Introduction
Hypertension is a major modifiable risk factor for stroke and other cardiovascular diseases [
1]. Blood pressure levels are increasing driven by population aging, urbanisation and rising incomes in China, which can be largely attributed to the high stroke mortality [
2,
3]. According to the Seventh National Population Census: 18.70% of the population is over 60 years old and 13.50% is over 65 years old in China in 2020. Surveys indicated that hypertension is highly prevalent, which was 25.2% in 2012 according to the China Health Statistics Yearbook, but the awareness, treatment and control rates of hypertension remain low in China across studies [
1,
3‐
7].
China launched a new round of health care reform in 2009, giving priority to public health strengthening [
8]. Chronic disease management, including hypertension and diabetes management, was then added to the package of basic public health services. Blood pressure control, which used to be the aim of local research projects organised by experts, became a national public health priority led by the government [
9]. The service scope of disease management for patients with hypertension is designed by the government, including (i) screening, (ii) follow-up, (iii) classified intervention/treatment and (iv) medical examination. All basic public health services are provided to all residents for free at primary care facilities which play an important role in the prevention and treatment of hypertension [
10,
11]. Primary care facilities can assist patients with hypertension in leading healthier lives, thereby reducing the burden of hypertension-related complications and improving the efficiency of medical resource utilization in healthcare systems. Previous studies showed that patients registered and managed by primary care facilities would have better control of blood pressure and significant decrease of related complication [
12].
Though previous surveys (conducted after the health care reform) revealed that China achieved improvements in awareness, treatment and control rates of hypertension, which were nearly two, two and three times as that in 2002, respectively, [
4,
13,
14] the rates were still low compared with high-income countries [
4]. Moreover, there were geographic variations in hypertension management with regard to the management rate, quality of services and patient or provider satisfaction [
15‐
17]. Most studies used cross-sectional data to present the status of the hypertension epidemic and compared the results with previous surveys. Research on trajectories of hypertension management using longitudinal data is lacking, which may be helpful to understand and predict dynamic trends. Previous studies analysed variations at the regional level (e.g. Eastern/Central/Western China) or provincial level, but to our knowledge, no study has examined the variations at the facility level. Results have proved that primary care facility characteristic (e.g. having more primary care physicians with at least a bachelor’s degree) is associated with hypertension awareness, treatment and control rate [
3].
China implemented the national basic public health services project to introduce hypertension management services in 2009, so an understanding of the output of hypertension management which is an important indicator for project assessment and will be the basis of quality of care in primary care facilities is important. The National Basic Public Health Service Project mandates that primary care facilities should carry out free annual blood pressure screening for residents aged 35 and above living in the jurisdiction and provide health management and physical examinations for patients with hypertension. This study evaluated the output of hypertension management in basic public health services projects between 2009 and 2017, and explore the associated factors at primary care facilities to provide a basis for improving output of hypertension management.
We address the following research questions specifically:
1.
How has the output of hypertension management developed in China’s basic public health services projects from 2009 to 2017?
2.
What are the latent class characteristics of output of hypertension management at primary care facilities between 2009 and 2017?
3.
What are the economic, geographical and facility-level characteristics associated with the output of hypertension management at primary care facilities?
Discussion
This study reveals that there was a rapid increase in the hypertension management rate from 2009 to 2012, but the growth slowed down from 2012 to 2017. We identified five distinct trajectories of hypertension management output in primary healthcare facilities from 2009 to 2017 in China and labelled them based on start point and increase rate. Facilities with trajectories of low-sharp increase, middle-sharp increase, and persistently high were more commonly found in central and western rural areas of China. Additionally, the study found that geographic characteristics, including region, urban-rural classification, and landform, as well as facilities-level and economic characteristics, were significantly associated with different trajectories.
The implementation of the national project of basic public health services has resulted in a continuous increase in hypertension management output. Figure
2 shows that the growth rate of output exhibited a turning point in 2012. As the project was just beginning to be implemented in 2009, a large number of patients with hypertension availed of health management services during the first few years, which led to a rapid increase in output. Growth slowed down from 2012 to 2017, which indicated the saturation point in standardised management of the existing patients with hypertension. However, previous survey data showed a large gap between the current number of people under management and the total number of patients with hypertension. According to the China Health Statistics Yearbook, there were 2520 patients with hypertension in a population of 10,000 [
21]. This study showed that only 610.27 patients with hypertension were managed per 10,000 population in 2017, which was the maximum output. The possible reason for such a large gap lies in the low awareness rate of patients to their own hypertension disease [
16,
22,
23]. A previous study showed that the crude hypertension awareness rate was 43.8% and the age-standardised hypertension awareness rate was only 27.2% in 2015 [
24]. As we cannot obtain the data of the hypertension awareness rate of the same population from the sample areas, we used the data from a nationally representative survey to validate our reasoning. It revealed that a significant number of patients with hypertension had not undergone screening and detection, or if they had, they had not received adequate health management. The survey data also revealed that the output of hypertension management was stable after 2012. The average growth rate of hypertension management output was 5.94% from 2012 to 2017, which was slightly lower than the rate of increase in prevalence. A study from China Health and Nutrition Survey showed that the average increase rate of prevalence of hypertension was 7.73% during 2011–2015 [
25]. This result indicated that patients with new-onset hypertension had not been managed completely. The gap may continue to grow between the number of patients with hypertension under management and the total patients with hypertension. Therefore, we suggest that primary healthcare facilities implement health education programs, disease screening, and other measures to improve the awareness and health literacy of patients with hypertension. Additionally, we recommend optimizing the allocation of human resources in primary care facilities and improving the accessibility of health services to promote the management of patients with new-onset hypertension.
