Chinese General Practice

Challenge of Sustainable Development to General Practice in China：Management Strategies for Multiple Chronic Diseases in the Community　

CAI Xixuan，WANG Jianbang，WU Jiang，HE Wen

2020, 23(34): 4279-4284，4290. DOI: 10.12114/j.issn.1007-9572.2020.00.576

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Against the backdrop of ever-increasing medical care needs and heavy burden of chronic diseases in the growing aging population，how to successfully manage multiple chronic diseases in the community has posed a challenge to the sound and sustainable development of primary care and general practice in China，which is still in an exploratory stage. We made a detailed discussion of the theory and practice（consisting of three key steps for general practice team fostering and environmental preparation and patient-centered healthcare and shared decision making） related to community-based management of multiple chronic diseases based on the review of relevant novel developments，to explore a better way for community-based management of multiple chronic diseases and to offer a reference for the sustainable development of general practice in China.

Strategies to Develop Home-based Medical Care in China：a SWOT-CLPV Analysis　

CHEN Tao，BAI Meng，ZHOU Rui，WU Bingxian，ZHANG Zhenzhen，YAO Nengliang

2020, 23(34): 4285-4290. DOI: 10.12114/j.issn.1007-9572.2020.00.579

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To meet the health needs of the whole population，some health institutions have initiated the exploration of home-based medical care，providing health services to patients at their home. Home-based medical care has both advantages and disadvantages，and faces opportunities and threats brought by the environment. We developed the SWOT-CLPV model of home-based medical care in China referring to relevant policies，literature and our previous study，reviewed the strengths，weaknesses，opportunities and threats of home-based medical care，and analyzed its control，leverage，vulnerability and problems，then put forward strategies to develop home-based medical care in China.

Workload of Public Health Services in Primary Medical and Health Institutions: a Seven-year Trend Analysis　

SHI Jianhua，GU Huining，QIAN Mengcen，JIANG Hongli

2020, 23(34): 4291-4297. DOI: 10.12114/j.issn.1007-9572.2020.00.480

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Background　In the assessment of the performance of public health services in primary care recently，increasing attentions have been paid to quality-related dimensions of the services，but the volume of such services is also worthy of great concern. Objective　To explore the changes in volume and category composition of public health services delivered by primary care and associated reasons. Methods　Data were collected from a community health center in Shanghai，including monthly workload and categories of public services，and public health team task load during January 2010 to December 2016. Composition analysis，trend description and Joinpoint regressions were used to describe temporal changes in workload. Results　During the study period，the total public health service workload of the community health service center was 58 937.83 person days. The highest monthly workload was 1 020.79 person days in December 2016 and the lowest was 461.56 person days in January 2012. Results from Joinpoint analysis showed that on average monthly workload declined by 4.1% before February 2011，and since then changed to a monthly increase of 0.6%（P<0.05）. The top-ranked four categories in terms of workload had always been chronic disease prevention and treatment，maternal and child health care，vaccination services，and government's practical projects，the combined composition ratio of which rose from 71.97% in 2010 to 79.84% in 2016. The median monthly workload of public health staff was higher than the legal standard of 20.83 days except for December 2010 and January 2012. And there were 6，5，9 months in 2010，2015，and 2016，respectively with a median workload above 30 days. Conclusion　Monthly workload of public health services for this community health center steadily increased since 2011，composition of key tasks continuously increased，in particular for prevention and treatment of chronic diseases，and workload of public health staff has been high. Workload varies with higher requirements，changes of population needs，and major public health programs or key projects in a specific phase.Future plans should focus more on the balance between essential public health services and major public health projects，impacts of heavy workload of public health staff，and treatment and prevention integration in order to improve the efficiency of services.

Strategies Derived from COVID-19 Outbreak Containment for Improving the Long-term Mechanism of Developing the Community Public Health Team　

LIU Yajun，LIU Zhigang，ZHAO Jing，JIA Jianping，WANG Dongrui，WU Wenjuan，ZHANG Xiangdong

2020, 23(34): 4298-4303. DOI: 10.12114/j.issn.1007-9572.2020.00.528

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Background　Community-based containment of COVID-19 outbreak in 2020 in China has revealed that community public health professionals involving in the containment are insufficient and their distribution is uneven，so it is urgently to strengthen and improve the development of community public health（CPH） teams. Objective　To summarize and analyze the main problems in long-term development of CPH teams and community-based COVID-19 containment，and based on this，to develop strategies for improving long-term construction of CPH teams amid COVID-19. Methods　We collected the data during February to April 2020 by reviewing the contents of Essential Information of Community Health Professionals in Beijing legally reported to Beijing Municipal Health Commission. We analyzed the trend of changes in the quantity，structure，post attraction and distribution inequality（using Gini coefficient） of incumbent CPH professionals during 10 consecutive years（2010—2019） using descriptive analysis. Results　The annual growth rate of the number of CPH professionals was 5.58%（from 2 139 in 2010 to 3 488 in 2019），which was higher than that of community staff（3.25%） and health professionals（3.26%） in the same period. The average age of CPH professionals was（35.9±10.7） years in 2010，and （37.6±9.4） years in 2019. The proportion of young people（under 30 years old） decreased（χ2=197.252，P<0.001）compared to 2010. In 2010，those with three-year college degree were the majority（41.37%），while in 2019，those with 5-year college degree were the majority（46.33%）. The percentage of those with an intermediate or senior professional title increased from 26.60% to 38.27%. The percentage of Beijing natives decreased from 74.10% to 70.99%. The percentage of officially budgeted decreased from 82.89% to 78.21%. Except those retired normally，a total of 1 327 cases flowed out. The number and percentage of cases flowed out increased yearly. Gini coefficients for CPH professionals distribution by the number of population and geography were 0.300 1，and 0.763 6，respectively in 2010，and were 0.222 8，and 0.696 6，respectively in 2019. Conclusion　The number of CPH professionals，as same as the structure of education and professional titles，has been gradually optimized during long-term construction in Beijing. Local government-led community health system can ensure a high level of equity in the distribution of CPH professionals based on population and ensure the effective implementation of epidemic containment and other community public health services.However，some problems have gradually revealed，such as gradually increased average age of CPH professionals，and decreased post attraction，which are worth noting and thinking for the sake of further optimizing the long-term mechanism of developing the CPH team.

