Chinese General Practice

Quality Appraisal and Content Analysis of Clinical Practice Guidelines for Chronic Rhinosinusitis　

CHEN Ji，SUN Yue，GAO Ya，LI Ji，DU Jintao，TIAN Jinhui

2020, 23(13): 1583-1591. DOI: 10.12114/j.issn.1007-9572.2020.00.224

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Background　Chronic rhinosinusitis（CRS） is a high-incidence disease in the ENT Department，which causes severe sufferings and economic burden on patients.However，there are differences in the recommendations of the current clinical practice guidelines（CPGs） for the diagnosis and treatment of CRS at home and abroad.Objective　To assess the quality of CPGs for CRS and analyze the treatment recommendations，in order to provide advice for the development of guidelines and the adoption of recommendations.Methods　Literatures were retrieved in the Chinese and English databases and professional guideline websites in February，2019 and the references were tracked to screen recommendations on the treatment of CRS in adolescents and adults in CPGs.The retrieval time was from the date the database was built to the date when the retrieval started.The methodological quality was appraised by the AGREE II instrument and the reporting quality was evaluated using RIGHT checklist.Then the bubble chart and mind mapping were produced to compare and analyze the treatment recommendations on CRS.Results　Eight CPGs were included.The average total score of AGREE II was 48.76%（30.90%-73.09%），only two guidelines were strongly recommended（score>60%），and the other six were recommended after revision.The overall report rate of right items was 34.29%-65.71%，among which the report rate of review and quality control was 0.The consistent treatment methods recommended by CPGs were corticosteroids，nasal saline irrigation and endoscopic surgery，oral antihistamines for allergy suffers.Optional treatments included bacterial lysate，mucolytic agents，proton pump inhibitors，phytotherapy，capsaicin，leucine antagonists，nasal furosemide，nasal saline irrigation with xylitol，nasal saline irrigation with sodium hypochlorite，and nasal saline irrigation with baby shampoo.While there were some conflicts on the use of antibiotics，decongestants，leukotriene receptor antagonists，anti-IgE and aspirin desensitisation for aspirin exacerbated respiratory disease.Conclusion　There is still room for the formulation of CPGs and the quality of the reporting.It is recommended to adopt patient preference，use unified tools for evidence and recommendations evaluation，and consider the applicability.Recommendations from a more rigorous CPG should be considered primarily in clinical practice，in case of conflicting recommendations.

Analysis and Evaluation of Multiple Drug Use among Elderly Patients with Multiple Chronic Conditions in Community　

LIU Wei，YU Dehua，JIN Hua，TANG Lan

2020, 23(13): 1592-1598. DOI: 10.12114/j.issn.1007-9572.2020.00.026

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Background　Multiple chronic conditions（MCC） refers to patients having two or more chronic diseases with a high incidence among the elderly population clinically and especially the problem of multiple drug use.Multiple drug use has brought about potential irrational drug use，which is a risk factor affecting the prognosis of the disease.The evaluation，management and optimization of multiple drug use are very important parts of the clinical management of MCC.It may be a way to improve the clinical efficacy and reduce medical costs.Objective　To analyze retrospectively the basic situation of multiple drug use in elderly patients with MCC and its influencing factors in the community.Methods　Through the community health management system，the basic data of the elderly patients aged ≥65 years old and signed with the community from June 2016 to June 2018 were obtained.According to the International Classification of Diseases（ICD-10），the data was classified and statistically analyzed.The elderly patients with two or more chronic diseases were defined as patients with MCC.Among them，400 patients were selected according to the random number table and enrolled in the multiple drug use（≥5 kinds of drugs） survey.Using Beers and STOPP/START standards to assess the potentially inappropriate medication（PIM）.Results　The patients with MCC accounted for 81.01%（10 908/13 465） of the total elderly patients over 65 years old.The main combinations of multiple chronic diseases were hypertension + coronary heart disease（22.0%），hypertension + diabetes（15.8%），and coronary heart disease+diabetes（16.2%）.Of the 400 questionnaires distributed，360 were effectively recovered，including 271 patients had multiple medications with the multiple medication rate of 75.3% and an average number of taking 5.7 kinds of drugs，up to 10 kinds.The drugs taken were mainly based on cardiovascular and endocrine therapy.Using STOPP/START standard，80（22.2%） patients were detected with 95 items of PIM，and a total of 21 potential ointments were detected in 18 patients（5.0%），and 57（15.8%）items of PIM were detected by Beers standard.Multivariate Logistic analysis showed that age and the main methods of prescriptions were the influencing factors of PIM（P<0.05）.Conclusion　The prevalence of MCC in the elderly over 65 years old is high.The proportion of multiple drug use in community elderly patients with MCC is high，and there is a problem of irrational drug use.Advanced age，unscheduled drug follow-up and evaluation，and single treatment mode may be the cause of irrational use for multiple drugs.As general practitioners who manage MCC chiefly，it is necessary for them to grasp the principle of assessing irrational drug use and improve the PIM of multiple drug use.

Research Progress on Decisional Balance Tools of Health-related Behaviors　

LIN Beilei，MEI Yongxia，ZHANG Zhenxiang，LIU Lamei，ZHANG Yan，WANG Yongli，WANG Wenna，GUO Yunfei

2020, 23(13): 1599-1605. DOI: 10.12114/j.issn.1007-9572.2020.00.114

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Decision making is a critical process in modifying health-related behaviors and decisional balance acts as an important mediator or decisive variable in the process.Large scales of studies have been conducted relevant to the important value of decisional balance in other countries，while only limited researches have been reported in China.To comprehensively summarize the advantages，disadvantages，applicability and limitations of domestic and foreign decisional balance tools，this paper reviews the origin，composition，development and application status of the corresponding assessment tools for behaviors like smoking，alcohol intaking，exercise，nutrition，cancer screening，prescription drug application，emotion management，cannabis abusing and other chronic disease-related behaviors.This paper may provide evidence and reference for developing decisional balance tools suitable for China's national conditions for healthy people，high-risk groups and even patients with chronic diseases.

