Table of Content

05 May 2024, Volume 27 Issue 13

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Guidelines·Consensus

Interpretation of Global Strategy for the Diagnosis, Treatment, Management and Prevention of Chronic Obstructive Pulmonary Disease 2024 Report

CHEN Dian, LONG Huanyu, LI Shurun, CHEN Yahong

2024, 27(13):  1533-1543.  DOI: 10.12114/j.issn.1007-9572.2023.0867

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Global initiative for chronic obstructive lung disease (GOLD) 2024 report was released on November 13th, 2023. In general, the definition, diagnosis, assessment, and therapy of chronic obstructive pulmonary disease (COPD) are the same as GOLD 2023, with corresponding content added in ten aspects, including the expansion of the information about PRISm, a new section on hyperinflation, further clarification about pre-bronchodilator spirometry, a new section on screening for COPD in targeted populations, the update of blood eosinophil count, the update of interstitial lung abnormalities, the revision of the section on smoking cessation, the update of vaccination recommendations for people with COPD, the expansion of managing inhaled therapy, and the addition of pharmacotherapies for smoking cessation. The article introduces and interprets the new contents.

Chinese General Practice/Community Health Service Research

Implementation Status, Problem Analysis, and Policy Recommendations of Hypertension Management in Primary Care in China from the Perspective of Health System Based on Semi-structured Interview

WANG Yao, QIN Tingting, GU Mingyu, BAI Xinyuan, QIAO Kun, YANG Yutong, LI Xingming

2024, 27(13):  1544-1549.  DOI: 10.12114/j.issn.1007-9572.2022.0886

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Background

Hypertension is a common chronic non-communicable disease affecting the health of the people in China. As an important gateway for hypertension management and control, the management ability of primary care directly affects the management effect. The current status and common rules of hypertension management in primary care in China need to be further explored.

Objective

To understand the current status of hypertension management in primary care in China, summarize the typical experience, and provide suggestions for the optimization of hypertension management in China.

Methods

From November to December 2021, semi-structured interviews were conducted with 29 hypertension management stakeholders in five provinces in China. Guided by the World Health Organization's health system, the interviews were analyzed from six dimensions of leadership and governance, service delivery, health workforce, health financing, access to medicines and equipment, and health information system.

Results

For leadership and governance, hypertension management in primary care mainly relies on contracted family doctor service, and requires the collaborative management of medical institutions and public health departments. In terms of service provision, general practice and specialty integration services should be provided to meet the individual medical needs of patients. For health workforce, community general practitioners are the main force of hypertension management in primary care, and their work motivation should be improved by performance appraisal and distribution according to their work. For health financing, hypertensive patients can obtain preferential policy support of medical insurance reimbursement at primary care. For medicine accessibility, basic medical equipment and essential hypertension drugs are available in primary care. For health information system, the regional medical and health information platform can realize health information sharing and service coordination among contracted patients.

Conclusion

Primary health care institutions are responsible for the long-term follow-up and management of hypertension patients. It is necessary to further enhance the capacity of primary health care comprehensive management and primary health service supply, strengthen the capacity building of primary health care personnel, improve the reimbursement and payment system of medical insurance, improve the drug and equipment conditions for hypertension treatment in primary care, and effectively empower hypertension management in primary care through informatization, which can effectively improve hypertension management in primary care.

Policy Analysis on Children's Hierarchical Medical System between Beijing and Shenzhen

LIU Shuyan, YAO Mi, ZHANG Jiawei, QI Zhennan, QI Jianguang, XIAN Junfang, CHI Chunhua

2024, 27(13):  1550-1555.  DOI: 10.12114/j.issn.1007-9572.2023.0110

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Background

In order to solve the children's medical dilemmas of poor accessibility and high cost, a hierarchical medical system has been carried out in our country. No systematic research on policy analysis of children's hierarchical medical system has been reported in China at present.

Objective

Beijing and Shenzhen are the first pilot cities of the hierarchical medical system, but there are obvious differences in the status of community health services for children. This study aims to explore the impact of policies on community health services for children by analyzing the policies in these two cities.

Methods

According to the research framework of policies on community health services developed by an expert group (community first contact care, dual referral, medical alliance, salary compensation mechanism, pediatric professional training, publicity, rural medical accessibility), policy documents about hierarchical medical services for children were searched from the official website of Beijing Municipal Government, Beijing Municipal Health Commission, Shenzhen Municipal Government, and Shenzhen Municipal Health Commission. Compare the number and content of policies that meet the inclusion and exclusion criteria in the two cities and analyze similarities and differences.