Theoretical and Practical Exploration of Using Standardized Workload Method to Upgrade the Operation Level of Community Public Health Sector　

ZHU Meihong，ZHANG Xian，GONG Weihua，LI Xiaohong

2020, 23(34): 4304-4308. DOI: 10.12114/j.issn.1007-9572.2020.00.532

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Background　Using performance assessment as a lever to ensure the working enthusiasm of medical workers and patient safety has become a consensus in salary reform of the healthcare industry，and standardized workload method is a measurement tool for performance evaluation of primary care workers. Objective　To develop a performance allocation scheme for community public health sector using standardized workload method to incentivize the working enthusiasm of primary public health physicians to improve the delivery efficiency and quality of community health services. Methods　From January to December 2019，using literature review，focus group interview，and expert consultation，and standardized workload method，4 professionals（consisting of members from the public health department of Shanghai Hongkou District Beiwaitan Subdistrict Community Health Center and experts invited from other institutions） developed a performance allocation scheme for community public health workers，and used it to measure the performance of 6 teams of this health center in implementing the ongoing service projects，to be specific，calculating the standardized value of each item，determining the ratio of performance-based pay（calculated using the standardized workload method） to the total salary，and the method for allocating the total standardized workload for individuals，in other words，through means of management of the total performance of the staff，precise assignment management of each service item，and management of the total standardized workload of individuals，the tasks may be properly assigned to individuals and performance assessed using standardized workload method may reflect the value of services provided by each public health worker. Results　 Using this new scheme，we made a list of two categories of services（353 scope items in total） with different granularity levels，determined the uniform benchmark projects for different public health teams，calculated the standardized value for each service，and determined the ratio of performance-based pay（calculated using the standardized workload method） to the total salary as 45%-65%，and the individual standardized workload was assigned by the total standardized workload of public health staff. The comparisons of the performance allocation method and results before and after using the new scheme，combined with public health workers' assessment of the new scheme suggested that the new performance allocation scheme has gained acceptance in these workers. Conclusion　Using the scheme，we comprehensively sorted out the scope items of public health module，scientifically calculated the standardized value of each item，and rationally assigned the total standardized workload for individuals，which reflect the value of services delivered by public health workers，and improve their quality of services via incentivizing working enthusiasm and ensuring rational intensity of workload. Our explorative study may be contributive to the performance incentivization and assessment for community public health workers，showing the recognition of the value of their services，by which their working enthusiasm may be improved，ultimately benefiting the building of a more solid and stable community-based public health prevention and control network.

Implementation Effectiveness of the National Essential Public Health Services：a Qualitative Interview Study Using Grounded Theory　

HE Gaoxing，ZHENG Senshuang，WEN Xin，WANG Yuan，SUN Zhong，LU Wenli

2020, 23(34): 4309-4314. DOI: 10.12114/j.issn.1007-9572.2020.00.578

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Background　In general，the implementation of the national essential public health services project in China has achieved relatively good results at the national level，but the practical effect is still the focus of the government and society. Reasonable evaluation of the implementation effect and identification of the associated factors are the prerequisite and foundation for improving the implementation of the services. Objective　To evaluate the implementation effects and influencing factors of the national essential public health services，analyze the existing problems and discuss the rationality of project planning，to provide support for further development of such services. Methods　Using purposive sampling，a total of 26 resident representatives and public health professionals were selected from Heping District，Tianjin. Regarding the implementation effect，evaluation and influencing factors of national essential public health service projects，focus interviews were conducted to collect data in April 2017，and grounded theory coding was used for analysis. Results　The coding of the interview results yielded 53 open codes，16 axial codes and 4 selective codes. The selective codes included project lead，project traction，implementation guarantee and project results. The first three were interrelated and influenced each other，and collaboratively affected project results. Project results covered 4 axial codes：recognized project，problematic project，medical workers' satisfaction with the project and residents' satisfaction with the project. "Demand-oriented-well-matched supply and demand"（21 times），"service delivery mode-team mode"（3 times），"management experience-solid foundation formed by years of development"（5 times） and "fund management-appropriate fund for each service item"（5 times） were main reasons for good healthcare management of elderly people and women and children. "Demand-oriented-well-matched supply and demand" and "project evaluation mechanism" were obstacles to health records management，health education，severe mental illness management and tuberculosis management. "Project evaluation mechanism-high requirements for quantification of indicators"（26 times），"fund management-relatively sufficient funds but insufficient in actual practice"（22 times），"service delivery mode-different delivery patterns for medical and public health services" （10 times） and "project planning"（9 times） were main factors associated with medical workers' satisfaction with the project. "Policy interpretation"（7 times），"satisfaction with medical care"（7 times），"equipment accuracy"（5 times） and "professional level of medical workers"（4 times） were main factors associated with residents' satisfaction with the project. Conclusion　Project lead，project traction，and implementation guarantee are prerequisites and guarantees for effective implementation of the national essential public health service projects. Relevant departments should optimize the project setting based on demand，optimize the project evaluation based on the performance indices，and support the implementation of the related policies to ensure the implementation of the project，and overcome the difficulties of insufficient amount and unsatisfied quality of community health resources，to promote and improve the national essential public health service projects.

