社区卫生双向转诊在区域性医疗联合体建设中的实践与思考

背景　医疗联合体（以下简称医联体）建设是我国深化医药卫生体制改革的重要举措，对促进资源共享、患者双向转诊、构建有序就诊秩序具有重要作用。探索合理有效的双向转诊模式对分级诊疗实现有序就医、促进医疗卫生资源高效利用至关重要。目的　分析上海市徐汇区枫林街道社区卫生服务中心（以下简称本中心）采用多种方式开展双向转诊的数据，探讨社区卫生双向转诊在区域性医联体建设中的作用。方法　收集本中心2013-2018年通过社区门诊（包括综合管理平台电子转诊、手工签转诊单转诊、全专云平台转诊）和住院病房（主要定向转诊到上海交通大学附属第六人民医院骨外科等）进行转诊及2017-2018年通过门诊全专云平台进行转诊的转诊患者构成比，以及转诊至二、三级医院排名前三位的医院转诊患者的就诊流向及全专云平台转诊情况。结果　2013-2018年本中心双向转诊患者共19 493例次，其中社区门诊转出共13 704例次（占70.3%）〔综合管理平台电子转诊转出共1 262例次（占9.2%），手工签转诊单转出共12 386例次（占90.4%），全专云平台转出共56例次（占0.4%）〕，住院病房转出共573例次（占2.9%），住院病房转入5 216例次（占26.8%）。2013-2018年本中心综合管理平台电子转诊转出率、手工签转诊单转出率、住院病房转出率、住院病房转入率比较，差异均有统计学意义（P<0.001）；2017-2018年本中心全专云平台转出率比较，差异有统计学意义（P=0.001）。2013-2018年，本中心经手工签转诊单转诊至二、三级医院排名前三位医院的患者共8 591例次，分别是复旦大学附属中山医院3 330例次（占38.8%）、上海中医药大学附属龙华医院3 544例次（占41.3%）和上海交通大学医学院附属精神卫生中心1 216例次（占14.2%）；转诊至二级医院中排名前三位的医院分别是复旦大学附属中山医院徐汇医院216例次（占2.5%）、上海市徐汇区牙病防治所186例次（占2.1%）和上海市第八人民医院99例次（占1.1%）。2013-2018年本中心住院病房转入转出共5 789例次。患者住院病房转出至三级医院分别是上海交通大学附属第六人民医院共277例次、复旦大学附属中山医院138例次和上海中医药大学附属龙华医院70例次；转诊至二级医院复旦大学附属中山医院徐汇医院88例次。2017-2018年本中心通过全专云平台开展双向转诊共365例次，其中在线咨询患者共309例次（占84.9%）、预约检查共11例次（占2.7%）、预约专家看诊共40例次（占11.0%）、预约住院5例次（占1.4%）。结论　利用医联体模式采取多种方式开展双向转诊，可以提高社区转诊实效性；就近建立区域医联体对双向转诊具有优势；特色全专云平台服务，可以开展各类咨询及相关会诊，减少患者往返，提高转诊有效率。医联体模式上转例次远超下转例次，上转患者有信息化记录，但下转患者信息化记录缺乏，使社区医疗机构的全科医生与二三级医院的专家团队对接还不够精准。因此进一步通过信息化手段，实现自动记录下转信息，加强与二三级医院对接，建立全科医生与专科医生之间点对点的社区转诊模式是未来双向转诊发展的重要举措。

Reflection on the Implementation of Community-based Bi-directional Referrals in the Construction of Regional Medical Consortium

