The risk of severe COVID-19 if an individual becomes infected is known to be higher in older individuals and those with underlying health conditions. Understanding the number of individuals at ...increased risk of severe COVID-19 and how this varies between countries should inform the design of possible strategies to shield or vaccinate those at highest risk.
We estimated the number of individuals at increased risk of severe disease (defined as those with at least one condition listed as “at increased risk of severe COVID-19” in current guidelines) by age (5-year age groups), sex, and country for 188 countries using prevalence data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 and UN population estimates for 2020. The list of underlying conditions relevant to COVID-19 was determined by mapping the conditions listed in GBD 2017 to those listed in guidelines published by WHO and public health agencies in the UK and the USA. We analysed data from two large multimorbidity studies to determine appropriate adjustment factors for clustering and multimorbidity. To help interpretation of the degree of risk among those at increased risk, we also estimated the number of individuals at high risk (defined as those that would require hospital admission if infected) using age-specific infection–hospitalisation ratios for COVID-19 estimated for mainland China and making adjustments to reflect country-specific differences in the prevalence of underlying conditions and frailty. We assumed males were twice at likely as females to be at high risk. We also calculated the number of individuals without an underlying condition that could be considered at increased risk because of their age, using minimum ages from 50 to 70 years. We generated uncertainty intervals (UIs) for our estimates by running low and high scenarios using the lower and upper 95% confidence limits for country population size, disease prevalences, multimorbidity fractions, and infection–hospitalisation ratios, and plausible low and high estimates for the degree of clustering, informed by multimorbidity studies.
We estimated that 1·7 billion (UI 1·0–2·4) people, comprising 22% (UI 15–28) of the global population, have at least one underlying condition that puts them at increased risk of severe COVID-19 if infected (ranging from <5% of those younger than 20 years to >66% of those aged 70 years or older). We estimated that 349 million (186–787) people (4% 3–9 of the global population) are at high risk of severe COVID-19 and would require hospital admission if infected (ranging from <1% of those younger than 20 years to approximately 20% of those aged 70 years or older). We estimated 6% (3–12) of males to be at high risk compared with 3% (2–7) of females. The share of the population at increased risk was highest in countries with older populations, African countries with high HIV/AIDS prevalence, and small island nations with high diabetes prevalence. Estimates of the number of individuals at increased risk were most sensitive to the prevalence of chronic kidney disease, diabetes, cardiovascular disease, and chronic respiratory disease.
About one in five individuals worldwide could be at increased risk of severe COVID-19, should they become infected, due to underlying health conditions, but this risk varies considerably by age. Our estimates are uncertain, and focus on underlying conditions rather than other risk factors such as ethnicity, socioeconomic deprivation, and obesity, but provide a starting point for considering the number of individuals that might need to be shielded or vaccinated as the global pandemic unfolds.
UK Department for International Development, Wellcome Trust, Health Data Research UK, Medical Research Council, and National Institute for Health Research.
Abstract Background China is reshaping its health-care system to orient towards primary care. We developed a short instrument on the basis of the Primary Care Assessment Tool-Adult Edition (PCAT-AE) ...to assess patients' experiences of primary-care delivery in community health centres, the major primary-care provider in urban areas. Methods A multistage cluster sampling method was used to select seven geographical regions in southern China where the population's ageing and gender structure is similar to that of China's overall population. A validated PCAT-AE (Mandarin Chinese short version) with 33 PCAT items on a four-point Likert-type scale was used, with higher scores representing better primary-care experiences. This study was approved by the Ethics Committee of Guangzhou Medical University, Guangzhou, China, and the Survey and Behaviour Research Ethics Committee of The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (TB106179/MD10606). All study participants provided written consent. Findings The overall response rate of adult subjects interviewed at community health centres was 85·8% (3360 of 3916). Both frequent (2237) and less-frequent service users (1123) were surveyed, among which 1122 (33%) patients had an optimum PCAT score (higher than the third quantile of the score range—ie, above 99 of 132). The proportion of subjects with optimum scores in individual primary-care domains ranged from 62·1% (95%CI 59·8–64·3) in the comprehensiveness of service attribute to only 16·6% (14·7–18·7) in the community orientation attribute. Among all subjects, those with social medical