学术发表

• Global vaccine coverage and childhood survival estimates: 1990–2019
  Apr 2024
  作者： Hai Fang, et al.
  摘要： Objective To quantify the association between reduction in child mortality and routine immunization across 204 countries and territories from 1990 to 2019. Methods We used child mortality and vaccine coverage data from the Global Burden of Disease Study. We used a modified child survival framework and applied a mixed-effects regression model to estimate the reduction in deaths in children younger than 5 years associated with eight vaccines. Findings Between 1990 and 2019, the diphtheria–tetanus–pertussis (DTP), measles, rotavirus and Haemophilus influenzae type b vaccines were significantly associated with an estimated 86.9 (95% confidence interval, CI: 57.2 to 132.4) million fewer deaths in children younger than 5 years worldwide. This decrease represented a 24.2% (95% CI: 19.8 to 28.9) reduction in deaths relative to a scenario without vaccines. The DTP and measles vaccines averted 46.7 (95% CI: 30.0 to 72.7) million and 37.9 (95% CI: 25.4 to 56.8) million deaths, respectively. Of the total reduction in child mortality associated with vaccines, 84.2% (95% CI: 83.0 to 85.1) occurred in 73 countries supported by Gavi, the Vaccine Alliance, with an estimated 45.4 (95% CI: 29.8 to 69.2) million fewer deaths from 2000 to 2019. The largest reductions in deaths associated with these four vaccines were in India, China, Ethiopia, Pakistan and Bangladesh (in order of the size of reduction). Conclusion Vaccines continue to reduce childhood mortality significantly, especially in Gavi-supported countries, emphasizing the need for increased investment in routine immunization programmes.
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• Subsidized gestational diabetes mellitus screening and management program in rural China: a pragmatic multicenter, randomized controlled trial
  Mar 2024
  作者： Hai Fang, et al.
  摘要： Background The increasing prevalence of gestational diabetes mellitus (GDM) is a major challenge, particularly in rural areas of China where control rates are suboptimal. This study aimed to evaluate the effectiveness of a GDM subsidy program in promoting GDM screening and management in these underserved regions. Methods This multicenter, randomized controlled trial (RCT) was conducted in obstetric clinics of six rural hospitals located in three provinces in China. Eligible participants were pregnant women in 24–28 weeks’ gestation, without overt diabetes, with a singleton pregnancy, access to a telephone, and provided informed consent. Participants were randomly assigned in a 1:1 ratio to either the intervention or control groups using an internet-based, computer-generated randomization system. The intervention group received subsidized care for GDM, which included screening, blood glucose retesting, and lifestyle management, with financial assistance provided to health care providers. In contrast, the control group received usual care. The primary outcomes of this study were the combined maternal and neonatal complications associated with GDM, as defined by the occurrence of at least one pre-defined complication in either the mother or newborn. The secondary outcomes included the GDM screening rate, rates of glucose retesting for pregnant women diagnosed with GDM, dietary patterns, physical activity levels, gestational weight gain, and antenatal visit frequency for exploratory purposes. Primary and secondary outcomes were obtained for all participants with and without GDM. Binary outcomes were analyzed by the generalized linear model with a link of logistic, and odds ratios (OR) with 95% confidence intervals (CIs) were reported. Count outcomes were analyzed by Poisson regression, and incidence rate ratios with 95% CIs were reported. Results A total of 3294 pregnant women were randomly assigned to either the intervention group (n = 1649) or the control group (n = 1645) between 15 September 2018 and 30 September 2019. The proportion of pregnant women in the intervention group who suffered from combined maternal and/or neonatal complications was lower than in the control group with adjusted OR = 0.86 (0.80 to 0.94, P = 0.001), and a more significant difference was observed in the GDM subgroup (adjusted OR = 0.66, 95% CI 0.47 to 0.95, P = 0.025). No predefined safety or adverse events of ketosis or ketoacidosis associated with GDM management were detected in this study. Both the intervention and control groups had high GDM screening rates (intervention: 97.2% [1602/1649]; control: 94.5% [1555/1645], P < 0.001). Moreover, The intervention group showed a healthier lifestyle, with lower energy intake and more walking minutes (P values < 0.05), and more frequent blood glucose testing (1.5 vs. 0.4 visits; P = 0.001) compared to the control group. Conclusion In rural China, a GDM care program that provided incentives for both pregnant women...
