Summary Background The prevalence of chronic kidney disease is high in developing countries. However, no national survey of chronic kidney disease has been done incorporating both estimated ...glomerular filtration rate (eGFR) and albuminuria in a developing country with the economic diversity of China. We aimed to measure the prevalence of chronic kidney disease in China with such a survey. Methods We did a cross-sectional survey of a nationally representative sample of Chinese adults. Chronic kidney disease was defined as eGFR less than 60 mL/min per 1·73 m2 or the presence of albuminuria. Participants completed a lifestyle and medical history questionnaire and had their blood pressure measured, and blood and urine samples taken. Serum creatinine was measured and used to estimate glomerular filtration rate. Urinary albumin and creatinine were tested to assess albuminuria. The crude and adjusted prevalence of indicators of kidney damage were calculated and factors associated with the presence of chronic kidney disease analysed by logistic regression. Findings 50 550 people were invited to participate, of whom 47 204 agreed. The adjusted prevalence of eGFR less than 60 mL/min per 1·73 m2 was 1·7% (95% CI 1·5–1·9) and of albuminuria was 9·4% (8·9–10·0). The overall prevalence of chronic kidney disease was 10·8% (10·2–11·3); therefore the number of patients with chronic kidney disease in China is estimated to be about 119·5 million (112·9–125·0 million). In rural areas, economic development was independently associated with the presence of albuminuria. The prevalence of chronic kidney disease was high in north (16·9% 15·1–18·7) and southwest (18·3% 16·4–20·4) regions compared with other regions. Other factors independently associated with kidney damage were age, sex, hypertension, diabetes, history of cardiovascular disease, hyperuricaemia, area of residence, and economic status. Interpretation Chronic kidney disease has become an important public health problem in China. Special attention should be paid to residents in economically improving rural areas and specific geographical regions in China. Funding The Ministry of Science and Technology (China); the Science and Technology Commission of Shanghai; the National Natural Science Foundation of China; the Department of Health, Jiangsu Province; the Sichuan Science and Technology Department; the Ministry of Education (China); the International Society of Nephrology Research Committee; and the China Health and Medical Development Foundation.
Abstract Background Patient–physician mistrust has become deeply embedded in medical clinics within a wide variety of settings, including many in China. The purpose of this research was to develop a ...series of actionable policy recommendations to rebuild patient–physician trust in China. Methods Our interdisciplinary group included experts in medicine, public health, philosophy, ethics, law, regulation, China studies, anthropology, sociology, and communications. Recommendations were identified by team members and presented at a two-day workshop at the Harvard Center, Shanghai, China. The group divided into three teams (medical education, ethics and law, and healthcare systems) in order to revise and finalise the recommendations. Findings We identified a total of 18 recommendations focused on medical schools, ethical guidance, legal systems, and health systems to rebuild patient-physician trust. Medical education recommendations included a requirement for medical humanities as a core component, promotion of experiential learning and community–medical school partnerships, and improvement of evaluation of medical humanities education. Ethical and legal recommendations included encouragement of more transparency in doctor practices and the healthcare system, creating laws to promote mandatory medical error reporting, and acceleration of the development of neutral procedures for recording and resolving medical disputes. Healthcare systems recommendations included promoting healthcare systems that facilitate and acknowledge caregiving, transitioning from red packets (gifts to physicians) and towards higher physician salaries, strengthening primary healthcare systems, and establishment of non-punitive systems for error reporting in hospitals. Interpretation Several educational, legal, ethical, and healthcare system reforms to rebuild patient–physician trust are feasible. Our recommendations go beyond the healthcare sector alone, suggesting that policy responses within education, legal, and ethical norms are also critical. The presence of mistrust should not be misconstrued as an errant medical system, but rather as an opportunity and a responsibility to rebuild patient–physician trust. Our recommendations are relevant within the Chinese context and in other transitioning healthcare systems. Funding Harvard China Fund and the China Medical Board