insurance were more likely to report optimum primary care experience (adjusted odds ratio 2·30, 95% CI 1·92–2·75) than those uninsured. In the stratified analysis among subjects who were uninsured, those attending community health centres owned and managed by the government as their usual source of primary care had the highest PCAT scores compared with other models of community health centres owned and managed by secondary or tertiary hospitals (95·16 vs 90·18; p=0·0001) or by private investors (95·16 vs 87·80; p<0·0001), as a result of better first-contact care and coordination of care. Interpretation The study suggests an urgent need to understand and address how social medical insurance coverage could affect patients' experiences. The community health centre model with a government-dominant top-down approach seems to be most effective in solving conundrums for China's health-care reform. Funding This study was funded by the Bauhinia Foundation Research Centre; Department of Health, Guangdong province (C2009006/2009–2013); Department of Education, Guangdong province (BKZZ2011047/2010–2013); Medical Research Fund, Chinese Medical Association (2010-08-05); and Community Health Research Fund, Community Health Association of China (2012-2-91). HHXW was supported by a postdoctoral research fellowship in the Hong Kong–Scotland Partners in Post Doctoral Research programme, Research Grants Council of Hong Kong and the Scottish Government (S-CUHK402/12). JJW is supported by Guangdong Exemplary Centres for Exploratory Teaching in Higher Education Institutions—General Practice Exploratory Teaching Centre (GDJG-2010-N38-35, Guangdong Department of Education) and The Ninth Round of Guangdong Key Disciplines—General Practice (GDJY-2012-N13-85, Guangdong Department of Education), both of which he leads.
Abstract Background China's comprehensive health-care reform was embarked on in 2009, targeting health-care financing, care delivery, drug supply, and hospital reform. The aim of this study was to ...explore the extent to which being people with multiple long-term disorders who are unemployed and uninsured are prevented from accessing hospital inpatient care. Methods We analysed data from a large community household survey of about 5% of the general resident population with household registry in three prefectures in southern China in 2011. Close-ended questions on demographics, socioeconomics, and lifestyle behaviours were derived from the National Health Services Survey (NHSS) 2008. Open-ended questions on chronic disorders (clinically diagnosed or being treated) and admissions to hospitals at the secondary level or above in the previous 12 months were designed by a research panel. The multistage sample designs and sampling weights were taken into account in the binary logistic regression analysis of the survey response. We cross-validated self-reported chronic disorders with paper-based medical reports obtained from previous health-care visits and annual check-ups. Multimorbidity was defined as having two or more chronic disorders from a validated list of 40 morbidities. Findings 124 829 residents (aged ≥20 years) from 53 760 households participated in the survey. In the previous 12 months, 7211 (5·8%, 95% CI 5·7–5·9) residents had at least one admission to hospital, of whom 3002 (42%, 40·8–42·4) had multimorbidity. Admission to hospital was associated with the number of chronic disorders (≥4 disorders vs none: adjusted odds ratio 17·13 95%CI 16·15–18·16), having social medical insurance (1·41 1·37–1·44), household income per head (highest household income group vs the lowest household income group: 1·80 1·74–1·85), and unemployment (1·61 1·55–1·66). We found a statistically significant interaction between employment status and the presence of medical insurance on hospital admission, meaning that patients who were unemployed and not covered by a social medical insurance were least likely to be admitted to a hospital (0·50, 0·47–0·52). Interpretation The ability to pay a medical bill seems to be significantly predictive of inpatient service use for multimorbidity. A better designed social medical insurance system with more government contribution would be of particular necessity to improve equitable access to health care, particularly for people with less affordability because of unemployment. Funding Department of Health, Guangdong province, China (C2009006/2009–2013), Department of Education, Guangdong province, China (BKZZ2011047/2010–2013), Medical Research Fund, Chinese Medical Association, China (2010-08-05), and Community Health Research Fund, Community Health Association of China, China (2012-2-91). HHXW was supported by a postdoctoral research fellowship in the Hong Kong-Scotland Partners in Post Doctoral Research programme, Research Grants Council of Hong Kong, and the Scottish Government, UK (S-CUHK402/12). JJW is supported by Guangdong Exemplary Centres for Exploratory Teaching in Higher Education Institutions – General Practice Exploratory Teaching Centre GDJG-2010-N38-35, Guangdong Department of Education, China, and The Ninth Round of Guangdong Key Disciplines – General Practice GDJY-2012-N13-85, Guangdong Department of Education, China, both of which he leads. The Scottish School of Primary Care partly supported SWM's post and the development of the National Research Programme on Multimorbidity, which he leads.
