Primary care safety-net delivery sites in the United States: A comparison of community health centers, hospital outpatient departments, and physicians' offices

CONTEXT: The US primary care safety net is composed of a loose network of community health centers, hospital outpatient departments, and physicians' offices. National data on how the mix of patients and services differ across sites are needed. OBJECTIVE: To develop and contrast national profiles of patient and service mix for primary care. DESIGN, SETTING, AND PATIENTS: Comparative analyses of 3 national surveys of primary care visits occurring in 1994: for data on physician's office visits, the National Ambulatory Medical Care Survey (NAMCS); for hospital outpatient department data, the National Hospital Ambulatory Medical Care Survey (NHAMCS); and for data on community health centers, the Bureau of Primary Health Care's 1994 Survey of Visits to Community Health Centers. A time trend analysis also was conducted using the 1998 NAMCS and NHAMCS. MAIN OUTCOME MEASURES: National estimates of primary care visit rates, types of patient presentation, patient case-mix, disposition of patients, and management interventions in 1994, and compared with 1998 data. RESULTS: The US population made 1.3 primary care visits per person in 1994, which accounted for 43.5% of all ambulatory visits to physicians' offices, community health centers, and hospital outpatient departments. Primary care visits per person were 20% lower for Hispanics and 33% lower for black, non-Hispanic persons compared with white, non-Hispanic persons. Visits to community health centers were more likely to be made by ethnic minorities, patients with Medicaid or no insurance, and rural dwellers than visits made to the other delivery sites. Visits at hospital outpatient departments were made by sicker populations and were characterized by less continuity than the other delivery sites. Controlling for patient mix, visits made to hospital outpatient departments were more commonly associated with imaging studies, minor surgery, and specialty referrals than those made to physicians' offices. In 1998, the US population made an estimated 3. 4 visits per person, 45.6% of which were primary care visits. National estimates of primary care visit rates and patient mix and practice pattern comparisons between hospital outpatient departments and physicians' offices were similar in 1998 and 1994. CONCLUSIONS: Expanding community health centers will likely improve access to primary care for vulnerable US populations. However, enhancing access to of physicians' offices is also needed to bolster the safety net. The greater service intensity and poorer continuity for primary care visits in hospital outpatient departments that we observed raises concern about the suitability of these clinics as primary care delivery sites. JAMA. 2000;284:2077-2083.     

After-hour home care service provided by a hospice in Singapore

A home care Hospice programme was set up to provide care to the patients with advanced diseases and their families in Singapore. After office-hour, the service is managed by a doctor on weekdays, with the assistance of a nurse during daytime on Saturdays, Sundays and public holidays. The doctor on-call made an average of 3.1 phone calls and 1.3 visits each weekday evening. Over the weekends and public holidays, there were a mean of 16.7 phone calls and 6 visits each day. More than half of the visits (50.3%) were made for certification of death. The commonest symptoms that prompted visits were dyspnoea (20%) and pain (12.2%). The busiest period during weekdays was between 6.00 pm and 11.00 pm, when our doctors did most of their visits. The workload of the hospice home care service is likely to increase and resources such as family health physicians can be explored to help to meet this increasing demand. This can be achieved through the provision of comprehensive training and easy accessibility to medical records which are kept with patients.     

上海市居民就医流向分析及政策建议

目的了解上海市居民就医流向并提出政策建议。方法采用随机分层抽样,选取上海市中心地区、城乡结合区和郊区各2个区,每个区在门诊部选取400名居民（医院和社区卫生服务中心各200人）,在住院部选取200名居民（包括住院患者、该时间段内曾经在门诊就诊的陪同人员和未就医的陪同人员）,共对3 600人进行问卷调查。问卷内容包括患者的基本资料、就诊时首选医院的级别以及选择该院就诊的原因。结果回收有效问卷3 244份（90.1%）。门诊患者中,56.3%首选社区医院,34.0%首选三级医院;住院患者中38.3%首选社区医院,42.9%首选三级医院。门诊患者首选该院的原因：44.8%为就近方便,31.2%为医疗水平高,10.3%为服务态度好,5.2%为费用低;住院患者首选该院的原因：49.9%为医疗水平高,27.2%为就近方便,7.6%为服务态度好。结论应尽快构建改善上海市居民就医状况和提高就医满意度的新型特色医疗卫生服务模式,完善医疗服务网络,建立两级医疗服务网络架构——区域医疗服务中心和基层医疗卫生机构。     

