Table of Content

05 November 2021, Volume 24 Issue 31

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Monographic Research

Construction of Community Hospitals in China as of 2020：an Analysis Using Tracking and Monitoring Data　

LIN Chunmei，QIN Jiangmei，ZHANG Lifang，ZHANG Yanchun，MENG Yeqing，WANG Xin

2021, 24(31):  3909-3913.  DOI: 10.12114/j.issn.1007-9572.2021.00.301

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Background　China has launched the construction of community hospitals as an important key initiative to satisfy people's essential primary healthcare needs in the new era，and a key segment to promote the development of a high-quality and efficient healthcare system. China has issued a series of policy documents to facilitate the development of community hospitals since the pilot construction of community hospitals initiated in 2019. As of 2020，1 410 community hospitals had been successfully built，and it is essential to analyze their construction using the tracking and monitoring data. Objective　To analyze the monitoring data of the construction of community hospitals in China as of 2020，and put forward policy recommendations to solve the problems and difficulties during the construction. Methods　We collected the tracking and monitoring data of the construction of community hospitals in China in December 2020，and analyzed the data in terms of whether meeting the recommended standards，building area，number of sick beds，setting up departments，and allocation of general practitioners，as well as made a summary of the advances in constructing community hospitals in each region during the period of 2019—2020. Results　By the end of 2020，the number of community hospitals had reached 1 410，73.12% of which（1 023/1 399） met the recommended standards of "Activities for Achieving Quality Primary Healthcare Services"，including all community hospitals in Shanxi and other eight regions. In 2020，the average building area of each community hospital across the country reached 6 822 square meters，with an increase of 347 square meters compared with that of 2019. The share of community hospitals with a building area of more than 3 000 square meters got up to 96.07%（1 343/1 398）. There were 91 sickbeds in each community hospital on average，which increased by 3 than that of 2019. 97.13%（1 355/1 395） of community hospitals had equipped with more than 30 sick beds. Overall，the department setting of community hospitals had been improved. Most community hospitals had set up departments of general practice，rehabilitation department and traditional Chinese medicine，and the share of those reaching the standard of "having at least 5 other clinical departments" was 89.15%（1 241/1 392）. In 2020，the top 3 clinical departments added to community hospitals were fever clinic〔18.95%（260/1 372）〕，rehabilitation department〔9.10%（126/1 384）〕，and mental health department〔6.55%（89/1 358）〕. The number of general practitioners in each community hospital was 16.15 on average，which increased by 1.16 than that of 2019. Conclusion　The development of community hospitals kept improving smoothly，which was manifested as doubled number of community hospitals，strengthened infrastructure equipment，increased clinical departments，and improved service capabilities. However，there were obvious inter-regional differences in terms of the number of community hospitals，and community hospitals in some regions failed to meet the recommended standards. There is a way to go in improving related policies and human resource constructions. It is recommended that local governments steadily strengthen community hospitals constructions according to the 14th Five-Year Plan，focusing on high-quality development of community hospitals under multi-department cooperation and related policy improvement.


Evaluation of Guidelines for Community Management of People with Dementia Based on AGREE Ⅱ　

ZHANG Haina，LI Jing，DU Juan

2021, 24(31):  3914-3922.  DOI: 10.12114/j.issn.1007-9572.2021.00.300

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Background　Dementia is a term describing a group of symptoms of acquired cognitive impairment，whose progression is associated with significantly decreased activities of daily living，learning，work and social abilities，seriously affecting the quality of life. Comprehensive and effective community management of dementia contributes to the delay of dementia progression，and high-quality clinical practice guidelines can provide effective management strategies，so the use of both of them may improve the quality and consistency of community management of dementia. Objective　 To assess the qualities of clinical practice guidelines and consensuses covering community management of dementia，providing a reference for the management of dementia in primary care. Methods　From September 2019 to January 2020，we searched for evidence-based clinical practice guidelines on dementia management and dementia care consensuses published between 2008 and 2020 from literature databases and websites，and screened them based on the inclusion and exclusion criteria. We reviewed the eligible guidelines and consensuses using the AGREE Ⅱ，and assessed the overall agreement among reviewers using the kappa coefficient. Results　A total of 45 guidelines were finally included. The mean values of standardized percentage of these guidelines in terms of six domains of scope and purpose，stakeholder involvement，rigour of development，clarity of presentation，applicability，and editorial independence were （77.2±8.96）%，（46.3±21.16）%，（39.19±20.8）%，（71.70±17.3）%，（26.3±17.35）%，and（40.6±33.73）%，respectively. By comprehensive evaluation，one was A-rated，23 were B-rated，and 21 were C-rated. Inter-rater agreement was good and the kappa coefficient was（0.73±0.16）（P<0.001）. Finally，24 moderate-to-high quality guidelines were selected，and the mean values of their standardized percentage scores in the above-mentioned six domains were （80.20%±7.90）%，（54.50±16.98）%，（48.90±16.03）%，（77.90±7.99）%，（33.20±17.34）%，（53.3±35.63）%，respectively. The average kappa coefficient for inter-rater agreement for rating these 24 guidelines was （0.73±0.16）（P<0.001）. Conclusion　 By use of the AGREE Ⅱ，we singled out evidence-based moderate-to-high quality guidelines/consensuses on the management of people with dementia. Although the methodology needs to be further standardized and strengthened，these overall high-quality guidelines could be used as guidance for the management of dementia in primary care，and as a reference for the development of guidelines on the management of dementia in primary care.


