Public preferences for health care facilities in rural China: A discrete choice experiment

How should regulatory schemes be optimized to enhance deterrence against medical insurance fraud by enrollees? Evidence from a discrete choice experiment in China

Medical insurance fraud (MIF) poses a substantial global financial challenge, necessitating effective regulatory strategies, especially in China, where such measures are in a critical developmental phase. This study investigates the effectiveness of various regulatory components in deterring MIF among enrollees and explores preference heterogeneity among individuals with different characteristics, utilizing a discrete choice experiment survey. Grounded in deterrence theory, our conceptual framework incorporates five attributes: intensity of economic penalties, restrictions on medical insurance benefits, deterioration of social reputation, and certainty and celerity of penalties. Employing a D-efficiency design, 24 choice sets were generated and blocked into three versions. A multistage stratified sampling method was adopted to collect data from the basic medical insurance enrollees in Shanghai. The survey was conducted from September to October 2022. The sample representativeness was further improved via the entropy balancing approach. Data from the final sample of 1034 respondents were analyzed using mixed logit models (MIXLs), incorporating interactions with individual characteristics to assess preference heterogeneity. Results reveal that escalating economic penalties, suspending insurance benefits, listing individuals as unfaithful parties, ensuring penalty certainty, and expediting enforcement significantly enhance the deterrent effect. We observed preference heterogeneity across different demographics, including age, gender, education, health status, and employment status. The study underscores the pivotal role of economic penalties in deterring MIF, while also acknowledging the significance of non-economic measures such as enforcement efficiency and social sanctions. These findings offer valuable insights for policymakers to tailor and strengthen regulatory schemes against MIF, contributing to the advancement of more effective and precise healthcare policies.

Healthcare preferences of chronic disease patients under China's hierarchical medical system: an empirical study of Tianjin's reform practice

To alleviate the contradiction in healthcare resources, the Chinese government formally established the framework of a hierarchical medical system in 2015, which contains the following brief generalities: " separate treatment of emergencies and slows, first-contact care at the primary, two-way referral, and upper and lower linkage, ". This study systematically summarizes and models the connotations of China's hierarchical medical system and a sample of 11,200 chronic disease patients in Tianjin, the largest port city in northern China, was selected for the empirical study to investigate the relationship between chronic disease patients' policy perceptions of the hierarchical medical system and their preference for healthcare. We found that under the strategy of separate treatment, improving the healthcare accessibility, drug supply, and lowering the cost of medical care would have a positive impact on increasing the preference of patients with chronic diseases to go to the primary hospitals. Under the two-way triage strategy, improving the level of physician services, referral convenience and treatment Standards have a positive impact on chronic disease patients' preference for primary care; The impact of the hierarchical medical system on the preference for healthcare differed between groups, focusing on differences in health literacy level, age and household type; The role of " upper and lower linkage " is crucial in the hierarchical medical system and it plays a part in mediating the influence of the " separate treatment of emergencies and slows" design and the "two-way referral " order on the treatment preferences of chronic disease patients. The results of the study provide a reference for the further development of a scientific and rational hierarchical medical system in the future.

Association between health insurance cost-sharing and choice of hospital tier for cardiovascular diseases in China: a prospective cohort study

Background

Hospitals in China are classified into tiers (1, 2 or 3), with the largest (tier 3) having more equipment and specialist staff. Differential health insurance cost-sharing by hospital tier (lower deductibles and higher reimbursement rates in lower tiers) was introduced to reduce overcrowding in higher tier hospitals, promote use of lower tier hospitals, and limit escalating healthcare costs. However, little is known about the effects of differential cost-sharing in health insurance schemes on choice of hospital tiers.

Methods

In a 9-year follow-up of a prospective study of 0.5 M adults from 10 areas in China, we examined the associations between differential health insurance cost-sharing and choice of hospital tiers for patients with a first hospitalisation for stroke or ischaemic heart disease (IHD) in 2009-2017. Analyses were performed separately in urban areas (stroke: n = 20,302; IHD: n = 19,283) and rural areas (stroke: n = 21,130; IHD: n = 17,890), using conditional logit models and adjusting for individual socioeconomic and health characteristics.

Findings

About 64-68% of stroke and IHD cases in urban areas and 27-29% in rural areas chose tier 3 hospitals. In urban areas, higher reimbursement rates in each tier and lower tier 3 deductibles were associated with a greater likelihood of choosing their respective hospital tiers. In rural areas, the effects of cost-sharing were modest, suggesting a greater contribution of other factors. Higher socioeconomic status and greater disease severity were associated with a greater likelihood of seeking care in higher tier hospitals in urban and rural areas.

Interpretation

Patient choice of hospital tiers for treatment of stroke and IHD in China was influenced by differential cost-sharing in urban areas, but not in rural areas. Further strategies are required to incentivise appropriate health seeking behaviour and promote more efficient hospital use.

Funding

Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and National Natural Science Foundation of China.

Equity and efficiency of health resource allocation in township health centers in Sichuan Province, China

OBJECTIVE

To analyze the equity and efficiency of health resource allocation in township health centers in Sichuan Province, and to provide a scientific basis for promoting the development of township health centers in Sichuan Province, China.

METHODS

The Lorenz curve, Gini coefficient and health resource density index were used to analyze the equity of health resource allocation in township health centers in Sichuan Province from 2017 to 2021, and data envelopment analysis(DEA) was used to analyze the efficiency of health resource allocation in township health centers in Sichuan Province from 2017 to 2021.

RESULTS

The Gini coefficient of health resources of township health centers in Sichuan Province is below 0.2 by population in addition to the number of beds in 2020-2021 and practicing (assistant) physicians in 2021, and the Gini coefficient of health resources of township health centers in Sichuan Province is above 0.6 by geography. The Lorentz curve of health resources of township health centers in Sichuan Province is closer to the equity line by population allocation and further from the equity line by geographical allocation. The average level of township health centers in Sichuan Province is used as the standard to calculate the health resource density standard index(W) of each region, the Ws of Panzhihua, Ganzi, Aba and Liangshan are less than 1, and the Ws of Ziyang, Neijiang, Deyang and Meishan are greater than 1. The overall efficiency of township health centers in Sichuan Province in 2017 and 2021 is 1, and the DEA is relatively effective. The overall efficiency of township health centers in Sichuan Province in 2018 and 2019 is not 1, and the DEA is relatively ineffective. The overall efficiency of all health resources in Mianyang and Ziyang is 1, and the DEA is relatively effective. The overall efficiency of all health resources in Suining, Neijiang, Yibin, Aba and Ganzi is not 1, and the DEA is relatively ineffective.

CONCLUSION

The equity of health resource allocation by population is better than that by geography in township health centers in Sichuan Province. Combining population and geographical factors, the health resource allocation of Panzhihua, Ganzi, Aba and Liangshan is lower than the average level of Sichuan Province. The efficiency of health resource allocation in township health centers in Sichuan Province is low.

