Which Medical Institution Should Perform Gatekeeping in Rural China? Results from a Cross-Sectional Study

Abstract

Background: China’s healthcare system is developing very fast but needs a regulatory practice, which helps to improve effectiveness and efficiency. This is a problem in rural China, in particular. The government is promoting a providing system with gatekeeping and mandatory referral procedures in order to limit resulting problems. However, there exists little evidence, which of the primary healthcare facilities in rural China should be given these functions.

Objective: It is this study’s objective to determine the impact of the specific medical institution of an initial visit on the patients’ following move through the healthcare system. On that reason, we want to find evidence which level of primary health sectors in rural China is more appropriate to perform gatekeeping and to integrate care based on referrals. The alternatives are either to prefer village clinics or township health centers.

Methods: The data were collected through a cross-sectional study in 2012, which used a stratified random sampling method to select 4 counties. 420 patients who wanted to see the doctors more than 3 times during the past 6 months were included as the study sample. We described the patients’ move through the healthcare system by measuring the density, dispersion and sequence of visits according to the Continuity of Care model (COC). The logistic regression model was used to determine the influence of medical institution of initial visit on patients’ moves after controlling other variables.

Results: We found that patients who chose the county hospital as medical institution for their initial visit had 5.88 times of the odds of high (vs. low) density, 4.17 times the odds of high (vs. low) dispersion, and 2.86 times the odds of high (vs. low) sequence of visits than those choosing village clinics as medical institution for the initial visit. However, patients choosing the county hospitals as medical institution of initial visit did not report higher density, dispersion or sequence of visit than the patients who chose the township health centers.

Conclusion: For the overwhelming majority of rural areas in China, the township health centers are more appropriate to perform the gatekeeping role than village clinics are. We see that as the conclusion at least at the present stage of the system’s development.

Zusammenfassung

Hintergrund: Chinas Gesundheitssystem entwickelt sich sehr schnell, es benötigt aber eine Regulationspraxis, die hilft, die Wirksamkeit und die Effizienz des Systems zu verbessern. Dies ist besonders in den ländlichen Regionen ein großes Problem. Die Regierung des Landes unterstützt deshalb den Aufbau eines Systems mit Gatekeeping und einem verpflichtenden Überweisungssystem, um die Probleme zu begrenzen. Derzeit existiert jedoch keine Erfahrung, welche der in den ländlichen Regionen zu findenden Versorgungseinrichtungen diese Aufgaben übernehmen könnte.

Studienziel: Es soll untersucht werden, welchen Einfluss die von einem Pateinten zuerst aufgesuchte Gesundheitseinrichtung für den weiteren Weg des Pateinten durch das System hat. Es sollen deshalb belastbare Kenntnisse gefunden werden, welche der Einrichtungstypen für eine solche Funktion geeignet ist. Die Alternativen sind die sog. „village clinics“ und die „township health centers“.

Methode: Die Daten für die Studie wurden im Jahre 2012 mittels einer Querschnittsstudie in 4 Kommunen gesammelt. Die Studie schloss insgesamt 420 Pateinten ein, die häufiger als 3-mal innerhalb der letzten 6 Monate einen Arzt aufgesucht hatten. Die Regionen der Studie resultieren aus einer stratifizierten Zufallsauswahl. Die Wanderungen der Patienten durch das Versorgungssystem werden mittels der Messkriterien “Dichte der Inanspruchnahme des gleichen Arztes” (density), „Inanspruchnahme unterschiedlicher Ärzte“ (dispersion) und „Häufigkeit der Kontakte mit unterschiedlichen Ärzte“ (sequence) beschrieben. Mittels eines logistischen Regressionsmodells wurde dann der Einfluss der zuerst aufgesuchten Einrichtung auf die weiteren Entscheidungen der Patienten bestimmt.

Ergebnis: Im Ergebnis der Studie zeigt sich, dass Patienten, die zunächst ein County Hospital aufsuchten eine 5,88 höhere Dichte der Inanspruchnahme ihres Arztes hatten als jene, die eine „Village Clinic“ aufsuchten. In Bezug auf die Inanspruchnahme verschiedener Ärzte war diese 4,17-mal höher. Die Sequenze der Inanspruchnahme verschiedener Ärzte war 2,86-mal höher als in den „village clinics“. Diese Unterschiede zeigen sich im Vergleich der County Hospitals zu den Township Health Centers nicht.

Schlussfolgerung: Die Autoren folgern, dass für die Mehrheit der ländlichen Bevölkerung die „township health centers“ geeigneter sind, um die primärärztlichen Aufgaben des Gatekeeping und der Überweisung der Patienten in andere Einrichtungen wahrzunehmen.

Key words

gatekeeping - referral - patient survey - rural China

Schlüsselwörter

Gatekeeping - Überweisungen - Querschnittsstudie - ländliche Regionen China

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