Department of Health Economics, School of Health Management, Inner Mongolia Medical University, Hohhot, China.
Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Rd, Wright Hall 116, Athens, GA, 30602, USA.
BMC Health Serv Res. 2021 Aug 30;21(1):895. doi: 10.1186/s12913-021-06908-0.
With economic development, aging of the population, improved insurance coverage, and the absence of a formal referral system, bypassing primary healthcare facilities appear to have become more common. Chinese patients tend to visit the secondary or tertiary healthcare facilities directly leading to overcrowding at the higher-level facilities. This study attempts to analyze the factors associated with bypassing primary care facilities among patients of age 45 years or older in China.
Random effects logistic models were used to examine bypassing of primary health facilities among rural-urban patients. Data from 2011 to 2015 waves of the China Health and Retirement Longitudinal Study were used.
Two in five older patients in China bypass primary health centers (PHC) to access care from higher-tier facilities. Urban patients were nearly twice as likely as rural patients to bypass PHC. Regardless of rural-urban residence, our analysis found that a longer travel time to primary facilities compared to higher-tier facilities increases the likelihood of bypassing. Patients with higher educational attainment were more likely to bypass PHCs. In rural areas, patients who reported their health as poor or those who experienced a recent hospitalization had a higher probability of bypassing PHC. In urban areas, older adults (age 65 years or older) were more likely to bypass PHC than the younger group. Patients with chronic conditions like diabetes also had a higher probability of bypassing.
The findings indicate the importance of strengthening the PHCs in China to improve the efficiency and effectiveness of the health system. Significantly lower out-of-pocket costs at the PHC compared to costs at the higher tiers had little or no impact on increasing the likelihood of utilizing the PHCs. Improving service quality, providing comprehensive person-centered care, focusing on family health care needs, and providing critical preventive services will help increase utilization of PHCs as well as the effectiveness and efficiency of the health system.
随着经济发展、人口老龄化、保险覆盖范围的扩大以及缺乏正式转诊制度，绕过基层医疗机构就诊的现象似乎越来越普遍。中国患者往往直接前往二级或三级医疗机构就诊，导致较高层级医疗机构人满为患。本研究试图分析中国 45 岁及以上患者绕过基层医疗机构就诊的相关因素。
采用随机效应逻辑模型分析城乡患者绕过基层卫生保健机构的情况。使用了 2011 年至 2015 年中国健康与退休纵向研究的数据。
中国有五分之二的老年患者绕过基层医疗中心（PHC）前往更高层级的医疗机构就诊。城市患者绕过 PHC 的可能性是农村患者的近两倍。无论城乡居住情况如何，我们的分析发现，与前往更高层级医疗机构相比，前往基层医疗机构的交通时间较长会增加绕过 PHC 的可能性。受教育程度较高的患者更有可能绕过 PHC。在农村地区，自述健康状况较差或近期住院的患者更有可能绕过 PHC。在城市地区，年龄在 65 岁及以上的老年人比年轻群体更有可能绕过 PHC。患有糖尿病等慢性病的患者也更有可能绕过 PHC。
研究结果表明，中国有必要加强基层医疗机构，以提高卫生系统的效率和效益。与较高层级医疗机构相比，基层医疗机构的自付费用明显较低，但这对增加基层医疗机构的利用率几乎没有影响。提高服务质量，提供全面的以患者为中心的护理，关注家庭的健康需求，提供关键的预防服务，将有助于提高基层医疗机构的利用率以及卫生系统的效率和效益。