Abstract Background Health literacy is important in public health and health care, particularly in effective communication between patients and nurses. The aim of this study was to explore the health ...literacy level and its influence factors in undergraduate nursing students. Methods We did a cross-sectional study by stratified sampling of nurses studying at the medical university in Chongqing, south-western China. Nurses had to attend class, be willing to participate, and be younger than 28 years. We used the health literacy questionnaire (HLQ), which was created by Osborne and colleagues, to assess literacy. Analyses were done with χ2 tests, ANOVA, and multiple linear regression models. We set the low health literacy to scores lower than 60% of the total score and the high health literacy to scores higher than 80% of the total score. The study protocol was approved by the Ethics Committee of Chongqing Medical University (record number 2015002). And we obtained written informed consent from all participants. The study protocol was approved by the Ethics Committee of Chongqing Medical University (record number 2015002). Findings Between March 23, 2015, and April 16, 2015, a total of 612 undergraduate nursing students filled the survey, 316 were in grade one, 168 in grade two, and 128 in grade three. The total score of HLQ was 40·00; the mean score of HLQ was 26·18 (SD 3·95). The mean scores of HLQ in nine scales, including (1) feeling understood and supported by healthcare providers, (2) having sufficient information to manage my health, (3) actively managing my health; (4) social support for health, (5) Appraisal of health information, (6) ability to actively engage with health-care providers, (7) navigating the health-care system, (8) ability to find good health information, and (9) understand health information well enough to know what to do were 2·16 (SD 0·57), 2·54 (0·47), 2·60 (0·49), 2·88 (0·46), 2·61 (0·46), 3·24 (0·76), 3·16 (0·69), 3·42 (0·65) and 3·56 (0·61), respectively. Participants with higher grades were more likely to have higher scores than those with lower grades in scales 1 to 9 (F=30·852, p<0·001; F=49·456, p<0·001; F=32·347, p<0·001; F=40·272, p<0·001; F=52·483, p<0·001; F=30·852, p<0·001; F=240·018, p<0·001; F=215·972, p<0·001; F=158·258, p<0·001 and F=200·215, p<0·001). Participants with average or higher socioeconomic status were more likely to have higher scores than those with lower socioeconomic status in scales 3, 6 to 9 (t=–2·127, p=0·034; t=–3·540, p<0·001; t=–3·756, p<0·001; t=–4·210, p<0·001 and t=–4·785, p<0·001).. Participants whose parent had completed high school had higher scores than those whose parents had not completed high school in scales 5 to 9 (t=–2·044, p=0·041; t=–3·866, p<0·001; t=–3·886, p<0·001; t=–3·268, p=0·001 and t=–6·255, p<0·001). Regression analysis showed that higher grades (t=9·418, p<0·001 and t=16·923, p<0·001), higher parent's level of education (t=5·366, p<0·001), and higher socioeconomic status (t=4·764, p<0·001) were associated with higher scores of the HLQ. Interpretation Our findings indicate that the health literacy levels of the undergraduate nursing students are insufficient. We suggest that school should pay more attention to cultivate nursing students' health literacy level. Funding This project was supported by the Humanity and Social Science Foundation of China's Ministry of Education ( 15YJA860020 ).
Summary Background China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. ...Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China. Methods Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013. Findings All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4·0 years in Hebei province to 14·2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0–14, 15–49, and 50–74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990. Interpretation Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems. Funding China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.
