Chinese General Practice

Incentives and salaries

YANG Hui

2018, 21(25): 3029-3032. DOI: 10.12114/j.issn.1007-9572.2018.25.001

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Financial Incentive Policies for General Practitioners in the UK and Its Inspiration to China

LIU Yong-jun，LIU Na，ZHANG Qi，WANG Zhao，GU Ying-li，LI Zi-yang

2018, 21(25): 3033-3037. DOI: 10.12114/j.issn.1007-9572.2018.25.002

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In the UK，the general practitioner system was established rather early，and financial incentive policies for general practitioners（GPs） are relatively well-developed，both of them are important guarantees for the efficient and economic operation of the NHS.In contrast，in China，the development and implementation of the performance appraisal system for GPs are still in the initial phrase，so advanced lessons from abroad should be learned.In order to provide a reference for domestic development of the performance appraisal system for GPs，we systematically introduced the major contents of the financial incentive policies for GPs in the UK，including payment method，structural model，implementation effectiveness，and so on，and proposed suggestions such as developing the authoritative and efficient management and service system for GPs，building the regional comprehensive general practice information network based on the local conditions，improving the wage and welfare levels of GPs as well as enhancing the government investment in general practice.

Construction of Incentive Salary Model Based on Family Doctor Services System　

GUI Xiao-hai1，WANG Hong-bo，LIU Hui，YANG Yu-feng

2018, 21(25): 3038-3043. DOI: 10.12114/j.issn.1007-9572.2018.25.003

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Objective　To explore the model of incentive system for physicians under the family doctor services system and its influencing factors，so as to provide support for medical reform and the implementation of family doctor services system.Methods　Following a literature search on policies of family doctor services system and salary system for medical staff，the incentive salary model for family doctor services was divided into 3 parts：the balance of medical insurance fund according to the prepaid package，package service fee of chronic diseases such as diabetes and high blood pressure，and traditional medical income paid by inspection items.We then constructed the incentive salary model and analyzed its influencing factors according to doctors' net income function from Handbook of Health Economics.A total of 3 182 residents were selected in the Haidian District Family Doctor Pilot Program to analyze the relationship between the patient's age，illness and medical expenses in October 2016.Results　Based on the established incentive salary models，we found that health insurance payment methods，doctor behavior and patient characteristics affected incentive salaries of medical staff.The incentive salary was maximized when the productivity of the doctor reached the maximum，the service subject had minor illness with less medical expenditure.Based on the study in Haidian District，medical expenses rose as the patient ages.A small number of patients with frequent visits and serious illnesses were key determinants of medical insurance control and incentive salary.Conclusion　It is necessary to establish a flexible salary model for medical staff that meets the characteristics of the family doctor services system.Combination of payment methods，improvement of medical services quality，information technology，and data-based means can realize patient segmentation and personalized performance assessment to achieve common interests of health insurers，doctors and patients.

Strategy and Empirical Study on Labor Costs in Community Health Service Centers under Comprehensive Budget Management

KONG Chun-hui，QIAN Ling-ying

2018, 21(25): 3043-3050. DOI: 10.12114/j.issn.1007-9572.2018.25.004

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Objective　To calculate the workload of health services in Laoximen Community Health Service Center in Huangpu District，Shanghai，and to construct a calculation method of labor cost under the comprehensive budget management.Methods　The labor cost of community health services was estimated in three stages from October 2016 to September 2017.Ten heads of departments in Laoximen Community Health Service Center were invited to collect information of ongoing community health services.These services were subdivided according to the principle that one service unit can be completed by one person；two-round questionnaire survey under Delphi method was carried out on physicians from various departments to evaluate three dimensions in terms of workload of health services，including the labor and time consumption，technical difficulties and risks.The standardized workload value of unit services was calculated by results；the unit labor cost of standard workload was calculated by the historical data including workload and staff performance in the community health service center between January and June 2017.Results　Five types of community health services were carried out in the center：clinics，nursing，medical technology，public health and other categories，with a total of 960 items.The labor cost in the community health service center was ￥0.72/unit standardization workload between January and June 2017.The labor cost of clinics，traditional Chinese medicine，nursing and public health were ￥1.05，￥0.80，￥1.13 and ￥0.37/unit standardization workload，respectively.Conclusion　This study constructs a labor cost calculation method based on the standardized workload of the community health service center，which can be used to guide the community's budget expenditure management.The budget for labor costs in community public health services is highly underestimated.The community should adjust the budget of each service category based on the results of labor cost measurement in health services.

Economic Performance of Community Health Centers in Wuhan before and after the China's Health Care Reform Lauched in 2009　

QIAO Jia-jun，ZENG Yi-ni

2018, 21(25): 3051-3055. DOI: 10.12114/j.issn.1007-9572.2018.25.005

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Objective　To analysis the economic performance of community health centers in Wuhan before and after the China's health care reform lauched in 2009.Method　Income and expenditure，patients flows，efficiency and effectiveness of health service provision of Wuhan community health centers were analyzed by using Health Financial Annual Report 2008—2016 in Wuhan.Results　Annual average growth rate of total income in Wuhan community health centers was 21.4% during 2008—2016，and distributable balances were below zero in a continuous expansion trend.The share of government subsidy increased from 32.4% in 2008 to 60.0% in 2016，of which subsidy for public health services increased by 7.7%；the proportion of medical income was generally declining，from 59.4% in 2008 to 37.7% in 2016，of which the proportion of drug income fell from 38.9% in 2008 to 32.3% in 2016.The number of outpatient and emergency visits increased from 2.005 million in 2008 to 3.988 million in 2014，and decreased to 3.592 and 2.984 million in 2015 and 2016 respectively.The number of discharged patients increased from 12 000 in 2008 to 73 000 in 2014，and fell to 53 000 and 41 000 in 2015 and 2016 respectively.The utilization rate of beds decreased to 44.4% by 2016 from 80.9% in 2009.The income from medical insurance for 100 yuan fixed assets（excluding drug income） increased from 61.2 yuan in 2008 to 135.1 yuan in 2011，in a generally decline trend.It fell to 66.9 yuan in 2016.Conclusion　Economic operation of Wuhan community health centers was lower than the national average since the China's health care reform lauched in 2009；the public health service function has been enhanced，but the medical services function has been weakened.We recommend continuously improving the medical service capacity of community health centers and mobilizing the enthusiasm of community staff to improve work efficiency and ultimately promote hierarchical diagnosis and treatment.

