Gatekeeping and the utilization of community health services in Shenzhen, China: A cross-sectional study.

To assess the effects of the gatekeeper policy implemented in Shenzhen, China, in conjunction with a labor health insurance program, on channeling patients toward community health centers (CHCs).Eight thousand patients who visited 8 CHCs in Shenzhen were surveyed between May 1, 2013 and July 28, 2013. Half of the patients were subject to gatekeeper policy and the other half of them were not. Structured questionnaire was used to collect patients' choices of initial medical institution, use of CHCs and their satisfaction with health care. Bivariate and regression analyses were used to compare patient's choice, utilization, and satisfaction of CHCs.Compared with patients who were free to seek medical care at any place, patients with gatekeepers were 1.77 (95% CI 1.37-2.30) times more likely to choose CHCs first when seeking care. In the past year, the group with gatekeeper made 0.88 more visits to CHCs in the past year than the group without gatekeeper (P < .01), controlling for influencing factors. The 2 groups were equally satisfied with all satisfaction measures except for "waiting time," which was higher among patients without gatekeepers (P < .01).Our study indicates that, as repeatedly proven in other parts of the world, gatekeeping is effective in orienting patients toward primary care system. Along with increased efforts in rebuilding China's primary care network and expanding health insurance coverage, implementation of gatekeeper policy may help increase access to care, reduce inappropriate use of health resources, and strengthen primary care institutions.

Depression and the risk of breast cancer: a meta-analysis of cohort studies.

BACKGROUND: Whether depression causes increased risk of the development of breast cancer has long been debated. We conducted an updated meta-analysis of cohort studies to assess the association between depression and risk of breast cancer. MATERIALS AND METHODS: Relevant literature was searched from Medline, Embase, Web of Science (up to April 2014) as well as manual searches of reference lists of selected publications. Cohort studies on the association between depression and breast cancer were included. Data abstraction and quality assessment were conducted independently by two authors. Random-effect model was used to compute the pooled risk estimate. Visual inspection of a funnel plot, Begg rank correlation test and Egger linear regression test were used to evaluate the publication bias. RESULTS: We identified eleven cohort studies (182,241 participants, 2,353 cases) with a follow-up duration ranging from 5 to 38 years. The pooled adjusted RR was 1.13(95% CI: 0.94 to 1.36; I2=67.2%, p=0.001). The association between the risk of breast cancer and depression was consistent across subgroups. Visual inspection of funnel plot and Begg's and Egger's tests indicated no evidence of publication bias. Regarding limitations, a one-time assessment of depression with no measure of duration weakens the test of hypothesis. In addition, 8 different scales were used for the measurement of depression, potentially adding to the multiple conceptual problems concerned with the definition of depression. CONCLUSIONS: Available epidemiological evidence is insufficient to support a positive association between depression and breast cancer.

Shift work and diabetes mellitus: a meta-analysis of observational studies.

BACKGROUND: Observational studies suggest that shift work may be associated with diabetes mellitus (DM). However, the results are inconsistent. No systematic reviews have applied quantitative techniques to compute summary risk estimates. OBJECTIVES: To conduct a meta-analysis of observational studies assessing the association between shift work and the risk of DM. METHODS: Relevant studies were identified by a search of PubMed, Embase, Web of Science and ProQuest Dissertation and Theses databases to April 2014. We also reviewed reference lists from retrieved articles. We included observational studies that reported OR with 95% CIs for the association between shift work and the risk of DM. Two authors independently extracted data and assessed the study quality. RESULTS: Twelve studies with 28 independent reports involving 226 652 participants and 14 595 patients with DM were included. A pooled adjusted OR for the association between ever exposure to shift work and DM risk was 1.09 (95% CI 1.05 to 1.12; p=0.014; I(2)=40.9%). Subgroup analyses suggested a stronger association between shift work and DM for men (OR=1.37, 95% CI 1.20 to 1.56) than for women (OR=1.09, 95% CI 1.04 to 1.14) (p for interaction=0.01). All shift work schedules with the exception of mixed shifts and evening shifts were associated with a statistically higher risk of DM than normal daytime schedules, and the difference among those shift work schedules was significant (p for interaction=0.04). CONCLUSIONS: Shift work is associated with an increased risk of DM. The increase was significantly higher among men and the rotating shift group, which warrants further studies.

Depression and the risk of coronary heart disease: a meta-analysis of prospective cohort studies.

BACKGROUND: Several systematic reviews and meta-analyses demonstrated the association between depression and the risk of coronary heart disease (CHD), but the previous reviews had some limitations. Moreover, a number of additional studies have been published since the publication of these reviews. We conducted an updated meta-analysis of prospective studies to assess the association between depression and the risk of CHD. METHODS: Relevant prospective studies investigating the association between depression and CHD were retrieved from the PubMed, Embase, Web of Science search (up to April 2014) and from reviewing reference lists of obtained articles. Either a random-effects model or fixed-effects model was used to compute the pooled risk estimates when appropriate. RESULTS: Thirty prospective cohort studies with 40 independent reports met the inclusion criteria. These groups included 893,850 participants (59,062 CHD cases) during a follow-up duration ranging from 2 to 37 years. The pooled relative risks (RRs) were 1.30 (95% CI, 1.22-1.40) for CHD and 1.30 (95% CI, 1.18-1.44) for myocardial infarction (MI). In the subgroup analysis by follow-up duration, the RR of CHD was 1.36 (95% CI, 1.24-1.49) for less than 15 years follow-up, and 1.09 (95% CI, 0.96-1.23) for equal to or more than 15 years follow-up. Potential publication bias may exist, but correction for this bias using trim-and-fill method did not alter the combined risk estimate substantially. CONCLUSIONS: The results of our meta-analysis suggest that depression is independently associated with a significantly increased risk of CHD and MI, which may have implications for CHD etiological research and psychological medicine.