Download Yale-China Collaborative Program to Improve Health and Health Care

Yale-China Collaborative Program to
Improve Health and Health Care
“The enormous scope of the clinical and outcomes research by
Yale's Center for Outcomes Research and Evaluation (CORE) in
collaboration with investigators in hundreds of hospitals across
China promises to provide not only critically important knowledge
for the citizens of China, but a meaningful opportunity to bring the
research enterprises and individuals of the two countries closer in
genuine cultural understanding.”
Jerome P. Kassirer, M.D.
Distinguished Professor, Tufts University School of Medicine,
Editor-in-Chief Emeritus, New England Journal of Medicine
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CONTENTS
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Introduction ......................................................................................... 3
Mission Statement ................................................................................ 3
Our Network ........................................................................................... 4
Current Projects .................................................................................... 5
Cardiology Registries ............................................................... 5
Cardiac Surgery Registry ....................................................... 5
Mobile Health Interventions ................................................ 6
Qingdao Port Study ................................................................... 7
The Millions Persons Study .................................................. 8
Future Projects .................................................................................. 9
Chronic Disease Registries .................................................... 9
The Lancet Commission ......................................................... 9
Leadership ............................................................................................ 10
Collaborators ....................................................................................... 11
Publications .......................................................................................... 12
Introduction
Yale’s Center for Outcomes Research and Evaluation (CORE) and the Chinese
National Center for Cardiovascular Diseases (NCCD) began their landmark
collaboration in 2010. Since then, the two sides have come together to form
a strong team that serves as a bridge between two ofOur
the Network
world’s leading
countries. The collaboration has yielded several groundbreaking national
studies in China and 20 academic publications in the last two years alone,
many appearing in the premier journals in their fields. Such work has
brought together dozens of leading scholars in medicine, biostatistics, and
epidemiology, with hundreds of on-the-ground site coordinators and
administrators; involved the study of hundreds of thousands of participating
patients; and is serving as a foundation for health reform and quality
improvement efforts across China.
Mission Statement
To improve health and health care through international friendship,
research-generation, and knowledge application. We strive to leverage the
strengths of the US and China, through partnership and friendship, to foster
meaningful collaboration and mutual understanding—and promote medical
and public health advances. We are committed to expanding the scientific
knowledge base, accelerating medical breakthroughs and cures, and sharing
our findings with a global audience so that what we learn may benefit our
countries and the world.
Dr. Harlan M. Krumholz, the center’s leader, meets China's Premier, Li Keqiang, at the
Great Hall of the People in Beijing to receive China's Friendship Award, given to ‘foreign
experts who have made outstanding contributions to the country's economic and social
progress.’
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Our Network
The extensive national hospital network that participates in the China
PEACE and Chinese Cardiac Surgery Registry platforms.
The China Patient-Centered Evaluative Assessment of Cardiac Events (China
PEACE) is a national network of more than 200 hospitals—spanning almost
every province and autonomous region in China—that participates in
research designed, managed, and disseminated by our international team.
The hospital network has been involved in building numerous patient
registries that can be used to answer important questions about trends and
outcomes in cardiovascular care in China. It is also being used to launch
one of the first multi-center text message-based mobile health
interventions in China and has anchored one of the world’s largest
population-based studies of cardiovascular disease.
The Chinese Cardiac Surgery Registry extends our research’s reach to the
operating room. Put together, our network of 87 participating hospitals
accounts for nearly half of all CABG procedures performed in China each
year. It has allowed us to investigate the national prevalence and quality of
coronary artery bypass (CABG) and valvular surgery in China. The network,
managed by the NCCD’s top cardiac surgeons, has also been leveraged to lead
two of China’s largest and earliest mHealth interventions—one web-based
and the other app-based—that translate earlier research into impactful
platforms for both physicians and patients. These quality improvement
measures, along with our annual surgical outcomes reports, released to all
free of charge, have already made a huge impact on cardiac surgery care in
China. In the future, our collaborations with the NCCD’s surgical teams will
break new ground by launching a large registry of young patients who suffer
from congenital heart conditions, thus bringing our work into the
pediatric sphere.
