China's health system performance

Trends in hospitalization for female breast and gynecological cancer in China from 2004 to 2020

Breast and gynecological cancers are common cancers with high mortality and have profound effects on the various physical functions of women. This study assessed trends in the number of hospitalizations, in-hospital mortality, length of stay (LOS), and hospital charges for female breast and gynecological cancer from 2004 to 2020. The data for this study come from the China Health Statistics Yearbook. Time trends of categorical variables were assessed with the Cochran-Armitage Test. The linear model was used to test for the trend of continuous variables. The hospitalizations for breast cancer increased from 15,204 to 276,387 (P for trend < 0.001) and gynecological cancer increased from 12,418 to 214,956 (P for trend < 0.001). The in-hospital mortality rate due to breast cancer decreased from 1.70 to 1.07% (P for trend < 0.001). Hospitalizations for both breast and gynecological cancer increased clearly, whether in urban or rural. The gap between urban and rural has narrowed. The average cost per hospitalization for breast cancer significantly increased. However, the average LOS for breast cancer gradually decreased (from 17.0 to 10.7 days, P for trend < 0.001). The average cost per hospitalization for gynecological cancer increased significantly. However, this steady downward trend was observed in the average LOS for gynecological cancer (from 10.34 to 6.69 days, P for trend = 0.003). The increase in hospitalizations and medical expenses for breast and gynecological cancer should encourage healthcare policymakers and healthcare system stakeholders to develop more cost-effective approaches to women's cancer management.

Temporal trend in hospitalizations for malignant neoplasm and benign neoplasm: a nationwide study, China, 2004-2020

The increasing cancer burden calls for reliably assessed changes in the hospitalizations for tumors over time and space in China. This study evaluated trends in hospitalization rate, in-hospital mortality, length of stay (LOS), and medical costs for malignant and benign neoplasms. Data were derived from China Health Statistical Yearbooks from 2004 to 2020. Temporal trends in hospitalization rates and in-hospital mortality rates were assessed through the Cochran-Armitage Test. We used the linear model with continuous variables to test for the trend. The malignant neoplasm hospitalization rate increased from 1.1‰ to 5.8‰ and the benign neoplasm increased from 1.0‰ to 2.0‰. The in-hospital mortality rate due to malignant neoplasm and benign neoplasm decreased from 5.11 to 2.87% (P for trend < 0.001) and 0.14-0.01% (P for trend < 0.001), respectively. Among all patients hospitalized with malignant neoplasm, the average cost per hospitalization significantly increased during the study period (P for trend < 0.001), adjusted for the Consumer Price Index. However, the average LOS gradually decreased (P for trend < 0.001). In line with the trend of malignant neoplasm, the average cost per hospitalization increased significantly among all patients hospitalized for benign neoplasm (P for trend < 0.001), and the average LOS showed a steady downward trend (P for trend < 0.001). We found upward trends in hospitalization rates, and medical costs in neoplasms. By contrast, substantial decreases in in-hospital mortality and LOS. The hospitalization rate gap between urban and rural areas is narrowed.

Effects of the Implementation of Transport-Driven Poverty Alleviation Policy on Health Care-Seeking Behavior and Medical Expenditure Among Older People in Rural Areas: Quasi-Experimental Study

BACKGROUND

Improving the rural residents' accessibility to and affordability of health care is recognized as a common target globally. The Health in All Policies approach, from the Declaration of Helsinki to the United Nations' Decade Of Healthy Ageing, strengthened the far-reaching effect of large-scale public policies on health care-seeking behavior; however, the effects of national transport policy on health care-seeking behavior is unclear.

OBJECTIVE

This quasi-experimental study aimed to examine the effects of the implementation of transport-driven poverty alleviation (TPA) policy on health care-seeking behavior and medical expenditure among older adults in rural areas and the mechanism underlying these effects.

METHODS

We designed a quasi-experiment to estimate the effects of TPA policy implementation on health care-seeking behavior and medical expenditure among older adults in rural areas through a difference-in-differences (DID) analysis based on data from the China Health and Retirement Longitudinal Study in 2011, 2013, 2015, and 2018. The underlying mechanism was analyzed and effect modification patterns were further investigated by poor households, health status, and age.

RESULTS

Our findings validated a positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas. After the implementation of TPA policy, the number of inpatient visits increased by annually 0.35 times per person, outpatient medical expenditure increased by 192% per month, and inpatient medical expenditure increased by 57% annually compared with those of older adults in rural areas without the implementation of TPA policy. Further, there was a significant modification effect, with a positive effect among poor households, healthier older adults, and those aged 60-80 years. Additionally, the policy improved the patients' capabilities to seek long-distance care (β=23.16, 95% CI -0.99 to 45.31) and high-level hospitals (β=.08, 95% CI -0.02 to 0.13), and increased individual income to acquire more medical services (β=4.57, 95% CI -4.46 to 4.68).

CONCLUSIONS

These findings validate the positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas; however, the medical expenditure incurred was also high. Concerted efforts are needed to address health care-seeking dilemmas in rural areas, and attention must be paid to curbing medical expenditure growth for older adults in rural areas during TPA policy implementation.

National and subnational incidence, mortality and associated factors of colorectal cancer in China: A systematic analysis and modelling study

Background

Due to their known variation by geography and economic development, we aimed to evaluate the incidence and mortality of colorectal cancer (CRC) in China over the past decades and identify factors associated with CRC among the Chinese population to provide targeted information on disease prevention.

Methods

We conducted a systemic review and meta-analysis of epidemiolocal studies on the incidence, mortality, and associated factors of CRC among the Chinese population, extracting and synthesising data from eligible studies retrieved from seven global and Chinese databases. We pooled age-standardised incidence rates (ASIRs) and mortality rates (ASMRs) for each province, subregion, and the whole of China, and applied a joinpoint regression model and annual per cent changes (APCs) to estimate the trends of CRC incidence and mortality. We conducted random-effects meta-analyses to assess the effect estimates of identified associated risk factors.

Results

We included 493 articles; 271 provided data on CRC incidence or mortality, and 222 on associated risk factors. Overall, the ASIR of CRC in China increased from 2.75 to 19.39 (per 100 000 person-years) between 1972 and 2019 with a slowed-down growth rate (APC1 = 5.75, APC2 = 0.42), while the ASMR of CRC decreased from 12.00 to 7.95 (per 100 000 person-years) between 1974 and 2020 with a slight downward trend (APC = -0.89). We analysed 62 risk factors with synthesized data; 16 belonging to the categories of anthropometrics factors, lifestyle factors, dietary factors, personal histories and mental health conditions were graded to be associated with CRC risk among the Chinese population in the meta-analysis limited to the high-quality studies.

Conclusions

We found substantial variation of CRC burden across regions and provinces of China and identified several associated risk factors for CRC, which could help to guide the formulation of targeted disease prevention and control strategies.

Registration

PROSPERO: CRD42022346558.

Changes in Geographic Variation and Socioeconomic Inequalities in Esophageal Cancer Mortality in China, 1973-2017

BACKGROUND

Geographic variability in esophageal cancer has been reported in China, but data are lacking at the local level. We aimed to investigate changes in disparities in esophageal cancer-related mortality among Chinese counties and whether county-level socioeconomic status was associated with this variation.

METHODS

We used data from a nationwide survey and population-based cancer registries to calculate esophageal cancer-related mortality rates for 782 Chinese counties for the periods of 1973-1975 and 2015-2017. We performed hotspot analysis to identify spatial clusters. We used a multivariable negative binomial regression model to estimate the associations between county-level socioeconomic factors and mortality.

RESULTS

From 1973-1975 to 2015-2017, the age-standardized esophageal cancer-related mortality rate decreased from 27 to 8 per 100,000 person-years in China. By county, 577 (74%) of 782 counties experienced decreasing mortality. Geographic disparities in mortality substantially narrowed, with the gap in mortality rates between 90th and 10th percentile counties decreasing from 55 per 100,000 person-years in 1973-1975 to 16 in 2015-2017. However, clusters of elevated rates persisted across north-central China. Rurality [adjusted mortality rate ratio (MRR) 1.15; 95% confidence interval (CI), 1.10-1.21], per capita gross domestic product (adjusted MRR, 0.95; 95% CI, 0.91-0.98), and percentage of people with a high-school diploma (adjusted MRR, 0.86; 95% CI, 0.84-0.87) in a county were significantly associated esophageal cancer-related mortality rates.

CONCLUSIONS

China has made substantial progress in reducing esophageal cancer-related mortality and disparities, but the intercounty differences remain large.

IMPACT

Continued efforts are needed to address the geographical and socioeconomic disparities in esophageal cancer.

