Table of Content

05 May 2021, Volume 24 Issue 13

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Monographic Research

General Practice Department in China's General Hospitals: Functions and Development Strategies　

ZHOU Yafu，FANG Lizheng，YU Dehua，MA Li，WANG Liuyi，FENG Mei6

2021, 24(13):  1581-1584.  DOI: 10.12114/j.issn.1007-9572.2021.00.163

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The Opinions of the General Office of the State Council of the People's Republic of China on Reforming and Improving Incentive-based Mechanisms to Foster and Employ General Practitioners issued in 2018，requires general hospitals accredited as a standardized residency training base to establish a general practice department independently. In the same year，the National Health Commission of the People's Republic of China promulgated Guidance on the Standards for Standardized Residency Training Bases（General Hospitals） to Establish a General Practice Department（for Trial Implementation）. All these highlight the increasing importance of the strategic functions and development of general practice department in general hospitals，and how to define its functions and improve its development have become relevant researchers' core concerns. We analyzed the six functions of the general practice department mainly in tertiary general hospitals assuming the duties of training residents in a standardized way，including discipline construction，talent training， improving the functions and structure of hospital，diagnosis and treatment of undifferentiated diseases and coexistence of multiple diseases，tiered diagnosis and treatment，hospital culture and brand building，and proposed "consolidating clinical practice as the foundation of general practice development，strengthening general practice education，cooperating with the community，and enhancing general practice research" as the strategies for developing this department，hoping to provide insights into the acceleration construction and sustainable development of general practice department in general hospitals.


Patient Safety in Primary Care in China：Problems and Solutions　

CHEN Qian，FENG Lei

2021, 24(13):  1585-1591.  DOI: 10.12114/j.issn.1007-9572.2021.00.303

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Primary care is a gatekeeper of health，whose level of patient safety management is an important criterion measuring the levels of healthcare and health promotion in China. The problems of patient safety in primary care institutions are basic，objective，bilateral（involving both the hospital and patients），and similar. However，patient safety problems in primary care have not gained sufficient attentions generally，and there are still some specific problems such as low capacity of providing healthcare services，low rate of reporting adverse events，difficulties in ensuring medication safety and insufficient construction of patient safety culture. To better ensure patient safety in primary care to promote the national health level，we put forward the following recommendations：setting goals for patient safety at the primary level，improving the capability of primary care institutions in providing health services，trying to identify potential causative factors for patient safety problems as many as possible，strengthening medication supervision in primary care and building a sound patient safety culture.


Counting the Cost of Pandemics：Spanish Flu vs COVID-19　

Leon Piterman，Marika Vicziany1，LIN Chuling（translator），HUANG Wenjing（translator），YANG Hui（translator）

2021, 24(13):  1592-1596.  DOI: 10.12114/j.issn.1007-9572.2021.00.036

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There have been at least 20 plagues or pandemics clearly recorded in human history. The historical lessons are always worth learning. During the last century，human society has made great progress，while repeated the mistakes they had made. This article is a collaboration between medical expert and historian to compare the current COVID-19 pandemic with the "Spanish Flu" pandemic 100 years ago，with Australia as the base of comparison. The purpose is to enlighten and emphasize the needs to review our policies and actions. Researchers believe that the contexts of the two pandemics have been dramatically changed，the most obvious of which is the overall progress of the social economy and science and technology marked by the Information Age. However，when faced the attack of viral pathogens，the epidemic prevention strategies adopted as well as mistakes made are somewhat similar. The mental health effects of a pandemic are often neglected while health professionals deal with acute life-threatening risks. There are significant impacts which manifested as anxiety，depression and substance use disorders，especially PTSD，and its impact on family，health professionals，and on unemployed，youth and other socially disadvantaged groups. The researchers analyzed the characteristics of the mental health effects of the three stages of the COVID-19 pandemic，and suggested more needs to be learned about its psycho-social impact on communities across the globe and the effect of the imminent economic recession on the physical and mental well-being of this，and subsequent，generations.


Role Orientation and Pathway of Primary Care during Containing COVID-19：a Case Study of Shanghai W Community Health Center　

HUANG Jiaoling，FU Xuanqin，WANG Liqiang，MA Haiping，ZHANG Shuwei，ZHU Min，WANG Zhaoxin，SHI Jianwei，YU Wenya，TANG Lan

2021, 24(13):  1596-1601.  DOI: 10.12114/j.issn.1007-9572.2021.00.187

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Background　Primary care has played an significant role in containing COVID-19. But there is a lack of studies on the mechanism and pathway of its action. Objective　To explore the role of primary care during the containment of COVID-19，and to map the systematic pathway. Methods　This study was conducted between February and March 2020 in W Community Health Center（CHC），Shanghai. Data about major measures taken by center for containing COVID-19 were collected via interviews by telephone，email，WeChat voice，or key informant，and were analyzed to examine the role orientation of this CHC and to map its systematic pathway in containing the pandemic using system dynamics diagram. Results　The major actions taken by this CHC to contain COVID-19 included：establishing a COVID-19 containment management team，implementing COVID-19 screening and triage，undertaking emergency responses to COVID-19，strengthening ward management，and providing online health services. This CHC's role during COVID-19 containment was mainly summarized as: providing essential healthcare services for residents，undertaking the anti-COVID-19 tasks assigned by higher level institutions，delivering community-based anti-COVID-19 services，and parallelly cooperating with other relevant institutions. The system dynamics flow diagram showed that the CVID-19 containment system in primary care based on the practice of this CHC is composed of four subsystems: execution path，emergency path，cooperation path，and essential healthcare service path. Conclusion　Our study indicates that primary care plays an important role in COVID-19 containment，which may be summarized as "implementing duties in collaboration with other relevant institutions using parallel or vertical mode"，and recommendations for the implementation may be summarized as "providing essential healthcare services for residents，strengthening the organization and management of anti-COVID-19 services delivery，enhancing team building and improving the cooperation with other institutions".


