Mutual referral: a survey of GPs in Beijing

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.

Fighting against COVID-19: preparedness and implications on clinical practice in primary care in Shenzhen, China

Background

The new coronavirus pneumonia (NCP) caused by COVID-19 has affected more than 46 million people worldwide. In China, primary care has played a vital role during the COVID-19 outbreak, and it is important to examine the challenges faced by general practitioners (GPs). This study investigated the roles, preparedness and training needs of GPs in China in managing the NCP outbreak. Based on the outcomes of the study, we hope to take lessons and identify how GPs could be supported in delivering their gatekeeping roles and clinical duties in times of infectious disease outbreak.

Methods

An online survey on the official website of Shenzhen Continuing Education Center. It included questions on GPs’ demographics, their awareness of COVID-19 and their preparedness in managing suspected cases of NCP, as well as referrals and their training needs. Conditional multi-variate logistic models were used to investigate the relationships between GPs’ preparedness, situational confidence and anxiety.

Results

GPs’ clinical practice was significantly affected. GPs endeavoured to answer a flood of COVID-19-related enquiries, while undertaking community preventive tasks. In addition to in-person consultations, GP promoted COVID-19 awareness and education through telephone consultations, physical posters and social media. Overall GPs in Shenzhen felt well supported with adequate Personal Protective Equipment (PPE) and resources from secondary care services. Higher levels of self-perceived preparedness (OR = 2.19; 95%CI, 1.04–4.61), lower level of anxiety (OR = 0.56; 95%CI, 0.29–1.09) and fewer perceived family worries (OR = 0.37; 95%CI, 0.12–1.12) were associated with better confidence in coping at work.

Conclusions

Training and supporting GPs while reducing their (and their families’) anxiety increase their confidence in delivering the important roles of gatekeeping in face of major disease outbreaks.

Patients' perspectives on the barriers to referral after telescreening for diabetic retinopathy in communities

OBJECTIVE

To understand the referral completion and explore the associated barriers to the referral after telescreening for diabetic retinopathy (DR) among people with vision-threatening DR (VTDR).

RESEARCH DESIGN AND METHODS

All participants with VTDR after DR telescreening in the communities completed the self-reported questionnaires to assess referral completion and their perspectives on referral barriers. Sociodemographic characteristics and perceived barriers related to incomplete referrals were identified by conducting univariate analysis and multiple logistic regression model. The final model was then built to predict incomplete referral.

RESULTS

Of the 3362 participants, 46.1% had incomplete referral. Old age and lower education level showed significant association with incomplete referral. Almost all participants had at least one barrier during the referral process. Knowledge-related and attitude-related barriers, including 'Too old to want any more treatment', 'Difficulty in getting time to referral', 'No serious illness requiring treatment at present', 'My eyes are okay', 'Distrust the recommended hospital' and 'Have not been diagnosed or treated before', and logistics-related barrier 'Mobility or transportation difficulties' showed significant association with incomplete referral.

CONCLUSIONS

The issue of incomplete referral after DR telescreening is serious among individuals with VTDR, particularly in the elder and low education level population. The negativity of knowledge-related and attitude-related factors might be more prominent than logistic barriers in predicting incomplete referral. Therefore, new strategies to improve the compliance with referral assist in optimizing the referral accessibility, and the ongoing educational support to improve the awareness of disease and increase the effectiveness of physician-patient communication.

Who will protect the health of rural residents in China if village doctors run out?

This paper discusses the current situation of Chinese village doctors and highlights the importance of increasing the number of village doctors for better health service and a stronger health system. This study reviewed relevant health policies and data from the Chinese Statistic Year Book 2016 to assess the current status of Chinese village doctors and clinics. The Chinese government has launched a set of healthcare reforms to strengthen primary health care (PHC), especially in rural areas. However, the recruitment and retention of village doctors has not been successful. The analysis of available data suggests that fewer doctors or graduated medical students want to work in village clinics and provide services for rural residents. It is widely recognised in China and other countries that a good PHC system protects the population's health at low cost. To achieve a better health system, the Chinese government should strengthen PHC, expanding the village clinics' coverage to improve access to PHC and basic public health, and introduce more sustainable policies to attract more PHC practitioners to Chinese villages.

