Abstract
The improvement of early rehabilitation service capacity is of great importance for meeting health needs of the population; however, there is still a lack of information on early rehabilitation interventions in hospitals in China. This study selected the first page data of 7,914,692 medical records suffered the stroke and brain injury, spinal cord injury, spinal and joint degeneration, fracture and sports injury from 1305 tertiary general hospitals in China from 2016 to 2022. We found that the rate of early rehabilitation intervention in tertiary general hospitals in China increased annually from 2016 to 2022, especially in 2020. The rate of early rehabilitation intervention in patients with complications was higher than that in patients without complications at 7 years. Regardless of complications, the mortality rate of patients undergoing early rehabilitation was lower than that of patients without early rehabilitation. However, the length of hospital stay and total cost were higher in patients undergoing early rehabilitation than those without early rehabilitation. The change in this indicator varied from province to province. This study combined quality improvement measures to summarize the experience of improving the early rehabilitation intervention rate in less developed countries.
Key Words: Early Rehabilitation, Epidemiology, Tertiary General Hospitals in China, Mortality
Key messages
This study selected the data of 7,914,692 medical records suffered the stroke and brain injury, spinal cord injury, spinal and joint degeneration, fracture and sports injury from 1305 tertiary general hospitals in China from 2016 to 2022.
We found that the rate of early rehabilitation intervention in tertiary general hospitals in China increased annually from 2016 to 2022, especially in 2020.
The rate of early rehabilitation intervention in patients with complications was higher than that in patients without complications at 7 years. Regardless of complications, the mortality rate of patients undergoing early rehabilitation was lower than that of patients without early rehabilitation.
Early rehabilitation intervention refers to the rehabilitation assessment and rehabilitation training carried out after the injury or surgery when the vital signs and the condition are stable. Observational studies based on small samples show that standardized rehabilitation treatment in the early stage of disease can effectively avoid or reduce patients’ dysfunction, improve their self-care ability and quality of life, and reduce the burden on families and society.1–3 The 2021 World Health Organization study on rehabilitation needs based on the global burden of disease shows that China has the largest demand for rehabilitation worldwide, with a population of more than 460 million.4 The improvement of early rehabilitation service capacity is of great significance to meet the health needs of the masses.
China’s National Medical Service and Quality and Safety Report5 shows that in the past years, the early rehabilitation intervention rate of inpatients in general hospitals in China has been increasing year by year, but it is still at a low level.6 In addition, the data collection method of this report is manual filling by departments, and the data integrity and accuracy are not ideal. Reliable data on early rehabilitation intervention rates are lacking in China. In recent years, the National Health Commission of China has taken improving the early rehabilitation intervention rate of inpatients as one of the goals of national medical quality improvement. But there is a lack of effect evaluation after the implementation of the policy. In addition, no matter in developed or developing countries, there is still a lack of real world big data to support the evaluation of early rehabilitation intervention in medical resource consumption and benefits.
This study aims to describe the changing trend of early rehabilitation intervention rate in recent 5 yrs by using a large national medical database (Hospital Quality Monitoring System [HQMS]), analyze the temporal and spatial changes of the tendency of early rehabilitation intervention for patients with complications from 2016 to 2022.
METHODS
Study Design and Population
It was a population-based retrospective study and a project of China National Center for Quality Control of Rehabilitation Medicine. Our study was approved by the Institutional Review Board of the authors’ institute.
This study was a cross-sectional study based on the HQMS established by the National Health Commission of China to monitor the quality of medical care in all tertiary hospitals of 31 provinces and municipalities in mainland China except for Hong Kong, Macao, and Taiwan province. Since 2016, the HQMS has automatically collected the first page of standardized electronic hospitalized discharge records from class 3 hospitals in China, which are also called tertiary hospitals (all hospitals in China are certificated by the government as class 1, 2, or 3, with class 3 being the highest grade, according to the scale of facilities, number of patients, level of technology, quality of care, and other standards). In the HQMS database, all diagnoses of disorders and diseases were coded using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, or ICD-10. The system consistently collects a dataset of the first page of medical records from all inpatient and contains 346 variables including department demographic characteristics, diagnoses, procedures, and expenses etc. The format and variables of the information on the first page of medical records are uniform throughout the country. The HQMS was described as previous study and several papers had published based on HQMS by Chinese research groups.7,8 Sensitive information in the database (name, ID number, contact details, hospital name, etc.) is managed by HQMS and data analysts cannot view individual case information.
