Nurses' practices and their influencing factors in palliative care.

Background: In 2017, the Chinese government launched a pilot project in palliative care, in which Shanghai was a pioneer. Nurses play a key role in palliative care services as they are the main providers improving the quality of services for patients and their families. However, little is known about practices and influencing factors in the field of palliative care from a nursing perspective in China. This is an original empirical study that has meticulously analyzed the interrelationship and intensity between practices and other factors among nurses in the initial stage of palliative care in primary healthcare institutions in Shanghai, China. Methods: A descriptive-correlational study design was used to sample 2,829 eligible palliative care nurses by purposive sampling survey in 225 healthcare institutions in Shanghai, China. Descriptive analyses were performed using IBM SPSS 24.0 software. Structural equation modeling was applied to analyze the data by AMOS 20.0. Data were collected using the well-designed Knowledge, Attitudes, and Practices of Hospice Care (KAPHC) scale. Results: The final model showed a good model fit. Self-efficacy directly influenced practices (ß = 0.506, P < 0.01) and indirectly influenced practices (ß = 0.028, P < 0.01) through intention. Subjective norm directly influenced practices (ß = 0.082, P < 0.01) and indirectly influenced practices (ß = 0.030, P < 0.01) through intention. Intention (ß = 0.152, P < 0.01) and knowledge (ß = 0.068, P < 0.01) directly influenced practices. Perceived susceptibility (ß = -0.027, P < 0.01), perceived benefits (ß = -0.017, P < 0.01), and perceived barriers (ß = -0.014, P < 0.01) indirectly influenced practices through intention. Conclusion: This study provided evidence of the associations of knowledge, perceived susceptibility, benefits, barriers, subjective norm, self-efficacy, intention, and practices among nurses concerning palliative care and interventions improving their actual work practices. Our findings revealed that self-efficacy, intention, and subjective norms greatly influenced practices. It is imperative to take interventions that focus precisely on self-efficacy, intention, and subjective norms to improve nurses' practices.

Attitudes and influencing factors of nursing assistants towards hospice and palliative care nursing in chinese nursing homes: a cross-sectional study.

BACKGROUND: Hospice and palliative care nursing (HPCN) in China is mainly available at public primary care institutions, where nursing homes (NHs) are rarely involved. Nursing assistants (NAs) play an essential role in HPCN multidisciplinary teams, but little is known about their attitudes towards HPCN and related factors. METHODS: A cross-sectional study was designed to evaluate NAs' attitudes towards HPCN with an indigenised scale in Shanghai. A total of 165 formal NAs were recruited from 3 urban and 2 suburban NHs between October 2021 and January 2022. The questionnaire was composed of four parts: demographic characteristics, attitudes (20 items with four sub-concepts), knowledge (nine items), and training needs (nine items). Descriptive statistics, independent samples t-test, one-way ANOVA, Pearson's correlation, and multiple linear regression were performed to analyse NAs' attitudes, influencing factors, and their correlations. RESULTS: A total of 156 questionnaires were valid. The mean score of attitudes was 72.44 ± 9.56 (range:55-99), with a mean item score of 3.6 ± 0.5 (range:1-5). The highest score rate was "perception of the benefits for the life quality promotion" (81.23%), and the lowest score rate was "perception of the threats from the worsening conditions of advanced patients" (59.92%). NAs' attitudes towards HPCN were positively correlated with their knowledge score (r = 0.46, P < 0.01) and training needs (r = 0.33, P < 0.01). Marital status (ß = 0.185), previous training experience (ß = 0.201), location of NHs (ß = 0.193), knowledge (ß = 0.294), and training needs (ß = 0.157) for HPCN constituted significant predictors of attitudes (P < 0.05), which explained 30.8% of the overall variance. CONCLUSION: NAs' attitudes towards HPCN were moderate, but their knowledge should be improved. Targeted training is highly recommended to improve the participation of positive and enabled NAs and to promote high-quality universal coverage of HPCN in NHs.

Volunteers' spiritual care competence and its relationship with attitudes toward palliative care: A cross-sectional study.

