An exploratory study on the design of an integrated healthcare organization structure from the demand side perspective of health services

doi:10.21203/rs.3.rs-1757855/v1

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An exploratory study on the design of an integrated healthcare organization structure from the demand side perspective of health services

https://doi.org/10.21203/rs.3.rs-1757855/v1

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Background

China has entered a severely aging society, and the elderly have an increasing demand for health care. The current medical policy can no longer meet the growing demand for health services for the elderly.

Objective

To analyze the unmet needs of the elderly in Chinese communities, and put forward a plan from the perspective of health service demand side to make full use of health service resources and ensure the balance between the supply and demand of health service.

Methods

A questionnaire survey was conducted to analyze the unmet needs of 1527 elderly people in N district of H city, Zhejiang province, China.

Results

The unmet health needs of the elderly in this community were mainly related to chronic diseases, and the top three diseases in terms of chronic disease prevalence were hypertension (40.2%), dyslipidemia (8.4%), and diabetes (7.0%).

Conclusions

We propose that in the context of integrated medical policy, chronic disease management of the elderly in the community should break the concept of the original three-level medical system hierarchy and build an integrated chronic disease service system with general practitioners as the core.

demand side of health services

integrated healthcare

balance between supply and demand

general practitioners

the elderly

chronic diseases

The general practitioner acts as a gatekeeper in the integrated health care system, especially in primary health care services.

What this study adds: Using general practitioners in secondary medical and health services as a hub, the role of general practitioners is fully utilized to integrate resources and meet the health service needs of the elderly.

According to the result of China's seventh census in 2020, the population aged 60 and above was 260 million, accounting for 18.7% of the total population, far exceeding the 10% aging standard set by the United Nations, and China has entered a seriously aging society. "Healthy aging" has become the goal of social development. Standardized health management can effectively improve the quality of life of the elderly and promote the development of healthy aging.¹ According to a study, the satisfaction rate of the elderly with their health is only 25.4%.² In recent years, the Chinese government has emphasized relying on the community to provide comprehensive health management services for the elderly, but community-based health support services for the elderly are still at the exploration stage. The number of health support services provided by the community accounts for less than 50% of all services, and the content is mainly health education and knowledge propaganda, which is a single form and cannot fully meet the health service needs of the elderly .³ The "Healthy China 2030" Plan Outline proposes to promote the construction of a health care service system and strengthen health management for the elderly, while emphasizing that building a high-quality and efficient integrated healthcare service system is a key initiative to "build a healthy China and achieve health for all”.⁴ Integrated healthcare has been recognized as a means to improve the accessibility, quality and continuity of services in a more effective manner.⁵ In order to build a better integrated health service system and adapt the existing organizational structure of integrated healthcare to the needs of the elderly, a questionnaire survey was conducted to analyze the unmet needs of the elderly in the district from the perspective of the demand side of health services (in this study, the elderly in the community) and to propose the scope of business of the supply side of health services (in this study, the medical and health institutions at all levels) and how to integrate resources better, so as to provide some ideas and suggestions for the design of integrated healthcare organization structure.

Study design and participants

Elderly people in N district of H city, Zhejiang province, China, were used as the study population for the demand side of health services, and three of the streets (townships) were randomly selected by lottery method with whole-group sampling of resident elderly people. Inclusion criteria: ① age ≥ 60 years ② clear consciousness, able to answer questions correctly. Exclusion criteria: non-resident population of the district. A total of 1527 cases were included. This study was approved by the Ethics Committee of Huzhou University, ethics number 2020529-18. All respondents signed informed consent forms.

This study was implemented by means of a questionnaire. The Family Health Questionnaire for the Survey of Chronic Diseases and Their Risk Factors was used uniformly. The questionnaire is consisted of basic family information, basic personal information, major chronic diseases and consultation, behavior and lifestyle, knowledge related to core knowledge of chronic disease prevention and control, and medical examination form.

