The trend in primary health care preference in China: a cohort study of 12,508 residents from 2012 to 2018

Preference for primary care in Chinese homebound patients

OBJECTIVE

This study aims to describe the preference for primary healthcare (PHC) and investigate associated factors among homebound residents in both rural and urban areas of China. It provides valuable insights to facilitate the rational allocation of healthcare resources and promote the utilization of PHC.

METHODS

In this nationally representative cross-sectional study, we utilized the most recent data (2020) from the China Family Panel Studies (CFPS). Participants were recruited from 25 provincial-level administrative regions in both rural and urban areas of China. Homebound patients were asked to provide details about their individual characteristics, variables related to family caregiving, and preferences for PHC. Multivariable logistic models were used to analyze potential factors associated with preference for PHC. Estimates of association were reported as odds ratios (OR) and their 95% confidence intervals (CI).

RESULTS

The study found that 58.43% of rural patients reported a preference for PHC, while 42.78% of urban patients favored PHC. Compared to rural participants who did not received inpatient care in the past year, those who received inpatient care in the past year had 67% lower odds of choosing PHC (OR:0.33, 95% CI:0.19-0.59); Compared to rural participants who did not received family caregiving when ill, those who received family caregiving when ill had 59% lower odds of choosing PHC (OR: 0.41, 95% CI:0.21-0.77). Correspondingly, Compared to urban participants who did not received inpatient care in the past year, those who had received inpatient care in the past year had 75% lower odds of choosing PHC (OR: 0.25, 95% CI: 0.10-0.56); Compared to urban participants who did not received family caregiving when ill, those who received family caregiving when ill had 73% lower odds of choosing PHC (OR: 0.27, 95% CI: 0.11-0.63); Compared to urban participants who with agricultural Hukou, those with Non-agricultural Hukou had 61% lower odds of choosing PHC (OR: 0.39, 95% CI:0.18-0.83); Compared to urban participants living in the eastern part of mainland China, those living in the central part of China had 188% higher odds of choosing PHC (OR: 2.88, 95% CI: 1.14-7.29).

CONCLUSION

Policymakers should focus on tailoring PHC to vulnerable populations and prioritizing family-based public health strategies for enhancing homebound patients' perceptions of PHC. Furthermore, further study is needed on whether the Hukou registration system affects the barriers that homebound patients experience in choosing healthcare providers.

Use of Primary Healthcare Among Chinese Older Adults With Functional Limitations

The aim of this study was to assess the factors associated with primary healthcare (PHC) utilization among older adults with functional limitations, providing insights for improving the effectiveness of PHC for this population. We used the China Health and Retirement Longitudinal Study (CHARLS) dataset, which encompasses 28 provinces in China. Logistic regression was used to analyze the people-related, care context-related, and linkage-related factors associated with PHC utilization. Approximately 55.61% of older adults with functional limitations utilized PHC in the past month, regardless of visit frequency or extent. Participants with lower educational attainment, those reporting more pain, and those living in rural areas had a higher likelihood of PHC utilization. Participants who received inpatient care in the past year had a lower likelihood of PHC utilization. We recommend that policymakers complement existing PHC health programs with increased health and social welfare support for this population.

Cost-effectiveness analysis of serplulimab in combination with cisplatin plus 5-fluorouracil chemotherapy compared to cisplatin plus 5-fluorouracil chemotherapy as first-line treatment for advanced or metastatic esophageal squamous cell carcinoma in China

Background

This study evaluated the cost-effectiveness of serplulimab plus chemotherapy versus chemotherapy alone in treating advanced/metastatic esophageal squamous cell carcinoma (ESCC) within the Chinese health care system.

Methods

A partitioned survival model based on ASTRUM-007 trial patient characteristics was developed. Efficacy, safety, and medical/economic data were obtained from the trial and real-world clinical practice. Costs, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs) were calculated for both treatment strategies. Sensitivity, subgroup, and scenario analyses were performed to assess the uncertainty impact.

