Chinese General Practice

The Progress of the Pilot Work of Construction in Community Hospitals　

ZHANG Lifang，LI Xinfang，QIN Jiangmei，ZHANG Yanchun，LIN Chunmei，MENG Yeqing

2020, 23(31): 3895-3899. DOI: 10.12114/j.issn.1007-9572.2020.00.487

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Background　Carrying out the pilot work of Community hospital construction is a powerful process to improve the capacity of primary health care services，also a major measure to promote the construction of the hierarchical medical system. In 2019，the National Health Commission started pilot work of community hospital construction in 20 provinces. Objective　To monitor the progress and effectiveness of the pilot work to provide data support and policy recommendation for promoting the Community hospital construction. Methods　The data were obtained from the questionnaire survey of 608 community hospitals in 20 pilot provinces in December 2019. The work progress was reflected by quantitative analysis of the indicators，such as the business room area of community hospitals，the actual number of open beds，The bed utilization ratio department settings，service quality，etc. Results　By October 2019，community hospitals with a business building area of more than 3 000 square meters accounted for 97.4%（592/608） of the total. Community hospitals with more than 30 open beds accounted for 98.2%（597/608），and the utilization ratio of beds reached 79.1%，the community hospitals with clinical departments more than 5 accounted for 91.0%（553/608）. Compared to the same period in 2018，The average building area of each community hospital business building（6 275 square meters） increased by 368 square meters，the actual number of open beds（91） increased by 5 beds，the utilization ratio of bed held the line. The clinical business department of new increased by 0.64. The number of outpatients and emergency visits（92 500 person-times），the number of hospital admissions（2 616 persons），and the number of outpatient and emergency visits of pediatric（10 800 person-times） increased by 8.2%，5.6% and 15.2% year-on-year respectively. Conclusion　The pilot work of community hospital construction has achieved significant results，but there are still some problems such as unbalanced construction in different pilot provinces，a few community construction has not yet up to standard，service quality needing to be improved and incomplete supporting policies. We should continue to strengthen the infrastructure construction，improve the service capabilities and relevant policies of the community hospital construction.

Learning from the Outside World：Challenges and Reflections of COVID-19 #br#

Leon Piterman

2020, 23(31): 3900-3904. DOI: 10.12114/j.issn.1007-9572.2020.00.471

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Effectiveness of Measures for Containing COVID-19 Pandemic in a Regional Medical Consortium in Beijing：a Case Study　

CHU Hongling，PIAO Yufen，SHE Ruifang，ZHEN Dongyun，LI Han，ZENG Lin，ZHUO Lin，TAO Liyuan，ZHAO Yiming，LEI Yi

2020, 23(31): 3905-3911.

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Background　To contain the COVID-19 pandemic，the Beijing municipal government has issued multiple measures. During the process of combating the pandemic，Beijing's regional medical consortiums，a kind of key institutions established for promoting the optimization of healthcare resources，have played an important role. Evaluating their anti-pandemic performance may provide a reference for such institutions to take actions to deal with public health emergencies and for assessing their responses to the emergencies. Objective　To evaluate the responses of a Beijing's regional medical consortium to COVID-19 pandemic to investigate the role of regional medical consortiums in containing the pandemic. Methods　Convenient and purpose sampling were used to select a core hospital and 3 community health centers（CHCs） in a medical consortium in Beijing. Semi-structured in-depth interviews were conducted in March 2020 with 17 participants in total after obtaining their informed consent：1 manager from the core hospital，and 4 managers，2 senior nursing officers，4 GPs and 6 patients from the CHCs，which mainly involved actions taken by the regional medical consortium to deal with COVID-19，and the assessment of these measures using a framework developed based on the normalisation process theory and process evaluation of complex interventions（consisting of 5 domains:coherence between the actions and actual work，coverage of actions，effectiveness of implementation，barriers and or facilitators for implementation，and impact of the actions on the development of the regional medical consortium）. The interviews were recorded，and transcribed and were analyzed using thematic analysis with NVivo. Results　The major actions taken by this regional medical consortium during the period are as follows：（1）Holding trainings. A total of 2 trainings were conducted among member institutions to improve the knowledge，diagnostic and therapeutic techniques and preventive interventions related to COVID-19，with the need to be more targeted and practical for community hospitals. （2）Strengthening the appointment for referrals in CHCs. The appointment services covered 16 community hospitals. These hospitals made 50 upward referrals，and suggested intra-hospital referrals of 246 screened suspected cases to the fever clinic. Although more patients preferred visiting CHCs，which promoted the implementation of the hierarchical medical system，the criteria for referrals should be more clear. （3）Transferring patients with infusion treatment from the core hospital to CHCs. 380 with infusion treatment were transferred to the CHCs from core hospital，which eased the pressure of emergency treatment in the core hospital，and also provided patients with a more convenient and safe infusion environment，and enhanced the cohesion and collaboration within the member institutions，but information sharing should be strengthened within the medical consortium. Conclusion　This regional medical consortium has played a hierarchical diagnostic and therapeutic role in combating COVID-19 pandemic by united and collaborative efforts of its members. The aspects need to be improved are related trainings，criteria for referrals and information sharing. This study may be referred by other regional medical consortiums in China for further development.

