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Introduction: Owing to an increasing demand for a continuous and coordinated health service, integrated care is being promoted worldwide. Chinese research on integrated care has rapidly increased over the last 20 years. However, popular topics, paths and trends of integrated care research in China have not been systematically summarised. The study aimed to examine the evolution of integrated care research in China and predict future research trends. Methods: We searched for integrated care research in China published 2000-2020 in Chinese (China National Knowledge Infrastructure) and English (Web of Science). Research articles that met the inclusion criteria were selected. CiteSpace 5.7.R3 was used to perform keyword clustering, timeline view and burst detection analyses. Results: We included 786 Chinese articles and 124 English articles. Chinese articles formed 10 clusters with 1814 keywords. English articles formed 5 clusters with 487 keywords. From 2000 to 2020, integrated care research in China comprised three stages: (1) In the start-up stage (2000-2007), keywords mainly focus on medical resource integration and two-way referral; (2) In the emergence stage (2008-2015), keywords primarily include integrated model, benefits of integration, paths to integration and incentive mechanisms; (3) In the maturation stage (2016-2020), the main keywords are patient preferences, shared management mechanisms, symbiosis theory, valuebased care, payment methods and people-oriented care. Discussion: With increasing health care system reform, popular integrated care research topics in the next stage will likely focus on people-oriented integrated care, service value and payment method reform. Academic research on integrated care in China will help to shape and lead policymaking. Conclusions: Integrated care research in China has gone through three stages over the last two decades. In the future, integrated care theory in China will be informed by concepts from other fields, such as value co-creation in public management, to address the current problem of lack of synthesis in integrated care in China. [ABSTRACT FROM AUTHOR]

Introduction: China's organised health system has remained outdated for decades. Current health systems in many less market-oriented countries still adhere to traditional administrative-based directives and linear planning. Furthermore, they neglect the responsiveness and feedback of institutions and professionals, which often results in reform failure in integrated care. Complex adaptive system theory (CAS) provides a new perspective and methodology for analysing the health system and policy implementation. Methods: We observed the typical case of Qianjiang's Integrated Health Organization Reform (IHO) for 2 years to analyse integrated care reforms using CAS theory. Via questionnaires and interviews, we observed 32 medical institutions and 344 professionals. We compared their cooperative behaviours from both organisational and inter-professional levels between 2013 and 2015, and further investigated potential reasons for why medical institutions and professionals did not form an effective IHO. We discovered how interested parties in the policy implementation process influenced reform outcome, and by theoretical induction, proposed a new semi-organised system and corresponding policy analysis flowchart that potentially suits the actual realisation of CAS. Results: The reform did not achieve its desired effect. The Qianjiang IHO was loosely integrated rather than closely integrated, and the cooperation levels between organisations and professionals were low. This disappointing result was due to low mutual trust among IHO members, with the main contributing factors being insufficient financial incentives and the lack of a common vision. Discussion and Conclusions: The traditional organised health system is old-fashioned. Rather than being completely organised or adaptive, the health system is currently more similar to a semi-organised system. Medical institutions and professionals operate in a middle ground between complete adherence to administrative orders from state-run health systems and completely adapting to the market. Thus, decision-making, implementation and analysis of health policies should also be updated according to this current standing. The simplest way to manage this new system is to abandon linear top-down orders and patiently wait for an explicit picture of IHO mechanisms to be revealed after complete and spontaneous negotiation between IHO allies is reached. In the meantime, bottom-up feedback from members should be paid attention to, and common benefits and fluid information flow should be prioritised in building a successful IHO. [ABSTRACT FROM AUTHOR]

