基本医疗卫生制度框架下农村地区医疗服务分流研究
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摘要
我国医药卫生体制改革的目标是建立基本医疗卫生制度,通过政府的统一组织和安排,向国民提供均等的公共卫生服务和基本医疗服务,在基本医疗卫生制度框架下加强农村医疗服务体系建设,是为了更好地实现向农村居民提供基本医疗服务的目标。新医改对我国农村医疗服务体系建设的要求是要加快建立健全农村三级医疗卫生服务网络,县级医疗机构主要负责以住院为主的基本医疗服务及危重急症病人的抢救,乡镇卫生院负责提供常见病、多发病的诊疗,村卫生室承担行政村的一般疾病的诊治等工作。从理论上来说,农村常见病的诊治应该在乡镇卫生院及以下机构完成,大病和疑难病的诊治在县级及以上机构完成,农村三级医疗网应该有效地分流农村患者,使农村居民的大部分基本医疗卫生需要在基层医疗卫生机构得到满足,卫生资源结构也应该与农民健康需求的结构基本一致。但是目前由于我国城乡医疗资源配置失衡和不公平引发的农村地区县级医疗机构服务过度而乡镇卫生院服务不足已成为严重问题,乡镇卫生院医疗资源配置不足和患者流失形成恶性循环,转诊制度的缺位也使由高层级医疗机构向低层级医疗机构的转诊几乎难以实现,要解决这一问题,必须实现乡镇卫生院对常见病、多发病诊疗的骨干作用,促进农村医疗服务向基层医疗机构合理分流。
医疗服务分流是指在不影响临床诊断治疗及预后的情况下,由适当层级的医疗机构对病人提供医疗服务,包括向上分流和向下分流。医疗服务合理分流是改善医疗服务提供宏观结构不合理的方法之一,通过对医疗服务提供在各级医疗机构分布的重新调整,利用资源跟着病人走的方式,可以促进卫生资源配置结构和卫生资源投向的调整。促进农村地区医疗服务合理分流,对于缓解县级医疗机构服务过度和乡镇卫生院服务不足现象、合理配置农村医疗服务资源、使农村居民更好地获得基本医疗服务具有重要意义。目前关于医疗服务分流的研究多集中于城市大医院和社区卫生服务机构之间的转诊研究,缺少对农村医疗服务分流的系统研究,特别是缺乏在系统制度安排条件下的农村医疗服务分流研究,我国农村地区县、乡医疗机构中有哪些疾病和医疗服务可以分流,可分流的比例有多大,可分流的疾病有哪些,影响农村地区医疗服务分流的因素是什么,应该用什么样的模式进行分流,分流的标准如何确定,从体系和制度安排的角度要实现农村医疗服务分流需要制定哪些政策措施和相关的保障制度等,都是需要进一步研究解决的问题。
因此本研究的目的是通过对山东省农村地区医疗服务现状的调查研究,对各层级医疗服务机构门诊和住院病人的流向进行描述,分析其中可分流的空间、可分流的内容,并且结合专家访谈等定性研究的结果,深入分析目前影响山东省农村地区医疗服务分流的主要因素,探讨分流的具体模式和标准,在此基础上提出在建立基本医疗卫生制度框架下,农村地区医疗服务分流的内容、方法以及相关制度安排和政策保障。
研究方法：
论文采用定量研究和定性研究的方法,现场调查的数据资料来源于两部分,一部分是《农村卫生适宜技术及产品研究与应用》项目基线调查,选取了即墨、平阴和嘉祥三个县作为样本,每个样本县选取当地的县人民医院、县中医医院、县妇幼保健院、4个乡镇卫生院及每个乡镇卫生院下设的4个村卫生室作为样本。共抽取了3个县人民医院、3个县中医医院、3个县妇幼保健院、12个乡镇卫生院和48个村卫生室,通过抽样调查获取了样本机构一定时间段内县、乡、村三级医疗机构实际发生的门诊和住院病历信息。第二部分是请县、乡两级医疗机构有经验的临床医生对已获得的实际病历理论上应该由哪级医疗机构进行诊治做出判断,选取了嘉祥、曲阜两个县作为样本,每个县选择县医院、县中医院、6个乡镇卫生院作为调查场所,共2所县医院,2所县中医院和12所乡镇卫生院,调查对象为县级医疗机构各主要临床科室中工作年限在10年以上,具有中级以上职称的临床医生,乡镇卫生院各主要科室年资最高的临床医生。数据采用Microsoft access二次录入系统录入,采用SPSS11.5软件进行分析,主要采用描述性统计分析、单因素统计分析。访谈资料来源于对所调查医疗机构管理者的访谈。
主要结果：
(1)县级医疗机构门诊就诊患者中有67.25%的患者应当分流到低层级的医疗机构就诊,县级医疗机构住院患者中有23.15%的患者应该向基层医疗机构分流；在乡镇医疗机构门诊和住院患者中,几乎没有应当向基层医疗机构分流的患者；乡镇卫生院诊治门诊患者中只有6.38%的患者应该向上级医疗机构转诊,住院患者中有17.77%的患者应当在上级医疗机构诊治。
(2)县级医疗机构最应优先分流的门诊疾病和医疗服务有急性上呼吸道感染、产前检查、胃炎、气管炎、糖尿病、一般外伤、阴道炎、疱疹性咽峡炎、高血压、早期妊娠、冠心病、肺炎、人工流产、湿疹、妇科检查、健康查体、腰痛、荨麻疹、肠炎、月经失调、乳腺增生、皮炎、淋巴结炎、盆腔炎、腹泻和泌尿道感染,共24种疾病,占所有常见病门诊量的55.95%,这些病种的患者实际上只有16.89%是在乡镇卫生院就诊的；最应优先分流的住院疾病和医疗服务有正常分娩、各类外伤、高血压、冠心病、慢性支气管炎、急性支气管炎、痔疮、急性阑尾炎、上呼吸道感染、腹股沟斜疝、人工流产、脑震荡、贫血、慢性胃炎、扁桃体炎,共15种疾病,占住院常见病的50.43%,这些病种的患者实际上只有20.86%是在乡镇卫生院就诊的。
(3)门诊就诊率前15位的病种,县级医疗机构临床医生认为适宜在乡镇卫生院诊治的比例均低于乡镇卫生院临床医生认为适宜在乡镇卫生院诊治的比例；住院常见病中就诊率前15位的病种,县级医疗机构临床医生认为适宜在乡镇卫生院诊治的比例也低于乡镇卫生院临床医生认为适宜在乡镇卫生院诊治的比例。差异具有统计学意义的都是一些病情严重程度差别较大,必须根据病情确定诊治层级的疾病,例如冠心病、肺炎等。差异没有统计学意义的都是一些治疗难度较低或较高的病种。有23.91%的县级医疗机构医生不愿意将患者向基层医疗机构转诊。
(4)常见门诊疾病和医疗服务在县级医疗机构诊治的医疗费用在绝对数值上明显高于在乡镇卫生院诊治的医疗费用,但是这种差别没有统计学意义；多数住院疾病或服务在医疗费用的绝对数值上也高于乡镇卫生院,县、乡医疗机构医疗费用存在显著性差异的疾病主要有两类,一类是慢性非传染性疾病例如高血压、冠心病和慢性呼吸系统疾病,另一类是需要进行外科手术的疾病,例如痔疮、急性阑尾炎、剖腹产术、子宫肌瘤等。
(5)县级医疗机构门诊患者中适宜分流的有67.25%,但乡镇卫生院的服务能力能够承接的只有48.45%,县级医疗机构住院患者中适宜分流的有23.15%,乡镇卫生院实际能够承接的只有16.50%。62.39%的调查对象认为影响乡镇卫生院服务能力的最大障碍是缺乏人才,人才问题中80.95%的调查对象认为,引进不了高技术专业人才是最主要的问题。
(6)关于医疗服务分流模式,多数受访者认为应该采取多种转诊模式相结合的方法进行分流。主要观点有可以根据疾病的严重程度、恢复程度等,确定每一级医院相应的转诊标准,并制定相应的监督及奖惩措施；鉴于乡镇卫生院的实际服务能力确实有限,应该由县级医疗机构负责对疾病的诊断,而由乡镇卫生院承担更多的疾病治疗和康复工作。
讨论和政策建议：
县级医疗机构门诊和住院患者存在较大的可分流空间或潜在可分流空间,在制定促进农村地区医疗服务分流的相关政策时,应把加强对县级医疗机构门诊患者的向下分流、引导门诊患者在基层就诊作为主要的政策目标。
影响农村地区医疗服务分流的因素有：(1)县、乡医疗机构经济利益对立以及县、乡医疗机构临床医生对疾病分流判断的认知差异；(2)同病种在县、乡医疗机构诊治的医疗费用差异；(3)乡镇卫生院的实际服务能力不足。
现阶段农村地区医疗服务分流的模式可以考虑按病种、按疾病病程相结合的模式。具体方式为根据各地常见病、多发病情况以及各级医疗机构的实际诊治能力,制定符合当地实际的应当转诊的疾病名单和具体病种的规范化诊疗程序作为转诊的标准。同时必须考虑到农村基层医疗机构服务能力相对不足的现状,应该采取由县级医疗机构明确疾病诊断的方式,由县级医疗机构的临床医生决定患者应当在哪个层级的医疗机构就诊；由县级医疗机构制定诊疗方案以后再由乡镇卫生院执行治疗方案,也更能保证治疗的效果。
