Table of Content

05 November 2023, Volume 26 Issue 31

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Research Focus

"Patients-centered" in the Reform of Public Primary Health Care Institutions: Does Doctor-patient Communication Improve the Quality of Primary Care Services?

LI Dongxu, SU Min, LIU Bin, ZHANG Tianjiao, ZHANG Weile

2023, 26(31):  3847-3855.  DOI: 10.12114/j.issn.1007-9572.2023.0089

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Background

The concept of "patients-centered" has presented higher requirements doctor-patient communication and reconstructing doctor-patient relationship in public primary health care institutions.

Objective

To analyze the impact of "patients-centered" doctor-patient communication on the quality of primary care services, and provide scientific evidence to promote reforms in public primary health care institutions.

Methods

All public community health centers providing primary care services in the main urban area of a city in Inner Mongolia Autonomous Region were selected as the study sites to conduct a field survey in 2021 using the standardized patient method, which included 118 items of doctor-patient communication data involving 26 medical institutions, 59 doctors, and 12 standardized patients. Common cold, asthma, and unstable angina were selected as the types of diseases to be portrayed by the standardized patients in this study. A combination of multiple regression model and Probit model was used to evaluate the impact of "patients-centered" doctor-patient communication on the quality of primary care services.

Results

Results obtained from the 118 items of doctor-patient communication data revealed that the median adherence rate for recommended consultation items was 17.6% (14.6%), and the median adherence rate for recommended examination items was 25.0% (40.0%), among them, 75 cases (63.6%) were correctly diagnosed, and 59 cases (50.0%) were correctly treated. The median total cost was 84.84 yuan (130.44 yuan), and the median drug cost was 37.62 yuan (47.38 yuan), among them, 66 (55.9%) involved unnecessary drugs, and 71 (60.2%) included unnecessary examinations. The median visit duration was 13.625 (10.850) min. The average score for "patients-centered" doctor-patient communication was (26.712±10.658), with the first dimension scoring (12.915±5.355) points, the second dimension scoring (7.492±2.867) points, and the third dimension scoring (6.305±3.465) points. The results of multiple linear regression model and Probit model indicated that for every one-point increase in the total score of patient-centered doctor-patient communication, the adherence rates for both recommended consultation items and recommended examinations items increased by 0.001 percentage points, the correct diagnosis rate increased by an average of 4.6 percentage points, the correct treatment rate increased by 4.2 percentage points, the total cost increased by 1.993 yuan, the drug cost increased by 0.517 yuan, the proportion of unnecessary drugs decreased by 3.4 percentage points, the proportion of unnecessary examinations increased by 0.2 percentage points, and the visit duration decreased by 0.291 minutes.

Conclusion

"Patients-centered" doctor-patient communication enhances the effectiveness and safety of medical services, while it also increases medical costs. It is necessary to promote "patients-centered" doctor-patient communication from the aspects of resource endowment, salary incentives, doctor-patient relationships, and collaborative services, thereby improving the quality of primary care services.

Development Dilemma of Primary Health Care Institutions: a Grounded Theory Study Based on Guilin City

WANG Siyuan, HANG Ranfeng, WEI Yingjue, LIU Jianying, SHI Wuxiang, HUANG Zhaoquan

2023, 26(31):  3856-3862.  DOI: 10.12114/j.issn.1007-9572.2022.0897

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Background

Since the new medical reform, primary health care institutions have made remarkable achievements in the number of consultations and basic public health service projects, however, the problems including low quality and high mobility of personnel, weakened capacity and low efficiency of service still remain. Therefore, it has become an urgent task to solve the development dilemma of primary health care institutions.

Objective

To analyze the development dilemma of primary health care institutions and propose corresponding countermeasures.

Methods

From April to May 2021, the heads of 16 primary health care institutions in 6 counties and 2 districts in Guilin were selected using multi-stage sampling method to conduct semi-structured interviews, which mainly included resource allocation, service capacity building, health insurance policy implementation, and development dilemmas. NVivo 11.0 qualitative analysis software and the research method of ground theory were used to classify, ummarize and refine the original interview data at each level.

Results

A total of 38 initial concepts, 9 initial categories, 4 main categories, and 1 core category were extracted, and nodes of stagnation in four dimensions including "resource allocation constraints" "obstruction of the path of three medical linkage" "deviation of functional positioning" and "accessibility lacking in medical community construction" were obtained.

Conclusion

The development of primary health care institutions is constrained by a variety of factors, with resource allocation balance and compensation mechanism improvement as core issue, synergy of the three medical linkage paths as external condition, adjustment of functional positioning as key link, and the construction of close medical community as important approach.

