本文選題：基層衛(wèi)生服務(wù) + 人際連續(xù)性　； 參考：《華中科技大學(xué)》2016年碩士論文

【摘要】：[目的]人際連續(xù)性是衡量衛(wèi)生服務(wù)連續(xù)性、協(xié)調(diào)性的重要維度之一,目前國內(nèi)關(guān)于衛(wèi)生服務(wù)人際連續(xù)性的實(shí)證研究十分薄弱。本研究的目的在于分析農(nóng)村衛(wèi)生服務(wù)人際連續(xù)性特征及其影響因素,找出阻礙人際連續(xù)性實(shí)現(xiàn)的因素。在此基礎(chǔ)上結(jié)合地區(qū)衛(wèi)生條件、醫(yī)改措施和政策導(dǎo)向,提出農(nóng)村基層衛(wèi)生服務(wù)人際連續(xù)性改進(jìn)的建議。[方法]1.文獻(xiàn)分析法通過萬方、中國知網(wǎng)、PubMed、Google Scholar等數(shù)據(jù)庫資源查詢中英文文獻(xiàn);分析衛(wèi)生服務(wù)人際連續(xù)性及相關(guān)主題的概念,查找并篩選研究指標(biāo),總結(jié)研究方法,梳理衛(wèi)生服務(wù)連續(xù)性及相關(guān)研究現(xiàn)狀。2.問卷調(diào)查和訪談法對(duì)樣本地區(qū)農(nóng)村居民進(jìn)行入戶調(diào)查,最終回收有效問卷1177份。對(duì)鄉(xiāng)村醫(yī)生、鄉(xiāng)鎮(zhèn)衛(wèi)生院院長、衛(wèi)生行政和醫(yī)保部門負(fù)責(zé)人進(jìn)行深入訪談,了解基層衛(wèi)生服務(wù)提供者的服務(wù)理念與行為,與衛(wèi)生服務(wù)人際連續(xù)性有關(guān)的關(guān)鍵事件。3.關(guān)鍵信息提取本研究中調(diào)查對(duì)象就診經(jīng)歷的獲取方式為機(jī)構(gòu)記錄提取而非問卷調(diào)查,為此,從縣新農(nóng)合系統(tǒng)提取樣本鄉(xiāng)鎮(zhèn)報(bào)銷(門診和住院)記錄,從縣級(jí)醫(yī)院提取門診日志,構(gòu)建農(nóng)村居民就診流向數(shù)據(jù)庫。并在相關(guān)機(jī)構(gòu)提取政策文件資料。4.統(tǒng)計(jì)學(xué)方法計(jì)量資料描述用(?x?s),采用中位數(shù)、率分別對(duì)等級(jí)資料和分類資料進(jìn)行描述,計(jì)量資料組間比較采用方差分析,分類資料的比較用卡方分析,等級(jí)資料的組間比較采用非參數(shù)檢驗(yàn)。顯著性水平α為0.05,數(shù)據(jù)分析操作使用Excel 2007和SPSS13.0完成。[結(jié)果]1.首診醫(yī)療機(jī)構(gòu)和就診習(xí)慣農(nóng)村居民首診醫(yī)療機(jī)構(gòu)為村衛(wèi)生室的比例最高(53.4%),其次分別是縣級(jí)醫(yī)院(19.54%)、鄉(xiāng)鎮(zhèn)衛(wèi)生院(16.23%)、市級(jí)及以上醫(yī)院(6.54%)和其他醫(yī)療機(jī)構(gòu)(4.25%)。不同地區(qū)、年齡、收入來源和是否患有慢性病的人群首診醫(yī)療機(jī)構(gòu)分布具有顯著性差異(均p0.05)。影響農(nóng)村居民選擇首診機(jī)構(gòu)的因素依次是“交通方便程度”、“疾病嚴(yán)重程度”、“醫(yī)療機(jī)構(gòu)診療水平”、“是否有熟悉的醫(yī)生”、“自費(fèi)醫(yī)療費(fèi)用”、“服務(wù)態(tài)度”、“報(bào)銷比例”和“有無家人陪護(hù)”。28.55%患者在就診時(shí)攜帶就診資料,44.6%會(huì)主動(dòng)告知醫(yī)生之前就診經(jīng)歷。2.人際連續(xù)性建立和維持70.52%的被調(diào)查者(830/1177)表示自己有一位熟悉、信任的醫(yī)生(usualdoctor),830人中,多數(shù)居民(62.8%)與usualdoctor縱向連續(xù)度在10年以上;文化程度、地區(qū)、是否慢病為是否有usualdoctor的影響因素(均p0.05)。居民報(bào)告usualdoctor的執(zhí)業(yè)機(jī)構(gòu)分布依次是村衛(wèi)生室(72.77%)、鄉(xiāng)鎮(zhèn)衛(wèi)生院(13.25%)、縣級(jí)醫(yī)院(6.43%)、私人診所(4.22%)和其他(3.13%)。不同地區(qū)、性別、婚姻狀況和是否慢性的農(nóng)村居民的usualdoctor執(zhí)業(yè)機(jī)構(gòu)分布不同,差異具有顯著性(均p0.05)。3.衛(wèi)生服務(wù)利用和最常去機(jī)構(gòu)經(jīng)過與村民就診流向數(shù)據(jù)庫的匹配,1177位被調(diào)查者中有507位有就診經(jīng)歷,人均就診6次;其中就診3次以上的患者376名;地區(qū)、年齡、是否慢病、健康狀況是衛(wèi)生服務(wù)利用(用就診次數(shù)表示)的影響因素(均p0.05)。最常去醫(yī)療機(jī)構(gòu)為村衛(wèi)生室的患者最多(41.54%);其次分別為縣級(jí)醫(yī)療機(jī)構(gòu)(33.46%)、鄉(xiāng)鎮(zhèn)衛(wèi)生院(20.40%);市級(jí)及以上醫(yī)院(4.60%),最常去機(jī)構(gòu)與調(diào)查對(duì)象報(bào)告的首診機(jī)構(gòu)分布存在顯著性差異(p0.001),不同地區(qū)、年齡組和收入來源的人群最常去機(jī)構(gòu)的分布具有顯著性差異(均p0.05)。4.基于就診經(jīng)歷的人際連續(xù)性各維度衛(wèi)生服務(wù)人際連續(xù)性緊密度、分散度和順序度分別用upc、coc和secon表示,其取值的中位數(shù)分別為0.75、0.60和0.71;人際連續(xù)性順序度低于緊密度(p0.001),有109名調(diào)查對(duì)象人際連續(xù)性緊密度、分散度和順序度的取值均為1.00。地區(qū)是基層衛(wèi)生服務(wù)人際連續(xù)性各維度的影響因素(均p0.001)。人際連續(xù)性順序度隨就診次數(shù)增大呈提高趨勢,緊密度和分散度無顯著變化。5.基層衛(wèi)生服務(wù)提供者行為和地區(qū)衛(wèi)生政策分析基層衛(wèi)生服務(wù)提供者尤其鄉(xiāng)村醫(yī)生對(duì)多數(shù)服務(wù)對(duì)象比較熟悉,在服務(wù)提供中注重人際連續(xù)性的維持與利用。