对此研究我们提出以下政策建议：(1)进一步明确农村医疗服务体系的功能定位,由县级医疗机构承担更多的疾病诊断和确定治疗方案的功能,而乡镇卫生院则应更多地承担明确了诊断和治疗方案后的后续治疗工作以及对进入康复阶段疾病的治疗功能。(2)加强农村卫生服务制度建设,包括加强农村卫生服务体系和能力建设,重点是农村基层卫生服务人员的能力建设；解决医疗机构之间经济利益对立的问题,通过制度安排使三级医疗机构之间由全面竞争的关系转变为协作的关系；加强农村地区医疗服务分流制度建设,促使医疗机构和临床医生严格按照当地的转诊病种和病种服务流程对病人实施转诊,以医疗服务分流为导向调整农村医疗卫生资源的配置,根据确定的分流病种和病种服务流程,按照治疗要求为各级医疗机构配置相应的人员、设备等。(3)各地卫生部门应当根据本地实际情况组织确定当地主要可转诊病种和可转诊病种的规范化诊疗程序和转诊标准,并要求医疗机构及临床医生严格按照此程序和标准及时转诊病人。(4)拉大新型农村合作医疗制度在县、乡医疗机构诊疗的起付线和补偿比例的差距,差别至少要超出20%以上。(5)相关制度建设,包括建立相应的监督考核机制,确保转诊能够实现；根据各地的转诊病种和疾病规范化诊疗流程,有针对性地加强对基层医疗机构相应疾病知识和服务能力的培训,提高基层医疗机构承接转诊病例的能力；加强对基层医疗机构医疗质量的监管,对转诊病种的后续治疗结果进行监督考核,确保患者在不同层级的医疗机构能够获得相同的治疗效果。
The overall goal of the health care system reform is to establish the basic health care system which provides people with equal public health services and basic health care services through government's leading roles and responsibilities in planning, supervision and regulation. Under this basic health care system, enhancing the rural health service network is crucial to achieve the goal of providing basic health services to rural residents. The reform requires for further completing the rural health care service network. The county-level hospital shall be mainly in charge of treating and saving patients with severe or acute diseases; the township health centres shall take the responsibilities of diagnosing and treating the commonly or frequently encountered diseases; the village clinics shall take the responsibilities of the administrative villages'diagnoses and treatment of general diseases and other services. Theoretically speaking, in rural areas the commonly or frequently encountered diseases should be treated at or under the township level hospitals, while the severe diseases should be treated at or above the county level hospitals. In rural areas, patients should be effectively referred to appropriate levels of health institutions through the three-tier health care networks, and rural residents'demands for basic health care services should be met in grass-roots health institutions, in accordance with the distribution of health resources. However, the over-use of the county level hospitals and the under-use of the township health centres become a severe problem because of the inequity and the imbalanced distribution of health resources between urban and rural areas. Moreover, a vicious cycle due to the insufficient input and the drain of patients in township health centres and the lack of flow system make it impossible to refer patients from the higher levels to the lower levels of the health institutions. To solve these problems, an effective flow system should be established in which township health centres play crucial roles in treating the commonly or frequently encountered diseases and patients should be guided to use the grass-roots health institutions for general diseases.
Medical service flow is a process in which patients receive the health care services in a more appropriate institution than the initial one without affecting the clinical treatment and prognosis, including upward referral and downward referral. To set up a reasonable and effective flow system is one of the key approaches to improve the macro health care system. Through the rearrangement of the health care services provision by different levels of health institutions and the reallocation of the resources by patients, the structure of the health resources and the direction of the health input shall be effectively adjusted. The reasonable referral in rural areas is significant to solve the problem of over-use of county level hospitals and under-use of township health centres, to promote the reasonable allocation of rural health resources and to improve the access to basic health care services for rural residents.
