Chinese General Practice

Practice and Effect of "First-class Financial Supply，Second-class Performance Management" Plan in Primary Health Care Institutions　

ZHANG Lifang，QIN Jiangmei，ZHANG Yanchun，LIN Chunmei，MENG Yeqing，TAO Mengyuan

2020, 23(1): 1-6. DOI: 10.12114/j.issn.1007-9572.2020.00.093

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"First-class Financial Supply，Second-class Performance Management" Plan in public welfare is the key content of the current comprehensive reform in primary health care.Guangdong Province took the lead in implementing this plan and has received certain achievements.Therefore，its reform experience has been popularized as the typical demonstration nationwide.But there are differences in the actual situation of different regions，problems and reform priorities in pushing forward this reform plan are also various.Based on the 2019 Typical Cases of Comprehensive Reform in Primary Health Care and field investigation，this paper summarized and analyzed the specific measures in the implementation of "First-class Financial Supply，Second-class Performance Management" Plan in public welfare in Guangdong Province（especially Yingde City and Shaoguan City），Hainan Province（especially Lingshui County and Wuzhishan City），and Heze City of Shandong Province.The achievements of each region in improving service ability and stimulating operational workload of primary health care institutions，and improving the attractiveness to and satisfaction of patients were briefly described.Although different regions are faced with various problems and reform priorities，the vigorous promotion of the government，the close cooperation between departments，and the initiative of primary health care institutions are all important factors in advancing the "First-class Financial Supply，Second-class Performance Management" Plan.

The Development Trend and Allocation Equity of General Practitioners in China　

FU Yingjie，WANG Jian，MENG Yan，YU Lexin，YAN Weihua，KONG Yuejia

2020, 23(1): 7-13. DOI: 10.12114/j.issn.1007-9572.2019.00.787

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Background　General practitioners are "gatekeepers" of residents' health.It is one of the key tasks of current medical reform to vigorously train general practitioners and carry out the initial diagnosis and treatment of family doctors at the grassroots level and to promote hierarchical diagnosis and treatment.At present，there is a lack of research on the equity of allocation of general practitioners with recent data.Objective　To analyze the current situation of allocation of general practitioners in China，in order to explore its development trend and equity.Methods　Data from the China Statistical Yearbook 2013—2018 and China Health and Family Planning Statistical Yearbook（China Health Statistics Year Book）2013—2018 were used to describe statistically the basic situation of allocation of general practitioners in China.The resource allocation equity of general practitioners was measured from the aspects of the population，geographical area and economic development using Lorenz curve，Gini coefficient and Theil index.Results　From 2012 to 2017，the number of general practitioners in China increased from 109 794 to 252 712，with an average annual growth rate of 18.14%.In 2012 and 2017，the Gini coefficients of Chinese general practitioners based on population distribution were 0.31 and 0.26，based on economic development were 0.25 and 0.18，and based on geographic area were 0.74 and 0.72.The results of Theil index analysis showed that the intra-group difference was greater than the inter-group difference.Among them，the iniquity of population and economic distribution mainly came from the high per capita gross domestic product（GDP） group，and the iniquity of the distribution according to the geographical area mainly came from the low per capita GDP group.Conclusion　The construction of general practitioner team in China has developed rapidly，but there are still problems of insufficient resource and the uneven regional development.The allocation of general practitioners according to population distribution and economic development is fairly fair，while the allocation equity according to geographical area is in an unfair state.Economic factors have a great impact on the allocation equity of general practitioners in China.

Current Status of the Construction of Family Doctor Group and Corresponding Countermeasures in the Implementation of Hierarchical Medical Treatment System　

PENG Yarui，SHI Nan，TAO Shuai，ZHANG Li，NI Ziling，TAO Hongbing

2020, 23(1): 14-18. DOI: 10.12114/j.issn.1007-9572.2019.00.699

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With the deepening of medical and health reform in China，the service system of family doctor group has been constantly improved.But it still faces many problems including insufficient service ability and enthusiasm and lack of supporting tools.And worst of all，remaining in a disadvantaged and subordinate position，family doctor group cannot play a core and basic role in hierarchical medical treatment system.Based on the above problems，according to the literature review and field research，this paper summarizes the construction experience of family doctor group in Minhang District of Shanghai City，Luohu District of Shenzhen City，and Xi County of Henan Province，and then puts forward the following suggestions：to stratify health risk and develop personalized service plan centered on residents；to increase personnel in family doctor group and adjust the team structure of family doctors；to improve the salary of family doctors and narrow the gap of remuneration between them and doctors in superior hospitals；to strengthen the emphasis of superior hospitals on family doctors through medical insurance bundled payment；to formulate the clinical pathway of two-way referral；and to speed up the informatization construction that is conducive to medical services of family doctors.

Competence-based Incentive Payment Mechanism for General Practitioners in a Family Doctor Team　

LI Hao，LI Jinlin，ZHU Jingrong

2020, 23(1): 19-24. DOI: 10.12114/j.issn.1007-9572.2019.00.630

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The development of a competence-based incentive payment mechanism for general practitioners（GPs） is beneficial to the increase of GPs' initiative in delivering contracted family doctor services.We firstly calculated the competency-based marginal cost for GPs by use of combination weighting algorithm，then developed a proactive incentive payment mechanism by competence level using the principal-agent theory，namely，according to their own competence，GPs actively choose the level of performance and performance-related pay listed in the incentive payment mechanism for GPs designed by the government department，by which a win-win situation can be achieved for the government department and GPs.By use of this mechanism，equal pay for equal work regardless of the levels of performance may be changed，and the pay may be closely associated with performance of GPs，realizing incentive cooperation between the government department and GPs.

