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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 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.

Background: Hospice and palliative care (HPC) in China are mainly available at public primary care institutions, where nursing homes (NHs) are rarely involved. Nursing assistants (NAs) play an essential role in the HPC multidisciplinary team, but little is known about their attitudes towards HPC. This study aimed to identify the attitudes and factors influencing HPC among NAs.Methods: A cross-sectional study was designed to evaluate NAs’ attitudes towards HPC with an indigenized 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 4 parts, demographic characteristics, attitudes (20 items with 4 sub-concepts), knowledge (9 items), and training needs (9 items) for HPC. 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: In total, 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 HPC were positively correlated with knowledge score (r=0.46, ppβ=0.185), previous training experience (β=0.201), area of NHs (β=0.193), knowledge of HPC (β=0.294), and training needs (β=0.157) for HPC constituted the significant predictors of attitudes (pConclusion: NAs’ attitudes towards HPC were moderate, but the knowledge level still needs improvement. As integrated HPC in NHs can be achieved only with the participation of positive and enabled NAs, thus targeted training is highly recommended based on the significant factors identified in this study.

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.

Background: With the rising burden of palliative care and limited health care resource, volunteers are an integral resource in palliative care. However, the spiritual care competence and the relationship between spiritual care competence and attitude towards palliative care among volunteers has rarely been investigated. This study examined volunteers’ spiritual care competence; and identified factors affecting spiritual care competence.Methods: The correlational study was conducted with 385 volunteers in Shanghai, China. Data was collected using a structured questionnaire. Results: Volunteers’ spiritual care competence level was not high (58.50±10.92). And attitude towards palliative care was significantly correlated with spiritual care competence (r=0.49, pConclusion: A need exists to organize and design diversified education and training programs about spiritual care targeting to different kinds of volunteers to continually improve their spiritual care competence. Considering attitude towards palliative care is a significant factor of spiritual care competence, education and training programs should be developed to help volunteers establish positive attitude towards palliative care.

Since multiple microRNAs can target 3’ untranslated regions of the same mRNA transcript, it is likely that these endogenous microRNAs may form synergistic alliances, or compete for the same mRNA harbouring overlapping binding site matches. Synergistic and competitive microRNA regulation is an intriguing yet poorly elucidated mechanism. We here introduce a computational method based on the multivariate information measurement to quantify such implicit interaction effects between microRNAs. Our informatics method of integrating sequence and expression data is designed to establish the functional correlation between microRNAs. To demonstrate our method, we exploited TargetScan and The Cancer Genome Atlas data. As a result, we indeed observed that the microRNA pair with neighbouring binding site(s) on the mRNA is likely to trigger synergistic events, while the microRNA pair with overlapping binding site(s) on the mRNA is likely to cause competitive events, provided that the pair of microRNAs has a high functional similarity and the corresponding triplet presents a positive/negative ‘synergy-redundancy’ score.

Using information measures to infer biological regulatory networks can observe nonlinear relationship between variables, but it is computationally challenging and there is currently no convenient tool available. We here describe an information theory R package named Informeasure that devotes to quantifying nonlinear dependence between variables in biological regulatory networks from an information theory perspective. This package compiles most of the information measures currently available: mutual information, conditional mutual information, interaction information, partial information decomposition and part mutual information. The first estimator is used to infer bivariate networks while the last four estimators are dedicated to analysis of trivariate networks. The base installation of this turn-key package allows users to approach these information measures out of the box. Informeasure is implemented in R program and is available as an R/Bioconductor package at https://bioconductor.org/packages/Informeasure.

Background: In recently years, China has been growing awareness about the hospice service movement although hospice care was Initially introduced 30 years ago. Hospice care providers’ knowledge, attitudes, self-efficiency, and practices status in China should be investigated. This study aims to survey the general actuality of hospice care providers’ knowledge, attitudes, and practices of hospice care (KAPHC) in five cities in China, and explore relevant influencing factors.Method: Relying on our KAPHC scale, we randomly surveyed 3647 valid health care providers in five sampled cities of China in 2019, which respectively represent the north, northeast, east, central, and southwest area. In each city, 14 institutions were selected and 50 health providers were surveyed in each institution. Increment of voluntary participation was accepted. The scaling outcomes were compared among each sampled city-groups with Chi-square test or ANOVA. Multiple correspondence analyses were also performed for further results.Results: Of all, 41.46% providers had real experience in providing hospice care, and 58.68% confirmed willingness of providing. The overall knowledge correct rate was 57.13%. The average scores of threats, benefits, barriers, subjective norms, confidence, and self-report behaviour items were 15.40, 41.56, 16.75, 15.65, 41.56, and 38.61. Providers from eastern China, willing to provide hospice care, or experienced death witness in providing hospice care, proved better score in knowledge, threats, benefits, barriers, subjective norms, confidence, and self-report behaviour (PConclusions: The investigation reflected urgent need for systematic training of professional knowledge and skills on hospice care for health care providers. Governments’ attention and policy measures are crucial as most Chinese hospice care providers practiced as “organization actors”. More attention was need on balanced development of different areas.

