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Abstract Reporting the results of quality indicators can narrow the gap in the quality of care between hospitals. While most studies rely on outcome indicators, they may not accurately measure the quality of care. Process indicators are not only strongly associated with treatment outcomes, but are also more sensitive to whether patients are treated accurately, enabling timely intervention. Our study aims to investigate whether process indicators provide a more reasonable assessment of hospital quality of care compared to outcome indicators. Data were sourced from the Specific Disease Medical Service Quality Management and Control System in China. A total of 113,942 patients with breast cancer treated in 298 hospitals between January 2019 and April 2023 were included in this retrospective study. The rankability of 11 process indicators was calculated and used as a weight to create a new composite indicator. The composite indicators and outcome measures were compared using the O/E ratio categories. Finally, in order to determine the impact of different years on the results, a sensitivity analysis was conducted using bootstrap sampling. The rankability ( $$\rho$$ ρ ) values of the eleven process indicators showed significant differences, with the highest $$\rho$$ ρ value for preoperative cytological or histological examination before surgery (0.919). The $$\rho$$ ρ value for the outcome indicator was 0.011. The rankability-weighting method yielded a comprehensive score ( $$\rho$$ ρ = 0.883). The comparison with categorical results of the outcome indicator has different performance classifications for 113 hospitals (37.92%) for composite scores and 140 (46.98%) for preoperative cytological or histological examinationbefore surgery. Process indicators are more suitable than outcome indicators for assessing the quality of breast cancer care in hospitals. Healthcare providers can use process indicators to identify specific areas for improvement, thereby driving continuous quality improvement efforts.

Background Osteoarthritis (OA) is a degenerative disease requiring additional research. This study compared gene expression and immune infiltration between lesioned and preserved subchondral bone. The results were validated using multiple tissue datasets and experiments. Methods Differentially expressed genes (DEGs) between the lesioned and preserved tibial plateaus of OA patients were identified in the GSE51588 dataset. Moreover, functional annotation and protein–protein interaction (PPI) network analyses were performed on the lesioned and preserved sides to explore potential therapeutic targets in OA subchondral bones. In addition, multiple tissues were used to screen coexpressed genes, and the expression levels of identified candidate DEGs in OA were measured by quantitative real-time polymerase chain reaction. Finally, an immune infiltration analysis was conducted. Results A total of 1,010 DEGs were identified, 423 upregulated and 587 downregulated. The biological process (BP) terms enriched in the upregulated genes included “skeletal system development”, “sister chromatid cohesion”, and “ossification”. Pathways were enriched in “Wnt signaling pathway” and “proteoglycans in cancer”. The BP terms enriched in the downregulated genes included “inflammatory response”, “xenobiotic metabolic process”, and “positive regulation of inflammatory response”. The enriched pathways included “neuroactive ligand–receptor interaction” and “AMP-activated protein kinase signaling”. JUN, tumor necrosis factor α, and interleukin-1β were the hub genes in the PPI network. Collagen XI A1 and leucine-rich repeat-containing 15 were screened from multiple datasets and experimentally validated. Immune infiltration analyses showed fewer infiltrating adipocytes and endothelial cells in the lesioned versus preserved samples. Conclusion Our findings provide valuable information for future studies on the pathogenic mechanism of OA and potential therapeutic and diagnostic targets.

BackgroundKnee cartilage is the most crucial structure in the knee, and the reduction of cartilage thickness is a significant factor in the occurrence and development of osteoarthritis. Measuring cartilage thickness allows for a more accurate assessment of cartilage wear, but this process is relatively time-consuming. Our objectives encompass using various DL methods to segment knee cartilage from MRIs taken with different equipment and parameters, building a DL-based model for measuring and grading knee cartilage, and establishing a standardized database of knee cartilage thickness.MethodsIn this retrospective study, we selected a mixed knee MRI dataset consisting of 700 cases from four datasets with varying cartilage thickness. We employed four convolutional neural networks—UNet, UNet++, ResUNet, and TransUNet—to train and segment the mixed dataset, leveraging an extensive array of labeled data for effective supervised learning. Subsequently, we measured and graded the thickness of knee cartilage in 12 regions. Finally, a standard knee cartilage thickness dataset was established using 291 cases with ages ranging from 20 to 45 years and a Kellgren–Lawrence grading of 0.ResultsThe validation results of network segmentation showed that TransUNet performed the best in the mixed dataset, with an overall dice similarity coefficient of 0.813 and an Intersection over Union of 0.692. The model’s mean absolute percentage error for automatic measurement and grading after segmentation was 0.831. The experiment also yielded standard knee cartilage thickness, with an average thickness of 1.98 mm for the femoral cartilage and 2.14 mm for the tibial cartilage.ConclusionBy selecting the best knee cartilage segmentation network, we built a model with a stronger generalization ability to automatically segment, measure, and grade cartilage thickness. This model can assist surgeons in more accurately and efficiently diagnosing changes in patients’ cartilage thickness.

