Family physician services and blood pressure control in China: A population-based retrospective cohort study

Abstract

Objective

Given the importance of continuous family physician (FP) care in the management of hypertension, we explored the effects of such care among hypertensive patients in China, a country where such care is generally underutilized. We examined the longitudinal association between the use and continuity of FP services and health outcomes including blood pressure (BP) control rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP).

Methods

We conducted a population-based cohort study using data from the retrospective regional electronic health record database in Xiamen City, China. The study considered 18,119 hypertensive patients aged over 18 years who had at least two visits to a health center in the preceding 12 months. The generalized estimating equation model was adopted to estimate the longitudinal association between FP service utilization and health outcomes.

Results

Hypertensive patients treated by their own FPs had a higher BP control rate (OR = 1.14, 95% CI: 1.02–1.28) and lower DBP (−0.36 mmHg, 95% CI: −0.52 to −0.20) than those without a FP or those with a FP but treated by a general community physician (GCP). Compared with hypertensive patients treated exclusively by GCPs, patients treated continuously and exclusively by a FP were 45% more likely to have their BP under control (OR = 1.45, 95% CI: 1.32–1.60), and their SBP and DBP were lower by 0.6 mmHg (95% CI: −0.78 to −0.39) and 0.6 mmHg (95% CI: −0.79 to −0.47), respectively.

Conclusions

Hypertensive patients continuously treated by their own FPs performed better in terms of BP control rate, SBP and DBP values. In addition, the number and continuity of FP visits were associated with better BP control.

Keywords

family physician continuity of care hypertension blood pressure control

Introduction

Hypertension is a major preventable risk factor for cardiovascular diseases and all-cause deaths globally.¹ The overall prevalence of hypertension among adults is around 30–45% worldwide.² In China, the crude prevalence is 27.9%, according to the latest China Hypertension Survey.³ The blood pressure (BP) control rate remains suboptimal in China,⁴ especially compared to several higher-income settings such as the United Kingdom, Japan, and the United States.^5-7 Therefore, improving patients’ BP control rate is a salient issue with important clinical and public health implications.

The care provided by family physicians (FPs) offers several advantages in the management of hypertension. Compared with physicians generally, FPs can have a better understanding of individual patients, their families, and local communities; they offer easier access to healthcare and better monitoring of patients’ health conditions; and they ensure greater continuity of care.⁸ FPs can also play a significant role in BP control among hypertensive patients by providing them with health education, information on behavioral risk factors, and necessary BP control services, such as referrals and medical appointments.^9–11 FPs can also act as mediators between patients and social healthcare service systems,^10,11 and provide direct services to patients, such as measuring and monitoring their BP.¹¹

In member countries of the Organisation for Economic Co-operation and Development and in other high-income countries, FPs often serve as a patient’s first point of contact in the health care system. They provide health management services, promote healthy behaviors, and diagnose and treat specific conditions of the patients on their panel. More importantly, they determine whether patients need to be referred to specialists, and in this sense are the gatekeepers to other health care resources.¹² The FP-patient relationship is a distinctive feature of general practice agencies, which is usually long term and more likely to be characterized by repeated transactions.

FPs typically provide continuity of care, with patients consulting their FPs much more frequently than they use higher-level care services. Such continuity enhances the accumulation of knowledge not just for patients themselves, but also for their spouses and families. Patients who have a regular FP are more likely to follow the physician’s advice on treatment and prevention.¹³ In such a relationship, FPs can feel a stronger sense of commitment, gain greater job satisfaction, and are more willing to work for patients’ health outcomes. In addition, consultations with familiar patients are shorter than those with new ones, and extensive workups are less often needed.

