Assessment of Early Glaucomatous Optic Neuropathy in the Dog by Spectral Domain Optical Coherence Tomography (SD-OCT).

BACKGROUND: Inherited primary open-angle glaucoma (POAG) in Beagle dogs is a well-established large animal model of glaucoma and is caused by a G661R missense mutation in the ADAMTS10 gene. Using this model, the study describes early clinical disease markers for canine glaucoma. METHODS: Spectral-domain optical coherence tomography (SD-OCT) was used to assess nine adult, ADAMTS10-mutant (median age 45.6 months, range 28.8-52.8 months; mean diurnal intraocular pressure (IOP): 29.9 +/- SEM 0.44 mmHg) and three related age-matched control Beagles (mean diurnal IOP: 18.0 +/- SEM 0.53 mmHg). RESULTS: Of all the optic nerve head (ONH) parameters evaluated, the loss of myelin peak height in the horizontal plane was most significant (from 154 +/- SEM 38.4 µm to 9.3 +/- SEM 22.1 µm; p < 0.01). There was a strong significant negative correlation between myelin peak height and IOP (Spearman correlation: -0.78; p < 0.003). There were no significant differences in the thickness of any retinal layers evaluated. CONCLUSIONS: SD-OCT is a useful tool to detect early glaucomatous damage to the ONH in dogs before vision loss. Loss in myelin peak height without inner retinal thinning was identified as an early clinical disease marker. This suggests that initial degenerative changes are mostly due to the loss of myelin.

Efficiency trends of essential public health services and possible influencing factors since the new round health reform in China: a case study from Hainan Province.

Objective: This article aimed to evaluate the efficiency trends and influencing factors of essential public health services in Hainan Province after the healthcare reform launched in 2009 in China. Methods: The efficiency of essential public health services (EPHS) at primary health institutions was assessed using data envelopment analysis (DEA), and the efficiency change was analyzed by employing the Malmquist productivity index (MPI). We used Tobit regression to identify the influence of environmental factors on the efficiency of public health services. The bootstrap method was adopted to reduce the impact of random errors on the result. Results: The bootstrapping bias-corrected efficiency revealed that the average values of technical efficiency, pure technical efficiency, and scale efficiency were 0.7582, 0.8439, and 0.8997, respectively, which meant that the EPHS in Hainan Province were not at the most effective state. The average bias-corrected MPI was 1.0407 between 2010 and 2011 and 1.7404 between 2011 and 2012. MPIs were less than 1.0000 during other periods investigated, ranging from 0.8948 to 0.9714, indicating that the efficiency of EPHS has been decreasing since 2013. The Tobit regression showed that the regression coefficients of per capita GDP, population density, the proportion of older people aged over 65, and the proportion of ethnic minority population were 0.0286, -0.0003, -0.0316, and - 0.0041 respectively, which were statistically significant (p < 0.05). Conclusion: There was a short-term improvement in the efficiency of EPHS in Hainan after the launch of the new round of health reform. However, this trend has not been sustained after 2013. In particular, equalized financial investment in essential public health could not fulfill the needs of poor counties. This has resulted in the inability to improve scale efficiency in some counties, which in turn has affected the improvement of overall EPHS efficiency. Therefore, to promote EPHS efficiency sustainably, it is suggested that under this model of provincial control of counties, the equity of resource allocation should be effectively improved while further advancing the technology of service delivery.

A health economic analysis of an integrated diabetes care program in China: based on real-world evidence.

