Sunday, 1 March 2015

A violent week for attacks on medical staff in China: My weekly blog of medical news from China

by Michael Woodhead
Who would be a doctor in China? There's something about Chinese New Year that makes people a bit more bonkers than the rest of the year. Maybe it's the social pressure, the expectation - who knows. But this week has seen an unprecedented number of attacks on medical staff in China. First there was the "hostage siege" at a Henan hospital at which doctors were bailed up by patients and forced to drink urine. The incident occurred after doctors failed to save the life of a drunk man who had killed himself by drinking insecticide. The man's relatives became angry when he died and accused emergency department staff of not doing enough to save him. The staff said they did all they could but he was already beyond help when brought in. The family became enraged and summoned more people to blockade the hospital entrance. They then barricaded the doctors in their office and tried to force them to drink urine. The situation was only defused when riot police arrived.
Sometimes violence is more random. At a Jiangsu hospital a cardiologist was attacked suddenly by the son of an 82-year old woman who died. The man became angry when requesting a death certificate, grabbed the doctor's stethoscope and used it to hit the doctor on the head, causing a major wound that bled. Police are investigating.
And in another similar incident in Hubei, a young female doctor had her skull fractured (see picture) when she was attacked by relatives of a women who died of a heart attack. Witnesses say the female doctor had been trying to resuscitate the women but was unsuccessful. She had not even taken her gloves off when she was attacked by a male relative of the dead women who hit her so hard it fractured her skull around the eye.
And finally in Hangzhou a female psychiatrist was stabbed by a 16 year old patient at the city's Jingdu hospital. The doctor is in a stable condition, and there is no stated reason for the attack.
And even if the patients don't physically attack you, thy may take to the courts instead. This week there was a report of a female obstetrician who is facing a three year jail sentence for manslaughter after being prosecuted over the death of a baby during childbirth. However, colleagues of the doctor say she is being made a scapegoat and there should be no criminal case made against doctors in medical situations such as this.

In other news head lines ...

Chinese doctors don't read English medical journals
A survey of 910 doctors in from teaching hospitals found that two thirds only read medical journals in Chinese. Only 44% were aware of major English-language journals in their speciality and  17% said they had never read a single English paper or textbook in English.

Hospitals banned from buying expensive drugs for commission
In an attempt to cut down on pharmaceutical corruption and bribery, China's hospitals  have been told they must buy their drugs only from approved pharma companies and wholesalers. The move is intended to cut out the system of commissions and kickbacks that currently exists, and which encourages hospitals to buy and use more expensive drugs.

Hangzhou eliminates hepatitis B with vaccination
Health authorities in Hangzhou have achieved dramatic reductions in hepatitis B thanks to a long term vaccination campaign. In a comparison with 1990 a recent survey found that the hepatitis B incidence and mortality of Hangzhou had declined dramatically since the introduction of universal childhood vaccination against the infection.

Alarm over resistant tuberculosis
Rates of drug resistant tuberculosis are "alarmingly high" according to researchers from Beijing. A study by the China CDC of Mycobacterium tuberculosis strains from children and teens between  2005 and 2012 found that  levels of drug resistance and multi-drug resistance (MDR) rates were 55% and 22%  respectively. In children with multi-drug resistance, new cases accounted for 41.

Sunday, 22 February 2015

Gong Xi Fa Cai! Medical news in the Year of the Sheep

Chinese New Year is upon us, with businesses closing up for a long holiday and most Chinese families looking forward to a reunion. But of course people still get sick at Spring Festival and the Chinese media has been full of stories praising the heroic and dedicated doctors and nurses who forego the holiday and put duty ahead of family to stay at work.  There are stories of doctors working solo for 24 hours to keep up with all the demand during the Spring Festival. From Hubei there is the story of the man bitten by his rabid pet dog who went to the hospital and was hugely relieved to find that the infectious diseases doctor was on duty to give him a rabies injection. At Fuzhou Hospital on New Years Eve the medical and nursing staff gather together to have the "big family banquet" that they would normally have with their families at home.  And there is even a story of the doctor at a Zhejiang leper colony who was urged by his ailing patients to go home and see his family rather than spend New Year on duty at the sanatorium.

