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ABSTRACTReal-world studies of pyruvate kinase (PK) deficiency and estimates of mortality are lacking. This retrospective observational study aimed to identify patients with PK deficiency and compare their overall survival (OS) to that of a matched cohort without PK deficiency. Patients with ≥1 diagnosis code related to PK deficiency were selected from the US Veterans Health Administration (VHA) database (01/1995–07/2019); patients with a physician-documented diagnosis were included (PK deficiency cohort; index: date of first diagnosis code related to PK deficiency). Patients in the PK deficiency cohort were matched 1:5 to patients from the general VHA population (non-PK deficiency cohort; index: random visit date during match’s index year). OS from index was compared between the two cohorts. Eighteen patients in the PK deficiency cohort were matched to 90 individuals in the non-PK deficiency cohort (both cohorts: mean age 57 years, 94% males; median follow-up 6.0 and 8.0 years, respectively). At follow-up, patients in the non-PK deficiency cohort had significantly longer OS than the PK deficiency cohort (median OS: 17.1 vs. 10.9 years; hazard ratio: 2.3; p = 0.0306). During their first-year post-index, 75% and 40% of the PK deficiency cohort had laboratory-confirmed anemia and iron overload, respectively. Among patients who died, cause of death was highly heterogeneous. These results highlight the increased risk of mortality and substantial clinical burden among patients with PK deficiency. While the intrinsic characteristics of the VHA database may limit the generalizability of the results, this is the first real-world study to characterize mortality in patients with PK deficiency.

Abstract Chinese health system remains the crucial one for understanding the wider healthcare landscape across the Global South and in particular the leading Emerging Markets. Purpose of our observation was to understand the inner dynamics of mainland Chinese health reforms adopting a lengthy time horizon. We have analysed the public reports and seminal evidence on Chinese of multiple waves of national health reforms taking place since 1980s in terms of medical care and pharmaceuticals provision and financing. Chinese international trade with ASEAN nations and wider South-East Asia is accelerating its growth after the recovery of trade routes. In terms of health sector this means that global demand and supply of medical goods, services and pharmaceuticals remains largely driven by Chinese domestic developments. Furthermore, Chinese domestic manufacturing and sales of decent quality medical devices and services have grown exponentially. Some temporary pitfalls and increasing in rural–urban inequalities in equity of access and affordability of medical care and pharmaceuticals did take place. Despite these difficulties to generate a balanced development strategy for the largest global market, this is a clear path upwards. Further upcoming improvements expanding health insurance coverage are in strong demand for certain layers of the society. Domestic bottleneck weaknesses yet remain manufacturing, import and market penetration of cutting-edge pharmaceuticals such as monoclonal antibodies and targeted oncology agents. Yet some of these obstacles are likely to be overcome in foreseeable future with the adoption of responsible strategies by governmental agencies in health care arena.

Abstract Background β-thalassaemia major poses a substantial economic burden, especially in adults. We aimed to estimate the economic burden of adult patients with β-thalassaemia major from a societal perspective using the real-world data. According to the clinical guideline, we also estimated the annual medical costs for patients with the same body weight and calculated the lifetime medical costs over 50 years in mainland China. Methods This was a retrospective cross-sectional study. An online survey with snowball sampling covering seven provinces was conducted. We extracted patient demographics, caregiver demographics, disease and therapy information, caring burden, and costs for adult patients diagnosed with β-thalassaemia major and their primary caregivers. In the real world, we estimated the annual direct medical cost, direct nonmedical cost, and indirect cost. In addition, we calculated the annual direct medical cost and lifetime direct medical cost by weight with discounted and undiscounted rates according to the clinical guideline. Results Direct medical costs was the main driver of total cost, with blood transfusion and iron chelation therapy as the most expensive components of direct medical cost. In addition, adult patients with β-thalassaemia major weighing 56 kg were associated with an increase of $2,764 in the annual direct medical cost using the real-world data. The undiscounted and discounted (5% discount rate) total lifetime treatment costs were $518,871 and $163,441, respectively. Conclusions Patients with β-thalassaemia major often encounter a substantial economic burden in mainland China. Efforts must be made to help policymakers develop effective strategies to reduce the burden and pevalence of thalassaemia.

Abstract Objective To explore generating a health utility value set for the Chinese medicine Quality of life-11 Dimensions (CQ-11D), a utility instrument designed to assess patients’ health status while receiving TCM treatment, among the Chinese population. Methods The study was designed to recruit at least 2400 respondents across mainland China to complete one-to-one, face-to-face interviews. Respondents completed ten discrete choice experiment with survival duration (DCETTO) tasks during interviews. The conditional logit models were used to generate the health utility value set for the CQ-11D using the DCETTO data. Results A total of 2,586 respondents were invited to participate in the survey and 2498 valid interviews were completed (a completion rate of 96.60%). The modified conditional logit model with combing logically inconsistent levels was ultimately selected to construct the health utility value set for the CQ-11D instrument. The range of the measurable health utility value was -0.868 ~ 1. Conclusion The study provides the first utility value set for the CQ-11D among the Chinese population. The CQ-11D and corresponding utility value set can be used to measure the health utility values of patients undergoing traditional Chinese medicine interventions, and further facilitate relevant cost-utility analyses. The application of the CQ-11D can support TCM resource allocation in China.

BackgroundThe Deep South of the United States, and Louisiana in particular, bears a greater burden of obesity, diabetes, and heart disease compared with other regions in the United States. Throughout the COVID-19 pandemic, there has been a substantial increase in telehealth visits for diabetes management to protect the safety of patients. Although there have been significant advancements in telehealth and chronic disease management, little is known about patient and provider perspectives on the challenges and benefits of telehealth visits among people living with diabetes and providers who care for patients with diabetes in Louisiana. ObjectiveThis study aimed to explore barriers, facilitators, challenges, and benefits to telehealth for patients with diabetes and health care providers as they transitioned from in-person to remote care during the early COVID-19 pandemic to understand potential optimization. MethodsA total of 24 semistructured qualitative interviews were conducted with 18 patients living with diabetes and 6 clinicians who served patients with diabetes to explore their experiences and perceptions of telehealth services for diabetes care. Approximately half of the participants identified as Black or African American, half as White, and 75% as female. Interviews were recorded, transcribed, and coded by experienced qualitative researchers using inductive and deductive techniques. A narrative, descriptive approach to the patient and clinician journey framed the study, including the development of internal journey maps, and reflexive thematic analysis was applied to the transcripts, with special attention to barriers and facilitators. ResultsIn total, 5 themes illustrated barriers and facilitators for participants: convenience, safety, and comfort are the benefits of telehealth for patients and clinicians; yet telehealth and in-person visits are valued differently; the convenience of telehealth may have a downside; technology acts as a double-edged sword; and managing expectations and efficiency of the visit experience was an important factor. Individual experiences varied in relation to several factors, including comfort level and access to technology, health system protocols for providing telemedicine, and level of diabetes control among patients. ConclusionsRecommendations for optimization include providing support to help guide and inform patients about what to expect and how to prepare for telehealth visits as well as allowing clinicians to schedule telehealth and in-person visits during discrete blocks of time to improve efficiency. Further research should address how hybrid models of telehealth and in-person care may differentially impact health outcomes for patients with diabetes, particularly for people with multiple chronic conditions in settings where access to technology and connectivity is not optimal.

