Table of Content

05 January 2021, Volume 24 Issue 1

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Monographic Research

Theme Analysis of Academic Journals of General Practice Worldwide　

YANG Hui，HAN Jianjun，XU Yanli

2021, 24(1):  1-10.  DOI: 10.12114/j.issn.1007-9572.2021.00.073

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Background　Articles published in academic journals of professional colleges reflect status and direction of the discipline. Different with standardized systematic review，purposeful analysis of college journals will provide much specific information for development of the discipline，the journals and the industry. Objective　To analyze the journals of general practice worldwide to grasp the development trend of general practice research，providing a significant reference for general practice research and management of related academic journals in China. Methods　Representative academic journals worldwide published by general practice/family medicine organizations were purposively selected and searched，in which the articles published during September 2019 to September 2020 were enrolled，and their themes，study objects，research methods and other key essentials were analyzed. Results　（1）The included 10 journals have rapid responses to the times，for example，101 articles about COVID-19 were published in them during the year，including 9 research articles.（2）The journals published a total of 1 524 articles in the year. Among them，the top four with the most number of articles published were British Journal of General Practice（BJGP），Canadian Family Physician（CFP），Australian Journal of General Practice（AJGP），and the Annals of Family Medicine（AFM）.（3）Research articles numbered 463，accounting for 30.4% of the total articles. Most of them published in BJGP and AFM，followed by Scandinavian Journal of Primary Health Care（SJPHC），AJGP，and CFP.（4）The first authors of the research articles come from 25 countries / regions，with the U.K.，the United States，Canada，Australia，New Zealand，Japan，Sweden，Norway，Malaysia，the Netherlands，Denmark and Finland ranking high.（5）One hundred and six research articles had participants with clear socio-demographic features，with the elderly，children and adolescents，women，vulnerable groups and ethnic groups as the target populations sorted in terms of study frequencies from most to least. One hundred and seven focused on current and future human resources of general practices，involving general practitioners / essential medical services providers，members of the general practice team，other workers，medical students and general practitioner trainees. The present performances of general practices were also a frequent concern. One hundred and fifty-six articles studied specific diseases and problems，with four categories classified by the ICPC-2 were mainly involved：cardiovascular diseases or problems，endocrine，metabolic and nutritional diseases，psychological or mental disorders，and respiratory diseases.（6）The studying problems of research articles were diversified，involving a wide range of aspects.（7）The interventions or measures included in the research articles consisted of general clinical diagnosis and treatment，service system management，critical thinking，general practice education and leadership，rational use of drugs，integrated multidisciplinary care，electronic services，quality and safety，and so on.（8）Quantitative research method was the most frequently used method，which was adopted in 284（61.3%） research articles，including 47 with an experimental design（23 randomized controlled trials and 24 non-randomized controlled trials），and 237 with an observational design（containing 161 descriptive analyses without controls）. Qualitative research method was used in 108（23.3%） research articles. The most frequently used type was key informant in-depth interview（72 articles），followed by focus group discussion（11 articles）. Mixed research methods were used in 24 research articles（5.2%）. Conclusion　Academic journals of general practice organisations should give responses to community needs，with subjects determined in accordance with community health needs，and a focus on general practice human resource development，and various problems and diversified interventions. Moreover，for articles to be published in an issue，quantitative or observational research method is recommend for most of which，and the number of articles using qualitative research method is suggested to be less than 20% of the reviews. Furthermore，for improving the academic level of academic journals of general practice in China，the review of related academic journals worldwide is a good approach.


Prevention and Control of Major Infectious Diseases in Primary Health Care Organizations：Experiences，Problems and Countermeasures from Case-based Studies　

QIN Yi, HUANG Yuanying, HE Zhongchen, ZHANG Jian, LUO Lan, TANG Guizhong

2021, 24(1):  11-16.  DOI: 10.12114/j.issn.1007-9572.2021.00.035

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As the providers of public health and essential medical and health services，primary health care organizations play an increasingly important role in the prevention and treatment of major infectious diseases. However，as revealed by actions in containing the 2003 SARS epidemic，2009 H1N1 pandemic and COVID-19 pandemic，their capacities in the containment of such diseases are unsatisfactory，with specific manifestations of imperfection of primary containment mechanisms for infectious diseases，insufficient primary health resources，oversights in preventive health education and low level of informatization. Hence，we proposed the following recommended solutions：further reforming the infectious diseases emergency preparedness and response mechanism，optimizing the allocation of health resources including medical professional and equipments by forms such as combining multiple bodies to co-deliver public health services and attracting social capitals to input in public health programs，further implementing the hierarchical medical system and family doctor system，enhancing informatization level，bearing in mind the idea of delivering routine medical services with sound emergency preparedness in non-epidemic period and making emergency responses to public health emergencies when needed and promoting health education.


Roles of Primary Care Doctors in COVID-19 Pandemic：Level of Consistency Across Perceptions of Doctors and Experts and Impact Factors　

YANG Chenbin，LI Yanmei，LI Zhangping，YANG Hui，NI Yunchao，LIN Jin，WANG Dongsheng，XU Huaqing，SONG Wenxing

