Navigating Fragmented Care: A Qualitative Study on Multimorbidity Management Challenges in Beijing’s Tiered Healthcare System

Navigating Fragmented Care: A Qualitative Study on Multimorbidity Management Challenges in Beijing’s Tiered Healthcare System | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Navigating Fragmented Care: A Qualitative Study on Multimorbidity Management Challenges in Beijing’s Tiered Healthcare System Conglei You, Jingyi Zhao, Tengyang Fan, Lingling Wang, Lijuan Zhang, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6860604/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Aug, 2025 Read the published version in BMC Primary Care → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Multimorbidity is a growing public health concern, especially in countries with aging populations. Although a tiered healthcare system has been implemented to improve primary care, managing patients with multimorbidity has been challenging. Methods: This study conducted focus group discussions involving 21 patients with multimorbidity in Beijing viaa flexible topic guide to explore their experiences. Participants were sampled from urban and rural areas, ensuring a diverse representation of demographics and health conditions. The datawere analyzed using the framework method. The themes and subthemes were identified through iterative coding and discussion. Results: Four main themes emerged: (1) Living with multimorbidity, where patients view chronic conditions as an inevitable part of aging but strugglewith self-management, particularly medication adherence and lifestyle modifications; (2) healthcaresystem fragmentation, driven by ineffective tiered policies and digital exclusion, especially among elderly patients; (3) financial burdens, with rural patients facing greaterout-of-pocket costs due to insurance inequities and policy-induced strains; and (4) doctor-patient dynamics, where communication gaps and a lack of continuity hinderpatient-centered care. Patients emphasized the need for better care coordination, financial support, and empathetic communication. Conclusion: This study underscores systemic gaps in China's healthcare system for multimorbidity care. To address these issues, policymakers should prioritize (1) strengthening primary care coordination through multidisciplinary teams, (2) expanding financial protection for chronic disease management to reduce urban-rural disparities, and (3) training providers in patient-centered communication and shared decision-making. These actionable steps can serve as a blueprint for LMICs aiming to build integrated, patient-centered systems for multimorbidity management. Multimorbidity Qualitative study Healthcare experiences China Background Multimorbidity, which is defined as the co-occurrence of two or more chronic conditions in individuals [ 1 ], is a major public health challenge worldwide, especially in countries with aging populations [ 2 ]. The prevalence of multimorbidity is rapidly increasing. Recent epidemiological data have suggested that multimorbidity affects more than 50% of adults aged ≥ 60 years worldwide [ 3 ]. The prevalence of multimorbidity is especially high in low- and middle-income countries (LMICs), including China [ 4 ]. Some studies have reported that the incidence rates of multimorbidity are 45.5–56.73% among middle-aged and older adults [ 5 , 6 ]. Thus, multimorbidity has adverse effects on health outcomes, healthcare utilization, and quality of life. Multimorbidity adversely affects health outcomes, healthcare utilization, and quality of life, leading to poor functional status, increased frailty, and increased mortality rates [ 7 – 9 ]. Managing these patients is complex, as their needs extend beyond single-disease frameworks, requiring integrated care models [ 10 ]. However, healthcare systems in LMICs, including China, remain fragmented, prioritizing acute and single-condition management over coordinated care [ 11 , 12 ]. This disconnect results in polypharmacy challenges, uncoordinated specialist visits, and significant financial burdens for patients [ 13 ]. The Chinese government has recognized the need for an integrated healthcare system to address the growing burden of multimorbidity. In 2015, policy guidelines were introduced in China to develop a hierarchical diagnosis and treatment system to optimize healthcare delivery by categorizing diseases based onseverity and complexity and assigning them to appropriate levels of care [ 14 ]. However, the implementation of this system has been associated with various challenges. The limited professional competence of primary healthcare personnel and the absence of stringent protocols mandating primary healthcare providers as the initial point of contact have resulted in patients frequently preferring general hospitals over primary healthcare institutions [ 15 , 16 ]. This has led to an underdeveloped primary care system that cannot effectively meet the needs of patients with multimorbidity. Beijing, China's capital, serves as a critical hub for political, economic, and cultural activities and is a pioneer in the nation's healthcare planning. However, Beijing faces several challenges in healthcare resource distribution, including a shortage of primary healthcare services and structural imbalances in health resources [ 17 ]. Additionally, the aging population of Beijing is rapidly increasing, and the city will enter a phase of moderate aging in 2021 [ 18 ]. The prevalence rates of multimorbidity among older adults in Beijing increased from 32.5% in 2004 to 53.2% in 2017 [ 19 ]. Thus, Beijing is an ideal setting for studying the healthcare experiences of patients with multimorbidity and identifying systemic issues that need to be addressed. Despite the increasing burden of multimorbidity, few studies in China have explored patients’ lived experiences within this tiered system. Existing research focuses on prevalence and disease burden, leaving critical gaps in understanding patient perspectives on access, coordination, and communication [ 20 ]. Qualitative research offers a valuable perspective for understanding these experiences, providing insights into how individuals manage their conditions, interact with the healthcare system, and perceive their care [ 21 ]. These insights are crucial for designing healthcare services that meet the needs of patients with multimorbidity and for informing policy and practice improvements. This study examined the healthcare experiences of patients with multimorbidity in Beijing, focusing on challenges in access, care coordination, and financial burdens. Second, systemic barriers within China’s tiered healthcare system that hinder effective multimorbidity management should be identified, and targeted interventions to improve care integration and patient outcomes should be identified. By addressing these gaps, this study seeks to contribute evidence for policies that align healthcare delivery with the complex needs of patients with multimorbidity. Methods Study Design This study employed a qualitative research design with focus groups to minimize the influence of social distance between the facilitator and participants on the discussions and facilitate the exploration of complex issues and the sharing of experiences through group interaction. The study was underpinned by a phenomenological approach to explore participants' lived experiences of multimorbidity. A flexible topic guide was used to encourage open discussion and comprehensively address the key issues relevant to the investigation of multimorbidity experiences. The topic guide was developed through consensus among all researchers according to the study’s purpose and systematic review of the literature on multimorbidity. The guide was pilot-tested with one focus group (n = 4) to refine question clarity and flow. The Focus group discussion guide is available in the online supplement. The research team comprised clinicians and public health researchers with expertise in qualitative methodologies and multimorbidity management. The principal researcher (MY&CLY) is a general practitioner (GP) with over a decade of clinical experience in primary care, and dedicated to qualitative research. MY (a male PhD, who has conducted public health research at the University of Birmingham in the UK) conducted all the focus group discussions as a facilitator, whereas JYZ (a female GP with rich multimorbidity management experience) was a co-facilitator. Both facilitators received formal training in qualitative methods, including bracketing techniques, to minimize preconceptions during data collection. Interviews were conducted face-to-face, with each focus group comprised 3–5 patients. Each focus group lasted approximately 60–90 minutes. Sessions were audio-recorded and supplemented by field notes documenting non-verbal cues and contextual observations. Only researchers and participants were present during discussions. Recruitment The recruitment and focus group discussions occurred from July 2023 to December 2024. A purposive sampling strategy was employed to ensure diversity across key dimensions relevant to multimorbidity experiences, including the following: (1) Geographic location: participants were sampled from urban (Dongcheng District) and rural (Miyun District) areas of Beijing to capture disparities in healthcare access; (2) socioeconomic status: various educational backgrounds (junior high school or below to college or above) and employment status (retired, farmer, working) were included; (3) clinical complexity: participants were selected on the basis of the duration of multimorbidity and the number of chronic conditions; and (4) insurance type: enrollment included urban employee basic medical insurance (UEBMI), urban resident basic medical insurance (URBMI), and the New Rural Cooperative Medical Scheme (NRCMS) to reflect financial inequities. The participants were recruited from one tertiary hospital (Peking University First Hospital), one community health center (Donghuashi Community Health Service Centre) in an urban setting, and one rural hospital (Miyun Hospital) to ensure institutional diversity. The eligibility criteria were as follows: age > 18 years, ≥ 2 chronic conditions for ≥ 1 year, ≥ 2 healthcare visits in the past year, and Beijing residency for ≥ 1 year. The exclusion criterion was cognitive impairments or severe mental health conditions. Patients were recruited for the study after they agreed to provide written informed consent. A small compensation (RMB 100) was provided for participation. The participants were requested to complete a questionnaire to collect demographic information, including age, sex, multimorbidity duration, educational background, and employment status. None of the participants were known to the interviewers. No dropouts occurred post-recruitment. No repeat interviews were performed. An adequate number of participants were recruited to draw meaningful conclusions. Recruitment was stopped when data saturation had been achieved. Data saturation was defined as no new codes and no new significant themes being identified from subsequent data. Data saturation was rigorously assessed through iterative coding and negative case analysis. Analysis The audio-recorded data were transcribed verbatim and reviewed for accuracy by two researchers (MY & CLY). One focus group transcript was randomly selected by researchers and returned to participants for comments within 2 days of the group discussion to check the accuracy of the transcription. No corrections were required after the participants checked the transcript (MY&CLY). Thematic analysis was performed via the framework method [ 22 ]. Two researchers (MY & CLY) developed an a priori dedicated codebook informed by the literature and the interview guide. Consequently, they independently examined two random focus group transcripts and field notes and refined the codebook by adding inductive codes. After resolving the discrepancies and disagreements through discussion and consensus, the finalized codebook was developed, which was then applied to all remaining transcripts using NVivio 14.23.2 software. After all the data had been coded using this framework, the data were summarized in a matrix based on the similarities and differences of the codes. The subthemes were generated from the dataset by reviewing the matrix and connecting the codes. The themes and subthemes were identified until data saturation was achieved. The analysis and interpretation of the data were discussed by the authors (MY & CLY). Any disagreements were resolved by arriving at a consensus. Relevant quotations were identified and selected from the transcripts to highlight the themes. The findings were provided to four participants in one focus group for review. These participants agreed that the content accurately reflected their discussions. