Tertiary hospitals or community clinics? An enquiry into the factors affecting patients' choice for healthcare facilities in urban China

Most Chinese patients tend to seek primary care services in tertiary hospitals rather than community clinics, which has caused the malfunction of China's multi-tiered health system. This study aimed to identify the factors that affected patients' decisions when selecting healthcare facilities and use these to design policies to redirect patient flow from tertiary hospitals back to community clinics. A cross-sectional survey was conducted in Shanghai in 2017 using the best-worst scaling experiment. A total of 202 respondents were included in the analysis, including 97 community residents, 56 tertiary hospital patients, and 49 community clinic patients. The latter two had made their choices so the three samples were analyzed separately. Seven attributes were used in the experiment with each varying across two or three levels to accommodate the features of primary care services in Shanghai. The values of attribute levels were estimated using the mixed logit model. Relative importance across attributes and attribute levels were derived and policy simulations were undertaken to examine the impact of changing attribute levels on choices. Results suggest that the three samples are composed of different types of people who presented different preference patterns. The community residents are representative of the population and to them sufficient test and examinations, doctors with expertise, and good service attitude are the most desirable features for a healthcare facility while unfriendly practitioners and lengthy visit the least attractive features. In terms of attributes, friendliness of doctors and the availability of tests and examinations are the two major drivers in selecting healthcare facilities. Our findings provide supportive evidence and useful inputs to the ongoing healthcare reform in China.