上海市居民就医流向分析及政策建议

目的 了解上海市居民就医流向并提出政策建议.方法 采用随机分层抽样,选取上海市中心地区、城乡结合区和郊区各2个区,每个区在门诊部选取400名居民(医院和社区卫生服务中心各200人),在住院部选取200名居民(包括住院患者、该时间段内曾经在门诊就诊的陪同人员和未就医的陪同人员),共对3 600人进行问卷调查.问卷内容包括患者的基本资料、就诊时首选医院的级别以及选择该院就诊的原因.结果 回收有效问卷3 244份(90.1%).门诊患者中,56.3%首选社区医院,34.0%首选三级医院;住院患者中38.3%首选社区医院,42.9%首选三级医院.门诊患者首选该院的原因:44.8%为就近方便,31.2%为医疗水平高,10.3%为服务态度好,5.2%为费用低;住院患者首选该院的原因:49.9%为医疗水平高,27.2%为就近方便,7.6%为服务态度好.结论 应尽快构建改善上海市居民就医状况和提高就医满意度的新型特色医疗卫生服务模式,完善医疗服务网络,建立两级医疗服务网络架构--区域医疗服务中心和基层医疗卫生机构.     

上海市某社区居民利用医疗资源情况调查

目的了解城市社区居民健康状况及利用医疗资源情况,探索创新全科团队服务模式在引导居民就医行为中的作用和方法。方法采取整群抽样的方法,在上海市某社区居民中抽取1 089名18岁及以上居民进行现场问卷调查。结果 (1)42.3%的被调查者自我感觉身体较好或很好,9.8%认为自己身体较差或很差;33.3%的被调查者有卫生服务需求时,会首选社区卫生服务机构;选择就诊医院的主要影响因素为医生服务水平、就诊的便利性及平均花费时间的多少。(2)2周内,266人(占24.9%)曾有就医经历,其中220人(占就诊总人数的82.7%)选择社区卫生服务机构就诊。结论社区居民对社区卫生服务机构的认同度明显提高,但仍存在盲目就医、利用医疗资源不合理,社区卫生服务机构在提高医疗质量和改进服务的同时,应加强"六位一体"内涵建设,继续推行创新性全科团队服务模式,实行模块化综合管理,采取与社区居民互动的方式,对其就医不当行为加以引导,适时推进家庭医生责任制,让社区健康照顾从"走近社区"到"走进居民家庭"。     

我国基层医疗卫生机构医护人员的医防整合行为及影响因素研究

背景　构建医防整合型卫生服务体系,基层卫生服务不可或缺,医护人员在服务过程中的行为直接影响患者接受服务的质量和健康状况,揭示整合服务行为的影响因素对准确、科学制定医防整合服务政策有重要意义。目的　分析基层医护人员的医防整合行为及其影响因素,为加强基层医防整合服务提供政策建议。方法　于2019年4-10月,采用全国性多阶段抽样,使用自设问卷对基层医护人员进行调查,主要包括基本信息、医防整合认识和服务行为指标等,利用两水平线性回归和多元线性回归模型分析服务行为的影响因素。结果　共计发放问卷810份,基层医护人员自报预防服务时间占比有效问卷数量是624份,有效率为77.4%;固定患者服务比例有效问卷数量是609份,有效率为75.2%。基层医护人员自报预防服务时间占比和固定患者服务比例的均值分别为（37.7±23.033）%和（27.3±24.312）%。预防服务时间占比资料层级结构明显,两水平线性回归模型结果显示日常服务过程中的预防服务时间占比影响因素包括是否参与家庭医生团队、合作互动和专业界限认识（P<0.05）;多元线性回归模型获得的固定患者服务比例影响因素包括人员类型、是否参与家庭医生团队、合作互动和本机构工作年限（P<0.05）。结论　推进家庭医生团队建设和签约服务;明确服务分工,加强科室和多学科合作;转变医防人为分割的固化思维等有利于医务人员为患者提供连续协调的医防整合服务。     

