Table of Content

05 April 2023, Volume 26 Issue 10

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Guideline Interpretation

Interpretation of the 2022 World Guidelines for Falls Prevention and Management for Older Adults: a Global Initiative

WU Yan, WANG Guangling, NIE Zuoting, LIANG Wei, DU Yan, LI Qing, ZENG Kai, CHEN Long, GAO Shiying, TAO Lu, YANG Rumei, DING Yaping

2023, 26(10):  1159-1163.  DOI: 10.12114/j.issn.1007-9572.2022.0842

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As China enters a deep aging society, falls and fall-related injuries in older adults have gained increased attention, with increasing emergence of relevant studies, and continuous updates in relevant guidelines. In 2022, The World Falls Task Force assembled 96 experts from 39 countries to develop the World Guidelines for Falls Prevention and Management for Older Adults: a Global Initiative. The guidelines were developed using the person-centered methodology and the latest evidence on e-health for the prevention of falls, with full consideration of the needs of fall management of older adults, and their caregivers and other stakeholders' perspectives on preventing falls in older adults, as well as the guideline applicability in various care settings and locations with limited resources, which provide new clinical recommendations on the screening, assessment, and management of risk for falls among community-dwelling older adults. This paper offers an in-depth interpretation of the guidelines and an analysis of the effective practical guidance in the guidelines, providing practical guidance for Chinese physicians, nurses and community health workers to prevent and manage falls in older adults.

Interpretation on Key Points of International Consensus Statement on the Diagnosis, Multidisciplinary Management and Lifelong Care of Individuals with Achondroplasia

SUN Wenwen, LIU Jing, KONG Dexian, ZHANG Zhimin, MA Huijuan

2023, 26(10):  1164-1171.  DOI: 10.12114/j.issn.1007-9572.2022.0589

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Achondroplasia is a rare disease leading to growth and developmental disorders in children, mainly manifested as skeletal dysplasia and disproportionate short stature, which can lead to respiratory abnormalities, hearing loss, spinal involvement, limb joint deformity and other problems, thus making patients encounter a variety of treatment and rehabilitation issues throughout their life, with greatly impaired quality of life. However, the clinical treatment and care pathways of achondroplasia are still not completely unified. To facilitate the standardization of clinical treatment of achondroplasia, the International Consensus Statement on the Diagnosis, Multidisciplinary Management and Lifelong Care of Individuals with Achondroplasia was developed by a group of international experts. We interpreted the key points of the consensus, mainly involving lifelong care and multidisciplinary clinical management, aiming to promote the standardization of care for individuals with achondroplasia in order to improve their clinical outcomes and quality of life as well as reduce their mortality.

Reflection & Decision-making

The Doctor-patient Trust in General Practice Service and Its Countermeasure Suggestions Based on Trusted Source Model

MA Zhiqiang, WU Xianglan

2023, 26(10):  1172-1178.  DOI: 10.12114/j.issn.1007-9572.2022.0316

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Enhancing doctor-patient trust is the key to improving medical service quality in the context of the general pracitce service system. This paper explores the doctor-patient trust in general practice services in depth based on doctor-patient trusted source model combining with literature analysis. It is concluded that the intensity of supervision of contracted services by the health administration, the facility environment of community health service institutions, the quality of services provided by general practitioners, and residents' own trust tendency are the key factors affecting the doctor-patient trust. From the perspective of the above four subjects, suggestions including strengthening the supervision of health administration, enhancing institutional trust, strengthening doctor-patient communication, enhancing interpersonal trust, and giving full play to residents' social supervision power are put forward in this paper, in order to improve the willingness to access primary health care services of residents and the quality of general practice services.

Collaboration between Primary Care Pharmacists and General Practitioner Teams: Recent Developments, Challenges and Countermeasures

DENG Zhiling, LU Yiting, LIANG Xujian, ZENG Ruifeng, LI Haixin, LU Panpan, XU Zhijie

2023, 26(10):  1179-1185.  DOI: 10.12114/j.issn.1007-9572.2022.0615

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With the transformation of the role of pharmacists, the model and content of pharmacy services in primary care delivered by them have changed significantly, and they may play a greater role in the collaboration with general practitioner teams. This paper elaborated the content and model of collaboration between primary care pharmacists and general practitioner teams globally, analyzed the current effects of collaboration on improving clinical outcomes of patients, saving medical expenses and standardizing rational use of medicines, and summarized the challenges and barriers to collaboration, including general practitioners' low willingness to collaborate, patients' lack of confidence in the professional competence of primary pharmacists, barriers to role conversion of primary care pharmacists, additional medical costs, and imperfect infrastructure, etc. In view of the above barriers, this paper proposed five coping strategies, including clearly defining the responsibility of pharmacists in general practitioner teams, developing the incentive system and improving the management of fund, enhancing the training for community pharmacists and constructing the position-specific competencies evaluation system, strengthening the communication and mutual trust between general practitioners and pharmacists, and optimizing the pattern of collaboration. All of these provide theoretical reference and strategic support for the development of the collaboration between primary care pharmacists and general practitioners teams in China.

Original Research·Focus on Primary Health Services

Psychological Capital and Associated Factors among Community General Practitioners in China

ZHANG Li, ZHENG Yanling, FENG Jing, GAN Yong

2023, 26(10):  1186-1191.  DOI: 10.12114/j.issn.1007-9572.2022.0602

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Background

Psychological capital (PsyCap) has a significant impact on individual attitude, behavior, and performance. Currently, studies on the level and associated factors of PsyCap among general practitioners (GPs) are limited.

Objective

To investigate the level of PsyCap and its associated factors among community GPs in China, providing evidence for human resource management in primary health care.

