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Special Issue: Treatment-prevention integration

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1. Degree of Family Doctor Teamwork and Influencing Factors under the Program of Integration of Medical and Preventive Care
FAN Wenyu, MA Xingli, ZHANG Shilong, ZHANG Xindan, ZHAO Yang, WANG Haipeng
Chinese General Practice    2025, 28 (16): 1966-1972.   DOI: 10.12114/j.issn.1007-9572.2024.0390
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Background

As the aging of the population intensifies and the burden of non-communicable diseases continues to rise, traditional health service models have become insufficient to meet people's health needs. Therefore, promoting the integration of medical and preventive care has become crucial for improving residents' health levels. Family doctor teams, as the main implementers of these integrated care, play a pivotal role. However, the current lack of effective multidisciplinary collaboration among family doctor teams has severely hindered the effective implementation and provision of integrated medical and preventive care.

Objective

To investigate the teamwork of family doctors in the integration of medical and preventive care in Shandong Province, explore its influencing factors, so as to provide a reference for further improving the contract service of family doctors and the integration of medical and preventive care.

Methods

In August 2023, a multi-stage stratified random sampling method was employed, selecting Yantai City, Weifang City, and Liaocheng City from the eastern, central, and western regions of Shandong Province, taking into account geographical location and economic development levels. Within each city, one district and one county city were randomly selected as sample areas, resulting in a survey of 481 family doctors. Based on extensive searches of relevant domestic and international literature and consultations with experts, a specialized questionnaire for primary care doctors was designed for the survey. This questionnaire encompassed three key sections: a general information survey, an assessment of the provision of integrated medical and preventive care services, and an evaluation of the collaboration levels among family doctor teams within these services. Questionnaires were used to investigate the implementation of integrated medical and preventive care and the collaboration among family doctors within these services. Binary Logistic regression analysis was employed to examine the factors influencing the collaboration among family doctors in integrated medical and preventive care.

Results

76.1% (366/481) of family doctors exhibited a high level of teamwork in the integration of medical and preventive care. The results showed that family doctors with bachelor's degree or above (OR=2.343), professional titles of primary (OR=1.887) and intermediate and above (OR=2.978), understanding of the integration of medical and prevention system (OR=6.618), believe that the institution attaching importance to integration of medical and preventive care (OR=2.861), and participating in one (OR=2.561) and two or more trainings within half a year (OR=3.833) had a higher level of teamwork in integration of medical and preventive care (P<0.05) .

Conclusion

At this stage, there is still a lot of room for improvement in the teamwork level of family doctors in the integration of medical and preventive care. It is necessary to continue to improve the awareness of family doctors on the integration of medical and preventive care, improve the system of providing institutional medical and prevention integration services, provide reasonable economic subsidies and policy incentives for family doctors, strengthen training, and further improve the level of teamwork of family doctors.

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2. Conception and Satisfaction of Integration of Medicine and Prevention from Providers' Perspective
WANG Zijing, GAO Junwen, LI Cancan, YAN Huosheng, BAI Zhongliang, XIAO Jincheng, HU Zhi
Chinese General Practice    2025, 28 (13): 1655-1660.   DOI: 10.12114/j.issn.1007-9572.2023.0736
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Background

For a long time, "emphasizing medicine over prevention" has fragmented China's medical and health service system, making it difficult for residents to obtain comprehensive, coordinated, high-quality and efficient health services. The integration of medicine and prevention plays an essential role in enhancing the continuity and coordination of medical and health services and improving the health of residents. As the providers of the integration of medicine and prevention services, the enthusiasm and initiative of medical staff directly affect the integration of medicine and prevention services.

Objective

To explore the current status and problems during the integration of medicine and prevention from the perspective of medical and public health service providers and to put forward appropriate countermeasures.