Equity of General Practitioner Distribution in China　

QIAO Guanhua，LIAO Peng，JIA Jinzhong，LI Wenzhuo，CHEN Tianzhi，WANG Zhifeng

2020, 23(13): 1606-1610. DOI: 10.12114/j.issn.1007-9572.2020.00.074

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Background　Nowadays，the society is faced with problems such as aging population and high incidence of chronic diseases.The implementation of general practitioner（GP） system is an important way to guarantee and maintain residents' health.A sufficient number of GPs is a necessary condition for residents to obtain the services from GPs.The GP system has made great progress in recent years，but the distribution of GPs is different in areas with different economic development levels.It is an important part of achieving universal health to understand the situation of GPs in areas with different economic development levels and guide the reasonable allocation of GPs in each area.Objective　To analyze the distribution of GPs and its change trends in regions with different economic development levels in China.Methods　Using the data of the National data website of the People's Republic of China from 2013 to 2018，31 provinces（autonomous regions and municipalities） in China were divided into five different economic level groups according to the per capita GDP.Combined with the number of GPs in different regions in China Health and Family Planning Statistical Yearbook 2013—2017 and China Health and Wellbeing Statistical Yearbook 2018，a descriptive analysis was made on the distribution of the GPs in each group.The concentration index was used to analyze the trend of fairness changes，and the overall difference in distribution was configured through the Theil index.Results　From 2012 to 2017，the number of GPs in China increased from 0.109 8 million to 0.252 7 million with an increase of 130.15%.The number of GPs per 10 000 population in the highest economic level group was significantly larger than the other economic level groups，reaching 3.61 per 10 000 population in 2017.During the same period，the GP concentration index declined first and then rose，reaching the lowest level in 2015（0.192 1）.According to the decomposition of Theil index contribution rate，the annual difference rate between different economic level groups contributed more than 70%.Conclusion　The number of GPs in China has increased significantly.The number of GPs and the proportion of GPs registering in general practice as specialty are both relatively great in areas with high economic development level.The distribution fairness of GPs is poor in regions with different economic development levels，and the difference between groups with different economic levels is the main source of the unfair distribution of GPs.

Game Theory on Stakeholders in the Construction of County-level Medical Alliance under the Background of Hierarchical Diagnosis and Treatment System　

HE Guangxiu，TANG Shaoliang

2020, 23(13): 1611-1614. DOI: 10.12114/j.issn.1007-9572.2020.00.085

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The county-level medical alliance has received increasing attention from the government departments in recent years.However，due to the inadequate supervision system，the low enthusiasm of participants，and the unreasonable interest distribution mechanism，the implementation process of the medical alliance has been hindered.It is of great significance to analyze the stakeholders and their conflicts of interest to further promote the construction of county-level medical alliance.Using the theory of stakeholders and game theory，this research constructed two models of central government-local government model and local government-county-level medical institutions-patients model to study the relationship between the central government and local government，and game relationship between local government，county-level medical institutions and patients.It was found that the central government's supervision and management of local government，the costs paid by local government and county-level medical institutions，the rewards and penalties for county-level medical institutions，and the costs paid by patients and the benefits they received would affect the construction of county-level medical alliance.Therefore，government departments should improve the evaluation and incentive mechanism and act as the leader in coordinating the interests of all parties.The propaganda of the medical alliance policy should be strengthened to make relevant groups take the initiative to become participants.The county-level medical institutions should help each other and jointly improve patient satisfaction with medical treatment.

The Utilization of Inpatient Health Services and Influencing Factors of Hospitalization Costs of Urban Stroke Patients in China　

YANG Yong，LI Shuo，WANG Xi，GUO Yiwei，MA Yong，SHI Xuefeng

2020, 23(13): 1615-1620. DOI: 10.12114/j.issn.1007-9572.2020.00.091

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Background　As the second most common cause of death in the world，stroke has brought both great economic burden and family burden to patients.Meanwhile，the utilization of health services will affect patients' medical expenses.However，there are few studies on the utilization of inpatient health services for urban stroke patients in China.Objective　To investigate the utilization of health services among urban stroke inpatients in China and explore the influencing factors of hospitalization costs，in order to provide theoretical support and evidence for reducing the economic burden of diseases，strengthening the economic protection of patients and controlling the excessive growth ofmedical expenses.Methods　We extracted 56 485 cases of ischemic stroke inpatients from "National Basic Medical Insurance and Health Service Utilization Survey Database"（data from 2010 to 2015） by the method of mechanical samplingin October 2018.Inpatients' basic information and their utilization of health service（frequency of hospitalizations，length of stay，and costs of hospitalization） were collected.Univariate analysis was used to comparethe differences in the utilization of inpatienthealth services.Meanwhile，multiple linear regression was adopted to analyze the influencing factors of hospitalization costs.Results　The average annual number of hospitalizations of urban stroke patients in China was 1（0），and the average length of stay was 11.0（6.0） days，and the average hospitalization cost was 6 070.06（8 289.87）yuan.There were differences in the average annual number of hospitalizations，the average length of stay，and the average hospitalization cost among stroke inpatients with different genders，age，insurance types，stroke types，hospital levels，regions，and city levels（P<0.05）.Multiple linear regression analysis showed that genders，age，insurance types，stroke types，hospital levels，regions，city levels，and average length of stay were the influencing factors for the hospitalization cost.Among them，the hospitalization cost of male patients was 1.8% higher than that of female patients；the cost of hospitalization increased by 0.07% for every 1-year-old；the hospitalization cost of stroke inpatients covered by the urban employees' basic medical insurance（UEBMI） was 20.1% higher than those covered by the urban residents' basic medical insurance（URBMI）；the hospitalization cost of patients with cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries（I63.2） and cerebral infarction due to thrombosis of cerebral arteries（I63.3） was 40.8% and 38.8% higher than those of patients with cerebral infarction（I63）；the hospitalization cost of patients who visited secondary as well as tertiary hospitals was 72.1% and 121.1%，respectively，higher than those of patients who visited primary hospitals；and the hospitalization cost of patients in eastern region was 23.5% and 34.0% higher than those of patients in central and western regions，respectively（P<0.05）.The frequency of hospitalizations also was the influencing factor for the hospitalization cost，the cost of hospitalization increased by 57.7% for each additional hospitalization（P<0.05）.Conclusion　There are differences in the utilization of health services for stroke inpatientswith different characteristics，and the hospitalization cost is related to multiple factors.It is essential to take measures such as improving medical technology，shortening the length of stay and strengthening the health educationfor patients to control the hospitalization cost and reduce the economic burden of stroke inpatients.

