National Health Plan Research Articles

Telemedicine Implementation Challenges in Underserved Areas of the Philippines

During these difficult times of global pandemic, mobility restrictions and lockdowns were put in place to prevent an outbreak. However, patients with medical needs must deal with regular face-to-face consultations with physicians for their prescriptions and medications. It is important to review the various telemedicine research in the Philippines and abroad and how to formulate a national framework for telemedicine so the program can be implemented in the entire country. As a developing nation and an archipelago, the Philippines needs to work on massive infrastructure project for national broadband and health care facilities. The increase of medical professionals per 1000 of population and prevent them from migrations will help implement such innovation in medical field. A national policy to support the program in terms of funding and its transparency, establishment of processes and standards, and safeguarding digital information should be put in place. The country will need to address these gaps in technology and processes and encourage the population to partake in national health plans and initiatives to increase awareness and engagement of all stakeholders. Keywords— Challenges, Developing Countries, eHealth, Implementation, IoMT, Philippines, Rural, Telehealth, Telemedicine, Underserved

Health system gaps in cardiovascular disease prevention and management in Nepal

BackgroundCardiovascular diseases (CVDs) are the leading cause of deaths and disability in Nepal. Health systems can improve CVD health outcomes even in resource-limited settings by directing efforts to meet critical system gaps. This study aimed to identify Nepal’s health systems gaps to prevent and manage CVDs.MethodsWe formed a task force composed of the government and non-government representatives and assessed health system performance across six building blocks: governance, service delivery, human resources, medical products, information system, and financing in terms of equity, access, coverage, efficiency, quality, safety and sustainability. We reviewed 125 national health policies, plans, strategies, guidelines, reports and websites and conducted 52 key informant interviews. We grouped notes from desk review and transcripts’ codes into equity, access, coverage, efficiency, quality, safety and sustainability of the health system.ResultsNational health insurance covers less than 10% of the population; and more than 50% of the health spending is out of pocket. The efficiency of CVDs prevention and management programs in Nepal is affected by the shortage of human resources, weak monitoring and supervision, and inadequate engagement of stakeholders. There are policies and strategies in place to ensure quality of care, however their implementation and supervision is weak. The total budget on health has been increasing over the past five years. However, the funding on CVDs is negligible.ConclusionGovernments at the federal, provincial and local levels should prioritize CVDs care and partner with non-government organizations to improve preventive and curative CVDs services.

Convergences between the Brazilian National Health Plan and scientific articles on Neglected Tropical Diseases

In Brazil, the National Health Plan (NHP) was the central instrument for public health planning from 2016 to 2019. In this paper, we show that there is a convergence between the Plan and the publication of scientific articles written by institutional researchers in the context of Neglected Tropical Diseases. The methodology used consisted of the following stages: identification of the universe of researchers, data collection, thematic characterization of Neglected Tropical Diseases in the Plan, organization of information, and production of indicators. In total, there were 2,719 researchers and 18,023 journal articles from 2015 to 2018. Of these, 2,541 articles, or 14.09%, were related to Neglected Tropical Diseases. Regarding the convergences, there was strong alignment with leishmaniasis, Chagas disease, dengue, leprosy, schistosomiasis, and Chikungunya fever. However, the coverage of topics by scientific publications was broader than that of the political instrument due to the inclusion of other themes: snake bites, helminthiasis and lymphatic filariasis.

Comparable Outcomes Using Oral Methylprednisolone vs. Prednisone in IgA Nephropathy: A Retrospective Cohort Study

