上海市社区慢性病患者家庭医生签约服务偏好研究

Preferred Family Doctor Services in Contracted Chronic Disease Patients in Shanghai

背景上海市慢性病患者家庭医生签约率较高,然而“签而不约”现象普遍存在。目的量化分析上海市慢性病患者对于家庭医生签约服务的偏好,为优化慢性病签约服务内涵、提升签约服务效率及调整签约服务包提供证据支持。方法采用方便抽样法,于2019年4—7月在上海市松江区对慢性病患者开展问卷调查。运用离散选择试验(DCE)的方法编制问卷,内容包括调查对象基本信息、DCE问题(共包括定期随访频率、药品供应可及性、家庭医生诊疗水平、健康管理活动、转诊服务便捷性、预约就诊时间弹性、医患共同决策氛围7个属性,每个属性有3个水平)。开展问卷调研的同时,对慢性病患者进行定性访谈,以了解其对于签约服务的其他需求。采用混合Logit回归模型分析慢性病患者对不同签约服务的偏好情况。结果共发放问卷300份,回收有效问卷248份,有效回收率为82.7%。混合Logit回归模型分析结果显示,慢性病患者对不同签约服务的偏好依次为:在社区完全能配到二、三级医院药品(β=0.57,P<0.05),高水平的家庭医生诊疗(β=0.43,P<0.05),经常性的健康管理活动(β=0.36,P<0.05),高频次的定期随访(β=0.31,P<0.05),良好的医患共同决策氛围(β=0.12,P<0.05),高通畅的转诊服务便捷性(β=0.06,P<0.05),高弹性的预约就诊时间(β=0.04,P<0.05)。慢性病患者对签约服务的其他需求包括:实时健康咨询、专科医疗服务、医保报销、健康体检、康复指导、个性化健康评估等。结论上海市慢性病患者偏好较高的家庭医生签约服务是药品供应可及性(在社区完全能配到二、三级医院药品)、家庭医生诊疗水平(高水平)、健康管理活动(经常,6次/月)。应加强患者偏好评估,把握偏好变化,不断优化慢性病签约服务内涵,从而满足患者的就医需求,促进卫生资源的高效供给。

Background The rate of contracting family doctor services in chronic disease patients in Shanghai is high,however,the visiting rate is relatively low.Objective This study aimed to quantify the preferences of chronic disease patients for contracted family doctor services in Shanghai,with a view to providing evidence for optimizing the contracted services and adjusting service packages specially designed for this group as well as improving the service efficiency.Methods A questionnaire survey was carried out in a convenience sample of adult chronic disease patients in Songjiang District,Shanghai from April to July 2019.The questionnaire used was developed by our research group based on the discrete choice experiment(DCE),which includes the demographic information,DCE problems(including seven three-level attributes:frequency of regular follow-up,drug accessibility,management level of family doctors,health management activities,convenience of referral service,flexibility of appointment times,shared decision-making atmosphere).Meanwhile,qualitative interviews were performed with patients to acquire their other needs for contracted services.A mixed Logit regression model was used to analyze the patients'preferences for contracted services.Results Altogether,248 of the 300 cases who participated in the survey handed in responsive questionnaires,obtaining a response rate of 82.7%.The mixed Logit analysis showed that the most preferred contracted services are as follows:community-based access to drugs distributed to secondary and tertiary hospitals(β=0.57,P<0.05),high-quality medical services provided by family doctors(β=0.43,P<0.05),regular health management activities(β=0.36,P<0.05),high-frequency regular follow-ups(β=0.31,P<0.05),good shared decision-making atmosphere(β=0.12,P<0.05),highly convenient referral service(β=0.06,P<0.05),and very flexible appointment time(β=0.04,P<0.05).Other needs of the respondents for contracted services include:real-time health consultation,specialty medical services,medical insurance reimbursement,physical examination,rehabilitation guidance,personalized health assessment,etc.Conclusion In Shanghai,the highly preferred contracted family doctor services in chronic disease patients include communitybased accessibility of drugs(generally distributed to second and tertiary hospitals),(high-quality)diagnosis and treatment level of family doctors,and〔regular(for example,six times a month)〕health management activities(often,six times a month).It is necessary to strengthen the evaluation of preferred services of these patients,by which the contracted services specifically for them can be constantly optimized to better meet their healthcare needs and promote highly efficient utilization of health resources.