Construction of an Evaluation Indicator System for the Effectiveness of Integration of Medical Care and Preventive Services for Chronic Diseases at the Primary Care Level

Yike Wang, Xianghe Cheng, Ling Lin, Guilin Liu, Jinghui Zhu, Xiao Li

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¹ School of Medical Humanities and Management, Wenzhou Medical University, China,

² Yongxing Street Community Health Service Center, Longwan District, Wenzhou City, China,

³ Puzhou Street Community Health Service Center, Longwan District, Wenzhou City, China,

ssr 2026 , 8(6), 47–59; https://doi.org/10.26689/ssr.v8i6.15392

Abstract

China’s primary healthcare system has vigorously promoted the integration of medical care and preventive services for chronic disease management, yet a mature and validated evaluation tool to quantify its operational effectiveness is still lacking. This study aimed to construct a scientific and practical evaluation indicator system to fill this research gap. Two rounds of Delphi expert consultation were conducted with 15 invited experts, and the Analytic Hierarchy Process (AHP) was applied to determine the weight of each indicator. The finalized system consists of six primary dimensions, including service team building, service facility configuration, service process implementation, medical service effectiveness, health behavior management effectiveness, and service cost control, along with 32 secondary indicators. The established indicator system can provide a methodological reference for researchers and policy-makers to scientifically assess the real-world performance of the integration of medical care and preventive services at the primary care level.

References

Lin XD, 2023, A Study on Influencing Factors and Mechanisms of Health-promoting Lifestyle among Patients with Chronic Diseases, thesis, Guangzhou: Southern Medical University.

Liu MB, He XY, Yang XH, et al., 2025, Interpretation of Key Points of the Hypertension Chapter in the China Cardiovascular Health and Disease Report 2024. Chinese Journal of Hypertension (Chinese & English), 33(12): 1138–1141.

Central Committee of the Communist Party of China, State Council, 2016, Outline of the “Healthy China 2030” Plan. https://www.gov.cn/zhengce/2016 10/25/content_5124174.htm

National Health Commission of the People’s Republic of China, 2018, Notice on the 2018 Family Doctor Contract Service Work. https://www.nhc.gov.cn/jws/c100073/201804/abc630c492914e2c8ed6a3790dba1fff.shtml

Zhao YL, Gu ZP, Zhang XY, 2024, Progress and Challenges in Integrating Medical Treatment and Prevention for Non-communicable Diseases. Chinese General Practice, 27(36): 3953–3957.

Zhu X, Chen AY, 2023, Implications of Classic Chronic Disease Management Models Abroad for Chronic Disease Management in China. Chinese General Practice, 26(1): 21–26.

Martin JL, Lowrie R, Mcconnachie A, et al., 2015, Physical Health Indicators in Major Mental Illness: Data from the Quality and Outcomes Framework in the UK. Lancet, 2015(385): S61–S61.

Polanco NT, Zabalegui IB, Irazusta IP, et al., 2015, Building Integrated Care Systems: A Case Study of Bidasoa Integrated Health Organisation. International Journal of Integrated Care, 2015(15): e026.

Ku GMV, van de Put W, Katsva D, et al., 2024, A Framework for Chronic Care Quality: Results of a Scoping Review and Delphi Survey. Global Health Action, 17(1): 1–19.

Chen ZR, Zheng Y, Dai T, et al., 2018, Evaluation Framework for Integrated Healthcare Service System. Chinese Journal of Health Policy, 11(1): 29–35.

Ren GY, Jiang ZY, Hong ZM, et al., 2020, Performance Index Evaluation System for Integrated Health Services and Empirical Study. Health Economics Research, 37(11): 16–20.

Guo J, Sun HJ, Chen Y, et al., 2023, Construction of an On-Site Evaluation Indicator System for the Quality of Integrated Medical and Preventive Care for Chronic Diseases in Primary Healthcare Institutions. Chinese General Practice, 26(7): 840–847.

Li Y, Huang H, Shi JW, et al., 2026, Key Mechanisms and Optimization Strategies for Implementing Integrated Medical and Preventive Care Business Models for Chronic Diseases in Primary Healthcare Institutions. Chinese General Practice, 29(1): 108–114.

Donabedian A, 1988, The Quality of Care: How can it be Assessed? JAMA: The Journal of the American Medical Association, 260(12): 1743–1748.

Zhang BL, 2022, Construction of a Nursing Quality Evaluation Indicator System for Adult Liver Transplant Recipients and Preliminary Application of Indicator Monitoring, thesis, Qingdao: Qingdao University.

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