OBJECTIVES: Given the rising burden of palliative care and the limited human resources for its facilitation in China, volunteers are becoming increasingly indispensable. In particular, there is a high demand for volunteers who can serve as spiritual caregivers. However, a volunteer's ability to provide good spiritual care in a palliative setting may be influenced by their attitude toward palliative care. To uncover the current state of spiritual caregiving in palliative settings in China and insights into best practices for its improvement, this study measured spiritual care competence and identified its influencing factors and explored its relationship with attitudes toward palliative care among volunteers. Notably, this study is the first to consider spiritual care competence alongside attitudes toward palliative care. METHODS: A descriptive cross-sectional study using online survey methods was conducted with 385 volunteers in Shanghai, China. Data were collected using a structured questionnaire. RESULTS: Volunteers demonstrated relatively low levels of spiritual care competence (58.50 ± 10.92). Statistically significant correlations were found between spiritual care competence and the following variables: age, educational background, marital status, religious beliefs, occupational status, and relevant training and practical experience. Attitude toward palliative care significantly correlated with spiritual care competence (r = 0.49, p < 0.001). SIGNIFICANCE OF RESULTS: To continually improve volunteers' spiritual care competence, diversified education and training programs about spiritual care should be designed for different kinds of volunteers; moreover, because attitude toward palliative care significantly impacted spiritual care competence, such programs should encourage positive attitudes toward palliative care.

Predicting the behavioral intentions of hospice and palliative care providers from real-world data using supervised learning: A cross-sectional survey study.

Background: Hospice and palliative care (HPC) aims to improve end-of-life quality and has received much more attention through the lens of an aging population in the midst of the coronavirus disease pandemic. However, several barriers remain in China due to a lack of professional HPC providers with positive behavioral intentions. Therefore, we conducted an original study introducing machine learning to explore individual behavioral intentions and detect factors of enablers of, and barriers to, excavating potential human resources and improving HPC accessibility. Methods: A cross-sectional study was designed to investigate healthcare providers' behavioral intentions, knowledge, attitudes, and practices in hospice care (KAPHC) with an indigenized KAPHC scale. Binary Logistic Regression and Random Forest Classifier (RFC) were performed to model impacting and predict individual behavioral intentions. Results: The RFC showed high sensitivity (accuracy = 0.75; F1 score = 0.84; recall = 0.94). Attitude could directly or indirectly improve work enthusiasm and is the most efficient approach to reveal behavioral intentions. Continuous practice could also improve individual confidence and willingness to provide HPC. In addition, scientific knowledge and related skills were the foundation of implementing HPC. Conclusion: Individual behavioral intention is crucial for improving HPC accessibility, particularly at the initial stage. A well-trained RFC can help estimate individual behavioral intentions to organize a productive team and promote additional policies.

Healthcare Provider Knowledge, Attitudes, and Practices in Hospice Care and Their Influencing Factors: A Cross-sectional Study in Shanghai.

BACKGROUND: In 2017, the Chinese government launched a pilot project in hospice care (HC), in which Shanghai was a pioneer. Healthcare provider knowledge, attitudes, and practices in hospice care (KAPHC) may facilitate or hinder HC development. To determine how to design targeted training for healthcare providers and policies to improve their KAPHC, we conducted an original study based on an indigenized KAPHC scale to (a) comprehensively measure the KAPHC baseline of healthcare providers in Shanghai and (b) explore its influencing factors. METHODS: A cross-sectional study was designed to evaluate healthcare providers' KAPHC with the indigenized KAPHC scale. Descriptive analysis, linear regression, and Pearson's (r) correlation analysis were performed to uncover providers' KAPHC, its influencing factors, and their correlations. RESULTS: The KAPHC scale proved applicable to the knowledge, attitudes, and practices of the large sample of providers we surveyed. The 7027 KAPHC scaling results revealed that 42.44% of participants had HC experience and 57.49% were willing to provide HC. The mean accuracy of the responses related to knowledge was 59.30%. Scoring rates for attitudes, confidence, and self-reported practices were 74.20%, 73.96%, and 75.55%, respectively. The linear regression revealed that higher KAPHC scores were associated with experience and willingness and varied with professional specializations. The Pearson's (r) correlation evidenced that HC practices were strongly correlated with confidence (r = 0.648, P<.001) and moderately correlated with attitudes (r = 0.463, P<.001). CONCLUSION: We uncovered that targeted training for enhancing healthcare provider KAPHC in Shanghai should focus on psychological and spiritual care, the management of pain and other symptoms, and traditional Chinese medicine (TCM). Additionally, training should be scaled up for providers with different characteristics. Meanwhile, policy should encourage providers to work enthusiastically in HC-universal high-quality HC requires well-trained, supported, and motivated providers.

