Chinese General Practice

Pediatric Resources and Medical Service Delivery Capability in Primary Healthcare Institutions in China

QIN Jiangmei，LIN Chunmei，ZHANG Lifang，ZHANG Yanchun，DONG Yali

2019, 22(13): 1511-1515. DOI: 10.12114/j.issn.1007-9572.2019.00.214

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Background The outbreak of influenza in the spring of 2018 revealed the vulnerability of the capability for delivering pediatric services in primary care system in China.Opinions on Strengthening the Reform and Development of Pediatric Healthcare Services issued in 2016 required that at least 1 general practitioner should be equipped to each township hospital or each community health facility to provide standardized essential pediatric medical care.Therefore，pediatric resources and capacity for delivering pediatric services in primary healthcare institutions deserve high concern.Objective To study pediatric resources distribution and capacity for providing pediatric services in primary healthcare institutions in China.Methods Data were collected from 2 volumes of China's Health Statistics Yearbook（2011—2012），5 volumes of China's Health and Family Planning Statistical Yearbook（2013—2017），and China's Hygiene and Health Statistical Yearbook 2018.Proportions of numbers of pediatric departments，pediatric beds，practising pediatric physicians（assistants），pediatric emergency visits，and pediatric discharges in primary healthcare institutions（including community and township health centers），and in healthcare institutions were analyzed.Results In 2017，among all the community health centers，those delivering pediatric services accounted for 25.60%，and numbers of pediatric beds，practising pediatric physicians（physician assistants），pediatric emergency outpatient visits，and pediatric discharges owned by them accounted for 2.69% of the total beds，1.32% of the total physicians（physician assistants），2.73% of the total emergency outpatient visits，and 3.22% of the total discharges，respectively.During the same year，of all the township health centers，those offering pediatric services made up 50.84%，and numbers of pediatric beds，practising pediatric physicians（physician assistants），pediatric emergency outpatient visits，and pediatric discharges owned by them occupied 7.41% of the total beds，1.47% of the total physicians（physician assistants），7.64% of the total emergency outpatient visits，and 7.71% of the total discharges，respectively.During the period of 2010—2017，among all the primary healthcare institutions，the percentage of pediatric resources held by those delivering pediatric services and their capability level for delivering such services generally demonstrated year-over-year downward trends.Moreover，among all the healthcare institutions，the percentage of pediatric resources held by primary healthcare institutions delivering pediatric services and their capability level for delivering such services also showed year-over-year downward trends on the whole.Conclusion The capability level for delivering pediatric services in primary healthcare institutions is unsatisfied.In view of this，improvement strategies are suggested as follows：incorporating the enhancement of pediatric resources allocation and pediatric service delivery capability in primary healthcare institutions into the overall health development programs of the local area，actively promoting the construction of pediatric alliance，increasing the pediatric service capacity level of general practitioners and introducing pediatric professionals to primary care when necessary，increasing the number and kinds of pediatric medicines in primary healthcare institutions and strengthening the guidance on safety of drug use in children.

Conceptual Framework Model of Performance Evaluation of Family Doctors' Contracted Services

HUANG Jinling，CONG Ziwei，YANG Yang，ZENG Zhirong

2019, 22(13): 1516-1521. DOI: 10.12114/j.issn.1007-9572.2019.00.127

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On the basis of a comparative analysis of common international frameworks for healthcare performance evaluation，we developed clear ideas for establishing a family doctors' performance appraisal framework in the delivery of contracted services in China，determined its contents，and divided it into five subscales（structure，input，process，output，outcomes）using content analysis.Moreover，output and outcomes of family doctor services were distinguished from the demand-supply perspective.Our framework can provide guidance for the establishment of a scientific family doctors' performance management mechanism in the delivery of contracted services.

The Enlightenment of Value-based Pay for Performance Program in California on Improving the Performance Evaluation System and Incentive Mechanism of General Practitioners in China

WANG Simin，XU Wei，CUI Zidan，SHI Qionghua

2019, 22(13): 1522-1527. DOI: 10.12114/j.issn.1007-9572.2019.00.215

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A well-run incentive mechanism and performance evaluation system are key to improve the general practitioner system in China.This study thoroughly analyzed value-based pay for performance program（VBPFP） in California，with emphasis on its performance measures and incentive mechanism and compared it with that in China.On the basis of the comparative analysis，we found that the performance evaluation goals of VBPFP program was specific，which required general practitioners to pay equal attention to the quality and cost of patient care.The performance measures were mainly centered on the prevention and treatment of chronic diseases.The hybrid medical insurance payment methods were adopted to maximize the enthusiasm of general practitioners.Therefore，we put forward suggestions that our performance assessment should add indicators of chronic disease prevention and health management and that we should establish a hybrid payment method links to the medical insurance for general practitioners.In addition，timely disclosure of general practitioners' performance appraisal results and open recognition and reward for general practitioners with outstanding performance are also important to stimulate their enthusiasm at work.

Standardized Workload-based Position Management for Community Health Centers

WU Jun，LIU Shanshan，JIANG Guoqiang，HUANG Jiaoling，YU Buqing，WANG Peng，HE Rongrong，ZHANG Yimin

