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      Practices and attitudes of doctors and patients to downward referral in Shanghai, China

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          Abstract

          Objectives

          In China, the rate of downward referral is relatively low, as most people are unwilling to be referred from hospitals to community health systems (CHSs). The aim of this study was to explore the effect of doctors' and patients' practices and attitudes on their willingness for downward referral and the relationship between downward referral and sociodemographic characteristics.

          Methods

          Doctors and patients of 13 tertiary hospitals in Shanghai were stratified through random sampling. The questionnaire surveyed their sociodemographic characteristics, attitudes towards CHSs and hospitals, understanding of downward referral, recognition of the community first treatment system, and downward referral practices and willingness. Descriptive statistics, χ 2 test and stepwise logistic regression analysis were employed for statistical analysis.

          Results

          Only 20.8% (161/773) of doctors were willing to accept downward referrals, although this proportion was higher among patients (37.6%, 326/866). Doctors' willingness was influenced by education, understanding of downward referral, and perception of health resources in hospitals. Patients' willingness was influenced by marital status, economic factors and recognition of the community first treatment system. Well-educated doctors who do not consider downward referral would increase their workloads and those with a more comprehensive understanding of hospitals and downward referral process were more likely to make a downward referral decision. Single-injury patients fully recognising the community first treatment system were more willing to accept downward referral. Patients' willingness was significantly increased if downward referral was cost-saving. A better medical insurance system was another key factor for patients to accept downward referral decisions, especially for the floating population.

          Conclusions

          To increase the rate of downward referral, the Chinese government should optimise the current referral system and conduct universal publicity for downward referral. Doctors and patients should promote understandings of downward referral. Hospitals should realise the necessity of downward referral, effectively reduce workloads and provide continuing education for doctors. Increasing monetary reimbursement is urgent, as is improving the medical insurance system.

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          Most cited references68

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          Emerging issues in public health: a perspective on China's healthcare system.

          China's expenditure on healthcare has increased dramatically over the last 20 years, and three broad trends are seen in the associated health outcomes. First, limited improvements have been achieved to aggregate high-level health outcomes, e.g. infant mortality. Second, development of large and widening health inequalities associated with disparate wealth between provinces and a rural-urban divide. Finally, the burden of disease is shifting from predominantly communicable diseases to chronic diseases. Reasons for the limited gains from investment in healthcare are identified as: (1) increased out-of-pocket expenditure including a high proportion of catastrophic expenditure; (2) a geographical imbalance in healthcare spending, focusing on secondary and tertiary hospital care and greater expenditure on urban centres compared with rural centres; and (3) the commercialization of healthcare without adequate attention to cost control, which has led to escalation of prices and decreased efficiency. Recently, the Chinese Government has initiated widespread reform. Three key policy responses are to establish rural health insurance, partly funded by the Government (the New Rural Co-operative Medical Care System); to develop community health centres; and to aspire to universal basic healthcare coverage by 2020 (Healthy China 2020). Copyright © 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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            The Ecology of Medical Care in Beijing

            Background We presented the pattern of health care consumption, and the utilization of available resources by describing the ecology of medical care in Beijing on a monthly basis and by describing the socio-demographic characteristics associated with receipt care in different settings. Methods A cohort of 6,592 adults, 15 years of age and older were sampled to estimate the number of urban-resident adults per 1,000 who visited a medical facility at least once in a month, by the method of three-stage stratified and cluster random sampling. Separate logistic regression analyses assessed the association between those receiving care in different types of setting and their socio-demographic characteristics. Results On average per 1,000 adults, 295 had at least one symptom, 217 considered seeking medical care, 173 consulted a physician, 129 visited western medical practitioners, 127 visited a hospital-based outpatient clinic, 78 visited traditional Chinese medical practitioners, 43 visited a primary care physician, 35 received care in an emergency department, 15 were hospitalized. Health care seeking behaviors varied with socio-demographic characteristics, such as gender, age, ethnicity, resident census register, marital status, education, income, and health insurance status. In term of primary care, the gate-keeping and referral roles of Community Health Centers have not yet been fully established in Beijing. Conclusions This study represents a first attempt to map the medical care ecology of Beijing urban population and provides timely baseline information for health care reform in China.
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              Development of a medical academic degree system in China

              Context The Chinese government launched a comprehensive healthcare reform to tackle challenges to health equities. Medical education will become the key for successful healthcare reform. Purpose We describe the current status of the Chinese medical degree system and its evolution over the last 80 years. Content Progress has been uneven, historically punctuated most dramatically by the Cultural Revolution. There is a great regional disparity. Doctors with limited tertiary education may be licensed to practice, whereas medical graduates with advanced doctorates may have limited clinical skills. There are undefined relationships between competing tertiary training streams, the academic professional degree, and the clinical residency training programme (RTP). The perceived quality of training in both streams varies widely across China. As the degrees of master or doctor of academic medicine is seen as instrumental in career advancement, including employability in urban hospitals, attainment of this degree is sought after, yet is often unrelated to a role in health care, or is seen as superior to clinical experience. Meanwhile, the practical experience gained in some prestigious academic institutions is deprecated by the RTP and must be repeated before accreditation for clinical practice. This complexity is confusing both for students seeking the most appropriate training, and also for clinics, hospitals and universities seeking to recruit the most appropriate applicants. Conclusion The future education reforms might include: 1) a domestic system of ‘credits’ that gives weight to quality clinical experience vs. academic publications in career advancement, enhanced harmonisation between the competing streams of the professional degree and the RTP, and promotion of mobility of staff between areas of excellence and areas of need; 2) International – a mutual professional and academic recognition between China and other countries by reference to the Bologna Accord, setting up a system of easily comparable and well-understood medical degrees.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2017
                3 April 2017
                : 7
                : 4
                : e012565
                Affiliations
                [1 ]Institute of Military Health Management, Second Military Medical University , Shanghai, China
                [2 ]Maternal and Child Service Center of Rizhao City , Rizhao, China
                [3 ]No 187th hospital of PLA, Haikou, China
                [4 ]Shanghai Sixth People's Hospital , Shanghai, China
                Author notes
                [Correspondence to ] Professor Lulu Zhang; zllrmit@ 123456aliyun.com

                WY, ML and XN contributed equally to this research.

                Article
                bmjopen-2016-012565
                10.1136/bmjopen-2016-012565
                5387945
                28373247
                f6ce854c-ed3c-4be9-bb3e-411f19ace2d4
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 13 May 2016
                : 6 March 2017
                : 7 March 2017
                Categories
                Health Services Research
                Research
                1506
                1704
                1703

                Medicine
                downward referral,doctors and patients,practices and attitudes,influencing factors,health care seeking behavior

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