Instrument development of health providers' Knowledge, Attitude and Practice of Hospice Care Scale in China.

OBJECTIVE: To match the reform of hospice development in China, this study aimed to construct an indigenized health providers' Knowledge, Attitude and Practice of Hospice Care (KAPHC) Scale in China with good validity and reliability. METHODS: We used three steps to develop the scale, establishing items-pool firstly based on literature review and expert consultation, followed by forming a draft-scale design through synthetically consideration, and finally modifying the draft by conducting a self-administrative survey in sampled institution and testing the reliability and validity by statistical analysis. RESULTS: The KAPHC Scale was comprised of 15 knowledge items, 24 attitude items and 22 practice items. In the part of knowledge, the Cronbach's α coefficient was 0.686, the average difficulty was 0.62 and average discrimination was 0.46. The attitude items were divided into four domains (KMO = 0.770), with Cronbach's α coefficient of 0.868. The practice items included confidence of practices and self-reported behaviors (KMO = 0.732), with Cronbach's α coefficient of 0.958. CONCLUSION: The KAPHC Scale demonstrated good validity and reliability. As an effective tool, the scale may contribute to assessing health providers' KAP status of hospice care and exploring their future education needs in mainland China.

Analysis of related factors and disease costs of respiratory infection and environmental pollution in children.

BACKGROUND: In recent years, air pollution and the number of children with respiratory tract infections increased. This also increased the burden related to the treatment of disease, so the government and relevant departments need to strengthen their management. OBJECTIVE: The aim of the present study was to quantitatively analyze the relationship between respiratory infection and air quality in children and gain insight into the burden of related diseases. METHODS: Data regarding outpatient and emergency department visits in children of 14 years or younger in 16 public and private medical institutions were collected for four months. Routine air quality monitoring data in Shanghai from the same period were correlated with these medical data by descriptive statistics, Pearson's correlation analysis and multivariate linear regression analysis. RESULTS: There was a positive correlation between respiratory tract infections in 73376 children and Air Quality Index (AQI), PM2.5, SO2 and NO2 levels. The total medical expense per patient was 80.22 yuan, and the average compensation ratio of medical insurance per patient was 18.95%. The increase in AQI and the concentration of major air pollutants will lead to increased medical treatment for children with respiratory diseases. CONCLUSION: It is suggested that the intensity of air pollution control should be increased, so that the special period of childhood respiratory protection is strengthened. Moreover, child medical insurance coverage should also be moderately increased to safeguard the rights and interests of children's health.

Economic Implications of Chinese Diagnosis-Related Group-Based Payment Systems for Critically Ill Patients in ICUs.

OBJECTIVES: To evaluate the economic implications of payments based on Chinese diagnosis-related groups for critically ill patients in ICUs in terms of total hospital expenditure, out-of-pocket payments, and length of stay. DESIGN: A pre-post comparison of patient cohorts admitted to ICUs 1 year before and 1 year after Chinese diagnosis-related group reform was undertaken. Demographic characteristics, clinical data, and medical expenditures were collated from a health insurance database. SETTING: Twenty-two public hospitals in Sanming, Southern China. PATIENTS: All patients admitted to ICUs from January 1, 2017, to December 31, 2018. INTERVENTION: The implementation of Chinese diagnosis-related group-based payments on January 1, 2018. MEASUREMENTS AND MAIN RESULTS: Economic variables (total expenditures, out-of-pocket payments, and length of stay) were calculated for each patient from the day of hospital admission to the day of hospital discharge. Adjusted mean out-of-pocket payment estimates were 29.46% (p < 0.001) lower following reform. Adjusted mean out-of-pocket payments fell by 41.32% for patients in neonatal ICU, whereas there were no significant decreases in out-of-pocket payments for patients in PICU and adult ICU. Furthermore, adjusted mean out-of-pocket payments decreased by 55.74% in secondary hospitals, but there was no significant change in tertiary hospitals after Chinese diagnosis-related group reform. No significant changes were found in total expenditures and length of stay. CONCLUSIONS: Chinese diagnosis-related group policy provided an opportunity for critically ill patients in ICUs to achieve at least short-term financial benefits in reducing out-of-pocket payments, without affecting the total expenditures and length of stay. Chinese diagnosis-related group-based payment significantly relieved financial burdens for patients with lower illness severities, such as patients in neonatal ICU. The results of this study can offer significant insights for policymakers in reducing the financial burden on critically ill patients, both in China and in other countries with similar systems.

