Table of Content

05 October 2023, Volume 26 Issue 28

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Guidelines·Consensus

Expert Consensus on Screening, Diagnosis and Treatment of Perinatal Mental Disorders

CHEN Jing, ZOU Tao, ZHAO Danqing, XIAO Ziwen, WU Xianqing, Chinese Medical Association Psychosomatic Medicine Branch Perinatal Mental Disorders Collaborative Group

2023, 26(28):  3463-3470.  DOI: 10.12114/j.issn.1007-9572.2023.0114

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Perinatal mental disorders are one of the most common disorders during pregnancy and may lead to adverse maternal and offspring outcomes. There is an increasing number of women currently at risk for emotional problems such as anxiety and depression during pregnancy and childbirth, and women with previous mental disorders are also at risk of relapse during pregnancy. At the same time, the lack of clinical guidelines for the diagnosis and treatment of perinatal mental disorders has made the work of clinicians even more challenging. The expert writing group integrated the latest medical evidence and clinical practice in related fields at home and abroad to form the expert consensus, consisting of the epidemiology and pathogenesis, clinical manifestations, clinical evaluation, diagnosis, treatment and management of perinatal mental disorders, which can provide reference and guidance for practical clinical work. The consensus advocates comprehensive, whole-process, hierarchical, multidisciplinary and collaborative diagnosis and treatment, to help frontline clinicians screen, rationally assess and clinically diagnose perinatal pregnant women as soon as possible, as well as provide necessary psychological interventions and clinical medication for them.

Speculation and Controversy

Exercise is the Foundation of Weight Loss

WANG Qianqian, WANG Xiaohang, ZHOU Xiaoying, QIU Shanhu, SUN Zilin

2023, 26(28):  3471-3476.  DOI: 10.12114/j.issn.1007-9572.2023.0105

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The prevalence of overweight and obesity has been increasing yearly and become a global public health problem with a range of consequences causing widespread concern. Weight loss can reduce the incidence of type 2 diabetes, cardiovascular risk, and all-cause mortality. The most common approaches of weight loss are drug therapy, surgery and lifestyle interventions including diet and exercise, however, exercise intervention remains the healthiest and most fundamental approach of weight loss. Exercise can reduce cellulite, increase muscle mass and improve metabolism. The combination of exercise and other weight loss approaches can reduce adverse reactions and produce better results. Continuing exercise after weight loss can also effectively prevent rebound and maintain weight loss effects. This paper reviews the definition, mechanism, effect, and management of "exercise is the foundation of weight loss", and provide a reference for weight loss through exercise in the context of the experience of Zhongda Hospital.

Exercise is Not the Foundation of Weight Loss

JIANG Qiuhui, LI Xuejun

2023, 26(28):  3477-3481.  DOI: 10.12114/j.issn.1007-9572.2023.0104

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Obesity is an increasingly prevalent and costly public health problem. Many people regard exercise as an effective weight loss strategy, even superior to dieting. However, the effectiveness and safety of exercise for weight loss in obese individuals need to be carefully weighed. This paper briefly discusses the view that "Exercise is not the foundation of weight loss" in the combination of evidence-based medicine, from the aspects of mild effect of exercise on weight loss, poor adherence to long-term high-intensity exercise, safety of high-intensity exercise in obese individuals, and the mechanism of poor weight loss effect of exercise.

Original Research·Foucus on Treatment-prevention Integration

Impact of Chronic Diseases Follow-up on Health Behaviors and Blood Pressure/Glucose Control of Patients with Hypertension and Diabetes in the Context of Treatment-prevention Integration

CHENG Xiaoran, ZHANG Xiaotian, LI Mingyue, CHENG Haozhe, TANG Haoqing, ZHENG Huixian, ZHANG Baisong, LIU Xiaoyun

2023, 26(28):  3482-3488.  DOI: 10.12114/j.issn.1007-9572.2023.0275

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Background

Hypertension and diabetes are two major chronic diseases affecting population health, and need to be controlled through chronic diseases follow-up. However, there is currently insufficient understanding of the impact of different chronic diseases follow-up forms and contents on disease control and healthy behaviors of patients.

Objective

To explore the impact of the chronic diseases follow-up on health behaviors and blood pressure/glucose control of patients with hypertension and diabetes in the context of treatment-prevention integration.

Methods

Yiyang County in Henan Province, Xianfeng County in Hubei Province and Yangqu County in Shanxi Province were selected as study sites to collect data from the basic public health information system from 2017-01-01 to 2022-06-30. Patient survey was conducted in July 2022 to collect information on basic public health follow-up receiving, health behaviors and disease control of patients. Finally, 102 769 patients with hypertension and 26 586 patients with diabetes were obtained from the basic public health information system, the data of 1 172 patients with hypertension and 456 patients with diabetes were obtained through patient surveys. Multivariate Logistic regression was used to analyze the effects of the standard-reaching frequency of follow-up, follow-up forms and contents on health behaviors and disease control of patients.

Results

In 2021, the standard-reaching rates of follow-up frequency of patients with hypertension and diabetes were 90.83% (67 709/74 545) and 83.35% (13 390/16 065) , with frequency≥4 times/year as the standard. The follow-up forms included household follow-up〔25.74% (408/1 585) 〕, follow-up at institutional visits〔58.80% (932/1 585) 〕, telephone or network follow-up〔15.46% (245/1 585) 〕. The follow-up contents included blood pressure and blood glucose measurements〔91.15% (1 484/1 628) 〕, lifestyle guidance〔74.14% (1 207/1 628) 〕, disease inquiry〔70.02% (1 140/1 628) 〕, and drug use understanding〔69.29% (1 128/1 628) 〕. Multivariate Logistic regression analysis showed that patients with higher standard-reaching rates of follow-up frequency had higher rates of blood pressure control (OR=1.09, P<0.05) and glucose control (OR=1.31, P<0.05) , lower rates of smoking and drinking (OR=0.83, P<0.05) , and higher rates of regular exercise habits (OR=1.30, P<0.05) . The proportions of smoking and alcohol cessation (OR=2.38, P<0.05) and regular exercise habits (OR=1.62, P<0.05) were higher in the patients followed up at institutional visits than those followed up by telephone or network. The proportions of smoking and alcohol cessation (OR=2.33, P<0.05) and regular exercise habits (OR=2.54, P<0.05) of patients received household follow up were higher than those followed up by telephone or network. Patients who received lifestyle guidance, disease inquiry, and drug use understanding had higher rates of blood pressure control (OR=1.61, 1.34, and 1.62, respectively; P<0.05) , smoking and alcohol cessation (OR=3.59, 3.54, and 2.91, respectively; P<0.05) and regular exercise habits (OR=3.16, 2.15, 2.45, respectively; P<0.05) .