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• Cost-Effectiveness of Salt Substitute and Salt Supply Restriction in Eldercare Facilities
  Feb 2024
  作者： Hai Fang, et al.
  摘要： Importance Salt substitution has been reported to be a cost-saving sodium reduction strategy that has not yet been replicated in different contexts. Objective To estimate the cost-effectiveness of sodium reduction strategies within the DECIDE-Salt trial. Design, Setting, and Participants The DECIDE-Salt trial cluster randomized in a 1:1:1:1 ratio 48 eldercare facilities in China into 4 groups for evaluation of 2 sodium reduction strategies for 2 years: 1 with both strategies, 2 with either strategy, and 1 with neither strategy. The trial was conducted from September 25, 2017, through October 24, 2020. Interventions The 2 intervention strategies were replacing regular salt with salt substitute and progressively restricting salt supply to kitchens. Main Outcomes and Measures The main outcomes included per-participant costs of intervention implementation and medical treatments for hypertension and major adverse cardiovascular events (MACEs) against mean reductions in systolic blood pressure, hypertension prevalence, MACE incidence, and mortality. The incremental cost-utility ratio was then assessed as the additional mean cost per quality-adjusted life-year gained. Analyses were conducted separately for each strategy, comparing groups assigned and not assigned the test strategy. Disease outcomes followed the intention-to-treat principle and adopted different models as appropriate. One-way and probabilistic sensitivity analyses were conducted to explore uncertainty, and data analyses were performed between August 13, 2022, and April 5, 2023. Results A total of 1612 participants (1230 males [76.3%]) with a mean (SD) age of 71.0 (9.5) years were enrolled. Replacing regular salt with salt substitute reduced mean systolic blood pressure by 7.14 (95% CI, 3.79-10.48) mm Hg, hypertension prevalence by 5.09 (95% CI, 0.37-9.80) percentage points, and cumulative MACEs by 2.27 (95% CI, 0.09-4.45) percentage points. At the end of the 2-year intervention, the mean cost was $25.95 less for the salt substitute group than the regular salt group due to substantial savings in health care costs for MACEs (mean [SD], $72.88 [$9.11] vs $111.18 [$13.90], respectively). Sensitivity analysis showed robust cost savings. By contrast, the salt restriction strategy did not show significant results. If the salt substitution strategy were rolled out to all eldercare facilities in China, 48 101 MACEs and 107 857 hypertension cases were estimated to be averted and $54 982 278 saved in the first 2 years. Conclusions and Relevance The findings of this cluster randomized clinical trial indicate that salt substitution may be a cost-saving strategy for hypertension control...
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• Sex Disparities in Management and Outcomes Among Patients With Acute Coronary Syndrome
  Oct 2023
  作者： Shuduo Zhou; Ming Xu; et al.
  摘要： Question Is there an association between health care quality improvement programs and sex disparities among patients with acute coronary syndrome (ACS)? Findings In this cross-sectional study,1 095 899 patients with ACS were analyzed. The findings highlight significant sex-related differences in the quality of services for ACS by regionalization of prehospital emergency and in-hospital treatment systems, standardization of treatment procedures, and health education at the community level. Meaning These findings suggest that the concept of sex differences should be included in health care quality improvement programs from a systemic perspective to further reduce the sex disparities in patients with ACS.
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• Air pollution kills competition: Evidence from eSports
  Sep 2023
  作者： Ye Yuan，Jiawei Mo, Zenan Wu
  摘要： This article investigates how environmental adversity affects competitive performance in cognitive-intensive settings. Using a comprehensive dataset of professional eSports tournaments and match-hour variation of fine particulate matters, we find robust evidence that pollution kills competition. Specifically, higher air pollution levels diminish the performance and winning odds of the weaker team in a matchup while boosting that of the stronger team, widening the gap between them. We document two operating channels: (i) pollution leads to heterogeneous performance-reducing effects contingent on a team’s relative strength against their opponent, rather than its absolute competitiveness; and (ii) a weaker team adjusts their strategic decision-making differently in a polluted environment compared to their stronger counterparts. Our findings elucidate the distributional impact of environmental adversity and underscore its influence on strategic decision-making.
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• Reducing single-use cutlery with green nudges: Evidence from China’s food-delivery industry
  Sep 2023
  作者： Yuhang Pan, et al.
