An index of open-access community health service content relevant to primary care
Frequency Characteristics and Influencing Factors of Adult Visits in Community Health Service Institutions Based on Real World Data
HUANG Yanli，CAO Peiya
Abstract
Background "Frequency of medical visits" is an important data that truly reflects patients' utilization of medical institutions，but there are few related researches in China，and there is no research on the relationship between visit behavior reflected by "frequency of medical visits" and contract service. Objective To analyze the characteristics of the frequency of visits by contracted/non-contracted patients in urban primary care，as well as the factors that affect the frequency of visits by contracted populations，in order to identify the tendency of patients with different characteristics to use primary care resources and related influencing factors，help the family doctor team invest resources better，establish a more stable service relationship with patients. Methods In January 2021，after desensitizing patients' identities，contact information，and specific disease diagnosis information，the outpatient behavior and contract status data of 13 community health service centers in Chengdu Wuhou District and their 18 service stations from 2020-01-01 to 2020-12-31 were extracted. The frequency of patient visits and its influencing factors were analyzed. Results In 2020，a total of 300 634 adults visited community health service institutions，and 1 243 436 outpatient records were generated. The average age of outpatient visits was（51.5±18.4） years，and the average frequency of outpatient visits was（4.14±5.94）. Only 9 448 patients（3.14%） had cross-community health service visiting behavior，among which only 17 patients were contracted. 34.73%（104 399/300 634） of adults visiting community health service institutions were contracted populations，and 63.91%（794 710/1 243 436） of the total outpatient visits were contracted populations. 86.04%（168 840/196 235） of the non-contracted patients visited the hospital occasionally，69.93%（137 229/196 235） of the patients with relatively simple conditions. 52.30%（55 812/104 399） of the contracting population were treated with continuous management，and 29.90%（31 211/104 399） had relatively simple conditions. Calculated by the number of people，the rate of active appointment was 40.29%（42 061/104 399），and the rate of regular visit was 37.86%（39 522/104 399）. Calculated by frequency，the rate of active appointment was 18.58%（147 685/794 710），and the rate of regular visit was 18.12%（144 009/794 710）. There were statistically significant differences in age，medical frequency，the number of patients receiving traditional Chinese medicine services，number of clinicians，frequency of visits，and complexity of diagnosis between contracted patients and non-contracted patients（P<0.05）. The results of ordered multi-classification Logistic regression analysis showed that the degree of disease complexity，whether to make an appointment actively，whether to seek regular medical treatment，whether to use traditional Chinese medicine services，age，whether have outpatient medical insurance，contracted institution and number of doctors signing contracts were the influencing factors for the frequency of patients visit（P<0.05）. Conclusion The contracted population in Wuhou district have established stable service relationship with family doctors. To make better use of the contracted service functions of community health service institutions，on the one hand，the number of contracted groups can be increased from the non-signing groups with the characteristics of frequent and abnormal frequent visits，high utilization of traditional Chinese medicine and have outpatient medical insurance，on the other hand，according to the characteristics of the influencing factors of the contracted population，through the adjustment of performance assessment indicators，the frequency of contracted patients can be further controlled in a reasonable interactive range for scientific and continuous management.
Community Health Centers' Capabilities for Outpatient Service Provision：a Study Based on Real-world Diagnostic Data
HUANG Yanli
Chinese General Practice 2021, 24 (34): 4336-4342. DOI: 10.12114/j.issn.1007-9572.2021.00.316
Abstract
Background To improve the capabilities of general practitioners（GPs） working in primary care，one key approach is targeting patients' needs and problems，but there is no big data analysis of the gap between patients' needs and provision of services using the real-world data in China. Objective To examine the capabilities of urban community health centers（CHCs） for outpatient service provision using a big data analysis of the real-world diagnostic data，offering a reference for improving GP's capabilities for providing first-contact services precisely targeting patients' needs. Methods We collected outpatient diagnoses（n=2 897 700） by ICD-10 code from CHCs of Wuhou District in 2020，and analyzed the structure，diagnoses ranked from most to least，and degree of accuracy in diagnosing 4 types of chronic diseases using data structure analysis and data distribution analysis. Results Of the diagnoses，99.31%（2 877 700/2 897 700）were assigned 912 types of six-digit diagnostic codes with a frequency greater than 30；87.31%（2 392 603/2 740 333） with assigned three-digit diagnostic codes were concentrated in the top 10. Among them，preventive diagnostic records are more concentrated，mainly for physical examination（including child health examination） and vaccination services. Most（11/13） CHCs' diagnostic and treatment capabilities had reached grade A standard defined in the Service Capacity Assessment for Community Health Centers（hereinafter referred to as SCACHCs），but the rank order of disease diagnoses was different from the diagnostic coding catalogue in the SCACHCs. The mean coefficients of variation of ICD type，common type，preventive type or clinical type across CHCs were all greater than 25%. The top 10 diagnoses with assigned three-digit diagnostic codes were highly consistent with the national essential public health services. Other common diagnoses included sleep disorders，acute respiratory diseases，digestive diseases and insomnia. Patients with chronic diseases such as hypertension，cardiovascular and cerebrovascular diseases，type 2 diabetes，（lipid） metabolic disorders，and sleep disorders were more likely to have higher number of CHCs visits（more than 5 times per year），and physical examination ranked last among the top 10 services ranked in terms of average number of annual use frequencies per capita. The majority of diagnostic records of common chronic diseases（more than 90%） were concentrated in the code bar of "not specifically specified" in this type of diagnosis. The number of CHCs visits for COPD（n=4 268） was lower than that of those for hypertension，type 2 diabetes or hyperlipidemia. Meanwhile，the number of COPD patients（n=1 675） encountered by the CHCs was less than that of patients with hypertension，type 2 diabetes and hyperlipidemia. Conclusion Outpatient diagnoses in CHCs of Wuhou District were concentrated，especially in the field of preventive health care. Common diagnoses for diseases were highly consisted with the service profile and population of the national essential public health projects. Most of the CHCs' diagnostic and treatment capabilities had reached the standard of excellence，but there is still room for improvement in comprehensive diagnosis of patients，especially those with chronic diseases，with highlights on taking actions to improve capacities for comprehensive diagnosis of hypertension and related cardiovascular diseases，type 2 diabetes，acute respiratory diseases，digestive diseases，organic sleep disorders，non-organic sleep disorders or other diseases，and for management of diagnosis and treatment of such diseases. Heavy workload may result in the prevalence of diagnostic inertia in GPs，especially under the circumstances of encountering common chronic diseases. So it is suggested to take factors associated with GPs，family doctor teams，and institutional supply and security into account when systematically designing the path to improve CHCs' capabilities for outpatient service provision.
Infectious Disease Prevention and Control Capacity of Community Health Institutions in Beijing：Current Status and Recommendations for Problems
SU Ning，XU Xiaomin，ZHU Rui，ZHANG Xiangdong，YU Jianping
Chinese General Practice 2021, 24 (28): 3578-3583. DOI: 10.12114/j.issn.1007-9572.2021.00.275
Abstract
Background During the fight against the COVID-19 pandemic，Beijing's community health institutions showed some weaknesses in infectious disease prevention and control. To improve their capabilities in this aspect to fully play their role as a sentinel for monitoring infectious diseases，it is urgent to investigate and analyze their current status to find problems，then put forward recommendations. Objective To investigate the infectious disease prevention and control level in Beijing's community health institutions，and identify and analyze the problems，with suggestions put forward. Methods From May to July 2020，a questionnaire survey was conducted in all community health centers（CHCs） in Beijing. Information was collected，including the basic situation，departments，staff structure，infrastructure situation，the provision of public health services，and emergency response capacity for infectious diseases and public health emergencies of the CHC，and was analyzed using descriptive analysis. The above-mentioned data were checked and supplemented if necessary in accordance with the information in the China's National COVID-19 Surveillance Network and Beijing Community Health Statistics 2019. Results Of the 342 CHCs in total in Beijing as of 2019，90（26.32%） had a fever clinic，102（29.82%） had a gastrointestinal clinic，and 54（15.79%） had both a fever clinic and a gastrointestinal clinic. Among the incumbent workers in the CHCs（n=28 809），2 887（10.02%） held a position in public health，and 178（6.17%） had a senior professional title. HIV testing was carried out in 159 CHCs（46.49%）. SARS-CoV-2 nucleic acid testing was accessible in 11 CHCs（3.22%）. For 29 kinds of common infectious diseases，140（40.94%） CHCs had no diagnosis and treatment capabilities，135（39.47%） had capabilities managing 1-5 kinds，only 29（8.48%） were able to diagnose and treat >10 kinds. Conclusion The CHCs in Beijing may have a series of problems in the infectious disease prevention and control system and mechanism，sentinel fever clinic，infectious disease diagnosis and treatment capacity，public health workforce development and other aspects. Therefore，the infectious disease prevention and control plan of the CHCs should be developed more appropriately from an overall point of view，to address the problems and improve the current status as soon as possible.
Capability of Community Health Centers in Cities to Provide Childcare Services
WANG Xi，YIN Tao，YANG Huimin，ZHENG Xiaoguo，LI Ruili，WANG Lihong，YIN Delu
Chinese General Practice 2021, 24 (28): 3571-3577. DOI: 10.12114/j.issn.1007-9572.2021.00.250
Abstract
Background The implementation of universal two-child policy has brought a significant increase in the number of children in China. The needs of childcare services are increasing rapidly，but the capability of community health centers（CHCs） to provide such services is still unclear. Objective To investigate the capability of CHCs in some cities of China to provide childcare services. Methods In April 2020，by use of multi-stage stratified sampling，we selected 35 CHCs in 14 cities of China，and conducted two online surveys using self-developed questionnaires，one with administrators of the CHCs for investigating the general status，personnel，equipment and facilities allocation，and implementation regarding childcare services，and one with childcare staff of the CHCs for investigating their knowledge regarding childcare services and job satisfaction. Results The survey included 35 community health service centers in 14 cities across the country，and the total number of health technicians in the sample center was 8 009. Among the health technicians，191（2.38%） were pediatricians（including licensed physicians and assistant physicians with pediatrics included in their scope of practice），154 of them（80.63%） had a bachelor degree or above，and 112（58.64%） had intermediate or above professional title；488（6.09%） were general practitioners（received post-shift training with pediatrics before being a childcare provider），293 of them（65.37%） had a bachelor degree or above，and 355（79.30%） had intermediate or above professional title；320（4.00%） were pediatric preventive healthcare physicians，and more than 80.00% of them had the national physician license and pediatric training certificate. A total of 999 people accepted the survey of satisfaction and knowledge level. The job satisfaction level of the childcare providers and the accuracy of the pediatric knowledge test performed by them was（61.38±9.11）%，and （50.40±21.93）% on average，respectively. The pediatric consulting room accounted for less than 1% of the total consulting rooms of the CHCs on average. More than 90% of the CHCs were equipped with 8 kinds of common equipment and facilities for providing childcare services. More than 50% of the CHCs were equipped with less than 7 kinds of common pediatric diagnostic and therapeutic equipment and facilities. Only 10 of the 23 common pediatric medicines could be accessible in more than 50% of the CHCs. In 2019，the number of visits of children to the CHCs accounted for 2.91% of the total visits. And the number of admissions of children to the CHCs accounted for 1.48% of the total admissions. Over 85 percent of the national essential public health projects have been carried out. Simple obese children accounted for the highest number of children receiving management while those with congenital dislocation of the hip accounted for the lowest. Conclusion Overall，the number of childcare providers in the CHCs was insufficient，with relatively high education level and professional title，but unsatisfactory level of pediatric knowledge，and low job satisfaction. The CHCs were equipped with insufficient equipment and facilities as well as pediatric drugs. The spatial distribution of children's health service level was not balanced. To improve the capability of CHCs to provide childcare services，it is suggested to strengthen guidance and training to improve the ability level of primary childcare providers，establish an effective performance assessment mechanism to improve their job satisfaction，increase types and quantity of pediatric drugs，and reasonably allocate pediatric diagnostic and therapeutic equipment and facilities.
