Importance Primary health care (PHC) systems worldwide face persistent workforce shortages, access barriers, and quality gaps. As patients increasingly turn to low-cost easily accessible AI chatbots for health advice, real-world evidence is needed on how patient-facing AI performs compared with PHC physicians. Objective To compare patient-facing AI chatbots with PHC physicians in diagnostic accuracy, clinical safety, and patient-centered communication using standardized patients in real-world PHC settings. Design, Setting, and Participants This standardized patient field experiment was conducted from February 6 to February 27, 2025, in 62 PHC institutions in China. Standardized patients (SPs) presented the same cases of unstable angina and asthma to 248 PHC physicians and to 2 widely used AI chatbots, ChatGPT-4o and DeepSeek-R1, on the same day. The analysis included 744 SP encounters. Exposures Consultation with a PHC physician, ChatGPT-4o, or DeepSeek-R1 for the same conditions. Main Outcomes and Measures Primary outcomes included diagnostic accuracy (correct diagnosis and correct medication), clinical safety (number and rate of unnecessary tests and medication prescribing), and patient-centeredness (range 1–4, with higher scores indicating more patient-centered communications). Results Among 248 PHC physicians, 66.9% were male and the mean (SD) age was 44.7 (9.4) years. Compared with PHC physicians, ChatGPT-4o and DeepSeek-R1 had higher rates of correct diagnosis (94.0% and 99.2% vs 30.6%; P<.001), correct medication recommendation (100.0% and 100.0% vs 35.4%; P<.001), and higher patient-centeredness scores (3.28 and 3.35 vs 2.55; P<.001), particularly in understanding the whole person and finding the common ground . However, both chatbots ordered more tests and recommended more medications than physicians, resulting in higher rates of unnecessary testing (90.3% and 96.4% vs 33.1%; P<.001) and inappropriate medication recommendations (73.4% and 62.1% vs 23.4%; P<.001). Findings were robust in multivariable regression models and when local physician performance was benchmarked against a nationally representative sample of PHC providers in China. Conclusions and Relevance In this field experiment, patient-facing AI chatbots had higher diagnostic accuracy and patient-centered communication scores than PHC physicians, but were substantially more likely to recommend unnecessary tests and inappropriate medications. These findings suggest that patient-facing AI may improve access to diagnostic and communicative support in under-resourced primary care, while also creating a risk of persuasive, AI-induced low-value care. Governance of patient-facing AI should therefore focus not only on diagnostic accuracy, but also on preventing excessive recommendations that may shape patient expectations before clinical encounters.

Primary health care quality is central to recent reforms in China, yet real-world evidence remains limited. This study aimed to assess the quality of primary care delivered by village clinics in rural China after primary health care reforms and to identify system-level drivers of performance gaps. We conducted an explanatory sequential mixed-methods study combining unannounced standardised patient (SP) visits with qualitative interviews and non-participant observation (direct observation of routine clinic practice without researcher involvement, included to contextualise clinician behaviour). Sixty-one unannounced SP visits were completed (influenza n = 30; tuberculosis n = 31). Fifteen participants were interviewed and 42 h of non-participant observation were conducted in six clinics. Outcomes included SP-assessed process quality, diagnostic accuracy and correct case management benchmarked to clinical guidelines. Qualitative analysis of determinants drew on Structure–Process–Outcome and the Consolidated Framework for Implementation Research. Process quality was low: clinicians completed 14.6

The association between exposure to inter-parental violence (IPV) and depression remains to be further explored. This study aimed to explore the association between childhood exposure to IPV and depression in middle-aged and older adults, and to explore the mediating roles between the two. Using data from the 2011, 2013, 2015, 2018, and 2020 China Health and Retirement Longitudinal Study (CHARLS), and the 2014 Life History Survey Questionnaire. Generalized estimating equation was used to investigate the relationship between childhood exposure to IPV and depression in middle-aged and older adults, the bootstrap method was used to analyse the mediating roles between the two, and multi-group analysis was used to examine the gender differences in their relationship. A total of 9,909 sample were included in the study. This study found 18.6