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.

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

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.

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.

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.

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.

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.

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.

Summary 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.

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.

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.

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

Background General practitioners have an important role in primary health care, and the number of general practitioners can to some extent represent the quality of primary health care. This study aimed to quantify changes in the general practitioner workforce in China after recent health-care reforms, and assess the equity of general practitioner allocation in terms of geography and population. Methods We adopted the method of literature review to obtain relevant historical data from official statistical bulletins and publications. We analysed the equity of general practitioners' allocation in China, from the aspects of geography (east, central, and western regions) and resident population. Findings From 2012 to 2015, the total population of China increased by 1·52%. The number of general practitioners increased from 109 794 to 188 649, with an average annual growth of 19·77%. Meanwhile, the number of general practitioners per 10 000 population increased from 0·81 to 1·37. General practitioners accounted for 4·20% of doctors in 2012, increasing to 6·21% in 2015. The population density in east, central, and western China in 2015 was 526·23, 254·95, and 54·44 per km 2 , respectively, while the numbers of general practitioners per 10 000 population in each area were 1·83, 1·05, and 1·06. The density of general practitioners per 10 000 km 2 was 614·08 in east China, 131·41 in central China, and 30·77 in western China in 2012, increasing to 961·94, 268·51, and 57·03, respectively, in 2015. Interpretation Inadequate numbers and inequitable distribution of general practitioners represents one of the most obvious problems in primary health-care resourcing in China. Eastern China has been relatively successful in developing and increasing its general practitioner workforce since 2012. By contrast, the number of general practitioners per 10 000 population in central China has run at a lower level. Funding National Nature Science Foundation of China (#71503170; for data interpretation), Shanghai Municipal Commission of Health and Family Planning (#201440036; for data collection), Pudong New Area Health and Family Planning Commission (#PW2016A-4; for data analysis).

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, χ2 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.

Background The so-called health brain-drain—which refers to the health workers leaving their present jobs to other institutions, especially in rural areas—severely restricts the development of primary healthcare. To solve the problem, Pudong New Area of Shanghai carried out a series of incentive policies such as salary bonus, promotion and housing from July, 2014. In our study we aimed to analyse the change in health brain-drain which resulted from this policy. Methods There are 45 community health centres in Pudong, which we classified into 4 categories by geographical division: remote rural, general rural, suburban, and urban. The policy only applied to the 32 community health centres classified as remote rural, general rural, and suburban. Healthcare personnel in these community health centres were given a monthly bonus of ¥1000–6000. We did an institutional survey about the quantity and structure of the overall and outflowed health personnel in all 45 community health centres from December 31, 2013, to December 31, 2015. This study was approved by the ethics committee of Pudong Institute for Health Development and was performed in compliance with the Declaration of Helsinki. Findings The overall rate of health brain-drain decreased from 8·1% (568/6996) in 2013 to 4·6% (302/6553) in 2015. The rate in community health centres in remote rural, general rural, and suburban areas decreased from 6·3% (298/4699) to 3·8% (170/4528), and from 11·8% (270/2297) to 6·5% (132/2025) in community health centres in urban areas. In community health centres in remote rural, general rural, and suburban areas, the rate of decline in general practitioners, public health physicians and clinicians, and nurses in decreased by 0·5 (from 1·75% to 1·22%), 2·0 (from 9·31% to 7·27%) and 4·6 (from 8·23% to 3·67%) percentage points, respectively, in 2015 compared with 2013. Moreover, in areas where highest bonuses were offered (remote rural), rates of decline were smaller than in areas where no bonuses were offered (urban): 0·0% versus 2·8% for general practitioners, 5·6% versus 9·7% for public health physicians and clinicians, and 2·6% versus 6·8% for nurses. Interpretation External economic incentives have relieved the health brain-drain in rural areas and the stability of general practitioners and nurses in remote rural areas has been strengthened. However, there was still unfavorable health brain-drain of public health physicians and clinicians in rural areas. Thus, the policy sustainability and health brain-drain of public health physicians should remain a concern. Funding National Nature Science Foundation of China (#71503170) and Shanghai Municipal Commission of Health and Family Planning (#201540400, #201540134).

