Does a GP service package matter in addressing the absence of health management by the occupational population? A modelling study.

OBJECTIVE: To assess the influence of supply and demand factors on the contract behavior of occupational populations with general practitioner (GP) teams. METHODS: We employed a system dynamics approach to assess and predict the effect of the general practitioner service package (GPSP) and complementary incentive policies on the contract rate for 2015-2030. First, the GPSP is designed to address the unique needs of occupational populations, enhancing the attractiveness of GP contracting services, including three personalized service contents tailored to demand-side considerations: work-related disease prevention (WDP), health education & counseling (HEC), and health-care service (HCS). Second, the complementary incentive policies on the supply-side included income incentives (II), job title promotion (JTP), and education & training (ET). Considering the team collaboration, the income distribution ratio (IDR) was also incorporated into supply-side factors. FINDINGS: The contract rate is predicted to increase to 57.8% by 2030 after the GPSP intervention, representing a 15.4% increase on the non-intervention scenario. WDP and HEC have a slightly higher (by 2%) impact on the contract rate than that from HCS. Regarding the supply-side policies, II have a more significant impact on the contract rate than JTP and ET by 3-5%. The maximum predicted contract rate of 75.2% is expected by 2030 when the IDR is 0.5, i.e., the GP receives 50% of the contract income and other members share 50%. CONCLUSION: The GP service package favorably increased the contract rate among occupational population, particularly after integrating the incentive policies. Specifically, for a given demand level, the targeted content of the package enhanced the attractiveness of contract services. On the supply side, the incentive policies boost GPs' motivation, and the income distribution motivated other team members.

The impact of hypertension follow-up management on the choices of signing up family doctor contract services: does socioeconomic status matter?

BACKGROUND: This study aimed to explore the association between hypertension follow-up management and family doctor contract services, as well as to examine whether socioeconomic status (SES) had an interaction effect on this relationship among older adults in China. METHODS: We used data from the sixth National Health Service Survey of Shandong Province, China, including 3,112 older adults (age ≥ 60 years) with hypertension in 2018. Logistic regression models and a margins plot were used to analyze the role of SES in the relationship between hypertension follow-up management and family doctor contract services. RESULTS: The regular hypertension follow-up management rate and family doctor contracting rate were 81.8% and 70.9%, respectively, among older adults with hypertension. We found that participants with regular hypertension follow-up management were more likely to sign family doctor contract services (OR=1.28, 95%CI: 1.04, 1.58, P=0.018). The interaction effect occurred in the groups who lived in rural areas (OR=1.55, 95%CI: 1.02, 2.35), with high education level (OR=0.53, 95%CI: 0.32, 0.88) and had high incomes (OR=0.53, 95%CI: 0.35, 0.81). CONCLUSIONS: Our findings suggested that regular hypertension follow-up management was associated with family doctor contract services and SES influenced this relationship. Primary health care should improve the contracting rate of family doctors by strengthening follow-up management of chronic diseases. Family doctors should focus on improving services quality and enriching the content of service packages especially for older adults with higher income and education level.

Public trust in general practitioners and its association with primary care contracts: a cross-sectional study of community residents in China.

OBJECTIVES: This study aimed to assess the level of public trust in general practitioners (GPs) and its association with primary care contract services (PCCS) in China. STUDY DESIGN: Cross-sectional study. METHODS: Between September and December 2021, 4158 residents across eastern, central, and western China completed a structured self-administered questionnaire. Trust was assessed using the Chinese version of Wake Forest Physician Trust Scale. Multivariable linear regression models were established to identify predictors of trust. The effect size of PCCS on trust was estimated by the average treatment effect for the treated (ATT) through propensity score matching. RESULTS: The study participants had a mean Wake Forest Physician Trust Scale score of 36.82 (standard deviation = 5.45). Enrollment with PCCS (ß = 0.14, P < 0.01), Han ethnicity (ß = 0.03, P < 0.05), lower educational attainment (ß = -0.06, P < 0.01), higher individual monthly income (ß = 0.03, P < 0.05), better self-rated health (ß = 0.04, P < 0.05), chronic conditions (ß = 0.07, P < 0.01), and higher familiarity with primary care services (ß = 0.12, P < 0.01) and PCCS (ß = 0.21, P < 0.01) were associated with higher trust in GPs. The ATT of PCCS exceeded 1 (P < 0.05). CONCLUSIONS: PCCS are associated with higher levels of trust in GPs. PCCS may become an effective tool to attract public trust in GPs, although the relationship between the two may be bi-directional.