Development of a Standardized Process of Community-based Osteoarthritis Prevention and Treatment with Integrated Traditional Chinese and Western Medicine by Zhuanqiao Community Health Center
XU Chengyan，CHEN Guorong，LI Yan，CHEN Junxiang，WANG Jiaoming，LI Liqiu
Chinese General Practice 2021, 24 (28): 3560-3570. DOI: 10.12114/j.issn.1007-9572.2021.00.278
Abstract
Background Osteoarthritis is the third leading chronic disease in older people. There are quite a lot of osteoarthritis sufferers，and a large number of people at high risk for osteoarthritis. However，due to lack of research on standardized community-based diagnosis and treatment of osteoarthritis，and a complete，scientific process regarding standardized community-based management of osteoarthritis，long-term management of osteoarthritis is still not accessible in the community. Objective To develop a complete，practical standardized process for community-based osteoarthritis prevention and treatment with integrated traditional Chinese and western medicine（hereinafter referred to as "osteoarthritis prevention and treatment process"） with a detailed analysis of the major technical points and difficulties. Methods The osteoarthritis prevention and treatment process was developed from March to December 2020，which consists of preparatory，development and informatization stages. In the preparatory stage，literature review，investigation approach，and group discussion were used to develop a literature database including guidelines/standards on osteoarthritis prevention and treatment，and the aspects and services involved in the prevention and treatment process were determined. In the development stage，the standard operating procedure（SOP） for osteoarthritis prevention and treatment was updated from version 1.0 to version 4.0 in accordance with a two-round group discussion and focus group discussion，as well as the results of the pilot implementation of the osteoarthritis prevention and treatment process. In the informatization stage，based on the literature database formed in the preparatory stage，and SOP 4.0，a database of indicators involved in the osteoarthritis prevention and treatment process was developed，and used for further informatizing the process. Results In the preparatory stage，10 eligible guidelines/standards were included. The determined osteoarthritis prevention and control process consists of five aspects〔community mobilization，evaluation（screening），diagnosis，intervention and follow-up〕，with a focus on community mobilization，evaluation（screening），and follow-up. In the development stage，the developed SOP 4.0 for osteoarthritis prevention and treatment includes 10 items: service population，service time，settings，must-have service tools，providers，must-have professional skills of providers，service profile（list），service spending（cost），the generated data list，and evidence-based basis for operation. And the complete prevention and control process was formed. In the informatization stage，a table of the structure of the above-mentioned five aspects was presented. Conclusion Our osteoarthritis prevention and treatment process could guide community healthcare workers to deliver osteoarthritis prevention and treatment services using available community resources to all the people in the local community. Our development process may be used as a reference for other community health institutions to develop the prevention and treatment pathway of osteoarthritis or other single diseases according to their own conditions.
Effect of Standardized Workload Used in Comprehensive Performance Management in Community Health Institutions: a Practice-based Analysis
LIN Jixiang，GU Jinghua，WANG Tianying，HUANG Shuxian，JIAO Lulu，GAO Jun，JIANG Wenzhen，ZHANG Wenyu，MA Junling，YANG Huilan，SHEN Yongmei，KANG Jie，CHEN Biao，ZHOU Jingyu，ZHANG Lina，GUO Haiying，et al
Chinese General Practice 2021, 24 (25): 3210-3220. DOI: 10.12114/j.issn.1007-9572.2021.00.183
Abstract
Background Standardized workload is a tool that can be used by community health institutions to accurately measure the manpower consumption in delivering a service. The parameters and variables used in the calculation of standardized workload may involve all aspects of the development of such institutions. Therefore，this tool is highly applicable. However，there is a lack of research on guiding the practical use of it in the operation and comprehensive assessment of community health institutions. Objective To comprehensively and systematically analyze the application of standardized workload in staff performance management by Beicai Community Health Center，providing evidence for organizing the services of a health institution，and for using standardized workload to measure the workload of newly developed services，and to build a relationship between different business departments. Methods A real-world research design was used. The measurement of standardized workload by Beicai Community Health Center was discussed in terms of themes（n=4） and steps（n=6）. Results The actual operation process，applied principles and formulas for measuring the performance of all employees and for pricing new services were summarized. Conclusion The experience of Beicai Community Health Center analyzed in detail may be directly used by other community health institutions to guide the measurement of standardized workload，including the pricing of newly developed services，performance assessment for workers in different departments，and so on，which may help to maintain the unity of operation strategies of the institution.
Methods for Accurately Assigning the Value of Technical Difficulty and Risk Degree of Standardized Workload of Community Health Services
LIN Jixiang，GU Jinghu，WANG Tianying，HUANG Shuxian，JIAO Lulu，GAO Jun，JIANG Wenzhen，ZHANG Wenyu，MA Junling，YANG Huilan，SHEN Yongmei，KANG Jie，CHEN Biao，ZHOU Jingyu，ZHANG Lina，GUO Haiying,et al
Chinese General Practice 2021, 24 (25): 3205-3209. DOI: 10.12114/j.issn.1007-9572.2021.00.220
Abstract
Background The calculation formula of standardized workload includes three variables:manpower time，technical difficulty and risk degree. Among them，technical difficulty and risk degree are subjective measurements. Business personnel in different departments or engaging in different types of work have their own measures. In general，the workload measurement of business personnel of the same type of work is relatively consistent. But it is impossible to use the same criteria to measure the workload of people in different departments or engaging in different types of work，which makes the technical difficulty and risk measurement of different departments incomparable. Objective To estimate the standardized workload of community health services to homogenize the subjective measurements of technical difficulty and risk degree of workload across departments. Methods We collected the initial assignment values of each service（including manpower hour，technical difficulty and risk degree） delivered by representative professional workers from pharmaceutical and healthcare business departments. Then，using the calculation principle of standardized workload，we converted them according to the principles of minimum and average，and multiplied the converted values of technical difficulty and risk degree by inter-department conversion coefficient obtained by using the series method to obtain the final comparable values of the technical difficulty and risk degree of different departments，with the sorting method used for solving the controversy before determining the final value. Results The degree of authority of the invited experts for consultation was greater than 0.7，and the results were scientific and reliable. The technical difficulty and risk degree conversion coefficients between departments were obtained. And the final comparable values for technical difficulty and risk degree of all services delivered by each department were obtained. Conclusion The measurement and evaluation of the standardized workload of each service in terms of technical difficulty and risk level，requires the selection of representative professional workers to obtain their evaluation results，and then adopts the minimum and average principles，series method，and sorting method，the final comparable values of technical difficulty and risk level for each service delivered by different business departments within a hospital can be successfully obtained.
Development of a Tool for Community Health Institutions to Rapidly Evaluate the Feasibility of Single Disease Prevention and Control Services
CHEN Junxiang，CAO Yongqi，DING Qing，WANG Xiongxing，LI Liqiu
Chinese General Practice 2021, 24 (19): 2494-2500. DOI: 10.12114/j.issn.1007-9572.2021.00.174
Abstract
Background During the development of featured services and specialties，it is necessary for community health institutions to choose or determine an appropriate option in the light of their own limited resources，and contradictions between diversified demand and requirements for healthcare of government，market，residents and healthcare disciplines. Objective To develop an auxiliary tool for community health institutions to rapidly evaluate the feasibility of prevention and treatment services for a single disease，providing a reference for the establishment of single disease care unit in community hospitals. Methods This study was conducted between December 19，2017 and October 28，2019 using semi-structured interviews with a group of 6 experts from fields of general care，public health，rehabilitation and community management on topics such as the principles，requirements and targets for establishing a single disease prevention and treatment unit in the community hospital and the designed roles of this unit，and using a questionnaire survey with 20 experts from community，general and TCM hospitals and a college on discussing the values of single disease screening principles and methods for evaluating the feasibility of single disease clinical pathway construction in a community hospital summarized from the results of above-mentioned semi-structured interviews and screened the eligible ones using boundary value analysis. In accordance with the investigation results，the Single Disease Screening Flow Chart for Constructing a Pathway to Community-based Care was developed. Results Twenty-five single disease screening principles were determined finally，including four exclusion principles，and 21 admission principles. The admission principles cover historical data analysis（10 items，with weights sorted by the value of item-related information collected by community information department），and subjective scoring（11 items，each using a 7-Point Likert Scale to score the manifestations of a single disease）. The three diseases with the highest scores in total were determined as the first choice for a community hospital to build a clinical care unit for the diseases. Conclusion Our tool includes 25 single disease screening principles with detailed measurements and implementation procedure，which is worthy of promotion owing to its theoretical scientificity and representativeness and practical feasibility.
Outpatient Expenses among Diabetic Patients Treated in Community Health Centers：an Investigation based on BCDS
XU Nan，WANG Mei，LIU Xiaodong，GU Xuefei，LI Tingting，YUAN Shenyuan，YUAN Mingxia
Chinese General Practice 2021, 24 (16): 2028-2033. DOI: 10.12114/j.issn.1007-9572.2021.00.202
Abstract
Background Beijing Tongren Hospital has carried out a 10-year three-stage standardized community-based diabetes management program（hereinafter referred to as BCDS），aiming to provide community-dwelling diabetic patients with standardized and continuous follow-up management services. After long-term management，whether the actual effect has economic and social benefits has not been evaluated by empirical health economics. Objective To understand the annual outpatient diabetes care expenses in community health centers（CHCs） by analyzing the real-world data collected via a field investigation in CHCs implementing the BCDS. Methods We conducted a field investigation for 10 consecutive months since November 2016 using health economics method in 9 of the CHCs who have implemented the first and second stages of the Tongren diabetes program. One third of the diabetic patients receiving the program management were selected randomly，and data about their outpatient expenses in 2012，2014 and 2016，including drug and examination expenses，were collected. Kruskal-Wallis test and descriptive research were used to analyze the annual expenses. Descriptive research was conducted to analyze the cost of structure and drug use. Results After adjusting for inflation，the annual outpatient expenses per capita were 10 312.91，10 885.56，and 11 733.50 yuan，respectively. The analysis of cost of structure found that，the annual cost of diabetes prevention and treatment related drugs ranged from 4 690.37 to 5 251.85 yuan，accounting for around 44.76%-45.48% of the annual expenses per capita. Traditional Chinese medicine expenses and other expenses accounted for nearly half of the total，about 47.31%-48.34%. Conclusion With the interventions of Tongren diabetes program，the drug use and annual outpatient expenses of diabetic patients are generally stable，indirectly indicating that the overall conditions of the intervened patients are relatively stable. The structure of the cost is partial irrationally，such as the proportion and growth rate of traditional Chinese medicine expenses and other expenses are not ideal，and use of too many types of Chinese patent medicines，and the ranking of the top 10 drugs（because their prophylactic and anti-diabetic effects are still unclear），which needs further improved. In view of this，we put forward the following recommendations: developing a structured and refined payment system for major chronic diseases；in terms of outpatient chronic disease payment，appropriately determining and controlling the proportion of expenses of auxiliary therapies；reasonably modifying the proportions of expenses of Chinese patent medicines as auxiliary therapies and other expenditures based on deeply analyzing their meanings.