COVID-19 Screening and Triage Using a Unified Approach to the Management of Relevant Healthcare Workers，Procedure and Goals within a Regional Medical Consortium：a Development from Disorderly to Orderly　

XIONG Ziyu，CHEN Yanfang，ZHANG Yinglan，ZHANG Sumin，ZHANG Yushu，TANG Xiaoya，CUI Yingying，CHEN Dong，LI Ning，XIE Rihua

2020, 23(31): 3912-3916. DOI: 10.12114/j.issn.1007-9572.2020.00.545

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Background　It was difficult for primary care to take emergency actions to contain COVID-19 at the beginning of its outbreak，and the management of screening and triage procedure was disorderly. To address the situation，it is critical to make a sound management method for appropriately screening，triage，treat and transfer the patients. Objective　To evaluate the effect of an approach for unified management of COVID-19 screening and triage in members within a regional medical consortium. Methods　This study was carried out in a regional medical consortium with five unified features including unified goal，legal person，information platform，service team and salary scheme. An approach developed by our research group，has been used for unified management（of relevant goals，healthcare workers and procedure） of COVID-19 screening and triage in this consortium led by a tertiary hospital，together with 18 stations of a community health center，and the implementation results between January 25 and April 4，2020 were analyzed. Results　During this period，of the 173 841 cases screened and triaged in the tertiary hospital，440 were triaged to the COVID-19 fever clinic，2 051 to the general fever clinic，271 to the quarantine ward due to suspected COVID-19 symptoms，and 4 were confirmed and referred to the designated hospital. The 18 stations of community heath centers screened and triaged 52 525 cases，including 25 who were triaged to the COVID-19 fever clinic，and 122 to the general fever clinic. There were no missed screening of suspected COVID-19 cases and cross infections within the medical consortium. Conclusion　Our unified management approach has effectively facilitated the development of COVID-19 screening and triage from disorderly to orderly within the regional medical consortium，demonstrating good effects in containing the COVID-19 pandemic.

Structure，COVID-19-related Knowledge，Attitudes and Work Characteristics of the Community COVID-19 Containment Team　

QIU Chuangliang，WANG Hongrui，ZHAO Yuxin，GAN Yong，LU Zuxun

2020, 23(31): 3917-3923. DOI: 10.12114/j.issn.1007-9572.2020.00.482

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Background　COVID-19 is an emerging infectious disease that is extremely difficult to prevent and control. Community prevention and control is an important way to curb the spread of the pandemic. The community workers for containing COVID-19 are the main body of COVID-19 prevention and control force，undertaking tasks such as registering the brief health-related information of persons entering and leaving the community，governing the community environment，and publicizing knowledge pertaining to COVID-19 prevention. However，their COVID-19-related knowledge level and specific work tasks are not clear. We performed a survey concerning their structure，COVID-19-related knowledge，attitudes，and work characteristics，providing information for improving the mechanism of community-based regular epidemic prevention and control.Objective　To investigate the structure，COVID-19-related knowledge，attitudes，and work characteristics of the community COVID-19 containment team，to provide a scientific basis for optimizing the allocation of human resources for community COVID-19 containment and for promoting the popularizing of COVID-19-related knowledge. Methods　A self-designed questionnaire was used to conduct a survey with community workers for containing COVID-19 selected from five streets in Baoan District，Shenzhen from March 12 to 21，2020 by convenience sampling，for collecting their demographics，COVID-19-related knowledge and attitudes. Results　Of the 756 workers，753（99.6%） who completed the questionnaire effectively were included for final analysis，including 552 men（73.3%） and 201 women（26.7%），with 18-35 age group〔61.1%（460/753）〕 or those with high school or specialized school〔31.2%（235/753）〕attainment accounting for the largest percentage. Three aspects concerning COVID-19 containment obtained the highest awareness rates：required days for continuing to monitor self-health after discharge〔73.3%（552/753）〕，incubation period〔44.6%（336/753）〕，and criteria for releasing from quarantine〔39.0%（294/753）〕. Men had a higher awareness rate of main symptoms of COVID-19 but had lower awareness rates of the class of COVID-19 as an infectious disease，kinds of disinfectants for deactivating the SARS-CoV-2 virus，the follow-up period and revisit time as well as number of self-health monitoring days（P<0.05）. Younger age was associated with lower awareness rates of the class of COVID-19 as an infectious disease，and incubation period of COVID-19，but higher awareness rate of COVID-19 main symptoms（P<0.05）. Education level was associated with higher or lower awareness rates of the aspects concerning COVID-19 related information（P<0.05） except the awareness rate of transmission routes of COVID-19. Occupation was associated with significant differences in the awareness rates of the class of COVID-19 as an infectious disease and number of self-health monitoring days（P<0.05）. Higher annual household income per capita was associated with higher awareness rate of number of self-health monitoring days（P<0.05）. Poorer self-rated health was associated with lower awareness rate of incubation period of COVID-19 but higher awareness rate of number of self-health monitoring days（P<0.05）. The average score for the attitudes toward COVID-19 was（46.07±5.77）. The average number of working days for containing COVID was （42.77±14.87）.Those worked for 8-12 hours per working day accounting for the largest percentage〔51.5%（388/753）〕. 498（66.1%） participated in the community-based COVID-19 containment consisting of monitoring，screening and treatment. And 240（31.9%）played a role in undertaking at least 3 tasks. Conclusion　The structure of these community teams for containing COVID-19 was not appropriate，with a low awareness rate of information about containing COVID-19，and negative attitudes towards the pandemic. Their demographics showed different associations with different aspects of COVID-19-related information. Moreover，the COVID-19 containment may be long-term，arduous and complicated. Against the backdrop of regular COVID-19 containment in the community，the allocation of the workers for pandemic containment should be optimized，their tasks should be adjusted appropriately，and COVID-19 containment trainings for them should be strengthened.

Delivery of Essential Medical Services with National Essential Public Health Services via Five Integrated Measures in Primary Care Settings: a Practical Study　

WANG Xianjun，TANG Zhiyou，YANG Wenmei，XIAO Zhi，TANG Fanfan，HU Bin

2020, 23(31): 3924-3929. DOI: 10.12114/j.issn.1007-9572.2020.00.454

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Promoting the delivery of intensive integrated essential medical services and national essential public health services，as well as contracted family doctor services by primary care settings，are important tasks to deepen the reform of the pharmaceutical and healthcare system. To explore an appropriate health management mode for delivering both essential medical services and national essential public health services in primary care，we have tried to provide such services for hypertensive and diabetes patients by a contracted general practitioner team via five integrated measures（integration of management，workforce，scope items，performance assessment，and information of the two types of services）. In this way，the patient could access to both medical services and national essential public health services in an outpatient consultation. This kind of comprehensive health management（consisting of preventive，treatment and management services） is conducive to improving the service quality and residents' sense of gain，as well as promoting the intra-hospital horizontal integration of such services and inter-hospital vertical integration of medical resources.

