Factors associated with hospital choice of Chinese patients: A meta-analysis

Introduction:

While China continues to optimize the tiered medical care system, the status quo of patients preferring higher-tier hospitals has not improved. Herein, we aimed to analyze the factors influencing patients’ healthcare choices in China and to provide an evidentiary basis for optimizing the tiered healthcare system.

Patient concerns:

Most patients are concerned that primary care services will not provide appropriate treatment or health advice. Also, patients consider medical technology, cost, experience, quality of service and convenience before seeking care.

Outcomes:

A total of 18 cross-sectional studies involving 10,348 samples were included. After combining the effect size, the factors affecting the choice of Chinese patients for medical treatment were medical technology and quality (49%), the convenience of medical treatment (37%), medical expenses (23%), hospital service quality (20%) medical insurance policy (16%), and acquaintance relationship (11%).

Conclusion:

The selection of medical treatment for Chinese residents is primarily influenced by medical technology and convenience. The medical insurance policy does not provide sufficient guidance. Furthermore, the tiered medical care system should be optimized to improve the usability of primary care services.

1. Introduction

The choice of medical treatment is based on the careful consideration of various factors such as medical technology level, medical expenses, medical experience, service quality and convenience of medical treatment, and the selection of a suitable medical institution for medical treatment.^[1] Patients’ medical behavior is affected by a range of internal and external factors. When choosing a medical institution, patients first tend to evaluate the degree of illness and then choose the level of consumption of medical treatment based on the quality of medical care, medical expenses, transportation convenience, and family income.^[2,3] The Chinese National Health and Family Planning Commission placed gradual diagnosis and treatment at the core of the new medical reform in 2015.^[4] According to the Chinese 2018 National Statistical Bulletin on Health Care Development, the proportion of primary medical institutions in the national medical institutions was 92.4%; however, the rate of primary medical treatment reached only 53.1%.^[5] As a result, the number of medical and health institutions at different levels is out of balance with the corresponding number of patients, resulting in unreasonable use of medical resources. In addition, the basic medical insurance system in China is burdened by certain problems, such as the low compensation rate, the limited scope of medical treatments and the reimbursement of medicines, as well as the lack of funding and facilities in primary medical facilities, which also influences patients’ choice of medical treatment.^[6]

In view of the prominent inconsistency between the supply and demand of healthcare services in China, it is socially critical to understand patients’ preferences for medical care and the factors influencing their choices. Thus far, no relevant literature has summarized and analyzed this issue both qualitatively and quantitatively. Therefore, we conducted a meta-analysis of the factors influencing patient choice in China, with the aim of providing an evidence-based medical rationale for optimizing the healthcare system and improving the patient experience.

2. Materials and methods

2.1. Search strategy

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched MEDLINE, EMBASE, CNKI, Wanfang, VIP, China Biology Medicine disc (CBMdisc), and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant studies published from the establishment of the database to December 2021. We developed a search strategy by counseling a medical information specialist using keywords such as “Choice of medical care,” “Health seeking,” “Influencing factors,” “Chinese patient”). To avoid omission of relevant literature, the reviewers conducted multiple reviews of all relevant citations. Moreover, manual searches of reference lists of relevant studies were conducted to identify additional eligible studies.

2.2. Inclusion and exclusion criteria

Inclusion criteria were the following: the language of the literature was restricted to Chinese and English; descriptive or analytic studies of factors influencing Chinese residents’ health care choices published in domestic and foreign journals; each literature had reported research methods and sample size clearly; The study provided a traceable number or proportion of factors influencing residents ‘health care choices.

Exclusion criteria were: duplicate publications; literature with incomplete data and missing information; studies for special populations, including patients with major diseases, occupational diseases, military personnel, and people with disabilities; case reports, comments, and gray literature databases.

2.3. Data extraction and quality assessment

Two authors independently extracted relevant data. Another author made the final decision for the inclusion of the study by reading the full text of the study. Discrepancies were resolved through discussion with the other authors. The abstracted data included the first author’s surname, year of publication, the geographical location of the participants, sex and age range of participants, and the influence of 6 factors on Chinese residents’ choice of medical treatment, such as convenience of medical treatment, medical expenses, medical technology and quality, medical insurance policy, acquaintances, hospital service quality. Two researchers independently evaluated the literature quality by using the observational study quality evaluation recommended by the American Agency for Healthcare Research and Quality (AHRQ), which included 11 items with the highest mark of 11.

2.4. Statistical analysis

The effect size was calculated using the “adjusted and equal-weighted summation” method, after which the transformed rates were selected for meta-analysis to calculate the combined statistic effect size. For pooled data, the I² statistic was used to estimate heterogeneity and risk of bias, specifically publication bias, with the Egger and Begg tests. Small-study effects were assessed in sensitivity analyses. Forest plots were generated showing either prevalence proportions or odds ratio (OR) with a corresponding 95% confidence interval (CI) for each study and the overall random-effects pooled estimate. A subgroup analysis of the included literature was performed to explore sources of heterogeneity. STATA 12 (Stata Corporation, College station, TX) was used for all statistical analyses.

