Factors associated with residents' contract behavior with family doctors in community health service centers: A longitudinal survey from China

Family physician service quality and sustainability: a roadmap for Pakistan's healthcare sector

Introduction

The number of family medicine consultants has increased during and after the COVID-19 pandemic. However, research on family medicine services specific to Pakistan remains limited. Therefore, this study aimed to explore family physician services in Pakistan.

Methods

To meet the study goals, we collected data using snowball and purposive sampling. A questionnaire was used exclusively to collect data from family physician consultations. The data were examined using the SmartPLS structural equation model to test the study model's reliability and validity.

Results

The study findings showed that using resource utilization and allocation, utilization of technology, professionalism improvement, medical attention, cooperation, and caring were positively significant to employee welfare and assistance in family medicine services. These dimensions were also positively significant to community involvement and advocacy for the sustainable development of family medical services in Pakistan.

Conclusion

The study concluded that effective resource utilization, professionalism, medical care, cooperation, and the evaluation of quality and outcomes are key factors in promoting the growth of family medicine services. These indicators may enhance staff satisfaction, community involvement, and family physician service sustainability.

Development, feasibility, and preliminary effects of a culturally adapted, evidence-based, and theory-driven diabetes self-management programme for Chinese adults with type 2 diabetes receiving insulin injection therapy

AIMS

To describe the development of a culturally adapted, evidence-based, and theory-driven diabetes self-management programme for Chinese adults with type 2 diabetes receiving insulin injection therapy and to assess the feasibility, acceptability, and preliminary effects of the newly developed intervention.

METHODS

The Medical Research Council framework was adopted to guide the intervention development and a feasibility study. A prospective, two-arm, parallel-group, assessor-blinded randomised controlled trial was conducted. Participants were randomly allocated to receive either the newly developed intervention or parallel attention control contact from community nurses. Between-group differences in changes in outcome variables were analysed using the Mann-Whitney U test.

RESULTS

The newly developed intervention consists of one individual interview session, three group-based education sessions, and two telephone-based maintenance sessions. A total of 24 participants were recruited with the recruitment rate and overall retention rate of 77.4 % and 95.8 %, respectively. The results indicated that the intervention participants reported significantly greater improvements in self-efficacy (Hedge's g = 1.69) and self-management behaviours (Hedge's g = 3.24), and reductions in diabetes-related distress (Hedge's g = 1.49) compared with those in the control group (all p< 0.05).

CONCLUSION

The diabetes self-management programme was feasible and acceptable. The intervention showed promising patient-centred benefits. A future large-scale randomised controlled trial is warranted.

Influencing factor analysis of family doctor contract service among older adults: evidence from China

Background

Family doctor contract services are essential to primary healthcare and play a significant role in improving the health of older adults. However, contract rates among older adults vary widely. Investigating the factors influencing contract rates is crucial for optimizing policies and increasing participation in family doctor services.

Methods

This study used data from Wangying Community Health Service Center, encompassing 5,684 older adults in 2018. To address the endogeneity issue arising from sample selection bias, the study utilized a 1:1 nearest-neighbor matching method for counterfactual testing, balancing potential confounding factors between the contract and non-contract groups. Subsequently, multiple logistic regression analysis was performed on the matched data to explore the impact of gender, age, number of medical visits, and the number of chronic conditions on family doctor contract behavior.

Results

Gender did not significantly impact contracting behavior. However, age, the number of medical visits, and the number of chronic diseases significantly influenced family doctor contract (β = 0.457, p < 0.01; β = 0.286, p < 0.05; β = -0.229, p < 0.1). An inverted U-shaped relationship was found between age and contracting behavior (β = -0.003, p < 0.01).

Conclusion

The factors influencing older residents' decisions to sign up for family doctor services are complex and diverse. The conclusion of the study provides valuable reference and guidance for policymakers to further improve the family doctor contracting system and optimize contracting strategies by considering the characteristics of different older adults.

A study of patients' choice of medical treatment based on rational choice theory: a cross-sectional survey from China

OBJECTIVE

To describe how patients choose between primary care institutions (PCIs) and non-PCIs using rational choice theory from the perspective of survival rationality, economic rationality, and social rationality.

METHODS

Multi-stage stratified sampling and convenience sampling were applied to select 1723 patients to conduct the questionnaire survey. Chi-square test and binary logistic regression were performed to analyze the factors associated with patients' choice of PCIs.

RESULTS

In total 55.83% of 1723 patients would attend a PCIs for healthcare. The results of the univariate analysis revealed that patients who are female (58.46%, P = .015), suffering from chronic diseases (56.26%, P = .047), inpatients (67.58%, P < .001), Beijing (59.62%, P = .002), partial understanding of the family doctor contracting system (62.30%, P < .001), and not understanding of the medical alliance policy (58.04%, P = .031) had significantly higher probability of choosing PCIs. Logistic regression analysis showed that females were more unwilling to attend PCIs (odds ratio (OR) = 0.822, 95%CI: 0.676-0.999). Following survival rationality, patients without chronic diseases were more likely to attend PCIs (OR = 1.834, 95%CI: 1.029-3.268), and inpatients were more unlikely to attend PCIs (OR = 0.581, 95%CI: 0.437-0.774). From an economic rationality perspective, patients from the Fujian province were more likely to attend PCIs (OR = 1.424, 95%CI: 1.081-1.876). From a social rationality perspective, patients who partial understanding of the family doctor contracting system were more unlikely to attend PCIs (OR = 0.701, 95%CI: 0.551-0.892), and patients who partial and complete understanding of the medical alliance policy were more likely to attend PCIs (OR = 1.340, 95%CI: 1.064-1.687; OR = 1.485, 95%CI: 1.086-2.030).

CONCLUSIONS

Survival, economic, and social rationality are involved in patients' choice to attend PCIs. Compared to survival rationality and social rationality, economic rationality showed a lower association with patients' choice to attend PCIs. Medical institutions are recommended to adopt a "patient health-centered" approach when providing medical services and further optimize the family doctor contracting system and construction of medical alliances.

Community Health Centers' Responsiveness and Its Associated Factors Among Outpatients in Southeast China: A Cross-Sectional Study

Background

The responsiveness of community health centers can reflect the soft capacity of medical institutions and is related to the improvement of health outcome indicators. This study is aimed at assessing the level and distribution of community health centers' responsiveness and its associated factors among outpatients under the health-oriented integrated healthcare system in China.

Methods

A total of 634 outpatients were recruited from six community health centers in Zhejiang Province, China, in July 2022. SPSS software was used to conduct the analysis (version 23.0). Health system responsiveness was used as a measure of outpatient responsiveness to health care services through a self-administered questionnaire. Determinants of community health centers' responsiveness were determined by using a multiple linear regression model at a p-value <0.05.