A spatial feature analysis of primary health care utilization in a large city in China and its implications for family doctor contract service policy.

BACKGROUND: Family doctor contract policy is now run by the State Council as an important move to promote the hierarchical medical system. Whether the family doctor contract policy achieves the initial government's goal should be measured further from the perspective of patient visits between hospitals and community health centers, which are regarded as grass medical agencies. METHODS: The spatial feature measurement method is applied with ArcGIS 10.2 software to analyze the spatial aggregation effect of patient visits to hospitals or community health centers among 20 districts of one large city in China and analyze the family doctor contract policy published in those areas to compare the influence of visit tendencies. RESULTS: From year 2016-2020, visits to hospitals were in the high-high cluster, and the density was spatially overflow, while there was no such tendency in visits to community health centers. The analysis of different family doctor contract policy implementation times in 20 districts reflects that the family doctor contract policy has a very limited effect on the promotion of the hierarchical medical system, and the innovation of the family doctor contract policy needs to be considered. CONCLUSIONS: A brief summary and potential implications. A multi-integrated medical system along with family doctor contract policy needs to be established, especially integrated in leadership and governance, financing, workforce, and service delivery between hospitals and community health centers, to promote the hierarchical medical system.

Factors influencing contracting of residents with family doctors in China: a national cross-sectional survey.

BACKGROUND: Family doctor contract services (FDCS) have been introduced in China in 2009 [1] and rapidly expanded recently. This study sought to investigate factors that influenced the willingness of Chinese residents to use FDCS. METHODS: We employed multistage stratified and convenience sampling to administer questionnaires to 1455 Beijing, Qinghai, and Fujian residents. The willingness of residents in each province to contract family doctors was analyzed using the chi-square test and binary logistic regression. RESULTS: The analysis in this study found that the signing rate of family doctors in China was about 27.77%, with differences in the signing up levels in Beijing (13.68%), Fujian (64.49%) and Qinghai (11.22%). In addition, the binary logistic regression results emphasized the relative importance of age, education, medical preference and policy knowledge on the willingness to sign up. Distrust of family doctors' medical skills (65.7%), not knowing how to contract (47.8%), and not knowing what medical problems can be solved (41.1%) were the top three reasons accounting for the reluctance of residents to contract with family doctors. CONCLUSION: Residents from different backgrounds have different willingness to sign up, so the specific circumstances and needs of different groups should be taken into account. In order to increase the signing-up rate, consideration can be given to promoting the family doctor model in Fujian throughout the country. Individual hesitation can be eliminated by increasing the reimbursement rate of health insurance, reducing the out-of-pocket expenses of contracted patients, and providing incentives of certain discounts for consecutive contracted patients.

The association of family doctor contract service and patient trust in doctor: evidence from twenty-five village clinics of three counties in rural China.

