Chinese General Practice

Recent Developments in Performance Assessment Policies and Practices in Primary Healthcare in China　

QIN Jiangmei，WANG Fang，LIN Chunmei，ZHANG Yanchun，ZHANG Lifang

2021, 24(16): 1989-1994. DOI: 10.12114/j.issn.1007-9572.2021.00.194

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Using common performance assessment theories and methods，we systematically reviewed the performance assessment policies in primary healthcare published between 2009 and 2020，and summarized typical local practices，experiences as well as problems during the period in China. In this period，the policies on performance assessment in primary healthcare are consistent in essence but have been improved successively，such as the Guiding Opinions on the Implementation of Performance Assessment in Healthcare（No. 98〔2010〕of Department of Personnel of the Ministry of Health），Guiding Opinions on Strengthening the Performance Assessment in Public Healthcare Institutions（No. 94〔2015〕of Department of Personnel of the Ministry of Health），and Guiding Opinions on Strengthening the Performance Assessment in Primary Healthcare（Trial Version）（No. 9〔2020〕 of Department of Primary Health of the National Health Commission），the latter one strengthens the applicability of the assessment，and focuses more on economic operation and informatization. Considering the local innovative practices，typical experiences and problems，we put forward four recommendations on the basis of review of available evidence and our own experience of participating in the drafting of these policies：（1）Modifying the performance assessment system for primary healthcare at the regional level to be a version with clear normal reference value for each indicator and detailed scoring methods.（2）The normal reference values for indicators and scoring methods should be simulated with historical data，and modified continuously.（3）Determining the indicators assessed at the regional level，enhancing the tiered assessment，and highlighting the application of performance assessment results.（4）Using technologies to directly grasp quantitative data from the information platform to reduce the burden of assessing performance of primary healthcare institutions. We expect these recommendations will assist local primary healthcare institutions in implementing and improving performance assessment.

Incentive Mechanism for the Delivery of Family Doctor Services：a Case Study of Xiamen's Practice for Promoting the Specialty Physician-general Practitioner-health Manager Management　

LYU Yun，JING Rize，WANG Demeng，FANG Hai

2021, 24(16): 1995-2002. DOI: 10.12114/j.issn.1007-9572.2021.00.191

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To develop an integrated healthcare system，Fujian's Xiamen has made many efforts，for example，it has produced a featured healthcare delivery model，that is，providing hypertension and diabetes patients with tertiary care specialty physician-primary care general practitioner-health manager management. While enhancing the efficiency and quality of the management with low cost，Xiamen improves the incentive mechanism for family doctors. By establishing and implementing systems for financing for carrying out family doctor services，distributing the service fee，and appraising and assessing performance as well as non-financial incentive mechanisms，Xiamen has improved the income and working enthusiasm of primary healthcare workers，and the quality and contracting rate of family doctor services as well as patient-doctor communications，manifesting the initial effectiveness of using innovative systems to facilitate the implementation of key actions of "patients are willing to visit primary care，primary care workers are capable of providing care for patients，and tertiary hospitals are willing to transfer patients to primary hospitals" to achieve tiered diagnosis and treatment.

Exploration and Practice of Internet Community Hospital Construction　

PENG Derong，CUI Ming，SUN Xiaoting，KONG Bin，CHEN Chen，FU Songhua，XU Weigang，WANG Qicheng

2021, 24(16): 2003-2007. DOI: 10.12114/j.issn.1007-9572.2021.00.176

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Internet plus is a kind of product derived from the deep integration of the internet innovation technologies and various traditional socioeconomic industries. There is a part-whole relationship between Internet-based healthcare and "internet plus health". The internet hospital，a newborn thing in "big health" and a new healthcare provider，is a product of intensive integration of information technologies，internet platforms and traditional healthcare industries，is a health facility in nature，whose essential functions include online follow-ups and prescription refill for chronic disease patients. From the viewpoint of functions of health facilities，a primary healthcare institution is suitable for constructing its own internet hospital. We introduced the experience of Pengpu New Village Community Health Center，as the first community hospital in China，in constructing its own internet hospital，including top-level design，technical architecture，business model，offline drug distribution and electronic bills，and summarized the achievements as well as problems，aiming at promoting the development of Internet-based healthcare and internet hospital.

China's Floating Population's Healthcare Utilization Choices and Influencing Factors　

ZHANG Jian，CAI Jinlong，HUANG Yuanying，HE Zhongchen，TANG Guizhong

2021, 24(16): 2008-2014. DOI: 10.12114/j.issn.1007-9572.2021.00.125

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Background　China's floating population reached 244.5 million in 2017，and it has gradually entered a period of adjustment from a period of rapid growth. However，the structural contradiction between supply and demand of medical and health services of the floating population has long existed，and their health rights and medical needs cannot be fully met. Objective　To analyze healthcare utilization choices and influencing factors of China's floating population，to provide a decision-making basis for improving the accessibility of essential medical services for this population. Methods　Data were collected from the 2017 National Floating Population Dynamics Monitoring Survey in July 2020，and a total of 169 989 cases of the floating population who floated over than 1 month and aged over than 16 were selected for inclusion in the study. Andersen's Behavioral Model of Healthcare Utilization was used to develop a framework for analyzing floating population's healthcare utilization. The Logistic model was constructed using the stepwise regression method to explore the factors affecting healthcare utilization choices in this population. Results　Among the 169 989 cases，10 996 individuals（6.47%） who had an illness within two weeks prior to the survey were enrolled finally. The prevalence of visiting a doctor within two weeks was 59.38%（6 529/10 996）. In particular，healthcare seeking prevalence in primary care was 65.46%（4 274/6 529）. Fourteen indicators belonging to four aspects were found to be associated with healthcare utilization choices（P<0.05）：gender，age，education level（predisposing factors），range of mobility，mobility time，willingness to settle down（mobility characteristics），region，urban/rural area，annual household income per capita，medical insurance，time required to go to the nearest healthcare institution from home（enabling factors） and self-rated health，chronic disease，and establishment of health records（need factors）. Conclusion　In a word，the floating population had low initiative in seeking healthcare，but had a high healthcare seeking prevalence in primary care. Therefore，it is necessary to optimize the policies for inter-regional on-the-spot settlement of medical bills as soon as possible，develop a scientific pattern of easy access to healthcare，and vigorously carry out health education and health promotion projects for the floating population to guide them to rationally choose healthcare institutions for treatment.

