The ecology of medical care in Beijing

Ecology of End-of-life Medical Care for Advanced Cancer Patients in China

AIMS

Cancer is a leading cause of death worldwide. Approximately 30% of global cancer-related deaths occur in mainland China. However, there is a paucity of information regarding the end-of-life care-seeking behavior of patients with advanced cancer in China. Our study was to investigate end-of-life care-seeking behavior and to quantify the association between sociodemographic characteristics and the location and pattern of end-of-life care.

METHODS

We conducted a mortality follow-back survey using caregivers' interviews to estimate the number of individuals pre 1000 who died between 2013 and 2021 in the last 3 months of life. We collected data on hospitalization, outpatient visits, cardiopulmonary resuscitation, palliative care and hospice utilization, and place of death, stratified by age, gender, marital status, household income, residential zone, insurance type, and the primary end-of-life decision-maker of the decedents.

RESULTS

We analyzed data from 857 deceased cancer patients, representing an average of 1000 individuals. Among these patients, 861 experienced at least moderate or more severe pain, 774 were hospitalized at least once, 468 received intensive treatment, 389 had at least one outpatient visit, 270 died in the hospital, 236 received cardiopulmonary resuscitation and 99 received specialist hospice care.

CONCLUSIONS

Our study provides insights into the end-of-life care-seeking behavior of advanced cancer patients in China and our findings serve as a useful benchmark for estimating the use of end-of-life medical care. It highlights the need for the establishment of an accessible and patient-centered palliative care and hospice system.

Social determinants of health and their relation to suboptimal health status in the context of 3PM: a latent profile analysis

Background

Suboptimal health is identified as a reversible phase occurring before chronic diseases manifest, emphasizing the significance of early detection and intervention in predictive, preventive, and personalized medicine (PPPM/3PM). While the biological and genetic factors associated with suboptimal health have received considerable attention, the influence of social determinants of health (SDH) remains relatively understudied. By comprehensively understanding the SDH influencing suboptimal health, healthcare providers can tailor interventions to address individual needs, improving health outcomes and facilitating the transition to optimal well-being. This study aimed to identify distinct profiles within SDH indicators and examine their association with suboptimal health status.

Method

This cross-sectional study was conducted from June 16 to September 23, 2023, in five regions of China. Various SDH indicators, such as family health, economic status, eHealth literacy, mental disorder, social support, health behavior, and sleep quality, were examined in this study. Latent profile analysis was employed to identify distinct profiles based on these SDH indicators. Logistic regression analysis by profile was used to investigate the association between these profiles and suboptimal health status.

Results

The analysis included 4918 individuals. Latent profile analysis revealed three distinct profiles (prevalence): the Adversely Burdened Vulnerability Group (37.6%), the Adversity-Driven Struggle Group (11.7%), and the Advantaged Resilience Group (50.7%). These profiles exhibited significant differences in suboptimal health status (p < 0.001). The Adversely Burdened Vulnerability Group had the highest risk of suboptimal health, followed by the Adversity-Driven Struggle Group, while the Advantaged Resilience Group had the lowest risk.

Conclusions and relevance

Distinct profiles based on SDH indicators are associated with suboptimal health status. Healthcare providers should integrate SDH assessment into routine clinical practice to customize interventions and address specific needs. This study reveals that the group with the highest risk of suboptimal health stands out as the youngest among all the groups, underscoring the critical importance of early intervention and targeted prevention strategies within the framework of 3PM. Tailored interventions for the Adversely Burdened Vulnerability Group should focus on economic opportunities, healthcare access, healthy food options, and social support. Leveraging their higher eHealth literacy and resourcefulness, interventions empower the Adversity-Driven Struggle Group. By addressing healthcare utilization, substance use, and social support, targeted interventions effectively reduce suboptimal health risks and improve well-being in vulnerable populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-024-00365-5.

Needs and views on healthy lifestyles for the prevention of dementia and the potential role for mobile health (mHealth) interventions in China: a qualitative study

OBJECTIVES

Over the coming decades, China is expected to face the largest worldwide increase in dementia incidence. Mobile health (mHealth) may improve the accessibility of dementia prevention strategies, targeting lifestyle-related risk factors. Our aim is to explore the needs and views of Chinese older adults regarding healthy lifestyles to prevent cardiovascular disease (CVD) and dementia through mHealth, supporting the Prevention of Dementia using Mobile Phone Applications (PRODEMOS) study.

DESIGN

Qualitative semi-structured interview study, using thematic analysis.

SETTING

Primary and secondary care in Beijing and Tai'an, China.

PARTICIPANTS

Older adults aged 55 and over without dementia with an increased dementia risk, possessing a smartphone. Participants were recruited through seven hospitals participating in the PRODEMOS study, purposively sampled on age, sex, living area and history of CVD and diabetes.

RESULTS

We performed 26 interviews with participants aged 55-86 years. Three main themes were identified: valuing a healthy lifestyle, sociocultural expectations and need for guidance. First, following a healthy lifestyle was generally deemed important. In addition to generic healthy behaviours, participants regarded certain specific Chinese lifestyle practices as important to prevent disease. Second, the sociocultural context played a crucial role, as an important motive to avoid disease was to limit the care burden put on family members. However, time-consuming family obligations and other social values could also impede healthy behaviours such as regular physical activity. Finally, there seemed to be a need for reliable and personalised lifestyle advice and for guidance from a health professional.

CONCLUSIONS

The Chinese older adults included in this study highly value a healthy lifestyle. They express a need for personalised lifestyle support in order to adopt healthy behaviours. Potentially, the PRODEMOS mHealth intervention can meet these needs through blended lifestyle support to improve risk factors for dementia and CVD.

TRIAL REGISTRATION NUMBER

ISRCTN15986016; Pre-results.

The use of health care during the SARS-CoV-2 pandemic: repeated cross-sectional survey of the adult Swiss general population

BACKGROUND

The distribution of health care resources during a pandemic is challenging. The aim of the study was to describe the use of health care in a representative sample of the Swiss population during the SARS-CoV-2 pandemic in 2020, and to compare it to data from a survey conducted in 2018.