Not all doctors have been heaped with praise at Chinese New Year, however. In Guangzhou there has been an uproar among the medical community after the city authorities sent anti-corruption teams in to raid hospitals just before Spring Festival. The city disciplinary affairs committee said the inspection teams were looking for evidence of bribes and 'hongbao' (red envelopes) given by patients to doctors. The raids have so far turned up little evidence of bribery, and doctors have been indignant at being suspected of corruption. They objected to having their everyday items such as snacks being documented - and also being questioned in detail about the origin of their possessions - and even for receipts for goods. Doctors said the actions of the inspectors went beyond their powers and the actions should have been a matter for the police. One doctor said a public hospital was not a place where bribes could be openly given or solicited among colleagues - and he was also indignant that many doctors had prepared hongbao or gifts for their families which were assumed by inspectors to be bribes from patients.

Chinese New Year is also a peak risk time for influenza in China. In Guangdong it has been reported there have been 53 cases and 13 deaths from  H7N9 avian influenza. In neighbouring Hong Kong there has also been a very severe flu season caused by the regular influenza H3N2 strain which has been causing as many as 18 deaths per day in the city. There have been reports of shortages of antivirals such as Tamiflu in Hong Kong, and the flu vaccine this year has been ineffective because the H3N2 strain of flu is a new mutation that is not covered by the vaccine. Of course influenza does not stop at the border, so we can only assume that the flu toll has been equally high in mainland China.

Another major infectious disease under the microscope this week is the recent outbreak of measles  affecting more than 1200 people in Beijing. Infectious disease specialists in the capital found that most of the cases originated in wholesale clothing markets popular with  locals and international visitors - so an MMR vaccination might be a pre-requisite if you are going to the Silk Market. The analysis found that many of the cases occurred in migrant workers who (unlike Beijing residents and tourists) had low levels of measles vaccination. The researchers recommended that outreach services be set up to vaccinate migrant workers in Beijing and "the offer of measles vaccine to workers as they register to live and work in the commodity markets might be a reasonable strategy to prevent future measles outbreaks."

In other news this week - the high demand for blood products in China is driving  a thriving black market in organised gangs of donors, organised by the so-called "blood heads" who are paid thousands of RMB for supplying blood. In the field of diabetes, some Chinese endocrinologists have been blasted in the pages of the Lancet for writing a review article that recommended the use of expensive new drugs as first line treatment for diabetes. Their critics say the endocrinologists failed to mention the more effective and cheaper drugs such as metformin - and the Chinese doctors also failed to mention their financial conflicts of interest with the Big Pharma makers of the expensive new drugs.

And finally, the quality of medical education in China has been questioned in several articles published this week. The Year of the Sheep is a milestone for China's medical educators in that they are now requiring a standard 5+3 medical degree + internship program be implemented nationally. However, some commentators have said that the new system will be no better than the current haphazard postgraduate 'Masters' programs if medical graduates receive insufficient clinical experience and supervision. They also say that the internship scheme should include 'exit examinations' to ensure that trainees have actually acquired the specialist skills they have trained in. Coincidentally this week Shanghai media report that trainee doctors get little experience in anatomy because there is a national shortage of donated cadavers. Chinese culture prohibits citizens from 'donating their bodies to science' as is done in the west. This means that Chinese medical graduates get all their anatomy learning from textbooks and have very little "hands on" experience. This is worrying for students going into specialties such as surgery - as they may never have practiced techniques such as cervical spine surgery before being asked to do the real thing. Not surprising then that a special anatomy cadaver training class at Shanghai's Fudan University was heavily oversubscribed.


Sunday, 15 February 2015

Research fraud and inappropriate treatment: my blog about medical news from China for Sunday 15 February.

Last week I blogged about how so many medical journal articles in China are simply "vanity publications", written by ghostwriters to satisfy the doctor's need to achieve a quota of published articles. However, this week we see that there are also major problems with 'serious' research clinical trials carried out in China. An article in JAMA this week by Charles Seife reveals that the FDA found serious problems with the Chinese clinical trials of apixaban, a novel anticoagulant.
 At one site the FDA concluded that patient records had been altered. When they investigated further the FDA inspectors declared that data from 23 other Chinese clinical trial sites was suspect and should be excluded from their evaluation of apixaban (Eliquis). We often hear that western pharma companies are shifting their R&D from the US and Europe to China. It may be cheaper but with reports like this you have to wonder if it is worth it in the long run.

