离散选择实验在居民基层医疗服务利用中的应用及偏好异质性分析
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摘要
目的:分析居民对基层医疗服务利用的偏好,掌握不同人群的偏好异质性及特征,为基层医疗服务提升提供依据与建议。方法:采用分层抽样法,确定服务方式、服务类型、医疗费用、居民距最近医疗机构的时间、医生类别5个属性,运用离散选择实验引出偏好,运用潜在分类模型分析偏好。结果:在全国东、中、西部6个城市36个社区使用自制问卷调查2019名居民。受访者被分为经济型(37.79%)、专家型(34.17%)、综合型(27.29%)、随机型(0.75%)4个类别。为了获得专家服务和全科服务,受访者分别愿意多自付604.31元、237.25元,需要补贴202.12元才能更多提高中医服务的接受度。结论:居民对高质价优的医疗服务需求是医改的落脚点,需注重全人群的健康预防教育,增加低收入者的健康福利,引导全科医疗和中医服务在基层服务体系中进一步发挥作用。
Objective: Through analyzing the residents' preferences for the utilization of primary care services, it could accurately grasp the preferences of different groups, and provide suggestions for the improvement of primary medical services. Methods: The sample points were selected by stratified sampling method to define the attributes including service mode, service type, medical expenses, residents' access time for the nearest institution and doctor category. The preference was derived by discrete choice experiment and the preference was analyzed by latent class model. Results: The self-made questionnaire was us ed to interview 2019 residents in 36 communities in 6 cities in east, central and west region in China. Respondents were divided into price dominant(37.79%), quality seeker(34.17%), comprehensive type(27.29%) and random type(0.75%). In order to obtain expert services and general practice services, respondents were willing to pay 604.31 yuan and 237.25 yuan extraly, and needed to subsidize 202.12 yuan to improve the acceptance of TCM services. Conclusion: The residents' demand for high-quality and low-price medical services was the foothold of medical reform. It was necessary to pay attention to health prevention education of the whole population, increase the health benefits of low-income people, and guide general medical and traditional Chinese medicine services to further play its role in the grassroots service system.
Objective: Through analyzing the residents' preferences for the utilization of primary care services, it could accurately grasp the preferences of different groups, and provide suggestions for the improvement of primary medical services. Methods: The sample points were selected by stratified sampling method to define the attributes including service mode, service type, medical expenses, residents' access time for the nearest institution and doctor category. The preference was derived by discrete choice experiment and the preference was analyzed by latent class model. Results: The self-made questionnaire was us ed to interview 2019 residents in 36 communities in 6 cities in east, central and west region in China. Respondents were divided into price dominant(37.79%), quality seeker(34.17%), comprehensive type(27.29%) and random type(0.75%). In order to obtain expert services and general practice services, respondents were willing to pay 604.31 yuan and 237.25 yuan extraly, and needed to subsidize 202.12 yuan to improve the acceptance of TCM services. Conclusion: The residents' demand for high-quality and low-price medical services was the foothold of medical reform. It was necessary to pay attention to health prevention education of the whole population, increase the health benefits of low-income people, and guide general medical and traditional Chinese medicine services to further play its role in the grassroots service system.
引文
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[15]钱磊,杨丹琳,李林贵.离散选择实验模型在卫生人力资源研究中的运用[J].中国初级卫生保健,2014,28(1):15-16
[16]朱大伟,郭娜,王健,等.离散选择实验在疫苗接种偏好及需求研究中的应用[J].中国卫生经济,2016,35(2):5-7.
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[20]MILTE R,RATCLIFFE J,CHEN G,et al.What characteristics of nursing homes are most valued by consumers?A discrete choice experiment with residents and family members[J].Value in health,2018,21(7):843-849.
[21]国家卫生计生委统计信息中心.2013第五次国家卫生服务调查分析报告[M].中国协和医科大学出版社,2015.
[22]刘瑞江,张业旺,闻崇炜,等.正交试验设计和分析方法研究[J].实验技术与管理,2010,27(9):52-55.
[23]HANLEY N,RYAN M,WRIGHT R.Estimating the monetary value of health care:lessons from environmental economics[J].Health economics,2003,12(1):3-16.
[24]ANDERSEN R.A behavioral model of families’use of health services[J].Journal of human resources,1968,7(1):125-127.
[25]邱皓政.潜在类别模型的原理与技术[M].北京:北京大学出版社,2008:22-25.
[26]HOMBURG C,KOSCHATE N,HOYER W D.Do satisfied customers really pay more?A study of the relationship between customer satisfaction and willingness to pay[J].Journal of marketing,2005,69(2):84-96.
[27]MUURINEN J.Demand for health:a generalised grossman model[J].Journal of health economics,1982,1(1):5-28.
[28]席彪,吴海江,赵雅婷,等.全科医疗服务的机制[J].医学研究与教育,2018,35(4):29-34.
[29]匡莉.全科医疗核心特征功能概念与内涵界定的研究思路[J].中国卫生政策研究,2017,10(5):1-6.
[30]ADAMOWICZ W,BOXALL P,WILLIAMS M,et al.Stated preference approaches for measuring passive use values choice experiments and contingent valuation[J].American journal of agricultural economics,1998,80(1):64-75.
[31]SEBASTIáN C,ORTúZAR J D D,RIZZI L I,et al Assessing the influence of design dimensions on stated choice experiment estimates[J].Transportation research,part B(Met hodological),2005,39(7):621-640.