Protocol for Evidence-based Core Information Guideline for Health Communication of Tobacco Control　

QUAN Chenxi，LIU Jin，WEI Shuting，LIU Zhefeng，SHI Linling，ZHOU Pengxiang，WU Yibo，QI Fei

2021, 24(31):  3923-3928.  DOI: 10.12114/j.issn.1007-9572.2021.00.245

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Background　As smoking and passive smoking have become serious public health issues，taking effective tobacco control measures is a matter of great urgency，in which dissemination of tobacco health information through old and new media is an important method but with little success because of mixed and complicated evidence and low public literacy on tobacco use. Objective　To summarize the developing process of Evidence-based Core Information Guideline for Health Communication of Tobacco Control（hereinafter referred to as the Guideline），ensuring that the development of the guideline is science- and evidence-based. Methods　The protocol for the development of the Guideline was introduced，including guidance method and members，scope of application，item development，identification and collection of outcome indicators，evidence collection，investigation of audience preferences and values，economic analysis，attachment of recommendation and consensus，guideline publication，update，promotion，implementation and evaluation，etc. Results　The construction of guidance committee，expert group and secretary group for developing the Guideline，and the registration of the Guideline （registry number：IPGRP-2020CN072） have been completed. The included issues and outcome indictors in the guideline encompass the impact of smoking，impact of passive smoking，impact of smoking on drug absorption，metabolism and safety，and the improvement of quality of life and physical condition by quitting smoking. The full text and interpretation of the Guideline will be published in 2022，and it will be updated every 5 years. Conclusion　This protocol will help to improve the effectiveness of health communication of tobacco control，and provide structured suggestions for future development of guidelines on health communication.


Quality Frameworks and Quality Indicators for Hypertension and Diabetes Management in Primary Care in China，the US and the UK：a Comparative Study　

HUANG Yanli, YE Jingxue, LIU Hongyuan

2021, 24(31):  3929-3941.  DOI: 10.12114/j.issn.1007-9572.2021.00.144

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Background　How to improve healthcare quality to provide residents with integrated health services，is a salient challenge faced by China. How to define and measure quality is still a controversial topic worldwide. The quality framework is a systematic tool that can be used to assess primary care quality，contributing to the development of the quality improvement plan and offering insights into thoughts about quality. There are few studies on primary care and primary care quality in China，and no cross-sectional comparative case studies on primary care quality evaluation systems as well as evaluation indicators targeting the care for a disease in multiple countries. Objective　To compare the monitoring，assessment or certification system regarding primary care quality and the included quality indicators for hypertension and diabetic management in China，the US and the UK，to obtain a deeper understanding of primary care quality，and mechanism of actions of care quality evaluation system in improving primary care. Methods　Literature regarding primary care quality in China，the US and the UK evaluated using Donabedian's classic system-based framework of structure，process and outcome was searched. The input，process and outcome concerning primary care quality evaluation as well as the effect of quality evaluation methods on primary care quality performance results in the three countries were analyzed. Cross-sectional comparison of evaluation indicators were performed to find the differences in the quality focus of primary care policies across the countries. Results　The structure and service load for a general practitioner（GP） team are different: In the UK and the US，each GP team serves about 1 200 people（the whole population）on average，while in China，the number reaches 4 632. All three countries have included the care for two diseases，hypertension and diabetes，in the quality assessment scope of primary care as main assessment items. In terms of the structure of quality monitoring system，China and the UK have adopted similar clinical evidence-based indicators by disease entity or key population，while the US has adopted mainly service practice process monitoring. In addition，the domains for quality improvement have been included in the monitoring scope in the US and the UK. In terms of quality indicators，both the US and the UK have adopted exception report as a method for balancing the requirements of population-based health assessment and individual patient characteristics. In China，a relatively single method，that is，care quality assessment results for a sample，is mainly used to represent those of a target population. In terms of the feedback of evaluation results，both the UK and the US inform the assessed subjects and the public of the results，while in China，the feedback is mainly within the administrative and assessment system. As for the informationalized support for primary care quality monitoring and assessment，professional data-fetching programs have been used in the US and the UK，which may avoid the problems caused by using the assessment results of a simple sample representing those of a population to the greatest degree，and are an important basis used for giving feedback to subjects and the public，and for the development，analysis and research of health programs. Conclusion　Due to characteristic healthcare needs and resources，the quality assessment criteria for primary care are different across the three countries，but all are improving in accordance with the changes of supply and demand in primary care and health resources，showing a trend of people-centered and continuous quality improvement incentivized in primary care. For China，relatively good quality results of primary care have been achieved using limited resources，and further effective improvement of the quality indicators is suggested to conduct in accordance with the healthcare system reform，such as the training of primary care workers，structure modification of primary care human resources，quality assessment method for contracted integrated medical and public health services，operation and management ways of a medical consortium as a gatekeeper，mechanisms for health insurance imbursement programs，and the changing of primary care delivery ways according to healthcare needs using digital technologies.


Development and Applicability of Hypertension and Diabetes Health Management Quality Indicators in China's Primary Care Based on the Experience of the US and the UK　