Background: To compare effectiveness and adverse reactions after oral methylprednisolone versus prednisone in patients with IgA nephropathy. Methods: A retrospective cohort study was conducted in 85 patients with IgA nephropathy. Patients were divided into three groups: 34 patients received oral methylprednisolone of 0.4 mg/kg/d (MP-QD group), 31 patients received prednisone of 0.5 mg/kg/d (PND-QD group), and 20 patients received prednisone of 0.5 mg/kg on alternate days (PND-QOD group). The levels of creatinine and proteinuria, and adverse reactions were monitored for 6 months of follow-up. Results: The excretion of urine protein at 24h was significantly decreased while serum creatinine was not significantly changed after corticosteroids treatment. 20 adverse events were observed in 16 participants (47.1%) in the MP-QD group, 8 adverse events were observed in 7 participants (22.5%) in the PDN-QD group, and 2 adverse events were observed in 2 participants (10%) in the PDN-QOD group. The risk of adverse events in PDN-QD and PDN-QOD groups was lower than that in MP-QD group with a risk difference of 40.4% (95% CI, 16.6 to 98.2%, P = 0.045) for the comparison of PDN-QD vs MP-QD, and a risk difference of 17.2% (95% CI, 4.1 to 75.1%, P = 0.019) for the comparison of PDN-QOD vs MP-QD. Conclusions: Oral methylprednisolone or prednisone therapy in patients with IgA nephropathy significantly decreased the excretion of proteinuria and no obvious change was found in the level of serum creatinine in 6-month follow-up period. However, more adverse effects were observed in the patients who received oral methylprednisolone. Funding Information: None. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and with the Methods for the Ethical Review of Biomedical Research Involving Humans issued by the National Health and Family Planning Commission of China. The study was approved by the Ethics Review Committee of Sixth Affiliated Hospital of Sun Yat-sen University (ID: 2020ZSLYEC-224). As the data were obtained retrospectively from patient charts, it is impossible to recall each patient one by one and sign the inform consents form in person and the research project does not involve personal privacy or commercial interests, informed consent was deemed unnecessary following the above guidelines.

Global and regional overview of the inclusion of paediatric surgery in the national health plans of 124 countries: an ecological study

ObjectiveThis study evaluates the priority given to surgical care for children within national health policies, strategies and plans (NHPSPs).Participants and settingWe reviewed the NHPSPs available in the WHO’s Country Planning...

Intergenerational differences and influential factors of basic public health service utilization for floating population.

The Fourth Plenary Session of the 19th Central Committee of the Communist Party of China put forward the idea of "promoting the equalization of basic public services". The utilization of basic public health services by the floating population is an important indicator to measure the equalization of basic public health services. This study aims to understand the intergenerational differences in the utilization of basic public health services between the older generation and the new generation of floating population, and to analyze the influential factors. We employed the personal questionnaire (A) of the national health and family planning dynamic monitoring survey on floating population in 2017. Pearson Chi-square test, bi-grouping logistic regression, and Poisson regression were applied to analyze the basic situation of the floating population and the intergenerational differences in the use of basic public health services between the new and old generations. The proportions of the new generation and the old generation who had established the residents' health records in the inflow area were 36.42% and 34.96%, respectively, with the significant difference (P<0.01). In the new generation, 74.07% of the floating population received at least one health education, 5.33 percentage higher than that in the old generation. The proportion of the old generation in the health education of chronic disease prevention and control was significantly higher than that of the new generation (P<0.01). The proportions of the other eight kinds of health education were significantly lower than those of the new generation (all P<0.05). Although the coverage of basic public health services for the two generations of floating population is obviously different, the utilization of basic public health services of the floating population is still at a low level both in the new generation and in the old generation. There is an urgent need to improve the utilization of public health services for the whole floating population according to the characteristics of generations.

P472 Payer addressable burden of Crohn’s disease in patients treated with ustekinumab and vedolizumab in the United States

Abstract Background Vedolizumab (VDZ) and ustekinumab (UST) are treatments for moderate-to-severe Crohn’s disease (CD). The payer addressable burden (PAB) is the total allowed cost of care of a national health plan based on an actuarial analysis of all members total cost burden, for a given disease, regardless of any other underlying conditions. We used an actuarial retrospective claims analysis of direct and indirect costs associated with payer allowed resource utilizations to understand the US payer cost burden of the biologic-treated CD population. Methods Mean annual allowed cost per member with CD in the commercial health plan population was examined from a health plan actuarial and financial perspective. Data were obtained from medical and prescription claims of commercial and Medicare health plan members from Optum’s proprietary de-identified Normative Health Information database. Administrative claims data for all commercial members with pharmacy and medical coverage were used to determine medical utilization and medication unit cost patterns for CD treatment for 2017–2019. PAB analysis includes resource utilizations and associated costs among CD patients (pts) whose last biologic agent received in a year was UST subcutaneous (SC) or VDZ intravenous (IV). Costs captured were the total paid by plan and pts for medical or pharmacy claims. ICD-10 diagnosis codes were used to identify prescriptions to be included based on CD diagnosis. Members with diagnostic codes for concomitant ulcerative colitis (UC) were included only if they had more claims for CD than UC. Allowed claims costs, the sum of all medical and pharmacy costs, were categorized as CD-specific PAB and all-cause PAB. Cost per member per month was estimated by dividing total costs by total member enrolled months. Results In this retrospective claims analysis, more members with CD were treated with VDZ IV than UST SC in 2017 and 2018. Total and CD-related costs were lower with VDZ IV than with UST SC in overall members with CD and biologic-naïve members with CD (Figure 1). Both CD-related and all-cause PAB were markedly lower for VDZ IV than UST SC (Figure 2). Conclusion PAB can help payers identify opportunities for cost-saving. For patients with CD, the payer cost burden was lower with VDZ IV than with UST SC. This analysis provides a cross-sectional view of financial burden for US payers in managing members with CD. The analysis did not include longitudinal follow-up of pts for cost difference or adjustment of confounders in biologic-treated pts. The results capture the real-world burden of all forms of clinical practice and resource utilization in treating pts with CD enrolled in a commercial national plan.