2021, 24(1):  17-22.  DOI: 10.12114/j.issn.1007-9572.2021.00.027

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Background　Primary doctors have participated in containing the COVID-19 pandemic outbroken in December 2019 at the primary level. Investigating their perception of their own roles in the pandemic containment and influencing factors is necessary，since their perceived roles have impact on their recognition of obligations. Objective　To investigate the consistency of primary doctors and experts' perceptions of roles of primary doctors in COVID-19 containment，providing evidence for the development of targeted trainings for primary doctors and the determination of the roles of them in major public health events. Methods　A questionnaire survey was conducted among 1 758 primary care doctors from Zhejiang Province from February 21 to 27，2020 for investigating their perceptions of roles of primary care doctors in COVID-19 containment，including whether health education of infectious diseases should be conducted，the classification of COVID-19 and classification，reporting and referral of suspected cases，treatment of suspected or confirmed cases，follow-up of patients after treatment. The role positioning of primary care doctors was compared the consensus rate with expert recommendations，and the consistency rate was high when it was more than 90%. Multivariate Logistic regression was used to analyze the factors that the self-role orientation of primary care doctors was inconsistent with the expert's suggestion. Results　Among 1 758 participants，1 513（86.1%） participated in the frontline containment of COVID-19 pandemic. Respondents and experts had highly identical perceptions on primary care doctors' roles in carrying out health education on infectious diseases〔99.6%（1 751/1 758）〕，reporting or referring suspected cases〔96.8%（1 702/1 758）〕 and following-up of the treaded patients〔91.3%（1 605/1 758）〕，while they were at variance over diagnosing and classifying COVID-19〔49.5%（871/1 758）〕 as well as treating suspected cases〔61.4%（1 080/1 758）〕. Logistic regression analysis indicated that working at a clinic or health station，and intermediate or senior professional title were facilitators for respondents having similar perceptions on primary care doctors' roles in diagnosing and classifying COVID-19（P<0.05）；working at a clinic or health station，intermediate or senior professional title，and participating in COVID-19 containment were facilitators for respondents having similar perceptions on treating suspected cases to those of experts（P<0.05）. Conclusion　Most primary care doctors have participated in frontline COVID-19 containment. Their perceptions of their roles over diagnosing and classifying COVID-19，and treating suspected cases are low consistent with those of experts. In view of this，functional support for diagnosing and treating COVID-19 and guidance on how to appropriately understand primary doctors' roles in COVID-19 containment should be given to primary doctors with junior professional title，less years of working as a doctor，working at the community（township） health center，or without an experience of containing COVID-19 at the frontline.


Exploration and Practice of Primary Health Care during the Construction of County-level Medical Alliance　

DAI Wenyun，HU Ling

2021, 24(1):  23-29.  DOI: 10.12114/j.issn.1007-9572.2020.00.188

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The construction of county-level medical alliance（CMA） is an important breakthrough to improve the ability of health care at grassroots level and deepen the medical reform. However，there is currently no unified operation mode of CMA in China. Zhejiang Province carried out the pilot construction of CMA in September 2017，and determined the pilot reform path of "three unifications" of unified institutional setting，staff recruitment and allocation，and medical and health resource allocation，"three integrated plans" for fiscal and financial management，medical insurance payment，and information sharing，and "three emphasis" on hierarchical diagnosis and treatment，contracted family doctor services，and public health. Zhejiang Province comprehensively promoted the above reform plan in the whole province in September 2018，and has made some positive progress. This paper summarizes and analyzes the main methods of health-related work in Zhejiang Province under the background of comprehensively promoting the construction of medical alliance. It mainly includes the work responsibilities and tasks of relevant departments，contracted services of family doctors，basic public health services，and the reform of compensation mechanism of primary health care institutions. In addition，this paper reports in detail the achievements that Zhejiang Province has made in terms of the grassroots service ability，CMA pattern，and the enthusiasm of primary health care staff since the construction of medical alliance. It is hoped that the practice of "Zhejiang Mode" in this paper can provide reference for the construction of medical alliance in other regions.


Bi-directional Referrals in Urban and Suburban Community Health Centers：a Comparative Study　

SHI Xiaoxiao，SONG Huijiang，GE Xuhua，JIN hua，WANG Zhaoxin，YANG Sen，SONG Yang,HE Juanmei，ZHU Minjie，YU Dehua

2021, 24(1):  30-35.  DOI: 10.12114/j.issn.1007-9572.2020.00.269

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Background　Realizing successful bi-directional referrals is an essential target of the comprehensive medical reform for public hospitals launched in 2009 in China. Bi-directional referrals in urban and suburban areas are different due to domestic uneven distribution of health resources，and administrative regional differences of medical and human resources as well as disease management. It is of great significance to understand bi-directional referrals in urban and suburban areas to maximize the utilization of health resources. Objective　To perform a comparative analysis of bi-directional referrals in urban and suburban community health centers（CHCs） in Shanghai with reasonable suggestions proposed，providing a practical and reliable reference for better promoting such services in Shanghai. Methods　From November to December 2018，244 administrators and 4 047 general practitioners（GPs） were enrolled from 244 CHCs in 16 districts of Shanghai. A survey was conducted among the administrators using a self-developed questionnaire（for administrators） for collecting their demographic data，and their perceptions of organizational mechanism，process and results of referrals. And another survey was conducted in the GPs using a self-developed questionnaire（for GPs） for collecting the data about demographics，modes of bi-directional referrals and contact ways for upward referrals used，prevalence of filling the referral information except the referral form，and prevalence of communicating with physicians in the higher level hospital when receiving the downward referred patient. Results　The two surveys achieved response rates of 100.00% （244/244） and 96.98%（3 925/4 047），respectively. Of the 3 925 GP respondents，2 641（32.71%） worked in suburbs and 1 284（67.29%） in urban areas. There were significant differences in gender ratio，distribution of title and working years between urban and suburban GPs（P<0.05）. Of the CHCs，97.54%（238/244） established a bi-directional referral system，and 89.34%（218/244） signed a bi-directional referral agreement with secondary and tertiary hospitals. There are significant differences between urban and suburban CHCs in having a worker of communications for bi-directional referrals，setting up bi-directional referral files，reserving beds for downward referred patients，network connections for bi-directional referrals，peer-to-peer communication with corresponding experts or departments，and communication with the worker responsible for bi-directional referrals in higher level hospitals（P<0.05）. 50.41%（123/244） of the CHCs had less than 100 upward referrals and 75.00%（183/244） had less than 10 downward referrals per month. There was a significant difference in the average number of upward referrals per month between urban and suburban CHCs（P<0.05）.Conclusion　Shanghai's urban and suburban CHCs have many differences in bi-directional referrals，which are composed of mainly upward referrals. To improve the development of bi-directional referral system，it is suggested to improve the construction of suburban community health services，establish a health record-based bi-directional referral platform using the Internet technologies plus favorable recommendations，and actively establishing regional medical groups.


