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Gong X.,Shanghai JiaoTong University | Xu Q.,Shanghai JiaoTong University | Xu Z.,Shanghai JiaoTong University | Xiong P.,Shanghai JiaoTong University | And 2 more authors.
Breast Cancer Research and Treatment | Year: 2011

The prognostic significance of ultrasound realtime elastography (RTE) in patients with breast lesions is controversial. There are two different diagnostic methods: the elasticity score (ES) and the strain ratio (SR). A metaanalysis was performed using a random-effect model to assess the overall sensitivity and specificity of RTE in the differentiation of breast lesions. MEDLINE, EMBASE, PubMed, and the Cochrane Library before February 2011 were searched. A total of 22 studies, which included 4,713 breast nodules in 4,266 patients were analyzed. The overall mean sensitivity and specificity for the diagnosis of malignant breast lesions by RTE were 0.834 [95% confidence interval (CI) 0.814-0.853] and 0.842 (95% CI, 0.829-0.854) for ES, and 0.883 (95% CI, 0.844-0.916) and 0.814 (95% CI, 0.786-0.839) for SR, respectively. RTE has a high sensitivity and specificity in the evaluation of breast lesions and can potentially reduce unnecessary breast biopsies. © Springer Science+Business Media, LLC. 2011.


PubMed | Shanghai JiaoTong University, Emory University and Pudong Institute for Health Development
Type: Journal Article | Journal: PloS one | Year: 2015

Smoking among youths is a worldwide problem, particularly in China. Many endogenous and environmental factors influence smokers intentions to smoke; therefore, a comprehensive model is needed to understand the significance and relationship of predictors. This study aimed to develop a prediction model based on problem-behavior theory (PBT) to interpret intentions to smoke among Chinese youths.We conducted a cross-sectional study of 26,675 adolescents from junior, senior, and vocational high schools in Shanghai, China. Data on smoking status, smoking knowledge, attitude toward smoking, parents and peers smoking, and media exposure to smoking were collected from students. A structural equation model was used to assess the developed prediction model.The experimental smoking rate and current smoking rate among the students were 11.0% and 3%, respectively. Our constructed model showed an acceptable fit to the data (comparative fit index = 0.987, root-mean-square error of approximation = 0.034). Intention to smoke was predicted by perceived environment ( = 0.455, P < 0.001) system consisting of peer smoking ( = 0.599, P < 0.001), parent smoking ( = 0.152, P < 0.001), and media exposure to smoking ( = 0.226, P < 0.001), and behavior system ( = 0.487, P < 0.001) consisting of tobacco experimentation ( = 0.663, P < 0.001) and current smoking ( = 0.755, P < 0.001). Smoking intention was irrelevant for personality system in students ( = -0.113, P>0.05) which consisted of acceptance of tobacco use ( = 0.668, P < 0.001) and academic performance ( = 0.171, P < 0.001).The PBT-based model we developed provides a good understanding of the predictors of intentions to smoke and it suggests future interventions among youths should focus on components in perceived environment and behavior systems, and take into account the moderating effects of personality system.


PubMed | Fudan University, Pudong New Area Health and Family Planning Commission, Pudong New Area New Rural Cooperative Medical Scheme Management Office and Pudong Institute for Health Development
Type: | Journal: Lancet (London, England) | Year: 2016