2019, 22(13): 1528-1532. DOI: 10.12114/j.issn.1007-9572.2019.00.204

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Background Position management improvement in community health centers is an important part of comprehensive reform of community healthcare，involving the achievement of healthcare goals of community healthcare institutions，and the match between staff's number and abilities and workload，and affecting the reduction of operating costs and efficiency improvement of such institutions.Objective To compare the estimated ideal number of workers obtained by standardized workload analysis with the actual number in community health centers（CHSs） in Pudong New Area，providing a reference for optimizing the position management in CHSs.Methods According to the classification criteria for streets and towns made by Pudong New Area Committee Office，we classified the CHSs in Pudong New Area into four types：A（remote rural areas），B（general rural areas），C（urban-rural fringe） and D（urban areas）.Through the Pudong New Area Community Cloud Management Platform，we collected the annual standardized workload for each type of CHSs and for general practitioners（GPs） and GP assistants working in each type of CHSs in 2017.Then，by standardized workload analysis，we derived the estimated ideal numbers of positions in CHSs，and compared them with the actual numbers.Results The total annual standardized workload in 2017 for GPs and GP assistants in types A，B，C，and D CHSs were 6 193 199，9 231 475，8 893 767，and 12 495 055，respectively.The corresponding total ideal positions calculated by us were 1 817，2 529，2 285，and 3 022，respectively.However，all these CHSs were found with less number of total positions than the ideal.To be specific，the numbers of incumbent GPs，nurses，and public health physicians were all less than the ideal，but the numbers of other types of incumbent workers were all more than the ideal.Conclusion In general，the total numbers of positions in CHSs in Pudong New Area are insufficient，but the increase should be improved based on requirements.The improvement measures are given as follows：establishing a dynamic mechanism for increasing positions；rationalizing the position designation structure；standardizing the position designation；optimizing the internal structure of positions；reducing the effect of associated factors on actual position designation；improving the incentive mechanism to attract the scarce health talents.

Ownership-related Differences in Efficiency of Community Health Centers

DONG Yali，QIN Jiangmei，LIN Chunmei，ZHANG Lifang

2019, 22(13): 1532-1536. DOI: 10.12114/j.issn.1007-9572.2019.00.200

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Background With the development of community health services in China，how to improve the operational efficiency of community health institutions is a focus of current community health service reform research.Objective To analyze the efficiency and changes in the trend of total factor productivity（TFP） of community health centers（CHCs） in Urumqi by type of ownership，and put forward suggestions for the existing problems.Methods Data were obtained from 5 volumes of Urumqi's Health and Family Planning Statistical Yearbook（2012—2016）.Percentage method，and data envelopment analysis（DEA） using Banker-Charnes-Cooper（BCC） model and Malmquist index were applied to analyze the operational efficiency of CHCs by types of ownership.Results DEA with BCC model revealed that during the period of 2012—2016，efficient CHCs accounted for 52.9%（18/34），33.3%（12/36），40.0%（14/35），33.3%（14/42），15.2%（7/46） of the total CHCs，respectively.In 2016，efficient CHCs owned by the government，public hospitals，enterprises，and individuals accounted for 0（0/6），20.0%（3/15），18.2%（2/11），14.3%（2/14） of the total，respectively.Malmquist index found that compared with 2015，in 2016，the TFP of CHCs decreased by 17.2% in general.But specifically speaking，the TFP of 21.7%（10/46） of the CHCs increased，among which enterprises-owned CHCs〔27.3%（3/11）〕 made up the largest portion，followed by public hospitals-owned CHCs〔26.7%（4/15）〕，individually owned CHCs〔21.4%（3/14）〕，and government-owned CHCs〔0（0/6）〕.Conclusion The percentage of efficient CHCs in Urumqi in 2016 is lower than 2012，which is related to the polarization development of the CHCs.But the overall TFP of the CHCs in Urumqi decreased，which is related to the technological recession.

Shared Mode-based Optimization of Disease Screening and Cost Estimation in Community Health Centers

WU Xiaodan，HE Jialin，YUE Dianmin，LI Juan

2019, 22(13): 1537-1541. DOI: 10.12114/j.issn.1007-9572.2019.00.198

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Background In China，community health centers are classified as primary healthcare institutions in accordance with the hierarchical medical system，and quality improvement of diagnostic and treatment services delivered by them is conducive to meeting people's growing demand for medical services.Objective To shorten patient waiting time for disease screening in a community health center by using a shared screening scheme，improving service efficiency，and patient satisfaction.Methods Disease screening in community health centers was deemed as a queuing system，and was optimized by a shared screening scheme，then its characteristics were compared with those of other three screening schemes.Results Queuing-model based analysis of patient waiting time for disease screening by using 4 optimization schemes derived different outcomes using different control strategies.If optimizing the disease screening procedure without increasing the investment，patient waiting time could be shortened by the shared mode，namely，3 community health centers，and physicians from these centers carried out disease screening in collaboration.Conclusion Queuing theory can be used as an auxiliary tool for primary care managers to optimize the service system with different control factors.In addition，sharing healthcare services in primary care improves the service efficiency and patient satisfaction，promotes rational medical resources allocation，and enhances the comprehensive strength of primary care system.

The Personnel Allocation of Core Family Doctor Team for Contract Service under the People-centered Active Care Model

WANG Xiaogang，YANG Ziyu，DAI Xiaoyi，TAN Xue，ZHANG Jun，YANG Minrong，LIN Xi

2019, 22(13): 1542-1547. DOI: 10.12114/j.issn.1007-9572.2019.00.217

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Background People-centered Active Care（PCAC） model aims to improve the service quality and efficiency with good patient experience while based on such a model how to allocate team members，divide responsibilities and manage team operations has become an urgent problem to be solved.Objective To explore the personnel allocation and division of responsibilities of the family doctor team members under PCAC model.Methods During January and February in 2018，24 family doctor teams who had started the contracted family doctor service under the PCAC model were selected in Wuhou District of Chengdu，and questionnaires were distributed to 206 members in these 24 teams to investigate their cognition of physician assistants and health facilitators as well as the division of tasks in each position.The actual work tasks of each position were recorded and sorted out in November 2017. According to the results of the questionnaire and combined with the actual work and international advanced experience in medical care，the responsibilities of each position will be determined.Results Among 206 medical staff，62.1%（128/206） of them knew the role and division of tasks of physician assistants；92.2%（190/206） of them thought that the physician assistants were important.And 30.6%（63/206） of the medical staff understood the role of health facilitators，and 79.1%（163/206） of the medical staff thought the health facilitators were important.Taking 1 000 contracted residents as the base，the proportion of members in the core family doctor team was family doctor:physician assistant:health facilitator=1∶1∶1.The duties of family doctors were leading and managing the team，coordinating the teamwork，solving problems.Family doctors were responsible for diagnosing and treating residents，making decisions for residents' referral，developing treatment plans for residents，analyzing diagnosis results，and training the medical staff.The duties of the physician assistants were assisting family doctors to formulate the annual work plan，completing the work arranged by family doctors，assisting the family doctors to supervise the service quality of the whole team，supervising family doctors to prevent the occurrence of mistakes，and assisting family doctors to complete the statistical report.The duties of the health facilitators were assisting the signing of the contracts，assisting the management of internal affairs of the team，coordinating the communications outside the team，managing the crowd by data driven，and promoting health education.Conclusion It is suggested to raise the awareness of PCAC model in the family doctor team.The task items of core family doctor team and the division of tasks for each position constructed in this study can provide a basis for other communities to reshape their family doctor teams and sort out the responsibilities of each position.

