Evaluation and learning in complex,rapidly changing health systems: China’s management of health sector reform

Healthcare systems are increasingly recognised as complex, in which a range of non-linear and emergent behaviours occur. China’s healthcare system is no exception. The hugeness of China, and the variation in conditions in different jurisdictions present very substantial challenges to reformers, and militate against adopting one-size-fits-all policy solutions. As a consequence, approaches to change management in China have frequently emphasised the importance of sub-national experimentation, innovation, and learning. Multiple mechanisms exist within the government structure to allow and encourage flexible implementation of policies, and tailoring of reforms to context. These limit the risk of large-scale policy failures and play a role in exploring new reform directions and potentially systemically-useful practices. They have helped in managing the huge transition that China has undergone from the 1970s onwards. China has historically made use of a number of mechanisms to encourage learning from innovative and emergent policy practices. Policy evaluation is increasingly becoming a tool used to probe emergent practices and inform iterative policy making/refining. This paper examines the case of a central policy research institute whose mandate includes evaluating reforms and providing feedback to the health ministry. Evaluation approaches being used are evolving as Chinese research agencies become increasingly professionalised, and in response to the increasing complexity of reforms. The paper argues that learning from widespread innovation and experimentation is challenging, but necessary for stewardship of large, and rapidly-changing systems.     

Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium diffcile(the Benefits of Enhanced Terminal Room Disinfection study):a cluster-randomised,multicentre,crossover study

中文:背景患者入院后可从不当消毒的环境表面获得多药耐药菌和艰难梭菌。本文确定了3种强化的终末消毒(入住同一病房的两名患者之间的消毒)策略,对感染耐甲氧西林金黄色葡萄球菌(MRSA)、耐万古霉素肠球菌(VRE)、艰难梭菌(CD)和多重耐药不动杆菌的影响。方法本文在美国东南部的9家医院开展了一项务实的、集群-随机、交叉研究。凡曾有感染或定植目标细菌感染患者居住过的病房,患者出院后随机采取4种消毒策略中的一种方法进行终末消毒:对照(季胺盐类消毒剂消毒,但凡遇到CD采用含氯消毒剂);UV(季胺盐类+UV-C消毒,但凡遇到CD采用含氯消毒剂+UV-C);含氯消毒剂;含氯消毒剂+UV-C。凡入住目标病房的患者被列为暴露人群。这4种终末消毒方法分别在每家医院连续实施7个月的周期。本文随机设计这几种消毒策略在每家医院内的实施顺序(1:1:1:1)。主要产出的结果是,观察暴露患者中目标细菌的感染的发生或定植情况,以及ITT人群中暴露患者CD感染发生率。本研究ClinicalTrials.gov注册编号:NCT01579370。结果共有31 226名患者暴露,其中21 395(69%)符合标准,包括4 916名对照组,5 178名UV组,5 438名含氯消毒剂组,以及5 863名含氯消毒剂+UV组。在对照组中,22 426个暴露日中有115名患者发生目标细菌的感染(51.3/10000暴露日)。在标准清洁策略的基础上增加UV消毒的暴露患者,其目标细菌感染的发生率明显较低(n=76;33.9/10 000暴露日;RR:0.70,95%CI:0.50～0.988;P=0.036)。含氯消毒剂组(n=101;41.6/10 000暴露日;RR:0.85,95%CI:0.69～1.04;P=0.116),或含氯消毒剂+UV组患者(n=131;45.6/10 000暴露日;RR:0.91,95%CI:0.76～1.09;P=0.303)的目标细菌的感染率,其差异无统计学意义。同样,在含氯消毒剂的基础上增加UV消毒,暴露患者中CD感染率也没有发生改变((n=38 vs 36;30.4 vs 31.6/10 000暴露日;RR:1.0,95%CI:0.57-1.75;P=0.997)。解释污染的医疗机构环境是获得病原微生物的重要来源;强化终末消毒可以降低这一风险。     

Arsenic association with circulating oxidized low-density lipoprotein in a Native American community