Conclusion

Receiving chronic diseases follow-up at least 4 times per year, with follow-up at institutional visits and household follow-up as the forms, provided with blood pressure and blood glucose measurements, lifestyle guidance, disease inquiry and drug use understanding as the contents in patients were positive correlated with blood pressure/glucose control, smoking and alcohol cessation, and regular exercise habits.

Construction of On-site Evaluation Index System for Integration of Medical and Preventive Services for Chronic Diseases in Primary Health Care Institutions

GUO Jia, SUN Huajun, CHEN Ying, ZHANG Jiawen, ZHANG Yaxin, MA Ying, DU Yue

2023, 26(28):  3489-3495.  DOI: 10.12114/j.issn.1007-9572.2023.0277

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Background

Currently, scholars in China are exploring chronic disease management models based on treatment-prevention integration, however, the quantitative evaluation researches are scarce and in the initial stage, lacking in relevance and timeliness.

Objective

To construct the on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions and provide a reference for the quality improvement of integration of medical and preventive services.

Methods

The on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions was initially constructed by literature review, policy induction and expert interview. From June to August 2022, two rounds of expert consultation with 17 experts were conducted using the Delphi method, the index system was determined according to the results of expert consultation, and the weight of each index was calculated by using the analytic hierarchy process.

Results

The on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions was initially constructed consisting of 5 primary indexes, 12 secondary indexes and 37 tertiary indexes. The effective questionnaire recovery rate of the two rounds of expert consultation was 100.0% with the expert authority coefficient of 0.81; the Kendall coordination coefficients of the importance of the three levels of indexes were 0.239 (χ²=8.76, P<0.05) and 0.275 (χ²=4.15, P<0.05) , the Kendall coordination coefficients of the feasibility of the three levels of indexes were 0.234 (χ²=19.63, P<0.05) and 0.248 (χ²=12.43, P<0.05) . The on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions was finally constructed consisting of 5 primary indexes, 12 secondary indexes and 40 tertiary indexes, the weight of the five primary indicators was 0.200 0.

Conclusion

The evaluation index system has a certain practical guidance for the improvement of the capacity of integration of medical and preventive services for chronic diseases in urban and rural community health service institutions. However, the evaluation index system should also be dynamically adjusted according to the specific situation to effectively reflect the quality of integration of medical and preventive services for chronic diseases in primary health care institutions.

Influence Mechanism of Capitation for Outpatient Services in Basic Medical Insurance on Medical Expenses Based on the Concept of System Dynamics: a Case Study of Outpatient Payment Mode Reform in Shengzhou, Zhejiang Province

WANG Yudong, MA Xiaojing, WANG Fang

2023, 26(28):  3496-3501.  DOI: 10.12114/j.issn.1007-9572.2023.0174

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Background

Since August 2022, Shengzhou City of Zhejiang Province has been carrying out the reform of outpatient payment mode in medical insurance, gradually carrying out the reform of capitation by implementing the total budget, updating the calculation standard of capitation fee, improving the incentive and constraint mechanism and other measures, so as to encourage primary health care institutions to provide appropriate basic medical services, reduce primary medical expenses, and promote the sustainable development of medical insurance fund.

Objective

To analyze the influence mechanism of capitation for outpatient services in basic medical insurance on medical expenses in Shengzhou City, Zhejiang Province, and to provide reference for improving the relevant payment system.

Methods

Using "capitation" and "medical costs" as both English and Chinese search terms, databases such as CNKI, Wanfang, PubMed and Web of Science were searched for relevant literature on capitation from 2000-01-01 to 2022-07-31, as well as the policy documents, government reports and news reports related to the implementation of capitation from April to July 2022. Personal interviews were conducted with representatives of capitation payment policy makers and implementers in Shengzhou City from September to December 2022 (n=13) . A qualitative analysis of capitation reform policy on medical expenses under the total outpatient budget in Shengzhou City, Zhejiang Province was performed by using system dynamics approach.

Results

The policies of the current round of medical insurance payment reform in Shengzhou were plotted as a cause graph with five feedback loops obtained, showing that the implementation of the total capitation budget policy can motivate primary health care institutions to provide standardized medical services for residents, promote an increase in the contracting rate in primary care, thus controling medical expenses; a scientific capitation fee standard can motivate primary health care institutions to autonomously control and reduce costs; increasing the reimbursement ratio of medical insurance can effectively reduce the medical burden of patients; improving the performance appraisal system is conducive to the continuous improvement of service capabilities of primary health care institutions; strengthening the construction of information sharing mechanisms can achieve data sharing and exchange, and comprehensively improve the health of residents.

Conclusion

The implementation of capitation reform in conjunction with multiple policy measures can improve the contracting and consultation rates in primary care institutions, broaden the sources of medical insurance fund, ensure the sustainability of medical insurance fund, improve the medical service and capabilities of primary care institutions, improve the health status of residents, and significantly improve the prevention and treatment effect of chronic diseases.

