Chinese General Practice

Force and Effect of Policies Associated with the Implementation of Hierarchical Diagnosis and Treatment in China　

WU Qinde, XIE Xianyu, WU Yong, CHEN Congbo, DENG Weiwei, WU Shaoyan

2021, 24(34): 4293-4300. DOI: 10.12114/j.issn.1007-9572.2021.00.253

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Background　China has issued a series of policies for the implementation of three-tiered healthcare system since the healthcare reform launched in 2009. However，there is still a big gap between the achievements obtained by more than ten years of efforts and the pre-defined goals. Hence，it is essential to make a systematic and quantitative analysis of the policies related to the system. Objective　To evaluate the force and effect of policies related to the implementation of three-tiered healthcare system in China. Methods　In September 2020，by using "iered diagnosis and treatment" "bi-directional referral" "initial treatment in primary care" as search terms，we searched databases of PKULAW.CN，Wanfang Data，and Baidu，and government websites for policies issued by the State Council and government ministries during 2009—2019，and enrolled 236 policy documents related to the implementation of three-tiered healthcare system after screening. Effectiveness can be divided into four dimensions：policy measures，policy objectives，policy feedback，and policy intensity. Effectiveness is expressed by the number of outpatient and emergency visits in primary medical and health institutions，and regression analysis is conducted on the implementation effects of hierarchical diagnosis and treatment of three different policy tools by constructing multiple regression models. Results　On the whole，change trends of the number and overall force of policies related to three-tiered healthcare system were basically the same over the 10 years，but the average force of the policies changed more insignificantly. The average scores for four evaluation dimensions，policy measures，objectives，feedback，and intensity were about 3.00（except 2013），less than 2.50（except 2019），2.25，less than 2.44 points，respectively. Three types of policies，supply-side，environmental，and demand-side showed the same change trend basically in terms of number，although the former two outnumbered the latter generally. Among the supply-side policies，those regarding the development of healthcare facilities occupied the largest proportion（36.67%），but the average force produced by those regarding funding or resource allocation was the largest（20.00）. Among the demand-side policies，those regarding medical insurance occupied the largest proportion（61.70%），and produced the largest force on average（15.07）. Of the environmental policies，those regarding objective planning accounted for the largest proportion（49.25%），and produced the largest force on average（20.25）. The regression coefficients for supply-side，demand-side and environmental policies were 1.271 9，2.013 8，and 1.937 8，respectively（P<0.10），with an effect lag ranging from 1-3 years. Conclusion　Our study indicates that the force and effect of policies related to three-tiered healthcare system may be owing to the cumulative effect of the number of policies. In terms of evaluation dimensions，policy measures were rated high on average，but the quantitative degree of policy objectives was low，the requirement for policy feedback was vague，and the policy intensity lacks promotion by high-level departments. Both supply-side and environmental policies basically outnumbered demand-side policies. The score of policy force and effect mainly depended on policy measures，especially supply-side and environmental policies. All these three types of policies have facilitated the promotion of tiered diagnosis and treatment in China，but demand-side policies may have the shortest effect lag and largest force and effect，so it is suggested that government departments should make efforts to fully use the effect of demand-side policies to guide residents to seek healthcare appropriately.

Risks in the Delivery of Family Doctor Services Using Internet Technologies：an Analysis Using the Social Amplification of Risk Framework　

LYU Hui，LI Luochang，FENG Lei

2021, 24(34): 4301-4305. DOI: 10.12114/j.issn.1007-9572.2021.00.242

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In China，attempts have been made to use appropriate Internet technologies in delivering family doctor services，thanks to the continuous advancement of such technologies. However，analysis using the social amplification of risk framework indicates that the use of Internet technologies in the delivery of family doctor services may generate new risks while continue to amplify traditional risks，in which the Internet technology risk，human-computer interaction risk，and risk in online services have been continuously amplified，leading to rippling reactions such as moral hazard，stigmatization and so on. Therefore，we suggest strengthening information sharing，intervening key nodes of risk amplification，and reducing risk secondary effects to avoid these risks.

Comparative Study of Shanghai's Fever Alertness Clinics and Singapore's PHPCs　

ZHU Xiaoyan，YANG Yonghua，HUANG Yuncong，ZHU Min，HUANG Qian，ZHOU Liang，SHI Jianwe，WANG Zhaoxin，LIANG Hong，HUANG Jiaoling

2021, 24(34): 4306-4311. DOI: 10.12114/j.issn.1007-9572.2021.00.283

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Background　Among the regions in China，Shanghai has took the lead in proposing the establishment of fever alertness clinics in community health centers. As a component of the epidemic control and prevention system，fever alertness clinics assume the role of containing an epidemic at the primary level. The Public Health Preparedness Clinic（PHPC） is a branch of Singapore's sound public health system. Objective　To compare fever alertness clinics of Shanghai and Singapore's PHPCs，then put forward suggestions to improve the construction of Shanghai's fever alertness clinics. Methods　This study was carried out from December 2020 to April 2021. For studying Shanghai's fever alertness clinics，policy documents analysis，literature review and field survey were used. Besides，interviews were also used，which were conducted in two rounds，separately for managers and healthcare workers who were selected from a random sample of three fever alertness clinics（one in the central urban area，one in the outer suburb and one in the urban fringe） of Shanghai. Guided by different outlines，the interviews for the two groups were aimed to collect their perspectives of the organizational structure，setting，operation，and management of fever alertness clinics. For studying Singapore's PHPCs and relevant practice，literature review was used. Results　The number and density of PHPC in Singapore are higher than those in Shanghai fever alertness clinic. Shanghai has higher standards for setting up fever alertness clinic，but PHPCs in Singapore has a higher entry threshold. Shanghai fever alertness clinic have more specific treatment procedures and standardization. Singapore's PHPC system is more prominent in terms of subsidies for epidemic prevention and protection of medical staff. Conclusion　The construction of Singapore's PHPCs needs longer preparation time，and the government is responsible for setting standards，admittance approval，planning and layout using the top-down approach，so the development of PHPCs shows higher homogeneity and meticulousness. In contrast，the construction of fever alertness clinics in Shanghai started late，showing higher personalized and localized characteristics.

