Factors on Perceived Quality and Continuous Use Intent of Medical Institutions : Differences between Primary Care Clinics and General Hospitals

Objectives: To addressing the question of what hospital/doctor attributes influence medical consumers’selection of a specific medical institution. Methods/Statistical Analysis: First, we conducted a factor analysis in order to extract the factors that influence consumer’s selection of primary care clinics and general hospitals. Second, a multiple regression analysis was performed to see what elements of the set of hospital and doctor attributes affect perceived quality and continuous use intent of the medical institutions. Cronbach’s Alpha index would show the internal consistency among the measurement items and the reliability of each scale. Findings: First, it was found that reputation was the most importantly considered in selecting general hospitals. In selecting primary care clinics, in contrast, consumers take convenience into more consideration than other factors, perhaps because they are mostly neighbor hospitals. Second, it was found that expertise of doctors is the most importantly considered attribute in consumers’ selection of general hospitals was expertise, followed by attractiveness, reputation, and externality. Third, it was found that the doctor attributes affecting the perceived quality were doctors’ reputation and expertise for general hospitals, and intimacy for primary care clinics, on the other hand. Fourth, it was found that medical consumers reported greater intent to continuously use a particular medical hospital with greater recognition of doctors’ reputation and attractiveness. Improvements/Applications: We expect that the findings of the current analysis would provide meaningful base data for planning strategies for marketing in the rapidly changing environment of the medical industry. Factors on Perceived Quality and Continuous Use Intent of Medical Institutions: Differences between Primary Care Clinics and General Hospitals EunHee Kim1* and SeungYeob Yu2 1Department of Advertising and Public Relations and Journalism, Mokwon University/ 35349, Republic of Korea; eunhee0103@empas.com 2Department of Advertising and Public Relations, Namseoul University/31020, Republic of Korea; ysyeob@hanmail.net


Introduction
Medical institutions have recently faced a variety of changes in the industry: market opening policy, a number of regulatory policies and extremely competitive market.Medical consumers, in turn, require multiple options and improved medical service, thanks to their enhanced level of income and education, in their selection of a medical institution.
Such changes in medical service environment have brought a big change to both medical consumers and institutions.Consumers' enlarged medical knowledge and quest for medical information were resulted a wider range of selection and opportunities.Excessive supply of medical service has also led to intensive competition and, as a consequence, slowdown of profits 1 .Now, the concepts of hospital management 2,3 or hospital marketing 4 are not strange anymore.
In such a context, medical institutions are exerting effort to keep up with such a changing environment: they promote gentrification and enlargement, introduce stateof-the-art medical technology and equipment, and secure excellent medical staff.In short, a variety of measures for consumer-oriented medical service are being arranged.Such transitions in focus to medical consumers have brought about big changes in hospital management 5 .
The use of medical service is basically made by medical consumers' selection of a medical institution.They tend to take hospital and doctor attributes into careful consideration in making their choices.
The present research attempts to identify what factors are taken into consideration when medical consumers select a particular medical institution to have their diseases or illnesses treated.Also, the influencing power of such factors will be discussed in light of the contrast between primary care clinics and general hospitals.
The list of topics under discussion is as follows.First, we intend to identify what hospital/doctor attributes affect consumers' selection of primary care clinics and general hospitals.Second, we address the question of how these factors affect perceived quality of the two kinds of medical institutions.Third, we also investigate into the question of what are the hospital and doctor attributes that influence their continuous use intent.The results of the present research are expected to provide meaningful data for arranging customized marketing strategies of hospitals, and, as a consequence, help secure their competitiveness and effective management.

Measurement Tools
In order to identify the influential factors of doctor/ hospital attributes in medical customers 'choosing medical institutions, research model was adopted 6 .
Perceived quality refers to consumers' overall sentiment and it stands for subjective perception of a certain product or service 7 .A slightly modified version of Agarwal and Teas's model was adopted to measure perceived quality for the present research 8 .The items include the following five statements: 'The quality of medical service of the X hospital is high.' 'The quality of medical service of the X hospital is higher than others.' , 'The medical service of the X hospital is trustworthy.' , 'I can expect consistent medical service from the X hospital.' and 'The medical service of the X hospital is the best among those of the same kind.Cronbach's Alpha was obtained at .847.
Continuous use intent is an evaluation of multiple experiences of consumers 9 .A slightly modified version of Morgan and Hunt was adopted for the present research 10 .The three measurement items include the following statements: 'I would like to use the X hospital in the future.' , 'I have an intention to keep using use the X hospital.' and 'I am likely to keep relationship with and use the X hospital.' Cronbach's Alpha was obtained at .805.

