Choosing health facilities and impact factors of the choice in context of tiered medical system: A questionnaire survey of opinions of patients with multi-morbidity

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BackgroundIn recent years, there has been limited research in China on the behavior of patients with multi-morbidity in choosing healthcare facilities under tiered medical system. Exploring the pattern of their choice will inform to better policy practice. ObjectiveThis study aims to analyze the behavior of patients with multi-morbidity in choosing healthcare facilities in context of tiered medical system, and its influencing factors. This will provide a reference for further implementing the tiered medical system and the rational allocation of medical resources. MethodsUsing a random sampling method, we selected patients with multi-morbidity who attended from June 1, 2019, to January 1, 2020, at the Shanghai Yangpu District Central Hospital Regional Medical Group, which includes Shanghai Yangpu District Central Hospital and three community health centers (Dinghai, Yanji, and Changbai). A self-designed questionnaire was used to collect general data from patients with multi-morbidity, to understand their awareness and actual compliance with the tiered medical system policy, their willingness to first visit community health centers under different disease control conditions, and the factors they consider when choosing healthcare facilities. Binary logistic regression was used to analyze the factors influencing the decision of patients with multi-morbidity to choose community health center for their initial consultation. ResultsA total of 1,100 questionnaires were distributed, and 1,072 valid questionnaires were completed, with a response rate of 97.45 %. Of the 1,072 participants with multi-morbidity, 912 (85.07 %) were aged above 60 years old; 624 participants (58.21 %) were aware of the tiered medical system; 940 participants (87.69 %) were willing to follow the design of medical treatment process under tiered medical system; 368 participants (34.33 %) were very familiar with the “1+1+1” (patients can choose one community health centre, one district hospital and one city hospital as preferred medical facilities, so called ‘1+1+1’ preference) combination contract project; 964 participants (89.93 %) had participated in the “1+1+1” combination contract project, but among these, 44 participants (4.56 %) chose non-contract medical facilities for their current medical treatment. 86.57 % (928/1072) patients with stable multiple conditions and 85.82 % (920/1072) patients with mild poorly controlled conditions choose community health centre as their first preferred medical provider. The factors considered by participants with multi-morbidity when choosing healthcare facilities were ranked by average score as follows: medical accessibility (5.50), medical technology level (5.13), patient satisfaction (3.74), medical insurance (3.60), medical expenses (2.93), and other factors (2.24). Binary logistic regression analysis showed that age and medical insurance were significant influencing factors in the decision to choose community health center for their initial consultation (P<0.05). ConclusionOlder adults are the most affected group by multi-morbidity and the main group choosing community health centre as their preferred medical service providers. Compared to regional medical centers, community health center has higher accessibility, which is a favorable factor for achieving first consultations in primary care for patients with multi-morbidity. Therefore, accelerating the construction of regional medical group, promoting the sharing and applying of high-quality resources in primary care, and improving the service quality and capacity of primary care facilities are beneficial for achieving the first consultations in primary care advocated by tiered medical system.