Survey Research on the Setting and Utilization of the Fever Clinic at Primary Healthcare Institutions　

YAN Yunyun，XIAN Honghong，WANG Jie，SUN Xianjin，WANG Haitang，GU Yanfeng，DU Zhaohui，SUN Xiaoming

2021, 24(34): 4312-4318. DOI: 10.12114/j.issn.1007-9572.2021.00.318

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Background　During the prevention and control of the COVID-19，the setting of fever clinic in primary healthcare institutions is an important experience summary and pilot practice. At present，the pilot sentinel surveillance has been carried out for more than one year，and it is necessary to analyze its operation situation. Objective　To investigate the setting and utilization of fever clinic in primary healthcare institutions，summarize experience and put forward corresponding suggestions. Methods　From 2021-02-22 to 2021-03-02，a multi-stage sampling method was adopted to select primary healthcare institutions（community healthcare centers/township health centers） who participated in the prevention and control of the COVID-19 epidemic to conduct a questionnaire survey（including fever sentinel surveillance clinics set up during epidemic prevention and fever clinics set up before epidemic prevention），cumulative use time，cumulative number of visits，cumulative referral rate，and cumulative number of diagnoses. Results　718 valid responses from 408 primary healthcare institutions were totally obtained. Among them，208 institutions（51.0%） set up fever sentinel surveillance clinic during the prevention and control of the COVID-19 epidemic，91 institutions（22.3%） had set up before the prevention and control of the COVID-19 epidemic，and 109 institutions（26.7%） had not set up. 271 subjects participated in the work of the fever sentinel surveillance clinic. According to the 271 questionnaires：as the end of January 2021，the median cumulative use time of the fever sentinel surveillance clinic is 12（10） months；188 cases（69.4%） of the respondents indicated that the cumulative number of visits was <300，and 45 cases（16.6%） indicated that the cumulative number of visits was >1 000；184（67.9%） respondents indicated that the cumulative referral rate was <3%，and 35（12.9%） respondents indicated that the cumulative referral rate was >70%；238（87.8%） of the respondents indicated that the number of patients who were finally diagnosed with novel coronavirus pneumonia was 0 out of all the patients admitted. The test results of χ2 showed that the cumulative number of visits between the setting of the fever clinic during the prevention and control of the novel coronavirus pneumonia epidemic and the setting of the fever clinic before the epidemic prevention and control is statistically significant（P<0.05）；However，there is no statistically significant difference in the cumulative number of visits，the cumulative referral rate，and the cumulative number of diagnoses in fever clinic in different regions（including economic zone，geographical location within the city，and the highest risk level during the epidemic period of the region）. The results of Spearman rank correlation analysis showed that the setting time of fever clinics was significantly positively correlated with cumulative use time and cumulative visits（rs values were 0.37，0.18，P<0.05），and the region（east，central，and western） was significantly positively correlated with cumulative diagnoses（rs=0.13，P<0.05）. Conclusion　According to the survey，more than two thirds of primary healthcare institutions in China have set up fever sentinel surveillance clinics/fever clinics，and of which no difference were indicated in the cumulative visit number of febrile patients，cumulative referral rate and cumulative number of confirmed COVID-19 infections based on the different economic zones，geographical locations and regions with different highest risk level. The higher cumulative number of visits to fever clinics than fever sentinel surveillance clinics demonstrated the potential capacity of managing patients with fever during the pandemic of infectious diseases.

A WHO Guide on Integrating Palliative Care and Symptom Relief into Primary Health Care : Key Points and Implications for China　

DONG Lili，LIANG Tao，YANG Haojie

2021, 24(34): 4319-4323. DOI: 10.12114/j.issn.1007-9572.2021.00.179

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The WHO has released several palliative care guidelines since 2014，providing important evidence for the implementation of palliative care. In the situation of limited medical resources，increased demand for palliative care，and limited palliative care specialists，community-based palliative care may be an effective model to solve the underuse of palliative care.In 2018，the WHO Department of Service Delivery and Safety，in collaboration with experts from the United States，the United Kingdom and other countries and regions，developed the Integrating Palliative Care and Symptom Relief into Primary Health Care，which is the first guide on how to systematically integrate palliative care into primary health care. This guide consists of eight chapters. We explained the scientific and practical significance of integrating palliative care into primary health care based on Chapter 3，and discussed how to integrate palliative care into primary health care based on Chapters 4，5 and 6，mainly including the allocation of essential medical resources and drug management in the community，core palliative care competencies requirements for primary care providers，as well as the important role of community health workers. In addition，we introduced successful integration cases of some regions and countries in the guide，and put forward suggestions feasible for domestic implementation in accordance with relevant domestic policies and research. The introduction of this guide may provide help for the development of palliative care and further integration of community medical resources in China.