Prevention and Restraining of Induced-demand for Community Health Services by Contracted Family Doctors in China　

YIN Tianlu，GAO Xiaohuan，HAN Jianjun

2020, 23(34): 4315-4319. DOI: 10.12114/j.issn.1007-9572.2020.00.598

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Physician-induced demand is a global medical phenomenon，which harms the interests of patients，and even leads to uneven distribution of medical resources. Recently in China，along with the increase in investment in primary care，the promotion and development of hierarchical medical system and contracted family doctor services，the shift in outpatient volume from tertiary hospitals to primary care settings has brought an increased growth of medical expenditure in primary care，and the profits and improvement strategies regarding contractual community medical services has become an important research direction，and has a bearing on the success of the healthcare reform initiated in 2009. We analyzed induced demand by community family doctors in China using economic theory of supply and demand，and identified factors associated with induced demand in community primary care during the promotion of contracted family doctor services. To address these factors，we put forward the following recommended solutions based on the coping experiences of the United States，Australia and EU countries summarized from studies concerning physician-induced demand in these countries：（1）Supervising practice behaviors and restraining induced demand behaviors of community family doctors while increasing the number of them and incentivizing them to improve service delivery to satisfy residents' healthcare needs.（2）Increasing the price paid for making decisions of induced demand in community family doctors by pressures from medical market competition.（3）Reducing the influence of physician-induced demand on residents by increasing their disease-related knowledge via strengthened public health education，improved transparency of healthcare through speeding up the construction of informatization in primary care，and by increasing the options of healthcare seeking.

Current Status of Core Competencies of Health Management among Community Health Workers and Its Influencing Factors　

HE Lin，TIAN Hui，WANG Lan

2020, 23(34): 4320-4325. DOI: 10.12114/j.issn.1007-9572.2020.00.223

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Background　The community health service center is the basic unit to provide health management services in our country，which requires community health workers to have core competencies of health management. Objective　To investigate the core competencies of health management among community health workers and to understand the current status of their competencies and its influencing factors，in order to formulate corresponding intervention strategies to improve the core competencies of health management among community health workers. Methods　Using the core competency questionnaire including five dimensions of professional practice ability，interpersonal skills，professional attitude，comprehensive knowledge，and professional development ability，for health management，a questionnaire survey was conducted among 264 community health workers engaged in health management in Tianjin from November to December in 2018. Logistic regression was used to analyze the influencing factors. Results　Totals of 250（94.6%） valid questionnaires were collected. The overall score of core competencies of health management among community health workers in Tianjin was（187.89±37.23），among which the scores of five dimensions of professional practice ability，interpersonal skills，professional attitude，comprehensive knowledge，and professional development ability were（64.52±14.53），（34.74±6.86），（34.45±6.41），（27.08±6.22） and（27.11±6.39），respectively，all of which were at the middle and low level. The results of Logistic regression analysis showed that the understanding of health management was an influencing factor for the core competencies of health management among community health workers（P<0.05）. Conclusion　The core competencies of health management among community health workers is at the middle and low level in Tianjin，and the overall level of core competencies needs to be improved. Community health service centers could provide systematic training of core competencies of health management among community health workers to improve their knowledge of health management and enhance their core competencies of health management.

Chinesization of Community Client Need Classification System and Testing of Its Reliability and Validity　

FENG Rongfang，WANG Yu，WANG Peng，ZHANG Zhenxiang，SI Dayan，LI Mengmeng，JIAO Jiawei

2020, 23(34): 4326-4331. DOI: 10.12114/j.issn.1007-9572.2019.00.769

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Background　With the aging of the global population and the increasing burden of medical care，most of the elderly have been suffering from chronic diseases，and the best choice for them was returning the community and family to receive the community medical services. However，the community medical and health services in China are still relatively weak lacking the evaluation tools for comprehensive management of chronic diseases. Objective　To translate the Community Client Need Classification System（CCNCS） into Chinese and evaluate its reliability and validity in patients with chronic diseases，in order to provide a reference for the management of chronic diseases in the community and the formulation of targeted interventions.Methods　The translation of CCNCS was carried out by Brislin model，and the semantic adjustment of its items were carried out through expert consultation and pilot study. From April to June 2018，243 patients with chronic diseases from three community health service centers in Zhengzhou were selected by convenience sampling for questionnaire survey that included general information questionnaire and Chinese version of CCNCS（C-CCNCS），and the reliability and validity of C-CCNCS were tested. A total of 243 questionnaires were distributed，and 240 valid questionnaires were collected with an effective recovery rate of 98.8%. Twenty-eight out of 240 respondents were selected by random number table method and were re-investigated by C-CCNCS after two weeks. SPSS 21.0 software was used for statistical analysis. The validity was evaluated by content validity and predictive validity. The reliability was evaluated by internal consistency reliability，test-retest reliability and inter-rater agreement. Results　C-CCNCS includes seven dimensions：environmental factors，psychosocial needs，physiological care needs，case and care management，nursing assessment，caregiver and family support，health education and health promotion. Pearson correlation analysis showed that the scores of each dimension of C-CCNCS were positively correlated with the total score（r=0.368-0.739，P<0.05）. The C-CCNCS validity test showed that item-level content validity index（I-CVI） was 0.80-1.00，and the average scale-level content validity index（S-CVI/Ave） was 0.97. Predictive validity test：Spearman correlation analysis showed that the direct nursing time（r=0.490） and indirect nursing time（r=0.635） were positively correlated with the need levels（P<0.05），and the differences of the direct nursing time（F=13.500）and indirect nursing time（F=120.984） among all need levels were statistically significant（P<0.05）. Reliability test of C-CCNCS：the coefficient of Cronbach's α of C-CCNCS was 0.763；the test-retest reliability of C-CCNCS was 0.860；and the test-retest reliability of each dimension was between 0.803 and 0.863. The inter-rater agreement for C-CCNCS was 93.75%. Conclusion　The C-CCNCS has good reliability and validity，which could be used for evaluating the levels of health service needs among community patients with chronic diseases.