METHODS

We conducted an observational, population-based, nationwide, repeated cross-sectional survey of the adult Swiss general population in 2018 and in March and April 2020 during the first wave of the SARS-CoV-2 pandemic. Recruitment and data acquisition was conducted by the Link Institute in Lucerne in representative samples of Swiss citizens in 2020 and in 2018. Variables of interest were estimates of health problems, health seeking behaviour, medication and health care use in the population.

RESULTS

In total, we included data of 1980 individuals (in 2018 N = 958 and in 2020 N = 1022). Across both rounds of data collection the median age was 46 years (range = 18-79 years) and 50% were women. Per 1000 adults, half had at least one symptom and a quarter sought medical advice across both surveys. The most frequently consulted health providers in 2020 were general practitioners (GP) (180/1000), specialist physicians (41/1000), pharmacies (38/1000), the internet (26/1000) and accident and emergency units (25/1000). Compared to 2018, we noted a significant increase in the use of health providers during the pandemic, which was independent of demographic variables for the following health care providers: use of internet (OR = 9.8), pharmacy (OR = 2.64), accident and emergency units (OR = 2.54), and a significant decrease in the number of people who consulted specialist physicians (OR = 0.46). Overall, 76/1000 contacted their GP in relation to COVID-19.

CONCLUSIONS

Compared to 2018, GPs remained the most important source of medical advice for the population during the first wave of the COVID-19 pandemic in Switzerland. While the self-appraisal of health problems and of the need for medical advice remained constant, individuals seemed to change their provider choice during the pandemic, with an increased utilisation of accident and emergency units and pharmacies, which represent easily accessible and low-threshold medical services.

The ecology of medical care in Shanghai

Background

To better understand the distribution and consumption patterns of resources in different ethnic groups and at different levels of economic development, this paper chose to describe the healthcare seeking behavior in Shanghai.

Methods

The data are from the Sixth Health Service Survey of Shanghai, which encompasses 23,198 permanent residents. Descriptive analyses were conducted to estimate the number of patients who reported health-related symptoms and healthcare-seeking behaviors per 1,000 residents. Logistic regression analyses were conducted to examine differences in reporting health-related symptoms and healthcare-seeking behaviors by age, gender and area of residence.

Results

This paper have mapped the ecology of healthcare in Shanghai in 2018. Of 1000 individuals considered during a 1-month period, 444 reported sickness, 433 received treatment, 288 went to medical institutions, 195 went to primary medical institutions, 86 took a self-healing approach, 26 received TCM services, 7 were hospitalized, and 3 underwent surgery.

Conclusions

Age is a risk factor leading to disease, medical treatment, self-medication, medical institution visits, TCM service, hospitalization and surgery. But age is a protective factor in the use of primary health care services. By gender, the number of people receiving medical services was similar, but women were statistically more likely to have surgery. As the income level increased, the number of patients and people receiving medical services showed a decreasing trend. Compared with the local population, the probability of non-local people visiting medical institutions was lower and statistically significant. Compared with the people who had health insurance, fewer uninsured people reported sickness and utilized healthcare services.

Inequalities in Cervical Cancer Screening Uptake Between Chinese Migrant Women and Local Women: A Cross-Sectional Study

INTRODUCTION

Uptake of cervical cancer screening services in Chinese migrant workers is unknown and may be lower than non-migrant workers in China.

METHODS

We conducted a cross-sectional study among migrant and non-migrant women aged 21-65 at 7 provinces across China and administered a questionnaire investigating knowledge and attitudes regarding cervical cancer, human papillomavirus (HPV), and HPV vaccine. We used multivariable logistic regression to evaluate odds of previous cervical cancer screening in migrant workers.

RESULTS

737 women participated in the study. Mean age was 41.9 ± 7.2 years. 50.2% of the participants were migrant workers. 27.6% of the migrant workers reported previous cervical cancer screening compared to 33.2% of local participants. 36.6% migrant workers reported awareness of HPV compared to 40.2% of local participants. In adjusted analysis migrant status was not associated with increased odds of previous cervical cancer screening (aOR = 1.11 95%CI: 0.76-1.60). High school or higher education compared to less than high school education and employer-sponsored insurance compared to uninsured were associated with increased odds of previous cervical cancer screening (aOR = 2.15 95%CI: 1.41-3.27 and aOR = 1.67 95% CI: 1.14-2.45, respectively). Having heard of HPV compared to no awareness of HPV was associated with increased odds of cervical cancer screening (aOR = 2.02 95%CI: 1.41-2.91). Awareness of HPV among migrant workers was associated with increased odds of cervical cancer screening compared to migrant and local participants without awareness (aOR = 2.82 95% CI: 1.70-4.69 and 2.97 95%CI: 1.51-5.83, respectively).

CONCLUSIONS

Efforts to increase education opportunities, provide insurance, and promote HPV awareness could increase cervical cancer screening uptake in migrant women in China.

Economic impact of medical genetic testing on clinical applications in Thailand

Background

Although the clinical benefits of medical genetic testing have been proven, there has been limited evidence on its economic impact in Thai setting. Thus, this study aimed to evaluate the economic impact of genetic testing services provided by the Center for Medical Genomics (CMG) in Thailand.

Methods

Cost-benefit analysis was conducted from provider and societal perspectives. Cost and output data of genetic testing services provided by the CMG during 2014 to 2018 and published literature reviews were applied to estimate the costs and benefits. Monetary benefits related to genetic testing services were derived through human capital approach.

Results

The total operation cost was 126 million baht over five years with an average annual cost of 21 million baht per year. The net benefit, benefit-to-cost ratio, and return on investment were 5,477 million baht, 43 times, and 42 times, respectively. Productivity gain was the highest proportion (50.57%) of the total benefit.

Conclusions

The provision of genetic testing services at the CMG gained much more benefits than the cost. This study highlighted a good value for money in the establishment of medical genomics settings in Thailand and other developing countries.