The hyperfine structure (HFS) constants and isotope shifts (ISs) for some Cu I and Cu II levels were determined by fitting Fourier transform (FT) spectra from the US National Solar Observatory. The HFS constants of 43 levels of Cu I and 31 levels of Cu II were determined, of which 35 results of Cu I and 16 results of Cu II are reported for the first time, to the best of our knowledge. Meanwhile, the ISs of 52 Cu I transitions and 31 Cu II transitions were also determined. These transitions respectively cover wavelengths from 223.078 to 2461.4 nm for Cu I and from 224.77 to 1791.747 nm for Cu II. Since in the stellar atmosphere copper is mainly present as singly ionized species, the new HFS data of Cu II will be very valuable for more accurate astronomical spectral analysis related to copper.

The magnetic dipole hyperfine structure (HFS) constants A of neutral and singly ionized europium (Eu I and Eu II) were determined using the emission spectra recorded by the Fourier transform spectrometer at the National Solar Observatory (NSO) at the Kitt Peak, USA. The HFS constants of 29 levels of Eu I and 15 levels of Eu II were determined, from which 22 results for Eu I and 8 results for Eu II are reported for the first time, as far as we know. The isotope shifts (ISs) of 30 transitions of Eu I and 19 transitions of Eu II were also determined, and the ISs of 22 transitions of Eu I and 8 transitions of Eu II are reported for the first time. This work increases the total number of levels with experimentally determined HFS constants A to 202 for Eu I and 24 for Eu II, and increases the number of transitions with known ISs to 359 for Eu I and 36 for Eu II.

Evidence has demonstrated that enhancer RNAs (eRNAs) play a vital role in the progression and prognosis of cancers, but few studies have focused on the prognostic ability of eRNA-regulated genes (eRGs) for hepatocellular carcinoma (HCC). Using gene expression profiles of HCC patients from the TCGA-LIHC and eRNA expression profiles from the enhancer RNA in cancers (eRic) data portal, we developed a novel and robust prognostic signature composed of 10 eRGs based on Lasso-penalized Cox regression analysis. According to the signature, HCC patients were stratified into high- and low-risk groups, which have been shown to have significant differences in tumor immune microenvironment, immune checkpoints, HLA-related genes, DNA damage repair-related genes, Gene-set variation analysis (GSVA), and the lower half-maximal inhibitory concentration (IC50) of Sorafenib. The prognostic nomogram combining the signature, age, and TNM stage had good predictive ability in the training set (TCGA-LIHC) with the concordance index (C-index) of 0.73 and the AUCs for 1-, 3-, and 5-year OS of 0.82, 0.77, 0.74, respectively. In external validation set (GSE14520), the nomogram also performed well with the C-index of 0.71 and the AUCs for 1-, 3-, and 5-year OS of 0.74, 0.77, 0.74, respectively. In addition, an important eRG (AKR1C3) was validated using two HCC cell lines (Huh7 and MHCC-LM3) in vitro, and the results demonstrated the overexpression of AKR1C3 is related to cell proliferation, migration, and invasion in HCC. Altogether, our eRGs signature and nomogram can predict prognosis accurately and conveniently, facilitate individualized treatment, and improve prognosis for HCC patients.

