The impact of family doctor system on patients' utilisation of general practitioner in primary care facilities-Evidence from Hangzhou, China

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.

Acceptance of family doctors among residents in China: a cross-sectional study

Objectives

This study aimed to investigate the level of acceptance of family doctors (FDs) exhibited by residents in China.

Methods

A cross-sectional study based on a structured self-administered questionnaire was conducted to investigate residents in eastern, central, and western China between September and December 2021. A multivariable stepwise logistic regression model was employed to identify the factors associated with health-seeking behavior after the signing of agreements concerning family doctor contract services (FDCS) as well as residents' willingness to change FDs.

Results

Among the 2,394 respondents included in this research, 55.8% sought primary care from their FDs when they became ill, whereas 9.7% expressed a willingness to change FDs. Residents who reported high levels of satisfaction with FDCS [odds ratio (OR) = 2.162] and trust in FDs (OR = 1.430) were more likely to seek initial help from FDs. In addition, residents from central China (OR = 0.546) and western China (OR = 0.704) and those who exhibited a high level of trust in FDs (OR = 0.238) were less likely to change FDs.

Conclusion

The level of FD acceptance among Chinese residents was relatively high. Satisfaction with FDCS and trust in FDs were associated with the acceptance of FDs among residents. FDs should make efforts to enhance the quality of health services as well as the overall health experience of residents.

GP's GP, general practitioner's health and willingness to contract family doctors in China: a national cross-sectional study

OBJECTIVES

General practitioners are trained to care for patients with a high level of responsibility and professional competency. However, there are few reports on the physical and mental health status of general practitioners (GPs) in China, particularly regarding help seeking and self-treatment. The primary aims of this study were to explore GPs' expectations of their own family doctors and their reflection on role positioning, and to explore the objective factors that hinder the system of family doctors.

STUDY DESIGN

Cross-sectional study.

METHODS

We conducted an online survey of Chinese GPs. Descriptive statistics were used to summarize the findings.

RESULTS

More than half of the participants (57.20%) reported that their health was normal over the past year. A total of 420 participants (23.35%) reported having chronic diseases. For sleep duration, 1205 participants (66.98%) reported sleeping 6-8 h per day; 473 participants (26.29%) reported chronic insomnia. Two hundred thirty-one participants (12.84%) had possible depression. A total of 595 (33.07%) participants reported that they had contracted a fixed family doctor. In terms of preventing themselves from contracting for a family doctor, the following factors were identified: lack of sufficient time (54.81%), could solve obstacles themselves (50.97%), and embarrassment (24.24%). The proportion of the contract group (12.44%) taking personal relationship as a consideration was higher than that of the non-contract group (7.64%) (χ2 = 10.934 P = 0.01). Most participants (79.90%) in the non-signed group reported never having seen a family doctor. In terms of obstacles, more than half of the signed group thought that they could solve obstacles themselves, while the non-signed group (39.20%) was less confident in the ability of family doctors than the signed group (29.75%) (χ2 = 15.436, P < 0.01).

CONCLUSIONS

GPs work under great pressure and lack of self-care awareness, resulting in an increased prevalence of health conditions. Most GPs did not have a regular family doctor. Having a family doctor with a fixed contract is more conducive to the scientific management of their health and provides a reasonable solution to health problems. The main factors hindering GPs from choosing a family doctor were time consumption, abilities to solve obstacles themselves, and trust in the abilities of GPs. Therefore, simplifying the process of family doctor visits, Changing the GPs' medical cognition, and strengthening the policy of GP training would be conducive to promoting a family doctor system that enhances hierarchical diagnosis and treatment. International collaboration could integrate GP health support into global healthcare system.

Strategies for General Practitioners to Enhance Cancer Care: Insights from a Patient-Centered Questionnaire Survey in Southern China

Background

The incidence of cancer is increasing, and cancer survivors are also growing exponentially. Cancer is defined as a new chronic disease. Nevertheless, the management of cancer in the form of chronic diseases in China is still in its infancy, without a standardized care model.

Objective

This study aimed to explore the current status of management of cancer care from the patient's perspective.