Methods

To conduct the questionnaire survey, 40 community health service institutions from their list of community health service institutions were randomly chosen, 4 632 GPs (40% of whom were on duty) were randomly selected from each community health service institution's duty roster on the day of the survey, and all five provinces (autonomous, municipalities) regions in the east, central, and west China were chosen by use of multi-stage stratified random sampling between March and May 2021. The questionnaire consisted of 3 sections: general information, workplace violence, and PsyCap, and statistical analysis was performed using general descriptive analysis, rank sum test, and generalized linear regression.

Results

A total of 4 376 community GPs were finally included as eligible respondents. The total median score and average total score of PsyCap were 104 (20) and 4.33 (0.83), higher than the theoretical median (3.50 points). The region〔central China (b=1.355) 〕, age〔40~49 (b=2.609), ≥50 (b=4.035) 〕, marital status〔married (b=1.801) 〕, practice setting〔rural (b=2.088) 〕, holding an administrative post〔no (b=-1.734) 〕, weekly working hours〔>50 (b=2.743) 〕, average number of daily consultations〔20~39 (b=2.177) 〕, workload〔moderate (b=6.900), high (b=8.146) 〕, occupational stress〔moderate (b=-6.936), high (b=-10.309) 〕, occupational development opportunities〔general (b=2.073), more (b=7.747) 〕, and the frequency of workplace violence〔low (b=-3.132), medium (b=-3.990), high (b=-7.033) 〕were factors associated with the level of PsyCap among GPs significantly (P<0.05) .

Conclusion

The PsyCap of community GPs in China is at an upper medium level, and the associated factors are complicated. To improve the level of PsyCap among GPs, attention should be paid to their mental health status, and provide them with interventions targeting PsyCap-related factors to lessen the GPs' stress.

Mechanisms Affecting the Effectiveness of Contracted Family Doctor Services: a Grounded Theory Analysis

MENG Wenqi, LIU Songyi, JIANG Xiaoli, PENG Haibo, LI Zixin, YU Qianqian, YIN Wenqiang, SUN Kui, CHEN Zhongming, GUO Hongwei

2023, 26(10):  1192-1197.  DOI: 10.12114/j.issn.1007-9572.2022.0719

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Background

It is urgent to improve the effectiveness of contracted family doctor services due to high prevalence of problems such as uninformed contracting, and contracting but making no appointments.

Objective

To analyze the mechanism influencing the effectiveness of contracted family doctor services.

Methods

From September 2021 to January 2022, in-depth interviews were conducted with 24 family doctors, 8 institutional managers, and 25 contracted residents purposively sampled from Weifang, Heze, and Jinan of Shandong Province, using an interview guide regarding implementation status of relevant policies and their work status, performance distribution and supervision and management, and sense of gain obtained from the contracting and desired services, respectively. The grounded theory using three levels of coding was used to systematically analyze the mechanism affecting the effectiveness of contracted family doctor services.

Results

Through the coding, 90 concepts (such as "residents' weak health awareness"), 24 categories (such as "awareness of the contracting"), and 8 core categories (such as "capacity in primary care") were obtained. A theoretical model of mechanisms influencing the effectiveness of contracted family doctor services was constructed, mainly including the implementation deviation of policies related to contracted family doctor services, capacity of primary care, and characteristics of residents.

Conclusion

The effectiveness of contracted family doctor services is affected by the deviation in implementing relevant policies, the capacity of primary health services and characteristics of residents. Therefore, to improve the effectiveness of these services, it is necessary to optimize the implementation path of relevant policies, improve family doctors' capacities, and improve residents' health literacy level.

Impact of Appointment Service on the Quality of Family Doctor Contract Service Outcomes

ZHOU Qiru, LI Jushuang, HAO Chun, WANG Yonggang, SHEN Rui, ZHU Minxian, CHENG Xin

2023, 26(10):  1198-1204.  DOI: 10.12114/j.issn.1007-9572.2022.0438

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Background

At present, the contracting rate of family doctors in China is high, but there are problems such as low service quality and low service utilization rate.

Objective

To comprehensively investigate the current situation of contracting, performance and renewal of family doctor services in Meizhou and Heyuan cities of Guangdong Province, and explore the impact of appointment consultation service on the quality of contract services.

Methods

From July to August 2021, 11 districts and counties in Meizhou and Heyuan cities were selected using a multi-stage sampling method, the list of rural health centers that can be investigated was provided by the health bureau of each district (county). The questionnaire was administered through the "questionnaire star" platform to the head of the rural health centers or the directors of public health. The questionnaire was prepared by the Guangdong Internet + Family Doctor Contract Guidance Center, which was called "Guangdong Family Doctor Contract Service Current Situation Questionnaire", including the basic information of the invesgated rural health centers, the current situation and progress of family doctor contract service. Based on the structure-process-outcome (SPO) model, the dependent variables were set as outcome quality indicators (effective contract rate of general population/focused population, number of institutions with difficulty in compliance and low renewal rate) to compare the current situation of family doctor contract service in rural health centers with different appointment consultation service provision capacity. The Logistic regression was used to analyze the impact of appointment consultation service on the outcome quality of contract service.