Summary Background Current staging methods do not accurately predict the risk of disease recurrence and benefit of adjuvant chemotherapy for patients who have had surgery for stage II colon cancer. ...We postulated that expression patterns of multiple microRNAs (miRNAs) could, if combined into a single model, improve postoperative risk stratification and prediction of chemotherapy benefit for these patients. Method Using miRNA microarrays, we analysed 40 paired stage II colon cancer tumours and adjacent normal mucosa tissues, and identified 35 miRNAs that were differentially expressed between tumours and normal tissue. Using paraffin-embedded specimens from a further 138 patients with stage II colon cancer, we confirmed differential expression of these miRNAs using qRT-PCR. We then built a six-miRNA-based classifier using the LASSO Cox regression model, based on the association between the expression of every miRNA and the duration of individual patients' disease-free survival. We validated the prognostic and predictive accuracy of this classifier in both the internal testing group of 138 patients, and an external independent group of 460 patients. Findings Using the LASSO model, we built a classifier based on the six miRNAs: miR-21-5p, miR-20a-5p, miR-103a-3p, miR-106b-5p, miR-143-5p, and miR-215. Using this tool, we were able to classify patients between those at high risk of disease progression (high-risk group), and those at low risk of disease progression (low-risk group). Disease-free survival was significantly different between these groups in every set of patients. In the initial training group of patients, 5-year disease-free survival was 89% (95% CI 77·3–94·4) for the low-risk group, and 60% (46·3–71·0) for the high-risk group (hazard ratio HR 4·24, 95% CI 2·13–8·47; p<0·0001). In the internal testing set of patients, 5-year disease-free survival was 85% (95% CI 74·3–91·8) for the low-risk group, and 57% (42·8–68·5) for the high-risk group (HR 3·63, 1·86–7·01; p<0·0001), and in the independent validation set of patients, was 85% (79·6–89·0) for the low-risk group and 54% (46·4–61·1) for the high-risk group (HR 3·70, 2·56–5·35; p<0·0001). The six-miRNA-based classifier was an independent prognostic factor for, and had better prognostic value than, clinicopathological risk factors and mismatch repair status. In an ad-hoc analysis, the patients in the high-risk group were found to have a favourable response to adjuvant chemotherapy (HR 1·69, 1·17–2·45; p=0·0054). We developed two nomograms for clinical use that integrated the six-miRNA-based classifier and four clinicopathological risk factors to predict which patients might benefit from adjuvant chemotherapy after surgery for stage II colon cancer. Conclusion Our six-miRNA-based classifier is a reliable prognostic and predictive tool for disease recurrence in patients with stage II colon cancer, and might be able to predict which patients benefit from adjuvant chemotherapy. It might facilitate patient counselling and individualise management of patients with this disease. Funding Natural Science Foundation of China.
Summary Background Acute kidney injury (AKI) has become a worldwide public health problem, but little information is available about the disease burden in China. We aimed to evaluate the burden of ...AKI and assess the availability of diagnosis and treatment in China. Methods We launched a nationwide, cross-sectional survey of adult patients who were admitted to hospital in 2013 in academic or local hospitals from 22 provinces in mainland China. Patients with suspected AKI were screened out on the basis of changes in serum creatinine by the Laboratory Information System, and we reviewed medical records for 2 months (January and July) to confirm diagnoses. We assessed rates of AKI according to two identification criteria: the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) AKI definition and an increase or decrease in serum creatinine by 50% during hospital stay (expanded criteria). We estimated national rates with data from the 2013 report by the Chinese National Health and Family Planning Commission and National Bureau of Statistics. Findings Of 2 223 230 patients admitted to the 44 hospitals screened in 2013, 154 950 (7·0%) were suspected of having AKI by electronic screening, of whom 26 086 patients (from 374 286 total admissions) were reviewed with medical records to confirm the diagnosis of AKI. The detection rate of AKI was 0·99% (3687 of 374 286) by KDIGO criteria and 2·03% (7604 of 374 286) by expanded criteria, from which we estimate that 1·4–2·9 million people with AKI were admitted to hospital in China in 2013. The non-recognition rate of AKI was 74·2% (5608 of 7555 with available data). Renal referral was done in 21·4% (1625 of 7604) of the AKI cases, and renal replacement therapy was done in 59·3% (531 of 896) of those who had the indications. Delayed AKI recognition was an independent risk factor for in-hospital mortality, and renal referral was an independent protective factor for AKI under-recognition and mortality Interpretation AKI has become a huge medical burden in China, with substantial underdiagnosis and undertreatment. Nephrologists should take the responsibility for leading the battle against AKI. Funding National 985 Project of China, National Natural Science Foundation of China, Beijing Training Program for Talents, International Society of Nephrology Research Committee, and Bethune Fund Management Committee.
