Patient dissatisfaction in China: What matters

Highlights

• Investigate patient dissatisfaction determinants and explore major reasons in China.

• Patients' gender, education, insurance status are significant predicators.

• Lower competition and higher private hospitals share correlates with dissatisfaction.

• Exorbitant medical costs are the major reason for dissatisfaction.

Abstract

Patient satisfaction is a focal concern of health-care delivery and an expected outcome of medical care. Recently, the violent conflict between doctors and patients in China has intensified. Patient dissatisfaction has been recognized as an important concern and an urgent issue in the reform of China's health care. The objectives of this study are to investigate the determinants of patient dissatisfaction attributed to patient, hospital, and health-care market characteristics, as well as to explore the major determinants in the context of China. Data from 2007 to 2010 Urban Resident Basic Medical Insurance Survey (URBMIS) are used in this study. A total of 13,336 patients are selected conditional on health-care utilization. Analysis of satisfaction is based on outpatient utilization (last 2 weeks' reference, 6393 individuals) and inpatient utilization (last 1-year reference, 6943 individuals). Satisfaction was measured as ordinal variables (scales 1–5). Ordinary least squares (OLS) regression and an ordered probit model are applied to investigate the determinants. Blinder–Oaxaca decomposition is further employed to detect the proportion each predictor's contribution. The results indicate that patients' gender, education, and insurance status are significantly related to patient satisfaction. Higher-level hospitals are found to negatively correlate with patient satisfaction. Lower competition in providers' market and a higher market share of private hospitals are found to positively correlate with patient dissatisfaction. Meanwhile, the survey indicates that “medical charges too expensive” is chiefly responsible for patient dissatisfaction. Our study provides empirical evidence on the determinants of patient dissatisfaction in China. In particular, the results indicate that establishing a high competition among various providers in the health-care market will act as a “double-edged sword,” with great policy implications.

Introduction

Although the Chinese government has made great efforts to provide more health benefits to its citizens, poor health-care services and inefficiencies in their delivery are still widely criticized. Patient dissatisfaction is on the rise, even resulting in serious violence against doctors in recent past (Chen, 2012, Yuan, 2012). During the last 10 years, the number of violent events in medical facilities has increased 10 times (GuangZhou Daily, 2014). Of these disputes, 73.5% involved harassment of hospital staff and disruption of routine work, 45% referred to destruction of hospital infrastructure, and 35% involved direct injuries to medical personnel (note: the events are not mutually exclusive). In most cases, these incidents could be attributed to unsatisfactory standards of medical care, medical errors, or exorbitant costs. Moreover, a recent paper highlighted a growing concern of hospital disturbances by criminal gangs in China – a phenomenon known as Yi Nao, involving organized disturbance or violence in hospitals or other health facilities to obtain compensation for actual or perceived malpractice (Hesketh et al., 2012). This growing tension between patients and health service providers has challenged the current health-care practice in China, making patient (dis)satisfaction one of the primary concerns of the health-care system.

Patient satisfaction is a key indicator of the quality of health care, and it is commonly used as a measure of health service performance (Gill and White, 2009). Theoretical studies of patient satisfaction have been conducted since the 1960s. Among the extensive literature, five representative theories can be identified: Fox and Storms (1981) proposed the discrepancy and transgression theory, wherein patient satisfaction is the result of an interplay between patients' perspective of what constitutes good-quality health care and the providers' view of the quality. The expectancy-value theory of Linder-Pelz (1982) focused on sociopsychological determinants and stated that patient satisfaction was mediated by patients' prior expectations, personal beliefs, and values of health care. Similarly, in the determinants and components theory, Ware et al. (1983) claimed that patient satisfaction is a function of patients' personal preferences and their expectation from health care. On the other hand, Fitzpatrick and Hopkins (1983) propounded a multiple-model theory, and they emphasized that expectations are socially mediated, reflecting the health goals of the patient and the extent to which illness and health care violated the patient's personal sense of self. Donabedian (1980) proposed the health-care quality theory, stating that satisfaction is an integral component of a three-pronged structure of the medical market, the process of provision of health care, and the outcome of the treatment. Based on these studies, a comprehensive model of the patient satisfaction process was developed to attempt to incorporate all influences on satisfaction, thereby providing a holistic framework for exploring the interactions between variables that affect the evaluation of patients (Fig. 1).

Further empirical investigations have been carried out to identify provider- and patient-related factors that are associated with patient satisfaction. Many researchers have argued that sociodemographic characteristics such as age, race, gender, education, and health status influence patient satisfaction (Young et al., 2000, Malat, 2002, Henderson and Weisman, 2005), while others regard these indicators as unimportant. Studies on the relationship between sociodemographic characteristics of patients and their level of satisfaction were found to have inconsistent results. For example, some studies found that female patients tend to be more satisfied with the health service (e.g., Fox and Storms, 1981), while others found higher satisfaction levels among male patients (e.g., Quintana et al., 2006). Recent empirical studies have also found that patient expectations from health care are important independent predictors of patient satisfaction, with high expectations being associated with high levels of dissatisfaction (Bjertnaes et al., 2012, McGregor et al., 2013). The sociodemographic characteristics of patients are complex: their influence on expectations, trust, adherence to medical counsel, perceived symptom resolution, and final satisfaction is dynamic and contextual. Thus, the effect of the sociodemographic characteristics of patients needs to be considered within the broader social structure/culture and health-care institutional settings. In other words, the micro-level process of provider–patient interaction must be linked to more macro-level processes in the health-care delivery system (Carr-Hill, 1992). Accordingly, provider-related factors, including the ownership attributes of providers, the price of health care, types of services available, quality of infrastructure, and the overall quality of care (actual or perceived), have also been found to be important predictors of patient satisfaction (Geron et al., 2000, Walsh and Lord, 2004).

Although several studies have investigated the determinants of patient satisfaction in developed countries, evidence from developing countries remains scarce. So far, only a few studies have emerged from China, which are only limited to certain types of treatments or health conditions, with relatively small sample sizes. For example, in a sample of 586 inpatients in one tertiary hospital in China, Jiao et al. (2010) found that young age, male gender, and low level of education were significantly associated with a higher level of satisfaction with health services. To investigate provider-related factors, Ma (2009) used data from cardiothoracic surgery inpatients in one tertiary hospital and found that perceived quality of nursing care, communication with patients, and professional behavior of doctors were key predictors of patient satisfaction.

The studies mentioned earlier provide a useful, but limited insight, as it cannot be generalized to the diverse population groups in China. In this study, our theoretical aim is to expand the research on the impact of both patient- and provider-related characteristics on patient satisfaction by adopting a nationally representative household survey data in urban China. In addition, we include variables of the medical market structure in the Chinese institutional context, especially taking our transitional health-care delivery system and social welfare system into account, to explain the general differences among patients (dis)satisfaction. The findings will provide substantial insight into the predictors of patient satisfaction from the largest and most populated developing countries. The reasons for patient dissatisfaction are also explored, which will help health services decision makers identify key target areas for improving patient satisfaction. To our knowledge, this paper is the first to investigate patient satisfaction in China using a large representative sample from urban China.