成都市某三甲医院患者分级诊疗参与现况及影响因素分析

The Implementation Status and Influencing Factors of Hierarchical Diagnosis and Treatment of Patients in A First Tertiary Hospital in Chengdu

目的调查成都市某三甲医院患者对分级诊疗的参与情况与影响因素,并提出针对性改进措施。方法采用偶遇抽样的方法,从2017-10/2018-10到该院门诊就诊患者中抽取1 200例作为本次研究对象。采用问卷调查法,从患者选择基层医疗机构就诊的原因、由基层医疗机构转诊至上级医院的因素、上级医院转诊至基层医疗机构的影响因素、到院就诊患者分级诊疗实施现状、到院就诊患者对分级诊疗认知情况5个方面进行调查。采用Excel 2007软件对数据进行录入、整理和分析。结果调查的1 200例患者中,基层医疗机构首诊为115例(9.58%),均因疾病控制不佳,在基层医生建议下到本院就诊;其余1 085例患者均为直接至该院就诊(90.42%)。1 085例患者中,重度病例为80例,轻、中度但伴有所患慢性疾病危急情况的有182例,轻、中度且无明显症状的有823例,占比分别为7.37%、16.77%和75.85%。患者选择基层医疗机构首诊的主要因素为基层医疗机构距离家庭住址近(85.00%)、所患疾病无需去上级医院(57.33%)、基层医疗机构收费低(42.58%);从基层医疗机构转诊至上级医院的因素包括有绿色通道(77.50%),能享受一定费用减免(56.83%),能获取专家号(45.00%),重复性检查可避免(29.17%);转诊至上级医院的担忧主要为转诊手续繁琐(72.67%),无特别优惠政策(47.67%),无法自由选择优惠政策(30.00%),减免费用少(11.25%),需额外支付转诊手续费用(8.83%);愿意从上级医院转诊至基层医疗机构的因素包括病情稳定、后续康复可在基层医疗机构进行(84.33%),距离家庭住址近(45.00%),可提供健康咨询服务(8.50%),收费低(8.25%);而不愿从上级医院转诊至基层医疗机构的因素包括认为基层医护人员医疗水平低(67.50%),习惯性去大医院(54.17%),担心需要重复检查(42.92%),转诊麻烦(33.25%);患者中基层医疗机构首诊占比低(9.58%),直接至本院就诊的患者中重度患者占比低;到院就诊患者对分级诊疗知晓率较低。结论分级诊疗在到院就诊患者中的实施现状不理想,且受到多方面因素的影响。另外,患者对分级诊疗的认知情况仍有待改善,在实际工作中要加强相关知识的宣传工作,并对医疗体系进行强化,改善分级诊疗实施情况。

Objective To investigate the participation status and influencing factors of hierarchical diagnosis and treatment of patients in a first tertiary hospital in Chengdu,and propose targeted improvement measures.Methods From October 2017 to October 2018,there were 240 outpatients selected from the hospital.The questionnaire was surveyed in the reasons for selecting a primary medical institution,factors for referral from a primary medical institution to a higher level hospital,factors affecting the referral from a higher-level hospital to a primary medical institution,implementation status of a hierarchical diagnosis and treatment of patients,and knowledge about hierarchical diagnosis and treatment.All the data was inserted,sorted out and analyzed by Excel 2007.Results In the 1 200 patients,115 of them chose a primary medical institution for diagnosis(9.58%)and were referred to this hospital as the suggestion of primary doctors for the poor control of disease,and the rest 1 085 patients visited this hospital directly(90.42%).In the 1 085 patients,80 of them were severe cases,182 cases were mild,moderate but with chronic disease and in urgent condition,and 823 cases were mild,moderate and no obvious symptoms,which took 7.37%,16.77%,and 75.85%respectively of all.The reasons for selecting a primary medical institution were close to the home address(85.00%),no need to a higher level hospital(57.33%),low expense(42.58%).Factors for referral from a primary medical institution to a higher level hospital were green channel(77.50%),reimbursement of a certain fee reduction(56.83%),odds to get a medical expert visit(45%),and repeated medical examinations could be avoided(29.17%).Worries for referral from a primary medical institution to a higher level hospital were complicated referral procedures(72.67%),no special preferential policy(47.67%),unable to choose the preferential policy freely(30.00%),less expense reduction(11.25%),and additional payment for the referral fee(8.83%).Factors affecting the referral from a higher-level hospital to a primary medical institution included stable disease condition and rehabilitation could be carried out in primary care institutions(84.33%),close to home address(45.00%),the supply of health consultation service(8.50%),low medical expense(8.25%).Factors affecting the unwillingness of referral from a higher-level hospital to a primary medical institution contained the low medical service level in primary medical institution(67.50%),habitually visit the big hospital(54.17%),worried about the repeated medical examinations(42.92%),complicated referral procedure(33.25%).Patients visiting primary medical institution first took a low proportion of all(9.58%),the severe cases visiting this hospital directly accounted low proportion,and the knowledge about hierarchical diagnosis and treatment of patients in this hospital was in a low rate.Conclusion The implementation status of hierarchical diagnosis and treatment in patients of this hospital is unsatisfactory,which affected by many factors.In addition,the knowledge about hierarchical diagnosis and treatment needs to be improved.It is necessary to enhance the promotion of relevant knowledge,strengthen the medical system,and improve the implementation of hierarchical diagnosis and treatment.