In recent years, China has attached great importance to strengthening the development of general practitioner (GP) workforce and primary care service system. To innovate the incentive mechanism for GP training and employment and improve the training system for GPs, the government has also promulgated a series of policies and put forward major reform measures involving many aspects.
To analyze and evaluate the fairness of distribution of general practitioner (GP) resources in China, and to provide theoretical support for scientific and equitable allocation of GP resources.
Data were sourced from five volumes of China Health and Family Planning Statistical Yearbook (2017—2021), China Health Statistical Yearbook (2017—2021), and China Statistical Yearbook (2017—2021) in June 2022, including the number of GPs, the number of people registered as general medicine professionals, the number of people who obtained the General Practitioner Certificate after training, the number of GPs per 10 000 population, and the number of practicing (assistant) physicians in China, in each geographical division (eastern, central or western), and in each regionin, and the annual gross domestic product (GDP), gross regional product (GRP), and the year-end total population data of each region during 2016 and 2020. Additionally, the total land area of each region was extracted from the China ABC column on the website www.gov.cn. The Lorenz curve and the Gini coefficient were used to analyze the fairness in the distribution of GP resources. The Theil index was used to analyze differences in the distribution of GP resources in eastern, central and western China.
The number of GPs in China increased from 209 083 in 2016 to 408 820 in 2020, showing a growth rate 95.53%. In 2020, the proportion of GPs among all practicing (assistant) physicians reached 10.01% (408 820/4 085 689), and the number of GPs per 10 000 population was 2.90. The Gini coefficients measuring demographic, economic, and geographical distribution inequalities of GP resources were 0.235, 0.178, 0.722, respectively for 2016, 0.231, 0.170 and 0.726, respectively for 2017, 0.225, 0.161 and 0.729, respectively for 2018, 0.177, 0.147 and 0.714, respectively for 2019, and 0.157, 0.136, and 0.707, respectively, for 2020. Overall, the Lorenz curve measuring the inequality in the distribution of GP resources by demographics or economy had lower degree of curvature than that by geography. A reduction was found in Theil index measuring unequal demographic, economic or geographical distribution of GP resources in 2020 compared with that in 2016 (from 0.046 to 0.020; from 0.022 to 0.013; from 0.482 to 0.428) .
During the five years, the distribution of GP resources in China presented the following features: the number of GPs increased rapidly and became an important part of the workforce of practicing (assistant) physicians, the registration rate of GPs gradually increased, and the total GP resources showed a continuous growth, but the ratio of GPs per 10 000 population was still unsatisfactory, great inter-region differences existed in the distribution of GP resources, and the equity of the distribution of GP resources by geography was more unsatisfactory than by demographics or economy.
In China, the governance of public health by the public health committee, a grassroots mass autonomous organization, is a new approach managing public health services in primary care. Many regions are exploring governance models of public health by the public health committee, aiming to make it a key hub to realize the vertical connection and horizontal linkage grid management of grassroots communities.
To analyze the policy documents related to the construction of local public health committees of various regions in China using policy document analysis, so as to provide a reference for improving the primary-level public health governance system and governance capacity.
In March 2022, we searched policy documents related to the construction of public health committees on the official websites of the local governments and health commissions of eight sample regions (Beijing, Guangdong, Chongqing, Shandong, Anhui, Guizhou, Gansu, and Ningxia Hui Autonomous Region) in which village (residential) public health committees have been constructed using "public health committee" as the key search term. Through literature review and policy document analysis, an analytical framework for the governance system of the public health committee was constructed. Nvivo 11 Plus was used for word frequency and coding analyses of the included policy literature.
A total of 15 policy documents and 2 guidance manuals for the work of public health committees were ultimately included. Word frequency analysis showed that the five words, "hygiene" "public" "work" "committee" and "health", appeared most frequently, indicating that the selected policy literature conformed to the research theme. By using the analytical framework, the structural dimensions of the policy literature were determined, including four root nodes, namely, governance subjects, governance mechanisms, institutional guarantees, and capacity building, and 13 sub-nodes. There are 208 reference points for governance subjects, 48 reference points for governance mechanisms, 57 reference points for institutional guarantees, and 87 reference points for capacity building.
The local policy documents of the sample regions cover the contents of the four dimensions, but have different focuses. According to the framework in this study, further construction of the public health committee needs to set certain admission criteria with clear determination of rights and responsibilities for new committee members, establish an effective cooperation and communication mechanism, improve the system guarantee and provide financial and technical support.
The reimbursement of outpatient services is an essential part of the reform of medical insurance payment methods. With the comprehensive promotion of the reform on the medical insurance payment methods for inpatient services in China, the reform on insurance payment methods for outpatient services, such as capitation-based reimbursement and ambulatory patient groups (APG) point method, will gradually be put on the agenda.