The New Rural Cooperative Medical Scheme (NRCMS) covers 900 million farmers (about 95%) in China, but its fund is at serious risk of deficit. Shanghai, one of the developed cities in China, has developed its Rural Cooperative Medical Scheme and NRCMS as an advanced and exemplary representative of Chinese rural health insurance. The participating rate of NRCMS was 9990% in Pudong New Area in 2015, which meant 277310 farmers were involved, accounting for 29% of Shanghais participants. Pudong New Area of Shanghai implemented NRCMS capitation reform in August, 2012, aimed at controlling the increasing medical costs for farmers and avoid risk to the NRCMSs fund. We aimed to assess long-term effect of the reform.We performed a retrospective time series analysis of the NRCMS fund by examining data acquired from Jan 1, 2011, until Dec 31, 2015 (60 months), in Pudong. The analysis was based on time series data modelling before Aug 1, 2012, and we compared forecast data produced with Winters additive models and with simple seasonal models with observed data for the 40 months after capitation reform. Outcome measurements included numbers and costs of insured outpatients and inpatients.The mean forecasted outpatient cost per visit (10200, mean absolute percentage error [MAPE] 29%) and inpatient cost (1283663, 19%) by Winters additive models were both higher than observed values (outpatient cost 9037, p<00001; inpatient: 11 17695, p<0001). However, visit forecasts based on simple seasonal models did not differ from observed monthly visits (predicted outpatient visits 511550 vs actual visits 486976, p=0121; predicted inpatient visits 2173 vs actual visits 2147, p=074). NRCMS fund surplus rate was 884% in 2015, which was 693 percentage points higher than it was in 2011.Capitation reform led to declines in per outpatient and inpatient costs, while the medical need remained unchanged. Furthermore, the increased surplus rate ensured the funds security.National Nature Science Foundation of China (#71503170; for data interpretation), Shanghai Municipal Commission of Health and Family Planning (#201440036, #2016HP009; for data collection and analysis).


PubMed | Fudan University, University of Alberta, Pudong New Area Health and Family Planning Commission, Pudong New Area New Rural Cooperative Medical Scheme Management Office and Pudong Institute for Health Development
Type: Journal Article | Journal: The International journal of health planning and management | Year: 2016

The Rural Cooperative Medical Scheme (RCMS) had played an important role in guaranteeing the acquisition of basic medical healthcare of Chinas rural populations, being an innovative model of the medical insurance system for so many years here in China. Following the boom and bust of RCMS, the central government rebuilt the New Rural Cooperative Medical Scheme (NRCMS) in 2003 across the whole country. Shanghai, one of the developed cities in China, has developed its RCMS and NRCMS as an advanced and exemplary representative of Chinese rural health insurance. But in the past 10years, its NRCMS has encountered such challenges as a spiral of medical expenditures and a decrease of insurance participants. Previous investigations showed that the capitation and general practitioner (GP) system had great effect on medical cost containment. Thus, the capitation reform combined with GP system reform of NRCMS, based on a system design, was implemented in Pudong New Area of Shanghai as of 1 August 2012. The aim of the current investigation was to present how the reform was designed and implemented, evaluating its effect by analyzing the data acquired from 12months before and after the reform. This was an empirical study; we made a conceptual design of the reform to be implemented in Pudong New Area. Most data were derived from the institution-based surveys and supplemented by a questionnaire survey, qualitative interviews and policy document analysis. We found that most respondents held an optimistic attitude towards the reform. We employed a structure-process-outcome evaluation index system to evaluate the effect of the reform, finding that the growth rate of the insured populations total medical costs and NRCMS funds slowed down significantly after the reform; that the total medical expenditure of the insured rural population decreased by 3.60%; and that the total expenditure of NRCMS decreased by 3.99%. The capitation was found to help the medical staff build active cost control consciousness. Approximately 2.3% of the outpatients flowed to the primary hospitals from the secondary hospitals; and farmers annual medical burden was relieved to a certain degree. Meanwhile, it did not affect farmers utilization and benefits of healthcare. However, further reform still faces new challenges: The capitation reform should be well combined with the primary healthcare system to realize the dual gatekeeper of GPs; a variety of payment methods should be mixed on the basis of capitation to avoid possible mistakes by one single approach; and the supervision of medical institutions should be strengthened. A long-term follow-up study need to be carried out to evaluate the effects of the capitation reform so as to improve the design of the program. Copyright 2015 John Wiley & Sons, Ltd.


