Management of imported malaria cases and healthcare institutions in central China, 2012-2017: application of decision tree analysis.
BACKGROUND
Imported malaria has been an important challenge for China. Fatality rates from malaria increased in China, particularly in Henan Province, primarily due to malpractice and misdiagnoses in healthcare institutions, and the level of imported malaria. This study aims to investigate the relationship between the state of diagnosis and subsequent complications among imported malaria cases at healthcare institutions, based on malaria surveillance data in Henan Province from 2012 to 2017.


METHODS
A retrospective descriptive analysis was performed using data from the Centre for Disease Control and Prevention, Zhengzhou City, the capital of Henan Province. A decision tree method was exploited to provide valuable insight into the correlation between imported malaria cases and healthcare institutions.


RESULTS
From 2012 to 2017, there were 371 imported malaria cases, mostly in males aged between 20 and 50 years, including 319 Plasmodium falciparum cases. First visits of 32.3%, 19.9% and 15.9% malaria cases for treatment were to provincial, municipal and county healthcare institutions, respectively. The time interval between onset and initial diagnosis of 284 cases (76.5%) and the time interval between initial diagnosis and final diagnosis of 197 cases (53.1%) was no more than 72 h. An apparent trend was found that there were notably fewer patients misdiagnosed at first visit to healthcare institutions of a higher administrative level; 12.5% of cases were misdiagnosed in provincial healthcare institutions compared to 98.2% in private clinics, leading to fewer complications at healthcare institutions of higher administrative level due to correct initial diagnosis. In the tree model, the rank of healthcare facilities for initial diagnosis, and number of days between onset and initial diagnosis, made a major contribution to the classification of initial diagnosis, which subsequently became the most significant factor influencing complications developed in the second tree model. The classification accuracy were 82.2 and 74.1%, respectively for the tree models of initial diagnosis and complications developed.


CONCLUSION
Inadequate seeking medical care by imported malaria patients, and insufficient capacity to diagnose malaria by healthcare institutions of lower administrative level were identified as major factors influencing complications of imported malaria cases in Henan Province. The lack of connection between uncommon imported malaria cases and superior medical resources was found to be the crucial challenge. A web-based system combined with WeChat to target imported malaria cases was proposed to cope with the challenge.
['Wang|Xi-Liang|XL|', 'Cao|Jie-Bin|JB|', 'Li|Dan-Dan|DD|', 'Guo|Dong-Xiao|DX|', 'Zhang|Cheng-Da|CD|', 'Wang|Xiao|X|', 'Li|Dan-Kang|DK|', 'Zhao|Qing-Lin|QL|', 'Huang|Xiao-Wen|XW|', 'Zhang|Wei-Dong|WD|http://orcid.org/0000-0002-0314-7820']
D000293:Adolescent D000328:Adult D000368:Aged D002681:China D000076263:Communicable Diseases, Imported D003663:Decision Trees D005260:Female D006268:Health Facilities D006801:Humans D008288:Malaria D008297:Male D008875:Middle Aged D010961:Plasmodium D012189:Retrospective Studies D055815:Young Adult
Management Imported malaria Healthcare institutions Henan Diagnosis Complications