Improving Data Surveillance Resilience Beyond COVID-19: Experiences of Primary heAlth Care quAlity Cohort In ChinA (ACACIA) Using Unannounced Standardized Patients.

We analyzed COVID-19 influences on the design, implementation, and validity of assessing the quality of primary health care using unannounced standardized patients (USPs) in China. Because of the pandemic, we crowdsourced our funding, removed tuberculosis from the USP case roster, adjusted common cold and asthma cases, used hybrid online-offline training for USPs, shared USPs across provinces, and strengthened ethical considerations. With those changes, we were able to conduct fieldwork despite frequent COVID-19 interruptions. Furthermore, the USP assessment tool maintained high validity in the quality checklist (criteria), USP role fidelity, checklist completion, and physician detection of USPs. Our experiences suggest that the pandemic created not only barriers but also opportunities to innovate ways to build a resilient data collection system. To build data system reliance, we recommend harnessing the power of technology for a hybrid model of remote and in-person work, learning from the sharing economy to pool strengths and optimize resources, and dedicating individual and group leadership to problem-solving and results. (Am J Public Health. 2022;112(6):913-922. https://doi.org/10.2105/AJPH.2022.306779).

Effects of health insurance integration on health care utilization and its equity among the mid-aged and elderly: evidence from China.

BACKGROUND: The fragmentation of health insurance schemes in China has undermined equity in access to health care. To achieve universal health coverage by 2020, the Chinese government has decided to consolidate three basic medical insurance schemes. This study aims to evaluate the effects of integrating Urban and Rural Residents Basic Medical Insurance schemes on health care utilization and its equity in China. METHODS: The data for the years before (2013) and after (2015) the integration were obtained from the China Health and Retirement Longitudinal Study. Respondents in pilot provinces were considered as the treatment group, and those in other provinces were the control group. Difference-in-difference method was used to examine integration effects on probability and frequency of health care visits. Subgroup analysis across regions of residence (urban/rural) and income groups and concentration index were used to examine effects on equity in utilization. RESULTS: The integration had no significant effects on probability of outpatient visits (ß = 0.01, P > 0.05), inpatient visits (ß = 0.01, P > 0.05), and unmet hospitalization needs (ß =0.01, P > 0.05), while it had significant and positive effects on number of outpatient visits (ß = 0.62, P < 0.05) and inpatient visits (ß = 0.39, P < 0.01). Moreover, the integration had significant and positive effects on number of outpatient visits (ß = 0.77, P < 0.05) and inpatient visits (ß = 0.49, P < 0.01) for rural residents but no significant effects for urban residents. Furthermore, the integration led to an increase in the frequency of inpatient care utilization for the poor (ß = 0.78, P < 0.05) among the piloted provinces but had no significant effects for the rich (ß = 0.25, P > 0.05). The concentration index for frequency of inpatient visits turned into negative direction in integration group, while that in control group increased by 0.011. CONCLUSIONS: The findings suggest that the integration of fragmented health insurance schemes could promote access to and improve equity in health care utilization. Successful experiences of consolidating health insurance schemes in pilot provinces can provide valuable lessons for other provinces in China and other countries with similar fragmented schemes.

The multi-tiered medical education system and its influence on the health care market-China's Flexner Report.

BACKGROUND: Medical education is critical and the first step to foster the competence of a physician. Unlike developed countries, China has been adopting a system of multi-tiered medical education to training physicians, which is featured by the provision of an alternative lower level of medical practitioners, or known as a feldsher system since the 1950s. This study aimed to illustrate the impact of multi-tiered medical education on both the equity in the delivery of health care services and the efficiency of the health care market. METHODS: Based on both theoretical reasoning and empirical analysis, this paper documented evidence upon those impacts of the medical education system. RESULTS: First, the geographic distribution of physicians in China is not uniform across physicians with different educational training. Second, we also find the evidence that high-educated doctors are more likely to be hired by larger hospitals, which in turn add the fuel to foster the hospital-center health care system in China as patients choose large hospitals to chase good doctors. Third, through the channels of adverse selection and moral hazard, the heterogeneity in medical education also imposes costs to the health care market in China. DISCUSSION: Overall, the three-tiered medical education system in China is a standard policy trade-off between quantity and quality in training health care professionals. On the one hand, China gains the benefit of increasing the supply of health care professionals at lower costs. On the other hand, China pays the price for keeping a multi-tiered medical education in terms of increasing inequality and efficiency loss in the health care sector. Finally, we discuss the potential policy options for China to mitigate the negative impact of keeping a multi-tiered medical education on the performance of health care market.