China is also trying to make a name for itself in high tech areas such as stem cell transplantation. An announcement in the Shanghai media said the city was to build the world's largest hospital for 'blood diseases'. This seems to be a reference to  hematopoietic stem cell transplant procedures for patients with blood diseases such as leukaemia. This is a highly specialised and expensive form of treatment for a small niche of patients (and often of limited benefit), so it is odd that a city that can't even meet demand in its emergency departments  is pushing ahead with a hospital for rare diseases. perhaps the explanation is that the project is being run by the China Stem Cell Group Co Ltd. This may be more about making profits than providing needed health facilities.

China's love of high tech for its own sake is  also manifest in the move by a Guangdong hospital to set up 1000 telehealth stations in pharmacies to provide online consults. The move by the Second People's Hospital of Guangdong to set up the Guangdong Online Hospital will reportedly include 200 doctors providing services via videolink. All sounds very modern, but how exactly does a doctor do a physical exam, order tests and imaging and provide 'hands on' care over a video link? It might be of limited value in follow up counselling consultations and for repeat prescriptions, but it sounds like a gimmick to me.

Online hospitals are supposed to help address the problem of overcrowded hospitals. I'm not sure how they will help the cancer patients who need a bed but can't get one. In places such as Changsha in Hunan the hospital bed shortages are so acute that patients have to make do with 'cancer hotels' instead. Patients with cancer who require treatment but who are on the waiting list pay 1100 yuan a month to stay in hotels adjacent to the cancer hospitals so they can go into outpatients for treatment. Locals say that about half the hotels near the hospital are occupied by patients, who face 1-2 month waits for a bed.

Breast cancer is an increasing concern in China, but rates are still not as high as in the west, perhaps due to dietary and lifestyle factors. Screening for breast cancer is also not part of the Chinese health system, although there has been some use of mammography. However ultrasound has been favoured by some Chinese clinicians, reportedly because it is more suitable to the smaller and more dense breast tissue of Chinese women. Now a study has confirmed that ultrasound is a more effective screening method for breast cancer in Chinese women. A study of more than 12,500 women who underwent either or both found that of the 30 cancers detected, five were in the mammography group and 11 in the ultrasound group, and 14  in the combined group. Ultrasound was more sensitive had the same specificity and positive predictive value as mammography. It was also considerably cheaper, costing $7876 to detect one cancer compared to $45253 for mammography.

In other clinical news, metabolic syndrome (a highly dangerous combination of abnormal cholesterol, high blood pressure and pre-diabetes) was found to occur in 27% of Chinese people. A study of 15,477people in NE China found that 28% of men and 26% of women had metabolic syndrome. The condition was more common in Chinese on high incomes, those who ate more rice and those who did less physical activity - in other words, 'to get rich is glorious' but it also comes at a price of this disease of affluence. 

However, Chinese people might be forgiven for thinking twice about going for a jog, given the terrible air pollution in many cities. This has now been confirmed by Dr Liu Yu of the Key Laboratory of Exercise and Health Sciences at Shanghai University of Sport. This week he published an article in the BMJ which warned that the harms of ambient air pollution on the cardiovascular and respiratory systems might outweigh the benefits of exercise. He estimated that air pollution probably caused more than a thousand deaths a year in the city.

It's not all bad news from China, though. A paper published by the WHO this week shows that Chinese healthcare workers have had great success in reducing deaths from HIV using a simple 50c antibiotic, co-trimoxazole. Their study showed that giving the antibiotic at the same time as antiretroviral reduced HIV deaths by 37% - a staggering achievement. If routinely use in China for HIV patients  this could save thousands of lives among HIV positive people, the researchers sai.d Unfortunately, however, antibiotic use if often missed in this patient group.

Sunday, 8 February 2015

My weekly medical news blog for 7th February

There have been few takers for GP training places in Nanjing. The city's community health centres need to recruit 110 family doctors to fill their positions but have only had 49 applicants. Under new health ministry regulations, all doctors including GPs must have the 5+3 education and training (5 years undergraduate and 3 years postgraduate.) However, despite offering a masters degree and a one month placement with GPs in Taiwan, most medical graduates have given the GP training scheme the cold shoulder. The reason is the low status and poor pay of 'community doctors'. After eight years training, GPs can expect to earn only about 80,000 yuan (US$13,000) a year, which is much lower than hospital-based specialists earn. Also there is no chance of promotion or career progression and GPs are expected to move around many clinics in suburbs and villages. Health educators say the Chinese government needs to put more emphasis and resources into primary care if it is to develop a healthcare gatekeeper system similar to those used successfully in developed countries.