Use of ICD-10 in Community Health Care and Associated Factors：a Real World Study
HUANG Yanli，NI Zhigang，WU Xingwei
Chinese General Practice 2021, 24 (13): 1607-1615. DOI: 10.12114/j.issn.1007-9572.2021.00.193
Abstract
Background Population management is an important general practice service provided by primary care. The International Classification of Diseases（ICD） is a key diagnostic tool that is used to code and classify the morbidity data from patients' medical records，but is rarely used in primary care and research. Objective To investigate the use of ICD-10 in primary care and its associated factors based on analyzing the practices of community health care，Chengdu's Wuhou District， for achieving the standardization of diagnosis. Methods A questionnaire was designed in accordance with the constructs of the Consolidated Framework for Implementation Research，and used to investigate all the outpatient physicians and managers from 13 community health centers（CHCs） in Wuhou District，for understanding their perceptions of barriers and risks for achieving standardization of diagnosis by using the ICD-10. Through the back-end database of the hospital information system，trigger records and standardized rates of diagnoses made at different stages from June 2017 to October 2020，and consultation data during the application of ICD-10 between November 2019 and July 2020 were extracted. Results 83.1% of the respondents thought it was essential to promote the standardization of diagnosis in primary care. The effect of ICD-10 on the promotion of contracted family doctor service was expected to focus on population management（59.4%，95/160），risk stratification（55.6%，89/160） and diagnostic quality（53.8%，86/160）. Multiple linear regression analysis showed that population management，risk stratification，patient communication，work arrangement within the team，diagnosis quality，scientific research data acquisition based on management population，establishment of patient trust，and communication with external resources promoted the signing service of family doctors were the influencing factors of promoting the standardization of primary medical diagnosis（P<0.05）. During the use of ICD-10，the rate of questions raised by the consultation group was only 0.01%，mainly focusing on the operation of the information system（19.5%，38/195）. No self-defined diagnosis beyond the scope of ICD-10 system needed to be added；the proportion of diagnosis of most diseases increased，and the structure and order of diagnosis changed greatly. Conclusion It is necessary to take measures to achieve standardization of diagnosis in primary care，and the ICD is an appropriate tool. Relevant research on the standardization of diagnosis and management of the application of the tool are suggested to be strengthened by the government，so as to lay a foundation for the development of data-driven primary care services.
Role Orientation and Pathway of Primary Care during Containing COVID-19：a Case Study of Shanghai W Community Health Center
HUANG Jiaoling，FU Xuanqin，WANG Liqiang，MA Haiping，ZHANG Shuwei，ZHU Min，WANG Zhaoxin，SHI Jianwei，YU Wenya，TANG Lan
Chinese General Practice 2021, 24 (13): 1596-1601. DOI: 10.12114/j.issn.1007-9572.2021.00.187
Abstract
Background Primary care has played an significant role in containing COVID-19. But there is a lack of studies on the mechanism and pathway of its action. Objective To explore the role of primary care during the containment of COVID-19，and to map the systematic pathway. Methods This study was conducted between February and March 2020 in W Community Health Center（CHC），Shanghai. Data about major measures taken by center for containing COVID-19 were collected via interviews by telephone，email，WeChat voice，or key informant，and were analyzed to examine the role orientation of this CHC and to map its systematic pathway in containing the pandemic using system dynamics diagram. Results The major actions taken by this CHC to contain COVID-19 included：establishing a COVID-19 containment management team，implementing COVID-19 screening and triage，undertaking emergency responses to COVID-19，strengthening ward management，and providing online health services. This CHC's role during COVID-19 containment was mainly summarized as: providing essential healthcare services for residents，undertaking the anti-COVID-19 tasks assigned by higher level institutions，delivering community-based anti-COVID-19 services，and parallelly cooperating with other relevant institutions. The system dynamics flow diagram showed that the CVID-19 containment system in primary care based on the practice of this CHC is composed of four subsystems: execution path，emergency path，cooperation path，and essential healthcare service path. Conclusion Our study indicates that primary care plays an important role in COVID-19 containment，which may be summarized as "implementing duties in collaboration with other relevant institutions using parallel or vertical mode"，and recommendations for the implementation may be summarized as "providing essential healthcare services for residents，strengthening the organization and management of anti-COVID-19 services delivery，enhancing team building and improving the cooperation with other institutions".
Healthcare Human Resources in Community Health Centers in Beijing，2012—2018
WANG Mei，GUO Moning，TAN Peng，LI Ang
Chinese General Practice 2021, 24 (10): 1211-1217. DOI: 10.12114/j.issn.1007-9572.2021.00.029
Abstract
Background Healthcare human resources in community health centers（CHCs） play an essential role in promoting the development of primary health services and take a key role in the development of hierarchical medical system. Objective To investigate the size and allocation of healthcare human resources in CHCs in Beijing from 2012 to 2018. Methods Data were collected from the 2012—2018 annual reports and questionnaires regarding the essential information of healthcare human resources of Beijing's CHCs. The size，allocation，education levels and professional titles of healthcare human resources were studied. Results In 2018，each CHC had 98 healthcare professionals，with 84.3% as the rate of occupied budgeted posts，and 6.4% as the annual turnover rate on average. From 2012 to 2018，the number of healthcare professionals in CHCs showed an increase trend generally. Specifically，the number of practising（assistant） TCM physicians had the highest annual growth rate（6.0%），while that of public health workers had the lowest（only 0.1%）. The proportion of general practitioners in the total number of practising physicians decreased by 6.7 percentage points. The average numbers of community healthcare professionals，practising（assistant） physicians，registered nurses，and practising（assistant） TCM physicians per 1 000 people increased from 1.05，0.52，0.33，0.10 in 2012 to 1.30，0.63，0.44，0.13 in 2018，respectively. The average number of general practitioners per 10 000 people increased from 2.75 in 2012 to 2.95 in 2018. The average number of public health workers per 1 000 people decreased from 0.06 in 2012 to 0.05 in 2018. The ratio of doctors to nurses improved from 1∶0.64 in 2012 to 1∶0.72 in 2018. The proportion of healthcare professionals with bachelor degree or above was 30.7%，which increased by 7.3 percentage points compared with that of 2012. The proportion of healthcare professionals with a senior professional title was 5.7%，which increased by 1.4 percentage points in comparison with that of 2012. Conclusion During this period，Beijing's CHCs had a gradual increase in the size of healthcare human resources with improved education level，a yearly improvement in the vacancy of budgeted posts，and a yearly growth in the number of healthcare workers without a budgeted post，indicating that the allocation of healthcare workers has been improved. However，according to requirements of national governmental planning，there is a great shortage of registered general practitioners and nurses. Moreover，the proportion of healthcare workers with a senior professional title need to be increased. Based on the above analysis，it is suggested to innovate the construction of the personnel management system，improve the talent incentive mechanism，explore new modes for training general practitioners and strengthen the construction of nursing workforce.
Criteria for the Establishment of a Simulation Center for GPs in the Community Health Center
LI Yaling，WANG Haitang，SHAN Meiqing，DU Zhaohui
Chinese General Practice 2021, 24 (10): 1198-1204. DOI: 10.12114/j.issn.1007-9572.2020.00.417
Abstract
Background Simulation center for GPs，an important platform for fostering and evaluating GPs，has been developed rapidly in the context of the requirement of improving GPs' clinical abilities. So it is urgent to establish a set of criteria for the building of simulation centers for GPs，to provide a reference for the functional configuration of such centers.Objective To establish a set of scientific，practical and reasonable criteria for the building of a simulation center for GPs in the community health center. Methods Literature review and practical experience were used to develop a draft content framework of criteria for the building of a simulation center for GPs in the community health center，which was used to formulate a questionnaire after being determined according to group discussion results. From May 28，2019 to July 10，2019，the questionnaire was revised in accordance with two rounds of consultations with 25 invited experts using the Delphi technique after the positive and authoritative coefficients of the experts and Kendall's W of their judgments were assessed as eligible. Based on the above，the final content of the criteria was determined. Results The average years of working in their own field for the 25 experts were （14.42±6.90） years. The positive coefficients of the experts in the first and second rounds of consultations were 96.2% and 100.0%，respectively. For the hardware，software，and staffing configuration，the authoritative coefficients of the experts in the first round of consultation were 0.83，0.83，0.85，respectively，and were 0.90，0.89，0.89，respectively，in the second round of consultation. The Kendall's W values of the necessity were 0.133，0.498，respectively（P<0.001），and the availability were 0.280，0.390，respectively（P<0.001）. Finally，we established a set of criteria for the establishment of a simulation center for GPs in the community health center，including 3 first-level indicators（hardware，software，and staffing），13 second-level indicators，and 17 third-level indicators. Conclusion The positive and authoritative coefficients of the experts were relatively high，and Kendall's W of their judgments was good in the consultations，indicating that our criteria are reliable，which can be applied and promoted.
Further Clinical Training for In-service Medical Workers in a Community Health Center of Beijing
JI Yan，SUN Yange，YAN Chunze，DING Lan，DING Jing
Chinese General Practice 2021, 24 (4): 490-495. DOI: 10.12114/j.issn.1007-9572.2020.00.235
Abstract
Background Further clinical training for medical workers is a way to improve the quality of medical treatment. Further study in primary care community helps to provide targeted training and guidance for medical workers working at the community health center. Moreover，drawing lessons from the statistical analysis of the study results facilitates the hosted healthcare settings to improve the study program. Objective To perform a statistical analysis of the overall status of further clinical training for medical workers from 2016 to 2019 conducted by Yuetan Community Health Center，Fuxing Hospital，Capital Medical University，to provide evidence for improving the design of study procedure in a reasonable way，and enhancing the overall as well as individual effectiveness of training in physicians. Methods Data were collected from Yuetan Community Health Center，Fuxing Hospital，Capital Medical University，during March 2016 to July 2019，mainly including further clinical training status（number of each batch of trainees，training duration，source region，work unit，training cost），demographic information of trainees（n=67）（gender，age，title，department，position），and training arrangements（planned and actual training departments，and number of actual training departments）. A group interview was conducted with 7 trainees who participated in the training in July 2019 for investigating their satisfaction with the training in training course arrangement necessity, course content and so on. Results Statistics showed that during this period from March 2016 to July 2019，this community center launched 33 batches of trainings lasting for at least 5 days in total. In 21 batches of trainings（63. 6%），there was only one trainee. 15 batches of trainings lasted for less than 30 days，accounting for a major proportion of the total（45.4%）. The trainees participating in 20 batches of trainings（60.6%） came from regions except Beijing or from other countries. The trainees mainly worked at community health centers（stations） 〔16 batches（48.5%）〕. 24 batches of trainings（72.7%） were free. Most of the trainees were female 〔39（56.5%）〕，aged between 30 and 40 years old〔37（53.6%）〕，had intermediate title〔31（44.9%）〕，worked at general practice department 〔21（30.4%）〕 and administrative department 〔16（23.2%）〕，and had no administrative position〔43（62.3%）〕. The top 3 planned training departments were general practice department 〔30 trainees（46.4%）〕，administrative department〔14 trainees（20.3%）〕，nursing department tied with rehabilitation department 〔9 trainees（13.0%），respectively〕. The top 3 actual training departments were general practice department 〔41 trainees（59.4%）〕，preventive health care department〔27 trainees（39.1%）〕，and administrative department〔25 trainees（36.2%）〕. The trainees were trained in 1-4 departments actually，and the largest and the second largest portions of them were 1 department〔32（46.4%）〕and 2 departments〔17（24.6%）〕，respectively. In terms of the necessity of curriculum arrangement，six trainees held the attitude of "very need"，one of them held the attitude of "need"，and seven people rated the satisfaction of the lecturer as "very satisfied". Seven trainees were interested in the content of the course. Conclusion Yuetan Community Health Center holds many batches of further clinical trainings for medical workers to satisfy the high demand of medical workers. These trainees mainly have intermediate titles with no administrative position，and mainly choose to be trained in 1-4 departments，and the largest proportion of them are trained in one department. Moreover，they are highly satisfied with the training. However，there are also problems such as delays in the update of the training process，so further optimization of the process is required to ensure scientific training，standardized management，and high-quality teaching.
