Chinese General Practice

General Practice in Chinese Primary Health Care：Development and Challenges

YANG Hui

2018, 21(28): 3407-3410. DOI: 10.12114/j.issn.1007-9572.2018.28.001

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The Almaty-Ata Declaration has been in existence for 40 years since its publication in 1978，and the global health goal has changed from "health for all by the year 2000"（HFA） to universal health coverage（UHC），but primary health care（PHC） still is the basic way to achieve the goal of global health strategy. Based on the Almaty-Ata Declaration，this paper expounds the meaning of HFA and UHC，and sorts out the development history of PHC and general practice in China. It also proposes the challenges faced by China when developing general practice and hopes to provide a reference for practitioners and researchers in the field of general practice.

Ethical Responsibilities of General Practitioners in Tobacco Control

YAO Mi，XU Zhijie，LI Haixin，Joan Mitchell RN（EC），ZHANG Chen

2018, 21(28): 3411-3416. DOI: 10.12114/j.issn.1007-9572.2018.28.002

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In 2016，the World Health Organization（WHO）indicated a fact through its published report concerning global tobacco epidemic that there are approximately 6 million deaths per year due to tobacco induced diseases.Moreover，smoking causes serious economic burden to the society while endangering the physical and mental health of the residents.As the "gatekeeper" for the health of community-dwelling residents，general practitioners（GPs）play an important role in resolving the challenges of tobacco control.From a perspective of professional ethics，this article details the following ethical responsibilities that GPs should take in reducing tobacco use at the societal level：firstly，GPs shall make themselves as a good example of abandoning the use of tobacco absolutely；secondly，GPs shall endeavor to advise their patients to stop smoking and advocate to build tobacco-free communities；thirdly，GPs shall publicize the opinions of creating tobacco-free hospitals in the healthcare system，and list smoking cessation interventions as the routine medical services.Lastly，GPs shall make great efforts to promote the implementation of WHO FCTC at the national level in order to enhance the global tobacco control.

Implementation Progress in Performance Appraisal for the Staff of Community Health Institutions in China after New Health Reform　

YUAN Linlin，SHAO Yuchen，REN Lemeng，SUN Xiaojie

2018, 21(28): 3417-3422. DOI: 10.12114/j.issn.1007-9572.2018.28.003

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A performance appraisal system is to motivate providers to effectively promote the transformation of service model，improve quality and efficiency of healthcare and sustain strong performance，as well as to motivate the enthusiasm of medical staff.This article introduced several performance appraisal systems for the staff in Chinese community health institutions after the new health reform.We also discussed their strengths and limitations.As "health gatekeepers"，community health institutions need to upgrade the performance appraisal system to define job functions clearly，choose key performance indicators wisely，provide impactful incentives to key performers，use performance data to improve care，and improve the efficiency of appraisal process with new information technology "Internet+".

Contractual Rights and Obligations of the Providers and Recipients of the Contracted Family Doctor Services from the Perspective of Law

WANG Huanyan，GAO Lei，YE Yuan，QI Ji，YANG Xi，MA Yuanshuo，LIU Ming，FAN Lihua

2018, 21(28): 3423-3429. DOI: 10.12114/j.issn.1007-9572.2018.28.004

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Objective　To explore the contractual rights and obligations of the providers and recipients of the contracted family doctor services，increasing the perceptions of laws and regulations concerning the family doctor system implemented in China.Methods　The questionnaire surveys were conducted during July to August 2017.The enrolled participants consisted of 389 health workers（including members of the family doctor teams and health administration workers） taken from 12 community health centers（CHCs） in 4 provinces/municipalities（Zhejiang，Anhui，Beijing，and Shanghai） and 360 residents from the service areas of these CHCs.Two sets of self-developed questionnaires（one for the health workers and one for the residents，both including demographic data and perceptions of the contractual rights and obligations arising from the family doctor service contracts） were used in the survey.The contractual rights，obligations and responsibilities of the providers and recipients of contracted family doctor services identified by the surveys were reviewed and modified based on Delphi consultations with 20 experts.Results　Totaled 320 health workers returned responsive questionnaires.According to the survey results，of the 20 rights and 14 obligations listed in the questionnaire，"inviolability of personal safety"（89.7%，287/320），"have a safe and healthy working environment"（87.5%，280/320），and "request the contracted residents to provide true personal information"（87.5%，280/320） were ranked as the top three rights，and "concern and care for and respect patients"（90.3%，289/320） and "ensure the confidentiality of the patient's conditions and personal privacy，and only disclose the information to other people with the patient's consent"（90.0%，288/320） were ranked as the top two obligations．Totaled 342 residents returned responsive questionnaires.In accordance with the survey results，of the 7 rights and 10 obligations listed in the questionnaire，"obtain concern，care and respect from health workers"（91.5%，313/342），and "get the contractual services"（90.0%，308/342） were ranked as the top two rights，and "faithfully inform the contracted family doctor team the conditions of one's own"（96.5%，330/342），"timely inform the contracted family doctor team the changes in physical conditions of one's own"（95.3%，326/342），"respect the family doctor team"（91.8%，314/342），"maintain effective communication with the contracted family doctor team"（90.0%，308/342） were ranked as the top four obligations．With the help of Delphi expert consultations，we finally determined the contractual rights and obligations for the providers（16 rights and 15 obligations） and recipients（8 rights and 11 obligations） of the contracted family doctor services，and 7 contractual responsibilities that both of them should fulfill during the implementation of the family doctor service contracts.Conclusion　The residents and health workers signing the family doctor service contracts showed different perceptions of the contractual rights and obligations.Accordingly，the contractual rights，obligations and responsibilities for both contracting parties should be clearly defined.