Background: While integrated health care system has been proved an effective way to help improving patient health and system efficiency, the exact behaviour model and motivation approach are not so clear in poor rural areas where health human resources and continuous service provision are urgently needed. To gather solid evidence, we initiated a comprehensive intervention project in Qianjiang District, southwest part of rural China in 2012. And after one-year's pilot, we developed an intervention package of team service, comprehensive pathway and prospective- and performance-based payment system. Methods: To testify the potential influence of payment interventions, we use clustered randomised controlled trial, 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences. Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway. The outcomes are: quality of care, disease burden, supplier cooperative behaviour and patient utilisation behaviour and system efficiency. Repeated multivariate variance analysis will be used to statistically examine the outcome differences. Discussion: This is the first trial of its kind to prove the effects and efficiency of integrated care. Though we adopted randomised controlled trial to gather the highest rank of evidence, still the fully randomisation was hard to realise in health policy reform experiment. To compensate, the designer should take efforts on control for the potential confounders as much as possible. With this trial, we assume the effects will come from: (1) improvement on the quality of life through risk factors control and lifestyles change on patient's behaviours; (2) improvement on quality of care through continuous care and coordinated supplier behaviours; (3) improvement on the system efficiency through active interaction between suppliers and patients. Conclusion: The integrated care system needs collaborative work from different levels of caregivers. So it is extremely important to consider the supplier cooperative behaviour. In this trial, we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles. Also, the multidisciplinary team, the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution. [ABSTRACT FROM AUTHOR]

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Background: Telehealth devices are considered with potential to foster improved health outcome for patients with hypertension. However, the longitudinal use trajectories of telehealth devices have not been identified yet, nor has the connection between developmental trajectories of telehealth devices use and health outcome over time. Objective: To identify the longitudinal trajectories of use of telehealth devices among patients with hypertension, characterize features for each trajectory, and to unravel the correlation between longitudinal trajectories of telehealth devices use patterns and BP control outcome. Methods: A total of 122 patients with hypertension were enrolled, portable telehealth device were given to them to monitor blood pressure. Socio-demographics (e.g. name, age, sex, marital status) were collected at baseline. The real-time measured data, including time and both systolic and diastolic blood pressure data, were sent up to cloud platform through the portable device. The latent class growth analysis modeling approach was used to determine the latent trajectory of telehealth use. And the joint trajectory method was used to identify the correlation between the longitudinal trajectories of telehealth use and BP control status. Results: 5 distinct trajectories were finally identified: Persistently low (47.1%), Moderate with decreasing (23.9%), Sharply decreasing (11.2%), High with decreasing (11.3%), Persistently high with increasing (6.6%). However, no statistical significant differences in age, marital status, BP (both SBP and DBP) and BP control status in the first period between the 5 trajectories were found. It provided evidence that strong correlation existed between the longitudinal telehealth devices use patterns and individuals' longitudinal BP control status. Conclusions: The latent trajectories of telehealth use were identified; yet, no predictors of trajectory membership have been found. Although more prove of the causal relationship needs to be revealed in further studies, this study demonstrated that regular monitor has some positive correlation with improved BP control. [ABSTRACT FROM AUTHOR]