Reform Effect of Primary Health Care Institutions in Jiangsu Province　

ZHANG Yanyan，WANG Jinfan

2020, 23(1): 25-29. DOI: 10.12114/j.issn.1007-9572.2019.00.702

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Background　Primary health care institutions are the base of China's medical and health service system.Jiangsu Province has implemented comprehensive medical reform since 2014 and as one of the four provinces that took the lead in carrying out the comprehensive provincial medical reform，it started fully the comprehensive medical reform in 2015.Objective　To understand the financial input，team building and capacity building of primary health care institutions before and after the pilot comprehensive medical reform in Jiangsu Province，in order to provide suggestions and support for the reform and development of primary health care institutions.Methods　The data were derived from the questionnaire of the Jiangsu Provincial Health and Family Planning Commission from 2012 to 2016.The research was carried out from October to December in 2017.The results of primary health care reform were evaluated from two dimensions：health resource conditions and medical service output.The selected evaluation indicators of health resource conditions were financial subsidy income，the number of primary health care institutions，and the number of beds and health technicians；the selected evaluation indicators of medical service output were medical income and drug proportion，and the number of visits and hospital admissions.Based on the values of indicators in 2014，the changes of each indicator were analyzed by calculating the fixed base ratio.Results　From 2012 to 2016，the health resource conditions and medical service output in primary health care institutions showed an upward trend，but its proportion in the province decreased year by year.According to the calculated fixed base ratio，the financial subsidy income in health resource conditions increased rapidly（the fixed base ratio was 134.84% in 2016），and the medical income in medical service output increased rapidly（the fixed base ratio was 115.58% in 2016）.From 2012 to 2014，the average annual growth rate of beds in primary health care institutions was 3.74%，and it fell to 1.82% from 2014 to 2016.From 2012 to 2014，the annual growth rate of medical income in primary health care institutions was 11.38%，and it decreased to 7.51% from 2014 to 2016.From 2012 to 2016，the ratio of doctors to nurses in primary health care institutions was 1∶0.54-1∶0.59.The drug proportion in primary health care institutions in 2016 was higher than that in 2014 and 2015，reaching 55.82%.Conclusion　After the pilot comprehensive medical reform in Jiangsu Province，primary health care institutions have received some achievements，but there is still room for improvement.The service ability to provide primary health care should be further enhanced.

Operational Efficiency of Community Health Service Centers in Tianjin before and after the Implementation of Hierarchical Diagnosis and Treatment　

ZHAO Lin，YANG Licheng

2020, 23(1): 30-34. DOI: 10.12114/j.issn.1007-9572.2019.00.633

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Background　In October 2016，Tianjin started to comprehensively implement the hierarchical diagnosis and treatment.Community health institutions are major institutions delivering such services，but studies about their operational efficiencies are very limited.Objective　To perform a comparative analysis of the operational efficiencies of community health centers（CHCs） in Tianjian before and after the implementation of hierarchical diagnosis and treatment，providing a scientific basis for improving the hierarchical diagnosis and treatment and promoting the equity in essential health services.Methods　Data about healthcare costs，health workers and health service workload of a random sample of 64 CHCs in Tianjin during 2014 to 2017 were collected from March to June 2018.A dynamic network data envelopment analysis（DEA） model was used to analyze the efficiencies in the delivery of essential public health services and essential medical services before（2014—2015） and after（2016—2017） the implementation of hierarchical diagnosis and treatment.Results　The average efficiency of essential public services delivery for the 64 CHCs before and after the implementation of HDT was 0.791 and 0.851，respectively.A total of 48 CHCs showed increased efficiency of essential public services delivery after the implementation of such services.The average efficiency of essential medical services delivery for the 64 CHCs before and after the implementation of HDT was 0.705 and 0.759，respectively.43 CHCs demonstrated increased efficiency of essential medical services delivery after the implementation of such services.Before the implementation of HDT，45 CHCs had higher efficiency in delivering essential pubic services than delivering medical pubic services，but the number of such CHCs decreased to 42 after the implementation of HDT.The average efficiency of essential public health services delivery declined in Jinghai and Heping Districts and Binhai New Area，but increased in other 13 districts after the implementation of HDT.The average efficiency of essential medical services delivery decreased in 10 districts （in particular，the decrease was 0.337 in Xiqing District），unchanged in Jinghai District，and increased in Jizhou，Hongqiao，Heping，Beiche and Baodi Districts.Conclusion　After the implementation of HDT，an increase has been seen in both the efficiencies of most CHCs in Tianjin in delivering essential public health services and essential medical services，but the efficiency in delivering the former services is lower than delivering the latter services on the whole.

