Abstract:

Objective: Using the China Family Panel Studies (CFPS, 2012-2022), this study aimed to characterize changes in the distribution of usual sources of care and in subjective perceptions among Chinese adults, and to examine the associations of subjective perceptions and income change with next-wave transitions in usual source of care. Methods: This was a retrospective longitudinal observational study based on adult CFPS data from 2012, 2014, 2016, 2018, 2020, and 2022. We first described temporal trends in three types of usual source of care (primary care, hospitals, and clinics), as well as trends in residents' subjective perceptions of healthcare providers, and in relative income change. We then constructed person-period samples from adjacent survey waves and analyzed two transition processes separately: outflow from primary care among baseline primary care users and inflow to primary care among baseline non-primary care users. Key predictors were prior-wave satisfaction, perceived medical competence, and relative income change; the income-change variable was defined based on changes in relative income group within the same wave and same province sample. Descriptive analyses applied cross-sectional weights; the main regressions were unweighted binary Logistic models with individual-level cluster-robust standard errors, reporting odds ratios (OR), 95% confidence intervals (95% CI), and P va-lues. Results: The pooled sample comprised 135 986 observations from 34 010 individuals. From 2012 to 2022, the proportion using primary care as the usual source of care declined from 43.49% to 30.34%, whereas the hospital share rose from 34.06% to 46.81%. The decline in primary care was steeper during 2012-2018 (43.49% to 33.72%) and persisted at a slower pace thereafter (33.72% to 30.34%). Across adjacent survey waves, primary care outflow increased from 35.47% to 45.22%, while primary care inflow decreased from 30.09% to 19.60%, indicating simultaneous increases in exits and decreases in entries. Subjective perceptions improved for all three provider types over time; however, the relative gap between primary care and hospitals widened on perceived medical competence, and primary care shifted from a slight advantage over clinics to a clear disadvantage in composite subjective perceptions. The proportion of residents with unchanged relative income group rose from 50.64% to 60.33%. In multivariable models, each one-unit increase in satisfaction with primary care was associated with 7.5% lower odds of leaving primary care (OR=0.925, P < 0.001). In contrast, each one-unit increase in perceived medical competence of non-primary care providers was associated with 5.3% lower odds of moving into primary care (OR=0.947, P < 0.001). Compared with stable relative income group, upward relative income-group mobility, particularly low-to-high movement, was associated with higher odds of outflow from primary care and lower odds of inflow to primary care (outflow OR=1.166; inflow OR=0.840), whereas downward relative income-group mobility, especially high-to-low movement, showed the opposite pattern (outflow OR=0.785; inflow OR=1.371). Conclusion: Primary care utilization in China continued to decline, with increased outflow from primary care and reduced inflow to primary care occurring simultaneously. Residents ' subjective perceptions were associated with different considerations in retention in versus movement into primary care: the former was more closely related to satisfaction, whereas the latter was more closely related to perceived medical competence. People with upward relative income-group mobility showed a lower inclination to use primary care. Hierarchical care policy should address both entry into and retention in primary care by strengthening continuity of care, reinforcing service capability and institutional design, and aligning payment incentives.

Key words: Primary health care, Usual source of care, Patient acceptance of health care, Patient satisfaction, Income, Longitudinal studies