3. Results

Among a total of 1415 extracted articles, 223 were written in the English language. After exclusion and screening in accordance with the inclusion and exclusion criteria, 18 articles were finally included, including one in the English language.^[7–24] The flow chart showing the details of the study selection process is listed in Figure 1.

Figure 1.

PRISMA_flowdiagram2020. PRISMA = preferred reporting items for systematic reviews and meta-analyses.

3.1. Baseline characteristics and quality assessment

The baseline characteristics of participants are listed in Table 1. The included articles clearly underlined the use of the random sampling method for the questionnaire survey. Seventeen of these studies focused on ease of access, cost of care, level of care, and service attitude in the questionnaire. The sample size ranged from 135 to 1632. Fifteen studies focused on specific regions, including 5 in northern China and 10 in southern China. The quality score of articles assessed by the AHRQ criteria ranged from 3 to 7 (see Table 1, http://links.lww.com/MD/I346, Supplemental Content, which illustrates the Quality assessment of included studies by AHRQ criteria).

Table 1.

Baseline characteristics of included studies (N.M: Not Mentioned).

Name	Yr	Sample	Convenience	Expend	Medical technology	Medical insurance	Acquaintance	Service quality	NOS score
Xie Y	2010	135	110	32	11	16	N.M	94	5
Huang H	2010	574	45	114	361	N.M	N.M	49	5
Wu T	2010	271	58	158	N.M	39	16	N.M	5
Yang JN	2011	595	102	174	526	N.M	N.M	190	5
Liu H	2011	322	63	12	310	51	1	18	5
Liu LJ	2011	1632	1084	34	282	42	160	13	5
Xu ZB	2011	1093	N.M	662	439	N.M	N.M	90	5
Zhao RJ	2015	275	53	14	140	18	15	3	5
Li L	2015	435	246	318	344	216	150	251	5
Xiao SX	2016	829	246	6	245	N.M	N.M	50	5
Kang XL	2016	244	52	72	151	45	53	60	5
Duan ZQ	2016	801	89	57	104	38	12	57	5
Liu XL	2016	453	38	24	25	7	9	9	5
Gan Y	2016	681	300	64	414	N.M	N.M	N.M	5
Gan Y	2019	710	380	26	256	15	41	68	5
Xing YY	2020	608	301	212	151	N.M	N.M	229	5
Su Y	2020	536	349	N.M	407	256	N.M	213	5
Zhang Y	2020	154	100	48	117	N.M	48	27	5

3.2. Factors influencing Chinese patients’ choice of medical care

Included studies were tested for heterogeneity, which showed that 7 of included influence factors were all heterogeneous (I² > 90%, P < .01). Thus, a random effects model was used to perform a meta-analysis of factors affecting the medical treatment of Chinese residents. The results of the single-group meta-analysis showed that medical technology and quality were the most significant factors influencing the choice of medical treatment for Chinese patients (49%, 95%CI: 32%~65%) (Fig. 2). Other influencing factors were convenience of medical treatment (37%, 95%CI: 26%~49%), medical expenses (23%, 95%CI: 17%~30%), hospital service quality (20%, 95%CI: 15%~25%), medical insurance policy (16%, 95%CI: 10%~21%), and whether the hospital has acquaintances (11%, 95%CI: 7%~14%) (Figs. 2–4).

Figure 2.

Medical technology.

Figure 4.

Cost, service attitude and service quality, medical insurance policy, and acquaintance.

Figure 3.

Convenience of medical treatment.

3.3. Subgroup analysis

Due to the high heterogeneity between studies, subgroup analysis was used to analyze the sources of heterogeneity. The included studies were classified into subgroups based on region (South and North China), sample size (<500, 501–1000, >1001), and the publication year (2010–2015, 2016–2021). The results of the subgroup analysis showed that the heterogeneity did not disappear in the subgroup.

Subgroup analysis was further conducted by area (urban/rural) (see Figs. 1–6, http://links.lww.com/MD/I347, Supplemental Content, which illustrates The influence of medical technology on residents’ medical choice based on different factors [urban and rural]).

3.4. Publication bias analysis

The Begg’s and Egger’s test showed no publication bias for medical technology (Begg = 0.25, Egger = 0.43) and convenience factors (Begg = 0.1, Egger = 0.13). However, as there were publication biases in other influencing factors (P < .05), we conducted a trim and fill analysis, finding no significant publication bias.