OBJECTIVES:The impact of concurrent adherence to antihypertensives, antidiabetics, and statins on cardiovascular disease (CVD) outcomes and intermediate clinical outcomes in people with hypertension and diabetes remains unclear. This study aimed to evaluate the association between medication adherence and CVD outcomes in such patients. METHODS:This retrospective cohort study analyzed the electronic medical records of 36,211 adults aged 18 or older diagnosed with hypertension and diabetes between January 2008 and June 2016 in Canada. Patients were prescribed antihypertensives, antidiabetics, and statins, with a minimum 1-year follow-up post-diagnosis. Medication adherence was determined by the proportion of days covered (PDC). For monotherapy, a PDC≥80% and <80% was reflected high and low adherence respectively. In multiple medication scenarios, adherence was considered high when each medication was at PDC≥80%; low when any medication fell below 80%. The primary outcome encompassed cardiac events, including coronary heart disease, stroke, and heart failure. Intermediate clinical outcomes included changes in diastolic blood pressure (DBP), Systolic Blood Pressure (SBP), glycated hemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC). Cox regression models assessed the association between medication adherence and CVD morbidity, all-cause mortality, and intermediate clinical outcomes. RESULTS:High adherence to antidiabetic and statin monotherapy was associated with a lower all-cause mortality risk (aHR=0.67, P=0.001; aHR=0.68, P<0.001, respectively). For patients simultaneously prescribed three medications, higher adherence was linked to significant reductions in DBP (6 months: coefficient -0.52, P=0.01; 12 months: coefficient -0.44, P=0.02; 18 months: coefficient -0.55, P=0.004) and LDL-C (6 months: coefficient -0.04, P=0.02; 12 months: coefficient -0.05, P=0.01; 18 months: coefficient -0.04, P=0.02). CONCLUSIONS:High adherence to antidiabetic and statin monotherapy correlated with lower all-cause mortality risk and improved intermediate clinical outcomes. However, simultaneous adherence to three medications did not significantly affect CVD outcomes, but influenced intermediate outcomes. Therefore, improving adherence to antihypertensives, antidiabetics, and statins among patients with hypertension and diabetes is important in primary care settings.

This study aims to identify the role and pathways through which social class plays a part in the impact of the social environment on residents’ health. Using data from the China General Social Survey 2021, we analyzed a sample of 2715 participants to assess the role and pathways of social class in the influence of the social environment on residents’ health. We employed the Ordinary Least Squares model to quantify the impact of the social environment on residents’ health and utilized the Karlson-Holm-Breen method along with the construction of product terms to estimate the mediating and moderating effects of social class. To address endogeneity, we conducted robustness tests using the instrumental variable method. Our findings indicate that in the process of the social environment’s impact on residents’ health, social class acts as a moderator, functioning with an approximate effect of 20%. In terms of the pathway of action, this moderating function is realized by exerting an influence on residents’ mental health. When analyzing the social determinants of health, it is necessary to consider the significant role played by social class and to pay more attention to the potential impact of the mental health of different social classes on their overall health.

BackgroundTreatment non-adherence poses a serious risk to survival and hinders the improvement of tuberculosis (TB) control effectiveness in Inner Mongolia, China. To improve treatment adherence and health outcomes in Inner Mongolia, this study aims to maximize the impact of an electronic monitor and smartphone app (EM program) by developing interventions that optimize the EM program, putting it into practice and evaluating it, and developing scale-up activities of the optimized EM program.MethodsFirst, a Consolidated Framework for Implementation Research will be used to assess the implementation of electronic monitors to improve treatment adherence and health outcomes for TB patients in China and identify the facilitators and barriers. Second, we will use the Expert Recommendations for Implementing Change protocol to identify appropriate implementation strategies to optimize the EM program in the Inner Mongolian context. Third, the optimized EM program will be implemented and assessed during a 12-month pragmatic, parallel, cluster-randomized trial in three chosen cities in Inner Mongolia. The treatment adherence of TB patients will be the main result. The secondary outcomes will be TB treatment outcomes as defined by the World Health Organization, including the treatment completion rate, loss to follow-up rate, treatment failure rate, and treatment-related deaths. Based on the RE-AIM framework, the impact of the improved EM program will also be assessed in comparison to standard care for the subsequent secondary outcomes (reach, effectiveness, adoption, implementation, and maintenance).DiscussionThis study will be the first to develop and implement interventions that improve the treatment adherence and health outcomes of TB patients in addition to developing strategic options for the scalability and generalizability of the optimized interventions in remote areas of China and other low- and middle-income countries. All intervention activities will be developed for incorporation into regular TB care, with strong local ownership. Through the trial, we hope to uncover more information about the long-term effects, efficacy, cost-effectiveness, and practicability of our intervention.Trial registrationISRCTN15169616. Registered on 29 July 2023.