BACKGROUND: China is implementing the family doctor (FD) system to reform the primary healthcare (PHC). The family doctor contract service (FDCS) policy plays a crucial role in this system implementation, aiming to transform the doctor-patient relationship and enhance PHC quality. This study aims to investigate the impact of FDCS on the doctor-patient relationship in PHCs using field research methodology. METHOD: The field research methodology was employed to address the research questions. Quantitative methods were utilized for data collection and analysis. A structure questionnaire was used to collect data based on the research questions. Our investigation encompassed twenty-five village clinics across three counties in China. A total of 574 subjects helped us to finish this investigation in the study. The collected data was analyzed using statistical analysis including ordinary least squares (OLS) model and propensity scores matching model (PSM) to estimate the relationship. RESULT: The findings from ordinary least squares (OLS) regression revealed that FDCS had a positive influence on patient trust in doctors within PHCs, with patients who participated the FDCS exhibiting higher levels of trust compared to those who did not participate. Propensity score matching (PSM) analysis further confirmed these results by accounting for selection bias. CONCLUSIONS: The implementation of family doctor contract service has brought about significant transformation in the doctor-patient relationship within rural Chinese PHCs. In essence, it has revolutionized the service model of doctor in PHC, playing a pivotal role in improving primary health quality and enhance the service capability of doctors in PHC. This transformative process has been crucial for carrying out hierarchical diagnosis and treatment policy, which aims to adjust the medical service structure and optimizing the health service system. Therefore, it is imperative for government authorities and health administration departments to ensure continuous support for this essential service through appropriate formulation.

Facts about hospital-insurer contracting.

OBJECTIVES: To use publicly available price transparency data files to establish empirical regularities about hospital-insurer contracting. STUDY DESIGN: Retrospective analysis of 10 price transparency data files from HCA Healthcare. METHODS: Cross-sectional qualitative analysis of 524 hospital-insurer contracts across 10 hospitals. RESULTS: We ascertain 4 empirical regularities in these files. First, hospitals contract with many payers, ranging from 35 to 82 across the hospitals in the sample. Second, contract structure varies significantly within and across hospitals: Of the 524 contracts in our sample, the median contract contained 9 contract elements, whereas the mean contract contained 1285 contract elements. Third, most of the contracts in our sample contained multiple contracting methodologies (eg, both fixed fee and percentage of charges). Fourth, these contracts indicated substantial variation for the same service within and across hospitals, validating findings from analyses based on claims data and hospital price transparency files. CONCLUSIONS: Hospital-insurer contracts dictate the flow and structure of a significant portion of total health care expenditure in the US. Increased attention by both researchers and policy makers would lead to a greater understanding of this vital-yet understudied-element of the market for hospital services.

Activities of daily living limitations and family doctor contract services among overweight and obese older adults: is there a rural-urban difference?

BACKGROUND: The purpose of this study was to evaluate the relationship between activities of daily living (ADL) limitations and family doctor contract services among overweight and obese older adults, as well as to examine whether this association varies by urban-rural residence. METHODS: Data for the present study were obtained from the sixth Health Service of Shandong province, China. A total of 4,249 overweight and obese older adults were included in this study. Binary logistic regression models were used to evaluate the relationship between ADL limitations and family doctor contract services, to examine the potential differences between urban and rural areas. RESULTS: Of 4,249 overweight and obese older adults, the prevalence of limitations in ADL and family doctor service contracting rate in Shandong province were 12.47% and 66.46%, respectively. The results of the regression analyses revealed that overweight and obese older adults with ADL limitations were more likely to sign up for family doctor services than those without ADL limitations (OR = 1.27, 95%CI: 1.02-1.58, P = 0.033). Only among rural overweight and obese older adults, the relationship between ADL limitations and family doctor contract services was statistically significant (OR = 1.50, 95%CI: 1.13-1.99, P = 0.005). CONCLUSIONS: Our study found a significant association between ADL limitations and family doctor contract services among overweight and obese older adults in Shandong, China. This relationship differed by urban-rural residence. To promote the positive development of the family doctor contract service system, the government should increase publicity, provide personalized contracted services, and prioritize the healthcare needs of overweight and obese older adults with ADL limitations, with special attention to rural areas.

Study on the determinants of health professionals' performance on diabetes management care in China.