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Cardiology—Retrospective Registry
Ischemic heart disease is an issue of great public health importance in China.
As the country continues to grow economically, it faces an epidemiological
transition with rising mortality due to non-communicable diseases. The first
study from the China PEACE network formed the foundation for our work
in China. This study built a retrospective registry of Chinese patients from
200 hospitals to find out more about trends in acute myocardial infarction
(AMI) and percutaneous coronary intervention (PCI) over the last decade.
Over 18,000 medical records were abstracted at three time points—2001,
2006, and 2011—to provide a nationally representative sample of patients
who were discharged with a diagnosis of AMI or who had a PCI procedure in
hospital. We identified large increases in the estimated national rate of
hospitalization for ST-segment elevation myocardial infarction (STEMI), a
growing burden of prevalent cardiovascular risk factors, persistent delays in
admission to hospitals, and significant gaps in the quality of care provided
to patients across China. Our team has published over 15 papers in-highimpact journals such as The Lancet from this study alone. This foundational
study has since informed and inspired our work to elevate the quality of care
in China and improve patient outcomes.
Cardiology—Prospective Registry
To find out more about patients’ experiences after hospitalization in China
for AMI and PCI, we built on the success of our retrospective registry with the
PEACE prospective registries for AMI and PCI. Since 2013, just under
10,000 patients have been enrolled and followed for 12 months after their
first hospitalization for AMI or PCI. An unprecedented aspect of the registries
is their focus on patient-reported outcomes collected at key time points
across those 12 months, through phone and face-to-face interviews. By
examining patients’ clinical outcomes, as well as their own reported
outcomes such as their health status, depression, stress and health-related
quality of life, we hope to be able to describe their experiences and care
trajectories in more meaningful detail. This approach is new in China and still
on the cutting-edge in the US and Europe, where an emphasis on better
understanding patients’ experiences of their illness and care is also relatively
recent. The teams at Yale CORE and Fuwai Hospital are currently working to
disseminate the results of multiple studies based off information collected in
these registries, with over 10 papers already in progress.
Cardiac Surgery—Prospective Registry
The Chinese Cardiac Surgery Registry is a prospective registry that, since
2013, has enrolled thousands of patients who have undergone CABG or
valvular surgery in China. Like the China PEACE prospective AMI and PCI
registries, it follows patients for one year after discharge from their
procedure and collects information on complications and outcomes. We use
this information to generate quarterly and annual surgical outcome reports
that we release to all surgical teams in China.
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This has allowed our team to extend its impact to countless Chinese
operating rooms. There is also evidence that this and other resources have
contributed to a marked improvement in complication and in-hospital
mortality rates after CABG in China over the past five years. In a paper
that our team will publish later this year, we found that isolated CABGrelated in-hospital mortality, major complication rates, and length of stay
(LOS) have improved in large urban teaching hospitals in China over the last
decade. These rates are now approaching those seen in the US, though
prescription rates for secondary prevention drugs and cardiac
rehabilitation therapies remain lower in China than the US. This registry
has already produced 17 published papers, with many more in the
works.
Mobile Health Interventions
The patient portal for the MISSION-2 smartphone
application
Our team has also leveraged the China PEACE and Chinese Cardiac
Surgery Registry networks to design and implement interventions geared
toward directly improving care quality and patient outcomes. The
MISSION-1 study is an ongoing web- and mobile-based intervention that
provides education on the most-up-to-date prescription practices to
physicians caring for patients who have undergone a coronary bypass. Its
sister study, MISSION-2, is an ongoing app-based intervention focused on
improving medication adherence in coronary bypass patients. The studies
are some of the earliest academic forays into the exciting space of mobile
health (mHealth) in China, which boasts the world’s largest number of
smartphone users and is increasingly an innovation leader in the
development of health-based devices and apps.