Research Status of Advance Care Planning at Home and Abroad from the Perspective of Community　

XING Bingyu，MIAO Qunfang，ZHANG Jinsheng，ZHANG Jing

2021, 24(34): 4324-4329. DOI: 10.12114/j.issn.1007-9572.2021.00.216

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The patient-centered and family oriented community health service center is a new way to promote the advanced care planning（ACP），and it is an important part of community palliative care. There have been practical experience and theoretical discussion in some developed countries and regions. At present，the research on community ACP in China is still in its infancy. We need to learn from the advanced ideas and experience of foreign community ACP development to explore the ACP development model suitable for the Chinese community. Based on the perspective of community，this paper expounds the current situation of ACP development at home and abroad，analyzes the advantages of community ACP implementation combined with the current situation of community in China，and puts forward some suggestions for the development of ACP in Chinese communities，so as to provide reference for the research and practice of ACP in domestic communities.

General Practitioners' Participation in Home-based Hospice Care in Foreign Countries：Practice Experience and Enlightenment　

LI Wenxia，MA Jun，DU Xue

2021, 24(34): 4330-4335. DOI: 10.12114/j.issn.1007-9572.2021.00.223

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Hospice care improves a patient's quality of life at the end of life via reducing his physical and mental sufferings，and also relieves the physical and mental burden endured by his family members. In recent years，rich experience in developing hospice care has been accumulated in other countries，with a prominent feature of GPs being primary providers of home-based hospice care. However，given that the development of hospice care in China started late，the development of relevant essential projects is weak，and the research on GPs involvement in hospice care is still in its initial stage，it is necessary for China to accelerate the construction of a hospice care system to meet the increasing demand for hospice care. In view of this，we analyzed and summarized the useful experience of GPs participating in hospice care in the US，the UK，Australia and other countries，then put forward insightful suggestions in accordance with current status and characteristics of China's hospice care system：establishing a multi-level hospice care system，supplemented by activity-based payment and health insurance coverage；formulating guidelines for home-based hospice care services with the clarified scope of practice and responsibilities of GPs；strengthening hospice care education and training for GPs and nurses to improve their competencies；raising the awareness of advance care planning among doctors and patients with effective publicity tools to promote the long-term development of hospice care in China.

Community Health Centers' Capabilities for Outpatient Service Provision：a Study Based on Real-world Diagnostic Data　

HUANG Yanli

2021, 24(34): 4336-4342. DOI: 10.12114/j.issn.1007-9572.2021.00.316

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Background　To improve the capabilities of general practitioners（GPs） working in primary care，one key approach is targeting patients' needs and problems，but there is no big data analysis of the gap between patients' needs and provision of services using the real-world data in China. Objective　To examine the capabilities of urban community health centers（CHCs） for outpatient service provision using a big data analysis of the real-world diagnostic data，offering a reference for improving GP's capabilities for providing first-contact services precisely targeting patients' needs. Methods　We collected outpatient diagnoses（n=2 897 700） by ICD-10 code from CHCs of Wuhou District in 2020，and analyzed the structure，diagnoses ranked from most to least，and degree of accuracy in diagnosing 4 types of chronic diseases using data structure analysis and data distribution analysis. Results　Of the diagnoses，99.31%（2 877 700/2 897 700）were assigned 912 types of six-digit diagnostic codes with a frequency greater than 30；87.31%（2 392 603/2 740 333） with assigned three-digit diagnostic codes were concentrated in the top 10. Among them，preventive diagnostic records are more concentrated，mainly for physical examination（including child health examination） and vaccination services. Most（11/13） CHCs' diagnostic and treatment capabilities had reached grade A standard defined in the Service Capacity Assessment for Community Health Centers（hereinafter referred to as SCACHCs），but the rank order of disease diagnoses was different from the diagnostic coding catalogue in the SCACHCs. The mean coefficients of variation of ICD type，common type，preventive type or clinical type across CHCs were all greater than 25%. The top 10 diagnoses with assigned three-digit diagnostic codes were highly consistent with the national essential public health services. Other common diagnoses included sleep disorders，acute respiratory diseases，digestive diseases and insomnia. Patients with chronic diseases such as hypertension，cardiovascular and cerebrovascular diseases，type 2 diabetes，（lipid） metabolic disorders，and sleep disorders were more likely to have higher number of CHCs visits（more than 5 times per year），and physical examination ranked last among the top 10 services ranked in terms of average number of annual use frequencies per capita. The majority of diagnostic records of common chronic diseases（more than 90%） were concentrated in the code bar of "not specifically specified" in this type of diagnosis. The number of CHCs visits for COPD（n=4 268） was lower than that of those for hypertension，type 2 diabetes or hyperlipidemia. Meanwhile，the number of COPD patients（n=1 675） encountered by the CHCs was less than that of patients with hypertension，type 2 diabetes and hyperlipidemia. Conclusion　Outpatient diagnoses in CHCs of Wuhou District were concentrated，especially in the field of preventive health care. Common diagnoses for diseases were highly consisted with the service profile and population of the national essential public health projects. Most of the CHCs' diagnostic and treatment capabilities had reached the standard of excellence，but there is still room for improvement in comprehensive diagnosis of patients，especially those with chronic diseases，with highlights on taking actions to improve capacities for comprehensive diagnosis of hypertension and related cardiovascular diseases，type 2 diabetes，acute respiratory diseases，digestive diseases，organic sleep disorders，non-organic sleep disorders or other diseases，and for management of diagnosis and treatment of such diseases. Heavy workload may result in the prevalence of diagnostic inertia in GPs，especially under the circumstances of encountering common chronic diseases. So it is suggested to take factors associated with GPs，family doctor teams，and institutional supply and security into account when systematically designing the path to improve CHCs' capabilities for outpatient service provision.

