上海市社区卫生服务中心全专结合门诊建设现况调查及建设路径和策略探索

Investigation on the current situation and exploration of development paths and strategies for the outpatient services featuring integration of general practice and specialized care in Shanghai community health service centers

目的了解上海市社区卫生服务中心全专结合门诊建设现况和路径,总结实践中存在的问题,探索解决策略。方法该研究为混合方法学研究,共分成3个阶段。第1阶段于2021年8—12月对上海市16个行政区的249家社区卫生服务中心进行问卷调查,了解全专结合门诊建设现况。第2个阶段于2021年12月至2022年8月从已经开展全专结合门诊的中心中,采用随机数字表法抽样选取7家,对7家中心参与全专结合门诊的全科、专科医师进行问卷调查了解其对全专结合门诊的评价。第3个阶段为定性访谈,同期从7家社区卫生服务中心中各选择1名管理者,了解社区全专结合门诊建设初步成效及存在问题。结果(1)实际调查上海市所有行政区的社区卫生服务中心239家,有效应答率为96.0%。78.2%(187/239)的社区卫生服务中心已开展了全专结合门诊,其中有71.1%(133/187)社区开展多种类疾病的全专结合诊疗项目,排名前3位的项目分别是:糖尿病(134家)、慢性阻塞性肺疾病(66家)和高血压病(56家)全专结合门诊。(2)当前开展全专结合门诊的路径主要有两类,一类是综合性医院专科医师下沉社区,与社区卫生服务中心联合开展全专结合门诊,占78.6%(147/187)。另一类为全科诊疗基础上开设特色专病门诊,同时聘请综合性医院的专家定期指导培训的方式,占15.5%(29/187)。(3)55名全专结合门诊医师参与问卷调查,应答率为100.0%。所有调查医师均支持社区卫生机构开设全专结合门诊。54.6%(30/55)的调查医师发现全专结合门诊的就诊量较普通门诊上升。90.9%(50/55)的调查医师认为慢性疾病患者在全专结合门诊就诊疗效较普通门诊更佳。(4)定性访谈结果显示,全专结合门诊建设面临的挑战:管理制度不完善、缺乏信息化管理平台、上级医院专科医师基层指导不足及社区全专结合门诊的知晓度不高。结论上海市社区卫生服务中心开设全专结合门诊较为普遍,开展形式多样,建设路径主要有两类,对实践中存在的问题可采取针对性举措进一步完善。

Objective To understand the current status and paths of outpatient services construction of integration of general practice and specialized care in Shanghai communities health service centers(CHC),summarize the existing problems in practice,and to explore solutions.Methods This study adopted a mixed-methods approach,divided into three phases.Phase 1,conducted from August to December 2021,included a questionnaire survey of 249 CHC across 16 administrative districts in Shanghai to understand the current status of outpatient service construction of the intergration of general practice and specialized care.In the second phase,from December 2021 to August 2022,seven centers that had already implemented outpatient services of integration of general practice and specialized care were randomly selected using a random digit table method.A questionnaire survey was conducted among general practitioners and specialists participating in outpatient services of integration of general practice and specialized care in these seven centers to understand their evaluation of the outpatient services construction of integration of general practice and specialty.The third phase involved qualitative interviews.During this phase,one manager was selected from each of the seven centers.This was conducted concurrently to understand the preliminary effectiveness and existing problems of outpatient services of integration of general practice and specialized care in the community.Results(1)The actual survey covered 239 community health service centers in all administrative districts of Shanghai,with an effective response rate of 96.0%.Among them,78.2%(187/239)of CHC had implemented outpatient services of integration of general practice and specialized care,with 71.1%(133/187)of CHC offering integrated diagnosis and treatment projects for various types of diseases.The top three projects in terms of implementation were diabetes(n=134),chronic obstructive pulmonary disease(n=66),and hypertension(n=56)integrated outpatient services.(2)At present,there were mainly two ways of implementing outpatient services of integration of general practice and specialized care in the community.One way involved specialists from comprehensive hospitals based in the community who provided outpatient services of integration of general practice and specialized care with CHC,accounting for 78.6%(147/187).The other way was to set up specialty disease clinics based on general practice,with regularly recruitment of experts from comprehensive hospitals for guidance and training,which accounted for 15.5%(29/187).(3)The actual survey included 55 physicians in outpatient clinic of intergration of general practice and specialized care,with a response rate of 100.0%.All investigated physicians expressed support for the opening of integrated general and specialist outpatient services in CHC.Compared with regular outpatient services,54.6%(30/55)physicians who treated in outpatient clinic of intergration of general practice and specialized care have seen an increase in the number of patients.And 90.9%(50/55)of surveyed physicians believed that the treatment effectiveness of patients with chronic diseases in outpatient services of integration of general practice and specialized care was better than that in regular outpatient services.(4)The results of qualitative interviews showed that challenges encountered in outpatient services construction of integration of general practice and specialized care included incomplete management systems,a lack of information management platforms,insufficient guidance from specialist physicians at higher-level hospitals,and low awareness of outpatient services of integration of general practice and specialized care in community.Conclusions In Shanghai,the establishment of outpatient services of integration of general practice and specialized care in CHC is relatively common,with various implementation methods.There are two main paths of the integration outpatient construction.Targeted measures can be taken to further improve the existing problems in practice.