Table of Content

05 January 2022, Volume 25 Issue 01

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Editorial

Ten-year Development of General Practice in China：Opportunities and Challenges

YANG Hui, HAN Jianjun, XU Yanli, GAO Xiaohuan, WANG Yang, YANG Yunli, CAO Xinyang

2022, 25(01):  1-13.  DOI: 10.12114/j.issn.1007-9572.2021.00.337

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To review the strengths and limitations of the development of general practice in China during the last decade (2010—2020) and to assess the opportunities and challenges for its future development.

Data were collected from statistic reports, journal articles and official policies and guidelines regarding general practice development in China from 2010—2020. Donabedian model was applied to examine and assess the quality of essential general practice services in China. SWOT analysis was used to identify internal and external determinants of general practice development in China.

(1) Structural quality of general practice: the ten-year policies about general practice development were a continuation of the past relevant policies in essence but with developments, with highlights on continuous construction of general practice workforce and discipline, tiered diagnosis and treatment and regional medical consortium, but relevant fiscal and management policies still need improvements. The number of general medical workers has increased rapidly, while the lion's share of them are still allocated at tertiary hospitals. Full-time equivalent is suggested to be used to predict the staffing and assess the performance of these workers. The number of community health centres showed a steady increase, but its growth rate was still slower than that of hospital facilities. Relevant health economics data need to be further supplemented. (2) Process quality of general practice: in 2020, there were 2.045 billion visits in community health centers (stations) and township health centers, that is, 1.5 visits per person per year on average. There was a significant development when found only 1 visit per person per year for primary care in 2010. However, the frequency of visits for primary care was still lower than that of visiting hospital-based outpatients (an average of 2.7 visits per person per year) . The COVID-19 pandemic had a significant impact on community health services/general medical services, and the number of outpatient visits dropped by about 20%. The number of general practice research articles reached a peak in 2018, mainly focusing on bi-directional referrals, tiered diagnosis and treatment, general practitioners (GPs) /family doctors, general medicine, community health services, chronic disease management (especially hypertension and diabetes) , and analysis of factors associated with aspects involved in general medical services. General practice research is expected to provide more support for developing innovative and critical thoughts, more practice-based evidence for clinical services, and more assistance for service quality and patient outcomes improvement as the discipline advances. (3) Results of implementing general medical services: there is no sufficient evidence on the influence of general medical services on people's health. The experiences and views of people including healthy individuals and patients indicated that those receiving general medical services or contracted family doctor services perceived positive experience and expressed high satisfaction, but perceptions and views of general population in the community toward general medical services need to be explored. GPs' own experience and opinions on general practice were quite different. Gender, age, professional title, urban and rural areas, and geographical location may be associated with their experience and job satisfaction. There may be instability in the general practice workforce, mainly due to personal income, workload and time pressure. (4) The major strengths of developing general practice in China are as follows: strong policy-based promotion and government leadership; rapidly constructing and developing GPs teams owing to the excellent resource allocating ability shown by the centralized system from central to all local governments; significantly enhanced general practice education and training systems; increased core professionals as general practice educators and trainers; special development of general practice characterized by the integration of medical sciences and Chinese traditional humanistic theories. (5) The development of general practice in China has been facing limitations similar to those in other countries. Besides that, its special limitations include late development of the discipline, unsatisfactory quality of workforce, high work pressure and high prevalence of burnout in the workforce, as well as impact of generation gap on education and practice among GPs. In addition, the relation between specialists and GPs is on transition of from undifferentiated attachment to self-recognised uniquity, and further seeking transdisciplinary. The teaching competences of GPs teachers, especially those teaching community and clinical care, are inadequate. GPs team building and management need to advance from the formation to the storming and performing phases. (6) Opportunities for further development of general practice in China include strategies for achieving the goals of Healthy China, and an all-round well-off society, the important role of primary health care in sustainable development and universal health coverage reaffirmed by the Declaration of Astana, as well as significantly improved health literacy of people. (7) Challenges for the development of general practice in China include population ageing, and aging-related changes in burden of disease and socio-economic status, the aging and dynamic changes of GPs human resources, the variation of urban and rural areas and regional differences, and the inverted pyramid structure of allocation of medical and health resources (namely, the largest part is allocated to tertiary care while the smallest to primary care) . Relevant recommendations to address these challenges comprise strengthening the advocacy of the development of general practice services, establishing a wide-ranging community collaborative network, and developing general practice professional organizations.

The development of general practice in China is advancing, which is manifested as rapidly increased number of general medical workers, strong government promotion, quickly improved accessibility of essential medical services, and notably increased utilization rate of primary care services. However, the development is facing challenges, such as high discipline and social expectations regarding general practice, instability in the workforce due to high work pressure of the knowledge- and labor-intensive job, GPs' insufficient recognition of their self-identity, and unclear status of financial funding for general practice development. Given that there are unprecedented favorable conditions for general practice development, medical industries and general medical workers are suggested to make efforts to turn challenges into opportunities to develop general medical services, thereby universal health outcomes will be improved.

Epidemiologic Features and Containment of SARS-CoV-2 Omicron Variant

WU Yu, LIU Jue, LIU Min, LIANG Wannian

2022, 25(01):  14-19.  DOI: 10.12114/j.issn.1007-9572.2021.00.348

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Since the first case of the Omicron (B.1.1.529) variant discovered in South Africa was reported to the WHO on November 24, 2021, a total of 57 countries (regions) had reported Omicron cases as of December 8, 2021. Omicron has become the dominant strain in some African countries and is spreading rapidly. Although Omicron causes mild symptoms, with most cases being asymptomatic and mild, the rapid increase in the number of cases could put a heavy strain on global health systems. In addition, its source, transmission characteristics and vaccine resistance remain unclear, which brings great challenges to pandemic prevention and control in all countries (regions) . We reviewed the latest developments in etiological characteristics, mutation sources, transmission characteristics and possible mechanisms, pandemic status, vaccine protection effect and containment measures regarding Omicron, providing a reference for scientific containment of Omicron mutant.

