Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China

Document Type : Original Article

Authors

1 School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel

2 Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA

3 Shanghai Health Development Research Center, Shanghai, China

4 Braun School of Public Health and Community Medicine, Hebrew University, Jerusalem, Israel

5 School of Public Health, Fudan University, Shanghai, China

Abstract

Background 
Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders’ perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation.

Methods 
In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis.

Results 
Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors’ work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct “organizational incentives” suggested that current pay-for-performance incentives function as a “double-edged sword,” increasing family doctors’ motivation to excel while creating pressures to “game the system” among some physicians. When considering the CFIR construct “reflecting and evaluating,” policy-makers perceived the online evaluation application – which provides daily reports on family doctors’ work – to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the “network and communication” construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs.

Conclusion 
The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital–community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.

Highlights

 

Commentaries Published on this Paper

 

  • The Performance of Primary Healthcare in China: The Need for a Systematic Design for Improvement; Comment on “Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China”

        Abstract | PDF

 

  • Rethinking Performance Measurement of Primary Care in China; Comment on “Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China”

        Abstract | PDF

 

  • Quality Measurement as a Path to High Quality Care; Comment on “Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China”

        Abstract | PDF

 

Keywords


  1. World Health Organization (WHO), United Nations Children's Fund (‎UNICEF)‎. A Vision for Primary Health Care in the 21st Century: Towards Universal Health Coverage and the Sustainable Development Goals. WHO, UNICEF; 2018.
  2. Hort K, Gilbert K, Basnayaka P, Annear PL. Strategies to Strengthen Referral from Primary Care to Secondary Care in Low- and Middle-Income Countries. Vol 6. World Health Organization; 2019.
  3. Xu J, Gorsky M, Mills A. Historical roots of hospital centrism in China (1835-1949): a path dependence analysis. Soc Sci Med. 2019;226:56-62. doi:1016/j.socscimed.2019.02.025
  4. Shivashankar R, Kirk K, Kim WC, et al. Quality of diabetes care in low- and middle-income Asian and Middle Eastern countries (1993-2012): 20-year systematic review. Diabetes Res Clin Pract. 2015;107(2):203-223. doi:1016/j.diabres.2014.11.004
  5. International Diabetes Federation (IDF). IDF Diabetes Atlas. 10th ed. IDF; 2021.
  6. Gu D, Reynolds K, Duan X, et al. Prevalence of diabetes and impaired fasting glucose in the Chinese adult population: International Collaborative Study of Cardiovascular Disease in Asia (InterASIA). Diabetologia. 2003;46(9):1190-1198. doi:1007/s00125-003-1167-8
  7. Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA. 2009;301(20):2129-2140. doi:1001/jama.2009.726
  8. Li Y, Teng D, Shi X, et al. Prevalence of diabetes recorded in mainland China using 2018 diagnostic criteria from the American Diabetes Association: national cross sectional study. BMJ. 2020;369:m997. doi:1136/bmj.m997
  9. Li X, Xu Z, Ji L, et al. Direct medical costs for patients with type 2 diabetes in 16 tertiary hospitals in urban China: a multicenter prospective cohort study. J Diabetes Investig. 2019;10(2):539-551. doi:1111/jdi.12905
  10. Huang Y, Vemer P, Zhu J, Postma MJ, Chen W. Economic burden in Chinese patients with diabetes mellitus using electronic insurance claims data. PLoS One. 2016;11(8):e0159297. doi:1371/journal.pone.0159297
