In January 2022, Longhua District, Shenzhen piloted a digitally enabled generalist and specialist collaborative care model to deliver consistent, continues services for patients with chronic conditions managed in community health centers. This system-level initiative integrated hospital-based specialists and community-based general practitioners through a vertically aligned care model supported by a shared digital platform.

To evaluate the effect of this digitally enabled generalist-specialist collaborative care model on hypertension management capacity at community health centers.

We employed a difference-in-difference approach to examine changes in center level outcomes before and after the model was implemented during 2021-2024. The treatment group included 84 health centers in Longhua District, and the comparison group included 448 health centers in the rest of districts that were not influenced by the policy. Health centers in treatment group used the collaborative care model to delivery follow-up services, whereas health centers in comparison groups continued to provide routine services in accordance to the National Basic Public Health Services Program Standards (Third Edition) . Multivariate linear regression with district and time fixed effects was constructed, controlling for health center characteristics and adjusting for inverse probability of treatment weights, with standard errors clustered at the center level. Robustness checks were conducted to evaluate the reliability and stability of the model.

After the implementation of the digitally enabled collaborative care model, compared to centers in comparison groups, on average, quarterly standardized hypertension management rate and hypertension control rate in the treatment group increased by 4.3-percentage-point (DID=0.043, SE=0.011, P<0.001) and 11.5-percentage-point increase (DID=0.115, SE=0.012, P<0.001) per center, respectively. On average, the quarterly number of upward referrals per center decreased by 17.1% (P=0.038) , and the quarterly number of total patient visits per centers increased by 22.1% in treatment group (P=0.003) , as compared to comparison groups.

Our study highlights the significance of the digitally enabled specialist and generalist collaborative care model in enhancing health center capacity in hypertension management, reducing upward referrals, and optimizing resource utilization. Our study underscores the importance of incorporating this initiative into national health strategies, such as the National Basic Public Health Services Program, to strengthen chronic care management services delivery in more areas of China. Future policies and research should focus on scaling up this approach to a broader range of medical conditions and prioritizing investments in health centers by ensuring stable funding streams and optimizing the implementation strategies for digital integration pathway.

根据医防融合工作部署，在开展基本公共卫生服务基础上，深圳市龙华区于2022年1月在全区推行"数字化+健康管理"全-专协同服务试点，通过数字化赋能基层全科与医院专科的协同融合，以期提升慢性病患者的区域内就诊率和规范管理率。

评估数字化赋能下全科医生与专科医生协同服务模式在提升基层卫生服务机构高血压管理能力方面的政策实施效果，为政策优化与推广决策提供依据。

本研究采用准自然实验设计，以深圳市2021—2024年运营的532家社区卫生服务机构为研究对象，将龙华区84家机构作为试验组，其余448家未受该政策干预影响的机构作为对照组。试验组自2022年1月起实施数字化全-专协同服务模式管理高血压患者，对照组依据《国家基本公共卫生服务规范（第三版）》要求，为高血压患者提供常规健康管理服务。采用逆概率加权法，构建双重差分回归模型，分析政策实施前后试验组与对照组机构之间各项管理指标的差异，通过稳健性检验验证模型可靠性和稳定性。

数字化全-专协同政策试点实施后，相比于对照组，在控制了其他相关因素后，试验组机构高血压规范管理率每季度平均上升了4.3个百分点（DID回归系数=0.043，SE=0.011，P<0.001），管理人群血压控制率每季度平均上升了11.5个百分点（DID回归系数=0.115，SE=0.012，P<0.001），在管患者向上转诊人次数每季度平均减少17.1%（P=0.038），总诊疗人次数平均增加22.1%（P=0.003）。

实施数字化全-专协同显著提升了试验组社区卫生服务机构高血压规范管理水平，改善了管理人群健康结局，有效减少了在管患者向上转诊次数，同时通过政策外溢效应促进了基层就诊量，对分级诊疗的完善具有重要作用。未来可通过完善政策机制、建立标准化实施路径等措施，为数字化全-专协同服务的全面推广提供参考，助力推进基本公共卫生服务均等化和高质量发展。