Quality Improvement in General Practice Services

Differences of Community Health Service Quality Evaluation in China and Abroad：a Systematic Review

ZHANG Qianqian, JIN Hua, YU Dehua

2022, 25(01):  20-28.  DOI: 10.12114/j.issn.1007-9572.2021.00.339

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In China, the assessment of community health services has been increasingly valued as the development of such services advances, but relevant research is still at the exploratory stage. Therefore, establishing a community health service quality evaluation system suitable for China's national conditions is critical to domestic development of such services.

To perform a review of studies about community health service quality evaluation in China and abroad to identify the similarities and differences in terms of assessment perspectives and contents between them, providing theoretic evidence for further implementation of such evaluations in China.

Studies regarding community health service quality evaluation were systematically searched in databases of China National Knowledge Infrastructure, CQVIP, Wanfang and PubMed from inception to October 15, 2020. Two researchers performed literature screening, data extraction, and comparative analysis of community health service quality evaluation at home and abroad by assessment perspectives and contents, separately. Descriptive analysis was used to analyze the comparative results.

In total, 62 articles in English, and 16 articles in Chinese were included, among which 10 in English and 7 in Chinese evaluated the quality of community health services in terms of the major factors of features of community health services (first contact, humanization, accessibility, continuity, coordination and comprehensiveness) . The top 3 highlights of these 10 foreign articles were coordination (7/10) , humanization (6/10) and accessibility (5/10) , while those of 7 domestic articles were humanization (6/7) , comprehensiveness (4/7) and accessibility (4/7) . Fifty-two articles in English and 9 articles in Chinese assessed the quality of specific community health services, and these foreign articles mostly focused on the management of chronic diseases〔type 2 diabetes (12/52) , cardiovascular and cerebrovascular diseases (11/52) , hypertension (7/52) , respiratory diseases (7/52) , chronic kidney disease (5/52) 〕, followed by the use of antibiotics (5/52) , cancer screening (5/52) , medication safety (5/52) , child health care (5/52) and geriatric care (5/52) , while domestic articles mostly focused on the management of chronic diseases〔type 2 diabetes (3/9) , hypertension (3/9) 〕, and maternal health management (3/9) .

The quality of community health services is increasingly valued by relevant academic circles. Compared to foreign studies, domestic studies are far less concerned about first contact and coordination, and the assessed specific services in which are not complete, with no quality assessment of diagnosis and treatment of common diseases and frequently-occurring diseases. It is suggested to address the above-mentioned issues to promote the community health service quality evaluation, and improve the depth and breadth of relevant research, thereby the community health service quality evaluation system could be improved constantly.

Exploration of Primary General Medical Care Quality Management：a Case Study of Shanghai General Practice Clinical Quality Control Center

JIN Hua, YI Chuntao, SHI Ling, SONG Huijiang, CHEN Yuge, PAN Ying, YU Dehua

2022, 25(01):  29-34.  DOI: 10.12114/j.issn.1007-9572.2021.00.334

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The general medical care quality management system plays an essential and key role in assuring the quality of general medical care and patient safety in primary care settings. There are no unified criteria and methods for assessing the primary general medical care quality, and rare relevant quality improvement research and practical explorations in China.We reviewed the primary general medical care quality management nationwide, and highlighted the problems, then particularly detailed the three-year (2018—2020) implementation status and achievements of Shanghai, in which the primary general medical care quality was managed by Shanghai General Practice Clinical Quality Control Center (hereinafter referred to as Quality Control Center) in an exploratory way. And the management actions taken by the quality control center were as follows: defining the organizational objectives and tasks; developing the organizational framework and allocating workers; establishing municipal-and district-level organizational networks and operational systems for primary general medical care quality control; developing the inspection indicators for assuring primary general medical care quality; conducting an annual investigation of the general medical care in each of the primary care settings in Shanghai, and providing targeted guidance as well as supervision. The actions of the Quality Control Center provide strong support for quality improvement and safety assurance of primary general medical care. And the practical explorations of the Quality Control Center could be a reference for improving primary general medical care quality management nationwide. To improve the primary general medical care quality management at the naitonal level, which is still in its early phase, we put forward four recommendations: improving the development of the organization system, developing a scientific system for assessing the primary general medical care quality, comprehensively and dynamically carrying out quality controlsupervision regarding primary general medical care, and strengthening the quality controlsupervision.

Quality of General Medical Care in Community Health Centers in 2019—2020：Overview and Problems Analysis

JIN Hua, YI Chuntao, NI Hengru, GU Wenye, GU Jiangtao, CHEN Yuge, YU Dehua

2022, 25(01):  35-42.  DOI: 10.12114/j.issn.1007-9572.2021.00.335

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Strengtheningclinical quality control and supervision is one of the effective ways to ensure medical quality. Supervising the quality of general medical care in primary care settings in the local region could contribute to the systematical assessment of general medical care quality and identification of relevantproblems in such settings.

To analyze the supervision of quality of general medical care in Shanghai's primary care settings conducted in 2019 and 2020, and based on this, to give targeted, rational recommendations on the identified problems in quality management of general medical care.

The quality of general medical care in a cluster sample of community health centers (CHCs) of Shanghai was supervised in 2019 and 2020 by relevant experts from Shanghai's municipal and district general practice quality control departments using the Clinical Quality Control and Supervision Standards for General Medical Care in Shanghai's Community Health Centers (hereinafter referred to as CQCSS) developed by Shanghai General Practice Clinical Quality Control Center. In May 2021, the supervision results of the two years were analyzed using descriptive analysis, then compared, and the identified problems were summarized and analyzed.