Original Research·Foucus on Health Status in Middle-aged and Older Populations

Association of Blood Pressure Level with the Risk of Chronic Kidney Disease among the Elderly in Longevity Areas of China

ZHANG Yunsheng, ZHANG Peng, JIN Yujing, GAO Ying

2023, 26(28):  3502-3506.  DOI: 10.12114/j.issn.1007-9572.2022.0876

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Background

Chronic kidney disease (CKD) is a serious risk to the health and longevity of the elderly, and hypertension is closely related to CKD. However, the studies on the correlation of blood pressure levels with the development and progression of CKD in older adults have shown inconsistent results.

Objective

To explore the association between blood pressure levels and the risk of CKD among the elderly in longevity areas of China.

Methods

From October 2021 to May 2022, a total of 989 older adults who underwent physical examination with biomedical indicators collected in 2012 were selected as subjects based on the subcohort of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) -Healthy Aging and Biomarkers Cohort Study (HABCS) . Age, gender, height, weight, blood pressure, blood lipid, blood glucose, routine blood and urine indicators were collected at baseline, and follow-up monitoring was conducted in 2014. Cox proportional hazards regression model was used to analyze the association between the blood pressure levels and the risk of CKD.

Results

A total of 989 subjects were included in the study, with a median age of 79 (70, 88) years. The cumulative follow-up were 2 046 person-years, with an average follow-up time of (2.07±0.50) years. There were 183 new cases of CKD, the cumulative incidence of CKD was 18.5%〔95%CI (16.1%, 21.1%) 〕, and the incidence density was 89.4/1 000 person-years. During the follow-up, 9.8% (10/102) , 14.0% (47/335) and 22.8% (126/552) of the older adults in the normal blood pressure, high normal blood pressure and hypertension groups developed CKD, respectively, and the difference was statistically significant among the three groups (χ²=16.40, P<0.001) . The results of Cox regression showed that after adjusting for age, sex, BMI, waist circumference, calf circumference, fasting blood glucose, glycosylated serum protein, total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, uric acid, superoxide dismutase, vitamind3, white blood cell count, red blood cell count, platelet count, blood urea nitrogen and history of diabetes, the older adults in the hypertension group had a higher risk of CKD〔HR (95%CI) =2.28 (1.13, 4.60) 〕 than those in the normal blood pressure group; the risk of CKD was 1.83 times〔95%CI (1.02, 3.29) 〕 higher in the older adults with baseline SBP≥140 mmHg (1 mmHg=0.133 kPa) than those with baseline SBP<120 mmHg, and the risk of CKD was 1.55 times〔95%CI (1.02, 2.35) 〕 higher in the older adults with baseline DBP≥90 mmHg than those with baseline DBP<80 mmHg (P<0.05) .

Conclusion

Hypertension is an independent risk factor for CKD in the elderly. It is particularly important to increase screening and prevention of CKD in older adults with predominantly elevated systolic blood pressure.

Relationship between Sleep Duration and All-cause Mortality in Middle-aged and Older Adults

XU Zhe, ZHANG Jinxia, ZHANG Xiuhong, XIE Kaihong

2023, 26(28):  3507-3512.  DOI: 10.12114/j.issn.1007-9572.2023.0199

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Background

The scale and follow-up time of studies related to the association between sleep duration and all-cause mortality in middle-aged and older adults vary widely, and the results of studies such as correlations and recommended sleep duration remain controversial.

Objective

To explore the association between sleep duration and the risk of all-cause mortality in middle-aged and older adults.

Methods

From January to December 2022, the longitudinal study cohort was created based on the case ID numbers of coding manual combined with baseline and follow-up data of the China Health and Retirement Longitudinal Study (CHARLS) and Chinese Longitudinal Healthy Longevity Study (CLHLS) databases from January to December in 2022, which ultimately included 43 922 respondents. Social demographics, health status and health-related behaviors, sleep duration and death related information were extracted from CHARLS and CLHLS databases, recoding and variable transformations were performed according to the measurement and evaluation criteria of relevant indicators. The Kaplan-Meier method of Log-Rank test was used to plot survival curves, and the Cox proportional hazard regression model was used to explore the relationship between sleep duration and mortality risk in the middle-aged and older adults, followed by unrestricted cubic spline to observe the effect of the continuous-type variable of sleep duration on mortality risk.

Results

Among 43 922 middle-aged and older adults with a median follow-up of 6 years and an average sleep duration of 7.32 h, 9 369 cases (21.33%) had sleep duration of≤5 h, 7 779 cases (17.71%) had sleep duration of >5-6 h, 295 cases (0.67%) had sleep duration of >6-7 h, 15 611 cases (35.54%) had sleep duration of >7-8 h, 2 567 cases (5.84%) had sleep duration of >8-9 h, 5 011 cases (11.41%) had sleep duration of >9-10 h and 3 290 cases had sleep duration >10 h (7.49%) . Kaplan-Meier survival analysis showed that middle-aged and older adults with moderate sleep duration (>6-7 h) had the highest probability of survival, and those with extra-long sleep duration (>10 h) had the lowest probability of survival. Cox regression model results showed that compared with middle-aged and older adults with sleep duration >10 h, middle-aged and elderly adults with sleep duration of ≤5 h〔HR (95%CI) =1.19 (1.09, 1.29) , P<0.05〕, >7-8 h〔HR (95%CI) =1.16 (1.08, 1.25) , P<0.05〕, >8-9 h〔HR (95%CI) =1.32 (1.19, 1.46) , P<0.05〕, and >9-10 h〔HR (95%CI) =1.12 (1.04, 1.22) , P<0.05〕 had increased risk of death. Restricted cubic spline showed an S-shaped non-linear association between sleep duration and risk of all-cause death (P=0.023) , with no significant association of sleep duration of 4.62-7.97 h with the risk of death, significant association of sleep duration <4.62 h and >7.97-10.00 h with all-cause mortality risk.

