Chinese General Practice

Quality Evaluation and Content Analysis of Lifestyle and Dietary Guidelines/Consensus on Secondary Prevention of Myocardial Infarction　

LI Wenjiao，CHENG Lyu，ZHAO Mengzhu，RAO Chang，JIN Changde，JIN Yinghui，LI Yan

2020, 23(4): 377-387. DOI: 10.12114/j.issn.1007-9572.2020.00.032

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Background　As an important part of secondary prevention of myocardial infarction，a healthy lifestyle and diet can effectively reduce the risk of recurrent myocardial infarction，and improve the prognosis of patients with myocardial infarction.It is necessary to summarize the high-quality evidence，so as to promote the clinical practice of secondary prevention of myocardial infarction.Objective　To systematically retrieve and screen the evidence-based practice guidelines/consensus on lifestyles and dietary for secondary prevention of myocardial infarction at home and abroad and evaluate rigorously the quality of included guidelines/consensus，and to extract，analyze and summarize relevant recommendations in order to provide a theoretical basis for promoting the clinical transformation of evidence.Methods　Guidelines/consensus on myocardial infarction，or guidelines/consensus on lifestyle or dietary guidelines for myocardial infarction prevention，were electronically retrieved in the website of Guidelines International Network（GIN），National Institute for Health and Care Excellence（NICE），Scottish Intercollegiate Guidelines Network（SIGN），National Guideline Clearinghouse（NGC），Australian Clinical Practice Guidelines（ACPG），New Zealand Guidelines Group（NZGG），and World Health Organization（WHO），and databases，such as PubMed，CNKI，WanFang Data，and VIP from January 1 in 2013 to December 31 in 2018，and the search was completed in June of 2019.In addition，relevant guidelines/consensus were recommended by cardiovascular experts，and the references of related guidelines/consensus were also searched to supply the guidelines/consensus.Appraisal of Guidelines for Research & Evaluation Ⅱ Instrument（AGREE Ⅱ） was used to evaluate the quality of guidelines/consensus，and then the recommendations for lifestyles and dietary were summarized.Results　A total of 10 guidelines/consensus were included from the United States，the United Kingdom，Australia，New Zealand，and China.For the overall quality，one of them was grade A，seven of them were grade B，and two of them were grade C.Finally，49 items of recommendations were summarized including six parts of lifestyles in smoking cessation，alcohol control，weight management，sleep management，emotional management，and physical exercise，and dietary recommendations covering dietary habits，nutritional structure，dietary patterns and dietary goals.Conclusion　The overall quality of the included guidelines/consensus is high，but the formulation and reporting process of the guidelines/consensus still needs to be further standardized.The lifestyle and dietary recommendations in guidelines/consensus for myocardial infarction cover a wide range providing evidence for clinical practice.It is recommended that clinical practice should be based on the best evidence，and clinical staff should fully integrate the research evidence into the provision of health care.After considering the promotion and hindrance of evidence application，and patient values and preferences，then the best evidence for clinical practice could be selected.The makers of guidelines/consensus should further consider the opinions of patients and other stakeholders，and then refine the recommendations in a more targeted way to ultimately improve patient outcomes.

The Role of General Practitioners in China's Medical and Health System　

WANG Ronghua，WANG Suping

2020, 23(4): 388-394. DOI: 10.12114/j.issn.1007-9572.2020.00.084

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China is currently carrying out a new round of medical and health system reform，and general practitioners（GPs） play an important role in this medical reform.It is helpful to explore the value of GPs in the medical and health system to encourage various stakeholders to take measures jointly to promote the development of GP services.This article analyzed the current challenges faced by China's medical and health system from the aspects of basic medical coverage，medical resource utilization，medical treatment pattern，limitations of coping with chronic diseases，health cost flow，and doctor-patient relationship.It was proposed that GPs could play an important role in the following six aspects：to help to achieve the goal of "health care for all" in China；to balance the medical information asymmetry between doctors and patients and reduce excessive medical treatment in the medical system；to contribute to the formation of a reasonable medical treatment pattern and efficient use of health resources；to make medical services continuous，proactive，and interactive to meet the challenges of chronic diseases；to attract the attention to the prevention of diseases，so that the health input would get better output；and to improve the harmony of doctor-patient relationship.On this basis，this paper put forward some corresponding countermeasures and suggestions on how to better play the role of GPs in China.

Analysis on Implementation Difficulties of Family Physician Policy Based on Ambiguity-Conflict Model　

WANG Anqi，YIN Wenqiang，MA Guangbin，ZHOU Longde，ZHAO Zixuan，CHEN Xingmin，YANG Xueling，TANG Changhai，HAN Yan，LI Lingyu，CHENG Cheng，CHEN Zhongming

