The integration of medical treatment and prevention improves the ability to prevent and treat chronic diseases

Source: People's Daily

Photo (1): A community health center in Guangming District, Shenzhen, conducts colorectal cancer screening for residents. Photo by Mak Choi-ying (2): Medical staff at a community health center in Pingshan District, Shenzhen, follow up patients in family beds. Lian Zhi telephoto (3): Students from the Gardener School of Shenzhen Nanshan Experimental Education Group are outdoors. Photo by Luo Xun

Take grandchildren, do housework, square dance...... In the Kwai Chung community in Dapeng New District, Shenzhen, Guangdong, Zhang Meng, a 58-year-old resident, lives a full and energetic life. It's hard to imagine that she was a patient with lung adenocarcinoma.

Today's healthy life started with a free cancer screening 5 years ago. Thanks to the "Early Diagnosis and Early Treatment of Urban Cancer" project implemented by Shenzhen, Zhang Meng, who suffered from early-stage lung adenocarcinoma, was detected and treated in time and recovered quickly.

General Secretary Xi Jinping pointed out: "The most important indicator of modernization is people's health, which is the foundation of people's happy life. The "Decision" of the Third Plenary Session of the 20th Central Committee of the Communist Party of China proposed, "Implement the strategy of giving priority to the development of health, improve the public health system, and promote social co-governance, medical and prevention coordination, and medical and prevention integration".

In recent years, with the aging of the mainland population and changes in residents' lifestyles, the incidence of chronic diseases such as cardiovascular and cerebrovascular diseases and cancer has generally shown an upward trend, and the number of deaths caused by chronic diseases accounts for more than 80% of the total deaths.

From improving the chronic disease monitoring system, to promoting hierarchical diagnosis and treatment of chronic diseases, to building more than 400 national demonstration zones for comprehensive prevention and control of chronic diseases, the mainland has comprehensively implemented a comprehensive prevention and control strategy and gradually established a nationwide chronic disease prevention and control service system. In 2023, the premature mortality rate of patients with major chronic diseases will drop to 15%, 3.5 percentage points lower than in 2015.

Since 2010, when the National Demonstration Zone for Comprehensive Prevention and Control of Chronic Diseases was launched, Shenzhen has successively established chronic disease prevention and control institutions at the municipal and district levels, and has joined forces with hospitals and community health service organizations (hereinafter referred to as "community health institutions") to build a chronic disease prevention and control network, and explored a chronic disease health management service system of "screening, treatment, management and prevention". In 2017, Shenzhen achieved full coverage of the National Demonstration Zone for Comprehensive Prevention and Control of Chronic Diseases with municipal districts as the unit. In 2022, the average life expectancy of the city was 83.93 years, and in 2023, the increase in new malignant tumors in the city's permanent population decreased by nearly 40% year-on-year.

How to promote the integration of medical treatment and prevention, accelerate the transformation of disease treatment to health management, and weave a dense network for the prevention and treatment of chronic diseases? Recently, the reporter went to Shenzhen for on-the-spot interviews.

"Sift" as early as possible

Set up three "screening passes" to find out the base number of patients with chronic diseases, early detection and early intervention

"If it hadn't been for that screening, the consequences would have been dire." Zhang Meng sighed.

In July 2019, doctors from the Kwai Chung Community Health Service Center under Kwai Chung People's Hospital held a lecture in the community to introduce the "Early Diagnosis and Early Treatment of Urban Cancer" project being implemented in Shenzhen. Hearing that cancer screening was available for free, Zhang Meng quickly signed up.

The initial screening is carried out by the community health service center (hereinafter referred to as the "community health center") by means of "questionnaire + biological testing". First, a questionnaire survey was conducted to assess the risk factors for cancer, followed by three tests, including hepatitis B surface antigen, Helicobacter pylori, and fecal occult blood.

"Zhang Meng cooks for a family all year round, inhales kitchen fumes almost every day, and runs a decoration building materials store for more than 20 years." Hui Yunwei, director of the Kwai Chung Community Health Center, said that through the information collected from the questionnaire, Zhang Meng was assessed as a high-risk group for lung cancer. At the same time, Zhang Meng's fecal occult blood test result was positive, and she was also included in the high-risk group for colorectal cancer.

