Original Article

Temporal trend in mortality due to congenital heart disease in China

from 2008 to 2021
Youping Tian1,2, Xiaojing Hu1,2, Qing Gu1,3, Miao Yang1, Pin Jia1, Xiaojing Ma1,2,3,4, Xiaoling Ge1, Quming Zhao1,2,3,4, Fang Liu1,2,3,4,
Ming Ye1,2,3,4, Weili Yan2,4,5, Guoying Huang1,2,3,4
1
National Management Office of Neonatal Screening Project for Congenital Heart Disease, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai
201102, China;
2
Research Unit of Early Intervention of Genetically Related Childhood Cardiovascular Diseases (2018RU002), Chinese Academy of Medical Sciences, Shanghai 201102, China;
3
Pediatric Heart Center, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China;
4
Shanghai Key Laboratory of Birth Defects, Shanghai 201102, China;
5
Department of Clinical Epidemiology and Clinical Trial Unit, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China.

Abstract
Background: Congenital heart disease (CHD) is a leading cause of birth defect-related mortality. However, more recent CHD
mortality data for China are lacking. Additionally, limited studies have evaluated sex, rural–urban, and region-specific disparities
of CHD mortality in China.
Methods: We designed a population-based study using data from the Dataset of National Mortality Surveillance in China between
2008 and 2021. We calculated age-adjusted CHD mortality using the sixth census data of China in 2010 as the standard popu-
lation. We assessed the temporal trends in CHD mortality by age, sex, area, and region from 2008 to 2021 using the joinpoint
regression model.
Results: From 2008 to 2021, 33,534 deaths were attributed to CHD. The period witnessed a two-fold decrease in the age-ad-
justed CHD mortality from 1.61 to 0.76 per 100,000 persons (average annual percent change [AAPC] = −5.90%). Females
tended to have lower age-adjusted CHD mortality than males, but with a similar decline rate from 2008 to 2021 (females:
AAPC = −6.15%; males: AAPC = −5.84%). Similar AAPC values were observed among people living in urban (AAPC = −6.64%)
and rural (AAPC = −6.12%) areas. Eastern regions experienced a more pronounced decrease in the age-adjusted CHD mortality
(AAPC = −7.86%) than central (AAPC = −5.83%) and western regions (AAPC = −3.71%) between 2008 and 2021. Approx-
imately half of the deaths (46.19%) due to CHD occurred during infancy. The CHD mortality rates in 2021 were lower than
those in 2008 for people aged 0–39 years, with the largest decrease observed among children aged 1–4 years (AAPC = −8.26%),
followed by infants (AAPC = −7.01%).
Conclusions: CHD mortality in China has dramatically decreased from 2008 to 2021. The slower decrease in CHD mortality in
the central and western regions than in the eastern regions suggested that public health policymakers should pay more attention
to health resources and health education for central and western regions.
Keywords: Congenital heart disease; Time trend; Mortality; Public health

Introduction crude mortality rate due to CHD has declined from 7.1 per
100,000 in 1990 to 2.8 per 100,000 in 2019.[1] Previous
Congenital heart disease (CHD) is one group of the most studies using data from the Global Burden of Disease
common birth defects, with 13.3 million patients world- (GBD) study also demonstrated a downward trend in
wide in 2019.[1] In China, the number of CHD cases is mortality due to CHD in China from 1990 to 2019.[6,7]
approximately 2 million,[2] with approximately 150,000
new cases annually.[3] CHD is the leading cause of birth An imbalance in public service resource allocation is
defect-related mortality, accounting for approximately a universal problem worldwide. As the world’s largest
40% of deaths in those with birth defects under 20 years developing country, China also has an unbalanced alloca-
of age.[4] Over the past decades, progress in diagnostic and tion of healthcare resources between urban and rural areas,
treatment capabilities for CHD has substantially reduced and among the eastern, central, and western regions.[8]
mortality for the entire spectrum of CHD.[5] The global Large disparities in healthcare resources can significantly

Access this article online

Correspondence to: Guoying Huang, Pediatric Heart Center, Children’s Hospital of
Quick Response Code: Fudan University, Shanghai 201102, China
Website:
E-Mail: [email protected]
www.cmj.org
Copyright © 2024 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the
CC-BY-NC-ND license. This is an open access article distributed under the terms of the Creative
DOI: Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is
10.1097/CM9.0000000000003057 permissible to download and share the work provided it is properly cited. The work cannot be
changed in any way or used commercially without permission from the journal.
Chinese Medical Journal 2025;138(6)
Received: 10-07-2023; Online: 25-04-2024 Edited by: Jing Ni