The Medical Database as a Tool for Improving Maternal/Infant Continuity of Care

Analysis of the Sinai Health System's integrated medical database revealed a serious discontinuity of care, frequently observed in underserved communities, for mothers who delivered at the hospital but failed to return on a timely basis for postpartum visits for themselves and newborn visits for their babies. Since the Sinai Health System (SHS) is a fully integrated health system including community-based primary care, a process improvement project to improve rates of return was initiated. Prior to hospital discharge, a staff member visited each new mother and baby to schedule clinic follow-up appointments. Appointment compliance was monitored using the SHS integrated medical database. Results after the first year showed marked improvement. Eighty percent of mothers returned for postpartum care within 4 months of delivery compared to 46 at baseline. Eighty eight percent of newborns were seen in the clinics within the four month timeframe compared to a baseline of 59%. The integrated medical database not only allowed for identification of this problem but was an essential tool at each point in the intervention.     

基于计划行为理论的社区卫生服务中心老年患者频繁就诊行为影响因素的质性研究

背景　在社区卫生服务中心,老年人的频繁就诊行为较为普遍,占用了较多的医疗资源。目的　了解社区卫生服务中心老年患者频繁就诊行为及其影响因素。方法　2018年5月通过目的性抽样和信息饱和原则抽取20例在上海某社区卫生服务中心具有3年持续频繁就诊行为（3年内就诊次数均在前10%）的老年患者进行半结构化访谈,访谈提纲的制定以计划行为理论模型为依据,主要包括认知测量、态度测量、主观规范测量、知觉行为控制测量及对本社区卫生服务中心的意见或建议。根据访谈结果,探析老年人群频繁就诊行为的影响因素。结果　18例患者对自己的频繁就诊行为不自知。9例对频繁就诊有具体定义,55.6%（5/9）患者定义每月就诊≥3次为频繁就诊患者。90.0%（18/20）患者认为频繁就诊行为对自己的生活或健康无不良影响,60.0%（12/20）患者认为频繁就诊能够获得一定的心理安慰,50.0%（10/20）患者提及频繁就诊对于控制及改善病情有一定的帮助。签约政策（70.0%,14/20）、家人支持（45.0%,9/20）、他人行为（15.0%,3/20）均可影响到患者的频繁就诊行为。慢性疾病（100.0%,20/20）、社区医院的便捷性（90.0%,18/20）、医患关系较好（90.0%,18/20）、对自身健康的关心（60.0%,12/20）、急性病症（45.0%,9/20）、自觉健康状况不佳（30.0%,6/20）等均会促使患者的就诊行为,而行动不便（20.0%,4/20）、经济原因（10.0%,2/20）、家中琐事（10.0%,2/20）等原因会限制患者的就诊频次。结论　老年患者的频繁就诊行为受较多因素影响,需要全科医师对患者的疾病、心理、社会等多方面进行关注并解决其真实需求。     

上海市静安区高龄悬空老年人医疗、护理及养老服务利用现状调查

目的　了解上海市静安区高龄悬空老年人的医疗、护理及养老服务的利用现状,探讨存在的问题及解决方案,以满足高龄悬空老年人的健康保障需求。方法　采用目的抽样法,在上海市静安区14个街道中选取老式住宅较为密集的临汾路街道、彭浦新村街道、彭浦镇街道为样本区;再按照1∶1∶1的比例在3个街道内随机抽取居住在老式无电梯楼房3层及以上楼层、年龄80岁及以上的高龄老年人为调查对象。于2017年3月,采用自行设计的调查问卷对高龄悬空老年人进行入户调查。问卷的主要内容包括：高龄悬空老年人的基本情况,过去1个月内对医疗服务、护理服务、养老服务的利用情况。共发放问卷224份,回收有效问卷224份,问卷的有效回收率为100.0%。结果　224例高龄悬空老年人中,71.9%（161/224）的老年人过去1个月内使用过医疗服务;使用医疗服务方式为门诊者占72.7%（117/161）;使用医疗服务项目为用药、拿药服务者占98.1%（158/161）;医疗服务中的困难为下楼困难者占77.6%（125/161）。60.3%（135/224）的老年人过去1个月内使用过护理服务。护理服务由家人和亲属提供者占68.1%（92/135）,认为护理服务经济压力大者占40.0%（54/135）。25.4%（57/224）的老年人过去1个月内使用过养老服务。以市场化家政、送餐方式使用养老服务者占39.6%（21/53）。突发情况发生时,准备以自己本人电话方式应对者占52.3%（104/199）。结论　上海市静安区高龄悬空老年人对医疗、护理服务的利用率较高,养老服务利用率较低。目前存在部分高龄悬空老年人独居居住安排不合理,护理服务经济压力大、护理服务质量不高,社会化养老服务资源利用不足,紧急情况应对准备不足等问题。建议完善高龄悬空老年人医疗、护理、养老服务提供,建立紧急应对处置的长效机制。     