Unveiling the Evolution of Eldercare Facilities in Rural China: Tracing the Trajectory from Eldercare Support Pattern and Service to Facilities for the Aging Population

The phenomenon of population aging in rural China presents a compelling societal challenge, necessitating a growing demand for both the quantity and quality of facilities supporting the needs of older people. However, a lack of comprehensive understanding concerning the underlying mechanisms that drive the emergence of these facilities, coupled with the distinctive historical backdrop and social development stage of the nation, engenders complexities in achieving sustainable rural eldercare services. This paper endeavors to comprehensively elucidate diverse eldercare facility types in rural China, delineating their intrinsic characteristics and prerequisites for construction. Additionally, the research delves into the political and economic contexts and advancements in healthcare and eldercare services, culminating in the formulation of an integrated framework that interconnects eldercare support patterns with the political landscape and public service provisions. The implications derived from this nuanced framework provide insightful reflections on significant historical transitions, intricacies faced by rural eldercare facilities, and strategic pathways for fostering future eldercare service delivery systems and allied facilities. The paper's findings furnish insights for bolstering the well-being of the aging population in rural China and lay a substantive foundation for addressing the evolving requisites of eldercare within this distinctive context.

Preferences for Enhanced Primary Care Services Among Older Individuals and Primary Care Physicians

OBJECTIVE

We aimed to identify the factors that are most important for community-dwelling older individuals (i.e., users) and primary care (PC) providers to enhance PC services.

METHODS

Discrete choice experiment surveys were administered to 747 individuals aged ≥ 60 years and 242 PC physicians in Singapore between December 2020 and August 2021. Participants were asked to choose between two hypothetical PC clinics and their current clinic. Latent class models were used to estimate the relative attribute importance (RAI) and to calculate the predicted uptake for enhanced PC services.

RESULTS

Based on the attributes and levels used in this study, the out-of-pocket cost (RAI: 47%) and types of services offered (RAI: 25%) were the most important attributes for users while working hours (RAI: 28%) and patient load (RAI: 25%) were the most important for providers. For out-of-pocket visit costs ranging from Singapore dollars (S)$100 to S$5, users' predicted uptake for enhanced PC services ranged from 46 to 84%. For daily patient loads ranging from 60 to 20 patients, providers' predicted uptake ranged from 64 to 91%, assuming their income remains unchanged.

CONCLUSIONS

Our study provides timely insights for the development of strategies to support the government's new health care initiative (HealthierSG), which places PC at the center of Singapore's healthcare system. The ability to choose their preferred clinic, low out-of-pocket costs and types of services offered (for users), and reasonable working conditions (for providers) were the key factors for users and providers to participate in enhanced PC services.

Preferences of patients with diabetes mellitus for primary healthcare institutions: a discrete choice experiment in China

OBJECTIVES

To quantify the preference of patients with diabetes mellitus (DM) for primary healthcare (PHC) institutions in China to redirect the patient flow and improve health outcomes.

DESIGN

Cross-sectional study. Discrete choice experiment (DCE) surveys asked patients with DM to choose between hypothetical institutions that differed in the medical service capacity, out-of-pocket (OOP) medical costs per month, travel time, the attitude of medical staff and the availability of diabetes drugs.

SETTING

Shandong province, China.

PARTICIPANTS

The participants were 887 patients with DM from 36 urban communities and 36 rural villages in Shandong province. One participant did not provide any DCE answers and a further 57 patients failed the internal consistency test. 829 fully completed surveys were included in the final data analysis.

MAIN OUTCOMES AND MEASURES

A mixed logit model was used to calculate the willingness to pay and predict choice probabilities for PHC institution attributes. Preference heterogeneity was also investigated.

RESULTS

All five attributes were associated with the preferences of patients with DM. The OOP medical costs and the medical service capacity were the most influential attributes. Improvements simultaneously in the attitude of medical staff, drug availability and travel time increased the likelihood of a patient's PHC institution choice. Preferences differed by region, annual household income and duration of diabetes.

CONCLUSIONS

Our patient preference data may help policymakers improve health services and increase acceptance of choosing PHC institutions. The OOP medical costs and medical service capacity should be regarded as a priority in decision-making.

Examining clinical capability of township healthcare centres for rural health service planning in Sichuan, China: an administrative data analysis

OBJECTIVE

This study aimed to examine the clinical capability of township healthcare centres (THCs), the main primary care providers in rural China, as a basis for rural health service planning.

DESIGN

Observational study of quantitative analysis using administrative data.

SETTING

Three counties with low, middle and high social economic development level, respectively, in Sichuan province western China.

PARTICIPANTS

9 THCs and 6 county hospitals (CHs) were purposively selected in the three counties. Summary of electronic medical records of 31 633 admissions from 1 January 2015 to 30 December 2015 of these selected health institutions was obtained from the Health Information Centre of Sichuan province.

MAIN OUTCOME MEASURES

Six indicators in scope of inpatient services related to diseases and surgeries in the THCs as proxy of clinical capability, were compared against national standard of capability building of THCs, among counties, and between THCs and CHs of each county.

RESULTS

The clinical capability of THCs was suboptimal against the national standard, though that of the middle-developed county was better than that in the rich and the poor counties. THCs mainly provided services of infectious or inflammatory diseases, of respiratory and digestive systems, but lacked clinical services related to injuries, poisoning, pregnancy, childbirth and surgeries. A large proportion of the top 20 diseases of inpatients were potentially avoidable hospitalisations (PAHs) and were overlapped between THCs and CHs.

CONCLUSIONS

The clinical capability of THCs was generally suboptimal against national standard. It may be affected by the economics, population size, facilities, workforce and the share of services of THCs in local health systems. Identification of absent services and PAHs may help to identify development priorities of local THCs. Clarification of the roles of THCs and CHs in the tiered rural health system in China is warranted to develop a better integrated health system.

The heterogeneity of public preferences for the first healthcare visit: A discrete choice experiment in the context of Vietnam

Primary healthcare is critical in addressing the main health problems of communities. In Vietnam, the increasing healthcare demands cause major challenges, especially overcrowding. This study identified public preferences regarding the selection of healthcare facilities for first visit. A discrete choice online survey was generated from five attributes including visit duration, travel time, personal connection with medical staff, doctors' experience, and health insurance. A D_z -efficient design constructed 36 choice sets, divided into three blocks of 12 choice sets. Each block formed one version of the questionnaire, which was randomly distributed to the participants. Heterogeneity in participant preferences was analysed by a latent class model with socio demographic characteristics and experiences of the last visit. 822 participants valued doctors' experience for both minor and severe symptoms. Preference heterogeneity for minor symptoms was quick service provision, highly experienced doctors, and payment through health insurance for the first (44.18%), second (32.17%), and third classes (23.66%), respectively. Regarding severe symptoms, they favoured all five attributes, quick health service, and reduced travel time for the first, second, and third classes, respectively (heterogeneities of 58.16%, 27.79%, and 14.05%, respectively). Predictions of choice from the worst to optimal healthcare facility scenario were 8.91%-61.91% and 10.16%-69.83% for minor and severe symptoms, respectively. Knowledge regarding public preference heterogeneity supports policymakers increase public acceptance in choosing primary healthcare facilities. Visit duration and doctors' experience should be considered a priority in decision making.