Development and Effectiveness Analysis of a Community-based Family Doctor-centered Care Delivery Model

LU Ping，ZHU Jie，JIN Minjie，WENG Lili，LU Yuwei

2018, 21(28): 3430-3435. DOI: 10.12114/j.issn.1007-9572.2018.28.005

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During the implementation of a new round of comprehensive reform of community-based care system in Shanghai，Malu Community Health Service Center（MCHSC） rebuilt a family doctor team consisting of members recruited competitively，with defined service content and family doctor-centered internal management mechanism，offering services in a community-based family doctor-centered care delivery model via specific ways of working based on the conditions of the service area（including working in the family doctors' studio constructed specially）.Since this care delivery model was put into practice，MCHSC has achieved significantly increased rate of resident population and chronic disease patients signing a contract with the family doctor team，obviously enhanced rate of visiting，substantially improved basic public health service quality indicators，social indicators for evaluating the performance of family doctors，allocation status of general practitioners and research capabilities.The community-based family doctor-centered care delivery model is of vital significance in giving full play to the role of the family doctor as a gatekeeper contributing to primary care quality assurance and healthcare cost control，advancing healthcare seeking in a hierarchical manner and promoting residents' health.

Associations Analysis of Work-related Quality of Life，Professional Identity and Presenteeism among Family Doctors Based on PLS-SEM

LU Huimin，YANG Dandan，MIAO Chunxia，HUANG Qi，GAO Xiuyin

2018, 21(28): 3436-3442. DOI: 10.12114/j.issn.1007-9572.2018.28.006

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Objective　To explore the associations between work-related quality of life，professional identity and presenteeism，providing a reference for improving the working efficiency of family doctors.Methods　By cluster sampling，we enrolled all the family doctors（n=400） from 33 community health centers（CHCs） delivering family doctor services sampled representatively from Yunlong District，Quanshan District，Gulou District，Tongshan District，Pizhou City，Pei County and Feng County of Xuzhou City （4-6 CHCs were selected from each district/county/county-level city）．Then，from November 2017 to March 2018，we conducted a survey in the sampled family doctors with a self-developed questionnaire consisting of demographic characteristics，Chinese version of Work-related Quality of Life（C-WRQoL） Scale，Professional Identity Scale（PIS），Chinese version of Stanford Presenteeism Scale （C-SPS-6）．Totaled 324（81.0%） returning responsive questionnaires were finally included.Multiple linear regression and partial least squares structural equation modeling （PLS-SEM） were used to investigate the associations between work-related quality of life，professional identity and presenteeism and construct the model，respectively.Results　The subscale scores of the C-WRQoL Scale and the CIS were negatively linearly correlated with the total score of C-SPS-6 （P<0.01）．The subscale scores（except the score of stress at work） of the C-WRQoL Scale were positively linearly correlated with the total score of PIS （P<0.01）．Scores of 4 subscales of the C-WRQoL Scale （job and career satisfaction，home-work interface，stress at work，control at work），and scores of 3 subscales of the PIS（tendency of professional behaviors，professional value，professional belongingness） were the factors influencing the total score of C-SPS-6.The work-related quality of life had a positive effect on professional identity with a path coefficient of 0.629，but had a negative effect on the presenteeism with a path coefficient of -0.343；the professional identity produced a negative effect on presenteeism，with a path coefficient of -0.431；the work-related quality of life affected the presenteeism through the intermediary role of professional identity，with an overall effect of -0.614.Conclusion　Family doctors have a high subjective evaluation of work-related quality of life，which has a positive impact on improving their professional identity，and further reduces their productivity loss due to presenteeism.

Role of General Practitioners in the Whole Course of Care for Congenital Heart Disease in Children

LIAN Siqing1，2，ZHENG Jiatang1，2，DI Na1，2，YAN Hui3*，TAO Xia1，2，4

2018, 21(28): 3443-3446. DOI: 10.12114/j.issn.1007-9572.2018.28.007

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A congenital heart disease （CHD），is a congenital malformation of heart，coronary vessels，and of the connection between the heart and adjacent vessels.It has become the most common birth defect in China，and the leading cause of death among children under 5 years of age.With the development of general practice and the hierarchal medical system，general practitioners （GPs） are increasingly tending to serve populations of all age groups.We explored the important role of GPs in the care （including consultation，diagnosis，treatment and follow-up management） of CHD in children at different disease management stages，which would be meaningful for the improvement of quality of life in this population.