2020, 23(4): 395-402. DOI: 10.12114/j.issn.1007-9572.2020.00.027

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Background　The contracted family doctor service has played an active role in improving the service capacity at grassroots level，meeting residents' medical needs，and implementing hierarchical diagnosis and treatment system.However，problems such as the low quality of performance，low degree of residents' recognition，and low enthusiasm of family physicians in the course of policy implementation have gradually become apparent.How to optimize and guarantee the implementation of the family physician policy has become the focus of grassroots reform.Objective　To explore difficulties in the implementation of family physician policy in our country and put forward the corresponding elimination paths，with a view to providing reference for the improvement of the family physician system.Methods　This paper retrieved relevant policy documents on family physician issued by the State Council and the National Health Commission from 2016，and searched documents in the China National Knowledge Infrastructure database，Wanfang Data database and VIP database with "family physician" as the key word.Excluding duplicate and irrelevant documents，1 393 qualified documents were finally included.In addition，China Health and Family Planning Statistics Yearbook（2015—2017），2018 China Health Statistics Yearbook and China's Health and Wellness Development Statistical Bulletin 2018 were served as quantitative data sources.On this basis，this paper analyzed the difficulties in the implementation of family physician policy from the ambiguity of policy objectives and policy means，the conflict between policy participants，and the dominant factors in policy implementation using the ambiguity-conflict theory.Results　The ambiguity of the family physician policy was gradually reduced，and the conflict between the policy participants was still more significant that mainly manifested in the gap between government's vision plan and residents' medical seeking mode，the benefit balance dilemma in the upper and lower hospitals，and the low degree of policy recognition of the family physicians.At the same time，the policy implementation process was transformed from symbolic implementation to political implementation，and the dominant factors were transformed from the coalition strength to power.Conclusion　The implementation of the family physician policy has not achieved the desired effect.The policy implementation effect was affected by the small difference in policy target areas，the weak service capacity at grassroots level，the imperfect benefit distribution and compensation mechanism，the lack of legal protection，and insufficient resource allocation.To solve difficulties in the policy implementation process，it is recommended to adjust policy objectives and means，clarify the benefit distribution and division of labor and cooperation mechanism among medical institutions and personnel at all levels，improve residents' sense of gain from contracted services，improve the legal guarantee of policies，and adjust the allocation structure of health resources.

Current Situation of Service Ability in Primary Health Care Institutions and Corresponding Improvement Measures in Wuhan　

LI Li

2020, 23(4): 403-408. DOI: 10.12114/j.issn.1007-9572.2020.00.028

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Due to the emphasis on primary health care and policy guidance at the national level，the infrastructure construction，medical equipment and medical technology in primary health care institutions in Wuhan have been greatly improved in recent years.But primary health care institutions still can not get the trust of urban and rural residents.In view of this，this study summarized the current situation of the service ability in the primary health care institutions in Wuhan and gave a review of the corresponding countermeasures and improvement measures.It was found that the primary health care institutions in Wuhan were lack of standardized business management and rational resource allocation；medical service capacity needed to be further improved，and the grassroots characteristic service needed further construction；the combination of medical and preventive work still needed to be strengthened.It was expected that through continuously improving the service capacity of primary health care institutions，residents' satisfaction and gain of sense in primary health care institutions could be enhanced in order to better promote the formation of hierarchical medical system.

Resource Allocation Equity of Chinese General Practitioners Based on Lorenz Curve and Gini Coefficient　

ZHANG Huayu，MIAO Yudong，QU Xiaoyuan，WANG Liuyi，WANG Juzhen，GU Jianqin

2020, 23(4): 409-413. DOI: 10.12114/j.issn.1007-9572.2019.00.783

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Background　The resource allocation of general practitioners（GPs） is one of the basic indicators for the evaluation of health equity.At present，the research on the allocation equity of GPs in China is mostly limited to a single year or the regional data and lacks the research on the dynamic change trend of national data.Objective　To analyze the fairness of the allocation of GPs in China from 2013 to 2017 in order to provide a reference for optimizing the allocation of GPs and strengthening its scientific management.Methods　Based on the 2014—2017 China Health and Family Planning Statistical Yearbook and the 2018 China Health and Wellness Statistical Yearbook，we collected the number of GPs from each of its regions in China from 2013 to 2017.Lorenz curve and Gini coefficient were used to analyze the allocation equity of GPs in China from 2013 to 2017.Results　From 2013 to 2017，the number of GPs in China increased from 145 511 to 252 717 with an increase of 107 206，and the number of GPs per 10 000 people increased from 1.07 to 1.82 with an increase of 0.75.The Lorenz curve of the distribution of Chinese GPs according to the service population was close to the line of absolute fairness，while the Lorenz curve according to the service area had deviated from the line of absolute fairness.The Gini coefficient of the distribution of Chinese GPs according to the service population in 2013—2017 was 0.29，0.26，0.25，0.24 and 0.24，respectively，and the Gini coefficient according to the service area was 0.73，0.72，0.72，0.72 and 0.73，respectively.Conclusion　The allocation fairness of GPs by service population distribution is superior to that by service area distribution in China.The fairness by service population distribution is in a normal state，while that by service area distribution is in a highly dangerous state.The government should take measures to enhance the coordinated development of GP resources among different regions.

Distribution Equity and Development Trend of General Practitioners in Shandong Province during 2013—2016　