Distribution of variable vs fixed costs of hospital care

CONTEXT: Most strategies proposed to control the rising cost of health care are aimed at reducing medical resource consumption rates. These approaches may be limited in effectiveness because of the relatively low variable cost of medical care. Variable costs (for medication and supplies) are saved if a facility does not provide a service while fixed costs (for salaried labor, buildings, and equipment) are not saved over the short term when a health care facility reduces service. OBJECTIVE: To determine the relative variable and fixed costs of inpatient and outpatient care for a large urban public teaching hospital. DESIGN: Cost analysis. SETTING: A large urban public teaching hospital. MAIN OUTCOME MEASURES: All expenditures for the institution during 1993 and for each service were categorized as either variable or fixed. Fixed costs included capital expenditures, employee salaries and benefits, building maintenance, and utilities. Variable costs included health care worker supplies, patient care supplies, diagnostic and therapeutic supplies, and medications. RESULTS: In 1993, the hospital had nearly 114000 emergency department visits, 40000 hospital admissions, 240000 inpatient days, and more than 500000 outpatient clinic visits. The total budget for 1993 was $429.2 million, of which $360.3 million (84%) was fixed and $68.8 million (16%) was variable. Overall, 31.5% of total costs were for support expenses such as utilities, employee benefits, and housekeeping salaries, and 52.4% included direct costs of salary for service center personnel who provide services to individual patients. CONCLUSIONS: The majority of cost in providing hospital service is related to buildings, equipment, salaried labor, and overhead, which are fixed over the short term. The high fixed costs emphasize the importance of adjusting fixed costs to patient consumption to maintain efficiency.     

脑血管意外家庭照护的需求分析与应对措施

目的了解上海市长桥社区内20例脑血管意外病人的家庭照护需求,以期有的放矢地对家庭照护者实施家庭照护指导,增强他们的照顾意识,提高他们的护理能力,从而降低患者的再住院率,减少家庭经济负担。方法通过家庭访视本社区2008年11月-2009年6月脑血管意外新发病患者,康复治疗2～4周出院,仍需在家中接受照料的20例脑血管意外新发病的患者及其主要家庭照护者,并采用问卷调查、疾病指导和体格检查的方法。结果 90%的家庭需要专业、系统的家庭照护指导并倾向于医护人员上门进行指导,发放一些预防保健的宣传资料。对于指导人员的背景,90%的受访者选择了社区卫生服务中心的全科医师和护师。结论通过调查,使我们得到了信息,了解到不论是脑血管意外患者还是其他慢性病患者,都有不同程度的家庭照护需求。针对此次需求调查的结果,社区卫生服务中心的慢性病关爱家园制定相对应的措施,积极有特色的、个体化的家庭照护指导工作,使社区公共医疗卫生资源得到充分利用。集中体现社区卫生服务中心集医疗、预防、保健、康复、健康教育、计划生育指导六位一体的综合服务。     