Equity and trends in general practitioners' allocation in China: based on ten years of data from 2012 to 2021

BACKGROUND

General practitioners (GP) are the gatekeepers of residents' health, 2021 is the 10th year of the establishment of the GP system in China. This study aims to assess the equity and trends of GP allocation in China from 2012 to 2021, summarize the efforts and progress of GPs in China during the decade, predict the development trend of GPs in mainland China in the next 5 years to provide a reference for regional health planning and rational allocation of GPs in China.

METHODS

Data from 2012 to 2021 on GPs in 22 provinces, 5 autonomous regions, and 4 municipalities directly under the central government in mainland China (excluding Hong Kong, Macao, and Taiwan) are collected by us. Gini coefficient, Lorenz curve and health resource agglomeration degree (HRAD) were used to analyze the equity of the allocation of GPs in China from different dimensions, a Grey prediction model was used to forecast the number of GPs in 2022-2026.

RESULTS

The number of GPs in mainland China increased from 109 794 to 434 868 from 2012 to 2021, with 3.08 GPs per 10 000 people in 2021. The Gini coefficient of GPs allocation by population in China decreased from 0.312 to 0.147 from 2012 to 2021, while the Gini coefficient of geographic dimension remained between 0.700 and 0.750. Compared with the degree of curvature of the Lorenz curve in the geographic dimension, the degree of curvature of the population and economic dimension were smaller. In 2021, the HRAD in the Eastern region was 4.618, the Central region was 1.493, with different degrees of imbalance among regions, the HRAD/PAD (population agglomeration degree) in the Eastern, Central and Western regions were 1.196, 0.880 and 0.821, respectively. GPs in the Eastern region is still concentrated, while the Central and Western regions were at a similar level, GPs were more scarce. The GM (1,1) model predicts that the number of GPs in mainland China will reach about 720 000 in 2026, the number of GPs per 10 000 people will reach 4.9.

CONCLUSION

After a decade of development, the number of GPs in China has increased significantly. It has reached the goal of the GP system when it was first established. However, the equity of the geographical dimension, both in terms of Gini coefficient and HRAD, has great differences between different regions. The average Gini coefficient at the geographic dimension is 0.723. The average HRAD index was 4.969 in the East and 0.293 in the West. The Western region has the problem of insufficient GP allocation in both population and geographical dimension. In the future, the number of GPs in China will continue to grow rapidly with the support of policies. The "2030" goal, proposed in 2018, is expected to be achieved by 2026. Due to certain factors (such as COVID-19), the actual situation may be different from the predicted results.

Trends in care quality in China from 2011 to 2017: An analysis based on the National Specific (Single) Disease Monitoring System

Background

The Ministry of Health of China conducted a study targeting in single-disease quality control in 2009, aimed to strengthen quality management and improve health care services. This study retrospectively investigated the trends of quality indicators for six monitored diseases 2011-2017 to evaluate the improvement of care quality for the first batch of single-disease.

Methods

We extracted data from the National Specific (Single) Disease Monitoring System for 2011-2017. We focused on six conditions: acute myocardial infarction, heart failure, community-acquired pneumonia, coronary artery bypass graft, hip / knee replacement, and acute ischemic stroke. A total of 56 quality indicators (QIs) were adopted to monitor the quality change and determine the trends in care quality. We also calculated the hospital process composite performance (HPCP) using a denominator-based weighting method for each hospital per year. The estimated annual percentage changes (EAPC) 2011-2017 were calculated at national and regional levels.

Results

The results showed that use of four QIs had significant downward trends, whereas 25 QIs (including reversed indicators) showed significant upward trends from 2011 to 2017. The greatest improvement was observed in CAP-4 (antibiotic treatment within four hours after admission to the hospital for critical pneumonia) in the central region (EAPC = 48.36, 95% CI = 15.92-89.87); while the largest decrease appeared in AIS-1 (thrombolytic therapy within 4.5 hours of symptom onset) in the western region (EAPC = -13.44, 95% CI = -24.98,-0.11). An increased HPCP was observed in four diseases nationwide, but not for acute myocardial infarction and heart failure. However, there were significant differences across regions in the process of care and outcomes, with the performance of Eastern and Western regions showing remarkable advantages compared with the Central region.

Conclusions

We provide evidence for major advancement in care quality in China nationwide. However, the improvement of care in China was unbalanced geographically and should be carefully considered. Future challenges include expanding the coverage of quality monitoring, greater delivery efficiency, and region-balanced health care.

The Mediation Effect of Perceived Attitudes toward Medical Service on the Association between Public Satisfaction with the Overall Medical Service and Self-Rated Health among the General Population in China: A Cross-Sectional Study

This study aimed to examine the association between public satisfaction with the overall medical service and individuals' self-rated health among 18,852 Chinese adults aged 16-60 years by using data from the 2018 China Family Panel Studies. We further test whether such an association is mediated by perceived attitudes toward the medical service. The logistic regression model is used to explore the association between public satisfaction with the overall medical service and individuals' self-rated health (SRH) outcomes. Mediation analysis was conducted by using the Karlson-Holm-Breen (KHB) method. We found that public satisfaction with the overall medical service was associated with good SRH. Additional results indicated that the association between public satisfaction with the overall medical service and SRH was significantly mediated by perceived attitudes toward the medical service. The degree of mediation is much larger for individuals' satisfaction with the level of medical expertise than for trusting in doctors, attitudes toward medical service problems, and the attitude toward the level of the hospital. Targeted medical policy interventions are designed to promote individuals' perceived attitudes toward the medical service, which might help to improve individuals' health benefits.

Provincial variations in catastrophic health expenditure and medical impoverishment in China: a nationwide population-based study

Background

Financial protection, as a key dimension of Universal Health Coverage (UHC), has been under increasing attention in recent years. A series of studies have examined the nationwide extent of catastrophic health expenditure (CHE) and medical impoverishment (MI) in China. However, disparities in financial protection at the province level have rarely been studied. The aim of this study was to investigate provincial variations in financial protection as well as its inequality across provinces.

Methods

Using data from the 2017 China Household Finance Survey (CHFS), this study estimated the incidence and intensity of CHE and MI for 28 Chinese provinces. Ordinary least square (OLS) estimation, using robust standard errors, was used to explore the factors associated with financial protection at the province level. Moreover, this study examined the urban-rural differences in financial protection within each province, and calculated the concentration index of CHE and MI indicators for each province using household income per capita.

Findings

The study revealed large provincial variations in financial protection within the nation. The nationwide CHE incidence was 11.0% (95% CI: 10.7%, 11.3%), ranging from 6.3% (95% CI: 5.0%, 7.6%) in Beijing to 16.0% (95% CI: 14.0%, 18.0%) in Heilongjiang; the national MI incidence was 2.0% (95% CI: 1.8%, 2.1%), ranging from 0.03% (95% CI: 0.00%, 0.06%) in Shanghai to 4.6% (95% CI: 3.3%, 5.9%) in Anhui province. We also found similar patterns for provincial variations in intensity of CHE and MI. Moreover, substantial provincial variations in income-related inequality and urban-rural gap existed across provinces. Eastern developed provinces in general had much lower inequality within them, compared with central and western provinces.

Interpretation

Despite the great advances towards UHC in China, substantial provincial variations exist in financial protection across provinces. Policymakers should pay special attention to low-income households in central and western provinces. Provision of better financial protection for these vulnerable groups will be key to achieving UHC in China.

Funding

This research was supported by the National Natural Science Foundation of China (Grant Number: 72074049) and the Shanghai Pujiang Program (2020PJC013).

How to promote the hierarchical diagnosis and treatment system: A tripartite evolutionary game theory perspective

Due to the disorderly access to medical care and inefficient use of health resources, the advancement of the hierarchical diagnosis and treatment is more valued in promoting health system reform. Hence, this article integrates prospect theory into an evolutionary game model of the local government health departments, the medical institutions, and the patients in the system promotion of the hierarchical diagnosis and treatment. The simulation shows the specific influencing mechanism of the psychological perceived value of game subjects. Then by introducing the stochastic evolutionary game model, the system promotion under different medical cultures is also discussed in detail. The results indicate that for local government health departments, the amount and duration of financial subsidies are the key factors influencing the game system's evolution. For medical institutions, participating in the hierarchical diagnosis and treatment system is relatively beneficial. For patients, the recovery rate in primary hospitals matters more than the cost of treatment. Changes in the risk sensitivity coefficient will cause the equilibrium of the game system to change. However, changes in the loss avoidance factor do not change the equilibrium and only have an impact on the speed of convergence. With the health departments' intervention, patients in rural medical culture are more inclined to support the hierarchical diagnosis and treatment system than those in urban or town medical culture. Therefore, in order to promote the hierarchical diagnosis and treatment system, this article recommends that more attention should be paid to the regulatory role of health departments and the participation improvement of medical institutions and patients.