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to prepare this report (see online supplement) [ 23 ]. Results This study conducted four focus group discussions involving 21 participants with multimorbidity (7 males and 14 females). Among the participants, half of the participants reside in the city, and 14 reported living with multimorbidity for >5 years. Among these 14 participants, eight had had multiple chronic conditions for more than a decade. Moreover, 9 patients were diagnosed with three or more concurrent chronic conditions. The details of the participant and focus group characteristics are provided in Table 1. The following four main themes were identified after analyzing the focus group discussions: 1) living with multimorbidity, 2) healthcare system challenges: policy-driven fragmentation, 3) financial burdens: insurance inequalities as a systemic barrier, and 4) doctor-patient dynamics: hierarchical care in transition. The themes and subthemes are presented in Table 2. Themes 1: Living with multimorbidity 1a. Acceptance as aging The acceptance of multimorbidity among patients is influenced primarily by their coexisting chronic conditions. Most patients with non-oncological conditions attribute the development of multiple chronic conditions to the natural process of aging, viewing it as an inherent aspect of the life cycle that aligns with the “natural law” of birth, aging, illness, and death. Thus, these patients expressed a sense of acceptance and approached their conditions relatively easily. Some respondents even adopted an optimistic perspective, as they considered falling ill to be a beneficial catalyst. These participants tended to conscientiously prioritize and address their health concerns. Patients diagnosed with malignant tumors frequently exhibited heightened levels of negative emotional responses, including fear, frustration, complaints, and a sense of confusion, during the interviews. FG3-P3: “As you get older, it is inevitable that you will develop some chronic diseases. The key mindset is how you approach this matter (getting sick). I think if you need to take medicine, then take it. If you are ill, just get the treatment.” FG1-P4: “For me, being sick is actually a good thing. Before being diagnosed with a disease, I never went to the hospital. Due to being diagnosed with cervical cancer, I actively check for other problems in my body every time I go for a follow-up examination. After getting sick, I began to pay attention to my health issues. So it can be regarded as a blessing in disguise.” 1b. Self-management Strategies In contrast to managing a single chronic condition, the simultaneous management of multiple diseases is associated with challenges for patients, requiring them to prioritize health issues and focus on addressing the conditions they perceive as most critical. This prioritization is predominantly influenced by patients’ comprehension of their conditions and personal experiences with illness. For example, two patients diagnosed with both hypertension and coronary heart disease demonstrated distinct health priorities based on their perceptions and experiences. One patient prioritized the management of hypertension over coronary heart disease. This patient had a comprehensive understanding of the risks associated with high blood pressure and consequently deemed its management to be of greater importance. Moreover, the other patient prioritized coronary heart disease, as it almost “took his life”. FG3-P3: “Among these two diseases (hypertension and CHD), I pay more attention to blood pressure. I do not understand (know much about) heart disease very well. However, I know that if blood pressure is not well controlled, many diseases are related to it.” FG3-P4: “I think heart disease (CHD) is more serious than hypertension because if a heart attack occurs and medical treatment is not sought in time, there may not even be a chance for rescue. I have had several angina attacks, which almost cost me my life.” The management of polypharmacy is a major challenge for patients with multimorbidity. As multiple medications must be administered daily often with varying schedules, almost all respondents reported instances of missed doses. Consequently, these patients have developed personalized strategies to remember to adhere to their medication regimens. Additionally, these patients believed that “missing a dose is preferable to (safe) overmedication”. FG3-P3: “I never forget to take the medicine before going to bed because it is the last thing to do before sleep. I often forget to take medicine in the morning, as there are so many things to do and I am always in a hurry. I have forgotten to take my antihypertensive pills several times.” FG3-P5: “I found several small iron boxes and put the morning medicine, evening medicine, medicine to be taken before meals, and medicine to be taken after meals in different boxes, respectively. When it is time (to take the medicine), I take out the medicine and consume it.” About half of the respondents emphasized the critical role of family support in effectively managing their chronic conditions. In addition to assisting in disease management, families also provide essential support in various aspects of daily living. Some patients preferred self-sufficiency and were reluctant to impose burdens on their families, especially their children. These patients viewed their children as being engaged in their responsibilities and therefore incapable of offering further assistance. Thus, patients refrain from discussing symptoms and illnesses to avoid imposing additional burdens on their children. FG5-P2: “I do not expect the hospital to take such good care of me that I will be completely restored. I think family support is very important. If my wife is in relatively good health, she can be attentive to me in terms of taking medicine, nursing, etc., which may be beneficial to me.” FG1-P4: “My children are busy with work, and I do not want to trouble them for help. They also have children to take care of and face considerable living burdens. Whenever I feel a bit unwell, I am reluctant to tell them. If you tell them, they will just get worried too.” A subset of patients demonstrated awareness of their personal responsibility in managing lifestyle-related factors, such as smoking cessation and daily rehabilitation exercises. However, the level of implementation appeared to be suboptimal. Furthermore, patients with multimorbidity frequently exhibit proactive behavior in seeking medical information to enhance their understanding of disease, with some even aspiring to utilize this knowledge to guide their treatment decisions. The primary source of medical information for these individuals was the internet; however, the heterogeneous nature and questionable reliability of online resources generated significant concerns regarding their credibility. G1-P3: “I am fully cognizant that smoking cessation is imperative after being diagnosed with COPD, and I am genuinely motivated to quit. Despite one year of sustained cessation efforts, I have unfortunately relapsed into smoking behavior.” G4-P3: “Following a medical diagnosis, I typically engage in online health information-seeking behavior to investigate the pathogenesis of the condition and explore potential preventive strategies. However, I encounter significant challenges in navigating the extensive volume of heterogeneous medical information available online, which frequently presents conflicting perspectives and varying degrees of reliability.” Themes 2: Healthcare System Challenges: Policy-Driven Fragmentation 2a. Ineffective Tiered System Most patients select healthcare institutions on the basis of their individual needs, preferences, and access to medical resources without policy limitations. For example, some respondents expressed reservations about the professional competence of community-based physicians and indicated a preference for seeking care at general hospitals. Moreover, other respondents reported community hospitals as convenient, especially for routine visits, such as seeking care for minor health concerns or obtaining medications. FG4-P2: “I am willing to go to a large hospital. This is because the doctors there see more patients and are more experienced. The experience level of community doctors is limited, often leading to misdiagnoses.” Almost all the respondents reported never having experienced the benefits of a formal referral system. Patients typically seek treatment at tertiary hospitals on their own when they encounter issues requiring higher-level care during visits to primary hospitals. Primary care physicians recommended that appropriate hospitals and conscientious doctors frequently remind and urge patients to seek further care, a practice for which patients expressed gratitude. FG1-P3: “Once, when I had an acute attack of kidney stones, I was in so much pain that I was rolling on the ground. I went to the community clinic, but they could not handle it and told me to go to Hospital A. However, no urologists were available at the hospital, as the Mid-Autumn Festival was that day. In the end, I had no choice but to go to Hospital B.” 2b. Digital Exclusion The online appointment registration system posed significant difficulties for most respondents, especially elderly patients, who expressed helplessness and uncertainty about navigating healthcare access at advanced ages. In addition, respondents stated that "high-tech", such as online payments and appointment checkups, have also caused varying degrees of medical burden on them. FG1-P4: “Currently, when going to the hospital for medical treatment, it is necessary to make an online appointment for registration first. I do not know how to do it, and I cannot get an appointment either.” Themes 3: Financial burdens: Insurance inequalities as a systemic barrier 3a. Urban-Rural Divides The reimbursement rates vary significantly across different types of medical insurance plans. Compared with urban UEBMI holders, rural participants with NRCMS faced higher out-of-pocket costs. In the interviews, the issue of heavy treatment burden was mentioned more frequently in rural patients. High out-of-pocket expenses can compromise patient adherence, potentially resulting in patients preferring alternative treatments, such as traditional Chinese medicines, rather than physician-recommended treatments. This is because the cost of alternative treatments is lower than that of physician-recommended treatments. The financial burden stemming from inadequate medical insurance coverage compels patients to balance healthcare expenses with other non-medical financial obligations, including bill payments, the ability to support family and leisure activities, and overall savings. FG3-P4: “Seeing a doctor is too expensive. Last time, I spent nearly 1,000 yuan during my one-day-and-one-night stay in the emergency department. I feel that I cannot afford to see a doctor anymore.” FG1-P4: “The out-of-pocket part for medicine has increased. So I have to cut down on other living expenses because I cannot stop taking medicine.” 3b. Policy-Induced Strain Government-mandated changes in drug brands and restrictions on prescription durations have contributed to the treatment burden on patients. Some respondents complained that different hospitals, especially community hospitals and higher-level hospitals, often have different brands of the same medication. Sometimes a certain brand of medication suddenly runs out of stock and needs to be replaced with another brand of medication (such as switching from an imported brand to a domestic brand). They are inevitably confused and worried about whether the brand change will affect the treatment effect. Additionally, the respondents expressed frustration with the extended duration required for providing medical services, citing prolonged delays in receiving treatment and scheduling diagnostic examinations. FG4-P2: “When prescribing medicine, it is necessary to meet the time limit (for example, only 30 days’ supply can be prescribed) and ensure that it is in whole boxes. Therefore, each time the medicine is prescribed, some can last for 30 days, and some can last for 45 days. When it is time to refill the prescription again, one type of medicine may be available for prescription, while other medicines may not. Therefore, I have to go to the hospital several times, which is truly troublesome.” FG5-P1: “Over the past two years, the brands of medications I require for long-term use have been successively substituted, raising concerns regarding the consistency of their therapeutic efficacy and the potential adverse effects of such pharmaceutical brand transitions on my health. Occasionally, to procure medications of the original brand, I must visit multiple medical institutions, resulting in significant inconvenience.” Themes 4: Doctor-Patient Dynamics: Hierarchical Care in Transition 4a. Communication Gaps The respondents valued every opportunity to communicate with their physicians. The patients sought a clear understanding of the “ins and outs” of their conditions and desired explanations of their diagnoses and treatment plans in an accessible and comprehensible manner. However, the patients frequently perceived a lack of effective communication from their physicians, resulting in confusion and uncertainty about their conditions and treatment plans, especially regarding medications. Additionally, patients often lack sufficient understanding of drug interactions and side effects. Some patients also expressed a desire for shared decision-making with their physicians. According to the patients, if they thoroughly understand their health conditions, they can collaborate on treatment plans, including being consulted before finalizing prescriptions. FG1-P4: “Doctors should proactively explain precautions when prescribing medications to patients. For example, some people take the lipid-lowering drug pitavastatin, whereas others take pravastatin. Why do I take this one, and they take that one? If the doctor could explain it clearly when prescribing the medication for me, I would feel more at ease.” FG4-P2: “Last time I saw a specialist for kidney stones, he was truly great. He told me that I should drink plenty of water every day. He said, “Look, the stones are composed of salts. If you drink a lot of water, you can flush them out. Otherwise, they will settle down and form stones.” After he explained it like this, I understood very clearly.” FG2-P4: “I know best about my own physical condition. I hope I can have a further discussion with the doctor about what I should do.” More than half of the respondents expressed a need for compassionate care from physicians, including non-medical support, such as a willingness to understand their family circumstances, treatment burdens, and engaging in informal conversations. Patients consider these interactions to provide significant emotional comfort and foster the development of trust-based relationships. However, most respondents felt that physicians often inadequately addressed their needs, especially those in general hospitals. The patients attributed this to physicians’ overwhelming workloads and time constraints. Patients with multimorbidity reported that they can easily establish close and natural doctor-patient relationships with community-based physicians, owing to frequent and accessible interactions. FG3-P3: “It always seems that there is something in between doctors and patients. Doctors treat patients as pure patients and themselves as pure doctors. It would be better if doctors and patients could have some small talk. For example, doctors could take the initiative to ask patients about their family conditions and whether they have any financial burdens when seeing a doctor or receiving medications. These simple questions can narrow the gap between doctors and patients. Seeing a doctor in a relaxed atmosphere will make everyone feel good.” FG4-P2: “Sometimes when the doctor says a few more words to me, it is a great comfort to me and provides strong psychological support. I think that after getting sick, patients have a strong psychological dependence on doctors.” 