Retinopathy among Chinese subjects with type 2 diabetes mellitus in Shanghai: A community-based follow-up study.

OBJECTIVE: To determine the incidence, progression, and regression rates of diabetic retinopathy (DR), as well as their associated factors, in Chinese type 2 diabetic patients. METHODS: Diabetic patients who participated in a previous survey were recruited for a 1-year follow-up study. Nonmydriatic fundus photographs were acquired to assess the severity of DR as per the International Clinical Diabetic Retinopathy Disease Severity Scale (2002). Factors that potentially influence DR outcomes, including its incidence, progression, and regression, were identified via statistical analyses. RESULTS: We initially recruited 2453 subjects, among whom 2331 were followed and included in the final analysis. The incidences of new and progressed (ie, ≥2 scale steps) DR were 10.6% and 6.1%, respectively. Moreover, 7.3% of patients with established DR at baseline experienced complete regression. Multivariate logistic regression analysis revealed that high glycosylated haemoglobin (HbA1c) (odds ratio [OR] = 1.50, P = .021) and hyperlipidaemia (OR = 1.46, P = .025) were independent predictors of DR development, high HbA1c (OR = 4.16, P = .027) and macroalbuminuria (OR = 5.60, P = .010) predicted DR progression, and low HbA1c (OR = 0.20, P = .001) and low triglyceride levels (OR = 0.34, P = .026) were associated with DR regression. CONCLUSIONS: Albumin and HbA1c levels should be closely monitored as signs of progressive retinal damage in diabetic subjects. Optimized control of glucose and triglyceride levels is vital for reducing the incidence of DR or promoting its regression in afflicted patients.

Exploration and practice of the "1 + 10 + 1100000" model.

The exploration and practice of the "1 + 10 + 1100000" model of local medical consortium includes three aspects: graded diagnosis and treatment, two-way referral, and dynamic flow; seamless connection between general practice and specialty to realize health management; and establishment of the "community health center-East Hospital-Tongji University" teaching platform.

Risk factors for diabetic nephropathy complications in community patients with type 2 diabetes mellitus in Shanghai: Logistic regression and classification tree model analysis.

BACKGROUND: The prevalence of type 2 diabetes mellitus (T2DM) in China was 11.6% in 2010. Chronic complications are the main diabetes-related cause of death and disability, accounting for more than 80% of the cost of diabetes treatment. Diabetic nephropathy (DN) is a common microvascular complication and is the second leading cause of end-stage renal failure in China. OBJECTIVE: We aimed to analyse the DN status among community-based T2DM patients and to explore risk factors for T2DM with DN. METHODS: This study was conducted in six communities of Shanghai. We administered a questionnaire, physical examination, and biochemical tests to 5078 patients with T2DM. Logistic regression and the classification tree model were used to analyse risk factors for T2DM with DN. RESULTS: In total, 1937 patients were diagnosed with DN (prevalence 38.4%). The logistic regression model indicated that course of disease more than 15 years, body mass index (BMI) greater than 24 kg/m2 , haemoglobin A1c (HbA1c) greater than 7.5%, fasting blood glucose (FBG) greater than 11.0 mmol/L, total cholesterol (TC), and high-density lipoprotein (HDL)-C control failure, hypertension, and diabetic retinopathy were risk factors for T2DM with DN (P < .05). The classification tree model identified seven risk factors (HbA1c, FBG, hypertension, postprandial blood glucose, BMI, triacylglycerol, and HDL), of which, HbA1c (cut-off point 7.45%), hypertension, and FBG showed the strongest association. CONCLUSION: This suggests that screening for DN based on HbA1c, FBG, and hypertension should be more extensively promoted by the government on a community level, more attention should be focused on patients' health management, and that patients should be educated on self-management.

Disparities in mental health care utilization among inpatients in various types of health institutions: a cross-sectional study based on EHR data in Shanghai, China.

