县域居民医疗服务利用的村落效应分析

Analysis of the Village Effect on the Utilization of Medical Services by County-level Residents

目的:提出并探讨居民医疗服务利用在村级层面上的群体效应,测量不同村落群体效应差异的特征与关联因素。方法:基于2015年当阳市医保报销数据,以村为单位清理标化,基于村民服务利用的水平和分布分为4类,运用聚类分析与箱线图描述村落效应的个体差异,通过线性回归分析村落效应的关联因素。结果:当阳市175个村落医疗服务利用群体差异明显,利用较高的村落人均服务当量(37.47)是利用较少村落(0.40)的90多倍,人均费用分别是1323.82和260.68元。聚类分析将175个村落依次分为高费用高利用(8.00%)、高费用低利用(43.29%)、低费用低利用(36.71%)、低费用高利用(12.00%)4类;乡镇卫生院服务能力(β=0.22)和至县医院距离(β=-0.39)是人均医疗费用的重要影响因素,至县医院距离(β=-0.50)和村医数(β=0.16)对居民医疗服务利用数量有明显影响。结论:同一县域居民在医疗服务利用上存在村落效应。低利用村落表现为所在乡镇卫生院发展能力弱、地形崎岖,导致就诊不便。高费用村落表现为村医少,离县医院近,居民趋高就诊并产生高费用。建议进一步加强偏远村落服务能力建设,同时尝试"互联网+医疗"新模式的运用。

Objective:To understand the group effects of residents’health service utilization status at the village level and to identify the characteristics and causes of service utilization differences in villages.Methods:Based on the 2015 Danyang city health insurance reimbursement database,the data were first cleaned and standardized by village,then cluster analysis of indicators was conducted to determine the classification framework,and finally one-way analysis of factors with box-line plots was applied to analyze the characteristics and causes of these four categories.Results:The 175 villages in Danyang City had significant differences in health service utilization groups,with the per capita service equivalent in the high utilization villages(37.47)being almost more than 90 times that of the lesser utilization villages(0.40),at a per capita cost of 1323.82 yuan and 260.68 yuan,respectively.The study used cluster analysis to classify different villages into four categories:high cost high utilization(8.00%),high cost low utilization(43.29%),low cost low utilization(36.71%)and low cost high utilization(12.00%).The service capacity of village health center(/3=0.22)and distance to county hospital(β=-0.39)were significant influencing factors of per capita medical cost.Conclusion:Village effects exist in the utilization of medical services by residents of different villages under the same county.Low-use villages are characterized by weak development capacity of the township health center in which they are located and inconvenient access to medical care in rugged terrain.High-cost villages are characterized by few village doctors,close to the county hospital,and residents tend to visit high-cost clinics.It is recommended to further focus on strengthening the service capacity of remote villages,while strengthening the collaboration of"internet+healthcare".