Level and Associated Factors of Patients' Satisfaction with the Procedures for Upward Referral-to-Downward Referral during the Implementation of Hierarchical Medical System

JIA Li-li，LI Xiu-qin，GUO Kun

2018, 21(25): 3056-3062. DOI: 10.12114/j.issn.1007-9572.2018.25.006

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Objective　To investigate the level and associated factors of patients' satisfaction with the procedures for upward referral-to-downward referral during the implementation of hierarchical medical system.Methods　We conducted a survey in a sample of 415 patients from those who were transferred to an affiliated hospital of a medical college in Xi'an from lower-level institutions between November 2016 and May 2017 with a self-designed questionnaire for obtaining the data about sociodemographic characteristics，levels of satisfaction with the services delivered by the lower-level and upper-level medical institutions，level of satisfaction with the procedures for upward and downward referrals.A total of 400 returned responsive questionnaires，achieving a response rate of 96.4%.Results　The patients' satisfaction was found to be 30.0%（120/400），81.8%（327/400），65.5%（262/400），48.3%（28/58），for services delivered by the lower-level and upper-level medical institutions，the procedure for upward referrals，and the procedure for downward referrals，respectively.Multivariate logistic regression analysis showed that patients' age，satisfaction with the capabilities of healthcare professionals，service attitude of health workers and healthcare cost were associated factors for patients' satisfaction with the services delivered by lower-level medical institutions（P<0.05）；patients' mean monthly income and type of medical insurance，patients' satisfaction with the capabilities of healthcare professionals，service attitude of health workers，healthcare cost and the environment in healthcare settings were associated factors for patients' satisfaction with the services delivered by upper-level medical institutions（P<0.05）；patients' age and educational level，patients' satisfaction with the convenience of referral procedure and duration of referral were associated factors for their satisfaction with the procedure for upward referrals（P<0.05）；patients' educational level，satisfaction with the convenience of referral procedure and duration of referral were associated factors for their satisfaction with the procedure for downward referrals（P<0.05）.Conclusion　The services delivered by the upper-level medical institutions and the procedure for upward referrals achieved high levels of patients' satisfaction，but the procedure for downward referrals achieved low level of patients' satisfaction，the services delivered by the lower-level medical institutions，even worse，achieved the lowest level of patients' satisfaction.Patients' age and educational level，capabilities of healthcare professionals，service attitude of health workers toward patients，healthcare cost，convenience of the referral procedure，and duration of the referral were associated factors for patients' satisfaction with the procedures for upward referral-to-downward referral.

Reasons and Countermeasures of Residents Signing the Contract with the Family Doctor but Not Making Appointments during the Implementation of Hierarchical Medical System

XIAO Lei，ZHANG Tai-hui，ZHANG Ya-li，LI Jia-wei

2018, 21(25): 3063-3068. DOI: 10.12114/j.issn.1007-9572.2018.25.007

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Despite the progress in contracted family doctor services（CFDSs） has been made in recent years，there still exist contracts with little consumption，which affects the implementation of the hierarchical medical system.We analyzed the reasons of residents signing the contract with family doctors but not making an appointment from a supply-demand perspective，which include the following：supply-side factors：family doctors are in serious shortage and underpaid，the implementation of the CFDSs lacks of corresponding supports as well as reasonable assessment mechanism；demand-side factors：residents lack of a good knowledge of the CFDSs and distrust the capabilities of family doctors，and medical insurance policies have underplayed their role in guiding health-seeking behaviors of residents properly.Therefore，we proposed the following recommendations：making the general practice as a career be more attractive，expanding the workforce and improving the capabilities of general practitioners；advancing the attractiveness of the CFDSs，and formulating the service standards and procedures；Giving full play to the lever role of medical insurance in promoting the development of the CFDSs；intensifying the publicity of the CFDSs.

Willingness and Influencing Factors of Initial Diagnosis at Community Level in the Mode of "1+1+1" Hierarchical Medical System in Shanghai　

DAI Hui-min，LI Ya-ling，DU Zhao-hui

2018, 21(25): 3068-3072. DOI: 10.3969/j.issn.1007-9572.2018.25.008

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Objective　To investigate the willingness and associated factors of initial diagnosis at the community level among residents in the mode of "1+1+1" hierarchical medical system.Methods　Six hundred community residents were selected by random sampling method in Weifang Community Health Service Center，Pudong New Area from October to December 2017.A structured questionnaire designed by our research team consisting of questions about demographic characteristics，awareness level and signing situation of the "1+1+1" hierarchical medical system，medical treatment in community health services and first choice of medical institutions was used.A total of 600 questionnaires were distributed and 580 were recovered，with an effective recovery rate of 96.7%.Results　Of the 580 participants，463 subjects（79.8%） had the willingness of having first diagnosis at the community level.There were no significant differences in willingness of first diagnosis at the community level among residents in terms of gender，age，education level，marital status，family average monthly income，medical insurance payment method（P>0.05）.Residents who were aware of "1+1+1" hierarchical medical system had significantly higher willingness of having initial diagnosis in community service centers than those who were unaware of（P<0.05）.Residents who signed the contract had the same higher willingness than those un-signed（P<0.05）.Higher willingness of initial diagnosis at community medical services occurred in communities with fixed doctors（P<0.05）.Residents who were satisfied with doctors' service had significantly higher willingness of having initial diagnosis in community medical services than those who were neutral/unsatisfied（P<0.05）.Multivariate Logistic regression analysis showed that choice of signing "1+1+1" and continuity of care are factors influencing the willingness of initial diagnosis at the community level（P<0.05）.Conclusion　The "1+1+1" signing mode can improve the willingness of residents to have their first diagnosis in the community medical services，which will promote an orderly medical pattern.