  摘要： Rising consumer demand for online food delivery has increased the consumption of disposable cutlery, leading to plastic pollution worldwide. In this work, we investigate the impact of green nudges on single-use cutlery consumption in China. In collaboration with Alibaba’s food-delivery platform, Eleme (which is similar to Uber Eats and DoorDash), we analyzed detailed customer-level data and found that the green nudges—changing the default to “no cutlery” and rewarding consumers with “green points”—increased the share of no-cutlery orders by 648%. The environmental benefits are sizable: If green nudges were applied to all of China, more than 21.75 billion sets of single-use cutlery could be saved annually, equivalent to preventing the generation of 3.26 million metric tons of plastic waste and saving 5.44 million trees.
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• Cohort studies have great potential in healthy ageing research. Lancet Healthy Longevity
  Sep 2023
  作者： Yaohui Zhao, Yafeng Wang
  摘要： Most studies of healthy ageing have used surveys of older adults. Although these data provide snapshots of the health status of older individuals, any study of patterns or determinants of health in older age is inevitably hampered by mortality selection. Such a selection could alternatively be called health-care selection. For example, if a health-care system is unable to prevent deaths among individuals with ill-health, then the people who are in the sample tend to be healthy. Conversely, if a health-care system succeeds in preventing deaths, then the sample tends to be unhealthy. Without adjusting for mortality selection, the first scenario might cause a population to be labeled as attaining healthy ageing while, in fact, it has not. Although macro-level statistics explicitly account for both morbidity and mortality, such as disability-adjusted life years (DALY), such a concept is not defined at the individual level as required by research on determinants of health status. One approach to correct the mortality selection is to explicitly model the mortality process to derive suitable weights, which requires data on causes of death. However, the best way to mitigate this selection bias is to use a preselection population, as Tuija M Mikkola and colleagues have done in their recent paper, published in The Lancet Healthy Longevity.1 In their study, they analysed longitudinal data from the Helsinki Birth Cohort Study, which comprises 13 345 individuals born in Helsinki, Finland between 1934 and 1944, who were still alive in 1971. The study modified the concept of healthy ageing by including mortality and coined a new term, healthy survival, defined as being alive and free of chronic diseases that are likely to have an impact on functioning. This is a valuable concept that can potentially be adopted in other studies. Many longitudinal studies in the family of Health and Retirement Studies recruited respondents from middle age onwards. For example, individuals were aged 45 years or older in the China Health and Retirement Longitudinal Study.2 Studying individuals when at younger age in these cohort studies and following them through to older age will permit the study of healthy survival...
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• Regulatory Reliance for Convergence and Harmonization in the Medical Device Space in Asia-Pacific
  Aug 2023
  作者： Ming Xu,Zhenyu Zhang, et al.
  摘要： While some sort of regulatory convergence and harmonisation are often needed for achieving regulatory reliance, in reality, regulatory reliance as a strategy towards convergence and harmonisation has never been more significant in Asia-Pacific (APAC). A sustained, rapid and large-scale provision of medical devices, including articles and apparatus used in diagnosis, care, treatment or prevention of disease and softwares, etc, across national boundaries, is the key to winning the fight against future pandemics and improving people’s well-being in such a populous and geographically diverse region. The COVID-19 pandemic highlighted the value of regulatory reliance to enable easier access to medical devices that have gone through regulatory approvals in countries with mature regulatory systems based on the Quality Management System and product assessment guidelines of the International Medical Device Regulators Forum. This analysis focuses on why regulatory reliance is needed, how much has been achieved, its impact on the development of the medical device industry and challenges to be addressed in the region. By drawing on the experience from the Singapore Health Sciences Authority–Thai Food and Drug Administration regulatory reliance pilot and Vietnam’s inclusion of Korea Ministry of Food and Drug Safety and China National Medical Products Administration as reference markets for fast review/approval, it aims to explore next viable steps and future trend of the APAC regional regulatory harmonisation mechanism through regulatory reliance in the post-COVID-19 era.
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• Ex-ante moral hazard and health insurance: Evidence from China's urban residence basic medical insurance scheme
  Jul 2023
  作者： Gordon G. Liu, Chen Chen, et al.
