Donald K. T. Li

Patients’ Experiences in Different Models of Community Health Centers in Southern China

PURPOSE Current health care reforms in China have an overall goal of strengthening primary care through the establishment and expansion of primary care networks based on community health centers (CHCs). Implementation in urban areas has led to the emergence of different models of ownership and management. The objective of this study was to evaluate the primary care experiences of patients in the Pearl River Delta as measured by the Primary Care Assessment Tool (PCAT) and the relationships with ownership and management in the 3 different models we describe. METHODS This cross-sectional study was conducted on-site at CHCs in 3 cities within the Pearl River Delta, China, using a multistage cluster sampling method. A validated Mandarin Chinese version of the PCAT–Adult Edition (short version) was adopted to collect information from adult patients regarding their experiences with primary care sources. PCAT scores for individual primary care attributes and total primary care assessment scores were assessed with respect to sociodemographic characteristics, health characteristics, and health care service utilization across 3 primary care models. RESULTS One thousand four hundred forty (1,440) primary care patients responded to the survey, for an overall response rate of 86.1%. Respondents gave government-owned and -managed CHCs the highest overall PCAT scores when compared with CHCs either managed by hospitals (95.18 vs 90.81; P = .005) or owned by private and social entities (95.18 vs 90.69; P =.007) as a result of better first-contact care (better first-contact utilization) and coordination of care (better service coordination and information system). Factors that were positively and significantly associated with higher overall assessment scores included the presence of a chronic condition (P <.001), having medical insurance (P = .006), and a self-reported good health status (P <.001). CONCLUSIONS This study suggests that government-owned and -managed CHCs may be able to provide better first-contact care in terms of utilization and coordination of care, and may be better at solving the problem of underutilization of the CHCs as the first-contact point of care, one key problem facing the reforms in China.

Comparing Quality of Public Primary Care between Hong Kong and Shanghai Using Validated Patient Assessment Tools

Objectives Primary care is the key element of health reform in China. The objective of this study was to compare patient assessed quality of public primary care between Hong Kong, a city with established primary care environment influenced by its colonial history, and Shanghai, a city leading primary care reform in Mainland China; and to measure the equity of care in the two cities. Methods Cross sectional stratified random sampling surveys were conducted in 2011. Data were collected from 1,994 respondents in Hong Kong and 811 respondents in Shanghai. A validated Chinese version of the primary care assessment tool was employed to assess perceived quality of primary care with respect to socioeconomic characteristics and health status. Results We analyzed 391 and 725 respondents in Hong Kong and Shanghai, respectively, who were regular public primary care users. Respondents in Hong Kong reported significant lower scores in first contact accessibility (1.59 vs. 2.15), continuity of care (2.33 vs. 3.10), coordination of information (2.84 vs. 3.64), comprehensiveness service availability (2.43 vs. 3.31), comprehensiveness service provided (2.11 vs. 2.40), and the total score (23.40 vs. 27.40), but higher scores in first contact utilization (3.15 vs. 2.54) and coordination of services (2.67 vs. 2.40) when compared with those in Shanghai. Respondents with higher income reported a significantly higher total primary care score in Hong Kong, but not in Shanghai. Conclusions Respondents in Shanghai reported better quality of public primary care than those in Hong Kong, while quality of public primary care tended to be more equitable in Shanghai.

Comparison of three models of ownership of community health centres in China: A qualitative study

Objectives Community health centres are the main form of provision of primary care in China. There are three models: government managed, hospital managed and private. Our aim was to describe and compare primary care under the three ownership models. Methods Four aspects of primary care were studied: services, organization, financing and human resources. Interviews were undertaken with 60 managerial and professional staff in 13 community health centres in the Pearl River Delta region in 2010. Three community health centres were selected in the capital city and two were selected from each of the other five cities. Thematic framework analysis was conducted. Results Government-managed community health centres received the largest public funding, followed by hospital-managed community health centres, while private community health centres received the least. Private community health centres were the smallest in scale and provided lower quality public health services compared with the other two models. Patient out-of-pocket costs accounted for the majority of the revenue in all models of community health centres despite improved government funding for preventive services. General challenges such as the shortage of public funding, the exclusion of migrants in the funding for preventive services, low capacity in human resources and the separation of clinical and preventive care in community health centres were identified in all three models of community health centres. Conclusions The ownership and management of a community health centre greatly influence the service it provides. Private community health centres are in a disadvantaged position to deliver high quality clinical and preventive care.

