Chinese General Practice

Curriculum Development: a How to Primer

Jill Schneiderhan，Timothy C Guetterman，Margaret L Dobson（writing），ZHANG Yanan（translator）2，HAN Jianjun，XU Yanli，YANG Hui（reviser）

2019, 22(25): 3023-3027. DOI: 10.12114/j.issn.1007-9572.2019.00.525

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Curriculum development is a topic everyone in the field of medical education will encounter. Due to the breadth of ages and types of care provided in family medicine，family medicine faculty in particular need to be facile in developing effective curricula for medical students，residents，fellows and for faculty development. In the area of medical education，changing and evolving learning environments，as well as changing requirements necessitate new and innovative curricula to address these evolving needs. The process of developing a medical education curriculum can seem daunting but when broken down into smaller components can become very straightforward and easy to accomplish. This paper focuses on the curriculum development process using a six-step approach：performing a needs assessment，determining content，writing goals and objectives，selecting the educational strategies，implementing the curriculum and，finally，evaluating the curriculum. This process may serve as a template for family medicine educators，and all medical educators looking to design（or redesign）their own medical education curriculum.

Continuous Quality Improvement Methodology：a Case Study on Multidisciplinary Collaboration to Improve Chlamydia Screening　

Allison Ursu，Grant Greenberg，Michael McKee（writing），WANG Yang（translator），HAN Jianjun，XU Yanli，YANG Hui（reviser）

2019, 22(25): 3028-3034. DOI: 10.12114/j.issn.1007-9572.2019.00.541

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This article illustrates quality improvement（QI）methodology using an example intended to improve chlamydia screening in women.QI projects in healthcare provide great opportunities to improve patient quality and safety in a real-world healthcare setting，yet many academic centres lack training programmes on how to conduct QI projects.The choice of chlamydia screening was based on the significant health burden chlamydia poses despite simple ways to screen and treat.At the University of Michigan，we implemented a multidepartment process to improve the chlamydia screening rates using the plan-do-check-act model.Steps to guide QI projects include the following：（1）assemble a motivated team of stakeholders and leaders；（2）identify the problem that is considered a high priority；（3）prepare for the project including support and resources；（4）set a goal and ways to evaluate outcomes；（5）identify the root cause（s）of the problem and prioritise based on impact and effort to address；（6）develop a countermeasure that addresses the selected root cause effectively；（7）pilot a small-scale project to assess for possible modifications；（8）large-scale roll-out including education on how to implement the project；and（9）assess and modify the process with a feedback mechanism.Using this nine-step process，chlamydia screening rates increased from 29% to 60%.QI projects differ from most clinical research projects by allowing clinicians to directly improve patients' health while contributing to the medical science body.This may interest clinicians wishing to conduct relevant research that can be disseminated through academic channels.

Conducting Health Policy Analysis in Primary Care Research：Turning Clinical Ideas into Action　

Alina Engelman，Ben Case，Lisa Meeks，Michael D Fetters（writing），ZHAO Xinyue（translator），HAN Jianjun，XU Yanli，YANG Hui（reviser）

2019, 22(25): 3035-3040. DOI: 10.12114/j.issn.1007-9572.2019.00.526

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Healthcare guidelines play a prominent role in the day- to- day practice of primary care providers，and health policy research leads to the formation of these guidelines.Health policy research is the multidisciplinary approach to public policy explaining the interaction between health institutions，special interests and theoretical constructs.In this article，we demonstrate how primary care providers can conduct high-impact health policy research using Eugene Bardach's eightfold policy analysis framework in a primary care context.In a medical case，a woman with a history of total hysterectomy had scheduled a visit for a Papanicolaou（Pap）smear screening test as part of a wellwoman health check-up with a family medicine resident.Conflicting recommendations on Pap smear screening after total hysterectomy sparked an investigation using the US Preventive Services Task Force criteria for conducting a health policy analysis.We illustrate broadly how clinical care dilemmas can be examined by using Bardach's broadly applicable health policy framework in order to inform meaningful policy change.Bardach's framework includes （1） defining the problem，（2） assembling evidence，（3） constructing alternatives，（4） selecting criteria，（5） projecting outcomes，（6） confronting trade-offs，（7）decision-making and （8） sharing the results of the process.The policy analysis demonstrated insufficient evidence to recommend Pap test screening after hysterectomy and the findings contributed to national recommendations.By following Bardach's steps，primary care researchers have a feasible and powerful tool for conducting meaningful health policy research and analysis that can influence clinical practice.

Needs of Home-based Health Services Delivered by Community Healthcare Institutions among China's Elderly People　

TAN Wenjing，CHEN Gong

2019, 22(25): 3041-3048. DOI: 10.12114/j.issn.1007-9572.2019.00.528

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Background　Community healthcare institutions（CHIs）are a top priority for China's medical reform.Home-based health services are a type of featured services delivered by CHIs.Identifying the overall needs and intersubgroup differences in needs of home-based health services among the elderly is conducive to the formulation of regimens for the delivery of home-based health services.Objective　To investigate the status and features of overall needs and intersubgroup differences in needs of home-based health services delivered by community healthcare institutions among China's elderly people.Methods　Participants were 7 626 older adults selected from the respondents of 2014 China Longitudinal Aging Social Survey（CLASS）．Analysis was performed on their needs of home-based health services delivered by community healthcare institutions including home-based nursing care，consultation and rehabilitation.Logistic regression was used to analyze the influencing factors of home-based health service needs of elderly.Results　22.83%（1 741/7 626）of the participants needed home-based health services delivered by community healthcare institutions.Among them，the most needed〔91.96%（1 601/1 741）〕was home-based consultation.The needs of home-based nursing care，consultation，and rehabilitation were significantly different among different age groups.Home-based consultation was more needed in those who were much older and those living in rural areas and urban village communities.In those born in 1934 and earlier，gender，preferred place for living after retirement，current living arrangement，number of houses owned，place of residence，and community type were the influencing factors of needs of home-based health services（P<0.1）．In those born from 1935 to 1944，self-rated health status，main source of livelihood，place of residence，and community type were the influencing factors of needs of home-based health services（P<0.1）．In those born from 1945 to 1954，gender，marital status，education level，self-rated health status，preferred place for living after retirement，current living arrangement，and community type were the influencing factors of needs of home-based health services（P<0.1）．Conclusion　The rate of needing home-based health services delivered by community healthcare institutions among China's elderly people is low，which is associated with birth year，living environment，individual preferred status for living after retirement and other special personal characteristics.

