Volume 30 Issue 9
Sep.  2017
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LI Wen Zhen, GAN Yong, ZHOU Yan Feng, CHEN Ya Wen, LI Jing, KKANDAWIRE Naomiem, HU Sai, QIAO Yan, LU Zu Xun. Factors Affecting Patient Satisfaction with Community Health Service under the Gatekeeper System:A Cross-sectional Study in Nanjing, China[J]. Biomedical and Environmental Sciences, 2017, 30(9): 685-690. doi: 10.3967/bes2017.092
Citation: LI Wen Zhen, GAN Yong, ZHOU Yan Feng, CHEN Ya Wen, LI Jing, KKANDAWIRE Naomiem, HU Sai, QIAO Yan, LU Zu Xun. Factors Affecting Patient Satisfaction with Community Health Service under the Gatekeeper System:A Cross-sectional Study in Nanjing, China[J]. Biomedical and Environmental Sciences, 2017, 30(9): 685-690. doi: 10.3967/bes2017.092

Factors Affecting Patient Satisfaction with Community Health Service under the Gatekeeper System:A Cross-sectional Study in Nanjing, China

doi: 10.3967/bes2017.092
Funds:

This work was supported by the National Natural Science Foundation of China NSFC, 71373090, 'Study on the gatekeeper policy of CHS'

More Information
  • Author Bio:

    LI Wen Zhen, Post-Doctor, female, born in 1988, majoring in community health service, health policy, social factors and health

    GAN Yong, male, born in 1988, Post-doctor, field of majoring in community health service; social factors and health and evidence-based medicine

  • Corresponding author: LU Zu Xun, Tel:86-27-83693756, E-mail:zuxunlu@yahoo.com
  • Received Date: 2017-04-24
  • Accepted Date: 2017-08-17
  • The gatekeeper policy has been implemented for approximately ten years on a pilot population in China. It is necessary to assess the satisfaction of patients utilizing community health service (CHS) under the gatekeeper system. Our study showed that the cognition of gatekeeper policy was associated with four dimensions including doctor-patient relationships, information and support, organization of care, and accessibility (P < 0.001). One or more factors such as gender and self-perceived health scores also affected their satisfaction. General practitioners must be prepared to focus on these aspects of information and support, organization of care, and accessibility as indicators of potential opportunities for improvement. Additionally, policymakers can improve patients' satisfaction with CHS by strengthening their awareness of the gatekeeper policy.
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  • [1] Hesketh T, Wei XZ. Health in China. From mao to market reform. BMJ, 1997; 314, 1543-5. http://pubmedcentralcanada.ca/pmcc/articles/PMC2126766/
    [2] Blumenthal D, Hsiao W. Privatization and its discontents-the evolving chinese health care system. N Engl J Med, 2005; 353, 1165-70. doi:  10.1056/NEJMhpr051133
    [3] Yip W, Hsiao W. Harnessing the privatisation of China's fragmented health-care delivery. Lancet, 2014; 384, 805-18. doi:  10.1016/S0140-6736(14)61120-X
    [4] Velasco Garrido M, Zentner A, Busse R. The effects of gatekeeping:A systematic review of the literature. Scand J Prim Health Care, 2011; 29, 28-38. doi:  10.3109/02813432.2010.537015
    [5] Hussey PS, Anderson GF, Osborn R, et al. How does the quality of care compare in five countries? Health Aff, 2004; 23, 89-99. http://www.nsfc.gov.cn/Portals/0/fj/20130930_fj02.doc
    [6] Roland M, Elliott M, Lyratzopoulos G, et al. Reliability of patient responses in pay for performance schemes:analysis of national general practitioner patient survey data in England. BMJ, 2009; 339, b3851. doi:  10.1136/bmj.b3851
    [7] Cheng TM. Early results of China's historic health reforms:the view from minister Chen Zhu. Interview by Tsung-Mei Cheng. Health Aff, 2012; 31, 2536-44. https://www.ncbi.nlm.nih.gov/pubmed/23129685
    [8] Heje HN, Vedsted P, Sokolowski I, et al. Doctor and practice characteristics associated with differences in patient evaluations of general practice. BMC Health Serv Res, 2007; 7, 46. doi:  10.1186/1472-6963-7-46
    [9] Guangqiang Lai YW, Heqing Huang, Jian Chen, et al. Reliability analysis on satisfaction on general physician's service. Chinese Health Resources, 2009; 12, 2. (In Chinese) http://tarupublications.com/journals/jios/full-text/JIOS-27-1-2006/jios134.pdf
    [10] Heje HN, Vedsted P, Sokolowski I, et al. Patient characteristics associated with differences in patients' evaluation of their general practitioner. BMC Health Serv Res, 2008; 8, 178. doi:  10.1186/1472-6963-8-178
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Factors Affecting Patient Satisfaction with Community Health Service under the Gatekeeper System:A Cross-sectional Study in Nanjing, China

doi: 10.3967/bes2017.092
Funds:

