Shared decision-making is a practice that fully reflects the idea of patient-centered care, but its clinical implementation process is not ideal. Physicians are main participants to promote the implementation of shared decision-making, but there are few studies on their behaviors in shared decision-making.
To explore the process and main behavioral characteristics of physicians' participation in shared decision-making, offering evidence for the promotion and implementation of shared decision-making in clinical practice.
A mixed-methods convergent design was used to collect quantitative and qualitative data. In the quantitative study, convenience sampling method was used to select in-service physicians (n=360) from a grade A tertiary hospital in Shanghai to attend a questionnaire survey from May to December 2020 to understand the status of their participation in shared decision-making. K-means clustering was conducted to analyze the distribution characteristics of physicians' participation in shared decision-making. In the qualitative study, 23 physicians selected from the participants of the quantitative study using convenience sampling and purposive sampling from June to December 2020 were recruited to attend semi-structured interviews to explore the process and experience of their participation in shared decision-making and identify the main behavioral characteristics of them in each part of the process of shared decision-making.
Quantitative data analysis: in all, 325 (90.3%) of the physicians who returned responsive questionaries were included for analysis. The average total score of their participation behavior in shared decision-making was (80.44±14.88) . The further analysis found that physicians had the highest participation in behaviors of "Explain the advantages and disadvantages of the treatment options to my patient" (4.38±0.74) and "I told my patient that there are different options for treating his/her medical condition" (4.30±0.84) ; physicians had the lowest participation in behaviors of "I made clear to my patient that a shared decision needs to be made" (3.72±1.22) and "My patient and I selected a treatment option together" (3.74±1.03) . The results of cluster analysis showed that the behavioral characteristics of physicians' participation in shared decision-making could be divided into three groups, namely informed consent group, partial patient participation group and shared decision-making group. Qualitative data analysis: physicians' participation behaviors in shared decision-making included building up the awareness of shared decision-making, providing the patient with information, examining patient comprehension of the information, clarifying patient values, co-assessment (of the feasibility of the options) , reaching a decision and decision implementation. Analysis of the mixed-methods research results showed that in the decision-making process, physicians paid more attention to the provision of information, and ignored the behavioral factors of promoting patient participation at the level of doctor-patient communication. The behavioral characteristics of physicians' participation in shared decision-making were different.
The physicians' participation behavior in shared decision-making was limited. And they may have misunderstandings about the behavior process of shared decision-making. To promote the practical implementation of shared decision-making in clinical practice, it is suggested to help physicians clarify the process of shared decision-making via interventions enhancing their knowledge and attitudes regarding shared decision-making, deepen their understanding of shared decision-making through scenario simulation and role-playing, and improve their recognition of patient values in decision-making.
Primary care physicians play a vital role in the health management of hypertensive patients. Health assessment is an important tool for screening, diagnosis, and risk prediction of hypertension. Risk assessment allows early detection of target organ damage in hypertensive patients and provides a basis for treatment planning. Currently, the national public health service specification has clear requirements for health assessment for hypertensive patients, and such assessments have been carried out in primary health care institutions, but there are few reports on the competence of primary care physicians in health assessment for hypertensive patients.
To understand the levels of knowledge, attitude and practice (KAP) about health assessment for hypertensive patients among primary care physicians, and to analyze their influencing factors.
From May to June 2022, an online questionnaire survey was conducted among a multistage stratified sample of 420 primary care physicians in northern, central and southern Shanxi Province for collecting information of their baseline demographics, levels of KAP for health assessment for hypertensive patients, and hypertension assessment devices equipped in their medical institutions. Multiple linear regression was used to identify factors associated with primary care physicians' level of health assessment for hypertensive patients.
