients into an integrated Traditional Chinese and western medicine group and a conventional medicine group and compared the two groups and found that the cost of the integrated Chinese and Western medicine group (RMB11,570) was significantly lower than that of Western medicine group (RMB15,843.33) (p < 0.05) [38]. Gu et al. conducted a health economics evaluation of integrated traditional Chinese and Western medical for patients with Knee Osteoarthritis, Cervical Spondylosis and Lumbar Disc Herniation in a community health services center and found that integrated traditional Chinese and Western medical was more cost-effective compared to Chinese medical treatment alone [39]. Therefore, we believe that the development of integrated Chinese and Western medicine medical guidelines could have a high potential to reduce total medical costs. We urgently need a strategy for combining Chinese and Western medicine in the treatment of thalassemia to balance the use of TCM and conventional medicine, reduce patients’ expenditures, and improve treatment efficiency and clinical outcomes.

Thalassemia is often regarded as a rare disease in Chinese folk due to its limited treatment and area of occurrence. In recent years, the Chinese government has paid more and more attention to rare diseases and issued documents such as the Catalog of the First Group of Rare Diseases and Guidelines for the Diagnosis and Treatment of Rare Diseases. In 2019, the National Health Commission of the People’s Republic of China selected 324 hospitals with strong diagnosis and treatment capabilities and more cases of rare diseases to jointly establish a National Rare Disease Diagnosis and Treatment Cooperation Network to improve China’s comprehensive diagnosis and treatment capacity for rare diseases. In order to control medical costs and respond to the national policy of “attaching equal importance to both traditional Chinese medicine and Western medicine”, healthcare providers should consider the wider use of TCM, balance the relationship between TCM and Western medicine, and develop detailed guidelines for the combination of TCM and conventional medicine to treat thalassemia.

This study has several limitations. First, the study was limited by a small sample size. Rural residents, patients using only over-the-counter medications, and patients not receiving treatment from a healthcare provider were excluded. Second, due to lack of clinical indicators in the database, so the number of comorbidities was used to replace disease severity and the percentage of TCM cost to substitute the degree of TCM use. The limitation of the anonymous database prevented us from obtaining more personal information about the patients such as the patient’s income status. Third, although as many control variables as possible were included, there were significant differences in basic information between the two groups of patients, which might have influenced our findings. Fourth, we only analyzed the cost of TCM, and the nonpharmacy cost services of TCM such as acupuncture, moxibustion, massage, etc. were not included. Finally, our study only covered 2010–2016, and the post-2016 healthcare reforms may affect subsequent outcomes.

Total hospitalization expenses for TCM users were higher than TCM nonusers. The proportion of conventional medication cost and nonpharmacy cost of TCM users in total inpatient medical cost were as high as 95.6%, indicating that the use of TCM is not the only reason for the high cost of TCM users. Conventional medication cost and nonpharmacy cost were positively correlated with TCM cost. We infer that TCM mainly plays a complementary role but not an alternative role in the treatment of thalassemia due to the lack of integrated Chinese and Western medical treatment guidelines. It is suggested that relevant departments should formulate diagnosis and treatment guidelines for cooperative Chinese and Western medicine treatment, and balance the use of TCM and conventional medicine, so as to reduce the economic burdens on patients.