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ObjectivesThere is uncertainty with respect to the hospital volume and clinical outcomes for patients with stroke. This study aimed to assess the association between hospital volume, processes of care and outcomes after ischaemic stroke.DesignA multicentre prospective cohort study.SettingTwo hundred and seventeen secondary or tertiary public hospitals from China.ParticipantsA total of 17 550 patients within 7 days of acute ischaemic stroke were included.Main outcome measuresThe outcomes included all-cause mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. The patients were divided into four groups based on quartiles of the hospital volume. We compared the difference in the process of care across the groups and estimated the effects of hospital volume on mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. Restricted cubic splines were used to illustrate the association between hospital volume and clinical outcomes.ResultsThere were no significant differences in the process of care across the four groups. When adjusted for confounders, the effect of hospital volume on mortality, recurrent stroke and combined vascular events was not significant. However, compared with the highest quartile, the patients in the lowest quartile of hospital volume tend to have poor outcome at 1 year (OR=1.29, 95% CI 1.01 to 1.64, p=0.0393). The restricted cubic spline analyses suggested a non-linear relationship between hospital volume and 1-year combined vascular events and poor outcome at 3 months and 1 year.ConclusionsWe found no significant associations between hospital volume, processes of care at the hospital, and mortality, recurrent stroke, and combined vascular events in patients with ischaemic stroke. However, hospital volume may be associated with poor outcome at 1 year.

ObjectivesThis study explored the prevalence of and individual influencing factors for metabolic syndrome (MS) as well as associated socioeconomic factors and regional aggregation.DesignFour cross-sectional surveys were analysed for trends in MS and associations with socioeconomic and individual factors through multilevel logistic regression analyses. The risk associated with nutrient intake was also assessed through a dietary survey in 2015.SettingFrom 2010 to 2018, 8–15 counties/districts of West China were included.ParticipantsA total of 28 274 adults were included in the prevalence analysis. A total of 23 708 adults were used to analyse the related factors.ResultsThe overall prevalence of MS ranged from 21.4% to 27.8% over the 8 years, remaining basically stable within the 95% CI. Our study found that the urbanisation rate and hospital beds per 1000 people were positively associated with MS, and the number of doctors in healthcare institutions per 1000 persons was negatively associated with MS. The ORs for females, people with college education and higher and unmarried or single people were 1.49, 0.67 and 0.51, respectively (pConclusionThe high burden of MS, unreasonable proportions of energy and micronutrient intake and low percentage of high levels of physical activity were the major challenges to public health in western China. Improving the human resources component of medical services, such as the number of doctors, increasing the availability of public sports facilities and E-health tools and improving individual dietary quality and education might help prevent MS.

ObjectiveTo evaluate the trends in disease burden and the epidemiological features of central nervous system (CNS) cancer in China from 1990 to 2019.DesignA population-based observational study.SettingThe incidence, prevalence, death and disability-adjusted life years (DALYs) due to CNS cancer in China, stratified by sex, age and provincial region, were collected from the Global Burden of Disease Study 2019.ParticipantsData were publicly available and individuals were not involved.ResultsIn 2019, the incident cases of CNS cancer in China were 347 992 (95% UI 262 084–388 896), and the age-standardised rate (ASR) of incidence was 5.69 (95% UI 4.36–6.78) per 100 000 person-years increased by 27.9% compared with that in 1990; meanwhile, CNS cancer caused 63 527 (95% UI 47 793–76 948) deaths in China in 2019, and the ASR of death was 3.5 (95% UI 2.62–4.21) per 100 000 person-years decreased by 9.6%. The ASRs of incidence and prevalence of CNS cancer in China increased more rapidly than the global average; meanwhile, the ASRs of DALYs owing to CNS cancer declined more rapidly. The burden of CNS cancer showed no significant differences between men and women, but was more pronounced in early childhood and old adulthood. The ASRs of incidence and prevalence were higher in high-income provinces, confirmed by the positive correlation with Sociodemographic Index (SDI), with correlation coefficient r of 0.322 and 0.767, respectively (both pConclusionsFrom a global perspective, China has been bearing a substantial burden of CNS cancer. More attention should be paid to children and elderly populations for CNS cancer. The disease burden varied significantly at the subnational level of China, which was associated with socioeconomic development.

