Patients' experiences in community health centres under the health-care reform: research findings from a cross-sectional study using the Primary Care Assessment Tool in China

Abstract

BackgroundChina is reshaping its health-care system to orient towards primary care. We developed a short instrument on the basis of the Primary Care Assessment Tool-Adult Edition (PCAT-AE) to assess patients' experiences of primary-care delivery in community health centres, the major primary-care provider in urban areas. MethodsA multistage cluster sampling method was used to select seven geographical regions in southern China where the population's ageing and gender structure is similar to that of China's overall population. A validated PCAT-AE (Mandarin Chinese short version) with 33 PCAT items on a four-point Likert-type scale was used, with higher scores representing better primary-care experiences. This study was approved by the Ethics Committee of Guangzhou Medical University, Guangzhou, China, and the Survey and Behaviour Research Ethics Committee of The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (TB106179/MD10606). All study participants provided written consent. FindingsThe overall response rate of adult subjects interviewed at community health centres was 85·8% (3360 of 3916). Both frequent (2237) and less-frequent service users (1123) were surveyed, among which 1122 (33%) patients had an optimum PCAT score (higher than the third quantile of the score range—ie, above 99 of 132). The proportion of subjects with optimum scores in individual primary-care domains ranged from 62·1% (95%CI 59·8–64·3) in the comprehensiveness of service attribute to only 16·6% (14·7–18·7) in the community orientation attribute. Among all subjects, those with social medical insurance were more likely to report optimum primary care experience (adjusted odds ratio 2·30, 95% CI 1·92–2·75) than those uninsured. In the stratified analysis among subjects who were uninsured, those attending community health centres owned and managed by the government as their usual source of primary care had the highest PCAT scores compared with other models of community health centres owned and managed by secondary or tertiary hospitals (95·16 vs 90·18; p=0·0001) or by private investors (95·16 vs 87·80; p<0·0001), as a result of better first-contact care and coordination of care. InterpretationThe study suggests an urgent need to understand and address how social medical insurance coverage could affect patients' experiences. The community health centre model with a government-dominant top-down approach seems to be most effective in solving conundrums for China's health-care reform. FundingThis study was funded by the Bauhinia Foundation Research Centre; Department of Health, Guangdong province (C2009006/2009–2013); Department of Education, Guangdong province (BKZZ2011047/2010–2013); Medical Research Fund, Chinese Medical Association (2010-08-05); and Community Health Research Fund, Community Health Association of China (2012-2-91). HHXW was supported by a postdoctoral research fellowship in the Hong Kong–Scotland Partners in Post Doctoral Research programme, Research Grants Council of Hong Kong and the Scottish Government (S-CUHK402/12). JJW is supported by Guangdong Exemplary Centres for Exploratory Teaching in Higher Education Institutions—General Practice Exploratory Teaching Centre (GDJG-2010-N38-35, Guangdong Department of Education) and The Ninth Round of Guangdong Key Disciplines—General Practice (GDJY-2012-N13-85, Guangdong Department of Education), both of which he leads.