Solving of Knowledge-based Clinical Questions by General Practitioners in Daily Practice　

LI Yuanjie，XU Na，SHA Yue，SU Qiaoli，ZHU Weiguo，ZENG Xuejun

2021, 24(13):  1602-1606.  DOI: 10.12114/j.issn.1007-9572.2021.00.047

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Background　A major difficulty during the promotion of the three-tiered healthcare delivery system in China is to improve the level of first-contact care provided by general practitioners（GPs）. Studying GPs' solving of problems encountered in daily clinical practice is valuable to provide targeted assistance to improve GPs' competency. Objective　To investigate the frequency of knowledge-based clinical questions encountered by Chinese GPs and their management methods.Methods　From February to April 2020，an online questionnaire survey was conducted with a convenience sample of 300 GPs attending the activities carried out by local GP associations. Details of frequency and types of knowledge-based clinical questions encountered by GPs and their management were investigated. Factors associated with the rate of seeking answers to questions，and the rate of giving an answer to the questions were analyzed by multivariate logistic regression. Results　A total of 297 cases（99.0%） who responded to the survey were included for analysis. Among them，women，those with an intermediate or senior professional title，and those with a working experience of at least 10 years accounted for 69.7%（207/297），75.2%（221/294），and 48.5%（144/297），respectively. 117（39.4%） reported that they often encountered clinical questions that they could not answer on-site，with a frequency of 1 question per 4.6 patients on average，commonly involving drug use，pathophysiology，differential diagnosis and diagnosis. 50.7%（150/296） of the respondents reported that they tried to seek answers to most（more than 60%） of the questions，mainly by consulting textbooks，searching websites using an engine（for example，Baidu），and consulting others，but only 12.9%（38/296） finally succeeded in retrieving satisfactory answers to over 80% of those questions. 91（30.6%） reported that there was information retrieval condition in the workplace. Multivariate Logistic regression analysis suggested that less visits per working unit，lower frequency of encountering questions，and being accustomed to searching for medical information（P<0.05）were associated with higher possibility of seeking answers（P<0.05）. Lower frequency of encountering questions，and actively seeking answers were associated with higher possibility of finding a correct answer（P<0.05）. Conclusion　It is common that GPs fail to give satisfactory answers to knowledge-based clinical questions（including diagnosis and treatment） related to patient care，which may be caused by GPs' lack of sufficient time and a habit of seeking answers highly efficiently.


Use of ICD-10 in Community Health Care and Associated Factors：a Real World Study　

HUANG Yanli，NI Zhigang，WU Xingwei

2021, 24(13):  1607-1615.  DOI: 10.12114/j.issn.1007-9572.2021.00.193

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Background　Population management is an important general practice service provided by primary care. The International Classification of Diseases（ICD） is a key diagnostic tool that is used to code and classify the morbidity data from patients' medical records，but is rarely used in primary care and research. Objective　To investigate the use of ICD-10 in primary care and its associated factors based on analyzing the practices of community health care，Chengdu's Wuhou District， for achieving the standardization of diagnosis. Methods　A questionnaire was designed in accordance with the constructs of the Consolidated Framework for Implementation Research，and used to investigate all the outpatient physicians and managers from 13 community health centers（CHCs） in Wuhou District，for understanding their perceptions of barriers and risks for achieving standardization of diagnosis by using the ICD-10. Through the back-end database of the hospital information system，trigger records and standardized rates of diagnoses made at different stages from June 2017 to October 2020，and consultation data during the application of ICD-10 between November 2019 and July 2020 were extracted. Results　83.1% of the respondents thought it was essential to promote the standardization of diagnosis in primary care. The effect of ICD-10 on the promotion of contracted family doctor service was expected to focus on population management（59.4%，95/160），risk stratification（55.6%，89/160） and diagnostic quality（53.8%，86/160）. Multiple linear regression analysis showed that population management，risk stratification，patient communication，work arrangement within the team，diagnosis quality，scientific research data acquisition based on management population，establishment of patient trust，and communication with external resources promoted the signing service of family doctors were the influencing factors of promoting the standardization of primary medical diagnosis（P<0.05）. During the use of ICD-10，the rate of questions raised by the consultation group was only 0.01%，mainly focusing on the operation of the information system（19.5%，38/195）. No self-defined diagnosis beyond the scope of ICD-10 system needed to be added；the proportion of diagnosis of most diseases increased，and the structure and order of diagnosis changed greatly. Conclusion　It is necessary to take measures to achieve standardization of diagnosis in primary care，and the ICD is an appropriate tool. Relevant research on the standardization of diagnosis and management of the application of the tool are suggested to be strengthened by the government，so as to lay a foundation for the development of data-driven primary care services.