Most of the current researches focus on the referral between urban hospitals and community health centres, while little attention is paid to the flow system in rural areas. Therefore it is important to pursue the following questions:in the county-level and township-level health care institutions, what kind of and how much of diseases and services can be referred, what are the influential factors, what referral models can be used, how to set referral standards, and what policies and supportive systems are needed to establish the rural health care flow system.
The general objective of this study is:through the study on the current situation of health care services in rural Shandong, describe the flow both of outpatients and inpatients between different levels, analyze what kind of and how much of the diseases and services can be referred, explore the influential factors of referral in rural Shandong and the models and standards for referral, propose the contents and methods of and the relative policies for the flow system in rural areas.
Date and Methods
This study used both quantitative and qualitative study methods. The study data are from two sources. One is the baseline survey for the project "Proper technologies and productions for rural areas". We selected Jimo, Pingyin and Jiaxiang as the sample counties. In every county, we selected county hospital, county traditional Chinese traditional medicine hospital, county maternal and child health hospital, four township health centres and four village clinics of each town. In all,3 county hospitals,3 county Chinese traditional medicine hospitals,3 county maternal and child health hospitals,12 township health centres and 48 village clinics were selected. We obtained the outpatient and inpatient medical reports of a specific period of the three levels institutions through the survey.
The second part of the data is from the questionnaire survey of the experienced clinical doctors who gave their judgments on which level of the rural health institutions should the patients theoretically be referred to according to the medical records. We selected county hospital, county traditional Chinese medicine hospital and 6 township health centres respectively in Jiaxiang and Qufu County.2 county hospitals,2 county traditional Chinese medicine hospitals and 12 township health centres were selected in total. We interviewed the clinical doctors who work more than 10 years and have the intermediate technical titles in county hospitals and who have the highest qualification in township health centres.
We used the Microsoft Access software to input data and the SPSS11.5 software to conduct the analysis. The descriptive statistical analysis and single factor analysis were the main analysis methods for quantitative data. The qualitative data were from the interviews of the managers of the sample institutions.
Main results
(1) 67.25% outpatients in the county-level medical facilities are supposed to referred to the lower medical facilities, and 23.15% inpatients in the county-level medical facilities should be transferred to the gross-roots medical facilities; Almost no patients in the township-level medical facilities are thought to be referred to the gross-roots medical facilities, and only 6.38% outpatients and 17.77% inpatients respectively; in the township-level medical facilities should be transferred to the superior medical facilities.