The management of chronic diseases such as hypertension may be undemanding, but understanding the patient as a person is a long-term, indeed permanent, intellectual challenge for the physican.¹³ Moreover, the patient who has a good relationship with the FP is less likely to complain or litigate if something goes wrong.¹³ Some studies indicate that care provided by FPs can improve patients’ adherence to medication regimens, safety and healthcare outcomes, especially among patients with chronic diseases,¹⁴ and across a range of long-term conditions, accessible and flexible continuity can significantly improve chronic disease patients’ experiences of health care.¹⁵ Increasing continuity of care has also been found to be associated with reduced mortality.¹⁶

Since 2016, the Chinese government has promoted a new FP system, under which local providers invite residents to voluntarily sign up with a specific FP at their local community health center (CHC), and patients who have entered into such a FP contract can experience greater continuity of primary care services.¹⁷ Unlike typical physicians’ offices in the United States and the United Kingdom, Chinese CHCs feature many doctors, all of whom function as FPs. The services offered as part of the FP contract include online consultations, referrals to a specialist if needed (prioritized by a patient’s medical needs), and health checkups. Patients may enter into a contract with an individual FP, but this is not compulsory. Contracted hypertensive patients can freely choose to use the services of their own FPs, or, if they prefer or if their FPs are not available, visit general community physicians (GCPs).

However, the program has faced challenges from insufficient coordination and integration between primary, secondary, and tertiary care, as well as patients’ concerns about the quality of primary care, and imperfect financing and incentive mechanisms for FPs.¹⁸ There was a step forward in the training of family doctors, but the numbers trained remain low.¹⁹ As a result, hypertensive patients may not find FP contracts attractive, or even if they do sign up for such a contract, they may still be treated by GCPs during their follow-up visits.²⁰

Hypertensive patients can therefore be divided into three groups, based on their FP service utilization status: (1) without a FP, and treated by a GCP, (2) with a FP, but treated by a GCP, and (3) with a FP, and treated by that FP.

To understand the as yet unrealized potential beneficial impact of FP care on chronic disease control in China, identifying the correlation between successful program implementation and patient outcomes may provide the foundation for later causal analyses. This study explored policy performance in the early and initial stages of FP contract services in China. We assessed the associations between the use and continuity of FP services and patient health outcomes as measured by the BP control rate, as well as the specific values of systolic blood pressure (SBP) and diastolic blood pressure (DBP), among a sample of hypertensive patients in urban China.

Methods

Data sources

We conducted a population-based cohort study using data from the retrospective regional electronic health record database in Xiamen City, Fujian Province, China. The FP service system implemented in Xiamen City since 2016 is a team-based care model for chronic disease management. Prior to each consultation, hypertensive patients are asked to measure their BP using the CHC’s electronic sphygmomanometer. The BP values are directly uploaded as electronic health records, and then go to the GCPs, or their own FPs, for treatment.

Using unique encoded identifiers, patients are linked across different systems: a public health information system, primary healthcare service cloud platform, and a database of FP contracts. Patients’ health outcomes, use of FP services, and basic characteristics (including age, gender, and health insurance coverage) can be retrieved from a unified database.

We were able to collect information on adults who had utilized primary care in four CHCs in Xiamen City, Fujian Province, China, between 1 July 2018 and 30 June 2019. We included a total of 18,119 hypertensive patients aged 18 years and above who had at least one diagnosis code of hypertension, according to ICD-10 (I10-I15), and at least two recorded visits. The primary healthcare service cloud platform showed that these 18,119 hypertensive patients were treated by 61 doctors, and we matched in the database of FP contracts by the doctor code and then decided whether the doctor to treat patients was the patients’ FP.

Therefore, we circulated a questionnaire in July 2019 in Xiamen City to collect information on the characteristics of the 61 doctors providing services to patients. Personal interviews and strict quality control were performed, thereby catching all 61 doctors’ information, including each doctor’s age, gender, marital status, professional title (reflecting the technical level and working ability of FPs), and working hours per day.

Continuity of care

We regarded the proportion of visits with a patient’s own FP as the indicator of the continuity of FP care. The continuity of own FP visits is a continuous variable ranging from 0% to 100%. At one end, if a patient did not have a FP, or had but was treated exclusively by GCPs, the proportion was 0%. At the other end, if a patient was treated exclusively by the FP with whom they had signed a service contract (hereafter termed their “own FP”), the proportion was 100%.

