Perceptions of permitting physician dual practice with restrictions: empirical evidence of public hospital managers from East, Middle and West of China

doi:10.21203/rs.3.rs-1540054/v1

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Perceptions of permitting physician dual practice with restrictions: empirical evidence of public hospital managers from East, Middle and West of China

https://doi.org/10.21203/rs.3.rs-1540054/v1

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Background: This study aims to explore public hospital managers’ perceptions of permitting Physician dual practice (PDP) with restrictions in China.

Methods: A cross-sectional study among 1,513 public hospital managers in 31 provinces of mainland China was carried out from January to October, 2019. Presidents in charge of medical affairs, and directors of medical affairs departments in Chinese public hospitals were recruited for this study. Exploratory factor analysis (EFA) was conducted to determine the factorial validity of perceptions of permitting physician dual practice with restrictions (institution-oriented restriction, IR; physician-oriented restriction, PR). Generalized linear models (GLM) were used to explore and analyze perceptions of permitting PDP with restrictions of public hospital managers with demographic and working-related characteristics.

Results: Public hospital managers’ decision of prohibiting PDP, allowing PDP, and implementing PDP with restrictions was 5.7%, 8.9%, 85.4%, respectively. Mean scores of IR and PR were 16.49 ± 3.03 and 10.84 ± 2.55 respectively. General hospital managers (coefficient of -0.52; P <.01) showed less preference to IR; managers from public hospitals in the West (coefficient of 0.77; P <.01) and Middle of China (coefficient of 0.50; P <.05) favoured IR; managers with academic background of clinical medicine (coefficient of -0.37; P <.05) held lower PR intention. On the contrary, female managers (coefficient of 0.54; P <.01) and managers from public hospitals in non-provincial capital cities (coefficient of 0.35; P <.05) preferred PR.

Conclusions: From the perspectives of the public hospital managers in China, permitting PDP with restrictions would be feasible compared to completely prohibiting or allowing PDP, which could be further enforced in terms of IR and PR. Moreover, public hospital managers hold a slightly more positive view about IR than PR.

Physician Dual Practice

Public Hospital

Managers

Perceptions

Restriction

China

Physician dual practice (PDP) is referred to as a combination of public and private clinical practice by physicians [1]. For health authorities in many counties, whether and how PDP should be regulated is certainly an important policy concern, which has impacts on human resources and provision of clinical services. PDP has been receiving attention for its association with negative impacts for the public provision of health care, since dual practitioners are suspected to pursue profit-maximization [2, 3]. Eventually, a ban or restrictions on dual practice is widely advocated. In some countries, PDP is completely banned, such as in Canada and Cuba [4]. In few countries, PDP is allowed without restrictions, such as in Bangladesh and Egypt [5]. The vast majority of countries adopted restrictive policies on PDP, including the United Kingdom, France, Italy, Austria, Germany, Ireland, Sweden, Austria, Spain, Portugal, Greece, the United States, Argentina, Russia, Australia, Thailand, Bahrain, Kenya and Zambia [5]. Since bans usually do not prevent PDP, but instead take PDP outside of the regulatory system, the need for regulatory measures towards PDP is commonly stressed [6]. Most health literature advocates for regulatory responses to PDP in the form of restrictions [7, 8]. Regulation encourages certain norms of behaviour, and also helps to define parameters of professional conduct.[9, 10] Financial and licensure restrictions, as well as promotional incentives, were wildly employed by countries [5].

China’s PDP policy differs from those in many other countries because of its top-down approach, with its emphasis on the government’s role and hospital administrative intervention. It was not until 2014 that PDP was exempt from “documented permission from the hospital”. The central government expected PDP to optimize health human resources, and promote equal access to health services. Although official documents state that “Any hospital administrative interventions seeking to restrict or eliminate PDP are not allowed”, the implementation encounters constant resistance from the public hospitals. There is a growing acknowledgment of conflict between the health authority and public hospitals concerning PDP in China. In July 2016, two directors of a tertiary public hospital in Beijing were deposed for unrecorded dual practice activities [11]. In March 2017, a director of a psychiatric department in a public hospital in Wuhan was served a deposition for the same reason [12]. Hence, the health authorities take it for granted that public hospital managers are just not in favor of PDP. Such a conclusion is based on assumptions and lacks broader supports from empirical studies. A recent investigation in Shanghai demonstrated that, among 100 managers from 10 public tertiary public hospitals, 81.7% preferred PDP with restrictions, rather than a total ban on PDP [13]. Another investigation revealed that the majority of public hospital managers in China were not against PDP, and implementing PDP with proper conditions left much flexibility and feasibility for the government [14].

