Sociodemographic and endogenous factors associated with access to eye care in Canada, 2016 to 2019.

Introduction: Eye care is important, but it is not always promoted as much as other aspects of health. A visit to an eye care professional is made when need, stimulus, access and availability exist. Data and methods: Data from cycles 5 and 6 (2016 to 2019) of the Canadian Health Measures Survey were used. Analyzed variables were related to sociodemographic characteristics, general health, behaviour and eye health. Estimates were obtained using survey weights, and 95% confidence intervals were obtained with bootstrap weights. Results: From 2016 to 2019, 75% of people diagnosed with diabetes visited an eye care professional during the previous year. For people not diagnosed with diabetes, the rate varied, at 57% for those aged 6 to 18 years, 40% for those aged 19 to 64, and 63% for those aged 65 to 79. For those aged 6 to 64, wearing glasses and having access to a family doctor were the main factors associated with a visit to an eye care professional in the previous year. For those aged 65 to 79, cataracts, sex, marital status and self-perceived quality of life were the most significant factors. Interpretation: Although wearing glasses or having eye diseases was associated with a visit to an eye care professional, this study revealed additional emerging associated factors: access to a family doctor for people aged 6 to 64, and an excellent or very good self-perceived quality of life for those aged 65 to 79.

Financing and payment reforms for primary health care and universal health care in Africa.

No abstract available.

A Signaling Game of Family Doctors and Residents from the Perspective of Personalized Contracted Service.

The role of the family doctor contracted service system in China's medical and health system is increasing day by day. However, with the steady increase in contracting coverage, the phenomenon of "signing up but not contracting" has become common; to improve the current situation, the personalized signing service model has been strongly advocated. To promote the smooth implementation of the personalized contracted service model with family doctor competency as its core, this study used the signal game model to analyze the market equilibrium state of the signing service model. The results of this analysis reveal the following: (1) The camouflage of the number of contracts leads to distortion of the signal effect and to market failure, that is, the cost of competency camouflage is the primary factor affecting the equilibrium of contracted services. (2) The incompleteness of contracted services leads to quantity but not quality in the contracting market, that is, the payment of personalized service packages, the value-added utility of personalized services, and service gaps are the key factors that affect the decision-making behavior of the public. With this knowledge in mind, a compensation incentive mechanism that matches the competence level of the family doctor should be established, the formulation of contracted service agreements should be improved, and the participation of family doctors and residents should be encouraged, while the promotion of personalized contracted services should be enhanced and relevant supporting measures should be improved.

The Impact of a Family Doctor Contract Service on Outcomes for Type 2 Diabetes Patients in Zhejiang Province.

This study evaluated the effect of family doctor contract service on the health management in Chinese type 2 diabetes mellitus (T2DM) patients over a 24-month period. According to whether patients signing contracts with family doctors or not, the contracting status was divided into contracted and noncontracted. The analysis of covariance was used to examine changes in weight, body mass index, waist circumference, systolic blood pressure, fasting plasma glucose, and lipid parameters between the two groups. The hazard ratios for incident diabetes-related complications were calculated using a Cox proportional hazard model. Of the 2310 patients, 1155 were contracted. The contracted patients displayed the improved fasting blood glucose control and lower low-density lipoprotein cholesterol level than the noncontracted group. Patients signed up with family doctors had a lower risk of diabetes-related complications than those who did not. The data suggested that family doctor contract service might help to achieve better T2DM control.

Effects of Family Doctor Contract Services on the Health-Related Quality of Life Among Individuals With Diabetes in China: Evidence From the CHARLS.