According to the results of the initial screening, the community health center organized high-risk personnel like Zhang Meng to go to Shenzhen Hospital, Cancer Hospital of the Chinese Academy of Medical Sciences, to complete the screening of five high-incidence cancers, including lung cancer, colorectal cancer, upper gastrointestinal cancer, breast cancer, and liver cancer.

During this screening, Zhang Meng was diagnosed with early-stage lung adenocarcinoma and was immediately hospitalized for tumor resection surgery. "It's been 5 years and I'm in good health now." Zhang Meng said.

Early screening is the key to reducing the risk of chronic diseases and moving the prevention and treatment threshold forward.

In recent years, Shenzhen has carried out precise special screening for chronic diseases for key populations and key diseases, and identified high-risk personnel and potential patients as early as possible, so as to achieve early detection, early intervention and early treatment, and reduce morbidity and mortality.

"Taking colorectal cancer as an example, if it is detected early, the 5-year survival rate can reach more than 90%, but if it is at an advanced stage, the 5-year survival rate will be less than 10%." Lei Lin, deputy director of the Cancer Prevention and Control Department of Shenzhen Chronic Disease Prevention and Control Center, said that by the end of 2023, the city had completed the risk assessment of 213,000 colorectal cancer cases and confirmed 443 cases.

To find out the base number of patients with chronic diseases, in addition to the key chronic disease early screening projects, Shenzhen has also set up two "screening gates".

The first is the characteristic inspection pass. All districts in Shenzhen have carried out special chronic disease screening actions according to local conditions, and targeted efforts have been made to help patients detect their conditions early.

Can't wake up in the morning and can't sleep at night...... In April this year, at the Liancheng Community Health Center in Nantou Street, Nanshan District, after listening to Li Yan's condition, the doctor instructed her to open a WeChat mini-program to carry out a self-examination of depression evaluation, and then referred her to the Nanshan District Chronic Disease Prevention and Treatment Hospital (Nanshan District Mental Health Center), where she was diagnosed with depression. Now, through psychological counseling and drug treatment, Li Yan has successfully walked out of the predicament, and the symptoms of physical discomfort have been greatly alleviated.

Zou Quan, vice president of the Nanshan District Chronic Disease Prevention and Control Hospital, said that since 2018, the hospital has carried out a depression prevention and screening project in the whole district, screening more than 1,800 suspected patients, of which more than 360 have been diagnosed.

In Guangming District, 19 community health centers have been able to carry out pulmonary function tests to accurately screen patients with chronic obstructive pulmonary disease. In response to the myopia problem of primary and secondary school students, Luohu District has equipped students participating in the "Eye Insight Project" project with sports bracelets, and the system will remind their parents once vision loss is detected.

The second is to support the bottom census. Shenzhen stipulates that citizens can enjoy basic medical care, public health, health management and other services after signing a contract with a family doctor.

"Family doctors focus on screening patients with chronic diseases and incorporating their information into the chronic disease management system during their daily visits and follow-up services." Zhao Zhiguang, deputy director of the Shenzhen Chronic Disease Prevention and Control Center, said.

At present, Shenzhen has a team of 5,130 family doctors, which will provide contracted services for nearly 6.7 million residents in 2023, and guide more than 510,000 elderly people aged 65 and above to carry out health check-ups such as early screening for disability and dementia.

Graded "governance"

Promote hierarchical diagnosis and treatment, improve the prevention and treatment capacity of grassroots medical institutions, and promote the provision of medical treatment and good medical treatment for the sick

On the checklist, the urine protein test index returned to normal, which made 61-year-old Dai Yonghui very happy.

Three years ago, during a physical examination at the Fuzhongfu Community Health Center of Shenzhen Bao'an District Central Hospital, Dai Yonghui was found to have excessive urine protein, high blood sugar and blood pressure. "This means that there is diabetic nephropathy, and if it is not well controlled, it is likely to develop uremia." Yu Hanbing, director of the Fuzhong Fu Community Health Center, said.

Subsequently, Yu Hanbing had an emergency meeting with the nephrologist of Bao'an District Central Hospital to formulate a treatment plan for Dai Yonghui.

"Based on his monthly check-ups, we are constantly adjusting the medication to improve the efficacy and reduce the side effects." What makes Yu Hanbing quite pleased is that since May this year, Dai Yonghui's urine protein index has been greatly reduced, and his blood sugar and blood pressure have gradually stabilized.

