Why Patients Dissatisfy with Medical Care in China--Evidence from the Patient Perceived Value


 - Background: Enlarged financial and managerial resources spending on medical improvement had rarely to decrease the crowed waiting line or increase the patient satisfaction. Investigating patients’ perceived value (PPV) gain an insight of patients’ satisfaction. PPV is a valuable perspective for hospitals to strategically improve medical care quality and performance from functional and emotional sides. - Methods: According to the theory of perceived value, an empirical study had been carried out by field survey and data collection in 7 well-known hospitals in Zhejiang Province China. 2586 questionnaires with valid data were analyzed according to PPV.- Results: Beside of the importance of functional values (effectiveness of treatment effect, reasonable and accurate prices, standardization and normalization, convenience and accessibility), the emotional values (communication with doctors/nurses, comfortable environment and facilitates) were highlighted. The preferences of patients’ perceived value were influenced by patients’ background features, and then the differentiation of patients’ satisfaction was proceeded. These patients, who are young, female, outpatient, light ill condition, high educational level and high income, tend to be relatively high demanding on medical care services but in high dissatisfaction level. Additionally, the findings show an advantage to pass the reasonability of waiting time to patients’ thought.- Conclusion: Classified convenience receiving approaches according to differentiated PPV and background features of patients, equipped up with e-enabled health care environment, can bring worthwhile patients’ satisfaction in Chinese hospitals .


Background
Patient satisfaction is widely considered as a critical indictor of performance and quality improvement in hospitals [1] [2] . Medical care is characterized by high di culty, risks and cost [3] . However, even though the last decades medical quality-inspired reforms, the increased number and violence degree of medical con icts is proposed to be a signi cant type of social contradictions in China [4] [5] . The unbalanced medical and human resources allocation force patients ow to big hospitals in cities and thus make their experiences worse [3] [6] . One survey in one Beijing hospital stated the workload of a doctor even access 200 patients per day, which leave very limited minutes for one patient who waiting for hours [7] . Thus far, previous research investigations have shown mixed reasons of patients' dissatisfaction, such as treatment effectiveness and service accessibility which are mainly from the quality of medical techniques and capacities [8] [9] . A research indicated that 82% of dissatis ed responds was from the limited information they received, 67% from medical staff's unsympathetic clarity, and 63% dissatis ed with the accuracy of treatment due to no time to ask questions freely [10] . Another survey also indicated that 73% of patients totally do not trust doctors and 8% of the patients perform complete trust [11] . Untrustworthiness between patients and doctors signi cantly increase con icts and medical disputes in China [12] . Inadequate time and communication between patients and doctors results in nontransparent or unclear of the treatment details or process, and consequently, any unwilling effect will amplify patients' negative judgements and untrustworthiness [11] .
It seems likely that the majority of patient dissatisfaction is concentrated on doctor-patients interaction specially in big public hospitals, besides of hospitals' medical technics [13] [14] . Some researches were based on framework analysis from the evaluation of quality of service [15] , which covered the structure (hospital's physical facility and environment), process (patients' perception of interaction with hospital staffs) and outcomes (results received from interactions) [16] . Cengiz and Kirkbir (2007) demonstrated in a qualitative survey that patients struggled with the aspects of functional value, emotional value and social value [17] . Although treatment normalization and quality is the primary as functional value [18] , convenience and waiting time were found as core signi cant types of dissatisfaction, which are related to the added values asides from treatment quality [19] . These results lead a growth researches of managing satisfaction and relationships in hospitals to the perspective of patient' value analysis [20] .
PPV is re ected by the received service against expectations. The advantage of PPV is that it may explain why improved medical capability and technics still result in low satisfaction and loyalty level from perspectives of patients [21] . PPV was further developed into more detailed dimensions, such as service quality, facilities, convenience, price, professionalism, social reputation, control and hedonics [22][23] [24] . Importantly, a high quality of medical care communication is one important element in PPV [25] . A research from Chinese hospitals indicated that 82% dissatis ed patients were from inadequate information from doctors, 67% from unsympathetic clarity, and 44% from a low opportunity to ask questions freely [19] . Communication is expected on the foundation that doctors and patients shared a decision-making model, which mainly based on patient knowledge, clear clarify of possible bene ts and harms of treatment options, and the patient's values and preferences [20] . Faster assess, communication and convenience related to environment may furthermore result in more comfortable emotion, accompanied by fairness and e ciency perceptions [26] [27] . Patients will feel stressed, bored, anxious or worried during a long waiting for services, and mood would usually affect the customers' evaluation and satisfaction of the service [26] . Moreover, a well patients-doctors relationship and public reputation of the hospitals is seen as the keystone to guide patients' choice decision, which will release patients' harsh tension from high medical expenses (drugs or techniques), otherwise lead to over-prescription and over-treatment expectation [27] .
PPV gains even more importance in the near future that patient satisfaction is an overall assessment of medical skill and service quality [19] [20] . The conception of PPV was mainly developed from the theory of Customer Perceived Value, and based on weighing up the utility gained from treatment effects, service, environment and expenses paid like time, money, and risks [29] . Nevertheless, there is little systematically quantitive evident in China regarding the patient perspective value' characteristics and its impact on satisfaction management [30] . This study focused on the role of PPV to better understand how to target patientrelated value and thus tailor their dissatisfaction with hospitals. Specially, learn more about the characteristics of PPV, determine the impact on PPV by patients' background features, and nally determine the impact on PPV on the patient satisfaction. This study adds to the research led by gathering wide data using control important confounding factors (actual perceived value, degree of importance, importance of aspects, importance of primary indicators) and differentiate the patients background and features(such as health conditions, gender, age, educational and economic background) on their perceived value (functional value and emotional value).

