重庆市某医联体医患双方对双向转诊认知的调查研究

背景　医疗联合体（以下简称医联体）模式是促进医疗资源合理分配、完善分级诊疗的有效途径之一。截至2018年，重庆市已经实现医联体模式全面覆盖，重庆医科大学附属第一医院医联体于2011年3月成立，经过6年多的发展，医联体取得一定成效。本研究选择该医联体为样本，研究医疗体内医患双方对双向转诊的运行情况，为完善重庆市分级诊疗格局提供政策参考。目的　调研重庆市某医联体医患双方对双向转诊的认知现状、双向转诊中存在的问题，探讨问题解决方案。方法　2017年9-11月和2017年8-10月，采用随机抽样调查分别对重庆医科大学附属第一医院医联体内共6家医疗机构的医务人员和住院患者进行问卷调查。自行设计调查问卷，问卷内容包括医务人员及患者基本信息、对双向转诊的知晓情况，医务人员双向转诊开展情况及相关因素、患者双向转诊及影响因素，医患双方对双向转诊顺畅的认可情况及对双向转诊实施的认可情况。结果　医务人员有效问卷应答率为88.3%（309/350）。288例（93.2%）医务人员对双向转诊知晓。不同职称、来源医院医务人员对双向转诊知晓情况比较，差异有统计学意义（P<0.05）。在工作中有过为患者提供转诊服务经历的医务人员282例（91.3%）。有过为患者提供转诊服务经历的医务人员中双向转诊者151例（53.5%），向上转诊诊者62例（22.0%），向下转诊者69例（24.5%）。核心医院医务人员向下转诊患者时考虑因素主要是病情已稳定，处于康复期或恢复期；托管区县医院医务人员向上转诊患者时考虑因素主要是患者病情需要。阻碍核心医院医务人员向下转诊的因素主要是患者对基层医疗技术水平不满意。阻碍托管区县医院医务人员向下转诊的因素主要是下级医院能力不足。核心医院、托管区县医院医务人员对双向转诊顺畅的认可率比较，差异无统计学意义（χ2=0.090，P=0.764）。医务人员对双向转诊实施的认可率为57.9%（179/309）。核心医院、托管区县医院医务人员对双向转诊实施的认可情况比较，差异有统计学意义（χ2=4.742，P<0.05）。患者有效问卷应答率为85.7%（257/300）。182例（70.8%）患者对双向转诊知晓。不同文化程度患者对双向转诊的知晓情况比较，差异有统计学意义（χ2=8.555，P<0.05）。有过转诊经历的患者83例（32.3%）。促进患者向上转诊的主要因素是患者病情需要，阻碍患者向上转诊的主要因素是诊疗费用高。促进患者向下转诊的主要因素是病情已经处于康复期，没有必要继续治疗；阻碍患者向下转诊的主要因素是对基层医疗技术水平不满意。核心医院和托管区县医院患者对双向转诊顺畅的认可率分别为98.8%（79/80）和89.3%（158/177），差异无统计学意义（χ2=0.011，P=0.918）。核心医院、托管区县医院患者对双向转诊实施的认可率分别为42.5%（34/80）和33.3%（59/177），差异无统计学意义（χ2=-1.484，P=0.138）。结论　重庆市某医联体医患双方对双向转诊的认知普遍较高，双向转诊不够顺畅，向上转诊易向下转诊难，医联体医患双方认可度低，基层医疗机构服务能力有待提高。应提高基层医疗机构服务能力，加大医联体内双向转诊指导、监管和激励力度，保障转诊顺畅。

Research on Two-way Referral Cognition of Doctors and Patients in Medical Treatment Partnership System in Chongqing

Background The medical treatment partnership system is one of the effective ways to promote rational distribution of medical resources and improve hierarchical diagnosis and treatment.As of 2018,Chongqing has achieved comprehensive coverage of the medical treatment partnership system.The medical treatment alliance of the First Affiliated Hospital of Chongqing Medical University was established in March 2011 and has achieved some progress over the past six years.This paper takes the medical treatment partnership system as a sample to study the operation of two-way referral among doctors and patients in the system,so as to provide policy reference for improving the hierarchical diagnosis and treatment pattern in Chongqing.Objective To investigate the cognitive status of two-way referral,the problems existing in two-way referral,and to explore its solutions.Methods From September to November 2017 and from August to October 2017,a random sampling survey was used to investigate the medical staff and inpatients of six medical institutions in the medical treatment partnership system of First Affiliated Hospital of Chongqing Medical University.Self-designed questionnaire included topics such as basic information of medical staff and patients,knowledge of two-way referral,implementation of two-way referral by medical staff and relevant factors,two-way referral of patients and influencing factors,reorganization of smooth two-way referral and the implementation of two-way referral among medical staff and the authors.Results The response rate of questionnaire among health care providers was 88.3%(309/350).A total of 288(93.2%)health care professionals were aware of the two-way referral.The medical staff with different professional titles and source hospitals had significant difference in knowing the two-way referral(P<0.05).There were 282(91.3%)health care professionals who had provided referral services to patients during their work;among them,there were 151(53.5%)two-way referrals,62(22.0%)were upward referral visits,and 69(24.5%)downward referrals.Factors that promoted the downward referral of medical staff in core hospitals mainly included stable disease condition,and patients in the rehabilitation or recovery period.Factors that should be considered when promoting up-referral of patients by medical personnel in hosted county hospitals was mainly the need of the patient.Factors that hindered the downward referral of medical personnel in core hospitals were mainly patient dissatisfaction with the technical level of primary care institutions.Factors that hindered the downward referral of health care professionals in hosted county hospitals were the fact that higher level hospitals believed that subordinate hospitals had insufficient capability.There was no statistically significant difference in the recognition rate of two-way referral among the medical personnel of core hospitals and hosted county hospitals(χ^2=0.090,P=0.764).The recognition rate of two-way referral by healthcare professionals was 57.9%(179 cases).There was statistically significant difference in the recognition of two-way referral between the medical personnel of core hospitals and county hospitals(χ^2=4.742,P<0.05).The patient response rate to a valid questionnaire was 85.7%(257/300).Two-way referral was known in 182 patients(70.8%).There were significant differences in the awareness of bilateral referral among patients with different degrees of literature(χ^2=8.555,P<0.05).There are 83 patients(32.3%)who had a referral experience.The main factor that promoted the patient’s upward referral was the patient’s condition needs,and the main factor that hindered the patient’s upward referral was the high cost of diagnosis and treatment.The main factor contributing to the downward referral was that the condition was already in the rehabilitation period,and no need to continue treatment,and the main factor preventing the downward referral was dissatisfaction with medical technique level in primary care institutions.The recognition rate of smooth two-way referral was 98.8%(79 cases)in core hospitals and 89.3%(158 cases)in county hospitals,and the difference was not statistically significant(χ^2=0.011,P=0.918).The recognition rate of bilateral referral was 42.5%(34 cases)in core hospitals and 33.3%(59 cases)in county hospitals,and the difference was statistically significant(χ^2=-1.484,P=0.138).Conclusion The cognition of two-way referral of doctors and patients in a medical association in Chongqing is generally high,the upward referral is easy and the downward referral is difficult.The recognition of doctors and patients in the medical association are both low,and the service ability of basic medical institutions needs to be improved.We should improve the service ability of primary care institutions,increase guidance,supervision and incentive of two-way referral,so as to ensure the smooth referral.