The Evaluation of Community Health Services for Patients with Multimorbidity in a Community of Shenzhen Based on Contracted Family Doctor Services　

YANG Zhipeng，ZHANG Shengchao，ZHANG Jiayun，HUANG Zhijie，ZHONG Yongyi，ZHANG Man，WANG Haoxiang，WANG Jiaji

2020, 23(13): 1621-1626. DOI: 10.12114/j.issn.1007-9572.2020.00.222

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Background　Community health service centers with contracted family doctor services as the main body are the main battlefields for the prevention and treatment of multimorbidity.High-quality primary health care services are an essential guarantee for better health outcomes.However，there are few literatures on the evaluation of community health services for patients with multimorbidity.Objective　To investigate the evaluation of community health services for patients with multimorbidity in a community of Shenzhen and its influencing factors.Methods　Patients with multimorbidity were selected by simple random sampling for a baseline investigation in June of 2017.The follow-up survey was conducted at the six and twelve months under the background of contracted family doctor services.The Primary Care Assessment Tool（PCAT） was used to evaluate community health services and the results were analyzed by generalized estimation equation.Results　The average score of community health services was（84.57±19.72） at the baseline survey，（93.74±15.34） at the first follow-up，and （98.39±15.15） at the second follow-up.There were significant differences in scores of community health services in three times of surveys（P<0.001） and in pairwise comparisons（P<0.05）.The results of multivariate analysis showed that education level，marital status，types of medical payment，having contracted family doctors or not，hospitalization in past three years，self-assessment of health status and treatment burden were influencing factors of community health service evaluation.Conclusion　 The evaluation of community health services among patients with multimorbidity in a community of Shenzhen is gradually increasing.Patients with multimorbidity who have contracted family doctor services have a higher evaluation of community health services.For the health management of patients with multimorbidity，the contracted family doctor should be the key point for the comprehensive，continuous，holistic and integrated management.

Positioning and Evaluation Indices of General Practice Department in Standardized Clinical Residency Training Bases（General Hospitals）：a Qualitative Inductive Analysis of Focus Group Discussions　

SHEN Shili，ZHANG Xinyan，LI Yixuan，ZHANG Xu，GONG Xue，YU Xiaosong

2020, 23(13): 1627-1631. DOI: 10.12114/j.issn.1007-9572.2020.00.157

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Background　The establishment of a general practice department in standardized clinical residency training（SCRT） bases（general hospitals） is a new initiative of the National Health Commission of the People's Republic of China to promote the development of general practice.However，due to lack of a standardized evaluation system for general practice department，although the specialist department evaluation system is not suitable for general medicine，it has been used to evaluate the general practice department in many SCRT bases（general hospitals）.Furthermore，problems such as inaccurate orientation of general practice department，and general practice's affiliation to other clinical departments are quite common，too.So it is urgently to develop a sound evaluation system for the general practice department in hospitals.Objective　To explore the positioning and evaluation system for general practice department in SCRT bases（general hospitals）.Methods　During the 6th Cross-Strait Congress of General Practitioners held from 29th to 31st March，2019，we（a research team of 6 members）used purposive sampling to select several directors of general practice department of general hospitals in different regions of China to attend a two-round focus group discussions（7 of them attending the first round，and 4 attending the second round）.The first round of focus group discussion was based on the outline of initial evaluation system for general practice department in general hospitals（consisting of 5 first-level indices:basic conditions，medical team，medical service capability level，medical quality，and research and teaching） previously developed by us，and the second round of discussion was based on the organized contents of the first round of discussion after analyzing.The discussions were hosted by the president，and were recorded，transcribed，coded and analyzed timely，and based on the results，the indicators of the initial evaluation system for general practice department were revised.Results　The general practice department in SCRT bases（general hospitals） was positioned to train general practitioners in primary care.The initial ＂research and teaching＂ index in the system was revised as ＂teaching and research＂.The specific contents of the 5 first-level indices are as follows:1.Basic conditions:dimensions of ward，number of beds，dimensions of the outpatient clinic，development environment，eligible established relevant departments in SCRT bases（general hospitals），comprehensive levels of cooperative primary healthcare institutions，and spaces and equipments in both SCRT bases（general hospitals） and cooperative primary healthcare institutions for the requirements of rotation training of SCRT.2.Medical team:general practice leaders，key professionals，physician teams，and nurse teams.3.Medical service capability level:overall level，diagnosis and treatment capabilities，and radiation scope.4.Medical quality:the evaluation criteria refer to general professional quality requirements for hospitals.5.Teaching and research:SCRT of general practice，research directions，research projects and achievements.Conclusion　The positioning and inductive analysis of the indices of evaluation system for general practice department in SCRT bases（general hospitals） may be contributive to further improvement of the evaluation system.

