Hyperaccumulator extracts promoting the phytoremediation of rare earth elements (REEs) by Phytolacca americana: Role of active microbial community in rhizosphere hotspots.

The increased usage of rare earth elements (REEs) leads to the extensive exploitation of rare earth mines, and the REEs pollution in soil caused by the legacy mine tailings has brought great harm to environment and human health. Although Phytolacca americana can remove REEs from contaminated soil to some extent, there is still an urgent problem to improve its efficiency. Hyperaccumulator extract is a new organic material with potential in metal phytoextraction, but its role in REEs phytoremediation and the related underlying processes remain unclear. In this study, hyperaccumulator extracts from P. americana root (PR), stem (PS), leaf (PL) and EDTA were used to improve the phytoremediation efficiency of REEs with P. americana. Soil zymography was applied to assess the enzyme hotspots' spatial distribution in the rhizosphere, and the hotspots' microbial communities were also identified. The results indicated that the application of hyperaccumulator extracts improved the biomass and REEs uptake of P. americana, and the highest REEs content in plant was observed in the treatment of PS, which increased 299% compared to that of the control. Hotspots area of ß-glucosidase, leucine aminopeptidase and acid phosphatase were concentrated in the pant rhizosphere along the roots and increased 2.2, 5.3 and 2.2 times after PS application compared to unamended soils. The PS application increased the relative abundance of Proteobacteria, Cyanobacteria, Bacteroidota and Firmicutes phyla in rhizosphere. Soil fungi have a higher contribution on promoting REEs activation than that of bacteria. Available P and extractable REEs were leading predictors for the plant biomass and REEs concentrations. The co-occurrence network showed that the application of PS creates a more efficient and stable microbial network compared to other treatments. In conclusion, stem-derived hyperaccumulator extract is excellent in stimulating REEs phytoremediation with P. americana by improving hotspots microbial activities and form a healthy rhizosphere microenvironment.

The translocation and fractionation of rare earth elements (REEs) via the phloem in Phytolacca americana L.

Rare earth elements (REEs) are considered to be emerging contaminants due to their widespread use and lack of recycling. Phytolacca americana L. has great potential for REEs phytoextraction. Our understanding of REEs in P. americana focuses mostly on root absorption and xylem translocation, but the role of phloem translocation has received little attention. In this research, the translocation and fractionation of REEs from phloem to organs in P. americana were investigated. In addition, the effect of organic acids in the REEs translocation via phloem exudates was also examined. The results showed that REEs could transport bidirectionally via the phloem, and 86% of REEs exported from old leaves could move downwards to the root, whereas only 14% of them transported upwards to the young leaves. Heavy rare earth elements (HREEs) enrichment was found in the REEs fractionation processes both from phloem to leaf and from stem to root, indicating that HREEs were preferentially transferred not only down to roots, but also up to the young leaves. The concentration of oxalic acid in phloem exudates was much higher than other organic acids. 94.7% oxalic acid in phloem exudates was preferred to combine with REEs, especially HREEs. Additionally, the concentrations of HREEs had a high positive correlation with oxalic acid in phloem exudates, which demonstrated oxalic acid may play a significant role in the long-distance transport of HREEs in phloem. In conclusion, HREEs have higher translocation ability than light rare earth elements (LREEs) in both xylem and phloem of P. americana. As far as we know, this is the first report focused on the phloem translocation and redistribution of REEs in P. americana, which provides a valuable understanding of the mechanism for phytoremediation of REEs contaminated soils.

Rare Earth Elements (REEs) Adsorption and Detoxification Mechanisms in Cell Wall Polysaccharides of Phytolacca americana L.

The cell wall (CW) is critical for the accumulation of heavy metals in metal-tolerant plants. Polysaccharides, the main component of the CW, contribute significantly to the immobilization of heavy metals. However, the mechanisms of rare earth elements (REEs) adsorption and detoxification by polysaccharides in the cell walls of Phytolacca americana L. (P. americana) remain unclear. In this work, we explored the binding sites of REEs and the modifications to polysaccharides in the cell walls of roots and leaves in P. americana, in order to elucidate the adsorption and fixation mechanism of REEs by the cell wall. Our findings indicated that up to 40.7% and 48.1% of cell-wall-bound REEs were present in the root and leaf pectin, respectively. The removal of pectin led to a 39.8% and 23.6% decrease in the maximum adsorption of REEs in the CW, suggesting that pectin was the main binding site for REEs in the cell walls of P. americana. Hydroxyl (-OH) and carboxyl (-COOH) groups in the cell wall interacted mainly with REEs ions under stress conditions, which played a key role in REEs binding. An obvious REEs fractionation was found during the various fractions of the CW, and all fractions of the root cell wall were enriched with HREEs, whereas all fractions of the leaf cell wall were enriched with LREEs. Moreover, P. americana modulated cell wall composition in reaction to REEs stress. In conclusion, cell wall pectin is the main binding site of REEs, and the functional groups on the cell wall play a significant role in the binding of REEs. At the same time, plants can control the selective adsorption and fixation of REEs by adjusting the composition of cell walls. This study offers valuable insights into the mechanisms of REEs adsorption and fixation in cell walls of P. americana, contributing to a theoretical basis for the bioremediation of REEs pollution.