(2) Diseases that should be primarily referred in the outpatient service were 24 diseases, such as acute upper respiratory tract infection, prenatal examination, gastritis, tracheitis, diabetes mellitus, general traumatic, vaginitis, herpangina, hypertension, early pregnancy, coronary heart disease, pneumonia, induced abortioneczema, gynecological examination, health examination, lumbago, urticaria, enteritis, menstrual disorder, hyperplasia of mammary glandsdermatitis, lymphadenitis, pelvic inflammation, diarrhea and urinary tract infections only 16.89% of these patients saw the doctors in township hospitals; the diseases should be transferred in inpatient service were about 15, such as normal delivery, all kinds of trauma, hypertention, coronary heart disease, chronic bronchitis, acute bronchitis, haemorrhoids, acute appendicitis, the upper respiratory tract, groin indirect hernia, induced abortion, cerebral concussion, anemia, chronic gastritis, tonsillitis and so on, which made up 50.43% of the common illnesses in the inpatient service, while only 20.86% of these diseases were treated in the township hospitals.
(3)Among the top 15 diseases in the outpatient service visit, proportion of diseases considered to be treated in the township hospitals by doctors in county-level medical facilities was lower than the township hospital physicians, while in the top 15 diseases in the inpatient service visit, it's the same situation. Only the diseases vary largely in the severity and must according to the state of the disease to ensure the facility of the treatment, for instance, coronary heart disease and pneumonia, there was statistical difference, while statistically difference didn't exist in the much easily or difficultly cured diseases. Also,23.19% physicians in the county-level medical facilities didn't have the willingness to refer their patients to the grass roots medical facilities.
(4) The medical expense of the common illness in the outpatient service in county-level medical facilities was obviously higher than that in the township medical facilities; however, there was no statistic difference; so was the medical expense of the inpatient services. There was significant difference in the medical expense of two kinds of diseases between county-level and township medical facilities, one kind was chronic non-infectious disease, such as hypertension, coronary heart disease and chronic respiratory disease, the other kind was the disease needing surgery, for example hemorrhoids, acute appendicitis, caesarean birth and hysteromyoma.
(5) Outpatients supposed to be referred in the county-level medical facilities are 67.25%, while the service capability of the township medical facilities was only 48.45%; inpatients supposed to be referred in the county-level medical facilities are 23.15%, while the service capability of the township medical facilities was only 16.50%.62.39% respondents thought that the largest barrier to develop the service capability of the township medical facilities was shortage of the talent, among which 80.95% respondents believed that the key problem was too difficult to introduce high technology professionals.
(6) As to the medical service referral model, most interviewees preferred to adopt the combination of more kinds of referral models. Main opinions included:according to the severity and recovery status of the diseases, to work out the referral standard of each level hospital and draw up the supervision, rewards and punishment system. In consideration of the limited service capability of the township hospital, the county-level medical facilities should take the responsibility to diagnosis, while the township medical facilities focused on more treatment work.
Discussions and policy implications
There is large and potential room of referral for outpatients and inpatients in county level hospitals. During the policy formulation process, it is important to make it a policy goal that the outpatients in county level hospitals should be referred downward and guided to use the services in township health centres and village clinics.
The main influential factors for referral in rural areas:(1) County level hospitals and township health centres are in opposite positions of interests and have cognitive gap in judgment of disease referral. (2) There are expense gap of similar disease treatment between county and township hospitals. (3) Township health centres are poor in service capacity.
At the present stage, the medical service referral model for rural area could take into account the combination model of disease category and duration. In detail, in line with the prevalence of common illness and the service capability of all levels medical facilities, the standard of referral including the list of the diseases ought to be referred and the flow of the normal diagnosis and treat should be formulated. Meanwhile, the current situation that the service capabilities of the rural gross-roots medical facilities are relatively insufficient should be considered. The way we ought to take is that the diagnosis of the disease should be cleared by the county-level medical facilities, the proper level of the medical facility the patient should be treated ought to be decided by the physician of county-level medical facilities, and the treatment scheme should be formulated by the county-level medical facilities and implemented by the township medical facilities to assure the treatment effect.
As to this study, we propose the policy recommendations as follows (1) Health departments in various regions should ensure the main referable disease and their normal treatment flow and the referral standard, which strictly obeyed by the medical institutions and the clinical doctors to refer the patients in time. (2) Further to clear and definite the function of the medical service system in rural areas. More work on diseases diagnosis and treatment scheme should be assumed by the county-level medical facilities, while more work on cure and recovery in the following period after the treatment scheme has been drawn up ought to be taken on by the township hospitals. (3) Strengthening the construction of the health care service system in rural area, including the construction of institution and capability, especially the ability building of the service personal of grass-roots medical facilities; by means of institutional arrangement to replace the fully competition relationship with coordination among the three-level medical facilities for the purpose of solving the contradiction of economic interest among all-level medical institutions. Strengthen the establishment of medical service flow system in rural area and impel the medical facilities and physicians to abide by local referral disease category and treatment flow to copy with patients, guided by the medical service referral to adjust the health care resource allocation, in accordance with the decided referral disease category, treatment flow and cure requirement to allocate the workers and equipments to various-level medical facilities. (4) Enlarging the gap of deductible and reimbursement ratio between county-level and township medical facilities, and the gap is 20% at least. (5) Establishment of system related, including the construction of supervision and assessment mechanism to ensure the accomplishment of flow. In line with local referral disease category and normal treatment flow to enhance training of corresponding disease knowledge and service ability in grass-roots medical facilities to improve the capability of accepting the referral case in grass-roots medical facilities. Increase the supervision for the quality of grass-roots medical facilities, for instance, supervising and accessing the effect of the following treatment of the referral disease category to make sure that patients can acquire the similar treatment effect in different-level medical facilities.
