Chinese General Practice

Recommendations on the Standardized General Practice Residency Training Program in China Based on Reflections on the Survey Concerning COVID-19 Pandemic Containment among Chinese General Practitioners　

CHEN Shuling1，WU Suwei，DU Xueping，JIA Jianguo，LIU Dianwu，CHENG Yutian，GUO Aimin1

2020, 23(28): 3503-3507. DOI: 10.12114/j.issn.1007-9572.2020.00.452

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The General Office of the National Health Commission of the People's Republic of China has called for community health centers（stations），township hospitals，and village clinics and other primary care institutions throughout the country to strengthen the efforts to contain the COVID-19 pandemic at primary level. General practitioners（GPs） in primary care play an irreplaceable role during fighting against COVID-19. However，they also encounter many difficulties. To explore and address these difficulties，the Chinese Medical Doctor Association conducted an open-ended questionnaire survey among 41 GPs from 10 regions，and the results revealed：the difficulties encountered by GPs in combating COVID-19 are mainly lack of sufficient knowledge of public health and infectious diseases；the groups are most susceptible to COVID-19 are healthcare workers combating the pandemic，vulnerable groups at high risk of COVID-19，and those with poor consciousness of COVID-19 prevention；the learning of courses of public health，infectious diseases and epidemiology in the GPs training program should be strengthened. In view of this，we put forward that the standardized general practice residency training program should highlight the aspects of dealing with public health emergencies，infectious disease prevention and treatment，and relevant health education as well as psychological counseling，to improve GPs' competencies.

Task-based Analysis of the Necessity of the Revision of the Contents and Standards of Standardized General Practice Residency Training Program（2019 Revised Edition）　

YAN Chunze，WANG Junxia，WANG Quan，LI Xiaoxiao，JI Yan，DU Xueping

2020, 23(28): 3508-3515. DOI: 10.12114/j.issn.1007-9572.2020.00.458

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Background　In China，the primary healthcare system has played a frontline role in the prevention and treatment of COVID-19 since the outbreak of the pandemic. During the process，a series of problems have been exposed，such as general practitioners'（GPs'） inadequate knowledge and insufficient practice of containing infectious diseases，suggesting that the research on the training mechanism of GPs in China should be further deepened. Objective　To analyze the task of GPs after the completion of the national standardized general medicine residency training program，to provide a basis for further revision of the Contents and Standards of Standardized General Practice Residency Training Program（2019 Revised Edition）. Methods　Participants were general residents who completed the national standardized general medicine residency training program with a certificate less than 3 years ago，and worked at institutions consisted mainly of township health centers，community health centers（stations） and the general practice department of general hospitals. An email-based survey using a self-designed questionnaire was conducted among the participants to collect their demographic data，tasks，symptoms and diseases encountered during practice，and knowledge and skills required to complete the tasks. Results　Among the respondents，the percentages of working at township health centers，urban community health centers，general hospitals，and other types of institutions were 42.3%（220/520），36.2%（188/520），20.4%（106/520），and 1.1%（6/520），respectively. The percentages of working as GPs，GPs and public health physicians（whose practice tasks consist of equal parts of general practice and public health issues），public health physicians（whose practice tasks consist of mainly public health issues），and other types of roles were 63.4%（330/520），20.4%（106/520），8.1%（42/520），and 8.1%（42/520），respectively. The top 3 tasks most frequently practiced were medical history collection，physical examination，and diagnosis and differential diagnosis. In terms of the weight for practical application of theoretical knowledge included in the national standardized general medicine residency training program，the diagnosis and treatment of common chronic noncommunicable diseases，clinical thoughts targeting the health problems of served individuals or populations，and standardized management of common chronic noncommunicable diseases were top-ranked ones. In terms of task weight in performance，the top-ranked 10 essential skills included in the national standardized general medicine residency training program are as follows：clinical examination and result analysis，wound dressing change and suture removal，operation of electrocardiograph，systematic physical examination，debridement and suture of small wound，standardized management of hypertension，standardized management of diabetes，chest X-ray interpretation，writing electrocardiographic diagnosis report，and health education. The top-ranked symptoms and systematic diseases encountered by GPs in terms of frequency and importance were all commonly seen in clinical practice. Conclusion　The Contents and Standards of Standardized General Practice Residency Training Program（2019 Revised Edition） is relatively matched with the actual work of residents，but it is also necessary to strengthen the training of theory and skills required by some practical tasks. Furthermore，the outbreak of COVID-19 pandemic suggests the need to enhance theoretical and skills training of infectious diseases and public health.

The Problem Analysis and Breakthroughs of Domestic and Overseas Chronic Disease Management Models Based on the Systematic Review　