Summary Background Helicobacter pylori is one of the most common gastric pathogens, affecting at least half the world's population, and is strongly associated with gastritis, peptic ulcer, gastric ...adenocarcinoma, and lymphoma. We aimed to assess the efficacy, safety, and immunogenicity of a three-dose oral recombinant H pylori vaccine in children in China. Methods We did this randomised, double-blind, placebo-controlled, phase 3 trial at one centre in Ganyu County, Jiangsu Province, China. Healthy children aged 6–15 years without past or present H pylori infection were randomly assigned (1:1), via computer-generated randomisation codes in blocks of ten, to receive the H pylori vaccine or placebo. Participants, their guardians, and study investigators were masked to treatment allocation. The primary efficacy endpoint was the occurrence of H pylori infection within 1 year after vaccination. We did analysis in the per-protocol population. This trial is registered with ClinicalTrials.gov , number NCT02302170. Findings Between Dec 2, 2004, and March 19, 2005, we randomly assigned 4464 participants to either the vaccine group (n=2232) or the placebo group (n=2232), of whom 4403 (99%) participants completed the three-dose vaccination schedule and were included in the per-protocol efficacy analysis. We extended follow-up to 3 years. We recorded 64 events of H pylori infection within the first year (14 events in 2074·3 person-years at risk in the vaccine group vs 50 events in 2089·6 person-years at risk in the placebo group), resulting in a vaccine efficacy of 71·8% (95% CI 48·2–85·6). 157 (7%) participants in the vaccine group and 161 (7%) participants in the placebo group reported at least one adverse reaction. Serious adverse events were reported in five (<1%) participants in the vaccine group and seven (<1%) participants in the placebo group, but none was considered to be vaccination related. Interpretation The oral recombinant H pylori vaccine was effective, safe, and immunogenic in H pylori -naive children. This vaccine could substantially reduce the incidence of H pylori infection; however, follow up over a longer period is needed to confirm the protection of the vaccine against H pylori -associated diseases. Funding Chongqing Kangwei Biological Technology.
Summary Background Controversy remains over whether high-risk human papillomavirus (HPV) DNA testing should be used as a primary screen for cervical cancer. The aims of our study were to assess ...whether HPV DNA testing could be applied to cervical-cancer screening programmes in China, as well as other similar developing countries. Methods We did a pooled analysis of population-based cervical cancer screening studies done in mainland China from 1999 to 2008 with concurrent HPV DNA testing (Hybrid Capture 2 assay; Qiagen, Gaithersburg, MD, USA), liquid-based cytology (LBC), and visual inspection with acetic acid (VIA). Eligible women were sexually active, not pregnant, had an intact uterus, and had no history of cervical intraepithelial neoplasia (CIN), cervical cancer, or pelvic irradiation. All women positive for any test were referred for colposcopy and biopsy. Cervical lesions were diagnosed by directed or random biopsy. We assessed the diagnostic accuracy of HPV DNA testing for the detection of CIN grade 3 or greater. Findings 30 371 women from 17 cross-sectional, population-based studies in various parts of China were screened. 1523 women were subsequently excluded because of inadequate HPV DNA specimens or they did not have a biopsy taken, which included women with atypical squamous cells of undetermined significance; low-grade squamous intraepithelial lesion or worse; positive HPV, negative cytology, and missing or positive colposcopy results; and unsatisfactory cytology results. HPV DNA testing had a higher sensitivity of 97·5% (95% CI 95·7–98·7) for detection of CIN grade 3 or worse, and a lower specificity of 85·1% (82·3–87·9), compared with cytology (sensitivity 87·9% 95% CI 84·7–90·7, specificity 94·7% 93·5–96·0) and VIA (54·6% 48·0–61·2, 89·9% 86·8–93·0). Sensitivity did not vary by study or age (<35 years, 35–49 years, ≥50 years); however, specificity did vary with age (p<0·0001) and was highest in women younger than 35 years (89·4%; 95% CI 86·1–91·5). An increase in the positive cutoff point from the manufacturer recommended 1 pg/mL to 2 pg/mL led to a decrease in the overall HPV DNA