The data of inpatient medical records from 2016 to 2022 were selected. Inclusion criteria are as follows: 1) the hospital continuously uploaded the first page data of cases in 7 years; 2) class 3 general hospital; 3) the ICD codes conform to the stroke and brain injury, spinal cord injury, spinal and joint degeneration, fracture, and sports injury (Supplementary materials 1, http://links.lww.com/PHM/C770). This code is based on the team’s previous research9 and is the main disease treated in China’s rehabilitation medicine discipline. Exclusion criteria are as follows: 1) incomplete main diagnostic information and 2) the hospitalization fee information is incomplete or logically incorrect.
Primary Exposure Variable Definition
Early rehabilitation intervention: the cost of rehabilitation treatment in the nonrehabilitation specialized departments is considered as the rehabilitation treatment, which is reflected in the data as the sum of clinical physical therapy cost and rehabilitation cost is greater than 0.
Complications: one of the pressure ulcers, venous thrombosis of the lower limbs, venous thrombosis of the upper limbs, complex regional pain syndrome, pulmonary embolism, urinary tract infection, and respiratory complications considered to be a complication. See Supplementary Materials 2, http://links.lww.com/PHM/C770, for specific ICD code.
In-hospital mortality: the number of deaths in a hospital during a certain period of time/the total number of hospitalized during a certain period of time.
Statistical Analysis
Preliminary processing and analysis of all data was performed using SAS9.4. Groups were divided according to the presence or absence of the seven complications mentioned above. The association between rehabilitation intervention and complications with relative risk (RR) > 1 indicates an increased risk of complications. China was divided into 32 provinces and autonomous regions, and the association between rehabilitation intervention rates and complications in each province was calculated. The proportion of hospitalization days, total cost, rehabilitation cost, and drug cost did not conform to normal distribution. Median and quartile were used for description, and nonparametric test was used for comparison between groups. The age was described by mean and standard deviation, and the comparison between groups was performed by independent sample T test. The frequency and percentage of categorical variables were described, and χ2 test was used for comparison between groups. When P < 0.05 on both sides, the difference was considered statistically significant.
RESULTS
Characteristics of the Study Population
In this study, 1305 tertiary general hospitals providing the first page data of medical records from 2016 to 2022 were selected, with a total of 7,914,692 cases, covering 32 provinces and autonomous regions.
There were 987,082 overall complications during the 7-yr period with a complication rate of 12.5%. Diagnosis was divided into a complication group (n = 987,082) and a no-complication group (n = 6,927,610). The baseline distribution of the two groups is shown in the Table 1.
TABLE 1.
Distribution of baseline values of the two groups
| Characteristic | Complication Group | Noncomplication Group |
|---|---|---|
| Age, mean ± SD | 64.0 ± 14.9 | 58.0 ± 15.6 |
| Gender, % | ||
| Male | 14.5 | 85.5 |
| Female | 10.3 | 89.7 |
| LOS, median (p25,p75) | 22 (14,35) | 13 (8,21) |
Annual Change of Early Rehabilitation Intervention Rate
The overall rate of early rehabilitation intervention and the rate of early rehabilitation intervention of patients with or without complications are increasing year by year. Especially in 2020, the increase of early rehabilitation intervention rate is the most obvious. The rehabilitation intervention rate of patients with complications was higher than that of patients without complications and the RR of the two groups was between 1.33 and 1.17 (Table 2).
TABLE 2.
Annual change of early rehabilitation intervention rate
| Year | Early Rehabilitation Intervention Rate | Complication G | Noncomplication G | RR | ||
|---|---|---|---|---|---|---|
| Count | Rate | Count | Rate | |||
| 2016 | 52.1% | 50,256 | 67.3% | 498,160 | 50.5% | 1.33 |
| 2017 | 55.9% | 75,439 | 66.5% | 761,574 | 54.8% | 1.21 |
| 2018 | 56.6% | 103,989 | 65.1% | 905,771 | 55.6% | 1.17 |
| 2019 | 58.9% | 153,202 | 69.4% | 1,232,376 | 57.6% | 1.20 |
| 2020 | 65.2% | 171,950 | 77.4% | 1,113,461 | 63.3% | 1.22 |
| 2021 | 67.1% | 212,865 | 79.1% | 1,238,688 | 65.0% | 1.22 |
| 2022 | 68.2% | 219,381 | 80.2% | 1,177,580 | 65.9% | 1.22 |
Comparison of In-Hospital Outcomes of Patients
In the complication group, we compared the in-hospital outcomes of patients who underwent early rehabilitation with those who did not, as shown in Table 3. The mortality of patients undergoing early rehabilitation was lower than that of the group without early rehabilitation, but the length of hospital stay and total cost were higher than that of the group without early rehabilitation. The same trend was observed in the uncomplicated group, but the case fatality, length of hospital stay, and total cost were much lower than in the complication group.