YE Jingxue，HUANG Yanli，LIU Hongyuan

2021, 24(31):  3942-3948.  DOI: 10.12114/j.issn.1007-9572.2021.00.145

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Background　Evidence-based，high-quality and clinically applicable high-level health service is one of the important promoters to achieve the reform goals of improving people's health and patients' medical experience，as well as the efficiency of health services. With the promotion of contracted family doctor services，it is very important to assess the quality of such services for patients with chronic diseases. However，there is a lack of relevant criteria and assessment indices in China although there are various foreign criteria and systems for chronic disease management. Objective　To develop hypertension and diabetes health management quality indicators in China's primary care based on the experience of the US and the UK，and assess their applicability in Chengdu's Wuhou District. Methods　Based on the relevant contents of NHS-QOF，NCQA-PCMH and China basic public service specification，the first draft of "two diseases" health management quality index system is constructed. From December 2018 to June 2019，26 experts were invited to conduct two rounds of correspondence by Delphi method to form the final draft of the index system. The consensus index system is applied to the residents' health archives center of Wuhou District，the relevant population data are extracted according to the index definition，and the problems or barriers directly identified in the test process were analyzed，as well as the impact of the index system on the service quality of the contracted service team of family doctors. Results　The response rate，authority coefficients and Kendall's W were 100.0%（14/14），0.772，0.609（χ2=87.039，P<0.001），respectively，for the first round of expert consultation regarding hypertension management quality indicators in primary care，and were 87.5%（7/8），0.838，0.298（χ2=37.522，P<0.001），respectively，for the second round. The response rate，authority coefficients and Kendall's W were 100.0%（16/16），0.781，0.513（χ2=69.312，P<0.001），respectively，for the first round of expert consultation regarding diabetes management quality indicators in primary care，and were 87.5%（7/8），0.848，and 0.688（χ2=48.181，P<0.001）respectively，for the second round. Finally，a hypertension management quality system with three domains and 14 indicators，and a diabetes management quality system with three domains and 11 indicators，used for assessing family doctor services for hypertension and diabetes in primary care were developed. In terms of extracting data，we can directly extract the information used for 13 indicators. As the reading values of blood pressure are obtained by the monitoring of equipment，the accuracy of blood pressure needs to be further verified. For 12 indicators can not be extracted directly，we obtain five of them through improving the information system，and obtain other seven through other means of investigation. At the same time，the verification and application of monitoring indicators in Wuhou District has improved the family doctor's chronic disease management ability，and the chronic disease management has changed from process management to result management. Conclusion　There is no obvious cognitive difference between domestic experts on hypertension and diabetes management quality indicators in primary care. The information for most of indicators can be directly fetched and used for monitoring，feedback and assessment in the areas with residents' health records center. The application effect of the monitoring indicators is obvious.


Estimated Healthy Life Expectancy and Associated Factors among Chinese Elderly People　

YING Yubo, TONG Yan, ZHANG Xinxin, ZHENG Jianzhong

2021, 24(31):  3949-3954.  DOI: 10.12114/j.issn.1007-9572.2021.00.286

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Background　Owing to rapid economic development and advances in healthcare services，the life expectancy of the elderly has increased. But longer life expectancy does not mean higher quality of life. Healthy life expectancy is a healthy survival indicator that assesses both the length of life and quality of life，so it may be better for assessing the health status of the population. Objective　To estimate the healthy life expectancy of Chinese elderly people and associated factors，providing evidence for improving the health status of this population. Methods　This study was conducted between March and April 2021. Participants were part of the surveyees of the CLHLS during 2014—2018. The multistate life table was used to calculate healthy life expectancy and self-rated healthy life expectancy. Multiple linear regression was used to explore the factors associated with the healthy life expectancy. Results　A total of 5 261 subjects were included. Both the healthy life expectancy and self-rated healthy life expectancy showed a trend of decrease with age. The 70-72 age group had the longest average healthy life expectancy（17.85 years） and average self-rated healthy life expectancy（16.62 years）. The average healthy life expectancy was longer than the average self-rated healthy life expectancy in those younger than 88 years old. The average healthy life expectancy was slightly shorter than the average self-rated healthy life expectancy in 88-and-over age groups. Gender，age，marital status，education level and anxiety were main factors associated with healthy life expectancy（P<0.05）. Younger age，being married and non-anxiety might be associated with longer healthy life expectancy and self-rated health life expectancy，while being male and lower education level might be associated with shorter healthy life expectancy and self-rated health life expectancy（P<0.05）. Conclusion　To improve the health level of the elderly，especially those who are at an advanced age，live alone，have lower education level，it is suggested to pay attention to their health status，actively offer them community-based health education，and take interventions to satisfy their mental health needs as far as possible.