BACKGROUND: Reform of the health care system in China has prompted concerns about the utilization of mental health services. This study aims to compare the utilization of mental health services among inpatients in various types of health institutions in Shanghai (community health care centres, secondary general hospitals, tertiary general hospitals, and specialty hospitals). METHODS: Based on electronic health record (EHR) data, we extracted all of the mental hospitalization data from various types of public health institutions in Pudong New Area, Shanghai, China, from 2013 to 2016. The distribution of mentally ill inpatients and the possible factors contributing to the observed differences in these institutions were analysed. RESULTS: Specialty psychiatric hospitals in Pudong New Area, Shanghai, admitted more inpatients and treated in patients with more severe disorders (49.73%). However, those who were male (OR = 0.545), were elderly (OR = 20.133), had inferior insurance (urban social insurance for citizens: OR = 4.013; paying themselves, OR = 29.489), had a longer length of stay (OR = 1.001) and had lower costs (OR = 0.910) were more likely to choose community health centres than specialty hospitals. Those who preferred the secondary and tertiary hospitals to the specialty ones were more likely to be in the male, elderly, married, shorter length of stay and higher-cost groups. Notably, compared to those with urban social insurance for workers, those who had urban social insurance for citizens (OR = 3.136) or paid out-of-pocket (OR = 9.822) were significantly clustered in the tertiary hospitals rather than the specialty hospitals. CONCLUSIONS: Inpatients who were male, were older, had inferior insurance, had a longer length of stay and had lower costs preferred the elementary health services. However, the utilization of mental health care in high-tier institutions reflected defects, especially the fact that the current health insurance system does not adequately restrict patients' choices, and those who paid more tended to choose tertiary hospitals instead of professional specialty ones. We suggest that psychiatric services should be enhanced by instituting reforms, including public education, improved health insurance, a forceful referral system, and competency reinforcement for primary care physicians, to provide a more integrated mental health system.

Health-personnel recruitment and retention target policy for health care providers in the rural communities: A retrospective investigation at Pudong New Area of Shanghai in China.

To tackle the shortage of health personnel in the rural areas of Pudong New Area of Shanghai, the local government issued an incentive policy as one of the medical reforms. The current investigation focused on the relevant incentive measures and their corresponding effects and problems with a view to providing referential and useful experiences for those who are engaged in addressing the same problem at home and abroad. The details of the incentive policy were derived from the government document, and the related data about the flow of the rural community health care providers, from the institutional investigation. As indicated by the current investigation, the incentive policy produced some positive effect in attracting health care providers to work in the rural community health centers, especially general practitioners, nurses, MS/MD degree holders, and intermediate professional title holders to be employed in the farther ones. However, it was turned out that the population of high quality health care providers was still not sufficient enough to cover the whole rural areas, which suggested that it was still hard to draw such qualified medical individuals. To conclude in the current investigation, we made three recommendations for the policymakers to take into account in terms of policy maintenance, benefits for health personnel, and guarantee of their lawful rights and interests.

Enablers and barriers to improving worksite canteen nutrition in Pudong, China: a mixed-methods formative research study.

OBJECTIVE: To identify individual-level and organisation-level enablers and barriers to the provision and consumption of healthier foods at worksite canteens in China and to develop a theoretical framework and evidence-based, specific, practical intervention strategies. DESIGN: Mixed-methods formative research, with in-depth interviews, focus group discussions and quantitative questionnaires. SETTING: Two community health centres (CHCs) in Pudong, Shanghai, China. PARTICIPANTS: In-depth interviews with three CHC administrators and three canteen managers and staff. Six focus groups with a total of 19 male and 36 female employees, aged 25-67 years. RESULTS: Three subthemes were identified as important for influencing individual food choice: the cultural perception of 'eating well', the need to balance taste preferences and nutrition, and the emphasis on food safety in healthfulness. At the organisation level, two related subthemes emerged: the balance of canteen budget and food safety with the variety and quality of offerings, and the interplay between key stakeholders. Key barriers included cost, poor communication between employees and management, individuals' emphasis on taste over healthfulness, variation in individual preferences and discordance between perceived and actual weight status, particularly among men. Key enablers included strong, positive food culture in China and trust in canteen food. An ecological framework to describe determinants of worksite food environment in Shanghai was developed and intervention strategies were mapped onto this framework. CONCLUSIONS: A balancing act occurs at multiple levels and ultimately determines the worksite food environment and employee food choice at CHCs in Shanghai of China. There is a need to implement these findings and evaluate their impact on diet and health.

Development and enrolee satisfaction with basic medical insurance in China: A systematic review and stratified cluster sampling survey.

