As a health and development economist, Hao Xue has studied the implementation of school-based health and nutrition programs, the interventions to improve early childhood health and development, and the measurement and interventions to improve the quality of primary care in China. Most recently, Hao's research focuses on designing and evaluating innovative approaches to improve health services in China. He has taught classes of impact evaluation and Health Economics. He received his PhD in Economics from a joint program of the Northwest University in China and Stanford University.

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All Publications

  • Diagnostic ability and inappropriate antibiotic prescriptions: a quasi-experimental study of primary care providers in rural China JOURNAL OF ANTIMICROBIAL CHEMOTHERAPY Xue, H., Shi, Y., Huang, L., Yi, H., Zhou, H., Zhou, C., Kotb, S., Tucker, J. D., Sylvia, S. Y. 2019; 74 (1): 256–63


    China has one of the highest rates of antibiotic resistance. Existing studies document high rates of antibiotic prescription by primary care providers but there is little direct evidence on clinically inappropriate use of antibiotics or the drivers of antibiotic prescription.To assess clinically inappropriate antibiotic prescriptions among rural primary care providers, we employed unannounced standardized patients (SPs) who presented three fixed disease cases, none of which indicated antibiotics. We compared antibiotic prescriptions of the same providers in interactions with SPs and matching vignettes assessing knowledge of diagnosis and treatment to assess overprescription attributable to deficits in diagnostic knowledge, therapeutic knowledge and factors that lead providers to deviate from their knowledge of best practice.Overall, antibiotics were inappropriately prescribed in 221/526 (42%) SP cases. Compared with SP interactions, prescription rates were 29% lower in matching clinical vignettes (42% versus 30%, P < 0.0001). Compared with vignettes assessing diagnostic and therapeutic knowledge jointly, rates were 67% lower in vignettes with the diagnosis revealed (30% versus 10%, P < 0.0001). Antibiotic prescription in vignettes was inversely related to measures of diagnostic process quality (completion of checklists).Clinically inappropriate antibiotic prescription is common among primary care providers in rural China. While a large proportion of overprescription may be due to factors such as financial incentives tied to drug sales and perceived patient demand, our findings suggest that deficits in diagnostic knowledge are a major driver of unnecessary antibiotic prescriptions. Interventions to improve diagnostic capacity among providers in rural China are needed.

    View details for PubMedID 30285113

  • Tuberculosis detection and the challenges of integrated care in rural China: A cross-sectional standardized patient study PLOS MEDICINE Sylvia, S., Xue, H., Zhou, C., Shi, Y., Yi, H., Zhou, H., Rozelle, S., Pai, M., Das, J. 2017; 14 (10): e1002405


    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.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, p < 0.001) and village clinics (OR 0.02, 95% CI: 0.0-0.17, p < 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.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.

    View details for PubMedID 29040263

  • Survey using incognito standardized patients shows poor quality care in China's rural clinics. Health policy and planning Sylvia, S., Shi, Y., Xue, H., Tian, X., Wang, H., Liu, Q., Medina, A., Rozelle, S. 2015; 30 (3): 322-333


    Over the past decade, China has implemented reforms designed to expand access to health care in rural areas. Little objective evidence exists, however, on the quality of that care. This study reports results from a standardized patient study designed to assess the quality of care delivered by village clinicians in rural China. To measure quality, we recruited individuals from the local community to serve as undercover patients and trained them to present consistent symptoms of two common illnesses (dysentery and angina). Based on 82 covert interactions between the standardized patients and local clinicians, we find that the quality of care is low as measured by adherence to clinical checklists and the rates of correct diagnoses and treatments. Further analysis suggests that quality is most strongly correlated with provider qualifications. Our results highlight the need for policy action to address the low quality of care delivered by grassroots providers.