Enhancer RNAs (eRNAs) are present specifically in tumors, where they affect the expression of eRNA-regulated genes (ERGs). Owing to this characteristic, ERGs were hypothesized to improve prognosis of overall survival in heterogeneous low-grade and intermediate-grade gliomas. This study aimed to construct and validate an ERG prognostic tool to facilitate clinical management, and offer more effective diagnostic and therapeutic biomarkers for glioma. Survival-related eRNAs were identified, and their ERGs were selected based on eRNA and target gene information. The ERG prognostic model was constructed and validated using internal and external validation cohorts. Finally, biological differences related to the ERG signature were analysed to explore the potential mechanisms influencing survival outcomes. Thirteen ERGs were identified and used to build an ERG risk signature, which included five super-enhancer RNA (seRNA)-regulated genes and five LGG-specific eRNA-regulated genes. The prognostic nomogram established based on combining the ERG score, age, and sex was evaluated by calibration curves, clinical utility, Harrell’s concordance index (0.86; 95% CI: 0.83-0.90), and time-dependent receiver operator characteristic curves. We also explored potential immune-related mechanisms that might cause variation in survival. The established prognostic model displayed high validity and robustness. Several immune-related genes regulated by seRNAs or specific eRNAs were identified, indicating that these transcripts or their genes were potential targets for improving immunotherapeutic/therapeutic outcomes. The functions of an important specific eRNA-regulated gene (USP28) were validated in robust vitro experiments. In addition, the ERG risk signature was significantly associated with the immune microenvironment and other immune-related features.

Background: Gliomas are the most malignant tumors of the nervous system. Even though their survival outcome is closely affected by immune-related genes (IRGs) in the tumor microenvironment (TME), the corresponding regulatory mechanism remains poorly characterized.Methods: Specific enhancer RNAs (eRNAs) can be found in tumors, where they control downstream genes. The present study aimed to identify eRNA-regulated IRGs, evaluate their influence on the TME, and use them to construct a novel prognostic model for gliomas.Results: Thirteen target genes (ADCYAP1R1, BMP2, BMPR1A, CD4, DDX17, ELN, FGF13, MAPT, PDIA2, PSMB8, PTPN6, SEMA6C, and SSTR5) were identified and integrated into a comprehensive risk signature, which distinguished two risk subclasses. Discrepancies between these subclasses were compared to explore potential mechanisms attributed to eRNA-regulated genes, including immune cell infiltration, clinicopathological features, survival outcomes, and chemotherapeutic drug sensitivity. Furthermore, the risk signature was used to construct a prognostic tool that was evaluated by calibration curve, clinical utility, Harrell’s concordance index (0.87; 95% CI: 0.84–0.90), and time-dependent receiver operator characteristic curves (AUCs: 0.93 and 0.89 at 3 and 5 years, respectively). The strong reliability and robustness of the established prognostic tool were validated in another independent cohort. Finally, potential subtypes were explored in patients with grade III tumors.Conclusion: Overall, eRNAs were associated with immune-related dysfunctions in the TME. Targeting of IRGs regulated by eRNAs could improve immunotherapeutic/therapeutic outcomes.

Objective: To investigate the profiles of brain volumetric measurements in children with attention deficit hyperactivity disorder (ADHD), and the consistency of these brain volumetric measurements derived from the synthetic and conventional T1 weighted MRI (SyMRI and cT1w MRI).Methods: Brain SyMRI and cT1w images were prospectively collected for 38 pediatric patients with ADHD and 38 healthy children (HC) with an age range of 6–14 years. The gray matter volume (GMV), white matter volume (WMV), cerebrospinal fluid (CSF), non-WM/GM/CSF (NoN), myelin, myelin fraction (MYF), brain parenchyma volume (BPV), and intracranial volume (ICV) were automatically estimated from SyMRI data, and the four matching measurements (GMV, WMV, BPV, ICV) were extracted from cT1w images. The group differences of brain volumetric measurements were performed, respectively, using analysis of covariance. Pearson correlation analysis and interclass correlation coefficient (ICC) were applied to evaluate the association between synthetic and cT1w MRI-derived measurements.Results: As for the brain volumetric measurements extracted from SyMRI, significantly decreased GMV, WMV, BPV, and increased NON volume (p < 0.05) were found in the ADHD group compared with HC; No group differences were found in ICV, CSF, myelin volume and MYF (p > 0.05). With regard to GMV, WMV, BPV, and ICV estimated from cT1w images, the group differences between ADHD and HC were consistent with the results estimated from SyMRI. And these four measurements showed noticeable correlation between the two approaches (r = 0.692, 0.643, 0.898, 0.789, respectively, p < 0.001; ICC values are 0.809, 0.782, 0.946, 0.873, respectively).Conclusion: Our study demonstrated a global brain development disability, but normal whole-brain myelination in children with ADHD. Moreover, our results demonstrated the high consistency of brain volumetric indices between synthetic and cT1w MRI in children, which indicates the high reliability of SyMRI in the child-brain volumetric analysis.