Prevalence and Patterns of Multimorbidity among Chinese Elderly People　

LI Yanna，WANG Yiqiao

2021, 24(31):  3955-3962.  DOI: 10.12114/j.issn.1007-9572.2021.00.295

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Background　Multimorbidity，the coexistence of multiple chronic diseases，is common in older adults，and is an ongoing challenge for public health. However，only a few studies on multimorbidity have been conducted in China. Objective　This research was aimed to identify the prevalence and patterns of multimorbidity among Chinese older adults，providing scientific suggestions for the prevention and management of multimorbidity in this population. Methods　Data were extracted from the China Health and Retirement Longitudinal Study（CHARLS）2018，involving 10 836 adults aged 60 and older with complete information of key variables（chronic disease prevalence，age，sex，education level，marital status，and type of hukou）. Chi-square test was used to assess differences in the prevalence of single and multiple chronic diseases by sex. Chi-square test for trend was used to assess the differences in the trend in prevalence of single and multiple chronic diseases by age. Weighted networks were adopted to present the complex patterns of multimorbidity. Gephi was used for visualizing the patterns of associative multimorbidity. Results　Up to 86.23%（n=9 344）of the participants had at least one chronic disease. Hypertension〔46.46%（5 034/10 836）〕，arthritis or rheumatism〔44.68%（4 842/10 836）〕，and gastric or digestive diseases〔31.64%（3 429/10 836）〕 were top three most prevalent chronic conditions. The prevalence of chronic diseases increased with age（χ2 =31.953，P<0.001），with a greater prevalence in women than in men〔88.30%（4 899/5 548）vs 84.06%（4 445/5 288），χ2=41.069，P<0.001〕. At least two chronic diseases coexisted in 7 059 cases（65.14%）. Women had higher prevalence of multimorbidity than men〔68.71%（3 812/5 548）vs 61.40%（3 247/5 288），χ2=63.650，P<0.001〕. The prevalence of multimorbidity increased with age（χ2=31.118，P<0.001）. The 14 chronic conditions among the participants demonstrated 91 pair multimorbidity patterns. The top three pair patterns of multimorbidity with corresponding prevalence were hypertension & arthritis or rheumatism〔22.13%（2 398/10 836）〕，arthritis or rheumatism & gastric or digestive diseases〔19.15%（2 075/10 836）〕，and arthritis or rheumatism & heart disease〔16.67%（1 806/10 836）〕. The age-specific patterns of multimorbidity had certain differences. For those aged 60 to 69，the top three multimorbidity patterns were hypertension & arthritis or rheumatism〔19.81%（1 290/6 512）〕，arthritis or rheumatism & gastric or digestive diseases〔18.54%（1 207/6 512）〕，and hypertension & dyslipidemia〔16.68%（1 086/6 512）〕. For those aged 70 to 79，hypertension & arthritis or rheumatism〔25.33%（813/3 209）〕，arthritis or rheumatism & gastric or digestive diseases〔20.91%（671/3 209）〕，and hypertension & heart disease〔19.79%（635/3 209）〕were the top three patterns with the highest prevalence. For those aged 80 and older，the top three patterns of multimorbidity were hypertension & arthritis or rheumatism〔26.46%（295/1 115）〕，hypertension & heart disease〔17.67%（197/1 115）〕，arthritis or rheumatism & gastric or digestive diseases〔17.67%（197/1 115）〕. Conclusion　The prevalence of multimorbidityhy among elderly Chinese population was high. And the patterns of multimorbidity varied by age. To realize the co-management，co-prevention and co-reduction of multiple conditions，public health practitioners should provide integrated healthcare services. Our findings suggest that clinical guidance on the assessment and management of multimorbidity should be developed，taking influential diseases such as hypertension as a breakthrough and along with different strategies by age and gender.


The Rural-Urban Differences and Influencing Factors in the Anxiety Symptoms of Chinese Elderly People　

WANG Miao，PAN Qing

2021, 24(31):  3963-3970.  DOI: 10.12114/j.issn.1007-9572.2021.00.294

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Background　Anxiety is a common psychological problem that hinders the healthy aging process of the elderly. At present，most studies on the mental health of the elderly are focused on the urban or rural elderly in local areas，and there are limited comparative studies on the anxiety level of the nationwide elderly and the difference between urban and rural areas. Objective　To investigate the incidence of anxiety among the elderly nationwide，analyze and compare the detection rate and influencing factors of anxiety symptoms between rural and urban elderly，in order to provide a basis for mental health intervention for the elderly. Methods　In February 2021，data from the 2018 Chinese Longitudinal Healthy Longevity Survey conducted by the Peking University Center for Healthy Aging and Development was adopted. A total of 14 417 survey subjects who were aged≥60 years，received an anxiety survey and had complete values of related variables were selected as the research subjects. Anxiety was evaluated by 7-item Generalized Anxiety Disorder Scale（GAD-7），which is stratified by place of residence（urban/rural），and different characteristics（demographic characteristics，socioeconomic status，health status，life satisfaction，lifestyle and medical services accessibility）were compared. Unconditional Logistic regression was used to analyze related factors. Results　Among 14 417 elderly people，1 751 people had anxiety symptoms，and the overall detection rate was 12.15%，including 1 400 people with mild anxiety（79.95%），256 people with moderate anxiety（14.62%），and 95 people with severe anxiety（5.43%）. The incidence of anxiety symptoms in rural elderly〔13.05%（1 459/11 183）〕was higher than that in urban elderly〔9.03%（292/3 234）〕（χ2=37.946，P<0.001），and the severity of anxiety was higher in rural compared with urban elderly people（Z=-2.312，P=0.021）. The results of multivariate analysis showed that western region，bad self-reported financial conditions，with ordinary or bad self-reported health status，with bad self-reported life satisfaction，no smoking were independent risk factors affecting the occurrence of anxiety in urban elderly（P<0.05），and having sleep time of 7~8 hours was a protective factor（P<0.001）for the occurrence of anxiety in urban elderly. Female，central region，with ordinary or bad self-reported financial conditions，with ordinary or bad self-reported health status，with ordinary or bad self-reported life satisfaction，serious illness cannot be treated in time，salty diet were risk factors affecting the occurrence of anxiety in rural elderly（P<0.05），and having sleeping time of 7~8 hours or more than 8 hours was protective factor（P<0.001）for the occurrence of anxiety in rural elderly. Conclusion　The detection rate of anxiety symptoms in the Chinese elderly is relatively high and the detection rate of anxiety symptoms in rural elderly is higher than that in urban elderly. The factors associated with anxiety symptoms in urban and rural elderly people were partially different. So urban-rural differences should be considered when delivering preventive interventions or improving management interventions for such people.


