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、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。     

全科医疗核心特征功能概念与内涵界定的研究思路

全科医疗(general practice)是基础保健(primary care)的核心,全科医疗的特征功能包括:首诊、可及性、连续性、综合性、协调性(核心特征功能)和以家庭为基础、以社区为导向、以病人为中心(衍生特征功能)。特征功能是全科医疗的本质功能,全科医生在提供基础医疗服务时,只有将这些功能整合在一起提供,全科医疗才能转化成高质量的健康照护。特征功能理论是基础保健理论的重要组成部分,特征功能概念的定义与内涵则是该理论的核心和基础,然而,目前已有的基础保健核心特征功能的定义与内涵之间存在着交叉重叠和边界不清。本文首先对基础保健核心特征功能的概念与内涵界定所遇到的问题进行梳理,然后对问题的原因进行探讨,最后给出基础保健特征功能的概念和内涵界定的三个原则,即可控性原则、互斥性原则和穷尽性原则。     

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。     

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。     

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。     

全科医学专业设置的必要性和可行性调研报告

全科医学专业设置的必要性和可行性调研报告汪宗越（黄山医科大学２３００５１）１９６０年以来，全科医学作为一门新的医学专业在欧美蓬勃发展，以其医疗、预防、保健服务的连续性、综合性、协调性、可及性（方便性）等特点，成为理想的初级保健的模式。医学高度专科化和...     

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…     

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。     

What patients want from primary care consultations: a discrete choice experiment to identify patients' priorities

PURPOSE The consultation is fundamental to the delivery of primary care, but different ways of organizing consultations may lead to different patient experiences in terms of access, continuity, technical quality of care, and communication. Patients’ priorities for these different issues need to be understood, but the optimal methods for assessing priorities are unclear. This study used a discrete choice experiment to assess patients’ priorities.METHODS We surveyed patients from 6 family practices in England. The patients chose between primary care consultations differing in attributes such as ease of access (wait for an appointment), choice (flexibility of appointment times), continuity (physician’s knowledge of the patient), technical quality (thoroughness of physical examination), and multiple aspects of patient-centered care (interest in patient’s ideas, inquiry about patient’s social and emotional well-being, and involvement of patient in decision making). We used probit models to assess the relative priority patients placed on different attributes and to estimate how much they were willing to pay for them.RESULTS Analyses were based on responses from 1,193 patients (a 53% response rate). Overall, patients were willing to pay the most for a thorough physical examination ($40.87). The next most valued attributes of care were seeing a physician who knew them well ($12.18), seeing a physician with a friendly manner ($8.50), having a reduction in waiting time of 1 day ($7.22), and having flexibility of appointment times ($6.71). Patients placed similar value on the different aspects of patient-centered care ($12.06–$14.82). Responses were influenced by the scenario in which the decision was made (minor physical problem vs urgent physical problem vs ambiguous physical or psychological problem) and by patients’ demographic characteristics.CONCLUSIONS Although patient-centered care is important to patients, they may place higher priority on the technical quality of care and continuity of care. Discrete choice experiments may be a useful method for assessing patients’ priorities in health care.     

Practice features associated with patient-reported accessibility, continuity, and coordination of primary health care

PURPOSE On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients.METHODS Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic.RESULTS One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office.CONCLUSIONS The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.     

What are the key attributes of primary care for patients? Building a conceptual ‘map’ of patient preferences

BACKGROUND: Responding to the preferences of patients is a key focus of current health policy and is especially important in primary care. Responding effectively to patient preferences requires a clear understanding of the way in which patients assess primary care services. OBJECTIVE: This study was designed to provide a 'map' of the content and structure of the key attributes of patient preferences concerning primary care. DESIGN: The development of the 'map' used secondary research methods. Electronic databases were searched for published conceptual reviews of patient preferences, which were used to develop a basic 'map' through content analysis. A search for recently published primary empirical studies of patient preferences was conducted to extend and develop the 'map'. The 'map' was tested by taking a random sample of patient assessment instruments and categorizing the item content. RESULTS: Seven major categories and multiple subcategories were described. The major categories were access, technical care, interpersonal care, patient-centredness, continuity, outcomes, and hotel aspects of care. The coverage of these attributes in a selection of patient assessment instruments varied widely, and the coding of a proportion of items in the patient assessment instruments according to the 'map' was problematic. CONCLUSIONS: The conceptual 'map' can be used to plan comprehensive assessment of patient preferences in primary care. It also raises many theoretical issues concerning the nature of attributes and their interrelationships. The implications for the measurement of patient preferences are discussed.     

Patient-reported care coordination: associations with primary care continuity and specialty care use

PURPOSE Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use.METHODS We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use.RESULTS Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77).CONCLUSIONS High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.     

Primary care attributes and mortality: a national person-level study

PURPOSE

Research demonstrates an association between the geographic concentration of primary care clinicians and mortality in the area, but there is limited evidence of a mortality benefit of primary care at the individual patient level. We examined whether patient-reported access to selected primary care attributes, including some emphasized in the medical home literature, is associated with lower individual mortality risk.

METHODS

We analyzed data from 2000–2005 Medical Expenditure Panel Survey respondents aged 18 to 90 years (N = 52,241), linked to the National Death Index through 2006. A score was constructed from 5 yes/no items assessing whether the respondent’s usual source of care had 3 attributes: comprehensiveness, patient-centeredness, and enhanced access. Scores ranged from 0 to 1 (higher scores = more attributes). We examined the association between the primary care attributes score and mortality during up to 6 years of follow-up using Cox survival analysis, adjusted for social, demographic, and health-related characteristics.

RESULTS

Racial/ethnic minorities, poorer and less educated persons, individuals without private insurance, healthier persons, and residents of regions other than the Northeast reported less access to primary care attributes than others. The primary care attributes score was inversely associated with mortality (adjusted hazard ratio = 0.79; 95% confidence interval, 0.64–0.98; P = .03); supplementary analyses showed mortality decreased linearly with increasing score.

CONCLUSIONS

Greater reported patient access to selected primary care attributes was associated with lower mortality. The findings support the current interest in ensuring that patients have access to a medical home encompassing these attributes.