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Our team is uniquely positioned to harness China’s growing
entrepreneurial spirit in the field of e-and mHealth—much of the innovation
actually takes place in the NCCD’s backyard, at nearby Peking and Tsinghua
universities—to improve the country’s health system and outcomes. A
new, patient-centered mHealth texting intervention—China PEACEIII—is slated to begin in the summer of 2016, where high-risk patients will
receive texts encouraging them to live more heart-healthy lives. In this
intervention, we will target factors such as high rates of smoking, lack of
physical activity and high blood pressure. In the future, this intervention
will also introduce wearables to monitor patients’ vital signs and
experiment with artificial intelligence to make texts ‘smarter,’ more
interactive, and better tailored to a patient’s individual needs and goals.
The Qingdao Port Study
The team reviews study data with a nurse in the port city of Qingdao
The Qingdao Port Cardiovascular Health Study marked Yale CORE’s and
the Chinese NCCD's first foray into population-based health studies. In
collaboration with the Qingdao Port Group, a large company based in the
northeastern coastal city of Qingdao, over 32,000 employees of the port
group have been studied from 2000 through 2013. In bringing together data
collected from annual health assessments and biospecimen analyses over
many years, the project has important resemblances to the Whitehall Study
from the UK. Findings from preliminary and published work suggest that
China’s working-age population has experienced a dramatic increase in
cardiovascular risk factors, including hypertension, hyperlipidemia,
diabetes, and high body mass index. The rise of such risk factors in China’s
working population coupled with a rapidly aging population due to the One
Child Policy suggests that the productivity gains essential to continued high
economic growth may be threatened.
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The Millions Persons Project
The team’s most ambitious initiative to-date is the Millions Persons Project
(MPP), which will leverage our experience with patient registries to collect
important health data from 4 million people across China, making it one
of the world’s largest academic population-based studies. China is in the
midst of a historic and monumental demographic transition: driven in large
part by rapid economic growth, its population is becoming increasingly old
and decreasingly rural. This has contributed to a dramatic rise in chronic
and non-communicable diseases, especially cardiovascular diseases. The
pilot study for the MPP, completed in 2015 after collecting information on
400,000 people, found that roughly 1 in 4 Chinese adults screened was at
high risk for cardiovascular disease.
By bringing together information on blood pressure, height, weight, diet,
smoking and lifestyle with data collected from blood, urine, and genetic
samples, the MPP will offer an unrivalled platform for the application of
innovative statistical, epidemiological, and big data techniques to
investigate cardiovascular disease trends, outcomes, and pathologies in more
detail. Much like the Precision Medicine Initiative launched by the NIH in
2015, our MPP initiative will bring together collaborators in fields as diverse
as medicine and applied math to accelerate scientific breakthroughs and find
new cures. The project also serves as a showcase for the strengths of our
team’s partnership, where the will, ingenuity, and grand vision of our
China-based collaborators are paired with the traditional strength of
Yale’s cutting edge research.
MAJOR ACCOMPLISHMENTS
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Nearly 30 publications in peer-reviewed academic journals
More than five years of partnership between US and Chinese researchers
The construction of multiple registries with over 20,000 enrolled patients
Three innovative mHealth trials currently in the field
One of the largest public health screening studies ever conducted
“Distinguished by its strong design, rigorous quality control, and
cutting-edge data analysis, the China PEACE study is an exceptional
model for high-level multi-center clinical research in cardiovascular
disease. We are looking forward to broader and deeper cooperation
between CORE and the NCCD based on the solid foundation they have
built during their first five years of their partnership.”
Ye Li, Chief, Planning Division
Department of Health Science, Technology and Education
National Health and Family Planning Commission
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Future Projects
The China PEACE V: Chronic Disease Registries initiative will build upon
the knowledge and experience we have generated in our previous studies
by constructing five new chronic disease registries. The registries will
enroll patients who have experienced stroke, chronic kidney disease,
diabetes, heart failure, and valvular heart disease. Our team will lead
the design and construction of the registries on heart failure and valvular
heart disease while serving as a consultant on the others. Although China
has made significant progress in expanding health insurance and access to
care over the past decade, due to its unique demographic and economic
circumstances, the country now faces a dual burden of disease:
infectious diseases in the countryside and chronic diseases in urban
areas. This initiative will harness our extensive network of hospitals to
address the growing need to understand chronic disease prevalence and
care in China at a time when, for the first time, urban residents outnumber
rural residents. The share of the Chinese population living in urban areas is
projected to rise from 51% today to US levels (80%) by 2030, suggesting
that the burden of chronic conditions like heart failure and stroke will
only increase. Our project will meet the urgent need to provide more
evidence about chronic disease care in China so that effective economic,
social and health policies can be made and implemented.