Refection on the Collaborative and Integrated Management Pathway for Atrial Fibrillation by a Large Tertiary General Hospital and a Community Hospital　

YANG Rong，LIU Changming，LIAO Xiaoyang，WANG Lei

2021, 24(1):  36-39.  DOI: 10.12114/j.issn.1007-9572.2020.00.481

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Atrial fibrillation（AF） is one of the least manageable cardiovascular diseases in the 21st century. As a result of deepening understanding of AF，continuous promotion of the implementation of hierarchical medical system，and appropriately allocating medical resources to primary care gradually，a tertiary general hospital actively cooperates with a community hospital to carry out a new pattern for integrated management of AF has become an exploratory focus during the medical consortium development. AF，as a high-risk chronic disease，plays an important role in the cardiovascular disease continuum，given that hypertension is its high-risk factor and stroke is one of its complications. Therefore，in addition to managing patients with hypertension，it is necessary for community hospitals to early screen hypertension or stroke or other coexisting conditions in AF patients，and deliver a series of targeted comprehensive management accordingly. We introduced an example of comprehensive management of AF by West China Hospital，Sichuan University and Shuangliu District Xihanggang Community Hospital，a tertiary general hospital in combination with a community hospital. Specifically，by means mainly consist of providing online and offline precise trainings for community general practitioners by physicians from West China Hospital，providing AF-related health education and free consultations for contracted residents，and adopting a bi-directional referral pathway for AF patients，the two hospitals collaboratively managed AF dynamically and comprehensively based on the patient's conditions using integrated general care or/and specialty care in an exploratory way. By presenting a detailed analysis and concise summary of the collaborative experience of these two hospitals，we aimed to offer help for the development of a systematic and standard pattern for collaborative management of AF by a tertiary general hospital and a community hospital，and for the empirical exploration of new ways for the specific implementation of hierarchical medical system.


Perception and Evaluation of Integrated Medical and Preventive Services among Primary Care Doctors and Nurses in China　

YU Menggen，ZHAO Xuan，LI Huiwen，YU Yahang，YUAN Beibei，MENG Qingyue

2021, 24(1):  40-45.  DOI: 10.12114/j.issn.1007-9572.2021.00.038

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Background　 The perceptions of integrated medical and preventive services of primary care doctors and nurses，key providers for essential medical and public health services，affects the provision of such services，so it is essential to study their perceptions for formulating and implementing supportive policies of such services. Objective　 To investigate primary care doctors and nurses' subjective perceptions and associated factors of integrated medical and preventive services，providing a reference for the development of integrated medical and preventive care system. Methods　 From April to October 2019，we conducted a survey using a self-developed questionnaire on perception and evaluation of integrated medical and preventive services with questions presented using a Likert scale among a nationwide sample of primary care doctors and nurses selected by multistage sampling. The survey achieved a response rate of 89.5%（725/810）. We used factor analysis to reduce the dimensionality of the 12 variables，extracted and explained the common factors，and calculated factor scores. Results　Factors reflecting subjective perceptions of integrated medical and preventive services were summarized as follows：institutional environment support factor，departmental cooperation and interaction factor，and individual professional boundary factor. The cumulative variance explained by them reached 70.43%. By using a 4-point rating system，the factors of institutional environment support，departmental cooperation and interaction，and individual professional boundary were rated （2.97±0.54），（2.81±0.55） and （2.46±0.65） points，respectively，and the comprehensive perceptions of integrated medical and preventive services were rated （2.86±0.53） points. Conclusion　 According to the subjective perceptions of integrated medical and preventive services of primary care doctors and nurses，the institutional environment support was not high，inter-departmental cooperation was rare，and professional boundary was strong. To build an integrated health care system and achieve accessible integrated medical and preventive services in primary care，related governmental departments should offer more policy support，the cooperation between multidisciplinary professionals should be strengthened，and the thoughts of medical and preventive services being unconnected in primary care doctors and nurses should be changed.


Primary Care Doctors and Nurses' Behaviors in the Delivery of Integrated Medical and Preventive Services and Its Influencing Factors　

YU Menggen，ZHAO Xuan，LI Huiwen，YU Yahang，YUAN Beibei，MENG Qingyue

2021, 24(1):  46-51.  DOI: 10.12114/j.issn.1007-9572.2021.00.037

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Background　Primary care is an indispensable part of integrated medical and preventive care system that is constructed currently. Primary care doctors and nurses' behaviors in service delivery may directly affect care quality and health status of patients，so identifying the associated factors of these medical workers' behaviors is necessary for the development of appropriate and scientific policies related to such services. Objective　To analyze primary care doctors and nurses' behaviors and associated factors in the delivery of integrated medical and preventive services，to provide policy suggestions for the development of such services. Methods　From April to October 2019，we carried out a survey among a nationwide multi-stage sample of primary care doctors and nurses using a self-designed questionnaire for investigating their demographics and perception of integrated medical and preventive services，as well as evaluation indicators for behaviors in service delivery.We used two-level linear regression and multiple linear regression models to analyze the influencing factors of their behaviors in service delivery. Results　Of the 810 cases attending the survey，624（77.4%） gave responsive answers to questions about self-reported percentage of preventive service delivery time with notable hierarchical structure of answer responses，and 609（75.2%） gave responsive answers to questions about the percentage of regular patients encountered. The mean self-reported percentage of preventive service delivery time was（37.7±23.033）%. And the mean percentage of regular patients encountered was（27.3±24.312）%. Two-level linear regression analysis showed that the influencing factors for self-reported percentage of preventive service delivery time included whether being a family physician team member，cooperation and interaction，and understanding of professional boundary（P<0.05）. Factors influencing self-reported percentage of regular patients encountered obtained by multiple linear regression analysis included demographic information，whether being a family physician team member，cooperation and interaction，and years of working in the institution（P<0.05）. Conclusion　To improve the delivery of sustainable and coordinated integrated medical and preventive services，efforts should be made to promote the development of family physician teams and contracted services，determine the roles of each member，strengthen inter-departmental and multidisciplinary cooperation，and change the rigid thinking of medical and preventive services being unconnected.