Intention and Associated Factors of Renewing the Contract with Family Doctors　

LIU Cai-yin，JIANG Dong-dong，WANG Quan

2018, 21(25): 3073-3078. DOI: 10.12114/j.issn.1007-9572.2018.25.009

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Objective　To investigate the intention and associated factors of renewing the contract with family doctors，providing a reference for promoting the development of contracted family doctor services（CFDS）.Methods　By random sampling，from 21 community health centers（township hospitals）offering CFDS in Yichang，we enrolled 750 residents who received the medical services including the CFDS during September to December 2017.A self-designed questionnaire survey was conducted with them for collecting the demographic data，awareness，perception and utilization of CFDS，level of satisfaction with CFDS and the intention of renewing the contact with family doctors.Totaled 735 returned responsive questionnaires，with a response rate of 98.0%（735/750）.Results　Among the 735 residents，85.9% （631/735）intended to renew the contract with family doctors.The intention of renewing the contract with family doctors differed significantly by age，health status，level of supporting initial treatment in primary care settings，the time needed to walk to the grassroots medical institution nearest to home（P<0.05）.Moreover，it varied obviously by the level of awareness of CFDS（including knowing one's own contracted family doctor or not），level of perception of CFDS（including level of trust in family doctors，level of perceived necessity of CFDS，whether the CFDS can reduce the incidence of diseases，medical costs and improve the convenience in seeking healthcare or not），level of utilization of CFDS（including home-based care，telephone-based follow-up，free physical examinations，and building health records），level of satisfaction with CFDS（including satisfaction with the professional capabilities，service attitude and overall quality of family doctors）（P<0.05）.Multivariate stepwise Logistic regression analysis showed that residents' intention of renewing the contract with family doctors was associated with age，level of supporting initial treatment in primary care settings，level of trust in family doctors，level of perceived necessity of CFDS，levels of satisfaction with the professional capabilities and overall quality of family doctors （P<0.05）.Conclusion　On the whole，the level of intention of renewing the contract with family doctors was high in Yichang's residents，which was associated with age，level of supporting initial treatment in primary care settings，level of trust in family doctors，level of perceived necessity of CFDS，and levels of professional capabilities and overall qualities of family doctors.

Finnish Diabetes Risk Score and Chinese Diabetes Risk Score for Community-based Screening of Diabetes in Xinjiang：a Comparative Study

ZHANG Chun-tao，SU Yin-xia，WANG Shu-xia，WANG Yu-shan，ZHOU Hong，WEI Jun，YAO Hua，LI Yu-kai

2018, 21(25): 3079-3083. DOI: 10.12114/j.issn.1007-9572.2018.25.010

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Objective　To compare the performance of Finnish Diabetes Risk Score （FINDRISC） with that of Chinese Diabetes Risk Score （CDRISC） in community-based screening of diabetes in Xinjiang，providing a theoretical basis for this kind of screening in this area.Methods　By multi-stage random sampling，1 680 community-dwelling residents aged 18-75 years were recruited from Urumqi of Xinjiang in May 2017.FINDRISC，CDRISC and OGTT （gold standard for the diagnosis of diabetes） were used to screen diabetes risk，and the results of the former two were compared in terms of sensitivity，specificity，Youden's index，as well as the area under the ROC curve （AUC），and were compared with the OGTT results.Results　A total of 1 649 residents completed the 3 tests.By OGTT，402 （24.38%） were found with type 2 diabetes，other 1 247 （75.62%） without diabetes.In screening diabetes risk，the sensitivity，specificity and Youden's index were 88.81%，61.59%，0.50，respectively for FINDRISC with an identified optimal cut-off point of 9 points，and were 79.85%,40.66%， 0.21 respectively for CDRISC with an identified optimal cut-off point of 25 points.Moreover，FINDRISC demonstrated a larger AUC than CDRISC in the screening{0.833〔95%CI（0.813，0.854）〕vs 0.634〔95%CI（0.604，0.663）〕}（P<0.05）.Conclusion　As being more accurate than CDRISC，FINDRISC is reliable for community-based screening of diabetes in Xinjiang.

