Jiefang Daily: The Inverted Pyramid in the Medical System Is Gradually Rectified in Songjiang——How Should Big Hospitals Support the Regional Medical Alliance

Normally, the medical system should be a Pyramid: tertiary hospitals are at the top, mainly treating difficult miscellaneous diseases; secondary hospitals are in the middle, treating common diseases and frequently-occurring diseases, providing outpatient emergency treatment and inpatient care; community health service institutions are at the bottom, treating common diseases and frequently-occurring diseases, providing hospital transfer, follow-up visit and other health management services. However, the Inverted Pyramid has existed for a long time. Many patients are concentrated in tertiary hospitals at the top. Secondary and community hospitals apparently lack popularity. In Songjiang, this situation has changed.

According to the National Health Commission’s plan, the normal medical system should be a Pyramid: tertiary hospitals are at the top, mainly treating difficult miscellaneous diseases; secondary hospitals are in the middle, treating common diseases and frequently-occurring diseases, providing outpatient emergency treatment and inpatient care; community health service institutions are at the bottom, treating common diseases and frequently-occurring diseases, providing hospital transfer, follow-up visit and other health management services. However, the Inverted Pyramid has existed for a long time. Many patients are concentrated in tertiary hospitals at the top. Secondary and community hospitals apparently lack popularity. It’s gratifying that in Songjiang, this situation has changed. According to the District Health Commission’s statistics, in 2016 in Songjiang District, 144,500 patients were transferred from community health service centers to secondary and tertiary hospitals; 3,437 patients were transferred from secondary and tertiary hospitals to community health service centers. An orderly hierarchical diagnosis and treatment model is gradually established.

“Give us ten years, nothing is impossible!” Shanghai General Hospital’s President Wang Xingpeng often quotes this. The hospital started from zero. After 10 years of cultivation, by improving the ability of providing regional primary medical services, the hospital has become a “pillar” in the regional hierarchical medical system in the test field of Songjiang District.

A Tutorial System Trains Community General Practitioners

“Before Shanghai General Hospital came to Songjiang District, residents in Songjiang and Qingpu had to go downtown to see experts. The district’s registered population is a little more than 600,000, but the permanent resident population is more than 1.8 million. The situation was obviously imbalanced.” The person in charge of the District Health Commission said frankly.

How to do? Improving the medical capacity of the doctors at community health service centers became the key. In Oct. 2014, Songjiang District Health Commission and Shanghai General Hospital started the “Commission-Hospital Cooperation——Community General Practitioner Tutorial System Training Program”. 46 general practitioners from 15 community health centers in the district attended the 2-year Tutorial System training program. Wang Yufan, Director of the Endocrinology Department of Shanghai General Hospital’s South Division, became a trainer in the program.

“Every week, apart from the fixed daily ward rounds and half-day outpatient service, there are hospital-wide or department-level occupational study, skill training and follow-up patient visits. These general practitioners are very busy. Some of them have to use their spare time.” Wang Yufan told the reporter. There were 14 trainees from the Endocrinology Department. In addition, there were trainees from 11 departments, such as the Cardiology Department, Pneumology Department, Neurology Department, etc. The aim was to meet the urgent need of diagnosis, treatment and management of common diseases in local communities.

Back then, Wang Yufan just returned from Canada. With great enthusiasm, she threw herself into training general practitioners and gradually noticed some problems in local communities. “Let’s use diabetes as an example. Some residents’ blood sugar levels may rise in some stressful situations. Community doctors prescribe antidiabetic drugs in the absence of a definite diagnosis. This can lead to hypoglycemia. In fact, such patients in the critical range need to be re-examined. Some doctors cannot tell Type I diabetes from Type II diabetes, so they cannot prescribe the right dosage or usage of insulin. Some doctors don’t prescribe medication following the standards. They don’t timely and regularly adjust the dosage and variety of medication for patients, making the effect of blood sugar control not ideal.” In response to such situations, she organized a series of lectures on disease diagnosis and treatment standards, typical cases, workshops on difficult and critical cases, which let family doctors bring scientific new ideas back to their communities.

“Ms. Wang often reminds everybody: why are you here? You are here to train the ability of diagnosing and treating common diseases, recognizing difficult and complicated diseases, to let your patients achieve self-management of health in the future.” Xiaokunshan Town Community Health Service Center’s doctor Lu Yuanying recalled that there was a patient whose blood sugar level was high for a long time and the condition didn’t improve after adjusting the medication. After transferring the patient to Wang Yufan, she learnt the patient had GH adenoma and diabetes. The patient had a surgery at Shanghai General Hospital’s South Division, then he was transferred back to the community health service center for follow-up visits after his condition became stable. Now, his condition is good. “If some difficult or complicated disease is missed in the diagnosis, Ms. Wang always shares with us in our WeChat group, to broaden our professional horizons.” 