  11. Sun M, Rasooly A, Fan X, Jian W. Assessing the quality of primary healthcare for diabetes in China: multivariate analysis using the China Health and Retirement Longitudinal Study (CHARLS) Database. BMJ Open. 2020;10(12):e035192. doi:1136/bmjopen-2019-035192
  12. Caring for Quality in Health: Lessons Learnt from 15 Reviews of Health Care Quality. OECD; 2017.
  13. Wolters RJ, Braspenning JCC, Wensing M. Impact of primary care on hospital admission rates for diabetes patients: a systematic review. Diabetes Res Clin Pract. 2017;129:182-196. doi:1016/j.diabres.2017.05.001
  14. Braithwaite J, Hibbert P, Blakely B, et al. Health system frameworks and performance indicators in eight countries: a comparative international analysis. SAGE Open Med. 2017;5:2050312116686516. doi:1177/2050312116686516
  15. Bramesfeld A, Wensing M, Bartels P, et al. Mandatory national quality improvement systems using indicators: an initial assessment in Europe and Israel. Health Policy. 2016;120(11):1256-1269. doi:1016/j.healthpol.2016.09.019
  16. Meng Q, Xu L, Zhang Y, et al. Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study. Lancet. 2012;379(9818):805-814. doi:1016/s0140-6736(12)60278-5
  17. Li X, Krumholz HM, Yip W, et al. Quality of primary health care in China: challenges and recommendations. Lancet. 2020;395(10239):1802-1812. doi:1016/s0140-6736(20)30122-7
  18. Yi H, Miller G, Zhang L, Li S, Rozelle S. Intended and unintended consequences of China's zero markup drug policy. Health Aff (Millwood). 2015;34(8):1391-1398. doi:1377/hlthaff.2014.1114
  19. Li X, Lu J, Hu S, et al. The primary health-care system in China. Lancet. 2017;390(10112):2584-2594. doi:1016/s0140-6736(17)33109-4
  20. Ma X, Wang H, Yang L, Shi L, Liu X. Realigning the incentive system for China's primary healthcare providers. BMJ. 2019;365:l2406. doi:1136/bmj.l2406
  21. Yuan S, Wang F, Li X, Jia M, Tian M. Facilitators and barriers to implement the family doctor contracting services in China: findings from a qualitative study. BMJ Open. 2019;9(10):e032444. doi:1136/bmjopen-2019-032444
  22. Tian M, Wang F, Jia M, et al. Study on policy implementation of family doctors′ contracted services. Chin J Hosp Admin. 2020;36(7):549-552. doi:3760/cma.j.cn111325-20200408-01052
  23. National Health Commission of People's Republic of China (NHC). China Health Statistical Yearbook 2019. NHC; 2019.
  24. Qin JM, Lin CM, Zhang LF, Zhang YC. Patient satisfaction with primary care in highly focused districts/counties during the comprehensive reform of primary care system in China. Chin Gen Pract. 2018;21(1):36-40. doi:3969/j.issn.1007-9572.2018.01.009
  25. Xu J, Mills A. Challenges for gatekeeping: a qualitative systems analysis of a pilot in rural China. Int J Equity Health. 2017;16(1):106. doi:1186/s12939-017-0593-z
  26. Liu Z, Tan Y, Liang H, al. Factors influencing residents' willingness to contract with general practitioners in Guangzhou, China, during the GP policy trial phase: a cross-sectional study based on Andersen's behavioral model of health services use. Inquiry. 2019;56:46958019845484. doi:1177/0046958019845484
  27. Jing L, Shu Z, Sun X, Chiu JF, Lou J, Xie C. Factors influencing patients' contract choice with general practitioners in Shanghai: a preliminary study. Asia Pac J Public Health. 2015;27(2 Suppl):77S-85S. doi:1177/1010539514561654
  28. Li X, Krumholz HM, Yip W, et al. Quality of primary health care in China: challenges and recommendations. Lancet. 2020;395(10239):1802-1812. doi:1016/s0140-6736(20)30122-7
  29. Yip W, Fu H, Chen AT, et al. 10 years of health-care reform in China: progress and gaps in Universal Health Coverage. Lancet. 2019;394(10204):1192-1204. doi:1016/s0140-6736(19)32136-1
  30. Coles E, Anderson J, Maxwell M, et al. The influence of contextual factors on healthcare quality improvement initiatives: a realist review. Syst Rev. 2020;9(1):94. doi:1186/s13643-020-01344-3
