Abstract

The primary healthcare facilities are the principal units to provide the healthcare service and they undertake the task for treating the common and regular diseases of the residents in China.However, with the development of health system reform, problems on the quality of the primary care have been exposed, such as the insufficient of health resources, the poor equipment and environment, drug abuse, and low level of diagnosis and treatment, which hinder the process of the hierarchical health system.

In 2015, General Office of the State Council promulgated the“Guiding Opinions on promoting the construction of the hierarchical health system”, which is aimed to conduct the first contact care at community health services, establish a two-way referral system, achieve the separate diagnosis and treatment of the acute and chronic diseases, and realize the interaction between superior health institutions and subordinate health institutions.In 2017, General Office of the State Council promulgated the“Guiding Opinions on the Construction and Development of Health Alliance”, which is aimed to give full play to its dominant role, promote the sinking of health resources, and improve the quality of the primary care.Health Alliance is an association led by tertiary hospitals and composed of primary and secondary hospitals within a particular administrative region.It is an effective carrier of the tiered diagnosis and treatment model.With the development of the tiered diagnosis and treatment, the implementation of Health Alliance is imperative.However, the fundamental question is whether Health Alliance has led to actual improvement in the quality of the primary care and in the formation of scientific and reasonable health service order.This study aimed to assess whether Health Alliance improved the quality of the primary care, and compared the impact of tight Health Alliances and loose Health Alliances on the quality of the primary care in urban China.It is significant to provide a scientific theoretical basis for the improvement of the primary care, and the perfection of Health Alliance.In general, Health Alliance operates under two main models in urban China: tight Health Alliances(THA), and loose Health Alliances(LHA).There is currently little objective evidence on the impact of Health Alliance and its model.

In this study, the primary care facility was defined as community health centers(CHCs)in urban areas.We selected all CHCs that provide the primary care in 7 urban districts of City A in Shannxi as our samples.Standardized patients(SPs), recruited from local community and trained to portray an actual patient’s historical and physical features in a standardized way in real settings, presenting fixed cases(unstable angina and asthma)were employed to assess the quality of the primary care in CHCs.After data cleaning, 484 interactions from 61 CHCs between the primary care physicians and SPs were adopted for empirical analysis.

Donabedian model and the model from National Academy of Medicine(NAM)were employed to evaluate the impact of Health Alliance and its model on the quality of the primary care from the aspects of structure, process and outcome.Coarsened exact matching method(CEM)was employed to match the CHCs that implemented Health Alliance with the unimplemented CHCs, and match the CHCs implemented tight Health Alliance with loose Health Alliance, respectively.The matched data were used to analyze the impact of Health Alliance and its model.Difference-in-difference and multiple regression models were used to evaluate the impact of Health Alliance and its model on the quality of the primary care.

Based on the above research, the following major conclusions were drawn:

Firstly, structure quality: The health human resources were insufficient, and the distribution of human resources were uneven.The health equipment was also insufficient.Process quality: 1)Overall, the effectiveness of the primary care was poor.The adherence to the recommended questions and exams in clinical checklist was 27.89%and 34.20%, respectively.The correct diagnosis and correct treatment were 54.48%and 24.17%, respectively. 2)There were several security threats in the primary care.The percentage of interactions that provide invasive examinations, unnecessary examinations, and harmful medications were 60%, 60%, and 30%, respectively. 3)The consulting time between the primary care physicians and SPs increased.However, the waiting time was still high.Therefore, the optimization of treatment processes is needed.Outcome quality: patient-centered model has not been formed yet.

Secondly, Health Alliance were more likely to improve the adherence to clinical checklist and correct treatment; tight Health Alliance were more likely to improve the adherence to clinical checklist and correct diagnosis.

Thirdly, Health Alliance and tight Health Alliance were more likely to improve the safety of the primary care.However, the percentages of interactions provide invasive examinations, unnecessary examinations, and harmful medications were still high in general.