To explore a capitation-based reimbursement scheme for chronic diseases applicable to Beijing based on an analysis of capitation-based reimbursement implemented in different countries and regions and the current situation of chronic disease management in Beijing, to provide a reference for implementing the capitation-based reimbursement reform for chronic diseases in Beijing.
This study used information related to essential medical services, reimbursement by health insurance, and essential public health service funds in Beijing's C and H districts. Then through an analysis of the information, the calculation method for capitation-based reimbursement standard for four common chronic diseases (hypertension, diabetes, coronary heart disease and stroke were selected in this study) applicable in the districts was designed to calculate the capitation-based reimbursement standard for major chronic diseases in primary outpatient clinics, providing a reference for promoting the capitation reform for chronic diseases in outpatient clinics.
By analyzing the above-mentioned information in 2017—2019, the capitation-based reimbursement standard was 4 693.11 yuan/person for hypertension, 6 597.70 yuan/person for diabetes, 5 644.46 yuan/person for coronary heart disease, and 6 437.78 yuan/person for stroke in H district calculated using the bottom-up costing, and was 4 884.18 yuan/person for hypertension, 5 960.63 yuan/person for diabetes, 3 733.93 yuan/person for coronary heart disease, and 3 886.66 yuan/person for stroke in C district calculated using the top-down estimating.
In calculating the capitation-based reimbursement standard, as different chronic disease patient groups have different outpatient costs, considering the equity of medical insurance reimbursement and the rationality of capitation-based reimbursement, it is necessary to adjust the risk of the benchmark capitation, and develop personalized service packages for different types and severity of chronic diseases. In the promotion of capitation payment for chronic disease patients, it is necessary to provide personalized essential medical service and public health service packages for patients with different chronic diseases, further improve the chronic disease management capacity of community health institutions to improve the contracting rate and establish an effective incentive and assessment mechanism for general practitioners to rationally allocate capitation balance.
Exploring the factors affecting health service utilization is of great significance for optimizing the allocation of health services. Health-related quality of life (HRQoL) focuses on individuals' subjective self-assessment of their current health status, and may affect their health-seeking behaviors, but there are few studies on the impact of HRQoL on health service utilization of rural residents in China.
To explore the relationship between HRQoL and health service utilization of rural residents in Ningxia Hui Autonomous Region, and to provide a reference for the development of relevant policies/plans, and for the optimization health services in rural areas.
Data were collected from the Health Survey of Rural Residents Families 2019 conducted in four sample counties of Ningxia (Haiyuan, Pengyang, Xiji, Yanchi) from July to August 2019, involving 9 310 cases (≥15 years) with complete key information (gender, age, HRQoL-related indicators, health service utilization indicators). Detailed data of the residents were extracted, including socio-economic and demographic characteristics, health services accessibility, prevalence of chronic diseases, HRQoL measured using European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) and utilization of health services. The effects of health state utility values and visual analog scale (VAS) score on outpatient and inpatient health service utilization were analyzed by binary Logistic regression.
The utilization rates of outpatient and inpatient health services of rural residents in Ningxia were 10.85% (1 010/9 310) and 18.86% (1 756/9 310), respectively. The mean health state utility values and mean VAS score of them were (0.965±0.090) and (69.97±17.84), respectively. Difference testing showed that residents with impaired self-care (in the EQ-5D-3L descriptive system) had higher rates of using outpatient health services〔OR (95%CI) =3.197 (2.633, 3.883), P<0.001〕and inpatient health services〔OR (95%CI) =4.802 (4.059, 5.681), P<0.001〕compared with those with impaired mobility, usual activities, or higher level of pain/discomfort or anxiety/depression. Binary Logistic regression analysis showed that after adjusting for various confounding factors, health state utility values and VAS score were associated with the use of outpatient and inpatient health services (P<0.05). Moreover, the prevalence of chronic diseases also significantly affect the utilization of outpatient and inpatient health services (P<0.05) .
HRQoL and the prevalence of chronic diseases were leading factors affecting the utilization of outpatient and inpatient services in Ningxia rural residents. As an independent predictive factor of residents' health service utilization, HRQoL can be used to assist in the evaluation and monitoring of health service quality and effect, and provide guidance for rational allocation of health resources.
With the increasing aging and the transformation of the disease spectrum of residents, there is increasing national attention to the development of Traditional Chinese Medicine (TCM) services. It is of great significant in better utilizing the proper value of TCM community services in the future to understand the current situation and influencing factors of TCM community services utilization.
To understand the current situation and influencing factors of TCM community services utilization among residents in the main urban areas of Chongqing from demander's perspective, so as to provide reference for the sustainable development of TCM community services.
