基于分级诊疗制度下徐州市慢性病患者就医选择影响因素分析研究

背景　分级诊疗制度是提高卫生资源的使用效率，发挥各级医疗机构作用，解决居民“看病难、看病贵”问题的重要途径。目前我国慢性病患病人数不断增加，其就医选择一定程度上影响着分级诊疗制度作用的发挥。目的　了解徐州市慢性病患者分级诊疗制度认知及就医选择情况，分析其就医选择的影响因素，为急慢分诊的分级诊疗格局的形成提供实践依据。方法　2017年7-8月，采用分层整群抽样法抽取徐州市600例慢性病患者进行问卷调查。采用自行设计调查问卷进行面对面调查，调查问卷包括患者基本情况及其对分级诊疗制度的认知及就医选择情况。采用多因素Logistic回归分析探究慢性病患者就医选择的影响因素。结果　共发放调查问卷600份，回收有效问卷534份，有效回收率89.0%。534例慢性病患者中，41.9%（224/534）的患者知晓分级诊疗制度，76.6%（409/534）的患者赞成分级诊疗制度。287例患者最近一次就医选择基层卫生服务机构就诊，占53.7%，247例选择综合医院就诊，占46.3%。居住地〔OR=2.142，95%CI（1.331，3.448）〕、平均月收入〔3 000~4 999元：OR=4.489，95%CI（2.165，9.311）；≥5 000元：OR=5.773，95%CI（2.216，15.037）〕、步行到基层卫生服务机构时间〔≥30 min：OR=3.421，95%CI（1.685，6.947）〕、乘车到综合医院时间〔30~59 min：OR=0.480，95%CI（0.255，0.906）；≥60 min：OR=0.244，95%CI（0.126，0.472）〕、疾病严重程度〔中度：OR=1.799，95%CI（1.053，3.071）；重度：OR=2.559，95%CI（1.400，4.679）〕、知晓分级诊疗制度〔是：OR=0.288，95%CI（0.186，0.445）〕、赞成分级诊疗制度〔是：OR=0.311，95%CI（0.188，0.513）〕是慢性病患者就医选择的影响因素（P<0.05）。结论　徐州市慢性病患者基层卫生服务机构就医率不高，且居住地、平均月收入、步行到基层卫生服务机构时间、乘车到综合医院时间、疾病严重程度、知晓分级诊疗制度情况、赞成分级诊疗制度情况是其就医选择的影响因素。因此卫生行政部门需进一步加强基层全科医生队伍建设，规范慢性病诊疗流程，促进急慢分诊的分级诊疗格局的形成。

Associated Factors for Choice of Medical Institutions for Treatment in Chronic Disease Patients during the Implementation of Hierarchical Medical System:a Survey in Xuzhou

Background The implementation of hierarchical medical system is an important way to improve the use efficiency of health resources,better the performance of medical institutions,and solve the problem of"It is difficult and expensive to see a doctor"among the residents in China.However,its implementation effect may be affected by the choice of medical institutions for treatment among gradually increased chronic disease patients.Objective To investigate the awareness of hierarchical medical system,and choice and associated factors of medical institutions for treatment among chronic disease patients in Xuhzhou,providing evidence for the development of the pattern of treating acute and chronic diseases separately.Methods From July to August 2017,by stratified cluster sampling,600 chronic disease patients from Xuzhou were recruited to participate a face-to-face survey to fill a self-administered questionnaire covering demographic data,awareness of hierarchical medical system and choice of medial institutions for treatment.Multivariate Logistic regression was used to explore the influencing factors of choice of medical institutions for treatment.Results The survey obtained a response rate of 89.0%(534/600).Among the respondents,41.9%(224/534)knew the hierarchical medical system,and 76.6%(409/534)approved the implementation of the hierarchical medical system to solve the problem of"ppris difficult and expensive to see a doctor".In terms of the medical institution visited for latest treatment,287 respondents(53.7%)chose a primary healthcare institution,and other 247(46.3%)chose a general hospital.Place of residenceOR=2.142,95%CI(1.331,3.448)],average monthly income3000-4999 yuan:OR=4.489,95%CI(2.165,9.311);≥5000 yuan:OR=5.773,95%CI(2.216,15.037)],time used to get to the nearest primary healthcare institution from home on foot≥30 min:OR=3.421,95%CI(1.685,6.947)],time used to get to the nearest general hospital from home by bus or car30-59 min:OR=0.480,95%CI(0.255,0.906);≥60 min:OR=0.244,95%CI(0.126,0.472)],disease severitymoderate:OR=1.799,95%CI(1.053,3.071);severe:OR=2.559,95%CI(1.400,4.679)],awareness level of the hierarchical medical systemawareness:OR=0.288,95%CI(0.186,0.445)]and approval of the implementation of the hierarchical medical systemapproval:OR=0.311,95%CI(0.188,0.513)]were associated factors for the choice of medical institutions for treatment.Conclusion The prevalence of seeking healthcare in primary healthcare institutions is unsatisfactory in chronic disease patients from Xuzhou,which is associated with place of residence,average monthly income,time used to get to the nearest primary healthcare institution from home on foot,time used to get to the nearest general hospital from home by bus or car,disease severity,awareness level of the hierarchical medical system and approval of the implementation of the hierarchical medical system.In view of this,health administrative departments should strengthen the development of general practitioners,standardize the diagnosis and treatment procedure for chronic diseases,to promote the development of the pattern of treating acute and chronic diseases separately.