Current Status of Contracted Family Doctor Services in Yunnan Province　

YAN Li，PENG Yan

2020, 23(1): 35-39. DOI: 10.12114/j.issn.1007-9572.2019.00.588

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Background　Family doctor contract service is an important task to strengthen the function of primary health care service network，deepen the reform of medical and health system，and also an important way to establish the hierarchical diagnosis and treatment system and promote the health of people.Understanding problems existing in the family doctor contract service in Yunnan Province is of great significance to promote its orderly development.Objective　To investigate the problems in family doctor contract service in Yunnan Province.Methods　A combination of quantitative and qualitative research methods was used.Quantitative research was divided into three parts：the first part was about the analysis of the data collected from the "family doctor contract service" from the written investigation of the medical reform from November to December 2017；the second part was about the analysis of the data from Health Statistics Materials of Yunnan Province in 2016 and 2017 Statistics Yearbook of Yunnan Province；the third part was the analysis of the results conducted with a self-designed questionnaire by using a multi-stage stratified sampling in May，2018.We selected 213 residents to survey their basic situation and knowledge of family doctor contract service in May 2018.The qualitative research was based on individual interviews with 4 leaders who were responsible for family doctor contract service and 36 staff engaged in family doctor contract service.Results　Health statistics materials indicated there were 4 737 general practitioners in Yunnan Province in 2016，with the number of general practitioner per 10 000 population of only 0.99；practicing（assistant） physicians per 1 000 population was only 0.56，which was lower than the national level，except for Kunming.Questionnaire results indicated the access that residents received information on contract service were mainly doctor informed（65.3%），television and radio broadcast（64.8%），billboards（54.5%），WeChat and Weibo（50.7%）；public awareness of family doctor contract service was low.Only 13（6.1%） out of the 213 respondents said they had full knowledge of family doctor contract service，and 63（29.6%） said they just knew some.Qualitative interviews showed there were 4 problems in family doctor contract service：poor publication of family doctor contract service，low awareness rate among the public；high pressure from family doctor contract service；weak information technology，low work efficiency；and poor supporting measures.Conclusion　The number of general practitioners in primary health institutions in Yunnan Province is low，and the professional and education level of practicing（assistant） physicians are also at a low level；residents' awareness of family doctor contract service is low.It is recommended to increase the training of general practitioners and practicing（assistant） physicians，strengthen the publication of family doctor contract service，speed up the informationization of primary health institutions，and improve related supporting measures，to promote the orderly development of family doctor contract service in Yunnan Province.

Evaluation of Family Doctor Services and Intention of Renewing the Contract with the Family Doctor among Contracted Residents in Shenzhen　

LIU Jianxin，QIAO Yan，GAN Yong，LU Zuxun

2020, 23(1): 40-44. DOI: 10.12114/j.issn.1007-9572.2019.00.320

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Background　In recent years，some progress has been made in the implementation of contracted family doctor services in Shenzhen，but the phenomena such as "some contracted residents make no appointments" and "some contractual services are unsatisfactory" still exist.To study the evaluation of family doctor services and intention of renewing the contract with the family doctor among the residents，the demand side of healthcare services，may greatly promote the effective development of such services.Objective　To explore the evaluation of family doctor services and intention of renewing the contract with the family doctor among contracted residents in Shenzhen，providing scientific evidence for facilitating the development of such services.Methods　This survey was conducted in a stratified multistage random sample of 1 000 contracted residents from three community health centers of Shenzhen's Baoan District during July 2016 to September 2017.A self-designed questionnaire was used in the survey，which consists of general personal characteristics，use and evaluation of family doctor services，and intention and reasons of renewing the contract.Altogether，900 of them returned responsive questionnaires，obtaining a response rate of 90.0%.Results　 Among the 900 respondents，807（89.7%） were satisfied with family doctor services.Family doctors' attitude toward residents during delivering services was evaluated as（92±8） points on average.820（91.1%） of the respondents were willing to renew the contract with a family doctor because they thought they could obtain healthcare more conveniently.Among the 80 cases who were not willing to renew the contract，56（70.0%） thought the contractual services were ineffective.Chi-square analysis showed that the intention of renewing the contract differed significantly by the level of familiarity with the family doctor's name and consultation time，number of the family doctor taking the initiative to contact the patient，level of satisfaction with the attitude of the family doctor during delivering healthcare services，whether the family doctor is more careful than other types of doctors during delivering healthcare services，level of satisfaction with family doctor services，and level of trust in the family doctor（P<0.05）．Conclusion　 Family doctor services obtained high appraisals from the contracted residents of Shenzhen.And most of these residents intended to renew the contract.To promote the sustainable development of family doctor services，it is suggested to strengthen the publicity and promotion of such services，increase the level of quality of such services，and improve the family doctor system.

Contracted Residents' Use of and Satisfaction with Family Doctors Services in Zhengzhou City　

ZHANG Tian，MIAO Yudong，GU Jianqin

2020, 23(1): 45-50. DOI: 10.12114/j.issn.1007-9572.2019.00.692

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Background　Zhengzhou has initially developed a multi-area，deep-seated and wide-ranging urban community health service network based on the "physician accountability system in delivering healthcare for each area" proposed in 2008.However，some relevant studies show that problems such as unbalanced development among communities and irregular management still exist.With the constant advancement of the contracted family doctor services，the contracted residents' satisfaction with and use of the contracted services need further investigation and analysis.Objective　To explore contracted residents' utilization of and satisfaction with the contracted services as well as the associated factors in Zhengzhou，providing a theoretical basis for promoting the development of such services.Methods　This face-to-face survey was conducted from September to October 2018 in 1 000 contracted residents living in the serving areas of two community health centers（CHCs），Zhengzhou，selected by use of two-stage sampling.A self-made questionnaire developed based on the EUROPEP questionnaire（extended version） was used in the survey，which consisted of sociodemographic data，use of，and overall and specific satisfaction with 10 essential family doctor services，changes in community health services spending，health literacy，and number of CHCs visits.Results　The contracted residents' satisfaction levels with the 10 essential family doctor services were good or above good.Essential medical services〔（10.16±0.33）times〕，and public services〔（8.51±0.27）times〕 were used more often，while priority referral services〔（3.40±0.13）times〕 and long-term prescription services〔（2.57±0.08）times〕 were used less frequently.After contracting，most of the residents（57.9%） thought that no changes were found in their community health services spending，but the majority of residents（71.7%） reported that their health literacy increased，and 53.3% reported to have increased CHCs visits.Of the 30 items of the EUROPEP questionnaire，"Listen to your share about the illness（37.6%）" "Establishment and management of health records（36.6%）" "Providing related services for disease prevention（35.7%）" and other dimensions of doctor-patient communication，disease prevention and health care got the higher respond rate with the "very satisfied"，while "Get help from other employees（15.1%）" "Provide comprehensive diagnosis and treatment（12.2%）" and "waiting time for treatment（8.4%）" and other dimensions of technical support and service organization got lower respond rate with the "very satisfied". Education level was a influencing factor of satisfaction level with family doctor services（P<0.05），and having chronic diseases，and the visited CHC being a member of the regional medical consortium were associated with higher satisfaction level with family doctor services（P<0.05）.Conclusion　The implementation of contracted family doctors services in Zhengzhou focuses on the delivery of essential medical services，which can enhance residents' awareness of disease prevention and health care，and promote the effective communication between doctors and patients.However，the service organization is still inadequate.So adequate cooperations among medical institutions should be further strengthened to promote the development of contracted family doctor services.

