Impact of family doctors on gradient utilization of health services among diabetic patients: evidence from a real-world study.

Objective: The family doctor system plays a crucial role in promoting the gradient utilization of health resources. However, empirical evidence regarding the use of health services across different levels of care by diabetic patients under family doctor contracts remains limited. This study aimed to investigate the impact of the family doctor system on the gradient utilization of health services among diabetic patients using real-world data.

Methods: We conducted an eight-year cohort study in Shanghai from 2014 to 2021, with a final sample size of 491,674 participants, including 459,600 contracted and 32,074 non-contracted patients. We employed inverse probability weighted regression adjustment (IPWRA) and zero-inflated negative binomial regression models to estimate the net effects. Among contracted patients, 52.08% were female, with an average age of 66.31 years; in comparison, non-contracted patients were younger, and over 60% resided in urban areas. The annual number of outpatient and inpatient visits was 32.47 and 0.42 for contracted patients, and 34.63 and 0.35 for non-contracted patients, respectively.

Results: Study results showed that, outpatient visits decreased across all levels of hospital (coef. = -7.37%, IRR = 0.92 P < 0.01), with a more pronounced reduction in secondary and tertiary hospitals compared to community health centers. This translated to a notable decrease of 2.43 days in the total number of outpatient visits. Conversely, hospitalization rates increased, particularly in community health centers (coef. = 26.88%, IRR = 1.30, P < 0.01). Overall, the data suggest that having a family doctor is associated with reduced outpatient visits, especially in higher-level hospitals, while hospitalizations are more concentrated in community health centers.

Conclusion: Hospitalization rates can be reduced through targeted measures: strengthening early screening for diabetic complications; implementing a health-focused digital management system with outcomes-linked performance evaluations; enhancing clinical decision support and re mote monitoring systems to enable timely interventions by family doctors; developing clear referral protocols to minimize unnecessary hospital admissions; and conducting regular competency training for primary care providers.