【作者】 陈瑛；

【导师】 周小军； 徐匡根；

【作者基本信息】 南昌大学 ， 公共卫生（专业学位）， 2023， 硕士

【摘要】 目的:了解并掌握江西省基层医疗卫生机构高血压与糖尿病医防融合服务实施现状及存在的问题,进行阶段性效果评价,对医防融合服务开展过程进行经验总结,提出促进高血压与糖尿病医防融合服务的相关对策,为完善江西省基层医防融合提供参考依据,为推动高血压与糖尿病防控高质量发展提供支撑。方法:于2022年7-12月,采用单纯随机抽样法,抽取了8家开展了医防融合工作的基层医疗卫生机构为医防融合组,8家未开展该项工作的为对照组(即非医防融合组),机构调查内容主要为服务效率;同时调查了16家机构1395例服务患者的服务体验与服务效果,并对样本机构的分管领导进行了访谈。采用t、χ~2检验进行对比分析,访谈资料采用原因分析法。结果:(1)基层医疗卫生机构运行效率。医防融合机构和非医防融合机构2022年与2021年相比:(1)门急诊总人次增长率更高33.8%vs-6.5%,但高血压人次增长率有所下降4.4%vs5.5%;(2)出院总人次增长率更高5.9%vs-4.3%;(3)次均门诊、次均住院费用增长率均更高(1.8%vs-12.0%、13.3%vs-9.8%);(4)上门出诊人次增长率更高10.4%vs-29.0%,但预约总人次增长率更低19.1%vs41.0%;(5)签约人数增长率18.4%vs-15.6%、居民健康档案建档数增长率30.0%vs8.5%,健康体检总人次增长率34.1%vs-1.1%均更高;(6)高血压规范管理率、血压控制率的增长率更明显(2.6%vs1.5%,10.0%vs2.2%),糖尿病规范管理率、血糖控制率的增长率明显更高(11.9%vs0.9%、1.1%vs0.2%)。(2)患者对相关服务的体验。共调查患者1395人,其中医防融合组706人,非医防融合组689人。医防融合组患者就诊频率高于非融合组(P<0.001)。医防融合组医务人员询问过健康状况、建档情况和体检情况均高于非融合组(94.1%vs79.5%、94.9%vs77.6%、96.9%vs87.5%,均P<0.001)。患者在医防融合组的建档率(94.8%vs84.6%)、免费体检率(96.9%vs91.7%)、享有医保门诊统筹率(90.5%vs61.1%)、与医生团体签约率(87.0%vs63.4%)和转诊服务知晓率(56.1%vs40.9%)均高于非融合组(均P<0.001)。两组患者对“本机构帮助联系转诊”、“上级机构帮助联系转诊”服务的知晓率(97.5%vs96.1%、86.4%vs84.8%)和实际转诊服务接受率(43.4%vs39.7%)均亦无差别(P>0.05)。(3)患者接受服务情况。医防融合组和非医防融合组患者服务接受率相比:相关知识健康教育(92.2%vs67.2%)、用药指导(93.6%vs70.4%)、饮食指导(94.1%vs69.5%)、身体活动指导(90.5%vs67.8%)和随访服务(95.6%vs77.2%)均更高(均P<0.001);患者控制血压/血糖措施采取率(98.6%vs97.2%)无差别(P>0.05)。(4)对患者服务的效果。以高血压和糖尿病患者对疾病相关知识、态度和行为改变来评价医防融合组和非医防融合组的服务效果,结果为:(1)医防融合组对疾病相关知识知晓评分10.04±5.57高于非融合组8.79±6.19(t=3.944,P<0.001),其中危险因素、症状和预防措施相关知识知晓评分均以医防融合组高(均P<0.05),两组患者对并发症知识知晓评分无差别(P>0.05)。(2)两组患者对疾病相关态度评分11.00±52.36vs10.79±2.29无差异(P>0.05)。(3)医防融合组健康行为评分18.51±3.95明显高于非融合组17.61±3.94(t=4.283,P<0.001)。(5)患者满意度评分。医防融合组对服务总体的满意度评分32.62±3.61高于非融合组29.93±4.84(P<0.001)。其中,两组患者对诊疗服务4.69±0.53vs4.38±0.67、预防服务4.68±0.57vs4.31±0.72、签约服务4.64±0.63vs4.12±0.98、健康管理服务4.66±0.56vs4.28±0.76、服务价格4.60±0.61vs4.21±0.80、服务流程4.64±0.57v s4.28±0.72等满意度评分,均为医防融合组高于非融合组(P<0.001)。(6)定性研究发现。江西省基层医防融合服务目前主要存在的问题包括:基于供方主要是医护人员医防融合意识不高、参与的积极性还有所欠缺、公共卫生专业人才缺乏和信息建设滞后多数未实现互联互通;基于需方主要是多数患者对医防融合服务模式不理解、部分服务内容接受度不高等。结论:(1)医防融合服务模式明显提高了基层医疗卫生机构运行效率。医防融合机构和非融合机构相比:(1)门急诊总人次、出院总人次和上门出诊人次的增长率均更高,但预约总人次增长率更低;(2)签约人数、居民建档数、高血压规范管理率和糖尿病规范管理率等增长率均更高;(3)次均门诊及次均住院费用增长率均亦更高。(2)医防融合服务模式明显提高了患者的服务体验。主要表现在医防融合组患者就诊频率、建档率、免费体检率、享有医保门诊统筹率、与医生团体签约率和转诊服务知晓率均高于非融合组;医防融合组医务人员询问过健康状况、建档情况和体检情况均高于非融合组,但两组患者对“本机构帮助联系转诊”、“上级机构帮助联系转诊”服务的知晓率及实际转诊服务接受率均无差别。(3)医防融合服务模式明显提高了患者部分服务接受率。医防融合组相关知识健康教育、用药指导、饮食指导、身体活动指导和随访的服务接受率均更高,但控制血压/血糖措施采取率无差别。(4)医防融合服务模式明显提高了患者对部分疾病相关知识知晓评分及健康行为评分。医防融合组对疾病相关知识知晓评分、健康行为评分高于非融合组,其中危险因素、症状、预防措施相关知识知晓评分均以融合组高,但两组患者对并发症知识知晓评分无差别。两组患者对疾病相关态度评分无差异。(5)进一步提升医防融合服务的相关建议:要加强顶层设计,完善医防融合的相关政策并落实;加强基层机构能力建设,引进高素质的专业技术人才及相应的配套设备;强化信息化建设,实现医疗和公共卫生系统数据信息共享;加大政策宣传力度,提高居民预防意识和对医防融合服务的接受率,提升居民幸福感、获得感。更多还原

【Abstract】 Objective:To understand and grasp the current situation and problems of the implementation of the integration of hypertension and diabetes prevention services in primary health care institutions in Jiangxi Province,to conduct a phased effect evaluation,to summarize the experience of the process of the integration of medical prevention services,to propose relevant countermeasures to promote the integration of hypertension and diabetes prevention services,to provide a reference basis for improving the integration of primary health care in Jiangxi Province,and to provide support for promoting the high-quality development of hypertension and diabetes prevention and control.The study will provide support for the development of quality prevention and control of hypertension and diabetes.Methods:In July-December 2022,a simple random sampling method was used to select eight primary health care institutions that had carried out health care integration work as the health care integration group and eight that had not carried out this work as the control group(non-health care integration group),and the institutions were surveyed mainly for service efficiency;The service experience and service effectiveness of 1395cases of patients served in 16 institutions were also investigated,and interviews were conducted with the divisional leaders of the