Two hundred and forty-three CHCs were involved in the 2019 supervision, and 244 were involved in the 2020 supervision. The average total CQCSS score for 2019 was (87.32±5.97) points, and that for 2020 was (86.67±5.36) points. Compared to the results in 2019, the scores of first-level indicators of basic conditions (99.93% vs 99.80%) , staffing and determining job responsibilities of general practitioners (GPs) (93.44% vs 91.90%) , diagnosis and treatment ability of GPs (85.82% vs 85.72%) , chronic disease management ability of GPs (81.07% vs 80.95%) and scientific research and teaching levels (29.99% vs 28.87%) increased in 2020. The problems mentioned were mainly distributed in five aspects: staffing〔176 (22.03%) 〕, GPs' clinical management ability〔154 (19.27%) 〕, quality of inpatient medical records〔92 (11.51%) 〕, quality of home sickbed patients' medical records〔91 (11.39%) 〕, allocation of facilities〔91 (11.39%) 〕. In terms of the mentioned frequency, the top five problems were: ineligible senior GPs to registered GPs ratio〔84 (10.51%) 〕, poor scientific research〔84 (10.51%) 〕, less than 3.5 GPs per 1 000 residents〔61 (7.63%) 〕, unsatisfactory clinical skills〔40 (5.01%) 〕, and insufficient number of home sickbeds〔36 (4.51%) 〕.

These two years of quality control supervision has initially promoted the quality improvementof general medical care in CHCs. To further improve it, it is suggested to take actions to deepen the core essence of general medical care quality management, improve the diagnosis and treatment ability of GPs, as well as their teaching and research ability.

Original Research·Health Services Utilization

Utilization of National Essential Public Health Services and Its Relationship with Management Effect in Chinese Type 2 Diabetic Patients

LIU Meicen, YANG Linghe, CHEN Xinyue, LIU Yuanli, YOU Lili

2022, 25(01):  43-49.  DOI: 10.12114/j.issn.1007-9572.2021.00.326

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The national essential public health services (NEPHS) , which have been implemented since 2009, may be the largest population-based intervention practice for Chinese patients with diabetes currently. It is important to understand the utilization and management effect of such services in diabetic population over this period of more than 10 years of development.

To understand the utilization and management effect of NEPHS as well as their association in Chinese type 2 diabetics.

By use of multi-stage stratified sampling, 1 527 type 2 diabetics (≥35 years old) were selected from 20 community (township) health centers in 10 districts (counties) of 5 cities in eastern, central and western China during November to December 2019. Sociodemographic characteristics, utilization and management effect of NEPHS in these patients were collected by face-to-face surveys with a self-designed questionnaire.

According to the survey, patients' self-reported rates of creating health records, use of health records, undergoing standardized blood glucose tests, and receiving standard follow-ups were 90.34% (1 375/1 522) , 52.80% (725/1 373) , 83.69% (1 262/1 508) , and 90.18% (1 377/1 527) , respectively. Household follow-ups and hospital follow-ups accounted for 29.24% (443/1 515) and 61.06% (925/1 515) of the total last follow-ups, respectively. The analysis of management effect showed that patients' self-reported rates of home-based self-monitoring blood glucose and regular medication in the past 6 months were 53.57% (818/1 527) , and 89.26% (1 363/1 527) , respectively. The rates of patients who were satisfied with glycemic control, and overall medical services assessed in the last follow-up were 65.23% (996/1 527) , and 95.15% (1 453/1 527) , respectively. In those≥65 years old, the prevalence of home-based self-monitoring blood glucose differed significantly by the creation of health records and Chinese medicine services (P<0.05) . The prevalence of regular medication differed significantly by number of follow-ups (P<0.05) . The level of overall satisfaction with services differed significantly by the access to personal medical records at any time, Chinese medicine services, number of home-based self-monitoring blood glucose, and type of follow-up (P<0.05) . In those aged from 35 to 64, the prevalence of home-based self-monitoring blood glucose differed significantly by the creation of health records, access to personal medical records at any time, Chinese medicine services, number of blood glucose testing, and number of follow-ups (P<0.05) . The prevalence of regular medication differed significantly by the type of follow-up (P<0.05) . The satisfaction rate of blood glucose control differed significantly by access to personal medical records at any time (P<0.05) . The overall service satisfaction rate differed significantly by follow-up type and creation of health records (P<0.05) .

NEPHS have influenced community-based management of type 2 diabetic patients, the standard implementation of which has enhanced the management effect and the overall service satisfaction in these patients.

Changes in Beijing Residents' Primary Care Utilization during the New Round of Healthcare Reform：a Study Based on 2013 and 2018 Waves of the National Health Service Survey

WANG Huijuan, LIU Xiaoyun

2022, 25(01):  50-54.  DOI: 10.12114/j.issn.1007-9572.2021.00.263

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Beijing has taken a series of measures to promote patients to use primary healthcare since the implementation of the new round of healthcare reform in 2009, especially after the comprehensive reform of separating medical treatment and drug sales, but there is a lack of evidence on the improvement in Beijing residents' use of primary healthcare. The features of users of primary healthcare are still unclear, and if the majority of them have low socioeconomic status, which may bring about the issue of inequity in healthcare use.

To examine the features of Beijing residents choosing a healthcare institution for treatment between 2013 and 2018, and analyze the changes over the period, to provide evidence for promoting the development of tiered diagnosis and treatment system.

This study was carried out from July to September 2020 using the data of Beijing part of the Fifth National Health Service Survey (2013) and Sixth National Health Service Survey (2018) , involving residents≥15 years old with medical experience in the two weeks prior to the survey. Residents' healthcare utilization behaviors were analyzed using Andersen's behavioral model of healthcare utilization, and the changes over the period were analyzed using multiple logistic regression and the Chow test.