Methods

The data for this study was collected from a survey on the integration of medicine and prevention conducted in Anhui Province from July to August 2021, which combined typical sampling and stratified sampling methods, taking into account both representativeness and regional distribution. One county (district) was selected from the northern, central, and southern parts of Anhui Province for the survey. Based on the review of domestic and foreign literature and relevant policy documents, in consideration of the characteristics of the integration of medicine and prevention, the research team, after discussion and expert validation, developed a self-designed questionnaire for medical staff on the integration of medicine and prevention. The questionnaire mainly includes the basic information of the respondents, their cognition of the integration of medicine and prevention, the implementation and satisfaction of the integration of medicine and prevention. Binary Logistic regression analysis was used to explore the influencing factors of medical staff's satisfaction with the integration of medicine and prevention.

Results

71.2% of medical staff expressed understanding of the integration of medicine and prevention, 18.6% expressed very good understanding, 50.4% considered the integration of medicine and prevention very important, and 48.5% considered it necessary. The primary way to provide services of integration of medicine and prevention was to guide healthy lifestyles, which accounted for 92.0% of the total, 83.3% of the total for education on health knowledge, and 84.1% for guidance on the rational use of medication. The main factors that affected the implementation of the integration of medicine and prevention included financial support, lack of human resources, lack of incentive mechanisms, etc. The satisfaction score of medical staff with the integration of medicine and prevention was (4.02±0.78). The regression results showed that career development, salary, and work pressure significantly affected overall satisfaction with the integration of medicine and prevention (P<0.05) .

Conclusion

This paper found that there are insufficients of the integration of medicine and prevention concerning service providing scope, ability, and guarantee mechanism. Therefore, to better provide residents with a high-quality integration of medicine and prevention, further expansion of the ways of service providing, optimizing the capacity and quality of the service team, and improving the guarantee mechanism are suggested.

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3. Current Situation and Obstacles of Integrated Services for Chronic Diseases Provided by Family Doctor Team: a Qualitative Research
ZHAO Linlin, LUO Qi, HU Qinghua, CHEN Xiaolei, DU Juan, SHAO Shuang
Chinese General Practice    2025, 28 (13): 1661-1667.   DOI: 10.12114/j.issn.1007-9572.2024.0151
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Background

The integration of medical care and prevention is an important measure for the implementation of the Healthy China Strategy. Family doctor teams as the mainstay and chronic disease management as the entry point are important tools for the implementation of the medical and preventive integration in primary health institutions.

Objective

To understand the current situation and obstacles of the integration of medicine and prevention in chronic disease management in Beijing urban areas, so as to provide a basis for decision-making on sustainable development of the medical and preventive integration services.

Methods

From December 2023 to February 2024, the purposive sampling was used to invite 20 participants, including the members of the family doctor teams and primary care managers working on the the medical and preventive integration and the chronic disease management in 12 primary health institutions in the urban area of Beijing, to conducted semi-structured interviews focus on the content, division of labour, resource allocation, and existing problems of above services. Thematic analysis was used to analyse and generalise the interview data.

Results

Although the primary health institutions had explored a variety of service modalities to promote the implementation of the integration of medical care and prevention. The qualitative research showed that the main body of the current service was still the general practitioner and the community nurse, and continued the kernel of the chronic disease management service, with the content of the service yet to be innovated, and the service process of pre-consultation, consultation, and post-consultation yet to be promoted. In terms of the operating environment, there were insufficient members of the family medicine team, heavy workload, emphasis on "quantity" rather than "quality" in assessment and evaluation, "information silos", lack of top-level design, and lack of a special funding mechanism. The phenomenon of "medical and prevention fragmentation" is obvious, with the existence of "two lines" of the management systems, "two disconnections" between the main bodies, and regional dispersion of work areas of the medical and preventive integration.

Conclusion

Due to insufficient resources allocation and optimisation of the operation mode, it's necessary to strengthen talent training, reinforce medical insurance support, accelerate information sharing within the region, improve assessment and evaluation mechanisms, as well as strengthen the top-level design, clarify the service pathway, implement community functions, and form a replicable and scalable integrated service model with the participation of the government, community, hospitals and patients.

