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BMJ Open. 2019 Jan 15;9(1):e022304. doi: 10.1136/bmjopen-2018-022304.

Can unsuccessful treatment in primary medical institutions influence patients' choice? A retrospective cluster sample study from China.

Niu Y1,2, Zhang L1,2, Ye T1,2, Yan Y1,2, Zhang Y1,2.

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School of Health and Medicine Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, China.



China has been attempting to control the patients' choice of high-level medical institutions through series measures of first point of contact at primary medical institutions, but the outcome is considered poor. We aim to analyse whether unsuccessful treatment in primary medical institutions can lead to the patients' choice of high-level medical institutions.


A retrospective cluster sample study.


The study setting was in Macheng city, Hubei province.


The respondents are township-county (TC) patients (patients who first went to township hospitals and then county hospitals within 30 days for the same disease) who experienced unsuccessful treatment in primary medical institutions. A total of 2090 TC patients were screened out based on the New Rural Cooperative Medical System database in 2013.


The choice of patients between township hospitals (primary medical institutions) and county hospitals was observed. We compared TC patients' ratio of choosing county hospitals (RoCC) before TC experience with after TC experience. Thereafter, we compared RoCC of TC patients and non-TC patients (patients who did not experience TC) based on coarsened exact matching.


The ratio of TC for outpatient in township hospitals is 0.68% and that of TC for inpatient in township hospitals is 3.37%. RoCC for TC disease increased from 20.8% to 35.5% (p<0.001), RoCC for other disease increased from 35% to 37.3% (p=0.01). TC patients had significantly higher RoCC than non-TC patients (p<0.001).


Patients' choice of high-level medical institutions is highly associated with the experience of unsuccessful treatment in primary medical institutions. Moreover, people likely select high-level medical institutions thereafter regardless of conditions in rural China. Unsuccessful treatment in primary medical institutions is inevitable for patients. Thus, additional measures should be considered in lowering the potential risks for patients when treatments fail.




china; choice behavior; health policy; primary medical institution; rural health

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