The cost-effectiveness of a co-managed care model for elderly hip fracture patients in China: a modelling study.

Background: The clinical effectiveness of multidisciplinary co-managed care for hip fracture patients in China has been demonstrated in a multicenter non-randomized controlled study. This study aims to estimate the cost-effectiveness of the co-managed care. Methods: The study is based on a multicenter clinical trial (n = 2071) in China. We developed a state transition microsimulation model to estimate the cost-effectiveness of the co-managed care compared with usual care for hip fracture patients from healthcare system perspective. The costs incorporated into the model included hospitalization costs, post-discharge expenses, and secondary fracture therapy costs. Effectiveness was measured using quality-adjusted life years (QALYs). Costs and effects were discounted at 5% annually. A simulation cycle length of 1-year and a lifetime horizon were employed. The cost-effectiveness threshold was established at USD 37,118. To address uncertainties, one-way deterministic sensitivity analysis and probabilistic sensitivity analysis were conducted. Findings: In the base case analysis, the co-managed care group had a lifetime cost of USD 31,571 and achieved an effectiveness of 3.22 QALYs, whereas the usual care group incurred a cost of USD 27,878 and gained 2.85 QALYs. The incremental cost-effectiveness ratio was USD 9981 per QALY gained; thus the co-managed care model was cost-effective. The cost-effectiveness was sensitive to the age of having hip fractures and hospitalization costs in the intervention group. Interpretation: The co-managed care in hip fracture patients represents value for money, and should be scaled up and prioritized for funding in China. Funding: The study is supported by Capital's Funds for Health Improvement and Research (2022-1-2071, 2018-1-2071).

Establishing cost-effectiveness threshold in China: a community survey of willingness to pay for a healthylife year.

INTRODUCTION: The willingness to pay per quality-adjusted life year gained (WTP/Q) is commonly used to determine whether an intervention is cost-effective in health technology assessment. This study aimed to evaluate the WTP/Q for different disease scenarios in a Chinese population. METHODS: The study employed a quadruple-bounded dichotomous choice contingent valuation method to estimate the WTP/Q in the general public. The estimation was conducted across chronic, terminal and rare disease scenarios. Face-to-face interviews were conducted in a Chinese general population recruited from Jiangsu province using a convenience sampling method. Interval regression analysis was performed to determine the relationship between respondents' demographic and socioeconomic conditions and WTP/Q. Sensitivity analyses of removing protest responses and open question analyses were conducted. RESULTS: A total of 896 individuals participated in the study. The WTP/Q thresholds were 128 000 Chinese renminbi (RMB) ($36 364) for chronic diseases, 149 500 RMB ($42 472) for rare diseases and 140 800 RMB ($40 000) for terminal diseases, equivalent to 1.76, 2.06 and 1.94 times the gross domestic product per capita in China, respectively. The starting bid value had a positive influence on participants' WTP/Q. Additionally, residing in an urban area (p<0.01), and higher household expenditure (p<0.01), educational attainment (p<0.02) and quality of life (p<0.02) were significantly associated with higher WTP/Q. Sensitivity analyses demonstrated the robustness of the results. CONCLUSION: This study implies that tailored or varied rather than a single cost-effectiveness threshold could better reflect community preferences for the value of a healthy year. Our estimates hold significance in informing reimbursement decision-making in health technology assessment in China.

Assembly of an A6 L6 Anion Trigonal Antiprism and Binding of Glucopyranosides and Polyethylene Glycols (PEGs).

Anion-coordination-driven assembly (ACDA) has proven to be a very effective strategy for the construction of polyhedral structures. Here we demonstrate that variation of the "angle" of the backbone of C3 -symmetric tris-bis(urea) ligands, from triphenylamine to triphenylphosphine oxide, results in the change of the final construct from an A4 L4 tetrahedron to a higher-nuclearity, A6 L6 trigonal antiprism (A=anion, herein PO4 3- ; L=ligand). Most interestingly, this assembly features a huge hollow internal space that is divided into three compartments: one central cavity and two large outer pockets. This multi-cavity character enables the binding of different guests, namely monosaccharides or polyethylene glycol molecules (PEG600, PEG1000 and PEG2000), respectively. The results prove that anion coordination by multiple hydrogen bonds may provide both sufficient strength and flexibility, thus making possible the formation of complicated structures with adaptive guest binding ability.

Socio-demographic disparities in health-related quality of life after hip fracture in China: evidence from the China Health and Retirement Longitudinal Study.