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4. Evaluation and Improvement Countermeasures Research of the Current Situation of Integrated Outpatient Service for Chronic Diseases in County Medical Community in Zhejiang Province from the Perspective of Medical Prevention Integration
LIN Xiaoling, QU Kaixiao, LI Xu, CHEN Jingchun, HUANG Qunfang, ZHOU Chi
Chinese General Practice    2025, 28 (13): 1649-1654.   DOI: 10.12114/j.issn.1007-9572.2024.0296
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Background

In order to promote the hierarchical diagnosis and treatment system and the construction of healthy China, the General Office of the State Council clearly pointed out that a medical community should be established in the county. Zhejiang Province took the lead in exploring the integrated outpatient service of chronic diseases in the construction of medical community. At present, the research on the integrated outpatient service of chronic diseases in China mainly focuses on the discussion of concepts, and less quantitative research is carried out on the current situation of services.

Objective

To analyze the current situation of the integrated outpatient service of chronic diseases in county medical communities in Zhejiang Province and explore its influencing factors, so as to provide countermeasures and suggestions for improving the operation of the integrated outpatient service of chronic diseases.

Methods

From October to November 2023, using the typical sampling method and taking into account the principle of geographical balance, 18 community health service centers/township hospitals under 6 medical communities in Linping District of Hangzhou, Yuhuan City of Taizhou, Jiangshan City of Quzhou and Jiashan County of Jiaxing in Zhejiang Province were selected, and outpatients were intercepted at the outpatient waiting offices of corresponding institutions as the research objects. A self-designed questionnaire was used to investigate the patients' evaluation of integrated outpatient services for chronic diseases. The evaluation content involved three aspects: service category, service approach and team building.

Results

A total of 540 questionnaires were distributed and 510 valid questionnaires were recovered, with an effective recovery rate of 94.4 %. The overall score of patients' integrated outpatient service for chronic diseases was (4.4±0.5) points, and the scores of each service category were: pre-diagnosis service (4.4±0.5) points, in-diagnosis service (4.3±0.5) points, and post-diagnosis service (4.1±0.6) points. The average score of each item in the service approach dimension was ≥3.7 points, and the average score of each item in the service team building dimension was ≥3.9 points. The results of multiple linear regression analysis showed that factors such as age, education, monthly income, whether the overall medical services of the hospital could meet their own needs, and satisfaction with the hospital 's diagnosis and treatment environment would have an impact on the evaluation of the development of integrated outpatient clinics for chronic diseases (P<0.05) .

Conclusion

The current situation of integrated outpatient services for chronic diseases in county medical communities in Zhejiang Province is generally good, but there is still room for improvement in post-diagnosis services, service channels, and overall medical services. The primary medical and health institutions in Zhejiang Province should pay attention to the continuity of post-treatment services, strengthen the integrated outpatient service mode and team building of chronic diseases, promote the development of medical services in a diversified and high-quality direction, and enhance the residents' sense of medical experience.

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5. Demand Analysis of Diabetes Primary Healthcare and Prevention Integration Services in the Context of Digital Health
WU Xinyi, ZHANG Yongze, YANG Chenghu, WU Xiaoyuan
Chinese General Practice    2024, 27 (31): 3958-3965.   DOI: 10.12114/j.issn.1007-9572.2023.0597
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Background

With the acceleration of the aging process of the population and the change of the disease spectrum of residents, the prevalence of chronic diseases such as diabetes is increasing year by year. It is urgent to establish a wide coverage and efficient medical prevention integration mode. Most of the existing studies have focused on the demand for health management services and the influencing factors of service adoption, and few have identified and analyzed the demand for chronic disease healthcare and prevention integration services under digital technology.

Objective

To explore the demand of residents for medical and preventive integration services for diabetes in the context of digital health, and the impact of different service contents on the acceptance and satisfaction of service objects, so as to provide a theoretical basis for the public to improve the whole process and all-round medical and preventive integration services.