Conclusion

Middle-aged and older adults with moderate sleep duration had the highest probability of survival, so the recommended sleep duration for middle-aged and older adults is 5-7 h.

Association between Self-rated Health and Frailty among Community-dwelling Older Adults: the Moderating Role of Apathy

TAO Lu, LI Sha, DING Yaping, ZONG Qianxing, GAO Shiying, NIE Zuoting, CHEN Long, WU Yan, YANG Rumei

2023, 26(28):  3513-3519.  DOI: 10.12114/j.issn.1007-9572.2022.0841

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Background

Previous studies have shown that self-rated health would be used as a simple assessment indicator for frailty, and individuals with poor self-rated health status are at higher risk of frailty. However, the association between self-rated health and frailty may be different and the effectiveness of self-rated health in frailty assessment may vary in apathetic older adults.

Objective

To explore the moderating role of apathy in the association between self-rated health and frailty among community-dwelling older adults, so as to provide theoretical guidance for the application of the self-rated health in the assessment of frailty in apathetic older adults.

Methods

From November 2021 to March 2022, a total of 384 community-dwelling older adults were selected as respondents by convenience sampling method, including 179 cases in Nanjing Dongshan Community and 205 cases in Lianyungang Qinghu Community. Questionnaire surveys were conducted using the General Information Questionnaire, Fried Frailty Phenotyp (FFP) , Geriatric Depression Scale (GDS-3) , and the self-reported health (SRH) . Generalized linear model was used to analyze the association between self-rated health and frailty of community-dwelling older adults. The model 1 of the SPSS macro program process compiled by Hayes was used to analyze the moderating role of apathy on the association between the self-rated health and frailty, with simple slope analyze performed and simple slope graphs plotted.

Results

The median FFP and SRH item scores of 384 community-dwelling older adults were 1.00 (2.00) and 4.00 (1.00) , respectively, with the detection rate of apathy of 55.5% (213/384) . The results of the generalized linear model showed that the relationship between the self-rated health and frailty of community-dwelling older adults was significant (b=0.310, P<0.001) . The results of the moderating effect test showed that apathy played a moderating role in the relationship between self-rated health status and frailty in community-dwelling older adults (b=0.355, t=3.074, P=0.002) , and the results of simple slope analysis showed that the simple slope of the non-apathy group and apathy group was 0.100 (t=1.209, P=0.228) and 0.455 (t=5.206, P<0.001) respectively.

Conclusion

There is an association between self-rated health and frailty in community-dwelling older adults, and the application of the self-rated health can help community health workers assess frailty in older adults. Apathy plays a moderating role in the relationship between self-rated health and frailty. Compared with the non-apathetic older adults, the association between self-rated health and frailty is significant in apathetic older adults. Strengthening the self-rated health assessment of older adults is beneficial to the identification of their frailty.

Prevalence of Dyslipidemia and Its Influencing Factors among Elderly Community Residents

HUANG Qixian, WEN Yanting, HUANG Jun, LI Weibin, XU Yongneng, LIN Xiayi, WANG Haoxiang, WENG Fan, YANG Lianping

2023, 26(28):  3520-3525.  DOI: 10.12114/j.issn.1007-9572.2022.0808

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Background

Dyslipidemia is the most important and causal independent risk factor for atherosclerotic cardiovascular disease (ASCVD) . The prevalence of dyslipidemia in elderly residents in Guangdong Province is high, and it is urgent to analyze the specific prevalence of dyslipidemia and its influencing factors among the elderly, and to carry out targeted preventive and control measures for dyslipidemia.

Objective

To investigate the epidemiological status of dyslipidemia and its risk factors among elderly residents included in the national basic public health service in Yuexiu District, Guangzhou.

Methods

A total of 41 469 elderly residents aged 65 years and above with complete important variables were selected as subjects from the information system of community health service center in Yuexiu District, Guangzhou City in 2020, the 2020 health checkup data was used to describe the epidemiological characteristics of the included patients such as basic information, BMI and blood lipid levels. Restricted cubic spline (RCS) fitting Logistic regression model was used to analyze the relationship between age, BMI and the prevalence of dyslipidemia.

Results

The prevalence of dyslipidemia in 41 469 elderly residents was 53.65% (22 247/41 469) , with a standardized prevalence of 53.89%. The prevalence of hypercholesterolemia (HTC) , hypertriglyceridemia (HTG) , mixed hyperlipidemia and low high-density lipoprotein cholesterol was 21.43%, 16.50%, 14.51% and 3.80%, with the standardized prevalence of 21.57%, 16.53%, 14.61%, 3.78%, respectively. Multivariate Logistic regression analysis showed that gender, age, education level, exercise status, and BMI were all influencing factors for dyslipidemia in elderly residents, among which female, low age group, and high BMI were risk factors for dyslipidemia in elderly residents (P<0.05) . The results of RCS fitting showed a non-linear relationship between age, BMI and the prevalence of dyslipidemia in elderly residents. The overall prevalence of dyslipidemia in elderly residents showed a decreasing trend with the increase of age. The risk of dyslipidemia showed on increasing and then decreasing trend with the increase of BMI, the OR increased significantly at low BMI, while decreased at high BMI.

Conclusion

The prevalence of dyslipidemia is relative high among elderly residents aged 65 years and above included in the national basic public health services in Yuexiu District, Guangzhou. The prevalence of dyslipidemia in the elderly group tends to decrease with the increase of age, and the risk of dyslipidemia prevalence tends to increase and then decrease with the increase of BMI, suggesting special features in the management of dyslipidemia among the elderly, the analysis of risk factors for dyslipidemia in the elderly should be focused on and early preventive and control measures should be carried out.

Association of Health Promotion Behaviors and Multimorbidity in the Elderly in Ningxia

HE Yuzheng, YU Jiqing, ZHENG Jianzhong, TONG Yan

2023, 26(28):  3526-3532.  DOI: 10.12114/j.issn.1007-9572.2023.0026

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Background

In the context of increasing population aging, maintaining the health of the elderly is the key to successful aging. Multimorbidity is an important factor threatening the health of the elderly, and its relationship with the health promotion behaviors of the elderly has been rarely reported.

