Centered Structures and Trend Changes in Academic Narratives of 10-year Development of Hierarchical Medical System in China
The narratives of hierarchical medical sytem are generally classified into two patterns, one is the policy narrative, which is used to persuade the target audience to gain their support in practice, and the other is the academic narrative, which describes the thinking process of researchers to explore problems and enhance perceptions using words. The narratives of the hierarchical medical system are rich and diverse, but have been rarely systematically reviewed and summarized.
We explored the evolution process, focuses and characteristics of academic narratives of 10-year development of hierarchical medical system in China using social network analysis, aiming to provide a reference for improving the implementation of hierarchical medical system.
On March 21, 2021, we searched the database of CNKI for studies regarding hierarchical medical system in China published in academic journals in Chinese during January 1, 2009 to March 21, 2021 using "hierarchical medical system" "seeking healthcare in an orderly way" "seeking diagnosis and treatment services in an orderly way" "division of healthcare" "division of diagnosis and treatment" "first contact in primary care" "treating acute and chronic diseases separately" "cooperation between tertiary and secondary/primary hospitals" "bi-directional referrals" as keywords. Bibliometric methods, SATI 3.0 and UCINET 6.0 were used to explore the process, focuses and characteristics of academic narratives of hierarchical medical system through time series analysis, high-frequency keywords analysis, centrality analysis and small group analysis, and to generate visualized co-occurrence network diagrams of high-frequency keywords.
A total of 4 882 studies were included for analysis. According to the results of time series analysis, the development of the hierarchical medical system could be roughly divided into three stages: embryonic stage (2009—2013) , acceleration stage (2014—2017) and standardization stage (2018 to present) . In terms of the use of frequency, the top five high-frequency keywords were "hierarchical medical system" "medical consortium" "primary healthcare institutions" "bi-directional referrals" and "public hospitals". In terms of closeness centrality, the top five high-frequency keywords were "hierarchical medical system" "medical consortium" "primary healthcare institutions" "bi-directional referrals" and "general practitioners". Small-group analysis yielded three groups of word clusters: core word clusters (including "medical consortium" "reform of public hospitals" "bi-directional referrals" "general practitioners" and "first contact in primary care") , secondary word clusters (including "the internet" "internet-based healthcare" "internet-based hospital" and "telemedicine") , and marginal word clusters (including "diabetes" "chronic disease" "cognition" and "influencing factors") . Health policy rhetoric was an important part of the core word clusters. And secondary and marginal word clusters were constantly evolving and generating.
The academic narratives of hierarchical medical system have gradually derived from the mutually-promoted development of policies and real implementation regarding the hierarchical medical system, generally demonstrated various structures and relatively homogeneous research direction. Available academic and policy narratives of the hierarchical medical system are still limited to the scope of guiding principles, and the implementation of the concept and system still relies on the top-down push from the policy-making level, while the self-motivated micro-practices of hierarchical medical system in primary care have not yet emerged.
Influencing Factors and Path Combination of County Medical Community Innovation by Local Government：a Crisp Set Qualitative Comparative Analysis
The analysis of the influencing factors of local government innovation has always been an important topic in the research of local government innovation.
To analyze the influencing factors and various combination types of local government's practice innovation toward county medical community.
In March 2021, the preliminary results of the 2nd "Searching for Value Cases of County Medical Community Practice" held by the County Medical Community Branch of the China Hospital Association was used as the source of cases; The "type of policy innovation" was used as the outcome variable ("central dominative innovation"/"local responsive innovation"=0; "local autonomous innovation"=1) ; The level of economic development, administrative level, geographical location, problem attributes, and platform were used as condition variables; The crisp set qualitative comparative analysis (csQCA) was used to explore the factors influencing the county medical community innovation by local government, in order to constructthe path models of innovation practice through necessary condition analysis and conditional combination analysis.