Methods

Combined with relevant research and practical work, 20 survey items on demand for diabetes medical and prevention integration services were established. From January to June 2023, convenient sampling method was used to survey diabetes patients and risk groups in Fujian Province, Guangdong Province and Yunnan Province, and 410 respondents' data were obtained. According to five demographic characteristics of gender, age, education level, residence type and medical insurance type, attribute classification analysis was carried out according to Kano model analysis method, to investigate the relationship between service demand of different attributes and residents' satisfaction, and then put forward the supply strategy of diabetes medical and prevention integration services.

Results

Residents with different demographic characteristics show common and individual differences in the demand for medical and preventive integration services for diabetes. Among them, the demand for services among people of different ages and educational levels is quite different. The demand for medical prevention integration services of diabetes prevention and treatment groups focuses on screening, prevention and treatment, but the relevant convenient services provided by the Internet and social media have nothing to do with user satisfaction.

Conclusion

The level of personalization of diabetes primary health care and prevention services should be improved to fully satisfy the needs of the service population for essential attributes such as "initial screening for diabetes and complications", improve the services for desired attributes such as "establishment of a full-cycle personal electronic health record", and enhance the services for charismatic attributes such as "risk prediction" and "remote health monitoring". It will also improve services with desired attributes such as the establishment of a full-cycle personal electronic health record, and enhance services with attractive attributes such as "risk prediction" and "remote health monitoring".

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6. The Grid-style Management Mode of Family Doctors Based on the Concept of Treatment and Prevention Integration
殷道根, 冯程程, 杨潍屹, 王庆川, 杨俊, 贺宇峰, 何崇辉
Chinese General Practice    2024, 27 (31): 3966-3968.   DOI: 10.12114/j.issn.1007-9572.2023.0685
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7. Progress and Challenges in the Integration of Treatment and Prevention of Chronic Non-communicable Diseases
ZHAO Yuling, GU Zhengping, ZHANG Xueying
Chinese General Practice    2024, 27 (31): 3953-3957.   DOI: 10.12114/j.issn.1007-9572.2023.0417
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With the aging of the global population and the transformation of lifestyle, the incidence of chronic non-communicable diseases continues to rise, thus having brought great challenges to global public health. In this context, medical and health services must adapt to this growing trend, which necessitates carrying out research on the medical prevention integration mode, and gradually strengthening its application in clinical practice. This paper aims to explore the application status quo, and future development trends of the treatment-prevention integration mode, as well as the challenges it faces from the perspective of chronic non-communicable disease management. We first introduce the background of chronic non-communicable disease management, and then describe the integration of treatment and prevention from multiple aspects in chronic disease management, including multidisciplinary collaboration, patient follow-up system, family doctor signing services, and health education on chronic diseases, so as to realize the comprehensive, chronic disease management throughout the life cycle, and improve patients' health level and living quality. Finally, we believe that in the future, it is necessary to strengthen scientific and interdisciplinary research, intensify the training and education of medical staff, and enhance the development of digital medical technology, in order to better meet the growing health needs of the people. Therefore, this paper has significant reference value for exploring the management methods of chronic non-communicable diseases and promoting public health services.

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8. Research on Implementation Mechanism of Treatment-prevention Integration Under the Background of Constructing Integrated Service System
HU Meili, ZHANG Qian, SHEN Dou, LI Hongli, LIU Yuehua, YANG Wen, YANG Jinlan, GU Fang
Chinese General Practice    2024, 27 (22): 2706-2713.   DOI: 10.12114/j.issn.1007-9572.2023.0722
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Background

The key task in China's medical and health field during the "14th Five-Year Plan" period is to realize treatment-prevention integration and innovate the mechanism of treatment-prevention integration.

Objective

This paper analyzes the implementation mechanism of treatment-prevention integration under the background of integrated service system construction, and provides reference for exploring the path of medical and prevention integration adapting to the strategy of "Healthy China".