Composition of Diseases in Patients Discharged from General Wards of Suburban Community Health Centers，Pudong New Area
MA Xiujun，XIA Qingshi，ZHANG Shengbing，FAN Yun，DU Zhaohui
Chinese General Practice 2021, 24 (4): 473-479. DOI: 10.12114/j.issn.1007-9572.2021.00.021
Abstract
Background With the change of functional orientation，community health centers（CHCs） become a supplier for general healthcare services consisting of 6 types（prevention，medical，healthcare，health education，rehabilitation services and guidance on family planning） instead of mainly medical services，and the original specialty wards such as internal，surgical and gynecology and obstetrics have become the general wards. Understanding the composition of diseases in inpatients receiving general care in CHCs helps primary care institutions to accurately identify the patients' health needs and formulate targeted disease prevention and treatment strategies. Objective To investigate the composition of diseases in inpatients receiving general care from suburban community health centers，Pudong New Area，providing a reference for the implementation of targeted interventions for disease prevention and treatment，and for carrying out appropriate professional trainings for medical workers. Methods Retrospective analysis was used to analyze the sex ratio，age，first diagnosis and other data of discharged patients from the general wards of suburban CHCs，Pudong New Area from 2015 to 2017. These information were derived from "Shanghai Medical Institutions Medical Records Statistical Management System". Results From 2015 to 2017，there were a total of 49 352 patients discharged from the general ward in the suburb CHCs of Pudong New Area，including 27 294 females（55.30%），and 22 058 males（44.70%）. 42.59% （21 019/49 352） of them aged 80 and above. The top 3 systemic diseases were respiratory diseases〔40.95%（20 208/49 352）〕，circulatory system diseases〔32.46%（16 021/49 352）〕，and digestive system diseases〔7.32%（3 611/4 352）〕. The monthly percentage of these 3 systemic diseases showed that among the total discharged patients，respiratory disease patients accounted for the largest percentage in January〔13.94%（2 816/20 208）〕，circulatory system disease patients accounted for the largest percentage in March〔9.53%（1 527/16 021）〕，and digestive system disease patients accounted for the largest percentage in August〔12.21 %（441/3 611）〕. The top 3 single illnesses were sequelae of cerebral infarction〔12.90%（6 244/49 352）〕，chronic obstructive pulmonary disease with acute lower respiratory tract infection〔12.65%（6 366/49 352）〕，and acute bronchitis〔9.44%（4 658/49 352）〕. The top one single illness was chronic obstructive pulmonary disease with acute lower respiratory tract infection 〔17.75%（3 915/22 058）〕 in males，and was sequelae of cerebral infarction〔13.37%（3 649/27 294）〕 in females. Conclusion Among the discharged patients from general ward of suburban CHCs，Pudong New Area，elderly patients with chronic diseases accounted for the largest percentage；the peak incidence was associated with season；the challenges to prevent and treat cerebral infarction and chronic obstructive pulmonary disease were great. In view of this，general practitioners in these CHCs，the main supplier for healthcare services，should formulate disease prevention and treatment strategies in accordance with the patient's age，disease profile，peak incidence，and other features as well as the conditions of the CHCs，and improve the delivery of demand-oriented community health services. Besides，comprehensive abilities of community general practitioners and nurses should be improved by strengthening the theoretical and practice trainings regarding the diagnosis and treatment of high-incidence diseases in the community.
Influencing Factors of Frequent Visits of the Elderly in a Community Health Service Center Based on the Theory of Planned Behavior：a Qualitative Study
LI Nana，SHOU Juan
Chinese General Practice 2021, 24 (1): 70-74. DOI: 10.12114/j.issn.1007-9572.2020.00.286
Abstract
Background The frequent visits of the elderly in community health service centers are common and occupy a large amount of medical resources. Objective To understand the influencing factors of frequent visits of elderly patients in a community health service center. Methods Through the purposive sampling and information saturation principle，20 elderly patients who had frequent medical consultations in a community health service center of Shanghai for the past three years（the number of visits within 3 years were in the top 10%） were selected for a semi-structured interview in May of 2018. Based on the theory of planned behavior，the interview outline mainly included the cognitive measurement，attitude measurement，subjective norm measurement，perceived behavior control measurement，and opinions and suggestions for the community health service center. According to the results of interviews，the influencing factors of the frequent visits of the elderly were analyzed. Results Eighteen patients were unaware of their frequent visit behaviors. Nine patients had specific definitions of frequent visits，and 55.6%（5/9） defined 3 visits or more per month as frequent visits. And 90.0%（18/20） believed that frequent visits had no adverse effect on their lives and health；60.0%（12/20） thought that frequent visits could brought them psychological comfort，and 50.0%（10/20） mentioned that frequent visits were helpful to control and improve their health condition. Policies of contracted services（70.0%，14/20），family support（45.0%，9/20），and the behavior of others（15.0%，3/20） could affect patient's frequent visit behaviors. Chronic diseases（100.0%，20/20），convenience of community hospitals（90.0%，18/20），good doctor-patient relationship（90.0%，18/20），concern for their own health（60.0%，12/20），acute illness（45.0%，9/20），and poor conscious health status（30.0%，6/20） could contribute to frequent visits，while inconvenient movements（20.0%，4/20），economic reasons（10.0%，2/20），and household chores（10.0%，2/20） may limit the frequency of patient visits. Conclusion The frequent visit behaviors of elderly patients are affected by many factors，which requires the attention of general practitioners on patient's disease，psychology，society and other aspects to meet their real needs.
Bi-directional Referrals in Urban and Suburban Community Health Centers：a Comparative Study
SHI Xiaoxiao，SONG Huijiang，GE Xuhua，JIN hua，WANG Zhaoxin，YANG Sen，SONG Yang,HE Juanmei，ZHU Minjie，YU Dehua
Chinese General Practice 2021, 24 (1): 30-35. DOI: 10.12114/j.issn.1007-9572.2020.00.269
Abstract
Background Realizing successful bi-directional referrals is an essential target of the comprehensive medical reform for public hospitals launched in 2009 in China. Bi-directional referrals in urban and suburban areas are different due to domestic uneven distribution of health resources，and administrative regional differences of medical and human resources as well as disease management. It is of great significance to understand bi-directional referrals in urban and suburban areas to maximize the utilization of health resources. Objective To perform a comparative analysis of bi-directional referrals in urban and suburban community health centers（CHCs） in Shanghai with reasonable suggestions proposed，providing a practical and reliable reference for better promoting such services in Shanghai. Methods From November to December 2018，244 administrators and 4 047 general practitioners（GPs） were enrolled from 244 CHCs in 16 districts of Shanghai. A survey was conducted among the administrators using a self-developed questionnaire（for administrators） for collecting their demographic data，and their perceptions of organizational mechanism，process and results of referrals. And another survey was conducted in the GPs using a self-developed questionnaire（for GPs） for collecting the data about demographics，modes of bi-directional referrals and contact ways for upward referrals used，prevalence of filling the referral information except the referral form，and prevalence of communicating with physicians in the higher level hospital when receiving the downward referred patient. Results The two surveys achieved response rates of 100.00% （244/244） and 96.98%（3 925/4 047），respectively. Of the 3 925 GP respondents，2 641（32.71%） worked in suburbs and 1 284（67.29%） in urban areas. There were significant differences in gender ratio，distribution of title and working years between urban and suburban GPs（P<0.05）. Of the CHCs，97.54%（238/244） established a bi-directional referral system，and 89.34%（218/244） signed a bi-directional referral agreement with secondary and tertiary hospitals. There are significant differences between urban and suburban CHCs in having a worker of communications for bi-directional referrals，setting up bi-directional referral files，reserving beds for downward referred patients，network connections for bi-directional referrals，peer-to-peer communication with corresponding experts or departments，and communication with the worker responsible for bi-directional referrals in higher level hospitals（P<0.05）. 50.41%（123/244） of the CHCs had less than 100 upward referrals and 75.00%（183/244） had less than 10 downward referrals per month. There was a significant difference in the average number of upward referrals per month between urban and suburban CHCs（P<0.05）.Conclusion Shanghai's urban and suburban CHCs have many differences in bi-directional referrals，which are composed of mainly upward referrals. To improve the development of bi-directional referral system，it is suggested to improve the construction of suburban community health services，establish a health record-based bi-directional referral platform using the Internet technologies plus favorable recommendations，and actively establishing regional medical groups.
Current Situation and Recommendations for Continuing Medical Education for General Practitioners：Online Training of Diagnosis and Treatment of Common Diseases in Primary Care
SUN Xinran，WAN Heping
Chinese General Practice 2021, 24 (7): 875-880. DOI: 10.12114/j.issn.1007-9572.2021.00.023
Abstract
Background Continuing medical education is a significant way for general practitioners（GPs） to improve the skills of diagnosis and treatment，however，the design of the education programs should satisfy the needs of GPs and should be suitable for GPs with different professional skills. Objective To investigate the factors associated with results of a training as a continuing medical education program in GPs and their training needs based on a survey，providing a reference for developing appropriate continuing education programs for GPs. Methods Data of GPs who participated in an online continuing education program of diagnosis and treatment of common diseases in primary care conducted in Shanghai from October to December 2019 were collected，including demographics，score of test of the training contents，needs of contents and forms of training，and satisfaction with training. The associations of training test score with years of attending consecutive trainings，geographical location of the working area，and professional title were analyzed. The associations of needs of training contents with geographical location of the working area，and professional title were analyzed. Spearman's correlation was used to analyze the correlation between satisfaction with training contents and training test score. Results A total of 3 344 GPs completed this training，whose average test score was（4.80±2.67）. GPs with two consecutive years（2018 and 2019） of trainings had much higher test score than those with one-year training（2019）〔（5.09±2.60）vs（4.15±2.71），P<0.05〕. Suburban GPs had much higher test score than urban GPs〔（4.97±2.68）vs（4.30±2.58），P<0.05〕．The test score〔（3.77±2.73）〕 of GPs with no professional title was much lower than that〔（4.82±2.65）〕 of those with a junior professional title or intermediate title 〔（4.85±2.65）〕（P<0.05）. Suburban GPs were in more need of trainings regarding guidance on residents' self-management of hypertension and diabetes，home-based stroke rehabilitation，emergency knowledge and skills，gynecology and obstetrics and pediatrics treatment，and coronary heart disease prevention and treatment，while urban GPs were in more need of trainings regarding the skills of imaging and electrocardiogram diagnosis（P<0.05）. GPs with no professional title had greater needs for trainings regarding nutrition knowledge，psychological knowledge and doctor-patient communication skills（P<0.008），while those with junior professional title had greater needs for trainings regarding the skills of imaging and electrocardiogram diagnosis（P<0.008），and those with an intermediate professional title had greater needs for trainings regarding emergency knowledge and skills（P<0.008）. GPs were highly satisfied with the training content（92.54%，844/912）. The test scores was positively correlated with the satisfaction evaluations of the training content （r=0.098，P<0.05）. Mobile phone-based training was the most popular form of training（92.16%，762/1 198）. Conclusion In comparison，the effect of regular trainings of general practitioners continuously is better, and there are differences in the training content needs of general practitioners in suburban areas and different titles. We put forward the following suggestions in accordance with the survey: carrying out regular trainings continuously as continuing medical education for GPs；modifying the difficulty degree of trainings and compiling training contents according to geographical location of the working area and professional title；recruiting professionals who are familiar with primary care as the teachers for trainings，and compiling training contents according to the needs of primary care workers；promoting the application of the form of mobile phone-based training.