TABLE 3.
Comparison of in-hospital outcomes of patients
| Complication Group | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Early rehabilitation intervention group | None intervention group | ||||||||||
| Year | Count | Mortality | LOS (d) | Ave all-in cost (¥) | Average rehab cost | Ave medicine cost | Count | Mortality | LOS (d) | Ave all-in cost (¥) | Ave medicine cost |
| 2016 | 33.804 | 0.33% | 36.6 | 41.942 | 17.9% | 30.5% | 16,452 | 0.55% | 29.5 | 25,196 | 30.4% |
| 2017 | 50.148 | 0.30% | 34.0 | 38.977 | 18.4% | 25.9% | 25,291 | 0.45% | 29.0 | 24,875 | 25.5% |
| 2018 | 67.680 | 0.26% | 33.3 | 38.201 | 19.4% | 22.4% | 36,309 | 0.43% | 28.0 | 25,241 | 24.0% |
| 2019 | 106.263 | 0.25% | 31.7 | 36.129 | 21.4% | 21.0% | 46,939 | 0.42% | 30.2 | 24,864 | 22.6% |
| 2020 | 133.126 | 0.24% | 32.8 | 38.260 | 21.5% | 19.3% | 38,824 | 0.44% | 28.9 | 25,146 | 20.0% |
| 2021 | 168.408 | 0.24% | 31.5 | 36.988 | 22.6% | 17.9% | 44,457 | 0.40% | 28.5 | 24,569 | 19.4% |
| 2022 | 176.027 | 0.28% | 29.0 | 33.519 | 22.3% | 16.9% | 43,354 | 0.74% | 26.8 | 21,608 | 18.6% |
| Noncomplication group | |||||||||||
| Early rehabilitation intervention group | None intervention group | ||||||||||
| Year | Count | Mortality | LOS (d) | Ave all-in cost (¥) | Ave rehab cost | Ave medicine cost | Count | Mortality | LOS (d) | Ave all-in cost (¥) | Ave medicine cost |
| 2016 | 251.756 | 0.04% | 21.1 | 14.416 | 21.1% | 24.0% | 246,404 | 0.05% | 20.6 | 9330 | 22.7% |
| 2017 | 417.427 | 0.03% | 19.1 | 12.490 | 22.1% | 19.8% | 344,147 | 0.04% | 16.8 | 9070 | 19.9% |
| 2018 | 503.704 | 0.03% | 18.7 | 12.315 | 22.4% | 17.3% | 402,067 | 0.04% | 16.8 | 9051 | 19.5% |
| 2019 | 710.176 | 0.02% | 18.0 | 11.852 | 23.2% | 16.3% | 522,200 | 0.04% | 24.7 | 8400 | 17.3% |
| 2020 | 704.406 | 0.03% | 18.7 | 12.660 | 23.0% | 14.8% | 409,055 | 0.05% | 15.4 | 8061 | 15.7% |
| 2021 | 805.631 | 0.02% | 18.3 | 12.478 | 23.6% | 13.9% | 433,057 | 0.04% | 15.5 | 8257 | 15.7% |
| 2022 | 776.203 | 0.04% | 17.3 | 11.707 | 22.7% | 13.8% | 401,377 | 0.05% | 14.7 | 7727 | 15.6% |
Early Rehabilitation in Provinces and Municipalities
In 7 yrs, the rate of early rehabilitation intervention has continued to increase across the country, especially in 2020. In 2022, the early rehabilitation intervention rate was 68.2%. By province, most provinces also saw year-on-year growth. Among the provinces and municipalities, the highest was 82.15% in Shanghai and the lowest was 14.00% in Tibet Autonomous Region (Table 4, Fig. 1).
TABLE 4.