Preferred Family Doctor Services in Contracted Chronic Disease Patients in Shanghai　

SUN Hui，WANG Meifeng，LUO Yashuang，JIN Chunlin，WANG Haiyin

2020, 23(31): 3930-3934. DOI: 10.12114/j.issn.1007-9572.2020.00.295

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Background　The rate of contracting family doctor services in chronic disease patients in Shanghai is high，however，the visiting rate is relatively low. Objective　This study aimed to quantify the preferences of chronic disease patients for contracted family doctor services in Shanghai，with a view to providing evidence for optimizing the contracted services and adjusting service packages specially designed for this group as well as improving the service efficiency. Methods　A questionnaire survey was carried out in a convenience sample of adult chronic disease patients in Songjiang District，Shanghai from April to July 2019. The questionnaire used was developed by our research group based on the discrete choice experiment（DCE），which includes the demographic information，DCE problems（including seven three-level attributes：frequency of regular follow-up，drug accessibility，management level of family doctors，health management activities，convenience of referral service，flexibility of appointment times，shared decision-making atmosphere）. Meanwhile，qualitative interviews were performed with patients to acquire their other needs for contracted services. A mixed Logit regression model was used to analyze the patients' preferences for contracted services. Results　Altogether，248 of the 300 cases who participated in the survey handed in responsive questionnaires，obtaining a response rate of 82.7%. The mixed Logit analysis showed that the most preferred contracted services are as follows：community-based access to drugs distributed to secondary and tertiary hospitals（β=0.57，P<0.05），high-quality medical services provided by family doctors（β=0.43，P<0.05），regular health management activities（β=0.36，P<0.05），high-frequency regular follow-ups（β=0.31，P<0.05），good shared decision-making atmosphere（β=0.12，P<0.05），highly convenient referral service（β=0.06，P<0.05），and very flexible appointment time（β=0.04，P<0.05）.Other needs of the respondents for contracted services include：real-time health consultation，specialty medical services，medical insurance reimbursement，physical examination，rehabilitation guidance，personalized health assessment，etc.Conclusion　In Shanghai，the highly preferred contracted family doctor services in chronic disease patients include community-based accessibility of drugs（generally distributed to second and tertiary hospitals），（high-quality）diagnosis and treatment level of family doctors，and 〔regular（for example，six times a month）〕 health management activities（often，six times a month）. It is necessary to strengthen the evaluation of preferred services of these patients，by which the contracted services specifically for them can be constantly optimized to better meet their healthcare needs and promote highly efficient utilization of health resources.

Factors Associated with Attitudes and Behavioral Intention Concerning Advance Directives among Physicians and Nurses　

MA Wei，XUE Qingyun

2020, 23(31): 3935-3940. DOI: 10.12114/j.issn.1007-9572.2020.00.527

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Background　Nowadays，increasing attention has been paid on "dignified death" and quality of life at the end of life. Instead of simply extending the length of life，hospice care patients with decision-making abilities begin to seek ways to make advance directives（AD）. As important participants in the process of making AD of patients，physicians and nurses' awareness of AD is directly associated with the promotion effect of AD. Objective　To explore the feasibility and practical path of promotion of AD by investigating the attitudes and behavioral intention concerning AD among physicians and nurses. Methods　From September to October 2019，stratified sampling and simple random sampling were adopted to select 540 medical workers from township hospitals and community health centers，and secondary and tertiary hospitals，Shandong Province. They received a questionnaire survey for collecting data regarding demographics，experience of encountering relatives' death and patients' death，attitudes towards AD and reasons，and so on. Multivariate Logistic regression was used to analyze the independent factors influencing their attitudes and behavioral intention concerning AD. Results　A total of 530（98.1%） valid questionnaires were collected. Among the 530 respondents，445（84.0%） agreed with the directive living wills，and the first reason was "Respecting the patient's right of choice"〔98.2%（437/445）〕，while 85（16.0%） disagreed with such living wills，with the first reason for disapproval being "Do not know whether making directive living wills is legal"〔68.2%（58/85）〕. 373（70.4%） agreed with surrogate medical decision-making，and the first reason was "It can reflect the patient's will"〔84.4%（315/373）〕，but 157（16.0%） disagreed with that，and the first reason was "the patient's refusal to continue treatment may be subject to change by proxy"〔77.7%（122/157）〕. 384（72.4%） were willing to assist patients in making AD，446（84.1%） were delighted to introduce AD-related knowledge to others，and 257（48.5%） were happy to sign a living will immediately. Logistic regression analysis revealed that physicians and nurses' willingness to help patients develop AD was influenced by many factors including age，experience of discussing AD with patients，and awareness of AD（P<0.05）. Conclusion　Age and awareness of AD are associated with physicians and nurses' intention of helping the patient to make AD. AD-related trainings may improve their intention level，so the trainings should be strengthened through various ways.

Knowledge and Attitudes Regarding Advance Directives and Associated Factors among Community-dwelling Older Adults and Families　