Variables measured

In this study, three indicators were regarded as health outcomes of hypertension: (1) whether the BP at each follow-up visit was controlled over one contract year (1 = controlled, 0 = uncontrolled), (2) SBP value at each visit, and (3) DBP value at each visit.

Adequate BP control among hypertensive patients was defined as an average SBP less than 140 mm of mercury (mmHg) and an average DBP of less than 90 mmHg. BP control among hypertensive patients with diabetes mellitus (DM) was defined as an average SBP less than 130 mmHg and an average DBP of less than 80 mmHg. Patients not meeting these criteria were considered to have uncontrolled BP.

The selection of covariates was based on previous studies and included patients’ and their visiting doctors’ characteristics.^21,22 Patients’ confounders included age, gender (male vs female), and health insurance status (with vs. without health insurance). FPs’ confounders included age, gender (male vs female), marital status (married vs unmarried), education (bachelor’s degree and below vs. master’s degree and above), professional title (primary title, medium title, and senior title), and working hours per day.

Statistical analysis

We produced summary statistics by using frequencies and proportions for categorical variables and means, and standard deviations for continuous variables. We compared the association between the use of FP services at the first visit during the study period and health outcomes at the next visit, using ANOVA and chi-square tests.

The generalized estimating equation (GEE) model is specifically used to deal with repeated measurement data including unbalanced longitudinal data. It can control for the intraindividual correlation between repeated measurements, then estimate the regression coefficients using weighted least squares and the assumed working correlation, and estimate the standard errors robustly. In this study, we adopted the GEE model to estimate the longitudinal association between the use of FP services and health outcomes at the next visit after controlling for other confounders including both patient and doctor characteristics. The model was also used to estimate the longitudinal association between the continuity of FP care and health outcomes after controlling for the basic characteristics as well as the number of visits.

We conducted four sensitivity analyses: (1) we ran the GEE model after controlling for baseline BP control, SBP, and DBP values, (2) we ran the GEE model to explore the association between baseline and follow-up differences in BP value and the use of FP services/the proportion of FP visits, (3) we used a multilevel mixed-effects generalized linear model to test the correlations because of the homogeneity of FPs, and (4) we ran the GEE model to analyze these associations by patients’ age groups, and only for patients with DM.

Analyses were conducted using Stata 16.0 (Stata Corporation LLC).

Results

Table 1 gives the descriptive statistics for the hypertensive patients in the present study. Of the 18,119 hypertensive patients, 50.80% were male, 91.40% had health insurance, and 69.25% had their own FPs. Over 1 year, the average number of visits for patients with their own FPs was 7.98, while the number of visits for patients without own FPs was 6.03.

Table 1.

Descriptive statistics of hypertensive patients for the first and the last community visits in one contract year.

Variable	Total	Without own FP	With own FP
N (% of total)	18,119	5572 (30.75%)	12,547 (69.25%)
First community visit in one contract year
BP control rate, %	90.10	88.20	91.00
SBP, mmHg, mean (SD)	130.03 (10.77)	130.26 (11.93)	129.92 (10.20)
DBP, mmHg, mean (SD)	78.44 (7.87)	78.82 (8.83)	78.27 (7.40)
Age, years, mean (SD)	64.29 (12.57)	61.97 (13.24)	65.32 (12.12)
Last community visit in one contract year
BP control rate, %	94.80	94.10	95.10
SBP, mmHg, mean (SD)	128.39 (8.60)	128.36 (8.72)	128.41 (8.55)
DBP, mmHg, mean (SD)	77.55 (6.08)	77.94 (6.34)	77.37 (5.95)
Age, years, mean (SD)	65.08 (12.60)	62.63 (13.26)	66.18 (12.14)
Average number of visits, mean (SD)	7.38 (4.49)	6.03 (4.21)	7.98 (4.47)
Male, %	50.80	52.70	50.00
With health insurance, %	91.40	89.60	92.20

N: number of patients; FP: family physician; BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; mmHg: millimeters of mercury; SD: standard deviation.

