Medication adherence and costs of medical care among patients with Parkinson's disease: an observational study using electronic medical records.

BACKGROUND: Adherence to antiparkinsonian drugs (APDs) is critical for patients with Parkinson's disease (PD), for which medication is the main therapeutic strategy. Previous studies have focused on specific disorders in a single system when assessing clinical factors affecting adherence to PD treatment, and no international comparative data are available on the medical costs for Chinese patients with PD. The present study aimed to evaluate medication adherence and its associated factors among Chinese patients with PD using a systematic approach and to explore the impact of adequate medication adherence on direct medical costs. METHODS: A retrospective analysis was conducted using the electronic medical records of patients with PD from a medical center in China. Patients with a minimum of two APD prescriptions from January 1, 2016 to August 15, 2018 were included. Medication possession ratio (MPR) and proportion of days covered were used to measure APD adherence. Multiple linear regression analysis was used to identify factors affecting APD adherence. Gamma regression analysis was used to explore the impact of APD adherence on direct medical costs. RESULTS: In total, 1,712 patients were included in the study, and the mean MPR was 0.68 (± 0.25). Increased number of APDs and all medications, and higher daily levodopa-equivalent doses resulted in higher MPR (mean difference [MD] = 0.04 [0.03-0.05]; MD = 0.02 [0.01-0.03]; MD = 0.03 [0.01-0.04], respectively); combined digestive system diseases, epilepsy, or older age resulted in lower MPR (MD = -0.06 [-0.09 to -0.03]; MD = -0.07 [-0.14 to -0.01]; MD = -0.02 [-0.03 to -0.01], respectively). Higher APD adherence resulted in higher direct medical costs, including APD and other outpatient costs. For a 0.3 increase in MPR, the two costs increased by $34.42 ($25.43-$43.41) and $14.63 ($4.86-$24.39) per year, respectively. CONCLUSIONS: APD adherence rate among Chinese patients with PD was moderate and related primarily to age, comorbidities, and healthcare costs. The factors should be considered when prescribing APDs.

Socioeconomic inequalities in depressive symptoms in China: The role of social capital.

This cohort study used the China Health and Retirement Longitudinal Study (CHARLS, 2015-2018) to investigate the effects of socioeconomic status and social capital to the incidence of depressive symptoms among middle-aged and older individuals in China, incorporating a sample size of 9949 participants. Socioeconomic status, social capital and other explanatory variables were collected in 2015, while depressive symptoms were assessed in 2018. Basic characteristics and social capital measures were compared between urban and rural residents using the chi-square test. Logistic regression was used to explore the relationship between socioeconomic status, social capital and depressive symptoms, and the Karlson, Holm, and Breen (KHB) method was employed to verify the mediating role of social capital. We reported persistent socioeconomic inequalities in depressive symptoms, with rural residents and the illiterate having 1.45 times and 1.34 times higher odds of depression. We ascertained social capital from both the cognitive and structural constructs, where we enriched the measurement of structural social capital from three specific dimensions, i.e., informal interaction, altruism, and formal social participation. We found that both cognitive and structural social capital were associated with lower incidence of depressive symptoms, where informal interaction had the largest effect. The mediation analysis further illustrated that informal interaction contributed most to explain 6 %-12 % of the socioeconomic inequalities in depressive symptoms. These results highlighted the unsatisfied mental wellbeing of the vulnerable older people living in rural areas. The finding suggested that older people may benefit more from personal interactions than formal participations. To fulfill the Health in All vision, government and social organizations should consider how to create opportunities to better integrate the older people into the community.

Tracking progress towards universal health coverage for essential health services in China, 2008-2018.