On December 1, 2021, 23 community health service centers were selected by quota sampling method in proportion to the population in 9 central urban areas of Chongqing, and the residents in each community health service center and its surrounding communities by incidental sampling method were selected to conduct questionnaire surveys. The actual number of questionnaires distributed was 840 with 806 valid questionnaires and effective rate of 96.0%. Based on Anderson's health service utilization behavior analysis framework, the factors influencing individual service utilization behavior were summarized into three categories: tendency characteristics, enabling resources and demand factors. At the same time, the dimension of personal TCM culture was added. Binary Logistics regression was used to analyze the influence of the four dimensions on the utilization of TCM in the community.
The utilization rate of TCM community services among the surveyed residents was only 35.9% (289/806), 12 indicators in 4 dimensions were associated with the TCM community services utilization, including propensity characteristics (age, marital status), enabling resources (type of medical insurance, medical expenditure in the last 2 weeks, whether the institutions can meet the basic medical needs of families, whether institutions provide TCM services), demand factors (chronic diseases, self-perception of physical condition in 2 weeks, demand for TCM community services), personal TCM culture (TCM referral willingness, TCM culture trust level, community TCM cultural atmosphere) (P<0.05) .
There are multidimensional and multifactorial influences on the TCM community services utilization among residents. Therefore, targeted measures should be taken to promote residents' utilization of TCM community services.
The promotion of appropriate traditional Chinese medicine (TCM) techniques in primary care institutions is an important measure emphasizing the co-development of Chinese and western medicine, and enhancing the inheritance and development of TCM.
To analyze primary health workers'preferences for the use of appropriate TCM techniques, providing policy recommendations for the promotion and use of such techniques in primary healthcare institutions.
This questionnaire survey was conducted between July and August 2021. A discrete choice model with seven attributes and 18 choice sets obtained through the use of an efficient orthogonal design were used to develop the questionnaire used in the survey, and the questionnaire has three versions each version with evenly allocated six choice sets (including an opt-out option). Additionally, the three versions have a common general demographic part (sex, age, education level, professional title, etc.) and one common consistency test question. A randomized multistage stratified cluster sampling was used to select 319 health workers on duty on the survey day from a total of 23 primary healthcare institutions in three counties in eastern, central and western China (one county was extracted from each region), and each worker was required to complete one version of the questionnaire extracted sequentially by themselves. Two hundred and ninety-five cases who returned a questionnaire passing a consistency test were included for analysis, resulting in a response rate of 92.5%. Primary health workers' preferences for appropriate TCM techniques were analyzed using conditional Logit models and latent class models. Furthermore, the changes in utility of primary health workers due to attribute level changes were monetized using willingness to pay and presented accordingly.
The conditional Logit analysis showed that medical insurance, the average duration of each operation with the TCM technique, the influence of operation with the TCM technique on income, work burden, the promotion of professional title, and patient healthcare cost, as well as effectiveness of the TCM technique were associated with primary health workers' preferences for the use of appropriate TCM techniques (P<0.05). The latent class model revealed that the opt-out option coefficient for those holding a wait-and-see attitude toward the use of TCM techniques (16.2%) was -3.660 (P<0.001), while that for those supporting the use of TCM techniques (83.8%) was 2.189 (P<0.001). Moreover, those holding a wait-and-see attitude toward the use of techniques exhibited a stronger preference for appropriate TCM techniques that have been proven to be more efficacious (β=1.275), and those supporting the use of TCM techniques showed no significant preference for those with unchangeable effectiveness (β=0.054) .
Primary health workers prefer to use appropriate TCM techniques that can increase their income without workload increase, facilitate their professional title promotion, retain or reduce patient costs, and are covered by health insurance and have good efficacy. To effectively promote primary health workers' enthusiasm in the use of appropriate TCM techniques, it is suggested to add these techniques to the medical insurance reimbursement list, and make a connection between the use of these techniques and title promotion. In addition, different incentive strategies should be adopted for different types of primary health workers.
China has made some achievements in the construction of hierarchical medical system, but the development of its primary healthcare settings is still relatively slow.
To analyze the changes in patient visits and associated determinants in primary healthcare settings in Guangdong during 2013 to 2020, providing a basis for deepening the construction of hierarchical medical system.
In December 2021, this study extracted patient visits in primary healthcare institutions of Guangdong from Guangdong Health Statistics Yearbook (2013—2015), Guangdong Health and Family Planning Statistical Yearbook (2016—2017), and Guangdong's Hygiene and Health Statistical Yearbook (2018—2020) as the reference sequence, and extracted the population data and per capita disposable income from Guangdong Statistical Yearbook 2021, and the financial subsidy for primary healthcare institutions and the number of medical insurance participants from China Health and Family Planning Statistical Yearbook (2015—2017) and China's Hygiene and Health Statistical Yearbook (2018—2021) as the comparative sequence. Grey relational analysis was used to evaluate the strength of correlation between the number of patient visits and its potential associated determinants involving demographic and socioeconomic status, health resource allocation and medical insurance participation.
