561654 research-article2014
APHXXX10.1177/1010539514561654Asia-Pacific Journal of Public HealthJing et al
Original Article
Factors Influencing Patients’ Contract Choice With General Practitioners in Shanghai: A Preliminary Study
Asia-Pacific Journal of Public Health 2015, Vol. 27(2S) 77S–85S © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514561654 aph.sagepub.com
Limei Jing, PhD1,2, Zhiqun Shu, MS2, Xiaoming Sun, PhD1,3, John F. Chiu, CCFP4, Jiquan Lou, MS2, and Chunyan Xie, MS5
Abstract The general practitioner (GP) system has been widely applied around the world and experimented with in Shanghai, China. To analyze some of the influencing factors on patient-GP contracts, we developed a questionnaire and conducted site investigations in 2011 and 2012 to 1200 patients by random sampling from 6 pilot community health service (CHS) centers in Pudong, Shanghai. The t test, χ2 test, factor analysis, and logistic regression analysis were used to analyze the data. The factors influencing patients’ contract behavior were age (OR = 1.03; 95%CI = 1.02-1.04), education level (OR = 0.83; 95% CI = 0.75-0.93), social interaction of social capital (OR = 1.34; 95% CI = 1.15-1.56), acceptance of first contact in community (OR = 3.25; 95% CI = 2.07-5.12), the year of investigation (OR = 2.58; 95% CI = 1.92-3.47), and the exposure to publicity (OR = 1.60; 95% CI = 1.39-1.85). Elderly patients formed a focus group to sign contracts with GPs. To increase trust in GPs by patients, it is recommended to improve the level of CHSs, strengthen publicity, and cultivate social capital among patients. Keywords general practitioner system, gatekeeper, first contact in community, primary health care
Introduction The establishment of a new health service system based on community health services (CHSs) is one of the emphases in the Opinions of the Communist Party of China Central Committee and the State Council on Deepening the Health Care System Reform in 2009.1 Furthermore, the Guidance on Establishing a general practitioner (GP) system2 issued by the State Council of the People’s Republic of China in 2011 has strengthened the importance of CHS provided by GPs in the national health strategy. With the understanding that GPs can meet at least 80% of patients’ needs 1School
of Public Health, Fudan University, Shanghai, China Institute for Health Development, Shanghai, China 3Pudong New Area Health and Family Planning Commission, Shanghai, China 4University of Alberta, Edmonton, AB, Canada 5Shanghai Health Development Research Center, Shanghai, China 2Pudong
Corresponding Author: Xiaoming Sun, School of Public Health, Fudan University, Shanghai, 200125, China. Email: [email protected]
Downloaded from aph.sagepub.com at UNIV OF WISCONSIN OSHKOSH on November 14, 2015
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Asia-Pacific Journal of Public Health 27(2S)
as well as acting as gatekeepers, they can contribute to cost control by reducing unnecessary hospital admissions.3 More than 50 countries in the world have health care systems based on the GP model. China is now calling for a primary care system based on GPs to ensure good quality care and cost effective care.4 Being a major city in China, Shanghai has CHS-based GPs, particularly in Pudong New Area, which has one of the most advanced health care systems in the country.5 In a primary care model based on GPs, the system of first contact in community (FCC) should be used. To attract and guide the patients to have first contact in CHS centers, GP teams and administrative departments are working on the promotion of contract relationships with community patients all over China. The purpose is to supply the public with basic health care services by separating the government public finance expenditure and fundamentally improve and reshape the doctor-patient relationship.6 The ultimate goal of the GP system is that each family can have its own GP, and the patient-GP contract is the first critical step.7 In these contracts, the rights and obligations between the 2 sides are clearly defined. GPs would have an obligation to provide primary health care services, including traditional Chinese medicine, disease prevention, home care services, periodic health assessment, and health management. The patients have an obligation to provide their personal health information and to receive timely treatment through appointments and referrals to regional medical institutions. Thus, the contract rate based on GP care will directly affect the successful implementation of health care reform in China. Previous Chinese studies mainly dealt with investigating the importance and actual effects of the contract, the implementation experience of the contract, and contractual difficulties.8-10 Some studies noted that the concept of social capital should be explored within the GP system.11 The main purpose of this study is to analyze the main influencing factors of contract behavior, including the concept of social capital, and put forward some suggestions for further development of the GP system of health care.
Methods Study Design and Sample As the largest district in Shanghai, Pudong New Area has 45 CHS centers. By 2012, there were 6 pilot CHS centers involved in the implementation of the GP system. This study was conducted in the first 2 weeks of October 2011 and 2012 in all 6 CHS centers in Pudong New Area. In each CHS center, 100 patients were randomly selected from those who were seeing a GP. Participants were permanent community inhabitants in Shanghai older than 18 years and agreed to sign the informed consent. Those who either refused to sign the informed consent or were patients with major psychiatric disorders were excluded from our sample. Our preinvestigation showed that most outpatients in CHS centers were older people. This is mainly because older people always have more accessible and convenient health care services needs than young people. It also meets with CHS centers’ present function. As the aging population increases all around China, older people will undoubtedly be the main group utilizing CHS resources.12 Furthermore, considering the current shortage of GPs in China, focusing on older people is one appropriate entry point to improve the GP system, which will be more consistent with the actual situation in Pudong New Area and even in China.
