推行家庭医生签约对社区卫生服务利用的影响

Influence of family physician contract services on utilization of community health services

目的：了解上海市长宁区家庭医生制的实施效果，为完善家庭医生服务内容提供依据和支撑。方法：使用自行设计的“家庭医生服务利用及效果评价”调查表，采用入户调查的方式收集资料，所有的调查员均由复旦大学统一培训。结果：共调查社区常住居民736人，其中签约居民412人（56.0%），60岁以上居民占60.1%，38.9%的调查对象有明确诊断的慢性病。既往半年有就诊记录的调查对象中，签约居民对社区卫生服务中心的利用率（77.9%）是非签约居民（31.5%）的2.47倍（P〈0.01）。家庭居住区域、是否签约家庭医生、家庭人均年收入影响社区居民的就诊行为。签约居民、低学历居民、41～80岁社区居民生病后到社区卫生服务中心的首诊意愿高于非签约居民（OR=1.80，95%CI：1.11～2.92）、高学历居民（其中初中及以下组OR=4.45，95%CI：1.86～10.61；大专组OR=2.29，95%CI：1.06～4.97）、40岁及以下居民（其中41～60岁组OR=2.78，95%CI：1.10～7.00；61～80岁组OR=3.46，95%CI：1.00～11.90；80岁以上组OR=4.55，95%CI：0.97～21.43）。签约居民对家庭医生满意度非常高，总体评分为93.44。结论：上海市长宁区试行的家庭医生制成效明显，为探索“优化社区卫生资源配置、建立分级诊疗制度”提供了科学依据。

Objective：To understand the implementation effect of the family physician services in Changning District,Shanghai and to provide the basis and support for improving family physician services.Methods：Self-designed“family physician service utilization and evaluation” questionnaires were used. Household surveys were conducted. All of the investigators were trained uniformly by Fudan University.Results：A total of 736 permanent residents of the community were investigated,412 of them had signed for family physician services（56.0%）. Residents over the age of 60 accounted for 60.1%. A total of 38.9% of the respondents had a clear diagnosis of chronic diseases. Among respondents who had medical records in the past six months,the utilization rate of community health services in residents who signed contracts（77.9%）was 2.47 times of residents who did not sign（31.5%）（P〈0.01）. Family living area,whether to contract with family physicians,and family annual income per capita affected the behavior of community treatment. The willingness of choosing community health service centers as first diagnosis when ill in residents who signed contracts,lowly educated residents,residents aged 41-80 years was higher than residents who did not sign（OR=1.80,95%CI：1.11-2.92）,highly educated residents（junior high school and below groupOR=4.45, 95%CI：1.86-10.61,junior college groupOR=2.29,95%CI：1.06-4.97）,residents aged 40 and below（41-60 years old groupOR=2.78,95%CI：1.10-7.00,61-80 years old groupOR=3.46,95%CI：1.00-11.90,over 80 years old group（OR=4.55,95%CI：0.97-21.43）. The satisfaction with family physician in residents signed was very high,with 93.44 of the overall score.Conclusion：The pilot study of family physician system in Changning District of Shanghai has achieved remarkable results,which provides a scientific basis for exploring“optimizing the allocation of resources in community health and creating a grading medical service system”.