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BACKGROUND: This study aims to establish a multi-agent system model to provide accurate suggestions for the policy proposal of controlling the unreasonable growth of medical expenses charged by public hospitals in China. METHODS: A multi-agent system model was employed in this study. Agents of this model were divided into patients, doctors, medical institutions, the government, and medical insurance agencies. The model was composed of two subsystems: the disease and medical-seeking subsystem, and the medical expenses subsystem. Policy intervention experiments were conducted on patients' medical-seeking preferences, doctors' public welfare behaviors, and the government's financial investment. RESULTS: At present, medical expenses in China are unreasonable and keep increasing, and the proportion of medicine and physical examination expenses to total medical expenses for public hospitals is unreasonable. Intervention experiments suggested that expanding the promotion and application of the community first-visit system could rationalize patients' medical-seeking preferences, increasing doctors' incomes and reducing workload could significantly restrict doctors' over-prescription behaviors. Also, improving the government's financial investment could guide public hospitals to strengthen their commitment to public welfare responsibilities. These interventions could decrease the unreasonable growth of medical expenses of public hospitals. The combined intervention effects on suppliers, demanders, and the government were better than the effect of these agents independently. CONCLUSIONS: The main reasons for the unreasonable increase in patient medical expenses at public hospitals could be attributed to patients' unreasonable medical-seeking preferences, doctors' weak public welfare incentives, and the government's inadequate financial investment. Policy-makers should consider proposals to restrict and guide the behaviors of suppliers, demanders, and the government, simultaneously. The government should consider the ...

BACKGROUND: Infectious and endemic diseases are a serious public health concern worldwide, and their prevention and treatment are globally controversial. This study aimed to establish an system dynamics (SD) model to analyze the factors influencing public health services provided by the Chinese Centers for Disease Control and Prevention (China CDC) to implement infectious and endemic disease control in China, by establishing more effective interventions to provide public health services and thus achieving the goal of controlling infectious and endemic diseases. MATERIALS AND METHODS: An SD model was constructed using the Vensim DSS program. Intervention experiments were performed using the SD model, which reflected the influences on disease control by adjusting the governmental investment and compensation level for public health products. RESULTS: The experimental results showed that increasing the governmental investment in China CDC and compensation level for public health products will significantly increase the public health product rate provided by China CDC. DISCUSSION: Problems with infectious and endemic disease prevention and treatment are the result of the system's incomplete functioning and limited health resources. To address the current problems and improve the system, the government should increase its investment in the public health service system and improve the compensation system to ensure smooth implementation of infectious and endemic disease prevention and treatment and, ultimately, improve public health in China.

Meina Li,1,* Wenya Yu,1,* Wei Tian,2,* Yang Ge,3 Yuan Liu,1 Tao Ding,1 Lulu Zhang1 1Department of Military Health Service Management, College of Military Health Service Management, Second Military Medical University, Shanghai, China; 2Medical Care Department, Dalian Rehabilitation Center of PLA, Dalian, China; 3School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China *These authors contributed equally to this work Background: Infectious and endemic diseases are a serious public health concern worldwide, and their prevention and treatment are globally controversial. This study aimed to establish an system dynamics (SD) model to analyze the factors influencing public health services provided by the Chinese Centers for Disease Control and Prevention (China CDC) to implement infectious and endemic disease control in China, by establishing more effective interventions to provide public health services and thus achieving the goal of controlling infectious and endemic diseases. Materials and methods: An SD model was constructed using the Vensim DSS program. Intervention experiments were performed using the SD model, which reflected the influences on disease control by adjusting the governmental investment and compensation level for public health products. Results: The experimental results showed that increasing the governmental investment in China CDC and compensation level for public health products will significantly increase the public health product rate provided by China CDC. Discussion: Problems with infectious and endemic disease prevention and treatment are the result of the system's incomplete functioning and limited health resources. To address the current problems and improve the system, the government should increase its investment in the public health service system and improve the compensation system to ensure smooth implementation of infectious and endemic disease prevention and treatment and, ultimately, improve public health in China. Keywords: epidemic model, transmission, spread, epidemiology, public health, system dynamics, disease management