Analysis Methods
First, a factor analysis was conducted to extract the factors that affect consumers' selection of primary care clinics and general hospitals.This factor analysis was intended to analyze the correlation among multiple measurement variables 11 .A principal component analysis; VARIMAX rotation analysis, Kaiser-Meyer-Olkin scales and Bartlett's sphericity test were conducted for the purpose of reducing variables and identifying meaningful processes.Extraction of a variable was considered adequate if the Eigen value is greater than 1, the factor load is greater than 0.4 and the commonality is greater than 0.4 [12][13][14] .
Second, a multiple regression analysis was performed to see whether perceived quality and continuous use intent of the medical institutions is influenced by any hospital/ doctor attribute.Cronbach's Alpha index would show the reliability of each scale.

Hospital Attributes Affecting Selection of Medical Institutions
A factor analysis was expected to exhibit the hospital attributes that people take into consideration in their selection of general hospitals.The result was illustrated in Table 1.A set of 24 items were under discussion, eliminating one item whose commonality was less than 0.4.A set of 6 factors satisfied the criterion of Eigen value being greater than 1.0.The explanatory power of the hospital attributes for total distribution was obtained at 58.40% (Table 1).The factor of 'reputation' contained five items: Cronbach's Alpha=.805.The second factor of 'internal convenience' consisted of four items: Cronbach's Alpha=.815.The third factor consisting of five items was called 'external convenience': Cronbach's Alpha=.797.The fourth named 'expertise/trust' consisted of four items: Cronbach's Alpha=.764.The fifth factor involved three items and it was named 'externality': Cronbach's Alpha=.712, and the sixth factor consisting of three items was named 'convenience (ease of use)': Cronbach's Alpha=.706).In sum, the hospital attributes that influence consumers' selection of medical institutions were their reputation, internal and external convenience, expertise/trust, externality and convenience.Next, a factor analysis was performed to extract the hospital attributes that are considered in selecting primary care clinics.The findings of the analysis are shown below in Table 2.It was found that two measurement items should be eliminated, since the factor load and commonality did not meet the requirement: they were less than 0.4.Thus, a set of 21 items were used for analysis under discussion.A set of six factors whose Eigen value were greater than 1.0 were extracted.The explanatory power of the hospital attributes for total distribution was obtained at 65.66 %(Table 2).
To summarize, a set of hospital attributes considered in selecting primary are clinics were extracted: convenience, reputation, expertise/reliability, internal convenience, externality and easy accessibility.In comparison with general hospitals, convenience was more importantly considered in the consumers' selection of primary care clinics.In contrast, reputation was the most important factor in their selection of general hospitals.It is worthwhile to note that easy accessibility was extracted as an influential factor in selecting primary care clinics.

Hospital Attributes Influencing Perceived Quality of Medical Institutions
This research intended to address the question of what doctor attributes would affect the perceived quality of primary care clinics and general hospitals.First, we conducted a multiple regression analysis to identify the effect under discussion.Table 3 illustrates the result of the analysis.It was found that the expertise/reliability and internal convenience of general hospitals had a positive influence on their perceived quality, whereas external convenience had a negative effect.The same multiple regression analysis was performed for primary care clinics.As shown in Table 4, it was found that easy accessibility and internal convenience had a positive effect on the perceived quality of primary care clinics.

Hospital Attributes Affecting Continuous Use Intent for Medical Institutions
We conducted a multiple regression analysis to identify what factors of hospital attributes exert influence on continuous use intent for the two types of medical institutions.As for general hospitals, Table 5 showed that external convenience had a negative impact on continuous use intent, while expertise/reliability and externality had a positive effect.The same multiple regression analysis for primary care clinics found that, as shown in Table 6, accessibility, externality and internal convenience exerted a positive influence on continuous use intent.