Abstract Background Approximately 7.4 million Americans with diabetes used insulin. This study aimed to document the 10‐year trend of insulin and other glucose‐lowering medications expenditure among insured and uninsured populations and to examine the impact of insulin out‐of‐pocket (OOP) payment and insurance status on glucose‐lowering medication OOP expenditure. Methods We extracted data from the Medical Expenditure Panel Survey (2009–2018) to document trends in the expenditure of insulin among people with diabetes. Total expenditures and OOP spending per person were documented on insulin and noninsulin glucose‐lowering medications among insured and uninsured populations. Multivariable regression was applied to assess the association of insulin OOP payment and insurance status on glucose‐lowering medication OOP expenditure. Results Although insulin usage was stable over the decades, total insulin expenditure almost doubled per person per year after the Affordable Care Act (ACA) regardless of the insurance status. The OOP cost of insulin by the uninsured population increased from $1678 per person per year in the pre‐ACA period to $2800 per person per year in the post‐ACA period. After the ACA was enacted, the uninsured population had $403.96 and $143.64 more on OOP costs than the people with public and private insurance, respectively. Conclusion For insured people, the rising financial burden of insulin was borne mainly by insurance. The uninsured population is bearing a heavy burden due to the high price of insulin. Policymakers should take action to reduce the insulin price and improve the transparency of the insulin pricing process.

Abstract Purpose To assess the reporting quality of published economic evaluations of the negotiated oncology drugs listed for China’s 2020 National Reimbursement Drug List (NRDL). Methods A comprehensive search was conducted to identify economic evaluation studies of negotiated oncology drugs listed in China’s 2020 NRDL using the PubMed/MEDLINE, Embase, Web of Science, CNKI, SinoMed, and WanFang Database up to March 31, 2021. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist scored the reporting quality between 0 and 100. A linear regression analysis was employed to examine the influence of various characteristics on the reporting quality scores. Results Eighty papers were included in the study, with the majority published during the past decade. Furthermore, more than half of the articles (57.5%, or 46 out of 80) were written in English. The average CHEERS score was 74.63 ± 12.75 and ranged from 43.48 to 93.75. The most inadequately reported items included choice of model, characterization of heterogeneity, and discussion, as well as currency, price date and conversion. Higher scores were associated with articles published from 2019 to 2021 and English publications. Conclusion The economic evaluation studies of negotiated oncology drugs listed in 2020 NRDL had moderate reporting quality. The Chinese economic evaluation publications could improve the reporting quality if the CHEERS checklist is consistently implemented. Also, the Chinese journals maybe explore introducing a reporting standard for economic evaluations.

Background: In the context of China's aging population, meeting consumer demand is an essential way for nursing homes to fulfill social responsibilities and improve competitive advantages. However, since little is known about the elderly's service level and price choices for nursing home care, this study aims to explore the non-disabled elderly's nursing home admission intention, service level, and price choices. Methods: A cross-sectional survey of 402 non-disabled respondents was conducted in three different income level cities of Zhejiang Province, in July and August 2018. Multinomial logistic regression and multiple linear regression were used to identify the determinants of admission intention, service level choice, and price choice. Results: Education, residence, and number of children were significantly associated with nursing home admission intention. Compared to those with no intention, the elderly with higher income and household wealth were less likely to have conditional intentions, and those living with the family were less likely to have unconditional intentions. Compared to medium-level services, the elderly with higher monthly income (relative risk ratio [RRR] 3.07, 95% confidence interval [CI]: 1.801 to 5.233), household wealth (RRR 5.451, 95% CI: 2.249 to 13.216), and age (RRR 1.528, 95% CI: 1.004 to 2.326) were more likely to prefer high-level services, while older adults with higher monthly income (RRR 0.516, 95% CI: 0.344 to 0.774), and those with pensions (RRR 0.267, 95% CI: 0.076 to 0.931) were less likely to prefer low-level services. The elderly's price preference increased by 398 CNY as monthly income increased by 1 000 CNY, and by 270 CNY as the housing number increased by one. Having pensions increased price preference (468 CNY), whereas having health insurance decreased price preference (–690 CNY). Conclusion: The elderly's intention of nursing home admission was primarily affected by sociodemographic factors, while price and service level choices were primarily affected by financial factors. Nursing homes should use the market segmentation method to provide precision nursing home care for different groups of non-disabled elderly.

Although a key tenant of the Sustainable Development Goals is to achieve universal health coverage, the global drug gap persists—over a third of the global population lack access to essential medicines. Without access to affordable drugs, people have worse health outcomes, higher medical expenses, and productivity loss, pushing them into poverty. Health technology assessments (HTAs) offer an opportunity to decrease the global drug gap and increase access to essential medicines by overcoming barriers to medicine access. These barriers include drug procurement, drug affordability for payers and patients, a patient's ability to obtain essential medicines, and health system capacity. Using HTAs can therefore close the global drug gap by increasing access to affordable essential medicines. In turn, people have better health outcomes, spend less money on medical care, and can have better productivity. Ultimately, use of HTAs can lift the population out of poverty and force fewer people into poverty by creating better health outcomes at affordable prices.

Abstract Background More than 30 states have either expanded Medicaid or are actively considering expansion. The coverage gains from this policy are well documented, however, the impacts of its increasing coverage on poverty disparity are unclear at the national level. Method American Community Survey (2012–2018) was used to examine the effects of Medicaid expansion on poverty disparity in insurance coverage for nonelderly adults in the United States. Differences-in-differences-in-differences design was used to analyze trends in uninsured rates by poverty levels: (1) 400 % federal poverty level (FPL). Results Compared with uninsured rates in 2012, uninsured rates in 2018 decreased by 10.75 %, 6.42 %, and 1.11 % for 400 % FPL, respectively. From 2012 to 2018, > 400 % FPL group continuously had the lowest uninsured rate and

Abstract Cadmium (Cd) is highly toxic to living organisms and the contamination of Cd in paddy soil in China has received much attention. In the present study, by conducting pot experiment, the influence of S fertilizer (S0) on rice growth, iron plaque formation, Cd accumulation in rice plants and bacterial community in rice rhizosphere soil was investigated. The biomass of rice plants was significantly increased by S0 addition (19.5–73.6%). The addition of S0 increased the formation of iron plaque by 24.3–45.8%, meanwhile the amount of Cd sequestered on iron plaque increased. In soil treated with 5 mg/kg Cd, addition of 0.2 g/kg S0 decreased the diffusive gradients in thin films (DGT) extractable Cd by 60.0%. The application of S0 significantly decreased the concentration of Cd in rice grain by 12.1% (0.1 g/kg) and 36.6% (0.2 g/kg) respectively. The addition of S0 significantly increased the ratio of Acidobacteria, Bacteroidetes in rice rhizosphere soil. Meanwhile, the ratio of Planctomycetes and Chloroflexi decreased. The results indicated that promoting Fe- and S-reducing and residue decomposition bacterial in the rhizosphere by S0 may be one biological reason for reducing Cd risk in the soil-rice system.