Influencing Factors and Countermeasures of the Development of Contracted Community-based Family Doctor Services from Family Doctors' Perspective in Hubei Province

HE Zhe，SHAO Piaopiao，SHAO Tian，LONG Chengxu，FENG Zhanchun

2018, 21(28): 3447-3452. DOI: 10.12114/j.issn.1007-9572.2018.28.008

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Objective　To investigate the demographic characteristics，working status，job satisfaction，awareness of contracted family doctor services （CFDSs） and of the influencing factors for the delivery of such services among the members of community-based family doctor teams.Methods　This study was conducted using in-depth and key informant interviews about the barriers for the implementation of CFDSs with 30 members of family doctor teams and a survey with a self-developed questionnaire among 558 medical professionals delivering CFDSs from 14 community health centers located in three cities of Wuhan，Xiangyang and Yichang combined with a literature review.Results　Most（46.1%） of the 558 family doctor team members had junior college degree.The average monthly income was about 4 000 yuan for those from Yichang and Wuhan，but 2 355.8 yuan for those from Xiangyang.The median number of professional trainings per year was 6.50，2.00，2.00 times for those from Yichang，Wuhan，Xiangyang，respectively.61.3% of the participants showed a great interest in job，but only 39.8% of them showed satisfaction with the level of social recognition won by family doctor as an occupation，and only 35.5% of them presented satisfaction with the workload.Even worse，less than 41.0% of them were satisfied with the staffing of the team，office environment，and medical equipment allocation.Over 70% of the participants thought that poor propagation of CFDSs，high level of residential mobility，insufficient family doctors，inadequate residents' awareness of CFDSs，and heavy workload were the factors hindering the successful implementation of CFDSs.Conclusion　In order to better promote the delivery of CFDSs，the recruitment of and professional trainings about CFDSs for community health workers should be improved，the service performance of community health organizations should be advanced，the performance evaluation mechanisms for family doctors should be perfected，and the propagation of the policies related to CFDSs should be strengthened.

Evaluation of Home Health Services by General Practitioners in Beijing：a Qualitative Study

ZHAO Chunyan，LIU Yingjie，SHAO Shuang，WANG Meirong，DU Juan

2018, 21(28): 3453-3458. DOI: 10.12114/j.issn.1007-9572.2018.00.115

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Objective　To investigate the current situation and existing problems of home health services in Beijing，so as to provide suggestions for the sustainable development of home health services.Methods　During the period between January and February，2017，a total of 12 community health service institutions were selected from 6 urban districts of Beijing，of an institution from each of Dongcheng，Xicheng and Shijingshan districts，and 3 institutions from each of Haidian，Chaoyang and Fengtai districts，and 10 institutions were selected from suburban districts of Beijing by purposive sampling，of 4 institutions from Changping district，and 2 institutions from each of Tongzhou，Shunyi and Fangshan districts.A general practitioner was sampled from each of these 22 community health service institutions，and the general practitioners were divided into the urban group（n=12）and suburban group（n=10）for interviews.Focus-group interviews were done for data collection，and content analyses were performed for data management.Results　Home health services included family hospital beds，home nursing，home visits，and home health consultation.As the main body of home health services，general practitioners' service levels and professional capability directly affected the quality of home health services.Because of the high demand of home nursing，community nurses had the greatest workload in all home health services.Following analyses of the focus-group interview data，five themes were extracted，including（1）home health services could meet the urgent needs of home medical and nursing services for the elderly，notably the disabled elderly；（2）home health services have potential medical disputes and risks；（3）home health services lack perfect laws and operational guidelines；（4）healthcare workers have insufficient enthusiasms for home health services；and（5）currently，the ability of home health services is limited，and the service level varies between the urban and suburban regions.Conclusion　Home health services in Beijing meet the demand of health services for the disabled elderly；however，it is necessary to gradually improve the supporting management system and the guarantee mechanism，so as to further promote home health services.

YANG Duoer，TANG Shaoliang

2018, 21(28): 3459-3466. DOI: 10.12114/j.issn.1007-9572.2018.28.010

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Objective　To study the current situation of health-related quality of life of patients with chronic diseases in Sichuan，Hebei and Gansu and to find out its influencing factors by Tobit model.Methods　 A total of 745 patients with chronic diseases were selected from 9 hospitals in Sichuan，Hebei and Gansu provinces by stratified sampling and random sampling in May，July and November 2017.Questionnaires were used to collect information about patients' household registration，gender，age，height，body mass，marital status，occupation，medical insurance type，financial sources，physical examination in the past year，and chronic diseases.The EQ-5D-5L scale was used to investigate the patients' health-related quality of life.Health-related quality of life （HRQOL） of chronic disease patients with different characteristics was compared，and Tobit regression model was used to analyze the influencing factors of HRQOL.Results　A total of 745 questionnaires were distributed，and 721 recovered，with 96.8% of recovery rate.Health utilities index of chronic diseases in Sichuan，Hebei and Gansu provinces were （0.75±0.28）．Difficulties of five dimensions were ranked by severity：pain or discomfort （72.7%，524/721），anxiety or depression （61.6%，444/721），daily activities （39.5%，285/721），mobility （38.8%，280/721） and self-care （35.4%，255/721）．There were significant differences in health-related quality of life （daily activities，pain or discomfort，anxiety or depression） among patients with chronic diseases in Sichuan，Hebei and Gansu provinces （P<0.05）．Tobit model analysis showed that age，marital status，occupation，and types of chronic diseases （respiratory diseases，cerebrovascular diseases and cancer） were the influencing factors of health-related quality of life （P<0.05） of patients with chronic diseases in Sichuan，Hebei and Gansu；marital status and economic sources were the influencing factors of health-related quality of life of patients with chronic diseases in Sichuan （P<0.05）; age，BMI type，marital status，occupation，and medical insurance type were the influencing factors of health-related quality of life of patients with chronic diseases in Hebei （P<0.05）；age，body mass index（BMI）type，marital status，occupation，medical insurance type，and types of chronic diseases （respiratory system disease，cerebrovascular disease and cancer） were the influencing factors of health-related quality of life of patients with chronic diseases in Gansu （P<0.05）．Conclusion　Patients with chronic diseases in Sichuan，Hebei and Gansu provinces had poor health-related quality of life in the dimensions of "pain or discomfort" and "anxiety or depression".Age，marital status，occupation，types of chronic diseases （respiratory diseases，cerebrovascular diseases and cancer） are the main factors affecting the health-related quality of life of patients with chronic diseases in three provinces.