北京市失能老年人对上门医疗服务利用现状的混合方法学研究

背景　随着全球人口老龄化的加剧,失能、半失能老年人迅速增加,以全科医生团队为基础、面向家庭的上门医疗服务成为世界新趋势。目前我国的上门医疗服务还缺乏规范的管理制度和系统的运作机制。目的　基于失能老年人的视角,探讨北京市上门医疗服务利用现状和存在问题,为构建合理化社区上门服务体系提供建议。方法　采用质性研究和量性研究相结合的方法。2018年5-6月,采用目的抽样法选取8名失能老年人的主要照顾者进行个人深入访谈,内容包括对上门医疗服务的需求情况、了解程度、利用情况及其满意度和具体意见建议等。2018年7-9月,采用多阶段抽样方法对北京市6家社区卫生服务中心的370名失能老年人照顾者进行问卷调查,收集失能老年人的健康状况、照顾资源、对上门医疗服务项目内容的利用和满意度情况。结果　质性研究发现上门医疗服务能部分满足失能老年人的需求,但患者担心上门医疗费用较高且无法医保结算、上门医疗服务知晓率低、社区卫生机构的上门医疗服务能力有限,影响了上门医疗服务的有效利用。量性研究结果显示：370例失能老年人平均年龄（80.9±8.4）岁,202例（54.6%）中度、重度失能,256例（69.2%）患有3种及以上慢性病,168例（45.4%）需要聘请保姆照顾;314例（84.9％）愿意接受上门医疗服务,但仅76例（20.5%）实际利用过社区上门医疗服务,利用程度较高的前5项服务项目依次是测量血压血糖心电图〔49（13.2%）〕、康复型家庭病床〔26（7.0%）〕、治疗型家庭病床〔22（5.9%）〕、化验标本采集〔22（5.9%）〕、定期性家访〔21（5.7%）〕;56例（15.1%）不愿意接受上门医疗服务,不愿意接受上门服务的前5位原因依次是担心收费较高〔39（69.6%）〕、担心费用无法报销〔23（41.1%）〕、不了解服务项目内容〔21（37.5%）〕、认为服务内容少或能力有限〔14（25.0%）〕、担心泄漏个人隐私〔14（25.0%）〕。结论　北京市失能老年人家庭照顾负担沉重,对上门医疗服务需求迫切,社区上门医疗服务呈现“高意愿,低利用”的现状,建议推动医保支付和社会保险改革,提升社区卫生机构的上门医疗服务能力和服务水平,加强宣传和引导,促进上门医疗服务的有效利用。     

某地区军队人员健康状况调查分析

目的:调查我国东南地区某部军队人员的健康状况及其影响因素,为部队制订卫生服务保障计划提供依据.方法:采用多阶段分层整群随机抽样法在我国东南地区调查了2035名军队人员的两周患病及就诊、半年慢性病患病、住院等情况,由统一培训的调查员进行面对面询问调查.结果:2周内有25.26%军队人员患病.门诊服务利用主要集中在营卫生所、团卫生队及师医院,分别占45.86%、29.28%、8.29%.半年内慢性病患病率为8.30%.1年内有4.86%的军队人员住院治疗,住院服务利用主要集中在驻军医院,占住院总人数的54.72%.半年内牙病患病率为18.77%.入伍以来认为没有必要进行心理咨询的人员为70.12%.结论:军队人员卫生服务需求高于我国城市和农村居民.卫生管理机构应加大对基层部队卫生服务保障的力度,满足军队人员的卫生服务需求,同时应重视对军队人员口腔及心理疾病的防治.     

基于真实世界数据的成年人社区卫生服务机构就诊频次特征及其影响因素研究

背景　“就诊频次”是真实反映患者对医疗机构利用情况的重要数据，但国内相关研究较少，且未对“就诊频次”反映出来的就诊行为与签约服务的关系进行研究。目的　通过真实世界数据，分析城市基层门诊服务签约/非签约患者的就诊频次特征，以及影响签约患者就诊频次的因素，以期识别不同特征的患者对基层医疗资源利用的倾向性和影响因素，帮助家庭医生团队更好地投入资源，与患者建立更为稳定的服务关系。方法　于2021年1月，通过居民健康信息中心，脱敏患者身份、联系方式和具体疾病诊断信息后，提取成都市武侯区13家社区卫生服务中心及其下属18个服务站自2020-01-01至2020-12-31的门诊患者就诊行为和签约状态数据，分析患者就诊频次及其影响因素。结果　共获取2020年在社区卫生服务机构就诊的300 634例成年人的数据，产生了1 243 436次门诊记录，平均就诊年龄（51.5±18.4）岁，平均就诊频次（4.14±5.94）次。仅有9 448例（3.14%）患者会产生跨社区卫生服务机构就诊行为，其中签约患者中仅有17人。在社区卫生服务机构就诊的成年人中34.73%（104 399/300 634）为签约患者，总门诊人次中63.91%（794 710/1 243 436）为签约患者就诊。86.04%（168 840/196 235）的非签约患者为偶发就诊，69.93%（137 229/196 235）病情相对简单；52.30%（55 812/104 399）的签约患者为持续管理就诊，29.90%（31 211/104 399）病情相对简单。以人数计算，签约患者主动预约到诊率为40.29%（42 061/104 399），固定就诊率为37.86%（39 522/104 399）；以频次计算，签约患者主动预约到诊率为18.58%（147 685/794 710），固定就诊率为18.12%（144 009/794 710）。签约患者与非签约患者年龄、就诊频次、接受中医服务人数、特殊门诊就诊人数、就诊频次、诊断复杂程度比较，差异有统计学意义（P<0.05）。有序多分类Logistic回归分析结果显示：病情复杂程度、是否主动预约到诊、是否固定就医、是否利用中医服务、年龄、是否在特殊门诊就诊、签约所在机构和医生签约人群规模是患者就诊频次的影响因素（P<0.05）。结论　成都市武侯区签约患者与家庭医生已建立了较稳定的服务关系。要更好地发挥社区卫生服务机构的签约服务功能：一方面可以从频繁及异常频繁就诊、中医利用度高、特殊门诊就诊这几个特征的非签约患者入手提高签约数量；另一方面可根据签约患者的影响因素特征，通过绩效考核指标的调整，进一步将签约患者就诊频次控制在合理的互动区间，以进行科学的持续管理。     

