【摘要】 背景对未分化疾病的诊治是社区全科医生诊疗能力和卫生机构管理质量的体现。郊区基层医疗卫生服务的需求与城区逐步拉近,也存在较大潜力。目的本研究旨在了解和比较上海市区和郊区的各家社区卫生服务中心的全科医生对门诊未分化疾病的认知、行为、需求和能力,以及对诊治水平的影响因素,为促进基层医疗服务,优化其资源布局提供方向。方法 2018年11月通过自制问卷,分两轮分别调查上海市16个行政区(包含7个城区和9个郊区)的244家社区卫生服务中心的每位行政负责人,以及所有社区按照50%比例随机选取职称结构匹配产生的4 047例全科医生。调查社区卫生服务中心对未分化疾病的管理现况和认知,全科医生诊治未分化疾病的需求和能力自评,并进行城郊对比,采用多因素Logistic回归分析影响全科医生处理未分化疾病能力的因素。结果两轮问卷的回收率分别为100.00%(244/244)和96.98%(3 925/4 047)。参与调查的全科医生在城区和郊区工作者分别占32.71%(1 284/3 925)和67.29%(2 641/3 925)。社区卫生服务中心方面,郊区中包含专科医生和助理全科医生的比例高于城区;城区中包含眼科和五官科医生的比例高于郊区;城区中包含对分化疾病诊疗能力培训、首诊处理流程、转诊设定的比例高于郊区。全科医生方面,城区和郊区全科医生的日门诊量、对未分化疾病的处理能力和转诊率比较,差异有统计学意义(P<0.05)。影响全科医生处理未分化疾病能力的指标包括职称、工作年限、全科日门诊量、对未分化疾病的首诊处理流程及转诊率,这些指标构成在城郊之间都存在统计学差异(P<0.05)。结论当前社区卫生服务中心对未分化疾病的相关管理、全科医生对疾病相关处理的认知和能力仍较薄弱。郊区社区卫生服务中心及全科医生对于未分化疾病的诊治现况较城区更为薄弱,工作资历和实践相对不足,更缺乏规范的诊治流程,转诊需求更高。更多还原

【Abstract】 Background Community-based management of undifferentiated diseases embodies the level of professional abilities of community general practitioners(GPs) and the management quality of community healthcare institutions for the diseases. The differences of primary care needs between urban and suburban areas are becoming less,indicating that healthcare services have great development potentials in suburban areas. Objective To perform a comparative analysis of the perceptions,outpatient management interventions,and level and associated factors of management of undifferentiated diseases,as well as required supports among GPs from community health centers(CHCs) in urban and suburban areas of Shanghai,offering guidance for promoting the development of primary care,and optimizing the distribution of primary care resources. Methods November 2018,an online survey was conducted using a self-developed questionnaire A(CHC administrators) in administrators extracted from 244 CHCs in 16 districts(7 urban and 9 suburban) of Shanghai at a ratio of 1 ∶ 1. And another online survey was carried out using a self-developed questionnaire B(CHC GPs) among 4 047 professional title composition-matched community GPs randomly selected from these 244 CHCs(from each CHC,50% of the GPs were randomly selected according to professional title). Data obtained from the surveys included perceptions and management of undifferentiated diseases,required help and self-rated management abilities. Urban and rural status was compared. And multivariate Logistic regression analysis was used to identify the factors associated with GPs’ management abilities of undifferentiated diseases. Results The response rates of the two surveys were 100.00%(244/244) and 96.98%(3 925/4 047),respectively. The proportions of GPs surveyed working in urban and suburban areas were 32.71%(1 284/3 925) and 67.29%(2 641/3 925),respectively. The percentages of specialists and assistant GPs in suburban CHCs were higher than those in urban CHCs. The percentages of ophthalmologists and ENT doctors in urban CHCs were higher than those of suburban CHCs. The percentages of requiring trainings for undifferentiated diseases,first management procedure of undifferentiated diseases,and requiring to be informed of designed referral rate in urban CHCs were higher than those of suburban CHCs. GPs in suburban CHCs showed higher rate of consulting less than 50 outpatients daily compared with those in urban CHCs. There were significant differences in daily outpatients volume,ability to deal with undifferentiated disease and refferal rate to higher level hospitals between GPs in urban and suburban. The factors affecting GPs’ ability for managing undifferentiated diseases included title,working years,daily outpatient workload,procedure for first management of undifferentiated diseases,and rate of transferring patients with undifferentiated diseases,which were also associated with significant differences in the ability of managing the undifferentiated diseases between GPs in urban and suburban CHCs(P<0.05). Conclusion In Shanghai,the management of undifferentiated diseases by CHCs is relatively poor,which is more obvious in suburban areas. Community GPs have relatively insufficient perceptions of undifferentiated diseases,as well as insufficient ability for managing these diseases. Relatively speaking,compared with those working in urban CHCs,GPs in suburban CHCs have higher rates of owning less professional qualifications and less sufficient practice,requiring the training of standardized procedure for managing these diseases,and transferring undifferentiated disease patients to higher level hospitals. In view of this,relevant guidelines should be improved,and first management procedure development as well as trainings and clinical management of undifferentiated diseases should be strengthened.更多还原