Research Capacity Building in General Practice

Interpretation of Update on Consolidated Framework for Implementation Research (CFIR 2.0)

HUANG Jiajie, LAI Honghao, SUN Mingyao, LIU Jianing, ZHAO Weilong, TANG Wenjing, YANG Shuihua, PAN Bei, TIAN Jinhui, MA Xiaoting, GE Long

2023, 26(31):  3863-3871.  DOI: 10.12114/j.issn.1007-9572.2023.0082

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The Consolidated Framework for Implementation Research (CFIR) is a commonly used theoretical framework in the field of implementation science, which helps researchers identify potential and actual influencing factors of the progress and effectiveness of implementation. CFIR was firstly proposed in 2009 with a 13-year history of development. In 2022, the CFIR development team updated CFIR based on user feedback, adding 21 constructs and 19 subconstructs to the original framework structure, adjusting some of the constructs and redefining certain concepts, resulted in CFIR 2.0 which is more practical and general. This paper aims to provide a reference for domestic researchers to understand and use CFIR 2.0 by reviewing and introducing the development background, origin, and update content of CFIR.

Scientific Research Conception Guided by General Practice Thinking

YU Dehua

2023, 26(31):  3872-3876.  DOI: 10.12114/j.issn.1007-9572.2023.0053

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With the increasing attention to primary care services and the growing of society needs, a large number of scientific research questions have emerged in the field of general practice and community health. This problem-based scientific research promotes the construction and development of the discipline. The discipline connotation characteristics and professional thinking elements of general practice belonging to the scope of clinical medicine and community health focusing on public health determine the design focus and research methods of scientific research. However, the common problem of scientific research in general practice and community health in China is the lack of attention to the characteristics of scientific general practice research thinking and insufficient depth of thinking. This paper explains the implemention of scientific research in detail guided by general practice thinking in three aspects including the identification and location of research questions, the building of multidisciplinary research team to achieve technology crossover and the development of holistic and systematic research design based on the elements of general practice thinking ("human-centred", holistic approach, systematization), supplemented by the practice cases of the department of general practice of Yangpu Hospital, Tongji University, in order to provide a reference for researchers on general practice and community health to implement scientific research focus on the connotation characteristics, and contribute to the positive development of scientific research in general practice.

Approaches to Improving General Practice

How Can Undifferentiated Diseases Be Synchronized with General Practice?

PAN Qi, REN Jingjing, ZHANG Meng, YIN Zhaoxia, HE Quan, YAO Chenjiao, WU Jingyi, LI Kaijun, YANG Kaichao, XU Jiayu, ZHU Lan, WANG Zhen

2023, 26(31):  3877-3883.  DOI: 10.12114/j.issn.1007-9572.2023.W0007

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Article

Association between Serum Uric Acid Level and the Risk of Chronic Kidney Disease among the Elderly in Longevity Areas of China

ZHANG Peng, GAO Ying, YANG Hongxi, WAN Chunxiao

2023, 26(31):  3884-3889.  DOI: 10.12114/j.issn.1007-9572.2023.0001

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Background

Hyperuricemia (HUA) caused by elevated serum uric acid (SUA) has been shown to be an independent risk factor for the development and progression of chronic kidney disease (CKD). However, there are few cohort studies on the correlation of SUA level with the development and progression of CKD in the elderly of China.

Objective

To explore the association of baseline SUA level and its changes with the risk of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) in the elderly in longevity areas of China.

Methods

Based on the Healthy Aging and Biomarkers Cohort Study (HABCS), a sub cohort of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), the older adults who received physical examination and with biomedical indicators in 2012 and 2014 were selected as the study subjects from December 2021 to May 2022. The age, gender, blood pressure, blood lipids, blood glucose and other biomedical indicators were collected at baseline and follow-up period. Cox proportional hazards regression model was used to analyze the association of different SUA levels with the risk of CKD. Spearman rank correlation and generalized linear model analysis were used to analyze the association between baseline SUA level and baseline eGFR level and the linear correlation between changes in SUA level and eGFR changes in the elderly, respectively.

Results

A total of 981 subjects were included in the study, with the median age of 79 (70, 88) years, the prevalence of HUA of 6.8% (67/981), the cumulative follow-up of 2 029 person-years and the median follow-up of 2.05 years, including 179 new cases of CKD, the cumulative incidence of CKD during the follow-up was 18.2%〔95%CI (15.9%, 20.8%) 〕, and the incidence density was 88.22/1 000 person-years〔95%CI (76.24/1 000 person-years, 101.41/1 000 person-years) 〕. Cox proportional hazards regression analysis with SUA quartile grouping as the independent variable showed that compared with the lowest quartile group of baseline SUA level (Q1), the HR value for the risk of CKD in the highest quartile group of baseline SUA level (Q4) was 2.08〔95%CI (1.27, 3.41), P=0.004〕. Cox proportional hazards regression analysis with SUA level as the independent variable showed that, for every 10 μmol/L increase in baseline SUA level, the risk of CKD in the elderly increased by 4% (P<0.001). Cox proportional hazards regression analysis with HUA as the independent variable showed an increased risk of CKD in elderly with HUA compared to those without HUA, with the HR value of 2.00〔95%CI (1.20, 3.24), P=0.007〕. The median baseline SUA was 270.60 (223.10, 325.90) μmol/L, the median baseline eGFR was 84.07 (73.08, 98.38) mL·min^-1· (1.73 m²) ^-1 in the elderly. Spearman rank correlation analysis showed a negative correlation between the above two (r_s=-0.363, P<0.001). The results of generalized linear model analysis showed that for every 10 μmol/L increase in baseline SUA level, the baseline eGFR decreased by 0.897 mL·min^-1· (1.73 m²) ^-1 (P<0.001). The median change of SUA level was -3.55 (-40.60, 31.90) μmol/L and the median change of eGFR was 3.49 (-8.13, 15.89) mL·min^-1· (1.73 m²) ^-1 in the elderly during the follow-up period of this study, and Spearman rank correlation analysis showed a negative correlation between the above two (r_s=-0.355, P<0.001). The results of the generalized linear model analysis showed that for every 10 μmol/L increase in SUA level in the elderly during the follow-up period, eGFR decreased by 1.027 mL·min^-1· (1.73 m²) ^-1 in the elderly (P<0.001) .