The consistency of all five conditional variables was<0.9, which meant that the level of economic development, administrative level, geographical location, problem attributes, and platform were not necessary conditions for autonomous innovation. The results of conditional combination analysis (based on intermediate solution) showed that a total of five sets of sufficient conditions were obtained, including "the level of economic development and non-geographical location and platform" "administrative level and non-geographical location and platform" "the level of economic development and problem attributes and platform" "non- the level of economic development and geographical location and non-problem attributes and platform" "the level of economic development and administrative level and geographical location and problem attributes", separately. All five groups had a sufficient condition consistency index of 1, original coverage of 0.14-0.43, net coverage of 0.14-0.43, and overall coverage of 1. The innovation practice of local government's medical community practice mainly presents two types of models, namely platform innovation model and motivational innovation model.
If local governments want to achieve high-level medical community innovation practice, they should pay attention to the strong correlation between policies and local economic development levels, activate local governments' willingness to innovate actively, and strengthen platform support for county medical communities. This study provided a special reference significance for understanding the practice innovation mechanism of county medical community.
Coordinated Development of Primary Care Resource Allocation and Economy as Well as Associate Factors in China: a Fuzzy-set Qualitative Comparative Analysis
The allocation of medical resources in China has been in an "inverted triangle" state for a long time. The unreasonable allocation of grass-roots medical resources is difficult to meet the increasingly diversified needs of medical services. The coupling and coordination between the allocation of grass-roots medical resources and economic development will affect the level of regional economic development and the service capacity of grass-roots medical institutions. At present, there is a lack of research on the current situation of their coordinated development and how their influencing factors work through combination.
To assess the level of coordinated development of primary care resource allocation and economy in China, and to determine the associated factors, providing a decision-making basis for further improving medical resource allocation and planning.
The research was carried out from November 2020 to April 2021. Data were collected from China Health Statistics Yearbook 2019 and China Statistical Yearbook 2019. fsQCA was implemented to assess the influence of the number of licensed (assistant) doctors, number of registered nurses, financial subsidy for part of salary, number of beds, number of primary care institutions, regional gross domestic product (GDP) , regional fiscal revenue, per capita disposable income, and per capita GDP (used as conditional variables) on the level of interconnected, coordinated development level of primary care resource allocation and economic level (the outcome variable) in 31 regions of China.
In 2018, only the mean level of interconnected, and coordinated development of primary care resource allocation and economy in eastern China (0.61) was within the range (0.6, 1.0] of coordinated development, and that in central China (0.50) was within the transitional harmony range (0.4, 0.6], while that in western China (0.38) was within the range of imbalanced and recessional development[0, 0.4]. The coordinated development of primary care resource allocation and economic level were found to be affected by many factors, and it may be facilitated by four configurations of its associated factors revealed by the configuration analysis: (1) number of beds * number of licensed (assistant) doctors * number of registered nurses * number of primary care institutions * financial subsidy for part of salary* ~ per capita disposable income * ~ per capita GDP; (2) ~ number of beds * ~ number of licensed (assistant) doctors * number of registered nurses * number of primary care institutions * ~ financial subsidy for part of salary* regional GDP * ~ per capita disposable income * per capita GDP; (3) number of licensed (assistant) doctors * number of registered nurses * number of primary care institutions * financial subsidy for part of salary * regional GDP * regional fiscal revenue * per capita disposable income * per capita GDP; (4) ~ number of beds * ~ number of licensed (assistant) doctors * ~ number of registered nurses * ~ number of primary care institutions * financial subsidy for part of salary * regional GDP * regional financial income * per capita disposable income * per capita GDP (* for "and", ~ for "not") . And these four configurations could be classified into three types of paths: primary care resource allocation-driven type, primary care resource allocation and economic balance type, and economic development-driven type.
The overall level of coordinated development of primary care resource allocation and economy in China was unsatisfactory, with obvious regional differences, which was mainly affected by the number of registered nurses, regional GDP, and regional fiscal revenue, but may be facilitated greatly by the above-mentioned four configurations of associated factors. Therefore, it is suggested that each region chooses one path to achieve high level of interconnected, and coordinated development of primary care resource allocation and economy according to their own resources and conditions, so as to promote the rational primary care resource allocation, and the coordinated development of medical resources and economic level, thereby improving the level of primary care services in China.