Overall Status and Urban-suburban Comparative Analysis of Outpatient Management of Undifferentiated Diseases by Community General Practitioners，Shanghai
ZHANG Hanzhi，HAN Yiping，JIN Hua，CHEN Yuge，SHI Jianwei，CHEN Yang，MA Le，YU Dehua
Chinese General Practice 2021, 24 (7): 855-863. DOI: 10.12114/j.issn.1007-9572.2020.00.408
Abstract
Background Community-based management of undifferentiated diseases embodies the level of professional abilities of community general practitioners（GPs） and the management quality of community healthcare institutions for the diseases. The differences of primary care needs between urban and suburban areas are becoming less，indicating that healthcare services have great development potentials in suburban areas. Objective To perform a comparative analysis of the perceptions，outpatient management interventions，and level and associated factors of management of undifferentiated diseases，as well as required supports among GPs from community health centers（CHCs） in urban and suburban areas of Shanghai，offering guidance for promoting the development of primary care，and optimizing the distribution of primary care resources. Methods November 2018，an online survey was conducted using a self-developed questionnaire A（CHC administrators） in administrators extracted from 244 CHCs in 16 districts（7 urban and 9 suburban） of Shanghai at a ratio of 1∶1. And another online survey was carried out using a self-developed questionnaire B（CHC GPs） among 4 047 professional title composition-matched community GPs randomly selected from these 244 CHCs（from each CHC，50% of the GPs were randomly selected according to professional title）. Data obtained from the surveys included perceptions and management of undifferentiated diseases，required help and self-rated management abilities. Urban and rural status was compared. And multivariate Logistic regression analysis was used to identify the factors associated with GPs' management abilities of undifferentiated diseases. Results The response rates of the two surveys were 100.00%（244/244） and 96.98%（3 925/4 047），respectively. The proportions of GPs surveyed working in urban and suburban areas were 32.71%（1 284/3 925） and 67.29%（2 641/3 925），respectively. The percentages of specialists and assistant GPs in suburban CHCs were higher than those in urban CHCs. The percentages of ophthalmologists and ENT doctors in urban CHCs were higher than those of suburban CHCs. The percentages of requiring trainings for undifferentiated diseases，first management procedure of undifferentiated diseases，and requiring to be informed of designed referral rate in urban CHCs were higher than those of suburban CHCs. GPs in suburban CHCs showed higher rate of consulting less than 50 outpatients daily compared with those in urban CHCs. There were significant differences in daily outpatients volume，ability to deal with undifferentiated disease and refferal rate to higher level hospitals between GPs in urban and suburban. The factors affecting GPs' ability for managing undifferentiated diseases included title，working years，daily outpatient workload，procedure for first management of undifferentiated diseases，and rate of transferring patients with undifferentiated diseases，which were also associated with significant differences in the ability of managing the undifferentiated diseases between GPs in urban and suburban CHCs（P<0.05）. Conclusion In Shanghai，the management of undifferentiated diseases by CHCs is relatively poor，which is more obvious in suburban areas. Community GPs have relatively insufficient perceptions of undifferentiated diseases，as well as insufficient ability for managing these diseases. Relatively speaking，compared with those working in urban CHCs，GPs in suburban CHCs have higher rates of owning less professional qualifications and less sufficient practice，requiring the training of standardized procedure for managing these diseases，and transferring undifferentiated disease patients to higher level hospitals. In view of this，relevant guidelines should be improved，and first management procedure development as well as trainings and clinical management of undifferentiated diseases should be strengthened.
Reference | Related Articles | Metrics
The Perceptions of Grief Counseling in General Practitioners from Wuhan and Countermeasures
GAO Xudong，WANG Zhenkun，KONG Chan，WANG Simei
Chinese General Practice 2021, 24 (7): 829-833. DOI: 10.12114/j.issn.1007-9572.2020.00.534
Abstract
Background Although the concept of grief counseling has been introduced into China in recent years，it has developed slowly in China. Many general practitioners（GPs） have not received relevant training and do not know how to comfort the bereaved scientifically. Therefore，the purpose of this study was to analyze GPs' perceptions of grief counseling，and find out the deficiency of grief counseling in community. Objective To investigate the perceptions of grief counseling of GPs in Wuhan，to provide a reference for improving community health services. Methods From October to December 2019，a total of 263 GPs from 23 community health centers，Wuhan，were sampled by convenience sampling and investigated using a questionnaire consisting of demographic information，skills and attitudes of grief counseling scales. Multiple linear stepwise regression was used to analyze the influencing factors of skills and attitudes of grief counseling. Results Altogether，241 GPs（91.6%） who returned responsive questionnaires were included for final analysis. The average score of grief counseling skills was（19.05±4.76），with a scoring rate of 59.5%. Multiple linear stepwise regression analysis showed that influencing factors of grief counseling skills included roles and responsibilities，training，and frequency of contact with the bereaved family member（P<0.05）. The average score of grief counseling attitudes was（32.70±9.36），with a scoring rate of 65.4%. The influencing factors of grief counseling attitudes included other skills of grief counseling，education level，communication ability，and working experience seniority（P<0.05）. Conclusion The skills and attitudes of grief counseling of GPs should be improved. The community should set up a group of grief counseling and build a related long-term and comprehensive training system.
Changes in Policies for General Practitioners in Sichuan Province：a Policy Instrument-based Analysis
LIU Lidi，LIAO Xiaoyang，DU Peng，ZHANG Peng，WANG Lei，YANG Ziyu，CHEN Bowang，CHEN Lu，LIU Changming，ZHANG Yalin，ZOU Chuan
Chinese General Practice 2021, 24 (4): 407-413. DOI: 10.12114/j.issn.1007-9572.2020.00.414
Abstract
Background Currently，the ratio of general practitioners（GPs） to 10 000 residents fails to reach the 2020 target set in China's 13th Five-year Plan（2016—2020）. Moreover，the rate of registered GPs is low，especially in western China. Policy instruments are a general term for the means adopted by the government to achieve policy objectives. Only when policy instruments are appropriate，can policy implementation results be consistent with the policy objectives. Objective To analyze the highlights and weaknesses as well as changes of the policies for GPs issued by the People's Government of Sichuan Province from 2009〔the year in which deepening the reform of the pharmaceutical and healthcare system（the new round of medical reform） was initiated〕 to 2019. Methods From December 2019 to January 2020，using "general practitioners" in Chinese as key words，we searched the official websites of the People's Government of Sichuan Province and Health Commission of Sichuan Province for policy documents for GPs issued from January 1，2009 to December 31，2019，and performed content analysis and quantitative analysis of the texts of the policy documents in terms of types and development changes of policy instruments. Results A total of 48 policy documents were included，involving 268 coded policy instruments，consisting of normative，incentive，capacity-developing，authoritative，systematic reform，symbolic and hortatory instruments，accounting for 4.9%（13/268），8.6%（23/268），22.4%（60/268），54.5%（146/268），7.8%（21/268） and 1.9%（5/268），respectively. The number of policy instruments had a first peak in 2012，with authoritative instruments as the major type. Then authoritative instruments decreased significantly and incentive instruments increased significantly. And the instruments had a second peak in 2018，with capacity-developing instruments as the major type. Goals and planning were used the most〔32.1%（86/268）〕，while consensus propaganda was least frequently used〔0.4%（1/268）〕. Policy planning，policy implementation，policy supervision and policy evaluation accounted for 51.1%（137/268），44.4%（119/268），3.4%（9/268）and 1.1%（3/268），respectively. Conclusion The results of the policy instruments for GPs implemented since 2009 in Sichuan Province show that the instruments could meet GPs' actual needs and benefit their development. Future policy optimization should focus on the use of symbolic and hortatory and incentive instruments，with consideration of comprehensive associations between different types of instruments，and appropriately balanced use of them. Moreover，supervision and evaluation during policy implementation should be strengthened.
Ways of Implementing Continuing Medical Education for General Practitioners
JI Yan，YAN Chunze，SUN Yange，DING Jing
Chinese General Practice 2021, 24 (1): 88-91. DOI: 10.12114/j.issn.1007-9572.2019.00.715
Abstract
Continuing medical education（CME） is an important way for general practitioners（GPs） to update medical knowledge，improve job competency and teaching capabilities. Studies show that during the implementation of CMEs，there are some problems，such as insufficient organizational forms，simple implementation ways and GPs' low satisfaction. Moreover，the ideal ways for carrying out the CME remain controversial. Although the implementation ways for the CME are various，to increase GPs' satisfaction with it，the implementation ways still need to be enriched continually，and should be adequately selected to apply. We reviewed the implementation status and several common implementation ways of CMEs for GPs，aiming to provide a reference for the selection of appropriate implementation ways for CMEs.
