Table of Content

05 September 2023, Volume 26 Issue 25

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Guidelines·Consensus

Expert Consensus on Construction and Application of the Internet Medical Intelligent Auxiliary Prescription Review System

Chinese Medical Association Clinical Pharmacy Branch, Shanghai Medical Association Clinical Pharmacy Branch, Shanghai Pharmacy Association Hospital Pharmacy Professional Committee

2023, 26(25):  3079-3090.  DOI: 10.12114/j.issn.1007-9572.2023.0222

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With the prosperous development of Internet medical care and increasing flow of electronic prescriptions, electronic prescription review has become an important guarantee for rational drug use in the online medication environment. However, in the Internet scenario, inefficient manual review with low quality increases the risk of adverse drug events. The application of the intelligent auxiliary prescription review system can significantly reduce the working pressure of pharmacists reviewing prescriptions and improve the efficiency of review, but there is a lack of setting standards and standardized management measures in the system architecture, system functions and prescription review rules setting of the Internet medical intelligent auxiliary prescription review system at present, which cannot meet the rapidly developing needs of Internet medical care. Using the construction experience of the prescription review system in medical institutions as a reference, this expert consensus makes recommendations on the construction and application of the Internet medical intelligent auxiliary prescription review system based on the functions and methods of formulating prescription review rules of the existing prescription review system, to further promote the standardization of the Internet medical prescription review work and ensure rational drug use.

Original Research·Population Health

Current Status and Influencing Factors of Depression among Rural Middle-aged and Elderly Women in China

YANG Lu, ZONG Zhanhong, YI Yingying

2023, 26(25):  3091-3095.  DOI: 10.12114/j.issn.1007-9572.2023.0130

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Background

With the population aging, mental health of the middle-aged and elderly adults is of great concern, especially in middle-aged and elderly women. Compared with urban women, rural women are more likely to suffer from mental diseases due to their poorer health status, lower education level and backward living conditions, however, the accessibility of mental health services among them is low.

Objective

To understand the prevalence of depression among middle-aged and elderly women in rural China and analyze its influencing factors, in order to provide empirical evidence for improving the mental health of middle-aged and elderly women.

Methods

From May to July 2021, the follow-up data of the 2018 China Health and Retirement Longitudinal Study (CHARLS) was extracted, and rural women aged 45 years and above were selected as the study subjects (n=6 736) . The scores of the simplified version of the Center for Epidemiologic Studies Depression Scale (CES-D) were used to determine the depression status of rural middle-aged and elderly women. Chi-square tests and multivariate Logistic regression model were used to analyze the influencing factors of the occurence of depressive symptoms among rural middle-aged and elderly women (including individual characteristics, health behaviors, social participation and utilization of medical services utilization) .

Results

The CES-D score of 6 736 rural middle-aged and elderly women was (20.0±6.9) , 42.46% (2 860/6 736) of whom had depressive symptoms. The results of multivariate Logistic regression analysis showed that satisfication with health status〔OR (95%CI) =0.40 (0.36, 0.45) 〕, sleep duration ≥6 h〔OR (95%CI) =0.48 (0.43, 0.54) 〕, Internet use〔OR (95%CI) =0.63 (0.50, 0.80) 〕 and satisfication with life 〔OR (95%CI) =0.25 (0.21, 0.30) 〕 were correlated with lower risk of depression; hysical disability〔OR (95%CI) =1.41 (1.16, 1.71) 〕, suffering from chronic diseases〔OR (95%CI) =1.35 (1.21, 1.50) 〕, receiving outpatient services within 1 month〔OR (95%CI) =1.25 (1.09, 1.43) 〕 and hospitalization services within 1 year〔OR (95%CI) =1.31 (1.13, 1.52) 〕 were correlated with higher risk of depression.

Conclusion

Based on the results of this study, the depression status of middle-aged and elderly women in rural China is relatively severe and affected by individual characteristics, health behaviors, social participation, and the medical services utilization. It is recommended that governments and civil affairs departments at all levels pay close attention to the mental health of rural middle-aged and elderly women, especially through the intervention and prevention from multiple dimensions such as health promotion and education, medical service quality, and accessibility of information, in order to promote the construction of healthy villages and process of health aging in China.

Comparison of the CQ-11D, SF-6Dv1 and EQ-5D-3L Contemporaneous Utility Scores in Patients with Chronic Disease

WANG Wei, XIE Shitong, ZHOU Jiameng, PAN Jie, ZHU Wentao

2023, 26(25):  3096-3103.  DOI: 10.12114/j.issn.1007-9572.2022.0806

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Background

China is facing an increasing number of chronic disease patients. Health-related quality of life (HRQoL) is an important indicator assessing the effect of prevention and treatment measures for chronic diseases, so it is important to select an appropriate HRQoL measurement tool for these patients.

Objective

To compare the validity, consistency and correlation of the Chinese Medicinal Quality of Life scale (CQ-11D) , Short-form 6-dimension version 1 (SF-6Dv1) , and the 3-level version of EQ-5D (EQ-5D-3L) in terms of utility values measuring HRQoL in chronic disease patients, and to identify a scale that is most applicable to Chinese chronic disease patients.

Methods

From February 2021 to April 2021, this study recruited the initial sample of Chinese people using quota sampling with quotas based on sex and age from a total of 28 representative provinces, autonomous regions or municipalities selected from seven geographical regions (north China, northeast China, east China, central China, southwest China, northwest China, and south China, with 2 to 6 selected from each of the regions) . A face-to-face survey was used to collect the sample people's basic demographic information and the situation of chronic diseases, and self-reported HRQoL measured using the CQ-11D, SF-6Dv1 and EQ-5D-3L, respectively, then according to the survey results, those with chronic diseases were selected, and the utility values of the three scales in them were analyzed. Bland-Altman chart and intraclass correlation coefficient (ICC) were used to analyze the consistency and correlation of the three scales. Kruskal-Wallis H test was used for univariate analysis to determine whether or not there is a statistically significant difference between the utility values of the scales across age or sex groups.