4b. Continuity vs. Efficiency The nature of hospital care is compartmentalized, where individual departments address specific conditions. Thus, some respondents were uncertain whether the department or physician should consult for their multiple coexisting conditions. These patients preferred continuity of care with a fixed physician, as this would enable a comprehensive understanding of their health status, reduce consultation time, and prevent redundant examinations resulting from switching doctors, consequently minimizing financial and medical resource waste. FG2-P3: “A specialist can only solve one of my problems. They cannot view the situation comprehensively. I hope that every patient can have a dedicated doctor who can solve most of their problems. Moreover, having a fixed doctor can save many procedures and laboratory tests because he understands my situation. Every time I change to a new doctor, I have to go through all the examinations again.” Discussion This study comprehensively explores the healthcare experiences of patients with multimorbidity in Beijing, China, within the context of a tiered healthcare system. The findings of this study revealed systemic gaps in care coordination, financial burdens, and patient-provider dynamics, which collectively hinder effective multimorbidity management. These challenges are not unique to China but reflect global issues in managing multimorbidity, especially in LMICs, where healthcare systems are often under-resourced and overburdened [ 24 – 26 ]. However, the Chinese context adds unique layers of complexity due to the rapid epidemiological transition, the aging population, and the ongoing reforms in the healthcare system. Below, we discuss the implications of these findings and propose targeted interventions to address the identified issues. Living with Multimorbidity: Acceptance and Self-Management In this study, patients with multimorbidity often viewed their conditions as an inevitable part of aging, especially those with non-oncological chronic diseases. This acceptance, while potentially reducing psychological distress, does not mitigate the physical, emotional, and social burdens associated with managing multiple chronic conditions [ 24 ]. The study highlights the critical role of self-management strategies, such as medication adherence and prioritization of health issues. Moreover, the present study revealed a significant gap in patient education and support. This study revealed that patients often do not receive necessary information during these consultations, which was attributed to time constraints and communication challenges. Healthcare providers frequently attribute these issues to systemic limitations within the healthcare framework. For example, Dinh et al. [ 27 ] reported that GPs cannot provide adequate support in areas such as health promotion, disease prevention, and self-management due to limited time and resources. Similarly, Damarell et al. [ 28 ] highlighted insufficient evidence for managing multimorbidity. Consequently, clinicians do not have clear guidance to address complex clinical questions, further complicating care delivery. Increasing the number of healthcare professionals alone may not address challenges in the short term, given the supply-demand imbalance of GPs and resulting doctor-patient conflicts. A more effective approach could leverage underutilized resources, such as nurses and pharmacists, to address care gaps. However, our study revealed that patients rely primarily on physicians, with limited recognition of non-physician providers’ roles, reflecting the marginalization of team-based care in China’s current model. Previous studies [ 25 , 27 ] highlight that these providers can play a critical role in multimorbidity management, including patient education, daily disease management, and care coordination. Enhancing their training in multimorbidity management could enable the delegation of certain physician responsibilities, supplementing GPs in primary care, while fostering collaborative, integrated care models. Such models could reduce care fragmentation, address service gaps, and mitigate conflicting management approaches [ 29 ]. Additionally, this study revealed a notable contrast between the self-management strategies adopted by Chinese patients and those emphasized in Western research. Western studies [ 30 ] often highlight behavioral interventions and lifestyle modifications, whereas Chinese patients with multimorbidity tend to focus predominantly on pharmacological treatments, overlooking the importance of lifestyle changes. This may be due to insufficient patient education. Chinese patients often perceive medication as the primary treatment modality and underestimate the value of behavioral interventions. However, this reliance on pharmacological interventions alone may hinder long-term disease management. Lifestyle modifications and behavioral changes are critical for effective multimorbidity care. Healthcare System Challenges: Fragmentation and Digital Exclusion The tiered healthcare system in China, designed to optimize resource allocation, has inadvertently created fragmentation, with patients often bypassing primary care institutions because of perceived inadequacies in professional competence. This finding aligns with previous research [ 15 , 31 , 32 ] highlighting the underdevelopment of primary care in China and the preference for tertiary hospitals among patients. Digital exclusion emerged as a significant barrier, particularly for elderly patients who struggle with online appointment systems and other digital healthcare tools. This issue calls for the development of user-friendly digital platforms and alternative access methods to ensure equitable healthcare delivery. Additionally, implementing interoperable electronic health records (EHRs) can reduce fragmentation, minimize redundant tests, and improve care continuity [ 33 ]. Initiatives to promote telemedicine and remote monitoring can also increase access to care, particularly in underserved areas. Financial Burdens: Inequities and Policy-Induced Strain The study reveals stark disparities in financial burdens, with rural patients facing higher out-of-pocket costs than their urban counterparts. These inequities compromise treatment adherence and force patients to make difficult choices between healthcare and other essential expenses. Government-mandated changes in drug brands and reimbursement policies further exacerbate strain, creating confusion and dissatisfaction among patients. To address these issues, policymakers should revise insurance policies to provide comprehensive coverage for chronic disease management, including medications and long-term care. Flexible reimbursement plans tailored to disease progression and transparent drug reimbursement policies could alleviate financial burdens and improve access to necessary treatments [ 34 ]. Doctor-Patient Dynamics: Communication and Continuity of Care This study highlights the importance of doctor-patient relationships and communication in the management of multimorbidity. Patients strongly desire compassionate care, clear communication, and shared decision-making. However, the current healthcare system emphasizes efficiency and throughput but cannot provide meaningful patient-provider interactions. Previous studies have demonstrated that patient-centered care, which includes shared decision-making (SDM) and continuity of care, is essential for effectively managing multimorbidity. One study [ 35 ] reported that although healthcare providers recognize the importance of involving patients with multimorbidity in clinical decision-making, they frequently struggle to implement this in real-world practice consistently. Thus, doctor-patient communication should be improved. Training programs for healthcare providers should focus on patient-centered care, active listening, and SDM. Decision aids could also help bridge the communication gap [ 28 ]. Continuity of care, which involves consulting the same provider over time, allows for a deep understanding of the patient’s history and current situation [ 36 ]. This approach can enhance trust, improve treatment adherence, and reduce the burden of navigating a fragmented healthcare system [ 36 ]. Training programs for healthcare providers should emphasize patient-centered communication and shared decision-making to bridge the existing gaps. Pilot programs testing integrated care models, such as multidisciplinary teams, could offer valuable insights for scaling effective solutions [ 33 ]. Limitations This study has several limitations. First, the single-city focus on Beijing—a resource-rich megacity with distinct healthcare infrastructure—may limit generalizability to other regions in China. Rural areas and smaller cities often face greater shortages of primary care resources and more pronounced urban-rural disparities in insurance coverage, which could amplify challenges such as financial burdens or digital exclusion for patients with multimorbidity. Second, the focus group setting may have introduced social desirability bias, as participants might have avoided criticizing healthcare providers or policies due to perceived authority figures (e.g., hospital-affiliated researchers moderating discussions). Third, while rigorous translation and back-translation procedures were employed, nuances in local dialects or culturally specific expressions may have been lost during translation, potentially affecting thematic interpretation. Finally, the purposive sampling strategy, while ensuring diversity in insurance types and geographic settings, may not fully capture underrepresented subgroups. Future multi-center studies across diverse regions could strengthen the external validity of these findings. Conclusions This study highlights the complex challenges faced by patients with multimorbidity in navigating the healthcare system. Addressing these challenges requires a multifaceted approach that includes improving patient self-management support, enhancing care coordination, reducing financial burdens, and fostering doctor-patient communication. Policymakers and healthcare providers must collaborate to develop a more patient-centered, integrated healthcare system that meets the needs of this growing population. This will enable China to improve the quality of care for patients with multimorbidity and establish a precedent for other LMICs facing similar challenges. Abbreviations LMICs Low- and Middle-income Countries GP General Practitioner UEBMI Urban Employee Basic Medical Insurance URBMI Urban Resident Basic Medical Insurance NRCMS New Rural Cooperative Medical Scheme EHRs Electronic Health Records SDM Shared Decision-making Declarations Acknowledgements We would like to than all the study participants for their help. Authors’ contributions YCL and MY contributed to the design of the study. YCL analyzed and interpreted data, and wrote the article. JYZ contributed to patient recruitment and organized interviews. YM supervised the study and proofread the manuscript. YCL and JYZ contributed equally to the manuscript. All authors contributed to editing the manuscript. All authors read and approved the final manuscript. Funding This work was supported by the National High Level Hospital Clinical Research Funding /Scientific Research Seed Fund of Peking University First Hospital(2023SF31); and the National Natural Science Foundation of China (72304005). Availability of data and materials Data sharing restrictions apply to the availability of the data; therefore, they are not publicly available. However, the data of this study can be obtained from the corresponding author under the condition of reasonably making a request. Ethics approval and consent to participate This study was approved by the Research Ethics Committee of the Peking University First Hospital, Beijing, China (2023yan292-002). This study was conducted following the principle of the Declaration of Helsinki. All respondents provided informed, voluntary written consent prior to participating in this study. Permission was also requested from participants prior to audio recording interviews. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Salisbury C. Multimorbidity: redesigning health care for people who use it. Lancet. 2012;380:7-9. Whitty CJM, MacEwen C, Goddard A, Alderson D, Marshall M, Calderwood C, et al. Rising to the challenge of multimorbidity. BMJ. 2020;368:l6964. Chowdhury SR, Chandra Das D, Sunna TC, Beyene J, Hossain A. Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis. eClinicalMedicine. 2023;57:101860. PLOS Medicine Editors. Multimorbidity: Addressing the next global pandemic. PLoS Med. 2023;20:e1004229. Zhong Y, Qin G, Xi H, Cai D, Wang Y, Wang T, et al. Prevalence, patterns of multimorbidity and associations with health care utilization among middle-aged and older people in China. BMC Public Health. 2023;23:537. Zhao Y, Zhao S, Zhang L, Haregu TN, Wang H. Impacts of multimorbidity on medication treatment, primary healthcare and hospitalization among middle-aged and older adults in China: evidence from a nationwide longitudinal study. BMC Public Health. 