Behavioral Determinants of Hospital Selection in Urological Care: Evidence From China's Hierarchical Healthcare System.

Purpose: This study aims to identify the key factors influencing hospital selection among urological patients in China. Despite policy efforts to promote tiered care through the Hierarchical Diagnosis and Treatment (HDT) system, many patients continue to bypass primary care. Understanding the behavioral and psychological drivers of this pattern is essential for improving patient guidance and optimizing healthcare resource allocation. Patients and Methods: Data were collected from a stratified random sample of 676 patients between June 10 and October 10, 2024 from tertiary, secondary, and community healthcare institutions in Jiangsu Province. We collected detailed information on demographic characteristics, clinical profiles, psychological states, health behaviors, and economic factors. Multinomial logistic regression was employed to identify independent predictors of hospital choice, while Sankey diagrams and multiple correspondence analysis (MCA) were used to visualize patient-level decision pathways and structural patterns. Results: A substantial proportion of patients sought care at tertiary hospitals for conditions that could be effectively managed at lower levels, reflecting a disconnect between actual patient behavior and the goals of the HDT system. Hospital choice was shaped by clinical needs, emotional responses, and perceived institutional trust. Patients choosing tertiary hospitals were more likely to have undergone surgery, experienced severe pain, and reported negative emotional reactions. Secondary hospital users commonly had benign prostatic hyperplasia, moderate symptom burden, rural residence, and engaged in regular physical activity. Community healthcare facilities users typically presented with mild symptoms, shorter illness duration, mild anxiety, lower financial burden, and closer geographic proximity. Across all tiers, anxiety levels and trust perceptions emerged as key behavioral drivers contributing to the bypassing of primary care. Conclusion: Despite policy efforts to promote primary care, many patients with manageable conditions continue to bypass lower-tier facilities. Building trust and providing triage support in primary care are essential for achieving the goals of hierarchical healthcare.