Frequency Characteristics and Influencing Factors of Adult Visits in Community Health Service Institutions Based on Real World Data　

HUANG Yanli，CAO Peiya

2021, 24(34): 4343-4348. DOI: 10.12114/j.issn.1007-9572.2021.00.317

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Background　"Frequency of medical visits" is an important data that truly reflects patients' utilization of medical institutions，but there are few related researches in China，and there is no research on the relationship between visit behavior reflected by "frequency of medical visits" and contract service. Objective　To analyze the characteristics of the frequency of visits by contracted/non-contracted patients in urban primary care，as well as the factors that affect the frequency of visits by contracted populations，in order to identify the tendency of patients with different characteristics to use primary care resources and related influencing factors，help the family doctor team invest resources better，establish a more stable service relationship with patients. Methods　In January 2021，after desensitizing patients' identities，contact information，and specific disease diagnosis information，the outpatient behavior and contract status data of 13 community health service centers in Chengdu Wuhou District and their 18 service stations from 2020-01-01 to 2020-12-31 were extracted. The frequency of patient visits and its influencing factors were analyzed. Results　In 2020，a total of 300 634 adults visited community health service institutions，and 1 243 436 outpatient records were generated. The average age of outpatient visits was（51.5±18.4） years，and the average frequency of outpatient visits was（4.14±5.94）. Only 9 448 patients（3.14%） had cross-community health service visiting behavior，among which only 17 patients were contracted. 34.73%（104 399/300 634） of adults visiting community health service institutions were contracted populations，and 63.91%（794 710/1 243 436） of the total outpatient visits were contracted populations. 86.04%（168 840/196 235） of the non-contracted patients visited the hospital occasionally，69.93%（137 229/196 235） of the patients with relatively simple conditions. 52.30%（55 812/104 399） of the contracting population were treated with continuous management，and 29.90%（31 211/104 399） had relatively simple conditions. Calculated by the number of people，the rate of active appointment was 40.29%（42 061/104 399），and the rate of regular visit was 37.86%（39 522/104 399）. Calculated by frequency，the rate of active appointment was 18.58%（147 685/794 710），and the rate of regular visit was 18.12%（144 009/794 710）. There were statistically significant differences in age，medical frequency，the number of patients receiving traditional Chinese medicine services，number of clinicians，frequency of visits，and complexity of diagnosis between contracted patients and non-contracted patients（P<0.05）. The results of ordered multi-classification Logistic regression analysis showed that the degree of disease complexity，whether to make an appointment actively，whether to seek regular medical treatment，whether to use traditional Chinese medicine services，age，whether have outpatient medical insurance，contracted institution and number of doctors signing contracts were the influencing factors for the frequency of patients visit（P<0.05）. Conclusion　The contracted population in Wuhou district have established stable service relationship with family doctors. To make better use of the contracted service functions of community health service institutions，on the one hand，the number of contracted groups can be increased from the non-signing groups with the characteristics of frequent and abnormal frequent visits，high utilization of traditional Chinese medicine and have outpatient medical insurance，on the other hand，according to the characteristics of the influencing factors of the contracted population，through the adjustment of performance assessment indicators，the frequency of contracted patients can be further controlled in a reasonable interactive range for scientific and continuous management.

Development of a System for Identifying Community-dwelling Outpatients with Mental Disorders Needing Emergency Management Amid a Public Health Emergency by General Practitioners　

ZHANG Hanzhi，JIN Hua，LIU Huailei，PENG Yangyang，GUO Aizhen，YU Dehua

2021, 24(34): 4349-4355. DOI: 10.12114/j.issn.1007-9572.2021.00.314

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Background　In the context of public health emergencies，for example，the COVID-19 pandemic，community hospitals may face challenges to provide diagnosis and treatment services and to reduce the disease burden for patients with mental problems. However，general practitioners（GPs）' capabilities in diagnosing and treating mental disorders are unsatisfactory. Objective　To develop a system for identifying community-dwelling outpatients with mental disorders needing emergency management amid a public health emergency by GPs，to promote GPs' capabilities in diagnosing and treating mental disorders，and the health of such patients. Methods　From May to June 2020，based on a literature review and an investigation of work requirements for GPs，we formed a framework for identifying community-dwelling outpatients with mental disorders needing emergency management amid a public health emergency by GPs with indicators initially determined. Then we screened and revised the indicators according to the results of a two-round Delphi survey with 15 experts（in the field of general practice or mental health medicine），and finally determined the indicators（with a mean value of weighted importance>3.5，coefficient of variation <25%，and rate of getting full marks >20%） for the formal system identifying community-dwelling outpatients with mental disorders needing emergency management amid a public health emergency by GPs. Results　Information of the experts surveyed：13 of them had a graduate degree，and 10 had a senior professional title. Positive coefficients of the experts：All the experts（100%） actively responded to the two rounds of survey. Authority coefficients of the experts：the authority coefficient of the six domains were >0.70. The degree of agreement between the experts：the Kendall's W in the second round of survey was 0.278（χ2=100.197，P<0.001），which was higher than 0.245（χ2=73.597，P<0.001）in the first round of survey. The final indicators：24 indicators in six domains involving mental symptoms，diagnosis of mental illness，severity of mental illness，personality，physical status，family and social background. Conclusion　Our system may help GPs to high-efficiently identify community-dwelling outpatients with severe mental disorders needing emergency treatment or referrals. However，the accuracy of the system needs to be verified further.