CHENG Yanmin，XU Yanfei，WEN Nan，MA Xia，WANG Fan

2020, 23(4): 414-418. DOI: 10.12114/j.issn.1007-9572.2020.00.019

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Background　General practitioners（GPs），the 'gatekeeper' of residents' health，play a major role in delivering primary healthcare services in China.Vigorously developing the GP force is a key task of the ongoing pharmaceutical and healthcare reform in China.Objective　To analyze the distribution equity and development trend of GPs in Shandong Province from 2013 to 2016.Methods　Data of GPs，population and geography were collected from Shandong Health and Family Planning Statistical Yearbook（2014—2017） and Shandong Statistical Yearbook（2014—2017）.Gini coefficient and Theil index were used to analyze the allocation equity of GPs.Results　The number of GPs in Shandong Province increased from 7 709 in 2013 to
11 377 in 2016，with an annual growth rate of 13.85% during the 5-year period.The number of GPs per 10 000 people increased from 0.80 to 1.14，with an average annual growth rate of 12.53%.The majority of GPs have obtained a GP certification after training.The Gini coefficient for GPs distribution by population and geographical distribution decreased from 0.282 3 to 0.205 8，and from 0.290 4 to 0.259 2，respectively.The Theil index for GPs distribution by population and geographical distribution fell from 0.125 3 to 0.068 8，and from 0.136 3 to 0.106 9，respectively.Whether it was by population or geographical configuration，the intra-regional differences contributed more than 94% to the total in the allocation of GPs.Conclusion　The number of GPs in Shandong Province is growing year by year，but the growth rate is limited.The training mode of GPs needs to be optimized.The distribution equity of GPs is generally good，and the intra-area differences of eastern，central and western parts are the main influencing factors of equity.

Effectiveness Evaluation and Improvement Strategy of Family Doctor Team　

HOU Jin

2020, 23(4): 419-423. DOI: 10.12114/j.issn.1007-9572.2020.00.056

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It is an important way to improve the efficiency of the contracted family doctor team and enhance continuously the sense of gain of the contracted residents to do a good job practically in the contracted family doctor service.Improving the effectiveness of the family doctor team is the premise and foundation for the implementation and optimization of the contracted family doctor service.Using the evaluation model of team effectiveness，this paper analyzed the team effectiveness of family doctor team critically，and it was found that the family doctor team had certain advantages in terms of talent quantity，service quantity and quality，and incentive mechanism，but it also had disadvantages in terms of skills，methods，abilities，communication，work structure，behavior norms，team objectives，and external environment factors.Based on Lewin's three-stage model of change and Herzberg's two-factor theoretical model of motivation，this paper put forward some improvement measures and strategies，such as according to the complexity of the job content and tasks of the family doctor team building the family doctor team，clarifying the team objectives，establishing the team values，carrying out active organizational reform，implementing effective incentives，adjusting the organizational structure and strengthening performance management.

Value of Obesity Indicators in Diabetes Risk Prediction among Middle-aged and Elderly People of Different Gender in the Community　

ZHANG Xiaoxia，HUANG Junxuan，PENG Xin，XIE Yixian，BAO Xinyu，LIU Yan，CHEN Mengjiao，WANG Peixi

2020, 23(4): 424-429. DOI: 10.12114/j.issn.1007-9572.2019.00.639

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Background　Diabetes is a disease seriously threatening the health of middle-aged and elderly people in the community.Although many studies have explored the predictive effect of obesity indicators on diabetes，the results are still controversial due to different participant populations and obesity indicators involved.Objective　To explore the values of six obesity indicators in diabetes risk prediction among middle-aged and elderly population in the community，so as to provide a reference for early detection of high-risk groups of diabetes.Methods　We recruited 2 070 middle-aged and elderly individuals，1 000 men and 1 070 women，from the entire population of two communities in Pearl River Delta attending a medical examination.We used univariate and banal logistic regression to perform a sex-based analysis of the relationships of diabetes with six obesity indicators〔BMI，waist circumstance（WC），waist-to-hip ratio（WHR），waist-to-stature ratio（WSR），ponderal index（PI） and body adiposity index（BAI）〕，and conducted an ROC curve analysis and area under curve（AUC） to examine the value of the six indicators in diabetes risk prediction.Results　Of the six obesity indicators，WC was most closely associated with diabetes，either in men or in women.Moreover，the risk of diabetes increased with the growth of WC in both men〔OR（95%CI）=1.601（1.322，1.938）〕and women〔OR（95%CI）=1.496（1.242，1.802）〕.ROC curve showed that the AUC of WC and WSR was the largest（0.645）in male middle-aged and elderly population，and PI was the largest（0.654） in female middle-aged and elderly population.WC was 87.95 cm，WSR was 0.54，and PI was 14.81 kg/m3.Conclusion　The risk of diabetes as well as diabetes prediction indicators differ significantly in male and female middle-aged and elderly individuals in the community.WC and WSR are more suitable to be used as obesity index for predicting diabetes in male population and PI is more suitable to be used as obesity index for predicting diabetes in female population..

Target Organ Damage in Elderly Patients with Essential Hypertension and 25-hydroxyvitamin D Level　