Objective

To understand the multimorbidity patterns and distribution of health promotion behaviors among the elderly in Ningxia, analyze the relationship between multimorbidity patterns and health promotion behaviors in the elderly, so as to provide a reference for the development of management and intervention strategies for the health of elderly.

Methods

The population aged 65 years and above in Ningxia were selected as study subjects by using random cluster sampling method from January 2021 to July 2021, and surveyed by self-designed questionnaire〔including general information questionnaire, patient health questionnaire-9 (PHQ-9) , mini-mental state examination (MMSE) , health promoting lifestyle profile-Chinese version (HPLP-C) 〕. Multimorbidity patterns of the elderly was analyzed by association rules of Apriori algorithm, the correlation between multimorbidity and health promotion behaviors of the elderly was analyzed by multivariable Logistic regression analysis.

Results

A total of 2 010 older adults aged 65 years and above were included, with the multimorbidity rate of 31.00% (623/2 010) . The most common binary multimorbidity pattern was coronary heart disease and hypertension〔25.36% (158/623) 〕, the most common ternary multimorbidity pattern was hypertension, coronary heart disease and stroke〔4.49% (28/623) 〕. The association rules revealed 16 patterns of multimorbidity, 15 of which were related to hypertension, 10 were related to coronary heart disease, and 7 were related to asthma. The multivariate Logistic regression analysis showed that compared with older adults with poor health promotion behaviors, those with general〔OR (95%CI) =0.364 (0.185, 0.714) 〕, good〔OR (95%CI) =0.488 (0.251, 0.948) 〕, excellent〔OR (95%CI) =0.426 (0.213, 0.853) 〕health promotion behaviors had a lower risk of multimorbidity (P<0.05) . HPLP-C physical activity〔OR (95%CI) =0.960 (0.925, 0.997) 〕and stress management〔OR (95%CI) =0.963 (0.938, 0.989) 〕dimension scores in older adults were negatively associated with the occurrence of multimorbidity; HPLP-C health responsibility〔OR (95%CI) =1.038 (1.013, 1.063) 〕dimension score was positively associated with the occurrence of multimorbidity.

Conclusion

The multimorbidity patterns of the elderly in Ningxia are complex, and there is an association between health promotion behaviors and occurrence of multimorbidity. The risk of multimorbidity can be reduced by interventions such as encouraging the elderly to practice health promotion behaviors and improve their lifestyles.

Original Research·Focus on General Practice Education

Current Situation of Cognition and Formulation of Faculty Teaching Objectives in Standardized Training for Residency Practitioners: a Qualitative Study

YIN Zhaoxia, LIU Caiyun, ZHANG Baoshuang, CHEN Yanli, GONG Weijie

2023, 26(28):  3533-3538.  DOI: 10.12114/j.issn.1007-9572.2022.0801

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Background

Teaching objectives are the soul and pillar of teaching activity and closely related to class teaching effects. Currently, the cognition and formulation of faculty teaching objectives in standardized training for residency practitioners (abbreviated as general practice residency) has been rarely reported at present.

Objective

To understand the cognition, formulation basis, construction and writing of teaching objectives among outstanding teachers of general practice in China, so as to discuss the approaches of teachers to better promote teaching through teaching objectives in the general practice residency during the process of developing general practice residency, which is highly specialized, focused on post competency development, and different from institutional education.

Methods

The outstanding general practice teachers with the title of associate chief physician and above and related teaching honors on a college level or above, who have been teaching in general practice residency for 5 years or more and are still involved in teaching visits and developing teaching objectives in their teaching activities were selected as research subjects from the general practice departments of national general practice residency base in the hospitals affiliated with well-known medical colleges located in the regions with high development level of general practice. One-to-one semi-structured in-depth interview was conducted by online video conference from February to June 2022. The thematic framework analysis was used to organize and analyze the data and to refine the interview themes through NVivo 12 software.

Results

A total of 8 general practice teachers were enrolled. Through the analysis of the interview data, a total of 3 themes and 4 sub-themes were extracted, including that general practice teachers can better grasp the establishment principles of teaching objectives; there is a lack of institutional guarantees in the construction of teaching objectives, involving 2 sub-themes of the lack of theoretical foundation and normative environment for the construction of teaching objectives; general practice teachers have insufficient cognition of the role of teaching objectives in the development of post competency, involving 2 sub-themes of cognitive deficiencies in teaching objectives, little significance of teaching objectives in guiding teaching activities.

Conclusion

There are still problems in the recognition and formulation of teaching objectives even among the outstanding general practice teachers, which may affect the teaching effects. It is necessary to focus on and ensure the effective formulation of teaching objectives and enhance relevant theoretical training. The teaching objectives should be taken as a starting point to promote the homogeneous development and construction of general practice teachers, so as to train more qualified general practitioners.

Doctor-patient Communication Skills in Master Supervisors in General Practice during Outpatient Encounters: a Survey from Beijing

ZHAO Tiefu, ZHANG Bin, MA Hanying, HAN Hongya, MA Liping, GAO Xuxia, LUO Tianxiang, LUO Hongchi

2023, 26(28):  3539-3543.  DOI: 10.12114/j.issn.1007-9572.2022.0637

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Background

Graduate supervisors in general practice are responsible for the important task of training future general practice professionals, so their abilities to communicate with patients are essential for the development of general practice.

Objective

To examine the abilities to communicate with patients in supervisors of master's students in general practice during outpatient encounters.