Clinical Characteristics of Acute Pancreatitis among Diabetic Patients

WANG Beibei，LIAO Shanying，BU Xiaoling，NIE Shengli，SHA Weihong，MA Juan*

2018, 21(28): 3467-3470. DOI: 10.12114/j.issn.1007-9572.2018.00.044

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Objective　 To investigate the clinical characteristics of acute pancreatitis（AP） among patients with diabetes mellitus（DM）．Methods　We enrolled 329 cases of AP from Guangdong General Hospital from 2013 to 2016，including 80 with a history of DM（DM with AP group）and 249 without（simple AP group）. Based on reviewing the medical records，we collected the clinical data about sex，age，past medical history，etiology，levels of triacylglycerol（TG） and total cholesterol（TC），length of stay（LOS），incidence of mortality，severity levels of AP evaluated by the Chinese Guidelines for the Management of Acute Pancreatitis（Shanghai，2013） and severity scores of conditions〔comprehensively evaluated by Ranson's score，APACHE-Ⅱ score，bedside index for severity in acute pancreatitis （BISAP） score，and modified CT severity index（MCTSI）〕，complications and compared them between the groups. Results　 Compared with DM with AP group，simple AP group had lower rate of patients with a history of previous pancreatitis，and lower levels of TG and TC（P<0.05）. The distribution of etiologies differed significantly between the two groups（P<0.05）.However，two groups showed no significant differences in the distribution of sex，age，LOS，mortality，severity levels of AP and severity scores of conditions（assessed by Ranson's score，APACHE-Ⅱscore，BISAP score，and MCTSI），and incidence of the aforementioned local and systemic complications（P>0.05）. Conclusion　Diabetic status has little effect on the severity of AP，the incidence of local and systemic complications caused by AP，the mortality as well as LOS.

Risk Factors of High Serum Uric Acid Level in Patients with Chronic Kidney Disease　

SUN Na，WANG Xichao，ZHANG Wenyu，LIU Ying，SONG Xinyuan，CHANG Wenxiu

2018, 21(28): 3471-3478. DOI: 10.12114/j.issn.1007-9572.2018.28.012

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Objective　To characterize the risk factors of high serum uric acid level in patients with chronic kidney disease（CKD）．Methods　321 CKD patients were sampled from Department of Nephrology，Tianjin First Central Hospital from December 2012 to December 2015，including 161 with high serum uric acid level and 160 with low uric acid level（high or low serum uric acid level was defined as greater or lower than the median level of 379.00 μmol/L）．They were assigned to eGFR≥60 ml·min-1·（1.73 m2）-1 group （n=156） and eGFR<60 ml·min-1·（1.73 m2）-1 group （n=165）by the eGFR used for CKD diagnosis.Logistic regression analyses were performed to characterize the risk factors of high serum uric acid level.Results　Multivariate stepwise Logistic regression analysis showed that male，high body mass index （BMI），low eGFR，high blood urea nitrogen（BUN） were risk factors of high serum uric acid level in CKD patients（P<0.05）；high BMI，low educational level，low eGFR，and high TG were risk factors of high serum uric acid level in male patients；high BUN and TG were the risk factors of hyperuricemia in female patients（P<0.05）；male，high BMI were the risk factors of high serum uric acid level in CKD patients with eGFR≥60 ml·min-1·（1.73 m2）-1（P<0.05）；male，older age and high BMI，high diastolic blood pressure and high BUN were the risk factors of high serum uric acid level in CKD patients with eGFR<60 ml?min-1?（1.73 m2）-1（P<0.05）．Conclusion　The risk factors of high serum uric acid level in CKD patients differed significantly by sex and eGFR level，suggesting that preventive and treatment measures should be taken according to the characteristics of the patients.
Chronic kidney disease；Hyperuricemia；Risk factors；Glomerular filtration rate

Effect of Home Visits Based on Comprehensive Geriatric Assessment by Community Health Workers on the Quality of Life of Elderly Patients with Hypertension　

