乡镇卫生院新农合不合理入院主体决策行为与决策机制研究

发布时间：2018-05-08 01:15

本文选题：乡镇卫生院 + 不合理入院　；参考：《华中科技大学》2016年硕士论文

【摘要】：[目的]本研究在“明确的非诊断性标准”的指导下,采用“田野研究”方法,对乡镇卫生院门诊诊疗过程中就诊患者及医务人员的行为进行深入观察,了解入院决策的决策主体和决策动机,并对入院治疗的患者进行跟踪调查,从需方的角度进一步了解患者做出入院决策的原因、心理动机和决策目标。在此基础上,分析乡镇卫生院供需双方不合理入院决策的主要决策人、行为动机和决策机制。[方法]通过查阅国内外医疗服务供需双方行为、医疗服务不合理提供与利用方面的文献,了解供方诊疗行为、需方就医行为的影响因素,不合理医疗服务利用和提供方面的研究进展,为本文研究奠定基础;然后运用现场调查方法,主要采用“田野调查”、问卷调查、关键知情人访谈等方法,了解实际就诊过程中的入院决策人、决策的合理性、医患双方的行为动机。随后,通过SPSS12.0运用描述分析及卡方检验对调查数据进行统计分析,并通过典型案例分析法,剖析典型案例中供需双方的入院决策行为。[结果]1.田野调查A、B地区共153例住院患者,不合理入院患者56例,不合理入院率36.60%。其中A地区住院患者86例,不合理入院率34.88%;B地区住院患者67例,不合理入院率38.80%。A、B地区不合理入院率没有统计学差异。2.调查分析表明乡镇卫生院入院决策人主要为医生,A、B地区共计153例住院患者,其中110(71.90%)例医生为入院决策人,53例需方为决策人(26例患者为入院决策人,17例家属为入院决策人)。合理入院决策中医生作为决策人占比为77.31%,不合理入院决策中医生作为决策人占比62.5%。3.调查中发现拒绝入院决策的主体主要为患者,36例拒绝入院患者中医生拒绝入院的2例,患者拒绝入院的34例。4.从入院决策合理性分析,?2检验显示入院决策人对入院合理性有影响,供方决策中不合理入院构成比(31.48%)低于需方决策中不合理入院构成比(48.84%),需方在不合理入院决策中发挥重要作用。5.患者问卷调查分析表明,患者的自我感觉疾病严重程度影响入院决策合理性,差别具有显着性差异(P=0.004),自觉疾病中度严重的患者不合理入院构成比最大,为55.56%,自觉疾病严重程度严重的患者不合理入院构成比仅为15.15%;此外,晚上不住在医院的患者不合理入院构成比(46.65%)高于晚上住在医院的患者不合理入院构成比(22.95%),差别具有统计学意义。6.田野调查研究发现,需方角度分析,患者年龄、家庭属性、是否患有慢性病、就诊距离、经济条件、住院费用报销等因素对患者入院决策行为有影响,慢性病、经济条件好、医疗费用报销较高的五保户、低保户、优抚对象患者更容易做出不合理入院决策;供方角度分析,医生以住院治疗疗效好及住院费用报销后经济划算诱导患者做出不合理入院决策。[结论]1.乡镇卫生院不合理入院决策中,供方防御性治疗、诱导需求导致的不合理入院决策与患者主动要求入院治疗导致的不合理入院决策同时存在,其中新农合医疗保险的报销方案是供需双方不合理入院决策的重要影响因素。2.建议:完善供需双方行为监督机制,减少卫生院不合理入院;推进分级诊疗制度,提高村卫生室服务能力,减少卫生院不合理入院;探索基层医疗机构“医养结合”发展模式,减少老年人不合理入院;合理规范供方的诊疗行为,减少供方主导的不合理入院;合理引导需方的就医行为,减少需方主导的不合理入院。
[Abstract]:[Objective] in this study, under the guidance of "clear non diagnostic standard", the "field research" method was used to observe the behavior of the patients and medical staff in the outpatient clinic of the township hospital, to understand the decision-making body and the decision-making motivation of the admission decision, and to follow the investigation of the hospitalized patients, from the demand side. On the basis of this, the main decision-makers, behavior motivation and decision-making mechanism of the irrational admission decision of both supply and demand in township hospitals are analyzed. [Methods] through consulting the behavior of both domestic and foreign medical service supply and demand, the unreasonable provision and utilization of medical service In order to understand the diagnosis and treatment behavior of the supplier, the influencing factors of the demand for medical treatment, the research progress of the use and supply of irrational medical services, this paper lays the foundation for this study. Then, using the field survey method, we mainly use "field survey", questionnaire survey, key lovers interview and other methods to understand the actual treatment process. The hospital decision maker, the reasonableness of the decision and the behavioral motivation of both doctors and patients. Then, the statistical analysis of the survey data is carried out by the SPSS12.0 analysis and the chi square test, and the typical case analysis method is used to analyze the admission decision-making behavior of both the supply and demand in the typical case. [results]1. field survey A, 153 patients in the B area, unreasonable entry. There were 56 cases of hospital patients. The irrational admission rate was 36.60%., of which 86 were hospitalized in the area of A, the irrational admission rate was 34.88%, 67 in the B area, the irrational admission rate was 38.80%.A, the irrational admission rate in the B area was not statistically different from that of the.2. investigation and analysis. It was found that the decision makers in the township hospital were mainly doctors, A, and B area, with 153 hospitalized patients. 