Development of type 2 diabetes mellitus quality indicators in general practice by a modified Delphi method in Beijing, China

BACKGROUND

The service capacity of primary care has improved in China. General practice also takes growing responsibility in the management of type 2 diabetes mellitus, but there are concerns about the paucity of evidence of the quality of care delivered. And there is an absence of systematic quality indicators of type 2 diabetes mellitus in general practice in China. This study aimed to develop a set of type 2 diabetes mellitus quality indicators to facilitate quality measurement in general practice in China.

METHODS

Preliminary quality indicators were generated and refined by literature review and an expert consultation meeting. Two rounds of email-based Delphi survey and a consensus meeting were carried out to identify quality indicators. Delphi questionnaires with 43 indicators were sent to 30 participants in the first round. There were 16 general practitioners and 10 community health service center leaders from primary care, 3 endocrinologists and a primary care researcher in the first round. And 27 out of the 30 participants participated in the second round. The consensus meeting was held among 9 participants to refine the indicators and a last round of rating was carried out in the meeting. The indicators were rated in terms of importance and feasibility. The agreement criteria were defined as median ≥ 7.0 and ≥ 85.0% of ratings in the 7-9 tertile for importance; median ≥ 7.0 and ≥ 65.0, 70.0, 75.0% of ratings in the 7-9 tertile for feasibility respectively in the three rounds of rating.

RESULTS

After 2 rounds of Delphi survey and the consensus meeting, total 38 indicators achieved consensus for inclusion in the final set of indicators. The final set of indicators were grouped into 7 domains: access (5 indicators), monitoring (12 indicators), health counseling (7 indicators), records (2 indicators), health status (7 indicators), patient satisfaction (2 indicators) and self-management (3 indicators).

CONCLUSIONS

A set of 38 potential quality indicators of type 2 diabetes mellitus in general practice were identified by an iterative Delphi process in Beijing, China. Preliminary approach for measurement and data collection were described. However, the indicators still need to be validated by testing in a further study.

Cancer diagnosis and care among rural-to-urban migrants in China

Introduction

Cancer is a leading cause of death in China. Rural-to-urban migrants are a group of over 260 million people in China sometimes termed the 'floating' population. This study assessed the prevalence of cancer diagnosis and access to needed healthcare by residence and migration status in China.

Methods

We used data from the China Health and Retirement Longitudinal Survey, a nationally representative population-based random sample of adults age 45 years and older and their spouses in China. We used multivariable logistic regressions to compare outcomes among rural-to-urban migrants, local urban residents and local rural residents after adjusting for province of residence, socioeconomic status and demographic characteristics.

Results

The sample included 7335 urban residents, 9286 rural residents and 3255 rural-to-urban migrants. Prevalence of cancer diagnosis was 9.9 per 1000 population among rural-to-urban migrants (95% CI 6.5 to 15.1 per 1000 population). Rural-to-urban migrants had higher tobacco use (OR=2.01; 95% CI 1.59 to 2.56, p<0.001), lower use of a health check-up (OR=0.57; 95% CI 0.48 to 0.67, p<0.001) and lower prevalence of diagnosed cancer (OR=0.41; 95% CI 0.18 to 0.95, p=0.037) than urban residents. Among participants with diagnosed cancer, residence and migration status were not predictive of foregoing needed healthcare, but were predictive of diagnosis with a screen-detectable tumour (ie, breast, colon, prostate or cervical cancer) (OR=0.17; 95% CI 0.05 to 0.63, p=0.007 for rural residents; OR=0.34; 95% CI 0.09 to 1.22, p=0.098 for rural-to-urban migrants, compared with urban residents).

Conclusion

Rapid and large migration is still a driving force transitioning China. Due to some remaining dual policy settings in favour of local residents, rural migrants tend to use lower primary care and preventive health check-ups in general, and diagnosis of screen-detectable tumours in particular, leading to potentially higher risk of missing early diagnosis of cancers. Closing gaps in diagnosis of screen-detectable tumours could increase treatment and improve cancer outcomes.

The ecology of medical care: access points to the health care system in Austria and other developed countries

Objective: This study aimed to analyze the Austrian health care system using the ecology of care model. Our secondary aim was to compare data from Austria with those available from other countries.Design: 3508 interviews employing a 30-item questionnaire related to the utilization of the health care system including demographic factors were conducted. Participants were chosen by a Random Digital Dialing procedure. Further, a literature review of studies of other countries use of the ecology of care model was conducted.Main outcome measures: Austria has one of the highest utilization of health care services in any of the assessed categories. The comparison with the literature review shows that Austria has the highest utilization of specialists working in the outpatient sector as well as the highest hospitalization rates. Taiwan and Korea have comparable utilization patterns. Canada, Sweden, and Norway are countries with lower utilization patterns, and the U.S. and Japan are intermediate.Conclusion: In Austria and similarly organized countries, high utilization of all health care services can be observed, in particular, the utilization of specialists and hospitalizations. The over-utilization of all levels of health care in Austria may be due to the lack of a clear demarcation line between the primary and secondary levels of care, and the presence of universal health coverage, which also allows for unrestricted and undirected access to all levels of care. Previous studies have shown that comparable countries lack the health benefits of a strong primary care system with its coordination function.Key pointsIn Austria and similarly organized countries, there appears to be high utilization of health care in general, as well as with particular utilization of specialists and hospitalizations.The high utilization of all levels of care in Austria may be the result of competition, lack of a clear demarcation line between the primary and secondary level of care, and the presence of universal health coverage.Pathways between primary and secondary care should be strengthened as previous studies have shown that comparable countries lack the health benefits of strong primary care and its function for health care coordination.