The average age of patients treated by their own FPs at the first community visit was 65.32, and their measured health outcomes of BP control rate, SBP, and DBP—all better than those of patients without FPs—were 91.00%, 129.92 mmHg, and 78.27 mmHg, respectively. At the last community visit, patients’ average age was 66.18, and health outcomes had changed to 95.10%, 128.41 mmHg, and 77.37 mmHg, respectively.

The average age of patients treated by a GCP at the first visit in the year was 61.97, and the BP control rate, SBP, and DBP were 88.20%, 130.26 mmHg, and 78.82 mmHg, respectively. At the last community visit, the average age was 62.63, and health outcomes had improved and changed to 94.10%, 128.36 mmHg, and 77.94 mmHg, respectively.

Table 2 compares health outcomes across all patients by FP service utilization status in the previous visit. The health outcomes of patients with a FP were better than those of patients without a FP. The BP control rate was 95.27% for hypertensive patients treated by their own FPs at the previous visit—higher than that (93.66%) of patients without a FP. The SBP and DBP of patients treated by their own FPs were lower than that of patients without a FP and treated by a GCP (p < 0.001). Meanwhile, among the three groups with different usage of FP services, the average age of patients treated by their own FPs was the highest. All the above differences were statistically significant at the 1% level by ANOVA and chi-squared tests.

Table 2.

Descriptive statistics of health outcomes for hypertensive patients treated by different physicians in the previous visit.

	Without own FP, and treated by GCPs	With own FP		Chi²/F value	p value
	Without own FP, and treated by GCPs	Treated by GCPs	Treated by own FP	Chi²/F value	p value
N	28,070	49,058	38,489
BP control rate, %	93.66	94.17	95.27	89.00	<0.001
SBP, mmHg, mean (SD)	128.96 (8.51)	129.11 (8.20)	129.18 (8.26)	5.93	0.003
DBP, mmHg, mean (SD)	78.20 (6.50)	77.82 (6.05)	77.67 (6.05)	62.06	<0.001
Age, years, mean (SD)	62.27 (13.40)	66.05 (12.11)	66.60 (11.77)	1362.53	<0.001

N: number of visits; FP: family physician; GCP: general community physician; BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; mmHg: millimeters of mercury; SD: standard deviation.

Table 3 reports the results of a generalized estimating equation model using longitudinal data for hypertensive patients in 1 year. After controlling for all confounders, compared with the reference group of patients without a FP, hypertensive patients treated by their own FPs had a higher BP control rate (OR = 1.14, 95% CI: 1.02–1.28) and DBP (−0.36 mmHg, 95% CI: −0.52 to −0.20). There were no significant differences in BP control, SBP, and DBP between patients without their own FPs and those with FPs but treated by GCPs. The analysis also indicated that female and insured patients were positively associated their BP control. Additionally, there was a positive correlation between receiving treatment by doctors with higher degree and professional title and BP control of patients.

Table 3.

Longitudinal association between health outcomes for hypertensive patients and previous use of FP services in one contract year.

	BP control		SBP		DBP
	OR	95% CI	Coef	95% CI	Coef	95% CI
The use of FP services (vs. Without own FP, and treated by GCPs)
With own FP, but treated by GCPs	0.92	(0.83, 1.02)	0.09	(-0.10, 0.28)	−0.10	(−0.26, 0.06)
With own FP, and treated by own FP	1.14*	(1.02, 1.28)	−0.18	(-0.37, 0.01)	−0.36***	(−0.52, −0.20)
Patients
Male (vs. female)	0.80***	(0.74, 0.88)	0.34***	(0.18, 0.49)	0.54***	(0.42, 0.67)
Age	1.01***	(1.01, 1.01)	0.02***	(0.01, 0.02)	−0.06***	(−0.07, −0.05)
With health insurance (vs. no health insurance)	1.88***	(1.62, 2.18)	0.55**	(0.10, 0.99)	0.54**	(0.22, 0.87)
Doctors
Male (vs. female)	2.16***	(1.96, 2.37)	0.22**	(0.04, 0.40)	−0.14*	(−0.27, −0.01)
Age	1.05***	(1.03, 1.06)	0.03**	(0.01, 0.04)	−0.05***	(−0.06, −0.03)
Married (vs. unmarried)	0.83**	(0.72, 0.95)	0.04	(−0.28, 0.36)	0.85***	(0.63, 1.06)
Education (vs. Bachelor’s degree and below)
Master’s degree and above	1.29***	(1.16, 1.43)	−1.43***	(−1.68, −1.19)	−1.09***	(−1.26, −0.91)
Professional title (vs. primary title)
Medium title	1.61***	(1.42, 1.83)	1.20***	(0.88, 1.52)	0.28*	(0.07, 0.49)
Senior title	1.26**	(1.04, 1.52)	1.98***	(1.60, 2.35)	0.45**	(0.18, 0.72)
Working hours per day	0.85***	(0.82, 0.89)	0.08	(−0.01, 0.18)	−0.31***	(−0.38, −0.24)