INTRODUCTION: We comprehensively evaluate whether the Chinese Government's goal of ensuring Universal Health Coverage for essential health services has been achieved. METHODS: We used data from the 2008, 2013 and 2018 National Health Services Survey to report on the coverage of a range of Sustainable Development Goals (SDG) indicator 3.8.1. We created per capita household income deciles for urban and rural samples separately. We report time trends in coverage and the slope index (SII) and relative index (RII). RESULTS: Despite much lower levels of income and education, rural populations made as much progress as their urban counterparts for most interventions. Coverage of maternal and child health interventions increased substantially in urban and rural areas, with decreasing rich-poor inequalities except for antenatal care. In rural China, one-fifth women could not access 5 or more antenatal visits. Coverage of 8 or more visits were 34% and 68%, respectively in decile D1 (the poorest) and decile D10 (the richest) (SII 35% (95% CI 22% to 48%)). More than 90% households had access to clean water, but basic sanitation was poor for rural households and the urban poorest, presenting bottom inequality. Effective coverage for non-communicable diseases was low. Medication for hypertension and diabetes were relatively high (>70%). But adequate management, counting in preventive interventions, were much lower and decreased overtime, although inequalities were small in size. Screening of cervical and breast cancer was low in both urban and rural areas, seeing no progress overtime. Cervical cancer screening was only 29% (urban) and 24% (rural) in 2018, presenting persisted top inequalities (SII 25% urban, 14% rural). CONCLUSION: China has made commendable progress in protecting the poorest for basic care. However, the 'leaving no one behind' agenda needs a strategy targeting the entire population rather than only the poorest. Blunt investing in primary healthcare facilities seems neither effective nor efficient.

Quality Assessment of Hypertension Treatment-Related Information on WeChat: Cross-sectional Study.

BACKGROUND: The WeChat platform has become a primary source for medical information in China. However, no study has been conducted to explore the quality of information on WeChat for the treatment of hypertension, the leading chronic condition. OBJECTIVE: This study aimed to explore the quality of information in articles on WeChat that are related to hypertension treatment from the aspects of credibility, concreteness, accuracy, and completeness. METHODS: We searched for all information related to hypertension treatment on WeChat based on several inclusion and exclusion criteria. We used 2 tools to evaluate information quality, and 2 independent reviewers performed the assessment with the 2 tools separately. First, we adopted the DISCERN instrument to assess the credibility and concreteness of the treatment information, with the outcomes classified into five grades: excellent, good, fair, poor, and very poor. Second, we applied the Chinese Guidelines for Prevention and Treatment of Hypertension (2018 edition) to evaluate the accuracy and completeness of the article information with regard to specific medical content. Third, we combined the results from the 2 assessments to arrive at the overall quality of the articles and explored the differences between, and associations of, the 2 independent assessments. RESULTS: Of the 223 articles that were retrieved, 130 (58.3%) full texts were included. Of these 130 articles, 81 (62.3%) described therapeutic measures for hypertension. The assessment based on the DISCERN instrument reported a mean score of 31.22 (SD 8.46). There were no articles rated excellent (mean score >63); most (111/130, 85.4%) of the articles did not refer to the consequences-in particular, quality of life-of no treatment. For specific medical content, adherence to the Chinese Guidelines for Prevention and Treatment of Hypertension was generally low in terms of accuracy and completeness, and there was much erroneous information. The overall mean quality score was 10.18 (SD 2.22) for the 130 articles, and the scores differed significantly across the 3 types (P=.03) and 5 sources (P=.02). Articles with references achieved higher scores for quality than those reporting none (P<.001). The results from the DISCERN assessment and the medical content scores were highly correlated (ρ=0.58; P<.001). CONCLUSIONS: The quality of hypertension treatment-related information on the WeChat platform is low. Future work is warranted to regulate information sources and strengthen references. For the treatment of hypertension, crucial information on the consequences of no treatment is urgently needed.

Can case-based payment contain healthcare costs? - A curious case from China.

We adopted a difference-in-difference (DID) design to evaluate the impact of a case-based payment pilot in Tianjin, China on hospital admission, utilization of varied therapeutic regimes, and the associated costs. We used claim data of all admissions of angina and acute myocardial infarction during July 2015 to June 2018, 18 months before and after the program. Our analyses were supported by convincing common trends tests and a couple of sensitivity analyses. As intended, for patients who received percutaneous coronary stenting (PCS) and were counted in the case-based payment system, we showed that the program decreased length-of-stay, per-admission spending, and out-of-pocket spending by 20.8%, 14.2%, and 95.5%, respectively, but did not increase readmissions. However, when considering all patients who suffered from the two types of coronary heart diseases, we found that the program otherwise increased per-admission spending by nearly 11%. As a result, the program took a perverse effect in increasing monthly spending for the health insurance scheme and the society by 1005.6 thousand USD (47·5%) and 1095·7 thousand USD (34·7%), respectively. Increases in hospital admissions, and proportion of performing PCS accounted for 66·7% and 39·2% of the rise, respectively. In addition, our analysis provided evidence of health providers' cream-skimming behaviors, including selecting younger patients with lower CCI in the case-based system, up-coding complications, and keeping higher cost patients in the fee-for-service payment system. We draw lessons that case-based payment may make an unintended impact that increases healthcare costs when incentives are not properly designed.

