Perceptions of Hierarchical Medical System and Associated Factors in Key Primary Care Practitioners
The establishment and improvement of hierarchical medical system will help optimize health resource allocation and develop a sound healthcare-seeking pattern. As the key practitioners of hierarchical medical system, primary care workers' perception of the system is vital to the implementation of the system, so studying their perception of the system and associated factors is of great significance.
To analyze primary care professionals' perceptions of hierarchical medical system and associated factors based on the results of 2018 Sixth China National Health Survey, providing a reference for further improvement of the system.
From April to October 2019, one representative urban district and one suburban county were chosen from each of six selected provinces in which hierarchical medical system has been implemented. Then by stratified random sampling, about six community health centers/township health centers were extracted from each district (county) (46 community health centers and 30 township health centers in total) , in which primary care professionals who were on duty on the day of survey were invited to attend a questionnaire survey for understanding their demographics, perceptions of the importance and effectiveness of, as well as barriers to the implementation of hierarchical medical system.
Altogether, 1 308 cases who effectively completed the survey were included for final analysis. According to the analysis, the benefits of implementing hierarchical medical system were: improving the health service system〔approved by 1 231 cases (94.11%) 〕, improving the healthcare services for patients and residents〔agreed by 1 219 cases (93.20%) 〕; improving the quality of medical services〔1 209 (92.43%) 〕; improving the efficiency of medical services〔1 189 (90.90%) 〕; improving doctor-patient relationship〔1 087 (83.10%) 〕; reducing the medical risk〔786 (60.09%) 〕; reducing medical expenses〔611 (46.71%) 〕. As for the outcome of implementing hierarchical medical system, its implementation would not hinder the development of health institutions〔982 (75.08%) 〕. When it comes to the barriers to the implementation of hierarchical medical system, there were no relevant incentives〔759 (58.03%) 〕, patients and their families' were unwilling to accept hierarchical medical system due to getting used to free healthcare-seeking pattern〔753 (57.57%) 〕, there were no unified bi-directional referral criteria and system〔712 (54.43%) 〕, the implementation of hierarchical medical system may lead to conflict of interests between medical institutions〔451 (34.48%) 〕, there was no an effective referral route〔403 (30.81%) 〕, their medical institutions had insufficient capacities to effectively implement hierarchical medical system〔387 (29.59%) 〕. Univariate analysis revealed that primary care professionals' perceptions of hierarchical medical system differed significantly by province, sex, educational background, professional title, type of their medical institution, and type of post (P<0.05) . Multiple linear regression analysis indicated that province, sex, educational background, professional title, and officially budgeted post were associated with primary care professionals' perceptions of hierarchical medical system (P<0.05) .
These primary care professionals had good perceptions of the importance and effectiveness of the implementation of hierarchical medical system, but also showed their concerns about the barriers to its implementation. Professional title and province were associated with their perceptions of the system. To promote the implementation of hierarchical medical system, it is suggested that the government departments increase investment, improve policy details, provide corresponding incentives, and carry out targeted publicity and education.
Burnout and Associated Factors among Family Doctor Team Members in Different Types of Primary Healthcare Institutions：a Comparative Study
Burnout has become a prominent issue as the increase of workload in family doctor team members in primary healthcare institutions during the promotion of contracted family doctor services. There is still a lack of research comparing the differences in burnout among family doctor team members in different types of primary healthcare institutions.
To compare burnout prevalence and associated factors between family doctors in community/township health centers, and those in community health stations/village clinics, providing a basis for improving the mental health status and team stability of family doctors, as well as the quality of services provided by them.
From August 1 to 21, 2020, a multistage cluster random sampling method was used to select 760 family doctor team members〔201 (26.4%) working at community/township health centers, and 559 (73.6%) working at community health stations/village clinics〕 as the participants from primary healthcare institutions in 6 counties/county-level cities /districts of Taian City, Shandong Province. They were invited to attend a survey to complete Demographic Questionnaire and the Chinese version of Maslach Burnout Inventory-General Survey (MBI-GS) .
Overall, the prevalence of burnout among the participants was 68.9% (524/760) . Overall, the prevalence of burnout among the participants was 68.9% (524/760) , and the prevalence of burnoutof family doctor team members in community/township health centers and community health stations/village clinics was 63.7% (128/201) and 70.8% (396/559) , respectively. The levels of burnout of family doctor team members in community health stations/village clinics was higher than that of those in community/township health centers, with a statistically significant difference (P<0.05) . Family doctor team members in community health stations/village clinics had higher total score of MBI-GS and higher subscale score of reduction of professional efficacy than did those in community /township health centers, with a statistically significant difference (P<0.05) . Multivariate Logistic regression analysis showed that: for family doctor team members in community/township health centers, the risk of burnout of those aged 41-50 years is higher than that aged≤30 years〔OR (95%CI) =7.119 (1.770, 28.638) 〕, the risk of burnout of those with monthly income >4 000 yuan is lower than that with monthly income <2 000 yuan〔OR (95%CI) =0.194 (0.040, 0.941) 〕, the risk of burnout of those with high/very high self-rated work pressure is higher than that of those without/little self-rated work pressure〔OR (95%CI) =3.629 (1.475, 8.929) 〕, the risk of job burnout of those who evaluated the incentive mechanism as ordinary and relative effective/very effective was lower than that evaluated the incentive mechanism as very ineffective/less effective〔OR (95%CI) were 0.196 (0.052, 0.739) and 0.235 (0.066, 0.834) 〕. For the family doctor team members in community health stations/village clinics, the risk of burnout in women is lower than that in men〔OR (95%CI) =0.603 (0.396, 0.920) 〕, the risk of job burnout of those with general and relatively high/very high self-assessment residents' recognition is lower than that with very low/relatively low self-assessment residents' recognition〔OR (95%CI) were 0.258 (0.113, 0.590) and 0.428 (0.199, 0.918) 〕, the risk of burnout of those with high/very high self-rated job stress is higher than that without/little self-rated job stress〔OR (95%CI) =2.320 (1.368, 3.935) 〕.