Most of the 'research' published by China's doctors is rubbish and there's a simple reason for this - the publish-for-promotion system. To gain promotion (and often just to stay in the job) all China's doctors have to meet a certain quota of  papers published in medical journals. The problem is that most of China's doctors are way too busy treating patients to be doing research and writing up papers. Many are simply not interested. The result is a thriving industry in academic fakery and plagiarism. It is common knowledge that doctors hire 'publishing agents' and ghostwriters to source the articles that will be published under their name. Ironically, many of the articles are written by medical students, and so there is an inverted system whereby the most knowledgeable and experienced clinicians are publishing articles written by the least knowledgeable. The going rate is about 3000-4000 yuan for a good paper - payment on publication, of course. Experts say the system has become a wasteful farce, and they are calling for reform of the one-size-fits-all quote system, to divide doctors into three categories: 'craftsmen' (no research, just treating patients), physicians (some research) and medical scientists (more  research, fewer patients).

The government says it expects to see a dramatic increase in uptake of private medical insurance before 2020, with new policies encouraging Chinese citizens to take out private cover. Ma Xiaowei, deputy head of the health ministry, the National Health and Family Planning Committee, told a news conference this week that the central and provincial government would "encourage the development of various types of commercial insurance to increase people's ability to deal with risks posed by major diseases." He said private cover was needed to help fund demand for health services, with the number of people over 60 already exceeding 200 million. However Mr Ma didn't explain how people will be enticed to take out private health insurance given that there are currently virtually no private doctors or hospitals and very few services or benefits from having insurance.

Underpaid, overworked and under fire: that's the life of an emergency medicine specialist in Guizhou province, according to a Sina article this week. In China, emergency doctors accompany ambulances and are often first on the scene of trouble, even before police. One doctor said he often had to jump in and stop bleeding in stabbing victims while people were still fighting around him. Another said emergcny doctors were often faced with physical challenges such as getting critically ill patients down stairs of apartment blocks with no lifts. Emergency doctors said they worked 24 hour shifts then had a day off during which they mostly slept, and there was no time for leisure, holidays or study. The stress of daily life as an emergency doctor meant there were high rates of burnout - and doctors were considered grizzled veterans if they lasted three years, they said.

In clinical news, new research shows that older Chinese are consuming more calories - and eating more unhealthy food - than their counterparts of the previous generation. A study from nine provinces found that the average daily energy intake had increased among older Chinese adults from 1379 total kilocalories in 1991 to 1463 kilocalories in 2009. The increases had come from greater consumption of high fat and high carbohydrate foods such as plant oil, wheat buns, and wheat noodles.

Chinese are also consuming more polluted air and it is killing them as much as smoking. A study carried out by the School of Public Health in Peking University found that there were
257,000 premature deaths related to PM2.5 pollution in 31 major Chinese cities. This made air pollution a major killer equivalent to smoking. Conditions such as lung cancer and stroke triggered by air pollution killed about 18,000 people in Beijing alone in 2013, the researchers said.

And finally, a study from Shanghai as shown that the number of cervical cancer diagnoses in the city has increased six fold in the last decade. Data from 13,518 women with gynaecological cancers  from 2003 to 2013 showed that the number of women with diagnosed gynaecological cancers increased by almost sixfold with the increase largely due to the increase of women with newly diagnosed cervical cancer. The study also showed that the age of diagnosis of cervical cancer had increased.

Sunday, 1 February 2015

My weekly news blog for 1 Feb

The medical news in China has been dominated this week by the death of a doctor at a Luoyang hospital after a brawl with a drunken patient. Both fell down a lift shaft and were killed. It's just the latest in a long line of violent incidents against medical staff. Each time one occurs there are protest by staff, stern editorials in the media and vows to crack down on such incidents. There have even been gimmicks, including plans to have 'volunteers' or police patrols in hospitals to defend doctors from violence and defuse violent situations And yet still they continue. I can't understand why Chinese hospital don't have 'crash' alarms like they do in western countries, that trigger lockdowns and mutual protection protocols.

On a more positive note, Chinese drug makers have registered the world's first Sabin-inactivated poliovirus vaccine (S-IPV). The vaccine, developed by the Chinese Academy of Medical Sciences is being produced by the Institute of Medical Biology within the Kunming Hi-Tech Zone. It is said to be more effective than the current oral polio vaccine and also inexpensive.

