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Hydroclimate reconstruction for the last millennium is essential to understand the differences in hydroclimate extremes and their causes under cold/warm conditions. In this study, the first gridded drought/flood grades (D/F grades) dataset in eastern China (EC) during the last millennium was generated. This D/F grades dataset mainly consisted of two components. The first section was created by interpolating drought/flood grades from 1500 to 2000 using the angular distance weight method. Sampling error estimates were employed to assess the effects of the interpolated dataset. The second section for the D/F grades dataset during 960–1500 was generated by constructing best subset regression models using selected tree-ring chronologies in the United States through atmospheric teleconnection. The validation parameters of the calibration equations were also derived, including the adjusted R2, predicted R2, RE, and CE. This dataset provides critical support for investigating the characteristics and causes of hydroclimate extremes in EC at various spatiotemporal scales, as well as the relationship with climate modes, such as El Niño-Southern Oscillation, Pacific Decadal Oscillation, and East Asia Summer Monsoon. [ABSTRACT FROM AUTHOR]

The major droughts and floods in the Hanjiang River Basin, central China, have a significant impact on flood prevention and control in the middle reaches of the Yangtze River and water resources management in the areas of the South–North Water Diversion Middle Line Project. However, there is a lack of understanding of the multi-decadal to centennial-scale patterns of extreme droughts and floods in the area. Applying the yearly drought and flood records from historical documents and precipitation data in the period of instrumental measurements, this study constructs a time series of extreme droughts and floods in the Hanjiang River Basin from 1426–2017 and analyzes the temporal and spatial characteristics of the extreme drought and flood event variations. The results show that there were a total of 45 extreme droughts and 52 extreme floods in the basin over the past 592 years. Extreme droughts and floods were highly variable on a multi-decadal to centennial scale, and the frequencies were higher in the first and last 100 years or so of the study period and lower in between. Spatially, the frequencies of extreme droughts and floods were generally higher in the middle and lower reaches than in the upper reaches. It was also found that there is a good correlation of drought and flood frequencies between the upper Hanjiang River Basin and North China. These results are informative for the study of mechanisms and predictability of multi-decadal to centennial-scale variability of extreme hydroclimatic events in the river basin. [ABSTRACT FROM AUTHOR]

Suitable planting areas for winter wheat in north China are expected to shift northwardly due to climate change, however, increasing extreme events and the deficient water supply are threatening the security of planting systems. Thus, based on predicted climate data for 2021–2050 under the Shared Socioeconomic Pathways (SSP1-2.6, SSP3-7.0, and SSP5-8.5) emission scenarios, as well as historical data from 1961–1990, we use four critical parameters of percentages of extreme minimum temperature years (POEMTY), first day of the overwintering period (FD), sowing date (SD), and precipitation before winter (PBW), in order to determine the planting boundary of winter wheat. The results show that the frequency of extreme minimum temperature occurrences is expected to decrease in the North winter wheat area, which will result in a northward movement of the western part of northern boundary by 73, 94, and 114 km on average, in addition to FD delays ranging from 6.0 to 10.5 days. Moreover, agrometeorological conditions in the Huang-Huai winter wheat area are expected to exhibit more pronounced changes than the rest of the studied areas, especially near the southern boundary, which is expected to retreat by approximately 213, 215, and 233 km, northwardly. The north boundary is expected to move 90–140 km northward. Therefore, the change in southern and northern boundaries will lead the potential planting areas of the entire North winter wheat area to increase by 10,700 and 28,000 km2 on average in the SSP3-7.0 and SSP5-8.5 scenarios, respectively, but to decrease by 38,100 km2 in the SSP1-2.6 scenario; however, the lack of precipitation remains a limitation for extending planting areas in the future. [ABSTRACT FROM AUTHOR]