This work was supported by the National Natural Science Foundation of China NSFC, 71373090, 'Study on the gatekeeper policy of CHS'

  • Author Bio:

  • Corresponding author: LU Zu Xun, Tel:86-27-83693756, E-mail:zuxunlu@yahoo.com

Abstract: The gatekeeper policy has been implemented for approximately ten years on a pilot population in China. It is necessary to assess the satisfaction of patients utilizing community health service (CHS) under the gatekeeper system. Our study showed that the cognition of gatekeeper policy was associated with four dimensions including doctor-patient relationships, information and support, organization of care, and accessibility (P < 0.001). One or more factors such as gender and self-perceived health scores also affected their satisfaction. General practitioners must be prepared to focus on these aspects of information and support, organization of care, and accessibility as indicators of potential opportunities for improvement. Additionally, policymakers can improve patients' satisfaction with CHS by strengthening their awareness of the gatekeeper policy.

LI Wen Zhen, GAN Yong, ZHOU Yan Feng, CHEN Ya Wen, LI Jing, KKANDAWIRE Naomiem, HU Sai, QIAO Yan, LU Zu Xun. Factors Affecting Patient Satisfaction with Community Health Service under the Gatekeeper System:A Cross-sectional Study in Nanjing, China[J]. Biomedical and Environmental Sciences, 2017, 30(9): 685-690. doi: 10.3967/bes2017.092
Citation: LI Wen Zhen, GAN Yong, ZHOU Yan Feng, CHEN Ya Wen, LI Jing, KKANDAWIRE Naomiem, HU Sai, QIAO Yan, LU Zu Xun. Factors Affecting Patient Satisfaction with Community Health Service under the Gatekeeper System:A Cross-sectional Study in Nanjing, China[J]. Biomedical and Environmental Sciences, 2017, 30(9): 685-690. doi: 10.3967/bes2017.092
  • Since 1980, the Chinese health care system has improved greatly by relying on the community health care system, which is funded and owned by the government[1]. However, the privatization of China's economy based on market-oriented economic reforms[2] resulted in the large-scale dismantling of the community health service (CHS) system. In recent years, although the level of CHS had improved and is much better than before, patients still prefer well-known hospitals to community health care facilities owing to their distrust of CHS. Therefore, admissions and visits keep occurring at comprehensive and specialized hospitals[3].

    As is well known, the gatekeeping function performed by CHS providers contributes to the formation of an equitable and efficient health care delivery system[4]; however, patients subjected to the gatekeeper policy are therefore restricted with regard to their choices, which may influence their satisfaction with CHS. Patient satisfaction, an indicator of the service quality, includes continuity of the service, doctor-patient relationships, communication, and professional skills of the service providers and is increasingly used to assess care quality and payment schemes by policymakers[5] and health insurance companies[6].

    With the near completion of universal health insurance coverage and the establishment of the community health care network[7], the Chinese government has been implementing the gatekeeper policy on special populations such as the elderly, migrant workers, etc., and, in 2009, launched a large pilot program involving all residents with the Urban Employee's Basic Medical Insurance (UEBMI) in Nanjing. The research among this population on patient satisfaction with CHS can be helpful for improving the quality of services and policymaking.

    This cross-sectional study was conducted at four community health service centers (CHCs) in Nanjing in 2015. A total of 1, 100 questionnaires were distributed, out of which 1, 058 were completed and collected. The European Patients Evaluate General/ Family Practice (EUROPEP) scale, which contains 23 items, was used to assess patients' satisfaction with CHS. The assessment method has been introduced in a previous publication[8]. A chi-squared (χ2) test and multi-regression analyses were used to explore the influencing factors of patient satisfaction in the context of the gatekeeper policy.

    Table 1 shows the sociodemographic characteristics of participants. More than half of the participants were females (59.2%), retired (54.7%), and with chronic conditions (56.9%). Last year, about half of the participants visited the CHC 0-3 times (50.2%), and had higher self-perceived health scores (53.9%). Of the respondents, more than half had good cognition of the gatekeeper policy (59.5%). The distribution of baseline characteristics and patients' assessments of CHS are presented in the attachment (Supplementary Tables 1a-1e, available in www.besjournal.com).