Results

Serplulimab combined with chemotherapy yielded an ICER of US$ 53,538.27/QALY. Deterministic sensitivity analysis identified patient survival and serplulimab price as influential parameters. Probabilistic sensitivity analysis showed a 47.33% probability of cost-effectiveness at a willingness-to-pay (WTP) threshold of US$ 53,541/QALY and 0.05% at three times China's GDP per capita. Subgroup analysis revealed that patients with a programmed death-ligand 1 (PD-L1) expression combined positive score (CPS) ⩾10 had a lower hazard ratio (0.59) and ICER (US$ 29,935.23/QALY), with a 95.36% probability of cost-effectiveness. Scenario analysis demonstrated that the drug donation discount policy significantly increased the likelihood of cost-effective serplulimab-chemotherapy combinations in Jiangsu, Fujian, and Guangdong at 99.99%, 99.90%, and 94.16%, respectively.

Conclusion

Compared to chemotherapy alone, serplulimab combined with chemotherapy is currently not a cost-effective first-line treatment for advanced/metastatic ESCC in China. However, as serplulimab plus chemotherapy regimens evolve and price competition among programmed death 1 (PD-1) inhibitors intensifies, this combination may become a cost-effective treatment option.

Health and health system impacts of China's comprehensive primary healthcare reforms: a systematic review

China's comprehensive primary healthcare (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality healthcare services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In 13 August 2022, international databases and three Chinese databases were searched for randomized controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group and assessed impacts on expenditures, utilization, care quality and health outcomes. Study quality was assessed using Risk of Bias In Non-randomized Studies of Interventions, and results were synthesized narratively. From 49 174 identified records, 42 studies were included-all with quasi-experimental designs, except for one randomized control trial. Nine studies were assessed as at low risk of bias. Only five low- to moderate-quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilization, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N = 15) and financing reforms (N = 11) were the most studied policies, whilst policies on primary care provision (i.e. family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilization (N = 17) and improved health outcomes in people with non-communicable diseases (N = 8). Evidence on healthcare costs was unclear, and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups that accrued greater benefits (N = 8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilization, improving some health outcomes and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance universal health coverage.

Evaluating smoking cessation interventions in China's primary care facility networks for hypertensive patients aged 45 years and older: A retrospective cohort study

INTRODUCTION

In China's aging population, hypertension, aggravated by smoking, constitutes a substantial health concern. However, the effectiveness of the national public health interventions for smoking cessation under the Essential Public Health Services remains unverified. Our aim was to examine smoking prevalence, the proportion of individuals receiving smoking cessation advice, its impact on successful cessation among Chinese hypertensive patients aged ≥45 years, and to discern disparities in the coverage and efficacy of smoking cessation interventions between primary care facilities and hospitals.

METHODS

Employing a longitudinal cohort approach, we examined four waves (2011-2018) of the China Health and Retirement Longitudinal Study (CHARLS). We surveyed a nationally representative cohort of hypertensive individuals, accounting for smoking status, cessation advice, healthcare preferences, and 11 pertinent covariates.

RESULTS

Among the 4269 hypertensive patients, smokers were predominantly male, aged <65 years, with lower education and lower wealth. Smoking prevalence decreased from 25.2% in 2011 to 21.1% in 2018. The incidence of physician-provided smoking cessation advice reached a peak of 60.3% in 2015, decreasing to 54.8% in 2018. Visitors to primary care facilities reported the highest rate of advice reception. While patients receiving advice exhibited a higher smoking prevalence, instrumental variable regression and subgroup analyses found no significant correlation between advice receipt and successful cessation.

CONCLUSIONS

We observed a substantial smoking prevalence among older hypertensive Chinese individuals and limited effectiveness of existing cessation programs. This underscores the necessity for augmenting primary care and devising a comprehensive health policy for more successful smoking cessation interventions, particularly considering China's rapidly aging population.

Patient experience in community health services and first choice for medical attention: A cross-sectional study in Wuhan, China

OBJECTIVES

In China, it is up to the patients to choose between hospitals and primary care facilities to initiate their medical care. This study aimed to determine the association between patient experience with community health centres (CHCs, a predominant provider of community-based primary care) and patient preference of taking community-based primary care facilities as a first choice for medical attention.

