社区慢性病患者医养护一体化服务体验的影响因素研究

Factors Associated with Community-dwelling Chronic Disease Patients'Experience of Integrated Medical-elderly-nursing Services

背景医养护一体化服务有望成为解决老龄化社会中众多慢性病患者健康养老问题的有效途径,但服务质量有待关注。目的分析社区慢性病患者医养护一体化服务体验的影响因素,为改善服务质量、提升服务体验提供借鉴和参考。方法2020年6—9月,便利抽取浙江省杭州市接受医养护一体化服务的社区慢性病患者525例,对其进行问卷调查,问卷内容包括患者一般资料(个体特征)、服务相关资料(服务特征)和服务体验3部分。采用基于服务差距分析模型的服务质量评价量表,计算服务感受-期望间的差距,以测量服务体验。在结构-过程-结果质量保障模型的指导下,假设结构性因素(接受医养护一体化服务的社区慢性病患者的个体特征)影响过程性因素(医养护一体化的服务特征),两者共同影响结果(慢性病患者的服务体验),构建结构方程模型。结果杭州市社区慢性病患者医养护一体化服务的感受总均分为(5.14±0.44)分,期望总均分为(6.80±0.01)分,感受-期望间差距的总均分为(-1.65±0.44)分。多重线性回归分析结果显示,性别、月收入、医疗费用支付方式、患病数量、是否更换过服务团队、接受的服务内容项目数和服务方式种类数是慢性病患者医养护一体化服务感受-期望间差距得分的影响因素(P<0.05)。结构方程模型结果显示:慢性病患者的医养护一体化服务体验主要受到服务特征(签约时长、服务内容、服务方式、智慧医疗)的影响(路径系数=-0.51,P<0.001),服务特征直接影响服务体验(直接效应量=-0.51,P=0.002);个体特征(年龄、文化程度、自理能力、患病数量)直接影响服务体验(直接效应量=-0.14,P=0.026),并通过服务特征间接影响服务体验(间接效应量=-0.24,P=0.002)。结论医养护一体化服务得到了患者的认可,但服务体验仍有较大提升空间。未来可通过提高该服务内容的利用率、提供多样化的服务方式、充分发挥智慧医疗的作用、为患者制定更为个性化的干预方案等途径,进一步改善社区接受医养护一体化的慢性病患者的服务体验。

Background The integrated medical-elderly-nursing(IMEN)services are promising to be very effective in addressing healthcare problems in multiple chronic disease patients in an aging society,but the quality of the services has been less focused.Objective To identify the factors associated with community-dwelling chronic disease patients'experience of IMEN services,so as to provide a reference for improving the quality of IMEN services and the experience of this group.Methods From June to September 2020,a questionnaire survey was conducted with a convenience sample of 525 communitydwelling chronic disease patients with IMEN services selected from Hanghou,Zhejiang Province,to collect their individual characteristics,process of IMEN services,and experience of IMEN services.The Chinese version of SERVQUAL developed based on the GAP Model of Service Quality was used to measure the discrepancy between patients'expectations for IMEN services and their perceptions of the services.With referring to the structure-process-outcome model,a structural equation model was developed,assuming that the features of IMEN services(process factors)were influenced by patients'individual characteristics(structure factors),and both of them affected patients'experience of IMEN services(outcome factors).Results The total average score of feeling and expectation of IMEN services for community patients with chronic diseases in Hangzhou was(5.14±0.44),(6.80±0.01),and the total average score of the gap between feeling and expectation was(-1.65±0.44).Multiple linear regression analysis showed that gender,monthly income,payment method of medical expenses,number of illnesses suffered,prevalence of changing the service team,service items and number of service delivery patterns were associated with the discrepancy between patients'expectations for IMEN services and their perceptions of the services(P<0.05).The analysis based on the structural equation model revealed that patients'experience of IMEN services was mainly directly affected by the features(duration of contracting the IMEN services,service items,and delivery patterns,smart medical care)of IMEN services(path coefficient=-0.51,P<0.001;direct effect size=-0.51,P=0.002).Moreover,patients'experience of IMEN services was also directly influenced by individual characteristics(age,education level,self-care ability,number of illnesses)(direct effect size=-0.14,P=0.026),and indirectly influenced by such individual characteristics through features of IMEN services(indirect effect size=-0.24,P=0.002).Conclusion Community-dwelling chronic disease patients accepted the IMEN services,but their service experience needed to be improved further by interventions such as improving the utilization of IMEN services,enriching the service delivery patterns,making full use of smart medical care and providing more personalized services.