Factors and 10-year Survival Outcome Associated with 24-hour Ambulatory Diastolic Blood Pressure in the Elderly　

QIU Yuping，GUAN Mengshan，LI Ying，XIE Zhiquan

2020, 23(1): 51-57. DOI: 10.12114/j.issn.1007-9572.2019.00.608

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Background　Low diastolic blood pressure（DBP） is common in the elderly.However，the antihypertensive targets for the elderly in various hypertension guidelines usually only focus on systolic blood pressure，with less attention paid to DBP，and the maintenance level of DBP is still unclear.Objective　To explore the influencing factors of and 10-year survival outcome associated with 24-hour ambulatory DBP in the elderly.Methods　We enrolled 787 retired veterans（65-95 years old） who received inpatient services from Chinese PLA General Hospital of Southern Command during 2003 to 2008，and stratified them into three groups by 24-hour ambulatory DBP：<70 mm Hg group（n=352），70-80 mm Hg group（n=346） and > 80 mm Hg group（n=89）.We used multiple linear regression analysis to identify the associated factors of 24-hour ambulatory DBP.We collected the survival status of all groups during a 10-year follow-up，and explored it with Kaplan-Meier survival analysis.Results　The mean 24-hour ambulatory DBP for all the participants was（71±8）mm Hg.Those aged 65-79 year showed higher mean 24-hour ambulatory DBP than those aged 80-95 years（P<0.05）.Multiple linear regression analysis showed that age，BMI，heart rate，24-hour ambulatory SBP and hemoglobin were the influencing factors of 24-hour ambulatory DBP（P<0.05）.<70 mm Hg group aged 65-79 years showed higher prevalence of coronary heart disease and myocardial infarction than other two groups of the same age group（P<0.017）.And >80 mm Hg group aged 65-79 years demonstrated higher prevalence of hypertension compared with other two groups of the same age group（P<0.017）.The prevalence of coronary heart disease decreased successively in those aged 80-95 years in <70 mm Hg group，70-80 mm Hg group，and >80 mm Hg group（P<0.017）.Analysis with Cox proportional hazards regression model revealed that compared with 24-hour ambulatory DBP <70 mm Hg，24-hour ambulatory DBP >80 mm Hg was associated with 3.527〔95%CI（1.119，11.113）〕 times high risk of death from cardiovascular diseases in age group of 65-79（P<0.05）.However，in those aged 80-95 years，24-hour ambulatory DBP was not associated with the death from cardiovascular diseases（P>0.05）.The median survival time of <70 mm Hg group，70-80 mm Hg group，and > 80 mm Hg group was 149.27，161.11 and 161.65 months，respectively，showing a significant intergroup difference（P<0.05）.Conclusion　The 24-hour ambulatory DBP in the elderly is affected by age，BMI，heart rate，24-hour ambulatory SBP and hemoglobin.It plays an important role in the onset of coronary heart disease，myocardial infarction and hypertension，and may affect the 10-year survival of the elderly.The appropriate DBP target level may be 70-80 mm Hg for those aged 65-79 years，and may be higher（>80 mm Hg） for those aged 80 or over.

Incidence Trend of Influenza in China from 2005 to 2015　

WANG Lingling，SUN Jiao，YOU Lili，REN Guoqin*

2020, 23(1): 58-63. DOI: 10.12114/j.issn.1007-9572.2019.00.725

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Background　Influenza is a common acute respiratory disease with a high incidence，which often affects the quality of life，and may result in serious complications and may even lead to death.So monitoring and analyzing influenza are essential for the prevention and control of this disease.Objective　To explore the incidence and trend of influenza in China from 2005 to 2015 by region，sex and age group，and to determine the developmental trajectory of subgroups.Methods　The research was developmented from February to November 2018.The data of incidence of influenza in China from 2005 to 2015 were obtained from the National Scientific Data Sharing Platform for Population and Health.Descriptive analysis was performed on the incidence of influenza by region，sex and age group，and annual growth rate during the period was calculated.The trajectory model was used to explore the number of subgroups and corresponding characteristics of different trajectories.Results　During this period，the annual incidence of influenza increased from 3.51% in 2005 to 14.37% in 2015，generally showing an upward trend.Males had a higher overall incidence than females.But the average annual growth rate was higher in females（15.93%） than that in males（14.51%）.And greater increase of incidence was found in the elderly aged 70-year-old and above（32.04%） and children below 5 years old（29.41%）.Three types of trajectories could be categorized for different trends of influenza.The first subgroup had the highest incidence with a general upward trend，gradually reaching a relatively steady state，in particular，the situation of prevention and control for people under 5 years old and 5-14 years old in Tianjin，Hebei，Shanghai，Fujian，Hubei，Hunan，Guangdong，Gansu and Ningxia is more severe.The second subgroup had a mid-level incidence and a continual increase，it is urgent to control its rising momentum. Shanxi and Henan are the areas that need to be focused on. The lowest incidence was found in the third subgroup，which increased slowly.Conclusion　The incidence of influenza in China from 2005 to 2015 had different trajectories.Identifying different trajectories of age-，gender-，and region-specific incidence of influenza is helpful for taking targeted measures for influenza prevention and control.

