基层医疗卫生服务体系建设现状分析

梳理及归纳了我国在转变基层医疗卫生机构运行机制和服务模式,改善社区卫生、农村卫生的结构与功能,完善投入机制,加强基层卫生人才队伍建设,努力构建城乡一体化的基层医疗卫生服务体系等方面的探讨与实践,为建立健全基层医疗卫生服务体系,使城乡居民享受到安全、有效、方便、价廉的基本医疗服务提供参考。     

基层医疗卫生机构的基本医疗服务范围研究 ——基于常见病、多发病的视角

目的 基于常见病、多发病的视角界定基层医疗卫生机构的基本医疗服务范围。方法 以广东省A市为例,根据该市基本医疗保险参保人的微观数据,统计分析了该市的常见病、多发病,并对该市128个医疗机构进行问卷调查。结果 分别确定了社区卫生服务中心104个病种、乡镇卫生院101个病种、社区卫生服务站38个病种和村卫生室34个病种作为四类基层医疗卫生机构的基本医疗服务范围。结论 应依据四类基层医疗卫生机构的基本医疗服务范围从诊疗项目、药品目录、基层首诊制等方面进行政策调整与完善。     

基层医疗卫生机构住院医疗服务诊疗范围探究

??????? 目的 探究基层医疗卫生机构的住院医疗服务诊疗范围,为基本医疗服务范围的界定及其相关的基本药物目录、基本诊疗目录、基本设施目录提供理论支持和参考。方法 通过专家咨询和实地调查的方法,按照疾病就诊人数降序排列,筛选出覆盖基层医疗卫生机构就诊人数超过90%的疾病。结果 全国和各地区就诊人次比例占90%的疾病,不同地区的数量不同,其所占的住院费用百分比也不同;不同地区筛选出的疾病与全国的疾病有差异; 确定各地区均有的14种疾病为基层医疗卫生机构住院医疗服务诊疗范围。 结论 在制定全国的诊疗范围基础之上,根据不同地区的疾病谱和服务水平作适当调整。     

我国基层医疗卫生信息系统功能建设与应用现状研究

目的 调查全国基层医疗卫生服务机构信息系统功能建设、使用和应用效果。方法 采取分层整群随机抽样,对全国3 245家基层医疗卫生机构进行网络问卷调查,采用描述、χ²检验等统计方法进行分析。结果 我国基层医疗卫生信息系统覆盖率达到了75%以上;所有已建功能的使用率均超过了80%,其中基本公共卫生服务类功能使用率最高,医疗协同类功能使用率最低;功能的使用率与其数据的共享程度密切相关;有40.65%的机构对现有系统支撑业务的能力表示不满意;用户的满意程度与系统是否存在重复录入之间存在直接的关联。结论 我国基层医疗卫生信息系统建设得到长足发展,但数据重复录入等问题有待进一步改善,通过整合系统、提高数据共享程度,避免数据重复录入将有效提升用户满意度,充分发挥系统业务支撑作用。

     

药品可及性视角下国家基本药物制度实施效果评价

目的 研究基本药物制度对我国基层医疗卫生机构药品可及性的影响。方法 选取上海、江西、四川和重庆共24家基层医疗机构进行问卷调查和小组访谈。结果 基本药物制度实施后,基层医疗卫生机构药品的配备率、招标采购、配送时间以及患者药品负担得到了明显改善,药品零差率销售补偿机制不断完善。结论 我国基层医疗卫生机构基本药物的可及性不断提高,但是在目录遴选、招标采购、药品配送、人才队伍建设和补偿机构方面仍然存在着诸多问题。     

