山西省某医联体内部医院之间双向转诊运行现状及优化研究

发布时间：2018-05-26 02:29

本文选题：医联体 + 双向转诊　；参考：《山西医科大学》2017年硕士论文

【摘要】：目的:本次研究的目的是通过对一个医联体内部三级医院的医生、基层医院的医生、三级医院管理人员、基层医院管理人员、住院患者五个人群的问卷调查,了解其对医联体内部医院之间双向转诊的认知情况,其所在医院的双向转诊实施现状,对转诊现状的满意情况与效果评价,发现影响医联体内部医疗机构间顺利转诊的主要问题,查找问题的根本原因,并提出针对性的、具体的、可行的解决方案及对策。为促进医联体内部医院之间双向转诊的顺利进行,实现山西省区域医疗卫生资源的重新整合提供决策依据。方法:本次研究资料主要有三个来源渠道:1.文献法。搜集国家、山西省和其他几个省份有关分级诊疗、医联体、双向转诊的政策性文件;搜集2013年、2014年山西省卫生统计年鉴;在PubMed、Wikipedia、中国知网、万方医学网、《相关期刊论文》中搜集关于医疗卫生体制改革、医疗卫生政策研究的资料,对所得资料进行理论研究。2.现场调查法。对山西省一个医联体内部的一家三级医院、两家县级医院的医生、医院管理人员以及这三家医院的住院患者进行关于对双向转诊认知情况、其所在医院的双向转诊实施情况、对转诊现状的满意度与效果评价等方面的调查。3.统计分析法。利用统计软件SPSS17.0对医生、医院管理人员、患者的基本情况以及对双向转诊的认知情况进行描述性分析,对医生转诊意愿以及患者转诊意愿的影响因素进行单因素卡方检验和多因素Logistic回归分析。结果:本研究的结果主要有三个方面:1.医联体内部医院的医生对双向转诊认知情况的研究结果(1)双向转诊率低,且基层医院医生的双向转诊率高于三级医院医生。基层医院医生最近一个月的双向转诊率为27.78%,其中上转率为18.61%,下转率为9.17%;三级医院医生最近一个月的双向转诊率为14.45%,上转率为11.12%,下转率为3.33%。两者转诊率比较的卡方检验结果为χ2=67.590,p=0.001。(2)基层医院医生对双向转诊的了解程度高于三级医院医生,分别为91.94%和47.41%,两者对比的卡方检验结果为χ2=56.453,p=0.001;对双向转诊过程的主要障碍问题的认识,不同级别医院的医生有差异(χ2=10.992,p=0.012),三级医院医生认为患者对基层医疗水平不信任和没有统一的转诊制度与标准是转诊不畅最主要的原因;基层医院医生认为患者对基层医疗水平不信任和对双向转诊认识不足是转诊不畅最主要的原因。通过对医生转诊意愿的影响因素分析可知,有明确的转诊指南(χ2=5.206,p=0.023)会使三级医院医生的下转意愿可能性增加。2.医联体内部医院的管理人员对双向转诊认知情况的研究结果(1)医院管理人员对双向转诊的知晓率低。三级医院管理人员与基层医院管理人员对双向转诊的知晓率分别为58.3%和67.8%;三级医院管理人员和基层医院管理人员对双向转诊实施现状的满意度低,分别为54.1%和67.8%。(2)针对双向转诊不满意的原因分析,有50%的三级医院管理人员认为没有统一的双向转诊标准,有54.1%的三级医院管理人员认为医院之间缺乏交流;有80.6%的基层医院管理人员对转诊不满意的原因是与上级医院之间缺乏交流,无法共享信息;有38.7%的基层医院管理人员认为没有统一的转诊标准。在与上级医院交流不足的情况下,只有35.5%的基层医院管理者表示会经常跟踪了解病情。(3)在是否有必要将双向转诊纳入绩效考核的问题上,三级医院和基层医院管理人员的看法有差别(χ2=7.464,p=0.024)。三级医院管理人员较基层医院管理人员认为将双向转诊纳入绩效考核的必要性更大。3.患者对双向转诊认知情况的研究结果(1)患者对双向转诊的知晓率低(32.4%),医疗机构对患者关于双向转诊的宣传力度小,仅有28.7%的患者是从医务人员那里听说过双向转诊。(2)通过对患者转诊意愿的影响因素分析可知,居住地附近有社区医院或者乡镇卫生院(χ2=7.225,P=0.027)、有医疗保障(χ2=18.677,P=0.001)、具有转诊经历(χ2=12.560,P=0.001)的患者转诊意愿较强。针对患者不愿转诊的原因调查显示,有60.3%的患者表示不信任基层医院的诊疗水平。结论:山西省医联体内部医疗机构之间的双向转诊服务已经初步开展,三级医院和基层医院的不同功能定位已经初步形成。但仍然存在一些问题:双向转诊率低,上转容易下转难;双向转诊知晓率低;缺乏统一的转诊标准和规范的转诊制度;转诊后续服务欠缺,信息无法共享;双向转诊制度的运行缺乏一套系统完善的监督管理机制;患者对基层医疗机构的诊疗水平缺乏信任;患者主动参与双向转诊的积极性不高。根据对调查结果的研究,再综合国内相关研究的基础上,我们挖掘了这些问题存在的深层次的原因,并且提出了针对性的解决措施,同时探讨了转诊标准。
[Abstract]:Objective: the purpose of this study was to understand the cognition of the two-way referral between the hospital internal hospitals through a questionnaire survey of the doctors of the three level hospital, the doctors at the basic level hospital, the management staff of the three level hospital, the management staff of the primary hospital and the five inpatients, and the two-way referral of the hospital in the hospital. The present situation, the satisfaction of the status of the referral and the evaluation of the effect, found the main problems affecting the smooth referral between medical institutions within the Medical Union, find the fundamental reasons for the problems, and put forward specific, specific and feasible solutions and countermeasures. In order to promote the smooth implementation of two-way referral between medical hospitals, the Shanxi province area is realized. The reintegration of medical and health resources provides a basis for decision-making. Methods: the research data are mainly three sources: 1. literature. Collect the policy documents of the state, Shanxi province and several other provinces on the classification, Medical Association, and two-way referral; collect the 2013, 2014 Health Statistics Yearbook in the province of Shanxi; in PubMed, Wikipedia, China Knowledge Network, Wanfang medical network, < China Journal Full Text Database > to collect information on medical and health system reform, medical and health policy research, theoretical research on the income data,.2. field survey method, a three level hospital within a Medical Union in Shanxi Province, two doctors at the county hospital, hospital administrators, and the three hospitals The inpatients carried out a.3. statistical analysis of the cognition of two-way referral, the implementation of the two-way referral in the hospital, the satisfaction and effect evaluation of the referral status, and the basic situation of the doctors, the hospital administrators, the patients and the cognition of two-way referral. A single factor chi square test and multiple factor Logistic regression analysis were carried out on the intention of doctor referral and the influencing factors of patient referral will. Results: the results of this study were mainly three aspects: the results of the study on the cognition of the two-way referral in the internal hospital of 1. medical couplet (1) the rate of two-way referral was low, and the doctors at the grass-roots hospital The two-way referral rate was higher than that of the three level hospital