Preference of Health Management Services in Urumqi Residents：a Discrete Choice Experiment Study　

SU Tianyuan，LI Yukai，ZHANG Qiqi，ZHUANG Wei

2021, 24(16): 2015-2021. DOI: 10.12114/j.issn.1007-9572.2021.00.101

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Background　As public health concept changes，the people's health management needs and consumption capacity have increased. Under the context of supply-side structural reform in healthcare field，how to rationally guide residents' healthcare needs and consumption as well as healthcare-seeking behaviors via supply-demand measures，has become an issue to be solved urgently. Objective　To explore the trade-off process and result of choosing a preferred health management service in residents in accordance with their real health needs，providing a decision-making basis for policy makers and health management service providers. Methods　Simple random sampling and convenience sampling were used to select participants for a questionnaire survey using a discrete choice experiment design from seven districts of Urumqi from July to October 2019.The questionnaire includes：basic demographic information，and the choice set of discrete choice experiments〔including the service provider，service scope，provision of online healthcare services，traditional Chinese medicine（TCM） services，and contracted family doctor services，as well as out-of-pocket expenses，with each attribute including several levels〕．Stata 15.0 was used to build a discrete choice model. Mixed Logit regression model was used to analyze residents' preference of health management services. Results　A total of 945 individuals attended the survey，and 802 of them（84.9%） who responded effectively were enrolled finally. Discrete choice analysis demonstrated that the most frequently used combined health management scheme was：health management department of public hospitals，health examination，health education with health consultation or health examination with health intervention，abundant online healthcare services，TCM services，and contracted family doctor services（P<0.05）. Conclusion　Urumqi residents are most concerned about service provider when choosing health management services，and their potential demand for service still needs to be guided. Meanwhile，they have preferences for online healthcare services，TCM services and family doctor services. Hence，it is essential to strengthen the publicity of related policy health information and improve policy guidance on residents' healthcare-seeking behaviors，give full play to the role of various health management agencies in health management，improve the closed-loop online and offline services，actively introduce TCM services for chronic disease prevention and control，and continue to promote the orderly development of contracted family doctor services.

Measurement and Application of the Standardized Workload of Contracted Family Doctor Services　

LI Jie，ZHU Xian，ZENG Zhirong

2021, 24(16): 2022-2027. DOI: 10.12114/j.issn.1007-9572.2021.00.199

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Background　The promotion of family doctor services urgently needs a practical and feasible system assessing the service performance of family doctors scientifically and fairly，and the measurement of workload is the core of the performance management. Objective　To scientifically standardize the workload of services delivered by Guangzhou family doctors using appropriate ways after determining the service scope according to the new regular pattern and features of provision of such services in primary care，to achieve scientific and dynamic performance management of the family doctor team. Methods　In 2018，a questionnaire survey was used to investigate and determine the contracted services delivered by family doctors from 60 community health centers in Guangzhou. And semi-structured interview，objective observation and subjective evaluation were adopted to measure and standardize the workload of such services. The application of standardized workload in estimating performance and compensation was also discussed. Results　The contracted services provided by Guangzhou family doctors include six categories with 152 items. With onsite health record establishment（including health card establishment） being set as one standardized point value，and a consideration of multiple factors，such as time consumption，physical consumption，technical difficulty and stress intensity in service delivery，the standardized point values for the 152 services were determined. The least square estimation and ridge regression were used to develop a RBRVS formula to calculate the workload，with goodness of fit tested to be greater than 89%. Performance allocation was simulated based on the standardized workload. Conclusion　The performance income distribution and financial compensation scheme based on the standardized workload point scale is simpler and more practicable，which may be used by the hospital to achieve compensation more accurately and effectively. And the performance management using it may fully reflect the labor value of doctors，encouraging them to get more by doing more and doing better.

Outpatient Expenses among Diabetic Patients Treated in Community Health Centers：an Investigation based on BCDS　