FENG Qingrui，JIN Lei，SHI Baoxin

2020, 23(31): 3941-3948. DOI: 10.12114/j.issn.1007-9572.2020.00.544

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Background　Community-dwelling elderly residents are a key group for the use of advance directives. Understanding the knowledge and attitudes regarding advance directives among these residents and families helps to promote the use of advance directives. Objective　To explore the knowledge and attitudes regarding advance directives and associated factors among community-dwelling elderly residents and their families. Methods　This survey was carried out from November to December 2019 using the Demographic Information Questionnaire developed by our research group，Knowledge of Advance Directives Scale（KADS） and Attitudes Towards Advance Directives Scale（AADS）. Participants were elderly residents（n=200） and family members（n=200） selected from 10 communities in Tanggu Street，Binhai New Area of Tianjin. Results　170 questionnaires were collected from the elderly residents in the community and 180 questionnaires were collected from family members. The median scores of KADS for older residents and their families were 0（0，0），0（0，0），respectively. The rates of knowing advance directives for older residents and family members were 6.5%（11/170） and 10.6%（19/180），respectively. The rates of accepting advance directives for older residents and family members were 41.2%（70/170） and 58.9%（106/180），respectively. Stepwise Logistic regression analysis showed that education level，whether to give up treatment and valuing quality of life or survival time when the conditions are difficult to be reversed or at the late stage of the disease，and prevalence of hearing about advance directives were independently associated with the acceptance of advance directives in the older residents（P<0.05）. And education level，living style with the elderly, and knowledge of advance directives，opinion of whether use of symptomatic treatment when the condition is difficult to be reversed or at the late stage of the disease，and prevalence of hearing about living will were independently associated with the acceptance of advance directives in familie members（P<0.05）. Conclusion　The levels of knowledge of advance directives among these community-dwelling elderly residents and familiee members are quite low，and their acceptances of advance directives need to be improved. In view of this，related education for them should be strengthened via the propaganda of advance directives by community medical and nursing care workers.

Acceptance of Advance Directives and Influencing Factors among Elderly Patients with Chronic Diseases in the Community　

YANG Zhen，ZHANG Huijun

2020, 23(31): 3949-3953. DOI: 10.12114/j.issn.1007-9572.2020.00.538

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Background　The prevalence of chronic disease in the elderly is increasing with the accelerating process of aging in China. The development of short- and long-term complications of chronic diseases，may seriously affect these patients' ability of communication and decision-making in medical affairs. Therefore，it is essential for them to timely make an advance care plan to state their needs clearly. Objective　To investigate the preference and influencing factors of making an advance care plan in community-dwelling elderly patients with chronic diseases. Methods　From October 2019 to January 2020，280 community-dwelling elderly chronic disease patients were selected from Jinzhou by convenient sampling method. The Demographic Data Questionnaire developed by our research group，Elderly Death Attitude Scale（EDAS），Modified Barthel Index and Patient's Advance Care Planning Acceptance（PACP） Questionnaire were used to investigate them. Multiple linear regression analysis was used to analyze the factors associated with the acceptance of advance care planning. Results　271 valid questionnaires were collected，and the effective recovery rate was 96.8%. The average scores of EDAS，activities of daily living and PACP in the respondents were （73.42±12.96），（83.99±21.07） and（66.20±8.31），respectively. Escape-oriented death acceptance dimension（r=-0.206，P<0.001） and death escape dimension（r=-0.260，P<0.001） were negatively correlated with ACP acceptance，while natural acceptance dimension（r=0.303，P<0.001） was positively correlated with ACP acceptance. Activities of daily living（r=-0.361，P<0.001） was negatively correlated with ACP acceptance. Multiple linear regression analysis showed that the acceptance of ACP was 73.740 + 1.602 × education level-0.234 × escape-oriented death acceptance + 0.673 × natural acceptance-0.403 × death escape-0.141 × activities of daily living. Conclusion　The acceptance of ACP in elderly patients with chronic diseases in community was above the middle level. Death attitude and activities of daily living were the important factors influencing the acceptance of ACP. In addition to providing medical and health services to elderly patients with chronic diseases，community medical workers should also give them ACP-related health education via oral form，brochures and posters to improve their overall awareness of ACP. Neighborhood committees and social work groups can regularly give lectures on death education and hospice care to these patients to make them have a positive attitude towards death and an effective understanding of hospice care，thereby improving their acceptance of ACP.

Clinical Features in Newly Diagnosed Inpatients with Type 2 Diabetes Mellitus with Insulin Therapy：Analysis Based on Real-world Data　

ZHANG Zhihui，CHEN Mingyun，KE Jiangfeng，LI Lianxi

2020, 23(31): 3954-3958. DOI: 10.12114/j.issn.1007-9572.2020.00.407

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Background　The prevalence of type 2 diabetes mellitus（T2DM） is increasing.Insulin therapy is one of the important means to control the hyperglycemia of T2DM in the later stage. However，there are few studies on the clinical use of insulin and its influencing factors in newly diagnosed T2DM patients. Objective　To obtain the clinical features in newly diagnosed T2DM patients treated with insulin（including insulin analogues） based on the real-world data analysis，to provide clinical basis for clinicians to use insulin reasonably in T2DM patients. Methods　In May 2019，the clinical data of 628 newly diagnosed patients with T2DM who were hospitalized in Department of Endocrinology and Metabolism，Shanghai Jiaotong University Affiliated Sixth People's Hospital from January 2007 to June 2009 were retrospectively analyzed. By the prevalence of using clinically prescribed insulin therapy，they were divided into insulin therapy group and non-insulin therapy group. Two groups' detailed clinical data were collected，including age，gender，history of hypertension and obesity，height，weight，waist circumference，hip circumference，blood pressure，plasma glucose，C-peptide level，glycated albumin（GA），liver function，renal function and glycated hemoglobin A1c（HbA1c） level . The factors affecting insulin use in these patients were analyzed by multivariate Logistic regression. Results　Of the participants，219（34.9%） were female and 409（65.1%） were male. The non-insulin therapy group included 194（30.9%） patients，with an average age of（54.0±13.0） years. 434（69.1%） patients were included in insulin therapy group，with an average age of（52.0±16.0） years. There were significant differences in the prevalence of hypertension and obesity，average waist circumference，body mass index，fasting plasma glucose，fasting C-peptide，2-hour postprandial C-peptide，GA，HbA1c，serum creatinine，alanine aminotransferase，urinary albumin excretion and estimated glomerular filtration rate between the two groups（P<0.05）.However，there were no significant differences in average age，gender，average waist-to-hip ratio，blood pressure，2-hour postprandial plasma glucose and aspartate aminotransferase between the groups（P>0.05）. Multivariate Logistic regression analysis showed that male，higher 2-hour postprandial plasma glucose，lower 2-hour postprandial C-peptide and higher HbA1c levels were independent factors influencing the use of insulin（P<0.05）. Conclusion　The newly diagnosed patients with T2DM had a high prevalence of using insulin therapy，which suggests that the diagnosis of T2DM in China is late，and higher blood glucose level at the time of diagnosis leads to a high prevalence of insulin use. Male，high blood glucose level，and poor islet function may be independent factors influencing insulin use. It is suggested that clinicians should refer to the patient's plasma glucose level and islet function when developing a hypoglycemic treatment protocol and choosing a reasonable treatment time for newly diagnosed T2DM patients.