In China, historical documents record a large quantity of information related to climate change and grain harvest. This information can help to explore the impacts of extreme drought or flood on crop production, which can provide implications for the adaptation of agriculture to higher-probability extreme climate in the context of global warming. In this paper, reported extreme drought/flood chronologies and reconstructed grain harvest series derived from historical documents were adopted in order to investigate the association between the reported frequency of extreme drought/flood in eastern China and reconstructed poor harvests during 801–1910. The results show that extreme droughts were reported more often in 801–870, 1031–1230, 1481–1530, and 1581–1650 over the whole of eastern China. On a regional scale, extreme droughts were reported more often in 1031–1100, 1441–1490, 1601–1650, and 1831–1880 in the North China Plain, 801–870, 1031–1120, 1161–1220, and 1471–1530 in Jianghuai, and 991–1040, 1091–1150, 1171–1230, 1411–1470, and 1481–1530 in Jiangnan. The grain harvest was reconstructed to be generally poor in 801–940, 1251–1650, and 1841–1910, but the reconstructed harvests were bumper in 951–1250 and 1651–1840, approximately. During the entire period from 801 to 1910, the frequency of reporting of extreme droughts in any subregion of eastern China was significantly associated over the long term with lower reconstructed harvests. The association between reported frequency of extreme floods and reconstructed low harvests appeared to be much weaker, while reconstructed harvest was much worse when extreme drought and extreme flood in different subregions were reported in the same year. The association between reconstructed poor harvests and reported frequency of regional extreme droughts was weak during the warm epoch of 920–1300 but strong during the cold epoch of 1310–1880, which could imply that a warm climate could weaken the impact of extreme drought on poor harvests; yet other historical factors may also contribute to these different patterns extracted from the two datasets. [ABSTRACT FROM AUTHOR]

Reconstructed hydroclimatic spatial patterns from historical documents, the chronology of El Niño events since 1525, Meiyu (a unique rainy season dominated by the East Asian summer monsoon in eastern China) series since 1736, and a 1000-year control simulation using the Community Earth System Model were used to analyze the occurrence of anomalous summer precipitation patterns over eastern China with El Niño events. The results show that the frequency of the south-flood north-drought during 1525–2005 was significantly higher during El Niño episodes. Specifically, the occurrences of the triple pattern with floods in the Yangtze River Valley but droughts in its north and south (FYRDNS) as well as the dipole pattern with floods in the south but droughts in the north (FSDN) divided by the Yangtze River both increased in El Niño developing years, while the occurrence of FSDN increased in El Niño decaying years. Among 44 severe and extreme Meiyu events over the middle and lower reaches of the Yangtze River in 1736–2016, 75% of events occurred during El Niño episodes. Especially, 80% of extreme Meiyu events occurred in El Niño decaying years. The 1000-year control simulation captured well the reconstructed triple pattern of FYRDNS in developing years and the dipole pattern of FSDN in decaying years, with more noticeable precipitation anomalies for developing years of very strong and extremely strong El Niño events. These results implicated that the El Niño is likely an early signal for the occurrence of the south-flood north-drought over eastern China. [ABSTRACT FROM AUTHOR]

Background: The capacity of spot urine samples for detecting changes in population sodium and potassium excretion is unclear.Methods: Changes in urinary sodium and potassium excretion, over a 6-month to 2-year interval, were measured from 24-h urine samples and estimated from spot urine samples using several published methods in 3270 Chinese. Additional estimates were made by multiplying individual spot sodium and potassium concentrations by a single estimated 24-h urine volume derived from external data.Results: The measured difference in 24-h urinary excretion between intervention and control groups was -0.35 g (95% CI: -0.68 to -0.02; P = 0.039) for sodium and 0.66 g (95% CI: 0.52 to 0.80; P < 0.001) for potassium, based upon 24-h urine samples. The corresponding estimates of sodium differences for the Tanaka (-0.06 g), Kawasaki (-0.09 g), Intersalt without potassium (-0.09 g) and Intersalt with potassium (-0.14 g) equations were all smaller and identified no reduction in sodium excretion (all P > 0.10). The estimates were -0.65 g for sodium and 1.11 g for potassium using individual spot urine concentrations and an externally derived standard urine volume (both P < 0.01).Conclusions: The published equations were unable to detect the differences in sodium excretion measured by 24-h urine samples. A method based upon spot urine electrolyte concentrations and a standard urine volume may offer an alternative approach to measuring differences in sodium and potassium excretion between population groups without requiring 24-h urine, but will need further investigation. [ABSTRACT FROM AUTHOR]