XU Nan，WANG Mei，LIU Xiaodong，GU Xuefei，LI Tingting，YUAN Shenyuan，YUAN Mingxia

2021, 24(16): 2028-2033. DOI: 10.12114/j.issn.1007-9572.2021.00.202

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Background　Beijing Tongren Hospital has carried out a 10-year three-stage standardized community-based diabetes management program（hereinafter referred to as BCDS），aiming to provide community-dwelling diabetic patients with standardized and continuous follow-up management services. After long-term management，whether the actual effect has economic and social benefits has not been evaluated by empirical health economics. Objective　To understand the annual outpatient diabetes care expenses in community health centers（CHCs） by analyzing the real-world data collected via a field investigation in CHCs implementing the BCDS. Methods　We conducted a field investigation for 10 consecutive months since November 2016 using health economics method in 9 of the CHCs who have implemented the first and second stages of the Tongren diabetes program. One third of the diabetic patients receiving the program management were selected randomly，and data about their outpatient expenses in 2012，2014 and 2016，including drug and examination expenses，were collected. Kruskal-Wallis test and descriptive research were used to analyze the annual expenses. Descriptive research was conducted to analyze the cost of structure and drug use. Results　After adjusting for inflation，the annual outpatient expenses per capita were 10 312.91，10 885.56，and 11 733.50 yuan，respectively. The analysis of cost of structure found that，the annual cost of diabetes prevention and treatment related drugs ranged from 4 690.37 to 5 251.85 yuan，accounting for around 44.76%-45.48% of the annual expenses per capita. Traditional Chinese medicine expenses and other expenses accounted for nearly half of the total，about 47.31%-48.34%. Conclusion　With the interventions of Tongren diabetes program，the drug use and annual outpatient expenses of diabetic patients are generally stable，indirectly indicating that the overall conditions of the intervened patients are relatively stable. The structure of the cost is partial irrationally，such as the proportion and growth rate of traditional Chinese medicine expenses and other expenses are not ideal，and use of too many types of Chinese patent medicines，and the ranking of the top 10 drugs（because their prophylactic and anti-diabetic effects are still unclear），which needs further improved. In view of this，we put forward the following recommendations: developing a structured and refined payment system for major chronic diseases；in terms of outpatient chronic disease payment，appropriately determining and controlling the proportion of expenses of auxiliary therapies；reasonably modifying the proportions of expenses of Chinese patent medicines as auxiliary therapies and other expenditures based on deeply analyzing their meanings.

Community-based Prevalence of the Coexistence of Multiple Chronic Diseases among Young and Middle-aged People in Shanghai　

ZHANG Yajun，LIU Hua，WANG Zhaoxin，SHI Jianwei

2021, 24(16): 2034-2038. DOI: 10.12114/j.issn.1007-9572.2021.00.046

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Background　Chronic non-communicable diseases（NCDs） have become the leading "killer" of Chinese residents' health. At present，chronic disease management services have basically covered the aging population. The study on the epidemic trend of chronic diseases and coexistence of multiple NCDs among young and middle-aged residents will provide a basis for further development of the focuses of chronic disease management services. Objective　To investigate the community-based prevalence of NCD and coexistence of multiple NCDs among young and middle-aged people in Shanghai，to provide theoretical basis and data support for community-based management of NCDs in this population. Methods　The data of patients aged 18 to 50 were collected through the hospital information system of a community hospital in Shanghai from January 2017 to December 2019. The prevalence of NCDs and combinations of multiple NCDs were analyzed. Results　Among the 34 720 participants，8 922（25.70%） had one chronic disease，3 134（9.03%） had two chronic diseases，and 3 484（10.03%） had three or more chronic diseases. The prevalence of multiple NCDs was 19.06%（6 618/34 720）. The prevalence of multiple NCDs differed significantly by sex，age and having contracted healthcare services or not（P<0.05）. Men，older age or having contracted services was associated with higher prevalence of multiple NCDs（P<0.05）. The top five diseases were hypertension，joint and spinal diseases，gastroduodenal inflammation，functional bowel disorders，and cerebrovascular diseases. The coexisted two NCDs were mainly arbitrary combinations of two of four NCDs（hypertension，diabetes，joint and spinal diseases，and gastroduodenal inflammation）. The three or more diseases combinations were mainly the combination of hepatobiliary disease and other diseases. Conclusion　The community-based prevalence of multiple NCDs among young and middle-aged people in Shanghai should not be ignored. The disease combinations in them were obviously different from those of elderly population，showing the specificity of the young and middle-aged，which requires community family doctors to provide targeted chronic disease management services.

Personalized Needs of Contracted Family Doctor Services in White-collar Workers Working in Office Buildings　

CUI Yaqi，HAO Yu，LIU Tiexin，LIU Rui，WANG Zhaoxin，SHI Jianwei，YANG Yonghua，MA Xiaojun，SUN Jing，HUANG Jiaoling

2021, 24(16): 2039-2043. DOI: 10.12114/j.issn.1007-9572.2021.00.049

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Background　Against the backdrop of implementing the Healthy China 2030 initiative using the guideline issued by the state council，the contraction rate of family doctor services has exceeded 45% in Shanghai's general population，but it is lower in white-collar workers working in office buildings，a special group with increasing prevalence of serious sub-health problems. Objective　To investigate the personalized needs of contracted family doctor services in white-collar workers working in office buildings in Shanghai，to provide theoretical evidence for Shanghai's relevant health departments to develop health promotion policies targeting this group. Methods　Multi-stage sampling was performed to select employees working in 8 business office buildings in Hongkou District of Shanghai to attend a questionnaire survey from August to September 2019. The survey covered three parts: socio-demographic information，needs of contracted family doctor services，and of personalized service package delivered by family doctors. Results　A total of 1 040 cases attended the survey，and 993 of them（95.48%） who returned a responsive questionnaire were included finally. Among the options of "general medical services delivered by family doctors needed very much"，the top one chosen by the respondents was proxy medication dispensing〔29.49%（253/858）〕. Of the options of "off building-based health services delivered by family doctors needed very much"，the top one chosen was prevention and treatment of cervical spondylosis and other diseases〔36.37%（315/866）〕. 63.30%（507/801） of the respondents needed personalized service package delivered by family doctors. And such needs of them differed significantly by the level of education and medical insurance（P<0.05）. The "most expected" delivery pattern，delivery time and range of fee for personalized services provided by family doctors were on-site consultation〔26.53%（230/867）〕，1-hour midday break〔40.43 %（399/987）〕，and 0-100 yuan〔48.38%（417/862）〕，respectively. Conclusion　The white-collar workers have personalized demand for health management，but there is a lack of corresponding convenient and accessible services. It is recommended to develop various paid personalized service packages for them and to issue policies supporting the delivery.