Results

The median family doctor contract rate of 100 rural health centers for focused population and general population was 69.0% (60.0%, 85.0%) and 31.8% (29.1%, 54.5%), respectively; the number of institutions reaching family doctor contract service coverage target for focused population/general population of 2025 was 42 (42.0%) and 30 (30.0%), respectively. A total of 78 (78.0%) of these 100 rural health centers faced difficulties in compliance implementation, including 38 (90.5%) rural health centers did not provide appointment consultation service; 50 (50.0%) rural health centers had problems with low renewal rates, including 18 (42.9%) of which did not provide appointment consultation service and faced difficulties in compliance implementation. Logistic regression analysis showed that among the health centers reaching the target, there was no effect the providing of appointment consultation service on the contracting rate of family doctors in the focused and general population (P>0.05) ; among the 100 investigeted health centers, the providing of appointment consultation service had a significant effect on the compliance difficulties of the contracted institutions〔OR (95%CI) =0.28 (0.08, 0.98), P<0.05〕; and the providing of appointment consultation service had no effect on the low renewal rate of contracted residents (P>0.05) .

Conclusion

The performance of family doctor contract service in Guangdong Province is closely related to the providing of appointment consultation service by the health cenyers, and it is recommended to enrich the form and content of appointment service in the process of subsequent service, enhance residents' trust and motivation to use the service actively through the Internet + platform "improve efficiency and quality", while injecting motivation for service provision and utilization from both doctors and patients in order to provide continuous and effective integrated medical and health services as well as health management.

Willingness to Refer Patients with Common Illnesses to Lower Level Institutions and Associated Factors in County Hospital Physicians

SUN Jingjing, ZHANG Yan, KUANG Wenbo, LUO Yimeng, HUANG Pengqun, MAIREYAMUGULI· Aihemaiti, JIN Mengyuan, GAO Zeyu, DU Hanlin, DAI Xiaojie

2023, 26(10):  1205-1211.  DOI: 10.12114/j.issn.1007-9572.2022.0640

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Background

The phenomenon of "no referral" still exists against the backdrop of implementing the hierarchical medical system, which has been preliminarily constructed in China. Most existing studies on addressing this phenomenon are mostly from the perspective of hospital management policies, ignoring the role of doctors as "health gatekeepers" in making decisions during the hierarchical diagnosis and treatment process.

Objective

To investigate the influence of personal, institutional, environmental, and policy factors on the willingness of physicians in county hospitals to refer patients with common diseases to lower level of institutions from physicians' perspective.

Methods

This study was conducted from July to August 2021. By use of region-based stratified and convenience sampling, seven county-level people's hospitals were selected as settings from eastern, central and western China. By use of cluster sampling, physicians (n=142) in internal medical departments were selected from the above-mentioned hospitals to attend an online (through the WJX.cn platform) or off-line (hospital) questionnaire survey to understand their willingness to refer patients with a common illness to lower level institutions, and personal, institutional, environmental, and policy factors associated with their willingness during a consultation described using the scenario simulation method. The survey achieved a response rate of 96.5% (137/142). Binary Logistic regression was used to analyze the effects of personal, institutional, environmental, and policy factors on physicians' willingness to refer the patients to a lower level institution.

Results

The mean score of physicians' willingness to refer the patients to a lower level institution was (9.92±2.20). Fifty-six physicians (40.9%) had higher level of willingness to conduct downward referrals. Education level, awareness level of referrals, and frequency of communication of referrals between higher and lower level institutions were associated with scores of physicians' willingness to conduct downward referrals (P<0.05). Spearman correlation analysis showed that self-rated overall workload, risk of medical disputes and patient-doctor relationship (in the institutional factor dimension) were positively correlated with physicians' willingness to conduct downward referrals (r_s=0.26, 0.32, and 0.23; P<0.05). Binary Logistic regression analysis showed that higher awareness level of referrals was associated with increased level of willingness to conduct downward referrals in physicians〔OR (95% CI) =1.62 (1.19, 2.22) 〕. Higher influence of the referral system implemented within the hospital on medical dispute risk was associated with increased physicians' level of willingness to conduct downward referrals〔OR (95%CI) =3.275 (1.10, 9.73) 〕. However, higher influence of the referral system implemented within the hospital on performance was associated with reduced level of willingness to conduct downward referrals in physicians〔OR (95%CI) =0.400 (0.20, 0.79) 〕.

Conclusion

This study suggests that the willingness of physicians in county hospitals to conduct downward referrals is low on the whole, but it can be improved by increasing physicians' awareness level of referrals, and improving the influence of the referral system implemented within the hospital on the risk of medical disputes, and decreasing the influence of the referral system implemented within the hospital on the performance. In view of this, it is recommended that hospitals adopt a performance appraisal model that incorporates policy values, highlights policy recognition of referrals, and measures economic losses caused by referrals and the value of extra labor load, strengthen the popularization of hierarchical medical system in primary hospitals, and innovatively use the Internet-based hierarchical diagnosis and treatment model.

Changes in the Efficiency of Member Township Hospitals in County-level Medical Communities Constructed in Typical National Pilot Areas

MENG Yeqing, LI Sisi, QIN Jiangmei, LIN Chunmei, ZHANG Yanchun, ZHANG Lifang

2023, 26(10):  1212-1217.  DOI: 10.12114/j.issn.1007-9572.2022.0525

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Background

The county-level medical community has helped improve the capacity of primary care institutions and the quality of primary care services, and promoted the operational efficiency of primary care institutions through various "strengthening primary healthcare" measures.

Objective

To evaluate the efficiency of service delivery and the total factor productivity (TFP) of member township hospitals in county-level medical communities constructed in typical national pilot areas in China.

Methods

We collected the annual monitoring data and annual health statistics reports during 2018 to 2019 of county-level medical communities (involving 143 member township hospitals) in eight counties (cities) of four regions in central and western China (Anhui Province, Jiangxi Province, Guangxi Zhuang Autonomous Region and Xinjiang Uygur Autonomous Region). We used data envelopment analysis (DEA) and Malmquist inde (MI) to analyze the change in TFP of the township health hospitals before and after the pilot construction of county medical communities.