Results

The total score of community health centers responsiveness was 8.25±1.01, and the Gini coefficient is 0.027. Within these domains, social support and dignity received the highest scores, while choice of providers and autonomy scored the lowest. Age group between 60-74 years (β: 0.129; 95% CI: 0.042-0.529), ≥75 years (β: 0.095; 95% CI: 0.006-0.707), monthly income with 8000 RMB and above (β: 0.098; 95% CI: 0.035-0.653), having a family doctor (β: 0.124; 95% CI: 0.096-0.410), and satisficing with community health service (β: 0.298; 95% CI: 0.848-1.428) were significant predictors of community health centers' responsiveness.

Conclusion

The Chinese community health centers show high responsiveness, indicating that the construction of a health-oriented integrated healthcare system has been effective. The family doctor contract service is important and should continually enhance both technical proficiency and health promotion capabilities. Encourage residents to actively participate in their treatment process is also essential.

Public trust in general practitioners and its association with primary care contracts: a cross-sectional study of community residents in China

OBJECTIVES

This study aimed to assess the level of public trust in general practitioners (GPs) and its association with primary care contract services (PCCS) in China.

STUDY DESIGN

Cross-sectional study.

METHODS

Between September and December 2021, 4158 residents across eastern, central, and western China completed a structured self-administered questionnaire. Trust was assessed using the Chinese version of Wake Forest Physician Trust Scale. Multivariable linear regression models were established to identify predictors of trust. The effect size of PCCS on trust was estimated by the average treatment effect for the treated (ATT) through propensity score matching.

RESULTS

The study participants had a mean Wake Forest Physician Trust Scale score of 36.82 (standard deviation = 5.45). Enrollment with PCCS (β = 0.14, P < 0.01), Han ethnicity (β = 0.03, P < 0.05), lower educational attainment (β = -0.06, P < 0.01), higher individual monthly income (β = 0.03, P < 0.05), better self-rated health (β = 0.04, P < 0.05), chronic conditions (β = 0.07, P < 0.01), and higher familiarity with primary care services (β = 0.12, P < 0.01) and PCCS (β = 0.21, P < 0.01) were associated with higher trust in GPs. The ATT of PCCS exceeded 1 (P < 0.05).

CONCLUSIONS

PCCS are associated with higher levels of trust in GPs. PCCS may become an effective tool to attract public trust in GPs, although the relationship between the two may be bi-directional.

Does a GP service package matter in addressing the absence of health management by the occupational population? A modelling study

OBJECTIVE

To assess the influence of supply and demand factors on the contract behavior of occupational populations with general practitioner (GP) teams.

METHODS

We employed a system dynamics approach to assess and predict the effect of the general practitioner service package (GPSP) and complementary incentive policies on the contract rate for 2015-2030. First, the GPSP is designed to address the unique needs of occupational populations, enhancing the attractiveness of GP contracting services, including three personalized service contents tailored to demand-side considerations: work-related disease prevention (WDP), health education & counseling (HEC), and health-care service (HCS). Second, the complementary incentive policies on the supply-side included income incentives (II), job title promotion (JTP), and education & training (ET). Considering the team collaboration, the income distribution ratio (IDR) was also incorporated into supply-side factors.

FINDINGS

The contract rate is predicted to increase to 57.8% by 2030 after the GPSP intervention, representing a 15.4% increase on the non-intervention scenario. WDP and HEC have a slightly higher (by 2%) impact on the contract rate than that from HCS. Regarding the supply-side policies, II have a more significant impact on the contract rate than JTP and ET by 3-5%. The maximum predicted contract rate of 75.2% is expected by 2030 when the IDR is 0.5, i.e., the GP receives 50% of the contract income and other members share 50%.

CONCLUSION

The GP service package favorably increased the contract rate among occupational population, particularly after integrating the incentive policies. Specifically, for a given demand level, the targeted content of the package enhanced the attractiveness of contract services. On the supply side, the incentive policies boost GPs' motivation, and the income distribution motivated other team members.

The impact of hypertension follow-up management on the choices of signing up family doctor contract services: does socioeconomic status matter?

BACKGROUND

This study aimed to explore the association between hypertension follow-up management and family doctor contract services, as well as to examine whether socioeconomic status (SES) had an interaction effect on this relationship among older adults in China.

METHODS

We used data from the sixth National Health Service Survey of Shandong Province, China, including 3,112 older adults (age ≥ 60 years) with hypertension in 2018. Logistic regression models and a margins plot were used to analyze the role of SES in the relationship between hypertension follow-up management and family doctor contract services.

RESULTS

The regular hypertension follow-up management rate and family doctor contracting rate were 81.8% and 70.9%, respectively, among older adults with hypertension. We found that participants with regular hypertension follow-up management were more likely to sign family doctor contract services (OR=1.28, 95%CI: 1.04, 1.58, P=0.018). The interaction effect occurred in the groups who lived in rural areas (OR=1.55, 95%CI: 1.02, 2.35), with high education level (OR=0.53, 95%CI: 0.32, 0.88) and had high incomes (OR=0.53, 95%CI: 0.35, 0.81).

CONCLUSIONS

Our findings suggested that regular hypertension follow-up management was associated with family doctor contract services and SES influenced this relationship. Primary health care should improve the contracting rate of family doctors by strengthening follow-up management of chronic diseases. Family doctors should focus on improving services quality and enriching the content of service packages especially for older adults with higher income and education level.

The awareness rate of knowledge of chronic diseases and influencing factors among 4790 adults in anhui province: An online survey using WeChat

Objective

To investigate public awareness about core information regarding chronic diseases and identify factors influencing that awareness among Anhui Province residents, provide a scientific basis for policy-making, and formulate corresponding intervention measures.

Methods

From March to April 2021, 12 provincial-level representative counties and districts of Anhui province in the China Adult Chronic Disease and Nutrition Surveillance were selected as survey sites, and 4790 residents were recruited for the survey using stratified multi-stage cluster random sampling. Basic details about the study participants were collected and their awareness of core information about major chronic diseases was measured through an online survey using WeChat.

Results

In 2021, the awareness rate of core information about chronic diseases among residents of Anhui Province was 54.93%. Multivariate logistic regression analysis showed that a higher awareness rate was associated with the following factors: non-housework occupations (agriculture, forestry, animal husbandry, and fishery: OR = 1.309, commercial services and production and transportation: OR = 1.450, institutions, and professional and technical personnel: OR = 1.461), a high education level (high school/junior high school/technical school OR = 1.357, college and above OR = 2.133), and residence in the southern and northern Anhui areas (southern Anhui OR = 1.282, northern Anhui OR = 1.431); whereas in rural areas (by district and country) (OR = 0.863), the awareness rate was low (all P < 0.05).

Conclusions

The awareness rate of core information about chronic diseases among residents of Anhui, China, is low. It is necessary to strengthen awareness about chronic disease prevention and management by targeting specific groups of people in this region.

Factors influencing contracting of residents with family doctors in China: a national cross-sectional survey

BACKGROUND

Family doctor contract services (FDCS) have been introduced in China in 2009 [1] and rapidly expanded recently. This study sought to investigate factors that influenced the willingness of Chinese residents to use FDCS.

METHODS

We employed multistage stratified and convenience sampling to administer questionnaires to 1455 Beijing, Qinghai, and Fujian residents. The willingness of residents in each province to contract family doctors was analyzed using the chi-square test and binary logistic regression.

