Since 1980, the Chinese health care system has improved greatly by relying on the community health care system, which is funded and owned by the government^[1]. However, the privatization of China's economy based on market-oriented economic reforms^[2] resulted in the large-scale dismantling of the community health service (CHS) system. In recent years, although the level of CHS had improved and is much better than before, patients still prefer well-known hospitals to community health care facilities owing to their distrust of CHS. Therefore, admissions and visits keep occurring at comprehensive and specialized hospitals^[3].

As is well known, the gatekeeping function performed by CHS providers contributes to the formation of an equitable and efficient health care delivery system^[4]; however, patients subjected to the gatekeeper policy are therefore restricted with regard to their choices, which may influence their satisfaction with CHS. Patient satisfaction, an indicator of the service quality, includes continuity of the service, doctor-patient relationships, communication, and professional skills of the service providers and is increasingly used to assess care quality and payment schemes by policymakers^[5] and health insurance companies^[6].

With the near completion of universal health insurance coverage and the establishment of the community health care network^[7], the Chinese government has been implementing the gatekeeper policy on special populations such as the elderly, migrant workers, etc., and, in 2009, launched a large pilot program involving all residents with the Urban Employee's Basic Medical Insurance (UEBMI) in Nanjing. The research among this population on patient satisfaction with CHS can be helpful for improving the quality of services and policymaking.

This cross-sectional study was conducted at four community health service centers (CHCs) in Nanjing in 2015. A total of 1, 100 questionnaires were distributed, out of which 1, 058 were completed and collected. The European Patients Evaluate General/ Family Practice (EUROPEP) scale, which contains 23 items, was used to assess patients' satisfaction with CHS. The assessment method has been introduced in a previous publication^[8]. A chi-squared (χ²) test and multi-regression analyses were used to explore the influencing factors of patient satisfaction in the context of the gatekeeper policy.

Table 1 shows the sociodemographic characteristics of participants. More than half of the participants were females (59.2%), retired (54.7%), and with chronic conditions (56.9%). Last year, about half of the participants visited the CHC 0-3 times (50.2%), and had higher self-perceived health scores (53.9%). Of the respondents, more than half had good cognition of the gatekeeper policy (59.5%). The distribution of baseline characteristics and patients' assessments of CHS are presented in the attachment (Supplementary Tables 1a-1e, available in www.besjournal.com).

The patients' assessment of CHS is presented in Table 2. Among their assessments of five aspects of CHS, patients' positive assessment of the doctor-patient relationship was the highest (48.9%), while their most positive assessment of accessibility was only 13.9%. The Supplementary Table 2a, available in www.besjournal.com highlights the percentage of patients who gave the highest rating ('4' or '5') in the EUROPEP instrument.

Table 3 shows the results of the multiple regression analysis (including only the 100% category and the 0%-49% category) on the five dimensions of patient satisfaction with the care they received at the CHCs. Notably, good cognition of the gatekeeper policy among patients did positively influence their satisfaction on four dimensions, (P < 0.001) especially with regard to accessibility (7.497, 3.552-15.823), but did not positively influence medical care. Besides, it was also the only influencing factor for the dimension of information and support (1.775, 1.734-3.891 for good and 2.056, 1.704-5.094 for general).

China's health care reform has resulted in the expansion of health insurance coverage and strengthened the infrastructure of primary health facilities since 2009. However, it is difficult to transform investments and insurance coverage into cost-effective services with fragmented and inefficient health care delivery^[7]. In this case, the asymmetries in medical information between patients and health care providers make it difficult for patients to make sound choices without guidance and, in return, aggravate the inefficient delivery of health service. In many developed countries, gatekeeper policies play an important role in the process of forming an effective health service system^[4]. In China, many pilot programs of gatekeeper policy have been launched, and this study is the first attempt to assess patients' satisfaction among the population with UEBMI.

The EUROPEP scale is beneficial for the makers of health policies in developing First Step systems and has been implemented in 16 European countries^[8]. In China, few studies on patient satisfaction have been conducted using the EUROPEP scale and only one study^[9] evaluated its reliability (Cronbach's α = 0.945). Our study shows that the EUROPEP scale is suitable for assessing patient satisfaction with high reliability and validity (Cronbach's α = 0.960 and KMO = 0.958), and we believe it will contribute to international comparisons of patient satisfaction with CHS, especially in countries where the general practitioner (GP) is the gatekeeper.

Consistent with the previous study^[10], our study indicates that sociodemographic differences with statistical significance vary in assessments of CHS. In China, doctor-patient relationships have become a public health concern to which close attention is paid. Our results suggest that patients are most satisfied with the doctor-patient relationship aspect, which indicates the advantage of CHCs and the importance of the gatekeeper policy. In addition, our study shows that a high proportion of patients poorly assessed the aspect of medical care, which is an influencing factor of community patients' satisfaction. It is worth noting that patients are least satisfied with accessibility, and the aspects of 'getting through to the practitioner on the phone' and 'getting an appointment to suit you' may be good goals to improve accessibility. Thus, GPs must be prepared to focus on the aspect of accessibility as an indicator of the potential opportunity for improvement. In addition, the item 'waiting time in the waiting room' was positively assessed, which suggests that it is easier for patients to visit doctors at CHCs rather than at hospitals in China.

The multivariable logistic regression analyses suggest that the influencing factors of patients' satisfaction among the five dimensions are diverse and that age, marital status, educational background, self-perceived health status, frequency of visits to CHCs, and chronic diseases influence their assessment of CHS at different levels. As such, excepting to improve services by making residents comprehend the policy may be important to achieve overall satisfaction among patients.

There are some limitations to this study. First, the potential influencing factors of patient satisfaction with CHS are possibly more than those we investigated. Second, the study is based on a convenient sample of patients who had just completed their visits to CHCs. The fact that they were at the CHCs at the moment of the survey may indicate their willingness to seek care at CHCs, which may have induced an overestimated level of satisfaction. Finally, although our results illustrate the high reliability and validity of the EUROPEP scale, more studies are needed to examine the further applicability of the scale to the Chinese population.

Patients' satisfaction, as the basic criteria for acquiring information with regard to what extent their expectations are met, is an important indicator for the assessment of the gatekeeper policy. Patients' good cognition of the policy is positively associated with their satisfaction, and improvements of the aspects of information and support, medical care, and accessibility may be good goals for patient satisfaction.

SUPPLEMENTARY INFORMATION