LI Zhen，SHI Jianwei，CHEN Ning，LIU Qian，JIN Hua，YU Dehua，WANG Zhaoxin3

2020, 23(28): 3516-3521. DOI: 10.12114/j.issn.1007-9572.2020.00.216

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Background　The efficient and perfect chronic disease management model is of great importance. But the diversified chronic disease management models in China have not been thoroughly applied yet. Objective　To analyze the development situation of chronic disease management models currently at home and abroad，and summarize the existing bottlenecks and key issues，in order to propose the breakthroughs to the improvement of chronic disease management models in China. Methods　Chinese key words including "慢病/慢性病（chronic disease）" "慢病管理（chronic disease management）"
"慢病管理模式（chronic disease management model）" "现况（current situation）" "问题（problems）" "效果（effect）" and "评价（evaluation）"，and English key words including "chronic disease" "chronic disease management" "chronic disease management model" "current situation" "problem" "effect" and "evaluation" were used to search Google and Baidu search engine，CNKI，Wanfang，VIP，PubMed and Web of Science database from January 1，1990 to July 1，2019. The literature of nearly 30 years since 1990 had been sorted out and analyzed，and the defects and key problems of the current chronic disease management model had been sorted out according to the literature mention rate. Using Delphi method，the chronic disease management problems would be ranked according to the importance and severity after two rounds of interviews. The ranking based on the literature mention rate and the ranking based on expert interviews were combined to get a comprehensive ranking from low to high. Results　The top 10 core problems that hindered the application of the current chronic disease management model were the obstacles in the two-way referral work，the low enthusiasm of patients，the lack of community health service capacity，the lack of awareness of medical consortia，the lack of information technology level，the lack of long-term incentive mechanism，the lack of supporting policies，the lack of guidance of medical insurance policies，the loose structure of medical consortia，and the lack of government supervision. Conclusion　The key issues of the existing chronic disease management models were that the systematic and structural obstacles in two-way referral mechanism，passive participation of patients or families，and the uncompleted informatization construction. Through the two-way referral mechanism and the informatization construction，the high efficiency of the chronic disease management model is expected to fully mobilize the initiatives of various parties to achieve the positive participation as well as the effective collaboration of hospitals，communities and families.

The Present Situation of Chronic Disease Follow-up in Medical Institutions and the Analysis of Key Problems　

HUANG Xiaoxu，LI Ziyun，WANG Zhaoxin，CHEN Chen，HUANG Jiaoling，YU Wenya，CHEN Ning，LIU Qian，GONG Xin，SHI Jianwei

2020, 23(28): 3522-3526. DOI: 10.12114/j.issn.1007-9572.2020.00.290

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Background　At present，chronic diseases have become a major problem that seriously threatens resident's health in China and affects the country's economic and social development. As of 2015，the number of patients with chronic diseases in China reached 280 million，accounting for 70% of the total disease burden. For many complications and a long course of disease，effective follow-up work and methods can greatly delay the process of chronic diseases. Objective　To investigate the current status of chronic disease follow-up in China，and analyze the advantages and key problems of the existing follow-up methods，in order to explore the direction of improving success rate and quality of chronic disease follow-up. Methods　Systematically search the literature related to chronic disease follow-up in the databases of CNKI，WANFANG data knowledge service platform，CQVIP network，PubMed，Web of Science，and Scopus from January 1，2000 to July 31，2019，and comprehensively obtain the current situation and related problems of chronic disease follow-up in China. In August 2019，the non-structured interview + semi-structured interview method was adopted to conduct in-depth interviews with 12 doctors from different levels of medical institutions in a district of Shanghai on follow-up methods，its advantages and disadvantages，and bottlenecks. Based on literature meta-analysis and interview results，the current situation and key problems of chronic disease follow-up in China were summarized. Results　Face-to-face follow-up was the main method in community health service centers currently. The combination of face-to-face follow-up and telephone follow-up was commonly used in the secondary and tertiary general hospitals，but the efficiency was not high and the application of online intelligent follow-up was less. The key problems were poor initiative and compliance of the follow-up subjects，backward information technology，and insufficient allocation of follow-up resources. Conclusion　In the future，it is necessary to optimize the follow-up methods as well as stimulate patients' active health awareness with the help of intelligent technology to achieve effective management of chronic diseases.

Self-rated Ability to Obtain Evidence-based Chronic Disease Prevention and Control Information in Community Medial Workers，Shanghai：an Empirical Analysis　

CHEN Ning，WANG Zhaoxin，YANG Yan，LIU Qian，HUANG Jiaoling，YU Wenya，FAN Feng，JIN Hua，YU Dehua，GONG Xin，SHI Jianwei

2020, 23(28): 3527-3532. DOI: 10.12114/j.issn.1007-9572.2020.00.470

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Background　Chronic disease prevention and control is still the primary health proposition in modern society. So it is urgent to improve the ability of chronic disease prevention and control in community medical workers. Evidence-based chronic disease prevention and control，a means for improving relevant abilities of medical workers，has achieved notable results in western countries，but has been rarely studied in China. Objective　To explore the ways and ability for obtaining chronic disease prevention and control evidence and associated factors in community medial workers，offering a theoretical basis for improving the related abilities in such workers. Methods　Using stratified sampling，a self-administered questionnaire survey was conducted in 975 medical workers in 75 community health centers from April to July 2019，for collecting the data about their socio-demographic information，awareness of evidence-based medicine，and ways and ability to obtain evidence for chronic disease prevention and control（with items scored on a self-rated 7-point Likert scale）. Stepwise multiple linear regression analysis was applied to identity the influencing factors of ability for obtaining the evidence. Results　A total of 892（91.5%） community medical workers returned responsive questionnaires. The results showed that clinical guidelines are the most common way for obtaining chronic disease prevention and control evidence，scoring（4.583±1.177） on average. The average self-rated score for the accuracy and effectiveness of obtained chronic disease prevention and control evidence was（4.312±0.979）. The average self-rated scores for obtaining and using the evidence about risk factors for chronic diseases were（4.244±1.028）（4.280±0.995），respectively. Stepwise multiple linear regression analysis revealed that working at a community healthcare institution affiliated to a university was associated with the obtaining and use of chronic disease prevention and control evidence as well as the accuracy and effectiveness of the evidence（P<0.05）. Conclusion　Working at a community healthcare institution affiliated to a university may be the foremost factor associated with the ability of obtaining chronic disease prevention and control evidence in community medical workers. So the ways for obtaining the evidence in this group should be attached importance，and their abilities of obtaining and using the evidence should be improved by training.