Methods

Seventy-five supervisors of master's students in general practice from Capital Medical University were selected by use of cluster sampling to receive a survey using a self-developed demographic questionnaire conducted from April to June 2022. Then their doctor-patient communication skills during outpatient encounters were assessed by relevant professionals who participated in the whole encounter process as accompaniers using the SEGUE Framework. The total score and dimension scores of SEGUE Framework of these supervisors were compared with those of outpatient specialists in tertiary hospitals and general practitioners (GPs) in community health centers (CHCs) in our previous studies, and were compared across these supervisors by sex, employment method and level of medical institutions. Then the total score of SEGUE Framework was compared between the supervisors and US GPs.

Results

The total score of SEGUE Framework attained by the supervisors ranged from 12 to 24 points, and the average score was (17.8±2.6) . The average scores of five dimensions (set the stage, elicit information, give information, understand the patient's perspective, and end the encounter) obtained by them were (3.9±0.9) , (6.5±1.7) , (3.1±1.1) , (2.6±0.9) and (1.7±0.5) , respectively. These supervisors scored higher on dimensions of set the stage and end the encounter than GPs in CHCs and outpatient specialists in tertiary hospitals (P<0.05) . Compared with their counterparts working in primary hospitals, supervisors working in secondary hospitals scored lower on the SEGUE Framework and set the stage dimension (P<0.05) , and those working in tertiary hospitals scored lower on the SEGUE Framework and set the stage and elicit information dimensions (P<0.05) . These supervisor scored lower on the SEGUE Framework than the US GPs (P<0.05) .

Conclusion

There is still considerable room for improvement of the skills for communicating with patients in outpatient encounters in these supervisors. Their level of communication skills was still lower than that of US GPs. In view of this, the teaching management department responsible for general practice department (school) should pay attention to the training of the abilities of master supervisors to communicate with patients, thereby improving the level of medical humanities in practice in master's students in general practice by supervisors' words and deeds.

Perceptions toward General Practice Career among Non-targeted Admission General Medical Graduates Completing the Standardized General Residency Training Program

LI Bing, YANG Shan, WANG Cong, CHEN Jinjing, XU Zhiwei, LIU Xiaoyu, WANG Liuyi

2023, 26(28):  3544-3550.  DOI: 10.12114/j.issn.1007-9572.2023.0122

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Background

The long-term and stable development of the general practitioner workforce is crucial to the implementation of policies related to contracted family doctor services, the continuous promotion of construction of the hierarchical diagnosis and treatment system, and the realization of national strategic goals for achieving "big health". Whether a general practitioner continues to work in general practice depends primarily on his confidence in the profession. Exploring the perceptions toward general practice as a career among general medical graduates finishing the standardized general residency training program (SGRTP) , can provide a reference for the improvement of training content and relevant policy formulation. However, there are few relevant studies.

Objective

To explore the perceptions toward general practice career among non-targeted admission general medical graduates completing the SGRTP, offering insights into how to better retain general practice talents.

Methods

In August 2021, stratified cluster random sampling was used to select non-targeted admission general medical graduates who had been admitted to the SGRTP in 10 standardized general residency training bases in Henan Province during 2014 to 2017, and completed the SGRTP as of the survey date. They attended a self-administered survey conducted through an online platform named "Wenjuanxing", using a questionnaire developed by our research group for understanding their general information, standardized training information, current work situation and perceptions toward a career in general practice.

Results

Three hundred and twenty-six cases attended the survey, and 271 (83.1%) of them who handed in responsive questionnaires were finally included, among whom 77 (28.4%) went into the career of general practice after the completion of SGRTP. Compared with their counterparts who did not work in general practice following the completion of training, the trainees who worked in general practice rated the disciplinary position of general medicine and the social position of general practitioners higher (P<0.05) . Moreover, the percentage of them〔80.5% (62/77) 〕 intending to work in general practice in their whole life was higher (P<0.05) . The score for disciplinary position of general medicine rated by the trainees varied by age and whether or not being the only child of the family (P<0.05) . The score for social position of general practitioners rated by the trainees varied by maternal education level (P<0.05) . The score for the career prospect of general practitioners rated by the trainees varied by age (P<0.05) . Age, marital status, education level, maternal occupation, and current work unit were associated with the differences in scores for intending to be a general practitioner in the whole life given by the trainees (P<0.05) . The top three factors limiting the development of general medicine according to the trainees were "inadequate supporting policies" (150 cases, 55.4%) , "low salary for general practitioners" (146 cases, 53.9%) , and "poor equipment in primary care" (137 cases, 50.6%) . The rates of trainees choosing restrictors of the development of general medicine did not vary by whether or not working in general practice following the completion of SGRTP (P>0.05) . The top three advantages of primary care institutions were "better health guidance for residents" (213 cases, 78.6%) , "optimal allocation of medical resources, relieving pressure on major hospitals and avoiding waste of resources" (165 cases, 60.9%) , and "solving the problem of'seeing a doctor is difficult and expensive' among the masses" (162 cases, 59.8%) . The rates of trainees choosing the options of advantages of primary care institutions did not vary by whether or not working in general practice following the completion of SGRTP (P>0.05) . The top three disadvantages of primary care institutions according to the trainees were "low salary for general practitioners" (212 cases, 78.2%) , "poor hardware and equipment" (181 cases, 66.8%) , and "inadequate social security mechanism" (111 cases, 41.0%) . The rate of trainees choosing "inadequate social security mechanism" or "great concern in educational issues for children due to backward development in remote rural areas" varied by whether or not working in general practice following the completion of SGRTP (P<0.05) , but the rate of choosing each of the other options of disadvantages of primary care institutions did not (P>0.05) .

Conclusion

Age, education level, marital status, mother's education level and occupation, whether or not being the only child in the family, and current work unit were associated with the perceptions toward general practice career in non-targeted admission general medical graduates completing the SGRTP. The supporting policies and salary system are main factors affecting the development of general medicine and primary care institutions, and priority should be given to the allocation of hardware and equipment and the education guarantee for children of general practitioners.