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influence health outcomes. However, few studies has 40–44 years, 45–49 years, 50–54 years, 55–59 years,
evaluated region-specific disparities in mortality due to 60–64 years, 65–69 years, 70–74 years, 75–79 years,
CHD in China, although there was one population-based 80–84 years, and ≥85 years), area of residence (urban
study that reported the national trend in mortality due to and rural), and geographic region of residence (eastern,
CHD in urban and rural Chinese populations from 2003 central, and western). The dataset classified all counties
to 2010.[9] In fact, many policies have been implemented (including county-level cities) into rural areas and all dis-
in China to promote the health of children with CHD, tricts of a city into urban areas, and divided 31 provincial
such as listing CHD in specific relief programs for major administrative regions (provinces, municipalities, and
critical illnesses since 2017.[10] Additionally, Shanghai has autonomous regions) in the Chinese mainland into eastern
effectively implemented a newborn screening program for regions (Beijing, Tianjin, Hebei, Liaoning, Shanghai,
CHD since 2016,[11] and given the successful experience Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, and
and benefits of newborn screening for CHD in Shanghai, Hainan), central regions (Shanxi, Jilin, Heilongjiang,
the National Health Commission of China implemented Anhui, Jiangxi, Henan, Hubei, and Hunan), and western
newborn screening for CHD as one public policy in China regions (Inner Mongolia, Guangxi, Chongqing, Sichuan,
in 2018.[12] This population-based study thus aimed to Guizhou, Yunnan, Xizang, Shaanxi, Gansu, Qinghai,
investigate the temporal trends in mortality due to CHD Ningxia, and Xinjiang). Based on preliminary analysis
in China from 2008 to 2021 overall and by age, and and human development theory, we categorized age into
evaluate the sex-specific, rural–urban, and region-specific six groups: <1 year, 1–4 years, 5–19 years, 20–39 years,
disparities. 40–59 years, and ≥60 years of age.

Methods Statistical analyses

For each year of the study and by sex, area, and region, we
Data sources calculated age-adjusted CHD mortality rates. The age-ad-
We designed a population-based longitudinal study using justed CHD mortality rate is the weighted average of
data from the Dataset of National Mortality Surveillance the age-specific CHD mortality rate per 100,000 people,
in China (2008–2021), which is free of charge and pub- where the weights represent the proportions of people in
licly available for download at https://ncncd.chinacdc. the corresponding age groups of the general population.
cn. This dataset is one of the most commonly used and In this study, we calculated the age-adjusted CHD mortal-
highest-quality sources of detailed mortality in China, ity rate using the sixth census data of China in 2010 as the
which is compiled and released annually by the Chinese standard population. All mortality rates were calculated
Centre for Disease Control and Prevention (CDC) using as the number of deaths per 100,000 people.
data from the Disease Surveillance Points System (DSPs).
Since this study was a secondary analysis of nationally We assessed the temporal trends in CHD mortality by age,
representative data and did not involve any interactions sex, area, and region from 2008 to 2021 using the join-
with human subjects or personal identifying informa- point regression model, which is particularly effective at
tion, ethical approval and informed consent were not identifying changes in the temporal trends of events over
required according to the Ethical Review Measures time.[18] This method uses validated segmented regression
for Biomedical Research Involving Human Subjects in models that allow for the identification of significant
China. changes in the slope of a trend line over time. It can
describe trends by connecting several different line seg-
The DSPs is a key sample registration system for disease ments and identifying time points (joinpoint) where linear
surveillance and vital events for all ages in China,[13,14] trends change during the time period examined. The num-
covering nearly a quarter of the population (323.8 million) ber and locations of the joinpoint and the corresponding
with 605 surveillance points.[15] All of these were selected P values were determined by Monte Carlo permutation
using an iterative method involving multistage stratifica- tests. Joinpoint regression fitting was performed using
tion, and causes of death were coded using the International log-transformed data, and the annual percentage change
Classification of Diseases, 10th Revision (ICD-10) after (APC) with its 95% confidence interval (CI) was calcu-
2001. More details of the system design, stratification lated for each period. The average annual percent change
methods, surveillance points selection, death information (AAPC) with its 95% CI was also obtained, which is
collection and certificate, coding and determining underlying a single value describing trends in mortality over the
cause-of-death, and quality control procedures have been entire study period. The joinpoint regression model was
reported elsewhere.[15] The representativeness and quality performed using Joinpoint Regression Program 4.9.1.0
of data collection in DSPs also have been demonstrated in (Surveillance Research Program of the US National Can-
previous studies.[15–17] cer Institute, Bethesda, MD, USA). Statistical significance
was set at P value <0.05.
In the present study, we directly extracted data on
total population, number of deaths, and mortality rate Results
from the Dataset of National Mortality Surveillance in
China according to sex (male and female), age group From 2008 to 2021, a total of 18,006,024 deaths were
(<1 year, 1–4 years, 5–9 years, 10–14 years, 15–19 years, reported by the Dataset of National Mortality Surveillance
20–24 years, 25–29 years, 30–34 years, 35–39 years, in China, and 33,534 deaths were attributed to CHD,