Perception，Utilization and Satisfaction Regarding Bi-directional Referral Services in Young and Middle-aged White-collar Workers Working in Office Buildings　

LIU Tiexin，HAO Yu，CUI Yaqi，LIU Rui，YANG Yonghua，MA Xiaojun，SUN Jing，WANG Zhaoxin，LU Wei，HUANG Jiaoling

2021, 24(16): 2044-2050. DOI: 10.12114/j.issn.1007-9572.2021.00.048

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Background　Bi-directional referral services are an important part of tiered healthcare services in China. There are few studies on such services under the conditions that it is difficult and expensive for the masses to see a doctor. Analyzing their perception，utilization and satisfaction regarding bi-directional referral services is of great significance to the promotion of such services. Objective　To explore the perceptions，utilization and satisfaction regarding bi-directional referral services as well as associated factors in young and middle-aged white-collar workers working in office buildings. Methods　From August to September 2019，we used multi-stage sampling to select employees working in eight business office buildings in Shanghai's Hongkou District to participate in a questionnaire survey for obtaining data about their general demographics，socio-economic status，perceptions，utilization and satisfaction regarding bi-directional referral services. The survey gained a response rate of 95.48%（993/1 040）. Results　The rate of knowing bi-directional referral services was 17.27%（167/967）. Among 958 respondents who had self-reported use of referral services，165（17.22%） used bi-directional referral services. Among 182 who had self-reported use of referral mode，101（55.49%） asked for referral themselves，43（23.63%） were referred following the advice of their physician-in-charge，and 38（20.88%） asked for referral themselves and also were suggested for referral by their physician-in-charge. Of the 181 respondents who had self-reported referral process，108（59.67%） thought that their referral did not run smoothly. In terms of satisfaction with the services，the rates of being "very dissatisfied" "partly satisfied" "fairly satisfied" "relatively satisfied" "very satisfied" with the services were 8.51%（16/188），16.49%（31/188），54.26%（102/188），18.09%（34/188），and 2.66%（5/188），respectively. Both rates of knowing and utilizing bi-directional referral services varied significantly in the respondents by sex，usual address，marital status，education level，occupation，annual income，level of knowing family doctors and utilization of family doctor services（P<0.05）. The level of satisfaction with bi-directional referral services varied significantly in the respondents by education level and occupation（P<0.05）. Conclusion　Our survey suggests that this group have relatively low rates of knowing and utilizing bi-directional referral services，and the understanding of family doctors and use of family doctor services may partly improve the rates of knowing and utilizing referral services，eventually promoting seeking healthcare in primacy care，relieving the pressure of higher level hospitals，and stabilizing the implementation of tiered healthcare system.

Investigation on the Demand and Willingness of Elementary Students Signing a Health Service Contract with the Family Doctor：Perspectives from Parents　

ZHONG Yanxi，WANG Junzhou

2021, 24(16): 2051-2056. DOI: 10.12114/j.issn.1007-9572.2021.00.128

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Background　Chengdu Wuhou District of Chengdu City has vigorously carried out family doctor contract service with community health service center since 2012 and achieved effective results，but there is no family doctor contract service for elementary students at present. Find out the demand and willingness of elementary students' families for family doctor contract service and the influencing factors will be conducive to further expanding the service scope and coverage rate of family doctor service. Objective　Find out the demand of families for elementary students' family doctor contract service，to evaluate the willingness to receive the service，and to explore the influencing factors to sign a health contract，and based on this，to put constructive suggestions for the further development of elementary students' family doctor contract service. Methods　Three primary schools in Wuhou District of Chengdu were randomly selected，and the parents of all qualified primary school students were investigated by questionnaire from September to December 2019. The self-designed questionnaires mainly included the basic characteristics of parents or families，demand for health services and the willingness to sign a contract of family doctor health service. 2 988 effective questionnaires were collected from 2 991 parenets，with an effective rate of 99.90%. Results　55.29%（1 652/2 988） of parents were the first grade to third grade elementary students' parents，and 41.57%（1 242/2 988） family members with the highest educational level were bachelor degree or associate degree 544（18.20%） parents most wanted their children to enjoy health education services after signing family doctor contract；424（14.19%） parents most wanted their children to receive health education services on vision care knowledge；463（15.50%） parents most wanted family doctor to contact stomatology specialist resources from the perspective of primary school students' disease diagnosis and treatment needs；753（25.20%） parents thought that primary school students should sign family doctor contract The biggest advantage of family doctor appointment is good accessibility. 2 293（76.74%） parents of primary school students were willing to sign family service contracts for their children. The comparison of the willingness of signing a contract due to the different grades，household annual income，highest education level of the family members，occupations，and whether they knew the specific location of the nearest community health service center（or station） and whether they had heard or accepted family doctor service，there was a statistically significant difference（P<0.05）. Multivariate Logistic regression analysis showed that the main factors influencing the parents' willingness of signing family doctor contract services for elementary school students were the grade of the students，the household annual income，the highest educational level of the family members，occupations，and whether the parents had heard or received the family doctor contract service（P<0.05）. Conclusion　The parents of primary school students in Wuhou District of Chengdu pay more attention to promoting the health management of primary school students，and they are more willing to sign family contract service for primary school students. The parents with high annual income of family，and high education background are more willing to sign a contract.

