Résumé

Objectif

Surveiller la prévalence, la sensibilisation, le traitement et le contrôle de l'hypertension en Chine deux à trois ans après une réforme majeure du système de santé.

Méthodes

Les données d'une enquête nationale menée en 2011-2012 auprès de Chinois âgés de 45 ans ou plus (qui comprenait des mesures anthropométriques détaillées) ont été utilisées pour estimer la prévalence de l'hypertension et les pourcentages de patients souffrant d'hypertension, qui ne connaissaient pas, ne recevaient pas de traitement et/ou ne surveillaient pas correctement leur hypertension. Des modèles de Poisson modifiés ont été utilisés pour estimer les risques relatifs (RR).

Résultats

Au moment de l'enquête, près de 40% des individus chinois âgés de 45 ans ou plus présentaient un trouble de l'hypertension. Parmi les personnes souffrant d'hypertension, plus de 40% ignoraient leur maladie, environ 50% ne recevaient aucun médicament pour la traiter et environ 80% ne la surveillaient pas correctement. En comparaison avec les autres individus souffrant d'hypertension, ceux qui étaient affiliés à des régimes d'assurance couvrant les coûts des soins ambulatoires étaient plus susceptibles d'être au courant de leur hypertension (RR ajusté, rra: 0,737; intervalle de confiance à 95%, IC: 0,619 à 0,878), à recevoir un traitement pour la traiter (rra: 0,795; IC à 95%: 0,680 à 0,929) et à la contrôler efficacement (rra: 0,903; IC à 95%: 0,817 à 0,996).

Conclusion

En Chine, de nombreux cas d'hypertension restent non détectés et non traités, même si le système de santé semble offrir des soins efficaces aux personnes qui savent qu'elles souffrent d'hypertension. Une réduction des coûts des soins ambulatoires prodigués aux patients pourrait probablement améliorer la gestion de l'hypertension en Chine.

Resumen

Objetivo

Inspeccionar la prevalencia, concienciación, tratamiento y control de la hipertensión en China dos o tres años después de la reforma principal del sistema sanitario.

Métodos

Se emplearon los datos de una encuesta nacional realizada en 2011-2012 entre la población china de 45 años o más, que incluyó mediciones antropométricas en detalle, para estimar la prevalencia de la hipertensión y los porcentajes de individuos hipertensos que desconocían padecer esta condición, no recibían tratamiento, y/o no controlaban la hipertensión correctamente. Se utilizaron regresiones de Poisson modificadas para estimar los riesgos relativos (RR).

Resultados

En el momento de la encuesta, casi el 40 % de los chinos de 45 años o más sufría un trastorno de hipertensión. Entre las personas hipertensas, más del 40 % no era consciente de su condición, el 50 % no recibía ningún medicamento para la hipertensión y el 80 % no la controlaba adecuadamente. En comparación con los otros individuos hipertensos, aquellos que eran miembros de planes de seguros que cubrían los costes de la atención ambulatoria eran más susceptibles de ser conscientes de padecer hipertensión (RR ajustado, RRA: 0,737, intervalo de confianza del 95 %, IC: 0,619 a 0,878) recibir el tratamiento correspondiente (RRA: 0,795, IC del 95 %: 0,680–0,929) y controlarla de forma eficaz (RRA: 0,903; 95% CI: 0,817–0,996).

Conclusión

En China muchos casos de hipertensión no se diagnostican ni se tratan, incluso aunque el sistema sanitario parece ofrecer una atención eficaz a las personas conscientes de que la padecen. Reducir las tasas de atención ambulatoria a los pacientes probablemente mejoraría la gestión de la hipertensión en China.

ملخص

الغرض

رصد انتشار فرط ضغط الدم والتوعية به وعلاجه ومكافحته في الصين عقب سنتين إلى ثلاث سنوات من الإصلاح الرئيسي الذي شهده النظام الصحي.

الطريقة

تم استخدام البيانات من مسح وطني أجري في الفترة من 2011 إلى 2012 بين الأشخاص الصينيين الذين تبلغ أعمارهم 45 عاماً فأكثر – والتي اشتملت على قياسات بشرية مفصلة – لتقييم انتشار فرط ضغط الدم والنسب المئوية للأفراد المصابين بفرط ضغط الدم الذين لا يدركون إصابتهم بفرط ضغط الدم أو لا يتلقون علاجاً له و/أو لا يكافحونه بشكل جيد. وتم استخدام ارتدادات بواسون المعدلة لتقييم الخطورة النسبية (RRs).

النتائج

كانت نسبة 40 % من الأشخاص الصينيين الذين تبلغ أعمارهم 45 عاماً فأكثر مصابة باضطراب فرط ضغط الدم وقت المسح. وكان أكثر من 40 % من الأفراد المصابين بفرط ضغط الدم غير مدركين لحالتهم ولم يتلق حوالي 50 % أي علاج له، ولم تكافحه بشكل جيد نسبة 80 % تقريباً. ومقارنة بغيرهم من الأفراد المصابين بفرط ضغط الدم، يرجح إدراك الأفراد، المشاركين في مخططات تأمين غطت تكاليف رعاية المرضى الخارجيين، إصابتهم بفرط ضغط الدم (الخطورة النسبية المعدلة: 0.737؛ فاصل الثقة 95 %، فاصل الثقة: من 0.619 إلى 0.878) والذين يتلقون علاجاً له (الخطورة النسبية المعدلة: 0.795؛ فاصل الثقة 95 %، فاصل الثقة: من 0.680 إلى 0.929) والذين يكافحونه بفعالية (الخطورة النسبية المعدلة: 0.903؛ فاصل الثقة: من 0.817 إلى 0.996).

الاستنتاج

لا يتم اكتشاف العديد من حالات فرط ضغط الدم أو علاجها في الصين، على الرغم مما يبدو من أن النظام الصحي يقدم رعاية فعالة للأفراد الذين يدركون إصابتهم بفرط ضغط الدم. ومن المحتمل أن يحسّن خفض تكاليف رعاية المرضى الخارجيين إلى المرضى من تدبير فرط ضغط الدم في الصين.