Risk Factors for Progression of Renal Function

LIU Ding-yang，ZHUO Lin，GONG Jia-hui，WANG Guo-wei，MA Yi-fei，WANG Xiu-ying，XU Ling，ZHUO Lang

2018, 21(25): 3084-3088. DOI: 10.12114/j.issn.1007-9572.2018.25.011

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Objective　To analyze the risk factors for progression of renal function in people receiving physical examination，so as to provide a basis for delaying the decline in renal function and improve quality of life.Methods　People who had more than four consecutive physical examinations in Xuzhou Central Hospital from 2005 to 2012 were enrolled in this study.Thirty-seven patients （154 times） with progression of renal function who had decreased eGFR were selected as the case group，and 111 people （447 times） in the same gender，similar age and without eGFR decline as the control group.Gender，age，systolic blood pressure （SBP），diastolic blood pressure （DBP），pulse pressure （PP），serum creatinine （Scr），urea nitrogen，fasting blood glucose （FPG），triacylglycerol （TG），total cholesterol （TC），high density lipoprotein cholesterol （HDL-C），low density lipoprotein cholesterol （LDL-C），plasma viscosity （PV），body mass index （BMI） and other indicators were compared between the two group.Risk factors for progression of renal function were analyzed by multivariate Logistic regression analysis.The proportion of renal function decline in different blood pressure grades was compared by chi-square test.Results　 There were no statistical differences in age，gender，baseline eGFR，Scr，and urea nitrogen between the two groups （P>0.05）.The 8-year average eGFR was significantly lower than control group，the 8-year average Scr and urea nitrogen in the case group was significantly higher than those in the control group（P<0.05）.There were no statistical differences between the two groups regarding PP，FPG，TG，TC，LDL-C and PV （P>0.05）.The SBP，DBP and BMI in the case group were significantly higher than those in the control group （P<0.05）.The HDL-C in the case group was significantly lower than in the control group（P<0.05）.DBP was an independent factor of decreased eGFR in three models of multivariate analysis，〔model 1：OR=1.027，95%CI（1.011，1.044），P<0.05；model 2：OR=1.028，95%CI（1.004，1.053），P<0.05；model 3：OR=1.027，95%CI（1.003，1.052），P<0.05〕，and other factors were not statistically significant in the multiple factors analysis.As the level of hypertension elevated，the proportion of decline in renal function increased（χ2 Linear-by-Linear Association =10.312，P=0.001）.Conclusion　 In this study，we find the DBP is an independent risk factor for progression of renal function.Healthy people should maintain good living habits and DBP to delay renal progression.

Effect of Timing of Initiating Exercise Rehabilitation on the Prognosis of Motor Function in Acute Ischemic Stroke　

WANG Fu-dong，HUANG Shi-ya，ZHAO Hong-yu

2018, 21(25): 3089-3094. DOI: 10.12114/j.issn.1007-9572.2018.25.012

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Objective　To investigate the effect of timing of initiating exercise rehabilitation on the prognosis of motor function in patients with acute ischemic stroke（AIS）.Methods　We enrolled 67 cases of AIS from Emergency Department and Neurology Ward，Shengjing Hospital of China Medical University from September 2015 to August 2017 and randomized them into group A（n=35），and group B（n=32，2 patients withdrew from the study），receiving an exercise rehabilitation initiated within 24-48 h，48-120 h，respectively after the onset of AIS.The intervention for both groups ended on the 90th day after the onset of AIS.Baseline characteristics were collected by reviewing the medical records.The motor function was evaluated by both Modified Rankin Scale （MRS） and Fugl-Meyer Assessment（FMA） on the 7th，14th，30th，60th，and 90th days after the onset of AIS，respectively.Results　Two groups showed no significant differences in baseline characteristics and the mean MRS score measured on the 7th day after the onset of AIS （P>0.05），but group A demonstrated a significantly decreased mean MRS score on the 90th day after the onset of AIS （P<0.05）.Although the overall mean upper extremity FMA score did not differ significantly between the groups（P>0.05），the mean upper extremity FMA score varied substantially between the groups at different times during the rehabilitation period （P<0.05），in particular，it was much higher in group A than that of group B at the end of the 7th day of rehabilitation （P<0.05）.The overall mean lower extremity FMA score and mean lower extremity FMA score at different times during the rehabilitation period differed significantly between the groups（P<0.05），to be specific，group A showed much higher mean lower extremity FMA score than group B at the end of the 7th，14th，30th，60th，and 90th days of rehabilitation （P<0.05）.In addition，the FMA scores for both the upper and lower extremities were not influenced obviously by the interaction effect of the timing of initiating exercise rehabilitation and duration of the rehabilitation （P>0.05）.Conclusion　For AIS patients with an MRS score of 3-4，exercise rehabilitation initiated within 48 h after the onset of AIS can significantly improve the motor function.

Effects of Waist-to-height Ratio and Skinfold Thickness on Impaired Fasting Glucose and Diabetes in the Elderly

LIU Hong-yan，LIU An-nuo，PAN Zheng-wen，ZHANG Dong-mei，MA Ying，CHEN Gui-mei，WANG Su-fang，LIU Kai-yong，YANG Lin-sheng，TAO Fang-biao

2018, 21(25): 3095-3101. DOI: 10.12114/j.issn.1007-9572.2018.25.013

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Objective　To investigate the effects of waist-to-height ratio（WHtR） and triceps，subscapular，and abdominal skinfold thicknesses on the prevalence of impaired fasting glucose（IFG） and diabetes in the elderly.Methods　We enrolled 1 080 elderly residents aged 60 or over from a urban and a rural communities selected from Jin'an and Yu'an Districts of Anhui's Liuan City by stratified cluster sampling.All of them received a face-to-face survey with a self-developed questionnaire and a physical examination for collecting the data concerning demographic characteristics〔geographical location（rural or urban area），sex，age，educational attainment，occupation，and so on〕，WHtR，triceps，subscapular，and abdominal skinfold thicknesses and fasting blood glucose（FBG）.The relationships of WHtR and triceps，subscapular，and abdominal skinfold thicknesses with the prevalence of IFG and diabetes were examined using multivariate Logistic regression.Results　Of the 983 cases finally included in the analysis，the prevalence of IFG was 19.1%（188/983），and that of diabetes was 19.1%（188/983）.Univariate analysis showed that FBG varied significantly by geographical location，sex，smoking，WHtR，triceps，subscapular，and abdominal skinfold thicknesses（P<0.05），but not by age，educational attainment，occupation，alcohol consumption，history of chronic diseases（hypertension，coronary heart disease，stroke）（P>0.05）.Multivariate Logistic regression analysis revealed that geographical location，hypertension and subscapular skinfold thickness were significantly associated with the prevalence of IFG（P<0.05），and geographical location，WHtR，triceps，subscapular，and abdominal skinfold thicknesses were obviously associated with the prevalence of diabetes（P<0.05）.Conclusion　The subscapular skinfold thickness is an associated factor for IFG，and WHtR，triceps，subscapular，and abdominal skinfold thicknesses are associated factors for diabetes in the elderly.