PubMed | Fudan University, Pudong Service Center for Health Human Resources, Pudong New Area Health and Family Planning Commission and Pudong Institute for Health Development
Type: | Journal: Lancet (London, England) | Year: 2016

The so-called health brain-drain-which refers to the health workers leaving their present jobs to other institutions, especially in rural areas-severely restricts the development of primary healthcare. To solve the problem, Pudong New Area of Shanghai carried out a series of incentive policies such as salary bonus, promotion and housing from July, 2014. In our study we aimed to analyse the change in health brain-drain which resulted from this policy.There are 45 community health centres in Pudong, which we classified into 4 categories by geographical division: remote rural, general rural, suburban, and urban. The policy only applied to the 32 community health centres classified as remote rural, general rural, and suburban. Healthcare personnel in these community health centres were given a monthly bonus of 1000-6000. We did an institutional survey about the quantity and structure of the overall and outflowed health personnel in all 45 community health centres from December 31, 2013, to December 31, 2015. This study was approved by the ethics committee of Pudong Institute for Health Development and was performed in compliance with the Declaration of Helsinki.The overall rate of health brain-drain decreased from 81% (568/6996) in 2013 to 46% (302/6553) in 2015. The rate in community health centres in remote rural, general rural, and suburban areas decreased from 63% (298/4699) to 38% (170/4528), and from 118% (270/2297) to 65% (132/2025) in community health centres in urban areas. In community health centres in remote rural, general rural, and suburban areas, the rate of decline in general practitioners, public health physicians and clinicians, and nurses in decreased by 05 (from 175% to 122%), 20 (from 931% to 727%) and 46 (from 823% to 367%) percentage points, respectively, in 2015 compared with 2013. Moreover, in areas where highest bonuses were offered (remote rural), rates of decline were smaller than in areas where no bonuses were offered (urban): 00% versus 28% for general practitioners, 56% versus 97% for public health physicians and clinicians, and 26% versus 68% for nurses.External economic incentives have relieved the health brain-drain in rural areas and the stability of general practitioners and nurses in remote rural areas has been strengthened. However, there was still unfavorable health brain-drain of public health physicians and clinicians in rural areas. Thus, the policy sustainability and health brain-drain of public health physicians should remain a concern.National Nature Science Foundation of China (#71503170) and Shanghai Municipal Commission of Health and Family Planning (#201540400, #201540134).


Jing L.,Fudan University | Jing L.,Pudong Institute for Health Development | Shu Z.,Pudong Institute for Health Development | Sun X.,Fudan University | And 4 more authors.
Asia-Pacific Journal of Public Health | Year: 2015

The general practitioner (GP) system has been widely applied around the world and experimented with in Shanghai, China. To analyze some of the influencing factors on patient-GP contracts, we developed a questionnaire and conducted site investigations in 2011 and 2012 to 1200 patients by random sampling from 6 pilot community health service (CHS) centers in Pudong, Shanghai. The t test, χ2 test, factor analysis, and logistic regression analysis were used to analyze the data. The factors influencing patients' contract behavior were age (OR = 1.03; 95%CI = 1.02-1.04), education level (OR = 0.83; 95% CI = 0.75-0.93), social interaction of social capital (OR = 1.34; 95% CI = 1.15-1.56), acceptance of first contact in community (OR = 3.25; 95% CI = 2.07-5.12), the year of investigation (OR = 2.58; 95% CI = 1.92-3.47), and the exposure to publicity (OR = 1.60; 95% CI = 1.39-1.85). Elderly patients formed a focus group to sign contracts with GPs. To increase trust in GPs by patients, it is recommended to improve the level of CHSs, strengthen publicity, and cultivate social capital among patients. © 2014 APJPH.


