Building a People-Centred Integrated Care Model in Urban China: A Qualitative Study of the Health Reform in Luohu

Delivering Integrated Community Care for the Elderly: A Qualitative Case Study in Southern China

The rapid aging and increasing care demands among the elderly population present challenges to China's health and social care system. The concept of aging in place has prompted the implementation of integrated community care (ICC) in the country. This study aims to provide empirical insights into the practices of integrated care policies and approaches at the community level. Data for this study were collected through six months of participatory observations at a local community health service center in a southern Chinese city. Semi-structured interviews were conducted with the multidisciplinary community care team to gather frontline formal caregiver perceptions of ICC, thereby facilitating a better understanding of the obstacles and opportunities. Qualitative analysis revealed four themes: the ICC delivery model and development strategies within the community care scheme, the person-centered guiding principle, and the challenges and struggles encountered by formal caregivers within China's current ICC system. The case study presented herein serves as a notable example of the pivotal role of primary care in the successful implementation of elderly care within a community setting. The adoption of a private organization-led approach to medico-social integration care in the community holds significant potential as a service delivery model for effectively addressing a wide range of elderly care issues.

Effective policy research of county and township health sector integration in China: Empirical evidence from the difference-in-differences model

Medical service fragmentation is a common problem worldwide, and many countries have adopted integration to solve the difficulty. Contrary to developed countries, developing countries such as China must consider how to implement integration under a relatively weak medical foundation. This study aims to evaluate the effect of the "Compact Union of County and Township Health Sectors" policy on the medical service capacity of a typical integration model represented by Shanxi Province in China and determine the path the policy followed. By using Shanxi's county-level medical integration as a quasi-natural experiment, this study establishes a difference-in-differences model to investigate the effect of the policy using official data. A series of tests are conducted to verify the robustness of the result. Finally, the policy pathway is tested. The results show that the third-level surgeries and outpatient service utilization of leading hospitals and township institutions increased. Still, inpatient service utilization and fourth-level surgeries did not show a significant change in either type of institution. Moreover, the enhancement of leading hospitals' service capacity comes mainly through improving asset efficiency and personal income, while the improvement of township institutions' capacity comes primarily through increased personal income. Compact integration of county-level medical institutions can stimulate and improve service capacity by improving asset efficiency and personal income, even with a weak medical foundation. However, to achieve continuous service capacity improvement, the professional level of county-level institutions must be strengthened with a superior hospital's assistance, and personnel's enthusiasm for active innovation must be cultivated.

Utilisation of community healthcare services among older adults with disabilities in Luohu district, Shenzhen: a community-based survey

OBJECTIVE

China faces the challenge of an ageing population with disabilities. Community healthcare centres (CHCs) serve as frontline community healthcare providers for older adults with and without disabilities. Despite their significance, there is a lack of literature examining the utilisation of CHC services among older adults. This study aims to examine and compare the utilisation and satisfaction of CHC healthcare services among older adults with and without disabilities.

SETTING

Data from the 2019 Community Health Diagnosis Questionnaire, which interviewed 259 older adults residing in the Luohu district of Shenzhen, were used in the current study.

PRIMARY OUTCOME MEASURES

Participants self-reported outcomes including use of CHCs, use of home health services from CHCs and satisfaction with CHCs. Five different disability types and an integrated disability variable were assessed as independent variables. Linear probability models were used to determine the relationship between disability types and outcome variables.

RESULTS

Among 259 older adults aged 60 years and older, 70.66% self-identified as having a disability. No statistically significant associations were found between the use of CHCs, the use of home health services from CHCs and satisfaction with CHCs, and disability status. However, older adults with mobility and cognitive disabilities were more likely to receive home health services from CHCs.

CONCLUSION

Community health promotion policies should be implemented to improve access to health services for older adults with and without disabilities. In addition, CHCs should implement effective health management plans to ensure the health needs of older adults with disabilities.

High performing primary health care organizations from patient perspective: a qualitative study in China

BACKGROUND

There is a global call to build people-centred primary health care (PHC) systems. Previous evidence suggests that without organization-level reform efforts, the full potential of policy reforms may be limited. This study aimed to generate a profile of high performing PHC organizations from the perspective of patients.