Performance Evaluation Indicators Screening for the Vertical and Compact Medical Consortium　

WANG Manli，FANG Haiqing，TAO Hongbing

2020, 23(28): 3533-3539. DOI: 10.12114/j.issn.1007-9572.2019.00.724

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Background　The vertical and compact medical consortium is an important form of the integration of medical institutions in China，whose performance evaluation is directly related to its sound development. Hence，it is necessary to construct a sound performance evaluation system for this type of medical consortium. Objective　To establish a framework for the performance evaluation of the vertical and compact medical consortium，to provide a reference for the construction and performance management of medical consortiums in China. Methods　We conducted this study from August 2017 to October 2018. On the basis of analyzing related literature and semi-structured interview results，we developed the initial version of vertical and compact medical consortiums performance evaluation system（VCMCPES），and revised it in accordance with results of two rounds of Delphi consultation with 16 experts. We used the Kendall's W to assess the agreement among experts. Results　The expert response rate of two rounds of consultation was 100.0%，the anthority coefficient of two-round of Delphi consultation was 0.73，the coordination coefficients for the two-round of Delphi consultation were 0.30，0.51（P<0.01），respectively，meeting the requirements of Kendall's W test. Finally，a framework of VCMCPES was developed，which consisted of six first-level indicators including accessibility of health services，quantity of health services，quality of health services，efficiency of health services，effect of health services and affordability of health services and 24 second-level indicators. Conclusion　The response level，authority coefficient and coordination coefficient of the experts involved in the consultation are high. And the reliability and specificity of the included indicators are good. To optimize the system，expert consultations should be carried out，and the indicators should be verified further.

Influencing Factors of Medical Staff in the Promotion of Contracted Family Doctor Services in Western Regions　

DING Liwen，XIA Yuanhang，CHEN Hongdou，HU Lan

2020, 23(28): 3540-3545. DOI: 10.12114/j.issn.1007-9572.2020.00.288

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Background　As medical service providers，medical staff's cognition of the requirements for family doctors is of great significance to promote the contracted family doctor services from the perspective of the supplier. Objective　To understand the cognition of medical staff in the medical and health system at all levels in Western China on the conditions necessary to promote the development of the contracted family doctor service project，in order to provide a reference for the better implementation and detailed system work of family doctor services. Methods　Using a multi-stage sampling method，a self-designed questionnaire survey was conducted among medical staff in 60 medical institutions in Nanchong，Mianyang and Chongqing from March to May in 2019 through the on-site and online self-administered questionnaire. The questionnaire included the basic information of medical staff，the internal conditions required for the development of contracted family doctor service project，and the situation and willingness of medical staff to participate in the project. After the data was sorted，statistical description，factor validity test and Logistic regression analysis were used to analyze the survey data. Results　Among the
1 797 medical staff，221（12.30%） were male，1 576（87.70%）were female，1 347（74.96%）were in the establishment，and 450（25.04%） were out of the establishment. Logistic regression analysis showed that factors affecting the participation of medical staff in contracted family doctor services currently included occupational quality factors，family environmental factors，life attitude and additional occupational quality factors（P<0.05）. Factors affecting the willingness of medical staff to participate in contracted family doctor services were occupational quality factors，family environmental factors，and additional occupational quality factors（P<0.05）. Conclusion　From the perspective of the supplier，the development of contracted family doctor service project could be continuously improved through providing compensation for medical staff who are overloaded with working hours，improving the occupational quality of medical staff，and improving the support of medical staff families to the work of family doctors.

Development of the Family Doctor-led Team-based In-home Medical and Nursing Elderly Services Scale　

CHEN Xiaohang，ZHONG Wenjuan，XIANG Shuangqiong，WANG Zhihong，ZHU Wenmin，XU Bo

2020, 23(28): 3546-3552. DOI: 10.12114/j.issn.1007-9572.2020.00.302

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Background　A recently emerged new type of community-based elderly care in China，which integrates nursing services into medical and elderly care services，has become a trend and an increased choice. The services can be accessed conveniently. So，this type of services has gained high social recognition. However，there is few research on the content of the service requirements. Objective　To develop a family doctor-led team-based in-home medical and nursing elderly services scale. Methods　The items of the draft were formulated based on document retrieval conducted between November and December 2017 and semi-structured interviews conducted between January and March 2018. Then in March and April，2018，using the questionnaire developed by our research group，two rounds of Delphi consultations were carried out with 18 experts（in general medicine，clinical geriatric medicine and nursing，community-based nursing management and education，rehabilitation medicine，or scientific research and education）. After being revised according to the consultation results，the draft was developed to be the family doctor-led team-based in-home medical and nursing elderly services scale，and then its reliability and validity were pretested between April and October in a voluntary convenient sample of 200 elderly people with normal hearing，sight and cognitive function（≥60 years old） from Dongxihu，Jiang'an and Qiaokou Districts of Wuhan City. Results　The response rate and average authoritative coefficient were 100.0% and 0.836，respectively，for the first round of consultation，and were 94.4% and 0.906，respectively，for the second round of consultation. The final scale consisted of 6 first-level indicators（basic medical care，basic public health services，health management，family ward，rehabilitation health services and health guidance），and 38 second-level indicators（with Kendall's W of 0.109，0.113，0.305 for necessity，feasibility and risk，respectively，P<0.01）. The Cronbach's α coefficient and content validity index of the scale estimated based on the survey were 0.968，and 0.941，respectively. Conclusion　The scale developed by us showed good reliability and validity in the survey，which can be used as a reference for the formulation of family doctor-led team-based elderly services.