Methods
The data materials for this study are varied to the complexity by assigning surveys to the patients in the 7 dominated hospitals four main cites in Zhejiang Province of China over twelve-month periods, according to the ranking from Zhejiang Province Health Committee. 7000 questionnaires have been sent out to randomly selected impatient and outpatients' patients and received 2865 questionnaires. 2586 questionnaires had valid data (37% gross response rate).

PPV variables: support for patient satisfaction
The main interest of this report is in the varied impacts on patients' perceived values on satisfaction levels. Based on this, the respondents would be divided into strong, modest, and weak sensitivity degrees of their satisfaction and three categories (different types, prices, and waiting time) would be discussed according to different patients' perceived values (functional value, emotional value, social value). In the majority of cases, medical disputes arise due to an enlarged gap between the level of medical effect and patients' expectation [31] . China government had made a series of laws and regulations to standardize the treatment normalization of doctors and nurses. But when doctors are dissatis ed with their overtime work or underpaid awards, the negative emotion would pass to patients and make a rush or unquali ed impression, consequently leading to a prejudge of poor treatment performance [28] . Timing enlarged the tensions and con icts after a long waiting lists or delayed appointment [4] . In this case, wide use of IT systems did adopt in Chinese hospitals now to improve the work ow e ciency and convenience of hospital service, such as online appointment system, electronic registering machine, electronic payment machine, electronic health records (EHRs). Nevertheless, these e-programs seem not signi cantly link to positive doctor-patient relationships, patient satisfaction still were varied in different hospitals [13] . It gave a high value of communication [10] . Interestingly, the dissatisfaction rate would be uctuated after concerning the medical expenses [28] . Low price means lower patients' expectation as well as nancial stress, but an opposite effect was they may think low consultation fee lead to over-investigation (high drugs and techniques charging). Thus there would be critically to consider the issue of patient-doctor relationship as the keystone of patient retention in the medical institution [32] . Media reports of medical disputes and medical incidents broke public belief and damage hospital reputation. According to the above, intensi ed patient dissatisfaction and medical disputes in China should capture these unbalanced expected value comparing with the paid time and nancial costs.

2.2The survey instrument
The questionnaire rstly consisted of 7 dimensions 57 items from the Perceived Value Theory to measure patients' satisfaction with medical care. It covered the standardization and normalization of treatment service, self-assessment of illness states, communication and relationship between doctor-patients, trust and reputation of hospitals and doctors, comfort and convenient environment during medical services, as well as the costs of time, money, and even risks. Then, general information was sent to gain patients' expectation indicators from pilot 50 interviews (from medical disputes claimers) in 7 well-known hospitals in Zhejiang Province in China. It included past negative experiences, revisit rate, prepared time in hospitals and if searched hospital acquaintance before seeing doctors. Seven variables and 35 indication items were nally concluded into the constructs of treatment effect, medical normalization, convenience, communication, comfort, price and hospital reputation.
Next, accordingly modi ed surveys were conducted via online-based and on-site methods to analyze the comprehension of different PPV. The questionnaire consists of three parts: basic demographic information of patients, items requiring patients to differentially weight according to individual medical experience, and open questions about other experiences assessment in treatment. Respondents will scaled these items on a 1-5 scale (1 = not important; 5 = extremely important). These variables were nally summarized into 35 indication items in the survey. The age, living area, education level, family income, occupation, payment methods would be accessed to obtain a sample of a certain size for comparisons with various population statistics. 2685 questionnaires showed about 53% of them were received from inpatients, and the rest 47% of them were collected from outpatients; 2658 samples of the valid feedbacks showed that 43% of them were male patients and 57% of them were female patients. According to the received questionnaires from patients, the results would be further studied by patients' different sensitivities of perceived value, degrees of their satisfaction, importance to the recent medical services.