Preferences for public long-term care insurance among middle-aged and elderly residents: A discrete choice experiment in Hubei Province, China

Objective

It is critical to incorporate residents' preferences into the design of long-term care insurance (LTCI). However, little is known about middle-aged and elderly residents' preferences for personalized need-related attributes of LTCI in China. Through a discrete choice experiment (DCE), we aimed to focus on the direct beneficiaries of LTCI and then elicit their preferences for LTCI under a hypothetical scenario of dysfunction.

Methods

Attributes and levels were defined through a literature review and two rounds of expert consultations (n = 8). A D-optimal fractional factorial design was used to generate the DCE questionnaire. Face-to-face interviews with middle-aged and elderly residents were conducted in two cities in Hubei Province, China, between November and December 2020. A mixed logit model was utilized for estimation.

Results

Five attributes were identified and incorporated into the DCE questionnaire. A total of 390 participants completed DCE questionnaires. Care facilities, care content, reimbursement rate, caregivers, and annual premium per person all had a significant impact on residents' preferences. Residents had significantly higher preferences for the LTCI scheme with home and community-based care centers (β = 1.40, p < 0.01), multi-level services (β = 0.44, p < 0.01), 90% reimbursement rate (β = 0.37, p < 0.01), and sufficiently trained caregivers (β = 0.26, p < 0.01). Individual characteristics, such as gender, employment, and education level were the factors that drove heterogeneity in preferences for LTCI.

Conclusion

This study provides new evidence on the preferences of middle-aged and elderly residents for personalized need-related public LTCI features. The design of the LTCI scheme in China needs to take these findings into account to maximize the utility for direct beneficiaries of LTCI and enhance their enrollment.

Health service behaviors of migrants: A conceptual framework

Universal health coverage is vital to the World Health Organization's (WHO's) efforts to ensure access to health as a human right. However, it has been reported that migrants, including both international immigrants and internal migrants, underuse health services. Establishing a conceptual framework to facilitate research on the health service behaviors (HSB) of migrants is particularly important. Many theoretical frameworks explaining the general population's HSB have been published; however, most theoretical frameworks on migrants' HSB only focus on international immigrants without the inclusion of internal migrants. Of note, internal migrants are much more abundant than immigrants, and this group faces similar barriers to HSB as immigrants do. Based on theoretical frameworks of immigrants' HSB and Anderson's behavior model, the author proposes a new conceptual framework of migrants' HSB that includes both immigrants and internal migrants. The new conceptual framework divides the determinants into macro-structural or contextual factors, health delivery system characteristics, and characteristics of the population at risk and describes subgroup-specific factors. The author added some variables and reclassified variables in some dimensions, including characteristics of health delivery systems and access to healthcare. The characteristics of health delivery systems comprise the volume, organization, quality, and cost of the health delivery system, while the characteristics of access to healthcare include time accessibility, geographic accessibility, and information accessibility. The outcomes of HSB have been expanded, and relationships between them have been reported. The mediating effects of some variables have also been described. This conceptual framework can facilitate a deep and comprehensive understanding of the HSB determination process for migrants, including internal migrants.

Healthcare preferences of the general Chinese population in the hierarchical medical system: A discrete choice experiment

Background

Chinese health insurance system faces resource distribution challenges. A patient-centric approach allows decision-makers to be keenly aware of optimized medical resource allocation.

Objective

This study aims to use the discrete choice model to determine the main factors affecting the healthcare preferences of the general Chinese population and their weights in the three scenarios (chronic non-communicable diseases, acute infectious diseases, and major diseases).

Methods

This study firstly identified the key factors affecting people's healthcare preferences through literature review and qualitative interviews, and then designed the DCE questionnaire. An online questionnaire produced by Lighthouse Studio (version 9.9.1) software was distributed to voluntary respondents recruited from mainland China's entire population from January 2021 to June 2021. Participants were required to answer a total of 21 questions of three scenarios in the questionnaire. The multinomial logit model and latent class model were used to analyze the collected data.

Results

A total of 4,156 participants from mainland China were included in this study. The multinomial logit and latent class model analyses showed that medical insurance reimbursement is the most important attribute in all three disease scenarios. In the scenario of "non-communicable diseases," the attributes that participants valued were, from the most to the least, medical insurance reimbursement (45.0%), hospital-level (21.6%), distance (14.4%), cost (9.7%), waiting time (8.3%), and care provider (1.0%). As for willingness to pay (WTP), participants were willing to pay 204.5 yuan, or 1,743.8 yuan, to change from private hospitals or community hospitals to tertiary hospitals, respectively.

Conclusions

This study explores the healthcare preferences of Chinese residents from a new perspective, which can provide theoretical reference for the refinement of many disease medical reimbursement policies, such as developing different reimbursement ratios for various common diseases and realizing rational configuration of medical resources.

Maternal choices and preferences for screening strategies of gestational diabetes mellitus: A exploratory study using discrete choice experiment

Aims

This study aimed to investigate maternal preferences for gestational diabetes mellitus (GDM) screening options in rural China to identify an optimal GDM screening strategy.

Methods

Pregnant women at 24-28 gestational weeks were recruited from Shandong province, China. A discrete choice experiment (DCE) was conducted to elicit pregnant women's preferences for GDM screening strategy defined by five attributes: number of blood draws, out-of-pocket costs, screening waiting-time, number of hospital visits, and positive diagnosis rate. A mixed logistic model was employed to quantify maternal preferences, and to estimate the relative importance of included attributes in determining pregnant women's preferences for two routinely applied screening strategies ("one-step": 75 g oral glucose tolerance test [OGTT] and "two-step": 50 g glucose challenge-test plus 75 g OGTT). Preference heterogeneity was also investigated.

Results

N = 287 participants completed the DCE survey. All five predefined attributes were associated with pregnant women's preferences. Diagnostic rate was the most influential attribute (17.5 vs. 8.0%, OR: 2.89; 95%CI: 2.10 to 3.96). When changes of the attributes of "two-step" to "one-step" strategies, women's uptake probability from full "two-step" to "one-step" significantly increased with 71.3% (95%CI: 52.2 to 90.1%), but no significant difference with the first step of "two-step" (-31.0%, 95%CI: -70.2 to 8.1%).

Conclusion

Chinese pregnant women preferred the "one-step" screening strategy to the full "two-step" strategy, but were indifferent between "one-step" and the first step of "two-step" strategies.