Current Situation, Problems, and Strategies of Continuing Medical Education for Rural Order-oriented General Practitioners in Guizhou Province

PU Haifeng, WANG Yinsheng, YU Changyin, CHEN Lingli, XIAO Xue, ZHANG Nian, CHEN Chuying, ZHU Jiming

2023, 26(28):  3551-3558.  DOI: 10.12114/j.issn.1007-9572.2023.0090

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Background

The competency in primary performance positions of rural order-oriented medical graduates of standardized general residency training program (abbreviate for oriented general practitioners) has attracted wide attention. Strengthening continuing medical education is an important measure to enhance the competency of oriented general practitioners.

Objective

To understand the current situation, problems and needs of continuing medical education for oriented general practitioners in Guizhou Province, and to provide a basis for improving continuing medical education for oriented general practitioners.

Methods

From November to December 2021, 42 oriented general practitioners from 39 township hospitals in 9 cities in Guizhou Province were selected as the research subjects for semi-structured interviews by the purposive sampling and snowball sampling methods. The interview results were coded and analyzed by the research method of procedural grounded theory to extract and summarize the current situation, problems and needs of their continuing medical education.

Results

After three-level coding, 145 concepts, 23 categories and 5 domains related to the continuing medical education of oriented general practitioners were finally sorted out, and a story line was consequenty formed: the continuing medical education of oriented general practitioners is influenced by several factors, among which actual situation is the obstacle, competency requirement is the extrinsic driver, policy system is important guarantee, self-demand is the intrinsic motivation, and the improvement of the training process management is the key process.

Conclusion

The training intention of oriented general practitioners remains to be strengthened in Guizhou Province. The quality of continuing medical education, integration degree of training content and demand, and attention of primary care institutions need to be improved. The support for continuing medical education and the construction of information platform should be strengthened, and the content and form of continuing medical education suitable for oriented general practitioners should be improved, in order to improve the quality and effect of training in continuing medical education.

Evidence-based Medicine

A Systematic Review of Medication Preferences for Patients with Depression Based on Discrete Choice Experiment and Best-worst Scaling

REN Yanfeng, LIU Shimeng, TAO Ying, CHEN Yingyao

2023, 26(28):  3559-3564.  DOI: 10.12114/j.issn.1007-9572.2022.0824

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Background

Drug therapy is one of the main treatment approaches for depression, and a consideration of patient preferences can effectively improve patient compliance with medication. Several studies have been conducted to explore the medication choice preferences of patients with depression, but there is a lack of studies to systematically collect and summarize the medication choice preferences of patients with depression.

Objective

To systematically review the studies related to the application of discrete choice experiment (DCE) and best-worst scaling (BWS) to the medication choice preferences of patients with depression, in order to provide reference for clinical rational drug use of patients with depression and future studies of preferences.

Methods

CNKI, Wanfang Data Knowledge Service Platform, VIP, PubMed, Web of Science and EmBase were systematically searched for the studies related to the application of DCE and BWS to the medication choice preferences of patients with depression from inception to 2021-12-31, using "DCE" "BWS" "depression" "discrete choice experiment" "best-worst scaling" as keywords on January 2022. Data were extracted from the included literature, and the PREFS checklist was used for the quality assessment of all studies. The attributes included in the study were classified into three categories of outcome, process and cost, and their relative importance on the impact of medication preferences of patients was assessed.

Results

A total of 7 papers were included, all of which were studies related to DCE, involving 47 attributes, among which 41 were classified as outcome attributes, 5 were classified as process attributes, and 1 was classified as a cost attribute. A total of 9 most important attribute results were obtained from the 7 studies, the outcome attribute was considered most important 8 times and the cost attribute was considered most important 1 time. Among the outcome attributes, adverse effects were considered most important 5 times and effectiveness was considered most important 3 times. Based on the PREFS checklist, one study received a score of four and six studies received a score of three. Most studies need further improvement in terms of respondents and findings.

Conclusion

Outcome attributes are most important in the medicine taking process of patients with depression, which needs attention of clinicians and policy makers. There is room for improvement in the dimensions of variance reporting and experimental design, it is recommended for further improvement of research design in terms of respondents interpretation of findings and experimental design in future research, in order to provide more high-quality evidence for research of medication preferences of patients with depression.

A Meta-synthesis of Qualitative Studies on the Real Experiences and Care Experience during Hospital-to-home Transition for Elderly Patients with Chronic Diseases

SUN Mengjie, LIU Lamei, WANG Jia'nan, WANG Peng, ZHANG Zhenxiang

2023, 26(28):  3565-3572.  DOI: 10.12114/j.issn.1007-9572.2022.0654

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Background

Understanding the real experiences of elderly patients with chronic diseases during hospital-to-home transition and their expectations of care services can help promote the quality improvement of care services during the transition. In recent years, qualitative studies on real experiences of elderly patients with chronic diseases during the hospital-to-home transition and their experience of care services have gradually increased, however, the results of single qualitative study may not be generalizable and representative.

Objective

To systematically evaluate qualitative studies on the real experiences of elderly patients with chronic diseases during the hospital-to-home transition and their experience of care services.

Methods

In May 2022, PubMed, Web of Science Core Collection, EmBase, CINAHL, CNKI, and Wanfang Data Knowledge Service Platform were searched for the qualitative studies on the real experiences of elderly patients with chronic diseases during hospital-to-home transition and their experience of care services from inception to May 2022. Two researchers separately screened the literature and extracted data, evaluated the quality of included studies according to the Critical Appraisal Skills Programme (CASP) developed by evidence-based medicine center of University of Oxford. Meta synthesis was applied to integrate the results of the studies.

Results

A total of 13 studies were included with 45 research results extracted, and 3 synthesized findings were integrated from 8 categories grouped by similar findings, including barriers to care services during hospital-to-home transition for elderly patients with chronic diseases; facilitators of care services during hospital-to-home transition for elderly patients with chronic diseases; expectations of elderly patients with chronic diseases for care services during hospital-to-home transition.