FP: family physician; GCP: general community physician; BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; OR: odds ratio; CI: confidence interval; coef.: coefficient.

*p < 0.05, **p < 0.01, ***p < 0.001.

Turning to Table 4, hypertensive patients treated exclusively by their own FPs achieved the best BP control over the study period. We compared them with hypertensive patients treated exclusively by GCPs, while controlling for other confounding variables and the number of visits, finding that patients treated exclusively by their own FPs (the proportion of visits with their own FPs was 100%) were 45% more likely to have their blood pressure under control (OR = 1.45, 95% CI: 1.32–1.60), and both SBP and DBP values were lower than the reference group by 0.6 mmHg (95% CI: −0.78 to −0.39), and 0.6 mmHg (95% CI: −0.79 to −0.47), respectively. In other words, increasing the proportion of own FP visits was positively associated with BP control rate. In addition, the number of visits, female, having health insurance for patients, and visiting doctors with higher degree and professional title also had a significantly positive association with BP control.

Table 4.

Longitudinal association between health outcomes for hypertensive patients and the proportion of visits with own FP in one contract year.

	BP control		SBP		DBP
	OR	95% CI	Coef	95% CI	Coef	95% CI
Proportion of visits with own FP	1.45***	(1.32, 1.60)	−0.59***	(−0.78, −0.39)	−0.63***	(−0.79, −0.47)
The number of visits	1.08***	(1.07, 1.09)	−0.10***	(−0.12, −0.08)	−0.05***	(−0.06, −0.04)
Patients
Male (vs. female)	0.77***	(0.71, 0.83)	0.43***	(0.28, 0.58)	0.68***	(0.56, 0.80)
Age	1.01***	(1.01, 1.02)	0.01**	(0, 0.02)	−0.07***	(−0.08, −0.07)
With health insurance (vs. no health insurance)	1.97***	(1.76, 2.21)	0.21	(−0.19, 0.61)	0.36*	(0.07, 0.65)
Doctors
Male (vs. female)	1.86***	(1.72, 2.02)	−0.12	(−0.29, 0.05)	−0.04	(−0.17, 0.09)
Age	1.03***	(1.02, 1.04)	0.16***	(0.15, 0.18)	−0.02*	(−0.03, 0.01)
Married (vs. unmarried)	1.07	(0.95, 1.21)	−1.30***	(−1.6, −0.99)	0.56***	(0.36, 0.77)
Education (vs. Bachelor’s degree and below)
Master’s degree and above	1.60***	(1.46, 1.75)	−2.91***	(−3.15, −2.68)	−2.06***	(−2.22, −1.89)
Professional title (vs. primary title)
Medium title	1.71***	(1.52, 1.91)	0.50**	(0.20, 0.81)	0.37***	(0.18, 0.56)
Senior title	2.08***	(1.71, 2.52)	−0.30	(−0.67, 0.07)	−0.71***	(−0.96, −0.45)
Working hours per day	0.86***	(0.82, 0.89)	−0.10*	(−0.19, 0.01)	−0.93***	(−1.00, −0.86)

FP: family physician; BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; OR: odds ratio; CI: confidence interval; coef.: coefficient.

*p < 0.05, **p < 0.01, ***p < 0.001.