江苏省基层医疗卫生机构改革成效研究

背景　基层医疗卫生机构是我国医疗卫生服务体系的网底。江苏省自2014年开始实行综合医改,2015年作为全国4个率先进行省级综合医改试点的省份之一,全面启动医改工作。目的　了解江苏省综合医改试点前后基层医疗卫生机构财政投入、队伍建设、能力建设调整情况,为江苏省基层医疗卫生机构改革和发展提供建议与支持。方法　数据来源于2012-2016年原江苏省卫生和计划生育委员会调查表,研究开展时间为2017年10-12月。分别从卫生资源条件、医疗服务产出2个维度来评价基层医疗卫生机构的改革成效。选取的卫生资源条件评价指标为财政补助收入、基层医疗卫生机构数量、床位数及卫生技术人员数;选取的医疗服务产出评价指标为医疗收入和药占比、诊疗人次、入院人次。以2014年各指标数值为基础,通过计算定基比分析各指标的变化情况。结果　2012-2016年基层医疗卫生机构卫生资源条件、医疗服务产出总体上呈逐年增加趋势,但在全省中的占比逐年下降。根据计算所得定基比,卫生资源条件中财政补助收入的增长较快（2016年定基比为134.84%）,医疗服务产出中医疗收入的增长较快（2016年定基比为115.58%）。2012-2014年基层医疗卫生机构床位数年增长率为3.74%,2014-2016年增长率下降为1.82%;2012-2014年基层医疗卫生机构医疗收入年增长率为11.38%,2014-2016年增长率下降为7.51%。2012-2016年基层医疗卫生机构医护比为1∶0.54~1∶0.59。2016年基层医疗卫生机构药占比高于2014、2015年,达55.82%。结论　江苏省综合医改试点后,基层医疗卫生机构改革取得了一定成效,但仍有提升空间,应该进一步加大对基层医疗服务能力的提升。     

全国社区卫生服务现状调查--医院服务与社区卫生服务的连续性与综合性比较

目的比较分析社区卫生服务与医院服务的连续性和综合性的特点。方法问卷调查3省市综合医院和社区卫生服务机构的就诊患者,比较患者在不同医疗机构就诊时接受健康教育、医生对患者家庭其他成员的健康指导、每次就诊时是否找同一位医生以及社区医生是否指导患者进一步就医等情况。结果76·60%的医院就诊患者和87·34%的社区卫生服务机构就诊患者在接受医疗服务的同时,获得了健康教育服务;社区卫生服务机构对患者的健康教育活动明显高于医院;70·19%和26·10%的社区卫生服务就诊者和医院就诊者接受了医生为其家庭其他成员提供的健康指导服务;38·25%的医院就诊患者和71·95%的社区卫生服务机构就诊患者经常就诊于同一位医生;62·65%的社区卫生服务机构就诊患者接受了社区医生关于进一步就诊的指导。结论健康教育活动在社区卫生服务和医院服务中均有较广泛的开展,但健教手段、方式及方法应多样化;连续性的医学照顾是社区卫生服务的根本,应大力提倡和规范化;以家庭为中心的连续性照顾是提高社区卫生服务质量的关键,是社区卫生服务的发展方向;应加强社区医生对患者进一步就医的指导,促进双向转诊机制的建立。     

Telephone care as a substitute for routine clinic follow-up.