This study analyzed the impact of hip fractures on people's health-related quality of life and its socio-demographic disparities in China. PURPOSE: Hip fractures cause high mortality and worsened health-related quality of life (HRQoL). This study aimed to investigate whether socio-demographic-related inequities in post-hip fracture participants' HRQoL exist in China. METHODS: Data from the China Health and Retirement Longitudinal Study (waves 2013, 2015, and 2018) were used. The measurement of HRQoL in this study focused on 5 health dimensions: depression, body pain, mobility, basic activities of daily living, and instrumental activities of daily living. A difference-in-differences (DID) analysis with multiple time periods was performed to gauge the impact of hip fracture on HRQoL. A multivariate regression approach was used to explore socio-demographic-related factors associated with inequities of HRQoL. RESULTS: A total of 23,622 individuals were included, and 341 participants reported hip fracture events during the survey period. In participants with hip fracture, the presentation rate of body pain increased by 14% (p < 0.01) and the HRQoL of other health dimensions worsened (p ≤ 0.01) after hip fracture. The DID analysis showed that hip fracture had a negative impact on all HRQoL dimensions (p < 0.01). Socioeconomic-related factors of HRQoL inequities included school education level and location of residence. Study participants with hip fracture with greater educational attainment or living in urban areas had higher (p < 0.05) levels of HRQoL. In addition, comorbidities also correlated with a worse HRQoL (p < 0.05). CONCLUSION: Hip fracture significantly affects people's HRQoL in China, and the impact is more profound for those with lower educational attainment or living in rural areas. Targeted interventions should be designed to narrow this inequity.

Productivity Losses Due to Diabetes in Urban Rural China.

BACKGROUND: Productivity losses due to diabetes are increasing in China, but research about the impact of diabetes on productivity in urban and rural areas requires further in-depth study. This article provides the first estimate of the cost of productivity losses attributed to diabetes in individuals 20-69 years old in urban and rural areas of China. METHODS: The human capital approach is employed to measure the productivity losses attributed to absenteeism, presenteeism, labor force dropout, and premature deaths due to diabetes of the 20-69-year-old population of males and females in urban and rural areas of China. Based on the life table modelling, we calculate the years of potential life lost and working years of life lost of people with diabetes. RESULTS: In 2017, we estimated that there were 100.46 million people with diabetes, with the total cost of productivity losses being USD 613.60 billion, comprising USD 326.40 billion from labor force dropout, USD 186.34 billion from premature death, USD 97.71 billion from absenteeism, and USD 27.04 billion from presenteeism. Productivity loss was greater in urban (USD 490.79 billion) than rural areas (USD 122.81 billion), with urban presenteeism (USD 2.54 billion) greater than rural presenteeism (USD 608.55 million); urban absenteeism (USD 79.10 billion) greater than rural absenteeism (USD 18.61 billion); urban labor force dropout (USD 261.24 billion) greater than rural labor force dropout (USD 65.15 billion); and urban premature death (USD 147.90 billion) greater than rural premature death (USD 38.44 billion). CONCLUSIONS: Diabetes has a large and significant negative impact on productivity in urban and rural China. Productivity loss is significantly higher in urban versus rural regions. Further investment is required in the prevention, diagnosis, and control of diabetes in under-resourced health services in rural locations as well as in urban areas, where most diabetes cases reside. Specifically, targeted and effective diabetes prevention and management actions are urgently required.

Sociodemographic and health system factors associated with variations in hospitalization costs for fractures in adults aged 45 years and over: a cross-sectional study of provincial health accounts in Jiangsu Province, China.

This study reports hospitalization costs of fracture in Chinese patients aged over 45 years and evaluates their related factors in different fracture groups. PURPOSE: To report hospitalization costs of treating fractures in Chinese patients aged over 45 years and to investigate the sociodemographic and health system factors related to variation in the costs. METHODS: Study participants were selected from the 2016 Health Accounts Database in Jiangsu in which patients' hospitalization costs were kept at various levels in hospitals. A multi-stage stratified sampling method was used to select study participants. Electronic medical records of patients aged 45 years and over with fractures were included. The International Classification of Diseases, Tenth Revision (ICD-10) was used to identify patients who were hospitalized due to fractures. A generalized linear model was used to estimate the extent to which a range of health system and sociodemographic factors were associated with the variation on hospitalization costs. Costs data were presented and analyzed using 2016 U.S. dollars. RESULTS: A total of 39,300 patients were included in the study. Vertebra, tibia/fibula, and hip were the most frequent fracture sites. The mean (median) of hospitalization cost of included fractures ranged from USD 3142 (USD 2420) for hand and wrist fractures to USD 10,355 (USD 9673) for hip fractures. Longer length of hospital stay, higher hospital level, and being covered by a health insurance were associated with higher hospitalization costs for all fracture types. CONCLUSION: Our study reports hospital costs of the fracture using a large health accounts database in China and investigates the associated factors of hospital costs. Our results may inform cost-of-illness studies and economic evaluations of fracture preventions.