Results

A total of 692 chronic disease patients were finally included. The mean (standard deviation) of utility scores of CQ-11D, SF-6Dv1 and EQ-5D-3L scales were (0.855±0.168) , (0.793±0.132) and (0.876±0.136) , respectively. The top three prevalent chronic diseases were hypertension (n=275) , arthritis (n=128) and hyperlipidemia (n=124) . Histogram showed that EQ-5D-3L had obvious ceiling effect, and CQ-11D was more widely distributed. The Bland-Altman chart showed that the consistency between the three scales was relatively good, and the points within the 95% limits of agreement (LOA) were all about 95%. The strength of correlation between CQ-11D and visual analogue score (VAS) was the highest (P<0.001) . The ICC among the three scales ranged from 0.528 to 0.625, showing a moderate level of correlation (P<0.001) . Both Bland-Altman chart and ICC analysis showed that SF-6Dv1 and EQ-5D-3L had the best consistency. The results of analysis for the three chronic diseases in subgroups were similar to those in the total sample. Univariate analysis showed that male patients with hypertension or hyperlipidemia had higher utility scores of three scales than their female counterparts (P<0.05) . And the utility scores of three scales were the lowest in 60-year-olds and above among patients with hyperlipidemia.

Conclusion

The ceiling effect of EQ-5D-3L scale is obvious in patients with chronic diseases. CQ-11D demonstrated a wide range of distribution of utility values in measuring the three chronic diseases, which may be more suitable for measuring HRQoL in Chinese chronic disease population, as no ceiling effect was observed and its correlation with VAS was the strongest.

Application of metaPRS and APOEε4 to Optimize Genetic Risk Prediction Modeling Strategy for Mild Cognitive Impairment

LI Zimeng, WANG Rong, CHEN Shuai, ZHAO Caili, WANG Xiaocong, WEN Yalu, LIU Long

2023, 26(25):  3104-3111.  DOI: 10.12114/j.issn.1007-9572.2022.0756

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Background

Mild cognitive impairment (MCI) is an important stage to intervene and delay the progression of dementia, and it has been shown closely associated with genetic factors, among which apolipoprotein E (APOE) ε4 is recognized as an important risk allele of MCI in the medical field. Due to the lack of Genome-Wide Association Study (GWAS) summary data of MCI, it is common to use the GWAS summary data of Alzheimer's disease (AD) as the base dataset to calculate the polygenic risk score (PRS) of MCI, resulting in suboptimal PRS genetic risk prediction for MCI.

Objective

To explore the and optimize the statistical modeling strategy of genetic risk in MCI from the perspective of generalized linear model and machine learning, using meta-polygenic risk score (metaPRS) and APOEε4 as important predictors.

Methods

PRS for the 12 MCI-related traits were calculated and integrated into metaPRS for MCI by elastic-net Logistic regression model. SCORE_APOE was calculated by weighting the APOEε4 effect size with age correction. XGBoost, GBM, Logistic regression and Lasso regression were used as statistical modeling methods to verify the inclusion strategies of different predictors based on metaPRS, SCORE_APOE and basic demographic information (age, gender, education level) . AUC and F-measure were used to evaluate the predictive effect of statistical modeling of genetic risk of MCI.

Results

metaPRS and SCORE_APOE have high predictive value for the genetic risk of MCI. After including metaPRS, SCORE_APOE and basic demographic information (age, gender, education level) , the predictive effect of each statistical modeling method is XGBoost (AUC=0.69, F-measure=0.88) , GBM (AUC=0.76, F-measure=0.87) , Logistic regression (AUC=0.77, F-measure=0.89) , and Lasso regression (AUC=0.76, F-measure=0.92) .

Conclusion

When the sample size is 325 (less than 500) , the Lasso regression model constructed by including metaPRS, SCORE_APOE and basic demographic information (age, gender, education level) as predictors has the best effect on MCI genetic risk prediction, providing a new idea and perspective for statistical modeling of genetic risk of complex diseases such as MCI.

Traditional Chinese Medicine Disease Spectrum Analysis in Outpatient Clinics of Contracted Residents by Family Doctors in Shenzhen Community Health Service Centers

YIN Zhaoxia, KONG Chongyu, ZOU Xianhui, LI Chuang, HUANG Yin, FENG Yang, WANG Yunfei, GONG Weijie

2023, 26(25):  3112-3117.  DOI: 10.12114/j.issn.1007-9572.2022.0601

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Background

The development of traditional Chinese medicine (TCM) has been listed as a national development strategy with vigorous improvement of TCM service capacity in primary care institutions as the important elements, however, there are few studies on the disease spectrum of TCM in community health service institutions.

Objective

To analysis the TCM disease spectrum in outpatient clinics of contracted residents by family doctors in Shenzhen community health service centers (abbreviated as CHSC) and understand the capability of TCM in Shenzhen health centers, thus providing a theoretical basis for promoting the development of TCM in primary care in China.

Methods

From May to June 2022, the records of outpatient consultations with treatment cost of 10 Shenzhen CHSCs from 2021-01-01 to 2021-06-30 were extracted by the unified information platform of the Health Commission of Shenzhen Municipality (Hangchuang Community Health Service Center Business System) . The 385 138 records with purpose of TCM treatment, matching diagnosis and treatment costs, first diagnosis can be coded in Classification and Codes of Diseases and ZHENG of Traditional Chinese Medicine (TCD) were collected. The disease spectrum was analyzed based on the classification of disease in TCD, mainly involving department categories, specialty system classifications, and TCM disease terms.