Concomitant Disease and Drug of Choice in Patients with Rheumatoid Arthritis in Different Genders

XU Li-ling，ZHU Hua-qun，ZHONG Hua，SU Yin

2018, 21(25): 3101-3106. DOI: 10.12114/j.issn.1007-9572.2018.25.014

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Objective　To explore concomitant disease and drug use in patients with rheumatoid arthritis （RA） in clinical practice between different genders，thus raising the awareness of patients with RA.Methods　A total of 15 353 patients admitted to Peking University People's Hospital were enrolled from September 2014 to September 2015.Their basic information，including gender，age，laboratory features and drug use were collected from clinical laboratory information system and electronic medical record system of Yidu Cloud Technology Company Ltd.Statistical analysis of concomitant disease and drug use were compared by chi-square test.Results　Among the subjects，4 002 were male （26.07%） and 11 351 female （73.93%），with a ratio of approximately 1∶2.8.The common concomitant rheumatic diseases in patients with RA were sjogren syndrome （SS，5.24%），systemic lupus erythematosus （SLE，2.53%），and ankylosing spondylitis （AS，1.07%）.Except for RA patients aged 65 years and over，the prevalence rates of SS and SLE in female patients with RA were higher than those in male （P<0.05），and of AS in male patients with RA was higher than that in female （P<0.05）.Other concomitant diseases were osteoarthritis （37.56%），osteoporosis （33.37%），hypertension （29.87%），hyperlipidaemia （19.49%），coronary heart disease （19.16%），peptic ulcer （16.80%），cerebrovascular disease （13.59%），chronic gastritis （13.11%），diabetes （10.90%），and atherosclerosis （10.17%）.The significant difference was found on above-mentioned concomitant diseases （except chronic gastritis，cerebral vascular disease in patients aged 44 years or below and osteoarthritis，hyperlipidemia，cerebrovascular disease and atherosclerosis in patients aged 65 years and over） between female and male patients with RA in different ages （P<0.05）.The most common 10 kinds of drugs used in patients with RA were leflunomide （54.63%），methotrexate （26.20%），hydroxychloroquine sulfate （23.14%），diclofenac （22.20%），loxoprofen （21.20%），celecoxib （20.20%），total glucosides of paeony （18.52%），glucocorticoid （16.77%），meloxicam （15.90%） and sulfasalazine （13.75%）.The use of leflunomide was significantly higher in male patients than in female patients （P<0.05），while the use of methotrexate，hydroxychloroquine sulfate，glucocorticoid，and total glucosides of paeony were significantly higher in female patients （P<0.05）.Conclusion　The concomitant disease and drug of choice were significantly different between female and male patients with RA，which should be paid more attention to in clinics.

Therapeutic Effect of Shenbai Fuzheng Granules Combined with Apatinib in the Treatment of Metastatic Breast Cancer with Multi-line Therapy Failure　

LUO Yue-qiong，LIAO Da-zhong

2018, 21(25): 3107-3112. DOI: 10.12114/j.issn.1007-9572.2018.25.015

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Objective　To investigate the effect of Shenbai Fuzheng Granules combined with Apatinib in the treatment of metastatic breast cancer with multi-line therapy failure and its effect on vascular endothelial growth factor receptor 2（VEGFR2） and immune function.Methods　A total of 96 patients with metastatic breast cancer who failed multi-line treatment were randomly divided into the control group（n=48） and the experimental group（n=48）.The control group was treated with oral Apatinib and the experimental group was given oral Shenbai Fuzheng Granules combined with Apatinit.The clinical efficacy，traditional Chinese medicine（TCM） syndrome scores，levels of serum insulin-like growth factors-1（IGF-I），CA153，interleukin8（IL-8），VEGFR2，CD4+，CD8+，CD4+/CD8+，natural killer cell（NK），IgG，IgA，adverse reactions，progression-free survival（PFS） and overall survival（OS） were compared between two groups.Results　The treatment efficiency and tumor control rate in the experimental group were significantly higher than those in the control group（P<0.05）.The TCM syndrome scores of the experimental group after the treatment were significantly lower than those before the treatment and those of the control group after the treatment（P<0.05）.After treatment，the levels of serum IGF-I，CA153，IL-8 and VEGFR2 in two groups were significantly lower than those before the treatment（all P<0.05），and these indexes in the experimental group were significantly lower than those in the control group（all P<0.05）.After treatment，the experimental group demonstrated higher levels of serum CD4+，CD4+/CD8+，NK，IgG，IgA and lower level of serum CD8+ compared with the control group（P<0.05）.The total incidence of adverse reactions in the experimental group was not significantly different from that in the control group（P>0.05）.The PFS and OS of the experimental group were significantly longer than those of the control group（P<0.05）.Conclusion　The effect of Shenbai Fuzheng Granules combined with Apatinib in the treatment of metastatic breast cancer with multi-line treatment failure is effective，which can effectively reduce the level of VEGFR2 and improve the immune function with higher safety.