Wenya Yu,* Yipeng Lv,* Chaoqun Hu,* Xu Liu, Haiping Chen, Chen Xue, Lulu Zhang Department of Military Health Service Management, College of Military Health Service Management, Second Military Medical University, Shanghai, People's Republic of China *These authors contributed equally to this work Objectives: Emergency medical system for mass casualty incidents (EMS-MCIs) is a global issue. However, China lacks such studies extremely, which cannot meet the requirement of rapid decision-support system. This study aims to realize modeling EMS-MCIs in Shanghai, to improve mass casualty incident (MCI) rescue efficiency in China, and to provide a possible method of making rapid rescue decisions during MCIs.Methods: This study established a system dynamics (SD) model of EMS-MCIs using the Vensim DSS program. Intervention scenarios were designed as adjusting scales of MCIs, allocation of ambulances, allocation of emergency medical staff, and efficiency of organization and command.Results: Mortality increased with the increasing scale of MCIs, medical rescue capability of hospitals was relatively good, but the efficiency of organization and command was poor, and the prehospital time was too long. Mortality declined significantly when increasing ambulances and improving the efficiency of organization and command; triage and on-site first-aid time were shortened if increasing the availability of emergency medical staff. The effect was the most evident when 2,000 people were involved in MCIs; however, the influence was very small under the scale of 5,000 people.Conclusion: The keys to decrease the mortality of MCIs were shortening the prehospital time and improving the efficiency of organization and command. For small-scale MCIs, improving the utilization rate of health resources was important in decreasing the mortality. For large-scale MCIs, increasing the number of ambulances and emergency medical professionals was the core to decrease prehospital time and mortality. For super-large-scale MCIs, increasing health resources was the premise. Keywords: system dynamics model, emergency medical system, mass casualty incidents

Wenya Yu,1,* Meina Li,1,* Chen Xue,1,* Jingrui Wang,1 Jiazhen Liu,2 Haiping Chen,1 Lulu Zhang1 1Institute of Military Health Management, Second Military Medical University, 2Shanghai Sixth People's Hospital, Shanghai, People's Republic of China *These authors contributed equally to this work Objective: Most patients in the People's Republic of China prefer tertiary hospitals when seeking medical services. The aim of this study was to assess outpatient satisfaction with tertiary hospitals in the People's Republic of China, test overall and subscale satisfaction, and explore whether sociodemographic characteristics lead to different degrees of satisfaction and whether subscale outpatient satisfaction contributes to overall satisfaction.Methods: A closed questionnaire was given out to investigate outpatients' sociodemographic characteristics, overall satisfaction, and various subtypes of satisfaction, and a 5-point Likert scale was employed to measure the degree of outpatient satisfaction. Descriptive analysis, Kruskal–Wallis test, Spearman's rank correlation coefficient, and logistic regression analysis were employed for statistical analysis.Results: Response rate was 92.48% (971/1,050). Outpatients' sociodemographic characteristics (including sex, age, occupation, monthly income, residence, and marital status) were related to various subtypes of satisfaction to varying degrees. Outpatients who were male, older, married, with low or middle incomes, living in Shanghai or other areas of the People's Republic of China, medical staff, or students were more satisfied with various subtypes of satisfaction than those without these characteristics. In further analyses, satisfaction with their medical needs being met by doctors had the strongest relation to overall satisfaction, followed by satisfaction with doctors' service attitudes, medical costs, waiting time, prescription, and diagnosis and treatment time. Satisfaction with environment had the weakest contribution to overall satisfaction.Conclusion: This study gave some suggestions for tertiary hospitals in advanced areas of the People's Republic of China. Outpatient sociodemographic characteristics should be paid more attention by medical staff to improve the degree of satisfaction. Tertiary hospitals in the People's Republic of China should provide more support on the management of doctors, medical costs, and time. Keywords: outpatient satisfaction, tertiary hospitals, sociodemographic characteristics, influencing factor