Examining income-related inequality in health literacy and health-information seeking among urban population in China.

BACKGROUND: Health literacy and health-information seeking behaviour (HISB) play vital roles in health outcome improvements. This study examines the extent of income-related inequality in health literacy and health-information seeking as well as the contributions of the main socioeconomic determinants in China. METHODS: We analysed representative data of participants aged over 18 years as well as older adults from the Guangzhou Community Health Survey. A concentration index (CI) was used to quantify the degree of income-related inequity in health literacy and health-information seeking. Probit regression models were employed to decompose the CI into the contributions to each factor. RESULTS: Results showed a significant pro-rich distribution of adequate health literacy (CI: 0.0602, P < 0.001; horizontal index [HI]: 0.0562, P < 0.001) and HISB from healthcare professionals (CI: 0.105, P < 0.001; HI: 0.0965, P < 0.001). The pro-rich distribution of health literacy was mainly attributable to education background (contribution: 54.76%), whereas income inequalities contributed most to the pro-rich distribution of health-information seeking among an urban population (contribution: 62.53%). CONCLUSION: Public interventions in China to reduce inequality in health literacy and HISBs among the urban population, coupled with easily accessible information sources on health, warrant further attention from policymakers.

Adaptation and assessments of the Chinese version of the ICECAP-A measurement.

BACKGROUND: This study adapts the ICECAP measure for Adults (ICECAP-A) to assess its capacity to measure the quality of life in China for economic evaluation. METHODS: Qualitative and quantitative methods were used to translate the ICECAP-A measure for wellbeing, established by the University of Birmingham, UK, to the Chinese cultural context. A focus group discussion solved the appropriateness and wording of the ICECAP attributes in Chinese; and a randomly selected sample of 1000 adults aged over 18 years were online surveyed. We conducted psychometric tests and compared the factors influencing the ICECAP-A measure with those influencing EQ-5D-3 L. RESULTS: Members of the focus group discussion agreed that the five attributes of the ICECAP-A measure are sufficient to evaluate wellbeing in China. However, the terms "being settled" and "friendship" were changed to "stability" and "kindness" for the Chinese cultural context. Our results show that the Chinese version of ICECAP-A has good internal consistency with an overall Cronbach's Alpha coefficient of 0.7999. The concurrent validity indicates that ICECAP-A is moderately correlated with EQ-5D-3 L (r ≤ 0.52). CONCLUSIONS: The ICECAP-A measure can be adapted to evaluate wellbeing in China, but cultural changes to the wording are necessary. It is a valid measurement of wellbeing and can complement the EQ-5D already used in China. However, further work is still needed to evaluate the sensitivity of the ICECAP-A measure in relation to public health and social care.

The trend and features of physician workforce supply in China: after national medical licensing system reform.

BACKGROUND: The annual number of newly licensed physicians is an important indicator of medical workforce supply, which can accurately reflect an inflow into the health care market over a period. In order to both regulate medical professions and improve the quality of health care services, China established its medical licensing system from the point of the implementation of 'Law on Practising Doctors' in 1999. The objective of this study is to depict the trend and structure of newly licensed physicians thereafter. METHODS: This study analyses a unique census data set that provides the headcount of newly licensed physicians from 2005 to 2015 in China. We also review a short history of medical licensing system reform in China since the 1990s. RESULTS: The annual number of first-time licensed physicians in China increased from 159 489 in 2005 to 221 639 in 2015. Up to 2015, over half of newly licensed physicians had not received a medical education equivalent to a bachelor degree or higher. Around 51% of China's newly licensed physicians were female in 2005, while the same ratio for females in 2015 was 56%. CONCLUSION: This article first provides an exploratory analysis of physician inflow into health care market in China using physician licensing data. The medical licensing system in China allows entering physicians with a broad range of educational levels. Moreover, the feminisation of the physician supply in China has become increasingly apparent and its impacts on health care provision still require more rigorous examination.

Separation of prescription and treatment in health care markets: A laboratory experiment.