Cost-Effectiveness of Presbyopia Correction Among Seven Strategies of Bilateral Cataract Surgery Based on a Prospective Single-Blind Two-Center Trial in China.

INTRODUCTION: The aim of this study was to explore a method to rank the cost-effectiveness of presbyopia correction in diverse strategies of bilateral cataract surgery to provide references for healthcare policymakers in rationalizing resource utilization and surgeons in customizing patient management. METHODS: The cost-effectiveness analysis based on a prospective single-blind two-center clinical trial included seven strategies in bilateral cataract surgery: monofocal, monovision, diffractive bifocal, blended, refractive bifocal, trifocal, and extended depth of focus (EDOF) strategies. The effectiveness according to the objective spectacle independence rate (hereafter "rate", a novel indicator defined as the proportion of patients with binocular uncorrected distance, intermediate and near visual acuity all better than 0.1 logMAR, logarithm of the minimum angle of resolution), costs, average cost-effectiveness ratios (ACERs, $/1% rate), and incremental cost-effectiveness ratios (ICERs, $/1% incremental rate) were estimated. RESULTS: In 194 participants (388 eyes), the trifocal strategy achieved the highest rate [93.10% (95% confidence interval (CI) 83.8-102.35%)]. The refractive bifocal strategy had the minimum ACER [$45.54/1% rate (95% CI 34.57-56.50)], followed by the blended [$59.10/1% rate (95% CI 31.72-86.48)], diffractive bifocal [$69.06/1% rate (95% CI 30.89-107.21)], EDOF [$72.85/1% rate (95% CI 52.02-93.70)], trifocal [$93.01/1% rate (95% CI 83.23-102.79)], monovision [$136.83/1% rate (95% CI - 55.40 to 329.14)], and monofocal [$264.45/1% rate (95% CI - 97.45 to 626.55)] strategies. Compared with the refractive bifocal strategy, the probabilities that the trifocal strategy (ICER $289.74/1% incremental rate) is very cost-effective and cost-effective were 81.7% and 93.2%, respectively, at the wiliness-to-pay threshold of one and three times China's annual disposable income per capita in 2021 per 10% incremental rates. CONCLUSIONS: Cost-effectiveness analysis with ACER and ICER according to objective spectacle independence rate is a helpful tool to identify highly cost-effective presbyopia-correcting strategies in cataract surgery for clinical and policy decisions. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04265846).

Factors affecting the frequency and contents of routine antenatal care in remote rural China in 2009-2016: An observational study.

OBJECTIVE: We assessed factors associated with the frequency and contents of antenatal care (ANC) in remote rural China, including the province of residence and individual-level factors. DESIGN: Survey-based cross-sectional study. SETTING: Five provinces in remote rural China: Guizhou, Hunan, Jilin, Ningxia and Shaanxi. SAMPLE: A cohort of 3918 women with a live birth in 2009-2016. METHODS: Poisson regression. MAIN OUTCOME MEASURES: ANC frequency: five or more visits, starting in the first trimester. ANC contents: coverage of six care components and overuse of ultrasound. RESULTS: Three-quarters (72.9%) of women had five or more ANC visits, starting in the first trimester; 68.8% received all six care components and 94.5% had three or more ultrasounds. Only 30.9% of women sought ANC from township hospitals, paying between $3.80 and $25.80 per visit. ANC frequency and contents were associated with the socio-economic characteristics of the women, but provincial effects were much greater, even after adjusting for individual factors. Women living in Guizhou and Ningxia, the two poorest provinces, with high proportions of ethnic minorities, were particularly underserved. Compared with women in Shaanxi, women in Guizhou were 33% (adjusted RR 0.67, 95% CI 0.61-0.74) less likely to receive five or more ANC visits, starting in the first trimester; women in Ningxia were 17% less likely (adjusted RR 0.83, 95% CI 0.76-0.90) to receive all six care components. CONCLUSIONS: The province of residence was a stronger predictor of ANC frequency and contents than the individual characteristics of women in China, suggesting that strengthening the decentralised system of the financing and organisation of ANC at the province level is crucial for achieving success. Future efforts are warranted to engage subregional administrations. TWEETABLE ABSTRACT: The province of residence was a stronger predictor of ANC frequency and contents than the individual characteristics of women.