Development of a Service Capability Training Curriculum System for Family Doctor Teams

HUANG Rui，MA Xidan，XIAO Li，ZHU Jianjun

2019, 22(13): 1548-1553. DOI: 10.12114/j.issn.1007-9572.2019.00.218

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Background There is no mature service capability training curriculum system for family doctor teams in China.Objective To construct a capability training curriculum system for family doctor teams delivering integrated person-centered services（PCIC）.Methods From June to September 2017，we drew up the initial version of family doctor team service capability training curriculum system based on literature review and results of in-depth interviews with family doctor teams and experts responsible for intensively transforming general practice service delivery patterns in Wuhou District.Then，during October 2017 to January 2018，we conducted two rounds of email consultation among 15 selected experts，during which the importances of modules and contents of the initial curriculum system were evaluated by the experts，and the system was revised according to the consensus and coordination of experts' opinions and suggestions.Results The response rates of the two rounds of consultation were all 100.0%，with an average authority coefficient of 0.91.Finally，a formal curriculum system was constructed in which 9 modules（PCIC model concept interpretatin，standardized health management process，population management，service quality management，patient participation，coordination ability，service package development and designation，team building，team operation），and 57 courses are included，with scores of 3.55-4.82 points on average in terms of importance evaluated by experts，and coefficients of variation of 0.08-0.24.The Cronbach's αof the courses ranged from 0.780 to 0.945.Conclusion This service capability training curriculum system is scientific and practical，and is suitable for family doctor teams delivering integrated person-centered contracted services.

Development of a Service Capability Building Evaluation System for Family Doctor Teams

LUO Xiaolu，HUANG Yanli，HAO Jiaping，MA Xidan

2019, 22(13): 1554-1558. DOI: 10.12114/j.issn.1007-9572.2019.00.216

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Background The capability of family doctor teams is a key factor involved in effective delivery of the contracted services，so corresponding capability building is very important.But there is still lack of a system that can objectively evaluate the building.Objective To construct a scientific and practical service capability building evaluation system to assess the advantages and disadvantages of service capability building in family doctor teams，improving the orientation and accuracy of the building.Methods We drew up the initial version of the family doctor service capability building evaluation system based on literature review and results of expert consultation.Then，the contents of the system were revised after being discussed in another two rounds of consultation（one was conducted on December 14，2017，and the other was on January 14，2018） with 13 experts who had a good grasp of general practice theories，and three models of care〔patient-centered medical home（PCMH），person-centered integrated care（PCIC） and people-centered active care（PCAC）〕.Results The attending rates for the later first and second round of consultation were 100.0%（13/13），92.3%（12/13），respectively.The final system covers 8 first-level indicators：training of skills used for delivering contracted services，person-centered care and communication，accessible and continuous services，team-based planning services，collaborative services and management，specific group identification and management，application of information systems and tools，and quality testing and improvement.In addition，35 second-level indicators and 113 third-level indicators are also included.Conclusion Our family doctor team service capability building evaluation system fully demonstrates that the contracted services delivered by the team are person-centered，accessible and continuous services in essence，which can be easily conducted to promote people's health with targeted interventions，and can be referred for family doctor team service capability building.

Status Quo of Contracted Family Doctor Service in Wuhou District，Chengdu

LUO Xiaolu，HUANG Yanli

2019, 22(13): 1559-1565. DOI: 10.12114/j.issn.1007-9572.2019.00.219

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The Wuhou District of Chengdu has been piloting the contracted family doctor service under the People-Centered Active Care（PCAC） model since 2014，and preliminary results have been achieved.As of June 30，2018，31.0% of the residents in Wuhou District have signed contracts with family doctors，55.0% of the key population has signed contracts with family doctors，and 5.1% of the population used ID cards to sign the contracts that were regarded as the effective ones.Data from Electronic Patient Management platform were analyzed，and the up-to-standard rate of key indicators of patients with hypertension and diabetes in July 2017 to June 2018 was better than that in July 2016 to June 2017 as well as the screening rate of complications.For the contracted residents，the appointment rate on their own initiatives，the rate of visits to a doctor after an appointment，and the fixed visit to one's own family doctor rate in July to December in 2017 were higher than those in January to June in 2018．The number of contracted residents refeeal to hospitals from community or to community from hospitals，and specialists serving at the community from July 2017 to June 2018 was higher than that from July 2016 to June 2017（P<0.05），while there was no difference in the number of contracted residents receiving remote cooperative service（P>0.05）．Meanwhile the salary income of community medical workers increased as well as the satisfaction of residents.However，there are still some problems of the contracted family doctor service at present in Wuhou District，such as insufficient personnel allocation，imperfect information construction，and lack of supporting policies such as medical insurance.The further major work will be carried out around the above issues.

