农村卫生服务人际连续性现状与对策研究

发布时间：2018-05-26 19:02

本文选题：基层卫生服务 + 人际连续性　；参考：《华中科技大学》2016年硕士论文

【摘要】：[目的]人际连续性是衡量卫生服务连续性、协调性的重要维度之一,目前国内关于卫生服务人际连续性的实证研究十分薄弱。本研究的目的在于分析农村卫生服务人际连续性特征及其影响因素,找出阻碍人际连续性实现的因素。在此基础上结合地区卫生条件、医改措施和政策导向,提出农村基层卫生服务人际连续性改进的建议。[方法]1.文献分析法通过万方、中国知网、PubMed、Google Scholar等数据库资源查询中英文文献;分析卫生服务人际连续性及相关主题的概念,查找并筛选研究指标,总结研究方法,梳理卫生服务连续性及相关研究现状。2.问卷调查和访谈法对样本地区农村居民进行入户调查,最终回收有效问卷1177份。对乡村医生、乡镇卫生院院长、卫生行政和医保部门负责人进行深入访谈,了解基层卫生服务提供者的服务理念与行为,与卫生服务人际连续性有关的关键事件。3.关键信息提取本研究中调查对象就诊经历的获取方式为机构记录提取而非问卷调查,为此,从县新农合系统提取样本乡镇报销(门诊和住院)记录,从县级医院提取门诊日志,构建农村居民就诊流向数据库。并在相关机构提取政策文件资料。4.统计学方法计量资料描述用(?x?s),采用中位数、率分别对等级资料和分类资料进行描述,计量资料组间比较采用方差分析,分类资料的比较用卡方分析,等级资料的组间比较采用非参数检验。显著性水平α为0.05,数据分析操作使用Excel 2007和SPSS13.0完成。[结果]1.首诊医疗机构和就诊习惯农村居民首诊医疗机构为村卫生室的比例最高(53.4%),其次分别是县级医院(19.54%)、乡镇卫生院(16.23%)、市级及以上医院(6.54%)和其他医疗机构(4.25%)。不同地区、年龄、收入来源和是否患有慢性病的人群首诊医疗机构分布具有显著性差异(均p0.05)。影响农村居民选择首诊机构的因素依次是“交通方便程度”、“疾病严重程度”、“医疗机构诊疗水平”、“是否有熟悉的医生”、“自费医疗费用”、“服务态度”、“报销比例”和“有无家人陪护”。28.55%患者在就诊时携带就诊资料,44.6%会主动告知医生之前就诊经历。2.人际连续性建立和维持70.52%的被调查者(830/1177)表示自己有一位熟悉、信任的医生(usualdoctor),830人中,多数居民(62.8%)与usualdoctor纵向连续度在10年以上;文化程度、地区、是否慢病为是否有usualdoctor的影响因素(均p0.05)。居民报告usualdoctor的执业机构分布依次是村卫生室(72.77%)、乡镇卫生院(13.25%)、县级医院(6.43%)、私人诊所(4.22%)和其他(3.13%)。不同地区、性别、婚姻状况和是否慢性的农村居民的usualdoctor执业机构分布不同,差异具有显著性(均p0.05)。3.卫生服务利用和最常去机构经过与村民就诊流向数据库的匹配,1177位被调查者中有507位有就诊经历,人均就诊6次;其中就诊3次以上的患者376名;地区、年龄、是否慢病、健康状况是卫生服务利用(用就诊次数表示)的影响因素(均p0.05)。最常去医疗机构为村卫生室的患者最多(41.54%);其次分别为县级医疗机构(33.46%)、乡镇卫生院(20.40%);市级及以上医院(4.60%),最常去机构与调查对象报告的首诊机构分布存在显著性差异(p0.001),不同地区、年龄组和收入来源的人群最常去机构的分布具有显著性差异(均p0.05)。4.基于就诊经历的人际连续性各维度卫生服务人际连续性紧密度、分散度和顺序度分别用upc、coc和secon表示,其取值的中位数分别为0.75、0.60和0.71;人际连续性顺序度低于紧密度(p0.001),有109名调查对象人际连续性紧密度、分散度和顺序度的取值均为1.00。地区是基层卫生服务人际连续性各维度的影响因素(均p0.001)。人际连续性顺序度随就诊次数增大呈提高趋势,紧密度和分散度无显著变化。5.基层卫生服务提供者行为和地区卫生政策分析基层卫生服务提供者尤其乡村医生对多数服务对象比较熟悉,在服务提供中注重人际连续性的维持与利用。样本地区对卫生服务人际连续性有影响的卫生政策和医改措施有分级诊疗、协作医疗、城乡居民医保统筹和村级门诊统筹,这些改革举措会从不同方向影响基层卫生服务提供者和需求方的行为,从而进一步影响卫生服务的人际连续性。[结论]相比较于村卫生室和县级医院,农村居民对乡镇卫生院信任程度低,在实际就诊行为中,对基层卫生服务的利用仍显得不够充分。农村居民建立医患人际联系的对象主要为基层卫生服务提供者,尤其是乡村医生,且人际连续性持续时间较长,但质量有限。按照紧密度、分散度和顺序度衡量的卫生服务人际连续性处于较高水平,但透过这些维度反映的农村居民就诊流程和习惯仍需进一步提高。源于地区间存在的经济社会发展水平、卫生条件和医改措施的不同,地区间卫生服务人际连续性差异明显;福建省农村居民卫生服务人际连续性紧密度、分散度和顺序度最高,青海省人际连续性持久度最高,而河南省农村居民与基层卫生服务提供者的联系最为紧密。应在总结样本地区有效实践的基础上,提出有针对性的提高基层卫生服务人际连续性的建议和举措,例如推行协作医疗促进患者下转和康复服务在基层,实行门诊统筹政策增加居民对基层卫生服务的利用。
[Abstract]:[Objective] interpersonal continuity is one of the important dimensions to measure the continuity and coordination of health services. At present, the empirical research on interpersonal continuity of health services is very weak in China. The purpose of this study is to analyze the interpersonal continuity characteristics and its influencing factors in rural health services, and find out the factors that impede the realization of interpersonal continuity. On the basis of the regional health conditions, medical reform measures and policy guidance, the suggestions for improving interpersonal continuity in rural health services are proposed. [method]1. literature analysis method is used to query the Chinese and English literature through the database resources such as Wanfang, China's Chinese network, PubMed, Google Scholar and so on. Screening research indicators, summarizing the research methods, combing the continuity of health service and related research status.2. questionnaire survey and interview method to investigate the rural residents in the sample area, and finally reclaim 1177 valid questionnaires. The service concept and behavior of the health service provider, the key event related to the interpersonal continuity of health service.3. key information extraction in this study, the way to obtain the visiting experience of the investigation object is the institutional record extraction but not the questionnaire. For this reason, from the county new CMS system, the sample Township Town reimbursement (outpatient and hospitalized) records, from the county hospital. The outpatient log was extracted, and the rural residents' visiting flow database was constructed. The statistical data of.4. were extracted from the relevant institutions, and the statistical data were described by (? X? S). The median was used to describe the grade data and the classification data respectively. The analysis of variance was used in the measurement data group, and the comparison of the classification data was analyzed with the chi square analysis, etc. The level of data was compared with the non parametric test. The significant level of alpha was 0.05, the data analysis operation was completed by Excel 2007 and SPSS13.0. [results the highest proportion of the first medical institutions and the rural residents' first medical institutions for the village residents (53.4%), followed by the county hospitals (19.54%), the township hospitals (16.23%), and the city (16.23%), and the city (16.23%), and the city's municipal hospital (16.23%). Level and above hospitals (6.54%) and other medical institutions (4.25%). The distribution of first medical institutions in different areas, ages, income