Doctor Attributes Affecting Consumers' Selection
First, we did a factor analysis was for the purpose of identifying what doctor attributes exert a significant influence on customers' choice of general hospitals.A set of 10 items, eliminating one inadequate item, were analyzed and the analysis extracted four factors whose Eigen values were greater than 1.It was found that the factors' explanatory power for total distribution was 57.92 %(Table 7).The factor named 'professional expertise 'consisted of seven items: Cronbach's Alpha=.823.Theattractiveness factor with six items marked Cronbach's Alpha at .809.Cronbach's Alpha for the reputation factor with four items was .773.The 'externality factor consisted of two items and its Cronbach's Alpha was .705.In sum, it was found that medical consumers put important considerations on doctors' expertise, reputation, attractiveness, and externality.AIn order to see what attributes are considered when medical consumers choose primary care clinics, a factor analysis was performed.After eliminating one inadequate item, the rest of 19 items were used for analysis.A set of four factors whose Eigen value were greater than 1 were extracted.The explanatory power of the factors was 59.34% (Table 8).The 'professional expertise' factor consisted of five items and its Cronbach's Alpha was .791.The factor of 'externality 'contained seven items and its Cronbach's Alpha was .778.The third factor called 'intimacy 'included four items and its Cronbach's Alpha was .799.Finally, the factor of 'knowledge' with four items marked Cronbach's Alpha at .713.In sum, it was found that medical consumers take doctors' expertise, externality, intimacy and knowledge into consideration.

Effect of Doctor Attributes on Perceived Quality of Medical Institutions
First, we performed a multiple regression analysis to see what doctor attributes are considered in selecting general hospitals.The analysis showed the results below in Table 9.It was found that doctors' reputation had the greatest positive influence on the perceived quality of general hospitals, followed by their expertise.A similar multiple regression analysis for primary care clinics on the same topic found the results illustrated in Table 10.It was found that intimacy had a positive effect on the perceived quality of primary care clinics.

Effect of Doctor Attributes on Continuous Use Intent
The figures in Tables 11 and 12 show that doctor's hospitable attractiveness exerted a positive influence