  摘要： This study examines whether implementing Urban Residents Medical Insurance Scheme decreased an individual's risky lifestyle behavior before illness, termed ex-ante moral hazard. Ex-ante moral hazard is predicted by the classical economic theory suggesting that health insurance coverage reduces an individual's incentive to take preventive efforts to remain healthy. Studies have provided mixed evidence for this prediction. China's 2006 nationwide social experiment of implementing the Urban Residents Basic Medical Insurance Scheme offers an excellent opportunity for examining the effect of the transition from uninsured to insured on an individual's health behaviors. We exploit the longitudinal dimension of a representative survey data for 2007–2010 and employ the instrumental variable technique, thereby addressing the issue of self-selection into voluntary health insurance schemes. The results do not provide evidence for and contrast the prediction of the ex-ante moral hazard. Significant differences exist between insured and uninsured groups with respect to smoking, drinking habits, and being overweight. People with insurance care more about their health than people without insurance do. The main results still hold if we use alternative estimation methods and other robustness tests.
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• Enhanced food system efficiency is the key to China’s 2060 carbon neutrality target
  Jul 2023
  作者： Hancheng Dai, et al.
  摘要： Bioenergy with carbon capture and storage, among other negative-emission technologies, is required for China to achieve carbon neutrality—yet it may hinder land-based Sustainable Development Goals. Using modelling and scenario analysis, we investigate how to mitigate the potential adverse impacts on the food system of ambitious bioenergy deployment in China and its trading partners. We find that producing bioenergy domestically while sticking to the food self-sufficiency ratio redlines would lower China’s daily per capita calorie intake by 8% and increase domestic food prices by 23% by 2060. Removing China’s food self-sufficiency ratio restrictions could halve the domestic food dilemma but risks transferring environmental burdens to other countries, whereas halving food loss and waste, shifting to healthier diets and narrowing crop yield gaps could effectively mitigate these external effects. Our results show that simultaneously achieving carbon neutrality, food security and global sustainability requires a careful combination of these measures.
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• Go with the wind: Spatial impacts of environmental regulations on economic activities in China
  Jun 2023
  作者： Ye Yuan, Tingting Xie
  摘要： This paper assesses the spatial effects of environmental regulations on economic activities. By exploiting the progressive rollout of a national pollution control program in China, which constructed a monitoring network that covered the urban center of every city, we find that polluting firms located in the unmonitored upwind region of the city experienced a substantially larger reduction in output than non-upwind firms after the program. Because the wind can transport upwind pollution emissions to the monitoring network-covered urban center, local governments are incentivized to enforce tighter regulations on upwind firms. Although industrial activities were suppressed, commercial businesses and residential services were promoted in the upwind region, accompanied by a greater supply of corresponding land and increased land prices. Altogether, the monitoring program led to a substantial reduction in population exposure to air pollution and an redistribution of industrial and residential activities within the city. Our findings shed light on the policy-making of future environmental regulation programs.
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• Health technology assessment to inform decision making in China: progress, challenges, and sustainability
  Jun 2023
  作者： Gordon G. Liu, et al.
  摘要： Yingyao Chen and colleagues examine China’s health technology assessment system and suggest how it can be strengthened. China has made considerable achievements in social and economic development during the past four decades, yet it is an upper middle income country, albeit the largest, according to World Bank classification.12 Achieving universal health coverage has gained momentum, and the Chinese government has committed to it by providing financial risk protection; access to quality essential health services; and safe, effective, and affordable essential medicines and vaccines for a population of 1.4 billion.34 To attain universal health coverage, decision makers need to ask: What services and technologies should be covered? Who pays for those services and technologies? What cost sharing arrangements should be adopted? They need to find a balance between services that are covered and those that are not, low or high out-of-pocket expenses, generic or brand name pharmaceuticals, a focus on common diseases or rare diseases, generosity or solvency of insurance funds, and so on. Universal health coverage in China also needs to take into account the increasing need to deal with communicable and non-communicable diseases,5 a rapidly ageing population, and fast changing health technologies. Escalating investment in healthcare resources (likely to exceed predicted gross domestic product growth) will be a major challenge. As a widely used decision making tool, health technology assessment (HTA) is a multidisciplinary activity used to determine the effectiveness or cost effectiveness of a health technology to inform decision making for achieving a high quality healthcare system.6 Since its introduction to China in the 1990s, HTA has had an increasingly important role in healthcare decision making. However, HTA development and its roles in decision making has not been examined in depth. In this article we give an overview of HTA activities in China, summarising the development and current status of HTA, identifying challenges and opportunities for HTA, and discussing how it can be strengthened. Other articles in this BMJ collection, written by experts in various HTA subfields, will consider specific areas in more detail (www.bmj.com/hta-in-china).