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representing 1 in 537 deaths. From 2008 to 2021, there was CHD mortality rate (from 1.65 to 0.57 per 100,000
an approximately two-fold decrease in the age-adjusted persons, AAPC = −7.86%, 95% CI: −9.38% to −6.31%)
mortality rate due to CHD from 1.61 to 0.76 per 100,000 than central regions (from 1.74 to 0.80 per 100,000 per-
persons [Table 1 and Supplementary Figure 1, http:// sons, AAPC = −5.83%, 95% CI: −7.76% to −3.85%) and
links.lww.com/CM9/B935]. The mean annual decrease western regions (from 1.61 to 0.98 per 100,000 persons,
in mortality due to CHD (AAPC = −5.90%, 95% CI: AAPC = −3.71%, 95% CI: −6.37% to −0.99%, Table 1),
−7.49% to −4.27%) was faster than the age-adjusted all- and the disparity in mortality due to CHD tended to be
cause mortality (AAPC = −1.67%, 95% CI: −2.01% to larger among eastern, central, and western regions over
−1.33%). time [Figure 3].

All-cause and age-adjusted CHD mortality by sex, area, and Age-specific CHD mortality
region
Unlike the J-shaped pattern of all-cause mortality with
Compared to males, females tended to have lower age, we observed an L-shaped association between age
age-adjusted all-cause mortality and CHD mortality, but and mortality due to CHD [Figure 4]. Mortality due
with similar temporal trends over the entire study period to CHD was highest among infants and lowest among
[Figure 1]. Additionally, the disparities in age-adjusted adults aged 40–59 years and above 60 years. CHD
CHD mortality tended to decrease between sexes over mortality rate in 2021 was lower than that in 2008 for
time. The age-adjusted all-cause mortality rate significantly people aged 0–39 years, with the largest decrease among
decreased from 2008 to 2021 in both males (AAPC08–21 = children aged 1–4 years (from 4.78 to 1.47 per 100,000
−1.66%, 95% CI: −1.90% to −1.41%) and females persons, AAPC = −9.01%, 95% CI: −11.23% to −6.74%),
(AAPC08–21 = −1.90%, 95% CI: −3.44% to −0.33%). The followed by infants (from 76.28 to 22.22 per 100,000
age-adjusted CHD mortality increased but not significantly persons, AAPC = −8.65%, 95% CI: −11.13% to −6.10%).
from 2008 to 2011 in males and from 2008 to 2012 in
females, and then significantly decreased from 2011 to Approximately half of the deaths due to CHD occurred dur-
2021 in males (APC11–17 = −7.76%, P value = 0.002; ing infancy (n = 15,488, 46.19%). Infant mortality due to
APC17–21 = −12.30%, P value = 0.001) and from 2012 CHD was consistently higher in males than females through-
to 2021 in females (APC12–21 = −8.95%, P value <0.001). out the study period, whereas the disparity in infant mortality
The AAPC of age-adjusted CHD mortality was −6.15% due to CHD tended to decrease between males and females
(95% CI: −8.93% to −3.29%) in males and −5.84% since 2018 [Supplementary Figure 2, http://links.lww.com/
(95% CI: −7.35% to −4.31%) in females [Table 1]. CM9/B935]. The mean annual decrease in infant mortality
due to CHD was faster among people living in urban areas
The age-adjusted all-cause mortality fluctuated among than those living in rural areas (urban: AAPC = −10.69%,