医疗服务分流是指在不影响临床诊断治疗及预后的情况下,由适当层级的医疗机构对病人提供医疗服务,包括向上分流和向下分流。医疗服务合理分流是改善医疗服务提供宏观结构不合理的方法之一,通过对医疗服务提供在各级医疗机构分布的重新调整,利用资源跟着病人走的方式,可以促进卫生资源配置结构和卫生资源投向的调整。促进农村地区医疗服务合理分流,对于缓解县级医疗机构服务过度和乡镇卫生院服务不足现象、合理配置农村医疗服务资源、使农村居民更好地获得基本医疗服务具有重要意义。目前关于医疗服务分流的研究多集中于城市大医院和社区卫生服务机构之间的转诊研究,缺少对农村医疗服务分流的系统研究,特别是缺乏在系统制度安排条件下的农村医疗服务分流研究,我国农村地区县、乡医疗机构中有哪些疾病和医疗服务可以分流,可分流的比例有多大,可分流的疾病有哪些,影响农村地区医疗服务分流的因素是什么,应该用什么样的模式进行分流,分流的标准如何确定,从体系和制度安排的角度要实现农村医疗服务分流需要制定哪些政策措施和相关的保障制度等,都是需要进一步研究解决的问题。
因此本研究的目的是通过对山东省农村地区医疗服务现状的调查研究,对各层级医疗服务机构门诊和住院病人的流向进行描述,分析其中可分流的空间、可分流的内容,并且结合专家访谈等定性研究的结果,深入分析目前影响山东省农村地区医疗服务分流的主要因素,探讨分流的具体模式和标准,在此基础上提出在建立基本医疗卫生制度框架下,农村地区医疗服务分流的内容、方法以及相关制度安排和政策保障。
研究方法：
论文采用定量研究和定性研究的方法,现场调查的数据资料来源于两部分,一部分是《农村卫生适宜技术及产品研究与应用》项目基线调查,选取了即墨、平阴和嘉祥三个县作为样本,每个样本县选取当地的县人民医院、县中医医院、县妇幼保健院、4个乡镇卫生院及每个乡镇卫生院下设的4个村卫生室作为样本。共抽取了3个县人民医院、3个县中医医院、3个县妇幼保健院、12个乡镇卫生院和48个村卫生室,通过抽样调查获取了样本机构一定时间段内县、乡、村三级医疗机构实际发生的门诊和住院病历信息。第二部分是请县、乡两级医疗机构有经验的临床医生对已获得的实际病历理论上应该由哪级医疗机构进行诊治做出判断,选取了嘉祥、曲阜两个县作为样本,每个县选择县医院、县中医院、6个乡镇卫生院作为调查场所,共2所县医院,2所县中医院和12所乡镇卫生院,调查对象为县级医疗机构各主要临床科室中工作年限在10年以上,具有中级以上职称的临床医生,乡镇卫生院各主要科室年资最高的临床医生。数据采用Microsoft access二次录入系统录入,采用SPSS11.5软件进行分析,主要采用描述性统计分析、单因素统计分析。访谈资料来源于对所调查医疗机构管理者的访谈。
主要结果：
(1)县级医疗机构门诊就诊患者中有67.25%的患者应当分流到低层级的医疗机构就诊,县级医疗机构住院患者中有23.15%的患者应该向基层医疗机构分流；在乡镇医疗机构门诊和住院患者中,几乎没有应当向基层医疗机构分流的患者；乡镇卫生院诊治门诊患者中只有6.38%的患者应该向上级医疗机构转诊,住院患者中有17.77%的患者应当在上级医疗机构诊治。
(2)县级医疗机构最应优先分流的门诊疾病和医疗服务有急性上呼吸道感染、产前检查、胃炎、气管炎、糖尿病、一般外伤、阴道炎、疱疹性咽峡炎、高血压、早期妊娠、冠心病、肺炎、人工流产、湿疹、妇科检查、健康查体、腰痛、荨麻疹、肠炎、月经失调、乳腺增生、皮炎、淋巴结炎、盆腔炎、腹泻和泌尿道感染,共24种疾病,占所有常见病门诊量的55.95%,这些病种的患者实际上只有16.89%是在乡镇卫生院就诊的；最应优先分流的住院疾病和医疗服务有正常分娩、各类外伤、高血压、冠心病、慢性支气管炎、急性支气管炎、痔疮、急性阑尾炎、上呼吸道感染、腹股沟斜疝、人工流产、脑震荡、贫血、慢性胃炎、扁桃体炎,共15种疾病,占住院常见病的50.43%,这些病种的患者实际上只有20.86%是在乡镇卫生院就诊的。
(3)门诊就诊率前15位的病种,县级医疗机构临床医生认为适宜在乡镇卫生院诊治的比例均低于乡镇卫生院临床医生认为适宜在乡镇卫生院诊治的比例；住院常见病中就诊率前15位的病种,县级医疗机构临床医生认为适宜在乡镇卫生院诊治的比例也低于乡镇卫生院临床医生认为适宜在乡镇卫生院诊治的比例。差异具有统计学意义的都是一些病情严重程度差别较大,必须根据病情确定诊治层级的疾病,例如冠心病、肺炎等。差异没有统计学意义的都是一些治疗难度较低或较高的病种。有23.91%的县级医疗机构医生不愿意将患者向基层医疗机构转诊。
(4)常见门诊疾病和医疗服务在县级医疗机构诊治的医疗费用在绝对数值上明显高于在乡镇卫生院诊治的医疗费用,但是这种差别没有统计学意义；多数住院疾病或服务在医疗费用的绝对数值上也高于乡镇卫生院,县、乡医疗机构医疗费用存在显著性差异的疾病主要有两类,一类是慢性非传染性疾病例如高血压、冠心病和慢性呼吸系统疾病,另一类是需要进行外科手术的疾病,例如痔疮、急性阑尾炎、剖腹产术、子宫肌瘤等。
(5)县级医疗机构门诊患者中适宜分流的有67.25%,但乡镇卫生院的服务能力能够承接的只有48.45%,县级医疗机构住院患者中适宜分流的有23.15%,乡镇卫生院实际能够承接的只有16.50%。62.39%的调查对象认为影响乡镇卫生院服务能力的最大障碍是缺乏人才,人才问题中80.95%的调查对象认为,引进不了高技术专业人才是最主要的问题。
(6)关于医疗服务分流模式,多数受访者认为应该采取多种转诊模式相结合的方法进行分流。主要观点有可以根据疾病的严重程度、恢复程度等,确定每一级医院相应的转诊标准,并制定相应的监督及奖惩措施；鉴于乡镇卫生院的实际服务能力确实有限,应该由县级医疗机构负责对疾病的诊断,而由乡镇卫生院承担更多的疾病治疗和康复工作。
讨论和政策建议：
县级医疗机构门诊和住院患者存在较大的可分流空间或潜在可分流空间,在制定促进农村地区医疗服务分流的相关政策时,应把加强对县级医疗机构门诊患者的向下分流、引导门诊患者在基层就诊作为主要的政策目标。
影响农村地区医疗服务分流的因素有：(1)县、乡医疗机构经济利益对立以及县、乡医疗机构临床医生对疾病分流判断的认知差异；(2)同病种在县、乡医疗机构诊治的医疗费用差异；(3)乡镇卫生院的实际服务能力不足。
现阶段农村地区医疗服务分流的模式可以考虑按病种、按疾病病程相结合的模式。具体方式为根据各地常见病、多发病情况以及各级医疗机构的实际诊治能力,制定符合当地实际的应当转诊的疾病名单和具体病种的规范化诊疗程序作为转诊的标准。同时必须考虑到农村基层医疗机构服务能力相对不足的现状,应该采取由县级医疗机构明确疾病诊断的方式,由县级医疗机构的临床医生决定患者应当在哪个层级的医疗机构就诊；由县级医疗机构制定诊疗方案以后再由乡镇卫生院执行治疗方案,也更能保证治疗的效果。
对此研究我们提出以下政策建议：(1)进一步明确农村医疗服务体系的功能定位,由县级医疗机构承担更多的疾病诊断和确定治疗方案的功能,而乡镇卫生院则应更多地承担明确了诊断和治疗方案后的后续治疗工作以及对进入康复阶段疾病的治疗功能。(2)加强农村卫生服务制度建设,包括加强农村卫生服务体系和能力建设,重点是农村基层卫生服务人员的能力建设；解决医疗机构之间经济利益对立的问题,通过制度安排使三级医疗机构之间由全面竞争的关系转变为协作的关系；加强农村地区医疗服务分流制度建设,促使医疗机构和临床医生严格按照当地的转诊病种和病种服务流程对病人实施转诊,以医疗服务分流为导向调整农村医疗卫生资源的配置,根据确定的分流病种和病种服务流程,按照治疗要求为各级医疗机构配置相应的人员、设备等。(3)各地卫生部门应当根据本地实际情况组织确定当地主要可转诊病种和可转诊病种的规范化诊疗程序和转诊标准,并要求医疗机构及临床医生严格按照此程序和标准及时转诊病人。(4)拉大新型农村合作医疗制度在县、乡医疗机构诊疗的起付线和补偿比例的差距,差别至少要超出20%以上。(5)相关制度建设,包括建立相应的监督考核机制,确保转诊能够实现；根据各地的转诊病种和疾病规范化诊疗流程,有针对性地加强对基层医疗机构相应疾病知识和服务能力的培训,提高基层医疗机构承接转诊病例的能力；加强对基层医疗机构医疗质量的监管,对转诊病种的后续治疗结果进行监督考核,确保患者在不同层级的医疗机构能够获得相同的治疗效果。