Reassessing the Ecology of Medical Care in Japan

Studies on ecology of medical care can provide valuable information on how people seek healthcare in a specific geographic area. The objective of this study was to update a 2003 report on the ecology of medical care in Japan, identifying relevant changes in healthcare patterns. We collected information based on a prospective health diary recorded for a month in 2013 (n = 4548; 3787 adults and 797 children) using a population-weighted random sample from a nationally representative panel. We compared our overall and stratified findings with a similar study conducted in 2003. During a one-month period, per 1000 adults and children living in Japan, we estimated that 794 report at least one symptom, 447 use an over-the-counter (OTC) drug, 265 visit a physician's office, 117 seek help from a professional provider of complementary or alternative medicine (CAM), 70 visit a hospital outpatient clinic (60 community-based and 10 university-based), 6 are hospitalized, and 4 visit a hospital emergency department. After adjusting for demographic variables, we found that healthcare seeking behaviors were influenced by age, gender and area of living. Compared with the 2003 study, participants in this study had fewer symptoms, fewer physician and emergency room visits, and less OTC use, but reported higher frequency of CAM use (p < .01 for all). Compared with 2003, reported symptoms, physician visits and OTC use has decreased, while CAM use has increased. Our findings may be useful to policymakers in Japan in a context where healthcare expenditure and a rapidly aging population are two challenging issues.

The ecology of medical care on the westernmost remote island, Yonaguni Island, Japan: A cross-sectional study

Yonaguni Island is a remote and isolated westernmost island in Japan, which is the fastest aging country in the world. This study evaluated the current status of medical supply-and-demand on the island and compared these results with previous surveys carried out in rural parts of Japan. This was a retrospective cohort study conducted at the Yonaguni Municipal Clinic, the only medical facility in Yonaguni Island. The participants were patients who visited the clinic over one year, between July 2015 and June 2016. We calculated the rate per 1,000 persons per month of clinic visits, referrals to off-island medical facilities (e.g., hospitals and specialist clinics), referrals to off-island emergency departments, off-island hospitalizations after referral, home visits, and overnight observations at the clinic. In total, 6,197 patients (males, 46.3%) visited the clinic. The rate of clinic visits per 1,000 persons per month was 516.4 (Standard deviation [SD] 28.1, 95% confidence interval [CI]: 500.5-532.3). The rate per 1,000 persons per month was 14.0 (SD 3.9, 95% CI: 11.8-16.2) for off-island referrals, 3.8 (SD 2.1, 95% CI: 2.6-5.0) for referrals to emergency departments, 4.8 (SD 2.6, 95% CI: 3.3-6.2) for hospitalizations, and 3.2 (SD 1.7, 95% CI: 2.2-4.1) for home visits. The rate of clinic visits was higher in Yonaguni Island than in other rural areas, although the rate of off-island referrals was lower. There were no significant differences between the number of referrals to emergency departments, hospitalizations, and home visits in Yonaguni Island, in comparison to other studies. Our study showed that patients presenting with emergencies had similar rates of healthcare-seeking behavior to those reported in previous studies in Japan; however, the referral rate was lower. We assessed the ecology of medical care in this district by evaluating patient behavior on an isolated island where access to medical care is geographically limited.

Reasons for encounter and health problems managed by general practitioners in the rural areas of Beijing, China: A cross-sectional study

OBJECTIVE

The purpose of this study was to describe the patients' reasons for encounter (RFE) and health problems managed by general practitioners (GPs) in the rural areas of Beijing to provide evidences for health services planning and GPs training.

METHODS

This study was conducted at 14 community health service centers (CHSCs) in 6 suburban districts of Beijing, using a multistage sampling method. A total of 100 GPs was selected from the study sites. A self-designed data collection form was developed on the basis of Subjective-Objective-Assessment-Plan (SOAP), including patient characteristics, RFEs, health problems, interventions, and consultation length. Each GP recorded and coded their 100 consecutive patients' RFEs and health problems with the International Classification of Primary Care, 2nd version (ICPC-2). Descriptive statistics were employed to describe the distribution of RFE and health problems. Student t-test and analysis of variance were used to compare the differences of mean number of RFE or health problems per encounter by patient characteristics.

RESULTS

A total of 10,000 patient encounters with 13,705 RFEs and 15,460 health problems were recorded. The RFEs and health problems were mainly distributed in respiratory, circulatory, musculoskeletal, endocrine, metabolic and nutritional, and digestive systems. Cough and hypertension were the most common RFE and health problem, respectively. With increased ages, the mean number of RFEs decreased and the mean number of health problems increased. Patients with Beijing medical insurance had less RFEs and more health problems than those in other cities (p<0.001). Patients who had visited the CHSC previously and signed contracts with the GP team had more health problems than those who had not (p<0.001).

CONCLUSIONS

These findings present a view of patients' demands and work contents of GPs in Beijing rural areas and can provide reference for health services planning and GPs training.

Practices and attitudes of doctors and patients to downward referral in Shanghai, China

OBJECTIVES

In China, the rate of downward referral is relatively low, as most people are unwilling to be referred from hospitals to community health systems (CHSs). The aim of this study was to explore the effect of doctors' and patients' practices and attitudes on their willingness for downward referral and the relationship between downward referral and sociodemographic characteristics.

METHODS

Doctors and patients of 13 tertiary hospitals in Shanghai were stratified through random sampling. The questionnaire surveyed their sociodemographic characteristics, attitudes towards CHSs and hospitals, understanding of downward referral, recognition of the community first treatment system, and downward referral practices and willingness. Descriptive statistics, χ2 test and stepwise logistic regression analysis were employed for statistical analysis.

RESULTS

Only 20.8% (161/773) of doctors were willing to accept downward referrals, although this proportion was higher among patients (37.6%, 326/866). Doctors' willingness was influenced by education, understanding of downward referral, and perception of health resources in hospitals. Patients' willingness was influenced by marital status, economic factors and recognition of the community first treatment system. Well-educated doctors who do not consider downward referral would increase their workloads and those with a more comprehensive understanding of hospitals and downward referral process were more likely to make a downward referral decision. Single-injury patients fully recognising the community first treatment system were more willing to accept downward referral. Patients' willingness was significantly increased if downward referral was cost-saving. A better medical insurance system was another key factor for patients to accept downward referral decisions, especially for the floating population.