摘要

目的

监测中国在医疗卫生体制重大改革两到三年之后的高血压患病率、知晓率、治疗率和控制率。

方法

使用来自2011-2012 年针对45 岁或以上中国人的全国性调查的数据(包括详细的人体测量数据)来估计高血压的患病率以及不知道、没有接受治疗和/或没有很好控制其高血压病情的高血压患者百分比。使用修正泊松回归估计相对风险(RR)。

结果

在调查中,近40%年龄在45 岁或以上的中国人有高血压症。高血压患者中超过40%的人不知道其病情,约50%的患者没有接受药物治疗,大约80%患者的病情没有控制得很好。相比其他的高血压患者,门诊医疗费用由医保报销的参保人员则更有可能知晓到自己有高血压(调整RR,aRR:0.737;95%置信区间,CI:0.619–0.878)、接受治疗(aRR:0.795;95% CI:0.680–0.929)以及进行有效的控制(aRR:0.903;95% CI:0.817–0.996))。

结论

在中国,尽管卫生系统似乎对知晓到患有高血压的个人提供了有效的护理,但是很多高血压病例仍未得到发现和治疗。减少患者医疗门诊的成本可能会改善中国高血压的管理状况。

Резюме

Цель

Отслеживание распространенности , осведомленности, лечения и контроля гипертензии в Китае спустя два-три года после масштабной реформы здравоохранения.

Методы

Данные национальных медицинских осмотров, собранные в 2011-2012 гг. у жителей Китая в возрасте 45 лет и старше, включающие подробные антропометрические измерения, использовались для оценки распространенности гипертензии и процентной доли лиц с гипертензией, которые не были осведомлены о ее наличии, не получали лечение и/или не контролировали свою гипертензию должным образом. Для оценки относительного риска (RR) применялся модифицированный метод регрессии Пуассона.

Результаты

В ходе исследования гипертензивные расстройства были обнаружены приблизительно у 40% жителей Китая в возрасте 45 лет и старше. Среди лиц с гипертензией более 40% не были осведомлены о своем состоянии, около 50% не получали медикаментозного лечения и около 50% не контролировали это состояние должным образом. В сравнении с другими лицами, страдающими гипертензией, участники страховых схем, покрывающих расходы на амбулаторное лечение, с большей вероятностью были осведомлены о своей гипертензии (приведенный показатель RR, aRR: 0,737; 95% доверительный интервал, CI: 0,619–0,878), подвергались лечению по этому поводу (aRR: 0,795; 95% CI: 0,680–0,929) и эффективно контролировали свое состояние (aRR: 0,903; 95% CI: 0,817–0,996).

Вывод

В Китае множество случаев гипертензии остаются необнаруженными и не подвергаются лечению, хотя система здравоохранения оказывает эффективную помощь лицам, которые осведомлены о своей гипертензии. Снижение расходов пациентов на амбулаторное лечение, по всей вероятности, способно улучшить контроль гипертензии в Китае.

Introduction

Cardiovascular and other noncommunicable diseases are currently responsible for two thirds of global mortality.¹1 Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095–128. doi: http://dx.doi.org/10.1016/S0140- 6736(12)61728-0 PMID:23245604
https://doi.org/10.1016/S0140-6736(12)61... ^,22 Global status report on noncommunicable diseases 2010.GenevaWorld Health Organization2011 Universal health coverage may allow great improvements in the control of such diseases³3 Global status report on noncommunicable diseases 2010. Geneva: World Health Organization; 2011
https://doi.org/10.1016/S0140-6736(13)60... ^,44 Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. New York: United Nations; 2011. but the best way to achieve such coverage, especially in low- and middle-income countries, remains unclear.⁵5 Maimaris W, Paty J, Perel P, Legido-Quigley H, Balabanova D, Nieuwlaat R et al. The influence of health systems on hypertension awareness, treatment, and control: a systematic literature review. PLoS Med 2013;10:e1001490. doi: http://dx.doi.org/10.1371/journal.pmed.1001490 PMID:23935461
https://doi.org/10.1371/journal.pmed.100...

Hypertension is a consistent and independent risk factor for cardiovascular and kidney diseases and stroke.⁶6 Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13. doi: http://dx.doi. org/10.1016/S0140-6736(02)11911-8 PMID:12493255
https://doi.org/10.1016/S0140-6736(02)11... It is also very common, its global prevalence being about 40%.²2 Global status report on noncommunicable diseases 2010.GenevaWorld Health Organization2011 Hypertension, which plays a part in approximately 55% of the global mortality caused by cardiovascular diseases and in 7% of all disability-adjusted life years,⁷7 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224–60. doi: http://dx.doi.org/10.1016/S0140-6736(12)61766-8 PMID:23245609
https://doi.org/10.1016/S0140-6736(12)61... could be managed at fairly low cost, even in resource-poor settings.⁸8 A global brief on hypertension – silent killer, global public health crisis. Geneva: World Health Organization; 2013.^–1010 Lu Z, Cao S, Chai Y, Liang Y, Bachmann M, Suhrcke M et al. Effectiveness of interventions for hypertension care in the community – a meta-analysis of controlled studies in China. BMC Health Serv Res 2012;12:216. doi: http:// dx.doi.org/10.1186/1472-6963-12-216 PMID:22827968
https://doi.org/10.1186/1472-6963-12-216... In the developed world, more than 80% of people with hypertension are aware of their condition and receiving treatment.¹¹11 Guo F, He D, Zhang W, Walton RG. Trends in prevalence, awareness, management, and control of hypertension among United States adults, 1999 to 2010. J Am Coll Cardiol 2012;60:599–606. doi: http://dx.doi. org/10.1016/j.jacc.2012.04.026 PMID:22796254
https://doi.org/10.1016/j.jacc.2012.04.0... ^–1313 Guessous I, Bochud M, Theler JM, Gaspoz J-M, Pechère-Bertschi A. 1999–2009 trends in prevalence, unawareness, treatment and control of hypertension in Geneva, Switzerland. PLoS One 2012;7:e39877. doi: http:// dx.doi.org/10.1371/journal.pone.0039877 PMID:22761919
https://doi.org/10.1371/journal.pone.003... However, the health systems in most developing countries fail to detect and manage hypertension effectively.¹⁴14 Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet 2012;380:611–9. doi: http://dx.doi.org/10.1016/S0140-6736(12)60861-7 PMID:22883510
https://doi.org/10.1016/S0140-6736(12)60... ^,1515 Basu S, Millett C. Social epidemiology of hypertension in middle-income countries: determinants of prevalence, diagnosis, treatment, and control in the WHO SAGE study. Hypertension 2013;62:18–26. doi: http://dx.doi. org/10.1161/HYPERTENSIONAHA.113.01374 PMID:23670299
https://doi.org/10.1161/HYPERTENSIONAHA....