The rate of using primary healthcare in the residents increased to 64.40% (4 125/6 405) in 2018 from 60.89% (1 527/2 508) in 2013, showing a statistical difference (χ²=9.61, P=0.002) . Compared to the year 2013, the year 2018 witnessed increased rates of primary healthcare utilization in females, those≥60 years old, living in urban areas, having non-low income, urban employee basic medical insurance, or two or more chronic diseases (P<0.05) . Multiple Logistic regression analysis showed that age, residential area, type of medical insurance and prevalence of chronic diseases were the influencing factors for the selection of medical institutions in Beijing in 2013 (P<0.05) , and gender, age, per capita income level of family, type of medical insurance and prevalence of chronic diseases were the influencing factors for the selection of medical institutions in Beijing in 2018 (P<0.05) . The Chow test demonstrated that increased rates of primary healthcare utilization were found mainly in residents with urban employee basic medical insurance〔OR (95%CI) =1.56 (1.24, 1.97) 〕 and those living in urban areas〔OR (95%CI) =1.27 (1.01, 1.58) 〕 (P<0.05) .

In general, the primary healthcare utilization behaviors of Beijing residents showed an increase trend from 2013 to 2018, and the majority of them were those living in urban areas and/or having urban employee basic medical insurance.

Utilization and Associated Factors of Community Health Management Services in Hypertensive and Diabetic Patients

XU Ying, GUO Yanfang, LIU Zheng, ZHAO Rencheng, YUAN Qing, WANG Yirong, LEI Lin

2022, 25(01):  55-61.  DOI: 10.12114/j.issn.1007-9572.2021.00.323

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Hypertension and diabetes have been included in the list of China's essential public health services since 2009. During these years, the use and associated factors of community health management services in community-living hypertensive and diabetic patients are not very clear and need to be further studied.

To investigate the use and potential associated factors of community health management services in Shenzhen community-living hypertensive and diabetic residents.

Data stemmed from the results of Shenzhen Epidemiological Survey on Chronic Non-communicable Diseases and Risk Factors conducted between September and November 2018. The chi-square test and multinomial Logistic regression were used to examine the association of sex, age, place of hukou registration (Shenzhen or not) , marital status, monthly household income per capita, occupation type, years of living in Shenzhen, prevalence of medical insurance enrollment, and the level of medical institutions making a definite diagnosis with the use of community health management services.

Altogether, 10 042 participants were finally enrolled, including 1 132 with self-reported hypertension, and 402 with self-reported diabetes. Among the hypertensive participants, 530 (46.82%) indicated that they received follow-up management of hypertension from the community health center. Specifically, 436 (82.31%) received blood pressure measurement by the doctor, and 399 (75.25%) received medication guidance from the doctor. Of the diabetic patients, 194 (48.26%) indicated that they received follow-up management of diabetes from the community health center. Specifically, 173 (89.37%) of the 193 cases (one case was excluded due to missed information) received blood glucose measurement by the doctor, and 154 (79.62%) received medication guidance from the doctor. The prevalence of hypertensive participants receiving guidance on smoking cessation or smoking less from the doctor was relatively low (lower than 40%) , and so was that of diabetic participants. The prevalence of hypertensive participants receiving guidance on drinking cessation or drinking less from the doctor was relatively low (lower than 40%) , and so was that of diabetic participants. Multinomial Logistic regression analysis revealed that sex, age, monthly household income per capita, years of living in Shenzhen, and prevalence of medical insurance enrollment were associated with the utilization of community health management services in hypertensive patients (P<0.05) . Age, occupational type, and monthly household income per capita were associated with the utilization of community health management services in diabetic patients (P<0.05) .

Less than half of the community-living hypertensive and diabetic participants used or were involved in community health management services. Being female, 18-44-year-old, low or moderate monthly household income per capita, and short years of living in Shenzhen were associated with lower rate of utilizing such services. Moreover, hypertensive cases without medical insurance, and diabetics engaging in a manual labor job were far less likely to utilize the services. In view of this, it is suggested to strengthen the publicity of essential public health services in the above-mentioned priority groups. Besides that, the awareness of doctors in community health centers should be strengthened to provide patients with guidance on developing healthy lifestyles, such as stopping smoking and drinking.

Original Research·Community-based Diabetes Management

Effect of Core Values of General Practice on Adherence of Patients with Diabetes

YANG Siman, ZHANG Xi, ZHOU Mengping, LIU Shixing, XIE Yuting, KUANG Li

2022, 25(01):  62-69.  DOI: 10.12114/j.issn.1007-9572.2021.00.331

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Treatment adherence is closely related to disease control for patients with diabetes. Primary care is general, and continuous, which may satisfy the general and continuous healthcare needs of diabetic patients. But the association of core values of general practices with adherence of diabetic patients is not yet clear.

To explore the effect of core values of general practice (first contact/first line care, continuity, accessibility, comprehensiveness, coordination and patient-oriented) on the adherence (medication adherence, diet adherence, exercise adherence, self-monitoring adherence and regular hospital visits adherence) of type 2 diabetic patients, providing a reference for improving the adherence of such patients by precisely enhancing the core values of general practices.

A survey was conducted between August and September 2019 with a convenience sample of type 2 diabetics receiving contacted family doctor services from Shayuan Community Health Center of Guangzhou using a questionnaire consisting of three parts〔demographic information, the Chinese version of Primary Care Assessment Survey (ASPC) , and Adherence to Out-of-hospital Treatment of Type 2 Diabetics (AOTTD) 〕. Treatment adherence was compared by various personal factors. Multiple linear regression was used to analyze the association of the core values of general practice with treatment adherence.

Altogether, 224 cases who handed in responsive questionnaires were included for final analysis. The average scores of AOTTD, and ASPC of the respondents were (80.57±11.27) and (72.95±11.40) , respectively. The scores of AOTTD differed significantly by sex and understanding level of type 2 diabetes (P<0.05) . The total score of ASPC and the score of its each domain were associated with the total score of AOTTD, or the domain score of regular hospital visits (P<0.10) . The scores of two domains (accessibility and coordination) of the ASPC were associated with the medication adherence score (P<0.10) . The domain score of coordination was associated with the diet adherence score (P<0.10) . The score of each domain of the ASPC (except for coordination) was associated with the self-monitoring adherence score (P<0.10) .