Using a 17-site seasonal precipitation reconstruction from a unique historical archive, Yu-Xue-Fen-Cun, the decadal variations of extreme droughts and floods (i.e., the event with occurrence probability of less than 10% from 1951 to 2000) in North China were investigated, by considering both the probabilities of droughts/floods occurrence in each site and spatial coverage (i.e., percentage of sites). Then, the possible linkages of extreme droughts and floods with ENSO (i.e., El Niño and La Niña) episodes and large volcanic eruptions were discussed. The results show that there were 29 extreme droughts and 28 extreme floods in North China from 1736 to 2000. For most of these extreme drought (flood) events, precipitation decreased (increased) evidently at most of the sites for the four seasons, especially for summer and autumn. But in drought years of 1902 and 1981, precipitation only decreased in summer slightly, while it decreased evidently in the other three seasons. Similarly, the precipitation anomalies for different seasons at different sites also existed in several extreme flood years, such as 1794, 1823, 1867, 1872 and 1961. Extreme droughts occurred more frequently (2 or more events) during the 1770s-1780s, 1870s, 1900s-1930s and 1980s-1990s, among which the most frequent (3 events) occurred in the 1900s and the 1920s. More frequent extreme floods occurred in the 1770s, 1790s, 1820s, 1880s, 1910s and 1950s-1960s, among which the most frequent (4 events) occurred in the 1790s and 1880s. For the total of extreme droughts and floods, they were more frequent in the 1770s, 1790s, 1870s-1880s, 1900s-1930s and 1960s, and the highest frequency (5 events) occurred in the 1790s. A higher probability of extreme drought was found when El Niño occurred in the current year or the previous year. However, no significant connections were found between the occurrences of extreme floods and ENSO episodes, or the occurrences of extreme droughts/floods and large volcanic eruptions. [ABSTRACT FROM AUTHOR]

Modern meteorological observations in South China from 1960 to 2009 show a strong correlation between winter temperatures and two snowfall parameters, the southern boundary of the snow and the number of snowy days. Based on this relationship, the variation in annual winter mean temperature in South China from 1736 to 2009 was reconstructed using data acquired from Chinese historical documents dating from the Qing dynasty, such as memos and local gazettes. The reconstructed time series were used to analyse variations in winter temperature in South China. Significant interannual and interdecadal changes were found. The maximum temperature difference between neighbouring years was 3.1 °C for 1958-2009 and 3.0 °C for 1736-1957, whereas the maximum temperature difference between adjacent decades was 0.8 °C for the 1960s-2000s and 0.6 °C for the 1740s-1950s. The 2000s was the warmest decade; the mean temperature was 1.6 °C higher than that of the 1870s, which was the coldest decade between the 1740s and the 2000s. The mean winter temperature was warmer in the 18th and 20th centuries and coldest in the 19th century. [ABSTRACT FROM AUTHOR]

Zheng, J., Ding, L., Hao, Z. & Ge, Q. 2012 (January): Extreme cold winter events in southern China during AD 1650-2000. Boreas, Vol. 41, pp. 1-12. 10.1111/j.1502-3885.2011.00225.x. ISSN 0300-9483. We defined extreme cold winter events as those with occurrence probabilities lower than the 10th percentile of the probability density function, based on observed winter temperatures in southern China since 1951. Subsequently, we constructed impact severity levels using documentary evidence for those events during 1951-2000, considering three indexes for the freezing of rivers/lakes, widespread snow/ice storms, and cold damage to subtropical/tropical crops. Using these criteria we identified 50 extreme cold winters for the period AD 1650-1949 based on ∼4000 pieces of comparable information extracted from local gazettes in southern China, after verification using data from three weather stations with long records. It was found that the frequencies of the extreme cold winter events since 1650 varied over time. The most frequent occurrences were found during AD 1650-1699 and in the first and second halves of the 19th century, with frequencies twice as high as in the second half of the 20th century. In contrast, the frequencies of extreme winters during the 18th century were close to that in the second half of the 20th century. High frequencies of extreme cold winters in AD 1650-1720 and AD 1795-1835 occurred during the sunspot Maunder and Dalton Minima. The intensities of some historical cold events, such as those during 1653-1654, 1670, 1690, 1861, 1892 and 1929, exceeded those of the coldest winter events since 1951. [ABSTRACT FROM AUTHOR]