Results

A total of 385 138 records of TCM diagnosis and treatment were selected in this study, including 170 077 (44.16%) male cases and 215 061 (55.84%) female cases, with an average age of (36.7±9.4) years. All of the 7 TCD categories of disease spectrum were involved, including internal medicine accounting for 56.98% (219 445 cases) , pediatrics accounting for 20.56% (79 201 cases) , otolaryngology accounting for 12.45% (47 965 cases) , gynecology accounting for 7.95% (30 620 cases) , surgery accounting for 1.51% (5 797 cases) , orthopedics accounting for 0.37% (1 407 cases) and ophthalmology accounting for 0.18% (703 cases) . Apart from the specialty system classifications of tumor diseases, cancer diseases in each category, classifications of middle canthal disease, black eye disease, pupillary disease, traumatic eye disease in Ophthalmology, the disease spectrum involves all specialty system classifications in 7 categories. The cumulative diagnosis and treatment volume of several disease spectrums accounted for 90.00% of the total diagnosis and treatment in each category. The top 5 system diseases in the spectrum included respiratory system diseases accounting for 54.19% (208 701 cases) , musculoskeletal system diseases accounting for 19.05% (73 369 cases) , gynecological system diseases accounting for 7.95% (30 620 cases) , cardiovascular and cerebrovascular system diseases accounting for 7.15% (27 539 cases) , and the digestive system diseases accounting for 4.98% (19 162 cases) . Patients aged <15 years and 15-24 years mainly suffered from diseases related to the respiratory and digestive systems, and the incidence of diseases such as paralysis, dizziness, headache, insomnia, fatigue were increased with the increase of age; cold ranked the first for patients aged below 45 years, the paralysis of muscle and joint pain ranked the first for patients aged above 45 years.

Conclusion

The TCM diseases spectrum in Shenzhen CHSCs is wide, but the categories are relatively concentrated and single, mainly involving internal medicine, concentrating on respiratory system diseases, musculoskeletal system diseases, gynecological system diseases, cardiovascular and cerebrovascular system diseases, and digestive system diseases. It is necessary to strengthen and expand the TCM diagnosis and treatment capabilities in CHSCs to better meet diverse health needs of the residents.

Original Research·Incentive Mechanisms for Utilization of General Practitioners

Job Characteristics Model-based Study of the Intrinsic Incentive Mechanism for Primary Health Workers

ZHAO Shichao, PING Jing, ZHU Hong, JI Wanting, WANG Yuyan, WANG Ying

2023, 26(25):  3118-3126.  DOI: 10.12114/j.issn.1007-9572.2022.0642

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Background

The incentivation for primary health workers is vital for the realization of two goals of the new healthcare reform in China, namely strengthening primary healthcare and achieving hierarchical diagnosis and treatment. Most previous studies put more emphasis on extrinsic incentive measures and their effect on job outcomes, ignoring the intrinsic motivation effect of job itself.

Objective

To perform an analysis of the job characteristics of primary health workers using the framework of Job Characteristics Model, assess their intrinsic motivation effect on job outcomes of these workers, and compare the strength of impact of the five dimensions of job characteristics and income and other extrinsic motivators on job outcomes, and put forward policy recommendations for improving work motivation and performance of primary health workers.

Methods

A survey using a self-developed questionnaire was conducted with primary health workers who were on duty on the day of the survey selected from a multistage sample of healthcare settings (including 18 community health centers and 20 township health centers) in three cities of Shandong Province from February to June 2021. Then, from those who effectively completed the survey, 167 cases were selected using convenience sampling to attend semi-structured interviews to understand their views of the characteristics of job as a primary health worker. Pearson correlation was used to analyze the correlations of the five dimensions of job characteristics and extrinsic motivators with autonomous motivation, performance, burnout, and turnover intention. Hierarchical multiple linear regression was used to analyze the strength of impact of the five dimensions of job characteristics and extrinsic motivators on job outcomes. Thematic analysis was used to analyze the interview data.

Results

A total of 870 cases who handed in effective questionnaires were included for analysis. Among the five dimensions of job characteristics, respondents scored highest and lowest on skill variety (4.09±0.71) and task identity (3.18±1.04) , respectively, and their scores on task significance, feedback from job and autonomy were (3.91±0.76) (3.46±0.83) and (3.43±0.79) , respectively. Pearson correlation analysis showed that the level of each of the five dimensions of job characteristics had a positive correlation with autonomous motivation and performance (P<0.05) , and had a significant negative correlation with burnout and turnover intention (P<0.05) . Hierarchical multiple linear regression revealed that the five dimensions of job characteristics had significant impacts on job outcomes, specifically, autonomous motivation (R²=18.8%) , performance (R²=11.3%) , job burnout (R²=16.5%) and turnover intention (R²=21.9%) , whose explanatory power was stronger than that of five extrinsic motivators (The R² values of the five extrinsic motivators' contributions to the four job outcomes were 1.7%, 3.4%, 5.8%, and 11.8%, respectively) . The interview results reflected the problems of task fragmentation, limited autonomy and insufficient feedback from job.

Conclusion

In primary health workers, the intrinsic motivation effect of job characteristics outweighs the extrinsic motivation effect in terms of explanatory power for job outcomes. And there is a gap between actual and theoretical job characteristics. Attention should be paid to the intrinsic motivation effect of job itself. Some measures should be taken, such as increasing training opportunities and quality, reducing work-related burden of these workers and empowering them, increasing resource investment and reducing policy constraints, improving the performance management system, to reshape job perceptions to improve work motivation and performance of primary health workers.

Relationship between Psychological Capital and Intention to Stay among General Practitioners in China: the Mediating Role of Professional Identity

PAN Wen, FENG Jing, ZHENG Yanling, LEI Zihui, GAN Yong

2023, 26(25):  3127-3132.  DOI: 10.12114/j.issn.1007-9572.2022.0838

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Background

General practitioners (GPs) mainly provide basic medical and health services. The construction of GPs human resources is closely related to the development of primary care system.

Objective

To investigate the current status of psychological capital (PsyCap) , professional identity, and intention to stay of GPs in China and explore the relationship among the above three.

Methods

A total of 4 632 GPs were selected for electronic questionnaire investigation in the eastern, central, and western China from March to May in 2021 by using a multi-stage stratified random sampling. The questionnaire mainly included basic information, PsyCap, professional identity, and intention to stay. Pearson correlation analysis, hierarchical multiple regression analysis and structural equation model were used to explore the relationship among professional identity, PsyCap, and intention to stay.