RESULTS

The analysis in this study found that the signing rate of family doctors in China was about 27.77%, with differences in the signing up levels in Beijing (13.68%), Fujian (64.49%) and Qinghai (11.22%). In addition, the binary logistic regression results emphasized the relative importance of age, education, medical preference and policy knowledge on the willingness to sign up. Distrust of family doctors' medical skills (65.7%), not knowing how to contract (47.8%), and not knowing what medical problems can be solved (41.1%) were the top three reasons accounting for the reluctance of residents to contract with family doctors.

CONCLUSION

Residents from different backgrounds have different willingness to sign up, so the specific circumstances and needs of different groups should be taken into account. In order to increase the signing-up rate, consideration can be given to promoting the family doctor model in Fujian throughout the country. Individual hesitation can be eliminated by increasing the reimbursement rate of health insurance, reducing the out-of-pocket expenses of contracted patients, and providing incentives of certain discounts for consecutive contracted patients.

Research on the control rate of hypertension under family physician-contracted service

BACKGROUND

Hypertension is one of the global public health problems. Family physician-contracted service (FPCS) is widely used in the health management of hypertension patients in China. The purpose of this study was to assess the effect of FPCS on hypertension control.

METHODS

PubMed, Web of Science, the Cochrane Library, China National Knowledge Network, Chinese Scientific and Technological Journal Database (CQVIP), and Wanfang Database were searched for randomized controlled trials related to family physician-contracted service and hypertension control effect, and meta-analysis was performed on the literature meeting the inclusion criteria. The source of heterogeneity was discovered by meta-regression, and it was further investigated by subgroup analysis. The risk difference (RD) and 95% confidence interval (CI) were utilized as effect values. Evaluations of publication bias and sensitivity analysis were also conducted.

RESULTS

A total of 46 studies were included, and the pooled RD suggested that FPCS could effectively improve the control rate by 19% (RD = 0.19; 95%CI: 0.16-0.21; P < 0.001; I2 = 59.3%). The average age (β = 0.28; P = 0.05) and the intervention mode (β = 0.36; P < 0.001) were found to be heterogeneous sources by the meta-regression. According to subgroup analysis, the hypertension control rates of the elderly and working-age population in the experimental group were 93.6% and 90.1%, respectively; the control rates of the "family physician" mode (FP), "family physician + patient" mode (FPP) and "family physician + patient + family member" mode (FPPF) in the experimental group were 90.1%, 94.4%, and 92.6%, respectively. The sensitivity analysis revealed steady results, with no discernible publication bias.

CONCLUSIONS

The FPCS is beneficial to the control of hypertension. The control effect is influenced by average age and intervention mode. The control effect of hypertension in the elderly is better than that in the working-age population, and FPP and FPPF are more beneficial to the management of hypertension than FP. The quality and continuity of FPCS should receive more focus in the future, patient self-management and family support are also essential for managing hypertension.

Preparing future general practitioners: the effects of individual, familial, and institutional characteristics

BACKGROUND

There is a substantially increasing need for general practitioners (GPs) for future unpredictable pandemic crises, especially at the community-based health services (CBHS) level to protect the vast and varied grassroot-level population in China. Thus, it is crucial to understand the factors that affect Chinese medical students' GP career choices and commitments to CBHS.

METHODS

Leveraging the self-administered data collected across the country, this study conducted logistic regressions with 3,438 medical students. First, descriptive statistics of outcome variables and independent variables were provided. Then, stepwise logistic regression models were built, starting from adding individual characteristics, and then familial and institutional characteristics. Last, post-estimation was conducted to further assess whether there were significant marginal effects.

RESULTS

Results showed that women students were 24% less likely to choose GP careers but were 1.25 times more likely to commit to CBHS than their men peers, holding other individual, familial, and institutional characteristics constant. In addition, students who major in GP-orientated were more likely to choose GP careers and commit to CBHS, respectively, than those who major in clinical medicine. Furthermore, familial characteristics like annual income and mother's educational level only significantly predicted commitments to CBHS. Notably, sex-related differences in GP career choices and commitments to CBHS - by different regions - were observed.

CONCLUSIONS

Understanding the factors that affect medical students' GP career choices sheds light on how medical education stakeholders can make informed decisions on attracting more medical students to GP-orientated majors, which in turn cultivates more GP professionals to meet the nation's demand for GPs. In addition, by understanding the factors that influence medical students' commitment to CBHS, policymakers could make beneficial policies to increase medical students' motivations to the grassroot-level health institutions, and devote to CBHS as gatekeepers for a large population of residents' health.

Changes of the acute myocardial infarction-related resident deaths in a transitioning region: a real-world study involving 3.17 million people

Background

The impact of acute myocardial infarction (AMI) on the life span of residents in a transitioning region has not been studied in depth. Therefore, we aimed to evaluate the changes in AMI-related resident deaths in a transitioning region in China.

Methods

A longitudinal, population-based study was performed to analyze the deaths with/of AMI in Pudong New Area (PNA), Shanghai from 2005 to 2021. The average annual percentage change (AAPC) of AMI in crude mortality rates (CMR), age-standardized mortality rates worldwide (ASMRW), and rates of years of life lost (YLLr) were calculated by the joinpoint regression. The impact of demographic and non-demographic factors on the mortality of residents who died with/of AMI was quantitatively analyzed by the decomposition method.

Results

In 7,353 residents who died with AMI, 91.74% (6,746) of them were died of AMI from 2005 to 2021. In this period, the CMR and ASMRW of residents died with/of AMI were 15.23/105 and 5.17/105 person-years, the AAPC of CMR was 0.01% (95% CI: -0.71,0.72, p = 0.989) and 0.06% (95% CI: -0.71,0.84, p = 0.868), and the ASMRW decreased by 2.83% (95% CI: -3.66,-2.00, p < 0.001) and 2.76% (95% CI: -3.56,-1.95, p < 0.001), respectively. The CMR of people died of AMI showed a downward trend (all p < 0.05) in people ≥60 years but an upward trend [AAPC = 2.47% (95% CI: 0.07,4.94, p = 0.045)] in people of 45-59 years. The change in CMR of people died with/of AMI caused by demographic factors was 28.70% (95% CI: 12.99,46.60, p = 0.001) and 28.07% (95% CI: 12.71,45.52, p = 0.001) per year, respectively.

Conclusion

Preventative strategies for AMI should be applied to enhance the health management of residents aged 45-59 years or with comorbidities in the transitioning region.

What factors affect Beijing residents' contracts with family doctors? A comparative study of Beijing's urban and suburban areas

Objective

To improve the health of residents and promote hierarchical diagnosis and treatment to achieve an orderly pattern of medical treatment, Beijing implemented family doctor contract services (FDCSs) in 2011. The aims of this study were to analyze the current status of Beijing residents' contracts with family doctors (FDs), compare the differences in contracting between urban and suburban residents, and explore the factors that affect residents' contract behavior.

