The hierarchical medical system in China aims to guide patients toward primary healthcare institutions for first-contact care. Nevertheless, the proportion of visits at the primary level has continued to decline. The system's actual effectiveness and the mechanisms underlying changes in primary care service volume remain insufficiently understood.
To examine trends in primary care service volume and identify key driving factors after implementation of the hierarchical medical system, thereby providing empirical evidence for policy optimization.
Data were drawn from the China Health Statistical Yearbook series spanning 2005 to 2023. Interrupted time series (ITS) analysis was used to evaluate policy effects, and the logarithmic mean divisia index (LMDI) method was employed to decompose and quantify the contribution of each driving factor.
The ITS model showed that total primary care visits increased at an annual rate of 196 million (P=0.005), yet the proportion declined by 0.67 percentage points per year (P<0.001). At the point of policy intervention (2016), primary care visits fell abruptly by approximately 435 million (P<0.001), with the proportion dropping by 2.14 percentage points (P<0.001). After policy implementation, growth slowed markedly; the annual increase was 168 million fewer than in the pre-intervention period (P<0.001). LMDI results indicated a cumulative change of 2 351 million in primary care visits from 2005 to 2023. The per capita investment effect (EP) and institutional scale effect (SI) were the main positive drivers, while the capital intensity effect (IE, -12 409 million) and physician service productivity effect (PD, -1 551 million) posed major impediments to growth. In the post-implementation period, PD shifted from positive to negative, reflecting weakened growth momentum.
Primary care growth in China exhibits characteristics of an extensive model marked by high input and low efficiency. Resource and workforce productivity have not kept pace with investment increases, which may constrain the patient-diversion capacity of the hierarchical medical system.
The construction of medical alliance is an important and practical path to achieve hierarchical diagnosis and treatment. Collaborative governance of medical quality management in medical alliance has always been the goal pursued by health management departments at all levels and medical professional quality control institutions.
This study constructed a collaborative governance system for medical quality management within regional medical consortiums, and verified its governance effects.
A collaborative governance system for medical quality management in regional medical consortiums was established under the framework of synergy theory. Fengtai District of Beijing was selected as the case area, where collaborative governance was rolled out across 340 medical and health institutions under its jurisdiction. A questionnaire on cognition of medical quality management was developed. Stratified cluster sampling was adopted to recruit 7 653 medical staff from medical consortiums, who participated in a baseline survey (Q4 2023) and a post-intervention follow-up survey (Q4 2024) to analyze changes in their cognition of medical quality management. In addition, policy-led and market-led medical consortiums were compared to explore the correlation between governance effects and consortium types.
The implementation framework for collaborative medical quality governance of regional medical consortiums includes: integrating administrative departments, quality control centers, leading hospitals of medical consortiums and regional medical institutions to form a multi-stakeholder governance body; establishing communication, coordination and resource-information integration mechanisms among all stakeholders; and operating a collaborative working model featuring tiered liaison, tiered quality control, information sharing, and monitoring & evaluation. One year after the launch of collaborative governance, the correct response rates of medical staff regarding knowledge of nosocomial infection control, nursing management, medical administration and pharmaceutical quality management were all significantly higher than baseline levels (P<0.05). Comparative analysis of different consortium types showed that after intervention, medical staff in policy-led consortiums achieved significantly higher correct rates in 68 questionnaire items (P<0.05), while those in market-led consortiums saw statistically significant improvements in 76 questionnaire items (P<0.05). Before collaborative governance, significant inter-group differences in correct rates existed for 67 items between the two types of consortiums (P<0.05), and disparities remained significant for 36 items after implementation (P<0.05).
Mutual promotion and graduated quality control were effective approaches to gradually promote the quality homogenization management of all medical institutions within a jurisdiction, with satisfactory outcomes achieved in both types of medical consortiums. These strategies could provide practical guidance for health management departments to promote the collaborative governance and management homogenization of regional medical quality.
With the accelerating aging of the population, multimorbidity has become a major public health challenge in Beijing. Obesity serves as a key pathological basis for multimorbidity, and weight management is an important strategy for improving the health of patients with multimorbidity. However, the current status of integrated diagnosis and treatment for obesity and multimorbidity remains unclear.
To assess the availability of health services related to obesity comorbidities in medical institutions of Beijing, and to provide scientific evidence for the formulation of clinical guidelines and hierarchical medical policies targeting obesity combined with three highs (hypertension, diabetes mellitus, and hyperlipidemia).