    Characteristicn (%)
    Age
     18-40258 (24.4)
     40-60330 (31.2)
     ≥ 60470 (44.4)
    Gender
     Male432 (40.8)
     Female626 (59.2)
    Marital status
     Married931 (88.0)
     Single127 (12.0)
    Educational background
     Primary school and below72 (6.8)
     Middle school559 (52.8)
     College degree and above427 (40.3)
    Income of family monthly(RMB)
     ≤ 3, 000424 (40.1)
     3, 000-5, 000221 (20.9)
     ≥ 5, 000413 (39.0)
    Occupational type
     Administrative institution105 (9.9)
     Retired579 (54.7)
     Enterprise staff219 (27.5)
     Other83 (7.8)
    Health score
     ≥ 80570 (53.9)
     60-80379 (35.8)
      < 60109 (10.3)
    Chronic conditions
     No456 (43.1)
     Yes602 (56.9)
    Visiting times to CHC last year
     0-3531 (50.2)
     4-6110 (10.4)
     7-12107 (10.1)
     ≥ 12310 (29.3)
    Cognition of gatekeeper policy
     Good630 (59.5)
     General148 (14.0)
     Bad280 (26.5)

    Table 1.  Distribution of Patients by Their Socio-demographic Characteristics

    The patients' assessment of CHS is presented in Table 2. Among their assessments of five aspects of CHS, patients' positive assessment of the doctor-patient relationship was the highest (48.9%), while their most positive assessment of accessibility was only 13.9%. The Supplementary Table 2a, available in www.besjournal.com highlights the percentage of patients who gave the highest rating ('4' or '5') in the EUROPEP instrument.

    CharacteristicMost Positive Assessments*Neutral Assessments#Poor Assessments
    n%n%n%
    Doctor-patient-relationship (6 items)51748.932730.921420.2
    Medical care (5 items)42540.222921.640438.2
    Information and support (4 items)35733.731930.238236.1
    Organization of care (2 items)3393232130.439837.6
    Accessibility (6 items)14713.922120.969065.2
      Note.*Patients who marked 100% of the answered questions in one of the two most positive answering categories. #Patients who marked 100%-50% of the answered questions in one of the two most positive answering categories. Patients who marked less than 50% (0%-49%) of the answered questions in one of the two most positive answering categories.

    Table 2.  Distribution of Patients' Satisfaction with Community Health Services

    Table 3 shows the results of the multiple regression analysis (including only the 100% category and the 0%-49% category) on the five dimensions of patient satisfaction with the care they received at the CHCs. Notably, good cognition of the gatekeeper policy among patients did positively influence their satisfaction on four dimensions, (P < 0.001) especially with regard to accessibility (7.497, 3.552-15.823), but did not positively influence medical care. Besides, it was also the only influencing factor for the dimension of information and support (1.775, 1.734-3.891 for good and 2.056, 1.704-5.094 for general).