Antiretroviral drugs are being tried as candidates for the pre-exposure prophylaxis (PrEP) against HIV for a considerable period, due to their potential for immediate inhibition of viral replication. Discrepancies in the findings called for a critical review of the relevant efforts and their outcomes. A systematic literature search identified 143 eligible articles of which only 5 reported complete findings while another 11 were still on-going. Observed moderate efficacy and good safety profile seemed to identify PrEP as a promising step for minimizing the spread of HIV to relatively unaffected population and controlling the epidemic among high risk population groups. But the duration of this efficacy was found to depend heavily on the availability, adherence and other related issues like cost, political commitment, ethical consideration etc. To prevent potential cultural and behavioral modifications, proper pre-administration counseling also seemed critical for the success of PrEP as a cost-effective intervention with adequate coverage.

BACKGROUND: Since 2000, China has been developing primary care institutions to serve as the gateway to the healthcare system. However, the investment of resources in primary care institutions is not based on the actual medical demands of the public. This study analysed primary care utilization to provide targeted guidance for the improvement of primary healthcare delivery in China. METHODS: We extracted outpatient visit data from all community healthcare centres in Shanghai from 2014 to 2018. Diseases were then classified according to ICD-10 codes. The disease spectrum (frequency, proportion, rank) was stratified by sex, age, and region. RESULTS: Most primary care outpatients were female (58.20%), 60–79 years old (57.91%), and in suburban regions (62.18%). Chronic diseases accounted for the majority (91.41%). Hypertension, chronic ischaemic heart disease, diabetes, and acute upper respiratory tract infections were the top four disorders for primary care visits regardless of sex. In the group aged 0–18 years, symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified accounted for 37.96% of the top 20 reasons. Acute upper respiratory tract infections were the most common diseases in the groups aged 0–18 (11.20%) and 19–39 (11.14%) years. However, hypertension was the most common disease in the group aged > 39 years old (> 20%). There were more outpatients with respiratory and digestive diseases in suburban areas than in urban areas. In addition, problems associated with medical equipment and other healthcare deficiencies were relatively more common in suburban areas (suburban: 4.13%, rank 5; urban: 2.29%, rank 10). CONCLUSIONS: To meet the patients' needs and to develop the primary care system, the Shanghai government should focus on diseases with regionally high proportions. Disease diagnosis and treatment should be improved in the younger and suburban populations.

PURPOSE: The purpose of this study was to use the hospital information system to analyze the cancer profile and compare demographics, hospitalization, status of surgery and treatment cost of various cancer categories based on the electronic health record (EHR) of outpatient children with tumors in Shanghai, China. PATIENTS AND METHODS: Information was collected from 3834 inpatients aged 0–18 who were diagnosed with malignant tumors in all 17 hospitals with pediatric wards in the Pudong New District of Shanghai from 2011 to 2016. All patients were classified according to the International Classification of Childhood Cancer-3 (ICCC-3). The chi-squared test was used to compare demographics, hospitalization information, status of surgery and treatment cost according to inpatients' cancer category. RESULTS: In both the malignant non-solid tumor and solid tumor groups, males and those aged 0–4 years were the dominant groups. Lymphocytic leukemia was the most common cancer in all inpatients (n=994, 25.93%), and the acute myeloid leukemia had the longest length of stay of inpatients (median=26.00 days). In both the non-solid and solid tumor groups, patients who received only one type of surgery had an advantage. The highest proportion of patients who had undergone surgery was found in non-Hodgkin lymphoma patients. In terms of total cost, surgical cost and medicine cost, the expenditure of central nervous system tumor patients was the highest. Astrocytoma had the highest total cost. CONCLUSION: Leukemia is common in children with cancer in Pudong and should be given attention. Because the highest financial burden falls on patients with central nervous system tumors and acute myeloid leukemias, the government should take immediate and targeted measures for these cancers in particular.