METHODS

We conducted semi-structured interviews with 58 PHC users from six provinces (Shandong, Zhejiang, Shaanxi, Henan, Shanxi, Heilongjiang) in China using purposive and snowball sampling techniques. Transcription was completed by trained research assistants through listening to the recordings of the interviews and summarizing them in English by 30-s segments to generate the narrative summary. Informed by the Classification System of PHC Organizational Attributes, thematic analysis aimed to identify domains and attributes of high performing PHC organizations.

RESULTS

A profile of a high performing PHC organization with five domains and 14 attributes was generated. The five domains included: (1) organizational resources including medical equipment, human and information resource; (2) service provision and clinical practice including practice scope, internal integration and external integration; (3) general features including location, environment and ownership; (4) quality and cost; and (5) organizational structure including continuous learning mechanism, administrative structure and governance.

CONCLUSIONS

A five-domain profile of high performing PHC organizations from the perspective of Chinese PHC users was generated. Organizational resources, service delivery and clinical practices were most valued by the participants. Meanwhile, the participants also had strong expectation of geographical accessibility, high quality of care as well as efficient organizational structure. These organizational elements should be reflected in further reform efforts in order to build high performing PHC organizations.

The Early Impact of the People-centred Integrated Care on the Hypertension Management in Shenzhen

Objective

To evaluate the impact of the integrated care in Luohu, China on the hypertension management.

Methods

Hypertensive patients aged 35-74 years were recruited by the cluster-randomized sampling method from Luohu district which adopted integrated care and another district that remained original routine care during October 2018~January 2020, with 1353 and 583 patients from integrated and routine care communities, respectively. Health information, knowledge, attitude, and practice (KAP) towards cardiovascular diseases, pharmaceutical expenditure on hypertension and its comorbidities, and healthcare-related satisfaction were collected by questionnaires, with the expenditure additionally verified by hospitals' billing records database. Continuous and categorical variables were compared by Wilcoxon test and Chi-square test, respectively. The age-standardized hypertension control rate was calculated by direct standardization.

Results

The standardized hypertension management rate in the integrated care communities (45.75%) was significantly higher than that in routine care communities (14.07%) (P < 0.0001), while the age-standardized hypertension control rates were similar (integrated care: 50.3%, routine care: 52.65%, P = 0.518). The pharmaceutical expenditure on hypertension and its comorbidities in the integrated care communities was Ұ264.23 ± 357.38/month/person, lower than that in the routine care communities (Ұ354.56 ± 430.59/month/person). Patients in the integrated care had higher KAP scores (73.48 ± 11.54), compared with routine care (68.89 ± 15.51) (P < 0.0001). Moreover, the integrated care communities had higher satisfaction rates towards the convenience of dual referral (90.15% vs. 77.99%) and service quality (95.18% vs. 87.81%) than routine care communities (P < 0.0001).

Conclusion

The practice of the integrated care in Luohu has substantially improved the hypertension management and the healthcare-related satisfaction while with relatively low pharmaceutical expenditure. The investigation of long-term impact of the integrated care on hypertension control and management is warranted.

Evolutionary Trends in Integrated Care in 2000–2020 in China: A Scientometric Review Using CiteSpace

Introduction:

Owing to an increasing demand for a continuous and coordinated health service, integrated care is being promoted worldwide. Chinese research on integrated care has rapidly increased over the last 20 years. However, popular topics, paths and trends of integrated care research in China have not been systematically summarised. The study aimed to examine the evolution of integrated care research in China and predict future research trends.

Methods:

We searched for integrated care research in China published 2000–2020 in Chinese (China National Knowledge Infrastructure) and English (Web of Science). Research articles that met the inclusion criteria were selected. CiteSpace 5.7.R3 was used to perform keyword clustering, timeline view and burst detection analyses.

Results:

We included 786 Chinese articles and 124 English articles. Chinese articles formed 10 clusters with 1814 keywords. English articles formed 5 clusters with 487 keywords. From 2000 to 2020, integrated care research in China comprised three stages: (1) In the start-up stage (2000–2007), keywords mainly focus on medical resource integration and two-way referral; (2) In the emergence stage (2008–2015), keywords primarily include integrated model, benefits of integration, paths to integration and incentive mechanisms; (3) In the maturation stage (2016–2020), the main keywords are patient preferences, shared management mechanisms, symbiosis theory, value-based care, payment methods and people-oriented care.

