Description: Objective In general, published studies analyse healthcare utilisation, rather than foregone care, among different population groups. The assessment of forgone care as an aspect of healthcare system performance is important because it indicates the gap between perceived need and actual utilisation of healthcare services. This study focused on a specific vulnerable group, middle-aged and elderly people with chronic diseases, and evaluated the prevalence of foregone care and associated factors among this population in China. Methods Data were obtained from a nationally representative household survey of middle-aged and elderly individuals (≥45 years), the China Health and Retirement Longitudinal Study, which was conducted by the National School of Development of Peking University in 2013. Descriptive statistics were used to analyse sample characteristics and the prevalence of foregone care. Andersen’s healthcare utilisation and binary logistic models were used to evaluate the determinants of foregone care among middle-aged and elderly individuals with chronic diseases. Results The prevalence of foregone outpatient and inpatient care among middle-aged and elderly people was 10.21% and 6.84%, respectively, whereas the prevalence of foregone care for physical examinations was relatively high (57.88%). Predisposing factors, including age, marital status, employment, education and family size, significantly affected foregone care in this population. Regarding enabling factors, individuals in the highest income group reported less foregone inpatient care or physical examinations compared with those in the lowest income group. Social healthcare insurance could significantly reduce foregone care in outpatient and inpatient situations; however, these schemes (except for urban employee medical insurance) did not appear to have a significant impact on foregone care involving physical examinations. Conclusion In China, policy-makers may need to further adjust healthcare policies, such as health insurance schemes, and improve the hierarchical medical system, to promote reduction in foregone care and effective utilisation of health services.

Description: Objectives Few studies have systematically examined the effects of the existing regulations for alleviating corruption in China. This study assesses the effectiveness of China’s reforms to curb medical corruption. Methods We used mixed methods for the evaluation of existing countermeasures. First, qualitative informant interviews based on the Donabedian model were conducted to obtain experts’ evaluation of various kinds of countermeasures. Second, using data from ‘China Judgements Online’, we analysed the trend of occurrence and the characteristics of the medical corruption cases in recent years to reflect the overall effects of these countermeasures in China. Results Since 1990s, China has implemented three main categories of countermeasures to oppose medical corruption: fines and criminal penalties, health policy regulations, and reporting scheme policy. Information from the interviews showed that first the level of fines and criminal penalties for medical corruption behaviours may not be sufficient. Second, health policy regulations are also insufficient. Although the National Reimbursement Drug List and Essential Drug List were implemented, they were incomplete and created additional opportunities for corruption. Moreover, the new programme that centralised the purchase of pharmaceuticals found that most purchasing committees were not independent, and the selection criteria for bidding lacked scientific evidence. Third, the reporting scheme for commercial bribery records by the health bureau was executed poorly. In addition, quantitative online data showed no obvious decrease of institutional medical corruption in recent years, and most criminals have been committing crimes for a long time before getting detected, which further demonstrated the low effectiveness of the above countermeasures. Conclusions Although existing countermeasures have exerted certain effects according to Chinese experts, more rigorous legislation and well-functioning administrative mechanisms are needed. Fundamentally, financial incentives for hospitals/physicians and the health insurance system should be improved.

Description: Objective To evaluate the trend of catastrophic health expenses (CHE) for inpatient care in relation to the commencement of the New Cooperative Medical Scheme (NCMS) in rural China from 2003 to 2013, and the roles of NCMS in protecting affected households from CHE. Methods We assessed the 10-year trend of the incidence and severity of CHE in rural households with hospitalised members using data from the Chinese National Health Services Survey. Generalised estimating equations were used to estimate the OR and 95% CI of the association between incidence rates of CHE ( RCHE ) and NCMS reimbursement. Results The incidence and severity of CHE after NCMS reimbursement both decreased and their changes increased rapidly from 2003 to 2013. After adjustment of the covariates, RCHE before reimbursement was significantly higher than that after reimbursement, and the OR (95% CI) was 1.50 (1.24 to 1.81), 1.79 (1.69 to 1.90) and 2.94 (2.77 to 3.11) in 2003, 2008 and 2013, respectively. Conclusion The incidence and severity of CHE both reduced after NCMS reimbursements in each year. Excluding some confounding factors, RCHE was significantly associated with NCMS reimbursement. NCMS partly protected the rural households with hospitalised members from CHE. However, the inequalities between different income groups still existed. RCHE in rural households with hospitalised members was still rather high in 2003, 2008 and 2013 even though they were covered by NCMS. This study will provide suggestions for further reforms in China and guidance for other low-income/middle-income countries.