Prevention and treatment of chronic diseases, screening and curing should be done well. Shenzhen vigorously promotes the integrated development of district general hospitals and community health institutions, realizes hierarchical diagnosis and treatment of chronic diseases, and allows residents to see good diseases at their doorsteps.

In 2019, Shenzhen launched the reform of the management system and operation mechanism of primary medical groups, led by the district general hospital, and successively established 21 primary medical groups and 922 community health institutions, weaving a dense network of primary medical services.

When he first went to the community health institution to see a doctor, Dai Yonghui also muttered: "This disease is not easy to treat, can it be done?" As the treatment took effect, he gradually dispelled his doubts, "Compared with the big hospitals, Dr. Yu can communicate with me more often, and he can also ask doctors from the district central hospital to see me." ”

"Community health institutions are equivalent to the dispatched agencies of hospitals, from human resources to financial management, medical management, quality control, etc., all of which are coordinated by the hospital." Wang Liling, secretary of the Party Committee of Bao'an District Central Hospital, told reporters that the hospital will also regularly send specialist doctors to community health institutions for consultation.

Hierarchical diagnosis and treatment, two-way referral channels need to be unblocked. Shenzhen has clarified that community health institutions can transfer patients to higher-level hospitals, and after completing treatment, higher-level hospitals can also transfer patients back to community health institutions for follow-up rehabilitation treatment. At the same time, the specialty number source of the higher-level hospital will be prioritized for the transferred patients of the community health institution.

In order to guide patients with chronic diseases to seek medical treatment in the community, Shenzhen has also issued a policy to use personal medical insurance accounts to pay a 7% discount for patients who seek medical treatment in community health institutions, and has launched preferential policies such as "entering the community health care and getting a 5% discount" and "signing a family doctor and getting 2 discounts" for 8 chronic diseases such as hypertension and diabetes.

In 2023, 85.5% of patients with hypertension and 79% of patients with diabetes in Shenzhen will be treated in community health institutions, and 76% of the diagnosis and treatment volume of the primary medical service system, dominated by primary medical groups, will be treated.

There is a cure for the sick, and there must be a good doctor for the sick. Shenzhen has successively introduced and established a number of high-level hospitals such as the Cancer Hospital of the Chinese Academy of Medical Sciences and Shenzhen Hospital, and since the "14th Five-Year Plan", 15 new tertiary hospitals have been added, bringing the total number of tertiary hospitals in the city to 33.

More importantly, improve the prevention and treatment capacity of primary medical institutions. To this end, relying on the city's high-level hospitals, Shenzhen has set up a group of expert working groups on the integration of medical treatment and prevention of chronic diseases, and stationed in community health institutions to carry out medical services, business guidance, and talent training.

"There are about 20 experts in each expert working group on the integration of medical treatment and prevention, and each expert arranges at least two days a month to carry out outpatient teaching and health education in community health institutions." Huang Yin, deputy director of the Primary Health and Aging Health Department of the Shenzhen Municipal Health Commission, said.

Since October 2023, Jiang Hongnan, deputy chief physician of the Department of Breast Surgery of Shenzhen Hospital, Cancer Hospital of Chinese Academy of Medical Sciences, has been visiting the Longdan Community Health Center of the Seventh People's Hospital of Longgang District almost every week, and at the same time carrying out general practitioner training, case diagnosis and treatment teaching, and early cancer diagnosis and treatment publicity.

In January this year, a patient was found to have a lump in his breast after examination by Jiang Hongnan, and he was still in the stage of carcinoma in situ. "Strictly speaking, carcinoma in situ is a precancerous lesion that can be treated surgically without chemotherapy, and the cure rate is very high." Jiang Hongnan comforted the patient while explaining to the doctor of Longdan Community Health Center.

The teaching of case diagnosis and treatment has enriched the experience of general practitioners in primary medical institutions. In Jiang Hongnan's WeChat group, general practitioners will ask for guidance in the group whenever they encounter a suspected case. Jiang Hongnan also regularly conducts online training on breast cancer diagnosis and treatment, and the participants cover all community health institutions in Longgang District.

High-quality resources sink down, and the level of treatment rises. In the past three years, the medical treatment rate of Shenzhen residents in Shenzhen has exceeded 98%, basically realizing that "serious illnesses do not leave Shenzhen".