The impact of the reference pricing policy in China on drug procurement and cost.

High drug costs are putting pressures on health care budgets and posing an obstacle for China to achieve universal coverage. Policies such as the direct price ceiling, and the Essential Medicines Program-with the Zero Markup Drug Policy (ZMDP) one key component-were implemented, coming out with limited evidence for a success. As a benchmark of China's recent health reform, Sanming city initiated the ZMDP in January 2013; and further piloted the first reference pricing (RP) policy in China in September 2014, with the intention to dis-incentivize the use of costly original drugs. In this study, we used hospital-based drug procurement data of 14 drug substances that were subjected to the RP, from four hospitals in Sanming and a neighbouring city Longyan, between 2012 and 2016. Adopting the difference-in-difference (DID) approach, we evaluated the impacts of the RP together with the ZMDP. On the one hand, we found that the ZMDP had no impact on drugs' procurement prices, volumes and costs. While on the other hand, we found that the introduction of RP was not associated with changes in unit prices for the 14 drugs in Sanming. However, the RP pilot was associated with a 25.9% [95% confidence interval (CI), 12.9-37.0%] decrease in monthly drug procurement volumes and a 47.7% (95% CI, 33.7-58.7%) decrease in the total drug costs. In particular, it reduced the procurement volumes of original drugs by 56.8% (95% CI, 47.0-64.7%). Subgroup analyses by hospital level and therapeutic class found similar results. We draw lessons for the Chinese government to experiment RP on a larger scale, considering the development and effective regulation of the generic market. This is a first report on the effects of RP in China, Asia and middle-income countries.

Short-Term Ambient Particulate Air Pollution and Hospitalization Expenditures of Cause-Specific Cardiorespiratory Diseases in China: A Multicity Analysis.

BACKGROUND: Ambient air pollution is leading risk factor for health burden in China. Few studies in China have investigated the economic loss related to short-term exposure to ambient PM2.5, which could trigger acute onset of cardiorespiratory diseases within a few days. METHODS: Daily ambient air pollutants data are obtained for each city from the National Air Quality Monitoring System and daily hospitalization data are obtained from the urban employee-based basic medical insurance scheme database in 74 Chinese cities with an average coverage of 88.5 million urban employees during 2016-2017. A three-stage time-series analytic approach is used in this study to investigate the impact of short-term exposure to ambient fine particulate (PM2.5) air pollution on hospital admissions, expenses and hospital stays of three cause-specific cardiorespiratory diseases, including lower respiratory infections (LRI), coronary heart disease (CHD) and stroke in the included cities. FINDINGS: Based on the time-series analysis using daily hospitalization data, 28,560 LRI cases, 54,600 CHD cases, and 23,989 stroke cases are attributable to ambient PM2.5 in the 74 cities during the study period, and the related attributable expenses are 220 million CNY (US$ 32.9 million) for LRI, 458 million CNY (US$ 68.5 million) for CHD, and 410 million CNY (US$ 65.8 million) for stroke, respectively. These attributable numbers account for 1.45% to 2.05% of total hospital admissions and 1.10% to 1.51% of total expenses for the three diseases during 2016-2017, respectively. The attributable numbers for the three cause-specific cardiorespiratory diseases would increase to 362,007 hospital admission cases and 3.68 billion CNY expenses ($US550 million) in the entire urban employee population (299 million) in China during 2016-2017, and the related direct economic loss of absence from work would be 798 million CNY (US$ 119.3 million). INTERPRETATION: Our results support that short-term exposure to ambient PM2.5 pollution could lead to significant health and economic impacts in China. Reducing levels of ambient PM2.5 can avoid substantial health damage and expenditures, and generate appreciable economic benefits from decreasing absence from work. FUNDING: Natural Science Foundation of China (82073509, 71903010, 71903011), and the National Key Research and Development Program of China (2017YFC0211600, 2017YFC0211601).

Socio-economic inequalities in the chronic diseases management among Chinese adults aged 45 years and above: a cross sectional study.