Changes in the perceived quality of primary care in Shanghai and Shenzhen, China: a difference-in-difference analysis

Abstract Objective To assess changes in the quality of primary care in two megacities following the introduction of health system reforms in China. Methods We conducted multistage stratified random face-to-face surveys of patients visiting community health centres in Shanghai in 2011 and 2013, and Shenzhen in 2012 and 2013. Quality of primary care was measured using an assessment tool. Difference-in-difference analyses based on multiple linear regressions were used to compare the changes over time, after controlling for potential confounders. Findings Most (2721) of the 3214 participants used a community health centre as their regular source of care and were included in our analyses. The mean total scores for quality of primary care were similar for Shanghai and Shenzhen at baseline. In Shenzhen, the mean total scores for all participants and those on low incomes had worsened by 0.922 (95% CI: 0.629 to 1.215) and 1.203 (95% CI: 0.397 to 2.009), respectively. In Shanghai, however, there were improvements in the mean total scores which included increases in the scores for first-contact utilization, continuity, coordination of information and comprehensiveness. Conclusion The quality of primary care improved in Shanghai but not in Shenzhen. This may be because, in Shanghai, beneficial long-term relationships between patients and general practitioners were supported by capitation payments and the provision of services tailored to the local health priorities.

Performance comparison among the major healthcare financing systems in six cities of the Pearl River Delta region, mainland China.

Background The healthcare system of mainland China is undergoing drastic reform and the optimal models for healthcare financing for provision of primary care will need to be identified. This study compared the performance indicators of the community health centres (CHCs) under different healthcare financing systems in the six cities of the Pearl River Delta region. Methods Approximately 300 hypertensive patients were randomly recruited from the computerized chronic disease management records provided by one CHC in each of the six cities in 2011 using a multi-stage cluster random sampling method. The major outcome measures included the treatment rate of hypertension, defined as prescription of ≥ one antihypertensive agent; and the control rate of hypertension, defined as systolic blood pressure levels <140 mmHg and diastolic blood pressure levels <90 mmHg in patients without diabetes mellitus, or <130/80 mmHg among patients with concomitant diabetes. Binary logistic regression analyses were conducted with these two measures as outcome variables, respectively, controlling for patients’ socio-demographic variables. The financing system (Hospital- vs. Government- vs. private-funded) was the independent variable tested for association with the outcomes. Results From 1,830 patients with an average age of 65.9 years (SD 12.8), the overall treatment and control rates were 75.4% and 20.2%, respectively. When compared with hospital-funded CHCs, patients seen in the Government-funded (adjusted odds ratio [AOR] 0.462, 95% C.I. 0.325–0.656) and private-funded CHCs (AOR 0.031, 95% C.I. 0.019–0.052) were significantly less likely to be prescribed antihypertensive medication. However, the Government-funded CHC was more likely to have optimal BP control (AOR 1.628, 95% C.I. 1.157–2.291) whilst the privately-funded CHC was less likely to achieve BP control (AOR 0.146, 95% C.I. 0.069–0.310), irrespective of whether antihypertensive drugs were prescribed. Conclusions Privately-funded CHCs had the lowest rates of BP treatment and control due to a variety of potential factors as discussed.

The impact of cardiovascular multimorbidity on healthcare service utilisation under three primary care organisational models in China

Purpose China’s current healthcare reform leads to the emergence of community health centres (CHCs) of different models for delivering primary care services especially for patients with chronic conditions. Cardiovascular multimorbidity is a frequent phenomenon among such patients, yet less is known on its impact on healthcare service utilization in the primary care setting. This study aimed to compare the healthcare utilization patterns with cardiovascular multimorbidity under different CHC organisational models in China. Methods Cardiovascular multimorbidity was defined as the presence of two or more medical conditions related to cardiovascular diseases. Data on patients with cardiovascular multimorbidity who had a regularly attended CHC were extracted from a previous multicentre study in Guangdong province in southern China. Healthcare service utilization was measured in terms of primary care consultations in the previous 6 months, and a 4-point liker-type scale was developed to measure the continuity of care. Analysis of covariance was performed after Bonferroni-corrected adjustments were made for covariates. Results A total number of 383 primary care patients fulfilled all the inclusion criteria and the average number of cardiovascular diseases is 2.22 (95% CI: 2.18–2.27). Multiple linear regression analysis showed that healthcare service utilization was significantly increased among patients with cardiovascular multimorbidity (2.10; 95% CI: 0.73–3.47, p=0.003). After adjustment weremade for age and gender, patients of government-owned CHCs exhibited superior scores in the continuity of care (13.83; 95% CI: 13.51–14.14), compared to patients of privately-owned CHCs (12.93; 95% CI: 12.66–13.20, p Conclusion The study suggested government-owned primary care providers might perform better continuous primary care services for patients with cardiovascular multimorbidity. Further in-depth understanding of the impact of cardiovascular multimorbidity and multimortality is needed to inform the way in which primary care providers are performed to correspond to the challenge from cardiovascular multimorbidity.