Such a vaccine may have a role in remote parts of China such as Xinjiang, which recently reported an outbreak of polio. After more than a decade being polio free, in 2011 there were 23 polio cases reported, 55% of which were in young adults.  The polio was presumably brought in from the neighbouring Muslim state of Pakistan, where polio has not been eradicated due to the Taliban.

Another first for China this week was the first patient to be treated - and survived - a new H5N6 strain of avian influenza. The patient treated by well-known specialist Dr Zhong Nanshan at Guangzhou hospital after contracting the infection from - guess where - a live poultry market (why don't they just shut them down for good?). Dr Zhong said this was the second patient to contract the dangerous infection - the first one died. he said the second patient had been treated with high doses of antivirals and was in a stable condition. China is also struggling with a winter outbreak of H7N9 avian flu, with 30 cases so far around Guangdong.

In the healthcare reforms, some healthcare managers have said that hospital reforms should focus on the model of funding, and switch to an 'activity based funding' system to reward outcomes. At a meeting of the Beijing Chinese Peoples Consultative Committee they said that the funding system based on "diagnosis-related groups" (DRG)  would "break the link between doctors' incomes and prescriptions, thereby preventing excessive medical treatments and over-prescription of drugs." Hospital managers complained that they were underfunded because fees had been fixed at low prices set in 1999 whereas costs (and incomes) had risen considerably since then.

Well, fees may be too low according to hospital managers, but some patients still can't afford them. A woman has made news in Kunming by dressing up in a wedding gown and offering herself for marriage to any man who will pay her brother's medical fees. Her brother has leukaemia and she says he needs 300,000 yuan for treatment. China is supposed to have a public health fund for people with catastrophic illness, but it obviously hasn't trickled don to this young man.

Monday, 26 January 2015

My January news blog ...

Regrettably, I am cutting back on my blogging about China medical news this year. I've been doing this for more than a year now, out of enthusiasm and my own personal interest in the area, but it's becoming too much of a burden on my time. And of course it is all unpaid. Unless there is a sponsor out there who wishes a regular stream of China medical news? After my day job doing much the same thing about Australian medical news I find it hard to sit down at home and do the writing for this blog. So from now on I shall probably only update the site about once a week. That is not enough to cover the many things happening in healthcare in China, but that's your lot. As they say in Yorkshire, you don't get owt for nowt.

This week I have been reading about how patients in Shanghai with chronic diseases will now be able to pick up their repeat prescriptions from community clinics instead of the big hospitals. It's a move intended to relieve the overcrowding at the tertiary hospitals and sounds like an obvious and sensible idea. Whether it will work or not depends on whether China's hospital-obsessed patients can be persuaded to show up at the low-status community clinics.

There are also moves to try curb China's high levels (approaching 50%) of caesarean section intervention in pregnancy. A feature article by Yang Wanli describes how some obstetricians in China are trying to persuade women to opt for natural birth. However, the barriers are a lack of available analgesia for women in labour and the industrial production-line mentality of China's hospitals.

Rural health is a major issue in China this month, with the State Council approving a plan to boost the rural medical workforce. The Council wants to see rural areas of China have qualified doctors replace the current 'barefoot' practitioners. However, well-meaning intentions will not fix the huge rural medical workforce problem in China. The simple problem is that university qualified doctors do not want to work in rural villages. The pay is pathetic, there is no status and the workload is high. As this article shows, the current rural medical workforce is mostly unqualified and often dangerously lacking in skills.

That's not to say that rural health is completely hopeless in China. There have been great achievements in some areas of public health such as immunisation and basic child health. However, as a major article by Chinese paediatricians the Archives of Diseases in Childhood shows, the next step for China is to try reduce the incidence of more complex diseases in children. China has done well in tackling the easily preventable causes of child disease, now it must turn its attention to the difficult stuff - the consequences of preterm birth, and the many congenital and metabolic diseases.

One problem with monitoring China's progress in child health is knowing whether or not the official  figures are true. Take measles vaccination for example. According to official reports, China has 95% measles vaccine coverage of infants. But when researchers analysed the causes of measles outbreaks in Hunan and Jiangsu that affected hundreds of children they found that the actual rates of measles immunisation more like 80%.

And finally, for those who put their faith in western healthcare companies helping improve the health of China, take a cautionary look at the sorry tale of GSK. A well regarded company in the west, GSK was the subject of high profile bribery allegations and a court case that jailed one of its British executives for  his role in the bribes to doctors and hospitals. Now the company is reported to be cutting the jobs of 1000 employees in China following the downturn in its business there (including a 60% drop in revenue).

