It is of great significance to study the choice of a healthcare institution in patients with multimorbidity in China during the implementation of hierarchical medical system since relevant research is still insufficient.
To study the choice of a healthcare institution and associated factors in patients with multimorbidity in China during the implementation of hierarchical medical system, providing a reference for further implementation of the hierarchical medical system and rational allocation of medical resources.
A survey using a self-developed questionnaire was conducted with a random sample of patients with multimorbidity who visited the healthcare institutions in Shanghai Yangpu District Central Hospital Medical Consortium〔including Shanghai Yangpu District Central Hospital, and three community health centers (Dinghai, Yanji and Changbai) 〕from June 1, 2019 to January 1, 2020 for collecting their demographics, knowledge related to supportive policies of hierarchical medical system, practical adherence to the policies, willingness to choose a community health center for initial treatment under different controlled conditions of diseases, and considerations when choosing a healthcare institution. Binary Logistic regression was used to analyze the factors influencing the choice of a community health center for initial treatment.
Of the 1 100 cases who attended the survey, 1 072 (97.45%) who responded effectively were finally included, among whom 85.07% (912/1 072) were older people (≥60 years old). 624 cases (58.21%) have a knowledge of hierarchical medical system; 940 cases (87.69%) approved of concepts proposed by hierarchical medical system; 368 cases (34.33%) were well aware of "1+1+1" type of contracted services; 964 cases (89.93%) had signed the contract of "1+1+1" type of contracted services, among whom 44 cases (4.56%) chose non-designated medical institutions for treatment. Patients who were willing to choose a community health center for initial treatment during the stable phase or when having mildly poorly controlled condition accounted for 86.57% (928/1 072) and 85.82% (920/1 072), respectively. The factors considered by patients when choosing a healthcare institution were ranked as follows (from high to low according to the average comprehensive score) : accessibility (5.50 points), level of medical technology (5.13 points), satisfaction with treatment (3.74 points), medical security (3.60 points), medical expenses (2.93 points), and other factors (2.24 points). Binary Logistic regression analysis showed that age and health insurance were independent influencing factors for the choice of a community health center for initial treatment (P<0.05) .
Older people are at high risk for multimorbidity, and are the major group seeking first treatment in primary care. Compared to regional medical centers, community health centers are more accessible, which is favorable for these patients seeking first-contact care. To promote the choice of a primary care institution for initial treatment advocated by the hierarchical medical system, it is suggested to accelerate the construction of regional medical consortiums, promote the sharing of various high-quality resources and the allocation of such resources to primary care, and improve service quality and capacity of primary care.
As population aging progresses, the prevalence of multimorbidity and polypharmacy is increasing in older adults, which may increase the risk of potentially inappropriate medication, causing adverse health outcomes.
To systematically assess the prevalence and associated factors of potentially inappropriate medication in community-dwelling Chinese older adults, in order to provide a reference for developing relevant intervention strategies.
In June 2022, we searched databases of CNKI, CQVIP, Wanfang Data, SinoMed, PubMed, EmBase, and Web of Science from inception to June 2022 for studies on potentially inappropriate medication in community-dwelling older adults in China. Two reviewers independently selected studies, extracted data and assessed the quality of included studies according to the Agency for Healthcare Research and Quality methodology checklist. Meta-analysis was conducted using Stata 12.0.
A total of 24 studies were included, including two with high quality and 22 with moderate quality. Meta-analysis showed that the pooled prevalence of potentially inappropriate medication was 34.8%〔95%CI (31.3%, 38.3%) 〕in community-dwelling older adults in China. Pooled estimates showed 75 years or above〔OR (95%CI) =1.261 (1.074, 1.481) 〕, five or more comorbidities〔OR (95%CI) =3.287 (1.405, 7.691) 〕, and taking five or more medications〔OR (95%CI) =1.800 (1.305, 2.481) 〕or taking 10 or more medications〔OR (95%CI) =4.380 (2.612, 7.347) 〕were associated factors of potentially inappropriate medication.
Potentially inappropriate medication is common in community-dwelling older adults in China, whose risk is associated with older age, multimorbidity and polypharmacy. Prevention and management of potentially inappropriate medication should be paid attention to individuals with the above characteristics.
The treatment burden of elderly patients with coexisting chronic diseases is high. Accurate and effective evaluation of the treatment burden provides a crucial assessment tool for the development of individualized intervention protocol and evaluation of intervention effects. However, there is no localized treatment burden scale for elderly patients with coexisting chronic diseases.
To develop and test the reliability and validity of the treatment burden scale for elderly patients with coexisting chronic diseases, and provide a suitable assessment tool for scientific evaluation of the effectiveness of interventions for elderly patients with coexisting chronic diseases.
The item pool for the scale was constructed through literature analysis and patient interviews, and the initial scale was developed through expert consultation. The semantics and best presentation formats of the initial scale items were modified by pretesting. From September to November in 2021, 294 elderly patients with coexisting chronic diseases were selected using convenience sampling method, and items of the initial scale were screened using item analysis and exploratory factor analysis to form a test version of the scale. From November to January in 2022, 316 elderly patients with coexisting chronic diseases were selected using convenience sampling method, and the test version of the scale was scientifically evaluated using reliability, validity, and feasibility to finally form the official version of the scale.
The official version of the treatment burden scale for elderly patients with coexisting chronic diseases included 33 items in 7 dimensions, including economic burden, burden of self-management, burden of access to healthcare, burden of medication management, burden of adverse drug reactions, burden of sociability, and psychological burden. The results of the confirmatory factor analysis showed that χ2/df=1.506, comparative fit index (CFI) =0.933, Tucker-Lewis index (TLI) =0.925, standardized residual mean root (SRMR) =0.054, and root-mean-square error of approximation (RMSEA) =0.040. The Cronbach's α coefficient for the total scale was 0.895, the split-half reliability was 0.938, and the retest reliability was 0.939 (P<0.01). The item-level content validity index (I-CVI) was 0.833~1.000, the scale-level content validity index (S-CVI/Ave) was 0.939, the correlation coefficient between the scale items and each dimension ranged from 0.522 to 0.897 (P<0.01). The results of the feasibility test showed that the recovery rate of the scale was 95.8%, the completion rate was 100.0%, and the completion time was 10-15 minutes.
The treatment burden scale for elderly patients with coexisting chronic diseases developed in this study has good reliability and validity, which is suitable for assessing the treatment burden of elderly patients with coexisting chronic diseases in China.
