Current Status and Influencing Factors of Downward Referral Behavior Among Rehabilitation Physicians in Secondary and Tertiary Hospitals

Objective This study aims to systematically analyze the current status of downward referral among rehabilitation physicians in secondary and tertiary hospitals and investigate its influencing factors.By identifying key bottlenecks in the rehabilitation referral process,this study seeks to provide recommendations for optimizing the hierarchical medical system. Methods A multi-stage stratified cluster sampling method was employed to recruit 203 rehabilitation physicians from 33 secondary and tertiary medical institutions across 18 cities in eastern,central,and western China.Data were collected via self-administered online questionnaires,covering demographic characteristics,professional background,and hierarchical medical system-related factors.An ordered multinomial logistic regression model was used to analyze the factors influencing rehabilitation physicians' downward referral behavior. Results After controlling for confounding factors,the nature of the institution in which the doctor worked (OR=0.475, 95%CI=0.245-0.923, P=0.028),downward referral based on the doctor's own clinical experience (OR=0.423, 95%CI=0.217-0.824, P=0.011),the number of outpatient (emergency) visits received in the last week (OR=1.006, 95%CI=1.001-1.011, P=0.018),knowledge of two-way referrals (OR=1.646, 95%CI=1.042-2.601, P=0.033),confidence in correctly judging the timing of patient referrals (OR=1.556, 95%CI=1.013-2.391, P=0.043),and willingness to refer patients downward (OR=1.901, 95%CI=1.366-2.646, P<0.001) were all independent factors influencing rehabilitation physicians' downward referral behavior. Conclusions Rehabilitation physicians' downward referral behavior is influenced by institutional nature,clinical experience,patient volume,referral system awareness,confidence in referral decisions,and referral intention.To enhance referral efficiency and promote the balanced development of rehabilitation services within the hierarchical medical system,this paper proposes the following recommendations:improving bidirectional referral policies,optimizing medical insurance payment structures,strengthening rehabilitation physician training,and encouraging public-private collaboration.