Do medical alliances truly work? Perspectives on health service utilisation among outpatients with chronic diseases in Shanghai, China

Keywords: China, chronic disease management, community health centres, distribution, health service utilisation, healthcare reform, medical alliance, trend.

Integrated care is a concept generally accepted in developed countries (Goodwin 2016). To manage the high medical costs incurred by the aging population and the increase in chronic non-communicable diseases, integrated medical systems have been promoted as a way to combine medical resources for the benefit of outpatients, and to ease the burden on secondary and tertiary hospitals (Starfield and Shi 2002; Armitage et al. 2009; Kodner 2009). In developed countries, integrated health systems were implemented earlier and achieved positive results. A study in Singapore illustrated that this model effectively reduced outpatient and inpatient visits to hospitals, and that older individuals could have their complex care needs met in the communities where they lived (Keong et al. 2012). Additionally, in the US, Chu et al. (2016) found that the number of outpatient visits to patient-centred medical homes, which represented a composition of integrated health care, was greater than that for non-patient-centred medical home clinics (Chu et al. 2016). Integrated health care provided continuum referrals and services for patients who have access to high-quality health care at a low cost (Rosenthal 2008). These successful experiences indicated that primary health organisations in integrated health systems played a vital role in patients’ health and reducing health costs.

In China, most individuals seek care in advantaged secondary and tertiary hospitals in or near urban centres, which have been reported to have better technology and more highly skilled physicians; over time, demand has weakened the capacity of these primary health institutions to meet it (Wang et al. 2017). The Chinese government focused on improving primary health care services, and suggested the construction and development of medical alliances (MAs) as an important means to that end (Hung et al. 2012) until China’s latest round of healthcare reform in 2009 (Chen 2009). In 2016, the pilot work of MA construction proposed promoting rational medical resource allocation and the medical capabilities of primary health care institutions through cooperation and alliances between medical institutions at different levels (National Health and Family Planning Commission of the People’s Republic of China 2016), as well as improving the level of health management and chronic disease management (Wang et al. 2014). In April 2017, the General Office of the State Council issued ‘Guiding Opinions on Promoting Medical Consortium Construction and Development,’ which proposed establishing MAs in cities with the aims of gradually decreasing the proportion of patients with common, frequently occurring and stable chronic diseases in tertiary hospitals, and offering medical services for these people, for geriatric patients and for patients with advanced cancer in primary health care institutions (General Office of the State Council of the People’s Republic of China 2017). These policies advocated improving the medical treatment functions of community health centres (CHCs) and guiding outpatients with chronic diseases who chose CHCs for diagnosis.

Currently, there are two main types of medical alliances in China: loose and compact alliances (Ying et al. 2018). A compact MA (also known as close-knit MA; Zou et al. 2020) is linked by assets with other medical institutions; an organisation controls personnel and finances, and manages all of the facilities in the alliance. A loose MA is connected through management and technology, but facilities in the alliance manage their own personnel and finances. In these MAs, a tertiary hospital merges with secondary hospitals and CHCs in a ‘1 + N’ pattern. Most MAs follow this pattern. As one of the earliest regions in China to explore the establishment of MAs, Shanghai issued the ‘Guidelines for the Pilot Project for the Construction of Shanghai Regional Medical Alliances’ in October 2010 (Shanghai Health Bureau 2010). The guidelines proposed combining pilot tertiary hospitals with several CHCs in the region to establish regional MAs as compact and independent legal entities. The proposal called for improving the diagnosis and treatment levels of CHCs, and the referral of outpatients to CHCs. There have been some studies evaluating the effects of MAs. For instance, Yang et al. (2020) used the Parker–Harding model to evaluate the advantages and disadvantages of four typical Chinese MAs from the perspectives of government and institutions. Fang et al. (2014) found through the comparison before and after the establishment of an MA that core hospitals (tertiary hospitals) in a close-knit MA benefit the patients (Fang et al. 2014). The majority of the existing studies, however, have been quantitative, and there has been a lack of quantitative comparison of the effectiveness of MAs from the perspective of the abilities to provide various types of disease treatments that precisely improve the chronic disease management capacity for primary care.