Methods

Taking 2018 as the time node, relevant literature was searched on CNKI and Wanfang Data Knowledge Service Platform with keywords of "treatment-prevention integration" "medical and prevention coordination" "combination of prevention and treatment" and literatures on case policies, measures and implementation effects of integrated service systems such as medical alliance. Finally, 18 literatures and 15 cases were selected. Based on the rainbow model, system integration, organizational integration, professional integration, service integration, functional integration and normative integration were determined as condition variables from macro, meso and micro levels and supporting factors, and the effect of treatment-prevention integration was determined as result variable. QCA was adopted to explore the implementation mechanism of medical and preventive integration under the background of integrated service system construction.

Results

There were four configuration paths that could effectively improve the effect of treatment-prevention integration, and the four paths were in line with the multi-layer integrated path and the medium-micro integrated path respectively. The following results were obtained: (1) It was more effective to carry out treatment-prevention integration relying on the integrated service system, and there are multiple paths that can effectively improve the effect of treatment-prevention integration under the integrated service system; (2) Service integration plays a fundamental role in improving the effect of medical and preventive integration; (3) The setting of relevant policy indicators for improving the system integration, professional integration and functional integration of treatment-prevention integration is not perfect.

Conclusion

(1) Relying on the construction of integrated service system to promote the improvement of treatment-prevention integration effect; (2) Give full play to the basic guarantee role of service integration; (3) Make reference to the successful experience of multi-level integration cases, set policy indicators at macro, meso and micro levels in a balanced manner, and improve the integration of system integration, professional integration and supporting elements.

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9. Analysis of Factors Influencing the Implementation of Medical Defense Integration Based on the Horn-mitte Model
LAI Qingling, XU Chuanchuan, FENG Yuanyuan, LIANG Peifeng, LI Yinshan
Chinese General Practice    2024, 27 (22): 2700-2705.   DOI: 10.12114/j.issn.1007-9572.2023.0780
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As an important direction of China's medical and health system reform, medical and prevention integration is of great significance to meet the all-round health needs of the people, and how to establish a scientific and effective medical and prevention integration model is a top priority. Using literature analysis and other methods to collect data, the implementation status and dilemma of China's medical and prevention integration policy were reviewed, and the influencing factors of medical and prevention integration policy implementation were analyzed based on the six dimensions of the Horn-mitte model. On this basis, it is proposed to refine policy objectives, clarify policy implementation standards, increase resource supply, enrich policy implementation methods, explore common interests of medical and defense institutions, improve "coordination mechanisms", and actively guide policy implementers to carry out medical and prevention integration services. It aims to provide reference significance for the high-quality improvement of medical and prevention integration services in the future.

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10. Innovative Integration of Treatment and Prevention to Build a Healthy China Together: Expert Consensus from the Healthy China Research Network in 2023
Expert Group of the Healthy China Research Network
Chinese General Practice    2024, 27 (22): 2685-2688.   DOI: 10.12114/j.issn.1007-9572.2024.0136
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The innovative integration of treatment and prevention is pivotal for enhancing the healthcare system and advancing Healthy China. Guided by a focus on preventive health policies, it fosters collaboration between treatment and preventive services, ensuring seamless linkage across health promotion, prevention, treatment, rehabilitation, and end-of-life care. Conceptually, this shift involves transitioning from unidirectional intervention to comprehensive health management, from provider-driven to participatory decision-making, and from transient doctor-patient relationships to sustained accountability relationships. Structurally, it emphasizes coordination between medical and public health systems, collaboration among healthcare institutions, and multi-stakeholder governance. Institutionally, it optimizes evaluation, financing, remuneration, and talent development systems while leveraging intelligent means for integration and promoting interoperability across personnel, resources, and information.