Toe-brachial Index As a Risk Predictor for Cardiovascular and Cerebrovascular Events in Patients with Diabetic Foot　

CHEN Ying，YANG Caizhe，WANG Liangchen，XIAO Li，ZHANG Da，WANG Chenrui，CHEN Hongmei，WANG Luning

2020, 23(34): 4332-4336，4348. DOI: 10.12114/j.issn.1007-9572.2020.00.313

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Background　Diabetic foot（DF） is associated with a high mortality rate mainly due to DF-related cardiovascular and cerebrovascular accidents. There are few studies on risk predictors of cardiovascular and cerebrovascular events and risk stratification of cardiovascular events in DF patients. Therefore，it is of great significance to screen out a promising indicator to accurately predict the risk of cardiovascular and cerebrovascular events in DF patients. Objective　The study aimed to evaluate the value of toe-brachial index（TBI） as a predictor of cardiovascular and cerebrovascular events in DF patients.Methods　A retrospective study was carried out on 197 DF patients with hospitalized treatment selected from Department of Endocrinology，Air Force Medical Center，PLA from February 2014 to September 2016. They were divided into three groups according to the TBI value：normal TBI（N-TBI group，TBI≥0.7，n=107），low TBI（L-TBI group，0.5≤TBI<0.7，n=41） and extremely low TBI（EL-TBI group，TBI<0.5，n=49）. Clinical data，including gender，age，body mass index（BMI），duration of diabetes，history of hypertension，hyperlipidemia，chronic renal insufficiency and smoking，levels of HbA1c，serum creatinine，and blood lipid indicators，and use of aspirin and statin were collected. All of them were followed up for 36 months. Multivariate Logistic regression analysis，Kaplan-Meier survival analysis and Cox regression models were used to evaluate the value of TBI in predicting the risk of cardiovascular and cerebrovascular events. Results　The mean follow-up time for the participants was（33.5±7.9） months，during which 27（13.7%） developed cardiovascular and cerebrovascular events，and 10（5.1%）died. Multivariate Logistic regression analysis showed that TBI<0.7 was associated with increased risk of cardiovascular and cerebrovascular events in DF patients〔OR（95%CI）=11.034（3.486，34.922）〕. The survival time revealed by Kaplan-Meier analysis was 35.24，32.81，and 30.56 months for N-TBI，L-TBI and EL-TBI groups，respectively，with significantly different risks for cardiovascular and death events（P<0.05）. Cox regression analysis showed that after adjusting for age，the HR value of cardiovascular and cerebrovascular events in L-TBI and EL-TBI groups increased by a factor of 4.749〔95%CI（1.199，18.804）〕，and 10.495〔95%CI（3.210，34.313）〕，respectively，compared with that of N-TBI group. Conclusion　TBI can be used as an independent predictor of cardiovascular and cerebrovascular events in patients with DF，and the risk of cardiovascular and cerebrovascular accidents increases significantly with the decrease of TBI.

The Prevalence of Hypertension and Its Influencing Factors in Middle-aged and Elderly People in China　

YUAN Jiao，WU Qingsong，LEI Shu，YE Lin

2020, 23(34): 4337-4341. DOI: 10.12114/j.issn.1007-9572.2020.00.285

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Background　Hypertension is a common chronic disease and a principal influencing factor of cardiovascular and cerebrovascular diseases. It has become one of the major public health problems in China. Objective　To analyze the prevalence of hypertension in the middle-aged and elderly population in China and identify its influencing factors，with a view to taking proactive measures in advance for high-risk factors to prevent the occurrence and progression of hypertension. Methods　People aged 45 and older who had been included in the China Health And Retirement Longitudinal Survey（CHARLS） in 2015 were taken as the research objects. The general demographic and sociological data，such as gender，age，place of residence，education background and marital status，and physical data，such as height and weight，and living data，such as sleep time，smoking and drinking habits，and other general data，such as results of health self-assessment，disease history and income as well as the status of hypertension were collected. The influencing factors of hypertension were analyzed by binary Logistic regression. Results　A total of 15 645 subjects were included in this study with an average age of （61.3±10.1）. And 5 379 patients had hypertension with the overall prevalence rate of 34.38%，of which the prevalence rate was 33.79%（2 504/7 410）in males and 34.91%（2 875/8 235） in females. Logistic regression analysis revealed that gender，age，place of residence，BMI，alcohol consumption，number of chronic diseases，presence of dyslipidemia and diabetes were factors involved in the development of hypertension（P<0.05）. Conclusion　The prevalence of hypertension remains a relatively high level in our country.The risk factors of hypertension are male，advanced age，living in the city，having drinking habit，with more than one chronic disease，and having dyslipidemia and diabetes. There is a need to strengthen the health education for middle-aged and elderly people with or without hypertension and encourage them to adopt healthy life styles to prevent the occurrence and progression of hypertension.