Associations of Hair Cortisol with Burnout and Quality of Life in Patients with a First Episode of Acute Coronary Syndrome　

ZHANG Min，SHANG Li，CAI Hongyan，LI Jian，HU Enyuan，SU Rui，XIAO Jianming

2020, 23(1): 64-69. DOI: 10.12114/j.issn.1007-9572.2019.00.495

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Background　Hair cortisol is a biomarker that reflects chronic stress.Previous studies of our research team show that burnout may be an independent risk factor for acute coronary syndrome（ACS）．But the associations of hair cortisol with burnout and ACS are rarely reported in China.Objective　To investigate the associations of hair cortisol with burnout and quality of life at one month after discharge in patients with a first episode of ACS.Methods　Participants were recruited from the First Affiliated Hospital of Kunming Medical University from March 2015 to February 2018，including 89 inpatients with a first onset of ACS from Cardiovascular Department（experimental group），and 42 healthy cases undergoing annual physical examination（control group）．Hair cortisol assay was conducted in both groups by detecting a small sample of hair.Personal burnout subscale of the Copenhagen Burnout Inventory（CBI） was used to measure the burnout level.8-item Short-Form Health Survey（SF-8）and Seattle Angina Questionnaire（SAQ） were adopted to assess the quality of life at one month after discharge.T-test was applied to compare natural log transformed hair cortisol data between the groups，and multiple linear regression was used to analyze the results after excluding the confounding factors.Partial correlation analysis was conducted to investigate the correlation between hair cortisol and burnout in ACS patients.Multiple linear regression model was developed and used to analyze the correlation between hair cortisol and quality of life at one month after discharge in ACS patients.Results　Finally，75 ACS patients and 38 healthy controls underwent the hair cortisol assay.ACS patients had higher mean hair cortisol concentration than the controls 〔2.00±1.82（ln ng/g）vs 1.59±1.48（ln ng/g），t=2.42，P=0.017〕.After excluding confounding factors of sex，age，BMI，employment status，education level，smoking and drinking，multiple linear regression analysis found ACS was associated with hair cortisol〔b（95%CI）=2.038（0.198，3.878），P=0.037〕.Hair cortisol was correlated positively with burnout level in ACS patients after excluding confounding factors of sex，age，BMI，employment status，education level，marital status，smoking，drinking，Killip class，past and family medical history of cardiovascular disease（partial correlation coefficient=0.303，P=0.011）．Hair cortisol concentration was significantly associated with physical function score of SF-8〔b（95%CI）=-1.459（-1.984，-0.934），P<0.05〕，anginal stability score of SAQ〔b（95%CI）=-8.821（-15.629，-2.013），P<0.05〕，and anginal frequency score of SAQ〔b（95%CI）=-6.342（-12.653，-0.031），P<0.05〕in ACS patients at one month after discharge.Conclusion　ACS patients showed higher hair cortisol concentration than healthy people.Burnout level increased with hair cortisol concentration in ACS patients.Higher hair cortisol concentration at baseline was associated with lower quality of life in ACS patients at one month of discharge.

TCM Syndrome Types of Diabetic Nephropathy and Their Correlation with Laboratory Indices 　