Introduction: Worldwide, many countries have established their own gatekeeper system. Tertiary hospitals in China have experienced explosive growth both in the quantity and quality since 2009. However, the healthcare delivery system in China is fragmented for its weak coordination between different faculties. And it was not well prepared for the tremendous and complex needs, especially the grassroots healthcare faculties whittled by the tertiary hospitals. Moreover, it has caused the increasing of total health expenditure and occurrence of catastrophic health expenditure. Policy context and objective: To deal the unreasonable resources distribution among the tertiary-grassroots faculties and urban-rural areas, and establish a high-value healthcare delivery system. In January 2013, the tiered healthcare service delivery was first implemented among Qinghai and Hubei province. Given emerging problems might influence the current policy analysis from different perspective may achieve contrasting results, it is necessary to evaluate the secular effects of the previous pilots and synthesis its experience for the following programs with the similar contextual settings. Targeted population: The New Rural Cooperative Medical System enrollee in the Dangyang. Highlights: A quasi-natural experiment was designed in Dangyang, Hubei province. And the policy were piloted in October 2014, policies related to this reform and claim data from January 2011 to December 2015 were collected from the New Cooperative Medical Scheme (NCMS) enrollees. First, the patients are motivated to take the grassroots faculties for the initial treatment-seeking, with different reimbursement ratio settings varied with the delivery system levels. Second, all the county-level hospitals have to establish the integrated delivery system with more than township faculties. Third, all community healthcare centers should carry out the family doctors system and the grassroots faculties in rural areas should be equipped with a physician good at the Traditional Chinese Medicine. The outcomes indicated the changes in cost and patients flow were included to evaluate its effects and calculated monthly based on the claim data. Policy analysis and interrupted time series analysis model were designed to estimate the before-after changes in the indicators with Stata version 13.0. All the cost data was adjusted according the 2016 China Health Statistics Yearbook. The actual reimburstment ratio and the proportion of total medical expenses in township hospitals increased significantly in the first month of the implementation of the tired medical system policies, and has reversed the orginal downward trend. Meanwhile, the upward trend and level of out-of-pocket has significantly declined. However, the level and trend of proportion of health expenditure and patient visits in health care facilities outside Dangyang did not decreased significantly, so does the average length of stay and average total cost. The proportion of total patient visits in township hospitals increased at first, but not reversed significantly in the long term. Conclusions: Although this policy has not achieved all its expected outcomes temporarily, it has reduce the out-of-pocket cost for patients and improve the effectiveness of the grassroots facilities. Further studies should focus on the more comprehensive evaluation of health system and an appropriate control group should be found. [ABSTRACT FROM AUTHOR]

Background: In China, the increases in caesarean section (CS) rates and in delivery costs have posed questions about the reform of the medical insurance payment system. Case payment is useful in regulating the behavior of health providers and in controlling CS rates and the unreasonable increase in medical expenses. New Cooperative Medical Scheme (NCMS) agencies in Xi County in Henan Province piloted a case payment reform (CPR) in delivery for inpatients. We aim to observe the change in CS rates, compare the changes in delivery-related variables, and find variables related to delivery cost before and after the CPR in Xi County. Methods: A total of 28,314 cases were selected from the Xi County NCMS agency from 2009 to 2010 and from 2014 to 2015. The one-way ANOVA and chi-squared test were adopted to compare the distributions of CS and vaginal delivery (VD) before and after the CPR under different indicators. We applied multivariate linear regressions for the total medical cost of the VD and CS groups and total samples to identify the relationship between medical expenses and variables. Results: The CS rates in Xi County increased from 26.1% to 32.5% after the CPR. The length of stay (LOS), the total medical cost, and the proportion of county hospitals increased in the CS and VD groups after the CPR, which had significant differences. The total medical cost in the CS and VD groups and total samples was significantly influenced by patient age, LOS, and hospital type and had a significant correlation with the CPR in the VD group and total samples. Conclusion: The CPR might fail to control the unreasonable medical expense growth and regulate the behavior of providers, possibly resulting from the unreasonable compensation standard of case payment, prolonged LOS, and the increasing proportion of county hospitals. The NCMS should modify the case payment standard of delivery to inhibit the motivation of providers to render CS services. The LOS should be controlled by implementing clinical guidelines, and a reference system should be established to guide patients in choosing reasonable hospitals. [ABSTRACT FROM AUTHOR]