Positive effects of PDP could be only achieved if PDP was well-regulated [15]. PDP policy in China was made and revised mainly from the perspective of the government, and public media was concerned with the implementation of PDP from the perspective of physicians. Whereas, little is known about public hospital managers’ perceptions towards PDP. This study collected cross-national survey data of public hospital managers in China, especially on perceptions of permitting PDP with IR (type of services, specialties, practicing sites, exclusive contracts or flexible contracts) and PR (income ceiling, professional titles, practicing time constrains), with aims to explore public hospital managers’ regulatory decisions towards PDP.

Study Design and Sample

Data was collected from January to October 2019. In view of the large patients visiting volume and huge operational scale in public hospitals, it is extremely difficult to investigate public hospital managers, who usually fully occupied by dealing with various tasks during their working hours. Therefore, convenience sampling method was used for data collection at a series of meetings, conferences, and training sessions for public hospital managers held by the national health commission. To be specific, presidents in charge of medical affairs, and directors from medical affairs departments in Chinese public hospitals were recruited for this study. All respondents were informed of the details of this study, and provided with written consent prior the investigation. Data collection was conducted by research assistants from Wenzhou medical university. Details on data collection and quality control could be found in elsewhere[14]. In total, 1,513 participants completed the survey. Managers’ decision of prohibiting PDP, allowing PDP, and implementing PDP with restrictions was 5.7%, 8.9%, 85.4%, respectively. This study focused on 1,292 managers for implementing PDP with restrictions, excluding those for prohibiting PDP (n = 86), and allowing PDP (n = 135) (see Table S1 in Additional file 1). The ethical approval of this study was granted by the first affiliated hospital of Wenzhou medical university (No. 2020-011).

Study Instrument

Perceptions of permitting PDP with restrictions served as the dependent variables for this study (see Table S1 in Additional file 1). We defined the dependent variables in terms of interventions on PDP based on reports on actual situation in Chinese public hospitals and relevant literature [5], followed with a focus group interview for preliminary modifications to the initial questionnaire of this study. The focus group interview composed of three officials from medical administration bureau, two professors in the field of health policy research and hospital management and five public hospital presidents. In addition, a pre-survey was conducted to test the reliability and validity of the questionnaire, with a convenience sample of 252 managers from public hospitals in Wenzhou and Hangzhou, most competitive Top 2 cities of ample medical resources and robust healthcare industries in Zhejiang Province, China. The final formal questionnaire included 7 items: limits on the type of PDP services; restrictions on PDP specialties; restrictions on practicing sites by designation; exclusive/flexible contracts; imposition of income ceilings on PDP; restrictions on professional title of PDP; and restrictions on PDP time allocation. Using a 5-point likert-type scale, the response categories for each question were “1 = completely disagree, 2 = disagree, 3 = unsure, 4 = agree, 5 = completely agree”. The higher the score, the more agreement for the proposed regulation.

We included demographic and work-related characteristics as the independent variables (see Table S1 in Additional file 1). Demographic characteristics included respondents’ sex, age and education. Sex was dichotomized as male or female. Age was classified into three groups: ≤ 40 years, 41–50 years, and over 50 years. Respondents’ education level was categorized into four groups: PhD’ degree, master’ degree, bachelor’ degree and lower than bachelor’ degree. Work-related characteristics included managers’ academic background, years of service, level of managers’ position, institutional category, institutional level, institutional territory and institutional location. The academic background was identified into two groups: clinical medicine and others (administration, law, economics, management, etc). Years of service was categorized into three groups: 0–5 years, 6–10 years, and 11 or more years. Managers’ position was divided into two categories (lower than county level, county level and higher). Institutional category of the public hospital was also classified into two groups: general hospital and others (special hospitals, Chinese medicine hospitals, hospitals of traditional Chinese and Western medicine, nursing hospitals). Institutional level of the public hospital was dichotomized as tertiary level or lower than tertiary level. Institutional territory of the public hospital was classified as East of China, Middle of China, and West of China. Institutional location of the public hospital was categorized as provincial capital city and non-provincial capital city.