Questionnaire A questionnaire was designed based on the literature review13,14 and subject to an expert consultation. The questionnaire consists of 4 parts: the sociodemographic characteristics of patients, such as gender, age, education level, occupation, and type of insurance; first contact tendency and attitude toward FCC; social capital; and satisfaction with the publicity campaign.
Downloaded from aph.sagepub.com at UNIV OF WISCONSIN OSHKOSH on November 14, 2015
79S
Jing et al Table 1. Rotated Component Matrix for Publicity-Level Explanatory Variables.a Variables
FAC 4
1. Have you ever heard of the GP system services of CHS center? 2. Do you know whether the CHS center in your subdistrict has already started to supply GP system services? 3. Have you ever received publicity about GP system services?
0.891 0.915
aKMO
0.843
= 0.709; Bartlett’s test, P < .001.
In our study, FCC means that patients should first go to see their contracted GPs in the CHS center for initial diagnosis and treatment. The GPs will refer patients to secondary medical institutions in a timely fashion if needed, which forms the basis of establishing a primary care GP referral to consultants system. A previous study had noted that the GP system is lacking in social interaction and social identity, which creates a bottleneck, and, therefore, the concept of social capital should be introduced.15 The new definition of social capital by Canadian Policy Research Initiative is a social network based on trust, mutual benefit, and mutual assistance.16 Its factors can be defined from social interaction, trust, and sense of security; mutual benefit and social support; network of personal relationships; neighborhood cohesion; informal social control; community identification; and a sense of belonging.15 Based on existing research about social capital and expert consultations, 7 questions were designed. In the implementation of the GP system, public awareness through publicity campaigns is important. Since 2011, system designers and administrative management departments had a publicity campaign to get people to understand the GP system and ultimately accept it. Three questions were designed to explore the effectiveness of the publicity campaigns; they are listed in Table 1.
Data Collection All participants in the study were voluntary, and they signed informed consent prior to their inclusion. Ten investigators underwent group training in advance. Questionnaires were checked by quality controllers at the end of each day in case of any problems. Any problems identified were rectified by contacting the corresponding participant. The participants who came to CHS centers for consultation were asked to complete the questionnaires before they left. Finally, 1200 valid questionnaires were collected. The definition of a valid questionnaire was that it should have
APHXXX10.1177/1010539514561654Asia-Pacific Journal of Public HealthJing et al
Original Article
Factors Influencing Patients’ Contract Choice With General Practitioners in Shanghai: A Preliminary Study
Asia-Pacific Journal of Public Health 2015, Vol. 27(2S) 77S–85S © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514561654 aph.sagepub.com
Limei Jing, PhD1,2, Zhiqun Shu, MS2, Xiaoming Sun, PhD1,3, John F. Chiu, CCFP4, Jiquan Lou, MS2, and Chunyan Xie, MS5
Abstract The general practitioner (GP) system has been widely applied around the world and experimented with in Shanghai, China. To analyze some of the influencing factors on patient-GP contracts, we developed a questionnaire and conducted site investigations in 2011 and 2012 to 1200 patients by random sampling from 6 pilot community health service (CHS) centers in Pudong, Shanghai. The t test, χ2 test, factor analysis, and logistic regression analysis were used to analyze the data. The factors influencing patients’ contract behavior were age (OR = 1.03; 95%CI = 1.02-1.04), education level (OR = 0.83; 95% CI = 0.75-0.93), social interaction of social capital (OR = 1.34; 95% CI = 1.15-1.56), acceptance of first contact in community (OR = 3.25; 95% CI = 2.07-5.12), the year of investigation (OR = 2.58; 95% CI = 1.92-3.47), and the exposure to publicity (OR = 1.60; 95% CI = 1.39-1.85). Elderly patients formed a focus group to sign contracts with GPs. To increase trust in GPs by patients, it is recommended to improve the level of CHSs, strengthen publicity, and cultivate social capital among patients. Keywords general practitioner system, gatekeeper, first contact in community, primary health care
Introduction The establishment of a new health service system based on community health services (CHSs) is one of the emphases in the Opinions of the Communist Party of China Central Committee and the State Council on Deepening the Health Care System Reform in 2009.1 Furthermore, the Guidance on Establishing a general practitioner (GP) system2 issued by the State Council of the People’s Republic of China in 2011 has strengthened the importance of CHS provided by GPs in the national health strategy. With the understanding that GPs can meet at least 80% of patients’ needs 1School
of Public Health, Fudan University, Shanghai, China Institute for Health Development, Shanghai, China 3Pudong New Area Health and Family Planning Commission, Shanghai, China 4University of Alberta, Edmonton, AB, Canada 5Shanghai Health Development Research Center, Shanghai, China 2Pudong
Corresponding Author: Xiaoming Sun, School of Public Health, Fudan University, Shanghai, 200125, China. Email: [email protected]
Downloaded from aph.sagepub.com at UNIV OF WISCONSIN OSHKOSH on November 14, 2015
78S
Asia-Pacific Journal of Public Health 27(2S)