2021;21:1380. Vetrano DL, Palmer K, Marengoni A, Marzetti E, Lattanzio F, Roller-Wirnsberger R, et al. Frailty and multimorbidity: a systematic review and meta-analysis. J Gerontol Ser A. 2019;74:659-66. Singh K, Patel SA, Biswas S, Shivashankar R, Kondal D, Ajay VS, et al. Multimorbidity in South Asian adults: prevalence, risk factors and mortality. J Public Health. 2019;41:80-9. Klompstra L, Ekdahl AW, Krevers B, Milberg A, Eckerblad J. Factors related to health-related quality of life in older people with multimorbidity and high health care consumption over a two-year period. BMC Geriatr. 2019;19:187. Nguyen H, Manolova G, Daskalopoulou C, Vitoratou S, Prince M, Prina AM. Prevalence of multimorbidity in community settings: A systematic review and meta-analysis of observational studies. J Comorbidity. 2019;9:1-15. Albreht T, Dyakova M, Schellevis FG, Van den Broucke S. Many diseases, one model of care? J Comorbidity. 2016;6:12-20. Tinetti ME, Esterson J, Ferris R, Posner P, Blaum CS. Patient priority–directed decision making and care for older adults with multiple chronic conditions. Clin Geriatr Med. 2016;32:261-75. Moody E, Martin‐Misener R, Baxter L, Boulos L, Burge F, Christian E, et al. Patient perspectives on primary care for multimorbidity: An integrative review. Health Expect. 2022;25:2614-27. The State Council of the People's Republic of China. Guidance on promoting the construction of hierarchical diagnosis and treatment system ‌(Guo Ban Fa [2015] No. 70). Gaz State Counc People's Repub China. 2015;27:27-31. Li X, Krumholz HM, Yip W, Cheng KK, De Maeseneer J, Meng Q, et al. Quality of primary health care in China: challenges and recommendations. Lancet. 2020;395:1802-12. Qin J, Lin C, Zhang L, Zhang Y. Patient satisfaction with primary care in highly focused districts/counties during the comprehensive reform of primary care system in China. Chin Gen Pract. 2018;21:36-40. Zhang J, Han P, Sun Y, Zhao J, Yang L. Assessing spatial accessibility to primary health care services in Beijing, China. Int J Environ Res Public Health. 2021;18:13182. Liu M, Yang J, Wang C, Yang S, Wang J, Hou C, et al. Cohort profile: Beijing Healthy Aging Cohort Study (BHACS). Eur J Epidemiol. 2024;39:101-10. Zhang L, Sun F, Li Y, Tang Z, Ma L. Multimorbidity in community-dwelling older adults in Beijing: prevalence and trends, 2004–2017. J Nutr Health Aging. 2021;25:116-9. Mair FS, Gallacher KI. Multimorbidity: what next? Br J Gen Pract. 2017;67:248-9. Pyo J, Lee W, Choi EY, Jang SG, Ock M. Qualitative research in healthcare: necessity and characteristics. J Prev Med Public Health. 2023;56:12-20. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349-57. Duguay C, Gallagher F, Fortin M. The experience of adults with multimorbidity: A qualitative study. J Comorbidity. 2014;4:11-21. Birke H, Jacobsen R, Jønsson ABR, Guassora ADK, Walther M, Saxild T, et al. A complex intervention for multimorbidity in primary care: A feasibility study. J Comorbidity. 2020;10:1-8. Rosbach M, Andersen JS. Patient-experienced burden of treatment in patients with multimorbidity–A systematic review of qualitative data. PLoS One. 2017;12:e0179916. Dinh TS, Brünn R, Schwarz C, Brueckle MSD, M., González González AI, van den Akker M. How do middle-aged patients and their healthcare providers manage multimorbidity? Results of a qualitative study. PLoS One. 2023;18:e0291065. Damarell RA, Morgan DD, Tieman JJ. General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research. BMC Fam Pract. 2020;21:131. Whitehead L, Palamara P, Allen J, Boak J, Quinn R, George C. Nurses' perceptions and beliefs related to the care of adults living with multimorbidity: A systematic qualitative review. J Clin Nurs. 2021;31:2716-36. Smith SM, Wallace E, O'Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2021;1:CD006560. Yip W, Fu H, Chen AT, Zhai T, Jian W, Xu R, et al. 10 years of health-care reform in China: progress and gaps in Universal Health Coverage. Lancet. 2019;394:1192-204. Qian J, Ramesh M. Strengthening primary health care in China: governance and policy challenges. Health Econ Policy Law. 2023;19:57-72. Aramrat C, Choksomngam Y, Jiraporncharoen W, Wiwatkunupakarn N, Pinyopornpanish K, Mallinson PAC, et al. Advancing multimorbidity management in primary care: a narrative review. Prim Health Care Res Dev. 2022;23:e36. de Silva Etges APB, Liu HH, Jones P, Polanczyk CA. Value-based reimbursement as a mechanism to achieve social and financial impact in the healthcare system. J Health Econ Outcomes Res. 2023;10:100-3. Sathanapally H, Sidhu M, Fahami R, Gillies C, Kadam U, Davies MJ, et al. Priorities of patients with multimorbidity and of clinicians regarding treatment and health outcomes: a systematic mixed studies review. BMJ Open. 2020;10:e033445. Schwarz D, Hirschhorn LR, Kim JH, Ratcliffe HL, Bitton A. Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage. BMJ Glob Health. 2019;4:e001435. Tables Table 1 General and health-related characteristics of participants with multimorbidity Participants Gender Age-ranges(yrs) Status of employment Education background Diagnosis* Diagnosis period (yrs) Health insurance** Location FG1-P1 Male 65-69 retired High school Hypertension, Coronary heart disease (CHD), Cerebral infarction ≥10 Free medical service City center FG1-P2 Female 65-69 retired High school Hypertension, Diabetes 5–9 UEBMI City center FG1-P3 Male 65-69 retired High school Hypertension, Diabetes 5–9 UEBMI City center FG1-P4 Female 60-64 retired High school Diabetes, Malignant neoplasm of cervix uteri 1–4 UEBMI City center FG1-P5 Female 60-64 retired High school Hypertension, Osteoporosi 1–4 UEBMI City center FG2-P1 Male ≥70 farmer Junior high school or below CHD, Chronic obstructive pulmonary disease (COPD) 1–4 NRCMS Rural or suburb FG2-P2 Male 65-69 farmer Junior high school or below Hypertension, Renal cell carcinoma, Cholecystitis ≥10 NRCMS Rural or suburb FG2-P3 Female 65-69 farmer Junior high school or below Hypertension, Lipid disorder ≥10 NRCMS Rural or suburb FG2-P4 Female 65-69 farmer Junior high school or below Hypertension, Diabetes, Gastritis 5–9 NRCMS Rural or suburb FG2-P5 Female 60-64 farmer Junior high school or below Hypertension, CHD ≥10 URBMI Rural or suburb FG3-P1 Female ≥70 farmer Junior high school or below Cerebral infarction, Lumbar spondylosis 1–4 NRCMS Rural or suburb FG3-P2 Female ≥70 farmer Junior high school or below Cerebral infarction, Cervical spondylosis, Rheumatoid arthritis, Gastritis ≥10 NRCMS Rural or suburb FG3-P3 Male 65-69 retired College or above Hypertension, CHD 5–9 UEBMI City center FG3-P4 Female 65-69 retired Junior high school or below Hypertension, CHD 5–9 UEBMI City center FG3-P5 Female ≥70 retired Junior high school or below Hypertension, CHD, Diabetes 5–9 UEBMI City center FG4-P1 Female 50-59 retired College or above Lipid disorder, Leiomyoma of uterus ≥10 UEBMI City center FG4-P2 Female 60-64 retired College or above Malignant neoplasms of bladder, Anemia of other chronic disease, Nontoxic goiter ≥10 UEBMI City center FG4-P3 Female 50-59 working Junior high school or below Hypertension, Lipid disorder ≥10 UEBMI City center FG5-P1 Male 60-64 retired High school CHD, Lipid disorder, Chronic pancreatitis 1–4 UEBMI City center FG5-P2 Male 65-69 working College or above Diabetes, Malignant neoplasms of bronchus and lug 1–4 Free medical service City center FG5-P3 Female 65-69 farmer Junior high school or below Hypertension, Non-Hodgkin Lymphoma 5-9 NRCMS Rural or suburb *Diagnostic information classified according to the 10th revision of the International Statistical Classification of Diseases (ICD-10). **UEBMI: Employee Basic Medical Insurance; URBMI: Urban Resident Basic Medical Insurance; NRCMS: New Rural Cooperative Medical Scheme Table 2 Themes and subthemes Themes Subthemes 1. Living with multimorbidity a. Acceptance as aging b. Self-management Strategies 2. Healthcare System Challenges: Policy-Driven Fragmentation a. Ineffective Tiered System b. Digital Exclusion 3. Financial Burdens: Insurance Inequities as a Systemic Barrier a. Urban-Rural Divides b. Policy-Induced Strain Doctor-Patient Dynamics: Hierarchical Care in Transition a. Communication Gaps b. Continuity vs. Efficiency Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Published Journal Publication published 28 Aug, 2025 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 27 Jun, 2025 Reviews received at journal 26 Jun, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviews received at journal 26 Jun, 2025 Reviewers agreed at journal 18 Jun, 2025 Reviewers invited by journal 16 Jun, 2025 Editor assigned by journal 16 Jun, 2025 Editor invited by journal 13 Jun, 2025 Submission checks completed at journal 13 Jun, 2025 First submitted to journal 13 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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System","fulltext":[{"header":"Background","content":"\u003cp\u003eMultimorbidity, which is defined as the co-occurrence of two or more chronic conditions in individuals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], is a major public health challenge worldwide, especially in countries with aging populations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The prevalence of multimorbidity is rapidly increasing. Recent epidemiological data have suggested that multimorbidity affects more than 50% of adults aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The prevalence of multimorbidity is especially high in low- and middle-income countries (LMICs), including China [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Some studies have reported that the incidence rates of multimorbidity are 45.5\u0026ndash;56.73% among middle-aged and older adults [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Thus, multimorbidity has adverse effects on health outcomes, healthcare utilization, and quality of life.\u003c/p\u003e \u003cp\u003eMultimorbidity adversely affects health outcomes, healthcare utilization, and quality of life, leading to poor functional status, increased frailty, and increased mortality rates [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Managing these patients is complex, as their needs extend beyond single-disease frameworks, requiring integrated care models [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, healthcare systems in LMICs, including China, remain fragmented, prioritizing acute and single-condition management over coordinated care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This disconnect results in polypharmacy challenges, uncoordinated specialist visits, and significant financial burdens for patients [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Chinese government has recognized the need for an integrated healthcare system to address the growing burden of multimorbidity. In 2015, policy guidelines were introduced in China to develop a hierarchical diagnosis and treatment system to optimize healthcare delivery by categorizing diseases based onseverity and complexity and assigning them to appropriate levels of care [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, the implementation of this system has been associated with various challenges. The limited professional competence of primary healthcare personnel and the absence of stringent protocols mandating primary healthcare providers as the initial point of contact have resulted in patients frequently preferring general hospitals over primary healthcare institutions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This has led to an underdeveloped primary care system that cannot effectively meet the needs of patients with multimorbidity.\u003c/p\u003e \u003cp\u003eBeijing, China's capital, serves as a critical hub for political, economic, and cultural activities and is a pioneer in the nation's healthcare planning. However, Beijing faces several challenges in healthcare resource distribution, including a shortage of primary healthcare services and structural imbalances in health resources [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, the aging population of Beijing is rapidly increasing, and the city will enter a phase of moderate aging in 2021 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The prevalence rates of multimorbidity among older adults in Beijing increased from 32.5% in 2004 to 53.2% in 2017 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Thus, Beijing is an ideal setting for studying the healthcare experiences of patients with multimorbidity and identifying systemic issues that need to be addressed.\u003c/p\u003e \u003cp\u003eDespite the increasing burden of multimorbidity, few studies in China have explored patients\u0026rsquo; lived experiences within this tiered system. Existing research focuses on prevalence and disease burden, leaving critical gaps in understanding patient perspectives on access, coordination, and communication [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Qualitative research offers a valuable perspective for understanding these experiences, providing insights into how individuals manage their conditions, interact with the healthcare system, and perceive their care [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These insights are crucial for designing healthcare services that meet the needs of patients with multimorbidity and for informing policy and practice improvements.\u003c/p\u003e \u003cp\u003e This study examined the healthcare experiences of patients with multimorbidity in Beijing, focusing on challenges in access, care coordination, and financial burdens. Second, systemic barriers within China\u0026rsquo;s tiered healthcare system that hinder effective multimorbidity management should be identified, and targeted interventions to improve care integration and patient outcomes should be identified. By addressing these gaps, this study seeks to contribute evidence for policies that align healthcare delivery with the complex needs of patients with multimorbidity.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003e This study employed a qualitative research design with focus groups to minimize the influence of social distance between the facilitator and participants on the discussions and facilitate the exploration of complex issues and the sharing of experiences through group interaction. The study was underpinned by a phenomenological approach to explore participants' lived experiences of multimorbidity.