    VariablesDoctor-patient-relationship
    (6 items)
    Medical Care
    (5 items)
    Information and Support
    (4 items)
    Organization of Care
    (2 items)
    Accessibility
    (6 items)
    OR (95% Cl)POR {95% Cl)POR (95% Cl)POR (95% Cl)POR {95% Cl)P
    Age
     18-400.600 (0.277, 1.301)0.1961.468 (0.769, 2, 869)0.2380.850 (0.427, 1.695)0.6450.921 (0.463, 1.831)0.8411.350 (0.575, 3.172)0.41
     40-600.747 (0.426, 1.309)0.3090.856 (0.530, 381)0.5240.611 (0.366, 1.019)0.0591.091 (0.655, 1.815)0.7380.986 (0.504, 1.926)0.967
     ≥60ReferenceReferenceReferenceReferenceReference
    Gender
     Female1.540 (1.078, 2.199)0.0181.313 (0.964, 1.793)0.0841.372 (0.995, 1.892)0.0541.607 2.233)0.0051.432 (0.949, 2.161)0.087
     MaleReferenceReferenceReferenceReferenceReference
    Marital status
     Married0.731 (0.422, 1.266)0.2630.654 (0.393, 1.0S8)0.1020.707 (0.438, 1.141)0.1560.891 (0.549, 1.446)0.6400.806 (0.454, 1.433)0.463
     SingleReferenceReferenceReferenceReferenceReference
    Educational Background
     Primary school and below0325 (0.154, 0.689)0.0030.412 (0.204, 0.831)0.0130.684 (0.337, 1.388)0.2930.334 (0.145, 0.774)0.0100.247 (0.069, 0.983)0.033
     Middle school0.834 (0.539, 1.289)0.4140.932 (0.645, 1.347)0.7090.846 (0.578, 1.237)0.3880, 868 (0.590, 1, 275)0.4700.646 (0.404, 1.032)0.068
     College degree and aboveReferenceReferenceReferenceReferenceReference
    Income of family monthly (RMB)
     ≤3, 0000.753 (0.486, 1.165)0.2020.871 (0.603, 1.258)0.4620.783 (0.532, 1.151)0.2140.899 (0.608, 1.B30)0.5941.283 (0.787, 2.092)0.317
     3, 000-5, 0000.655 (0.410, 1.047)0.0770.823 (0.551, 1.228)0.3390.879 (0.580, 1.3B2)0.5430.S9B (0.586, 1.B62)0.5991.223 (0.728, 2.055)0.446
     ≥ 5, 000ReferenceReferenceReferenceReferenceReference
    Occupational type
     Administrative Institution0.440 (01804.071)0.070.620 (0.305, 1.261)0.1870, 632(0.301, 1.328)0.2260.598(0.2914-231)0.1630.727 (0.311, 1.701)0.462
     Retired0.384 (0.164, 0.899)0.0270.704 (0.354, 1.401)0.3180.638(0.306, 1.331)0.2310.600(0.296, 1-216)0.1560.567 (0.233, 1.379)0.221
     Enterprise staff0.573 (0.269, 1.221)0.1490.750 (0.407, 1.384)0.3570.913 (0.482, 1.729)0.7800.703 (0.381, 1.296)0.2590.638 (0.306, 1.330)0.231
     OtherReferenceReferenceReferenceReferenceReference
    Health score
     ≥801.865 (0.989, 3.517)0.0541.810 (1.053, 3.113)0.0321.666 (0.962, 2.886)0.0691.089 (0.605, 1.961)0.7751.750 (0.731, 4.194)0.209
     60-801.429 (0.772, 2.644)0.2561.719 (1.013, 2.918)0.0151.038 (0.606, 1.778)0.8920.832 (0.465, 1.490)0.5371.374 (0.577, 3.273)0.473
      < 60ReferenceReferenceReferenceReferenceReference
    Chronic conditions
     No1.039 (0.666, 1.620)0.8661.355 (0.916, 2.005)0.1281.085 (0.721, 1.632)0.6971.214 (0.806, 1.829)0.3521.100 (0.661, 1.831)0.714
     YesReferenceReferenceReferenceReferenceReference
    Visiting times to CHC last year
     0-30.339(0.203, 0.566)< 0.0010.653 (0.431, 0.988)0.0440.653 (0.424, 1.006)0.0530.458 (0.290, 0.722)0.0011.282 (0.727, 2.261)0.390
     4-60.584 (0.295, 1.156)0.1220.823 (0.474, 1.428)0.4880.937 (0.534, 1.643)0.821.048 (0.587, 1.868)0.8751.881 (0.923, 3.832)0.082
     7-120.376 (0.196, 0.725)0.0030.645 (0.374, 1.114)0.1160.595 (0.331, 1.070)0.0830.804 (0.449, 1.440)0.4641.269 (0.600, 2.682)0.533
     ≥12ReferenceReferenceReferenceReferenceReference
    Cognition of the gatekeeper policy
     Good1.780 (1.201, 2.638)0.0041.273 (0.892, 1.818)0.1841.775 (1.734, 3.891)0.0022.962(1.997, 4.392)< 0.0018.211 (3.878, 17.386)< 0.001
     General1.230(0.729, 2.076)0.4371.431 (0.883, 2.321)0.1462.056 (1.704, 5.094)0.0052.847 (1.674, 4.843)< 0.0019.335 (4.034, 21.602)< 0.001
     BadReferenceReferenceReferenceReferenceReference

    Table 3.  Multi-factor Analysis of Patients' Satisfaction on Five Dimensions of Community Health Services

    China's health care reform has resulted in the expansion of health insurance coverage and strengthened the infrastructure of primary health facilities since 2009. However, it is difficult to transform investments and insurance coverage into cost-effective services with fragmented and inefficient health care delivery[7]. In this case, the asymmetries in medical information between patients and health care providers make it difficult for patients to make sound choices without guidance and, in return, aggravate the inefficient delivery of health service. In many developed countries, gatekeeper policies play an important role in the process of forming an effective health service system[4]. In China, many pilot programs of gatekeeper policy have been launched, and this study is the first attempt to assess patients' satisfaction among the population with UEBMI.