Environmental Support for the Delivery of Integrated Medical and Preventive Services in Primary Healthcare Institutions　

YU Yahang，ZHAO Xuan，LI Huiwen，YU Menggen，YUAN Beibei，MENG Qingyue

2021, 24(1):  52-59.  DOI: 10.12114/j.issn.1007-9572.2021.00.039

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Background　In China，primary healthcare institutions provide healthcare services at the primary level，whose competence development for delivering integrated medical and preventive services associates with the end-results of constructing an integrated healthcare system. Objective　To evaluate the supporting level and potential influence of current operational mechanism and institutional arrangement in primary healthcare institutions on their delivery of integrated medical and preventive services based on a functional framework of health system，to provide a basis for promoting the development of integrated medical and preventive services. Methods　This was a mixed-methods study with a quantitative analysis of two questionnaire surveys supplemented with a qualitative analysis of interviews with a subset of respondents for improving logic analysis. From April to October 2019，by use of multistage sampling，75 primary healthcare institutions were selected from eastern，central and western China，from which，75 administrators were extracted（one from each institution） to receive a questionnaire survey on the institution's general information，human resource management，revenue and expenditure structure，provision and utilization of health services，delivery pattern of family doctor services，prevention and management of diabetes，and parameters of integrated medical and preventive services，and 1 435 medical workers were extracted to receive a questionnaire survey on their demographics，and their perspectives of practice behaviors of the contracted family doctor，provision and understanding of integrated medical and preventive services，with slight differences in questions by types of positions. 189 cases，a subset of the respondents（including 75 administrators and 114 medical workers） were selected to attend semi-structured interviews regarding perceptions of current implementation of the integrated medical and preventive services，self-assessed professional abilities，changes in practice behaviors of the professionals delivering the integrated services，as well as the role of a family doctor team in delivering such services. Results　Questionnaire survey among the administrators revealed that in 2018，the average surplus of public health funds accounted for 13.77% of the average total revenue of institutions，which was lower than the ratio of average surplus of medical insurance funds（31.14%）. 90.54%（67/74）of the institutions provided integrated diabetes care and prevention with family doctor teams as the main force，and with acceptable number of general practitioners，time for health education as well as proportion of regular patients. Moreover，electronic file sharing and connection of diabetes information platform with large electronic system were achieved in 63.01%（46/73），and 52.70%（39/74） of the institutions，respectively. 89.83%（53/59） of the administrators approved that medical performance parameters influenced the income of healthcare professionals most. Questionnaire survey among the medical workers showed that，41.75%（567/1 358）of the respondents believed that their self-evaluated professional abilities might be limited due to their own positions，58.54%（795/1 358）still held the view that clinical care did better on improving health than preventive services，and 53.57%（721/1 346）thought that the delivery of preventive services would not affect their income. These respondents' views demonstrated that intra-institution communication and cooperation were slightly better than inter-institution communication and cooperation，and the incentive system for the delivery of such integrated services should be further improved. Interview results indicated that the revenue composition of both primary care institutions and primary healthcare workers depended on the effectiveness of chronic disease management by a medical team or a family doctor team，the development degree of information system，and the effect of driving force of capacities of providing medical services on the capacities of providing public health services. Conclusion　The support of multiple levels of the operation mechanism on the delivery of integrated medical and preventive services in primary care showed an increasing trend，but the funding structure，incentive system，views of such integrated services and informatization construction needed further improvement. Furthermore，a region with strong medical service delivery capacity was also found to have good environmental support for the delivery of integrated medical and preventive services. In view of this，the reform of healthcare system at all levels is suggested to be used as an aid for the targeted promotion of the environmental support construction for the delivery of integrated medical and preventive services in primary care.


Baseline Fasting Glucose and Risk of Acute Pancreatitis：a Prospective Cohort Study　

ZHANG Bing，ZHU Guoling，SUN Qiu，JI Ruigeng，CHEN Shuohua，LI Guangjian，YUAN Nan，ZHAO Li，CAO Liying

2021, 24(1):  60-64.  DOI: 10.12114/j.issn.1007-9572.2020.00.602

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Background　The number of patients with acute pancreatitis is increasing year by year. Epidemiological surveys at home and abroad focus on the study of high-risk factors of acute pancreatitis. Most of the studies focus on the relationship between the incidence of acute pancreatitis and blood glucose. There are few prospective cohort studies on the relationship between fasting blood glucose and the risk of acute pancreatitis. Objective　To investigate the association of baseline fasting glucose and the incidence of new-onset acute pancreatitis. Methods　A prospective study was conducted among a cohort of eligible workers（n=125 088） from Kailuan Group who received the initial staff physical examination from 2006 to 2007 or from 2008 to 2009，with no history of acute pancreatitis and complete data of fasting glucose levels. The incidence of new-onset acute pancreatitis was recorded，and the cumulative incidence of this disease was calculated. Log-Rank test was performed to validate the result. Multivariable Cox proportional hazards regression was used to evaluate the association of baseline fasting glucose and incidence of new-onset acute pancreatitis. Results　A follow-up lasting for（10.14±1.71） years on average was given to the participants，during which there were a total of 297 cases of new-onset acute pancreatitis，with incidence rate of 1.83/10 000，2.38/10 000，2.00/10 000，and 3.18/10 000 person-years for those with baseline fasting glucose level of ≤4.69，>4.69-5.13，>5.13-5.72，and >5.72 mmol/L，respectively. After adjusting for confounding factors，multivariable Cox proportional hazards regression analysis found that，the risk of acute pancreatitis in the subgroup with baseline fasting glucose >5.72 mmol/L was 1.44 times higher than that of subgroup with baseline fasting glucose ≤4.69 mmol/L〔HR（95%CI）=1.44（1.04，2.01）〕. Conclusion　Baseline fasting glucose level more than 5.72 mmol/L may increase the risk of acute pancreatitis.