In China, the overall prevalence of hypertension rose substantially between 2002 and 2010 – from around 20% to 34%.¹⁶16 Yang ZJ, Liu J, Ge JP, Chen L, Zhao Z-G, Yang W-Y; China National Diabetes and Metabolic Disorders Study Group. Prevalence of cardiovascular disease risk factor in the Chinese population: the 2007–2008 China National Diabetes and Metabolic Disorders Study. Eur Heart J 2012;33:213–20. doi: http://dx.doi.org/10.1093/eurheartj/ehr205 PMID:21719451
https://doi.org/10.1093/eurheartj/ehr205... ^–1818 Chinese Centre for Disease Control and Prevention. Report on chronic disease risk factor surveillance in China 2010. Beijing: Military Medical Science Press; 2012. Unfortunately, the management of hypertension in China has been ineffective for many years. In 2010, for example, only 35.7% of hypertensive individuals were aware of their condition and fewer than 18% of such individuals were effectively controlling their hypertension.¹⁷17 Wu Y, Huxley R, Li L, Anna V, Xie G, Yao C et al.; China NNHS Steering Committee; China NNHS Working Group. Prevalence, awareness, treatment, and control of hypertension in China: data from the China National Nutrition and Health Survey 2002. Circulation 2008;118:2679–86. doi: http:// dx.doi.org/10.1161/CIRCULATIONAHA.108.788166 PMID:19106390
https://doi.org/10.1161/CIRCULATIONAHA.1... ^–1919 Gu D, Reynolds K, Wu X, Chen J, Duan X, Muntner P et al.; InterASIA Collaborative Group. The International Collaborative Study of Cardiovascular Disease in ASIA. Prevalence, awareness, treatment, and control of hypertension in china. Hypertension 2002;40:920–7. doi: http://dx.doi. org/10.1161/01.HYP.0000040263.94619.D5 PMID:12468580
https://doi.org/10.1161/01.HYP.000004026... It has been estimated that hypertension was associated with 20% of the deaths recorded in China in 2005, including 2.33 million – nearly 80% – of the deaths from cardiovascular disease.²⁰20 He J, Gu D, Chen J, Wu X, Kelly TN, Huang JF et al. Premature deaths attributable to blood pressure in China: a prospective cohort study. Lancet 2009;374:1765–72. doi: http://dx.doi.org/10.1016/S0140-6736(09)61199-5 PMID:19811816
https://doi.org/10.1016/S0140-6736(09)61... Hypertension not only causes premature death; it may also add to household costs. In a study conducted in rural China, for example, it was estimated that 4.1% of households suffered impoverishment as a result of hypertension.²¹21 Le C, Zhankun S, Jun D, Keying Z. The economic burden of hypertension in rural south-west China. Trop Med Int Health 2012;17:1544–51. doi: http:// dx.doi.org/10.1111/j.1365-3156.2012.03087.x PMID:22973901
https://doi.org/10.1111/j.1365-3156.2012...

The prevention and control of noncommunicable diseases have been on China's policy agenda for decades.²²22 Wang L, Kong L, Wu F, Bai Y, Burton R. Preventing chronic diseases in China. Lancet 2005;366:1821–4. doi: http://dx.doi.org/10.1016/S0140- 6736(05)67344-8 PMID:16298221
https://doi.org/10.1016/S0140-6736(05)67... In 2009, however, there was a huge reform of the national health system. The main aim of this reform was to attain universal coverage with affordable and equitable basic health care.²³23 Chen Z. Launch of the health-care reform plan in China. Lancet 2009;373:1322–4. doi: http://dx.doi.org/10.1016/S0140-6736(09)60753-4 PMID:19376436
https://doi.org/10.1016/S0140-6736(09)60... ^,2424 YipWCHsiaoWCChenWHuSMaJMaynardAEarly appraisal of China's huge and complex health-care reforms.Lancet20123798334210.1016/S0140-6736(11)61880-122386036
https://doi.org/10.1016/S0140-6736(11)61... Three of the five pillars of the reform – a national programme of primary health care, a national essential medicine system and universal health insurance – are directly linked to the management of noncommunicable diseases.

Each year, the national programme of primary health care now spends 25 yuan per capita – or about 6.3 billion United States dollars in total – on community health-care providers. These providers work in urban community health-care centres or rural township hospitals and deliver a defined package of health care that includes the management of noncommunicable diseases.²³23 Chen Z. Launch of the health-care reform plan in China. Lancet 2009;373:1322–4. doi: http://dx.doi.org/10.1016/S0140-6736(09)60753-4 PMID:19376436
https://doi.org/10.1016/S0140-6736(09)60... ^–2525 Liang L, Langenbrunner JC. The long march to universal coverage: lessons from China. Universal Health Coverage (UNICO) studies series. Washington: The World Bank; 2013. The centres for community health care are responsible for establishing a health record and providing free health examinations – that include the measurement of blood pressure – for every person living in their catchment areas. The centres also provide advice on anti-hypertensive medication and hypertension control whenever appropriate. They should have access to more than 400 essential medicines, including various anti-hypertensive drugs such as beta blockers and calcium channel blockers. Provision of these medicines is heavily subsidized by the Chinese government on a non-profit basis.²⁶26 Li Y, Ying C, Sufang G, Brant P, Bin L, Hipgrave D. Evaluation, in three provinces, of the introduction and impact of China’s National Essential Medicines Scheme. Bull World Health Organ 2013;91:184–94. doi: http:// dx.doi.org/10.2471/BLT.11.097998 PMID:23476091
https://doi.org/10.2471/BLT.11.097998... Development of the two national programmes (primary health care and essentials medicine system) was expected to lead to substantial improvements in the detection, treatment and control of hypertension.