    The EUROPEP scale is beneficial for the makers of health policies in developing First Step systems and has been implemented in 16 European countries[8]. In China, few studies on patient satisfaction have been conducted using the EUROPEP scale and only one study[9] evaluated its reliability (Cronbach's α = 0.945). Our study shows that the EUROPEP scale is suitable for assessing patient satisfaction with high reliability and validity (Cronbach's α = 0.960 and KMO = 0.958), and we believe it will contribute to international comparisons of patient satisfaction with CHS, especially in countries where the general practitioner (GP) is the gatekeeper.

    Consistent with the previous study[10], our study indicates that sociodemographic differences with statistical significance vary in assessments of CHS. In China, doctor-patient relationships have become a public health concern to which close attention is paid. Our results suggest that patients are most satisfied with the doctor-patient relationship aspect, which indicates the advantage of CHCs and the importance of the gatekeeper policy. In addition, our study shows that a high proportion of patients poorly assessed the aspect of medical care, which is an influencing factor of community patients' satisfaction. It is worth noting that patients are least satisfied with accessibility, and the aspects of 'getting through to the practitioner on the phone' and 'getting an appointment to suit you' may be good goals to improve accessibility. Thus, GPs must be prepared to focus on the aspect of accessibility as an indicator of the potential opportunity for improvement. In addition, the item 'waiting time in the waiting room' was positively assessed, which suggests that it is easier for patients to visit doctors at CHCs rather than at hospitals in China.

    The multivariable logistic regression analyses suggest that the influencing factors of patients' satisfaction among the five dimensions are diverse and that age, marital status, educational background, self-perceived health status, frequency of visits to CHCs, and chronic diseases influence their assessment of CHS at different levels. As such, excepting to improve services by making residents comprehend the policy may be important to achieve overall satisfaction among patients.

    There are some limitations to this study. First, the potential influencing factors of patient satisfaction with CHS are possibly more than those we investigated. Second, the study is based on a convenient sample of patients who had just completed their visits to CHCs. The fact that they were at the CHCs at the moment of the survey may indicate their willingness to seek care at CHCs, which may have induced an overestimated level of satisfaction. Finally, although our results illustrate the high reliability and validity of the EUROPEP scale, more studies are needed to examine the further applicability of the scale to the Chinese population.

    Patients' satisfaction, as the basic criteria for acquiring information with regard to what extent their expectations are met, is an important indicator for the assessment of the gatekeeper policy. Patients' good cognition of the policy is positively associated with their satisfaction, and improvements of the aspects of information and support, medical care, and accessibility may be good goals for patient satisfaction.

  • ItemMost Positive
    Assessments*
    (517)
    Neutral
    Assessments#
    (327)
    Poor Assessments(214)χ2P
    Age
     18-40134 (25.9)70 (21.4)54 (25.2)2.7010.609
     40-60155 (30.0)11110 (33.6)65 (30.4)
     ≥ 60228 (44.1)147 (45.0)95 (44.4)
    Gender
     Male200 (38.7)131 (40.1)100 (46.9)4.1460.126
     Female317 (61.3)196 (59.9)114 (53.1)
    Marital status
     Married449 (86.8)293 (89.6)189 (88.3)1.4660.481
     Single68 (13.2)34 (10.4)25 (11.7)
    Educational Background
     Primary school and below26 (5.1)21 (6.4)25 (11.7)12.2550.016
     Middle school274 (53.0)170 (52.0)115 (53.7)
     College degree and above217 (41.9)136 (41.6)74 (34.6)
    Income of family monthly
     ≤ 3, 000201 (38.8)128 (39.2)96 (44.7)6.6650.155
     3, 000-5, 000103 (20.0)67 (20.4)51 (24.0)
     ≥ 5, 000213 (41.2)132 (40.4)67 (31.3)
    Occupational type
     Administrative institution43 (8.3)43 (13.1)19 (8.9)14.2340.027
     Retired272 (52.6)189 (57.8)118 (55.1)
     Enterprise staff158 (30.6)69 (21.1)64 (29.9)
     Other44 (8.5)26 (8.0)13 (6.1)
    Health score
     ≥ 80287 (55.5)172 (52.6)111 (51.9)11.3560.023
     60-80192 (37.1)108 (33.0)79 (36.9)
      < 6038 (7.4)47 (14.4)24 (11.2)
    Chronic conditions
     No225 (43.5)133 (40.7)98 (45.8)1.4560.483
     Yes292 (56.5)194 (59.3)116 (54.2)
    Visiting times to CHC last year
     0-3250 (48.4)146 (44.6)135 (63.1)28.434< 0.001
     4-655 (10.6)36 (11.0)19 (8.9)
     7-1246 (8.9)35 (10.7)26 (12.1)
     ≥ 12166 (32.1)110 (33.6)34 (15.9)
      Note. *Patients who marked 100% of the answered questions in one of the two most positive answering categories. #Patients who marked 50%-100% of the answered questions in one of the two most positive answering categories. Patients who marked less than 50% (0%-49%) of the answered questions in one of the two most positive answering categories.