After controlling for baseline BP control, SBP, and DBP, or regarding difference in BP value between baseline and follow-up visits as dependent variable, we have found that FPs use and the continuity of care were positively associated with BP control (see online Supplement, Tables S1, S2, S3, and S4). The multilevel mixed-effects generalized linear model also showed the robust and similar results (see online Supplement, Tables S5 and S6). Further age-group analysis showed that for all ages, increasing continuity of own FP visits had a positive correlation with BP control (see online Supplement, Tables S7 and S8). Finally, when only focusing on hypertensive patients with DM, the use of FP services and the proportion of own FP visits were not associated with BP control (see online Supplement, Tables S9 and S10).

Discussion

Our study finds a clear and consistent association between the continuity of FP services and BP control in China. Hypertensive patients treated by their own FPs at their previous visit performed better in terms of health outcomes than those without a FP. This is true although patients with a FP were older than those without a FP, and age is widely acknowledged as an important risk factor for uncontrolled BP.²³ After controlling for age and other characteristics of patients and their treating physicians, we continue to find statistically and clinically significant better outcomes among hypertensive patients treated by their own FPs, relative to those treated by similarly qualified GCPs.

These associations provide encouraging evidence that treatment by FPs can be beneficial for BP control among hypertensive patients. This study contributes to a small but growing literature on innovations in primary care, including the FP contract service system, for the control of hypertension and other chronic diseases in China. For example, one study found that entering into contracts with FPs could promote positive self-management of health-related behaviors among patients with noncommunicable diseases.²⁴ Another emphasized that a lack of appropriate or personalized care is an important cause of poor BP control rate in China, and that there is a shortage of qualified FPs in the country.²⁵

Our findings complement randomized controlled trials and other studies conducted in high-income settings and countries with well-developed FP service systems. One study demonstrated that enhanced tracking services provided by community health workers could increase follow-up visits by 39.4%.²⁶ Another found that patients assigned to tracking interventions saw significant improvement in their BP control.¹¹ A single-blind, randomized clinical trial in Philadelphia, Pennsylvania, indicated that community health workers led to improvements in several chronic diseases, especially patients with hypertension.²⁷ The present study builds on this existing literature with evidence from a middle-income setting and country with a less-developed FP service system, showing that FP services for hypertensive patients are conducive to BP control.

The characteristics and functions of primary care have been well identified, including people-centeredness, comprehensiveness and integration, continuity of care, and participation of patients, families and communities.²⁸ The FPs in primary health care can serve as an agency to address the information asymmetry in the physician-patient relationship, and act as “gatekeepers” to maintain the health outcomes of residents. This study indicates that continuity of care may be one of the primary channels through which FPs affect BP control.

Studies have emphasized that continuity of primary care is an important hallmark of health delivery systems for the control of chronic disease.¹⁹ Effective primary care provides comprehensive, continuous, and appropriate treatment and health management.⁸ The FP contract system in China is designed to promote regular visits to the same community physician—the contracted FP—to enhance continuity of care. Hypertensive patients that are treated by GCPs, perhaps different ones at each visit, do not experience the same continuity. One empirical study reports that patients who contracted with FPs had greater continuity of primary care than those without FPs.¹⁷

The present study indicates that a larger proportion of visits to FPs was particularly conducive to BP control, revealing the significance of not only increasing the FP contract rate, but also of enhancing the utilization of FP services by those who sign such contracts. The continuity of primary care can bring a wide range of benefits to patients.¹⁵ However, it is not compulsory for patients in China to visit their FPs as their first choice, even if they have a contract with them. Patients have exhibited a strong preference for free choice between FPs and specialists.²⁹ FP service is still in an early stage in many regions of China and its potential has yet to be fully realized. Therefore, it is essential to improve physicians’ and patients’ awareness of the importance of the continuity of primary care, improve the training and capacity of FPs, pay attention to the refinement of chronic disease management when providing services, such as BP control in the case of comorbidities, and experiment with and evaluate the benefits of a gatekeeping system in China.¹⁹