A significant relationship is present between childhood hunger experiences (CHEs) and health, but explorations of the longitudinal persistence of this relationship and its mediating mechanisms are still lacking. This study aims to evaluate the effects of CHEs on health in middle and old age and determine the underlying mechanisms. Using data from the five 2011—2020 China Health and Retirement Longitudinal Study (CHARLS) and the 2014 China Life History Survey Questionnaire, a sample of 9,909 individuals aged 45 years and older who participated in all six surveys was obtained. We conducted panel analyses, used Probit and ordinary least squares regression models to analyze the effects of CHEs on the health in middle and old age, and used stepwise regression tests to analyze the mediators of the relationship. CHEs significantly predicted self-assessment of health (β = −0.18; 95

Social adaptability is essential for healthy aging. This study examines how Contracted Family Doctor Services (CFDS) affect social adaptability in rural Chinese middle-aged and older adults, assessing the mediating role of regular health management (RHM). Using national cross-sectional data from the 2018 China Health and Retirement Longitudinal Study (CHARLS), we analyzed 13,895 community-dwelling adults. We employed generalized linear models (GLM), mediation analysis, and an instrumental variable-based control function approach (IV-CFA) to evaluate causality and control for confounding. Research demonstrated that CFDS participation was significantly associated with enhanced social adaptability (β = 0.204, p < 0.01). RHM partially mediated this relationship, explaining 29.5

Background:The global prevalence of depression is on the rise, and has evolved into a major public health concern. Given that parental favouritism in childhood exerts a long-term impact on children's mental health, we aimed to explore its association depression in old age. Methods:We retrieved 19 180 data points from 3836 individuals aged 60 years and over from the China Health and Retirement Longitudinal Study 2011, 2013, 2015, 2018, and 2020 waves, among whom depression was measured using the Centre for Epidemiological Studies Depression Scale. We used logistic analysis to determine the relationship between parental favouritism in childhood and depression in old age, and the bootstrap method to analyse the mediating role of smoking, drinking, socialising, exercising, and sleep duration. Results:Approximately 17% of older adults experienced parental favouritism during childhood. We found that parental favouritism significantly increased the probability of depression by 29.9% (β = 0.299; 95% confidence interval (CI) = 0.145, 0.453), as did mother's favouritism by 28.4% (β = 0.284; 95% CI = 0.117, 0.450), and father's favouritism by 23.6% (β = 0.236; 95% CI = 0.058, 0.415). Socialising (β = -0.0018; 95% CI = -0.0028, -0.0009), exercising (β = 0.0009; 95% CI = 0.0003, 0.0017), and sleep duration (β = 0.0046; 95% CI = 0.0015, 0.0076) mediated this relationship. An analysis of heterogeneity by gender found that women are more influenced by parental favouritism. Conclusions:Parental favouritism in childhood significantly predicts the probability of depression in old age. Promoting socialising, exercising, and sleep duration could help to alleviate this issue. We also noted that women are more influenced by parental favouritism. These findings provide guidance for targeted interventions, such as mental health screening and promotion of healthy lifestyles.