Results

Taking the county as the decision-making unit, compared with 2018, the technical efficiency change, technological progress change, pure technical efficiency change, scale efficiency change and TFP change of township hospitals in the typical areas in 2019 were 0.977, 1.037, 0.995, 0.982 and 1.013, respectively, and the TFP of township hospitals increased by 1.3% on average. Taking township health centers as the decision-making unit, compared with 2018, the TFP of township hospitals increased by 4.5% in 2019. Specifically, the TFP of township hospitals increased by 47.83% in Anhui's A1 county, 66.67% in Anhui's A2 county, 54.84% in Jiangxi's B1 county, 59.26% in Jiangxi's B2 county, 70.00% in Guangxi's C1 county, 90.91% in Guangxi's C2 county, 78.57% in Xinjiang's D1 county, and 55.56% in Xinjiang's D2 county.

Conclusion

The "strengthening primary health care" measures implemented during the reform of county-level medical communities have played a role in elevating the efficiency of township hospitals. The continuous improvement in the efficiency of township hospitals relies on both the leading hospital providing targeted assistance and mobilizing the productivities and enthusiasm of the township hospitals.

Investigation on the Demand for TCM "Preventive Treatment of Disease" Service in Community Elderly Care Facilities

YAN Zheng, JIANG Haixian, LI Yunjia, LI Qin, LI Tianshu, SHEN Fulai

2023, 26(10):  1218-1223.  DOI: 10.12114/j.issn.1007-9572.2022.0145

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Background

The theoretical system and intervention technologies of TCM "preventive treatment of disease" service are mature, with certain economic and cultural advantages coping with health needs in different states. Providing TCM "preventive treatment of disease" service in community elderly care facilities closer to residents can both promote the efficient utilization of resource and enhance the experience of the elderly access to health services.

Objective

To explore the perceptions, attitudes and needs of the providers (medical workers providing TCM "preventive treatment of disease" service) and demanders (elderly access to health services) in community elderly care facilities, in order to clarify the service contents that should be promoted and complementary operational conditions when providing TCM "preventive treatment of disease" service in community elderly care facilities.

Methods

From 2020-07-31 to 2020-08-10, the medical workers providing health care service and the elderly access to services in the community elderly care facilities with the highest average daily service attendance administered by 6 community health service centers were investigated using self-designed questionnaire by the project team members. The questionnaire for providers mainly included the perspectives and suggestions on the performance of TCM "preventive treatment of disease" service which was completed by themselves. The questionnaire for demanders to services mainly included thier health needs, acceptability of TCM "preventive treatment of disease" service and its providing in community elderly care facilities which was completed by the health care workers mentioned before by questioning.

Results

The survey results of the providers showed that 81.6% (93/114) of the participants indicated that they had heard of or understood the concept of preventive treatment of disease, 41.2% (47/114) of them had performed health service project in community elderly care facilities, and 91.2% (104/114) of them considered that community elderly care facilities are suitable for providing health services. The survey results of the demanders showed that common helth problems mentioned by the elderly in the community included hypertension (57.0%, 138/242), diabetes (40.1%, 97/242), and low back pain (30.2%, 73/242), etc. 56.2% (136/242) of the participants indicated that they had received TCM health services with the satisfaction rate of 52.2% (71/136), 74.8% (181/242) of them had not heard of or learn much about preventive treatment of disease, 50.4% (122/242) of them were interested in TCM health services provided in community elderly care facilities. The suivey results of both providers and demanders showed that the the top 5 TCM "preventive treatment of disease" services suitable for community elderly care facilities are TCM four diagnostic methods, sports health care, living adjustment method, diet therapy and emotion regulation.

Conclusion

The health needs of the elderly in community elderly care facilities are consistent with the disease spectrum of the community. There is a demand and interest of preventive treatment of disease among the residents in the facilities. Community family physicians are interested and willing to provide the services in the facilities. The providing of TCM "preventive treatment of disease" services in community elderly care facilities have mass foundation and technical feasibility. However, there is a demand to strengthen the promotion, clarify charge, facilitate service delivery, and supply with appropriate service technologies.

Original Research·Focus on Cognitive Impairment

Characteristics and Application Value of Handwriting in Elderly Patients with Mild Cognitive Impairment

WEI Zhuqin, ZHANG Ruoyu, ZHANG Chen, SU Liming, HUANG Cheng, ZHANG Junwei, QIAN Mincai, QI Hengnian, WANG Lina

2023, 26(10):  1224-1233.  DOI: 10.12114/j.issn.1007-9572.2022.0729

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Background

Handwriting synthesis techniques have been extensively studied in the detection of cognitive impairment in dementia and Parkinson's disease. But handwriting characteristics in older adults with mild cognitive impairment (MCI) still need to be studied further.

Objective

To explore the differences between the handwriting characteristics of elderly patients with MCI and normal elderly people, and to assess the value of handwriting features in MCI screening.

Methods

By use of convenience sampling, 33 older adults with MCI were recruited from Huzhou communities from January to April 2022 (observation group), and were compared to age-, sex- and education level-matched 43 community-living older adults with normal cognitive function (control group). The General Information Questionnaire, the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment-Basic (MoCA-B), the Activity of Daily Living Scale (ADL), and the 15-item Geriatric Depression Scale (GDS-15) were used to survey subjects. Subjects were invited to complete six handwriting tasks (four are Chinese characters tasks and the other two are graphical drawing tasks) using a dot matrix digital pen to collect their kinematic parameters of handwriting. The classification accuracy, sensitivity and specificity of handwriting characteristics for the diagnosis of MCI were analyzed by discriminant analysis and receiver operating characteristic (ROC) curve, and predictive values of different schemes for MCI were analyzed.