Value of Autonomic Nerve Function Assessment in Community-dwelling Patients with Hypertension　

ZOU Wusong，YU Yijun，WANG Zhihong，WANG Yuanmei，GU Ye

2021, 24(1):  65-69.  DOI: 10.12114/j.issn.1007-9572.2020.00.421

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Background　Hypertension is a serious threat to human health. The occurrence of hypertension is related to excessive sympathetic activation and autonomic dysfunction. At present，there are few studies on autonomic nerve function detection in community-dwelling population. Objective　To explore the association of impaired autonomic function with hypertension incidence and blood pressure control rate in community-dwelling population. Methods　A retrospective study was conducted. Participants with complete data of 24-hour ambulatory ECG were recruited from a community health center during June 2017 to June 2019，including 120 hypertensive cases（including 67 with controlled hypertension and 53 with uncontrolled hypertension） and 100 non-hypertensive cases. The parameters of heart rate variability〔standard deviation of RR intervals（SDNN），standard deviation of the 5-minute mean RR intervals（SDANN），square root of the mean squared differences of successive RR intervals（rMSSD），number of successive RR intervals differing by >50 ms divided by the total number of successive RR intervals（pNN50），very low frequency（VLF），low frequency（LF），high frequency（HF），LF/HF〕，and non-specific ST-T wave changes were compared between hypertensive and non-hypertensive cases，and between hypertensive cases with controlled and uncontrolled hypertension. Multivariate Logistic regression model was used to analyze the risk factors of hypertension and hypertension control. Results　The mean values of rMSSD，VLF，LF and HF were significantly lower in the hypertensive group than those in the non-hypertensive group（P<0.05）. Multivariate Logistic regression analysis showed that reduced rMSSD，and VLF were risk factors of hypertension after adjusting for gender，age，body mass index，smoking and coronary heart disease（P<0.05）. Hypertensive cases with controlled hypertension had higher prevalence of combination drug treatment， and lower mean values of rMSSD，pNN50，HF，VLF and LF than those with uncontrolled hypertension（P<0.05）. Multivariate Logistic regression analysis showed that reduced rMSSD，pNN50 and VLF value and non-specific ST-T wave changes were risk factors for uncontrolled hypertension after adjusting for gender，age，body mass index，smoking and coronary heart disease（P<0.05）. Conclusion　Our study shows that impaired autonomic function may be a risk factor for hypertension and uncontrolled hypertension in community-dwelling population. The autonomic nerve function evaluated by 24-hour ambulatory ECG has predictive value for hypertension in this group.


Influencing Factors of Frequent Visits of the Elderly in a Community Health Service Center Based on the Theory of Planned Behavior：a Qualitative Study

LI Nana，SHOU Juan

2021, 24(1):  70-74.  DOI: 10.12114/j.issn.1007-9572.2020.00.286

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Background　The frequent visits of the elderly in community health service centers are common and occupy a large amount of medical resources. Objective　To understand the influencing factors of frequent visits of elderly patients in a community health service center. Methods　Through the purposive sampling and information saturation principle，20 elderly patients who had frequent medical consultations in a community health service center of Shanghai for the past three years（the number of visits within 3 years were in the top 10%） were selected for a semi-structured interview in May of 2018. Based on the theory of planned behavior，the interview outline mainly included the cognitive measurement，attitude measurement，subjective norm measurement，perceived behavior control measurement，and opinions and suggestions for the community health service center. According to the results of interviews，the influencing factors of the frequent visits of the elderly were analyzed. Results　 Eighteen patients were unaware of their frequent visit behaviors. Nine patients had specific definitions of frequent visits，and 55.6%（5/9） defined 3 visits or more per month as frequent visits. And 90.0%（18/20） believed that frequent visits had no adverse effect on their lives and health；60.0%（12/20） thought that frequent visits could brought them psychological comfort，and 50.0%（10/20） mentioned that frequent visits were helpful to control and improve their health condition. Policies of contracted services（70.0%，14/20），family support（45.0%，9/20），and the behavior of others（15.0%，3/20） could affect patient's frequent visit behaviors. Chronic diseases（100.0%，20/20），convenience of community hospitals（90.0%，18/20），good doctor-patient relationship（90.0%，18/20），concern for their own health（60.0%，12/20），acute illness（45.0%，9/20），and poor conscious health status（30.0%，6/20） could contribute to frequent visits，while inconvenient movements（20.0%，4/20），economic reasons（10.0%，2/20），and household chores（10.0%，2/20） may limit the frequency of patient visits. Conclusion　The frequent visit behaviors of elderly patients are affected by many factors，which requires the attention of general practitioners on patient's disease，psychology，society and other aspects to meet their real needs.