people living in urban areas from 2008 to 2016, and then 95% CI: −15.35% to −5.77%; rural: AAPC = −7.69%,
decreased remarkably from 2016 to 2021 (APC16–21 = 95% CI: −10.61% to −5.12%). The period of 2008–2021
−3.70%, P value = 0.001), while it continually decreased witnessed decreasing trends in infant mortality due to CHD
among people living in rural areas between 2008 and 2021 in all regions, with the fastest decrease in eastern regions
(APC08–21 = −1.69%, P value <0.001, Figure 2). For the (AAPC = −12.18%, 95% CI: −15.61% to −8.61%), fol-
age-adjusted CHD mortality, one joinpoint was identified lowed by central (AAPC = −7.69%, 95% CI: −10.32% to
for both urban and rural people in the joinpoint regression −4.98%) and western regions (AAPC = −5.75%, 95% CI:
model, with a significant decrease in urban people from −8.72% to −2.67%). Additionally, the difference in infant
2015 to 2021 (APC15–21 = −13.38%, P value <0.001) mortality due to CHD has tended to be larger in the eastern,
and in rural people from 2012 to 2021 (APC12–21 = central, and western regions since 2018 [Supplementary
−9.11%, P value <0.001). Over the entire study period, Figure 3, http://links.lww.com/CM9/B935].
urban people had similar AAPC values of age-adjusted
CHD mortality as rural populations [Table 1]. Death in children aged 1–4 years and 5–19 years
accounted for 13.50% (n = 4526) and 13.51% (n = 4532)
From 2008 to 2021, the age-adjusted all-cause mortality of all deaths due to CHD, respectively. Mortality due
significantly decreased in all regions of China (eastern: to CHD significantly decreased from 4.78 to 1.47 per
APC08–17 = −0.87%, P value = 0.06; APC17–21 = −4.48%, 100,000 persons and from 1.06 to 0.75 per 100,000
P value = 0.001; central: APC08–19 = −1.74%, P value persons among children aged 1–4 years and 5–19 years,
<0.001; APC19–21 = −4.55%, P value = 0.01; western: with an average annual decrease of 9.01% and 2.54%,
APC08–18 = −0.99%, P value = 0.001; APC18–21 = −3.60%, respectively [Table 1]. Consistent with the findings among
P value = 0.001, Figure 3). The age-adjusted CHD mortality infants, the declining rate of mortality due to CHD was
continually decreased in eastern regions, with a signifi- faster among children living in the eastern regions than
cantly downward trend from 2012 to 2021 (APC12–16 = those living in the central and western regions. However,
−8.31%, P value = 0.002; APC16–21 = −13.20%, P value mortality due to CHD significantly decreased among
<0.001). Similar significantly downward trends were rural children but not among urban children aged 5–
observed in central regions from 2012 to 2021 (APC12–21 = 19 years.
−8.72%, P value <0.001) and in western regions from
2011 to 2021 (APC11–21 = −7.46%, P value <0.001). The During the study period, mortality due to CHD signifi-
period from 2008 to 2021 witnessed that eastern regions cantly decreased among young adults aged between
experienced a more pronounced decrease in age-adjusted 20 years and 39 years (from 0.65 to 0.45 per 100,000

