This study aimed to compare patients’ perceived quality of primary health care delivered by CHCs/CHSs in urban areas and THCs/RHSs in rural areas in China. The study added evidence that community based primary care institutions could perform well in cultural competence, comprehensiveness (services provided), and first contact domains. However, the two domains of community orientation and family centeredness did not receive a high evaluation.
Cultural competence received the highest scores in all domains, indicating patients would recommend familiar doctors to their relatives, the doctors in the primary care institutions can speak both Mandarin and Cantonese, and provide traditional Chinese medicine to patients in need. Since both Mandarin and Cantonese are the most common languages spoken in Guangdong, medical staff, especially those working in primary care facilities, are required to speak Cantonese in addition to Mandarin. Traditional Chinese medicine has a long tradition in use in Guangdong, which has been promoted in grassroots medical institutions and widely accepted by residents.
THCs/RHSs received higher PCAT total scores than CHCs/CHSs even after controlling for patients' demographic characteristics, health status, and health service utilization, suggesting that THCs/RHSs in the rural area provide higher level primary care compared to the CHCs/CHSs settings in urban areas. Primary care delivery in THCs/RHSs settings performed better in four domains, including first contact, accessibility, ongoing care, and community orientation.
The results of well-performed first contact and accessibility in THCs/RHSs may be explained by the following factors: convenient travel distance to THCs/RHSs, patients and doctors were familiar to each other, and doctors were not limited to workdays. The higher performance in ongoing care suggested patients would keep a closer relationship with doctors, such as seeing the same doctor every time and called doctors for medical consultation. This finding is consistent with the previous research . Compared to CHCs/CHSs in urban areas, THCs/RHSs in rural areas are smaller medical institutions; the provider and the patient are more willing to build a long-term relationship to foster mutual understanding and knowledge of the other’s expectations and needs.
However, CHCs/CHSs in urban areas performed better in coordination (referrals), which means doctors in CHCs/CHSs were likely to advise their patients to seek medical service in the upper-level hospitals and provide referrals service to the patients in need. This should be due to the health insurance reimbursement stipulation. Since 2014, some cities in Guangdong implemented a preferential policy that patients upward referred from CHCs/CHSs receive an extra 10 or 15 percent reimbursement for healthcare expenditures occurring at hospitals.
Consistent with findings from the previous studies[30, 31], the standardized mean score for community orientation was the lowest among all domains, which suggested that community-based health services were not well-performed. Community-oriented primary care requires meeting the health care needs of not only the patients and families but also residents in the community. Though scores of THCs/RHSs were significantly higher when compared with CHCs/CHSs, scores in this domain barely met minimum expectation and should be further improved.
Family-centeredness was the other domain not receiving a satisfying evaluation in THCs/RHSs as well as CHCs/CHSs. It suggested that doctors would not seek advice from patients or their family members when making treatment plans. This finding was in line with several previous studies[33–35]. Though many experts called for more autonomy and participation for patients, it was difficult for patients to achieve equality in their medical decisions due to insufficient medical knowledge or communication barriers[13, 36]. This situation usually occurred not only in primary care institutions but also in hospitals.
The results indicated that education background was the only demographic character affecting patients’ experience of primary care when controlling for confounding factors. Compared to those with primary school and below education, those who had a college degree and above reported lower primary care score. This may be explained by the fact that patients with high education level have more diversified access to medical services and higher expectations for quality of medical service.
Consistent with other studies[37, 38], having chronic diseases was associated with better primary care quality, after controlling for other influencing factors. Further sub-analyses showed that better coordination in terms of referrals and information system, and comprehensiveness (services provided), may account for the higher PCAT scores among those who had a chronic disease. Coordination in terms of the information system can be explained by health record system and regular follow-up service for patients with chronic diseases due to an effective implementation of the basic public health service package in 2009, which was funded by the central or local governments. This finding was consistent with the conclusion that patients with the chronic condition reported better coordination in terms of an information system. Better coordination in terms of referrals may be due to the implementation of general practitioner system since 2014 in Guangdong, which aimed to deliver integrated health care, including referrals for patients with chronic diseases. Furthermore, this study showed primary care institutions performed well in providing comprehensiveness (services provided) service for patients with chronic disease, which was important in dealing with the mounting challenge of addressing non-communicable diseases.
Compared to those who preferred hospitals, patients who preferred primary care institutions when getting sick rated higher scores on their primary care experience. There are significant differences in 8 domains between the two groups, except for coordination and family-centeredness. This may be explained by the fact that patients who preferred primary care institutions tended to be more satisfied with primary care facilities, and patients who were more satisfied with primary care facilities also gave higher scores for the quality of their primary care experience. The conclusion that higher patient satisfaction was associated with higher PCAT total scores was corroborated by several previous studies[15, 29].
More health service utilization was positively associated with a better assessment of primary care quality after controlling for confounding factors. Patients who visited primary health institutions 7 times or more in the previous year gave a higher score. This finding is in line with a previous study in Guangdong, which reported that those who visited medical facilities with higher frequency tended to report better primary care experience. Further sub-analyses showed that better ongoing care, better coordination in terms of an information system, superior comprehensiveness (services provided), and better cultural competence might account for the higher PCAT scores among those who made more use of primary care services. This may be due to the fact that the patients who visited medical facilities with higher frequency are mainly those in chronic condition or the senior citizen, who were included in the basic public health service package which allowed them access to more primary care services.
Consistent with a previous study, the presence of health insurance was not associated with the PCAT total scores. Respondents’ socio-demographic characteristics, such as gender, age, and family monthly income, did not influence the perceived quality of primary care service, which was inconsistent with former studies[15, 29, 38].
There were several limitations in the study. First, some unmeasured confounders could lead to potential residual confounding of data. Second, we conducted a cross-sectional survey from July to December. The patients’ disease patterns we met may be different from those collected in other seasons, which may affect the evaluation of their perceived service quality. Furthermore, the impact of time should be considered, especially with the implementation of a series of reforms aimed at strengthening community-based primary care delivery system. Further study about whether the patients’ perceived quality of primary medical service has improved should be conducted. Third, the survey data were based entirely on self-reports, and recall bias could be a potential limitation that reduces the reliability in our analysis. Fourth, this study examined patients’ perceived experiences. Differences in patients’ characteristics may influence their assessment of primary care services. Further research is needed to investigate providers to verify the consistency of the demand side and provider side.