CONCLUSIONS

To increase the rate of downward referral, the Chinese government should optimise the current referral system and conduct universal publicity for downward referral. Doctors and patients should promote understandings of downward referral. Hospitals should realise the necessity of downward referral, effectively reduce workloads and provide continuing education for doctors. Increasing monetary reimbursement is urgent, as is improving the medical insurance system.

Risk Factors for Chronic Diseases and Multimorbidity in a Primary Care Context of Central Argentina: A Web-Based Interactive and Cross-Sectional Study

Global health agencies estimate an increase of chronic diseases in South America. Nevertheless, few studies have investigated chronic diseases and their risk factors in the perspective of multimorbidity. This research aimed to identify these aspects in a primary health care setting of central Argentina. The Pan America version of the STEP wise approach surveillance (STEPS) instrument of the World Health Organization was applied to 1044 participants, 365 men and 679 women, with a mean age of 43 years. High prevalence of overweight (33.5%), obesity (35.2%), central obesity (54%), dyslipidemia (43.5%), metabolic syndrome (21.1%), low intake of fruit and vegetables (91.8%), low levels of physical activity (71.5%), risky alcohol consumption (28%), and smoking (22.5%) were detected. Hypertension and diabetes were the most prevalent chronic conditions and the total prevalence of multimorbidity was 33.1%, with 2, 3, 4, 5 and 6 chronic conditions found in 19.9%, 9.1%, 2.6%, 1.1% and 0.4% of the population, respectively. Multimorbidity affected 6.4% of the young, 31.7% of the adults, and 60.6% of the elderly, and was more prevalent among women, and in participants with lower levels of education. Having multimorbidity was significantly associated with obesity, central obesity, and higher concentrations of total blood cholesterol, low-density lipoprotein cholesterol, triglycerides, and glucose. A website was made available to the participants in order to share the experimental results and health-promoting information.

The Ecology of Medical Care in Korea

This study aimed to describe the ecology of medical care in Korea. Using the yearly data of 2012 derived from the Korea Health Panel, we estimated the numbers of people per 1,000 residents aged 18 and over who had any health problem and/or any medical care at a variety of care settings, such as clinics, hospitals, and tertiary hospitals, in an average month. There was a total of 11,518 persons in the study population. While the number of those who had any health problem in an average month was estimated to be 939 per 1,000 persons, the estimated numbers of ambulatory care users were 333 at clinics, 101 at hospital outpatient departments, 35 at tertiary hospital outpatient departments, and 38 for Korean Oriental medical providers. The number of people who used emergency care at least once was 7 per 1,000 persons in an average month. The numbers of people hospitalized in clinics and hospitals were 3 and 8, respectively, while 3 persons were admitted to tertiary hospitals. There was a gap between the number of people experiencing any health problem and that of those having any medical care, and primary care comprised a large share of people's medical care experiences. It was noteworthy that more patients received ambulatory care at tertiary hospitals in Korea than in other countries. We hope that discussion about care delivery system reform and further studies will be encouraged.

The Interactive Association of General Obesity and Central Obesity with Prevalent Hypertension in Rural Lanzhou, China

OBJECTIVE

To evaluate the interactive association between obesity with different anthropometry indices and prevalence of hypertension in rural Lanzhou.

METHODS

A cross-sectional survey was conducted in rural Lanzhou from April to July in 2013. The available information of 1275 rural residents aged more than 35 years was collected with a unified questionnaire and their blood pressure and anthropometry indices were measured in the field. The male-to-female ratio was 1:1.1. A generalized estimate equation (GEE) linear model was used to determine the association between obesity with different indexes and hypertension.

RESULTS

There was a moderate prevalence of general obesity (~11%) and very high prevalence of central obesity (53.2~67%) among the adults of rural Lanzhou. The prevalence of hypertension approximated 28%. GEE linear models showed that obesity with any one of anthropometry indices was associated significantly with the increased prevalence of hypertension among both males and females. In females, general obesity increased the prevalence of hypertension by 37% (0.37, 95%CI: 0.27,0.47) but in males by 23% (0.23, 95%CI: 0.12,0.35). The hypertensive effect of all central obesity was much lower than that of general obesity but approximately comparable to that of overweight. In addition, the interactions of the classified body mass index (BMI) and central obesity showed that when general obesity or overweight coexisted with any one of central obesity, the prevalence of hypertension was increased significantly, and this effect was a little higher than the corresponding main effect of general obesity or overweight in females but was much higher in males. In addition, general obesity or overweight which did not coexist with central obesity was not significantly associated with the increased prevalence of hypertension, nor were the other situations of central obesity in the normal weight or underweight except for the situation of central obesity with waist-to-hip ratio in the males of normal weight or underweight.

CONCLUSION

In rural Lanzhou, higher BMI had larger associations with the increased prevalence of hypertension than central obesity indices. Only when general obesity or overweight coexisted with central obesity, the prevalence of hypertension was significantly increased. So, central obesity indices should be used jointly with BMI in evaluating the risk of hypertension.

Review of the Cervical Cancer Burden and Population-Based Cervical Cancer Screening in China

Cervical cancer continues to be a serious public health problem in the developing world, including China. Because of its large population with geographical and socioeconomic inequities, China has a high burden of cervical cancer and important disparities among different regions. In this review, we first present an overview of the cervical cancer incidence and mortality over time, and focus on diversity and disparity in access to care for various subpopulations across geographical regions and socioeconomic strata in China. Then, we describe population-based cervical cancer screening in China, and in particular implementation of the National Cervical Cancer Screening Program in Rural Areas (NACCSPRA) and the challenges that this program faces. These include low screening coverage, shortage of qualified health care personnel and limited funds. To improve prevention of cervical cancer and obtain better cancer outcomes, the Chinese government needs to urgently consider the following key factors: reducing disparities in health care access, collecting accurate and broadly representative data in cancer registries, expanding target population size and increasing allocation of government funding for training of personnel, improving health education for women, enhancing quality control of screening services and improving a system to increase follow up for women with positive results.