Improvement of Co-training Model for General Practitioners and Specialists Driven by EPAs-DOC Theory and Information Technology Platform in the Regional Medical Consortium Led by Tertiary Hospitals　

GAO Shenshen，GU Shihao，HE Yi，WANG Xin，YANG Hui，ZHAO Ren

2020, 23(13): 1632-1639. DOI: 10.12114/j.issn.1007-9572.2020.00.046

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Background　During the implementation of hierarchical diagnosis and treatment in a regional medical consortium，how to effectively coordinate the medical behaviors of general practitioners（GPs） and specialists has always been a difficulty，and how to use post competency assessment has always been the focus of current research.We used entrustable professional activities（EPAs）to try to address the difficulty，which is a first attempt in China.Objective　To explore ways to vertically allocate medical resources from the tertiary hospital to the community hospital in a regional consortium，to alleviate the contradiction between increasing healthcare needs of the people and insufficient medical resources，and to make tertiary hospitals to better play their radiation role in sharing their resources.Methods　Ruijin Hospital（North），Shanghai Jiaotong University School of Medicine，developed a questionnaire in 2018，which consists of demographic information，EPAs evaluation indicators，and position competencies indicators for pediatric GPs and GI specialists，using introduced overseas theories of EPAs and position competencies，and data from the hierarchical diagnosis and treatment platform〔composed of 4 modules（referral management，combined use of hospital beds，follow-up services for referrals，information inquiry）〕 constructed by this hospital in 2018.Then，Ruijin Hospital（North） conducted an online survey concerning cooperation between GPs and specialists in a regional medical consortium based on the www.wjx.cn platform by randomly posting the electronic version of the questionnaire to email addresses of pediatric GPs and GI specialists.A total of 1 476 cases returned responsive questionnaires.The survey results were used to construct a cooperative training model，and to evaluate the general-specialist physician correlations in terms of EPAs and position competencies scores，and to test the model's reliability.Results　The mean evaluation scores of EPAs indicators for pediatric GPs showed prominent positive correlation with those of pediatric GI specialists（P<0.05）.Likewise，the mean position competencies scores for pediatric GPs were positively correlated with those of pediatric GI specialists（P<0.05）.Conclusion　We explored a general-specialist physician co-training model through the introduction of the theory of EPAs-DOC to facilitate the medical coordination and synergy between general physicians and specialist physicians，by integrating data from our electronic management platform（involving whole life cycle electric health records，physicians and technicians appointments and a joint sickbed integration platform） as part of the construction of tertiary hospital-led regional medical consortium.

Follow-up Investigation of the Effect of the New-onset and Untreated Hypertension on the Elderly Patients with Mild Cognitive Impairment in Community　

QIN Hongyun，ZHU Binggen，WANG Ling，GUO Yi，CAO Zhicheng，HU Chengping

2020, 23(13): 1640-1646. DOI: 10.12114/j.issn.1007-9572.2019.00.785

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Background　Hypertension is one of the risk factors for Alzheimer's disease，whose neuropathological changes associated with memory and cognitive function predate clinical symptoms for many years.Therefore，it is of great significance to effectively identify high-risk groups of dementia in patients with hypertension for its prevention clinically.Objective　To investigate the changes of cognitive function of elderly people in community and analyze the effects of hypertension-related treatment，other combined physical diseases and blood pressure control on the transformation from mind cognitive impairment（MCI） to dementia，so as to provide a basis for preventing and delaying the occurrence of dementia.Methods　From July to December 2017，439 elderly patients with MCI who had been sampled by probability proportional to size（PPS） in 2011 were examined for their simple mental state with the remeasurement by the Montreal Cognitive Assessment Scale，Hamilton Depression Scale，Clinical Dementia Assessment Scale and the criteria for the diagnosis of cognitive impairment.The outcomes of follow-up were divided into the stable type（MCIs），the progressive type（MCIp） for dementia and the reversed type（MCIr） for normal cognitive status.The follow-up outcomes of MCI was compared between different history of hypertension and its related treatment.And Logistic regression was used to analyze the related influencing factors of MCI without deterioration.Results　There were significant differences in the number of children，BMI and hyperlipidemia among the elderly with hypertension history in 2011（P<0.05）.There were no differences in age，gender，single status，monthly income，education level，occupation type，personality tendency，family structure，alcoholism history，smoking history，memory decline and type 2 diabetes history between the two groups（P>0.05）.The age of new-onset and untreated hypertension group was higher than that of non-hypertension group，and the systolic and diastolic blood pressure levels of non-hypertension group were lower than those of new-onset and untreated hypertension group，and the diastolic blood pressure level of persistent hypertension group was lower than that of untreated hypertension group（P<0.05）.The average age of MCIp group was higher than that of MCIs group，and the difference was significant（P<0.05）.Logistic regression analysis showed that old age was a risk factor for MCIp（OR=0.856，P=0.011），while high month income was a protective factor（OR=2.288，P=0.045）.Conclusion　Community untreated and new-onset hypertension may promote the progression of MCI to dementia and old age is a risk factor.Decreasing or increasing blood pressure is the result of compensatory or disease progression accompanied by neurodegenerative changes.

Correlation of Activation with Psychological Distress and Social Support in Chronic Kidney Disease Patients：an Outpatient Follow-up Study　

PAN Yongyi，XIE Wenhong，JIA Ling，HUANG Jingxin，XIE Di，YANG Xiaobing，TAO Xiaolei，ZHAO Hao

2020, 23(13): 1647-1653. DOI: 10.12114/j.issn.1007-9572.2019.00.454

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Background　Disease spectrum changes as time goes on.Chronic kidney disease（CKD） has become a global public health problem threatening people's health，causing a substantially great burden.The traditional disease-centered model is no longer applicable，the new appropriate chronic disease management model highlights the central role of the patient in disease prevention and treatment.Hence，how to increase patient self-management initiative，namely，patient activation，has become a research hotspot of CKD follow-up management.Objective　To explore the correlation of activation with psychological distress and social support in CKD patients with outpatient follow-up management，providing evidence for improving patient activation.Methods　A single-center，cross-sectional design with convenience sampling was adopted in the research carried out between August 2017 and October 2018.Participants were totally 301 non-dialysis patients with CKD stages 1-5 who received regular outpatient follow-up from the Clinic of Kidney Disease Center，Nanfang Hospital.They were investigated with Patient Activation Measure（PAM），Kessler Psychological Distress Scale（KPDS） and Social Support Scale.Results　The rates with activation levels of 1-4 were 12.3%（37/301），18.3%（55/301），36.5%（110/301），and 32.9%（99/301），respectively，with corresponding mean evaluation score of 45.1（43.2，46.1），51.1（51.1，52.6），61.1（59.4，64.1），and 73.1（68.1，77.0），respectively.The PAM score was negatively correlated with KPDS score（rs=-0.301，P<0.01），but was positively correlated with the total score of social support，scores of objective support，subjective support and utilization of support（rs=0.195-0.359，P<0.01）.Conclusion　The activation for most CKD patients is not high，indicating that they have no sufficient self-management knowledge and confidence，and skills for health maintenance and promotion.In addition，CKD patients' activation increases with the growth of social support，but decreases with the aggravation of psychological distress.So the activation of such patients during the outpatient follow-up management may be enhanced by psychological rehabilitation interventions and increased social support.