The importance of the management system of the diagnostic health professions and action strategies

The Italian national health system, in addition to being a world-class excellence, over the years has become increasingly competitive and dynamic, pushing those who coordinate and manage to have to work alongside staff figures and the most suitable tools to face the most pressing needs and contingencies strategic and operational. For this reason, the National Health Plan (PSN), the Regional Health Plan (PSR) and the National Prevention Plan (PNP) have been identified as the main planning tools, which are the basis of health planning at all levels, from that National to regional and local. The figure of the Head of the Health Professions and, specifically, that of the technical-diagnostic area, in the context of complex health systems such as Healthcare Companies and Hospitals, is indispensable within the strategic staff and as a necessary figure for the implementation of the programming and coordination of activities. Moreover, it is essential to deal with the fundamental issues regarding processes and work cycles by building, on these bases, the concept and importance of the choice of the management system according to advanced skills and thanks to the possession of a strong managerial culture.

The importance of the management system of the diagnostic health professions and action strategies

The Italian national health system, in addition to being a world-class excellence, over the years has become increasingly competitive and dynamic, pushing those who coordinate and manage to have to work alongside staff figures and the most suitable tools to face the most pressing needs and contingencies strategic and operational. For this reason, the National Health Plan (PSN), the Regional Health Plan (PSR) and the National Prevention Plan (PNP) have been identified as the main planning tools, which are the basis of health planning at all levels, from that National to regional and local. The figure of the Head of the Health Professions and, specifically, that of the technical-diagnostic area, in the context of complex health systems such as Healthcare Companies and Hospitals, is indispensable within the strategic staff and as a necessary figure for the implementation of the programming and coordination of activities. Moreover, it is essential to deal with the fundamental issues regarding processes and work cycles by building, on these bases, the concept and importance of the choice of the management system according to advanced skills and thanks to the possession of a strong managerial culture.

Using Weibo and WeChat social media channels to assess public awareness and practices related to antimicrobial resistance, China, 2019

BackgroundAntimicrobial resistance (AMR) is a global healthcare problem, including in China where high rates of resistance to common bacterial infections have been documented. In 2016, the National Health and Family Planning Commission (NHFPC) in China established a comprehensive strategic plan to increase awareness about AMR through education programs.MethodsWe conducted an online survey to assess changes in public knowledge, awareness and practices related to AMR in China since 2016. The survey was administered using China’s national and provincial level 12320 Health Hotline Weibo (micro-blog site) and WeChat (text messaging service) social media accounts from April 12, 2019 to May 7, 2019. All persons ≥16 years of age able to read Chinese were eligible to participate.ResultsA total of 2773 respondents completed the survey. Of the 2633 respondents indicating recent use of antibiotics, 84% (2223) reported obtaining their course of antibiotics from a hospital or pharmacy, 9% (246) of respondents reported using antibiotics saved from a previous prescription or treatment course, and 42% (1115) of respondents reported that they had stopped taking antibiotics as soon as they started feeling better. Most respondents correctly indicated that antibiotics can effectively treat urinary tract infections (86% [2388]) and skin infections (76% [2119]), but many incorrectly indicated that antibiotics can also treat viral infections such as measles (32% [889]) or a cold or flu (26% [726]). Of all respondents, 95% (2634) had heard of ‘antibiotic resistance’. Almost half (47% [1315]) reported using antibiotics within the last 6 months.ConclusionWhile awareness of AMR was high in this survey of social media users in China, inappropriate antibiotic use remains common, including the believe that antibiotics can effectively treat viral infections. Multiple interventions targeting the correct use of antibiotics and information on the cause AMR are likely needed. The 12320 Health Hotline provides a platform for conducting routine surveys to monitor antibiotic use and knowledge about AMR.