Community General Practitioners' Perception of Community-based Cardiac Rehabilitation for Stable Coronary Artery Disease：a Survey in Beijing's Xicheng District　

DONG Yuming，YANG Ling，DONG Jianqin，DU Xueping

2021, 24(34): 4356-4363. DOI: 10.12114/j.issn.1007-9572.2021.00.309

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Background　The number of patients with coronary heart disease（CHD）is increasing year by year in China. As an important means of prevention and treatment，cardiac rehabilitation can improve the quality of life，reduce the readmission rate and mortality of CHD patients. However，community-based cardiac rehabilitation is less developed at present，and CHD patients have gained less merits from sleeping guidance，psychological counseling and cardiac risk assessment in exercise. Objective　To explore community general practitioners'（GPs'）perception of community-based cardiac rehabilitation for stable coronary artery disease（SCAD）providing a scientific basis for the development of community-based cardiac rehabilitation. Methods　By use of cluster sampling，we selected frontline general practitioners（GPs）（n=212）from 5 community health centers（Yuetan，Guangwai，Zhanzhan Road，Taoranting，Desheng）in November 2020. Then we conducted a survey on wjx.cn（an online questionnaire survey platform）using a self-administered questionnaire（consisting of basic demographics，attitudes and perceptions regarding community-based cardiac rehabilitation for SCAD，essential knowledge and practice of cardiac rehabilitation）developed by us，and invited the GPs to anonymously complete the survey via scanning the WeChat QR code or printed QR code using a mobile phone or computer between November 26 and December 31，2020. The survey data were collected to input into a database，and analyzed for understanding GPs' perceptions of community-based cardiac rehabilitation for SCAD. Willingness of community GPs' to provide community-based cardiac rehabilitation services for patient swith SCAD and scores of GPs obtained by answering the questions about community-based cardiac rehabilitation for SCAD by demographic factors were compared. Binary Logistic regression was used to identify potential factors associated with community GPs' willingness to provide community-based cardiac rehabilitation services for SCAD patients. Results　A survey response rate of 98.1%（208/212）was obtained. In accordance with the analysis，of the respondents，91.3%（190/208）thought that SCAD patients need community-based cardiac rehabilitation，90.4%（188/208）thought that community-based cardiac rehabilitation could be safely implemented without monitoring，74.0%（154/208）were willing to provide the services. Binary Logistic regression analysis showed that participating in cardiac rehabilitation training for CHD patients 〔OR（95%CI）=6.042（1.935，18.867），P<0.05〕，and perceptions of SCAD patients needing community-based cardiac rehabilitation〔OR（95%CI）=10.792（2.361，49.336），P<0.05〕 were associated with community GPs' willingness to provide community-based cardiac rehabilitation services for SCAD patients. The respondents obtained an average SCAD cardiac rehabilitation knowledge test score of（70.12±9.54），with a pass rate of 86.5%（180/208）. There is a statistically significant difference in SCAD cardiac rehabilitation knowledge test score among professional title groups（P<0.001）. The correct rates of the respondents answering "basic concept of cardiac rehabilitation" "selection of target population for intervening" "health education" "follow-up" and "psychological and sleep management" were 94.2%（196/208），90.4%（188/208），98.6%（205/208），92.8%（193/208），and 98.1%（204/208），respectively. But the correct rates of them answering "comprehensive cardiovascular evaluation" "cardiovascular risk control" "risk stratification of coronary heart disease" and "formulation of exercise prescription" were 1.9%（4/208），1.9%（4/208），3.4%（7/208），and 1.4%（3/208），respectively. Only 10.1%（21/208）of the respondents knew the 6-min walk test and often used it. Conclusion　The GPs generally thought that community-based cardiac rehabilitation services for SCAD patients is necessary and feasible，and they were willing to provide such services with high enthusiasm，but their awareness rate of key contents of SCAD cardiac rehabilitation was low. To ensure the successful implementation of community-based cardiac rehabilitation，multi-party collaboration should be strengthened to improve GPs' community cardiac rehabilitation skills.