ObjectivesCurrently, in China, several strategies exist to prevent mother-to-child transmission (MTCT) of the hepatitis B virus (HBV). These include providing Hepatitis B vaccination and hepatitis B immunoglobulin (HBIG) injection with different types of administration and dosages. The aim of this study is threefold: first, to evaluate the economic viability of current hepatitis B vaccination strategies for preventing MTCT from a public health policy perspective; second, to optimize the current immunization strategy for preventing perinatal transmission of the HBV; and third, to offer policy options to the National Health Commission in China.MethodsTo simulate the disease outcome for the entire life of newborns infected with HBV, a Markov model with eight possible health states was built by using TreeAge Pro 2011 software. In the present study, the model parameters were probability and cost, which were extracted from literature and calculated using Microsoft Excel 2013. The optimal immunization strategies were identified through cost-benefit analyses. A benefit-cost ratio (BCR) > 1 indicated that the strategy had positive benefits and vice versa. A one-way sensitivity analysis was used to investigate the stability of the results.ResultsFrom a public health care system perspective, we evaluated the economic viability of 11 strategies in China. For all 11 strategies, the BCR was > 1, which indicated that the benefits of all the strategies were greater than the costs. We recommended strategy number 9 as being optimal. In strategy number 9, babies born to hepatitis B surface antigen (HBsAg)-positive mothers were given an HBIG (200 IU) within 24 h of birth and three injections of hepatitis -B vaccine (20-μg each) at 0, 1, and 6 months, and the strategy had a BCR of 4.61. The one-way sensitivity analysis revealed that the full vaccination coverage and effective rates of protection were two factors that greatly influenced the BCR of the different prevention strategies; other factors had little effect.ConclusionThe benefits of all strategies were greater than the costs. For decision-making and application, the strategy should be based on local socio-economic conditions so that an appropriate immunization strategy can be selected.

Abstract Objective This research describes the clinical pathway and characteristics of two cohorts of patients. The first cohort consists of patients with a confirmed diagnosis of lung cancer while the second consists of patients with a solitary pulmonary nodule (SPN) and no evidence of lung cancer. Linked data from an electronic medical record and the Louisiana Tumor Registry were used in this investigation. Materials and methods REACHnet is one of 9 clinical research networks (CRNs) in PCORnet®, the National Patient-Centered Clinical Research Network and includes electronic health records for over 8 million patients from multiple partner health systems. Data from Ochsner Health System and Tulane Medical Center were linked to Louisiana Tumor Registry (LTR), a statewide population-based cancer registry, for analysis of patient’s clinical pathways between July 2013 and 2017. Patient characteristics and health services utilization rates by cancer stage were reported as frequency distributions. The Kaplan-Meier product limit method was used to estimate the time from index date to diagnosis by stage in lung cancer cohort. Results A total of 30,559 potentially eligible patients were identified and 2929 (9.58%) had primary lung cancer. Of these, 1496 (51.1%) were documented in LTR and their clinical pathway to diagnosis was further studied. Time to diagnosis varied significantly by cancer stage. A total of 24,140 patients with an SPN were identified in REACHnet and 15,978 (66.6%) had documented follow up care for 1 year. 1612 (10%) had no evidence of any work up for their SPN. The remaining 14,366 had some evidence of follow up, primarily office visits and additional chest imaging. Conclusion In both cohorts multiple biopsies were evident in the clinical pathway. Despite clinical workup, 70% of patients in the lung cancer cohort had stage III or IV disease. In the SPN cohort, only 66% were identified as receiving a diagnostic work-up.

Background: Millions of Americans have hepatitis C and other liver diseases, many of whom have end-stage osteoarthritis requiring total joint arthroplasty (TJA). This study aimed to determine the extent to which hepatitis C and other liver diseases are independent risk factors for complications, including readmission and reoperation, in patients undergoing TJA. Methods: Retrospective study of a REACHnet data set containing demographics, International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and clinical and laboratory data for patients who underwent primary total knee or hip replacement from 2013 to 2017 at 3 hospital systems in Louisiana and Texas. Multivariable logistic regression analyses examined predictors of complications. Any complication was defined as a 90-day medical complication or readmission or reoperation within 1 year. Results: Among 13,673 patients who met inclusion criteria, 14.9% (2044/13,673) had any complication, 11.7% (1600/13,673) were readmitted within 90 days, and 3.6% (497/13,673) had a reoperation within 1 year. Liver disease increased the odds for any complication (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.18), 90-day medical complication (OR, 1.13; 95% CI, 1.04-1.22), and 90-day readmission (OR, 1.11; 95% CI, 1.06-1.17). Hepatitis C was not, by itself, associated with an increase in any type of complication but was usually associated with liver disease. Comorbidity severity was the strongest predictor of all types of complications after TJA. Conclusion: Patients in Louisiana and Texas with liver disease were at increased risk for complications after TJA, corroborating findings of previous studies. Hepatitis C was not an independent predictor of complications because of its high association with liver disease.

Abstract Background Echinococcosis is considered a neglected zoonotic disease and has been a major worldwide public health problem. Although it is known that health literacy is closely related to health behaviours and health outcomes, few studies have paid attention to echinococcosis related health literacy. This study aims to examine the association between echinococcosis-specific health literacy (ES-HL) and behavioural intention to prevent echinococcosis (BIPE) among herdsmen on the Tibet Plateauin in China. Methods A cross-sectional study of 401 Tibetan herdsmen was conducted in Gande county of Qinghai Province, China. Participants were recruited from August to September 2018 and from February to March 2019. A self-developed questionnaire was used to measure demographic information, ES-HL and BIPE. Hierarchical regression analysis was done to identify the factors associated with BIPE. Results In the hierarchical regression analysis, we entered age, sex, education level, marital state and family monthly income per capita into model 1 which explained a significant amount of variance in BIPE (Adjusted R2 change = 0.029, P = 0.006). Sex (β = − 0.125, P = 0.013) and family monthly income per capita (β = − 0.133, P = 0.009) were found to be associated with BIPE. Subsequently, the three factors of ES-HL were added to Model 1 to create Model 2. In Model 2, the two factors of ES-HL, perceived echinococcosis information support (β = 0.229, P

