中文版全科医疗核心特征功能患者体验量表的开发与验证

Development and Validation of the Chinese Version of Assessment Survey of Primary Care

背景全科医疗核心特征功能包括首诊/第一线照护、可及性、连续性、综合性、协调性、以患者为中心,是全科医学学科的基本原则/属性,构成全科医疗实践的核心价值。从患者视角测量全科医疗核心特征功能,是评价基础医疗质量的重要维度和组成部分。我国目前尚缺乏本土化的全科医疗核心特征功能患者体验(ASPC)工具。目的开发具有国际性和本土性双重特征的中文版ASPC量表。方法通过4个阶段开发和验证量表。第一阶段采取理论研究、文献研究和专家咨询法,构建量表概念框架和内涵要素。第二阶段运用文献综述和知情人深度访谈法获得原始条目池,经过373例患者预试验,完善条目,形成测试版量表。第三阶段采用多阶段抽样策略,在多元化基层医疗卫生机构中的1185例患者中对测试版量表施测。第四阶段按照健康测量工具遴选指南(COSMIN)检验量表的信度和效度,最终获得正式版量表。结果经探索性因子分析,中文版ASPC量表形成了6个维度9个亚维度因子结构,分别是首诊/第一线照护、服务可及性、医患关系的连续性(包括医患关系长久稳定性、医患双方的信赖感与责任感两个亚维度)、综合性服务(包括健康生活方式与心理咨询指导、健康检查与疾病筛查干预建议两个亚维度)、协调性服务(包括协调性服务条件、协调性服务两个亚维度)和以患者为中心的照护。量表总体Cronbach'sα系数为0.915,9个亚维度的Cronbach'sα系数分别为0.659~0.863,均>0.65。验证性因子分析中,χ2/df值为2.828、拟合指数(CFI)为0.875,所有亚维度组合信度(CR)均>0.7,平均方差提取值(AVE)均>0.5或接近0.5。量表及各维度得分与患者满意度呈正相关,家庭医生签约与非签约患者的量表得分存在差异。结论中文版ASPC量表信效度符合心理计量学标准,量表整体和各维度具备良好的内部一致性、可靠的内容效度、与理论构想一致的结构效度和建构效度。中文版ASPC量表所依循的理论框架与国际上公认的基础医疗六大基本原则保持一致,保证了量表的实证研究结果与国外同类研究结果具有可比性;量表亚维度符合我国本土医疗卫生服务体系情境,能更全面精确地刻画我国全科医疗绩效的图像。

Background First-contact care,accessibility,continuity of care,comprehensiveness of care,coordination,and patient-centered care are core domains and key features of primary care.Measuring these core domains from patients'perspectives is is an important domain and component of primary care quality evaluation.However,domestically developed instruments for assessing core domains of primary care have not yet existed in China.Objective This study aimed to develop a Chinese version of Assessment Survey of Primary Care(ASPC)with domestic and international characteristics.Methods We developed a Chinese version of ASPC and tested its validity based on a four-stage approach.In the first stage,research on related theoris and studies,and expert consultation were conducted to construct the conceptual framework and connotative elements of the scale.In the second stage,the original item pool was formed through literature review and in-depth interviews with stakeholders.A pilot study was conducted with 373 patients to refine items and develop the test version of the scale.In the third stage,a multi-level sampling strategy was used to select 1185 patients from diversified primary care institutions to pre-test the test version of the scale.In the fourth stage,the reliability and validity of the instrument were tested according to the consensus-based standards for the selection of health status measurement instruments(COSMIN)checklist,and then the final version of the scale was developed.Results Results of the exploratory factor analysis showed that the Chinese version of ASPC consisted of nine subdimensions of six dimensions,including first-contact care,accessibility,continuity of the physicianpatient relationship(covering subdimensions of longitudinal and stable relationships between physicians and patients,mutual trust between physicians and patients,and physicians'responsibility),comprehensiveness(covering subdimensions of health,lifestyle and psychological counseling and guidance,health examination,disease screening,interventions and suggestions),coordination(covering subdimensions of coordination conditions and services),and patient-centered care.The Cronbach'sαcoefficient of the scale was 0.915,while the coefficients of the nine subdimensions were all greater than 0.65(ranged from 0.659 to 0.863),indicating high reliability.In the confirmatory factor analysis,the chi-square/df value and the comparative fit index value of the scale were 2.828 and 0.875,respectively.For all subdimensions,all the composite reliability values were larger than 0.7,and the average variance extracted values were larger than 0.5 or close to 0.5,responding that the convergent validity was appropriate for all sub-dimensions.The scale score or the score in each dimension was positively associated with patients'satisfaction.Moreover,there were significant differences in the scale score between two groups of patients with or without a contracted family doctor.Conclusion The Chinese version of ASPC has good psychometric properties with good scale and subscale internal consistency reliability and content validity,as well as structural and construct validity consistent with the theoretical conception.The theoretical framework of the scale is consistent with the six internationally recognized core domains of primary care,ensuring that the empirical research results of this instrument are comparable to similar foreign research results.The subdimensions of the instrument conform to the conditions of the Chinese healthcare system and can describe the performance of Chinese primary care comprehensively and accurately.