Background The construction of medical consortium is an important move for deepening the reform of medical and healthcare system in China.Medical association plays a pivotal role in promoting healthcare resource sharing,bidirectional referrals and building an orderly treatment order.Exploring a reasonable and effective bi-directional referral mode is essential for the achievement of orderly healthcare-seeking pattern and for the promotion of highly efficient use of medical and health resources.Objective To investigate the role of community-based bi-directional referrals in the construction of regional medical consortium based on the analysis of multiple patterns of bi-directional referrals implemented in Xuhui District Fenglin Community Health Center(XDFCHC).Methods Data were collected from XDFCHC,including percentages of communitybased outpatient referrals(consisting of electronic referrals based on an integrated platform and referrals based on the printed form with physician manual signature for referral,and a general practitioner-specialist cloud platform),ward referrals(mainly referred to an oriented hospital,namely,Orthopeadic Surgery,the Sixth People’s Hospital Affiliated to Shanghai Jiaotong University)implemented in 2013—2018,and outpatient referrals via the general practitioner-specialist cloud platform implemented in 2017—2018,top 3 secondary and tertiary hospitals that patients were transferred to and referrals via the general practitioner-specialist cloud platform.Results There were 19493 referrals during 2013 to 2018 in total.To be specific,there were 13704 community-based upward referrals from outpatient department,accounting for 70.3%,including 1262(9.2%)electronic referrals via an integrated platform,12386(90.4%)referrals based on the printed form with physician manual signature,and 56(0.4%)referrals via the general practitioner-specialist cloud platform,and there were 573(2.9%)upward referrals from the ward,and 5216(26.8%)downward referrals to the ward.From 2013 to 2018,there was a significant difference in the rates of upward referrals from consisting of electronic referrals based on an integrated platform and referrals based on the printed form with physician manual signature for referral,and a general practitioner-specialist cloud platform,and the ward,and downward referrals to the ward(P<0.001).The rates of upward referrals via the general practitioner-specialist cloud platform differed significantly across 2017 to 2018(P=0.001).From 2013 to 2018,there were 8591 cases were transferred to the top three hospitals,included the second and third level hospitals,based on the printed form with physician manual signature.The top 3 transferred tertiary hospitals were Zhongshan Hospital Affiliated to Fudan University3330 referrals(38.8%)],Longhua Hospital,Shanghai University of Traditional Chinese Medicine3544 referrals(41.3%)],and Mental Health Center Affiliated to Shanghai Jiaotong University School of Medicine1216 referrals(14.2%)].The top 3 transferred secondary hospitals were Xuhui Hospital,Zhongshan Hospital Affiliated to Fudan University216 referrals(2.5%)],Xuhui Dental Disease Prevention and Treatment Institute186 referrals(2.1%)]and Shanghai Eighth People’s Hospital99 referrals(1.1%)].From 2013 to 2018,there were 5789 ward referrals.The top 3 transferred tertiary hospitals were the Sixth People’s Hospital Affiliated to Shanghai Jiaotong University(277 referrals),Zhongshan Hospital Affiliated to Fudan University(138 referrals),and Longhua Hospital,Shanghai University of Traditional Chinese Medicine(70 referrals),and the transferred secondary hospital was Xuhui Hospital,Zhongshan Hospital Affiliated to Fudan University(88 referrals).From 2017 to 2018,365 bi-directional referrals via the Xuhui featured general practitioner-specialist cloud platform were implemented,including 309(84.9%)online consultations,11(2.7%)examination appointments,40 specialist appointments(11.0%),5 admission appointments(1.4%).Conclusion Multiple patterns of bi-directional referrals within the regional medical consortium may improve the efficiency of community-based referrals.Bi-directional referrals in healthcare institutions in the regional medical consortium near to the patient’s home provide geographical convenience for seeking healthcare.Online counseling and group consultations via the featured general practitioner-specialist cloud platform can reduce the times of actual healthcare seeking,and improve the effectiveness of referrals.Upward referrals outnumber downward referrals within the regional medical consortium.However,the handover between general practitioners and specialists in higher level hospitals is not accurate due to downward referrals without electronic records although upward referrals with.To strengthen the handover,electronic records for downward referrals should be automatically recorded by informatization means.And the development of a point-to-point community-based referral pattern is an important means for the handover between general practitioners and specialists.