The National Health Plan 2030: Its Purpose and Directions of Development.

The National Health Plan 2030 (HP2030) started to be prepared in 2017 and was completed and announced in December 2020. This study presents an overview of how it was established, the major changes in policies, its purpose, and future directions. This study analyzed the steps taken in the past 4 years to establish HP2030 and reviewed major issues at the international and governmental levels based on an evaluation of HP2020 and its content. HP2030 establishes 6 divisions and 28 topic areas, and it will continue to expand investments in health with a total budget of 2.5 trillion Korean won. It also established goals to enhance health equity for the first time, with the goal of calculating healthy life expectancy in a way that reflects the circumstances of Korea and reducing the gap in income and healthy life expectancy between regions. The establishment of HP2030 is significant in that it constitutes a sustainable long-term plan with sufficient preparation, contains policy measures that everyone participates in and makes together, and works towards improvements in universal health standards and health equity. With the announcement of HP2030, which includes goals and directions of the national health policy for the next 10 years, it will be necessary to further strengthen collaboration with relevant ministries, local governments, and agencies in various fields to concretize support for prevention-centered health management as a national task and to develop a health-friendly environment that considers health in all policy areas.

Planning for health equity in the Americas: an analysis of national health plans.

ABSTRACTThere is growing recognition that health and well-being improvements have not been shared across populations in the Americas. This article analyzes 32 national health sector policies, strategies, and plans across 10 different areas of health equity to understand, from one perspective, how equity is being addressed in the region. It finds significant variation in the substance and structure of how the health plans handle the issue. Nearly all countries explicitly include health equity as a clear goal, and most address the social determinants of health. Participatory processes documented in the development of these plans range from none to extensive and robust. Substantive equity-focused policies, such as those to improve physical accessibility of health care and increase affordable access to medicines, are included in many plans, though no country includes all aspects examined. Countries identify marginalized populations in their plans, though only a quarter specifically identify Afro-descendants and more than half do not address Indigenous people, including countries with large Indigenous populations. Four include attention to migrants. Despite health equity goals and data on baseline inequities, fewer than half of countries include time-bound targets on reducing absolute or relative health inequalities. Clear accountability mechanisms such as education, reporting, or rights-enforcement mechanisms in plans are rare. The nearly unanimous commitment across countries of the Americas to equity in health provides an important opportunity. Learning from the most robust equity-focused plans could provide a road map for efforts to translate broad goals into time-bound targets and eventually to increasing equity.

How is surgery included in the Strategic Health Plans of the Pacific, Papua New Guinea and Timor-Leste?

Papua New Guinea, Pacific Island nations, and Timor-Leste represent a range of island nations with populations ranging from a few thousand to 8 million. They perform on average about 25% of the Lancet Commission of Global Surgery's target 5000 per 100 000 population and their health workforce have significant deficits of trained surgeons and anaesthetists. This study was conducted to determine how the current national health plans of these nations have included surgery and anaesthesia. The most recent (as of December 2018) published national health plans of 10 Pacific Island nations (Cook Islands, Fiji, Nauru, Federated States of Micronesia, Kiribati, Samoa, Solomon Islands, Tonga, Tuvalu and Vanuatu), Papua New Guinea and Timor-Leste were reviewed for content and process, searching for key words and identifying themes related to surgery and anaesthesia. There were 12 national health plans with a combined total of 478 pages. There was limited surgical and/or anaesthesia input within the planning process. Injuries, blindness, cancer and non-communicable diseases were included themes, but the potential role of surgical care in addressing these conditions was not well documented. The need for better information and registries was noted by several nations but possible surgical care delivery or outcome metrics were not included. There is limited mention of surgical and anaesthesia care planning within current health plans in the Pacific, PNG and TL. There is a need for greater surgical and anaesthesia engagement in future plans with performance measured against World Health Organization core surgical indicators.