General Practitioner Trainers' Perspectives on Continuing Medical Education in General Practice in China：a Qualitative Study　

YOU Conglei，YAO Mi，QI Jianguang

2021, 24(34): 4364-4371. DOI: 10.12114/j.issn.1007-9572.2021.00.302

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Background　Continuing medical education in general practice（CMEGP）is an important approach to improve quality of general practitioners（GPs）. GP trainers are indispensable participants in the implementation of CMEGP. Understanding their perceptions and experience regarding CMEGP could help discover and solve problems in CMEGP from a new perspective. Objective　To explore GP trainers' perspectives on CMEGP in China，offering evidence for further improving the quality of CMEGP. Methods　From November 2020 to February 2021，snowball and purposive sampling methods were used to recruit qualified GP trainers with rich experience in CMEGP to attend an in-depth，semi-structured personal video interview. The interview results were recorded，and transcribed，then coded using NVivo 12，and analyzed using thematic analysis. Results　In total，10 GP trainers（6 men and 4 women）in the age range of 29-49 years〔average age of（38.7±5.8）years〕，attended the interview，8 of whom had a master or doctor degree；9 worked as a GP in a tertiary medical institution. The average years of them working a GP trainer was 4-12 years〔（7.8±2.8）years on average〕. Five themes emerged from the analysis：Self-factors of GPs affect the effect of CMEGP；construction and management of GP trainers are insufficient；teaching theories are important but insufficient for CMEGP；the effect of CMEGP may be improved by taking actions in accordance with the development needs of primary care and teaching approaches；the quality of CMEGP may be affected by external factors. Conclusion　There are many difficulties and challenges in the development of CMEGP in China：defects in the management and training of GP trainers，and the quality of CMEGP needs to be improved. Clarifying the connotation of GP trainers，and improving the training system and assessment standards for GP trainers are essential for exploring effective training models and improving the quality of CMEGP.

Evaluation of the Effectiveness of a General Practice Clinical Skills Workshop Program　

ZHOU Hong，Timothy Noel Stephens，LUO Yucheng，GUO Jingzhu，LIU Ye，CAI Xianli

2021, 24(34): 4372-4377. DOI: 10.12114/j.issn.1007-9572.2021.00.246

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Background　The standardization of general practitioner（GP） training in China has been basically established，but medical students' understanding of GP and their willingness to pursue a career as a GP needs to be improved. Objective　To conduct training for medical school students using a general practice clinical skills workshop program，and evaluate the effectiveness of the program. Methods　Research subjects included 120 undergraduate students who voluntarily selected a general practice clinical skills workshop course at Hainan Medical University，including students from clinical medicine，pharmacy，and non-clinical majors. A self-designed questionnaire was used to conduct a pre- post- self-controlled comparative study of the included students in June 2018（before training） and December 2018（after training） to investigate their knowledge，attitudes，and career intentions related to general practice before and after training and feedback on general practice teaching. Results　73 of the students completed the questionnaire. Survey results showed that of the 73 respondents，29（39.7%） majored in medicine and pharmacy，and 44（60.3%） majored in non-clinical，but only 18（24.7%） had taken the course Introduction to General Practice. After training，72（98.6%） believed that it is necessary to offer a general practice course for clinical majors. After training，participants' mastery of the definition of general practice，the character of general practice，the role of GPs，and the role of general practice in the healthcare system improved significantly（P<0.05）. The percentage of participants who scored "above average" for the knowledge test section of the questionnaire before and after training was 9.6%（7/73） and 50.7%（37/73），respectively. The proportion of medical and pharmacy students willing to engage in a career in general practice increased from 69.0%（20/29） before training to 96.6%（28/29） after training. Conclusion　This general practice clinical skills workshop group facilitated improvement in undergraduate medical students' understanding of general practice and their willingness to work in general practice. These results may provide a reference for innovative general practice education models.

Development of a Contracted Service Performance Assessment System for China's Family Doctors　

SUN Caixia，SI Sijun，JIANG Feng，LIU Tingfang

2021, 24(34): 4378-4385. DOI: 10.12114/j.issn.1007-9572.2021.00.249

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Background　The implementation of contracted family doctor services is one of the tasks to achieve successful reform of the pharmaceutical and healthcare system in China. Currently，although the services are available nationwide，healthcare workers for delivering such services have not been fully incentivized by existing performance assessment systems，so it is essential to develop a set of more scientific and effective performance assessment system. Objective　To develop a system for assessing the performance of China's family doctors in the delivery of contracted services，promoting the domestic development of the services. Methods　Through reviewing relevant policy documents，literature，and sophisticated evaluation tools，we developed an item pool for the initial version of the contracted service performance assessment system for China's family doctors. Then from March to May in 2020，we selected 30 experienced experts from relevant fields，and invited them to attend a two-round Delphi survey using a self-developed Delphi Expert Consultation Form. After that，we calculated the authoritative coefficient and other indicators，and according to the consultation results，we revised the initial version of the system to a final one. Results　Either the first or second round of survey achieved a 100.0% response rate，with a 100.0% positive coefficient of experts. Furthermore，the authoritative coefficient（Cr） of experts for both rounds of the survey ranged from 0.850 to 1.000，with an average value of 0.913. All of that reached the acceptable standard. In terms of the value of the first-，second-，and third-level indices of the system，the Kendall's concordance coefficients in the first round of survey were 0.144（P<0.05），0.254（P<0.01），and 0.268（P<0.01），respectively，and those in the second round of survey were 0.158，0.354，and 0.495（all P<0.01），respectively，suggesting that the experts' opinions gradually reached a consensus，and the evaluation results were stable and reliable. The final system includes three first-level indices，10 second-level indices，and 59 third-level indices involving the quality of service structure，service delivery process and service outcome. Conclusion　The consulted experts were highly motivated with high degree of authority. And they obtained a consensus on the indices of the system after two rounds of survey，indicating that our system is reliable.