JI Yajing，WANG Xiaoli，QIAN Panpan，ZOU Xiaofang

2020, 23(4): 430-436. DOI: 10.12114/j.issn.1007-9572.2019.00.637

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Background　Current medical research on 25-hydroxyvitamin D〔25-（OH）-D〕mainly focuses on calcium homeostasis and bone metabolism，inflammatory reaction，glycolipid metabolism and immunity.But there are few studies on serum 25-（OH）-D levels and target organ damage in elderly adults with hypertension.Objective　To examine the associations of serum 25-（OH）-D with left ventricular hypertrophy，renal damage and carotid atherosclerosis in elderly patients with essential hypertension.Methods　325 patients with essential hypertension（aged from 60 to 79） were selected from the Cardiovascular Ward，Geriatric Ward and clinics，the First Affiliated Hospital of Jinzhou Medical University between September 2016 and September 2018.They were divided into simple hypertension subgroup（n=68），single target organ damage group（n=124，including 29 coexisted with left ventricular hypertrophy，44 with renal damage，and 51 with carotid atherosclerosis），and multiple target organ damage subgroup（n=133） by the prevalence of target organ damage，and were divided into 25-（OH）-D-sufficient subgroup（n=25），25-（OH）-D-insufficient subgroup（n=58）and 25-（OH）-D-deficient subgroup（n=242）by the level of 25-（OH）-D.General clinical data and biochemical indicators were compared between target organ damage subgroups and 25-（OH）-D subgroups.The influencing factors of target organ damage were explored by multiple ordinal Logistic regression analysis.Results　Mean age，course of hypertension，SBP and DBP increased and mean 25-（OH）-D decreased successively in simple hypertension，single target organ damage and multiple target organ damage subgroups（P<0.05）．In comparison to 25-（OH）-D-sufficient group，the level of TG was significantly higher in 25-（OH）-D-deficient group（P<0.05）．Pearson correlation analysis showed that 25-（OH）-D level was negatively correlated with TG（r=-0.12，P<0.05）．Mean serum 25-（OH）-D level was higher in those without target organ damage than that of those with coexisting left ventricular hypertrophy，renal damage or carotid atherosclerosis（t=3.019，P=0.003；t=2.660，P=0.009；t=2.437，P=0.016）．Multiple ordinal Logistic regression analysis showed that older age，longer duration of hypertension，elevated SBP and DBP，and low 25-（OH）-D increased the risk of target organ damage in essential hypertension（OR=1.10，1.06，1.12，1.07，0.94，respectively；P<0.05）．Conclusion　25-（OH）-D deficiency is common in elderly patients with essential hypertension.The 25-（OH）-D level is negatively correlated with TG.Older age，longer duration of hypertension，elevated blood pressure，and 25-（OH）-D deficiency are independent risk factors for target organ damage.

Correlation between 6MWD and Body Composition in Patients Awaiting Bariatric Surgery　

REN Ziqi，YANG Ningli，LIANG Hui，XU Qin

2020, 23(4): 436-441. DOI: 10.12114/j.issn.1007-9572.2019.00.683

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Background　Obese patients undergoing bariatric surgery generally have preoperative problems associated with reduced exercise capacity，which affects their postoperative weight loss outcomes.6MWT is an easy and well-validated method for evaluating the functional abilities of obese adults.Studies have shown that there is a close relationship between exercise capacity and different body composition indicators.However，there is no research conducted to investigate the impact of body composition on exercise capacity in these patients before the bariatric surgery.Objective　To investigate the impact of body composition on 6MWD in bariatric surgery candidates.Methods　Convenience sampling was used to recruit 202 obese patients undergoing metabolic surgery in bariatric and metabolic surgery of a grade A tertiary hospital in Jiangsu Province from August 2017 to November 2018.All included subjects measured body composition with InBody 770 Body Composition Analyzer，and then performed 6MWT before surgery.Pearson correlation analysis was performed to explore the correlation between 6MWD and body composition.Stepwise multiple regression was used to examine the association between preoperative body composition and 6MWD.Results　The mean preoperative distance of 6MWD was（486.65±52.26） m in patients before metabolic surgery，and（520.13±60.56） m in healthy adults of the same age，height and body mass，with statistically significant difference（t=-23.718，P<0.001）.Analysis results showed that 6MWD was negatively correlated with weight（r=-0.236，P<0.05），body fat mass percentage（FM%）（r=-0.357，P<0.05），FM% of upper limps （r=-0.363，P<0.05），of lower limbs（r=-0.344，P<0.05），and of trunk（r=-0.240，P<0.05），and BMI（r=-0.358，P<0.05） and visceral fat area（r=-0.258，P<0.05），while there was a positive relationship between 6MWD and body's fat-free mass percentage（FFM%）（r=0.357，P<0.05），FFM % of upper limps（r=0.363，P<0.05），of lower limbs（r=0.344，P<0.05），and of trunk （r=0.240，P<0.05）．Stepwise multiple regression showed that BMI and FFM% of lower limbs were independently associated with 6MWD（P<0.05）.Conclusion　Patients awaiting bariatric surgery are found with reduced exercise capacity.The lower the BMI and the higher the FFM% of the lower extremity，the farther the patient's 6MWD is.

Effects of Blood Test Indicators on Pulmonary Infection in Patients with First-ever Ischemic Stroke　

YANG Xinlei，WU Honghu，ZHOU Wei，XU Yuan，GE Yanqiu，YI Yingping

2020, 23(4): 442-446. DOI: 10.12114/j.issn.1007-9572.2019.00.691

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Background　Pulmonary infection during hospitalization significantly increases hospitalization costs，length of stay and mortality，and seriously increases the disease burden.Whether the blood test indicators within 24 hours after admission have effects on pulmonary infection in ischemic stroke patients is not well known.Objective　To evaluate the effects of blood test indicators on pulmonary infection in patients with first-ever ischemic stroke.Methods　Clinical data of 6 284 patients with first-ever ischemic stroke admitted to the Second Affiliated Hospital of Nanchang University from January 2009 to July 2017 were retrospectively collected.The patients were divided into two groups according to whether they were complicated by pulmonary infection.The gender，age，current drinking status，current smoking status and blood test indicators within 24 hours after admission were compared between the two groups.Non-conditional Logistic regression were used to analyze the influencing factors.Results　During the observation period，a total of 373（237 males and 136 females）cases out of 6 284 patients were complicated with pulmonary infection with an average age of（72.6±10.1） and the incidence was 5.94%.Logistic regression analysis showed that age，smoking status，platelet count，hemoglobin，absolute neutrophil count，standard deviation of distribution width（RDW-SD），creatinine and lipoprotein（a） were independent influencing factors of pulmonary infection（OR=2.316，2.258，0.998，0.987，1.106，1.029，1.003 and 1.056）（P<0.05）.Conclusion　Blood test indicators have predictive effects on pulmonary infection in patients with first-ever ischemic stroke.Platelet count and elevated hemoglobin are protective factors.Patients with increased neutrophil，RDW-SD，creatinine and lipoprotein（a） are associated with the increased risk of pulmonary infection.