Introduction: An integrated care program was set up in China to improve the collaboration between primary healthcare centers and hospitals on diabetes management. This study aims to evaluate the economic value of this program with real-world data and to examine whether it can be promoted in primary healthcare settings in China. Methods: This integrated diabetes care program was implemented in Yuhuan City, China, to coordinate primary care and specialty care, treatment and prevention services, as well as the responsibilities of doctors and nurses. Cost-effectiveness analysis was used to compare the short-term economic value of this program (intervention group) versus usual diabetes management (control group). The cost data were collected from a societal perspective, while the effectiveness indicators pointed to the improvement of control rates of fasting blood glucose (FBG), systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels after the 1 year intervention. In addition, cost-utility analysis was applied to evaluate the long-term value of the two groups. Patients' long-term diabetes management costs and quality-adjusted life years (QALYs) were simulated by the United Kingdom Prospective Diabetes Study Outcomes Model 2. Results: The results showed that for 1% FBG, SPB, and DBP control rate improvement, the costs for the intervention group were 290.53, 124.39, and 249.15 Chinese Yuan (CNY), respectively, while the corresponding costs for the control group were 655.19, 610.43, and 1460.25 CNY. Thus, the intervention group's cost-effectiveness ratios were lower than those of the control group. In addition, compared to the control group, the intervention group's incremental costs per QALY improvement were 102.67 thousand CNY, which means that the intervention was cost-effective according to the World Health Organization's standards. Discussion: In conclusion, this study suggested that this integrated diabetes care program created short-term and long-term economic values through patient self-management support, primary care strengthening, and care coordination. As this program followed the principles of integrated care reform, it can be promoted in China. Also, its elements can provide valuable experience for other researchers to build customized integrated care models.

Continuity of Care and Healthcare Costs among Patients with Chronic Disease: Evidence from Primary Care Settings in China.

Background: Though critical to primary care, continuity of care has rarely been examined in China. This study aims to assess the relationship between continuity of care and healthcare costs among patients with chronic diseases within primary care settings in China. Methods: In this cross-sectional study, we used a social health insurance claims dataset of 1406 patients with hypertension and/or diabetes in Yuhuan City, Zhejiang Province collected in 2017-2019. We measured continuity of care using the Bice-Boxerman Continuity of Care (COC) Index, Herfindahl Index (HI), Sequential Continuity of Care (SECON) Index, Usual Provider of Care (UPC), and a binary variable indicating whether a patient's UPC was a primary care provider. We examined the associations between continuity of care and healthcare costs in the same period and the subsequent year, using ordinary least squares regression for the outpatient costs and two-part regression for the inpatient costs. Based on the regression coefficients, we predicted costs saved if each continuity measure was set to 1 from the status quo. Results: When optimum continuity were to be achieved, 7.12-27.29% of total outpatient costs and 55.38-73.35% of total inpatient costs could be saved compared to the status quo during the two-year study period. If optimum continuity were to be achieved in the first year, 7.47%-21.78% of total outpatient costs and 8.84-40.22% of total inpatient costs could be saved in the second-year. Conclusions: Care continuity indicators were consistently associated with reduced outpatient costs and hospitalization risks. Future health reform in China should further enhance continuity of care in primary care.

Introducing the non-invasive prenatal testing for detection of Down syndrome in China: a cost-effectiveness analysis.

OBJECTIVE: This study aimed to compare the health economic value of a non-invasive prenatal testing (NIPT) strategy against a second-trimester triple screening (STS) strategy for the detection of Down syndrome based on real-world data from China. DESIGN: A decision-analytical model was developed to compare the cost-effectiveness of five strategies from a societal perspective. Cost and probability input data were obtained from the real-world surveys and published sources. SETTING: China. PARTICIPANTS: Women with a singleton pregnancy. INTERVENTIONS: The five strategies for screening were: (A) maternal age with STS (no NIPT); (B) STS plus NIPT screening; (C) age-STS plus NIPT screening (the currently referral strategy in China); (D) maternal age with NIPT screening and (E) universal NIPT screening. MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratios (ICERs) per additional Down syndrome case terminated, univariate and probabilistic sensitivity analysis and cost-effectiveness acceptability curves were obtained. RESULTS: Strategy A detected the least number of Down syndrome cases. Compared with the cheapest Strategy B, Strategy D had the lowest ICER (incremental cost, US$98 944.85 per additional Down syndrome case detected). Strategy D had the highest probability of being cost-effective at the willingness-to-pay level between US$110 000.00 and US$535 000.00 per additional Down syndrome case averted. Strategy E would not be cost-effective unless the unit cost of the NIPT could be decreased to US$60.50. CONCLUSION: Introducing NIPT screening strategies was beneficial over the use of STS strategy alone. Evaluating maternal age in combination with the NIPT screening strategy performs better than China's currently referral strategy in terms of cost-effectiveness and safety. Lowering the price of NIPT and optimising payment methods are effective measures to promote universal NIPT strategies in China.