Results

Thirty-five policy documents that fit the research framework were selected from 6 953, of which 27 were from Beijing and 8 from Shenzhen. Both cities have policies on medical alliances, wage incentives and pediatric training. Compared with Shenzhen, Beijing has policies on publicity, and rural medical accessibility, but not on community first contact care and dual referral.

Conclusion

It may be of great significance to improve the situation of community health services for children by implementing the community first contact care or increasing the gap in medical insurance payment ratio, completing the indications for dual referral, promoting the medical alliance, salary compensation mechanism and training of pediatric skills policies.

Development of the "First Distribution" Indicator System of Family Doctor Team Performance Based on Contract Service Fee

CHEN Hong, ZHOU Rong, SHI Jianwei, YU Wenya, LYU Yipeng, ZHOU Liang, GAO Xiang, HUANG Lei, WANG Zhaoxin

2024, 27(13):  1556-1560.  DOI: 10.12114/j.issn.1007-9572.2023.0021

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Background

The family doctor contract service is being vigorously promoted. Compared with the individual performance appraisal scheme, the performance appraisal scheme based on the family doctor team including the two processes of "first distribution" and "secondary distribution" is more capable of mobilizing the work motivation of family doctor team members, thus improving service efficiency and quality.

Objective

To develop the "first distribution" indicator system of family doctor team performance based on contract service fee.

Methods

The draft of the "first distribution" indicator system of family doctor team performance was preliminarily formulated through literature analysis and semi-structured interviews. On the basis of the draft, an expert consultation questionnaire was designed, and two rounds of expert consultation were implemented and completed from October 2021 to April 2022 to develop the "first distribution" indicator system of family doctor team performance based on contract service fee.

Results

The recovery rate of the two rounds of expert consultation questionnaires was 100.0%. The authority coefficient of the first round of correspondence was 0.761 6, and the Kendall coordination coefficients of the two rounds of consultations were 0.067 (P<0.001) and 0.712 (P<0.001), respectively. Finally, the "first distribution" indicator system of family doctor team performance was finally constructed, including 3 primary indicators and 15 secondary indicators.

Conclusion

The performance allocation system constructed in this study based on contract service fee, which includes three primary indicators (effective contracting, effective service, and effective fee control), has a certain degree of logic and scientificity that reflects the labor value of the contracted service provided by the family doctor team, and is conducive to special incentive effect of the contract service fee.

The Role of a Ladderlike Communication Skill Course on Fostering Doctor-Patient Communication Competence of Students in Rural-oriented Free Tuition Medical Education Program

CHEN Enran, SHEN Ying, WEI Yuning, WEI Siyu

2024, 27(13):  1561-1567.  DOI: 10.12114/j.issn.1007-9572.2023.0215

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Background

The phase of undergraduate medical education is the starting point for fostering communication competence of students in Rural-oriented Free Tuition Medical Education Program (RTME), which lays the foundation both for communication competence training in the postgraduate education phase and performing effective communications with patients and their relatives, colleagues, and other health personnel in the career life of general practitioners (GPs). It is of great practical significance to explore how to improve quality of doctor-patient communication education in the stage of undergraduate medical education and develop doctor-patient communication competence of the RTME students.

Objective

To explore the role of the ladderlike communication skill course on fostering doctor-patient communication competence of students in rural-oriented free tuition medical education program.

Methods

A total of 259 RTME students of Grade 2019 were selected from Guangxi Medical University in September 2019 to establish Cohort 1, and 262 undergraduate medical students of Grade 2019 were selected to establish Cohort 2. From September 2019 to January 2022, the students in Cohort 1 were trained in a ladderlike communication skill course lasting for five consecutive semesters; from September 2021 to January 2022, the students in both cohorts were trained in a doctor-patient communication course. The final exam scores and process assessment scores of the two cohorts on the doctor-patient communication course were compared and the evaluation of teaching effectiveness and satisfaction of ladderlike communication skill course were investigated in the students in Cohort 1.

Results

The RTME students achieved significantly greater total scores for the final exam of the doctor-patient communication course, in which the RTME students performed better on the sections of case analysis and small essay, but worse on the single-choice question section compared to the undergraduate medical students (P<0.05). Similarly, the RTME students obtained higher scores on the process assessment of the doctor-patient communication course than undergraduate medical students, resulting from higher scores on the dimensions of information collection, information giving, negotiation and resolution, and nonverbal communication skills (P<0.05), and there was no statistically significant difference in the scores on the dimension of establishing first impression (P>0.05). Over 80% of RTME students felt satisfied or absolutely satisfied with the content, pedagogical measures, faculty, schedule and effects of the ladderlike communication skill course, and more than 60% believed it helped or absolutely helped promote learning interest, increase confidence to encounter difficult patients, and raise multiple competence, including empathy, doctor-patient communication, language expression, problem resolution, and team work.