樣本地區(qū)對(duì)衛(wèi)生服務(wù)人際連續(xù)性有影響的衛(wèi)生政策和醫(yī)改措施有分級(jí)診療、協(xié)作醫(yī)療、城鄉(xiāng)居民醫(yī)保統(tǒng)籌和村級(jí)門診統(tǒng)籌,這些改革舉措會(huì)從不同方向影響基層衛(wèi)生服務(wù)提供者和需求方的行為,從而進(jìn)一步影響衛(wèi)生服務(wù)的人際連續(xù)性。[結(jié)論]相比較于村衛(wèi)生室和縣級(jí)醫(yī)院,農(nóng)村居民對(duì)鄉(xiāng)鎮(zhèn)衛(wèi)生院信任程度低,在實(shí)際就診行為中,對(duì)基層衛(wèi)生服務(wù)的利用仍顯得不夠充分。農(nóng)村居民建立醫(yī)患人際聯(lián)系的對(duì)象主要為基層衛(wèi)生服務(wù)提供者,尤其是鄉(xiāng)村醫(yī)生,且人際連續(xù)性持續(xù)時(shí)間較長,但質(zhì)量有限。按照緊密度、分散度和順序度衡量的衛(wèi)生服務(wù)人際連續(xù)性處于較高水平,但透過這些維度反映的農(nóng)村居民就診流程和習(xí)慣仍需進(jìn)一步提高。源于地區(qū)間存在的經(jīng)濟(jì)社會(huì)發(fā)展水平、衛(wèi)生條件和醫(yī)改措施的不同,地區(qū)間衛(wèi)生服務(wù)人際連續(xù)性差異明顯;福建省農(nóng)村居民衛(wèi)生服務(wù)人際連續(xù)性緊密度、分散度和順序度最高,青海省人際連續(xù)性持久度最高,而河南省農(nóng)村居民與基層衛(wèi)生服務(wù)提供者的聯(lián)系最為緊密。應(yīng)在總結(jié)樣本地區(qū)有效實(shí)踐的基礎(chǔ)上,提出有針對(duì)性的提高基層衛(wèi)生服務(wù)人際連續(xù)性的建議和舉措,例如推行協(xié)作醫(yī)療促進(jìn)患者下轉(zhuǎn)和康復(fù)服務(wù)在基層,實(shí)行門診統(tǒng)籌政策增加居民對(duì)基層衛(wèi)生服務(wù)的利用。
[Abstract]:[Objective] interpersonal continuity is one of the important dimensions to measure the continuity and coordination of health services. At present, the empirical research on interpersonal continuity of health services is very weak in China. The purpose of this study is to analyze the interpersonal continuity characteristics and its influencing factors in rural health services, and find out the factors that impede the realization of interpersonal continuity. On the basis of the regional health conditions, medical reform measures and policy guidance, the suggestions for improving interpersonal continuity in rural health services are proposed. [method]1. literature analysis method is used to query the Chinese and English literature through the database resources such as Wanfang, China's Chinese network, PubMed, Google Scholar and so on. Screening research indicators, summarizing the research methods, combing the continuity of health service and related research status.2. questionnaire survey and interview method to investigate the rural residents in the sample area, and finally reclaim 1177 valid questionnaires. The service concept and behavior of the health service provider, the key event related to the interpersonal continuity of health service.3. key information extraction in this study, the way to obtain the visiting experience of the investigation object is the institutional record extraction but not the questionnaire. For this reason, from the county new CMS system, the sample Township Town reimbursement (outpatient and hospitalized) records, from the county hospital. The outpatient log was extracted, and the rural residents' visiting flow database was constructed. The statistical data of.4. were extracted from the relevant institutions, and the statistical data were described by (? X? S). The median was used to describe the grade data and the classification data respectively. The analysis of variance was used in the measurement data group, and the comparison of the classification data was analyzed