True cost of surgical aortic valve replacement and implications for price setting and diagnosis-related groups: evidence from a tertiary hospital in Eastern China.

Background: Surgical aortic valve replacement (SAVR) has long been the standard treatment for patients with severe aortic stenosis in China, but the costs of SAVR from a hospital perspective in China have not been thoroughly researched. Currently, diagnosis-related groups in China are based on historical expenses that are closely related to the unit charges set by the official pricing department and are frequently inaccurate compared with actual resource consumption. Materials & methods: Through a retrospective empirical study on the costs and charges of SAVR cases in a tertiary hospital, this study aimed to compare the costs and charges of service items. We collected clinical information from patients undergoing SAVR (isolated or concomitant procedures) and financial information from the hospital in 2015 and 2016. Top-down full cost accounting and step-allocation were the main methods used in this study. Result: This research selected 203 SAVR cases in 2015 and 214 cases in 2016. The median length of hospital stay was 15.92 days (6.07 days pre surgery and 9.57 days post surgery). The average human resource cost of care per day per bed in the cardiovascular surgery department, including doctors and nurses, was US $62.22 in 2015 and $66.17 in 2016, but the corresponding charge was no more than $24. For operation, the cost of isolated SAVR was $665 in 2015 and $1015 in 2016, while the charge was $820. For anesthesiology, the cost of isolated SAVR was $400 in 2015 and $526 in 2016, while the average charge was $192. For examination service items, some costs did not exceed charges. The average total cost of a case was $19,299 ± 8954, while the average total charge was $18,923 ± 9194. Conclusion: SAVR is associated with significant resource utilization and hospital stay duration. The fees for human resources and services associated with SAVR do not reflect the true costs of SAVR in a Chinese hospital setting. This study may assist in future budget planning and price setting for policy makers in China.

Cost-effectiveness analysis of malaria rapid diagnostic test in the elimination setting.

BACKGROUND: As more and more countries approaching the goal of malaria elimination, malaria rapid diagnostic tests (RDT) was recomendated to be a diagnostic strategy to achieve and maintain the statute of malaria free, as it's less requirments on equipment and experitise than microscopic examination. But there are very few economic evaluations to confirm whether RDT was cost-effective in the setting of malaria elimination. This research aimed to offer evidence for helping decision making on malaria diagnosis strategy. METHODS: A cost-effectiveness analysis was conducted to compare RDT with microscopy examination for malaria diagnosis, by using a decision tree model. There were three strategies of malaria diagnostic testing evaluated in the model, 1) microscopy, 2) RDT, 3) RDT followed by microscopy. The effect indicator was defined as the number of malaria cases treated appropriately. Based on the joint perspective of health sector and patient, costs data were collected from hospital information systems, key informant interviews, and patient surveys. Data collection was conducted in Jiangsu from September 2018 to January 2019. Epidemiological data were obtained from local malaria surveillance reports. A hypothetical cohort of 300 000 febrile patients were simulated to calculate the total cost and effect of each strategy. One-way, two-way, and probabilistic sensitivity analysis were performed to test the robustness of the result. RESULTS: The results showed that RDT strategy was the most effective (245 cases) but also the most costly (United States Dollar [USD] 4.47 million) compared to using microscopy alone (238 cases, USD 3.63 million), and RDT followed by microscopy (221 cases, USD 2.75 million). There was no strategy dominated. One-way sensitivity analysis reflected that the result was sensitive to the change in labor cost and two-way sensitivity analysis indicated that the result was not sensitive to the proportion of falciparum malaria. The result of Monte Carlo simulation showed that RDT strategy had higher effects and higher cost than other strategies with a high probability. CONCLUSIONS: Compared to microscopy and RDT followed by microscopy, RDT strategy had higher effects and higher cost in the setting of malaria elimination.

