Shi et al. International Journal for Equity in Health (2015) 14:90 DOI 10.1186/s12939-015-0222-7 RESEARCH Open Access Community health centers and primary care access and quality for chronically-ill patients – a case-comparison study of urban Guangdong Province, China Leiyu Shi1, De-Chih Lee2, Hailun Liang3, Luwen Zhang4, Marty Makinen5, Nathan Blanchet5, Ruth Kidane5, Magnus Lindelow6, Hong Wang7 and Shaolong Wu4* Abstract Objective: Reform of the health care system in urban areas of China has prompted concerns about the utilization of Community Health Centers (CHC). This study examined which of the dominant primary care delivery models, i.e., the public CHC model, the ‘gate-keeper’ CHC model, or the hospital-owned CHC models, was most effective in enhancing access to and quality of care for patients with chronic illness. Methods: The case-comparison design was used to study nine health care organizations in Guangzhou, Dongguan, and Shenzhen cities within Guangdong province, China. 560 patients aged 50 or over with hypertension or diabetes who visited either CHCs or hospitals in these three cities were surveyed by using face-to-face interviews. Bivariate analyses were performed to compare quality and value of care indicators among subjects from the three cities. Multivariate analyses were used to assess the association between type of primary care delivery and quality as well as value of chronic care after controlling for patients’ demographic and health status characteristics. Results: Patients from all three cities chose their current health care providers primarily out of concern for quality of care (both provider expertise and adequate medical equipment), patient-centered care, and insurance plan requirement. Compared with patients from Guangzhou, those from Dongguan performed significantly better on most quality and value of care indicators. Most of these indicators remained significantly better even after controlling for patients' demographic and health status characteristics. The Shenzhen model (hospital-owned and -managed CHC) was generally effective in enhancing accessibility and continuity. However, coordination suffered due to seemingly duplicating primary care outpatients at the hospital setting. Significant associations between types of health care facilities and quality of care were also observed such that patients from CHCs were more likely to be satisfied with traveling time and follow-up care by their providers. Conclusion: The study suggested that the Dongguan model (based on insurance mandate and using family practice physicians as ‘gate-keepers’) seemed to work best in terms of improving access and quality for patients with chronic conditions. The study suggested adequately funded and well-organized primary care system can play a gatekeeping role and has the potential to provide a reasonable level of care to patients. Keywords: Primary care, Chronic disease, Community health centers, Integrated care, Quality of care * Correspondence: [email protected] 4School of Public Health of Sun Yat-sen University, 74, Zhongshan Road II, Guangzhou 510275, China Full list of author information is available at the end of the article © 2016 Shi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shi et al. International Journal for Equity in Health (2015) 14:90 Page 2 of 17 Introduction model is that of an independent CHC fully funded by Primary care refers to first-contact, continuous, compre- the government and acting as a first-contact option for hensive, and coordinated care provided to individuals re- patients seeking primary care. The rational is that by gardless of gender, disease, or organ system affected [1]. providing easy access and affordable care, CHC would Over the past two decades, preponderance of research attract patients from hospitals. However, under this pub- around the world has demonstrated that effective pri- lic CHC model, patients still have the option of choosing mary care can not only improve population health, but hospitals for their primary care needs. Most CHCs in also has the potential to reduce health disparities [2–12]. Guangzhou and Beijing are under this model. The Countries or regions within a country with strong pri- Beijing government established Beijing Management mary care system see improved health outcomes for Center for Community Health Services (CCHS) in 2006, their populations, particular reflected in reduced morbid which served as an executive agency and played the role conditions, higher quality of life, and better health care of drafting and implementing standards and norms for system satisfaction in elderly individuals [7, 13–17]. In public CHCs around the city. Another more restrictive 2008, the World Health Organization (WHO) urged that model uses insurance payment arrangement to require primary care be used as an approach to provide effective, patients to use CHC as their first-contact ‘gate-keeper.’ fair, and efficient care and that primary care systems be Dongguan is the first pilot city implementing ‘gate- strengthened in all countries [18]. Studies in the United keeper’ model since 2008. A third emerging model fo- States have credited the community health center model cuses on the integration of hospital and CHC where with providing accessible, cost-effective, and high quality CHC serves as extension of the hospital. In this model, primary care and reducing health disparities [19–46]. CHC is staffed and managed by the hospital. The ration- These studies suggest that primary care matters to popu- ale is that by making the CHC part of the hospital, the lation health and that the health center model might be technical expertise of the doctors can be assured and a an effective approach to advance primary care. seamless referral (between CHC and hospital) can be fa- China has a three-tiered health care delivery system, cilitated. Implementation of the hospital-owned CHC with community health centers (CHCs) at the bottom, model began in Shenzhen and was expanded to Chong- secondary hospitals in the middle, and tertiary hospitals qing as well as other cities around the nation. Despite at the top [47, 48]. Despite this classification, patients these and other emerging models of primary care deliv- can access primary care in all facilities across the three ery, no systematic research has been conducted to assess levels, having the freedom to choose a doctor or health their effectiveness. care facility without the constraints of health insurance The purpose of this study was to fill this gap in the lit- policy [49]. Most people prefer higher-level hospitals erature by evaluating which of the dominant primary due to better medical technology and perceived tech- care delivery models are most effective in enhancing ac- nical quality of the provider, although they will not see cess and quality for patients with chronic illness, using the same doctor each time and expenditure at the hos- the province of Guangdong as the study site. Guangdong pital setting is much higher than that at the community. is a coastal province located in Southern China. The However, higher-level hospitals require registering in a population of permanent residents in Guangdong is long queue, which has a significant time constraint. This more than 100 million, making it the most populous also means that doctors have less time to treat and inter- province in China. With 30 % of its total population being act with their patients. This may result in unsatisfactory migrants, it accounts for the largest number of internal experience of care, as patients often complain that their migrant population in China [53]. Variable economic and doctors hustle them through appointments. geographic development makes Guangdong a good case In an attempt to address the access and cost problems study for China. Guangzhou is larger in land area and associated with seeking hospital care for all health prob- population (3834 square kilometers and 12,927 thousand) lems, the Chinese government has undertaken a series compared with Shenzhen (1997 square kilometers and of reforms aimed at strengthening community-based pri- 10,629 thousand) and Dongguan (2465 square kilometers mary care delivery and the referral system [50]. The cen- and 8317 thousand). However, GDP per capita was higher tral and local governments have been investing heavily in Shenzhen (RMB 136,948) than in Guangzhou (RMB in primary care service institutions to provide full fund- 119,695) or Dongguan (RMB 66,109). In terms of health ing for their staff and the supply of zero-profit drugs status, while the three cities had comparable infant [51, 52]. Numerous models have occurred around the mortality (2.2-3.5 per 1000 live births), Shenzhen had country to enhance community-based primary care. As lower mortality rate than Dongguan and Guangzhou socioeconomic conditions and health care development (1.07 vs. 4.60 and 5.44 %). In terms of health care resources, vary in different urban regions, the primary care models Shenzhen had more CHCs than Dongguan and Guangzhou implemented also differ accordingly. The most popular (609 vs. 389 and 316). There were more hospital beds and Shi et al. International Journal for Equity in Health (2015) 14:90 Page 3 of 17 higher bed occupancy rate in Guangzhou (5.67 beds per Study subjects 1000 population and 91.2 %) compared to Shenzhen (2.76 The study subjects were individuals age 50 or over with beds per 1000 population and 84.4 %) and Dongguan (3.09 hypertension or diabetes who visited either CHCs or beds per 1000 population and 88.2).1 hospitals in these three cities in March 2015.