我国患者双向转诊行为决策及影响因素研究

Behavioral Decision in Two-way Referral and Its Influencing Factors in China

目的探讨我国患者双向转诊的行为决策及影响因素,并提出政策建议。方法通过查阅《2012中国卫生统计年鉴》中关于居民就诊行为的调研数据,分析患者选择就诊单位的影响因素。通过对2013年我国12个省份30多家医院2 006例患者的调查,分析患者双向转诊的影响因素,同时构建患者就诊单位的选择行为模型和患者下转的选择行为模型。结果患者选择就诊单位的影响因素主要有距离近(占56.7%)、质量好(占15.8%)、有熟人/信赖医生(占10.7%)、定点医院(占6.3%)和价格低(占5.6%)。508例转诊患者中,上转467例(占91.9%),下转41例(占8.1%)。患者上转的影响因素有:基层医疗条件限制(占31.8%,162/508)、疑难杂症(占19.1%,97/508)、急危重症(占19.1%,97/508)、急诊抢救(占17.9%,91/508)、患者家属要求(占12.1%,61/508),各因素构成间差异有统计意义(χ2=127.369,P<0.001)。患者不愿下转的影响因素有:对基层医院医技水平不满意(占28.0%,142/508)、转诊手续繁琐(24.0%,122/508)、医生和医院对转诊的不支持(占21.0%,107/508)、对基层医院药品品类不满意(占17.9%,91/508)、对基层医院服务态度不满意(占9.1%,46/508),各因素构成间差异有统计意义(χ2=96.248,P<0.001)。结论患者双向转诊行为中存在上转容易下转难现象。针对基层医疗条件、转诊流程、医生和医院对转诊的态度等方面问题,应加大政策支持,制定转诊指征,明确医疗体系中各医疗主体单位的功能,加强医疗机构之间的协作。

Objective To investigate the behavioral decision in two- way referral and its influencing factors and put forward suggestions for policy making in China. Methods By looking up data about residents＇ clinical consultation behavior in China Health Statistics Yearbook 2012,we analyzed influencing factors for patients＇ choice of medical setings. By the investigation on 2 006 patients from more than 30 hospitals in 12 provinces of China in 2013,we analyzed influencing factors for two- way referral and built a behavioral model of choosing medical settings and a behavioral model of downward referral. Results The influcing factors for choosing maedical settings were short distance（ 56. 7%）, superior qualtiy（ 15. 8%）, trust in doctors /acquaintance（ 10. 7%）,fix- point hospitals（ 6. 3%） and low price（ 5. 6%）. Among 508 referral patients,467（ 91. 9%）patients had upward referral and 41（ 8. 1%） patients had downward referral. The influencing factors for upward referral included restricted medical condition at primary level（ 31. 8%,162 /508）,rare dieases（ 19. 1%,97 /508）,acute and critical diseases（ 19. 1%,97 /508）,first- aid treatment（ 17. 9%,91 /508）,the requirement of patients＇ families（ 12. 1%,61 /508）,with signifcant differences in proportion among these factors（ χ2= 127. 369, P〈0. 001） . The influencing factors for the unwillingness for downward referral include disatisfaction with medical and technical level at primary level（ 28. 0%,142 /508）,complicated referral procedure（ 24. 0%,122 /508）, nonsupport of doctors and hospitals for referral（ 21. 0%,107 /508）,disatisfaction with the categories of medicine in primary level hospitals（ 17. 9%,91 /508）,disatifaction with the service attitude of primary level hospitals（ 9. 1%,46 /508）,with significant differences in proportion among these factors（ χ^2= 96. 248,P〈0. 001）. Conclusion Patients prefer upward referral to downward referral. According to the problems in terms of medical condition at primary level,complicated referral precedure and the attitide of doctors and hospitals toward referral,we suggest that policy support should be enhanced,standards should be formulated for referral,functions of various medical settings in medical system should be clearly defined,and the collaboration among medical settings should be strengthened.