Bi-directional Referral Situation and Influencing Factors in Haidian Community-dwelling Residents Receiving Healthcare Services from a Regional Medical Consortium　

LEI Yi，ZHAO Yan，SUN Jing

2019, 22(25): 3049-3054. DOI: 10.12114/j.issn.1007-9572.2019.00.391

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Background　Bi-directional referrals have been carried out nationwide，but there are still problems during the implementation，such as unsuccessful referrals，easy implementation of upward referrals but difficult implementation of downward referrals，and bi-directional referrals almost becoming unidirectional referrals.Understanding the status of bi-directional referrals and influencing factors in community-dwelling residents greatly promotes the improvement of the bi-directional referral system.Objective　To investigate bi-directional referrals and influencing factors in community-dwelling residents in Haidian District，Beijing，providing evidence for the development of referral programs and policies for the medical consortium.Methods　A combination of quantitative and qualitative research methods is used.Quantitative research is divided into two parts.The first part is about the statistic analysis of number of patients transferred from lower level hospitals and related department data provided by Appointment and Referral Center，Peking University Third Hospital.The second part is about the analysis of the results（including basic socio-demographic data，referral experience and influencing factors） of a survey〔achieving a response rate of 91.2%（547/600）〕conducted with a self-developed questionnaire among community-dwelling residents with referral experience from February to June 2018 in the Peking University Third Hospital Medical Consortium，Haidian District，Beijing.The qualitative research was based on individual interviews with a outpatient department leader，2 doctors，and 2 doctors from a core hospital，a tertiary hospital，and a primary care hospital in a regional medical consortium，respectively，and 10 community-dwelling residents with referral experience in the regional medical consortium.Results　In the medical consortium，the number of patients transferred upwardly increased by 2 507 in 2016 compared with 2014，with an increase rate of 106.5%.But that decreased in 2017 compared with 2016.Among the 547 respondents，474（86.7%） experienced upward referral，106（19.4%） experienced downward referral，and 33（6.0%） experienced bi-directional referrals.The main reason for upward referral reported by most respondents（73.0%） was high level of diagnosis and treatment in the tertiary hospital.Age，monthly income，education level and type of medical insurance were associated with upward referral（P<0.05）.The main reason for downward referral reported by most respondents（51.9%） was short distance between their home and the hospital.Monthly income and awareness level of bi-directional referrals were associated with downward referral（P<0.05）.Qualitative interviews showed that major facilitators to residents' referral behaviors were referrals meeting the healthcare needs，and referrals being convenient for healthcare seeking.And the major barriers to residents' referral behaviors were insufficient publicity of the service capacity of primary care institutions and poor service delivery initiative in primary care doctors.Conclusion　The development of bi-directional referral in the regional medical consortium shows a good trend since it has been implemented，but it is far from perfect.In order to better implement the bi-directional referral system and policies，it is suggested to increase inputs to primary care institutions，improve residentsh awareness level of bi-directional referral，and build departments with competitive advantages in primary care institutions.

Working Models of Family Doctor Assistants in Jiading District of Shanghai：a Current Survey　

LU Qiuxia，CHEN Ping，ZHAI Jiayi，TAO Qiongying

2019, 22(25): 3055-3061. DOI: 10.12114/j.issn.1007-9572.2019.00.496

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Background　The supporting documents for the new round of comprehensive community health reform（launched in 2015） in Shanghai proposed that family doctor assistants（FDAs） should be included in the family doctor team.However，the specific definition and duties of FDAs are not elaborated in detail.Objective　To examine the career development status and pathways of FDA workforce in Shanghai's Jiading District，offering a reference for further determination of the working models of FDAs.Methods　This survey was conducted in four community health centers（CHCs） selected from Shanghai's Jiading District（one is in urban area，one in the suburban area，and two in the peri-urban area） from January 2 to 4，2018.Interviews were carried out with three groups（managers，family doctor team leaders，and FDA representatives） from each CHC，respectively，involving a series of questions about the organizational structure of the family doctor team，employment mechanisms，duties，performance allocation and career development pathways of FDAs.Results　All these CHCs had medical assistants for family doctors，but the duties were implemented part time by the members of the family doctor team.Two CHCs had full-time administrative assistants for family doctors without staffing.Each CHC self-determined the duties of FDAs.And the position title，attached department，general tasks，and working relationship of the FDAs differed significantly across the CHCs.For the management of FDAs，two CHCs used two-level assessment and two-level allocation mechanisms.In two CHCs，the family doctor team leader had the right to assess and allocate the performance for FDAs，but in other two，the family doctor team leader had not.In terms of the most suitable person for the position，nurses were proposed by one CHC，while general practitioner assistants receiving trainings of "3+2" program were proposed by other CHCs.Conclusion　In Shanghai's Jiading District，the employment mechanism，duties，and performance allocation for FDAs in each CHC are distinctive，and differ significantly across the CHCs.Moreover，working models of FDAs in all CHCs are not unified.It is suggested that the working mode of FDAs should be constructed according to the ratio of service urban areas to rural areas of the CHC，the needs of the residents served，and the conditions of the local areas.Furthermore，to play the due role of family doctor as the main body responsible for delivering family doctor services，and to achieve the maximum professional value of both family doctors and FDAs，family doctor is suggested to determine the duties of FDAs，allocate tasks to them，and assess and supervise their performance.