A total of 402 cases (95.7%) who returned responsive questionnaires were finally included. The total average score of KAP of the primary care physicians on the health assessment for hypertensive patients was (127.16±18.65) , with an average score of (53.68±8.95) on the knowledge dimension, (28.62±4.09) on the attitude dimension and (44.86±7.53) on the practice dimension. The results of multiple linear regression analysis showed that work unit, the level of highest educational attainment, specialty, participation in standardized training, learning the latest National Guidelines for the Management of Primary Hypertension in Primary Care, receiving health management-related training, frequency of learning chronic disease knowledge and skills organized by their medical institutions, and weekly hours of independent learning were associated with the knowledge dimension of hypertension health assessment among primary care physicians (P<0.05) . The participation in standardized training, mode of employment, learning the latest National Guidelines for the Management of Primary Hypertension in Primary Care, frequency of learning chronic disease-related knowledge and management skills organized by their medical institutions, and weekly hours of independent learning were factors influencing primary care physicians' scores on the attitude dimension of hypertension health assessment (P<0.05) . Acquisition of physician qualifications, the participation in standardized training, learning the latest National Guidelines for the Management of Primary Hypertension in Primary Care, receiving health management-related training, frequency of learning chronic disease-related knowledge and management skills organized by their medical institutions, and weekly hours of independent learning were factors influencing primary care physicians' scores on the behavioral dimension of hypertension health assessment (P<0.05) . In terms of the hypertension assessment equipment equipped in the medical institutions of primary care physicians, except for sphygmomanometer, height and weight measuring instruments and soft rulers for measuring waist circumference with a configuration rate of more than 96.8%, the configuration rates of routine hematology analyzers, routine urine chemistry analyzers, blood biochemistry analyzers, electrocardiogram machines, and chest X-ray (radiography) equipment (35.6%, 35.8%, 26.9%, 42.8%, and 23.1%, respectively) were all less than 45.0%, and the configuration rates of ambulatory blood pressure monitor, cardiac ultrasound machines, vascular color Doppler ultrasound equipment and funduscopic examination equipment were even lower (less than 15.0%) .
Primary care physicians have a relatively positive attitude toward health assessment for hypertensive patients, and there is still room for improvement in their levels of related knowledge and practical skills. In the future, we can improve primary healthcare services and standards by strengthening the standardized training of professional knowledge and skills of primary care physicians, improving the incentive and assessment system of primary healthcare institutions, and stimulating the awareness of independent learning of primary care physicians.
Allergic rhinitis (AR) is a highly prevalent chronic non-communicable disease. The research on the understanding and treatment of AR in China is mainly in otorhinolaryngology specialists, but rarely in general practitioners (GPs) in primary care. And recommendations on the diagnosis and treatment of AR in primary care are also insufficient.
To explore the understanding of AR and diagnosis and treatment capacities related to AR in GPs in primary care.
By use of simple random sampling, 432 GPs from 21 community health service organizations in Beijing's Chaoyang District were chosen between August and September 2020. The questionnaire was combined with the Guidelines for the Diagnosis and Treatment of Allergic Rhinitis (Tianjin, 2015) (China 2015 AR Guidelines) and Allergic Rhinitis and Its Impact on Asthma (ARIA) Guidelines: 2010 Revision, and its 2016 annual revision, and refinement of the questionnaire after consultation with experts and pre-survey. The information obtained from the questionnaire included basic information about the subjects, understanding level, diagnostic and therapeutic behaviors, training, and support needs regarding AR, et al.
The 383 (88.7%) of the 432 questionnaires were finally returned. Only 0.8% (3/383) of the GPs correctly responded to all of the questions on typical AR symptoms, diagnosis, treatment philosophies, first-line drug classes, and regimens suggested by guidelines. Guidelines for AR, including China 2015 AR Guidelines and ARIA Guidelines, were known to 32.4% (124/383) of the GPs, Web-based continuing education such as www.haoyisheng.com, www.dxy.cn and WeChat and related training. When treating each patient with a respiratory illness, the prevalence of GPs differentiating AR from others, providing recommendations on environmental control, suggesting nasal rinsing, recommending other treatments instead of immunotherapy, and referring the patient to the specialty department without any treatment, was 59.8% (229/383) , 37.1% (142/383) , 17.8% (68/383) , 49.4% (189/383) , and 13.1% (50/383) , respectively. In terms of pharmacological treatment, 17.5% (67/383) of GPs said their hospital offered all four classes of first-line AR medications. As for AR-related training, 75.7% (366/383) of the GPs reported not having taken any AR-related training in 2019; and 91.7% (266/290) needed the training. And 95.6% (290/383) of the GPs said AR should be handled standardizedly in the community. A multivariate stepwise regression Logistic analysis revealed that when encountering patients with respiratory symptoms, GPs with a master's degree or higher〔OR (95%CI) =2.790 (1.057, 7.366) 〕and a good grasp of AR-related health knowledge〔OR (95%CI) =3.537 (2.015, 6.209) 〕were more likely to make a differential diagnosis of AR from other illnesses, GPs with a good grasp of AR-related health knowledge〔OR (95%CI) =4.397 (0.534, 1.576) 〕were more likely to offer patients guidance on environmental control behaviors, GPs who were familiar with nasal irrigation procedures〔OR (95%CI) =6.592 (3.038, 14.306) 〕were more likely to recommend nasal irrigation, and GPs knowing about immunotherapy〔OR (95%CI) =1.881 (1.087, 3.254) 〕, accurately answering questions on the principles of treatment〔OR (95%CI) =128.330 (16.628, 990.402) 〕or their institution providing some/all laboratory testing services〔OR (95%CI) =2.210 (1.299, 3.760) 〕were prone to recommend immunotherapy.