Results
The data give Chinese hospitals a deep understanding why dissatisfaction is a common phenomenon in China. From the data as shown Table 1, these high ratios of dissatisfaction reasons tend to support earlier ndings that the functional values (such as effectiveness of medical treatment and diagnosis, reasonability and accurate prices, standardization and transparent of process, convenience and accessibility), emotional value (such as doctors or nurses' attitudes, comfortable environment and facilitates) and social value (hospital reputation) got extra attentions form patients. Speci cally, the attitudes from doctors and nurses were highly valued in patients' emotion, otherwise, diagnosis and treatment effects were the main focus in functional value. Notice: 1. The secondary indictors only showed the most important two; 2. "Importance of aspects" were average values of "Importance of Primary indicators", and "Importance of Primary indicators" were average values of "Importance of secondary indicators".
When considering the background features of patients (gender, ages, education level, household income) and patients' emotional value and functional value, the descriptive statistics for the variables showed signi cant deviation with patients' backgrounds in affecting their perceived value, as presented Table 2. The preferences of patients' perceived value were in uenced by patients' background features, and then the differentiation of patients' satisfaction was proceeded. The research about patient perceived value's relation with medical service convenience and waiting time has been analyzed. The ndings re ect that there is no correlation between individual patient's time adequacy and perceived convenience. But there is a positive correlation between perceived convenience and perceived value. In addition, the difference in gender, age and educational level have small differentiation on the sensitivity on functional vale. For the overall satisfaction assessment, inpatients provided more favorite feedback than outpatients (F = 147.8, P < 0.01) and male patients held better attitude to hospitals than females (F = 5.523, P < 0.01). Additionally, younger patients indicated lower overall assessment scores than elder patients (F = 13.757, P < 0.01). The education level (F = 7.314, P < 0.05), income level (F = 2.597, P < 0.05) and occupation (F = 2.367, P < 0.05) also showed signi cant difference. As for households income, the group of "3001-5000" RMB per month showed lowest grades and the rest groups offered similar grades on overall valuation. O cers re ected best valuation while patients from business and service gave the worse comments. The residence place (urban, town or rural) did not offer any signi cant impact on overall satisfaction assessment.
For more detailed analysis, the diverse types of patients (F = 197.7, P < 0.01), gender (F = 3.388, P < 0.05), ages (F = 12.195, P < 0.01) and education level (F = 3.168, P < 0.01) have signi cant difference in relationship with the perceived value of treatment effect. Inpatients, male, the group of "60 age and above" and higher education level showed a higher value from perspective of treatment effect than others. The patients in the age of 19-29 have the lowest focus on treatment effect. These different features of resident place, income level and occupation did not display signi cant difference in evaluating treatment effect. show signi cant difference in evaluating the convenience of medical seeking, but male patients and senior groups of "50-59 age" and "60 age and above" displayed a higher importance. On the other side, the higher education level, upper monthly income level and these busy technic and business occupation gave signi cant lower satisfaction at waiting time, as well as the convenience of medical seeking.