Abstract Objective To examine patient/caregiver preference for key attributes of treatments for spinal muscular atrophy (SMA). Background In the rapidly evolving SMA treatment landscape, it is critically important to understand how attributes of potential treatments may impact patient/caregiver choices. Design/methods A discrete choice experiment survey was developed based on qualitative interviews. Patients with SMA (≥ 18 years) and caregivers of patients were recruited through a U.S. patient organization. Respondents made choices in each of 12 sets of hypothetical treatments. The relative importance of five treatment characteristics was compared (measured by regression coefficients [RC] of conditional logit models): (1) improvement or stabilization of motor function, (2) improvement or stabilization of breathing function, (3) indication for all ages or pediatric patients only, (4) route of administration [repeated intrathecal (IT) injections, one-time intravenous (IV) infusion, daily oral delivery] and (5) potential harm (mild, moderate, serious/life threatening). Results Patient ages ranged from less than 1 to 67 years (n = 101, 65 self-reported and 36 caregiver-reported) and 64 were female. Total SMA subtypes included: type 1 (n = 21), type 2 (n = 48), type 3 (n = 29), other (n = 3). Prior spinal surgery was reported in 47 patients. Nusinersen and onasemnogene abeparvovec-xioi use were reported in 59 and 10 patients, respectively. Improvement in motor and breathing function was highly valued [RC: 0.65, 95% confidence interval (CI): 0.47–0.83 and RC: 0.79, 95% CI: 0.60–0.98, respectively]. Oral medication and one-time infusion were strongly preferred over repeated IT injections (RC: 0.80, 95% CI: 0.60–0.98 and RC: 0.51, 95% CI: 0.30–0.73, respectively). Patients least preferred an age-restricted label/approved use (≤ 2 years of age) (RC: − 1.28, 95% CI: − 1.47 to − 1.09). Cross-attributes trade-off decision suggested a lower willingness for a high-risk therapy despite additional efficacy gain. For some patients, there may be willingness to trade off additional gains in efficacy for a change in route of administration from repeated intrathecal administration to oral medication. Conclusions Improvements in motor/breathing function, broad indication, oral or one-time infusion, and minimal risk were preferred treatment attributes. Treatment decisions should be made in clinical context and be tailored to patient needs.

Abstract Background Clinical guidelines recommend a stepped-escalation treatment strategy for type 2 diabetes (T2DM). Across multiple treatment strategies varying in efficacy and costs, no clinical or economic studies directly compared them. This study aims to estimate and compare the cost-effectiveness of 10 commonly used pharmacologic combination strategies for T2DM. Methods Based on Chinese guideline and practice, 10 three-stepwise add-on strategies were identified, which start with metformin, then switch to metformin plus one oral drug (i.e., sulfonylurea, thiazolidinedione, α-glucosidase inhibitor, glinide, or DPP-4 inhibitor) as second line, and finally switch to metformin plus one injection (i.e., insulin or GLP-1 receptor agonist) as third line. A cohort of 10,000 Chinese patients with newly diagnosed T2DM was established. From a healthcare system perspective, the Cardiff model was used to estimate the cost-effectiveness of the strategies, with clinical data sourced from a systematic review and indirect treatment comparison of 324 trials, costs from claims data of 1164 T2DM patients, and utilities from an EQ-5D study. Outcome measures include costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and net monetary benefits (NMBs). Results Over 40-year simulation, the costs accumulated for a patient ranged from $7661 with strategy 1 to $14,273 with strategy 10, while the QALY gains ranged from 13.965 with strategy 1 to 14.117 with strategy 8. Strategy 7 was dominant over seven strategies (strategies 2~6, 9~10) with higher QALYs but lower costs. Additionally, at a willingness-to-pay threshold of $30,787/QALY (i.e., 3 times GDP/capita for China), strategy 7 was cost-effective compared with strategy 1 (ICER of strategy 7 vs. 1, $3371/QALY) and strategy 8 (ICER of strategy 8 vs. 7, $132,790/QALY). Ranking the strategies by ICERs and NMBs, strategy 7 provided the best value for money when compared to all other strategies, followed by strategies 5, 9, 8, 1, 3, 6, 10, 2, and 4. Scenario analyses showed that patients insist on pharmacologic treatments increased their QALYs (0.456~0.653) at an acceptable range of cost increase (ICERs, $1450/QALY~$12,360/QALY) or even at cost saving compared with those not receive treatments. Conclusions This study provides evidence-based references for diabetes management. Our findings can be used to design the essential drug formulary, infer clinical practice, and help the decision-maker design reimbursement policy.

Abstract Background Acromegaly patients managed on Somatostatin receptor ligands (SRLs), the most common first-line pharmacotherapy for acromegaly, may still experience acromegaly symptoms such as headache, sweating, fatigue, soft tissue swelling, and joint pain, even those with normal IGF-1. Additionally, treatment with SRLs may cause injection site reactions and other side effects such as gastro-intestinal (GI) symptoms. This study utilized patient-reported outcome measures to examine the burden associated with acromegaly and its treatment for patients receiving a stable dose of long-acting SRLs in routine clinical practice. Methods US acromegaly patients on a stable dose of SRL seen by their treating healthcare provider in the past 12 months completed a one-time online survey including the Acro-TSQ, an acromegaly-specific tool for assessing symptom burden and treatment satisfaction and convenience. Results One hundred five patients were enrolled (mean age 49.9 years, 79.1% female). Patients experienced numerous symptoms, including > 80% who experienced joint pain, acro-fog, swelling of soft tissue, and fatigue/weakness. Many symptoms occurred constantly, while some occurred at the end of the injection cycle, even among those with IGF-1 3 acromegaly provider visits/year. Conclusions Despite receiving a stable dose of SRL and regular visits with an acromegaly healthcare provider, US acromegaly patients in routine clinical practice, and even the subgroup with normal IGF-1, report significant burden of disease and treatment.

Background and Purpose The association between hemoglobin A1c (HbA1c) and stroke risk along with its subtypes is rarely reported. We aimed to investigate the association between HbA1c and the risk of incident stroke in patients with type 2 diabetes based on real world data from three healthcare systems. Methods We performed a retrospective cohort study of 27,113 African Americans and 40,431 whites with type 2 diabetes. Demographic, anthropometric, laboratory, and medication information were abstracted from the National Patient-Centered Clinical Research Network common data model. Incident stroke events including both ischemic and hemorrhagic stroke were defined. Results During a mean follow-up period of 3.79±1.68 years, 7,735 patients developed stroke (6,862 ischemic and 873 hemorrhagic). Multivariable-adjusted hazard ratios across levels of HbA1c at baseline (

The cost to U.S. consumers of specialty drugs is too high, and cost-sharing obligations are reducing patient access to affordable and life-changing medications. While accounting only for approximately 2% of prescriptions filled, specialty drugs accounted for nearly 45% of the U.S. drug spend in 2018, and this rate continues to rise. This review analyzes the current state of the U.S. specialty drug market and recommends six policy options for decreasing out-of-pocket costs to consumers. A systematic review was conducted, gathering articles from peer-reviewed and government resources published from January 2014 to May 2019 using databases such as PubMed, OVID, and the Congressional Research Service (CRS). Articles were reviewed for unique and relevant information relating to cost specialty drugs, industry trends, underlying legislation and policy challenges, and viable policy options. The findings show that, while the cost of specialty drug prices is growing, the rate of growth is projected to slow to a compound annual growth rate (CAGR) of 4 to 7% between 2019 and 2023, as compared to a CAGR of 7.2% from 2014 to 2018, largely due to the Food and Drug Administration's approval of 10 new biosimilars in 2018 and early 2019. However, specialty drug spending as a percentage of total spending continues to rise and can cost payers and patients more than USD 3,500 on average per month. We recommend six policy options for reducing consumers' out-of-pocket cost obligations: (1) discourage “pay-for-delay” agreements and patent evergreening; (2) align incentives across the specialty drug supply chain with value-based pricing; (3) tighten orphan drug eligibility or impose a sales tax on drugs if the sales tax exceeds a specified threshold until federal subsidies are recouped; (4) increase transparency in transactions between specialty drug supply chain stakeholders; (5) tax the direct-to-consumer advertising of specialty drugs and use the proceeds to fund public research; and (6) support copay cards and patient assistance programs. While the consensus across the industry is that the out-of-pocket costs of specialty drugs to patients are too high, industry stakeholders must agree about which set of policy options to implement. Lawmakers must explore options for reducing the out-of-pocket costs of specialty medications and gather public input on how to best align stakeholder incentives across the specialty drug supply chain.

