Table of Content

05 August 2020, Volume 23 Issue 22

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Monographic Research

Significance and Challenges of Patients' Online Access to Their Electronic Health Records in Community Health Service Centers

PANG Hui，YAO Mi，GAO Chang，CHI Chunhua

2020, 23(22):  2735-2740.  DOI: 10.12114/j.issn.1007-9572.2020.00.055

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Electronic health record（EHR） is one of the most important means of informatization in the development of community health. On June 20，2018，the National Health Commission of the People's Republic of China（formerly the National Health and Family Planning Commission of the People's Republic of China） issued relevant documents requiring community health service centers to gradually open EHRs to individuals. To investigate the potential impact and significance，this paper reviewed the history and development of EHRs in community health service centers at home and abroad as well as related research on the implementation of open EHRs to individuals. It was found that the current utilization rate and maintenance rate of EHRs in China are low，and they have not yet played their due value. The future development direction of promoting patients' online access to their EHRs should include health reminders，doctor-patient communication and self-management，which will significantly improve health outcomes，promote patient-centered care and increase patient satisfaction. However，there are still many problems that need solving，such as national policy support，technical and financial support，personnel allocation and information security risks.

Enlightenment of the Typical Models of Integrated Delivery System Abroad to the Development of Integrated Health Management System in China

XIONG Mei，WU Jia，LIU Lixia，LIAO Xiaoyang，ZHAO Qian

2020, 23(22):  2741-2748.  DOI: 10.12114/j.issn.1007-9572.2020.00.344

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Against the backdrop of aging society，changing disease spectrum and furthering the implementation of Healthy China 2030 strategic blueprint measures，China has ushered in a new era of healthy China construction，during which transforming a regional medical consortium into an integrated health management system（IHMS） via upgrading，and the development of IHMS tend to be inevitable. We analyzed the typical models of integrated delivery system abroad at the micro，meso and macro levels with foci on the historical background，specific measures and achievements，and summarized the successful experience. And based on this，we put forward the following recommendations for addressing the challenges faced by the healthcare system and for improving the development of IHMS in China：integrating health-related factors as many as possible to benefit the whole population through the whole life；strengthening the healthcare talent system development with great emphasis on fostering primary care workers；giving priority to the healthcare needs of key population groups and developing interdisciplinary teams；forming high-efficient healthcare delivery modes；enhancing the informatization construction；developing rational and effective incentive mechanisms.

Experiences of New Family Physicians Finding Jobs with Obstetrical Care in the USA

Aimee R Eden，Tyler Barreto，Elizabeth Rose Hansen

2020, 23(22):  2749-2756.  DOI: 10.12114/j.issn.1007-9572.2020.00.404

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Background　Adequate family medicine obstetricians are crucial to ensuring that patients can access to the obstetrical services that they need. However，previous research has shown that the number of family doctors with obstetrics included in the scope of practice is declining year by year，with fewer than 10% of the total now delivering babies. Objective　This study aimed to explore how new family medicine graduates who want to include obstetrics in their scope of practice identify and select jobs and to understand how employment influences scope of practice in family medicine，particularly the ability to provide maternity care and deliver babies. Methods　A mixed-methods study including a survey and qualitative interviews was conducted in 2017. We electronically surveyed US family physicians and followed up with a purposeful subsample of these physicians to conduct in-depth，semistructured telephone interviews. The survey measured the reasons for not doing obstetrics as a family physician. To identify themes regarding finding family medicine jobs with obstetrics，we used a team-based，immersion-crystallisation approach to analyse the transcribed qualitative interviews. Of the 2 098 US family medicine residency graduates 2014—2016 who indicated that they intended to deliver babies in practice，1 016（48.43%） completed the survey，and 56 of them were interviewed by telephone. Results　Survey results showed that not finding a job that included obstetrics was the primary reason newly graduated family physicians who intended to do obstetrics were not doing so. Qualitative interviews revealed that family physicians often find jobs with obstetrics through connections or recruitment efforts and make job decisions based on personal considerations such as included geographical preferences，family obligations and lifestyle. However，job-seeking and job-taking decisions are constrained by employment-related issues such as job structure，practice characteristics and lack of availability of family medicine jobs with obstetrics. Conclusion　While personal reasons drove job selection for most physicians，their choices were constrained by multiple factors beyond their control，particularly availability of family medicine jobs allowing obstetrics. The shift from physician as practice owner to physician as employee in the USA has implications for job-seeking behaviours of newly graduating medical residents as well as for access to healthcare services by patients；understanding how employment influences scope of practice in family medicine can provide insight into how to support family physicians to maintain the scope of practice they desire and are trained to provide，thus，ensuring that families have access to care.

Quantitative Analysis of China's Rural Doctor Policies from the Perspective of Policy Tools

LIU Yongwen，DAI Mengna，GUO Jing，YANG Jie，ZHANG Jianhua

2020, 23(22):  2757-2762.  DOI: 10.12114/j.issn.1007-9572.2020.00.279

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Background　Rural doctors are the "net bottom" of China's medical and health system. The orderly development of rural doctors cannot be separated from the guidance and support of national policies. Policy tools are used as a link between policy objectives and results. Only by selecting appropriate and effective policy tools and making maximum use of them can the policy results reach the expected value of policy objectives. Objective　To explore the existing problems in the relevant rural doctor policies in China，with a view to providing the reference for the formulation and development of follow-up policies. Methods　The quantitative analysis method was used on June 21 in 2019 to analyze the policy tools in 29 policy documents related to rural doctors issued from 2009 to 2019 at the national level. The policy tools in these documents were analyzed. A two-dimensional analysis framework was constructed from the perspective of policy tool types and rural doctor issues to analyze in depth the policy documents related to rural doctors in China. Results　In the X dimension，capacity building，command，incentive，symbol and exhortation policy instruments accounted for 35.8%（48/134），26.9%（36/134），19.4%（26/134） and 17.9%（24/134） respectively. In Y dimension，growth，treatment，identity and source accounted for 41.3%（52/126），36.5%（46/126），11.9%（15/126） and 10.3%（13/126） respectively. Conclusion　In the X dimension，there was a deviation in the use of policy tools in policy documents related to rural doctors，and the internal structure was unreasonable. In the Y dimension，the attention of policy tools on identity and source issues was still insufficient. It is suggested to balance various policy tools to form a policy synergy，and pay attention to the combination of external coordination and internal systematicness. The treatment issue should be effectively solved to ensure the source of rural doctors. The identity should be changed to improve the quality of rural doctors.