The number of hospital visits in Guangdong increased from 334.592 million in 2013 to 401.317 million in 2019, with an average annual growth of 3.08%. The number of patient visits in primary healthcare settings in the province reached 437.317 million in 2019, and the average annual growth in these settings was 2.10% during 2013 to 2019. In 2020, the number of patient visits in hospitals and in primary healthcare settings both decreased significantly because of the COVID-19 pandemic. The number of patients visits in primary healthcare settings accounted for 50.7% of all patients visits in medical institutions in 2013, which declined to 48.1% in 2020. Grey relational analysis showed that both the number of residents (r=0.913) and the number of people aged over 65 years old (r=0.913) had the strongest correlation with the number of patient visits in primary healthcare settings, followed by the number of urban-rural resident basic medical insurance participants (r=0.899), the number of beds in primary healthcare settings (r=0.893), the number of primary healthcare settings (r=0.886) and the number of urban employee basic medical insurance participants (r=0.872) .
At present, many patients still choose to hospitals for medical services, which calls for actions to strengthen the first contact in primary care system. It is suggested to meet the needs of residents for nearby medical treatment by enriching the connotation of primary care services, widening the gap of healthcare expenses reimbursed by medical insurance among medical institutions and improving the service capacity of primary healthcare settings under the background of population aging.
As the prevalence of hypertension in China's rural areas is very high, hypertension management in these areas is particularly important.
To summarize the characteristics and weaknesses of hypertension management in Shandong's rural areas using the Innovative Care for Chronic Conditions Framework (ICCC) proposed by the WHO, and to put forward targeted recommendations.
According to the socio-economic level and geographical distribution of hypertension prevalence, three county-level centers for disease control and prevention, 9 town health centers and 36 village clinics were selected from A county of Heze, B district of Jinan and C city of Weihai in Shandong Province, from which 84 cases (including individuals responsible for hypertension management programs, medical workers and hypertensive patients) were selected from June to July 2021 using a purposive sampling method to attend a face-to-face semi-structured interview for understanding the status of hypertension management in Shandong's rural areas. NVivo 12 and Qualitative Data Analysis Model proposed by MILES and HUBERMAN, were used to encode and analyse the interview results using the macro-, meso- and micro-level components of the ICCC.
A total of 13 themes and 51 subthemes were derived from the analysis at three levels. At the macro level, the implementation of hypertension management in Shandong's rural areas was generally in a positive policy environment, such as implementing national policies regarding chronic disease management and publicizing chronic disease management, but the policy framework was not complete, the integration within the departments in the health system was poor, and shortages of professional hypertension managers and sufficient financial support were serious. At the meso level, various medical institutions strived to promote the continuity of medical services, but the organization and deployment of family doctor teams and the promotion and use of information systems still needed to be further strengthened. At the micro level, the cooperation between patients and their families and the family doctor team needed to be improved, and the involvement of patients and their families in hypertension management should be enhanced as well.
The implementation of hypertension management in Shandong's rural areas is good generally, but the following efforts should be made for improvements: vigorously strengthening the leadership and supervision role of the government, formulating and integrating relevant policies, and promoting the integration of relevant departments; increasing financial support, and addressing the relatively shortage of health human resources and improving the weakness of informatization construction in rural areas to promote the delivery of high-quality medical services; attaching importance to the interaction between patients and families, health service team and community partners to promote patients' self-management.
Psychological capital (PsyCap) has a significant impact on individual attitude, behavior, and performance. Currently, studies on the level and associated factors of PsyCap among general practitioners (GPs) are limited.
To investigate the level of PsyCap and its associated factors among community GPs in China, providing evidence for human resource management in primary health care.
To conduct the questionnaire survey, 40 community health service institutions from their list of community health service institutions were randomly chosen, 4 632 GPs (40% of whom were on duty) were randomly selected from each community health service institution's duty roster on the day of the survey, and all five provinces (autonomous, municipalities) regions in the east, central, and west China were chosen by use of multi-stage stratified random sampling between March and May 2021. The questionnaire consisted of 3 sections: general information, workplace violence, and PsyCap, and statistical analysis was performed using general descriptive analysis, rank sum test, and generalized linear regression.