Huining Zhou,1,* Zhengyi Wu,1,* Hui Wang,1 Wenya Yu,1 Jiaoling Huang,1 Liang Zhou,1 Dehua Yu,2 Tianchun Hou,1 Yipeng Lv,1 Chen Chen,3 Li Luo,4 Jianwei Shi,1,5 Zhaoxin Wang1,6 1School of Public Health, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; 2Department of General Practice, Yangpu Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China; 3Shanghai Jing'an District Jiangning Road Community Health Service Center, Shanghai, People's Republic of China; 4School of Public Health, Fudan University, Shanghai, People's Republic of China; 5Shanghai General Practice and Community Health Development Research Center, Shanghai, People's Republic of China; 6General Practice Center, Nanhai Hospital, Southern Medical University, Foshan, People's Republic of China*These authors contributed equally to this workCorrespondence: Jianwei Shi; Zhaoxin WangSchool of Public Health, Shanghai Jiaotong University School of Medicine, 227 South Chongqing Road, Shanghai 200025, People's Republic of ChinaTel +86 188 1820 9852; +86 139 1853 7473Email shijianwei_amy@126.com; supercell002@sina.comPurpose: The purpose of this study was to use the hospital information system to analyze the cancer profile and compare demographics, hospitalization, status of surgery and treatment cost of various cancer categories based on the electronic health record (EHR) of outpatient children with tumors in Shanghai, China.Patients and Methods: Information was collected from 3834 inpatients aged 0– 18 who were diagnosed with malignant tumors in all 17 hospitals with pediatric wards in the Pudong New District of Shanghai from 2011 to 2016. All patients were classified according to the International Classification of Childhood Cancer-3 (ICCC-3). The chi-squared test was used to compare demographics, hospitalization information, status of surgery and treatment cost according to inpatients' cancer category.Results: In both the malignant non-solid tumor and solid tumor groups, males and those aged 0– 4 years were the dominant groups. Lymphocytic leukemia was the most common cancer in all inpatients (n=994, 25.93%), and the acute myeloid leukemia had the longest length of stay of inpatients (median=26.00 days). In both the non-solid and solid tumor groups, patients who received only one type of surgery had an advantage. The highest proportion of patients who had undergone surgery was found in non-Hodgkin lymphoma patients. In terms of total cost, surgical cost and medicine cost, the expenditure of central nervous system tumor patients was the highest. Astrocytoma had the highest total cost.Conclusion: Leukemia is common in children with cancer in Pudong and should be given attention. Because the highest financial burden falls on patients with central nervous system tumors and acute myeloid leukemias, the government should take immediate and targeted measures for these cancers in particular.Keywords: malignant tumors, disease burden, demographics, hospitalization information, epidemiology

OBJECTIVES: Since 2010, the Chinese government has gradually increased its investment in the training of general practitioners (GPs) to support their role as 'gatekeepers' in the healthcare system. However, this training is still organised from the perspective of specialist care. We aimed to assess the appropriateness of the principal GP admission training programme curricula in China, including Residents Training for GPs (RTGP), Residents Training for Assistant GPs (RTAGP) and Training for Specialists with General Practice interest (TSGP). SETTING: The study focussed on GP training programmes in Shanghai, China. PARTICIPANTS: Data on disease competences developed in three GP clinical training programmes (RTGP, RTAGP and TSGP) were derived from official programme training manuals. Data on the proportion of outpatient visits for each disease were taken from the Shanghai community healthcare centres grassroots outpatient database. PRIMARY AND SECONDARY OUTCOME MEASURES: We first conducted a quantitative analysis by comparing the structure of current training curricula with actual outpatient utilisation patterns across all community healthcare institutions in Shanghai from 2014 to 2018. Qualitative analysis was then conducted to evaluate GP training programmes based on Donabedian's model. RESULTS: Quantitative analysis showed that the distribution of diseases for which competences were taught did not match the composition of outpatient visits in community healthcare institutions. Concerns identified through qualitative analysis included teachers who were mostly specialists, lack of equipment for differential diagnosis in community healthcare institutions, insufficient teaching of referral standards and GP training in large hospitals that consistently neglected communication skills. CONCLUSIONS: The establishment and implementation of admission training programmes for GPs in China lacks a focus on general practice training and may be improved by adopting an evidence-based general perspective aligned with the medical ...