Discussion:

With increasing health care system reform, popular integrated care research topics in the next stage will likely focus on people-oriented integrated care, service value and payment method reform. Academic research on integrated care in China will help to shape and lead policymaking.

Conclusions:

Integrated care research in China has gone through three stages over the last two decades. In the future, integrated care theory in China will be informed by concepts from other fields, such as value co-creation in public management, to address the current problem of lack of synthesis in integrated care in China.

Research on the Current Situation and Countermeasures of Inpatient Cost and Medical Insurance Payment Method for Rehabilitation Services in City

Objective

This study aimed to introduce bed-day payment for rehabilitation services in City S, China, and analyze the cost of inpatient rehabilitation services. Key issues were defined and relevant countermeasures were discussed.

Methods

The data about the rehabilitation cost of 3,828 inpatient patients from June 2018 to December 2019 was used. Descriptive statistics and the Kruskal–Wallis test were employed to describe sample characteristics and clarify the comparity of cost and length of stay (LOS) across different groups. After normalizing the distribution of cost and LOS by Box–Cox transformation, multiple linear regression was used to explore the factors influencing cost and LOS by calculating the variance inflation factor (VIF) to identify multicollinearity. Finally, 20 senior and middle management personnel of the hospitals were interviewed through a semi-structured interview method to further figure out the existing problems and countermeasures.

Results

(1) During 2015–2019: both discharges and the cost of rehabilitation hospitalization in City S rose rapidly. (2) The highest number of discharges were for circulatory system diseases (57.65%). Endocrine, nutritional, and metabolic diseases were noted to have the longest average length of stay (ALOS) reaching 105.8 days. The shortest ALOS was found to be 24.2 days from the diseases of the musculoskeletal system and connective tissue. Neurological, circulatory, urological, psychiatric, infectious, and parasitic diseases were observed to be generally more costly. (3) The cost of rehabilitation was determined to mainly consist of the rehabilitation fee (23.63%), comprehensive medical service fee (22.61%), and treatment fee (19.03%). (4) Type of disease, age, nature of the hospital, and grade of the hospital have significant influences both on cost and LOS (P < 0.05). The most critical factor affecting the cost was found to be the length of stay (standardized coefficient = 0.777). (5) The key issues of City S's rehabilitative services system were identified to be the incomplete criteria, imperfections in the payment system, and the fragmentation of services.

Conclusions

Bed-day payment is the main payment method for rehabilitation services, but there is a conflict between rapidly rising costs and increasing demand for rehabilitation. The main factors affecting the cost include the length of stay, type of disease, the grade of the hospital, etc. Lack of criteria, imperfections in the payment system, and the fragmentation of services limit sustainability. The core approach is to establish a three-tier rehabilitative network and innovate the current payment system.

Title: the impact of a pilot integrated care model on the quality and costs of inpatient care among chinese elderly: a difference-in-difference analysis of repeated cross-sectional data

Background

Recently, integrated care has received tremendous popularity in China, a leading example of which is the Luohu model. In the present analysis, we aimed to examine the impacts of the Luohu model on the quality and costs of inpatient care.

Methods

We conducted a retrospective analysis using administrative claims databases of Shenzhen City (the city that the Luohu district sits) from Jan 2015–Apr 2017, which encompassed the time before and after the implementation of the pilot model. The outcomes were 30-day readmission, inpatient costs, and length of stay (LOS). Multivariable difference-in-difference analyses were conducted.

Results

In the first year following the integration, the Luohu model did not have impacts on any of the outcomes. Although its effect on readmission (ratio of odds ratio: 1.082; 95% CI: 0.865 to 1.353) was still not identified in the first four months of the second post-integration year, it decreased inpatient costs by CN¥ 1224.1 (95% CI: 372.7 to 2075.5) and LOS by 0.938 days (95% CI: 0.0416 to 1.835) per hospitalization episode during the same period.

Conclusions

The Luohu model may reduce costs and LOS in the long term. It is potentially a viable approach to improve the value of inpatient care in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00361-4.

Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review

Background:

The complex needs of patients with multiple chronic diseases call for integrated care (IC). This scoping review examines several published Asian IC programmes and their relevant components and elements in managing multimorbidity patients.