BACKGROUNDS: Non-communicable diseases (NCDs) have become a priority public health issue. The aim of this study was to examine whether socio-economic inequalities exist in chronic disease management among Chinese adults, and whether the relationship between SES and chronic disease management mediated by social capital. METHODS: We used combined data from China Health and Retirement Longitudinal Study (CHARLS). A total of 19,291 subjects, including 14,905 subjects from 2011 survey, 2036 subjects from 2013, and 2350 subjects from 2015 was included in this study. RESULTS: Subjects living in urban setting, with higher education attainment and economic status were more likely to have annual health checks, and to be diagnosed for those with hypertension, diabetes and dyslipidemia (all P < 0.05). Social participation could mediate the association between social economic status (SES) and annual health checks, diagnosis of hypertension and dyslipidemia, and health education of hypertension. Health checks could mediate the association between social participation and the diagnosis of hypertension, diabetes and dyslipidemia. The proportions of mediation were 17.5, 23.9 and 8.9%, respectively. There were no mediating effects observed from cognitive social capital variable-perceived helpfulness. CONCLUSION: It is necessary to deeply reform our social security system and enhance the social capital construction to promote those low SES people's physical health.

Equity in Essential Maternal, Newborn, and Child Health Interventions in Northeastern China, 2008 to 2018.

Objectives: We aim to analyze equity in maternal, newborn, and child health (MNCH) interventions in Jilin, a northeastern province of China, 2008-2018. Study design: Cross-sectional study. Methods: We used provincially representative survey data from 2008, 2013, and 2018. We included 18 essential MNCH interventions, analyzed equity, and calculated the composite coverage score. We used logistic and multiple linear regressions to adjust sampling clusters and covariates. Results: Coverage of hospital-based interventions, such as hospital delivery and antenatal B-ultrasound tests, was nearly universal in Jilin province. Cesarean sections persisted at alarmingly high rates (57.6%). Enormous unmet needs and rural-urban inequalities existed for community-based interventions, such as improved drinking water sources (85.4 vs. 97.9%, p < 0.01), improved sanitation facilities (52.5 vs. 94.2%, p < 0.01), four government-funded antenatal care services (55.8 vs. 84.1%, p < 0.01), and at least eight antenatal care sessions (26.8 vs. 46.3%, p < 0.05). Compared to rural-urban inequity, individual-level disparities across income and education were either small in scale or statistically insignificant. The inequity in coverage of maternal and newborn care shrank during 2008-2018. Conclusions: Despite its success in reducing mortality, China's unique obstetrician-led safe motherhood strategy may come at the cost of over-medicalization and health inequity. Jilin province's recent efforts to revitalize primary health care show the potential to make a change. An integrated system that links families, communities, and all levels of health care organizations seems to be the most effective and efficient model to offer continuing MNCH care.

Undiagnosed and Uncontrolled Chronic Conditions in China: Could Social Health Insurance Consolidation Make a Change?

Policy makers in China are considering consolidating the country's fragmented health insurance programs. This system consists of three components. The Urban Employee Basic Medical Insurance (UEBMI) covers formal employees, the New Cooperative Medical Scheme (NCMS) covers rural residents, and the Urban Resident Basic Medical Insurance (URBMI) covers urban residents. Consolidation could, in theory, create a more efficient health system that is better able to address noncommunicable diseases. Using national survey data during 2011 to 2013, I found that 44% to 76% cases of hypertension, diabetes, and dyslipidemia went undiagnosed among Chinese adults aged 45 and older. I found that the UEBMI enrollees had a greater number of health checks and 10% higher rates of diagnosis. Assuming that this level of efficiency would be possible under an integrated system, I conducted microsimulation analyses to project future benefits. Such consolidation could result in 46.2 million new diagnoses, and 30.0 million of these cases would be controlled.

Extending access to essential services against constraints: the three-tier health service delivery system in rural China (1949-1980).