Limitations

When interpreting the results of this study, four major limitations should be noted. First, further investigation would be required to determine whether the results of this study are generally applicable beyond Xiamen. Residents in Xiamen have a 16.67% prevalence of hypertension,³⁰ which is lower than the national level in China.³ The BP control rate of the study population was also better than the overall rate in China.³ One possible reason is that, as one of the first areas to establish a FP system, Xiamen City has invested a considerable amount to improve community services for the diagnosis and treatment of diabetes and hypertension, and its referral system between primary and secondary care is well-organized.³⁰

Second, while a randomized clinical trial could identify the causal impact of FP services on health outcomes, this study was not able to use such a study design. And earlier records prior to implementation were difficult to access for our studied population. Therefore, we could not perform before-and-after analysis. In addition, the study is limited by the lack of sufficient control of confounding. As patients are free to use their own FP or not, it is plausible that patients who always use the same FP are those who have greater confidence and trust in their FP. Thus, the confidence/trust may translate to better adherence to clinician-prescribed treatment plan. Therefore, the strong association can merely be due to the FPs in this cohort being the “better” FPs who generate greater patient confidence and trust.

Third, all Chinese residents are free to choose their primary healthcare facilities in follow-up visits. As such, our study probably missed data for some of the hypertensive patients who went to other primary care facilities during the year under study.

Fourth, the changes in SBP and DBP values noted in our study were not very large compared with those in other studies.^11,27 This was likely due to two reasons: (1) our study population exhibited rather good BP control from the outset, with low SBP and DBP values at the first community visit, and (2) the study period—a single year—was relatively short.

Conclusions

In our study, FP care was significantly and positively associated with BP control. The hypertensive patients treated by their own FPs performed better in terms of their BP control rate, as well as SBP and DBP values, over 1 year, compared with patients without a FP or who did not regularly visit their own FPs. In addition, a greater number of visits and continuity of FP visits are associated with better BP control. The results should be taken into consideration in national primary health care policymaking. Identifying the FPs who best attract and retain patients, improving physicians’ incentives to better serve their empaneled patients, and enhancing patients’ utilization of their own FPs may all be promising avenues for improving hypertension management.

Supplemental Material

Supplemental Material - Family physician services and blood pressure control in China: A population-based retrospective cohort study

Supplemental Material for Family physician services and blood pressure control in China: A population-based retrospective cohort study by Rize Jing, Karen Eggleston, Xiaozhen Lai, and Hai Fang in Journal of Health Services Research & Policy

Footnotes

Acknowledgements

The survey was conducted by the Peking University Group. The authors thank the Xiamen Municipal Health Commission, China, for their willingness to provide the data of hypertensive patients and also thank Ms. Lu Zhang from People’s Medical Publishing House of China for her data collation. We would also like to thank the anonymous reviewers, whose comments greatly helped to improve the article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by grant from the MOE (Ministry of Education in China) Project of Humanities and Social Sciences and the National Natural Science Foundation of China (grant number 71774006)

Ethical approval

This study was approved by Peking University Institutional Review Board (IRB00001052-19072).

ORCID iD

Hai Fang

Supplemental Material

Supplemental material for this article is available online.

References

Rapsomaniki

Timmis

George

, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. Lancet 2014; 383: 1899–1911.

Chow

Teo

Rangarajan

, et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-middle-and low-income countries. JAMA 2013; 310: 959–968.

Wang

Chen

Zhang

, et al. Status of Hypertension in China. Circulation 2018; 137: 2344–2356.

Wang

, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project). Lancet 2017; 390: 2549–2558.

National Center for Health Statistics (US) . Health, United States, 2018 [Internet]. Hyattsville, MD: National Center for Health Statistics (US), 2019.

Falaschetti

Mindell

Knott

, et al. Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet 2014; 383: 1912–1919.

Satoh

Arima

Ohkubo

, et al. Associations of socioeconomic status with prevalence, awareness, treatment, and control of hypertension in a general Japanese population. J Hypertens 2017; 35: 401–408.

Beaglehole

Epping-Jordan

Patel

, et al. Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care. Lancet 2008; 372: 940–949.