\u003c/p\u003e \u003cp\u003eA flexible topic guide was used to encourage open discussion and comprehensively address the key issues relevant to the investigation of multimorbidity experiences. The topic guide was developed through consensus among all researchers according to the study\u0026rsquo;s purpose and systematic review of the literature on multimorbidity. The guide was pilot-tested with one focus group (n\u0026thinsp;=\u0026thinsp;4) to refine question clarity and flow. The Focus group discussion guide is available in the online supplement.\u003c/p\u003e \u003cp\u003eThe research team comprised clinicians and public health researchers with expertise in qualitative methodologies and multimorbidity management. The principal researcher (MY\u0026amp;CLY) is a general practitioner (GP) with over a decade of clinical experience in primary care, and dedicated to qualitative research. MY (a male PhD, who has conducted public health research at the University of Birmingham in the UK) conducted all the focus group discussions as a facilitator, whereas JYZ (a female GP with rich multimorbidity management experience) was a co-facilitator. Both facilitators received formal training in qualitative methods, including bracketing techniques, to minimize preconceptions during data collection.\u003c/p\u003e \u003cp\u003eInterviews were conducted face-to-face, with each focus group comprised 3\u0026ndash;5 patients. Each focus group lasted approximately 60\u0026ndash;90 minutes. Sessions were audio-recorded and supplemented by field notes documenting non-verbal cues and contextual observations. Only researchers and participants were present during discussions.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRecruitment\u003c/h3\u003e\n\u003cp\u003eThe recruitment and focus group discussions occurred from July 2023 to December 2024. A purposive sampling strategy was employed to ensure diversity across key dimensions relevant to multimorbidity experiences, including the following: (1) Geographic location: participants were sampled from urban (Dongcheng District) and rural (Miyun District) areas of Beijing to capture disparities in healthcare access; (2) socioeconomic status: various educational backgrounds (junior high school or below to college or above) and employment status (retired, farmer, working) were included; (3) clinical complexity: participants were selected on the basis of the duration of multimorbidity and the number of chronic conditions; and (4) insurance type: enrollment included urban employee basic medical insurance (UEBMI), urban resident basic medical insurance (URBMI), and the New Rural Cooperative Medical Scheme (NRCMS) to reflect financial inequities. The participants were recruited from one tertiary hospital (Peking University First Hospital), one community health center (Donghuashi Community Health Service Centre) in an urban setting, and one rural hospital (Miyun Hospital) to ensure institutional diversity. The eligibility criteria were as follows: age\u0026thinsp;\u0026gt;\u0026thinsp;18 years, \u0026ge;\u0026thinsp;2 chronic conditions for \u0026ge;\u0026thinsp;1 year, \u0026ge;\u0026thinsp;2 healthcare visits in the past year, and Beijing residency for \u0026ge;\u0026thinsp;1 year. The exclusion criterion was cognitive impairments or severe mental health conditions.\u003c/p\u003e \u003cp\u003e Patients were recruited for the study after they agreed to provide written informed consent. A small compensation (RMB 100) was provided for participation. The participants were requested to complete a questionnaire to collect demographic information, including age, sex, multimorbidity duration, educational background, and employment status. None of the participants were known to the interviewers. No dropouts occurred post-recruitment. No repeat interviews were performed.\u003c/p\u003e \u003cp\u003eAn adequate number of participants were recruited to draw meaningful conclusions. Recruitment was stopped when data saturation had been achieved. Data saturation was defined as no new codes and no new significant themes being identified from subsequent data. Data saturation was rigorously assessed through iterative coding and negative case analysis.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eThe audio-recorded data were transcribed verbatim and reviewed for accuracy by two researchers (MY \u0026amp; CLY). One focus group transcript was randomly selected by researchers and returned to participants for comments within 2 days of the group discussion to check the accuracy of the transcription. No corrections were required after the participants checked the transcript (MY\u0026amp;CLY).\u003c/p\u003e \u003cp\u003eThematic analysis was performed via the framework method [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Two researchers (MY \u0026amp; CLY) developed an a priori dedicated codebook informed by the literature and the interview guide. Consequently, they independently examined two random focus group transcripts and field notes and refined the codebook by adding inductive codes. After resolving the discrepancies and disagreements through discussion and consensus, the finalized codebook was developed, which was then applied to all remaining transcripts using NVivio 14.23.2 software.\u003c/p\u003e \u003cp\u003eAfter all the data had been coded using this framework, the data were summarized in a matrix based on the similarities and differences of the codes. The subthemes were generated from the dataset by reviewing the matrix and connecting the codes. The themes and subthemes were identified until data saturation was achieved. The analysis and interpretation of the data were discussed by the authors (MY \u0026amp; CLY). Any disagreements were resolved by arriving at a consensus. Relevant quotations were identified and selected from the transcripts to highlight the themes. The findings were provided to four participants in one focus group for review. These participants agreed that the content accurately reflected their discussions.\u003c/p\u003e \u003cp\u003eThe Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to prepare this report (see online supplement) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis study conducted four focus group discussions involving 21 participants with multimorbidity (7 males and 14 females). Among the participants, half of the participants reside in the city, and 14 reported living with multimorbidity for \u0026gt;5 years. Among these 14 participants, eight had had multiple chronic conditions for more than a decade. Moreover, 9 patients were diagnosed with three or more concurrent chronic conditions. The details of the participant and focus group characteristics are provided in Table 1.\u003c/p\u003e\n\u003cp\u003eThe following four main themes were identified after analyzing the focus group discussions: 1) living with multimorbidity, 2) healthcare system challenges: policy-driven fragmentation, 3) financial burdens: insurance inequalities as a systemic barrier, and 4) doctor-patient dynamics: hierarchical care in transition. The themes and subthemes are presented in Table 2.\u003c/p\u003e\n\u003cp\u003eThemes 1: Living with multimorbidity\u003c/p\u003e\n\u003cp\u003e1a. Acceptance as aging\u003c/p\u003e\n\u003cp\u003eThe acceptance of multimorbidity among patients is influenced primarily by their coexisting chronic conditions. Most patients with non-oncological conditions attribute the development of multiple chronic conditions to the natural process of aging, viewing it as an inherent aspect of the life cycle that aligns with the \u0026ldquo;natural law\u0026rdquo; of birth, aging, illness, and death. Thus, these patients expressed a sense of acceptance and approached their conditions relatively easily. Some respondents even adopted an optimistic perspective, as they considered falling ill to be a beneficial catalyst. These participants tended to conscientiously prioritize and address their health concerns. Patients diagnosed with malignant tumors frequently exhibited heightened levels of negative emotional responses, including fear, frustration, complaints, and a sense of confusion, during the interviews.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG3-P3: \u0026ldquo;As you get older, it is inevitable that you will develop some chronic diseases. The key mindset is how you approach this matter (getting sick). I think if you need to take medicine, then take it. If you are ill, just get the treatment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG1-P4: \u0026ldquo;For me, being sick is actually a good thing. Before being diagnosed with a disease, I never went to the hospital. Due to being diagnosed with cervical cancer, I actively check for other problems in my body every time I go for a follow-up examination. After getting sick, I began to pay attention to my health issues. So it can be regarded as a blessing in disguise.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1b. Self-management Strategies\u003c/p\u003e\n\u003cp\u003eIn contrast to managing a single chronic condition, the simultaneous management of multiple diseases is associated with challenges for patients, requiring them to prioritize health issues and focus on addressing the conditions they perceive as most critical. This prioritization is predominantly influenced by patients\u0026rsquo; comprehension of their conditions and personal experiences with illness. For example, two patients diagnosed with both hypertension and coronary heart disease demonstrated distinct health priorities based on their perceptions and experiences. One patient prioritized the management of hypertension over coronary heart disease. This patient had a comprehensive understanding of the risks associated with high blood pressure and consequently deemed its management to be of greater importance. Moreover, the other patient prioritized coronary heart disease, as it almost \u0026ldquo;took his life\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG3-P3: \u0026ldquo;Among these two diseases (hypertension and CHD), I pay more attention to blood pressure. I do not understand (know much about) heart disease very well. However, I know that if blood pressure is not well controlled, many diseases are related to it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG3-P4: \u0026ldquo;I think heart disease (CHD) is more serious than hypertension because if a heart attack occurs and medical treatment is not sought in time, there may not even be a chance for rescue. I have had several angina attacks, which almost cost me my life.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe management of polypharmacy is a major challenge for patients with multimorbidity. As multiple medications must be administered daily often with varying schedules, almost all respondents reported instances of missed doses. Consequently, these patients have developed personalized strategies to remember to adhere to their medication regimens. Additionally, these patients believed that \u0026ldquo;missing a dose is preferable to (safe) overmedication\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG3-P3: \u0026ldquo;I never forget to take the medicine before going to bed because it is the last thing to do before sleep. I often forget to take medicine in the morning, as there are so many things to do and I am always in a hurry. I have forgotten to take my antihypertensive pills several times.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG3-P5: \u0026ldquo;I found several small iron boxes and put the morning medicine, evening medicine, medicine to be taken before meals, and medicine to be taken after meals in different boxes, respectively. When it is time (to take the medicine), I take out the medicine and consume it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAbout half of the respondents emphasized the critical role of family support in effectively managing their chronic conditions. In addition to assisting in disease management, families also provide essential support in various aspects of daily living. Some patients preferred self-sufficiency and were reluctant to impose burdens on their families, especially their children. These patients viewed their children as being engaged in their responsibilities and therefore incapable of offering further assistance. Thus, patients refrain from discussing symptoms and illnesses to avoid imposing additional burdens on their children.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG5-P2: \u0026ldquo;I do not expect the hospital to take such good care of me that I will be completely restored. I think family support is very important. If my wife is in relatively good health, she can be attentive to me in terms of taking medicine, nursing, etc., which may be beneficial to me.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG1-P4: \u0026ldquo;My children are busy with work, and I do not want to trouble them for help. They also have children to take care of and face considerable living burdens. Whenever I feel a bit unwell, I am reluctant to tell them. If you tell them, they will just get worried too.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA subset of patients demonstrated awareness of their personal responsibility in managing lifestyle-related factors, such as smoking cessation and daily rehabilitation exercises. However, the level of implementation appeared to be suboptimal. Furthermore, patients with multimorbidity frequently exhibit proactive behavior in seeking medical information to enhance their understanding of disease, with some even aspiring to utilize this knowledge to guide their treatment decisions. The primary source of medical information for these individuals was the internet; however, the heterogeneous nature and questionable reliability of online resources generated significant concerns regarding their credibility.