Factors associated with cardiovascular multimorbidity among primary care patients in southern China

Purpose Management of the rising prevalence of long-term conditions is one of the major challenges facing China’s current primary care reform. Better understanding of factors associated with cardiovascular multimorbidity is necessary to develop a comprehensive strategy to support primary care physicians in China to provide patient-centred and continuous care. This study aimed to examine factors on individual socio-economic status in relation to the prevalence of cardiovascular multimorbidity among patients in primary care. Methods The study settings were the community health centres (CHCs) in Guangdong province in southern China. Multistage cluster sampling methods were adopted to select patients aged above 18 who had a usual source of primary care. Socio-demographic characteristics and health care information of patients were collected during November 2010 to April 2011 by on-site face-to-face interviews and paper-based medical record. Factors associated with cardiovascular multimorbidity were explored using one binary logistic regression model. Results The data from a total number of 5,370 Chinese primary care patients were analysed and 7.1% (95% CI: 6.4–7.8%) developed at least two cardiovascular conditions. However, more than one fourth (27.5%; 95% CI: 24.4–30.7%) of patients aged above 65 years were cardiovascularmultimorbid. Advanced age (aged above 65 years; adjusted odds ratio (aOR) 5.48; 95% CI: 4.21–7.13, p Conclusion Our study implied that cardiovascular multimorbidity were more likely to occur among older patients and those who had higher income with household registry in the primary care setting. Further longitudinal studies are also needed to explore the associations with cardiovascular multimortality thus to provide evidence on how best to organise tailor-made disease management services for people suffering from cardiovascular multimorbidity.

Elderly healthcare service at the community health centers in the Pearl River Delta region, China

Objective The recent population census showed China had officially become a graying society. In the meantime, China also faces a growing burden of non-communicable diseases. Since 2009, a series of policies have been implemented to enhance primary care at the community level. This study describes the elderly care services provided in the differently organized community health centers (CHCs). Methods It covered 13 CHCs of six cities located within the Pearl River Delta (PRD) region. In-depth interviews were conducted with a total of 59 health administrators, CHC managers, and CHC doctors regarding elderly care. Results The study found that accessibility of healthcare for elders has been improved due to the development of health insurance schemes as well as preferential policy to encourage the CHC utilization by the elderly. All the CHCs provide health examinations and chronic disease management to the permanent elderly within their catchment district. However, some preventative care such as fall prevention, immunization and mental health management are not provided. Conclusion Key barriers include low capacity of health service providers in the CHCs, and a lack of government investment in CHCs. Our report provides an empirical evidence for the health care reform in China.

M1032 Factors Associated with Practice of Colorectal Cancer Screening Among Primary Care Physicians in Hong Kong: A Cross-Sectional Study

vs use of colonoscopy for symptoms (diagnostic) or higher risk patients (surveillance), may contribute to the mortality difference if such differences resulted in diagnosis at a more advanced stage. Our aim was to explore if Caucasian patients were more likely to undergo primary screening colonoscopies vs. diagnostic or surveillance colonoscopies than were nonCaucasian patients. Methods: We randomly sampled 650 veterans from the national VA administrative databases (Austin Information Technology Center (AITC)), aged 50 and older, who had undergone outpatient colonoscopy between October 2005 and September 2006 in VA facilities using ICD-9 procedure codes. We then abstracted colonoscopy indication and race from their electronic medical records through VistAWeb. Colonoscopy indication was classified as either screening, diagnostic or surveillance. A chi-squared test was used to examine differences in colonoscopy indication by the dichotomous race variable (Caucasian vs. Non-Caucasian). Results: In our sample 84% of veterans were Caucasian and 16% were non-Caucasian (90% of non-Caucasians were African American). We deleleted 81 individuals from the analysis due to missing data for race. Our sample size for this analysis was 569. The indications for Caucasians and non-Caucasians were not significantly different (p=0.72) and were 32% and 34% screening, 22% and 33% diagnostic, and 45% and 41% surveillance. Furthermore, the distribution of the indication patterns was similar in the group missing race data. Conclusions: During the study period about a third of the colonoscopies in this national VA sample were for primary CRC screening. There is no evidence that Caucasian patients weremore likely to have had colonoscopy for primary screening, versus for symptoms or surveillance, than were minority patients. These results support the equity of the VA system, but do not explain the cancer mortality difference.