Construction of a New General Medical Services System Using the Internet　

ZHANG Zhaochun，HU Haiyuan，ZHANG Yili

2019, 22(25): 3062-3067. DOI: 10.12114/j.issn.1007-9572.2019.00.553

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General medical services are an important part of the primary health care system.We analyzed the present situation and existing problems of general medical services system in China.On the basis of this，by using the internet technology，we constructed the framework of a new internet-based general medical services system，and explained the new pathways for building it，benefiting the improvement of China's general medical services system.Constructing this new system faces both opportunities and challenges，which requires the joint efforts of the government，general medical institutions，operators，suppliers and patients.

Information Construction in Community Health Service Centers and Implications for Policy　

XIA Yinghua，HONG Zihui，CAO Rong，LIU Guoheng，CAI Hui，HE Qun

2019, 22(25): 3068-3075. DOI: 10.12114/j.issn.1007-9572.2019.00.527

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Background　The big data strategy and "internet+ health service" policy which are promoted from the national level to the grassroots level are faced with the dilemma of isolated data islands.Under the background of "strengthening grassroots"，research on development of informatization at grassroots is scarce.Objective　To investigate the current status of information systemin community health service centers（CHSCs）from aspects of construction，data collection approach，and data utilization of these data，and give recommendations for policy making.Methods　A case study was conducted in one of the National Top 100 CHSCs in Guangzhou from December 2018 to January 2019.Field observations and focus interviews were used to collect data.Relevant documents were also collected.NVivo was used in content analysis.Results　In the CHSC under observation，there were a total of 35 information systems and these systems were not connected to each other.Data were collected in a low efficiency manner and repeated collection was a problem.Related work performance assessment negatively impacted the working motivation of the staff because the function of the information systems was imperfect.The center seldom used data in these systems to plan and enhance community health services.This phenomenon reflected the insufficiency of the upper-level administrative department in system design and planning and data use guidance.Conclusion　Information collection in information systems is inconvenient in the CHSC and information does not play a significant role in promoting community health service ability.Informatization supports work performance assessment in some extent，but it has a negative impact on work enthusiasm of the staff，especially the public health personnel.We suggest that speeding up improvement of upper level policies about the construction of information platform and data sharing，and transforming polices into regulations to guide the market development.We also suggest change the approaches of data collection and work performance assessment，and strengthen guidance of community information utilization.

Exploration and Practice of Internet Plus Contracted Family Doctor Services　

HUANG Yumei，GONG Yiwei，FANG Hui

2019, 22(25): 3076-3080. DOI: 10.12114/j.issn.1007-9572.2019.00.519

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The integration of internet and contracted family doctor services（CFDS） represents a new development direction of community health services.This paper mainly introduces the practice of Datang Community Health Service Center of Wuzhou City.By integrating the medical data and resources in the region，Datang Community Health Service Center constructed a new model of internet plus CFDS by using three measures of advanced technology support，local policy support，and cooperation mode innovation.This model improved the service capacity of community health service institutions as well as the management efficiency of family doctors，provided residents with online and offline services of internet，and improved residents' self-consciousness in participating in health management，which could provide the reference for the development of "internet plus family doctors" services in other cities.

Prevalence and Economic Risks of Common Chronic Non-communicable Diseases among Older Adults in Rural Yunnan Province　

LI Xiao，CAI Le，CUI Wenlong，WANG Xuming，HUANG Jingjing，WU Chao，LYU Siqi

2019, 22(25): 3082-3087. DOI: 10.12114/j.issn.1007-9572.2019.00.545

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Background　The prevalence of chronic non-communicable diseases（NCDs）is increasing due to economic development and rapid population aging，which imposes a heavy economic burden on patients and their families.Objective　The aim of this study was to estimate the prevalence and economic risks of hypertension，diabetes，coronary heart disease（CHD），stroke and chronic obstructive pulmonary diseases（COPD）among older adults in rural Yunnan Province.Methods　Multi-stage stratified random sampling was used to select the study sample consisted of 4 833 adults aged 60 years and over in rural Yunnan Province from July 2016 to July 2017.Each participant received personal interview survey and physical examination.Information on demographic，economic status，prevalence of hypertension，diabetes，CHD，stroke and COPD，medical expenditure and access to medical service were collected in the interview.Height，weight，blood pressure（BP），fast blood glucose（FBG）and 2-hour postprandial blood were measured.The t-test was used to compare the economic risks〔relative risk（RR）and adjusted relative risk（ARR）〕of five chronic NCDs，and chi-square test was computed to compare the prevalence of chronic NCDs，incidence of catastrophic health expenditure and impoverishing health spending by demographic characteristics.Results　Among the population，the overall prevalence of hypertension，diabetes，CHD，stroke and COPD was 50.63%（2 447/4 833），10.22%（494/4 833），5.56%（269/4 833），6.45%（312/4 833）and 5.48%（265/4 833），respectively.Females had higher prevalence of hypertension and diabetes than males（53.13% vs 47.63%，11.00% vs 9.23%，P<0.05），whereas males had a higher prevalence of COPD than females（6.32% vs 4.78%，P<0.05）．Older adults with poor household assets and poor access to medical services had higher prevalence of hypertension，CHD，stroke and COPD than their counterparts with good household assets and good access to medical services（P<0.05）．CHD，stroke and COPD patients had higher economic risk than the observed population：RR were 1.92，1.91，1.65，respectively，and ARR were 1.69，1.59，1.70，respectively.The incidence of catastrophic health expenditure due to hypertension，diabetes，CHD，stroke and COPD was 17.5%（478/2 477），22.5%（111/494），36.1%（92/269），37.5%（118/312）and 35.8%（95/265），respectively，whereas incidence of impoverishing health spending due to these five diseases was 9.1%（223/2 477），11.7%（58/494），19.3%（52/269），18.3%（57/312）and 18.1%（48/265），respectively.Poor household assets were associated with higher incidence of catastrophic health expenditure and impoverishing health spending due to hypertension，diabetes，and stroke（P<0.05）．Poor access to medical services was associated with higher incidence of catastrophic health expenditure due to hypertension（P<0.05）．Conclusion　In rural Yunnan Province，older adults with stroke，CHD，or COPD have higher economic risk of diseases.Future medical support should be strengthened for families having an older chronic disease member and poor household assets，as well as poor access to medical care.

