16 How to live after a chronic disease diagnosis

Pooled from 21 studies and 46,847 people (meta-analysis): compared with people who take medicine on and off, people who take it as prescribed have about a 44% lower chance of dying over the same period. The original value is an odds ratio of 0.56, 95% CI 0.50–0.63 (confidence interval). Looking only at treatments that truly work, about 45% lower (0.55, 0.49–0.62)

A document from the National Healthcare Security Administration (国家医保局) says this has already been reached. The original wording is: "Cross-province direct settlement of outpatient costs for 5 outpatient chronic special diseases, including hypertension, diabetes, outpatient chemo or radiotherapy for malignant tumors, dialysis for uremia, and anti-rejection treatment after organ transplant, is basically accessible at county level." "Accessible at county level" (县域可及) means it can be handled at county level. On top of these 5, the document adds another 5

Chronic conditions require seeing how values shift over time; a single point is not enough. For hypertension, one meta-analysis pooled individual data from 15 randomized trials and 7,138 people. Compared with usual care, home self-measurement at 12 months meant mean change in office systolic blood pressure −3.2 mmHg (95% CI −4.9 to −1.6). Self-measurement alone without other support showed no clear effect: −1.0 mmHg (−3.3 to 1.2, difference may be chance). The most supported package lowered by 6.1 mmHg (3.2 to 9.0). Supported care means a doctor, pharmacist, or patient adjusting meds from readings, plus health education and lifestyle guidance. The author’s conclusion: measuring alone does not lower pressure; pairing readings with dose adjustment does. These endpoints are blood pressure, not death. When changing hospitals, a joint measure from the National Health Commission «国家卫健委» and three other agencies states: if the patient’s existing test results meet mutual-recognition rules and satisfy clinical need, the hospital and clinician must not repeat tests. Recognized reports carry an “HR” mark, e.g. (全国HR) (national HR)

Two US cancer-registry studies looked at non-metastatic, potentially curable breast, prostate, lung, and colorectal cancer. The first compared patients who used only alternative therapy and did none of surgery, chemo/radiotherapy, or endocrine treatment with matched standard-care patients: death risk 2.5-fold (HR 2.50, 95% CI 1.88–3.27, about 1.5 times higher). Breast cancer 5.68-fold (3.22–10.04), lung 2.17-fold (1.42–3.32), colorectal 4.57-fold (1.66–12.61). The second looked at standard treatment plus complementary therapy: refusal rates were surgery 7.0% vs 0.1%, chemo 34.1% vs 3.2%, radiotherapy 53.0% vs 2.3%, endocrine therapy 33.7% vs 2.8%. Five-year survival 82.2% vs 86.6%; death risk 2.08-fold (HR 2.08, 1.50–2.90, about double). After accounting for delay and refusal, complementary therapy alone was not linked to death (HR 1.39, 0.83–2.33). The author’s conclusion: extra deaths came from refusing standard treatment. China’s State Administration for Market Regulation requires health-food labels to state: “Health food is not medicine and cannot replace drugs to treat disease.” The US National Center for Complementary and Integrative Health (NCCIH) states that St John’s wort (贯叶连翘) weakens several drugs, including cyclosporine for transplant rejection and the anticoagulant warfarin

You do not have to go back and forth to a large hospital every month and queue for a refill. In the same insured place (also called a pooled region, 统筹地区), the inpatient reimbursement rate at a primary-level hospital is in principle about 10 percentage points higher than at the next tier up

Basic service package is paid by yibao (医保) per rules. Personalized packages are fully self-paid and must be filed with the county-level health administration (县级卫生健康部门)

Damage from diabetes to the back of the eye is called retinopathy; damage to the foot is called diabetic foot. Both are almost without feeling before they go wrong. Caught early, they can still be treated. Once vision is gone or the foot has broken down, it is late

A 5-year randomized controlled trial in 199 patients with a first calcium stone and no cause found (also called idiopathic calcium stones). The water group drank at least 2 liters of water a day; the other group had no intervention. Recurrence over 5 years: 12/99 (12.1%) in the group that drank more water, 27/100 (27.0%) in the group with no intervention, P=0.008. A smaller P value means the difference between the groups is less likely to be chance. Mean time until recurrence: 38.7±13.2 months versus 25.1±16.4 months, P=0.016. The 24-hour urine volume measured at the start was clearly lower in stone patients than in people without stones: men 1057±238 mL versus 1401±562 mL (P<0.0001), women 990±230 mL versus 1239±440 mL (P<0.001). Clause 1.8.1 of NICE guideline NG118 recommends that adults drink 2.5 to 3 liters of water a day, and that children and adolescents drink 1 to 2 liters by age. Add a little fresh lemon juice to the water, do not drink carbonated drinks, and keep salt for adults to no more than 6 grams a day. Clause 1.7.1 of the same NICE guideline recommends considering a stone composition analysis for adults who have had a kidney stone or a ureteral stone. For people with recurrence whose stone is more than half calcium oxalate, clause 1.8.3 recommends considering potassium citrate. NICE found no evidence on 24-hour urine testing and gives no recommendation. The stone guideline of the European Association of Urology (EAU) is written differently: every patient with a stone should have a reliable stone composition analysis. People with recurrence count as high risk and should give 24-hour urine twice in a row for a dedicated metabolic workup. Its general prevention target is 2.5 to 3 liters of water a day, and a daily urine volume of 2 to 2.5 liters