Conclusion

Elevated SUA level in the elderly is associated with an increased risk of CKD and a declined eGFR in China.

Association between Physical Activity and Risk of All-cause Mortality in Middle-aged and Elderly People in China: a Prospective Cohort Study

CHEN Xi, ZHANG Juan, LI Lin, ZHANG Jiaqi, WU Yaoli, GUO Hui, WANG Chaoqun

2023, 26(31):  3890-3895.  DOI: 10.12114/j.issn.1007-9572.2023.0287

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Background

Insufficient physical activity is one of the most important public health problems in the 21st century and studies have found an association between physical activity and mortality. The effect of physical activity on mortality risk has attracted much attention in recent years, but few studies have reported the relationship between physical activity and all-cause mortality risk in different populations.

Objective

To explore the relationship between physical activity and all-cause mortality risk in middle-aged and older adults (45 years old and above) in China.

Methods

Based on the data of China Health and Retirement Tracking Survey (CHARLS) from 2011 to 2018, a total of 2 799 middle-aged and older adults from the 2011 baseline population of the CHARLS were selected as the research subjects on September 10, 2022, their baseline data such as demographic variables, lifestyle variables, and number of chronic diseases were collected, and physical activity level was evaluated based on the International Physical Activity Questionnaire (IPAQ) as low level physical activity〔600 metabolic equivalent (MET) /week) 〕, moderate level of physical activity (600-3 000 MET/week), high level of physical activity (3 000 MET/week). The follow-up period was from 2011 to 2018, and data from 2013, 2015 and 2018 were selected for follow-up, with all-cause death as the endpoint event, and the subjects were divided into the survival group (n=2 424) and all-cause death group (n=375) according to their survival status. Cox proportional hazard regression model was used to analyze the relationship between physical activity level and all-cause mortality risk in middle-aged and older adults, sensitivity analysis and stratification analysis were also performed.

Results

During the 7-year follow-up, 375 cases of all-cause death occurred among 2 799 middle-aged and older adults with the incidence of all-cause death of 13.40%. There were statistically significant differences in physical activity level, gender, age, marital status, education level, ADL limitation, BMI, smoking, alcohol consumption and the number of chronic diseases between the survival group and all-cause death group (P<0.05). After adjusting for confounding factors, multivariate Cox proportional hazard regression analysis showed that the risk of all-cause death was reduced by 43%〔HR=0.57, 95%CI (0.44, 0.75), P<0.001〕and 64%〔HR=0.36, 95%CI (0.27, 0.48), P<0.001〕in the middle-aged and older adults with low level of physical activity and high level of physical activity, respectively. The results of both sensitivity analyses showed a reduced risk of all-cause mortality in the middle-aged and older adults with moderate and high levels of physical activity compared with those with low level of physical activity (P<0.001), indicating that the results are robust. Stratified analysis showed that moderate level of physical activity could reduce the risk of all-cause death by 50%〔HR=0.50, 95%CI (0.33, 0.76), P<0.001〕in people aged 60-74 years and 51%〔HR=0.49, 95%CI (0.33, 0.73), P<0.001〕in people with normal BMI. High levels of physical activity were associated with a 74%〔HR=0.26, 95%CI (0.14, 0.47), P<0.001〕 and 65%〔HR=0.35, 95%CI (0.24, 0.51), P<0.001〕lower risk of all-cause death in people aged 45 to 59 and 60 to 74 years, respectively, and a 71%〔HR=0.29, 95%CI (0.20, 0.43), P<0.001〕and 64%〔HR=0.36, 95%CI (0.22, 0.59), P<0.001〕lower risk of all-cause death in people with normal BMI, overweight or obesity.

Conclusion

Both moderate and high levels of physical activity can reduce the risk of all-cause death in middle-aged and older adults, and the effect of high level of physical activity is more obvious. From the perspective of reducing the risk of all-cause death, it is suitable for people aged 45-59 years old, overweight and obese people to choose high level of physical activity. People aged 60-74 years and with normal BMI can benefit from moderate or high levels of physical activity. There is no clear recommendation with sufficient evidence for people aged≥75 years old and lean people, who should make decisions according to their own specific situations.