The Mediating Effect of Health Services Utilization on the Association between Childhood Adversity and Middle-aged and Elderly Health　

FENG Guiping，JIANG Tingkai

2020, 23(31): 3959-3964. DOI: 10.12114/j.issn.1007-9572.2020.00.268

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Background　The Outline of Healthy China 2030 points out that it is necessary to cover the entire life cycle realizing the full range of health services and guarantees from the cradle to the grave and comprehensively safeguard people's health，which means the long-term effects of early life experiences on health should be emphasized. Objective　To explore the influence mechanism of childhood adversity on the health status of middle-aged and elderly people，and to analyze the mediating effect of medical and health services utilization. Methods　Data were drawn from China Health and Retirement Longitudinal Survey 2014—2015 based on CHARLS Life History Questionnaire 2014 and CHARLS Baseline Questionnaire 2015，and Center for Epidemiologic Studies Depression Scale（CES-D 10 Scale）. The binary Logistic regression model and KHB method were used to analyze the association between childhood adversity and middle-aged and elderly health. Results　A total of 18 587 cases were included in the sample population，of which 13 289（71.50%） cases considered themselves unhealthy；12 096（65.08%） cases failed to actively participate in life；5 810（31.26%） cases had unhealthy mental conditions；12 337（66.37%） cases experienced at least one adverse experience in childhood；12 319（66.28%） cases had lower social and economic status in childhood，and 4 015（21.60%） cases lacked medical care in childhood. The results of Logistic regression showed that childhood health was the influencing factor of self-rated health and mental health of middle-aged and elderly people（P<0.05）. Gender，age，social and economic status in childhood，adverse experience in childhood，and lack of medical care in childhood were the influencing factors of self-rated health，mental health and active participation in life of middle-aged and elderly people（P<0.05）.The analysis of mediating effect showed that the mediating effect of medical and health services utilization on the association between social and economic status in childhood，the lack of childhood medical care and the self-rated health of middle-aged and elderly people was 5.84% and 5.34%，respectively. The mediating effect of medical and health services utilization on the association between social and economic status in childhood，the lack of childhood medical care and the mental health of middle-aged and elderly people was 8.74% and 5.25%，respectively. The mediating effect of medical and health services utilization on the association between social and economic status in childhood，the lack of childhood medical care and active participation in life of middle-aged and elderly people was 5.54% and 5.98%，respectively. Conclusion　The social and economic status in childhood and the lack of childhood medical care show the indirect effect on the health of middle-aged and elderly people through affecting medical and health services utilization.

Gender Differences in Health-seeking Behaviors among Elderly Patients with Essential Hypertension　

YU Jie，ZHANG Xiyu，LI Jian，WANG Limin，TAO Yuchun，WANG Qi，ZHANG Zuoming，DONG Junhong，YIN Hui

2020, 23(31): 3965-3970. DOI: 10.12114/j.issn.1007-9572.2019.00.767

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Background　The mortality caused by hypertension has increased year by year with gender differences in recent years. It is of great significance to study the gender differences in health-seeking behaviors of patients with essential hypertension. Objective　To explore the influencing factors of health-seeking behaviors among elderly patients with essential hypertension of different genders，so as to provide a theoretical basis for more effective control of community hypertension and improving patients' quality of life. Methods　From May to August 2016，367 patients with essential hypertension aged≥60 in Nangang District and Daoli District of Harbin were selected by multi-stage sampling method for questionnaire survey. The questionnaire included general information，health-related cognition and health-seeking behaviors of patients. The differences of health-seeking behaviors and other variables among the elderly patients with essential hypertension of different genders were compared，and Logistic regression was used to analyze the influencing factors of health-seeking behaviors. Results　A total of 343（93.5%） valid questionnaires were collected. 183（84.7%） female and 94（74.0%）male elderly patients with essential hypertension had health-seeking behaviors，and the incidence of health-seeking behaviors among female elderly patients with hypertension was higher than that of male elderly patients with hypertension（χ2=5.900，P=0.015）. And 322（93.9%） cases paid their attention to health conditions；more than 70% of cases had a correct understanding of hypertension，while they had low cognitive accuracy associated with hypertension drugs.The monthly income，physical examination behavior，health concern，and whether the cognition of "coronary heart disease could caused by poor blood pressure control" and "taking medicine when blood pressure is high，and stopping medication when blood pressure is normal" were correct were influencing factors of health-seeking behaviors of male elderly patients with essential hypertension（P<0.05）. The education level and whether the cognition of "hypertension can not be completely cured" were correct were influencing factors of health-seeking behaviors of female elderly patients with essential hypertension（P<0.05）. Conclusion　There are gender differences in the sensitive factors of the formation of health-seeking behaviors among urban elderly patients with essential hypertension.Targeted interventions for health-seeking behaviors should be conducted according to sensitive targets of different genders.