Abstract Background There are differences in the quality of care among breast cancer patients. Narrowing the quality differences could be achieved by increasing the utilization rate of indicators. Here we explored key indicators that can improve the quality of care and factors that may affect the use of these indicators. Methods A total of 3669 breast cancer patients were included in our retrospective study. We calculated patient quality-of-care composite score based on patient average method. Patients were divided into high- and low-quality groups according to the mean score. We obtained the indicators with large difference in utilization between the two groups. Multilevel logistic regression model was used to analyze the factors influencing quality of care and use of indicators. Results The mean composite score was 0.802, and the number of patients in the high- and low-quality groups were 1898 and 1771, respectively. Four indicators showed a difference in utilization between the two groups of over 40%. Histological grade, pathological stage, tumor size and insurance type were the factors affecting the quality of care. In single indicator evaluation, besides the above factors, age, patient income and number of comorbidities may also affect the use of these four indicators. Number of comorbidities may have opposite effects on the use of different indicators, as does pathological stage. Conclusions Identifying key indicators for enhancing the quality-of-care of breast cancer patients and factors that affect the indicator adherence may provide guides for enhancing the utilization rate of these indicators in clinical practice.

Cancer cells are metabolically adaptable and the identification of specific vulnerabilities is challenging. Here the authors identify a subset of neuroendocrine cell lines exquisitely sensitive to inhibition of SQLE, an enzyme in the cholesterol biosynthetic pathway, due to the toxic accumulation of pathway intermediate squalene.

Objectives This study aimed to set a data-driven achievable performance benchmark, explore the process–outcome association and speculate about the net gain in quality improvement with benchmarking.Design Observational study.Setting Patient survey conducted at 466 secondary and tertiary hospitals across 31 provinces, autonomous regions and municipalities in China.Participants 183 334 patients diagnosed with chronic heart failure (CHF) who were treated at 466 Chinese hospitals from January 2011 through May 2017.Primary independent variables Hospital process composite performance (HPCP).Secondary independent variables Patient-level and hospital-level characteristics.Primary outcome measure Patients getting better or recovered after treatment, in-hospital mortality, length of hospital stay (LOS) and medical cost.Methods HPCP was calculated using denominator-based weights. Mixed random-intercept models were used to evaluate the contributions of HPCP on patient outcomes and to speculate quality improvement after adjusting HPCP to benchmark level.Results When all hospitals were to operate at the benchmark level, the proportion of patients getting better or recovered after treatment would increase in most hospitals, particularly those with low baseline rates. However, there was no evidence for lowering in-hospital mortality, significant savings in cost or shortening LOS.Conclusions Increasing the adherence rate of CHF care and closing the gap in HPCP between hospitals have important implications for improving patient condition.

Abstract Background The optimal timing of radiotherapy (RT) with respect to surgery remains controversial for locally advanced non-small cell lung cancer (LA NSCLC) undergoing surgery and the long-term effect of neoadjuvant RT, adjuvant RT, and chemotherapy-only on survival is unknown. Methods A retrospective study with Greedy 5 → 1 Digit propensity score matching technique was performed for locally advanced NSCLC patients identified from the Surveillance, Epidemiology, and End Results (SEER) database during 2004 to 2012. Kaplan-Meier and the log-rank test were conducted to compare NSCLC-specific survival. Cox proportional hazards multivariable regression was performed to assess the impact of different treatment regimens on cancer-specific mortality after adjustment for demographic factors, histology type, tumor grade, tumor size, nodal stage, and extent of resection. Results One thousand, two hundred and seventy-eight locally advanced NSCLC patients undergoing surgery were identified after propensity matching. Cox regression analyses showed the risk of cancer-specific mortality is not significantly different among neoadjuvant RT, adjuvant RT, and chemotherapy-only. Subgroup analyses showed that for patients with T1/2 & N2/3, the surgery plus chemotherapy-only group showed markedly higher mortality risk (HR = 1.42, 95%CI:1.10–1.83) than the neoadjuvant RT group. Other risk factors include older age, higher tumor grade, larger tumor size, and greater lymph node involvement. Conclusions The findings of this study suggest that the benefit of additional neoadjuvant or adjuvant RT to chemotherapy may be linked to a proper selection of LA NSCLC patients who undergo surgery. The timing of radiotherapy should be decided on the premise of fully considering patients’ condition and the quality of life after treatment.