Treatment patterns for patients with advanced/metastatic cancers by site of care.

To compare treatments, overall survival (OS), and total costs among patients receiving anticancer therapy in hospital outpatient vs physician office settings. This retrospective observational study utilized claims data from a large national health plan to identify patients with advanced/metastatic non-small cell lung cancer (aNSCLC), metastatic colorectal cancer (mCRC), or metastatic breast cancer (mBC) treated in hospital outpatient or physician office settings. Patients enrolled in Medicare Advantage Prescription Drug or commercial plans for at least 180 days prior to and at least 30 days after start of first-line (1L) therapy were included. Treatments by lines of therapy, OS, and total costs were evaluated by site of care. Eligible patients included 4618 with aNSCLC, 2304 with mCRC, and 1411 with mBC. There were no major differences in 1L, second-line, or third-line therapy by site of care. Patients with aNSCLC in physician office had longer 1L duration (hospital outpatient, 96 days vs physician office, 102 days; P < .01), but there were no differences in duration of therapy by site of care for mBC or mCRC. Costs were higher in the hospital outpatient setting for mCRC and mBC, but there were no differences in OS for any of the cancers. Although patients received similar care in hospital outpatient and physician office settings, the differences in duration of treatment and costs warrant further evaluation.

Mental Health in Australia and the Challenge of Community Mental Health Reform.

Australia was one of the first countries to develop and implement a national mental health plan, 30 years ago. This national approach belied the countrys federal structure, in which the federal government takes responsibility for primary care while state and territory governments manage acute and hospital mental health care. This arrangement has led to significant variations across jurisdictions. It has also left secondary care, often provided in the community, outside of this governance arrangement. This article explores this dilemma and its implications for community mental health, and suggests key steps towards more effective reform of this vital element of mental health care.

Análise crítica do modelo de atenção à saúde das pessoas privadas de liberdade no Brasil

Objetivo: a universalidade e a integralidade do direito à saúde devem ser garantidas no contexto prisional como princípios constitucionais. A pesquisa teve como objeto o conjunto de leis e portarias construídas sobre o tema por mais de trinta anos, a fim de analisar criticamente o modelo de atenção à saúde das pessoas privadas de liberdade no sistema prisional, a partir do levantamento normativo, sua cronologia e hierarquia. Metodologia: o estudo qualitativo documental utilizou as bases de dados da Presidência da República, Câmara dos Deputados, Senado Federal e Biblioteca Virtual em Saúde do Ministério da Saúde, para identificar normas vigentes que envolvem as questões do sistema de saúde no âmbito penal e de atenção aos presos propriamente dita. Resultados: foram analisadas 11 normas federais, de acordo com seus fundamentos e definição de parâmetros de implementação pelos órgãos de segurança e de saúde. Destacam-se o Plano Nacional de Saúde no Sistema Penitenciário e a Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP). Conclusão: são urgentes medidas efetivas intersetoriais dispostas a modificar o quadro de violência institucional e iniquidades nas unidades prisionais, em um processo de corresponsabilização, por meio da Rede Atenção à Saúde, segundo os parâmetros do Sistema Único de Saúde (SUS).

Quels outils thérapeutiques en faveur du rétablissement dans la schizophrénie ?

