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Authors: Shiwei Liu, Yichong Li, Maigeng Zhou
Journal: JAMA Cardiology (2019)

In Reply A decline in age-standardized mortality rate of cardiovascular diseases (CVDs) overall from 1990 to 2016 in China could be explained by the advancing medical techniques and cardiovascular care and improved access to health services. 1However, improvement in cardiac surgical care lags behind the gain in overall cardiovascular health.Quality surgical care highly concentrates in the economically developed cities, such as Beijing, Shanghai, and Guangzhou.In contrast, cardiac surgery volume per surgeon and quality is much lower in less developed areas, especially rural areas.This can be partially explained by the following reasons.First, surgical care resources are unevenly allocated across China owing to the extremely unbalanced economic development.Second, high-quality cardiac surgery needs fine support from anesthetists, medical specialists for extracorporeal circulation, and well-trained nurses, and many facilities cannot afford an experienced team.Third, cardiac interventional therapy is increasingly adopted by hospitals in less developed areas for the treatment of coronary artery disease, and those hospitals may not invest in cardiac surgery that costs more.Despite the huge burden from CVDs worldwide and in China, most of them are preventable. 2The 2017 Global Burden of Disease study indicated that 85.94% of CVD deaths worldwide were attributable to 84 modifiable risk factors, including behavioral, environmental, and metabolic risks, and this rate was a similar 84.60% for China. 3The high epidemic of cardiovascular risk factors over the past decades in China contributed to the increase in age-standardized prevalence. 1 Risk factors control is still adopted as the top priority to effectively reduce CVD burden in China.Even for congenital heart disease, its risk still can be lowered by avoiding prenatal exposure to environment risk factors. 4he Global Burden of Disease study failed to assess the effect of medical treatment on health, including surgical procedure.How much cardiac surgery could reduce the disease burden as measured by years lived with disability remains unknown.However, we agree that improving the quality of cardiac surgical care can help reduce the prominent CVD burden in China.To note, the volume of cardiac surgical procedures and interventional therapy in China has been rapidly increasing in the last decade, 5 and new surgical approaches are adopted by more and more facilities, such as hybrid surgery and minimally invasive cardiac surgery.It is particularly important to strengthen the quality improvement of cardiac surgeries and postoperative care for improving the general health of patients with CVDs.Given the complexities in the incidence and progression of chronic diseases, including CVDs, integrated strategies of prevention and treatment have been introduced worldwide and reaffirmed in top policies of the Chinese government, such as the Healthy China 2030 plan, 6 the 13th Five-Year Plan for Economic and Social Development, and the 13th Five-Year Plan for Hygiene and Health, suggesting a shift from the past patientcentered and treatment-dominated model to a peoplecentered and health-centered model.A life course management of disease across the entire spectrum of health care services, from prevention, screening, and treatment to disease management and rehabilitation, is recommended.