Abstract. A Nationwide Nitrogen Deposition Monitoring Network (NNDMN) containing 43 monitoring sites was established in China to measure gaseous NH3, NO2, and HNO3 and particulate NH4+ and NO3− in air and/or precipitation from 2010 to 2014. Wet/bulk deposition fluxes of Nr species were collected by precipitation gauge method and measured by continuous-flow analyzer; dry deposition fluxes were estimated using airborne concentration measurements and inferential models. Our observations reveal large spatial variations of atmospheric Nr concentrations and dry and wet/bulk Nr deposition. On a national basis, the annual average concentrations (1.3–47.0 μg N m−3) and dry plus wet/bulk deposition fluxes (2.9–83.3 kg N ha−1 yr−1) of inorganic Nr species are ranked by land use as urban > rural > background sites and by regions as north China > southeast China > southwest China > northeast China > northwest China > Tibetan Plateau, reflecting the impact of anthropogenic Nr emission. Average dry and wet/bulk N deposition fluxes were 20.6 ± 11.2 (mean ± standard deviation) and 19.3 ± 9.2 kg N ha−1 yr−1 across China, with reduced N deposition dominating both dry and wet/bulk deposition. Our results suggest atmospheric dry N deposition is equally important to wet/bulk N deposition at the national scale. Therefore, both deposition forms should be included when considering the impacts of N deposition on environment and ecosystem health.

Abstract. Global reactive nitrogen (Nr) deposition to terrestrial ecosystems has increased dramatically since the industrial revolution. This is especially true in recent decades in China due to continuous economic growth. However, there are no comprehensive reports of both measured dry and wet Nr deposition across China. We therefore conducted a multiple-year study during the period mainly from 2010 to 2014 to monitor atmospheric concentrations of five major Nr species of gaseous NH3, NO2 and HNO3, and inorganic nitrogen (NH4+ and NO3−) in both particles and precipitation, based on a Nationwide Nitrogen Deposition Monitoring Network (NNDMN, covering 43 sites) in China. Wet deposition fluxes of Nr species were measured directly; dry deposition fluxes were estimated using airborne concentration measurements and inferential models. Our observations reveal large spatial variations of atmospheric Nr concentrations and dry and wet Nr deposition. The annual average concentrations (1.3–47.0 μg N m−3) and dry plus wet deposition fluxes (2.9–75.2 kg N ha−1 yr−1) of inorganic Nr species ranked by region as North China > Southeast China > Southwest China > Northeast China > Northwest China > the Tibetan Plateau or by land use as urban > rural > background sites, reflecting the impact of anthropogenic Nr emission. Average dry and wet N deposition fluxes were 18.5 and 19.3 kg N ha−1 yr−1, respectively, across China, with reduced N deposition dominating both dry and wet deposition. Our results suggest atmospheric dry N deposition is equally important to wet N deposition at the national scale and both deposition forms should be included when considering the impacts of N deposition on environment and ecosystem health.

The zero-markup drug policy (ZMDP) was heralded as the biggest reform to China’s modern health system. However, there have been a very limited number of investigations of the ZMDP at county hospital level, and those limited county hospital studies have several limitations in terms of sample representativeness and study design. We investigated the overall and dynamic effects of ZMDP at traditional Chinese medicine (TCM) county hospitals. We obtained longitudinal data from all TCM county hospitals in 2004–16 and the implementation year of ZMDP for each hospital. We used differences-in-difference methods to identify the overall and dynamic effects of ZMDP. On average, the ZMDP reform was associated with the reduction in the share of revenue from drug sales (3.1%), revenue from western medicines sales (12.7%), revenue from medical care services (3.6%) and gross hospital revenue (3.4%), as well as increased government subsidies (24.4%). The ZMDP reform was not significantly associated with the number of annual outpatient and inpatient visits. In terms of dynamic effects, the share of revenue from drug sales decreased by 2.5% in the implementation year and by about 5% in the subsequent years. Revenue from western medicine sales fell substantially in the short term and continued to drop in the long term. Government subsidies went up strikingly in the short term and long term, and revenue from medical care services and gross revenue decreased only in the implementation year. The ZMDP achieved its stated goal through reducing the share of revenue from drug sales without disrupting the availability of healthcare services at TCM county hospitals. The success of ZMDP was mainly due to the huge growth in the government’s financial investment in TCM hospitals.