Correlation between Oral Health and Depression　

HAN Yaru，XU Jiang，DING Hongzhong

2021, 24(1):  75-79.  DOI: 10.12114/j.issn.1007-9572.2020.00.476

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Background　Patients with depression have poor oral health and salivary cortisol can be used as a biomarker reflecting mental stress of patients with depression. Data showed that salivary cortisol concentration increased in patients with depression，but the relationship between salivary cortisol and oral disease in patients with depression is not clear. Objective　To investigate the relationship between oral health and depression by measuring the concentration of salivary cortisol. Methods　A total of 96 patients with depression from the Department of Psychology in the First Affiliated Hospital of Shihezi University School of Medicine from November 2018 to May 2019 were selected as depression group；96 cases of physical examination in the First Affiliated Hospital of Shihezi University School of Medicine during the same period were selected as non-depression group. 1 ml of mixed saliva from the two groups of subjects was collected，the cortisol concentration in the specimens was measured by enzyme linked immunosorbent assay，the subject's oral condition was checked and the impact of oral health status to life quality was self-tested by Oral Health Impact Scale（OHIP-14）. Multivariate Logistic regression analysis was adopted to analyze the influencing factors of depression. Results　Oral plaque index（PLI），bleeding index（BI），periodontal probing depth（PD），attachent loss（AL），decay missing filling surface（DMFS），prevalence rate of dental caries，caries average，prevalence rate of periodontal disease，OHIP-14 score and concentration of salivary cortisol in the depression group were higher than those in the non-depression group，and the differences were statistically significant（P<0.05）. The females' concentration of salivary cortisol was higher than that of males both in the depression group and non-depression group，and the difference was statistically significant（P<0.05）. The results of multivariate Logistic regression analysis showed that after controlling the degree of caries，periodontal disease and oral condition，the concentration salivary and the degree of oral health impact were influencing factors for depression（P<0.05）. The results of correlation analysis showed that OHIP-14 score was positively correlated with PD，AL，BI and concentration of salivary cortisol in patients with depression（P<0.05）. Conclusion　Depression can increase the concentration of saliva cortisol，leading to a decline in oral health and quality of life. Depressed people are more likely to suffer from dental caries and periodontal disease than non-depressed people.Increased salivary cortisol concentration is a risk factor for both depression and oral disease in patients with depression.

Effect of "1+1+1" Type of Contracted Family Doctor Services in the Management of Post-PCI Patients　

ZOU Xiaohong，DENG Wenyu，CHEN Dongdong，WANG Haiqin

2021, 24(1):  80-83.  DOI: 10.12114/j.issn.1007-9572.2021.00.024

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Background　Cardiovascular disease is the leading cause of death worldwide. Percutaneous coronary intervention（PCI），a commonly treatment for cardiovascular disease，can significantly reduce the mortality of coronary heart disease（CHD），but the post-PCI follow-up compliance is low and the incidence of post-PCI in-stent restenosis and cardiovascular adverse events is high in Chinese patients. Targeted health management for patients undergoing PCI is a key strategy to low the incidence of restenosis，protect heart function，and improve survival and quality of life. Objective　To evaluate the effect of "1+1+1" type of contracted services delivered by a family doctor team in Xuhui District of Shanghai in the management of post-PCI CHD patients. Methods　127 CHD patients treated with initial PCI between January and December 2016 who underwent post-PCI follow-up in our hospital were selected，and divided into control group（n=63） and intervention group （n=64） randomly，intervened with routine follow-up services，and "1+1+1" type of contracted family doctor services（health education on the prevention and treatment of CHD，and life style interventions for reducing CHD-related risk factors，continued outpatient pharmacological treatment prescribed by a specialist in the higher level hospital by family doctor team members，bi-directional referral services and online collaborative care via a could platform），respectively. The effects of intervention in two groups were evaluated after a 2-year follow-up by the control status of blood pressure，blood glucose and blood lipid and the incidence of major adverse cardiovascular events（MACE） using the "assessment methods and simple assessment tools of ischemic cardiovascular disease risk in Chinese adults". Results　There were no significant differences in baseline clinical factors between the groups. The follow-up showed that higher rate of blood pressure control，glycemic control or blood lipid control was found in the intervention group（P<0.05）. The men in the intervention group had lower 10-year risk for ischemic cardiovascular disease than those in the control group（P<0.05）. In terms of the incidence of MACE，the intervention group had a lower incidence of angina（P<0.05），but had similar incidence of recurrent myocardial infarction，cardiac insufficiency and overall incidence of MACE to the control group（P>0.05）. Conclusion　The "1+1+1" type of contracted services delivered by a family doctor team may better control cardiovascular risk factors，lower the incidence of angina in post-PCI CHD patients. Moreover，the services may also reduce the 10-year risk for ischemic cardiovascular disease in male patients.


Research and Practice on Blended Teaching Design of Introduction to General Practice Course Based on Small Private Online Course Curriculum　

LIU Yan，ZHANG Dongqing，HUANG Jing，ZHONG Yu

2021, 24(1):  84-87.  DOI: 10.12114/j.issn.1007-9572.2020.00.054

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Opinions of the General Office of the State Council on Deepening the Coordination of Medical Education to Further Promote its Reform and Development（〔2017〕 No.63 issued by General Office of the State Council） points out that the focus of specialized clinical medicine major in the future is to train assistant general practitioners for rural grassroots and strengthen the general practice education for all medical students. The Introduction to General Practice course is a course that introduces the basic concepts，principles，methods and techniques of general practice. There are 34 class hours in the Introduction to General Practice course in Chongqing Medical and Pharmaceutical College. The traditional teaching method is mainly based on theoretical lectures with only six class hours of practical training，which makes it difficult to expand the knowledge and simulate the actual work content of general practitioners. Therefore，students are not enthusiastic in learning this course. Since 2017，teachers in the Teaching and Research Section of General Practice in the Clinical Medical College of Chongqing Medical and Pharmaceutical College have developed and designed the Introduction to General Practice course based on SPOC. This paper introduces the course from the three aspects of curriculum resource development，teaching process arrangement and teaching evaluation design.


