A comparative study of patients’ satisfaction in different levels of hospitals in Beijing: Why do patients prefer high-level hospitals?

Abstract

Introduction

The "Chinese model" of health care reform since 2009 has achieved remarkable effect in the past decade ^[1-2]. The accessibility of medical services and the health indicators of residents have been greatly improved.

In China, hospitals and primary medical institutions are the main institutions for patients to seek medical treatment. Hospitals are divided into three levels according to their functions and tasks. The first-level hospital provides basic medical care, prevention, rehabilitation, and health care services to a community. The second-level hospital is responsible for providing diagnosis and treatment of common diseases and frequently occurring diseases to a number of communities, receiving referral patients from primary medical institutions and the tertiary hospitals and undertakes some teaching, training and scientific research tasks. The tertiary hospital is a regional medical institution that provides specialized medical services to a number of regions. This kind of hospitals provide prevention, health care and rehabilitation service and undertakes clinical teaching, training and scientific research tasks. The tertiary hospitals are also provincial and national high-level medical institutions and technology centers. In addition, there are many community health service centers as primary medical institutions in city. Their main functions are the initial diagnosis of common diseases, health guidance for chronic diseases, disease screening, monitoring and management of high-risk groups, prevention of infectious diseases and control and health education ^[3].

In China, the medical resources are unevenly distributed, mainly concentrated in “big cities” and “high-level hospitals” ^[4]. Besides, with the lacks of Chinese medical insurance system constraints and other factors, which leads to the phenomenon of " disordered medical treatment " ^[5]. Disordered medical treatment means that the patient does not seek medical treatment according to the classification and functional positioning of the hospital, instead, goes to the high-level hospital for any disease. This behavior resulted in a larger number of patients visits in core hospitals than in cooperative hospitals. The Chinese government proposed a hierarchical diagnosis and treatment system in the new health care reform of 2009 for the first time in hopes that patients can be guided to seek medical treatment by nonmandatory way. Patients whose disease cannot be diagnosed and treated by the primary medical institutions will be referred to a higher-level hospital for treatment. When the patient goes into recovery, they will be referred to the primary care institutions for long-term treatment or rehabilitation ^[6-8]. It was proposed for the first time in 2012 to encourage the establishment of “medical alliances” among hospitals afterwards. The medical alliance, as a push power for the implementation of hierarchical diagnosis and treatment systems, strengthens the vertical integration of medical resources of different levels. Medical alliances are dominated by the government. According to the degree of cooperation, medical alliances can be divided into closed medical alliance and loose medical alliance. In the closed medical alliance, the personnel and property of the cooperative hospital are uniformly managed by the core hospital, and they have coherent benefits. Loose medical alliance mainly based on the medical technology cooperation, and there are many institutional barriers. In China, the largest number of medical alliances are loose medical alliances ^[9]. In a medical alliance, the medical institutions with the highest medical technologies in the region are regarded as core hospitals (generally tertiary hospitals), and a certain number of other medical institutions in the region are cooperative hospitals (including second-level general hospitals, first-level general hospitals and community health service centers). The core hospitals are responsible for such efforts as the diagnosis and treatment of difficult diseases, doctors’ training, teaching, and research. The cooperative hospitals are responsible for, for instance, multiple diseases, common disease diagnosis and treatment, rehabilitation of referral patients and public health tasks. In a medical alliance, the following series of measures have been implemented: Total prepaid medical insurance and other payment methods. Doctors do not need to apply for a change of practice location, nor do they need to record in the practice of other hospitals in the medical alliance. The continuous electronic health records and medical records, information sharing and mutual recognition of inspection results are promoted among hospitals ^[10]. According to the disease spectrum, key disease diagnosis and treatment needs, core hospitals will send their doctors to cooperative hospitals, to promote the integration of medical resources through various ways, such as joint construction of specialties, clinical teaching, medical technology teaching, teaching rounds and scientific research cooperation ^[11].