Level of Clinical Preventive Services Delivered by General Practitioners in Outpatient Primary Care Consultations：a Direct Observational Study　

ZHOU Mengping1，KUANG Li，LUO Zhuojun，LIANG Cuiying，LI Lina，YANG Siman，ZHONG Chenwen

2021, 24(13):  1616-1620.  DOI: 10.12114/j.issn.1007-9572.2021.00.146

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Background　General practitioners（GPs） may be the most appropriate provider of clinical preventive services，and outpatient consultations may be the most suitable delivery way. However，the level of clinical preventive services provided by GPs during outpatient consultations is unknown in China. Objective　To examine the level of clinical preventive services provided by GPs during consultations in outpatient primary care settings in China. Methods　This study was implemented during July 2018 to January 2019. By using a three-stage sampling，18 GPs from 8 community health centers in Guangdong Province，and 649 patients managed by them were selected. The data of outpatient consultations were obtained with direct observation and audio recording，in which the information of preventive interventions was described structurally and quantitatively using the internationally used Davis Observation Code. Results　Of the 649 cases，186（28.7%） received at least one kind of clinical preventive service. Only 3 GPs provided clinical preventive services in more than 50% of their outpatient consultations.Patient nutrition counseling，disease screening and vaccination counseling and sleep counseling with recommended tips offered by GPs，accounted for 13.4%，9.4%，5.6% of all consultations，respectively. And the average consultation duration for the above-mentioned services was（17.61±18.37），（15.77±15.62） and （13.53±18.59） seconds，respectively，among the service recipients. Conclusion　The level of clinical preventive services provided by Chinese GPs during outpatient consultations is still very low，which may considerably fall behind that in foreign countries.

Development and Validation of the Chinese Version of Assessment Survey of Primary Care　

KUANG Li，LI Lina，LUO Zhuojun，ZHONG Chenwen，LIANG Cuiying，ZHOU Mengping

2021, 24(13):  1621-1628.  DOI: 10.12114/j.issn.1007-9572.2020.00.496

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Background　First-contact care，accessibility，continuity of care，comprehensiveness of care，coordination，and patient-centered care are core domains and key features of primary care. Measuring these core domains from patients' perspectives is is an important domain and component of primary care quality evaluation. However，domestically developed instruments for assessing core domains of primary care have not yet existed in China. Objective　This study aimed to develop a Chinese version of Assessment Survey of Primary Care（ASPC） with domestic and international characteristics. Methods　We developed a Chinese version of ASPC and tested its validity based on a four-stage approach. In the first stage，research on related theoris and studies，and expert consultation were conducted to construct the conceptual framework and connotative elements of the scale.In the second stage，the original item pool was formed through literature review and in-depth interviews with stakeholders. A pilot study was conducted with 373 patients to refine items and develop the test version of the scale. In the third stage，a multi-level sampling strategy was used to select 1 185 patients from diversified primary care institutions to pre-test the test version of the scale. In the fourth stage，the reliability and validity of the instrument were tested according to the consensus-based standards for the selection of health status measurement instruments（COSMIN） checklist，and then the final version of the scale was developed. Results　Results of the exploratory factor analysis showed that the Chinese version of ASPC consisted of nine subdimensions of six dimensions，including first-contact care，accessibility，continuity of the physician-patient relationship（covering subdimensions of longitudinal and stable relationships between physicians and patients，mutual trust between physicians and patients，and physicians' responsibility），comprehensiveness（covering subdimensions of health，lifestyle and psychological counseling and guidance，health examination，disease screening，interventions and suggestions），coordination（covering subdimensions of coordination conditions and services），and patient-centered care. The Cronbach's α coefficient of the scale was 0.915，while the coefficients of the nine subdimensions were all greater than 0.65（ranged from 0.659 to 0.863），indicating high reliability. In the confirmatory factor analysis，the chi-square/df value and the comparative fit index value of the scale were 2.828 and 0.875，respectively. For all subdimensions，all the composite reliability values were larger than 0.7，and the average variance extracted values were larger than 0.5 or close to 0.5，responding that the convergent validity was appropriate for all sub-dimensions. The scale score or the score in each dimension was positively associated with patients' satisfaction. Moreover，there were significant differences in the scale score between two groups of patients with or without a contracted family doctor. Conclusion　The Chinese version of ASPC has good psychometric properties with good scale and subscale internal consistency reliability and content validity，as well as structural and construct validity consistent with the theoretical conception. The theoretical framework of the scale is consistent with the six internationally recognized core domains of primary care，ensuring that the empirical research results of this instrument are comparable to similar foreign research results. The subdimensions of the instrument conform to the conditions of the Chinese healthcare system and can describe the performance of Chinese primary care comprehensively and accurately.

