基于政策计量与图谱分析的上海市分级诊疗政策研究

Effectiveness Evaluation of Policies Related to the Implementation of Hierarchical Medical System in Shanghai Using Econometric and Knowledge Mapping Techniques

背景我国新医改已经第十年,分级诊疗政策作为改善人民医疗问题、提升人民医疗体验感的重要举措之一,亟须对其发布规律及关注重点进行系统的、科学的整理与分析。上海市是我国省级综合医改试点城市,且分级诊疗政策提出较早,对其进行分析具有较高的价值。目的通过上海市政府发布在其官网的分级诊疗政策,了解上海市分级诊疗政策现状,并通过对政策关键词的深入分析,探索分级诊疗政策的关键节点,为政策制定提供参考。方法在"中国上海"网站(http://www.shanghai.gov.cn/)中,以"分级诊疗"为关键词在"政府信息公开"栏目内进行检索与整理,最终得到2010年10月—2018年8月的政策文件77条。查阅《中国卫生健康统计年鉴》2018卷、《中国卫生和计划生育统计年鉴》2013—2017卷,以及《中国卫生统计年鉴》2009—2012卷,从中获得历年上海市分级诊疗相关卫生统计数据。在中国知网、万方数据知识服务平台,通过关键词"上海""分级诊疗""效果评价",检索2014年8月—2019年8月与上海市分级诊疗实施效果相关的文献。利用Microsoft Excel 2016软件和Microsoft Access2016软件建立数据库并录入数据进行政策计量与分析,图谱分析则是基于Python 3.6.6的jieba 0.39中文分词程序及Ucinet软件实现,同时采用文献法对已有研究进行整理总结。结果2010—2013年分级诊疗政策文件发布数量较少,2014—2017年分级诊疗政策文件发布的数量迅速增长,年均增速达到164.58%。共得到186个关键词,经政策关键词中心性分析得到"医疗""管理""卫生""服务"等是分级诊疗政策的关键节点。进一步分析关键词词频可得2016年对医疗保险关注度、2017年对中医药的关注度较高。截至2018年8月,家庭医生"1+1+1"医疗机构组合签约人数已超480万,社区卫生服务中心诊疗人次年均增速为6.29%,2017年达到8690.63万人次,同时2017年市级医院收治高难度病例数增长了70%,占比提高了1.39%;高难度手术例数增长了64%,占比提高了4.71%。结论上海市分级诊疗政策数量不断增加,市级医院与基层医疗卫生机构职能区分更清晰,平稳发展,分级诊疗效果显现。上海市应以继续医疗卫生管理与服务为关键点,不断完善与贯彻配套政策规范,充分结合医保政策、中医药发展等方面,快速推动构建满足社会需求的分级诊疗体系。

Background China's new medical reform has been in its tenth year.Policies related to the implementation of hierarchical medical system are one of the important measures to resolve people's medical problems and improve their sense of healthcare-seeking experience.It is urgently need to organize and analyze the regular release patterns and foci of the policies in a systematical and scientific way.As Shanghai is a provincial city for the implementation of comprehensive medical reform in pilot with early formulation and adoption of the related policies,it is of great value to evaluate the effectiveness of such policies in this city.Objective To investigate the status of the policies related to the implementation of hierarchical medical system in Shanghai by reviewing these polices published by the Shanghai Municipal Government on its official website,and to explore the key points of the polices through in-depth analysis of the keywords,so as to provide references for policy formulation.Methods 77 policy documents were obtained after organizing the information published from October 2010 to August 2018 in the column of"Government Information Disclosure"of the official website(http://www.shanghai.gov.cn/)of Shanghai Municipal Government searched using"分级诊疗"(hierarchical medical system)as the key word.The health statistics related to the implementation of hierarchical medical system in Shanghai were collected via checking the China's Hygiene and Health Statistical Yearbook 2018,5 volumes of China Health and Family Planning Statistical Yearbook(2013—2017),and 4 volumes of China Health Statistics Yearbook(2009—2012).By searching the databases of CNKI,WANFANG and so on using"上海"(Shanghai),"分级诊疗"(hierarchical medical system)and"效果评价"(effectiveness evaluation)as the keywords,literature related to the implementation effect of hierarchical medical system in Shanghai from August 2014 to August 2019 was retrieved.Econometric analysis was performed to analyze the data inputted in a database created using Microsoft Excel 2016 and Microsoft Access 2016.Knowledge mapping was carried out with jieba 0.39 module of Python 3.6.6 as well as Ucinet.Literature review was conducted to organize and summarize the available related studies.Results The number of policy documents related to the implementation of hierarchical medical system issued from 2010 to 2013 was relatively small,but increased rapidly from 2014 to 2017,with an average annual growth rate of 164.58%.A total of 186 keywords were obtained,among which"医疗"(medical),"管理"(management),"卫生"(health),"服务"(service)were identified to be the key nodes of the policies by centrality analysis.Further analysis of the keyword frequency showed that attentions paid to medical insurance in 2016 and to Chinese medicine in 2017 were significantly higher.As of August 2018,the number of people with contracted'1+1+1'type family doctor services had exceeded 4.8 million;the number of diagnostic and therapeutic services delivered by community health centers had an average annual growth rate of 6.29%,reaching 86.9063 million in 2017.Also,in 2017,the number and proportion of significantly difficult cases admitted to municipal hospitals increased by 70%,and 1.39%,respectively.The number and proportion of significantly difficult surgeries increased by 64%,and 4.71%,respectively.Conclusion The number of policies related to the implementation of hierarchical medical system in Shanghai has been increasing,and the functional distinction between municipal-level hospitals and primary medical and health institutions has become clearer.With steady development,the results of hierarchical diagnosis and treatment have appeared.To quickly promote the establishment of a local hierarchical medical system meeting social needs,Shanghai should continuously improve and implement supporting policies and norms,and fully integrate medical insurance policies and the development of Chinese medicine with medical and health management and services as key points.