Beijing began to explore the establishment of medical alliances in 2012. By March 2018, 58 medical alliances had been built with regional boundaries, including 55 core hospitals and 528 cooperative hospitals, covering all 16 districts in Beijing. With the construction and promotion of medical alliances in Beijing, the average length of stay in the core hospital has been shortened. The function of hospitals became clearer. Core hospitals strengthen the medical technology and information communication, improve the technical level of the cooperative hospital doctors through various training activities, medical experts to visit at the primary medical institutions regularly. Medical alliances provide a continuous health record. Patients can directly make an appointment at the community health service center for expert outpatient service, and they can be referred can quickly through the green channel if they need ^[12]. However, the situation of disordered medical treatment has not been greatly improved ^[13]. The data showed that the number of outpatients and emergency visits in tertiary hospitals of Beijing in 2012 was 80.723 million and reached 99.774 million at the end of 2017 with a 23.60% increase. While the number in primary medical institutions in 2012 was 36.268 million and was 37.01 million in 2017, only increasing 3.12% ^[14]. Based on the above data, the policy has intensified, to a certain extent, efforts of tertiary general hospitals to attract patients, while the crucial reason for patients to prefer high-level hospitals for medical treatment should be discussed ^[15].

Through the previous research on medical alliances in Beijing, the patients’ choice of medical treatment and the willingness to first visit primary care institutions were partly affected by the patients’ satisfaction ^[16]. In other studies, similar conclusions have been found ^[17]. A study based on 999 hospitals in Germany showed that region, profit orientation, size, staffing per bed and quality scores had a significant influence on the patient satisfaction dimensions. Patients in East Germany, in small hospitals or in not-for-profit hospitals, were more satisfied ^[18]. Patient satisfaction is the degree of consistency between the medical service of the patient in the ideal state and the medical service actually felt by the patient ^[19]. According to customer satisfaction theory, the higher the customer satisfaction, the higher customer loyalty, and the more likely they will repeat the purchase and recommend it to others. In the medical field, this theory means that patients are more likely to choose the hospital they are more satisfied ^[20]. According to the above data (the number of outpatients and emergency visits in tertiary hospitals and primary medical institutions of Beijing), patients in Beijing prefer to visit core hospitals with higher hospital levels. Does this mean that compared with cooperative hospitals, core hospitals are more reassuring and satisfying to Chinese patients? In order to explore the reasons for the high-level medical treatment behavior of patients and guide patients to visits orderly, we conducted a cross-sectional survey in 16 districts of Beijing to compare the differences in patients’ satisfaction between the core hospitals and the cooperative hospitals within a medical alliance.

Materials And Methods

2.1 Survey respondents

This is a comparative study based on cross-sectional data. This study conducted a questionnaire survey among 1,250 patients who were selected in 18 medical alliances in Beijing from October to December 2016.

In the "Beijing Main Functional Area Plan" published by the Beijing government on September 17, 2012, the 16 districts in Beijing were divided into four different functional areas. A and B districts were classified as the "Capital functional core area." The C, D, E, and F districts are classified as the “Urban functional development area.” The G, H, I, J, and K districts are classified as “New area of urban development,” and the L, M, N, O, and P districts are classified as the “Ecological conservation development area.” Therefore, this classification is adopted for the current address of the respondents in this study.

2.2 Interview and questionnaire

Firstly, this study conducted a 48-person interview with doctors using the qualitative interview method to understand their attitudes toward medical alliances.  10 personal in-depth interviews and 38 focus group interviews were conducted respectively. We used interview guidelines for conducting the interviews. We prepared three questions: 1. What is the current status of the medical alliance? 2. What are the current problems of the Medical alliance? 3. What are the results and effects of the medical alliance? These questions are related to patient satisfaction.

Then, a self-reported questionnaire was designed based on the interview results. After the first version of the questionnaire was formulated, we conducted two rounds of expert discussion, inviting doctors, hospital administrators and staff of health administration departments to repeatedly discuss and modify the questionnaire. The experts agreed that the final version of the questionnaire was effective, reliable and scientific, and could be used for questionnaire survey. Finally, we conducted a test of reliability and validity. Reliability tests were performed on the patient satisfaction and the choice of medical treatment mainly involved in the questionnaire. The Cronbach coefficients were 0.67. The KMO value is 0.60, the sample meets the reasonable requirements for the data structure, p <0.001 passed the Bart spheric test, and the cumulative variance interpretation rate value is 54.04%. In summary, this questionnaire has good reliability and validity ^[21-22].