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eG1-P3: \u0026ldquo;I am fully cognizant that smoking cessation is imperative after being diagnosed with COPD, and I am genuinely motivated to quit. Despite one year of sustained cessation efforts, I have unfortunately relapsed into smoking behavior.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eG4-P3: \u0026ldquo;Following a medical diagnosis, I typically engage in online health information-seeking behavior to investigate the pathogenesis of the condition and explore potential preventive strategies. However, I encounter significant challenges in navigating the extensive volume of heterogeneous medical information available online, which frequently presents conflicting perspectives and varying degrees of reliability.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThemes 2:\u0026nbsp;Healthcare System Challenges: Policy-Driven Fragmentation\u003c/p\u003e\n\u003cp\u003e2a. Ineffective Tiered System\u003c/p\u003e\n\u003cp\u003eMost patients select healthcare institutions on the basis of their individual needs, preferences, and access to medical resources without policy limitations. For example, some respondents expressed reservations about the professional competence of community-based physicians and indicated a preference for seeking care at general hospitals. Moreover, other respondents reported community hospitals as convenient, especially for routine visits, such as seeking care for minor health concerns or obtaining medications.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG4-P2: \u0026ldquo;I am willing to go to a large hospital. This is because the doctors there see more patients and are more experienced. The experience level of community doctors is limited, often leading to misdiagnoses.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlmost all the respondents reported never having experienced the benefits of a formal referral system. Patients typically seek treatment at tertiary hospitals on their own when they encounter issues requiring higher-level care during visits to primary hospitals. Primary care physicians recommended that appropriate hospitals and conscientious doctors frequently remind and urge patients to seek further care, a practice for which patients expressed gratitude.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG1-P3: \u0026ldquo;Once, when I had an acute attack of kidney stones, I was in so much pain that I was rolling on the ground. I went to the community clinic, but they could not handle it and told me to go to Hospital A. However, no urologists were available at the hospital, as the Mid-Autumn Festival was that day. In the end, I had no choice but to go to Hospital B.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2b. Digital Exclusion\u003c/p\u003e\n\u003cp\u003eThe online appointment registration system posed significant difficulties for most respondents, especially elderly patients, who expressed helplessness and uncertainty about navigating healthcare access at advanced ages. In addition, respondents stated that \u0026quot;high-tech\u0026quot;, such as online payments and appointment checkups, have also caused varying degrees of medical burden on them.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG1-P4: \u0026ldquo;Currently, when going to the hospital for medical treatment, it is necessary to make an online appointment for registration first. I do not know how to do it, and I cannot get an appointment either.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThemes 3: Financial burdens: Insurance inequalities as a systemic barrier\u003c/p\u003e\n\u003cp\u003e3a. Urban-Rural Divides\u003c/p\u003e\n\u003cp\u003eThe reimbursement rates vary significantly across different types of medical insurance plans. Compared with urban UEBMI holders, rural participants with NRCMS faced higher out-of-pocket costs. In the interviews, the issue of heavy treatment burden was mentioned more frequently in rural patients. High out-of-pocket expenses can compromise patient adherence, potentially resulting in patients preferring alternative treatments, such as traditional Chinese medicines, rather than physician-recommended treatments. This is because the cost of alternative treatments is lower than that of physician-recommended treatments. The financial burden stemming from inadequate medical insurance coverage compels patients to balance healthcare expenses with other non-medical financial obligations, including bill payments, the ability to support family and leisure activities, and overall savings.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG3-P4: \u0026ldquo;Seeing a doctor is too expensive. Last time, I spent nearly 1,000 yuan during my one-day-and-one-night stay in the emergency department. I feel that I cannot afford to see a doctor anymore.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG1-P4: \u0026ldquo;The out-of-pocket part for medicine has increased. So I have to cut down on other living expenses because I cannot stop taking medicine.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e3b. Policy-Induced Strain\u003c/p\u003e\n\u003cp\u003eGovernment-mandated changes in drug brands and restrictions on prescription durations have contributed to the treatment burden on patients. Some respondents complained that different hospitals, especially community hospitals and higher-level hospitals, often have different brands of the same medication. Sometimes a certain brand of medication suddenly runs out of stock and needs to be replaced with another brand of medication (such as switching from an imported brand to a domestic brand). They are inevitably confused and worried about whether the brand change will affect the treatment effect. Additionally, the respondents expressed frustration with the extended duration required for providing medical services, citing prolonged delays in receiving treatment and scheduling diagnostic examinations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG4-P2: \u0026ldquo;When prescribing medicine, it is necessary to meet the time limit (for example, only 30 days\u0026rsquo; supply can be prescribed) and ensure that it is in whole boxes. Therefore, each time the medicine is prescribed, some can last for 30 days, and some can last for 45 days. When it is time to refill the prescription again, one type of medicine may be available for prescription, while other medicines may not. Therefore, I have to go to the hospital several times, which is truly troublesome.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG5-P1: \u0026ldquo;Over the past two years, the brands of medications I require for long-term use have been successively substituted, raising concerns regarding the consistency of their therapeutic efficacy and the potential adverse effects of such pharmaceutical brand transitions on my health. Occasionally, to procure medications of the original brand, I must visit multiple medical institutions, resulting in significant inconvenience.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThemes 4: Doctor-Patient Dynamics: Hierarchical Care in Transition\u003c/p\u003e\n\u003cp\u003e4a. Communication Gaps\u003c/p\u003e\n\u003cp\u003eThe respondents valued every opportunity to communicate with their physicians. The patients sought a clear understanding of the \u0026ldquo;ins and outs\u0026rdquo; of their conditions and desired explanations of their diagnoses and treatment plans in an accessible and comprehensible manner. However, the patients frequently perceived a lack of effective communication from their physicians, resulting in confusion and uncertainty about their conditions and treatment plans, especially regarding medications. Additionally, patients often lack sufficient understanding of drug interactions and side effects. Some patients also expressed a desire for shared decision-making with their physicians. According to the patients, if they thoroughly understand their health conditions, they can collaborate on treatment plans, including being consulted before finalizing prescriptions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG1-P4: \u0026ldquo;Doctors should proactively explain precautions when prescribing medications to patients. For example, some people take the lipid-lowering drug pitavastatin, whereas others take pravastatin. Why do I take this one, and they take that one? If the doctor could explain it clearly when prescribing the medication for me, I would feel more at ease.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG4-P2: \u0026ldquo;Last time I saw a specialist for kidney stones, he was truly great. He told me that I should drink plenty of water every day. He said, \u0026ldquo;Look, the stones are composed of salts. If you drink a lot of water, you can flush them out. Otherwise, they will settle down and form stones.\u0026rdquo; After he explained it like this, I understood very clearly.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG2-P4: \u0026ldquo;I know best about my own physical condition. I hope I can have a further discussion with the doctor about what I should do.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMore than half of the respondents expressed a need for compassionate care from physicians, including non-medical support, such as a willingness to understand their family circumstances, treatment burdens, and engaging in informal conversations. Patients consider these interactions to provide significant emotional comfort and foster the development of trust-based relationships. However, most respondents felt that physicians often inadequately addressed their needs, especially those in general hospitals. The patients attributed this to physicians\u0026rsquo; overwhelming workloads and time constraints. Patients with multimorbidity reported that they can easily establish close and natural doctor-patient relationships with community-based physicians, owing to frequent and accessible interactions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG3-P3: \u0026ldquo;It always seems that there is something in between doctors and patients. Doctors treat patients as pure patients and themselves as pure doctors. It would be better if doctors and patients could have some small talk. For example, doctors could take the initiative to ask patients about their family conditions and whether they have any financial burdens when seeing a doctor or receiving medications. These simple questions can narrow the gap between doctors and patients. Seeing a doctor in a relaxed atmosphere will make everyone feel good.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG4-P2: \u0026ldquo;Sometimes when the doctor says a few more words to me, it is a great comfort to me and provides strong psychological support. I think that after getting sick, patients have a strong psychological dependence on doctors.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e4b. Continuity vs. Efficiency\u003c/p\u003e\n\u003cp\u003eThe nature of hospital care is compartmentalized, where individual departments address specific conditions. Thus, some respondents were uncertain whether the department or physician should consult for their multiple coexisting conditions. These patients preferred continuity of care with a fixed physician, as this would enable a comprehensive understanding of their health status, reduce consultation time, and prevent redundant examinations resulting from switching doctors, consequently minimizing financial and medical resource waste.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFG2-P3: \u0026ldquo;A specialist can only solve one of my problems. They cannot view the situation comprehensively. I hope that every patient can have a dedicated doctor who can solve most of their problems. Moreover, having a fixed doctor can save many procedures and laboratory tests because he understands my situation. Every time I change to a new doctor, I have to go through all the examinations again.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study comprehensively explores the healthcare experiences of patients with multimorbidity in Beijing, China, within the context of a tiered healthcare system. The findings of this study revealed systemic gaps in care coordination, financial burdens, and patient-provider dynamics, which collectively hinder effective multimorbidity management. These challenges are not unique to China but reflect global issues in managing multimorbidity, especially in LMICs, where healthcare systems are often under-resourced and overburdened [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, the Chinese context adds unique layers of complexity due to the rapid epidemiological transition, the aging population, and the ongoing reforms in the healthcare system. Below, we discuss the implications of these findings and propose targeted interventions to address the identified issues.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLiving with Multimorbidity: Acceptance and Self-Management\u003c/h2\u003e \u003cp\u003eIn this study, patients with multimorbidity often viewed their conditions as an inevitable part of aging, especially those with non-oncological chronic diseases. This acceptance, while potentially reducing psychological distress, does not mitigate the physical, emotional, and social burdens associated with managing multiple chronic conditions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The study highlights the critical role of self-management strategies, such as medication adherence and prioritization of health issues. Moreover, the present study revealed a significant gap in patient education and support.\u003c/p\u003e \u003cp\u003eThis study revealed that patients often do not receive necessary information during these consultations, which was attributed to time constraints and communication challenges. Healthcare providers frequently attribute these issues to systemic limitations within the healthcare framework. For example, Dinh et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] reported that GPs cannot provide adequate support in areas such as health promotion, disease prevention, and self-management due to limited time and resources. Similarly, Damarell et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] highlighted insufficient evidence for managing multimorbidity. Consequently, clinicians do not have clear guidance to address complex clinical questions, further complicating care delivery.