Background: Family doctor contract services (FDCS) has played a key role in diabetes management in China since 2016. The influence of FDCS on the physiological indexes of individuals with diabetes has been examined. However, little attention has been paid to its effect on the Health-Related Quality of Life (HRQoL). This study aims to fill this knowledge gap by evaluating the effect of FDCS on the HRQoL of individuals with diabetes. Methods: We identified 382 individuals with diabetes receiving all follow-up surveys in 2013, 2015, and 2018 from the China Health and Retirement Longitudinal Study (CHARLS). The HRQoL of the included individuals was estimated using results from the Short Form 36 (SF-36) questionnaire. The propensity score matching with the difference-in-differences (PSM-DID) approach was applied to quantify the effect of FDCS on the HRQoL among individuals with diabetes. A robust test was performed by setting the 2015 data as the treatment group for the placebo test. Results: The mean score of role-emotional (RE) increased from 54.25 to 61.63 among those who signed up to receive FDCS, while the corresponding score decreased from 57.77 to 51.04 among those who did not receive FDCS. Results from the regression analysis indicated that the use of FDCS was associated with significant improvement in RE (+14.10, p = 0.04) among individuals with diabetes. We did not find a statistically meaningful association between the FDCS and any of the other HRQoL domains: physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), and mental health (MH), respectively. The robustness analysis of the model indicated that the results were robust. Conclusion: The FDCS for diabetes in China was associated with a significant improvement in RE. Due to a limited time since the launch of FDCS (i.e., 2016), the recipient's physical health did not show marked improvement. In the future, FDCS should pay more attention to the physiological health of individuals with diabetes. Moreover, psychological services also need to be maintained and not slackened. At the same time, it is strongly recommended to pay more attention to the HRQoL of individuals with diabetes and more comprehensive health.

Development and Validation of a Model to Predict the Contract Service of Family Doctor: A National Survey in China.

Background: Previous studies have reported a relatively low utilization of family doctor contract services (FDCS) in China, while the associated factors are unknown. The current study aimed to explore the factors associated with the utilization of FDCS, and then developed and validated a predictive model based on these identified factors. Methods: We conducted a nationwide cross-sectional study using an online questionnaire, from March 2019 to April of 2019. Routinely collected variables in daily practice by family doctors were used to develop a derivation model to determine the factors associated with FDCS utilization, and then the external performance of the model was tested. Results: A total of 115,717 and 49,593 participants were included in the development and validation datasets, respectively. Nearly 6.8% of the participants who signed a contract with FDCS received healthcare services from family doctors in China. Factors associated with the utilization of FDCS included age, male sex, self-reported household income, education attainment, insurance status, self-reported health status, smoking, drinking, self-reported physical activity status, chronic disease, walking distance from the nearest community center, and illness in the last 2 weeks, with an area under the receiver operating characteristic curve (AUC) of 0.660 [95% confidence interval (CI), 0.653-0.667] and good calibration. Application of this nomogram in the validation dataset also showed acceptable diagnostic value with an AUC of 0.659 (95% CI, 0.649-0.669) and good calibration. Conclusion: Twelve easily obtainable factors in daily practice of family doctors were used to develop a model to predict the utilization of FDCS, with a moderate performance.

Building primary health care teams for universal health coverage in Africa.

No abstract available.

Family Doctor Contract Services and Awareness of Blood Pressure Measurement Among Hypertension Patients: A Cross-Sectional Study in Rural Shandong, China.

