China's primary health care system is advancing family doctor contract services, aiming to provide integrated and continuous services for residents, which are essential characteristics needed by chronic disease patients such as those with diabetes. Existing studies have largely focused on descriptive analyses of the coverage rate of family doctor contract services, with insufficient assessment of their actual effects in chronic disease services.
To understand the impact of family doctor contract services on the cognition, behavior, and health outcomes of diabetic patients.
From February 22 to 25, 2023, a multi-stage stratified random sampling method was used to survey 716 registered diabetic patients in a city in Shandong Province. The questionnaire included demographic information, disease and medical conditions, acceptance of diabetes management services, and patients' disease cognition, health management behaviors, and health outcomes. Descriptive analysis was conducted on the coverage rate of diabetes management services accepted by patients to reflect the integration of family doctor team services. Multifactorial Logistic regression analysis was used to explore the impact of contracting with a family doctor on patients' disease cognition, health management behaviors, and health outcomes.
The contract rate of diabetic patients was 80.9% (579/716). Among them, 47.8% (277/579) felt that the family doctor understood their psychological condition.The rate of receiving follow-up recently was 89.8% (643/716). Among them, 76.0% (489/643) received diabetes health education, and 43.9% (282/643) received the complication-related examination items such as fundus, ECG, and dorsalis pedis artery pulsation. Of the patients with sudden worsening/acute complications, 37.7% (32/85) contacted the family doctor, among which 37.5% (12/32) received emergency treatment, and 25.0% (8/32) received referral services. The correct rate of patients' cognition on diabetes diagnosis was 19.8% (142/716), and the correct rate of cognition on intervention methods other than drug treatment was <70.0%. The results of the multifactorial Logistic regression analysis showed that the probability of contracted patients having a disease cognition score >5.5 was higher [OR (95%CI) =1.80 (1.23-2.62), P<0.05], the probability of undergoing glycosylated hemoglobin testing was higher [OR (95%CI) =2.67 (1.75-4.18), P<0.05], the probability of regular self-monitoring of blood glucose was higher [OR (95%CI) =4.28 (2.57-7.09), P<0.05], the probability of dietary control was higher [OR (95%CI) =0.46 (0.28-0.80), P<0.05], and the acceptance rate of diabetes-related expenses was lower [OR (95%CI) =1.58 (1.04-2.39), P<0.05] .
Family doctor contracted services have shown a significant impact on enhancing the quality of management services for chronic diseases. However, there is still a need for further improvement in implementing patient health education and psychological care components within the service package. Establishing a robust referral mechanism and improving the screening of diabetes complications are essential steps towards enhancing these services. Meanwhile, greater attention should be given to the health services of patients who have not enrolled in the contracted services.
Shanghai has been implementing the "1+1+1" combined family doctor contract service for nearly a decade, and its effectiveness in promoting graded diagnosis and treatment and guiding residents to seek medical treatment at the grassroots level needs to be verified. Existing related studies mostly focus on the number of visits to primary clinics and patients' willingness to visit primary clinics as key analysis variables. However, these two indicators cannot comprehensively and truly reflect the actual utilization of primary healthcare services by residents.
To investigate the influencing factors of family doctors' signing up for type 2 diabetes patients to see doctors at the grass-roots level, so as to provide a scientific basis for further optimizing the allocation of community health service resources.
In May 2023, 550 patients with type 2 diabetes who have signed a contract with family doctors were selected by random sampling in Jinshanwei Town, Jinshan District, Shanghai. By accessing the medical data of patients enrolled in the regional health information platform in 2022, if the proportion of patients' visits to community health service institutions in that year to the total number of visits is less than 90%, it is considered that the compliance with grassroots medical treatment is poor, and if it is greater than or equal to 90%, it is considered that the compliance with grassroots medical treatment is good. Conduct a "face-to-face" questionnaire survey on the included patients, covering their basic information, disease and treatment status, health policy awareness and service utilization, etc. According to the Anderson model, the indicators are divided into three categories: propensity factors, ability factors, and need factors. The influencing factors of compliance of contracted type 2 diabetes patients with primary care were analyzed by binary logistic regression.