Community General Practitioners' Perception of Community-based Cardiac Rehabilitation for Stable Coronary Artery Disease：a Survey in Beijing's Xicheng District
DONG Yuming，YANG Ling，DONG Jianqin，DU Xueping
Chinese General Practice 2021, 24 (34): 4356-4363. DOI: 10.12114/j.issn.1007-9572.2021.00.309
Abstract
Background The number of patients with coronary heart disease（CHD）is increasing year by year in China. As an important means of prevention and treatment，cardiac rehabilitation can improve the quality of life，reduce the readmission rate and mortality of CHD patients. However，community-based cardiac rehabilitation is less developed at present，and CHD patients have gained less merits from sleeping guidance，psychological counseling and cardiac risk assessment in exercise. Objective To explore community general practitioners'（GPs'）perception of community-based cardiac rehabilitation for stable coronary artery disease（SCAD）providing a scientific basis for the development of community-based cardiac rehabilitation. Methods By use of cluster sampling，we selected frontline general practitioners（GPs）（n=212）from 5 community health centers（Yuetan，Guangwai，Zhanzhan Road，Taoranting，Desheng）in November 2020. Then we conducted a survey on wjx.cn（an online questionnaire survey platform）using a self-administered questionnaire（consisting of basic demographics，attitudes and perceptions regarding community-based cardiac rehabilitation for SCAD，essential knowledge and practice of cardiac rehabilitation）developed by us，and invited the GPs to anonymously complete the survey via scanning the WeChat QR code or printed QR code using a mobile phone or computer between November 26 and December 31，2020. The survey data were collected to input into a database，and analyzed for understanding GPs' perceptions of community-based cardiac rehabilitation for SCAD. Willingness of community GPs' to provide community-based cardiac rehabilitation services for patient swith SCAD and scores of GPs obtained by answering the questions about community-based cardiac rehabilitation for SCAD by demographic factors were compared. Binary Logistic regression was used to identify potential factors associated with community GPs' willingness to provide community-based cardiac rehabilitation services for SCAD patients. Results A survey response rate of 98.1%（208/212）was obtained. In accordance with the analysis，of the respondents，91.3%（190/208）thought that SCAD patients need community-based cardiac rehabilitation，90.4%（188/208）thought that community-based cardiac rehabilitation could be safely implemented without monitoring，74.0%（154/208）were willing to provide the services. Binary Logistic regression analysis showed that participating in cardiac rehabilitation training for CHD patients 〔OR（95%CI）=6.042（1.935，18.867），P<0.05〕，and perceptions of SCAD patients needing community-based cardiac rehabilitation〔OR（95%CI）=10.792（2.361，49.336），P<0.05〕 were associated with community GPs' willingness to provide community-based cardiac rehabilitation services for SCAD patients. The respondents obtained an average SCAD cardiac rehabilitation knowledge test score of（70.12±9.54），with a pass rate of 86.5%（180/208）. There is a statistically significant difference in SCAD cardiac rehabilitation knowledge test score among professional title groups（P<0.001）. The correct rates of the respondents answering "basic concept of cardiac rehabilitation" "selection of target population for intervening" "health education" "follow-up" and "psychological and sleep management" were 94.2%（196/208），90.4%（188/208），98.6%（205/208），92.8%（193/208），and 98.1%（204/208），respectively. But the correct rates of them answering "comprehensive cardiovascular evaluation" "cardiovascular risk control" "risk stratification of coronary heart disease" and "formulation of exercise prescription" were 1.9%（4/208），1.9%（4/208），3.4%（7/208），and 1.4%（3/208），respectively. Only 10.1%（21/208）of the respondents knew the 6-min walk test and often used it. Conclusion The GPs generally thought that community-based cardiac rehabilitation services for SCAD patients is necessary and feasible，and they were willing to provide such services with high enthusiasm，but their awareness rate of key contents of SCAD cardiac rehabilitation was low. To ensure the successful implementation of community-based cardiac rehabilitation，multi-party collaboration should be strengthened to improve GPs' community cardiac rehabilitation skills.
Development of a System for Identifying Community-dwelling Outpatients with Mental Disorders Needing Emergency Management Amid a Public Health Emergency by General Practitioners
ZHANG Hanzhi，JIN Hua，LIU Huailei，PENG Yangyang，GUO Aizhen，YU Dehua
Chinese General Practice 2021, 24 (34): 4349-4355. DOI: 10.12114/j.issn.1007-9572.2021.00.314
Abstract
Background In the context of public health emergencies，for example，the COVID-19 pandemic，community hospitals may face challenges to provide diagnosis and treatment services and to reduce the disease burden for patients with mental problems. However，general practitioners（GPs）' capabilities in diagnosing and treating mental disorders are unsatisfactory. Objective To develop a system for identifying community-dwelling outpatients with mental disorders needing emergency management amid a public health emergency by GPs，to promote GPs' capabilities in diagnosing and treating mental disorders，and the health of such patients. Methods From May to June 2020，based on a literature review and an investigation of work requirements for GPs，we formed a framework for identifying community-dwelling outpatients with mental disorders needing emergency management amid a public health emergency by GPs with indicators initially determined. Then we screened and revised the indicators according to the results of a two-round Delphi survey with 15 experts（in the field of general practice or mental health medicine），and finally determined the indicators（with a mean value of weighted importance>3.5，coefficient of variation <25%，and rate of getting full marks >20%） for the formal system identifying community-dwelling outpatients with mental disorders needing emergency management amid a public health emergency by GPs. Results Information of the experts surveyed：13 of them had a graduate degree，and 10 had a senior professional title. Positive coefficients of the experts：All the experts（100%） actively responded to the two rounds of survey. Authority coefficients of the experts：the authority coefficient of the six domains were >0.70. The degree of agreement between the experts：the Kendall's W in the second round of survey was 0.278（χ2=100.197，P<0.001），which was higher than 0.245（χ2=73.597，P<0.001）in the first round of survey. The final indicators：24 indicators in six domains involving mental symptoms，diagnosis of mental illness，severity of mental illness，personality，physical status，family and social background. Conclusion Our system may help GPs to high-efficiently identify community-dwelling outpatients with severe mental disorders needing emergency treatment or referrals. However，the accuracy of the system needs to be verified further.
General Practitioners' Participation in Home-based Hospice Care in Foreign Countries：Practice Experience and Enlightenment
LI Wenxia，MA Jun，DU Xue
Chinese General Practice 2021, 24 (34): 4330-4335. DOI: 10.12114/j.issn.1007-9572.2021.00.223
Abstract
Hospice care improves a patient's quality of life at the end of life via reducing his physical and mental sufferings，and also relieves the physical and mental burden endured by his family members. In recent years，rich experience in developing hospice care has been accumulated in other countries，with a prominent feature of GPs being primary providers of home-based hospice care. However，given that the development of hospice care in China started late，the development of relevant essential projects is weak，and the research on GPs involvement in hospice care is still in its initial stage，it is necessary for China to accelerate the construction of a hospice care system to meet the increasing demand for hospice care. In view of this，we analyzed and summarized the useful experience of GPs participating in hospice care in the US，the UK，Australia and other countries，then put forward insightful suggestions in accordance with current status and characteristics of China's hospice care system：establishing a multi-level hospice care system，supplemented by activity-based payment and health insurance coverage；formulating guidelines for home-based hospice care services with the clarified scope of practice and responsibilities of GPs；strengthening hospice care education and training for GPs and nurses to improve their competencies；raising the awareness of advance care planning among doctors and patients with effective publicity tools to promote the long-term development of hospice care in China.
Prevalence and Associated Factors of Rational Use of Lipid-regulating Agents in Urban General Practitioners in Beijing
YU Xiaoyi，WU Hao，ZHAO Yali，GAO Wenjuan，WEI Xuejuan，GE Caiying
Chinese General Practice 2021, 24 (31): 3986-3989. DOI: 10.12114/j.issn.1007-9572.2021.00.267
Abstract
Background As China vigorously facilitates the implementation of tiered diagnosis and treatment system，there is an increasing number of residents who tend to make first visit with the community physician，which requires a relatively high diagnostic ability for general practitioners（GPs）. And also，the management of dyslipidemia in Chinese residents could be heavily affected by GP's cognition and treatment strategies for dyslipidemia. Objective To examine the prevalence and associated factors of rational use of lipid-regulating agents in urban GPs in Beijing. Methods From March to May 2019，440 GPs were selected from community health centers in six urban districts of Beijing by stratified cluster random sampling for a face-to-face survey using a questionnaire developed by our research team involving demographics and rational use of lipid-regulating agents（assessed by a 9-item 7-point Likert scale）. Results The survey obtained a response rate of 98.0%（431/440）. The mean score for the 9 items about rational use of lipid-regulating agents scored by the respondents was（4.32±1.39）. The score of the respondents regarding rational use of lipid-regulating agents differed significantly by sex，major of the highest education，number of receiving the training of dyslipidemia management，average number of daily visits，and the proportion of dyslipidemia cases encountered（P<0.05）. Multiple linear regression analysis indicated that sex，number of receiving the training of dyslipidemia management，and proportion of dyslipidemia cases encountered were associated with rational use of lipid-regulating agents（P<0.05）. Conclusion Overall，the urban GPs of Beijing obtained relatively low score of rational use of lipid-regulating agents. So it is suggested to strengthen the training of dyslipidemia management for these GPs to improve their level of rational use of lipid-regulating agents to better manage dyslipidemia patients.
Self-rated Capability of Identifying，Diagnosing and Treating Medically Unexplained Physical Symptoms in Shanghai General Practitioners in Community Health Centers
ZHOU Yingda，ZHUO Shuxiong，JIN Hua，YU Dehua
Chinese General Practice 2021, 24 (31): 3979-3985. DOI: 10.12114/j.issn.1007-9572.2021.00.304
Abstract
Background Increasing attentions have been given to medically unexplained physical symptoms（MUPS） with the deepening of primary healthcare reform，and the capability of primary care in managing MUPS is considered as equal to managing chronic diseases. However，there are few investigative or evaluative studies on the diagnosis and treatment of MUPS by general practitioners（GPs） in China. Objective To investigate the self-rated capability of identifying，diagnosing and treating MUPS of Shanghai GPs in primary care，and to attempt to explore the potential associated factors，providing a reference for raising GPs' capability of diagnosing and treating MUPS commonly encountered in the community. Methods This study was carried out from June 2019 to June 2020. By use of stratified random sampling，320 GPs from 32 community health centers in Shanghai's urban and suburban areas were selected（10 were extracted from each community health center）. A 5-point Likert Scale Questionnaire developed by our research group was used in a survey to collect these GPs self-rated capability of identifying，diagnosing and treating MUPS. Stepwise linear regression was used to explore the factors potentially associated with GPs' capability of diagnosing and treating MUPS. Results A total of 283 cases（88.4%） who completed the survey were included for final analysis. One hundred and fifty-eight（55.8%） GPs knew nothing about the definition and concept of MUPS or knew of MUPS without good understanding of MUPS. GPs who had standardized residency training program had a better understanding of the definition and concept，research status，books for continuing education，and guidelines regarding MUPS（P<0.05）. The average scores of self-rated capability of routinely diagnosing and treating MUPS，self-rated capability of emergently treating acute and severe MUPS，and self-rated capability of transferring MUPS patients by GPs，were （3.32±0.567），（3.42±0.677），
（3.38±0.654），respectively. Stepwise linear regression revealed that whether completing the standardized residency training program，education level，professional title，and the region of work were associated with GPs' self-rated capability of routinely diagnosing and treating MUPS（P<0.05）. The completion of the standardized residency training program was associated with GPs' self-rated capability of emergently treating acute and severe MUPS（P<0.05）. The completion of the standardized residency training program and region of work were associated with GPs' self-rated capability of transferring MUPS patients（P<0.05）. Conclusion It is necessary to further improve Shanghai GPs' capability in the identification，diagnosis and treatment of MUPS. The standardized residency training may significantly improve GPs' capability in MUPS diagnosis and treatment. To improve the favorable influence of general practice in the diagnosis and treatment of MUPS，it is suggested to give more attention to MUPS，make more efforts to further improve the implementation of the standardized residency training for GPs，and provide effective evidence-based and adjuvant supports for diagnosing and treating MUPS.