Tuesday, 13 January 2015

Lost post

I just spent an hour writing a great article about the Chinese government's moves to encourage public hospital doctors to work in private practice. But my internet browser crashed and I lost it.

Short version: there is little enthusiasm for this move by doctors because of the practical barriers: pensions, medical indemnity insurance and new contracts on working hours/remuneration. Also barriers because public hospitals don't want to lose their 'talent' and see the same doctors working in 'competition' against them (not to mention the conflict of interest this creates). And importantly for doctors, their careers are determined by the public hospital system, from which they get their experience, evaluations, academic training and status.

Conclusion: Moving to more flexible public/private working arrangements in healthcare is an immense challenge for China and won't happen overnight.

Monday, 12 January 2015

Fertility clinics drive thriving black market in eggs

Young Chinese women are risking their fertility by selling off their eggs to unscrupulous fertiliy clinics, a CCTV program has claimed.

As part of an investigation into the "human egg black market" CCTV found that high school students and university students were selling their eggs to agents for a few thousand yuan. The clinics then offer these eggs to infertile women who pay 30,000- 100,000 yuan (US$5000-$15,000).

The report said young girls were picked because of their looks, education and health and had to endure a series of injections with fertility hormones to stimulate ovulation so their eggs could be harvested by clinics. The young women said they used the cash to pay off credit card debts, but most were unaware of the serious risks of the procedures, including infertility.

Commentators said the commercial transactions of human eggs were illegal and banned, but there was little enforcement of the rules in practice. They said illegal clinics and the doctors who worked in them made large amounts of money, offering infertile women the chance to select a donor egg based on looks, intelligence and other personal characteristics of the donor. Despite being illegal, the egg black market was a thriving market and barely concealed  with advertisements by agents common on the internet.

The report said the fertility agents and their networks also offered infertile women other services such as surrogate mothers, as part of packages that could cost as much as 400,000 yuan.The trade was very lucrative and many young women saw nothing ethically wrong with what they were doing, it said.
The commentators said there was a need for a widespread crackdown to enforce the regulations on artificial reproductive technology. There was also a need to better regulate reproductive clinics and promote legitimate egg donation rather than the commercial practices, they added.

Sunday, 11 January 2015

Statin therapy has disappointing results in Chinese patients

by Michael Woodhead
Only about one in four Chinese patients taking a statin have their cholesterol levels under control, according to a new study.

A review of the effects of statin therapy in 8965 outpatients with cardiovascular disease from 200 clinical departments of 122 hospitals across China found that about 75% of patients still had poorly controlled lipid levels.

The findings, published in the International Journal of Cardiology showed that despite taking long term statin therapy in medium to high doses, about 75% of patients had an above-target LDL-cholesterol level. In a similar manner elevated levels of total cholesterol and triglycerides as well as low HDL-cholesterol persisted in 34–43% of patients despite statin therapy, according to Professor Wei Yidong and colleagues at the Department of Cardiology, Shanghai Tenth People’s Hospital and Tongji University School of Medicine.

Only about 10% of patients overall had optimal levels of all lipid measures (LDL, HDL and triglycerides) despite taking statins. Patients with diabetes had slightly better control of lipid levels (43%) compared to those without diabetes (39%).

The study authors said it was not clear why patients taking statins did not have good control of their lipid levels. Oddly, there appeared to be no relationship between the potency of the statin doses and the degree of lipid level control.

About 77% of patients taking low doses of statins had LDL-C not at goal, compared to 72% of patients taking medium potency regimens and 74% of patients taking high potency courses of statins.
Chinese patients may need more intensive lipid-lowering therapy with additional agents other than statins, to improve their lipid levels. Patients may also need more attention on lifestyle factors such as diet and exercise before starting statin therapy, they added.

However, they could not rule out poor adherence to treatment a a possible cause of the poor lipid control.

Friday, 9 January 2015

China's doctors now officially encouraged to moonlight in the private sector

China's 'health ministry', the National Health and Family Planning Commission, has told doctors in the public hospital system that they should seek additional work in  private hospitals.
Health minister Li Bin told a conference this week that the registration regulations for doctors had been changed to encourage practitioners to work outside of the public hospital system.
"Limited resources of talent will be optimized among hospitals of various types under the initiative, which helps with the sustainable and healthy development of privately funded medical institutions," she said.
Doctors will no longer 'belong' to public hospitals and will be encouraged to work for market-set fees in private hospitals.
According to the China Daily, one senior doctor said he hoped his patients would 'follow' him to the better environment of the private hospital where he intends to practice, despite him charging much higher fees there.
The health minister told a NHFPC conference this week that she was urging private health institutions to provide a range of healthcare services, both treatment and prevention, to help divert patients from public hospitals, which are usually overloaded with work.