For type 2 diabetics, strengthening each of the core values of general practice could contribute to the increase of their treatment adherence, and regular hospital visits adherence. Improving the accessibility of general practice could enhance their medication adherence. Improving the coordination of general practice could enhance their medication adherence and diet adherence. Improving first contact/first line care, continuity, accessibility, comprehensiveness, coordination and patient-oriented values of general practice could contribute to the increase of their medication adherence. But no association was found between the core values of general practice and patients'exercise adherence, which suggests that providing more exercise resources and environmental support for these patients may be a solution.

Prevalence and Associated Factors of Behaviors of Monitoring to Prevent Chronic Diabetic Complications among Type 2 Diabetes Patients Involved in Community-based Management

JIANG Yuan, JIANG Lingjun, LIU Suzhen, LI Hang

2022, 25(01):  70-78.  DOI: 10.12114/j.issn.1007-9572.2021.00.322

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Chronic diabetic complications are highly prevalent, which may be an underlying cause of diabetes-related disability and death. Regularly and continuously self-monitoring may contribute to early detection, diagnosis and treatment of various diabetic complications, which is essential to reducing the adverse consequences of diabetes, and is a key program in community-based management that should be highly valued.

To investigate the prevalence and associated factors (such as diabetes prevalence and monitoring and other factors) of behaviors of monitoring (self-observation and screening tests) to prevent chronic diabetic complications among type 2 diabetes patients receiving community-based management.

The convenience sampling was used to select 785 type 2 diabetes patients from Chengdu's central urban areas who received community-based type 2 diabetic management from May to November 2019. They were invited to attend a survey for understanding their socio-demographic information and monitoring behaviors to prevent chronic diabetic complications using a questionnaire developed by us.

Only 103 (13.1%) of the patients did not suffer from any chronic complications, and 435 (55.4%) suffered from both metabolic syndrome and chronic diabetic complications. The average total score for self-observation of chronic diabetic complications in the participants was (2.58±0.86) , but the average total score of regularly self-observation of pulsations of the dorsalis pedis artery was only (1.47±0.84) . The average total score of performing screening tests for chronic diabetic complications was (2.77±0.57) . The average score of diabetic retinopathy screening, peripheral neuropathy screening, and lower extremity vascular disease screening was (1.88±0.99) , (1.46±0.84) , and (1.47±0.84) , respectively. About 78.2% (614/785) of patients underwent screening tests following the doctors' advices. But only 9.9% (78/785) took the initiative to conduct regular tests. About 17.7% (139/785) and 49.0% (385/785) of the patients could not correctly manage the abnormal results of self-observation and the screening test results. Multiple linear regression analysis indicated that the duration of diabetes since diagnosis, prevalence of chronic diabetic complications, and management of self-observed abnormalities were associated with the score of self-observation of chronic diabetic complications (P<0.05) . The duration of diabetes since diagnosis, the most recently measured HbA_1c value, prevalence of chronic diabetic complications, causes and results management of screening tests for chronic diabetic complications were associated with average total score of performing screening tests for chronic diabetic complications (P<0.05) .

The prevalence of behaviors of monitoring to prevent chronic diabetic complications in community-dwelling type 2 diabetes patients was unsatisfactory, which was affected by the duration of diabetes since diagnosis, prevalence of chronic diabetic complications, the most recently measured HbA_1c value, causes and results management of screening tests for chronic diabetic complications. In view of this, in the delivery of community-based management services, attentions should be paid to improving patients' initiative to actively and regularly observe their conditions and undergo relevant screening tests, thereby improving early diagnosis and treatment rates of chronic type 2 diabetic complications.

Effect of Health Literacy and Exercise Intervention on Medical Mistrust of Type 2 Diabetes Patients in the Community

WANG Mengyan, WANG Lei, CHEN Yingyao, FANG Hong, XIA Qinghua, Russell L Rothman, XU Wanghong

2022, 25(01):  79-86.  DOI: 10.12114/j.issn.1007-9572.2021.00.336

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Medical distrust in patients has been related with poor compliance to medications and suboptimal clinical outcomes. Effective interventions may improve medical distrust in patients which is warranted specific studies.

To evaluate the effect of health literacy and exercise interventions on medical mistrust in patients with type 2 diabetes (T2DM) .

This study was based on a cluster randomized-controlled trial conducted during February 2015 to March 2016. A total of 800 T2DM patients were recruited from four community health service centers in Minhang and Changning Districts of Shanghai by using a multi-stage sampling method. All patients were randomly divided into the control group and 3 intervention groups in the community. Routine care was provided to all the patients, and on this basis, health literacy intervention, exercise intervention and health literacy + exercise intervention (comprehensive intervention) were performed to the three intervention groups based on partnership to improve diabetes education (PRIDE) toolkit, respectively. Information was collected using the Chinese versions of Health Literacy Management Scale (c-HeLMS) , the 5-item Diabetes Numeracy Test Scale (c-DNT-5) , and Medical Mistrust Index (c-MMI) at baseline, 3-, 6-, 12- (end of intervention) and 24-months follow-up (post-intervention) . The generalized estimating equation was used to evaluate the effect of the interventions at each time point.

A total of 780 patients were recruited in this study. The c-MMI was a reliable and valid scale to measure medical mistrust in our subjects, with Cronbach's α of 0.826. The median score and interquartile range of c-MMI was 31 (7) at baseline while the rate of medical mistrust (scores≥30) was 65.9% (514/780) , both of which decreased at almost each follow-up survey in four groups. Compared with the control group, a lower risk of medical mistrust was observed at the 3-months〔OR (95%CI) =0.42 (0.23, 0.78) 〕 and 6-months of follow-up〔OR (95%CI) =0.46 (0.24, 0.88) 〕 for the health literacy group, at the 6-months〔OR (95%CI) =0.50 (0.25, 0.99) 〕, 12-months〔OR (95%CI) =0.43 (0.22, 0.86) 〕 and 24-months of follow-up〔OR (95%CI) =0.37 (0.19, 0.72) 〕 for the exercise group, and at the 6-months〔OR (95%CI) =0.30 (0.16, 0.56) 〕 for the comprehensive group.