Factors Associated with Telemedicine Services Provision for Sexually Transmitted Disease Diagnosis and Treatment Among Dermatologists: Evidence from China

BACKGROUND

Telemedicine has experienced rapid growth in China, with wide applications for chronic disease management.

OBJECTIVE

This study examined a unique survey dataset to identify the provision of telemedicine services by dermatologists, and to explore its association with physician characteristics, perception of diagnosis, and physicians' perceptions of the advantages and disadvantages of telemedicine.

MATERIALS AND METHODS

Responses to an anonymous voluntary questionnaire were collected from 238 dermatologists in Zhejiang Province, China, via a mixed mode of online and in-person data collection. Data were analyzed using Stata 16.0. Empirical analyses utilized descriptive statistics and multivariable logistical regression.

RESULTS

Among a total of 238 physicians, 34.9% provided telemedicine services. Results from the multivariable logistic regression indicated that, if physicians can use their spare time to help patients, seniority and their perception of the benefit of telemedicine are the two most important factors determining their likelihood of providing telemedicine services among the studied sample.

CONCLUSION

Telemedicine holds great promise, but its practices need to be more efficient to save time and reduce the risk of misdiagnosis so that more physicians may participate.

Is There Always a Negative Causality between Human Health and Environmental Degradation? Current Evidence from Rural China

This study explores the incidence and trend of zoonoses in China and its relationship with environmental health and proposes suggestions for promoting the long-term sustainable development of human, animal, and environmental systems. The incidence of malaria was selected as the dependent variable, and the consumption of agricultural diesel oil and pesticides and investment in lavatory sanitation improvement in rural areas were selected as independent variables according to the characteristics of nonpoint source pollution and domestic pollution in China's rural areas. By employing a fixed effects regression model, the results indicated that the use of pesticides was negatively associated with the incidence of malaria, continuous investment in rural toilet improvement, and an increase in economic income can play a positive role in the prevention and control of malaria incidence. Guided by the theory of One Health, this study verifies human, animal, and environmental health as a combination of mutual restriction and influence, discusses the complex causal relationship among the three, and provides evidence for sustainable development and integrated governance.

Evidence for an expanded hypertension care cascade in low- and middle-income countries: a scoping review

Background

With nearly 90% of annual hypertension-related deaths occurring in low- and middle-income countries (LMICs), there is an urgent need to measure the coverage of health services that effectively manage hypertension. However, there is little agreement on how to define effective coverage and the existing hypertension care cascade (hypertension prevalence, percent aware, percent treated, and percent controlled) does not account for the quality of care received by patients. This study reviews definitions of effective coverage and service quality for hypertension management services and proposes an expanded hypertension care cascade to improve measurement of health systems performance.

Methods

A systematic scoping review of literature published in six electronic databases between January 2000 and October 2020 identified studies that defined effective coverage of hypertension management services or integrated dimensions of service quality into population-based estimates of hypertension management in LMICs. Findings informed an expanded hypertension care cascade from which quality-adjusted service coverage can be calculated to approximate effective coverage.

Results

The review identified 18 relevant studies, including 6 that defined effective coverage for hypertension management services and 12 that reported a measure of service quality in a population-based study. Based on commonly reported barriers to hypertension management, new steps on the proposed expanded care cascade include (i) population screened, (ii) population linked to quality care, and (iii) population adhering to prescribed treatment.

Conclusion

There is little consensus on the definition of effective coverage of hypertension management services, and most studies do not describe the quality of hypertension management services provided to populations. Incorporating aspects of service quality to the hypertension care cascade allows for the calculation of quality-adjusted coverage of relevant services, enabling an appropriate measurement of health systems performance through effective coverage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08190-0.

Self-Reported Sleep Characteristics Associated with Cardiovascular Disease Among Older Adults Living in Rural Eastern China: A Population-Based Study

Purpose

To investigate the cross-sectional associations of self-reported sleep characteristics with cardiovascular diseases (CVDs) and cardiovascular multimorbidity in older adults living in rural Eastern China.

Patients and Methods

This population-based study included 4618 participants (age ≥65 years; 56.5% women) living in rural Eastern China. In March–September 2018, data were collected through interviews, clinical examinations, neuropsychological testing, and laboratory tests. Sleep parameters were assessed using the Pittsburgh Sleep Quality Index, Epworth Sleepiness Score, and Berlin questionnaire. Coronary heart disease (CHD), heart failure (HF), and stroke were defined according to in-person interviews, clinical and neurological examinations, and electrocardiogram examination. Data were analyzed using logistic regression and restricted cubic spline regression.

Results

CHD was diagnosed in 991 participants, HF in 135 participants, and stroke in 696 participants. The multivariable-adjusted odds ratio (OR) of CHD was 1.27 (95% CI, 1.09–1.49) for sleep duration ≤6 hours/night (vs >6–8 hours/night), 1.40 (1.20–1.62) for poor sleep quality, and 1.22 (1.04–1.43) for high risk for obstructive sleep apnea (OSA). The OR of HF was 2.16 (1.38–3.39) for sleep duration >8 hours/night, and 1.76 (1.22–2.54) for high risk for OSA. In addition, the OR of stroke was 1.23 (1.04–1.46) for poor sleep quality, 1.32 (1.01–1.72) for excessive daytime sleepiness, and 1.42 (1.19–1.70) for high risk for OSA. The associations of poor sleep with cardiovascular multimorbidity (≥2 CVDs) were stronger than that of sleep problems with a single CVD.

Conclusion

Extreme sleep duration, high risk for OSA, and other sleep problems were associated with CVDs, especially cardiovascular multimorbidity.

The Impact of Multidimensional Health Levels on Rural Poverty: Evidence from Rural China

Poor health and poverty interact and restrict each other. While this relationship is acknowledged, little is known about the extent of its impact. By integrating multisource data, this study used spatial econometric models to quantitatively reveal the relationship between health and rural poverty and explore its intrinsic mechanisms. The results indicated that health-care system input, individual health status, and individual health-seeking behavior have a significantly positive effect on the eradication of rural poverty. The health-care system input is characterized by spatial spillover, significantly contributing to rural poverty alleviation in the region and neighboring regions, as well. However, the effect of health-care system services’ capability was negative. Thus, it is necessary to increase investment in the health-care system and pay attention to both the health status and healthy behaviors of rural residents. Moreover, further effort should be given to the supply-side reform of health services as a breakthrough point.

Evaluation of the development ability of medical association based on evidential reasoning and prospect theory

China has proposed medical couplet body to alleviate residents’ difficulties in seeking medical treatment, and the future development ability of medical couplet body has gradually become a research interest. On the basis of prospect theory, this study constructs a comprehensive evaluation index system with qualitative and quantitative indexes, clear hierarchy, and diverse attribute characteristics. The development ability of medical couplet body is also comprehensively and systematically evaluated. In addition, the evidential reasoning method is proposed on the basis of the equivalent transformation of prospect value. Furthermore, the validity and feasibility of the model are proven through experiments, and the influence of decision makers’ risk attitude on the evaluation results is discussed.

The effects of health system reform on medical services utilization and expenditures in China in 2004-2015

Background

In 2009, China began to implement new health system reform aimed at reducing the financial burden of patients. This study aimed to compare changes in the utilization of medical services and expenditures in different groups from 2004 to 2015.

Methods

Pooled cross-sectional data from 2004 to 2015 from the China Health and Nutrition Survey Database were used to conduct a segmental linear regression to estimate changes in the medical expenditures of different groups before and after implementation of the reform.

Results

During the reform process, the utilization rate of outpatient healthcare, primary health services and hospital health services showed a trend of increasing first and then decreasing slightly. The frequency of residents using inpatient services increased after the reform. The average medical expenditures increased significantly, especially for uninsured and primary health services users.

Conclusions

China's new round of health reform increased the coverage rate of basic medical insurance. Medical insurance has controlled the growth of the average medical expenditures; nevertheless, the average medical expenditures per patient has shown a continuous upward trend. Consequently, both basic medical insurance funds and residents face greater economic burdens and financial risks. Effective methods of controlling the growth of medical expenditures are therefore required.

Incidence and prevalence of moyamoya disease in urban China: a nationwide retrospective cohort study

BACKGROUND AND OBJECTIVE

Moyamoya disease (MMD) is an increasingly recognised cause of stroke, mainly described in East Asia. China is the largest nation in Asia, but few studies reported the epidemiology of MMD, especially at a national level. We aimed to estimate the incidence and prevalence of MMD in China.