Despite their low awareness levels of AR expertise and guidelines, and unsatisfied practice standardization, GPs in primary care in Chaoyang District demonstrated proactive attitude towards continuing education and carrying out standardized AR treatment in primary care. As high awareness levels of AR-related knowledge and guidelines promote the practice standardization, relevant trainings for GPs in primary care should be strengthened, and AR-related guidelines applicable to primary care should be developed, which can provide support for the standardization of AR treatment at the primary care level.
With the aging of the population, the prevalence of atrial fibrillation is increasing year by year. As the "gatekeepers" of community residents' health, grassroots medical staff with a high level of knowledge about atrial fibrillation is particularly important for standardized management of atrial fibrillation.
To analyze the mastery of atrial fibrillation-related knowledge among grassroots medical staff in Fengxian District, Shanghai and its influencing factors, thus, providing a theoretical basis for subsequent training work.
This study is a cross-sectional survey study. From June to July 2021, a systematic sampling method was used to select 1 393 grassroots medical staff as the research objects including general practitioners, nurses, pharmacists, public health physicians and other medical staff (imaging technology/physician, laboratory technician, traditional Chinese medicine doctor and so on) from 21 community health service centers in Fengxian District, Shanghai. This study used a self-developed electronic questionnaire to investigate them. The contents of the questionnaire included general information and knowledge related to atrial fibrillation (basic knowledge about atrial fibrillation, knowledge about anticoagulant therapy and knowledge about rhythm/heart rate control) . This study compared the mastery of atrial fibrillation-related knowledge among grassroots medical staff in different positions, and used univariate Logistic regression, ordinal multiple classification or binary Logistic regression to analyze the influencing factors of grassroots medical staff's mastery of atrial fibrillation-related knowledge.
A total of 1 383 valid questionnaires were recovered, and the valid questionnaire recovery rate was 99.28%. Among 1 383 grassroots medical staff, 506 cases (36.59%) were general practitioners. 54.88% (759/1 383) , 97.69% (1 351/1 383) and 69.63% (963/1 383) failed in the basic knowledge about atrial fibrillation, knowledge about anticoagulation and knowledge about heart rhythm/heart rate control, respectively. There were statistically significant differences in the scores of atrial fibrillation knowledge, anticoagulation knowledge and heart rhythm/heart rate control knowledge among grassroots medical staff in different positions (P<0.05) . Ordinal multiple classification or binary Logistic regression analysis showed that the position as a general practitioner and professional title were the influencing factors of score in the basic knowledge related to atrial fibrillation among grassroots medical staff (P<0.05) . Age and position as a general practitioner were the influencing factors of whether the score in knowledge related to anticoagulation therapy reaches the pass level or above among grassroots medical staff (P<0.05) . The position as a general practitioner, received standardized training and reading the atrial fibrillation guideline within one year were the influencing factors of the score in knowledge related to heart rhythm/heart rate control among grassroots medical staff (P<0.05) .
The mastery of knowledge about atrial fibrillation among grassroots medical staff is generally not ideal, especially the lack of knowledge about anticoagulation therapy. Atrial fibrillation related knowledge training should be especially strengthened for grassroots medical staff who are not general practitioners, have low professional titles, and have not received standardized training.