SU Baolin，LI Jing，TANG Shuifu，CHEN Gangyi

2020, 23(1): 70-74. DOI: 10.12114/j.issn.1007-9572.2019.00.510

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Background　Studies about the TCM syndrome type and the laboratory index in diabetic nephropathy（DN） have obtained some results，showing that the two have a certain correlation，which provides a theoretical basis for normalizing and standardizing the TCM diagnosis and treatment system of DN.However，the diagnostic criteria for TCM syndrome of DN still have not been unified and standardized.Objective　To study TCM syndrome types of diabetic nephropathy and their correlation with laboratory indices.Methods　During January 2017 to March 2018，from Department of Nephrology，The First Affiliated Hospital of Guangzhou University of Chinese Medicine，and Department of Endocrinology，Zengcheng TCM Hospital，125 outpatients and inpatients（including 31 with T2DM，31 with stage Ⅲ DN，32 with stage Ⅳ DN，and 31 with stage Ⅴ DN），and other sex- and age-matched 30 healthy physical examinees were enrolled.Number and percentages of incidental and fundamental syndromes in each group were obtained.And urea nitrogen（BUN），serum creatine（Scr），cystatin C（CysC），estimated glomerular filtration rate（eGFR），total cholesterol（TC），triacylglycerol（TG），serum protein（ALB），24-hour urine protein quantity and hemorheological indices were measured in groups with different syndrome types.Results　In terms of primary syndromes，T2DM patients showed yin deficiency and dryness heat syndromes〔32.2%（10/31）〕 and qi-yin deficiency syndrome〔58.1%（18/31）〕，those with stage Ⅲ DN showed spleen and kidney qi deficiency syndromes〔48.4%（15/31）〕，those with stage Ⅳ DN demonstrated yin-yang deficiency syndrome〔46.9%（15/32）〕 and spleen and kidney qi deficiency syndromes〔31.2%（10/32）〕，and those with stage Ⅴ DN presented yin-yang deficiency syndrome〔64.5%（20/31）〕．The incidental syndromes in all T2DM and DN patients mainly were dampness syndrome and blood stasis syndrome.Renal function indices，ALB and 24-hour urine protein quantity differed by stage of DN in DN patients（P<0.05）．DN patients with yin deficiency and dryness heat syndrome had the highest mean levels of BUN，Scr，CysC and 24-hour urine protein quantity，followed by those with qi-yin deficiency syndrome，those with spleen and kidney qi deficiency syndromes，and those with yin-yang deficiency syndrome.DN patients with yin-yang deficiency syndrome demonstrated the highest mean levels of eGFR and ALB，followed by those with spleen and kidney qi deficiency syndromes，those with qi-yin deficiency syndrome，and those with yin deficiency and dryness heat syndromes.Laboratory indices did not vary significantly across those with dampness syndrome，those with phlegm syndrome and those with blood stasis syndrome（P>0.05）．Spearman correlation analysis showed that there was a positive correlation between primary syndrome type and BUN，Scr，CysC，24-hour urine protein quantity，and had a negative correlation with eGFR and serum ALB（P<0.05）．Conclusion　In DN patients，with the progression of the disease，the main manifestations of TCM syndrome type are yin deficiency and dryness heat，qi-yin deficiency，spleen and kidney qi deficiency，yin-yang deficiency.And the levels of BUN，Scr，CysC，eGFR，ALB，and urine protein results may be correlated with TCM syndromes.

Association between Joint Stiffness and Health-related Quality of Life in Community Elderly People　

WANG Zaisheng，HAN Kunyuan，LI Qiumin，LIN Guixiang，LI Yuanling

2020, 23(1): 75-79. DOI: 10.12114/j.issn.1007-9572.2019.00.607

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Background　Joint stiffness has a high incidence in the elderly population，which may affect the quality of life and even cause disability in severe cases leading to inability to take care of oneself and a series of complications.The different stiff locations，number of stiff joints and duration of stiffness may affect differently on patients' quality of life.Objective　To explore the relationship between joint stiffness and health-related quality of life（HRQOL） in elderly people in community.Methods　A total of 586 elderly people aged 65 and over were recruited in Haikou City of Hainan Province from May to November in 2017.Questionnaires were used to assess whether there was stiffness in the neck，back，shoulder，elbow，hand or wrist，hip，knee，and ankle or foot.The duration of stiffness was obtained.HRQOL was assessed by 12 Concise Health Status Questionnaire（SF-12） and European Quality of Life Five-dimensional Scale（EQ-5D）.Multivariate Logistic regression was used to analyze the effects of the number of stiff joints，duration and locations of joint stiffness on HRQOL.Results　A total of 530（90.4%） valid questionnaires were collected and the prevalence of joint stiffness was 54.0%（286/530） among the elderly in the community.The average SF-12 and EQ-5D scores of patients with more than three locations of joint stiffness were（88.3±3.4） and（8.5±0.6），while those with joint stiffness lasting more than 60 minutes had average SF-12 and EQ-5D scores of（88.9±3.7） and（8.6±0.6）.The quality of life of the two groups was at a moderate level.Multivariate Logistic regression analysis showed that the number of stiff joints and duration of joint stiffness were the influencing factors of HRQOL among the elderly in the community（P<0.05）；elbow stiffness，knee stiffness and ankle stiffness were the influencing factors of HRQOL among the elderly in the community（P<0.05）.Conclusion　The prevalence of joint stiffness is high in the elderly in community，and joint stiffness will affect their quality of life.The more the number of stiff joints and the longer the duration of stiffness，the lower the HRQOL of the elderly in community.The elderly in community with elbow stiffness，knee stiffness and ankle stiffness have the lower HRQOL.

Relationship between Salt Intake and Blood Pressure Variability in Hypertensive Populations in Ningxia　

CUI Jizhi，LIU Yuan，LI Huajie，LIU Xuemei，LIANG Peifeng

2020, 23(1): 80-86. DOI: 10.12114/j.issn.1007-9572.2019.00.550

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Background　High-salt diet is a risk factor for hypertension，stroke and cardiovascular disease.Blood pressure variability（BPV） is a reliable independent predictor of cardiovascular events and deaths.There are few studies on the relationship between salt intake and BPV.Objective　To explore the relationship between salt intake and BPV in hypertensive populations in Ningxia.Methods　We selected 605 hypertensive residents from a community in Yinchuan during January 2015 to January 2017 by opportunistic screening，priority population screening and physical examination screening.By a questionnaire survey and a physical examination，we collected their demographic data，history of diseases，and behavioral risk factors for cardiovascular disease，levels of triglyceride，total cholesterol（TC），low-density lipoprotein cholesterol（LDL-C），high-density lipoprotein cholesterol（HDL-C），and fasting blood glucose（FBG）via analyzing the venous blood sample，and 24-hour blood pressure via 24-hour ambulatory blood pressure monitoring，and daily salt intake determined gravimetrically.We divided the residents into low-salt intake group（n=332）and high-salt intake group（n=273）according to average daily salt intake，and coMAPred demographic data，laboratory test results and 24-hour blood pressure between the groups.We performed multiple linear regression analysis to identify associated factors for BPV.Results　Two groups had significant differences in sex，BMI，prevalence of tobacco consumption，alcohol consumption，exercise frequency and family history of cardiovascular disease（P<0.05）.High-salt intake group showed lower average HDL-C and TC than low-salt intake group（P<0.05）.Two groups showed no significant differences in mean daytime SBP（dSBP），dDBP，and dMAP，mean nighttime SBP（nSBP），nDBP，and nMAP，and mean 24 h SBP，24 hDBP，and 24 hMAP（P>0.05）.CoMAPred with the low-salt intake group，high-salt intake group had higher standard deviation（SD） of dSBP（dSBPSD），dMAPSD，24 hSBPSD，24 hDBPSD，and 24 hMAPSD（P<0.05）.Multiple linear regression analysis showed that in the unadjusted model，in the model with adjusted sex，age，minzu，and BMI，and in the model with adjusted sex，age，minzu，BMI，prevalence of tobacco and alcohol consumption，labor intensity，exercise frequency，history of diabetes，and family history of cardiovascular disease，daily salt intake was significantly associated with dSBPSD，and dMAPSD（P<0.05）.Conclusion　 Salt intake is an influencing factor for dSBPSD and dMAPSD in hypertensive populations in Ningxia.So guidance on eating a salt-restricted diet is essential for the control of blood pressure and BPV in this group.