LIU Yunyun，CHEN Hong，LIU Guolian，NIU Meng，HE Xuwen，FENG Yutao

2018, 21(28): 3478-3484. DOI: 10.12114/j.issn.1007-9572.2018.28.013

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Objective　To explore the effect of home visits based on Comprehensive Geriatric Assessment （CGA） by community health workers on the quality of life of elderly hypertensive patients.Methods　We randomly selected 78 elderly hypertensive patients from 2 community health stations sampled conveniently from Yinchuan on the day of undergoing physical examination，39 of whom from one community health station received a 6-month home visits based on CGA（intervention group），while other 39 ones from other community health station received a 6-month conventional home visits（control group）．Quality of life and blood pressure were measured before the intervention，and at the end of the third and sixth months of intervention.Results　Totaled 71 patients including 35 in the intervention group and 36 in the control group finished the intervention. The mean systolic blood pressure（SBP）and diastolic blood pressure（DBP） were similar in both groups before and after intervention（P>0.05）. The SBP and DBP differed significantly between the groups over the intervention time（P<0.05）. SBP was affected obviously by the interaction effect of the type and duration of intervention （P<0.05） while DBP was not（P>0.05）. The mean scores of the domains of physical health, psychological health, social relationships, and environment were similar in both groups before intervention（P>0.05）, but at the end of the intervention, all of them improved significantly in the intervention group（P<0.05） except for the mean scores of environment（P>0.05）.Conclusion　Home visits based on CGA by community health workers is conducive to effectively controlling blood pressure and improving the quality of life of elderly hypertensive patients.

Relationship between Nutritional Status and Severity of Pneumonia in Elderly Patients with Community-acquired Pneumonia　

KANG Yu，FANG Xiangyang，HOU Yuanping，ZHANG Ying，CHEN Xiuli，WANG Xiaojuan

2018, 21(28): 3485-3489. DOI: 10.12114/j.issn.1007-9572.2018.28.014

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Objective　This study aims to determine whether nutritional status is a risk factor contributing to the severity of pneumonia in elderly patients with community-acquired pneumonia （CAP） and to investigate the predictive value of mini nutritional assessment （MNA） in severe pneumonia.Methods　A total of 131 elderly patients with community-acquired pneumonia hospitalized in the General Department of Beijing Chao-yang Hospital （from 2016 to 2017） were enrolled.All patients were divided into non-severe pneumonia group （n=77） and severe pneumonia group （n=54）．The pneumonia data including clinical factors and laboratory data were recorded.Multivariable Logistic stepwise regression analysis was performed to investigate the risk factors of patients with severe pneumonia，and the receiver operating characteristic（ROC） curve to assess the predictive value of MNA score in severe pneumonia.Results　Of 131 elderly patients with CAP，54 subjects were severe pneumonia （41.2%），and 45 had malnutrition （34.4%）．Age，incidence of malnutrition，proportion of CAP with chronic obstructive pulmonary disease，proportion of CAP with chronic heart failure，proportion of CAP with cerebrovascular disease，oxygen partial pressure，serum creatinine level and blood urea nitrogen level in two groups were significantly different （P<0.05）．According to the results of multivariable Logistic stepwise regression analysis，malnutrition，CAP combining chronic obstructive pulmonary disease and CAP combining chronic heart failure were risk factors of severe pneumonia （P<0.05）．The accuracy of MNA score predicted severe pneumonia was 0.804 〔95%CI（0.724，0.884）〕 as measured by the area under the ROC curve.The best cut-off point in MNA score was 17.5 （17 for malnutrition） and the sensitivity and specificity rate were 86.3% and 66.7%.Conclusion　Malnutrition may be considered as an independent factor of severe pneumonia in elderly patients with community-acquired pneumonia，and MNA score has predictive value for severe pneumonia.

Associated Factors for Blood Pressure Variability in a Community-dwelling Hypertensive Population in Ningxia　

CUI Jizhi，MA Yuhua，LI Huajie，LIU yuan，ZHANG Ping，LIANG Peifeng

2018, 21(28): 3490-3494. DOI: 10.12114/j.issn.1007-9572.2018.28.015

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Objective　To investigate the associated factors for blood pressure variability（BPV） in a community-dwelling hypertensive population in Ningxia.Methods　From January 2015 to January 2017，605 patients with hypertension were selected from a community in Yinchuan City．The data regarding sex，age，BMI，minzu，physical labor intensity，tobacco and alcohol consumption，daily salt intake，and exercise frequency were collected and 24-hour dynamic blood pressure monitoring was performed in them．The BPV was analyzed by sociodemographic characteristics and its associated factors were explored by multiple linear regression.Results　The standard deviation of 24-hour systolic blood pressure（24 hSBPSD），standard deviation of 24-hour diastolic blood pressure（24 hDBPSD），and standard deviation of 24-hour mean arterial pressure（24 hMAPSD） did not differ significantly between the patients by sex，age，BMI，minzu，alcohol consumption and exercise frequency（P>0.05）．Although 24 hDBPSD did not vary obviously between the patients by physical labor intensity（P>0.05），24 hSBPSD and 24 hMAPSD were much less in those with moderate-intensity physical labor compared with those with light-intensity physical labor（P<0.05）．24 hSBPSD changed significantly between the patients by tobacco consumption（P<0.05） but 24 hDBPSD and 24 hMAPSD did not（P>0.05）．Those with high daily salt intake（>6 g/d） had much higher 24 hSBPSD，24 hDBPSD and 24 hMAPSD than those with low daily salt intake（≤6 g/d，P<0.05）．Multiple linear regression analysis revealed that physical labor intensity，tobacco consumption，daily salt intake and exercise frequency were associated factors for 24 hSBPSD（P<0.05）；sex，tobacco consumption and daily salt intake were associated factors for 24 hDBPSD（P<0.05）；age，decreased physical labor intensity and daily salt intake were associated factors for 24 hMAPSD（P<0.05）．Conclusion　Sex，age，physical labor intensity，tobacco consumption，daily salt intake and exercise frequency are the factors influencing short-term BPV.