METHODS

A questionnaire survey was conducted on 1919 patients who sought medical care in 55 CHCs in Wuhan, China. Respondents were asked to identify their preferred first choice for medical attention and rate their satisfaction with eight aspects of CHCs (basic facility, medical equipment, medical services, nursing services, treatment process, courtesy and responsiveness, time spent with medical doctor, pharmacy services). Multivariate logistic regression models were established to determine the association between the CHC experience and the first choice of providers after adjustment for variations in sociodemographic characteristics.

RESULTS

Over 90% of respondents were satisfied or very satisfied with the eight aspects of CHCs; but only 75% preferred to take community-based primary care facilities as their first choice for medical attention. Those who were older and had a lower income were more likely to choose community-based primary care facilities. Geographic proximity and higher levels of satisfaction with the basic facility, courtesy and responsiveness, and pharmacy services in the CHCs were associated with a higher likelihood of taking community-based primary care facilities as a first choice for medical attention.

CONCLUSION

The consumers of CHCs are generally satisfied with the services they received. However, one quarter of the CHC patients are yet to be convinced to accept community-based primary care facilities as a preferred first provider for medical care. Geographic proximity and patient experience with CHCs are associated with the patient choice.

Preferences of patients with diabetes mellitus for primary healthcare institutions: a discrete choice experiment in China

OBJECTIVES

To quantify the preference of patients with diabetes mellitus (DM) for primary healthcare (PHC) institutions in China to redirect the patient flow and improve health outcomes.

DESIGN

Cross-sectional study. Discrete choice experiment (DCE) surveys asked patients with DM to choose between hypothetical institutions that differed in the medical service capacity, out-of-pocket (OOP) medical costs per month, travel time, the attitude of medical staff and the availability of diabetes drugs.

SETTING

Shandong province, China.

PARTICIPANTS

The participants were 887 patients with DM from 36 urban communities and 36 rural villages in Shandong province. One participant did not provide any DCE answers and a further 57 patients failed the internal consistency test. 829 fully completed surveys were included in the final data analysis.

MAIN OUTCOMES AND MEASURES

A mixed logit model was used to calculate the willingness to pay and predict choice probabilities for PHC institution attributes. Preference heterogeneity was also investigated.

RESULTS

All five attributes were associated with the preferences of patients with DM. The OOP medical costs and the medical service capacity were the most influential attributes. Improvements simultaneously in the attitude of medical staff, drug availability and travel time increased the likelihood of a patient's PHC institution choice. Preferences differed by region, annual household income and duration of diabetes.

CONCLUSIONS

Our patient preference data may help policymakers improve health services and increase acceptance of choosing PHC institutions. The OOP medical costs and medical service capacity should be regarded as a priority in decision-making.

Behavioral deviations: healthcare-seeking behavior of chronic disease patients with intention to visit primary health care institutions

BACKGROUND

Although primary health care (PHC) has been proven to be effective in preventing and treating chronic diseases, the visits rate of PHC institutions is still not ideal. Some patients initially express a willingness to visit PHC institutions but end up seeking health services at non-PHC institutions, and the reasons for this behavior remain unclear. Therefore, the objective of this study is to analyze the factors that contribute to behavioral deviations among chronic disease patients who originally intended to visit PHC institutions.

METHODS

Data were collected from a cross-sectional survey among chronic disease patients with original intention to visit PHC institutions in Fuqing City, China. The analysis framework was guided by Andersen's behavioral model. Logistic regression models were employed to analyze the factors affecting the behavioral deviations among chronic disease patients with a willingness to visit PHC institutions.

RESULTS

A total of 1,048 individuals were finally included and about 40% of the participants with the original willingness to seek care from PHC institutions finally chose non-PHC institutions in their subsequent visits. The results of logistic regression analyses indicated that at the predisposition factor level, older participants (aOR_60-69 = 0.602, P < 0.01; aOR_70-75 = 0.475, P < 0.01) were less likely to have behavioral deviations. At the enabling factor level, compared to those covered by Urban Employee Basic Medical Insurance (UEBMI) and not reimbursed, those covered by Urban-Rural Resident Basic Medical Insurance (URRBMI) (aOR = 0.297, P < 0.01), and those answering that reimbursement from medical institutions was convenient (aOR = 0.501, P < 0.01) or very convenient (aOR = 0.358, P < 0.001) were less likely to have behavioral deviations. At the need factor level, participants who visited PHC institutions due to illness last year (aOR = 0.348, P < 0.001) and with polypharmacy (aOR = 0.546, P < 0.01) were less likely to have behavioral deviations compared to those without the visit of PHC institutions and not taking polypharmacy, respectively.