Influencing Indicators and Spatial Variation of Diabetes Mellitus Prevalence in Shandong, China: A Framework for Using Data-Driven and Spatial Methods.

To control and prevent the risk of diabetes, diabetes studies have identified the need to better understand and evaluate the associations between influencing indicators and the prevalence of diabetes. One constraint has been that influencing indicators have been selected mainly based on subjective judgment and tested using traditional statistical modeling methods. We proposed a framework new to diabetes studies using data-driven and spatial methods to identify the most significant influential determinants of diabetes automatically and estimated their relationships. We used data from diabetes mellitus patients' health insurance records in Shandong province, China, and collected influencing indicators of diabetes prevalence at the county level in the sociodemographic, economic, education, and geographical environment domains. We specified a framework to identify automatically the most influential determinants of diabetes, and then established the relationship between these selected influencing indicators and diabetes prevalence. Our autocorrelation results showed that the diabetes prevalence in 12 Shandong cities was significantly clustered (Moran's I = 0.328, p < 0.01). In total, 17 significant influencing indicators were selected by executing binary linear regressions and lasso regressions. The spatial error regressions in different subgroups were subject to different diabetes indicators. Some positive indicators existed significantly like per capita fruit production and other indicators correlated with diabetes prevalence negatively like the proportion of green space. Diabetes prevalence was mainly subjected to the joint effects of influencing indicators. This framework can help public health officials to inform the implementation of improved treatment and policies to attenuate diabetes diseases.

Multimorbidity and Mental Health: The Role of Gender among Disease-Causing Poverty, Rural, Aged Households in China.

(1) Background: The association between multimorbidity and mental health is well established. However, the role of gender in different populations remains unclear. Currently, China is facing an increased prevalence of multimorbidity, especially in its disease-causing poverty population. The present study explores the gender-based differences in the relationship between multimorbidity and mental health using data from the rural, disease-causing poverty, older-age population in Shandong province, China, as a case study. (2) Methods: The data were obtained from the survey on the health and welfare of disease-causing poverty households in rural Shandong province. We identified 936 rural participants who were over 60 years old from disease-causing poverty households. The mental health status was measured using the Kessler Psychological Distress Scale (K10) instrument. Using a multivariable linear regression model, including the interaction of gender and multimorbidity, gender differences in the association between multimorbidity and mental health were explored. (3) Results: Multimorbidity was a serious health problem in rural, disease-causing poverty, older-age households, with the prevalence of multimorbidity estimated as 40% for women and 35.4% for men. There was a strong association between multimorbidity and mental health, which was moderated by gender. Women had higher K10 scores than men, and the mean K10 score was highest in women with three or more chronic diseases. Compared with men, women with multimorbidity had a higher risk of mental health problems. (4) Conclusions: The prevalence of multimorbidity in older-age rural disease-causing poverty subpopulations is a severe public health problem in China. The association between multimorbidity and mental health differed by gender, where multimorbid women suffered an increased mental health risk compared with men. Gender differences should be addressed when delivering effective physical and mental healthcare support to disease-causing poverty, older-age, rural households.

Health-Related Quality of Life and Health Service Use among Multimorbid Middle-Aged and Older-Aged Adults in China: A Cross-Sectional Study in Shandong Province.