Prevalence and Associated Factors of Subclinical Atherosclerosis in Adults under 35 Years Old in Beijing　

LIU Kuo，GUO Xiuhua，YANG Kun，HUANG Dan，XU Junfeng

2018, 21(28): 3495-3499. DOI: 10.12114/j.issn.1007-9572.2018.28.016

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Objective　To investigate the prevalence and associated factors of subclinical atherosclerosis in adults under 35 years old in Beijing.Methods　A total of 1 317 adult physical examinees under 35 years old were recruited from a grade A tertiary hospital in Beijing between 2007 and 2012.Data on demographic characteristics and laboratory findings and so on were collected and compared by sex.Brachial-ankle pulse wave velocity （baPWV） and ankle brachial index （ABI） were also obtained and compared by sex and age group.Multiple linear regression analysis was performed to explore the associated factors of baPWV.Results　Of the participants，males were older and higher on average，and they had greater average weight，larger average waist circumference，higher average BMI，systolic blood pressure （SBP），diastolic blood pressure （DBP），fasting blood glucose （FBG），total cholesterol （TC），triglyceride （TG），low-density lipoprotein cholesterol （LDL-C），and uric acid （UA） levels，higher prevalences of alcohol consumption and hypertension，but lower average high-density lipoprotein cholesterol （HDL-C） levels compared with females （P<0.001）．The prevalences of smoking and diabetes were similar in males and females （P>0.05）．baPWV increased significantly with age either in males or females （P<0.001）．Males showed much higher average baPWV and ABI than females in each age group （P<0.05）．The overall prevalence rate of baPWV>900 cm/s was 93.92% （1 237/1 317）．The prevalence rate of baPWV>900 cm/s increased significantly with age in females （P<0.05）．The overall prevalence of baPWV>1 400 cm/s was 4.71% （62/1 317）．The prevalence of baPWV>1 400 cm/s increased obviously with age in males （P<0.05）．The prevalences of baPWV>1 400 cm/s were higher in males than in females in age groups of 26-30，and 31-35 （P<0.001）．Multiple linear regression analysis demonstrated that age，sex，SBP，DBP，FBG，TG and HDL-C were factors associated with baPWV （P<0.05）．Conclusion　The subclinical atherosclerosis in adults under 35 years old in Beijing was mainly manifested by baPWV abnormality，with a prevalence of 4.71%，which was mainly influenced by blood pressure.

How to Train General Practitioners during the Implementation of the Healthcare Reform Launched in 2009 in China：a Report from a Symposium　

ZENG Xuejun，SHA Yue，WANG Fang，SHEN Qiang，WANG Hui，CAO Guili

2018, 21(28): 3500-3507. DOI: 10.12114/j.issn.1007-9572.2018.28.017

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We invited the representatives from several health institutions to share their experiences in the training of general practitioners（GPs） during the implementation of the healthcare reform launched in 2009 and invited a representative physician to share her learning from the GP training.ZENG Xuejun，Director of Department of General Internal Medicine，Peking Union Medical College Hospital，and Dean of Department of General Practice，Peking Union Medical College（PUMC） introduced their training goals for GPs and experiences in the building of general practice teaching workforce.SHA Yue，an associate professor of Department of General Practice，PUMC made a summary of PUMC's training of GPs from three aspects（college education，post-graduation education，continuing education）．WANG Fang，Director of Dongcheng District Community Health Service Management Center，summed up the problems existing in training GPs in Beijing's Dongcheng District and gave the corresponding countermeasures.SHEN Qiang，Deputy Director of Dongcheng District Community Health Service Management Center，introduced the web-based teaching mode applied in Beijing's Dongcheng District for training GPs.WANG Hui，Director of Chaoyang District Gaobeidian Community Health Center，offered an overview of their experience in the improvement of the service capabilities.CAO Guili，a physician from Dongcheng District Community Center，summarized her learning from the training co-held by Peking Union Medical College Hospital and Dongcheng District Community Health Service Management Center.It is hoped that the above can provide a reference for the implementation of training programs for GPs across the regions of China.

