【作者】 王超；

【导师】 卢祖洵；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2021， 博士

【摘要】 研究目的构建我国分级诊疗体系建设效果评价指标体系,分别从国家、省、区县、居民(患者)层面评价我国分级诊疗体系建设效果。基于此,总结我国分级诊疗体系建设的成效及现存问题,并提出针对性政策建议,为建设和完善我国分级诊疗体系提供参考。研究方法2019年1～8月,分别赴重庆市彭水县、武汉市硚口区、深圳市罗湖区及山西省开展现场调研,考察各地区分级诊疗体系建设的创新举措,搜集分级诊疗相关的卫生健康统计报表等数据资料。2019年3～4月,对全国31个省(自治区、直辖市)的11250名居民开展“居民家庭医生签约服务利用情况”问卷调查。另外,本研究还分别于2020年10～11月和2021年6～7月采取线上和线下相结合的方式与上述地区卫生健康部门和医疗卫生机构联系以补充相关数据。通过检索CNKI、万方、维普、Pub Med、Web of Science等中外文数据库,搜集国内外与分级诊疗体系建设相关的理论及实证研究,了解分级诊疗体系建设的研究现状和趋势;检索国家和地方卫生健康行政部门网站,收集分级诊疗体系建设相关的政策文件以及卫生健康统计年鉴、卫生健康事业发展统计公报等资料,把握我国分级诊疗体系建设的政策关切和发展现状;通过提取分级诊疗体系建设相关政策及文献中的效果评价指标,结合指标筛选原则和专家函询结果,构建我国分级诊疗体系建设效果评价指标体系。在数据收集的基础上,综合运用描述性统计、趋势分析、线性回归等方法,从国家、省、区县等层面对我国分级诊疗体系建设效果进行评价;采用描述性统计、混合效应模型、logistic回归分析等,分析我国居民对家庭医生的信任程度、对家庭医生服务满意程度以及续签家庭医生意愿,并探讨其影响因素。研究结果1.我国分级诊疗体系建设效果评价指标体系构建我国分级诊疗体系建设效果评价指标体系包含一级指标3个、二级指标9个、三级指标49个。各指标重要性和可行性均数均大于4.00,变异系数均小于0.25,且内容效度均良好(I-CVI为0.786～1.000,S-CVI/Ave=0.927)。2.我国分级诊疗体系建设效果评价2.1国家层面2009～2019年,我国分级诊疗体系不断完善,其中医疗卫生机构数(9.93%)、卫生人员数(66.14%)、床位数(99.41%)、医疗卫生机构收入(291.48%)、诊疗服务量(58.90%)等指标均显著增长。然而,分级诊疗体系建设的总体效果尚不明显,如基层医疗卫生机构诊疗量在总诊疗量中的占比平均每年以1%的速度下降等,这与分级诊疗体系建设的目标背道而驰。2.2省级层面山西省以“县乡医疗卫生机构一体化”改革为抓手推进分级诊疗体系建设。2014～2019年,山西省医疗卫生机构数(3.40%)、卫生人员数(18.11%)、床位数(23.11%)、医疗卫生机构收入(73.20%)以及下转诊疗量(16.63%)等不断增加,但基层卫生服务能力仍然不足,医疗资源配置结构也有待优化。2.3区县层面2014～2019年,通过公立医院改革和实行“总额包干、结余奖励”的医保支付方式等,罗湖医院集团社区健康服务中心数(43.48%)、卫生人员数(81.01%)、床位数(86.63%)、医疗卫生机构收入(163.77%)、家庭医生签约人数(505.75%)等指标均有所增加;硚口区通过落实两个“千方百计”工程、发展特色专科等,医疗卫生机构数(80.49%)、卫生人员数(85.99%)、床位数(49.03%)、医疗卫生机构收入(74.83%)、医联(共)体数(55.56%)、家庭医生签约人数(264.03%)以及双向转诊量(27.23%)等均有所提升;彭水县通过基层医疗卫生机构集团化管理、构筑“资金池”等,医疗卫生机构数(4.73%)、卫生人员数(37.06%)、床位数(79.69%)、医疗卫生机构收入(83.82%)、双向转诊人次数(90.24%)以及诊疗服务量(10.25%)等均有所增长。整体来看,罗湖区、硚口区和彭水县分级诊疗体系建设措施各具特色且均取得一定成效,但整体效果仍有待进一步提升。3.居民(患者)家庭医生信任度、家庭医生服务满意度及续签意愿本研究共纳入11250名调查对象。其中,信任家庭医生、满意家庭医生服务和愿意续签家庭医生的居民(患者)分别占调查对象的71.38%、68.90%和71.25%。本地户籍(OR=1.192)、参加医疗保险(OR=1.299)、自评健康状况良好(OR=1.246)、步行到最近医疗机构时间更短(<15分钟:OR=1.209;15～30分钟:OR=1.288)、信任家庭医生(OR=4.403)以及对家庭医生服务感到满意(OR=18.514)等均显著增加居民续签家庭医生的意愿(P<0.05)。研究结论与建议我国分级诊疗政策框架逐步健全,地方分级诊疗体系建设各具特色,基层医疗卫生机构硬件条件也有所改善,但相关政策和措施却鲜有触及分级诊疗的核心问题。建议完善分级诊疗相关法律法规体系,强化政府主体责任,构筑紧密型医联体,优化医疗资源配置结构,推进医保支付方式改革,引导利益主体自觉参与分级诊疗。同时,借鉴国际分级诊疗体系建设经验,创新体制机制,进而助力我国分级诊疗体系建设行稳致远。创新点与局限性本研究分别从国家、省、区县、居民(患者)等层面对我国分级诊疗体系建设效果进行综合评价,较好地实现了宏观和微观结合、代表性与适用性并重;评价指标选择上,本研究不仅有系统性梳理分级诊疗体系建设效果评价指标的尝试,也有对居民续签家庭医生意愿等创新性指标的探索;另外,本研究得出多个创新性结论,实现对以往研究结果的补充。然而,由于分级诊疗体系建设的复杂性、发展性和地区差异性,相关数据收集可能不完全,梳理出的分级诊疗体系建设效果评价指标也可能无法全面反映地区实际。另外,以信任度、满意度、续签意愿等反映政策感受方对分级诊疗体系建设效果的评价,其效力稍显不足,有必要继续从其他角度开展相关研究。更多还原

【Abstract】 ObjectiveThis study sought to establish the assessment indicators system for the construction effect of the Hierarchical Medical System(HMS)in China,and appraise the construction effect of HMS from the national,provincial,district or county,and residents’(or patients’)levels,respectively.Based on above findings,we summarized the effectiveness and shortcomings of China’s HMS construction,and then proposed targeted policy proposals.MethodsFrom January to August 2019,we went to Pengshui County in Chongqing,Qiaokou District in Wuhan,Luohu District in Shenzhen,and Shanxi Province for field researches and investigated the typical practical experiences and creative measures in different regions.From March to April 2019,we conducted a questionnaire survey,namely,“Residents’ Utilization of Contracted Services by Family Doctors” among11250 participants in 31 provincial-level administrative regions across China.In addition,we further supplemented the missing data in previous surveys by contacting with the health administration departments of above regions via online or offline methods from October to November 2020 