Conclusion

The ladderlike communication skill course significantly elevates the effects of doctor-patient communication education in the phase of undergraduate medical education for the RTME students, facilitates the development of doctor-patient communication competence and other comprehensive competence. The ladderlike course mode is an effective measure fostering doctor-patient communication competence of medical students in medical education, and makes a useful reference for communication competence training for postgraduate education and continuing education of general practice.

Construction of Evaluation Index System for Post Competency of Primary Care General Practitioners

WANG Xingyou, SU Qiaoli, LI Shuangqing, CHIEN Ching-Wen

2024, 27(13):  1568-1572.  DOI: 10.12114/j.issn.1007-9572.2023.0340

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Background

Hierarchical diagnosis and treatment system is crucial for deepening the medical and health system reform and establishing the basic medical and health system with Chinese characteristics. Primary care institutions play an essential role in hierarchical diagnosis and treatment system by assuming the role of "gatekeepers" of residents health. The post competency of general practitioners, who are the core of primary care institutions, significantly influences the service capacity of these institutions.

Objective

To construct an indicator system for the evaluation of post competency of general practitioners in primary care institutions.

Methods

From September to December 2022, 13 medical professionals were consulted through two-round Delphi expert consultation method; the hierarchical analysis and entropy method was used to calculate the weights of the indicators.

Results

The indicator system was optimized and sifted through two rounds of Delphi expert consultation, the evaluation system of primary general practitioners was finally constructed, consisting of 5 primary indicators and 27 secondary indicators. The weights of the indicators at all levels were clarified through the hierarchical analysis combined with the entropy method, in which the basic public health service capacity indicator had the highest weight and was the core indicator. The indicator system was tested for reliability and validity by small samples, and all of them were at an acceptable level.

Conclusion

An indicator system for evaluation the post competency of general practitioners in primary care institutions was constructed, contributing to the selection and appointment of general practitioners, which will provide an objective reference for the evaluation of post competence of general practitioners in primary care institutions.

Design and Development of Scales in Primary Care: Practical Steps and Statistical Methods

WANG Fei, TANG Jingqi, SUN Xiaonan, SUN Xinying, LI Jun, MENG Xingxing, WU Yibo

2024, 27(13):  1573-1583.  DOI: 10.12114/j.issn.1007-9572.2022.0819

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This study outlines statistical methods and practical steps for designing and developing valid and reliable questionnaires in primary care. A series of studies on questionnaire development and scale design are reviewed and a standardized process for scale design in the primary care is developed. The process involves key and practical steps in the scale design process as well as statistical methods, which is illustrated with examples of previous relevant studies within the field. The suggested seven-step approach to developing a questionnaire in the primary care is: (1) defining the construction of measurement; (2) generating the pool of items; (3) selecting the scoring system and response format; (4) pre-testing (assessing content validity and face validity, etc.) ; (5) eliminating items by item analysis; (6) evaluating the scale initially, including evaluating the reliability and validity of the scale, and factor analysis or Rasch analysis; (7) re-evaluating the scale to re-examine the nature of the scale, including retesting reliability and constructing validity. In general, the studies on scale design should strictly follow the standardized steps of scale development, and the integrated use of Rasch model and factor analysis can make the measurements more objective.

Basic Design and Implementation Steps for Cross-sectional Studies in General Practice and Primary Care

LI Xueying, KANG Xiaoping, CHI Chunhua, WANG Xicheng, SHANG Meixia, ZHOU Guopeng, GAO Chang, PAN Zihan

2024, 27(13):  1584-1593.  DOI: 10.12114/j.issn.1007-9572.2022.0905

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Cross-sectional study is one of the classic research design methods, which is widely used in clinical research. Cross-sectional study designs are used to answer a large number of scientific questions in general practice research. This includes not only the investigation of population health characteristics, disease characteristics or health service status, but also a variety of research scenarios such as the construction of disease screening and diagnosis methods for community people. Therefore, this paper will sort out and summarize the key points of cross-sectional research in the field of general medicine, and provide reference for future research work. In the field of general practice, cross-sectional studies can be used for status description, comparative analysis, correlation factor analysis and exploration of community screening diagnostic methods. The clinical development of cross-sectional studies should include two stages, study design and study implementation. The design stage includes accurate extraction of study objectives, defining clinical factors such as study population, study factors and outcome indicators, and determining the method of sample acquisition, determining the basis for sample size and rational statistical analysis strategies. In the implementation stage, complete research plan and case report form should be used to present research design ideas, and data collection should be carried out under the premise of ethical approval. Meanwhile, quality of data management and statistical analysis methods in the plan should be strictly implem.