Relationship between Thyroid Hormone Levels and Non-alcoholic Fatty Liver Disease in Euthyroid Population　

LIU Yiting，WANG Wei

2019, 22(25): 3088-3093. DOI: 10.12114/j.issn.1007-9572.2019.00.494

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Background　The incidence of non-alcoholic fatty liver disease（NAFLD） is rising year by year，and is increasingly occurring in younger people.Moreover，its occurrence is related to the components of metabolic syndrome，while hypothyroidism is closely related to the occurrence of metabolic syndrome.Currently，the relationship between thyroid hormone levels and NAFLD in people with normal thyroid function in studies has not been determined.Objective　To investigate the relationship between thyroid hormone levels and NAFLD in people with normal thyroid function，so as to provide a basis for the prevention and treatment of NAFLD.Methods　From the hospital information system database of the First Affiliated Hospital of China Medical University，15 660 physical examinees with normal thyroid function were enrolled during January 2013 to October 2018.By color Doppler ultrasound examination of the liver，7 095 were found with NAFLD（NAFLD group），and 8 565 without（non-NAFLD group）．The levels of thyroid-stimulating hormone（TSH），free triiodothyroine（FT3） and free thyroxine（FT4） in the two groups were compared.Logistic regression analysis was conducted to explore the changes in prevalence of NAFLD by thyroid hormone level.Stepwise multiple Logistic regression was used to analyze the effect of thyroid hormone level on the prevalence of NAFLD.Results　NAFLD group showed higher mean serum levels of TSH and FT3，and lower mean serum FT4 level compared with non-NAFLD group（P<0.05）．The prevalence of NAFLD increased with the elevation of serum TSH and FT3 levels but reduced with the growth of FT4 level（Ptrend<0.05）．Stepwise multiple regression analysis showed that after excluding the multicollinearity effect of thyroid hormone level，and adjusting for sex，age and other metabolism-related indicators，serum TSH〔OR=1.065，95%CI（1.019，1.113）〕，FT3〔OR=1.175，95%CI（1.078，1.282）〕，and FT4〔OR=0.934，95%CI（0.908，0.961）〕 levels were the influencing factors of NAFLD（P<0.05）．Conclusion　In people with normal thyroid function，higher serum TSH and FT3 levels and lower serum FT4 level are associated with higher risk of NAFLD.To effectively prevent and delay the occurrence and development of NAFLD in this group，health managers should focus on monitoring the changes of TSH，FT3 and FT4 levels.

Relationship of Lipid Accumulation Product and Alcohol Consumption with Risk of Hypertension in Men　

SUN Liangliang，XIE Hong，ZHANG Yanfang，WANG Lihua

2019, 22(25): 3094-3098. DOI: 10.12114/j.issn.1007-9572.2019.00.438

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Background　Heavy alcohol consumption and obesity are two important modifiable risk factors for hypertension，and the mechanisms of the two risk factors leading to hypertension are similar.Lipid accumulation product（LAP），a new obesity index，is more closely related to metabolic diseases.There may be interactions between high LAP and heavy alcohol consumption on the risk of hypertension in men.Objective　To explore the relationship of LAP and alcohol consumption with the risk of hypertension in men，and to analyze whether there is additive interaction between high LAP and heavy alcohol consumption.Methods　Stratified random sampling method was used to select 1 822 permanent male residents over 18 years in Longzihu District of Bengbu from July to August 2015，and 1 306 of them were eligible for the final analysis.Participants were divided into non-hypertension groups（n=673） and hypertension（n=633），and intergroup comparison of the demographic characteristics，results of the physical examination，laboratory examination results.The Youden's index was used to determine the optimal cut-off point of LAP screening for hypertension.High LAP was defined as equal to or higher than the optimal cut-off point.Multivariate Logistic regression was used to analyze the relationship of high LAP and/or heavy alcohol consumption with the risk of hypertension，and to further assess the impact of interaction between high LAP and heavy alcohol consumption on hypertension.Synergy index（SI），relative excess risk due to interaction（RERI），and the attributable proportion due to interaction（AP）were calculated.Results　There were significant differences in age，alcohol consumption，physical activity and family history of hypertension between hypertension and non-hypertension groups（P<0.05）．The total cholesterol，triglyceride，fasting blood glucose，glycosylated hemoglobin，waist circumference，body mass index and LAP in hypertension group were significantly higher than those in non-hypertension group（P<0.05）．The optimal cut-off point of LAP in the screening of hypertension was 29.69 cm•mmol/L（sensitivity and specificity were 0.64，0.59，respectively）．After adjusting for age，smoking，physical activity and family history of hypertension，participants with high LAP〔OR=2.79，95%CI（2.19，3.55）〕or heavy alcohol consumption〔OR=1.60，95%CI（1.15，2.21）〕had a higher risk of hypertension.And the risk was even higher for those with both high LAP and heavy alcohol consumption〔OR=4.75，95%CI（3.10，7.27），SI=1.64，95%CI（0.91，2.98），RERI=1.47，95%CI（-0.47，3.40），and AP=0.31，95%CI（<0.01，0.62）〕.Conclusion　High LAP or heavy alcohol consumption increased the risk of hypertension in men.And the risk would be higher if both high LAP and heavy alcohol consumption coexist.But no significant additive interaction was found between the two factors on the risk of hypertension.