Item Development of the Chinese Version of Assessment Survey of Primary Care　

LI Lina，KUANG Li，ZHONG Chenwen

2021, 24(13):  1629-1636.  DOI: 10.12114/j.issn.1007-9572.2020.00.497

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Background　Developing a scale for evaluating the core functions of primary care is of great significance for the development of primary care practice，and evaluation，management and promotion of population health. Objective　To report the process of item development for the Chinese version of Assessment Survey of Primary Care（ASPC） adaptable to China's health care system based on the theoretical framework and connotative elements of the core functions of primary care. Methods　We carried out this study from January to October 2018. We first conducted a literature review to collect items related to the evaluation of core functions of primary care from eligible scale studies to form the original item pool. We then carried out individual interviews with informants（5 community health centers' directors，10 general practitioners and 20 patients） for understanding their opinions on the original item pool. An initial version of the scale was born after summarizing，streamlining，and localizing the original item pool according to their opinions. A pilot study of 373 patients was conducted and the exploratory factor analysis and Cronbach's α were used to further modify and improve the items and construct a test version of the Chinese version of ASPC. Results　A total of 25 studies were included with 18 relevant scales and 201 items selected. According to the interviews with informants，the original items were summarized and condensed into 34 items，which formed the initial version of the scale. And in accordance with the pilot study，these items were revised to 41 items to form the test version of the scale，and were expected to measure the six domains of primary care：first-contact care，accessibility，continuity of doctor-patient relationships，comprehensiveness，coordination，and patient-centered care. Conclusion　Using a complete and standardized methodological procedure，we developed the Chinese version of ASPC with 41 items based on China's social culture and health care system that could be used for appropriately assessing the core functions of primary care in China.


Policy Instrument Analysis of Chronic Disease Prevention and Control Policies in China　

SHEN Huihuang，ZHAO Jing，FU Yunxiang，ZHANG Fengyi

2021, 24(13):  1637-1643.  DOI: 10.12114/j.issn.1007-9572.2021.00.186

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Background　The containment of chronic diseases is a systematic project，whose implementation and promotion are due in large part to the government，which plays an important role in organizing various forces to make efforts cooperatively. The application of policy instruments in containing chronic diseases is conducive to extending the using scope of policies，and offering implications for reference. Objective　To perform a text analysis of the policy documents about chronic disease prevention and control in China，with detailed discussions of the highlights and insufficiencies，providing a reference for modifying such policies. Methods　In October 2019，using “慢性病”（chronic diseases in Chinese） as a keyword，policy documents related to chronic diseases issued from January 2009 to December 2018 were searched in the policy documents column of official websites of the State Council，the National Development and Reform Commission，and the National Health Commission of the People's Republic of China. The included documents were coded and study-related information was extracted and described statistically from the perspectives of policy instruments classification and systems theory. Results　Thirty qualified policy documents were finally incorporated. The X-domain perspective（policy instruments classification） analysis screened a total of 133 codes for texts of the policy documents，and the coded documents were classified into directive，incentive，competency，systematic reform，informative and exhortatory types，accounting for 26.3%（35/133），9.0%（12/133），27.8%（37/133），10.5%（14/133） and 26.3%（35/133） of the total，respectively. Among the 112 codes derived from Y-domain perspective（systems theory） analysis，the codes in the internal and external submodules accounted for 58.9%（66/112），and 41.1%（46/112），respectively. Conclusion　Most of these policy instruments are directive types. The implementation of some mandatory instruments causes negative effects，which may be due to inappropriate use. The internal structure of policy instruments is irrational，and some are ignored. Some are partially offset. The incentive and guiding effects of policy documents are not strong. The internal differences between the internal and external submodules are significant，with unbalanced distribution. In view of this，it is suggested to diversify the use of such instruments，modify the internal structure of policy instruments classification，strengthen the use of incentive instruments in combination with guidance instruments and attach great importance to the role of political，economic，social and technical systems（in the external submodule） in the use of such policy instruments.


Impact of Pay-for-performance Program for Family Physicians on Medical Expenses of Type 2 Diabetics　

ZOU Xin, HAN Yarong, GUAN Shenyi, TANG Zemin, QIU Min, ZHANG Shuqin, WU Xuming, GAO Yuexia

2021, 24(13):  1644-1649.  DOI: 10.12114/j.issn.1007-9572.2020.00.043

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Background　A diabetes pay-for-performance（P4P） program has been implemented in Haimen District since January 2018，to incentivize family physicians to improve the quality of family physician care for type 2 diabetics.Objective　To investigate the impact of P4P program for family physicians on type 2 diabetics' blood glucose control，medication compliance，health service utilization and medical expenses. Methods　From March to June 2019，we selected type 2 diabetics from the name list of confirmed type 2 diabetics receiving the management from village health clinics（one was extracted every 10 cases） in Nantongli Tongzhou and Haimen Districts，including 496 with care delivered by family physicians incentivized by the P4P program（incentive group），and 589 with care delivered by family physicians without the program as an incentive（control group），and surveyed them using a questionnaire for collecting their information involving demographics，healthcare utilization，medical expenses，fasting blood glucose and medication compliance. Negative binomial regression，Logistic regression and OLS regression were used to analyze the influencing factors of annual outpatient visits，annual inpatient service utilization and medical costs. Results　There were statistically significant differences between the two groups in terms of the distribution of education level and mean number of coexisted chronic diseases，and annual household income（P<0.05）. The incentive group had statistically lower mean fasting blood glucose level，less mean number of annual outpatient visits，lower annual inpatient service utilization rate and lower mean annual total medical costs than the control group（P<0.05）. The incentive group also showed statistically higher medication compliance（P<0.05）. After adjustment for demographic characteristics and fasting blood glucose，multivariate regression analysis found that compared with the control group，the incentive group demonstrated a reduction of 34.6% in mean annual outpatient visits（IRR=0.654，P<0.05），an increase of 54.96%（eb-1=0.549 6，P<0.05） in mean annual medication cost，and a decrease of 34.43%（eb-1=-0.344 3，P<0.05） in mean annual total medical costs. Further age-based subgroup analysis found that compared with the patients aged <60 and >70 in the control group，the number of outpatient visits of the same age patients in the incentive group decreased by 63.2%（IRR=0.368，P<0.05） and 54.2%（IRR=0.458，P<0.05） respectively；compared with the patients aged >70 in the control group，the utilization rate of inpatient services of the patients aged >70 in the incentive group decreased by 48.0%（OR=0.520，P<0.05）. Conclusion　The diabetes P4P program for family physicians may partially contribute to reducing the outpatient care utilization in type 2 diabetics，and reducing the annual inpatient service utilization rate and annual total medical costs in over 70-year-old type 2 diabetics.