CONCLUSIONS

The deviations between the original willingness of PHC institution visits and subsequent behavior among chronic disease patients were associated with a number of predisposing, enabling, and need factors. Developing the health insurance system, strengthening the technical capacity of PHC institutions, and steadily developing a new concept of orderly healthcare-seeking behavior among chronic disease patients, will help promote their access to PHC institutions as well as improve the effectiveness of the tiered medical system for chronic disease care.

Association between Health-Related Quality of Life and Access to Chronic Disease Management by Primary Care Facilities in Mainland China: A Cross-Sectional Study

The integration of chronic disease management (CDM) services into the essential public health services offered by primary care facilities has been a major strategy in China's healthcare reform since 2009. We aimed to measure the percentage of patients with chronic diseases in China who believed that they could easily obtain CDM services at a nearby primary care facility in mainland China and determine its association with the EQ visual analog scale (EQ-VAS) score and the utility index of the 5-level EQ-5D version (EQ-5D-5L). A cross-sectional survey was conducted nationwide between 20 June 2022 and 31 August 2022, involving 5525 patients with chronic diseases from 32 provincial-level administrative divisions, of which 48.1% (n = 2659) were female with a median age of 55.0 years. The median EQ-VAS score was 73.0 and the utility index of the EQ-5D-5L was 0.942. A majority of patients reported definite (24.3%) or mostly (45.9%) easy access to CDM services from nearby primary care facilities. Multivariable logistic regression analysis revealed that easy access to CDM services in primary care facilities was positively associated with higher HRQoL. Our findings indicate that, as of 2022, approximately 70% of patients with chronic diseases in mainland China had easy access to CDM services provided by primary care facilities, which was significantly and positively associated with their health status.

Variation in quality of care by medical institute level in China: a systematic review protocol

INTRODUCTION

Quality variation has been widely witnessed and discussed in China. However, limited evidence reveals quality gaps by the medical institute level, especially between hospitals and primary care institutes. This systematic review will synthesise the available evidence on quality variation between medical institutes at different levels in China. By adopting a quality framework, we will also explore the detailed domains (structure, process and outcomes) and dimensions (safety, effectiveness, timeliness, patient-centredness, efficiency, integration and equity) of quality gaps.

METHODS AND ANALYSIS

An extensive literature search will be conducted on eight key electronic databases: MEDLINE, Web of Science, Cochrane Library, Scopus, EMBASE, ProQuest, China National Knowledge Infrastructure and WANFANG database. The Grey Matter Checklist will be used to screen relevant grey literature. The publication time limit should be before 31 December 2022 when we plan to conduct a literature search. All kinds of studies that revealed the quality difference between medical institutes at different levels will be included, no matter if quality improvement intervention is involved. All quality measures and indicators will be recorded and sorted into appropriate domains and dimensions. For those studies that took the completion rate of standard operations to assess the quality, we will also record the name of the clinical pathways, guidelines or checklists used. Two reviewers will independently perform the study selection, data extraction and quality assessment process. A narrative or quantitative synthesis will be performed based on the available data.

ETHICS AND DISSEMINATION

Ethics approval is not applicable. The results of this study will be submitted to a widely accepted peer-review journal. The findings will also be used to inform administration about quality gaps by different medical institute levels and, therefore, help them to design policies that will minimise the quality variation.

PROSPERO REGISTRATION NUMBER

CRD42022345933.

Willingness rate of the first visit to primary healthcare services and the associated factors in China: a meta-analysis

BACKGROUND

In September 2015, the State Council of China issued guidelines on building a hierarchical medical system, stating that the first visit rate to primary healthcare (PHC) facilities should be increased to 70% for all medical facilities by 2017. This meta-analysis aims to estimate the willingness of the first visit to PHC services in China after the year 2015 and identify its determinants.

METHODS

A meta-analysis was conducted.