Community-based Health Support and Self-rated Health Status of the Elderly　

ZHANG Yunfan，CHEN Yingchun，GAO Hongxia，SU Dai，TAN Min，ZHANG Yan

2021, 24(31):  3971-3978.  DOI: 10.12114/j.issn.1007-9572.2021.00.306

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Background　To address the challenges brought by accelerated aging，the Chinese government has actively promoted a model improving older people's health，namely，community-based health support model. However，the relationship of different community health support services with the health status of the elderly is unclear，and still needs to be studied systematically. Objective　To explore the association of different community-based health support services with self-rated health of older people，offering ideas for improving such services. Methods　2018 waves of the Chinese Longitudinal Healthy Longevity Survey data were obtained，with a total of 8 860 valid samples included. The relationship of self-rated health status of the elderly with four types of community-based health support services received，including personal daily care，mental health support，home visits and medication delivery，and health education，was analyzed by means of propensity score matching（PSM）. The kernel matching was used to match the processing group with the control group，with quadratic kernel used by default，and bandwidth set at 0.06. The K-nearest neighbor matching and radius matching were used to check the robustness. Results　The average score of self-rated health status of the 8 860 respondents was（3.43±0.90），which was in the general level. The supply of 4 types of community-based health support services：10.01%（887/8 860） of the respondents received community-based personal daily care，35.11%（3 111/8 860） received community-based home visits and medication delivery，14.35%（1 271/8 860）received community-based mental comfort and chatting services for relieving boredom，and 43.16%（3 824/8 860） received community-based health education. The supply of these 4 services showed significant differences across rural and urban areas，as well as eastern，central and western China（P<0.05）. PSM analysis showed that the average self-rated health status score in the processing group was 0.123 points higher than that of the control group（ATT=0.123，P<0.05），indicating that self-rated health status was associated with community-based personal daily care. No significant correlation existed between the self-rated health status and community-based home visits and medication delivery（ATT=0.012，P>0.05）. A significant correlation was found between community-based mental comfort and chatting services for relieving boredom and the self-rated health status. After matching，the ATT value was 0.083（P<0.05）. No significant correlation was found between community-based health education and the self-rated health status（ATT=-0.017，P>0.05）. Heterogeneity test revealed that the associations of self-rated health status with the four health support services in all participants were basically the same as those in subgroups stratified by sex，age，education level and geographical region. Those with higher annual household income，and higher education level living in urban communities of eastern China were more likely to benefit from community-based health support services. Conclusion　The participatory health management service is more beneficial to maintaining or improving the health level of the elderly than passively accepting service. Communities should further enrich the supply mode of essential medical and health services，and accelerate the integration of medical and old-age services. By doing so，the transformation of delivering community-based health support services from a pattern of "regardless of specific health needs of individuals" to the one of "precisely targeting individual specific health needs" will be promoted gradually.


Self-rated Capability of Identifying，Diagnosing and Treating Medically Unexplained Physical Symptoms in Shanghai General Practitioners in Community Health Centers　

ZHOU Yingda，ZHUO Shuxiong，JIN Hua，YU Dehua

2021, 24(31):  3979-3985.  DOI: 10.12114/j.issn.1007-9572.2021.00.304

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Background　Increasing attentions have been given to medically unexplained physical symptoms（MUPS） with the deepening of primary healthcare reform，and the capability of primary care in managing MUPS is considered as equal to managing chronic diseases. However，there are few investigative or evaluative studies on the diagnosis and treatment of MUPS by general practitioners（GPs） in China. Objective　To investigate the self-rated capability of identifying，diagnosing and treating MUPS of Shanghai GPs in primary care，and to attempt to explore the potential associated factors，providing a reference for raising GPs' capability of diagnosing and treating MUPS commonly encountered in the community. Methods　This study was carried out from June 2019 to June 2020. By use of stratified random sampling，320 GPs from 32 community health centers in Shanghai's urban and suburban areas were selected（10 were extracted from each community health center）. A 5-point Likert Scale Questionnaire developed by our research group was used in a survey to collect these GPs self-rated capability of identifying，diagnosing and treating MUPS. Stepwise linear regression was used to explore the factors potentially associated with GPs' capability of diagnosing and treating MUPS. Results　A total of 283 cases（88.4%） who completed the survey were included for final analysis. One hundred and fifty-eight（55.8%） GPs knew nothing about the definition and concept of MUPS or knew of MUPS without good understanding of MUPS. GPs who had standardized residency training program had a better understanding of the definition and concept，research status，books for continuing education，and guidelines regarding MUPS（P<0.05）. The average scores of self-rated capability of routinely diagnosing and treating MUPS，self-rated capability of emergently treating acute and severe MUPS，and self-rated capability of transferring MUPS patients by GPs，were （3.32±0.567），（3.42±0.677），
（3.38±0.654），respectively. Stepwise linear regression revealed that whether completing the standardized residency training program，education level，professional title，and the region of work were associated with GPs' self-rated capability of routinely diagnosing and treating MUPS（P<0.05）. The completion of the standardized residency training program was associated with GPs' self-rated capability of emergently treating acute and severe MUPS（P<0.05）. The completion of the standardized residency training program and region of work were associated with GPs' self-rated capability of transferring MUPS patients（P<0.05）. Conclusion　It is necessary to further improve Shanghai GPs' capability in the identification，diagnosis and treatment of MUPS. The standardized residency training may significantly improve GPs' capability in MUPS diagnosis and treatment. To improve the favorable influence of general practice in the diagnosis and treatment of MUPS，it is suggested to give more attention to MUPS，make more efforts to further improve the implementation of the standardized residency training for GPs，and provide effective evidence-based and adjuvant supports for diagnosing and treating MUPS.