Results

Compared with the control group, the observation group had higher average pressure in writing (Z=-2.122, P=0.034), longer time in air (Z=-4.302, P<0.001), writing time (Z=-3.663, P<0.001) and total time (t'=-5.565, P<0.001), lower average writing velocity (Z=-2.458, P=0.014), horizontal (Z=-2.950, P=0.003) and vertical (Z=-2.094, P=0.040) average writing velocity and maximum horizontal writing velocity (Z=-2.206, P=0.027), lower average acceleration of writing in horizontal direction (Z=-2.667, P=0.008) and overall score for writing correctness (Z=-3.593, P<0.001) in completing graphical drawing tasks. The observation group had relatively longer time in air (Z=-3.464, P=0.001) and total time (Z=-2.940, P=0.003) in completing Chinese characters tasks. Compared with the total time for completing Chinese characters tasks, the total time for completing graphical drawing tasks had higher specificity (93.0% vs 55.8%) in differentiating between MCI and control groups, with an area under the curve (AUC) of 0.828. The summary of handwriting characteristics for graphical drawing tasks correctly classified 80.3% (61/76) of older adults with MCI, with 87.9% sensitivity and 79.1% specificity, and had higher diagnostic efficacy for those with MCI than the MMSE scale (Z=1.993, P=0.046) and the summary of handwriting characteristics for Chinese characters tasks (Z=2.408, P=0.016) .

Conclusion

Handwriting characteristics of graphical drawing tasks may have potential application in screening of older adults at risk for MCI, which can be used simultaneously or prior to sets of neuropsychological tests conducted for the diagnosis of MCI in community health care facilities.

Prevalence and Associated Factors of Very Early Cognitive Impairment in COVID-19 Convalescents: a Study Using Data from a Questionnaire Survey

HUA Qiaoli, LIU Huiling, XU Xiaohua, ZHENG Danwen, WANG Qian, LIU Yuntao, ZHOU Xin, YANG Rongyuan, DING Banghan, GUO Jianwen, ZHANG Zhongde

2023, 26(10):  1234-1240.  DOI: 10.12114/j.issn.1007-9572.2022.0870

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Background

COVID-19 may impair the central nervous system, but the prevalence and related factors of very early cognitive impairment in discharged COVID-19 convalescents are still unclear.

Objective

To assess the prevalence of very early cognitive impairment in discharged COVID-19 convalescents, and to identify its influencing factors.

Methods

This study included 574 COVID-19 convalescents from August 28 to September 30, 2020, including individuals who were discharged from designated hospitals for treating COVID-19 in Wuhan from December 2019 to April 2020 randomly selected from the hospital information system, and those with informed consent recruited through news media. According to the Eight-item Informant Interview to Differentiate Aging and Dementia (AD8) score, the subjects were divided into a very early cognitive impairment group (AD8≥2) and a non-very early cognitive impairment group (AD8<2). A questionnaire survey was conducted with the subjects by four investigators at Hubei Provincial Hospital of Traditional Chinese& Western Medicine, using the General Information Questionnaire to collect demographic information and past disease history of the patients (including gender, age, underlying disease, classification of COVID-19 on admission, interval between discharge and the current survey, and various symptoms present at the time of follow-up), using the Generalized Anxiety Disorder-7 (GAD-7), the PTSD Check List–Civilian Version (PCL-C), and the Short Form 36 Health Survey Questionnaire (SF-36) to assess patients' anxiety, post-traumatic stress disorder, and quality of life, respectively. Three hundred and eleven cases finally completed the cognitive function screening. Multiple Logistic regression was used to evaluate the effects of gender, age, underlying disease and admission classification of COVID-19 on very early cognitive impairment. A restricted cubic spline model was used to assess the quantitative relationship between anxiety level and very early cognitive impairment.

Results

311 (54.18%) who effectively responded to the survey was finally enrolled, including 170 (54.7%) with very early cognitive impairment and 141 (45.3%) without. 230 (23.9%) had residual symptoms after discharge. Comparisons of gender, age, insomnia, fatigue, chest tightness, shortness of breath, loss of appetite, generalized anxiety disorder, PTSD positive, and the score of each SF-36 entry among COVID-19 convalescents with and without very early cognitive impairment were statistically significant (P<0.05). Multivariate Logistic regression analysis suggested that females〔OR (95%CI) =2.658 (1.528, 4.625) 〕, advanced age〔OR (95%CI) =3.736 (1.083, 12.890) 〕, and having generalised anxiety disorder〔OR (95%CI) =5.081 (1.229, 21.008) 〕were influential factors in increasing very early cognitive impairment (P<0.05). Restricted cubic spline models indicated a linear quantitative relationship between anxiety level and very early cognitive impairment, with higher levels of anxiety associated with a greater likelihood of very early cognitive impairment (P for non-linear test =0.132) .

Conclusion

The incidence of very early cognitive impairment is high in COVID-19 convalescents, and it may be higher in those who are older, female, or have generalized anxiety symptoms. Timely interventions for psychiatric problems and alleviation of anxiety symptoms in COVID-19 convalescents, especially in older women, may help to improve their cognitive function and Alzheimer's disease.

Correlation of Subjective Cognitive Decline with Multimorbidity among Elderly People

SONG Yinhua, LIU Yushuang, YANG Qing, WANG Shibin, HU Qing, ZHENG Chunchan, ZHANG Ping

2023, 26(10):  1241-1249.  DOI: 10.12114/j.issn.1007-9572.2022.0800

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Background

Subjective cognitive decline (SCD) is a target for early prevention of Alzheimer's disease (AD). AD is closely related to multimorbidity, but the correlation of SCD with multimorbidity has not been well defined.