Fourthly, Health Alliance and tight Health Alliance were more likely to improve the timeliness and improve the sufficiency of communication between patients and physicians.

Fifth, Health Alliance and tight Health Alliance were more likely to improve the patient-centeredness of the primary care.

Sixth, Health Alliance and tight Health Alliance were more likely to improve the quality of the primary care.

Seventh, there is significant quality inequality in different primary care models.Public CHCs might have higher quality.

Finally, our findings showed the patient-centered communication model in the primary care settings has positive associations with the quality of the primary care.

The innovation of the study is mainly reflected on the following five aspects:

Firstly, in terms of evaluation model: the Donabedian model was firstly integrated with model proposed by the National Academy of Medicine.Using the newly established evaluation model and combining with the characteristics of China’s primary health facilities, the evaluation index system of the quality of the outpatient care in community health centers was constructed.It provides reference for relevant research to choose reasonable evaluation index.

Secondly, in terms of research ideas: unlike the existing domestic studies in pursuit of comprehensive evaluation, this study takes specific diseases as the research object to carry out the quality evaluation of the outpatient care on the basis of learning from foreign experience, in order to make the research results more specific and reliable.In addition to the structural evaluation and outcome evaluation, this study pays special attention to the process evaluation, which will contribute to the transformation of research ideas in other studies.

Thirdly, in terms of research content: it is the first time to systematically and comprehensively evaluate the impact of the Health Alliance on the quality of the primary care, and compare the implementation effects of different modes(tight Health Alliances, and loose Health Alliances), which will provide a scientific basis for improving the construction of Health Alliance system.

Fourthly, in terms of analysis methods: the study adopts the international advanced standardized patient method to evaluate the quality of the outpatient service, and comprehensively uses the coarsened exact matching method, the Difference-in-difference method combined with multiple regression model to control the confounding factors, which enhance the accuracy and reliability of research results.

Finally, in terms of research conclusions: this study analyses the status and changes of the primary medical services’quality, revealing that the quality of the primary care has not improved significantly.After depth analysis of the impact of Health Alliance on the quality of the primary care, the results show that the Health Alliance is conducive to improving the quality of the primary care.Com-bined with qualitative interview results, the main reason is that the Health Alliance sinks through resources, taking the lead in comprehensive hospital’s superior resources drive the service capabilities of primary medical institutions to improve grassroots service capabilities, standardize diagnosis and treatment behavior, and improve the quality of the primary care services.The impact of the tight Health Alliance on the quality of the primary care is discussed.The results show that the tight Health Alliance is more conducive to improving the quality of the primary care.The main reason is that the model unified management of materials and the formation of a real community of interests and a community of responsibility between medical institutions at all levels within the organization based on the integration of ownership and assets, and implements human and financial resources.This study puts forward that policy recommendations for improving the quality of the primary care and improving the construction of tight Health Alliance.There is significant quality inequality in different primary care models.Public CHCs might have higher quality.The patient-centered communication model in the primary care settings has positive associations with the quality of the primary care.

We put forward the following suggestions according to the findings of this paper:

Firstly, we put forward the suggestions from the four aspects(effectiveness, security, timeliness, and patient-centered care)to improve the quality of the primary care; Secondly, it is suggested to build the tight Health Alliance, strengthen the integration of property rights within the Health Alliance, improve the service system and mechanism, strengthen supervision and management, and improve the health human resources sharing mechanism; Finally, we should promote the public-private cooperation and improve the health service supply network.

In a word, the tight Health Alliance is conducive to improving the quality of the primary care.However, there are still many problems in the current construction of the Health Alliance, and the quality of the primary care is pretty low.Therefore, we must actively deal with the above problems to achieve the high-quality development of hierarchical health system and the tight Health Alliance, and contribute to achieving prosperity for all.

KEY WORDS: The quality of primary care; Health alliance; Tight Health Alliances; Loose Health Alliances; Standardized patients; Coarsened exact matching; Difference in difference

TYPE OF RESEARCH: Applied Research