Primary Care–Based COPD Management Under Different Family Doctor Contract Service Arrangements: A Comparative Qualitative Study

Abstract

BackgroundChronic obstructive pulmonary disease (COPD) has recently been incorporated into China’s Basic Public Health Services package (BPHS), with family doctor contracting services (FDCS) positioned as a key mechanism to strengthen chronic disease management. This study specifically aimed to compare different team management model of Suzhou and Shanghai FDCS in term of COPD management, to understand the experiences and perceptions of multiple stakeholders including primary healthcare providers, hospital physicians and patients, and to identify key challenges and underlying mechanisms influencing implementation in real-world settings. Methods A qualitative study was conducted in two economically developed eastern Chinese cities between April and July 2025. Participants including 12 family doctors, 5 nurses, 1 health coordinators, 5 hospital physicians, and 8 patients were recruited using purposive sampling. Semi-structured interviews were analyzed using thematic analysis. Results In Suzhou and Shanghai, COPD management is organized through distinct primary care approaches with different team arrangements. In Suzhou, management is primarily led by family doctors under a “3+N” model, typically comprising a core team of a family doctor, a nurse, and a public health physician, supported by additional members (e.g., specialists or other staff) as needed. In contrast, in Shanghai, COPD management is delivered through a more vertically integrated team arrangement, in which family doctors collaborate closely with hospital-based physicians who provide regular clinical support, resulting in a more clearly defined division of responsibilities across care levels. Despite these differences in organizational approach, similar challenges were observed across both settings, reflecting constraints across multiple health system components. These included unclear task allocation related to leadership and governance, limited incentives for proactive follow-up of COPD patients associated with financing arrangements, workforce constraints, inconsistent accessibility of essential inhaled medicines for COPD treatment, insufficient access to spirometry for COPD diagnosis and monitoring, and fragmented information systems that hindered referral coordination. As a result, key components of COPD care including early screening, stable-phase management, and continuity of care were not systematically implemented. Participants proposed strengthening cross-tier coordination, clarifying operational responsibilities, integrating COPD into existing chronic disease workflows, and institutionalizing early screening and structured health education to improve implementation feasibility and patient engagement. Conclusion This study found that differences in FDCS team management models between Suzhou and Shanghai did not lead to substantial variation in COPD management practices or challenges. Instead, similar barriers were observed across both settings, particularly in limited access to essential inhaled medications and spirometry, which constrained service delivery and reduced patient engagement in primary care. These challenges were rooted less in team structure and more in broader health system constraints, including misalignment in leadership, financing, and resource allocation. Within the existing BPHS framework, strengthening institutional support and clarifying responsibilities across tiers may be more critical than modifying FDCS team management structures.