The phenomenon of "no referral" still exists against the backdrop of implementing the hierarchical medical system, which has been preliminarily constructed in China. Most existing studies on addressing this phenomenon are mostly from the perspective of hospital management policies, ignoring the role of doctors as "health gatekeepers" in making decisions during the hierarchical diagnosis and treatment process.

To investigate the influence of personal, institutional, environmental, and policy factors on the willingness of physicians in county hospitals to refer patients with common diseases to lower level of institutions from physicians' perspective.

This study was conducted from July to August 2021. By use of region-based stratified and convenience sampling, seven county-level people's hospitals were selected as settings from eastern, central and western China. By use of cluster sampling, physicians (n=142) in internal medical departments were selected from the above-mentioned hospitals to attend an online (through the WJX.cn platform) or off-line (hospital) questionnaire survey to understand their willingness to refer patients with a common illness to lower level institutions, and personal, institutional, environmental, and policy factors associated with their willingness during a consultation described using the scenario simulation method. The survey achieved a response rate of 96.5% (137/142). Binary Logistic regression was used to analyze the effects of personal, institutional, environmental, and policy factors on physicians' willingness to refer the patients to a lower level institution.

The mean score of physicians' willingness to refer the patients to a lower level institution was (9.92±2.20). Fifty-six physicians (40.9%) had higher level of willingness to conduct downward referrals. Education level, awareness level of referrals, and frequency of communication of referrals between higher and lower level institutions were associated with scores of physicians' willingness to conduct downward referrals (P<0.05). Spearman correlation analysis showed that self-rated overall workload, risk of medical disputes and patient-doctor relationship (in the institutional factor dimension) were positively correlated with physicians' willingness to conduct downward referrals (r_s=0.26, 0.32, and 0.23; P<0.05). Binary Logistic regression analysis showed that higher awareness level of referrals was associated with increased level of willingness to conduct downward referrals in physicians〔OR (95% CI) =1.62 (1.19, 2.22) 〕. Higher influence of the referral system implemented within the hospital on medical dispute risk was associated with increased physicians' level of willingness to conduct downward referrals〔OR (95%CI) =3.275 (1.10, 9.73) 〕. However, higher influence of the referral system implemented within the hospital on performance was associated with reduced level of willingness to conduct downward referrals in physicians〔OR (95%CI) =0.400 (0.20, 0.79) 〕.

This study suggests that the willingness of physicians in county hospitals to conduct downward referrals is low on the whole, but it can be improved by increasing physicians' awareness level of referrals, and improving the influence of the referral system implemented within the hospital on the risk of medical disputes, and decreasing the influence of the referral system implemented within the hospital on the performance. In view of this, it is recommended that hospitals adopt a performance appraisal model that incorporates policy values, highlights policy recognition of referrals, and measures economic losses caused by referrals and the value of extra labor load, strengthen the popularization of hierarchical medical system in primary hospitals, and innovatively use the Internet-based hierarchical diagnosis and treatment model.

目前，我国分级诊疗体系已经初步构建，但"有分级，无分诊"的现象仍旧存在，目前已有的研究多从医院管理政策的角度出发，忽略了医生作为"健康守门人"在分级诊疗过程中的决策作用。

本文从医生个人意愿出发，探究个人、机构、环境、政策因素对县级医院医生向下转诊常见病患者意愿的影响。

于2021年7—8月，采用分层方便抽样的方法，抽取东、中、西部7个县（区）的7家人民医院，采用整群抽样的方法，抽取样本医院所有内科相关科室临床医生142例展开问卷调查。回收问卷137份，有效回收率为96.5%。问卷调查以网络调查（"问卷星"系统）和现场调查两种形式展开，采用情景模拟法向医生刻画特定疾病患者的就诊情况，调查医生向下转诊常见病患者的意愿，以及个人、机构、环境、政策4个维度的背景信息。采用二元Logistic回归分析个人、机构、环境、政策因素对医生向下转诊常见病患者意愿的影响。

医生向下转诊意愿的平均得分为（9.92±2.20）分，高意愿者56例（40.9%）。不同学历、对分级诊疗认知水平、上下级机构分级诊疗业务交流频率医生的意愿得分比较，差异有统计学意义（P<0.05）。Spearman秩相关分析结果显示，机构维度的评分中，工作总量、纠纷风险、医患关系与医生向下转诊常见病患者意愿呈正相关（r_s值分别为0.26、0.32、0.23，P<0.05）。二元Logistic回归分析显示，医生对分级诊疗认知水平越高〔OR（95%CI）=1.62（1.19，2.22）〕，医院内的分级诊疗制度对纠纷风险的影响程度越高〔OR（95%CI）=3.275（1.10，9.73）〕，则医生向下转诊意愿越高；医院内的分级诊疗制度对绩效收入影响程度越高，医生向下转诊意愿越低〔OR（95%CI）=0.400（0.20，0.79）〕。

本研究提示县级医院医生的向下转诊意愿整体不高，提升医生对分级诊疗的认知水平和医院内的分级诊疗制度对纠纷风险的影响程度、降低医院内分级诊疗制度对绩效收入的影响程度，可以提高医生的向下转诊意愿。建议医院采用纳入政策价值的绩效考核模式，凸显政策认同，正视经济损失与额外劳动量；加强基层医院分级诊疗宣传；创新引用互联网+分级诊疗模式。