Background: SSaSS (Salt Substitute and Stroke Study), a 5-year cluster randomized controlled trial, demonstrated that replacing regular salt with a reduced-sodium, added-potassium salt substitute reduced the risks of stroke, major adverse cardiovascular events, and premature death among individuals with previous stroke or uncontrolled high blood pressure living in rural China. This study assessed the cost-effectiveness profile of the intervention.Methods: A within-trial economic evaluation of SSaSS was conducted from the perspective of the health care system and consumers. The primary health outcome assessed was stroke. We also quantified the effect on quality-adjusted life-years (QALYs). Health care costs were identified from participant health insurance records and the literature. All costs (in Chinese yuan [¥]) and QALYs were discounted at 5% per annum. Incremental costs, stroke events averted, and QALYs gained were estimated using bivariate multilevel models.Results: Mean follow-up of the 20 995 participants was 4.7 years. Over this period, replacing regular salt with salt substitute reduced the risk of stroke by 14% (rate ratio, 0.86 [95% CI, 0.77-0.96]; P=0.006), and the salt substitute group had on average 0.054 more QALYs per person. The average costs (¥1538 for the intervention group and ¥1649 for the control group) were lower in the salt substitute group (¥110 less). The intervention was dominant (better outcomes at lower cost) for prevention of stroke as well as for QALYs gained. Sensitivity analyses showed that these conclusions were robust, except when the price of salt substitute was increased to the median and highest market prices identified in China. The salt substitute intervention had a 95.0% probability of being cost-saving and a >99.9% probability of being cost-effective.Conclusions: Replacing regular salt with salt substitute was a cost-saving intervention for the prevention of stroke and improvement of quality of life among SSaSS participants. [ABSTRACT FROM AUTHOR]

It still remains uncertainty whether China's future investment is conducive to carbon reduction of Belt and Road (B&R) region or not. Here, the possible impact of China's investment was revealed by comparing the CO 2 emissions of B&R region in different Chinese investment scenarios. The results showed that CO 2 emissions of B&R region will cumulatively increase by 1973 Gt in 2018–2100 in the "No-Chinese Investment Scenario (NIS)". Regionally, the India (IND), Middle East Central Asia (MECAsia), and Southeast Asia and its surrounding (SEAsia) has the largest increment. Comparing with the NIS, the CO 2 emissions of B&R region will cumulatively decrease by 44.16 Gt and 79.48 Gt, respectively, in the "Business-as-usual Chinese Investment Scenario (BIS)" and "Strengthening Chinese Investment Scenario (SIS)". Regionally, the cumulative CO 2 emissions of all subregions will decrease in BIS and SIS, of which SEAsia and MECAsia have the largest decrement. Technique and structural effects of China's investment have positive impact on cumulative CO 2 emission reduction of B&R region, especially in the structural effect. The scale effect has the negative contribution, but it cannot neutralize the positive impact induced from technique and structural effects. As a result, China's future investment is conductive to reducing CO 2 emission of B&R region and holding the temperature increase below 2 °C. [ABSTRACT FROM AUTHOR]

Importance: Lowering sodium intake reduces blood pressure and may reduce the risk of cardiovascular diseases. The use of reduced-sodium salt (a salt substitute) may achieve sodium reduction, but its effectiveness may be associated with the context of its use., Objective: To identify factors associated with the use of salt substitutes in rural populations in China within the Salt Substitute and Stroke Study, a large-scale cluster randomized trial., Design, Setting, and Participants: This sequential mixed-methods qualitative evaluation, conducted from July 2 to August 28, 2018, in rural communities across 3 provinces in China, included a quantitative survey, collection of 24-hour urine samples, and face-to-face interviews. A random subsample of trial participants, selected from the 3 provinces, completed the quantitative survey (n = 1170) and provided urine samples (n = 1025). Interview respondents were purposively selected from the intervention group based on their different ranges of urinary sodium excretion levels. Statistical analysis was performed from September 18, 2018, to February 22, 2019., Exposures: The intervention group of the Salt Substitute and Stroke Study was provided with the free salt substitute while the control group continued to use regular salt., Main Outcomes and Measures: Knowledge, attitudes, and behaviors regarding the use of the salt substitute were measured using quantitative surveys, and urinary sodium levels were measured using 24-hour urine samples. Contextual factors were explored through semistructured interviews and integrated findings from surveys and interviews., Results: A total of 1170 individuals participated in the quantitative survey. Among the 1025 participants with successful urine samples, the mean (SD) age was 67.4 (7.5) years, and 502 (49.0%) were female. The estimated salt intake of participants who believed that high salt intake was good for health was higher; however, it was not significantly different (0.84 g/d [95% CI, -0.04 to 1.72 g/d]) from those who believed that high salt intake was bad for health. Thirty individuals participated in the qualitative interviews (18 women [60.0%]; mean [SD] age, 70.3 [6.0] years). Quantitative and qualitative data indicated high acceptability of and adherence to the salt substitute. Contextual factors negatively associated with the use of the salt substitute included a lack of knowledge about the benefits associated with salt reduction and consumption of high-sodium pickled foods. In addition, reduced antihypertensive medication was reported by a few participants using the salt substitute., Conclusions and Relevance: This study suggests that lack of comprehensive understanding of sodium reduction and salt substitutes and habitual consumption of high-sodium foods (such as pickled foods) were the main barriers to the use of salt substitutes to reduce sodium intake. These factors should be considered in future population-based, sodium-reduction interventions.