\u003c/p\u003e \u003cp\u003eIncreasing the number of healthcare professionals alone may not address challenges in the short term, given the supply-demand imbalance of GPs and resulting doctor-patient conflicts. A more effective approach could leverage underutilized resources, such as nurses and pharmacists, to address care gaps. However, our study revealed that patients rely primarily on physicians, with limited recognition of non-physician providers\u0026rsquo; roles, reflecting the marginalization of team-based care in China\u0026rsquo;s current model. Previous studies [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] highlight that these providers can play a critical role in multimorbidity management, including patient education, daily disease management, and care coordination. Enhancing their training in multimorbidity management could enable the delegation of certain physician responsibilities, supplementing GPs in primary care, while fostering collaborative, integrated care models. Such models could reduce care fragmentation, address service gaps, and mitigate conflicting management approaches [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, this study revealed a notable contrast between the self-management strategies adopted by Chinese patients and those emphasized in Western research. Western studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] often highlight behavioral interventions and lifestyle modifications, whereas Chinese patients with multimorbidity tend to focus predominantly on pharmacological treatments, overlooking the importance of lifestyle changes. This may be due to insufficient patient education. Chinese patients often perceive medication as the primary treatment modality and underestimate the value of behavioral interventions. However, this reliance on pharmacological interventions alone may hinder long-term disease management. Lifestyle modifications and behavioral changes are critical for effective multimorbidity care.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHealthcare System Challenges: Fragmentation and Digital Exclusion\u003c/h3\u003e\n\u003cp\u003eThe tiered healthcare system in China, designed to optimize resource allocation, has inadvertently created fragmentation, with patients often bypassing primary care institutions because of perceived inadequacies in professional competence. This finding aligns with previous research [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] highlighting the underdevelopment of primary care in China and the preference for tertiary hospitals among patients.\u003c/p\u003e \u003cp\u003eDigital exclusion emerged as a significant barrier, particularly for elderly patients who struggle with online appointment systems and other digital healthcare tools. This issue calls for the development of user-friendly digital platforms and alternative access methods to ensure equitable healthcare delivery. Additionally, implementing interoperable electronic health records (EHRs) can reduce fragmentation, minimize redundant tests, and improve care continuity [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Initiatives to promote telemedicine and remote monitoring can also increase access to care, particularly in underserved areas.\u003c/p\u003e\n\u003ch3\u003eFinancial Burdens: Inequities and Policy-Induced Strain\u003c/h3\u003e\n\u003cp\u003eThe study reveals stark disparities in financial burdens, with rural patients facing higher out-of-pocket costs than their urban counterparts. These inequities compromise treatment adherence and force patients to make difficult choices between healthcare and other essential expenses. Government-mandated changes in drug brands and reimbursement policies further exacerbate strain, creating confusion and dissatisfaction among patients.\u003c/p\u003e \u003cp\u003eTo address these issues, policymakers should revise insurance policies to provide comprehensive coverage for chronic disease management, including medications and long-term care. Flexible reimbursement plans tailored to disease progression and transparent drug reimbursement policies could alleviate financial burdens and improve access to necessary treatments [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDoctor-Patient Dynamics: Communication and Continuity of Care\u003c/h2\u003e \u003cp\u003eThis study highlights the importance of doctor-patient relationships and communication in the management of multimorbidity. Patients strongly desire compassionate care, clear communication, and shared decision-making. However, the current healthcare system emphasizes efficiency and throughput but cannot provide meaningful patient-provider interactions.\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated that patient-centered care, which includes shared decision-making (SDM) and continuity of care, is essential for effectively managing multimorbidity. One study [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] reported that although healthcare providers recognize the importance of involving patients with multimorbidity in clinical decision-making, they frequently struggle to implement this in real-world practice consistently. Thus, doctor-patient communication should be improved. Training programs for healthcare providers should focus on patient-centered care, active listening, and SDM. Decision aids could also help bridge the communication gap [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eContinuity of care, which involves consulting the same provider over time, allows for a deep understanding of the patient\u0026rsquo;s history and current situation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This approach can enhance trust, improve treatment adherence, and reduce the burden of navigating a fragmented healthcare system [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Training programs for healthcare providers should emphasize patient-centered communication and shared decision-making to bridge the existing gaps. Pilot programs testing integrated care models, such as multidisciplinary teams, could offer valuable insights for scaling effective solutions [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the single-city focus on Beijing\u0026mdash;a resource-rich megacity with distinct healthcare infrastructure\u0026mdash;may limit generalizability to other regions in China. Rural areas and smaller cities often face greater shortages of primary care resources and more pronounced urban-rural disparities in insurance coverage, which could amplify challenges such as financial burdens or digital exclusion for patients with multimorbidity. Second, the focus group setting may have introduced social desirability bias, as participants might have avoided criticizing healthcare providers or policies due to perceived authority figures (e.g., hospital-affiliated researchers moderating discussions). Third, while rigorous translation and back-translation procedures were employed, nuances in local dialects or culturally specific expressions may have been lost during translation, potentially affecting thematic interpretation. Finally, the purposive sampling strategy, while ensuring diversity in insurance types and geographic settings, may not fully capture underrepresented subgroups. Future multi-center studies across diverse regions could strengthen the external validity of these findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights the complex challenges faced by patients with multimorbidity in navigating the healthcare system. Addressing these challenges requires a multifaceted approach that includes improving patient self-management support, enhancing care coordination, reducing financial burdens, and fostering doctor-patient communication. Policymakers and healthcare providers must collaborate to develop a more patient-centered, integrated healthcare system that meets the needs of this growing population. This will enable China to improve the quality of care for patients with multimorbidity and establish a precedent for other LMICs facing similar challenges.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLMICs \u0026nbsp; Low- and Middle-income Countries\u003c/p\u003e\n\u003cp\u003eGP \u0026nbsp; \u0026nbsp; \u0026nbsp;General Practitioner\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUEBMI \u0026nbsp;Urban Employee Basic Medical Insurance\u003c/p\u003e\n\u003cp\u003eURBMI \u0026nbsp;Urban Resident Basic Medical Insurance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNRCMS \u0026nbsp;New Rural Cooperative Medical Scheme\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEHRs \u0026nbsp; \u0026nbsp;Electronic Health Records\u003c/p\u003e\n\u003cp\u003eSDM \u0026nbsp; \u0026nbsp; Shared Decision-making\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to than all the study participants for their help.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eYCL and MY contributed to the design of the study. YCL analyzed and interpreted data, and wrote the article. JYZ contributed to patient recruitment and organized interviews. YM supervised the study and proofread the manuscript. YCL and JYZ contributed equally to the manuscript. All authors contributed to editing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National High Level Hospital Clinical Research Funding /Scientific Research Seed Fund of Peking University First Hospital(2023SF31); and the National Natural Science Foundation of China (72304005).\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eData sharing restrictions apply to the availability of the data; therefore, they are not publicly available. However, the data of this study can be obtained from the corresponding author under the condition of reasonably making a request.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Research Ethics Committee of the Peking University First Hospital, Beijing, China (2023yan292-002). This study was conducted following the principle of the Declaration of Helsinki. All respondents provided informed, voluntary written consent prior to participating in this study. Permission was also requested from participants prior to audio recording interviews.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSalisbury C. 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Patient priority\u0026ndash;directed decision making and care for older adults with multiple chronic conditions. Clin Geriatr Med.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2016;32:261-75.\u003c/li\u003e\n \u003cli\u003eMoody E, Martin‐Misener R, Baxter L, Boulos L, Burge F, Christian E, et al. Patient perspectives on primary care for multimorbidity: An integrative review. Health Expect.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2022;25:2614-27.\u003c/li\u003e\n \u003cli\u003eThe State Council of the People\u0026apos;s Republic of China. Guidance on promoting the construction of hierarchical diagnosis and treatment system \u0026zwnj;(Guo Ban Fa [2015] No. 70). Gaz State Counc People\u0026apos;s Repub China.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2015;27:27-31.\u003c/li\u003e\n \u003cli\u003eLi X, Krumholz HM, Yip W, Cheng KK, De Maeseneer J, Meng Q, et al. Quality of primary health care in China: challenges and recommendations. Lancet.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;395:1802-12.\u003c/li\u003e\n \u003cli\u003eQin J, Lin C, Zhang L, Zhang Y. Patient satisfaction with primary care in highly focused districts/counties during the comprehensive reform of primary care system in China. Chin Gen Pract.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2018;21:36-40.\u003c/li\u003e\n \u003cli\u003eZhang J, Han P, Sun Y, Zhao J, Yang L. Assessing spatial accessibility to primary health care services in Beijing, China. Int J Environ Res Public Health.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;18:13182.\u003c/li\u003e\n \u003cli\u003eLiu M, Yang J, Wang C, Yang S, Wang J, Hou C, et al. Cohort profile: Beijing Healthy Aging Cohort Study (BHACS). Eur J Epidemiol.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2024;39:101-10.\u003c/li\u003e\n \u003cli\u003eZhang L, Sun F, Li Y, Tang Z, Ma L. Multimorbidity in community-dwelling older adults in Beijing: prevalence and trends, 2004\u0026ndash;2017. J Nutr Health Aging.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;25:116-9.\u003c/li\u003e\n \u003cli\u003eMair FS, Gallacher KI. Multimorbidity: what next? Br J Gen Pract.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;67:248-9.\u003c/li\u003e\n \u003cli\u003ePyo J, Lee W, Choi EY, Jang SG, Ock M. Qualitative research in healthcare: necessity and characteristics. J Prev Med Public Health.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2023;56:12-20.\u003c/li\u003e\n \u003cli\u003eGale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2013;13:117.\u003c/li\u003e\n \u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2007;19:349-57.\u003c/li\u003e\n \u003cli\u003eDuguay C, Gallagher F, Fortin M. The experience of adults with multimorbidity: A qualitative study. J Comorbidity.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2014;4:11-21.\u003c/li\u003e\n \u003cli\u003eBirke H, Jacobsen R, J\u0026oslash;nsson ABR, Guassora ADK, Walther M, Saxild T, et al. A complex intervention for multimorbidity in primary care: A feasibility study. J Comorbidity.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;10:1-8.\u003c/li\u003e\n \u003cli\u003eRosbach M, Andersen JS. Patient-experienced burden of treatment in patients with multimorbidity\u0026ndash;A systematic review of qualitative data. PLoS One.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;12:e0179916.\u003c/li\u003e\n \u003cli\u003eDinh TS, Br\u0026uuml;nn R, Schwarz C, Brueckle MSD, M., Gonz\u0026aacute;lez Gonz\u0026aacute;lez AI, van den Akker M. How do middle-aged patients and their healthcare providers manage multimorbidity? Results of a qualitative study. PLoS One.