上海市闵行区分级诊疗实践效果研究

doi:10.12114/j.issn.1007-9572.2020.00.353

摘要/Abstract

摘要： 背景　为进一步深化医药卫生体制机制改革，完善闵行区医疗服务体系，闵行区2015年起启动社区卫生综合改革试点，为逐步实现分级诊疗打下基础。目的　分析闵行区2017—2018年社区卫生综合改革试点实践效果及存在问题，为进一步建立可推广的社区服务评价体系及完善分级诊疗制度提供实践基础和政策建议。方法　2017—2018年，通过上海市社区卫生综合改革云管理平台（市社区综改平台），收集2018年上海市16个区（县）社区卫生综合改革全年得分情况，通过闵行区公立医疗机构管理中心下发的2017—2018年闵行区医疗机构管理核心数据分析报告及闵行区社管平台运行情况周报表收集2017—2018年闵行区社区卫生综合改革签约服务情况、上级医院和社区医疗服务量情况，通过闵行区卫生健康委员会医政核心数据报表及医联体核心数据报表收集2017—2018年闵行区医联体内双向转诊量及上级医院对社区技术帮扶情况。结果　2018年上海市16个区（县）社区卫生综合改革全年总得分前3位分别为金山区〔（76.88±3.67）分〕、闵行区〔（76.78±2.50）分〕、松江区〔（76.06±2.16）分〕，后3位分别为杨浦区〔（58.71±3.65）分〕、黄浦区〔（53.68±2.45）分〕、长宁区〔（37.61±17.60）分〕；闵行区主要失分项为签约覆盖、就诊流向、频次费用指标。闵行区2018年“1+1+1”签约率、60岁以上居民签约率高于2017年，签约居民人均就诊次数、签约居民人均门诊费用、签约居民社区就诊率、签约居民组合内就诊率、签约居民组合外就诊开具延处方比例低于2017年（P<0.05）。与2017年相比，2018年闵行区上级医院门急诊人次增加0.99%，住院人次增加6.55%；社区门诊人次下降1.32%，住院人次增加0.25%；社区慢性病长处方量增加7.58%，慢性病长处方量占比增长5.25个百分点，社区延处方量增加33.95%，延处方金额增加86.42%；上转人次增加709.70%，下转人次下降35.34%，区属医疗机构在医联体内上级医院引进专家数增加13.92%，上级医院对社区进行技术指导次数增加4.87%，社区至上级单位进修、学习人次增加16.35%，上级医院对社区影像远程会诊次数增加1.32%，上级医院对社区心电图远程会诊次数增加10.91%。结论　2018年上海市闵行区在市社区综改平台中总得分排名靠前，签约率明显提高，签约居民就诊次数及门诊费用得到有效控制，长处方及延处方量明显增加，社区门诊人次减少，医联体内引进专家量、双向转诊量和上级医院对社区技术帮扶明显增多，总体上社区卫生综合改革试点效果突出，为建立可推广的评价体系及完善分级诊疗制度提供实践基础。但仍存在就诊流向不足、下转不畅等问题，后续工作需进一步完善双向转诊机制。