Characteristic of Lung Function Abnormalities in HFpEF　

CHEN Haoran，MAI Miaomei，LI Geli，OUYANG Ruiping，HE Jiehua，MI Huiying，ZHAO Qiuhang，ZHENG Gengfeng，CHEN Jue

2020, 23(4): 447-452. DOI: 10.12114/j.issn.1007-9572.2019.00.357

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Background　Heart failure with preserved ejection fraction（HFpEF） is the most prevalent form of heart failure in outpatients.Yet，the pathophysiology of this syndrome is unclear and pharmacological treatment does not improve prognosis.Because breathlessness during activities of daily living is the most frequent complaint of patients with HFpEF，we hypothesize that lung function may be often abnormal in these patients due to either a direct effect of HFpEF and/or shared risk factors.Objective　To explore the frequency，type and severity of lung function abnormalities in HFpEF.Methods　138 cases of newly diagnosed symptomatic HFpEF were selected from Cardiovascular Clinic，Guangdong Tongjiang Hospital between September 2016 and December 2017.Forced spirometry，static lung volumes，diffusing capacity of the lungs for carbon monoxide（DLCO） and arterial blood gases were measured.Results　94.2%（130/138） of the patients showed abnormalities in at least one of the lung function measurements，and 80.8%（105/130） of them were undiagnosed and untreated.Forced spirometry was abnormal in 58.7%（81/138）〔percents of mild，moderate and severe were 23.2%（32/138），26.8%（37/138），8.7%（12/138），respectively〕，DLCO was found in 83.3%（115/138）〔percents of mild，moderate and severe were 47.8%（66/138），29.0%（40/138），6.5%（9/138），respectively〕 and arterial hypoxaemia was present in 60.9%（84/138）〔percents of mild，moderate and severe were 34.8%（48/138），21.0%（29/138），5.1%（7/138），respectively〕.Abnormal spirometry and DLCO were more prevalent in NYHA classⅢ patients than those of NYHA class Ⅰ/Ⅱ patients（P<0.05）.Conclusion　Lung function abnormalities are very frequent in HFpEF patients.Abnormalities in forced spirometry and DLCO，and arterial hypoxaemia are also quite common.Attention should be paid to these abnormalities.A greater awareness of them among clinicians may contribute to improve the management and health status of the patients.

Correlation Analysis between Comorbidity and Functional Recovery after Stroke in Middle-aged and Elderly Patients with Acute Ischemic Stroke　

LIU Yuhua，GUO Fuqiang，WANG Jianhong，YANG Jing

2020, 23(4): 453-458. DOI: 10.12114/j.issn.1007-9572.2019.00.614

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Background　A large number of clinical diagnosis results show that middle-aged and elderly patients with acute ischemic stroke suffer from a variety of chronic diseases at the same time，and this co-disease state has a great impact on the recovery of prognostic function of patients.Objective　To investigate the relationship between comorbidity and the National Institutes of Health Stroke Scale（NIHSS） scores and modified Rankin Scale（mRS） scores after three months in middle-aged and elderly patients with acute ischemic stroke.Methods　Information of 293 patients with acute ischemic stroke aged 45 and over who were hospitalized in the Department of Neurology in Wenjiang District People's Hospital from January 2016 to June 2018 were prospectively collected，including their clinical information，Cumulative Illness Rating Scale（CIRS） scores，comorbidity index，severity index，NIHSS scores at admission and discharge（the discharge NIHSS score was 0 to 2 points or decreased ≥4 points compared with the admission score, and the discharge score was improved），and mRS scores after three months（mRS score ≤2 after three months discharge was considered as a good prognosis）.The relationship between comorbidity and functional recovery at follow-up after three months of discharge was analyzed.Results　The average CIRS score was（9.58±5.04）；the severity index was（0.67±0.36）；the comorbidity index was（3.30±1.83）；and the scores of admission NIHSS and discharge NIHSS were 6（4，11） and 3（1，8） respectively.The age，severity index，comorbidity index，admission NIHSS score，discharge NIHSS score，length of stay，and mRS score of the stratified patients with different CIRS scores showed statistically significant differences（P<0.05）.Stratified comparison of CIRS scores of patients with different discharge improvement conditions showed statistically significant difference（P<0.05）.CIRS score stratification，age，severity index，comorbidity index，discharge NIHSS score and length of hospital stay of patients with different prognosis showed statistically significant differences（P<0.05）.NIHSS scores at discharge and admission，severity index，the CIRS scores，atrial fibrillation，comorbidity index，age and hospitalization time were positively correlated with mRS scores after thee months．Hypertension was negatively correlated with mRS scores after thee months（P<0.05）.Conclusion　There is a significant relationship between comorbidity and NIHSS scores at discharge and mRS scores after three months in middle-aged and elderly patients with acute ischemic stroke.The patients who are younger with lower CIRS scores，comorbidity index and severity index have a good prognosis.

