Liu Yun, Zhong Liwei, Yuan Shasha, van de Klundert Joris
Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
BMJ Glob Health. 2018 Sep 19;3(5):e000854. doi: 10.1136/bmjgh-2018-000854. eCollection 2018.
Despite policy measure to strengthen and promote primary care, Chinese patients increasingly choose to access higher level hospitals. The resulting overcrowding at higher level hospitals and underutilisation of primary care are viewed to diminish the effects of the continuing health system investments on population health. We explore the factors that influence the choice of healthcare facility level in rural and urban China and aim to reveal the underlying choice processes.
We conducted eight semistructured focus group discussions among the general population and the chronically ill in a rural area in Chongqing and an urban area in Shanghai. Respondents' discussions of (evidence-based) factors and how they influenced their facility choices were analysed using qualitative analysis techniques, from which we elicited choice process maps to capture the partial order in which the factors were considered in the choice process.
The factors considered, after initial illness perception, varied over four stages of health service utilisation: initial visit, diagnosis, treatment and treatment continuation. The factors considered per stage differed considerably between the rural and urban respondents, but less so between the general population and the chronically ill. Moreover, the rural respondents considered the township health centres as default and prefer to continue in primary care, yet access higher levels when necessary. Urban respondents chose higher levels by default and seldom moved down to primary care.
Disease severity, medical staff, transportation convenience, equipment and drug availability played important roles when choosing healthcare facilities in China. Strengthening primary care correspondingly may well be effective to increase primary care utilisation by the rural population but insufficient for the urban population. The developed four-stage process maps are general enough to serve as the basis for (partially) ordering factors influencing facility level choices in other contexts.
尽管采取了加强和促进基层医疗的政策措施，但中国患者越来越多地选择前往更高层级的医院就医。由此导致的高层级医院过度拥挤以及基层医疗利用不足的情况，被认为会削弱持续的卫生系统投资对人群健康的影响。我们探讨了影响中国农村和城市地区医疗设施层级选择的因素，旨在揭示潜在的选择过程。
我们在重庆农村地区和上海城市地区的普通人群及慢性病患者中进行了八次半结构化焦点小组讨论。使用定性分析技术分析了受访者对（循证）因素及其如何影响其设施选择的讨论，从中我们绘制了选择过程图，以捕捉在选择过程中考虑这些因素的部分顺序。
在最初的疾病认知之后，所考虑的因素在医疗服务利用的四个阶段有所不同：初诊、诊断、治疗和持续治疗。农村和城市受访者在每个阶段考虑的因素差异很大，但普通人群和慢性病患者之间的差异较小。此外，农村受访者将乡镇卫生院作为默认选择，并倾向于继续在基层医疗就诊，但必要时会前往更高层级的医疗机构。城市受访者默认选择更高层级的医疗机构，很少转回基层医疗。
在中国选择医疗设施时，疾病严重程度、医务人员、交通便利性、设备和药品供应起着重要作用。相应地加强基层医疗可能有效地提高农村人口对基层医疗的利用率，但对城市人口来说还不够。所绘制的四个阶段的过程图具有足够的通用性，可作为在其他背景下对影响设施层级选择的因素进行（部分）排序的基础。