Prevalence and Associated Factors of Use of Appointment-based Community Health Services in Residents from a Central District of Shanghai　

WU Shuyao，He Ming，CHEN Liping，LENG Huaqing，WU Pengliang，REN Jiahui

2021, 24(13):  1650-1655.  DOI: 10.12114/j.issn.1007-9572.2020.00.479

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Background　Visiting the doctor with an advanced appointment may reduce the treatment waiting time and improve patient satisfaction significantly. However，low acceptance of making an appointment in community care is a common phenomenon. Thus，it is urgent to design an appointment system suitable for the community health center. Objective　To investigate the prevalence and associated factors of residents' use of appointment-based community health services，providing evidence for the improvement of such services. Methods　From February to March 2019，a questionnaire survey was conducted in a convenience sample of 1 000 residents who received outpatient services from 10 subdistrict community health centers and stations in Shanghai's Huangpu District for collecting data about their demographics，health and healthcare-seeking status，awareness and use of contracted family doctor services and appointment-based community health services. Stepwise multivariate logistic regression was used to analyze the associated factors of use of appointment-based community health services. Results　993（99.3%） cases who returned responsive questionnaires were included for analysis. Of these respondents，73.1%（726/993） had at least one illness；86.3%（857/993） knew contracted family doctor services，mainly acquired related information from the community hospital〔88.4%（758/857）〕，and 84.9% （728/857） of them had a contracted family doctor，and 95.9%（698/728） knew their contracted doctor. Nearly half of the respondents〔46.0%（457/993）〕 knew the community hospital delivering appointment-based health services，and 48.4%（221/457）of them had used appointment-based general medical services，and 54.3%（248/457）had used appointment-based non-general medical services. Multivariate logistic regression analysis found that knowing the contacted family doctor was associated with increased rate of using appointment-based general medical services（P<0.05），while having chronic diseases except hypertension，diabetes，cardiovascular diseases，osteoarthropathy，and respiratory diseases，evaluating the doctor's attitude as fair or good or very good（compared with very bad），and knowing contacted family doctor services via watching TV were associated with decreased rate of using such services（P<0.05）. Knowing contracted family doctor services and the contracted family doctor were associated with increased rate of using appointment-based non-general medical services（P<0.05），while evaluating the doctor's attitude as fair or good or very good（compared with very bad），and knowing contracted family doctor services through the community hospital were associated with decreased rate of using such services（P<0.05）. Conclusion　To improve the use of appointment-based community health services in residents，we put forward the following suggestions：promoting the use of contracted family doctor services by strengthening the publicity of these services among residents，especially those with chronic diseases needing long-term follow-up or management；improving the experience of seeking appointment-based non-general medical services by optimizing the outpatient procedure，and controlling the treatment waiting time via offering conveniences for making an appointment at a chosen time，and making or cancelling a remote appointment.


Burnout Prevalence and Associated Factors among Family Doctors in Xicheng District of Beijing　

LIU Meixing, DING Jing, JI Yan, CHEN Xue

2021, 24(13):  1656-1664.  DOI: 10.12114/j.issn.1007-9572.2020.00.537

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Background　Studies show that family doctors are a population at high risk of job burnout. Job burnout may closely related to the quality of contracted services delivered by family doctors as they are the direct provider of medical services. Objective　To investigate the prevalence of job burnout and its associated factors based on analyzing its associations with anxiety and depression in family doctors from community health organizations of Beijingo inicheng District，providing a reference for the development of comprehensive management and countermeasures for job burnout. Methods　From May to July 2019，a questionnaire survey was conducted among family doctors from 15 community health centers and affiliated health stations in Xicheng District，Beijing using the General Demographic Questionnaire，Maslach Burnout Inventory（MBI），Zung Self-Rating Anxiety Scale（SAS） and Zung Self-Rating Depression Scale（SDS）. Spearman correlation analysis was used to analyze the correlation of the dimension scores of SAS and SDS with those of MBI. Multivariate Logistic regression analysis was used to analyze the influencing factors of job burnout. Results　A total of 282 cases attended the survey，and 275 of them（97.5%） responded effectively. The respondents were mostly women （85.5%，235/275），married（86.9%，239/275），with attainment of university education（72.4%，199/275） and intermediate professional title（63.6%，175/275）. The prevalence of job burnout was 56.0%（154/275）. Spearman correlation analysis found that the domain scores of SAS and SDS were significantly correlated with those of MBI. Multivariate analysis revealed that the scores of SAS and SDS were associated with the prevalence of job burnout（P<0.05）. The scores of SAS and SDS were associated with emotional exhaustion（P<0.05）. Factors affecting depersonalization included temperament type，monthly income，number of contracted patients，satisfaction with doctor-patient relationship，and the scores of SAS and SDS（P<0.05）. The SDS score was associated with low personal accomplishment（P<0.05）. Conclusion　The job burnout in family doctors in Xicheng District of Beijing is not optimistic. To reduce job burnout prevalence，attention should be paid to the anxiety and depression prevalence in this group，and interventions should be given to those with these symptoms timely. Moreover，efforts should be made to increase the steadiness of sanguine family doctors. Furthermore，the specified number of contracted patients for a family doctor may be reduced appropriately，and the monthly income for family doctors as well as family doctor-patient relationship should be improved.