Parental Intentions and Associated Factors of Contracting Pediatric Oral Healthcare Services Delivered by Family Doctors　

YANG Mei，JIANG Changyong，SHEN Haiying，HU Wei

2021, 24(16): 2057-2061. DOI: 10.12114/j.issn.1007-9572.2021.00.130

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Background　The dental caries prevalence rate in children is high，posing a serious challenge to healthcare system. In China，the number of oral healthcare providers is insufficient and unevenly distributed，and the supply of oral health care for a special group is inadequate. Objective　To study parental intentions and associated factors of contracting pediatric oral healthcare services delivered by family doctors，providing a reference for promoting the delivery of comprehensive，continued and coordinated pediatric oral healthcare services and for containing pediatric dental caries. Methods　October 2019 to January 2020，a random sample was selected from the children receiving oral healthcare in six community health centers extracted from Chengdu's Wuhou District by use of stratified sampling. The children's parents（one parent of each child） were invited to attend a questionnaire survey for investigating their and their children's information about basic demographics，children's oral health status and history of using oral healthcare，and choice of institutions for oral healthcare. Results　A total of 311 parents（of 311 children） attended the survey，and 303 of them（97.4%） who responded effectively were finally included. According to the survey results，39.6%（120/303） of children had had oral health problems，11.6%（35/303） of children had received pit and fissure sealing or fluoridation for the prevention of dental caries，36.3%（110/303） of children had received guidance on pediatric oral health，and 68.3%（207/303） of children's parents were willing to accept contracted pediatric oral healthcare services. The parents' intention to contract pediatric oral healthcare services delivered by family doctors differed significantly by whether they had received professional guidance on pediatric oral health，their awareness of oral health knowledge，and whether their children had received pit and fissure sealing or fluoridation for the prevention of dental caries（P<0.05）. Multivariate analysis showed that the parents' intention to contract pediatric oral healthcare services delivered by family doctors was associated with whether their children had received preventive interventions for dental caries such as pit and fissure sealing or fluoridation（P<0.05）. Conclusion　Parents who have oral health knowledge，have received professional oral health guidance and their children have received pit and fissure sealing or fluoridation for the prevention of dental caries are more likely to contract pediatric oral healthcare services delivered by family doctors. So during vigorously carrying out comprehensive intervention projects for children's oral diseases in schools，primary medical institutions should deliver management services involving both pediatric health and school health with priority given to health education and outpatient preventive interventions，and actively deliver contracted pediatric oral healthcare services to all school-age children to reduce dental caries prevalence rate.

Application Effect of an Intelligent Outbound Call Platform in Fangzhuang Community Health Center　

WANG Yue，CHEN Ying，WU Hao，WEI Xuejuan，GAO Wenjuan，LU Xiaoliang

2021, 24(16): 2062-2067. DOI: 10.12114/j.issn.1007-9572.2021.00.200

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Background　General practitioners play an ever-growing role as heath gatekeepers in satisfying the increasing primary care needs of residents under the situation of advancing the tiered diagnosis and treatment system. However，there is a shortage of primary care professionals. To improve health services via reducing the burden of medical workers，Fangzhuang Community Health Center（FCHC） has introduced an intelligent outbound call system. Objective　To explore the application effect of the intelligent outbound call system in FCHC，providing evidence for the feasibility of popularizing this kind of system in the community. Methods　The Family Doctor Follow-up Center，FCHC has carried out robo outbound calling services using a speech template developed with the help of iFlytek intelligent voice technology. From April to October 2019，the intelligent outbound call system was used for medical examination appointment and notification for contracted residents，follow-up management of hypertension patients，hospital patient satisfaction survey and other services. Results　During the period，the total number of visits served by the system was 83 342，with a cumulative call duration of 25 606 minutes. An increase of 1 629 times of medical examination in the elderly，an increase of 7.91% in the elderly health management rate. Among the 319 contracted hypertension patients with follow-up management within this consecutive 6-month period，the number of hypertensive patients with normal blood pressure increased from 180（56.33%） in April to 188（58.82%） in October. There were 8 more hypertensive patients with normal blood pressure，accounting for 2.49 percentage points. The number of hypertensive patients whose blood pressure was at risk dropped from 79（24.89%） in April to 56（17.65%） in October. The number of hypertensive patients with blood pressure at risk dropped by 23，accounting for 7.24 percentage points. Among the 291 people who were followed up for hospital satisfaction，those who were satisfied with the hospital increased from 236（81.09%） in April to 249（85.56%）in October. The number of people who were satisfied with the hospital increased by 13，and the rate of patient satisfaction with hospital increased by 4.47 percentage points. Conclusion　The application experience of FCHC indicated that the intelligent outbound call platform may save the labor cost of outbound calling，improve the quality of calling，improve the health management efficiency of the family doctor team and the effect of hypertension management，enhance the patient experience，and hospital management level，as well as promote the health of residents.