and May to July 2021.The domestic and foreign theoretical and empirical studies related to the construction of the HMS were collected by searching CNKI,Wanfang,CQVIP and Pub Med,Web of Science to understand the research status and trends of HMS’s construction;The websites of the health administration department were searched to collect relevant policy documents,the Health Statistics Yearbook and the Statistical Bulletin of the Health Development,to grasp the policy concerns and development status of the HMS in China;The evaluation index system for the construction effect of China’s HMS was built by collecting relevant indicators from policy documents and previous studies,which was combined with the index screening principles and results of experts’ consultations.With data collection,descriptive statistical analyses,trend analyses and linear regression had been applied to assess the construction effect of HMS from the national,provincial,district and county levels.Furthermore,descriptive statistics,mixed-effects model,and multiple stepwise logistic regression were used to analyze residents’(or patients’)trust in family doctors,satisfaction with family doctor services and willingness to maintain contracts with family doctors.Results1.Establishment of the assessment indicators system for HMS’s constructionThe established assessment indicators system for construction effect of China’s HMS includes 3 first-level indicators,9 second-level indicators,and 49 third-level indicators.The importance and feasibility of all the indicators have average scores greater than 4.00,the coefficient of variation are less than 0.25,and the Content Validity are all appropriate(I-CVI ranges from 0.786 to 1.000;S-CVI/Ave is 0.927).2.Evaluation on the construction effect of HMS2.1 National level.With the development of HMS’s framework,numbers of medical and health institution(9.93%),health personnel(66.14%),hospital bed(99.41%),income(291.48%),and patients served(58.90%)in China have increased significantly from 2009 to 2019.However,the overall effect of HMS construction remains limited.For example,the proportion of the primary healthcare visits in the total number of visits has been decreasing with an average annual rate of 1%.2.2 Provincial level.Shanxi Province takes the “Integration Reform of County and Township Medical and Health Institutions” as its starting point to promote the HMS’s development.From 2014 to 2019,numbers of medical and health institutions(3.40%),health personnels(18.11%),hospital beds(23.11%),income(73.20%)and the downward referrals in Shanxi Province have been enriched continually,but the capacity of primary healthcare is still insufficient,and its medical resource allocation structure also needs to be optimized.2.3 District and county levels.From 2014 to 2019,numbers of community healthcare center(43.48%),health personnels(81.01%),hospital beds(86.63%),income(163.77%)and residents contracted with family doctors(505.75%)in Luohu Hospital Group have increased gradually;Through implementation of “Qian Fang Bai Ji” projects and development of specialized specialties in primary healthcare centers,numbers of medical and health institutions(80.49%),health personnels(85.99%),hospital beds(49.03%),income(74.83%),medical consortiums(55.56%),residents contracted with family doctors(264.03%)and bidirectional referrals(27.23%)in Qiaokou District have benn improved;With the group management of primary healthcare institutions and the construction of “Funding Pool”,numbers of medical and health institutions(4.73%),health personnel(37.06%),hospital beds(79.69%),income(83.82%),bidirectional referrals(90.24%)and patients