ObjectiveWith escalating health expenditures and increasing health needs, improving health system performance has become imperative in China and internationally. The objective of this study is to examine the efficiency of China’s health system and to understand the underlying causes of the variation in efficiency across provinces.SettingA system-wide perspective is adopted, focusing on performance in maternal health, child health and non-communicable diseases (NCDs) in the 31 provinces of mainland China during 2015.MethodsAnalyses were performed using bootstrapping data envelopment technique. Health outcomes were measured by infant survival rates, maternal survival rates and healthy life years calculated only considering NCDs. Health inputs were measured using health expenditure, and density of medical personnel and hospital beds. The model also examined the impact of environmental factors on health system efficiency.ResultsDue to wide-spread scale inefficiency in the country, the average bias-corrected overall technical efficiency (OTE) was 0.8022 (95% CI values ranging from 0.7251 to 0.8492). Socioeconomic status, hospitalisation rate and share of out-of-pocket expenditures were significant determinants of OTE. Nearly 60% of the provinces operated at a decreasing return to scale, meaning that a gain in efficiency could be achieved only through downsizing the scale of operation.ConclusionsGiven the pervasive nature of diminishing returns across provinces, health policy makers must explore the optimum operational scale which is people-centred and focused on prevention, rather than on treatment, of diseases. Moreover, due consideration should be afforded to social determinants of health and health financing arrangements to complement health-sector based reforms and meet the ambitious goals of the Healthy China 2030 Plan.

ObjectivesTo investigate potential geographical and socioeconomic patterning of allostatic load (AL) in China.DesignMultilevel longitudinal study of the 2010 Chronic Disease Risk Factor Surveillance linked to the National Death Surveillance up to 31 December 2015.SettingAll 31 provinces in China, not including Hong Kong, Macao or Taiwan.Participants96 466 ≥ 18 years old (women=54.3%).ExposuresPerson-level educational attainment and mean years of education in counties.OutcomeAL was measured using clinical guidelines for nine biomarkers: body mass index; waist circumference; systolic blood pressure; diastolic blood pressure; fasting blood glucose; total cholesterol; triglycerides; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol.ResultsMultilevel logistic regressions adjusted for sex, age, marital status, person-level education, county mean years of education and urban/rural reported ORs of 1.22 (95% CI 1.08 to 1.38) for 5-year all-cause mortality (n=3284) and 1.20 (1.04–1.37) for deaths from non-communicable diseases (n=2891) among people in AL quintile 5 (high) compared with quintile 1 (low). The median rate ratio estimated from unadjusted multilevel negative binomial regression showed AL clustered geographically (province=1.14; county=1.12; town=1.11; village=1.14). After adjusting for aforementioned confounders, AL remained higher with age (rate ratio 1.02, 95% CI 1.02 to 1.02), higher in women compared with men (1.17, 1.15 to 1.19), lower among singletons (0.83, 0.81 to 0.85) and widowers (0.96, 0.94 to 0.98). AL was lower among people with university-level compared with no education (0.92, 0.89 to 0.96), but higher in counties with higher mean education years (1.03, 1.01 to 1.05). A two-way interaction suggested AL was higher (1.04, 1.02 to 1.06) among those with university-level compared with no education within counties with higher mean years of education. Similar results were observed for alternative constructions of AL using 75th and 80th percentile cut-points.ConclusionsAL in China is patterned geographically. The degree of association between AL and person-level education seems to be dependent on area-level education, which may be a proxy for other contextual factors that warrant investigation.

Objectives - To examine the modification of temperature-mortality association by factors at the individual and community levels. Design and methods - This study investigated this issue using a national database comprising daily data of 66 Chinese communities for 2006–2011. A ‘threshold-natural cubic spline’ distributed lag non-linear model was utilised to estimate the mortality effects of daily mean temperature, and then examined the modification of the relationship by individual factors (age, sex, education level, place of death and cause of death) using a meta-analysis approach and community-level factors (annual temperature, population density, sex ratio, percentage of older population, health access, household income and latitude) using a meta-regression method. Results - We found significant effects of high and low temperatures on mortality in China. The pooled excess mortality risk was 1.04% (95% CI 0.90% to 1.18%) for a 1°C temperature decrease below the minimum mortality temperature (MMT), and 3.44% (95% CI 3.00% to 3.88%) for a 1°C temperature increase above MMT. At the individual level, age and place of death were found to be significant modifiers of cold effect, while age, sex, place of death, cause of death and education level were effect modifiers of heat effect. At the community level, communities with lower socioeconomic status and higher annual temperature were generally more vulnerable to the mortality effects of high and low temperatures. Conclusions - This study identifies susceptibility based on both individual-level and community-level effect modifiers; more attention should be given to these vulnerable individuals and communities to reduce adverse health effects of extreme temperatures.