Cost-effectiveness analysis of malaria rapid diagnostic tests: a systematic review.

BACKGROUND: Rapid diagnostic tests (RDT) can effectively manage malaria cases and reduce excess costs brought by misdiagnosis. However, few studies have evaluated the economic value of this technology. The purpose of this study is to systematically review the economic value of RDT in malaria diagnosis. MAIN TEXT: A detailed search strategy was developed to identify published economic evaluations that provide evidence regarding the cost-effectiveness of malaria RDT. Electronic databases including MEDLINE, EMBASE, Biosis Previews, Web of Science and Cochrane Library were searched from Jan 2007 to July 2018. Two researchers screened studies independently based on pre-specified inclusion and exclusion criteria. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was applied to evaluate the quality of the studies. Then cost and effectiveness data were extracted and summarized in a narrative way. Fifteen economic evaluations of RDT compared to other diagnostic methods were identified. The overall quality of studies varied greatly but most of them were scored to be of high or moderate quality. Ten of the fifteen studies reported that RDT was likely to be a cost-effective approach compared to its comparisons, but the results could be influenced by the alternatives, study perspectives, malaria prevalence, and the types of RDT. CONCLUSIONS: Based on available evidence, RDT had the potential to be more cost-effective than either microscopy or presumptive diagnosis. Further research is also required to draw a more robust conclusion.

Trends in Between-Country Health Equity in Sub-Saharan Africa from 1990 to 2011: Improvement, Convergence and Reversal.

It is not clear whether between-country health inequity in Sub-Saharan Africa has been reduced over time due to economic development and increased foreign investments. We used the World Health Organization's data about 46 nations in Sub-Saharan Africa to test if under-5 mortality rate (U5MR) and life expectancy (LE) converged or diverged from 1990 to 2011. We explored whether the standard deviation of selected health indicators decreased over time (i.e., sigma convergence), and whether the less developed countries moved toward the average level in the group (i.e., beta convergence). The variation of U5MR between countries became smaller from 1990 to 2001. Yet this sigma convergence trend did not continue after 2002. Life expectancy in Africa from 1990-2011 demonstrated a consistent convergence trend, even after controlling for initial differences of country-level factors. The lack of consistent convergence in U5MR partially resulted from the fact that countries with higher U5MR in 1990 eventually performed better than those countries with lower U5MRs in 1990, constituting a reversal in between-country health inequity. Thus, international aid agencies might consider to reassess the funding priority about which countries to invest in, especially in the field of early childhood health.

The effectiveness of mindfulness-based stress reduction (MBSR) for survivors of breast cancer: study protocol for a randomized controlled trial.

BACKGROUND: After treatment completion, breast cancer (BC) survivors frequently experience residual symptoms of pain, fatigue, high levels of psychological stress, anxiety, depression, fear of recurrence, and metastasis. Post-treatment stress, in particular, can adversely affect health-related quality of life, which, in turn, induces onset or recurrence of chronic diseases. Effective interventions that target these psychological symptoms and their physiological consequences are needed, especially for economically disadvantaged patients. However, in China, few evidence-based intervention strategies have been established among BC survivors. This study will formally adapt, develop, and evaluate an intensive mindfulness-based stress reduction (MBSR) intervention protocol to improve mental health, quality of life, and compliance with medication among Chinese BC survivors. METHODS: A randomized, waitlist-controlled clinical trial will be conducted. Based on our power calculation, 418 BC survivors will be recruited from 10 low-income communities in Shanghai. All subjects will be randomly assigned either to the MBSR program or to a waitlisted usual care regimen that will offer the MBSR program after the completion of the other trial arm (after 6 months follow-up). Our 8-week MBSR intervention program will provide systematic training to promote stress reduction by self-regulating arousal to stress. Assessments will be made at baseline, 4 weeks (in the middle of the first MBSR intervention), 8 weeks (at the end of the first MBSR intervention), 6 months, and 12 months, and will include measures of psychological symptoms (depression, anxiety, and perceived stress), quality of life, and medication adherence. The expected outcome will be the improvement in psychological symptoms, quality of life, and medication compliance in the MBSR intervention group. DISCUSSION: This study will help develop an affordable, self-care psychological intervention protocol to help Chinese BC survivors improve their quality of life, and could be helpful in further developing affordable disease management plans for patients of other chronic diseases. TRIAL REGISTRATION: ChiCTR-IOR-14005390 (10/27/2014).