Factors associated with the choice of primary care facilities for initial treatment among rural and urban residents in Southwestern China

Objective

To explore influential factors contributing to the choice of primary care facilities (PCFs) for the initial treatment among rural and urban residents in Southwestern China.

Methods

A face-to-face survey was conducted on a multistage stratified random sample of 456 rural and 459 urban residents in Sichuan Province from January to August in 2014. A structured questionnaire was used to collect data on residents’ characteristics, provider of initial treatment and principal reason for the choice. Multivariate logistic regression was performed to identify factors associated with choosing PCFs for the initial treatment.

Results

The result showed that 65.4% of the rural residents and 50.5% of the urban residents chose PCFs as their initial contact for medical care. Among both rural and urban residents, the principal reason for choosing medical institutions for the initial treatment was convenience (42.3% versus 40.5%, respectively), followed by high quality of medical care (26.5% versus 29.4%, respectively). Compared to rural residents, urban residents were more likely to value trust in doctors and high quality of medical care but were less likely to value the insurance designation status of the facilities. Logistic regression analysis showed that both rural and urban residents were less likely to choose PCFs for the initial treatment if they lived more than 15 minutes (by walk) from the nearest facilities (rural: OR = 0.15, 95%CI = 0.09–0.26; urban: OR = 0.19, 95%CI = 0.10–0.36), had fair (rural: OR = 0.49, 95%CI = 0.26–0.92; urban: OR = 0.31, 95%CI = 0.15–0.64) or poor (rural: OR = 0.14, 95%CI = 0.07–0.30; urban: OR = 0.22, 95%CI = 0.11–0.44) self-reported health status. Among rural residents, attending college or higher education (OR = 0.21, 95%CI = 0.08–0.59), being retired (OR = 0.90, 95%CI = 0.44–1.84) and earning a per capita annual income of household of 10,000–29,999 (OR = 0.24, 95%CI = 0.11–0.52) and 30,000–49,999 (OR = 0.26, 95%CI = 0.07–0.92) were associated with lower rates of seeking care at PCFs.

Conclusion

Efforts should be made to improve the accessibility of PCFs and to upgrade the services capability of PCFs both in rural and urban areas in China. At the same time, resources should be prioritized to residents with poorer self-reported health status, and rural residents who retire or have better education and higher income levels should be taken into account.

Does having a usual primary care provider reduce patient self-referrals in rural China's rural multi-tiered medical system? A retrospective study in Qianjiang District, China

INTRODUCTION

Within China's multi-tiered medical system, many patients seek care in higher-tiered hospitals without a referral by a primary-care provider. This trend, generally referred to as patient self-referral behavior, may reduce the efficiency of the health care system. This study seeks to test the hypothesis that having a usual primary care provider could reduce patients' self-referral behavior.

METHODS

We obtained medical records of 832 patients who were hospitalized for common respiratory diseases from township hospitals in Qianjiang District of Chongqing City during 2012-2014. Logit regressions were performed to examine the association between having a township hospital as a usual provider and self-referring to a county hospital after being discharged from a township hospital, while controlling for patients' gender, age, income, education, severity of disease, distance to the nearest county hospital and the general quality of the township hospitals in their community. A propensity score weighting approach was applied.

RESULTS

We found that having a usual primary care provider was associated with a lower likelihood of self-referral (odds ratio = 0.58, 95% confidence interval [CI] =0.41-0.82), and a 9% (95% CI: -14%, - 3%) reduction in the probability of patients' self-referral behavior.

DISCUSSION/CONCLUSION

The results suggest that establishing a long-term relationship between patients and primary care providers may enhance the patient-physician relationship and reduce patients' tendency for unnecessary use of medical resources.