Description: Background The short-term outcomes and prognostic factors of patients with spinal dural arteriovenous fistulas (SDAVFs) have not been defined in large cohorts. Objective To define the short-term clinical outcomes and prognostic factors in patients with SDAVFs. Methods A prospective cohort of 112 patients with SDAVFs were included consecutively in this study. The patients were serially evaluated with the modified Aminoff and Logue’s Scale (mALS) one day before surgery and at 3 months, 6 months and 12 months after treatment. Univariate and multivariate analyses were performed to identify demographic, clinical and procedural factors related to favourable outcome. Results A total of 94 patients (mean age 53.5 years, 78 were men) met the criteria and are included in the final analyses. Duration of symptom ranged from 0.5 to 66 months (average time period of 12.7 months). The location of SDAVFs was as follows: 31.6% above T7 level, 48.4% between T7 and T12 level (including T7 and T12) and 20.0% below T12 level. A total of 81 patients (86.2%) underwent neurosurgical treatment, 10 patients (10.6%) underwent endovascular treatment, and 3 patients (3.2%) underwent neurosurgical treatment after unsuccessful embolisation. A total of 78 patients demonstrated an improvement in mALS score of one point or greater at 12 months. Preoperative mALS score was associated with clinical improvement after adjusting for age, gender, duration of symptoms, location of fistula and treatment modality using unconditional logistic regression analysis (p〈0.05). Conclusion Approximately four fifths of the patients experienced clinical improvement at 12 months and preoperative mALS was the strongest predictor of clinical improvement in the cohort.

Description: Objective Few studies have examined the spectrum and trends of non-communicable diseases (NCDs) in inpatients in eastern coastal China, which is transforming from an industrial economy to a service-oriented economy and is the most economically developed region in the country. This study aimed to dynamically elucidate the spectrum and characteristics of severe NCDs in eastern coastal China by analysing patients’ longitudinal electronic health records (EHRs). Setting To monitor the spectrum of NCDs dynamically, we extracted the EHR data from 12 general tertiary hospitals in eastern coastal China from 2003 to 2014. The rankings of and trends in the proportions of different NCDs presented by inpatients in different gender and age groups were calculated and analysed. Participants We obtained a total sample of 1 907 484 inpatients with NCDs from 2003 to 2014, 50.05% of whom were men and 81.53% were aged 50 years or older. Results There was an increase in the number of total NCD inpatients in eastern coastal China from 2003 to 2014. However, the proportion of chronic respiratory diseases and cancer inpatients decreased over the 12-year period. Compared with men, women displayed a significant increase in the proportion of mental and behavioural disorders (p〈0.001) over time. Additionally, digestive diseases and sensory organ diseases significantly decreased among men, but not women. The older group accounted for a larger and growing proportion of the NCD inpatients, and the most common conditions in this group were cerebral infarctions, coronary heart disease and hypertension. In addition, the proportion of 21-year-old to 50-year-old inpatients with diabetes, blood diseases or endocrine diseases skyrocketed from 2003 to 2014 (p〈0.001). Conclusions The burden of inpatients’ NCDs increased rapidly, particularly among women and younger people. The NCD spectrum observed in eastern coastal China is a good source of evidence for developing prevention guides for regions experiencing transition.