Both health literacy and exercise intervention may effectively decrease the scores of c-MMI and reduce the risk of medical mistrust in diabetes patients.

Original Research·Community-based Health Management for Older Adults

Factors Associated with Older Adults' Intention to Use Community-based Elderly Care：a Study Using the Decision Tree and Logistic Regression Models

YAN Rui, ZHAO Shoumei, ZHANG Xinxin, LYU Yumei

2022, 25(01):  87-93.  DOI: 10.12114/j.issn.1007-9572.2021.00.321

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Community-based elderly care may effectively contribute to the handling of serious elderly care challenges brought by an increasingly aging population in China.

To explore the factors associated with older adults' intention to choose community-based elderly care using the decision tree and Logistic regression models.

This questionnaire survey was conducted in three communities selected from Daqing by convenient sampling from August to December 2020. 500 eligible community-dwelling older adults (≥60 years old) were selected as the research objects. The decision tree and Logistic regression models were used to explore factors associated with these older adults' intention to choose community-based elderly care via analyzing their demographics, self-rated physical and mental health, and family and social support collected by the survey.

Altogether, 489 cases (97.8%) who effectively responded to the survey were included for analysis. The prevalence of intending to choose community-based elderly care in the respondents was 32.5% (159/489) . Logistic regression analysis revealed that the older adults' understanding level of community-based elderly care, views of elderly care, sense of loneliness, and intergenerational relationship had varying degrees of influence on their intention to choose community-based elderly care (P<0.05) . The decision tree analysis found that the older adults' understanding level of community-based elderly care, views of elderly care, sense of loneliness, social network, self-rated health, education level, and living status (alone or not) were key factors influencing their intention to choose community-based elderly care (P<0.05) . By both Logistic regression and decision tree analyses, understanding level of community-based elderly care, views of elderly care, and sense of loneliness were found to be three factors influencing older adults' intention to use community-based elderly care most. In exploring the factors associated with older adults' intention to choose community-based elderly care, Logistic regression analysis had an AUC of 0.985 (0.974, 0.996) with 94.34% sensitivity and 95.75% specificity, and decision tree analysis had an AUC of 0.980 (0.968, 0.992) with 88.05% sensitivity and 97.87% specificity, the performance of the two was similar (Z=-0.625, P=0.268) .

The combination of decision tree and Logistic regression model has high application value in the study of influencing factors of community pension willingness of the elderly. The prevalence of intending to use community-based elderly care was relatively low in Daqing older adults. To improve this, it is suggested to take actions to change older adults' traditional views of elderly care, to better their physical and mental health and family relationships.

Investigation on Advance Care Planning Behaviors in Elderly Chronic Disease Patients in the Community

LI Jiayin, LIU Dongling, WANG Zichen, LIU Xuebing, ZHANG Qiongwen, ZHANG Lingli

2022, 25(01):  94-99.  DOI: 10.12114/j.issn.1007-9572.2021.00.266

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As the physical function declines with age, and the disease progresses, elderly chronic disease patients face decreased cognitive function and abilities in communicating medical affairs and making relevant decisions, which will have a certain impact on the expression of end-of-life will. Early implementation of the advance care planning (ACP) for elderly patients will guarantee their medical decision-making autonomy. To facilitate the delivery of interventions to promote the implementation of ACP, it is important to study ACP behaviors and related stages of behavior change in this population.

To investigate ACP behaviors, and stages of behavior change as well as associated factors in elderly chronic disease patients in the community.

From May to July 2020, by use of convenience sampling, 410 elderly chronic disease patients were selected from the community with coverage of healthcare services delivered by Hanghai East Road Community Health Center, Zhengzhou, and were invited to attend a survey using the General Information Questionnaire and the Chinese version of Advance Care Planning Engagement Survey. Stepwise multiple linear regression was used to identify the influencing factors of stages of behavior change of ACP.

Altogether, 384 (93.7%) individuals who returned responsive questionnaires were included for analysis. Among the respondents who had been involved in ACP. 42 (10.9%) had "talked with family and friends about the medical decision maker", 39 (10.1%) had "talked with family and friends about medical care", 23 (6.0%) had "talked with the medical decision maker about decision-making flexibility", 12 (3.1%) had "asked doctors questions", but no one was involved in four main ACP behaviors. Two hundred and ninety-two (76.0%) respondents were in the pre-contemplation stage of behavior change, and 92 (24.0%) were in the contemplation stage of behavior change. Of the behavior change constructs, the total score of the knowledge showed no significant differences by socio-demographic factors (P>0.05) , but the total score of the contemplation differed significantly by education level, self-rated disease severity and healthcare-seeking related experience in recent five years (P<0.05) . Stepwise multiple linear stepwise regression analysis revealed that education level, hospitalization experience and medical-decision making in the past five years were associated with the contemplation of behavior change construct (P<0.05) .

Only some elderly chronic disease patients in the community had been involved in ACP, and had contemplated ACP behaviors. To promote patient engagement in ACP, it is suggested that medical workers should consider ACP as a continuous process composed of multiple behaviors rather than a single behavior during the delivery of health education, and guide patients to increase their understanding of ACP process based on contemplating their ACP behaviors, as well as offer patients targeted interventions based on their current stage of behavior change.

Mediating Role of Family Function between Disability Severity and Family Resilience in Home-living Older Adults with Disability in Minority Areas of Xinjiang

ZHANG Mengmeng, WANG Yuhuan, TANG Xueting, ZHAO Shuhua, ZHOU Jia

2022, 25(01):  100-108.  DOI: 10.12114/j.issn.1007-9572.2021.00.307

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As a multi-ethnic and economically underdeveloped region, Xinjiang faces severe challenges coming with an aging population. To promote active aging under the circumstances of unsatisfied comprehensive strength and imperfect home care system, it is important for Xinjiang to give priority to groups with disabilities, improve family resilience via enhancing family functions, and gradually develop a family-centered home care system with community support.