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Table 1: Temporal trends in all-cause mortality rate and CHD-specific mortality rate in China, by age, sex, areas, and regions, 2008–2021.
All-cause mortality rate (1/100,000) CHD mortality rate (1/100,000)
Population subgroup 2008 2021 AAPC (%, [95% CI]) 2008 2021 AAPC (%, [95% CI])
All ages
Overall 622.91 500.26 –1.67 (–2.01, –1.33) 1.61 0.76 –5.90 (–7.49, –4.27)
Sex
Male 743.24 598.10 –1.66 (–1.90, –1.41) 1.68 0.73 –6.15 (–8.93, –3.29)
Female 508.05 395.96 –1.90 (–3.44, –0.33) 1.62 0.74 –5.84 (–7.35, –4.31)
Residence
Urban 513.05 445.56 –1.08 (–2.01, –0.14) 1.60 0.66 –6.64 (–8.25, –5.00)
Rural 645.64 517.38 –1.69 (–2.04, –1.33) 1.77 0.78 –6.12 (–7.58, –4.63)
Area
Eastern 571.34 439.53 –1.76 (–2.70, –0.80) 1.65 0.57 –7.86 (–9.38, –6.31)
Central 634.91 477.11 –1.82 (–2.07, –1.57) 1.74 0.80 –5.83 (–7.76, –3.85)
Western 631.85 512.21 –1.46 (–2.09, –0.83) 1.61 0.98 –3.71 (–6.37, –0.99)
Age at death, <1 year
Overall 795.53 185.68 –10.30 (–12.41, –8.14) 76.28 22.22 –8.65 (–11.13, –6.10)
Sex
Male 894.93 197.47 –10.46 (–12.43, –8.45) 79.64 22.78 –9.11 (–12.06, –6.06)
Female 685.11 172.73 –9.71 (–11.20, –8.20) 72.56 21.60 –7.91 (–10.61, –5.12)
Residence
Urban 548.30 166.25 –8.66 (–11.45, –5.77) 74.77 16.83 –10.69 (–15.35, –5.77)
Rural 897.61 194.84 –10.66 (–11.65, –9.66) 76.91 24.75 –7.69 (–9.13, –6.23)
Area
Eastern 570.95 130.94 –10.17 (–13.90, –6.27) 86.27 13.19 –12.18 (–15.61, –8.61)
Central 663.40 191.10 –9.41 (–12.53, –6.18) 78.97 25.86 –7.69 (–10.32, –4.98)
Western 244.72 254.26 –11.56 (–12.88, –10.22) 63.29 29.14 –5.75 (–8.72, –2.67)
Age at death, 1–4 years
Overall 66.39 22.59 –8.00 (–9.93, –6.03) 4.78 1.47 –9.01 (–11.23, –6.74)
Sex
Male 72.91 25.04 –7.54 (–9.50, –5.54) 3.76 1.59 –8.57 (–12.13, –4.87)
Female 59.14 19.89 –8.22 (–9.27, –7.15) 5.91 1.33 –9.46 (–12.08, –6.76)
Residence
Urban 36.83 17.75 –4.82 (–7.00, –2.59) 3.53 1.29 –7.99 (–11.15, –4.71)
Rural 78.66 24.76 –9.09 (–10.06, –8.11) 5.30 1.55 –8.65 (–11.73, –5.45)
Area
Eastern 44.84 16.40 –6.51 (–8.66, –4.32) 4.77 0.86 –11.42 (–14.6, –8.12)
Central 49.32 21.19 –6.87 (–8.27, –5.45) 4.20 1.36 –8.71 (–11.86, –5.45)
Western 108.68 33.11 –8.53 (–10.77, –6.24) 5.45 2.46 –6.02 (–9.76, –2.13)
Age at death, 5–19 years
Overall 32.38 20.07 –4.05 (–4.67, –3.43) 1.06 0.75 –2.54 (–3.70, –1.37)
Sex
Male 42.50 23.68 –4.61 (–5.67, –3.54) 1.14 0.73 –2.98 (–4.50, –1.43)
Female 21.33 15.80 –2.43 (–3.31, –1.55) 0.98 0.77 –2.06 (–3.40, –0.71)
Residence
Urban 24.93 16.31 –2.89 (–3.90, –1.87) 0.72 0.63 –1.03 (–3.84, 1.87)
Rural 35.35 21.68 –4.45 (–5.08, –3.81) 1.20 0.80 –3.12 (–4.69, –1.52)
Area
Eastern 24.58 16.26 –3.74 (–4.68, –2.8) 0.90 0.54 –3.91 (–5.63, –2.16)
Central 29.28 19.68 –3.10 (–3.51, –2.69) 1.27 0.80 –2.41 (–3.80, –0.99)
Western 45.21 25.01 –4.15 (–5.42, –2.87) 1.00 0.93 –1.59 (–3.61, 0.47)
Age at death, 20–39 years
Overall 85.01 57.23 –3.35 (–4.57, –2.11) 0.65 0.49 –3.78 (–4.92, –2.62)
Sex
Male 117.53 81.18 –3.25 (–4.52, –1.96) 0.69 0.58 –3.49 (–5.04, –1.92)
(continued)

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Table 1
(Continued)

All-cause mortality rate (1/100,000) CHD mortality rate (1/100,000)