sources and people with chronic diseases has significant differences (all P0.05). The factors affecting rural residents' selection of first consultation institutions are "traffic convenience", "severity of disease", "medical institution diagnosis". "Treatment level", "whether there is a familiar doctor", "self expense medical expenses", "service attitude", "reimbursement ratio" and "no family escort".28.55% patients carry the medical information at the visit, 44.6% will voluntarily inform the doctor about the experience of establishing and maintaining 70.52% of the interpersonal continuity of the doctor before the doctor (830/1177) expresses himself There was a familiar and trusted doctor (usualdoctor). Among the 830 people, most residents (62.8%) and usualdoctor had more than 10 years of longitudinal continuity; and whether or not the chronic disease was affected by usualdoctor (all P0.05). The distribution of usualdoctor in the resident report was the village health room (72.77%) and the township hospital (13.25%). County-level hospitals (6.43%), private clinics (4.22%) and other (3.13%). Different regions, sex, marital status and chronic rural residents have different distribution of usualdoctor practice institutions, the difference is significant (P0.05).3. health service utilization and the most frequent visits to the database of villagers' visits to the village, and 5 of the 1177 respondents 07 patients had medical experience, 6 times per person, of which 376 were treated with more than 3 times; area, age, slow disease, health status as the influence factors (all P0.05). Most often went to the village health service (41.54%); the second was County medical institutions (33.46%), township health Hospital (20.40%); municipal and above hospitals (4.60%), there was a significant difference in the distribution of first consultation between the most frequent organizations and the survey subjects (p0.001). The distribution of the most frequent organizations in different regions, age groups and income sources had significant differences (all P0.05).4. based on the interpersonal continuity of the medical experience. The continuity tightness, dispersion and order degree are respectively UPC, COC and secon, respectively, the median of the values are 0.75,0.60 and 0.71, the sequence degree of interpersonal continuity is lower than the degree of tightness (p0.001), and there are 109 subjects of interpersonal continuity tightness, and the value of dispersion and order degree are all 1.00. area is the interpersonal continuity of basic health service. Influence factors (all p0.001). The sequence degree of interpersonal continuity increased with the increasing number of visits. There was no significant change in the degree of tightness and dispersion..5. grassroots health service providers and regional health policies were analyzed at grass-roots level health service providers, especially rural doctors were more familiar with most of the service objects. Maintenance and utilization of continuity. The health policy and medical reform measures in the sample area have graded diagnosis and treatment, cooperative medical care, medical insurance plan for urban and rural residents and the overall planning of village level outpatients. These measures will affect the behavior of the provider and the demand side of the grass-roots health service from different directions, thus further affecting the health. Compared to village health rooms and county hospitals, compared to village health rooms and county-level hospitals, rural residents have low trust in township hospitals. In practice, the use of grass-roots health services is still inadequate. The main object of rural residents to establish medical and patient relationships is to be the primary health service providers, especially rural doctors. The continuity of health services, which is measured by tightness, dispersion and order, is at a high level, but the procedures and habits of rural residents who are reflected through these dimensions still need to be further improved. The difference of medical reform measures, the difference of interpersonal continuity between regional health services is obvious. The interpersonal continuity of rural residents in Fujian province has the highest degree of interpersonal continuity, the highest degree of dispersion and order, the highest interpersonal continuity in Qinghai Province, and the closest relations between the rural residents in Henan and the primary health service providers. On the basis of effective practice, some suggestions and measures are proposed to improve the interpersonal continuity of primary health services, such as promoting cooperative medical treatment to promote patients' down and rehabilitation services at the grass-roots level, and implementing the policy of out-patient co-ordination to increase the utilization of residents' health services at the grass-roots level.
【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

【引证文献】