Tuberculosis remains a public health concern, and electronic monitors show promise in improving treatment adherence and health outcomes among patients with tuberculosis. This Review aims to provide a comprehensive understanding of the implementation barriers and facilitators of electronic monitors for patients with tuberculosis, by use of an implementation science framework. A literature search was done across Ovid MEDLINE, CINAHL, Embase, Cochrane Library, Web of Science, and Global Health databases from their inception to April 25, 2024. Studies reporting on the barriers and facilitators of electronic monitors among patients with tuberculosis were included and study characteristics and evidence were tabulated. Implementation factors were synthesised applying the updated Consolidated Framework for Implementation Research framework. This Review was registered with PROSPERO (CRD42023395747). Of 8816 records, 31 eligible studies were included. Barriers mainly included the information technology infrastructure, materials, and equipment resources, whereas facilitators included access to knowledge and information, communications, and reflecting and evaluating. Innovation design and patients' motivation were identified as both common barriers and facilitators. Inter-relationships between these factors were also explored. Cooperative and patient-centred efforts are required to address the barriers identified. Specific recommendations include improving education and training, eliminating stigma, and resolving technical challenges with feedback to boost patients' treatment adherence and outcomes.

Poor adherence to anti-tuberculosis treatment is a main threat for the treatment success. Digital health interventions such as electronic monitors (e-monitors) and the WeChat application (app) may improve treatment adherence in TB patients. The study aimed to examine the key facilitators, barriers, and drivers of barriers of implementing e-monitors and the WeChat app. Personal, semi-structured interviews with workers in healthcare institutions in three cities in Inner Mongolia were conducted between June and December 2023 when e-monitors and the WeChat app were introduced as part of a TB treatment strategy. The consolidated framework for implementation research (CFIR) was used to develop interview questions. A total of 143 healthcare workers were interviewed. The key facilitators included the e-monitors helped to improve medication adherence. Second, the intervention itself was cost-effective. Respondents took the initiative to learn about the intervention. Finally, the indicators were implemented through a top-down process, which increased the efficiency of the implementation of this policy decision. The key barriers were insufficient external financial incentives, available resources are inadequate in primary healthcare setting, negative attitudes of the implementers, a lack of feedback in implementation. Drivers of barriers included the values with limited utility of the intervention, rigid organizational administrative hierarchy, and rights and responsibilities mismatch. policymakers should pay attention to the barriers and its drivers to implementing the intervention. Adherence to patient-cantered, cultivate a teamwork atmosphere, and improve incentives and performance evaluation systems are necessary to improve the implementation of the intervention. ISRCTN15169616. Registered on 29 July 29, 2023

Social adaptability is an important aspect of health. This study aimed to investigate the association between the community-based family doctor system (CFDS) and social adaptability and test the mediating effect. We used cross-sectional data from the 2018 China Health and Retirement Longitudinal Survey. A total of 13,895 samples were included. The OLS model, mediated effects model, and instrumental variables method were used for analysis. This study reveals a significant positive association between the CFDS and higher social adaptability among the middle-aged and older people in rural China. Outpatient utilization and life satisfaction were found to play a partial mediating role between the CFDS and social adaptability. Heterogeneity analyses revealed that the benefits of the CFDS varied across groups. It is necessary to improve the contracting rate of the CFDS among middle-aged and older populations in rural areas needs improvement. Additionally, family doctors should enhance their ability to detect health risks and diversify their services to cater to diverse needs.

Hunger is an important public health issue. This study aims to explore the impact of childhood hunger experiences (CHEs) on activities of daily living (ADL) disability and to discover the mediating role of depression on this correlation. Data were derived from the China Health and Retirement Longitudinal Study 2011, 2013, 2015, 2018, and 2020. Depression was assessed using the Centre for Epidemiological Studies Depression Scale. ADL disability, basic ADL (BADL) disability and instrumental ADL (IADL) disability were assessed using the ADL scale. The relationships between CHEs, depression and ADL disability were estimated using probit methods, and the mediating effect of depression was estimated using the stepwise regression test and bootstrap methods. A total of 9,905 sample were included in the study. The study found that CHEs increased ADL disability by approximately 9.1

