我国卫生服务体系整合改革中多机构协作模型的建构与效果评价:一项农村社区干预实验

多机构协作是新医改政策执行中的一个瓶颈,且未从理论层面获得足够关注。本研究在借鉴D’Amour组织协作模型基础上,重新修订出适合我国多层级卫生服务体系的多机构协作模型,并研制了完整干预方案和措施。通过两年半的农村社区干预,研究对机构协作水平进行了前后和分组对照,并就医生身份对协作效果的影响进行了检验。结果显示,采取多机构协作模型干预的实验组协作水平有显著性提高,其中有共同激励干预的实验组为"积极型协作",显著性高于未采取共同激励干预的实验组—"发展型协作"和未采取干预的对照组—"潜在型协作";县级临床医生对协作的认同显著性低于乡镇卫生院临床医生和慢病管理人员。建议今后协作改革应以提升县级医院临床医生的内在认同作为政策靶点,同时,激励方式应在利益共享的基础上进一步多样化,以促进多机构协作从目前的结构性整合向功能性整合和文化性整合方向转变。

Rebuild and evaluate the effect of multi-institutional collaboration model in healthcare system integration reform:Evidence from a community-based rural quasi-experiment

It is well acknowledged nowadays that the collaboration among different medical institutions is an unsolved problem which needs both theoretical and empirical evidence. In this study we improved the D''Amour Inter-professional Collaboration Model by adding a new dimension of integrated incentives and making a local adjustment to better fit the hierarchically regulated health system in China. We also designed and implemented an intervention trial in rural area for 30 months to prove the model"s efficacy in promoting multi-institutional collaboration and to find whether and how much it would be influenced by doctors'' working locations. The results showed that the multi-institutional collaboration remained "potential collaboration" in the control group and respectively increased to "developing collaboration" and "positive collaboration" in the single and double treated groups. The new model was proved to have a significantly positive effect on collaboration improvement and the inclusion of performance-based and prospective payment system would add to the marginal benefits. We also found out that the low acceptance from higher-level hospital doctors was a major obstacle in multi-institutional collaboration and in accordance solutions to win the mutual trust would be suggested in the future medical system reform so as to gradually bring more functional and cultural integration into the current structural organizational integration.