    Table 1a.  Distribution of Characteristics among Patients on Doctor-Patient-Relationship

    ItemMost Positive
    Assessments* (425)
    Neutral
    Assessments#(229)
    Poor Assessments
    (404)
    χ2P
    Age
     18-40135 (31.8)48 (21.0)75 (18.6)21.491< 0.001
     40-60118 (27.8)75 (32.8)137 (33.9)
     ≥ 60172 (40.5)106 (46.3)192 (47.5)
    Gender
     Male164 (38.5)92 (40.2)176 (43.5)2.1750.337
     Female261 (61.5)137 (59.8)228 (56.5)
     Marital status
     Married369 (86.9)190 (82.9)371 (91.9)11.570.003
     Single56 (13.1)39 (17.1)33 (10.1)
    Educational Background
     Primary school and below18 (4.3)12 (5.2)42 (10.4)18.9260.001
     Middle school218 (51.2)119 (52.0)223 (55.1)
     College degree and above189 (44.5)98 (42.8)139 (34.5)
    Income of family monthly
     ≤ 3, 000153 (36.0)93 (40.7)178 (44.1)8.1720.085
     3, 000-5, 00088 (20.8)45 (19.5)88 (21.9)
     ≥ 5, 000184 (43.2)91 (39.8)138 (34.0)
    Occupational type
     Administrative institution43 (10.1)20 (8.7)42 (10.4)12.3010.056
     Retired207 (48.7)136 (59.4)236 (58.4)
     Enterprise staff137 (32.2)55 (24.0)99 (24.5)
    other38 (8.9)18 (7.9)27 (6.7)
     Health score
     ≥ 80244 (57.4)124 (54.1)202 (50.0)10.2330.037
     60-80150 (35.3)82 (35.8)147 (36.4)
      < 6031 (7.3)23 (10.0)55 (13.6)
    Chronic conditions
     No210 (49.4)90 (39.3)156 (38.6)11.5670.003
     Yes215 (50.6)139 (60.7)248 (61.4)
    Visiting times to CHC last year
     0-3215 (50.6)108 (47.2)208 (51.5)2.6180.855
     4-646 (10.8)26 (11.4)38 (9.4)
     7-1239 (9.2)23 (10.0)45 (11.1)
     ≥ 12125 (29.4)72 (31.4)113 (28.0)
    Cognition of the gatekeeper policy
     Good265 (62.3)140 (61.1)225 (55.7)13.8970.008
     General69 (16.3)21 (9.2)58 (14.4)
     Bad91 (21.4)68 (29.7)121 (30.0)
      Note. *Patients who marked 100% of the answered questions in one of the two most positive answering categories. #Patients who marked 50%-100% of the answered questions in one of the two most positive answering categories. Patients who marked less than 50% (0%-49%) of the answered questions in one of the two most positive answering categories.