Population subgroup 2008 2021 AAPC (%, [95% CI]) 2008 2021 AAPC (%, [95% CI])
Female 51.17 32.22 –3.81 (–4.79, –2.82) 0.60 0.41 –4.10 (–5.44, –2.75)
Residence
Urban 65.81 43.40 –3.59 (–4.75, –2.41) 0.57 0.37 –4.17 (–5.77, –2.54)
Rural 95.35 65.20 –3.02 (–4.42, –1.60) 0.69 0.56 –3.62 (–5.03, –2.20)
Area
Eastern 69.53 46.86 –3.62 (–4.32, –2.91) 0.49 0.45 –4.10 (–6.47, –1.67)
Central 78.39 55.92 –2.85 (–4.30, –1.39) 0.74 0.47 –4.36 (–5.81, –2.88)
Western 113.70 74.83 –3.31 (–4.38, –2.24) 0.75 0.58 –2.64 (–4.13, –1.13)
Age at death, 40–59 years
Overall 397.31 307.68 –1.96 (–2.93, –0.98) 0.33 0.41 –0.12 (–1.96, 1.75)
Sex
Male 531.25 434.57 –1.27 (–1.75, –0.79) 0.28 0.40 0.45 (–1.47, 2.39)
Female 257.96 180.06 –2.77 (–3.51, –2.03) 0.39 0.42 –0.72 (–3.22, 1.84)
Residence
Urban 323.65 250.01 –1.65 (–2.41, –0.89) 0.34 0.37 –1.86 (–3.78, 0.10)
Rural 444.81 339.33 –1.04 (–3.22, 1.18) 0.33 0.42 1.03 (–1.29, 3.41)
Area
Eastern 354.75 263.09 –2.01 (–2.51, –1.51) 0.40 0.39 –1.17 (–3.73, 1.46)
Central 405.01 316.94 –1.83 (–2.54, –1.12) 0.28 0.37 –0.00* (–2.86, 2.93)
Western 457.78 365.40 –1.73 (–2.85, –0.6) 0.29 0.48 0.76 (–1.53, 3.12)
Age at death, ≥60 years
Overall 3436.83 2891.17 –1.37 (–2.03, –0.70) 0.35 0.36 –4.03 (–10.55, 2.96)
Sex
Male 3939.95 3316.70 –1.49 (–1.84, –1.14) 0.27 0.31 –4.50 (–12.29, 3.98)
Female 2957.02 2497.05 –1.26 (–2.10, –0.42) 0.43 0.40 –3.73 (–9.74, 2.69)
Residence
Urban 3017.54 2696.68 –0.75 (–1.65, 0.17) 0.41 0.50 –2.65 (–6.72, 1.60)
Rural 3714.40 2991.05 –1.65 (–1.95, –1.35) 0.31 0.28 –4.14 (–10.90, 3.14)
Area
Eastern 3335.08 2759.22 –1.39 (–2.30, –0.47) 0.37 0.35 –2.52 (–5.81, 0.89)
Central 3659.36 2914.16 –1.70 (–2.00, –1.40) 0.20 0.29 –5.30 (–15.46, 6.08)
Western 3320.94 3093.23 –0.78 (–1.32, –0.24) 0.51 0.47 –1.99 (–13.05, 10.48)
Mortality rates are calculated as the number of deaths per 100,000 for all age groups. Mortality rates for “all ages” are age-adjusted using the 2010
population of China as the reference; mortality rates for individual age groups are crude (age-specific). *The AAPC value is less than –0.001; AAPC:
Average annual percent change; CHD: Congenital heart disease; CI: Confidence interval.

persons, AAPC = −3.78%, 95% CI: −4.92% to −2.62%), with similar decline rates among male, female, urban,
but not among other adult groups [Table 1]. and rural Chinese populations. However, the disparity
in mortality due to CHD has tended to be larger among
the eastern, central, and western regions of China over
Discussion time, especially among infants since 2018, when a policy
Understanding a country’s mortality due to CHD and of newborn screening for CHD was launched nationwide.
its temporal trend is beneficial to determine the level of It has been progressing more rapidly in the eastern regions
medical care for CHD and overall public health needs of China. Most cases of mortality due to CHD occurred
in children. The period of 2008–2021 witnessed faster
in that country, and is essential to properly implement
decreases in mortality due to CHD among infants and
public health programs. The present study used data from
children aged 1–4 years than in other age groups.
the Dataset of National Mortality Surveillance in China
to update the temporal trend in mortality due to CHD Consistent with the global time trend in mortality due to
from 2008 to 2021 overall and by age, and evaluated CHD from 1999 to 2019,[4] and the time trends in the
the sex-specific, rural–urban, and region-specific dispari- US from 1999 to 2017,[19] the present study, using data
ties in mortality due to CHD in detail. Overall, CHD from the Dataset of National Mortality Surveillance, also
mortality decreased by 52.80% from 1.61 to 0.76 per demonstrated an overall downward trend in China from
100,000 persons in China during the 14-year study period, 2008 to 2021, which can be explained by the progress in