Construction of Family Doctor's Competency Indicator System Based on the Delphi Method　

LU Ping，LU Zhimin，QIAN Zhifang

2020, 23(28): 3553-3560. DOI: 10.12114/j.issn.1007-9572.2020.00.069

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Background　The positions of family doctors are mostly occupied by personnel from other departments. The overlap of positions and unclear division of duties have become obstacles for family doctors to carry out their work. How to identify and select good family doctors requires a set of assessment tools to measure the competency of family doctors. Objective　To establish a practical and effective competency indicator system of family doctors in order to provide a basis for family doctor's ability assessment and competitive recruitment. Methods　In December 2018，through the methods of literature review and group interview，the framework of family doctor's competency indicator system was preliminarily formulated. Two rounds of consultation were performed towards 31 experts using the Delphi method. The importance of indicators was scored by experts and indicators were deleted according to the coordination and concentration of experts' opinions. Besides，by employing the analytic hierarchy process，the weights of the first-level，second-level and third-level indicators were determined. Results　The effective recovery rate of the two rounds of consultation was 100.0%，and the overall authoritative coefficient of the experts was 0.852>0.70，and the expert coordination coefficients of the first-level，second-level and third-level indicators were 0.265，0.350，and 0.280（P<0.01）. Finally，a family doctor's competency indicator system was established consisting of 6 first-level indicators，13 second-level indicators，63 third-level indicators and their weights. The weights of the 6 first-level indicators of basic medical service ability，public health service ability，humanistic practice ability，interpersonal communication ability，education and learning ability and comprehensive management ability were 0.350，0.053，0.119，0.187，0.146，and 0.146，respectively. Conclusion　The family doctor's competency indicator system is scientific and forward-looking with 6 first-level indicators，13 second-level indicators，and 63 third-level indicators. Family doctor's competency evaluation pays more attention to the basic medical service ability. The next step is to build an assessment system of family doctor's comprehensive competency based on the competency model in order to provide a tool for family doctor's ability assessment.

Development of a Comprehensive Ability Assessment Method for Family Doctors Based on Post Competency　

LU Ping，GE Yuanyuan，QIAN Zhilong，TANG Yanwen，SHEN Lin，LU Zhimin，WENG Lili，YAN Haifeng

2020, 23(28): 3561-3568. DOI: 10.12114/j.issn.1007-9572.2020.00.075

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Background　As the position of family doctors is increasingly favored by general practitioners，some community health service centers have adopted the method of job competition to select outstanding family doctors. Therefore，for managers of community health service centers，how to scientifically evaluate the comprehensive capacity of competitors to appoint the suitable talents is an urgent issue to be solved. Objective　To clarify the measurement methods and scoring methods for the assessment indicators of family doctors' comprehensive capacity，so that to provide evidence for family doctors' job competition in community. Methods　On the basis of the Family Doctors' Competency Indicator System，a comprehensive assessment method for family doctors was established using the SMART principle from January to May in 2019 through the literature review and focus group meeting. Results　The 63 third-level indicators in the Family Doctors' Competency Indicator System had 100 corresponding measurement indicators. According to the results of the assignment，the family doctors' comprehensive ability assessment scale had a total score of 1 000 points. Among them，the first-level indicators were divided into indicators of basic medical service ability（308 points），public health service ability（86 points），humanism practice ability（113 points），interpersonal skills（163 points），education and learning ability（153 points） and comprehensive management ability（177 points）. Conclusion　The assessment method for comprehensive ability of family doctors（including measurement methods and scoring methods） constructed in this study has certain scientific and practical significance. It is suggested that training of family doctors' ability should focus on basic medical service ability，comprehensive management ability and interpersonal skills. The assessment method can be applied to the job competition of community family doctors.

Construction of Evaluation Index System for General Practitioner Assistants Based on the Post Competency in Shanghai　

XU Yingzi，HUANG Wuquan，ZHAI Jiayi，LU Juping，LU Qiuxia

2020, 23(28): 3569-3575. DOI: 10.12114/j.issn.1007-9572.2020.00.215

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Background　The post competency model is widely used in the recruitment of healthcare talents，but there are few relevant studies on the construction of evaluation index system for general practitioner assistants. This study intends to make use of the post competency model to conduct research in conjunction with the practical experience of general practitioner assistants in the region. Objective　To construct an evaluation index system for the job admission of general practitioner assistants，in order to provide a basis for the scientific and efficient recruitment and selection of suitable healthcare talents. Methods　A post competency modeling group was established from August to October in 2018. The job categories of general practitioner assistants were classified through group meetings and the job content were analyzed through key event interviews. A total of 15 experts including managers，personnel directors，and leaders of family doctor team from five community health service centers were invited from October to November in 2018 to participate in two rounds of Delphi expert consultation to build a post competency model for general practitioner assistants and determine the index weight of indicators for the job admission of general practitioner assistants based on the analytic hierarchy process. Results　A dictionary of post competencies of the general practitioner assistant was sorted out，including basic knowledge，interpersonal skills，professional accomplishment，professional development ability，professional practice ability and management ability. Finally，17 first-level indicators and 59 second-level indicators were formed for the evaluation index system for the job admission of general practitioner assistants based on these six characteristic indicators of the post competency. Among them，the indicators whose weights were ranked in the top three were interpersonal skills（0.385 6），professional accomplishment（0.281 1） and professional practice ability（0.126 5）. Conclusion　When recruiting and selecting general practitioner assistants，we should pay more attention to three characteristic indicators of the post competency of interpersonal skills，professional accomplishment and professional practice ability. The introduction of competency evaluation system could put forward more comprehensive requirement for the quality and ability of general practitioner assistants and help family doctor team to select the assistants with the best competencies.