A total of 4 376 community GPs were finally included as eligible respondents. The total median score and average total score of PsyCap were 104 (20) and 4.33 (0.83), higher than the theoretical median (3.50 points). The region〔central China (b=1.355) 〕, age〔40~49 (b=2.609), ≥50 (b=4.035) 〕, marital status〔married (b=1.801) 〕, practice setting〔rural (b=2.088) 〕, holding an administrative post〔no (b=-1.734) 〕, weekly working hours〔>50 (b=2.743) 〕, average number of daily consultations〔20~39 (b=2.177) 〕, workload〔moderate (b=6.900), high (b=8.146) 〕, occupational stress〔moderate (b=-6.936), high (b=-10.309) 〕, occupational development opportunities〔general (b=2.073), more (b=7.747) 〕, and the frequency of workplace violence〔low (b=-3.132), medium (b=-3.990), high (b=-7.033) 〕were factors associated with the level of PsyCap among GPs significantly (P<0.05) .
The PsyCap of community GPs in China is at an upper medium level, and the associated factors are complicated. To improve the level of PsyCap among GPs, attention should be paid to their mental health status, and provide them with interventions targeting PsyCap-related factors to lessen the GPs' stress.
It is urgent to improve the effectiveness of contracted family doctor services due to high prevalence of problems such as uninformed contracting, and contracting but making no appointments.
To analyze the mechanism influencing the effectiveness of contracted family doctor services.
From September 2021 to January 2022, in-depth interviews were conducted with 24 family doctors, 8 institutional managers, and 25 contracted residents purposively sampled from Weifang, Heze, and Jinan of Shandong Province, using an interview guide regarding implementation status of relevant policies and their work status, performance distribution and supervision and management, and sense of gain obtained from the contracting and desired services, respectively. The grounded theory using three levels of coding was used to systematically analyze the mechanism affecting the effectiveness of contracted family doctor services.
Through the coding, 90 concepts (such as "residents' weak health awareness"), 24 categories (such as "awareness of the contracting"), and 8 core categories (such as "capacity in primary care") were obtained. A theoretical model of mechanisms influencing the effectiveness of contracted family doctor services was constructed, mainly including the implementation deviation of policies related to contracted family doctor services, capacity of primary care, and characteristics of residents.
The effectiveness of contracted family doctor services is affected by the deviation in implementing relevant policies, the capacity of primary health services and characteristics of residents. Therefore, to improve the effectiveness of these services, it is necessary to optimize the implementation path of relevant policies, improve family doctors' capacities, and improve residents' health literacy level.
At present, the contracting rate of family doctors in China is high, but there are problems such as low service quality and low service utilization rate.
To comprehensively investigate the current situation of contracting, performance and renewal of family doctor services in Meizhou and Heyuan cities of Guangdong Province, and explore the impact of appointment consultation service on the quality of contract services.
From July to August 2021, 11 districts and counties in Meizhou and Heyuan cities were selected using a multi-stage sampling method, the list of rural health centers that can be investigated was provided by the health bureau of each district (county). The questionnaire was administered through the "questionnaire star" platform to the head of the rural health centers or the directors of public health. The questionnaire was prepared by the Guangdong Internet + Family Doctor Contract Guidance Center, which was called "Guangdong Family Doctor Contract Service Current Situation Questionnaire", including the basic information of the invesgated rural health centers, the current situation and progress of family doctor contract service. Based on the structure-process-outcome (SPO) model, the dependent variables were set as outcome quality indicators (effective contract rate of general population/focused population, number of institutions with difficulty in compliance and low renewal rate) to compare the current situation of family doctor contract service in rural health centers with different appointment consultation service provision capacity. The Logistic regression was used to analyze the impact of appointment consultation service on the outcome quality of contract service.
The median family doctor contract rate of 100 rural health centers for focused population and general population was 69.0% (60.0%, 85.0%) and 31.8% (29.1%, 54.5%), respectively; the number of institutions reaching family doctor contract service coverage target for focused population/general population of 2025 was 42 (42.0%) and 30 (30.0%), respectively. A total of 78 (78.0%) of these 100 rural health centers faced difficulties in compliance implementation, including 38 (90.5%) rural health centers did not provide appointment consultation service; 50 (50.0%) rural health centers had problems with low renewal rates, including 18 (42.9%) of which did not provide appointment consultation service and faced difficulties in compliance implementation. Logistic regression analysis showed that among the health centers reaching the target, there was no effect the providing of appointment consultation service on the contracting rate of family doctors in the focused and general population (P>0.05) ; among the 100 investigeted health centers, the providing of appointment consultation service had a significant effect on the compliance difficulties of the contracted institutions〔OR (95%CI) =0.28 (0.08, 0.98), P<0.05〕; and the providing of appointment consultation service had no effect on the low renewal rate of contracted residents (P>0.05) .
The performance of family doctor contract service in Guangdong Province is closely related to the providing of appointment consultation service by the health cenyers, and it is recommended to enrich the form and content of appointment service in the process of subsequent service, enhance residents' trust and motivation to use the service actively through the Internet + platform "improve efficiency and quality", while injecting motivation for service provision and utilization from both doctors and patients in order to provide continuous and effective integrated medical and health services as well as health management.