 The questionnaire includes 24 questions in four parts. The first part is the characteristics of patients (including gender, age, household registration, residence time, current address, chronic diseases status, patient type, medical insurance type, average monthly medical expenses), the second part is the patients’ understanding degree and method of the medical alliance policy, the third part is the utilization degree of the medical alliance(including the willingness and reasons for choosing cooperative hospitals or core hospitals for treatment, construction effect of medical alliance, etc.), and the fourth part is the patients’ satisfaction with the medical alliance.

2.3 survey methods

 The study used a stratified random sampling method to collect patients from 18 core hospitals and 80 cooperative hospitals of 18 medical alliances in 16 districts of Beijing. Because the number of medical institutions and health personnel in district C and district D is much higher than in other districts, two medical alliances were randomly selected from district C and district D, and one medical alliance was randomly selected from other areas to ensure the representativeness of the survey subjects.

The inclusion criteria of this study were patients aged between 18 and 85 years, who had received medical services in the medical alliance. The exclusion criteria in this study were patients who had no autonomous behavior ability and awareness. In order to improve the valid response rate of the questionnaire, we distributed the questionnaire through the government channels by Beijing Municipal Health Commission and obtained the informed consent of the respondents. We distributed 540 questionnaires in core hospitals. A total of 457 valid questionnaires were collected, and the valid response rates was 84.63%. We distributed 900 questionnaires in cooperative hospitals. A total of 793 valid questionnaires were collected, and the valid response rates was 88.11%. In total, 1,250 questionnaires were collected, and the valid response rate was 86.81%.

2.4 Patients’ satisfaction calculation method

The calculation method of overall satisfaction score is very typically in international literature. Patients’ satisfaction score = (number of very dissatisfied patients * 1 + number of quite dissatisfied patients * 2 + number of neither satisfied nor dissatisfied patients * 3 + number of quite satisfied patients * 4 + number of very satisfied patients * 5)/total number of participants in the evaluation ^[23-24].

2.5 Statistical analysis

The data was double entered using the Epidata 3.1 software to establish a database, and SPSS 20.0 was used for statistical analysis. Nonparametric test is used for the age and the average monthly medical expenses. Chi-square test is used for the type of hospital, gender, household registration, residence time, current address, patient type, medical insurance type, chronic diseases status, understanding level of policy and method of understanding. P<0.05 was considered statistically significant.

In logistic regression analysis, this study took the patients' satisfaction evaluation of the medical alliance services as the dependent variable and reduced the dimensionality of the ordered dependent variable as a binary variable (very dissatisfied, quite dissatisfied, neither satisfied nor dissatisfied were classified as dissatisfied; quite satisfied and very satisfied were classified as satisfied)^[25]. The independent variables included the type of hospitals the patients visited, the basic information of the patients (gender, age, household registration, current address, residence time, chronic diseases status, patient type, medical insurance type, and average monthly medical expenses), and the patients’ cognition of medical alliances (understanding levels and of policy) (see Table 1). Model 1 included the hospital type. Then we introduced the confounding factor of hospital type in next two steps. Model 2 included the type of hospital and patients’ basic information (gender, age, household registration, current address, residence time, Chronic diseases status, patient type, medical insurance type, and average monthly medical expenses), and Model 3 included the type of hospital, patients’ basic information, and patient's cognition of medical alliance (understanding level of policy and method of understanding).

Table 1  Variable assignment

Results

3.1 Characteristics among patients

A total of 1,250 patients participated in the survey, including 731 females (58.48%), of which 474 (37.92%) were aged between 41 and 60. Nearly half of the patients were from an urban area of Beijing with 588 patients (47.04%), and 409 patients (32.72%) living in the new area of urban development. The majority of respondents, 1110 patients (88.80%), lived in the city for more than two years. 452 patients’ average monthly medical expenses are less than 300yuan, accounting for the highest proportion (36.16%). Almost half of all patients (46.50%) participated in Urban Employee Basic Medical Insurance. In terms of chronic diseases status, the number of people suffering from hypertension was the highest with 501 patients (31.59%).