(1) Background: The management of multiple chronic diseases challenges China's health system, but current research has neglected how multimorbidity is associated with poor health-related quality of life (HRQOL) and high health service demands by middle-aged and older adults. (2) Methods: A cross-sectional study was conducted in Shandong province, China in 2018 across three age groups: Middle-aged (45 to 59 years), young-old (60 to 74 years), and old-old (75 or above years). The information about socio-economic, health-related behaviors, HRQOL, and health service utilization was collected via face-to-face structured questionnaires. The EQ-5D-3L instrument, comprising a health description system and a visual analog scale (VAS), was used to measure participants' HRQOL, and χ2 tests and the one-way ANOVA test were used to analyze differences in socio-demographic factors and HRQOL among the different age groups. Logistic regression models estimated the associations between lifestyle factors, health service utilization, and multimorbidity across age groups. (3) Results: There were 17,867 adults aged 45 or above in our sample, with 9259 (51.82%) female and 65.60% living in rural areas. Compared with the middle-aged adults, the young-old and old-old were more likely to be single and to have a lower level of education and income, with the old-old having lower levels than the young-old (P < 0.001). We found that 2465 (13.80%) suffered multimorbidities of whom 75.21% were older persons (aged 60 or above). As age increased, both the mean values of EQ-5D utility and the VAS scale decreased, displaying an inverse trend to the increase in the number of chronic diseases (P < 0.05). Ex-smokers and physical check-ups for middle or young-old respondents and overweight/obesity for all participants (P < 0.05) were positively correlated with multimorbidity. Drinking within the past month for all participants (P < 0.001), and daily tooth-brushing for middle (P < 0.05) and young-old participants (P < 0.001), were negatively associated with multimorbidity. Multimorbidities increased service utilization including outpatient and inpatient visits and taking self-medicine; and the probability of health utilization was the lowest for the old-old multimorbid patients (P < 0.001). (4) Conclusions: The prevalence and decline in HRQOL of multimorbid middle-aged and older-aged people were severe in Shandong province. Old patients also faced limited access to health services. We recommend early prevention and intervention to address the prevalence of middle-aged and old-aged multimorbidity. Further, the government should set-up special treatment channels for multiple chronic disease sufferers, improve medical insurance policies for the older-aged groups, and set-up multiple chronic disease insurance to effectively alleviate the costs of medical utilization caused by economic pressure for outpatients and inpatients with chronic diseases.

Disease causing poverty: adapting the Onyx and Bullen social capital measurement tool for China.

BACKGROUND: Disease-causing poverty is a serious problem in rural China, where social capital can mediate the disease-poverty relationship. However, there is no generally accepted reliable, robust and viable measure of social capital for China's unique socio-cultural context. This study adapts for China the widely used Onyx and Bullen social capital measurement scale and tests the validity and reliability of a modified Chinese Onyx-Bullen general scale, the Chinese Onyx-Bullen health scale, for a disease-causing-poverty subpopulation in rural China. METHODS: We conducted the forward and backward translation procedure and cross-cultural adaptation process to derive the 34 item Chinese Onyx-Bullen general scale. Next we collected through face-to face interviews a sample of disease-causing poverty population in rural Shandong province in China to test a 29 item modified Chinese Onyx-Bullen general scale for a health subpopulation. Most of the rural respondents had no formal work, so 5 work-related items in the Onyx-Bullen general scale were deleted in the Chinese Onyx-Bullen health scale. Exploratory factor analysis was conducted to evaluate the structure, validity, internal consistency and reliability of the Chinese Onyx-Bullen health scale. SPSS21.0 software was used for data analysis. RESULTS: A total of 467 people completed the scale. For the 29-item scale, a better simple structure was found when the number of factors was limited to 8. The absolute values of inter-factor correlations were in the range of 0.004 to 0.213 and the Kaiser-Meyer-Olkin value was 0.834. All the eight factors explain a total of 59.51% of the variance. The total scale had a Cronbach's alpha = 0.868, in which seven of the eight factors had Cronbach's α greater than 0.5. CONCLUSION: The Chinese health version of the Onyx-Bullen general social capital scale showed an adequate reliability and validity in a rural disease-causing poverty subpopulation in Shandong province, providing the first general, robust, consistent and reliable measure of social capital in China. The Chinese Onyx-Bullen general social capital scale provides a scale for testing social capital in China or for modification along the lines of the Chinese Onyx-Bullen health scale.

Seasonal and Monthly Patterns, Weekly Variations, and the Holiday Effect of Outpatient Visits for Type 2 Diabetes Mellitus Patients in China.

OBJECTIVE: To explore the seasonal and monthly patterns, weekly variations, and the holiday effect of outpatient visits for type 2 diabetes mellitus patients, as well as the influence of gender, age, and insurance type on variations. METHODS: Data were obtained from the Shandong medical insurance database, including all outpatients in 12 cities of Shandong province in China from 2015 to 2017. The seasonal index (St) was calculated in terms of seasons, months, and weeks by the moving average method. RESULTS: A total of 904,488 patients received outpatient services during the study period. The seasonal indices of outpatient visits by type 2 diabetes patients were higher in autumn (108.36%) and spring (102.67%), while lower in winter (89.92%) and summer (99.04%), exhibiting an obvious seasonality. Gender and age had no effect on seasonal patterns. The month impacted the seasons patterns: January to February were the lowest and December the highest months of outpatient visits, complicating the seasonal patterns. We also identified a weekly pattern of outpatient visits. In addition, the outpatient visits for type 2 diabetes mellitus patients was also strongly affected by the Spring Festival, Lantern Festival, and National Day holiday periods. The type of medical insurance had a significant impact on outpatient visits. CONCLUSIONS: The outpatient visits for type 2 diabetes mellitus patients displayed seasonal patterns that were contradictory to the variations in blood glucose fluctuations found in previous studies and was also strongly affected by the holiday effect. The type of medical insurance impacted the pattern of outpatient visits.

