The Lancet Regional Health - Western Pacific 12 (2021) 100166

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The Lancet Regional Health - Western Pacific

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Research paper

Anaesthesiology in China: A cross-sectional survey of the current

status of anaesthesiology departments ✩
Changsheng Zhang, MD, PhD a, Shengshu Wang, MD, PhD b, Hange Li, MD c, Fan Su, MD,
PhD d, Yuguang Huang, MD c,∗, Weidong Mi, MD, PhD a,∗∗ , The Chinese Anaesthesiology
Department Tracking Collaboration Group
a
Anaesthesia and Operation Centre, First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, China
b
Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Centre for Geriatric Diseases, Second Medical Centre of
Chinese PLA General Hospital, Beijing, 100853, China
c
Department of Anaesthesiology, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
d
Affiliated Hospital of Shandong Medical University of TCM, No.16369, Jingshi Road, Jinan, Shandong, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: The discipline of anaesthesiology in China has undergone historical changes and develop-
Received 19 February 2021 ment during the past century. However, nationwide comprehensive data on the current status of each
Revised 19 April 2021
hospital department providing anaesthesia care has been lacking since the discipline was first established
Accepted 22 April 2021
in China. This information is essential for effective regulation of healthcare policies by both the profes-
Available online 17 June 2021
sional associations and the government health ministry. Therefore, a nationwide survey was set up in
2018 to investigate the current status of Chinese anaesthesiology. This paper reports the findings of the
survey.
Methods: We performed a cross-sectional nationwide census survey of the current status of each hospital
department providing anaesthesia care in 31 provinces across the Chinese mainland. The content of the
survey included general information of the department, the hospital level and scale, the volume of the
anaesthesiology department, the characteristics of anaesthesiologists, and the caseload of the anaesthesi-
ology departments. Face-to-face interviews were performed by trained interviewers. The Chinese Anaes-
thesiology Department Tracking Database (CADTD) was established during the survey. Data quality con-
trol was undertaken by the investigation committee throughout the survey process.
Findings: The nationwide census survey was completed by 11,432 hospital departments providing anaes-
thesia care throughout mainland China from June 1, 2018 to June 30, 2019. Among the 11,432 depart-
ments, 4591 (40•16%) belonged to specialised hospitals, while 6841 (59•84%) were affiliated to general
hospitals. The proportion of independent anaesthesiology departments was 45•15% in mainland China.
There was a total of 92,726 anaesthesiologists, or 6•7 per 10 0,0 0 0 of the population. Regions with better
economic conditions had more anaesthesiologists per 10 0,0 0 0 of the population. From 2015 to 2017, the
workload of anaesthesiologists has increased by 10%.
Interpretation: The discipline of anaesthesiology in China has entered a rapid development phase. How-
ever, the current status of anaesthesiology is not well defined, which makes it difficult to meet the needs
of the increasing Chinese healthcare demand. The evidence from this survey offers valuable information
for policy makers and anaesthesiology associations to monitor the development of the discipline and
regulate healthcare policies effectively.
Funding: National Key Research and Development Program of China (Grant No. 2018YFC2001900).
© 2021 The Author(s). Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

✩ ∗∗
Editor note: The Lancet Group takes a neutral position with respect to territorial Corresponding author: Weidong Mi, MD, PhD, Anaesthesiologist-in-Chief,
claims in published maps and institutional affiliations. Anaesthesia and Operation Centre, First Medical Centre of Chinese PLA General Hos-
∗
Co-corresponding author: Yuguang Huang, MD, Anaesthesiologist-in-Chief, De- pital, 28th Fuxing Rd, Haidian District, Beijing, P.R. China, 100853
partment of Anaesthesiology, Peking Union Medical College Hospital, No. 1 Shuai- E-mail addresses: [email protected] (Y. Huang), [email protected] (W. Mi).
fuyuan, Dongcheng District, Beijing, P.R. China, 100730

https://doi.org/10.1016/j.lanwpc.2021.100166
2666-6065/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
C. Zhang, S. Wang, H. Li et al. The Lancet Regional Health - Western Pacific 12 (2021) 100166

Research in context reau of Statistics, the total number of surgeries performed in China
in 2017 was 55•96 million, with an annual increase of 10•1% [2],
but the annual number of hospitalisations was more than 10 times
Evidence before this study that in the 1980s [3]. The substantial increase of healthcare qual-
ity and rapid increase in the number of surgeries epitomise the
The discipline of anaesthesiology in China has experi-
fast-paced development of modern medicine in China during the
enced rapid development in the past century as the economy
has grown. However, for a long time, the nation’s standard- past decades. Simultaneously, the discipline of anaesthesiology in
ised reporting system for the current status of each region’s China has exhibited drastic changes and progressive growth, trans-
anaesthesiology was lacking, and the status of anaesthesiol- forming from traditional Chinese medicine anaesthesia to modern
ogy has never been comprehensively investigated nationwide anaesthesia [4]. This historical change and development reflect the
since the formal establishment of the discipline in China in development of anaesthesiology in China, which is different to that
the 1950s. As a result, national investigative evidence was in the Western world.
seldom available whenever there was a need to make policy With the increasing demand of the Chinese population for
relevant to anaesthesiology, which hindered the development healthcare services and the rapid growth in the number of surg-
of Chinese anaesthesiology to a certain degree. Therefore, a
eries, anaesthesiology departments in China are facing enormous
nationwide survey was set up in 2018 to investigate the cur-
rent status of Chinese anaesthesiology. challenges [5]. In addition, the shortage of anaesthesiologists and
their high burnout rate has hindered development of the discipline
Added value of this study [6]. Moreover, the contradiction between the uneven development
of Chinese anaesthesiology and the growing demand of Chinese
This was the first general survey of all hospital anaes- citizens for healthcare services is becoming increasingly significant,
thesia departments in the Chinese mainland. The Chinese which makes greater action at policy and hospital level urgently
Anaesthesiology Department Tracking Database (CADTD) was necessary.
established. A full picture of the current status of Chinese To gain a better general understanding Chinese anaesthesiol-
anaesthesiology was surveyed, including general information ogy and gather more information for accelerating the develop-
of the department, the hospital level and scale, the vol-
ment of the discipline, a cross-sectional nationwide survey was de-
ume of the anaesthesiology department, the characteristics
signed and completed by the Chinese Association of Anaesthesiol-
of anaesthesiologists, and the caseload of the anaesthesiol-
ogy department. The study summarised the constructional ogists (CAA), the Chinese Society of Anaesthesiologists (CSA), the
achievements of Chinese anaesthesiology, and revealed ex- Chinese Society of Integrative Anaesthesiology (CSIA), and the Na-
isting problems under current conditions. The specialty of tional Centre for Anaesthesia Medical Quality and Quality Control.
anaesthesiology is very large in scale, fast developing with This was the first general survey of all anaesthesia departments in
a heavy case load increasing year-by-year. However, the per- Chinese mainland hospitals since the establishment of anaesthesi-
centage of independent anaesthesiology departments among ology in China. The aim of the survey was to obtain information
all hospital departments providing anaesthesia care is less about the current situation of anaesthesiology in China and com-
than half, and the anaesthesiology workforce is limited, with pare this with other countries. Information collected in the study
improper configuration. The development of Chinese anaes-
included the independent establishment of anaesthesiology and its
thesiology will be a long and painstaking process in the near
future. The continuous update of the CADTD will provide im- influencing factors, the proportion and geographical distribution of
portant evidence for policy makers and professional associa- anaesthesiologist human resources, the annual workload of anaes-
tions to effectively regulate healthcare policies, especially re- thesiologists, and the correlation between the proportion of anaes-
garding anaesthesiology and surgery. thesiologists and health economic indicators.