Personal Lung Cancer Risk Assessment with the Rothman-Keller Method

LI Yawen，ZHANG Lu，ZHENG Qianwen，JIANG Min，ZHU Cairong

2019, 22(13): 1566-1570. DOI: 10.12114/j.issn.1007-9572.2019.00.201

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Background Lung cancer prevention is one of the ways to reduce the burden of lung cancer in China.It is particularly important to strengthen the primary prevention of lung cancer and to explore new ways of prevention.Disease risk assessment can reduce the risk of disease by assessing disease risk，and guiding daily life behaviors via health education based on personal conditions.It is widely used in community health and health management as an important way to prevent chronic diseases.Objective To establish a risk assessment model to predict the absolute and relative risks of lung cancer in Chinese population. Methods We collected and reviewed the epidemiological studies of lung cancer in Chinese population from October 2017 to March 2018.The search time was from the establishment of the database to March 31，2018.After this，we determined the major risks for lung cancer and quantified their degrees of association with lung cancer，and used them to construct a lung cancer risk assessment model with the Rothman-Keller method.Results A total of 12 factors were included in the model，including active smoking，passive smoking，average annual PM2.5 in the region，occupational exposure（asbestos，dust），history of pulmonary diseases （chronic bronchitis, emphysema, tuberculosis），BMI，fresh vegetables consumption，cooking fume and other environmental factors.And the model was proved to be effective in predicting personal relative risk of lung cancer and 5-year risk of lung cancer.Conclusion This model can be used for primary prevention of lung cancer，indirectly promoting people to develop a good lifestyle.

Vascular Lesions and Risk Factors in Hypertensive Patients in the Community

ZHANG Man，LIN Shengqiang，YANG Yuming，HU Zhiqiang，WANG Haoxiang，WANG Jinming，YANG Zhipeng，HUANG Zhijie，ZHONG Yongyi，WANG Jiaji

2019, 22(13): 1571-1576. DOI: 10.12114/j.issn.1007-9572.2019.00.110

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Background With the development of social economy and the aggravation of aging，the prevalence of hypertension is increasing.Monitoring the elasticity and sclerosis of arteries and giving corresponding interventions in hypertensive patients，can prevent，and delay the progression of cardiovascular disease.Objective To explore the prevalence of vascular lesions and its influencing factors in patients with hypertension in the community，providing a theoretical basis for early detection and prevention of arteriosclerosis.Methods The enrolled 411 hypertensive patients were sampled from individuals undergoing physical examination in the outpatient clinic of Shunde Lecong Community Health Center between May and July 2018，including 45 with ideal blood pressure control（group A），142 with good blood pressure control（group B） and 224 with poor blood pressure control（group C）．The brachial-ankle pulse wave velocity（baPWV），carotid-femoral pulse wave velocity（cfPWV） as well as ankle-brachial index（ABI） were analyzed comparatively.Influencing factors of the detected vascular lesion were analyzed by using multivariate Logistic regression.Results Mean baPWV and cfPWV differed significantly between the groups（P<0.05），while mean ABI did not（P>0.05）．There was a significantly positive correlation between blood pressure control and baPWV（rs=0.406，P<0.001），as well as cfPWV（rs=0.381，P<0.001）.Multivariate Logistic regression model indicated age〔OR=1.102，95%CI（1.069，1.136）〕，serum ALT〔OR=0.966，95%CI（0.934，0.999）〕 and serum total bilirubin〔OR=1.065，95%CI（1.023，1.110）〕 were independent influencing factors of baPWV；and age〔OR=1.106，95%CI（1.071，1.141）〕，serum ALT〔OR=0.952，95%CI（0.917，0.988）〕and serum AST〔OR=1.052，95%CI（1.007，1.100）〕were independent influencing factors of cfPWV.Conclusion Blood pressure control is associated with vascular sclerosis in hypertensive patients.So community-based hypertension management should be strengthened to effectively prevent or delay the occurrence and development of cardiovascular diseases.

Clinical Analysis of Binge Eating Disorder in T2DM Patients

ZHENG Lili，ZHANG Qiu，LI Dongfeng

2019, 22(13): 1577-1581. DOI: 10.12114/j.issn.1007-9572.2019.00.192

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Background There is a close relationship between binge eating disorder（BED） and type 2 diabetes mellitus（T2DM）．At present，there is a great difference in the research results of BED among patients with T2DM.Moreover，the mechanism of BED is mainly discussed from the perspectives of mental state and psychological model，and there is no analysis of clinical biochemical indicators.Objective To study the incidence of BED in T2DM patients，T2DM patients with an increased risk of BED，and its influence on blood sugar，blood lipid，comorbidities and complications.Methods 234 T2DM patients were selected from Department of Endocrinology，Lu'an Second People's Hospital from January to June 2018.Symptoms data were collected by consultations.According to the DSM-Ⅴ diagnostic criteria for BED，they were divided into BED and non-BED groups.Comparative analyses of two groups' demographic data（sex，age，and BMI） and biochemical data 〔glycated hemoglobin（HbA1c），fasting blood glucose（FPG），serum C-peptide（C-P），total cholesterol（TC），triglyceride（TG），high-density lipoprotein cholesterol（HDL-C），and low-density lipoprotein（LDL-C）〕 and incidence of 7 chronic complications /comorbidities were performed.Results The incidence of BED was 9.0%（21/234）．Compared with non-BED group，BED group had lower percentage of males，greater mean age，and higher BMI，HbA1c and FPG levels（P<0.05），but had similar mean T2DM duration，and mean serum C-P，TC，TG，HDL-C and LDL-C levels（P>0.05）．Moreover，two groups showed insignificant difference in the incidence of chronic complications and comorbidities（peripheral neuropathy，peripheral vascular disease，diabetic nephropathy，diabetic retinopathy，diabetic foot，coronary heart disease and cerebral infarction）（P>0.05）．Conclusion The incidence of BED in patients with T2DM is high.In particular，those who are female or obese are more susceptible to BED.BED can have adverse effects on blood sugar control in patients with T2DM，but has little effect on blood lipid level，complications and comorbidities.

