It is of great significance to study the choice of a healthcare institution in patients with multimorbidity in China during the implementation of hierarchical medical system since relevant research is still insufficient.

To study the choice of a healthcare institution and associated factors in patients with multimorbidity in China during the implementation of hierarchical medical system, providing a reference for further implementation of the hierarchical medical system and rational allocation of medical resources.

A survey using a self-developed questionnaire was conducted with a random sample of patients with multimorbidity who visited the healthcare institutions in Shanghai Yangpu District Central Hospital Medical Consortium〔including Shanghai Yangpu District Central Hospital, and three community health centers (Dinghai, Yanji and Changbai) 〕from June 1, 2019 to January 1, 2020 for collecting their demographics, knowledge related to supportive policies of hierarchical medical system, practical adherence to the policies, willingness to choose a community health center for initial treatment under different controlled conditions of diseases, and considerations when choosing a healthcare institution. Binary Logistic regression was used to analyze the factors influencing the choice of a community health center for initial treatment.

Of the 1 100 cases who attended the survey, 1 072 (97.45%) who responded effectively were finally included, among whom 85.07% (912/1 072) were older people (≥60 years old). 624 cases (58.21%) have a knowledge of hierarchical medical system; 940 cases (87.69%) approved of concepts proposed by hierarchical medical system; 368 cases (34.33%) were well aware of "1+1+1" type of contracted services; 964 cases (89.93%) had signed the contract of "1+1+1" type of contracted services, among whom 44 cases (4.56%) chose non-designated medical institutions for treatment. Patients who were willing to choose a community health center for initial treatment during the stable phase or when having mildly poorly controlled condition accounted for 86.57% (928/1 072) and 85.82% (920/1 072), respectively. The factors considered by patients when choosing a healthcare institution were ranked as follows (from high to low according to the average comprehensive score) : accessibility (5.50 points), level of medical technology (5.13 points), satisfaction with treatment (3.74 points), medical security (3.60 points), medical expenses (2.93 points), and other factors (2.24 points). Binary Logistic regression analysis showed that age and health insurance were independent influencing factors for the choice of a community health center for initial treatment (P<0.05) .

Older people are at high risk for multimorbidity, and are the major group seeking first treatment in primary care. Compared to regional medical centers, community health centers are more accessible, which is favorable for these patients seeking first-contact care. To promote the choice of a primary care institution for initial treatment advocated by the hierarchical medical system, it is suggested to accelerate the construction of regional medical consortiums, promote the sharing of various high-quality resources and the allocation of such resources to primary care, and improve service quality and capacity of primary care.