BACKGROUND: China has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas. This was partly achieved through the building of a three-tier health system in the 1950s, established as a linked network with health service facilities at county, township and village level, to extend services to the whole population. METHODS: We developed a Theory of Change to chart the policy context, contents and mechanisms that may have facilitated the establishment of the three-tier health service delivery system in rural China. We systematically synthesized the best available evidence on how China achieved universal access to essential services in resource-scarce rural settings, with a particular emphasis on the experiences learned before the 1980s, when the country suffered a particularly acute lack of resources. RESULTS: The search identified only three peered-reviewed articles that fit our criteria for scientific rigor. We therefore drew extensively on government policy documents, and triangulated them with other publications and key informant interviews. We found that China's three-tier health service delivery system was established in response to acute health challenges, including high fertility and mortality rates. Health system resources were extremely low in view of the needs and insufficient to extend access to even basic care. With strong political commitment to rural health and a "health-for-all" policy vision underlying implementation, a three-tier health service delivery model connecting villages, townships and counties was quickly established. We identified several factors that contributed to the success of the three-tier system in China: a realistic health human resource development strategy, use of mass campaigns as a vehicle to increase demand, an innovative financing mechanisms, public-private partnership models in the early stages of scale up, and an integrated approach to service delivery. An implementation process involving gradual adaptation and incorporation of the lessons learnt was also essential. CONCLUSIONS: China's 60 year experience in establishing a de-professionalized, community-based, health service delivery model that is economically feasible, institutionally and culturally appropriate mechanism can be useful to other low- and middle-income countries (LMICs) seeking to extend essential services. Lessons can be drawn from both reform content and from its implementation pathway, identifying the political, institutional and contextual factors shaping the three-tier delivery model over time.

Health care-seeking behaviours and health expenditures in adults aged 45 years and older in China, 2011-2013.

OBJECTIVES: To provide an assessment of China's progress to universal health coverage (UHC) from the perspective of people-centred care. METHODS: We obtained data on 28 103 participants from the China Health and Retirement Longitudinal Study (CHALRS) during 2011-2013. We used logistic regressions and generalised linear models to analyse care-seeking behaviours and medical expenditures. RESULTS: We found that 95.5% of the subjects were covered by social health insurance in 2013, and nearly 60% subjects in need of medical care were self-medicated. Health insurance was a strong predictor for the access to outpatient care. Use of pure and mixed self-medication increased by 15% and 32% respectively, while use of pure outpatient care fell by 10% between 2011 and 2013, after adjusting for predisposing, service needs and enabling factors. Such trends were particularly evident for the Urban Resident Basic Medical Insurance and the New Cooperative Medical Scheme, which covered more than 80%. The monthly out-of-pocket medical expenditures and the probability of encountering catastrophic health expenditures for outpatient care were four times larger than that for self-medication. Between 2011 and 2013, outpatient care medical costs rose by nearly 50%, whereas there was no such obvious trend for self-medication. People with insurance schemes offering lower cost sharing incurred consistently higher out-of-pocket outpatient payments. CONCLUSIONS: The monitoring of global progress to UHC should incorporate self-medication. In China, it seems that the current reform and the huge government investment have not resulted in access to affordable quality care. To achieve UHC, not only universal insurance, but system-level efforts are needed.

Health system strengthening and hypertension awareness, treatment and control: data from the China Health and Retirement Longitudinal Study.

OBJECTIVE: To monitor hypertension prevalence, awareness, treatment and control in China two to three years after major reform of the health system. METHODS: Data from a national survey conducted in 2011-2012 among Chinese people aged 45 years or older - which included detailed anthropometric measurements - were used to estimate the prevalence of hypertension and the percentages of hypertensive individuals who were unaware of, receiving no treatment for, and/or not controlling their hypertension well. Modified Poisson regressions were used to estimate relative risks (RRs). FINDINGS: At the time of the survey, nearly 40% of Chinese people aged 45 years or older had a hypertensive disorder. Of the individuals with hypertension, more than 40% were unaware of their condition, about 50% were receiving no medication for it and about 80% were not controlling it well. Compared with the other hypertensive individuals, those who were members of insurance schemes that covered the costs of outpatient care were more likely to be aware of their hypertension (adjusted RR, aRR: 0.737; 95% confidence interval, CI: 0.619-0.878) to be receiving treatment for it (aRR: 0.795; 95% CI: 0.680-0.929) and to be controlling it effectively (aRR: 0.903; 95% CI: 0.817-0.996). CONCLUSION: In China many cases of hypertension are going undetected and untreated, even though the health system appears to deliver effective care to individuals who are aware of their hypertension. A reduction in the costs of outpatient care to patients would probably improve the management of hypertension in China.

Social, economic, political and health system and program determinants of child mortality reduction in China between 1990 and 2006: A systematic analysis.