Socioeconomic Disparities in Iranians’ Preferences toward Dental Care Services: A Population-Based Survey

Background and Aims

Patients' perspectives and preferences are considered an essential influencing factor for healthcare utilization. This study is one of the first to investigate patient preference for dental services across socioeconomic and demographic indicators in Iran.

Materials and Methods

This cross-sectional study was conducted through telephone interviews with adult residents in Mashhad and Kerman cities. A representative sample was selected by stratified random sampling. A valid structured questionnaire was used for data collection, including people's preference toward dental care services in terms of dental settings, choosing a general or specialist dentist, prevention or treatment, and the preferable gender of the dentist. Factors potentially associated with preferences included gender, age, educational level, job, monthly income, house size, family number, insurance coverage, dental insurance, type of insurance, and social class in the city were investigated.

Results

1475 individuals participated in the study [response rate 63%]. Our findings showed higher preferences for private offices (50.6%), specialist dentists (76.2%), treatment services (40.8%), and no specific gender preference for the dentist (60.6%). Their preferences were significantly influenced by age range, social class, insurance status, dental insurance, and type of insurance. Income, household size, level of education, and job were not statistically significant with none of the preferences.

Conclusions

Socioeconomic and demographic factors' correlation with people's preferences was observed. Efforts are needed to promote preventive care demand in deprived regions. Moreover, increasing financial resources allocated to preventive care and covering preventive dental services in insurance plans are recommended.

Would you zoom with your doctor? A discrete choice experiment to identify patient preferences for video and in-clinic consultations in German primary care

INTRODUCTION

The popularity of video consultations in healthcare has accelerated during the COVID-19 pandemic. Despite increased availability and obvious benefits, many patients remain hesitant to use video consultations. This study investigates the relative importance of the consultation mode compared to other attributes in patients' appointment choices in Germany.

METHODS

A discrete choice experiment was conducted to examine the influence of appointment attributes on preferences for video over in-clinic consultations. A total of 350 participants were included in the analysis.

RESULTS

The level of continuity of care (46%) and the waiting time until the next available appointment (22%) were shown to have higher relative importance than consultation mode (18%) and other attributes. Participants with fewer data privacy concerns, higher technology proficiency, and more fear of COVID-19 tended to prefer video over in-clinic consultations. The predicted choice probability of a video over a typical in-clinic consultation and opting out increased from <1% to 40% when the video consultation was improved from the worst-case to the best-case scenario.

CONCLUSION

This study provides insight into the effect of the consultation mode on appointment choice at a time when telemedicine gains momentum. The results suggest that participants preferred in-clinic over video consultations. Policymakers and service providers should focus on increasing the level of continuity of care and decreasing the time until the next available appointment to prompt the adoption of video consultations. Although participants preferred to talk to their physician in person over consulting via video per se, the demand for video consultations can be increased significantly by improving the other appointment attributes of video consultations such as the level of continuity of care.

Provider competence in hypertension management and challenges of the rural primary healthcare system in Sichuan province, China: a study based on standardized clinical vignettes

BACKGROUND

Improving primary care providers' competence is key to detecting and managing hypertension, but evidence to guide this work has been limited, particularly for rural areas. This study aimed to use standardized clinical vignettes to assess the competence of providers and the ability of the primary healthcare system to detect and manage hypertension in rural China.

METHODS

A multi-stage random sampling method was administered to select target health facilities, providers, and households. The clinical vignette script was developed to evaluate provider competence in managing first-visit patients with symptoms of hypertension. Logistic regression was used to explore the factors correlated with provider competence. Provider referral and management rates were combined with patients' facility sorting behaviors to assess the ability of the rural healthcare system to manage hypertension in three policy scenarios.

RESULTS

A total of 306 providers and 153 facilities were enrolled in our study. In the 306 clinical vignette interactions, 25.9% of providers followed the national guidelines for hypertension consultation. The correct diagnosis was achieved by only 10.1% of providers, and 30.4% of providers were able to prescribe the correct treatment. Multi-variable regression results showed that younger providers (OR = 0.85, 95%CI: 0.73, 0.98) and those who work in township health centers (OR = 4.47, 95%: 1.07, 18.67) were more likely to provide a correct diagnosis. In a free-selection scenario, 29.8% of patients with hypertension were managed correctly throughout the rural system. When all patients first visit village clinics, system-level correct management is reduced to 20.5% but increases to 45.0% when all patients first visit township health centers.

CONCLUSIONS

Rural primary care providers do not have enough competence to detect and treat hypertension cases in China to an acceptable degree. Policy constraints may limit the competence of the rural healthcare system. Research to improve detection and treatment competence in hypertension and optimize health policy is needed.

Analysis on the willingness and influencing factors of choosing primary healthcare institutions among patients with chronic conditions in China: a cross-sectional study

OBJECTIVE

To assess the willingness and factors influencing the choice of primary healthcare (PHC) institutions among patients with chronic conditions in China.

DESIGN

A nationwide population-based study with binary logistic regression was conducted and used to estimate the ORs of the influencing factors of health-seeking at PHC institutions using the Anderson model as a theoretical framework.

SETTING

The China Family Panel Studies (CFPS) database.

PARTICIPANTS

The study sample included 7967 patients with chronic conditions identified from the 2016 and 2018 CFPS databases.

RESULTS

From 2016 to 2018, the rate of choosing PHC institutions for patients with chronic conditions dropped from 51.0% to 47.7%. The logistic regression results showed that patients with low family income (OR value of >60 000 group was 0.57, 95% CI 0.43 to 0.74), low education level (OR value of bachelor degree or above was 0.54, 95% CI 0.35 to 0.83;), older age (OR value of >65 group was 1.31, 95% CI 1.08 to 1.60;), hypertension and diabetes (OR 1.26, 95% CI 1.13 to 1.41), living in rural areas (OR value of urban was 0.47, 95% CI 0.38 to 0.60), immigrating from rural to urban areas (OR 1.64, 95% CI 1.26 to 2.13), reporting good health (OR value of very good was 1.33, 95% CI 1.05 to 1.68) and those from areas with a high proportion of PHC institutions (OR 1.05, 95% CI 1.02 to 1.07) were more inclined to choose PHC institutions. Conversely, patients with urban employee health insurance (OR 0.62, 95% CI 0.49 to 0.80) and more than one chronic disease (OR 0,83, 95% CI 0.75 to 0.92) preferred choosing a hospital.

CONCLUSIONS

The patients' willingness to choose PHC institutions was low. The health-seeking preference of patients with chronic conditions is derived from medical needs and is influenced by the predisposing factors and tendencies of enabling resources. Measures should be taken to improve the capacity of PHC institutions.

Stated preferences for family doctor contract services: a survey of the rural elderly in Anhui Province, China

OBJECTIVE

A number of factors contribute to the utilisation of family doctor contract services (FDCS) in China. This study aims to measure the preferences of the elderly for the FDCS and identify the key factors (and their relative importance) that may guide policymakers in more accurately providing the FDCS.