Analysis of the Difference between the Prevalence of Caries and Eating Patterns of Preschool Children Aged 3 to 5 in the North and South of Jiangxi Province

YAO Yao，OU Xiaoyan，ZHOU Xiaojun，ZHOU Yinshuang，LUO Die，LAI Jiawei

2019, 22(25): 3099-3103. DOI: 10.12114/j.issn.1007-9572.2019.00.451

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Background　Dental caries are common oral diseases of children，and children's eating habits make deciduous teeth easy to have caries.Understanding dietary differences and caries status of preschool children in southern and northern Jiangxi Province is of great significance for caries prevention of children in these two areas.Objective　To understand the caries status and dietary patterns of children aged 3 to 5 in the north and south of Jiangxi Province，and to explore the relationship between caries and dietary patterns，so as to provide scientific basis for caries prevention and treatment in the areas.Methods　From December 2015 to October 2016，1 152 children aged 3 to 5 in southern and northern Jiangxi Province were selected by stratified random cluster sampling method.Clinical examination of preschool children's caries，decayed teeth（dt），missing teeth（mt），filled teeth（ft） and average dental caries（dmft） was carried out by a dental specialist according to World Health Organization standards.Investigators conducted a questionnaire on children's eating patterns.The survey included the preschool children's frequency of eating sweet desserts，drinking sweet drinks and sweetened milk，and eating sweet desserts before going to bed.Results　The caries rate of children in northern Jiangxi Province was 56.3%，which was significantly higher than that of children in southern Jiangxi Province（42.0%）.The difference was statistically significant（χ2=23.354，P<0.001）.The dmft of children in northern Jiangxi Province was（2.99±3.94），which was higher than that of children in southern Jiangxi Province（1.74±2.89）.The difference was statistically significant（Z=5.841，P<0.001）.The frequency of children eating sweet desserts and drinking sweetened milk in southern and northern Jiangxi Province was statistically different（P<0.05）.Logistic regression analysis showed that caries were more likely to occur in children with elder age，high frequency of eating desserts before going to bed in the north of Jiangxi Province（P<0.05）.Spearman correlation analysis showed that the higher the frequency of eating desserts，drinking sweet drinks，and eating desserts before going to bed it was，the more dmft teeth the children had（P<0.05）.Conclusion　The caries rate and dmft of children in northern Jiangxi Province are higher than those of children in southern Jiangxi Province.The caries rate of children is correlated with the frequency of sweet food intake.The eating patterns of children in northern Jiangxi Province are generally sweet.Changing the eating patterns of preschool children in northern Jiangxi Province is of great significance for the prevention of dental caries in children.

Glycosylated Hemoglobin Control and Associated Factors in Patients with Type 2 Diabetes Mellitus in the Community#br#

YANG Lijuan，ZHU Wenkui，XU Qi，DU Zhaohui，ZHANG Linying，TANG Xiaochun，XUE Weibin，CAO Yi，QIAO Huihua，ZHAO Hui，XUE Jinhua，XUE Feng

2019, 22(25): 3104-3109. DOI: 10.12114/j.issn.1007-9572.2019.00.392

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Background　Community-based management of diabetes has the advantages of geographical convenience and regular monitoring.Researching the control status of glycosylated hemoglobin（HbA1c） of diabetic patients in the community is of great significance for diabetes prevention and treatment.Objective　To investigate the control status of HbA1c and its influencing factors in patients with type 2 diabetes mellitus（T2DM） in Hudong Community of Shanghai.Methods　By use of random cluster sampling，692 T2DM patients from Hudong Community were enrolled and received a face-to-face survey，a physical examination and a laboratory test.By the level of HbA1c，they were divided into 3 groups：standard-reaching group（HbA1c<7%，n=314），good and fair control group（7%≤HbA1c<9%，n=276），and poor control group（HbA1c≥9%，n=102）．Body mass index（BMI），waist circumference，blood pressure，blood glucose，blood lipid，renal function and other factors in the three groups were compared and the factors influencing HbA1c were analyzed.Results　Among the 692 cases，the rates of achieving fasting plasma glucose（FPG） target，HbA1c target，total cholesterol（TC） target，triacylglycerol（TG） target，low-density lipoprotein cholesterol（LDL-C） target and high-density lipoprotein cholesterol（HDL-C） target were 31.4%（n=217），45.4%（n=314），37.0%（n=256），65.0%（n=450），32.1%（n=222），and 69.5%（n=481），respectively.Mean FPG and TG levels in good and fair control group were significantly higher than those of the standard-reaching group（P<0.05）．Poor control group showed much higher mean FPG and urinary albumin to creatinine ratio（UACR），and lower mean serum uric acid（SUA） and estimated glomerular filtration rate（eGFR） compared with other two groups（P<0.05）.Spearman correlation coefficient analysis showed that waist circumference，FPG，TG and UACR were positively associated with HbA1c（rs=0.077，0.584，0.114，0.142；P<0.05），and HDL-C and SUA were negatively associated with HbA1c（rs=-0.087，-0.156；P<0.05）．Logistic regression analysis showed that FPG and SUA were the influencing factors of HbA1c level（P<0.05）．Conclusion　The HbA1c control in patients with T2DM in this community needs to be further improved.HbA1c level is related to blood lipid and waist circumference.So community-based diabetes management should also strengthen the delivery of comprehensive interventions，such as weight control and blood lipid control，besides glycemic control.