with the chi square analysis, etc. The level of data was compared with the non parametric test. The significant level of alpha was 0.05, the data analysis operation was completed by Excel 2007 and SPSS13.0. [results the highest proportion of the first medical institutions and the rural residents' first medical institutions for the village residents (53.4%), followed by the county hospitals (19.54%), the township hospitals (16.23%), and the city (16.23%), and the city (16.23%), and the city's municipal hospital (16.23%). Level and above hospitals (6.54%) and other medical institutions (4.25%). The distribution of first medical institutions in different areas, ages, income sources and people with chronic diseases has significant differences (all P0.05). The factors affecting rural residents' selection of first consultation institutions are "traffic convenience", "severity of disease", "medical institution diagnosis". "Treatment level", "whether there is a familiar doctor", "self expense medical expenses", "service attitude", "reimbursement ratio" and "no family escort".28.55% patients carry the medical information at the visit, 44.6% will voluntarily inform the doctor about the experience of establishing and maintaining 70.52% of the interpersonal continuity of the doctor before the doctor (830/1177) expresses himself There was a familiar and trusted doctor (usualdoctor). Among the 830 people, most residents (62.8%) and usualdoctor had more than 10 years of longitudinal continuity; and whether or not the chronic disease was affected by usualdoctor (all P0.05). The distribution of usualdoctor in the resident report was the village health room (72.77%) and the township hospital (13.25%). County-level hospitals (6.43%), private clinics (4.22%) and other (3.13%). Different regions, sex, marital status and chronic rural residents have different distribution of usualdoctor practice institutions, the difference is significant (P0.05).3. health service utilization and the most frequent visits to the database of villagers' visits to the village, and 5 of the 1177 respondents 07 patients had medical experience, 6 times per person, of which 376 were treated with more than 3 times; area, age, slow disease, health status as the influence factors (all P0.05). Most often went to the village health service (41.54%); the second was County medical institutions (33.46%), township health Hospital (20.40%); municipal and above hospitals (4.60%), there was a significant difference in the distribution of first consultation between the most frequent organizations and the survey subjects (p0.001). The distribution of the most frequent organizations in different regions, age groups and income sources had significant differences (all P0.05).4. based on the interpersonal continuity of the medical experience. The continuity tightness, dispersion and order degree are respectively UPC, COC and secon, respectively, the median of the values