METHODS

We performed a population-based study using data from the national databases of Urban Basic Medical Insurance between 2013 and 2016, covering approximately 0.50 billion individuals. MMD cases were identified by diagnostic code (International Classification of Diseases, 10th Revision I67.5) or related diagnostic text.

RESULTS

A total of 1987 MMD patients (mean age 44.45±14.30 years, female-to-male ratio 1.12) were identified, representing a national crude incidence of 0.59 (95% CI: 0.49 to 0.68) and a prevalence of 1.01 (95% CI: 0.81 to 1.21) per 100 000 person-years in 2016. Rates were higher in females than in males for the incidence (0.66 vs 0.52) and prevalence (1.05 vs 0.90). And the age-specific rates showed a bimodal distribution, with the highest peak in middle-aged group and the second peak in child group.

CONCLUSIONS

Our results confirm that MMD is relatively common in East Asians, but the rates in China were lower than those in other East Asian countries such as Japan and Korea. The unique epidemiological features, including a relatively weak female predominance and a shift in the highest peak of incidence from children to adults, revealed new sight into MMD. Further research is expected to explore the potential pathogenesis of MMD.

Use of Cardiovascular Drugs for Primary and Secondary Prevention of Cardiovascular Disease Among Rural-Dwelling Older Chinese Adults

Cardiovascular risk factors and related disorders are common among older adults, and use of various classes of cardiovascular (CV) drugs could reduce the risk of cardiovascular disease (CVD). However, data are sparse with regard to the use of CV drugs among rural-dwelling older adults in China. Therefore, this population-based study aimed to describe use of CV drugs among older adults living in the rural communities in China, while taking into account the use of CV drugs for primary and secondary prevention of CVDs. This study included 5,246 participants (age ≥65 years; 57.17% women; 40.68% illiteracy) in the baseline examination of the MIND-China study. In March-September 2018, data on health-related factors, CVDs (ischemic heart disease, atrial fibrillation, heart failure, and stroke), and CV drug use were collected via face-to-face survey, clinical examination, and laboratory tests. We classified CV drugs according to the Anatomical Therapeutic Chemical classification system for western medications and specific cardiovascular effects for the products of traditional Chinese medicine (TCM). We conducted descriptive analysis. The overall prevalence of major cardiovascular risk factors ranged from 14.30% in diabetes and 23.81% in dyslipidemia to 66.70% in hypertension, and CVDs affected 35.07% of all participants (36.28% in women vs. 33.47% in men, p = 0.035). In the total sample, calcium channel blockers (C08) were most commonly used (10.39%), followed by TCM products (7.64%), hypoglycemic agents (A10, 4.73%), renin-angiotensin system (RAS)-acting agents (C09, 4.61%), and lipid-lowering agents (C10, 4.17%). The proportions of CV drugs for primary prevention (i.e., use of CV drugs among people without CVD) were 3.14% for antithrombotic agents (mainly aspirin), 1.38% for lipid-lowering agents, and 3.11% for RAS-acting agents; the corresponding figures for secondary prevention (i.e., use of CV drugs among people with CVD) were 13.97%, 9.35%, and 7.39%. In conclusion, despite highly prevalent cardiovascular risk factors and CVDs, a fairly low proportion of the rural-dwelling older adults take CV medications for primary and secondary prevention. Notably, TCM products are among the most commonly used CV drugs. These results call for additional efforts to promote implementation of the evidence-based recommendations for prevention of CVDs in the primary care settings.

Rural and urban differences in health system performance among older Chinese adults: cross-sectional analysis of a national sample

Background

Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China.

Method

We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain.

Findings

Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64).

Conclusion

Our findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities.

Health System Outcomes in BRICS Countries and Their Association With the Economic Context

The aim of the article is to compare health system outcomes in the BRICS countries, assess the trends of their changes in 2000−2017, and verify whether they are in any way correlated with the economic context. The indicators considered were: nominal and per capita current health expenditure, government health expenditure, gross domestic product (GDP) per capita, GDP growth, unemployment, inflation, and composition of GDP. The study covered five countries of the BRICS group over a period of 18 years. We decided to characterize countries covered with a dataset of selected indicators describing population health status, namely: life expectancy at birth, level of immunization, infant mortality rate, maternal mortality ratio, and tuberculosis case detection rate. We constructed a unified synthetic measure depicting the performance of individual health systems in terms of their outcomes with a single numerical value. Descriptive statistical analysis of quantitative traits consisted of the arithmetic mean (xsr), standard deviation (SD), and, where needed, the median. The normality of the distribution of variables was tested with the Shapiro–Wilk test. Spearman's rho and Kendall tau rank coefficients were used for correlation analysis between measures. The correlation analyses have been supplemented with factor analysis. We found that the best results in terms of health care system performance were recorded in Russia, China, and Brazil. India and South Africa are noticeably worse. However, the entire group performs visibly worse than the developed countries. The health system outcomes appeared to correlate on a statistically significant scale with health expenditures per capita, governments involvement in health expenditures, GDP per capita, and industry share in GDP; however, these correlations are relatively weak, with the highest strength in the case of government's involvement in health expenditures and GDP per capita. Due to weak correlation with economic background, other factors may play a role in determining health system outcomes in BRICS countries. More research should be recommended to find them and determine to what extent and how exactly they affect health system outcomes.

The trends of mortality and years of life lost of cancers in urban and rural areas in China, 1990-2017

Background

With the rapid development of the socioeconomic status, the mortality of several cancers has been changed in China during the past 30 years. We aimed to estimate the trends of mortality and years of life lost (YLLs) of various cancers in urban and rural areas of China from 1990 to 2017.

Methods

The mortality data were collected from Chinese yearbooks and the age structure of population from the Chinese sixth population census were used as reference to calculate age‐standardized mortality rates (ASMRs) and YLLs rates. Joinpoint regression analysis was implemented to calculate the annual percent change (APC) of mortality rates and YLL rates for cancers. YLLs owing to premature death were calculated as age‐specific cancer deaths multiplied by the reference life expectancy at birth of 80 years for male and 82.5 years for female.

Results

The ASMRs of all cancers showed significant decreasing trends for urban residents from 1990 to 2017, such downward trend without significance was also observed among rural residents. Interestingly, ASMRs of lung cancer and breast cancer have raised continuously in rural areas since 1990. The age‐standardized YYL rates for urban and rural residents decreased with 1.02% and 0.85% per year, respectively. YLLs in rural areas were higher than those in urban areas, whereas YLLs of urban outstripped those of rural finally with the increasing in YLLs of urban areas (216.71% for men and 207.87% for women).

Conclusion

The ASMRs and YLL rates of all cancers have declined in urban and rural areas from 1990 to 2017. YLLs increased in urban areas and remained higher level in rural areas after 2014 year. Preventive measures should be strengthened to against cancer, especially for lung cancer.

Birth weight charts for a Chinese population: an observational study of routine newborn weight data from Chongqing

Background

To construct birth weight charts for the Chongqing municipality, China and to identify whether differences in birth weight exist across urban/rural populations, thereby warranting separate charts.

Methods

Secondary analysis of routinely collected data from 338,454 live infants between 2014 and 2017 in Chongqing municipality. Sex-specific birth weight-for-gestational age centiles were constructed by the lambda-mu-sigma method via the GAMLSS R-based package. This method remodels the skewed birth weight distribution to estimate a normal distribution, allowing any birth weight centile to be generated. A separate set of centiles were created, accounting for urban/rural differences in birth weight.

Results

The centiles performed well across all gestational ages. For example, 2.37% (n = 4176) of males and 2.26% (n = 3656) of females were classified as below the 2nd centile (expected percentage = 2.28%), 49.75% of males (n = 87,756) and 50.73% of females (n = 82,203) were classified as below the 50th centile (expected proportion = 50%) and 97.52% of males (n = 172,021) and 97.48% of females (n = 157,967) were classified as below the 98th centile (expected proportion = 97.72%). The overall estimated centiles of birth weight for rural infants were higher than the centiles for urban infants at the earlier gestational ages (< 37 gestational weeks). However, this trend was reversed in infants born at term.

Conclusion

We have constructed a readily utilizable set of birth weight references from a large representative sample of births in Chongqing. The method used to construct the references allows for the calculation of the exact centile for any infant delivered between 28 and 42 completed weeks, which was not possible with previous charts.