The capillary effect has wide applications from biology and textile engineering to nanotechnology especially the micro-electromechanical systems and microfluidics device. The capillary vibration significantly affects its mass transmission. This paper establishes a nonlinear oscillator of a deforming capillary tube. The geometric potential theory is used to estimate the capillary force. The paper reveals that the low-frequency property of capillary vibration plays an important role not only in life but also engineering applications.

Abstract Background The insurance reimbursement rate of medical cost affects the quality and quantity of health services provided in China. The nature of this relationship, however, has not been reliably described in the field of non-small cell lung cancer (NSCLC). The objective of the current study was to examine the impact of low reimbursement rates of medical costs on diagnosis, treatment and outcomes among patients with NSCLC. Methods We examined care of 2643 NSCLC patients and we divided the study cohort into a high reimbursement rate group and a low reimbursement rate group. The impact of reimbursement rates of medical costs on quality of care of NSCLC patients were examined using logistic regression and generalized linear models. Results Compared with patients insured with high reimbursement rate, patients insured through lower reimbursement rate programs were less likely to benefit from early detection and treatment services. Delayed detection was more common in low reimbursement group and they were less likely to be recommended for adjuvant chemotherapy, or to receive adjuvant chemotherapy and postoperative radiation therapy and they had lower odds to receipt chemotherapy response assessment. However, low reimbursement rate group had lower rate of in-hospital mortality and metastases. Conclusions Low reimbursement rate mainly negatively influenced the diagnosis and treatment of NSCLC. Reducing the gap in reimbursement rate between the three health insurance schemes should be a focus of equalizing access to care and improving the level of medical compliance and finally improving quality of care of NSCLC.

Abstract Background Large gap exists between clinical practice and recommended care and large room exists for the improvement of care quality for non-small cell lung cancer (NSCLC) in China. Results of some studies have shown that assessment of care quality can help to make improvement and the development of quality indicators is deemed as the initial and most essential part. Yet there is no such an indicators system specifically suitable for Chinese health care system. The goal of the study is to set up a group of Chinese quality indicators for NSCLC care and make it the first step towards the improvement of NSCLC care quality in China. Methods We constructed a new indicator framework based on the characteristics of NSCLC care and the nature of Chinese health care system. Under the new framework, potential indicators were collected and a 3-round modified Delphi process was conducted by a national multi-disciplinary Expert Panel to develop a set of indicators until they reached the final consensus. Results A new indicator framework (structure, process, communication, management of symptoms or treatment toxicity and outcome) was developed. Seventy four indicators were extracted from guidelines and relevant literatures as potential indicators; 43 indicators plus 1 suggested indicator were remained after the discussion of Round 1; questionnaires of Round 2 were rated by Expert Panel and 19 indicators met the inclusion criteria and entered Round 3; 2 of the eliminated indicators in Round 2 were retrieved by the Expert Panel at the in-person meeting (Round 3). Therefore, 21 indicators got the final consensus of the Expert Panel. Conclusions Guided by the new indicator structure, a set of indicators suitable for Chinese healthcare system was developed and can be utilized to measure and improve the care quality of non-small cell lung cancer.

Though evidence-based treatments have been recommended for breast cancer, underuse of the treatments was still observed. To certain extent, patients' access to care, which can be enhanced by increasing the coverage of health insurance, could account for the current underuse in recommended care. This study aimed to examine the association between different proportions of reimbursement and quality of recommended breast cancer care, as well as length of hospital stay. In this retrospective study, 3669 patients diagnosed with invasive breast cancer between 1 June, 2011 and 30 June, 2013 were recruited. Seven quality indicators from preoperative diagnosis procedures to adjuvant therapy and one composite indicator were selected as dependent variables. Logistic regression and generalized linear models were used to explore the association between quality of care and length of hospital stay with different reimbursement rates. Compared with UEBMI (urban employment basic medical insurance), which represented high level reimbursement rate, patients with lower rates of reimbursement were less likely to receive core biopsy, HER-2 (human epidermal growth factor receptor-2) testing, BCS (breast conserving surgery), SLNB (sentinel lymph nodes biopsy), adjuvant therapy and hormonal treatment. No significant difference in preoperative length of hospital stay was observed among the three insurance schemes, however URBMI (urban resident basic medical insurance) insured patients stayed longer for total length of hospital stay. Significant disparities in utilization of evidence-based breast cancer care among patients with different proportions of reimbursement were observed. Patients with lower rate of reimbursement were less likely to receive recommended care. Our findings could provide important support for further healthcare reform and quality improvement in breast cancer care.

