The family doctor contract service for elderly people in rural areas faces issues such as a generally poor patient experience and a lack of perceived benefits, as well as phenomena such as "signing up but not fulfilling the contract" and "failure to renew the contract". The underlying causes of these issues require further investigation.
To investigate the status and influencing factors of consistency between expressed and perceived needs for family doctor contracted services among rural older adults in Ningxia Hui Autonomous Region of China.
A cross-sectional study was conducted from July to September 2024. Stratified cluster sampling was applied to find participants. In the 5 prefecture-level cities of the Ningxia Hui Autonomous Region, 2 counties were selected from each city by convenience sampling method, and 1 administrative village was selected from each county. Two counties were selected from each of the five cities in Ningxia, and one village was chosen from each of the counties. A total of 456 rural older people from the 10 villages were invited into the survey. Socio-demographic information and expressed and perceived needs for family doctor contract services were collected using a self-designed questionnaire. Multiple stepwise regression analysis was used to identify influencing factors, while a random forest model was employed to rank the importance of these factors.
The average score for consistency between expressed and perceived needs for family doctor contract services among rural older adults was (11.6±5.3), indicating an overall low level of consistency. The expressed need for basic public health service items (such as establishing health records) was as high as 96.1% (438/456), the perceived need reached 96.7% (441/456), and the satisfaction rate also reached 92.9% (424/456), all of which were at a high level. In contrast, only 5.3% (24/456) of rural older adults expressed a need for special health services (such as home-based care services), 40.1% (183/456) perceived the need, and the satisfaction rate was as low as 5.0% (23/456), all indicating low levels. The results of multiple stepwise linear regression analysis showed that the consistency between expressed and perceived needs for family doctor contract services among rural older adults was affected by multiple factors, including satisfaction with contracted service items, personal health attention, chronic disease status, economic burden, medical treatment experience in primary medical and health institutions in the past year, and smoking habits (P<0.05). Among these factors, satisfaction with contracted service items was the most significant predictor of the consistency of the two needs.
The consistency between expressed and perceived needs for individual health services in the family doctor contract among rural older adults remains low, influenced by both subjective factors and objective factors, such as chronic conditions, satisfaction with services, and awareness of self-health. Therefore, the author suggests designing and providing family doctor contract service packages in a way that is tailored to local contexts, especially focusing on service items that address individual perceived needs. The improvement of consistency between expressed and perceived needs will better meet the diverse health management needs of the rural elderly.
With the acceleration of urbanization and aging, chronic diseases such as hypertension combined with diabetes bear a heavy burden, while community management faces challenges like unsystematic medication management and poor patient compliance, and existing medication therapy management (MTM) practices rely on large hospitals, are limited to in-hospital settings and lack standard paradigms suitable for primary care, so it is urgent to build a standardized and easy-to-implement home-based MTM service model.
To develop a home-based pharmaceutical care model adapted for primary care settings based on MTM principles, and to evaluate its implementation feasibility and preliminary clinical effects among community-dwelling patients with hypertension and diabetes comorbidity.
A prospective randomized-controlled study was conducted. A total of 168 contracted patients with comorbid hypertension and diabetes were recruited from March to April 2024 from a community health center in Xuzhou. Among them, 18 patients were excluded for failing to meet the inclusion criteria, and 6 were excluded due to refusal to participate or inability to complete follow-up. Finally, 144 patients were included in the study. The patients were randomly assigned in a 1∶1 ratio to an intervention group (n=72) or a control group (n=72) using a computer-generated random sequence. The intervention group received a 6-month home-based MTM pharmaceutical care intervention, including comprehensive medication assessment and reconciliation, multidisciplinary collaborative intervention, and standardized monitoring and follow-up using simple tools (paper logbooks, WeChat groups). The control group received routine follow-up management for 6 months. Differences in medication adherence, disease control rates, safety, and direct medical costs were compared. Feasibility indicators such as recruitment rate and intervention completion rate were also assessed.
After the intervention, the medication adherence score in the intervention group was higher than that in the control group (P<0.05); systolic blood pressure, diastolic blood pressure, and HbA1c levels were lower than those in the control group (P<0.05); and the control rates of blood pressure and HbA1c were higher than those in the control group (P<0.05). There was no statistically significant difference in the incidence of adverse drug reactions (ADR) between the two groups (P>0.05). The per capita direct medical cost in the intervention group was lower than that in the control group (P<0.05). The recruitment rate was 85.7% (144/168), the intervention completion rate was 94.4% (68/72), and the service acceptability score was (4.3±0.7).
The home-based MTM pharmaceutical care model developed in this study was generally feasible and well accepted in primary care settings, and showed potential in improving medication adherence, disease control, and medication safety. Its clear workflow and simple tools provide a referable pathway for standardized pharmaceutical care for chronic diseases in primary care.
Contracted family doctor service is the main way of community prevention and treatment of hypertension and type 2 diabetes. With the continuous development of the concept and practice of "patient-centered" medical and health services, accurate allocation of service attributes and levels based on patient preferences has become a key path to improve service accessibility, compliance and health outcomes.
This study takes the research on the preference choices of patients with comorbidity of hypertension and type 2 diabetes mellitus (HTN-T2DM) for family doctor contract services as an example, detailing the entire process of attribute and level development, providing a reference and guidance for the development of attributes and levels in discrete choice experiments (DCE), and offering a reference for formulating strategies for family doctor contract services for patients with HTN-T2DM.
Under the guidance of the consolidated framework for implementation research (CFIR), a literature review and policy analysis were conducted to extract and collate potential attributes and construct an attribute pool, semi-structured interviews were carried out with 5 family doctors, 3 institutional principals, and 20 patients with HTN-T2DM from primary-health-care institution in Haikou city to specify the attributes and levels. Finally, 50 HTN-T2DM patients were recruited by convenience sampling to participate in a pretest to verify the rationality of the attributes and levels.
Through a literature review, 23 literatures were combed, among which 15 were in Chinese and 8 in English, and 18 attributes were collated. In combination with semi-structured interviews, 8 attributes and corresponding levels were determined. Through the pre-experiment, 7 attributes and levels were ultimately determined, namely, the nature of the institution (government-run/social-run/individual-run), service content (health consultation and guidance/traditional Chinese medicine for preventive treatment of diseases/personalized examination items), service mode (institutional visit/remote diagnosis and treatment/home visit service), self-payment cost (50/100/200 yuan per month), doctor's professional title (junior/intermediate/senior), implementation environment (with priority referral/without priority referral), and medication guidance (2 weeks/1 month/2 months).
Scientifically determining attributes and their levels is a crucial foundation for ensuring the effectiveness of DCE. Under the guidance of the CFIR, this study develops 7 attributes and corresponding levels for the preference of family doctor contract services for patients with HTN-T2DM, providing a reference for advancing research on the preference of family doctor contract services for HTN-T2DM patients. Empirical research can be carried out based on these findings in the future to promote the improvement of family doctor contract service strategies.