Development of General Practice Diagnostic Terminology and Coding and Empirical Study on Its Application

HONG Yuchun, WU Hua, DU Yishan, LI Shuran, SUN Wenmin, YE Mingyu, ZHANG Yongjian, LI Yang

2023, 26(31):  3896-3901.  DOI: 10.12114/j.issn.1007-9572.2022.0718

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Background

Establishing a unified set of diagnostic terms and codes for general practice is an important means to improve the service level of community health service institutions and promote the construction of general practice system in China. Establishing a unified set of diagnostic terms and codes of general practice is an important way to improve the service level of community health service institutions and the construction of general practice system in China. However, there has been a lack of standardized diagnostic terms and codes suitable for the development situation of general practice in China, leading to non-standard diagnosis of general practitioners, which has seriously hindered the development of general practice in China.

Objective

To construct a set of diagnostic terms and codes for general practice in community health care service, and validate its efficiency, so as to promote the standardization of community general practice diagnosis.

Methods

A set of diagnostic terms and codes for general practice suitable for community health care service was constructed based on ICD-10 by using literature research and expert consultation, combined with the spectrum of common health problems and diseases in the community, and piloted in 259 community health service centers in two administrative districts of Shenzhen from September 2021 to February 2022 to conduct an empirical study. The pilot implementation was analyzed to verify the rationality and validity of the diagnostic terms and codes set by using the background diagnostic data of the community health service information system and questionnaire study with a sample of community general practitioners as the basic data.

Results

A set of diagnostic terms and codes for general practice was completed, including 41 general practice diagnostic categories, involving 6 629 standardized diagnostic terms and codes for general practice. The pilot results of the two districts in Shenzhen indicate that the composition of standardized diagnostic names in the standardized intervention areas was 86.13% to 95.38% higher than the non-pilot areas. The number of diagnostic names involved in this period in the pilot area decreased by 96.60% year-on-year. The standardized intervention resulted in a significant focus on common diagnoses in general practice, which is basically consistent with the disease spectrum in the community, with a high degree of clustering of common disease diagnoses in the community. The results of the questionnaire survey showed that 87.31% (227/260) of the survey respondents believed that the code set can promote the standardization of community diagnosis, and 77.31% (201/260) of the respondents supported the online application of the code set.

Conclusion

The research has preliminarily established a standardized set of diagnostic terms and codes for general practice, forming a community general practice diagnostic term dictionary to solve the problem of polysemy in data analysis, while taking into account upward and downward referrals and medical insurance dockin, which has effectively improved the efficiency and standardization of community diagnosis and treatment, and played a positive role in promoting the development of primary health services.

Prevalence and Associated Factors of Potentially Inappropriate Medication among Elderly Outpatients

DUAN Yanqin, PENG Ying, LIU Shenglan, LIU Haijiao, YANG Huiqiong, HU Haiqing

2023, 26(31):  3902-3907.  DOI: 10.12114/j.issn.1007-9572.2022.0774

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Background

China's aging adults are increasing, and have increasing prevalence of multimorbidity and polypharmacy, leading to a high risk of drug-drug interactions and adverse drug reactions. There are few studies on potentially inappropriate medication (PIM) in the elderly, and PIM in this group has not yet received sufficient attention clinically.

Objective

To perform a retrospective analysis of the PIM prevalence and associated factors in elderly outpatients in a hospital using the 2019 Updated AGS Beers Criteria? for Potentially Inappropriate Medication Use in Older Adults (hereinafter referred to as the 2019 Beers Criteria), providing precise medication guidance for clinical rational use of medications in the elderly.

Methods

Prescriptions of older outpatients written from January to December 2021 were collected from the "Smart Pharmacy Platform" of Changsha Hospital of Hunan Normal University on January 10, 2022. Each prescription was evaluated independently to find whether there was a PIM using the 2019 Beers Criteria. Multivariate Logistic regression was used to analyze the associated factors of PIM.

Results

The prescriptions of 39 275 outpatients were collected in the analysis, who had an average age of (74.0±6.8) years, an average number of diagnosed illnesses of (1.49±0.81), and an average number of types of drugs used of (2.70±1.75). The overall prevalence of PIM was 31.72% (12 458/39 275), involving 11 134 cases of drug-related PIM, 23 cases of disease- or symptom-related PIM, 2 109 cases of medication should be used with caution-related PIM in elderly patients, 99 cases of drug-drug interactions-related PIM that should be avoided in elderly patients, 2 cases of avoiding drug-related PIM and 8 cases of reducing drug-dose-related PIM in elderly patients with renal insufficiency. The departments with higher incidence of prescribing PIM were neurology〔1 908 (61.17%) 〕, geriatrics〔972 (49.49%) 〕, and general medicine〔1 495 (42.21%) 〕. The major prescribed PIM included benzodiazepines, proton pump inhibitors, oral nonsteroidal anti-inflammatory drugs, and glimepiride. Multivariate Logistic regression analysis showed that age, number of diagnosed illnesses and the number of types of medication were independently risk factors of PIM (P<0.05) .