Article

Trends in Prevalence and Burden of Asthma and Its Risk Factors in China, 1990-2019

QU Yuanyuan, CAO Miao, WANG Jing, CHENG Li, HE Xiaoshuang

2024, 27(13):  1594-1600.  DOI: 10.12114/j.issn.1007-9572.2023.0172

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Background

Asthma is one of the most common chronic respiratory diseases. Understanding its prevalence, trend and risk factors is of great significance to take targeted preventive and control measures.

Objective

To analyze the prevalence, burden and trend of asthma in China from 1990 to 2019, and analyze the rank of asthma risk factors, so as to provide a basis for effective prevention and control of asthma in China.

Methods

Based on the Global Burden of Disease Database 2019 (GBD 2019), disability-adjusted life years (DALY), years of life lost (YLL), years lived with disability (YLD) and prevalence rates were used to analyse trends in the burden of disease by gender and age in China from 1990 to 2019. Changes in asthma risk factors were analyzed by population attributable faction (PAF) of standardized DALY rate and mortality rate.

Results

In 2019, the age-standardized DALY rate, YLL rate and YLD rate for asthma in China was 102.81/ 100 000, 24.50/100 000 and 78.31/100 000, respectively, and the standardized prevalence rate was 1 974.16 /100 000, which was higher in all males than females, and higher in the 1-9 and ≥65 years old groups than the other groups. 1990-2019, the crude YLL rate was gradually decreasing in the ≥40 years old group, with DALY crude rates, YLD crude rates and prevalence all crossing over in the <65 years old group, but then showing a decreasing trend year on year. Secondary risk factors for asthma were ranked in order of tobacco use, high body mass index (BMI) and occupational hazards. Tobacco uses consistently ranked as the top risk factor for the burden of asthma, with high BMI rising to second place in 2019 and its PAF for mortality rising to first place.

Conclusion

From 1990 to 2019, there was an overall downward trend in per capita health loss in the asthma population, but the burden of asthma remained at a high level in the 1 to 9 and ≥65 years age groups. The burden of asthma disease was higher in men than women. The PAF of asthma-related risk factors has changed, with a relative decline in the importance of occupational hazards and the increasingly prominent impact of tobacco use and high BMI. The focus of asthma prevention and control can be focused on screening of high-risk groups (aged 1 to 9 years, aged≥65 years, males, tobacco use, with occupational exposure), smoking cessation education, weight control, monitoring and management of occupational settings.

Changes in the Burden of Five Common Chronic Diseases among Rural Residents in Yunnan Province in 2011 and 2021

WU Xia, LIU Lan, ZHAO Yi, LI Guohui, CUI Wenlong, SUN Chenghuan, CAI Le

2024, 27(13):  1601-1607.  DOI: 10.12114/j.issn.1007-9572.2023.0276

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Background

Chronic diseases have become a major public health problem affecting the health of the population, and the number of patients with chronic diseases in China continues to increase, as well as the increasing number of deaths due to chronic disease by year, and the increasing burden of disease on patients gradually. Understanding the changes in the burden of chronic diseases is of great importance for the prevention and control of chronic diseases. However, there is a lack of research on the changes in the burden of common chronic diseases in rural Yunnan Province.

Objective

To examine the changes in the disease burden of five common chronic diseases [hypertension, coronary heart disease (CHD), stroke, asthma, and chronic obstructive pulmonary disease (COPD) ] among rural residents in Yunnan Province in 2011 and 2021.

Methods

A repeated cross-sectional design was used to select 8 400 and 7 700 rural residents aged≥35 years in Yunnan Province using multistage stratified random sampling method in 2011 and 2021 as the research subjects, respectively. Data were collected from on-site questionnaires and physical examinations of study participants, as well as data on the causes of death of five common chronic diseases. Principal component analysis was used to construct a socioeconomic position (SEP) indicator by selecting three variables including education level, annual household income per capita and accessibility to medical services, the coefficients of the variables were used to calculate the SEP composite score, and the SEP was classified into four grades of low, medium-low, medium-high and high based on the quartiles of the SEP composite score. Disability-adjusted life year (DALY) was used to measure the magnitude of the disease burden for five chronic diseases.