Thus, this study aimed to analyse the trends and changes among outpatients with various chronic diseases regarding CHCs and hospitals to reflect the effects of MAs in guiding outpatients, especially those with chronic diseases, to properly choose various services. We included chronic disease in the analysis, because proper service utilisation should be the priority of MAs in China, and the specific distribution can help provide direction for improvement. The district of Pudong New Area covers one-fifth of Shanghai (Shanghai Municipal Bureau of Statistics, Shanghai Investigation Corps of the National Bureau of Statistics 2017). In 2015, a Chuansha MA was established in the east of Pudong New Area with an outpatient medical information platform. In this MA, a tertiary hospital led the merger of three secondary specialty hospitals and nine community health centres, forming a ‘1 + N’ loose pattern. They jointly undertook medical services for more than 70 000 permanent residents within a 140 km² area. The Chuansha MA was one of the first medical alliances across urban and rural areas in Shanghai (Xu et al. 2016), and its mission was to improve primary health institutions and the overall level of health care services in the region. Thus, the typical loose Chuansha MA in the Pudong New Area of Shanghai is taken as an example to provide policy suggestions and guidance for MA improvement in other areas.

The Chuansha MA in Pudong New Area, Shanghai, provided data on outpatients with chronic diseases. To evaluate the outpatient trends, this study extracted the number of chronic disease outpatients of the Chuansha MA (n = 22 539 060) from 2016 to 2020, encompassing the years after the Chuansha MA was established. They were classified into 13 supercategories by using the International Classification of Diseases, 10th revision. Chronic diseases were divided into 13 categories. We collected the following demographic data: the level of the medical institution where they were treated (the MA included one tertiary hospital, three secondary hospitals and seven community health centres); sex (male, female); and age (0–18, 19–39, 40–59, 60–79 and ≥80 years; Shi et al. 2020).

Additionally, we described the changes in the total and average outpatient costs in the MAs. The inflation rate is an important factor when comparing time-series data. The consumer price index can reflect the inflation rate (Feng et al. 2021). According to the data on the consumer price index in health care from the Shanghai Municipal Bureau of Statistics (Shanghai Municipal Bureau of Statistics 2016), we obtained the adjusted costs for outpatients with chronic diseases in the Chuansha MA from 2016 to 2020 using the following equation:

where AC is the adjusted cost; C is the cost; I is the inflation rate; and i is the year from 2017 to 2020. The year 2016 was regarded as the base year.

We performed a descriptive analysis of all outpatients in the Chuansha MA in Pudong New Area of Shanghai. The Chi-Square tests were used to test the hypotheses of categorical variables, including sex, age and time. The trends (upwards or downwards) by chronic disease categories from 2016 to 2020 were also analysed by correlation analysis (two-tailed test). The statistical analyses were performed by using Statistical Package for the Social Sciences software version 20.0 (SPSS, Chicago, IL, USA) and GraphPad Prism software (version 8.0.1).

The data were outpatient data collected anonymously from the Chuansha Medical Alliance. We acquired administrative permissions to access the data. The design of this study was approved by the ethics committee at Shanghai Jiaotong University.

All outpatients (22 539 060) were extracted from the Chuansha MA from 2016 to 2020, including 11 380 405 (50.49%) outpatients from hospitals and 11 158 655 (49.51%) from CHCs (Table 1). The number of female outpatients was greater both in hospitals (female: n = 6 019 019, 52.89%; male: n = 5 361 299, 47.11%) and CHCs (female: n = 6 007 981, 53.84%; male: n = 5 150 632, 46.16%). The majority of visiting outpatients were aged 60–79 years (57.20%) in CHCs. In hospitals, the 60- to 79-year-old group accounted for the largest proportion, at 29.80%. Including the base year, the number of outpatient visits to hospitals increased from 2016 (1 988 902, 17.48%) to 2020 (2 012 700, 17.69%), and peaked at 2 624 861 (23.07%) in 2019, whereas the number of outpatient visits to CHCs decreased between 2016 (2 149 385, 19.26%) and 2020 (1 986 614, 17.80%), although it underwent an increase from 2016 to 2019.