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11. Community-oriented Integration of Medicine and Prevention: an Analysis of Theoretical Basis and Contemporary Implementation Pathways
WANG Yang, JIN Hua, YUAN Beibei, HUAN Hongmei, YANG Hui, YU Dehua, FANG Hai
Chinese General Practice    2024, 27 (22): 2689-2699.   DOI: 10.12114/j.issn.1007-9572.2024.0060
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In this commentary, we elucidate two distinctive characteristics of China's primary health care system relative to the global primary health care framework: a more narrowly defined patient population and scope of services, along with a diminished clinical capacity in primary care. Building upon this foundation, we critically examine and juxtapose the two quintessential theoretical-practical models of the 20th century that are intimately linked with the integration of medication and prevention. They are the "Community-Oriented Primary Care" Model and the "Barefoot Doctor" Model. Additionally, leveraging a series of practical cases observed within Shanghai's primary care settings in the fourth quarter of 2023, we deliberate on viable approaches for adapting and applying these models in China's primary care infrastructure. We further delineate the requisite external conditions for such a transformation and offer targeted recommendations for the deployment of these models across diverse locales.

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12. Identification of COVID-19 Infection in Vulnerable Population and Its Prevention and Treatment Perspectives
ZHENG Jinping, XUE Wujun, JU Chunrong, MA Jun, ZENG Xiaofeng
Chinese General Practice    2024, 27 (02): 132-137.   DOI: 10.12114/j.issn.1007-9572.2023.0230
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The COVID-19 pandemic has devastated human health and global economy. Diminished immune function of health-related vulnerable populations leads to insufficient protective effect of the vaccine with a higher risk of severe illness and death following infection, and there is a lack of adequate targeted drugs for the prevention and treatment of COVID-19. In the context that COVID-19 treated as a Category B disease in China, vulnerable populations have become the priority populations for epidemic prevention and control. Therefore, the strategies of individual immunization and prevention should be further optimized for vulnerable populations. In addition to vaccines, other prevention strategies should be supplemented, such as long-acting neutralizing antibodies. Based on this, this paper reviews the identification, immune function characteristics and prevention strategies of COVID-19 in vulnerable populations, to provide a reference for the prevention and control strategies for health-related vulnerable populations in China, expecting that more suitable preventive drugs for vulnerable populations can be developed in the future to reduce the risk of COVID-19 in vulnerable populations.

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13. Current Status and Prospects of General Practitioners in Community-based Prevention and Control of Communicable Diseases
MA Yundi, REN Jingjing, QIU Yan
Chinese General Practice    2024, 27 (02): 138-143.   DOI: 10.12114/j.issn.1007-9572.2023.0216
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The prevention and control of communicable diseases is a major concern for the livelihood of the people.General practitioners play an irreplaceable role in the community-based prevention and control of communicable diseases as one of the key providers of primary care. This study discusses the shortcomings of general practitioners and the role they should play in the community-based prevention and control of communicable diseases based on their current situation by reviewing relevant domestic and foreign literature, and proposes that the laws and regulation system for the prevention and control of communicable diseases should be improved, a hierarchical medical system should be implemented, a robust information platform of prevention and control system should be enhanced, an efficient incentive and development mechanism should be established, and the financial and material investment in primary care, continuing medical education and regular drills should be enhanced, aiming to enhance the job attraction of general practitioners and the capabilities of community-based comprehensive prevention and control of communicable diseases.

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14. 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
Chinese General Practice    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.

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15. 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
Chinese General Practice    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.

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16. Construction of an Innovative Model of Chronic Disease Management in Compact County Medical Alliance with Treatment-prevention Integration
DENG Hongyu, WU Miaomiao, YANG Zheng, HE Yang, ZHU Linlin, ZHAO Qian, DAI Hua, WU Jia, LIAO Xiaoyang, ZHANG Yonggang
Chinese General Practice    2023, 26 (22): 2720-2725.   DOI: 10.12114/j.issn.1007-9572.2023.0150
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Background

In 2019, the National Health Commission launched the construction of compact county medical alliance to strengthen chronic diseases management in primary care, and the construction of chronic disease management models varies among county medical alliance sites. Xindu District, as one of the first national compact county medical alliance sites in Sichuan Province, has explored both dimensions of theoretical and practical innovation in the construction of the innovative model of chronic disease management in compact county medical alliance with treatment-prevention integration, providing a new approach for the innovative development of primary compact county medical alliance in China.