Advantages of Patients with Multisystem Diseases Receiving Diagnosis and Treatment in General Practice Department of General Hospitals　

HUANG Lingjuan，HE Wenyun

2020, 23(1): 87-91. DOI: 10.12114/j.issn.1007-9572.2020.00.025

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Background　Since the implementation of the national strategy for general practice，the proportion of patients with multisystem diseases visiting General Practice Department has been increasing.However，there is a lack of reports on whether patients with multisystem diseases have more advantages in receiving general-practice treatment than specialized treatment in China.Objective　To compare the visits of patients with multisystem diseases in General Practice Department and specialized departments in order to provide theoretical basis for patients to choose the treatment department in general hospitals.Methods　A total of 502 hospitalized patients with multisystem diseases in General Practice Department and 412 patients in specialized departments of the First Affiliated Hospital of Xi'an Medical University were selected in 2018.Clinical data were analyzed statistically by browsing electronic medical histories and issuing questionnaires to patients，which included the basic information of patients，the time of diagnosis，the diagnosis condition of disease，disease consultations，the situation of referral，medical expenditure，daily communication time with medical staff，satisfaction with medical staff，follow-up visits，and further consultations in half a year.Results　The disease information of 502 patients was compared with 412 patients in specialized departments with no significant differences（P>0.05）.However，it was found that General Practice Department did better than specialized departments in terms of disease consultations，the situation of referral，daily communication time with medical staff，satisfaction with medical staff，follow-up visits，and further consultations in half a year by comparing the diagnosis and treatment of patients with multisystem diseases in other departments（P<0.01）.The differences in the time of diagnosis，the diagnosis condition of disease，and medical expenditure were not statistically significant（P>0.05）.Conclusion　Most health problems of patients with multisystem diseases have been solved more optimally in General Practice Department of general hospitals.The establishment of General Practice Department in general hospitals may meet the needs of patients with multisystem diseases.

Features and Consultation Reasons in Fatigue Outpatients from the General Practice Department of a General Hospital

LIU Ying，ZHU Hongyue，HE Ying，QIU Yan，REN Wen，REN Jingjing

2020, 23(1): 92-95. DOI: 10.12114/j.issn.1007-9572.2019.00.673

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Background　The patients who are treated for medically unexplained physical symptoms（such as fatigue，etc.） account for a large proportion of the total patients visiting the general practice department of general hospitals in China. However，the characteristics and consultation reasons in patients with fatigue are rarely studied.Objective　To explore the characteristics and consultation reasons in outpatients with fatigue visiting the general practice department of the general hospital.Methods　Data（including sex，age，consultation time，initial reason for consultation，diagnosis，the first and subsequent consultations） were collected from the electronic medical record system of the First Affiliated Hospital，Zhejiang University，involving 301 eligible outpatients with fatigue seeking primary care between July 1，2017 and June 30，2018.Results　All the participants were from the general practice department，including 148 males（49.2%），and 153 females（50.8%），with an average age of（48.3±13.3） years old. The consultations peaked in summer（95 cases，31.6%） in 2018. Initial reason for consultation was fatigue（181 cases，60.1%）. The causes of fatigue could be identified initially in the general practice department in 26.2%（79/301） of the participants. And those〔25.3%（76/301）〕 whose causes of fatigue could not be identified were suggested to transferred to specialty departments，mostly to the mental health department〔39.5%（30/76）〕. Initial reason for consultation of fatigue was significantly associated with the classifications of consultation purpose and consultation outcome（P<0.05），while sex，age and consultation time were not（P>0.05）．Conclusion　Fatigue can be seen in any age，and at any time of a year in men and women. It can be an acute or a chronic health problem. As a general practitioner，it is necessary to grasp the correct assessment of fatigue and the identification of the cause，as well as the standardized follow-up of patients with chronic fatigue.