Methods

From August 2020 to October 2020, a stratified sampling method was adopted to select residents from community health centers (CHCs) in districts D (urban area) and S (suburb) of Beijing to conduct a questionnaire survey. Chi-square tests, rank sum tests and logistic regression analyzes were used to analyze the current status and influencing factors of residents' contracting with FDs.

Results

A total of 4,113 valid questionnaires were included in the final analysis. District D was rich in medical resources, and the FD contract rate of residents there (93.09%) was significantly higher than that of residents in district S (78.06%; p < 0.05). Residents' district (OR = 1.55, 95% CI = 1.18-2.05), understanding of FDCS policies (OR = 4.13, 95% CI = 3.63-4.69), preferred medical institutions (OR = 0.58, 95% CI = 0.42-0.79 for tertiary hospitals in the district; OR = 0.36, 95% CI = 0.22-0.59 for urban medical institutions in Beijing), age, education level, average annual medical expenses and medical insurance type were factors that influenced residents' contracts with FDs (p < 0.05).

Conclusion

This study shows that residents who are located in districts with rich medical resources, prefer CHCs as their first choice, have a better understanding of FDCS policies, and are more inclined to contract with FDs than other residents. It is recommended that the number and quality of FDs in suburban areas be increased and that medical staff strengthen publicity about FDCSs and actively encourage residents to contract with FDs.

Risk factors associated with home care safety for older people with dementia: family caregivers' perspectives

BACKGROUND

Many older people with dementia currently prefer home care; however, homes are neither professionally designed nor regulated like health care facilities, and home care is more prone to safety incidents. Many studies have examined home care safety for older people with dementia. However, factors contributing to safety incidents in home care have not been adequately considered. This study explored the risk factors for home care safety for older people with dementia based on the perspective of family caregivers.

METHODS

This study used a qualitative research approach; a total of 24 family caregivers were interviewed face-to-face and semi-structured from February 2022 to May 2022, and the Colaizzi seven-step phenomenological research method was used to analyze the data and refine the themes.

RESULTS

Safety risks in home care for older people with dementia stem from five areas: poor health of older people with dementia, dementia symptoms, unsafe home environment, the insufficient caring ability of family caregivers, and lack of safety awareness of family caregivers.

CONCLUSION

The risk factors for home care safety for older people with dementia are complex. And as the primary caregivers of older people with dementia, the caregiving ability and safety awareness of family caregivers primarily determine the safety of home care for older people with dementia. Therefore, when addressing home care safety for older people with dementia, the focus should be on providing targeted education programs and support services for family caregivers of older people with dementia.

Associations between the signing status of family doctor contract services and cervical cancer screening behaviors: a cross-sectional study in Shenzhen, China

BACKGROUND

As a core part of the primary healthcare system, family doctor contract services (FDCS) may help healthcare providers promote cervical cancer screening to the female population. However, evidence from population-based studies remains scant. This study aimed to investigate the potential associations between the signing status of FDCS and cervical cancer screening practices in Shenzhen, China.

METHODS

A cross-sectional survey among female residents was conducted between July to December 2020 in Shenzhen, China. A multistage sampling method was applied to recruit women seeking health services in community health service centers. Binary logistic regression models were established to assess the associations between the signing status of FDCS and cervical cancer screening behaviors.

RESULTS

Overall, 4389 women were recruited (mean age: 34.28, standard deviation: 7.61). More than half (54.3%) of the participants had signed up with family doctors. Women who had signed up for FDCS performed better in HPV-related knowledge (high-level rate: 49.0% vs. 35.6%, P<0.001), past screening participation (48.4% vs. 38.8%, P<0.001), and future screening willingness (95.9% vs. 90.8%, P<0.001) than non-signing women. Signing up with family doctors was marginally associated with past screening participation (OR: 1.13, 95%CI: 0.99-1.28), which tended to be robust among women with health insurance, being older than 25 years old at sexual debut, using condom consistently during sexual intercourse, and with a low level of HPV related knowledge. Similarly, signing up with family doctors was positively associated with future screening willingness (OR: 1.68, 95%CI: 1.29-2.20), which was more pronounced among women who got married and had health insurance.

CONCLUSIONS

This study suggests that signing up with family doctors has positive associations with cervical cancer screening behaviors among Chinese women. Expanding public awareness of cervical cancer prevention and FDCS may be a feasible way to achieve the goal of cervical cancer screening coverage.

Development of a performance measurement system for general practitioners' office in China's primary healthcare

BACKGROUND

General practitioners are the main providers of primary care services. To better strengthen the important role of general practitioners in primary healthcare services, China is promoting the general practitioners' office system. There is a lack of well-accepted methods to measure the performance of general practitioner offices in China. We thus aim to develop a systematic and operable performance measurement system for evaluating the general practitioner's office.

METHODS

We establish an index pool of the performance measurement system of general practitioners' offices by a cross-sectional study and the literature research method and adopt the focus group method to establish the preliminary system. The Delphi method is then used to conduct three rounds of consultation to modify indices, which aims to form the final indicator system. We determine the weight of each index by the analytic hierarchy process method, which together with the final indicator system constitutes the final performance measurement system. Finally, we select three offices from three different cities in Sichuan Province, China, as case offices to conduct the case study, aiming to assess its credibility.

RESULTS

Our results show that the first office scored 958.5 points, the second scored 768.1 points, and the third scored 947.7 points, which corresponds to the reality of these three offices, meaning that the performance measurement system is effective and manoeuvrable.

CONCLUSIONS

Our study provides support for standardizing the functions of China's general practitioner's office, improving the health service quality of generalists, and providing a theoretical basis for the standardization of the general practitioner's office.

Awareness of initiative practice for health in the Chinese population: A questionnaire survey based on a network platform

BACKGROUND

In 2016, the Chinese government issued the Healthy China 2030 plan, which also produced the initiative practice for health (IPFH) concept. However, people’s knowledge and awareness of the IPFH are unclear.

AIM

To investigate awareness of IPFH in the Chinese population and explore the relevant influential factors.

METHODS

An internet-based self-designed questionnaire survey was used to collect respondents’ demographic characteristics and awareness of health and the IPFH from March 26 to April 18, 2020. IPFH consciousness was assessed by the scores for different related questions. The Student’s t test, the Chi-square test, and multiple logistic regression analysis were performed to analyze the differences and influencing factors.

RESULTS

A total of 2678 valid questionnaires were collected. Of the respondents, 973 (36.3%) had heard of the IPFH concept. In addition, 89.5% of participants agreed with the view that the IPFH is beneficial to improving quality of life, and over half thought that a regular schedule, a reasonable diet, tobacco and alcohol control, a cheerful mood, specific life goals and plans, taking the initiative to accept health-related education and implement health knowledge, good interpersonal relationships, and regular physical examinations were closely related to the IPFH. The majority of respondents paid attention to their health and usually obtained health-related knowledge via social media and were also willing to promote the IPFH. Most of the participants underestimated the role of hospitals, family doctors, and health managers in promoting the IPFH. Age, monthly income, and medical-related work experience were the influencing factors for IPFH awareness.

CONCLUSION

The Chinese population has limited knowledge of the IPFH. People with strong IPFH awareness are older, earn more, and have medical-related work experience.