Objective

To analyze the innovation model and its effectiveness of chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District with the experience of international integrated medical models.

Methods

The chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District was constructed with "one center, two integration, three reforms and four safeguard mechanisms" under the leadership of Xindu District Health Bureau, to strengthen the management of chronic diseases mainly including hypertension and diabetes.

Results

As of June 2022, the number of hypertension or diabetes patients under standardized management in the district increased by 50.87% compared with the initial stage of construction, the number of hypertension or diabetes patients increased by 55.28% and 49.04%, respectively; while the proportion of patients with HbA1c<7% or BP<140/90 mmHg (1 mmHg=0.133 kPa) increased by 70.69% and 115.28% in the past year among them, respectively. The outpatient visits of primary care increased by 14.30% in one year, among which the outpatient visits for hypertension or diabetes increased by 36.01%; while downward referrals within medical communities increased by 14.55%, creating a number of demonstration units for the transformation of treatment-prevention integration in primary care.

Conclusion

The innovative model of chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District has a significant effect on improving the quality and efficiency of chronic disease management in primary care.

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17. Cooperated and Shared Care: Reflections on Treatment-prevention Integration
YANG Hui
Chinese General Practice    2023, 26 (22): 2711-2714.   DOI: 10.12114/j.issn.1007-9572.2022.W0006
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The persistent elevation of the prevalence of chronic non-communicable diseases and sudden pandemic of COVID-19 infections have once again attracted the attention of the whole society to prevention activities closely associated with epidemic prevention. Although the correlation between prevention and treatment of health is a long-term topic, innovation and mechanism of treatment-prevention integration proposed by Chinese health administration after the peak of COVID-19 epidemic has attracted attention and reflections of the medical and academic fields. Medical treatment and prevention are inseparable. The questions such as how to achieve the coordination and balance between treatment and prevention, what is the solution of treatment-prevention integration, are worth further study and exploration. Beginning with clarifying the concept of treatment and prevention, this paper analyzes the reasons for the separation of treatment and prevention, explores the approaches for effective connection and cooperative interaction between the two, thus providing further research directions for general practice researchers, calling on colleagues in general practice to contribute their wisdom and promote the contribution of treatment-prevention integration to healthy China.

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18. Practice Strategy of Treatment-prevention Integration of Family Doctor Team in China
ZHAO Linlin, SHAO Shuang, LUO Qi, CHEN Xiaolei, DU Juan
Chinese General Practice    2023, 26 (22): 2715-2719.   DOI: 10.12114/j.issn.1007-9572.2023.0246
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The integration mechanism of medical treatment and prevention based on family doctor teams is a key way to break down the barrier between "medical" and "prevention". In this paper, we explain the definition and connotation of treatment-prevention integration, review the development history of family doctor teams, systematically review the typical practice strategies and the shortcomings of treatment-prevention integrationon family doctor teams in China. Measures should be taken to promote the treatment-prevention integration, including improve the talent training system, change views of "attaching importance to treatment and neglecting prevention", strengthen the organization and management, innovate the assessment and incentive mechanism, reform the medical insurance payment method, encourage diversified forms of services, etc. The study aims to provide reference for improving the quality of services and developing treatment-prevention integration in the future.