    View details for DOI 10.1093/heapol/czu014

    View details for PubMedID 24653216

  • Combating HIV stigma in low- and middle-income healthcare settings: a scoping review. Journal of the International AIDS Society Smith, M. K., Xu, R. H., Hunt, S. L., Wei, C., Tucker, J. D., Tang, W., Luo, D., Xue, H., Wang, C., Yang, L., Yang, B., Li, L., Joyner, B. L., Sylvia, S. Y. 2020; 23 (8): e25553


    INTRODUCTION: Nearly 40years into the HIV epidemic, the persistence of HIV stigma is a matter of grave urgency. Discrimination (i.e. enacted stigma) in healthcare settings is particularly problematic as it deprives people of critical healthcare services while also discouraging preventive care seeking by confirming fears of anticipated stigma. We review existing research on the effectiveness of stigma interventions in healthcare settings of low- and middle-income countries (LMIC), where stigma control efforts are often further complicated by heavy HIV burdens, less developed healthcare systems, and the layering of HIV stigma with discrimination towards other marginalized identities. This review describes progress in this field to date and identifies research gaps to guide future directions for research.METHODS: We conducted a scoping review of HIV reduction interventions in LMIC healthcare settings using Embase, Ovid MEDLINE, PsycINFO and Scopus (through March 5, 2020). Information regarding study design, stigma measurement techniques, intervention features and study findings were extracted. We also assessed methodological rigor using the Joanna Briggs Institute checklist for systematic reviews.RESULTS AND DISCUSSION: Our search identified 8766 studies, of which 19 were included in the final analysis. All but one study reported reductions in stigma following the intervention. The studies demonstrated broad regional distribution across LMIC and many employed designs that made use of a control condition. However, these strengths masked key shortcomings including a dearth of research from the lowest income category of LMIC and a lack of interventions to address institutional or structural determinants of stigma. Lastly, despite the fact that most stigma measures were based on existing instruments, only three studies described steps taken to validate or adapt the stigma measures to local settings.CONCLUSIONS: Combating healthcare stigma in LMIC demands interventions that can simultaneously address resource constraints, high HIV burden and more severe stigma. Our findings suggest that this will require more objective, reliable and culturally adaptable stigma measures to facilitate meaningful programme evaluation and comparison across studies. All but one study concluded that their interventions were effective in reducing healthcare stigma. Though encouraging, the fact that most studies measured impact using self-reported measures suggests that social desirability may bias results upwards. Homogeneity of study results also hindered our ability to draw substantive conclusions about potential best practices to guide the design of future stigma reduction programmes.

    View details for DOI 10.1002/jia2.25553

    View details for PubMedID 32844580

  • Economic Implications of Chinese Diagnosis-Related Group-Based Payment Systems for Critically Ill Patients in ICUs. Critical care medicine Meng, Z., Ma, Y., Song, S., Li, Y., Wang, D., Si, Y., Sun, R., Zhang, R., Xue, H., Jing, L., Wu, H. 2020


    OBJECTIVES: To evaluate the economic implications of payments based on Chinese diagnosis-related groups for critically ill patients in ICUs in terms of total hospital expenditure, out-of-pocket payments, and length of stay.DESIGN: A pre-post comparison of patient cohorts admitted to ICUs 1 year before and 1 year after Chinese diagnosis-related group reform was undertaken. Demographic characteristics, clinical data, and medical expenditures were collated from a health insurance database.SETTING: Twenty-two public hospitals in Sanming, Southern China.PATIENTS: All patients admitted to ICUs from January 1, 2017, to December 31, 2018.INTERVENTION: The implementation of Chinese diagnosis-related group-based payments on January 1, 2018.MEASUREMENTS AND MAIN RESULTS: Economic variables (total expenditures, out-of-pocket payments, and length of stay) were calculated for each patient from the day of hospital admission to the day of hospital discharge. Adjusted mean out-of-pocket payment estimates were 29.46% (p < 0.001) lower following reform. Adjusted mean out-of-pocket payments fell by 41.32% for patients in neonatal ICU, whereas there were no significant decreases in out-of-pocket payments for patients in PICU and adult ICU. Furthermore, adjusted mean out-of-pocket payments decreased by 55.74% in secondary hospitals, but there was no significant change in tertiary hospitals after Chinese diagnosis-related group reform. No significant changes were found in total expenditures and length of stay.CONCLUSIONS: Chinese diagnosis-related group policy provided an opportunity for critically ill patients in ICUs to achieve at least short-term financial benefits in reducing out-of-pocket payments, without affecting the total expenditures and length of stay. Chinese diagnosis-related group-based payment significantly relieved financial burdens for patients with lower illness severities, such as patients in neonatal ICU. The results of this study can offer significant insights for policymakers in reducing the financial burden on critically ill patients, both in China and in other countries with similar systems.