Data Analysis

Statistical analyses were carried out by SPSS 22.0. Means ± standard deviation (SD) was used in the calculation of perceptions of permitting PDP with restrictions, while frequencies (percentages) were used to display the demographic, work-related characteristics of managers. Cronbach’s alpha was applied to examine internal consistency and reliability of the scale. In order to determine the factorial validity of the perceptions of permitting PDP with restrictions among public hospital managers, an exploratory factor analysis (EFA) was conducted using varimax rotation and principal component method. Kaiser-meyer-olkin (KMO) measure of sampling adequacy and bartlett’s test of sphericity were both conducted to support EFA. A factor loading > 0.5 for a variable was used to be considered adequately loaded on a factor. Variance analysis / t-tests were used to test the associations between the scores of managers’ multiple regulatory strategies for PDP and the independent variables described above. In order to determine the association between managers’ demographic, work-related characteristics and managers’ perceptions of permitting PDP with restrictions, GLM was applied. Generalized linear regression coefficients and associated confidence intervals (CI) were reported in the multivariate results. A P value < 0.05 was considered statistically significant (two-sided).

Exploratory factor analysis

EFA is a good method for determining underlying factor structures [16], which also accounts for measurement error, and contributes to give rise to more realistic assumptions [17].In this study, EFA was conducted to identify factors of perceptions of permitting PDP with restrictions, accounting for 67.44% of the total variance (Table 1). The results showed that factors of perceptions of permitting PDP with restrictions could be divided into IR and PR (KMO = 0.825, P < 0.001). IR indicates PDP regulations targeting at monitoring organizational behaviors, including type of services, specialties, practicing sites, as well as exclusive/flexible contracts. While PR refers to a series of personal limitations targeting at dual practitioner’s individual behaviors, such as income ceiling, practicing time constrains and professional titles restriction. The multiple regulatory strategies scale and its dimensions were proved reliable (Cronbach’s alpha value for the total scale, IR and PR were 0.82, 0.85 and 0.70 respectively).

Table 1

Factor structure for perceptions of permitting PDP with restrictions
Items	Factor 1:IR	Factor 2: PR
Item 1: limit type of services offered by PDP, such as those not covered by public sector	0.71
Item 2: impose limitations on PDP within certain specialties	0.85
Item 3: restrict PDP to designated practicing sites, such as primary health care institutions, clinics, private health sectors, or allow minimal private practice within public facilities, outside the normal working hours	0.90
Item 4: exclusive contracts, such as physicians engagement in dual practice cannot reach leadership positions in the public sector; flexible contracts, such as salary increases for physicians giving up dual practice	0.79
Item 5: imposition of an income ceiling on PDP		0.81
Item 6: restrict professional title, such as restricting PDP to senior physicians		0.70
Item 7: restriction of time allocated to PDP		0.79
Explained variance	39.99%	27.45%

Characteristics of participants.

Table 2 showed the profile of public hospital managers’ characteristics. Of 1,292 respondents, 740 were male managers (57.3%). Respondents were mainly between ages 41–50 years old (45.9%), and 57.2% had worked in their current positions for more than 6 years. 95.5% respondents had an education level of baccalaureate or higher, with 55.2% majored in clinical medicine. Most respondents (72.4%) came from non-provincial capital cities, and 78.6% held positions lower than the county level. Among them, 37.8% came from the East of China, 30.1% from the Middle of China, and 32.1% from the West of China. Approximately two thirds (63.3%) respondents worked in general hospitals, in contrast with the left 36.7% worked in special hospitals, Chinese medicine hospitals, hospitals of traditional Chinese and Western medicine, and nursing hospitals. The vast majority (95.7%) of respondents were public tertiary hospitals managers.

Table 2

Basic characteristics of managers (N = 1,292)
Variables	No. (%)
Demographic characteristics
Gender
Male	740 (57.3)
Female	552 (42.7)
Age (y)
≦40	411 (31.8)
41–50	593 (45.9)
>50	288 (22.3)
Education
Others	58 (4.5)
Bachelor	832 (64.4)
Master	345 (26.7)
PhD	57 (4.4)
Working-related characteristics
Academic background
Clinical medicine	713 (55.2)
Others	579 (44.8)
Length of service (y)
≤ 5	553 (42.8)
6–10	282 (21.8)
≥ 11	457 (35.4)
Level of managers’ position
<County level	1016 (78.6)
≥County level	276 (21.4)
Institutional category
General hospital	818 (63.3)
Others	474 (36.7)
Institutional level
<Tertiary level	55 (4.3)
Tertiary level	1237 (95.7)
Institutional territory
East of China	488 (37.8)
Middle of China	389 (30.1)
West of China	415 (32.1)
Institutional location
Provincial capital city	357 (27.6)
Non-provincial capital city	935 (72.4)

Relationship of managers’ characteristics and their perceptions of permitting PDP with restrictions

The mean score of IR was higher (16.49 ± 3.03) than PR (10.84 ± 2.55). As listed in Table 3, IR was found correlated with managers’ institutional category and institutional territory (P < .05). General hospitals managers showed less preference (16.33 ± 3.11) to IR than those from the other hospitals (16.75 ± 2.87). Compared to managers from East and Middle of China, those from West of China had stronger intentions on IR (16.84 ± 2.93).