Description: Objective Willingness to receive eldercare is an important factor affecting the reasonable allocation of resources and appropriate development of eldercare services. This study aimed to investigate the differences in willingness to receive eldercare and the influencing factors in urban and rural areas. Design Cross-sectional survey. Setting Research was conducted in the urban and rural areas of three cities (Harbin, Qiqihar and Jiamusi) in Heilongjiang province, China. Participants A total of 1003 elderly were selected through multistage sampling in Heilongjiang province, including 581 in urban areas and 422 in rural areas. Main outcome measures Descriptive statistics were reported for socioeconomic and demographic status, physical health, life satisfaction and social support in urban and rural areas. Mean differences were examined using t-tests, and categorical variable differences were examined using 2 tests. The factors influencing willingness to receive eldercare in urban and rural areas were analysed using logistic regression. Results The results showed that 51.6% of urban elderly and 59.0% of rural elderly preferred family eldercare. Factors that influenced willingness to receive eldercare for urban elderly were age (OR 2.791, 95% CI 1.644 to 4.737), house property (OR 0.494, 95% CI 0.329 to 0.740) and objective support (OR 0.764, 95% CI 0.681 to 0.858). For rural elderly, the factors were having children (OR 0.368, 95% CI 0.146 to 0.930), house property (OR 0.371, 95% CI 0.231 to 0.596) and living arrangement (OR 3.361, 95% CI 1.436 to 7.866). Conclusion More attention should be paid to improving the functioning of family eldercare and promoting the development of varied eldercare services. Investments and targeted policies should be undertaken for different subgroups of urban and rural elderly.

Description: Objectives To estimate prevalence and clustering of cardiovascular risk factors (CRFs), and investigate the association between relevant characteristics and CRF clustering among adults in eastern China. Design Community-based cross-sectional study. Setting Data were collected by interview survey, physical measurements and laboratory examinations from the 2011 Nanjing Chronic Disease and Risk Factor Surveillance. Participants A representative sample of 41 072 residents aged ≥18 years volunteered to participate in the survey, with a response rate of 91.3%. We excluded 1232 subjects due to missing data or having a history of cardiovascular diseases; a total of 39 840 participants were included in the analysis. Outcome measures Prevalence and clustering of five major CRFs including hypertension, diabetes, dyslipidaemia, overweight or obesity and current smoking. Results Of 39 840 participants (mean age 47.9±16.2 years), 17 964 (45.1%) were men and 21 876 (54.9%) were women. The weighted prevalence of CRFs ranged between 6.2% for diabetes and 35.6% for overweight or obesity. The proportion of CRFs tended to be higher in men, the elderly, participants who lost a life partner, or lived in rural areas, or had lower level of education and total annual income. Overall, 30.1% and 35.2% of participants had one and at least two CRFs, respectively. Multivariate logistic regression revealed that men, older age, loss of a life partner, lower level of socioeconomic status, rural areas, insufficient physical activity or unhealthy diets were positively associated with CVD risk factor clustering, compared with their counterparts. Conclusions High regional prevalence of hypertension, dyslipidaemia, overweight or obesity and their clustering are present in Nanjing. The Nanjing government should develop effective public health policies at the regional level especially for high-risk groups, such as enhancing the public’s health awareness, organising health promotion programmes, implementing smoke-free law, producing healthy nutrient foods, providing free or low-cost public sports and fitness facilities.