To explore the mechanism of mediating action of family function between disability severity and family resilience in home-living older adults with disability in Xinjiang's minority areas, offering new ideas for relevant departments to improve family resilience of this population.

From July to August 2020, a household survey was conducted with older adults with disability, and their primary caregivers and core family members of 431 Uygur or Kazak households selected from Xinjiang's Bortala Mongol Autonomous Prefecture by use of stratified multistage sampling. Questionnaires including demographic questionnaire developed by our research team, Katz Index of Independence in Activities of Daily Living (Katz ADL) , Mini-mental State Examination (MMSE) , Family Resilience Assessment Scale (FRAS) , and the Family Concern Index Questionnaire (APGAR) were used in the survey to collect information regarding degree of disability, family resilience, and family functions of the older adults with disability. Spearman correlation analysis was used to explore the relationship of family resistance with disability severity, family function and its five functional components (adaptability, partnership, growth, affection, and resolve) . Multiple linear regression analysis and Bootstrap test were used to verify and examine the medicating effect of family function and its five components between disability severity and family resilience.

From the 431 households, older adults with disability, primary family caregivers, and core family members were selected at a ratio of 1∶1∶1 (each group contained 431 cases) . Among the older adults with disability, the prevalence of mild, moderate and severe disability was 46.9% (202/431) , 40.1% (173/431) , and 13.0% (56/431) , respectively. The prevalence of intact family function, moderate and severe family dysfunction in the households was 46.4% (200/431) , 43.6% (188/431) , and 10.0% (43/431) , respectively. The prevalence of low and high family resilience in the households was 51.7% (223/431) , and 48.3% (208/431) , respectively. Spearman correlation analysis revealed that disability severity of the older adults reduced with the increase of family function and its five components as well as family resilience (P<0.05) . And family resilience grew with the increase of family function and its five components (P<0.05) . Mediation analysis found that family function partially mediated between disability severity and family resilience, with an effect size accounting for 67.2% of the total effect. The components of adaptability, partnership, growth, affection, and resolve also partially mediated between disability severity and family resilience, with effect sizes accounting for 38.7%, 47.1%, 48.2%, 24.2%, and 25.3% of the total effect respectively.

Family function played a partial mediating role between the degree of disability and family resilience in home-living older adults with disability in minority areas of Xinjiang. In view of this, for those with severe disability, besides offering more medical assistance, relevant governments are suggested to pay attention to improving their family function by making use of family internal resources, so as to improve family resilience to enhance the quality of care for this population.

Evidence-based Medicine

Prevalence and Distribution Trends of Mild Cognitive Impairment among Chinese Older Adults：a Meta-analysis

SHI Luping, YAO Shuihong, WANG Wei

2022, 25(01):  109-114.  DOI: 10.12114/j.issn.1007-9572.2021.00.315

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Mild cognitive impairment (MCI) has become a major disorder affecting the quality of life of Chinese older adults, a rapidly increasing population. Understanding MCI prevalence in this population is important for promoting healthy ageing, but there is a lack of comprehensive reports on MCI prevalence in a large national sample of older adults in the past decade.

To examine the trends of MCI prevalence and geographical distribution in Chinese older adults in the past 10 years, providing data support for further research on public service policies for the elderly.

In January 2021, we searched for studies about MCI prevalence in Chinese older adults published from January 2010 to December 2020 from databases of SinoMed, CQVIP, Wanfang Data, CNKI, PubMed, Ovid, SpringerLink, and EmBase, and extracted data regarding MCI prevalence from the eligible ones, then chose effects models with indicators based on the within-study heterogeneity.

A total of 47 studies were included, involving 137 599 samples. The overall prevalence of MCI in Chinese older adults in the last decade was 19%〔95%CI (17%, 21%) 〕. Demographic analysis showed the following results: the MCI prevalence was 17%〔95%CI (15%, 19%) 〕 and 19%〔95%CI (17%, 21%) 〕 for men and women, respectively, 16%〔95%CI (11%, 22%) 〕 and 23%〔95%CI (16%, 30%) 〕 for urban and rural areas, respectively, 16%〔95%CI (14%, 19%) 〕 and 24%〔95%CI (20%, 28%) 〕for those living with a spouse and without, respectively, and 13%〔95%CI (9%, 17%) 〕, 12%〔95%CI (9%, 15%) 〕, 17%〔95%CI (13%, 20%) 〕, 26%〔95%CI (20%, 31%) 〕, 33%〔95%CI (24%, 42%) 〕and 42%〔95%CI (22%, 62%) 〕 for those at 60-64 years, 65-69 years, 70-74 years, 75-79 years, 80-84 years, 85 and above, respectively. Besides this, MCI prevalence showed a trend of decrease with the increase of education level: 30%〔95%CI (25%, 35%) 〕 in those with little education (<1 year of education) , while 10%〔95%CI (7%, 13%) 〕 in those with university education (>12 years of education) . Spatial distribution trend: prevalence varied significantly between provinces (autonomous regions/municipalities) (15%-37%) and between northern, northwestern, eastern, south-central, southwestern parts of China (17%-22%) . Temporal distribution trend: the prevalence showed an increasing trend in the last decade (11%-28%) .

The prevalence of MCI in Chinese elderly population showed an increasing trend from January 2010 to December 2020, with differences across provinces (autonomous regions/ municipalities) and 5 geographical regions. In addition, the prevalence was higher in the female, less educated, older, rural, and spouseless groups.

Dyslipidemia Prevalence in Chinese Older Adults：a Meta-analysis

CHEN Zengli, JIANG Yunlan, LU Yutong, LI Jie, LIAO Shiqin, LIU Mingting

2022, 25(01):  115-121.  DOI: 10.12114/j.issn.1007-9572.2021.00.328

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China has stepped into an aging society, and its aging population is rapidly increasing. Recent years have seen a notable increased dyslipidemia prevalence in older adults, which has gained growing attentions as a major risk for cardiovascular and cerebrovascular diseases in this population. There is little consistency between studies on dyslipidemia prevalence in Chinese older adults due to differences of size and features of sample, design and setting.