Objectives: The widespread usage of traditional Chinese medicine (TCM) and the government's emphasis on TCM in China have created a positive macro-environment and great opportunities to develop and strengthen health technology assessment (HTA) in TCM. Over the past ten years, a series of policies have been issued by the government to promote the application of HTA and the development of TCM in China. This study reviews the concepts and characteristics of TCM, summarizes the current status of HTA in TCM, and analyzes the opportunities and challenges faced by HTA development in TCM with respect to deepening of healthcare reforms. Methods: Literature review and website searches were used to acquire information regarding the basic theories of TCM and the current status, opportunities, and challenges for HTA in TCM. Results: The number of articles on HTA in TCM rose substantially, especially those published in China National Knowledge Infrastructure (CNKI). With the optimistic policy environment and huge market demand for TCM, the development of HTA in TCM is expected to flourish in China. However, HTA in TCM also faces numerous challenges such as the absence of a clinical efficacy evaluation system for TCM and insufficient basic research evidence and qualified personnel. Conclusions: TCM has unique characteristic that distinguishes it from Western medicine. Currently, it is important to take all measures to address the existing main challenges and thereby take advantage of the present opportunities to develop and improve HTA in TCM.

Diabetes is a chronic disease that affects over 30 million people in the United States. Of these, approximately 7.4 million use one or more formulations of insulin to manage their condition. There is a significant financial burden on diabetic individuals, as the price of insulin keeps increasing each year. Such consistent and drastic increases in the price of insulin are due to the complexities in the insulin supply chain, pricing mechanisms particularly due to pharmacy benefit managers (PBMs), and the dominance of a few insulin manufacturers in the market. This policy analysis has been undertaken independently and is based on information from peer-reviewed journals, government organizations and agencies, and credible news sources. Politicians and various stakeholders in the supply chain have made several policy recommendations on the pricing of insulin. From the data and information collected, we suggest basing a patient's co-payment on the net price instead of the list price of insulin, and that there should be real-time transparency in the negotiations between PBMs and pharmaceutical companies on rebates.

Objectives: This study aimed to describe and compare health-related quality of life (HRQoL) among populations with normal glycemic levels, prediabetes, and diabetes in southwest China and to offer baseline data that can be easily compared to other regions in China or across countries.Methods: A quality of life survey based on the EuroQoL-5 Dimension-5 level (EQ-5D-5L) scale was conducted through face-to-face or telephone interviews. A total of 403 respondents with diabetes, 404 with prediabetes, and 398 with normal blood glucose were enrolled in the survey. Propensity score matching (PSM) was used to decrease the bias of three groups, conditioned on age and gender, body mass index (BMI), and household income. For the three groups, we matched two groups first and then matched the result with the third group. Differences among groups were compared by chi-square test one-way ANOVA after adjusting by PSM.Results: In general, the blood glucose of people with diabetes was generally well-controlled in southwest China, but they were often accompanied by the circulatory system and nutritional metabolic diseases. Ninety-nine individuals from each group were matched. The EuroQoL-5 Dimension index of the population with normal glycemic levels, prediabetes, and patients with diabetes was 0.901, 0.948, and 0.897. The EuroQol-visual analog scales (EQ-VAS) scores of each group above were 73.76, 77.45, and 68.34. HRQoL in males was higher than that of females in the three study groups. The results after PSM were consistent with that before matching.Conclusion: There was a general trend that patients were associated with a decline of HRQoL from the prediabetic population, population with normal glycemic levels to diabetic population. Pain/discomfort and anxiety/depression might not be specific for the population with or without diabetes.

Introduction Considerable confusions on treatment target have resulted from recent changes in guidelines. Evidence in medical guidelines came from clinical trials with highly selected patients, whereas treatment goals may differ in some subgroups. This study aimed to assess optimal treatment goals (A1C, blood pressure, low-density lipoprotein cholesterol (LDL-C)) for patients with type 2 diabetes mellitus (T2DM), which lead to optimal health outcomes by different treatment strategies.Research design and methods A retrospective longitudinal study was conducted for veterans with T2DM by using US Veterans Affairs Administrative Database (2005−2015). Medical records were prepared for repeated evaluation performed at 6-month intervals and multivariate longitudinal regression was used to estimate the risk of microvascular and macrovascular complication events. Second-degree polynomial and splines were applied to identify the optimal goals in their associations with lowest risk of clinical outcomes, controlling for demographic characteristics, medical history, and medications.Results A total of 124 651 patients with T2DM were selected, with mean of 6.72 follow-up years. In the general population, to achieve the lowest risk of microvascular and macrovascular complication, the optimal goals were A1C=6.81%, LDL-C=109.10 mg/dL; and A1C=6.76%, LDL-C=111.65 mg/dL, systolic blood pressure (SBP)=130.60 mmHg, respectively. The optimal goals differed between age and racial subgroups. Lower SBP for younger patients and lower LDL-C for black patients were associated with better health outcomes.Conclusions Optimal treatment goals were identified and multi-faceted treatment strategies targeting hyperglycemia and hyperlipidemia and hypertension may improve health outcome in veterans with T2DM. In addition to guidelines’ recommended goals, health systems may examine their own large diverse patients with T2DM for better quality of care.

BackgroundThe issuing of regulation schemes and the expanding health insurance coverage for virtual visits of internet hospitals would incentivize Chinese providers and patients to use virtual visits tremendously. China’s internet hospitals vary in sponsorship. However, little is known about patients’ intention to use virtual visits delivered by different sponsorship types of internet hospitals. ObjectiveThe goal of the research is to examine patients’ intention to use virtual visits, as well as virtual visits delivered by different sponsorship types of internet hospitals. In addition, we will identify determinants of patients’ intention to use virtual visits, as well as intention to use virtual visits delivered by different sponsorship types of internet hospitals. MethodsA cross-sectional survey of 1653 participants was conducted in 3-tier hospitals in 3 cities with different income levels in May and June 2019. Binary logistic regression analysis was used to identify the factors that affect patients’ intention to use virtual visits. Multinomial logistic regression analysis was conducted to identify the determinants of the intention to use virtual visits delivered by different sponsorship types of internet hospitals (ie, enterprise-sponsored, hospital-sponsored, and government-sponsored). ResultsA total of 76.64% (1145/1494) of adult participants were online medical information seekers, and 87.06% (969/1113) of online medical information seekers had intention to use virtual visits. Public hospital–sponsored internet hospitals were the most prevalent ones among Chinese patients (473/894, 52.9%), followed by the provincial government internet hospital platform (238/894, 26.6%), digital health companies (116/894, 13.0%), medical e-commerce companies (48/894, 5.4%), private hospitals (13/894, 1.5%), and other companies (6/894, 0.7%). Gender, education, monthly income, and consumer type were significantly associated with the intention to use virtual visits. Gender, age, education, city income level, consumer type, and trust in the sponsor of a health website were significantly associated with the patient’s intention to use virtual visits delivered by 3 different sponsorship types of internet hospitals. ConclusionsChinese patients who were online medical information seekers had high intention to use virtual visits and had different intentions to use virtual visits delivered by different sponsorship types of internet hospitals. Public hospitals, the government, and digital health companies were the top 3 sponsorship types of internet hospitals that patients had intention to use. Trust in a health website sponsor significantly influenced the patient’s intention to use virtual visits delivered by different sponsorship types of internet hospitals. Gender, education, and consumer type were the factors significantly associated with both the intention to use virtual visits and the intention to use virtual visits delivered by different sponsorship types of internet hospitals.