关键词: 分级诊疗, 社区卫生服务, 社区卫生综合改革, 上海, 医联体

Abstract: Background　To further advance the reform of the pharmaceutical and healthcare system，and improve the healthcare delivery system in Minhang District，Minhang District has embarked on a pilot comprehensive reform of community healthcare system since 2015，which has laid a foundation for the progressive implementation of hierarchical medical system. Objective　To analyze the implementation results（including achievements and problems）of a pilot comprehensive community healthcare reform in Minhang District from 2017 to 2018，providing evidence and recommendations for developing a scalable community healthcare evaluation system and for improving the hierarchical medical system. Methods　From 2017 to 2018，the 2018 annual evaluation scores of comprehensive community healthcare reform of Shanghai's 16 districts were collected through Shanghai Cloud Management Platform of Comprehensive Community Healthcare Reform，the implementation of contracted services，and workload of community hospitals and higher level hospitals in Minhang District in 2017—2018 during the reform were obtained by reviewing the 2017—2018 Analytical Report on Minhang District Healthcare Institutions Core Data and 2017—2018 Weekly Reports on the Operation of Minhang District Community-based Healthcare Management Platform issued by Minhang District Public Healthcare Institutions Management Center，and data about bi-directional referrals and technical assistance for community hospitals offered by higher level hospitals within Minhang District medical consortiums during 2017—2018 were gathered from Minhang District Health Commission's Reports on Medical Affairs Core Data and Reports on Medical Consortium Core Data. Results　The top three districts with highest 2018 annual evaluation scores of comprehensive community healthcare reform were Jinshan District〔（76.88±3.67）points〕，Minhang District〔（76.78±2.50）points〕，and Songjiang District
〔（76.06±2.16）points〕，while the bottom three were Yangpu District〔（58.71±3.65）points〕，Huangpu District〔（53.68±2.45）points〕，and Changning District〔（37.61±17.60）points〕. The losing items for Minhang District mainly fell on such three indicators as the coverage of contracted services，the flow of consultations and the costs per consultation.Compared with 2017，in 2018，Minhang District obtained higher rate of signing "1+1+1" type contracted services，and higher percent of contracted residents over 60 years，but less average visits per capita，less average outpatient healthcare cost per capita，lower rates of visiting the contracted community hospital and the contracted hospitals，as well as lower rate of seeking healthcare and having extended prescriptions in non-contracted hospitals in contracted residents（P<0.05）. And compared with 2017，the year 2018 in Minhang District saw a rise of 0.99% of outpatient/emergency visits and 6.55% of inpatients at higher level hospitals，while at the community level，outpatient visits fell 1.32%，and inpatients rose 0.25%. The number of long-term prescriptions for chronic diseases increased by 7.58% with its accounting proportion up by 5.25%，and the number of extended prescriptions increased by 33.95% with its amount up by 86.42%. And the number of upward referrals rose 709.70% while that of downward referrals fell 35.34%. Experts introduced to the district medical institutions from higher-level hospitals in the medical consortium increased by 13.92%. The number of technical guidance provided by higher-level hospitals to the communities rose 4.87%. The number of persons sent from the communities to higher-level hospitals for further studies and trainings was up by 16.35%. And the number of remote community consultations conducted by higher-level hospitals via picture archiving and communication system increased by 1.32%，while that via Medigus Ultrasonic Surgical Endostapler system rose 10.91%. Conclusion　In 2018，Minhang was in the high-rankings in terms of the annual evaluation score of comprehensive community healthcare reform. The rate of contracting services increased significantly and contracted residents' visits and outpatient costs were effectively controlled. The number of long-term and extended prescriptions increased remarkably and community visits decreased，and the number of experts introduced to the community level，bi-directional referrals and the technical assistance offered by higher-level hospitals to communities increased sharply within the regional medical consortium. Generally，the pilot comprehensive reform of community healthcare system has achieved prominent effects，providing evidence for the establishment of a scalable evaluation system and for the improvement of the hierarchical medical system. However，there are still problems such as inadequate flow of consultations and poor downward transfers，and the like. Therefore，further work for bi-directional referrals is needed.

Key words: Hierarchical medical system, Community health services, Comprehensive reform of community health service, Shanghai, Medical consortiums

许成燕，宦红梅，程佳2杭文权，马应忠. 上海市闵行区分级诊疗实践效果研究[J]. 中国全科医学, 2020, 23(25): 3170-3174.

XU Chengyan，HUAN Hongmei，CHENG Jia，HANG Wenquan，MA Yingzhong. Implementation Effect of Hierarchical Medical System in Minhang District，Shanghai　[J]. Chinese General Practice, 2020, 23(25): 3170-3174.

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