Concluding Remarks
The main goal of the present research was to inquire into how medical consumers select medical institutions.A set of doctor and hospital attributes were established as the candidates of influential factors.We also aimed to see how these factors affect various perceived risks including mental, physical, social, and economic risks, and their use intent.Finally, we also addressed the question of which of the two, hospital or doctor attributes, had more impact on customers' selection of general hospitals.The following can be taken as a summary of our findings.First, it was found that reputation was the most importantly considered in selecting general hospitals.Such a result might be interpreted in such a way that medical consumers require professional and precise checkup and treatments when they visit general hospitals.Thus, brand awareness and reputation of hospitals to satisfy such demand should be important.Other attributes include internal convenience, external convenience, expertise/ reliability, externality and convenience.In selecting primary care clinics, in contrast, consumers take convenience into more consideration than other factors, perhaps because they are mostly neighbor hospitals.It might be assumed that waiting hours, treatment hours and low cost are important features in choosing primary care clinics.Next hospital attributes in order were expertise/reliability, internal convenience, externality and accessibility.
Second, it was found that external convenience had a negative (-) effect on the perceived quality of general hospitals.Low medical cost and a high level of familiarity and intimacy with general hospitals had a negative (-) influence on their perceived quality.Such a result might be attributable to consumers' avoidance of large hospitals or university hospitals due to their great number of treatments and serious diseases.Also, the perceived quality of general hospitals was higher if consumers attached greater importance to the expertise/reliability and medical equipment of the hospitals.It was also found that treatment hours, convenience facilities and waiting hours had a positive effect on the perceived quality of general hospitals.As for primary care clinics, in contrast, their accessibility had the greatest effect on their perceived quality, which was higher if the consumers attached more importance on easier transportation and nearer distance.Next, internal convenience, which involves the convenience of facilities, reservation system and kind staff members, was closely related with high perceived quality.In sum, we might conclude that selection of general hospitals clearly depends on their expertise and reliability, while consumers put more importance on easy accessibility and transportation in selecting primary dare clinics.Such a finding might be expected to be used as a useful source for establishing marketing strategies of medical institutions.
Third, it was identified that easy accessibility, transportation or distance from home did not play an important role for consumers' continuous use intent Vol 9 (46) | December 2016 | www.indjst.orgfor general hospitals.However, higher importance of expertise, reliability and medical equipment were closely related with higher continuous use intent.Also, the size of hospitals and higher class of facilities were found leading to higher continuous use intent.When medical consumers intended to continuously use primary care clinics or neighbor hospitals, their easy accessibility and transportation were the most important factors.Other influential factors for continuous use intent for primary care clinics were the size, high class of facilities, and internal convenience, which involves convenience of facilities, reservation system and kind staff members.In sum, it was found that the influential hospital attributes for continuous use intent were expertise/reliability and externality for general hospitals, and, on the other hand, accessibility, externality and convenience for primary care clinics.Such a finding is expected to help hospital marketers and managers arrange strategic measures to enhance medical consumers' royalty.
Fourth, it was found that the doctor attribute most importantly considered in medical consumers' selection of general hospitals was expertise, followed by attractiveness, reputation, and externality.For primary care clinics, expertise was also the most important doctor attribute, followed by externality, intimacy and knowledge.Fifth, it was identified that doctors' reputation had the greatest impact on the perceived quality of general hospitals: the greater perceived doctors' reputation, the greater perceived quality of general hospitals.Next, doctors' expertise, which combines professional skills, career and knowledge, had a positive effect on the perceived quality of general hospitals.As for primary care clinics, on the contrary, intimacy was the most influential factor for the perceived quality: intimacy contains familiarity, favorableness and kindness.That is, the greater intimacy medical consumers felt, the greater perceived quality they reported.In sum, it was found that the doctor attributes affecting the perceived quality were doctors' reputation and expertise for general hospitals, and intimacy for primary care clinics, on the other hand.Thus, a meaningful and practical finding would be that the current research has identified major factors that can help enhance the perceived quality of medical institutions.
Sixth, it was found that medical consumers reported greater intent to continuously use a particular medical hospital with greater recognition of doctors' reputation and attractiveness.Next, doctors' attractiveness also had a positive effect on continuous use intent.As for primary care clinics, on the other hand, higher intimacy with doctors was closely related with higher continuous use intent: it came with higher recognition of good feeling, familiarity and kindness.In sum, as for general hospitals or university hospitals, medical consumers' continuous use intent was mainly affected by the academic background, dignity, reputation and fame of doctors that might be closely connected with hospitals' expertise and reliability.On the other hand, continuous use intent for primary care clinics, which usually refer to clinics in the neighborhood and are easily accessible in location and transportation, was mainly affected by the intimacy, familiarity, kindness and favorable feeling.Such a practical finding might be meaningful in that major doctor attributes were identified that might help medical consumers establish direct relationship with doctors, and that these attributes clearly affect their continuous use intent.
It should be admitted that the current research has some limitations.First, the subject group consisted only of college students who have received medical treatments at least once in the past year.Moreover, medical consumers' selection of medical institutions and the importance of a particular attribute clearly depend on the urgency and level of diseases.Also, consumers' measurement of the importance of hospital and doctor attributes might depend on different areas of treatments and different types of diseases.Therefore, future studies are expected to consider these limitations to come a more generalized conclusion.

Acknowledgement
Funding for this paper was provided by Namseoul University.

Table 3 .
Hospital attributes affecting perceived quality of general hospitals

Table 6 .
Hospital attributes affecting continuous use intent for primary care clinic Factors on Perceived Quality and Continuous Use Intent of Medical Institutions: Differences between Primary Care Clinics and General Hospitals * * p<.01, * * * p<.001

Table 8 .
Doctor attributes affecting selection of primary care clinics

Table 9 .
Doctor attributes affecting perceived quality of general hospitals on use intent.It clearly indicates that hospitality and attractiveness of medical doctors might help medical consumers decide to continue to use general hospitals to cure their diseases.