Stated preferences for family doctor contract services: a survey of the rural elderly in Anhui Province, China

OBJECTIVE

A number of factors contribute to the utilisation of family doctor contract services (FDCS) in China. This study aims to measure the preferences of the elderly for the FDCS and identify the key factors (and their relative importance) that may guide policymakers in more accurately providing the FDCS.

PARTICIPANTS AND METHODS

A discrete choice experiment was performed to elicit the preferences for FDCS among the rural elderly in China. Attributes and levels were established based on qualitative methods. Four attributes were included: service type, service package, physician's reputation and annual contract costs. A D-efficient design was used to create a set of profiles that represented FDCS. The survey was conducted face to face using a sample of participants aged 60 and above in rural areas of Anhui Province. The data were analysed using a latent class logit (LCL) model.

RESULTS

A total of 545 valid questionnaires were included in the analysis. The average age of the participants was 69.44 (SD 5.80). Two latent classes were identified with the LCL model. All four attributes proved statistically significant at the level of both the population mean and the two classes. The rural elderly showed a preference for FDCS with a relatively good reputation, lower annual contract costs, the basic service with the add-on of chronic disease service and home visit. Age, gender, education, self-reported health status and the number of chronic diseases were found to be associated with latent class membership.

CONCLUSION

In this study, the physician's reputation had the largest impact on the rural elderly's choice of FDCS. Policy recommendations included the need to strengthen family doctor team training, devote greater attention to improving the family doctor's medical skills and service approaches, and increased FDCS efficiency for the care of the rural elderly.

Factors Influencing the Implementation of Foreign Innovations in Organization and Management of Health Service Delivery in China: A Systematic Review

Background: China has been encouraged to learn from international innovations in the organization and management of health service delivery to achieve the national health reform objectives. However, the success and effectiveness of implementing innovations is affected by the interactions of innovations with the Chinese context. Our aim is to synthesize evidence on factors influencing the implementation of non-Chinese innovations in organization and management of health service delivery in mainland China. Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched seven databases for peer-reviewed articles published between 2009 and 2020. Data were analyzed and combined to generate a list of factors influencing the implementation of foreign innovations in China. The factors were classified in the categories context, system, organization, innovation, users, resources, and implementation process. Results: The 110 studies meeting the inclusion criteria revealed 33 factors. Most supported by evidence is the factor integration in organizational policies, followed by the factors motivation & incentives and human resources. Some factors (e.g., governmental policies & regulations) were mentioned in multiple studies with little or no evidence. Conclusion: Evidence on factors influencing the implementation of foreign innovations in organization and management of health service delivery is scarce and of limited quality. Although many factors identified in this review have also been reported in reviews primarily considering Western literature, this review suggests that extrinsic motivation, financial incentives, governmental and organizational policies & regulations are more important while decentralization was found to be less important in China compare to Western countries. In addition, introducing innovations in rural China seems more challenging than in urban China, because of a lack of human resources and the more traditional rural culture.

The effect of patient perceived involvement on patient loyalty in primary care: The mediating role of patient satisfaction and the moderating role of the family doctor contract service

BACKGROUND

The Chinese government has taken many incentives to promote the implementation of the family doctor (FD) contract service; however, whether primary health care providers establishing a strong relationship with patients that shapes their loyalty is still unknown. Under this circumstance, drawing the public attention to patient loyalty in primary care and clarifying the underlying mechanism of loyalty is imperative to the development of primary care.

OBJECTIVE

To analyse the effect of patient perceived involvement on patient loyalty in primary care, investigate the mediating role of patient satisfaction, and explore the moderating role of the FD contract service on the relationship between patient perceived involvement and patient loyalty.

METHODS

A cross-sectional questionnaire survey of patients in primary health facilities was conducted in Jilin province of China. Participants comprised 1334 patients selected via a multi-stage sampling method.

RESULTS

Patient perceived involvement not only had a direct positive impact on patient loyalty but also had an indirect effect on patient loyalty via patient satisfaction. Furthermore, for patients who contracted with FDs, patient perceived involvement had a higher direct effect and indirect effect on patient loyalty when compared with patients who did not contract with FDs.

CONCLUSIONS

Our findings suggest that health managers should encourage patients to participate in medical visits to improve patient satisfaction. Additionally, customised and tailored health services that meet individuals' specific needs and preferences should be designed and implemented to attract more patients to contract the FD contract service.

Do older people with cardiovascular-metabolic multimorbidity prefer to sign contracts for family doctor services? Evidence from a cross-sectional study in rural Shandong, China

Background

Family doctor policy is an important part of deepening healthcare reform in China. The study aimed to explore the association between cardiovascular-metabolic multimorbidity and the status of signing a contract for family doctor services among the older people in rural Shandong, China.

Methods

A cross-sectional study was conducted in 3 cities of Shandong province, China. A total of 1395 rural residents over 60 years of age were included in this study using a multistage stratified random sampling method. Covariates included demographic and socioeconomic characteristics, health-related characteristics, health service utilization, and awareness of family doctor contract services. The univariate and multivariate regression logistic analysis was used to analyze the data.

Results

There were 28.2% of the rural older people contracted for the family doctor contract services. The contract rate of seniors with cardiovascular-metabolic multimorbidity was statistically higher than those without cardiovascular-metabolic multimorbidity (OR = 1.67, 95%CI, 1.21-2.32) after controlling for confounding factors. In addition, occupation, physical activities, self-rated health status, distance from the village clinic, the awareness of family doctor contract services were found to be associated with the signing behavior among the rural older adults.

Conclusion

This study demonstrated that the rural older people with cardiovascular-metabolic multimorbidity had a higher family doctor contract rate than those without cardiovascular-metabolic multimorbidity, and there was a gap between the current signing rate and the policy goal. To increase the rate of signing for family doctor contract services, the government should take joint efforts to expand the publicity and coverage, and give priority to meeting the healthcare demands of rural older adults with cardiovascular-metabolic multimorbidity.

Willingness of patients with chronic disease in rural China to contract with family doctors: implication for targeting characteristics

BACKGROUND

Rural residents with chronic conditions have a stronger need for health services, which should make using family doctor contract services a priority. This study aimed to evaluate the rate of willingness among rural residents with chronic conditions to contract with family doctors and examine its determinants.

METHODS

A cross-sectional study was conducted from May, 2018 to June, 2018 in Shandong Province in China. A total of 769 rural unsigned residents with chronic conditions were included in the analysis. Using the Andersen model as the theoretical framework, logistic regression models were chosen to analyse the factors associated with willingness to contract with family doctors.

RESULTS

This study found that the rate of willingness to contract with family doctors among chronic patients in rural Shandong was 46.7%. A higher willingness was observed in those living a further distance from the village clinic (more than 600 m: OR = 1.85, 95%CI =1.17-2.93), having received publicity for family doctor contract services (OR = 1.71, 95% CI = 1.06-2.76), reporting need for utilizing a chronic disease management program (OR = 3.36, 95% CI = 2.20-5.23), and reporting need for higher medical insurance reimbursement (OR = 1.91, 95% CI = 1.28-2.83).