Does capitation prepayment based Integrated County Healthcare Consortium affect inpatient distribution and benefits in Anhui Province, China? An interrupted time series analysis.

OBJECTIVE: This study aims to compare the level and trend changes of inpatient and funds distribution, as well as inpatient benefits before and after the official operation of the ICHC in Anhui. METHODS: A total of 1,013,815 inpatient cases were collected from the hospitalisation database in two counties in Anhui Province, China, during the course of the study from January 2014 to June 2017. The effect of the reform was assessed beginning with its formal operation in February 2016. Longitudinal time series data were analysed using segmented linear regression of an interrupted time series analysis. RESULTS: The average hospitalisation expenses showed a decreasing trend and the actual compensation ratio increased significantly (p-value < 0.01). Most of the indicators in the two counties performed well, and the effect of ICHC policy was better in Funan County than in Dingyuan County. The distribution of inpatients and NRCMS funds outside the county after the reform in Dingyuan showed an increasing trend (0.27, 95%CI: 0.12 to 0.42, p-value < 0.01; 0.70, 95%CI: 0.32 to 1.09, p-value < 0.01) and the distribution of inpatients and NRCMS funds in THs showed a more obvious upward trend after the reform in Funan (0.44, 95%CI: 0.22 to 0.67, p-value < 0.001; 0.34, 95%CI: 0.23 to 0.45, p-value < 0.001). CONCLUSIONS: This study suggests that the ICHC policy provides effective strategies in promoting the integration of the healthcare delivery system in China. These strategies include strengthening family doctor signing service system and health management, developing telemedicine technology, reducing the weak points of the healthcare services, and introducing private hospitals to form new ICHCs.

Determinants of inappropriate admission of elderly people in county-level hospitals: a cross-sectional study in rural China.

OBJECTIVE: The purpose of this paper is to investigate the characteristics and determinants of inappropriate admission to hospital of elderly people in rural China. DESIGN: A cross-sectional study of a comparison between the elderly and non-elderly groups of people. SETTING: The survey was conducted on the largest county-level general hospitals in four counties in central and western China. PARTICIPANTS: A total of 652 rural patients admitted in hospitals were surveyed, who were divided into two groups according to age: elderly group (n=230, age ≥60 years) and non-elderly group (n=422, age <60 years). PRIMARY MEASURES: The Chinese version of the appropriateness evaluation protocol was used to evaluate the inappropriate admission rates. The interactive regression models based on the relationship of age (elderly and non-elderly) with other factors and binary logistic regression models were used in the analysis of the specific factors and determinants of the inappropriate admission of elderly people. RESULT: The inappropriate admission rate for the rural elderly was 30%, which was lower than that of the non-elderly people (40.8%). Compared with the non-elderly group, women in the elderly group (OR=0.33, 95% CI 0.15 to 0.73) had a lower incidence of inappropriate admission, and elderly people with chronic diseases (OR=3.33, 95% CI 1.23 to 9.04) were more prone to being inappropriately admitted than non-elderly people with chronic diseases. The binary logistic regression analysis shows that county, age (OR=0.94. 95% CI 0.90 to 0.99), gender (OR=0.49, 95% CI 0.25 to 2.98), department and response to doctor's admission request were the determinants of the inappropriate admission of elderly patients. CONCLUSION: The inappropriate admission rate of elderly people in rural China was high. We found that gender and chronic disease are the specific factors that were specific to non-elderly people. County, age, gender, department and response to a doctor's admission request had substantial influence on the inappropriate admission of the elderly in rural China.

Distribution of the Indicator of the Appropriate Admission of Patients with Circulatory System Diseases to County Hospitals in Rural China: A Cross-Sectional Study.