药品“零差率”下基层医疗机构补偿机制转变实证分析

?????? 目的 为完善我国基层医疗卫生机构补偿机制提供参考。方法 在全国选取山东、湖北、四川三省，采用问卷收集了60家基层医疗卫生机构财务数据，用SPSS完成统计学分析。结果 2011年我国基层医疗卫生机构总收入平均为457.1万元，历史同期增长12.38%。药品收入为133.54万元，相比2010年下降12.70%，药占比由38.28%降为28.80%；政府投入为170.00万元，增长50.44%，占总收入比例由26.88%上升为36.32%；医疗业务收入增加不明显，但检查收入显著增加。政府投入增长显著，且在各地区水平均衡。结论 政府投入增加稳定了机构总收入，保障机构正常运营；要关注医疗机构检查收入的不合理增长；应提高政府投入的有效性，构建科学绩效考核制度，加强定量研究分析。     

基层医疗卫生机构基本药物制度实施现况调查分析

目的 对某县基层医疗卫生机构基本药物制度实施现况进行调查研究,为基本药物制度的推进提供借鉴。方法 对某县19家基层医疗卫生机构进行问卷调查,并对相关负责人进行非结构式访谈。结果 基本药物制度实施后药品销售额下降、门急诊人次增加,次均门诊费、次均住院费等下降,政府对机构的补偿逐渐加大。结论 基本药物制度实施后,基层医疗卫生机构要加大对国家基本药物的配备和使用,医生要转变用药观念,政府要制定出一套对机构合理补偿的措施。

     

公立医院与基层医疗卫生机构分工协作的现状及策略

公立医院与基层医疗卫生机构分工协作有利于医疗卫生资源合理化配置,有效降低医疗费用,是我国卫生事业改革、发展的目标和方向。文章通过文献研究,总结当前分工协作主要模式,对其存在的难点进行分析,并在此基础上结合实践提出政策建议。     

政府补偿与监管机制改革对医疗服务的影响分析

目的 分析政府补偿与监管机制改革前后闵行区公立医疗卫生机构的医疗卫生服务状况的变化,探索研究政府补偿与监管机制改革对医疗卫生机构运行绩效的影响。方法 进行机构调查和二手资料分析。结果 改革后,闵行区公立医疗机构医疗服务数量不断增加,服务质量保持在较高水平,服务效率有所改进,医疗费用得到控制;综合性医院和社区卫生服务中心的服务质量和费用控制均优于上海市平均水平。结论 政府补偿与监管机制改革在一定程度上提高了闵行区公立医疗卫生机构医疗服务的绩效。     

政府补偿与监管机制改革对公立医疗卫生机构收支状况的影响分析

目的 分析政府补偿与监管机制改革前后闵行区公立医疗卫生机构的收支及结构变化,并与上海市同期平均水平进行比较,探索研究政府补偿与监管机制改革对公立医疗卫生机构收支状况的影响。方法 进行问卷调查和二手数据分析。结果 改革后,闵行区公立医疗卫生机构的医疗与药品收入比例趋于合理,医疗费用得到控制,但政府财政补助水平仍有待提高。结论 政府应确保公立医院财政投入水平,落实取消药品加成后的相应补偿。     

Rural-to-Urban Migrants' Experiences with Primary Care under Different Types of Medical Institutions in Guangzhou,China

Objectives

China is facing the unprecedented challenge of rapidly increasing rural-to-urban migration. Migrants are in a vulnerable state when they attempt to access to primary care services. This study was designed to explore rural-to-urban migrants’ experiences in primary care, comparing their quality of primary care experiences under different types of medical institutions in Guangzhou, China.

Methods

The study employed a cross-sectional survey of 736 rural-to-urban migrants in Guangzhou, China in 2014. A validated Chinese version of Primary Care Assessment Tool—Adult Short Version (PCAT-AS), representing 10 primary care domains was used to collect information on migrants’ quality of primary care experiences. These domains include first contact (utilization), first contact (accessibility), ongoing care, coordination (referrals), coordination (information systems), comprehensiveness (services available), comprehensiveness (services provided), family-centeredness, community orientation and culturally competent. These measures were used to assess the quality of primary care performance as reported from patients’ perspective. Analysis of covariance was conducted for comparison on PCAT scores among migrants accessing primary care in tertiary hospitals, municipal hospitals, community health centers/community health stations, and township health centers/rural health stations. Multiple linear regression models were used to explore factors associated with PCAT total scores.

