Diabetes management at the grass-root level without gatekeeping: exploring the association between primary care seeking and health outcomes

Sun et al. BMC Primary Care (2025) 26:347 https://doi.org/10.1186/s12875-025-03058-8 BMC Primary Care Open Access RESEARCH Diabetes management at the grass-root level without gatekeeping: exploring the association between primary care seeking and health outcomes Jiaqian Sun1, Sumit Kane3, Weijun Zhang4, Gaofeng Zhang2, Yongsong Luo5*, Jiayan Huang1* and Yin Dong2* Abstract Background In countries without a gatekeeping system, including China, promoting primary healthcare (PHC) utilization can improve system efficiency and reduce healthcare burden. However, evidence on diabetes patients’ PHC utilization and its impact on health outcomes remains limited. This study employs continuity of care (COC) to examine care-seeking behavior at PHC institutions in China and assess its association with clinical outcomes and healthcare costs. Methods We conducted a retrospective cohort study in Yuhuan, Zhejiang Province, China, including 3,672 patients newly diagnosed with diabetes between 2016 and 2019. Data from chronic disease management records, follow-up service records, and electronic medical records from 2020 to 2023 were linked. COC was assessed from 2020 to 2022 using standard measures including the Continuity of Care Index (COCI), Usual Provider of Care (UPC), and Sequential Continuity (SECON), as well as PHC-specific measures: the Primary Healthcare Index (PHCI) and a binary indicator for having the primary healthcare institution as the usual provider of care (PHC-UPC). We evaluated clinical outcomes (hospitalization, glycemic control) and healthcare costs in 2023. Logistic and linear regression models were used to assess association, adjusting for patient demographics and clinical characteristics. Results The mean PHCI was 0.73. Higher PHCI was significantly associated with decreased outpatient costs (P < 0.001), decreased inpatient costs (P < 0.001), and a lower likelihood of hospitalization (OR = 0.503, P < 0.001). Similarly, having used a PHC-UPC was associated with reduced outpatient and inpatient costs (P < 0.001) and a lower likelihood of hospitalization (OR = 0.708, P < 0.001). However, among patients with poorly controlled diabetes, neither PHCI nor having used a PHC-UPC showed a positive association with glycemic control (OR = 0.496, P = 0.003; OR = 0.629, P = 0.002). *Correspondence: Yongsong Luo Jiayan Huang Yin Dong Full list of author information is available at the end of the article © The Author(s) 2025. 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To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Sun et al. BMC Primary Care (2025) 26:347 Page 2 of 9 Conclusions Continuity at PHC significantly lowers hospitalization and healthcare costs in China’s non-gatekeeping system. However, no significant improvement in glycemic control among poorly controlled diabetes was observed. Strengthening PHC capacity for personalized diabetes management and timely hospital referrals is essential to optimize outcomes. Keywords Chronic disease management, Primary healthcare, Continuity of care, Healthcare utilization, Health outcomes Introduction The global prevalence of diabetes continues to rise, posing one of the most significant public health challenges of our time. As of 2022, an estimated 828 million adults aged 18 and older were living with diabetes—nearly double the number reported in 1990 [1]. Faced with such a growing burden of diabetes, healthcare systems around the world are under tremendous pressure to respond effectively. To address this challenge, the World Health Organization (WHO) has emphasized Primary Health Care (PHC) as the most appropriate and equitable framework for delivering personalized healthcare interventions for diabetes care [2]. Guiding diabetes patients to seek care at the PHC level has thus become a widely accepted global strategy. In countries with established gatekeeping systems, the majority of basic healthcare needs of patients with diabetes can typically be addressed at the PHC level [3]. Gatekeeping systems require patients to initially seek care at PHC institutions, where general practitioners (GPs) or family physicians provide initial diagnosis and treatment [4, 5] and refer patients to high-level facilities, such as hospitals for more advanced care only when necessary [6]. Often integrated with a family doctor model, this approach facilitates continuity of care (COC), in which family physicians deliver basic medical care and followup services while also monitoring patients’ health status and lifestyle behaviors [7]. However, many low- and middle-income countries have not yet established a fully implemented gatekeeping system [8]. For example, in China, although the basic medical insurance system has extensive coverage, ensuring that most residents have access to basic healthcare services, a nationwide gatekeeping system has not been implemented [9, 10]. Patients are generally free to bypass PHC institutions and seek care directly at secondary or tertiary hospitals without undergoing initial screening by PHC providers [11]. In this context, strengthening the capacity and attractiveness of PHC institutions has become a key policy lever to guide patients, particularly those with chronic diseases, towards local care. Recent reform, such as the hierarchical healthcare system and expanded family doctor contract services, has gradually enhanced PHC service capabilities [12, 13]. Yet, it remains unclear whether these efforts have effectively redirected patients with diabetes to PHC institutions. Existing studies have examined the healthcare-seeking behaviors among diabetes patients in China, often using the Continuity of Care (COC) index as an evaluation metric [14, 15]. COC refers to the experience where a series of discrete healthcare seeking events are treated as being coherent, connected, and consistent with the patient’s medical needs and personal context [16]. While these studies have found that higher COC is associated with improved health outcomes, few studies have specifically assessed the role of PHC institut (...truncated)