QIAN Zhilong，GE Yuanyuan，LU Ping，WENG Lili，SHEN Lin，PAN Zhangshi，TANG Yanwen，XU Xiaofeng

2020, 23(28): 3576-3582. DOI: 10.12114/j.issn.1007-9572.2020.00.453

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Background　General practitioners（GPs） are the key workforce in community health organizations，delivering important services in various positions. However，current tools for assessing GPs' competencies are not conducive to the selection and training of GPs due to lack of assessment of competencies and attributes according to the position. Objective　To explore the similarities and differences of systems for assessing the competencies of GPs serving in different positions，to provide a reference for managers of medical institutions to allocate GPs to the appropriate position. Methods　This study was conducted during October 2018 and June 2019. Assessment indicators for GPs' competencies were explored by individual semi-structured interviews with high-quality GPs serving in various positions from community health centers（CHCs），Shanghai's Jiading District. Then the indicators were screened using the boundary value method according to the results of a Delphi consultation survey with experts（consisting of highly qualified and experienced GPs serving in different positions and managers of CHCs） using a questionnaire developed by our research group based on the above-mentioned interviews and literature review. And finally，assessment systems for position-specific competencies of GPs were developed. Results　The authoritative coefficient for experts according to the position were greater than 0.70，and the Kendall's W for experts according to the position were less than 0.4 except the secondary index of general outpatient service with 0.437（P<0.01）. The systems for assessing the competencies of GPs working as outpatient physician，TCM outpatient physician，inpatient physician，women' healthcare physician，child healthcare physician，family physician，family physician assistant，and preventive care physician included all the primary level indicators and all secondary level indicators except assessment indictors for teaching and research ability and team management ability. The systems for assessing the competencies of GPs working as inpatient physician，family physician and preventive care physician had team management ability，a secondary level indicator，while other systems had not. And the system for assessing the competencies of GPs working as family physician assistant was the only system without teaching and research ability，a secondary level indicator. Conclusion　The similarities of positions for GPs are determined by the characteristics of community health services and the attributes of the main practice groups for each position，and the differences are determined by the specific duties and characteristics of positions. The common and specific requirements for GPs' competencies of the positions may be used as the criteria for the initial and final selection of appropriate GPs，respectively.

Effects of Community Function and Public Services on Social Isolation of Elderly Residents at Different Ages　

FAN Rong，BAI Yali，LIU Yao，ZHAO Yaning，WANG Hui，LI Xuemei，HAN Ying

2020, 23(28): 3583-3589. DOI: 10.12114/j.issn.1007-9572.2019.00.762

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Background　With the increase of age，the physical function of the elderly people decreases with limited behavioral ability，and their work roles and some social roles disappeared. The elderly are gradually disconnecting from the social network and prone to social isolation. As the most important living place for the elderly，community plays a vital role in this process. Objective　To evaluate the occurrence of social isolation among the elderly people in community at different ages，and to explore the influence of community function and public services on social isolation of the elderly people at different ages. Methods　A total of 1 526 elderly residents of six typical elderly communities in Tangshan were selected as research objects by means of convenient sampling from September 2017 to August 2018. These elderly people were divided into different age groups（60-69 years old group，70-79 years old group，and 80 years old and above group）. The Lubben Social Network Scale 6（LSNS-6） was used to evaluate social isolation status of the elderly in community. At the same time，the self-designed general situation questionnaire and community function and public services questionnaire were used. Multivariate linear regression was used to analyze the influencing factors of social isolation among the elderly in different age groups. Results　Of the 1 526 community elderly residents，371（24.31%） cases had social isolation，and the LSNS-6 score was（16.32±5.429）. Among 651 cases aged 60-69，155（23.81%） cases had social isolation，and the LSNS-6 score was（16.25±5.257）；of 639 cases aged 70-79，126（19.72%） cases had social isolation，and the LSNS-6 score was（16.71±5.197）；among 236 cases over 80 years old in community，90（38.14%） cases suffered from social isolation，and the LSNS-6 score was（14.41±6.231）. There was significant difference in LSNS-6 scores among the elderly in different age groups（F=15.877，P<0.001）. Further comparisons between every two age groups showed that LSNS-6 scores of the elderly over 80 years old were lower than those of the elderly aged 60-69 and 70-79（P<0.001）. Multivariate linear regression analysis showed that pre-retirement occupation，residential floors，chronic diseases，marital status，community function，community cultural and recreational services and adaptability of community public services were the influencing factors of social isolation for elderly people aged 60-69（P<0.05）. Pre-retirement occupation，residential floors，chronic diseases，marital status，community function，community health services，community old-age services，adaptability of community public services and accessibility of community service centers were the influencing factors of social isolation for the elderly aged 70-79（P<0.05）. Pre-retirement occupation，residential floors，marital status，community function，available community health services and community old-age services were the influencing factors of social isolation for the elderly aged 80 and over（P<0.05）. Conclusion　Social isolation is most likely to occur among the elderly aged 80 and over. Community function and public services have different impacts on social isolation of the elderly at different ages. Community workers should provide targeted services for the elderly according to their different ages.