Research Progress on the Leadership of Managers in Primary Medical Institutions

YANG Sen，SHI Jianwei，JIN Hua，CHEN Chen，WANG Zhaoxin，YU Dehua1

2020, 23(22):  2763-2767.  DOI: 10.12114/j.issn.1007-9572.2020.00.127

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With the shift of the focus of medical strategy to the development of community general practice，the complexity of medical environment and the higher requirements of community population health management pose a greater challenge to the leadership of managers in primary medical institutions. However，compared with foreign countries，the theoretical and practical research on the leadership of managers in primary medical institutions in China is very scarce. Based on the contradiction between actual needs and actual lacks，this paper expounds the development process of medical administrators' leadership at home and abroad，summarizes the research ideas and effects of domestic and foreign medical institution managers' leadership，also this paper focuses on the progress and shortcomings of the research on the leadership of medical managers in China，and analyzes the necessity of carrying out the leadership research of managers in general departments at present，which put forwards policy recommendations and theoretical support for the future leadership development and research in primary medical institutions.

Effectiveness Evaluation of Policies Related to the Implementation of Hierarchical Medical System in Shanghai Using Econometric and Knowledge Mapping Techniques

HE Weipeng，XIANG Nan，YANG Yuchen，RENA·Aximu，ZHAO Liying，CHENG Wei

2020, 23(22):  2768-2774.  DOI: 10.12114/j.issn.1007-9572.2020.00.342

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　Background　China's new medical reform has been in its tenth year. Policies related to the implementation of hierarchical medical system are one of the important measures to resolve people's medical problems and improve their sense of healthcare-seeking experience. It is urgently need to organize and analyze the regular release patterns and foci of the policies in a systematical and scientific way. As Shanghai is a provincial city for the implementation of comprehensive medical reform in pilot with early formulation and adoption of the related policies，it is of great value to evaluate the effectiveness of such policies in this city. Objective　To investigate the status of the policies related to the implementation of hierarchical medical system in Shanghai by reviewing these polices published by the Shanghai Municipal Government on its official website，and to explore the key points of the polices through in-depth analysis of the keywords，so as to provide references for policy formulation. Methods　77 policy documents were obtained after organizing the information published from October 2010 to August 2018 in the column of "Government Information Disclosure" of the official website（http://www.shanghai.gov.cn/） of Shanghai Municipal Government searched using "分级诊疗" （hierarchical medical system） as the key word. The health statistics related to the implementation of hierarchical medical system in Shanghai were collected via checking the China's Hygiene and Health Statistical Yearbook 2018，5 volumes of China Health and Family Planning Statistical Yearbook（2013—2017），and 4 volumes of China Health Statistics Yearbook（2009—2012）. By searching the databases of CNKI，WANFANG and so on using "上海"（Shanghai），
"分级诊疗"（hierarchical medical system） and "效果评价"（effectiveness evaluation） as the keywords，literature related to the implementation effect of hierarchical medical system in Shanghai from August 2014 to August 2019 was retrieved. Econometric analysis was performed to analyze the data inputted in a database created using Microsoft Excel 2016 and Microsoft Access 2016. Knowledge mapping was carried out with jieba 0.39 module of Python 3.6.6 as well as Ucinet. Literature review was conducted to organize and summarize the available related studies. Results　The number of policy documents related to the implementation of hierarchical medical system issued from 2010 to 2013 was relatively small，but increased rapidly from 2014 to 2017，with an average annual growth rate of 164.58%. A total of 186 keywords were obtained，among which "医疗" （medical），"管理" （management），"卫生" （health），"服务" （service） were identified to be the key nodes of the policies by centrality analysis. Further analysis of the keyword frequency showed that attentions paid to medical insurance in 2016 and to Chinese medicine in 2017 were significantly higher. As of August 2018，the number of people with contracted '1 + 1 + 1' type family doctor services had exceeded 4.8 million；the number of diagnostic and therapeutic services delivered by community health centers had an average annual growth rate of 6.29%，reaching 86.906 3 million in 2017. Also，in 2017，the number and proportion of significantly difficult cases admitted to municipal hospitals increased by 70%，and 1.39%，respectively. The number and proportion of significantly difficult surgeries increased by 64%，and 4.71%，respectively. Conclusion　The number of policies related to the implementation of hierarchical medical system in Shanghai has been increasing，and the functional distinction between municipal-level hospitals and primary medical and health institutions has become clearer. With steady development，the results of hierarchical diagnosis and treatment have appeared. To quickly promote the establishment of a local hierarchical medical system meeting social needs，Shanghai should continuously improve and implement supporting policies and norms，and fully integrate medical insurance policies and the development of Chinese medicine with medical and health management and services as key points.

Establishment and Preliminary Application of Nursing Home Services Expectation-Satisfaction Model in the Elderly