Effect of Information Triage Used in Contracted Management Delivered by a General Practice Team　

FAN Aiqing，ZHANG Shaochen，ZHANG Peng，ZHANG Shengbing，PAN Zhigang

2021, 24(16): 2067-2071. DOI: 10.12114/j.issn.1007-9572.2021.00.195

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Background　With the continuous advancement of contracted services，some problems have gradually emerged，for example，there are no well-matched systems for policies regarding community-based first-contact care，tiered diagnosis and treatment，and bi-directional referrals. The comprehensive reform goal of community health services is to improve residents' sense of gain by further promoting the improvement of the quality of tiered diagnosis and treatment，and quality and efficiency of contracted family doctor services，as well as providing practical and attentive contracted services. Objective　To explore the effect of information triage used in the delivery of "1+1+1" type of contracted services by a general practice team，offering evidence for providing practical and attentive contracted health services. Methods　Five community health centers with serving population of 50 000 to 10 000，and comparable baseline data were selected from outer suburbs of Shanghai's Pudong New Area in 2019，among which one with one-year implementation of information triage and other four without were determined as intervention center，and control centers，respectively. And 10% of the people served by each family doctor from the intervention center and control centers，selected by random stratified sampling，were included in the intervention group，and control groups，respectively. A self-made questionnaire survey，the hospital information system and contracting APP platform were used to collect data regarding accurate rate of contracting information，residents' awareness rate of contracted family doctor services，rate of residents preferring community-based first-contact care，efficiency rate of contracted family doctor services，and residents' satisfaction level with contracted family doctor services，and these data were analyzed comparatively. Results　The rate of residents preferring community-based first-contact care and efficiency rate of contracted family doctor services in the intervention group was higher than that of other four control groups with statistically significant difference（P<0.05）. The rate of accurate contracting information and residents' awareness rate of contracted family doctor services of the intervention center was higher than that of other three control centers with statistically significant difference（P<0.05）. Conclusion　The information triage used in the delivery of "1+1+1" type of contracted services by a general practice team may produce good effect，which is similar to that of contracted policy-related intervention services，and can be popularized in the delivery of other types of family doctor services. Our analysis may be used as a reference for further implementing family doctor services as well as related policies.

Development of a Comprehensive Evaluation System for Multidisciplinary Team-based Supported Employment Services for People with Severe Mental Disorders　

DUAN Libo，ZHENG Hong，ZHUANG Jianlin

2021, 24(16): 2072-2076. DOI: 10.12114/j.issn.1007-9572.2020.00.533

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Background　Given a global consensus that the employment of people with severe mental disorders is beneficial to their mental rehabilitation，multidisciplinary involvement in supported employment services has become a research hotspot worldwide in recent years. However，since the service model is still at its infancy in China，the country is in urgent need of an evaluation index system that can help set up the service system. Objective　To develop a scientific，standard and comprehensive evaluation system for multidisciplinary team-based supported employment services for people with severe mental disorders and determine the weight coefficients of its indicators. Methods　Literature review and Delphi method were applied to establish an evaluation framework and develop a questionnaire for Delphi survey. A total of 10 experts were invited to complete two rounds of email-based questionnaire surveys from July to September 2019. According to the degrees of coordination and concentration of the experts' opinions in the survey，the indicators of the evaluation system were added，subtracted or modified to develop a comprehensive evaluation system and determine the weight coefficients of its indicators. Results　The finally developed comprehensive evaluation system consists of 3 first-level indictors（governmental and resource input，service process and outcome），13 second-level indictors and 60 third-level indictors with determined weight for each indicator. The positive coefficient of experts was 100.0%. The coefficients of experts' familiarity，judgment and authority were 0.930，0.850 and 0.890，respectively. The Kendall's concordance coefficients for the two rounds of surveys were 0.327 and 0.621，respectively，suggesting that the opinions of experts were very consistent（P<0.001）. Conclusion　The system was developed according to the two-round survey results with high positive coefficient of experts，high level of experts' authority and coordination and consensus，may provide a reliable basis for the evaluation of multidisciplinary team-based supported employment services for people with severe mental disorders. And it is conductive to further application and popularization of the supported employment services through the government platforms.

Development of a Three-tiered General Practitioners' Competence Assessment System and a Relevant TSH Model 　

WANG Haitang，LI Yaling，LIU Pingyang，DING Yan，SHAN Meiqing，DU Zhaohui

2021, 24(16): 2077-2084. DOI: 10.12114/j.issn.1007-9572.2021.00.127

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Background　The development of general practitioners'（GPs'） competence assessment systems has become mature in foreign countries. However，in China，GPs' competence has been assessed mainly by healthcare institutions themselves. Due to different standards and evaluation methods of various institutions，the authority and objectivity of the assessment results cannot be guaranteed. Therefore，it is necessary to establish a unified standard in line with the current development of general practice. Objective　To develop a tiered GPs' competence assessment system using the Delphi method，and based on this，to develop a theory-skill-humanity（TSH） cube model，to improve the GPs' competence assessment more accurately and objectively via promoting the homogenous progress. Methods　From April to May 2019，using literature review and group discussion，we developed a preliminary framework of a three-tiered GPs' competence assessment system consisting of 3 first-tier indices（general practice theory，skills and humanity），44 second-tier indices and 44 third-tier indices. Then we developed the GPs' competence assessment system after revising the framework according to the results analysis data of a two-round Delphi survey with 28 experts conducted from July 1 to September 10，2019. We analyzed the experts' basic personal information，suggestions for the framework，and their positive，authoritative and Kendall's concordance coefficients as well as consensus level in the survey. Results　The familiarity and judgment coefficients were 0.900 and 0.936，respectively，in the first round of survey，and were 0.948 and 0.952，respectively，in the second round.The authority coefficient in the first and second round expert consultation was 0.918 and 0.952，respectively，which were both above 0.70. The importance and accessibility coefficients were 0.471 and 0.409，respectively，for the first round of survey，and were 0.363 and 0.386，respectively，for the second round. The final GPs' competence assessment system includes three domains（general practice theory，clinical skills and humanity），and 43 assessment items. In accordance with this system and previous patents，the TSH model was developed.Conclusion　 Our GPs lusmpetence assessment system developed based on the results of email-based surveys with high expertsent sytive and authoritative coefficients and consensus，includes three first-tier indices，43 second-tier indices and 43 third-tier indices，which is scientific，reliable and reliable verified statistically.

