【作者】 刘强；

【导师】 陈希； 杜孝亲；

【作者基本信息】 西安电子科技大学 ， 工程硕士（专业学位）， 2021， 硕士

【摘要】 伴随着我国经济实力的迅速腾飞、现代通讯技术产业的蓬勃发展以及互联网行业的快速兴起,我国人民的医疗卫生服务需求缺口较大、我国现有的医疗资源仍然匮乏、各级医疗卫生服务机构的服务水平和服务效率亟待提升等医疗问题也在不断放大。自2006年起,我国开始推行“基层首诊、双向转诊、急慢分治、上下联动”的分级诊疗服务模式。国家和各级地方政府希望通过推行分级诊疗制度,实现以下一些目标:首先,实现大型综合医院患者的有效分流、避免基层医疗服务机构医疗资源的闲置浪费;其次,促进各级医疗服务机构上下联动、形成互利共赢的良好局面;最后,通过系统地调控手段来建立符合我国国情的分级诊疗模式,优化各级医疗卫生服务机构的资源配置,整体、全面地提升我国医疗系统的服务效率和质量。但在实施过程中,受制于基层医疗服务机构的医疗资源及医护人员水平的局限性,基层医疗服务机构难以充分满足就诊患者的全部需求,患者受到大型综合医院优质医疗服务资源的吸引,在初诊意愿选择上存在较为明显的倾向性;另一方面,具备较为完善的医疗设备、较为充足的医疗资源、较为专业的医护人员的大型综合医院在拥有较强竞争力的同时,不管是在经济利益还是社会声誉等方面还具有较为明显的趋利性。上述问题已经引起了国内外学者的广泛关注,在这一领域也有了一些研究成果,然而现有的研究大都从质性分析入手、缺乏实际背景,因此,分级诊疗情境中的关于多个主体的决策行为的量化分析以及研究方法等方面还有很多可以深入研究的问题。本文在对国内外研究现状进行整理分析和国家及各地方政府出台的相关政策进行深入了解后,就政策实施过程中的重要参与主体的一些转诊决策问题进行了探讨,主要进行了以下几个方面的研究工作:(1)基于演化博弈理论的上级医院、下级医院和地方政府的转诊决策分析。在梳理完现有相关研究的基础上,结合我国现行的有关制度,提出了分级诊疗体系下演化博弈模型的基本假设;在符合基本假设的前提下,对这一研究问题中的主体策略演化过程进行了一系列的数学推理和论证;结合实际获取的数据,运用仿真软件进行了实验分析,对最终得到实验结果进行了分析论述,并给出了各个主体在不同情形下的策略选择建议。(2)考虑空间可达性和多主体的下转医院两阶段选择方法。首先,基于空间位置信息和服务水平对下级医院进行初步筛选;然后,通过文献调查和整理,提炼出下转医院选择问题中医患双方各自的准则集合;为了避免主观给予权重造成的结果与实际情况存在偏差,同时简化不同准则权重获取的过程,采用了目前较为流行的BWM(Best Worst Method)方法来获取各准则的权重;在此基础上,运用较为经典的TOPSIS决策方法来对备选的下级医院进行比较排序,得出最优的备选方案。在理论上,本文在整理分析了相关研究基础上提炼出了符合我国医疗卫生系统现状的演化博弈基本假设,从定量分析的角度进行了较为深入的研究。在技术方法上,本文构建了不同情形下的演化博弈模型,对多个主体策略演化过程进行分析;提出了BWM-TOPSIS集成方法,有效地解决了下转医院选择问题。本文所做的研究工作丰富了分级诊疗体系下的转诊决策问题相关的研究方法和理论;不仅具备了一定的学术价值,而且还有一定的应用价值,为转诊决策相关的研究问题提供了一些可靠参考。更多还原