Relationship of H-type Hypertension with Oxfordshire Community Stroke Project Classification and Short-term Outcome of Acute Cerebral Infarction　

ZHANG Tian，FENG Xiaoli，WANG Tan，XU Zhongzhong

2019, 22(25): 3110-3115. DOI: 10.12114/j.issn.1007-9572.2019.00.412

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Background　Serum homocysteine（Hcy）may involve in the methylation of many kinds of cells.Hyperhomocysteinemia can increase the risk of stroke，while hypertension is the most important risk factor for stroke.However，there are few reports on the influence of H-type hypertension on the classification and short-term outcome of acute cerebral infarction（ACI）．Objective　To analyze the relationship of H-type hypertension with Oxfordshire Community Stroke Project（OCSP）classification and short-term outcome of ACI.Methods　226 patients clinically diagnosed with ACI in Department of Neurology，the First Affiliated Hospital of Hainan Medical University were enrolled from February 2016 to February 2018，and were divided into four groups according to the prevalence of primary hypertension and serum Hcy level：simple ACI group（n=41），simple high Hcy group（n=70），simple hypertension group（n=42），and H-type hypertension group（n=73）.Intergroup comparisons were performed in terms of OCSP classification and clinical characteristics of ACI，neurological status assessed by the National Institutes of Health Stroke Scale（NIHSS），and outcomes assessed by Barthel Index（BI）and modified Rankin Scale（mRS）at admission and on the 30th day after the onset of ACI.Results　The percentages of four subtypes of ACI assessed by OCSP classification differed significantly across the four groups（P<0.01）．Mean NIHSS score，BI and mRS score at admission and at the 30th day after onset of ACI also varied obviously across the four groups（P<0.01）．To be specific，H-type hypertension group showed higher mean NIHSS score at admission compared with simple hypertension group（P<0.05），lower BI on the 30th day after ACI onset compared with other three groups（P<0.05），and higher mRS score on the 30th day after ACI onset compared with simple ACI and simple hypertension groups（P<0.05）．In H-type hypertension group，lacunar infarction（LACI），posterior circulation infarction（POCI），partial anterior circulation infarction（PACI），and total anterior circulation infarction（TACI）patients showed significantly different mean NIHSS score，BI and mRS score at admission and at the 30th day after ACI onset（P<0.05）．TACI patients demonstrated higher mean NIHSS score at admission compared with other three subgroups（P<0.05）．LACI patients showed higher mean BI and lower mean mRS score at the 30th day after ACI onset compared with PACI and TACI subgroups（P<0.05）．Logistic regression analysis revealed that H-type hypertension，TACI，PACI and POCI were risk factors for poor outcome within 30 days after ACI onset（P<0.05）．Conclusion　H-type hypertension may be an important factor associated with the aggravation of the conditions and deterioration of the short-term outcome of ACI.In H-type hypertension patients with ACI，the most common subtype is LACI，with a relatively good outcome within 30 days after ACI onset，but TACI may has a relatively poor outcome.So the progression of ACI should be paid special attention.Early identification of H-type hypertension and delivering active interventions timely，are important actions to effectively prevent and control ACI，and reduce the level of stroke-induced disability.

Cost-benefit Analysis of Emergency Hepatitis B Vaccination in Beijing from 1992 to 2013　

WANG Xi，YUAN Shuting，BAI Qian，WU Jiang，SHI Xuefeng

2019, 22(25): 3116-3120. DOI: 10.12114/j.issn.1007-9572.2019.00.498

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Background　Cost-benefit analysis is an effective means for health economic evaluation.There are few studies on cost-benefit analysis of emergency hepatitis B vaccination in Beijing on municipal level.Since the implementation of the hepatitis B vaccination program in Beijing，huge costs have been invested.By analyzing the related data，costs and benefits of the implementation of the program may be assessed relatively accurately.Objective　To perform a cost-benefit analysis of the implementation of emergency hepatitis B vaccination program in Beijing from 1992 to 2013.Methods　From January 2016，we collected the data of the implementation of emergency hepatitis B vaccination program in Beijing from 1992 to 2013 by searching relevant literature and
querying existing work records，and used up-and-down method and step-by-step modeling to estimate costs and benefits of the implementation during this period.Results　During 1992 to 2013，the total costs of acute hepatitis B virus（HBV） infection were 122.398 6 million yuan.In 2017，the annual cost of this disease was highest（14.295 0 million yuan），which is 32.98 times higher than the lowest appeared in 1994（0.433 4 million yuan）.The planned total costs of hepatitis B immunization program showed a slight decrease trend during 1992 to 1996（from 5.421 4 million yuan to 3.786 5 million yuan），then grew gradually（it rose to 7.053 2 million yuan in 2010），and showed a sharp increase between 2011 and 2013（it rose to 13.272 0 million yuan in 2013）.From 1992 to 2013，the total benefits of preventing and treating of acute HBV infection in Beijing were 6 975 113.80 yuan，showing an overall upward trend，with an average annual benefit of 317 050.63 yuan，and an average annual growth rate of 8.08%.The incremental cost-benefit ratios for the hepatitis B immunization program implemented in 1992，1993—2006，and 2007—2013 were 0.02，-0.21，and 0.07，respectively.Conclusion　The implementation of hepatitis B immunization program in Beijing has achieved good results in general，effectively reducing the economic burden of patients with acute HBV infection.