Ways of Implementing Continuing Medical Education for General Practitioners　

JI Yan，YAN Chunze，SUN Yange，DING Jing

2021, 24(1):  88-91.  DOI: 10.12114/j.issn.1007-9572.2019.00.715

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JI Yan，YAN Chunze，SUN Yange，DING Jing*
Continuing medical education（CME） is an important way for general practitioners（GPs） to update medical knowledge，improve job competency and teaching capabilities. Studies show that during the implementation of CMEs，there are some problems，such as insufficient organizational forms，simple implementation ways and GPs' low satisfaction. Moreover，the ideal ways for carrying out the CME remain controversial. Although the implementation ways for the CME are various，to increase GPs' satisfaction with it，the implementation ways still need to be enriched continually，and should be adequately selected to apply. We reviewed the implementation status and several common implementation ways of CMEs for GPs，aiming to provide a reference for the selection of appropriate implementation ways for CMEs.


Recent 10-year Research Hotspots and Development Trends of Integrated Medical and Nursing Care in China：a CiteSpace-based Visual Analysis 　

WANG Xiaoxiao，GUO Qing

2021, 24(1):  92-97.  DOI: 10.12114/j.issn.1007-9572.2020.00.011

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Background　 In China，how to satisfy multi-level healthcare needs of rapidly increased elderly people is becoming a serious problem due to insufficient efficiency of traditional elderly support model.Integrated medical and nursing care, a new elderly support model, has achieved national and academic attentions. Objective　 To explore recent 10-year research hotspots and development trends of integrated medical and nursing care in China based on analyzing the relevant research, providing a reference for future research. Methods　 Articles about integrated medical and nursing care published from January 1 to April 3，2019 were searched on CNKI database during April 1 and July 1, 2019, and were counted. CiteSpaceⅤ was used to conduct a knowledge mapping analysis of the extracted authors, research institutions and keywords from the included articles.Results　 A total of 2 524 articles were finally included. The annual number of published articles showed a significant increase since 2013. Co-occurrences analyses revealed that, articles were mainly published by colleges and institutes, especially medical colleges, or authors from these institutions, but there was lack of academic cooperation between these institutions or between the authors. Knowledge map of high-frequency keywords showed that top 3 high-frequency keywords with high-level centrality were "elderly services industry" "elderly care institutions" "pension industry". Knowledge map of keywords with the strongest citation bursts showed that the top 3 were "the elderly"  "medical treatment" "gerocomium". The timeline map showed that the research on integrated medical and nursing care in the past ten years was composed of three stages：germination，prosperity and innovation. Conclusion　 The policy factor is an important facilitator to the research on integrated medical and nursing care. The research hotspots in the past ten years can be summarized as four topics：the research on the difficulties and countermeasures in the implementation of integrated medical and nursing care，the research on the delivery models of integrated medical and nursing care，the research on integrated medical and nursing care for the disabled elderly or empty nesters，and the research on the industry of integrated medical and nursing care. This paper predicts that This paper predicts that more social forces will participate in this industry, with highlights on TCM features and smartness.


The Influencing Factors of Care Cost in Elderly Care Institutions Using the Chinese Version of Continuity Assessment Record and Evaluation　

ZHI Mengjia，WANG Yifan，HU Linlin

2021, 24(1):  98-103.  DOI: 10.12114/j.issn.1007-9572.2021.00.026

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Background　The care cost for increasingly aging population will bring heavy economic burden to the society and families in China. So exploring the influencing factors of care cost in elderly care institutions will help make health care decisions，provide targeted services，allocate medical resources reasonably，plan long-term care insurance and financial investment according to the actual situation，which is very important for the elderly，families，health care service providers，elderly care institutions，national finance and medical insurance departments. Objective　The health and functional status of the elderly significantly affects their care need and cost. This study was to explore the impact of health and functional status on care cost in Chinese elderly adults from elderly care institutions using the Chinese version of Continuity Assessment Record and Evaluation（CARE-C）. Methods　Elders aged 60 years and older were recruited from an elderly care institution in Shunyi District of Beijing. 5 qualified assessors including 1 doctor，1 nurse and 3 caregivers in the elderly care institution，assessed the elderly from January to April 2018. The data were collected by using a mobile phone-based APP developed in accordance with the CARE-C. This study mainly extracted the evaluation results of 4 demographic and 20 subscales in CARE. Principal component analysis was used to extract the evaluation results of CARE 20 subscale into 6 main factors，and multiple linear stepwise regression was used to analyze the effects of 4 demographic variables and 6 main factors on care costs. Results　This study included 239 older adults （119 women and 120 men），with a mean age of（82.3±12.5） years. Multiple linear regression revealed that ability of self-care in daily life〔b=-1.244，95%CI=（-1.727，-0.761）〕，muscle strength〔b=16.140，95%CI=（9.106，23.175）〕，age〔b=-4.614，95%CI=（-6.765，-2.463）〕，diseases and medications〔b=21.849，95%CI=（3.261，40.437）〕，gender〔b=56.881，95%CI=（2.814，110.949）〕 were influencing factors of care cost. Conclusion　It is suggested that when determining the care level of the elderly and charging the care cost，domestic elderly care institutions should give more considerations for ability of self-care in daily life，muscle strength，age，disease and medication，and gender.