The overall goal of the health care system reform is to establish the basic health care system which provides people with equal public health services and basic health care services through government's leading roles and responsibilities in planning, supervision and regulation. Under this basic health care system, enhancing the rural health service network is crucial to achieve the goal of providing basic health services to rural residents. The reform requires for further completing the rural health care service network. The county-level hospital shall be mainly in charge of treating and saving patients with severe or acute diseases; the township health centres shall take the responsibilities of diagnosing and treating the commonly or frequently encountered diseases; the village clinics shall take the responsibilities of the administrative villages'diagnoses and treatment of general diseases and other services. Theoretically speaking, in rural areas the commonly or frequently encountered diseases should be treated at or under the township level hospitals, while the severe diseases should be treated at or above the county level hospitals. In rural areas, patients should be effectively referred to appropriate levels of health institutions through the three-tier health care networks, and rural residents'demands for basic health care services should be met in grass-roots health institutions, in accordance with the distribution of health resources. However, the over-use of the county level hospitals and the under-use of the township health centres become a severe problem because of the inequity and the imbalanced distribution of health resources between urban and rural areas. Moreover, a vicious cycle due to the insufficient input and the drain of patients in township health centres and the lack of flow system make it impossible to refer patients from the higher levels to the lower levels of the health institutions. To solve these problems, an effective flow system should be established in which township health centres play crucial roles in treating the commonly or frequently encountered diseases and patients should be guided to use the grass-roots health institutions for general diseases.
Medical service flow is a process in which patients receive the health care services in a more appropriate institution than the initial one without affecting the clinical treatment and prognosis, including upward referral and downward referral. To set up a reasonable and effective flow system is one of the key approaches to improve the macro health care system. Through the rearrangement of the health care services provision by different levels of health institutions and the reallocation of the resources by patients, the structure of the health resources and the direction of the health input shall be effectively adjusted. The reasonable referral in rural areas is significant to solve the problem of over-use of county level hospitals and under-use of township health centres, to promote the reasonable allocation of rural health resources and to improve the access to basic health care services for rural residents.
Most of the current researches focus on the referral between urban hospitals and community health centres, while little attention is paid to the flow system in rural areas. Therefore it is important to pursue the following questions:in the county-level and township-level health care institutions, what kind of and how much of diseases and services can be referred, what are the influential factors, what referral models can be used, how to set referral standards, and what policies and supportive systems are needed to establish the rural health care flow system.
The general objective of this study is:through the study on the current situation of health care services in rural Shandong, describe the flow both of outpatients and inpatients between different levels, analyze what kind of and how much of the diseases and services can be referred, explore the influential factors of referral in rural Shandong and the models and standards for referral, propose the contents and methods of and the relative policies for the flow system in rural areas.