The phenomenon of "no referral" still exists against the backdrop of implementing the hierarchical medical system, which has been preliminarily constructed in China. Most existing studies on addressing this phenomenon are mostly from the perspective of hospital management policies, ignoring the role of doctors as "health gatekeepers" in making decisions during the hierarchical diagnosis and treatment process.
To investigate the influence of personal, institutional, environmental, and policy factors on the willingness of physicians in county hospitals to refer patients with common diseases to lower level of institutions from physicians' perspective.
This study was conducted from July to August 2021. By use of region-based stratified and convenience sampling, seven county-level people's hospitals were selected as settings from eastern, central and western China. By use of cluster sampling, physicians (n=142) in internal medical departments were selected from the above-mentioned hospitals to attend an online (through the WJX.cn platform) or off-line (hospital) questionnaire survey to understand their willingness to refer patients with a common illness to lower level institutions, and personal, institutional, environmental, and policy factors associated with their willingness during a consultation described using the scenario simulation method. The survey achieved a response rate of 96.5% (137/142). Binary Logistic regression was used to analyze the effects of personal, institutional, environmental, and policy factors on physicians' willingness to refer the patients to a lower level institution.
The mean score of physicians' willingness to refer the patients to a lower level institution was (9.92±2.20). Fifty-six physicians (40.9%) had higher level of willingness to conduct downward referrals. Education level, awareness level of referrals, and frequency of communication of referrals between higher and lower level institutions were associated with scores of physicians' willingness to conduct downward referrals (P<0.05). Spearman correlation analysis showed that self-rated overall workload, risk of medical disputes and patient-doctor relationship (in the institutional factor dimension) were positively correlated with physicians' willingness to conduct downward referrals (rs=0.26, 0.32, and 0.23; P<0.05). Binary Logistic regression analysis showed that higher awareness level of referrals was associated with increased level of willingness to conduct downward referrals in physicians〔OR (95% CI) =1.62 (1.19, 2.22) 〕. Higher influence of the referral system implemented within the hospital on medical dispute risk was associated with increased physicians' level of willingness to conduct downward referrals〔OR (95%CI) =3.275 (1.10, 9.73) 〕. However, higher influence of the referral system implemented within the hospital on performance was associated with reduced level of willingness to conduct downward referrals in physicians〔OR (95%CI) =0.400 (0.20, 0.79) 〕.
This study suggests that the willingness of physicians in county hospitals to conduct downward referrals is low on the whole, but it can be improved by increasing physicians' awareness level of referrals, and improving the influence of the referral system implemented within the hospital on the risk of medical disputes, and decreasing the influence of the referral system implemented within the hospital on the performance. In view of this, it is recommended that hospitals adopt a performance appraisal model that incorporates policy values, highlights policy recognition of referrals, and measures economic losses caused by referrals and the value of extra labor load, strengthen the popularization of hierarchical medical system in primary hospitals, and innovatively use the Internet-based hierarchical diagnosis and treatment model.
The county-level medical community has helped improve the capacity of primary care institutions and the quality of primary care services, and promoted the operational efficiency of primary care institutions through various "strengthening primary healthcare" measures.
To evaluate the efficiency of service delivery and the total factor productivity (TFP) of member township hospitals in county-level medical communities constructed in typical national pilot areas in China.
We collected the annual monitoring data and annual health statistics reports during 2018 to 2019 of county-level medical communities (involving 143 member township hospitals) in eight counties (cities) of four regions in central and western China (Anhui Province, Jiangxi Province, Guangxi Zhuang Autonomous Region and Xinjiang Uygur Autonomous Region). We used data envelopment analysis (DEA) and Malmquist inde (MI) to analyze the change in TFP of the township health hospitals before and after the pilot construction of county medical communities.
Taking the county as the decision-making unit, compared with 2018, the technical efficiency change, technological progress change, pure technical efficiency change, scale efficiency change and TFP change of township hospitals in the typical areas in 2019 were 0.977, 1.037, 0.995, 0.982 and 1.013, respectively, and the TFP of township hospitals increased by 1.3% on average. Taking township health centers as the decision-making unit, compared with 2018, the TFP of township hospitals increased by 4.5% in 2019. Specifically, the TFP of township hospitals increased by 47.83% in Anhui's A1 county, 66.67% in Anhui's A2 county, 54.84% in Jiangxi's B1 county, 59.26% in Jiangxi's B2 county, 70.00% in Guangxi's C1 county, 90.91% in Guangxi's C2 county, 78.57% in Xinjiang's D1 county, and 55.56% in Xinjiang's D2 county.
The "strengthening primary health care" measures implemented during the reform of county-level medical communities have played a role in elevating the efficiency of township hospitals. The continuous improvement in the efficiency of township hospitals relies on both the leading hospital providing targeted assistance and mobilizing the productivities and enthusiasm of the township hospitals.