CONCLUSIONS

The prevalence of contract willingness was relatively low among unsigned rural residents with chronic conditions in rural Shandong, China. The need factors were powerful factors affecting their willingness to contract with family doctors. The government should therefore strengthen targeted publicity and education to rural residents with chronic conditions and provide targeted healthcare services, such as chronic disease management programs and medical services with higher reimbursement rates, to promote their willingness to contract with family doctors.

Who is willing to participate in and provide Family Doctor Contract Service?: A cross-sectional study based on the medical staff's perspective in China

China encourages medical staff from non-primary hospitals (higher-level hospitals) to participate in and provide Family Doctor Contract Service (FDCS) due to a lack of primary medical resources in community health service centers. This study aims to explore the factors affecting the willingness of family doctor contracting from the tertiary hospital medical staff's perspective. An anonymous self-administered survey was conducted among the medical staff from tertiary hospitals in Hangzhou, Zhejiang Province. Information of the socio-demographic characteristics, the willingness of participating in FDCS and its related reasons, and factors that might affect willingness were investigated. A multivariate logistic regression was used to identify the statistically significant variables associated with willingness. A total of 346 medical staff were recruited in the survey, and 37.86% of them were willing to participate in and provide FDCS. Medical staff with the following characteristics had stronger will: (1).. with higher education level; (2).. having better knowledge with family doctor; (3).. being more attracted by the national policy of FDCS; (4).. thinking it help for income increase. The majority of willing doctors (25.95%) believed that participating in FDCS could help them achieve their personal value, and the reason chosen most for unwilling reason was “low income and unrealized personal value (32.21%).” It is necessary for the government to establish the essential matching mechanisms to guarantee the development of the family doctor, including increasing the final financial support for primary health facilities, and developing the national incentive mechanism for family doctors.

Cost-effectiveness analysis of a community-based colorectal cancer screening program in Shanghai, China

OBJECTIVE

This study investigated the cost-effectiveness of a community-based colorectal cancer-screening program (C-CRCSP) in Shanghai, China, among the residents in the urban, suburban and rural areas.

METHODS

A Markov model was constructed to evaluate the cost-effectiveness of a 25-year annual C-CRCSP including 100 000 populations. Cost-effectiveness was determined by the incremental cost-effectiveness ratio (ICER); referring to either life-years gained, or quality-adjusted life-years (QALYs) gained. The threshold was gross domestic product per capita. Univariate and multivariate sensitivity analyses were performed to investigate the influence of compliance, prevalence, technological performance, medical cost and annual cost discount rate (3.5%) on ICER. A probabilistic sensitivity analysis evaluated the probability of the cost-effectiveness of C-CRCSP at different maximum acceptable ceiling ratios.

RESULTS

Compared with no screening, the C-CRCSP resulted in total gains of 7840 QALYs and 2210 life-years (LY), at a total cost of CNY 58.54 million; that is, the ICER were CNY 7460/QALYs and CNY 26650/LY. Stratifying by residency, the cumulative gains in QALYs and LY were estimated to be the lowest in the urban populations compared with the rural and suburban populations. The cost for the urban population was 3-fold and 6-fold that of the suburban and rural populations. The ICER for QALYs ranged from 2180 (rural) to 16 840 (urban).

CONCLUSION

The cost-effectiveness of a C-CRCSP in Shanghai was most favorable for the rural population, while the urban population benefits less in terms of QALYs. ICER could be enhanced by measures that increase compliance.

The Awareness and Attitude of Contracted Service Among General Medical Practitioners in Community Health Service Centers in Urban China: A Cross-Sectional Study

This study aims to explore the attitude, willingness, and satisfaction with contracted service (CS) among staff in community health service (CHS) centers in urban China and to explore the associated factors of satisfaction with CS. From August 2016 to July 2017, five CHS centers in three provinces of China were selected. Setting-level information was collected by official document review; and personal information on demographic characteristics, awareness, willingness, and attitude of CS among staff was collected by questionnaire survey. Univariate and multivariable logistic regression models were fitted to explore the associated factors of satisfaction with CS. Multiple correspondence analysis (MCA) was used to visually demonstrate the correlations among category data related with satisfaction with CS. The CS signing rates were 30.78, 12.72, 22.20, 14.32, and 21.19% in the five CHS centers. A total of 286 staff included family doctors (40.91%), nurses (31.12%), and others (27.97%) completed the survey. For the sense of self-worth, 86.01% (246/286) participants hold a positive attitude. The predominant barrier of CS signing was caused by the work pressure due to CS performance assessment (48.60%, 139/286). About 30% of family doctors and nurses reported a heavy work pressure, and more than 30% of doctors had great feeling of fatigue. Notably, 51.69% family doctors would like to change their job in the future. Compared with other staff, family doctors were more likely to be unsatisfied with CS (OR: 2.793, 95% CI: 1.155–6.754, p = 0.022). Participants in Sichuan province have lower satisfaction than other places. The MCA yielded similar factors consistent with multivariable results of clustering with different levels of CS satisfaction. Our study revealed that the CS coverage and satisfaction among staff from the primary healthcare system varied geographically and are associated with professional field, workload, and pressure. Measures that aim to promote the stability of primary care human resource should be considered in the future.

Utilization of community health care centers and family doctor contracts services among community residents: a community-based analysis in Shenzhen, China

BACKGROUND

Family doctor contract services (FDCS) began in China in 2016. Shenzhen, one of the most developed cities in China, also implemented a family doctor (FD) policy in 2017. The objectives of this study were to identify the impact of awareness of FDCS and signing service contracts with FDs on utilization of community health care centers (CHCs).

METHODS

Cross-sectional secondary data based on residents living in Luohu district was used for analysis. Descriptive analysis was conducted to identify utilization of CHCs by awareness of FDCS and signing service contracts with FDs, respectively. Linear probability models (LPM) were used to determine the association of utilization of CHCs with awareness of FDCS and signing service contracts with FDs, respectively.

RESULTS

Among 1205 adults included in the analysis, 27 % of the participants knew about the FDCS, 5 % signed with FD, and 20 % had chronic disease. Both awareness of the FDCS and signing service contracts with FDs significantly increased the probability of using CHCs as a first choice.

CONCLUSIONS

This study provided evidence that both awareness of FDCS and signing service contracts with FDs had a positive impact on utilization of primary health care services at the community level. More interventions to improve awareness of FDCS are needed to increase the utilization of primary health care services.