Status and Associated Factors of High-normal Blood Pressure in Populations Aged 15 and Over in Guizhou Province　

LI Mi，LIU Guo-qin，RAO Wen-bo，LIU Zhi-jun，CHU Ya-lin，WU Fang

2018, 21(25): 3113-3117. DOI: 10.3969/j.issn.1007-9572.2017.00.246

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Objective　To investigate the status of high-normal blood pressure（HNBP） in populations aged 15 and over in Guizhou Province，and to analyze the associated factors for the development from normal blood pressure to HNBP and from HNBP to hypertension，in order to provide a basis for strengthening the health management for HNBP populations，reducing the incidence of hypertension，and facilitating the community-based prevention and control of hypertension.Methods　This study was conducted from September 2014 to October 2015.Using stratified multistage random sampling，we selected 15 200 permanent residents aged 15 and over from 64 neighborhood（village） committees of 16 subdistricts（townships/towns） subordinated to 8 districts（counties） in Guizhou Province.We collected their basic demographic characteristics（sex，age，residence，ethnic group，educational level，marital status，employment status，prevalence of smoking and alcohol consumption） through personal interview survey and obtained their data of height，weight，waist circumference and blood pressure by physical examination.The survey achieved a response rate of 88.68%（13 480/15 200）.Multivariate Logistic regression analysis was performed to investigate the associated factors for the development from normal blood pressure to HNBP and from HNBP to hypertension in these people.Results　Of the 13 480 final participants，4 433（32.89%） were found with normal blood pressure，5 592（41.48%） with HNBP，and 3 455（25.63%） with hypertension.The analysis using multivariate Logistic regression models revealed that sex，age，residence，BMI and waist circumference were the associated factors for the development from normal blood pressure to HNBP（P<0.05）；age，residence，education level，prevalence of alcohol consumption，BMI and waist circumference were the associated factors for the development from HNBP to hypertension（P<0.05）.Conclusion　HNBP is found in many of the people aged 15 and over in Guizhou Province.Sex，age，residence，BMI and waist circumference are the associated factors of the development from normal blood pressure to HNBP；age，residence，education level，prevalence of alcohol consumption，BMI and waist circumference are the associated factors for the development from HNBP to hypertension.

Causes and Countermeasures of Disconnection between Trainging and Practice of General Practitioners in China

WEI Dong-hai，FENG Xin-xian，ZHANG Chen-fu，GU Yan-jue，CAO Xiao-wen

2018, 21(25): 3118-3122. DOI: 10.12114/j.issn.1007-9572.2018.25.017

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Sufficient and qualified general practitioners（GPs）are essential in establishing the "Gatekeeper health care system"，in which the patient's first consultation must be made by the GP.At present，the quantity of general practitioners in China is inadequate and cannot meet the actual demand within a short period of time.Meanwhile，the training and practice of general practitioners are disconnected，thus producing another problem in China.All of these directly affect the establishment of the "Gatekeeper system".This study took the "5+2+1 joint medical education model for general practitioners" at Guangzhou Medical University as an example and investigated the cause as to why students enrolled in this program from 2012 to 2016 were reluctant to practice as general practitioners.Through semi-structured interviews，the researchers try to find out the actual cause comparing training models at home and abroad and researching relevant data.The results showed that，on the surface，the causes included low income，poor working conditions，low social status，and poor career development prospects.But the root causes involved the medical system，the education system，the social security mechanism and the incentive mechanisms.Therefore，it is suggested that at the national level，the "Gatekeeper system" should be subject to legal restraint；establish a qualified recruitment and targeted training system for general practice；improve the working environment；develop a revised promotion system for general practitioners and strengthen the adjustment mechanism of medical insurance.Last but not least，the living conditions of general practitioners should be guaranteed to a certain extent by the government.

General Medical Students Career Confidence Index（GMSCCI） in China　

HUANG Mei-juan，QIU Ke，BAO Rui，ZHUANG Hai-shan，BAO Si，LUO Jia-li，WANG Xin-wang

2018, 21(25): 3123-3127. DOI: 10.12114/j.issn.1007-9572.2018.25.018

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Objective　To explore general medical students career confidence index（GMSCCI），and comprehensively quantify confidence of general medical students on general practitioners.Method　The online survey questionnaires were given to general medical students from 359 general practitioners' standardized training communities and Doctor Online Magazine readers between 20 May to 29 July 2016.All data of basic information，employment intension，the evaluation for the status quo and next 3 years' development of general practitioners（including 6 dimensions and 12 variables：training system，personal value，income level，career development，social respect，professional risk） were included in the questionnaire.We calculated Present Situation Index，Expectations Index and Confidence Index according to the result of the survey.Results　A total of 768 valid questionnaires were collected，which suggested 444（57.8%） general medical students intended to be general practitioners after graduation.Present Situation Index was 82.85，Expectations Index was 125.68 and GMSCCI was 104.27.The Confidence Index of training system，personal value，income level，career development，social respect，professional risk were 118.49，115.72，89.13，108.82，91.76 and 92.15，respectively.Conclusion　General medical students take negative attitudes towards present situation of general practitioners，while having positive attitudes to career expectations in next 3 years.In general，general medical students have confidence in general practitioners' career.They take negative attitudes towards income level，social respect and professional risk，while having positive attitudes to training system，personal value and career development.