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2023;18:e0291065.\u003c/li\u003e\n \u003cli\u003eDamarell RA, Morgan DD, Tieman JJ. General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research. BMC Fam Pract.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;21:131.\u003c/li\u003e\n \u003cli\u003eWhitehead L, Palamara P, Allen J, Boak J, Quinn R, George C. Nurses\u0026apos; perceptions and beliefs related to the care of adults living with multimorbidity: A systematic qualitative review. J Clin Nurs.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;31:2716-36.\u003c/li\u003e\n \u003cli\u003eSmith SM, Wallace E, O\u0026apos;Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;1:CD006560.\u003c/li\u003e\n \u003cli\u003eYip W, Fu H, Chen AT, Zhai T, Jian W, Xu R, et al. 10 years of health-care reform in China: progress and gaps in Universal Health Coverage. Lancet.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2019;394:1192-204.\u003c/li\u003e\n \u003cli\u003eQian J, Ramesh M. Strengthening primary health care in China: governance and policy challenges. Health Econ Policy Law.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2023;19:57-72.\u003c/li\u003e\n \u003cli\u003eAramrat C, Choksomngam Y, Jiraporncharoen W, Wiwatkunupakarn N, Pinyopornpanish K, Mallinson PAC, et al. Advancing multimorbidity management in primary care: a narrative review. Prim Health Care Res Dev.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2022;23:e36.\u003c/li\u003e\n \u003cli\u003ede Silva Etges APB, Liu HH, Jones P, Polanczyk CA. Value-based reimbursement as a mechanism to achieve social and financial impact in the healthcare system. J Health Econ Outcomes Res.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2023;10:100-3.\u003c/li\u003e\n \u003cli\u003eSathanapally H, Sidhu M, Fahami R, Gillies C, Kadam U, Davies MJ, et al. Priorities of patients with multimorbidity and of clinicians regarding treatment and health outcomes: a systematic mixed studies review. BMJ Open.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;10:e033445.\u003c/li\u003e\n \u003cli\u003eSchwarz D, Hirschhorn LR, Kim JH, Ratcliffe HL, Bitton A. Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage. BMJ Glob Health.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2019;4:e001435.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e General and health-related characteristics of participants with multimorbidity\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"964\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eParticipants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eAge-ranges(yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eStatus of employment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eEducation background\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eDiagnosis*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eDiagnosis period (yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eHealth insurance**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG1-P1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension,\u003c/p\u003e\n \u003cp\u003eCoronary heart disease (CHD),\u003c/p\u003e\n \u003cp\u003eCerebral infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eFree medical service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG1-P2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u0026ndash;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG1-P3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u0026ndash;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG1-P4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e60-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eDiabetes, Malignant neoplasm of cervix uteri\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG1-P5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e60-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, Osteoporosi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG2-P1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026ge;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eCHD, Chronic obstructive pulmonary disease (COPD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNRCMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eRural or suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG2-P2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, Renal cell carcinoma, Cholecystitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNRCMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eRural or suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG2-P3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, Lipid disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNRCMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eRural or suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG2-P4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, Diabetes, Gastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u0026ndash;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNRCMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eRural or suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG2-P5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e60-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, CHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eURBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eRural or suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG3-P1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026ge;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eCerebral infarction, Lumbar spondylosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNRCMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eRural or suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG3-P2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026ge;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eCerebral infarction, Cervical spondylosis, Rheumatoid arthritis, Gastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNRCMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eRural or suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG3-P3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCollege or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, CHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u0026ndash;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG3-P4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, CHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u0026ndash;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG3-P5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026ge;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, CHD, Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u0026ndash;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG4-P1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCollege or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eLipid disorder, Leiomyoma of uterus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG4-P2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e60-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCollege or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eMalignant neoplasms of bladder, Anemia of other chronic disease, Nontoxic goiter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG4-P3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eworking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, Lipid disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG5-P1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e60-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eretired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eCHD, Lipid disorder, Chronic pancreatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUEBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG5-P2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eworking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCollege or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eDiabetes, Malignant neoplasms of bronchus and lug\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eFree medical service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eCity center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFG5-P3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003efarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHypertension, Non-Hodgkin Lymphoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNRCMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eRural or suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*Diagnostic information classified according to the 10th revision of the International Statistical Classification of Diseases (ICD-10).\u003c/p\u003e\n\u003cp\u003e**UEBMI: Employee Basic Medical Insurance; URBMI: Urban Resident Basic Medical Insurance; NRCMS: New Rural Cooperative Medical Scheme\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Themes and subthemes\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003eThemes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eSubthemes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e1. Living with multimorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003ea. Acceptance as aging\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eb. Self-management Strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e2. Healthcare System Challenges: Policy-Driven Fragmentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003ea. Ineffective Tiered System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eb. Digital Exclusion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e3. Financial Burdens: Insurance Inequities as a Systemic Barrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003ea. Urban-Rural Divides\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eb. Policy-Induced Strain\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003col start=\"4\"\u003e\n \u003cli\u003eDoctor-Patient Dynamics: Hierarchical Care in Transition\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003ea. Communication Gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eb. Continuity vs. Efficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Multimorbidity, Qualitative study, Healthcare experiences, China","lastPublishedDoi":"10.21203/rs.3.rs-6860604/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6860604/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMultimorbidity is a growing public health concern, especially in countries with aging populations. Although a tiered healthcare system has been implemented to improve primary care, managing patients with multimorbidity has been challenging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis study conducted focus group discussions involving 21 patients with multimorbidity in Beijing viaa flexible topic guide to explore their experiences. Participants were sampled from urban and rural areas, ensuring a diverse representation of demographics and health conditions. The datawere analyzed using the framework method. The themes and subthemes were identified through iterative coding and discussion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFour main themes emerged: (1) Living with multimorbidity, where patients view chronic conditions as an inevitable part of aging but strugglewith self-management, particularly medication adherence and lifestyle modifications; (2) healthcaresystem fragmentation, driven by ineffective tiered policies and digital exclusion, especially among elderly patients; (3) financial burdens, with rural patients facing greaterout-of-pocket costs due to insurance inequities and policy-induced strains; and (4) doctor-patient dynamics, where communication gaps and a lack of continuity hinderpatient-centered care. Patients emphasized the need for better care coordination, financial support, and empathetic communication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This study underscores systemic gaps in China's healthcare system for multimorbidity care. To address these issues, policymakers should prioritize (1) strengthening primary care coordination through multidisciplinary teams, (2) expanding financial protection for chronic disease management to reduce urban-rural disparities, and (3) training providers in patient-centered communication and shared decision-making. These actionable steps can serve as a blueprint for LMICs aiming to build integrated, patient-centered systems for multimorbidity management.\u003c/p\u003e","manuscriptTitle":"Navigating Fragmented Care: A Qualitative Study on Multimorbidity Management Challenges in Beijing’s Tiered Healthcare System","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 07:10:41","doi":"10.21203/rs.3.rs-6860604/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-27T05:42:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-27T02:46:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150418120020288526686820587112395806833","date":"2025-06-27T02:39:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-27T00:13:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231203558958713264536882523146921377930","date":"2025-06-18T10:24:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-16T06:22:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T06:14:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-13T09:20:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-13T08:12:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-06-13T06:59:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e7b42135-ca6d-45ab-838c-0e67ef3d3bff","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T16:02:47+00:00","versionOfRecord":{"articleIdentity":"rs-6860604","link":"https://doi.org/10.1186/s12875-025-02967-y","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-08-28 15:57:09","publishedOnDateReadable":"August 28th, 2025"},"versionCreatedAt":"2025-06-18 07:10:41","video":"","vorDoi":"10.1186/s12875-025-02967-y","vorDoiUrl":"https://doi.org/10.1186/s12875-025-02967-y","workflowStages":[]},"version":"v1","identity":"rs-6860604","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6860604","identity":"rs-6860604","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}