Effect of Longitudinal Trajectories of Total Cholesterol on the Onset of a Stroke：a Prospective Cohort Study　

HUANGFU Chunmei，SONG Yongjian，YUAN Jianxin，YAN Lili，YANG Na，LI Xuemei

2020, 23(13): 1654-1662. DOI: 10.12114/j.issn.1007-9572.2020.00.073

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Background　Total cholesterol（TC） at baseline is an influencing factor of the incidence of stroke，while no studies have been conducted on the effect of longitudinal trajectories of TC on the incidence of stroke at home and abroad.Objective　To explore the effect of longitudinal trajectories of TC on the incidence of stroke.Methods　A prospective cohort study was conducted based on KaiLuan research cohort.Cox regression model was used to analyze the effect of single TC measurement on the incidence of stroke among baseline subjects（n=95 943） with complete TC data and no previous history of stroke in 2006.According to TC levels，patients were divided into normal level group（TC≤5.2 mmol/L，n=59 065），marginal increase group（5.2 mmol/L<TC≤6.2 mmol/L，n=26 330），and hypercholesterolemia group（TC>6.2 mmol/L，n=10 548）.The patients（n=51 394） with complete TC data in 2008 and 2010 and no previous history of stroke before 2010 were taken as the observation population for repeated measurement.The follow-up period was（6.77±1.00）years，and the incidence of stroke was collected annually during the follow-up period.According to the longitudinal trajectories of TC，three different groups were determined：22 116（43.03%） patients in the low-stable group，24 441（47.56%） patients in the medium-stable group，and 4 837（9.41%） patients in the high-stable group.The Cox regression model was used to analyze the influence of longitudinal trajectories of TC on the incidence of stroke.Results　In the baseline observation group，Cox regression analysis showed that compared with the ideal level group，the HR values（95%CI） of stroke，ischemic stroke and hemorrhagic stroke in the hypercholesterolemia group were 1.13（1.03，1.23），1.21（1.11，1.33），and 0.80（0.65，0.99），respectively，after adjusting for gender and other influencing factors.During the follow-up period，the cumulative incidence of stroke and ischemic stroke increased with the increase of TC longitudinal trajectories（P<0.05）.Cox regression analysis showed after adjusting for gender and other influencing factors，the HR values（95%CI） of stroke in each group were 1.21（1.08，1.35） and 1.32（1.11，1.57），and of ischemic stroke were 1.25（1.09，1.43） and 1.34（1.05，1.72） when compared with that in the low-stable group.The HR values of hemorrhagic stroke were not statistically significant（P>0.05）.In addition，after adjusting for baseline TC levels in 2010，the HR values（95%CI） of stroke in each group were 1.21（1.07，1.37） and 1.33（1.05，1.67），and of ischemic stroke were 1.25（1.13，1.44） and 1.34（1.20，1.72） when compared with that in the low-stable group.The HR values of hemorrhagic stroke were not statistically significant（P>0.05）.The baseline TC levels in 2010 had no statistical significance on stroke and ischemic stroke（P>0.05）.Conclusion　A single increase in TC levels is the risk factor of the incidence of stroke and ischemic stroke，while it is a protective factor of the incidence of hemorrhagic stroke.The increased longitudinal trajectory of TC levels is a risk factor of the incidence of stroke and ischemic stroke，while it has no statistical correlation with the risk of the incidence of hemorrhagic stroke.

Diagnostic Values of Routine Blood Indicators in Patients with AECOPD　

CHEN Kangxie，HUANG Yaoguang，LI Hui，YAO Guanjin，SUN Lanchun

2020, 23(13): 1663-1665. DOI: 10.12114/j.issn.1007-9572.2019.00.685

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Background　Acute exacerbation of chronic obstructive pulmonary disease（AECOPD） is a recurrent problem in patients with chronic obstructive pulmonary disease（COPD），which can lead to increased mortality.Due to lack of quantitative indicators for the prediction and diagnosis of AECOPD，it is important to explore the predictive and diagnostic values of commonly used routine blood indicators for AECOPD.Objective　To investigate the value of lymphocyte percentage（LY%），neutrophil/lymphocyte ratio（NLR），neutrophil percentage（NE%） and white blood cell count（WBC） in the diagnosis of AECOPD.Methods　 Participants were recruited from Central People's Hospital of Zhanjiang from November 2017 to September 2018，including 130 patients with AECOPD（AECOPD group） from Department of Respiratory Medicine，and 122 physical examinees（control group）.LY%，NLR，NE% and WBC levels were measured in all cases via a routine blood test，and their predictive and diagnostic values in AECOPD were evaluated by ROC curve analysis.Results　Compared with control group，patients in AECOPD group showed higher mean NLR，NE% and WBC，but lower mean LY%（P<0.05）.In the diagnosis of AECOPD，the AUC of LY% was 0.904（P<0.01），with a ROC curve-determined optimal cut-off value of 24.9%，with a sensitivity of 82.31%，and a specificity of 90.98%.The AUC of NLR was 0.901（P<0.01），with a ROC curve-determined optimal cut-off value of 2.73，with a sensitivity of 79.23%，and a specificity of 92.62%.The AUC of NE% was 0.892（P<0.01），with a ROC curve-determined optimal cut-off value of 65.4%，with a sensitivity of 78.46%，and a specificity of 93.44%.And the AUC of WBC was 0.616（P<0.01），with a ROC curve-determined optimal cut-off value of 9×109/L，with a sensitivity of 37.69%，and a specificity of 90.98%.Conclusion　 LY%<24.9%，NLR>2.73 and NE%>65.4% can effectively diagnose the occurrence of AECOPD，but WBC has lower diagnosis value.