Relationship between the Use Frequency of Insulin Needles and Lipohypertrophy：a Network Meta-analysis　

ZHANG Wei，ZHU Dongmei，FEI Chaoting，ZHOU Ming

2020, 23(34): 4342-4348. DOI: 10.12114/j.issn.1007-9572.2020.00.420

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Background　Lipohypertrophy is a common complication of insulin injection in diabetic patients.Current studies have not been consistent on whether there is a relationship between repeated use of needles and the occurrence of lipohypertrophy，since the conception of "reuse" is too broad. Objective　The purpose of this study is to evaluate the relationship between use frequency of insulin needles and the occurrence of lipohypertrophy. Methods　From March to November，2018，databases of PubMed，Cochrane Library，EMBase，Science Direct，CMB，and CNKI were searched from inception to October 2018 for collecting epidemiological and experimental studies on the relationship between lipohypertrophy and times （1，2-3，4，5，6-10） of use of insulin injection needles. Quality evaluation and data extraction of the included studies were performed. Network meta-analysis was performed using Stata15.0. Results　Patients who did not reuse insulin injection needles had the lowest incidence of lipohypertrophy（10.1%）. There was no significant difference in the incidence of lipohypertrophy among patients reusing the needles 2-10 times（P>0.05）. The incidence of lipohypertrophy rose significantly in those reusing needles 6-10 times compared with that of those without reuse behaviors〔OR=3.72，95%CI（1.05，13.17），P<0.05〕. The incidence of lipohypertrophy was not significantly different across patients who used needles 1-5 times（P>0.05）. Conclusion　Disposable insulin needles are highly recommended. If such needles are not available due to limited medical resources or other factors，the times of reusing needles should not exceed 5.

Impact of Dietary Nutrients on Coronary Plaque Vulnerability in Patients with Coronary Artery Disease　

WANG Weiqi，LIN Ping，WANG Yini，LIU Guojie

2020, 23(34): 4349-4355. DOI: 10.12114/j.issn.1007-9572.2020.00.577

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Background　Coronary artery disease（CAD） is a major chronic disease threatening Chinese residents' health. Rational intake of dietary nutrients is of vital importance to the prevention and treatment of CAD. Recently，robust evidence has indicated that coronary atherosclerotic vulnerable plaque is associated with an increased risk of disease progression. However，to the best of our knowledge，no previous study has evaluated the impact of dietary factors on coronary plaque vulnerability. Objective　To investigate dietary nutrients intake and its association with coronary plaque vulnerability in CAD patients. Methods　A total of 314 patients who were diagnosed with CAD by coronary angiography from September 2018 to March 2019 were invited to complete the Semi-Quantitative Food Frequency Questionnaire（SQFFQ）. The Nutrition Calculator V2.7.3 was used to calculate daily intakes of 22 nutrients. Vulnerability of the coronary plaque was assessed by optical coherence tomography. Results　The average intake of dietary fiber，folate，vitamin C and sodium in CAD patients was（17.21±6.59） g/d，（94.07±50.88）μg/d，（142.54±62.39）mg/d and（4.00±1.16）g/d，respectively. Logistic regression analysis indicated that high vitamin C intake was associated with reduced risk of lipid plaque〔OR=0.994，95%CI（0.990，0.998），P=0.003〕，thin-cap fibroatheroma（TCFA）〔OR=0.988，95%CI（0.981，0.994），P<0.001〕 and thrombus〔OR=0.988，95%CI（0.983，0.994），P<0.001〕；high dietary fiber intake was associated with reduced risk of macrophage infiltration〔OR= 0.955，95%CI（0.920，0.992），P=0.016〕and TCFA〔OR=0.934，95%CI（0.900，0.970），P<0.001〕；high folate intake was associated with reduced TCFA〔OR=0.986，95%CI（0.978，0.993），P<0.001〕 and plaque rupture〔OR=0.991，95%CI（0.985，0.997），P=0.005〕. However，high sodium intake was associated with increased risk of lipid plaque〔OR=1.597，95%CI（1.243，2.052），P<0.001〕，TCFA〔OR=1.617，95%CI（1.258，2.079），P<0.001〕，plaque rupture〔OR=1.359，95%CI（1.082，1.708），P=0.008〕 and thrombus〔OR=1.476，95%CI（1.077，2.022），P=0.015〕. Conclusion　In these CAD patients，the intake of dietary fiber and vitamin was insufficient，but sodium intake exceeded the standard seriously，indicating that their dietary composition is unreasonable. The intakes of vitamin C，dietary fiber，folate and sodium are closely associated with coronary plaque vulnerability. Therefore，dietary and nutrition guidance may be a good intervention to prevent the development and delay the progression of CAD.