  31. He J, Yang Y, Zhang T, et al. Progress and bottlenecks of family doctor system in Shanghai. Chin J Health Policy. 2014;7(9):14-18.
  32. Chen S, Hou X, Sun Y, et al. A seven-year study on an integrated hospital-community diabetes management program in Chinese patients with diabetes. Prim Care Diabetes. 2018;12(3):231-237. doi:1016/j.pcd.2017.12.005
  33. Shanghai Health Commission. Shanghai Community Healthcare Centers Comprehensive Evaluation Report for 2017. Shanghai Health Commission; 2018.
  34. Shanghai Municipal Government. Suggestions on the implementation of the reform and improvement of general practitioner training and use of incentive mechanisms in Shanghai. Published 2018. http://www.shanghai.gov.cn/nw2/nw2314/nw2319/nw12344/u26aw58014.html.
  35. Shen Y, Cai YY, Fang JY, Yang H, Shi R. Implementation status of performance appraisal in general practitioners and theirs team members in Shanghai. Chin Gen Pract. 2016;19(25):3033-3038. doi:3969/j.issn.1007-9572.2016.25.007
  36. Tan X. Indicator application in performance improvement: latest practices of performance improvement in USA, UK and Australia (in Chinese). China Health Quality Management. 2005;12(2):3-6.
  37. Zhang D, Xu S, Chen X. Job Evaluation Model in UK National Health System: Implications for Community Health Service in China (in Chinese). Chinese General Practice. 2012;5(4A):7-10.
  38. Ji Q, Bi F, Tan Y, Shi W. Research on the Construction of Quality Control and Evaluation System for Patient-centered Community Diabetes Patients Based on the UK Quality Assessment Framework (in Chinese). Chinese General Practice. 2019;22(S1):12-15.
  39. Tang C, Han C, Wang G. Cross sectional Study and reference to British QOF Management Mode and Control Mode of Diabetes in Communities of Shanghai (in Chinese). Chinese General Practice. 2014;7(17):2255-2258.
  40. National Health and Family Planning Commission (NHFPC). National Standards for Basic Public Health Services: Type 2 Diabetes Health Management Service Standards. 3rd ed. NHFPC; 2017.
  41. National Health and Family Planning Commission (NHFPC). National Basic Public Health Service Standard, 2009 Version. NHFPC; 2009.
  42. Shanghai Health Commission. Shanghai Community Healthcare Centers Comprehensive Evaluation Report for 2019. Shanghai Health Commission; 2020.
  43. Pham L. A review of advantages and disadvantages of three paradigms: positivism, interpretivism and critical inquiry. The University of Adelaide; 2018. doi:13140/rg.2.2.13995.54569
  44. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:1191/1478088706qp063oa
  45. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi:1186/1748-5908-4-50
  46. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11:72. doi:1186/s13012-016-0437-z
  47. Nouwens E, van Lieshout J, Wensing M. Determinants of impact of a practice accreditation program in primary care: a qualitative study. BMC Fam Pract. 2015;16:78. doi:1186/s12875-015-0294-x
  48. Eldh AC, Fredriksson M, Vengberg S, et al. Depicting the interplay between organisational tiers in the use of a national quality registry to develop quality of care in Sweden. BMC Health Serv Res. 2015;15:519. doi:1186/s12913-015-1188-2
  49. Yu W, Li M, Nong X, et al. Practices and attitudes of doctors and patients to downward referral in Shanghai, China. BMJ Open. 2017;7(4):e012565. doi:1136/bmjopen-2016-012565
  50. O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-1251. doi:1097/acm.0000000000000388
  51. Xu J, Yang Y. Traditional Chinese medicine in the Chinese health care system. Health Policy. 2009;90(2-3):133-139. doi:1016/j.healthpol.2008.09.003
  52. Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum. 2014;41(5):545-547. doi:1188/14.onf.545-547
  53. Cho J, Trent A. Validity in qualitative research revisited. Qual Res. 2006;6(3):319-340. doi:1177/1468794106065006
  54. Shi J, Jiang C, Tan D, et al. Advancing implementation of evidence-based public health in China: an assessment of the current situation and suggestions for developing regions. Biomed Res Int. 2016;2016:2694030. doi:1155/2016/2694030