Description: Objectives The neighbourhood availability of restaurants has been linked to the weight status. However, little is known regarding the relation between access to restaurant and obesity among the Chinese population. This study aims to explore the relationship between neighbourhood restaurant density and body mass index (BMI) in rural China. Design A longitudinal study using data from the China Health and Nutrition Survey (CHNS) was conducted. Participants aged 18 and older from the 2004, 2006, 2009 and 2011 CHNS were recruited Separate sex-stratified random intercept-slope growth models of repeated BMI observations were estimated in the study. Setting The data were derived from rural communities in nine provinces in China. Participants There were 11 835 male and 12 561 female person-years assessed in this study. Outcomes The primary outcome of this study was weight status. It is defined as a BMI value, a continuous variable which is calculated by dividing weight (kg) by the square of height (m 2 ). Results The study indicated that among men an increase of one indoor restaurant in the neighbourhood was associated with a 0.01 kg/m 2 increase in BMI, and an increase of one fixed outdoor food stall was associated with a 0.01 kg/m 2 decrease in BMI, whereas among women, an increase of one indoor restaurant in the neighbourhood was associated with a 0.005 kg/m 2 increase in BMI, and an increase of one fast-food restaurant and one fixed outdoor food stall was associated with a 0.02 and 0.004 kg/m 2 decline in BMI, respectively. Conclusions The density of neighbourhood restaurants was found to be significantly related to BMI in rural China. The results indicated that providing healthy food choices and developing related public health policies are necessary to tackle obesity among rural Chinese adults.

Description: Objectives Dietary cholesterol is the leading risk factor for cardiovascular disease and other chronic diseases. Changes in dietary patterns in China recently might have an impact on the trends of diet-related risk factors of chronic diseases. This study aims to monitor the changes in daily cholesterol intake and its food sources in Chinese adults. Design A longitudinal study using demographic and dietary data of adults younger than 60 years from eight waves (1991–2011) of the China Health and Nutrition Surveys was conducted. Mixed-effect models were used in this study. Setting The data were derived from urban and rural communities in nine provinces (autonomous regions) in China. Participants There were 21 273 participants (10 091 males and 11 182 females) in this study. Outcomes The major outcome is daily cholesterol intake amount, which was calculated by using the Chinese Food Composition Table, based on dietary data. Results The mean daily cholesterol intake in Chinese adults increased from 165.8 mg/day in 1991 to 266.3 mg/day in 2011. Cholesterol consumed by participants in different age (18–39 and 40–59 years), sex and urbanisation groups steadily elevated over time (p〈0.0001), as did the proportions of participants with greater than 300 mg/day cholesterol consumption. In each subgroup, cholesterol originating from most of the food groups showed increasing trends over time (p〈0.0001), except for animal fat and organ meats. Eggs, pork, fish and shellfish in that order remained the top three sources in 1991, 2000 and 2011, whereas milks were a negligible contributor. Cholesterol from animal fat declined and was insignificant in 2011 in most of the subgroups, while cholesterol being of poultry origin increased and became considerable in 2011. Conclusions Adults in China consumed increasingly high cholesterol and deviated from the recommended intake level over the past two decades. Adults need to pay more attention to intakes of eggs, pork, fish and shellfish.

Description: Introduction Emergence agitation after intracranial surgery is an important clinical issue during anaesthesia recovery. The aim of this multicentre cohort study is to investigate the incidence of emergence agitation, identify the risk factors and determine clinical outcomes in adult patients after intracranial surgery under general anaesthesia. Additionally, we will deliberately clarify the relationship between postoperative pneumocephalus and agitation. Methods and analysis The present study is a prospective multicentre cohort study. Five intensive care units (ICUs) in China will participate in the study. Consecutive adult patients admitted to the ICUs after intracranial surgery will be enrolled. Sedation-Agitation Scale (SAS) or Richmond Agitation-Sedation Scale (RASS) will be used to evaluate the patients 12 h after the enrolment. Agitation is defined as an SAS score of 5–7, or an RASS score of +2 to +4. According to the maximal SAS and RASS score, patients will be divided into two cohorts: the agitation group and the non-agitation group. Factors potentially related to emergence agitation will be collected at study entry, during anaesthesia and operation, during postoperative care. Univariate analyses between the agitation and the non-agitation groups will be performed. The stepwise backward logistic regression will be carried out to identify the independent predictors of agitation. Patients will be followed up for 72 h after the operation. Accidental self-extubation of the endotracheal tube and removal of other catheters will be documented. The use of sedatives and analgesics will be collected. Ethics and dissemination Ethics approval has been obtained from each of five participating hospitals. Study findings will be disseminated through peer-reviewed publications and conference presentations. Trial registration number NCT02318199.