Date and Methods
This study used both quantitative and qualitative study methods. The study data are from two sources. One is the baseline survey for the project "Proper technologies and productions for rural areas". We selected Jimo, Pingyin and Jiaxiang as the sample counties. In every county, we selected county hospital, county traditional Chinese traditional medicine hospital, county maternal and child health hospital, four township health centres and four village clinics of each town. In all,3 county hospitals,3 county Chinese traditional medicine hospitals,3 county maternal and child health hospitals,12 township health centres and 48 village clinics were selected. We obtained the outpatient and inpatient medical reports of a specific period of the three levels institutions through the survey.
The second part of the data is from the questionnaire survey of the experienced clinical doctors who gave their judgments on which level of the rural health institutions should the patients theoretically be referred to according to the medical records. We selected county hospital, county traditional Chinese medicine hospital and 6 township health centres respectively in Jiaxiang and Qufu County.2 county hospitals,2 county traditional Chinese medicine hospitals and 12 township health centres were selected in total. We interviewed the clinical doctors who work more than 10 years and have the intermediate technical titles in county hospitals and who have the highest qualification in township health centres.
We used the Microsoft Access software to input data and the SPSS11.5 software to conduct the analysis. The descriptive statistical analysis and single factor analysis were the main analysis methods for quantitative data. The qualitative data were from the interviews of the managers of the sample institutions.
Main results
(1) 67.25% outpatients in the county-level medical facilities are supposed to referred to the lower medical facilities, and 23.15% inpatients in the county-level medical facilities should be transferred to the gross-roots medical facilities; Almost no patients in the township-level medical facilities are thought to be referred to the gross-roots medical facilities, and only 6.38% outpatients and 17.77% inpatients respectively; in the township-level medical facilities should be transferred to the superior medical facilities.
(2) Diseases that should be primarily referred in the outpatient service were 24 diseases, such as acute upper respiratory tract infection, prenatal examination, gastritis, tracheitis, diabetes mellitus, general traumatic, vaginitis, herpangina, hypertension, early pregnancy, coronary heart disease, pneumonia, induced abortioneczema, gynecological examination, health examination, lumbago, urticaria, enteritis, menstrual disorder, hyperplasia of mammary glandsdermatitis, lymphadenitis, pelvic inflammation, diarrhea and urinary tract infections only 16.89% of these patients saw the doctors in township hospitals; the diseases should be transferred in inpatient service were about 15, such as normal delivery, all kinds of trauma, hypertention, coronary heart disease, chronic bronchitis, acute bronchitis, haemorrhoids, acute appendicitis, the upper respiratory tract, groin indirect hernia, induced abortion, cerebral concussion, anemia, chronic gastritis, tonsillitis and so on, which made up 50.43% of the common illnesses in the inpatient service, while only 20.86% of these diseases were treated in the township hospitals.