Method:

A scoping review was conducted by searching electronic databases encompassing Medline, Embase, Scopus, and Web of Science. Three key concepts – 1) integrated care, 2) multimorbidity, and 3) Asian countries – were used to define searching strategies. Studies were included if an IC programme in Asia for multimorbidity was described or evaluated. Data extraction for IC components and elements was carried out by adopting the SELFIE framework.

Results:

This review yielded 1,112 articles, of which 156 remained after the title and abstract screening and 27 studies after the full-text screening – with 23 IC programmes identified from seven Asian countries. The top 5 mentioned IC components were service delivery (n = 23), workforce (n = 23), leadership and governance (n = 23), monitoring (n = 15), and environment (n = 14); whist financing (n = 9) was least mentioned. Compared to EU/US countries, technology and medical products (Asia: 40%, EU/US: 43%-100%) and multidisciplinary teams (Asia: 26%, EU/US: 50%–81%) were reported less in Asia. Most programmes involved more micro-level elements that coordinate services at the individual level (n = 20) than meso- and macro-level elements, and programmes generally incorporated horizontal and vertical integration (n = 14).

Conclusion:

In the IC programmes for patients with multimorbidity in Asia, service delivery, leadership, and workforce were most frequently mentioned, while the financing component was least mentioned. There appears to be considerable scope for development.

Highlights

Cost-Utility Analysis of the Integrated Care Models for the Management of Hypertension Patients: A Quasi-Experiment in Southwest Rural China

Background: Hypertension has become the second-leading risk factor for death worldwide. However, the fragmented three-level “county–township–village” medical and healthcare system in rural China cannot provide continuous, coordinated, and comprehensive health care for patients with hypertension, as a result of which rural China has a low rate of hypertension control. This study aimed to explore the costs and benefits of an integrated care model using three intervention modes—multidisciplinary teams (MDT), multi-institutional pathway (MIP), and system global budget and performance-based payments (SGB-P4P)—for hypertension management in rural China.

Methods: A Markov model with 1-year per cycle was adopted to simulate the lifetime medical costs and quality-adjusted life-years (QALYs) for patients. The interventions included Option 1 (MDT + MIP), Option 2 (MDT + MIP + SGB–P4P), and the Usual practice (usual care). We used the incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB), and net health benefit (NHB) to make economic decisions and a 5% discount rate. One-way and probability sensitivity analyses were performed to test model robustness. Data on the blood pressure control rate, transition probability, utility, annual treatment costs, and project costs were from the community intervention trial (CMB-OC) project.

Results: Compared with the Usual practice, Option 1 yielded an additional 0.068 QALYs and an additional cost of $229.99, resulting in an ICER of $3,373.75/QALY, the NMB was –$120.97, and the NHB was −0.076 QALYs. Compared with the Usual practice, Option 2 yielded an additional 0.545 QALYs, and the cost decreased by $2,007.31, yielding an ICER of –$3,680.72/QALY. The NMB was $2,879.42, and the NHB was 1.801 QALYs. Compared with Option 1, Option 2 yielded an additional 0.477 QALYs, and the cost decreased by $2,237.30, so the ICER was –$4,688.50/QALY, the NMB was $3,000.40, and the NHB was 1.876 QALYs. The one-way sensitivity analysis showed that the most sensitive factors in the model were treatment cost of ESRD, human cost, and discount rate. The probability sensitivity analysis showed that when willingness to pay was $1,599.16/QALY, the cost-effectiveness probability of Option 1, Option 2, and the Usual practice was 0.008, 0.813, and 0.179, respectively.

Conclusions: The integrated care model with performance-based prepaid payments was the most beneficial intervention, whereas the general integrated care model (MDT + MIP) was not cost-effective. The integrated care model (MDT + MIP + SGB-P4P) was suggested for use in the community management of hypertension in rural China as a continuous, patient-centered care system to improve the efficiency of hypertension management.