Spatiotemporal Distribution of Tuberculosis during Urbanization in the New Urban Area of Nanchang City, China, 2010-2018

Background: Urbanization will play a key role in ending the tuberculosis (TB) epidemic by 2030, but understanding the relationship between urbanization and the health threats posed by TB is incomplete. Therefore, this study aimed to explore the spatiotemporal distribution of TB at the township level during urbanization in the new urban area of Nanchang. Methods: Seasonal-trend decomposition of time series analysis was used to explore the seasonal distribution and trend analysis. Global and local spatial autocorrelation statistics, and space–time scan statistics were performed to detect the spatiotemporal clusters of TB cases in the new urban area of Nanchang from 2010 to 2018. Results: A total of 3245 TB cases were reported in the study area from 2010 to 2018. Of all the TB cases, 68% occurred in individuals older than 40 years old, 73.2% were male cases, and 56.6% were farmers. The primary seasonal peak was in late spring (April), and a smaller peak was in early autumn (September). The results of local indicators of spatial association showed that Jiaoqiao town and Changleng town might be “High–High” clusters. The most likely spatiotemporal cluster was located in the southwest of the study area in 2010, which included five towns, and then shifted to the northeast gradually. Across 2010 to 2018, nine spatiotemporal clusters were identified. The most likely cluster was located at the northeast of the study area. The center of this area was in Nanji town with a circle radius of 43.74 kilometers. Conclusions: The spatial clusters of TB incidence shifted to the rural region and the fringe of the new urban area of Nanchang. Targeted management strategies for urban migrants in the process of urbanization should be strengthened.

Examining the Multi-Scalar Unevenness of High-Quality Healthcare Resources Distribution in China

Healthcare disparity is, to a large extent, ascribable to the uneven distribution of high-quality healthcare resources, which remains insufficiently examined, largely due to data unavailability. To overcome this barrier, we synthesized multiple sources of data, employed integrated methods and made a comprehensive analysis of government administrative structures and the socio-economic environment to build probably the most inclusive dataset of Chinese 3-A hospitals thus far. Calibrated on a sample of 379 hospitals rated by a reputable organization, we developed a realistic and viable evaluation framework for assessing hospital quality in China. We then calculated performance scores for 1246 3-A hospitals, which were aggregated and further analyzed at multiple scales (cities, provinces, regions, and economic zones) using general entropy indexes. This research shows that the fragmented governance and incoordination of "kuai" and "tiao" is rooted deeply in China's legacy of centrally-planned systems, and has had a far-reaching yet partially contradictory influence over the contemporary distribution and performance of healthcare resources. Additionally, the unevenness in the distribution of healthcare resources is related closely to a city's administrative rank and power. This study thus suggests that the policy design of healthcare systems should be coordinated with external socio-economic transformation in a sustainable manner.

The impact of the health care workforce on under-five mortality in rural China

BACKGROUND

Previous studies have focused on the relationship between increases in the health care workforce and child health outcomes, but little is known about how this relationship differs in contexts where economic growth differs by initial level and pace. This study evaluates the association between increased health professionals and the under-five mortality rate (U5MR) in rural Chinese counties from 2008 to 2014 and examines whether this relationship differs among counties with different patterns of economic growth over this period.

METHODS

We estimated fixed effects models with rural counties as the unit of analysis to evaluate the association between health professional density and U5MR. Covariates included county-level gross domestic product (GDP) per capita, female illiteracy rate, value of medical equipment per bed, and province-level health expenditures (measured as a proportion of provincial GDP). To explore modification effects, we assessed interactions between health professionals and county types defined by county poverty status and county-level trajectories of growth in GDP per capita. U5MR data have been adjusted for county-level underreporting, and all other data were obtained from administrative and official sources.

RESULTS

The U5MR dropped by 36.19% during the study period. One additional health professional per 1000 population was associated with a 2.6% reduction in U5MR, after controlling for other covariates. County poverty status and GDP trajectories moderated this relationship: the U5MR reductions attributed to a one-unit increase in health professionals were 6.8% among poor counties, but only 1.1% among non-poor ones. These reductions were, respectively, 6.7%, 0.7%, and 4.3% in counties with initially low GDP that slowly increased, medium-level GDP that rose at a moderate pace, and high GDP that rose rapidly.

CONCLUSIONS

This study demonstrates that increased health professionals were associated with reductions in U5MR. The largest association was seen in poor counties and those with low and slowly increasing GDP per capita, which justifies further expansion of the health care workforce in these areas. This study could be instructive for other developing countries to achieve Sustainable Development Goal 3 by helping them identify where additional health professionals would make the greatest contribution.

Effective coverage as a new approach to health system performance assessment: a scoping review

Background

Delivering interventions is the main task of health systems whose accurate measurement is an essential input into tracking performance. Recently, the concept of effective coverage was introduced by World Health Organization to incorporate into health system performance assessment. The aim of present scoping review was mapping the key elements and steps of effective coverage assessment in practical efforts including kinds of interventions, criteria for selecting them and the need, use and quality estimation approaches and strategies of each intervention.

Methods

We conducted a scoping review of health system/program assessments which assessed effective coverage till May 2017. Seven databases were systematically searched with no time and language restriction through applying combined keyword of “effective coverage”.

Results

Eighteen studies contributed findings on monitoring effective coverage of health interventions and they all were included in the review. Only 4 contributed findings on health system and the others were related to specific intervention(s) assessment. The interventions monitored by effective coverage were mainly in child health, prenatal and antenatal care and delivery, and chronic conditions areas. Potential impact on the burden of disease, leading causes of mortality and morbidity, and high occurrence and prevalence rate were among the main intervention selection criteria. Availability of data was the critical prerequisite, especially, in all of the studies applied ex post approach in estimating effective coverage. Estimation based on a norm, self- reporting from surveys and biomarkers were the main strategies and methods of need, utilization and quality measurement, respectively.

Conclusions

More studies are needed to contribute to the ongoing improvement in the development of effective coverage concept and increasing practical efforts, especially through defining prospective approaches and strategies into estimation of composite measures based on the effective coverage framework. Also, further attention needs to be paid to quality measures of effective coverage in a manner that better conceptualizes and measures the connection between coverage rates and interventions’ effectiveness. At the administrative system level, more innovation is needed to develop data systems in order to enhance capacity of routine health service information.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3692-7) contains supplementary material, which is available to authorized users.

Secular change in the association between urbanisation and abdominal adiposity in China (1993-2011)

BACKGROUND

Little attention has been paid to how the association between urbanisation and abdominal adiposity changes over the course of economic development in low-income and middle-income countries.

METHODS

Data came from the China Health and Nutrition Survey waves 1993-2011 (seven waves). A mixed linear model was used to investigate the association between community-level urbanisation with waist-to-height ratio (WHtR; an indicator of abdominal adiposity). We incorporated interaction terms between urbanisation and study waves to understand how the association changed over time. The analyses were stratified by age (children vs adults).

RESULTS

Adult WHtR was positively associated with urbanisation in earlier waves but became inversely associated over time. More specifically, a 1 SD increase in the urbanisation index was associated with higher WHtR by 0.002 and 0.005 in waves 1993 and 1997, while it was associated with lower WHtR by 0.001 in 2011. Among child participants, the increase in WHtR over time was predominantly observed in more urbanised communities.

CONCLUSION

Our study suggests a shift in adult abdominal adiposity from more urbanised communities to less urbanised communities over a time of rapid economic development in China. Children living in more urbanised communities had higher increase in abdominal obesity with urbanisation over time relative to children living in less urbanised communities.

Estimating benefit equity of government health subsidy in healthcare Services in Shandong Province, China: a cross-sectional study

Background

Government health subsidy (GHS) is an effective tool to improve population health in China. Ensuring an equitable allocation of GHS, particularly among the poorer socio-economic groups, is a major goal of China’s healthcare reform.

The paper aims to explore how GHS was allocated across different socioeconomic groups, and how well the overall health system was performing in terms of the allocation of subsidy for different types of health services.

Methods

Data from China’s National Health Services Survey (NHSS) in 2013 were used. Benefit incidence analysis (BIA) was applied to examine if GHS was equally distributed across income quintile. Benefit incidence was presented as each quintile’s percentage share of total benefits, and the concentration index (CI) and Kakwani index (KI) were calculated. Health benefits from three types of healthcare services (primary health care, outpatient and inpatient services) were analyzed, separated into urban and rural populations. In addition, the distribution of benefits was compared to the distribution of healthcare need (measured by self-reported illness and chronic disease) across income quintiles.

Results

In urban populations, the CI value of GHS for primary care was negative. (− 0.14), implying an allocation tendency toward poor region; the CI values of outpatient and inpatient services were both positive (0.174 and 0.194), indicating allocation tendencies toward rich region. Similar allocation pattern was observed in rural population, with pro-poor tendency of primary care service (CI = − 0.082), and pro-rich tendencies of outpatient (CI = 0.153) and inpatient services (CI = 0.203). All the KI values of three health services in urban and rural populations were negative (− 0.4991,-0.1851 and − 0.1651; − 0.482, − 0.247and − 0.197), indicating that government health subsidy was progressive and contributed to the narrowing of economic gap between the poor and rich.