Does Rapid and Sustained Economic Growth Lead to Convergence in Health Resources: The Case of China From 1980 to 2010.

China's rapid and sustained economic growth offers an opportunity to ask whether the advantages of growth diffuse throughout an economy, or remain localized in areas where the growth has been the greatest. A critical policy area in China has been the health system, and health inequality has become an issue that has led the government to broaden national health insurance programs. This study investigates whether health system resources and performance have converged over the past 30 years across China's 31 provinces. To examine geographic variation of health system resources and performance at the provincial level, we measure the degree of sigma convergence and beta convergence in indicators of health system resources (structure), health services utilization (process), and outcome. All data are from officially published sources: the China Health Statistics Year Book and the China Statistics Year Book. Sigma convergence is found for resource indicators, whereas it is not observed for either process or outcome indicators, indicating that disparities only narrowed in health system resources. Beta convergence is found in most indicators, except for 2 procedure indicators, reflecting that provinces with poorer resources were catching up. Convergence found in this study probably reflects the mixed outcome of government input, and market forces. Thus, left alone, the equitable distribution of health care resources may not occur naturally during a period of economic growth. Governmental and societal efforts are needed to reduce geographic health variation and promote health equity.

Factors associated with utilization of maternal serum screening for Down syndrome in mainland China: a cross-sectional study.

BACKGROUND: Knowledge of the factors that influence maternal serum screening (MSS) service utilization can be used to develop health policies to promote equitable access to MSS and further diagnostic tests. The purpose of this study was to find the factors associated with utilization of MSS as well as the current status of service utilization in mainland China. METHODS: This was a hospital-based cross-sectional study with respondents interviewed with a questionnaire designed based on Andersen's behavioral model. Descriptive statistics, univariate analysis, and multilevel logistic regression analysis were used to identify the factors associated with MSS utilization, and to explore potential methods to improve screening uptake. RESULTS: A total of 8110 women who had given birth within the previous 7 days in one of 111 participating institutions from six provinces in mainland China were interviewed. Approximately 36% of the participants had used MSS. Women between 20 and 35 years, who resided in urban areas, were educated, were in a stable occupation, who had health knowledge, who attended maternal preparation classes, who had received eight or more prenatal checkups, who were from a region of higher social economic status, and who delivered in a tertiary healthcare institution were significantly more likely to use MSS than their counterparts. As compared with other factors, insufficient education is the single most important demographic factor for service underutilization. CONCLUSIONS: Efforts should not only be made to target the population that underuses MSS, but the overall organization of MSS service delivery should be assessed during policy development to make access to MSS equitable to the entire population of mainland China.

Assessment of signs of anterior blepharitis using standardized color photographs.

PURPOSE: To describe a standardized technique for acquiring and viewing photographic images of eyelids, assess the reproducibility and validity of a grading protocol for signs of anterior blepharitis, and to explore whether the signs depend on the eyelid or the area of the eyelid assessed. METHODS: Subjects with anterior blepharitis ranging from none to severe were examined by ophthalmologists at clinical sites. Digital images of the eyelids of subjects were acquired using a protocol that allowed for the calibration of color and luminance. Three ophthalmologists at a centralized reading center applied a novel protocol for grading features of anterior blepharitis from the digital images viewed on color-calibrated monitors. The agreement among graders was assessed using percent agreement and weighted kappa statistics (Kw), and the correlation of photographic and clinical gradings was assessed using Spearman correlation coefficients. RESULTS: Agreement among graders was excellent (Kw > 0.80) on the number of eyelid margin vessels and was substantial (Kw between 0.61 and 0.80) for erythema, collarettes, number of engorged vessels, and number of lashes. Grading of the photographic images and the clinical assessments of erythema and lid debris were moderately correlated (r = 0.27-0.45). The grades for different features depended on whether the upper or lower eyelid, eyelid skin or lid margin, and central or lateral lid were assessed. CONCLUSIONS: The application of a protocol to obtain and display calibrated digital images of eyelids supports the standardized assessment of anterior blepharitis in clinical care and research studies.