Annual change of early rehabilitation intervention rate in provinces and cities
| Regions | Early Rehabilitation Intervention Rate | |||||||
|---|---|---|---|---|---|---|---|---|
| 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | Ave. | |
| Municipality | ||||||||
| Shanghai | 75.8% | 77.7% | 82.8% | 80.5% | 81.6% | 84.2% | 86.0% | 82.2% |
| Beijing | 89.5% | 87.5% | 82.1% | 79.7% | 67.4% | 73.0% | 67.2% | 80.7% |
| Tianjin | 35.1% | 56.5% | 76.8% | 68.6% | 72.4% | 80.1% | 82.7% | 66.2% |
| Chongqing | 50.7% | 53.3% | 63.5% | 56.4% | 61.7% | 61.1% | 59.0% | 58.6% |
| Province | ||||||||
| Guangdong | 79.4% | 81.5% | 69.0% | 80.0% | 78.3% | 80.7% | 81.0% | 78.7% |
| Zhejiang | 52.4% | 67.2% | 74.6% | 70.4% | 73.3% | 72.1% | 74.3% | 70.5% |
| Yunan | 52.0% | 59.8% | 65.6% | 69.0% | 72.1% | 75.1% | 75.7% | 69.1% |
| Liaoning | 45.5% | 51.0% | 60.4% | 56.7% | 76.6% | 79.3% | 81.0% | 66.8% |
| Tianjin | 35.1% | 56.5% | 76.8% | 68.6% | 72.4% | 80.1% | 82.7% | 66.2% |
| Jiangsu | 33.4% | 52.5% | 54.8% | 61.1% | 74.0% | 75.2% | 78.1% | 65.5% |
| Jiangxi | 53.3% | 58.4% | 62.1% | 57.5% | 68.1% | 66.2% | 67.9% | 63.5% |
| Hubei | 49.1% | 55.4% | 58.7% | 62.6% | 66.6% | 70.2% | 72.6% | 63.2% |
| Henan | 47.1% | 51.7% | 52.0% | 58.7% | 69.4% | 69.2% | 67.8% | 62.0% |
| Sichuan | 60.7% | 60.5% | 58.3% | 54.9% | 60.1% | 62.9% | 64.4% | 60.5% |
| Hebei | 34.8% | 47.3% | 48.8% | 55.4% | 62.9% | 71.1% | 75.6% | 59.5% |
| Shanxi | 72.7% | 60.8% | 56.3% | 46.2% | 55.5% | 63.9% | 67.7% | 59.4% |
| Shandong | 53.7% | 48.4% | 48.3% | 52.9% | 63.4% | 61.7% | 69.0% | 58.3% |
| Hainan | 51.5% | 51.4% | 53.8% | 47.6% | 53.3% | 62.1% | 79.1% | 58.0% |
| Heilongjiang | 51.5% | 54.0% | 52.0% | 59.7% | 66.3% | 59.1% | 55.0% | 57.0% |
| Hunan | 53.6% | 58.9% | 57.4% | 54.4% | 52.5% | 56.7% | 60.0% | 56.3% |
| Gansu | 6.6% | 22.0% | 28.3% | 59.7% | 65.2% | 59.6% | 61.2% | 51.1% |
| Anhui | 24.4% | 29.2% | 39.2% | 47.6% | 63.5% | 63.4% | 62.8% | 50.8% |
| Fujian | 47.8% | 61.5% | 55.4% | 46.0% | 43.5% | 45.2% | 47.0% | 48.6% |
| Shaanxi | 22.7% | 40.1% | 42.1% | 42.7% | 48.4% | 52.7% | 53.9% | 46.8% |
| Jilin | 24.7% | 29.4% | 27.3% | 39.7% | 61.0% | 60.0% | 63.2% | 44.4% |
| Qinghai | 16.4% | 23.0% | 10.3% | 13.3% | 32.6% | 49.8% | 47.9% | 31.8% |
| Guizhou | 27.7% | 28.2% | 27.6% | 30.9% | 37.6% | 35.0% | 29.3% | 31.7% |
| Autonomous region | ||||||||
| Xinjiang | 57.5% | 83.3% | 75.9% | 76.2% | 80.0% | 84.6% | 82.8% | 78.8% |
| Guangxi | 63.5% | 55.8% | 58.5% | 64.3% | 69.2% | 72.6% | 71.0% | 66.1% |
| Nei Monggol | 25.3% | 28.7% | 45.0% | 48.9% | 74.8% | 81.9% | 85.1% | 57.7% |
| Ningxia | 42.8% | 48.1% | 49.1% | 52.1% | 67.0% | 66.6% | 69.7% | 58.3% |
| Tibet | 0.0% | 0.0% | 0.0% | 0.0% | 5.3% | 11.7% | 17.8% | 14.0% |
| Xinjiang production and construction corps | ||||||||
| XPCCa | 41.7% | 54.8% | 65.4% | 76.5% | 85.7% | 81.7% | 85.4% | 73.6% |
| National average level | 52.1% | 55.9% | 56.6% | 58.9% | 65.2% | 67.1% | 68.2% | 62.0% |
FIGURE 1.