Subtype Characteristics of Symptom-based Rome Ⅳ Functional Dyspepsia in Adults：a Clinical Survey

YAO Xuemin，JIN Ying，XU Hua，ZHU Hong，TANG Jinhai，LIN Lin

2019, 22(13): 1582-1587. DOI: 10.12114/j.issn.1007-9572.2019.00.202

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Background Functional dyspepsia（FD） is the most common dyspepsia problem.Symptom overlap and psychosocial abnormalities are very prevalent in FD patients.Current diagnosis of FD is mainly based on the Roman criteria for functional gastrointestinal disorders.Objective To investigate the symptoms，overlapping symptoms，and mental and psychological conditions in patients with different subtypes of Rome Ⅳ FD .Methods A total of 172 adult outpatients（≥18 years old） with FD who received medical services in Department of GI Medicine，the First People's Hospital of Wujiang District Affiliated to Nantong University were enrolled from June to December 2017.All of them underwent gastroscopy，and according to the symptom-based results，48 of them were identified with epigastric pain syndrome（EPS），74 with postprandial discomfort syndrome（PDS），and 50 with PDS and EPS.Inductive analysis of symptom composition，overlapping symptoms，and combined anxiety and/or depression status was performed.Results EPS patients showed lower percentages of postprandial fullness，early satiety，belching and upper abdominal distension，and higher percentage of upper abdominal pain than PDS patients（P<0.017）．Those with EPS and PDS had higher percentages of postprandial fullness early satiety and postprandial nausea or vomiting compared with those with only EPS，and had higher percentages of upper abdominal pain and upper abdominal burning sensation than those with only PDS（P<0.017）．The proportion of those with PDS and EPS with overlapping symptoms was higher than that of those with EPS（P=0.015）．The average total symptom score of patients with EPS was lower than that of patients with PDS（P<0.05）．Those with PDS and EPS had higher average total symptom score than those with PDS or EPS（P<0.05）．The average total symptom score was found to be lower in EPS patients without anxiety symptom and with depressive symptom，or with depressive symptom compared with corresponding subgroups of PDS patients（P<0.05）．The average total symptom score was identified to be higher in patients with both EPS and PDS without anxiety symptom and with depressive symptom，with anxiety symptom and depressive symptom，without anxiety symptom and depressive symptom，with anxiety symptom，or with depressive symptom compared with corresponding subgroups of PDS or EPS patients（P<0.05）．EPS patients with overlapping symptoms showed lower average total symptom score compared with PDS patients with overlapping symptoms（P<0.05）．Those with PDS and EPS had higher average total symptom score than those with only PDS or EPS（P<0.05），which was not influenced by the prevalence of overlapping symptoms.Conclusion The symptoms of PDS patients are more complicated and serious than those of EPS patients.But when the patients develop both EPS and PDS，the symptoms become even more complicated and severe.

Relationship between Common Chronic Diseases and Disability among the Elderly with In-home Care：a Case-Control Study

JIANG Zhiyue，LI Yumei，WANG Xiuhong，WANG Junhua，LI Fang，DENG Kaisheng，DAI Lili

2019, 22(13): 1587-1591. DOI: 10.12114/j.issn.1007-9572.2019.00.111

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Background At present，the elderly are the focus group of the nationwide health construction.However，disability seriously affects the physical and mental health of the elderly.Some studies have found that chronic diseases may be associated with disability in the elderly，but most of these studies are cross-sectional studies，which have certain limitations in determining the relationship between chronic diseases and disability.Objective To study the relationship between chronic diseases and disability in the elderly with in-home care，providing a scientific basis for the prevention and control of disability in this group.Methods A community population-based，1∶2 matched case-control study was conducted between October and December 2016 in a sample of 201 older people aged ≥60 years receiving in-home care，including 67 rated as disabled by the Activities of Daily Living Scale（ADLs），and 134 age- and sex-matched non-disabled.Multivariate conditional Logistic regression analysis was used to investigate the relationship between chronic diseases and disability.Results After controlling for confounders，Logistic regression analysis results showed that subjects with chronic diseases had a 2.494 times higher risk of disability than those without〔95%CI （1.274，4.881）〕.Subjects with 2 or more chronic diseases had a 3.113-fold increased risk of disability〔95%CI（1.425，6.802）〕compared with those with 1 chronic disease or without.Sex-stratified analysis showed that stroke〔OR=9.750，95%CI（1.099，86.532）〕 and hypertension〔OR=3.402，95%CI （1.077，10.746）〕were found to increase the risk of disability in older men.Conclusion Disability of the elderly with in-home care is associated with chronic diseases.Strengthening the prevention and control of hypertension and cerebral apoplexy plays an important role in reducing the incidence of disability in the elderly especially older men.

Clinical Outcomes and Related Factors of Coronary Microvascular Obstruction in Patients with Delayed Admission after Acute Myocardial Infarction

WU Duoyi，XU Heping，SUN Juan，LI Quanni

2019, 22(13): 1592-1597. DOI: 10.12114/j.issn.1007-9572.2019.00.220

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Background About 1/3 of patients with ST-segment elevation myocardial infarction（STEMI） have delayed visits.The benefits of late myocardial salvage therapy are affected by the severity of coronary microvascular occlusion（MVO）．Objective To investigate the clinical outcomes，and related factors of MVO in coronary microvascular obstruction in patients with delayed admission after acute myocardial infarction.Methods From 2014 to 2017，78 STEMI patients with delayed admission（time between symptom onset and hospital arrival is greater than 12 hours） who received emergency percutaneous coronary intervention（PCI） in EICU and CICU，Hainan General Hospital were enrolled.According to the results of coronary angiography，MVO is determined when the thrombolysis in myocardial infarction（TIMI） perfusion grade is less than 2 or the final TIMI grade is 3 and the myocardial blush grade（MBG） is less than 2.Clinical results and echocardiographic follow-up were performed to assess the occurrence of major adverse cardiovascular events（MACE） and left ventricular remodeling.Results The incidence of MVO in the participants was 50.0%（39/78）．Multivariate Logistic regression analysis showed that older age and having left anterior descending branch as the culprit vessel were risk factors for MVO，and pre-infarction angina pectoris was protective factor for MVO（P<0.05）．The incidence of MACE and left ventricular remodeling in patients with MVO were higher than those of patients without（P<0.05）．Cox proportional hazards regression model showed that MVO and LAD were the predictors of MACE（P<0.05）．Conclusion STEMI patients with delayed admission are relatively susceptible to MVO and related adverse outcome events.Older age and having LAD as the culprit vessel are associated with increased risks while pre-infarction angina pectoris is associated with decreased risk of MVO.Appropriate management and follow-up strategies should be implemented in this group of high-risk patients.