sample institutions.The t andχ~2 tests were used for comparative analysis,and the interview data were analyzed by reason analysis.Results:(1)Operational efficiency of primary health care institutions.Medical-defense-integrated and non-medical-defense-integrated institutions in 2022 compared to 2021:(1)Total emergency department visits grew at a higher rate of 33.8%vs-6.5%,but hypertension visits grew at a lower rate of 4.4%vs 5.5%;(2)Higher growth rate of total discharges 5.9%vs-4.3%;(3)Higher growth rates in average per outpatient and per inpatient costs(1.8%vs-12.0%and 13.3%vs-9.8%);(4)A higher growth rate of 10.4%vs-29.0%for office visits,but a lower growth rate of 19.1%vs 41.0%for total appointments;(5)Higher growth rates of 18.4%vs-15.6%for the number of people contracted,30.0%vs 8.5%for the number of residents’health records created,and34.1%vs-1.1%for the total number of health checkups;(6)The growth rates of normative management of hypertension and blood pressure control were more pronounced(2.6%vs 1.5%and 10.0%vs 2.2%),and the growth rates of normative management of diabetes and glycemic control were significantly higher(11.9%vs 0.9%and 1.1%vs 0.2%).(2)Patient experience of relevant services.A total of 1395 patients were investigated,of which 706 were in the medical prevention integration group and 689 in the non-medical prevention integration group.The frequency of patient visits was higher in the medical-defense fusion group than in the non-fusion group(P<0.001).Medical staff inquired about health status,documentation and physical examination in the medical prevention integration group than in the non-integration group(94.1%vs79.5%,94.9%vs 77.6%,96.9%vs 87.5%,all P<0.001).Patients had higher rates of file creation(94.8%vs 84.6%),free medical checkups(96.9%vs 91.7%),access to medical insurance outpatient coordination(90.5%vs 61.1%),contracting with physician groups(87.0%vs 63.4%),and awareness of referral services(56.1%vs 40.9%)in the medical defense integration group than in the non-integration group(all P<0.001).The awareness rate(97.5%vs 96.1%,86.4%vs 84.8%)and the acceptance rate(43.4%vs39.7%)of the"local referral"and"higher level referral"services between the two groups were also not different(P>0.05).(3)Patient acceptance of services.Compared with the medical-prevention integration group and the non-medical-prevention integration group,patient service acceptance rates were higher:health education on relevant knowledge(92.2%vs 67.2%),medication guidance(93.6%vs 70.4%),dietary guidance(94.1%vs 69.5%),physical activity guidance(90.5%vs 67.8%)and follow-up services(95.6%vs 77.2%)(all P<0.001);There was no difference in the adoption rate of blood pressure/glucose control measures by patients 98.6%vs 97.2%(P>0.05).(4)Effectiveness of services for patients.The results of the service effectiveness of the medical prevention integration group and the non-medical prevention integration group were evaluated by the change in disease-related knowledge,attitude and behavior of patients with hypertension and diabetes:(1)The knowledge of disease related knowledge score of the medical prevention fusion group was 10.04±5.57 higher than that of the non-fusion group 8.79±6.19(t=3.944,P<0.001),among which the knowledge of risk factors,symptoms and preventive measures were higher in the medical prevention fusion group(all P<0.05),and there was no difference in the knowledge of complications between the two groups(P>0.05).(2)There was no difference between the two groups in the scores of 11.00±52.36 vs 10.79±2.29 for disease related attitudes(P>0.05).(3)The health behavior score of 18.51±3.95 in the medical prevention integration group was significantly higher than that of 17.61±3.94 in the non-integration group(t=4.283,P<0.001).