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

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

Practices and attitudes of doctors and patients to downward referral in Shanghai, China

OBJECTIVES

In China, the rate of downward referral is relatively low, as most people are unwilling to be referred from hospitals to community health systems (CHSs). The aim of this study was to explore the effect of doctors' and patients' practices and attitudes on their willingness for downward referral and the relationship between downward referral and sociodemographic characteristics.

METHODS

Doctors and patients of 13 tertiary hospitals in Shanghai were stratified through random sampling. The questionnaire surveyed their sociodemographic characteristics, attitudes towards CHSs and hospitals, understanding of downward referral, recognition of the community first treatment system, and downward referral practices and willingness. Descriptive statistics, χ2 test and stepwise logistic regression analysis were employed for statistical analysis.

RESULTS

Only 20.8% (161/773) of doctors were willing to accept downward referrals, although this proportion was higher among patients (37.6%, 326/866). Doctors' willingness was influenced by education, understanding of downward referral, and perception of health resources in hospitals. Patients' willingness was influenced by marital status, economic factors and recognition of the community first treatment system. Well-educated doctors who do not consider downward referral would increase their workloads and those with a more comprehensive understanding of hospitals and downward referral process were more likely to make a downward referral decision. Single-injury patients fully recognising the community first treatment system were more willing to accept downward referral. Patients' willingness was significantly increased if downward referral was cost-saving. A better medical insurance system was another key factor for patients to accept downward referral decisions, especially for the floating population.

CONCLUSIONS

To increase the rate of downward referral, the Chinese government should optimise the current referral system and conduct universal publicity for downward referral. Doctors and patients should promote understandings of downward referral. Hospitals should realise the necessity of downward referral, effectively reduce workloads and provide continuing education for doctors. Increasing monetary reimbursement is urgent, as is improving the medical insurance system.

Primary health care in China: is China's health reform reform for the whole nation?

BACKGROUND

Good primary health care can enhance national health status at relatively low cost. The barefoot doctor model in China was once considered to have been a successful health care policy. It was a model which was followed by other low-developed or developing countries. In recent decades, the Chinese government promulgated a number of new policies and health reforms to improve its health care system.

AIM

This paper aimed to highlight the great significance of primary health care and appeal to the policymakers to change the priority to primary health care in order to be able to guarantee universal health care for the whole nation at least at primary care level.

METHOD

This study discussed Chinese primary health care by reviewing its history and development.

FINDING

Chinese government's efforts do not seem to be leading to a completely successful outcome for all the people of China as a result of the substantial imbalance of investments between tertiary level hospitals and grass-root level health care institutions. The government appears to have neglected the importance of primary health care in the implementation of health systems and resources.

Risk Factors for Chronic Diseases and Multimorbidity in a Primary Care Context of Central Argentina: A Web-Based Interactive and Cross-Sectional Study

Global health agencies estimate an increase of chronic diseases in South America. Nevertheless, few studies have investigated chronic diseases and their risk factors in the perspective of multimorbidity. This research aimed to identify these aspects in a primary health care setting of central Argentina. The Pan America version of the STEP wise approach surveillance (STEPS) instrument of the World Health Organization was applied to 1044 participants, 365 men and 679 women, with a mean age of 43 years. High prevalence of overweight (33.5%), obesity (35.2%), central obesity (54%), dyslipidemia (43.5%), metabolic syndrome (21.1%), low intake of fruit and vegetables (91.8%), low levels of physical activity (71.5%), risky alcohol consumption (28%), and smoking (22.5%) were detected. Hypertension and diabetes were the most prevalent chronic conditions and the total prevalence of multimorbidity was 33.1%, with 2, 3, 4, 5 and 6 chronic conditions found in 19.9%, 9.1%, 2.6%, 1.1% and 0.4% of the population, respectively. Multimorbidity affected 6.4% of the young, 31.7% of the adults, and 60.6% of the elderly, and was more prevalent among women, and in participants with lower levels of education. Having multimorbidity was significantly associated with obesity, central obesity, and higher concentrations of total blood cholesterol, low-density lipoprotein cholesterol, triglycerides, and glucose. A website was made available to the participants in order to share the experimental results and health-promoting information.