Basic Medical Insurance (BMI) has changed remarkably over time in China because of health reforms that aim to achieve universal coverage and better health care with adequate efforts by increasing subsidies, reimbursement, and benefits. In this paper, we present the development of BMI, including financing and operation, with a systematic review. Meanwhile, Pudong New Area in Shanghai was chosen as a typical BMI sample for its coverage and management; a stratified cluster sampling survey together with an ordinary logistic regression model was used for the analysis. Enrolee satisfaction and the factors associated with enrolee satisfaction with BMI were analysed. We found that the reenrolling rate superficially improved the BMI coverage and nearly achieved universal coverage. However, BMI funds still faced dual contradictions of fund deficit and insured under compensation, and a long-term strategy is needed to realize the integration of BMI schemes with more homogeneous coverage and benefits. Moreover, Urban Resident Basic Medical Insurance participants reported a higher rate of dissatisfaction than other participants. The key predictors of the enrolees' satisfaction were awareness of the premium and compensation, affordability of out-of-pocket costs, and the proportion of reimbursement. These results highlight the importance that the Chinese government takes measures, such as strengthening BMI fund management, exploring mixed payment methods, and regulating sequential medical orders, to develop an integrated medical insurance system of universal coverage and vertical equity while simultaneously improving enrolee satisfaction.

Evidence for capitation reform in a New Rural Cooperative Medical Scheme in Pudong New Area, Shanghai: A longitudinal study.

Currently, China has been experiencing rapid growth of medical costs, serious waste of medical resources, increasing disease burden for residents, and a medical insurance fund deficit. Therefore, an urgent problem that needs to be solved is to choose a rational payment for the insurance system. To empirically evaluate the long-term effects of capitation reform in a New Rural Cooperative Medical Scheme in Pudong New Area, we collected and analysed data regarding financing, fund operation, medical service cost, and medical care-seeking behaviour from 2011 to 2015, a duration that includes data before and after reform. The data for financing and behaviours were compared year by year, and the monthly data for inpatient and outpatient costs were evaluated in a retrospective time series study. The capitation reform in Pudong New Area showed strong evidence of the power of medical cost control in the long run, while it was weak in reversing the number of patients flowing into secondary and tertiary hospitals. To make the payment of capitation play a bigger role in cost control in China, a tighter alignment of capitation with the general practitioner system and achieving dual referral is critical for future studies.

Changes in chronic disease management among community health centers (CHCs) in China: Has health reform improved CHC ability?

Since the 1980s, China has been criticized for its mode of chronic disease management (CDM) that passively provides treatment in secondary and tertiary hospitals but lacks active prevention in community health centers (CHCs). Since there are few systematic evaluations of the CHCs' methods for CDM, this study aimed to analyze their abilities. On the macroperspective, we searched the literature in China's largest and most authoritative databases and the official websites of health departments. Literature was used to analyze the government's efforts in improving CHCs' abilities to perform CDM. At the microlevel, we examined the CHCs' longitudinal data after the New Health Reform in 2009, including financial investment, facilities, professional capacities, and the conducted CDM activities. A policy analysis showed that there was an increasing tendency towards government efforts in developing CDM, and the peak appeared in 2009. By evaluating the reform at CHCs, we found that there was an obvious increase in fiscal and public health subsidies, large-scale equipment, general practitioners, and public health physicians. The benefited vulnerable population in this area also rose significantly. However, rural centers were inferior in their CDM abilities compared with urban ones, and the referral system is still not effective in China. This study showed that CHCs are increasingly valued in managing chronic diseases, especially after the New Health Reform in 2009. However, we still need to improve collaborative management for chronic diseases in the community and strengthen the abilities of CHCs, especially in rural areas.

Capacity evaluation for general practitioners in Pudong new area of Shanghai: an empirical study.