Effect of Community-based Standardized Management on Diabetic Patients　

WANG Zi-ming，YU Hai-yan，SHAO Hua

2018, 21(25): 3128-3132. DOI: 10.12114/j.issn.1007-9572.2018.25.019

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Objective　To evaluate the effects of community-based standardized management on the rate of meeting the glycemic targets in type 2 diabetic patients.Methods　We enrolled 151 type 2 diabetic patients who received community-based standardized glycemic control management from Jiangtai Community Health Center in Bejing's Chaoyang District in 2008.All of them underwent 4 times of physical examination per year.We collected their data such as systolic blood pressure（SBP），diastolic blood pressure （DBP），fasting plasma glucose（FPG），2-hour postprandial blood glucose（2 hPG），glycosylated hemoglobin （HbA1c） and so on between 2008 and 2016.A total of 111 cases with 8-year （from 2008 to 2016） community-based standardized management and complete data were finally included in the study，including 44 （39.6%） with simple type 2 diabetes （simple diabetes group），and 67 （60.4%） with type 2 diabetes combined with hypertension （diabetes combined with hypertension group）.Comparatively analyzed the data measured in 2008 and 2016.Results　Compared with 2008，in 2016，both SBP and DBP decreased in females significantly in diabetes combined with hypertension group，but only DBP decreased obviously in simple diabetes group with statistical significances （95%CI did not include 0）.Moreover，FPG declined in females in simple diabetes group，2 hPG and HbA1c declined substantially in both groups with statistical significances （95%CI did not include 0）.The rate of meeting glycemic targets increased significantly in all participants〔60.4%（67/111） vs 34.2%（38/111），χ2=15.198，P<0.001〕，simple diabetes group 〔56.8% （25/44） vs 31.8% （14/44）， χ2=5.272，P=0.018〕，and diabetes combined with hypertension group 〔62.7% （42/67） vs 35.8%
（24/67），χ2=10.942，P<0.001〕 in 2016 compared with 2008.In the simple diabetes group，except male，aged ≥60，a high school education or higher，eating properly，and family history of hypertension that were associated with little changed rate of meeting glycemic targets，poor drug compliance was associated with significantly decreased rate of meeting glycemic，other demographic factors were associated with significantly increased rate of meeting glycemic targets with statistical significant differences （95%CI did not include 0）.In the diabetes combined with hypertension group，except smoking，poor drug compliance，and family history of diabetes were associated with little changed rate of meeting glycemic targets，other demographic factors were associated with significantly increased rate of meeting glycemic targets with statistical significant differences （95%CI did not include 0）.Conclusion　Results from our study showed that community-based standardized glycemic control management could significantly improve the levels of blood pressure and glycemic control status.

Specialty Physician-General Practitioner-Health Manager Management for Members of Diabetes Network and Hypertension Network from Xiamen City　

LIN Fen，WU Yun-zhang，LIN Hai-nan

2018, 21(25): 3133-3138. DOI: 10.12114/j.issn.1007-9572.2018.00.073

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Objective　To analyze the theoretical characteristics and performance of specialty physician-general practitioner-health manager management for members of Diabetes Network and Hypertension Network from Xiamen.Methods　According to the inclusion criteria of Hypertension Network and Diabetes Network，we enrolled 845 cases of hypertension and 787 cases of diabetes from Xiamen Siming District Jialian Street from July 2015 to July 2016.All of them received 1-year intensive，full-range and comprehensive interventions codelivered by specialty physicians，general practitioners and health managers.The evaluators for this management are BMI，waist circumference，and the control rates of systolic blood pressure（SBP），diastolic blood pressure（DBP），fasting plasma glucose（FPG），total cholesterol（TC），triacylglycerol（TG），low-density lipoprotein cholesterol（LDL-C），high-density lipoprotein cholesterol（HDL-C），urine microalbumin and glycosylated hemoglobin（HbA1c） at the end of 1-year intervention.Results　At the end of 1-year management，for the hypertensive participants，compared with baseline，the control rates of SBP，DBP，TC，TG，HDL-C，and urine microalbumin increased significantly but the control rate of FPG decreased obviously（P<0.05），and BMI，waistline and control rates of LDL-C changed a little（P>0.05）；for the diabetic participants，compared with the baseline，the control rates for SBP，DBP，FBG，TC，TG，LDL-C，HDL-C and urine microalbumin improved significantly（P<0.05），while BMI，waistline and control rates of HbA1c changed slightly（P>0.05）.Conclusion　Specialty physician-general practitioner-health manager management can increase the control rates for SBP/DBP，FPG，blood fat，as well as urine microalbumin，showing its significant management effect on both hypertension and diabetes.

Awareness Level of Medical Consortia among Community-based General Practitioners

YUAN Sheng，CAI Lu-yao，LI Zheng-yang，WANG Jia-xin，YIN Xiao-xu，LU Zu-xun，CAO Shi-yi