Scientific "Tube"

The combination of online and offline, improve supervision and assessment, and help the refined management of chronic diseases with science and technology

Inject insulin once before meals, and go to the community health center for a check-up if there is any abnormality...... Suffering from type 2 diabetes for more than 10 years, 64-year-old Wu Juanjuan is now familiar with the management of the condition. ”

Four years ago, Wu Juanjuan moved to live in Fu'an Community, Longhua District. Once, when the grid staff visited her home, they found that she was a diabetic patient, so they uploaded her information to the refined management system of key populations. She was assigned a team of family doctors to follow up on the service.

For a long time, there have been problems such as low awareness rate, low contract rate, and low cooperation between doctors and patients. Since 2020, Longhua District has explored the grid management of family doctors, set up a team of family doctors, including doctors, nurses, grid members, etc., to comprehensively promote the contracted service of family doctors on a household basis; Focus on giving full play to the role of grid personnel, open up the grid population data and medical institution treatment data, and realize the refined management of chronic diseases.

Offline, regular follow-up; Online, Q&A at any time. In order to optimize the service, the family doctor team also included the patient's health information into the chronic disease patient management database, so that the data can be checked in real time and the information is shared. Open Wu Juanjuan's WeChat, there are nearly 500 patients with chronic diseases in the family doctor WeChat group at the top, and new messages flicker from time to time. "In the group, health questions can be answered." Wu Juanjuan said.

The community grid becomes a health grid. As of June this year, a total of 705 family doctor teams have been set up in Longhua District, and the signing rate of the elderly aged 65 and above, patients with hypertension, and patients with type 2 diabetes has exceeded 99%.

With the number of people under management exploding, how do you maintain the level of family doctor services and avoid signing up for a single visa?

In 2021, Longhua District will build a supervision and management system for basic public health service projects, and strengthen the supervision and assessment of the family doctor team in an intelligent way. Yang Weiyi, head of the Department of Traditional Chinese Medicine of the District Health Bureau, said that in the past, the supervision team was organized to conduct spot checks, and the annual supervision volume was less than 2,000 residents' health records, which is equivalent to 1‰ of the whole district; Now it has realized all-weather, fully quantitative online supervision, and once a problem is found, it can be automatically pushed to relevant personnel.

"On September 28, the family doctor did not do a follow-up ...... the outpatient clinic" opened the supervision and management system of the basic public health service project in Longhua District, clicked on a resident health file, and the existing problems were clear at a glance. Yang Weiyi told reporters that according to the requirements, when patients are diagnosed and treated in community health institutions, their family doctor teams should simultaneously carry out follow-up services such as health management and upload records. When the system detects that there is no record, the family doctor will alert you.

In addition, Longhua District stipulates that if the standardized management rate of chronic diseases reaches 90% or more in the responsibility area of the family doctor team, the team will receive special awards; If the incidence of the problem is high, penalties will be imposed. By the end of 2023, the standardized management rate of hypertensive patients in Longhua District has increased to 79.93%, and the standardized management rate of diabetic patients has increased to 73.17%. At present, this supervision and management system has been popularized and used in Shenzhen.

In Shenzhen, more and more digital and intelligent technologies are being used for the refined management of chronic diseases.

In May this year, Zhong Yunying, who has suffered from hypertension and diabetes for many years and lives in Fuzhongfu Garden Community, Bao'an District, applied for a family hospital bed due to paralysis of the right limb due to a sudden acute cerebral infarction.

The day after the family bed was set up, family doctor Fu Lixiong came to the door with a wearable device and provided massage rehabilitation treatment for Zhong Yunying. "Through the wearable device, I can keep abreast of the changes in the patient's condition at any time, and with the video inspection, I can adjust the management plan in time." Fu Lixiong said that after careful care, Zhong Yunying has been able to get out of bed and walk, and the family hospital bed has been cancelled.

In February 2021, the Shenzhen Municipal Health Commission issued the Measures for the Administration of Family Beds in Shenzhen (for Trial Implementation), which stipulates that all community health institutions and their host hospitals can provide family bed services for patients who are suitable for home diagnosis and treatment, rehabilitation and nursing.

Intelligent management to speed up the construction of family hospital beds. In 2023, more than 21,800 family hospital beds will be built in Shenzhen, an increase of more than 4,400 over 2022, and the average number of beds built by general practitioners in community health institutions will be 3.66.