Abstract Background This study aimed to investigate the utilization rate and equity of health examination service among the middle-aged and elderly population in China from 2011 to 2018. The contribution of various determinants to the inequity in health examination service utilization was also examined. Methods Data from the China Health and Retirement Longitudinal Survey (CHARLS) were analyzed to assess the health examination service utilization rate among the middle-aged and elderly population. A concentration curve and concentration index were employed to measure the equity of health examination service utilization and decomposed into its determining factors. Horizontal inequity index was applied to evaluate the trends in equity of health examination service. Results The health examination service utilization rates among the middle-aged and elderly population were 29.45%, 20.69%, 25.40%, and 32.05% in 2011, 2013, 2015, and 2018, respectively. The concentration indexes for health examination service utilization were 0.0080 (95% CI: − 0.0084, 0.0244), 0.0155 (95% CI: − 0.0054, 0.0363), 0.0095 (95% CI: − 0.0088, 0.0277), and − 0.0100 (95% CI: − 0.0254, 0.0054) from 2011 to 2018, respectively. The horizontal inequity index was positive from 2011 to 2018, evidencing a pro-rich inequity trend. Age, residence, education, region, and economic status were the major identified contributors influencing the equity of health examination service utilization. Conclusions A pro-rich inequity existed in health examination service utilization among the middle-aged and elderly population in China. Reducing the wealth and regional gap, providing equal educational opportunities, and strengthening the capacity for chronic disease prevention and control are crucial for reducing the inequity in health examination service utilization.

Download This Paper Open PDF in Browser Add Paper to My Library Share: Permalink Using these links will ensure access to this page indefinitely Copy URL Copy DOI

Abstract Previous research on the association between Family Doctor Contract Services (FDCS) and health has only considered a single indicator of health and has not considered the endogeneity of independent variables. This study aimed to evaluate the association from a multidimensional perspective of the health of middle-aged and older people using the instrumental variables method and determine the underlying mechanisms. Using data from the 2018 China Health and Retirement Longitudinal Study surveys, a total of 19,438 sample was obtained. Health was measured by health related-quality of life (HR-QoL), subjective well-being, and cognitive function. The instrumental variables method was used to estimate the association. Mediation analysis was employed to analyze the underlying mechanisms. The results of the instrumental variables method showed a correlation between FDCS and health, such as HR-QoL (η = 33.714, p < 0.01), subjective well-being (η = 1.106, p < 0.05), and cognitive function (η = 4.133, p < 0.05). However, we found no evidence that FDCS improved physical health. We also identified reduced utilization of healthcare services and increased social activities as mediators of the effect of FDCS on health. The Chinese government should improve incentive-based initiatives to improve the quality of FDCS. Moreover, more attention needs to be paid to the multidimensional health of middle-aged and older people, especially vulnerable groups, such as older individuals and those in rural areas.

背景"以患者为中心"对基层公立医疗机构的医患沟通方式和医患关系重构提出了更高要求.目的 分析"以患者为中心"的医患沟通对医疗服务质量的影响,为促进基层公立医疗机构改革提供相关科学依据.方法 选择内蒙古自治区某市主城区内所有提供基本医疗服务的公立社区卫生服务中心为研究现场,于 2021 年采用标准化病人法开展了现场调查.本次调查包括由来自 26 家医疗机构的 59 名医生和 12 名标准化病人产生的 118 条医患沟通数据.本研究选择感冒、哮喘和不稳定型心绞痛作为标准化病人所要扮演的疾病类型.结合多元回归模型和Probit模型,评估"以患者为中心"的医患沟通对医疗服务质量的影响.结果 由 118 条医患沟通数据得出的结果显示,中位推荐问诊条目依从性为17.6%(14.6%),中位推荐检查条目依从性为25.0%(40.0%);其中75条(63.6%)诊断正确,59 条(50.0%)治疗正确;中位总费用为 84.84(130.44)元,中位药物费用为 37.62(47.38)元;其中 66条(55.9%)有不必要药物,71条(60.2%)有不必要检查;中位就诊时间为13.625(10.850)min;"以患者为中心"的医患沟通平均得分为(26.712±10.658)分,第一维度得分为(12.915±5.355)分,第二维度得分为(7.492±2.867)分,第三维度得分为(6.305±3.465)分.多元线性回归模型和Probit模型结果显示,"以患者为中心"的医患沟通总得分每增加1分,推荐问诊条目依从性提高0.001个百分点,推荐检查依从性增加0.001个百分点,诊断正确率平均上升4.6个百分点,治疗正确率上升 4.2 个百分点,总费用提高 1.993 元,药物费用提高 0.517 元,不必要药物比例下降 3.4 个百分点,不必要检查比例增加 0.2 个百分点,就诊时间减少 0.291 min.结论 "以患者为中心"的医患沟通增加了医疗服务的有效性和安全性,但也提高了医疗费用.需要从资源禀赋、薪资激励、医患关系、协同服务四方面促进"以患者为中心"的医患沟通,进而提高医疗服务质量.