[2]张永光,傅薇,王晓锋,等.我国开展”以人为本的一体化卫生服务”模式的挑战及对策[J].中国卫生资源,2017,20(6):525-530.
[3]罗秀,王轶.以人为本的整合型卫生服务在荷兰的实践及其对我国的启示[J].中国全科医学,2017,20(13):1534-1538
[4]国家卫生健康委员会.关于坚持以人民健康为中心推动医疗服务高质量发展的意见[EB/OL].(2018-08-16)[2019-02-28].http://www.nhfpc.gov.cn/yzygj/s3594q/201808/1e5aeaf3dbf b457487bc1d92783b43d8.shtml,2018-08-16.
[5]廖成娟.行为经济学对卫生政策的启示:应用、评价与展望[J].中国卫生经济,2018,37(10):15-18.
[6]SCOTT K W,JHA A K.Putting quality on the global health agenda[J].New England journal of medicine,2014,371(1):3-5.
[7]KRUK M E,NIGENDA G,KNAUL F M.Redesigning primary care to tackle the global epidemic of noncommunicable disease[J].American journal of public health,2015,105(3)431-437.
[8]RYAN M,MCINTOSH E,DEAN T,et al.Trade-offs between location and waiting times in the provision of health care:the case of elective surgery on the Isle of Wight[J].Journal of public health medicine,2008,29(26):3503-3513.
[9]刘童童,李顺平,陈钢.离散选择实验用于癌症筛查偏好的国际研究进展[J].中国卫生经济,2017,36(5):75-78.
[10]KLEIJ K S,TANGERMANN U,AMELUNG V E,et al Patients’preferences for primary health care-a systematic literature review of discrete choice experiments[J].BMC health services research,2017,17(1):476-488.
[11]ALBADA A,TRIEMSTRA M.Patients’priorities for ambulatory hospital care centres.A survey and discrete choice experiment among elderly and chronically ill patients of a Dutch hospital[J].Health expectations,2009,12(1):92-105.
[12]BUJOSA A,RIERA A,HICKS R L.Combining discrete and continuous representations of preference heterogeneity:a latent class approach[J].Environmental&resource economics,2010,47(4):477-493.
[13]李玲,王健,袁嘉.医院距离对农村地区居民住院需求的影响:一个离散选择模型的应用[J].中国卫生经济,201433(1):11-13.
[14]吴笛,史玥,吴爽.基于离散选择实验的护理本科生对基层卫生工作偏好分析[J].中国全科医学,2017,20(30)3759-3762.
[15]钱磊,杨丹琳,李林贵.离散选择实验模型在卫生人力资源研究中的运用[J].中国初级卫生保健,2014,28(1):15-16
[16]朱大伟,郭娜,王健,等.离散选择实验在疫苗接种偏好及需求研究中的应用[J].中国卫生经济,2016,35(2):5-7.
[17]COAST J,ALJANABI H,SUTTON E J,et al.Using qualitative methods for attribute development for discrete choice experiments:issues and recommendations[J].Health economics,2012,21(6):730-741.
[18]HALL J,VINEY R,HAAS M,et al.Using stated preference discrete choice modeling to evaluate health care programs[J]Journal of business research,2004,57(9):1026-1032.
[19]BURTON C D,ENTWISTLE V A,ELLIOTT A M,et al The value of different aspects of person-centred care:a series of discrete choice experiments in people with long-term conditions[J].BMJ open,2017,7(4):e015689.
[20]MILTE R,RATCLIFFE J,CHEN G,et al.What characteristics of nursing homes are most valued by consumers?A discrete choice experiment with residents and family members[J].Value in health,2018,21(7):843-849.
[21]国家卫生计生委统计信息中心.2013第五次国家卫生服务调查分析报告[M].中国协和医科大学出版社,2015.
[22]刘瑞江,张业旺,闻崇炜,等.正交试验设计和分析方法研究[J].实验技术与管理,2010,27(9):52-55.
[23]HANLEY N,RYAN M,WRIGHT R.Estimating the monetary value of health care:lessons from environmental economics[J].Health economics,2003,12(1):3-16.
[24]ANDERSEN R.A behavioral model of families’use of health services[J].Journal of human resources,1968,7(1):125-127.
[25]邱皓政.潜在类别模型的原理与技术[M].北京:北京大学出版社,2008:22-25.
[26]HOMBURG C,KOSCHATE N,HOYER W D.Do satisfied customers really pay more?A study of the relationship between customer satisfaction and willingness to pay[J].Journal of marketing,2005,69(2):84-96.
[27]MUURINEN J.Demand for health:a generalised grossman model[J].Journal of health economics,1982,1(1):5-28.
[28]席彪,吴海江,赵雅婷,等.全科医疗服务的机制[J].医学研究与教育,2018,35(4):29-34.
[29]匡莉.全科医疗核心特征功能概念与内涵界定的研究思路[J].中国卫生政策研究,2017,10(5):1-6.
[30]ADAMOWICZ W,BOXALL P,WILLIAMS M,et al.Stated preference approaches for measuring passive use values choice experiments and contingent valuation[J].American journal of agricultural economics,1998,80(1):64-75.
[31]SEBASTIáN C,ORTúZAR J D D,RIZZI L I,et al Assessing the influence of design dimensions on stated choice experiment estimates[J].Transportation research,part B(Met hodological),2005,39(7):621-640.