    Table 1b.  Distribution of Characteristics among Patients on Medical Care

    ItemMost Positive
    Assessments* (357)
    Neutral
    Assessments#(319)
    Poor Assessments
    (382)
    χ2P
    Age
     18-40119 (33.3)58 (18.2)81 (21.2)25.928< 0.001
     40-6091 (25.5)107 (33.5)132 (34.6)
     ≥ 60147 (41.2)154 (48.3)169 (44.2)
    Gender
     Male137 (38.4)128 (40.2)166 (43.5)2.0440.360
     Female220 (61.6)191 (59.2)216 (56.5)
    Marital status
     Married301 (84.3)287 (89.9)343 (89.7)6.9230.031
     Single56 (15.7)32 (10.1)39 (10.3)
    Educational Background
     Primary school and below21 (5.9)17 (5.4)34 (8.9)13.8570.008
     Junior middle school168 (47.0)182 (56.8)210 (55.0)
     Associate college168 (47.0)120 (37.9)138 (36.1)
    Income of family monthly
     ≤ 3, 000126 (35.2)124 (39.0)174 (45.6)12.3390.015
     3, 000-5, 00080 (22.4)59 (18.4)83 (21.6)
     ≥ 5, 000151 (42.3)136 (42.5)125 (32.8)
    Occupational type
     Administrative institution36 (10.1)29 (9.1)40 (10.5)16.7520.010
     Retired170 (47.6)193 (60.5)216 (56.5)
     Enterprise staff122 (34.2)69 (21.6)100 (26.2)
    other29 (8.1)28 (8.8)26 (6.8)
    Health score
     ≥ 80217 (60.8)167 (52.4)186 (48.7)13.9440.007
     60-80109 (30.5)124 (38.9)146 (38.2)
      < 6031 (8.7)28 (8.8)50 (13.1)
    Chronic conditions
     No171 (47.9)127 (39.8)158 (41.4)5.230.073
     Yes186 (52.1)192 (60.2)224 (58.6)
    Visiting times to CHC last year
     0-3184 (51.5)142 (44.5)205 (53.7)11.4620.075
     4-642 (11.8)30 (9.4)38 (9.9)
     7-1230 (8.4)35 (11.0)42 (11.0)
     ≥12101 (28.3)112 (35.1)97 (25.4)
    Cognition of the gatekeeper policy
     Good226 (63.2)195 (61.1)209 (54.7)20.693< 0.001
     General63 (17.7)36 (11.3)49 (12.8)
     Bad68 (19.1)88 (27.6)124 (32.5)
      Note.*Patients who marked 100% of the answered questions in one of the two most positive answering categories. #Patients who marked 50%-100% of the answered questions in one of the two most positive answering categories. Patients who marked less than 50% (0%-49%) of the answered questions in one of the two most positive answering categories.

    Table 1c.  Distribution of Characteristics among Patients on Information and Support

    ItemMost Positive
    Assessments* (339)
    Neutral
    Assessments#(321)
    Poor Assessments
    (398)
    χ2P
    Age
     18-40101 (29.8)53 (16.5)104 (26.1)21.707< 0.001
     40-60112 (33.0)101 (31.5)117 (29.4)
     ≥ 60126 (37.2)167 (52.0)177 (44.5)
    Gender
     Male114 (33.7)138 (43.0)178 (44.9)10.6830.005
     Female225 (65.3)183 (57.0)218 (55.1)
    Marital status
     Married294 (86.6)290 (90.3)340 (87.2)2.4380.295
     Single45 (14.5)31 (9.7)50 (12.6)
    Educational Background
     Primary school and below11 (3.3)26 (8.1)35 (8.8)15.2130.004
     Middle school172 (50.7)181 (56.3)207 (51.9)
     College degree and above156 (46.0)114 (35.6)156 (39.3)
    Income of family monthly
     ≤ 3, 000123 (36.4)134 (41.6)168 (42.1)4.7890.310
     3, 000-5, 00073 (21.5)61 (18.9)88 (22.1)
     ≥ 5, 000143 (42.1)126 (39.4)142 (35.9)
    Occupational type
     Administrative institution36 (10.6)29 (9.0)40 (10.1)17.4780.008
     Retired161 (47.5)202 (62.9)216 (54.3)
     Enterprise staff107 (31.6)72 (22.4)112 (28.1)
     other35 (10.3)18 (5.6)30 (7.5)
    Health score
     ≥ 80203 (59.9)146 (45.5)221 (55.5)14.5040.006
     60-80106 (31.3)135 (42.0)138 (34.7)
      < 6030 (8.8)40 (12.5)39 (9.8)
    Chronic conditions
     No164 (48.4)108 (33.6)184 (46.2)17.143< 0.001
     Yes175 (51.6)213 (66.4)214 (53.8)
    Visiting times to CHC last year
     0-3161 (47.5)127 (39.6)243 (61.1)58.191< 0.001
     4-647 (13.9)27 (8.4)36 (9.0)
     7-1240 (11.8)28 (8.7)39 (9.8)
     ≥ 1291 (26.8)139 (43.3)80 (20.1)
    Cognition of the gatekeeper policy
     Good236 (69.5)188 (58.6)206 (51.8)42.825< 0.001
     General54 (16.0)44 (13.7)50 (12.6)
     Bad49 (14.5)89 (27.7)142 (35.7)
      Note.*Patients who marked 100% of the answered questions in one of the two most positive answering categories. #Patients who marked 50%-100% of the answered questions in one of the two most positive answering categories. Patients who marked less than 50% (0%-49%) of the answered questions in one of the two most positive answering categories.