3.2 Single-factor analysis of patients’ satisfaction

To explore the factors affecting the patients’ satisfaction with medical alliances, all variables were included in the analysis as independent variables, using the chi-square test and nonparametric test. The results showed that the type of hospital, the type of patient, understanding level of medical alliance policy and method of understanding are statistically significant (P<0.05). These variables are associated factors of patients’ satisfaction (see Table 2).

Table 2  Single-factor analysis of patients’ satisfaction

3.3 Comparison of satisfaction between core hospitals and cooperative hospitals

The overall satisfaction score of the medical alliances is 3.375, and the satisfaction score of core hospitals and cooperative hospitals is 2.77 and 3.07. The overall patient satisfaction rate is 44.62%, and the satisfaction rate of core hospitals and cooperative hospitals is 34.34% and 50.43%. The evaluation of cooperative hospitals is better than that of core hospitals. A nonparametric test is conducted on the satisfaction scores of core hospitals and cooperative hospitals. According to the nonparametric test (P=0.009), there is a difference in the satisfaction score between the core hospitals and cooperative hospitals.

3.4 Logistic analysis of associated factors of patients’ satisfaction

To further explore the impact of hospital type on patients’ satisfaction, all variables were included in a binary logistic regression analysis in three models. The results showed that the type of hospital is always the associated factor of the patients’ satisfaction with the medical alliance. In Model 3, understanding level of medical alliance policy is an associated factor of satisfaction (see Table 3).

Table 3   Logistic analysis of associated factors of patients’ satisfaction (OR, 95% CI; n=1250)

Note: *P<0.05

3.5 Analysis of the reasons for patients’ choice

Among the reasons for choosing cooperative hospitals for treatment, the top three are convenience (32.90%), the high proportion of medical insurance reimbursement (19.39%) and the short waiting time (11.83%). The main reasons why people think it is difficult to seek medical treatment in core hospitals are "long wait time for medical treatment," "difficulty in finding reliable doctors" and "less time to communicate with doctors," at 23.69%, 15.31% and 12.11%, respectively.

Discussion

From the above research results, hospital type and understanding level of medical alliance policy are the associated factors of patients’ satisfaction with the medical alliance, and cooperative hospitals have higher satisfaction than core hospitals. From an international perspective, previous studies have found differences in patients’ satisfaction among hospitals of different levels and types. For example, compared with urban hospitals, rural hospitals have higher satisfaction. Compared with large hospitals, small hospitals have higher satisfaction ^[26]. The results of this study seem similar to the measurement of patients’ satisfaction in other countries, but China has a characteristic health care system. Developed countries such as the United Kingdom and the United States all use compensation models based mainly on primary health care services. The demand of high-level medical services needs to be borne by the patients ^[27]. The Chinese government's financial investment in cooperative hospitals is nowhere near that of core hospitals, and the medical income of core hospitals far exceeds that of cooperative hospitals ^[28]. Core hospitals with funds, technology and personnel advantages should provide more satisfying services. However, the results of this study are inconsistent with the study assumption and the public's perception ^[29-30]. Through literature review in the preliminary study, most of the patients’ satisfaction studies focused on satisfaction with a certain treatment method and the influencing factors of outpatient and inpatients’ satisfaction. There were few studies on satisfaction with the medical alliance, especially comparative studies on satisfaction between the core hospitals and the cooperative hospitals. The survey of patients' satisfaction can truly reflect the problems in the Chinese health care system ^[31]. Especially in recent years, with doctor-patient conflicts increasing in China, this study has a practical significance to explore the patients’ satisfaction under the background of medical resource integration.

What cause the results of the study, that the patients’ satisfaction with cooperative hospitals in the medical alliance is higher than that of core hospitals? Firstly, different functions and tasks are undertaken by the two kinds of hospitals. In the cooperative hospital, the treatment effects are better with a lower disease complexity, so the satisfaction may be higher. Secondly, the main reasons that lead patients to choose cooperative hospitals are convenience, short waiting time, detailed communication, etc. Although the medical technology level of cooperative hospitals is inferior to that of core hospitals, the service attitude is relatively good. A doctor has more time to diagnose a disease and answer the doubts of a patient. At the same time, the cooperative hospital has undertaken many public health tasks and maintained a good doctor-patient relationship with local patients. Studies have shown that the “patient-oriented” new medical service model is more conducive to establishing a strong and intimate long-term relationship with patients, making patients have good autonomy and satisfaction ^[32]. Moreover, the medical technology of the cooperative hospitals has been greatly improved due to the construction of medical alliances, which is also one of the reasons for the higher satisfaction with cooperative hospitals ^[33].

