全科医疗核心特征功能定义与内涵界定研究——可及性

可及性是基础保健五大核心特征功能之一,与首诊功能紧密联系,与综合性互相促进,影响连续性、协调性功能的实现。本文首先回顾普适的可及性概念,并在此基础上梳理基础保健可及性的概念内涵和主要特点,进而辨析基础保健可及性与其他基础保健核心特征功能的联系与区别,最后依据可控性、穷尽性和互斥性三大原则,得出基础保健可及性定义与核心要素,为全科医疗特征功能测量评价工具的研制提供理论依据。     

全科医疗核心特征功能研究——基础保健的综合性

综合性是基础保健的重要特征功能,与首诊、可及性、连续性和协调性之间相互关联,共同形成基础保健高绩效的作用机制。面临人口老龄化、慢性病流行、医疗费用快速上涨的挑战,综合性服务的重要性日益凸显。明确基础保健综合性的概念内涵,是研究者、政策制定者和实践管理者亟待解决的一个根本性问题,是管理综合性服务的基础。针对我国基础保健综合性服务的概念及其内涵要素尚未清晰的现状,本文将系统梳理目前关于综合性定义与概念内涵的研究,把握综合性内涵、要素及其内涵;在此基础上,遵循可控性、穷尽性和互斥性原则,理清基础保健综合性与其他特征功能的内涵边界,给出全科医疗/基础保健综合性这一特征功能的定义与内涵,为后续建立全科医疗特征功能的可操作性定义奠定基础。     

全科医疗核心特征功能定义与内涵界定研究——连续性

连续性是基础保健的一个十分重要而独特的特征,与首诊、可及性、综合性和协调性之间以一种互为基础、相互支撑、彼此强化的方式共同作用,形成基础保健的作用机制。本文首先系统梳理目前关于连续性定义与概念内涵的研究,把握连续性内涵要素,明晰服务连续性的显性要素与隐性要素之间的关系;在此基础上,遵循可控性、穷尽性和互斥性原则,厘清基础保健下连续性与其他四个特征功能的内涵边界,给出全科医疗/基础保健连续性这一特征功能的定义与内涵,为后续建立全科医疗特征功能可操作性定义奠定基础。     

全科医疗核心特征功能、高绩效作用机制及其政策涵义

全科医疗是基础保健的核心,已经成为各国高价值卫生保健体系的基石。首诊、可及性、连续性、协调性和综合性五大特征构成了以功能为导向的全科医疗定义的要素。本文从全科医疗定义出发,厘清和归纳全科医疗五大特征功能的定义、内涵及其作用,探索五大特征功能对卫生体系高绩效的作用机制。并对我国全科医疗提出建议:将基层医疗卫生服务体系更名为基础保健体系;以五大核心特征功能为重点,发展强化基础保健体系,促进基层医疗卫生服务转型升级;重点从全科医生数量、薪酬制度、医保采购以及全科医生教育培训体系等方面完善全科医生制度;从组织层面建立有助于实施全科医疗特征功能的管理制度与服务流程。     

全科医疗特征功能的评价、影响因素分析及政策涵义

目的:全科医疗特征功能是构成基础保健高绩效的基础,是区别于专科医疗的核心所在。本研究将测量全科医疗特征功能,剖析其影响因素,探讨问题原因,为制定强化全科医疗特征功能政策提供依据。方法:使用本土化的基础保健测量工具PCAT-AE,选择8家社区卫生服务中心和深圳市港大医院全科医疗门诊部作为调查机构。采用面对面、一对一形式的问卷调查方法,共调查1 712名病人,有效问卷1 645份。结果:全科医疗特征功能总分49.0分,首诊利用(69.8)、连续性(63.1)和文化胜任力(51.2)维度得分相对较高,可及性(40.8)和以社区为导向(31.0)维度得分相对较低。全科医疗特征功能得分受人口社会学特征、健康特征和服务利用等多种因素影响,特征功能对病人的满意度起积极作用(OR1)。结论:国内全科医疗特征功能得分较低,与国外相比差距较大。可以从病人个体、组织和系统三个层面,全面强化全科医疗特征功能。     

