Factors influencing the choice of health system access level in China: a systematic review

Background In China, patients increasingly choose to access severely overcrowded higher level hospitals, whereas the lower level facilities often have low frequencies of use. This situation undermines effectiveness and efficiency of the health system. Moreover, the situation tends to worsen despite policy measures aimed at improvement. We therefore aimed to systematically review the factors affecting patient choice of health system access in China to synthesise scientific understanding. Methods We did a systematic review of peer-reviewed literature that investigated Chinese patients' choice of health-care facilities at different levels. We searched Embase, MEDLINE, Web of Science, and PubMed for English language articles, and three large Chinese databases (CNKI, VIP, and Wanfang) for articles in Chinese between April 1, 2009, and Jan 28, 2016, using search terms related to patients' choice of health-care facility access level, and how these factors affect the choice of level, such as health care access, decision making in health care, and health seeking behaviour. The primary outcome was to identify the factors that influenced patient choices of health system access level in China. Two structured forms were used to extract data from eligible studies, regarding the study characteristics, methodology, and factors. We appraised the methodological quality of the studies using Method Appraisal Tool (MMAT). Findings We identified and included 45 studies into our analysis. We identified four types of factors related to patient, provider, context, and composite factors from multiple types. Patient factors are mentioned in 31 (69%) of 45 studies, but the evidence on patient factors is mostly inconclusive. Context factors were the least frequently mentioned, and were reported in four (9%) studies. Evidence suggests that the provider factors, such as drug variety and equipment, and composite factor, such as perceived quality, push patients from lower levels towards higher levels. The MMAT quality score was 100% for 13 studies, 75% for 25 studies, 50% for six studies, and 25% for one study. Interpretation This systematic review provides an evidence base for measures to redirect patient flow from high level health-care facilities to lower level facilities, thus improving effectiveness and efficiency of the Chinese health system. The underuse of primary care facilities in the Chinese health system compromises the effectiveness and efficiency, and are likely to be amplified by current demographic trends. Evidence suggests that improving the drug availability, equipment, and perceived quality of primary care services can improve the situation. Our evidence suggests that further experimental research is needed, which also considers interactions between factors. Funding This study was partly funded by the China Scholarship Council (grant number 201507720036).