PARTICIPANTS AND METHODS

A discrete choice experiment was performed to elicit the preferences for FDCS among the rural elderly in China. Attributes and levels were established based on qualitative methods. Four attributes were included: service type, service package, physician's reputation and annual contract costs. A D-efficient design was used to create a set of profiles that represented FDCS. The survey was conducted face to face using a sample of participants aged 60 and above in rural areas of Anhui Province. The data were analysed using a latent class logit (LCL) model.

RESULTS

A total of 545 valid questionnaires were included in the analysis. The average age of the participants was 69.44 (SD 5.80). Two latent classes were identified with the LCL model. All four attributes proved statistically significant at the level of both the population mean and the two classes. The rural elderly showed a preference for FDCS with a relatively good reputation, lower annual contract costs, the basic service with the add-on of chronic disease service and home visit. Age, gender, education, self-reported health status and the number of chronic diseases were found to be associated with latent class membership.

CONCLUSION

In this study, the physician's reputation had the largest impact on the rural elderly's choice of FDCS. Policy recommendations included the need to strengthen family doctor team training, devote greater attention to improving the family doctor's medical skills and service approaches, and increased FDCS efficiency for the care of the rural elderly.

Preferences for healthcare services among hypertension patients in China: a discrete choice experiment

OBJECTIVES

Our study aimed to support evidence-informed policy-making on patient-centred care by investigating preferences for healthcare services among hypertension patients.

DESIGN

We identified six attributes of healthcare services for a discrete choice experiment (DCE), and applied Bayesian-efficient design with blocking techniques to generate choice sets. After conducting the DCE, we used a mixed logit regression model to investigate patients' preferences for each attribute and analysed the heterogeneities in preferences. Estimates of willingness to pay were derived from regression coefficients.

SETTING

The DCE was conducted in Jiangsu province and Shanghai municipality in China.

PARTICIPANTS

Patients aged 18 years or older with a history of hypertension for at least 2 years and who took medications regularly were recruited.

RESULTS

Patients highly valued healthcare services that produced good treatment effects (β=4.502, p<0.001), followed by travel time to healthcare facilities within 1 hour (β=1.285, p<0.001), and the effective physician-patient communication (β=0.771, p<0.001). Continuity of care and minimal waiting time were also positive predictors (p<0.001). However, the out-of-pocket cost was a negative predictor of patients' choice (β=-0.168, p<0.001). Older adults, patients with good health-related quality of life, had comorbidities, and who were likely to visit secondary and tertiary hospitals cared more about favourable effects (p<0.05). Patients were willing to pay ¥2489 (95% CI ¥2013 to ¥2965) as long as the clinical benefits gained were substantial.

CONCLUSIONS

Our findings highlight the importance of effective, convenient, efficient, coordinated and patient-centred care for chronic diseases like hypertension. Policy-makers and healthcare providers are suggested to work on aligning the service provision with patients' preferences.

Community residents' preferences for chronic disease management in Primary Care Facilities in China: a stated preference survey

Background

Although Chinese government has dedicated the past decades to treating chronic diseases by primary healthcare system, many more residents are apt to choose higher-tier facilities to treat minor chronic diseases. Understanding residents’ preferences for chronic disease management in primary care facilities can bridge the gap between residents’ choices and policy implementation. This study aims to elicit residents’ preferences for chronic disease management in primary care facilities in the hypothetical minor chronic disease scenario.

Methods

Six hundred eighty residents were administered a discrete choice experiment that elicited preferences for chronic disease management in primary care facilities. Services attributes were service mode, treatment measure, out-of-pocket expenditure (OOP), traveling time to healthcare facility and title of physician. Mixed logit models were used to estimate stated preferences and willingness to pay for attributes. WTP confidence intervals were estimated by the delta method.

Results

A total of 94.44% of the completed questionnaires were valid (680 of 720 respondents). The participants preferred chronic disease management service with modern medicine, traveling time ≤ 30mins, and less OOP expenditure. Compared with Traditional Chinese Medicine (TCM), residents prefer modern medicine, willing to pay 155.53 CNY ($21.97) to change from TCM to modern medicine. Compensation about 86.02 CNY ($12.15) was needed to enable residents to change the choice of the nearer primary care facility to a further one. Integrated medicine in community clinics by experts was residents’ most preferred scenario while TCM in the tertiary hospital was their least preferred one.

Conclusion

In order to increase the utilization of primary healthcare services in chronic diseases management, policy makers need to concern more about the services of medical treatment type, price and convenience. Therefore, we advise policy makers to provide nearer primary healthcare services for residents especially for residents in surrounding areas. Furthermore, balancing the resource allocation between Traditional Chinese Medicine and modern medicine is worthy of consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00728-8.

Measurements of quality of village-level care and patients' healthcare-seeking behaviors in rural China

Background

Although the progress in global health initiatives has improved the availability of primary health care (PHC), unqualified healthcare remains a serious challenge in low- and middle-income countries, where PHC is often underutilized. This study examines factors associated with patients’ healthcare-seeking behaviors in rural Chin—seeking healthcare at village-level PHC providers, at higher-level health facilities, self-medicating, and refraining from seeking medical help. We focus on provider-side factors, including (1) the unobservable quality indicator, (2) the observable quality indicator, and (3) the observable signal indicator.

Methods

We analyzed 1578 episodes of healthcare-seeking behaviors of patients with diarrhea or cough/runny nose symptom from surveys conducted in July 2017 and January 2018 in 114 villages of the Yunnan province. We investigated the correlation between quality-related factors with patients’ healthcare-seeking behaviors by multinomial logit regression.

Results

We found that rural patients were insensitive to the unobservable quality of healthcare providers, as measured by standardized clinical vignettes, which might be attributable to the credence nature of PHC. The observable quality indicator, whether the clinician has received full-time junior college formal medical education, was associated with patients’ healthcare choices. Patients, however, were more likely to select healthcare based on the observable signal indicator, which was measured by the availability of medicines. Additionally, the observable signal indicator had no significant association with two quality indicators. Notably, socioeconomically-disadvantaged patients relied more on the village-level PHC, which emphasized the role of PHC in promoting the welfare of rural populations.

Conclusions

Our study found an inconsistency between objective quality of healthcare provided by providers and subjective quality perceived by patients. Patients could not identify the actual quality of PHC precisely, while they were more likely to make decisions based on the observable signal indicator. Therefore, the quality of PHC should be more observable to patients. This study not only supplements the literature on healthcare-seeking choices by examining four types of behaviors simultaneously but also clarifies rural patients’ perceptions of the quality of PHC for policy decision-making on increasing the utilization of PHC and improving the medical welfare of the vulnerable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11946-8.

Association between service scope of primary care facilities and patient outcomes: a retrospective study in rural Guizhou, China

BACKGROUND

Extending service scope of primary care facilities (PCFs) has been widely concerned in China. However, no current data about association between service scope of PCFs with patient outcomes are available. This study aims to investigate association between service scope of PCFs and patient outcomes.