ObjectiveTo evaluate the 2017 implementation of China’s 2009 healthcare price reforms on Beijing’s secondary and tertiary traditional Chinese medicine (TCM) hospitals.DesignWe employed a panel-interrupted time-series model with hospital fixed effects to estimate the impact of the price reforms.SettingBeijing, April 2014 to April 2018.ParticipantsAll TCM hospitals in Beijing.Outcome measuresOur dependent variables comprised the monthly outpatient and inpatient revenues, the number of monthly outpatient visits and inpatient admissions, the average total expenditures per outpatient visit and per inpatient admission, the average drug expenditures (except herbal medicines) per outpatient visit and per inpatient admission and the average medical service expenditures per outpatient visit and per inpatient admission.ResultsIn tertiary hospitals, the price reforms led to significant reductions in the number of outpatient visits (23.1%), inpatients admission (4.6%) and drug expenditures (except herbal medicines) per inpatient admission (14.0%), and an instant raise in average total expenditure per outpatient (22.0%), medical service expenditures per outpatient visit (58.2%) and inpatient admission (19.0%). There was no significant association between the price reforms and the monthly outpatient and inpatient revenues. After the price reforms, the previous upward trend in medical service expenditures per outpatient visit rose more sharply (from 0.5% to 1.6%). In secondary hospitals, the price reforms decreased the level of drug expenditures (except herbal medicines) per outpatient visit (13.0%) and per inpatient admission (20.8%), but increased medical service expenditures per inpatient admission by 19.0%.ConclusionThe Beijing price reforms adjusted the cost structures in secondary and tertiary TCM hospitals without negatively impacting the operation of the hospitals, and through the increased hierarchical medical service fee, shifted patient choices away from tertiary to other health facilities, especially for patients with minor illnesses.

Long-term exposure to particulate matter 2.5 μm (PM2.5) air pollution is associated with an increased risk of lung cancer. However, the evidence is limited in low-income and middle-income countries. We estimated the association between the incidence of lung cancer and PM2.5 air pollution exposure in the Urban Employee Basic Medical Insurance (UEBMI) beneficiaries in China. A total of 16 483 new lung cancer cases diagnosed from 12 966 137 UEBMI beneficiaries from 36 cities between 2013 and 2016. The relative risk for lung cancer associated with a 10 µg/m3 increase in 3-year PM2.5 exposure was 1.12 (95% CI 1.00 to 1.26). The population attributable risk estimated for a reduction in PM2.5 concentration to 35 µg/m3 corresponded to a decrease of 14% in cases of lung cancer. Reducing PM2.5 air pollution has a significant public health benefit.

Background Evidence‐based policy making for delivering affordable lung cancer care relies on the breadth, depth and quality of knowledge of its treatment costs. This study estimates the annual prevalence, medical service utilization and direct treatment costs of lung cancer in urban China. Materials and Methods Using claim data from China's urban basic medical insurance between 2013 and 2016, we constructed a nationally representative sample of lung cancer patients in urban China. Weighted descriptive analyses, Poisson regressions and generalized linear modelling were used to analyse lung cancer medical service utilization and costs and their associations with patient characteristics. Results In urban China, the annual prevalence of lung cancer was 87.65/100000, with nearly 0.65% of total health expenditures of urban residents spent on lung cancer treatments. Weighted average annual total medical costs of lung cancer was RMB33.78 (US$5.36) thousand, with annual out‐of‐pocket costs of RMB10.26 (US$1.63) thousand. The average yearly number of lung cancer‐related outpatient visits was 2.42 and inpatient admissions was 2.07, with an average cost of RMB0.75 (US$0.12) thousand for outpatients and RMB 15.67 (US$2.49) thousand for inpatients. Inpatient expenses were the major component (95%) of lung cancer medical costs, with roughly 67% of inpatient services occurring in high‐level tertiary hospitals. Medical care utilization and direct medical costs were associated with sex, age and insurance status. Western medicine costs were the major contributor (39.4%) to average lung cancer‐related medical costs. Conclusion Lung cancer imposed a significant economic burden on China's health system and a financial cost on lung cancer sufferers and their families. Specific policies are required to efficiently allocate health resources, contain health expenditure and decrease the individual financial burden of lung cancer.