Table 3

Mean score of managers’ perceptions of permitting PDP with restrictions
Variables	IR		PR
Variables	Mean ± SD	P Value	Mean ± SD	P Value
Demographic characteristics
Gender		.41		< .01
Male	16.43 ± 3.15		10.57 ± 2.68
Female	16.57 ± 2.87		11.19 ± 2.31
Age (y)		.33		.86
≦40	16.30 ± 2.94		10.80 ± 2.42
41–50	16.58 ± 3.04		10.88 ± 2.61
>50	16.56 ± 3.13		10.81 ± 2.60
Education		.17		.12
Bachelor	16.60 ± 3.01		10.93 ± 2.55
Master	16.28 ± 2.90		10.61 ± 2.46
PhD	15.91 ± 3.89		10.51 ± 3.15
Others	16.64 ± 3.01		11.16 ± 2.35
Working-related characteristics
Academic background		.48		< .01
Clinical medicine	16.43 ± 3.10		10.62 ± 2.62
Others	16.55 ± 2.94		11.10 ± 2.44
Length of service (y)		.54		.07
≤ 5	16.44 ± 3.01		10.81 ± 2.47
6–10	16.37 ± 3.09		10.58 ± 2.54
≥ 11	16.61 ± 3.02		11.03 ± 2.64
Level of managers’ position		.82		.02
<County level	16.50 ± 3.05		10.93 ± 2.49
≥County level	16.45 ± 2.97		10.51 ± 2.72
Institutional category		.02		.11
General hospital	16.33 ± 3.11		10.75 ± 2.57
Others	16.75 ± 2.87		10.99 ± 2.51
Institutional level		.92		.23
< Tertiary level	16.53 ± 3.18		10.44 ± 2.93
Tertiary level	16.48 ± 3.02		10.86 ± 2.53
Institutional territory		< .01		.61
East of China	16.15 ± 3.09		10.76 ± 2.57
Middle of China	16.53 ± 3.03		10.83 ± 2.60
West of China	16.84 ± 2.93		10.93 ± 2.47
Institutional location		.24		.03
Provincial capital city	16.32 ± 3.01		10.57 ± 2.54
Non-provincial capital city	16.55 ± 3.04		10.92 ± 2.54

As to PR, we found more support from female managers (11.19 ± 2.31) than male managers (10.57 ± 2.68). Managers with academic background of clinical medicine held lower intention on PR (10.62 ± 2.62) than those with other academic backgrounds (11.10 ± 2.44). Managers of positions below county level (10.93 ± 2.49) and those from non-provincial capital cities (10.92 ± 2.54) showed more preference to PR.

Determinants of managers’ perceptions of permitting PDP with restrictions

GLM was used to determine factors associated with managers’ perceptions of permitting PDP with restrictions (Table 4). The results showed that, compared to those from hospitals of the other types, managers in general hospitals were less likely to choose IR (coefficient of -0.52; 95% CI: -0.90, -0.14). Managers came from hospitals in the West of China (coefficient of 0.77; 95% CI: 0.33, 1.22) and Middle of China (coefficient of 0.50; 95% CI: 0.04, 0.97) were more likely to choose IR than those from the East of China.