In the patients’ satisfaction aspect, the main reason why patients are reluctant to go to the core hospital include long waiting time for the medical treatment and inpatient beds, difficulty scheduling appointments, and less time to communicate with doctors. Poor medical experiences lead to decline in satisfaction naturally. So the most important reason why the satisfaction with core hospitals is less than the cooperative hospitals is that the number of emergency visits, inpatients and outpatients, leads to a decline in core hospitals’ service quality. Meanwhile, the diseases undertaken by the core hospitals are far worse than those in the cooperative hospitals. Therefore, the complexity of the disease treatment is higher, and the treatment effects are not always satisfactory likewise. When the treatment results of the diseases fail to meet the expectations of the patients, the patients will have great negative emotions that may lead to violence. Studies have shown that patients’ concerns most are the related medical condition, diagnosis and treatment plan, surgical risk and medications. Patients have a strong willingness to communicate with doctors, and the lack of communication will affect the evaluation of the hospital and even lead to disputes between doctors and patients ^[34]. Although core hospitals have high-quality medical equipment and excellent doctors, software construction seems to be more important if they want to improve satisfaction. Core hospitals should focus on improving medical services, strengthen patient-oriented communication between doctors and patients, simplify the admission procedure and shorten the waiting time so that patients can obtain a better medical experience.

Although the above findings indicate that Chinese patients are more satisfied with the cooperative hospitals than the core hospitals, most patients are still willing to choose the core hospitals for medical treatment, which is in contradiction with the customer satisfaction theory. This phenomenon is caused by a variety of factors, even after the publication of hierarchical diagnosis and treatment and the medical alliance policy. Due to the insufficient compensation of public hospitals in China, hospitals are forced to boost the medical market, resulting in profit-driven competition among hospitals ^[35]. Under the background of resource allocation dominated by market forces, the overcrowded tertiary hospitals have sufficient reasons to ask the government for more subsidies to finance their facility improvements and improve service capabilities, which causes the tertiary hospitals to develop in a better direction. Tertiary hospitals are more influential because they have higher administrative levels in China's government administration system. They have the ability to ask for more resources. As tertiary hospitals improve their capacity, they become more competitive, attract more patients, and justify further government subsidies or investment ^[36]. Other hospitals are arduous to attract patients and develop capacity, resulting in the inadequacy of the service capacity of primary medical institutions, which has a negative impact on the fairness of the access to primary health care services but also drives most patients to flock to high-level hospitals, resulting in the waste of medical resources ^[37-38]. In addition, there is no compulsory measures for patients to make the first visit to a primary care institution. The higher medical expectations of Chinese patients also lead to disordered medical treatment as well. The leverage effect of medical insurance in various regions of China is not satisfactory. The proportion of medical insurance reimbursement in different levels of hospitals is not large enough to play a role in guiding the hierarchical diagnosis and treatment ^[39]. The medicine types of core hospitals and cooperative hospitals vary greatly. Since primary health care institutions implement a basic medicine system, medicine types are more comprehensive in core hospitals. Once the patient is referred to the primary health care institutions, it is difficult to ensure the supply of a drug and the continuity of treatment ^[40].

From an international perspective, some developing countries such as India, Cuba, Russia, South Africa and Chile are in a period of rapid social and economic development, with defects in health care system, which are similar to the problems faced by Chinese ^[41-45]. The health care system does not have a compulsory primary consultation, patients can seek the medical treatment with the high-level hospitals in the region or in their own country freely, which may also lead to the phenomenon of disordered medical treatment, resulting in the low efficiency of the health service system and a higher national health accounts, even reducing the patients’ satisfaction ^[46]. Therefore, the results of this study and reform experience of China can provide reference for such countries. Meanwhile, other developing countries should avoid problems with health care reform in China. After the establishment of the medical alliance in china, core hospitals and cooperative hospitals compete for patients as much as possible, there is no reasonable mechanism for the distribution of benefits among hospitals. Doctors are not motivated enough to go to cooperative hospitals, and referrals are limited within the framework of system and policies. The main reason is that loose medical alliance can not mobilize the enthusiasm of hospitals and doctors, and there are no common benefits. Therefore, it is necessary to explore the establishment of closed medical alliances so that provide integrated medical services for patients. The closed medical alliance solves the external problems of property right, organization, personnel, medical insurance, and also realizes the unified management within the hospitals. The basic initial diagnosis can be realized by reforming the service model and clarifying the referral process. Closed medical alliance is considered to be the best form of comprehensive benefits, which can reduce the medical technology gap of core hospitals and cooperative hospitals, relieve the pressure of core hospitals, and improve patient satisfaction ^[47].

