政策因素对精神分裂症患者就医行为的影响研究

Influence of Policy Factors on Healthcare-seeking Behaviors in Patients with Schizophrenia

背景我国精神分裂症患者的基础就医需求较高,但不合理的就医行为可能会造成卫生资源的浪费,相关政策的出台旨在增进就医保障、合理引导患者就医。当前学界对于政策因素与就医行为的研究鲜少涉及精神卫生政策与精神分裂症患者就医行为的关联。目的分析政策因素对精神分裂症患者就医行为的影响,了解在基本医疗保险政策和精神卫生政策引导下精神分裂症群体的卫生服务利用情况和利用效果,为政策完善提供实证参考。方法于2019年11月以重庆市某区2018年三级精神病防治网络体系数据为基础,结合重庆市人力资源与社会保障局医疗保险信息平台匹配该区患者医疗卫生服务利用数据,最终获得关键数据有效的精神分裂症样本2314例。以患者是否发生就医行为及就医时选择的医疗机构为被解释变量,以患者的基本医疗保险参保情况(包括城乡居民/城镇职工基本医疗保险参保情况、门诊特殊病种报销办理情况)和精神卫生政策覆盖情况(包括社区康复服务、监护人补助、残联补助、“686”项目、“免费二代药”项目、精神残疾证)为关键解释变量,以患者的人口学特征为控制变量,进行多因素Logistic回归分析。结果纳入的2314例精神分裂症患者中,1915例(82.76%)发生就医行为。1482例发生门诊就医行为的患者中,选择到一级医疗机构就诊者252例(17.01%),二级医疗机构就诊者1080例(72.87%),三级医疗机构就诊者150例(10.12%);795例发生住院就医行为的患者中,选择到一级医疗机构就诊者38例(4.78%),二级医疗机构就诊者518例(65.16%),三级医疗机构就诊者239例(30.06%)。Logistic回归分析结果显示,基本医疗保险类型、门诊特殊病种报销办理情况、社区康复服务参与情况、“686”项目办理情况、“免费二代药”项目办理情况是精神分裂症患者是否就医的影响因素(P<0.05);基本医疗保险类型、门诊特殊病种报销办理情况、社区康复服务参与情况、“免费二代药”项目参与情况、精神残疾证办理情况是精神分裂症患者选择门诊医疗机构的影响因素(P<0.05),基本医疗保险类型、精神残疾证办理情况是精神分裂症患者选择住院医疗机构的影响因素(P<0.05)。结论政策因素对于引导精神分裂症患者就医发挥了积极作用,但存在参与度低、覆盖路径不够全面等问题。应尽快优化精神卫生政策,完善帮扶救助体系,加大宣传力度以提高政策参与度,积极引导家庭康复活动,进一步推动精神卫生服务社区化,持续健全精神卫生保障体系。

Background In China,schizophrenia patients have a high demand for basic medical care,but irrational healthcare-seeking behaviors among them may cause a waste of health resources.So relevant policies have been promulgated to improve the ensuring of healthcare and reasonably guide schizophrenia patients to seek medical care.The current research on policy factors and healthcare-seeking behaviors has rarely addressed the association between mental health policies and healthcare-seeking behaviors of patients with schizophrenia.Objective To analyze the influence of policy factors on healthcareseeking behaviors in schizophrenia patients,to understand the status and outcome of health service utilization in this group under the guidance of basic medical insurance policies and mental health policies,providing empirical evidence for policy improvement.Methods In November 2019,we obtained a sample of 2 314 schizophrenic individuals with valid key data by matching the personal data in the three-level psychiatric prevention and treatment network system in a district of Chongqing in 2018,with information related to personal health service utilization in the district obtained from the medical insurance information platform of Chongqing Human Resources and Social Security Bureau.Multivariate Logistic regression analysis was conducted with healthcareseeking behaviors and the medical institution chosen for treatment as explained variables,participation in basic medical insurance(including basic medical insurance for rural and urban non-working residents or basic medical insurance for urban employees,and reimbursement for medical cost due to special outpatient diseases) and mental health policy coverage(involving community rehabilitation services,guardianship subsidy,subsidy from the local disability federation,subsidy from the 686 program,and free second-generation antipsychotics,and the mental disability certificate) as key explanatory variables,and patients' demographic characteristics as control variables.Results Of the participants,1 915(82.76%) had medical visits,including 1 482 seeking outpatient treatment,and 795 seeking inpatient treatment.Among those seeking outpatient treatment,the prevalence of choosing primary,secondary and tertiary care institutions was 17.01%(252/1 482),72.87%(1 080/1 482),and 10.12%(150/1 482),respectively.And the prevalence of choosing primary,secondary and tertiary care institutions for inpatient treatment was 4.78%(38/795),65.16%(518/795),and 30.06%(239/795),respectively.Logistic regression analysis showed that the type of basic medical insurance,reimbursement for medical cost due to special outpatient diseases,receiving community rehabilitation services,enrolment in the 686 program and involvement in the free second-generation antipsychotics program were factors associated with healthcare-seeking behaviors(P<0.05).The type of basic medical insurance,reimbursement for medical cost due to special outpatient diseases,receiving community rehabilitation services,enrolment in the free second-generation antipsychotics program,and the level of mental disability were factors associated with choosing outpatient settings for treatment(P<0.05).The type of basic medical insurance and the level of mental disability were associated with choosing inpatient settings for treatment(P<0.05).Conclusion Policy factors played a positive role in guiding schizophrenia patients to seek medical treatment,but some problems were also revealed,such as low patient participation and insufficient coverage pathways.In view of this,efforts should be made as soon as possible to optimize mental health policies and the social support and assistance system,increase patient participation of relevant programs via strengthening the publicity of relevant policies,actively guide home-based rehabilitation activities,further promote community-based delivery of mental health services,and continuously improve the mental health security system.