Lancet Commission on Primary Care in China
In the past, The Lancet has launched commissions on climate change,
medical education, HIV/AIDS, and planetary health, with an aim to place a
spotlight on neglected, emerging, or seminal topics in global public
health. A newly announced Lancet Commission led by one of our team’s
leaders, Prof. Lixin Jiang from the NCCD, will inform future policy and
research on primary care in China. This is an incredibly important topic
in China, which currently lacks a functioning primary care system. Most
care in the country is delivered in hospitals, where space, resources,
and clinical care teams are increasingly stretched. The rise of noncommunicable and chronic diseases in China necessitates a change, and the
government has started to invest heavily in village and community health
centers to develop a more proactive and responsive primary care system.
However, there is a lack of consensus on what China’s primary care system
could and should look like. Our commission will involve partnerships with
a number of leading health experts from the US and China to define
the scope of the issue and offer recommendations and potential
solutions. The end product of the 18-month commission will be a 2530,000 document with profound academic and policy impacts.
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LEADERSHI
P
Lixin Jiang is an internationally renowned
researcher in cardiovascular disease control
and management. Based at Beijing’s Fuwai
Hospital, she is also the Assistant Director at
China’s National Centre for Cardiovascular
Diseases (NCCD), Co-Director of the China
Oxford Centre for International Health
Research, and Director of the National
Cardiovascular Bio-bank Centre in China. Her
work in nationwide care quality assessment and
improvement has greatly informed healthcare
policy on the management of major diseases in
China, particularly cardiovascular disease. She
has authored 96 original research papers and
reviews and has led 6 large-scale clinical trials
involving over 100,000 Chinese patients, with
several further studies currently under way. Dr.
Jiang is also Editor-in-Chief of The Lancet
(Chinese Edition). She received a Bachelor of
Medicine from Xuzhou Medical College, a Master
of Medicine (Cardiology) from Peking University
Health Science Center, and a PhD (Cardiology)
from the Chinese Academy of Medical Sciences
and Peking Union Medical College.
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Harlan M. Krumholz is the Harold H. Hines, Jr.
Professor of Medicine, Epidemiology and
Public Health at the Yale School of Medicine in
New Haven, CT, and is a practicing
cardiologist. He serves as Director of CORE
and Co-Director of the Robert Wood Johnson
Foundation Clinical Scholars Program at Yale.
He has led research and initiatives to improve
the quality and outcomes of clinical decisions
and health care delivery, reduce disparities,
enable transparency in practice and research,
and avoid wasteful practices. He is a member
of the Association of American Physicians, the
American Society for Clinical Investigation,
and the National Academy of Medicine. He has
also been awarded the People’s Republic of
China’s Friendship Award, the country’s
highest honor to “foreign experts who have
made outstanding contributions to the
country's economic and social progress.” He
received a BS from Yale, a masters in Health
Policy and Management from the Harvard
University School of Public Health, and an MD
from Harvard Medical School.