(5)Patient satisfaction scores.The overall satisfaction rating of the medical defense integration group with the service was 32.62±3.61 higher than the non-integration group 29.93±4.84(P<0.001).Among the two groups,patients’satisfaction scores for the diagnosis and treatment services 4.69±0.53 vs 4.38±0.67,prevention services 4.68±0.57 vs 4.31±0.72,contracted services 4.64±0.63 vs 4.12±0.98,health management services 4.66±0.56 vs 4.28±0.76,service prices 4.60±0.61 vs 4.21±0.80,and service process 4.64±0.57 vs 4.28±0.72 satisfaction scores were higher in the medical prevention integration group than in the non-integration group(all P<0.001).(6)Qualitative research findings.The main problems of primary health care integration services in Jiangxi Province include:low awareness of health care integration based on the supply side,mainly medical and nursing staff,lack of enthusiasm for participation,lack of public health professionals and lagging information construction,most of which are not interconnected;Based on the demand side,mainly most patients do not understand the service model of medical prevention integration,and the acceptance of some service contents is not high.Conclusion:(1)The medical and defense integration service model has significantly improved the operational efficiency of primary health care institutions.Medical defense fusion institutions compared to non-fusion institutions:(1)Higher growth rates for total outpatient visits,total hospital discharges and walk-in visits,but lower growth rates for total appointments;(2)Higher growth rates in the number of contracted persons,the number of residents’files,the rate of standardized management of hypertension and the rate of standardized management of diabetes;(3)The growth rates of average outpatient and average inpatient costs were also higher.(2)The medical defense integration service model has significantly improved the service experience of patients.The main manifestations are that patients in the medical prevention integration group have a higher frequency of consultation,file establishment rate,free medical examination rate,rate of access to medical insurance outpatient coordination,contracting rate with physician groups and awareness of referral services than those in the non-integration group;Medical staff in the medical defense integration group had asked about health status,documentation and medical examination more than the non-integration group.However,there was no difference between the two groups in terms of the awareness and acceptance rates of the services of"referral with the help of our institution"and"referral with the help of higher-level institutions".(3)The medical defense integration service model has significantly improved the acceptance rate of some services by patients.The acceptance rate of services related to knowledge health education,medication guidance,dietary guidance,physical activity guidance and follow-up was higher in the medical prevention integration group,but there was no difference in the adoption rate of blood pressure/glucose control measures.(4)The integrated medical prevention service model significantly improved patients’knowledge knowledge scores and health behavior scores for some diseases.The medical prevention fusion group had higher knowledge of disease related knowledge and health behavior scores than the non-fusion group,and the fusion group had higher knowledge of risk factors,symptoms and preventive measures,but there was no difference in the knowledge of complications between the two groups.There was no difference between the two groups in the scores of patients’attitudes related to the disease.(5)Suggestions to further enhance the integration of medical and defense services:To strengthen the top-level design,improve policies related to the integration of health care and prevention and implement them;Strengthening the capacity building of grassroots institutions and introducing highly qualified professional and technical personnel and corresponding supporting equipment;Strengthen information technology construction and realize data and information sharing in medical and public health systems;Increase policy promotion to improve residents’awareness of prevention and acceptance of medical prevention integration services,and enhance their sense of well-being and access.更多还原