Health care is a credence good, and its market is plagued by asymmetric information. In this paper, we use a laboratory experiment to test the performance of a potential remedy discussed in the applied literature, the separation of prescription and treatment activities. We observe a significant amount of overtreatment (and a smaller nonpredicted amount of undertreatment) in our baseline environment. Requiring a different than the treating physician to provide diagnosis and prescription for free is an effective way to reduce overtreatment in our laboratory setting. This effect, however, is partially offset by an increased frequency of undertreatment. Allowing prescription and treatment physicians to independently set prices for their services reduces efficiency due to coordination failures: In sum, prices are often higher than expected benefit of patients, who in turn do not attend to the physician. Also contrary to theory, bargaining power does not play a significant role for the distribution of profits between physicians.

The choice and preference for public-private health care among urban residents in China: evidence from a discrete choice experiment.

BACKGROUND: Public health care dominated the services provision in China before 1980s. However, the number of private health care providers in China has been increasing since then. The growth of private hospitals escalated after a market-oriented reform was implemented in 2001. Through an experimental approach, this study aims to a better understanding of the dynamic change in preference of health care utilisation among the residents in urban China. METHODS: Based on a discrete choice experiment (DCE) from a random sample of respondents in urban China, the study evaluated preference over health care attributes affecting individuals' choice for the utilisation of hospital health care. The marginal willingness-to-pay for five health care attributes was estimated, including public/private provision of health care, by analysing mixed logit and latent class models. RESULTS: The results indicated a significantly negative marginal willingness-to-pay for private health care, which was interpreted as representing people's previous interactions with the health care system. The latent class model further suggested preference heterogeneity across our sample. We found that Hukou type, a typical indicator of socioeconomic background, was significantly related to respondents' preference for health care utilisation. Permanent urban residents (urban Hukou) valued private health care less; in contrast rural migrants (rural Hukou) were more likely to be indifferent between public/private provision. CONCLUSION: Urban residents in China showed a high disposition to obtain health care from the public providers of health care. Our results have implications in the context of the Chinese government attempts to expand the private health care sector in the short term. Policy makers need to consider residents' preference for health care in health policy development as the preference can only change in the long term.

The specialty choice of medical students in China: a stated preference experiment.

BACKGROUND: Primary Care Providers (PCPs), such as internists and general practitioners, have been deemed a way of delivering cost-effective care in an equitable way because PCPs are responsible for providing accessible basic medical care for the general population. This study aims to examine medical students' preferences for PCP-based specialty choices in the context of an ageing population in China. METHODS: We implemented a Best-Worst Scaling (BWS) experiment, a recently developed preference elicitation method based on random utility theory. Three hundred and fifty graduating medical students from three medical colleges were randomly recruited to evaluate 11 common medical specialties in China. A counting approach, a conditional logit model, and K-means clustering have been used to analyse the relative importance of items and preference heterogeneity among medical students. RESULTS: One hundred and ninety of 350 students completed valid questionnaires. General surgery was identified as the most preferred specialty among the overall sample, yet internal medicine shares the same importance as surgery. Both geriatric medicine and psychiatric medicine were found to be the least selected specialties. Finally, the K-means clustering further suggested there was preference heterogeneity across our sample. CONCLUSIONS: Two aims were fulfilled in this study. First, through our experimental approach the results provide a better understanding of the career desires of medical students in China. Second, the results of this study indicate that despite the fact a non-PCP-based specialty is the most popular among the sampled students; a PCP-based specialty is still an important alternative choice.

Preferences of patients with diabetes mellitus for primary healthcare institutions: a discrete choice experiment in China.

OBJECTIVES: To quantify the preference of patients with diabetes mellitus (DM) for primary healthcare (PHC) institutions in China to redirect the patient flow and improve health outcomes. DESIGN: Cross-sectional study. Discrete choice experiment (DCE) surveys asked patients with DM to choose between hypothetical institutions that differed in the medical service capacity, out-of-pocket (OOP) medical costs per month, travel time, the attitude of medical staff and the availability of diabetes drugs. SETTING: Shandong province, China. PARTICIPANTS: The participants were 887 patients with DM from 36 urban communities and 36 rural villages in Shandong province. One participant did not provide any DCE answers and a further 57 patients failed the internal consistency test. 829 fully completed surveys were included in the final data analysis. MAIN OUTCOMES AND MEASURES: A mixed logit model was used to calculate the willingness to pay and predict choice probabilities for PHC institution attributes. Preference heterogeneity was also investigated. RESULTS: All five attributes were associated with the preferences of patients with DM. The OOP medical costs and the medical service capacity were the most influential attributes. Improvements simultaneously in the attitude of medical staff, drug availability and travel time increased the likelihood of a patient's PHC institution choice. Preferences differed by region, annual household income and duration of diabetes. CONCLUSIONS: Our patient preference data may help policymakers improve health services and increase acceptance of choosing PHC institutions. The OOP medical costs and medical service capacity should be regarded as a priority in decision-making.

