门诊患者对分级诊疗制度的认知评价调查

背景　分级诊疗作为优化卫生资源配置的重要形式，其意义已得到充分认可并在全国范围内开展探索工作。江苏省自2015年全面推进分级诊疗制度建设工作。目的　通过调查江苏省门诊患者对分级诊疗制度的知晓情况、就医意愿，探讨患者对分级诊疗制度的认知评价及其影响因素，为合理引导患者就医流向、促进分级诊疗制度的实施提供循证决策依据。方法　通过分层抽样方法选择江苏省6个城市，采用典型抽样法在每个城市选择4家医疗卫生机构，2017年11—12月采用偶遇抽样法对上述4家医疗卫生机构的门诊患者进行面对面访谈式调查，采用自行设计的调查问卷对门诊患者分级诊疗制度的知晓情况、基层首诊意愿及对双向转诊制度的评价进行调查。结果　有42.5%（738/1 738）门诊患者知晓分级诊疗制度，39.9%（694/1 738）门诊患者知晓基层首诊制度。不同文化程度、工作状态、职业类型、医疗保险类型、平均月收入、居住地、地区门诊患者对分级诊疗制度知晓情况比较，差异有统计学意义（P<0.05）。多因素Logistic回归分析结果显示，文化程度、医疗保险类型、地区是影响门诊患者对分级诊疗制度知晓情况的因素（P<0.05）。48.6%（845/1 738）门诊患者首诊愿意选择基层医疗卫生机构，51.4%（893/1 738）门诊患者首诊愿意选综合医院。知晓基层首诊制度的门诊患者与不知晓基层首诊制度的门诊患者对首诊机构的选择比较，差异有统计学意义（P<0.05）。结论　江苏省门诊患者对分级诊疗制度知晓率较低、基层首诊意愿低，双向转诊中转上不转下问题突出。卫生行政部门需要加强政策宣传与引导、加强基层医疗卫生机构服务能力建设、规范双向转诊制度流程、完善分级诊疗支撑保障制度的建设，逐步完善分级诊疗服务体系建设。

Knowledge and Evaluation of Hierarchical Diagnosis and Treatment System among Outpatients

Background　As an important form of allocation optimization of health resources，hierarchical diagnosis and treatment system has been fully recognized and explored nationwide.Jiangsu Province has comprehensively promoted the construction of hierarchical diagnosis and treatment system since 2015.Objective　By investigating the awareness and willingness of outpatients in Jiangsu Province about the hierarchical diagnosis and treatment system，this paper explored the knowledge and evaluation of hierarchical diagnosis and treatment system and its influencing factors，so as to provide evidence-based decision-making basis for reasonably guiding the flow of patients to medical treatment and promoting the implementation of hierarchical diagnosis and treatment system.Methods　Six cities in Jiangsu Province were selected by stratified sampling and four medical institutions were selected in each city by typical sampling.And outpatients in the medical institutions were interviewed face-to-face through occasional sampling from November to December 2017.The self-designed questionnaires were used to investigate the awareness of hierarchical diagnosis and treatment system，patients' willingness to have primary treatment at the community level，and the evaluation of two-way referral system.Results　42.5%（738/1 738）of outpatients had a certain knowledge of hierarchical diagnosis and treatment system and 39.9%（694/1 738）of outpatients had a certain knowledge of initial diagnosis at the community level.There were significant differences among outpatients in terms of different education level，work status，occupation type，type of medical insurance，average monthly income，residence and region （P<0.05）．The results of multivariate Logistics regression analysis showed that education level，type of medical insurance and area were the main factors influencing the knowledge of hierarchical diagnosis and treatment system （P<0.05）．48.6%（845/1 738）of outpatients showed a willingness to have the primary treatment in community health service centers and 51.4%（893/1 738）of outpatients showed a willingness to have the primary treatment in the hospital.There were significant differences in the choice of primary medical treatment institution among outpatients with or without the knowledge of the initial diagnosis at the community level （P<0.05）．Conclusion　Outpatients in Jiangsu Province have a low awareness of hierarchical diagnosis system and low willingness to have primary treatment at the community level.Problems on two-way referral are prominent.Therefore，the health administration should step up publicity and guidance on policies，strengthen the capacity building of primary health care institutions，and regulate two-way referral system process.They should also provide more support and improve hierarchical diagnosis and treatment system.