Background: Some studies found that family doctor contract services (FDCSs) had positive impact on the self-measurement behaviors of hypertension patients. However, evidence concerning the association between FDCSs and blood pressure measurement awareness among hypertension patients is not clear. Objective: This study aims to explore the relationship between FDCSs and blood pressure measurement awareness among the hypertension patients, and examine whether there is a difference in this relationship among middle-aged and aged adults in rural Shandong, China. Methods: A multi-stage stratified random sampling was adopted in 2018 in Shandong Province to conduct a questionnaire survey among the sample residents, in which 982 hypertension patients were included in the study. Pearson chi-square test and logistic regression model were employed using SPSS 24.0 to explore the association between FDCSs and blood pressure measurement awareness. Results: 76.8% of hypertension patients would measure blood pressure regularly. The blood pressure measurement awareness of the signing group was significantly higher than that of the non-signing group when controlling other variables (P < 0.001, OR = 2.075, 95% CI 1.391-3.095). The interaction of age and contracting status were significantly correlated with blood pressure measurement awareness (P = 0.042, OR = 1.747, 95% CI 1.020-2.992; P = 0.019, OR = 2.060, 95% CI 1.129-3.759). Factors including gender (P = 0.011, OR = 0.499, 95% CI 0.291-0.855), household income (P = 0.031, OR = 1.764, 95% CI 1.052-2.956), smoking status (P = 0.002, OR = 0.439, 95% CI 0.260-0.739), sports habits (P < 0.001, OR = 2.338, 95% CI 1.679-3.257), self-reported health (P = 0.031, OR = 1.608, 95% CI 1.043-2.477), distance to the village clinic (P = 0.006, OR = 1.952, 95% CI 1.208-3.153) and medications (P < 0.001, OR = 3.345, 95% CI 2.282-4.904) were also found to be associated with the blood pressure measurement awareness of hypertension patients. Conclusion: The government should take efforts to strengthen publicity and education of family doctors and pay more attention to uncontracted, middle-aged, female patients and patients with unhealthy life behaviors to improve the blood pressure measurement awareness.

Telehealth in Primary Health Care: A Scoping Review of the Literature.

Background: The use of telehealth as a viable mobility to deliver quality services steadily increases in various levels of the health system. Despite the increasing use of telemedicine in secondary and tertiary health care services, there is a long way to go in the use of this technology in public health and primary health care (PHC). This study aimed to explore the features, approaches, and various dimensions of telehealth in PHC. Methods: A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in three bibliographic databases including PubMed, Web of Sciences, and Scopus and in Google Scholar to collect papers published in November 2018 to 2000. Data were extracted according to a predefined form and check for completeness and accuracy by a second reviewer. Results: Through reviewing papers, the authors extracted information on the general characteristics and features of telehealth services, kinds of PHC services delivered via telehealth, hardware and software facilities used for providing health care through telehealth services packages, as well as their benefits, outcomes and obstacles. Conclusion: Telehealth can be used for different purposes of PHC through deploying a full range of communication channels available to the public. Due to the opportunistic use of existing devices and platforms, telehealth can provide scalable PHC services nationwide and worldwide. However, implementing telehealth in PHC faces challenges from technical, organizational, and human perspectives. Digital equity (in terms of technology access and e-health literacy) is required to expand telehealth services to the populations in underserved areas.

Can the implementation of family doctor contracted service enable the elderly to utilize primary health care services more equally? empirical evidence from Shandong, China.

BACKGROUND: While the elderly are facing greater health risks, they also face more serious inequalities in utilization of medical services. The family doctor contracted service is the core policy of the Chinese government to cope with aging and to achieve the outcome that everyone has the right to primary health care. However, previous research has neither revealed the degree of inequality in the use of contracted services among the elderly in China, nor has it revealed what factors are related to the inequality in the use of services. OBJECTIVE: Assess and decompose the inequality in the use of family doctors contracted services in the elderly population in China. METHODS: A cross-sectional study of 1037 elderly people was conducted in Shandong Province, China. According to the first consultation rate of family doctors, the physical examination rate, the healthy lifestyle guidance rate and the chronic disease management rate, the situation of elderly people's utilization of family doctor contracted service was investigated. The concentration index is used to measure the degree of inequality in the use of family doctors contracted services by the elderly. In order to test the contribution of different factors to the inequality of utilization of family doctors contracted services, the concentration index was also decomposed. RESULTS: The first consultation rate of family doctors for the elderly in Shandong Province was 24.6%, the physical examination rate was 65.8%, the healthy lifestyle guidance rate was 13.7%, and the chronic disease management rate was 52.2%. The horizontal inequality index of the healthy lifestyle guidance rate and the chronic disease management rate were 0.451 and 0.573, respectively, indicating that there is an inequality of pro-wealth. The concentration index of physical examination rate and chronic disease management rate is negative (- 0.260, - 0.518), which means inequality to the poor. Education level is the most important factor affecting the unequal utilization of health services for the elderly, followed by income. CONCLUSION: The family doctor contracted service has had a positive impact on alleviating the health inequality in the utilization of basic medical and health services for the elderly. Although there is still inequality in terms of pro-wealth for the elderly, the utilization of family doctor contracted service has weakened the inequality of service utilization brought about by income. Enhancing the health literacy of the elderly, narrowing the gap between the rich and the poor, bridging the gap between urban and rural areas, and building a harmonious family relationship can promote the realization of basic medical and health care services for every elderly.