Conclusion

Advanced age, high number of diagnosed illnesses and high number of types of medication were associated with higher risk of PIM. To promote rational use of drugs, clinicians and pharmaceutists should pay attention to PIM-related risk factors, and do well in screening for potential risks of PIM.

The Evaluation Index of Post Competence of General Practitioners in Less-developed Areas

ZHOU Dongdong, GE Xuhua

2023, 26(31):  3908-3914.  DOI: 10.12114/j.issn.1007-9572.2022.0629

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Background

Domestic studies on post competency evaluation indexes of general practitioners mainly focus on economically developed areas in the east. While the applicability of existing evaluation indexes of post competency of general practitioners in rural areas or less-developed areas may be insufficient due to unbalanced allocation of medical resources and large disparities in medical levels among different regions in China.

Objective

To construct an evaluation index system for the post competency of general practitioners and to provide reference for the training, assessment and evaluation of general practitioners in less-developed areas.

Methods

An evaluation index system for the post competency of general practitioners in less-developed areas was constructed preliminarily through literature research. From January to June of 2021, 18 consultant experts were selected respectively from general practice clinical workers practicing in less-developed areas, general practice/health administration workers in provinces/counties/towns and general practitioners who had participated in the counterpart support in the east-west counterpart support and worked in less developed areas by purposive sampling method. The expert consultation and hierarchical analysis were used to complete the screening of evaluation indexes of post competency of general practitioners and determine the weight of each index in less-developed areas.

Results

The effective recovery rate of two rounds of expert consultation questionnaires were 100.0%; the familiarity, judgment and authority coefficients were 0.76, 0.84 and 0.80; the Kendall coordination coefficients were 0.24 (χ²=297.543, P<0.001) and 0.26 (χ²=322.083, P<0.001). The evaluation index system for the post competency of general practitioners in less-developed areas was constructed consisting of 4 primary indexes, 20 secondary indexes and 44 tertiary indexes. The weights of primary indexes including "medical service capacity" "public health service capacity" "organizational management and coping ability" and "professionalism" were 0.350 9, 0.109 1, 0.189 1 and 0.350 9, respectively. The top 4 combination weighted indexes in secondary indexes were "professional quality" (0.177 1), "learning and thinking ability" (0.126 5), "communication and coordination in primary care" (0.118 6), "diagnosis and treatment of common diseases" (0.108 9). The top 4 combination weighted indexes in tertiary indexes were "civilized communication and friendship exchange with patients, colleagues and physicians at superior hospitals" (0.118 6), "humanistic care" (0.098 9), "mastering clinical appropriate technology such as cardiopulmonary resuscitation (CPR), defibrillation and catheterization" (0.088 3), "diagnosis and treatment of common and frequently-occurring diseases" (0.081 7) .

Conclusion

The evaluation index system for the post competency of general practitioners in less-developed areas constructed in the study have practicability and scientificity, which can provide scientific basis for the evaluation of post competency of general practitioners in less-developed areas.

The Development History and Current Situation of General Practice Education in Guangdong Province in the Past 30 Years

LI Fangjian, JI Zequan, YE Huiling, YAN Ping, CHEN Dexiong, ZHANG Kouxing, LIANG Xiang, WANG Jiaji, HU Bingjie

2023, 26(31):  3915-3921.  DOI: 10.12114/j.issn.1007-9572.2022.0802

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With the strong support of national and local policies, the construction of general practice education system and personnel training have been developed in Guangdong Province for nearly 30 years. Since 1996, general practice education in Guangdong Province has gone through four stages, including exploration and start, vigorous growth, development and perfection, comprehensive development. Colleges and universities in Guangdong Province, represented by Guangzhou Medical University, have explored and established a multi-level, multi-path, multi-form and multi-objective general practice education system of treatment-prevention integration, with interconnected academy education, job-transfer training, standardized training, postgraduate education and continuing education, and a standardized training model of general practitioners based on "5+3" has been basically established. The pass rate of the provincial training certificate examination of general practice training students has reached more than 85%. In 2020, there were 4 general practitioners per 10 000 residents, meeting the national requirement of 3 general practitioners per 10 000 residents in 2020. With the purpose to analyze the current situation of the development of general practice education in Guangdong Province, this paper comprehensively summarized the experience and lessons of discipline construction and education training of general practice, broadened the paths and modes of the quality of general practice personnel training, put forward relevant suggestions, to provide policy ideas and reference basis for the rapid development of general practice education in Guangdong Province and even in China in the future.

Current Situation of Community Pharmacy Services and the Integration of Pharmacists into Family Doctor Team in Shanghai

LIU Rui, CAO Yu, CHU Aiqun, WU Huanyun

2023, 26(31):  3922-3929.  DOI: 10.12114/j.issn.1007-9572.2022.0863

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Background

At present, polypharmacy is common among residents with high risk of unsafe medication due to the lack of drug reorganization and whole-course drug management. Community pharmacy services provided by community health service centers (CHSC) with regional advantages is in line with its functional orientation, but there is still a large gap between the supply of pharmacy services in CHSCs and the demand of the public.