Table 1.  Description of outpatients with chronic diseases in the Chuansha MA in Shanghai from 2016 to 2020.

As shown in Fig. 1, for nervous system diseases, CHC outpatients accounted for a larger proportion than hospital outpatients in the Chuansha MA, showing a significant upward trend (r = 0.884, P = 0.047). There was a significant upward trend in CHC outpatients with eye and adnexal diseases (r = 0.882, P = 0.048), surpassing the number treated in hospitals in 2020 (50.17%). However, those with musculoskeletal diseases and blood- and immune mechanism-related diseases visiting hospitals presented distinct increasing trends from 2016 to 2020. For cardiovascular and endocrine diseases, CHC outpatients were the majority, even though they had no significant trends (Supplementary Table S1).

Fig. 1.  The significant trends of outpatient visits in the Chuansha MA in chronic disease categories from 2016 to 2020. (a) Musculoskeletal diseases. (b) Nervous system diseases. (c) Eye and adnexa diseases. (d) Blood and haematopoietic organ diseases and certain diseases involving immune mechanisms.

For men with musculoskeletal diseases and blood- and immune-related diseases, the percentage of outpatient visits to hospitals increased with an obvious upward trend (r = 0.986, P = 0.002; r = 0.922, P = 0.026) from 2016 to 2020, similar to women (r = 0.982, P = 0.003; r = 0.888, P = 0.044; Fig. 2). However, for nervous system diseases, male outpatient visits to CHCs presented an evident upward trend (r = 0.915, P = 0.030). Female outpatients with eye and adnexal diseases experienced an upward trend in CHC visits (r = 0.887, P = 0.045). CHC outpatients with cardiovascular and endocrine diseases remained the majority (Table S2).

Fig. 2.  The significant trends of outpatient visits stratified by sex in the Chuansha MA in chronic disease categories with from 2016 to 2020. (a) Male. (b) Female.

In the 18–59 years age groups, there were more hospital outpatients than CHC outpatients, and there were significant upward trends (P < 0.05) in most chronic diseases (Fig. 3). However, for respiratory diseases, the number of hospital outpatients aged 40–59 years was lower in 2016 (41.43%), but increased to 53.79% in 2020. Among the age groups aged >60 years, there were more CHC outpatients for most chronic diseases, regardless of upward or downward trends. However, for blood- and immune-related diseases, the proportion of CHC outpatients aged 60–79 years was 53.9% in 2016 and continued to decrease to 37.18%, which was smaller than that in hospitals (62.82%) in 2020.

Fig. 3.  The significant trends of outpatient visits in the Chuansha MA in chronic disease categories from 2016 to 2020 stratified by age group. (a) Age 19–39 years. (b) Age 40–59 years. (c) Age 60–79 years. (d) Age >80 years. (e) Age <18 years.

Almost all younger patients (aged 0–18 years) had ear diseases and chose hospitals rather than CHCs, whereas more young patients with endocrine, nutritional and metabolic diseases chose CHCs (Table S3). More outpatients (aged >40 years) with cardiovascular diseases chose to visit CHCs instead of hospitals throughout the study period (Table S3).

The costs adjusted for inflation rate are shown in Table 2. In hospitals, although the adjusted total cost for outpatients decreased in 2020, the adjusted average cost underwent an increase of 24.49%. The increasing rates of adjusted average cost in 2017 and 2019 were −4.13% and 2.82%, respectively, which were lower than the year before. However, the adjusted average cost presented an upward trend both in hospitals and CHCs. As shown in Table 3, the adjusted average cost of blood- and immune-related diseases, digestive diseases, and genitourinary diseases increased significantly both in hospitals and CHCs (P < 0.05). In addition, outpatients with ear and musculoskeletal diseases had an obviously increasing adjusted average cost in CHCs (P < 0.05). It was noted that the adjusted average cost of blood- and immune-related diseases increased the most in hospitals, with a more than fourfold increase from 330.34 RMB in 2016 to 1383.83 RMB in 2020, whereas the cost of other chronic diseases slightly increased by less than twice both in hospitals and CHCs from 2016 to 2020.