Differences in behavioral outcomes between first-year and second-year participants in a community-based colorectal cancer education intervention.

INTRODUCTION: Colorectal cancer (CRC) is the third most prevalent cancer in China, and the fifth most lethal among all cancers. Community-based health education is helpful for health planners to promote cancer screening, yet relatively few studies tapped the temporal pattern of intervention effectiveness in a multiyear CRC education program. Using data from a two-year CRC community education, this study was aimed at exploring whether the health education intervention effectiveness differs between first-year and the second-year participants. METHOD: A two-year health education intervention was carried out in four communities in Shanghai, China. The health education focused on raising awareness about CRC, the principles of fecal occult blood test (FOBT) screening, and instruction about use of the FOBT kit. Local community health service centers conducted the lectures once a month. All adult residents were invited to attend these lectures. At the end of the first year and the second year, structured in-person interviews were conducted for the residents who attended the lectures. There were 205 enrollees who completed the first-year interviews and 836 enrollees who completed the second- year interviews. Logistic regression was used to compare the attitudinal and behavioral outcomes of enrollees in years 1 and 2. RESULT: Of the 1041 respondents, 24.5% had received FOBT during the program period, while 12% had received colonoscopy check, both substantially higher than the background screening rate in Shanghai. Respondents in year 2 were less willing to take FOBT than those in year 1 (O.R.=0.618, p<0.01), but there was no significant difference in terms of willingness to take colonoscopy after adjustment for covariates in logistic regression. Multiple logistic regression also showed that respondents in year 2 were significantly less likely to take FOBT than those in year 1 (O.R. = 0.263, p<0.01) and a similar tendency was noted for colonoscopy (O.R.=0.600, p=0.074). CONCLUSION: The CRC screening rate after the health education compared favorably with the background screening rate, yet the decline in screening rate in year 2 indicates that further study is needed to understand the determinants of intervention effectiveness.

Situation analysis of prenatal diagnosis technology utilization in China: current situation, main issues, and policy implications.

OBJECTIVES: The purpose of this study is to describe the situation with the distribution and utilization of prenatal diagnosis technology in China, to identify some important barriers to prenatal diagnosis use, and to suggest changes to improve the present situation. METHODS: The study uses cross-sectional surveys to capture quantitative data from both providers and consumers. Qualitative information based on focus group discussions is also presented. RESULTS: A mail survey of the provincial Bureaus of Health (BOHs) reveals that sixteen provincial prenatal diagnosis centers and twelve city level centers were accredited by the BOHs by July of 2001. These centers were located in thirteen provinces, of thirty in all of China. Of 147 selected institutions surveyed separately, 90.5 percent offer ultrasound examination, 72.1 percent provide pathogen tests (mainly Toxoplasma, rubella virus, cytomegalovirus, and herpes simplex or TORCH), 57.1 percent do biochemical tests, 21.8 percent have genetic counseling, 13.6 percent do karyotype testing, 7.5 percent do enzymology testing, and 5.4 percent carry out molecular genetic testing. Chromosome diseases, congenital diseases, and several gene diseases are the target diseases. According to qualitative data, macromanagement for prenatal diagnosis, supplier provision of tests, and population demand are the main influences on prenatal diagnosis use. CONCLUSIONS: From the quantitative and qualitative analysis, it is clear that the technology of prenatal diagnosis is not diffusing well throughout China and is apparently not appropriately used. The situation of prenatal diagnosis has implications for policy-makers, including identification of priorities, regulation of prenatal diagnosis, strategic planning, development of guidelines based on health technology assessment, and consumer orientation.