Results

A total of 4 376 GPs were included with the effective response rate of 94.47%. The total scores of PsyCap, professional identity, and intention to stay were (102.89±16.94) , (33.93±8.95) , and (21.69±4.04) , respectively. Pearson correlation analysis showed that there were significant positive correlations between PsyCap and professional identity, professional identity and intention to stay, PsyCap and intention to stay (r=0.402, 0.459, 0.236, respectively, P<0.001) . The results of hierarchical multiple regression analysis showed positive predictive effects of PsyCap and professional identity on intention to stay (b=0.079 and 0.361, respectively, P<0.001) , and professional identity had a mediating effect between PsyCap and intention to stay. The structural equation model showed that PsyCap and professional identity had a positive predictive effect on intention to stay (b=0.032, P<0.05; b=0.446, P<0.001) , and professional identity had a part mediating effect between PsyCap and intention to stay.

Conclusion

The intention to stay among GPs in China is at a moderate level. There are positive correlations among PsyCap, professional identity, and intention to stay among GPs in China. PsyCap can affect intention to stay through professional identity. Improving the PsyCap and professional identity of GPs is conducive to improving their intention to stay.

Income of Order-oriented Medical Graduates and General Clinical Graduates: a Longitudinal Comparative Study

ZHANG Baisong, WANG Ziyue, HU Dan, LI Mingyue, WANG Huijuan, WEI Tiantian, CHENG Xiaoran, CHENG Haozhe, LIU Xiaoyun

2023, 26(25):  3133-3139.  DOI: 10.12114/j.issn.1007-9572.2022.0325

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Background

The free training for rural order-oriented medical students has trained a large number of primary health personnel for the central and western regions of China. By the summer of 2021, the first order-oriented medical graduates had completed their compulsory service and face the choice of staying or leaving. The income is an important influencing factor of their choices, however, there are still few studies on the income of order-oriented medical graduates.

Objective

The panel data of order-oriented medical graduate cohort study was used to compare and analyze the change trend of the income of order-oriented medical graduates and general clinical graduates in the early career, and to explore the influencing factors of the change of income.

Methods

Qinghai University, Guangxi Medical University, Jiujiang Medical University and Gannan Medical University were selected to establish the order-oriented medical graduate cohort every year from 2015 to 2019, matching the general clinical graduates of the same grade as controls. The baseline survey was conducted, including basic information and family information. A total of four follow-up surveys were conducted in 2016, 2017, 2018 and 2020, including the status of standardized resident training (hereinafter referred to as "standardized training") , passing of medical licensing examination, working conditions and other information. Fixed effects model was used to explore the factors influencing the income of order-oriented medical graduates and general clinical graduates, and propensity score matching (PSM) was used to test the stability of the results.

Results

In the first two years after graduation, the income of order-oriented medical graduates was higher than general clinical graduates, and the difference was statistically significant (P<0.05) . Two years after graduation, the income of order-oriented graduates was lower than general clinical graduates, and the difference was statistically significant (P<0.05) . The results of the fixed effects model showed that completion of standardized training, passing of the medical licensing examination, working position, and year of graduation were factors influencing the income of order-oriented graduates (P<0.05) . The income of order-oriented graduates who completed the standardized training decreased by 47%, and the income of the graduates who passed the medical licensing examination and promoted increased by 16% and 10%, respectively; the income of the graduates in the third, fourth and fifth years after graduation increased by 7%, 16% and 34%, respectively, compared with the first year of graduation. Job change and graduation years were the factors influencing the income of general clinical graduates (P<0.05) ; Job change increased the income of general clinical graduates by 15%, and the income of graduates in the third, fourth and fifth year after graduation increased by 27%, 83% and 101%, respectively, compared with the first year. The regression results of two-way fixed effects model showed that the completion of standardized training, passing of the medical licensing examination, job change, staffing and graduation years had different effects on the income of order-oriented graduates and general clinical graduates (P<0.05) . The regression results of two-way fixed effects model using the data after PSM showed similar to the results of the original sample with good consistency.

Conclusion

The starting point of income of order-oriented graduates is higher, but the growth rate is significantly lower than general clinical graduates, the income gap between them has been increasing year by year. The main reasons include the loss of training allowance after the standardized training of order-oriented graduates and the income difference caused by different working institutions. At the same time, the income of order-oriented graduates decreases with the increase of graduation time, which will seriously affect their performance and willingness of primary care.

Original Research·County-level Health Development

Multiple Realization Pathways of County-level Medical Alliances to Improve Service Capacity: a Fuzzy Set Qualitative Comparative Analysis

XU Yue, HU Linlin, LIU Yuanli

2023, 26(25):  3140-3146.  DOI: 10.12114/j.issn.1007-9572.2023.0058

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Background

The long-standing dilemma of difficulties in the improvement of primary care in China has led to county-level medical alliances reforms in various regions throughout the country.

Objective

To analyze the combination of pathways that contribute to improving the service capabilities of county-level medical alliances, providing a reference for the improvement and promotion of county-level medical alliances.

Methods

CNKI and Wanfang Data Knowledge Service Platform were searched by using "county-level medical alliance" "county health care unit" as keywords from 2020-01-01 to 2022-11-26 to obtain 662 related papers, a total of 9 papers and 11 cases were selected in the analysis. Based on literature review and policy analysis, variables including scale of planning and implementation, close organizational structure, collaborative management system, information platform integration, regional resources sharing, medical insurance payment reform, and incentive mechanism design were identified as outcome variables, while the fuzzy set qualitative comparative analysis was used to identify multiple realization pathways for the service capability improvement of county-level medical alliances.

Results

Four combinations of pathways were found to improve the service capability of county-level medical alliances. Pathway S1: planning and implementation scale * close organizational structure * collaborative management system * regional resources sharing * medical insurance payment reform * incentive mechanism design. Pathway S2: close organizational structure * collaborative management system * information platform integration * regional resources sharing * medical insurance payment reform * incentive mechanism design. Pathway S3: smaller scale of planning and implementation * close organizational structure * collaborative management system * non-integrated information platform * non-sharing of regional resources * medical insurance payment reform * incentive mechanism design. Pathway S4: smaller scale of planning and implementation * close organizational structure * collaborative management system * non-integrated information platform * regional resource sharing * medical insurance payment reform * no incentive mechanism design.