Implications of all the available evidence

As can be concluded from the survey results, the rapid de- 2. Methods
velopment of Chinese anaesthesiology is unique to this par-
ticular part of the world, but problems such as imbalanced
The nationwide survey was conducted between June 1, 2018
development among regions, heavy workloads, and large gaps
and June 30, 2019. All institutions providing anaesthesia care in
in departmental construction are still common. More pref-
erential policies should be offered for the standardised and mainland China were included and potential respondents were the
healthy development of anaesthesiology in China. Successful department chiefs or other designated persons (usually the admin-
implementation of the general survey for the discipline in istrative secretaries) in anaesthesia departments.
China not only provides a benchmark for monitoring the de-
velopment of Chinese anaesthesiology, but also accumulates
valuable experience for future surveys and offers useful ref-
erence data for other medical disciplines around the world. 2.1. Data source and study sample

At the request of the Chinese Association of Anaesthesiologists

1. Introduction (CAA), Chinese Society of Anaesthesiologists (CSA), Chinese Society
of Integrative Anaesthesiology (CSIA) and the National Centre for
China has made remarkable progress in its economic develop- Anaesthesia Medical Quality and Quality Control, a national sur-
ment in the past four decades. At the same time, the healthcare vey collaboration network that included 31 provinces, municipali-
system in China, which provides clinical care and public health ser- ties and autonomous regions in mainland China was built for this
vices to one-fifth of the world’s population, has also advanced sig- study. With the help of local governments and health commissions,
nificantly. The healthcare access quality index (HAQ index) of China we identified 11,432 hospital anaesthesia departments; members
has increased dramatically from 42•6 in 1990 to 53•5 in 20 0 0 and of the CAA provincial branch were recruited to ensure the acces-
77•9 in 2016, and China has become one of the countries with the sibility and feasibility of the survey. The Chinese Anaesthesiology
most significant improvement in medical care quality [1]. In ad- Department Tracking Database (CADTD) was established from this
dition, according to annual statistics released by the National Bu- cross-sectional nationwide survey.

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C. Zhang, S. Wang, H. Li et al. The Lancet Regional Health - Western Pacific 12 (2021) 100166