DESIGN--Randomized trial. SETTING--A primary care clinic. PATIENTS--Four hundred ninety-seven men aged 54 years or older. OBJECTIVE--We examined the hypothesis that substituting clinician-initiated telephone calls (telephone care) for some clinic visits would reduce medical care utilization without adversely affecting patient health. INTERVENTION--Clinicians were asked to double their recommended interval for face-to-face follow-up and schedule three intervening telephone contacts; for control patients, the follow-up interval recommended by their clinician was unchanged. MAIN OUTCOME MEASURES--Use of medical services and health status. RESULTS--During the 2-year follow-up period, 7% of patients withdrew or became unavailable. Telephone-care patients had fewer total clinic visits, scheduled and unscheduled, than usual-care patients (19%, P less than .001). In addition, telephone-care patients had less medication use (14%, P = .006), fewer admissions, and shorter stays in the hospital (28% fewer total hospital days, P = .005), and 41% fewer intensive care unit days (P = .03). Estimated total expenditures for telephone care were 28% less per patient for the 2 years ($1656, P = .004). For the subgroup of patients with fair or poor overall health at the beginning of the study (n = 180), savings were somewhat greater ($1976, P = .01). In this subgroup, improvement in physical function from baseline (P = .02) and a possible reduction in mortality (P = .06) were also observed. CONCLUSION--We conclude that substituting telephone care for selected clinic visits significantly reduces utilization of medical services. For more severely ill patients, the increased contact made possible by telephone care may also improve health status and reduce mortality.     

Effect of a self-care education program on medical visits

A prospective, randomized, controlled trial of self-care educational interventions was conducted in a health maintenance organization to determine their effect on ambulatory care utilization. Statistically significant decreases in total medical visits and minor illness visits were found in each of three experimental groups as compared with a control group. These decreases averaged 17% and 35%, respectively. These results were most clearly linked to a system of written communications emphasizing personal decision making about the use of medical care. The addition of a nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent ona nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent on the educational interventions. Self-care education systems may have important effects on medical care costs, physician satisfaction, and patient confidence.     

General internal medicine reappears in the teaching hospital: the experience of the Royal Victoria Hospital.

The internal medicine unit of the Royal Victoria Hospital in Montreal was created in 1979 to improve the training of residents and the care of patients. The practices of four internists were brought together in one part of the institution, and within 2 years there were 10 attending staff and 6 residents. The unit now provides continuing care for 2500 patients, many of whom have multisystem or potentially lethal problems. Residents and attending staff share the responsibility of providing 24-hour coverage. The group handles 5000 outpatient visits per year (20% of them being consultations) and provides a general medical consulting service for other hospital departments, with about 300 consultations per year. The creation of the unit, with highly visible role models, appears to have given new prestige to general internists in the hospital. The unit has served as a model for the reorganization of the other medical clinics and provides a base for research in health care delivery.     

医改前后贵州省各级医疗机构诊疗人次与入院人数变化分析

目的：通过分析贵州省各级医疗机构诊疗人数变化情况,探讨新医改的成果及存在的问题,为进一步完善医改的制度和政策设计提供依据.方法：利用《中国卫生统计年报》资料及《中国卫生统计医改监测》资料,对贵州省2008～2011年县级及以上医院、乡镇卫生院和村卫生室等医疗卫生机构就诊人次数、入院人数及其构成比、环比增长情况进行描述性分析.2008年和2009年为医改前,2010年和2011年为医改后.结果：2008～2011年,贵州省医疗机构诊疗人数整体呈增加趋势,但不同机构间有较大差异.新医改后,县级及以上医院门诊就诊人次数及入院人数都保持了较强劲的增长趋势,2011年增长率分别达14.7％和14.8％;而乡镇卫生院、村卫生室和其他医疗机构就诊人次数增长有逐年减缓的趋势,其中,乡镇卫生院2011年门诊就诊人次数增长率为-1.7％.2010年和2011年入院人数增长率分别为-8.6％和-7.9％,门诊就诊人次数及入院人数占全省的比例逐年下降.结论：新医改后居民就诊和住院流向有向县级及以上医院集中的趋势,这有可能进一步加剧“看病难”和“看病贵”.