Efficacy of Interventions with Dietary Fiber and Resistance Exercise for Patients with Gestational Diabetes Mellitus and Hyperlipidemia：a Clinical Study

DENG Yingpei*，ZHAO Linyuan，PAN Feifei，WANG Jiake

2019, 22(13): 1598-1602. DOI: 10.12114/j.issn.1007-9572.2019.13.017

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Background At present，dietary and nutrition interventions and exercise are major treatments for patients with gestational diabetes mellitus（GDM） and hyperlipidemia.Objective To explore the effects of nutrition support in combination with interventions with dietary fiber and resistance exercise on GDM with hyperlipidemia.Methods 206 women who had GDM and hyperlipemia during the second and third trimesters of pregnancy were recruited from Luohe Central Hospital from December 2014 to December 2016 and were randomized into the control group（n=49），dietary fiber group（n=51），resistance exercise group（n=52），and combination group（n=54），receiving basic nutrition support，basic nutrition support and intervention with dietary fiber，basic nutrition support and resistance exercise，basic nutrition support with interventions with dietary fiber and resistance exercise，respectively.The intervention for all cases lasted for 12 weeks.Glycemic and lipid outcomes were evaluated by fasting blood glucose（FPG），2-hour postprandial blood glucose（2 hPG），glycosylated hemoglobin（HbA1c），triglyceride（TG），and total cholesterol（TC） at the end of the 4th and 12th weeks of intervention.Quality of life outcome was evaluated by the Adjusted Diabetes-specific Quality of Life（A-DQOL） at the end of the 4th and 12th weeks of intervention.And pregnancy outcome was assessed at the end of intervention.Results FPG，2 hPG，HbA1c，TG and TC of the four groups at the end of the 4th and 12th weeks of intervention were significantly different（P<0.05）．To be specific，at the end of the 4th week of intervention，combination group showed significantly decreased FPG，2 hPG，HbA1c，TG and TC levels than the control group，and significantly decreased 2 hPG than dietary fiber group，and resistance exercise group（P<0.05）．When the intervention ended，combination group demonstrated significantly decreased FPG，2 hPG，HbA1c，TG and TC levels than the control group，too（P<0.05）．Moreover，in comparison with dietary fiber group and resistance exercise group，combination group demonstrated significantly decreased 2 hPG and HbA1c（P<0.05）．The rates of adverse pregnancy outcomes，such as preeclampsia，polyhydramnios，preterm labor，cesarean section and macrosomia differed significantly in the groups（P<0.05）．In particular，they were significant lower in the combination group than those of other groups（P<0.008 3）．At the end of 4th and 12th weeks of intervention，the mean A-DQOL score varied significantly in all the groups（P<0.05），and it was much lower in the combination group than that of other groups（P<0.05）．Conclusion Basic nutrition support with interventions with dietary fiber and resistance exercise，helps to achieve effective glycemic and blood lipid control，improve the pregnancy outcome and quality of life in GDM patients with hyperlipidemia.

Effect of Visual Management on the Self-management Ability and Behaviors of Type 2 Diabetic Patients

ZHAO Ziyu，GAO Zhijuan，LU Jiayan，HU Xiaoxia，CHEN Jing，CHEN Peiyi1

2019, 22(13): 1603-1607. DOI: 10.12114/j.issn.1007-9572.2019.00.075

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Background The morbidity of diabetes，especially type 2 diabetes，increases annually in China.With the development of communication technology，mobile health has become an important method to prevent and treat diabetes.In recent years，visual management combined with mobile health technology has been proved to be a great method in improving the self-management ability of type 2 diabetes patients.Objective This study was to explore the effectiveness of visual management in improving the self-management ability and behaviors of type 2 diabetic patients.Methods Totals of 70 cases with type 2 diabetes were recruited from 2 tertiary grade A hospitals and 3 community health centers in Guangdong Province from September 2017 to January 2018.By use of a random number table，they were divided into the control group（35 cases）and experimental group（35 cases）.Both groups received routine diabetes management.The experimental group also received visual management.At baseline and at the end of a 12-week intervention，levels of glycosylated hemoglobin（HbA1c）and triacylglycerol（TG） were measured，and scores of the Chinese Diabetes Empowerment Scale-Short Form（CDES-SF），and Diabetes Self-Care Scale（DSC）were assessed. Moreover，adherence to self-monitoring of blood glucose（SMBG）was evaluated after the 12-week intervention.Results Except for 9 drop outs（5 from control group，4 from experimental group），the other participants completed the intervention.The average levels of HbA1c and TG，and average scores of CDES-SF and DSC showed no significant differences between the groups（P>0.05）.When the intervention ended，although the HbA1c and TG levels were still similar in both groups（P>0.05），the adherence to SMBG was much better and the average scores of CDES-SF and DSC were much higher in the experimental group（P<0.05）.Conclusion Visual management combined with routine diabetes management can improve the adherence to SMBG and self-efficacy，and enhance the self-care ability in diabetic patients.It is worth promoting in the management of type 2 diabetes.