doctors. The bi-directional referral rate of doctors in the primary hospital for the last month was 27.78%, with the rate of 18.61% and the conversion rate of 9.17%. The two-way referral rate of the three level hospital doctors in the last month was 14.45%, the rate of rotation was 11.12%, the rate of referral rate of the lower conversion rate was 3.33%. and the chi square test result was Chi 2=67.59 0, p=0.001. (2) doctors in primary hospitals were more aware of two-way referral than level three hospital doctors, 91.94% and 47.41% respectively. The results of chi square test for the two were x 2=56.453, p=0.001, the understanding of the main obstacles in the two-way referral process, doctors at different levels of hospital (x 2=10.992, p=0.012), three level hospital doctors thought Patients' distrust of medical level at the basic level and no unified referral system and standard are the main causes of poor referral. Doctors at the grass-roots hospital believe that the most important reason is that the patients' distrust of the medical level at the grass-roots level and the lack of understanding of the two-way referral are the main reasons. The referral guideline (x 2=5.206, p=0.023) will increase the possibility of the doctor's willingness to turn down in the three level hospital to increase the cognition of the two-way referral in the internal hospital of the.2. Medical Union. (1) the awareness rate of the two-way referral by the hospital administrators is low. The awareness rate of the two-way referral by the three level hospital administrators and the grass-roots hospital administrators 58.3% and 67.8% respectively; grade three hospital managers and grass-roots hospital managers have low satisfaction with the implementation of two-way referral status, 54.1% and 67.8%. (2) for two-way referral dissatisfaction, 50% of the three level hospital managers think there is no unified dual referral standard, 54.1% of three level hospital managers recognize. There was a lack of communication between hospitals; 80.6% of the primary hospital administrators were not satisfied with the referral, the lack of communication with the superior hospitals and the sharing of information; 38.7% of the grass-roots hospital administrators believed that there was no unified referral standard. Only 35.5% of the grass-roots hospital administrators expressed the lack of communication with the superior hospitals. (3) there is a difference in the question of whether it is necessary to incorporate two-way referral into the performance assessment, and there is a difference between the three and the grass-roots hospital managers (x 2=7.464, p=0.024). The management staff of grade three hospital are more necessary than the management staff in the basic level hospital. The need for the two-way referral to the performance assessment is greater than that of the.3. patients. Study results of referral cognition (1) the awareness rate of two-way referral was low (32.4%), and medical institutions had little publicity about two-way referral. Only 28.7% of the patients heard about two-way referral from medical staff. (2) through the analysis of the influencing factors of patient referral will, there was a community hospital near the place of residence, or The Township Health Hospital (x 2=7.225, P=0.027) had medical security (x 2=18.677, P=0.001), and the referral experience (x 2=12.560, P=0.001) was stronger. According to the cause of the patients' reluctance to referral, 60.3% of the patients expressed their distrust of the level of diagnosis and treatment in the primary hospital. The referral service has been preliminarily carried out. The different functions of the three level hospitals and primary hospitals have been preliminarily formed. However, there are still some problems: low two-way referral rate, easy turn up and difficult transfer, low awareness rate of two-way referral, lack of unified referral standards and standardized referral system, lack of follow-up service, information sharing, two-way information; The operation of the referral system lacks a complete set of systematic supervision and management mechanism; the patients lack confidence in the level of diagnosis and treatment at the grass-roots medical institutions; the initiative of the patients to participate in the two-way referral is not high. Based on the research on the results of the investigation and the comprehensive domestic related research, we have excavated the deep reasons for the existence of these problems. And put forward targeted solutions, and discussed referral criteria.
【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1

【参考文献】