The questionnaire of 508 patients (92.4%) was effectively collected. Among them, 371 cases (73.0%) had good compliance with grassroots medical treatment, and 137 cases (27.0%) had poor compliance. The average scores of patients on the four dimensions of policy awareness, institutional trust, medical expenses, and medical services are (11.0±3.6), (17.6±2.6), (12.8±1.9), and (17.0±2.3) points, respectively. The results of binary Logistic regression analysis showed that the occupation and the nature of residence in the propensity factors, the type of medical insurance, the per capita monthly income of families, the medical service score in the ability factors, and the institutional trust score in the need factors were the influencing factors of type 2 diabetes patients' compliance with grassroots medical treatment (P<0.05) .
The patients with type 2 diabetes didn't have enough knowledge of the service policy signed by family doctors. Higher quality medical services and more reliable institutional trust were the promoting factors for the grassroots medical behavior of contracted residents with type 2 diabetes. It is suggested to strengthen the policy promotion of family doctor contract services, further enhance the capacity of community health services, and optimize the quality of community health services.
With the comprehensive implementation of the family doctor system in China, community health service resources have been widely utilized. However, there is a lack of research on the utilization tendency of primary outpatient medical resources for adult diabetic patients using objective medical visit data.
To understand the characteristics of outpatient visits for diabetic patients in the community, analyze the factors influencing frequent visits by patients enrolled in family doctor services, correctly identify the utilization tendency of primary outpatient medical resources by enrolled patients, and provide a basis for promoting the high-quality development of family doctor contract services.
In August 2023, outpatient visit records of adult diabetic patients from 13 community health service centers in Minhang District, Shanghai, for the year 2021 were retrieved. Personal information such as names and contact details were forcibly anonymized, while data on sex, age, enrollment in family doctor services, triggered diagnosis records, frequency of medical treatment, department of medical treatment, and Chinese medicine services during visits were collected. The characteristics of outpatient visits for adult diabetic patients in the community were analyzed, and multiple logistic regression and decision tree models were used to analyze the factors influencing frequent visits by enrolled patients.
There were 66 838 adult patients, resulting in 1 281 972 outpatient records. Among them, 48.96% (32 723) were male; the median age of the patients who visited the hospital was 71 (66, 77) years old; the median number of diagnosis types was 6 (3, 10) ; the median frequency of visits was 15 (9, 26), 10.28% (6 871) of the adult patients frequently visited the hospital for 362 068 times; 1-2 departments were the main ones (60.38%), and 9.33% (6 233) of the patients with≥5 departments involved; 39.53% (26 423) visited Chinese medicine services. During the year, Contracted patients accounted for 92.77% (62 005) of all the patients, while non-contracted patients only accounted for 7.23% (4 833). There were significant differences between contracted patients and non-contracted patients in sex, age, complexity of illness, frequency of medical treatment, department of medical treatment, Chinese medicine service (P<0.05). The results of multivariate Logistic regression analysis showed that sex, age, complexity of illness, department of medical treatment, Chinese medicine service were the influencing factors of frequent visits by contracted patients (P<0.05). The results of decision tree model analysis showed that the complexity of the disease was the most important factor affecting the frequent visits of contracted patients.
The signing rate of adult diabetic patients in community primary clinics in Minhang District of Shanghai was high, the effect of family doctor signing system was remarkable, the aging of adult diabetic patients in community primary clinics was prominent, the contracted patients' condition was more complicated, and the demand for Chinese medicine treatment was stronger. The frequent visits of contracted patients were affected by many factors, especially the complexity of their condition. Therefore, it is suggested that relevant departments identify frequent patients efficiently according to the patients' condition, so as to make more rational use of medical resources in primary clinics.
