Abstract: Background　The implementation of hierarchical medical system in a scientific and orderly way is a key approach to enhancing the efficiency of healthcare delivery，reasonably using healthcare resources，and reducing medical costs.In China，it is very obvious that rural residents prefer to seek healthcare in higher level hospitals instead of the primary healthcare institutions，which leads to the waste of health resources，and hinders the effective implementation of hierarchical medical system.Objective　To investigate Xuzhou rural residents' intention and associated factors of seeking healthcare in primary healthcare institutions for common diseases during the implementation of hierarchical medical system，providing a reference for the improvement of first consultations in primary care system.Methods　From July to August 2016，a survey was conducted among 800 rural residents selected from 4 counties of Xuzhou by stratified multistage random sampling.A structured questionnaire developed by our research team was used in the survey，which consists of demographic characteristics，views on the implementation of hierarchical medical system，and intention of having first consultations in primary care.Multivariate Logistic regression was used to analyze the influencing factors associated with the residents' intention of having first consultations in primary care.Results　The questionnaire survey achieved a response rate of 95.4%（763/800）．Of the respondents，82.1%（626/763）preferred to seek healthcare in primary healthcare institutions when having a common disease，mainly because of short distance and low medical cost.But 95.1%（726/763）preferred to seek healthcare in a general hospital when having severe conditions，mainly because of high-quality medical services，and good diagnostic and therapeutic equipments.Multivariate Logistic regression analysis showed that low medical costs in the past year，long distance between home and the nearest secondary or tertiary hospital，good treatment experience in the primary healthcare institution，supporting for the implementation of hierarchical medical system，and perception of the implementation of medical insurance programs being a facilitator for the development of hierarchical medical system were factors associated with higher probability of intending to have first consultations in primary care（P<0.05）．Conclusion　The rate of intention of having first consultations in primary care among Xuzhou rural residents is reasonable at large.Medical costs in the past year，distance between home and the nearest secondary or tertiary hospital，treatment experience in the primary healthcare institution，attitude toward the implementation of hierarchical medical system，and perception of whether the implementation of medical insurance programs could facilitate the development of hierarchical medical system are associated factors for intention of having first consultations in primary care.

Key words: Hierarchical medical system, Primary health care, Patient preference, First visit, Commom disease, Root cause analysis

摘要： 背景　科学有序的分级诊疗制度是提高医疗卫生服务效率、合理利用医疗卫生资源、节约医疗费用的重要途径。我国农村居民的就医趋高现象突出，基层常受到“冷落”，浪费了卫生资源，阻碍分级诊疗制度的有效实施。目的　了解徐州市农村居民基层医疗卫生机构首诊意愿，并探讨分级诊疗制度背景下农村居民就诊意愿的影响因素及原因，为完善基层首诊制度提供参考依据。方法　于2016年7—8月，采用多阶段分层随机抽样的方法，对徐州市4个县的800例农村居民进行结构式问卷调查。主要内容包括农村居民基本情况、对分级诊疗制度的看法及基层首诊意愿等。采用多因素Logistic回归分析农村居民首选基层医疗卫生机构的影响因素。结果　回收有效问卷763份，有效回收率为95.4%。763例农村居民中，患常见病时，82.1%（626/763）的居民选择基层医疗卫生机构，原因主要是距离近、收费低；病情较重时，95.1%（726/763）的居民选择综合医院，原因主要是医疗水平高、设备好。多因素Logistic回归分析结果显示，上一年医疗费用低、最近二三级医疗机构的距离远、有基层就医经历、支持分级诊疗制度、认为现行的医保制度能促进分级诊疗制度的实施的农村居民，首选基层医疗卫生机构就医的意愿较高（P<0.05）。结论　徐州市农村居民基层首诊意愿趋于合理，上一年医疗费用、最近二三级医疗机构的距离、基层就医经历、对分级诊疗制度的态度及现行的医保制度能否促进分级诊疗制度的实施，与选择基层医疗卫生机构就医的意愿有关。

关键词: 分级诊疗, 初级卫生保健, 病人意愿, 首诊, 常见病, 影响因素分析