Interpretation of Guideline for the Diagnosis and Treatment of COPD（2021 revision） for General Practitioners
WANG Fengyan，ZHANG Dongying，LIANG Zhenyu，SU Guansheng，ZHENG Jinping，CHEN Rongchang
Chinese General Practice 2021, 24 (29): 3660-3663. DOI: 10.12114/j.issn.1007-9572.2021.01.304
Abstract
According to the Guideline for the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease （2021 revision），different levels of medical institutions undertake different tasks in the stratified diagnosis and treatment of chronic obstructive pulmonary disease （hereinafter referred to as COPD）. General practitioners are main force responsible for prevention of COPD. General practitioners use questionnaire surveys and popularize the application of simple lung function to implement early screening of COPD；implement drug treatment for stable maintenance treatment through patient education，supervision and regular follow-up；participate in the overall management of COPD by guiding and verifying the correct use of inhaled drugs，improving compliance，implementing respiratory rehabilitation treatment，etc. With reference to the revised guideline，general practitioners are expectedto participate in the overall management of COPD to improve the medical level of COPD in primary care institutions.
Community General Practitioner's Strategies for Managing Illness Anxiety Disorder
YU Yushan，XU Zhijie
Chinese General Practice 2021, 24 (28): 3648-3652. DOI: 10.12114/j.issn.1007-9572.2021.00.273
Abstract
Illness anxiety disorder（IAD）is a common mental disease encountered by community general practitioners （GPs），which often requires long-term treatment and follow-up. Although community health services are good applicable for treating IAD owing to its continuity and comprehensiveness，community-based management strategies for IAD are very limited，and the research on community GPs' perspectives regarding coping strategies for IAD is very rare. Based on a literature view of IAD，we performed an in-depth analysis of three essentials that community GPs should master for managing IAD：differentiating IAD from other illnesses，exploring potential factors associated with symptoms，evaluating available useful medical and information resources. Furthermore，we put forward IAD managing strategies for community GPs in accordance with features and ideas of community health services，including a thorough evaluation of symptoms and psychological states，implementing shared decision-making，and delivering continuous patient health education. Our study will help to enhance community GPs' management level of IAD.
Status and Influencing Factors of Work Stress among Chinese General Practitioners
HE Wu，PING Wenjun，ZHANG Xinyu，WANG Hongwei，BAO Xingshuo，FENG Jing，GAN Yong
Chinese General Practice 2021, 24 (28): 3590-3596. DOI: 10.12114/j.issn.1007-9572.2021.00.238
Abstract
Background Chinese general practitioners（GPs） are facing challenges to improve residents' quality of life via satisfying their healthcare needs rising with the social and economic development，and to learn and use new medical technologies as well as continuously developed highly informationized and intelligent healthcare delivery patterns，and their work stress is ever-increasing. Studying the work stress and its influencing factors among GPs in China could help to identify effective methods to relieve the work stress of GPs，benefiting the stabilization of GPs workforce. Objective To investigate the status，sources and associated factors of work stress in Chinese GPs. Methods The study was carried out between October 2017 and February 2018. By use of multistage stratified random sampling，3 244 GPs were selected from eastern，central and western China to attend a WeChat-based survey using a self-complied questionnaire named Attractiveness of Occupation as a General Practitioner. The chi-square test was used to compare the difference in prevalence and sources of work stress among GPs with different characteristics. Ordinal multinomial Logistic regression analysis was used to explore the major determinants associated with work stress. Results Altogether，99.75% of the GPs（3 236/3 244） who returned responsive questionnaires were finally included. The results showed that 58.56% of the GPs（1 895/3 236） had relatively high work stress. The top three sources of work stress were economic factors（low income or inability to buy an apartment）〔76.17%（2 465/3 236）〕，difficulty in achieving performance goals〔42.37%（1 371/3 236）〕 and lack of professional identity〔41.84%（1 354/3 236）〕. Logistic regression analysis indicated that male，working in eastern China，aged between 30-50 years old，longer average daily working hours and high frequency of working overtime were main factors associated with work stress among GPs（P<0.05）. Conclusion In general，the prevalence of work stress among Chinese GPs is high，which is associated with multiple factors，and the most important are economic factors（low income or inability to buy an apartment） . To reduce GPs' work stress，it is suggested to improve the salary and reduce the workload of GPs appropriately，modify the workload allocation and welfare benefits system for GPs，and pay more attention to improve the mental health of GPs.
Interpretation of 2020 American College of Rheumatology Guideline for the Management of Gout from the Perspective of General Practitioners
LIU Min，MENG Juan
Chinese General Practice 2021, 24 (25): 3148-3153. DOI: 10.12114/j.issn.1007-9572.2021.00.133
Abstract
The recent updates of guidelines for the management of gout have gradually promoted the standardization of gout diagnosis and treatment. What's more，the newly released 2020 American College of Rheumatology Guideline for the Management of Gout has made some vague concepts to be clear. As general practitioners play a vital role in the management of gout，a common and frequently-occurring disease，we interpreted the 2020 American College of Rheumatology Guideline for the Management of Gout from their perspective，and compared it to the latest Chinese guideline for the management of gout，offering proposal ideas to help general practitioners with the diagnosis and treatment of gout.
Research on the Mode of "College-Hospital-Community Linkage" Assistant General Practitioner Training
JIANG Lihua，WU Jianping，ZHANG Li，YE Jianli，QIU Mochang
Chinese General Practice 2021, 24 (22): 2870-2873. DOI: 10.12114/j.issn.1007-9572.2021.00.232
Abstract
To improve the quality of talent cultivation by strengthening the linkage between in-school phase and hospital-based phase for the "3+2" training program with assistant general practitioners（3-year education on clinical medicine+2-year training as an assistant general practitioner），Jiangxi Medical College，basing itself on the features of talent cultivation in these two phases，consolidates the hospital-college integration，and explores the reform in the "college-hospital-community linkage" training mode for assistant general practitioners. On account of this，the integration of college，the affiliated hospital and community hospital is fully conducive to the hospital affiliation to the medical college and their close cooperation in teaching. The two phases of "3+2" training mode，administered by the college as a whole，alternate theoretical teaching，practical training and professional spirit training，which promotes boosting the talent cultivation quality and provides an approach to optimizing medical talent cultivation system.
Specifications for Community General Practitioners to Screen for Thyroid and Carotid Diseases Using the Portable Ultrasound Device：Quality Evaluation Using AGREEⅡ and Recommendations
SONG Ye，ZHAO Feng，CHEN Ming，ZHANG Tao4
Chinese General Practice 2021, 24 (22): 2843-2849. DOI: 10.12114/j.issn.1007-9572.2021.00.150
Abstract
Background To enable community general practitioners（GPs） to screen for thyroid and carotid diseases using the portable ultrasound device high efficiently and effectively at the community level，we developed the Specifications for Community General Practitioners to Screen for Thyroid and Carotid Diseases Using the Portable Ultrasound Device（hereinafter referred to as the Specifications）. Objective To evaluate the quality of the Specifications using AGREEⅡ precisely，comprehensively and structurally by experts，to make further improvement. Methods In December 2019，for further improving the specifications via situation adaptation，we invited five experts from community and general hospitals to evaluate the specifications using the modified AGREEⅡ. Results On the whole，the items of the Specifications were rated high，each was rated higher than four out of seven points，with an average score of higher than five. Compared to the part of thyroid screening，the part of carotid screening was rated lower. And one expert abstained from the assessment for the part of carotid screening. Conclusion Overall，the experts rated the Specifications high，but specifically，they recommended the use of the part of thyroid screening owing to higher quality，but did not recommend the use of part of carotid screening presently due to lower quality and feasibility. Our study indicates that the AGREEⅡis suitable to be used to evaluate practice guidelines. In terms of evaluating the specific contents of such guidelines to improve the quality，we suggest to use the validity theory to perform a thorough item-by-item expert evaluation.
Development of the Specifications for Community General Practitioners to Screen for Thyroid and Carotid Diseases Using the Portable Ultrasound Device
ZHAO Feng，JIA Zhenxi，CHEN Yue，ZHANG Tao
Chinese General Practice 2021, 24 (22): 2838-2843. DOI: 10.12114/j.issn.1007-9572.2021.00.151
Abstract
Background Community general practitioners（GPs） with interests in learning ultrasound techniques need a tool with applicability in settings and academic disciplines to help them learn the techniques quickly，effectively，and efficiently. Objective To develop a set of simple guide specifications applicable for community GPs to screen for diseases of two external organs of human body（thyroid and carotid） using the portable ultrasound device in a standardized way. Methods We conducted this study in October 2019. By using in-depth，semi-structured interviews，we formulated the framework of specifications for community GPs to screen for thyroid and carotid diseases using the portable ultrasound device，and used it to develop the draft of the specifications by use of literature review，then revised it according to the review of GPs participating in the development，and revised it again according to the results of expert consultation to produce the final version. Results Two set of specifications were developed，one for thyroid screening，and the other for carotid screening. The community GPs were anxious about the data collection and assessment required by the specifications. The community sonographers believed that they could perform practices well according to the specifications，but they thought that whether it is a paid service or not would directly affect GPs' enthusiasm in the delivery and long-term delivery of such services. Conclusion The feedbacks for the development indicated that the first revised version of the specifications met the goals of development，and the final version is applicable. In the opinion of community GPs and sonographers involved in the development，the technical difficulty in delivery such services and performance measurement are closely associated with the application of the specifications. In addition，time consuming and missed diagnosis in the delivery are also issues to be considered. In short，to help GPs develop their interests in learning ultrasound techniques，one key is to select suitable body parts to be screened by GPs with settings，time consuming，technical difficulty，and risk in the implementation taken into account，and there is also a need to consider performance subsidy and ways for integrating the implementation of these services with the family doctor system.
General Practitioners' Learning Ultrasound Techniques and Future Applicability of Portable Ultrasound Device in Primary Care：Perspectives from General Practitioners and Sonographers
FU Xiaohong，JIA Zhenxi，ZHAO Feng，HUANG Guoqian，ZHANG Tao
Chinese General Practice 2021, 24 (22): 2832-2837. DOI: 10.12114/j.issn.1007-9572.2021.00.149
Abstract
Background Both ultrasound imaging and general medicine are developing rapidly. But it is still unknown that whether the advancement and popularization of portable ultrasound imaging can be used by general practitioners（GPs） to promote the development of general medicine，and what innovative ideas and methods can be used to accelerate the popularization of ultrasound imaging in primary care and to train ultrasound professionals with humanistic care，early disease screening，high service accessibility，and medical insurance expense control in primary care under consideration. Objective To explore the perspectives of multiple healthcare providers（community GPs，community sonographers，and general hospital sonographers） on GPs' learning ultrasound techniques and applying portable ultrasound devices，and their suggestions on the implementation goals and specific operation requirements. Methods The study was implemented from October to December 2019. In-person interviews using a semi-structured format were conducted with GPs and sonographers from Pudong New Area Jinyang Community Health Center，a community hospital that has trained the most GPs in China so far in terms of ultrasound learning and practice（two authors' current affiliation） for investigating their attitude and willingness regarding learning ultrasound techniques and delivering ultrasound services，and their opinions on the required ultrasound knowledge and level of actual performance. And two rounds of consultation using the Delphi technique were carried out with 17 sonographers with an experience of working at least 10 years in the general hospital for investigating their opinions on the specific requirements for community GPs to perform the ultrasound examination，such as collecting，storing and transmitting ultrasound imaging data，and making an ultrasound-based diagnosis. Results Altogether，six community GPs and three community sonographers attended the interviews. The results showed that community GPs had interests in learning ultrasound techniques，and expressed their concerns about the post-learning application. Community sonographers believed that trained GPs would be capable of performing ultrasound examinations，and they could begin from performing simple scanning of external organs，such as thyroid and carotid. The positive and authoritative coefficients of senior sonographers for the two rounds of consultation were all 100.0%，and greater than 0.7，respectively. The consultation results indicated that eligible community GPs for collecting data of ultrasound examinations should have: a bachelor degree or above，major in clinical medicine，at least three years' clinical practice，GP certification，ultrasound technician certification，and at least two times of attending continuing ultrasound education per year. The required levels of knowledge and skills for GPs to store and transmit ultrasound imaging data，and make an ultrasound-based diagnosis were almost the same for sonographers，including common instrument adjustment，postural guidance，operation techniques，plane choice，probe placement，knowledge of data should be recorded，stored and reported，and knowledge of common requirements for diagnostic classification. Conclusion Community GPs showed interests in learning ultrasound techniques for increasing their competencies，and they could try to begin from performing scanning of thyroid and carotid. The operational procedures and actual settings appropriate for GPs to perform ultrasound examinations should be determined. The use of portable ultrasound device may be a key to benefiting the ultrasound performance of GPs，which can be used to scan thyroid，carotid and other organs with a clear shape and simple structure，and to screen for chronic diseases as a chronic disease management program vigorously promoted in the community.