To assess factors associated with bone mineral density (BMD) in postmenopausal women in a longitudinal study, and to examine the relative contribution of lean mass, fat mass, dietary patterns, and years since menopause to BMD.Two hundred and eighty-two postmenopausal women were randomly selected from Hongqi Community Health Center, in Harbin City, China. All participants were followed up from 2009 to 2011. Dietary data were collected using a Food Frequency Questionnaire. BMD of the left hip, the lumbar spine, and the total body, and the body composition were measured by dual-energy X-ray absorptiometry at baseline and follow-up.Lean mass and fat mass were positively associated with BMD of the spine, hip, and the total body at both baseline and follow-up. The association between fat mass and BMD at the spine at baseline (P = 0.210) and at the spine (P = 0.116) and hip (P = 0.073) in the second year was not statistically significant when height was adjusted. Six dietary patterns were identified but only cereal grains-fruits pattern (P = 0.001 in the spine, P = 0.037 in hip) and milk-root vegetables pattern (P = 0.010 in hip) were associated with BMD of the spine and hip. The linear mixed model of follow-up data showed that lean mass, years since menopause, and age of menophania were the significant determinants of BMD of all sites. Moreover, lean mass was the best determinant of BMD (VIP = 1.936).Lean mass, years since menopause, age of menophania and dietary patterns are the important determinants of BMD of the spine, hip, and the total body. Lean mass is the best determinant of BMD.

To assess the trend of urban-rural disparities in hospital admissions and medical expenditure between 2003 and 2011 in the context of Chinese health-care system reform.The data were from three different national surveys: the Third National Health Services Survey in 2003, the Fourth National Health Services Survey in 2008 and the national health-care reform phased assessment survey in 2011. There were 151421, 143380 and 48356 respondents aged 15 years or older in 2003, 2008 and 2011, respectively.The health insurance coverage expanded considerably from 27.7% in 2003 to 96.4% in 2011 among respondents aged 15 years or older. Hospitalization rate increased rapidly from 4.1% in 2003 to 9.6% in 2011. Urban respondents had higher hospital admissions than rural respondents, and the RR (95% CI) of hospitalization was 1.23 (1.17-1.30), 1.06 (1.02-1.10) and 1.16 (1.10-1.23) in 2003, 2008 and 2011, respectively. The urban-rural disparity in hospital admissions significantly narrowed over time. Urban respondents had a higher admission rate if insured and a lower admission if not insured than their rural counterparts. Of the six medical expenditure measures, the disparities in reimbursement rate and the proportion of hospitalization direct cost to the total consumer spending significantly narrowed.The health insurance coverage has been continually expanding and health service utilization has been substantially improved. Urban-rural disparities have been narrowed but still exist. Therefore, policy-makers should focus on increasing investment and reimbursement levels, developing a uniform standard health insurance system for urban and rural residents and improving the medical assistance system.

OBJECTIVES: The purpose of this study was to examine the change in health status of China's adult population between the years of 2003 and 2008 due to rapid economic growth and medical system improvement. METHODS: Data from the third and fourth Chinese national health services surveys covering 141,927 residents in 2003 and 136,371 residents in 2008 who were aged >18 years were analyzed. RESULTS: Chinese respondents in 2008 were more likely to report disease than in 2003. Smoking slightly decreased among men and women, and regular exercise showed much improvement. Stratified analyses revealed significant subpopulation disparities in rate ratios for 2008/2003 in the presence of chronic disease, with greater increases among women, elderly, the Han nationality, unmarried and widow, illiterate, rural, and regions east of China than other groups. CONCLUSIONS: Chinese adults in 2008 had worse health status than in 2003 in terms of presence of chronic disease. China's reform of health care will face more complex challenges in coming years from the deteriorating health status in Chinese adults.