To systematically evaluate the prevalence of dyslipidemia among Chinese older adults.

Cross-sectional studies relevant to the prevalence of dyslipidemia among Chinese elderly population were searched in databases including CNKI, CBM, CQVIP, WanFang, PubMed, Web of Science, Embase and the Cochrane Library from inception to May 2021. Two researchers performed literature screening and data extraction, separately. The Agency for Healthcare Research and Quality methodology checklist was used to assess the risk of bias. Stata 15.1 was adopted for meta-analysis.

A total of 19 cross-sectional studies were included, involving 101 931 cases, and 45 785 of them had dyslipidemia. Meta-analysis results showed that the overall prevalence of dyslipidemia among the participants was 48.0%〔95%CI (41.0%, 54.0%) 〕. Specifically, the prevalence of elevated total cholesterol (TC) , triglyceride (TG) , and low-density lipoprotein cholesterol (LDL-C) as well as lowered low high-density lipoprotein cholesterol (HDL-C) was 19.7%〔95%CI (13.8%, 25.5%) 〕, 20.8%〔95%CI (16.2%, 25.4%) 〕, 15.3%〔95%CI (10.7%, 19.8%) 〕, and 20.2%〔95%CI (7.9%, 32.4%) 〕, respectively. Sex-specific analysis found that men had higher prevalence of elevated LDL-C than women (17.2% vs 9.0%) . Women had higher overall prevalence of dyslipidemia than men (48.8% vs 39.5%) . Moreover, women also had higher prevalence of elevated TC (24.0% vs 12.9%) , and TG (23.4% vs 19.0%) , as well as lowered HDL-C (20.4% vs 14.7%) . Age-specific analysis revealed that dyslipidemia prevalence in age groups of 60-69, 70-79, and ≥80 years old was 39.9%, 31.8%, and 31.4%, respectively, showing a trend of decrease with age. The prevalence of elevated TC in 60-69 year-olds (12.9%) was higher than that of 70-79 year-olds (12.1%) or 80 year-olds and above (9.5%) . The prevalence of elevated LDL-C in 60-69 year-olds (10.0%) was higher than that of 70-79 year-olds (9.4%) or 80 year-olds and above (6.5%) . The prevalence of elevated TG in 70-79 year-olds (19.3%) was higher than that of 60-69 year-olds (16.4%) or 80 year-olds and above (15.5%) . The prevalence of lowered HDL-C in 70-79 year-olds (10.5%) was higher than that of 60-69 year-olds (9.7%) or 80 year-olds and above (9.5%) . Those aged ≥80 years had lower prevalence of various forms of dyslipidemia than 60-69 year-olds and 70-79 year-olds. Region-specific analysis indicated that compared to those from western China, participants from eastern China had higher overall prevalence of dyslipidemia (49.3% vs 36.8%) . Moreover, they also showed higher prevalence of elevated TC (23.0% vs 11.4%) , elevated LDL-C (21.3% vs 7.8%) and lowered HDL-C (13.5% vs 7.8%) . However, they had slightly lower prevalence of elevated TG (19.7% vs 20.0%) .

The overall prevalence of dyslipidemia was high in Chinese older adults. Sex-, age group- and region-specific differences were found in the overall prevalence of dyslipidemia, and prevalence of various forms of dyslipidemia. Due to limited number and non-ideal quality of the included studies, the above conclusions need to be verified by more high-quality studies.

Review

Latest Developments in the Effects of Intermittent Fasting on Weight Loss and Glycolipid Metabolism

BA Tao, WANG Xiaoli, CHANG Xiangyun

2022, 25(01):  122-126.  DOI: 10.12114/j.issn.1007-9572.2021.00.329

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Dietary intervention is an important approach to treating obesity. Intermittent fasting (IF) is a eating pattern alternating between eating and energy-restricted fasting or fasting periods, whose types mainly include alternate-day fasting, periodic fasting, time-restricted fasting, Ramadan fasting and so on. Available research has shown that IF manages obesity and obesity-related metabolic disorders to improve health through a variety of mechanisms, but there is no conclusive evidence as to which IF regimen is more sustainable and effective. To provide evidence for in-depth promotion of the application of IF, we introduced several common IF regimens, and reviewed the latest developments in the effects and safety of IF in losing weight, and improving blood glucose and lipids, and found that IF is beneficial to weight loss, blood glucose and lipids reduction, as well as insulin resistance decrease with relatively high safety, but attentions should be paid to individual differences during the actual implementation of IF.

Research Progress on the Influence of Intermittent Fasting on Cardiovascular Disease Risk Factors

CUI Yanru, CEN Qiuyu, WEI Juanfang, WANG Wenchun, ZHANG Anren

2022, 25(01):  127-130.  DOI: 10.12114/j.issn.1007-9572.2021.00.330

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In recent years, the prevalence and mortality of cardiovascular diseases in China have shown a significant upward trend, cardiovascular disease has become a major disease endangering the health of Chinese residents. Intermittent fasting (IF) as a cyclical energy restriction dietary intervention has been proven to have a wide range of health benefits, which can reduce weight, improve glucose regulation, lower blood pressure and blood lipid levels, inhibit inflammation, so as to delay the occurrence and development of cardiovascular disease. Currently, researchers in China have paid insufficient attention to the potential role of IF in the prevention and treatment of cardiovascular diseases. This article reviews the effects and mechanisms of IF on cardiovascular disease risk factors such as dyslipidemia, obesity, diabetes and hypertension, in order to provide new ideas for the prevention and treatment of cardiovascular diseases. It is found that IF has potential application prospects in the prevention and treatment of cardiovascular diseases, which can be used to prevent and control the risk factors of cardiovascular disease, the IF-mediated metabolic benefits can be related to glucose-ketone body metabolic transformation, browning of white fat, autophagy pathway and remodeling of intestinal flora.