BACKGROUND: As the direct providers of diabetes management care in primary health care facilities (PHFs) in China, health professionals' performance on management care of diabetes determines the quality of services and patients' outcomes. This study aims to analyze the key determinants of health professionals' performance on diabetes management care in PHFs in China. METHODS: We conducted a cross-sectional study in 72 PHFs in 6 cities that piloted the contracted family doctor service (CFDS). Self-developed questionnaire was used to measure three kinds of factors (capacity, motivation and opportunity) potentially influencing the performance of health professionals. The performance of diabetes management care in the study was measured as whether health professionals delivered 7 service items required by the National Basic Public Health Service Guideline with a total of 7 points and was divided into three grades of good, medium and bad. The questionnaire is self-administered by all the health professionals involved in the study with the number of 434. The Chi-square tests were used to compare differences of performance on diabetes management care among health professionals with different characteristics. The ordinal logistic regression was used to analyze the determinants on the performance of diabetes management care. RESULTS: Health professionals who got higher score on diabetes knowledge test had odds of better performance on diabetes management care (OR = 1.529, P < 0.001). health professionals with higher degree of self-reported satisfaction on training (OR = 1.224, P < 0.05) and perception of decreasing workload (OR = 3.336, P < 0.01) had odds of better performance on diabetes management care. While health professionals with negative feeling on information system support had odds of worse performance on diabetes management care (OR = 0.664, P < 0.01). CONCLUSIONS: Attention should be paid to the training of health professionals' knowledge on diabetes management capacity. Furthermore, measures to improve training for health professionals could satisfying their needs for self-growth and improve the motivation of health professionals. The information system supporting management care should be improved continuously to improve the health professionals' working opportunities and decrease the workload.

Equality of public health service and family doctor contract service utilisation among migrants in China.

China initiated the equalisation of an essential public health service programme in 2009 with the goal of developing a more equitable and effective public health system for all people. This study employs data from the China Migrants Dynamic Survey to examine regional-level and household-level income-related inequalities in public health service utilisation and its determinants. Wagstaff concentration indices indicate that essential public health services and family doctor contract services are concentrated among less developed prefectures and poorer households. Decomposition analysis based on recentered influence function regression shows that education contributes to pro-poor inequality in health records and health education utilisation. China's policies of essential public health services and family doctor contract services reduce income-related inequalities in health service utilisation, which has important implications for developing countries striving to achieve universal health service coverage and equal health outcomes.

What factors affect Beijing residents' contracts with family doctors? A comparative study of Beijing's urban and suburban areas.

Objective: To improve the health of residents and promote hierarchical diagnosis and treatment to achieve an orderly pattern of medical treatment, Beijing implemented family doctor contract services (FDCSs) in 2011. The aims of this study were to analyze the current status of Beijing residents' contracts with family doctors (FDs), compare the differences in contracting between urban and suburban residents, and explore the factors that affect residents' contract behavior. Methods: From August 2020 to October 2020, a stratified sampling method was adopted to select residents from community health centers (CHCs) in districts D (urban area) and S (suburb) of Beijing to conduct a questionnaire survey. Chi-square tests, rank sum tests and logistic regression analyzes were used to analyze the current status and influencing factors of residents' contracting with FDs. Results: A total of 4,113 valid questionnaires were included in the final analysis. District D was rich in medical resources, and the FD contract rate of residents there (93.09%) was significantly higher than that of residents in district S (78.06%; p < 0.05). Residents' district (OR = 1.55, 95% CI = 1.18-2.05), understanding of FDCS policies (OR = 4.13, 95% CI = 3.63-4.69), preferred medical institutions (OR = 0.58, 95% CI = 0.42-0.79 for tertiary hospitals in the district; OR = 0.36, 95% CI = 0.22-0.59 for urban medical institutions in Beijing), age, education level, average annual medical expenses and medical insurance type were factors that influenced residents' contracts with FDs (p < 0.05). Conclusion: This study shows that residents who are located in districts with rich medical resources, prefer CHCs as their first choice, have a better understanding of FDCS policies, and are more inclined to contract with FDs than other residents. It is recommended that the number and quality of FDs in suburban areas be increased and that medical staff strengthen publicity about FDCSs and actively encourage residents to contract with FDs.

Barriers and facilitators of family doctor contract services in caring for disabled older adults in Beijing, China: a mixed methods study.