Universal health insurance coverage was another goal of the health system reform launched in 2009. The achievement of this goal is slightly hampered by the number of health insurance schemes that exist in China and by the variation in the type and extent of the coverage offered by these schemes. In urban China, the Employee Basic Medical Insurance Scheme covers some of the employed. Some government employees are – or were – covered by the Government Insurance Scheme, while some other urban dwellers are covered by the Urban Resident Basic Medical Insurance Scheme. In rural areas, a New Cooperative Medical Scheme has been developed. Although health insurance has already become almost universal in China,²⁴24 YipWCHsiaoWCChenWHuSMaJMaynardAEarly appraisal of China's huge and complex health-care reforms.Lancet20123798334210.1016/S0140-6736(11)61880-122386036
https://doi.org/10.1016/S0140-6736(11)61... ^,2525 Liang L, Langenbrunner JC. The long march to universal coverage: lessons from China. Universal Health Coverage (UNICO) studies series. Washington: The World Bank; 2013. most of the population relies either on the Urban Resident Basic Medical Insurance Scheme or the New Cooperative Medical Scheme. These schemes focus on inpatient expenses and offer almost no reimbursement for outpatient costs.²⁵25 Liang L, Langenbrunner JC. The long march to universal coverage: lessons from China. Universal Health Coverage (UNICO) studies series. Washington: The World Bank; 2013. Individuals who have to pay for outpatient care from their own pockets may be reluctant to seek medical care or advice and may never be checked for hypertension or other noncommunicable disorders until they are very ill and facing catastrophic expenditure.²⁷27 Yip W, Hsiao WC. Non-evidence-based policy: how effective is China’s new cooperative medical scheme in reducing medical impoverishment? Soc Sci Med 2009;68:201–9. doi: http://dx.doi.org/10.1016/j.socscimed.2008.09.066 PMID:19019519
https://doi.org/10.1016/j.socscimed.2008... ^–2929 Jing S, Yin A, Shi L, Liu J. Whether New Cooperative Medical Schemes reduce the economic burden of chronic disease in rural China. PLoS One 2013;8:e53062. doi: http://dx.doi.org/10.1371/journal.pone.0053062 PMID:23326382
https://doi.org/10.1371/journal.pone.005...

We investigated the prevalence, awareness, treatment and control of hypertension in China by using data from a national survey that was conducted in 2011–2012. The results indicate that changes in health financing and insurance may improve the detection and management of hypertension in China.

Methods

We used data collected in the China Health and Retirement Longitudinal Study (CHARLS) of Chinese people aged 45 years or older.³⁰30 Zhao Y, Hu Y, Smith JP, Strauss J, Yang G. Cohort profile: the China Health and Retirement Longitudinal Study (CHARLS). Int J Epidemiol 2012. Forthcoming doi: http://dx.doi.org/10.1093/ije/dys203 PMID:23243115
https://doi.org/10.1093/ije/dys203... ^,3131 Zhao Y, Strauss J, Yang G, et al. China health and retirement longitudinal study– 2011-2012 national baseline users' guide. Beijing: Peking University; 2013. The data were collected in a survey in which four-stage, stratified, cluster sampling was used to select eligible individuals. In the first stage, 150 county-level units from 28 provinces were selected to give a mix of urban and rural settings and a wide variation in the level of economic development. Three primary sampling units – administrative villages (cun) in rural areas and neighbourhoods (shequ) in urban areas – were then chosen in each selected county-level unit. All of the dwellings in each selected primary sampling unit were then outlined on Google Earth maps using the “CHARLS-GIS” software package that was specifically designed for the survey. Finally, for the present investigation, 24 of the mapped households in each primary sampling unit were randomly selected. If a selected household had more than one member aged 45 years or older, one such member – randomly chosen – and his or her spouse if also aged 45 years or older were selected as subjects of the survey. Overall, 17 708 individuals were investigated.³⁰30 Zhao Y, Hu Y, Smith JP, Strauss J, Yang G. Cohort profile: the China Health and Retirement Longitudinal Study (CHARLS). Int J Epidemiol 2012. Forthcoming doi: http://dx.doi.org/10.1093/ije/dys203 PMID:23243115
https://doi.org/10.1093/ije/dys203...

A structured questionnaire with several main sections was used to collect data from each subject. One section was used to record height, weight and blood pressure. Each subject's systolic and diastolic blood pressures were recorded three times by a trained nurse using an HEM-7112 electronic monitor (Omron, Kyoto, Japan). The mean values for each subject were then calculated but only given to the subjects once the interviews had ended. The interviewees were asked if they had hypertension and whether they were taking any form of anti-hypertensive medication, including Chinese traditional medicines. A subject was considered hypertensive if he or she had a mean systolic blood pressure of ≥ 140 mmHg, a mean diastolic blood pressure of ≥ 90 mmHg and/or was already taking anti-hypertensive medication.²2 Global status report on noncommunicable diseases 2010.GenevaWorld Health Organization2011 A systolic blood pressure of ≥ 160 mmHg or a diastolic blood pressure of ≥ 100 mmHg was considered indicative of stage 2 hypertension, while corresponding values of ≥ 180 and ≥ 110 mmHg were considered indicative of stage 3.³²32 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr et al.; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560–72. doi: http://dx.doi.org/10.1001/ jama.289.19.2560 PMID:12748199
https://doi.org/10.1001/jama.289.19.2560... Hypertensive persons who had previously received a doctor's diagnosis of hypertension or simply claimed to be hypertensive were considered to be aware of their hypertension. Hypertensive persons who claimed to be receiving any form of anti-hypertensive medication were considered to have treated hypertension. Hypertensive persons whose systolic blood pressure was < 140 mmHg or whose diastolic blood pressure was < 90 mmHg – or both – were considered to be controlling their hypertension well.¹⁴14 Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet 2012;380:611–9. doi: http://dx.doi.org/10.1016/S0140-6736(12)60861-7 PMID:22883510
https://doi.org/10.1016/S0140-6736(12)60...

Subjects were asked if they belonged to a health-insurance scheme and, if so, to identify the scheme. The schemes were separated into those providing the costs of outpatient care – the Employee Basic Medical Insurance Scheme and the Government Insurance Scheme – and those that contributed nothing or almost nothing to the costs of outpatient care – the Urban Resident Basic Medical Insurance Scheme or the New Cooperative Medical Scheme. All of the respondents with anthropometric measurements had health insurance.

