我国中老年患者分级诊疗现状及影响因素研究

Status and Influencing Factors of Hierarchical Medical System among Middle-aged and Elderly Patients in China

目的了解我国中老年患者的分级诊疗现状及影响因素,为推进分级诊疗改革提供政策性建议。方法于2016年5月,对中国健康与养老追踪调查(CHARLS)2011年基线数据和2013年追踪数据进行分析,共纳入自问卷填写时近1个月内有医疗机构就诊经历的中老年(≥45岁)患者6 981例。其中2011年3 233例(46.3%)、2013年3 748例(53.7%),居住地为农村4 294例(61.5%)、城镇2 687例(38.5%)。根据Andersen模型筛选出中老年患者选择就诊机构的影响因素,包括性别、年龄、文化水平、婚姻状况、地区、经济水平、医疗保险类型、慢性病患病情况及健康状况。采用混合Logistic回归模型,分别分析农村、城镇中老年患者选择至基层医疗卫生机构就诊的影响因素。结果 2011年与2013年农村、城镇中老年患者至基层医疗卫生机构就诊的选择率分别为70.9%(3 046/4 294)、51.3%(1 379/2 687),其中2011年分别为73.5%(1 481/2 015)、53.5%(652/1 218),2013年分别为68.7%(1 565/2 279)、49.5%(727/1 469),2013年较2011年下降的降幅分别为6.5%、7.5%。混合Logistic回归模型分析结果显示,年份、年龄、文化水平、经济水平、医疗保险类型、健康状况是农村中老年患者选择至基层医疗卫生机构的就诊率影响因素(P<0.05);文化水平、经济水平、医疗保险类型、慢性病患病情况、健康状况是城镇中老年患者选择至基层医疗卫生机构的就诊率影响因素(P<0.05)。2013年,城乡居民医疗保险参保农村中老年患者[OR(95%CI)=0.804(0.685,0.944)]、患慢性病农村中老年患者[OR(95%CI)=0.773(0.658,0.907)]、无社会医疗保险城镇中老年患者[OR(95%CI)=0.446(0.217,0.915)]选择至基层医疗卫生机构的就诊率较2011年降低。结论新医改以来中老年患者选择至基层医疗卫生机构的就诊率有所下降,这一现象在慢性病患者中尤为明显,社会医疗保险尚未起到引导患者到基层就医的作用。为实现分级诊疗,须着力解决卫生服务体系和医疗保障体系的"碎片化问题",建立不同级别医疗机构间协作与联动机制,加快医疗保障体系整合,实现患者就医合理分流。

Objective To investigate the present situation and influencing factors of the hierarchical medical system among middle-aged and elderly patients and provide policy suggestions for the reform of hierarchical medical system in China.Methods According to the baseline data of China Health and Retirement Longitudinal Study（CHARLS） in 2011 and tracking date in 2013,6 981 patients 45 years or above who sought outpatient care within nearly a month before the study in May2016 were involved in the questionnaire,including 3 233（46.3%） patients in 2011 and 3 748（53.7%） in 2013,and 4 294（61.5%） patients living in rural areas and 2 687（38.5%） in urban areas.Based on the Andersen＇s model,factors influencing the choice of health care providers among patients 45 years or above were chosen as gender,age,education,marital status,residence,economic level,health insurance,chronic diseases and self-rated health.The pooled Logistic regression model was used to analyze the influencing factors of middle and elderly patients in rural areas and villages when they choose the primary health care institutions.Results The rates of rural and urban elderly patients choosing primary health care institutions for medical help in these two years were 70.9%（3 046/4 294） and 51.3%（1 379/2 687） respectively,of which 73.5%（1 481/2 015）and 53.5%（652/1 218） were respectively in 2011,and 68.7%（1 565/2 279） and 49.5%（727/1 469） were respectively in 2013.Compared to 2011,the rates in 2013 declined 6.5% and 7.5% respectively.The results of pooled Logistic regression model analysis showed that year,age,culture level,economic level,medical insurance type and health status were the factors influencing rural middle-aged and elderly patients＇ choice of primary health care institutions（P〈0.05）,while cultural level,economic level,the types of medical insurance,the prevalence of chronic diseases and the condition of health were the influencing factors of middle-aged and elderly patients in urban areas（P〈0.05）.Compared to 2011,the rates of rural patients 45 years or above with medical insurance for urban and rural residents [OR（95% CI） = 0.804（0.685,0.944） ],chronic diseases [OR（95% CI） = 0.773（0.658,0.907） ]and urban patients aged over 45 years with no social health insurance [OR（95% CI） = 0.446（0.217,0.915） ]choosing primary health care institutions for medical help were less lower in 2013.Conclusion Since the implementation of the new medical reform,the proportion of patients above 45 years old choosing primary health care institutions for outpatient care has declined in recent years,especially for patients with chronic diseases.And social health insurance in China failed to guide patients to search medical help from primary health care institutions.In order to achieve the implement of hierarchical medical system,efforts should be made to address the double fragmentation problems both embedded in the health service system and the social insurance system.Collaboration and linkage mechanism should be established among different levels of medical institutions and the integration of the social health insurance system is expected to be implemented rapidly to achieve a reasonable diversion of patients for medical treatment.