BACKGROUND: Between 1990 and 2006, China reduced its under-five mortality rate (U5MR) from 64.6 to 20.6 per 1000 live births and achieved the fourth United Nation's Millennium Development Goal nine years ahead of target. This study explores the contribution of social, economic and political determinants, health system and policy determinants, and health programmes and interventions to this success. METHODS: For each of the years between 1990 and 2006, we obtained an estimate of U5MR for 30 Chinese provinces from the annual China Health Statistics Yearbook. For each year, we also obtained data describing the status of 8 social, 10 economic, 2 political, 9 health system and policy, and six health programmes and intervention indicators for each province. These government data are not of the same quality as some other health information sources in modern China, such as articles with primary research data available in Chinese National Knowledge Infrastructure (CNKI) and Wan Fang databases, or Chinese Maternal and Child Mortality Surveillance system. Still, the comparison of relative changes in underlying indicators with the undisputed strong general trend of childhood mortality reduction over 17 years should still capture the main effects at the macro-level. We used multivariate random effect regression models to determine the effect of 35 indicators individually and 5 constructs defined by factor analysis (reflecting effects of social, economic, political, health systems and policy, and health programmes) on the reduction of U5MR in China. RESULTS: In the univariate regression applied with a one-year time lag, social determinants of health construct showed the strongest crude association with U5MR reduction (R(2) = 0.74), followed by the constructs for health programmes and interventions (R(2) = 0.65), economic (R(2) = 0.47), political (R(2) = 0.28) and health system and policy determinants (R(2) = 0.26), respectively. Similarly, when multivariate regression was applied with a one-year time lag, the social determinants construct showed the strongest effect (beta = 11.79, P < 0.0001), followed by the construct for political factors (beta = 4.24, P < 0.0001) and health programmes and interventions (beta = -3.45, P < 0.0001). The 5 studied constructs accounted for about 80% of variability in U5MR reduction across provinces over the 17-year period. CONCLUSION: Vertical intervention programs, health systems strengthening or economic growth alone may all fail to achieve the desired reduction in child mortality when improvement of the key social determinants of health is lagging behind. To accelerate progress toward MDG4, low- and middle-income countries should undertake appropriate efforts to promote maternal education, reduce fertility rates, integrate minority populations and improve access to clean water and safe sanitation. A cross-sectoral approach seems most likely to have the greatest impact on U5MR.

Factors influencing rising caesarean section rates in China between 1988 and 2008.

OBJECTIVE: To identify factors driving the rapid increase in caesarean section in China between 1988 and 2008. METHODS: Data from four national cross-sectional surveys (1993, 1998, 2003 and 2008) and modified Poisson regression were used to determine whether changes in household income, access to health insurance or women's education accounted for the rise in caesarean sections in urban and rural areas. FINDINGS: In 2008, 64.1% of urban women and 11.3% of women in the poorest rural region reported giving birth by caesarean section. A fast rise was occurring in all socioeconomic groups. Between 1993 and 2008, the risk of caesarean section had increased more than threefold in urban areas (relative risk, RR: 3.63; 95% confidence interval, CI: 2.61-5.04) and more than 15-fold in rural areas (RR: 15.46; 95% CI: 10.46-22.86). After adjustment for improvements in income, education and access to health insurance over the study period, the RR dropped minimally in urban areas (RR: 3.07; 95% CI: 2.32-4.07), which suggests that these factors do not explain the rise; in rural areas, the adjusted RR dropped to 7.18 (95% CI: 4.82-10.69), which shows that socioeconomic change is only partly responsible for the rise. Socioeconomic region of residence was a more important driver of the caesarean section rate than individual socioeconomic status. CONCLUSION: The large variation in caesarean section rate by socioeconomic region--independent of individual income, health insurance or education--suggests that structural factors related to service supply have influenced the increasing rate more than a woman's ability to pay.

China's facility-based birth strategy and neonatal mortality: a population-based epidemiological study.