Income-related health inequality among rural residents in western China.

Objective: Health equality has drawn much public attention in both developed and developing countries. China, the largest developing country, has implemented a new round of health system reform to improve health equality since 2009. This study aims to examine the magnitude and sources of income-related health inequality in western rural regions of China. Methods: Data were obtained from the Survey of Rural Economic and Social Development in Western China conducted in 2014, in which 14,555 individuals from 5,299 households in 12 provinces were included. Health outcome variables of interest were self-rated health status, prevalence of chronic disease and four-week illness. Concentration index was calculated to assess magnitude of income-related health inequality, and nonlinear decomposition analysis was performed to identify the sources of health inequality. Results: The Concentration indexes for poor self-rated health status, prevalence of chronic disease and four-week illness were -0.0898 (P<0.001),-0.0860 (P<0.001) and -0.1284 (P<0.001), respectively. Income and education were two main sources of health inequality, accounting for about 25-50% and 15% contribution to the inequality. Ethnicity made <10% contribution to income-related health inequality, and enrollment in New Rural Cooperative Medical Scheme contributed to <1%. Conclusion: This study found slight income-related health inequality among rural residents in western China, implying that although China has made substantial progress in economic development and poverty alleviation, health inequality in western rural region should still be concerned by the government. To achieve health equality further, the Chinese government should not only strengthen its reimbursement mechanism of the current health insurance scheme to improve affordability of primary healthcare for residents in western rural regions, but also implement health poverty alleviation policies targeting socioeconomically vulnerable population and ethnic minorities in future.

Amending the Law for Licensing Medical Practitioners of China in 2021: A Commentary.

The Law for Licensing Medical Practitioners of the People's Republic of China, enacted in 1999, was amended in 2021. This commentary reviews the key points of the amendment and raises doubts as to one of its points. Specifically, we argue that the minimum education level required to take the physicians' licensing examination should be set to completion of a bachelor degree, instead of a vocational diploma or junior college graduation as in the 2021 amendment. China adopted a system of multi-tiered medical education more than 70 years ago. This policy has resulted in a threshold of entry-level medical education far below the global standards. The highly heterogeneous education background of physicians in China has led to low standards of practicing physicians, which in turn have significantly negative impacts on the health care market. We illustrate changes over time in the educational distribution and regional distribution of practicing physicians in China, and present reasons to improve entry-level educational standards, by setting the physician licensing threshold at an appropriate level. This will not only improve the overall quality of physicians but will also help address equity and efficiency issues in the health care market.

A taxonomy of Chinese hospitals and application to medical dispute resolutions.

Medical disputes can be viewed as a negative indicator of health care quality and patient satisfaction. However, dispute prevention from the perspective of systematic supervision is unexplored. This study examines hospital clustering based on diagnosis-related group (DRG) indicators and explores the association between hospital clusters and medical disputes. Health administrative data from Sichuan Province in 2017 were used. A twostep cluster analysis was performed to cluster hospitals based on DRG indicators. A multiple regression analysis was conducted to evaluate the relationship between clusters and the incidence/number of medical disputes. The 1660 hospitals were grouped into three DRG clusters: basic (62.5%, n = 1038), diverse (31.0%, n = 515), and lengthy (6.4%, n = 107). After adjusting for covariates, the diverse hospitals were associated with an increased probability of having medical disputes (OR 5.24, 95% CI 2.97-9.26), while the diverse and lengthy hospitals were associated with a greater number of medical disputes (IRR 10.67, 95% CI 6.58-17.32; IRR 4.06, 95% CI 1.22-13.54). Our findings highlighted that the cluster-level performance of hospitals can be monitored. Future studies could examine this relationship using a longitudinal design and explore ways to reduce medical disputes in hospitals.

Preferences for Patients with Type 2 Diabetes Mellitus for Medications in Shandong Province, China: A Discrete Choice Experiment.