Defining the Scope and Weights of Services of a Family Doctor Service Project for the Functional Community　

SUN Xinran，WAN Heping，HAN Yule，SU Lina，HE Biyu

2021, 24(34): 4386-4391. DOI: 10.12114/j.issn.1007-9572.2021.00.270

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Background　Current family doctor services could not fully satisfy general healthcare needs of the functional community due to lack of sufficient appropriateness. Objective　To define the scope and weights of services of a family doctor service project for the functional community，offering help for choosing appropriate family doctor services and assessing the priority of the services for the functional community. Methods　From July to October 2020，a two-round consultation with 16 community health experts using the Delphi technique was conducted to analyze the results of previous investigation of healthcare needs of the functional community and of relevant previous expert consultation to determine the domains of family doctor services for the functional community and specific services in each domain. Analytic hierarchy process was used to calculate the weight of each service. Results　Both two rounds of consultation achieved a 100% response rate. The judgment，familiarity and authority coefficients as well as Kendall's W were 0.963，0.881，0.922，and 0.194 ，respectively，for the first round of expert consultation（P<0.001），and were 0.975，0.881，0.928，and 0.219，respectively，for the second round of expert consultation（P<0.001）. The determined 5 domains of family doctor services for the functional community include essential healthcare services，occupational health services，individualized occupational health services，school health services and nursing home health services，with 0.320，0.109，0.068，0.320，0.183，as the corresponding weights，and 0.008 as the consistency ratio of the judgment matrix. The determined services were 46 in total，and the consistency ratio of the judgment matrix for services in the 5 domains was 0.018，0.027，0.027，0.006，and 0.009，respectively. Conclusion　This family doctor service project for the functional community has been demonstrated to be scientific and reliable in terms of the scope of services and weights of services，which may be useful to the formulation and implementation of relevant supportive policies.

Development of a Primary Care Needs-based Health Education Services Framework for Type 2 Diabetics Using the Nominal Group Technique　

LIN Kai, YAO Mi, XIE Jieying, YUAN Gang, JI Xinxin, CHEN Yongsong

2021, 24(34): 4392-4397. DOI: 10.12114/j.issn.1007-9572.2021.00.311

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Background　Most of the health education recommendations from Chinese guidelines ignore the characteristics and patient needs of primary health care，especially type 2 diabetes mellitus（T2DM） health education delivered by primary outpatient clinics is random，untargeted and so on. Objective　To develop a primary care needs-based health education services framework for T2DM patients using the nominal group technique（NGT），and to expand its essentials. Methods　From September to October 2020，NGT was used to conduct meetings in three groups of Chinese health professionals（n=23） in various medical specialties selected using purposive sampling. The results of meetings were recorded and transcribed，and divided into qualitative and quantitative data for analyses. After merging the similar ones of keywords of qualitative data of each group discussion，the list of network coded（NC） keywords was obtained，and essential contents of these key words were expanded，and analyzed using thematic analysis. Intra-group and overall ranking of keywords of the quantitative data in the list were determined. Finally，the hierarchical frameworkwas determined according to the quartile assigned by the overall ranking. Results　Twenty-eight keywords regarding T2DM health education were obtained through group discussions and decision-making，and classified into five themes by thematic analysis and content development：diabetes-related knowledge，self-management，community management，multiple comorbidities management，treatment and medication. After two rounds of ranking and stratification，a four-level hierarchical framework of health education for T2DM patients was finally determined. The A hierarchy includes four top-ranked keywords，accounting for 45.69% of the total mean rank scores. Conclusion　We applied NGT to develop a primary care needs-based health education services guiding framework for Chinese T2DM patients，and used an evidence-based approach to determine its four-level hierarchy and highlighted contents. As patients' primary care needs are complex，which need to be satisfied based on group decision-making，our framework may contribute to achieve a higher consistency between guidelines and clinical practice.

Factors Associated with Medication Adherence in Beijing Community-dwelling Residents with Type 2 Diabetes：a Study Using the Theory of Planned Behavior　

WU Yao，LIN Yanming，GUO Kai，WU Ming

2021, 24(34): 4398-4403. DOI: 10.12114/j.issn.1007-9572.2021.00.313

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Background　In accordance with the regulations of China's national essential public health services，community health centers（CHCs） are required to deliver health management services to diabetic patients to effectively achieve glycemic control. Taking medications regularly and on time is one of the main means to control diabetes. So it is of practical significance to explore the impact of community-based diabetes health management services on medication adherence of diabetic patients. Objective　To investigate the utilization status of community-based diabetes health management services and medication adherence in Beijing community-dwelling residents with type 2 diabetes，and to analyze the possible influencing factors of medication adherence. Methods　A face-to-face questionnaire survey was conducted between July and August 2018 with 1 218 diabetic patients selected by use of convenient sampling from six CHCs in Beijing using a questionnaire developed by our research group for collecting the patients' general demographics，utilization of community-based diabetes management services and medication adherence（including MMAS-8 and a questionnaire of intention to take medication based on the theory of planned behavior）. The structural equation modeling was used to explore the influencing factors of medication adherence. Results　Altogether，1 156 cases（94.91%） who effectively completed the survey were included for final analysis，and the medication adherence of them was 77.16%（892/1 156）. After verification，the number of face-to-face follow-ups and guidance on antidiabetic medications were included as covariates into the modified structural equation model. The values of RMSEA（0.041），CFI（0.893），PNFI（0.639），and CN（499） of the final model indicated that the goodness-of-fit of the model was excellent. Face-to-face follow-up and diabetes medication guidance affected the attitude towards medication（0.09） and subjective norms（0.08） respectively. Face-to-face follow-up indirectly affected medication adherence with an overall standardized effect size of 0.01（P=0.013）. Guidance on antidiabetic medications also indirectly influenced medication adherence with an overall standardized effect size of 0.01（P=0.011）. Conclusion　Community-based diabetes health management services indirectly affected the medication adherence of type 2 diabetics. Receiving medication guidance increased the patients' behavioral intention to adhere to medication，and face-to-face follow-ups enhanced the patients' belief in medication adherence，consequently，increasing the possibility of developing medication compliance behaviors.