The theoretical system and intervention technologies of TCM "preventive treatment of disease" service are mature, with certain economic and cultural advantages coping with health needs in different states. Providing TCM "preventive treatment of disease" service in community elderly care facilities closer to residents can both promote the efficient utilization of resource and enhance the experience of the elderly access to health services.
To explore the perceptions, attitudes and needs of the providers (medical workers providing TCM "preventive treatment of disease" service) and demanders (elderly access to health services) in community elderly care facilities, in order to clarify the service contents that should be promoted and complementary operational conditions when providing TCM "preventive treatment of disease" service in community elderly care facilities.
From 2020-07-31 to 2020-08-10, the medical workers providing health care service and the elderly access to services in the community elderly care facilities with the highest average daily service attendance administered by 6 community health service centers were investigated using self-designed questionnaire by the project team members. The questionnaire for providers mainly included the perspectives and suggestions on the performance of TCM "preventive treatment of disease" service which was completed by themselves. The questionnaire for demanders to services mainly included thier health needs, acceptability of TCM "preventive treatment of disease" service and its providing in community elderly care facilities which was completed by the health care workers mentioned before by questioning.
The survey results of the providers showed that 81.6% (93/114) of the participants indicated that they had heard of or understood the concept of preventive treatment of disease, 41.2% (47/114) of them had performed health service project in community elderly care facilities, and 91.2% (104/114) of them considered that community elderly care facilities are suitable for providing health services. The survey results of the demanders showed that common helth problems mentioned by the elderly in the community included hypertension (57.0%, 138/242), diabetes (40.1%, 97/242), and low back pain (30.2%, 73/242), etc. 56.2% (136/242) of the participants indicated that they had received TCM health services with the satisfaction rate of 52.2% (71/136), 74.8% (181/242) of them had not heard of or learn much about preventive treatment of disease, 50.4% (122/242) of them were interested in TCM health services provided in community elderly care facilities. The suivey results of both providers and demanders showed that the the top 5 TCM "preventive treatment of disease" services suitable for community elderly care facilities are TCM four diagnostic methods, sports health care, living adjustment method, diet therapy and emotion regulation.
The health needs of the elderly in community elderly care facilities are consistent with the disease spectrum of the community. There is a demand and interest of preventive treatment of disease among the residents in the facilities. Community family physicians are interested and willing to provide the services in the facilities. The providing of TCM "preventive treatment of disease" services in community elderly care facilities have mass foundation and technical feasibility. However, there is a demand to strengthen the promotion, clarify charge, facilitate service delivery, and supply with appropriate service technologies.
Since the full implementation of contracted family doctor services in 2016, we have achieved phased results. Further work needs to be paid equal attention to "quality" and "quantity", focusing on improving the residents' sense of service access and satisfaction, however, at present, the residents' evaluation of contracted family doctor services is not clear.
To investigate the contracted residents' evaluation for the continuity of family doctor contract, explore its influencing factors, and propose improvement strategies.
This study used a multi-stage stratified random sampling method to select 1 193 contracted residents from 9 community health service institutions and 9 township health centers in Heze City, Shandong Province in January 2021. A household survey was conducted on the included residents by using the continuity dimension of the Chinese version of the Primary Care Assessment Tools (PCAT) , which contains 15 items. We compared the PCAT-continuity dimension scores of contracted residents with different characteristics, and used multiple linear regression to analyze the factors influencing the PCAT-continuity dimension scores of contracted residents.
A total of 1 098 valid questionnaires were collected, with a valid response rate of 92.04%. 541 (49.27%) of them were contracted to community health service institutions and 557 (50.73%) of them were contracted to township health centers. The average score of the PCAT-continuity dimension of the contracted residents was (3.38±0.51) . The item with the highest score was "Does your family doctor listen to you patiently", with a score of (3.64±0.59) . The item with the lowest score was "Would you be willing to change your family doctor if it was easy to do so", with a score of (2.98±0.92) . Multiple linear regression analysis showed that the type of contract organization, age, education, marital status, occupation, and chronic diseases were the factors that influence the PCAT-continuity dimension score of contracted residents (P<0.05) .
The contracted residents had an overall good evaluation on the continuity of contracted family doctor services, and the long and stable doctor-patient relationship had been established. Township health centers are better than community health service institutions. To further improve the contracted residents' evaluation of contracted family doctor services, we need to pay more attention to the type of contracting institution, the age, education level, marital status, occupation of contracted residents and their chronic diseases.
The prevalence of age-related hearing loss is increasing gradually as population aging advances in China. Untreated hearing loss is strongly associated with many adverse health events. Age-related hearing loss is difficult to be detected due to slow progression of symptoms, and its harmfulness is often underestimated or neglected. General practitioners (GPs) in primary care could play a vital role in early screening, timely referral and health education management regarding age-related hearing loss.