4. Discussion

The results of this systematic review and meta-analysis indicated that the selection of Chinese patients for medical treatment depended on a number of factors. In the present study, we focused on the Chinese population; however, the topic has been rarely described in other languages and regions. Therefore, relevant literature was mainly in the Chinese language. Among these factors, medical technology and quality (49%), convenience of medical treatment (37%), medical expenses (23%), hospital service quality (20%), and medical insurance policy (16%) occupied the top 5 positions, respectively. Diagnostic and treatment technology was at the forefront of the determinants, suggesting that when patients choose medical units, they all wanted to get the best quality medical resources within the range of affordability and relieve the pain as quickly as possible. For patients, the initial treatment does not only relieve pain but also avoids delaying treatment. For chronically ill patients with a long history of illness who need to seek medical treatment many times, the convenience of requesting medical treatment is paramount, which makes the convenience of seeking medical treatment the second most influential factor. However, the medical insurance policy, as an important component in guiding patients to seek orderly medical treatment, was only in the penultimate position, which suggests that China’s current health insurance policy cannot respond to the real situation of residents and the effectiveness of the policy is weak. Although geographic location is not reflected in influencing factors, remote and poor regions are more likely to be constrained in medical options compared to rich regions.^[25–27]

In the past, studies have been carried out on the factors that influence the choice of medical treatment for residents, most of which focused on the residents’ own reasons as a dominant factor.^[28–32] Wei’s^[32] research on the factors affecting patients’ medical choice found that age (OR = 0.737), an education level (OR = 1.430), and monthly income (OR = 1.373) had an impact on patients’ choice of medical institutions. However, there were no statistically significant differences with respect to gender, health status, and marital status (P > .05). Meanwhile, studies have also shown that in terms of outpatient treatment, annual family income, education level, 1-way travel time, and self-evaluation of health status had a significant impact on basic medical treatment. For in-patient treatment, the type of household record, level of education, disability, and self-assessed level of health were found to have a significant effect on basic medical treatment.^[33]

A survey revealed that the utilization rate of primary health and medical services in China was only around 30%, which is below the international average.^[35] Therefore, the government should invest more in primary care facilities and progressively improve the basic drug system according to common diseases, frequent diseases, and chronic diseases. While meeting the basic drug needs of community residents, residents may benefit from preferred medications. At the same time, primary medical institutions should fully implement their geographic benefits to deliver practical and effective health services to patients. General hospitals should design the physician consultation process, reduce wait times and more effectively deliver medical services to patients. The health sector can formulate appropriate policies to encourage doctors to carry out family doctor contracting services and enhance doctor-patient communication and humanistic care. The government and healthcare workers need to do more to help residents access reasonable healthcare services and facilitate their basic access needs in primary care.

5. Limitations

Firstly, 17 out of the included studies were conducted in China; and most of these were in developed regions of China, which did not reflect the overall level and produced limited results. Secondly, the studies were all cross-section studies, limited by the inherent deficiencies of these studies (no control group, large heterogeneity, etc); no adjustment was made to the confounders, and interactions between the factors were not taken into account. Thirdly, the timeliness of the findings of this meta-analysis will diminish as China’s healthcare policies change and the economy develops.

6. Conclusion

The choice of Chinese patients for medical treatment determines the upstream and downstream development of China’s medical and health system and the wide gap in usage effectiveness. This meta-analysis found that superior medical technology, more practical transportation, and lower costs are important factors influencing patients’ choices for medical treatment. However, the reduction in costs and the increase in medical technology appear to be contradictory. As a result, under the existing tiered medical system, patients’ medical options may not change rapidly. In addition, a more reasonable medical insurance policy must be put in place to provide the necessary orientation and triage.

6.1. Implications for behavioral health

The number of medical institutions at different levels is out of balance with the visits of patients, resulting in unreasonable use of medical resources in China. The medical treatment choices of Chinese residents are primarily influenced by medical technology and convenience, and the medical insurance policy does not have a sufficient guiding role. Optimizing the tiered healthcare systems for diagnosis and treatment and creating an efficient behavioral health care model that incorporates geographic considerations and physician-patient communications may enable the expansion of the delivery of public health system services and increase access to more appropriate levels of behavioral health care.

Author contributions

Data curation: Xiaoming Che, Weidong Chen.

Formal analysis: Xiaoming Che, Weidong Chen.

Investigation: Xuehua Wu, Pengcheng Lin.

Methodology: Xuehua Wu, Pengcheng Lin.

Writing – original draft: Xiaoming Che, Weidong Chen, Xuehua Wu, Pengcheng Lin.

Writing – review & editing: Xiaoming Che, Weidong Chen, Xuehua Wu, Pengcheng Lin.

Supplementary Material

medi-102-e32699-s001.pdf ^{(196.9KB, pdf)}

medi-102-e32699-s002.pdf ^{(729.1KB, pdf)}