Background: The inappropriate admission of patients with circulatory system diseases (CSDs) have contributed to the rapid increase in hospitalisation rates in China. The purpose of this study is to identify the key indicators of appropriate admission and their distribution by analysing CSD cases. Methods: A total of 794 records of inpatient CSD cases were collected from county hospitals in five counties in midwestern rural China through stratified random sampling and evaluated by using the Rural Appropriateness Evaluation Protocol (RAEP). RAEP has two parts: Indicator A, which represents requirement for services, and Indicator B, which represents diseases severity. Indicator distribution was analysed through frequency analysis. A three-level logistic regression model was used to examine the sociodemographic determinants of the positive indicators of appropriate CDSs admissions. Result: The inappropriate admission rate of CSDs was 33.4% and varied between counties. A2 (Varying dosage/drug under supervision, 58.22%), A8 (Stopping/continuing oxygen inhalation, 38.19%), A7 (Electrocardiogram per 2 hours, 34.22%), A3 (Calculation of intake and output volume, 31.19%) and B14 (Abnormal blood condition, 27.98%) were the top five positive indicators of CSDs. Indicator A (requirements for services) was more active than Indicator B (disease severity). The limitation of the role of Indicator B over time may be attributed to the different policies and environments of rural China and stimulated the increase in inappropriate admission rates. The results of three-level logistic regression suggested that the influence of gender, year, region and disease type on positive indicators should receive increased attention in the evaluation of CSDs admissions. Conclusion: This study found that A2, A8, A7, A3 and B14 were the key indicators and were helpful to determine the appropriate admission of CSDs in rural China. Managers may focus on these indicators, particularly the use of indicator A.

Effect of an Integrated Payment System on the Direct Economic Burden and Readmission of Rural Cerebral Infarction Inpatients: Evidence from Anhui, China.

Rural China is piloting an integrated payment system, which prepays a budget to a medical alliance rather than a single hospital. This study aims to evaluate the effect of this reform on the direct economic burden and readmission rates of cerebral infarction inpatients. The settlement records of 78,494 cerebral infarction inpatients were obtained from the New Rural Cooperative Medical Scheme (NRCMS) database in Dingyuan and Funan Counties in the Anhui Province. The direct economic burden was estimated by total costs, out-of-pocket expenditures, the out-of-pocket ratio, and the compensation ratio of the NRCMS. Generalized additive models and multivariable linear/logistic regression were applied to measure the changes of the dependent variables along with the year. Within the county, the total costs positively correlated to the year (ß = 313.10 in 2015; 163.06 in 2016). The out-of-pocket expenditures, out-of-pocket ratios, and the length-of-stay positively correlated to the year in 2015 (ß = 105.10, 0.01, and 0.18 respectively), and negatively correlated to the year in 2016 (ß = -58.40, -0.03, and -0.30, respectively). The odds ratios of the readmission rates were less than one within the county (0.70 in 2015; 0.53 in 2016). The integrated payment system in the Anhui Province has considerably reduced the direct economic burden for the rural cerebral infarction inpatients, and the readmission rate has decreased within the county. Inpatients' health outcomes should be given further attention, and the long-term effect of this reform model awaits further evaluation.

Effect of inappropriate admissions on hospitalization performance in county hospitals: a cross-sectional study in rural China.

BACKGROUND: Inappropriate admissions cause excessive utilization of health services compared with outpatient services. However, it is still unclear whether inappropriate admissions cause excessive use of health services compared with appropriate admissions. This study aims to clarify the differences in the hospitalization performances between appropriately admitted inpatients and inappropriately admitted inpatients. METHODS: A total of 2575 medical records were obtained after cluster sampling in three counties. Admission appropriateness was assessed by appropriateness evaluation protocol (AEP). The propensity score matching (PSM) was computed to match patients in treatment and control group with similar characteristics, and to examine the differences in the utilization of hospitalization services between the two groups. The samples were matched in two major steps in this study. In the first step, total samples were matched to examine the differences in the utilization of hospital services between the two groups using 15 individual covariates. In the second step, PSM was computed to analyze the differences between the two groups in different disease systems using 14 individual covariates. RESULTS: For the whole sample, the inappropriate group has lower expenditure of hospitalization (EOH) (difference = - 0.12, p = 0.003) and shorter length of stay (LOS) (difference = - 0.73, p = 0.016) than the appropriate group. For number of clinical inspection (NCI), it has no statistically significant difference (difference = - 0.39, p = 0.082) between the two groups. Among different disease systems, no significant differences were observed between the two groups among EOH, LOS and NCI, except that the EOH was lower in the inappropriate group than that in the appropriate group for surgical disease (difference = - 0.169, p = 0.043). CONCLUSION: Inappropriate admissions have generated excessive health service utilization compared with appropriate admissions, especially for internal diseases. The departments in charge of medical services and hospital managers should pay high attention to the health service utilization of the inappropriately admitted inpatients. Relevant medical policies should be designed or optimized to increase the appropriateness in health care service delivery and precision in clinical pathway management.