Table 4

Multivariate analysis of determinants of managers’ perceptions of permitting PDP with restrictions by generalised linear model (N = 1,292)
Variables	IR		PR
Variables	Coefficients (95% CI)	P Value	Coefficients (95% CI)	P Value
Demographic characteristics
Gender (ref male)
Female	0.16 (-0.22–0.53)	.42	0.54 (0.22–0.85)	< .01
Age (y) (ref ≦ 40)
41–50	0.33 (-0.11–0.76)	.14	0.21 (-0.15–0.57)	.25
>50	0.27 (-0.30– 0.83)	.36	0.19 (-0.27–0.65)	.42
Education (ref others)
Bachelor	0.27 (-0.63–1.18)	.55	0.07 (-0.68–0.83)	.85
Master	0.12 (-0.85–1.09)	.80	-0.06 (-0.87–0.74)	.88
PhD	-0.34 (-1.59–0.92)	.60	0.05 (-0.99–1.09)	.92
Working-related characteristics
Academic background (ref others)
Clinical medicine	-0.20 (-0.58–0.18)	.30	-0.37 (-0.69– -0.05)	.02
Length of service (y) (ref ≤ 5)
6–10	-0.26 (-0.75–0.23)	.30	-0.25 (-0.65–0.15)	.21
≥ 11	-0.08 (-0.53–0.37)	.72	0.12 (-0.25–0.48)	.53
Level of managers’ position (ref < Country level)
≥County level	0.04 (-0.45–0.53)	.88	-0.27 (-0.67–0.13)	.18
Institutional category (ref others)
General hospital	-0.52 (-0.90– -0.14)	< .01	-0.27 (-0.59–0.04)	.09
Institutional level (ref < tertiary level)
Tertiary level	-0.23 (-1.13–0.68)	.62	0.36 (-0.37–1.08)	.34
Institutional territory (ref East of China)
Middle of China	0.50 (0.04–0.97)	.03	0.09 (-0.30–0.47)	.65
West of China	0.77 (0.33–1.22)	< .01	0.20 (-0.17–0.57)	.28
Institutional location (ref provincial capital city)
Non-provincial capital city	0.20 (-0.22–0.63)	0.35	0.35 (0.01–0.70)	< .05

As to PR, sex, academic background, and institutional location were significant predictors. Managers with academic background of clinical medicine were less likely to choose PR (coefficient of -0.37; 95% CI: -0.69, -0.05). There seemed a greater chance for female managers (coefficient of 0.54; 95% CI: 0.22, 0.85) and those worked in non-provincial capital cities (coefficient of 0.35; 95% CI: 0.01, 0.70) to turn to PR.

In China, the advantages of PDP for improving health care service access to those under-served areas have been well-noticed by managers in the public hospitals [14], and above all, they also recognized PDP as an effective way to readjust the price of health care service provided by Chinese’s public hospitals which has long been underestimated. However, in common with most countries, completely allowing PDP would inevitably result in a serious of negative outcomes, especially brain drains from public sector to private sectors, not to mention hidden damages to medical quality and patient safety. Moreover, responsibility on medical accidents or adverse events among dual practitioner, full time employer, and part time employer still remains vague in regulation, which greatly reduce the feasibility of completely allowing PDP in China. Therefore, most managers in Chinese’s public hospitals choose implementing PDP with restrictions, rather than completely prohibiting or allowing PDP.

General hospitals showed less preference for IR than the other types of public hospitals. One reason might be administrative cost of general hospitals on PDP. Regulations impose costs that have to be coupled with rewards and punishments in order to be enforceable. General hospitals were more diversified in terms of disciplines, services, positions, organization structure and human resource, so their administrative cost would be a comparatively more expensive solution. The other reason could partly be explained by over-load responsibilities for general hospitals. In China, general hospital physicians could barely afford time to PDP. According to the Chinese general hospital’s operations ranking 2020, the annual operation volume varied from 76 to 350 thousand (see Table S2 in Additional file 1) [18]. Based on the Chinese general hospital’s emergency and outpatients ranking 2020, the annual emergency and outpatients visiting volume varied from 3.25 million to 7.76 million, with total volume came up to 1542.42 million (see Table S3 in Additional file 1) [19], equal to 41.1% the total volume of 34,354 hospitals in China [20]. Facilities in public general hospitals are always fully occupied, and most physicians are “too busy to engage PDP” regardless of their willingness [21]. Hence, IR would be of little practicability for general hospitals.

Public hospitals in the West of China were found preferable to IR compared to hospitals in the East and the Middle of China. Judging from performance evaluation report by the national health committee in 2020, public tertiary hospitals in the East of China were of much better comprehensive competence, with Shanghai (Eastern), Beijing (Eastern), Zhejiang (Eastern) as the TOP 3 among all the 32 provincial administrative areas in mainland China. Moreover, Shanghai (Eastern), Beijing (Eastern), Jiangsu (Eastern), Guangdong (Eastern) and Zhejiang (Eastern) were recognized as the TOP 5 provinces for immigrant patients, accounting for 52.7% of the nation’s total volume [22]. In other words, public hospitals in the West of China are less attractive to both physicians and patients. As a consequence, physicians’ salary levels in the West China are much lower. Given such a situation, PR would probably give rise to negative responses. For example, putting earning limits on physicians may lead to problems such as low productivity, frequent absence, tardiness, inefficiency [23], brain drain, or under-the-table payments [24]. It is worth noticing that financial restrictions, intrinsically require well-established health financing systems to monitor physicians’ activities between public and private sectors [5]. A combination of tax-based public financing, mandatory health insurance and private insurance might be necessary, as well as transparent bureaucracies. Therefore, it is less feasible to maintain PR neither in the West nor in the Middle of China.