Background: Most of the integration-related policies are facing implementation problems. During 2012/07-2014/12, we implemented an trial-based intervention in Qianjing, a rural district in southwestern China, to test the effects of an innovative integrated care delivery model targeted for rural patients (RICDM) with hypertension. Using the difference-indifferences analysis, we found that the blood pressure did decrease in treatment group compared to the control group however the health-related quality of life did not, which violated our assumptions. To explore whether the provider performance interfered with the outcomes, we did a process evaluation mainly to compare their behaviors during trial implementation. Methods: All the doctors' behaviors were bimonthly-recorded using diaries, and their attitudes were evaluated using questionnaires adapted from D'Amour's inter-professional collaboration model. We firstly observed the referral amounts and provider communication frequency on four inter-professional cooperation types (village to town, town to county, county to town, and town to village - the former indicated the initiated party). Then we conducted interviews with the doctors, investigating the following aspects that potentially affected the collaboration: willing to cooperate, actual motivation, mutual trust, personal relations and ability to cooperate. All variables were compared between groups before and after intervention. After then we did a regression analysis examining the relations between the cooperation level and the identities of doctors. The implementation degree was also estimated by multiplying the percentage of reach scope for each step of trial process. Results: 120 doctors were included. There were no significant differences between treatment group and control group either on the referral amounts or the communication frequency (all P >0.05). Most of the cooperation aspects showed a low- and middle-level performance (>90%). The collaboration ability in treatment group was significantly higher than control group (P <0.001) after intervention, except for that, there were no differences compared to control group in willingness, motives, mutual trust or personal relationship improvement (all P >0.05). And the doctors from county hospitals showed a lower performance in each of the aspect compared to doctors from town hospitals and village clinics. Associated with the professional identity, the medical staff showed relatively low interests in collaboration compared to primary care professionals. By observing and analyzing the processes of exposure, enrollment, reach and follow-ups, we had found out the implementation degree to be only 61%. For each part, the patient were reached out by 100%, the supplier 72%, and the hospitals 85%. Lessons Learned: The RICDM improved patient health, but did not fully achieve desired effects. We inferred that one possible reason might lied in the providers' reluctance to cooperate. By furtherly investigating into the provider behaviors and implementing process, we had proved our guess and the actual model effect might therefore be underestimated. However the study did not successfully connect the health-related outcomes with the provider behaviors through statistical analysis, so we could not reach a direct conclusion that the incomplete implementation was the exact reason for imperfect model effects. Further studies need to be proposed and also potential bias from provider side should be properly dealt with in the stage of study design. [ABSTRACT FROM AUTHOR]

Background: Cost is a great concern for integrated care. China has been trying to build a hierarchical medical system to integrate services between different medical institutions, so that mild patients can be referred to primary institutions and cost can be cut. Our aim is to explore how much inpatient cost could be saved by the hierarchical medical system. Methods: This study was carried out in Xi County, China, based on the rural inpatient database in 2015. We firstly screen out the inpatient record in county hospitals which could have been in township hospitals based on self-evaluation capability and practical capability of township hospitals and then calculate the difference in cost between township and county hospitals which could have been saved. Self-evaluation capability referred to all the disease that township hospitals thought they could handle by inpatient service and practical capability referred to all the disease that township hospitals actually handled by inpatient service. Results: Under the self-evaluation capacity, 14.90% of the inpatient records in county hospitals could have been in township hospitals and 11.84 million? (5.20% of the total inpatient expenditure within county) could have been saved. Under the practical capability, 6.95% of the inpatient records in county hospitals could have been in township hospitals and 7.15 million? (3.14% of the total inpatient expenditure within county) could have been saved. Discussion: Cost reduction by service integration was limited by the capability of township hospitals. Conclusion: Cost reduction by the hierarchical medical system was small. Lessons learned: Capability improvement of primary medical institutions is a key task for service integration and effectiveness raise. Limitations: We did not compare the inpatient quality and take the patient's willingness into account. Suggestions for future research: Comparison of quality and patient willingness need to be considered in further studies. [ABSTRACT FROM AUTHOR]

Introduction: China has been trying to enhance service collaboration between different levels of medical institutions to lower patient flow and cut down medical expenditure. However, the outcome was poor. Township-County Readmission (TCR) means a patient is firstly admitted to a township hospital and then a county hospital within 30 days for the same disease. Our aim is to explore whether TCR can lower patients' costs in county hospitals. Method: This study was carried out in Qianjiang District, China. Firstly, we selected out TCR patients from the database. Then, we picked out patients who was admitted to county hospitals less than 30 days before TCR (CTCR patients) or after TCR (TCRC patients) for respiratory system disease as our objects. Finally, we compare the former expenditure in county hospital with the latter for TCRC patients and CTCR patients by paired-t test. Result: 74 TCRC patients and 40 CTCR patients of respiratory system disease were screened out. The average of former expenditure in county hospital for TCRC patients was 651.6$, and the latter was 564.0$ (t=-0.467, P=0.643). The average of former expenditure in county hospital for CTCR patients was 594.4$, and the latter was 653.8$ (t=-0.963P=0.339). Discussion: The difference between costs of single county inpatient and costs of county inpatient in TCR is not significant, which means that service provided by township hospitals during TCR is ineffective. Conclusion: Service collaboration between township hospitals and county hospitals didn't achieve the real continuity as wanted, which had enlarged waste and the inefficiency of supply system. Lessons learned: Cutting down the inefficiency during referral is a key task for service collaboration. At least, the patients should not pay for this. Limitation: The sample size was too small and disease severity was not included into the study. Suggestions for future research: More samples should be included. Disease severity needs to be better controlled. [ABSTRACT FROM AUTHOR]