Background: Understanding the treatment costs of stroke can guide health policies and interventions. However, few studies have analyzed the treatment costs of stroke in China. The aim of this study is to assess stroke-related medical service utilization, direct costs of stroke and associated stroke predictors, and, second, to understand the structure of medical resource use. Methods: This study used a 5% random sample of claim data from China’s Urban Basic Medical Insurance between January 2013 to December 2016. The sampling design assigned a sample weight to each beneficiary. Weighted descriptive analyses, Poisson regression and generalized linear model were used to analyze the medical service utilization, costs and their associations with patient characteristics. Results: In urban China, the annual prevalence of stroke was 730.43 (95% CI = 730.10-730.76) cases per 100 000 people, and nearly 2% of total health expenditures of urban residents was spent on stroke-related medical costs. Weighted average annual total medical cost of stroke was RMB10 637 [95% CI = 10 435-10 840] (US$1682, 95% CI = 1650-1714), with annual out-of-pocket (OOP) cost of RMB3093 [95% CI = 3026-3161] (US$489, 95% CI = 478-500). The average yearly number of stroke-related outpatient visit was 1.67 [SD = 3.39] and inpatient admission was 0.79 [SD = 0.83], with an average cost of RMB440 [SD = 739] (US$70, SD = 117) for outpatients and RMB12 702 [SD = 21 424] (US$2008, SD = 3387) for inpatients. Inpatient costs accounted for 94% (RMB10 034 or US$ 1586) of medical costs, and tertiary hospitals were the main provider of stroke care. Stroke-related medical care utilization and direct costs were associated with gender, age, pathological stroke types and insurance status. Medication costs contributed to 50.6% (RMB5382 or US$ 851) of the average stroke-related medical costs. Conclusion: China’s health system bares a large economic burden from stroke. Specific policies are needed to strengthen the capacity of secondary hospitals, alter the structure of medical resource allocation, and target specific sections of the stroke population.

Background: It is evident that comorbidity exacerbate the complexity of the management of lung cancer, however, limited research has been conducted to investigate the impact of comorbidity on health service utilization and cost, as well as the treatment choice among lung cancer patients. We examined the association of comorbidity with medical service utilization, cost and treatment choice among lung cancer patients in China. Methods: We used claims data from China Urban Employees' Basic Medical Insurance (UEBMI) and Urban Residents' Basic Medical Insurance (URBMI) between 2013 to 2016 and data from Hospital Information System (HIS) Database in Beijing Cancer Hospital (BCH). Elixhauser Comorbidity Index was used to assess comorbidity. Negative binomial regression, generalized linear model (GLM) with a gamma distribution and a log link, and logistic regression was applied to assess the associations between comorbidity and medical service utilization, cost and treatment choice, respectively. Results: Among 8655 patients with lung cancer, 31.3% of had at least one comorbid conditions. Having comorbidity was associated with increased number of annual outpatient visits (1.6, 95%CI: 1.3, 1.9) and inpatients admissions (0.8, 95%CI, 0.70, 0.90), increased outpatient (USD635.5, 95%CI: 490.3, 780.8) and inpatient expenditure (USD2 470.3, 95CI%: 1998.6, 2941), as well as increased possibility of choosing radio therapy (OR: 1.208, 95%CI: 1.012-1.441) and chemotherapy (1.363, 1.196-1.554), and decreased possibility of choosing surgery (0.850, 0.730-0.989). The medical utilization and expenditure, the possibility of choosing radiotherapy increases, and the possibility of choosing surgery decreases with the increasing number of chronic conditions. There are variations in the association with medical service utilization and expenditure, and treatment choice among individuals with different types of comorbid conditions. Conclusion: Comorbidity among lung cancer patients restricts the potential treatment choices and poses an extra substantial health care burden. Our findings provide implications for both the clinical management and health service planning and financing for lung cancer patients.