Geographic disparities in inpatient service in primary care and patients' choice of first point of consultation: a linked cross-sectional survey and administrative data analysis in Shaanxi of China

Background: The enhancement of primary care capacity and service quality has been demonstrated in numerous developed countries as an effective strategy for establishing hierarchical healthcare delivery systems. However, this established pattern shows limited applicability in China’s context. Our study investigates through empirical analysis whether strengthened inpatient service in primary care effectively incentivizes patients to select primary healthcare institutions (PHIs) as their first-point consultation (FPC) choice in Shaanxi, a western province in China, and whether this effect exhibits consistent efficacy across all regions. Methods: This study Linked the National Health Services Survey on population and administrative data on PHIs in 2023 in Shaanxi. 4,570 first point consultations from 4,464 patients in 3,704 households were included in our study. Generalized linear mixed models were employed to estimate the association between the annual number of hospitalizations of PHIs and patients’ choice of PHIs as their FPC. Results: Our findings demonstrated a positive association between annual number of hospitalizations in PHIs and increased FPC rates at PHIs (OR = 1.151, 95% CI 1.059 to 1.254). However, significant geographic heterogeneity emerged, with effects confined to urban–rural transition zones (OR = 2.457, 95% CI 1.768 to 3.415) and rural areas (OR = 2.322, 95% CI 1.672 to 3.223). Socioeconomic stratification analysis revealed an inverse relationship between household income quartiles and PHIs utilization rates, the lower the economic levels of residents in these areas, the higher the rate of first point consultation in PHIs will be. Conclusion: Our findings suggest that inpatient service in primary care enhancement exhibits heterogeneous effects on FPC rates across China's geographic and socioeconomic strata. Policy prioritization should focus on targeted interventions in underserved rural regions with medical resource scarcity, potentially yielding greater equity dividends in healthcare access. Improving the capacity of primary care services should remain a key direction of health system.