Do Residents and Healthcare Providers Differ in Preference for Family Doctor Contract Service? Evidence From a Discrete Choice Experiment.

OBJECTIVE: Few are known on how and to what extent residents and healthcare providers have different preferences for family doctor contract service (FDCS). This study aimed to elicit and compare the residents' and healthcare providers' preferences for FDCS through a discrete choice experiment (DCE). METHODS: Residents and healthcare providers recruited for the DCE were asked to choose repeatedly between two hypothetical service plans, which differed in six attributes: cost, service package, service delivery, type of service, accessibility of medicine, and level of healthcare team. We use mixed logit regression models to determine preferences for potential attributes. RESULTS: A total of 2,159 residents and 729 healthcare providers completed valid DCE questionnaires. The mixed logit model results suggested that cost, service package, service delivery, type of service, accessibility of medicine, and level of healthcare team all had a significant impact on residents' and healthcare providers' preference. The level of healthcare team was the most important characteristic of FDCS to both residents and healthcare providers, followed by types of service. They have different preferences on the cost and way of service delivery. CONCLUSIONS: This study provides new evidence on how and to what extent residents and healthcare providers have different preferences for FDCS by determining their perception of various service attributes. These findings suggested that the optimal design and improvement of FDCS plans should consider not only residents but also healthcare providers' preferences to maximize contract service uptake.

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

BACKGROUND: The Chinese government has taken many incentives to promote the implementation of the family doctor (FD) contract service; however, whether primary health care providers establishing a strong relationship with patients that shapes their loyalty is still unknown. Under this circumstance, drawing the public attention to patient loyalty in primary care and clarifying the underlying mechanism of loyalty is imperative to the development of primary care. OBJECTIVE: To analyse the effect of patient perceived involvement on patient loyalty in primary care, investigate the mediating role of patient satisfaction, and explore the moderating role of the FD contract service on the relationship between patient perceived involvement and patient loyalty. METHODS: A cross-sectional questionnaire survey of patients in primary health facilities was conducted in Jilin province of China. Participants comprised 1334 patients selected via a multi-stage sampling method. RESULTS: Patient perceived involvement not only had a direct positive impact on patient loyalty but also had an indirect effect on patient loyalty via patient satisfaction. Furthermore, for patients who contracted with FDs, patient perceived involvement had a higher direct effect and indirect effect on patient loyalty when compared with patients who did not contract with FDs. CONCLUSIONS: Our findings suggest that health managers should encourage patients to participate in medical visits to improve patient satisfaction. Additionally, customised and tailored health services that meet individuals' specific needs and preferences should be designed and implemented to attract more patients to contract the FD contract service.

The impact of public policy of family doctor contracting on medical expenses from the perspective of residents at community level in China.