Demands and Influencing Factors of Transitional Health Management among Elderly Patients with Chronic Diseases　

XU Ting，DONG Enhong，GUO Lijun，BAO Yong

2021, 24(13):  1665-1670.  DOI: 10.12114/j.issn.1007-9572.2021.00.014

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Background　Chronic disease among elderly patients usually has characteristic of long course，wide prevalence，high cost and high rates of disability and fatality. The application of transitional health management services to the post-discharge community follow-up of these patients is conducive to rational allocation of medical resources and substantial reduction of medical costs. Objective　To investigate the demands and influencing factors of transitional health management among elderly patients with chronic disease in Shanghai. Methods　From July to September in 2019，600 discharged elderly patients with chronic diseases from two grade A tertiary hospitals in Shanghai were investigated with a self-made health management needs questionnaire consisting of demographic information，needs of transitional health management（including treatment needs and health promotion needs） and preferred services of transitional health management. Pearson correlation analysis was used to explore the correlation of the above-mentioned factors with the needs of transitional health management. Multiple linear regression analysis was used to explore the associated factors of the overall needs of transitional health management and of treatment needs and health promotion needs. Results　A total 587 cases of 600 returned responsive questionnaires，achieving a survey response rate of 97.8%. The average score of the scale was （3.3±0.5）. And the average scores of treatment and health promotion needs dimensions were （3.8±0.3） and （2.9±0.8），respectively. The top three treatment needs were guidance for medication safety，disease monitoring and follow-up guidance，with corresponding average scores of （4.6±0.1），（4.5±0.2），（3.8±0.5）；the top three health promotion needs were guidance for reasonable exercise guidance，dietary nutrition guidance and psychological counseling（3.4±0.2），（3.4±0.2），（2.8±0.4），respectively. The results of multiple linear regression analysis showed that age and education level were the influencing factors of treatment needs，while relevant socio-economic factors had no influence on health promotion needs. Age，education level and disease were the influencing factors of the overall needs of transitional health management. Conclusion　The demands of transitional health management of elderly patients with chronic diseases is widespread but the cognition of transitional health management is not comprehensive enough. Patients' age and education level positively affected total demand demand. It is necessary to stimulate and guide the patients' needs through multiple channels，rationally allocate medical resources，and bring the transitional health management of chronic diseases to the community. The related policies，systems and evaluation standards of transitional health management should be further studied and introduced.


Treatment Burden and Influencing Factors of Elderly Patients with Multimorbidity in the Community　

DOU Liyuan，HUANG Juan，YE Sen，GUO Lixiang

2021, 24(13):  1671-1675.  DOI: 10.12114/j.issn.1007-9572.2021.00.094

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Background　The treatment burden of growing multimorbidity prevalence in increasing elderly people against the backdrop of rapid aging in China，has produced many negative effects on these people. Objective　To understand the treatment burden and influencing factors among elderly people with multimorbidity in the community. Methods　From September to December 2019，by use of convenience sampling，370 elderly individuals with multimorbidity were selected from communities receiving the healthcare services delivered by two community health centers of Zhengzhou，and were invited to attend a survey using the General Information Questionnaire and the Chinese version of Multimorbidity Treatment Burden Questionnaire（MTBQ）．Ordinal Logistic regression was used to identify the factors associated with treatment burden caused by multimorbidity. Results　Altogether，350（94.6%） individuals who returned responsive questionnaires were included for analysis，among whom，the prevalence of no，low，moderate，and high treatment burden was 1.1%（4/350），13.4%（47/350），49.4%（173/350），and 36.0%（126/350），respectively. Ordered Logistic regression analysis revealed that monthly household income per capita，type of medical insurance，number of chronic diseases，and Charlson Comorbidity Index（CCI）were associated with treatment burden. Conclusion　The treatment burden of most elderly patients with multimorbidity in the community was moderate-to-high. Attention should be paid to those with low household income per capita，multiple chronic diseases，high CCI，and/or new rural cooperative medical insurance. Moreover，to reduce the treatment burden of these patients，it is suggested to increase the proportion and scope of medical insurance reimbursement，and strengthen health education related to chronic diseases and targeted interventions delivered by medical workers.