A randomized controlled trial of 517 adults who had flared in the past 12 months. The nurse-led group had the disease explained, then had urate adjusted to target from the lab results. The other group had usual care from a general practitioner. At 2 years, the share with serum urate <360 µmol/L (6 mg/dL) was 95% versus 30%. The chance of reaching target was 3.18 times that of the usual-care group (RR 3.18, 95% CI 2.42–4.18, this interval is the confidence range of the figure), P<0.0001. In year 2, flare frequency, tophi, and quality of life, these secondary measures, were also better than in the usual-care group. Each extra year of life adjusted for quality of life (a quality-adjusted life year) cost £5066. The same trial also ran a follow-up: questionnaires went to 438 people and 82% came back. Both groups reported their own flare counts over the past 12 months. The median in the target group was 0 (the middle half of people fell between 0 and 0). Usual care was 1 (0–3), P<0.001. The range in those parentheses is called the interquartile range. The share still taking a urate-lowering drug was 1.19 times the usual-care group (adjusted RR 1.19, 1.09–1.30). The 2020 American College of Rheumatology gout guideline strongly recommends starting urate-lowering treatment for people with subcutaneous tophi, people whose imaging shows gout has eaten a defect into the bone, or people with ≥2 flares a year. For more than a single flare but fewer than 2 a year, the guideline conditionally suggests the drug; a conditional recommendation is settled between doctor and patient. For a first flare, it conditionally suggests not starting at once. The exception is chronic kidney disease of stage 3 or above, serum urate >9 mg/dL, or a past urinary stone; those are conditionally suggested to treat. The method is to keep watching serum urate and adjust the dose from the results until target, with a target <6 mg/dL. Allopurinol is the first choice, including for chronic kidney disease of stage 3 or above, at a starting dose ≤100 mg/day. At the start, also give an anti-inflammatory preventive drug for at least 3 to 6 months. The same guideline also cites a set of case observations. These patients stopped the drug after long good control, and after stopping, serum urate stayed <7 mg/dL. Among them, only 13% (27/211) had no flare at all over 5 years of follow-up. On diet, people who limited alcohol or stopped it had serum urate 1.6 mg/dL lower than people who did not limit it, and a serving of beer raised serum urate by 0.16 mg/dL. A healthy diet, a Mediterranean diet, and the DASH diet had smaller effects. Which urate-lowering drug to choose first is disputed. The American College of Rheumatology guideline strongly recommends allopurinol as the first choice, because at a high enough dose it works, is tolerated, is safe, and is cheap. It also conditionally suggests that a person on febuxostat (非布司他) who has a history of cardiovascular disease, or a new cardiovascular event, switch if another drug is available. That recommendation matches the boxed warning the FDA put on febuxostat. It draws on the CARES trial: 6190 gout patients with cardiovascular disease were randomized to febuxostat or allopurinol. All-cause death risk in the febuxostat group was 1.22 times the allopurinol group (HR 1.22, 95% CI 1.01–1.47, about 22% higher). Cardiovascular death was 1.34 times (1.03–1.73, about 34% higher). The European FAST trial came to a different conclusion. It enrolled 6128 patients aged 60 or older with cardiovascular risk factors; major cardiovascular events on febuxostat were not higher than on allopurinol (HR 0.85, 0.70–1.03). Deaths were 7.2% in the febuxostat group and 8.6% in the allopurinol group. For people taking a drug that promotes uric acid excretion through the kidney, the American College of Rheumatology conditionally suggests not alkalinizing the urine, because there is no evidence that it works and the certainty of the evidence is very low. It also requires telling those people to drink more water. People with known kidney stones, or with chronic kidney disease of stage 3 or above, should not use this class of drug. The same guideline notes that the HLA-B*5801 genotype is most common in people of Han, Korean, and Thai ancestry, at 7.4%, in African Americans at 3.8%, and in white people and in Hispanic people at 0.7% each. For Asian people and African Americans taking allopurinol, the risk of allopurinol hypersensitivity syndrome is 3 times the risk in white people. The guideline conditionally suggests testing these groups for HLA-B*5801 before allopurinol; the certainty of the evidence is very low