Conclusion

Hospital-to-home transition of elderly patients with chronic diseases is a challenging process, and there is still much room for improvement in the quality of care services during the transition. Families, communities, medical institutions, government, and society should actively improve the transition conditions for elderly patients at the individual, community, and social levels. The safe hospital-to-home transition of elderly patients with chronic diseases can be promoted by enhancing education for patients during transition, improving self-management abilities of patients, and providing nurse-led care services during transition.

Efficacy of Community-involved Hospice Care for Patients with Advanced Cancer: a Meta-analysis

HU Jingyi, HONG Jing, GUO Xiaodong, ZHANG Xiaohong, MO Ning, ZHOU Xiaocui, YU Qin, ZHOU Minhua, SUN Yan, NI Liu, SHI Xiaoli, SU Xiaoqing, LI Yuqian

2023, 26(28):  3573-3584.  DOI: 10.12114/j.issn.1007-9572.2022.0678

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Background

Community-based intervention is an important part of palliative care for advanced cancer patients. However, its role in the health management of advanced cancer patients remains to be supported by medical evidence.

Objective

To evaluate the efficacy of community-involved hospice care for patients with advanced cancer.

Methods

Wanfang Data Knowledge Service Platform, CNKI, VIP were searched by using Chinese keywords such as "community" "medical model" and "advanced cancer", Cochrane Library, PubMed and Web of Science were searched by using English keywords such as "Community-based" "Model of Palliative Care" "Advanced Cancer" "Quality of Life", to obtain randomized controlled trials (RCTs) related to the efficacy of community-involved hospice care from 2007-01-01 to 2022-05-10 by using Cochrane system evaluation method on 2022-05-22. The quality of RCTs meeting the inclusion criteria was evaluated, and the valid information was extracted for meta-analysis.

Results

A total of 11 RCTs in English and 9 RCTs in Chinese were included in the study, involving 2 356 and 1 238 patients, respectively. Meta-analysis showed that compared with routine cancer care, community-involved hospice care could improve quality of life and symptom severity in patients with advanced cancer, demonstrated by increasing Functional Assessment of Chronic Illness Therapy-Palliative Care scale socre〔MD (95%CI) =3.77 (0.83, 6.71) , P=0.01〕and Quality of Life Instruments for Cancer Patients scale total score〔MD (95%CI) =12.53 (2.36, 22.69) , P=0.02〕, reducing Functional Assessment of Cancer Therapy scale total score〔MD (95%CI) =-2.61 (-3.53, -1.70) , P<0.01〕 and Edmonton Symptom Assessment System score〔MD (95%CI) =-2.45 (-4.70, -0.20) , P=0.03〕. However, the improvement of community-involved hospice care on depressive symptoms and overall survival rates of patients remains controversial, and its effect on economic indicators such as admission rates, hospitalization days/numbers needs to be further explored.

Conclusion

Community-involved hospice care can improve the quality of life and symptom severity of patients with advanced cancer, however, its improvement in hospice care in the depressive symptoms and overall survival rates of the patients remains controversial, and its improvement in economic indicators such as admission rate and hospital stay/inpatients admissions remains to be further explored.

Experience Sharing

Exploration of Chronic Disease Management Model in Secondary Private General Hospital

GAO Yanli, WANG Hongjun, SUN Fei, JI Xiangqin, Changizi Roohollah

2023, 26(28):  3585-3590.  DOI: 10.12114/j.issn.1007-9572.2022.0693

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Background

Chronic non-communicable diseases have become the primary factor threatening human health at present. The strategy of "Healthy China 2030" in 2016 emphasized the comprehensive prevention and control of chronic diseases for the first time. In recent years, a growing number of general practitioners in China have been playing an important role as gatekeepers of health in community health care and chronic disease management. Primary care managers (PCMs) selected from experienced senior nurses who have received an appropriate training can form health management teams with general practitioners to improve clinical efficiency and management outcomes in chronic disease populations according to domestic and international literature.

Objective

To explore the feasibility and sustainability of collaborative outpatient chronic disease management model based on medical team consisting of general practitioners, internists and PCMs in secondary private general hospital.

Methods

General practitioners or internists were assigned as primary care physicians (PCPs) for patients with essential hypertension and/or type 2 diabetes mellitus (T2DM) , physician assistants or senior nurses in the corresponding departments were trained as PCMs, PCPs and PCMs form chronic disease management teams to collaborate on the health management of patients with chronic diseases. The control of blood pressure and/or glycated hemoglobin in the dynamic and fixed populations of patients from April 2020 to August 2021 was reviewed, two indexes for the quality control including the rates of poorly controlled blood pressure and blood glucose were used to assess the effectiveness of chronic disease management collaboratively conducted by the PCP-PCM team. A questionnaire was used to obtain feedback from PCP-PCM team members on chronic disease management efforts, and a net promoter score (NPS) questionnaire was used for the investigation of patients satisfaction on PCP.

Results

From April 2020 to August 2021, the rate of poorly controlled blood pressure in our hospital ranged from 18.34% to 20.82%, basically meeting the quality control target of no more than 20%; the rate of poorly controlled blood glucose ranged from 14.92% to 24.31%, with significant fluctuations, and did not meet the quality control target of no more than 20% in some months. The overall feedback from PCP-PCM team members on this chronic disease management model was very positive, but PCMs shared the concerns of excessive work load. The average NPS score for PCPs calculated from the results of 170 NPS questionnaires was 91, which was higher than than the average NPS department scores of general practitioners and internists in the same period (86 and 80, respectively) .

Conclusion

The chronic disease management model based on PCP-PCM team is effective in the improvement of clinical indicators in the hypertensive and diabetic patient populations, with positive feedbacks from PCPs, PCMs and patients suggesting feasibility of the chronic disease management model. However, the shortage of PCMs may have negative impact to the effectiveness of chronic disease management in long term, which is worthwhile to continue exploring in the sustainability of the model.