The Management Effect of Type 2 Diabetes Service Package in Hongshan Street Community in Guangzhou City

SHEN Lijun，HUANG Chengfeng，KONG Ying

2019, 22(13): 1608-1612. DOI: 10.12114/j.issn.1007-9572.2019.13.019

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Background The increasing incidence of diabetes and its complications has become a global public health problem，posing a great burden on individuals，families and socio-economic development.The personalized diabetes service package for community residents is conducive to optimal management.Objective To evaluate the management effect of diabetes service package of Hongshan Street Community in Guangzhou，by comparing its performance with that of national public health service package，providing a reference for the exploration of effective mode of for comprehensive community-based prevention and management of diabetes.Methods 232 patients with stable type 2 diabetes mellitus were selected from 6 residential committees served by Hongshan Street Community Health Center from September 2014 to September 2016.By random number method，they were equally divided into control group and intervention group，receiving the management with national public health service package，and management with diabetes service package of Hongshan Street Community.All of them also received a follow-up lasting for 9 months.The levels and rates of meeting the target objective of laboratory indicators（including glycemic and biochemical indicators，etc.） before and after intervention were compared between the two groups.Results In the control group and the intervention group，23 and 20 patients were lost to follow-up，and 93 and 96 patients were included in the analysis.There were no significant differences in all indicators before intervention between the two groups（P>0.05）．After intervention，fasting plasma glucose（FPG），2 h postprandial plasma glucose（2 hPG），and glycosylated hemoglobin（HbA1c） of intervention group were lower significantly than those of control group（P<0.05），but systolic blood pressure（SBP），diastolic blood pressure（DBP），body mass index（BMI），waist-hip ratio（WHR），total cholesterol（TC），triglyceride（TG），high-density lipoprotein（HDL），and low-density lipoprotein（LDL） did not（P>0.05）．The rates of meeting the target objective for all indicators were similar in both groups before intervention（P>0.05）．The rates of meeting the target objective for FPG and 2 hPG of intervention group were higher significantly than those of control group（P<0.05），but those for SBP，DBP，HbA1c，TC，TG，HDL and LDL were still similar in both groups after intervention（P>0.05）．Conclusion Hongshan Street Community diabetes service package has better effect on glycemic control in type 2 diabetes mellitus.It is of great significance to standardize the management of diabetes mellitus and to improve the hierarchical medical system.

Sedative and Hypnotic Drugs Use in Elderly Chronic Disease Patients Receiving Standardized Community-based Management

YANG Ying，SUN Yange，YAN Yan，LI Chao，LYU Kaimin

2019, 22(13): 1613-1617. DOI: 10.12114/j.issn.1007-9572.2019.00.221

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Background Inappropriate use of psychotropic drugs，especially sedatives and hypnotics，can increase the risk of falls in older people.Objective To examine the use of sedative and hypnotic drugs in elderly chronic disease patients receiving standardized community-based management.Methods By use of systematic sampling，we selected 581 cases as the participants from 60-80-year-old chronic disease patients receiving standardized community-based management from January to March in 2018 from Yuetan Community，Xicheng District，Beijing，including 512 of hypertension，277 of diabetes，50 of stroke and 190 of coronary heart disease.By consulting the electronic medical record system in 2017，we collected the data concerning sedative and hypnotic drugs use in the participants.Results Of the participants，33.2%（193 cases） with a definite diagnosis of insomnia used sedative and hypnotic drugs.And the use rate of such drugs increased with age and number of chronic diseases（P<0.05）．Participants with 2 chronic diseases had higher use rate of sedative and hypnotic drugs than those with only 1（P<0.05）．The most frequently used three drugs were estazolam（63.2%，122/193），zolpidem （18.7%，36/193），and zopiclone（15.5%，30/193）．Most of the participants〔95.9%（185/193）〕 used a normal dose，only 4.1%（8/193）used an increased dose.31.6%（61/193）needed to use such drugs intermittently for at least 6 months each year，and 68.4%（132/193） used for 1-2 months.Conclusion The use rate of sedative and hypnotic drugs in elderly chronic disease patients is high，and it increases with age and the number of chronic diseases，but the long-term use rate is not high.In view of this，we should pay attention to the medication status of those at a very advanced age or with multiple chronic diseases，and give them medication guidance，to reduce the occurrence of falls and other adverse health events

Status of and Individual-specific Differences in Pharmaceutical Service Needs among Community-dwelling People with Disability

SHEN Mei，WU Jianping，SUN Ke，LI Yan，GUO Jing，HUANG Jiaoling

2019, 22(13): 1617-1622. DOI: 10.12114/j.issn.1007-9572.2019.00.222

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Background People with disabilities are very susceptible to many diseases.Most of available studies have discussed medical services needs in this group，such as regular check-up，home-based care，and rehabilitation guidance，but relatively few have explored their pharmaceutical service needs.Objective To explore the needs of pharmaceutical services in community-dwelling people with disabilities，and analyze the differences in this group by basic demographic characteristics，socio-economic status，type and severity of disability.Methods From November to December 2017，a survey was conducted in a simple random sample of 230 registered people with disabilities from a street of Shanghai.A self-designed questionnaire was used in the survey to collect the following data：basic demographic characteristics （gender，age，marital status），socioeconomic status（educational level，retired or not，household monthly income per capita），type and severity of disability，pharmacy services（components and grade of pharmacy service needs，and providers satisfying such needs）．Results Altogether，226 cases（98.3%） responded effectively to the survey.The top two demands were "usage and dosage"（73.0%，165/226） and "indications and contraindications"（51.3%，116/226）．The rate of demanding "interpretation of drug package inserts" service differed significantly by the prevalence of retirement（P<0.05）．And the rate of needing services of interpreting "usage，dosage and course of treatment" varied significantly by household monthly income per capita（P<0.05）．The main provider satisfying pharmaceutical service demand was "doctor"（85.4%，193/226）．The rate of needing a doctor to satisfy such demands changed obviously by age，prevalence of retirement，and severity of disability（P<0.05）．The rate of satisfying such demands through social media varied significantly by age（P<0.05）．Pharmacy services were highly/relatively demanded in 48.2%（109/226）of the respondents.The grade of demanding of such services differed significantly by educational level，prevalence of retirement，type and severity of disability（P<0.05）．Conclusion Community-dwelling people with disabilities with different characteristics showed great differences in providers in demand for satisfying needed pharmaceutical services，and even greater differences in the grade of pharmaceutical services in demand，but showed similar components of such services in demand.So community pharmacists should deliver targeted medication education and pharmaceutical services in accordance with personal conditions.