Application of a Self-made Diabetic Diet Manager in Empty Nesters with Type 2 Diabetes and Poor Glycemic Control　

LYU Juanqin，SHEN Lilan，MENG Zuolong，WANG Xiaoping，LI Fulian

2021, 24(34): 4404-4408. DOI: 10.12114/j.issn.1007-9572.2021.00.265

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Background　Poor treatment adherence and glycemic control are common in older adults with diabetes. Diet is strongly associated with glycemic control，so studying diet management will greatly contribute to prognosis improvement of diabetic patients. Objective　To examine the effect of a self-made diabetic diet manager in empty nesters with type 2 diabetes and poor glycemic control. Methods　Participants were 120 empty nesters with type 2 diabetes and poor glycemic control selected from the Third Affiliated Hospital of Gansu University of Chinese Medicine，including 60 hospitalized between February and October 2018（traditional group with 6-month-follow-up routine health education），and 60 hospitalized between February and October 2019（diabetic diet manager group with 6-month-follow-up intervention using a diabetic diet manager developed by our research group）. Medical records and complete follow-up data were collected retrospectively. Pre- and post-follow-up fasting and two-hour postprandial glucose levels and self-care ability（evaluated by the Summary of Diabetes Self-care Activities）of two groups were compared. The complications and readmission of the two groups during intervention were observed and recorded. Results　After 6 months of intervention，the fasting blood glucose，two-hour postprandial blood glucose and glycated hemoglobin levels fell notably in both groups（P<0.05），and they decreased more significantly in diabetic diet manager group（P<0.05）. Both groups had an obvious increase in the scores of successful self-management of diet and exercise，blood glucose self-monitoring and taking medicines as prescribed（P<0.05），and a more significantly increase was observed in diabetic diet manager group（P<0.05）. No peripheral neuropathy and macroangiopathy were found in both groups. The incidence of diabetic retinopathy and diabetic nephropathy，and readmission rate in diabetic diet manager group were lower than those in the traditional group（P<0.05）. Conclusion　The intervention using the diabetes diet manager developed by us may be far superior to traditional health education in terms of improving self-care ability and glycemic control，as well as reducing complication incidence and readmission rate in empty nesters with type 2 diabetes and poor glycemic control，indicating that it has a high value of clinical application.

Recent Advances in Pharmaceutical Management of Falls in Older People　

HUANG Ya'nan, YANG Xiaoxuan, CHEN Xiao, YUAN Gang

2021, 24(34): 4409-4414. DOI: 10.12114/j.issn.1007-9572.2021.00.284

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In older people，the incidence of falls is high，which are an important cause of injury，disability and death. So assessing the risk of falls and managing falls are essential to reduce falls incidence and the severity of injuries. Pharmaceutical factors are a key component of risk assessment of falls. And pharmaceutical interventions are vital in the management of falls，but there are no uniform criteria for how to make decision to deliver and manage pharmaceutical interventions for falls，which may be due to inadequate importance attached to these aspects. Given that some scholars have carried out relevant research on the necessity and feasibility of delivering pharmaceutical interventions for falls，we reviewed the latest advances in pharmaceutical interventions for falls in older adults，aiming at providing useful ideas for furthering the development of pharmaceutical interventions.

Advances in the Use of Hearing Aids Improving Hearing Impairment in Older People with Community-based Home Care　

LIU Jiamin，ZHAO Yasha，WANG Jingrui，LIU Peixuan，XI Ruihan，HAN Lin，DAI Fumin

2021, 24(34): 4415-4420. DOI: 10.12114/j.issn.1007-9572.2021.00.277

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The prevalence of hearing impairment in older people with community-based home care is increasing，which has a negative impact on their quality of life，cognitive function and social behaviors，so it is of great significance to take measures to prevent and reduce such negative impacts. It has been found that the use of hearing aids effectively improves hearing level and sociability，as well as cognition，memory and perception of language in older people with community-based home care. However，relevant research is still in its infancy and there is no systematic review about it. We reviewed the latest studies on the use of hearing aids in older people with community-based home care，encompassing the overview of hearing impairment and hearing aids，current status and existing problems regarding the use of hearing aids in older people with community-based home care，and cognitive features of this group，as well as impact of using hearing aids on their cognitive function，then put forward recommendations facilitating the extensive use of hearing aids in this group，including hearing aids research and making，development of supportive policies to promote the development of hearing aid industry，the fostering of hearing care professionals，and the enhancement of high-risk individuals' knowledge，attitude and use regarding hearing aids，clinical study of the effect of hearing aids，and hearing aid related services.

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