医联体平台下慢性病患者对社区医疗服务的评价及其对就诊机构选择的影响研究

背景　《“健康中国2030”规划纲要》提出,要建设整合型医疗卫生服务体系。分级诊疗制度是实现整合型医疗卫生服务的基础,而慢性病管理又是分级诊疗的重点内容和推进突破口,然而我国基层服务能力不足,未能满足慢性病患者的需求,无法有效引导患者至基层就诊。目的　分析慢性病患者对社区医疗服务的相对满意度及重要性感知,探讨影响患者选择就诊机构的关键因素,为完善医联体建设提供参考。方法　抽取北京市朝阳医院医疗联盟内、外各2家社区卫生服务中心,于2018年7月,对慢性病就诊患者进行问卷调查,了解慢性病患者就医选择情况,以及对社区医疗服务的满意度及重要性感知。采用因子分析法提取社区医疗服务相关因素公因子,建立坐标轴探索各因素相对满意度与重要性关系,进一步应用Logistic逐步回归模型分析患者选择就诊机构的影响因素。结果　因子分析共提取医疗服务质量感知、服务可及性及医疗费用3个公因子。医疗服务质量感知方面,相对满意度评分为（6.4±2.3）~（8.3±1.7）分,联盟内、外患者评分顺位相同;重要性评分为（8.3±1.5）~（9.0±1.2）分,联盟内、外患者评分前3项均属于此公因子。服务可及性方面,相对满意度评分为（8.1±1.8）~（9.0±1.3）分,其中联盟内“候诊时间”短于联盟外（P<0.05）;重要性评分为（8.0±1.7）~（8.5±1.4）分。医疗费用方面,联盟内外患者相对满意度均最低;重要性评分,在两组内顺位相差5位次,联盟内患者对其评分顺位最低（第10）,而联盟外则居中（第5）。Logistic回归分析结果显示,医疗服务质量感知、年龄、受教育程度、家庭人均月收入及所在社区是否属于联盟内是患者就医选择的影响因素（P<0.05）。结论　社区医疗服务质量尚未达到患者预期,应补足卫生人员、探索个性化管理方式、提高药品配置能力。服务可及性高,但患者对候诊时间的获得感较低,应科学测算资源配置水平,以应对社区就诊人数增长所带来的挑战。样本地区患者对社区医疗费用的敏感度较低,需完善医保政策及患者管理模式。

Evaluation of Chronic Disease Patients on Community Health Services and Its Influence on the Selection of Medical Institutions under the Medical Treatment Alliance

Background　The "Healthy China 2030 Planning Outline" proposes to build an integrated health service system.The hierarchical medical system is the basis for the realization of integrated health service,and chronic disease management is the key content and point of promotion breakthrough in hierarchical medical system.However,medical service capacity is insufficient in community and fails to meet the medical needs of patients with chronic diseases,which makes it unable to effectively guide patients to use grassroots medical services.Objective　To analyze the relative satisfaction and perceived importance of community patients with chronic diseases in terms of medical service,and to investigate the key factors influencing patients' choices of medical institutions,in order to provide reference for improving the construction of medical treatment alliance.Methods　Each two community health service centers were selected both inside and outside the Beijing Chao-Yang Hospital Medical Treatment Alliance in July 2018,and the questionnaire survey was conducted on patients with chronic diseases to understand their medical choices,satisfaction and perceived importance with community medical services.Factor analysis method was used to extract the common factors of community medical services,and the coordinate axes were established to explore the relationship between relative satisfaction and the importance of various factors.Multivariate Logistic regression model was applied to analyze the main factors influencing patients' medical choices.Results　Factor analysis extracted three common factors,quality perception of medical services,medical service accessibility and medical expenses.In terms of quality perception of medical services,the score of both patients inside and outside the medical treatment alliance was（6.4±2.3）-（8.3±1.7） for relative satisfaction with the same order,and（8.3±1.5）-（9.0±1.2） for the importance with the same factors.In terms of medical service accessibility,the score of relative satisfaction was（8.1±1.8）-（9.0±1.3）,in which the "waiting time" within the alliance was shorter than that outside the alliance（P<0.05）,and the score of importance was（8.0±1.7）-（8.5±1.4）.In terms of medical expenses,both patients inside and outside the alliance had lowest relative satisfaction;in scores of the importance,patients within the alliance rated the lowest score,while patients outside the alliance gave the medium scores.The quality perception of medical services,age,education level,monthly per capita income and whether patient's community was in the medical treatment alliance were the main factors affecting patients' medical choices（P<0.05）.Conclusion　The quality of community medical services has not reached the expectations of patients.It should be improved from the aspects of supplementing health personnel,exploring individualized management methods and enhancing drug allocation capability.The medical service accessibility is high,but patients have a relatively low sense of gain of waiting time.The resource allocation should be scientifically measured to address the challenges posed by the growth of community visits.Patients in the sample area are less sensitive to community medical expenses.It is necessary to improve the medical insurance policy and patient management model.