BACKGROUND: China's success in improving the quality of and access to obstetric care in hospitals offers an opportunity to examine the effect of a large-scale facility-based strategy on neonatal mortality. We aimed to establish this effect by assessing how the institutional strategy of intrapartum care has affected neonatal mortality and its regional inequalities. METHODS: We did a population-based epidemiological study of China's National Maternal and Child Mortality Surveillance System from 1996 to 2008. We used data from 116 surveillance sites in China (37 urban districts and 79 rural counties) to examine neonatal mortality by cause, socioeconomic region, and place of birth, with Poisson regression to calculate relative risks. Rural counties were categorised into types 1-4, with type 4 being the least developed. We report attributable risks and preventable fractions for hospital births versus home births. FINDINGS: Neonatal mortality decreased by 62% between 1996 and 2008. The rate of neonatal mortality was much lower for hospital births than for home births in all regions, with relative risks (RR) ranging from 0·30 (95% CI 0·22-0·40) in type 2 rural counties, to 0·52 (0·33-0·83) in type 4 counties (p<0·0001). The proportion of neonatal deaths prevented by hospital birth ranged from 70% (95% CI 59·7-77·8) to 48% (16·9-67·3). Babies born in urban hospitals had a low rate of neonatal mortality (5·7 per 1000 livebirths); but those born in hospitals in type 4 rural counties were almost four times more likely to die than were children born in urban hospitals (RR 3·80, 2·53-5·72). INTERPRETATION: Other countries can learn from China's substantial progress in reducing neonatal mortality. The major effect of China's facility-based strategy on neonatal mortality is much greater than that reported for community-based interventions. Our findings will provide a great impetus for countries to increase demand for and quality of facility-based intrapartum care. FUNDING: China Medical Board, UNICEF China.

Socioeconomic inequalities in hospital births in China between 1988 and 2008.

OBJECTIVE: To assess trends in hospital births in China during 1988-2008 in an effort to determine if efforts to overcome financial barriers to giving birth in hospital have reduced the access gap between the rich and the poor. METHODS: Cross-sectional data obtained from four National Health Service Surveys were used to determine trends in hospital births during 1988-2008. Crude and adjusted annual rates were calculated by means of Poisson regression and were used to define trends across socioeconomic regions and households in different income quintiles. FINDINGS: In 2008 women throughout China were giving birth in hospital almost universally except in region IV, the most remote rural region, where the percentage of hospital births was only 60.8. Hospital births in this region had increased steadily before 2002, but after that year the upward trend slowed down. During 1988-2001 the average yearly increase had been 21%, but in 2002-2008 it dropped to 10% (P = 0.0031). Inequalities between socioeconomic regions were greater than among individual households belonging to different income strata. By 2008 the difference between low- and high-income households in the proportion of hospital births had become very small (96.1% and 87.7% of high- and low-income households, respectively, gave birth in hospital that year). CONCLUSION: Most Chinese women now give birth in hospital, but the poorest rural region is still lagging behind. A more active and comprehensive approach will be needed to increase hospital births in these remote, hard-to-reach populations.

Regional disparities in child mortality within China 1996-2004: epidemiological profile and health care coverage.

OBJECTIVE: China was one of the 68 "countdown" countries prioritized to attain Millennium Development Goals (MDG 4). The aim of this study was to analyze data on child survival and health care coverage of proven cost-effective interventions in China, with a focus on national disparities. METHODS: National maternal and child mortality surveillance data were used to estimate child mortality. Coverage for proven interventions was analyzed based on data from the National Health Services Survey, National Nutrition and Health Survey, and National Immunization Survey. Consultations and qualitative field observations by experts were used to complement the Survey data. RESULTS: Analysis of the data revealed a significant reduction in the overall under-5 (U5) child mortality rate in China from 1996 to 2007, but also great regional disparities, with the risk of child mortality in rural areas II-IV being two- to sixfold higher than that in urban areas. Rural areas II-IV also accounted for approximately 80% of the mortality burden. More than 60% of child mortality occurred during the neonatal period, with 70% of this occurring during the first week of life. The leading causes of neonatal mortality were asphyxia at birth and premature birth; during the post-neonatal period, these were diarrhea and pneumonia, especially in less developed rural areas. Utilization of health care services in terms of both quantity and quality was positively correlated with the region's development level. A large proportion of children were affected by inadequate feeding, and the lack of safe water and essential sanitary facilities are vital indirect factors contributing to the increase in child mortality. The simulation analysis revealed that increasing access to and the quality of the most effective interventions combined with relatively low costs in the context of a comprehensive approach has the potential to reduce U5 deaths by 34%. CONCLUSIONS: China is on track to meet MDG 4; however, great disparities in health care do exist within the country. It is therefore necessary to specifically target rural areas II-IV. Many causes of child mortality can be prevented or averted through the provision of basic health care. However, the leading predisposing factor contributing to child mortality in China is the insufficient coverage and poor quality of maternal and child health care services. Based on these data, we recommend that the government put more effort to ensure the health of the Chinese people, particularly in terms of providing the most vulnerable populations, i.e., children from the poorest areas and households, with access to good quality essential health care services.