Recovery is a multidimensional construct that encompasses both subjective (e.g. well-being, satisfaction with life, self-esteem) and objective outcomes (e.g. independent living, interpersonal and intimate relationships, work). Recovery can be defined either from a clinical perspective (i.e. clinical and functional remission) or from a consumer-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. Recovery-oriented practices imply to create pro-recovery environment seeking to enhance hope, control, strengths, goal striving and self-management. Their implementation in mental health services has shown effectiveness in improving personal recovery. Psychiatric rehabilitation brings together a wide range of recovery-oriented interventions. A comprehensive clinical, functional and cognitive assessment is performed to establish the individual's strengths and weaknesses, autonomy, and occupational level. Therapeutic tools are selected based on the participant's personal life goals as part of an individualized psychiatric rehabilitation action plan. The action plan can include strengths-based case management, psychoeducation, improvements in physical and mental health, peer-support interventions, joint crisis plans, cognitive remediation (CR), cognitive behavior therapy (CBT), social skills training (SST), self-stigma reduction, making empowered decisions about disclosure, family support, recovery-oriented interventions from preconception to post-partum care and supported housing and supported employment. Psychiatric rehabilitation interventions improve patient's outcomes after one year of follow-up (i.e. symptom reduction, improvements in insight, treatment adherence and cognitive and psychosocial function). The access to psychiatric rehabilitation interventions remains however limited (1/3 of the participants with SSD included in the FondaMental Advanced Centers of Expertise for SSD) and should be further developed. Supported housing and supported employment improve the access to stable housing and sustained competitive employment. They have been associated to improved patient's outcomes and have shown to be cost-effective. Recovery-oriented interventions from preconception to post-partum care (reproductive health counseling, strength-based case management by a trained midwife, shared action plan, self-stigma reduction, cognitive remediation, gender-sensitive CBT and SST) could reduce the risk of psychiatric, obstetrical and neonatal complications. They could reduce the risks of parent-infant separation and custody loss and could prevent the development of psychosis in family high-risk children. These interventions should be further developed and evaluated. Recovery-oriented practices and psychiatric rehabilitation support recovery in people with SSD. The access to a comprehensive standardized evaluation and to a personalized recovery-oriented care including psychosocial treatment remains limited. Their implementation in mental health services figures among the priorities under the French decree on the territory national mental health plan for recovery-focused care.

Equity as a consideration in National Cancer Control Plans from the American continent: a comparative content analysis

BackgroundSocial determinants of health contribute to disparities in cancer outcomes. At the same time, national cancer control plans (NCCP) are increasingly recognised as an important tool to address cancer burden, organise programmes, and promote equitable care. In this study, we aim to evaluate how cancer-related health plans in American countries promoted equity in cancer care. MethodsWe conducted a comparative content analysis of cancer-related health plans from countries within the American continent. We identified plans for inclusion by systematically screening the St. Jude Global CoreBank, the WHO Non-Communicable Disease (NCD) Document Repository, the International Cancer Control Partnership Portal, and doing online searches. Each plan was coded in accordance with 33 pre-defined indicators across three categories: coherence, or how plans align with priorities set and existing cancer control strategies; equity—which social determinants of health are prioritised and whether the plan prescribes public interventions that promote equity; and governance, measuring transparency, accountability, participation, and integrity. FindingsWe included 46 cancer-related health plans from 34 countries in North, Central, and South America in analysis (26 were written in Spanish, 18 in English, one in French, and one in Portuguese). Twenty-four countries (71%) included cancer control in their NCD strategy, of which 12 (35%) also had a NCCP. Five countries had only an NCCP, and the other five had national health plans with some cancer components. Eight countries (23%) included a situational analysis to support the plan's interventions. Countries were more consistent across governance indicators and less consistent in creating targeted equity interventions. Equity was most often framed as an access problem, and although 25 countries (73%) designed equitable interventions, 17 of them (50%) declared the intended outcomes without defining their measures, and no country dedicated a budget for these interventions. The most prioritised social determinants of health were socioeconomic status (25 countries, 73%), place of residence (22, 64%), race/ethnicity (21, 62%), and gender/sex (21, 62%). Most countries defined their monitoring plan and evaluation variables (33, 97%) as well as the responsible party for supervision (29, 85%). While the authorship process included participants from different backgrounds, 24 countries (71%) recruited stakeholders from the government to the implementation process, signalling a commitment to a Health in All Policies (HiAP) approach to cancer care. InterpretationAmerican NCCPs do not integrate equity sufficiently. When included, equity focused on care access, but did not translate into actionable measures. Lack of budget and proper implementation monitoring may limit plan effectiveness. Future NCCPs should define measurable equity objectives across the cancer continuum, strengthen the HiAP approach, and allocate a budget to all interventions. FundingNone.