One section of the questionnaire investigated the socioeconomic status of each subject and his or her modifiable indicators of hypertension risk. The socioeconomic factors investigated were setting, geographical region, sex, age, marital status, level of education and household income. Each subject was classified as a long-term urban resident, a long-term rural resident or a rural resident who had moved into an urban area. Level of education was categorized as illiterate, primary education only, secondary education but no higher, or educated to at least college level. Household income was split into five quintiles. The modifiable risk factors that we considered were body mass index, how often the subject drank alcohol in a month, whether the subject smoked tobacco every day, the subject's level of exercise, the number of times in the previous year that the subject's blood pressure had been measured, and whether the subject had had a health examination in the previous two years. A subject was categorized as “active” if he or she engaged in 30 minutes of moderate activity at least five times per week or in 20 minutes of vigorous activity at least three times per week. Those who engaged in < 10 minutes of continuous exercise each week were categorized as “sedentary”. All other subjects were considered to be “less active”.²2 Global status report on noncommunicable diseases 2010.GenevaWorld Health Organization2011

In the results, we report both weighted and unweighted proportions. The weights take account of the national representativeness of the results and the missing anthropometric measurements.³¹31 Zhao Y, Strauss J, Yang G, et al. China health and retirement longitudinal study– 2011-2012 national baseline users' guide. Beijing: Peking University; 2013. Multilevel Poisson regression was used – with allowance for the sample stratification and clustering at village and household level – to determine – for various groups – the crude and adjusted relative risks (RRs) for lack of awareness of hypertension in a hypertensive individual, lack of anti-hypertensive treatment of a hypertensive individual and failure of a hypertensive individual to control his or her hypertension well. Poisson regression was used because we wanted to compute RRs rather than odds ratios.³³33 Feng XL, Xu L, Guo Y, Ronsmans C. Socioeconomic inequalities in hospital births in China between 1988 and 2008. Bull World Health Organ 2011;89:432–41. doi: http://dx.doi.org/10.2471/BLT.10.085274 PMID:21673859
https://doi.org/10.2471/BLT.10.085274... Potential explanatory variables were added individually to determine their effects on the magnitudes of the RRs.

Results

Although 17 708 individuals were surveyed, full data were only available for 13 707 of them (Fig. 1). The proportion of subjects with any missing observations appeared unaffected by age, sex, level of education, setting, household income or marital status.³¹31 Zhao Y, Strauss J, Yang G, et al. China health and retirement longitudinal study– 2011-2012 national baseline users' guide. Beijing: Peking University; 2013. Although 22.7% of the interviewees who reported hypertension had missing information, the corresponding value for those not reporting hypertension – 20.8% – was similar.

Table 1 summarizes the background characteristics of the 13 707 subjects who were included in the final analysis. The weighted proportions were similar to the unweighted values. Most of the subjects lived in urban areas and were literate. Most belonged to health insurance schemes that did not cover the costs of outpatient care.

Of the 13 707 individuals whose data were analysed, 5295 (38.6%) were found to have hypertension, although the more severe forms of hypertension – stages 2 and 3 – were relatively rare (Table 2). More than 40% of the individuals found to have hypertension were unaware that they were hypertensive, more than half were not receiving any form of anti-hypertensive medication and < 20% were controlling their hypertension well (Table 2). The prevalence of hypertension was higher among urban than among rural residents – with weighted values of 44.8% and 37.1%, respectively – but, compared with their urban counterparts, rural hypertensive subjects were slightly less likely to be aware of their hypertension and to be on medication. There were no differences between urban and rural subjects in terms of hypertension control (Table 2).

Many of the subjects were overweight (weighted percentage: 26.5%) or obese (6.1%) and more than one in every five of them drank alcohol at least twice per month or smoked every day (Table 2). Most of the subjects lived sedentary lives, most had not had their blood pressure measured in the previous year, and most had not had a health examination in the previous 2 years (Table 2). In terms of the prevalences of these modifiable risk factors, the surveyed subjects in urban areas were similar to those in rural areas (Table 2).

When the subjects were divided into five age groups – < 50, 50–59, 60–69, 70–79 and ≥ 80 years – the prevalence of hypertension in every age group was found to be slightly higher among the members of health insurance schemes that covered the costs of outpatient care than among the members of other health insurance schemes (Fig. 2). However, the three aspects of the management of hypertension that we investigated – awareness, treatment and effective control – were also more common among the members of health insurance schemes that covered the costs of outpatient care (Fig. 3).

In terms of the awareness (Table 3) and treatment (Table 4) of hypertension, the differences seen between urban residents and rural residents were smaller than – and could be fully explained by – those seen between the two types of insurance coverage. After adjusting for sex, age, marital status, level of education and household income, the hypertensive members of health insurance schemes that covered the costs of outpatient care appeared to be more likely to be aware of their disorder (RR: 1.357; 95% confidence interval, CI: 1.139–1.616) and more likely to be receiving anti-hypertensive treatment (RR: 1.258; 95% CI: 1.010–1.471) than the other hypertensive subjects.

Compared with their female counterparts, hypertensive males were significantly less likely to be aware of their hypertension (Table 3) and to be receiving anti-hypertensive treatment (Table 4). Marital status and household income did not appear to have a significant independent effect on the management of hypertension. However, compared with their literate counterparts, the hypertensive subjects who were illiterate were significantly less likely to be aware of their hypotension (Table 3) and to be receiving anti-hypertensive treatment (Table 4).

Factors associated with the effective control of hypertension are shown in Table 5. Again, the differences seen between urban residents and rural residents could be fully explained by the type of insurance coverage. After adjusting for demographic factors, the RR for the effective control of hypertension among the members of insurance schemes that did not cover outpatient care – compared with the risk among members of other schemes – was 0.869 (95% CI: 0.783–0.965). Further adjustment – to include all of the modifiable risk factors – changed this RR again, to 0.903 (95% CI: 0.817–0.996). The significant association of the type of insurance scheme with hypertension management persisted after adjusting for all other potential differentials. Obesity appears to be the only other investigated factor that had a statistically significant association with the effective control of hypertension (Table 5).