Effect of Exenatide Combined with Insulin on Inflammatory Markers in Patients with Type 2 Diabetes　

ZHAO Qian，YING Changjiang，LING Hongwei，LI Shufa，ZHANG Ting，WANG Jiaxin，LI Wei

2020, 23(13): 1666-1671. DOI: 10.12114/j.issn.1007-9572.2019.00.689

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Background　One in twelve deaths in adults can be attributed to diabetes.Diabetic patients have significantly increased blood lipid and inflammatory markers.Moreover，hyperlipidemia，hyperglycemia and elevated inflammatory markers often increase the risk of cardiovascular disease.Objective　To investigate the effect of exenatide combined with insulin on fibrinogen（FIB），high-sensitivity C-reactive protein（hs-CRP），interleukin-6（IL-6） and tumor necrosis factor alpha（TNF-α） in patients with type 2 diabetes with poor glycemic control.Methods　A total of 193 outpatients and inpatients with T2DM were recruited from Department of Endocrinology，Affiliated Hospital of Xuzhou Medical University from June 2016 to June 2018，and were randomized into exenatide group（n=98） and insulin group（n=95）.All patients continued their previous diet，exercise，and oral medication.Besides，the exenatide group additionally took exenatide，and the insulin dose was temporarily reduced by 30%，then was adjusted according to blood glucose later.The insulin group only adjusted the insulin dose based on the blood glucose level.After 6 months of treatment，hypoglycemic effects and changes of FIB，hs-CRP，IL-6 and TNF-α were compared between the two groups.Multiple stepwise linear regression analysis was used to analyze the influencing factors of inflammatory markers.Results　FPG，2 hPG，HOMA-IR，HbA1c，TG，TC，LDL-C，hs-CRP，IL-6 and TNF-α were all decreased in both groups after treatment（P<0.05），whereas HOMA-IR，hs-CRP，IL-6 and TNF-α in exenatide group were significantly lower than those in the insulin group（P<0.05）.In the exenatide group，mean body weight，body mass index（BMI），waist circumference（WC） and daily insulin dosage were also decreased as compared with baseline（P<0.05），but the difference of FIB was not significant compared with the pre-treatment（P>0.05）.In the insulin group，mean body weight，BMI，WC and daily insulin dosage were increased as compared with baseline（P<0.05），but the difference of FIB was not significant（P>0.05）.The difference of pre- and post-treatment ΔFIB was positively correlated with ΔWC，Δbody weight，ΔBMI，and ΔHOMA-IR（r=0.269-0.423，P<0.05）.Δhs-CRP was positively correlated with ΔWC and ΔHOMA-IR（r=0.223-0.515，P<0.05）.ΔIL-6 and ΔTNF-α were positively correlated with ΔWC（r=0.215-0.379，P<0.05）.Multiple stepwise linear regression analysis showed that ΔBMI and ΔHOMA-IR were the influencing factors of ΔFIB，and ΔWC was the influencing factor of Δhs-CRP，ΔIL-6 and ΔTNF-α（P<0.05）.Conclusion　Exenatide with insulin treatment may achieve similar hypoglycemic effect as high-dose insulin，but is superior to the latter in reducing body weight，BMI，WC，insulin dosage，insulin resistance，as well as subclinical inflammation markers.

Relationship between Brain Function Indices and Sleep Quality in Patients with Primary Hypertension　

LI Xue，CHEN Guiying，ZHANG Miaomiao，LIU Shuang，YAN Yu，YAO Yanan，LI Mingzhi，SHAN Linghan，WU Qunhong

2020, 23(13): 1672-1674. DOI: 10.12114/j.ssn.1007-9572.2019.00.360

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Background　Sleep disorder is significantly associated with the risk of hypertension and hypertension-related complications，and circadian changes in blood pressure.Therefore，it is particularly important to evaluate the sleep quality in hypertensive patients.Objective　To explore the relationship between brain function indices and sleep quality in patients with primary hypertension.Methods　Eighty cases of primary hypertension were randomly selected from the cardiovascular outpatients and inpatients treated in the First Affiliated Hospital of Harbin Medical University during July 2017 to January 2019，and were divided into poor sleep quality group（n=40，PSQI score≥11） and good sleep quality group（n=40，PSQI score≤10）．Brain function indices（brain energy dissipation，drowsiness value + brain fag） of the two groups were compared.The correlation between brain function indices and PSQI score was analyzed by Pearson correlation.Results　The brain energy dissipation was（342.38±147.14） in poor sleep quality group and（211.03±116.07） in good sleep quality group，showing significant intergroup difference（t=4.433，P<0.001）．The drowsiness value + brain fag was（58.78±29.23） in poor sleep quality group and（43.73±19.96） in good sleep quality group，demonstrating significant intergroup difference（t'=2.329，P=0.027）．Pearson correlation coefficient analysis showed that brain energy consumption was positively correlated with the total score of PSQI（r=0.409，P<0.001），and the drowsiness value + brain fag was positively correlated with the total score of PSQI（r=0.341，P=0.002）．Conclusion　Brain function indices（brain energy dissipation，drowsiness value + brain fag） are related to sleep quality and can reflect the sleep quality in patients with primary hypertension.The assessment of brain function provides a more convenient and accurate method for the assessment of sleep quality in such patients.