Objective

To investigate the correlation between SCD and multimorbidity in the elderly, providing a theoretical basis for early prevention and intervention of AD.

Methods

From January 2021 to June 2022, 612 elderly people aged≥60 years were sampled by convenience sampling method in urban communities and elderly care institutions in Guangzhou. The objective cognitive function was assessed using the Chinese version of Montreal Cognitive Assessment-Basic (MoCA-BC), Chinese version of Clinical Dementia Rating Scale (CDR-C), and Chinese version of Hachinski Ischemic Scale (HIS-C). SCD was diagnosed using the conceptual framework proposed by the working group of the Subjective Cognitive Decline Initiative and Chinese version of Subjective Cognitive Decline-Questionnaire 9 (SCD-Q9-C). Then according to the assessment results, participants were divided into SCD group (having normal overall objective cognitive function, SCD and SCD-Q9-C score≥5) and normal cognitive (NC) group (having normal overall objective cognitive function, and SCD-Q9-C score<5). A general information questionnaire to collect socio-demographics〔gender, age, place of residence (community or elderly care institution), years of education, marital status, type of occupation before retirement, monthly income〕and health-related information〔body mass index, waist circumference, habits of smoking, alcohol consumption and drinking tea, exercise frequency, habit and average duration of siesta, sleep quality assessed using the Chinese version of Pittsburgh Sleep Quality Index (PSQI-C), depressive symptoms assessed using the Chinese version of Patient Health Questionnaire (PHQ-9-C), anxiety symptoms assessed using the Chinese version of Generalized Anxiety Disorder Scale-7 (GAD-7-C), and activities of daily living (ADLs) assessed using the ADL Scale for Chinese Adults〕. Besides, another questionnaire to collect the history of chronic illness. The level of multimorbidity was classified into three categories〔no multimorbidity (0-1), low multimorbidity (2-4) and high multimorbidity (≥5) 〕by the number of chronic conditions. A binary Logistic regression analysis was used to explore the effect of multimorbidity on the SCD.

Results

The mean SCD-Q9-C score was (4.20±1.95) in 612 elderly people in this survey. Two hundred and fifty cases (40.8%) and 362 cases (59.2%) were assigned to the SCD group, and NC group, respectively. Univariate analysis showed statistically significant differences in gender, age, years of education, type of occupation before retirement, monthly income, tea drinking habits, sleep quality, depressive symptoms, anxiety symptoms and ADL scores between SCD and NC groups (P<0.05). Five hundred and seventy-four cases (93.8%) had chronic diseases, and 475 (77.6%) of them had multimorbidity, including 352 (57.5%) with low multimorbidity level and 123 (20.1%) with high multimorbidity level. The differences in multimorbidity prevalence, multimorbidity level, diabetes, arthritis and osteoporosis between SCD and NC groups were statistically significant (P<0.05). Binary Logistic regression analysis showed that older age, poor sleep quality, presence of anxiety symptoms, poor ADLs, and high level of multimorbidity were statistically significant risk factors for SCD (P<0.05), with the risk of SCD being 1.826〔95%CI (1.037, 3.216) 〕times higher for high multimorbidity level than for no multimorbidity (P<0.05). Longer years of education was a protective factor for SCD (P<0.05) .

Conclusion

High multimorbidity level is associated with increased risk of SCD. Community and elderly care providers can use multimorbidity as an assessment indicator of cognitive decline, and collaboratively implement management of multimorbidity and related factors to actively identify and intervene in SCD in order to delay the development of AD in older adults and promote healthy ageing.

Association of Nighttime Sleep Duration with Cognitive Impairment among Community-dwelling Older Adults

NIE Huanhuan, LI Huaibiao, YANG Linsheng, HU Bing, SUN Liang, SHENG Jie, ZHANG Dongmei, CHEN Guimei, CHENG Beijing, MENG Xianglong, XU Peiru, XUE Guizhi, TAO Fangbiao

2023, 26(10):  1250-1256.  DOI: 10.12114/j.issn.1007-9572.2022.0766

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Background

With the rapid population aging in China, cognitive impairment in older adults has become a growing public health concern.

Objective

To examine the association between nighttime sleep duration and cognitive impairment among community-dwelling older adults.

Methods

Data were derived from the cohort of Older Adult Health and Modifiable Environmental Factors established in Fuyang City from July to September 2018, among whom a total of 4 837 older adults with complete data on cognitive function and sleep time were included in this study. General demographic characteristics〔gender, age, living area (urban or rural), education level, occupation, marital status〕, living habits, the history of chronic diseases, sleep duration, and overall cognitive function were extracted. Binary Logistic regression models were used to analyze the association between nighttime sleep duration and cognitive impairment. Restrictive cubic splines were used to further determine potential dose-response relationships between them.

Results

The participants had a mean nighttime sleep duration of (6.95±1.75) hours, among whom 1 773 (36.65%) slept ≤6 hours per day, 2 088 (43.17%) slept >6-8 hours per day, and 976 (20.18%) slept >8 hours per day. The detection rate of cognitive impairment was 37.44% (1 811/4 837). After adjusting for gender, age, living area, education level and other confounding factors, the detection rate of cognitive impairment was 1.26〔95%CI (1.09, 1.46) 〕 times higher in older adults with nighttime sleep duration of ≤6 hours, and was 1.22〔95%CI (1.03, 1.46) 〕 times higher in older adults with nighttime sleep duration of >8 hours than in those with nighttime sleep duration of >6-8 hours (P<0.05). The detection rate of cognitive impairment in male older adults with nighttime sleep duration of >8 hours was 1.35〔 (95%CI (1.06, 1.72) 〕 times higher than in those with nighttime sleep duration of >6-8 hours (P<0.05). The detection rate of cognitive impairment in female older adults with nighttime sleep duration of≤6 hours was 1.29〔95%CI (1.06, 1.58) 〕 times higher than in those with nighttime sleep duration of >6-8 hours (P<0.05). The restriction cube spline curve showed an approximate U-shaped relationship between nighttime sleep duration and the risk for cognitive impairment, with the lowest risk at 7 hours.

