title: Practices and attitudes of doctors and patients to downward referral in Shanghai, China.
abstract: 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.
  
  
  
  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, χ2test and stepwise logistic regression analysis were employed for statistical analysis.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Institute of Military Health Management, Second Military Medical University, Shanghai, China.
authors.forename: Wenya
authors.initials: W
authors.lastname: Yu
authors.affiliation: Institute of Military Health Management, Second Military Medical University, Shanghai, China.
authors.forename: Meina
authors.initials: M
authors.lastname: Li
authors.affiliation: Maternal and Child Service Center of Rizhao City, Rizhao, China.
authors.forename: Xin
authors.initials: X
authors.lastname: Nong
authors.affiliation: Institute of Military Health Management, Second Military Medical University, Shanghai, China.
authors.forename: Tao
authors.initials: T
authors.lastname: Ding
authors.affiliation: Institute of Military Health Management, Second Military Medical University, Shanghai, China.|No 187th hospital of PLA, Haikou, China.
authors.forename: Feng
authors.initials: F
authors.lastname: Ye
authors.affiliation: Institute of Military Health Management, Second Military Medical University, Shanghai, China.|Shanghai Sixth People's Hospital, Shanghai, China.
authors.forename: Jiazhen
authors.initials: J
authors.lastname: Liu
authors.affiliation: Institute of Military Health Management, Second Military Medical University, Shanghai, China.
authors.forename: Zhixing
authors.initials: Z
authors.lastname: Dai
authors.affiliation: Institute of Military Health Management, Second Military Medical University, Shanghai, China.
authors.forename: Lulu
authors.initials: L
authors.lastname: Zhang
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D002681:China; D003153:Community Health Services; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D010820:Physicians; D012017:Referral and Consultation; D062606:Tertiary Care Centers; D055815:Young Adult
keywords: Downward referral; doctors and patients; health care seeking behavior; influencing factors; practices and attitudes