Purpose: To evaluate preferences for medications among patients with type 2 diabetes mellitus (T2DM) from urban community health stations or rural village clinics in Shandong province, China. Methods: We use a discrete choice experiment (DCE) to measure the medication preferences. Each patient completed six DCE choice sets. The attributes for the DCE questionnaire include mode of administration, out-of-pocket medication cost per month, fasting blood glucose control effect and frequency of hypoglycemia events. The conditional logit model (Clogit) and mixed logit model (MXL) were used to evaluate choice data. Results: A total of 887 patients with T2DM completed the survey. The mean age of participants was 64 years, 36.42% experienced complications, and the mean duration of diabetes was about 8 years. Overall, patients' ideal medication would not have hypoglycemia events, provide normal fasting glucose levels, have oral medication three times a day and lower monthly medication cost. Patients prioritized the frequency of hypoglycemia events (ß=15.055, P < 0.01) and were willing to spend CNY 393.10 per month to avoid hypoglycemia events. For patients with higher educational levels and with longer diagnosis time, the effect of fasting blood glucose was more relevant than all other outcomes. Conclusion: This study provides information on T2DM patients' preference for medications. Our results suggest that clinical doctors should present patients with a variety of pharmaceutical characteristics and include their preference into medication decision, which will improve patient adherence and health outcomes.

Association of High-Speed Rail and Tuberculosis Transmission in Newly Integrated Regions: Quasi-Experimental Evidence from China.

Objectives: The spread of tuberculosis (TB) is related to changes in the social network among the population and people's social interactions. High-speed railway (HSR) fundamentally changed the integrated market across cities in China. This paper aims to examine the impact of HSR on TB transmission in newly integrated areas. Methods: By exploiting the opening and operation of the first HSR in Sichuan province as a quasi-natural experiment, we have collected and used the economic, social, and demographic data of 183 counties in Sichuan province from 2013 to 2016. Results: The new HSR line is associated with a 4.790 increase in newly diagnosed smear-positive TB cases per 100,000 people among newly integrated areas. On average, an additional increase of 34.178 newly diagnosed smear-positive TB cases occur every year in counties (or districts) covered by the new HSR. Conclusion: HSR development has significantly contributed to the transmission of TB. The public health system in China needs to pay more attention to the influences of new, mass public transportation.

The Impacts of Flattening Fiscal Reform on Health Expenditure in China.

Introduction: A number of provinces have implemented a fiscal reform of flattening government since the first decade of this century in China. This study aims to quantitatively analyze the influences of this government fiscal reform on county-level health expenditure. We also bring forward policy suggestions for improving county-level fiscal system and healthcare delivery. Methods: We collected a novel longitudinal county-level data from 2003 to 2010, including counties' socioeconomic data, fiscal revenue, and health expenditure. Jilin Province, Hebei Province, and Anhui Province were selected as representative samples for this policy evaluation. The study employed a time-varying difference-in-difference model specification to investigate the impacts of flattening fiscal reform on health expenditure. Results: The analyses find that the fiscal system reforms of the three provinces have a significantly positive impact on the health expenditure of county-level governments. However, we find no policy effects on the proportion of health expenditure to fiscal expenditure of county-level governments. The estimation results are robust after controlling several background variables. Conclusion: The results yield important policy insights that public finance and its reform significantly impacts health expenditures in China. The government may still need to strengthen the transfer payment system to guarantee the social welfare provision in healthcare.

Curse or Blessing? Obesity and Income-Related Inequality in the Chinese Labor Force.

China owns a huge labor force of around half billion workers in 2018. However, little is known about the prevalence of obesity and the association between obesity and economic status in this special population. By employing the concentration index (CI) and decomposition analysis, this paper addresses this knowledge gap by using the most recent nationally representative dataset. In specific, this study examines the prevalence of obesity and the socioeconomic gradient in the probability of obesity among Chinese workers between 16 and 65. Our results show that the prevalence of obesity is completely different by using a different measure: the overall prevalence of being general obesity (measured by body mass index, BMI ≥ 28) varies by gender and residency from a minimum of 5.88% to a maximum of 9.46%, whereas abdominal obesity (measured by waist circumference, WCmale ≥ 85 cm & WCfemale ≥ 80 cm) prevalence presents a socking level from 64.53% to 67.69%. Moreover, the results show a pro-rich distribution of obesity (general and abdominal) among male workers (CIBMI = 0.112; CIWC = 0.057) and a pro-poor distribution among female workers (CIBMI = -0.141; CIWC = -0.166). We also find that the direction of the contribution of socioeconomic factors to income-related inequalities in obesity differs by gender. These results have substantial implications for the measurement of socioeconomic inequality in adiposity and for improving health-related policies targeting the Chinese labor force.