Conclusion

The improvement of service capability of county-level medical alliances needs to focus on close organizational structure, establish management system focusing on the collaboration of departments and member institutions, and promote medical insurance payment reform such as total budget management system of medical insurance funds and diagnosis related groups (DRGs) .

Index System Construction and Application Case Analysis for County Health System Development Focusing on Primary Care

LI Ziqi, HE Ping, YUAN Beibei, ZHANG Wei, XU Hanyi, WEI Qianchen, MENG Qingyue, XU Jin

2023, 26(25):  3147-3152.  DOI: 10.12114/j.issn.1007-9572.2023.0100

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Background

Focusing on primary care is the primary content of health care policies, however, there is a lack of effective measurement tools in practice.

Objective

To construct a index system for county health system development focusing on primary care, provide a reference for its monitoring approaches, and perform analysis and presentation with application cases.

Methods

In the study conducted from 2021 to 2022, the index system, weights and percentage conversion methods were constructed based on literature review and Delphi method, case application and analysis were conducted based on the data of questionnaire survey, institutional survey and medical insurance collected by baseline survey among residents, patients and medical workers, as well as data of key informant interview, in 2 experimental counties of county health system reform in Guangxi Zhuang Autonomous Region from 2020 to 2022.

Results

The results of Delphi method showed that the authority coefficient of experts was 0.91, the coefficients of variation of two rounds of consultation were 0.14 and 0.13, respectively. The final constructed index system contains 3 domains, 15 dimensions, and 36 indicators, with a comprehensive index calculation method. The results showed that the overall scores for the two counties in Guangxi Zhuang Autonomous Region were 58.62 and 52.57, respectively, both of which were below the current national benchmark (60.00 points) .

Conclusion

Based on the data availability, the index system constructed in this study can be applied to monitor and evaluate county health system to achieve the goal of focusing on primary care, its application may improve visibility and priority of primary care development, facilitate the publish and implementation policies strengthening primary care.

Development of the Coordinated Regional Health Development Assessment System

SHI Xiaoxiao, SHI Jianwei, JIN Hua, ZHANG Qianqian, YU Dehua

2023, 26(25):  3153-3156.  DOI: 10.12114/j.issn.1007-9572.2022.0745

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Background

Coordinated regional health development aims to optimize resource allocation by constructing a well-structured and functional regional collaborative system to provide continuous medical services, and to leverage the unique features and strengths of medical centers and community health centers within a region via fully integrating resources and sharing information. However, current available systems for assessing coordinated regional health development mainly focus on outcomes, which are relatively non-diversified and unsystematic, thus further research is required to fill this gap.

Objective

We aimed to construct an evaluation system for coordinated regional health development, to provide scientific evidence for evaluating the coordinated development capacities of regions.

Methods

We collected essential factors related to coordinated regional health development through a literature review and semi-structured interviews, and used them to construct a draft version of the Coordinated Regional Health Development Assessment System (CRHDAS) . Then we selected 19 experts who were familiar with coordinated regional health development (engaging in general medicine, medical education, administrative management, and public health management) from Shanghai to attend two rounds of online combined with offline Delphi questionnaire surveys from December 2020 to March 2021 to determine the weights of the indicators and test the logical consistency of the weights of indicators at each level using Analytic Hierarchy Process. After that, we established the final version of CRHDAS.

Results

The effective response rate and authoritative coefficient were 95.0% and 0.87, respectively, for the first round of survey, and were 100.0% and 0.92, respectively, for the second round of survey. The CRHDAS consists of four first-level indicators (with corresponding weights of 0.387, 0.296, 0.187 and 0.130) , 12 second-level indicators, and 31 third-level indicators. The consistency ratios for the weights of three levels of indicators are <0.100.

Conclusion

The CRHDAS is of high-level scientificity and practicality, which can help identify problems and deficiencies of the collaboration mode between community health centers, providing a theoretical and practical basis for guiding coordinated regional health practice in the future.

Original Research·Digital and Intelligent Healthcare

Investigation on Platform for Evaluation Management and Consultation Services of Polypharmacy among Older Patients Needs of Healthcare Professionals

WEI Lan, HUANG Yue, SONG Yanan, HOU Lihong, WANG Yani, PAN Dongchen, FEI Xiaolu

2023, 26(25):  3157-3162.  DOI: 10.12114/j.issn.1007-9572.2023.0235

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Background

Polypharmacy is common among older patients with common diseases. There is a strong need for evaluation management and consultation services of polypharmacy among older patients from medical workers, patients and their families. However, the functional design of how to scientifically and accurately manage services and consultations based on Internet technology for different categories of users has not been adequately studied.

Objective

To conduct investigation on the design of the service functions and methods of platform for evaluation management and consultation services of polypharmacy among older patients for healthcare professionals, taking the Internet services oriented to improve irrational drug use and reduce drug-related adverse events in older patients as a new idea.

Methods

Healthcare professionals from medical institutions participating in the National Key Research and Development Program (Multiple Drug Use Risk Management for Common Diseases of the Elderly) from 2021-02-20 to 2021-03-06 were selected as research subjects, the self-designed Questionnaire on Platform for Evaluation Management and Consultation Services of Polypharmacy among Older Patients Needs of Healthcare Professionals focusing on the necessity, operation mode and function of the platform were distributed. Principal component analysis was used to extract common factors for each platform function, and further factor rotation was performed using Kaiser's normalized maximum variance method, and the mean values of each factor score were ranked to explain the relative importance of each factor.

Results

A total of 548 valid research questionnaires were collected in this study with recovery rate of 100.00%. The cumulative total variance explained by the third factor in the sum of squared factor extracted for the 8 platform functions (patient compliance evaluation, prescription appropriateness evaluation, prescription economy evaluation, medication administration notification and reminder, medication administration precautions, medication administration record management, potential medication problem reminder, adverse drug reactions record and analysis) was 77.036%. The 8 platform functions were finally extracted into 3 factors, named as reminder factor (F1) , evaluation factor (F2) , and adverse analysis factor (F3) , and the ranking of the mean values of the 3 factors in descending order was F1 (mean factor score of 2.977) , F2 (mean factor score of 0.118) , and F3 (mean factor score of 0.112) .

