我国基层医疗卫生机构医防整合支持环境现况研究

背景　基层医疗卫生机构作为我国医疗卫生服务“网底”，其医防整合能力的发展关系到我国构建整合型医疗卫生服务体系的最终成果。目的　基于卫生体系功能框架，探讨基层医疗卫生机构当前运行机制和制度安排对医防整合的支持水平和潜在影响，为推进基层医防整合提供证据支持。方法　本研究采取定量研究为主、辅以定性研究完善支撑逻辑分析的方法，于2019年4-10月采用多阶段全国性抽样在东中西部抽取75家基层医疗卫生机构、1 435例医务人员进行问卷调查，189例机构负责人和医务人员进行半结构化访谈。调查问卷分为机构和人员两类，机构问卷包括机构基本情况、人力资源管理、收支结构、卫生服务提供与利用、家庭医生服务模式、糖尿病防治管理及整合型卫生服务体系指标等；人员问卷包括卫生人员基本信息、家庭医生签约行为、医防整合服务提供与认知等部分，并因人员类别有所差异。定性研究采用半结构化访谈的方式，了解机构医防整合安排下人员对整合现状的看法、专业能力评价、工作行为改变及家庭医生团队参与情况。结果　定量结果表明，2018年公共卫生收入占基层医疗卫生机构总收入的13.77%，低于医保收入比例（31.14%）；90.54%（67/74）的调查机构以家庭医生团队为主导提供糖尿病医防融合管理服务，全科医生数量、健康教育时间和固定患者比例尚可，但41.75%（567/1 358）的基层人员自评专业能力局限于自身岗位工作，58.54%（795/1 358）的医护人员仍认为临床医疗比预防更能改善人群健康；63.01%（46/73）的机构实现电子文件互通共享，52.70%（39/74）的机构糖尿病管理信息系统与电子化系统实现对接；89.83%（53/59）的机构负责人认为医疗服务指标对人员收入影响最大，53.57%（721/1 346）的医务人员表示预防性工作不会影响收入；人员主观认知反映机构内交流协作稍优于跨机构专业合作，整合的激励制度有待加强。定性结果支持了基层医疗卫生机构、医务人员收入结构依赖于医疗、家庭医生团队对慢性病人群的有效管理、信息系统发展滞后及医疗服务能力对公共卫生的带动作用。结论　基层医疗卫生机构运行机制的各层面对医防整合的支持有加强趋势，但筹资结构、绩效激励、整合观念、信息化建设仍有不足。同时，医疗服务提供能力强的地区，其运行环境对医防整合的支持性也较好。建议借助卫生体系各层面改革，有针对性地推动基层医疗卫生机构医防整合支持性环境建设。

Environmental Support for the Delivery of Integrated Medical and Preventive Services in Primary Healthcare Institutions

Background In China,primary healthcare institutions provide healthcare services at the primary level,whose competence development for delivering integrated medical and preventive services associates with the end-results of constructing an integrated healthcare system.Objective To evaluate the supporting level and potential influence of current operational mechanism and institutional arrangement in primary healthcare institutions on their delivery of integrated medical and preventive services based on a functional framework of health system,to provide a basis for promoting the development of integrated medical and preventive services.Methods This was a mixed-methods study with a quantitative analysis of two questionnaire surveys supplemented with a qualitative analysis of interviews with a subset of respondents for improving logic analysis.From April to October 2019,by use of multistage sampling,75 primary healthcare institutions were selected from eastern,central and western China,from which,75 administrators were extracted(one from each institution)to receive a questionnaire survey on the institution's general information,human resource management,revenue and expenditure structure,provision and utilization of health services,delivery pattern of family doctor services,prevention and management of diabetes,and parameters of integrated medical and preventive services,and 1435 medical workers were extracted to receive a questionnaire survey on their demographics,and their perspectives of practice behaviors of the contracted family doctor,provision and understanding of integrated medical and preventive services,with slight differences in questions by types of positions.189 cases,a subset of the respondents(including 75 administrators and 114 medical workers)were selected to attend semi-structured interviews regarding perceptions of current implementation of the integrated medical and preventive services,self-assessed professional abilities,changes in practice behaviors of the professionals delivering the integrated services,as well as the role of a family doctor team in delivering such services.Results Questionnaire survey among the administrators revealed that in 2018,the average surplus of public health funds accounted for 13.77%of the average total revenue of institutions,which was lower than the ratio of average surplus of medical insurance funds(31.14%).90.54%(67/74)of the institutions provided integrated diabetes care and prevention with family doctor teams as the main force,and with acceptable number of general practitioners,time for health education as well as proportion of regular patients.Moreover,electronic file sharing and connection of diabetes information platform with large electronic system were achieved in 63.01%(46/73),and 52.70%(39/74)of the institutions,respectively.89.83%(53/59)of the administrators approved that medical performance parameters influenced the income of healthcare professionals most.Questionnaire survey among the medical workers showed that,41.75%(567/1358)of the respondents believed that their self-evaluated professional abilities might be limited due to their own positions,58.54%(795/1358)still held the view that clinical care did better on improving health than preventive services,and 53.57%(721/1346)thought that the delivery of preventive services would not affect their income.These respondents'views demonstrated that intra-institution communication and cooperation were slightly better than inter-institution communication and cooperation,and the incentive system for the delivery of such integrated services should be further improved.Interview results indicated that the revenue composition of both primary care institutions and primary healthcare workers depended on the effectiveness of chronic disease management by a medical team or a family doctor team,the development degree of information system,and the effect of driving force of capacities of providing medical services on the capacities of providing public health services.Conclusion The support of multiple levels of the operation mechanism on the delivery of integrated medical and preventive services in primary care showed an increasing trend,but the funding structure,incentive system,views of such integrated services and informatization construction needed further improvement.Furthermore,a region with strong medical service delivery capacity was also found to have good environmental support for the delivery of integrated medical and preventive services.In view of this,the reform of healthcare system at all levels is suggested to be used as an aid for the targeted promotion of the environmental support construction for the delivery of integrated medical and preventive services in primary care.