广州、东莞和深圳的全科医疗特征功能比较研究

目的:评价和比较广州、东莞和深圳三个城市四种全科医疗模式下全科医疗特征功能,为制定政策和强化全科医疗特征功能提供依据。方法:采用二阶段抽样,首先抽取广州市3家社区卫生服务中心,东莞市2家社区卫生服务中心,深圳市3家社康中心和深圳市1家公立医院,然后采用方便抽样的方法,使用本土化后的基础保健工具PCAT-AE对社区卫生服务中心/医院的病人进行问卷调查,测量病人对基础保健服务的体验。共有1 712名病人参与调查,其中有效问卷为1 645份。结果:深圳港大医院的全科医疗特征功能总体得分(55.3)要高于广州社区(45.9)、东莞社区(49.2)和深圳社区(51.7)的得分,且P0.05。结论:全科医疗特征功能总体较低,不同全科医疗实践模式显现不同特点,要针对每个地区的具体情况不断完善全科医疗功能服务。     

全科医疗特征功能视角下分级诊疗的定义及制度层次

明确分级诊疗定义和内涵是建立和完善分级诊疗制度的逻辑起点,是制度的基础性研究。本文在剖析国际上分级诊疗的相关概念、探求分级诊疗本质的基础上,辨析了国内分级诊疗的定义。认为国内分级诊疗制度存在以下不足:以疾病诊治的单一维度作为三级医疗服务分工依据,忽略了人们对医疗服务体系间接性医疗服务功能的需求;导致服务体系规划忽略了非直接性医疗服务功能,缺失了具有特征功能的全科医疗与专科医疗之间的分化和互补;全科医疗和专科医疗之间功能清晰、界限分明的医疗卫生服务体系结构尚未形成;用组织治理取代了原本属于全科医疗和专科医疗之间的专业治理。最后,本文从全科医疗特征功能视角,完善了分级诊疗的定义;尝试回答了分级诊疗的三个基础性问题,并归纳提出分级诊疗制度应该包括微观、中观、宏观三个层次。     

全科医疗核心特征功能对糖尿病患者自我管理效能影响

目的探究全科医疗核心特征功能对签约家庭医生的糖尿病患者自我管理效能及其分维度的影响,为提升糖尿病患者自我管理效能提供针对性作用环节。方法采用便利抽样方法,于2019年8—9月在广州市沙园社区卫生服务中心对签约家庭医生的2型糖尿病患者进行面对面问卷调查,收集相关数据。采用多重线性回归方法分析全科医疗核心特征功能对糖尿病患者总体自我效能及分维度的影响。结果共收集224名2型糖尿病患者数据,其自我效能总分为(76.24±12.31)分,全科医疗核心特征功能总分为(72.95±11.40)分。多重线性回归分析结果显示,第一线照护能够提高糖尿病患者总体自我效能(β=0.081,P<0.1);第一线照护(β=0.088,P<0.1)、可及性(β=0.207,P<0.1)、连续性(β=0.133、P<0.1)、协调性(β=0.275,P<0.1)及以病人为中心(β=0.187,P<0.1)可提高患者药物治疗效能;未发现全科医疗核心特征功能与患者血糖与足检查、饮食管理及运动管理效能之间存在关系。结论全科医疗核心特征功能可在总体上提升糖尿病患者自我管理效能和药物治疗效能,但对患者血糖与足检查、饮食管理及运动管理自我效能的作用尚未发现,提升这三个方面的自我效能,还需借鉴健康教育和健康促进理论,提供促成因素和强化因素,例如资源支撑和环境支撑等。     

浅论初级卫生保健与全科医学

全科医学（GeneralMedicine）乃是一门新兴学科，又称家庭医学，是在全科医疗与家庭医疗实践的基础上发展起来的综合性医学学科、世界卫生组织提出“2000年人人享有卫生保健的全球战略目标，实现这一目标的关键措施就是实施初级卫生保健（PHC）。基于初级卫生保健是广泛、综合的卫生项目，为群众提供预防、治疗及康复服务。因此，发展全科医学对提高初级卫生保健的整体水平有其重要的现实意义。本文就全科医学在初级卫生保健中的作用及其发展思路作一初步探讨。1全科医学的原则与特点全科医学遵循综合性保健为重要理论基础，功能上倡导连…     