Zhang Y.,Fudan University | Zhang Y.,Pudong Institute for Health Development | Zhang Y.,Key Laboratory of Public Health Security | Feng X.,Fudan University | Feng X.,Key Laboratory of Public Health Security
BMC Health Services Research | Year: 2011

Abstract. Background: Throughout China, a growing number of physicians are leaving or intending to depart from their organizations owing to job dissatisfaction. Little information is available about the role of occupational burnout in this association. We set out to analyze the relationship between job satisfaction, burnout, and turnover intention, and further to determine whether occupational burnout can serve as a mediator among Chinese physicians from urban state-owned medical institutions. Methods. A cross-sectional survey was carried out in March 2010 in Hubei Province, central China. The questionnaires assessed sociodemographic characteristics, job satisfaction, burnout, and turnover intention. The job satisfaction and occupational burnout instruments were obtained by modifying the Chinese Physicians' Job Satisfaction Questionnaire (CPJSQ) and the Chinese Maslach Burnout Inventory (CMBI), respectively. Such statistical methods as one-way ANOVA, Pearson correlation, GLM-univariate and structural equation modeling were used. Results: Of the 1600 physicians surveyed, 1451 provided valid responses. The respondents had medium scores (3.18 +/-0.73) on turnover intention, in which there was significant difference among the groups from three urban areas with different development levels. Turnover intention, which significantly and negatively related to all job-satisfaction subscales, positively related to each subscale of burnout syndrome. Work environment satisfaction (b = -0.074, p < 0.01), job rewards satisfaction (b = -0.073, p < 0.01), organizational management satisfaction (b = -0.146, p < 0.01), and emotional exhaustion (b = 0.135, p < 0.01) were identified as significant direct predictors of the turnover intention of physicians, with 41.2% of the variance explained unitedly, under the control of sociodemographic variables, among which gender, age, and years of service were always significant. However, job-itself satisfaction no longer became significant, with the estimated parameter on job rewards satisfaction smaller after burnout syndrome variables were included. As congregated latent concepts, job satisfaction had both significant direct effects (gamma21= -0.32, p < 0.01) and indirect effects (gamma11× beta21= -0.13, p < 0.01) through occupational burnout (62% explained) as a mediator on turnover intention (47% explained). Conclusions: Our study reveals that several, but not all dimensions of both job satisfaction and burnout syndrome are relevant factors affecting physicians' turnover intention, and there may be partial mediation effects of occupational burnout, mainly through emotional exhaustion, within the impact of job satisfaction on turnover intention. This suggests that enhancements in job satisfaction can be expected to reduce physicians' intentions to quit by the intermediary role of burnout as well as the direct path. It is hoped that these findings will offer some clues for health-sector managers to keep their physician resource motivated and stable. © 2011 Zhang and Feng; licensee BioMed Central Ltd.


PubMed | Fudan University, Pudong New Area Health and Family Planning Commission and Pudong Institute for Health Development
Type: | Journal: Lancet (London, England) | Year: 2016

Grassroots health-care institutions in China are facing a shortage of professionals, especially general practitioners. To encourage health-care providers to come to and stay at rural grassroots institutions, Pudong New Area of Shanghai undertook a series of incentive reforms for rural health-care providers in July, 2014. We evaluated the effectiveness of incentive reform.The reform covered Pudongs 32 rural community health centres (CHCs): 12 remote rural CHCs, 11 general rural CHCs, and 9 suburban CHCs. The 13 urban CHCs in Pudong were not covered. The scheme included general practitioners, public health physicians, and other medical personnel. Motivators included eight aspects, such as bonus, promotion, and housing, of which bonus was the most important. Health-care providers in rural areas could get a monthly bonus of 1000-6000; general practitioners in remote rural CHCs received 6000. Quantity and statuses of community health-care providers for 2013-2015 were collected from 45 CHCs in the form of an institutional survey. Ethics approval was obtained from the ethics committee of Pudong Institute for Health Development.From December 31, 2013, to December 31, 2015, the total number of general practitioners in rural and suburban CHCs increased by 124%, from 799 to 898. The inflow of general practitioners increased by three times in remote rural CHCs (from 1 to 4), 12 times in general rural CHCs (from 6 to 13), and 06 times in suburban CHCs (from 14 to 22), and decreased by 525% (from 61 to 29) in urban CHCs. In 2015, the proportion of general practitioners as a share of health personnel was 198% (898 of 4528) in rural and suburban areas, an increase of 28 percentage points compared with 2013. The turnover rate of rural health-care providers decreased from 63% to 38% in these areas and from 118% to 65% in urban areas.With the financial incentives intervention, rural and suburban CHCs were more attractive to health-care providers, especially general practitioners. Furthermore, the stability of health-care providers was improved, especially in remote rural areas. However, the sustainability of financial subsidies and the policy depression effect, which means that there might be more inflow of health-care providers from other remote areas to Pudong and this will exacerbate the shortages of health personnel in and outside Shanghai, should be of concern in the long term.National Nature Science Foundation of China (#71503170) for data interpretation. Shanghai Municipal Commission of Health and Family Planning (#201540400, #201540134) for data collection and analysis.