Is There a Difference in the Utilisation of Inpatient Services Between Two Typical Payment Methods of Health Insurance? Evidence from the New Rural Cooperative Medical Scheme in China.

This study aimed to evaluate the effects of the differences between two typical payment methods for the new rural cooperative medical scheme (NRCMS) in China on the utilisation of inpatient services. Interrupted time-series analysis (ITSA) and propensity score matching (PSM) were used to measure the difference between two typical payment methods for the NRCMS with regard to the utilisation of inpatient services. After the reform was formally implemented, the level and slope difference after reform compared with pre-intervention (distribution of inpatients in county hospitals (DIC), distribution of inpatients in township hospitals (DIT) and the actual compensation ratio of inpatients (ARCI)) were not statistically significant. Kernel matching obtained better results in reducing the mean and median of the absolute standardised bias of covariates of appropriateness of admission (AA), appropriateness of disease (AD). The difference in AA and AD of the matched inpatients between two groups was -0.03 (p-value = 0.042, 95% CI: -0.08 to 0.02) and 0.21 (p-value < 0.001, 95% CI: -0.17 to 0.25), respectively. The differences in the utilisation of inpatient services may arise owing to the system designs of different payment methods for NRCMS in China. The causes of these differences can be used to guide inpatients to better use medical services, through the transformation and integration of payment systems.

Effect of integrated urban and rural residents medical insurance on the utilisation of medical services by residents in China: a propensity score matching with difference-in-differences regression approach.

OBJECTIVES: In this study, we aim to evaluate the effect of urban and rural resident medical insurance scheme (URRMI) on the utilisation of medical services by urban and rural residents in the four pilot provinces. SETTING AND PARTICIPANTS: The sample used in this study is 13 305 individuals, including 2620 in the treatment group and 10 685 in the control group, from the 2011 and 2015 surveys of China Health and Retirement Longitudinal Study. OUTCOME MEASURES: Propensity score matching and difference-in-differences regression approach (PSM-DID) is used in the study. First, we match the baseline data by using kernel matching. Then, the average treatment effect of the four outcome variables are analysed by using the DID model. Finally, the robustness of the PSM-DID estimation is tested by simple model and radius matching. RESULTS: Kernel matching have improved the overall balance after matching. The URRMI policy has significantly reduced the need-but-not outpatient care and significantly increased outpatient care cost and inpatient care cost for rural residents, with DID value of -0.271, 0.090 and 0.256, respectively. After robustness test, the DID competing results of four outcome variables are consistent. CONCLUSIONS: URRMI has a limited effect on the utilisation of medical and health services by all residents, but the effect on rural residents is obvious. The government should establish a unified or income-matching payment standard to prevent, control the use of medical insurance funds and increase its efforts to implement URRMI integration in more regions to improve overall fundraising levels.

Determinants of inappropriate admissions of children to county hospitals: a cross-sectional study from rural China.

BACKGROUND: The incidence of inappropriate admissions in China has become the shackle of its' service supply system. This research aims to assess the level of children's inappropriate admissions to county hospitals in rural China and identify the characteristics and determinants of children's inappropriate admissions. METHODS: A retrospective review was conducted on data of children aged 0-14 years. A total of 771 children medical records in four county hospitals was collected by stratified random sampling in Midwestern China and was evaluated through the Rural Appropriateness Evaluation Protocol. A questionnaire survey was conducted among doctors whose names were shown in medical records. Chi-square test was used to analyse the characteristics of inappropriate admissions, and a binary logistic regression model was used to examine the determinants of inappropriate admissions. RESULTS: Inappropriate admissions indicate that patients who could have been treated as outpatients received services as inpatients. The average rate for inappropriate admissions of children in county hospitals was 61.35%. The highest rate of inappropriate admissions was found among children aged 1-5 years (68.42%). Inappropriate admissions mostly occurred in children with respiratory diseases (72.45%), circulatory diseases (72.22%) and certain infectious diseases and parasitic diseases (70.37%). Binary logistic regression analysis showed that county, normal health status, treating department, disease, the length of hospital stay and the doctor's self-evaluation on the understanding about the degree of the patient's feelings were determinants for children's inappropriate admissions. CONCLUSIONS: County hospitals have a high rate of inappropriate admissions of children. The relationship of children's inappropriate admissions to age distribution and the insurance compensation is affected by disease and hospitalisation expenses, respectively. The determinants of children's inappropriate admissions are directly related to the weak level of primary care services in the health service system, the initial requirements requested by children's admission decision makers and the interests among medical institutions and doctors.