Thursday, 8 January 2015

Inequity in access to healthcare: China has the worst record of any major country

by Michael Woodhead
Despite claiming to have health insurance coverage of more than 90%, China has some of the highest levels of inequity in access to healthcare in the world, a new study shows. 

A review of socioeconomic inequities in healthcare utilisation carried by by Dr Zhang Xin and colleagues at Harbin Medical University found that China fared very poorly compared to its neighbours such as Japan, South Korea and Thailand.

The study based on data from 2008, found huge differences in access to outpatient care based on income and even greater inequities for in-patient care. Chinese on low incomes were much less likely to be able to get hospital treatment compared to their compatriots on higher incomes, according to the findings published in the Asia-Pacific Journal of Public Health.

The researchers said their findings confirmed previous work that had shown that one in four poorer Chinese had been unable to get hospital treatment when they needed it because they could not afford it. Low income Chinese people with chronic and serious diseases were particularly badly affected by income disparities and lack of access to healthcare, they said.

They said that the New Rural Cooperative Medical Scheme introduced in 2003 had made a slight improvement to access to healthcare, but poor patients still missed out on needed treatment because of  high gap fees, limits to insurance cover eligibility and high insurance fees.

Dr Zhang said most OECD countries had a relatively little inequity for healthcare access, especially those that had good primary care systems and free-at-the-point-of-care treatment.

"Despite growth in health insurance coverage, the challenge of perusing equitable pathways toward universal health coverage is still truly daunting task in China," they concluded.

"Being poor and lacking the ability to pay additional out-of-pocket charges remains a significant barrier to access [to healthcare]."

Wednesday, 7 January 2015

Plague debrief: what really happened in the July 2014 Gansu case of pneumonic plague?

by Michael Woodhead
In July 2014 a case of pneumonic plague was widely reported in the media.

The victim was a 38-year old shepherd who caught the infection from a marmot (the usual carriers of the infection) after it was caught by his dog. At the time it was widely reported that the town of Yumen (near Jiayuguan) where he was treated, had been put into lockdown. None of the 30,000 residents were allowed to leave town and more than 150 close contacts were kept under observation in quarantine. It looks like Chinese authorities did the right thing - but only after a fatal delay in the initial diagnosis. A new report published by the local infection control team gives more details of the case.

Dr Ge Pengfei and colleagues say that the man contracted the Yersinia pestis infection from an infected marmot after it was caught by his dog on 11 July. He skinned the marmot for its pelt and fed the meat to his dogs. Two days later the shepherd started to develop respiratory symptoms and went into a nearby village to seek treatment. However, when he first went to the local clinic on 15 July he was mis-diagnosed as having a simple respiratory tract infection and given just a prescription for an antibiotic (clindamycin) and some anti-inflammatories. When his condition worsened later that day he was seen by doctors at the hospital in Yuman, who diagnosed pneumonia on x-ray and they gave him an ineffective antibiotic, cefoperazone, and more anti-inflammatory treatment.

It was only later that night when the man's condition deteriorated further and he started coughing up blood that throat swabs were taken, which showed the presence of the characteristic Yersinia bacilli when tested. Doctors then gave the man the recommended treatment of IV streptomycin, but this was too late and probably did more harm than good in the rapidly advancing conditions of the infection. Streptomycin must be used with great care in advanced plague because it cases the Y. pestis bacteria to burst (lysis) and release large amounts of the endotoxin that causes septic shock. This is what happened in the case of the Gansu shepherd, whose quickly deteriorated in the early hours of 16 July and he died at 5am.

The infection control team said they also detected Yersinia infection in the man's sister in law and in two patients who had been in close contact with him at the hospital. These people were among the 150 close contacts subject to quarantine and to preventive treatment with streptomycin. This containment strategy worked, as none of the close contacts developed full blown pneumonic plague.

The infection control team said them man may have survived if his infection has been detected earlier. However, the village clinic and hospital had only limited medical facilities, and the plague was only picked up when cultures were examined under a microscope.