Deep Integration and Connection between the Orthopedics Department and Rehabilitation Department

For a long time, as one of the four trauma centers in Shanghai, Shanghai General Hospital has been responsible for trauma treatment and medical rescue. Apart from the import of population, Songjiang is by Shanghai-Kunming Expressway, Shanghai-Chongqing Expressway and other expressways, so medical establishments here must be ready for all kinds of emergency traffic accidents. According to Wang Qiugen, Director of Shanghai General Hospital’s Trauma Center, who participated in the construction of Songjiang District’s trauma treatment system, to build a regional trauma treatment system, it cannot be limited to improvements within each hospital. “If the traditional first-aid model is followed, the injured will first receive an injury assessment after arriving at the hospital and then all departments will be gathered, which may delay the treatment.” As a result, he proposed to carry out hierarchical diagnosis and treatment for patients with different injuries. Today, in tertiary hospitals, the rate of receiving and treating patients with minor injuries has dropped by nearly 10%, while the rate of receiving and treating critical patients has risen by 9%; in secondary and primary hospitals, the rate of receiving and treating patients with minor injuries has respectively risen by 10% and 4%, while the rate of receiving and treating critical patients has respectively dropped by 6% and 0.6%.

However, patients often cannot return to normal life immediately after the acute treatment period. Ms. Zhang, a 32 years old woman who fell from her home on the 6^th floor by accident, had a rupture of her spleen and multiple fractures in her thoracolumbar vertebrae, pelvis, left talus, right tibia-fibula and ribs. After the operation, she still had spinal cord injury, incontinence and dyskinesia of both lower limbs. Chen Wenhua, Director of Shanghai General Hospital’s Rehabilitation Department, said due to the deep integration and connection between the Orthopedics Department and Rehabilitation Department, Shanghai General Hospital’s joint team provided Ms. Zhang with bedside rehabilitation training, including joint motion range in both lower limbs, muscle force and bladder, etc. “More than 40 days later, we assessed her condition. She met the post-acute discharge criteria, so we transferred her to Shanghai No. 5 Rehabilitation Hospital for stable rehabilitation treatment through the referral system.”

In 2012, as a national pilot district for the construction of a complete rehabilitation medical service system, Songjiang District established a three-level rehabilitation medical service system led by Shanghai General Hospital’s Rehabilitation Department: the former Ledu Hospital of Songjiang District became Shanghai No.5 Rehabilitation Hospital, uniting community health service centers and home rehabilitation as a bond, unifying personnel training and team building, to provide medical resources for rehabilitation patients in the region and even in the whole city. In May 2014, the hospital became the first rehabilitation institution in China to be certified by the Commission on Accreditation of Rehabilitation Facilities (CARF). Doctor Zhang Wen became the first CARF international examiner in China.

Chen Wenhua said according to international standards and requirements, rehabilitation is a continuous process. People-oriented rehabilitation institutions must develop in the linkage between referrals so that patients can receive continuous and homogeneous rehabilitation treatment and management wherever they are. This idea coincides with the orderly hierarchical referral, standard homogeneous diagnosis and treatment in regional linkage. With Shanghai General Hospital’s Rehabilitation Department and Shanghai No.5 Rehabilitation Hospital’s guidance and assistance, Songjiang District’s 15 community health service centers have established rehabilitation departments. 13 of them have rehabilitation wards. Higher hospitals have transferred 47 rehabilitation patients to community health service centers.

The Influence of a Tertiary Hospital Is Not in Its Size

Shanghai General Hospital’s President Wang Xingpeng says as a booster for rearranging the order of medical treatment, it’s time for the hierarchical diagnosis and treatment system to regroup. “Hierarchical diagnosis and treatment should be regional, led, influenced, supported and directed by tertiary hospitals, to build a system with a firm base. Since 10 years ago when we were commissioned to manage Songjiang District Central Hospital, our vision of building a regional medical center has never changed.” After 10 years of exploration, how to make tertiary hospitals abandon their fences and become responsible leaders is the topic he keeps thinking about.

Taking the tumor prevention and control system as an example, after Shanghai General Hospital’s South Division was established, the Oncology Department shifted its center of gravity to Songjiang. Based on local data, the hospital joined hands with the district’s Disease Control and Prevention Center, Central Hospital, Sijing Hospital, Fangta Traditional Chinese Medicine Hospital and 15 community health service centers to build a complete regional tumor prevention and control information network system covering Songjiang District’s 1.76 million permanent residents. In Sheshan Town, cervical TCT and HPV screening were carried out. 52 cases of early cervical lesions were found in the region. 11 of the patients with malignant transformation risks were transferred to Shanghai General Hospital’s South Division for surgery. After surgery, they successively returned to community health service centers for follow-up visits. They are in good condition now. In Yueyang Subdistrict, 2,899 registered residents in the 40-75 age range received pulmonary nodule screening. Guided by Shanghai General Hospital’s experts, the community has formulated unified standards and norms for the diagnosis and treatment of lung cancer, providing timely diagnosis and treatment opportunities for lung cancer patients

Wang Xingpeng thinks: “a tertiary hospital should no longer be judged by its size, but by its influence.” In his opinion, a tertiary hospital should play the role of six centers: demonstration center for standard diagnosis of common diseases, consultation and rescue center for critical diseases, medical standards setting center, clinical personnel training center, clinical technology research and development center and modern hospital management system innovation center. At the same time, a regional medical system in benign development needs to address the actual development needs of medical institutions at each level and become a chess game for sharing benefits. It’s learnt that Shanghai General Hospital is arranging regional medical linkage with the Yangtze River Delta, hoping to radiate its influence to a greater extent.

By Huang Yangzi, reporter with Jiefang Daily