Abstract Background The rising incidence and mortality of colorectal cancer (CRC) in China highlights the pressing need for population-based screening. Flexible sigmoidoscopy (FS) is becoming ...increasingly popular as a primary screening tool; and in many regions of China, colonoscopy capacity is limited. However, FS is preferred for patients with a low risk of advanced proximal neoplasia (APN; ie, higher numbers needed to screen NNS, since the test predominantly examines the distal colon. Tailoring endoscopic screening based on the risk of APN is necessary, especially in resource-deprived regions. Since old age and female sex are two important CRC risk factors, we hypothesised that younger Chinese women aged 50–59 years had a significantly lower APN rate than did older Chinese men. Methods In 2013–15, we recruited 5833 asymptomatic participants aged 50–75 years who were registered for CRC screening in a large hospital-based endoscopy unit in Shanghai, China. Those with poor bowel preparation and whose colonoscopy failed caecal intubation were excluded. All polyps were removed as deemed appropriate and examined by histopathologists who were masked to the patients' data. We used χ2 test to compare APN among different age and gender groups. The respective NNS were evaluated. Institutional ethics board approval was obtained by the hospital while informed consent was sought before subject recruitment. Findings For men, the prevalence of APN was 2·5% (31/1264, 95% CI 1·7–3·5) in those aged 50–59 years, 4·1% (30/735, 2·9–5·8) in those aged 60–64 years, and 5·2% (38/727, 3·8–7·1) in those aged 65–75 years. In women, the APN prevalence was 0·7% (11/1607, 0·4–1·2) in those aged 50–59 years, 0·8% (6/766,0·3–1·8) in those aged 60–64 years, 4·8% (35/734,3·4–6·6) in those aged 65–75 years in those aged 66 years or older (p<0·001). The NNS by colonoscopy to detect one APN was 124 (95% CI 80–270) women aged 50–59 years and 96 (57–310) women aged 60–64, compared with the significantly lower NNS in other age or gender subgroups (range 14–58; p<0·001). Interpretation These findings supported the application of sigmoidoscopy for CRC screening among female individuals younger than 65 years, given their low risk of APN and high NNS. Colonoscopy could be favoured for Chinese individuals aged 65 years or older. The feasibility and cost-effectiveness of this simple, tailored screening strategy in different Chinese populations should be further examined. Funding None.
Abstract Background The Dietary Approaches to Stop Hypertension (DASH) diet has been found to effectively lower blood pressure in Western populations within controlled experimental settings, with an ...efficacy similar to that of antihypertensive drugs. Nevertheless, studies of the pragmatic effectiveness of DASH counselling in the Chinese population are scarce. The aim of this study was to test the a priori hypotheses that DASH dietary intervention by a single counselling session with a dietician in addition to standard care by physicians improved estimated 10-year cardiovascular risk to a greater extent than standard care given by physicians alone. We also assessed participants who were less likely to have their cardiovascular risk optimised. Methods This parallel-group, randomised controlled trial was done with enrolment at two General Outpatient Clinics and at community health seminars through a primary-care network in Hong Kong. Computer-generated numbers with a block size of six and an allocation ratio of 1:1 were used for group allocation. The research nurse opened the opaque envelope in which the randomised sequence was sealed. Patients were notified into either intervention or control group, whereas the outcome assessors were masked. We recruited male and female patients (aged 40–70 years) who were newly diagnosed with grade 1 hypertension. Standard care was offered by the attending physician that lasted for 3–5 minutes, resembling the routine clinic practice. Only patients in the intervention group received a further 25 min one-off dietary counselling, based on the DASH recipe tailored-made for Chinese patients with hypertension, offered by a registered dietitian. Individualised DASH diet goals were recommended and educational pamphlets on the DASH diet were given. 10-year cardiovascular risk was estimated by a recalibrated and validated Chinese version of the Framingham equation. Analysis of covariance was performed to compare between-group differences, with adjustment for the effects of other factors and baseline outcome measures. This trial is registered with the Chinese Clinical Trial Register, number ChiCTRTRC-13003014. The study was approved by the Joint CUHK-NTEC Clinical Research Ethics Committee, Hong Kong. Each trial participant provided written informed consent. Findings We recruited a total of 556 patients (273 males; 283 females) aged 40–70 years who were newly diagnosed with grade 1 hypertension. 