2.2. Questionnaire design hours online before the start of the investigation to clarify the con-
tents of the questionnaire and improve investigation skills. In addi-
The design of the questionnaire was mainly based on a pre- tion, all investigators had to pass an examination prior to conduct-
vious human resources survey conducted by the CSA in 2015 [7]. ing the survey.
The questionnaire was designed to be completed by the anaesthe- Investigators visited all qualified anaesthesia departments. To
siology department chief or a designated person at every hospital. reduce possible biases and increase the response rate, and avoid
The questionnaire was divided into seven parts and comprised 26 the possible bias and low response rate of a non-mandatory ques-
items in total. In order to get the entire questionnaire filled in, all tionnaire survey, the questionnaire was conducted by way of a
the questions were designated as compulsory questions. The va- face-to-face interview with the chief or a designated person of the
lidity and reliability of the survey questionnaire was assessed and departments.
approved by experts of the CAA and statisticians who were not el- The purpose, significance, and main contents of the survey were
igible to be surveyed. explained, and written consent was obtained from the department
chief prior to the investigation. Data entry was performed by the
• Part 1 of the survey focused on general information about the
investigator synchronously. A verification system, including check-
anaesthesiology department chiefs, which included their age,
ing in the field by the interviewers themselves and checking in the
gender, anaesthesia service duration, ranking, educational back-
work group by supervisors, was applied during the survey. If mis-
ground, and work phone.
takes were found by data specialists, the data were sent back to in-
• Part 2 collected information on the hospital level, including the
vestigators for checking and refilling. Final data quality control was
name of the hospital and the department providing anaesthesia
undertaken by the investigation committee throughout the survey
care, its location, and the scale of the hospital.
process, including a logic check, sequential recording check, phone-
• Part 3 focused on the volume of the hospitals, which included
call check, and a re-interview check.
the total number of beds and beds in surgical departments, and
the number of surgeons in the hospital with the ranking of at-
2.5. Definitions and explanations
tending or above.
• Part 4 focused on the volume of the anaesthesiology depart-
2.5.1. The classification of Chinese hospitals
ment, including the number of operating rooms (OR), number
In China, public hospitals are classified into 3 tiers, i.e., tiers 1, 2
of beds in post-anaesthesia care units, number of outpatient
and 3 [8]. Each tier is further classified into three subsidiary levels
clinics, and the number of beds in intensive care units (ICUs)
based on the score assessed by the regional health commission,
and pain wards under the supervision of the anaesthesiology
i.e., Jia (A), Yi (B), or Bing (C). The higher the tier, the better the
department.
hospital. For the subsidiary levels, A is better than B, while B is
• Part 5 collected information on rankings, educational back-
better than C. For example, tier 3A hospitals are top level hospitals
ground, and the specialties of both anaesthesiologists and
in China, which are usually general hospitals in a city with a bed
nurses.
capacity exceeding 500. Tier 1C hospital are usually hospitals in
• Part 6 collected the annual caseload of the anaesthesiology de-
rural areas or community hospitals. However, if the bed capacity
partment from 2015 to 2017, including the number of anaesthe-
of the hospital just exceeds 500 but it has not yet been scored, the
sia cases inside and outside the OR, outpatient clinic numbers,
classification of the hospital would be regarded as ‘tier 3 other’.
the number of patients admitted to the ICU and pain ward un-
der the supervision of the anaesthesiology department, and the
2.5.2. History of the development of Chinese anaesthesiology
number of patients undergoing therapeutic procedures in the
Chinese anaesthesiology care services began relatively late. In
pain ward.
the 1980s, some anaesthesiologists were nurses rather than doc-
The questionnaire was built electronically on the Wenjuanxing tors due to a lack of doctors and specific medical education. It was
platform (https://www.wjx.cn) with a unique URL. not until 1989 that the Ministry of Health at the time announced
that anaesthesiology departments were to be changed from med-
2.3. Investigative procedures ical technical departments to clinical departments [4]. Therefore,
Chinese anaesthesiology departments had diverse affiliation rela-
The investigative procedures were determined by experts of the tionships, and they could be administered by the hospital, surgical
CAA and statisticians prior to the survey. In order to maximize the departments (such as departments of obstetrics and gynaecology),
accuracy of this national survey, quality control was performed at or operating rooms.
each process of the survey, including establishment of an investi-
gation committee, questionnaire design, data acquisition, and data 2.5.3. Physician ranking systems in China
analysis. The investigators were responsible for the follow-up, ob- The ranking of physicians in China includes junior (medical as-
taining written consent, conducting the questionnaire survey, and sistant, resident), intermediate (attending physician), deputy senior
cooperating with data specialists in assessing and controlling qual- (associate chief physician), and senior (chief physician), which are
ity. different to rankings used in Europe and America [9]. The upgrad-
The logicality and rationality of the uploaded data were as- ing of a physician’s ranking needs to be evaluated according to the
sessed by data specialists in each province. If unqualified ques- practice level, clinical work time, academic achievements, and ed-
tionnaire results were found by data specialist, the question- ucational background.
naire would be sent back to the corresponding hospital for re-
investigation and data acquisition. The statistician was responsible 2.5.4. GDP levels of the 31 provinces, autonomous regions, and
for the maintenance of the database, and the interpretation and municipalities of mainland China
analysis of data (see Figure 1). According to data from the national bureau of statistics of
China, the level of economic development assessed by gross do-
2.4. Questionnaire investigations mestic product (GDP) and GDP per capita can both be divided into
three categories: high, medium, and low (See Supplemental Table
A total of 1,548 investigators from 31 provinces, municipalities 1). Guangdong, Zhejiang, Shandong, Henan, Sichuan, Hubei, Hebei,
and autonomous regions from mainland China were trained for 8 Hunan, Fujian, Shanghai, and Beijing are regions with a high level

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C. Zhang, S. Wang, H. Li et al. The Lancet Regional Health - Western Pacific 12 (2021) 100166

Fig. 1. Investigative procedures profile. Stage one, initiation and design of the questionnaire was undertaken by the Chinese PLAGH; Stage two investigations were performed
by qualified investigators; Stage three, the logicality and rationality of the uploaded data were assessed by the data specialists in each province; Stage four, the maintenance
interpretation and analysis of data were performed by statisticians and epidemiologists. Chinese PLAGH = Chinese People’s Liberation Army General Hospital; CAA = Chinese
Association of Anaesthesiologists; CSA = Chinese Society of Anaesthesiologists; CSIA = Chinese Society of Integrative Anaesthesiology.