ZHU Zhu1，2，YAN Wu，JIANG Haiting，WANG Xuanxuan，ZHU Ya，XIA Yingqiu，CHEN Jiaying

2020, 23(22):  2775-2782.  DOI: 10.12114/j.issn.1007-9572.2020.00.386

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Background　The growing ageing population is a serious problem in China. To satisfy older people's elderly care needs，institution-based elderly care has become an effective supplement to home-based elderly care. Understanding the expectation and satisfaction on care in elderly people in nursing homes is essential for improving the quality of nursing home care as well as the elderly care system. Objective　To explore the expectation and satisfaction on nursing home services among older people. Methods　Based on the ERG（Existence，Relatedness and Growth） theory，we developed a nursing home services expectation-satisfaction model，for exploring older people's expectations on life care，medical services，cultural entertainment，mental comfort，health checkups，health education and rehabilitation training，as well as their satisfaction with daily care，food supply，sick care，living environment and charging levels. Then we developed a questionnaire based on the model，and used it to survey 203 older people in 11 nursing homes in Nanjing's Pukou District from July to September 2017. Results　Among the services expected by the elderly，life care project took the first place〔76.4%（155/203）〕，the second was medical service〔57.1%（116/203）〕，and the lowest was health education〔16.3%（33/203）〕. The elderly with different characteristics had different expectations on various services（P<0.05）. In terms of daily care，a decrease of 66% in the rate of lower satisfaction with daily care was found in those with a physical examination in the past year compared with those without，and a decrease of 46% in the rate of lower satisfaction with daily care was found in those with impaired function compared with those with intact function. Moreover，those with chronic diseases had greater OR（2.67-fold） of lower satisfaction with daily care compared with those without. In respect of food supply，a decrease of 63% in the rate of lower satisfaction with food supply was found in those with a physical examination in the past year compared with those without. Those with chronic diseases had greater OR（2.35-fold） of lower satisfaction with food supply compared with those without. A decrease of 39% in the rate of lower satisfaction with living environment was found in those with impaired function compared with those with intact function. Those with impaired function had greater OR（2.00-fold） of lower satisfaction with the cost of care compared with those with intact function. Those with no medical insurance had greater OR（3.63-fold） of lower satisfaction with the cost of care compared with those with urban employee basic medical insurance. Conclusion　The individual characteristics of the elderly including age，hukou location，activities of daily living，type of medical insurance，physical examination in the past year and chronic disease prevalence，are the important factors influencing the expectation and satisfaction on nursing home care. In view of this，nursing homes are suggested to improve the care quality to satisfy multi-level needs of the elderly.

Work Stress of Doctors in Towns and Villages under the Contracted Family Doctor Service Model：a Comparative Study

WANG Meinan，WANG Yiting，LIU Rugang，QIAN Dongfu

2020, 23(22):  2783-2787.  DOI: 10.12114/j.issn.1007-9572.2020.00.284

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Background　Under the contracted family doctor service model，doctors at township health centers and village clinics undertake different tasks facing different working environments，and they may have different levels of work stress from various sources. There is currently a lack of comparative research on the work stress of doctors at township health centers and village clinics. Objective　To understand the work stress of 182 doctors at township health centers and 176 doctors at village clinics under the contracted family doctor service model，and to analyze the differences of work stress between them，in order to improve the comprehensive understanding of the work stress among rural grassroots doctors. Methods　In July 2019，using a sampling method combining typical sampling，stratified sampling，and convenience sampling，doctors at township health centers and village clinics who participated in the contracted family doctor service from 18 townships in three counties（districts） of Jiangsu Province were selected for the questionnaire survey. The questionnaire included the basic information（practice area，job category，gender，age，education level，marital status，job title and working years） and the Challenge- and Hindrance-related Self-reported Stress Scale（C-HSS）. Data were analyzed using descriptive analysis，chi square test，rank sum test，and Ordinal regression analysis. Results　There were significant differences in gender，age，education level，job title and number of working years between doctors at township health centers and doctors at village clinics（P<0.05）. There was significant difference in challenge-related stress between doctors at township health centers〔3.83（0.71） points〕 and doctors at village clinics〔4.33（0.83） points〕（P<0.05），while there was no significant difference in the hindrance-related stress〔both were 2.80（1.00） points〕（P>0.05）. However，the differences between doctors at township health centers and doctors at village clinics in the term of "I cannot determine what my job responsibilities are" and "I need to go through a tedious process to complete the job" of hindrance-related stress were statistically significant（P<0.05）. After controlling for possible confounding factors such as practice area，gender，age，education level，marital status，job title and number of working years，the job category was the influencing factor of challenge-related stress and hindrance-related stress for grassroots doctors（P<0.05）. The challenging pressure and obstructive pressure of doctors in township clinics were 40%〔OR（95%CI）=0.60（0.47, 0.76）〕 and 27%
〔OR（95%CI）=0.73（0.58, 0.94）〕 respectively，lower than those in village clinics. Conclusion　Both doctors at township health centers and at village clinics are under great challenge-related stress，while the latter bear more. Therefore，it is necessary to pay attention to doctors' stress and reduce negative impact of challenge-related stress. Compared with doctors at township health centers，village clinic doctors bear more hindrance-related stress in their job responsibilities and working procedures，which shows that more training and education need to be strengthened.

Training Needs of Family Carers in Urban Areas of Beijing：a Qualitative Study

CHEN Zhaojuan1，2，LU Xiaoqin1，ZHANG Xiangdong3，WANG Dongrui3，SONG Xia1，WEI Yun1，ZHAO Yali1*

2020, 23(22):  2788-2792.  DOI: 10.12114/j.issn.1007-9572.2020.00.033

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Background　Chronic diseases have become the main factors for the consumption of limited health resources in China. The current management mode of family carers plays an important role in the prevention and control of chronic diseases. Objective　To understand the training needs of family carers in Beijing，in order to provide reference for the next step in formulating relevant policies. Methods　From October to November in 2018，a total of 20 family carers and 10 trainers from five community health service centers randomly selected from the previous survey including 30 community health service centers of 15 districts in Beijing were enrolled in our study. An individual in-depth interview was conducted. The interview materials were analyzed by content analysis method. Results　The topics of interviews for family carers included enriching training content，diversifying training methods and arranging training time reasonably. The topics of interviews for trainers included training teaching skills，training young and middle-aged family carers，strengthening financial support and increasing labor division and cooperation. Conclusion　The key to improve the quality of the family carer training is to enrich training content，diversify training methods，arrange training time reasonably，train family carers who are young and middle-aged，strengthen the teaching skills of the trainers，rejuvenate teaching staff，increase financial support，and allocate human resources reasonably.

