医院社区分级诊疗的医患认知研究:基于上海市家庭医生制度

Research of cognitive level of doctors and patients on grading health care in hospital and community health service center: on the basis of family doctor system in Shanghai

目的通过研究上海家庭医生制度背景下的医院与社区卫生服务中心的医生和患者双方对于分级诊疗相关问题的认知情况,从而为上海分级诊疗体系和家庭医生制服务的可持续发展提供政策建议。方法选取上海市的1家综合性医院和2家社区卫生服务中心作为调研现场,采用自行设计的调查问卷,分别调研综合性医院和社区卫生服务中心的医生和患者,研究其对于分级诊疗相关问题的认知现状,差异及影响因素。发放医生和患者问卷共467份,其中有效问卷453份,有效率97%。运用SPSS 20.0软件对定量资料进行描述性分析、χ2检验、秩和检验及Logistic回归分析。另外,还对综合性医院和社区卫生服务中心的关键知情人进行了访谈研究,作为对定量资料的补充。结果医院医生和社区医生之间的认知差异明显,风险共担、利益分配机制尚待建立;患者的自主择医意识很强;现行医保支付体系对于分级诊疗的经济杠杆引导力度不够;分级诊疗的相关配套措施不齐,医院与社区医疗机构的优势互补在短期内难以形成。结论建议创新机制破解转诊运行中的内忧;建议改革医保支付破解转诊运行中的外困;建议引导三级医院实现"顶天立地"的战略转型;建议发展医养一体化服务以延伸分级诊疗服务体系。

Objective To investigate the cognition status of doctors and patients on grading health care in hospital and community health service center under the background of family doctor system in Shanghai,so as to provide suggestions for sustainable development of grading health care and family doctor service in Shanghai. Methods One general hospital and two community health service centers in Shanghai were selected,in which 467 doctors and patients were investigated with self-designed questionnaire to acquire the cognitive status,differences and influences on their cognition of the present grading health care system,and 453 valid questionnaires had been collected,the effective rate was 97%. Then we performed statistical analysis on the quantitative data by using SPSS 20. 0 software,statistical methods like chi-square test,rank sum test and logistic regression analysis were used in this article. In addition,key informants of general hospital and community health service centers were interviewed as the complement to quantitative data. Results There were significant differences of cognition status between doctors,risk-sharing and interests distribution mechanism had not yet be established; The independent choice of patients＇ conscious was very strong; the economic leverage of current medical insurance payment system to guide grading care was not powerful; Relevant supplementary measures were insufficient,and complementary advantages in hospital and community health service center were difficult to achieve in a short term. Conclusion Some helpful recommendations are put forward,such as establishing innovative mechanism to solve the internal problems of referral system,reforming medical insurance payment to solve the external problems of referral system,implementing a strategic transition of tertiary level hospital to be top hospital and connect primary health care institutions,and developing medical-nursing integration to extend grading health care service system.