Average early rehabilitation intervention rate in provinces and cities from 2016 to 2022. The study was conducted in mainland China. Hong Kong, Macao, and Taiwan were not included.
The rate of early rehabilitation intervention in the complication group/the rate of early rehabilitation intervention in the noncomplication group (RR), RR > 1, was inclined to give early rehabilitation intervention to the complication group. The slope of RR change in 5 yrs is shown in the Table 5. If RR is greater than 0, this trend is increasing year by year.
TABLE 5.
RR slope of provinces and municipalities
| Regions | RR Slope |
|---|---|
| Gansu | 0.195 |
| Shaanxi | 0.104 |
| Fujian | 0.091 |
| Nei Monggol | 0.077 |
| Heilongjiang | 0.069 |
| Hunan | 0.024 |
| Shandong | 0.015 |
| Jiangsu | 0.014 |
| Sichuan | 0.010 |
| Shanxi | 0.010 |
| Hainan | 0.010 |
| Beijing | 0.009 |
| Tianjin | 0.006 |
| Hubei | 0.005 |
| Chongqing | 0.004 |
| Guangdong | −0.004 |
| Jiangxi | −0.007 |
| Guizhou | −0.009 |
| Shanghai | −0.010 |
| Xinjiang | −0.022 |
| Henan | −0.027 |
| Guangxi | −0.028 |
| Yunan | −0.029 |
| Anhui | −0.041 |
| Zhejiang | −0.069 |
| Liaoning | −0.077 |
| Ningxia | −0.080 |
| Hebei | −0.086 |
| XPCC | −0.106 |
| Jilin | −0.172 |
| Tibet | −0.360 |
| Qinghai | −0.632 |
DISCUSSION
The overall rate of early rehabilitation intervention in China’s tertiary general hospitals was 62.0% in the past 7 yrs. It is difficult to find the data of early rehabilitation intervention rate in developed countries in Europe and the United States in the previous literature. We have searched for data on early rehabilitation from other countries, but no specific numbers or references were found. We just found articles relevant to prioritizing and developing rehabilitation.10–12 Thus, it is difficult to compare the situation in China with the situation in the world. This may be because developed countries in Europe and the United States have long included early rehabilitation intervention in the medical system and clinical pathways, and the ratio may be close to 100%, so it has not become the focus of research teams. For example, in the White Book on Physical and Rehabilitation Medicine in Europe,13 it is clearly required that secondary and tertiary institutions, including intensive care unit, should provide mobile acute rehabilitation services based on MDT. The Medicare Benefits Policy of the United States also requires inpatient rehabilitation facility to provide intensive rehabilitation treatment for acute inpatients.14 Although the Chinese government issued relevant policies15 as early as 2013 to improve the early rehabilitation intervention rate, due to the shortage of rehabilitation resources in China, this ratio has not reached the ideal level.
The rate of early rehabilitation intervention is increasing year by year, especially in 2020. This may be due to the following reasons. China’s national health committee to “increase the rate of hospitalized patients with early rehabilitation intervention” as the annual quality improvement goal, the national center for rehabilitation medicine quality control will increase the rate of early rehabilitation intervention as the most important goals, to be included in all new index system, and every year for the national five hundreds of hospitals to carry out the training, stable cross country related documentation requirements, promote the integrated mode of clinical rehabilitation, give practical guidance to the provincial quality control center. These measures may have contributed to the growth of this indicator.