    View details for DOI 10.1097/CCM.0000000000004355

    View details for PubMedID 32317597

  • Using standardised patients to assess the quality of medical records: an application and evidence from rural China. BMJ quality & safety Wu, Y., Zhou, H., Ma, X., Shi, Y., Xue, H., Zhou, C., Yi, H., Medina, A., Li, J., Sylvia, S. 2019


    BACKGROUND: Medical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries.OBJECTIVE: To provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China.METHODS: A sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records.RESULTS: Medical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider's income (beta 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (beta -0.87, 95% CI -1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness.CONCLUSION: Despite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.

    View details for DOI 10.1136/bmjqs-2019-009890

    View details for PubMedID 31776199

  • The academic performance of primary school students from rural China Distribution and correlates CHINA AGRICULTURAL ECONOMIC REVIEW Liu, H., Xue, H., Shi, Y., Rozelle, S. 2019; 11 (2): 253–79
  • How does physician gender influence primary care quality? evidence from a standardised patient audit study in China Xue, H., Liu, G., Shi, Y., Nie, J., Auden, E., Sylvia, S. ELSEVIER SCIENCE INC. 2018: 66
  • Drivers of inappropriate antibiotic prescriptions: a quasi-experimental study of antibiotic prescription by primary care providers in rural China Xue, H., Shi, Y., Huang, L., Yi, H., Zhou, H., Zhou, C., Kotb, S., Tucker, J. D., Sylvia, S. ELSEVIER SCIENCE INC. 2018: 40
  • The Quality of Tuberculosis Care in Urban Migrant Clinics in China INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Xue, H., Hager, J., An, Q., Liu, K., Zhang, J., Auden, E., Yang, B., Yang, J., Liu, H., Nie, J., Wang, A., Zhou, C., Shi, Y., Sylvia, S. 2018; 15 (9)


    Large and increasing numbers of rural-to-urban migrants provided new challenges for tuberculosis control in large cities in China and increased the need for high quality tuberculosis care delivered by clinics in urban migrant communities. Based on a household survey in migrant communities, we selected and separated clinics into those that mainly serve migrants and those that mainly serve local residents. Using standardized patients, this study provided an objective comparison of the quality of tuberculosis care delivered by both types of clinics and examined factors related to quality care. Only 27% (95% confidence interval (CI) 14⁻46) of cases were correctly managed in migrant clinics, which is significantly worse than it in local clinics (50%, 95% CI 28⁻72). Clinicians with a base salary were 41 percentage points more likely to demonstrate better case management. Furthermore, clinicians with upper secondary or higher education level charged 20 RMB lower out of pocket fees than less-educated clinicians. In conclusion, the quality of tuberculosis care accessed by migrants was very poor and policies to improve the quality should be prioritized in current health reforms. Providing a base salary was a possible way to improve quality of care and increasing the education attainment of urban community clinicians might reduce the heavy barrier of medical expenses for migrants.

    View details for PubMedID 30231511

  • Depressive Symptoms of Chinese Children: Prevalence and Correlated Factors among Subgroups INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Zhou, M., Zhang, G., Rozelle, S., Kenny, K., Xue, H. 2018; 15 (2)


    Economic growth and socioeconomic changes have transformed nearly every aspect of childhood in China, and many are worried by the increasing prevalence of mental health issues among children, particularly depression. To provide insight into the distribution of depressive symptoms among children in China and identify vulnerable groups, we use data from the 2012 China Family Panel Survey (CFPS), a survey that collected data from a large, nationally representative sample of the Chinese population. Using the CFPS data, we construct a sample of 2679 children aged 10-15 years old from 25 provinces in China. According to our results, the incidence of depression varies by geographic area. Specifically, we find that rates of depressive symptoms are significantly lower in urban areas (14% of sample children) than in rural areas (23% of sample children). Our results also show that children from ethnic minorities, from poorer families, and whose parents are depressed are more likely to be depressed than other children. In contrast, we find that depressive symptoms do not vary by gender.

    View details for PubMedID 29414881

  • Who are rural China's village clinicians? CHINA AGRICULTURAL ECONOMIC REVIEW Xue, H., Shi, Y., Medina, A. 2016; 8 (4): 662-676