of GDP. Those with a medium level of economic development in- ties in mainland China in June 2018. Among the 11,432 depart-
clude Anhui, Liaoning, Shaanxi, Jiangxi, Guangxi, Chongqing, Tian- ments, 4591 (40•16%) departments belonged to specialised hos-
jin, Yunnan, Heilongjiang, and Inner Mongolia, while Jilin, Shanxi, pitals, while 6841 (59•84%) were affiliated to general hospitals.
Guizhou, Xinjiang, Gansu, Hainan, Ningxia, Qinghai, and Tibet are There were 2569 (22•49%), 7631 (66•80%), and 1232 (10•79%) de-
those with a low level of GDP (http://www.stats.gov.cn/). partments belonging to tier 3, tier 2, and tier 1 or lower hospi-
tals, respectively. The constituent ratios of departments providing
2.6. Statistical analysis anaesthesia care across mainland China are listed in Table 1 and
Figure 2.
Data were exported from the Wenjuanxing platform and anal-
ysed using R3.5.3. Continuous, normally distributed variables were 3.2. Hospitals providing anaesthesia range in scale from no fixed
presented as means ± standard deviation and tested by a t-test or beds to 15,000 beds, and no surgeons to 2450 surgeons
one-way ANOVA among groups. Non-normally distributed continu-
ous variables were presented as medians and interquartile ranges, The total number of beds in the 11,432 hospitals providing
and were compared by a Mann-Whitney U test. Frequency, rate anaesthesia care was 5,593,100, with an average of 489•25 beds
and prevalence were used for categorical data and tested by χ 2 per hospital. The total number of beds in all surgical departments
tests. was 1,818,332, with an average of 159•06 beds per hospital. There
Multiple logistic regression analysis was established to explore were 466,452 surgeons with an average of 40•08 surgeons per hos-
factors influencing the settings of independent anaesthesiology de- pital. The scale of anaesthesiology departments correlated with the
partments. The characteristics of chief physician personnel, profes- tier of the hospital. The higher the tier of the hospital, the higher
sional features, and the features of the hospital were independent the ratio of the number of operating rooms to the total number
variables in the model. A Pearson correlation was conducted be- beds of the hospital. The number of beds and surgeons in each
tween the number of anaesthesiologists per 10 0,0 0 0 of the popu- tier of hospitals are shown in Table 2.
lation and the gross domestic product (GDP), per capita GDP, per
capita disposable income, and per capita consumption expenditure.
3.3. The settings of departments providing anaesthesia care were not
Analysis of variance (ANOVA) was used to analyse differences in
same. The proportion of independent anaesthesiology departments
the distribution of anaesthesiologists in different regions in main-
was less than 50% in mainland China hospitals
land China. P<0•05 was considered statistically significant in this
study.
There were 5,161 (45•15%) independent anaesthesiology depart-
2.7. Role of the funding source ments among the 11,432 departments providing anaesthesia care.
The proportion of independent anaesthesiology departments was
The sponsors of this study played no role in the design of the higher in general hospitals (48•93%) than in specialised hospitals
survey, collection or analysis of data, interpretation of results, or (38•18%). And the proportion of independent anaesthesiology de-
in the preparation of this manuscript. The corresponding author partments had a positive correlation with the tier of the hospi-
had full access to all study data and had final responsibility for the tals. The higher the tier of the hospital, the higher the propor-
decision to submit for publication. tion of independent anaesthesiology departments. Tier 3A hospi-
tals had the highest proportion of independent anaesthesiology de-
3. Results partments (80•31%), while tier 1 or lower hospitals had the lowest
proportion (24•68%).
The nationwide questionnaire was completed by 11,432 hospi- Most independent anaesthesiology departments had affiliated
tal departments providing anaesthesia care in mainland China. The divisions, which included post-anaesthesia care units (PACUs,
results of the questionnaire were summarised and divided into five 83•18%), pain clinics (45•35%), pain departments (19•06%), and in-
parts as outlined below. tensive care units (ICUs, 17•18%). The higher the tier of the hospi-
tal, the higher the proportion of affiliated divisions. Tier 3A hospi-
3.1. Departments providing anaesthesia care in mainland China tals had the highest rate of PACUs (95•30%), while tier 1 or lower
hospitals had the lowest rate (60•20%). Moreover, most indepen-
There were 11,432 hospital departments providing anaesthe- dent anaesthesiology departments did not have an affiliated ICU in
sia care in 31 provinces, autonomous regions, and municipali- mainland China hospitals, with the average rate being 17•18%.

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C. Zhang, S. Wang, H. Li et al. The Lancet Regional Health - Western Pacific 12 (2021) 100166

Table 1
General characteristics of anaesthesiology in mainland China (n = 11,432)

Total GDP per capita

No.
High Medium Low

Hospitals providing anaesthesia care 11,432 3,841 (33•6%) 4,562 (39•9%) 3,029 (26•5%)
Independent anaesthesiology dept. 5,162 (45•2%) 2,095 (40•6%) 1,789 (34•6%) 1,278 (24•8%)
Regulated by other dept. 6,270 (54•9%) 1,746 (27•8%) 2,773 (44•3%) 1,751 (27•9%)
Anaesthesiologists and nurses (per 100,000)
Anaesthesiologists 0•67 0•75 0•65 0•58
Anaesthesia nurses 0•20 0•22 0•18 0•21
Tiers of hospitals
Tier 3 2,569 (22•5%) 1,041 (40•5%) 925 (36•0%) 603 (23•5%)
Tier 2 7,631 (66•7%) 2,278 (29•9%) 3,163(41•5%) 2,190 (28•7%)
Tier 1 1,232 (10•8%) 522 (42•4%) 474 (38•5%) 236 (19•2%)
Number of beds (per 100,000) 40•29 39•69 42•64 37•60
Ranking (per 100,000):
Chief 0•04 0•05 0•03 0•03
Associate chief 0•11 0•13 0•10 0•09
Attending 0•25 0•29 0•25 0•21
Residents 0•27 0•28 0•27 0•26
Educational background (per 100,000):
Doctoral degree 0•02 0•03 0•01 0•01
Master degree 0•03 0•06 0•02 0•01
Bachelor degree 0•15 0•19 0•14 0•10
Junior college or Technical secondary schools 0•19 0•23 0•17 0•16

Fig. 2. The regional distribution of anaesthesiologists (per 10 0,0 0 0 of the population) in mainland China. Territories in red include Anhui, Jiangxi, Henan, Shanxi, Guangxi,
Yunnan and Tibet. Territories in orange include Heilongjiang, Jilin, Fujian, Hebei, Guangdong, Hubei, Hunan, Hainan and Gansu. The territory in yellow is Sichuan. Territories
in light green include Liaoning, Inner Mongolia, Shandong, Tianjin, Chongqing, Guizhou and Xinjiang. Territories in green include Zhejiang, Shanghai, Jiangsu, Beijing, Shaanxi,
Ningxia and Qinghai.

The proportion of non-independent anaesthesiology depart- and educational background (p<0•05). The proportion of indepen-
ments was 54•85% (6,271 departments). These departments were dent anaesthesiology departments in tier 3A hospitals, tier 3 other
supervised by the operating rooms (4•06%) and surgical depart- hospitals, and tier 1 or lower hospitals was 2•53 (OR = 2•53,
ments (50•79%). The organisational structure of different tiers of 95% CI 2•16-2•96), 2•04 (OR = 2•04, 95% CI 1•74-2•41), and 0•67
hospitals is shown in Table 3. (OR = 0•67, 95% CI 0•58-0•78) times higher than that in tier 2 hos-
We discovered two major factors influencing the setting of non- pitals, respectively. The proportion of independent anaesthesiology
independent anaesthesiology departments. One factor was the ca- departments with a chief who had a doctoral degree (OR = 1•83,
pability of the anaesthesiologists-in-chief, including their ranking 95% CI 1•29-2•66) or master degree (OR = 1•62, 95% CI 1•38-1•90)

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Table 2
The number of beds and surgeons in each tier of hospitals

Scale of hospitals providing anaesthesia care in China

Number of beds in surgical depts. in Number of surgeons with a ranking

Number of beds in total total of attending or above

Subtotal Avg. Sub-total Avg. Subtotal Avg.