are 0.75,0.60 and 0.71, the sequence degree of interpersonal continuity is lower than the degree of tightness (p0.001), and there are 109 subjects of interpersonal continuity tightness, and the value of dispersion and order degree are all 1.00. area is the interpersonal continuity of basic health service. Influence factors (all p0.001). The sequence degree of interpersonal continuity increased with the increasing number of visits. There was no significant change in the degree of tightness and dispersion..5. grassroots health service providers and regional health policies were analyzed at grass-roots level health service providers, especially rural doctors were more familiar with most of the service objects. Maintenance and utilization of continuity. The health policy and medical reform measures in the sample area have graded diagnosis and treatment, cooperative medical care, medical insurance plan for urban and rural residents and the overall planning of village level outpatients. These measures will affect the behavior of the provider and the demand side of the grass-roots health service from different directions, thus further affecting the health. Compared to village health rooms and county hospitals, compared to village health rooms and county-level hospitals, rural residents have low trust in township hospitals. In practice, the use of grass-roots health services is still inadequate. The main object of rural residents to establish medical and patient relationships is to be the primary health service providers, especially rural doctors. The continuity of health services, which is measured by tightness, dispersion and order, is at a high level, but the procedures and habits of rural residents who are reflected through these dimensions still need to be further improved. The difference of medical reform measures, the difference of interpersonal continuity between regional health services is obvious. The interpersonal continuity of rural residents in Fujian province has the highest degree of interpersonal continuity, the highest degree of dispersion and order, the highest interpersonal continuity in Qinghai Province, and the closest relations between the rural residents in Henan and the primary health service providers. On the basis of effective practice, some suggestions and measures are proposed to improve the interpersonal continuity of primary health services, such as promoting cooperative medical treatment to promote patients' down and rehabilitation services at the grass-roots level, and implementing the policy of out-patient co-ordination to increase the utilization of residents' health services at the grass-roots level.
【學(xué)位授予單位】：華中科技大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R197.62

【引證文獻(xiàn)】

相關(guān)期刊論文 前1條

1 張翔;王潔;韓星;王蕾;謝云;;農(nóng)村衛(wèi)生機(jī)構(gòu)連續(xù)性互動(dòng)機(jī)制研究[J];醫(yī)學(xué)與社會(huì);2017年12期

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本文編號(hào)：1938518