Non-communicable disease (NCD) managers are the main force in the prevention and treatment of chronic obstructive pulmonary disease (COPD) . Understanding the perceptions of COPD among NCD managers in primary care in rural areas can provide a scientific basis for enhancing future prevention and management of COPD in primary care.
To investigate the perceptions of COPD in NCD managers in rural primary care, offering a scientific basis for the improvement of COPD prevention and management in primary care.
In June 2021, random sampling method was used to select 20 township hospitals in Zigong, Sichuan Province, and from which NCD managers〔including general practitioners (GPs) , public health workers and rural doctors〕were selected by use of cluster sampling. A survey was conducted with them using a self-developed questionnaire (consisting of two parts: general demographics and COPD-related knowledge) for understanding their perceptions of COPD.
All the cases (n=474) who participated in the survey returned responsive questionnaires, achieving a response rate of 100.0%, including 68 GPs (14.4%) , 177 public health workers (37.3%) , and 229 rural doctors (48.3%) . With regards to answering the questions of comprehensive COPD knowledge, GPs had statistically significant higher pass rate than rural doctors〔35.3% (24/68) vs 7.4% (17/229) 〕 (P<0.017) , and public health workers also had statistically notably higher pass rate than rural doctors〔31.6% (56/177) vs 7.4% (17/229) 〕 (P<0.017) . In terms of answering the questions about risk factors of COPD, GPs had statistically significant higher pass rate than rural doctors〔73.5% (50/68) vs 46.3% (106/229) 〕 (P<0.017) , and so did public health workers〔66.7% (118/177) vs 46.3% (106/229) 〕 (P<0.017) . In terms of answering the questions about diagnosis and evaluation of COPD, GPs had statistically significant higher pass rate〔38.2% (26/68) 〕than public health workers〔20.3% (36/177) 〕or rural doctors〔3.9% (9/229) 〕 (P<0.017) , and the pass rate of public health workers was statistically significant higher than that of rural doctors (P<0.017) . In terms of answering the questions about treatment strategies for COPD, GPs had statistically significant higher pass rate than rural doctors〔30.9% (21/68) vs 6.6% (15/229) 〕 (P<0.017) , and so did public health workers〔19.2% (34/177) vs 6.5% (15/229) 〕 (P<0.017) . In terms of answering the questions regarding follow-up management for COPD, public health workers had statistically significant higher pass rate than GPs〔46.9% (83/177) vs 29.4% (20/68) 〕and rural doctors〔46.9% (83/177) vs 14.4% (33/229) 〕 (P<0.017) . And GPs had statistically significant higher pass rate than rural doctors (P<0.017) .
The NCD managers in primary care in rural areas of Sichuan's Zigong have insufficient knowledge of COPD, especially its diagnosis, evaluation, treatment strategies and follow-up management. NCD managers from different positions have different perceptions of COPD, among them rural doctors have the lowest level of perception. In view of the above problems, we need to take targeted measures to improve the level of general prevention and management of COPD in rural primary care.
Message framing (gain-framed message vs loss-framed message) plays a major role in health education, but its significance in public stroke education is still unclear.
To compare the impact of gain- and loss-framed messages about "Stroke 1-2-0" (a kind of stroke educational video) on residents' intention to delay seeking care in the situation of identifying pre-stroke symptoms.
From January to September 2021, the gain-framed message video and loss-frame message video based on "Stroke 1-2-0" were developed through three steps: script writing, video production, and video evaluation. Then during October to November 2021, 81 residents aged 35-80 selected by convenience sampling from Guangzhou, Guangdong Province were randomized into a gain-framed message video intervention group (n=40) and a loss-framed message video intervention group (n=41) , to watch the gain-framed message video and loss-framed message video, respectively. The impact of the intervention was appraised by comparing pre- and post-intervention status of correct recognition and management of pre-stroke symptoms assessed using a self-developed Pre-stroke Symptom Recognition and Management Questionnaire, and pre- and post-intervention total score and domains scores of the Stroke Pre-hospital Delay Behavior Intention (SPDBI) scale.