Family doctor team members in community health stations/village clinics demonstrated higher burnout prevalence, and lower professional efficacy. To reduce the burnout prevalence and improve professional efficacy in family doctor team members, it is suggested to strengthen trainings, increase salary and further improve incentive mechanism for those in community/township health centers, and to increase the number of officially budgeted posts, and promotion opportunities as well as the propaganda of contracted family doctor services for those in community health stations/village clinics. Moreover, the workflow of contracting family doctor services should be simplified in all these institutions.
Development of an Incentive Model for General Practitioners in Fengxian District of Shanghai Based on Herzberg's Motivation-hygiene Theory
In view of the shortage of general practitioners (GPs) and limited community healthcare resources, it is urgently necessary for community health institutions to find accurate and scientific incentive methods to retain GPs and help them to realize their full potential, as well as promote the development of both community health institutions and GPs, thereby benefiting the health promotion of community residents.
To develop an incentive model for GPs to test the performance and effectiveness of current incentives for GPs, so as to put forward suggestions to improve the mechanisms of employing and retaining GPs.
In August 2019, we recruited 204 GPs from 11 community health centers (CHCs) in Shanghai's Fengxian District using stratified random sampling to attend an online survey using a questionnaire named General Practitioners' Perception and Evaluation of Incentive Measures developed based on our previous research results and Herzberg's motivation-hygiene theory. Then from August to September 2019, we invited directors responsible for medical care or public health issues, and medical quality control department heads from the above-mentioned 11 CHCs to attend an online survey using a questionnaire named Workload for General Practitioners in Community Health Centers of Fengxian District developed by usbased on a literature review. Then under the guidance of Herzberg's motivation-hygiene theory, we constructed a structural equation to develop an incentive model for GPs within Fengxian District with representative incentive policies, systems and initiatives related to GPs selected from the survey results as latent independent variables to measure GPs' (responders') perception and assessment of incentives, and with willingness to work, service radius, and workload of GPs as dependent variables.
The average scores for the implementation of incentive measures, and its associated influence on GPs' work status assessed by the 204 GPs were (0.77±0.14) , and (0.73±0.19) , respectively. The assessment score for implementation of incentive measures for GPs differed significantly by personal health condition and administrative position in the respondents (P<0.05) . The assessment score for the influence of implementing incentive measures on GPs' work status differed significantly by personal health condition in the respondents (P<0.05) . Spearman correlation analysis showed that GPs' work status was associated with the implementation of 25 incentive measures (one incentive measure at the subdistrict level was not included for analysis) (P<0.05) . The top three most highly correlated incentive measures were performance distribution (rs=0.652) , performance-based salary calculation (rs=0.621) , and wages and benefits (rs=0.614) . Partial correlation analysis indicated that, after controlling for variables such as the regional policy environment, the street and town government, and the work unit, the assessment score for implementation of either regional, or subdistrict or institutional incentive measures for GPs, was positively correlated with the assessment score for the influence of implementation of incentive measures for GPs on GPs' work status (r=0.381, 0.387, 0.528, P<0.001) . Theaverage assessment score for willingness to work by the respondents was (0.76±0.18) points. Theassessment scores of willingness to work by the respondents differed significantly by work unit (P<0.05) . Structural equation modeling revealed that the implementation of policy incentive measures influenced GPs' workload via GPs' willingness to work. Specifically, the implementation of policy incentive measures increased GPs' willingness to work (w1=0.43) , while GPs' willingness to work decreased with the increase of weighted workload (w2=-0.156) .
The GPs in Fengxian District showed higher level of willingness to work, namely, relatively high job stability, but they had not been incentivized by policy incentives to be competitive in obtaining improved performance, indicating that although policy incentives have produced partial effects on incentivizing GPs, the effects are still unsatisfactory. In the long run, it is necessary to consider whether there will be changes in GPs' retention status due to the lack of work initiative. For GPs, besides a guarantee of stable income, incentives to get more by doing more are also needed, which may be achieved by increasing the incentive authority and proportion of community health institutions when the total amount of incentives is limited.