Pre- and undiagnosed-hypertension in urban Chinese adults: a population-based cross-sectional study

Hypertension is common in adults and often undiagnosed, and the prevalence of pre- and undiagnosed-hypertension remains unclear. We aimed to investigate the prevalence of pre- and undiagnosed-hypertension and their correlates among urban Chinese adults. A total of 7435 participants aged 20-79 were included in this study. Data on demographics, lifestyle and medical history were collected through a structured interview. Pre- and undiagnosed-hypertension was defined as systolic blood pressure/ diastolic blood pressure (SBP/DBP) of 120-139/80-89 mm Hg and SBP⩾140 mm Hg and/or DBP⩾90 mm Hg, respectively, in participants without a history of hypertension and use of antihypertensive medication. Prevalence rates were calculated and standardized using local age- and gender-specific census data. Data were analysed using multinomial logistic regression with adjustment for potential confounders. Of all the participants, 2726 (36.7%) were diagnosed with pre-hypertension and 919 (12.3%) with undiagnosed-hypertension. Undiagnosed-hypertension accounted for 37.3% of all participants with hypertension. The prevalence of pre-hypertension gradually decreased with age, while undiagnosed-hypertension increased, although presenting different changing patterns among men and women. In a fully adjusted multinomial logistic regression, age, male sex, low socio-economic status (SES), abdominal obesity, alcohol drinking, physical inactivity and type 2 diabetes mellitus (T2DM) were significantly associated with increased odds of pre- and undiagnosed-hypertension. In conclusions, the prevalence of pre- and undiagnosed-hypertension was ~50% among urban Chinese adults. Abdominal obesity, low SES, alcohol drinking, physical inactivity and T2DM may be indicators for pre- and undiagnosed-hypertension.

The availability and affordability of orphan drugs for rare diseases in China

Background

Orphan drugs are intended to treat, prevent or diagnose rare diseases. In recent years, China healthcare policy makers and patients have become increasingly concerned about orphan drug issues. However, very few studies have assessed the availability and affordability of orphan drugs for rare diseases in China. The aim of this study was to provide an overview of the availability and affordability of orphan drugs in China and to make suggestions to improve patient access to orphan drugs.

Methods

Two components of the availability of orphan drugs were examined. Market availability was assessed by the extent to which orphan drugs were marketed in China with a comparison to orphan drugs in international markets, such as the U.S., EU and Japan. We conducted surveys and collected data from 24 tertiary public hospitals in China to measure hospital-level availability of orphan drugs. The affordability of orphan drugs was calculated using hospital dispensary prices and was expressed as days of average daily income required for the cost of a course of treatment. Affordability was also analyzed under the Chinese basic medical insurance system.

Results

Orphan drugs approved in the U.S., EU and Japan had 37.8 %, 24.6 % and 52.4 % market availability in China, respectively. Median availability of 31 orphan drugs surveyed at the 24 tertiary public hospitals was 20.8 % (very low). Within a periodic treatment course, the average treatment cost of 23 orphan drugs is approximately 4, 843. 5 USD, which equates to 505.6 days of per capita net income for an urban resident with a middle income (187.4 days for a high-income urban resident) or 1,582.8 days’s income for a rural resident with a middle income (657.2 days for a high-income rural resident). Except for homoharringtonine, 22 orphan drugs for 14 rare diseases were unaffordable for the most of residents in China. With 5 % out-of-pocket expenses, only three generics could be afforded by middle-income residents, whereas seven drugs for high-income urban residents.

Conclusions

The Chinese government can take more responsibility for improving the availability and affordability of orphan drugs through setting up incentive policies and public platforms for sharing of orphan drug information. Control of the high price of orphan drugs, combined with a joint funding model from both government and private enterprise can efficiently reduce the economic burden of affected patients in China.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-016-0392-4) contains supplementary material, which is available to authorized users.

Physical and mental health conditions of young college students with different Traditional Chinese Medicine constitutions in Zhejiang Province of China

OBJECTIVE

To investigate Traditional Chinese Medicine (TCM) constitutions of youths in colleges, and their physical and mental health conditions of different TCM constitutions, so as to provide a theoretical basis for the TCM way to improve young people's physical and mental health.

METHODS

The Standard TCM Constitutions' Classification and Determination Questionnaire was used to measure the body health condition, and the Symptom Checklist 90 Questionnaire and the Questionnaire of the National Student Physical Health Standards were used to determine mental and physical health conditions respectively in 1421 young participants validly answering the questionnaires in Zhejiang Province.

RESULTS

The participants had a mean age of 19.96 years (SD = 0.95 years) with the majority of females (55.10%). One fourth of the 1421 participants were the Ping-he constitution and others were the tendency constitutions. Participants with Pinghe module (which has characteristics of moderate posture, rosy, energetic and is a healthy condition in TCM) were healthier than those with tendency constitutions in physical and mental health, with 65.81 ± 7.83 (men) and 77.99 ± 7.24 (women) scores in the physical test and around 1.25 scores in the mental health test. College students with combined biased constitutions were more likely suffer force, sensitive, depression and anxiety.

CONCLUSION

Most of college students have a tendency or biased constitution which could be more likely to suffer suboptimal health status and diseases. Youths in college themselves and health providers should pay more attention to their potential health issues and make proper healthcare plan according to their own TCM constitution.

Long-term effect of respiratory training for chronic obstructive pulmonary disease patients at an outpatient clinic: a randomised controlled trial

OBJECTIVE

To assess the effect of respiratory training (RT) on lung function, activity tolerance and acute exacerbation frequency with chronic obstructive pulmonary disease (COPD).

DESIGN

A randomised controlled trial.

SETTING

Outpatient clinic and home of the COPD patients, Zhengzhou City, China.

SUBJECTS

Sixty participants with COPD were randomised into two groups: an intervention group (n = 30) which received the RT in self-management and a control group (n = 30) that received an education program during the study.