Conclusion

From the perspective of healthcare professionals, reminder, evaluation and adverse analysis are the main operation modes and core functions of the platform for evaluation management and consultation services of polypharmacy among older patients, with reminder-related functions as the most important functions, which will provide substantial help to ensure the effective contribution of the platform to the construction of polypharmacy risk monitoring and control system for common diseases of the elderly in China.

Investigation on Platform for Evaluation Management and Consultation Services of Polypharmacy among Older Patients Needs of General Population

WEI Lan, HUANG Yue, SONG Yanan, HOU Lihong, WANG Yani, PAN Dongchen, FEI Xiaolu

2023, 26(25):  3163-3169.  DOI: 10.12114/j.issn.1007-9572.2023.0236

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Background

Our research team has previously conducted investigation on platform for evaluation management and consultation services of polypharmacy among older patients needs of healthcare professionals to ensure a close association between the design and development of the platform and actual needs. However, the awareness of the risks associated with polypharmacy in the elderly and needs of manage services and consultations based on Internet among general population have been rarely reported in China.

Objective

To understand the awareness of platform for evaluation management and consultation services of polypharmacy among older patients of general population, so as to further explore the operation mode of the platform and provide guidance for its improvement and refinement.

Methods

The self-designed Questionnaire on Platform for Evaluation Management and Consultation Services of Polypharmacy among Older Patients Needs of General Population focusing on the operation mode and importance of each function were distributed to the users of HeFen Club platform of China Mobile from 2021-09-29 to 2021-10-09, using HeFen Club WeChat public platform of China Mobile as the investigation platform and web-based questionnaire survey for general population as the investigation method. Principal component analysis was used to extract common factors for each platform function, and Kaiser's normalized maximum variance method was further used to rotate the factors and rank the mean scores of each factor to explain the relative importance of each factor.

Results

A total of 29 502 valid questionnaires were collected in this study with a recovery rate of 94.89%. The cumulative total variance explained by the fourth factor in the sum of squared factor extracted for the 12 platform functions (patient compliance evaluation, prescription appropriateness evaluation, prescription economy evaluation, medication administration notification and reminder, medication administration precautions, medication administration record management, potential medication problem reminder, manual real-time consultation, manual non-real-time consultation, self-service query, medication administration reminder, and record analysis) was 76.791%; The 12 platform functions were finally extracted into 4 factors, named as reminder factor (F1) , evaluation factor (F2) , query and record factor (F3) and consultation factor (F4) , and the ranking of the mean values of the 4 factors in descending order was F2 (mean factor score of 0.507) , F1 (mean factor score of 0.457) , F3 (mean factor score of 0.430) , and F4 (mean factor score of 0.253) .

Conclusion

Nearly 90.00% of the respondents believe that older adults with multiple common diseases are at risk of polypharmacy and need a platform for management and consultation services of polypharmacy. From a public perspective, reminder, evaluation, querying and record, consultation are the main operation modes and core functions of the platform for evaluation management and consultation services of polypharmacy among older patients.

Original Research·Appropriate Health Technology

Application of Appropriate Technology for Screening, Diagnosis and Evaluation of Congenital Heart Disease in Neonates in Hainan Province

ZHANG Dufei, CHEN Renwei, MO Zelai, YANG Ling, WANG Yazhou, WANG Haifan

2023, 26(25):  3170-3177.  DOI: 10.12114/j.issn.1007-9572.2022.0687

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Background

Congenital heart disease (CHD) is one of the major types of birth defects in the world, which is the leading cause of death in children. However, the current situation of delayed diagnosis of CHD is not optimistic, making the early detection, diagnosis and treatment of children with CHD a hot research topic.

Objective

To establish and apply the appropriate technology system for screening, diagnosis and evaluation of CHD in neonates in Hainan Province, evaluate operational effect of the technology for its further promotion.

Methods

In accordance with the requirements of the Program of Neonatal CHD Screening Project issued by the National Health Commission, the relevant literatures were reviewed to establish the appropriate technology system for screening, diagnosis and evaluation of CHD in neonates, in which screening staff perform CHD screening on liveborn neonates within 6-72 hours after birth using integration of cardiac murmur auscultation and transcutaneous pulse oximetry (POX) , in all midwifery institutions of 17 cities and counties in Hainan province, as well as the local neonatology departments or neonatal intensive care units (NICUs) . Positive results of heart murmur auscultation and/or POX were considered positive for screening. 31 diagnostic facilities authorized by Hainan Provincial Health Commission were responsible for the echocardiography examinations for liveborn neonates with positive screening results. The qualified cardiovascular physicians and cardiac surgeons in the 6 certified tertiary hospitals reviewed the diagnosis results and made necessary re-evaluations, suggested or implemented medical intervention and proposed suggestions on clinical follow-up (3 to 12 months) according to the conditions. Screening, diagnosis, evaluation and treatment data were filled, uploaded and managed online through the neonatal CHD screening information management network. The operational effectiveness of this appropriate health technology was evaluated in 17 cities (counties) in Hainan Province from 2020-01-01 to 2021-12-31.

Results

From 2020-01-01 to 2021-12-31, the count of liveborn neonates in Hainan Province was 206 761, 204 442 of them were included in the screening program with an overall screening rate of 98.88% and screen-positive rate of 2.86% (5 847/204 442) . A total of 527 cases diagnosed with CHD by echocardiography, showing a CHD prevalence of 2.58‰ (527/204 442) , and atrial septal defect as the most common CHD lesion with a composition ratio of 38.14% (201/527) , including 291 insignificant type CHD cases (55.22%) , 142 significant type CHD cases (26.94%) , 88 serious type CHD cases (16.70%) and 6 critical type CHD cases (1.14%) . The sensitivity of auscultation, POX and combination of 2 indicators for CHD screening was 67.93%, 37.00% and 93.35%, respectively, and the specificity was 98.07%, 99.28% and 97.30%, respectively. Neonates with positive results for both indicators (heart murmur auscultation and POX) were more likely to suffer from severe CHD (severe and critical types) than those with positive results for a single indicator (P<0.001) . A total of 94 cases with severe CHD were treated promptly. A total of 4 cases with severe CHD died, the standardized mortality of neonates aged 0-1 year with CHD was 1.96/100 000, the mortality rate of neonates with severe CHD was 4.26% (4/94) .