METHODS

A multistage, stratified clustered sampling method was used to collect information about service scope of PCFs from rural Guizhou, China. Claim data of 299,633 inpatient cases covered by 64 PCFs were derived from local information system of New Rural Cooperation Medical Scheme. Service scope of PCFs was collected with self-administrated questionnaires. Primary outcomes were (1) level of inpatient institutions, (2) length of stay, (3) per capita total health cost, (4) per capita out-of-pocket cost, (5) reimbursement ratio, (6) 30-day readmission. A total of 64 PCFs were categorized into five groups per facility-level service scope scores. Generalized linear regression models, logistic regression model, and ordinal regression model were conducted to identify association between service scope of PCFs and patient outcomes.

RESULTS

On average, the median service scope score of PCFs was 20, with wide variation across PCFs. After controlling for demographic and clinical characteristics, patients living in communities with PCFs of greatest service scope (Quintile V vs. I) tended to have smaller rates of admission by county-level hospitals (-6.2 % [-6.5 %, -5.9 %], city-level hospitals (-1.9 % [-2.0 %, -1.8 %]), and provincial hospitals (-2.1 % [-2.2 %, -2.0 %]), smaller rate of 30-day readmission (-0.5 % [-0.7 %, -0.2 %]), less total health cost (-201.8 [-257.9, -145.8]) and out-of-pocket cost (-210.2 [-237.2, -183.2]), and greater reimbursement ratio (2.3 % [1.9 %, 2.8 %]) than their counterparts from communities with PCFs of least service scope.

CONCLUSIONS

Service scope of PCFs varied a lot in rural Guizhou, China. Greater service scope was associated with a reduction in secondary and tertiary hospital admission, reduced total cost and out-of-pocket cost, and 30-day readmission and increased reimbursement ratio. These results raised concerns about access to care for patients discharged from hospitals, which suggests potential opportunities for cost savings and improvement of quality of care. However, further evidence is warranted to investigate whether extending service scope of PCFs is cost-effective and sustainable.

The rural tax: comprehensive out-of-pocket costs associated with patient travel in British Columbia

BACKGROUND

A significant concern for rural patients is the cost of travel outside of their community for specialist and diagnostic care. Often, these costs are transferred to patients and their families, who also experience stress associated with traveling for care. We sought to examine the rural patient experience by (1) estimating and categorizing the various out of pocket costs associated with traveling for healthcare and (2) describing and measuring patient stress and other experiences associated with traveling to seek care, specifically in relation to household income.

METHODS

We have designed and administered an online, retrospective, cross-sectional survey seeking to estimate the out-of-pocket (OOP) costs and personal experiences of rural patients associated with traveling to access health care in British Columbia. Respondents were surveyed across five categories: Distance Traveled and Transportation Costs, Accommodation Costs, Co-Traveler Costs, Lost Wages, and Patient Stress. Bivariate relationships between respondent household income and other numerical findings were investigated using one-way ANOVA.

RESULTS

On average, costs for respondents were $856 and $674 for transport and accommodation, respectively. Strong relationships were found to exist between the distance traveled and total transport costs, as well as between a patient's stress and their household income. Patient perspectives obtained from this survey expressed several related issues, including the physical and psychosocial impacts of travel as well as delayed or diminished care seeking.

CONCLUSIONS

These key findings highlight the existing inequities between rural and urban patient access to health care and how these inequities are exacerbated by a patient's overall travel-distance and financial status. This study can directly inform policy related efforts towards mitigating the rural-urban gap in access to health care.

Whether Public Hospital Reform Affects the Hospital Choices of Patients in Urban Areas: New Evidence from Smart Card Data

The effects of public hospital reforms on spatial and temporal patterns of health-seeking behavior have received little attention due to small sample sizes and low spatiotemporal resolution of survey data. Without such information, however, health planners might be unable to adjust interventions in a timely manner, and they devise less-effective interventions. Recently, massive electronic trip records have been widely used to infer people's health-seeking trips. With health-seeking trips inferred from smart card data, this paper mainly answers two questions: (i) how do public hospital reforms affect the hospital choices of patients? (ii) What are the spatial differences of the effects of public hospital reforms? To achieve these goals, tertiary hospital preferences, hospital bypass, and the efficiency of the health-seeking behaviors of patients, before and after Beijing's public hospital reform in 2017, were compared. The results demonstrate that the effects of this reform on the hospital choices of patients were spatially different. In subdistricts with (or near) hospitals, the reform exerted the opposite impact on tertiary hospital preference compared with core and periphery areas. However, the reform had no significant effect on the tertiary hospital preference and hospital bypass in subdistricts without (or far away from) hospitals. Regarding the efficiency of the health-seeking behaviors of patients, the reform positively affected patient travel time, time of stay at hospitals, and arrival time. This study presents a time-efficient method to evaluate the effects of the recent public hospital reform in Beijing on a fine scale.

Nonurgent Patients' Preferences for Emergency Department Versus General Practitioner and Effects of Incentives: A Discrete Choice Experiment

Objective. This study investigates potential of a new financial incentive policy, the GP-referral discount scheme introduced in Singapore, in reducing nonurgent emergency department (ED) visits, and compares it with alternative interventions. Methods. A discrete choice experiment (DCE) was designed to elicit patients’ preferences for ED and general practitioner (GP) under hypothetical nonurgent medical conditions. Through latent class multinomial logistic regression, choice models were estimated to quantify how patients’ choices are influenced by GP-referral discount, other ED/GP attributes (waiting time, test facilities, and payment), patient demographics, and their perception of severity. The choice models were used to predict uptake of the GP-referral discount scheme and other countermeasures suggested by these models. Results. Survey responses from 849 respondents recruited from a public hospital in Singapore were included in the study. The choice model identified two prominent classes of patients, one of which was highly sensitive to GP-referral discount and the other to test-facility-availability. Patients’ perceptions of severity (“critical” v. “not critical” enough to go to ED directly) were highly significant in influencing preference heterogeneity. Predictive analysis based on the choice model showed that GP-referral discount is more effective when patients visit ED expecting “shorter” waits, as opposed to test-facility provision at GPs and perception-correction measures that showed stronger effects under “longer” expected waits. Conclusions. The new GP-referral financial incentive introduced in Singapore can be effective in reducing nonurgent ED visits, if it reasonably covers the (extra) cost of visiting a GP. It may serve as a complement to test-facility provision at GPs or perception-correction measures, as the financial incentive and the latter two measures appear to influence distinct classes (discount-sensitive and facility-sensitive) of patients.

Not just money: what mothers value in conditional cash transfer programs in India

Introduction

Conditional cash transfers (CCTs) have become an important policy tool for increasing demand for key maternal and child health services in low/middle-income countries. Yet, these programs have had variable success in increasing service use. Understanding beneficiary preferences for design features of CCTs can increase program effectiveness.

