北京市失能老年人对上门医疗服务利用现状的混合方法学研究

Utilization of Home-based Medical Services in Disabled Elderly People in Beijing:a Mixed-method Study

背景随着全球人口老龄化的加剧,失能、半失能老年人迅速增加,以全科医生团队为基础、面向家庭的上门医疗服务成为世界新趋势。目前我国的上门医疗服务还缺乏规范的管理制度和系统的运作机制。目的基于失能老年人的视角,探讨北京市上门医疗服务利用现状和存在问题,为构建合理化社区上门服务体系提供建议。方法采用质性研究和量性研究相结合的方法。2018年5—6月,采用目的抽样法选取8名失能老年人的主要照顾者进行个人深入访谈,内容包括对上门医疗服务的需求情况、了解程度、利用情况及其满意度和具体意见建议等。2018年7—9月,采用多阶段抽样方法对北京市6家社区卫生服务中心的370名失能老年人照顾者进行问卷调查,收集失能老年人的健康状况、照顾资源、对上门医疗服务项目内容的利用和满意度情况。结果质性研究发现上门医疗服务能部分满足失能老年人的需求,但患者担心上门医疗费用较高且无法医保结算、上门医疗服务知晓率低、社区卫生机构的上门医疗服务能力有限,影响了上门医疗服务的有效利用。量性研究结果显示:370例失能老年人平均年龄(80.9±8.4)岁,202例(54.6%)中度、重度失能,256例(69.2%)患有3种及以上慢性病,168例(45.4%)需要聘请保姆照顾;314例(84.9%)愿意接受上门医疗服务,但仅76例(20.5%)实际利用过社区上门医疗服务,利用程度较高的前5项服务项目依次是测量血压血糖心电图〔49(13.2%)〕、康复型家庭病床〔26(7.0%)〕、治疗型家庭病床〔22(5.9%)〕、化验标本采集〔22(5.9%)〕、定期性家访〔21(5.7%)〕;56例(15.1%)不愿意接受上门医疗服务,不愿意接受上门服务的前5位原因依次是担心收费较高〔39(69.6%)〕、担心费用无法报销〔23(41.1%)〕、不了解服务项目内容〔21(37.5%)〕、认为服务内容少或能力有限〔14(25.0%)〕、担心泄漏个人隐私〔14(25.0%)〕。结论北京市失能老年人家庭照顾负担沉重,对上门医疗服务需求迫切,社区上门医疗服务呈现“高意愿,低利用”的现状,建议推动医保支付和社会保险改革,提升社区卫生机构的上门医疗服务能力和服务水平,加强宣传和引导,促进上门医疗服务的有效利用。

Background The number of disabled and semi-disabled elderly people is increasing rapidly along with global aging.To satisfy their healthcare needs,the delivery of home-based medical services provided by general practitioner teams has been a new global medical service trend.However,there is a lack of standardized management system and systematic operational mechanism for such services in China.Objective To investigate the utilization of home-based medical services in the disabled elderly in Beijing,to identify the existing problems in the delivery of such services,and to provide suggestions for building a reasonable home-based medical service system.Methods An approach of mixed methods of qualitative and quantitative was adopted.During May to June,2018,personal in-depth interviews were carried out in a purposive sample of the major caregivers(n=8)of 8 disabled elderly people for collecting their evaluation of disabled elderly people's needs and utilization of home-based medical services,their understanding of,satisfaction with and suggestions on the services.During July to September,2018,a questionnaire survey was conducted in a multi-stage sample of caregivers(n=370)of 370 disabled elderly people receiving management services from 6 community health centers of Beijing to collect their evaluation of disabled elderly people's health status,accessible care resources,and utilization of home-based medical services,and their satisfaction with such services.Results Interviews results revealed that home-based medical services could partly meet the healthcare needs of disabled elderly people.The effective utilization of home-based medical service was affected deeply by worrying about the cost of home-based medical services being high priced and unreimbursed,low awareness of home-based medical services and limited service capability of community hospitals to provide.It was indicated by the questionnaire survey that:The 370 disabled people had an average age of(80.9±8.4)years,202(54.6%)of them suffered from severe or moderate disability,256(69.2%)suffered from 3 or more chronic diseases,and 168(45.4%)needed to employ caregivers.Among the 370 respondents,314(84.9%)were willing to use home-based medical services,but only 76(20.5%)reported that their carereceivers had used home-based medical services delivered by the community health centers.The top 5 utilized services were measurement of blood pressure,blood glucose,and electrocardiogram〔49(13.2%)〕,convalescent family bed〔26(7.0%)〕,therapeutic family bed〔22(5.9%)〕,specimen collection〔22(5.9%)〕,and regular home visits〔21(5.7%)〕.Other 56 respondents(15.1%)would not accept home-based medical services.The top 5 reasons were worrying about higher service charge〔39(69.6%)〕,worrying about the service charge being unreimbursed〔23(41.1%)〕,littlie understanding of the services〔21(37.5%)〕,holding the view that community health centers could provide few home-based medical services or had limited capabilities to provide such services〔14(25.0%)〕,and worrying about the leakage of their privacies〔14(25.0%)〕.Conclusion It was found that in Beijing,the care burden of the disabled elderly family is very heavy.Home-based medical services provided by the community hospital are needed rather urgently but used very infrequently by disabled elderly,presenting a status of“much-needed but underutilized”.To promote effective utilization of home-based medical services,it is suggested to promote the reform of medical and social insurance systems to reimburse for such services,to improve the capacity and service level of community health centers,and to strengthen the publicity of such services and guide on how to use them.