(3)Among the top 15 diseases in the outpatient service visit, proportion of diseases considered to be treated in the township hospitals by doctors in county-level medical facilities was lower than the township hospital physicians, while in the top 15 diseases in the inpatient service visit, it's the same situation. Only the diseases vary largely in the severity and must according to the state of the disease to ensure the facility of the treatment, for instance, coronary heart disease and pneumonia, there was statistical difference, while statistically difference didn't exist in the much easily or difficultly cured diseases. Also,23.19% physicians in the county-level medical facilities didn't have the willingness to refer their patients to the grass roots medical facilities.
(4) The medical expense of the common illness in the outpatient service in county-level medical facilities was obviously higher than that in the township medical facilities; however, there was no statistic difference; so was the medical expense of the inpatient services. There was significant difference in the medical expense of two kinds of diseases between county-level and township medical facilities, one kind was chronic non-infectious disease, such as hypertension, coronary heart disease and chronic respiratory disease, the other kind was the disease needing surgery, for example hemorrhoids, acute appendicitis, caesarean birth and hysteromyoma.
(5) Outpatients supposed to be referred in the county-level medical facilities are 67.25%, while the service capability of the township medical facilities was only 48.45%; inpatients supposed to be referred in the county-level medical facilities are 23.15%, while the service capability of the township medical facilities was only 16.50%.62.39% respondents thought that the largest barrier to develop the service capability of the township medical facilities was shortage of the talent, among which 80.95% respondents believed that the key problem was too difficult to introduce high technology professionals.
(6) As to the medical service referral model, most interviewees preferred to adopt the combination of more kinds of referral models. Main opinions included:according to the severity and recovery status of the diseases, to work out the referral standard of each level hospital and draw up the supervision, rewards and punishment system. In consideration of the limited service capability of the township hospital, the county-level medical facilities should take the responsibility to diagnosis, while the township medical facilities focused on more treatment work.
Discussions and policy implications
There is large and potential room of referral for outpatients and inpatients in county level hospitals. During the policy formulation process, it is important to make it a policy goal that the outpatients in county level hospitals should be referred downward and guided to use the services in township health centres and village clinics.
The main influential factors for referral in rural areas:(1) County level hospitals and township health centres are in opposite positions of interests and have cognitive gap in judgment of disease referral. (2) There are expense gap of similar disease treatment between county and township hospitals. (3) Township health centres are poor in service capacity.
At the present stage, the medical service referral model for rural area could take into account the combination model of disease category and duration. In detail, in line with the prevalence of common illness and the service capability of all levels medical facilities, the standard of referral including the list of the diseases ought to be referred and the flow of the normal diagnosis and treat should be formulated. Meanwhile, the current situation that the service capabilities of the rural gross-roots medical facilities are relatively insufficient should be considered. The way we ought to take is that the diagnosis of the disease should be cleared by the county-level medical facilities, the proper level of the medical facility the patient should be treated ought to be decided by the physician of county-level medical facilities, and the treatment scheme should be formulated by the county-level medical facilities and implemented by the township medical facilities to assure the treatment effect.
As to this study, we propose the policy recommendations as follows (1) Health departments in various regions should ensure the main referable disease and their normal treatment flow and the referral standard, which strictly obeyed by the medical institutions and the clinical doctors to refer the patients in time. (2) Further to clear and definite the function of the medical service system in rural areas. More work on diseases diagnosis and treatment scheme should be assumed by the county-level medical facilities, while more work on cure and recovery in the following period after the treatment scheme has been drawn up ought to be taken on by the township hospitals. (3) Strengthening the construction of the health care service system in rural area, including the construction of institution and capability, especially the ability building of the service personal of grass-roots medical facilities; by means of institutional arrangement to replace the fully competition relationship with coordination among the three-level medical facilities for the purpose of solving the contradiction of economic interest among all-level medical institutions. Strengthen the establishment of medical service flow system in rural area and impel the medical facilities and physicians to abide by local referral disease category and treatment flow to copy with patients, guided by the medical service referral to adjust the health care resource allocation, in accordance with the decided referral disease category, treatment flow and cure requirement to allocate the workers and equipments to various-level medical facilities. (4) Enlarging the gap of deductible and reimbursement ratio between county-level and township medical facilities, and the gap is 20% at least. (5) Establishment of system related, including the construction of supervision and assessment mechanism to ensure the accomplishment of flow. In line with local referral disease category and normal treatment flow to enhance training of corresponding disease knowledge and service ability in grass-roots medical facilities to improve the capability of accepting the referral case in grass-roots medical facilities. Increase the supervision for the quality of grass-roots medical facilities, for instance, supervising and accessing the effect of the following treatment of the referral disease category to make sure that patients can acquire the similar treatment effect in different-level medical facilities.
引文
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