Does County-Level Medical Centre Policy Influence the Health Outcomes of Patients with Trauma Transported by the Emergency Medical Service System? An Integrated Emergency Model in Rural China.

This study aimed to assess the effect of the county-level medical centre policy on the health outcomes of trauma patients transported by emergency medical service (EMS) system in rural China. The methodology involved the use of electronic health records (EHRs, after 2016) of patients with trauma conditions such as head injury (n = 1931), chest (back) injury (n = 466), abdominal (waist) injury (n = 536), and limb injury (n = 857) who were transported by EMS to the county-level trauma centres of Huining County and Huan County in Gansu, China. Each patient was matched with a counterpart to a county-level trauma centre hospital by propensity score matching. Cox proportional hazard models were used to estimate the hazard ratios (HRs) of such patients in different hospitals. The HRs of all patients with the abovementioned traumatic conditions transported by EMS to county-level trauma centre hospitals were consistently higher than those transported by EMS to traditional hospitals after adjusting for numerous potential confounders. Higher HRs were associated with all patients with trauma (HR = 1.249, p < 0.001), head injury (HR = 1.416, p < 0.001), chest (back) injury (HR = 1.112, p = 0.560), abdominal (waist) injury (HR = 1.273, p = 0.016), and limb injury (HR = 1.078, p = 0.561) transported by EMS to the county-level trauma centre hospitals. Our study suggests that the construction of county-level medical centre provides an effective strategy to improve the health outcomes of EMS-transported trauma patients in Gansu, China. Policy makers can learn from the experience and improve the health outcomes of such patients through a personalised trauma treatment system and by categorizing the regional trauma centre.

Changes in inpatients' distribution and benefits under institution level-based quota payment for specific diseases in rural China: An interrupted time-series analysis.

The distribution of patients is increasingly disordered in China, which leads to the waste of medical resources, increase in inpatients' economic burden, and decrease in benefits from health insurance. Institution level-based quota payment for specific diseases represents a typical payment-system reform mode in rural China that rationalizes the distribution of rural inpatients. The aim of this study is to evaluate the effectiveness of this mode by estimating rural inpatients' distribution among hospitals at different levels, per capita cost of hospitalization, and actual compensation ratio and then to provide suggestions to advance this mode. Interrupted time-series analysis was applied to evaluate the effect of the reform mode in the study, and Weiyuan County, Gansu Province, was selected as our sample. Institution level-based quota payment for specific diseases in Weiyuan County has rationalized the distribution of rural inpatients and improved their benefit levels. Further research should be conducted to evaluate the appropriateness of medical services, the health outcomes of rural inpatients, and the sustainability and replicability of the policy.

Effectiveness evaluation of quota payment for specific diseases under global budget: a typical provider payment system reform in rural China.

BACKGROUND: Quota payment for specific diseases under global budget is one of the most typical modes of provider payment system reform in rural China. This study aimed to assess this reform mode from aspects of the total fee, structure of the fee and enrollees' benefits. METHODS: A total of 127,491 inpatient records from 2014 to 2016 were extracted from the New Rural Cooperative Medical Scheme (NRCMS) database in Weiyuan County, Gansu Province. Total fee, actual compensation ratio, out-of-pocket ratio, constituent ratio of the treatment fee, constituent ratio of the inspection and laboratory fee, and length of stay were selected as dependent variables. Both generalized additive models (GAMs) and multiple linear regression models were used to measure the change in dependent variables along with year. RESULTS: Prior to the adjustment of the compensation type, out-of-pocket ratio and length of stay decreased, while total fee, actual compensation ratio, constituent ratio of the treatment fee, and constituent ratio of the inspection and laboratory fee increased. After the compensation type was adjusted, the mean of the total fee increased rapidly in 2015 and remained stable in 2016. The mean length of stay increased in 2015 but decreased in 2016. A comparison of inpatients suffering from diseases covered by quota payments and those suffering from general diseases revealed that total fee, out-of-pocket ratio, and length of stay decreased and actual compensation ratio increased for the former, whereas the opposite was true for the latter. Constituent ratio of the treatment fee and constituent ratio of the inspection and laboratory fee increased for both samples, except for the constituent ratio of the inspection and laboratory fee of quota payment diseases in 2016, which did not change. CONCLUSIONS: Quota payment for specific diseases under global budget had obviously positive effects on cost control in Weiyuan, Gansu. Considering the limited coverage of quota payment for diseases, the long-term effect of this reform mode and its replicability awaits further evaluation.