Conclusion

The combination of two indicators (heart murmur auscultation and POX) for CHD screening is favorable to promotion for the characteristics of noninvasion, simplicity, ease of operation and reliability. The establishment of appropriate technology system for screening, diagnosis, and evaluation of neonatal CHD is of great significance for its advantages in the timely diagnosing and treatment of CHD, especially in severe CHD, and reduction of mortality in neonates with CHD.

Analysis of Appropriate Technology Promotion for Stroke Rehabilitation in Southern Xinjiang

DU Yuying, WANG Cailing, CUI Senlin, LEI lei, WANG Yanping, SONG Xueqin, HAN Shuqin, ZHANG Yanmei, WANG Baolan, HUANG Haixia, CHEN Mi, YAN Huirong, LI Dong, ZHANG Jingjing, REN Yu

2023, 26(25):  3178-3184.  DOI: 10.12114/j.issn.1007-9572.2022.0099

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Background

Promoting appropriate health technology to rural and urban communities is an important measure to improve the technical level and service capacity of primary care institutions. The First Affiliated Hospital of Xinjiang Medical University carried out the promotion of appropriate health technology in southern Xinjiang.

Objective

To evaluate the effect of appropriate technology promotion for stroke rehabilitation in southern Xinjiang, understand the needs of rehabilitation workers in southern Xinjiang for appropriate technology promotion for stroke rehabilitation and the goals they hope to achieve by participating in appropriate technology promotion for stroke rehabilitation projects, providing a basis for health administrative departments to implement appropriate rehabilitation technology promotion work.

Methods

The rehabilitation workers from the rehabilitation medicine departments of 8 people's hospitals, affiliated township health centers and communities health centers, federation of the disabled, civil affairs system and other rehabilitation institutions in 8 deep poverty-stricken counties which were considered as sample source sites by using a multi-stage sampling method in July 2018. The appropriate technology promotion for stroke rehabilitation was performed followed by a investigation by using self-designed questionnaire. The monthly outpatient volume, hospitalization volume and treatment income of the rehabilitation medicine department of people's hospitals before (January 1, 2018 to June 30, 2018) and after participation (July 1, 2020 to December 31, 2020) in technology promotion for stroke rehabilitation projects were compared.

Results

The appropriate technology promotion for stroke rehabilitation in acute, subacute and convalescent stages, as well as community and family rehabilitation of stroke was performed from January 1, 2018 to June 30, 2018, involving motor function rehabilitation training, functional electrical stimulation, mandatory exercise therapy techniques, constraint induced movement therapy (CIMT) , mirror therapy, management and rehabilitation training of dysphagia, daily living activities training and rehabilitation care of stroke patient. A total of 384 valid questionnaires were collected. Among the 384 rehabilitation workers, 63.3% (243/384) identified the appropriate technology promotion within districts (counties) as very meaningful; 46.1% (177/384) thought the project was very applicable in their local area; 37.5% (144/384) believed that the technology for stroke rehabilitation can be carried out in their medical institutions with a slight improvement of the relevant conditions; 46.9% (180/384) believed that the difficulty level of the appropriate technology promotion project was easy in terms of operation skills; after the training, 42.2% (162/384) claimed to be knowledgeable about the technology and need to learn and receive further training. The monthly outpatient volume and monthly treatment income of the rehabilitation medicine department of people's hospitals after participating in stroke rehabilitation technology promotion projects increased significantly compared with before participation (P<0.05) . In terms of technology promotion for stroke rehabilitation, rehabilitation workers have the highest demand for practical training〔63.0% (242/384) 〕, and the lowest demand for teaching rounds〔19.8% (76/384) 〕. The percentages of workers who expected to improve operational ability〔77.1% (296/384) 〕and theoretical level 〔65.6% (252/384) 〕by participating in the appropriate technology promotion for stroke rehabilitation project ranked 1st and 2nd, respectively.

Conclusion

The promotion work of appropriate technology for stroke rehabilitation has achieved significant results. At present, there is a huge demand for rehabilitation of stroke patients in southern Xinjiang, but the overall rehabilitation medical service capacity is far from meeting the social needs. A series of initiatives can be taken to effectively improve the level of rehabilitation therapy in southern Xinjiang, including strengthening the promotion of appropriate health technology, encouraging rehabilitation workers to participate in further education and training, actively carrying out telehealth services, and accelerating the construction of medical associations.

Evidence-based Medicine

Prevalence of Frailty in Elderly Patients with Comorbidity: a Meta-analysis

LIN Yang, WANG Fang, WANG Han, WU Rong, WANG Yao, XU Ziyao, WANG Xu, WANG Yanding

2023, 26(25):  3185-3193.  DOI: 10.12114/j.issn.1007-9572.2022.0521

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Background

The prevalence of comorbidity in the elderly is showing a rising trend year by year with the acceleration of population aging. Comorbidity is a key risk factor for frailty in the elderly. Then frailty only increases the risk of adverse health outcomes for patients with comorbidity, but also significantly increases their family medical expenses. It has a certain guiding value for the management of comorbidity to identify the frailty conditions of elderly patients with comorbidity as early as possible.

Objective

To systematically review the prevalence of frailty in elderly patients with comorbidity.

Methods

CNKI, VIP, CBM, WanFang, PubMed, EmBase, Web of Science and Cochrane Library were searched in December 2021 for the investigation studies on the current status of frailty in elderly patients with comorbidity published from inception to December 4, 2021. Two researchers performed literature screening and data extraction independently. The cross-sectional study quality rating scale and Newcastle-Ottawa Scale (NOS) recommended by Agency for Healthcare Research and Quality (AHRQ) were used to assess the risk of bias of the included studies and Stata 14.0 was adopted for meta-analysis.