Prevalence and Associated Factors of Rational Use of Lipid-regulating Agents in Urban General Practitioners in Beijing　

YU Xiaoyi，WU Hao，ZHAO Yali，GAO Wenjuan，WEI Xuejuan，GE Caiying

2021, 24(31):  3986-3989.  DOI: 10.12114/j.issn.1007-9572.2021.00.267

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Background　As China vigorously facilitates the implementation of tiered diagnosis and treatment system，there is an increasing number of residents who tend to make first visit with the community physician，which requires a relatively high diagnostic ability for general practitioners（GPs）. And also，the management of dyslipidemia in Chinese residents could be heavily affected by GP's cognition and treatment strategies for dyslipidemia. Objective　To examine the prevalence and associated factors of rational use of lipid-regulating agents in urban GPs in Beijing. Methods　From March to May 2019，440 GPs were selected from community health centers in six urban districts of Beijing by stratified cluster random sampling for a face-to-face survey using a questionnaire developed by our research team involving demographics and rational use of lipid-regulating agents（assessed by a 9-item 7-point Likert scale）. Results　The survey obtained a response rate of 98.0%（431/440）. The mean score for the 9 items about rational use of lipid-regulating agents scored by the respondents was（4.32±1.39）. The score of the respondents regarding rational use of lipid-regulating agents differed significantly by sex，major of the highest education，number of receiving the training of dyslipidemia management，average number of daily visits，and the proportion of dyslipidemia cases encountered（P<0.05）. Multiple linear regression analysis indicated that sex，number of receiving the training of dyslipidemia management，and proportion of dyslipidemia cases encountered were associated with rational use of lipid-regulating agents（P<0.05）. Conclusion　Overall，the urban GPs of Beijing obtained relatively low score of rational use of lipid-regulating agents. So it is suggested to strengthen the training of dyslipidemia management for these GPs to improve their level of rational use of lipid-regulating agents to better manage dyslipidemia patients.


Use of Information-motivation-behavioral Skills Model and Motivational Interviewing in Cardiac Rehabilitation for Patients with Coronary Heart Disease in the Community　

MENG Jia，DU Shaoying，WANG Yan，LOU Shining

2021, 24(31):  3990-3994.  DOI: 10.12114/j.issn.1007-9572.2021.00.256

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Background　Cardiac rehabilitation is an important part of standardized rehabilitation for coronary heart disease（CHD），but 30%-40% of the patients will drop out of the program after 6 months and 50% will drop out after 1 year.  Objective　To explore the effect of information-motivation-behavioral skills（IMB） model and motivational interviewing used in cardiac rehabilitation education for CHD patients in the community. Methods　CHD patients recruited from a community health station during May to June 2019 were randomized into the experimental group（n=40） and control group（n=42），receiving a series of lectures on cardiac rehabilitation plus IMB model-based education and motivational interviewing，and a series of lectures on cardiac rehabilitation，respectively. The self-efficacy，self-management behaviors and exercise adherence of the two groups were compared before the intervention，and 3 and 6 months after the intervention. Results　The number of patients who completed follow-up in the experimental group and the control group were 36 and 41 respectively. Analysis using a repeated measures ANOVA revealed that the improvement in self-efficacy differed significantly across the two groups（F=4.176，P<0.05）. The interaction effect generated by intervention contents and duration on self-efficacy was statistically significant（F=5.173，P<0.05）. There was a statistically significant intergroup difference in the improvement in self-management behaviors（F=4.436，P<0.05）. The self-management behaviors differed significantly by intervention duration（F=50.573，P<0.05）. The experimental group showed statistically higher exercise adherence than the control group either at three or six months after the intervention（P<0.05）. Conclusion　IMB model and motivational interviewing may contribute to the improvement of self-efficacy and self-management behaviors of patients with CHD.


Working Status，Willingness of Long-term Retention in Township Heath Centers and Associated Factors in Targeted Admission Medical Graduates：a Qualitative Study　

SHEN Ying，HUANG Xing，YU Jia，LI Hong，CHEN Enran，KONG Yan，WEI Siyu，WU Huabei，ZHAO Yue，ZHANG Xin，ZUO Yanli

2021, 24(31):  3995-4002.  DOI: 10.12114/j.issn.1007-9572.2021.00.280

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Background　The rural-oriented tuition-free medical education（RTME）program has been launched in China since 2010，aiming to provide rural areas with general practitioners with medical undergraduate degrees and to address the shortage of rural physicians. The first graduates with RTME came back to the contracted township health center to work in 2018 and started fulfilling a 3-year obliged health services in rural areas. Objective　To investigate the working status of graduates with RTME in rural primary health care institutions，their intentions towards long-term retention in rural areas and relevant associated factors. Methods　A qualitative study was conducted from January to August 2019，using a semi-structured focus group discussion with 64 individuals with RTME who graduated from Guangxi Medical University in 2015 and started serving local rural areas in 2018. Guided by an outline，the discussion covered issues about salary，scope of work，work atmosphere，and working conditions in township health centers，intention of retaining in the township health center after fulfilling the contractual obligations，and factors associated with long-term retention in township health centers，and was recorded，transcribed，and organized into themes using thematic analysis. Results　A total of 11 main themes emerged，including：salaries in the township health center met expectations of most graduates with RTME but showed geographical differences；the township health center has kept its promise of providing officially budgeted posts and purchasing the "five social insurances and one housing fund" as well as basically solving the housing problem；the opportunities for continuing medical education were reported to be insufficient；graduates with RTME would be easily considered for administrative posts of rural primary health care organizations；graduates with RTME mainly engaged in clinical diagnosis and treatment of disease，some of them also in auxiliary examinations；graduates with RTME worked in an atmosphere of harmony and less competition，and would be noticed significantly by the leaders；insufficient essential drugs crippled performances of graduates with RTME；both behindhand medical equipment and deficiency of health technicians made some common auxiliary examinations unavailable in township health centers；the attitudes towards retention in township health centers after fulfilling the contractual obligations were unclear；national policies in favor of towns and villages development，promising career development，friendly work atmosphere，willingness to address rural health issues，and sense of achievement derived from working in rural areas were factors encouraging long-term retention in township health centers；insufficient essential drugs，behindhand medical equipment，scarce opportunities for continuing medical education，heavy workload，and low salaries were factors impairing long-term retention in township health centers. Conclusion　The graduates with RTME showed unclear intentions towards long-term retention in township health centers. The salary was not a leading factor to impair their retention in such organizations after fulfilling the contractual obligations. However，insufficient essential drugs，behindhand medical equipment，and scare opportunities for continuing medical education emerged as major barriers for rural areas to retain these graduates.