Application of the Chinese Version of the General Practitioner Assessment of Cognition in Screening for Mild Cognitive Impairment in Older Physical Examinees in Primary Care
LIU Yalin，LU Yuan，XU Shengming，YU Dehua，XUE Yaya，ZHOU Lulu
Chinese General Practice 2021, 24 (22): 2819-2825. DOI: 10.12114/j.issn.1007-9572.2021.00.228
Abstract
Background There are no effective treatments for dementia，a disease with a heavy burden，which is becoming increasingly prevalent among the rapidly growing aging population. As a pre-stage of dementia，mild cognitive impairment（MCI）has attracted wide attention，but the screening for it using scales has not been popularized due to various scale limitations. So it is very important to find a simple tool suitable for screening for MCI in primary care. Objective To explore the value of the Chinese version of the General Practitioner Assessment of Cognition（GPCOG-C） in screening for MCI in primary care. Methods By use of simple random sampling and systematic sampling，860 cases were selected from 4 962 physical examinees（≥ 60 years old）in Shanghai to attend a questionnaire survey conducted from May to July 2020 by unified trained college student volunteers using a demographic questionnaire developed by our research group，four MCI assessment scales〔Montreal Cognitive Assessment Basic（MoCA-B），Activities of Daily Living（ADL） Scale，Dementia Rating Scale（CDR）and GPCOG-C〕. MCI was diagnosed using the criteria proposed by Petersen et al. Participants with MCI were matched 1:1 to those with normal cognitive function randomly in terms of age，sex，and years of education using SPSS software to run a comparative analysis. ROC curve of the GPCOG-C in screening for MCI was plotted to examine its cut-off threshold，sensitivity，specificity，positive and negative predictive values. Spearman's rank correlation analysis was used to measure the reliability of the GPCOG-C. The internal consistency of the scale was measured by Cronbach's α. Results Altogether，812 cases completed the survey，and 192 of them（24.27%） were assessed to have MCI. 187 MCI cases（MCI group） and 187 matched cases of normal cognitive function（control group）were finally included. Compared with the criteria for MCI defined by Petersen et al，the gold standard，the GPCOG-C was found by ROC analysis to have a maximal Youden index of 0.43. When the cut-off threshold was determined as 12 points，the sensitivity，specificity，positive predictive value and negative predictive value of the GPCOG-C were 70.05%，69.52%，69.68% and 69.89%，respectively. The control group had higher mean scores of MoCA-B and GPCOG（P<0.05）. The mean time used for completing the MOCA-B differed significantly between the groups（P<0.05），but that used for completing the GPCOG-C did not（P>0.05）. MCI group had statistically significantly lower mean scores of time orientation，clock drawing，message，memory（first name，last name，city，road，house number），patient part，informed part and total score（P<0.05）. The inter-item correlation analysis of the GPCOG-C showed that the correlation between clock drawing and memory（last name） was negative and the correlation between clock drawing and informant section was negative. Other items were positively correlated to a certain extent，and the correlation coefficient r ranged 0.021 to 0.836. The Cronbach's α of GPCOG-C was 0.78. The mean time used for completing the MoCA-B was longer than that used for completing the GPCOG-C in all participants（P<0.001）. And the mean total GPCOG-C score was positively correlated with the mean MoCA-B score（rs=0.484，P<0.001）. Conclusion The reliability and validity of the GPCOG-C have proved to be reasonable，suggesting that it may used for the screening for MCI in primary care.
Essential Medicine Prescribing Behaviors of Urban General Practitioners in Beijing：a Qualitative Study
CHEN Xiaolei，SHAO Shuang，WU Ying，XU Xiaojingyuan，ZHANG Tiancheng，DU Juan
Chinese General Practice 2021, 24 (22): 2814-2818. DOI: 10.12114/j.issn.1007-9572.2021.00.190
Abstract
Background The role of China's national essential medicine system（NEMS） has been highlighted by its implementation effects on easing patient burden of healthcare costs via reducing the increased medical expenses. The General Office of the State Council of the People's Republic of China，clearly stated that the determined functions of essential medicines shall be strengthened，priority shall be given to the use of essential medicines for drug treatment，and the provision of essential medicines for initial treatment in primary care shall be ensured. Objective To investigate essential medicine prescribing behaviors in urban general practitioners（GPs） in Beijing，to provide a reference for the implementation and promotion of the NEMS in primary care. Methods Purposive sampling was used to select 17 GPs from 17 urban community health centers in Beijing from January to March 2020. Individual in-depth interviews were conducted with voice call in WeChat，and each interview was kept under 30 minutes. The interview data were analyzed through content analysis. Results In all，82.3%（14/17） of the GPs said that essential medicines prescriptions accounted for 50%-60% of the total prescriptions written by them. Six themes were identified：GPs had a low level of understanding of the NEMS；The supply of medicines in primary care was not timely；There was a lack of surveillance and follow-up for effectiveness and safety of essential medicines；The available essential medicines could not fully meet the clinical needs in primary care；The health insurance reimbursement for cost of essential medicines was similar to that for the cost of originally developed medicines，negatively affecting the promotion of the use ofessential medicines；Patients showed a low preference for essential medicines. Conclusion In Beijing，the proportion of essential medicine prescriptions written by urban GPs was not high，and the implementation of the NEMS needs to be improved. To further improve essential medicine prescribing behaviors of GPs，it is suggested to modify the policies related to the NEMS，and enhance the awareness levels of GPs and residents.
New Advances in Turnover Intention of General Practitioners at Home and Abroad
SHEN Xin，JIANG Heng，FENG Jing，GAN Yong，LU Zuxun
Chinese General Practice 2021, 24 (22): 2770-2776. DOI: 10.12114/j.issn.1007-9572.2021.00.106
Abstract
Enhancing the Attractiveness of General Practice as a Career：a SWOT Analysis
SHEN Xin，FENG Jing，GAN Yong，LU Zuxun
Chinese General Practice 2021, 24 (22): 2765-2769. DOI: 10.12114/j.issn.1007-9572.2021.00.152
Abstract （0） PDF （1305KB）（180） Save
In China，the shortage of general practitioners（GPs） and difficulties in retaining general practice talents have produced great effects on the development of primary healthcare services，and also brought great challenges to the implementation and promotion of the tiered healthcare system. So it is necessary to formulate policies to maintain and improve the attractiveness of general practice as a career. To this end，we performed a SWOT analysis based on an overview of domestic general practice and general practice workforce，and proposed the following ideas：strengths consist of extensive policy support，continuous development of general practice education and developmental significance similar to a goal of building a healthy China；weaknesses include low social identity for GPs，and lack of efficient manage system for GPs；opportunities cover the reform of the pharmaceutical and healthcare system，construction of the medical consortium，and development of health information technologies；threats contain lack of limitations for some medical practice behaviors，training system for GPs and appropriate hardware infrastructure. Then we put forward recommendations as incentive solutions to enhance the attractiveness of general practice as a career and promote the sustainable development of general practice，including increasing the financial support for general practices，strengthening the development of a management system for general practices，broadening the promotion platform for GPs，and optimizing the configuration of the GP team.
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Development of a Tool for Community Health Institutions to Rapidly Evaluate the Feasibility of New Services
LI Liqiu，XU Chengyan，ZHAO Liang，CHEN Guorong，CHEN Junxiang
Chinese General Practice 2021, 24 (19): 2489-2493. DOI: 10.12114/j.issn.1007-9572.2021.00.173
Abstract
Background As community health，general medicine and family doctor systems become increasingly well known，the upstream and downstream supply chains for community health institutions are seeking more opportunities to cooperate with community hospitals and their general practitioner（GP） teams in an effort to implement large quantities of various types of high-quality projects and to use featured technologies，etc. During the process，GPs are required to know the latest developments in the market. What's more，they should know how to evaluate and choose an appropriate project or technology that is worth investing time to negotiate to reduce the possibilities of making errors in attempts and misjudging market opportunities. Objective To develop an auxiliary tool for evaluating the feasibility of integrating a project，technology or business into family doctor services，to help an independent practice GP team to make decisions rapidly，efficiently and precisely. Methods From August to October 2019，we conducted a brainstorming session on technologies appropriate for community-based implementation and promotion with individuals invited from Shanghai，including 5 GPs as the session leaders with differences in seniority，background，workplace and district，3 senior community health practitioners （1 community health counselor，1 community health managers，and 1 manager of a GP team delivering family doctor services） as the session host and organizer，and 1 professional with project management experience and knowledge of community health affairs as the recorder of the session. According to the session，we summarized the necessary and sufficient conditions and evaluation criteria that are used to assess whether a technology，service or project is suitable to be implemented by a community hospital，and estimated their values by testing the ongoing representative projects in 7 sampled community hospitals. Results The finally developed tool contains 7 assessment criteria：（1）The project，service or technology can be implemented by the community hospital；（2）The service can only be accessed in the community hospital （for achieving maximum treatment convenience by using geographical advantage of community hospital）；（3）The project，service or technology can be used to satisfy the needs of patients with an illness of high morbidity and prevalence；（4）The implementation of the project，service or technology can show effectiveness rapidly；（5）The implementation of a project，service or technology is low cost；（6）The project，service or technology is appropriate for GPs or a GP team to implement in working hours and normal healthcare settings；（7）The implementation of the project，service or technology shall be paid service. A project，service or technology meeting all the above criteria was defined as with good feasibility，if not，it could not be implemented hastily. With regard to the ranking of the ongoing projects of the 7 community hospitals in terms of total score assessed by the 7 criteria，the top one scored 5.8 points，and the bottom one scored 2 points；3 scored above 4 points，50% had incomplete data，which were partly consistent with the actual implementation status. Among the criteria，the one of highest difficulty was criterion 7，followed by criteria 5，6，4，and 2，and the one of highest simplicity was criterion 1，followed by criterion 3. And criteria 6 and 7 were the most easily overlooked. Conclusion Our tool with 7 criteria，has proved to be feasible for use with practicability，which may help a GP team to make evidence-based decisions accurately and high-efficiently.