Implementation of Referral Appointments in Contacted Residents Receiving Family Doctor Services　

CHEN Xiaoyan，CHEN Bin，LUAN Wei，LI Ting，LU Haifeng

2020, 23(4): 459-463. DOI: 10.12114/j.issn.1007-9572.2020.00.125

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Background　Transferring contracted residents with a disease that cannot treated in the community health center to a higher level hospital via an appointment made in advance，is an important contracted task for family doctors，and is also a basis of implementing the hierarchical medical policies.Objective　To investigate the implementation of referral appointments in contracted residents，providing a theoretical basis for further improvement and popularization of the services.Methods　This study was conducted in 240 contracted patients from Minhang District Pujin Community Health Center（MDPCHC），including 120 with an experience of ever being transferred to a higher level hospital from MDPCHC after making an appointment in advance（appointment group） during January to June 2019，and 120 randomly selected cases with the record of seeking healthcare in a higher level hospital during the same period but without making an appointment（non-appointment group）.Basic general data and appointed referral data of the appointment group were collected from Shanghai Family Doctor Referral Appointment Platform.A telephone questionnaire survey based on hierarchical diagnosis and treatment and family doctor services was conducted in both groups.The influence of implementing referral appointments on relevant business development was analyzed.Results　The mean age of the appointment group was（65.4±8.7） years old，most of whom were elderly people.The average number of referral appointments was（1.5±1.0），and the average appointment period was（13.2±11.4） days.The hospital with the highest number of appointments was Southern Division of Renji Hospital，accounting for 70.1%（124/177） of the total appointment.The department with the highest number of appointments was digestive department（22.0%，39/177）.The survey showed that both groups' patients showed significant differences in the awareness rates of names of their contracted family doctors，and specific contents of contracted family doctors services，level of satisfaction with contracted family doctors services，community health services，and with the services delivered by the local general hospitals（P<0.05）.Conclusion　The implementation of the policies concerning referral appointments by family doctors has facilitated contracted residents to access to the registration of higher level hospitals，increased their awareness of and satisfaction with relevant medical services，and is conducive to the development of hierarchical diagnosis and treatment.To further take the advantages of making appointments with specialists working at higher level hospitals by the family doctor，it is suggested to strengthen the propaganda and use frequency of the referral appointment platform，ensure the implementation of family doctor services by the cooperative institutions of the medical consortium，increase the number of specialist appointments of the department with high-frequency referral appointments，and reduce the referral waiting time of the patients as far as possible.

The Effect of Family Doctor Service Reform Based on Increasing the Corresponding Visiting Rate of Contracted Residents　

CHEN Bin，CHEN Xiaoyan，LU Haifeng，LUAN Wei，LI Ting

2020, 23(4): 463-467.

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With the deepening of the comprehensive reform of community health services in Shanghai，the number of residents signing medical contracts with family doctors has continued to expand，but the problems of imperfect supporting measures and residents signing contracts without visiting still exist.Establishing a long-term and stable service relationship between contracted residents and family doctors is the basis for the practice of family doctor services.On the basis of consolidating the existing contract-signing rate of residents，the Pujin Community Health Service Center in Minhang District of Shanghai had shifted the focus of contracted family doctor service to provide the effective service，in order to explore the reform methods of family doctor service to improve the corresponding visiting rate of contracted residents.The main methods included carrying out the "three optimizations and two extensions" model（optimizing the shift arrangement of general practitioners，the publicity model，and outpatient registration and visiting queue system；extending the telephone consultation service hours and working-day noon service hours and opening the weekend clinics）；implementing the "two more policy" for drug supply after residents signed contracts（signed residents were issued a larger number of drug types and quantities for outpatient visits）；implementing the service of long prescription and extending its advantages；promoting the reform of performance and evaluation mechanism to widen the performance gap between contracted residents and non-contracted residents receiving outpatient consultation from family doctors；and issuing quality briefings to conduct appraisal feedback in the form of rectification notice.After one year of the reform（as of June 2019），the rates of consulting the contracted family doctor，visiting the contracted family doctor for outpatient services，and extending period of prescriptions by the contracted family doctor reached 38.53%，31.99% and 87.03%，respectively，which increased by 30.54，26.98 and 60.02 percentage points compared with the beginning of the reform（July 2018）.At the same time，the resource utilization of family doctor services，the awareness rate of family doctor services，and satisfaction degree of residents also improved to a certain extent.The purpose of this article is to introduce the reform methods，the effect and further work priorities of Pujin Community Health Service Center，in order to provide references for other areas to improve the effectiveness of contracted family doctor services.

Analysis of the Status Quo of Policies on Contracted Family Doctor Services in Taiyuan Based on In-depth Interview　