More than 500 abandoned uranium (U) mines within the Navajo Nation contribute U, arsenic (As) and other metals to groundwater, soil and potentially air through airborne transport. The adverse cardiovascular health effects attributed to cumulative exposure to these metals remains uncertain. The aim of this study was to examine whether environmental exposure to these metals may promote or exacerbate the oxidation of low-density lipoprotein (LDL) cholesterol in this Native American population. The correlation of cardiovascular biomarkers (oxidized LDL (oxLDL) and C-reactive protein (CRP)) from a Navajo cohort (n = 252) with mean annual As and U intakes from water and urine metals was estimated using linear regression. Proof-of-concept assays were performed to investigate whether As and U directly oxidize human LDL. Mean annual As intake from water was positively and significantly associated with oxLDL, but not CRP in this study population, while U intake estimates were negatively associated with oxLDL. In an acellular system, As, but not U, directly oxidized the apolipoprotein B-100 component of purified human LDL. Neither metal promoted lipid peroxidation of the LDL particle. Both the population and lab results are consistent with the hypothesis that As promotes oxidation of LDL, a crucial step in vascular inflammation and chronic vascular disease. Conversely, for outcomes related to U, negative associations were observed between U intake and oxLDL, and U only minimally altered human LDL in direct exposure experiments. Only urine U was correlated with CRP, whereas no other metals in water or urine were apparently reliable predictors of this inflammatory marker.     

Urinary metal concentrations among mothers and children in a Mexico City birth cohort study

Personal care product use is a potential source of metals exposure among children, but studies have been limited. We measured urinary concentrations of 10 metals (aluminum, arsenic [As], barium [Ba], cadmium, cobalt [Co], lead [Pb], manganese [Mn], molybdenum [Mo], nickel, and zinc [Zn]) in third trimester pregnant women (n?=?212) and their children at 8–14 years of age (n?=?250). Demographic factors (child sex, age, socioeconomic status, and maternal education), body mass index (BMI) z-score, and child personal care product use in the 24?h prior to urine collection were examined as predictors of urinary metal concentrations. Metals were detected in 80–100% of urine samples, with significant differences in maternal versus childhood levels. However, metal concentrations were not strongly correlated within or between time points. In linear regression models including all demographic characteristics, BMI z-score, and specific gravity, age was associated with higher Co (6% [95% CI: 2, 10]), while BMI z-score was associated with lower Mo (-6% [95% CI: -11, -1). In addition, significantly higher metal concentrations were observed among users of colored cosmetics (Mo: 42% [95% CI: 1, 99]), deodorant (Ba: 28% [3, 58]), hair spray/hair gel (Mn: 22% [3, 45]), and other toiletries (As: 50% [9, 108]), as well as with an increasing number of personal care products used (As: 7% [3, 11]) after adjustment for child sex, age, total number of products used, and specific gravity. However, significantly lower metal concentrations were noted for users of hair cream (As and Zn: -20% [-36, -2] and -21% [-35, -2], respectively), shampoo (Pb: -40% [-62, -7]), and other hair products (Pb: -44% [-65, -9]). We found that personal care product use may be a predictor of exposure to multiple metals among children. Further research is recommended to inform product-specific exposure source identification and related child health risk assessment efforts.     

Intraoral rhabdomyomas.

Review of the world literature revealed 16 cases of intraoral rhabdomyomas. Thirteen additional cases of intraoral rhabdomyomas from the files of the Armed Forces Institute of Pathology are reported. The neoplasm occurred principally in adults (mean age 56 years), and the male-female ratio was greater than 2:1. The majority of cases occurred in the floor of the mouth, followed by the soft palate, tongue, and buccal mucosa. Recurrences occurred in four (30 percent) cases, and there was one multiple recurrence. One residual tumor, the result of incomplete surgical removal was noted. Although these tumors have a characteristic microscopic appearance, they were frequently misinterpreted. The size, clinical presentation, and growth pattern of these tumors may reflect their ultimate behavior and prognosis.     

Refractory chronic periodontitis: effect of oral tetracycline hydrochloride and root planing

Refractory chronic periodontitis of 16 patients was treated by root planing and adjunctive tetracycline hydrochloride therapy. The antibiotic was taken orally one hour before root planing and continued for six days at a dosage of 250 mg six hourly. The clinical data for each patient were recorded as the number of probing depths in each of the 1-3 mm, 4-6 mm and 7-10 mm ranges. The Multivariate Analysis of Variance (MANOVA) procedure for repeated measurements was used to analyse the data. The results demonstrated that the number of sites with probing depths of 4-6 mm and 7-10 mm associated with incisors, canines, premolars and molars decreased with a corresponding increase in the number of sites in the 1-3 mm range. Incisor and canine teeth showed a better response to treatment than premolars, which responded better than molars. The cases were followed for varying periods of time from six months to two years following antibiotic therapy. The probing depth reduction achieved following root planing and tetracycline hydrochloride therapy was maintained during this review period.