Quality Frameworks and Quality Indicators for Hypertension and Diabetes Management in Primary Care in China，the US and the UK：a Comparative Study

doi:10.12114/j.issn.1007-9572.2021.00.144

Abstract

Abstract: Background　How to improve healthcare quality to provide residents with integrated health services，is a salient challenge faced by China. How to define and measure quality is still a controversial topic worldwide. The quality framework is a systematic tool that can be used to assess primary care quality，contributing to the development of the quality improvement plan and offering insights into thoughts about quality. There are few studies on primary care and primary care quality in China，and no cross-sectional comparative case studies on primary care quality evaluation systems as well as evaluation indicators targeting the care for a disease in multiple countries. Objective　To compare the monitoring，assessment or certification system regarding primary care quality and the included quality indicators for hypertension and diabetic management in China，the US and the UK，to obtain a deeper understanding of primary care quality，and mechanism of actions of care quality evaluation system in improving primary care. Methods　Literature regarding primary care quality in China，the US and the UK evaluated using Donabedian's classic system-based framework of structure，process and outcome was searched. The input，process and outcome concerning primary care quality evaluation as well as the effect of quality evaluation methods on primary care quality performance results in the three countries were analyzed. Cross-sectional comparison of evaluation indicators were performed to find the differences in the quality focus of primary care policies across the countries. Results　The structure and service load for a general practitioner（GP） team are different: In the UK and the US，each GP team serves about 1 200 people（the whole population）on average，while in China，the number reaches 4 632. All three countries have included the care for two diseases，hypertension and diabetes，in the quality assessment scope of primary care as main assessment items. In terms of the structure of quality monitoring system，China and the UK have adopted similar clinical evidence-based indicators by disease entity or key population，while the US has adopted mainly service practice process monitoring. In addition，the domains for quality improvement have been included in the monitoring scope in the US and the UK. In terms of quality indicators，both the US and the UK have adopted exception report as a method for balancing the requirements of population-based health assessment and individual patient characteristics. In China，a relatively single method，that is，care quality assessment results for a sample，is mainly used to represent those of a target population. In terms of the feedback of evaluation results，both the UK and the US inform the assessed subjects and the public of the results，while in China，the feedback is mainly within the administrative and assessment system. As for the informationalized support for primary care quality monitoring and assessment，professional data-fetching programs have been used in the US and the UK，which may avoid the problems caused by using the assessment results of a simple sample representing those of a population to the greatest degree，and are an important basis used for giving feedback to subjects and the public，and for the development，analysis and research of health programs. Conclusion　Due to characteristic healthcare needs and resources，the quality assessment criteria for primary care are different across the three countries，but all are improving in accordance with the changes of supply and demand in primary care and health resources，showing a trend of people-centered and continuous quality improvement incentivized in primary care. For China，relatively good quality results of primary care have been achieved using limited resources，and further effective improvement of the quality indicators is suggested to conduct in accordance with the healthcare system reform，such as the training of primary care workers，structure modification of primary care human resources，quality assessment method for contracted integrated medical and public health services，operation and management ways of a medical consortium as a gatekeeper，mechanisms for health insurance imbursement programs，and the changing of primary care delivery ways according to healthcare needs using digital technologies.

Key words: Primary health care；Health care quality, access, and evaluation；Quality improvement；Diabetes；Hypertension

摘要： 背景　为实现整合式医疗服务，中国所面临的一个突出挑战是如何改善卫生服务质量，什么是质量及如何衡量质量是我国和国际上正在辩论的主题。质量监测框架是帮助基层医疗服务评估质量状态、制定改进计划和激发对质量更广泛思考的系统工具。国内对基层医疗服务和质量的研究较少，尚未发现针对多个国家相关质量监测体系、疾病具体指标的横向对比案例研究报道。目的　通过整体分析中、英、美三国基层医疗卫生服务质量监测、考核或认证指标体系，以及其中涉及的具体病种指标，理解基层医疗服务的质量内涵，分析质量指标体系对服务质量改进的作用方式。方法　以Donabedian经典的基于系统的结构、过程和结果框架的质量框架为对比基线，检索案例国家关于基层医疗卫生服务相关文献。分析各案例国家在体现各自基层医疗卫生服务质量内涵上的相关投入、过程和结果关注，以及质量考核方式对质量绩效结果的影响。进一步通过对指标的横向对比，寻找政策关注差距。结果　三国人力资源结构和服务负荷不同，英、美平均每个全科医生团队服务1 200人（全人群）左右，而中国达到了4 632人。三国都将“两病”纳入基层医疗主流的考核范围。在质量监测结构上，中、英采用了类似的以病种或重点人群分类的临床循证指标监测方式，美国采用了以服务实践过程监测为主的方式；英、美都纳入了质量改进的监测领域。在质量指标上，英、美都采用了通过“例外报告”的方式考虑人群考核指标要求与患者个性化特征的平衡，中国主要采用了相对单一的抽样到个体来代表人群质量结果的方式。在评估结果反馈上，英、美都反馈到被评估对象和公众，中国主要在行政和考核体系内反馈。在信息化对考核和监测的支持上，英、美都配套了专业的数据抓取计划，最大限度规避了考核中用简单的个体抽样结果代替人群整体管理结果而导致的一系列问题，也是反馈、面向社会公布、分析研究、开发患者健康类应用的重要数据基础。结论　3个国家根据需求和资源不同，对基层医疗卫生服务的质量要求不同，但一直都随着供需和资源变化不断改进，并且呈现出在基层医疗卫生服务中鼓励“以人为中心”和“质量持续改进”的趋势。中国基层医疗卫生服务在资源有限的情况下，完成了较好的服务质量效果。在下一步质量指标完善过程中，必须与其他宏观意义上的体制机制改革配合才能有效实施，比如基层人力资源培养和结构调整、医疗和公共卫生真正结合的签约服务考核方式、基于基层“守门”的医联体运行管理模式和医保支付机制、以业务需求为导向的基层医疗数字化转型活动等。

关键词: 初级卫生保健；卫生保健质量, 获取和评价；质量改进；糖尿病；高血压

HUANG Yanli,YE Jingxue,LIU Hongyuan. Quality Frameworks and Quality Indicators for Hypertension and Diabetes Management in Primary Care in China，the US and the UK：a Comparative Study　[J]. Chinese General Practice, 2021, 24(31): 3929-3941. DOI: 10.12114/j.issn.1007-9572.2021.00.144.
黄艳丽,叶静雪,刘鸿源. 中美英基层医疗服务质量评价框架及“两病”质量指标对比研究[J]. 中国全科医学, 2021, 24(31): 3929-3941. DOI: 10.12114/j.issn.1007-9572.2021.00.144.

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