ZHANG Yaoru，SU Tianzhao，CHAI Qihui，WANG Xiao

2020, 23(4): 468-472. DOI: 10.12114/j.issn.1007-9572.2020.00.053

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Background　In recent years，the contracted family doctor service in Taiyuan has been gradually carried out，but the problems of "difficult to see a doctor and too expensive to have medical service" are highlighted in the process of medical treatment.In order to standardize the medical order and make patients seek medical treatment reasonably，it is of great significance to study the status quo of policies on contracted family doctor service.Objective　To understand the problems existing in the formulation and implementation of policies on contracted family doctor service in Taiyuan，in order to provide countermeasures and suggestions for its better development.Methods　Using the convenient sampling method，one family doctor team（17 cases in total） was selected from each of community health service centers in three urban districts（Yingze District，Xiaodian District and Jinyuan District） in Taiyuan，and 4 staff members from the Grassroots Division of Taiyuan Health and Family Planning Commission were selected as the research objects.Using the in-depth interview，21 cases were interviewed from April to June in 2019.The main contents of the interview were the progress of policy documents of contracted family doctor service in Taiyuan，indicators，contract items and goals in the process of formulating the contracted family doctor service policy，and problems in the implementation of contracted family doctor service.Finally，the interview materials were summarized to extract themes.Results　Through the analysis of the interview data，six themes were extracted.They were the contradiction between the virtual high signing rate and the low service utilization rate，the contradiction between the virtual high signing rate and the unclear contract information，the poor connection between the new and old policies and the lack of policy authority，the problems of "signing but not visiting"，the irregular diagnosis and treatment order，and the insufficient number of family doctors.Conclusion　It is suggested to solve the problems and contradictions in the implementation process of contracted family doctor service by establishing an effective signing mechanism，standardizing the content of service contracts，rationally allocating the old and new policies，standardizing the hierarchical diagnosis and treatment order，and cultivating high-quality talents.

Effect of Customized Precise Management Services in Contracted Family Doctor Services People with Disabilities　

MA Shanjun

2020, 23(4): 473-476. DOI: 10.12114/j.issn.1007-9572.2020.00.078

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Background　People with disabilities，especially those lack of family care，are facing both physical and mental health problems.Community-based health management for them is an important task for family doctors.Objective　To investigate the effect of customized precise management services delivered by the family doctor team in contracted people with disabilities，to improve the feasibility and precision of contracted services to meet the goals of health management in this group.Methods　In October 2018，people with disabilities managed by the family doctor team were recruited from Haizhou District，Lianyungang，and were given customized precise management services.Pre- and post-management rates of contracting individualized services，receiving standardized services，and level of satisfaction with services were compared.Results　143 disabled people met the research standard before the implementation of customized precise management，and 283 disabled people met the research standard after the implementation.After the customized precise management，the rates of contracting individualized services，receiving standardized services，and level of satisfaction with services increased significantly in all the participants，those with hearing disabilities，and those with limb disabilities（P<0.05）.However，the rates of contracting individualized services，receiving standardized services，and level of satisfaction with services showed little changes in those with visual disabilities and those with intellectual disabilities after the customized precise management（P>0.05）.In those with mental disabilities，the rates of contracting individualized services，and receiving standardized services increased significantly（P<0.05）.Moreover，the level of satisfaction with services demonstrated insignificant changes in those with mental disabilities（P>0.05）.Conclusion　The implementation of customized precise management services has significantly improved the management effect in people with disabilities.

Construction of the Outpatient-centered Model to Comprehensively Manage Diabetes in Community　

GU Wenjuan，CHEN Xubo，JIANG Minmin，LIU Jie，ZHANG Ming，FAN Liangliang，YE Jianhua，MA Yixin，FAN Qingsong

2020, 23(4): 477-482. DOI: 10.12114/j.issn.1007-9572.2019.00.410

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Background　Relying on the community is the most effective means of chronic disease management.Community chronic disease management is mainly based on outpatient service，but the outpatient service of general practitioners is still based on prescribing drugs and lacks health consultation and patient follow-up with uneven quality of service.For common chronic diseases such as diabetes，the community also lacks the performance appraisal system for the relevant population management and the operational behavior norms for doctors.Objective　To construct an outpatient-centered diabetes management model，so that to lay the foundation for the community diabetes management to integrate into the existing work of medical staff in community.Methods　Through literature review，expert consultation and practice summary，this study conducted an inventory of community diabetes management services from July to September 2017.Through brainstorming，the outpatient-centered community diabetes management process was sorted out.Results　In the outpatient-centered diabetes management model in community，a series of services were provided with residents，such as health records，general outpatient consultation，referral，drug treatment，medication guidance，diet guidance，exercise instruction，self-monitoring of blood glucose instruction，follow-up，health education，related physical examinations and laboratory inspection services.The service process in this model was centered on outpatient clinic，and in addition to increasing the identification of diabetes risk and health records for residents，other processes was consistent with the existing outpatient process.Conclusion　The orderly operation of the outpatient-centered diabetes management model needs to be based on the establishment and sharing of health records，and also needs the rational division of tasks，and there are few conflicts with their existing work in this model.

Mental Health Literacy and Influencing Factors among Community-dwelling Residents in Shanghai　