Objective: To analyze the impact of the contract of family doctors in community-level in Beijing on residents' medical expenses, so as to explore the efficacy of family physician contract service to facilitate the hierarchical treatment system. This study pioneeringly used the panel data of medical records and medical insurance settlement details provided by a community hospital in Beijing. By analyzing the correlation between family doctors and medical expenses, the study provided empirical support for the advancement of family doctor contracting in China. Methods: Using the panel data of medical records and medical insurance settlement details of 5,851 residents in a community hospital in Beijing from January 2018 to May 2021 for a total of 41 months, mixed-effects model and random-effects model were used for analysis. Results: The contract of family doctor has significantly increased residents' medical expenses. The types of medical insurance and whether patients with chronic diseases have a significant impact on residents' medical expenses. Conclusion: Family doctor contracting increases the probability of residents seeing a doctor in community hospitals. Community family doctor contracting services should be vigorously promoted, especially for special groups such as chronic disease patients and the elderly. The increase in the contracting rate of family doctors will become an important starting point for promoting hierarchical medical system and increasing the primary treatment at the community-level.

Utilización de servicios de salud por la población de cuatro consultorios del médico de la familia

RESUMEN Introducción: La utilización de los servicios de salud es un proceso social, dinámico y complejo. Objetivo: Describir la utilización de los servicios de salud por la población de cuatro consultorios del médico y la enfermera de la familia. Métodos: Estudio descriptivo de corte transversal entre los meses de enero de 2019 a enero de 2020. Se aplicó una encuesta a 775 personas de 18 años y más. Los datos se procesaron con el paquete estadístico SPSS versión 20.0 para Windows. Se utilizaron estadísticas descriptivas, expresando los resultados en tablas de distribución de frecuencias. Resultados: El rango de edades de mayor representatividad fue el de 70-74. El sexo femenino representó el 10,2 % (46) y el masculino el 12,7 % (41). En relación con la iniciativa para solicitar actividades de promoción y prevención, las más solicitadas fueron toma de tensión arterial, chequeo médico y peso corporal. La solicitud habitual de receta médica (706; 87,3 %) se realiza al médico del consultorio. El lugar a donde se dirige el paciente, fundamentalmente, en caso de necesitar atención médica no urgente es al consultorio médico de la familia (650; 83,9 %). Los lugares a donde se dirige, esencialmente, en caso de necesitar atención médica urgente son al cuerpo de guardia del hospital (520; 67,5 %) y al cuerpo de guardia del policlínico (208; 27,0 %). Conclusiones: La población de los cuatro consultorios estudiados utiliza los servicios en los diferentes niveles según el problema de salud que necesita resolver. Sería importante poder identificar en otras investigaciones por qué las actividades menos solicitadas son el tacto rectal, el antígeno prostático y el examen físico de mama, en aras de trazar estrategias que permitan incrementar el empoderamiento para la salud individual.

ABSTRACT Introduction: The use of health services is a social, dynamic and complex process. Objective: Describe the use of health services by the population of four family doctor and nurse's offices. Methods: Descriptive cross-sectional study carried out from January 2019 to January 2020. A survey was applied to 775 people of 18 years and older. The data was processed using the SPSS statistical package version 20.0 for Windows. Descriptive statistics were used, expressing the results in frequency distribution tables. Results: The age range of greatest representativeness was 70-74. The female sex represented 10.2% (46) and the male sex was 12.7% (41). In relation to the initiative to request promotion and prevention activities, the most requested were blood pressure testing, medical check-up and body weight. The usual request of prescriptions (706; 87.3%) is made to the doctor in the office. The place where the patient goes, fundamentally, in case of needing non-urgent medical attention is to the family doctor's office (650; 83.9%). The places where the patient goes, essentially, in case of needing urgent medical attention are the emergeny service in the hospital (520; 67.5%) and the emergency service of the polyclinic (208; 27.0%). Conclusions: The population of the four family doctor's office studied uses the services at different levels according to the health problem they need to solve. It would be important to be able to identify in other research why the least requested activities are digital rectal examination, prostate antigen and breast physical examination, in order to draw strategies that allow increasing empowerment for individual health.

Family doctor contract services and health-related quality of life among patients with chronic diseases in rural China: what is the role of socioeconomic status?