Kaczorowski

Myers

Gelfer

, et al. How do family physicians measure blood pressure in routine clinical practice? National survey of Canadian family physicians. Can Fam Physician 2017; 63: e193–e199.

10.

Becker

Yanek

Johnson

Jr , et al. Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease. Circulation 2005; 111: 1298–1304.

11.

Morisky

Lees

Sharif

, et al. Reducing disparities in hypertension control: a community-based hypertension control project (CHIP) for an ethnically diverse population. Health Promot Pract 2002; 3: 264–275.

12.

Reibling

Wendt

. Gatekeeping and provider choice in OECD healthcare systems. Current Sociology 2012; 60: 489–505.

13.

Gray

Evans

Sweeney

, et al. Towards a theory of continuity of care. J R Soc Med 2003; 96: 160–166.

14.

Hong

Kang

. Relationship between continuity of ambulatory care and medication adherence in adult patients with type 2 diabetes in Korea: a longitudinal analysis. Med Care 2014; 52: 446–453.

15.

Cowie

Morgan

White

, et al. Experience of continuity of care of patients with multiple long-term conditions in England. J Health Serv Res Policy 2009; 14: 82–87.

16.

Leleu

Minvielle

. Relationship between longitudinal continuity of primary care and likelihood of death: analysis of national insurance data. PLoS One 2013; 8: e71669.

17.

Zhong

Mei

, et al. Effect of family practice contract services on the quality of primary care in Guangzhou, China: a cross-sectional study using PCAT-AE. BMJ Open 2018; 8: e021317.

18.

Zhao

Lin

Qiu

, et al. Demand and Signing of General Practitioner Contract Service among the Urban Elderly: A Population-Based Analysis in Zhejiang Province, China. Int J Environ Res Public Health 2017; 14: 356.

19.

Krumholz

Yip

, et al. Quality of primary health care in China: challenges and recommendations. Lancet 2020; 395: 1802–1812.

20.

Yuan

Wang

, et al. Facilitators and barriers to implement the family doctor contracting services in China: findings from a qualitative study. BMJ Open 2019; 9: e032444.

21.

Liang

Wang

. Longitudinal study of the earliest pilot of tiered healthcare system reforms in China: Will the new type of chronic disease management be effective? Soc Sci Med 2021; 285: 114284.

22.

Jing

Mahmoudi

Lai

, et al. The Association Between Panel Size and Health Outcomes of Patients with Hypertension in Urban China: a Population-Based Retrospective Cohort Study. J Gen Intern Med 2021; 36: 3402–3409.

23.

Duprez

. Systolic Hypertension in the Elderly: Addressing an Unmet Need. Am J Med 2008; 121: 179–184.e173.

24.

Huang

Zhang

Wang

, et al. The effect of family doctor–contracted services on noncommunicable disease self‐management in Shanghai, China. Int J Health Plann Manage 2019; 34: 935–946.

25.

Wang

Chen

, et al. Hypertension Control in Community Health Centers Across China: Analysis of Antihypertensive Drug Treatment Patterns. Am J of Hypertens 2014; 27: 252–259.

26.

Krieger

Collier

Song

, et al. Linking community-based blood pressure measurement to clinical care: a randomized controlled trial of outreach and tracking by community health workers. Am J Public Health 1999; 89: 856–861.

27.

Kangovi

Mitra

Grande

, et al. Community Health Worker Support for Disadvantaged Patients With Multiple Chronic Diseases: A Randomized Clinical Trial. Am J Public Health 2017; 107: 1660–1667.

28.

World Health Organization . Primary health care now more than ever : introduction and overview. Geneva: World Health Organization, 2008.

29.

Liu

Chi

. Relationship preferences and experience of primary care patients in continuity of care: a case study in Beijing, China. BMC Health Serv Res 2017; 17: 585.

30.

Liu

, et al. Evaluation of the three-in-one team-based care model on hierarchical diagnosis and treatment patterns among patients with diabetes: a retrospective cohort study using Xiamen's regional electronic health records. BMC Health Serv Res 2017; 17: 779.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.26 MB