Methods

We conducted a Discrete choice experiment in two districts of Uttar Pradesh, India in 2018 with 405 mothers with young children (<3 years). Respondents were asked to choose between hypothetical CCT programme profiles described in terms of five attribute levels (cash, antenatal care visits, growth-monitoring and immunisation visits, visit duration and health benefit received) and responses were analysed using mixed logit regression.

Results

Mothers most valued the cash transfer amount, followed by the health benefit received from services. Mothers did not have a strong preference for conditionalities related to the number of health centre visits or for time spent seeking care; however, service delivery points were in close proximity to households. Mothers were willing to accept lower cash rewards for better perceived health benefits—they were willing to accept 2854 Indian rupees ($41) less for a programme that produced good health, which is about half the amount currently offered by India’s Maternal Benefits Program. Mothers who had low utilisation of health services, and those from poor households, valued the cash transfer and the health benefit significantly more than others.

Conclusion

Both cash transfers and the perceived health benefit from services are highly valued, particularly by infrequent service users. In CCTs, this highlights the importance of communicating value of services to beneficiaries by informing about health benefits of services and providing quality care. Conditionalities requiring frequent health centre visits or time taken for seeking care may not have large negative effects on CCT participation in contexts of good service coverage.

Healthcare-Seeking Behavior among Chinese Older Adults: Patterns and Predictive Factors

This study aimed to investigate the patterns and predictive factors of healthcare-seeking behavior among older Chinese adults. A sample of 10,914 participants aged ≥60 years from the 2011, 2013 and 2015 China Health and Retirement Longitudinal Study (CHARLS) was included. The bivariate analyses and Heckman selection model was used to identify predictors of healthcare-seeking behavior. Results shows that the utilization rate of outpatient services increased from 21.61% in 2011 to 32.41% in 2015, and that of inpatient services increased from 12.44% to 17.68%. In 2015, 71.93% and 92.18% chose public medical institutions for outpatient and inpatient services, 57.63% and 17.00% chose primary medical institutions. The individuals who were female, were younger, lived in urban, central or western regions, had medical insurance, had poor self-rated health and exhibited activity of daily living (ADL) impairment were more inclined to outpatient and inpatient services. Transportation, medical expenses, the out-of-pocket ratio and the urgency of the disease were associated with provider selection. The universal medical insurance schemes improved health service utilization for the elderly population but had little impact on the choice of medical institutions. The older adults preferred public institutions to private institutions, preferred primary institutions for outpatient care, and higher-level hospitals for hospitalization.

Treatment Preferences of Residents Assumed to Have Severe Chronic Diseases in China: A Discrete Choice Experiment

Objectives: This study aims to elicit the relative importance of treatment attributes that influence residents’ choice, assuming they are suffering severe non-communicable diseases (NCDs), to explore how they make trade-offs between these attributes and to estimate the monetary value placed on different attributes and attribute levels. Methods: A discrete choice experiment (DCE) was conducted with adults over 18 years old in China. Preferences were evaluated based on four treatment attributes: care provider, mode of service, distance to practice and cost. A mixed logit model was used to analyze the relative importance of the four attributes and to calculate the willingness to pay (WTP) for a changed attribute level. Results: A total of 93.47% (2019 of 2160) respondents completed valid questionnaires. The WTP results suggested that participants would be willing to pay CNY 822.51 (USD 124.86), CNY 470.54 (USD 71.41) and CNY 68.20 (USD 10.35) for services provided by experts, with integrated traditional Chinese medicine (TCM) and Western medicine (WM) and with a service distance <=30 min, respectively. Conclusions: The results suggested that mode of service, care provider, distance to practice and cost should be considered in priority-setting decisions. The government should strengthen the curative service capability in primary health facilities and give full play to the role of TCM in the prevention and treatment of severe chronic diseases.

How Can One Strengthen a Tiered Healthcare System through Health System Reform? Lessons Learnt from Beijing, China

How one can reshape the current healthcare sector into a tiered healthcare system with clarified division of functions between primary care facilities and hospitals, and improve the utilization of primary care, is a worldwide problem, especially for the low and middle-income countries (LMICs). This paper aimed to evaluate the impact of the Beijing Reform on healthcare-seeking behavior and tried to explain the mechanism of the change of patient flow. In this before and after study, we evaluated the changes of outpatient visits and inpatient visits among different levels of health facilities. Using the monitored and statistical data of 373 healthcare institutions 1-year before and 1-year after the Beijing Reform, interrupted time series analysis was applied to evaluate the impact of the reform on healthcare-seeking behavior. Semi-structured interviews were used to further explore the mechanisms of the changes. One year after the reform, the flow of outpatients changed from tertiary hospitals to community health centers with an 11.90% decrease of outpatients in tertiary hospitals compared to a 15.01% increase in primary healthcare facilities. The number of ambulatory care visits in primary healthcare (PHC) showed a significant upward trend (P < 0.10), and the reform had a significant impact on the average number of ambulatory care visits per institution in Beijing's tertiary hospitals (p < 0.10). We concluded that the Beijing Reform has attracted a substantial number of ambulatory care visits from hospitals to primary healthcare facilities in the short-term. Comprehensive reform policies were necessary to align incentives among relative stakeholders, which was a critical lesson for other provinces in China and other LMICs.

Realigning the provider payment system for primary health care: a pilot study in a rural county of Zhejiang Province, China

Aim:

This work aimed to evaluate a pre/post-reform pilot study from 2015 to 2018 in a rural county of Zhejiang Province, China to realign the provider payment system for primary health care (PHC).

Methods:

Data were extracted from the National Health Financial Annual Reports for the 21 township health centers (THCs) in Shengzhou County. An information system was designed for the reform. Differences among independent groups were assessed using Kruskal–Wallis H-test. Dunn’s post hoc test was used for multiple comparisons. Differences between paired groups were tested by Wilcoxon signed-rank test. Two-tailed P < 0.05 indicated statistical significance. Data were processed and analyzed using R 3.6.1 for Windows.

Findings:

First, payments to THCs shifted from a “soft budget” to a mixed system of line-item input-based and categorized output-based payments, accounting for 17.54% and 82.46%, respectively, of total revenue in 2017. Second, providers were more motivated to deliver services after the reform; total volumes increased by 27.80%, 19.22%, and 30.31% for inpatient visits, outpatient visits, and the National Essential Public Health Services Package (NEPHSP), respectively. Third, NEPHSP payments were shifted from capitation to resource-based relative value scale (RBRVS) payments, resulting in a change in the NEPHSP subsidy from 36.41 to 67.35 per capita among the 21 THCs in 2017. Fourth, incentive merit pay to primary health physicians accounted for 38.40% of total salary, and the average salary increased by 32.74%, with a 32.45% increase in working intensity. A small proportion of penalties for unqualified products and pay-for-performance rewards were blended with the payments. The reform should be modified to motivate providers in remote areas.