We found managers with academic background of clinical medicine held lower PR intention. PR require good competence in skills of communication, organization and coordination, however, most Chinese public hospital presidents lack systemic professional training in management [25], especially those major in clinical medicine. Compared to hospital presidents with non-clinical medicine academic background, most of whom majored in management or administration, it would be more challenging for managers with academic background of clinical medicine to adopt PR.

According to the contingency theory of leadership (CTL), managers’ decisions and strategies are influenced by their personality [26]. We found female managers in public hospitals favored PR, and the reason might lie in better interpersonal skills of women.

Managers from public hospitals in non-provincial capital cities were distinguished for preferring PR. In China, tertiary hospitals are geographically distributed in capital cities. In contrast, most public hospitals in non-provincial capital cities are of lower levels and charged less [27]. According to the Chinese general hospital’s operations ranking, 2020, 88% operations were performed by general hospitals in provincial capital cities [18]. Based on the Chinese general hospital’s emergency and outpatients ranking, 2020, 86% emergency and outpatients volume were from general hospitals in provincial capital cities [19]. Therefore, salaries of public hospitals in non-provincial capital cities are much less competitive, and financial incentive for physicians to engage in PDP would be stronger. Therefore, in non-provincial capital cities, it is necessary to monitor physicians’ public-private time allocation, and PR would be much more effective than IR.

Firstly, there might be selection bias due to the cross-sectional design and convenience sampling, although our data were collected in 31 provinces of China. Secondly, PDP inevitably involves interest conflicts among different stakeholders. This study merely focused on concerns of public hospital managers, regardless of other PDP stakeholders, such as physicians, patients, private hospital managers.

This study finds evidence that most managers in public hospitals in China consider it wise to permit PDP with restrictions. Besides, it also explores the relationship between public hospital managers’ characteristics and their decision based on a cross-national empirical evidence including: (1) permitting PDP with restrictions could be enforced in ways of IR and PR; (2) the importance of IR on PDP is perceived differently by public hospital managers of different institutional category and of institutional territory; (3) the interest in implementing PDP with PR varies among public hospital managers of different sex, academic background and institutional location. In general, characteristics would affect public hospital managers’ regulatory choices on PDP in ways that are somewhat predictable. Policy-makers have to take into consideration specific contexts, such as demographic characteristics and work-related characteristics before making regulations for PDP.

PDP Physician Dual Practice
IR Institution-oriented Restriction

PR Physician-oriented Restriction

KMO Kaiser-Meyer-Olkin

EFA Exploratory Factor Analysis

SD Standard Deviation

GLM Generalized Linear Model

CI Confidence Index

CTL Contingency Theory of Leadership

Ethics approval and consent to participate

This study was approved by the ethics committee of first affiliated hospital of Wenzhou medical university (No. 2020–011). Written informed consents were received from participants before the investigation. And all methods in the study were performed in accordance with relevant institutional / national / international guidelines.

Consent for publication

Not applicable.

Availability of data and materials

The dataset and materials used in this study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was funded by the National Social Science Fund of China (No. 18BGL247). The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors’ contributions

YY, YL and HX designed the study. XC, QL and XF collected data. YY, XC and XF provided suggestions for data analysis. YY, XC and XF analyzed data. YY, XC, LJ, HX and QL prepared and drafted a preliminary version of this manuscript. YY, WCC, XZ, YL and HX critically reviewed and revised the subsequent drafts. All authors read and approved the final manuscript.

Acknowledgements

We express our appreciation to all participants in this study for their participation and cooperation.

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Perceptions of permitting physician dual practice with restrictions: empirical evidence of public hospital managers from East, Middle and West of China

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Abstract

Background

Methods

Study Design and Sample

Study Instrument

Data Analysis

Results

Exploratory factor analysis

Relationship of managers’ characteristics and their perceptions of permitting PDP with restrictions

Determinants of managers’ perceptions of permitting PDP with restrictions

Discussion

Limitations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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