    Table 1d.  Distribution of Characteristics among Patients on Organisation of Care

    ItemMost Positive
    Assessments*(147)
    Neutral
    Assessments#(221)
    Poor Assessments
    (690)
    χ2P
    Age
     18-4057 (38.8)60 (27.1)141 (20.4)25.648< 0.001
     40-6044 (29.9)68 (30.8)218 (31.6)
     ≥ 6046 (31.3)93 (42.1)331 (48.0)
    Gender
     Male52 (35.2)88 (39.7)292 (42.3)2.5380.281
     Female95 (64.8)133 (60.3)398 (57.7)
    Marital status
     Married123 (83.4)195 (88.2)612 (88.8)2.9030.234
     Single24 (16.6)26 (11.8)78 (11.2)
    Educational Background
     Primary school and below3 (2.1)12 (5.4)57 (8.3)22.246< 0.001
     Middle school62 (42.1)118 (53.4)379 (54.9)
     College degree and above82 (55.9)91 (41.2)254 (36.8)
    Income of family monthly
     ≤ 3, 00052 (35.7)79 (35.9)293 (42.4)4.9970.288
     3, 000-5, 00033 (22.4)47 (21.4)141 (20.5)
     ≥ 5, 00062 (42.0)95 (42.7)256 (37.1)
    Occupational type
     Administrative institution20 (13.6)25 (11.3)60 (8.7)24.694< 0.001
     Retired58 (39.5)111 (50.2)410 (59.4)
     Enterprise staff53 (36.1)61 (27.6)177 (25.7)
     Other16 (10.9)24 (10.9)43 (6.2)
    Health score
     ≥ 8093 (63.3)126 (57.0)351 (50.9)10.2760.036
     60-8046 (31.3)72 (32.6)261 (37.8)
      < 608 (5.4)23 (10.4)78 (11.3)
    Chronic conditions
     No79 (53.7)99 (44.8)278 (40.3)9.2690.010
     Yes68 (46.3)122 (55.2)412 (59.7)
    Visiting times to CHC last year
     0-382 (55.8)99 (44.8)350 (50.7)10.9020.091
     4-618 (12.2)31 (14.0)61 (8.8)
     7-1215 (10.2)25 (11.3)67 (9.7)
     ≥ 1232 (21.8)66 (29.9)212 (30.7)
    Cognition of gatekeeper system
     Good106 (72.1)145 (65.6)378 (54.9)53.261< 0.001
     General32 (21.8)32 (14.5)84 (12.2)
     Bad9 (6.1)44 (19.9)227 (32.9)
      Note. *Patients who marked 100% of the answered questions in one of the two most positive answering categories. #Patients who marked 50%-100% of the answered questions in one of the two most positive answering categories. Patients who marked less than 50% (0%-49%) of the answered questions in one of the two most positive answering categories.

    Table 1e.  Distribution of Characteristics among Patients on Accessibility

    What is your opinion of the general practitioner and/or general practice over the last 12 months with respect to...RankPercent (%)
    Doctor-patient-relationship
     1 making you feel you had time during consultations468.9
     2 interest in your personal situation?568.8
     3 making it easy for you to tell him or her about your problems?178.1
     4 involving you in decisions about your medical care?1062.3
     5 listening to you?276.4
     6 keeping your records and data confidential?371.6
    Medical care
     7 quick relief of your symptoms?963.2
     8 helping you to feel well so that you can perform your normal daily activities?765.8
     9 thoroughness?1458.8
     10 physical examination of you?1359.6
     11 offering you services for preventing diseases?1651.4
    Information and support
     12 explaining the purpose of tests and treatments (eg. screening, health checks, immunisations)1260.0
     13 telling you what you wanted to know about your symptoms and/or illness?863.3
     14 helping you deal with emotional problems related to your health status?1840.3
     15 helping you understand the importance of following his or her advice?1162.0
    Organisation of care
     16 knowing what he or she had done or told you during contacts?1555.9
     17 preparing you for what to expect from specialist or hospital care?1938.9
    Accessibility
     18 the helpfulness of the staff (other than doctor)?1750.7
     19 getting an appointment to suit you?2225.1
     20 getting through to the practice on the phone?2323.2
     21 being able to speak to the general practitioner on the telephone?2034.4
     22 waiting time in the waiting room?666.1
     23 providing quick services for urgent health problems?2127.6
      Note. *With a score of 4 or 5 on the 5 point Likert scale.

    Table 2a.  Distribution of Patients' Most Positive Assessment* of Each Item

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