Elsevier

The Lancet

Volume 387, Issue 10015, 16–22 January 2016, Pages 251-272
The Lancet

Articles
Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013

https://doi.org/10.1016/S0140-6736(15)00551-6Get rights and content

Summary

Background

China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China.

Methods

Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013.

Findings

All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4·0 years in Hebei province to 14·2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0–14, 15–49, and 50–74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990.

Interpretation

Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems.

Funding

China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.

Introduction

From 1990 to 2013 China experienced rapid economic growth, with income per capita increasing from 1664 RMB to 41 908 RMB,1 and life expectancy at birth increased by 8·5 years.2 Under-5 death rates dropped from 59 per thousand in 1990 to 13 per thousand in 2013 so that China had the second fastest annualised rate of decline of all nations.3 Rapid reductions in mortality have also been associated with a progressive shift in burden from infectious diseases to non-communicable diseases, increasing the demand for affordable access to health services. Rising income inequality has also increased policy attention on the challenges of health inequalities.4 Concerns have been raised that health inequalities are rising.5

Levels and trends of mortality separated by cause are a crucial starting point to understand health inequalities across provinces. To our knowledge, there have not been any systematic studies of provincial causes of death in China.6, 7 Since the 1970s, there has been extensive analyses of variation between provinces, and even counties, for cancer death rates.8, 9 Various causes of heart disease, suicide, and injuries have been studied for selected provinces.10, 11, 12, 13, 14 More comprehensive cause of death studies have been done for some counties and several provinces.15, 16 Remarkably, there has been no previous comprehensive examination of levels of or trends in causes of death in China at the provincial level.

Research in context

Evidence before this study

China has been undergoing tremendous demographic and epidemiological transitions during the past three decades. Although overall population health, as represented by under-5 mortality rates and life expectancy at birth, has been improving at impressive speed, increasing burden from non-communicable diseases and an ageing population have presented great health-care challenges for the country. Although such challenges are much discussed at the national level, relatively little is known about the subnational level in China.

Added value of this study

To our knowledge, our study is the first ever systematic analysis of provincial level burden of disease in China. In this analysis, we took advantage of the largest demographic and epidemiological datasets assembled, including censuses, demographic surveys, the Disease Surveillance Points system, the Maternal and Child Health Surveillance systems, Cancer Registries, the newly established Death Registration System, Notifiable Infectious Disease Reporting System, and the National Surveillance System on Injuries. In addition to using the updated analytical tools of the GBD 2013, in order to fully utilise the data, we developed methods specific to this study, including China-specific garbage code redistribution and rural and urban weighting. We report high levels of heterogeneity in terms of both level and rate of change in both all-cause mortality and specific causes of death at the provincial level in China.

Implications of all the available evidence

The differential trends and composition of disease burdens we have identified at the provincial level have important implications for the health system in China. There is an ongoing effort by the Chinese Government to reform the health-care system. Consideration of subnational trends will be crucial to tackle the diverse health challenges faced by provincial governments, and localised health policies will likely be the key for overall success at the national level.

The Global Burden of Disease Study 2013 (GBD 2013) analysis of causes of death2 benefited from a close collaboration with the China Center for Disease Control and Prevention and the Maternal and Child Health Surveillance System. In this study, we use the GBD 2013 analysis to examine trends for 240 causes of death for all 33 province-level administrative units in mainland China from 1990 to 2013.

Section snippets

Overview

The GBD 2013 Mortality and Causes of Death Collaborators describe in detail the GBD 2013 cause list, the systematic approach to collating causes of death data from around the world, mapping across different revisions and national variants of the International Classification of Diseases and Injuries (ICD), redistribution of deaths assigned to causes that cannot be underlying causes of death through garbage code redistribution, and the cause of death modelling approach used for each cause. One

Provincial life expectancy changes by cause

The appendix (p 40) shows data for men and women combined. For men (figure 1), life expectancy in 1990 ranged from 55·2 years (95% UI 52·6–57·7) in Tibet to 74·1 years (72·1–76·2) in Shanghai, a gap of nearly 19 years (16·0–21·8). By 2013, the range was from 68·4 years (66·3–70·6) in Tibet to 80·2 years (78·0–82·7) in Shanghai, a gap of 11·8 years (9·3–14·5). In most provinces, reductions in diarrhoea, lower respiratory infections, and other infectious diseases (light brown bars) have made

Discussion

China has made extraordinary progress to reduce child mortality and increase life expectancy. Despite huge progress for all provinces, the gaps between provinces remain very large. Cause-of-death patterns are also highly variable. The shift from infectious diseases to non-communicable causes is occurring in all provinces, with important local or regional variations. In view of the demographic trends in China, this shift is highly likely to continue with many health system implications.

On the

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