Prevalence and Influencing Factors of Anxiety and Depression in Hospitalized Elderly Patients in the General Medicine Ward of a General Hospital　

DENG Xuexue，FANG Ronghua*，MAO Yan，SONG Hongxia

2020, 23(1): 96-100. DOI: 10.12114/j.issn.1007-9572.2019.00.603

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Background　Mental health status may affect the prognosis of the disease，prolong the hospital stay and increase the economic burden in the elderly.In view of this，to prevent the negative emotions from worsening in hospitalized elderly patients，it is particularly important to identify negative emotions timely，and rapidly evaluate the status of anxiety，depression and tendency of suicide，and based on this，to deliver appropriate psychological interventions.Objective　To investigate the prevalence and influencing factors of anxiety and depression in hospitalized elderly patients from a general medicine ward of a general hospital.Methods　Participants were 407 elderly hospitalized patients who were recruited from the General Medicine Ward，West China Hospital，Sichuan University during March to July 2017.The Huaxi Emotional-distress Index（HEI） developed by this hospital was used to screen the prevalence of anxiety and depression（HEI>8 points was determined as having anxiety and depression）．The General Data Questionnaire developed by our research team was used to collect sociodemographic data.Multiple Logistic regression was adopted to analyze the influencing factors of anxiety and depression.Results　The median HEI for the participants was 2.0（4.0）．And 35 cases（8.6%） were found with anxiety and depression.Multiple Logistic regression analysis showed that gender and comorbidity were the independent influencing factors for anxiety and depression in these patients（P<0.05）．Conclusion　In general，the mental status is relatively good in this group.Female and having at least a comorbidity are associated with higher risk of developing anxiety and depression.So more attention should be given to these priority subgroups clinically，in order to timely deliver interventions based on the detected psychological problems to promote the rehabilitation of such patients.

Narrative Reflection Education and Philosophy of General Medicine　

LUO Yingquan，HUANG Heying，ZHANG Hui4

2020, 23(1): 100-104. DOI: 10.12114/j.issn.1007-9572.2019.00.602

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Narrative reflection education is an important part of postgraduate medical education training and clinical resident training.Through narrative reflection，residents and graduate students can develop self-regulating learning skills，improve learning ability，humanistic spirit and professional identity，and its application in general medical education is particularly important.This paper intended to make a preliminary discussion of the narrative reflection practice and the philosophy of general medicine，and theoretically analyze the role of narrative reflection practice in medical education，so as to provide some thinking for further research.

General Practitioners' Perspective of Home-based Hospice Care for Advanced Cancer Patients：a Narrative-based Medicine Study　

HUANG Wenjing

2020, 23(1): 105-108. DOI: 10.12114/j.issn.1007-9572.2019.00.605

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Narrative-based medicine is a approach used in medical services，research and education，involves seeing the patients' symptoms or organ problems from their perspective，and paying attention to their community relationships and psychological conditions while treating the physical illness.In China，most textbooks associated with narrative-based medicine，medical humanities and empathy remain in theoretical framework and concepts，lacking of in-depth study and extensive promotion of training or practice generally，although there are some explorations in hospice care services.We reported a case of advanced liver cancer with home-based hospice care，with data collected from parallel medical records of the in-depth interviews with the patient and his supporters（family members，caregivers，clan relatives or the clan elder） written with a narrative approach after listening.The practice of narrative-based medicine in advanced cancer patients involves the multidisciplinary team and the patient support system，providing integrated physical，mental and spiritual care for alleviating the pain，and improving the quality of life of the patient via paying attention to them，and using empathy in healthcare perceived from writing parallel medical records of the patient's sufferings and thoughts with a narrative approach.

Progress in Study of Exercise Rehabilitation Management Strategy for Patients with Chronic Kidney Disease　

ZANG Li，WANG Shaoqing

2020, 23(1): 109-113. DOI: 10.12114/j.issn.1007-9572.2019.00.544

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Patients with chronic kidney disease（CKD）generally have a problem of reduced physical exercise，while exercise has an irreplaceable role in improving malnutrition，cardiorespiratory endurance and quality of life in patients with CKD.This problem is often overlooked by many health care workers and patients.This article focuses on the management strategy and effect evaluation of exercise rehabilitation in patients with CKD，in order to improve the attention of medical workers to the exercise of patients with CKD，and provide some guidance for clinical management of patients with CKD.

Research Progress in Improving the Treatment Compliance of Tuberculosis Patients with the Utilization of New Technologies　

ZHANG Jinjing，YANG Yunyun，PENG Dali

2020, 23(1): 114-119. DOI: 10.12114/j.issn.1007-9572.2019.00.361

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Improving the treatment compliance of tuberculosis（TB） patients is one of the most effective public health measures to cut down the spread of TB and control its prevalence.Therefore，Directly Observed Treatment（DOT） is recommended by the World Health Organization（WHO），but it is difficult to be implemented because of the serious shortage of health workers and inconvenient transportation.At present，various new technologies（such as smart phones，mobile networks and satellite communications） breaks the limitations of traditional medical behaviors and patterns by time and space，and are widely used in the management of TB patients.In order to provide the basis for popularizing the usage of related new technologies and improving the treatment compliance of TB patients，this paper reviews the intervention forms and effects and health workers and patients experience of using these new technologies to improve the treatment compliance of TB patients at home and abroad.

Research Progress on Correlation between Mild Cognitive Impairment and Symptoms of Depression and Anxiety　

MA Jia，ZHANG Shaowei，YU Dehua，LU Yuan

2020, 23(1): 120-124. DOI: 10.12114/j.issn.1007-9572.2019.00.342

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Mild cognitive impairment（MCI）is a transitional state between normal aging and dementia.As a precursor to dementia，patients with MCI is 10 times more likely to progress to dementia than normal middle-aged and elderly people.This paper reviewed the research progress on the correlation between mild cognitive impairment and depression and anxiety symptoms at home and abroad.It showed that the detection rate of depression and anxiety symptoms in patients with MCI was high，and depression and anxiety symptoms can promote the transformation of MCI into dementia.Therefore，it is of great significance to attach importance to the evaluation and early intervention of depression and anxiety symptoms in patients with MCI to prevent MCI deterioration and dementia.

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