Conclusion

Both shorter and longer nighttime sleep duration may be independent and dose-dependent risk factors for cognitive impairment in older adults. The optimal sleep time is about 7 hours. The association between longer sleep duration and cognitive impairment is pronounced in males, while the association between shorter sleep duration and cognitive impairment is pronounced in females.

Original Research·Focus on Diabetes Management

Short- and Long-term Effects of Group-based Self-management Activities on Comprehensive Glycemic Control among Patients with Type 2 Diabetes in the Community

XIA Zhang, MAO Fan, JIANG Yingying, DONG Wenlan, DONG Jianqun

2023, 26(10):  1257-1263.  DOI: 10.12114/j.issn.1007-9572.2022.0674

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Background

Diabetes self-management is an important measure to reduce the adverse impact of the disease and improve the outcome in patients with diabetes. Existing diabetes self-management studies mainly focus on the evaluation of short-term intervention effects, but rarely report the long-term effects.

Objective

To evaluate the short- and long-term effects of group-based self-management activities on comprehensive glycemic control in type 2 diabetes patients in the community.

Methods

In 2014, 500 adults with type 2 diabetes were recruited from Fangshan District, Beijing, and randomly divided into a control group (n=241) and an intervention group (n=259). Both groups received routine diabetes follow-up services. The intervention group also received a three-month group-based self-management activities. We conducted four surveys at different times (at baseline, and three months, two years and five years post-intervention) to collect patient demographics, disease condition, comprehensive glycemic control indicators〔body mass index (BMI), blood pressure, fasting plasma glucose (FGP), glycated hemoglobin (HbA_1c), high-density lipoprotein cholesterol (HDL-C), triacylglycerol (TG), low-density lipoprotein cholesterol (LDL-C) 〕. Generalized estimating equations were used to analyze the main effect of the self-management activities and the interaction effect of the activities with post-intervention time.

Results

After adjusting for potential confounders, the main effects of the self-management activities on BMI, systolic blood pressure, diastolic blood pressure, FPG, HbA_1c, HDL-C, TG an LDL-C were not statistically significant (P>0.05). The main effects of time of intervention on various indicators were statistically significant (P<0.05). Specifically, the BMI, systolic blood pressure, diastolic blood pressure, FPG, HbA_1c, HDL-C and LDL-C increased, and TG decreased in the patients after intervention. We found the self-management activities and the intervention time had an interaction effect on BMI〔β (95%CI) =-0.33 (-0.62, -0.05) 〕, FPG〔β (95%CI) =-1.03 (-1.71, -0.35) 〕, and TG〔β (95%CI) =-0.54 (-0.93, -0.14) 〕: the BMI of the intervention group was 0.31 kg/m² lower than that of the control group at baseline, and was 0.64 kg/m² lower than that of the control group at three months post-intervention; the FPG of the intervention group was 0.19 mmol/L higher than that of the control group at baseline, but was 0.84 mmol/L lower than that of the control group at two years post-intervention; the TG of the intervention group was 0.03 mmol/L higher than that of the control group at baseline, but was 0.51 mmol/L lower than that of the control group at five years post-intervention.

Conclusion

Group-based self-management activities have a short-term effect on controlling BMI, and may have a long-term effect on controlling FPG and TG in patients with type 2 diabetes.

Long-term Intervention Effects of Using Smart Bracelets in Community-dwelling Type 2 Diabetes Patients

TAN Ying, CAO Min, CHEN Meiling, ZHAO Zedi, ZHENG Peng, FENG Huiyao, ZHANG Yue, DONG Xiaomei, CHEN Xiongfei, WU Xueji

2023, 26(10):  1264-1270.  DOI: 10.12114/j.issn.1007-9572.2022.0657

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Background

Smart bracelets are increasingly used in chronic disease management, which help improve patient adherence and motivation to exercise interventions, but more evidence for their long-term effectiveness in patients with type 2 diabetes mellitus (T2DM) in the community needs to be explored.

Objective

To develop an intervention model for community-dwelling type 2 diabetes patients using smart bracelets, and to assess its long-term effectiveness in these patients.

Methods

From July to August 2018, this study selected 11 community health institutions from 11 districts of Guangzhou (one from each district) as study settings. And from each setting, 10-15 T2DM patients were selected (intervention group), and were compared to sex-matched and age-matched (+/- two years) T2DM patients (control group). The intervention was carried out from September 2018 to August 2019 in two groups, both received standardized health management services provided by the family physician team and underwent the exercise prescribed by an exercise prescriber. The intervention group additionally received health monitoring and management via wearing a smart bracelet, and set personalized exercise challenge goals under the guidance of an exercise prescriber. The score of the Chinese version of Summary of Diabetes Self-Care Activities Measure (SDSCA-C), comprehensive assessment indicators, and attainment rates of key glycemic indicators were compared between the two groups before and after the intervention.