positivity from 16·3% to 13·9% (p<0·0001), which could result in a decrease in referral rates, although sensitivity was slightly lower (97·5% to 95·2%). An increase in the cutoff point to 10 pg/mL in women younger than 35 years maintained a high sensitivity 97·7% (95% CI 87·7–99·9) and increased specificity to 93·5% (95% CI 91·9–94·6). Interpretation HPV DNA testing is highly sensitive and moderately specific for CIN grade 3 or worse, with consistent results across study sites and age groups—including women younger than 35 years. A rise in the cutoff point might be beneficial for future screening programmes in China, especially when screening women younger than 35 years. Funding Fogarty International Clinical Research Scholars Program (Fogarty International Center, US National Institutes of Health, through the International Clinical Research Fellows Program at Vanderbilt University); Academic Capacity Development Program of the Beijing Municipal Commission of Education; and Cancer Institute and Hospital of the Chinese Academy of Medical Sciences.
Summary China's current strategy to improve how health services are paid for is headed in the right direction, but much more remains to be done. The problems to be resolved, reflecting the setbacks ...of recent decades, are substantial: high levels of out-of-pocket payments and cost escalation, stalled progress in providing adequate health insurance for all, widespread inefficiencies in health facilities, uneven quality, extensive inequality, and perverse incentives for hospitals and doctors. China's leadership is taking bold steps to accelerate improvement, including increasing government spending on health and committing to reaching 100% insurance coverage by 2010. China's efforts are part of a worldwide transformation in the financing of health care that will dominate global health in the 21st century. The prospects that China will complete this transformation successfully in the next two decades are good, although success is not guaranteed. The real test, as other countries have experienced, will come when tougher reforms have to be introduced.
Abstract Background Unlicensed medical practice has been subject to high health supervision and inspection in China over the past decade. Unlicensed medical practice in China reflects not only the ...large gap between increases in demand and deficiencies in healthcare resources, but also the history and cultural background of the population. Our objectives were to describe current status of unlicensed medical practice and to discuss underlying causes of this phenomenon in China. Methods Data on unlicensed medical practice from January 1, 2012, to December 31, 2015, collected by Center of Inspection and Supervision of National Health and Family Planning Commission through National Health Inspection Information System (NHIIS), were used to assess characteristics of cases of unlicensed medical practice in China. Data analyses were done using SAS (version 9·4). The underlying causes of unlicensed medical practice were also studied using government documents, academic papers, and media reports. Findings Since 2005, unlicensed medical practice has become a national priority. Multiple Government Ministries collaborated with the aim of rectifying and standardising medical services, established long-term inspection mechanisms, and achieved initial results. Each province, autonomous region, and municipality has tried to restrict unlicensed medical practice following national plans and regulations as well as their own situation-specific procedures. 15 197 cases of unlicensed medical practice were reported in 2015—an increase of 2·0% since 2014 (14 893 cases), 17·8% since 2013 (12 494), and 41·4% since 2012 (8 911). Of all cases in 2015, 96% (14589 cases) were found with a permanent site, while the remaining cases worked from a mobile site. In 2015, 77% (11702 cases) of cases were imposed a penalty for the first time, 20% (3039 cases) were penalised at least once, and 3% (456 cases) were penalised twice or more. Interpretation With strict enforcement, more cases of unlicensed medical practice have been detected and punished. However, causes of unlicensed medical practice in China are complex. To help policy makers reduce the risks associated with unlicensed medical practice, increased understanding the underlying reasons for unlicensed medical practice is needed. Funding None.
PDF