Current Status of Illness Perception among Ordinary Patients and Its Influencing Factors　

MA Qianwen，ZHAO Jingbo

2020, 23(28): 3590-3594. DOI: 10.12114/j.issn.1007-9572.2020.00.081

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Background　Numerous studies at home and abroad have shown that illness perception greatly affects the treatment effect and prognosis. Therefore，it is essential to explore the current status of illness perception among ordinary patients and its possible influencing factors in China，which may provide the basis for improving negative illness perception of patients and their health conditions. Objective　To investigate the current status of illness perception among ordinary patients and its influencing factors. Methods　From January to March of 2018，500 patients from eight general hospitals in Guangdong Province were selected for an on-site investigation by convenience sampling method，and 384 cases（76.8%） of valid data were obtained. The Brief Illness Perception Questionnaire（BIPQ），the Wake Forest Physician Trust Scale（WFPTS），Ten-item Personality Inventory in China（TIPI-C），and Patient Health Questionnaire 2-item（PHQ-2） were used for investigation. Results　The score of BIPQ was（38.6±9.1），and scores of the dimension of cognition，emotion，and understanding were（22.1±7.0），（13.3±4.0），and（3.2±2.2）. The scores of BIPQ were significantly different among patients with different occupations and the impact of medical expenses on family economy（P<0.05）. Pearson correlation analysis showed that the scores of BIPQ had a linear negative correlation with the scores of WFPTS and its scores of the dimension of benevolence and technical competence，as well as scores of the dimension of pleasantness and emotional stability in the TIPI-C（r values were -0.39 to -0.14，P<0.05），and the scores of BIPQ were significantly correlated with the scores of PHQ-2 positively（r=0.41，P<0.05）. Multivariate linear stepwise regression analysis showed that influencing factors of the scores of BIPQ were the score of PHQ-2（b=2.308），the score of the dimension of emotional stability in TIPI-C（b=-0.781），and the score of the dimension of benevolence in WFPTS（b=-0.337）（P<0.05）. Conclusion　Patients in China have insufficient understanding of their own illness，and they are lack of confidence in treatment with more negative emotions. Depression and economic stress caused by medical expenses are risk factors for illness perception，while the emotional stability and benevolence of physicians are the protective factors.

The Application Value of Depression Structured Rehabilitation Skills Training Program in Primary Hospitals　

LI Yuepeng，SHANG Zhengjun，ZHOU Hongli，MA Weiyi，TANG Lirong

2020, 23(28): 3595-3599. DOI: 10.12114/j.issn.1007-9572.2020.00.110

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Background　The rehabilitation training is a good assisted therapy for depression. This paper attempts to introduce the mature depression rehabilitation technology，teach primary medical staff how to use this technology skillfully and involve all patients with depression within the jurisdiction in the rehabilitation training in order to improve the treatment outcome of patients with depression and reduce the risk of suicide. Objective　To investigate the application value of depression rehabilitation training program in primary hospitals. Methods　A total of 65 patients with depression who attended in the outpatient clinic service of Longquan Hospital of Mentougou District were selected from January to September in 2018. They were involved in the rehabilitation training and assessed by Hamilton Depression Scale（HAMD），Social Disability?Screening Schedule（SDSS），medication compliance，Nurses' Global Assessment of Suicide Risk（NGASR）and suicide risk questionnaire before the training and after three-month training. Results　A total of 61 cases completed the study. Patients' scores of HAMD and SDSS after three-month training were significantly lower than that before the training；the medication compliance was significantly improved except for stopping the medicine and the suicidal ideation significantly decreased（P<0.05）. Conclusion　Depression structured rehabilitation training program can effectively enhance the medication compliance of patients with depression，improve their depression symptoms and reduce their suicidal ideation，which is worthy of being promoted in primary hospitals.

WANG Cong，TANG Shaoliang

2020, 23(28): 3600-3607. DOI: 10.12114/j.issn.1007-9572.2020.00.403

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Background　Chronic diseases have become an important kind of diseases that haunt and threaten the health of residents，which seriously reduce the health-related quality of life in the suffered ones，and bring a heavy disease burden on them. Objective　To calculate the health utility value，and assess the health-related quality of life and its influencing factors in chronic disease patients in four provinces（Gansu，Hebei，Sichuan and Zhejiang）. Methods　From May 2017 to May 2018，by use of stratified sampling and random sampling，chronic disease patients from four provinces were enrolled，and were surveyed with a questionnaire developed by our research group for collecting sociodemographics and healthcare behaviors and utilization data，and with the Chinese version of EQ-5D-5L for assessing the health utility value. Health-related quality of life and its influencing factors were analyzed by descriptive statistical analysis，Tobit model，and censored least absolute deviations（CLAD） model. Results　The health utility value of patients with chronic diseases in the four provinces ranged from -0.391 0 to 1. Personal characteristics were associated with the differences in health utility value（P<0.05）. To be specific，health utility value differed significantly by age，marital status，employment status，monthly income，BMI and type of medical insurance（P<0.05）. Tobit regression results showed that age and marital status were the influencing factors of health-related quality of life（P<0.05）. And CLAD regression results showed that age，marital status，employment status，BMI，and whether having a health file were the influencing factors of health-related quality of life（P<0.05）. Conclusion　Our study found that CLAD regression analysis was superior to Tobit regression analysis in terms of identifying the factors affecting the health-related quality of life in chronic disease patients. Besides household register，marital status，and employment status，other sociodemographic factors such as BMI，whether having a medical examination in the past year，number of chronic diseases，and ratio of treatment cost reimbursed by medical insurance are worthy of special attention. In addition，regional healthcare policies should be developed based on the local practical characteristics.