Sleep Problems and Triglyceride to HDL-C Ratio among Beijing Adults in 2017　

WEI Yingqi，MA Aijuan，XIE Jin，FANG Kai，DONG Jing，XIE Chen，JIANG Bo，QI Kun，ZHAO Yue，DONG Zhong

2020, 23(34): 4356-4361. DOI: 10.12114/j.issn.1007-9572.2020.00.412

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Background　Serum triglyceride to high-density lipoprotein cholesterol（TG/HDL-C） ratio is a systemic indicator of serum lipid levels. Poor sleep may be a risk factor of dyslipidemia. Exploring the association of sleep problems with TG/HDL-C ratio and identifying relevant risk groups，may help to reduce the risk of dyslipidemia via improve sleeping quality. Objective　To examine the sleep quality and its association with TG/HDL-C ratio in Beijing adults in 2017，providing scientific evidence for plasma lipid control via improving sleep quality. Methods　Data were gathered from the 2017 Beijing Non-communicable Disease and Associated Risk Factors Surveillance Program，involving adult permanent residents aged 18-79 years from 16 districts of Beijing selected by multistage stratified sampling and cluster sampling. Demographic information（age，gender，marital status，education level），diagnosis and treatment of chronic diseases（hypertension，diabetes，dyslipidemia），lifestyle（smoking，drinking，and so on），sleep duration and sleep problems〔snoring / suffocation，difficulty falling asleep，awakenings from sleep（≥2），early awakening，use of sleeping pills〕，anthropometric parameters（height，weight，waist circumference and blood pressure），and fasting lipid profile（TC，TG，HDL-C，LDL-C） in venous samples were analyzed. The t-test，Kruskal-Wallis H test，Mann-Whitney U test，chi-square test，and multivariate Logistic regression were used to examine the association of sleep and TG/HDL-C ratio. Results　A total of 13 240 cases were included，with an average age of （44.79±15.47） years and a self-reported average sleep duration of （7.47±1.30） hours/day，and a median TG/HDL-C ratio of 0.99（0.84）. The prevalence of self-reported sleep problems within 30 days was 49.02%（6 490/13 240）. Those who slept 9 hours per day had lowest TG/HDL-C ratio，with a median level of 0.95（0.82）. TG/HDL-C ratio differed significantly in women by the length of sleep（χ2=37.14，P<0.01）. TG/HDL-C ratio differed significantly between those with self-reported sleep problems and those without（P<0.01）. After adjusting for gender，age，marital status，living in urban or rural area，education level，current smoking，drinking within 30 days，insufficient physical activity，hypertension，diabetes，BMI and other potential confounding factors，multivariate Logistic regression analysis showed that at least one kind of sleep problems were associated with elevated TG/HDL-C ratio〔OR=1.05，95%CI（1.01，1.08）〕. Sleep problems were associated with elevated TG/HDL-C ratio in men〔OR=1.05，95%CI（1.01，1.09）〕，and in those aged 18-44〔OR=1.06，95%CI（1.01，1.10）〕. Conclusion　Sleep problems such as too long or too short sleep duration，snoring or suffocation might，difficulty in falling asleep and taking sleeping pills be related to high serum TG/HDL-C ratio among Beijing residents aged 18-79 years. Men and those under 45 years old should be encouraged to take measures to improve their sleep quality.

Development of Practical Teaching Quality Evaluation System within the Community General Practice Base　

KONG Yan，ZUO Yanli，SHEN Ying，LI Hong，LIU Jianghua

2020, 23(34): 4362-4371. DOI: 10.12114/j.issn.1007-9572.2020.00.456

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Background　Practical teaching in community practice base plays an extremely important role in general practice medical education. However，the quality of community-based general practice teaching may be not guaranteed to be satisfied due to limitations of quality evaluation，which poses barriers to further development of teaching quality evaluation. So it is urgently to develop an appropriate targeted teaching evaluation system. Objective　To develop a quality evaluation system targeting practical teaching within the community general practice base，to provide a reference for this kind of evaluation. Methods　From September 2017 to September 2018，we initially formulated a quality evaluation system targeting practical teaching within the community general practice base and then determined its indices using literature review and Delphi consultation with 22 experts purposively sampled from 3 kinds of professionals（consisting of those who know medical education management and general practice teaching well，and primary care workers，and primary care mangers）. We used the analytic hierarchy process to calculate the weight of each index. Results　The final system covers 3 domains（community teaching management，community teachers and general medical students or residents），11 first-level indices，57 second-level indices，and 110 third-level indices. In terms of teaching management，it included three first-class indicators：teaching conditions，teaching management and teaching implementation，with weights of 0.510 5，0.282 9 and 0.206 6 respectively；in terms of teaching teachers，there were four first-class indicators：teaching method，teaching content，teaching ability and teaching efficacy，with weights of 0.475 2，0.200 7，0.177 5 and 0.146 5 respectively；in terms of general medical students or residents，there were four first-class indicators including general diagnostic and therapeutic ability，clinical skills，public health service ability and comprehensive quality，with weights of 0.318 3，0.188 0，0.189 5 and 0.304 1，respectively. Conclusion　Our system developed using the analytic hierarchy process may provide assistance for decision-making，intervention delivery and quality improvement in community practice teaching in a comprehensive way.