A total of 75 cases (37 in the gain-framed message video intervention group and 38 in the loss-framed message video intervention group) who completed the study were finally included. Two groups had no significant differences in pre-intervention rates of correct recognition and management of pre-stroke symptoms (P>0.05) . There were no significant intergroup differences in mean pre-intervention total score and each domain score of the SPDBI scale (P>0.05) . After intervention, significantly increased rates of correct recognition and management of various pre-stroke symptoms, and significantly lowered mean total score and domain scores (except the non-treatment justification) of the SPDBI scale were found in the gain-framed message video intervention group (P<0.05) . In the loss-framed message video intervention group, the correct recognition rate of various pre-stroke symptoms significantly improved (P<0.05) , and the rate of correct management of pre-stroke symptoms (except the deviated mouth) was also notably improved (P<0.05) . Moreover, the total score and each domain score of the SPDBI scale were lowered notably (P<0.05) . Post-intervention intergroup comparison demonstrated that the loss-framed message video intervention group had lower mean total score of the SPDBI scale and lower mean scores of three domains (non-treatment justification, symptom attributions, habitual response style) of the scale (P<0.05) .
The loss-framed message had stronger persuasive impact on reducing residents' intention to delay accessing of care when pre-stroke symptoms occurred. Thus, the loss-framed message can be used as an expression form of health education on pre-hospital delay in stroke, focusing on the relationship between pre-stroke symptoms and the time of triggering an emergency call on the phone, and highlighting the importance and urgency of seeking medical treatment quickly.
The knowledge-based management model has been widely used in chronic disease management recently. The online-to-offline (OTO) model, a common internet-based chronic disease management model integrating online and offline resources, has been used in disease prevention besides disease treatment, and proven to be effective in supporting chronic disease management. However, there are few studies on the application of OTO model in the management of older adults with diabetes in China.
To explore the influence of OTO model on glycemic control and self-management behaviors in older adults with type 2 diabetes in the community.
By use of convenient sampling, older adults with type 2 diabetes (n=110) who were transferred from a tertiary hospital to five community hospitals in Shenyang were selected from August to October 2020. They were randomly assigned in a 1∶1 ratio, to receive a 12-month usual community-based health management (control group) , or a 12-month OTO model-based health management (intervention group) . The intervention results were evaluated by fasting blood glucose (FBG) , 2-hour postprandial glucose (2 h-PBG) and glycosylated hemoglobin (HbA1c) at baseline, and 6 months and 12 months after intervention, and total score and dimension scores of the Chinese version of Summary of Diabetes Self-care Activities (SDSCA-C) at baseline and 12 months after intervention.
A total of 105 cases (53 in the intervention group and 52 in the control group) who completed the study were finally included. Two groups had was no significant differences in mean levels of baseline FBG, 2 h-PBG and HbA1c (P>0.05) . Significant interaction effects produced by the intervention method and time, and significant main effects brought by both intervention method and time on FBG, 2 h-PBG and HbA1c were observed (P<0.05) . FBG, 2 h-PBG and HbA1c levels in the intervention group decreased significantly either at 6 or 12 months after intervention (P<0.05) . But in the control group, only FBG and 2 h-PBG levels decreased significantly at 6 and 12 months after intervention (P<0.05) . The 12-month intervention lowered FBG, 2 h-PBG and HbA1c levels more significantly than 6-month intervention in the intervention group (P<0.05) . But in the control group, only 2 h-PBG level was lowered more significantly by 12-month intervention than 6-month intervention (P<0.05) . The intervention group had lower mean FBG, 2 h-PBG and HbA1c levels than the control group either at 6 or 12 months after intervention (P<0.05) . At baseline there were no differences between the two groups in total score and dimension scores of SDSCA-C (P>0.05) . After 12 months of intervention, the total score and dimension scores of SDSCA-C increased insignificantly in the control group (P>0.05) , but increased notably in the intervention group (P<0.05) . The intervention group had much higher total score and dimension scores of SDSCA-C than the control group after the intervention (P<0.05) .
The OTO model-based health management could contribute to improving glycemic control and self-management behaviors in older type 2 diabetics, which may benefit effective long-term management of diabetes.
Parkinson's disease (PD) is a common chronic neurodegenerative disease that seriously affects the quality of life of patients. Internationally, a whole-course specialist-general practitioner management mode of PD has been established, which can effectively improve the quality of life of patients and reduce PD burden on families and society. China has a health management system with its unique features, and lacks an applicable PD community management scheme.
