Primary care bypass behavior among older adults with chronic diseases in Shanghai, China: a cross-sectional study

Primary care bypass behavior—seeking care at a higher-level healthcare facility rather than a nearby primary healthcare institution—may challenge hierarchical healthcare systems. Identifying factors associated with bypass behavior among older adults with chronic diseases is important for optimizing the hierarchical medical system and promoting appropriate healthcare utilization. This study aimed to examine the prevalence of and factors associated with bypass behavior among older adults with chronic diseases in Shanghai, China. This cross-sectional study included 1,498 older adults with chronic diseases from a healthy aging surveillance survey whose residence was closest to a primary healthcare facility. The Andersen Behavioral Model guided variable selection. Firth’s logistic regression identified associated factors overall and by residential area. Bypass behavior was reported by 8.61% of participants. Compared with central urban residence, suburban (OR, 3.44; 95% CI, 1.46–8.37) and rural residence (OR, 6.27; 95% CI, 2.66–15.32) were associated with higher odds. Perceived convenience was associated with lower odds (OR, 0.05; 95% CI, 0.03–0.08), whereas high perceived technical competence of the facility visited was associated with higher odds (OR, 3.63; 95% CI, 1.88–7.04). Compared with cardio-metabolic diseases alone, other chronic diseases, mixed, and unclassified diseases were associated with higher odds. In the stratified analyses, perceived convenience of the visited facility remained associated with lower odds in all residential areas after false discovery rate correction, whereas high perceived technical competence remained associated with higher odds in suburban areas; the other area-specific findings were exploratory. Bypass behavior was reported by a minority of older adults with chronic diseases in Shanghai, but regional disparities were evident, with the highest bypass behavior observed in rural areas. Exploratory analyses suggested potential regional heterogeneity. Region-specific and disease-specific strategies are needed to advance the hierarchical medical system.