Abstract Background Evidence-based decision on drug list or formulary has been applied worldwide. Although the importance of scientific evidence was emphasized, the decision-making procedures for including medicines into the national reimbursement drug list were often challenged by their process opacity and relying on subjective expert opinion. This study aimed to explore and assess the evidence for the effectiveness of anti-hypertensive medicines included on the Chinese National Reimbursement Drug List (NRDL), and to provide recommendations for further improvement. Methods Three international evidence-based guidelines were selected to serve as reference criteria. The antihypertensive medicines included in NRDL of Urban Employee Basic Medical Insurance (UEBMI) were compared with recommended drugs in three international guidelines. Medicines recommended by at least two guidelines were considered to have sound evidence support for the effectiveness. Otherwise, published literature with high evidence grade, namely systematic review, meta-analysis and randomized controlled trial (RCT), were searched for further assessment. Medicines reported as fairly good effectiveness by literature with high evidence grade can be also considered having sound evidence for the effectiveness. Methodological quality of systematic review or meta-analysis was evaluated by AMSTAR scale and PRISMA statement. Literature quality of RCTs was assessed by Jadad scale. Results For the 97 antihypertensive medicines in NRDL, there were sound evidence supports for the effectiveness of 56 kinds of medicines. Specifically, twenty-six of them were supported by international evidence-based guidelines, twenty were supported by systematic review or meta-analysis and the other ten by RCT. However, for the rest 41 medicines, there is insufficient evidence for their effectiveness. Conclusions Some antihypertensive medicines in NRDL did not have sufficient evidence for their effectiveness. Further evaluation and revision were required. It is also recommended to standardize decision-making procedures for inclusion of medicines, set up high quality evidence database to timely provide sound evidence, and so on.

Purpose: The effectiveness of poly (adenosine diphosphate–ribose) polymerase (PARP) inhibitor olaparib for metastatic castration-resistant prostate cancer (MCRPC) with multiple loss-of-function alterations in genes that are involved in DNA repair has been demonstrated. We aimed to evaluate the cost-effectiveness of genomic test-directed olaparib on MCRPC from the US payer perspective.Methods: A partitioned survival model was adopted to project the disease course of MCRPC had at least one gene alteration in BRCA1, BRCA2 and ATM (Scenario A) and has alterations in any of all 15 prespecified genes (Scenario B) after next-generation sequencing test. The efficacy and toxicity data were gathered from the PROfound trial. Clinical probabilities related to survival were estimated from the reported survival probabilities in each PROfound group. Cost and health preference data were derived from the literature. The incremental cost-effectiveness ratio (ICER) was measured. Subgroup analysis and sensitivity analysis were performed for exploring the model uncertainties.Results: Olaparib yielded an additional 0.063 and 0.068 of quality-adjusted life year (QALY) with the augmented cost of $7,382 and saved the cost of $ 1,980 compared to standard care in scenario A and B, respectively, which yielded an ICER of $116,903/QALY and a cost-saving option. The lower weekly cost related to olaparib treatment led to the dominant findings in scenario B. The varied results between scenario A and B could be partly explained by different the number need to screen for identifying eligible patients who could be administered with olaparib, which sharply augmented the costs of the olaparib arm in scenario A. Subgroup analysis and sensitivity analysis revealed the results were generally robust in both of two scenarios.Conclusion: The genomic test-directed olaparib is a preferred option compared with standard care strategy for men with MCRPC who had any of all 15 prespecified genes.

Objective This study aimed to estimate the cost–utility of sofosbuvir/velpatasvir (SOF/VEL) compared with other direct-acting antivirals (DAAs) in Chinese patients with hepatitis C virus (HCV).Design A Markov model was developed to estimate the disease progression of patients with HCV over a lifetime horizon from the healthcare system perspective. Efficacy, clinical inputs and utilities were derived from the published literature. Drug costs were from the market price survey, and health costs for Markov health states were sourced from a Chinese study. Costs and utilities were discounted at an annual rate of 5%. One-way and probabilistic sensitivity analyses were conducted to test the impact of input parameters on the results.Interventions SOF/VEL was compared with sofosbuvir+ribavirin (SR), sofosbuvir+dasabuvir (SD), daclatasvir+asunaprevir (DCV/ASV), ombitasvir/paritaprevir/ritonavir+dasabuvir (3D) and elbasvir/grazoprevir (EBR/GZR).Primary and secondary outcomes Costs, quality-adjusted life years (QALYs) and incremental cost–utility ratios (ICURs).Results SOF/VEL was economically dominant over SR and SD. However, 3D was economically dominant compared with SOF/VEL. Compared with DCV/ASV, SOF/VEL was cost-effective with the ICUR of US$1522 per QALY. Compared with EBR/GZR, it was not cost-effective with the ICUR of US$369 627 per QALY. One-way sensitivity analysis demonstrated that reducing the cost of SOF/VEL to the lower value of CI resulted in dominance over EBR/GZR and 3D. Probabilistic sensitivity analysis demonstrated that 3D was cost-effective in 100% of iterations in patients with genotype (GT) 1b and SOF/VEL was not cost-effective.Conclusions Compared with other oral DAA agents, SOF/VEL treatment was not the most cost-effectiveness option for patients with chronic HCV GT1b in China. Lower the price of SOF/VEL will make it cost-effective while simplifying treatment and achieving the goal of HCV elimination.

ObjectiveTo evaluate physician risk-benefit preferences and trade-offs when making chemotherapy decisions for patients with non-small cell lung cancer (NSCLC).DesignA discrete choice experiment (DCE).SettingsTertiary hospitals in Beijing, Shanghai, Guangzhou and Chengdu of China.ParticipantsThe participants were 184 physicians (mean age of 37 years) with more than 1 year of NSCLC chemotherapy practice.OutcomesThe DCE survey was constructed by six attributes: progression-free survival (PFS), disease control rate (DCR), risk of moderate side effects, risk of severe side effects, mode of administration and out-of-pocket costs. Physicians’ relative preferences and trade-offs in patient out-of-pocket costs for each attribute level were estimated using a mixed logit model, and interaction terms were added to the model to assess preferences variation among physicians with different sociodemographic factors.ResultsPhysicians had the strongest preferences for improvements in PFS, followed by reducing the risk of severe side effects. The DCR, risk of moderate side effects and mode of administration were ranked in decreasing order of importance. There was little variation in preferences among physicians with different sociodemographic characteristics. Physicians were willing to trade $4814 (95% CI $4149 to $5480) of patient out-of-pocket costs per month for a chemotherapy that guaranteed 11 months of PFS, followed by $1908 (95% CI $1227 to $2539) for reducing the risk of severe side effects to 2%.ConclusionsWith regard to chemotherapy for patients with NSCLC, prolonging PFS, reducing severe and moderate side effects were primary considerations for physicians in China. The mode of administration and treatment costs significantly influenced physicians’ therapeutic decision. The current findings could add some evidence to inform NSCLC chemotherapy implementation and promote shared decision-making.