Table 2.  The cost of outpatients with chronic diseases in the Chuansha MA in Shanghai between 2016 and 2020.

Table 3.  The adjusted average cost of outpatient visits to the Chuansha MA among chronic disease systems between 2016 and 2020.

The construction of MAs is regarded as a measure to implement a hierarchical medical system in China, encouraging outpatients with common, frequently occurring diseases to make their first visit to a CHC and improving CHC capacities in chronic disease management (Shanghai Municipal Health Commission 2019). Our statistical results with respect to the age distribution of outpatients in hospitals and CHCs showed that the greatest number of outpatients were aged 60–79 years, followed by outpatients aged 40–59 years. This result reveals the severity of aging in the Chuansha area. Overall, we observed that in Chuansha MA, for cardiovascular and circulatory diseases, and endocrine, nutritional and metabolic diseases, more outpatients, particularly for groups aged >40 years, chose CHCs, in line with previous studies (Li et al. 2017; Shi et al. 2020). This finding might be explained by the location of a CHC within 15 min of residents (Yip and Hsiao 2014), making it convenient for older residents; a previous study in Beijing illustrated that the top reason for patients to choose hospitals for treatment was convenience (Cui et al. 2020). Additionally, residents who were assigned a family doctor received primary healthcare services for treatment or referral under the guidance of their family doctor (Xiao et al. 2014). Most of the people assigned a doctor were older individuals, which could be another reason for the aforementioned phenomenon (Shanghai Municipal Health Bureau, Shanghai Municipal Development and Reform Commission, Shanghai Municipal People’s Insurance Bureau, Shanghai Municipal Health Insurance Office, Shanghai Municipal Finance Bureau 2013).

We obtained some meaningful results in some disease systems. Regarding nervous system diseases, the proportion of outpatients increased in CHCs as time passed, both among men and women, and in older individuals (aged >60 years). Although the number of these outpatients is not as large as those with cardiovascular diseases, this finding cannot be ignored. The top disease of the nervous system was sleep disorder in our study (not shown), consistent with an analysis illustrating their high prevalence among older individuals (aged >60 years, 46.0%; Wang et al. 2022). As the factors of sleep disorders are complicated, CHCs might choose to provide health education for older people to ease their negative emotions and improve sleep quality.

Our study found that, although the proportion of outpatients of all ages with musculoskeletal diseases obviously decreased in CHCs, it remained higher than that in hospitals for the elderly group (aged >60 years). Considering as an example arthritis, which accounts for the largest proportion of all outpatients with musculoskeletal diseases in our study (not shown), a systematic review pointed out that the treatment of arthritis in CHCs is aimed at alleviating symptoms, but the therapeutic effects are not sufficiently satisfactory (Liu et al. 2022), which may reduce patients’ confidence and adherence to treatment. Indeed, the general practitioners in CHCs have obstacles to using the guidelines for the diagnosis and treatment of osteoarthritis, which are deeply professional and not applicable in primary medical institutions (Qiu et al. 2022). Thus, the inadequate medical capability of general practitioners could be an important factor contributing to patients choosing hospitals rather than CHCs. Conversely, more community-dwelling older adults still go to CHCs, most likely owing to the convenience (mentioned above) and some orthopedic specialists coming from the member organisations of the MAs (Song et al. 2019). In fact, increasing the capability for chronic disease treatment and health management is the overall development strategy of CHCs in China. Residents, especially patients with chronic diseases, are encouraged to visit CHCs for medical and care services. For diseases that exceed the service capability of CHCs, patients will be provided referrals to hospitals. The aim of these efforts is to optimise medical resource allocation for patients receiving high-quality, convenient and continuous medical services. Hence, it is critical for CHCs to improve their disease diagnosis and treatment capabilities to promote the operation of the hierarchical diagnosis and treatment system to achieve this goal.

