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      Achieving best outcomes of patients with cardiovascular diseases in China by enhancing the quality of medical care and establishing a learning health care system

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      , MD, PhD, , MD, SM, , MD, PhD, , MD, PhD, , MD, PhD
      Lancet (London, England)

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          Summary

          China faces the immediate need of addressing the rapidly growing population with cardiovascular disease (CVD) events and the increasing numbers who are living with CVD. Despite progress in increasing access to services, China faces the dual challenge of addressing gaps in quality of care and producing more evidence to support clinical practice. In this article, we address opportunities to strengthen performance measurement, programs to improve quality of care and national capacity to produce high impact knowledge for clinical practice. Moreover, we propose recommendations, with implications for other conditions, for how China can immediately leverage its Hospital Quality Monitoring System and other existing national platforms to evaluate and improve performance, as well as generate new knowledge to inform clinical decisions and national policies.

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          Most cited references86

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          ST-segment elevation myocardial infarction in China from 2001 to 2011 (the China PEACE-Retrospective Acute Myocardial Infarction Study): a retrospective analysis of hospital data.

          Despite the importance of ST-segment elevation myocardial infarction (STEMI) in China, no nationally representative studies have characterised the clinical profiles, management, and outcomes of this cardiac event during the past decade. We aimed to assess trends in characteristics, treatment, and outcomes for patients with STEMI in China between 2001 and 2011.
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            HPS2-THRIVE randomized placebo-controlled trial in 25 673 high-risk patients of ER niacin/laropiprant: trial design, pre-specified muscle and liver outcomes, and reasons for stopping study treatment

            Aims Niacin has potentially favourable effects on lipids, but its effect on cardiovascular outcomes is uncertain. HPS2-THRIVE is a large randomized trial assessing the effects of extended release (ER) niacin in patients at high risk of vascular events. Methods and results Prior to randomization, 42 424 patients with occlusive arterial disease were given simvastatin 40 mg plus, if required, ezetimibe 10 mg daily to standardize their low-density lipoprotein (LDL)-lowering therapy. The ability to remain compliant with ER niacin 2 g plus laropiprant 40 mg daily (ERN/LRPT) for ∼1 month was then assessed in 38 369 patients and about one-third were excluded (mainly due to niacin side effects). A total of 25 673 patients were randomized between ERN/LRPT daily vs. placebo and were followed for a median of 3.9 years. By the end of the study, 25% of participants allocated ERN/LRPT vs. 17% allocated placebo had stopped their study treatment. The most common medical reasons for stopping ERN/LRPT were related to skin, gastrointestinal, diabetes, and musculoskeletal side effects. When added to statin-based LDL-lowering therapy, allocation to ERN/LRPT increased the risk of definite myopathy [75 (0.16%/year) vs. 17 (0.04%/year): risk ratio 4.4; 95% CI 2.6–7.5; P 3× upper limit of normal, in the absence of muscle damage, was seen in 48 (0.10%/year) ERN/LRPT vs. 30 (0.06%/year) placebo allocated participants. Conclusion The risk of myopathy was increased by adding ERN/LRPT to simvastatin 40 mg daily (with or without ezetimibe), particularly in Chinese patients whose myopathy rates on simvastatin were higher. Despite the side effects of ERN/LRPT, among individuals who were able to tolerate it for ∼1 month, three-quarters continued to take it for ∼4 years.
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              Harnessing the privatisation of China's fragmented health-care delivery

              Summary Although China's 2009 health-care reform has made impressive progress in expansion of insurance coverage, much work remains to improve its wasteful health-care delivery. Particularly, the Chinese health-care system faces substantial challenges in its transformation from a profit-driven public hospital-centred system to an integrated primary care-based delivery system that is cost effective and of better quality to respond to the changing population needs. An additional challenge is the government's latest strategy to promote private investment for hospitals. In this Review, we discuss how China's health-care system would perform if hospital privatisation combined with hospital-centred fragmented delivery were to prevail—population health outcomes would suffer; health-care expenditures would escalate, with patients bearing increasing costs; and a two-tiered system would emerge in which access and quality of care are decided by ability to pay. We then propose an alternative pathway that includes the reform of public hospitals to pursue the public interest and be more accountable, with public hospitals as the benchmarks against which private hospitals would have to compete, with performance-based purchasing, and with population-based capitation payment to catalyse coordinated care. Any decision to further expand the for-profit private hospital market should not be made without objective assessment of its effect on China's health-policy goals.
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                Author and article information

                Journal
                2985213R
                5470
                Lancet
                Lancet
                Lancet (London, England)
                0140-6736
                1474-547X
                8 May 2016
                10 October 2015
                23 February 2017
                : 386
                : 10002
                : 1493-1505
                Affiliations
                National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease (LJ, XL, JL, SH), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine; Department of Health Policy and Management, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital (HMK), New Haven, Connecticut, United States
                Author notes
                Correspondence: Professor Shengshou Hu, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, 167 Beilishi Road, Beijing 100037, People's Republic of China; Tel: +86 10 8839 8359; Fax: +86 10 6833 2500; shengshouhu@ 123456yahoo.com
                [*]

                Co-first author

                [#]

                Full professor

                Article
                NIHMS730008
                10.1016/S0140-6736(15)00343-8
                5323019
                26466053
                9eb8956f-8a18-4304-9b56-7be01714ce82

                This manuscript version is made available under the CC BY-NC-ND 4.0 license.

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