Tier 3A 2,244,025 1303•15 797,758 463•27 217,038 126•04

Tier 3 other 613,134 723•89 207,620 245•12 53,345 62•98
Tier 2 2,607,466 341•69 775,824 101•67 188,209 24•66
Tier 1 or lower 128,475 104•28 37,130 30•14 7,860 6•38
Total 5,593,100 489•25 1,818,332 159•06 466,452 40•80

Table 3
The organisational structure of departments providing anaesthesia care in different tiers of hospitals in China (%)

Type and tier of Total Relationship of administrative subordination (%) Affiliated divisions of independent anaesthesiology depts. (%)
hospital (frequency)
Independent Regulated by Regulated by
anaesthesiology dept. surgical dept. operating room Pain clinic Pain dept. PACU ICU

Special 4,591 38•18 57•00 4•81 41•41 13•69 78•78 15•40

General 6,841 49•83 46•62 3•55 47•37 21•82 85•45 18•10
Tier 3A 1,722 80•31 19•05 0•64 59•65 22•78 95•30 15•47
Tier 3 other 847 67•53 31•17 1•30 47•73 25•00 92•83 19•41
Tier 2 7,631 38•04 57•49 4•47 39•48 16•88 77•92 18•53
Tier 1 or lower 1,232 24•68 67•13 8•20 31•91 11•84 60•20 7•89
Total 11,432 45•15 50•79 4•06 45•35 19•06 83•18 17•18

ICU = intensive care unit; PACU = post-anaesthesia care unit.

was significantly higher than those with a chief who had a bache- number of anaesthesiologists has increased rapidly within the last
lor degree. few years, there were only 0•78 anaesthesiologists for each operat-
The second factor was the characteristics of the hospital, in- ing room in 2018. The ratio of the number of operating rooms to
cluding type, tier, number of beds, and the number of doctors the number of anaesthesiologists was below 1:1•5 in each tier of
(p<0•05). The proportion of independent of anaesthesiology de- hospitals, which was lower than the national standards for anaes-
partments in general hospitals was 1.34 times higher than that in thesia departments. Besides, there was less than one anaesthesia
special hospitals (OR = 1•34, 95% CI 1•23-1•46). Hospitals with a nurse for every three operating rooms on average. The ratio of
high tier and more beds had a significantly higher proportion of the number of anaesthesiologists to the number of surgeons was
independent anaesthesiology departments (see Table 4). 1:5•03, which was again less than satisfactory [10]. The number of
anaesthesiologists, anaesthesia nurses and surgeons and their re-
lated ratios are shown in Table 6.
3.4. The quality and quantity of Chinese anaesthesiologists were less
In June 2018, there were on average 6•7 anaesthesiologists (full-
than satisfactory. Regions with better economic conditions had more
time residents) per 10 0,0 0 0 of the population in mainland China,
anaesthesiologists per 100,000 of the population
which was an increase of 1 when compared with the results of
an investigation performed in 2014 [7]. However, the survey also
General information on anaesthesiologists-in-chief, including
revealed the uneven distribution of anaesthesiologists throughout
age, length of work, ranking, and educational background were
mainland China, ranging from 3•1 to 6•6 anaesthesiologists per
collected. The male to female ratio was 3•26:1. 77•35% were
10 0,0 0 0 of the population with Tibet having the lowest number of
more than 40 years of age, while 48•99% were 40-49 years
anaesthesiologists (3•1 anaesthesiologists per 10 0,0 0 0 of the pop-
of age. The average working experience of anaesthesiologists-in-
ulation). The details of anaesthesiologists’ distribution in mainland
chief was 20•94 ± 9•42 years. The distribution of rankings and
China are shown in Figure 2.
educational background of Chinese anaesthesiologists are sum-
To further analyse the uneven distribution of Chinese anaesthe-
marised in Table 5. The ranking and educational background of
siologists, correlation analyses of the number of anaesthesiologists
the anaesthesiologists-in-chief differed significantly in the 3 tiers
per 10 0,0 0 0 of the population and local economic parameters were
of hospitals (p<0•01). The majority of department chiefs (65•02%)
performed. We divided the 31 provinces, autonomous regions, and
had bachelor degrees, while 8•81% and 2•96% of department chiefs
municipalities of China into three levels, high, medium, and low,
had master and doctoral degrees, respectively.
by gross domestic product (GDP) and GDP per capita. The results
The proportion of rankings, and educational background dif-
showed that regions with a higher GDP per capita level had a sig-
fered significantly among the tiers of the hospital. The distribution
nificantly higher number of anaesthesiologists per 10 0,0 0 0 of the
shape of anaesthesiologists’ education was a downward-pointing
population. However, regions with a higher GDP level did not have
one. The majority of anaesthesiologists from tier 3 hospitals had
a higher number of anaesthesiologists per 10 0,0 0 0 of the popula-
bachelor degrees or higher, while anaesthesiologists with a degree
tion (p<0•01) [see Table 7]. Furthermore, we found a positive cor-
lower than bachelor (i.e., graduated from a junior college or tech-
relation between the number of anaesthesiologists per 10 0,0 0 0 of
nical secondary school) usually worked at tier 2 hospitals. Anaes-
the population and the annual per capita consumption expendi-
thesiologists from tier 1 or lower hospitals graduated from junior
ture (r = 0•5642; p<0•05), annual per capita disposable income
college or technical secondary schools.
(r = 0•5634; p<0•05), and GDP per capita (r = 0•445; p<0•05).
In June 2018, there were a total of 92,726 anaesthesiologists
The annual anaesthesia quantity per anaesthesiologist had a pos-
and 28,200 anaesthesia nurses in the 31 provinces, autonomous
itive correlation with annual per capita consumption expendi-
regions, and municipalities across mainland China. Although the