Utilization of Home-based Medical Services in Disabled Elderly People in Beijing：a Mixed-method Study　

ZHAO Chunyan，YU Xiaoying，YANG Shanshan，SHAO Shuang，DU Juan

2021, 24(13):  1676-1683.  DOI: 10.12114/j.issn.1007-9572.2021.00.042

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Background　The number of disabled and semi-disabled elderly people is increasing rapidly along with global aging. To satisfy their healthcare needs，the delivery of home-based medical services provided by general practitioner teams has been a new global medical service trend. However，there is a lack of standardized management system and systematic operational mechanism for such services in China. Objective　To investigate the utilization of home-based medical services in the disabled elderly in Beijing，to identify the existing problems in the delivery of such services，and to provide suggestions for building a reasonable home-based medical service system. Methods　An approach of mixed methods of qualitative and quantitative was adopted. During May to June，2018，personal in-depth interviews were carried out in a purposive sample of the major caregivers（n=8） of 8 disabled elderly people for collecting their evaluation of disabled elderly people's needs and utilization of home-based medical services，their understanding of，satisfaction with and suggestions on the services. During July to September，2018，a questionnaire survey was conducted in a multi-stage sample of caregivers（n=370） of 370 disabled elderly people receiving management services from 6 community health centers of Beijing to collect their evaluation of disabled elderly people's health status，accessible care resources，and utilization of home-based medical services，and their satisfaction with such services. Results　Interviews results revealed that home-based medical services could partly meet the healthcare needs of disabled elderly people. The effective utilization of home-based medical service was affected deeply by worrying about the cost of home-based medical services being high priced and unreimbursed，low awareness of home-based medical services and limited service capability of community hospitals to provide. It was indicated by the questionnaire survey that：The 370 disabled people had an average age of（80.9±8.4）years，202（54.6%） of them suffered from severe or moderate disability，256（69.2%） suffered from 3 or more chronic diseases，and 168（45.4%） needed to employ caregivers. Among the 370 respondents，314（84.9%） were willing to use home-based medical services，but only 76（20.5%） reported that their carereceivers had used home-based medical services delivered by the community health centers. The top 5 utilized services were measurement of blood pressure，blood glucose，and electrocardiogram〔49（13.2%）〕，convalescent family bed〔26（7.0%）〕，therapeutic family bed〔22（5.9%）〕，specimen collection〔22（5.9%）〕，and regular home visits〔21（5.7%）〕. Other 56 respondents（15.1%） would not accept home-based medical services. The top 5 reasons were worrying about higher service charge〔39（69.6%）〕，worrying about the service charge being unreimbursed〔23（41.1%）〕，littlie understanding of the services〔21（37.5%）〕，holding the view that community health centers could provide few home-based medical services or had limited capabilities to provide such services〔14（25.0%）〕，and worrying about the leakage of their privacies〔14（25.0%）〕. Conclusion　It was found that in Beijing，the care burden of the disabled elderly family is very heavy. Home-based medical services provided by the community hospital are needed rather urgently but used very infrequently by disabled elderly，presenting a status of “much-needed but under-utilized”. To promote effective utilization of home-based medical services，it is suggested to promote the reform of medical and social insurance systems to reimburse for such services，to improve the capacity and service level of community health centers，and to strengthen the publicity of such services and guide on how to use them.


Enlightenment of Foreign Doctor-patient Communication Models to Relevant Trainings for General Practitioners in China　

DENG Lili, LIAO Xiaoyang, WU Jia, XIONG Mei

2021, 24(13):  1684-1689.  DOI: 10.12114/j.issn.1007-9572.2021.00.185

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Skills for communicating with patients are one kind of core ability that general practitioners（GPs） must possess，ensuring the improvement of services quality provided by GPs. The systematic，simple and practical doctor-patient communication models developed by foreign countries based on a large amount of research experience have been widely used in medical education，and proved to be crucial for improving doctors' skills for communicating with patients.In contrast，in China，GPs show relatively poor abilities in communicating with patients，which may be caused by insufficient awareness of training this ability in medical students influenced by the traditional biomedical model，and unsatisfied quality of such trainings due to lack of relevant teaching materials for medical students with different majors at different learning stages，and lack of relevant theoretical studies. As systematic，simple，and practical curriculum is the key to ensure the quality of training GPs' skills for communicating with patients，we detailedly analyzed the recommended major doctor-patient communication models in foreign countries（patient-centered communication，Calgary-Cambridge Guide，SEGUE Framework，Four Habits Model，Kalamazoo Essential Elements communication Checklist-Adapted），aiming at providing a reference for developing course contents of doctor-patient communication skills for GPs in China.


Training Needs and Influencing Factors of General Practitioners' Communication Skills under the Synergy of Health Care System and Medical Educational System　

DENG Lili，LIAO Xiaoyang，ZOU Chuan，WU Jia，CHENG Chunyan，ZHAO Qian，WANG Lifei，LUO Xiaolu