Objective

To understand the current situation of community pharmacy services and the integration of pharmacists into family doctor team in Shanghai, as well as the problems faced by community pharmacy services, so as to provide suggestions for promoting the development of community pharmacy services.

Methods

A combination of qualitative and quantitative research was adopted. In December 2020, a stratified sampling method was used to conduct a questionnaire survey on 307 pharmacy staff on duty with licensed pharmacist qualification from 29 CHSCs, including 6 in the central urban area, 8 in the near urban area, and 15 in the far urban area. The questionnaire included the basic information of pharmaceutical staff, the development of community pharmacy services, and the participation of community pharmacists in the family doctor team. In the same period, a convenience sampling method was used to invite 29 key insiders, including 11 pharmacy section chiefs, 6 family doctor representatives, 12 community center directors and health commission managers from central urban area, near urban area and far urban area, to conduct a semi-structured focus interview on pharmacy service needs, pharmacy resource allocation and pharmacy service process.

Results

The quantitative research results showed that the highest proportion of community pharmacists participating in training is 1-2 times〔139 (45.3%) 〕, and the main form of training is continuing education, accounting for 252 (82.1%). The three most frequently conducted pharmacy service projects by community pharmacists are prescription dispensing〔284 (92.5%) 〕, prescription review〔253 (82.4%) 〕, and pharmaceutical window or outpatient consultation guidance〔196 (63.8%) 〕. The three longest service hours occupied by pharmacists are prescription dispensing〔280 (91.2%) 〕, prescription review〔244 (79.5%) 〕, and prescription comment〔145 (47.2%) 〕. A total of 78 (25.4%) pharmacists joined the family doctor team. The qualitative study showed that the elderly residents in the community had a great demand for pharmacy service, but their awareness of rational drug use was weak. In the allocation of community pharmacy resources, the pharmacists are lacjing, the professional quality needs to be improved, the community pharmacy drug list remains uncompleted, and the role of informatization needs to be strengthened. In the process of community pharmacy service, the recognition degree of community pharmacists is not high, with single service content and relatively little targeted training on rational drug use, and pharmacists fail to play a role in the family doctor team.

Conclusion

At present, the resource allocation and supply capacity of community pharmacy service cannot meet the needs of residents, and the pharmacy service process needs to be improved and optimized. The role played by the only part of pharmacists joining the family doctor team is limited. Therefore, it is necessary to increase the incentive mechanism, clarify the service content and improve the service model.

Article·Focus on Medically Unexplained Disease

Bibliometrics and Visualization Analysis of Medically Unexplained Physical Symptoms Based on Web of Science Database

WANG Min, GUO Wenjun, CHEN Yongzhen, FENG Xinyu, TANG Zhongquan, ZHAO Xiaomin, OU Ting, DAI Xinyu, LI Yuntao

2023, 26(31):  3930-3938.  DOI: 10.12114/j.issn.1007-9572.2022.0850

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Background

In recent years, medically unexplained physical symptoms (MUPS) are widely concerned by domestic and foreign scholars. However, China started late in this field with relatively backward development. It is of significant importance for the promotion of MUPS field development in China to learn the researches on MUPS by international scholars.

Objective

To discusses the current status, research hotspots and development trends of MUPS internationally by using bibliometrics method.

Methods

The papers related to MUPS from inception to 2022-08-15 were searched based on Web of Science core collection databases from July to August in 2022. The bibliometric analysis was performed on the included papers in terms of publication volume trends and the distributions of authors, institutions and research areas after screening and data processing. CiteSpace 6.1R3 software was used to conduct visualization analysis on collaboration between countries or regions, document co-citation, keywords co-occurrence, keywords clustering, and keywords with bursts.

Results

A total of 1 615 papers were finally included, the number of annual publications in studies regarding MUPS showed an overall upward trend from 1985 to 2022, with the most rapid growth from 2014 to 2016. ROSMALEN J G M (43 papers), WITTHOFT M (41 papers) and RIEF W (31 papers) ranked the top three authors in terms of number of publications, and the total citations of the three scholars' papers also ranks in the top 10, with 954 times, 1 275 times and 1 339 times, respectively. The top three institutions in terms of number of publications were all from the UK, including University of London (143 papers), King's College London (95 papers) and University of Manchester (84 papers). The top three countries/regions in terms of number of publications were England (422 papers), the United States (341 papers), and Netherlands (268 papers), all of which cooperated closely with other countries. A total of 75 research areas were involved in all the literature, with most studies in psychiatry (605 papers). The literature co-citation network map includes 1 393 nodes and 6 108 connections, and the paper with the highest co-citation frequency was titled Somatoform Disorders and Medically Unexplained Symptoms in Primary Care. Except of "Medically unexplained symptoms", the top five keywords in terms of occurrence frequency were "primary care" (422 times), "somatoform disorder" (405 times), "somatization" (354 times), "prevalence" (217 times) and "depression" (211 times). A total of 12 clusters were obtained by keywords clustering analysis, reflecting in the subject category and epidemiological characteristics of MUPS, key subtypes of MUPS, main treatment methods and management of MUPS. Keyword with the highest intensity of burst was "somatic symptom disorder" "children" "bodily distress syndrome" "somatic symptom disorder" and "model" have burst in recent years and persisted till now.