A Questionnaire Survey-based Review of HPV Awareness and HPV Vaccine Acceptance　

DI Na，LIU Yingnan，ZHANG Jianxin，TAO Xia

2020, 23(13): 1675-1679. DOI: 10.12114/j.issn.1007-9572.2019.00.638

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HPV vaccination can reduce the incidence of cervical cancer by effectively preventing HPV infection.However，domestic and international investigations have found that the HPV awareness and HPV vaccination rate are not satisfactory.HPV vaccine has been officially introduced to Chinese mainland for more than two years.To improve the effectiveness of relevant policies，it is urgent to investigate residents' HPV awareness and HPV vaccine acceptance and influencing factors.Considering lack of relevant research in mainland China，this article reviews questionnaire surveys on HPV awareness and HPV vaccine acceptance，with a focus on participants，survey modes and contents as well as the reliability and validity of questionnaires，providing assistance for the development of a more reasonable and targeted questionnaire.

Problems and Countermeasures in the Implementation of National Cervical and Breast Screening Program for Women in Rural Areas　

HUANG Jing，YANG Xianghong，LIU Ai，ZHOU Wenjuan

2020, 23(13): 1680-1686. DOI: 10.12114/j.issn.1007-9572.2019.00.509

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Cervical cancer and breast cancer are two most common malignant tumors among Chinese women，which seriously damage their health.To reduce the morbidity and mortality of cervical and breast cancer，China launched the national cervical and breast cancer screening program in 2009，and promotes the screening actively，and the screening becomes available at the national level from 2016 onwards.Based on the field survey of the implementation of the "two cancer screening" project in the rural areas of a city in Hunan Province from 2016 to 2017，this paper summarizes the problems in the implementation of the project as follows：some rural women lack knowledge and social support of "two cancer"；geographical traffic factors，screening time and place arrangement，distrust of medical institutions affect women's participation in screening；some areas lack of screening atmosphere.It is proposed that in order to promote the development of this work，village doctors should take part in the launch，multiple means of repeated propaganda and stimulation，inform the screening results on the spot and timely return the follow-up results，and avoid recommending unnecessary follow-up services.

Research Status of Internet Addiction in Adolescents　

ZHAI Qian，FENG Lei，ZHANG Guofu，LIU Min，WANG Jingjing

2020, 23(13): 1687-1694. DOI: 10.12114/j.issn.1007-9572.2019.00.558

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With the advent of the information age，as a product of information science and technology，the internet enjoys a growing penetration rate year by year.The relationship between individuals and the internet constitutes a brand-new unit，where individuals play an important role.While the internet has brought unprecedented convenience，internet addiction as a new addiction has been widely concerned.The general youth population is at an important and special period of physical and psychological development，and also a crucial stage in the selection of literature and knowledge.As their psychological and physiological state is not yet mature and stable，adolescents are prone to internet addiction.The survey showed that the number of young internet users accounted for the highest proportion of internet users in the age structure of internet users.This paper reviewed the research status of internet addiction among adolescents from many aspects.

Utilization and Demands of Traditional Chinese Medicine Guidelines for Diabetes among Grassroots General Practitioners in Dongcheng District of Beijing　

ZHOU Yuan，LI Ye，SUN Xiaowen，MA Lin，LIU Ruizhi，ZHAO Linhua2

2020, 23(13): 1695-1698. DOI: 10.12114/j.issn.1007-9572.2019.00.768

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Background　Traditional Chinese medicine has the characteristics of simplicity，convenience，efficiency and low cost.It is widely used in the field of diabetes prevention and treatment and has obvious advantages in the treatment of pre-diabetes and complications.Objective　To explore the application and demands of the Clinical Evidence-based Practice Guidelines of Diabetes by Traditional Chinese Medicine（hereinafter referred to as the Guidelines） among community general practitioners in Dongcheng District of Beijing.Methods　From July to August in 2018，a total of 304 grassroots health workers from 7 community health service centers and 34 community health service stations in Dongcheng District of Beijing were selected by cluster sampling method，including 138 practitioners of traditional Chinese medicine and 166 practitioners of western medicine.A questionnaire was designed to investigate the application and demands of the Guidelines，including the health education of traditional Chinese medicine，the use of proprietary Chinese medicine，the awareness of the Guidelines and the demands of training.Results　The age，education level，working years and professional titles of general practitioners of traditional Chinese medicine were lower than those of general practitioners of western medicine（P<0.05）.Among 138 general practitioners of traditional Chinese medicine，133（96.4%） cases had health education of traditional Chinese medicine to patients，and 127（92.0%） cases had community diabetes prevention and treatment with proprietary Chinese medicine.Among 166 general practitioners of western medicine，134（80.7%） cases had health education of traditional Chinese medicine to patients，and 112（67.5%） cases had community diabetes prevention and treatment with proprietary Chinese medicine.The difference was statistically significant（χ2=17.274，P<0.001；χ2=27.038，P<0.001）.Of the 138 general practitioners of traditional Chinese medicine，25（18.1%） cases had not heard of the Guidelines；94（68.1%） cases had heard of it but did not learn it；and 19（13.8%） cases had studied it carefully.Of the 166 general practitioners of western medicine，33（19.9%） cases had not heard of the Guidelines；108（65.1%） cases had heard of it but did not learn it；and 25（15.0%） cases had studied it carefully.There was no significant difference（χ2=0.316，P=0.854）.Among the general practitioners of traditional Chinese medicine，the learning rate of Guidelines in men was higher than that in women（P<0.05）.With the increase of age，poor education background，high professional titles and long working years，the learning rate of Guidelines increased（P<0.05）.Among 138 general practitioners of traditional Chinese medicine，126（91.3%） cases had the training needs of the Guidelines；among 166 general practitioners of western medicine，144（86.7%） cases had the training needs of the Guidelines.There was no significant difference（χ2=1.576，P=0.209）.Among 138 general practitioners of traditional Chinese medicine，50（36.2%） cases wanted to have the training in a face-to-face manner；63（45.7%） cases wanted to have the training through video；and 25（18.1%） cases thought both methods were acceptable.Among 166 general practitioners of western medicine，59（35.5%） cases wanted to have the training in a face-to-face manner；69（41.6%） cases wanted to have the training through video；and 38（22.9%） cases thought both methods were acceptable.There was no significant difference（χ2=1.129，P=0.569）.Conclusion　In Dongcheng District of Beijing，the awareness rate and learning rate of the Guidelines among grassroots general practitioners are low，so it is necessary to strengthen the promotion of the Guidelines in the community，especially in the group of general practitioners of traditional Chinese medicine with young age，low professional titles and short working years.