2021, 24(13):  1690-1696.  DOI: 10.12114/j.issn.1007-9572.2021.00.018

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Background　The synergy of health care system and medical educational system aims to foster healthcare talents with a priority on general practitioners（GPs），which is a key to improving health care. Communication skills are one of the core competencies that GPs must master. Although China has opened doctor-patient communication training courses for GPs，the training effect is poor. Studies have demonstrated that the demand-oriented training model may quickly meet the clinical needs and significantly improve the quality of teaching. Objective　To explore the training needs and influencing factors of GPs under the synergy of health care system and medical educational system. Methods　By use of cluster sampling，we selected the community base of West China Hospital-community consortium for standardized training for GPs in October 2018，and invited 104 GPs from all the 12 community health centers in the consortium to participate in a structured questionnaire survey for collecting their demographic characteristics，perceived importance of doctor-patient communication，previous trainings of doctor-patient communication，needs of related trainings and intention to attend such trainings，and perceived influencing factors for doctor-patient communication. Binary logistic regression analysis was used to analyze the influencing factors associated with training needs of communication skills. Results　The survey achieved a 100.0% response rate. Among the respondents，95.2%（99/104）believed that doctor-patient communication was important，and 66.3%（69/104）had attended trainings in doctor-patient communication. The top topic that 82.6%（57/69）of participants had been trained was "building a healthy relationship"，the bottom was "empathy training" with 29.0%（20/69）. All the respondents had the training needs for communication. The top topic that 71.8%（61/85） of participants would like to be trained was "shared decisions making"，and the bottom was "history taking" with 16.4%（17/104）. Binary logistic regression analysis found that training needs was influenced by gender，age，education level，previous training experience，self-rated communication skills and doctor-patient relationship satisfaction（P<0.05）. The commonest barrier to doctor-patient communication was "lack of time and energy due to busy work"，followed by "lack of skills to effectively communicate with patients". Conclusion　Under the synergy of health care system and medical educational system，the GPs attached great importance to doctor-patient communication，and demonstrated strong training needs and willingness. There are differences between previous training contents and training needs. Continuous and dynamic assessment of training needs is the key to ensuring the quality of such trainings for GPs.


Design of Diabetic Diet Management System Using Big Data　

ZHANG Qi，ZHANG Wei，BAI Zhengyu

2021, 24(13):  1697-1702.  DOI: 10.12114/j.issn.1007-9572.2021.00.090

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Among the five treatments for diabetes（diet，exercise，medication，glycemic self-monitoring and health education），diet treatment is the most essential，and it matters much in each phase of diabetic treatment. To simply the cumbersome process of developing dietary management programs and improve the effect of diet treatment in diabetics，we designed an intelligent decision-making process of dietary management based on the clinical dietary management procedure，and designed an intelligent decision-making framework based on intelligent decision-making cases derived from data mining using the similarity calculation model，then by use of this kind of case-based reasoning approach and computer-based data visualization technologies，we finally developed a system suggesting diet regimens displayed on the user interface screen，achieving intelligent dietary management of diabetics using big data technologies. The use of this system may bring about workload reduction and efficiency improvement of diet treatment，and may provide help for rapid development of an effective，appropriate and personalized diabetic diet plan.


Medical Nutrition Strategies in Glycemic Management in Patients with Type 2 Diabetes　

LI Haixia，LI Xiangpei，ZHAO Xiaodi，WANG Ling

2021, 24(13):  1702-1706.  DOI: 10.12114/j.issn.1007-9572.2021.00.033

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Medical nutrition therapy（MNT） has become another important way to improve glycemic control and treat diabetes besides drugs. We reviewed and gave a summary of six nutritional strategies for glycemic control in patients with type 2 diabetes：choosing appropriate carbohydrate and eating the appropriate amount，eating specific types of dietary proteins，increasing the intake of polyunsaturated fatty acid，eating the Mediterranean diet，eating on time and strengthening postprandial exercise. These strategies may increase the options for healthcare professionals to choose for type 2 diabetics to achieve the optimal target glycemic level. Besides，our detailed analysis of the controversial aspects in the mechanisms of action of these strategies may provide a direction for further studies on nutritional therapies for type 2 diabetics.

Diagnostic Strategies for Cough in General Practice　

CHEN Kai，LIANG Cuifei

2021, 24(13):  1707-1710.  DOI: 10.12114/j.issn.1007-9572.2021.00.025

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As a common chief complaint in general practice，the diagnosis of cough is a constant challenge to general practitioners（GPs） due to its various causative factors as well as its potential association with some critical diseases. From the perspective of GPs，we analyzed and summarized the causes of cough，and developed the diagnostic idea for cough after reviewing relevant literature and guidelines，that is，appropriately evaluating patient conditions based on accurately analyzing medical history，results of physical and diagnostic examinations as well as past treatment（if any），with a view to helping GPs to make a clinical diagnosis of cough timely and accurately to reduce the possibilities of developing serious negative consequences，ultimately leading to better treatment effect and more harmonious patient-physician relationships.


General Practitioner-Psychotherapist Team-Based Care Study: a Case Report of Psychological Disorder with Physical Discomforts as the Chief Complaint　

TANG Fang，CAI Feiyue，LIU Ruihong，CHEN Zhiyuan，HUANG Zhiwei

2021, 24(13):  1711-1716.  DOI: 10.12114/j.issn.1007-9572.2021.00.022

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Psychological disorder patients with somatic symptoms often present to non-mental health departments in a general hospital such as gastroenterology，gynecology and neurology for help with different physical complaints.However，unsatisfied level of mental health care of non-mental health professionals may result in low accuracy in recognizing psychological problems early，which may lead to a delayed diagnosis of the real problems and cause an increase in medical burden.We reported a case of psychological disorder presenting with dizziness，chest discomfort and dyspnea treated with general practitioner-psychotherapist team-based care，and summarized that this kind of collaborative team care may help to recognize psychological problems accurately and early，and improve the actual utilization rate of psychotherapy services as well as the treatment outcome.This kind of care is a new exploration of the delivery of psychotherapy services by a general hospital，which may provide insights into future development of psychotherapy services delivery patterns feasible for such hospitals.