Methods

This cross-sectional study was a questionnaire survey of patients diagnosed with cancer, including information of the current situation of daily medical consultation, status of comorbidity, and expectations of seeking cancer care in future. Chi-square test and logistic regression analysis were used to explore the factors influencing patients' choice of cancer management mode.

Results

A total of 200 cancer patients were included in the study. The majority (n = 150) of cancer patients chose an oncologist in a tertiary hospital for cancer care. Difficulty in registration (45%), time-consuming (34.5%), repeated examinations (34.5%) and different treatment opinions (12.0%) were the main difficulties they encountered currently during tertiary hospital visits. In community hospital, lack of trust in general practitioners (n = 33) and the necessary drugs or testing items in community hospitals (n = 47) were the main difficulties during their visits. Logistic regression analysis showed that male (OR = 2.737, 95% CI, 1.332-5.627, p = 0.006) and elderly patients (OR = 3.186, 95% CI, 1.172-8.661, p = 0.023) were more likely to choose general practitioners (GPs) in community hospitals. Twenty-nine (14.5%) patients hope to have an integrated multidisciplinary management in tertiary and community hospitals with the active participation of GPs for cancer care.

Conclusion

Improving drug availability, equipment and quality of cancer care services can help to increase cancer patients' recognition of community hospital. In addition, the multidisciplinary management integrated tertiary hospitals and communities with the participation of GPs is a worth exploring mode that improves the management of cancer care.

The short- and long-term effects of community-family-doctor-based type 2 diabetes self-management interventions

OBJECTIVES

The popularity of contracted family doctor services in China has been growing in recent years, but community-family-doctor-based type 2 diabetes mellitus (T2DM) intervention programs have yet to be adequately studied. This study was to evaluate the short- and long-term effects of community-family-doctor-based self-management interventions for T2DM and to explore strategies for long-term glycemic control.

STUDY DESIGN

This was a randomized controlled trial.

METHODS

A total of 144 eligible participants were randomly assigned to intervention and control groups. The control group received only routine community diabetes care, and the intervention group received community-family-doctor-based interventions involving the same standard of care. The interventions lasted for 3 months, and the follow-up was continued for 15 months. Intention-to-treat analysis and generalized estimation equations were then used to determine the short- and long-term effects of the interventions on glycated hemoglobin (HbA1c), diabetes self-management, and medication adherence.

RESULTS

There were statistically significantly greater improvements in all aspects of the intervention group after 3 months of intervention. Compared with baseline, changes in the attitude (β = 0.384, 95% confidence interval [CI; 0.194, 0.574], P < 0.001), practice (β = 1.751, 95% CI [0.762, 2.739], P = 0.001), and knowledge, attitudes, practice total scores (β = 2.338, 95% CI [0.682, 3.995], P = 0.006) of patients in the intervention group were statistically significant after 15 months, and the HbA1c (8.19 ± 1.73%), knowledge (16.42 ± 3.21), and medication adherence (5.53 ± 1.76) scores were slightly better than those at baseline, although not statistically significant (P > 0.05).

CONCLUSIONS

T2DM self-management interventions based on community family doctors improved patients' HbA1c, diabetes self-management, and medication adherence, did not do so significantly in the long term.

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.

Can family doctor system improve health service utilization for patients with hypertension and diabetes in China? A difference-in-differences study

BACKGROUND

Family doctors, serving as gatekeepers, are the core of primary health care to meet basic health needs, provide accessible care, and improve attainable health. The study objective was to evaluate the impact of the family doctor system on health service utilization among patients with hypertension and diabetes in China.

METHODS

Difference-in-Differences (DID) models are constructed to estimate the net effect of the family doctor system, based on the official health management records and medical insurance claim data of patients with hypertension and diabetes in an eastern city of China.

RESULTS

The family doctor system significantly increases follow-up visits (hypertension patients coef. = 0.13, diabetes patients coef. = 0.08, both p < 0.001) and outpatient visits (hypertension patients coef. = 0.08, diabetes patients coef. = 0.05, both p < 0.001) among the contracted compared to the non-contracted. The proportion of outpatient visits in community health centers among the contracted significantly rose (hypertension patients coef. = 0.02, diabetes patients coef. = 0.04, both p < 0.001) due to significantly more outpatient visits in community health centers and fewer in secondary and tertiary hospitals. It also significantly mitigates the increase in inpatient admissions among hypertension patients but not among diabetes patients.