Conclusion

At present, the publications of international studies regarding to MUPS show an upward stage, with research hotspots and trends mainly focus on the sutypes of MUPS with more researches, attention to juvenile groups and creation of effective communication models, correct evaluation and long-term management of MUPS, effectiveness of cognitive behavioral therapy for MUPS.

Implementation Status and Strategy Research on the Construction of Clinical Pathways for Diagnosis and Treatment of Medically Unexplained Disease in Community General Practice

ZHOU Yingda, ZHUO Shuxiong, YANG Xi, JIN Hua, YU Dehua

2023, 26(31):  3939-3944.  DOI: 10.12114/j.issn.1007-9572.2023.0300

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The diagnosis and treatment level of medically unexplained disease (MUD) in the community is closely related to the overall health service capacity of primary healthcare centers. However, general practitioners are not competent enough to diagnose and treat such diseases as shown in current studies. By combing the historical evolution of the introduction of the clinical pathway model into the field of general practice in China, this paper shows that the application of clinical pathway model in China is in a critical period of transition from simple diseases to complex diseases, and from general hospital specialties to general practice in primary care institutions, which confirms a broad application prospect in the diagnosis and treatment of MUD for clinical pathway model. This paper then summarizes the key bottleneck problems faced by the community general practice clinical pathway in China, which mainly include low recognition of clinical pathway by medical staff, difficulty in selecting types of MUD, and the inconsistency between paper form or simple electronic clinical pathway and the rapid development of medical informatization. It is further proposed on the basis that the construction of clinical pathways for diagnosis and treatment of MUD in the community should be based on general practice thinking as the core, and further exploration should be carried out and taking the clinical decision-making information platform of regional medical coordination as a new mode of clinical pathway by breaking through specialty thinking, focusing on dominant diseases, standardizing community diagnosis coding, etc. This paper provides a certain theoretical basis and strategic ideas for the future construction of clinical pathways for diagnosis and treatment of MUD in community general practice.

Visits for Medically Unspecified Disease in General Internal Medicine Clinics of County General Hospitals

LOU Zheng, LIU Ying, REN Jingjing

2023, 26(31):  3945-3950.  DOI: 10.12114/j.issn.1007-9572.2023.0059

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Background

Medically unspecified disease (MUD) is characterized by complex and diverse symptoms that cannot be clearly diagnosed or rationally explained, which often leads to frequent hospital attendance, imposing a heavy economic burden on individuals, families and the healthcare system.

Objective

To understand the visits for MUD in general internal medicine clinics in county general hospitals by analyzing the results of a survey, providing a theoretical basis for standardized treatment of MUD by integrating evidence from this epidemiological survey and our ideas for general diagnosis and treatment of MUD in county general hospitals.

Methods

From January to March 2021, conditional sampling was used to select all patients (n=45 439) who attended the general internal medicine clinic (85 881 visits in total) in a grade B tertiary county general hospital in Taizhou, Zhejiang Province from January 1 to December 31, 2020 through the hospital information system. Among whom, adult patients with MUD were screened using the PRESUME screening method, and information involving the demographics, time of consultation and reasons for consultation was collected for analysis.

Results

A total of 497 adult patients were identified with visits due to MUD, with a mean number of visits of 2.23 visits/person, and a mean age at visit of (51.6±15.9) years. There were sex-specific differences in age composition and attendances of MUD patients (P<0.01). As for the reasons for visits, men had more visits due to anxiety than women (P<0.05). The visits due to abdominal pain, anxiety and cough differed significantly by age (P<0.05). The visits in different seasons showed no significant differences by sex and age (P>0.05). The visits for cough differed significantly across the seasons (P<0.05) .

Conclusion

According to this survey, the visits due to MUD are influenced by various factors such as gender, age and season. Frequent visits for MUD due to various reasons cause difficulties in identifying and rationally treating the disease in the general internal medicine clinic as the first contact setting. To provide more accurate diagnosis and treatment for MUD patients, it is necessary to further develop the general medicine department, and make the general medicine department in county hospitals become the primary care center for MUD, and comprehensively enhance the effectiveness of county hospitals in serving the society.

Article·Evidence-based Medicine

Domestic and International Assessment Tools for Medical Teamwork: a Systematic Review

WANG Jiaxin, ZHAO Yali

2023, 26(31):  3951-3962.  DOI: 10.12114/j.issn.1007-9572.2022.0659

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Background

In recent years, the promotion of "health-centered" concept and the increasing demands for health care of patients have placed greater demands on healthcare providers. The establishment of effective health care team is regarded as an important approach to improve service quality. The selection of objective and valid teamwork assessment tools is particularly important for the assessment of cooperation status among team members and team building.