served(10.25%)in Pengshui County have all increased to varying degrees.Overall,the construction measures of the HMS in each district or county have their own characteristics and have achieved certain results,but the overall effects are not satisfactory and still needs to be further improved.3.Residents’(Patients’)trust in family doctors,satisfaction with family doctor services,and willingness to maintain contracts with family doctorsA total of 11250 residents(patients)were included in this study.Among them,71.38% participants trust in family doctors,68.90% participants were satisfied with family doctor services,and 71.25% paticipants were willing to maintain contracts with family doctors.Local household registration(Odds Ratio(OR)=1.192),enrolling in medical insurance(OR=1.299),better self-report health status(OR=1.246),shorter walking time to the nearest healthcare institution(<15 minutes:OR=1.209;15～30 minutes: OR=1.288),trusting in family doctors(OR=4.403),and satisfying with healthcare services by family doctors(OR=18.514)were suggested to increase residents’ willingness to maintain contracts with family doctors significantly.Conclusions and RecommendationsThe policy framework for HMS in China has been refining gradually,the construction model of HMSs in different regions has its own strengths,and the hardware conditions of primary healthcare institutions have been improved to some extent.However,the fundamental contradictions are rarely touched by relevant policies and practical measures.It is recommended to regulate the construction of China’s HMS by improving relevant laws and regulations,implementing the government’s responsibility,building a closer medical alliance,optimizing the allocation structure of medical resource and exploring the reform of medical insurance payment methods,to guide medical and health institutions,medical workers,patients and other stakeholders to participate in HMS consciously.In addition,it is suggested to appropriately draw on the experiences of the international HMS’s construction,combining it with the actual medical and health condition in China,to promote the steady and long-term development of China’s HMS.Innovations and LimitationsIn terms of study perspective,we comprehensively evaluated the effect of China’s HMS from four levels: the country,province,district or county,and residents or patients.The results have been presented by the combination of macro-and microperspectives,representative and applicability.In terms of evaluation index selection,we not only attempted to construct a comprehensive systemic index system,but also explored innovative evaluation indicators,such as residents’ willingness to renew family doctors.In terms of study findings,this study has obtained a number of innovative findings,which could supplement previous research findings.However,due to the complexity and on-going development of the HMS,plus various ideas and measures for HMS’s construction in different regions,the evaluation indexes selected in this study could not fully reflect the characteristics of HMS in every region.In the empirical research,we mainly use the longitudinal comparison method to evaluate the construction effect of the HMS for each sample region,instead of the parallel comparison or horizontal comparison.In addition,it is slightly insufficient to reflect policy perceiver’s evaluation on the construction effect of HMS from the prospective of their trust in family doctors,satisfaction with family doctors or willingness to maintain contracts with family doctors,further studies from other perspectives are necessary to conduct to increase the strength of the evidences.更多还原