Results

After adjustments were made, migrants accessing primary care in tertiary hospitals (25.49) reported the highest PCAT total scores, followed by municipal hospitals (25.02), community health centers/community health stations (24.24), and township health centers/rural health stations (24.18). Tertiary hospital users reported significantly better performance in first contact (utilization), first contact (accessibility), coordination (information system), comprehensiveness (service available), and cultural competence. Community health center/community health station users reported significantly better experience in the community orientation domain. Township health center/rural health station users expressed significantly better experience in the ongoing care domain. There were no statistically significant differences across settings in the ongoing care, comprehensiveness (services provided), and family-centeredness domains. Multiple linear regression models showed that factors positively associated with higher PCAT total scores also included insurance covering parts of healthcare payment (P<0.001).

Conclusions

This study highlights the need for improvement in primary care provided by primary care institutions for rural-to-urban migrants. Relevant policies related to medical insurance should be implemented for providing affordable healthcare services for migrants accessing primary care.     

基于博弈论与激励相容理论的我国分级诊疗体系分析

目的 了解政府、大型综合医院、上级医疗机构与基层医疗机构在分级诊疗体系下的利益诉求，以推进分级诊疗体系的建立。方法 采用博弈论分析这些利益主体间的矛盾，利用激励相容理论提出建议。结果 政府投入不足，上级医疗机构不愿下沉医疗资源，基层医疗机构能力不足等问题阻碍了分级诊疗体系的推行。结论 发挥政府引领作用，加大政府投入；加强医疗机构的分工协作，合理配置医疗资源；提高基层医疗机构服务能力。     

山东省新农合单病种支付方式的实施效果分析

单病种支付作为一种合理控制医疗服务费用的方式,对医疗机构的行为有重要影响。调查显示,支付方案多采取最高限价和定额补偿相结合的方式,基层医院、民营医院执行的主动性相对较高,财务收入增高,诊疗质量也有改善。参合人员实际受益有限,遵循临床路径率不高,支付标准的设计不尽合理,大医院执行的动力不足。建议合理确定单病种支付标准,以乡镇卫生院、专科医院为实施重点,逐步推进到三级综合医院;建立质量与费用监控的指标体系、科学的考核和评价机制。

     

Evaluation of the Effectiveness of Nurse-Led Continence Care Treatments for Chinese Primary Care Patients with Lower Urinary Tract Symptoms

Background

The aim of this study was to evaluate whether community-based nurse-led continence care interventions are effective in improving outcomes for adult Chinese primary care patients with lower urinary tract symptoms (LUTS).

Research Design and Subjects

A case-controlled intervention study was conducted. An intervention group of 360 primary care patients enrolled into a nurse-led continence care programme were recruited by consecutive sampling. A control group of 360 primary care patients with LUTS identified by screening were recruited from the waiting rooms of primary care clinics by consecutive sampling. Both groups were monitored at baseline and at 12 months.

Measures

Outcome measures included symptom severity, health-related quality of life (HRQOL), self-efficacy, global health and self-reported health service utilization at 12-months. The effect of the continence care programme on symptom severity and HRQOL was assessed by the difference-in-difference estimation, using independent t-test and multiple liner regression. Chi-square test was used to compare the self-efficacy, global health and self-reported health service utilization between the two groups at 12-months.

Results

After adjusting for baseline severity and socio-demographics, the intervention group had significant improvements in LUTS severity (P<0.05) and HRQOL (P<0.05). Improvements in the amount of urine leakage were not significantly different between the two groups. A higher proportion of subjects in the intervention group reported increased self-efficacy (43.48% vs. 66.83%), improved global health condition (17.74% vs. 41.5%), having doctor consultation (18.5% vs. 8.06), having medication due to LUTS (26.50% vs.11.29%) and having non-drug therapy due to LUTS (59.5% vs.9.68%).

Conclusions

Community-based nurse-led continence care can effectively alleviate symptoms, improve health-related quality of life, and enhance self-efficacy and the global health condition of Chinese male and female primary care patients with LUTS.     