  55. Rawshani A, Rawshani A, Franzén S, et al. Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2018;379(7):633-644. doi:1056/NEJMoa1800256
  56. Wang B, Zhou Y, Wu J, et al. Review of Shanghai glycohemoglobin harmonization program. Chin J Lab Med. 2020;43(1):36-43.
  57. Li X, Qian M, Zhao G, et al. The performance of a community-based colorectal cancer screening program: evidence from Shanghai Pudong New Area, China. Prev Med. 2019;118:243-250. doi:1016/j.ypmed.2018.11.002
  58. Kondo KK, Damberg CL, Mendelson A, et al. Implementation processes and pay for performance in healthcare: a systematic review. J Gen Intern Med. 2016;31(Suppl 1):61-69. doi:1007/s11606-015-3567-0
  59. Leung K, Wu JT, Liu D, Leung GM. First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment. Lancet. 2020;395(10233):1382-1393. doi:1016/s0140-6736(20)30746-7
  60. He AJ, Shi Y, Liu H. Crisis governance, Chinese style: distinctive features of China’s response to the COVID-19 pandemic. Policy Des Pract. 2020;3(3):242-258. doi:1080/25741292.2020.1799911
  61. Zhang X, Luo W, Zhu J. Top-down and bottom-up lockdown: evidence from COVID-19 prevention and control in China. J Chin Polit Sci. 2021;26(1):189-211. doi:1007/s11366-020-09711-6
  62. Chen S, Zhang Z, Yang J, et al. Fangcang shelter hospitals: a novel concept for responding to public health emergencies. Lancet. 2020;395(10232):1305-1314. doi:1016/s0140-6736(20)30744-3
  63. Heilmann S. From local experiments to national policy: the origins of China's distinctive policy process. China J. 2008;59:1-30. doi:1086/tcj.59.20066378
  64. Kranzler Y, Parag Y, Davidovitch N. Public health from the middle-out: a new analytical perspective. Int J Environ Res Public Health. 2019;16(24):4993. doi:3390/ijerph16244993
  65. Dalton AR, Alshamsan R, Majeed A, Millett C. Exclusion of patients from quality measurement of diabetes care in the UK pay-for-performance programme. Diabet Med. 2011;28(5):525-531. doi:1111/j.1464-5491.2011.03251.x
  66. Chang RE, Lin SP, Aron DC. A pay-for-performance program in Taiwan improved care for some diabetes patients, but doctors may have excluded sicker ones. Health Aff (Millwood). 2012;31(1):93-102. doi:1377/hlthaff.2010.0402
  67. Chen TT, Chung KP, Lin IC, Lai MS. The unintended consequence of diabetes mellitus pay-for-performance (P4P) program in Taiwan: are patients with more comorbidities or more severe conditions likely to be excluded from the P4P program? Health Serv Res. 2011;46(1 Pt 1):47-60. doi:1111/j.1475-6773.2010.01182.x
  68. McDonald R, Roland M. Pay for performance in primary care in England and California: comparison of unintended consequences. Ann Fam Med. 2009;7(2):121-127. doi:1370/afm.946
  69. Fleetcroft R, Parekh-Bhurke S, Howe A, Cookson R, Swift L, Steel N. The UK pay-for-performance programme in primary care: estimation of population mortality reduction. Br J Gen Pract. 2010;60(578):e345-352. doi:3399/bjgp10X515359
  70. Forbes LJ, Marchand C, Doran T, Peckham S. The role of the Quality and Outcomes Framework in the care of long-term conditions: a systematic review. Br J Gen Pract. 2017;67(664):e775-e784. doi:3399/bjgp17X693077
  71. Ryan AM, Krinsky S, Kontopantelis E, Doran T. Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: a population study. Lancet. 2016;388(10041):268-274. doi:1016/s0140-6736(16)00276-2
  72. Alshamsan R, Lee JT, Majeed A, Netuveli G, Millett C. Effect of a UK pay-for-performance program on ethnic disparities in diabetes outcomes: interrupted time series analysis. Ann Fam Med. 2012;10(3):228-234. doi:1370/afm.1335
  73. Weinick RM, Hasnain-Wynia R. Quality improvement efforts under health reform: how to ensure that they help reduce disparities--not increase them. Health Aff (Millwood). 2011;30(10):1837-1843. doi:1377/hlthaff.2011.0617
Volume 11, Issue 12
December 2022
Pages 3019-3031
  • Receive Date: 17 May 2021
  • Revise Date: 17 May 2022
  • Accept Date: 17 May 2022
  • First Publish Date: 18 May 2022