Prevalence Rate of Multiple Chronic Conditions in Middle-aged and Elderly Chinese People from 2010 to 2019：a Meta-analysis　

WANG Meijie，ZHOU Xiang，LI Yajie，LIU Fangli，YAO Zhuoya

2021, 24(16): 2085-2091. DOI: 10.12114/j.issn.1007-9572.2020.00.477

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Background　With the acceleration of population aging，an increasing chronic disease prevalence is seen in middle-aged and elderly Chinese people，and a widespread prevalence of multiple chronic conditions is found in this population，which have brought unprecedented challenges to the management of chronic diseases. Objective　To systematically evaluate the prevalence rate of multiple chronic conditions in middle-aged and elderly population （≥45 years old） from 2010 to 2019 in China，providing a basis for the prevention of multiple chronic conditions. Methods　We searched cross-sectional studies regarding multiple chronic conditions prevalence in middle-aged and elderly Chinese people published from 2010-01-01 to 2020-01-01 in Chinese from databases of CNKI，Wanfang Data and VIP，and those in English from databases of the Cochrane Library，PubMed，Web of Science，and so on. Data extraction and quality evaluation of the included studies were performed. Stata 14.0 was used for statistical analysis. Results　A total of 25 studies were included，with a total of 173 085 patients. Meta analysis showed that the prevalence rate of multiple chronic conditions in middle-aged and elderly Chinese people was 41%〔95%CI（35%，46%）〕. Subgroup analysis showed that the prevalence of multiple chronic conditions was 41% in women〔95%CI（33%，50%）〕 and 38% in men〔95%CI（31%，45%）〕. The prevalence of 2 and 3 chronic diseases was 23%〔95%CI（20%，26%）〕，and 11%〔95%CI（9%，14%）〕，respectively. The prevalence of multiple chronic conditions was 41%〔95%CI（34%，47%）〕 from 2010 to 2015，and was 43%〔95%CI（28%，58%）〕 from 2016 to January 1，2020. The prevalence of multiple chronic conditions was 41%〔95%CI（34%，49%）〕 and 38%〔95%CI （27%，49%）〕 in those living in southern and northern China，respectively. Conclusion　The prevalence of multiple chronic conditions in this population is relatively high. Therefore，relevant departments should pay attention to early screening of chronic conditions in high-risk groups and provide targeted preventive measures for them.

Prevalence of Chronic Constipation in Chinese Adults：a Meta-analysis　

YANG Zhi，WU Chenxi，GAO Jing，BAI Dingxi，ZHU Lin，LIU Ruirui，LIANG Yun，WU Qiao

2021, 24(16): 2092-2097. DOI: 10.12114/j.issn.1007-9572.2021.00.092

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Background　Constipation has become a common problem among Chinese people along with the quickened pace of life. Although constipation is not fatal，it may increase the mortality rate of cardiovascular and cerebrovascular diseases. There is a lack of comprehensive data from large-scale surveys about chronic constipation prevalence in Chinese adults. Objective　To systematically evaluate chronic constipation prevalence in Chinese adults，so as to provide a basis for epidemiological studies of chronic constipation. Methods　Cross-sectional studies on chronic constipation in Chinese adults were searched in databases of CNKI，VIP，WanFang Data，CBM，PubMed，EMbase，The Cochrane Library，and Web of Science from inception to December 31，2019. Two reviewers enrolled studies in accordance with the inclusion and exclusion criteria，extracted data，and evaluated methodological quality using the ARHQ methodology checklist（11 items） for cross-sectional studies. Stata 15.0 was used for meta-analysis. Results　19 studies，involving 37 242 subjects were included. Meta-analysis showed that the overall chronic constipation prevalence in Chinese adults was 10.9%〔95%CI（8.8%，13.0%）〕. Subgroup analysis showed that the prevalence was 7.0%〔95%CI（4.1%，10.0%）〕 for men and 11.5%〔95%CI（9.3%，13.7%）〕 for women，and 9.3%〔95%CI（3.7%，14.8%）〕 for urban areas and 10.5%〔95%CI（5.8%，15.1%）〕 for rural areas. The prevalence for subgroups of elementary or below，junior/senior high school，and two-/three-year college education or above was 12.2%〔95%CI（7.4%，17.0%）〕，12.3%〔95%CI（8.1%，16.4%）〕，and 13.2%〔95%CI（8.2%，18.1%）〕，respectively. The prevalence was 7.4%〔95%CI（5.6%，9.2%）〕 for southerners and 15.0%〔95%CI（10.6%，19.4%）〕 for northerners. The prevalence for adults surveyed before 2003，between 2004—2008，2009—2013，and 2014—2018 was 5.0%〔95%CI（3.0%，7.0%）〕，6.3%〔95%CI（1.3%，11.3%）〕，11.2%〔95%CI（4.9%，17.5%）〕 and 13.4%〔95%CI（9.1%，17.7%）〕，respectively. Conclusion　The prevalence of chronic constipation among Chinese adults is increasing year by year，with differences by gender，place of residence（rural or urban），level of education and region.

Proper Use and Challenges of Internet Healthcare Information for Diabetes　

WANG Yang，WANG Miye，ZHOU Youlian，HE Longtao，LI Sheyu

2021, 24(16): 2098-2102. DOI: 10.12114/j.issn.1007-9572.2021.00.197

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Patient education is critical in the long-term management of diabetes. The past few decades witnessed the rapid transformation of the Internet and mobile techniques，pushing the development of diabetes education. However，the quality of online diabetes information is challenged for its inaccuracy and misleading potential. The Internet-based health education materials include websites，mobile applications，and social media. Each shows its advantages and faces its challenges. We call for the proper use and audit of these resources for improving the quality of diabetes care.