Effect of Application of Clinical Pathway on Cost Control of Respiratory Inpatient Care in Primary Healthcare Facilities 　

REN Xiaohong，XU Yunli，MAO Shan，TONG Bin，JI Li，SUN Di，SHAO Hongtao

2019, 22(25): 3121-3124. DOI: 10.12114/j.issn.1007-9572.2019.00.542

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Background　Clinical pathway（CP）is a modern management model widely used in large-scale general hospitals，which helps to improve the quality of healthcare.However，there are few studies concerning on its use in inpatient care for single diseases in primary healthcare facilities.Objective　To evaluate the effect of CP use on cost control of inpatient care for single diseases in primary healthcare facilities.Methods　This retrospective study was conducted in Qinhong Community Health Center after the single disease（respiratory disease）was determined and the corresponding CP management regimen was developed.Participants were composed of control group〔CAP inpatients（subgroup A1）and AECOPD inpatients（subgroup B1）treated without CP management（control group）during March to December 2016〕，and CP group〔CAP inpatients（subgroup A2）and AECOPD inpatients（subgroup B2）treated with CP management during January 2017 to March 2018〕.The average length of stay，total hospitalization expense，percentage of pharmaceutical cost，and percentage of antibiotics cost were compared between subgroups A1 and A2，and between subgroups B1 and B2.Results　There were no significant differences in average age，sex ratio，and disease severity between subgroups A1 and A2，and between subgroups B1 and B2（P>0.05）.Shorter average length of stay，less total hospitalization expense，lower percentage of pharmaceutical cost，and lower percentage of antibiotics cost were found in subgroup A2 instead of subgroup A1（P<0.05），and in subgroup B2 instead of subgroup B1（P<0.05）.Conclusion　Single disease management with CP can reduce the total hospitalization costs，shorten hospital days and standardize antibiotic use in primary healthcare facilities．

Moderation Effect of Family Interpersonal Relationship in the Path from Anger Trait and Expression to Anxiety among College Students　

LIU Liang，LIU Cuilian，ZHAO Xudong

2019, 22(25): 3125-3131. DOI: 10.12114/j.issn.1007-9572.2019.00.497

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Background　High trait anger and suppressing anger in individuals are correlated with the anxiety symptoms.Family interpersonal relationship is also related to individual anxiety.However，the role that family interpersonal relationship plays in the path from anger to anxiety remains unclear.Objective　To explore the moderation effect of family interpersonal relationship on the anger trait and expression in anxiety，in order to provide clinical implication for the prevention and treatment of anxiety among college students.Methods　From February to April 2018，a total of 2 451 college students were recruited from the first and second grades of a Chinese comprehensive university using convenient sampling method.Symptom Check List-90，State-trait Anger Expression Inventory-2，Family Adaptability and Cohesion Scale Ⅱ-Chinese Version，and Family Environment Scale-Chinese Version were used to assess students' anxiety levels，anger trait and expression，and family cohesion，adaptability and conflict.Multivariate linear regression analysis was used to analyze the moderation effect of family cohesion，adaptability and conflict on the anger trait and expression in anxiety among college students.Results　A total of 1 986（81.03%） valid questionnaires were returned.No significant differences in anxiety scores were found between genders（P>0.05）.Anxiety scores of male and female students were positively correlated with anger temperament，anger reaction，anger expression-in，anger expression-out and family conflict（correlation coefficients were 0.17 to 0.46，P<0.05） and negatively correlated with family adaptability and cohesion（correlation coefficients were -0.24 to -0.16，P<0.05）.The analyses demonstrated that family conflict of male students had the moderation effect on their anger temperament in anxiety（b'=-0.07，P<0.05）；and family adaptability of female students had the moderation effect on their anger reaction in anxiety（b'=-0.26，P<0.05）.Conclusion　Higher anger proneness contributes to the development of anxiety.The family circumstance where family conflict and negative emotions are publicly expressed with more openness may protect male students with higher anger trait against developing anxiety.Among female students accustomed to higher anger trait，a flexible and resilient family communication model is a protective factor which would reduce their vulnerability to anxiety.

Mediating Role of Attentional Control in the Relationship between Irrational Beliefs and Social Anxiety　

LI Ci，LI Tiantian，CAO Jianqin，SU Hong，SUN Hao，CAI Yunjiang

2019, 22(25): 3132-3137. DOI: 10.12114/j.issn.1007-9572.2019.00.529

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Background　Although many studies have confirmed the correlations between social anxiety，irrational beliefs，and attentional control，the study about whether attentional control can affect the relationship between irrational beliefs and social anxiety is rather scant.Objective　To explore the mediating role of attentional control in the relationship between irrational beliefs and social anxiety.Methods　In October 2016，1 611 college students were selected by stratified random cluster sampling.They received a paper survey with the Interaction Anxiousness Scale（IAS），Irrational Belief Scale（IBS）and Attentional Control Scale（ACS）.The structure equation model and Bootstrap were adopted to verify the mediating effect of attentional control in the relationship between irrational beliefs and social anxiety.Results　IAS score was positively correlated with the scores of three dimensions of IBS（r=0.112-0.349，P<0.001），but was negatively correlated with the scores of three dimensions of ACS（r=-0.376--0.288，P<0.001）.Structural equation modeling showed that attentional control played a partial mediation role between irrational beliefs and social anxiety（χ2/df=3.630，RMSEA=0.040，CFI=0.980，TLI=0.967，SRMR=0.030）.And Bootstrap indicated that the 95%CI of mediating effect of attentional control was（0.128，0.195），and the mediating effect accounted for about 36.6%.Conclusion　Attentional control partially mediates the relationship between irrational beliefs and social anxiety.So it may be used as an emotion regulation strategy to regulate the relationship between negative cognition and social anxiety，and may be used as a target in the future treatment of social anxiety disorder.