RESULTS

The combined estimate from 23 studies in China for the willingness rate of the first visit to PHC services was 56% (95% CI: 47-65). Chronic diseases may be one source of heterogeneity. We identified five main associated factors with the pooled odds ratio ranging from 1.39 to 10.28, including fair self-reported health status; high understanding of service content; good service attitude; solid expertise and advanced diagnostic methods; and a good medical environment.

CONCLUSION

In comparison with China's State Council recommendations, the willingness rate for the first visit to PHC services was significantly lower. The Government should develop strategies to facilitate the implementation of a hierarchical system for diagnosis and treatment.

Healthcare preferences of the general Chinese population in the hierarchical medical system: A discrete choice experiment

Background

Chinese health insurance system faces resource distribution challenges. A patient-centric approach allows decision-makers to be keenly aware of optimized medical resource allocation.

Objective

This study aims to use the discrete choice model to determine the main factors affecting the healthcare preferences of the general Chinese population and their weights in the three scenarios (chronic non-communicable diseases, acute infectious diseases, and major diseases).

Methods

This study firstly identified the key factors affecting people's healthcare preferences through literature review and qualitative interviews, and then designed the DCE questionnaire. An online questionnaire produced by Lighthouse Studio (version 9.9.1) software was distributed to voluntary respondents recruited from mainland China's entire population from January 2021 to June 2021. Participants were required to answer a total of 21 questions of three scenarios in the questionnaire. The multinomial logit model and latent class model were used to analyze the collected data.

Results

A total of 4,156 participants from mainland China were included in this study. The multinomial logit and latent class model analyses showed that medical insurance reimbursement is the most important attribute in all three disease scenarios. In the scenario of "non-communicable diseases," the attributes that participants valued were, from the most to the least, medical insurance reimbursement (45.0%), hospital-level (21.6%), distance (14.4%), cost (9.7%), waiting time (8.3%), and care provider (1.0%). As for willingness to pay (WTP), participants were willing to pay 204.5 yuan, or 1,743.8 yuan, to change from private hospitals or community hospitals to tertiary hospitals, respectively.

Conclusions

This study explores the healthcare preferences of Chinese residents from a new perspective, which can provide theoretical reference for the refinement of many disease medical reimbursement policies, such as developing different reimbursement ratios for various common diseases and realizing rational configuration of medical resources.

Levels, trends, and determinants of effectiveness on the hierarchical medical system in China: Data envelopment analysis and bootstrapping truncated regression analysis

Background

The hierarchical medical system (HMS) refers to the classification of treatment according to disease priorities based on severity and difficulty to promote the fairness of medical services for residents, which is regarded as the key to the success of medical reform in China.

Methods

In the past decade of "New Medical Reform," the efficiency of HMS, including secondary and tertiary hospitals and primary healthcare centers (PHCs), was measured horizontally and vertically by employing the combination of an output-oriented superefficiency slack-based model-data envelopment analysis (SE-SBM-DEA) model with the Malmquist total factor productivity index (MTFP). In the second stage, the overall technical efficiency (OTE) scores were regressed against a set of environmental characteristics and several managerial factors through bootstrapping truncated regression.

Results

On average, the OTE score in tertiary hospitals was 0.93, which was higher than that in secondary hospitals and PHCs (0.9 and 0.92, respectively). In terms of trend, the OTE of tertiary hospitals declined at first and then increased. The opposite was true of secondary hospitals, in which the APC of the OTE was 10.82 and -3.11% in early and late 2012, respectively. The PHCs generally showed a fluctuating downward trend. In the aspects of productivity, all institutions showed a downturn by an annual average rate of 2.73, 0.51, and 2.70%, respectively. There was a significant negative relationship between the ratio of outpatients to inpatients and tertiary hospitals. Additionally, the medical technical personnel per 1,000 population negatively affected PHCs. In contrast, the GDP per capita had a significantly positive effect on tertiary hospitals, and the number of beds per 1,000 population positively influenced PHCs.

Conclusion

The efficiency of medical institutions at various levels in HMS was unbalanced and took the form of an "inverted pyramid." Multilateral factors influence the efficiency of HMS, and to address it, multi-intervention packages focusing on sinking high-quality medical resources and improving healthcare capacity, and guiding hierarchical medical practice should be adopted.