The Characteristics of Iodine Nutrition Status in China after 20 Years of USI: An Epidemiology Study Covering 31 Provinces

Background: The mandatory universal salt iodization (USI) program has been implemented in China for about twenty years to correct iodine deficiency. At present, the actual iodine nutrition status of Chinese residents and whether they are adversely affected by iodine excess are issues of general concerns. Method: A nationally representative cross-sectional study was conducted. 78,470 participants, aged 18 or older, were enrolled from all 31 provincial regions of mainland China. The participants were interviewed and given a questionnaire. Urine iodine concentration (UIC) were measured by ICP-MS (inductively coupled plasma mass spectrometry) method. The goiter was examined by thyroid ultrasonography. The iodine category was based on the criteria of WHO. Results: The iodized salt coverage is 95·37% in the general population. The median urine iodine (MUI) was 177·89μg/L (interquartile range, 117·89-263·90μg/L) in the general population with goiter prevalence 1·17% (95%CI, 0·95-1·43%). The MUI was 199·7(interquartile range, 128·46-303·02) in school age children with prevalence of goiter 3·50% (95% CI, 2·93% to 4·13%). The percentage of moderate iodine deficiency (UIC<50μg/L) was 3·43%. The subjects with adequate iodine and more than adequate iodine in total accounting for 63·44% of the whole population. The data also manifested that gender, age, ethnic, geographic factors, BMI, smoking habits, education and income levels have a certain degree of influence on the iodine nutrition level. Conclusion: The mandatory USI program in China has successfully eliminated iodine deficiency disorders for 20 years. Our epidemiological investigation suggested that the iodine nutrition level of Chinese residents is generally within the safe range. Funding Statement: This work is supported by the Research Fund for Public Welfare from National Health and Family Planning Commission of China (Grant No. 201402005). Declaration of Interests: There is no conflict in interest. Ethics Approval Statement: The research protocols were approved by the Medical Ethics Committee of China Medical University.

The Secular Trends of the Maternal Near Miss Ratio in China, 2012-2018

Background: Maternal near miss (MNM) is one of the most vital health indicators reflecting the quality of obstetric care. The aim of this study was to explore the causes and change patterns in the maternal near miss ratio (MNMR) during the era of the two-child policy in Jiangsu Province, China. Methods: A retrospective cross-sectional study of 247,261 women who were pregnant in 11 hospitals in Jiangsu Province between January 2012 and December 2018 was conducted. The study period was divided into 3 stages: baseline, from January 2012 to June 2014; stage 1, from July 2014 (time of selective two-child policy begins to take effect) to June 2016; and stage 2, from July 2016 (time of universal two-child policy begins to take effect) to December 2018. Findings: Over seven years, a total of 883 mothers were identified as maternal near miss (MNM), yielding an overall MNMR of 3·70/1000 live births (LBs) (95% CI, 3·52-4·01). The MNMR slightly fluctuated around a mean of 2·75/1000 LBs at baseline and stage 1, and leveled at an additional 2·67/1000 LBs (95% CI 1·08-4·25, P = 0·001) at stage 2. We further investigated what conventional factors were the main determinants of the increase in the MNMR. Multivariate logistic regression analysis was used to identify the MNM-related risk factors: advanced maternal age (OR=1·55 and 1·82 for aged 30~35 and aged ≥35), multipara (OR=1·24), cesarean section (OR=3·22), abortion (OR=4·42), no antenatal visits (OR=1·99) and multiple births (OR=7·05). Among the identified MNM-related risk factors, the monthly percentage of multiparity pregnancy, advanced maternal age (≥35) and multiple births accumulated over time were positively related to the increasing monthly MNMR (r=0·54, 0·61, 0·31, respectively). We further evaluated that the accumulation of multiparas and mothers with advanced maternal age accounted for 71·75% of the increase in the MNMR. We then revealed that haemorrhagic disorder was the leading cause of MNM (n = 613, 69·42%). The heamorrhage-caused MNMR increased over seven years (Ptrend < 0·001), and the accumulation of multiparas and mothers with advanced maternal age were also main determinants of the increase (75·62%). Interpretation: Overall, the MNMR considerably increased from 2012 to 2018, which was largely driven by the increase of multiparas and advanced age. More attention needs to be paid to the health of mothers with advanced age and multiple pregnancies, including improving the referral system for pregnant women and raising the quality and standard of obstetric care. Funding Statement: This work was supported by grants from the National Key Research and Development Program of China, the Natural Science Foundation of Jiangsu Province, the State Key Program of National Natural Science of China, the National Health and Family Planning Commission of the People’s Republic of China, the National Natural Science Foundation of China, the China Medical Board, WHO, UNICEF, and China Postdoctoral Science Foundation. Declaration of Interests: The authors have declared that no competing interests exist. Ethics Approval Statement: The study was approved by the ethics committee of the West China Second University Hospital (protocol ID, 2012008). Informed consent was obtained for each participant.