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Practices and attitudes of doctors and patients to downward referral in Shanghai, China
  1. Wenya Yu1,
  2. Meina Li1,
  3. Xin Nong2,
  4. Tao Ding1,
  5. Feng Ye1,3,
  6. Jiazhen Liu1,4,
  7. Zhixing Dai1,
  8. Lulu Zhang1
  1. 1Institute of Military Health Management, Second Military Medical University, Shanghai, China
  2. 2Maternal and Child Service Center of Rizhao City, Rizhao, China
  3. 3No 187th hospital of PLA, Haikou, China
  4. 4Shanghai Sixth People's Hospital, Shanghai, China
  1. Correspondence to Professor Lulu Zhang; zllrmit{at}


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, χ2 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.

  • Downward referral
  • doctors and patients
  • practices and attitudes
  • influencing factors
  • health care seeking behavior

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  • WY, ML and XN contributed equally to this research.

  • Contributors This manuscript was jointly completed by WY, ML, XN, TD, FY, JL, ZD and LZ. WY, ML and XN contributed equally to this research. WY made substantial contributions to conception and design, analysis and interpretation of data, drafting the manuscript and revising it critically for important intellectual content. ML and XN made substantial contributions to conception and design, interpretation of data, and drafting the manuscript. TD, FY, JL and ZD were involved in data collection. LZ made substantial contributions to conception and design, and gave final approval of the version to be published.

  • Funding The project was supported by the National Natural Science Foundation of China (71233008, 71673291, 71303248, 91224005), Joint Research Project of Major Disease of Shanghai Health System (2013ZYJB0006) and the Major Project in the ‘12th Five-Year Plan’ of the People's Liberation Army (AWS12J002).

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The study was approved by the Ethics Committee of Second Military Medical University.

  • Data sharing statement No additional data are available.