Why people select the outpatient clinic of medical centers: a nationwide analysis in Taiwan

Introduction In contrast to other countries, Taiwan’s National Health Insurance (NHI) program allows patients to freely select the specialists and tiers of medical care facility without a referral. Some medical centers in Taiwan receive over 10,000 outpatients per day. In the NHI program, the co-payment was increased for high-tier facilities for outpatient visits in 2002, 2005, and 2017. However, the policies only mildly reduced the use of high-tier medical care facilities. The main purpose of this study was to evaluate the factors contributing to the patients’ selection of the outpatient clinic of medical centers without a referral. Methods An online anonymous survey was conducted by using the Google Forms platform utilizing a self-constructed questionnaire from September to October 2018. A nationwide sample in Taiwan was recruited using convenience sampling through social media. Based on a literature review and a focus group, 20 factors that may affect the choice of the outpatient institution were constructed. The associations between items that affect the patients selection of outpatient clinics were assessed using exploratory factor analysis. Principal axis factoring was performed to identify the major factors affecting the decision. Multiple logistic regression was performed to determine which factors satisfactorily explained “visiting the outpatient clinic of the medical center for an illness without a referral.” Results During the survey period, 5,060 people browsed the online survey, and 1,003 responded and completed the online questionnaire. Therefore, the response rate was 19.8%. A total of 987 valid responses was collected. Exploratory factor analysis revealed that three main factors, namely the “physician factor”, “image and reputation factor”, and “facility and medication factor”, affected the selection of outpatient clinics. A series of logistic regressions indicated that patients who reported that hospital facilities, high-quality drugs, and diverse specialties were very important were more likely to select the outpatient clinic of a medical center (OR = 2.218, 95% CI [1.514–3.249]). Patients who reported that physician factors were very important were less likely to select a medical center (OR = 0.717, 95% CI [0.523–0.984]). Patients who were previously satisfied with their experience of the primary clinics or had a regular family doctor were less likely to choose a medical center (OR = 0.509, 95% CI -0.435–0.595] and OR = 0.676, 95% CI [0.471–0.969]). Conclusion In Taiwan, patients with good primary medical experience and regular family physicians had significantly lower rates by selecting the outpatient clinic of a medical center. The results of this study support that the key to establishing graded medical care is to prioritize the strengthening of the primary medical system.

Methods. An online anonymous survey was conducted by using Google Form 34 responded and completed the online questionnaire. Therefore, the response rate was 19.8%.

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A total of 987 valid responses was collected. Exploratory factor analysis revealed that three 36 main factors, namely the "physician factor," "image and reputation factor," and " facility 37 and medication factor," affected the selection of outpatient clinics. A series of logistic

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Studies have reported that people in developed countries visit a doctor 5-6 times a year, 78 whereas in Taiwan, the average frequency of visits is 13. More than 30,000 insured residents in 79 Taiwan seek hospital inpatient and outpatient services over 100 times a year (Lynn et al., 2015).  119 The link to the survey was available for 8 weeks. All participants were invited to complete 120 an anonymous self-administered online questionnaire, which required approximately 10 minutes 121 to complete. Informed consent was requested from all participants on the first page of the 122 questionnaire. Only participants who were at least 20 years old and were able to read Chinese 123 fluently were given access. No rewards were provided to participants. A deduplication protocol 124 was applied to identify multiple submissions and preserve data integrity, including cross-   158 At the beginning of the study, the questionnaire was pretested in 20 patients to determine if 159 the content was appropriate and to ascertain whether the content was understandable. The 160 internal consistency reliability test was used for reliability analysis. Cronbach's alpha of the 161 questionnaire was 0.895, which is satisfactory.

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Descriptive statistics were used to present the results for patient hospital choices.
170 Independent samples t-tests and Chi-square tests were adopted to examine the association 171 between respondents' demographic characteristics and their outpatient preference. The normality 172 of the collected data was analyzed using the Kolmogorov-Smirnov test. The data followed a 173 normal distribution; thus, comparisons among the three groups were performed using analysis of 174 variance (ANOVA).A p value of <0.05 (two-tailed) was considered statistically significant.

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The associations between items that affect the patients' choice of outpatient clinics were 176 assessed using exploratory factor analysis. Measures of sample adequacy, such as Kaiser-Meyer- 218 Table 2 summarizes the average rating of respondents on the importance of each factor 219 when selecting an outpatient facility and their preferred outpatient institution. "Physicians were 220 highly reputable," "physicians explained in detail," and "physicians have a good medical 221 practice" were the rated most important factors to consider when selecting the outpatient 222 institution. The low copayment was the least important factor for outpatient medical choice 223 among all patients (Likert scale rating of 3.08 ± 1.16).

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In univariate analysis, six factors were significantly more important among the respondents 225 who chose to visit a medical center (p < 0.001). These factors were "physicians are highly 226 reputable," "physicians have a good medical practice," " the institution has advanced 227 equipment," "the institution has high-quality drugs," "the institution has diverse specialties, " and 228 "the institutions has a good reputation". In this study, we conducted exploratory factor analysis to 229 understand the potential common characteristics among factors and clarify the influencing 230 factors. We used principal component analysis to extract data using a correlation matrix and 231 oblimin rotation method. We removed six items because of cross-loading or because the factor 232 load was too low (< 0.4). Factors with eigenvalues greater than 1, cumulative percentages of 233 variance explained above 71.2%, KMO value reaching of 0.868, and p value less then 0.001 234 were excluded. Three main factors were retained in the final extraction (Table 3), namely 235 "physician factor," "image and reputation factor," and "facility and medication factor." We 236 subsequently converted the scores to three factors into a multivariable analysis model.
237 Table 4 illustrates three models of logistic regression for predicting "visits to the outpatient 238 clinic of the medical center for an illness." Age was a crucial predictor in all the models. The 239 likelihood of choosing to visit a medical center when ill increased by 2.7%-3.1% for every 240 additional year of age (95% CI = 1.4%-4.3%) when other variables were controlled.

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In Model 1, when age, gender, "have a regular family physician," and "consider that

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This study has several limitations that may affect the findings. First, participants were 310 recruited over the Internet because of the web-based survey design, thus the low response rate 311 warrants further exploration. Although the online survey represents a wide age range and 312 geographic distribution, the sample was younger and more highly educated than the general  Manuscript to be reviewed  4 Six factors were removed because the factor load was too low (< 0.4) or because of cross-5 loading. The removed factors were "consider the severity of the disease," "institution has 6 convenient transportation," "reasonable waiting time," "institution was recommended by 7 friends or relatives," "willing to prescribe for chronic diseases," and "low copayment."