Discussion

Using data collected in 2011–2012 from the CHARLS national survey, we found that nearly 40% of the inhabitants of China who are aged 45 years or older have some form of hypertensive disorder. Of the interviewees who were found to have hypertension at the time of the interview, more than 40% were unaware of their hypertension and about a half were not receiving any anti-hypertensive medication – irrespective of where they lived or their socioeconomic status. Although high prevalences and poor management of hypertension have been reported in China on several occasions,¹⁵15 Basu S, Millett C. Social epidemiology of hypertension in middle-income countries: determinants of prevalence, diagnosis, treatment, and control in the WHO SAGE study. Hypertension 2013;62:18–26. doi: http://dx.doi. org/10.1161/HYPERTENSIONAHA.113.01374 PMID:23670299
https://doi.org/10.1161/HYPERTENSIONAHA.... ^–1919 Gu D, Reynolds K, Wu X, Chen J, Duan X, Muntner P et al.; InterASIA Collaborative Group. The International Collaborative Study of Cardiovascular Disease in ASIA. Prevalence, awareness, treatment, and control of hypertension in china. Hypertension 2002;40:920–7. doi: http://dx.doi. org/10.1161/01.HYP.0000040263.94619.D5 PMID:12468580
https://doi.org/10.1161/01.HYP.000004026... ^,3434 Zhao Y, Yan H, Marshall RJ, Dang S, Yang R, Li Q et al. Trends in population blood pressure and prevalence, awareness, treatment, and control of hypertension among middle-aged and older adults in a rural area of northwest China from 1982 to 2010. PLoS One 2013;8:e61779. doi: http:// dx.doi.org/10.1371/journal.pone.0061779 PMID:23613932
https://doi.org/10.1371/journal.pone.006... ^–3737 Ma WJ, Tang JL, Zhang YH, Xu YJ, Lin JY, Li JS et al. Hypertension prevalence, awareness, treatment, control, and associated factors in adults in southern China. Am J Hypertens 2012;25:590–6. doi: http://dx.doi.org/10.1038/ ajh.2012.11 PMID:22337206
https://doi.org/10.1038/ajh.2012.11... it is disappointing to observe these problems two to three years after substantial reforms to the health system. The management of hypertension in China appears no better than that in other developing countries¹⁴14 Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet 2012;380:611–9. doi: http://dx.doi.org/10.1016/S0140-6736(12)60861-7 PMID:22883510
https://doi.org/10.1016/S0140-6736(12)60... ^,1515 Basu S, Millett C. Social epidemiology of hypertension in middle-income countries: determinants of prevalence, diagnosis, treatment, and control in the WHO SAGE study. Hypertension 2013;62:18–26. doi: http://dx.doi. org/10.1161/HYPERTENSIONAHA.113.01374 PMID:23670299
https://doi.org/10.1161/HYPERTENSIONAHA.... and the effective control of hypertension appeared to be as rare in China in 2011–2012 as it was a decade earlier.¹⁷17 Wu Y, Huxley R, Li L, Anna V, Xie G, Yao C et al.; China NNHS Steering Committee; China NNHS Working Group. Prevalence, awareness, treatment, and control of hypertension in China: data from the China National Nutrition and Health Survey 2002. Circulation 2008;118:2679–86. doi: http:// dx.doi.org/10.1161/CIRCULATIONAHA.108.788166 PMID:19106390
https://doi.org/10.1161/CIRCULATIONAHA.1... ^,1919 Gu D, Reynolds K, Wu X, Chen J, Duan X, Muntner P et al.; InterASIA Collaborative Group. The International Collaborative Study of Cardiovascular Disease in ASIA. Prevalence, awareness, treatment, and control of hypertension in china. Hypertension 2002;40:920–7. doi: http://dx.doi. org/10.1161/01.HYP.0000040263.94619.D5 PMID:12468580
https://doi.org/10.1161/01.HYP.000004026... Given that hypertension can be prevented and controlled at low cost,⁸8 A global brief on hypertension – silent killer, global public health crisis. Geneva: World Health Organization; 2013.^–1010 Lu Z, Cao S, Chai Y, Liang Y, Bachmann M, Suhrcke M et al. Effectiveness of interventions for hypertension care in the community – a meta-analysis of controlled studies in China. BMC Health Serv Res 2012;12:216. doi: http:// dx.doi.org/10.1186/1472-6963-12-216 PMID:22827968
https://doi.org/10.1186/1472-6963-12-216... there is no good reason why hypertension in China cannot be managed as well as hypertension in other, more developed countries. In Europe, Japan and North America, for example, more than 80% of hypertensive individuals are aware of their hypertension, more than 80% are receiving anti-hypertensive treatment and more than 60% are controlling their hypertension well.¹¹11 Guo F, He D, Zhang W, Walton RG. Trends in prevalence, awareness, management, and control of hypertension among United States adults, 1999 to 2010. J Am Coll Cardiol 2012;60:599–606. doi: http://dx.doi. org/10.1016/j.jacc.2012.04.026 PMID:22796254
https://doi.org/10.1016/j.jacc.2012.04.0... ^–1313 Guessous I, Bochud M, Theler JM, Gaspoz J-M, Pechère-Bertschi A. 1999–2009 trends in prevalence, unawareness, treatment and control of hypertension in Geneva, Switzerland. PLoS One 2012;7:e39877. doi: http:// dx.doi.org/10.1371/journal.pone.0039877 PMID:22761919
https://doi.org/10.1371/journal.pone.003... If the same proportions could be achieved in China, annual mortality among people aged 45 years or older would be reduced by an estimated 860 000 deaths – equivalent to 24 times the annual number of deaths among children younger than 5 years or 130 times the corresponding value for maternal mortality.³⁸38 Feng XL, Zhu J, Zhang L, Song L, Hipgrave D, Guo S et al. Socio-economic disparities in maternal mortality in China between 1996 and 2006. BJOG 2010;117:1527–36. doi: http://dx.doi.org/10.1111/j.1471-0528.2010.02707.x PMID:20937073
https://doi.org/10.1111/j.1471-0528.2010... ^,3939 Rudan I, Chan KY, Zhang JS, Theodoratou E, Feng XL, Salomon JA et al.; WHO/UNICEF’s Child Health Epidemiology Reference Group (CHERG). Causes of deaths in children younger than 5 years in China in 2008. Lancet 2010;375:1083–9. doi: http://dx.doi.org/10.1016/S0140-6736(10)60060-8 PMID:20346815
https://doi.org/10.1016/S0140-6736(10)60...