To formulate an GP management of age-related hearing loss system, promoting secondary prevention and management of this illness in primary health care.
By use of literature review and semi-structured reviews, we developed the first draft of General Practitioner Management of Age-related Hearing Loss System from April to June 2021. For reviewing the draft, we conducted a two-round e-mail-based consultation with a purposive sample of 15 experts (engaging in the field of otolaryngology, general practice, administrative management or public health management) from August to November 2021. Then we calculated the response coefficient, authority coefficient and Kendall's Wfor the two consultations, assessed the weights of indicators using analytic hierarchy process, checked the logical consistency of indicators, and determined the final draftof age-related hearing loss management system.
The first draft of General Practitioner Management of Age-related Hearing Loss System consisted of 6 primary indicators and 15 secondary indicators. The response coefficient was 100.0% for both consultations. The expert authority coefficient was 0.877 for the first round of consultation, and 0.920 for the second round. Kendall's W coefficients were 0.428 (χ2=89.821, P<0.001) , and 0.307 (χ2=87.387, P<0.001) , respectively for the first and second rounds of consultations. The final system consists of 6 primary indicators (theoretical knowledge of age-related hearing loss, screening skills for age-related hearing loss, referral ability of age-related hearing loss, ability to diagnose and treat ear diseases, ability to manage adverse events of age-related hearing loss, doctor-patient communication ability) , and 20 secondary indicators. The mean value of importance for all indicators was above 8.000, the coefficient of variation of all indicators was above 0.250, and the full score ratio of all indicators was above 30.0%. The weights of the above-mentioned six primary indicatorswere 0.082, 0.082, 0.082, 0.077, 0.077, and 0.077, respectively. The consistency ratio of primary and secondary indicators was 0.063 5, 0.043 2, respectively (<0.100 0) .
The response and authority coefficients, and Kendall's W coefficients of the consultations were high, suggesting that the consultation results were scientific, credible and reliable. This system can be used as a guidance system for secondary prevention and management of this illness by GPs in primary care.
With the trend of population aging, disabled or semi-disabled elderly people suffering from various chronic diseases have an urgent demand for home medical care services, but there are greater medical risks and safety hazards for primary health care workers to provide home medical care services, and strengthening the safety management of home medical care services is conducive to increasing the willingness of primary health care workers to provide home medical care services.
To investigate the safety support of home care services in primary health care institutions and the willingness of medical personnel to provide home care services, so as to provide a reference basis for further promoting the development of home medical care services.
From August to October 2021, 1 131 cases of medical personnel from 49 primary health care institutions in five economic regions of Sichuan Province were selected by convenience sampling method. A self-designed questionnaire was used to collect data in the form of an electronic questionnaire called "Questionnaire Star". The questionnaire included general information of medical staff (8 items) , experience of providing medical care at home (2 items) , safety support of medical staff by medical institutions (7 items) , and willingness of medical staff to provide home care (1 item) . The willingness of medical personnel to provide home medical care services was compared across different characteristics, and binary Logistic regression was used to analyze the factors influencing medical personnel's willingness to provide home medical care services.
Of the 1 131 primary care medical personnel, 692 (61.18%) reported experiences with home medical care services, 193 (17.06%) reported adverse events or safety events during the services, 531 (46.95%) reported that their medical institutions had not assessed the safety risks of patients receiving home medical care services, 199 (17.60%) reported that their institutions had assessed the safety risks of medical staff visiting the home, 299 (26.44%) reported that the app location system was used in the process of home services, 273 (24.14%) reported that medical staff equipped with devices such as alarms and delay warnings, 807 (71.35%) reported that they did not receive service support from other medical staff within their institutions during home medical care services, 303 (26.79%) and 352 (31.12%) indicated that the institution had organized special seminars on home medical care services and received special training on home medical care services, respectively, 853 cases (75.42%) of medical staff were willing to provide home medical care services. The results of binary Logistic regression analysis showed that the type of primary health care institution with which they worked, the professional and technical titles currently employed, assessing the safety risk of patients receiving home medical care services, using alarm and delayed warning devices during home medical care services, and attending special training on home medical care services had an effect on the medical staff's willingness to provide home medical care services (P<0.05) .
At this stage, the safety support for home health care services is insufficient, and various factors affect the willingness of primary health care workers to provide home health care services. Primary health care institutions should strengthen the assessment of the safety risks of patients receiving home medical care services, equip the medical personnel who provide home medical care services with alarm and delayed warning devices, and actively organize special training related to home medical care services and encourage medical personnel to participate, so as to reduce the risks of medical personnel who provide home medical care services and ensure their personal safety.