Conclusion:

In the context of a profit-driven, hospital-centered system, add-on payments – including categorized output-based payments to THCs and incentive merit pay to primary care physicians (PCPs) – are probably worth pursuing to achieve more active and output/outcome-based PHC in China.

Preferences of Patients with Non-Communicable Diseases for Primary Healthcare Facilities: A Discrete Choice Experiment in Wuhan, China

Objectives: To elicit stated preferences of patients with non-communicable diseases (NCDs) for primary healthcare (PHC) facilities and to explore the willingness-to-pay (WTP) for facility attributes. Methods: A discrete choice experiment (DCE) was conducted through face to face interviews. The DCE survey was constructed by five attributes: type of service, treatment measures, cost, travel time, and care provider. Patients’ preferences and willingness to pay for facility attributes were analyzed using a mixed logit model, and interaction terms were used to assess preference heterogeneity among patients with different sociodemographic characteristics. Results: Patients placed different weights on attributes, depending on whether they perceived their health condition as minor or severe. For conditions perceived as minor, patients valued treatment measures (56.60%), travel time (32.34%) and care provider (8.51%) most. For conditions perceived as severe, they valued treatment measures (52.19%), care provider (38.69%), and type of service (7.30%) most. The WTP related to the change from Traditional Chinese Medicine (TCM) service to Modern Medicine (MM) service was the largest for both severity scenarios. For conditions perceived as minor, patients would be willing to pay 102.84 CNY (15.43 USD) for a reduction in travel time to below 30 min. For conditions perceived as severe, WTP related to the change from general service to specialized service and from junior medical practitioner to senior medical practitioner, were highly valued by respondents, worth 107.3 CNY (16.10 USD) and 565.8 CNY (84.87 USD), respectively. Conclusions: Factors related to the provision of PHC, such as treatment measures, care provider and type of service were highly valued. The findings could contribute to the design of better PHC delivery, improve the participation of patients in PHC, and provide some evidence to promote shared decision-making.

Preferences heterogeneity of health care utilization of community residents in China: a stated preference discrete choice experiment

Background

To tackle the issue with the low usage of primary healthcare service in China, it is essential to align resource distribution with the preferences of the community residents. There are few academic researches for describing residents’ perceived characteristics of healthcare services in China. This study aims to investigate the preferences of healthcare services utilization in community residents and explore the heterogeneity. The findings will be useful for the policy makers to take targeted measures to tailor the provision of healthcare services.

Methods

The face-to-face interviews and surveys were conducted to elicit four key attributes (care provider; mode of services; cost; travel time) of the preference from community residents for healthcare utilization. A rational test was presented first to confirm the consistency, and then 16 pairs of choice tasks with 12 sociodemographic items were given to the respondents. Two hypothetical options for each set, without an opt-out option, were presented in each choice task. The latent class analysis (LCA) was used to analyse the data.

Results

Two thousand one hundred sixty respondents from 36 communities in 6 cities were recruited for our study. 2019 (93.47%) respondents completed valid discrete choice experiment (DCE) questionnaires. The LCA results suggested that four groups of similar preferences were identified. The first group (27.29%) labelled as “Comprehensive consideration” had an even preference of all four attributes. The second group (37.79%) labelled as “Price-driven” preferred low-price healthcare services. The third group labelled as “Near distance” showed a clear preference for seeking healthcare services nearby. The fourth group (34.18%) labelled as “Quality seeker” preferred the healthcare service provided by experts. Willingness to pay (WTP) results showed that people were willing to accept CNY202.12($29.37) for Traditional Chinese Medicine (TCM) services and willing to pay CNY604.31($87.81) for the service provided by experts.

Conclusions

Our study qualitatively measures the distinct preferences for healthcare utilization in community residents in China. The results suggest that the care provider, mode of services, travel time and cost should be considered in priority setting decisions. The study, however, reveals substantial disagreement in opinion of TCM between different population subgroups.

The impact of hospital attributes on patient choice for first visit: evidence from a discrete choice experiment in Shanghai, China

The underutilization of primary care in urban China threatens the efficiency and effectiveness of the Chinese health system. To guide patient flow to primary care, the Chinese government has rolled out a sequence of health care reforms which improve the affordability, the infrastructure and workforce of the primary care system. However, these measures have not yielded the desired effect on the utilization of primary care, which is lowest in urban areas. It is unclear how the factors identified to influence facility choice in urban China are actually impacting choice behaviour. We conducted a discrete choice experiment to elicit the quantitative impact of facility attributes when choosing a health care facility for first visit and analysed how the stated choice varies with these attributes. We found that the respondents placed different weights on the identified attributes, depending on whether they perceived their condition to be minor or severe. For conditions perceived as minor, the respondents valued visit time, equipment and medical skill most. For conditions perceived as severe, they placed most importance on equipment, travel time and facility size. We found that for conditions perceived as minor, only 14% preferred visiting a facility over opting out, a percentage which would more than double to 37% if community health centres were maximally improved. For conditions perceived as severe, improvements in community health centres may almost double first visits to primary care, mostly from patients who would otherwise choose higher-level facilities. Our findings suggest that for both severity conditions, improvements to medical equipment and medical skill at community health centres in urban China can effectively direct patient flow to primary care and promote the efficiency and effectiveness of the urban health system.

Preferences for Primary Healthcare Services Among Older Adults with Chronic Disease: A Discrete Choice Experiment

PURPOSE

The aim of this study was to quantify the relative importance of the preference heterogeneity of Chinese older adults with chronic disease for primary healthcare service (PHCS) in the hypothetical minor chronic disease scenario.

PATIENTS AND METHODS

A discrete choice experiment (DCE) was administered to the patients aged 60 and above with at least one chronic disease in China. Five DCE attributes were considered, including types of service, treatment options, out-of-pocket (OOP) cost per visit, distance to practice, and the seniority of medical practitioners. DCE data were analysed taking into account of potential preference heterogeneity using both a mixed logit model (MLM) and a latent class logit model (LCLM).

RESULTS

A total of 432 respondents consented to complete the questionnaires and 372 valid respondents were included in analysis. All attributes were significantly influencing respondents' PHCS choice except for the types of service. Significant preference heterogeneity was observed among respondents. Based on the preferred LCLM estimates, four latent classes were identified. The first class (28.8%) valued modern medicine service the most, the second class (17.8%) was dominated by distance to practice, the third class (29%) preferred all the attributes except the types of services and valued TCM service most, the fourth class (24.4%) paid more attention to the types of service. Education, gender, age, income, regions of residence, and status of the chronic condition were found to be associated with latent class memberships.

CONCLUSION

A better understanding of the relative importance of PHCS characteristics is a crucial step for the future policy implementations. The significant preference heterogeneity identified in this study highlights that effective policy interventions should be tailored to different patients' characteristics.