General practitioners versus other physicians in the quality of primary care: a cross-sectional study in Guangdong Province, China

BACKGROUND

The primary care in China can be provided by general practitioners (GPs) and other physicians (non-GPs). However, China's general practice system has never been really established. Chinese patients tend to consider the quality of primary care provided by GPs much lower than that of non-GPs. Besides, many GPs presently prefer leaving their own positions and seeking better development in big hospitals, which has made the already weak GP system weaker. Yet, few studies have specially compared the quality of primary care provided by Chinese GPs and other physicians and no studies have explored the independent predictors of Chinese GPs' intentions to stay on their current job. In this study, we aimed to compare the quality of primary care offered by GPs with non-GPs and to explore the independent predictors of GPs' future work intentions.

METHODS

This cross-sectional study applied multi-stage random cluster sampling methodology. The data were collected from November 2013 to September 2014 in Guangdong Province. In total, 401 effective questionnaires were selected from the physicians. Quality of primary care was assessed using the Primary Care Assessment Tool (PCAT) Provider Part, representing six primary care domains: ongoing care, coordination (i.e., referrals and information systems), comprehensiveness (i.e., service available and service provided), family-centeredness, community orientation and cultural competence.

RESULTS

Of 401 participating physicians, 163 (40.6 %) were GPs. The total PCAT score was 26.32 ± 2.24 which was the sum score of the six domains and represent the quality of primary care. GPs achieved significantly different total scores and scores on three individual scales: comprehensiveness: service available, comprehensiveness: service provided and community orientation. Multiple linear regressions revealed GPs had a higher total score and scores for comprehensiveness: service provided and community orientation after adjusting for sociodemographic characteristics. In addition, GPs were more likely to intend to stay in their current job in the coming year, and this was associated with their educational level.

CONCLUSIONS

Our findings showed that GPs reported higher quality of primary care than other physicians, and were more inclined to stay in their current job. With more comprehensive care and community orientation provided by GPs, residents could reach basic medical cares and needn't to crowd into larger hospitals.

Screening schizotypal personality disorder for detection of clinical high risk of psychosis in Chinese mental health services

Schizotypal personality disorder (SPD) is viewed as a marker of prodromal psychosis. However, information regarding genetic risk (e.g. SPD) is often overlooked in the identification process. This study assessed whether SPD screening questionnaire help the prodromal psychosis (also widely applied "clinical high risk" (CHR) for clinical sample) detection in Chinese mental health service. This work also examined whether SPD had higher frequency in genetic risk population and CHR subjects. Two wave studies concerning the SPD identification was used for analysis. Wave 1 survey: 3075 subjects were assessed by Personality Diagnostic Questionnaire for SPD (PDQ-SPD) and Structured Clinical Interview for DSM-IV Axis II (SCID-II). Wave 2 survey: 2113 subjects screened with the prodromal questionnaire -brief version (PQ-B), PDQ-SPD, and interviewed by Structured Interview for Prodromal Symptoms (SIPS). Subjects with family history of mental disorders or with psychosis reported significantly higher scores in SPD. Receiver operating characteristic curves suggested that PDQ-SPD had moderate sensitivity and specificity for identifying CHR subjects. There was significant higher on SPD features in subjects with early stage (Course less than 1 year) of psychosis. Identifying SPD may be useful in early detection of psychosis especially in detecting the genetic risk syndromes and can be integrated with existing prodromal screen tools to improve its efficiency.

Health system reforms, violence against doctors and job satisfaction in the medical profession: a cross-sectional survey in Zhejiang Province, Eastern China

OBJECTIVE

To explore the factors influencing doctors' job satisfaction and morale in China, in the context of the ongoing health system reforms and the deteriorating doctor-patient relationship.