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Figure 1: Temporal trends in age-adjusted all-cause mortality (top) and CHD mortality Figure 2: Temporal trends in age-adjusted all-cause mortality (top) and CHD mortality
(bottom), by sex, China, 2008–2021. Joinpoint regression was used to describe trends in (bottom), by residence, China, 2008–2021. Joinpoint regression was used to describe
CHD mortality by connecting several different line segments and identifying time points trends in CHD mortality by connecting several different line segments and identifying time
(joinpoint) where linear trends change during the time period examined. *P <0.05. APC: points (joinpoint) where linear trends change during the time period examined. *P <0.05.
Annual percent change; CHD: Congenital heart disease. APC: Annual percent change; CHD: Congenital heart disease.

the treatment capabilities for CHD. As a previous study sustaining a high surgical volume with low mortality for
has suggested,[4] improvements in the treatment of CHD children with critical CHD.[20] Importantly, those children
can reduce the risk for successively younger cohorts and with CHD and from low-income families could not afford
shift the risk for all age groups over time. It should also the cost for cardiac surgery, and underprivileged children
be noted that the age-adjusted CHD mortality declined had suboptimal outcomes after surgery.[21] In 2010, the
to 0.76 per 100,000 persons in China in 2021, which Chinese government began financially reimbursing families
was slightly lower than the US mortality due to CHD in for the care of children with catastrophic illnesses such
2017 (0.83/100,000), suggesting that the survival gap of as CHD, and charitable foundations provided additional
CHD with the US has dramatically narrowed. We found financial support for the treatment of children from
a non-significant increasing trend in CHD mortality from low-income families by 2012.[21]
2008 to 2012, which was not consistent with a US study
that found a continuous decreasing trend in CHD mor- Over the entire study period, the overall CHD mortality
tality from 1990 to 2017,[19] but was consistent with a rates decreased in both sexes, and females tended to have
previous population-based study that found a significant lower age-adjusted CHD mortality rates than males.
increase in mortality due to CHD from 2003 to 2010.[9] Although the fact that CHD mortality varies between
As a previous study has suggested,[9] the increasing preva- sexes is difficult to explain, many researchers have sug-
lence of CHD at birth and the rising CHD detection rate gested that the differences may be due to the composition
in infants and children may partly explain the growing of CHD in different sexes, the age of patients at the time
trend of CHD mortality during this period. Between 1996 of surgery, and some other factors.[22–24] Given that the
and 2009, the prevalence of CHD almost quintupled. underlying mechanisms of sex differences in outcomes
Additionally, poorly structured specialized centers for are not yet clear, future studies should be conducted to
pediatric cardiac surgery and low economic levels may explore the potential reasons. Despite the difference in
also have contributed to a significant increase in CHD CHD mortality between sexes, our study found that
mortality during this time period. Before 2013, only a males had similar temporal trends as females over the
few experienced pediatric cardiac centers were capable of entire study period, which was consistent with a US study