The Path Analysis of Family Doctor's Gatekeeper Role in Shanghai, China: A Structural Equation Modeling (SEM) Approach

Studies globally have provided substantial evidence that PHC could conduct doctor-visiting behaviors, control medical expense, and improve population health. This study aimed to map how family doctor (FD) in Shanghai achieved gate-keeper goals including health management, medical expense control, and conducting ordered doctor-visiting behavior. A total of 2754 and 1995 valid questionnaires were collected in 2013 and 2016 respectively in Shanghai. The data were analyzed using structural equation modeling (SEM). Invariance analysis was also performed for 2 waves of data. We found that the coefficient of cognition on health management (β₅ = 0.26, P < .05) was larger than that of signing with FD (β₄ = 0.06, P < .05). SEM model also showed that first-contact at community health service center (CHSC) had a positive effect on health management (β₆ = 0.30, P < .05), and the latter also affected health management results positively (β₈ = 0.39, P < .05), suggesting that the path for FD was through first-contact and health management. Besides, the gate-keeper role of medical expense control was significant through the first-contact (β₁₀ = −0.12, P < .05) mediation rather than health management (β₉ = 0.03, P > .05). The model fit was acceptable (RMSEA = 0.033). A “cognition-behavior-outcomes (health and medical expense)” path of FD’s gate-keeper role was found. It is necessary to consolidate FD contracted services rather than reimbursement discount the latter of which is proved to be unsustainable.

Residents' Willingness to Maintain Contracts with Family Doctors: a Cross-sectional Study in China

BACKGROUND

Most previous studies of the family doctor contract services (FDCS) evaluated its quality by using residents' signing rates, awareness, and satisfaction. We hypothesize that renewal willingness could be another important indicator to examine the quality of FDCS.

OBJECTIVE

To measure residents' willingness to maintain contracts with family doctors and examine the influencing factors.

DESIGN

Cross-sectional study.

PARTICIPANTS

11,250 residents in 31 provincial administrative regions across China.

MAIN METHODS

A multistage stratified random sampling method was used to recruit participants. Univariate analysis, mixed-effect regression model analysis, and stepwise multivariate logistic regression analysis were performed to determine the influencing factors of residents' willingness to maintain contracts with family doctors.

KEY RESULTS

About 71.3% participants who contracted with and received healthcare services from family doctors were willing to maintain contracts with family doctors in China. Residents registering as local households (OR = 1.192, 95% CI = 1.039-1.368), enrolled in medical insurance (OR = 1.299, 95% CI = 1.011-1.668), reporting better health (OR = 1.246, 95% CI = 1.100-1.413), with shorter walking time to the nearest healthcare center (compared with > 30 min walking time, < 15 min: OR = 1.209, 95% CI = 1.003-1.458; 15-30 min: OR = 1.288, 95% CI = 1.124-1.475), and trusting in (OR = 4.403, 95% CI = 3.849-5.036) and satisfied with (OR = 18.514, 95% CI = 16.195-21.165) their family doctors had significantly higher willingness to maintain contracts with family doctors.

CONCLUSIONS

Residents' willingness to maintain contracts with family doctors could be another evaluation indicator of the quality of FDCS in China. Improving the accessibility and quality of healthcare services from family doctors may increase residents' willingness to keep contracts with family doctors and promote the implementation of FDCS.

The effects of family physician-contracted service on health-related quality of life and equity in health in China

Background

Family physician-contracted service (FPCs) has been recently implemented in Chinese primary care settings. This study was aimed at measuring the effects of FPCs on residents’ health-related quality of life (HRQoL) and equity in health among the Chinese population.

Methods

The study data was drawn from the 2018 household health survey (Shaanxi Province, China) using multistage, stratified cluster random sampling. We measured HRQoL using EQ-5D-3L based on the Chinese-specific time trade-off values set. Coarsened exact matching (CEM) technique was used to control for confounding factors between residents with and without a contracted family physician. The concentration index (C) was calculated to measure equity in health.

Results

Individuals with a contracted family physician had significantly higher HRQoL than those without, after data matching (0.9355 vs. 0.8995; P <  0.001). Additionally, the inequity in HRQoL among respondents with a contracted family physician was significantly lower than those without a contracted family physician (Cs of EQ-5D utility score: 0.0084 vs. 0.0263; p <  0.001).

Conclusions

This study highlights the positive effects of FPCs on HRQoL and socioeconomic-related equity in HRQoL. Future efforts should prioritize the economically and educationally disadvantaged groups, the expansion of service coverage, and the competency of family physician teams to further enhance health outcome and equity in health.

Disease composition and epidemiological characteristics of primary care visits in Pudong New Area, Shanghai: a longitudinal study, 2016-2018

OBJECTIVES

This study aims to analyse the disease composition of primary care visits rather than specialist visits, the former of which had scarcely been studied. We adopted specific disease classification (International Statistical Classification of Diseases and Related Health Problems, 10th Revision), disease system and communicable/non-communicable/injury disease classification, and variations of sex and age were also analysed.

SETTING

We extracted data from all community health service centres (CHSCs) and community health service stations in Pudong, Shanghai, from 2016 to 2018 using the electronic health record systems of the Pudong health information centre.

PARTICIPANTS

Our data included all 46 720 972 primary care visits from 2016 to 2018 in CHSCs in Pudong.

RESULTS

We found that the top five diseases in primary care visits continued to be primary hypertension, problems related to medical facilities, chronic ischaemic heart disease, unspecified diabetes mellitus and acute upper respiratory infection. Lipoprotein metabolism disorder visits continued to increase over the study years. The numbers and proportions of patients with hypertension and unspecified diabetes were higher among men than women, and other cerebrovascular diseases were higher among women than men. The top five disease systems were circulatory system diseases, respiratory system diseases, endocrine/nutritional/metabolic diseases, factors influencing health status and digestive system diseases. The rankings of respiratory system and endocrine/nutritional/metabolic diseases rose over time. Non-communicable diseases (NCDs) accounted for approximately 90% of the primary care visits-a much higher percentage than other causes. The top five NCDs in primary care visits were cardiovascular and circulatory diseases, musculoskeletal disorders, diabetes, digestive diseases and urogenital diseases. Compared with women, men suffered from cardiovascular diseases at an earlier age.

CONCLUSIONS

Different from specialist visits, common diseases, especially NCDs, were the main disease composition of current primary healthcare visits while the former focused on intractable diseases such as tumours, indicating that primary healthcare had played the role of gatekeeper of the healthcare system.

Can Health Disparity Be Eliminated? The Role of Family Doctor Played in Shanghai, China

Background: Globally, the elimination of health disparity is a significant policy target. Primary health care has been implemented as a strategy to achieve this target in China for almost 10 years. This study examined whether family doctor (FD) policy in Shanghai contributed to eliminating health disparity as expected. Methods: System dynamics modeling was performed to construct and simulate a system of health disparity formation (business-as-usual (BAU) scenario, without any interventions), a system with FD intervention (FD scenario), and three other systems with supporting policies (Policy 1/Policy 2/Policy hybrid scenario) from 2013 to 2050. Health disparities were simulated in different scenarios, making it possible to compare the BAU results with those of FD intervention and with other policy interventions. Findings: System dynamics models showed that the FD policy would play a positive role in reducing health disparities in the initial stage, and medical price control—rather than health management—was the dominant mechanism. However, in this model, the health gap was projected to expand again around 2039. The model examined the introduction of two intervention policies, with findings showing that the policy focused on socioeconomic status improvement would be more effective in reducing health disparities, suggesting that socioeconomic status is the fundamental cause of these disparities. Conclusions: The results indicate that health disparities could be optimized, but not eliminated, as long as differences in socioeconomic status persists.