From October to December 2025, a multi-stage random sampling method was adopted to select 60 primary health service institutions and 16 tertiary hospitals in Beijing. Fourteen secondary hospitals were enrolled via purposive sampling as research subjects. Based on policy review, literature review and expert consultation, three versions of questionnaires (for primary medical and health institutions, secondary hospitals and tertiary hospitals, respectively) were self-developed. The questionnaire covered infrastructure and resource allocation related to weight management, hierarchical diagnosis and treatment positioning, construction of referral pathways, and practical difficulties in hierarchical medical service delivery.
Weight management clinics were established in 22 (36.7%) primary medical and health institutions, 7 (7/14) secondary hospitals and 14 (14/16) tertiary hospitals. The linear-by-linear association chi-square test revealed that the establishment rate of weight management clinics increased with the elevation of hospital grade (P<0.01). In terms of weight management equipment, among basic assessment equipment, only the possession rate of tape measures in secondary hospitals was less than 80.0%. As for specialized equipment, secondary hospitals had a possession rate of body fat analyzers below 60.0%, dietary guidance tools below 50.0%, sports venues below 40.0%, and professional weight management software below 10.0%. With regard to weight management service programs, 17 (28.3%) primary medical and health institutions and 5 (5/14) secondary hospitals failed to provide systematic weight management services, whereas all 16 tertiary hospitals offered such systematic services. For patients with obesity-related comorbidities, merely 7 (7/14) secondary hospitals could deliver services including supporting primary care institutions and transferring stable patients back to primary settings, and only 9 (9/14) secondary hospitals were capable of providing technical support to primary medical and health institutions. In respect of referrals for patients with obesity and comorbidities, no clear referral criteria or procedures were formulated in medical institutions at all levels. The primary barrier to referrals in tertiary hospitals was difficult follow-up of downward-transferred patients (7 hospitals). The main obstacles for secondary hospitals included patients’ reluctance to accept referrals and tendency to directly visit their preferred hospitals (11 hospitals), as well as unobstructed referral pathways (8 hospitals). For primary medical and health institutions, the predominant challenges were insufficient timely and effective information sharing among medical institutions at different levels (42 institutions) and inadequate feedback on referred patients from higher-level hospitals (37 institutions).
Under the context of tiered diagnosis and treatment, the availability of health services for patients with obesity-related comorbidities in Beijing is inadequate and structurally imbalanced. It is recommended to strengthen the hub function of secondary hospitals, establish regional fixed referral networks, promote specialized equipment deployment in primary and secondary institutions, and develop unified clinical pathways and information-sharing standards, so as to enhance the overall system efficiency and support the implementation of the "Healthy China" strategy.
Primary healthcare institutions commonly experience a "post-examination gap" in health checkup services, where high-risk populations lack unified risk stratification and proactive management pathways, thereby undermining the full value of health checkups. As potential strategies to enhance the continuity of post-examination care, color-coded management and active recall have not yet been systematically evaluated.
To evaluate the effectiveness of a post-examination service model centered on color-coded management and active recall in primary healthcare institutions.
Using the implementation of a post-examination service process reengineering at Jingshan Town Community Health Service Center, Yuhang District, Hangzhou as a natural boundary, 862 residents who underwent health checkups before the reengineering were assigned to the control group, and 712 residents who underwent checkups after the reengineering were assigned to the intervention group. The intervention group received color-coded management and active recall services. A self-designed questionnaire (Cronbach's α=0.89, KMO=0.87, Bartlett's test P<0.001) was used to assess service quality, process satisfaction, and post-examination management experience in both groups. Multivariate linear regression was used to analyze the independent effect of the intervention.
The intervention group scored significantly higher than the control group in all dimensions of service quality and process satisfaction (P<0.001). Multivariate linear regression showed that, after adjusting for confounders, the overall satisfaction score in the intervention group was 0.319 points higher than that in the control group (95%CI=0.278-0.360, P<0.001). In the intervention group, 98.0% (698/712) of respondents expressed overall satisfaction or had no specific suggestions, which was significantly higher than the 85.0% (733/862) in the control group (P<0.001). The coverage rate of color-coded management advice was 88.8% (632/712), that of active recall was 62.8% (447/712), and that of health intervention services was 74.3% (529/712); the median satisfaction scores for these services were all 4.00 (out of 4.00).
The post-examination service model centered on color-coded management and active recall significantly improved satisfaction and service experience among residents undergoing health examinations in primary healthcare institutions, effectively bridging the continuity gap in post-examination care. This model is worthy of promotion in primary care settings.