A study followed 633 gout patients online for 1 year, comparing a pair of days before each person's flare with a pair of their own days when they did not flare (a case-crossover study). Purine is a component of food that the body turns into uric acid. Splitting the purine total over that pair of days from low to high into five bands, and comparing with the lowest band, the chance of a flare in the higher bands was 1.17, 1.38, 2.21, and 4.76 times (OR, trend P<0.001). Counting only purine from animal sources, the figures were 1.42, 1.34, 1.77, and 2.41 times. Counting only purine from plant sources, they were 1.12, 0.99, 1.32, and 1.39 times. Split by sex, by whether the person drank, and by whether they took a diuretic, allopurinol, an anti-inflammatory pain drug, or colchicine, the result was the same. Another study by the same researchers looked at alcohol in the 24 hours before a flare in 724 gout patients. Compared with not drinking, 1 to 2 drinks was 1.36 times (95% CI 1.00–1.88, confidence interval), and 2 to 4 drinks was 1.51 times (1.09–2.09). Wine, beer, and spirits were each linked to flares. For people who have not had gout, another follow-up study applies: 47150 men in the United States followed for 12 years, recorded only, not assigned to groups. The top fifth by meat intake had about a 41% higher risk of gout than the bottom fifth (RR 1.41, 1.07–1.86). Seafood was about 51% higher (1.51, 1.17–1.95). The top fifth by dairy intake was instead about 44% lower (0.56, 0.42–0.74). Vegetables high in purine, and total protein, showed no link. In the same men, an extra 12-ounce bottle of beer a day (about 355 ml) raised risk by about 49% (1.49, 1.32–1.70). A daily drink of spirits raised it by about 15% (1.15, 1.04–1.28). Wine showed no statistical difference (1.04, 0.88–1.22)

A randomized trial in Shanghai of 18,816 people aged 35 to 59, all infected with hepatitis B virus or with a history of chronic hepatitis. The screening group was invited every 6 months for alpha-fetoprotein and ultrasound; the control group was not screened. Alpha-fetoprotein is a blood marker that often rises when liver cancer is present. Deaths from liver cancer were 32 in the screening group and 54 in the control group. Liver-cancer mortality was 83.2 versus 131.5 per 100,000 people. The screening group was 0.63 times the control group (95% CI 0.41–0.98, confidence interval), about 37% lower. Of the liver cancers found in the screening group, 46.5% were surgically removed, against 7.5% in the control group. A follow-up study in Taiwan of 3653 people aged 30 to 65 who were surface-antigen positive, followed for a mean of 11.4 years, recorded only, not assigned to groups. The more virus in the blood at entry, the more liver cancer later. Below 300 copies per milliliter, there were 108 liver cancers per 100000 person-years. At 1000000 or more copies per milliliter, there were 1152. The cumulative share who developed liver cancer was 1.3% and 14.9%. After accounting for sex, age, smoking, alcohol, aminotransferases, and cirrhosis, more virus still meant more liver cancer. An Asian randomized trial of 651 people with chronic hepatitis B who already had severe liver fibrosis or cirrhosis. One group took lamivudine and one took placebo, for a median of 32.4 months. Liver cancer was 3.9% versus 7.4%, about half the risk (HR 0.49, P=0.047). Worsening of disease was 7.8% versus 17.7% (HR 0.45, about 55% lower). The 2022 guideline of the Chinese Medical Association (中华医学会) states that people with chronic hepatitis B virus infection should have an abdominal ultrasound and alpha-fetoprotein every 6 months to screen for liver cancer. People at high risk should have them at least every 3 to 6 months. Carriers who do not yet need drugs should have a blood count, liver function, viral markers, alpha-fetoprotein, and ultrasound every 6 to 12 months. Once the conditions for treatment are met, start at once. If virus is detectable in the blood, antiviral treatment is recommended after age 30, whether or not aminotransferases are high. The same applies if someone in the family developed cirrhosis or liver cancer from hepatitis B. The oral drugs the guideline recommends are the entecavir and tenofovir class. The guideline states that most people need long-term treatment, and that the share whose virus rebounds after stopping is high