Abstract Background Distribution equity assessment of computed tomography (CT) and magnetic resonance imaging (MRI) scanners is an important dimension of access to health technology. However, limited studies on the subject have been done in China. This study aims to reveal the distribution status of CT and MRI scanners and assess their distribution equity of them in China. Methods Five provinces with 66 cities from China were selected as the study sites. Descriptive analysis was used for the absolute number and number per million population of CT and MRI scanners in the study sites. Fixed effect model was used to examine the health service factors that were associated with the allocation of CT and MRI scanners. The Gini coefficient and concentration index was used to evaluate the distribution equity of CT and MRI scanners. Results The absolute number and number per million population of CT and MRI scanners in five provinces were lower than those of Organization for Economic Co-operation and Development (OECD) countries, but annual growth rates were relatively higher from 2005 or 2006 to 2013. Population, GDP, number of hospitals, number of health professionals, number of hospital beds, number of outpatient visits, and number of inpatient visits all had a positive correlation with the allocation number of CT and MRI scanners. Moreover, the number of health professionals and the number of beds had a much closer correlation than other variables. All the Gini coefficients of CT and MRI had decreased overall. The concentration indices of CT and MRI were all positive and no more than 0.30. Conclusions Large gaps in the number of CT and MRI scanners per million population between China and OECD countries emerge, although the growth rate is higher in China. The distribution equity of CT and MRI scanners in China was relatively good from 2005 or 2006 to 2013. The overall distribution equity of CT and MRI scanners also improved during the period. However, consideration attention should be given to the area with large economic disparities.

Objectives: Economic growth and rapid development of health technology in China have created opportunities to strengthen health technology assessment (HTA) capacity. Over the time, HTA institutions have been established to conduct HTA related work. This study reviewed the current status of HTA in China and analysed the challenges of HTA development in the context of health reform under “new normal” economy.Methods: Literature review and webpage searches were used to document the development of HTA in China. An institutional survey has also been conducted to collect information on the HTA research institutions in China.Results: The number of articles and research projects on HTA were rising and are continuing to rise. HTA development has made substantial progress in China in terms of growing number of research institutions and qualified HTA workforce. However, HTA has notable weaknesses such as low capacity for conducting HTA research, limited experience in HTA researchers, and lack of knowledge translation.Conclusion: Currently, the translation of HTA findings to policy-making is limited and the integration of HTA in the policy-making processes is still in its infancy. The HTA development in China has had opportunities due to demands of health care, health insurance, and health technology as a result of health reform. Capacity building and institutionalization of HTA are urgently needed for further development of HTA in China.

ObjectivesStroke is the leading cause of death and adult disability in China, following a rise in incidence over the last few decades. We aimed to explore the geographic variations in hospital mortality and endovascular therapy (EVT) use among ischaemic stroke (IS) patients in China, and investigate the associated potential risk factors.DesignObservational cross-sectional study of patients hospitalised for stroke.SettingHospital discharge data for 1267 tertiary hospitals between 1 January 2015 and 31 December 2015 were derived from the Nationwide Hospital Discharge Database operated by the National Health Commission of China.Participants1 826 332 patients aged ≥18 years, hospitalised following stroke.Outcome measuresIn-hospital mortality and EVT use.ResultsThe nationwide hospital mortality rate of IS patients was 0.88% (95% CI 0.86% to 0.90%); there was a significantly greater risk of mortality in the Northeast (OR 2.37; 95% CI 2.23 to 2.52), West (1.65; 1.54 to 1.78), South (1.25; 1.17 to 1.33) and North (1.29; 1.20 to 1.39) than in the East. Tertiary B hospitals (OR 1.05; 95% CI 1.00 to 1.09), patients admitted from emergency departments and older patients were associated with higher hospital mortality. The national EVT use rate was 0.45% (95% CI 0.44% to 0.46%). Compared with in East China, EVT use was significantly lower in the Northeast (OR 0.22; 95% CI 0.20 to 0.24) and West (0.64; 0.58 to 0.71), though not the North (1.23; 1.14 to 1.33). Tertiary A hospitals (OR 2.62; 95% CI 2.43 to 2.83), male patients and patients admitted from emergency departments were also associated with higher EVT use rates.ConclusionsThere were substantial disparities in mortality and EVT use for hospitalised patients with IS among China’s tertiary hospitals, linked with both geographic and hospital characteristics. More targeted intervention at regional and hospital levels is needed for providing effective health technologies and eventually improving post-stroke outcomes.

Objective: Nearly one-third of adults in New York City (NYC) have high blood pressure and many social, economic, and behavioral factors may influence nonadherence to antihypertensive medication. The objective of this study is to identify profiles of adults who are not taking antihypertensive medications despite being advised to do so. Methods: We used a machine learning–based population segmentation approach to identify population profiles related to nonadherence to antihypertensive medication. We used data from the 2016 NYC Community Health Survey to identify and segment adults into subgroups according to their level of nonadherence to antihypertensive medications. Results: We found that more than 10% of adults in NYC were not taking antihypertensive medications despite being advised to do so by their health care providers. We identified age, neighborhood poverty, diabetes, household income, health insurance coverage, and race/ethnicity as important characteristics that can be used to predict nonadherence behaviors as well as used to segment adults with hypertension into 10 subgroups. Conclusions: Identifying segments of adults who do not adhere to hypertensive medications has practical implications as this knowledge can be used to develop targeted interventions to address this population health management challenge and reduce health disparities.

BackgroundPrevalence of acute myocardial infarction (AMI) is increasing in China, and AMI has become a major cause of mortality; however, information is very limited about the nationwide geographic and hospital variation in in‐hospital mortality (IHM) and the use of percutaneous coronary intervention (PCI) after AMI. Methods and ResultsFrom the Nationwide Hospital Discharge Database of China, we identified 242 866 adult admissions with AMI in 2015 from 1055 tertiary hospitals. We used multivariable logistic regressions to analyze the associations between geographic or hospital characteristics with IHM or PCI use. The national IHM rate was 4.71% (95% confidence interval, 4.62–4.79%). There was a greater risk of mortality in the Northeast (odds ratio [OR]: 1.86), West (OR: 1.73), South (OR: 1.32), and North (OR: 1.14) regions than in the East region of China. Non–teaching hospitals (OR: 1.18) and tertiary level B hospitals (OR: 1.06) were associated with higher IHM rates. The national PCI use rate was 45.3% (95% confidence interval, 45.1–45.5%). Compared with the East region of China, PCI use was lower in the Northeast (OR: 0.50), West (OR: 0.64), North (OR: 0.84), and South (OR: 0.88) regions. Non–teaching hospitals (OR: 0.83) and tertiary level B hospitals (OR: 0.55) were also associated with lower usage rates. There was a significant negative correlation between IHM and PCI use (r=−0.955), and IHM rates for patients with and without PCI both differed by geographic regions. ConclusionsThere were significant differences in IHM and PCI use among China's tertiary hospitals, linked to both geographic and hospital characteristics. More targeted intervention at national and regional levels is needed to improve access to effective health technologies and, eventually, outcomes following AMI.