Results

A total of 25 studies involving 16 062 elderly patients with comorbidity were included. Meta-analysis results showed that the prevalence of frailty and pre-frailty in elderly patients with comorbidity was 26.7%〔95%CI (21.9%, 31.5%) 〕and 47.7%〔95%CI (43.9%, 51.4%) 〕. Subgroup analysis showed that the prevalence of frailty in older adults with≥2, ≥3, ≥4, and≥5 chronic diseases was 25.1%〔95%CI (19.3%, 30.8%) 〕, 27.4%〔95%CI (13.7%, 41.0%) 〕, 60.7%〔95%CI (29.0%, 92.4%) 〕, and 23.5%〔95%CI (8.6%, 38.5%) 〕, respectively. The prevalence of frailty in elderly patients with comorbidity in Oceania (52.1%) and Asia (31.3%) were significantly higher than Europe (16.9%) and South America (13.2%) . The prevalence of frailty in elderly patients with comorbidity in hospital (26.2%) was significantly higher than community (23.2%) . The prevalence of frailty in elderly patients with comorbidity screened by Clinical Frailty Scale (CFS) , Fried frailty phenotype scale and FRAIL Scale was 42.8%〔95%CI (38.4%, 47.1%) 〕, 22.2%〔95%CI (17.8%, 26.7%) 〕and 8.5%〔95%CI (6.3%, 10.6%) 〕, respectively. The prevalence of frailty in elderly patients surveyed in 2001—2010, 2011—2015, and 2016—2020 was 21.0%〔95%CI (13.2%, 28.8%) 〕, 19.0%〔95%CI (13.1%, 24.8%) 〕and 37.7%〔95%CI (22.6%, 52.9%) 〕, respectively.

Conclusion

The prevalence of frailty in elderly patients with comorbidity is gradually increasing, with differences by number of co-morbidities, continents, assessment tools and study sites. Therefore, relevant personnel should pay attention to early screening of frailty in elderly patients with comorbidity and take timely measures to prevent the development of frailty in elderly patients with comorbidity.

Effect of Patient Decision Aids in the Diagnosis and Treatment of Colorectal Cancer: a Systematic Review

DUAN Yuxia, LI Zhen, ZHANG Siqi, FANG Zhixue, QIN Yuelan

2023, 26(25):  3194-3201.  DOI: 10.12114/j.issn.1007-9572.2022.0456

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Background

Patient decision aids (PDAs) are essential tools to assist patients in the process of shared-decision making. However, their effects have been reported to be inconsistent in shared-decision making in the diagnosis and treatment of colorectal cancer.

Objective

To assess the core factors in the development of PADs supporting decision-making in colorectal cancer diagnosis and treatment, and their application effects using a systematic review.

Methods

In February 2022, randomized controlled trials (RCTs) on PDAs supporting decision-making in colorectal cancer care were searched in databases including PubMed, Web of Science, CIHNAL, Cochrane Library, EmBase, PsycINFO, JBI, Scopus, CNKI, WanFang, CQVIP and SinoMed from inception to January, 2022. Two researchers performed literature screening and data extraction separately. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials (5.1.0) was used to assess the risk of bias. A descriptive analysis was conducted to describe the core factors used in the development of PDAs and to summarize the effect of PDAs.

Results

A total of 11 RCTs were included, involving PDAs for supporting decision-making in colorectal cancer screening, systemic therapy and supportive care for advanced colorectal cancer, chemotherapy for metastatic colorectal cancer, and genetic testing for hereditary nonpolyposis colorectal cancer. The quality was moderate on the whole. Specifically, the quality of one RCT was rated as level A and that of the other 10 was level B. The analysis found that: (1) currently, the development of PDAs for supporting decision-making in colorectal cancer is mainly under the guidance of the quality criteria framework published by the International Patient Decision Aids Standards Collaboration, and the core content of the tool include providing information about options, balanced presentation of options, clarifying and expressing values; (2) The use of PDAs increased patient knowledge (six RCTs) , reduced patient decisional conflicts (eight RCTs) and promoted informed choice (two RCTs) .

Conclusion

The use of PDAs has proven to be effective in improving patient decision-making behavior and results in colorectal cancer. Although the evidence is still insufficient, they have broad prospect in clinical practice. In the future, the PDAs that are applicable to Chinese patients in different stages of colorectal cancer can be developed with the support of foreign theoretical achievements about decision-making and in accordance with the conditions of Chinese population, and the application effects of them need to be assessed further.

Experience Sharing

Course Design of Clinical Reasoning in General Practice for General Practice Master Students of Tongji University

ZHAI Jiayi, LU Yuan, QIAN Shulei, YU Dehua

2023, 26(25):  3202-3206.  DOI: 10.12114/j.issn.1007-9572.2022.0715

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The construction of general practitioner (GP) workforce has tended to be mature over recent years, but the overall insufficient competencies of GPs is still one difficulty to be tackled for the construction of GP workforce. Clinical reasoning plays a central role in connecting various abilities in competency training of GPs in China, which is the key to improving the quality of general medical services. To cultivate the clinical reasoning of GPs, Tongji University offers a compulsory course named Clinical Reasoning in General Practice for general practice master students. The course is framed using the Miller's pyramid framework, includes three parts of core module (containing inquiry ability, physical examination, auxiliary examination and patient-doctor communication) , case module (covering undifferentiated illnesses, chronic disease management, coexistence of multiple diseases, psychosomatic diseases and health management) and practice module (including patient reception practice and medical record writing) , which fully reflect the basic characteristics of GPs' competencies. The course requires 32 credit hours, and is taught in multiple forms, including theory teaching, class discussion, problem-based learning and practical sessions. The effectiveness of course learning is assessed using the objective structured clinical examination, which is divided into four test stations: medical history collection, physical examination, patient-doctor communication and wring SOAP notes. Compared with relevant previous courses with separation between course design and actual community services, this course fully reflects the characteristics of general medicine, and helps students to enhance their competencies via improving the level of clinical reasoning.