Cross-sectional Study of Target Admission General Practitioners' Participation in Combating COVID-19 Pandemic　

CHENG Haozhe，WANG Ziyue，ZHANG Baisong，WANG Huijuan，WEI Tiantian，CHENG Xiaoran，LI Mingyue，HU Dan，LIU Xiaoyun

2021, 24(31):  4003-4008.  DOI: 10.12114/j.issn.1007-9572.2021.00.298

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Background　Primary healthcare workers have played an important role in combating the COVID-19 pandemic. Beginning in 2010，China initiated a national policy of implementing the rural-oriented tuition-free medical education（RTME） program，aiming to train general practitioners（GPs） with a medical undergraduate degree to work in rural areas to address the shortage of rural physicians. Since 2015，many graduates with RTME returned to the contracted rural hospital to fulfill a 3-year obliged health services，and their performance in combating COVID-19 epidemic is worth to be concerned about. Objective　To compare the participation and role of target admission GPs and other graduates trained with a five-year undergraduate degree program for clinical medical students in combating COVID-19 pandemic，and to analyze the duties and challenges for target admission GPs during the anti-pandemic period，then based on this，to put forward policy recommendations for incentivizing target admission GPs. Methods　The data were sourced from the Target Admission Medical Students Cohort Study Program. We conducted a follow-up survey among 1 631 target admission GPs and 1 009 other clinical medical graduates graduating from 4 medical colleges in central and western China using an online questionnaire in September 2020. Basic demographics，job information and work status during the COVID-19 pandemic were collected. Results　Among those who were employed in the study period，target admission GPs had a higher rate of participating in combating COVID-19 pandemic than other clinical medical graduates〔70.18%（1 113/1 586）vs 51.58%（293/568），P<0.05〕. Among target admission GPs，men had a higher rate of being involved in combating COVID-19 pandemic than women（P<0.05）；those admitted in 2015 and 2016 had a higher rate of being involved in combating COVID-19 pandemic than those admitted during 2017 to 2019（P<0.05）；and those who were married had a higher rate of being involved in combating COVID-19 pandemic than those who were unmarried/divorced/other marital status（P<0.05）. The top 3 types of work which most target admission GPs participated were "health promotion and education"〔88.59%（986/1 113）〕，"community epidemic prevention and management"〔85.62%（953/1 113）〕，and "SARS-CoV-2 nucleic acid testing and screening"〔67.30%（749/1 113）〕. The top three challenges most target admission GPs faced in combating COVID-19 pandemic were "lack of personal protective equipment"〔77.72%（865/1 113）〕，"too much workload and/or pressure"〔41.87%（466/1 113）〕，and "worrying about themselves and their family being infected"〔37.56%（418/1 113）〕. The prevalence of target admission GPs who reported that there was an increase in daily clinical work was 57.50%（640/1 113）. And that of target admission GPs who reported that there was an increase in daily public health services was 62.26%（693/1 113）. Conclusion　Target admission GPs have implemented multiple key services regarding COVID-19 containment，indicating that they have played a role in the national COVID-19 containment that cannot be ignored. However，they faced difficulties such as insufficient personal protective equipment and excessive work pressure. Measures need to be taken to improve the infrastructures in rural areas，and to provide more protection and support for primary healthcare workers.


First Targeted Admission Medical Graduates in Primary Care in Chongqing：Working Status and Recommendations　