PURPOSE: Few studies explored the relationship between the family doctor contract services (FDCS) and health-related quality of life (HRQOL) among patients with chronic diseases in rural China. This study aims to explore the relationship between the status of signing on FDCS and HRQOL among patients with chronic diseases and examine whether there are differences in the relationship between different socioeconomic status (SES). METHODS: A total of 1,210 respondents were included in this study. HRQOL was measured by EQ-5D-3L. The contracting status was divided into uncontracted and contracted. Tobit regression and Logistic regression were employed to explore the association between contracting status and HRQOL. The interaction terms were included to explore the differences in the association among different SES. RESULTS: Contracting with family doctors was associated with HRQOL (coefficient = 0.042; 95%CI 0.008 to 0.075). The association was different among different socioeconomic levels that the contracting status was only associated with HRQOL in sub-high-income (P < 0.01) and highly educated patients (P < 0.05). Compared with uncontracted patients, contracted patients reported higher ED-5D-3L utility value in the sub-high-income group (coefficient = 0.078; 95%CI 0.017 to 0.140) and high educational attainment (coefficient = 0.266; 95%CI 0.119 to 0.413). CONCLUSIONS: This study found a significant association between FDCS and HRQOL among chronic patients in rural Shandong, China. This relationship varied by income levels and educational attainment. The government should take efforts to formulate a variety of measures to encourage chronic patients to contract with family doctors, with special attention to people with low SES.

Family characteristics associated with rural households' willingness to renew the family doctor contract services: a cross-sectional study in Shandong, China.

BACKGROUND: In China, some previous studies have investigated the signing rate and willingness of residents to sign the family doctor contract services (FDCS). Few studies have explored residents' willingness to renew the FDCS. This study is designed to understand the family characteristics difference towards rural households' willingness of maintaining the FDCS. METHODS: A total of 823 rural households were included in the analysis. A descriptive analysis was conducted to describe the sample characteristics. The binary logistic regression model was used to explore the family characteristics that influence the renewal willingness for FDCS among rural households in Shandong province, China. RESULTS: Our study found that about 95.5% rural households had willingness to maintain the FDCS in Shandong, China. Those households with catastrophic health expenditures (CHE) (OR = 0.328, 95%CI = 0.153-0.703), with highest level of education at graduate or above (OR = 0.303, 95%CI = 0.123-0.747) were less willing to maintain the FDCS. Those whose households have more than half of the labor force (OR = 0.403, 95%CI = 0.173-0.941) and those households living in economically higher condition were less willing to maintain the FDCS. CONCLUSIONS: This study demonstrates a significant association between family characteristics (CHE, highest education in households, proportion of the household labor force) and willingness to maintain FDCS among rural households in Shandong, China. Targeted policies should be made for rural residents of identified at-risk families.

Can social capital play a role in contracting services of family doctors in China? Reflections based on an integrative review.

BACKGROUND: The family doctors' contract service problem is not about government management alone, but an interaction of a complex social environment. Consequently, the effect of contracted services of family doctors not only depends on policy incentives but also needs to win the participation, acknowledgement, and confidence of community residents. The purpose of this integrative review is to examine whether there is any significant evidence that social capital in the form of social networking groups and other forms of social groups have any positive impact on the acceptance and the effectiveness of family doctors' contractual services. METHOD: Research on qualitative, quantitative and hybrid methods published in peer-reviewed journals on the social capital role in the process of contract service of family doctors were eligible for inclusion. In view of the increasing attention paid to the contract service effect of family doctors during this period, a 10-year time scale was selected to ensure full coverage of relevant literature in the same period. In total, 809 articles were determined in the database retrieval results which were downloaded and transferred to the Mendeley reference application software. RESULTS: Twelve articles met the inclusion criteria for this integrative review and the quality of the included studies were assessed using the published criteria for the critical appraisal of quantitative and qualitative research methods. Majority of the articles assessed reported that there was evidence of a positive link between social support, especially a sense of belonging and the presence of regular family doctors. The influencing factors of patients' contract behavior of studies conducted in China were social interaction of social capital, acceptance of the first contact in the community, year of investigation, and exposure to the public. CONCLUSION: The study affirms previous studies that suggest that social resources have the propensity to improve relationship between patients and clients and between doctors and peers for the benefit of the patients and the stability of the overall healthcare system. Through the integration of various social resources family doctor systems accelerate the development of community construction. These social capital (social network groups) can guide residents to use family doctor services to maintain health. Social capital can also help residents have a regular and reliable family doctor.