Quality Assessment of Web Pages of Diabetes-related Health Care Information in China　

ZHOU Youlian，YUAN Xiang，YANG Xiaoling，AN Kang，LI Shuangqing，ZHOU Yiling，YUAN Li，LI Sheyu

2021, 24(16): 2103-2107. DOI: 10.12114/j.issn.1007-9572.2020.00.266

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Background　The Internet has become one of the main ways to obtain health information for diabetes patients in China. However，the quality of web pages of diabetes-related health care information is unclear. Objective　To assess the quality of web pages of diabetes-related health care information obtained using common search engines in China. Methods　In October 2018，using "糖尿病" as the key word，we searched for diabetes-related health care information on the first 50 web pages obtained by using each of the top six popular engines〔including Baidu，Shenma（mobile），Sougou，360 search，Google，Bing（domestic）〕 in an annual rank list（September 2017 to September 2018） of Internet search engines in China made by Stat Counter（an Internet traffic monitoring organization）. After screening，web pages with diabetes-related health care information suitable for diabetics and other people reading were included，and their quality was assessed by Silberg Scale，Interactivity Scale，Abbott's Aesthetic Criteria and self-made content tool. Results　The median Silberg Scale score，Interactivity score，Abbott's Aesthetic Criteria score，and self-made content tool assessed score for the included 173 web pages were 2.0（2.0），1.0（1.0），1.0（1.0），and 2.0（4.0），respectively. The average Interactive score and Abbott's Aesthetic Criteria score for web pages searched via different search engines were statistically different（P<0.05）. The accountability of the web pages assessed by Silberg scale showed that 50.3%（87/173）stated the date created/last modified specified，35.3%（61/173） stated the author's affiliation，but only 2.9%（5/173） stated the sponsorship disclosed. The interactivity of the web pages assessed by the Interactivity scale showed that 72.8%（126/173） provided intra-site search engines，but only 1.7%（3/173） provided evaluation questionnaires. The presentation of the web pages assessed by the Abbott's aesthetic criteria demonstrated that only 9.2%（16/173） provided diagrams and other visualization means，and 80.9%（140/173） of the websites had advertisements. Content quality assessment revealed that web pages with lifestyle interventions for diabetes were the most（61.3%，106/173），followed by clinical manifestations of diabetes（46.8%，81/173） and diabetic complications（39.9%，69/173）. Conclusion　The overall quality of web pages of diabetes-related health care information needs improving and auditing by the government in China.

Current Situation and Evaluation of WeChat Public Platforms in Supporting Diabetes Self-management　

WU Yuan，LI Sheyu，SHI Peijie，GUO Hui

2021, 24(16): 2108-2111. DOI: 10.12114/j.issn.1007-9572.2019.00.764

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Background　WeChat public platform is currently an essential part of mHealth for diabetes self-management，but the current situation of its use in diabetes management and the accuracy of its push information are still unknown. Objective　To understand the current situation of WeChat public platforms in supporting diabetes self-management，and to evaluate the accuracy of messages pushed by the platforms. Methods　On May 31 2018，We searched in NewRank website（https://www.newrank.cn/） using "糖尿病（diabetes）" as a keyword，and WeChat public platforms designed for diabetes patients and aiming at diabetes self-management support and education were included. For every platform，the publisher，the number of followers，and the highest number of views were collected. The functions of the platforms were classified by Taxonomy of APPs for Diabetes Self-management and the top-viewed messages in one week were classified by theme，and the accuracy of the messages was evaluated according to the clinical guidelines. Results　As of May 31 2018，46 WeChat public platforms supporting diabetes self-management were included. Among them，20（43.5%） platforms were ran by network technology companies and the number of active followers was 11 465（20 151）. In messages pushed by platforms，the highest number of views was 1 764（3 057）. Except for the basic function of patient education，19（41.3%） platforms had communication function；9（19.6%） platforms had data recording function；2（4.3%） platforms had structured display function；1（2.2%） had personalized feedback function；and 23（50.0%） platforms had sales promotion function. Of the highest weekly readings，20（43.5%） platforms focused on diet management；according to clinical guidelines，only 27（58.5%） platforms pushed accurate information. Conclusion　Currently，the majority of platforms are operated by the network technology companies mainly with patient education，communication，and data recording functions，while the accuracy of messages pushed by platforms could be further enhanced.

Advances in Impact of Internet Remote Management on Treatment Adherence in Hypertensive Patients in the Community　

YANG Rong，LIAO Xiaoyang，LI Zhichao

2021, 24(16): 2112-2116. DOI: 10.12114/j.issn.1007-9572.2020.00.022

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Hypertension is one of the most serious chronic diseases that endanger human health seriously. It has a high morbidity and mortality but low control rate worldwide，especially in less developed countries and regions. Effective hypertension management is the key to improving treatment compliance and influencing blood pressure control rate. Along with the development of the Internet，the traditional patterns of hypertension treatment compliance based on doctors' management have been changed. This paper discusses the research progress of Internet remote management on the hypertension treatment adherence at home and abroad，and concludes that the Internet remote management of blood pressure treatment adherence has lots of advantages in health education，economy，doctor-patient communication and follow-up，but disadvantages and shortcomings like use difficulties，inaccurate data，limited research evidence，and lack of guarantee of safety and reliability also exist. It is expected that the Internet remote management of blood pressure could be better applied on community management of hypertension treatment compliance.

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