Effectiveness of hierarchical medical system policy: an interrupted time series analysis of a pilot scheme in China

The Chinese healthcare system faces a dilemma between its hospital-centric approach to healthcare delivery and a rapidly ageing population that requires strong primary care. To improve system efficiency and continuity of care, the Hierarchical Medical System (HMS) policy package was issued in November 2014 and fully implemented in 2015 in Ningbo, Zhejiang province, China. This study aimed to investigate the impact of the HMS on the local healthcare system. We conducted a repeated cross-sectional study with quarterly data collected between 2010 and 2018 from Yinzhou district, Ningbo. The data were analysed with an interrupted time series design to assess the impact of HMS on the changes in levels and trends of three outcome variables: primary care physicians’ (PCPs’) patient encounter ratio (i.e. the mean quarterly number of patient encounters of PCPs divided by that of all other physicians), PCP degree ratio (i.e. the mean degree of PCPs divided by the mean degree of all other physicians, with the mean degree revealing the mean activity and popularity of physicians, which reflected the extent to which he/she coordinated with others in delivering health services), and PCP betweenness centrality ratio (i.e. the mean betweenness centrality of PCPs divided by the mean betweenness centrality of all other physicians; the mean betweenness centrality was interpreted as the mean relative importance of physicians within the network, indicating the centrality of the network). Observed results were compared with counterfactual scenarios computed based on pre-HMS trends. Between January 2010 and December 2018, 272 267 patients visited doctors for hypertension, a representative non-communicable disease with a high prevalence of 44.7% among adults aged 35–75 years, amounting to a total of 9 270 974 patient encounters. We analysed quarterly data of 45 464 observations over 36 time points. Compared to the counterfactual, by the fourth quarter of 2018, the PCP patient encounter ratio rose by 42.7% [95% confidence interval (CI): 27.1–58.2, P < 0.001], the PCP degree ratio increased by 23.6% (95%CI: 8.6–38.5, P < 0.01) and the PCP betweenness centrality ratio grew by 129.4% (95%CI: 87.1–171.7, P < 0.001). The HMS policy can incentivize patients to visit primary care facilities and enhance the centrality of PCPs within their professional network.