INTERVENTION

Pulmonary function, activity tolerance and frequency of acute exacerbation of these COPD patients were evaluated before and after the program. The intervention and control programs were delivered at monthly outpatient clinic visits over a period of 12 months. The pulmonary rehabilitation (PR) program was conducted by a physiotherapist (who delivered RT to the participant over a minimum of 1 h per visit) for the intervention group, whereas the control group received routine health education provided by physiotherapists. The intervention group patients were then instructed to perform exercises at home as taught in the RT at least 5 days per week at home.

RESULTS

After 12 months of RT, the lung function and the activity tolerance of the COPD patients in the intervention group were significantly improved and the exacerbation frequency was also decreased.

CONCLUSION

Long-term RT can improve lung function and activity tolerance while decreasing the frequency of acute exacerbation for COPD patients.

The Association Between Physical Activity, Mental Status, and Social and Family Support with Five Major Non-Communicable Chronic Diseases Among Elderly People: A Cross-Sectional Study of a Rural Population in Southern China

Background: Non-communicable chronic diseases (NCDs) have become the top threat in China. This study aimed to estimate the prevalence of major NCDs among the elderly population in rural areas in southern China and explore its associated social determinants. Methods: A multistage cluster random sampling methodology was adopted to select a total of 9245 rural elderly people from 3860 rural households in Guangdong Province. Interviews and physical examinations were performed to collect patient information. Descriptive and logistic regression analyses were conducted to explore factors associated with the presence of major NCDs. Results: Over one-third (38.5%) of the study population suffered from five major NCDs. The grade of activities of daily living (ADL), mental status, and social relationship of elderly people without NCDs were better than those with NCDs. The major factors associated with the presence of NCDs among the elderly people included age (70–79 years group and 80–89 years group), education level (senior high/technical secondary school and junior college and above), mental status (concentration, enrichment and happy life and memory), relationship with neighbours, activities of daily living (ADL) (being able to climb three floors and bend over), physical activity, marital status (bereft), and living conditions (with offspring and family members). Conclusions: The study identified several social determinants associated with the presence of major NCDs. A higher level of family support and physical exercise might contribute to improved physical condition, mental status, and ADL among the elderly people in rural areas in southern China.

Job burnout and organizational justice among medical interns in Shanghai, People's Republic of China

BACKGROUND

New challenges are occurring in the medical education in Mainland China, and the main risk is the loss of excellent physician candidates. This is due to lack of respect; a large, strong labor force; relatively low remuneration; unstable relationships between patients and doctors; pressures from the public media; and the possible existence of organizational injustice within the hospital. The study reported here looked at one of the in-hospital risks, psychological job burnout and organizational justice, to identify the possible internal cause-effect relationship at the two major general hospitals both affiliated to Shanghai Jiao Tong University School of Medicine.

OBJECTIVE

The aim of the reported study was to analyze the related factors associated with job burnout in Chinese medical interns in Shanghai and to provide some suggestions to better their occupational development.

METHODS

A total of 135 medical interns were investigated and assessed by the Organizational Justice Scale and the Maslach Burnout Inventory - General Survey.

RESULTS

There was a statistically significant negative correlation between organizational justice and job burnout (r=-0.298, P=0.000), suggesting the existence of job burnout among the participant interns. In particular, emotional exhaustion and cynicism were statistically more significant; the comparison between the N group (from Nanjing) and S group (Shanghai) showed significant difference in participation and reduced professional efficacy (P<0.05), with reduced professional efficacy in N group more significant than in S group, and participation in S group more significant than in N group.

CONCLUSION

Job burnout existed among Chinese medical interns, and was associated with fewer complaints and lower professional efficacy. Organizational justice should be promoted more, and school authorities should pay more attention to outside "non-home" interns. Finally, it is essential that the medical interns themselves establish reasonable judgment of their valuable profession.

Epidemiological Characteristics of Hypertension in the Elderly in Beijing, China

Background/Objectives

The prevalence rate of hypertension increases significantly with the aging society, and hypertension is obviously becoming a major health care concern in China. The aim of the study was to explore the epidemiological characteristics of hypertension in the elderly and to provide a basis for the prevention of hypertension.

Design

3-cross sectional studies in 2000, 2004, and 2007, respectively.

Setting

Beijing, China.

Participants

A group of 2,832, 1,828, and 2,277 elderly residents aged ≥60 years were included this study in 2000, 2004, and 2007, respectively.

Intervention

None.

Measurements

Statistical sampling techniques included cluster, stratification, and random selection. Trained staff used a comprehensive geriatric assessment questionnaire and a standard survey instrument to complete the assessments. During the person-to-person interviews, the participants’ demographic characteristics, living conditions, and health status were collected, and their blood pressure was measured.

Results

The prevalence rates (69.2%, 61.9%, and 56.0%) of hypertension and the control rates (22.6%, 16.7%, and 21.5%) lowered annually, while the awareness rates (43.7%, 55.8%, and 57.6%) of the treatment elevated annually in 2000, 2004, and 2007, respectively. There was no increase in the control rates for males (26.2%, 16.7%, and 20.8%), younger participants (28.0%, 18.4%, and 21.0%), and rural residents (19.5%, 9.6%, and 13.4%) in 2000, 2004, and 2007, respectively.

Conclusions

Our study findings indicated that the prevalence of hypertension is high in rural elderly participants, while the rates of awareness, treatment, and control were low. This suggests that effective public measures need to be developed to improve the prevention and control of hypertension.

The length and content of general practice consultation in two urban districts of Beijing: a preliminary observation study

Background

Community health service center (CHSC) and community health service station (CHSS) are the main institutions where general practitioners (GPs) deliver primary care in the urban area of China. Motivated by incentive policies, visits to community health service institutions (CHSIs) increased gradually in recent years, but concerns had been raised on the quality of general practice consultation. This is a preliminary study aimed to investigate the existing problems of general practice consultation in Beijing and provide practical evidence for developing relevant policies.