Times of Attaining the Target Blood Pressure Level and Cardio-cerebrovascular Disease Incidence in Hypertensive Patients　

MA Yihan，LI Xingyu，LIU Qian，HAN Xu，SONG Yongjian，LI Guo，WU Shouling，WU Yuntao

2020, 23(28): 3608-3614. DOI: 10.12114/j.issn.1007-9572.2020.00.418

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Background　Hypertension is a risk factor for new-onset cardio-cerebrovascular diseases in the general population. At present，most studies focus on whether attaining the target blood pressure level has an influence on the morbidity of newly developed cardio-cerebrovascular diseases in hypertensive patients. There is no research on the association of times of attaining the target blood pressure level and cardio-cerebrovascular disease incidence in patients with hypertension. Objective　To evaluate the association of times of attaining the target blood pressure level with cardio-cerebrovascular disease morbidity in hypertensive patients. Methods　A prospective cohort study design was applied. A total of 16 131 hypertensive participants who participated in four annual health examinations（2006，2008，2010，2012） conducted by Kailuan（Group） Limited Liability Corporation and had no history of cardio-cerebrovascular diseases and cancer were enrolled. The follow-up started from the completion of the 2012 annual health examination，and ended till the onset of newly diagnosed cardio-cerebrovascular disease，death or the last day of follow-up period（2017-12-31）. For ease of estimating the association of times of attaining the target blood pressure level with cardio-cerebrovascular disease incidence，those who were found with attaining the target blood pressure level for 0，1，2，and 3 times in 2008，2010，and 2012 annual examinations were assigned to zero-time（n=5 850），one-time（n=4 838），two-time （n=3 276），and three-time（n=2 167） groups，respectively，and baseline data and incidence of cardio-cerebrovascular disease were compared between the groups. The cumulative incidence was estimated by Kaplan-Meier approach，and was compared by Log-Rank test. Multivariate Cox regression model was used to analyze the effect of the times of attaining the target blood pressure level on the incidence of cardio-cerebrovascular diseases. After excluding those with diabetes，hyperlipidemia and smoking habit，the Cox regression model was analyzed for sensitivity analysis. Results　There were significant differences in average age，male proportion，SBP，DBP，FBG，TC，and hs-CRP，proportion of smokers，proportion of drinkers，proportion of physical exercisers，detection rate of diabetes，detection rate of hyperlipidemia，and proportions of people taking antihypertensive drugs and hypoglycemic drugs among the groups（P<0.05）. The average follow-up period was （4.61±0.80） years. The incidence rate of CVD was 102.40/10 000 years. The cumulative incidence of cardio-cerebrovascular disease for zero-time，one-time，two-time，and three-time groups was 7.5%，6.9%，3.4% and 1.9%，respectively. And Log-Rank test showed that the difference in cumulative incidence of cardio-cerebrovascular disease among the groups was significant（χ2=128.33，P<0.01）. The Cox regression analysis presented that after adjusting for age，gender，BMI，hs-CRP，hyperlipidemia，diabetes，history of taking antihypertensive drugs，smoking，drinking，and physical exercise，compared with zero-time group，the HR（95%CI） for cardio-cerebrovascular disease incidence in one-time，two-time，and three-time groups was 0.90（0.76，1.06），0.53（0.42，0.68）and 0.37（0.26，0.53），respectively. The above results were not changed after excluding the diabetic，smoking and hyperlipidemia participants in the sensitivity analysis. Conclusion　 More times of attaining the target blood pressure level may be a protective factor for cardio-cerebrovascular disease，and continuous attaining the target may be associated with decreased risk of cardio-cerebrovascular disease.

Effect of Different Chest Pain Management Models on Acute ST-segment Elevation Myocardial Infarction in Tianjin：a Comparative Study　

CHEN Jinyu，ZHAO Kun，HUO Yong，LI Chunjie，SUI Binyan

2020, 23(28): 3615-3619. DOI: 10.12114/j.issn.1007-9572.2020.00.270

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Background　Since the establishment of the first chest pain center in Tianjin in 2014，the mortality rate of acute myocardial infarction in Tianjin residents decreased for three consecutive years. Evaluating the significance of the construction of chest pain center may have important practical guidance for further establishment of high-quality and efficient healthcare delivery system. Objective　To compare the effect of acute ST-segment elevation myocardial infarction（STEMI） by different chest pain management models in Tianjin，providing suggestions for improving the construction of chest pain center，and offering evidence for the promotion of management model of chest pain center. Methods　From October 2014 to February 2019，8 011 STEMI patients who underwent emergency percutaneous coronary intervention（PCI） in 33 chest hospitals in Tianjin were selected. They were divided into groups A，B and C according to the chest pain management model in the hospital they visited：group A received the chest pain management without chest pain center certification（n=915），group B received the chest pain management with chest pain center certification（standard level）（n=6 981），and group C received the chest pain management with chest pain center certification（primary level）（n=115）. Symptom-to-door（S2D） time，symptom-to-first medical contact（S2FMC） time，first medical contact-to-ECG（FMC2ECG） time，first medical contact-to-balloon（FMC2B） time，and door-to-balloon（D2B） time were compared among three groups. Moreover，the prevalence rates of intensive 24-hour statins treatment，use of β-blockers，post-PCI TIMI grade 3 flow，and post-discharge combined use of drugs（dual antiplatelet drugs，statins，β-blockers，RAS blockers） were compared. Results　The median time of S2D，S2FMC，FMC2ECG，FMC2B and D2B in the participants were 117（147） min，100（128） min，2（2） min，76（47） min
and 67（32） min，respectively. There were significant differences in average median FMC2ECG time，FMC2B time，D2B time，as well as the prevalence rates of intensive 24-hour statins treatment，β-blocker use，post-PCI TIMI grade 3 flow，and post-discharge combined use of drugs among the three groups（P<0.05）. Further comparison showed that the prevalence rates of average median FMC2ECG time，FMC2B time，D2B time in group B were lower than those of group A（P<0.017），and post-PCI TIMI grade 3 flow in group B was higher than that of group A（P<0.017）；the prevalence rates of intensive 24-hour statins treatment，β-blocker use and post-discharge combined use of drugs in groups B and C were higher than those of group A（P<0.017）；Group C had lower average median FMC2ECG and D2B time and higher prevalence rate of intensive 24-hour statins treatment than group B（P<0.017）. From 2017 to 2019，the yearly median D2B time in group B was shorter than group A，and the prevalence rat of yearly median D2B time<90 min in group B was greater than group A. Conclusion　The standard chest pain management may significantly shorten the reperfusion time，standardize the clinical medication and improve the prognosis of acute STEMI patients，but the pre-hospital emergency time could not be shortened. It is necessary to continue to promote the construction of regional chest pain centers to save more patients.