COLLABORATORS
Robert L. McNamara, MD, MPH
Jing Li, MD, PhD
John A. Spertus, MD, MPH
Kumar Dharmarajan, MD, MBA
Shengshou Hu, MD, PhD
Frederick A. Masoudi, MD, MSPH
Nihar Desai, MD, MPH
Zhe Zheng, MD, PhD
Sharon-Lise T. Normand, PhD
Erica Spatz, MD, MHS
Haibo Zhang, MD
David J. Cohen, MD
Karthik Murigiah, MD
Xin Zheng, MD, PhD
Paul S. Chan, MD
Nicholas Downing, MD
Xi Li, MD, PhD
Ralph I. Horwitz, MD, MACP
Emily Bucholz, MD, PhD
Claire Masters, MHPol
Robert Yeh, MD, MSc, MBA
E. Kevin Hall, MBBCh
Yan Gao, MS
Xue Du, MD, PhD
Wade Schulz, MD, PhD
Jiapeng Lu, MD, PhD
Lihua Zhang, MD, PhD
Yuan Lu, ScD
Chaoqun Wu, MS
Shuang Hu, PhD
Rachel Dreyer, PhD
Meng Su, MD, PhD
Heng Zhang, MD, PhD
Zhenqiu Lin, PhD
Jiamin Liu, MD
Chenfei Rao, MD, PhD
Yongfei Wang, MS
Wuhanbilige Hundei, MD
Xiaotong, MS
Brita Roy, MD, MPH
Hao Dai, MS
Xueke Bai, MS
Jennifer Mattera, DrPH, MPH
Fang Feng, MS
Xingzi Zhang, MS
Priscilla Ding, MD, MS, RN
Wenchi Guan, MD
Xiao Xu, PhD
Yun Wang, PhD
Paul W. Horak, BS
Li Li, MD
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PUBLICATION
S
1.
Dharmarajan, K., et al., The China Patient-Centered Evaluative Assessment of Cardiac Events
(China PEACE) retrospective study of acute myocardial infarction: study design. Circ Cardiovasc
Qual Outcomes, 2013. 6(6): p. 732-40.
2.
Du, X., et al., The china patient-centered evaluative assessment of cardiac events (PEACE)
prospective study of percutaneous coronary intervention: Study design. Catheter Cardiovasc
Interv, 2016.
3.
Fan, H., et al., Risk factors and prevention of upper gastrointestinal hemorrhage after a coronary
artery bypass grafting operation. Surg Today, 2010. 40(10): p. 931-5.
4.
Gao, Y., et al., Trends in early aspirin use among patients with acute myocardial infarction in
China, 2001-2011: the China PEACE-Retrospective AMI study. J Am Heart Assoc, 2014. 3(5): p.
e001250.
5.
Guan, W., et al., National quality assessment evaluating spironolactone use during
hospitalization for acute myocardial infarction (AMI) in China: China Patient-centered
Evaluation Assessment of Cardiac Events (PEACE)-Retrospective AMI Study, 2001, 2006, and
2011. J Am Heart Assoc, 2015. 4(6): p. e001718.
6.
Hu, S., et al., Increasing long-term major vascular events and resource consumption in patients
receiving off-pump coronary artery bypass: a single-center prospective observational study.
Circulation, 2010. 121(16): p. 1800-8.
7.
Hu, S., et al., Coronary artery bypass graft: contemporary heart surgery center performance in
China. Circ Cardiovasc Qual Outcomes, 2012. 5(2): p. 214-21.
8.
Jiang, L., et al., Achieving best outcomes for patients with cardiovascular disease in China by
enhancing the quality of medical care and establishing a learning health-care system. Lancet,
2015. 386(10002): p. 1493-505.
9.
Li, J., et al., Protocol for the China PEACE (Patient-centered Evaluative Assessment of Cardiac
Events) retrospective study of coronary catheterisation and percutaneous coronary
intervention. BMJ Open, 2014. 4(3): p. e004595.
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10.
Li, J., et al., China Patient-centered Evaluative Assessment of Cardiac Events Prospective Study
of Acute Myocardial Infarction: Study Design. Chin Med J (Engl), 2016. 129(1): p. 72-80.
11.
Li, J., et al., Fibrinolytic therapy in hospitals without percutaneous coronary intervention
capabilities in China from 2001 to 2011: China PEACE-retrospective AMI study. Eur Heart J
Acute Cardiovasc Care, 2016.
12.
Li, J., et al., ST-segment elevation myocardial infarction in China from 2001 to 2011 (the China
PEACE-Retrospective Acute Myocardial Infarction Study): a retrospective analysis of hospital
data. Lancet, 2015. 385(9966): p. 441-51.
13.