Effect of Collaborative Governance on Medical and Nursing Service Combination: An Evaluation Based on Delphi and Entropy Method

[Background]: Improvement of synergies in medical and nursing services can help governments to optimize the allocation of medical resources; however, an appropriate evaluation method is critical for a suitable decision process in this regard. [Method]: To assess the medical and nursing service combination (MNSC) at a regional level, this study applied a five-dimension evaluation index composed of 28 basic response areas related to the MNSC development status in China, determining its respective weight through the Delphi and entropy methods. [Result]: This empirical exercise analyzed the MNSC supply system by interviewing nine heads of medical and nursing institutions and eleven healthcare-related government personnel during August of 2020 in Xinxiang City, Henan province, P.R China. Results showed: (1) public satisfaction with the fees charged by Medical and Nursing service Institutions (MNSI); (2) Medicare and supply services’ policy publicity; (3) the external financing situation of MNSI; (4) the medical staff’s professional quality; (5) the medical facilities and supply of MNSI; and (6) that the recognition level of the development plan of MNSI scored the highest effect on the synergy of MNSC supply among the assessed factors. [Conclusion]: These results showed that an evaluation based on the Delphi and entropy methods can effectively integrate the opinions of experts and related institutions to evaluate synergies on the medical and nursing service supply.

Factors associated with treatment and control of hypertension among elderly adults in Shenzhen, China: a large-scale cross-sectional study

OBJECTIVE

Hypertension has become the leading cause of death worldwide. Data on hypertension management among Shenzhen elderly are sparse. Our study aims to investigate treated and controlled hypertension in Shenzhen elderly, and identify relevant predictors.

DESIGN

A cross-sectional study.

SETTING

Communities in Shenzhen, Guangdong, China.

PARTICIPANTS

A cross-sectional study was conducted. We employed a convenience sampling method to select participants; 124 007 participants aged 65 years and older were recruited from January to December 2018 at local community health centres in Shenzhen.

MAIN OUTCOME MEASURES

Data on treatment, control and influencing factors of hypertension were obtained from a standard questionnaire, physical measurements and biochemical analyses.

RESULTS

Prevalence of hypertension was 55.8% among the sample population. Among this group of hypertensive patients, those undergoing hypertension treatment and those with hypertension under control were 54.4% and 32.3%, respectively. Employing multivariate analysis, significant associations were found between treatment and older age, junior high school education and above (OR=1.25, p＜0.05), being widowed rather than being married or cohabiting (OR=1.28, p＜0.05), engaging in physical activity (OR=1.14, p＜0.05), ex-smoker (OR=1.19, p＜0.05), habitual drinker (OR=0.72, p＜0.05), history of cardiovascular disease (CVD) (OR=2.20, p＜0.05) and comorbidities, with a higher probability for those with obesity (OR=1.89, p＜0.05), central obesity (OR=1.10, p＜0.05), diabetes (OR=1.49, p＜0.05) or dyslipidaemia (OR=1.20, p＜0.05). Male sex (OR=0.91, p＜0.05), junior high school education and above (OR=1.28, p＜0.05), engaging in physical activity (OR=1.06, p＜0.05), history of CVD (OR=1.82, p＜0.05) and individuals who had diabetes (OR=1.52, p＜0.05) or dyslipidaemia (OR=1.05, p＜0.05) were associated with increased likelihood of control. Aged 80 years and older (OR=0.93, p＜0.05), habitual drinker (OR=0.73, p＜0.05) and central obesity (OR=0.94, p＜0.05) were negatively associated with control of hypertension.

CONCLUSIONS

We found a high prevalence of hypertension, but a low prevalence of treatment and control among Shenzhen elderly.

Patient Choice and Willingness Toward Gatekeepers as First-Contact Medical Institutions in Chinese Tiered Healthcare Delivery System: A Cross-Sectional Study

Introduction: Gatekeeping mechanism of primary care institutions (PCIs) is essential in promoting tiered healthcare delivery system in China. However, patients seeking for higher-level institutions instead of gatekeepers as their first contact has persisted in the past decade. This study aims to explain patients' choice and willingness and to provide potential solutions. Methods: A survey was conducted among residents who had received medical care within the previous 14 days. Patients' choice and willingness of PCIs for first contact together with influencing factors were analyzed using binary logistic regression. Results: Of 728 sampled patients in Hubei, 55.22% chose PCIs for first contact. Patients who are older, less educated, with lower family income, not living near non-PCIs, with better self-perceived health status, only buying medicines, and living in rural instead of urban area had significantly higher probability of choosing PCIs. As of willingness, over 90% of the patients inclined to have the same choice for their first contact under similar health conditions. Service capability was the primary reason limiting patients' choice of PCIs. Conclusions: The gatekeeper system did not achieve its goal which was 70% of PCIs among all kinds of institutions for first contact. Future measures should aim to improve gate-keepers' capability.