BackgroundDepression in chronic disease patients was an important public health problem. However, limited work has been done on how to alleviate the depression of chronic disease patients. This paper attempted to explore the alleviating effect of health insurance and health service quality. MethodsA total of 11,500 middle-aged and elderly people were drawn from four waves (2011, 2013, 2015, and 2018) of the China Health and Retirement Longitudinal Study (CHARLS). We analyzed the effect of chronic disease on depression in middle-aged and elderly people in China, and explored the mechanism of action from health insurance and health service quality. ResultsAfter adjusting for sociodemographic factors, any chronic disease (coefficient 1.471, p < 0.01) and multiple chronic diseases (coefficient 1.733, p < 0.01) could significantly increase the depression score. Any chronic disease increased the depression score (165.3 and 147.4% in non-health insurance group and health insurance group, respectively), the multiple chronic diseases increased the depression score (190.6 and 173.5% in non-health insurance group and health insurance group, respectively). Any chronic disease increased the depression score (161.3 and 139.5% in lower health service quality group and higher health service quality group, respectively), the multiple chronic diseases increased the depression score (228.4 and 162.9% in lower health service quality group and higher health service quality group, respectively). And similar results were obtained after using depression status instead of depression score. ConclusionsChronic disease and multiple chronic diseases were important determinants of depression in middle-aged and elderly people. Health insurance and health service quality were the key factors in relieving the depression of chronic disease patients. Several strategies were urgently needed: paying attention to the mental health of chronic disease patients, increasing the participation rate of health insurance, further improving the quality of health service, and alleviating the psychological harm caused by chronic disease.

Background Tuberculosis (TB) has been regarded as ‘a relentless scourge’, increasing morbidity and mortality and burdening vulnerable populations. Poor adherence to TB treatment and ineffective traditional interventions hinders TB control. A novel TB approach called ‘electronic monitors’, equipping medication boxes with daily audio or visual reminders for electronically monitoring medication intake, seems promising in improving adherence and health outcomes and overcoming the weaknesses of traditional interventions. However, no review has systematically examined and synthesized the influencing factors of implementing electronic monitors. Implementation research offers the means to analyse the influencing factors of the implementation and its process, fitting well with the aim of this review. Therefore, the widely recognized Consolidated Framework for Implementation Research (CFIR), which offers a common taxonomy for evaluating intervention implementation, will be adopted to systematically identify barriers and facilitators of the electronic monitors for improving adherence and health outcomes in patients with TB. Methods and analysis The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature research will be conducted in five electronic databases (Ovid MEDLINE, CINAHL, EMBASE, Cochrane Library and Web of Science) to identify the barriers and facilitators of implementing electronic monitors in patients with TB. The CFIR will be used as a guide for categorizing and synthesizing the barriers and facilitators. Study screening, data extraction, quality appraisal and data analysis will be conducted by two independent reviewers. The use of additional reviewers will solve any disagreements between the two reviewers. Discussion Given the increased prominence of TB epidemiology and the adherence problem of electronic monitors, there is a solid rationale for synthesizing the existing studies via the CFIR. The findings and conclusion of this review will lay bare the achievements and effectiveness of implementing electronic monitors, as well as the attendant gaps and limitations. Further strategies for facilitating the implementation of electronic monitors will also be explored. This review will be of essential significance for research and practice, supporting future academic research initiatives centred on patients with TB and aiding electronic monitor design in lowering the morbidity and mortality associated with TB disease. Trial registration number: PROSPERO: CRD42023395747.