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• Addressing global health challenges requires harmonised and innovative approaches to the development assistance for health
  May 2023
  作者： Yinzi Jin, et al.
  摘要： There have been significant advances in the development assistance for health (DAH) in recent decades, with an estimated total DAH increasing from US$8.6 billion in 1990 to US$43 billion in 2019, and boosted to US$67 billion in 2021 in response to the COVID-19 pandemic.1 During this period, the focus has shifted towards alignment with the development goals, optimisation of monitoring and evaluation methods and process, and establishment of more evidence-based best practices. These achievements are a manifestation of the international recognition of the need to address health inequalities and promote people’s welfare. However, along with rapid development, critiques had indeed been raised over problems including the less satisfied additionality of DAH financing, the weak mechanism of accountability and the various rationales of the DAH system,2 covering the whole flow and every aspect of DAH; while at present, newly emerged or less stated challenges also exist in the links of DAH with regard to management, allocation and implementation, including adapting to a new financing paradigm, rethinking the current allocation pattern and balancing the different ways to deliver assistance, all of which require joint consideration.
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• Information, awareness, and mental health: Evidence from air pollution disclosure in China
  May 2023
  作者： Ye Yuan, et al.
  摘要： This paper assesses mental health responses to information on environmental risks. We exploit the progressive implementation of a national program in China that introduces more comprehensive air pollution monitoring and provides real-time air-pollution information to the public. The program leads to a sharp increase in public awareness and attention to air pollution issues and results in a large increase in the sensitivity of individual’s mental health to changes in air quality, especially among those with more exposure to pollution information and those more susceptible to mental illnesses. Information of worsening air quality has a direct effect on mental health as a source of stressors and an indirect behavioral effect through reducing outdoor activities and social integration. Our findings shed light on the design and delivery of environmental information disclosure programs, especially for countries with pressing environmental threats.
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• Association between inequalities in human resources for health and all cause and cause specific mortality in 172 countries and territories, 1990-2019: observational study
  May 2023
  作者： Jue Liu, et al.
  摘要： Objective To explore inequalities in human resources for health (HRH) in relation to all cause and cause specific mortality globally in 1990-2019. Design Observational study. Setting 172 countries and territories. Data sources Databases of the Global Burden of Disease Study 2019, United Nations Statistics, and Our World in Data. Main outcome measures The main outcome was age standardized all cause mortality per 100 000 population in relation to HRH density per 10 000 population, and secondary outcome was age standardized cause specific mortality. The Lorenz curve and the concentration index (CCI) were used to assess trends and inequalities in HRH. Results Globally, the total HRH density per 10 000 population increased, from 56.0 in 1990 to 142.5 in 2019, whereas age standardized all cause mortality per 100 000 population decreased, from 995.5 in 1990 to 743.8 in 2019. The Lorenz curve lay below the equality line and CCI was 0.43 (P<0.05), indicating that the health workforce was more concentrated among countries and territories ranked high on the human development index. The CCI for HRH was stable, at about 0.42-0.43 between 1990 and 2001 and continued to decline (narrowed inequality), from 0.43 in 2001 to 0.38 in 2019 (P<0.001). In the multivariable generalized estimating equation model, a negative association was found between total HRH level and all cause mortality, with the highest levels of HRH as reference (low: incidence risk ratio 1.15, 95% confidence interval 1.00 to 1.32; middle: 1.14, 1.01 to 1.29; high: 1.18, 1.08 to 1.28). A negative association between total HRH density and mortality rate was more pronounced for some types of cause specific mortality, including neglected tropical diseases and malaria, enteric infections, maternal and neonatal disorders, and diabetes and kidney diseases. The risk of death was more likely to be higher in people from countries and territories with a lower density of doctors, dentistry staff, pharmaceutical staff, aides and emergency medical workers, optometrists, psychologists, personal care workers, physiotherapists, and radiographers. Conclusions Inequalities in HRH have been decreasing over the past 30 years globally but persist. All cause mortality and most types of cause specific mortality were relatively higher in countries and territories with a limited health workforce, especially for several specific HRH types among priority diseases. The findings highlight the importance of strengthening political commitment to develop equity oriented health workforce policies, expanding health financing, and implementing targeted measures to reduce deaths related to inadequate HRH to achieve universal health coverage by 2030.
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