西安市双向转诊制度的实施现状与对策分析

Analysis of present implementation situation and countermeasures of the two-way referral in Xi'an

目的通过对西安市5家社区卫生服务中心及与之建立双向转诊关系的5家综合医院进行问卷调查,了解西安市双向转诊制度的实施现状,为进一步优化该制度的设计与运行提供政策建议。方法于2015年8—11月对西安市5家社区卫生服务中心和与之建立双向转诊关系的5家综合医院的医生、患者进行现场调查(自填式问卷法)。问卷共发放1 000份,回收有效问卷951份。结果不同文化程度、职业、收入情况的患者转诊经历有差异。患者不愿上转的原因主要为:"转诊程序繁琐""认为病情不严重,不需要转诊""家庭经济困难""无医疗保险""交通不便"等;不愿下转的原因主要为:"转诊程序繁琐""不信任社区医疗水平""医疗保险报销比例差距小""家庭经济困难""自认为病情不重、不愿意再继续治疗""社区未开展家庭病床、康复医疗"等。医务工作者认为双向转诊运行不畅的原因主要有:"没有明确的转诊标准、转诊监管机构及机制""缺乏基本医疗保险支持""医疗机构间的利益冲突""双向转诊的信息平台不完善""患者不信任社区医疗水平""患者不了解双向转诊制度"等。结论西安市目前双向转诊开展较少,且主要为社区医院向综合医院转诊。应从建立并完善双向转诊系统、增加医疗保险的经济杠杆作用等方面改进。

Objective In order to put forward some suggestion to solve the existing problems, five community health service centers and five general corresponding hospitals were selected to understand the status of two-way referral by ques- tionnaire survey, thus to optimize the design and implementation of the system. Methods A randomized cluster sam- pling was taken in each institution in Xi＇an during August, 2015 to November, 2015. We collected 951 valid ones from 1 000 questionnaires for doctors, patients and administrators in each community hospital and the general hospital. Results Different educational backgrounds, professions and income levels had significant differences. The main reasons why patients didn＇ t want to transfer to the general hospitals WERE cumbersome referral procedures, lack of recognition of the seriousness about their diseases, economic difficulties, no medical insurance, traffic inconvenience, etc ; on the other hand, the main reasons why patients didn＇ t want to go to the communities were cumbersome referral procedures, distrust in the doctors and medicine in communities, the small gap between Medicare reimbursement proportion, economic diffi- culties, lack of recognition of the necessity of continuing treatment, the lack of family beds and rehabilitation, etc. Medi- cal workers believed that the main reasons why the two-way referral operation impeded were as follows, unclear referral criteria, unclear referral regulatory, institutions and mechanisms, lack of basic medical insurance support, interest con- flicts between medical institutions, incomplete information platform of two-way referral, and lack of recognition of two-way referral etc. Conclusion The present situation of the two-way referral is not ideal in Xi＇ an, and most of the referrals are from communities to the general hospitals. We should establish and improve two-way referral system, strengthen the lever- age of medical insurance on two-way referral, and then we will have a better situation.