For health technology assessment (HTA) to be more policy relevant and for health technology-related decision-making to be truly evidence-based, promoting knowledge translation (KT) is of vital importance. Although some research has focused on KT of HTA, there is a dearth of literature on KT determinants and the situation in developing countries and transitional societies remains largely unknown.To investigate the determinants of HTA KT from research to health policy-making from the perspective of researchers in China.Cross-sectional study.A structured questionnaire which focused on KT was distributed to HTA researchers in China. KT activity levels in various fields of HTA research were compared, using one-way ANOVA. Principal component analysis was performed to provide a basis to combine similar variables. To investigate the determinants of KT level, multiple linear regression analysis was performed.Based on a survey of 382 HTA researchers, it was found that HTA KT wasn't widespread in China. Furthermore, results showed that no significant differences existed between the various HTA research fields. Factors, such as attitudes of researchers toward HTA and evidence utilization, academic ranks and linkages between researchers and policy-makers, had significant impact on HTA KT (p-values

Metformin is the first-line oral hypoglycemic agent for type 2 diabetes mellitus recommended by international guidelines. However, little information exists comparing it with acarbose which is also commonly used in China. This study expanded knowledge by combining direct and indirect evidence to ascertain the glucose lowering effects of both drugs.PubMed (1980- December 2013) and China National Knowledge Infrastructure databases (1994-January 2014) were systematically searched for eligible randomized controlled trials from Chinese and English literatures. Meta-analysis was conducted to estimate the glucose lowering effects of metformin vs. acarbose, or either of them vs. common comparators (placebo or sulphonylureas), using random- and fixed-effect models. Bucher method with indirect treatment comparison calculator was applied to convert the summary estimates from the meta-analyses into weighted-mean-difference (WMD) and 95% confidence intervals (CIs) to represent the comparative efficacy between metformin and acarbose.A total of 75 studies were included in the analysis. In direct comparison (8 trials), metformin reduced glycosylated hemoglobin (HbA1c) by 0.06% more than acarbose, with no significant difference (WMD,-0.06%; 95% CI, -0.32% to 0.20%). In indirect comparisons (67 trials), by using placebo and sulphonylureas as common comparators, metformin achieved significant HbA1c reduction than acarbose, by -0.38% (WMD,-0.38%, 95% CI, -0.736% to -0.024%) and -0.34% (WMD, -0.34%, 95% CI, -0.651% to -0.029%) respectively.The glucose lowering effects of metformin monotherapy and acarbose monotherapy are the same by direct comparison, while metformin is a little better by indirect comparison. This implies that the effect of metformin is at least as good as acarbose's.

To examine whether workplace social capital improved after implementing a workplace social capital intervention in community health centers in China.This study was conducted in 20 community health centers of similar size in Jinan of China during 2012-2013. Using the stratified site randomization, 10 centers were randomized into the intervention group; one center was excluded due to leadership change in final analyses. The baseline survey including 447 staff (response rate: 93.1%) was conducted in 2012, and followed by a six-month workplace social capital intervention, including team building courses for directors of community health centers, voluntarily public services, group psychological consultation, and outdoor training. The follow-up survey in July 2013 was responded to by 390 staff members (response rate: 86.9%). Workplace social capital was assessed with the translated and culturally adapted scale, divided into vertical and horizontal dimensions. The facility-level intervention effects were based on all baseline (n = 427) and follow-up (n = 377) respondents, except for Weibei respondents. We conducted a bivariate Difference-in-Difference analysis to estimate the facility-level intervention effects.No statistically significant intervention effects were observed at the center level; the intervention increased the facility-level workplace social capital, and its horizontal and vertical dimensions by 1.0 (p = 0.24), 0.4 (p = 0.46) and 0.8 (p = 0.16), respectively.The comprehensive intervention seemed to slightly improve workplace social capital in community health centers of urban China at the center level. High attrition rate limits any causal interpretation of the results. Further studies are warranted to test these findings.

**Purpose:** In 2010, the World Health Organization (WHO) released its report about health system financing and identified universal coverage as the best way to attain the right of every human being to enjoy “the highest attainable standard of health”. Over the past decade, Thailand has successfully implemented a universal health coverage scheme for its population, while its neighbor country, Indonesia, is still struggling to achieve the same goal. The purpose of this paper is to compare the health financing systems between Thailand and Indonesia. Both countries almost have similar socioeconomic conditions and suffered from severe financial crisis during the late 1990s. The objective of this study is to examine health systems in each country and to determine lessons on how health care financing can affect the health status of a population. **Methods:** The study is based on statistical data from various publicly available resources. For analysis, the authors followed The Health Systems Assessment Approach: A How-To Manual Version 1.0 issued by Health Systems 20/20 supported by United States Agency for International Development (USAID). The countries were compared using three groups of indicators in health systems performance and functioning: 1. Health Insurance System, 2. Amount and Sources of Financial Resources, and 3. Health Outcomes and Health Workforce Density. **Results:** In comparing the health financing of the two countries, we found that Thailand initiated much earlier health systems reforms in order to achieve universal health coverage. Indonesia, while on the right track, has moved at a slower pace than Thailand. Thailand and Indonesia have shown improving trends over time in all indicators, but Thailand outperformed Indonesia, especially in the groups of indicators regarding the amount and sources of financial resources. **Conclusions:** One important lesson identified in this study is that health care reform is unlikely to succeed without strong political support and constant pressure from the nation as a whole, which can be represented by local organizations or professional associations. However, the mere increase of available resources devoted to the health sector does not guarantee significant improvements of health outcomes of a population.

BACKGROUND: The New Cooperative Medical Scheme (NCMS) provides health insurance coverage for rural populations in China. This study aimed to evaluate changes in household catastrophic health expenditure (CHE) due to chronic disease before and after the reimbursement policies for services of chronic disease were implemented to provide additional financial support. METHODS: The study used data from the household surveys conducted in Shandong Province and Ningxia Hui Autonomous Region in 2006 and 2008. The study sample in village-level units was divided into two groups: 36 villages which implemented the NCMS reimbursement policies for chronic diseases as the intervention group, and 72 villages which did not as the control group. Health care expenditure of more than 40% of household's non-food expenditure was defined as a household with CHE (i.e., impoverishment). The conceptual framework was established based on the Andersen socio-behavioral model of health care utilization to explore how the NCMS reimbursement policies impacted health expenditures. A difference-in-difference model was employed to compare the change in the proportion of households incurring CHE due to chronic disease between the two groups over time. RESULTS: The households that participated in the NCMS were less likely to become impoverished (P