Results

Compared with 2011, the overall prevalence of hypertension (25.14% vs. 41.57%), stroke (1.03% vs. 2.52%), and COPD (9.23% vs. 12.60%) in rural Yunnan Province in 2021 increased (P<0.05), as well as the prevalence for males, females, and participants with all SEP grades (P<0.05) ; the overall prevalence of CHD (2.02% vs. 2.30%) and asthma (1.36% vs. 1.61%) did not change significantly (P>0.05), while an increase was found in the prevalence of CHD among males and those with high SEP grade, and in the prevalence of asthma among males and those with medium-high SEP grade (P<0.05). In 2021, the prevalence of all 5 chronic diseases was higher in males than in females (P<0.05), and there was a decreasing trend in the prevalence of COPD by different grades of SEP in 2021 (χ²_trend=6.801, P<0.001). In addition, an increase was found in DALY per 1 000 population of CHD (10.45 vs. 18.18), stroke (12.80 vs. 23.20), asthma (4.54 vs. 9.10), and COPD (35.99 vs. 49.07), while a decrease was found in DALY per 1 000 population of hypertension (1.38 vs. 1.26). COPD presents higher DALY per 1 000 population and years of life disability (YLD) per 1 000 population, while stroke presents higher years of life lost (YLL) per 1 000 population among the five chronic diseases.

Conclusion

The prevalence and disease burden of five common chronic diseases among rural residents in Yunnan Province in 2021 were mainly higher than 2011, and the disease burden of COPD was the heaviest in 2021, with males and those with low SEP grade being the key populations for future prevention and control of chronic diseases. Targeted prevention and control strategies should be adopted to reduce its harm to the health of population.

A Study on the Factors Influencing Performance of Chronic Disease Management among Population with Mild Cognitive Impairment in the Context of Family Doctor Service Based on Grounded Theory

ZHAI Jiayi, LU Yuan, TAO Qiongying, HUANG Wuquan, LIU Yalin, YU Dehua

2024, 27(13):  1608-1615.  DOI: 10.12114/j.issn.1007-9572.2023.0334

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Background

Management of mild cognitive impairment (MCI) can reduce the burden of disease on society, families and individuals. The performance of family doctor team is the key to the quality of service, which acts as the main force of chronic disease management in China.

Objective

To explore the factors influencing the performance of family doctor teams in providing chronic disease management service for patients with MCI.

Methods

In July 2021, a total of 28 medical workers from 8 community health service centers in 4 districts of Shanghai were selected by purposive sampling method to conduct semi-structured interviews, the interview data were coded and analyzed after the interviews.

Results

After three levels of coding, 114 concepts, 49 categories and 8 main categories were sorted out, 4 core categories of factors influencing performance were concluded of service organizer (government), service provider (doctor), service demander (patient) and task implementation. The theoretical framework was organized into five main processes, including organizers driving both provider and demander, provider taking the initiative to implement, demander cooperating with implementation, interaction between provider and demander, task execution cycle improvement.

Conclusion

Although performance of family doctor teams in providing chronic disease management service for patients with MCI is affected by many factors, the process and results are the key to test performance. The driving role of the organizer, execution function of the provider and cooperation of demander are the premise for execution process and result. However, the feedback effect of task execution can improve the quality of service, and eventually form a circular optimization mechanism from organizer drive, to provider execution and demander cooperation, to task execution feedback.

The Value of High Frequency Oscillatory Ventilation Combined with Volume Guarantee in Extremely Preterm Infants with Respiratory Distress Syndrome

LOU Wubin, LI Fang, ZHANG Weixing, SHEN Jie

2024, 27(13):  1616-1622.  DOI: 10.12114/j.issn.1007-9572.2023.0514

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Background

Early hypocapnia in extremely preterm infants is associated with intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD). The results of foreign studies show that high frequency oscillatory ventilation combined with volume guarantee ventilation (HFOV+VG) has been confirmed to reduce hypocapnia in preterm infants, but less is known of using HFOV+VG in extremely preterm infants born at <28 weeks gestational age.

Objective

To investigate the clinical efficacy of HFOV+VG in the treatment of respiratory distress syndrome with extremely premature infants.

Methods

Extremely preterm infants with respiratory distress syndrome admitted to the NICU of Xinxiang Central Hospital (the Fourth Clinical College of Xinxiang Medical College) at a gestational age of <28 weeks and a birth weight of <1 000 g, who required invasive mechanical ventilation, were prospectively selected as the study subjects and were divided into the HFOV+VG group and the synchronized intermittent mandatory ventilation (SIMV) group according to the randomized numeric table method. Arterial blood gas analysis was performed 48h after trial initiation for invasive ventilation duration, total respiratory support duration, case fatality, and incidence of hypocapnia, periventricular leukomalacia (PVL), retinopathy of prematurity (ROP), late onset sepsis (LOS), pneumothorax, ventilator-associated pneumonia (VAP), bronchopulmonary dysplasia (BPD), neonatal necrotizing enterocolitis (NEC), and grade 3-4 periventricular-intraventricular hemorrhage (IVH) .

