“精准帮扶”背景下新疆农村地区基层医疗机构卫生服务利用变化的定性调查

A qualitative investigation on change of health service utilization in primary medical institutions in rural areas of Xinjiang under the background of Precision Help

目的以"精准帮扶"政策为背景,了解"精准帮扶"政策对新疆农村地区基层医疗机构的卫生服务利用情况带来的变化,探讨影响的主次因素,并为提高机构卫生服务能力,促进农村居民健康提供政策性建议。方法自2019年2—10月,以目的抽样的方法,抽取南、北、东疆共106个农村基层医疗机构的396位医务人员进行半结构式访谈,根据扎根理论的研究方法,通过NVivo11.0质性分析软件按照三级编码原则进行编码、归纳、提炼,最后形成理论范畴,并运用帕累托图筛选关键因素、重要因素和一般因素。结果定性研究:"精准帮扶"政策对新疆农村地区基层医疗机构的卫生服务利用带来的变化归类为服务量、服务质量和服务效率等3个维度共8项,其中筛选出总诊疗人次、住院人次及签约率为影响基层医疗机构卫生服务利用的关键因素(<80%),转诊率、抢救人次、治愈率、抢救成功率及出院人数为一般因素(>90%)。文献研究:2015—2018年新疆农村地区基层医疗机构的总诊疗人次和门急诊人次呈正向增长,年均增长率分别为1.36%和0.44%,但低于同期全国水平(1.90%、1.44%),而住院人数和出院人数呈负向增长,年均增长率为-5.30%和-5.31%;平均住院日平均为6.1日低于同期全国水平(6.4日),病床使用率平均为71.30%,高于同期全国平均水平(60.35%);急诊病死率平均为0.01%低于全国平均水平(0.02%),入院患者病死率与全国平均水平一致为0。结论"精准帮扶"政策的推进下新疆地区基层医疗机构的门诊服务量有所上升,而住院服务呈现下降趋势,服务效率和服务质量的变化处于理想状态。建议利用现有"医共体"的资源优势继续完善全民体检项目,提高签约率和就诊率;以持续培养"全科医疗人才"为铺垫,引进高学历医疗人才来缓解高级住院医师等紧缺资源,以此提高服务质量和效率,同时还应注重协调3个疆域间资源分配的公平性。

Objective With the policy of"Precision Help"as the background,to understand the changes of health service utilization in primary medical institutions by"Precision Help",explore the primary and secondary factors of the impact,provide policy suggestions for improving health service capacity of institutions and promoting the health of rural residents.Methods From February to October 2019,396 medical workers were collected from 106 rural primary medical institutions in southern,northern and eastern Xinjiang by the objective sampling,to perform the semi-structured interviews.On the basis of the research method of root theory,NVivo11.0 qualitative analysis software was used to carry out the coding,induction,extraction according to the threelevel coding principles,and finally form a theoretical category.Pareto chart was used to screen key factors,important factors and general factors.Results Qualitative research:the changes brought by the work of"Precision Help"to the utilization of health services in primary medical institutions in rural areas of Xinjiang were classified as 8 items of three dimensions of service quantity,service quality and service efficiency.Among them,the key factors affecting the utilization of health services in primary medical institutions were the total number of diagnosis and treatment,number of inpatients and signing rate(<80%),while the general factors were referral rate,rescue person-time,cure rate,rescue success rate,and discharge number(>90%).Literature research:the total number of diagnosis and treatment and number of outpatient and emergency treatment in primary medical institutions in rural areas of Xinjiang showed an increasing trend from 2015-2018,with the average annual growth rate of 1.36%and 0.44%respectively,but was lower than the national level in the same period(1.90%,1.44%).However,The number of inpatients and the number of discharged patients showed a negative growth with the average annual growth rate of-5.30%and-5.31%respectively.The average length of stay was 6.1 days,which was lower than the national level in the same period(6.4 days).The rate of utilization of hospital beds was 71.30%,which was higher than the national level in the same period(60.35%).The average mortality rate in emergency department was 0.01%,which was lower than the national average(0.02%).The mortality of hospitalized patients was consistent with the national average(0).Conclusion The outpatient service volume of primary medical institutions in Xinjiang has increased under the policy of"Precision Help",while the inpatient services show a downward trend,and the change of service efficiency and service quality is in an ideal state.It is suggested that the national physical examination project should be improved by using the resource advantages of the existing"medical community",highly educated medical talents should introduced to alleviate the shortage of resources on the basis of continuous training of"general medical personnel",so as to improve service efficiency and quality.Meanwhile,it is necessary to pay attention to the fairness of resource allocation among the three regions.