Establishment of Evaluation Index System for Standardized Training Efficiency of General Practitioners Based on Kirkpatrick Model　

ZHANG Wei，SUN Ruiling

2020, 23(34): 4371-4376. DOI: 10.12114/j.issn.1007-9572.2020.00.024

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Background　In China，the number of medical and health personnel in primary medical and health institutions is small and the quality is poor. General practitioners are the most important medical and health personnel in primary medical and health institutions. To establish a team of general practitioners with general practitioners as the main body is an important measure to effectively alleviate the shortage of grassroots health personnel and improve the level of primary health services in China. Therefore，the establishment of the evaluation index system of the effect of standardized training for GPs will be important in improving the standardized training of GPs. Objective　To establish an evaluation index system for assessing the effectiveness of standardized training of GPs on the base of Kirkpatrick model，in order to provide references for the GP training. Methods　From July 2017 to July 2018，firstly，screening and establishing a preliminary evaluation index system through literature research method. Then，two rounds of expert consultation were conducted by Delphi method to establish an evaluation index system for assessing the effectiveness of standardized training of GPs. And the weight of each index was obtained by analytic hierarchy process. Results　An evaluation index system with 4 first-level indicators，10 second-level indicators，18 third-level indicators and 28 fourth-level indicators were constructed to evaluate the effectiveness of standardized training of GPs. Among them，4 first level indicators included reaction layer，learning layer，behavior layer and result layer，with weights of 0.209 0，0.180 5，0.352 2 and 0.258 3；10 second level indicators were respectively practical training（0.164 3），practical skills（0.140 0），development ability（0.133 9），professional ethics and team cooperation（0.116 3），service object satisfaction（0.116 3），working process（0.102 0），complaints and disputes（0.075 5），work plan completion（0.066 6），theoretical training（0.044 7），and theoretical knowledge（0.040 5）. Conclusion　The evaluation index system of standardized training efficiency of GPs established through two rounds of Delphi method and analytic hierarchy process is scientific to some extent，but further reliability and validity analysis will be needed to verify its feasibility.

Clinical Inertia in Type 2 Diabetes Treatment and Its Systematic Prevention Approach　

LI Dianjiang，WANG Qin，PAN Enchun，RONG Chao

2020, 23(34): 4377-4380. DOI: 10.12114/j.issn.1007-9572.2020.00.051

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Clinical inertia，defined as the failure to initiate or intensify therapy in a timely manner according to established treatment recommendations，is a key reason for the long-term uncontrolled hyperglycaemia in patients with type 2 diabetes which could subsequently lead to serious complications. It has received extensive attention from researchers abroad，yet very little research has addressed clinical inertia in China which is now home to the most diabetics worldwide. This paper systematically reviewed the definition and measurement methods of clinical inertia，and analyzed its causes and intervention measures. Focusing on the current research weakness，this paper finally proposed to determine the key failure mode of clinical inertia based on the healthcare failure mode and effects analysis（HFMEA）. The causal analysis method was used to find out the root cause of key failures and its mechanism，and then corresponding intervention measures were put forward to optimize the treatment process and form the standardized operation procedure to prevent clinical inertia. By continuously monitoring the diabetes treatment process，and tracking and analyzing failure indicators，thereby treatment delay could be prevented，undesirable effect could be corrected，and the risk of clinical inertia could be reduced.

Treatment Compliance and Years of Community-based Management in Type 2 Diabetes　

DENG Shijiao，YU Jie，YU Haixing，WU Chunxiang

2020, 23(34): 4381-4385，4393. DOI: 10.12114/j.issn.1007-9572.2020.00.416

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Background　Community-based management can improve the treatment compliance to obtain a better outcome in diabete patients. Available related studies mostly focus on the impact of community-based management on the treatment compliance of diabete patients. But the association of treatment compliance and years of community-based management has rarely been studied. Objective　To explore the treatment compliance and its association with years of community-based management in type 2 diabetes. Methods　From July to September 2017，15 088 type 2 diabetes who had applied for a health card and received community-based management as of September 29，2017 were recruited from Shanghai Putuo Community Health Service Center. Data regarding demographics and disease-related information，treatment and treatment compliance were obtained through the community-based diabetes management system. Logistic regression was used to examine the association between years of community-based management and treatment compliance. Results　The average duration of community-based management was （4.05±2.46） years，with oral hypoglycemic drugs as the major intervention（10 462 patients，69.34%）. Among them，12 156（80.57%） met the target HbA1c level，7 621（50.51%） had satisfied BMI control，9 589（63.55%） had good blood pressure control，but 5 855（38.81%） with central obesity did not meet the target waist circumference. The medication compliance was 95.55%（13 107/13 717）. The medication compliance varied significantly by age，course of type 2 diabetes，treatment，BMI control status and years of community-based management（P<0.05）. The diet control rate was 87.19%（13 155/15 088），which varied significantly according to sex，age，course of type 2 diabetes，treatment，BMI control status and years of community-based management（P<0.05）. The regular exercise rate was 47.45%（7 159/15 088）. The regular exercise rate differed significantly by age，course of type 2 diabetes，and years of community-based management（P<0.05）. After adjusting for sex，age，course of type 2 diabetes，BMI and treatment，Logistic regression analysis found that medium- and long-term（1-4 years） community-based management was a facilitator for regular exercise behavior〔OR=1.415，95%CI（1.225，1.637），P<0.05〕. Long-term（>4 years） community-based management was a facilitator for medication compliance〔OR=2.925，95%CI（2.109，4.022），P<0.05〕，good diet control〔OR=2.051，95%CI（1.689，2.481），P<0.05〕，and regular exercises〔OR=2.596，95%CI（2.239，3.016），P<0.05〕. Conclusion　On the whole，the treatment compliance was good in this group of diabetes，but the prevalence of regular exercises was poor. To further improve their treatment compliance，community-based exercise guidance for these patients should be strengthened. Moreover，it is suggested to give community-based management to diagnosed diabetes as early as possible，and long-term management is a better choice since it is more helpful to cultivate good treatment compliance.