Use of Small-dose Aspirin for Primary and Secondary Prevention of Cardiovascular and Cerebrovascular Diseases in Diabetic Patients: a Cross-sectional Community-based Survey

XU Qi，SHI Rong，DU Zhaohui，ZHANG Linying，ZHU Wenkui，TANG Xiaochun，YANG Lijuan，XUE Weibin，CAO Yi1，QIAO Huihua，TU Dongyan，ZHAO Hui，XUE Jinhua，XUE Feng，WANG Minghao，LIU Lianyong

2019, 22(13): 1623-1626. DOI: 10.12114/j.issn.1007-9572.2019.00.129

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Background For diabetic patients，community-based management is comparatively good，because by which glycemic and other essential indicators can be regularly monitored，real-time follow-up services can be obtained，and the management is easy to access owing to short spatial distance. However，how to deliver standardized community-based management for such patients is need to be cleared further. Objective To investigate the use of small-dose Aspirin for primary and secondary prevention of cardio-cerebrovascular diseases in community-dwelling type 2 diabetic patients. Methods We conducted this survey in December 2017 in a stratified and random sample of 490 type 2 diabetic patients who were under the management of 5 general practitioner teams from Shanghai Hudong Community Health Center. The survey contents consisted of 3 parts，namely，personal data（basic information，past history of ASCCVD，family history of ASCCVD，smoking history，and Aspirin use），anthropometric data（weight and blood pressure） and laboratory data（routine blood parameters，liver and kidney function parameters，and glycemic and lipid parameters），collected with a self-developed interview-based questionnaire，physical examination，fasting venous blood testing，respectively. Indications for using Aspirin for primary or secondary prevention of cardio-cerebrovascular diseases were assessed by the risk of developing ASCCVD，and the use status was evaluated. Reasons for those should use Aspirin but did not use were analyzed. Risk of Aspirin-related bleeding in the elderly was assessed. Results The study finally enrolled 465 cases，including 225（48.4%） males and 240（51.6%） females. Of them，219（47.1%） had indications for use of Aspirin for primary prevention of cardio-cerebrovascular diseases，with a rate of Aspirin use of 19.6%（43/219），208（44.7%） had indications for use of Aspirin for secondary prevention，showing a rate of Aspirin use of 49.5%（103/208），and other 38（8.2%） had no indications. Patients who had indications but did not use Aspirin were mostly due to knowing little about this or receiving no related information from the doctor〔62.3%（175/281）〕．The rate of using Aspirin for the prevention of cardio-cerebrovascular diseases in those aged ≥80 years was 50.0%（15/30），and 26.7%（4/15） of them were at high risk of Aspirin-related bleeding，13.3%（2/15） were found with extremely high risk predicted by the CRUSADE score.Conclusion Inadequate use of Aspirin for prevention of diabetes in community，especially primary prevention.For type 2 diabetic patients under community-based management，before using Aspirin for primary or secondary prevention of cardio-cerebrovascular diseases，individualized risk-benefit assessment of Aspirin use should be performed by GPs. Additionally，dynamic follow-ups should be delivered to the patients during Aspirin administration period.

Recent Advances in Cardiac Rehabilitation Adherence Assessment Tools

WANG Junhong，ZHANG Zhenxiang，YANG Qiaofang，WANG Peng

2019, 22(13): 1627-1631. DOI: 10.12114/j.issn.1007-9572.2019.00.109

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The positive effects of cardiac rehabilitation have been confirmed，but the adherence of patients participating in cardiac rehabilitation is not optimistic.In recent years，many studies have explored the reasons of low level of adherence to cardiac rehabilitation and formed relevant assessment tools.We reviewed the related assessment tools of cardiac rehabilitation adherence，and introduced the contents，reliability，validity，advantages and disadvantages of the forms of the Cardiac Rehabilitation Preference Form（CRPF），Cardiac Rehabilitation Enrolment Obstacles（CREO），the Cardiac Rehabilitation Barriers Scale（CRBS），Information Needs in Cardiac Rehabilitation（INCR），and so on aiming to provide a scientific reference for medical workers to reasonably select an assessment tool.

Recent Advances in Health-promoting Behaviors Assessment Tools

LIU Jing，LI Lunlan，GAN Yuyun，LI Zhen

2019, 22(13): 1632-1636. DOI: 10.12114/j.issn.1007-9572.2019.00.199

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Health-promoting behaviors are a kind of interventions used for preventing diseases，promoting，maintaining and improving health by modifying behaviors.They have increasingly attracted the attention of medical workers.At present，there are many assessment tools for health-promoting behaviors，including universal and specific assessment tools.Universal assessment tools comprise Health-Promoting Lifestyle Profile，Health Promoting Lifestyle Profile Ⅱ，Health Promoting Lifestyle Profile Short Form，Health Habits Scale，Health Behavior Scale，and the Conceptual Framework of the Health Behavior Questionnaire.Specific assessment tools include scales for the measurement of health-promoting behaviors in older adults and adolescents，and scales for the assessment of health-promoting behaviors in people having a special disease.The article reviews the contents，development process，reliability and validity，scoring rules of the common health-promoting behaviors assessment tools at home and abroad，with a view to providing a reference for medical workers to perform health behavior investigations and interventions.

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