as well as acting as gatekeepers, they can contribute to cost control by reducing unnecessary hospital admissions.3 More than 50 countries in the world have health care systems based on the GP model. China is now calling for a primary care system based on GPs to ensure good quality care and cost effective care.4 Being a major city in China, Shanghai has CHS-based GPs, particularly in Pudong New Area, which has one of the most advanced health care systems in the country.5 In a primary care model based on GPs, the system of first contact in community (FCC) should be used. To attract and guide the patients to have first contact in CHS centers, GP teams and administrative departments are working on the promotion of contract relationships with community patients all over China. The purpose is to supply the public with basic health care services by separating the government public finance expenditure and fundamentally improve and reshape the doctor-patient relationship.6 The ultimate goal of the GP system is that each family can have its own GP, and the patient-GP contract is the first critical step.7 In these contracts, the rights and obligations between the 2 sides are clearly defined. GPs would have an obligation to provide primary health care services, including traditional Chinese medicine, disease prevention, home care services, periodic health assessment, and health management. The patients have an obligation to provide their personal health information and to receive timely treatment through appointments and referrals to regional medical institutions. Thus, the contract rate based on GP care will directly affect the successful implementation of health care reform in China. Previous Chinese studies mainly dealt with investigating the importance and actual effects of the contract, the implementation experience of the contract, and contractual difficulties.8-10 Some studies noted that the concept of social capital should be explored within the GP system.11 The main purpose of this study is to analyze the main influencing factors of contract behavior, including the concept of social capital, and put forward some suggestions for further development of the GP system of health care.
Methods Study Design and Sample As the largest district in Shanghai, Pudong New Area has 45 CHS centers. By 2012, there were 6 pilot CHS centers involved in the implementation of the GP system. This study was conducted in the first 2 weeks of October 2011 and 2012 in all 6 CHS centers in Pudong New Area. In each CHS center, 100 patients were randomly selected from those who were seeing a GP. Participants were permanent community inhabitants in Shanghai older than 18 years and agreed to sign the informed consent. Those who either refused to sign the informed consent or were patients with major psychiatric disorders were excluded from our sample. Our preinvestigation showed that most outpatients in CHS centers were older people. This is mainly because older people always have more accessible and convenient health care services needs than young people. It also meets with CHS centers’ present function. As the aging population increases all around China, older people will undoubtedly be the main group utilizing CHS resources.12 Furthermore, considering the current shortage of GPs in China, focusing on older people is one appropriate entry point to improve the GP system, which will be more consistent with the actual situation in Pudong New Area and even in China.
Questionnaire A questionnaire was designed based on the literature review13,14 and subject to an expert consultation. The questionnaire consists of 4 parts: the sociodemographic characteristics of patients, such as gender, age, education level, occupation, and type of insurance; first contact tendency and attitude toward FCC; social capital; and satisfaction with the publicity campaign.
Downloaded from aph.sagepub.com at UNIV OF WISCONSIN OSHKOSH on November 14, 2015
79S
Jing et al Table 1. Rotated Component Matrix for Publicity-Level Explanatory Variables.a Variables
FAC 4
1. Have you ever heard of the GP system services of CHS center? 2. Do you know whether the CHS center in your subdistrict has already started to supply GP system services? 3. Have you ever received publicity about GP system services?
0.891 0.915
aKMO
0.843
= 0.709; Bartlett’s test, P < .001.
In our study, FCC means that patients should first go to see their contracted GPs in the CHS center for initial diagnosis and treatment. The GPs will refer patients to secondary medical institutions in a timely fashion if needed, which forms the basis of establishing a primary care GP referral to consultants system. A previous study had noted that the GP system is lacking in social interaction and social identity, which creates a bottleneck, and, therefore, the concept of social capital should be introduced.15 The new definition of social capital by Canadian Policy Research Initiative is a social network based on trust, mutual benefit, and mutual assistance.16 Its factors can be defined from social interaction, trust, and sense of security; mutual benefit and social support; network of personal relationships; neighborhood cohesion; informal social control; community identification; and a sense of belonging.15 Based on existing research about social capital and expert consultations, 7 questions were designed. In the implementation of the GP system, public awareness through publicity campaigns is important. Since 2011, system designers and administrative management departments had a publicity campaign to get people to understand the GP system and ultimately accept it. Three questions were designed to explore the effectiveness of the publicity campaigns; they are listed in Table 1.
Data Collection All participants in the study were voluntary, and they signed informed consent prior to their inclusion. Ten investigators underwent group training in advance. Questionnaires were checked by quality controllers at the end of each day in case of any problems. Any problems identified were rectified by contacting the corresponding participant. The participants who came to CHS centers for consultation were asked to complete the questionnaires before they left. Finally, 1200 valid questionnaires were collected. The definition of a valid questionnaire was that it should have