OBJECTIVE: To evaluate the current state of family doctor contract services (FDCS) in Beijing, identify the roles of family doctors who have worked with disabled older adults and investigate the barriers and facilitators faced by family doctors in providing care for them. DESIGN: A convergent mixed methods study was carried out from October 2020 to January 2021 to collect and analyse both quantitative and qualitative data. The integration strategies in this study were connecting the results of the quantitative phase to data collection of the qualitative phase. SETTING: A multi-stage sampling strategy was used to select 15 community health centres (CHCs) in four districts of Beijing. Of the four districts, two were from urban areas and two were from rural areas. PARTICIPANTS: The inclusion criteria for participants were (1) family doctors, (2) contracted with disabled older adults, (3) engaged in related work for disabled older adults more than 6 months. METHODS: A cluster sampling of 283 family doctors was used in the questionnaire. A purposive sample of 30 family doctors from the same CHCs was selected during the same period. Frequency and rank, rank-sum test, Kruskal-Wallis test were conducted in qualitative data analysis, the views of the interviewees were analysed through the thematic framework method. RESULTS: Currently, family doctors provided various services to satisfy the health needs of disabled older adults, while the usage of FDCS for disabled older adults is affected by many factors. The differences of the importance of family doctors' role (p<0.001) and service satisfaction (p=0.004) were significant among four districts. Compared with contracted health senior citizens, this study has identified five unique roles of family doctors, including 'psychological consultant', 'rehabilitation physiotherapist', 'health educator', 'health manager' and 'family health guardian'. Moreover, family doctors are confronted with a myriad of barriers (including high risks in the process of home visits, a lack of supervisory and incentive mechanisms, insufficiency of time and energy, etc) and facilitators (including establishing a doctor-patient trust relationship, developing humanistic care services, etc) in the FDCS for disabled older adults. CONCLUSIONS: Family doctors play a pivotal role in the FDCS for disabled older adults, while the effect and quality of FDCS in China needs to be improved. It is suggested that further research needs to focus on solving existing barriers of FDCS to optimise the health of disabled older adults and improve the quality of their lives.

Study on the application effect of the family doctor contract service mode of 'basic package+personalised package' in elderly hypertension management in Chengdu, China: a retrospective observational study.

OBJECTIVES: We conducted this study to assess the application effect of the family doctor contract service mode of 'basic package+personalised package' in the management of hypertension patients. DESIGN: Observational study. SETTING: The study was conducted at a community health centre in Southwest China. Data were collected from 1 January 2018 to 31 December 2020. PARTICIPANTS: From 1 January 2018 to 31 December 2020, hypertensive patients (age ≥65 years) who participated in the contract services of family doctors at a community health service centre in Chengdu, Southwest China, were selected as the study subjects. MAIN OUTCOME MEASURES: The primary outcomes included mean blood pressure (systolic, diastolic) and the rate of blood pressure control, secondary outcomes included the level of cardiovascular disease risk and self-management ability. Assessments of baseline and 6 months after signing up were conducted on all outcomes. The major statistical analysis methods included two independent sample t-tests, paired t-tests, Pearson's χ2 test, McNemar's test, two independent sample Mann-Whitney U tests and paired sample marginal homogeneity tests. RESULTS: Of the 10 970 patients screened for eligibility, 968 (8.8%) were separated into an observation group (receiving 'basic package+personalised package (hypertension)' service) (n=403) and a control group (receiving 'basic package' service) (n=565) according to the type of service package they received. In comparison to the control group, the observation group had lower mean systolic blood pressure (p=0.023), higher blood pressure control rate (p<0.001), lower cardiovascular disease risk level (p<0.001) and higher self-management ability level (p<0.001) at 6 months after signing up. The mean diastolic blood pressure of the two groups was not significantly different (p=0.735). CONCLUSIONS: The family doctor contract service model of 'basic package+personalised package (hypertension)' has a good application effect in the management of elderly hypertension, which can improve the average blood pressure, the rate of blood pressure control, the level of cardiovascular disease risk and self-management ability of the elderly with hypertension.