Prevalence of Asymptomatic Kidney Stones among Community Residents over 40 in China：a CT Survey

LOU Luxin，YU Aihong，LI Kai，YIN Lu，CHENG Xiaoguang，LI Wei

2020, 23(22):  2793-2796.  DOI: 10.12114/j.issn.1007-9572.2020.00.218

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Background　Many diseases of urinary system were caused by kidney stones. The prevalence of kidney stones is increasing year by year in China. However，there are few multiregional studies on it. Objective　To investigate the prevalence of asymptomatic kidney stones among community residents over 40 in China. Methods　The subjects of this survey were from a subgroup of Chinese population in a large global study of Prospective Urban and Rural Epidemiology（PURE）. Community residents over 40 years old from 12 PURE research centers in Beijing City，Jiangsu Province，Shanxi Province，Shaanxi Province，Liaoning Province，Jiangxi Province and Sichuan Province were underwent quantitative computed tomography（QCT） examination of the midsection at the fourth follow-up from 2015 to 2017 to evaluate the prevalence of osteoporosis and spinal fractures in the Chinese population. The CT images were read by radiologists to determine whether there were positive stones in the bilateral kidney areas，and the number of stones was recorded. Asymptomatic kidney stones were counted，and the prevalence was calculated by region，gender，and age. Results　A total of 3 360 subjects aged from 40 to 95 years old were enrolled with an average age of （62.0±9.1），including 1 231 males and 2 129 females. Finally，282（8.39%） cases with asymptomatic kidney stones were found. There was no significant difference in the prevalence of asymptomatic kidney stones among cases with different genders and different ages（P>0.05），while the difference among cases in different regions was statistically significant（P<0.05）. Conclusion　The prevalence of asymptomatic kidney stones was high in people over 40 years old. Based on this，it is speculated that the overall incidence of kidney stones，including patients with symptomatic kidney stones，will be higher，and there is no difference between genders and different ages，which requires attention.

The Risk Factors of Cardiovascular Disease in Patients with Essential Hypertension

CUI Weifeng，LIU Xiaoxiao，HAN Jingyi，FAN Junming

2020, 23(22):  2797-2803.  DOI: 10.12114/j.issn.1007-9572.2020.00.121

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Background　Essential hypertension has a high incidence in the world，and it is also a common complication of heart，brain，kidney and other target organ damage. Among them，cardiovascular diseases are the most common ones. Objective　To Screen the risk factors of cardiovascular diseases in patients with essential hypertension，in order to provide a basis for the prevention and intervention of cardiovascular risks. Methods　A retrospective cohort study was conducted to follow up patients with essential hypertension treated by traditional Chinese medicine（TCM） in Henan Province Chinese Medicine Research Institute from 2001 to 2013. The follow-up period was from January 2015 to December 2016. General data，medical history characteristics，laboratory indicators，vascular function and cardiac function examination indicators，and TCM syndromes，as well as the incidence of cardiovascular risk were collected. The COX proportional hazard regression model was used to screen the risk factors of cardiovascular disease in patients with essential hypertension. Results　A total of 985 patients entered the statistical analysis in this study with the age of （55.8±5.8） and the disease duration of （10.6±4.2） years，of which 284 patients had cardiovascular events. COX regression univariate analysis and collinearity diagnostics showed that there were significant difference in age，gender，course of disease，body mass index（BMI），family history of early cardiovascular disease，smoking history，mood，dietary habits，homocysteine（Hcy），Na+，average ankle-brachial blood pressure index（ABI），average arterial pressure，flow-mediated dilatation（FMD），headache，edema，Qi deficiency and blood stasis syndrome，Yin deficiency and Yang hyperactivity syndrome，liver-kidney Yin deficiency syndrome，and Yin and Yang deficiency syndrome in the prognosis of patients with essential hypertension（P<0.05）. The COX regression multivariate analysis suggested that gender〔HR（95%CI）=2.719（1.619，4.566）〕，the course of disease〔HR（95%CI）=1.282（1.131，1.322）〕，family history of early onset cardiovascular disease〔HR（95%CI）=1.547（1.214，1.970）〕，BMI〔HR（95%CI）=1.023（1.003，1.993）〕 and dietary habits〔HR（95%CI）=1.625（1.160，2.278）〕，Hcy〔HR（95%CI）=1.022（1.008，1.037）〕，mean ABI〔HR（95%CI）=0.058（0.015，0.223）〕， mean arterial pressure〔HR（95%CI）=1.204（1.064，1.987）〕，FMD〔HR（95%CI）=0.959（0.909，0.994）〕，headache〔HR（95%CI） =1.344（1.055，1.712）〕，edema〔HR（95%CI） =39.079（4.716，323.841）〕，syndrome of Qi deficiency and blood stasis〔HR（95%CI）=1.327（1.171，1.870）〕，syndrome of Yin deficiency and Yang hyperactivity〔HR（95%CI）=1.085（1.063，1.880）〕，syndrome of liver and kidney Yin deficiency 〔HR（95%CI）=1.172（1.086，1.595）〕，syndrome of Yin and Yang deficiency〔HR（95%CI）=1.204（1.143，2.439）〕 was closely associated with cardiovascular risk of essential hypertension（P<0.05）. Conclusion　Course of disease，gender，family history of early cardiovascular disease，BMI，dietary habits，Hcy，average ABI，average arterial pressure，FMD，headache，edema，Qi deficiency and blood stasis，Yin deficiency and Yang hyperactivity syndrome，liver-kidney Yin deficiency syndrome and Yin and Yang deficiency syndrome are the risk factors of cardiovascular risk in patients with essential hypertension. Clinically，prevention and intervention of cardiovascular risk in patients with essential hypertension should be strengthened according to these risk factors.