Data Collection

According to the content of the questionnaire and the patient's answers interview-style, investigators who were trained can fill out the questionnaire to ensure the accuracy and reliability of the completed content. The questionnaires were surveyed, filled out and collected on site. A total of 1527 copies of questionnaires were distributed, 1527 copies were collected and the recovery rate was 100%. Among them, 1447 valid questionnaires were recovered, with a valid recovery rate of 94.8%.

Statistical Methods

The collected questionnaires were coded and all eligible data were entered in pairs using EpiData 3.1 to create a database. SPSS 25.0 was used for statistical analysis, and the count data were expressed as frequencies and percentages.

Demographic data and general characteristics

Table 1 shows the demographics and general characteristics of the participants. Among the 1447 elderly people, there were 46.4% male and 53.6% female, respectively. The population of elementary school and below was 86.5%, and health insurance coverage was 100%. The overweight population accounted for 29.8%.

Table 1

Demographic data and general characteristics
Projects	Frequency
Gender	N (%)
Male	672 (46.4)
Female	775 (53.6)
Education level
Never went to school	507 (35.0)
Primary School	745 (51.5)
Junior high school and above	195 (13.5)
Medical Insurance
Publicly funded medical care	9 (0.6)
Basic medical insurance for urban and rural residents	1438 (99.4)
BMI
< 18.5	89 (6.1)
18.5–23.9	927 (64.1)
≥ 24	431 (29.8)
Total	1447 (100)

Prevalence Of Chronic Diseases
Table 2 shows the prevalence of chronic diseases. The top three diseases with chronic disease prevalence were hypertension (40.2%), dyslipidemia (8.4%) and diabetes (7.0%). Many elderly people were unaware of their diseases, with 2.8%, 1.7%, 3.2%, and 5.7% of them not knowing whether they had coronary heart disease, stroke, chronic respiratory disease, and cancer, respectively.

Table 2

Prevalence of chronic diseases

Projects

Frequency

Hypertension

N (%)

Yes

582 (40.2)

No idea

5 (0.3)

Diabetes

Yes

102 (7.0)

No idea

16 (1.1)

Dyslipidemia

Yes

122 (8.4)

No idea

245 (16.9)

Coronary heart disease

Yes

61 (4.2)

No idea

40 (2.8)

Stroke

Yes

17 (1.2)

No idea

25 (1.7)

Chronic respiratory diseases

Yes

38 (2.6)

No idea

47 (3.2)

Cancer

Yes

13 (0.9)

No idea

83 (5.7)

Unmet Needs Of Health Service Demanders To Obtain Disease-related Knowledge And Lack Of Health Concepts

Table 3 shows that the demand side of health services had unmet needs for disease-related knowledge and lacked health concepts. 74.5% of the elderly did not know the criteria of high-risk groups for chronic diseases, 31% did not know which diseases were chronic diseases, and only 18.7% knew their blood glucose levels, indicating a low awareness rate of chronic disease-related knowledge and disease-related knowledge needs are not met. Only 27% of patients with dyslipidemia received lipid-regulating medication within the past 2 weeks, with low medication adherence and unmet need for safe medication use.

Table 3

Health literacy - basic knowledge and concepts
Projects	Frequency N (%)
Don't know the criteria for people at risk for chronic diseases	1078(74.5)
Don't know which diseases are chronic diseases	448(31.0)
Don't know what factors are associated with the development of chronic diseases	426(29.4)
Believes that a healthy lifestyle can effectively prevent chronic diseases	965(66.7)
The most important thing to prevent and control cardiovascular diseases is to prevent and control risk factors such as high blood pressure	860(59.4)
Most cancers are considered preventable and treatable	523(36.1)
Considering that the prevention and control of chronic diseases requires the participation of the whole society	914(63.2)
Hypertensive person treated with antihypertensive medication within the last 2 weeks	544(93.5)
Diabetic treated with glucose-lowering drugs or insulin within the last 2 weeks	89(87.3)
Dyslipidemia treated with lipid-regulating drugs within the last 2 weeks	33(27.0)
Know your waist size	943(65.2)
Know your blood pressure	1069(73.9)
Know your blood sugar	270(18.7)