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C. Zhang, S. Wang, H. Li et al. The Lancet Regional Health - Western Pacific 12 (2021) 100166

Table 4
Multiple logistic regression analysis of independent factors associated with independent anaesthesiology departments

Variable OR 2•50% 97•50% Pr (>|z|) Significance

Age group 30-39 (ref) 1•00

Below 30 0•88 0•56 1•34 0•55
40-49 0•98 0•86 1•12 0•80
50-59 1•02 0•85 1•23 0•81
Above 60 1•24 0•88 1•75 0•22
Tier of hospital Tier 2 (ref) 1•00
∗∗∗
Tier 3A 2•53 2•16 2•96 <0•01
∗∗∗
Tier 3 other 2•04 1•74 2•41 <0•01
∗∗∗
Tier 1 or lower 0•67 0•58 0•78 <0•01
Education Bachelor degree (ref) 1•00
∗∗
Doctoral degree 1•83 1•29 2•66 <0•01
Junior college 0•97 0•87 1•09 0•63
∗∗∗
Master degree 1•62 1•38 1•90 <0•01
Technical secondary schools 0•82 0•64 1•05 0•12
Ranking Associate chief (ref) 1•00
∗∗∗
Chief 1•50 1•31 1•73 <0•01
∗∗∗
Attending or lower 0•62 0•56 0•68 <0•01
Anaesthesia service duration ≤5 (ref) 1•00
≥40 0•68 0•41 1•13 0•14
10~19 0•97 0•71 1•33 0•85
20~29 0•85 0•62 1•18 0•32
30~39 0•90 0•63 1•29 0•55
6~9 0•94 0•67 1•33 0•72
Gender Male (ref) 1•00
Female 0•95 0•86 1•05 0•29
Type of hospital Special (ref) 1•00
∗∗∗
General 1•34 1•23 1•46 <0•01
∗∗∗
Total number of beds in hospital 1•0005 1•0003 1•0006 <0•01
Number of beds in surgical dept. 1•0000 0•9998 1•0003 0•82
∗∗∗
Number of doctors in all surgical dept. 1•0018 1•0010 1•0026 <0•01
requiring anaesthesia cooperation
∗∗
p<0•01
∗∗∗
p<0•001.

Table 5
The distribution of ranking and educational background of Chinese anaesthesiologists from different tiers of hospitals
Tier Number of Ranking Educational background
of anaesthesiologists
hospital Chief Associate chief Attending Residents Doctoral degree Master degree Bachelor degree Other degrees

Tier 3A 38,101 3,215 7,447 14,258 13,181 2,922 12,637 19,533 3,009
Tier 3 other 9,943 549 1,755 3,825 3,814 79 1,147 6,779 1,938
Tier 2 41,707 1,100 5,765 15,981 18,861 163 1,874 21,591 18,079
Tier 1 or lower 2,975 65 272 1,040 1,598 19 133 1,258 1,565
Total 92,726 4,929 15,239 35,104 37,454 3,183 15,791 49,161 24,591
χ 2 : 2,540•9 df: 9 p-value:<0•01 χ 2 : 24,427 df: 9 p-value:<0•01

Table 6
The number of anaesthesiologists, anaesthesia nurses and surgeons, and related ratios

Number of Number of Number of

Number of Number of ORs: number of ORs: number of anaesthesiolo-
anaesthesiolo- anaesthesia anaesthesiolo- anaesthesia Number of gists: number
Tier of hospital gists nurses Number of ORs gists nurses surgeons of surgeons

Tier 3A 38,101 12,795 33,837 1:1•13 3:1•13 217,038 1:5•70

Tier 3 other 9,943 2,425 10,493 1:0•95 3:0•69 53,345 1:5•37
Tier 2 41,707 12,076 70,635 1:0•59 3:0•51 188,209 1:4•51
Tier 1 or lower 2,975 904 4,499 1:0•66 3:0•60 7,860 1:2•64
Total 92,726 28,200 119,464 1:0•78 3:0•71 466,452 1:5•03

OR = operating room.

ture (r = 0•1638; p<0•05), annual per capita disposable income The total number of anaesthesia cases from 2015 to 2017 is
(r = 0•1639; p<0•05), and GDP per capita (r = 0•101; p<0•05). summarised in Table 8 and Figure 3. The annual growth rate of
anaesthesia cases was 11•32% from 2015 to 2017, with a 9•29% an-
nual increase of anaesthesia cases in operating rooms and 15•64%
3.5. The workload of anaesthesiologists has been increasing annual increase of anaesthesia cases outside operating rooms.
year-by-year, by a rate of 10% The number of anaesthesia cases at different tiers of hospi-
tals from 2015 to 2017 is summarised in Table 9 and Figure 4.
From 2015 to 2017, Chinese anaesthesiologists performed a total Anaesthesiologists at different tiers of hospitals had a varied an-
of 138,208,490 cases of anaesthesia, and the number of anaesthesia nual workload. The higher the tier of the hospital, the larger the
cases per year during this period was 46,069,497. number of anaesthesia cases per capita. Anaesthesiologists in tier

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Table 7
The proportion of anaesthesiologists in regions with different levels of GDP

Number of Number of
anaesthesiologists per Number of anaesthesiologists per
GDP Number of Provinces 10 0,0 0 0 of population GDP per capita Provinces 10 0,0 0 0 of population

High 10 6•74 High 10 7•98

Medium 11 7•35 Medium 11 6•76
Low 10 6•32 Low 10 5•74
Total 31 6•82∗ Total 31 6•82∗
GDP Df Sum Sq Mean Sq F-value Pr (>F)
Level 2 5•60 2•801 0•940 0•402
Residuals 28 83•39 2•978
GDP per capita
Level 2 25•38 12•692 5•587 0•009
Residuals 28 63•60 2•272
∗
Mean value.