According to a recent study conducted in Hubei Province, China (Chen et al. 2021), most general practitioners had an optimistic attitude towards an integrated healthcare system, which would render the system more efficient and reduce outpatients’ health care costs. However, in our study, the adjusted average cost of outpatient visits increased both in hospitals and in CHCs in the Chuansha MA over the 5-year study period. The Chinese government proposed in 2015 decreasing the increasing rates of average outpatient costs annually (National Health and Family Planning Commission, National Development and Reform Commission, Ministry of Finance, Ministry of Human Resources and Social Security, State Administration of Traditional Chinese Medicine 2015). We found that the increasing rate of average cost of outpatients was −4.13% in 2017, indicating that it decreased compared with 2016. However, the annual increasing rate presented upward trends with fluctuations both in hospitals and in CHCs from 2016 to 2020. Our study showed that the construction of the Chuansha MA did not limit medical costs as expected.

Our study found that the medical costs from the blood and immune diseases category grew sharply in hospital. To find the possible reasons, we sequenced the blood and immune diseases by average medical costs, and the anaemic due to other causes ranked first with 2128.50 RMB (not shown); for example, renal anaemia occurred frequently in chronic kidney disease patients. In China, the prevalence of chronic kidney disease was 10.8% or approximately 120 million patients (Zhang et al. 2012). These chronic kidney disease patients who had renal anaemia had 23 562 RMB more in medical costs per year than those without renal anaemia, indicating that renal anaemia greatly increased the disease burden (Zuo et al. 2018). Furthermore, the medical price of blood and immune diseases are higher than those of other chronic non-communicable diseases, such as hypertension and diabetes. Because of the better therapeutic effects, more anaemia patients choose new imported drugs; hence, they have higher medicine expenses. We consider that the prices of new drugs and new therapeutic techniques are the reasons for the increasing average cost to outpatients with this disease; however, these hypotheses must be further supported by data.

Rising medical costs will continue to increase the pressure on the healthcare system and insurance industry in China; thus, the government should seriously consider and undertake a series of actions to control the growth of medical costs and form a more cost-effective healthcare system.

In total, there are many factors that influence outpatients’ decisions to choose a hospital or CHC. Based on the analysis of outpatient trends regarding treatment for chronic diseases and costs in the Chuansha MA, we suggest that the government optimise the medical resources to manage chronic diseases within the MA system, as proposed to control medical costs from increasing and decreasing the burden on outpatients. The government should also assist CHCs in improving their medical service capacities specific to the dominant chronic diseases in the region and tailoring health education to the needs of community residents and general practitioners.

There were several limitations of this study. First, we did not analyse inpatients in hospitals and CHCs, because hospitalisation data were not available for many CHCs. This population is representative of those who are in serious situations and will be analysed in future analyses. Second, we did not compare the data before and after the MA was established, because the previous data were not available due to a lack of centralised data management. Finally, we only investigated outpatients in the Chuansha MA; thus, the findings might not be generalisable to other areas. There is a need for more comprehensive and multicentre studies.

In our study, we clarified the tendencies of chronic disease outpatients in the type of health care institutions that they visited and their costs in the Chuansha MA in Shanghai. We found that outpatients aged >60 years visited CHCs more than hospitals for some chronic diseases. Thus, we believe that the Chuansha MA worked in guiding older outpatients to CHCs in this period, indicating that the family doctor contract service has some positive effect. However, the average cost to outpatients presented an increasing trend from 2016 to 2020, which did not reach the goal of reducing the increasing rate of average medical costs. To realise the hierarchical diagnosis and treatment of chronic diseases, it is vital to improve the medical capability of CHCs to attract all community-dwelling residents of all ages. In addition, the Chinese government should undertake more efforts to control increasing medical costs.

Supplementary material is available online.

The data that support this study will be shared upon reasonable request to the corresponding author.

The authors report no conflicts of interest in this work.

This study was supported and funded by the Health Commission of Pudong New Area Health Scientific Research Project (PW2019D-14). Data extraction was financially funded by the Shanghai Education Science Research Project (C2021039). The analysis and interpretation of the data were funded by the Natural Science Foundation of China (71603182) and National Key R&D Program of China (2022YFC3601505). The writing and revision, including the language improvement, were sponsored by the Excellent Academic Leader of Public Health in Shanghai (GWV-10.2-XD07), and Philosophy and Social Science Research Major Projects of the Ministry of Education (20JZD027).