Conclusions

The inequitable distribution of GHS in China exited in different healthcare services; however, the GHS benefit is generally progressive. Future healthcare reforms in China should not only focus on expanding the coverage, but also on improving the equity of distribution of healthcare benefits.

Comparison of outcomes in emergency department patients with suspected cardiac chest pain: two-centre prospective observational study in Southern China

BACKGROUND

Hong Kong (HK) and Guangzhou (GZ) are cities in China with different healthcare systems. This study aimed to compare 30-day and 6-month mortality and characteristics of patients with suspected cardiac chest pain admitted to two emergency departments (ED) in HK and GZ.

METHODS

A prospective observational study enrolled patients with suspected cardiac chest pain presenting to EDs in the Prince of Wales Hospital (PWH), HK and the Second Affiliated Hospital of Guangzhou Medical University (AHGZMU),GZ. The primary outcome was 30-day and 6-month mortality.

RESULTS

In total, 996 patients were recruited, 407 cases from GZ and 589 cases from HK.The 30-day and 6-month mortality of chest patients were 3.7% and 4.7% in GZand 0.3% and 1.9% in HK, respectively. Serum creatinine level (Cr) was an independent factor for 30-day mortality whilst Cr and systolic blood pressure (SBP) were independent factors for 6-month mortality. In Cox regression analysis, unadjusted and adjusted hazard ratios for 30-day and 6-month mortality in GZ were significantly increased.

CONCLUSION

The 30-day and 6-month mortality of patients with suspected cardiac chest pain in Guangzhou were higher than in Hong Kong due to due to different baseline clinical characteristics of patients and different distributions of diagnoses, which were associated with different healthcare systems. Serum creatinine and SBP were independent factors for 30-day and 6-month mortality.

A social change perspective on injury prevention in China

INTRODUCTION

China has undergone massive social change over the past four decades. Since national estimates became available in 1987, the overall fatal injury rate has decreased. This paper investigates targeted interventions and sociodemographic factors that may have contributed to fatal injury rate changes particularly for road traffic fatality (RTF), suicide and drowning.

AIMS

(1) To review the recent epidemiology of injury in China.(2)To investigate factors influencing trends in overall and specific cause injury mortality rates.

METHODS

Published injury mortality statistics and related literature were reviewed. Factors potentially influencing trends were investigated in the context of rapid development based on literature reviews of targeted interventions, macrolevel and microlevel contextual factors and changes specific to RTF, suicide and drowning.

RESULTS

Overall estimated national injury mortality rates in China decreased between 1987 and 2015, despite a rapid rise in RTF. Suicide and drowning rates decreased significantly and falls displaced drowning among the leading causes. The higher female to male suicide ratio reversed. Differences were observed in frequencies and proportions of deaths by major cause by age group and over time.

DISCUSSION

Economic and structural development and related social change in this period include: urbanisation, changes in demographics, life choices (eg, internal migration), education, poverty alleviation, health insurance and relevant regulations/legislation. These factors potentially explain much of the change in fatal injury rates in China. Data limitations persist. Increased investment in data and research would provide realistic opportunities for accelerated progress in implementing effective targeted interventions to further reduce China's injury burden.

Urbanization prolongs hantavirus epidemics in cities

Urbanization reduces exposure risk to many wildlife parasites and in general, improves overall health. However, our study importantly shows the complicated relationship between the diffusion of zoonotic pathogens and urbanization. Here, we reveal an unexpected relationship between hemorrhagic fever with renal syndrome incidence caused by a severe rodent-borne zoonotic pathogen worldwide and the process of urbanization in developing China. Our findings show that the number of urban immigrants is highly correlated with human incidence over time and also explain how the endemic turning points are associated with economic growth during the urbanization process. Our study shows that urbanizing regions of the developing world should focus their attention on zoonotic diseases.

Urbanization and rural–urban migration are two factors driving global patterns of disease and mortality. There is significant concern about their potential impact on disease burden and the effectiveness of current control approaches. Few attempts have been made to increase our understanding of the relationship between urbanization and disease dynamics, although it is generally believed that urban living has contributed to reductions in communicable disease burden in industrialized countries. To investigate this relationship, we carried out spatiotemporal analyses using a 48-year-long dataset of hemorrhagic fever with renal syndrome incidence (HFRS; mainly caused by two serotypes of hantavirus in China: Hantaan virus and Seoul virus) and population movements in an important endemic area of south China during the period 1963–2010. Our findings indicate that epidemics coincide with urbanization, geographic expansion, and migrant movement over time. We found a biphasic inverted U-shaped relationship between HFRS incidence and urbanization, with various endemic turning points associated with economic growth rates in cities. Our results revealed the interrelatedness of urbanization, migration, and hantavirus epidemiology, potentially explaining why urbanizing cities with high economic growth exhibit extended epidemics. Our results also highlight contrasting effects of urbanization on zoonotic disease outbreaks during periods of economic development in China.

Trends in injury morbidity in China, 1993-2013: A longitudinal analysis of population-based survey data

Understanding long-term trends in injury morbidity is critical to prevention and intervention planning. The aim of this study was to assess long-term trends in injury morbidity rates in China from 1993 to 2013. Using data from the National Health Service Survey (NHSS), which is conducted every five years, crude and age-standardized prevalence during the previous two weeks and hospitalization rates in the last 12 months with 95% confidence intervals (CI) were calculated. The Rao-Scott Chi-square test examined injury morbidity differences across the five survey years by location (urban/rural), sex, age group, and household income. Percent changes in morbidity rate were approximated using logistic regressions. Sampling weights were applied to all analyses. In 2013, crude two-week injury prevalence in China was 0.46% (95% CI: 0.40%, 0.52%) and 12-month crude hospitalization rate was 0.70% (95% CI: 0.63%, 0.77%). Age-standardized injury prevalence increased 31.4% (95% CI: 7.6%, 60.6%) between 1993 and 2013 (29.4%, 95% CI: 6.7%, 56.9% from 1993-2003; 1.6%, 95% CI: -14.8%, 21.0% from 2003-2013), and age-standardized hospitalization rates rose 107.2% (95% CI: 75.1%, 145.2%) from 1993 to 2013 (-9.5%, 95% CI: -24.6%, 8.6% from 1993-2003 and 129.0%, 95% CI: 93.9%, 170.4% from 2003-2013). Subgroup analyses showed similar trends over time. The leading cause of injury was dislocation, sprain or strain for prevalence, and fractures for hospitalization. In conclusion, injury morbidity increased substantially from 1993 to 2013 in China. Inconsistent changes in two-week prevalence and 12-month hospitalization rate merit attention from researchers and policy-makers.

Impact of universal medical insurance system on the accessibility of medical service supply and affordability of patients in China

Background

China’s universal medical insurance system (UMIS) is designed to promote social fairness through improving access to medical services and reducing out-of-pocket (OOP) costs for all Chinese. However, it is still not known whether UMIS has a significant impact on the accessibility of medical service supply and the affordability, as well as the seeking-care choice, of patients in China.

Methods

Segmented time-series regression analysis, as a powerful statistical method of interrupted time series design, was used to estimate the changes in the quantity and quality of medical service supply before and after the implementation of UMIS. The rates of catastrophic payments and seeking-care choices for UMIS beneficiaries were selected to measure the affordability and medical service flow of patients after the implementation of UMIS.

Results

China’s UMIS was established in 2008. After that, the trending increase of the expenditure of the UMIS was higher than that of increase in revenue compared to previous years. Up to 2014, the UMIS had covered 97.5% of the entire population in China. After introduction of the UMIS, there were significant increases in licensed physicians, nurses, and hospital beds per 1000 individuals. In addition, hospital outpatient visits and inpatient visits per year increased compared to the pre-UMIS period. The average fatality rate of inpatients in the overall hospital and general hospital and the average fatality rate due to acute myocardial infarction (AMI) in general hospitals was significantly decreased. In contrast, no significant and prospective changes were observed in rural physicians per 1000 individuals, inpatient visits and inpatient fatality rate in the community centers and township hospitals compared to the pre-UMIS period. After 2008, the rates of catastrophic payments for UMIS inpatients at different income levels were declining at three levels of hospitals. Whichever income level, the rate of catastrophic payments for inpatients of Urban Employee’s Basic Medical Insurance was the lowest. For the low-income patients, a single hospitalization at a tertiary hospital can lead to catastrophic payments. It is needless to say what the economic burden could be if patients required multiple hospitalizations within a year. UMIS beneficiaries showed the intention of growth to seek hospitalization services in tertiary hospitals.

