山东省试点城市城乡居民分级诊疗制度认知、态度及行为研究

Cognition,Attitude and Behavior of Urban and Rural Residents to the Hierarchical Medical System in Pilot Cities of Shandong Province

目的了解山东省分级诊疗试点城市城乡居民对分级诊疗制度的认知、态度及就医行为。方法采用多阶段分层随机抽样方法,在潍坊、东营、威海市按经济发展水平各抽取3个区(县),每个区(县)随机抽取2个城市社区和2个行政村,每个城市社区随机抽取45户,每个行政村随机抽取30户,共抽取1 350户。于2016年1—8月采用自行设计的调查问卷进行调查。问卷的主要内容包括:居民基本情况;对分级诊疗制度相关知识的认知情况;对实施分级诊疗制度的态度;基于分级诊疗制度的就医行为。共发放问卷1 350份,回收有效问卷1 306份,问卷的有效回收率为96.74%。结果 3 096例居民中,有1 215例(39.24%)知晓分级诊疗制度,不同居民类型、性别、年龄、文化程度、去年家庭收入、去年家庭医疗费用的居民对分级诊疗制度的知晓率比较,差异有统计学意义(P<0.05)。在简要了解分级诊疗制度的内涵与作用后,有1 877例(60.63%)认为分级诊疗制度能降低医疗费用,1 392例(44.96%)认为分级诊疗制度不影响诊疗疗效,2 140例(69.12%)认同实施分级诊疗制度。针对实施分级诊疗制度能否降低医疗费用、是否影响诊疗疗效、是否认同实施分级诊疗制度,不同居民类型、性别、年龄、去年家庭收入、去年家庭医疗费用的居民的态度比较,差异有统计学意义(P<0.05)。在认同实施分级诊疗制度的2 140例居民中,对于常见病、多发病、慢性病是否会选择到基层医疗卫生机构首诊这一问题,有714例(33.36%)选择不会,其中城镇居民693例(97.06%),原因为对基层医护人员的医疗水平不信任472例(68.11%);农村居民21例(2.94%),原因为基层医疗卫生机构没有所需药品16例(76.19%)。在上级医院疾病得到控制或者康复阶段是否会选择基层医疗卫生机构来继续治疗这一问题,有685例(32.01%)选择不会,其中城镇居民574例(83.80%),原因为对基层医护人员的医疗水平不信任342例(59.58%);农村居民111例(16.20%),原因为基层医疗卫生机构没有所需药品72例(64.86%)。结论山东省分级诊疗试点城市城乡居民对分级诊疗制度的知晓率不高,城乡居民对分级诊疗制度的态度不一,基层医疗水平和没有所需药品分别是影响城市、农村居民基层就医的关键因素。建议精准分级诊疗宣传途径和接触点,差异化分级诊疗相关领域配套制度,通过医疗联合体运作方式差异化以改变居民就医习惯。

Objective To observe the cognition,attitude and behavior of urban and rural residents to the hierarchical medical system in three pilot cities of Shandong Province. Methods Using multistage stratified random sampling method,three districts（ counties） were selected from each of three cities（ Weifang City,Dongying City and Weihai City）,and two urban communities and two administrative villages were selected randomly from each district（ county） according to the level of economic development. 45 households were selected randomly from each urban community and 30 households were selected randomly from each administrative village. A total of 1 350 households were selected. A self-designed questionnaire was used in the survey from January to August in 2016. The questionnaire mainly included the baseline information of residents,the cognition of the relevant knowledge about hierarchical medical system,the attitudes towards the implementation of hierarchical medical system,and the medical behavior based on hierarchical medical system. A total of 1 350 questionnaires were distributed and 1 306 valid questionnaires were collected. The effective recovery rate was 96. 74%. Results Among 3 096 residents,1 215（ 39. 24%）residents knew the hierarchical medical system. There were statistically significant differences in the awareness rate of the hierarchical medical system among different residents types,sex,age,educational level,family income last year and family medical expenses last year（ P 0. 05）. After a brief understanding of the connotation and function of the hierarchical medical system,1 877（ 60. 63%） residents thought that hierarchical medical system could reduce the medical expenses. 1 392（ 44. 96%） residents thought that the hierarchical medical system did not affect the curative effect,and 2 140（ 69. 12%）residents agreed the implementation of the hierarchical medical system. Whether the hierarchical medical system could reduce medical expenses and influence the curative effect and whether the residents agreed the implementation of the hierarchical medical system,there were statistically significant differences in the attitudes of residents among different residents types, sex, age,family income last year and family medical expenses last year（ P 0. 05）. Among 2 140 residents who agreed the implementation of hierarchical medical system,714（ 33. 36%） residents did not choose the primary medical institutions as their first visits to the doctor for the common diseases,frequently-occurring diseases and chronic diseases. Among these residents,693（ 97. 06%） residents were urban residents and the reason why they did not choose the primary medical institutions as their first visits to the doctor was that 472（ 68. 11%） residents had no confidence in the medical level of the medical staff in primary medical institutions. 21（ 2. 94%） residents were rural residents and 16（ 76. 19%） residents considered that the primary medical institutions did not have the medicines they need. Whether to choose the primary medical institutions to continue the treatment of the diseases that were controlled in the higher-level hospital or at the rehabilitation stage,685（ 32. 01%） residents gave negative answers. Among these residents, 574（ 83. 80%） residents were urban residents and the reason was that 342（ 59. 58%） residents had no confidence in the medical level of the medical staff in the primary medical institutions. 111（ 16. 20%） residents were rural residents and 72（ 64. 86%） residents considered that the primary medical institutions did not have the medicines they need. Conclusion The awareness rate of the hierarchical medical system of urban and rural residents is not high in pilot cities of Shandong province while urban and rural residents have different attitudes towards the hierarchical medical system. The primary medical level and whether there are drugs or not in the primary medical institutions are key factors that affect the choice of healthcare services among urban and rural residents. It is recommended to accurately grasp publicity channels and contact points of the hierarchical medical system and differentiate the supporting systems of the hierarchical medical system in related fields in order to change the medical habits of urban and rural residents through the different operation modes of medical consortium.