Fan Yin, Sui Mengyun, Shi Leiyu, Xue Long, Xu Su
Johns Hopkins University, Baltimore, MD, United States.
Shanghai Municipal Center for Disease Control & Prevention, Shanghai, China.
Front Health Serv. 2025 Aug 22;5:1618955. doi: 10.3389/frhs.2025.1618955. eCollection 2025.
The family doctor system plays a crucial role in promoting the gradient utilization of health resources. However, empirical evidence regarding the use of health services across different levels of care by diabetic patients under family doctor contracts remains limited. This study aimed to investigate the impact of the family doctor system on the gradient utilization of health services among diabetic patients using real-world data.
We conducted an eight-year cohort study in Shanghai from 2014 to 2021, with a final sample size of 491,674 participants, including 459,600 contracted and 32,074 non-contracted patients. We employed inverse probability weighted regression adjustment (IPWRA) and zero-inflated negative binomial regression models to estimate the net effects. Among contracted patients, 52.08% were female, with an average age of 66.31 years; in comparison, non-contracted patients were younger, and over 60% resided in urban areas. The annual number of outpatient and inpatient visits was 32.47 and 0.42 for contracted patients, and 34.63 and 0.35 for non-contracted patients, respectively.
Study results showed that, outpatient visits decreased across all levels of hospital (coef. = -7.37%, IRR = 0.92 < 0.01), with a more pronounced reduction in secondary and tertiary hospitals compared to community health centers. This translated to a notable decrease of 2.43 days in the total number of outpatient visits. Conversely, hospitalization rates increased, particularly in community health centers (coef. = 26.88%, IRR = 1.30, < 0.01). Overall, the data suggest that having a family doctor is associated with reduced outpatient visits, especially in higher-level hospitals, while hospitalizations are more concentrated in community health centers.
Hospitalization rates can be reduced through targeted measures: strengthening early screening for diabetic complications; implementing a health-focused digital management system with outcomes-linked performance evaluations; enhancing clinical decision support and re mote monitoring systems to enable timely interventions by family doctors; developing clear referral protocols to minimize unnecessary hospital admissions; and conducting regular competency training for primary care providers.
家庭医生制度在促进卫生资源的梯度利用方面发挥着关键作用。然而，关于签订家庭医生合同的糖尿病患者在不同级别医疗机构使用卫生服务的实证证据仍然有限。本研究旨在利用真实世界数据调查家庭医生制度对糖尿病患者卫生服务梯度利用的影响。
我们于2014年至2021年在上海进行了一项为期八年的队列研究，最终样本量为491,674名参与者，包括459,600名签约患者和32,074名未签约患者。我们采用逆概率加权回归调整（IPWRA）和零膨胀负二项回归模型来估计净效应。在签约患者中，52.08%为女性，平均年龄为66.31岁；相比之下，未签约患者较年轻，超过60%居住在城市地区。签约患者的年度门诊和住院就诊次数分别为32.47次和0.42次，未签约患者分别为34.63次和0.35次。
研究结果表明，各级医院的门诊就诊次数均有所减少（系数 = -7.37%，发病率比 = 0.92，<0.01），与社区卫生中心相比，二级和三级医院的减少更为明显。这导致门诊就诊总次数显著减少2.43天。相反，住院率有所上升，尤其是在社区卫生中心（系数 = 26.88%，发病率比 = 1.30，<0.01）。总体而言，数据表明拥有家庭医生与门诊就诊次数减少有关，尤其是在高级别医院，而住院则更集中在社区卫生中心。
可通过以下针对性措施降低住院率：加强糖尿病并发症的早期筛查；实施以健康为重点、与结果挂钩的绩效评估的数字管理系统；加强临床决策支持和远程监测系统，以便家庭医生能够及时进行干预；制定明确的转诊方案，以尽量减少不必要的住院；以及对初级保健提供者进行定期能力培训。