Li, Q., et al., National trends in hospital length of stay for acute myocardial infarction in China.
BMC Cardiovasc Disord, 2015. 15: p. 9.
14.
Li, Y., et al., Comparison of drug-eluting stents and coronary artery bypass surgery for the
treatment of multivessel coronary disease: three-year follow-up results from a single institution.
Circulation, 2009. 119(15): p. 2040-50.
15.
Liu, J., et al., Patterns of use of angiotensin-converting enzyme inhibitors/angiotensin receptor
blockers among patients with acute myocardial infarction in China from 2001 to 2011: China
PEACE-Retrospective AMI Study. J Am Heart Assoc, 2015. 4(2).
16.
Lu, J., et al., Protocol for the China PEACE (Patient-centered Evaluative Assessment of Cardiac
Events) Million Persons Project pilot. BMJ Open, 2016. 6(1): p. e010200.
17.
Rao, C., et al., The China Patient-Centred Evaluative Assessment of Cardiac Events (China
PEACE)-Prospective Study of 3-Vessel Disease: rationale and design. BMJ Open, 2016. 6(2): p.
e009743.
18.
Rao, C., et al., The Chinese Cardiac Surgery Registry: Design and Data Audit. Ann Thorac Surg,
2016. 101(4): p. 1514-20.
19.
Spatz, E.S., et al., Qingdao Port Cardiovascular Health Study: a prospective cohort study. BMJ
Open, 2015. 5(12): p. e008403.
20.
Yin, E.S., et al., Organizational culture in cardiovascular care in Chinese hospitals: a descriptive
cross-sectional study. BMC Health Serv Res, 2015. 15: p. 569.
21.
Zhan, L., et al., Trends in cardiac biomarker testing in China for patients with acute myocardial
infarction, 2001 to 2011: China PEACE-retrospective AMI study. PLoS One, 2015. 10(3): p.
e0122237.
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22.
Zhang, H., et al., National assessment of early beta-blocker therapy in patients with acute
myocardial infarction in China, 2001-2011: The China Patient-centered Evaluative Assessment
of Cardiac Events (PEACE)-Retrospective AMI Study. Am Heart J, 2015. 170(3): p. 506-15.e1.
23.
Zhang, H., et al., Influence of diabetes mellitus on long-term clinical and economic outcomes
after coronary artery bypass grafting. Ann Thorac Surg, 2014. 97(6): p. 2073-9.
24.
Zhang, H., et al., Efficacy of Long-Term beta-Blocker Therapy for Secondary Prevention of LongTerm Outcomes After Coronary Artery Bypass Grafting Surgery. Circulation, 2015. 131(25): p.
2194-201.
25.
Zhang, L., et al., National Quality Assessment of Early Clopidogrel Therapy in Chinese Patients
With Acute Myocardial Infarction (AMI) in 2006 and 2011: Insights From the China PatientCentered Evaluative Assessment of Cardiac Events (PEACE)-Retrospective AMI Study. J Am
Heart Assoc, 2015. 4(7).
26.
Zhang, L., et al., National Assessment of Statin Therapy in Patients Hospitalized with Acute
Myocardial Infarction: Insight from China PEACE-Retrospective AMI Study, 2001, 2006, 2011.
PLoS One, 2016. 11(4): p. e0150806.
27.
Zheng, X., et al., Coronary Catheterization and Percutaneous Coronary Intervention in China:
10-Year Results From the China PEACE-Retrospective CathPCI Study. JAMA Intern Med, 2016.
176(4): p. 512-21.
28.
Zheng, X., et al., Age-specific gender differences in early mortality following ST-segment
elevation myocardial infarction in China. Heart, 2015. 101(5): p. 349-55.
“Knowledge generated from these studies has been published in premier
journals, and will inform policy-making and clinical practice. The
collaboration makes enormous contributions in promoting medical and
public health advances, informing China’s health reform and also helping to
reduce the soaring disease burden faced by our two countries and the world.”
Zhe Yang, Deputy Director
Department of Science and Technology for Social Development
Ministry of Science and Technology, The People’s Republic of China
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