2018, 21(25): 3139-3143. DOI: 10.3969/j.issn.1007-9572.2018.00.037

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Objective　 To investigate the awareness level of medical consortia among community-based general practitioners（GPs） in Hubei province.Methods　 We recruited 764 GPs who took part in the standard training for GPs conducted in Hubei Province from April to June in 2017.In August 2017，we carried out a survey among them with a questionnaire developed by our research group for obtaining the data about sociodemographic characteristics, familiarity level with medical consortia, support level for medical consortia, awareness level of the construction of medical consortia, perception level of the healthcare cooperation between GPhe institutions and higher level hospitals, and status of participating in dual referrals between the members in the medical consortium.Totaled 749 returned responsive questionnaires，with a response rate of 98.0%.Results　Of the respondents，60.8%（448/737） were much or relatively familiar with medical consortia，88.3%（646/732） were very or relatively supportive of the construction of medical consortia.The familiarity level with medical consortia between he respondents varied significantly by the professional and technical title（P<0.05），while the support level for medical consortia did not（P>0.05）.According to the views of the respondents，the foremost benefit of the construction of medical consortia was the reduction of patients' medical costs（78.0%，584/749）；the first leading difficulty during the construction of medical consortia was that residents were unfamiliar with the medical consortium due to insufficient publicity（70.1%，525/749）；the primary suggestion for the construction of medical consortia was that higher level hospitals should regularly arrange doctors to community health service institutions to offer professional guidance（87.7%，657/749）.A total of 84.9%（626/737) of the respondents reported that their institutions had designated higher level hospitals receiving upward referrals，33.3%（245/735）of them reported that their institutions had received doctors from higher level hospitals for exchanging experience or offering professional guidance，53.5%（394/736） of them often referred patients often referred their patients to higher level hospitals，while 83.1%（608/732） of them occasionally or never received patients referred from higher level hospitals.The familiarity level with medical consortia in the respondents differed significantly by whether their institutions had designated higher level hospitals receiving upward referrals and had received doctors from higher level hospitals exchanging experience or giving professional guidance（P<0.05）.Conclusion　The overall awareness level of medical consortia among GPs in Hubei Province is relatively good，and the support level for the construction of medical consortia is relatively high.However，the publicity of the policies related to medical consortia should be strengthened and the cooperation and resource sharing between the members in the medical consortium should be improved.

Perception of Family Doctor System and Referral Behaviors among Specialists

FANG Shuai，HUANG Jiao-ling，LIANG Hong，ZHAO De-yu，LIU Shan-shan，HE Rong-rong，LU Wei，ZHANG Yi-min2

2018, 21(25): 3144-3148. DOI: 10.12114/j.issn.1007-9572.2018.25.022

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Objective　To investigate the perception of family doctor system and referral behaviors in specialists，and based on this，to analyze the effectiveness and challenges during the implementation of network-based platform of hierarchical diagnosis and treatment and collaborative referral mechanism concurring with the family doctor system construction.Methods　We enrolled all the clinical specialists（n=500） of a secondary grade A hospital located in a district of Shanghai selected representatively and surveyed them between July and August 2016 with a self-developed questionnaire of Specialist Assessment of the Implementation of Community Family Doctor System and Hierarchical Medical System consisting of demographic characteristics，perception of family doctor system，attitude toward the referrals from family doctors，and referral behaviors.The survey achieved a response rate of 77.2%（386/500）.Results　41.9% of the respondents（161/384） had a fair /good understanding of family doctor system and the responsibilities of family doctors，78 of whom（48.4%） thought the implementation of the system was conducive to the delivery of personalized，continued and comprehensive services，and 65（40.4%） thought the implementation of the system was beneficial to both the prevention and treatment of diseases.77.7%（150/193） of the respondents considered referrals made by family doctors were very/relatively necessary；96.4%（186/193） were quite/relative/fair willing to receive patients transferred from the primary care settings；44.1%（86/195） had received patients transferred by the contracted family doctor；66.2%（127/192） treated transferred and non-transferred patients the same；64.6%（248/384） and 63.0%（243/386）did not know whether the hospital that they worked had a referral department，network-based referral platform，respectively.Conclusion　The clinical specialists demonstrate a limited perception of the family doctor system and the responsibilities of family doctors，but most of them are willing to receive the transferred patients；The construction of the network-based general-special referral platform is still in the initial stage，and the referral mechanism has not fully played its due role.In view of this，specialists' level of perception of family doctor system should be improved and the general-special collaborative referral mechanism should be perfected.

Application of Reporting Guidelines on Medical Research Reports in Chinese Biomedical Journals and Its Influencing Factors

YAN Xing-min，DU Juan，LIU Tian-yi，PENG Xiao-xia

2018, 21(25): 3149-3154. DOI: 10.12114/j.issn.1007-9572.2018.25.023

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Objective　To analyze the application of reporting guidelines on medical research reports in Chinese biomedical journals and its influencing factors in order to provide a reference for the effective use of reporting guidelines on medical research reports and improve the quality of research reports.Methods　A total of 216 editors from Chinese biomedical journals were selected though the purpose sampling method.On the basis of searching literature and consulting experts，a questionnaire was designed from October 2017 to February 2018.The main contents of the questionnaire were the basic information of journals，the basic information of editors，the application situation of reporting guidelines on medical research reports and its influencing factors.A total of 216 questionnaires were distributed and 198 valid questionnaires were returned.The effective recovery rate was 91.7%.Results　Of the 198 journals，reporting guidelines were applied in 78 journals with an adoption rate of 39.4%.And 78（39.4%） journals used CONSORT Statement；19（9.6%） journals used STROBE Statement；18（9.1%） journals used STARD Statement；and 26（13.1%） journals used PRISMA Statement.The adoption rate of reporting guidelines in journals from different databases，the adoption rate of CONSORT Statement，and the adoption rate of PRISMA Statement were statistically significant（P<0.05）.And the adoption rate in core journals was higher than that in non-core journals（P<0.016 7）.In the 78 journals using reporting guidelines，the main problems encountered were authors did not cooperate well（66.7%，52/78） and strict requirements resulted in many manuscripts being unpublished，which affected the normal publication progress（64.1%，50/78）.Among 120 journals that did not adopt the reporting guidelines，the main possible reasons were strict requirements may result in many manuscripts being unpublished，which may affect the publication progress（65.8%，79/120） and authors did not cooperate well（55.8%，67/120）.Conclusion　At present，the adoption rate of reporting guidelines in biomedical journals still needs to be improved.The adoption rate in core journals is higher than that in non-core journals.The main factors affecting the application of reporting guidelines are authors cannot cooperate well and strict requirements，which may lead to many manuscripts being unpublished，affect the publication progress.It is recommended to strengthen the training of editors and medical students to promote the application of reporting guidelines and improve the quality of medical research reports.

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