医疗联合体及其模式对城市基层医疗服务质量的影响：基于标准化病人法

目的：分析医疗联合体及其模式对基层医疗服务质量的影响。方法：采用标准化病人方法收集医疗服务质量数据。采用粗糙化精确匹配法和倍差法，结合多元回归模型评估医疗联合体及其模式的效果。结果：紧密型医疗联合体使诊疗规范依从性上升了1.35个百分点（P<0.001），正确诊断率上升了0.61个百分点（P<0.001），不必要检查比例下降了1.65个百分点（P<0.05），有害或无用药物的比例下降了2.07个百分点（P<0.05），问诊时间增加了0.36分钟（P<0.05），以患者为中心总得分平均上升了1.35分（P<0.001）。结论：参加医疗联合体，特别是紧密型医疗联合体有利于提高基层医疗服务质量，但其作用有限。原因在于尚未形成真正意义上的责任共同体和利益共同体，难以推动内部运行机制的改革，制约着紧密型医疗联合体发挥其优势。

A study on the impacts from medical service complex and its models on the quality of primary medical services in urban China: Based on the standardized patient approach

Objectives:To analyze the impacts from Medical Service Complex (MSC) and its models on the quality of primary care. Methods:The Standardized Patient approach was employed to collect the data of primary medical service quality. The Coarsened Exact Matching approach, Difference-in-Difference (DID) approach and Multiple Regression model were adopted to evaluate the effects of MSC and its models. Results:Close-knit MSC increased the clinical practice compliance rate by 1.35 percentage points (P<0.001), improved the correct diagnosis rate by 0.61 percentage points (P<0.05), reduced the rate of unnecessary checks by 1.65 percentage points (P<0.05), lowered the rate of harmful or useless drugs by 2.07 percentage points (P<0.05), lifted the per-patient consultation time by 0.36 minutes (P<0.05), and raised the average total score of patient-centered communication by 1.35 points (P<0.001). Conclusions:Participation in MSC, especially close-knit MSC, is in favor of improving the quality of primary medical services. However, such positive effect is limited, because the community of responsibilities and interests in a real sense has not yet been formed, which makes it difficult to drive the reform of the internal operation mechanism, which, in turn, restricts close-knit MSC to exert its advantages.