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19. Effectiveness of a Mode Used in the Delivery of Preventive and Medical Services by Family Doctors Using a Grid System 
ZHONG Yu,LIU Luxia
Chinese General Practice    2021, 24 (19): 2412-2417.   DOI: 10.12114/j.issn.1007-9572.2021.00.225
Abstract694)   HTML13)    PDF(pc) (1504KB)(1402)    Save
Background Recently,the implementation of family doctor services provided by primary care has achieved some improvements,but there are still poor areas in family doctors' delivery of preventive and medical services,such as integrating the local resources,keep appointments,and collaborative services,so the priority current is to improve the quality and efficiency of community health services. The "12345" mode,a new contracting mode developed by Yuzhong District Daxigou Subdistrict Community Health Center used in the delivery of family services has formed a good pattern of integrating resources,co-contracting,service deepening,and joint management. Objective To introduce and analyze the effectiveness of a mode used in the delivery of preventive and medical services using a grid system by family doctors in Yuzhong District Daxigou Subdistrict Community Health Center,Chongqing. Methods Data regarding family services implemented from October 2017 to September 2019 were collected from the family doctor studio established by Yuzhong District Daxigou Subdistrict Community Health Center(hereinafter referred to as the Center),Chongqing,which were provided by the studio mainly,in coordination with other departments organized by the subdistrict office,with Big Health Care Idea as the service concept,centering on contracted services,mainly involving a grid system,two types of collaborative system,three types of publicity and cooperation,four co-management paths,and five detailed lists of services(abbreviated as the "12345" mode). Results As of September 2019,the contracting rate of the studio〔28.08%(5 086/18 109)〕 was significantly higher than that of the Center〔22.98%(14 352/62 453)〕. The renewal rate of the studio reached 91.41%(4 649/5 086),and 84.67%(370/437) of the rescinding group belonged to those moving from Yuzhong District due to relocation. In the appointment services for contracted people,the proportion of outpatient services,municipal examination,and home visit services increased by 159.07%(2 744/1 725),12.41%(149/1 201),and 21.92%(260/1 186),respectively,while the proportion of referrals and expert services decreased by 48.36%(118/244) and 24.55%(108/440),respectively. Compared to 2018,the standardized management rate and control rate of hypertension and diabetes in 2019 were all significantly higher(P<0.05). And the ratio of comprehensive evaluation,expert evaluation and appointment examination for hypertension and diabetes in 2019 were significantly higher(P<0.05). The studio achieved higher patient satisfaction than non-family doctor studios either in 2018(87.03% vs 42.91%) or in 2019(92.5% vs 57.5%)(P<0.05). Conclusion The "12345" mode,a new contracting mode developed by the Center used in the delivery of family services has improved residents' compliance,sense of gain and satisfaction,achieving good results.
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20. Construction Analysis of the Family Doctor Studio Providing Treatment and Prevention Services from the Aspects of Signing a Contract,Making an Appointment and Implementing an Appointment
ZHONG Yu,LIU Luxia,NIE Xiaoxu,TAN Guoying,WANG Qian
Chinese General Practice    2018, 21 (31): 3818-3822.   DOI: 10.12114/j.issn.1007-9572.2018.31.008
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Improving the service capabilities to provide high-quality and high-efficient contracted family doctor services for residents,is a critical problem needed to be solved by grassroots medical institutions in China.The family doctor studio,one of the major healthcare suppliers,plays an important role in promoting family doctor services,effectively integrating and utilizing the medical resources within a region,strongly facilitating the implementation of the hierarchical medical system,and improving residents' sense of achieving health benefits and satisfaction with healthcare.Since 2016,Yuzhong District Daxigou Street Community Health Center(located in Chongqing) has been actively exploring the construction of family doctor studios.It has established a type of family doctor studio providing prevention and treatment services,with an emphasis on improving the construction of three aspects(signing a contract,making an appointment and implementing an appointment) associated with the implementation of the contracted family doctor services.Moreover,an effective service delivery mode has been developed by this community health center,which is characterized by "three-designation" (designation of positions,duties and performance assessment criteria),"three-optimization" (optimization of service contents,delivery procedure,and delivery channels),and "two-combination"(delivery of services by general practitioners from the studio in combination with medical experts from municipal level hospitals,and community-based care in combination with municipal level hospital-based telemedicine services).We detailed the team construction,service contents and delivery modes of this studio,summarized and analyzed the corresponding construction strategies,with a view to offering a reference for the construction of family doctor studios in other regions.
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