Table 8
The total number of cases from 2015 to 2017

Setting of anaesthesia

Subtotal Anaesthesia cases inside the operating room Nonoperating room anaesthesia
Year
Number of cases Growth rate (%) Number of cases Growth rate (%) Number of cases Growth rate (%)

2015 41,294,776 28,357,219 12,937,557

2016 45,739,031 10•76 30,895,252 8•95 14,843,779 14•73
2017 51,174,683 11•88 33,872,909 9•64 17,301,774 16•56
Total 138,208,490 93,125,380 45,083,110

Fig. 3. The total number of anaesthesia cases from 2015 to 2017.

Table 9
The number of cases at different tiers of hospitals from 2015 to 2017

2017 2016 2015 3-year average Number of anaesthesiologists Annual average workload per capita

Tier 3A 25,222,817 22,345,355 20,100,331 22,556,167•67 38,101 592•01

Tier 3 other 5,625,891 5,026,237 4,465,684 5,039,270•67 9,943 506•82
Tier 2 19,255,741 17,441,162 15,895,280 17,530,727•67 41,707 420•33
Tier 1 or lower 1,070,234 926,277 833,481 943,330•67 2,975 317•09
Total 51,174,683 45,739,031 41,294,776 46,069,496•67 92,726 496•83

3A hospitals had to complete 592 anaesthesia cases per year on load per capita of anaesthesiologists at different tiers of hospitals,
average, while anaesthesiologists in tier 1 or lower hospitals only and its growth rate are shown in Table 10 and Figure 5.
needed to complete 317 anaesthesia cases per year on average, less
than a single case per day. Our survey also showed the rapid in- 4. Discussion
crease in the workload per capita from 2015 to 2017. Anaesthesiol-
ogists in tier 3A hospitals had to complete 75•52 more anaesthesia This survey is the first large investigation to be conducted since
cases per year in 2017 in comparison with 2016. The annual work- the discipline of anaesthesiology was established in China, and is

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C. Zhang, S. Wang, H. Li et al. The Lancet Regional Health - Western Pacific 12 (2021) 100166

Fig. 4. The number of anaesthesia cases at different tiers of hospitals from 2015 to 2017.

Table 10
The annual workload per capita of anaesthesiologists from different tiers of hospitals and growth rates

Tier 3A Tier 3 other Tier 2 Tier 1 or lower

Year
Workload Growth Workload Growth Workload Growth Workload Growth
per capita Growth rate (%) per capita Growth rate (%) per capita Growth rate (%) per capita Growth rate (%)

2015 527•55 449•13 381•12 280•16

2016 586•48 58•92 11•17 505•51 56•38 12•55 418•18 37•07 9•73 311•35 31•19 11•13
2017 662•00 75•52 12•88 565•81 60•31 11•93 461•69 43•51 10•40 359•74 48•39 15•54

Fig. 5. The annual workload per capita of anaesthesiologists in different tiers of hospitals.

an important step in comprehensively understanding the current thesiology workforce is limited with improper configuration, which
situation of Chinese anaesthesiology. General information and the leads to an uneven distribution of the workload around the coun-
current status of all hospital departments providing anaesthesia try.
care in mainland China were accurately collected from 11,432 de-
partments throughout the Chinese mainland. 4.2. Number of physician anaesthesia providers

4.1. Summary of the main findings The number of Chinese anaesthesiologists (or physician anaes-
thesia providers) has steadily increased and reached more than
In recent years, the discipline of anaesthesiology in China has 90,0 0 0, which basically meets the requirements and expectations
made significant progress, with an increase in the proportion of of the No. 21 document (Notice on Issuing Opinions on Strengthen-
independent anaesthesiology departments and affiliated third-level ing and Improving Anaesthesia Medical Services) [12]. The number
departments [11]. However, the percentage of independent anaes- of anaesthesiologists per 10 0,0 0 0 of the population in 2018 also
thesiology departments among all departments providing anaes- increased significantly from 2015, and the number of anaesthesia
thesia care (45•15%) is still far from satisfactory. And the anaes- nurses has tripled from 9,147 in 2015 to 28,200 in 2018.

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C. Zhang, S. Wang, H. Li et al. The Lancet Regional Health - Western Pacific 12 (2021) 100166

Fig. 6. The distribution of anaesthesiologists’ educational background in mainland China.