DESIGN

Cross-sectional survey using self-completion questionnaires.

STUDY SETTING

The survey was conducted from March to May 2012 among doctors at the provincial, county and primary care levels in Zhejiang Province, China.

RESULTS

The questionnaire was completed by 202 doctors. Factors which contributed most to low job satisfaction were low income and long working hours. Provincial level doctors were most dissatisfied while primary care doctors were the least dissatisfied. Three per cent of doctors at high-level hospitals and 27% of those in primary care were satisfied with the salary. Only 7% at high-level hospitals were satisfied with the work hours, compared to 43% in primary care. Less than 10% at high levels were satisfied with the amount of paid vacation time (3%) and paid sick leave (5%), compared with 38% and 41%, respectively, in primary care. Overall, 87% reported that patients were more likely to sue and that patient violence against doctors was increasing. Only 4.5% wanted their children to be doctors. Of those 125 who provided a reason, 34% said poor pay, 17% said it was a high-risk profession, and 9% expressed concerns about personal insecurity or patient violence.

CONCLUSIONS

Doctors have low job satisfaction overall. Recruitment and retention of doctors have become major challenges for the Chinese health system. Measures must be taken to address this, in order to ensure recruitment and retention of doctors in the future. These measures must first include reduction of doctors' workload, especially at provincial hospitals, partly through incentivisation of appropriate utilisation of primary care, increase in doctors' salary and more effective measures to tackle patient violence against doctors.

The ecology of medical care in Beijing

BACKGROUND

We presented the pattern of health care consumption, and the utilization of available resources by describing the ecology of medical care in Beijing on a monthly basis and by describing the socio-demographic characteristics associated with receipt care in different settings.

METHODS

A cohort of 6,592 adults, 15 years of age and older were sampled to estimate the number of urban-resident adults per 1,000 who visited a medical facility at least once in a month, by the method of three-stage stratified and cluster random sampling. Separate logistic regression analyses assessed the association between those receiving care in different types of setting and their socio-demographic characteristics.

RESULTS

On average per 1,000 adults, 295 had at least one symptom, 217 considered seeking medical care, 173 consulted a physician, 129 visited western medical practitioners, 127 visited a hospital-based outpatient clinic, 78 visited traditional Chinese medical practitioners, 43 visited a primary care physician, 35 received care in an emergency department, 15 were hospitalized. Health care seeking behaviors varied with socio-demographic characteristics, such as gender, age, ethnicity, resident census register, marital status, education, income, and health insurance status. In term of primary care, the gate-keeping and referral roles of Community Health Centers have not yet been fully established in Beijing.

CONCLUSIONS

This study represents a first attempt to map the medical care ecology of Beijing urban population and provides timely baseline information for health care reform in China.

The consultants' role in the referring process with general practitioners: partners or adjudicators? a qualitative study

Background

Within the health system, communication between the different levels of care is essential for the patients’ clinical pathways and medical treatment. This includes the referral process: how and why patients are sent from the primary care level to specialist health services. We wanted to identify and describe hospital consultants’ reflections on and attitudes to the referral process and cooperation with general practitioners (GPs).

Methods

A qualitative study of semi-structured interviews with 13 hospital consultants representing eight different specialties, analyzed using systematic text condensation. Interviews conducted from February 2011 to October 2012.

Results

The consultants reported a considerable workload assessing referrals from GPs and prioritizing patients for specialist services. National guidelines were used as well as individual standards and guidelines. Good referrals could make the prioritization process easier. The specialists expressed a deep concern about securing a fair priority of patients and a willingness to give reasonable advice back to the referring GP when rejecting a referral. Better communication, such as a telephone call to confer with a hospital specialist before referral, was wanted.

Conclusions

Better communication and cooperation between hospital consultants and GPs could make the referral process more balanced, and the participants more like partners.