Measurement Frequency and Target Meeting Rate of Glycosylated Hemoglobin in Diabetics with Lean Six Sigma Management　

GONG Hui，TANG Huashan，ZHANG Bo，ZHANG Tao，HUA Yingxue，SONG Daoping，YAN Weili

2020, 23(13): 1699-1704. DOI: 10.12114/j.issn.1007-9572.2020.00.111

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Background　Diabetic patients are a key contracted service population for a general practitioner team，and their measurement frequency and target meeting rate of glycosylated hemoglobin（HbA1c） are performance evaluation indicators of the team.To improve the management effect in such patients，it is urgently to coordinate the relationships between the general practitioner team members during the management.Objective　To explore the effect of Lean Six Sigma（LSS） management delivered by the general practitioner team on the measurement frequency and target meeting rate of HbA1c in diabetic patients in the community.Methods　This trial was conducted between January 2017 and December 2018.200 type 2 diabetic patients were equally randomized into the control group and intervention group.The control group received the routine follow-up management delivered by two general practitioner teams.The intervention group received LSS management，a project whose organization structure comprised of belt personnel designated as black belts and green belts and so on in the concept of Six Sigma，with DMAIC improvement cycle（define，measure，analyze，improve and control） as the driven force，and fishbone diagram，RACI，and action plan as the tools for improving the weaknesses of the original community-based management，and effect control during the whole management delivered by other two general practitioner teams receiving LSS training.The control group was only routinely followed up the requirements of the superior business department.Results　In these two years，the average number of measurements was（4.6±1.3）times in the intervention group and（3.7±1.3）times in the control group，with a significant difference（t=7.073，P<0.001）.The mean value of HbA1c was（6.5±0.6）mmol/L in the intervention group，and was（7.1±1.0）mmol/L in the control group，showing a significant difference（t=-7.401，P<0.001）.The compliance rate was 55.5% （111/200） in the control group and 84.5% （169/200） in the intervention group，with a statistically significant difference（χ2=40.048，P<0.05）.According to the measurement times of HbA1c，it was divided into 3 groups：<4 times，with 122 cases，and the mean value of HbA1c was（7.0±1.1）mmol/L；4-6 times，with 250 cases，and the mean value of HbA1c was（6.7±0.7）mmol/L；>6 times，with 28 cases，and the mean value of HbA1c was（6.6±0.4）mmol/L.The differences between the three groups were statistically significant（F=6.885，P<0.001）.Conclusion　The application of LSS in the management of type 2 diabetic patients may improve the measurement frequency as well as the target meeting rate of HbA1c.The increased target meeting rate of HbA1c may be associated with increased measurement frequency，and increased attention to glycemic control from both physicians and patients.The improvement phase of management with LSS is in compliance with the clinical diagnosis and treatment thoughts of the medical staff.In particular，the unique organization structure in LSS is especially suitable for the coordination of the members in multiple positions in the general practitioner team.It can effectively improve the efficiency of chronic disease management.

Periodontal Status of Patients with Type 2 Diabetes Mellitus Who Received Contracted Family Doctor Services and Its Influencing Factors in Yuetan Community of Beijing　

ZHANG Jie，DING Jing

2020, 23(13): 1705-1710. DOI: 10.12114/j.issn.1007-9572.2019.00.790

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Background　There is a two-way relationship between periodontal disease and diabetes.Although periodontal disease is a common complication of diabetes，it has not received much attention from patients and doctors.Objective　To investigate the periodontal status of patients with type 2 diabetes receiving contracted family doctor services in the Yuetan Community and analyze its influencing factors，in order to provide a theoretical basis for general practitioners to conduct oral health education for patients with type 2 diabetes.Methods　From March 1 to June 1 in 2018，200 patients with type 2 diabetes mellitus receiving contracted family doctor services in Yuetan Community Health Service Center and its subordinate stations were recruited by convenient sampling method for periodontal clinical examination and questionnaire survey.The survey included basic information，living habits，control situation of type 2 diabetes，and oral health care.Periodontal examination was performed using the community periodontal index（CPI） as a standard.Rank-sum test was used to analyze the highest and mean scores of CPI.Binary Logistic regression was used to analyze the influencing factors of excluded sextants.Results　There were 169 cases without excluded sextants，and the cases with highest CPI scores of 0，1，2，3，and 4 accounted for 3.5%，14.5%，46.5%，10.0%，and 10.0%，respectively.Univariate analysis of the highest and mean CPI scores of 169 patients showed that the highest CPI score of patients with duration of diabetes > 9 years was significantly higher than that of patients with duration of diabetes ≤9 years；the mean CPI score of patients never having the teeth cleaning was significantly higher than that of patients having the teeth cleaning every half a year to a year；the highest and mean CPI scores of patients who did not pay attention to oral health knowledge were both significantly higher than that of patients paying attention to oral health knowledge；the highest CPI score of patients who were not informed by the doctor about the relationship of diabetes and periodontal disease was significantly higher than that of patients who were informed；the highest CPI score of patients having bleeding gums during brushing was significantly higher than that of patients without gum bleeding（P<0.05）.There were 31 cases with excluded sextants and cases with 1，2，3，and 4 excluded sextants accounted for 5.5%，4.5%，3.0%，and 2.5%，respectively.The influencing factors of the presence of excluded sextants in patients with type 2 diabetes were age ≥ 65 years old〔OR=2.266，95%CI（1.011，5.079）〕，and duration of type 2 diabetes > 9 years〔OR=2.490，95%CI（1.056，5.889）〕（P<0.05）.Conclusion　Patients with type 2 diabetes who received contracted family doctor services in Yuetan Community have a poor periodontal condition，which is related to many factors.As a result，general practitioners need to pay more attention to patients' periodontal status and strengthen their oral health education.

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