The demand side of health services reasonable exercise, diet and nutrition needs are not met, lack of healthy lifestyles and behavior

As seen in Table 4, the demand side of health services for reasonable exercise, diet and nutrition was not met and lacked healthy lifestyles and behaviors. Smoking and alcohol consumption accounted for 21.2% and 18.3%, respectively. Only 17.9% of people do physical exercise in their spare time. Many elderly people lack exercise, and reasonable exercises needs have not been met. The proportion of those who do not eat fish, shrimp, eggs and fruits every week is about 10%, and the proportion of those who do not eat dairy products every week is as high as 84.9%, with unreasonable dietary structure and unmet dietary nutritional needs. Only 57.3% of the elderly would take the initiative to go to medical institutions when they are sick, lacking the awareness of taking the initiative to seek medical treatment.

Table 4

Health Literacy - Lifestyle and Behavior
Projects	Frequency
Smoking or not	N (%)
Smoking	307 (21.2)
Have quit smoking	131 (9.1)
Whether to drink alcohol
Drinking	265 (18.3)
Have quit drinking	77 (5.3)
Exercise in your spare time	259 (17.9)
Walking	671 (46.4)
Bicycling	135 (9.3)
Doing housework	936 (64.7)
No pork, beef or poultry per week	55 (3.8)
No weekly consumption of fish and shrimp	106 (7.3)
No eggs per week	125 (8.6)
No fruit per week	170 (11.7)
No weekly consumption of soy products	267 (18.5)
No dairy products per week	1229 (84.9)
No nuts per week	1301 (89.9)
Go to a medical institution for treatment after getting sick	829 (57.3)

The demand side of health services health information access, use of unmet needs, lack of basic health skills

Table 5 illustrates the unmet needs of health information acquisition and utilization and the lack of basic health skills on the demand side of health services. About 70% of the elderly do not know the daily intake of salt and cooking oil, and only 10.3% of the elderly pay attention to the nutrition labels on food packages when they buy food, so their needs for health information acquisition and utilization are not met, and they lack basic health-related skills.

Table 5

Health Literacy - Basic Skills
Projects	Frequency N (%)
Know the daily salt intake of healthy adults	535 (37.0)
Know the daily cooking oil intake for healthy adults	390 (27.0)
Know the food nutrition label	176 (12.2)
When buying food, look at the food nutrition label on the bag	149 (10.3)

From the results of this study, the main health problem of the elderly at this stage is chronic diseases, and their health service demand includes primary prevention, secondary prevention and tertiary prevention of chronic diseases, and the demand has the characteristics of comprehensiveness, continuity and integration.

Health management for elderly people in the community has been generally based on three basic steps: understanding health status; conducting health and disease risk assessments; and performing health interventions.⁶ However, it is not specified at which level of health service providers each step is to be completed. Some scholars suggest that health management for the elderly should be carried out mainly by primary health care institutions.⁷ In recent years, the government has responded to the increasing aging of the population and reduced the burden of non-communicable diseases represented by chronic diseases through the technical synergy and functional complementarity of health service providers at all levels in the region,⁸ knowledge sharing⁹ and integration of basic health care services with public health services.¹⁰However, due to the insufficient allocation of quality resources and inflexible operation mechanisms in primary health care institutions in China, the capacity of primary health care services is restricted.¹¹ So, the health service needs of the elderly in the community are not met.

Therefore, we believe that from the perspective of satisfying the balance between supply and demand of health services, integrated health resources should break the concept of the original three-level medical system hierarchy, clear the barriers in the form of services on the procedures of access to different levels of hospitals, and build an integrated chronic disease service system with general practitioners as the core.