Discussion
From the above analysis, it was found that dissatisfaction of patients in China was affected mostly by the patients' different background characteristics. Acknowledging the weight from differentiated features of patients' backgrounds on satisfaction and accordingly build classi ed managing modes are primary in medical care improvement projects. Medical institutions need to collect and categorize patients' information in a supporting database, and then establish an effective information transfer mechanism to revise medical care process. By analyzing the PPV attributes, a perceived value concentrated system should be formalized to build a sound convenience and communication environment to improve the doctor-and-patient matching degree. The highlight of personalized services can be achieved by effectively tracking patient's background information and their different expectation of the medical values. Moreover, through wide communication methods and reinforced doctors' and nurses' communication skills, patients can be effectively guided to seek suitable medical treatment according to their characteristic groups. After that, corresponding medical service and interaction experiences would be enhanced according to their different perceived value.
An interesting nding in this research was the most dissatis ed reasons were from adequacy of treatment time, waiting time and convenience. However, patient perceived convenience and the reasonable waiting time (adequacy of personal time) are the main factors related to patients' satisfaction, while there was no signi cant relevance from adequacy of treatment time. When consider the degree of perceived value, male would be higher than female, female patients tend to rely more on emotional value; young patients would be more sensitive on emotional value; the high level of education did weigh social value but have more negative perceived value; for functional value, the income level did not affect PPV. Their patient perceived value showed relatively low and signi cant difference emerged in emotional values from other type of patients.
The result indicated that inpatients were easier to perceive negative impressions from medical convenience, waiting time and treatment effect than outpatients. It is an unexpected nding that patients think little of the adequacy of treatment time from doctors and not signi cantly affect their satisfaction. It means even patients have su cient treatment time from doctors after a long wait, they are still in the negative mood. One reason would be that patients believe well-known hospitals have more advanced equipments and professional for particular medical issues. So that the time adequacy is less considered since patients trusted the high quality of these hospitals. Another reason is related to predicted outpatient number and understanding of heavy workloads in big hospitals which make patients have more endurable to the limited treatment time.
This study implied patients' personal time pressure and service requirements demand higher e cacy without time waste. Younger patients contained low satisfaction than elders due to their tight work schedule, particularly in the age of "18-29" and " 30-39" groups as shown in Table 3. A reason would be there are more transfers in outpatients' treatment processes, including waiting for register, different tests appointment and payment, report preparing, medicine payment and get and so on. Especially for the rst time visiting, unfamiliarity with a hospital's environment could bring more troubles in outpatients. This nding showed an advantage to pass the reasonability of waiting time to patients' thought. Hospitals should redesign the outpatient processes and set up an upside down revolution to reduce the total time patients spend, not only doctors' treatment e cacy but also the psychology management to shorten patients' time perception. Explicit signs, quali ed guide service, automatic payment system, EMR, friendly waiting rooms environment and so on. It means even patients have su cient treatment time from doctors after a long wait, they are still in the negative mood.
Patients with higher educational degree and income level were observed to have more dissatisfaction than others. Most patients with higher education live in big cities and may have upper social level with greater incomes but less free time. They may measure the medical values of various dimensions, whereas professional or personalized express service to different type of patients could be welcomed by educated or young patient, who are used to e-technologies and able to adopt online medical selfassistant intelligent facilitates. Especially in waiting time, they can experience AI pre-diagnose to better waiting time, convenience and perceived value of medical service. Education determine the patient's way of thinking and value judgment, and also cause signi cant differences in satisfaction.
Additionally, the perceived value of communication between inpatients and outpatients is dissimilar found in this research.
Inpatients thought they received more care and effective communication with doctors and nurses than outpatients, because they could understand their condition more comprehensively in variety of ways. The illness conditions affect patients' satisfaction level, where light ill conditions usually have better mood and more time to communicate in medical treatments advises.
Communication made much in uence on emotional value like attitudes of doctors and nurses, but little in uence on functional value like effectiveness of treatments.

Conclusion
The distinguished Chinese medic care circumstances make the perceived patient value would be different from that in other countries. The medical recourses in China are insu cient to satisfy its huge number of patients. Therefore, redundant waiting time, inconvenience, little communication and uncomfortable crows in visiting hospital would cause patients' signi cant dissatisfaction. Moreover, the relationship management level and communication skills are relatively low because they pay more attention to medical devices and techniques, but less to patients' emotion experiences. Nevertheless, the rapid development of economy and living standards make patients have an increasing expectation on the service quality of the health care. Then the gap enlarged between their expectation and the perceived value from the realistic experiences. It is meaningful to gure out dissatisfaction of Chinese patients and to analyze the reasons for improving future medical care service quality. From the above analysis, PPV can signi cantly affect the satisfaction, specially from functional value, emotional value and social value.
Dissatisfaction and changes into the perceived value of patients in China were mostly affected by patients' different background features. Corresponding patients satisfaction management strategies can be adopted to improve current medical service and enhance the patient's overall medical value perception. This study work has tried to nd a new direction as a researching map to suit the matured patients and fast development of Chinese hospitals. Hospitals should manage the circumstances of receiving medical treatments and bring background features of patients into categorized satisfaction management. The ndings of patients' perceived value would be worth in explaining the problems and ease the doctor-patient relationship tension in the special Chinese hospitals context.

Availability of data and materials
The data about the ndings of this study are available from the corresponding author upon reasonable request. The manuscript does not contain any individual persons data. The questionnaire developed for this study and dataset are provided as Additional File.

Competing interests
This paper was concluded from original researches and no con ict of interest existed in the submission of this paper.

Funding
This paper is supported by the National Natural Science Foundation of China [grant no.71673245] and Enze Hospital Management Institute. National Natural Science Foundation of China supported literature study. Enze Hospital Management Institute assisted the design of data collection.

6.6Authors' contributions
HQ analyzed the theories regarding the patients' perceived value, research constructs and interpreted the data. WL performed the data collection, analysis and manuscript writing. ZL was a major contributor in data analysis and result discussion. All authors have read and approved the publication.

Acknowledgements
Not applicable.