HE Chunxiang，GONG Fang，XIE Bo

2021, 24(31):  4009-4014.  DOI: 10.12114/j.issn.1007-9572.2021.00.299

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Background　So far，the rural-oriented tuition-free medical education（RTME） program initiated in 2010 by the National Development and Reform Commission and other four departments have trained nearly 57 000 targeted admission medical graduates to become healthcare workers in township health centers in central and western of China，achieving the objective of "full coverage" in terms of the number of general practitioners，namely，training one general practitioner with a five-year undergraduate medical degree for each township health center in central and western of China. The status of work and life of the targeted admission medical graduates，and the assessment for them by the primary hospitals deserve attention. Objective　To investigate the work and life situation of the first（2010 admitted） targeted admission medical graduates in primary care in Chongqing，offering suggestions for the culture and employment of these graduates. Methods　From August to December 2019，a survey was conducted among the first targeted admission medical graduates（n=160） who were admitted in 2010，and started to fulfill the obliged health services in primary care in Chongqing in 2018 after completing a five-year undergraduate medical degree program and a three-year national standardized residency training program using a questionnaire developed by our research group for collecting information regarding their contracted hospital，salary，career planning after fulfilling the contractual obligations，living conditions and difficulties，as well as job satisfaction. Besides，for collecting the assessment for them by their contracted side，factors associated with their retention in primary care as well as recommendations on fostering targeted admission medical graduates，focus group discussions were carried out with managers from the local health commissions of Yongchuan District，Nanan District，Liangping District，and Qianjiang District，administrators and middle-level managers from the contracted township health centers. Results　The survey achieved a response rate of 75.6%（121/160）. In terms of work status，the contracted township health centers of 35.5%（43/121） of the respondents had set up a general practice department/general practice clinic；13.2%（16/121） of the respondents worked as a general practitioner in their contracted hospital；81.0%（98/121） had a monthly income lower than 6 000 yuan；80.2%（97/121） had passed the intermediate professional title examination，but 92.8%（90/97） of them had not been employed as an attending physician；66.9%（81/121） had not participated in a continuing medical education training/academic conference in the last year. For career planning after the expiration of the contractual obligation services，54.6%（66/121） said they were unclear，but 4.1%（5/121） planned to continue to work in primary care. In terms of life condition，17.4%（21/121） of the respondents said that they were provided with a free room for temporary residence by the contracted hospital；76.9%（93/121） said that their contracted hospital could not help them to address some of the practical difficulties relating to living. In terms of satisfaction with job：71.1%（86/121） of the respondents were dissatisfied with their income；47.1%（57/121） were dissatisfied with their jobs and tasks；19.9%（24/121） were dissatisfied with their work performance；and 18.2%（22/121） were dissatisfied with being undervalued by leaders of their contracted hospital. Focus group discussions revealed that targeted admission medical graduates were evaluated with strong learning ability，and high overall personal qualities，but may be relatively underpaid. Moreover，due to many factors，their levels of intention to work in primary care for a long period of time were not high. And the fostering suggestions were as follows：Universities and organizations（implementing the national standardized residency training program） should strengthen the ideological guidance of working in primary care in targeted admission medical graduates；the contracted hospitals should strengthen communications with targeted admission medical graduates. Conclusion　The first targeted admission medical graduates working in primary care in Chongqing showed low level of job satisfaction，and may be undervalued by the contracted hospitals，indicating that the training mode for these graduates and requirements of the contracted hospitals may be not well matched. In view of this，it is suggested that universities and organizations implementing the national standardized residency training program should improve the training mode for targeted admission medical graduates，and relevant government departments should improve the treatment for these graduates，such as salary and professional title promotion，so that these graduates are willing to work and retain in primary care，and have chances to put into practice the things they learn.


An Introduction to Mixed Methods Appraisal Tool　

LIAO Xing，HU Ruixue，LI Bo，HU Jing，CHU Hongling，YIN Xuejun，CHEN Wei，ZHANG Yili

2021, 24(31):  4015-4020.  DOI: 10.12114/j.issn.1007-9572.2021.00.215

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As a third research paradigm，mixed methods research（MMR）refers to mixing or combining quantitative and qualitative research methods or approaches into a single study. The use of MMR in healthcare has become fashionable recently.Compared with using qualitative or quantitative research alone，MMR can be used to illustrate a phenomenon or problem from different perspectives，gaining a variety of different types of information. Mixed methods systematic reviews（MMSR）are preferred by researchers，as they can find and understand a plethora of syntheses related to a particular topic to generate evidence to guide decision-making. Critical appraisal tool enables MMSR researchers to assess the trustworthiness and relevance of results of included primary studies. Mixed Methods Appraisal Tool（MMAT） is designed for the appraisal stage of MMSR that permits to appraise the methodological quality of five categories to studies：qualitative research，randomized controlled trials，non-randomized studies，quantitative descriptive studies，and MMR. For each included study，after responding to the two screening questions，choosing the appropriate category of the study to appraise and then rate according to related criteria.This paper comprehensively introduces the new version of MMAT in order to further standardize and improve the application of MMR and MMSR in China.


Developing Attributes and Attribute-levels for a Discrete Choice Experiment Estimating Demand for Long-term Care Insurance　

WANG Qun，YANG Jin

2021, 24(31):  4021-4026.  DOI: 10.12114/j.issn.1007-9572.2021.00.287

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Discrete choice experiment is an important method for estimating the demand or preference of non-market products in health economics. Developing attributes and attribute-levels is one essential determinant for the effectiveness of the experiment，but there is no unified process and method regarding how to conduct it. To provide a key methodological reference for future research，we detailed the development of attributes and attribute-levels for a discrete choice experiment for estimating demand of long-term care insurance via using multiple methods including theoretical analysis，literature review，policy text analysis，and expert interview，in which the pilot policies regarding long-term care insurance and their differences were outlined，with consideration for current and future development of these policies.


Recent Advances in Non-pharmacological Treatment of Mild Cognitive Impairment　

ZHOU Lulu，LU Yuan，LIU Yalin，ZHANG Hui，YU Dehua，TANG Lan

2021, 24(31):  4027-4031.  DOI: 10.12114/j.issn.1007-9572.2021.00.221

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Mild cognitive impairment（MCI） is a transition status between normal aging and AD. Early non-pharmaceutical treatment improves the cognition and quality of life of MCI patients and delays the progression of AD. As there are no effective medications for MCI so far，cognitive training，physical and psychological therapies are often applied. This paper summarizes the current non-pharmaceutical treatment of MCI，in order to provide a useful supplementary means for the prevention and early intervention of dementia.


Recent Progress on Transitional Care Assessment Tools for Older Chronic Disease Patients　

WANG Jianan，LIU Lamei，SUN Mengjie

2021, 24(31):  4032-4036.  DOI: 10.12114/j.issn.1007-9572.2021.00.251

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Timely，appropriate and continuous care during hospital-to-home transitions may effectively reduce the readmission rate，emergency department visit rate and incidence of adverse events in older chronic disease patients. However，there is no unified evaluation tool for transitional care in China，which makes it impossible to objectively evaluate the effect of transitional care. We reviewed the latest progress on transitional care assessment tools for elderly chronic disease patients，summarized nine evaluation tools that evaluate the quality of transitional care from perspectives of patients and healthcare professionals，and the assessment contents and methods，reliability，validity and application of each tool were also expounded，with the aim of providing a recommendation for China's medical workers to select appropriate transitional care assessment tools.