Demographic and Professional Analysis of the General Practitioner Workforce Receiving "5+3 " Model of Standardized Training in Shanghai's Pudong New Area　

SHU Zhiqun1，2，JING Limei3*，LI Ming4，HUANG Xuan，DU Zhaohui，XIA Qingshi，ZHANG Shengbing，JING Yuan，LOU Jiquan

2018, 21(28): 3508-3512. DOI: 10.3969/j.issn.1007-9572.2018.00.042

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Objective　To analyze the general practitioner workforce receiving "5+3" model of standardized training in Shanghai's Pudong New Area from the demographic and professional perspectives.Methods　We conducted this study in a cohort of 1 469 registered general practitioners（GPs） from 46 community health centers in Shanghai's Pudong New Area in 2017.By reviewing the relevant studies，and analyzing the results of survey conducted in the institutions involved in the study，we collected the data about demographic characteristics and theoretical and practical examinations and compared them between GPs who received "5+3 " model of standardized training and those did not.Results　202（13.8%） became registered GPs after receiving "5+3 " model of standardized training，and all of them（100.0%） were found with a first degree of undergraduate or above.Furthermore，64（31.7%） of them had an intermediate professional and technical title；94（46.5%） were from the community health center located in urban areas.Among the 1 431 took the theoretical examination，GPs receiving "5+3 " model of standardized training achieved much higher total score and scores in domains of introduction of general practice，tumor and rehabilitation and maintaining good health with Chinese medicine compared with other GPs（P<0.05）.Among 586 took the practical examination，GPs receiving "5+3 " model of standardized training obtained much higher total score and scores in performing urethral catheterization as well as suturing a wound compared with other GPs （P<0.05）.Conclusion　Compared with other types of GPs，GPs receiving "5+3 " model of standardized training in this area demonstrated better performance in professional examinations.Moreover，the development of general practitioner workforce receiving "5+3 " model of standardized training shows a rapid trend.However，the number of such type of GPs is need to be increased to meet the residents' demands.Therefore，it is suggested to employ more GPs，and improve GPs' qualities by strengthening the "5+3 " model of standardized training.

Economic Benefit Analysis of Risk-based Screening of Pancreatic Cancer　

XU Kangjie，JIANG Hua，LIU Nana，XIAO Yue，GONG Xin，BO Xiaojie，WANG Chunxu，CHEN Ning，GENG Shasha，WANG Chaoxin

2018, 21(28): 3513-3517. DOI: 10.12114/j.issn.1007-9572.2018.28.019

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Objective　To explore the economic benefits of risk-based screening of pancreatic cancer，providing a new way for screening of pancreatic cancer.Methods　Literature review was used to identify the risk factors of pancreatic cancer： using "pancreatic cancer" and "risk factors" or "etiology" as the search terms，we searched the electronic databases of CNKI，Wanfang Data Knowledge Service Platform and Web of Science for studies concerning the risk factors of pancreatic cancer collected from their inception to February 28，2018.We recorded and counted the number and reference rate of risk factors of pancreatic cancer extracted from the eligible studies．Models established with the data of risk-based screening of pancreatic cancer in Shanghai's Pudong New Area with CA19-9 assay were used for the economic analysis.Results　Totaled 121 studies were included，involving 19 risk factors of pancreatic cancer.As the two leading risk factors，smoking〔71.9%（87/121）〕 and diabetes〔59.5%（72/121）〕produced positive additive interaction on the incidence of pancreatic cancer〔SI=1.989，AOR（95%CI）=29.943（5.358，167.332）〕，we incorporated them in the pancreatic cancer screening conducted in Shanghai's Pudong New Area.Compared with the whole-population screening，the costs of screening of pancreatic cancer in smokers，diabetics，smokers with diabetes decreased by 90.462%，83.523%，96.377%-96.922%，respectively，while the efficiencies of these three types of screening increased by 948.4%，506.9%，2 894.3%，respectively. Conclusion　Risk-based screening of pancreatic cancer is of great significance.Screening of pancreatic cancer based on the combination of risk factors provides a new way of pancreatic cancer screening，it can narrow the target populations quickly and accurately，thereby the screening of pancreatic cancer in a region can be completed in a shorter period of time with lower costs.

Utilization of Health Services in Hypertensive Patients Enjoying 4 Different Types of Basic Medical Insurance：a Comparative Analysis　

MA Jing，XU Aijun

2018, 21(28): 3518-3522. DOI: 10.12114/j.issn.1007-9572.2018.00.072

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Objective　To explore the use of health services in hypertensive patients participating in 4 different types of basic medical insurance 〔urban employee basic medical insurance（UEBMI），urban resident basic medical insurance（URBMI），new rural cooperative medical scheme（NRCMS），and urban and rural residents' basic medical insurance（URRBMI）〕.Methods　The data were derived from the monitored results of healthcare utilization among residents，a pilot survey initiated by the Statistics Information Center，National Health and Family Planning Commission of the PRC from July to December 2016.We enrolled 1 595 hypertensive patients who enjoyed 4 different types of basic medical insurance，and collected and compared their data concerning sociodemographic characteristics，prevalence of disease，and utilization of health services during the consecutive six-month monitoring period.Results　Among the participants，1 565（98.1%） enrolled in the basic medical insurance，including 896 enjoying UEBMI，88 enjoying URBMI，467 enjoying NRCMS and 114 enjoying URRBMI.The rate of seeking healthcare，rate of requiring treatment but receiving no treatment，length of stay differed significantly between the groups（P<0.05）．Moreover，the average outpatient treatment cost，average amount of self payment for outpatient treatment，average inpatient treatment cost，average amount of self payment for inpatient treatment varied obviously between the groups（P<0.05）．Furthermore，4 groups showed significant differences in the choice of medical institutions during seeking outpatient treatment（P<0.05）．In particular，the rate of seeking outpatient treatment in grassroots medical institutions for participants enjoying UEBMI，URBMI，NRCMS and URRBMI was 47.7%（299/627），68.5%（37/54），84.6%（154/182），78.4%（29/37），respectively，with significant differences（P<0.05）．However，the rate of receiving inpatient treatment as well as the choice of medical institutions for seeking inpatient treatment showed no significant differences between the groups（P>0.05）．Conclusion　The majority of hypertensive patients enrolled in the basic medical insurance.High level of utilization of health services was found in those enjoying UEBMI or URBMI，while the level of utilization of health services should be improved in those enjoying NRCMS and URRBMI.Hypertensive patients enjoying UEBMI demonstrated lower rate of seeking healthcare in grassroots medical institutions.