Which Matters More for Medication Adherence Among Disabled People in Shanghai, China: Family Support or Primary Health Care?

Most disabled people have poor health status. They often have multiple diseases requiring continual medication. This study aimed to explore the factors associated with medication adherence among disabled people, with a particular focus on the factors associated with family and primary health care support. A questionnaire survey was conducted among 226 disabled individuals. The analysis was performed using an ordered logistic regression model, including 4 categories of predictor variables. We found that the community health service center played a positive role in improving medication adherence, whereas the role played by the participant’s family was more complicated. Specifically, those obtaining a brochure were more likely to have higher medication adherence (odds ratio [OR] = 2.732, 95% confidence interval [CI] = 1.349-5.532). Compared with those who were married, widowed participants (OR = 0.207, 95% CI = 0.069-0.620) and divorced participants (OR = 0.330, 95% CI = 0.057-1.914) had lower odds of having greater adherence, whereas the odds of having greater adherence for single participants were 1.679 times the same odds for married participants (OR = 1.679, 95% CI = 0.668-4.224). The odds of having greater medication adherence for participants receiving help with prescriptions from a family member were almost 60% lower than these odds for those who did not receive this kind of help (OR = 0.460, 95% CI = 0.216-0.979). Thus, the role played by participants’ family members was both protective and damaging, whereas the role of the community health service center was clearer. These findings merit further exploration.

Factors associated with contracted services of Chinese family doctors from the perspective of medical staff and consumers: a cross-sectional study

Background

The family doctor system has developed rapidly all over the world, and in the past few years, China has actively explored family doctor-type contracted services. This study aimed to explore the related factors of Contracted Family Doctors Services (CFDS) from the perspectives of medical staff and consumers, and to provide a stronger basis for the development and promotion of CFDS.

Methods

A combination of quantitative and qualitative methods were used in this study. A self-reported questionnaire was designed through a literature analysis, group discussions, expert consultations and a pre-investigation, and conducted among community health service providers in 12 community health service centres across four provinces of China. A total of 389 participants participated, and 320 valid questionnaires were obtained, with an effective response rate of 82.3%. A total of 36 consumers participated in in-depth interviews, and the effective rate was 100.0%. An exploratory factor analysis, a confirmatory factor analysis, inductive methods, and expert consultations were used to analyse the related factors of CFDS.

Results

The related factors of CFDS from the perspectives of medical staff were divided into four dimensions, with the following weighting coefficients: national government factors (31.9%), community health service agency factors (24.7%), consumer-related factors (22.6%), and contracted doctor-related factors (20.8%). The related factors of CFDS from the perspectives of consumers were divided into four dimensions, with the following frequency sequence: national government factors, contract doctor-related factors, community health service agency factors, and consumers-related factors. National government factors played an important role in CFDS from the perspectives of medical staff and consumers.

Conclusions

The related factors of CFDS were the same from the perspective of medical staff and consumers, but the weight of each factor was different. The development of CFDS is inseparable from the support of policies. It is suggested that the government should strengthen the publicity of CFDS, expand the coverage, introduce personalised contract programs that meet the needs of different groups, and promote the rapid development of CFDS.

Facilitators and barriers to implement the family doctor contracting services in China: findings from a qualitative study

OBJECTIVE

To identify the facilitators and barriers to implement family doctor contracting services in China by using Consolidated Framework for Implementation Research (CFIR) to shed new light on establishing family doctor systems in developing countries.

DESIGN

A qualitative study conducted from June to August 2017 using semistructured interview guides for focus group discussions (FGDs) and individual interviews. CFIR was used to guide data coding, data analysis and reporting of findings.

SETTING

19 primary health institutions in nine provinces purposively selected from the eastern, middle and western areas of China.

PARTICIPANTS

From the nine sampled provinces in China, 62 policy makers from health related departments at the province, city and county/district levels participated in 9 FGDs; 19 leaders of primary health institutions participated in individual interviews; and 48 family doctor team members participated in 15 FGDs.

RESULTS

Based on CFIR constructs, notable facilitators included national reform involving both top-down and bottom-up policy making (Intervention); support from essential public health funds, fiscal subsidies and health insurance (Outer setting); extra performance-based payments for family doctor teams based on evaluation (Inner setting); and positive engagement of health administrators (Process). Notable barriers included a lack of essential matching mechanisms at national level (Intervention); distrust in the quality of primary care, a lack of government subsidies and health insurance reimbursement and performance ceiling policy (Outer setting); the low competency of family doctors and weak influence of evaluations on performance-based salary (Inner setting); and misunderstandings about family doctor contracting services (Process).

CONCLUSIONS

The national design with essential features including financing, incentive mechanisms and multidepartment cooperation, was vital for implementing family doctor contracting services in China. More attention should be paid to the quality of primary care and competency of family doctors. All stakeholders must be informed, be involved and participate before and during the process.

Residents' Awareness of Family Doctor Contract Services, Status of Contract with a Family Doctor, and Contract Service Needs in Zhejiang Province, China: A Cross-Sectional Study

In China, family doctor services originated in 2009. After two years, the Chinese government proposed the establishment of a family doctor contract system suitable for China's national conditions. Then, in 2016, a multi-department jointly issued an important document, which further clarified the development goals of family doctor contract services in the next five years. Zhejiang Province has been exploring responsible doctor contract services since 2012, which was promoted throughout the province in 2015.

OBJECTIVES

The aim of this study was to investigate the residents' awareness of Zhejiang Province, China, of family doctor contract services, the status of signing such a contract, and the demand for service items in the contracted service package. Further, we sought to explore the relevant influential factors in order to provide a reference and evidence-based recommendations for the further development of family doctor contract services.

DESIGN

We enrolled 3960 residents from nine counties in Zhejiang Province using a multistage stratified random sampling method. A survey using a self-designed questionnaire was used to collect the demographic data, residents' awareness of family doctor contract services, the status of contracting, and demand for different items from October to December 2017. Data were analyzed by SPSS 21.0.

RESULTS

In total, 3871 residents returned valid questionnaires, with a response rate of 97.75%. The awareness rate of residents of family doctor contract services was 71.58% (2771/3871). Age, education level, and chronic medical history status were the influencing factors affecting residents' awareness. The contracted rate was 50.43% (1952/3871). Age, education level, personal monthly income, chronic disease history, and awareness of family doctor contract services were the influencing factors. Residents who have a contract with family doctors have a higher demand for family doctor contract services, and different residents have different needs for the project because of their physical condition, education level, marital status, household registration, and personal monthly income level. The top three needs of the residents for contracted services were health consultation (84.64%), regular physical examination (81.71%), and increasing the proportion of medical insurance reimbursements (80.06%).

CONCLUSIONS

The awareness rate of family doctor contract services and the contracting rate are unsatisfactory among residents of Zhejiang Province. It is suggested that the government should more heavily publicize family doctor contract services, expand the coverage, introduce personalized contract schemes to meet the needs of different groups, and promote the rapid development of family doctor contract services in Zhejiang Province.