The Relationship between Sleep Quality and Sarcopenia in the Elderly

YAO Xuemei，LI Meiyan，WU Dong，XIAO Hui

2020, 23(22):  2804-2808.  DOI: 10.12114/j.issn.1007-9572.2020.00.176

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Background　Both sarcopenia and sleep disorders have high incidence in the elderly. Poor sleep quality can inhibit anabolic hormones，which affects the synthesis of skeletal muscle. However，there is little research on the relationship between sleep quality and sarcopenia in the elderly. Objective　To explore the relationship between sleep quality and sarcopenia in the elderly，and provide scientific basis for the prevention and treatment of senile sarcopenia. Methods　Using the method of random sampling，a questionnaire survey（about general demographic data and sleep quality） and physical examination（including skeletal muscle mass of limbs，walking speed，and grip strength） were conducted in 1 391 elderly people aged 60 and older who came to a physical examination center in Urumqi from December 2017 to December 2018. The sleep quality was estimated by The Pittsburgh Sleep Quality Index（PSQI）. The sarcopenia was diagnosed by the criteria of Asian Working Group for Sarcopenia. The effect of sleep quality on sarcopenia was analyzed by multivariate logistic regression. Results　Of the 1 391 respondents，194（13.9%） had sarcopenia，and the mean PSQI score was（6.22±3.87）. And 713（51.3%） respondents had a PSQI score>5，which meant their sleep quality was poor. There were significant differences in the incidence of sarcopenia among the elderly with different ages，monthly income，marital status and drinking status（P<0.05）. The proportions of poor sleep quality in patients with different genders，ages，education levels，monthly income，marital status，smoking ststus and drinking status were statistically significant（P<0.05）. Patients with sarcopenia had significantly higher PSQI scores and scores of subjective sleep quality，time to sleep，sleep time，sleep efficiency and daytime dysfunction than those without sarcopenia（P<0.05）. Compared with patients with PSQI scores≤5，those with PSQI scores>5 had a higher risk of sarcopenia〔OR（95%CI）=1.74（1.27，2.38）〕．After stratified by gender，compared with patients with PSQI scores≤5，female patients with PSQI scores>5 had a higher risk of sarcopenia〔OR（95%CI）=2.17（1.37，3.43）〕，while no significant difference was found in male patients〔OR（95%CI）=1.51（0.96，2.37）〕. Conclusion　Poor sleep quality is a risk factor of sarcopenia in women over 60.

Clinical Characteristics of Obstructive Sleep Apnea-hypopnea Syndrome Patients with Different Degrees of Obesity

ZHANG Maowei，CHEN Bi，ZHU Jiechen，LIU Yanan，ZHAO Ling，JI Lei，LIU Wenjing，ZHU Shuyang，ZHANG Wenhui

2020, 23(22):  2809-2814.  DOI: 10.12114/j.issn.1007-9572.2020.00.292

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Background　Obesity is a common risk factor for obstructive sleep apnea-hypopnea syndrome （OSAHS）. The vast majority of patients with OSAHS are overweight or obese. Differences may exist in the clinical characteristics of OSAHS patients with different degrees of obesity. Objective　The clinical characteristics of OSAHS patients with different degrees of obesity were compared to determine the influence of different degrees of obesity on OSAHS. Methods　Patients with OSAHS diagnosed by polysomnography（PSG） in Sleep Medical Center of Xuzhou Medical University from January 2014 to September 2018 were selected as research subjects. The clinical data of patients were collected，including demographic data，clinical complications and major sleep parameters. According to the criteria of China Obesity Task Force，OSAHS patients were divided into three groups by their BMI，normal weight group（<24.0 kg/m2），overweight group（24.0-27.9 kg/m2），and obesity group（≥28.0 kg/m2）. The differences of clinical characteristics，comorbidities，and major sleep parameters were compared，and the correlation between BMI and major sleep parameters was analyzed. Results　A total of 1 586 OSAHS patients were included in the study，including 1 259（79.38%） males and 1 062（66.96%） smokers，and the average BMI was（28.20±4.19） kg/m2. Hypertension（44.89%，712/1 586），cerebrovascular disease（20.62%，327/1 586），and heart disease（13.55%，215
/1 586） were common complications of OSAHS. According to BMI，206 patients were in the normal weight group，616 were in the overweight group，and 764 were in the obesity group. There were significant differences in age，BMI，Epworth sleepiness scale（ESS） score，hypertension，diabetes，heart disease，cerebrovascular disease，oxygen desaturation index（ODI），apnoea–hypopnoea index（AHI），mean oxygen saturation（MSaO2），lowest oxygen saturation（LSaO2），and microarousal index among patients in three groups（P<0.05）. A further pairwise comparison showed that patients in overweight group had lower MSaO2 and LSaO2 than those in normal weight group（P<0.05），while their BMI，ODI，AHI and microarousal index were higher（P<0.05），and number of cases with cerebrovascular disease was higher（P<0.016 7）. The mean age of patients in obesity group was lower than those of patients in normal weight group（P<0.05），while the number of cases with cerebrovascular disease was higher（P<0.016 7）. MSaO2 and LSaO2 in the obesity group were lower than those in the normal weight group and overweight group（P<0.05），while the BMI，ESS score，ODI，AHI and microarousal index were higher（P<0.05），and number of cases with hypertension，diabetes，and heart disease were higher（P<0.016 7）. Pearson correlation analysis showed that BMI and AHI were linear positively correlated（r=0.312，P<0.001），MSaO2 and LSaO2 were linear negatively correlated （r=-0.501，-0.566； P<0.001）. Conclusion　The BMI of OSAHS patients is positively correlated with AHI. Obese and overweight OSAHS patients showed more severe syndromes and a higher rate of comorbidities. It shows that obesity may aggravate the severity of OSAHS.

Relationship between Red Blood Cell Parameters and Coronary In-stent Restenosis

NAN Jing1，2，CHEN Ce2，LI Hong1，3，MENG Shuai1，HU Hongyu1，JIA Ruofei1，CHEN Wei1，YE Huiming2，LEI Licheng2，REN Lihui2，JIN Zening1，3*，PENG Jianjun2，4*