Technology empowers residents to manage chronic diseases well. By the end of 2023, the health management rate of children under the age of 7 in Shenzhen reached 99.53%, and the health management rate of the elderly reached 81.18%, both of which increased steadily over the same period last year.

Comprehensive "Defense"

Focus on "one old and one young", strengthen health management, and shift from "treating the disease" to "treating the disease before it happens"

He is 1.7 meters tall and weighs 120 pounds, and his body is well-proportioned and healthy. When they met for the first time, they couldn't tell that Wu Zhuokai was "the fattest person in the class".

Wu Zhuokai, who is now a third-grade student at the Gardener School of Shenzhen Nanshan Experimental Education Group, used to like fried food and all kinds of snacks, and when he was in the fourth grade of primary school, he weighed more than 100 kilograms. "At that time, I didn't like sports, and I didn't want to participate in group activities." Wu Zhuokai said a little shyly.

The change began with the introduction of health education courses at the Gardeners' School.

"The course materials are guided by experts from Shekou People's Hospital, and the school is responsible for organizing the compilation." Zhang Yechen, director of the moral education department of the gardener school, said that through a variety of activities such as health lectures, health knowledge competitions, and health carnivals, parents can learn a healthy lifestyle with their children.

Develop a nutritious meal plan and exercise weight loss plan, and join the gardener's school "Healthy Companions" volunteer team...... Nowadays, one physical education class a day has become Wu Zhuokai's favorite.

"Due to the excessive intake of high-sugar foods and beverages, the use of electronic products for too long, and the reduction of exercise, the obesity rate and myopia rate of children and adolescents are rising." Xiong Jingfan, director of the Department of Prevention and Control of Chronic Diseases in Children and Adolescents at the Shenzhen Chronic Disease Prevention and Control Center, said.

In recent years, the Shenzhen Chronic Disease Prevention and Control Center has taken the lead in implementing student nutrition and health actions in the city, building nutrition and health schools (kindergartens), popularizing nutrition and health knowledge, and promoting healthy behaviors and habits. So far, more than 400,000 students and their families from 300 primary and secondary schools and kindergartens have participated in the establishment of 93 nutrition and health schools (kindergartens) at all levels, including 28 at the provincial level and 18 at the national level.

Prevention and control are combined, and prevention is the mainstay. Focusing on "one elementary school", Shenzhen promotes the linkage of families, schools and hospitals to jointly provide health management for young people. Focusing on the "one old", Shenzhen actively explores the integration of medical and physical care, medical care and elderly care and other models, from "treating the disease" to "treating the disease".

On both sides of the trail, there are shaded trees. When I came to the Gaofa Community of Shahe Street, Nanshan District, some elderly people were walking slowly on the trail, and some were practicing Baduanjin.

"According to the 'exercise prescription', I have to walk slowly for half an hour every day. Every night I walked a few laps along the trail and then went to the community health centre for physiotherapy. Zhang Wenming, a 56-year-old community resident, said. Not long ago, the doctor prescribed him an "exercise prescription" with a detailed menu of nutritious meals.

The "exercise prescription" obtained by Zhang Wenming was formulated by Xi Rong, a doctor from the Nanshan District Chronic Disease Prevention and Treatment Hospital. "'Exercise prescription' is to move the health threshold forward to exercise intervention and prevent it in advance." Recently, Xi Rong has been busy training doctors in community health institutions, "If professional 'exercise prescriptions' can be prescribed in the community, it will be better able to promote the health of the whole people." ”

To create a healthy and supportive environment, Shenzhen has intensified its efforts to publicize and popularize science, designated August as the city's health activity month in the form of legislation, and organized a series of activities such as health science popularization and education, and the opening of healthy life venues, so as to improve the level of citizens' health knowledge and skills.

Walking through the streets of Shenzhen, all kinds of health knowledge signs such as non-smoking, sugar control, and slow walking can often be seen; Walking into large supermarkets, many have set up low-salt, low-fat, low-sugar food counters; Next to the carbonated drink counter, there is a reminder that "children and teenagers should not drink or drink less sugary drinks......

In 2023, the health literacy level of Shenzhen citizens will reach 49.84%. This data means that nearly half of Shenzhen's residents already have basic health knowledge and skills.

(Names have been changed.)