Facilitators and Barriers to be Physically Active in Patients with Chronic Kidney Disease Based on PEAKING Cohort　

SU Guobin，QIN Xindong，ZHANG La，WU Yifan，HUANG Jiasheng，HE Jiawei，ZENG Jiahao，MO Yenan，XIAO Cuixia，WEN Zehuai，LU Fuhua，LIU Xusheng

2020, 23(31): 3971-3975. DOI: 10.12114/j.issn.1007-9572.2020.00.172

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Background　Exercise is beneficial to improve the prognosis of patients with chronic kidney disease（CKD）.However，the popularity of exercise is still low in this population. Objective　To explore factors related to behavior change such as perception，motivation，facilitators and barriers of exercise in patients with CKD，in order to provide the basis for the future exercise intervention. Methods　The purpose sampling method was used to select CKD patients（n=10） with different physical activity levels and regular exercise conditions from the PEAKING cohort for the semi-structured qualitative interview from March to June in 2019. The content of the interview included patient's view on CKD，daily physical activities，opinions about the relationship between exercise and CKD，and the facilitators and barriers to the regular exercise. Content analysis method was used to analyze and summarize the interview data and results were reported according to the Consolidated Criteria for Reporting Qualitative Studies（COREQ）. Results　Facilitators to exercise included awareness of the benefits of exercise for physical and mental health（initiator），experience of the benefits of exercise and self-discipline after exercise（internal factors to maintain exercise），and support from families，exercise professionals and society（external factors to maintain exercise）. Barriers to exercise included aging，cardiopulmonary and renal comorbidities and fatigue（physical factors），fear of bone and kidney damage（concerns about the potential risks of exercise-related injuries），insufficient time，places，facilities and companions（lack of supportive factors）. Conclusion　In the exercise intervention in patients with CKD，it is recommended to emphasize those facilitators such as promoting benefits from exercise，enhancing the self-efficacy and improving external support，and to reduce barriers such as paying attention to preventing exercise-related injuries and creating more exercise conditions.

Meta-analysis of the Effect of Repetitive Transcranial Magnetic Stimulation on Vascular Cognitive Impairment　

ZHOU Wen，ZHANG Wenchao，HUANG Kaixiu

2020, 23(31): 3976-3982. DOI: 10.12114/j.issn.1007-9572.2020.00.437

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Background　Vascular cognitive impairment（VCI） affects the life quality，and causes great impact on the overall functional rehabilitation of patients. The application of repetitive transcranial magnetic stimulation（rTMS） in the treatment of neurological and mental diseases has attracted increasing attention.Studying the efficacy of rTMS is of great significance in finding non-drug approaches to VCI. Objective　To systematically evaluate the therapeutic effect of rTMS in Chinese patients with VCI. Methods　The systematic evaluation method was provided by the Cochrane Collaboration. From October 2019 to January 2020，clinical RCTs about VCI treated with rTMS published as of December 30，2019 were systemically and comprehensively searched from databases of PubMed，Embase，EBSCO，Web of Science，and Cochrane library and CNKI and printed journals. Meanwhile，those studies listed as references of the RCTs and relevant gray literature were also searched. The methodological quality of enrolled RCTs was evaluated by two reviewers independently using Cochrane risk-of-bias tool.RevMan 5.3 was used for meta-analysis. Results　A total of 12 RCTs with 837 patients were included. The risk assessment demonstrated that 5 RCTs reported detailed random grouping strategies，2 used concealed allocation，and 2 used ways to avoid measurement bias. Meta-analysis indicated that rTMS improved MoCA，MMSE and LOTCA scores in stroke patients. Sensitivity analyses using fixed effect model revealed that the overall effect size for interventions on MoCA score and MMSE score was WMD=2.52〔95%CI（2.04，3.00），P<0.05〕，and WMD=1.55〔95%CI（1.04，2.07），P<0.05〕，respectively. Due to limited number of RCTs，qualitative analysis was performed on the effect of interventions on LOTCA score，and the results showed that rTMS had a positive effect on the improvement of LOTCA score. Conclusion　These findings suggest that rTMS can improve the cognition function of VCI patients. Nonetheless，as the included RCTs are not very standardized with small sample，the effect of rTMS on VCI needs to be further evaluated by high-quality multicenter RCTs with a large sample size.

Effect of Repetitive Facilitative Exercise Combined with Acupuncture on the Recovery of Upper Limb Function after Stroke　

2020, 23(31): 3983-3987. DOI: 10.12114/j.issn.1007-9572.2020.00.495

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Background　Stroke is characterized by high morbidity，mortality and disability rate. 55%-75% of stroke patients will suffer from post-stroke upper limb motor dysfunction. Repetitive facilitative exercise（RFE） is a new approach to post-stroke hemiplegia developed by Kazumi Kawahira，whose effect has proved to be particularly notable in the improvement of upper limb function. However，there are few related studies in China. Objective　To explore the effect of RFE with acupuncture on the functional recovery of upper extremity after stroke，to provide objective and effective basis for clinical treatment and a solid foundation for the development of new techniques. Methods　From June to December 2018，55 eligible patients with post-stroke upper extremity dysfunction were enrolled and randomized into the observation group（27 cases） and control group （28 cases），with 2 cases in the observation group and 3 cases in the control group lost. Both groups were treated with routine basic medical treatment，routine rehabilitation training and acupuncture. In addition，RFE was given to the observation group. Upper limb function was evaluated by Fugl-Meyer Assessment（FMA） and activities of daily living was evaluated by Modified Barthel Index（MBI） before treatment，at 4 weeks after treatment and 8 weeks after treatment，respectively. Results　Two-way repeated measures ANOVA showed that the treatment protocol and treatment time had significant interaction effects on FMA score and MBI value（F=16.153，P<0.001； F=34.226，P<0.001）. The average FMA score and MBI value demonstrated no significant intergroup differences before treatment（P>0.05），but they increased significantly in the observation group at the end of the 4th and 8th weeks of treatment（P<0.05）. Conclusion　The improvement of symptoms was different in the two groups at different times during the treatment. RFE with acupuncture showed notable effect on the recovery of post-stroke upper limb function.