Introduction: Cardiovascular diseases (CVDs) are the leading causes of death and disability worldwide. Reducing dietary salt consumption is a potentially cost-effective way to reduce blood pressure and the burden of CVD. To date, economic evidence has focused on sodium reduction in food industry or processed food with blood pressure as the primary outcome. This study protocol describes the planned within-trial economic evaluation of a low-sodium salt substitute intervention designed to reduce the risk of stroke in China., Methods and Analyses: The economic evaluation will be conducted alongside the Salt Substitute and Stroke Study: a 5-year large scale, cluster randomised controlled trial. The outcomes of interest are quality of life measured using the EuroQol-5-Dimensions and major adverse cardiovascular events. Costs will be estimated from a healthcare system perspective and will be sought from the routinely collected data available within the New Rural Cooperative Medical Scheme. Cost-effectiveness and cost-utility analyses will be conducted, resulting in the incremental cost-effectiveness ratio expressed as cost per cardiovascular event averted and cost per quality-adjusted life year gained, respectively., Ethics and Dissemination: The trial received ethics approval from the University of Sydney Ethics Committee (2013/888) and Peking University Institutional Review Board (IRB00001052-13069). Informed consent was obtained from each study participant. Findings of the economic evaluation will be published in a peer-reviewed journal and presented at international conferences., Trial Registration Number: ClinicalTrials.gov Registry (NCT02092090)., Competing Interests: Competing interests: Between 24 months and 48 months, salt substitute in SSaSS has been provided by Jiangsu Sinokone Technology Co for free., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Average sodium intake and stroke mortality in northern China are both among the highest in the world. An effective, low-cost strategy to reduce sodium intake in this population is urgently needed., Objective: We sought to determine the effects of a community-based sodium reduction program on salt consumption in rural northern China., Design: This study was a cluster-randomized trial done over 18 months in 120 townships (one village from each township) from five provinces. Sixty control villages were compared to 60 intervention villages that were given access to a reduced-sodium, added-potassium salt substitute in conjunction with a community-based health education program focusing on sodium reduction. The primary outcome was the difference in 24-hour urinary sodium excretion between randomized groups., Results: Among 1,903 people with valid 24-hour urine collections, mean urinary sodium excretion in intervention compared with control villages was reduced by 5.5% (-14mmol/day, 95% confidence interval -26 to -1; p = 0.03), potassium excretion was increased by 16% (+7mmol/day, +4 to +10; p<0.001), and sodium to potassium ratio declined by 15% (-0.9, -1.2 to -0.5; p<0.001). Mean blood pressure differences were -1.1 mm Hg systolic (-3.3 to +1.1; p = 0.33) and -0.7 mm Hg diastolic (-2.2 to +0.8, p = 0.35) and the difference in the proportion with hypertension was -1.3% (-5.1 to 2.5, p = 0.56)., Conclusion: There were clear differences in population sodium and potassium intake between villages that were most likely a consequence of increased use of salt substitute. The absence of effects on blood pressure reflects the moderate changes in sodium and potassium intake achieved., Trial Registration: Clinicaltrials.gov identifier: NCT01259700., Competing Interests: Bruce Neal is the Chair of Australian Division of World Action on Salt and Health. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