Our survey showed, however, a relatively low number of anaes- 4.3. Expansion of the anaesthesia workload and workforce
thesiologists in many provinces of mainland China. At present, the
ratio of anaesthesiologists to surgeons, the ratio of operating rooms From 2015 to 2017, the workload of Chinese anaesthesiologists
to anaesthesiologists, and the ratio of operating rooms to anaesthe- has increased by 10% to 51,174,683 anaesthesia cases per year.
sia nurses do not meet the basic standards of the nation’s criteria Cases inside and outside operating rooms increased by 9% and 15%,
for the settings of anaesthesia departments and the quality control respectively. However, the number of anaesthesiologists only in-
of anaesthesiology departments, let alone comparisons with the ra- creased by 5•97% during the same period, which is half of the
tio of anaesthesiologists abroad. increased rate of anaesthesia cases. Predictably, if the growth in
There were marked disparities in the distribution of the anaes- the number of anaesthesia cases and anaesthesiologists continue
thesia workforce between regions and provinces. The number of in this manner, Chinese anaesthesiologists are going to be more
anaesthesiologists per 10 0,0 0 0 of the population in Beijing is close and more stressed in the near future, with increased burnout
to the world’s advanced level, but Tibet has yet to meet interna- and declining job satisfaction. There is increasing evidence that
tional minimum standards, with 5 anaesthesiologists per 10 0,0 0 0 burnout has negative effects on patient care, professionalism, the
of the population. This study also found that the number of anaes- physicians’ care and safety, and the viability of healthcare systems
thesiologists per 10 0,0 0 0 of the population is closely related to the [15,16]. In a previous study performed in 2015, burnout rates of
level of economic development of the region or province. anaesthesiologists in Beijing, Tianjin, and Hebei were 69%, 70%, and
When compared with other countries around the world, China 68%, respectively, which were much higher than those in western
has become the country with the largest number of anaesthesi- countries [17]. Therefore, it is particularly important to strengthen
ologists [13]. According to global standards for the proportion of the development of anaesthesiology and to increase the number of
anaesthesiologists issued by the World Federation of Societies of anaesthesiologists to mitigate the foreseeable inconsistencies be-
Anaesthesiologists (WFSA), a minimum of 5 anaesthesiologists per tween the anaesthesia workload and the workforce.
10 0,0 0 0 of the population is required [14]. However, the number of
anaesthesiologists per 10 0,0 0 0 of the population in China is still far 4.4. Characteristics of the survey
from that of high-income countries (17•96 per 10 0,0 0 0). The num-
ber in China has just about reached the average level of middle- This was the first general survey conducted by the national
high income countries (6•89 per 10 0,0 0 0), and is less than a third anaesthesiology official organisation of all anaesthesia departments
of that in Bolivia (19•21 per 10 0,0 0 0) [13]. When compared with in China, and it was supported by government health departments
other major developing countries in the world, such as Brazil, Rus- at all levels. It is also the first systematic description and macro
sia, India, and South Africa, the number of anaesthesiologists per summary of the current development of anaesthesiology in China.
10 0,0 0 0 of the population in China (5•12 per 10 0,0 0 0) only ex- The survey summarised the current status and characteristics
ceeds the number in India (1•26 per 10 0,0 0 0) and is far behind of Chinese anaesthesiology, compared differences in the develop-
that of Russia (20•91 per 10 0,0 0 0), Brazil (11•55 per 10 0,0 0 0), and ment of the discipline and workforce distribution among regions
South Africa (16•18 per 10 0,0 0 0) [13]. Therefore, the development with different economic development levels in China, and discov-
of Chinese anaesthesiology still has a long way to go. ered existing problems in the current construction. The survey
In addition, different tiers of medical institutions have differ- revealed that the current development of the anaesthesiology in
ent structures. Significant differences were found in educational China is gradually lagging behind the growing demand for medical
background and physician ranking between different tiers of hos- and health services by Chinese citizens.
pitals. The distribution shape of anaesthesiologists’ education is an The study observed that the proportion of independent anaes-
inverted triangle (Fig. 6). A large number of well-trained, higher thesiology departments is far below satisfactory. This finding sug-
educational background anaesthesiologists is concentrated in tier gests that the importance of anaesthesiology departments, which
3 hospitals, and there is a huge gap between tier 1 or lower hos- should be regarded as platform departments or core backbone de-
pitals and tier 3 hospitals in terms of the number of well-trained partments, are not fully recognised at the hospital level. Favourable
anaesthesiologists, their educational background, and rankings. policies should be implemented to emphasise the development of

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C. Zhang, S. Wang, H. Li et al. The Lancet Regional Health - Western Pacific 12 (2021) 100166

anaesthesiology among other medical disciplines in hospitals, and Declaration of Competing Interest
ultimately increase their proportion in Chinese hospitals.
The other important problem highlighted by the survey is that All authors confirm that no conflicts of interest exist and that
the number of Chinese anaesthesia providers is insufficient, which there is nothing to disclose.
implies: (1) that the attraction of anaesthesiology as a discipline
is less than satisfactory (which may be due to multiple reasons Contributors
such as high workloads and low wages); (2) the public awareness
of anaesthesiology in China needs to be improved, so as to increase Dr Changsheng Zhang and Dr Shengshu Wang are co-first au-
the social status of anaesthesiology and attract more medical stu- thors of this paper.
dents; and (3) that more attention should be paid to physician Dr Changsheng Zhang conceptualised and designed the study,
training and teaching, and medical schools should increase the en- coordinated and supervised data collection, interpreted data, and
rolment ratio of specialist anaesthesiologists. drafted the initial manuscript.
Therefore, the study provides objective evidence for healthcare Dr Shengshu Wang coordinated and supervised data collection,
policy makers to formulate policies for the overall development of analysed the data, and reviewed and revised the manuscript.
the discipline, and offers new supply-side reform ideas for mitigat- Dr Hange Li designed the questionnaire, analysed and inter-
ing the contradiction between doctors and patients. preted the data, and edited the manuscript.
In addition, the successful implementation of the survey accu- Prof. Fan Su conceptualised and designed the study, and coordi-
mulated valuable experience in the design, organisation and inves- nated and supervised data collection.
tigation of nationwide medical discipline surveys, which could also Prof. Yuguang Huang conceptualised and designed the study,
facilitate future surveys to some extent. At the same time, this and coordinated and supervised data collection.
study shares China’s experience of anaesthesiology specialty con- Prof. Weidong Mi conceptualised and designed the study, de-
struction with countries that have different economic development signed the questionnaire, coordinated and supervised data collec-
levels around the world. The discipline of anaesthesiology should tion, and reviewed and revised the manuscript.
have more preferential policies. Attention should be paid to the The Chinese Anaesthesiology Department Tracking Collabora-
construction of anaesthesia disciplines in hospitals of different lev- tion Group distributed and collected the questionnaire, entered,
els and regions with different economic development levels, and and validated the raw data.
to the cultivation and recruitment of anaesthesia professionals is All authors approved the final manuscript as submitted and
of great importance as well. agree to be accountable for all aspects of the work.

Acknowledgements

4.5. Limitations The authors thank Ms. Yi Li from the Department of Public
Health and Safety Monitoring, Chongqing Centre for Disease Con-
Firstly, despite the quality control measures that were imple- trol and Prevention for professional data management, statistical
mented, potential information bias cannot be eliminated. The ques- services, and preparation of the manuscript.
tionnaire surveys were primarily handled by local investigators in
each province with different levels of economic development, and Data sharing statement
the educational and work backgrounds were inconsistent among
the respondents. These factors could lead to information bias. Sec- The Chinese Anaesthesiology Department Tracking Database
ondly, data collection, regarding the number of anaesthesia nurses, (CADTD) is publicly available but need to obtain administrative
may not be accurate due to the different roles of nurses. For ex- permission from each investigative hospital.
ample, in some hospitals, anaesthesia departments share nurses
with operating theatres, and nurses working in the operating Supplementary materials
rooms can be both anaesthesia nurses, scrub nurses, or circulating
nurses. Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.lanwpc.2021.100166.

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