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.

近年来，国内针对多病共存患者在分级诊疗背景下就医机构选择行为的研究较少，研究多病共存患者的就医机构选择行为有重要的现实意义。

以分级诊疗为视角，分析多病共存患者就医机构选择行为及其影响因素，为进一步落实分级诊疗制度和合理配置医疗资源提供研究参考。

采用随机抽样法，选取2019-06-01至2020-01-01在上海市杨浦区中心医院医疗联合体（上海市杨浦区中心医院和上海市杨浦区定海、延吉、长白社区卫生服务中心）就诊的多病共存患者为研究对象。采用自设问卷对其进行调查，收集多病共存患者的一般资料，了解其对分级诊疗政策的认知情况及实际遵守情况、在不同疾病控制状况下至社区卫生服务中心首诊的意愿，以及其选择就诊医疗机构时考虑的因素等。采用二分类Logistic回归分析多病共存患者此次因病就医是否选择至社区卫生服务中心首诊的影响因素。

共发放1 100份问卷，回收有效问卷1 072份，有效问卷回收率为97.45%。1 072例多病共存患者中，老年（≥60岁）多病共存患者占85.07%（912/1 072）。624例（58.21%）患者表示知晓分级诊疗制度；940例（87.69%）患者表示愿意遵循分级诊疗制度所提倡的就医理念；368例（34.33%）患者表示对"1+1+1"组合签约模式非常了解；964例（89.93%）患者表示已经参加了"1+1+1"组合签约项目，但其中44例（4.56%）患者此次因病就医过程中选择至非签约医疗机构就诊；愿意在疾病稳定期或者疾病轻度控制不佳时选择至社区卫生服务中心首诊的患者分别占86.57%（928/1 072）和85.82%（920/1 072）。多病共存患者选择就诊医疗机构时考虑的因素按平均综合得分由高到低排列依次为医疗可及性（5.50分）、医疗技术水平（5.13分）、就医满意度（3.74分）、医疗保障情况（3.60分）、医疗费用支出（2.93分）和其他因素（2.24分）。二分类Logistic回归分析结果显示，年龄、医疗保障情况是多病共存患者此次因病就医是否选择至社区卫生服务中心首诊的影响因素（P<0.05）。

老年人是多病共存的高发群体，也是选择基层首诊的主要人群。相较于区域医疗中心，社区卫生服务中心可及性高，这也是实现多病共存患者基层首诊的有利因素。因此，加快医疗联合体建设步伐，推动各项优质资源共享和下沉基层，提高基层医疗卫生机构服务质量及能力，有利于实现分级诊疗制度所倡导的基层首诊。