Background: Since 2010, China has made vast financial investments and policy changes to the primary care system. We aimed to assess how hypertension awareness, treatment, and control might be used to assess quality of primary care systems, which reflect the outcomes of public health services and medical care.
Methods: We used The China Patient-centred Evaluative Assessment of Cardiac Events Million Persons Project, a government-funded public health project that focuses on cardiovascular disease risk in China. We linked primary care institution characteristics that were captured in the survey between 2016 and 2017 to the participant-level data gathered in baseline visits between 2014 and 2021. Participants were included if they had hypertension and lived in the towns or streets that took part in the primary care survey. Participants were excluded if they had missing data for blood pressure measurement, history of hypertension, sex, or age. Primary care institutions were excluded if the catchment area had fewer than 100 participants with hypertension. Hypertension awareness was defined as the proportion of participants with hypertension who self-reported a hypertension diagnosis. Hypertension treatment was defined as the proportion of participants who currently use antihypertensive medications among those who were aware. Hypertension control was defined as the proportion of participants with an average systolic blood pressure less than 140 mm Hg and an average diastolic blood pressure less than 90 mm Hg over two readings among those who were treated during the study. All patients were included in the analysis. This trial was registered at ClinicalTrials.gov, NCT02536456.
Findings: Between Sept 15, 2014, and March 16, 2021, we assessed 503 township-level primary care institutions for eligibility. 70 institutions were excluded as they could not be linked with individual data or because their catchment area had fewer than 100 participants with hypertension. We analysed 433 township-level primary care institutions across all 31 provinces of mainland China, including 660 565 individuals with hypertension in their catchment areas. Across townships, age-sex standardised hypertension awareness varied from 8·2% to 81·0%, treatment varied from 2·6% to 96·5%, and control proportions varied from 0% to 62·4%. Hypertension awareness, treatment, and control were significantly associated with the following institutional characteristics: government funding through balance allocation (ie, institutions have their human resources funded by local government, but need to be self-supporting in other aspects; awareness odds ratio 0·88, 95% CI 0·78-0·99; p=0·027), having financial problems that interrupted routine service delivery (awareness 0·81, 0·72-0·92; p=0·0007, control 0·84; 0·75-0·94, p=0·0034), setting performance-based bonus (treatment 1·39, 1·07-1·80; p=0·013), basic salary defined by number of patient visits (control 0·85, 0·76-0·95; p=0·0053), using electronic referrals (treatment 1·41, 1·14-1·73; p=0·0012, control 1·17; 1·03-1·33, p=0·014), implementing family physician contract services (awareness 1·13, 1·00-1·28; p=0·045, control 1·30; 1·15-1·46, p<0·0001), and proportion of physicians who are formally licensed (awareness per 10% increase 1·04, 1·01-1·08; p=0·019, treatment 1·08; 1·02-1·14, p=0·0077; control per 10% increase 1·07, 1·03-1·10; p=0·0006).
Interpretation: The role of primary care role in hypertension management might benefit from new strategies that promote best practices in institutional financing, performance appraisal, service delivery, and information technology.
Funding: Chinese Academy of Medical Sciences Innovation Fund for Medical Science, and the National High Level Hospital Clinical Research Funding.
Translation: For the Chinese translation of the abstract see Supplementary Materials section.
Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.