Bibliometric Study on Standardized Training of General Practitioners in China　

AN Zhenyu，ZHANG Shaoqun，HU Hong，ZOU Wanjun

2020, 23(31): 3988-3993. DOI: 10.12114/j.issn.1007-9572.2019.00.765

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Background　The training mode of general practitioners（GPs） suitable for the national conditions of our country has been basically formed at present，while its training system is not perfect. As the main way to train high-quality GPs in China，it is particularly important to summarize the research progress of standardized training. Objective　Through systematically evaluating the literature in the field of standardized training of GPs in China，it may provide reference for further improvement of the research on standardized training of GPs. Methods　From March to May in 2019，three databases，China CNKI database，Wanfang Data Knowledge Service Platform and CQVIP database，were used as data sources to systematically retrieve literature related to the standardized training of GPs in China with the keywords of "全科医生"+"规范化培训"，"全科医生"+"规范化培养"，"全科医生"+"规培"，"全科医师"+"规范化培训"，"全科医师"+"规范化培养" and "全科医师"+"规培". The retrieval time was set from the establishment of the database to December 31, 2018. Data statistics and descriptive statistical analysis on the authors，titles，sources，years of publication，and publishing organizations included in the literature was conducted through bibliometric methods. CiteSpace was used to analyze the hotspot knowledge map of the key words included in the literature. Results　A total of 459 articles were included from 140 journals. The first author belongs to 166 institutions，of which 85（51.2%） are colleges and universities，and Capital Medical University had the highest number of publications（59）. The authors were concentrated in Beijing，Shanghai and Zhejiang with a total of 242（52.7%） publications. From 2002 to 2018，the number of publications in the field of standardized training of GPs in China showed an overall increasing trend（4 to 86 articles），among which the number of publications from 2002 to 2011 was small（3 to 14 articles） and unstable；the number of publications from 2011 to 2012 increased sharply（10 to 38 articles）；the number of publications from 2012 to 2013 decreased（38 to 27 articles）；the number of publications from 2013 to 2018 was in a steadily increasing stage（27 to 86 articles）. The number of authors who published 1，2，3，4 and 5 articles was 307，41，16，3 and 2，respectively，which did not accord with the number of theoretical authors stipulated by Lotka's law. As for the key words frequently used in the field of standardized training of GPs，it included "general practice" "community health service" "medical education" "training mode" and "training effect". Conclusion　When it comes to the research on standardized training of GPs in China，it is in a stable stage of development，but it has not been perfect yet. The standardized training of GPs has attracted the attention of many scholars in China，which has formed high-yield research institutions and periodicals. However，the quality of the articles needs to be improved because of lacking stable scholars researching continuously. The research hotspots in this field mainly focus on three aspects，such as the development of standardized training and education for residents，the investigation on the present situation of standardized training of GPs，and the exploration and innovation of standardized training mode for GPs.

Training Effect of Standardized Training Courses for General Practice Residents from the Perspective of Post Competence　

YANG Sen，SHI Jianwei4，GE Xuhua，CHEN Chen，ZHANG Hanzhi，SHI Jianjun，MA Le，WANG Zhaoxin，YU Dehua

2020, 23(31): 3994-3999. DOI: 10.12114/j.issn.1007-9572.2020.00.123

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Background　Based on the Healthy China Strategy currently implemented nationally，Shanghai has developed general practice vigorously. Since the introduction of Standardized General Practice Residency Training（SGPRT） in 2000，a large number of general practitioners have been trained for grassroots community medical institutions. How to further improve the quality of general practice residency training and strengthen the comprehensive ability of general practitioners on this basis has become a hot topic in current research of general practice. Objective　To learn about the effect evaluation from SGPRT graduates of the standardized training curriculum system and teaching ability of general practice teachers from general hospitals，so as to provide guidance and suggestions for the optimization of the teaching ability and standardized training curriculum in general hospitals. Methods　From March to May in 2019，a total of 40 general practitioners were selected as our investigation objects，who had successfully completed SGPRT in Shanghai since 2010 and currently work in different community health service centers in Shanghai. Face-to-face interviews and telephone interviews were conducted and the interviews included the evaluation of the teaching ability of general practice teachers，the clinical practice curriculum system and the improvement of their post competency，and their suggestions to optimize the training curriculum of SGPRT. Results　And 72.5%（29/40） of the interviewees were satisfied with the training courses taught by general practice teachers. The satisfactory teaching methods included outpatient consultation（85.0%，34/40），knowledge sharing in the morning meeting（75.0%，30/40），case study（65.0%，26/40）and so on. In terms of content，the most satisfied was the introduction of diagnosis and treatment process of common diseases after admission（82.5%, 33 /40） and the least satisfied was the lack of pertinence of general practitioners' teaching（72.5%, 29/40）. In terms of clinical practice curriculum system，there was an urgent need in strengthening the referral indications of hypertension and diabetes，management of chronic diseases，tertiary prevention，and management of complications. The most obvious improvement of post competency was the ability to solve specific clinical problems，while the least obvious one is the community-oriented service capability. Conclusion　Generally，the graduates are satisfied with the SGPRT in Shanghai. However，it could be further improved in the teaching of general practice teachers and the knowledge system and management of SGPRT based on the feedback of general practitioners，to further optimize the standardized training program of general practice，improve the quality of general practice training and better serve the community practice.

Use of Antidiabetic Drugs in Diabetic Patients in Songjiang District of Shanghai: an Analysis Using the Data from a HIS Database　