BACKGROUND: Building highly qualified General Practitioners (GPs) is key to the development of primary health care. It's therefore urgent to ensure the GPs' quality service under the background of the new round of health care system reforms in China. A new model of GP qualification examination was originally implemented in Pudong New Area of Shanghai, China, which aimed to empirically evaluate the GPs' capability in terms of clinical performance and social recognition. In the current study, an analysis was made of the first two years (2014-2015) of such theoretical and practical examinations on the GPs there with a view to getting a deep insight into the GP community so as to identify the barriers to such a form of GP qualification examination. METHODS: The agency survey method was applied to the two-year database of the GP examinees, the formative research conducted to explore the key elements for developing the examination model. The data analysis was performed with SPSS for Windows (Version 19.0) to describe the GPs' overall characteristics, and to make comparisons between different groups. RESULTS: In 2015, the total number of GPs was 1264 in the area, in different districts of which, statistically significant differences were found in sex, age, professional title and employment span (P < 0.05). Such results were found to be similar to those in 2014. The examinees' theoretical scores were statistically different (F = 7.76; P < 0.05), showing a sloping trend from the urban district to the suburban, to the rural and then to the farther rural, as indicated by LSD-t test (P < 0.05). From the theoretical examinations the scores were higher on the western medicine than on the traditional Chinese medicine (F = 22.11; P < 0.05). CONCLUSIONS: As suggested by the current study on the GPs' qualification examination, which was pioneered in Pudong New Area of Shanghai, the construction of GP community was far from sufficient. It was a preliminary study and further studies are merited along the construction and development in terms of continuing medical education, performance appraisal and incentive mechanism.

NRCMS capitation reform and effect evaluation in Pudong New Area of Shanghai.

The Rural Cooperative Medical Scheme (RCMS) had played an important role in guaranteeing the acquisition of basic medical healthcare of China's rural populations, being an innovative model of the medical insurance system for so many years here in China. Following the boom and bust of RCMS, the central government rebuilt the New Rural Cooperative Medical Scheme (NRCMS) in 2003 across the whole country. Shanghai, one of the developed cities in China, has developed its RCMS and NRCMS as an advanced and exemplary representative of Chinese rural health insurance. But in the past 10 years, its NRCMS has encountered such challenges as a spiral of medical expenditures and a decrease of insurance participants. Previous investigations showed that the capitation and general practitioner (GP) system had great effect on medical cost containment. Thus, the capitation reform combined with GP system reform of NRCMS, based on a system design, was implemented in Pudong New Area of Shanghai as of 1 August 2012. The aim of the current investigation was to present how the reform was designed and implemented, evaluating its effect by analyzing the data acquired from 12 months before and after the reform. This was an empirical study; we made a conceptual design of the reform to be implemented in Pudong New Area. Most data were derived from the institution-based surveys and supplemented by a questionnaire survey, qualitative interviews and policy document analysis. We found that most respondents held an optimistic attitude towards the reform. We employed a structure-process-outcome evaluation index system to evaluate the effect of the reform, finding that the growth rate of the insured population's total medical costs and NRCMS funds slowed down significantly after the reform; that the total medical expenditure of the insured rural population decreased by 3.60%; and that the total expenditure of NRCMS decreased by 3.99%. The capitation was found to help the medical staff build active cost control consciousness. Approximately 2.3% of the outpatients flowed to the primary hospitals from the secondary hospitals; and farmers' annual medical burden was relieved to a certain degree. Meanwhile, it did not affect farmers' utilization and benefits of healthcare. However, further reform still faces new challenges: The capitation reform should be well combined with the primary healthcare system to realize the "dual gatekeeper" of GPs; a variety of payment methods should be mixed on the basis of capitation to avoid possible mistakes by one single approach; and the supervision of medical institutions should be strengthened. A long-term follow-up study need to be carried out to evaluate the effects of the capitation reform so as to improve the design of the program. Copyright © 2015 John Wiley & Sons, Ltd.

Factors influencing patients' contract choice with general practitioners in Shanghai: a preliminary study.

The general practitioner (GP) system has been widely applied around the world and experimented with in Shanghai, China. To analyze some of the influencing factors on patient-GP contracts, we developed a questionnaire and conducted site investigations in 2011 and 2012 to 1200 patients by random sampling from 6 pilot community health service (CHS) centers in Pudong, Shanghai. The t test, χ(2) test, factor analysis, and logistic regression analysis were used to analyze the data. The factors influencing patients' contract behavior were age (OR = 1.03; 95%CI = 1.02-1.04), education level (OR = 0.83; 95% CI = 0.75-0.93), social interaction of social capital (OR = 1.34; 95% CI = 1.15-1.56), acceptance of first contact in community (OR = 3.25; 95% CI = 2.07-5.12), the year of investigation (OR = 2.58; 95% CI = 1.92-3.47), and the exposure to publicity (OR = 1.60; 95% CI = 1.39-1.85). Elderly patients formed a focus group to sign contracts with GPs. To increase trust in GPs by patients, it is recommended to improve the level of CHSs, strengthen publicity, and cultivate social capital among patients.