Cost Accounting of Community Integrated Health and Social Care Service Based on Standardized Workload　

YANG Xi，CHEN Liyun，LI Juanping，LI Xuefeng，HE Pinting，ZHENG Kai

2021, 24(1):  103-108.  DOI: 10.12114/j.issn.1007-9572.2020.00.225

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Background　The community health service center，as a support platform for the integrated health and social care service，cannot provide continuous output of integrated service without reasonable compensation for the costs it consumes.However，the current research still lacks the full cost accounting of integrated health and social care service in China. Objective　To calculate the total cost of community integrated health and social care service，in order to provide a basis for reasonable compensation for community integrated health and social care service. Methods　The cost accounting were performed for 259 items of integrated health and social care service in Dongming Community Health Service Center of Pudong New Area in Shanghai from June to August in 2019. Various indicators required for cost accounting，including manpower consumption and time consumption，technical difficulty，degree of risk，relative manpower value per unit time，manpower expenditure of junior general practitioners，manpower expenditure of business segment，manpower expenditure of non-business segment，non-manpower expenditure，non-manpower expenditure（chargeable） and government subsidy，were mainly obtained from the management staff，backbone staff of the business segment，finance section and the personnel section of Dongming Community Health Service Center. Results　According to cost accounting，the various costs of community integrated health and social care service were direct labor cost of 5-3 444 yuan with a median of 31.7 yuan，indirect labor cost of 1.4-970.7 yuan with a median of 8.9 yuan，the non-manpower cost of 0.4-309.8 yuan with a median of 2.8 yuan，and the total cost of 6.9-4 724.5 yuan with a median of 43.4 yuan. The comparison with the price tag showed that among 118 items，75 items costed more in terms of the direct labor cost，and 19 items costed more in terms of the indirect labor cost. There were three items costing more than the price tag in terms of non-manpower cost. In terms of total cost，88 items costed more than the price tag. Conclusion　The cost accounting of the integrated health and social care service is reasonable in this study. The calculation results reveal the difference in the community input when meeting the various needs of the elderly，and it shows that the existing compensation methods may cause problems of living beyond their means. The continuous development of integrated health and social care service requires the joint support of community health service centers，governments and other relevant departments and institutions.


The Development of Evaluation Tools for Shared Decision Making at Home and Abroad：a Systematic Review　

BAI Xuefei, CAO Yu, ZHAO Yali

2021, 24(1):  109-117.  DOI: 10.12114/j.issn.1007-9572.2020.00.283

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Background　Shared decision making（SDM） is a decision-making process based on the best clinical evidence and combined with patients' preferences and values. The development and application of SDM evaluation tools is of great significance to promote the practice of SDM clinically. The SDM evaluation tools have been developed maturely abroad，while related research at home is still in its infancy. Objective　To review and update systematically relevant SDM evaluation tools at home and abroad based on the existing systematic reviews，in order to provide a reference for the practice and development of SDM evaluation tools under different clinical conditions in China. Methods　In January 2019，a systematic search was conducted to retrieve the relevant literature of SDM evaluation tools in PubMed database from September of 2017 to December of 2018，and CNKI database，CQVIP database and Wanfang data database before January of 2019. The basic characteristics and psychometric characteristics of SDM evaluation tools related to reliability and validity were extracted. Results　Twelve articles conforming to the standard were retrieved including 15 evaluation tools. There were total 66 SDM evaluation tools combined with 50 evaluation tools which had been extracted from the previous systematic reviews and one tool which was found on the website of Observer OPTION Instrument. According to the application object，66 evaluation tools were divided into the tools of patient's perspective（46），doctor's perspective（4），observer's perspective（13） and multiple perspectives（3）. Among them, the contentdimension of SDM assessment tool from patient's perspective includes before, during and after patients' participation in decision-making, SDM assessment tool from doctor's perspective includes doctor's evaluation of patient's participation in decision-making and doctor's satisfaction in medical decision-making, SDM assessment tool from observer's perspective is a third-party evaluation of doctor's decision-making and patient's participation in decision-making, multi-perspective SDM assessment tool is to evaluate the degree of patients' participation in decision-making from the at least two perspectives of doctors, patients or observers. Conclusion　As the increasing attention of patient's participation in clinical decision-making，the researches of the introduction or construction of SDM evaluation tools in China are now on the rise. The construction and localization of SDM evaluation tools based on multiple perspectives needs further attention.


Systematic Review of Factors Influencing Oral Health-related Quality of Life in School-age Children　

CHEN Xia，LIU Fangli，LI Rui，WANG Ying

2021, 24(1):  118-124.  DOI: 10.12114/j.issn.1007-9572.2020.00.474

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Background　Various oral problems prevalence remains higher in school-age children，furthermore，they begin developing their self-perception about the appearance of oral and maxillofacial in this crucial period. Oral health problems affect oral health-related quality of life（OHRQoL），what is more，poor OHRQoL has a negative impact on children's intellectual，athletic and social skills development. Therefore，it is important to identify the influencing factors of OHRQoL in children to develop scientific preventive measures. Objective　To identify the influencing factors of OHRQoL of school-age children，to offer theoretical guidance for improving OHRQoL in this group. Methods　From December 18 2019 to January 15 2020，5 databases of PubMed，the Cochrane Library，Web of Science，CNKI，and Wanfang Data were searched comprehensively for studies about OHRQoL in school-age children published from January 2010 to January 2020 using "oral health" "school-age children" and "oral health-related quality of life" as search terms. References of the included studies were also screened. Quality assessment was conducted by two researchers independently according to JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies. Results　1 251 studies were retrieved，and 24 cross-sectional studies of them were finally included. JBI risk of bias assessment revealed that the overall risk of bias was low. Analysis results showed that，clinical oral symptoms such as dental caries，malocclusion，traumatic dental injuries and periodontal disease were associated with decreased OHRQoL，while the use of fillers and fissure sealants and well-treated dental caries were associated with increased OHRQoL. In terms of socioeconomic factors，crowded living environment was associated with decreased OHRQoL，while high parental education level，high household income，and studying in a private school were associated with increased OHRQoL. Female gender，dental fear and bad oral habits and other factors related to personal belief and badly behavior habit were associated with decreased OHRQoL. Conclusion　OHRQoL of school-age children is influenced by clinical oral symptoms，socioeconomic conditions and school types，belief and behavior habit. Oral health together with OHRQoL is not just a public health problem，but also a socioeconomic issue，which needs concerns and supports from all sectors of society.