以DRGs为驱动的病种管理应用探索

自北京市实施按疾病诊断相关组付费改革以来,北京安贞医院在2013年启动了以疾病诊断相关组为驱动的病种管理。安贞医院通过2个周期的PDCA循环管理,建立以数学模型技术为支撑的病种管理体系,有效地提高了医疗质量和效率,保障了医疗安全和医疗费用的控制,并在实时精细化管理方面做了有益的尝试。     

Computerized clinical decision support systems for acute care management: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes

Background

There is a need to find innovative approaches for translating best practices for chronic disease care into daily primary care practice routines. Primary care plays a crucial role in the prevention and management of cardiovascular disease. There is, however, a substantive care gap, and many challenges exist in implementing evidence-based care. The Improved Delivery of Cardiovascular Care (IDOCC) project is a pragmatic trial designed to improve the delivery of evidence-based care for the prevention and management of cardiovascular disease in primary care practices using practice outreach facilitation.

Methods

The IDOCC project is a stepped-wedge cluster randomized control trial in which Practice Outreach Facilitators work with primary care practices to improve cardiovascular disease prevention and management for patients at highest risk. Primary care practices in a large health region in Eastern Ontario, Canada, were eligible to participate. The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period. Starting with audit and feedback, consensus building, and goal setting, the practices are supported in changing practice behavior by incorporating chronic care model elements. These elements include (a) evidence-based decision support for providers, (b) delivery system redesign for practices, (c) enhanced self-management support tools provided to practices to help them engage patients, and (d) increased community resource linkages for practices to enhance referral of patients. The primary outcome is a composite score measured at the level of the patient to represent each practice's adherence to evidence-based guidelines for cardiovascular care. Qualitative analysis of the Practice Outreach Facilitators' written narratives of their ongoing practice interactions will be done. These textual analyses will add further insight into understanding critical factors impacting project implementation.

Discussion

This pragmatic, stepped-wedge randomized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence-based approaches to care delivery. This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality-improvement program in primary care. It is anticipated that through the evaluation of IDOCC, we will demonstrate an effective, practical, and sustainable means of improving the cardiovascular health of patients across Canada.

Trial Registration

ClinicalTrials.gov: NCT00574808     

Alignment between Chronic Disease Policy and Practice: Case Study at a Primary Care Facility

Background

Chronic disease is by far the leading cause of death worldwide and of increasing concern in low- and middle-income countries, including South Africa, where chronic diseases disproportionately affect the poor living in urban settings. The Provincial Government of the Western Cape (PGWC) has prioritized the management of chronic diseases and has developed a policy and framework (Adult Chronic Disease Management Policy 2009) to guide and improve the prevention and management of chronic diseases at a primary care level. The aim of this study is to assess the alignment of current primary care practices with the PGWC Adult Chronic Disease Management policy.

Methods

One comprehensive primary care facility in a Cape Town health district was used as a case study. Data was collected via semi-structured interviews (n = 10), focus groups (n = 8) and document review. Participants in this study included clinical staff involved in chronic disease management at the facility and at a provincial level. Data previously collected using the Integrated Audit Tool for Chronic Disease Management (part of the PGWC Adult Chronic Disease Management policy) formed the basis of the guide questions used in focus groups and interviews.

Results

The results of this research indicate a significant gap between policy and its implementation to improve and support chronic disease management at this primary care facility. A major factor seems to be poor policy knowledge by clinicians, which contributes to an individual rather than a team approach in the management of chronic disease patients. Poor interaction between facility- and community-based services also emerged. A number of factors were identified that seemed to contribute to poor policy implementation, the majority of which were staff related and ultimately resulted in a decrease in the quality of patient care.

Conclusions

Chronic disease policy implementation needs to be improved in order to support chronic disease management at this facility. It is possible that similar findings and factors are present at other primary care facilities in Cape Town. At a philosophical level, this research highlights the tension between primary health care principles and a diseased-based approach in a primary care setting.