Objective

To perform a systematic review of domestic and international assessment tools for medical teamwork, in order to provide a reference for the rational selection of medical teamwork assessment tools according to different situations.

Methods

Pubmed, CNKI, Wanfang and VIP databases were searched in April 2022 for literature related to medical teamwork assessment tools from January 2016 to April 2022. Literature screening and information extraction were performed independently by two investigators and cross-checked. The Chinese version of COSMIN study design checklist was used to evaluate the quality of the assessment tools.

Results

A total of 30 articles were included, involving 32 medical teamwork assessment tools, localized versions of the tools were also included in their original versions of the tools, and a total of 49 medical teamwork assessment tools were finally included. The results of the overall design and methodological quality evaluation of 32 medical teamwork assessment tools covered by 30 included papers showed that in terms of the overall design of the tools, 20 were considered as "very good", 2 as "good", and 10 as "vague"; in terms of the content validity, 1 was considered as "very good", 12 as "good", and 19 as "vague"; in terms of the construct validity, 19 were considered as "very good", 10 as "good", and 3 as "poor"; in terms of internal consistency, 29 were considered as "very good", 1 as "good", and 2 as "vague"; in terms of stability, 6 were considered as "very good", 8 as "good", 1 as "vague" and other relevant information was not reported. The assessment tools were divided into the interprofessional teamwork assessment tools (n=43) and intraprofessional teamwork assessment tools (n=6) based on the professional background of the team members. The interprofessional teamwork assessment tools were divided into the physician-nurse team assessment tools (n=20) and integration of multiple roles team assessment tools (n=23) including physicians, nurses, pharmacists, therapists, dietitians and others based on the job categories.

Conclusion

The research on the assessment tools of medical teamwork has received increasing attention from scholars at home and abroad. The content of the assessment tools is relatively rich, but further development is needed to construct a teamwork assessment tool specifically applicable to primary health care team.

Efficacy of Non-pharmacological Interventions to Improve Perimenopausal Insomnia Symptoms: a Network Meta-analysis

HE Jingyi, WANG Fang, SHUI Xiaoling, LI Ling, LIANG Qian

2023, 26(31):  3963-3974.  DOI: 10.12114/j.issn.1007-9572.2022.0707

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Background

The presence of insomnia symptoms reduces the quality of life of perimenopausal women and increases their risk of developing other diseases. Currently, there are numerous non-pharmacological interventions available to improve perimenopausal insomnia symptoms, with disagreement as to which intervention is most effective.

Objective

To evaluate the efficacy of non-pharmacological interventions in improving perimenopausal insomnia symptoms using a network meta-analysis.

Methods

In March 2022, Cochrane Library, PubMed, EmBase, Web of Science, CNKI, Wanfang Data Knowledge Service Platform, VIP and CBM were searched for the randomized controlled trials (RCTs) on the improvement of perimenopausal insomnia symptoms by non-pharmacological interventions from inception to March 2022. Two investigators independently screened the literature, extracted data, and evaluated the risk of bias of the included literature using the RCT bias risk assessment tool recommended by the Cochrane Manual of Systematic Review 5.1.0. A Bayesian network meta-analysis was performed on the overall response rate to the improvement of perimenopausal insomnia symptoms, as well as improvement in Pittsburgh Sleep Quality Index Scale (PSQI) score, Kupperman score and estradiol (E₂) level under different non-pharmacological interventions by using R 4.1.3 software and the GeMTC package.

Results

A total of 44 RCTs including 3 354 patients were selected, involving 12 non-pharmacological interventions (moxibustion, electroacupuncture, acupoint pressing with beans, scraping, fire dragon pot, thumbtack needle, massage, warm acupuncture, bee acupuncture, acupoint embedding, music therapy, acupuncture). The results of meta-analysis showed that moxibustion, electroacupuncture, and acupuncture were superior to sedative-hypnotic western drugs in overall response rate to the improvement of perimenopausal insomnia symptoms (P<0.05), and moxibustion was identified as the most probable superior intervention. Moxibustion, electroacupuncture, scraping, and acupuncture were superior to sedative-hypnotic western drugs (P<0.05), moxibustion was more effective than warm acupuncture (P<0.05) in the improvement of PSQI score and identified as the most probable superior intervention. There was no significant difference in the improvement of Kupperman score and E₂ level among different interventions (P>0.05), with scraping emerging and acupuncture as the most probable superior intervention, respectively.

Conclusion

Current evidence demonstrates that moxibustion is superior in overall response rate to the improvement of perimenopausal insomnia symptoms and PSQI score in perimenopausal women, while scraping is superior in improving Kupperman score and acupuncture has advantages in improving E₂ level, however, further validation of this conclusion is needed by conducting more high-quality studies.