Regardless of complications, the mortality of patients undergoing early rehabilitation was lower than that of patients without early rehabilitation, but the length of hospital stay and total cost were higher than those without early rehabilitation. This may be because early rehabilitation interventions reduce mortality. Alternatively, maybe it is due to the fact that hospitals with early rehabilitation intervention are relatively better hospitals with lower mortality, higher length of stay, and higher total cost. Studies in some developed countries support this conjecture. Because the HQMS system’s medical information agency is confidential, we could not analyze this further. Some studies believe that early rehabilitation intervention is beneficial to patients, such as improving the activities of daily living in stroke,16,17 accelerating the recovery of nerve function in spinal cord injury,18 accelerating the recovery of movement in anterior cruciate ligament reconstruction,19 and improving the movement function in joint replacement.20 The above studies coincide with the key diseases selected in this study.
The RR values of rehabilitation intervention rates in patients with complications and in patients without complications may indicate the tendency to give early rehabilitation intervention to patients with complications. We guessed that RR was greater than 1 because of the relative shortage of rehabilitation medical resources in China, so patients with more complications tend to receive early rehabilitation treatment. The slope of RR change over 5 yrs is greater than 0, which may indicate that the development rate of rehabilitation medical resources cannot keep pace with that of other clinical specialties. This makes the trend more obvious year by year. This provides more precise spatial positioning for the improvement of rehabilitation medical quality.
The survey has some limitations. For example, the contents of the first page of the medical records of discharged patients in China cannot reflect the timing and specific content of early rehabilitation intervention, and the time of complications is also not included, so the causal relationship between early rehabilitation intervention and complications can only be inferred by common sense and time trends. The first page of medical records can only judge whether early rehabilitation intervention has been carried out by charging items, so the degree and scientificity of intervention cannot be stratified. Moreover, the distribution of medical resources in China is uneven, and the level of medical institutions varies greatly from region to region. However, the personal information of patients and the information of medical institutions in the HQMS system are strictly confidential, which makes it difficult for us to systematically analyze the impact of early rehabilitation intervention on the outcome of patients.
CONCLUSIONS
The rate of early rehabilitation intervention in China’s tertiary general hospitals increased year by year from 2016 to 2020, especially in 2020. Regardless of complications, the mortality of patients undergoing early rehabilitation was lower than that of patients without early rehabilitation, but the length of hospital stay and total cost were higher than those without early rehabilitation. The change of this indicator varies from province to city.
ACKNOWLEDGMENTS
The authors thank National Rehabilitation Medicine Quality Control Center Construction Funds. This article has been published in preprint and the authors disclose the preprint server at the time of submission.
Footnotes
Co-first author: Yuanmingfei Zhang and Hua Zhang contributed equally to this work.
Co-corresponding Author: Mouwang Zhou contributed equally to this work.
Author contributor statement: Conception or design of the work Mouwang Zhou, Zhan Siyan, Yuanmingfei Zhang, Hua Zhang
Data collection Haibo Wang, Ying Shi, Lanxia Gan
Data analysis and interpretation Hua Zhang, Yuanmingfei Zhang
Drafting the article Yuanmingfei Zhang, Hua Zhang
Critical revision of the article Yanyan Yang.
Reflexivity statement: Of the ten authors, four are females and six are males and span multiple levels of seniority. Two of the authors worked in government health departments, three worked in national health data collection and management departments, three were doctors in rehabilitation medicine and part-time staff of the National Rehabilitation Quality Control Center, and two were epidemiological researchers in universities and medical institutions. All authors have outstanding expertise in healthcare quality management and control.
Ethical approval: Ethical approval for this type of study is not required by our institute.
Role of the funding source: The funding source had no role in study design, data collection, analysis and interpretation, or drafting of the manuscript. The authors had full access to all the data in the study and all authors had final responsibility for the decision to submit for publication.
Data sharing: Dates are available upon reasonable request.
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
The preprint article at the link below.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.ajpmr.com).
Contributor Information
Yuanmingfei Zhang, Email: zymf@pku.edu.cn.
Hua Zhang, Email: zhanghua824@163.com.
Mouwang Zhou, Email: zhoumouwang@outlook.com.
Siyan Zhan, Email: siyan-zhan@bjmu.edu.cn.
Yanyan Yang, Email: yyykaixin@163.com.
Haibo Wang, Email: Haibo@mail.Harvard.edu.
Ying Shi, Email: Ying.shi@cltr.org.
Lanxia Gan, Email: lanagan@163.com.
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