Effects of the integrated delivery system and payment system of community-based intervention on rural patients of chronic diseases in Qianjiang District, China

quality improvement collaborative +system global b:multi-disciplinary team/multi-insitutional pathway + system global budget and performance-based payment

Control group:None

Eligibility

Sex/Gender

All

Age

35 Years to 80 Years

Inclusion criteria

Inclusion criteria: 1. had been registered as a managed chronic patient between year 2008 to Jan 2012, which meant the participants were all aged over 35 and had an official health records including their basic demographic information, symptoms and risk factors, and with a history of hypertension and/or diabetes type II no less than 6 months and taking BP/GLU records at least 4 times a year; 2. had been consistently enrolled in the New Rural Cooperative Medical Scheme; 3. constantly reside in his/her own cluster, which was defined for at least 1 year before intervention and at least 6 month after and must ensure that have a complete BP record.

Exclusion criteria

Exclusion criteria: 1. To be had a stable BP/GLU history (consistently under 120/80 mmHg and 6.5 m mol/L) longer than 1 year and thus would not admit having chronic diseases or refuse to take medicines; 2. To be estimated for a life expectancy less than 2 years due to old age, venerable situations or severe complications such as cerebral infarction or pancreatic cancer, thus would potentially call for apparent extra samples; 3. There is a potential of getting lost in follow-ups with high chances to go out, which was recognized for at least 6 months away yearly during the intervention period for reasons as migration for work, education or kinship-care-seeking; 4. There is a potential of hardly visiting or investigating due to intellectual or activity incompetence; 5. To be with mental damage or communication incapable; 6. Refuse to cooperate due to personal reasons.

Design outcomes

Primary

Measure	Time frame
BP;GLU;system efficiency;Continuity of care;	—

Secondary

Measure	Time frame
Lifestyles;Collaboration degree;	—

Countries

China

Contacts

Public ContactLiang Zhang

zhangliang@mails.tjmu.edu.cn+86 139 086 20122

Outcome results

None listed