They said that local clinics in areas such as Gansu where plague is present (on average there is one case per year in the region) should be alert for the early signs of the infection - and be prepared to take a careful history to see if there has been any contact with potential sources such as marmots and infected dogs. Despite the death of the patient, they said the incident had shown that quarantine and antibiotic prophylaxis procedures for contacts were effective.

"Doctors need to improve awareness and ask about contact history for the possibility of plague infection to avoid misdiagnosis," they recommended.

International Journal of Infectious Diseases.

Tuesday, 6 January 2015

Drug resistant bacteria - just how much of a problem are they in a typical Chinese hospital?

by Michael Woodhead
With broad spectrum antibiotics easily available over the counter in China  - and the Chinese cultural expectation of an antibiotic as the magic bullet for every viral fever - it's not surprising that drug resistance is a major problem in the PRC. 
But just how common is the problem for a typical provincial hospital? The rather worrying answer is quite a big problem. A study carried out in the Liaocheng People's Hospital in Shandong has found that one in three bacteria samples obtained from around the hospital were multi-drug resistant. Researchers at the hospital took almost 10,600 microbial samples from around the hospital and found that  33.4% were multi-drug resistant pathogens such as ESBLs producing E. coli and A. baumannii. The blackspots for resistant bacteria were in surgical departments and the intensive care department. Samples obtained from respiratory and secretions were the greatest source of resistant bacteria. The obvious consequences of these multi-drug resistant bacteria are treatment failure, longer hospital stays, increased mortality, and higher hospitalisation costs. As the authors conclude, their findings show the need for much greater attention to antibiotic resistance, especially from respiratory cases and surgical wounds.

Monday, 5 January 2015

Will Beijing's billion yuan "loss leader" private hospital be the model for the future?

by Michael Woodhead
Peking University's flagship new private hospital may lose almost a billion yuan but will still be counted a success if it drives other medical service usage, its backers say.

An article by He Chunmei in the financial magazine Caixin this week heralds the opening of the 1800-bed Peking University International Hospital (PUIH), which is a joint venture by Peking University and the Founder Group. The hospital in the north of the city is expected to lose as much as 800 million yuan but Founder CEO Li You says this is acceptable if the hospital generates revenue in other areas. "It's like a company's advertising department that spends money. We will earn money from other sectors. But the hospital is the foundation," he is quoted in Caixin as saying.

The new hospital is being portrayed as a flagship of China's foray into privately-invested healthcare as an alternative from the current overcrowded and underfunded public system. One of the main barriers to private hospital development in China to date has been the regulations that bar doctors from working outside the official public hospitals. The new hospital will test the recent relaxation of these rules by the government. But employment restrictions have not been the only barrier to private healthcare facilities - many clinicians have been reluctant to work outside the big hospital system for a variety of reasons - fear of stepping off the well-established career pathway, losing peer support groups and moving outside the system that is recognised by health insurance rebates. Doctors have also been unwilling to go it alone and take on the medicolegal risks of operating outside the mainstream system, especially at a time when patients are becoming increasingly distrustful of the healthcare system and prone to taking aggressive action in medical disputes.

The new Peking University International Hospital may overcome many of these reservations because it will 'share' doctors and other healthcare staff from other Peking University-affiliated hospitals, which already enjoy a good reputation for quality care. However the management of the new hospital acknowledge that the new workforce 'sharing' arrangements will require some work and 'adjustments' to coordinate different departments and different hospitals. The hospital says it will lure staff with offers of higher pay, which will be guided by the market rather than the patchy, commission-based remuneration of state-controlled public hospitals. "Head doctors usually earn several hundred of thousands of yuan every year at a public hospital," said Li You. "But if necessary, we'd like to pay more than 1 million yuan. We will fully follow the market."

The private hospital will also differ from public hospitals in being managed by a board of directors representing investors. Public hospitals are often a conglomeration of mini-empires, with directors of departments often having a lot of power and being unaccountable in terms of services, revenue and purchasing.

The Peking University Healthcare groups say they will be able to implement a more efficient system as they will have a controlling interest in the hospital, whereas public hospitals are often controlled by government agencies, business groups and hospital managers that are resistant to reform. Li says his ambition is to pioneer a new model of hospital management based on integrated databases that will create accountability and efficiency in procurement, servicing and supply. The management system will also encourage doctors in departments of larger hospitals to sponsor and support similar departments in smaller branch hospitals.

"We will grow to become China's largest hospital management company," Li told Caixin, "and control the largest medical database."