Results

In HFOV+VG group, the duration of invasive ventilation and total respiratory support time were shorter than SIMV group, and the incidence of hypocapnia and PVL were lower than SIMV group, and there were all significant statistical differences the two groups (P<0.05), while the incidence of ROP, LOS, pneumothorax, VAP, BPD, NECand grade 3-4 IVH were not significant (P>0.05) .

Conclusion

Compared with SIMV ventilation, HFOV+VG ventilation in extremely preterm infants born at <28 weeks gestational age has better clinical results and does not increase adverse effects, which deserves clinical promotion.

Clinical Characteristics of Patients with Idiopathic Inflammatory Myopathy and Risk Factors for the Development of Interstitial Lung Disease

LI Xingjun, LI Shuangrong, WANG Nan, WANG Xiangyu, CUI Ruomei, XU Jian, GUO Yulong, LIU Shuang

2024, 27(13):  1623-1629.  DOI: 10.12114/j.issn.1007-9572.2022.0003

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Background

Idiopathic inflammatory myopathy (IIM) is a group of connective tissue diseases characterized by muscle inflammation and muscle weakness, lung involvement is an important factor affecting the prognosis of patients. IIM can be classified into different clinical subtypes based on myositis-specific antibodies (MSAs), there are significant differences in clinical manifestations, organ involvement, prognosis and the risk of interstitial lung disease among different clinical subtypes.

Objective

To explore the characteristics of IIM and its different clinical subtypes, the risk factors for the development of interstitial lung disease.

Methods

The clinical data of patients hospitalizedin department of rheumatology and immunology of the First Affiliated Hospital of Kunming Medical University and diagnosed with IIM from April 2018 to February 2021 were collected. The included patients were divided into four clinical subtypes based on MSAs, including anti-MDA5-positive dermatomyositis (DM), anti-MDA5-negative DM, immune-mediated necrotizing myositis (IMNM) and anti-synthetase syndrome (ASS) subtypes. The general data, clinical manifestations, laboratory examination results were compared among different clinical subtypes. Multivariate Logistic regression model was established to explore the risk factors for ILD in patients with IIM.

Results

The 150 patients with IIM were divided into 4 clinical subtypes, including 30 patients with anti-MDA5-positive DM subtype (20.0%), 58 patients with anti-MDA5-negative DM subtype (38.7%), 14 patients with IMNM subtype (9.3%), and 48 patients with ASS subtype (32.0%). There were significant differences in the incidence of muscle weakness, myalgia, ILD, heliotrope rash, shawl sign, Gottron papules or Gottron sign, arthralgia, periungual red spot and dysphagia among the four clinical subtypes (P<0.05). The incidence of ILD in patients with anti-MDA5-positive DM and ASS subtypes was higher than patients with anti-MDA5-negative DM and IMNM subtypes, respectively (P<0.05) ; The incidences of heliotrope rash and shawl sign in patients with anti-MDA5-positive DM and anti-MDA5-negative DM subtypes were higher than patients with IMNM and ASS subtypes (P<0.05) ; The incidences of arthralgia in patients with anti-MDA5-positive DM subtype was higher than patients with anti-MDA5-negative DM subtype (P<0.05). There were significant differences in the levels of WBC, ALT, AST, serum creatinine, LDH, CK, C4, ferritin, T cell, CD8+ T cell, nature kill (NK) cell and incidence of ILD among patients with different subtypes (P<0.05). Multivariate Logistic regression analysis showed that anti-MDA5 antibody positive, anti-synthetase antibody positive, lung infection, ferritin>403.2 μg/L, IgG>14.15 g/L, LDH>359.5 U/L were all risk factors for ILD in IIM (P<0.05) .

Conclusion

The clinical manifestations of patients with different clinical subtypes differ significantly. DM patients with anti-MDA5 antibody positive are more likely to develop rash, arthralgia, ILD and leukopenia. MDA5 antibody positive, anti-synthetase antibody positive, lung infection and elevated ferritin, LDH and IgG levels are the risk factors for IIM with ILD.

Analysis of Psychosomatic Disorders Perceptions and Healthcare Seeking Behavior Characteristics Based on Patient-physician Multi-party Interviews

PENG Yangyang, LIU Huailei, ZHANG Hanzhi, YU Dehua

2024, 27(13):  1630-1637.  DOI: 10.12114/j.issn.1007-9572.2023.0194

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Background

Psychosomatic disorders present high prevalence and disease burden in the community. Currently, different disciplines of medical institutions possess unclear functions and inadequate process strategies for the diagnosis and treatment of psychosomatic disorders, resulting in differences in the perceptions of disease and behavioral characteristics of doctors and patients, which affects the management of disease in the community.