110 (71.90%) doctors were hospitalized decision makers, 53 cases were decision makers (26 patients were admission decision makers, 17 family members were hospitalized decision makers). The rational admission decision of traditional Chinese medicine students was 77.31%, and the irrational admission decision of traditional Chinese medicine was the main subject of the decision of refusing admission. In 36 cases, 2 cases of refusing admission by traditional Chinese medicine students, 34 cases of.4. refused admission to hospital, the 2 test showed that the admission decision makers had an impact on admission rationality, and the irrational admission ratio (31.48%) in the supplier decision was lower than the irrational admission ratio (48.84%) in the decision making, and the demand side was unreasonably hospitalized. The.5. patient questionnaire survey showed that the patient's self feeling disease severity affects the rationality of admission decision, the difference has significant difference (P=0.004), the proportion of irrational hospitalized patients with moderate serious illness is the largest, and 55.56%, the patients with serious severity of the disease are unreasonably hospitalized. The ratio was only 15.15%; in addition, the ratio of irrational admission to hospital patients (46.65%) was higher than that in the hospital at night (22.95%), and the difference was statistically significant (22.95%). The difference was statistically significant.6. field investigation, the angle of demand, the age of the patients, the family attributes, the chronic disease, the distance of treatment, the economic conditions, Inpatient expense reimbursement and other factors have an impact on patients' admission decision behavior, chronic diseases, good economic conditions, five insured households with higher reimbursement for medical expenses, low insured households, and patients who are more likely to make unreasonable admission decisions. [Conclusion] in the unreasonable admission decision of]1. township hospital, the unreasonable admission decision of the supplier and the unreasonable admission decision caused by the inducement demand and the unreasonable admission decision caused by the hospitalized treatment of the patient are the same. The reimbursement case of the new rural cooperative medical insurance is an important shadow of the unreasonable admission decision of both the supply and demand parties. .2. suggestion: improve the behavior supervision mechanism of both the supply and demand, reduce the irrational admission of the hospital, promote the system of grading diagnosis and treatment, improve the service ability of the village health room, reduce the irrational admission of the hospital, explore the development mode of the combination of medical care in the basic medical institutions, reduce the irrational admission of the old people, and standardize the diagnosis and treatment behavior of the supplier reasonably and reduce the diagnosis and treatment. It is unreasonable to guide the demand side to seek medical treatment and reduce unreasonable demand of the clients.

【学位授予单位】：华中科技大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R197.62

【参考文献】