On the basis of the trajectories of the output in Fig.
3, low-sharply increasing, middle-sharply increasing and persistently high groups, which accounted for over 60% of the total facilities, presented high-level output in the last 4 years of the studied time period. Table
2 revealed that facilities in rural areas had a higher percentage in these trajectories, which indicated that the majority of rural area facilities demonstrated good performance in the output. The result of good performance in the output in central and western rural areas might be related to the relationships and economic factors. Residents in rural areas had a closer relationship with village doctors, who were the actual operators of health management on behalf of township health centres in China. Research shows that social relationships could contribute to higher hypertension management outcomes, [
26] just like the social network formed between village doctors and residents in rural China. Urban and eastern rural residents were relatively better off so that they usually choose high-level healthcare facilities when needed, and thus the primary healthcare facilities did not have a comprehensive picture of the health status of residents in jurisdictions to decide who needs to be included in health management. According to former studies, the prevalence of management and control of hypertension in urban areas were higher than that in rural areas in China [
7,
14,
27]. As a result, the higher output in rural areas did not mean higher treatment rates or control rates of hypertension, the reason for the gap might be the quality of the management; [
28‐
31] facilities in rural areas managed patients with hypertension simply by filing cards sometimes without follow-up visits [
31,
32]. Therefore, we recommend that township hospitals improve management quality to increase the prevalence of control and decrease or delay complications by increasing the frequency of follow-up visits and medication guides [
33]. By comparison, facilities in urban areas had lower management output, which might be related to the self-medication [
34] and the disconnect of the information system between hospitals and primary care facilities [
35]. Urban residents sought treatment freely because of more hospitals in urban areas, and the lack of trust in primary care facilities led to bypassing community health centres [
36]. The reactive service-providing model and information between hospitals and primary care facilities was not exchanged demonstrated that primary care facilities could not fully grasp the disease situation of patients with hypertension in their catchment area [
31]. Therefore, we recommend that primary care facilities in urban areas carry out additional hypertension screening, and the information between hospitals and primary care facilities should be interconnected.
Trajectory trends showed that facilities in the low-gradually increasing and low-sharply increasing groups shared the same start point but differed in growth rate. Facilities in the low-sharply increasing groups were more likely to be located in central, western and rural areas [
37]. With the rapid economic and social development, a demographic change occurred in both urban and rural areas in China [
1]. The process of urbanisation promoted the migration of young population in rural areas to urban areas, and the proportion of the elderly population in rural areas kept rising, as well as the proportion of patients with hypertension [
38,
39]. As a result, the output of hypertension management of primary care facilities in rural areas increased rapidly. We recommend that facilities in rural areas should increase resource input in public health services to adapt to the rapidly increasing demand for chronic disease management. According to the existing studies, limited health personnel is one of the health system-related barriers to the appropriate control of hypertension, [
40] but the trend of its impact over time has not been discovered. The role of human resources was critical in hypertension management in primary care facilities, even for non-physician healthcare service providers [
41]. Healthcare service providers in primary care facilities were divided into public health service providers and other providers in China. Although the number of public health service providers contributed to the output, the current growth in the number of public health service providers cannot keep pace with the growth in services; the proportion of public health service providers is much lower than that of clinical service providers in facilities, whereas the proportion of public health services is much higher than that of medical services [
8]. Primary care facilities paid more attention to medical services than public health services, resulting in the decline in quality of public health services [
42]. We recommend increasing the input on human resources in grassroots facilities and maintaining and gradually improving the number of full-time public health personnel. It showed that the coefficient of the low-sharply increasing group (0.048) was lower than that of the low-gradually increasing group (0.225), and Wald test [
20] showed a significant statistical difference between the two groups (P < 0.0001). Therefore, facilities in the low-sharply increasing group completed more hypertension management tasks with fewer public health service providers and higher growth rates, which resulted in heavy workload of public health providers and poor performance [
43]. However, most of these facilities were concentrated in rural areas, which indicated some problems in management quality as patients with hypertension were not managed comprehensively and to a high standard [
31]. The effective development of public health services in primary care facilities should be encouraged through policy and special subsidies for public health services [
44,
45] to improve the output and standardisation of hypertension management.
Given the limitation in accessing the number of patients with hypertension, we employed management output instead of management rates to assess performance. Thus, we normalised the volume of services using the population of the area as the output, assuming that different regions shared the same prevalence of hypertension. We also determined the trend of management output to describe changes. We discovered that the increasing trend of hypertension management output was valuable to assess the effect of the national project as the project was implemented in 2009 and hypertension management was still at a low level.
Strengths of this study include that large sample and longitudinal data of primary care facilities for 9 years in China were involved and longitudinal data analysis methods were used to analyse the output of hypertension management. We analysed both time-dependent and time-stable characteristics influencing the trend of the hypertension management output. Given the limitation in accessing the number of patients with hypertension, we employed management output instead of management rates to assess performance.
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