Objective

To understand and analyze the cognitive and behavioral characteristics as well as the influencing factors of psychosomatic disorders from multiple perspectives of doctors and patients, and then provide strategic directions to improve the diagnosis and management of psychosomatic patients in the community.

Methods

During the period from 2022-02-01 to 06-31, 5 internists from a general hospital (H1) in Yangpu District, 12 general practitioners from 2 community health centers (H2, H3) in Yangpu District, and 2 community health centers (H4, H5) in Jiading and Pudong New Districts, 2 healthcare professionals from a mental health center hospital in Yangpu District, and 10 patients and with psychosomatic disorders who had been treated in the above hospitals or their relatives. The interview was performed by WeChat, face-to-face as well as telephone and other methods, with the content including perceptions of psychosomatic disorders, healthcare seeking behaviors, disease attitudes, problems and suggestions, and lasted 15-30 min. The interview content was recorded and transcribed into text, coded, summarized to generate themes, and finally quoted from representative interviewees.

Results

(1) There was a high level of disease awareness among general practitioners and psychiatrists, a low level of awareness among internists, and a general lack of awareness among patients. (2) General practitioners and psychiatrists possessed more experience in the diagnosis and treatment of psychosomatic disorders, but lacking sufficient work and effective treatment results. (3) The attitudes of multiple doctors and patients were varied with an overall lack of positivity. General practitioners had the most positive attitudes toward the diagnosis and treatment of psychosomatic disorders. (4) Doctors of different disciplines faced difficulties, including large patient bases, insufficient mental health resources, lack of solid psychological perceptions, lack of standardized guidelines for diagnosis and treatment, and busy practices, etc. (5) Most patients had not received psychotherapy, but they didn't exclude it either, while there were problems such as distrust of general practitioners, fear of treatment side effects, and health seeking behavior affected by many factors. (6) Both doctors and patients offered constructive suggestions, which included strengthening publicity and policy guidance to the public, promoting the continuous development of psychosomatic medicine, improving doctors' identification of psychological disorders, opening joint clinic for chronic disease and psychology, improving the experience of medical treatment, setting up a comfortable treatment environment, and coordinating referrals, etc.

Conclusion

Barriers such as differences in perceptions and attitudes between doctors and patients, unequal medical resources, and irregularities in behavior exist between doctors and patients. In the community, it is necessary to strengthen the advantages and functions of general practitioners on the management of psychosomatic disorders; fully implement and utilize relevant resources; and improve the negative attitudes of both doctors and patients, so that patients can seek proper medical treatment and improve their mental health.

Medical and Social Cooperation and Community Smart Health Huts: Reconstruction of Hierarchical Diagnosis and Treatment Path

WU Yuxia, MA Hongbo, MI Hong

2024, 27(13):  1638-1644.  DOI: 10.12114/j.issn.1007-9572.2023.0404

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Background

One of the important reasons for the slow progress of hierarchical diagnosis and treatment since its implementation is the lack of comprehensiveness in the analysis of multiple subjects and stakeholders.

Objective

To explore mechanism innovation solutions that combine both top-down and bottom-up paths by analyzing the interest relationships among diverse stakeholders in the hierarchical medical diagnosis and treatment system, and facilitate collaborative governance among diverse stakeholders through policy innovation and path innovation, to optimize the order of hierarchical patient flow.

Methods

From October 10, 2022, to March 20, 2023, two advanced urban districts in China (S district in X city and H district in N city) were selected as typical research areas. A total of 36 different stakeholders (involving municipal health administrative departments, tertiary hospital administrators, tertiary hospital specialists, community health service center administrators, general practitioners, health social workers, and patients) were selected as the study subjects for the in-depth interviews through snowball and purposive sampling methods. The stakeholder theory analysis method was employed to analyze the interests and constraints among the seven major stakeholder groups and their constraints on the healthy development of the order of hierarchical medical diagnosis and treatment, and explore the dilemma of the mechanism of hierarchical diagnosis and treatment. Furthermore, textual analysis of interview records of typical stakeholders in the pilot and non-pilot areas of the implementation of health social workers and community smart health huts in S district in X city and H district in N city was conducted to compare the effects before and after the implementation.