Characteristics of Inhibitory Control in Type 2 Diabetic Patients with Different Levels of Dietary Adherence　

ZHU Guiyue，LIU Annuo，DING Cuilu，SUN Xiaohong，ZHENG Hongying，CHEN Guohong，MA Wen，ZHANG Meng

2020, 23(34): 4386-4393. DOI: 10.12114/j.issn.1007-9572.2020.00.469

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Background　Diet therapy is the basis of diabetes treatment，but the overall dietary adherence in type 2 diabetics is poor. Inhibitory control，a cognitive function closely related to diet behavior regulation，has been concerned in recent years. It is of great significance to explore its relationship with diet adherence to improve the dietary adherence in such patients. Objective　To explore the characteristics of inhibitory control by dietary adherence and their relationship in type 2 diabetic patients，to develop an inhibitory control training program based on dietary adherence to improve dietary adherence in such patients. Methods　Using convenient sampling method，190 type 2 diabetic patients from Department of Endocrinology，First Affiliated Hospital of Anhui Medical University were selected from May to September 2019. According to the score of the Food Control Behavior Scale（FCBS），they were divided into high，medium and low dietary adherence groups. Stop signal task was used to measure the no-stop signal response time（NSRT） and stop signal response time（SSRT） in three groups under conditions with stimuli from high，medium and low energy food pictures. Results　The average NSRT showed no significant differences across three groups during implementing stop signal tasks with stimuli from different types of pictures（P>0.05）.During implementing stop signal tasks with stimuli from high and low energy food pictures，low dietary adherence group had longer average SSRT than other two groups（P<0.05）. Low dietary adherence group required greater NSRT to implement stop signal tasks with stimuli from medium energy food pictures instead of from high and low energy food pictures（P<0.05）. Low dietary adherence group needed less SSRT to implement stop signal tasks with stimuli from medium energy food pictures instead of other two types of pictures（P<0.05），and so did medium dietary adherence group（P<0.05）. Conclusion　Low dietary adherence may be associated with lower food-specific inhibitory control in type 2 diabetic patients.

Research Progress in the Application of Exercise Prescription in Cancer Patients　

GUO Chen，REN Hong，CAO Baoshan，MA Liwen，ZHOU Fanjie，WANG Ronghui

2020, 23(34): 4394-4399. DOI: 10.12114/j.issn.1007-9572.2019.00.687

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At present，the incidence and mortality of cancer in China rank first in the world. It is found that exercise prescription is one of the effective ways to improve the immune system function and the quality of life of cancer patients，and it has a satisfactory effect on alleviating the adverse reactions caused by cancer and its treatment. At the same time，"Healthy China 2030" Program Outline pointed out that the integration of physical medicine and non-medical health intervention should be strengthened to establish and improve the exercise prescription database for different groups of people with different physical conditions in different environments. However，the lack of exercise guidelines and prescriptions for cancer patients in China has limited the choice of exercise for medical staff and patients. Based on this，this paper reviewed the definition of exercise prescription，its important role in cancer treatment and prognosis，and the formulation and guidelines of exercise prescription for cancer patients，in order to provide theoretical basis for the research and formulation of exercise prescription for cancer patients in China.

Common Scales about Health-related Quality of Life among Menopausal Women and Their Application　

LI Bin，HUANG Yizhou，JIA Yingxian，MA Linjuan，YING Qian，ZHOU Jianhong

2020, 23(34): 4400-4404，4406. DOI: 10.12114/j.issn.1007-9572.2020.00.287

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The nature of menopause is the decline of ovarian function，which causes insufficient estrogen secretion and leads to the occurrence of vasomotor symptoms such as hot flashes and night sweats，genitourinary tract atrophy and psychological symptoms，as well as increases the risk of chronic diseases such as osteoporosis and metabolic disorders. Health-related quality of life refers to the relationship among individual's physical health，mental health and social functions in different cultures and value systems. Menopausal women have a higher incidence of menopausal symptoms that to some extent impair their quality of life. Therefore，it is of critical significance to evaluate the impact of menopausal symptoms on health-related quality of life among menopausal women. The most commonly used scales for menopausal health-related quality of life are the Greene Climacteric Scale（GCS），the MOS 36 Item Short Form Health Survey（SF-36），Menopause-specific Quality of Life Questionnaire（MENQOL） and Menopause Rating Scale（MRS）. All scales have their own advantages and limitations. This paper reviews relevant research results of scales for menopausal health-related quality of life at home and abroad to summarize and compare their effectiveness，deficiencies and applications，in order to provide a reference for the timely，accurate，and comprehensive assessment of menopausal women clinically，and provide ideas for related research and applications. By comparison，this article finds that MRS and GCS are less widely used in China，and MENQOL can be used alone for the assessment of menopausal symptoms and health-related quality of life among menopausal women. The SF-36 needs to be combined with the Modified Kupperman Index Scale to evaluate both comprehensively.

Thoughts about Associated Factors of Potential Inappropriate Medications among Geriatric Patients in Primary Care

2020, 23(34): 4405-4406. DOI: 10.12114/j.issn.1007-9572.2020.00.526

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