Strengthening the primary care system and promoting utilization of primary care are the major targets of China's ambitious health reforms to meet its people's escalating health care needs. However, the changing trend of primary care utilization 4 years before and after 2009, when the health reforms started, is against the government's stated goal. The percentage of outpatient visits in primary care significantly declined from 63% in 2005 to 59% in 2013 (P = .002). In Western China it went down from 66% in 2010 to 62% in 2013 (P = .017) and slightly dropped in Eastern and Central China. Causes are multiple and include major historic and institutional factors such as severe maldistribution of human resources and lack of primary care practitioners (PCPs), lack of a functional gate-keeping mechanism, the low educational attainment of PCPs, and the detrimental elements of health reforms. Immediate measures need to be taken to improve the situation. These include taking irrational hospital expansion under strict control through enhancing the government's accountability for health care industry regulation, strategies to recruit and retain a quality primary care workforce, empowering PCPs as gatekeepers in the system, timely evaluation of the impact of health reforms on primary care, and modifying damaging policies.

Underuse of Primary Care in China: The Scale, Causes, and Solutions

Doctor shopping is defined as seeing multiple treatment providers, either during a single illness episode or to procure prescription medications illicitly. According to the available literature, prevalence rates of doctor shopping vary widely, from 6.3 to 56 percent. However, this variability is partially attributable to research methodology, including the study definition of doctor shopping as well as the patient sample. The reasons for doctor shopping are varied. Some patient explanations for this phenomenon relate to clinician factors, such as inconvenient office hours or locations, long waiting times, personal characteristics or qualities of the provider, and/or insufficient communication time between the patient and clinician. Some patient explanations relate to personal factors and include both illness factors (e.g., symptom persistence, lack of understanding or nonacceptance of the diagnosis or treatment) as well as psychological factors (e.g., somatization, prescription drug-seeking). Importantly, not all doctor shopping is driven by suspect motivations. Being aware of these various patient justifications for doctor shopping is important in understanding and managing these challenging patients in the clinical setting, whether they emerge in psychiatric or primary care environments.

Doctor shopping: a phenomenon of many themes.

Many countries have implemented pay-for-performance programs to improve the quality of care. The structure of these programs, however, can have perverse consequences beyond improving care for patients. To investigate this possibility, we studied the pattern of enrollment of patients with diabetes in the first five years of a pay-for-performance program in Taiwan’s National Health Insurance Program from 2001 through 2005. Taiwan’s program did sharply improve quality of care for enrolled patients, producing 100 percent or nearly 100 percent adherence to all process measures. But at the same time, only a minority of the nation’s patients with diabetes were enrolled, because the program’s design encouraged physicians not to enroll their most complicated patients. By “cherry-picking” the healthiest patients most likely to perform well on selected measures, physicians were able to game the system and potentially reap the rewards of higher pay-for-performance payments without actually improving the care of all o...

A Pay-For-Performance Program In Taiwan Improved Care For Some Diabetes Patients, But Doctors May Have Excluded Sicker Ones

Background:Better continuity of care (COC) is associated with improved health care outcomes, such as decreased hospitalization and emergency department visit. However, little is known about the effect of COC on potentially inappropriate medication.Objectives:This study aimed to investigate the assoc

Continuity of care, potentially inappropriate medication, and health care outcomes among the elderly: Evidence from a longitudinal analysis in Taiwan

In this era of ubiquitous information, patient record exchange among hospitals still has technological and individual barriers including resistance to information sharing Most research on user attitudes has been limited to one type of user or aspect Because few analyses of attitudes toward electronic patient records (EPRs) have been conducted, understanding the attitudes among different users in multiple aspects is crucial to user acceptance This proof-of-concept study investigated the attitudes of users toward the inter-hospital EPR exchange system implemented nationwide and focused on discrepant behavioral intentions among three user groups The system was designed by combining a Health Level 7-based protocol, object-relational mapping, and other medical informatics techniques to ensure interoperability in realizing patient-centered practices After implementation, three user-specific questionnaires for physicians, medical record staff, and patients were administered, with a 70 % response rate The instrument showed favorable convergent construct validity and internal consistency reliability Two dependent variables were applied: the attitudes toward privacy and support Independent variables comprised personal characteristics, work characteristics, human aspects, and technology aspects Major statistical methods included exploratory factor analysis and general linear model The results from 379 respondents indicated that the patients highly agreed with privacy protection by their consent and support for EPRs, whereas the physicians remained conservative toward both Medical record staff was ranked in the middle among the three groups The three user groups demonstrated discrepant intentions toward privacy protection and support Experience of computer use, level of concerns, usefulness of functions, and specifically, reason to use electronic medical records and number of outpatient visits were significantly associated with the perceptions Overall, four categories of independent variables were associated with the mean difference in the perceptions Discrepant attitudes toward privacy and support among the three user groups are identified Patients may require further education and communication regarding the system Culturally fit e-Consent should be incorporated into the system to fully utilize the computing power of the Internet when also considering workload The concern for misuse of EPRs might lead to low support among physicians Highly readable EPR documents and managerial incentives for information exchange may improve system use

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Attitudes toward inter-hospital electronic patient record exchange: discrepancies among physicians, medical record staff, and patients

Study on doctor shopping behavior: Insight from patients with upper respiratory tract infection in Taiwan

Background:Long-term behaviour change in type 2 diabetic patients may provide effective glycemic control.Purpose:To investigate the key factors that promote behaviour change in diabetic subjects using the transtheoretical model.Methods:Subjects were selected by purposive sampling from type 2 diabetes outpatients. Self-administered questionnaires were used to collect the data related to the stages of behavioural change. HbA1C* values were measured to evaluate glycemic control. Data were analyzed with analysis of variance (ANOVA), multiple regression and multinomial logistic regression.Results:Routine management of diabetes was a key factor in behaviour change, which correlated indirectly with HbA1C values through compliance and was positively affected by social support. Undermining from family or friends was directly associated with HbA1C.Conclusions:Based on factors influencing stages of behaviour change in diabetic subjects, tailoring a programme to help patients balancing life-style with diabetes, stren...

Ming-Jye Wang

Papers

Study on doctor shopping behavior: Insight from patients with upper respiratory tract infection in Taiwan

Applying the transtheoretical model to investigate behavioural change in type 2 diabetic patients