发展全科医学 适应医学模式的转变

随着新的医学模式的确立和实现初级卫生保健目标的提出，为全科医学的兴起和发展奠定了科学的理论基础，全科医学是社会发展的需要，是社会发展的必然产物。根据易鑫、曾文俊氏界定的概念：“全科医学又称家庭医学，是医务人员直接深入家庭向群众提供医疗、预防、保健、康复一体化的全面的连续的指导与眼务的一门新兴医学科学。”是一种崭新的综合性的知识体系，是历史上开业医师的继续和现代化体现，是与各门专科医学具有同等地位，并且无法被取代的专业学科。发展全科医学的关键是什么？有人认为是培养人才。我认为关键是观念的转变。否则…     

The concepts of community care and primary care in the UK: the 1960s to the 1990s

The concepts of community care and primary care in UK health policy have emerged over a number of decades. This paper uses historical methods to investigate the changing definitions of community care and primary care in health policy since the 1960s. It draws on published primary and secondary sources including government documents, journals and the professional press. While policy makers have tended to separate community and primary care, the roles of the professions have tended to cut across the two sectors. The emergence and substantially separate development of the two concepts in policy and professional practice between 1960 and 1990 is described and analysed, illustrating the structural constraints on integration but noting the increasing tendency for the boundaries to be called into question. The second part of the paper examines the impact of the 1990 NHS and Community Care Act, the implementation of reforms during the 1990s and the policies currently being implemented by the Labour government. Community care and primary care have continued to be treated separately in the minds of policy makers. Policy for the former has been largely driven by governments' concern to control social security and NHS spending, whilst primary care policy largely focused on the role of general practitioners (GPs) in implementing market reforms. The new Labour government has put renewed emphasis on public health and reducing fragmentation, stressing partnership and cooperation. But the continued dominance of general practice in primary care policy may continue to be an obstacle to the integration of community care and primary care.     

The evolving concept of health literacy

The relationship between poor literacy skills and health status is now well recognized and better understood. Interest in this relationship has led to the emergence of the concept of health literacy. The concept has emerged from two different roots - in clinical care and in public health. This paper describes the two distinctive concepts that reflect health literacy, respectively, as a clinical "risk", or a personal "asset". In the former case a strong science is developing to support screening for poor literacy skills in clinical care and this is leading to a range of changes to clinical practice and organization. The conceptualization of health literacy as an asset has its roots in educational research into literacy, concepts of adult learning, and health promotion. The science to support this conceptualization is less well developed and is focused on the development of skills and capacities intended to enable people to exert greater control over their health and the factors that shape health. The paper concludes that both conceptualizations are important and are helping to stimulate a more sophisticated understanding of the process of health communication in both clinical and community settings, as well as highlighting factors impacting on its effectiveness. These include more personal forms of communication and community based educational outreach. It recommends improved interaction between researchers working within the two health literacy perspectives, and further research on the measurement of health literacy. The paper also emphasizes the importance of more general strategies to promote literacy, numeracy and language skills in populations.     

The evolving concept of health literacy

The relationship between poor literacy skills and health status is now well recognized and better understood. Interest in this relationship has led to the emergence of the concept of health literacy. The concept has emerged from two different roots – in clinical care and in public health. This paper describes the two distinctive concepts that reflect health literacy, respectively, as a clinical “risk”, or a personal “asset”. In the former case a strong science is developing to support screening for poor literacy skills in clinical care and this is leading to a range of changes to clinical practice and organization. The conceptualization of health literacy as an asset has its roots in educational research into literacy, concepts of adult learning, and health promotion. The science to support this conceptualization is less well developed and is focused on the development of skills and capacities intended to enable people to exert greater control over their health and the factors that shape health.The paper concludes that both conceptualizations are important and are helping to stimulate a more sophisticated understanding of the process of health communication in both clinical and community settings, as well as highlighting factors impacting on its effectiveness. These include more personal forms of communication and community based educational outreach. It recommends improved interaction between researchers working within the two health literacy perspectives, and further research on the measurement of health literacy. The paper also emphasizes the importance of more general strategies to promote literacy, numeracy and language skills in populations.