Background To help drive the consolidation and integrated management of basic medical insurance in China, we analysed participants' satisfaction, and factors associated with satisfaction, for the Urban Employees' Basic Medical Insurance (UEBMI), Urban Residents' Basic Medical Insurance (URBMI), and New Rural Cooperative Medical Scheme (NRCMS). Methods Pudong New Area in Shanghai was chosen as a typical sample of basic medical insurance coverage and management. 3395 residents (1200 households) were selected in September, 2013, by stratified cluster sampling and participants were interviewed face-to-face by trained investigators. Factors associated with satisfaction were analysed by ordinal logistic regression. Ethics approval was obtained from the ethics committee of Pudong Institute for Health Development. Findings URBMI participants reported a higher rate of dissatisfaction in outpatient (n=7, 5·10%), inpatient (7, 12·50%), and overall (127, 12·85%) experience. NRCMS had the highest rate of outpatient satisfaction (65, 84·4%), with no participants reporting dissatisfaction. UEBMI had the highest rate of inpatient satisfaction (96, 70·1%). Affordability of out-of-pocket cost, proportion of reimbursement, and time of insurance reimbursement were positively correlated with satisfaction for UEBMI; awareness of premium and compensation policy, affordability of out-of-pocket cost, proportion of reimbursement, and procedure of reimbursement were associated with greater satisfaction with URBMI, whereas participants with lower education were more satisfied. Factors associated with satisfaction with NRCMS were the same as for URBMI, with the exception of education level, and the addition of affordability of premium and time of reimbursement, which were positively correlated. Interpretation The Chinese government should take effective measures, such as taking advantage of the family doctor system, to regulate and reinstitute sequential medical order (referral from primary medical institutions to high level medical institutions), which could lead to short-term implications of satisfaction but will lead to both satisfaction and rational medical order in the long term. The fairness of financing and reimbursing across different basic medical insurance policies (in terms of reasonable costs to patients) needs to be improved. Funding Funded by the National Nature Science Foundation of China ( NSFC 71503170 ), Shanghai Municipal Commission of Health and Family Planning ( 201440036, 2016HP009 ).

Background The New Rural Cooperative Medical Scheme (NRCMS) covers 900 million farmers (about 95%) in China, but its fund is at serious risk of deficit. Shanghai, one of the developed cities in China, has developed its Rural Cooperative Medical Scheme and NRCMS as an advanced and exemplary representative of Chinese rural health insurance. The participating rate of NRCMS was 99·90% in Pudong New Area in 2015, which meant 277 310 farmers were involved, accounting for 29% of Shanghai's participants. Pudong New Area of Shanghai implemented NRCMS capitation reform in August, 2012, aimed at controlling the increasing medical costs for farmers and avoid risk to the NRCMS's fund. We aimed to assess long-term effect of the reform. Methods We performed a retrospective time series analysis of the NRCMS fund by examining data acquired from Jan 1, 2011, until Dec 31, 2015 (60 months), in Pudong. The analysis was based on time series data modelling before Aug 1, 2012, and we compared forecast data produced with Winters' additive models and with simple seasonal models with observed data for the 40 months after capitation reform. Outcome measurements included numbers and costs of insured outpatients and inpatients. Findings The mean forecasted outpatient cost per visit (¥102·00, mean absolute percentage error [MAPE] 2·9%) and inpatient cost (¥12 836·63, 1·9%) by Winters' additive models were both higher than observed values (outpatient cost ¥90·37, p vs actual visits 486 976, p=0·121; predicted inpatient visits 2173 vs actual visits 2147, p=0·74). NRCMS fund surplus rate was 8·84% in 2015, which was 6·93 percentage points higher than it was in 2011. Interpretation Capitation reform led to declines in per outpatient and inpatient costs, while the medical need remained unchanged. Furthermore, the increased surplus rate ensured the fund's security. Funding National Nature Science Foundation of China (#71503170; for data interpretation), Shanghai Municipal Commission of Health and Family Planning (#201440036, #2016HP009; for data collection and analysis).

Background Rural township health centres and urban community health centres play a crucial role in the delivery of primary health care in China. Over the past two-and-a-half decades, these health institutions have not been as well developed as high-level hospitals. The limited availability and low qualifications of human resources in health are among the main challenges facing lower-level health facilities. This paper aims to analyse the mobility of health workers in township and community health centres. Methods Data used in this paper come from a nationwide survey of health facilities in 2006. Ten provinces in different locations and of varying levels of economic development were selected. From these provinces, 119 rural township health centres and 89 urban community health centres were selected to participate in a questionnaire survey. Thirty key informants were selected from these health facilities to be interviewed. Results In 2005, 8.1% and 8.9% of health workers left township and community health centres, respectively. The health workers in rural township health centres had three to 13 years of work experience and typically had received a formal medical education. The majority of the mobile health workers moved to higher-level health facilities; very few moved to other rural township health centres. The rates of workers leaving township and community health centres increased between 2000 and 2005, with the main reasons for leaving being low salaries, limited opportunities for professional development and poor living conditions. Conclusion In China, primary health workers in township health centres and community health centres move to higher-level facilities due to low salaries, limited opportunities for promotion and poor living conditions. The government already has policies in place to counteract this migration, but it must step up enforcement if rural township health centres and urban community centres are to retain health professionals and recruit qualified health workers.