Introduction: Although the Chinese government has been emphasizing importance of the grassroots healthcare system as well as conducting reform in the rural health institutions, the efficiency and the effectiveness of healthcare are still very poor in rural China and the Chinese healthcare delivery system is highly fragmented. All organizations should be under hierarchical structure that is comprised of separate, but interconnected components. Though all these components are supposed to play complementary roles in order to accomplish not only their own tasks but also overall tasks, the division, decentralization and specialization found in complex organizations generally hinder the efficiency and quality goals. Objective: To explore the mechanism of Global Budget of Multi-level Institutions on one certain disease (GBMI) to stimulate health personnel supply integrated care in primary institutions. Theory: A case-control study was carried out in Qianjiang District, Chongqing, China. 4 similar township hospitals were divided into intervention group and control group. The intervention group was implemented by means of Global Budget of Multi-level Institutions (GBMI) on hypertension. The global budget was calculated through the actual costs of all patients with hypertension in the past three years, and the total expense was adjusted by CPI, growth coefficient and inflation factor. A Continuous Service Team (CST) was constructed including village health personnel, general practitioners, public health personnel in township hospital, hypertension specialists in county hospital, coordinator and so on. CST supplied all managed hypertension patients with all preventive and medical care in the fixed global budget. In the healthcare it includes blood pressure monitoring, health education, medical care and doctor visit. The possible budget balance will belong to CST while budget shortfalls would be apportioned into CST. The behavior of rejecting essential services and translating hypertension into other diseases would be punished by discounting the possible budget balance. The intervention period started from 1st July 2012 and will end on 31st December 2013. CST supplied above 10000 personalized health intervention services to 4167 managed patients by December 2012. Method: We have carried out 2 investigations including 300 managed patients per town by multistage stratified random sampling on 1st July and 31st December 2012. The contents of the questionnaire concentrate on the status of health self-assessment, experiences of seeing doctor, doctor visits and individual information. The data of expenditure of all managed patients were exported via Health Insurance Information Management System, and the medical records were collected in medical institutions regularly. Results: In 594 intervened hypotension patients, management rate of hypertension increased from 58.1% to 93.5% (P<0.01), standardized management rate increased from 37.1% to 42.3% (P<0.01) and medication adherence rate increased by 9.3%. The ratio of expenditure in township hospitals to total expenditure increased from 21.3% to 25.4% (P=0.023), which were all higher than those of control group. Standard control rate of hypertension is likely to reach 65% by Dec 2013 by means of Markov Prediction Model with continuous intervention. 38 patients have received continuous clinical services from CST while the average expenditure is 7% lower than that without CPT. Growth rate of hospitalized hypertension patient in county hospital decreased from 15% to 12% while that in township hospital decreased by 6.3%. Conclusion: The CST under GBMI can supply integrated care under the existing total expendture. Although the effect is not significant, a longer intervention period may make it better. The expansion of patients with hypertension could be controlled and the behavior could be changed. The cooperative mechanism established by CST and GBMI between county and village can play positive role in encouraging the health personnel to change concept, strengthening multilevel collaboration and improving effectiveness of service, thus it is in favor of continuity of medical and preventive services in rural China. [ABSTRACT FROM AUTHOR]