PubMed | Fudan University, Pudong New Area Health and Family Planning Commission and Pudong Institute for Health Development
Type: | Journal: Lancet (London, England) | Year: 2016

To help drive the consolidation and integrated management of basic medical insurance in China, we analysed participants satisfaction, and factors associated with satisfaction, for the Urban Employees Basic Medical Insurance (UEBMI), Urban Residents Basic Medical Insurance (URBMI), and New Rural Cooperative Medical Scheme (NRCMS).Pudong New Area in Shanghai was chosen as a typical sample of basic medical insurance coverage and management. 3395 residents (1200 households) were selected in September, 2013, by stratified cluster sampling and participants were interviewed face-to-face by trained investigators. Factors associated with satisfaction were analysed by ordinal logistic regression. Ethics approval was obtained from the ethics committee of Pudong Institute for Health Development.URBMI participants reported a higher rate of dissatisfaction in outpatient (n=7, 510%), inpatient (7, 1250%), and overall (127, 1285%) experience. NRCMS had the highest rate of outpatient satisfaction (65, 844%), with no participants reporting dissatisfaction. UEBMI had the highest rate of inpatient satisfaction (96, 701%). Affordability of out-of-pocket cost, proportion of reimbursement, and time of insurance reimbursement were positively correlated with satisfaction for UEBMI; awareness of premium and compensation policy, affordability of out-of-pocket cost, proportion of reimbursement, and procedure of reimbursement were associated with greater satisfaction with URBMI, whereas participants with lower education were more satisfied. Factors associated with satisfaction with NRCMS were the same as for URBMI, with the exception of education level, and the addition of affordability of premium and time of reimbursement, which were positively correlated.The Chinese government should take effective measures, such as taking advantage of the family doctor system, to regulate and reinstitute sequential medical order (referral from primary medical institutions to high level medical institutions), which could lead to short-term implications of satisfaction but will lead to both satisfaction and rational medical order in the long term. The fairness of financing and reimbursing across different basic medical insurance policies (in terms of reasonable costs to patients) needs to be improved.Funded by the National Nature Science Foundation of China (NSFC 71503170), Shanghai Municipal Commission of Health and Family Planning (201440036, 2016HP009).


PubMed | Fudan University, University of Alberta, Shanghai Health Development Research Center and Pudong Institute for Health Development
Type: Journal Article | Journal: Asia-Pacific journal of public health | Year: 2015

The general practitioner (GP) system has been widely applied around the world and experimented with in Shanghai, China. To analyze some of the influencing factors on patient-GP contracts, we developed a questionnaire and conducted site investigations in 2011 and 2012 to 1200 patients by random sampling from 6 pilot community health service (CHS) centers in Pudong, Shanghai. The t test, (2) test, factor analysis, and logistic regression analysis were used to analyze the data. The factors influencing patients contract behavior were age (OR = 1.03; 95%CI = 1.02-1.04), education level (OR = 0.83; 95% CI = 0.75-0.93), social interaction of social capital (OR = 1.34; 95% CI = 1.15-1.56), acceptance of first contact in community (OR = 3.25; 95% CI = 2.07-5.12), the year of investigation (OR = 2.58; 95% CI = 1.92-3.47), and the exposure to publicity (OR = 1.60; 95% CI = 1.39-1.85). Elderly patients formed a focus group to sign contracts with GPs. To increase trust in GPs by patients, it is recommended to improve the level of CHSs, strengthen publicity, and cultivate social capital among patients.

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