Therapeutic Evaluation of Irritable Bowel Syndrome with Diarrhea Treated by Warming the Spleen and Stomach and Nourishing the Gut　

ZHAO Hongbo，WU Xiaojing，YANG Yun，GE Zhiming

2019, 22(25): 3137-3143. DOI: 10.12114/j.issn.1007-9572.2019.00.530

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Background　The pathogenesis of irritable bowel syndrome with diarrhea（IBS-D）is not clear.It has many precipitating factors，and high incidence，and is easily to recur，but has no specific clinical diagnostic index.Objective　To evaluate the clinical and gastrointestinal hormone responses to Shipi Decoction in IBS-D patients with spleen deficiency with dampness obstruction syndrome.Methods　From September 2017 to October 2018，sixty-five IBS-D patients were randomly divided into TCM group（33 cases）and western medicine group（32 cases）by use of a random number table，receiving a 4-week oral administration of Shipi Decoction，and Dicetel，respectively.Serum levels of substance P（SP），5-hydroxytryptamine（5-HT），vasoactive intestinal peptide（VIP），interleukin-10（IL-10） and interleukin-1β（IL-1β）were measured before treatment，at the end of the 2nd and 4th weeks of treatment and at 3 months after withdrawal，respectively.IBS Bowel Symptom Severity Scale（IBS-BSS），IBS Quality of Life Questionnaire（IBS-QOL）and Traditional Chinese Medicine Pattern Curative Effect Scoring System（TCM-PES）were used to evaluate the clinical efficacy，quality of life，improvement of TCM syndromes and relapse，respectively.Results　Five cases dropped out during the treatment（2 cases were lost in TCM group，1 was lost and 2 abandoned treatment in western medicine group），the remaining 60 cases（92.3%）were included in the per-protocol analysis.TCM group showed lower post-treatment mean serum levels of SP，5-HT，VIP and IL-1β（P<0.05）and higher post-treatment mean IL-10 level（P<0.01）compared with western medicine group at the end of the 2nd and 4th weeks of treatment and at 3 months after withdrawal.After treatment，there were significant differences in scores of 5 items and total scores of IBS-BSS between the two groups（P<0.05）.Except for the scores of two subscales（body image and relationships），the scores of other 6 subscales of IBS-QOL differed significantly between the groups（P<0.05）.The improvements in TCM syndromes in TCM group were better than those of western medicine group at the end of the 2nd and 4th weeks of treatment（P<0.05）.After 3 months of withdrawal，recurrence occurred in 3 cases in TCM group and in 6 cases in western medicine group，showing significant difference（χ2=9.506，P=0.033）.Conclusion　For patients with IBS-D，Shipi Decoction could effectively relieve the clinical symptoms，improve the quality of life，and regulate gastrointestinal hormone levels with low recurrence rate，indicating it has a definite medium- and long-term efficacy.

Efficacy and Safety of "Bianmitong" on Opioid-induced Constipation in Cancer Patients　

CHEN Zegang，ZHAO Chunni，ZHANG Linsong

2019, 22(25): 3144-3148. DOI: 10.12114/j.issn.1007-9572.2019.00.543

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Background　Opioid-induced constipation（OIC）is often seen in patients with moderate to severe cancer pain using opioids.OIC can cause many patients to be forced to reduce or discontinue the use of opioids，which makes the treatment of OIC critical in cancer patients.Objective　An randomized controlled trial and an extended study were used to assess the efficacy and safety of "Bianmitong" on OIC in patients with cancer.Methods　From January 2017 to February 2018，129 cancer patients with OIC in the Department of Oncology in Traditional Chinese Medicine Hospital Affiliated to Southwest Medical University were enrolled in the study.Patients were divided into a placebo group of 64 patients and a Bianmitong group of 65 patients using a central randomization system and a minimized randomized algorithm for randomized controlled trials.After that，89 patients were enrolled in a 12-week extension study.The primary end point of efficacy was the proportion of spontaneous bowel movement（SBM）responders during the 2-week treatment period.The secondary study endpoints included weekly SBM frequency，complete spontaneous bowel movement（CSBM），and effortless SBM.Safety assessments included treatment-emergent adverse effects（TEAEs），Clinical Opiate Withdrawal Scale（COWS） scores，and an 11-point Numeric Rating Scale（NRS）scores for assessing pain intensity.The efficacy and safety of the placebo group and the Bianmitong group were compared and the safety of the extended group was analyzed.Results　There were no significant differences in demographic information and baseline data between the Bianmitong group，the placebo group，and the extended group（P>0.05）．The proportion of SBM responders in the Bianmitong group and placebo group were 72.3%（47/65）and 34.4%（22/64），respectively.The proportion of SBM responders in the two groups was statistically significant（χ2=18.651，P<0.001）．There was no significant difference in the baseline SBMs between the Bianmitong group and the placebo group（P>0.05）．The SBMs，CSBMs，and effortless SBMs in the Bianmitong group were higher than those in the placebo group（P<0.05）．There was no significant difference in TEAEs and the situation of withdrawal between the placebo group and the Bianmitong group（P>0.05）．The incidence of diarrhea in the Bianmitong group was higher than that in the placebo group（P<0.05）．The incidence of TEAEs，withdrawal，and diarrhea in the extended group were 28.0%（25/89），9.0%（8/89），and 15.7%（14/89）．There was no significant difference in the COWS scores between the Bianmitong group and the placebo group at baseline and 1 d，8 d，and 15 d after the first dose（P>0.05）．The COWS scores of the extended group at baseline，1 day before treatment，and 1 d，8 d，29 d，57 d，and 85 d after treatment were（1.51±0.57）（1.67±0.74）（1.58±0.56）（1.58±0.67）（1.58±0.58）（1.63±0.55）and（1.60±0.52），respectively.There were no significant differences in the NRS scores between the Bianmitong group and the placebo group at baseline and 1-14 d after treatment（P>0.05）．Conclusion　Bianmitong treatment of cancer patients with OIC is effective and safe.

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