Horizontal Integration and Financing Reform of Rural Primary Care in China: A Model for Low-Resource and Remote Settings

Primary health care (PHC) systems are compromised by under-resourcing and inadequate governance, and fail to provide high-quality health care services in most low- and middle-income countries (LMICs). As a response to solve the problems of underfunding and understaffing, Pengshui County, an impoverished area in rural Chongqing, China, implemented a profound reform of its PHC delivery system in 2009, focusing on horizontal integration and financing mechanisms. This paper aims to present new evidence from the Pengshui model, and to assess the relevant changes over the past 10 years (2009–2018). An inductive approach was adopted, based on analysis of national and local policy documents and administrative data. From 2009 to 2018, the proportion of outpatients who sought first-contact care in rural community or township health centers increased from 29% (522,700 of 1,817,600) in 2009, to 40% (849,900 of 2,147,800) in 2018 (the national average in 2018 was 23%). Our findings suggest that many positive results have been achieved through the reform, and that innovations in financial governance and incentive mechanisms are the main driving forces behind the improvement. Pengshui County’s experience has proven to be a successful experiment, particularly in rural and low-income areas.

REducing delay through edUcation on eXacerbations for people with chronic lung disease: Study protocol of a single-arm pre-post study

AIM

This study protocol aims to examine the effectiveness and preconditions of a self-management program-named REducing Delay through edUcation on eXacerbations (REDUX)-in China.

BACKGROUND

The high disease burden in people with chronic lung disease is mainly due to exacerbations. There is a need for effective exacerbation-management interventions. A nurse-led program, REDUX, helped patients self-manage exacerbations.

DESIGN

A single-arm pre-post study.

METHODS

Fifty-four patients and 24 healthcare professionals (HCPs) in Chinese primary care will be included. The core element of the program is a personalized action plan. HCPs will receive training in using the action plan to help patients manage exacerbations. The intervention will start when a patient is referred to the nurse for a post-exacerbation consultation and ends when the patient presents for the second post-exacerbation consultation. During the first post-exacerbation consultation, the patient and nurse will create the action plan. The primary outcomes in patients will include the delays between the onset of exacerbation and recognition, between exacerbation recognition and action, between exacerbation recognition and consultation with a doctor, and when the patients feel better after receiving medical help from HCPs. The secondary outcomes will include preconditions of the program. The ethics approval was obtained in September 2021.

DISCUSSION

This study will discuss a culturally adapted nurse-led self-management intervention for people with chronic lung disease in China. The intervention could help Chinese HCPs provide efficient care and reduce their workload. Furthermore, it will inform future research on tailoring nurse-led self-management interventions in different contexts.

IMPACT

The study will contribute to the evidence on the effectiveness and preconditions of REDUX in China. If effective, the result will assist the nursing of people with chronic lung disease.

TRIAL REGISTRATION

Registered in the Chinese clinical trial registry (ID: 2100051782).

Explaining the declining utilization of village clinics in rural China over time: A decomposition approach

With a goal of improving health system quality and efficiency, reforms of China's health system over the past decade have sought to strengthen primary healthcare in lower-level clinics and health centers. Despite these wide-ranging reforms and initiatives, population-based studies have documented dramatic declines in patients' use of primary care facilities during this period. In this paper, we explore the determinants of this trend in China's rural areas using detailed longitudinal data following a nationally-representative sample of rural households and village clinics from 2011 to 2018. We estimate that between 2011 and 2018, the probability that individuals sought care at village clinics when ill dropped by 44%. At the same time, the utilization of outpatient services in county hospitals increased by 56% and patient self-treatment increased by 20%. Detailed Kitagawa-Oaxaca-Blinder decompositions suggest four primary drivers of this trend: the shifting burden of disease in rural areas, changes in how patients choose to seek care given different disease conditions, declining drug inventory in village clinics, and the decreasing importance of remoteness as a determinant of healthcare seeking behavior. Our results highlight the deteriorating role of village clinics in the rural healthcare system and the increasing importance of self-treatment and higher-tier primary care services.

Patients' Willingness of First Visit in Primary Medical Institutions and Policy Implications: A National Cross-Sectional Survey in China

Background

The Chinese hierarchical treatment system expects patients to first visit primary medical institutions (PMIs), and patients' willingness determined their utilization of primary health care. The aim of this study was to explore the factors associated with patients' willingness to make their first visit to PMIs.