Results

Ninety-two patients in the control group and 144 patients in the intervention group completed one-year intervention and follow-up. After the intervention, the subscale scores of dietary management and foot care management and the total score of SDSCA-C increased notably in the intervention group (P<0.05), but changed insignificantly in the control group (P>0.05). Two groups had no statistically significant differences in all comprehensive assessment indicators at baseline (P>0.05). After one year of intervention, besides a decrease was found in total cholesterol, apolipoprotein A1 and apolipoprotein B in both groups, a reduction was found in waist circumference in the intervention group, and in fasting plasma glucose (FPG), triacylglycerol and low-density lipoprotein cholesterol in the control group (P<0.05) .In terms of the attainment rate of key indicators, the HbA_1c attainment rate increased in the intervention group after intervention (P<0.05), and the post-intervention rate was higher than that of the control group (P<0.05). The FPG attainment rate was higher after intervention in both groups (P<0.05). But the high-density lipoprotein cholesterol attainment rate was lower after intervention in both groups (P<0.05) .

Conclusion

Using a smart bracelet helps people with T2DM maintain self-management behaviors over time and keep their blood sugar at target levels. As dyslipidemia is an important factor affecting blood glucose control, pharmacological interventions should be initiated as early as possible to regulate lipid metabolism disorders in addition to lifestyle modification.

Characteristic of Polypharmacy in Older Adults with Type 2 Diabetes

CHEN Xiaomin, ZHANG Lina, LI Youjia

2023, 26(10):  1271-1277.  DOI: 10.12114/j.issn.1007-9572.2022.0536

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Background

The number of elderly diabetic patients is increasing rapidly with the aggravation of population aging. The coexistence of multiple conditions and polypharmacy are common in elderly diabetic patients. Strengthening clinically rational drug use can effectively reduce the incidence of adverse drug events and improve outcomes in these patients.

Objective

To understand the characteristics and patterns of polypharmacy including hypoglycemic, antihypertensive, lipid-lowering, antiplatelet agents in elderly patients with type 2 diabetes, so as to provide a reference for promoting rational medication use.

Methods

This study retrospectively selected 240 elderly inpatients with type 2 diabetes who were hospitalized in Department of Endocrinology, the Second Affiliated Hospital of Xi'an Jiaotong University from April 1, 2020 to March 31, 2022 by cluster sampling method in April 2022. The drugs used during hospitalization and post-discharge medication regimens were investigated. Descriptive analysis was used to analyze the treatment regimens of hypoglycemic, antihypertensive, lipid-regulating and antiplatelet.

Results

On average, the participants had (13.93±3.12) diagnoses at discharge, (16.48±5.41) kinds of medications during hospitalization, and (8.21±2.46) kinds of long-term medications after discharge. The rate of polypharmacy after discharge reached 89.2% (214/240). After discharge, 216 cases (90.0%) received hypoglycemic treatment, among whom 44.9% (97/216) used single drug therapy, and 58.3% (126/216) were treated with insulin. One hundred and eighty-three cases (76.2%) were treated with antihypertensive therapy, including 44.3% (81/183) with single drug therapy and 79.2% (145/183) with calcium channel blockers. One hundred and eighty-seven cases (77.9%) received lipid-regulation therapy, and 83.4% (156/187) of them received atorvastatin. One hundred and seventeen cases (48.7%) used antiplatelet drugs, among whom 77.8% (91/117) used aspirin. Eighty-four cases (35.0%) received hypoglycemic, antihypertensive, lipid-regulating and antiplatelet therapies.

Conclusion

Polypharmacy is common in elderly patients with type 2 diabetes, including hypoglycemic, antihypertensive, lipid-regulating, antiplatelet and other therapies, which indicates that they have received pre-treatment relatively comprehensive condition evaluation by medical workers. Although the rate of comprehensive management is high in this group, there are still some potential risks of adverse drug events due to irrational use of some drugs alone or in combination.

Consulting Room of General Practitioner

Intimate Partner Violence: Clinical Outcomes, Recognition and Management Techniques

ZHAO Zixiang, XIAO Jing, FENG Yan, JIANG Yue

2023, 26(10):  1278-1281.  DOI: 10.12114/j.issn.1007-9572.2022.0534

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Intimate partner violence (IPV) is the most common type of domestic violence, which not only harms the victim's physical and mental health and life safety but also leads to the degradation of marriage, family, and children's development. IPV occurs among all socioeconomic, religious, and cultural groups. About a quarter of Chinese women have suffered some forms of IPV from their partner. Most patients will not present to the clinic with IPV. It is difficult yet essential for clinicians to quickly identify possible IPV among various non-specific symptoms and signs. There are no official guidelines for diagnosing and treating IPV in China, and the Chinese literature on IPV is scarce. This paper summarizes the evidence in English literature on IPV, focusing on the clinical outcome, identification, and management techniques of IPV, and attempts to discuss how this evidence can be applied to China.

The Techniques for Encountering Victims of Domestic Violence in the General Outpatient

JIANG Yue, LI Jie

2023, 26(10):  1282-1286.  DOI: 10.12114/j.issn.1007-9572.2022.0586

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Victims of domestic violence may be suffer from both physical threats and psychological trauma, leading them to consult general practitioners for a wide range of physical and psychological problems. When encountering victims of domestic violence, general practitioners need to identify patients timely, fully assess and properly deal with their conditions. But in clinical practice, general practitioners often choose to ignore or simply refer such patients because of many problems such as difficulty in starting, lack of asking skills and proper handling methods. Based on the analysis of domestic violence cases, this paper discusses the techniques that contribute to the use of patient-centered method and bio-social-psychological model in carrying out diagnosis and treatment activities. This fully reflects the value of general practitioners and extends the concept of family-based treatment.