CONCLUSIONS

The examined family doctor system strengthens primary care, both by increasing follow-up visits and outpatient visits and promoting a rationalized structure of outpatient utilization in China.

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.

Choices of medical institutions and associated factors in older patients with multimorbidity in stabilization period in China: A study based on logistic regression and decision tree model

Background

As China's population ages, its disease spectrum is changing, and the coexistence of multiple chronic diseases has become the norm with respect to the health status of its elderly population. However, the health institution choices of older patients with multimorbidity in stabilization period remains underresearched. This study investigate the factors influencing the choices of older patients with multimorbidity to provide references for the rational allocation of healthcare resources.

Methods

A multistage, stratified, whole-group random-sampling method was used to select eligible older patients from September to December of 2022 who attended the Community Health Service Center of Guangdong Province. We adopted a self-designed questionnaire to collect patients' general, disease-related, social-support information, their intention to choose a healthcare provider. A binary logistic regression and decision tree model based on the Chi-squared automatic interaction detector algorithm were implemented to analyze the associated factors involved.

Results

A total of 998 patients in stabilization period were included in the study, of which 593 (59.42%) chose hospital and 405 (40.58%) chose primary care. Our binary logistic regression results revealed that age, sex, individual average annual income, educational level, self-reported health status, activities of daily living, alcohol consumption, family doctor contracting, and family supervision of medication or exercise were the principal factors influencing the choice of medical institutions for older patients with multimorbidity (p < 0.05). The decision-tree model reflected three levels and 11 nodes, and we screened a total of four influencing factors: activities of daily living, age, a family doctor contract, and patient sex. The data showed that the logistic regression model possessed an accuracy of 72.9% and that the decision tree model exhibited an accuracy of 68.7%. Prediction using the binary logistic regression was thus statistically superior to the categorical decision-tree model based on the Chi-squared automatic interaction detector algorithm (Z = 3.238, p = 0.001).

Conclusion

More than half of older patients with multimorbidity in stabilization period chose hospitals for healthcare. Efforts should be made to improve the quality of healthcare services and increase the medical contracting rate and recognition of family doctors so as to attract older patients with multimorbidity to primary medical institutions.

Effect of multiple chronic conditions on family doctor contracting in the elderly in China: the moderating role of socioeconomic status

BACKGROUND

China's family doctor contracting service is an important part of deepening the reform of the healthcare systems, aiming to further develop chronic disease management services, enhance the capacity of primary health care services and improve the health of residents. The purpose of this study was to explore the influence of multiple chronic conditions in the elderly on family doctor contracting and whether socioeconomic status played a moderating role.

METHODS

A cross-sectional survey was conducted in Beijing, China. A total of 1814 elderly people over 60 years old were included in this study using a whole-group sampling method. The univariate analysis and logistic regression analysis was used to analyze the data.

RESULTS

21.72% of the elderly signed up with family doctors. The multiple chronic conditions was a factor influencing the elderly to sign up with family doctors (OR = 1.44, 95%CI = 1.28-1.61), and the higher the degree of multiple chronic conditions, the stronger willingness to sign up. Socioeconomic status positively moderates the effect of multiple chronic conditions on signing. Also, physical activity intensity (OR = 1.25, 95%CI = 1.03-1.54) and willingness to first visit primary care facilities (OR = 1.38, 95%CI = 1.25-1.54) influenced the elderly to sign up with family doctors.

CONCLUSIONS

The elderly with a high degree of multiple chronic conditions, high activity intensity, and a strong willingness to first visit primary care facilities were more likely to sign up with family doctors. The health literacy of the elderly should be further improved, and publicity on the family doctor contracting service policies for the elderly with lower socioeconomic status should be strengthened to guide them to sign up with family doctors. At the same time, the service capacity of primary care facilities should be further improved to meet the health needs of the elderly.