Methods

We employed multistage stratified sampling and convenience sampling to administer questionnaires to 1,507 patients in Beijing, Qinghai, and Fujian. Patients' willingness of first visit in PMIs was analyzed using Chi-square test and binary logistic regression.

Results

Of the 1,507 participants in the survey, 55.1% were willing to make their first visit in PMIs. Fewer patients in Beijing (17.6%) are willing to make their first visit in PMIs than those in Qinghai (71.9%) and Fujian provinces (72.0%). Binary logistic regression analysis revealed that higher recognition of the community first visit policy and higher satisfaction with the medical technology of PMIs are associated with patients' willingness of first visit in PMIs.

Conclusions

Due to differences in local economic conditions, medical resources, and policy formulation, there are differences among provinces in patients' willingness of first visit in PMIs. To increase patients' rate of visits in PMIs, it is important to improve service capacity and quality of PMIs and change residents' attitudes for PMIs.

Obstacles to access to community care in urban senior-only households: a qualitative study

Background

The increased number of older adults living alone has created a substantial care need. However, the utilization rate of services and facilities to meet these needs are surprisingly low. Many of older adults experience difficulties accessing these services, although it remains unclear how these obstacles impede access to services. This study explored the obstacles and difficulties experienced by urban older adults in seeking community care.

Methods

A phenomenological study was carried out and participatory observation and in-depth interviews were employed to investigate the process of seeking care of older adults in urban communities. A total of 18 urban community-dwelling older adults aged 75 years and over were included. Data collected were analysed by content analysis.

Results

We identified the pathways by which senior-only households sought community care and encountered obstacles. (1) lack of community care information: older adults did not know where and how to get services, even though the care institutions scattered throughout the community; (2) limited mobility: older adults often suffered from various chronic diseases, which physically hindered their access to care resources; (3) complex process of achieving care: the functional fragmentation and geographical dispersion of care institutions made the care-seeking process challenging and confusing for older adults; (4) incomprehension of needs expression: limited interaction time and communication barriers between staff of institutions and the older adults were the final obstacle. Only by surmounting these obstacles one by one can older adults access the care resources effectively.

Conclusions

When older adults in the community initiated calls for help, they encountered several obstacles. Their physiological and social disadvantages limited their ability to seek care physically. Lack of integration and clear guidance in the process of providing community care exacerbated these difficulties. Reform of care services should focus on the visibility and accessibility of services for older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02816-y.

MMP9 SNP and MMP SNP-SNP interactions increase the risk for ischemic stroke in the Han Hakka population

OBJECTIVES

To investigate the association of eight variants of four matrix metalloproteinase (MMP) genes with ischemic stroke (IS) and whether interactions among these single nucleotide polymorphisms (SNPs) increases the risk of IS.

METHODS

Among 547 patients with ischemic stroke and 350 controls, matrix-assisted laser desorption/ionization time of flight mass spectrometry was used to examine eight variants arising from four different genes, including MMP-1 (rs1799750), MMP-2 (rs243865, rs2285053, rs2241145), MMP-9 (rs17576), and MMP-12 (rs660599, rs2276109, and rs652438). Gene-gene interactions were employed using generalized multifactor dimensionality reduction (GMDR) methods.

RESULTS

The frequency of rs17576 was significantly higher in IS patients than in controls (p = .033). Logistic regression analysis revealed the AG and GG genotypes of rs17576 to be associated with a higher risk for IS, with the odds ratio and 95% confidence interval being 2.490 (1.251-4.959) and 2.494 (1.274-4.886), respectively. GMDR analysis showed a significant SNP-SNP interaction between rs17576 and rs660599 (the testing balanced accuracy was 53.70% and cross-validation consistency was 8/10, p = .0107). Logistic regression analysis showed the interaction between rs17576 and rs660599 to be an independent risk factor for IS with an odds ratio of 1.568 and a 95% confidence interval of 1.152-2.135.

CONCLUSION

An MMP-9 rs17576 polymorphism is associated with increased IS risk in the Han Hakka population and interaction between MMP-9 rs17576 and MMP-12 rs660599 is associated with increased IS risk as well.