2020, 23(22):  2815-2820.  DOI: 10.12114/j.issn.1007-9572.2020.00.034

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Background　In-stent restenosis（ISR） is an important factor associated with the short-term and long-term prognosis of patients undergoing precutaneous coronary intervention（PCI）. Finding clinical indicators to effectively evaluate ISR has the important clinical value. Some previous studies have found that red blood cell distribution width（RDW） is related to the occurrence of ISR，but there are few studies on the relationship between red blood cell parameters and ISR. Objective　To investigate the relationship between peripheral red blood cell parameters and the incidence of ISR. Methods　Peripheral blood routine results of patients with coronary atherosclerotic heart disease who underwent PCI and received coronary angiography follow up in Cardiovascular Medicine Department in Beijing Shijitan Hospital of Capital Medical University were collected，and clinical data may be related to ISR were analyzed. Results　One hundred and seventy patients were enrolled with an average age of（65.1±10.5） and an average follow-up period of（25.38±9.91） months. There were 213 PCI vessels，and among them，21 vessels were with ISR，with an incidence rate of 12.7%. The univariate analysis results showed that patients with ISR had smaller mean corpuscular volume（MCV）〔（89.11±3.70） fl vs.（91.64±4.07） fl，P=0.008〕，lower mean corpuscular hemoglobin（MCH）（29.76 pg vs. 31.10 pg，P=0.001），and lower mean corpuscular hemoglobin concentration（MCHC）〔（332.67±11.62） g/L vs.（338.21±10.55） g/L，P=0.027〕. There were no significant differences in the total number of red blood cells，hemoglobin concentration，and red blood cell distribution width in two groups（P>0.05）. Other test results showed that patients with ISR had a higher proportion of women and higher serum creatinine levels（P<0.05）. The results of coronary angiography and PCI showed that there was no significant difference in terms of the types of lesions，the involvement of blood vessels，the number of stents，the length of the stents，whether the lesion type was a bifurcation lesion，and whether the inflatable balloon tamp was used after the stent was released and pressure after ballon dilatation（P>0.05）.  Binary Logistic regression analysis revealed that women and high serum creatinine levels were the independent risk factor for ISR after PCI（P<0.05），and neither red blood cell parameters were independent risk factors for ISR after PCI（P>0.05）. Analysis of ROC curve indicated that the areas under the curve of MCV，MCH，and MCHC for predictive value of ISR after PCI were 0.328，0.276，and 0.385，respectively. Conclusion　Venous red blood cell parameters are associated with the incidence of ISR in patients with coronary heart disease，but are not the independent risk factors for ISR. At the same time，the predictive value of these indicators is limited for ISR.


Vitamin D Status of Children Aged 0-14 in Inner Mongolia

2020, 23(22):  2820-2824.  DOI: 10.12114/j.issn.1007-9572.2020.00.170

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　Background　Vitamin D plays an important role not only in bone metabolism，but also in immune regulation，the maintenance of nervous system function，and the prevention of cardiovascular diseases，tumors and metabolic diseases. Therefore，it is of great significance to study the relationship between children's vitamin D status and gender，age，season，nationality and health status to prevent vitamin D deficiency in children. Objective　To study the relationship between nutritional status of vitamin D and gender，age，season，nationality and health status in children aged 0-14. Methods　The clinical data and serum 25-（OH）-D level of 7 963 children aged 0-14 who were tested for vitamin D in Department of Pediatrics of Hulunbeir People's Hospital in Inner Mongolia from January to December in 2018 were analyzed retrospectively.Results　There was no significant difference in the level of 25-（OH）-D between children with different genders（P>0.05）.The difference of 25-（OH）-D levels among children with different ages was statistically significant，and the back testing showed that 25-（OH）-D level was highest in infants，followed by preschool children，and lowest in school-age children（P<0.05）. Serum 25-（OH）-D level gradually increased with the increase of the month of age in infancy，and reached a high level at six months，which lasted for next six months and then gradually decreased with age. There was no significant difference in serum 25-（OH）-D level among infants in different seasons. School-age children and preschool children had the highest serum 25-（OH）-D level in summer，followed by autumn，winter and spring. The 25-（OH）-D level of infants of Han nationality was higher than that of infants of other minorities，and the difference was statistically significant（P<0.05），while there was no statistical difference in serum 25-（OH）-D levels between Han nationality and other minorities among school-age children and preschool children（P>0.05）. The levels of serum 25-（OH）-D in healthy preschool children and infants were higher than those in diseased children，and the difference was statistically significant（P<0.05）. There was no significant difference in serum 25-（OH）-D levels between diseased school-age children and healthy school-age children（P>0.05）. Conclusion　The vitamin D status of children aged 0-14 in Inner Mongolia has nothing to do with gender，but is related to age，season，nationality and health status.

Training Needs of General Practitioners in the Community Health Center within a Compact Medical Consortium

AN Kang1，SU Qiaoli1，XU Jiao1，ZHU Yuan1，ZHOU Yiling2，QU Furong2，CHEN Xiangyang2，ZHOU Youlian2，AN Zhenmei2，LI Shuangqing1，LI Sheyu2*

2020, 23(22):  2825-2830.  DOI: 10.12114/j.issn.1007-9572.2020.00.387

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Background　The evidence is absent to support the trainings for improving professional capabilities of community general practitioners（GPs） working within a medical consortium. Objective　To formulate a demand-oriented training plan for GPs in the community health center（CHC） within a compact medical consortium. Methods　A survey was conducted from November to December 2019 in a cluster sample of 65 GPs working at 9 CHCs within West China Hospital of Sichuan University medical consortium for collecting data about training needs of general practice. A questionnaire was used in the survey，which consists of essential theoretical knowledge，essential and other skills and clinical practice of general practice，with questions presented using 37 10-point Likert items（a higher score indicating a higher demand）. And the priority level of item contents was set later according to the rated score. Results　The items with an average score of≥9 revealed that，the most in-demand essential theoretical knowledge，essential and other skills and clinical practice of general practice were clinical diagnostic and treatment strategies〔47.7%（31/65）〕，general treatment of common respiratory system diseases〔55.4%（36/65）〕，community nutrition guidance〔36.9%（24/65）〕，and performance of oxygen therapy，and use of common inhalers and nebulizers for respiratory diseases〔46.2%（30/65）〕，respectively. According to the priority criteria，contents covered by 8 items，including general diagnostic and treatment strategies，general treatment of common cardiovascular and cerebrovascular diseases，and common respiratory diseases as well as common symptoms and emergencies in the community，first aid techniques，interpretation of common laboratory test results，common image recognition（X-ray and B-mode ultrasound images），interpretation of 12-lead ECG and dynamic ECG were set as the first choice of training content，and the contents covered by 13 items，involving general treatment of common digestive system diseases，were listed as the major alternatives. Conclusion　This study proposed a systematic training program with 8 aspects of first-choice training contents and 13 aspects of major alternatives listed，for community GPs working within a compact medical consortium，which may be used as a reference for medical institutions developing GPs training programs based on their own conditions.