Besides, the results show that the more patients know about the medical alliance policies, the higher their satisfaction with the services of medical alliance will be. However, there are many problems such as insufficient publicity, single publicity channel and limited publicity form, etc., the publicity and reports on the construction effect of medical alliance should be strengthened. The government plays an important guiding role in the publicity of medical alliance and the shaping of medical treatment concept. It should be promoted the advantages of primary consultation, hierarchical diagnosis, and two-way referral from the perspective of the patient and the disease diagnosis and treatment, so that patients can better understand the benefits of medical alliances and improve patient satisfaction.

Firstly, due to the concentration of medical resources in Beijing, the core hospitals in Beijing are not only serving local patients but also nationwide patients, and some specialist hospitals have 70% other provinces patients. Thus, the investigation of the satisfaction with Beijing medical alliances may magnify the findings or contradictions. However, the number of cooperative hospitals in this study was far more than that of core hospitals, and 87.36% of the 1,250 respondents were Beijing patients, so the limitations of this study have little effect on the results. Secondly, satisfaction is one aspect of patient attitudes, and it does not fully reflect all the problems of the Chinese health care system. Finally, with a larger proportion of patients concentrated in tertiary hospitals, it is not surprising that tertiary hospitals were not satisfied. Further empirical research is needed on the influencing factors of patients' choice of medical treatment orderly and how to guide patients to seek treatment at different levels.

Conclusion

The patients’ satisfaction with cooperative hospitals was higher than that of core hospitals. The results of this study are inconsistent with the customer satisfaction theory and study assumption. Although the patients are more satisfied with the service attitude of the cooperative hospitals, they still prefer core hospitals due to their higher expectation for medical treatment and greater trust in the medical technology of the core hospitals. Although the Chinese government has proposed the medical alliances, most of the loose medical alliances are unable to change the state of competition between hospitals and cannot reverse the phenomenon of disordered medical treatment. Therefore, the loose medical alliances formed by technical support cannot completely change the state of competition among hospitals. It is necessary to explore the establishment of the closed medical alliances under the unified management of human and financial resources, to promote medical alliances to become a community of common interests and provide integrated medical services for patients. In addition, the policy publicity of medical alliance should be strengthened. Through these methods, patient satisfaction will be improved.

Declarations

Abbreviations

This article does not contain any abbreviations.

Acknowledgements

The authors thank all who participated in this study, and thank the assistance from Beijing Municipal Health Commission for questionnaire issuance. This study was supported by the Beijing Social Science Fund (17SRB005). Furthermore, the authors thank all the patients who participated in the survey.

Authors’ contributions

Each author complies with the Health Policy standards for authorship. CSC, XZ and HYS contributed to the investigation; CSC contributed to data curation, software, formal analysis, resources, writing original draft; YJW and JYS made recommendations for the revision of the original draft; KM contributed to conceptualization, methodology, writing – review & editing, supervision, project administration, funding acquisition. All authors read and approved the final manuscript.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethical Review Committee of the Capital Medical University (No. 2018SY92）. Participation in the survey was completely voluntary and written consents were obtained from participants.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. E-mail: [email protected].

Competing interest

The authors declare that there is no competing interest.

No Duplicate Submission Declaration

I promise that the study has not duplicate submission, and has not been published in other journals previously.

Funding

This study was supported by the Beijing Social Science Fund (17SRB005). The funders had no roles in all aspects of this study, including study design, data collection and analysis, decision to publish or preparation of the manuscript.

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