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Figure 3: Temporal trends in age-adjusted all-cause mortality (top) and CHD mortality
(bottom), by area, China, 2008–2021. APC: Annual percent change; CHD: Congenital heart
disease. Joinpoint regression was used to describe trends in CHD mortality by connecting
several different line segments and identifying time points (joinpoint) where linear trends Figure 4: All-cause mortality (top) and CHD mortality (bottom), by age group, China,
change during the time period examined. *: P <0.05. 2008–2021. Due to the large differences in the magnitude of all-cause vs. CHD-specific
mortality rates, to visualize and compare their respective distributions by age, all-cause
mortality rates and CHD-specific mortality rates were plotted on the Y-axis with a log base
2 transformation. CHD: Congenital heart disease.
that found that the difference in the average APC in mor-
tality due to CHD did not change significantly between
males and females throughout their lifespan from 1999 urban–rural coordinating development as a strategy, and
to 2017.[19] subsequently made substantial efforts to reduce disparities
between rural and urban areas.[25] Urban–rural integra-
To our knowledge, only one population-based study tion is an organic unity of factor allocation and health
using data from the Chinese Health Statistics has eval- care resources, and thus might be beneficial for reducing
uated the temporal trends in mortality due to CHD in disparities in mortality due to CHD between urban and
urban and rural China from 2003 to 2010, and found rural areas.
significant increases in mortality due to CHD in both
urban and rural areas, which can be explained by the This study was designed to depict the temporal trends in
growing CHD detection rate.[9] However, this study did mortality due to CHD in the eastern, central, and western
not calculate the age-adjusted CHD mortality rate, and regions of China. The eastern region tended to have a
thus failed to reduce the effect of different age groups on lower age-adjusted CHD mortality throughout the study
the CHD mortality rate. Our present study calculated period and a faster descending rate than the central and
age-adjusted CHD mortality using the sixth census data western regions. Although a series of policies have been
of China in 2010 as the standard population to reduce the implemented to effectively boost the regional economic
age effect and make age-adjusted CHD mortality com- development of western and central regions in China,
parable across years. Our study found a non-significant such as the well-known “The West Development” in
increasing trend in mortality due to CHD in rural areas 2000 and “The Rise of Central China” in 2004, China
from 2008 to 2012 and a stable trend in urban areas from is still experiencing unbalanced development across
2008 to 2015, followed by significant decreasing trends regional economies, with an inequitable distribution of
in both areas. Importantly, we found that the difference in healthcare resources. In 2021, the disposable incomes per
the mean annual decreases in mortality due to CHD did capita were 44,980.3 CNY, 29,650.0 CNY, and 27,798.4
not change significantly between urban and rural areas CNY in eastern, central, and western regions of China,
from 2008 to 2021. As far back as 2002, China proposed respectively.[26] Additionally, approximately half of the

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grade A tertiary hospitals (the highest level hospitals) provide a more realistic picture of the temporal trend in
were located in eastern regions, with 32.0% in central mortality due to CHD during the study period. Another
regions and 22.0% in western regions.[27] It should also limitation is the lack of data on deaths from different sub-
be noted that eastern regions performed better in health types of CHD, as the data used in the present study were
literacy than central and western regions, which is strongly compiled and released annually by the Chinese CDC, and
associated with hospital admissions, self-management of are thus second-hand data. Thus, the present study failed
chronic diseases, and health outcomes.[28] Thus, it is rea- to analyze the temporal trends in mortality for different
sonable that eastern regions had lower age-adjusted CHD subtypes of CHD. Future studies should focus on the mor-
mortality and a faster descending rate than central and tality trends of each major subtype. Finally, the causes of
western regions, and future policies or strategies for the death may have been miscoded, which may have affected
development of central and western regions should target the estimates of mortality, as is common to any study
not only for the economy but also for health resource and using death certificate data.[31]
education.
Mortality due to CHD has dramatically decreased from
Consistent with previous studies,[9,19] our study demon- 2008 to 2021 in China, with similar rates of decline
strated that nearly half (46.19%) of all CHD mortalities among the male, female, urban, and rural Chinese popu-
occurred during infancy. In China, CHD can affect an lations. The slower decrease in mortality due to CHD in
estimated 9 in 1000 live births, with about one-third of the central and western regions than in the eastern regions
these being life-threatening major CHD (those leading should be given sufficient attention by public health poli-
to death or requiring invasive intervention before one cymakers.
year of age).[29] If left untreated, these major CHD may
cause serious outcomes, such as heart failure, cardio-
genic shock, acidosis, hypoxic–ischemic brain damage, Funding
and recurrent pneumonia, leading to infant death.[30] This study was supported by grants from the National
Diagnostic and treatment capabilities for CHD have Key Research and Development Program of China (Nos.
dramatically improved in China over the past decades. 2021YFC2701004 and 2016YFC1000506), CAMS Innova-
Importantly, newborn screening programs for CHD have tion Fund for Medical Sciences (No. 2019-I2M-5-002),
been implemented in Shanghai since 2016, with a success- Shanghai Health Commission of Health Industry Clinical
ful impact on reducing the infant mortality rate,[11] and Research Project (No. 20234Y0211), and Three-Year
have been promoted nationwide by the National Health Planning for Strengthening the Construction of Public
Commission of China since 2018.[12] Thus, CHD may Health System in Shanghai (No. GWIV-24).
be detected and treated as early as possible, resulting in
larger decreases in mortality due to CHD among infants
and children aged 1–4 years than other age groups during Conflicts of interest
the study period. Newborn screening programs for CHD None.
are effectively implemented in the eastern regions, espe-
cially in Shanghai, Jiangsu, Zhejiang, and Hainan, with
monumental governmental financial support, optimal References
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