Status of Continuing Medical Education in Medical Professionals in Yuetan Community Health Center，Xicheng District，Beijing

JI Yan，SUN Yange，YAN Chunze，DING Jing

2020, 23(22):  2831-2836.  DOI: 10.12114/j.issn.1007-9572.2019.00.610

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Background　Continuing medical education（CME） can continually improve the professional knowledge and skills of medial professionals. But current forms of CME are undiversified，and the contents are very unsatisfactory. To improve the effectiveness of CME，we evaluated the status and main problems of CME received by medial professionals from Yuetan Community Health Center，Fuxing Hospital，Capital Medical University，Xicheng District，Beijing（Yuetan Community Health）. Objective　To perform a statistical analysis of CME status in medical professionals from Yuetan Community Health，and to identify the main factors associated with attending the participation in CME，providing a theoretical basis for promoting the development of online CME programs，resolving the work–study conflict，and improving the efficiency and quality of CME. Methods　CME received by 561 medical professionals from Yuetan Community Health Center，Fuxing Hospital，Capital Medical University，Xicheng District，Beijing，during November 2015 to October 2018 was analyzed，which mainly includes the following：compulsory courses（municipal-，district- and staff-level compulsory courses），specialty courses（district-level chronic disease courses，district-level infectious disease courses，specialty courses educated by the healthcare institution itself），trainings/conferences（actively and passively participated trainings，conferences or exchanges），and sponsored or hosted projects（national-，municipal- and district-level projects）. The analysis results were counted by two researchers separately，and if their statistical results were not inconsistent，the data were reviewed till consistency was obtained. Unstructured interviews with 10 medical professionals were conducted to explore their perspectives of major factors associated with participating in CME. Results　A total of 561 cases received the continuing education of compulsory courses during three years，including 8 376-hour（221-hour face-to-face courses and 8 155-hour online courses） municipal-level compulsory courses，
3 366-hour district-level courses（all face-to-face courses），and 3 366-hour staff-level courses（all online courses）. Specialty courses were all taught in a face-to-face way.Continuing education of such courses were conducted for a total of 79 times，with an average of 2.2 times per month.In particular，chronic disease courses were taught for 57 times（72.2%），and infectious disease courses were taught for 22 times（27.8%）. The total number of cases learning such courses was 4 068（averaged 52 cases in each training）. Specifically，the average number of cases learning chronic disease courses，and infectious disease courses in each training was 34，and 96，respectively. There were more CME projects and a higher attending rate in the third quarter（May，June，and July） of each year. All actively and passively participated trainings/meetings were conducted in a face-to-face way. The total number of trainings/conferences conducted was 104，with an average number of 4.3 per month. And the number of participated cases was 244. In 2017，85 cases passively participated in 29 trainings/conferences，and 26 cases actively participated in 17 trainings/conferences. In 2018，92 cases passively participated in 38 trainings/ conferences，and 67 cases actively participated in 20 trainings/conferences. The total number of sponsored or hosted projects was 21，and all were conducted in a face-to-face way. All the interviewees considered that conflict between work and study was the major factor associated with participating in CME. Conclusion　The CME programs received by medical professionals from Yuetan Community Health are various，and are mainly conducted in the traditional face-to-face way. The medical professionals show high initiative in attending CME，and the most important problem faced by them is work-study conflict. In view of this，online CME programs are suggested to be carried out appropriately to improve the efficiency and quality of CME.

Discussion and Reflection on the Current Situation of Humanistic Quality Education of General Practitioners

LIU Ying，HUANG Liting

2020, 23(22):  2837-2840.  DOI: 10.12114/j.issn.1007-9572.2020.00.220

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　General practitioners（GPs） are rooted in the primary care and strive to improve and meet the overall needs of basic health services. It is precisely because of the particularity of the positioning and the service population of GPs that humanistic quality education plays a more important role in the training of GPs than specialists. Nowadays，more and more attention has been paid to the cultivation of humanistic quality of GPs at home and abroad，but there are still some deficiencies in China compared with developed countries. This paper further emphasizes the importance of humanistic quality education in GP's training and through comparing the current situation of GP's humanistic quality education at home and abroad，it further reflects on the methods of improving humanistic quality education in China.

Sociodemographic Inequalities in the Prevalence and Treatment of Chronic Non-communicable Diseases：a Concentration Index Decomposition Analysis

WU Shuang，HE Liping，LI Xiaomei，YU Zhen，MENG Jinliang，MU Fengting

2020, 23(22):  2841-2846.  DOI: 10.12114/j.issn.1007-9572.2019.00.723

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Background　Chronic non-communicable diseases have become one of the significant public health problems in the world. In China，chronic disease patients are increasing，and the rate of all deaths due to such diseases is high，but the sources of inequalities in the prevalence and treatment of chronic diseases are rarely studied. Objective　To evaluate the inequalities in the prevalence and treatment of chronic diseases in rural residents from Zhaotong，Yunnan Province，providing a basis for the development of population health promotion strategies. Methods　A household questionnaire survey was conducted between July and November，2013，in 9 988 permanent rural residents from three areas（Zhaoyang District，Ludian County and Yanjin County） of Zhaotong City，selected by multistage cluster sampling and stratified sampling，for collecting basic family status，sociodemographic characteristics of family members，prevalence and treatment of chronic diseases in family members in the past year，and so on. Concentration index（CI） and CI decomposition were used to analyze the sociodemographic inequalities in the prevalence and treatment of chronic diseases. Results　The prevalence of chronic diseases in this group of rural residents was 15.75%（1 573/9 988），and the treatment rate was 13.02%（1 300/9 988）. The main variables influencing the CI of chronic disease prevalence were annual household income per capita，age and marital status，with the contribution rate of -130.57%，43.03% and 20.95% respectively；the main variables influencing the CI of chronic disease visit rate were annual household income per capita，age，whether there was medical insurance or not，and marital status，with the contribution rate of -99.77%，37.49%，30.48% and 27.48% respectively. The standardized CIs for the prevalence and treatment of chronic diseases were -0.115 4，-0.118 2，respectively，showing that the prevalence and treatment of chronic diseases were more common among low-income individuals. Conclusion　The findings indicated that there were sociodemographic inequalities in chronic disease prevalence and treatments in rural residents from Zhaotong，which was most closely associated with the income level，followed by age.