To develop a standardized community-based management scheme for PD applicable to general practitioners (GPs) in China.
The full texts of guidelines, standards and consensuses related to PD diagnosis and management published from January 1, 2010 to December 31, 2020 were searched, and alternative items that could be included in the standardized community-based management scheme were screened and extracted, then relevant items were extracted to be used to develop a draft of standardized community-based management scheme for PD according to the experts interview and clinical evidence. After that, the draft was further revised under two rounds of email-based expert consultation using the Delphi technique.
A total of 16 experts were invited to consult by e-mail for this study. The response rate was 100.0% for both two rounds. The authority coefficient and Kendall's W were 0.84 and 0.248 (P<0.05) for the first round of email-based consultation, and were 0.85 and 0.255 (P<0.05) for the second round of email-based consultation. Finally, a standardized community-based management scheme was developed, which consists of four domains (managed subjects and contents, suggestions for upward referrals, suggestions for receiving referrals, and disease management) and 77 items.
The response rate and authority coefficient were high for both rounds of email-based expert consultation. After the consultation, the opinions of the experts tended to be consistent, indicating a high Kendall's W, so the results are reliable. The scheme developed in this study may provide guidance for GPs in clinical follow-up and daily management of PD, so as to improve the level of PD management in the community and reduce the economic pressure of PD patients.
With the development of general medicine in China, the number of visits to community medical institutions has increased, and the phenomenon of intermittent and continuous frequent visits exists, while some of these visits are abnormally frequent, resulting in the irrational use of community medical resources.
To understand the current situation of intermittent and continuous frequent visits among community residents in Beijing, and to analyze the characteristics of people with continuous frequent visits and discover the causes of frequent visits.
Residents who visited the community health service stations in Sanlihe District 2, Beijing from January 2017 to December 2019 were retrospectively selected as the study subjects, and those who visited the top 10% of the community health service stations in a year (from January to December) were considered frequent patients, those who visited the top 10% of the community health service stations in each of the three years were considered continuously frequent visited patients, and those who visited the top 10% of the community health service stations in only one or two years were considered intermittent frequent patients. Patients' visits, basic information and illnesses were analyzed, and "face-to-face" interviews were conducted with five patients each from intermittent and frequent visitors to find out the reasons for their frequent visits.
A total of 639 frequent patients were included in the study, divided into a continuous frequent group (92 patients) and an intermittent frequent group (547 patients) . There were no statistically significant differences between the two groups in terms of gender, age, marital status, education, proportion of overweight/obesity people, and proportion of people who have signed up with a family doctor (P>0.05) . The top 5 chronic diseases in both groups were hypertension, type 2 diabetes, dyslipidaemia, coronary heart disease and stroke; there was no statistically significant difference between the two groups in terms of hypertension, type 2 diabetes, dyslipidaemia, coronary heart disease and stroke and the complexity of the diseases (P>0.05) . Further interviews revealed that the top three reasons for choosing to visit the community included obvious geographical advantages and short waiting time (n=9) , good doctor-patient relationship and basic satisfaction of daily medical needs (n=7) , and higher reimbursement rate than specialist hospitals (n=6) . The top three reasons for intermittent frequent visits included smooth disease control resulting in fewer visits (n=2) after improvement in follow-up behavior (normative medication behavior, change in visiting habits) , a transient increase in the number of visits due to acute episodes or changes in chronic conditions (n=2) , and recurrent visits due to periodic "emotional" distress (n=1) ; The top 3 reasons for continuous frequent visits included taking medicines in multiple visits per month due to mismatch between the number of doses available in a single box and the number of doses in the disease cycle (n=3) , repeated visits due to prefer the original drug and refusal of substitution (n=1) , and repeated community visits due to untimely referrals (n=1) .
The phenomenon of frequent visits exists among community-dwelling people in Beijing, and patients with continuous frequent visits take up a larger amount of health care resources, which is characteristically not much different from patients with intermittent frequent visits, but their occupancies on medical resources are quite different, and the attention should be intensified to patients with abnormal frequent visits in the daily diagnosis and treatment, and convert patients with continuous frequent visits into those with intermittent frequent visits to make efficient use of medical resources.