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

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

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

Studies globally have provided substantial evidence that PHC could conduct doctor-visiting behaviors, control medical expense, and improve population health. This study aimed to map how family doctor (FD) in Shanghai achieved gate-keeper goals including health management, medical expense control, and conducting ordered doctor-visiting behavior. A total of 2754 and 1995 valid questionnaires were collected in 2013 and 2016 respectively in Shanghai. The data were analyzed using structural equation modeling (SEM). Invariance analysis was also performed for 2 waves of data. We found that the coefficient of cognition on health management (ß5 = 0.26, P < .05) was larger than that of signing with FD (ß4 = 0.06, P < .05). SEM model also showed that first-contact at community health service center (CHSC) had a positive effect on health management (ß6 = 0.30, P < .05), and the latter also affected health management results positively (ß8 = 0.39, P < .05), suggesting that the path for FD was through first-contact and health management. Besides, the gate-keeper role of medical expense control was significant through the first-contact (ß10 = -0.12, P < .05) mediation rather than health management (ß9 = 0.03, P > .05). The model fit was acceptable (RMSEA = 0.033). A "cognition-behavior-outcomes (health and medical expense)" path of FD's gate-keeper role was found. It is necessary to consolidate FD contracted services rather than reimbursement discount the latter of which is proved to be unsustainable.

The developing family doctor system: evidence from the progress of the family doctor signing service from a longitudinal survey (2013-2016) in Pudong New Area, Shanghai.

BACKGROUND: The family doctor system is a vital part of China's national medical and health system reform. Evidence of the degree of implementation of the family doctor system is required to assist managers and policy makers in Pudong with resource allocation planning. This study analyzed changes in indicators (family doctor team construction, contracted medical services, health management services and so on) over time to evaluate the progress of the family doctor system in Pudong. METHODS: We used a cross-sectional design with an online questionnaire survey to collect 3-year (2013-2016) consecutive data. The online questionnaires were completed by the doctors responsible for information reporting in each community health service center of Pudong. The data were sorted, and the indices calculated and analyzed using descriptive statistics and statistical tests. RESULTS: The proportion of registered general practitioners increased each year, from 50.8% in 2013 to 66.5% in 2016; this difference was statistically significant (P = 0.000). The number of family doctors per 10,000 permanent residents rose each year, from 1.7 in 2013 to 2.1 in 2016. The rate of contracted household residents was 55.7% in 2013 and increased to 71.7% in 2016, with the difference being significant in different years (P = 0.012). Analysis of referral services showed the people times of contracted residents transferring to higher-level hospitals from family doctors increased each year, from 172,734 in 2013 to 341,615 in 2016; differences among different regions were statistically significant for 2013-2016. The rate of health screening for contracted residents also increased each year, with statistically significant differences in different years (P = 0.000). The rate of health assessment interventions for contracted residents rose each year, with statistically significant differences in different years (P = 0.003). CONCLUSIONS: The family doctor signing service in Pudong made headway in general practitioner availability, contract service rate of household residents, and providing health management services. However, problems included family doctor shortages and limited supporting policies, especially in rural and suburban areas compared with urban divisions. Increasing the enrollment rate of family doctors and speeding up the implementation of "contract service fees" are key tasks for the sustainable development of the family doctor system in Pudong.