Conclusions

Introduction of the UMIS contributed to an increase in available medical services and the use thereof, and a decrease in fatality rate. The affordability of UMIS beneficiaries for medical expenses was successfully ameliorated. The differences in patients’ affordability are mainly manifested in different medical insurance schemes and different seeking-care choices. The ability of the poor patients covered by UMIS to resist catastrophic medical payments is still relatively weak. Therefore, the current UMIS should reform the insurance payment model to promote the integration of medical services and the formation of a tiered treatment system. UMIS also should establish supplementary medical insurance packages for the poor.

Impact of the New Cooperative Medical Scheme on the trend of catastrophic health expenditure in Chinese rural households: results from nationally representative surveys from 2003 to 2013

OBJECTIVE

To evaluate the trend of catastrophic health expenses (CHE) for inpatient care in relation to the commencement of the New Cooperative Medical Scheme (NCMS) in rural China from 2003 to 2013, and the roles of NCMS in protecting affected households from CHE.

METHODS

We assessed the 10-year trend of the incidence and severity of CHE in rural households with hospitalised members using data from the Chinese National Health Services Survey. Generalised estimating equations were used to estimate the OR and 95% CI of the association between incidence rates of CHE ([Formula: see text]) and NCMS reimbursement.

RESULTS

The incidence and severity of CHE after NCMS reimbursement both decreased and their changes increased rapidly from 2003 to 2013. After adjustment of the covariates, [Formula: see text] before reimbursement was significantly higher than that after reimbursement, and the OR (95% CI) was 1.50 (1.24 to 1.81), 1.79 (1.69 to 1.90) and 2.94 (2.77 to 3.11) in 2003, 2008 and 2013, respectively.

CONCLUSION

The incidence and severity of CHE both reduced after NCMS reimbursements in each year. Excluding some confounding factors, [Formula: see text] was significantly associated with NCMS reimbursement. NCMS partly protected the rural households with hospitalised members from CHE. However, the inequalities between different income groups still existed. [Formula: see text] in rural households with hospitalised members was still rather high in 2003, 2008 and 2013 even though they were covered by NCMS. This study will provide suggestions for further reforms in China and guidance for other low-income/middle-income countries.

Equity and efficiency of medical service systems at the provincial level of China's mainland: a comparative study from 2009 to 2014

BACKGROUND

The astonishing economic achievements of China in the past few decades have remarkably increased not only the quantity and quality of medical services but also the inequalities in health resources allocation across regions and inefficiency of the medical service delivery.

METHODS

A descriptive analysis was used to compare the inequities in inputs and outputs of the provincial medical service systems, a non-radial super-efficiency data envelopment analysis model was then used to estimate the efficiency, and a regression analysis of the panel data was used to explore the determinants.

RESULTS

The inputs and outputs of most provincial medical service systems increased gradually from 2009 to 2014. Overall, the eastern region allocated more human and capital resources than the other two regions, and produced more than 50% of the total outpatient and emergency room visits, whereas the western region produced more inpatient services (about 30% of the total volume of inpatient services) according to the distribution of the population. The average efficiency scores of the provincial medical systems in China's mainland were 0.895, 0.927, 0.929, 0.963, 0.977 and 0.968 from 2009 to 2014, with a slight average improvement of 1.60%. The efficiency score of each provincial medical service system varied greatly from one another: Tibet (1.475 ± 0.057) performed extremely well, whereas several others including Heilongjiang (0.579 ± 0.001) performed poorly. Furthermore, the proportion of high-class medical facilities was negatively associated with efficiency, whereas the proportion of the vulnerable population, the per capita Gross Domestic Product, the proportion of the illiterate population and the improvement of primary health care had positive effects on efficiency.

CONCLUSION

Inequity in health resources allocation and service provision existed across the regions, but not all the gaps have begun to narrow since 2009. The difference of efficiency was great among provincial medical service systems but minor across regions, and the score changed very little over time. More importantly, the central region held the lowest average efficiency score in the past 6 years, while the western region held the largest average efficiency score at the first 5 years, which should receive enough attention of the government and decision-makers. In practice, efficiency was related to many complicated factors, indicating that the improvement of efficiency is a complex and iterative process that requires the strong cooperation of many sectors.

Annual cost of illness of stomach and esophageal cancer patients in urban and rural areas in China: A multi-center study

Objective

Stomach and esophageal cancer are imposing huge threats to the health of Chinese people whereas there were few studies on the financial burden of the two cancers.

Methods

Costs per hospitalization of all patients with stomach or esophageal cancer discharged between September 2015 and August 2016 in seven cities/counties in China were collected, together with their demographic information and clinical details. Former patients in the same hospitals were sampled to collect information on annual direct non-medical cost, indirect costs and annual number of hospitalization. Annual direct medical cost was obtained by multiplying cost per hospitalization by annual number of hospitalization. Annual cost of illness (ACI) was obtained by adding the average value of annual direct medical cost, direct non-medical cost and indirect cost, stratified by sex, age, clinical stage, therapy and pathologic type in urban and rural areas. Costs per hospitalization were itemized into eight parts to calculate the proportion of each part. All costs were converted to 2016 US dollars (1 USD=6.6423 RMB).

Results

Totally 19,986 cases were included, predominately male. Mean ages of stomach cancer and urban patients were lower than that of esophageal cancer and rural patients. ACI of stomach and esophageal cancer patients were $10,449 and $13,029 in urban areas, and $2,927 and $3,504 in rural areas, respectively. Greater ACI was associated with male, non-elderly patients as well as those who were in stage I and underwent surgeries. Western medicine fee took the largest proportion of cost per hospitalization.

Conclusions

The ACI of stomach and esophageal cancer was tremendous and varied substantially among the population in China. Preferential policies of medical insurance should be designed to tackle with this burden and further reduce the health care inequalities.

The Trends in Cardiovascular Diseases and Respiratory Diseases Mortality in Urban and Rural China, 1990-2015

With the rapid development of the economy over the past 20 years, the mortality rates from cardiovascular diseases (CVDs) and respiratory diseases (RDs) have changed in China. This study aimed to analyze the trends of mortality rates and years of life lost (YLLs) from CVDs and RDs in the rural and urban population from 1990 to 2015. Using data from Chinese yearbooks, joinpoint regression analysis was employed to estimate the annual percent change (APC) of mortality rates from CVDs and RDs. YLLs due to CVDs and RDs were calculated by a standard method, adopting recommended standard life expectancy at birth values of 80 years for men and 82.5 years for women. Age-standardized mortality rates and YLL rates were calculated by using the direct method based on the Chinese population from the sixth population census of 2010. Age-standardized mortality rates from CVDs for urban residents and from RDs for both urban and rural residents showed decreasing trends in China from 1990 to 2015. Age-standardized mortality rates from CVDs among rural residents remained constant during above period and outstripped those among urban residents gradually. The age-standardized YLL rates of CVDs for urban and rural residents decreased 35.2% and 8.3% respectively. Additionally, the age-standardized YLL rates of RDs for urban and rural residents decreased 64.2% and 79.0% respectively. The age-standardized mortality and YLL rates from CVDs and RDs gradually decreased in China from 1990 to 2015. We observed more substantial declines of the mortality rates from CVDs in urban areas and from RDs in rural areas.

Survival of Cancer Patients in Northeast China: Analysis of Sampled Cancers from Population-Based Cancer Registries

PURPOSE

The cancer survival was characterized by following up sampled subgroups of cancer cases from three population-based cancer registries in Northeast China.

MATERIALS AND METHODS

Survival analysis was used to analyze 6,871 patients, who had one of the 21 most common cancers based on sampling from the population-based cancer registries of three cities in Liaoning Province. All patients were diagnosed between 2000 and 2002 and were followed up to the end of 2007 by active and passive methods. The 5-year age standardized relative survival rates (ASRS) were estimated for all cancers combined and each of the 21 individual cancers.

RESULTS

The survival status was traced for 80.8% of 8,506 sampled cancer cases. The 5-year ASRS for all 21 cancers combined was 41.5% (95% confidence interval, 40.3 to 42.7), the highest ASRS was observed for thyroid cancer (85.2%), breast cancer (78.9%), uterine corpus cancer (75.9%), and urinary bladder cancer (70.2%); the lowest 5-year ASRS was noted in pancreatic cancer (8.8%), liver cancer (11.0%), esophageal cancer (18.8), and lung cancer (19.6%). The cancer survival rates in Liaoning cities were similar to those of urban areas in mainland China, but significantly lower than those in Hong Kong, Korea, and Japan.