Development，Reliability and Validity of Evaluation Questionnaire of Family Management for Patients with COPD　

CHEN Binbin，ZHANG Qing

2018, 21(28): 3523-3526. DOI: 10.12114/j.issn.1007-9572.2018.28.021

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Objective　To develop a family management evaluation questionnaire for patients with chronic obstructive pulmonary disease（COPD） and test its reliability and validity.Methods　Based on the framework of knowledge-attitude-practice theory，the evaluation questionnaire of family management for COPD patients was prepared through literature review，expert consultations and other methods.A total of 245 COPD patients admitted to the outpatient clinics and respiratory wards in four tertiary Level A general hospitals of Tianjin from December 2016 to April 2017 were sampled for a questionnaire survey by convenience sampling method，and 10 days later，30 subjects among them were randomly selected for reliability retest.Content validity index （CVI），exploratory factor analysis，Pearson correlation coefficient，Cronbach's α coefficient and test-retest reliability coefficient were used to screen items and evaluate the reliability and validity of the questionnaire.Results　The final questionnaire consists of 3 dimensions （COPD family management knowledge，family management behavior，and family management attitude） and 44 items.The content validity index of each item （I-CVI） in the questionnaire reached 0.930 or more，and CVI of the questionnaire was 0.997；exploratory factor analysis was used to extract 3 common factors explained 60.143% of the total variance；the total Cronbach's α coefficient of the questionnaire was 0.959，and the test-retest coefficient was 0.938；the Cronbach's α coefficient of 3 dimensions was 0.943-0.953，and test-retest reliability 0.814-0.968.Conclusion　The family management evaluation questionnaire for COPD patients was proved to be reliable and valid.It can be used as a suitable tool to evaluate the level of family management in COPD patients.

Development，Reliability and Validity of Community Health Service Demand Questionnaire for Patients with COPD Based on Omaha System　

HUANG Yaqi，YU Hangqing，LIU Fang，ZHANG Qing

2018, 21(28): 3527-3532. DOI: 10.12114/j.issn.1007-9572.2018.28.022

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Objective　To develop a questionnaire with good reliability and validity to evaluate the demand of community health service for patients with chronic obstructive pulmonary disease （COPD） systematically.Methods　The questionnaire was based on the Omaha System.Literature review，group discussion and Delphi consultation were used to develop the initial questionnaire and a convenience sampling method was adopted to select patients with COPD in the Department of Respiration from 4 Grade Ⅲ Level A comprehensive hospitals in Tianjin from December 2016 to April 2017.A formal questionnaire was formed by using critical ratio （CR） method，correlation analysis，content validity index （CVI），exploratory factor analysis，retest reliability，and Cronbach's alpha coefficient to test its reliability and validity.Results　Through literature review，group discussion and expert consultation，the initial questionnaire was formed by 4 dimensions and 34 items.A total of 187 questionnaires was distributed and 177 valid questionnaires were collected，with an effective recovery rate of 94.7%.The results of the project analysis showed that the critical ratio value （CR value） of each item was 2.64 to 9.21 （P<0.05）．Except for A1 （reducing the medical service price related to COPD treatment in community hospitals），A3 （increasing the proportion of COPD drug reimbursement），and A4 （increasing the common drug type of COPD in community hospitals），the Pearson correlation coefficient of items and the total score （r value） were all >0.4.Content validity index of items （I-CVI） were 0.93-1.00，average content validity index of scale （S-CVI/Ave）=0.99.Four common factors were extracted after deleting one item in factor analysis，with a cumulative variance contribution rate of 55.76%.A total of 33 items of community health service demand questionnaire for patients with COPD was determined and divided into 4 dimensions：environmental requirements （9 items），psychosocial needs （6 items），physiological needs （6 items），and health-related behavior needs （12 items）．The overall test-retest reliability of the questionnaire was 0.88，of which each dimension was 0.76 to 0.90.The overall Cronbach's alpha coefficient of the questionnaire was 0.91，of which each dimension was 0.75 to 0.90.Conclusion　The community health service demand questionnaires for patients with COPD presents good reliability and validity.It can be served as an effective assessment tool for community health service agencies.

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