Results

The results of the in-depth interviews showed that four main dimensions, including the degree of interest, willingness to implement, the extent of impact by implementation, and the influence on implementation, are the major factors affecting the implementation of hierarchical medical diagnosis and treatment by the seven major stakeholder groups. These seven stakeholder groups hold varying interest positions and play different roles in facilitating or obstructing the implementation of the hierarchical medical diagnosis and treatment. The difficulty of forming a collaborative mechanism among diverse stakeholders is the key to the problem. In pilot areas, through the implementation of the community smart health huts and health social workers, and the resulting medical-social collaboration, the relevance of the seven major stakeholder groups can be enhanced and the hierarchical medical diagnosis and treatment order can be improved.

Conclusion

The community smart health huts serve as a physical space for the new medical-social collaboration mechanism, while health social workers act as the connectors and enablers of this new mechanism. With the help of the new carrier of community smart health huts and the new power of health social workers, the construction of a new path of medical-social collaboration centered on health social work can realize the front entrance of medical treatment and play the role of"energy enhancer"to form the order of hierarchical medical diagnosis and treatment.

How Can Macro Social Work Better Engage in Geriatric Health Services?

LIU Haitao, GU Donghui, GAO Haizhen

2024, 27(13):  1645-1650.  DOI: 10.12114/j.issn.1007-9572.2023.0563

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Background

As aging increases, geriatric health expectations and needs for social work profession and its services increase. Current social work engage in geriatric health services still focuses on micro-level changes for clients, but macro-level services such as promoting environmental change and advocating for policies are insufficient, that is the research from macro social work perspective is weak.

Objective

We explore the model and practice of macro social work in the field of geriatric health and provide a scientific basis and analysis for its engagement in geriatric health services through doctrinal analysis and field research.

Methods

From March to July 2021, the researcher entered the J social work professional organisation in Shanghai to conduct a field study, and the empirical data were mainly collected through two methods: participatory observation and semi-structured interview. The research subjects were selected based on the principle of purposive sampling. A total of 21 research participants were interviewed, including 5 agency administrators and social workers, 16 cognitive disorder patients in Shanghai. The interview outline was formulated based on the theory of development of social policy and welfare social division of labor. The typology method was used to categorise the clinical and macro practices of social workers in geriatric health services. NVivo 11 software was used to code and classify the interview contents, combining theoretical and empirical data to explore macro social work practices in geriatric health services.

Results

A total of 21 people with cognitive disorders were interviewed, including both providers and users of geriatric health services. Understanding the values of macro social work, understanding the issues and service populations, promoting change in the community as a field, and changing the systems approach with health policy and welfare can provide accurate systems services for the elderly, enrich macro social work services, and contribute to changes in the geriatric health service environment.

Conclusion

Macro social work can promote and change the environment to provide better well-being for elderly health. The development of health social work requires the synergistic development of various sectors, such as the National Health Commission and the National Ministry of Civil Affairs, and the convergence of the wisdom of clinical social work and macro social work in geriatric health services. This will jointly promote the quality development of geriatric health services.

Action Research on Constructing a Welfare Pluralism System for the Elderly with Dementia: Taking the Elderly Health Social Work Service of Beijing X Hospital as an Example

DU Jin, ZHANG Hongyu, QIAO Yuchen, LIU Yifan, LI Luling

2024, 27(13):  1651-1660.  DOI: 10.12114/j.issn.1007-9572.2023.0099

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In the context of population ageing, the number of elderly patients with dementia is increasing day by day. This disease seriously affects the quality of life of the elderly and causes huge burdens and pressures on families and society. At this stage, issues such as low level of attention at the national and social levels, weak ability of active screening and identification, high treatment and care costs, and fragmented social service system are prominent in the elderly dementia. It is imperative to actively explore the construction of a care system that covers the entire life cycle of dementia in the elderly, which is composed of multiple welfare subjects such as the government, community, family, market, and civil society organizations. Based on the practice of the full-cycle support project for elderly patients with dementia and their families in Beijing X Hospital, the research takes the theory of welfare pluralism as the framework, and constructs the implementation path and mechanism of the welfare pluralism care system for the elderly with dementia through action research. Based on the portrayal of the reality of the elderly with dementia, health social workers break through the shortcomings of the original medical social work service, such as the single service object, the confinement of the service place, the disconnection of the needs of patients with different disease cycles, and the poor effect of the resource link, etc., turn to the perspective of health social work to use the method of action research to try to break the situation from four directions: in the stage of early detection of dementia, we can clarify the responsibilities of service subjects and maximize service effectiveness; in the stage of early treatment of dementia, we can break down barriers between service subjects and realize the value of resources flow; in the stage of self-management of patients with dementia, we can mobilize the subjective initiative of service subjects to achieve positive transformation of target group; in the dementia friendly advocacy stage, we can respond to the internal needs of service subjects and achieve sustainable development of the care system.