Association between integrated service level and outpatient care-seeking patterns among rural chronic disease patients: a cross-sectional study in three Chinese counties

Corresponding author: LIU Xiaoyun, xiaoyunliu@pku.edu.cn

DOI: 10.12201/bmr.202608.00036

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  Abstract: Abstract Objective: To examine the association between integrated service level and outpatient care-seeking choices among chronic disease patients in rural China, identify the key dimensions and specific service components most closely associated with primary care utilization, and provide empirical evidence to inform the optimization of hierarchical medical system policies. Methods: Based on cross-sectional survey data collected in three counties across Shanxi, Henan, and Zhejiang provinces in 2024, this study included 1,148 patients with self-reported hypertension and/or diabetes who had outpatient visits in the past year. A three-dimensional integrated service measurement framework, developed based on formative measurement theory, was applied. Multivariable logistic regression was used to examine the association between the integrated service score (continuous variable) and primary care utilization for outpatient visits, with subsequent models incorporating the three dimension scores and core service indicators separately to identify independent effects. Results: Among the 1,148 patients, 76.7% chose primary care for their most recent outpatient visit. After adjusting for demographic, socioeconomic, and health status factors, each one-point increase in the integrated service score was associated with higher odds of primary care utilization (OR=1.010, 95% CI: 1.001–1.020, P=0.033). Dimensional analysis showed that primary integrated service was the only dimension with a statistically significant independent effect (OR=1.020, 95% CI: 1.001–1.040, P=0.041). Indicator-level analysis revealed that, after controlling for other indicators and confounders, downward information transmission—the extent to which primary care providers were informed of patients'' treatment at county hospitals—was the only supply-side service indicator with a significant independent effect (OR=1.86, 95% CI: 1.06–3.27, P=0.031). Neither referral recommendation nor referral appointment assistance had a significant independent effect on primary care utilization. Conclusion: Integrated service level was positively associated with primary care utilization among rural chronic disease patients. Primary integrated service emerged as the key dimension with a significant independent effect, and downward information transmission was the specific service component most strongly associated with primary care utilization. Policy efforts should prioritize establishing information feedback channels from county hospitals to primary care facilities, strengthening the overall capacity-building of primary integrated services, and enhancing the practical effectiveness of referral coordination mechanisms.

  Key words: Integrated health services; Care-seeking pattern; Hierarchical diagnosis and treatment; Chronic disease management; Primary health care

  Submit time: 17 August 2026

  Copyright: The copyright holder for this preprint is the author/funder, who has granted biomedRxiv a license to display the preprint in perpetuity.
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