Some of our data are encouraging. For example, the proportion of hypertensive individuals who were aware of their hypertension was never found to be more than  9% higher than the corresponding proportion of hypertensive individuals who were receiving anti-hypertensive medication. In other words, almost all individuals in China who know they are hypertensive have access to appropriate treatment. Furthermore, the hypertension in many of the individuals who are receiving anti-hypertensive medication appears to be under effective control. As primary health care becomes increasingly available and affordable in China,²⁴24 YipWCHsiaoWCChenWHuSMaJMaynardAEarly appraisal of China's huge and complex health-care reforms.Lancet20123798334210.1016/S0140-6736(11)61880-122386036
https://doi.org/10.1016/S0140-6736(11)61... ^,2626 Li Y, Ying C, Sufang G, Brant P, Bin L, Hipgrave D. Evaluation, in three provinces, of the introduction and impact of China’s National Essential Medicines Scheme. Bull World Health Organ 2013;91:184–94. doi: http:// dx.doi.org/10.2471/BLT.11.097998 PMID:23476091
https://doi.org/10.2471/BLT.11.097998... access to effective treatment and control of hypertension continues to improve – and the effective management of hypertension largely becomes a case identification problem. Too many inhabitants of China are unaware that they have hypertension, perhaps because most asymptomatic individuals believe they are healthy and see no benefit in routine health checks. In the CHARLS survey conducted two to three years after a health reform that was designed to establish a heath record and regular health checks for every inhabitant of China, it was very disappointing to see how few of our interviewees had had their blood pressures determined in the previous year. There are several reasons why many cases of hypertension are going undetected in China. The services provided by community health care in the country – which is based on the Soviet Semashko model⁴⁰40 Antoun J, Phillips F, Johnson T. Post-Soviet transition: improving health services delivery and management. Mt Sinai J Med 2011;78:436–48. doi: http://dx.doi.org/10.1002/msj.20261 PMID:21598269
https://doi.org/10.1002/msj.20261... – are often as specialized as those available in general hospitals. However, there are more physicians than nurses available for community health care, and many of the physicians spend most of their working days sitting in their offices, waiting for patients.⁴¹41 Zhang X, Chen LW, Mueller K, Yu Q, Liu J, Lin G. Tracking the effectiveness of health care reform in China: a case study of community health centers in a district of Beijing. Health Policy 2011;100:181–8. doi: http://dx.doi. org/10.1016/j.healthpol.2010.10.003 PMID:21040995
https://doi.org/10.1016/j.healthpol.2010... Some of the professionals are unwilling or insufficiently skilled to engage in general practice and preventive care. As a result of these problems in community health care, most of the people who live in China prefer to visit general hospitals for primary care⁴²42 Tang C, Luo Z, Fang P, Zhang F. Do patients choose community health services (CHS) for first treatment in China? Results from a community health survey in urban areas. J Community Health 2013. Forthcoming doi: http:// dx.doi.org/10.1007/s10900-013-9691-z PMID:23636415
https://doi.org/10.1007/s10900-013-9691-... and many are, in consequence, never offered the free health checks that should be provided by the community health-care workers. In addition, the monitoring and supervision of community health-care workers are suboptimal. This may explain why about half of the health records that have been created by such workers are considered inadequate.⁴³43 Wei Y, Lu R, Zeng W, Xia J, Liang X. Analyzing the status of residents’ health archives management in Chengdu and its countermeasures Chinese Health Serv Manage 2011;5:392–3. doi: http://dx.doi.org/10.1016/j. healthpol.2010.10.003 PMID:21040995WeiYLuRZengWXiaJLiangXAnalyzing the status of residents' health archives management in Chengdu and its countermeasuresChinese Health Serv Manage20115392310.1016/j.healthpol.2010.10.00321040995
https://doi.org/10.1016/j.healthpol.2010...

Interestingly, we found that the type of health insurance – that is, whether or not the subject's health insurance covered the costs of outpatient care – was the strongest predictor of the effective management of hypertension in China. Hypertensive individuals with insurance that covered outpatient care were much more likely to be aware of their hypertension – and to be receiving anti-hypertensive medication – than the hypertensive members of other schemes. These associations were independent of setting, demographic factors and socioeconomic status. In large-scale trials, demand-side reimbursements have been found to increase willingness to access outpatient care – particularly the utilization of primary and preventive services.⁴⁴44 Manning WG, Newhouse JP, Duan N, Keeler EB, Leibowitz A, Marquis MS. Health insurance and the demand for medical care: evidence from a randomized experiment. Am Econ Rev 1987;77:251–77. PMID:10284091^,4545 Wagstaff A, Lindelow M, Jun G, Ling X, Juncheng Q. Extending health insurance to the rural population: an impact evaluation of China’s new cooperative medical scheme. J Health Econ 2009;28:1–19. doi: http://dx.doi. org/10.1016/j.jhealeco.2008.10.007 PMID:19058865
https://doi.org/10.1016/j.jhealeco.2008.... Given the likely benefits in terms of the early detection of hypertension, the costs of outpatient care need to be included in all health insurance schemes in China. This should not only improve health outcomes but also provide financial risk protection²⁸28 Sun Q, Liu X, Meng Q, Tang S, Yu B, Tolhurst R. Evaluating the financial protection of patients with chronic disease by health insurance in rural China. Int J Equity Health 2009;8:42. doi: http://dx.doi.org/10.1186/1475- 9276-8-42 PMID:20003188
https://doi.org/10.1186/1475-9276-8-42... ^,2929 Jing S, Yin A, Shi L, Liu J. Whether New Cooperative Medical Schemes reduce the economic burden of chronic disease in rural China. PLoS One 2013;8:e53062. doi: http://dx.doi.org/10.1371/journal.pone.0053062 PMID:23326382
https://doi.org/10.1371/journal.pone.005... and improve the management of “catastrophic” chronic conditions in rural areas.²⁷27 Yip W, Hsiao WC. Non-evidence-based policy: how effective is China’s new cooperative medical scheme in reducing medical impoverishment? Soc Sci Med 2009;68:201–9. doi: http://dx.doi.org/10.1016/j.socscimed.2008.09.066 PMID:19019519
https://doi.org/10.1016/j.socscimed.2008... The current health system in China has been criticized for its fragmentation in providing preventive, primary and tertiary services, which has probably led to the inefficient use of the limited resources and the underuse of community health care.⁴⁶46 Yip W, Hsiao WC. The Chinese health system at a crossroads. ,Health Aff (Millwood) 2008;27:460–8. doi: http://dx.doi.org/10.1377/hlthaff.27.2.460 PMID:18332503
https://doi.org/10.1377/hlthaff.27.2.460... However, a more cost-effective, integrated delivery of health services in China is unlikely to be seen before the development of robust and unified financial arrangements.⁴⁷47 The world health report 2010 – health system financing: the path to universal coverage. Geneva: World Health Organization; 2010.