【Abstract】 With the rapid take-off of our country’s economic strength,the vigorous development of the modern communication technology industry and the rapid rise of the Internet industry,the demand for medical and health services of the Chinese people is large,the existing medical resources in our country are still scarce,and the medical and health service institutions at all levels are still in short supply.Medical problems such as urgent improvement of service level and service efficiency are also constantly magnifying.Since 2006,China has begun to implement a hierarchical diagnosis and treatment service model of "first consultation at the grassroots level,two-way referral,separate treatment for emergency and slow treatment,and upper and lower linkage".The state and local governments at all levels hope to implement a hierarchical diagnosis and treatment system to achieve the following goals: first,to achieve effective diversion of patients in large general hospitals,and to avoid idle waste of medical resources in primary medical service institutions;second,to promote the linkage of medical service institutions at all levels,form a good situation of mutual benefit and win-win;finally,through systematic control means to establish a hierarchical diagnosis and treatment model that meets China’s national conditions,optimize the resource allocation of medical and health service institutions at all levels,and improve the overall and comprehensive service efficiency and quality of China’s medical system.However,in the implementation process,due to the limitations of the medical resources and the level of medical staff of the primary medical service institutions,the primary medical service institutions cannot fully meet all the needs of the patients.The patients are attracted by the high-quality medical service resources of large general hospitals.There is a relatively obvious tendency in the choice of willingness;on the other hand,large general hospitals with relatively complete medical equipment,relatively sufficient medical resources,and relatively professional medical staff have strong competitiveness at the same time,regardless of economic benefits.It is still more profit-oriented in terms of social reputation and so on.The above-mentioned problems have attracted widespread attention from scholars at home and abroad,and there have been some research results in this field.However,most of the existing studies start with qualitative analysis and lack practical background.Therefore,in the context of hierarchical diagnosis and treatment,there are many issues that can be studied in depth in the quantitative analysis and research methods of decision-making behavior.After collating and analyzing the current research status at home and abroad,and having an in-depth understanding of the relevant policies issued by the state and local governments,this article discusses some referral decision-making issues of important participants in the policy implementation process,mainly including the following aspects of research work:(1)The referral decision analysis of higher-level hospitals,lower-level hospitals and local governments based on evolutionary game theory.On the basis of combing the existing relevant research,combined with the current relevant systems in my country,the basic assumptions of the evolutionary game model under the hierarchical diagnosis and treatment system are proposed;on the premise of conforming to the basic assumptions,the evolution process of the main strategy A series of mathematical reasoning and argumentation were carried out;combined with the actual data,the simulation software was used to carry out experimental analysis,the final experimental results were analyzed and discussed,and the strategy selection suggestions of each subject in different situations were given.(2)A two-stage selection method for transfer hospitals considering spatial accessibility and multi-agents.First,preliminary screening of lower-level hospitals based on spatial location information and service level;then,through literature investigation and sorting,extract the set of criteria for both doctors and patients in the selection of transfer hospitals;in order to avoid subjective weighting of results and actual results There are deviations in the situation,while simplifying the process of obtaining the weights of different criteria,the currently more popular BWM(Best Worst Method)method is used to obtain the weights of the criteria;on this basis,the more classic TOPSIS decision-making method is used to determine the alternatives.The lower-level hospitals compare and sort,and get the best alternatives.Theoretically,based on the analysis of relevant research,this article has extracted the basic assumptions of evolutionary game that are in line with the status quo of my country’s medical and health system,and conducted a more in-depth study from the perspective of quantitative analysis.In terms of technical methods,this paper constructs an evolutionary game model in different situations to analyze the evolution process of multiple agents’ strategies;proposes a BWM-TOPSIS integration method,which effectively solves the problem of selecting a transfer hospital.The research work done in this article has enriched the research methods and theories related to referral decision-making issues under the hierarchical diagnosis and treatment system;it not only has a certain academic value,but also has a certain application value,and provides research questions related to referral decision-making.Some reliable references.更多还原