A national sample survey in China gave lung-function tests to 50991 adults aged 20 and over. The share with COPD (chronic obstructive pulmonary disease) was 8.6% (95% CI 7.5–9.9, confidence interval), about 99,900,000 people. At 40 and over it was 13.7%. Among people with COPD, only 12.0% had ever had a lung-function test. An analysis pooled 144 studies in which a trained person watched 54354 patients use an inhaler. Fully correct technique was 31%, barely acceptable 41%, and poor 31%. Compared with the prior 20 years, the later 20 years showed no improvement. With a press-and-breathe spray, failure to match the press with the breath was 45%. Not inhaling fast enough or deep enough was 44%, and not holding the breath afterward was 46%. A French survey only recorded, with no assignment to groups: doctors watched 2935 COPD patients use an inhaler. More than half the maneuvers had an error. Critical errors that keep the drug from being inhaled ran from 15.4% to 46.9% across devices. Admission or an emergency visit for an exacerbation in the past 3 months was 3.3% among patients with no error and 6.9% among those with a critical error (OR 1.86, 1.14–3.04). The summary of the GOLD 2023 report states that doctors and patients must be taught to use inhaler devices correctly, and that technique should be checked regularly at follow-up. It also recommends that people with COPD receive influenza, pneumococcal, and similar vaccines as local rules require. A 2016 Cochrane review pooled 20 randomized trials and 1477 people. It compared pulmonary rehabilitation after a COPD exacerbation with usual care and no rehabilitation. 8 studies and 810 people looked at readmission. Readmission was about 56% lower with rehabilitation (OR 0.44, 95% CI 0.21–0.91); evidence quality was moderate. But the studies differed a great deal. 6 studies and 670 people looked at death, OR 0.68 (0.28–1.67); the difference may be chance, and evidence quality was low. The gain in quality of life was larger than patients can feel; evidence quality was high. The 6-minute walk was on average 62 meters longer (38–86 meters); evidence quality was high

China's national chronic-disease surveillance for 2018 to 2019 tested blood and urine in 176874 adults. About 8.2% had chronic kidney disease, about 82,000,000 people. Of them, 73.3% were still in early stage 1 to 2. Only 10.0% knew they had it. Another survey in 45 hospitals nationwide tested 9672 people with type 2 diabetes; 31% had chronic kidney disease. Of these 2997 people, only 27% had been checked for kidney disease before. The 2024 KDIGO kidney guideline says people at risk should be tested for both urine albumin and glomerular filtration rate (how much blood the kidney filters per minute). The first priority is people with hypertension, diabetes, or cardiovascular disease. The 2026 standards of the American Diabetes Association say that people with type 2 diabetes, whatever the treatment, should have the urine albumin-to-creatinine ratio and the estimated glomerular filtration rate checked at least once a year. The same applies to type 1 once the disease has lasted 5 years. For diabetes plus hypertension with urine albumin moderately raised (30 to 299 mg/g), a pril-class or sartan-class blood-pressure drug is recommended. Once it is found, there are drugs that can be used. A randomized trial enrolled 4304 people with chronic kidney disease, glomerular filtration rate between 25 and 75, and urine albumin-to-creatinine ratio 200 to 5000. Over a median of 2.4 years, 9.2% of the dapagliflozin group had any of these: kidney function falling by more than half, end-stage kidney disease, or death from kidney disease or cardiovascular disease. The placebo group was 14.5%. HR 0.61 (95% CI 0.51–0.72), about 39% lower. Deaths were 4.7% versus 6.8%, HR 0.69 (0.53–0.88), about 31% lower. The effect was similar with or without diabetes

A randomized trial at 55 centers (CHALLENGE) enrolled 889 people with colon cancer. All had finished surgery and adjuvant chemotherapy, were high-risk stage II or stage III, and had no metastasis at enrollment. They enrolled 2 to 6 months after chemotherapy ended, and before enrollment they exercised less than 150 minutes a week. 445 joined a 3-year exercise program; 444 received only health pamphlets. For the first 6 months of the program, they met an exercise coach every other week to talk about how to keep going, and also trained a session while the coach watched. From 6 to 12 months this became a meeting or a phone call, and from then until year 3 only minimal support remained. The target was 10 more metabolic-equivalent hours a week than before (a unit of exercise amount); anything of moderate intensity or above counted, and the program expected most people to choose walking. After a year, weekly leisure exercise had risen by 15.6 metabolic-equivalent hours in the exercise group and by 5.1 in the control group. Median follow-up was 7.9 years. Recurrence, a new cancer, or death was about 28% lower in the exercise group than in the control group, HR 0.72 (95% CI 0.55–0.94). At 5 years, the share free of these events was 80.3% versus 73.9%. Death was about 37% lower, HR 0.63 (0.43–0.94). At 8 years, 90.3% versus 83.2% were alive. Musculoskeletal adverse events were 18.5% versus 11.5%. A cost analysis of the same trial, on Canadian public health care, put the exercise program at 2917 Canadian dollars per person up front, but with fewer recurrences the 5-year total cost was 1589 Canadian dollars less per person