Will high-speed railway influence the healthcare seeking behaviour of patients? Quasi-experimental evidence from China.

This study examines the impacts of high-speed railway (HSR) transportation on the healthcare-seeking behaviour of patients along newly integrated areas of Sichuan province, China. The opening of the Cheng-Mian-Le intercity HSR is considered as quasi-experimental evidence from China, and we make a propensity score matching the difference in differences research design, using data from the monthly report database of the Sichuan Province health statistical data collection and Decision Support System from 2014 to 2015. We find that, first, the opening of the HSR resulted in significant healthcare-seeking behaviour with great heterogeneity. Second, patients are more likely to go to areas with high-density healthcare resources, in which case HSR may mitigate the diagnostic inaccuracies that patients face locally. Third, the 'distance enhancement effect' was present, and its marginal effect is more significant for long-distance patients. Fourth, the tiered-network healthcare policy has no significant restrictive impact on patients seeking high-level medical services. Our results show that HSR establishment has a substantial impact on the behaviour of people seeking medical treatment and medicine. Furthermore, we discuss the results' policy implications for the allocation and integration of China's healthcare market, and the accessibility of medical and health services.

What Are the Important Factors Influencing the Recruitment and Retention of Doctoral Students in a Public Health Setting? A Discrete Choice Experiment Survey in China.

OBJECTIVES: This study aims to investigate the employment preferences of doctoral students majoring in social medicine and health care management (SMHCM), to inform policymakers and future employers on how to address recruitment and retention requirements at CDCs across China. METHODS: An online discrete choice experiment (DCE) was conducted to elicit doctoral SMHCM students' job preferences. The scenarios were described with seven attributes: monthly income, employment location, housing benefits, children's education opportunities, working environment, career promotion speed, and bianzhi. A conditional logit model and a mixed logit model were used to evaluate the relative importance of the selected attributes. RESULTS: A total of 167 doctoral SMHCM students from 24 universities completed the online survey. All seven attributes were statistically significant with the expected sign and demonstrated the existence of preference heterogeneity. Monthly income and employment location were of most concern for doctoral SMHCM students when deciding their future jobs. Among the presented attributes, working environment was of least concern. For the sub-group analysis, employment located in a first-tier city was more likely to lead to a higher utility value for doctoral students who were women, married, from an urban area, and had a high annual family income. Unsurprisingly, when compared to single students, married students were willing to forgo more for good educational opportunities for their children. CONCLUSIONS: Our study suggests that monthly income and employment location were valued most by doctoral SMHCM students when choosing a job. A more effective human resource policy intervention to attract doctoral SMHCM students to work in CDCs, especially CDCs in third-tier cities should consider both the incentives provided by the job characteristics and the background of students. Doctoral students are at the stages of career preparation, so the results of this study would be informative for policymakers and help them to design the recruitment and retention policies for CDCs.

What Is Valued Most by Patients With Type 2 Diabetes Mellitus When Selecting Second-Line Antihyperglycemic Medications in China.

Objective: To estimate patient preferences for second-line antihyperglycemic medications in China. Methods: A face to face survey with the best-worst scaling (BWS) choices was administered in patients with diagnosed type 2 diabetes mellitus (T2DM). Study participants were asked to indicate which attribute they valued most and which attribute they valued least in 11 choice sets, each of which consisted of five alternatives out of 11 antihyperglycemic medication-specific attributes (treatment efficacy, weight change, hypoglycemic events, gastrointestinal side effects, cardiovascular health, urinary tract infection and genital infection side effects, edema, mode of administration, bone fracture, dosing frequency and out-of-pocket cost). A counting approach, a conditional logit model, and K-means clustering were used to estimate the relative importance of items and preference heterogeneity. Results: A total of 362 participants were included with a mean age of 63.6 (standard deviation: 11.8) years. There were 56.4% of participants were women, and 56.3% being diagnosed with diabetes for at least 5 years. Efficacy, cardiovascular health and hypoglycemic events were valued most, while dosing frequency, mode of administration and bone fracture were valued least. The K-means clustering further showed preference heterogeneity in out-of-pocket cost across the participants. Conclusion: Our study suggests that treatment efficacy, cardiovascular health and hypoglycemic events are valued most by Chinese patients with T2DM when selecting second-line antihyperglycemic medications. The study improves the understanding of patients' preferences for second-line antihyperglycemic medications in China.