The phenomenon of "no referral" still exists against the backdrop of implementing the hierarchical medical system, which has been preliminarily constructed in China. Most existing studies on addressing this phenomenon are mostly from the perspective of hospital management policies, ignoring the role of doctors as "health gatekeepers" in making decisions during the hierarchical diagnosis and treatment process.

To investigate the influence of personal, institutional, environmental, and policy factors on the willingness of physicians in county hospitals to refer patients with common diseases to lower level of institutions from physicians' perspective.

This study was conducted from July to August 2021. By use of region-based stratified and convenience sampling, seven county-level people's hospitals were selected as settings from eastern, central and western China. By use of cluster sampling, physicians (n=142) in internal medical departments were selected from the above-mentioned hospitals to attend an online (through the WJX.cn platform) or off-line (hospital) questionnaire survey to understand their willingness to refer patients with a common illness to lower level institutions, and personal, institutional, environmental, and policy factors associated with their willingness during a consultation described using the scenario simulation method. The survey achieved a response rate of 96.5% (137/142). Binary Logistic regression was used to analyze the effects of personal, institutional, environmental, and policy factors on physicians' willingness to refer the patients to a lower level institution.

The mean score of physicians' willingness to refer the patients to a lower level institution was (9.92±2.20). Fifty-six physicians (40.9%) had higher level of willingness to conduct downward referrals. Education level, awareness level of referrals, and frequency of communication of referrals between higher and lower level institutions were associated with scores of physicians' willingness to conduct downward referrals (P<0.05). Spearman correlation analysis showed that self-rated overall workload, risk of medical disputes and patient-doctor relationship (in the institutional factor dimension) were positively correlated with physicians' willingness to conduct downward referrals (r_s=0.26, 0.32, and 0.23; P<0.05). Binary Logistic regression analysis showed that higher awareness level of referrals was associated with increased level of willingness to conduct downward referrals in physicians〔OR (95% CI) =1.62 (1.19, 2.22) 〕. Higher influence of the referral system implemented within the hospital on medical dispute risk was associated with increased physicians' level of willingness to conduct downward referrals〔OR (95%CI) =3.275 (1.10, 9.73) 〕. However, higher influence of the referral system implemented within the hospital on performance was associated with reduced level of willingness to conduct downward referrals in physicians〔OR (95%CI) =0.400 (0.20, 0.79) 〕.

This study suggests that the willingness of physicians in county hospitals to conduct downward referrals is low on the whole, but it can be improved by increasing physicians' awareness level of referrals, and improving the influence of the referral system implemented within the hospital on the risk of medical disputes, and decreasing the influence of the referral system implemented within the hospital on the performance. In view of this, it is recommended that hospitals adopt a performance appraisal model that incorporates policy values, highlights policy recognition of referrals, and measures economic losses caused by referrals and the value of extra labor load, strengthen the popularization of hierarchical medical system in primary hospitals, and innovatively use the Internet-based hierarchical diagnosis and treatment model.