MA Jilin，ZHANG Xueping

2020, 23(31): 4000-4006. DOI: 10.12114/j.issn.1007-9572.2020.00.175

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Background　Glycemic control in diabetics is improving with the development of antidiabetic drugs and evidence-based medicine. As diabetes is a chronic disease requiring long-term and even lifetime drug treatment，ensuring medication safety has become a focus of the whole society，especially the majority of elderly diabetic patients and medical workers. Objective　To analyze the use of antidiabetic drugs in a diabetes population with relevant management from a district of Shanghai，to provide a reference for clinical rational drug use and diabetes management. Methods　Data of type 2 diabetics were collected from Shanghai's Songjiang District Health Management Platform，involving 31 199 cases registered from October 2016 to September 2017，including the number of antidiabetic drugs，DDDs，drug utilization index，HbA1c and glycemic monitoring method. Results　Among 31 199 diabetic patients，20 152（64.59%） used antidiabetic drugs. These antidiabetic drugs involved 7 kinds and 22 forms of hypoglycemic drugs，among which those with the greatest DDDs were biguanides，two sulfonylureas （including glimepiride and gliclazide），and two forms of insulin（ubilin and novoline） and one α-glucosidase inhibitor（acarbose）. Age-based analysis revealed that the utilization rate of antidiabetic drugs increased with age，so did the rate of combined use of antidiabetic drugs（P<0.05）. The rate of only using insulin injection decreased with age（P<0.05）. The rate of using both oral antidiabetic drugs and insulin injection increased with age （P<0.05）. The average dispensing times，total medication days，kinds of antidiabetic drugs，dosage of insulin and dosage of chemically synthesized oral antidiabetic drugs varied significantly across different age groups（P<0.05）. Glycemic monitoring was implemented in 61.33%（12 360/20 152） of the participants，with an annual monitoring frequency of 3 times per person. The distribution of glycemic monitoring methods varied significantly across different age groups（P<0.05）. The overall rate of meeting ideal and good target levels of HbA1c was lower in those using insulin injection than that of those using oral antidiabetic drugs（P<0.05）. Conclusion　In this community health center，the kinds of antidiabetic drugs are basically complete and their use is relatively reasonable. The first-choice drug is biguanides，followed by sulfonylureas. Most therapies consist of biguanides or sulfonylureas，used either alone or in combination.However，the use of insulin is extremely unreasonable，indicating that insulin therapy fails to exert its proper effect in the community. In addition，the rates of using antidiabetic drugs，good medication adherence and continuous glycemic monitoring in the diabetes group are low.

WANG Feng，WANG Lina，SHEN Xinhua，GE Chenxi，ZHOU Yanru，ZHANG Chen

2020, 23(31): 4007-4012. DOI: 10.12114/j.issn.1007-9572.2019.00.696

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Background　Chronic diseases are independent risk factors for mild cognitive impairment（MCI），and alone use or combination use of drugs may increase cognitive load together with physical diseases. There are limited studies about the relationship between medication characteristics and cognitive function in MCI population in China. Objective　To investigate the impact of drug use on cognitive impairment in MCI population in the community. Methods　Totals of 496 MCI suffers were randomly selected from 6 communities in Huzhou，Zhejiang Province. General Information Questionnaire，Drug Use and Disease Status Questionnaire and the Beijing version of the Montreal Cognitive Assessment（MoCA-B） were used to survey the participants. The MoCA-B score was compared by sociodemographic factors，and medication use and medication type prevalence. After controlling the covariates，multiple linear regression was used to analyze the effects of medication-related factors on the cognitive function of MCI patients. Results　There were statistically significant differences in MoCA-B scores of different gender，age，education level，occupation nature，marital status and classification of physical diseases（hypertension and sleep disorder）（P<0.05）. The scores of MoCA-B of β-blocker and sedative group were lower than those of non-taking group（P<0.05），and the scores of MoCA-B in angiotensin converting enzyme inhibitor（ACEI） group were higher than those in non-taking group（P<0.05）；The MoCA-B scores of the subjects in the combination of calcium channel blocker + β-blocker，calcium channel blocker + angiotensinⅡ receptor blocker（ARB），β-blocker + ARB，hypoglycemic drug + antihypertensive drug + statins combination group were lower than those of the non-taking group. Multiple linear regression analysis found that β-blockers，sedatives，ACEI，and calcium channel blockers in combination with ARB，β-blockers in combination with ARB，hypoglycemic drugs in combination with anti-hypertensive agents or statins were associated with increased risk of deterioration of cognitive functions，with a cumulative contribution rate of 39.4%（F=23.946，P<0.001） for the MoCA-B score after controlling demographic variables and somatic disease features. Conclusion　The combination use of drugs，such as β-blockers combined with sedatives，together with somatic diseases may impair the cognitive function. For the management of MCI patients with somatic diseases，medical workers should not only develop alternative treatment techniques for somatic diseases，and cognitive training techniques，but also enhance the knowledge of drug use. For the management of those with long-term monotherapy or drug combination therapy，medical workers should strengthen the safe medication management，and identify potential risk factors for cognitive impairment timely.

Research Progress of Health-related Behavioral Interventions in Obese Patients after Bariatric Surgery　

ZHU Hanfei，XU Qin，REN Ziqi，ZHU Shuqin

2020, 23(31): 4013-4017. DOI: 10.12114/j.issn.1007-9572.2019.00.706

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The safety and efficacy of bariatric surgery for the treatment of severe obesity and its comorbidities have been recognized. However，surgery alone may not result in optimum long-term weight loss and body mass outcome，which is related to postoperative health-related behaviors. Therefore，this article mainly introduces the single health-related behavioral intervention based on dietary intervention，exercise intervention，psycho-social intervention and the intervention of multiple health behavior change for postoperative patients in order to provide theoretical basis for the development of health-related behavioral interventions for postoperative patients in China.

Novel Developments in the Relationship between Diet and Female Fertility　

QIU Jie，ZHAO Mei，DING Peipei，WANG Jieyu，TU Youhui

2020, 23(31): 4018-4022. DOI: 10.12114/j.issn.1007-9572.2020.00.539

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Infertility morbidity is increasing with recent social and economic development，and has become the third most common disease after cancer and cardiovascular disease in women. Female fertility is affected by ovarian reserve function，the ability of ovarian cortical follicles to grow into fertilizable oocytes，which is associated with many factors such as heredity，immunity，environment，life style，age，disease and psychology. As a controllable factor，the positive and negative effects of different food and diet structure on female fertility have been preliminarily determined. We explored the impact of macronutrient intake on female fertility，with detailed analysis of the effects of several essential dietary macronutrients，aiming to provide healthy diet guidance for women of childbearing age to improve diet quality to protect reproductive function and prevent reproductive diseases.

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