Investigation and Analysis of Employment Orientation of General Practice Postgraduates Graduating from 2011 to 2018 in a University of Beijing　

CHEN Lifen，CUI Jie，WANG Yajun，JIA Jianguo，LU Xiaoqin

2020, 23(28): 3620-3623. DOI: 10.12114/j.issn.1007-9572.2020.00.021

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Background　At present，there is still a big gap of general practitioners（GPs） in China. There are some studies on the causes and countermeasures of the shortage of grassroots GPs，while there is no relevant research on the investigation and analysis of the employment prospects of postgraduates in general practice，which may be related to the late start of training for postgraduates in general practice，especially the parallel resident training，and the small scale of general practice graduates. It is of great significance for medical graduates，especially those majoring in general practice，to obtain employment in grassroots medical institutions to fill the long-term shortage of GPs in China. Objective　To understand the employment status of postgraduates in general practice and to analyze the strategies to reduce and avoid the outflow of talent in primary health care institutions. Methods　The employment prospects of all general practice postgraduates graduating from 2011 to 2018 in a university in Beijing were investigated and analyzed. The overall employment results and related information were collected and the nature of employment units，medical institution levels，job positions and other dimensions were compared between the different genders，education levels，and graduate years. Results　From 2011 to 2018，there were 116 graduate students of general practice，including 8 doctoral students of science degree，16 postgraduate students of science degree and 92 postgraduate students of professional degree. The employment rate（including enrollment） in the year of graduation was 100.0%. There were significant differences in the nature of employment units，hospital level and job positions of graduates of different genders（P<0.05）. There were significant differences in the nature of employment unit，hospital level and job position between the postgraduates of scientific degree and the postgraduates of professional degree（P<0.001）. The employment rate of medical institutions reached 100.0% in 2018，and the employment rate of hospitals at all levels remained relatively stable. The proportion of general practitioners engaged in general practice reached 82.9%. Conclusion　The employment expectation of general practice postgraduates is high and the overall employment rate is good，but the employment situation at the primary hospitals and communities is still not optimistic. We should continue to strengthen and improve the policy guidance and incentive mechanism，enhance the attractiveness of primary hospitals and communities，and continuously improve the quality of personnel and service level of primary hospitals and communities to form a virtuous circle of "policy guidance-talent sinking-medical service level upgrading-opportunity and high rates of remuneration realizing".

Investigation and Analysis of the First Batch of Graduated General Practice Trainees from Large General Hospitals in Henan Province　

GAO Yanxia，LIU Xiangwei1，XU Hongwei2，LI Yi3，GUO Yanke1，ZHAO Song4，LIU Huifan，WANG Xiuling，MA Taoran，LU Guangping，PAN Zhigang，ZHU Changju

2020, 23(28): 3624-3630. DOI: 10.12114/j.issn.1007-9572.2020.00.173

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Background　General practitioners（GPs） make up the bulk of the participants of standardized GP training（hereinafter referred to as GP training）. Their feedback and evaluations on the GP training directly reflect the effect and quality of this training and may influence the formulation of related policies of the general practice. Objective　This article analyzes the situation of general practice education in large-scale general hospitals，and tries to find out the existing problems and causes，in order to provide a reference for better GP training in the future and gradually improve the GP education，and to cultivate high-level GPs for the country. Methods　A total of 200 GPs who graduated in June of 2018 from the First Affiliated Hospital of Zhengzhou University were selected by cluster sampling from May to June in 2018. Anonymous questionnaires and written interviews were used to understand the situation of the GP training. The questionnaire mainly included five parts of the basic situation of GPs，the situation of GP residency，the understanding of general practice，the feedback of GP training，and the basic situation of GP's employment. Results　A total of 200 questionnaires were distributed，and 200 valid questionnaires were recovered. The effective recovery rate was 100.0%. And 7.5%（15/200） of the trainees did not pass the medical licensing examination；10.5%（21/200） of the trainees delayed their graduation；and 94.3%（182/193） of the trainees were well trained and influenced by the tutors during the three years of residency. After three years of residency，the proportion of trainees who had a good understanding of the general practice improved to 83.0%（166/200）. The proportion of trainees willing to engage in the work of general practice reached to 83.0%（166/200）. About the confidence in rooting in grassroots work，only 14.5%（29/200） of trainees showed confidence. Of the 113 order-oriented trainees，52.2%（59/113） were willing to return to the grassroots work. For their career plan after three years，only 10.6%（12/113） of the trainees were willing to stay at the grassroots level. Among 26 social GP graduates who have found jobs，88.5%（23/26） continued to engage in clinical work，of which 21.7%（5/23） worked in the tertiary hospitals. Among 15 consigned GP graduates，93.3%（14/15） were mainly from county hospitals. And 61.9%（13/21） of the 21 trainees who had postponed graduation due to maternity leave，and the percentage of trainees who failed to pass the examination or had physical reasons were both 19.0%（4/21）. Conclusion　The GP training should strengthen the comprehensive training of trainees from the aspects of basic knowledge，clinical skills and the general practice concept to further enhance their sense of professional identity，promote and standardize the training mode of dual-tutor system，and improve the comprehensive competitiveness of trainees. It is necessary to strengthen the construction of the faculty and ensure the effectiveness of GP training in various aspects，and to explore ways to increase the attractiveness of GP posts at grassroots level based on the true employment status of GP.

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