CONCLUSION

The strikingly poor cancer survival rates in three cities of Liaoning Province and in other places in China highlight the need for urgent investment in cancer prevention, early detection, and standardized and centralized treatment.

Policy experimentation and innovation as a response to complexity in China's management of health reforms

There are increasing criticisms of dominant models for scaling up health systems in developing countries and a recognition that approaches are needed that better take into account the complexity of health interventions. Since Reform and Opening in the late 1970s, Chinese government has managed complex, rapid and intersecting reforms across many policy areas. As with reforms in other policy areas, reform of the health system has been through a process of trial and error. There is increasing understanding of the importance of policy experimentation and innovation in many of China’s reforms; this article argues that these processes have been important in rebuilding China’s health system. While China’s current system still has many problems, progress is being made in developing a functioning system able to ensure broad population access. The article analyses Chinese thinking on policy experimentation and innovation and their use in management of complex reforms. It argues that China’s management of reform allows space for policy tailoring and innovation by sub-national governments under a broad agreement over the ends of reform, and that shared understandings of policy innovation, alongside informational infrastructures for the systemic propagation and codification of useful practices, provide a framework for managing change in complex environments and under conditions of uncertainty in which ‘what works’ is not knowable in advance. The article situates China’s use of experimentation and innovation in management of health system reform in relation to recent literature which applies complex systems thinking to global health, and concludes that there are lessons to be learnt from China’s approaches to managing complexity in development of health systems for the benefit of the poor.

Qualitative analysis of direction of public hospital reforms in China

Reforms in public hospitals are among the most important improvements in China's health care system over the last two decades. However, the reforms that should be implemented in public hospitals are unclear. Thus, a feasible direction of reforms in Chinese public hospitals is suggested and reliable policy suggestions are provided for the government to reform public hospitals. The data used in this study were mainly derived from a qualitative study. Focus group discussions and in-depth interviews were conducted in Shanghai, Guangdong, and Gansu between May and December 2014. Government funding accounted for approximately eight percent of the total annual revenue of public hospitals in China, and the insufficient government subsidy considerably affects the operation mechanism of public hospitals. However, solely increasing this subsidy cannot address the inappropriate incentives of public hospitals in China. The most crucial step in setting the direction of reforms in public hospitals in China is transforming inappropriate incentives by implementing a new evaluation index system for directors and physicians in public hospitals.

Prevalence of cardiovascular medication on secondary prevention after myocardial infarction in China between 1995-2015: A systematic review and meta-analysis

BACKGROUND

Myocardial Infarction (MI) has become a major cause of morbidity and mortality in China, but little is known about the prevalence of guideline-recommended cardiovascular medications after MI events over the last two decades. This systematic review and meta-analysis aims to summarize cardiovascular medication use between 1995-2015 and to assess factors in associated with the trends in cardiovascular medications.

METHOD

A systematic search was conducted in four databases (Pubmed, Embase, CENTRAL, and CNKI) to obtain observational studies published between 1995 and 2015, reporting on the use of cardiovascular medications in China. Risk of bias of individual studies was appraised and selected studies were pooled for estimated prevalence of cardiovascular medication. Prevalence of cardiovascular medication use for 1995 and 2015 was estimated by random effects meta-regression model.

RESULTS

From 13,940 identified publications, 35 studies, comprising 28,000 patients, were included. The pooled prevalence for aspirin, beta-blockers, statins, ACE-Inhibitors, ACE-Inhibitor/ARBs and nitrates was 92% [95% confidence interval (CI): 0.89-0.95], 63% (95% CI: 0.57-0.69), 72% (95% CI: 0.60-0.82), 49% (95% CI: 0.41-0.57), 59% (95% CI: 0.48-0.69) and 79% (95% CI: 0.74-0.91), respectively. A significant increase in beta-blocker and statin use and a decrease of nitrate use was observed over time. The estimated prevalence of beta-blockers, statins, and nitrates was 78%, 91.1%, and 59.3% in 2015, compared to 32%, 17% and 96% in 1995, respectively.

CONCLUSION

Cardiovascular medication use after MI is far from optimal in Chinese patients, even though the prevalence of use increased over the period 1995-2015. With a rapidly increasing number of MI patients in China, a comprehensive strategy on secondary prevention is warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42015025246).

Determinants of Catastrophic Dental Health Expenditure in China

This study explored catastrophic health expenditure in China, due to out-of-pocket payments for dental care, and its associated individual- and contextual-level factors. We pooled data from 31,566 adults who participated in the third National Oral Health Survey with province-level data from different sources. We defined catastrophic dental health expenditure (CDHE) as payments for dental services and/or medication for dental problems during the last year that exceeded the 10% and 20% of the household income. The association of individual and contextual factors with catastrophic dental health expenditure was evaluated using two-level logistic regression models with individuals nested within provinces. Socioeconomic position (education and household income), household size and dental status (pain in teeth or mouth and number of teeth) were the individual-level factors associated with CDHE among the full sample of participants; and, also, among those who used dental services in the past year. Greater gross domestic product per capita was the only contextual factor associated with CDHE, and only at the lower income threshold. This study shows that out-of-pocket expenses for dental services may put a considerable, and unnecessary, burden on households' finances. Our findings also help characterise those households more likely to face catastrophic expenditure on health if they have to pay for dental services.

Geographic distribution of hospital beds throughout China: a county-level econometric analysis

BACKGROUND

Geographical distribution of healthcare resources is an important dimension of healthcare access. Little work has been published on healthcare resource allocation patterns in China, despite public equity concerns.

METHODS

Using national data from 2043 counties, this paper investigates the geographic distribution of hospital beds at the county level in China. We performed Gini coefficient analysis to measure inequalities and ordinary least squares regression with fixed provincial effects and additional spatial specifications to assess key determinants.

RESULTS

We found that provinces in west China have the least equitable resource distribution. We also found that the distribution of hospital beds is highly spatially clustered. Finally, we found that both county-level savings and government revenue show a strong positive relationship with county level hospital bed density.

CONCLUSIONS

We argue for more widespread use of disaggregated, geographical data in health policy-making in China to support the rational allocation of healthcare resources, thus promoting efficiency and equity.

Determinants of the Transmission Variation of Hand, Foot and Mouth Disease in China

Severe outbreaks of hand, foot and mouth disease (HFMD) have occurred in China for decades. Our understanding of the HFMD transmission process and its determinants is still limited. In this paper, factors that affect the local variation of HFMD transmission process were studied. Three classes of factors, including meteorological, demographic and public health intervention factors, were carefully selected and their effects on HFMD transmission were investigated with Pearson's correlation coefficient and multiple linear regression models. The determining factors for the variation of HFMD transmission were different for the southeastern and the northwestern regions of China. In the northwest, fadeouts occurred yearly, and the average age at infection and the fadeout were negatively correlated with the population density. In the southeast, HFMD transmission was governed by the combined effects of the birth rate, the relative humidity and the interaction of the Health System Performance and the log of the population density. When the Health System Performance was low, HFMD transmission increased with the population density, but when the Health System Performance was high, the better health performance counteracted the transmission increase due to the higher population density.

Can socio-economic differences explain low expectation of health services among HIV patients compared to non-HIV counterparts?

Background

The health service of China has encountered significant challenges due to inequalities in socio-economic determinants of health. HIV patients are known to suffer from social stigma, and may receive inadequate responsiveness from health providers. Before assessing the responsiveness they receive, it is important to know their expectations. We aimed to compare levels of expectation towards the healthcare service among HIV and non-HIV patients with adjustment for socio-economic factors.

Methods

A cross-sectional study was conducted during January and February, 2015 among two consecutive groups of HIV positive and non-HIV patients in two hospitals in Kunming, China. Patients’ expectation towards eight domains of health system responsiveness was measured using 40 vignettes; five per domain. Each vignette was ranked from 1 “very good” to 5 “very bad”, and the responses were summed to obtain a total score for each domain. Differences in total scores were compared between the two groups and adjusted for other factors using multiple linear regression.

Results

The three domains with the highest scores, reflecting high expectation, were prompt attention, basic amenities and choice. Adjusted for other factors, HIV patients had significantly lower levels of expectation in all domains compared to the non-HIV group. Age was associated with the basic amenities domain, with young adults having higher expectations than other age groups. Minority ethnic groups had lower expectation towards dignity, prompt attention and autonomy domains compared to Han ethnicity. Those who lived in a home with 2–4 family members had higher expectations towards confidentiality than those who lived alone.

Conclusion

Patients with HIV have significantly lower levels of expectations even after adjusting for socio-economic factors. Assessment of health system responsiveness based on their judgments above may give biased results toward favorable service quality.