We reconstructed the annual temperature anomaly series in Xinjiang during 1850-2001 based on three kinds of proxies, including 17 tree-ring width chronologies, one tree-ring δ13C series and two δ18O series of ice cores, and instrumental observation data. The low- and high-frequency signal decomposition for the raw temperature proxy data was obtained by a fast Fourier transform filter with a window size of 20 years, which was used to build a good relationship that explained the high variance between the temperature and the proxy data used for the reconstruction. The results showed that for 1850-2001, the temperature during most periods prior to the 1920s was lower than the mean temperature in the 20th century. Remarkable warming occurred in the 20th century at a rate of 0.85°C/100a, which was higher than that during the past 150 years. Two cold periods occurred before the 1870s and around the 1910s, and a relatively warm interval occurred around the 1940s. In addition, the temperature series showed a warming hiatus of approximately 20 years around the 1970s, and a rapid increase since the 1980s.

Based on observational data and Asian monsoon intensity datasets from China, the relationships between the East Asian winter monsoon index and winter temperature, the East Asian summer monsoon index and Meiyu precipitation over the middle and lower reaches of the Yangtze River, were analyzed. We found that the monsoon signals were reflected in the temperature and Meiyu precipitation variations. Thus, we used the reconstructed Meiyu precipitation and winter temperature series for the past 300 years and detected the summer/winter monsoon intensity signals using multi-taper spectral estimation method and wavelet analysis. The main periodicities of Meiyu precipitation and winter temperature, such as interannual cycle with 2-7-year, interdecadal-centennial cycles with 30-40-year and 50-100-year, were found. The good relationships between the East Asian summer and winter monsoons suggested that they were in phase at 31-year cycle, while out of phase at 100-year cycle, but with 20-year phase difference. In addition, the winter monsoon intensity may be regulated by the North Atlantic Oscillation, the Arctic Oscillation and the Atlantic Multidecadal Oscillation, and the summer monsoon is closely related to the signal intensities of the Pacific Decadal Oscillation.

Background: Organizational and wider health system factors influence the implementation and success of interventions. Clinical Pathways in Acute Coronary Syndromes 2 is a cluster randomized trial of a clinical pathway-based intervention to improve acute coronary syndrome care in hospitals in China. We performed a qualitative evaluation to examine the system-level barriers to implementing clinical pathways in the dynamic healthcare environment of China., Methods and Results: A qualitative descriptive analysis of 40 in-depth interviews with health professionals conducted in a sample of 10 hospitals purposively selected to explore barriers to implementation of the intervention. Qualitative data were analyzed using the Framework method. In-depth interviews identified 5 key system-level barriers to effective implementation: (1) leadership support for implementing quality improvement, (2) variation in the capacity of clinical services and quality improvement resources, (3) fears of patient disputes and litigation, (4) healthcare funding constraints and high out-of-pocket expenses, and (5) patient-related factors., Conclusions: System-level barriers affect the ability of acute coronary syndrome clinical pathways to change practice. Addressing these barriers in the context of current and planned national health system reform will be critical for future improvements in the management of acute coronary syndromes, and potentially other hospitalized conditions, in China. Clinical Trial Registration- URL: http://www.anzctr.org.au/default.aspx. Register. Unique identifier: ACTRN12609000491268.

Background- Substantial evidence-practice gaps exist in the management of acute coronary syndromes (ACS) in China. Clinical pathways are tools for improving ACS quality of care but have not been rigorously evaluated. Methods and Results- Between October 2007 and August 2010, a quality improvement program was conducted in 75 hospitals throughout China with mixed methods evaluation in a cluster randomized, controlled trial. Eligible hospitals were level 2 or level 3 centers routinely admitting >100 patients with ACS per year. Hospitals were assigned immediate implementation of the American Heart Association/American College of Cardiology guideline based clinical pathways or commencement of the intervention 12 months later. Outcomes were several key performance indicators reflecting the management of ACS. The key performance indicators were measured 12 months after commencement in intervention hospitals and compared with baseline data in control hospitals, using data collected from 50 consecutive patients in each hospital. Pathway implementation was associated with an increased proportion of patients discharged on appropriate medical therapy, with nonsignificant improvements or absence of effects on other key performance indicators. Conclusions- Among hospitals in China, the use of a clinical pathway for the treatment of ACS compared with usual care improved secondary prevention treatments, but effectiveness was otherwise limited. An accompanying process evaluation identified several health system barriers to more successful implementation. Clinical Trial Registration- URL: http://www.anzctr.org.au/default.aspx. Unique identifier: ACTRN12609000491268.