In the integrated medical system, general practitioners play the role of "gatekeepers", while secondary medical and health service institutions serve as “a connecting link between the preceding and the following” among all levels of medical and health service institutions. In order to better meet the growing demand for health services for the elderly in the community, we suggest that general practitioners should be organically integrated with secondary health care institutions, with general practitioners as the hub, and give full play to their role as experts and gatekeepers in secondary health care institutions.¹² Primary care health services continue to develop a cluster model centered on general practitioners .^13,14To provide services such as lifestyle and behavioral counseling, health assessment, chronic disease management, and diagnosis and treatment of common diseases for the elderly; follow the people-oriented and population-based principle.⁵ It is responsible for monitoring the health status of the elderly in the community, carrying out routine medical check-ups and early screening of diseases to give the elderly an initial understanding of their health status; determining referral decisions;¹⁵maintaining good communication and interaction with medical specialists when making referrals;¹⁶ carrying out health promotion projects;¹⁷ bringing in outside professionals to provide the personal level of support needed by older adults.¹⁸ Active General Practice Liaison (GPL) service to improve information exchange and transfer between general practitioners and higher level hospitals ;¹⁹ to share information on examinations and treatments to avoid duplication of services ;²⁰ to make full use of the specialist workshops set up by higher-level medical institutions²¹ to provide more authoritative treatment plans and more detailed lifestyle and behavior guidance for the elderly; assist in the training of medical staff and quality control of medical services at lower levels, so that medical institutions at all levels can achieve the same quality of service.²²

Taking general practitioners in secondary medical and health service institutions as the hub, the integrated medical system is used as the working platform of general practitioners, who are given the authority to provide first consultation, health consultation, community rehabilitation, referral decision, service liaison, etc. At the same time, medical institutions at all levels are linked up and down, each doing their own job, with the core of meeting the health service needs of the elderly in the community, giving full play to the role of general practitioners based on their own functions and positioning, and making full use of the resources of integrated medical care, so as to achieve the goal of "healthy aging".

Ethics approval and consent to participate

Our study involving human participants accordance with the Declaration of Helsinki and passed the medical ethics review of Huzhou University, ethics number 2020529-18 and informed consent was obtained from all subjects and/or their legal guardian(s). All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests

There is no conflict of interest in this paper and all authors agree to submit this paper for publication.

Funding

1.The study was supported by the Department of Education of Zhejiang Province (Grant no. Y202043955)

2.The study was supported by grants from Provincial Public Welfare Technology Application Programme of Zhejiang (Grant no. LGF18H030007).

Authors' contributions

Bing Wang and Li Gao collected the data, performed the analyses and drafted the manuscript. Xiaohong Yang and Yongliang Pan revised the manuscript. Wenming Feng conceptualization, Methodology. Xuedan Pei and Yanfang Fan assisted in collecting information and analyzing data. All authors have read and approved the final manuscript.

Acknowledgements

We have read all the terms and conditions.

Abbreviations

No applicable.

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No competing interests reported.

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You are reading this latest preprint version

An exploratory study on the design of an integrated healthcare organization structure from the demand side perspective of health services

Status:

Version 1

Abstract

Background

Objective

Methods

Results

Conclusions

What Is Known On This Topic

Introduction

Method

Study design and participants

Data Collection

Statistical Methods

The collected questionnaires were coded and all eligible data were entered in pairs using EpiData 3.1 to create a database. SPSS 25.0 was used for statistical analysis, and the count data were expressed as frequencies and percentages.

Results

Demographic data and general characteristics

Unmet Needs Of Health Service Demanders To Obtain Disease-related Knowledge And Lack Of Health Concepts

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1

Projects	Frequency
Hypertension	N (%)
Yes	582 (40.2)
No idea	5 (0.3)
Diabetes
Yes	102 (7.0)
No idea	16 (1.1)
Dyslipidemia
Yes	122 (8.4)
No idea	245 (16.9)
Coronary heart disease
Yes	61 (4.2)
No idea	40 (2.8)
Stroke
Yes	17 (1.2)
No idea	25 (1.7)
Chronic respiratory diseases
Yes	38 (2.6)
No idea	47 (3.2)
Cancer
Yes	13 (0.9)
No idea	83 (5.7)