Neither marital status nor household income was an independent predictor of the management of hypertension in China but illiterate hypertensive individuals were less likely to be aware of their hypertension than their literate counterparts. Among those who were literate and hypertensive, however, level of education had no apparent impact on awareness. Socioeconomic status had no apparent impact on the effective control of hypertension. Taken together, these observations confirm that the main stumbling block in the effective management of hypertension in China is the identification of hypertensive individuals. Observations on the social determinants of health can help identify modifiable risk factors and guide risk reduction through either system-level multisectoral interventions or individual-level health promotion.⁴⁸48 Closing the gap in a generation: health equity through action on the social determinants of health: final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.^,4949 Di Cesare M, Khang YH, Asaria P, Blakely T, Cowan MJ, Farzadfar F et al.; Lancet NCD Action Group. Inequalities in non-communicable diseases and effective responses. Lancet 2013;381:585–97. doi: http://dx.doi.org/10.1016/ S0140-6736(12)61851-0 PMID:23410608
https://doi.org/10.1016/S0140-6736(12)61... However, behavioural changes to reduce the risk of hypertension are unlikely to be achieved quickly. In addition, in our study, the impact of insurance benefits on the control of hypertension was found to be larger than that of any of the modifiable risk factors that we investigated.

Our data come from the CHARLS survey, which was national and considered to be nationally representative once adjustments had been made for the sampling system. Encouragingly, our estimates of the prevalence of hypertension and of membership in the various health insurance schemes tally with those made in other studies in China.¹⁵15 Basu S, Millett C. Social epidemiology of hypertension in middle-income countries: determinants of prevalence, diagnosis, treatment, and control in the WHO SAGE study. Hypertension 2013;62:18–26. doi: http://dx.doi. org/10.1161/HYPERTENSIONAHA.113.01374 PMID:23670299
https://doi.org/10.1161/HYPERTENSIONAHA.... ^,1818 Chinese Centre for Disease Control and Prevention. Report on chronic disease risk factor surveillance in China 2010. Beijing: Military Medical Science Press; 2012.^,2525 Liang L, Langenbrunner JC. The long march to universal coverage: lessons from China. Universal Health Coverage (UNICO) studies series. Washington: The World Bank; 2013.^,3434 Zhao Y, Yan H, Marshall RJ, Dang S, Yang R, Li Q et al. Trends in population blood pressure and prevalence, awareness, treatment, and control of hypertension among middle-aged and older adults in a rural area of northwest China from 1982 to 2010. PLoS One 2013;8:e61779. doi: http:// dx.doi.org/10.1371/journal.pone.0061779 PMID:23613932
https://doi.org/10.1371/journal.pone.006... ^,3737 Ma WJ, Tang JL, Zhang YH, Xu YJ, Lin JY, Li JS et al. Hypertension prevalence, awareness, treatment, control, and associated factors in adults in southern China. Am J Hypertens 2012;25:590–6. doi: http://dx.doi.org/10.1038/ ajh.2012.11 PMID:22337206
https://doi.org/10.1038/ajh.2012.11... The close similarity between the weighted and unweighted proportions indicates that the sampling procedure used in the survey was good. It is unclear why hypertension prevalence was relatively high among members of health insurance schemes that covered the costs of outpatient care, although the memberships of the insurance scheme probably differ in certain demographic and lifestyle factors. The classification of four health insurance schemes into just two categories – those that generally covered the costs of outpatient care and those that did not – may have masked scheme-specific associations and within-scheme variations. For example, the Urban Resident Basic Medical Insurance Scheme and the New Cooperative Medical Scheme vary in their benefit packages by region and occasionally cover the costs of outpatient care. However, these schemes only seem to pay for the outpatient care of individuals who have a “severe and catastrophic” noncommunicable disease, such as severe cardiovascular or cerebrovascular complications.²⁵25 Liang L, Langenbrunner JC. The long march to universal coverage: lessons from China. Universal Health Coverage (UNICO) studies series. Washington: The World Bank; 2013.^,2828 Sun Q, Liu X, Meng Q, Tang S, Yu B, Tolhurst R. Evaluating the financial protection of patients with chronic disease by health insurance in rural China. Int J Equity Health 2009;8:42. doi: http://dx.doi.org/10.1186/1475- 9276-8-42 PMID:20003188
https://doi.org/10.1186/1475-9276-8-42... ^,2929 Jing S, Yin A, Shi L, Liu J. Whether New Cooperative Medical Schemes reduce the economic burden of chronic disease in rural China. PLoS One 2013;8:e53062. doi: http://dx.doi.org/10.1371/journal.pone.0053062 PMID:23326382
https://doi.org/10.1371/journal.pone.005... Although 20% of the CHARLS interviewees had missing anthropometric measurements – potentially leading to selection bias – these interviewees were fairly evenly distributed in terms of their background characteristics.³¹31 Zhao Y, Strauss J, Yang G, et al. China health and retirement longitudinal study– 2011-2012 national baseline users' guide. Beijing: Peking University; 2013. Furthermore, the weighted results – which took account of the missing values – were similar to the crude, unweighted results. As previously, we used Poisson regression to take account of the sampling design and compute robust estimates and RRs.³³33 Feng XL, Xu L, Guo Y, Ronsmans C. Socioeconomic inequalities in hospital births in China between 1988 and 2008. Bull World Health Organ 2011;89:432–41. doi: http://dx.doi.org/10.2471/BLT.10.085274 PMID:21673859
https://doi.org/10.2471/BLT.10.085274...

Hypertension has become a pressing national problem in China and its control should be on the country's post-2015 development agenda.⁵⁰50 Alleyne G, Binagwaho A, Haines A, Jahan S, Nugent R, Rojhani A et al.; Lancet NCD Action Group. Embedding non-communicable diseases in the post-2015 development agenda. Lancet 2013;381:566–74. doi: http:// dx.doi.org/10.1016/S0140-6736(12)61806-6 PMID:23410606
https://doi.org/10.1016/S0140-6736(12)61... Following the major health system reform of 2009, China seems to be performing well in delivering effective care to those who are aware of their hypertension. The main challenge that remains is how to identify and reach the many hypertensive individuals who are unaware of their hypertension, especially those who do not present for regular health check-ups or otherwise engage with the health system. Clearly, major changes need to be made to health service delivery in China. The scope of universal health-care coverage should go beyond financial risk protection and include more aspects of primary health care. With concerted efforts in integrating health finances and offering more generous outpatient service coverage, a stronger national health system – that could make huge and rapid improvements in the management of hypertension and other disorders – could be forged in China.

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References

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