Evaluating Family Planning Organizations Under China's Two-Child Policy in Shandong Province.

BACKGROUND: The 2015 two-child policy was the most important institutional change in China's family planning since the 1978 one-child policy. To implement the two-child policy, China merged the former health departments and family planning departments into the new Health and Family Planning Commission organization. We collected and analyzed funding and expenditure data, providing a novel approach to assessing the family planning outcomes under China's two-child policy. The paper shows how the management structure and funding levels and streams shifted with the new two-child policy and assesses the new management structure in terms of the ability to carry out tasks under the new family planning policy. METHODS: We collected data on the funding, structure of expenditure and social compensation fee in Shandong province from 2011 to 2016, to evaluate how resources were allocated to family planning before and after the organizational change. We also collected interview data from family planning administrators. RESULTS: While total family planning government financing was reduced after the organizational change, expenditures were shifted away from management to family planning work. Funding (80%) was allocated to the grass-root county and township levels, where family planning services were provided. The overlapping work practices, bureaucracy, and inefficiencies were curbed and information flows were improved. CONCLUSIONS: The new Health and Family Planning Commissions shifted resources to carry out the new family planning policy. The aims of the two-child policy to reduce inefficiencies, overlapping authorities and excessive management were achieved and expenditures on family planning work was enhanced and made more efficient.

Haze Attitudes and the Willingness to Pay for Haze Improvement: Evidence from Four Cities in Shandong Province, China.

BACKGROUND: Given the health and welfare impacts of haze, haze reduction governance challenges Chinese policy-makers. Surprisingly, there have been no studies of the differences in the public's willingness to pay (WTP) for haze governance within a province. Yet haze reduction policies are implemented at the provincial level. Based on the contingent valuation method, data on WTP for haze governance across four industrial cities in Shandong province were collected using a questionnaire survey. METHOD: A combination of stratified sampling and non-probability sampling methods were used, yielding a valid sample of 1006 respondents. The Heckman sample selection model was used to analyze factors determining WTP and WTP amount. RESULTS: 53% of respondents were unwilling to pay for haze reduction, while less than 1% of these respondents were satisfied with Shandong's air quality. About half (47%) of the respondents were willing to pay, on average, US$14.14 per household per year for haze governance. We found that there were significant inter-city differences in the WTP and WTP amounts: those with a higher income, education, haze knowledge, and haze concern were WTP; age, marital status, and subjective indicators displayed a negative relationship with WTP amount. About two thirds of the non-payers, and those with poor environmental knowledge, argued that air quality improvement was mainly the responsibility of governments (39.3%) and polluters (25.6%), instead of ordinary citizens. Further, 27% of non-payers said that their income was too low to contribute to a pollution tax and 6.3% claimed that they did not believe the funds would be used effectively for environmental conservation. CONCLUSIONS: City-specific differences in WTP may caution against "one size fits all" policies. The study indicates that the government may need to target policies to specific cities and the characteristics of residents in those cities by age, education, and income groups and residents' subjective evaluation of the government and the haze problem and those responsible for pollution.

Resistin-like molecule alpha enhances the proliferation and migration of aortic vascular smooth muscle cells.

OBJECTIVE: The mitogenic and chemotactic effects of resistin-like molecule alpha (RELMα) are thought to contribute to vascular remodeling in pulmonary arterial hypertension. Here we evaluate the expression of RELMα in atherosclerotic plaque and investigate its effects on the proliferation and migration of vascular smooth muscle cells (VSMCs). METHODS: An atherosclerotic model was established by feeding 4-week-old C57BL/6J ApoE-/- mice (n = 9) with a high-fat diet. Wild-type 4-week-old C57BL/6J (n = 9) were fed the same diet and were used as controls. RELMα expression was evaluated by immunohistochemistry and quantified using real-time PCR (RT-PCR). A (3)H-thymidine incorporation assay and the Boyden chamber assay, respectively, were used to explore the effects of different concentrations of RELMα on the proliferation and migration of VSMCs. RESULTS: Immunohistochemistry identified positively stained granules in atherosclerotic plaques. These results were confirmed by detection of RELMα mRNA using RT-PCR. We also demonstrated that in vitro exposure to RELMα significantly promoted the proliferation and migration of VSMCs in a dose-related manner (p < 0.01). CONCLUSIONS: RELMα expressed in atherosclerotic plaque of ApoE-/- mice appears to enhance the proliferation and migration of aortic VSMCs in a dose-related manner.