ZHAO Keying，HE Yanling，ZENG Qingzhi，YE Lu

2020, 23(4): 483-489. DOI: 10.12114/j.issn.1007-9572.2019.00.641

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Background　Along with rapid urbanization，population ageing and economic growth in China，the burden of common mental health issues such as anxiety and depression disorders is becoming heavier，spurring an increased need for mental health services in Chinese people.Mental health literacy is an important mental health facilitator.But it and its influencing factors have been rarely studied intensively.Objective　To investigate mental health literacy and associated factors in community-dwelling residents from Shanghai，providing evidence for the implementation of community-based mental health services and formulation of mental health policies.Methods　This study was conducted between August and December 2016 based on a cross-sectional design.A self-developed structured questionnaire was used to survey 3 502 residents from three communities，Shanghai，to collect their basic personal data，use of mental health services，core mental health knowledge，and mental health status（assessed by the GAD-7 and PHQ-9），as well as ways for obtaining mental health knowledge.Multiple linear regression was performed to identify the influencing factors for mental health literacy based on the Andersen Healthcare Utilization Model.Results　All the residents returned questionnaires.After excluding 97 who returned unresponsive ones，other 3 405 cases（97.23%） were finally included.The overall rate of correct answers was 59.84%.Multiple linear regression analysis showed that the level of mental health literacy was influenced significantly by predisposing factors，including age，education level，occupation，occupational status，religion，and need cognition of community-based mental health services（P<0.05），and enabling factors consisting of annual household income per capita and level of community-based mental health resources availability（P<0.05），but was not by need including anxiety symptoms and depression symptoms（P>0.05）．The major ways to acquire mental health knowledge were watching TV（50.90%），publicity of community-based mental health services（33.69%），guidance from doctors（25.90%） and reading books and newspapers（21.56%）．Conclusion　The mental health literacy level is low in this group of community-dwelling residents，which is mostly affected by predisposing factors such as sociodemographic characteristics and socio-cultural factors，and enabling factors such as level of community-based mental health resources availability and so on，but not significantly associated with the need for improving anxiety and depressive symptoms.This study highlights that mental health propaganda and education should be integrated into community-based health services，and should be more intensified and extensively in priority groups.

Investigation on Medication Compliance of Patients with Severe Mental Disorders and Its Influencing Factors in the Community of Wuxi　

WU Yue，FAN Jie，BAO Zhaohua，GUO Ting，TANG Li，FENG Wei，SHEN Wenyan，LUO Ying

2020, 23(4): 490-494. DOI: 10.12114/j.issn.1007-9572.2019.00.365

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Background　Medication compliance is the basic guarantee for the stable condition and comprehensive rehabilitation of patients，and the medication-taking rate is the core indicator to evaluate the quality of the management and treatment of patients with severe mental disorders in the community.As a professional institution of mental health，it is of great significance to understand the current status of drug treatment for patients at home in the region and propose effective measures to promote the quality of community mental health services.Objective　To investigate the medication compliance of patients with severe mental disorders and its influencing factors in the community of Wuxi，and to explore effective measures to further improve patients' medication-taking rate.Methods　A multi-stage cluster sampling method was used to conduct a questionnaire survey on the medication compliance of 1 285 patients with severe mental disorders in 12 streets/townships of Wuxi.The survey tools included Medication Compliance Questionnaire（self-designed），Insight and Treatment Attitude Questionnaire（ITAQ），and Scale of Stigma in People with Mental Illness（SSPMI）.A total of 1 220 patients completed all questionnaires，and the effective response rate was 94.94%.Multivariate logistic regression analysis was adopted to explore the factors associated with patients' drug compliance.Results　The medication compliance rate of patients with severe mental disorders was 75.33%（919/1 220）.The compliance rates of patients with schizophrenia，bipolar affective disorder，schizoaffective disorder，paranoid mental disorder，mental retardation accompanied by mental disorder and epilepsy were 78.56%（667/849），75.49%（154/204），69.57%（16/23），47.06%（8/17），35.71%（25/70），and 85.96%（49/57），respectively.Compliance rates differed significantly among patients with different education levels，marital status，family economy，guardians and their awareness of mental illness，types of the disease，course of disease，times of hospitalization，participating in community health lectures or not，distance between home and psychiatric hospitals，ITAQ scores，and levels of stigma（P<0.05）.Multivariate Logistic regression analysis showed that nine factors，including education level，guardian's awareness of mental illness，types of the disease，course of disease，times of hospitalization，whether to participate in health lectures，distance between home and psychiatric hospitals，ITAQ score，and level of stigma，were the influencing factors of medication-taking rate of community patients with severe mental disorders（P<0.05）.Conclusion　The medication compliance of patients with severe mental disorders in the community of Wuxi needs to be improved.To increase the medication-taking rate，establishing more mental health service centers，focusing on patients with mental retardation and new-onset patients，strengthening health publicity and education，and eliminating disease stigma are effective measures.

The Impact of Time of Delivery on Delivery Outcomes　

SUN Fangcan，HAN Bing

2020, 23(4): 495-498. DOI: 10.12114/j.issn.1007-9572.2019.00.622

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With the implementation of the "two-child" policy in China，the baby boom is coming to all regions.Obstetricians will face the pressure of increasing workload and the test of ensuring maternal and fetus safety.Exploring the relationship between biological rhythm，shift system and delivery outcomes can guide the rational arrangement of obstetric work，which has practical significance for improving work efficiency and ensuring perinatal health care quality.Thus，this article reviewed the association between time of delivery and obstetric outcomes and concluded that delivery time may have an impact on the outcome of childbirth，so as to give a theoretical basis for women to select appropriate delivery time and improve maternal and infant outcomes.

Advances in Information Continuity in Transitional Care for Elderly Patients with Chronic Diseases　

SHI Xiaoliu，GENG Guiling，GAO Jing，HUA Jianing

2020, 23(4): 499-504. DOI: 10.12114/j.issn.1007-9572.2019.00.449

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Information continuation in transitional care has become a research hotspot in recent years.By promoting the accurate transmission of patient's key information between institutions and individuals，it can reduce the possibilities of having poor outcomes and waste of medical resources，and facilitate the sound operation of healthcare institutions.This paper reviews the main contents and forms of information continuation，one part of transitional care，including the main contents and forms of discharge plan，medial history and drug therapy in discharge plan，as well as the existing problems and countermeasures in chronic disease elderly patients，aiming at strengthening the recognition and facilitating the innovation of information continuation among physicians and nurses，by which the quality of transitional care for older adults with chronic diseases can be improved.

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