275 patients were randomly assigned to receive standard care and 281 patients were assigned to receive standard care plus DASH-based dietary counselling. Outcome data were available for 504 (91%) patients at 6 months and 485 (87%) patients at 12 months. Between-group analyses showed no difference in the reduction of cardiovascular risk between the two groups at 6 months (–0·13% 95% CI –0·50% to 0·23%, p=0·477) and 12 months (–0·08% –0·33% to 0·18%, p=0·568). Multivariate regression analyses showed that men (p=0·012), patients younger than 55 years (p=0·049), current smokers (p=0·007), patients with educational level of junior secondary or below (p=0·009), and those who dined out for main meals for four times or more in a typical week (p=0·038) were significantly associated with no improvement in cardiovascular risk. Interpretation We found that additional counselling with a dietitian for Chinese patients with grade 1 hypertension might not confer additional benefits to those achieved with standard care. This finding does not support routine referral of these patients to dietary counselling. Patients with risk factors identified in this study should receive more clinical attention and regular follow-up to reduce cardiovascular risk. Future research is still necessary to assess the effectiveness of other plausible DASH diet delivery models. Funding The Health and Medical Research Fund and the Food and Health Bureau of the Hong Kong Government.
ABSTRACT Associations of multimorbidity and income with hospital admission were investigated in population samples from 3 widely differing health care systems: Scotland (n = 36,921), China (n = ...162,464), and Hong Kong (n = 29,187). Multimorbidity increased odds of admissions in all 3 settings. In Scotland, poorer people were more likely to be admitted (adjusted odds ratio aOR = 1.62; 95% CI, 1.41-1.86 for the lowest income group vs the highest), whereas China showed the opposite (aOR = 0.58; 95% CI, 0.56-0.60). In Hong Kong, poorer people were more likely to be admitted to public hospitals (aOR = 1.68; 95% CI, 1.36-2.07), but less likely to be admitted to private ones (aOR = 0.18; 95% CI, 0.13-0.25). Strategies to improve equitable health care should consider the impact of socioeconomic deprivation on the use of health care resources, particularly among populations with prevalent multimorbidity.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Abstract Purpose Current health care reforms in China have an overall goal of strengthening primary care through the establishment and expansion of primary care networks based on community health ...centers (CHCs). Implementation in urban areas has led to the emergence of different models of ownership and management. The objective of this study was to evaluate the primary care experiences of patients in the Pearl River Delta as measured by the Primary Care Assessment Tool (PCAT) and the relationships with ownership and management in the 3 different models we describe. Methods This cross-sectional study was conducted on-site at CHCs in 3 cities within the Pearl River Delta, China, using a multistage cluster sampling method. A validated Mandarin Chinese version of the PCAT–Adult Edition (short version) was adopted to collect information from adult patients regarding their experiences with primary care sources. PCAT scores for individual primary care attributes and total primary care assessment scores were assessed with respect to sociodemographic characteristics, health characteristics, and health care service utilization across 3 primary care models. Results One thousand four hundred forty (1,440) primary care patients responded to the survey, for an overall response rate of 86.1%. Respondents gave government-owned and -managed CHCs the highest overall PCAT scores when compared with CHCs either managed by hospitals (95.18 vs 90.81; P = .005) or owned by private and social entities (95.18 vs 90.69; P = .007) as a result of better first-contact care (better first-contact utilization) and coordination of care (better service coordination and information system). Factors that were positively and significantly associated with higher overall assessment scores included the presence of a chronic condition ( P <.001), having medical insurance (P = .006), and a self-reported good health status ( P <.001). Conclusions This study suggests that government-owned and -managed CHCs may be able to provide better first-contact care in terms of utilization and coordination of care, and may be better at solving the problem of underutilization of the CHCs as the first-contact point of care, one key problem facing the reforms in China.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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