The Effect of Cognitive Frailty on the Hospitalization Expenses of the Elderly with Comorbidity

ZHANG Rong1，YANG Ying2，LI Zheng1，CHEN Shanping2，FU Liangxiu3，XIAO Qiaofang4，WANG Ziqi1*

2020, 23(22):  2846-2851.  DOI: 10.12114/j.issn.1007-9572.2020.00.070

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Background　With an increasing number of elderly people，the prevalence of cognitive frailty is gradually growing at the same time. In fact，patients with cognitive frailty have a high incidence of falls，functional disability and hospitalization，and an increased risk of death，which brings a heavy economic burden to the society and the family. However，there is a lack of relevant studies on the hospitalization expenses of the elderly with cognitive frailty. Objective　To understand the effect of cognitive frailty on the hospitalization expenses of the elderly with comorbidity. Methods　Using the retrospective study method，118 inpatients with comorbidity aged ≥60 years old in the Department of Neurology and Department of Gerontology and Geriatrics of Chengdu Fifth People's Hospital were selected as the study objects from November 2015 to June 2016. Chinese version of the FRAIL scale，MMSE scale and ADL scale were used to assess the frailty status，cognitive function and activities of daily living among the elderly，respectively. The laboratory examination expenses and hospitalization expenses were extracted from the information system of Chengdu Fifth People's Hospital. According to whether there were frailty and mild cognitive dysfunction at the time of admission，the patients were divided into four groups：group N（no frailty or cognitive dysfunction），group C（no frailty but with cognitive dysfunction），group F（with frailty but no cognitive dysfunction），and group CF（with both frailty and cognitive dysfunction）. The social demographic data，living habits，anthropometric data，laboratory examination results，hospitalization expenses and hospitalization days of the four groups were compared，and the influencing factors of hospitalization expenses among the elderly with comorbidity were analyzed by Logistic regression. Results　The age and total hospitalization expenses of group CF were higher than those of the other three groups，and the albumin（ALB） level was higher than those of group N and group C；ALB level and total hospitalization expenses of group F were higher than those of group N（P<0.05）. The general medical cost，diagnosis cost，total treatment cost and traditional Chinese medicine treatment cost of group C and group F were higher than those of group N；the general medical cost of group CF was higher than that of group N and group C，while the diagnosis cost was higher than that of group N and group F，and the total treatment cost，Western medicine treatment cost and traditional Chinese medicine treatment cost were higher than that of group N，group C and group F，and the cost of consumables was higher than that of group N（P<0.05）. The results of Logistic regression analysis showed that among all the unadjusted model，the model with adjusted age，gender and marital status，the model with adjusted age，gender，marital status，smoking status and drinking status，and the model with adjusted age，gender，marital status，smoking status，drinking status，white blood cell count（WBC），hemoglobin（HB），platelet count（PLT），ALB and low density lipoprotein cholesterol（LDL-C），cognitive frailty increased the total hospitalization expenses of the elderly with comorbidity（P<0.05）. Conclusion　Cognitive frailty could increase the total hospitalization expenses of the elderly with comorbidity. The high hospitalization expenses of the elderly with comorbidity mainly come from drug treatment. The elderly inpatients with cognitive frailty relatively lack the rehabilitation exercise and have poor nutritional support. Therefore，reducing the drug use among elderly patients with cognitive frailty and strengthening the prevention and treatment of their combidities may reduce the total hospitalization expenses.

Sedentary Behavior and the Risk of Depression in Patients with Type 2 Diabetes Mellitus

WANG Ya，SUN Juan，ZHANG Xiaoyi，HE Hong，GAO Jing，YIN Lirong

2020, 23(22):  2856-2862.  DOI: 10.12114/j.issn.1007-9572.2019.00.684

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Background　The adverse effects of sedentary behavior on physical health have been widely studied，but its impact on mental health is rarely reported. The prevalence of sedentary behavior in patients with type 2 diabetes mellitus（T2DM） is relatively high，so it is of great significance to explore the relationship between sedentary behavior level and depression risk in this group. Objective　To explore the correlation between sedentary behavior and depression risk in patients with T2DM，providing a theoretical basis for clinical delivery of health education intervention for such patients. Methods　From January to November 2018，a questionnaire survey was conducted in a convenience sample of 410 T2DM outpatients from the endocrine outpatient clinic of a grade A tertiary hospital in Nantong area，for collecting the data about socio-demographic information，history of disease，subjective assessment of sedentary behavior，depression risk assessed by the Beck Depression Inventory 2nd Edition（BDI-Ⅱ），and physical activity assessed by the International Physical Activity Questionnaire-Short Form（IPAQ-SF）. Correlation analysis and Logistic regression model were used to analyze the relationship between sedentary behavior level and depression risk. Results　A total of 402（98.1%） cases returned responsive questionnaires. The average daily time spent in sedentary behavior was （5.62±2.60）h in all the respondents，and was at least 5 hours in 265（65.9%） cases. The sedentary behavior level differed significantly by average personal monthly income，body mass index（BMI），the number of comorbidities，glycosylated hemoglobin（HbA1c），total cholesterol（TC），triacylglycerol（TG），low-density lipoprotein cholesterol（LDL-C），BDI-II score and physical activity level（P<0.05）. Correlation analysis showed that sedentary behavior level was positively correlated with the number of comorbidities，diastolic pressure，BMI，waist circumference and depression level，and negatively correlated with physical activity level（P<0.05）. After controlling for socio-demographic factors consisting of age，sex，marital status，employment status，prevalence of smoking，drinking，and medical insurance，educational level，average personal monthly income，course of T2DM，number of complications，number of comorbidities，family history of T2DM，depression history，types of drug therapies，insulin therapy，systolic blood pressure，diastolic blood pressure，BMI，waist circumference and physical activity level，partial correlation analysis showed that sedentary behavior level was still positively correlated with depression level（pratial correlation coefficient was 0.637，P<0.001）. Stepwise Logistic regression analysis showed that the OR（95%CI） of depression risk in sedentary group was 29.68（16.11，54.68），and was 64.55（28.40，146.72） after adjusting for the above-mentioned socio-demographic variables. Conclusion　There is a positive correlation between sedentary behavior level and depression risk in patients with T2DM. Clinical workers should pay attention to the health education for reducing sedentary behavior in such patients.