Methods

Six GPs from 2 CHSCs and 3 CHSSs were selected by purposive sampling. The GPs were observed for 4 or 5 consecutive days during January 2013 to March 2013. The length and content of consultations were recorded in structured observation forms. Quantitative description was applied to describe the median, percentage and frequency of variables.

Results

A total of 1135 consultations were observed. The most frequent reason for consultations was specific prescription (61.6%), followed by presenting symptoms (20.7%), check-up (9.1%), counseling (5.4%), transfusion & injection (3.0%) and sickness certificate (0.2%). The median consultation length of all consultations was 2.0 minutes. The GPs prescribed in 81.0% of the consultations, on the other hand, history taking, physical examination, explanation of illness and health education only took place in 27.0%, 28.0%, 21.9% and 17.7% of the consultations respectively.

Conclusions

The adequacy of consultation length in CHSIs is in doubt. Most patients visited the CHSIs for prescription renewal. Health promotion e.g. health education are not adequately provided in consultations. The quality of general practice consultations was jeopardized by the large amount of patient flow for medicine renewal. Policies should be adjusted to reduce unnecessary consultations. Further studies are in need to evaluate the outcome and influencing factors of general practice consultation in China.

Hypertension prevalence, awareness, treatment and control among Han and four ethnic minorities (Uygur, Hui, Mongolian and Dai) in China

In the previous study, hypertension prevalence, awareness, treatment and control for Han and others four ethnic minorities (Uygur, Hui, Mongolian and Dai) has not been clearly documented in China. Therefore we used the baseline data of Prospective Urban and Rural Epidemiology (PURE) for further detailed study. Adjusted rate were estimated and compared through logistic regression after adjustment of age, sex, location and education. Among the total of 7137 participants (Han: 1626, ethnic minorities: 5511), hypertension prevalence, awareness, treatment and control were 2922(40.9%), 1199(41.0%), 873(29.9%) and 147(5.0%), respectively. The most commonly used antihypertensive drugs are traditional compound drugs (6.2%) and calcium channel blockers (5.2%). Hypertension prevalence in ethnic minorities was significantly higher than in Han (42.4% vs 34.4%, P<0.0001), while control rate (1.6% vs 9.8%, P=0.0198) and treated control rate (8.0% vs 25.0%, P=0.0200) were lower. Compared with Han counterparts, Dai had a higher prevalence (50.8% vs 29.9%, P<0.0001). Uygur had a lower treatment rate (33.2% vs 20.6%, P=0.0110). Mongolian had a lower control (5.1% vs 16.1%, P=0.0046) and treated control rate (14.1% vs 50.3%, P=0.0013). In conclusions, our study showed ethnic minorities had higher hypertension prevalence, especially for Dai and lower control and treated control rate for Mongolian. Hence, we need more attention with respect to hypertension in ethnic minorities.

Challenges to effective cancer control in China, India, and Russia

Cancer is one of the major non-communicable diseases posing a threat to world health. Unfortunately, improvements in socioeconomic conditions are usually associated with increased cancer incidence. In this Commission, we focus on China, India, and Russia, which share rapidly rising cancer incidence and have cancer mortality rates that are nearly twice as high as in the UK or the USA, vast geographies, growing economies, ageing populations, increasingly westernised lifestyles, relatively disenfranchised subpopulations, serious contamination of the environment, and uncontrolled cancer-causing communicable infections. We describe the overall state of health and cancer control in each country and additional specific issues for consideration: for China, access to care, contamination of the environment, and cancer fatalism and traditional medicine; for India, affordability of care, provision of adequate health personnel, and sociocultural barriers to cancer control; and for Russia, monitoring of the burden of cancer, societal attitudes towards cancer prevention, effects of inequitable treatment and access to medicine, and a need for improved international engagement.

Traditional Chinese medicine and new concepts of predictive, preventive and personalized medicine in diagnosis and treatment of suboptimal health

BACKGROUND

The premise of disease-related phenotypes is the definition of the counterpart normality in medical sciences. Contrary to clinical practices that can be carefully planned according to clinical needs, heterogeneity and uncontrollability is the essence of humans in carrying out health studies. Full characterization of consistent phenotypes that define the general population is the basis to individual difference normalization in personalized medicine. Self-claimed normal status may not represent health because asymptomatic subjects may carry chronic diseases at their early stage, such as cancer, diabetes mellitus and atherosclerosis. Currently, treatments for non-communicable chronic diseases (NCD) are implemented after disease onset, which is a very much delayed approach from the perspective of predictive, preventive and personalized medicine (PPPM). A NCD pandemic will develop and be accompanied by increased global economic burden for healthcare systems throughout both developed and developing countries. This paper examples the characterization of the suboptimal health status (SHS) which represents a new PPPM challenge in a population with ambiguous health complaints such as general weakness, unexplained medical syndrome (UMS), chronic fatigue syndrome (CFS), myalgic encephalomyelitis (ME), post-viral fatigue syndrome (PVFS) and chronic fatigue immune dysfunction syndrome (CFIDS).

METHODS

We applied clinical informatic approaches and developed a questionnaire-suboptimal health status questionnaire-25 (SHSQ-25) for measuring SHS. The validity and reliability of this approach were evaluated in a small pilot study and then in a cross-sectional study of 3,405 participants in China.

RESULTS

We found a correlation between SHS and systolic blood pressure, diastolic blood pressure, plasma glucose, total cholesterol and high-density lipoprotein (HDL) cholesterol among men, and a correlation between SHS and systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides and HDL cholesterol among women.

CONCLUSIONS

The SHSQ-25 is a self-rated questionnaire of perceived health complaints, which can be used as a new instrument for PPPM. An ongoing longitudinal SHS cohort survey (China Sub-optimal Health Cohort Study, COACS) consisting of 50,000 participants will provide a powerful health trial to use SHSQ-25 for its application to PPPM through patient stratification and therapy monitoring using innovative technologies of predictive diagnostics and prognosis: an effort of paradigm shift from reactive to predictive medicine.